Document 6bX1q3LG9vXVKwQQY2Oy4V86g

JE Come Cpt noneBtnvs GEE ARL26-0476 3M 8A.mmPolnasimuamChPoelrefclyusotrookoicntiannoaantde PHreopdautcitciEonnzWyomrekse,rCsh.olesterol and Lipoproteins in Toxicology research suggested, to a limited extent, that th incidence of pancreas acinar cell adenomas in ats fed perfluorooctanoic acid may be the result ofa mild but sustained increase in cholecystokinin (CCK) as a consequence ofhepatic cholestasis. To assess this hypothesis, plasma CCK levels were measured by radioimmunoassay for those Cottage Grove employees participating in the 1997 fluorochemicl surveillance examinations (n= 84). The mean serum PFOA level as measured by high performance Viquid chromatography mass spectrometry methods, was 6.8 ppm (median. 1.3 ppm, range 0.1 - $1.3 ppm). CCK values approximated the assay' reference range for a 12 hour fast and were negatively. not positively, associated with employees' serum PFOA. levels In addition to the CCK analyses, medical surveillance examinations were reviewed for the 1993, 1995 and 1997 time periods to assess the initial hypothesis generated from the 1990 fluorochemical medical surveillance data from this Cottage Grove workforce that PFOA (measured as total organic fluorine) may modulate hepatic responses to obesity and alcohol consumption (see studies # 5 and #7). In these three subsequent time periods, PFOA, assayed by mass spectrometry, did not appear to modulate hepatic responses to cither obesity or alcohol consumption. Regardless ofthe surveillance year, there was no indication ofsignificant clinical hepatic toxicity at the PFOA levels 03485 observed in this workforce. The study protocol for the assessment of cholecystokinin levels, the internal 3M Final Report and a manuscript that has been accepted for publication (Drug and Chemical Toxicology) are submitted. [Note: the PFOA category levels for the univariate analyses in the publication manuscript (0- < 1 ppm, 1 - < 10 ppm, > 10 ppm) are different than those reported in the 3M final report (0 < I ppm, 1 < 10 ppm, 10 - < 30 ppm, > 30 ppm). This change in the publication manuscript was done pear request made during the peer review process. This difference in categories did not affect the results or conclusions.) 03486 * [10 press 2000, Drug and Chemical Toxicolosy] : PLASAMNAD CLIHPOOLPERCOYTSETIONKSINININAMAMNODNHIEUPAMTPIECREFNLZUYOMERSO.OCCTHAONLOEASTTEEROL PRODUCTION WORKERS M(edJiecaalrWyD.epOalritemne*n.t.Je3a3n1M.ComBuprarinsy..M2ic2h0e.le3WM.-0B55u.r.lePwa,ulJefMfNr.ey 5H5.1M4a4n1d0e9l0 ABSTRACT [afpCmpPmlioAcnCatiEiuIonmCsO. p:e)r.f"lItuorrwaohpoiiccdthlaynoaditsiessoitcshieaatesapontiienonntbisoylmoighiecricmesduifaactan10t used in industrial perfluorooctancate aoCdfFeAhneCopFmataSis.c.CmOpaOayHncb]re.etahsePcaFonOndsAeqLiuesyednicpgeerocexlilsoamdeepnroomloaifesraiptneorrrfatutnosorwoTnohctetoanpeaatsnscseoasesothnaeciinn(caPirdFeOcneAcl,el Obsperreovuelde.of PheFpOatAicwachsolresetpaosrits.ed alcohol consumption tAolothhfaaovuemgihlmdondbouulsaistguensidtfaihicenapenadttiicnclcirrmeecasaspteoonhfeecihepolaueycytoosbxteiosckiiittynyinwaanasds, pSgeerrrafumlmiunoreodoctmaendoiactaelprasoumdruovcentigillopanrnocidenuc1td9ia9ot3na (wnoorfk=erm1s1.a1l)e,To1wf9ou9rr5tkhe(ernrsa=sio3ae0yro)slvwpeodd.ss1bh9ey9p7oat(hmemnsoens,iuwme oF of ddiarerPctFyOraAdmeitowhiaomdsmsu.nmoeaPaslssaausyrm.eadchSboeylreuchymisgtho-kbpiienoricnfhoewrmmaiascnacmlee.atessultsir.qeudiidn(ocnchlheyroinma1t9o9g7r)apbyhyh=ema7e4s)ss. 23Sapte1ms2t..2e.romlreadaningadenl0i1.p01oppro1pt1me4,i.n1rs.apnpgmSe)e;r0u0ma.nPd3F01.O90A9p7plemv)e;ls,19b9y5y(eamre,anwe6r.8ep. 1p9s93hSe(ppaaet1oi6n.cs0,oenmoze`ydpmipeamsn,, orraaunnrggeefa80s..t81:a86n.7d8p1wg:e3/rmepipnm)e)ga.aptipvrCeolCxyiK.mavtaelduetsh(amsesaanys(2m8r.ee5afneprge6i.nm4cie,prpSamnDgeS17D(.u1p1, 410m8,5e0dmiopadgn/em3rl3').)f5op3rep/apmmi1,2, sleovcelisa. teOdurwfiitnhdiPnFgsOAconlteivneules Toporfed obser 10nostugpgoessiitvtelhye,re as measured in aisssnoocisaitgendifwiictahntmcpllinoppere,nhsepnaotirc)toPxFicOitAy this workforce. Unlike x previously soebcetsiiotnyalordeaslicgovnhaotailsonco,onnlPsyuFm1Op7tAisoundb.ijdecrtosLtiwmaeiprtpaeteiacoronms mtooofnmtofhdeousrelaifhtienedtihhnergpesae.tismccirueeseppon1s)e.the either cross- stuhbejevcotlsunwtiatrhyseparrutmicliepvaetliso>n t1h0aptpmr,anged benveen 50 and 70 perennmeer.3)yetahres;fe2w) *Corresponding Author ccoas? INTRODUCTION Ammonium perfluorooctanoate [APFO; CFy(CF:)iCOYNH4'] is a potent synthetic surfactant used in industrial applications which rapidly dissociates in biologic media. to perfluorooctanoate. [CFy(CF2)CO;), which is the anion of perfluorooctanic acid [PFOA, CFy(CF2)COOH]. In laboratory animals, PFOA and its salts are: 1) absorbed by ingestion, inhalation or dermal contact," 2) distributed primarily in the liver and blood:* 3) not biotransformed, conjugated, incorporated into lipids or form coenzyme A conjugates;** and 4) eliminated in the female rat at a greater rate of renal excretion than , the male rat although no gender differences in excretion of PFOA have been seen in other laboratory animal species.'*? In rats, administration of APFO results in peroxisome proliferation, uncoupling of mitochondrial oxidative phosphorylation and altered lipid metabolism. "*'** In a 90-day gavage study of rhesus monkeys, all animals in the 100 mg/kg/day group and 3 of the 4 animals in the 30 mg/kg/day group died before the end of study.** Histopathologic examination revealed marked diffuse lipid depletion in the adrenals, slight to moderate hypocellularity of bone marrow, moderate atrophy of lymphoid follicles in the spleen and moderate atrophy of the lymphoid follicles of the Iymph nodes in the two highest treatment groups. There were no histopathologic changes in the 0.3 and 10 mg/kg/day dose groups. In lifetime feeding bioassays of rats, APFO in the diet at 300 ppm (daily dose of 15 mg/kg/day) increased the incidence of liver. Leydig cell and pancreas acinar cell adenomas. The liver and testicular tumors most likely occur via nongenotoxic mechanisms: oxidative stress and apoptosis in the development of the liver tumors; and enhanced hepatic aromatase activity which results in 4 hormone-mediated mechanism (increased estradiol for the formation of Leydig cell tumors.'*"" The pancreas acinar cell adenomas were hypothesized to be a result of a mild but sustained increase in cholecystokinin (CCK) levels secondary to hepatic cholestasis." CCK has been shown in animal models to produce pancreatichypertrophy, hyperplasia andneoplasia. "> Hepatic toxicity and hypolipidemia have not been observed in ammonium perfluorooctanoate production workers. *** Gilliland and Mandel did report that PFOA c034e8 may negatively modulate the effect alcohol has on high-density lipoprotein (HDL) levels and exacerbate the effect that obesity has on hepatic enzyme tests. This workforce was not found to be at an increased mortality risk for liver cancer or liver disease. However, there were four pancreatic cancer deaths compared to two expected deaths (Standardized Morality Ratio 2.0, 95% Confidence Interval 0.5-5.0). One of these four pancreatic cancer deaths had worked in the building where ammonium perfluorooctanoate was produced. The purpose of this analysis was to examine several additional years of medical surveillance data at this ammonium perfluorooctanoate production plant in order to determine: 1) whether CCK levels are positively associated with serum PFOA levels among production employees; 2) whether PFOA results in clinical hepatic toxicity; and 3) whether PFOA may modulate hepatic responses to obesity and alcohol. METHODS PFOA Production Ammonium perfluorooctanoate production at this 3M plant began in 1947. Ammonium perfluorooctanoate, a white powder, is produced via a five-stage process: electrochemical fluorination: isolating and converting the chemical to a salt slurry; converting the slurry. 0 a salt cake: drying the cake; and packaging. The greatest likelihood for exposure has ocaprred in the drying area Subject Selection and Data Collection Voluntary medical surveillance examinations were offered to the fluorochemical production workers in 1993, 1995 and 1997. The total number of male subjects, by year, who participated in these three cross-sectional investigations were: 1993 (n = 111); 1995 (n= 80): and 1997 (n= 74). (There were 100 few female employees to include in the data analysis.) Eligible voluntary participation rates among these production workers ranged 03489 from approximately 50 (1997) to 70 (1993) percent. There were 68 subjects in common for 1993 and 1995: 21 subjects in common between 1995 and 1997 (lower number due to employee mover and re-assignments): and 17 subjects in common for all three years. Surveillance activities included a sef-administered questionnaire, measurement of height, weight and pulmonary function, standard biochemical and urinalysis tests, serum PFOA determination and several male reproductive hormone assays. The hormone data were. collected in hepatic and 1993 and 1995 and the findings have been reported elsewhere.' lipoprotein-related biochemical tests included: alkaline phosphatase Serum (IU/L); gamma gluamyl tansfesse (GGT. TUL) aspartate aminotransferase (AST, TUL); alanine aminotransferase (ALT, TUL); total bilirubin (mg/dl: direct bilirubin (mg/d); total cholesterol (mg/dl); low-density lipoproteins (LDL. mg/dl); high-density lipoproteins (HDL. mg/dl): and triglycerides (mg/dl). In 1997, employees" plasma CCK- 33 (pgm) levels were determined. CCK exists in various forms and lengths, although sulfated CCK-33 (ic., a 33 amino-acid arrangement) appears to be the predominant form. For purposes of brevity, we will refer to CCK-33 as CCK. Employees were required to have fasted for 12 hours prior to their venipuncture. Because CCK analyses were not a standard analysis of the company's fluorochemical medical surveillance program,a study protocol was reviewed and approved by the company's human subjects committee and a signed, informed consent was obtained from each participant. Serum chemistries and hematology were evaluated at Allina Laboratories (Minneapolis, Minnesota). Plasma CCK was measured by direct radioimmunoassay by Inter Science Institute (Inglewood, California). Serum PFOA (ic., perflucrooctanoate) was determined by /thermospray (1993 and 1995) and electrospray (1997) high-performance liquid chromatography/mass spectrometry method3s. Data Analysis Simple and siaified analyses, analysis of variance (ANOVA), and multivariable regression techniques were used ( evaluate linear and nonlinear associations between PFOA and the biochemical parameters with adjustment for potential confounding variablesTM. Various serum category levels were used for the stratified analysis with no 034390 significant differences observed based on cutpoints as high as > 30 ppm. However, the. number of employees at > 30 ppm was $ or fewer (based on year). For purposes of this report, employees were stratified into three PFOA categories (0 - <I ppm: 1 - <10 ppm; and 210 ppm) in order to provide a greater number of employees in the highest (= 10 ppm) category. For multivariable regression analyses, PFOA, age, body mass index (BMD), alcohol use, and cigarette use were examined as both categorical and continuous variables. Alcohol use was analyzed as less than 1 drink per day, > 1 drink per day and non-response to this questionnaire item (almost all subjects reported between <I - 3 drinks/day). Linear and nonlinear transformations of PFOA were used to test for , associations. In particular, the multivariable models employed by Gilliland and Mandel were used (0 determine whether PFOA has a modulating effect on obesity or alcohol consumption in regards to hepatic serum chemistries (ALT, AST and GGT) and HDL. respectively. RESULTS Serum PFOA levels, by year, were: 1993 (mean 5.0 ppm, SD 122, median 1.1 ppm, range 0.0 - 80.0 ppm); 1995 (mean 6.8 ppm, SD 16.0, median 1.2 ppm, range 0.0 - 114.1 ppm); and 1997 (mean 64 ppm, SD 14.3, median 1.3 ppm, range 0.1 - 81.3 ppm). Provided in Table Iare the mean, standard deviation, median and range of the employees' age. BMI and hepatic. cholesterol and lipoprotein serum chemistry data stratified by PFOA level and the year of the medical surveillance examination. Depending upon the surveillance year, one to two orders of magnitude of difference were observed between themeans (and medians) of the lowest and highest serum PFOA categories. There was no evidence for abnormal liver function tests, hypolipidemia or cholestasis associated with increasing employees' serum PFOA levels. Controlling for potential confounders, multivariable regression analyses did not suggest otherwise. Other measures including renal function. blood glucose and hematology were not associated with serum PFOA levels (data not shown). The mean CCK value was 50 percent lower among employees with serum PFOA values 10 ppm than for those employees with serum PFOA levels < 1 ppm (Table I), Figure 03491 is a scatter plot of the natural log of CCK and PFOA. All but two CCK values were within the assay's reference range (up 10 80 pg/ml). These two CCK values (80.5 pg/ml and 86.7 pg/m) were of employees with 0.6 ppm and 5.6 ppm serum PFOA levels, respectively. Adjusting for potential confounding variables, we continued to observe a negative association between the natural log of CCK and serum PFOA levels (Table Il) although minimum variation was explained (R? = .08). Provided in Table Il are the multivariable regression models (as originally reported by Gilliland and Mandel with the 1990 medical surveillance data) which examined the potential modulating effect of PFOA on the association between alcohol and HDL. The coefficients of determination (R%, adjusted R%) were not large for any model. Based on these models, Table IV shows the change in HDL levels associated with a 10 ppm increase in serum PFOA levels among light and moderate drinkers (> 1 drink/day) compared to light drinkers (< 1 drink/day). [Note: tol serum organic fluorine measurements, rather than serum PFOA, were used in 1990.) Unlike the findings from the 1990 data, the effect of alcohol use on increasing HDL levels was not blunted by a 10 ppm increase in PFOA in any of the subsequent medical surveillance examination years Presented in Table V are multivariable regression models, including those originally reported using the 1990 surveillance data, regarding the potential effect of PFOA on hepatic enzyme responses to obesity as measured by BML Again, the coefficients of determination were not large for any model. In the 1990 surveillance data, ALT increased among obese (BMI = 35 kg/m) but not non-obese (BMI = 25 kg/m?) workers who had a 10 ppm change in serum PFOA (Table VI). However, this interaction was not observed in the 1993, 1995 or 1997 medical surveillance examinations. Likewise, we did not observe associations with AST or GGT (data not shown) as was reported in the 1990 medical surveillance examinations*. 03492 DISCUSSION `We observed a negative association between serum PFOA and plasma CCK. among 74 workers engaged in the production of ammonium perfluorooctanoate. This observation is opposite that proposed by Obourn et al who questioned whether chronic exposure to. peroxisome proliferators, like PFOA, can cause pancreatic adenomas in the rat as the consequence of a mild but sustained increase in CCK levels secondary to hepatic cholestasis." We do not believe the negative association observed in our study represents. an entirely different biological relationship than what was originally postulated because: , . 1)all CCK values observed in this study were within the assay's reference except for two values (which were not associated with high serum PFOA values); and 2) there was no. suggestion of cholestasis which was considered the underlying reason for the elevated CCK levels in the rat. There are several explanations for the lack of a positive association between PFOA and CCK in our study. First and foremost, the serum PFOA measurements in these production workers may have been t00 low to cause an increase in CCK if such a mechanism exists in humans. Second, the mechanistic reason for the elevated CCK levels in the Obourn et al study"? was not clearly established. Obourn et al examined the effects of Wyeth 14.643, a more potent peroxisome proliferator than PFOA; thus their findings may not be directly related to PFOA. The clinical pathology data indicative of cholestasis included alterations in bile flow and bile acid output. Absolute bile flow and flow relative-to-body weight were marginally increased and acinar cell proliferation, alifough numerically increased at 3 months, returned to control levels at 6 months. Obourn et al also conducted in vitro experiments of both Wyeth-14,643 and PFOA which argued against other biological pathways known to elevate plasma CCK levels including CCK-A receptor agonism. trypsin inhibition and increased dietary fat content "Third. the primary set of biochemical and cellular evens identified in rodents susceptible 0 the hepatic twmor effects of peroxisome proliferators has not been identified in either liver biopsies from humans exposed to peroxisome proliferators or in in vitro studies with human hepatocytes: however, the peroxisome proliferator-activated receptor (PPAR-01) is 03493 expressed at very low levels in the human liver." It should also be noted that unlike the pancreas of the rar. the human pancreas has no detectable CCK-A receptors and little to no mRNA for the receptor." Finally, whether CCK initiates or promotes pancreatic cancer is a controversial issue." Data from more than seventy laboratory animal studies have variably suggested that CCK has positive trophic effects, inhibitory effects, or no involvement in pancreatic mor growth. CCK has promoted growth of human pancreatic cancers in cell cultures." On the other hand, fasting plasma concentrations of CCK in unresected pancreatic cancer patients did not differ from healthy controls.' Also acinar cell malignancies in rats are rare in the human." Activation of the c-K-ras gene is. ' frequent in both human and hamster pancreatic cancer but is not found in azaserineinduced pancreatic cancer acinar cell adenoma models in the rat 4! Neither Gilliland and Mandel** nor ourselves observed significant clinical hepatic toxicity associated with the serum PFOA levels measured in this workforce. In the three surveillance years we examined (1993, 1995 and 1997), 88 percent, 81 percent and 85 percent of those employees who volunteered had serum PFOA levels less than 10 ppm, respectively. In a laboratory study, no significant hepatic toxicity was reported for the lowest dose (3 mg/kg/day) group of rhesus monkeys administered APFO by gavage for 90 days"? One of four primates in the next highest dose (10 mg/kgfday group) developed anorexia and black stools during the course of the study. There were no other abnormalities reported for this group. Only one animal survived in the 30 mg/kg/day `group and none survived in the highest (100 mg/kg/day) dose group. For the 3 and 10 mg/kg/day dose groups, their mean serum total organic fluorine levels were 54 and 67 Pp. respectively. Sixty-nine percent of the molecular weight of PFOA isorganic fluorine; therefore these total organic fluorine levels in the lower dose groups may correspond to serum PFOA. levels of 80 to 100 ppm. Total organic fluorine levels were analyzed in the liver for two animals in each of the two lowest two dose groups and the means were 5 and 10 ppm. respectively." Liver total organic fluorine levels were also analyzed for the 30 mg/kg/day (n = 4. mean = 98 ppm) and the 100 mg/kg/day (n= 2, mean = 213 ppm) dose groups; however, only the sole surviving animal in the 30 mg/kg/day group was analyzed for serum total organic fluorine (145 ppm which 03494 approximates 210 ppm of PFOA). The 30 mg/kg/day group did have higher hepatic wansaminase values after 30 days of compound administration than the control group. Serum chemistries were not performed for the 100 mg/kg/day group after the onset of compound administration. Relative (% body weigh) liver weights were higher among the 30 mg/kg/day (3.84%) and 100 mg/kg/day (3.31%) treatment groups than the control (236%). 3 mg/keglday (2.36%) and 10 mg/kg/day (2.32%) dose groups. No abnormal liver function results were observed among employees with the highest serum PFOA levels: nevertheless these workers have been restricted from potential high exposure workplace areas. , `We were unable to replicate, in three subsequent medical surveillance examinations, an earlier investigation'; finding that PFOA may modulate hepatic responses to obesity and alcohol * Total serum organic fluorine was used as a surrogate variable for PFOA in the 1990 medical surveillance exams. The use of total serum organic fluorine consfitutes additional potential exposure to perfluorocarbons: however, data suggest that PFOA would represent the greatest fraction of total serum organic fluorine levels in this employee population. Another explanation for the disparate findings, in particular as related to BMI is that there may have been measurement error regarding BMI in the original study as well as in our investigation. We have previously noted the lackofan expected positive association between BMI and estradiol in the 1990 data" Yet in the present study we did not observe the anticipated strong. postive correlation between BMI and ALT except in 1997. Correlation coefficients (p value in parentheses) were: 1993, 1 =.16,(p= 09) 1995.1 =.13, (p= 27); and 1997, r = 43 (p = 0001). Self-reported alcShol data collected in the occupational seting can be questioned for ts reliability as well as validity. The latter was not feasible to address; however, to partially examine the. issue of reliability, we examined the analyses of the 68 employees who participated both : in 1993 and 1995. The data showed good correlation between these two years for the. potential confounding factors of BMI (r = 94. p = 0001), alcohol consumption (r = 67. p =.0a0ndc0iga1ret)te smoking(r = 84p,= 0001). 03495 Several additional issues are worthy of consideration. i voluntary. Overall participation rates declined from The medical surveillanceprogram approximately 70 percent in 1993 10/50 percent in 1997. Serum PFOA levels could differ between participants and nonparticipants. the epportuniy The for high turnover of employees longitudinal assessment. In between 1995 this regard, we and did 1997 detracted from examine the change in several parameters among example, the average difference the in 68 subjects serum PFOA in common for was + 0.1 ppm 1993 and (Wilcoxin 1995. For signed-rank {est:= test = 540.5, p 500, p = = 0001), the mean change in 0.6) and the mean change ALT was 40.5 in cholesterol IU/L was (Wilcoxin signed-rank -1.6 mg/dL (Wileoxin signed-rank test= -60.0, p = 0.4). The change in serum PFOA levels did not predict, via regression analyses, the change in ALT or cholesterol. Besides the few employees in common across all three years of medical surveillance data (n = 17), another difference t(h1a9t93ocacnurdre1d99i5n) 1t9o97elwecatsrotshperamye(t1h9o9d7)ofhiagnahl-ypseirsfoorfmaPnFcOe Alicquhiadngcehdrofmraotmogtrhaeprhmyosmparsasy spectrometry. Also, the laboratory reference range substantially changed for ALT in 1997 (as can be seen in Table I by examining the lower mean values for ALT in 1997), Finally, the issue remains that the lack of a clinical hepatotoxic effect reported by Gilliland result in and Mandel and ourselves does a subelinical hepatic effect in this not rule out production the possibility population that that we PFOA may have yet to observe. 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WMyeecthha-n1i4,s6m4s3.forTtohxeipcaonlcArepaptlicPhoanrcmogaecnoilc1e4f5fe:c4t2s5-o4f3t6h,e 1p9e9r7.oxisome proliferator 19. FPoarnddtorlanSJ.JS (Peadnsc)reGaatsitcropihnytseisotlinoaglyaanndd LsievcerretDoirsyetaessetsi,ng.Vol(uInm)eSl1e,iWs.eBn.geSraMu,nders 20. VLCooLn.gWnPhe(iceldka)edrTelhDpeSh.iEaxE,oxcp1re9ir9n8ie,mePnpatanagclersema7os7:d1eB-li7so8lo2ofgeyx.oPcraitnheolpoagnycraenadtiDcisteuamosress., R(aIvne)n,GNoew 21. York, 1986, Longnecker pDaS.gesEx4p4e3r-i4m5e8.ntal pancreatic cancer: role of species, sex and diet. Bull Cancer 77:27-37, 1990. 03497 22. SP.ouCrurPrMen.tRkunnogweleRdGg.eBoifrtpaDn,crGeiantgiecllcaRr,ciLnaowgesnoensiTs.iNnatgheelhDa,msWtaelrlacnadveitLs.rSealelvmaanscie 23. o1P0noutprhaenPchMrue.matLaiancwdcsiaosrencaisTen..ogHeenCleagsneicsseoirnn St4,h7eD:1oh5na7nm3es-lt1le5yr8mT7.o,dSe1tl9.e8p1aCnaKr.cinEofgfeecntesoifsch9o:l5e9c7y-s6t0o1k.inin 1988. 24. UflbueolroFc,heSmoirceanlss:onAS,pRreolaicmhinDa.ryHreeapolrtth. stAamtusInodf pHlyagntAwsosrokce4r1s:5e8x4p-o5s8e9d,to1980. 25. lGiiplolpirloatnediFnsD,anMdancdhoellesJtSe.rolS:earusmtupdeyrfolfoucocrouopcattainooniacllacyiedxapnodsehdepmaetni.c enAzmymJes,nd 26. MGielldil1a2n9d:F56D0,-M56a8n,de1l99J6S.. Mortality among employees of a perfluorooctanoic acid 27. pOrlosdeunctGiWo,nGpillanlti.lanJdOFcDc,upBuMreldew3M5:M9.50B-u9r5r4i,s1J9M9,3MandelJS, Mandel JH. An , eepxipdoesmuiroelotogipcerifnlvueosrtoiogcattainonoiocfarciedp.rodJuOctcicveEnhvorMmeodnes40i:n61m4e-n62w2i,th19o9c8c.upational 28. pJeorhfnlsuoonroJoDc,taWnoolatteeraJnTd,pCeorlfaliuzoyroGoEct,anReestuhlwfiolnlatPeA,inNhelusmoannRsMe.rumQuuasnitnigfiicoant-ipoanirof esxptercatcrtoimoentarnydwihtihghaupteormfaotremdanscaemplilqeuipdrecpharroamtaiotno.gr3a3phCyo-mtphearnmyo,spStr.ayPamuals(sMN), 1996. 29. pAenrdfelrusooronocDtJa.nMaoualtveaannadDpEe.rfAlnuaolryotoicctaalnerseupolrftonfaotretihnehdeutmearnmisneatriuomnboyfLC/MS. 30. SAdAvSanIncsetdituBtieo,anInac.l"ytiScaAlSSeUrsveircsesG,uiIdnce.:, ISttahtaisctaic(sN.Y)V,er19s9i7o.n 6. SAS Institute, Inc., 31. Cary (NC),19%. Cattley RC, DeLuca J, Elcombe C, Fenner-Crisp P, Lake BG, Marsman DS, pPearsotxoirsoTmAe,pProolpipfeJrAa.tiRngobcionmspoonuDnEd,s SpcosheweathzeBp,atTouegarwcoiondogeJ,niWcahhialzaWr.d tDoohumans? 32. WReagnkToSxiAc,olPiPsheagrnmaaJcRo.lde2W7e:e4r7-t6h0,A. 1998. Cholecystokinin receptor family. Ann NY 33. Acad Sci 713:49-66. 1994. Gavin CE, Martin NP, Schlosser MJ. Absence of specific CCK-A binding sites on 34 human Gavin CpEa,ncMraealtniocsmkeemJbAr,anWehsi.te Toxicologist J, Schlosser 30:34, 1996. MJ. Species differences in expression 35. oAfxeplasncorneJa,tIincscehoI,leHcayksatnoskoinniRn.-A rPeacnecprteorast.ic Tcaonxciecro:logtihsetr3o6le:o2f32ch1o9l9e7cystokinin? 36. HSecrarnidngJtGoanstMrKo.entAedrroilan19T9E2.:2O7n:9t9h3e-9r9ol8e.ofTocxhiocloelcyAsptpolkiPnhianrimnapcaonlcr1e3a4ti:c18c-a2n5c,er1.995, 37. IPnatlJmePra-nScmrietahtoJl. K1r7a:m1e21S-T13.8S,o1l9o9m5o.n TE. CCK stimulates growth of six human 38. RpaenhcfreeladtiJcF.cavnacnerScoellilngleinWesW.in serum-free medium. The tumor biology RoefggPasetprriindeasnd22c:h3o4le1c:y3s4t9o,ki1n9in9.1. AdyCancerRes 63:295-347. 1994 03498 39. Anderson KE, Potter JD, Mack TM. Pancreatic cancer. (In) Schottenfeld D, UFnriavuemresniityJFPr(eesdss,)NeCawncYoerrk,Ep1i9d9e6m,ipoalgoegsy7a2n5d-7P7r1evention (2TM edition). Oxford 40. KvraenijKlrCaFn,enScHhJe,reVrerE.meuAclteinvaEt,ioSnchoofrce-nKL-,raBsaissJf,rWeqouuetnetrisnepnanRcAr,eavtainc IcearrscelinPo,mvaasnof Syrian 1482, 1h9a9m1s.ters, but is absent in pancreatic mors of rats. Carcinogenesis 12:147- 41. PCaanlcdraesaCt,olKe1m8:1S-E6., K-ras 1995. mutation and pancreatic adenocarcinoma. nt J , ` 03499 Tel CMohn,g edaieShtdSDovmteion 5ooo.fNs)1s0ndFagof Degg, gt, Coletti aloes Sr FOR wm 9s 1 CPoFOmAo ) Mem Mein SO - mm Mew Mew SD me ue wm sD fe US3E0h NBWw eaaom madnnm mwdmTooammm NSomePnoFOA(Bpodpahwm) uotsnw Bohmoeenmm woShhn aoonse aUonkm Aowslsei-onin Fen. 01 Fes, 0 Fe7.0n1 UPedLow B wM oow momom ommnEae Age 5 neo w&ko3n6 pmwaes4o8w 40ow oaomn mzwaew Fien37p- 2 Fae -02p-15 Fine=0z p08 US B h B mme wmas ew3L5 ommaeesnmss Fuiben 17pm. 23a oa Lh Neds 193 a8 BMI (kg/m?) oommmeee mm my n wou [er ---- CCK gaan -- wameasmn: mB bre BmLs380as mnmsemee Fie-opse 47 CFoBmraoocmd28oepmm00o3sSDenmeRes 1993 1995. CoPgFOAp"pm) Mew Mefin SD Rage Mew Madan SD Rage AlkalinePhosphatase(IU/L) L0-a1o 210 nom A "om6 ayasa BoM sem ooww ow B BoB om sweeles 3 sus FVae=07,p 52 FValuc= 14,p=25 1997 Mem Mesma SD Range : m momm on aalime 00 nm on aie Falie=13,p=28 Gar un a 0-alos3 N nm w 210 wm on enemw sta won " BBoooam leeww on aa 3w% asnxon isleea 00% do ses Value 15, p= 20 F Value =09, pe.d1 Fale=02,pe 78 AST(UL) <0-01 2zn 210 u # 2 07 pHieoe % 5163s 2a 2 n 2 n6 anoen 0 4 ase 3 [IY] 3x [ 7 TnEea + niu FValie=11,p=33 FValue 08.p=45 FValue=02,p= 83 ALT(UL) a 02-101oaa6s $a s u0m naaw a vo wae 5" a o pB ea nm s # nr wa BHmoww 300 aosw lneww Bows 2 FValue=02,p=82 & FValue=12, p=30 Flalue=03,p=73 RQaqg 1993 Categdoryoppm)ey" Mei SD tame LUBaOWe owsM mooma Molw mmeemw sei Fahe=02,pe 34 UPhne mm oomm oo m HOE mum asemess als Fale =03,p 77 1995 Man Metin SD Rew LDL (ng) m momw mm oowm aawoen gan Fale 01,pe96 Trigyceides (mg/d) omns ommoo a am om Is ssomm nae Flaie=27,p=07 1997 wen ww 50 mw iom 1om be Gy 8x ow Seuom Ni Fatie=23,p.11 amew logw wm le wweo om aneiwls 80% FYate=21,p513 Stdpopulations SupeSize PFOACary i 0c o3aht by PFOA category(pm) adesc t19m93 52 w19e9s5 e199r7 T "hi T Tw 2is% a T 3I 832 a8S . Table IL. ofPlasma CMuhlotliepclyestRoekgirneisnsiinonWoMrokdeerlsowfiFtahcStoerrsuPmrePdFicOtAingLetvheelNsatural Log Variable Intercept B 3.02 SEB) 048 5 value 0001 PFOA Age 0.008 0.0001 0.004 0.007 07 98 Alcohol BMI -0.005 0.086 0.009 0015 95 53 Cigarettes 0,009 0.007 17 / R= 08 AR = 02 . 03503 Table. MolivariableRegionModels"ofFactorsPredicting HighDensityLipoprocinin Workerswith SumPFOALevels 190 Veale 5 SEB) puke PFmOeAeq 6Ga0 loomw owl ILngahctDiionns' _ 9196203501 080s A[ RS Notreported 1093 Bsn pe sosuw 6o0n a00 aonm 5osm om AGR=E10 JR" BSED) pe So200 omWe wor Sowuzeon awsm Aw=j0a 1997 BSB puke soe ondois oasw S 03% anom owsm AwGReEn03 *hAedjl1u9s9to0edergoegPsaiF,oOcnABmMtxoId,ieigilhrsoeeDrdtinnokstael,aagnadmoneosrpeoanhded1ee3pnekntdesntqvuareisatio(alnslefroercy rence4ar 2n)d.sos) tron evel (1990,1993snd 1995). a 8a88 - 2 Serum PFOA Table IV. Change in HDL" from Light Alcohol Drinker (<1 drink/day) to: 1) a Light Drinker with a 10 ppm Change in Serum PFOA, 2) a Moderate Alcohol Drinker (> 1 drink/day); and 3) a Moderate Alcohol with a 10 ppm Change in Light Drinker with a Moderate Moderate Drinker with a -------------- 10 pm increase in PFOA Drinker 10 ppm increase in PFOA. Year ChangeinHDL(mg/dl) , 1990" 01 99 6.2 1993 13 48 34 1995 -08 5.1 41 woo 17 ss 50 "Determined index cigaret from multivariable models (se te use, and non-respondenttos e table alcoho 3) lq adjusted for age, uestion (all four body years) mass and testosterone (1990, 1993 and 1995 only). * Data in 1990 analyzed for total serum organic fluorine (see reference #25). ` 603505 Table. MolivariabeRegression Model"ofFactors PricingALTinWorkerswithScrum PFOALevels _ 19% 1993 1995 BSED) pe 5 SER pai B_ SEB) pie WBOeAep Bui aSsnk u4es 0os oom nm Imei' --O0802 a__o1_7__WooMos nonm wanm xae e0T o0 T oom wonm 22mg on 00 oomm is l 9 00 om PloRiesa [HiR= 0 A Rea om BSB) puke m wm omm w ooImswe ooomims oonm AwReen "isntedefto=ragPcF,cOaAilcooBoMlnIand iar se.The1990rgssionmodelusdttlnpc Ouia he dependent aisle sereference426) 8 a . a8 Table VI. Change Associated with a in 10 pAlpamniCnheaAnmgienoitnrSaenrsfuemrPasFeO(AALfTo)r *Three Body Mass Indices -- BMG2 ) ey 25 30 35 Year ChangeinALT(IU/L) ! 1990" -3.0 280 59.0 1993 22 09 05 1995 15 01 -12 1997 53 0s a7 "Determined from multivariable regression model (see table 5) adjusted for age, alcohol and cigarette use. " Data in 1990 analyzed total serum organic fluorine. (see reference #26). ` 03507 Scatter Plot of Nautural Log Figure 1 CCK (pg/ml) by Serum PFOA Level (ppm) [Linear Regression Model: Ln CCK = 3.24 - 0.006PFOA, P value of PFOA coefficeint = 0.19; R = 02] J / 03508 13 . re Spt Fghn e EF ' . . | oCee mw w Frontmanw eee , 23509