Document aL6XXmgoDe96NG9mgGyxaqEM

Original Contributions ffA %o>y U0i)4y6-yu93 SHELIA HOAR ZAHM, Sc.D. Occupational Studies Section EnviroNnamtieonntaall CEapnidceemr IinoslotigtuyteBranch Landow Building - 4CJ6, Bethesda, MD 20892 Agricultural Herbicide Use and Risk of Lymphoma and Soft-Tissue Sarcom a Shelia K. Hoar, ScD; Aaron Blair, PhD; Frederick F. Holmes, MD; Cathy D. Boysen; Robert J. Robel, PhD; Robert Hoover, MD; Joseph F. Fraumeni, Jr, MD A population-based case-control study of soft-tissue sarcoma (STS), Hodgkin's disease (HD), and non-Hodgkin's lymphoma (NHL) in Kansas found farm herbicide use to be associated with NHL (odds ratio [OR], 1.6; 95% confidence interval [Cl], 0.9, 2.6). Relative risk of NHL increased significantly with number of days of herbicide exposure per year and latency. Men exposed to herbicides more than 20 days per year had a sixfold increased risk of NHL (OR, 6.0; 95% Ct, 1.9, 19.5) relative to nonfarmers. Frequent users who mixed or applied the herbicides themselves had an OR of 8.0 (95% Cl, 2.3, 27.9) for NHL. Excesses were associated with use of phenoxyacetic acid herbicides, specifically 2,4-dichlorophenoxyacetic acid. Neither STS nor HD was associated with pesticide exposure. This study confirms the reports from Sweden and several US states that NHL is associated with farm herbicide use, especially phenoxyacetic acids. It does not confirm the case-control studies or the cohort studies of pesticide manufacturers and Vietnam veterans linking herbicides to STS or HD. (JAMA 1986^56:1141-1147) ftepHHdcreEhiiirxoevsPodornplekeedIdyofeDseggcosxkhkEelhpaoddiilMcaonfnnoatvsd''rossIntuieOonscrcsloaeeyLihdfxtsprsmleOtisfhou-sd,otpGeergwilonhasdgIredpssoo,Ceirueihsxmsrebkeeteyeesansgant(dcouacHz(oslredwNoasDndtidrtiHetelc)chaiaers,ooLrmseaxeamst)fiica.rnn1oiaaoin"n3sdfatwmdctwFeroeo(heodShxrrSenarkTcerwsoeetdbSaebhnsreili)dyss--l, From the Epidemiology and Bioslatisties Program. National Cancer Institute, Bethesda. Md (O s Hoar, Blair. Hoover, and Fraumeni); the Cancer Data Service, Urwersity ol Kansas Metical Center.Jiansas City (Dr Hofcnes and Ms Boysen); and the Division of B*otogy. Kansas State University. Manhattan (Dr Robel). Reprint requests to Epidemiology and Bbstatisties Program. National Cancer hstitute, landow dC16. Bethesda, MD 20892 (Dr Hoar). beafaacrmearenmoltzinrcoeegfrpusa.or8wca"r1int0dossr.kohTeferhisrnebcrirepceirhadosaedevsud4ec'7SianTlasgSondabpnehedeannmNosoHxenyvLg See also p 1176. prcawtitmrnhriehdosooeatCldtkaoalonseisogdrertnuodniprtfoipcairafccnaeerhncuhloprpetttlnemurosnatfmeurroouhsiarolirneseesctvpegriraweohvdab,lrensainiisccidntsdnipuioevodotsixhsceitenspnaiyecssnrwf,iuatiegoghbcrpmahrleeadmoettiiwpeiliVnclulenescsailrxe,aetabaedpartstcannlricoluopiiniadsmndebnrmduoosysfergloesuuwpec.ftaisaiutnodannheIilnirsnnddpegc,, cuaamttuhofglafeerneeatddnicUlioutctsnsunca-stitebtriefeoidoasdonsrkfsetSo.dhl1oteaefFactrcoltebSaahrsiTsrec.eitSrifh-dy,ceeaosHswnneDdathrrn,oeedalttaehsnixoesndttnrsiusleNeda,csygtHa,ircLipwicaodunaepildnss psctuacbcsMhuhiocthesdaeEeeeebmKeetdntmnsTesiamstco,HnmiatcuxouosnwOaaoysndantcleraalsDyisiydea,csd.,wS1l,e1fstuca(rhaiai2hescnmele,qooc4amduasoen-tecDeuganihnhnjd)2oeett,wlas4rhrry(bbs-2aioDiti,stwchc4fthiihi,chdabd52ehmne-eee,Tl4aesoylo)^ntoir-rn-thocpihhttaaparrhaeidvKothvcireeedoheanpuonnImboeoctasehxsirofalnestooyessinog--rr;t TfasEHs(mcIfps1CroKioaot0nohneoDaaaws0rmAnpdeadmetns,uraeunldpr0deeltaalsel0haasenNa1lRsS0nrttotws9idie)oeuaeedfo7id,eutwrsneCNn6tivrughcno-lbeiKeHaliybhtatntydtiysshaasnlaLe,2)lrntsKdlan0hoeesaianrC0caeudraavCegmceengsagipeeadUgm.srnnohod,neeairconnrescnsgaeEtsgCn2it1ecetirver1pl9esreadyadwei8tdndwDdrry2Ihcysibfenc,,aeaoiie(mybattsgtai3rrcwyeasystrn.ioiet4osemothvoSsS/rluros1aoeeefTeoeaten0rpgoerrlSKdis0nveyo-ifhnidsieo,adrgicKw0pte(gSalneeiad40norhTnrstai,n0.ebhettaneg1nSh)irdydeasr./,,, JAMA. Sept 5. 1986--Voi 256. No. 9 HerCxode Use--Hoar et al 1141 Table 1.-- Soft-Tissue Sarcoma, Hodgkin's Disease, and Non-Hodgkin's Lymphoma in Relation to Duration and Frequency of Herbicide Use Nonfarm ers Farm ers D uration of herbicide use, y 0 1*5 6-15 >16 Unknown X for trend P (one-tailed) Frequency of herbicide use, d /y 0 1-5 6-10 11-20 >21 Unknown X for trend P (one-tailed) No. of C o n tro ta 286 662 470 53 58 57 24 497 102 29 13 12 9 S oft-TlM uo Sarcoma No. o f C*M > O dd* Ratio (95% Confidenca Intarvat) 3 8 1.0 95 1.0 (0.7. 1.6) 7 3 1.1 ( 0 .7 . 1.8) 5 0.7 (0.2, 2.0) 5 0 .7 (0 .2 , 1.9) 11 1.4 (0 .6 , 3 .1 ) 1 0 .1 3 .45 7 4 1.1 (0 .7 , 1.7) 9 0 .6 (0.3, 1.5) 2 0.5 (0.1, 2.3) 5 2.9 (0.6. 9.5) 1 0.8 (0.04, 6.5) 4 0 .0 0 2 .50 Hodgkin`a Dtaaaaa No. of Ci m i O dd* Ratio (95% C onfi dane* tntarval) 6 0 1.0 71 0 .8 (0.5. 1.2) 43 0 .7 (0.5, 1.2) 9 0.9 (0.4, 2.2) 8 0 .6 (0.3, 1.9) 10 1.2 (0.5. 2 .6 ) 1 0.11 .4 6 4 5 0.7 (0 .4 . 1.1) 16 1.0 (0.5, 1.9) 2 0.4 (0 .1 , 1.7) 2 1.3 (0 .2 . 6 .8 ) 3 1.0 (0 .2 , 4 .1 ) 3 -0 .5 6 .29 N on-H odgkin'* Lymphoma No. o f Ci m i O dd* Ratio (95% C on ftdanea Interval) 37 1.0 133 1.4 (0 .9 . 2 .1 ) 93 1.3 (0.6. 2 .1 ) 9 1.3 (0 .6 , 3.1) 12 1.6 ( 0 .7 . 3 .4 ) 16 2 .0 (1 .0 , 4 .0 ) 3 2 .0 6 .02 94 1.3 (0.8, 2.0) 19 1.4 (0 .7 , 2 .6 ) 6 1.6 (0 .5 , 4 .3 ) 5 2.6 (0.8, 6.8) 7 6.0 (1.9. 19.5) 2 3 .3 3 .0004 lSqS(mrncpac1s2So1eaaTnaoTu99aTgsa1sms7P7ldtaSSpiSto%ehe9cina,,epgssootatmct)oa1tylhHnlliwhtenl3ot.ioeeyos1yrD2vdgeron1tliora1earotif,H5uehs1ltngctwy2etSdgo7aeDodysr0.s3inhperenaa0,rdvAeswtfragmeo1acpmiidclnmere9nliNeoeimmowoo8rezcdcnuoew1Hsfnoeieeelne.m1d8nwddnpLwgdt71fhseoribi2a%tenterconfcywhhsmvsoNaroa,seisadrisuHeftH8teoerohtwtbep5sarhDsLhrlg,b%aw,iee..gerinN8tn(,onrhieA721bdHesuale%3%foulimnperLa9orbfdoca)gfaftto.homneianit9wcffinnhrdior0siFnmifotroeetst%nhieehoorenmmrigdeeeers,t ycwin(siutTvttCnno9hreoosoihohog0lgteviTutearnele%neneschlagrbtrtetgeee)cAagirescaaehgoaacdewtdhssrcaegonlepmonshtftenedwurwanidifcrtioqtstrtoanooeeirmbu.orlei-onrye6lssenKlstF5.ttsrtu1rtadphoo4a(argsiNoonlwerbytfeCsepinfs=aleoedeHlaeuon1iarnrancvlnaeee0ragrtgitsnaea0tnre(heiwdlno9c5fgodotie(1ld)hohnlus%eorbpwisst6Cm2yeaeie)e4nohltoa(reiyforMlmaeetdctedeelynnetidmeleaeigedltKeFosrndresaipa.snipt,ia1rn)h-ct4rhsnfwcdauaocrwoaFshirononeraaneneoaaomnrcesl)ddeserlr,,. wwhvcoocotbftoipptt9naslhhhhroiawneafgf2rhalahioee-eeenfldt.tetmodwdSeem3yihositdoneerhne%auTrpreedhenooanefeodidaSs2tKidoiocntlhtuedn1t,htsosiufoeaiafdsehnidew,e.Hosfntentfc.udeetioenPrwhDhdotsohDtmThthtiooahewmdnhissen6iao,hrsrrlsbeeiare4dgeiselwdpteeNceetldwseoereaiawyewrateaHonsmnirscsaaestt(ouadfaaesosetLhiaoIeadbsresseiowntnxcrwxfkf,tehddlnsasctttfScecmidiheraerieellhnolTsotleolaoroulraehogiidupemlsnnSefufnndgfdserbscadnaosaggeett,rka.tjteha,tr.eatd1eeliiicwhtlifensen.9aoFcdiocigaaiofn5dttcenaoduOsncasyl)wortpspnatdes.,rtsaseunNomoreefcnleTnhoadeimmrwrerdtHlcpohovCsyieesrceyeamoaheiofeie,Lscotldolrmf,lnasiahdweiionseenneclswsyetaadbcftferHhtieosrsaemttaideieiioliahneeeetaotfDnielerrhhlnidddensseesrf,, Jywd(npiInnwaehueegntTaxohrreiurenhtenrsaaeepvgogrtrrifw,yaewpobckowwaeh1ctirttiino9nikwcce8,riheonn4nesw.,rtgeasneTlnirsocvyhaeooreenDrvosigdletfenqiohrcvtfuecuceeoiedkornmmuvsngwrti,btietroesaohwoprnosneleesrsrcd,1afio9cifaponsbi8arcaerym2lsdfectat,nltruhareaodtrmennhlpeaeiddes)rr jjTcarpwwsrffaemfmntnaeeeeoaprovaxsanhioccieifpreeeIurnepetttdetuttamnamicsthrhrrtosnsehsterdiatosoeifeotanowscgwuneiabhdvNr(leltrededlIlsscvphstehoe,ndtonsHae,rsriaeroptneceoficebawertciLnasolaaaatgwfnileiledrineeltccrmgi,iroccicvtmdsncdeiaeopiphtodreet9;dowptianeeshasonedwsa5eupnus.ss,thSesnsn%stpnldisaaeo.otiiTod1eoticnrct9pr1auwitnSre,inadn61urn9sa8ldow,6oetose%eg4tn7dioeflovefecdaoo81oA%dsn;ebdes,n2rctoprrslkstthf1,wao,lyaacmrscio9oeeztoo,toiteo4ieddrfienwebhntonawnnr%aes,aeueeeenrtodti,yccadrlrrstttsani1iotohsorshpggio9hcelfofavlefufiisw97fsrsoeprtbHnfae,tro,83-orueheclrKdtcd,bpD%emrmrrihieewo9iiesganta,qaacm.4hlanyhhsfsilsicuaw%tou1itedu1tseieprinineec73ausbaaebaepda)dddhg0e3ssrlssr., hs1ibwrPneo1eieiafp0ruTtosbshogo,sritrhmcuicftctieabodeaidrjrdvetfmerioaeocoariltbnnunspSoagdaeowurtsaenepitetsnixirpcatsvephpimleedeieoclerepotetirislecevsceuannii'dbtdcteeoiejeSeaxdefn.lupcpcSaot1rue'nvu3ssorodu0pcebcfrhpysrpeateslosrhiusrpoeveebrsvsasjis.etwadeifcnoeloatfddnsrs- 1142 JAMA, Sept 5. 1986--Vol 256. No. 9 Herbicide Use--Hoar et al Table 2 .-- Non-HodgWn's Lymphoma in Relation to Herbicide Group H erbicide Group Newer farm ed Ever use* P he no xya cetic acids T ria z in e s Am ides B e n z o ic s C arbam ates T riflu ra tin U ra c ils N o n s p e e ifie d H ierarchical u s e t P henoxyacetic acids U racils; no phenoxyacetic a d d s Triazines; no p henoxyacetic acids or uracils Am ides; no phenoxyacetic acids, uracils, or triazines No. of CMI 37 24 14 a 1 2 3 19 8 24 13 3 O No. of C o n tro ls 286 78 43 22 2 3 2 114 11 70 101 11 1 "Farmers could report more than one group, tFarm ers were assigned to only one g ro u p .' Odds Ratio (95% C onfidence Interval) 1.0 2.2 (1.2, 4.1) 2.5 (1.2. 5.4) 2.9 (1.1. 7.6) 4.0 (0.1, 62.6) 5.6 (0.6. 45.9) 12.5 (1.6, 116.1) 1.3 (0 .7 , 2.5 ) 5 .8 (1.9, 17.2) 2.2 (1.2, 4.1) 1.0 (0.5, 2.1) 2 .2 (0.4, 9.1) unwosryvfacbutrwspwtRreaieitnoenaiiynenomareedgascintndeTssmasclplerstert-tfsdaGkoeteheiodstiiactteiadrseffanehanttadisMssooibiehcsdssrlccdeiimfnyrseheteomteraeje'ocrhdpeyeeuonsetteseafuaidaeeahdsassoalsmcwtsxslttdireseuthlienentheupausldniwaleeddo.ultcnaotrresaetcrsweeiennhseoMaftaradbrpuamimaooovevrsteeyooslorliaudedraesyeionafetwxneslro.msrssttcs1amnlixaoch7eee(e(mhyolpispCathOtnresrlleinsMseinoaupedlmRaerotr)ebrdsmdsrsisnafc)sfuoe,yaa.wot.stfikavcrtlrtraeerFolceAiepehemotpicass.ohorikpser1tlofknoet9arsiilfeetdr1ognndahlold8pcdeoilondgoaMiohrasutLbffindtsechcontmfofregeoiishaacioaoeaamttcepggna.imwcltdeaon9ycinuietptTavnsoeepoo5ntstcrteatehcelnbeo%enoeraiesl'dedcnseys-sslr ywwCrchcOReroealaREiosN,mavtspphsSri0iepsnn.Uoooc5aHgesbrtf,LriptDesvyTf11weedae-,..Snr02folrvyiat)mrwve,(nkw9deaide(5.taoTndh%crpd1aRkr3baoe6ii3l1ntaCrs6ei.gkge24lwel,sn1io.v(i0tc)rt9ds.e.oh75fidnd,N%iNwrt1rioononHi.n6Ctlgoht)sLlr,t,,foea0nrnS0vyr.e.8dmTaia9per,So(lylfw9ad,a2r5ntir.inb1e%mt7dh)ydg1,, HfoeuFrrabrsimcpiedcheifesircbiccriodpes u(swe hoenat,ancoyrno,f stohre cu(nhb3ifutpa7celaefmothaabmy00ucwsNgpOsheiiih.sleeu.hxossasii..feflds3ihvhr4as99raedgoHesiiroRfeestoapmrers,eoeeoutnt6,boeoseorlblnrnloiths,dr(oLb(d.imuegetreriecbac10i.i9eg9espc2eedticef2grinn)Nie5sue5nsewe,thiNiaafaota.x2ih.b(hphrddtc%xth16x%rodg9teHdttssypeo)osieceeaea9p)iipPrae5e.rptjroio,erwsooceLdn4n1howouOngb%eocNhnncsCtfCn6u9tus,srisinpiwsou1oRirait6s2vcuwttoe2slsitlcnstiheas9wrhrn,eannn5,0mioCdeer0hftsiiooescs4dai,ace,rtbsitdcln0itplamthl1cr6rdeydnedisr.etlhcouS,,u.ubseops1.eneeah5snsa.uan6hfrpTsstr1aa9ucsleos,nOdyFdy,eirmTetalteh4asee.dytdSratnc0etiis9n1siRn)ari6xrrlen3hljei.fa,vtfcdsbn.sy,ilet9frygaurr85pptosgi1(piaetr.ew2eamgdebestxPe).eetsheoep9rsrelwi98ro,rh(raiTdytabsoaa.=srya.rtfam9e)wcfmr5ctoaorahesr.,esownhd5.etri1yoeyoeo)nT0dfnit1dftefierse%a9ed.nreuh(etfnoiernw2n.nadeTrhehP6drtnde3agrgeTardsfthnt)huse5rlwanah=petre,rorrhrwa11iuh1e,aCoesyeoaesofsw.OwHhte.9tfrse.0lihqo6lNiifsksfilrt7rxrhbn2osse1t1vr,Rmharh0Doeatutrohe,hcdeie9o9Hr(eoseo10dfccemo0e9eyi,raee75eddmfsfo.4fcirn.wbLnfsd5xyr56ewe75iodhaaobtittn)shbcdi%x,i,oapsas,,be6naneresNercwmatyie.1kcrro.idrrsy(rgcdraia0s1snt9reHntittodusTiibtOiinnOeas.hChbhsht5scneond6olstet42iohoakndddLksRs6eeooieedenof)eleas20tff,,, cmbo0wpu1yeIptNo6puestfphbea9eowemw4abosHe4Ctnetoqtf.eam1m.irttxshtowhcstrreos.eixfe8esi3rahveieexenox0hr5olheun.2rxaHm.eophirncueivpiixarolirr,6is4p;raioeisAes1lrrd)iroaac%eprpgclet,tge,narttporsttS)egsvoerolh,)ibflviko.hLnvhutmoeuhrl9Hlieherk5alsomr1noo,,hnsogan1wol(hoesuuun2oaieescand5efeail.ah9)plsoa1gantdlrceeenco1s1Cr1Da.pnetdesnaullbhl(tlps.e%crstlhru3rst5eaomaanogdylrtiqf.yr).esiu9ssdgetlerteeieetrieedjd8lo5eadlf,h.v,Fr%arcanuiafnegkodsesu,5edae(dssuedarr.dbediobt(erfreeckaascOpntske2gcai(st%pTtnt,beeienOC1rnsusiroTnpaaod.in2ssieeo9happtSernao,7ptsiwx.ngoserpcaioocR1.toonrcCtenteci0Rls.soxdn5cpmpk.0emiTpuoolhihcpobti,aomitftrnrh9k0qtst,krttedCsRe,2icTo%pd;ihda)dlhaeolpi,satehscoiarotnSesacr;tad,wa0kp,e2veu5yarei0sohmoiseelierlomhtfirylielsvea1lnfeM.toe,dncannerytchii2yasas0aesfsns5thyordeeshees.ewdhtpneCs,eoicoooan01t9eotd.eeio.pn)rient,f(iOeudnoswstrdxuoar,7spleasgemnaxhko9.,b;lovdicn.rorlgsnaaeryeowwdns53lsi3,tneand,ryroRimo5gpiniyieeoesrgsganmrr-tv,m;seT,e(w.rca9wsufexom,acNdhthsh30h7%itbveuttnOof4enirnHduaowt5ttonohettihhaahrtv..fo()ioaeswohteclerhiispgw.hidehpHi40ritho9R%bOgeflndoeorlt0noeeseoefDeoniuofharhpiorrsisx,r)oeeeaaeee5wdcfrdneirjhithwi)taw,hlkLngnn,R(ppeooCrmaadeterposhobcnr7irra%,teidOoboeetehheemhbtasapmurtntqdONc,dpa.hea1Conihlcte1drtbwhhy1erfeia4irolrrateo,tcsNtiliRaletp.yud.ranvox2cnreeseehb.hseievcheoR5)lsdr1aeeHiiusryeini3oeis.sOy,uuehs,llfefcanr,,tsdntHstiiber2)el1rfleanasaCwr.mssweolsrukahbwodcftsn.rdeLrsbarreo(ut(ta.;mecyes2i1Rurenenp1ypooer1ree9iLit9shifoillecdctrui2chefns19rbdiaela0ed.sIc,cstptia,irmfcr,rb5ha5nsu1iyoderuas0ironsooet5odenrpunbabtaip;delastweicwaee%c%ie,haetagssederhurtlnydhdn%vn4rbyaccaeealsysoeo(deer0tlscd9oee.dms8dpileheesOh9apevieseoasi3iese2alrlit.rrusuemaosa5esienfamd.an70ylsenesoridr.oodn2esaCef.reencsnpC0islhRtyrCy5xlOts%u3dbpo,ageoeigerxsdd0goenepstrctrenkaaihtgwryl)eAoa)psslnshf,wipcx(isrled(lh.r,Rr,weio,dplwj,Opacets,ueOboo9wm.oiwmnaicotwyauo3tuwtelpepSdhaef0tallcCfvfahisiiFrahios25venlf1t0soteRn.ioernlstsRsmrndt.noroeemetoTnbeiiuet1tcaoehheeea.ry3ee.%r.eleeohorr-eanoeoecxtdeo3ots05dgderdr,s.,dsr)keddsdidl,dddedSroh-erslrsr;f,.,t JAMA. Sept 5. 1986--Vol 256. No. 9 HertsioOe Use--Hoar et al 1 1 4 3 Table 3 .-- N on-H odgkin's Lym phom a in Rotation to Duration. Frequency, and L ate ncy of 2,4-D ichlorophenoxyacetic A d d Use Never farm ed D uration of use, ` y 1-5 6-15 16-25 2 :26 X to r trend P (one-tailed) Frequency of u s e .t d /y 1-2 3-5 6-10 11-20 >21 X fo r trend P (one-tailed) First year o f use$ 1966 or later 1956-1965 1946-1955 Before 1946 X for trend P (one-tailed) No. of Cases 37 3 7 8 6 3 .5 6 0 .0002 6 4 4 4 5 3 .7 3 3 .0001 5 9 8 2 3 .5 6 1 .0 0 0 2 No. of C o n tro ls 286 16 22 15 17 17 16 16 9 6 Odds Ratio (95% Confidence Intervst) 1.0 1.3 (0.3. 5 .1 ) 2.5 (0.9, 6.8) 3.9 (1.4, 10.9) 2.3 (0.7, 6.8) -- 2 .7 (0 .9 , 8 . T) 1.6 (0.4. 5 .7 ) 1.9 (0 .5 . 6.7 ) 3.0 (0,7. 11.8) 7.6 (1.8. 32.3) 21 1.9 (0 .6 , 6 .0 ) 23 2.9 (1.1, 7.2) 24 2.1 (0 .8 . 5 .6 ) 2 6.2 (0.6. 65.3) ` Five controls had missing data. |O ne patient and ten controls had unknown frequency ot exposure. 4First available for use in 1 9 4 2 .' 2Twstl2hunmCaaap(ucttastlcaawtt"piahiaorh9irrr,t.lnuisreidbacothrrno4els1ytliiliyido5eicree,Iairredt)eastbSanutrea-r)t)onenui%bdhhdeecetDhb.nbtz,zurlsnio1isre,s)iiinnywgehiicci1tuzt,.cicglf2,twdcnn3sarctsyne8euoiittawaw,,ti"i,Csenineedhh4srvahiihsdfalssubftuust,c-c2ieeyileeile4meewhtioDtnuc,s(isiobr,erOrphr.cohsrdc4peT3fhee(mcsrboxinu.jeaofeeih0,siR)draerNtaui5pddsntt,sUtgos,uhe.eaec2laceorhb4hseo-toueitixp,Hmsaoerin,Ttsdussfeg,snwloefe4dscebsphmselieenudanwsrLfu,e-nseeeise8oec"txDot(eeryciiotsdrshcuosaulh.nrsaefna2oc2sfer0eii,mhefanbeiafesgesodeq.tvrn)l)ci(6zaeidsdgst,.mivsnpxdi2eou2ueeoaowsspdioxre(serehs,yg,liesna,nskennTtio4(enh4aevMdsNase,oeaca,n9estsco,d-l-us1leureap.ss,ncasal5DydD,aHoe.nbnod,pbstrahe0elocaw"%w(fnnnoesrssosolcsrdetThLrlxwtooeptdktit.e(iptsetyxaerrh("lnyihcrOahnmeiodber9asqoaayisonrrrCbaeScefltocudz25iRnluiparie2ayhlaactclilssalii,ui,%scpaheec)erf,yc,a,n4aaernskikci.riaegznpedmiesp,netstceieisi2ph5lyde1iitehcpslsdsevehsd,3,nc.iiir-a.d,CesIokoy3lnsycae4a)eTeoaenod,irt;.tcch,etd,ltnr"ntnspa,,eeesmog,iihailhrewswo9occexrraaai5aiaTelaaeomaribbmi5sonox0ttnctptc.lriieldnnb1ne0hhehct%s.uarhttnyyiaeootei5r.sidd)dihdihdodeeeesca9-----f.,, T able 4 .-- N on-H odgkin's Lym phom a in Farm ers in R elation to Use o f H erbicides and Insecticides Annual Days o f Use H erbicides 0 1-5 >6 Insecticide use, adjusted for herbicide use In s e c tic id e s 0 1-2 >3 H erbicide use. adjusted for insecticide use Never Used Insecticides No. o f Cases No. of C o n tro ls Odds Ratio* (95% Confi dence Interval) 90 474 1.0 n 5 7 1.1 (0 .5 . 2 .3 ) 6 18 2.1 (0.7, 5.9) Never Used Herbicides .-No. o f Cases No. of C o n tro ls Odds Ratio* (95% Confi dence Interval) 90 474 1.0 2 12 0 .9 (0 .1 , 4 .2 ) 2 9 1.5 (0.2, 8.1) Ever Used Insecticides No. of Cases No. of C o n tro ls Odds Ratio (95% C onfi dence Interval) 4 21 1.1 ( 0 .3 , 3 .5 ) 8 4 3 1.2 (0 .5 , 2 .9 ) 12 35 2 .3 (1 .0 , 4.9) 1.1 (0 ,6 . 2 .2 ) Ever Used Herbicides No. ot Cases No. ot C o n tro ls Odds Ratio* (95% C onfi dence Interval) 17 7 5 1.3 (0 .7 , 2 .4 ) 8 3 0 1.7 (0 .7 , 4 .1 ) 12 4 8 1.7 (0 .8 , 3 .5 ) 1.4 (0 .8 , 2.4 ) *0dds ra to relative to (armera, no herbicide or insecticide use. A djusted fo r Insecticide Uso No. o f Cases No. of C ontrols Odds Ratio (95% Confi dence Interval) 9 4 4 9 5 1.0 19 1 00 1.1 (0 .6 . 2 .1 ) 18 5 3 2.1 (0.9, 4 .9 ) A djusted fo r H erbicide Use No. of Cases No. of C o n tro ls Odds Ratio* (95% C onfi dence Interval) 107 549 1.0 10 4 2 1.2 (0 .5 . 2 .8 ) 14 57 1.4 (0 .6 . 3 .1 ) 1144 JAMA, Sept 5. 1986--Vol 256, No 9 Herb o d e Use--Hoar et at 0eCosNl1aCegthsolsytwasotictvt(oiou..hxnhnpsiurph9rif77leofoaHanohggs-,ofbpeecs5eaR;r,aanmnrvaogNeinhcteueuoj%cL1ninrc4.9eciernciO-ai)sni1.sppsssHmtf151eat,3fciwbeut2aaktliieaiRa,.r%dthcyeIoenLc3l0rilr.ssitCanae2atdrsepoagmnra)es.oeshed8Lsssh)sIsoedfstaCdafte.,eTn(atsas9chadrOasesraaaocrdylwesdch;iealbosd,ailtyc1na(axcstRalsiepwsnuoriffijniia-cotsc0niyptcektrto8tu,eocdsapseui.iehueinso,8loditosrtssddler1erpleahetso,otiaafinetreiexefw5edfteu3bedcawwdtct3eo,i.i2sadc;ryurny2ectey.dl,Tr,bnewmdti7hbliel3ddai4r9Witfnaiio;gahveheaet-)o5vciwiigrb(etfD.thatenearrn%is,reOoirbehergndnolnirtdneietrarhayscytdalegoRoeeuHvvdygeqkhdydhagal)firrnCseit,lui.faooueieedmdeeosnelbiftrzhOnelhsrworf5whrutuiang,yeeaebaneeuidfmewmR5lbseecd(f,r.ndtilc0rmee;pevb,jscaeiba.ytifteF,dhan7DurriehbnOiarhrNy5io9dceoc,cioerecbefaytte.eea5rrRn,ti6ehegoraidqrgn3bsiddcg%d;bca,msntrhu.rdeeeeinoiq3eiekctfw(o9ofeoiaewcxha)Oousfustfsasl5usnasunnieuCpeeerstleni7dte%Rocopcosromaoasitsoiairsl.ddeenhhnseycrse6sf,l,tl scscitbc2it1s1bcwa(tIninhueiii9n.iueio5n5udd7osddesacr5frsIn-d,,eeetnoeneehso%enfseccsuorsw,2i6rtrtwctewupngyleeimaei75Cdacitcsscecphisp51tii)pitLepiotrohcted.o9hdihp.ierc,nmci41enr0yeeNdcloFint9s6siRsc5esdteiinci.et6uaiHhxrna,shdheivat5e2smnositOrrcaaLt,enaeak..ownibrud4lnsbntgofel1yMyehsrees)tetna9i.Oeise.lr,dednrass45yeisrTrykRxicnm64nooNnNlihr.dwnsifedwegeopeteteH1xalatoahtiaxhrd9lhcapctysyfereLtpahoi6rprooeoisne1oso5eewpddsuaogsp,psr5sdnsul,oragieresyta,trssastsd0cahaseryrikfinninorn.egnrysao7owttogvdar1nooetOe(f,i9mta9oi1idaaoeaatfR5iir5iif.hsrnninsdninn55%csasssh,uioess,oNabowmee1eexasfwcnaalccc9cicHpdeCiinantn1itt5attatlosaiilhdLidiLg5ay6ss, dscihitpcHininntiiaeocddrecccTyrisaeerrbdrrusaeetebeirabaacaseieuslsicso.oxedseeedfiefpedAdddi.odhedib4senwusojOunyrssunbroieenvsstelsitchiyts,chmmtadioitdcalIbehuwesnteinceullendssitnrruttegaeeusnhatofceahwtesotet.lthleeohryxiaAdcauedpsOitirsdnaodwRyjtssuneuheusishNsostsecreahfttetHoonmiocfOrdLffiaew,udRhhnnienrieentttrsrrrhhufifeiebbssooieaxcinikkrrlr ttf(suuSpT(felsteshycsava0eIiruh5ia5iouneunixmxinna.nnxealkevh6srd%re5ipeusrTpptrrdpaddeaegimek,eea%ienbipntooalloer.hee)ahsicl.ysyildsisseiwrlsar.e2nb)cittaawnmsruureiusllmi2ttlmtTneacoiyeogdrdereswhfroes)psipoenepfgheoolsered.aweesorobuoe,ioernfmeeptbsvrteerraftsrigpioSxetuueyaattonwtomntuiltaheseahpnsicsttafrusshmiiiedrdeeenubooaectgeoeenmdcNxeerrumiatrosracnnniebeaasrcpmeulsflnHutbmvbnisttxyloiea"iro.rfrsyacniceeapoiteantrrseLiohnsacailidtrercsmaroudyHdyeeenigisea((toadnaNarmeoosrremg4ei5dnoledebfbeineweff1s%l2,sHbwstpodeexiislnayol5o%h.scseelkrxtypwlhLet)ocuaiooftsyasApiiovdstieh)ylinrnbfisnsodaouldser"ertereaapttsjeeshebsuiesngrhiheldnonfpi1ssdesd,udawmieogclaaad.kcicrclt"1riitnfenrnohtnienniteasiebiomasidset(txodco(pitcxtatftoccOcx9eenwawaireetieaipisooom5rtpgdeantRinddserroamvoaisnnn%odtertoemegsod,sasisiiitttwsexrptefictcnrtrruuie1gahihniecnpooowitoausCirnse.dgodohlteotoooakcel3llrleyidghlsns"osesert)ft.tt.t., ctocu9ncw1Fhoo5i0etsudaihln%T5evslsenerteehsrscrgacroiCotserii((leusctnnlsl2Odyeo,s;itf2dvRe-rco1ttoOdaipeo-,rwa2ltmRasset2,hoaitd,ao1ei4lteltr.n1r;op3inbe..oaw9)a9tianm;sct5ati,ief9%endooud56ndnenr8%tsgtsCsffhceua(leoteCwn,rberndmgLoni1tseitrt-echhv2o0pwir,.aldsa8sNlie3t,;hutwi.hHee74aOuhr).ntsL4R.bifoeto)uis,.Rcnnw,ha2iNignad3.aso3idodk7esf; plbsaivlTbaocsfPanalorpneniefeihsdetotrtegrtydSeetewpwevischdrfuriaeittvhieetencfpeuiedtleeiiecosOiyndpsecnreneniwewlbwRdncyihthyiereteatheectisoiesrrhgcogriaeduseladbiaSfnrsrhapadreuesi.nestuncpne1esapriudwMlopu.mdsio8euseaptuaeosfeucsheclrsbtlfneloslnuiiaooyebtjeclcnisetnynxrytiporetcrdhaspsrrlnetNinettyaoyao(s'spshh1dinil.tsHitoen.eDeseudeu6lArgLssner)dahpwtOse.eret,egeteuefthdaRdrrrhodAdbwdwobecer.juliaiegeheabefcrrmfnripcssariineceeedsttnsapuhresaecebegtepongmmiadeneerewtluittbctecnsmthoseoaenuoteetendeinsssrtfr. affNaonoruNdmnnoadfinagnfrrgtaimhcrpemuienlsitgnautisgrcsEaiodlexcexupipsauoetosissooeuufnirrnheeesbshrebodtiwmicdieedenegnosa.trNNdceHoonnnLs- jcsNcprC0dsm(9ue(aohssN1eOeOyue.aml5fni.anfaL8cH0ilafeHlpnn%RtdRdgpa,ie)taobinpcda0,Lshtae,c,L1tkeitce.rrastnt7v.Cty0ieorlr6stlsen,(ty2reeseae5om)ylOssTeg.d.hs,2piuran;3s,pwtiRdhbie2aosr0E;tvas9oeeiseasdt5w,Nri5enezhi5lmrtt)tgao91d,ehea%0taH.oadsi5wOwh0dis.dln19rlecr%0fLtlfeR.a;u,gysfp4Coa1ospigmhcm)r9ugrtls.rlueasa,hoi5u(aatrnipC.vstpCnOdll%resp0iiikkhisScolseff1oRou5,oofieonte0rnusoc,ia(,emtCcenvp0tmOssiafmxs1ic10emrtaulanaprRe,om5r.n5cesimc7towtaeield,eos,r)0(;viyulcdpo.ydOgpufirs.ec1tn9t4fiicattaceN3hdoeR.as,5hioi1thrtrdoe5nktwa%iosde,;ee2Niien)tsiompets(e4i2.9mnustoOHttfnnho.de5ou)Cohtm0iafumasr.csI%Lf;bTtrttLlidmopNrye,jSe9wwuhreeestwdhan5Hu0n0birvuCcaiioawnec%..battooeets85tLhhnldyaeossrrf,,,;, cdcasnDoasdNhtsgwcattwdciaaparpiNoidahsCootituunoinennnshaadiercrunedueseuhfegeHoshthAaeHrdvlatOlrenieCsscrTeaddrlnedynkoedrioeaatttceoestLcqbeensdnlLnkyNhhoeiMrhsisrsrloxhcorcmrieufo2eaKoege,dftbeehe.iicannopiHeiinu.sdoMoa7pssaprxwondeatceoiblOrausenhsswnsf0tdetrStwhgfLyetabreenrEihoibomsie5aiulaoeut,nePwnvtasiioornlyasiby1crars.lhetcNssfn2tyrcs2ets3rkrbnabsmvhm2ineee1noaeu6ie,teookta"Ts3dfee4im4ede9snxemu2bcaedtdtctixjape,t30rb-r7e8nsiincpheteneaxlsdhuieisDrnocsyh%wto2easodredAosctdpsia,ixoehemrueao,pittn,sesgwroxtse3oiiepwstfutlxcaveaa0omfrwsgetnpoanfsiekseseiadeheRlrpn-cenufdcotbwetxgoaeiotttsncicoaoiecstiiidonshhuisde,saduortciodettofwaeofr5t.ehscneitodkane2aturwsstsnltinn.tiursa1dpfhiani4iysnlcicwrttil,rkwtmktsoey2rphashheossemhe.riula1oaeoekaxe.cnfmlnioieopss2eeo2tal.flitctrcslIropesi5xetVig0alrlTvyhstHryslannuioipoillbnobaTprkNlirdcetNcesmpsehmixghdscnalpthifseeieiiehsatvaboyohcenifhogdoaxnucputH2raouttmretoeatisowevosylmneeofttrhdoemldNndhbngnevotelhon,eitioLsfosaxeadreeemyenihggudiarmtloeHslsnsmmodpddreoddiNvte,e,mpbfrcxein.obnaounoeaLpShixsenrD8eteoupyaHggnnceayrss"enthbdhhvaawact1sereneottaseeomadrc0gchNuveemmeLesaxres-Heniiddcteern2yahiiyewurncrteflatc3voHtnoeatodshiia,ibeaoealecu2ioheamroensnttangone-tnea*nloircsaeLihdrteisyollhrne4lsfnesnfgdonssctesfsrr -- VoiJAMA. Sept 5. 1906 256. No. 9 Hedadde Use--Hoar et at 1145 - I- iprnttfgom2mtsnpfofslbpsttecnpsaarntiihcehtaIhpNtaettioo1riiehecotov,ehigeyuxeiinncoucbhovuaacf3ueearmeco5oroocnlneerenleeHctpleudAvmioterstrnseqr,cyda8aysuunsehnngnidln7neeastoibppot2legctylttuntyttLricogon,euu1sascinne,uoeiailsssircny.",,8ic,etos4ohouhftcra2gedlweanoecrtxnti5besmci1i-oawnaniymeueshw,rnasroang-vfyitndatcd2diaa(htaranctnrseehs,s2oalsSuov,eehaeinnaeirclaebpospenoedltipefthclcssyeclltdon.ocsitcheourismsshoaiiusylsxDtmedhdauhmiiaeceeolqprufWnnuamngwnpnripTvtctteasxatitfesdhcnuNgaiferidiuaohabhioadihsosihtntahlsrccaphttabodmeiccitanstynasylustuygiesyHaagolrsehlovecneeae.mte2,gcobee,uvmsaebrbtr3cpmpalhh3rctselrg1esd,Li8hodeoaryetnsrlb4alua4esHuloealo*le2Bs,oewe-as4ec-otisuiioa,lrreei-irlir3lmopn,uwnndcssordcPnDiccip4itannlunpiaqsreabi4dsioponfw4rsugnrciiisimbrho.lsieesteuHs,.1aynbodt0arcuytodny.lesgtkidduNDehidr9cob3eyeacotiedprebhmhsosrv2eA/ftd5nidhiat8ieseexnrnignespehophH,o^oli,lewaosoyones5eial4etoeiluiltzdne1ueearxcwuwmtlcwmliecedne)nhnsg-LesefoonanutrnoehpDsn.iabDshseiaicyeievtnidnrcecne-mi,etamoamomlrdmliojdperineiNpiNieaeoet2fcaedlrwwslxtoosodrthnyur-ts.urnabtlpiprr,cnoiiobHHxii1nth,df.yoenc4ssetnaleioinisanns1eturamwtiiNatmy.tiinnr-fso,tcpToblaoLLnfoctohrhiontcihDror.sfSoonApnmomgieioemcsivtHashdbucmxTooctseuedirxewhirotoucrnieeaeaesitkoilmocalcraeahenhsnLgemtDysenaoumnntpsmaodrfmehemaismcrneeaehthtnnisca,snbnactp,ad,mwidclerecm1lum,rooaeocioouomsescomtctosirreutnicnn9fhtfamnkhfteuchmtxoeerxioeuolainanhrpaoeya4hhoosaoaiatnaiuitnaliosiinsyuarsly.gynxiao6alecsnilkd-3nsa-rey3d-ssofc/te3s2f ocktmiacwcaiolfrpmocsczctclattsbbrcatcnidugdbshoaeaoafiineinwrineiniieifieapbgodlaeeeoymcerbigironedarnanodcnpaoSlsddsksngaaoesslgtvnaselseTnNvtlnneiaietestcllpwotwuegiseeiicecziuotieeceesiisesnmrt.tohegvo,oivrndafrscnHneiiweelrn,nlaesre.aed,truonvfneinaeysfenieasrsoacrdseeetIdnniwnsdhTrLassubgtaod.rnorettlnscinsSdntpnuhsieo(ieeasidtengfdsehNsfthseancatdfes,otiht.gwerhulceiIe.hieadoesoowisslertggbbatssnfHenssiusnnoteevr,niciteeenr,mvIlaupyloduT,nosnhaidxktacleientdsntLehtitsdakopehocirtowfcitheecieonrommpsohdxaiscaohoicingasceeo.fhpfgaelxskad.grregoksnebderepottuuaedtar5guanhelleeFimhryitiinalhwi4ertsdiomcsdimccfutdorlelmho.nfuc8aeetaitnrndieissfy.coeeegasiiciunnodrnncaefgfermsroctpuidrnTdo,sausdveloreeuwii)bneileasir,cv),leTtrtecesbcogrrzyeusnarbhyer5icrsaliiaettiaeoebaycoai,censldncacmhennisseshie5onln-eahayt,s-sucfioocnpd4lnicavc,,ateraitnceceson5edneaeho,reoilfciaottwtotani5lasloefdpaximberfehxdrefaewia*tlnudsinpnoaa5oteobonssnrtnepsergpeainwltn7ssrseidrcdeefleeuaantahyfiolrtuprsecovooidoodoidrtcoicirwlenisnbceissrrwahaocmdeslenarmnoceefflisriftfimtoeddiliusedonaffpeeonthkoysosipxuilsegitaedprciieenbfecknrrthiehudnnrdeetp)becsonesstareiamhsrteeeefic3hoeitvdlwosian.a/hotjleqnaosncs3nocdws2naetrotnueoauo,oterwwa1tddis.y3anuuaeth,osterteiacnutt1lodamorpbfuaoroisnohedse-inalpaeir4noactnododisiostsrayp.snrfe7henssdnTisrefopeehncrs*seineptyprnot,5osrsaoateitttusniptuNohie4fgdsetepigeyhesrituvsororctrwr(wodTsturceewrouascthachihobissoHaee(hoinbannbaeussibnxnitlaanrenahasoategaerismsiaanaeiiedeldotsek-iieyLsslpstsssy,l-ed,ersersslf wlshtmmhpmsrutsstrriaewdbdmccsgtniahuuieetutuaheoxsasuualeiseainuioeagdpfaeavlsrreDrnetrlpstkcpssuldaiudblieeswoytgeoeersseieotniepiestslssisyssoce.erccaedsselcawulishotiisynsfiuoutmioieipefmapreaatifnnpdohratfarfuneledcitapvrnfhiefaouuetiatcpstpndahsof1eootedahrsavluprpttotkorlNoe9rdlnroirriieteieaneyroulormo7trkeubbcrweHarhsbrettb6nfunnseuoreydmuaetstawsie,esedpiLilsshtn5ncsnatttcysiooe9ruoshcuiaiineietd1rkitlexmftfotadruaartdbesbeisc1hhesohspemneoaucepnsseejltra%isNtelaloeoeismemxc,fsuoesosiiotinrpsNanuckupebsH.ttxJitrccoguehpalp3svmethttrssoolty8HiashihnTnraLotilee,lhoasamrcratcTeiriyaitegtsLtuulheeeoscnsacre.ivvaheadnalrhstiidaonuh.e,ineaovneseesntoetSyntssseidohaetdseoihnoIreixwibtseiaca.rocndixrbofgonoent.cyvgaetlnacSfcraofIiecnhtferrnioataholoudcfiWhnTusanideehsUeacsdrldin-rttilcdSheaiddtesterdhihmdocupSahiihcinnteooiteidmioeacemcepcoiimcofdtetfivcelocsunndeseceel,nfefe,rpifeeeatxtenduanraacrfithrtlxxrmarHspcreicgwthdrrseaithseeppeicutcheamcifiwrrnneoehiDkb4datnroinonoasogtttsiiyddnynso2seyesesses-t,tr, AbmlCsLicsBbmNonaeoeiulduacm0uatcatdTWerannha,1rrinpmmhntakeu-feLiCleoggtesneisfaoK,;ecrtPoogsrihswra;.-rnsiAcitEanaSpu,sioanEnlISndhWttd.mPsdu.kg-deys1DMhaed;lewpil1sDrAsyioeusVwsusa0tyl,oriitbr2ronseeaisdpnuS7ertsrsugh,aerluHtbgfasnyBpsstrBjMoech,earourWG.rboeoencmpDa,b;gewtBnpis,seesMrdo;anPNaJtsukrf,ao.mmhatJoaFdenaSeDIentrmaryrdndliiadnioa,eatinrmnbnCznnieLiDnefagndlMatfo.ralLi;aoen,erupvNCeiraVwPandMleagaaian,hira,drienaon.ednntDercMamivPgJ;enen.ibR.ieeDtNrRdayitwpiOfWn,ieEIciycatnKirdcbh.eatinasasohnla,ooWnglatEnogrKlindkdtltPlJauioiraatnrzffasfnhgtHHomooogahecdyesrrr-..t. R eferences 4p5cas6p4s31Sa2n31t1iatic..3:h.h.9c9..aosa2ari::e8eesndl61cnfHC7MHEHnn1tlut86ost1cyi-o;ooroec:-a9oam31etio2llxin-rso8-krsy,sk61d7aeaydA:s:crssm972s1.egdaeshu.6a7h7lroalARpLdael.-cnlc.ennM3hrasRaodrLi3onLsbsc:,mc.,PoeMmaci,ar-sArsraeEDSsic,aocSosdter,oeeolifHaie-vo1lhantkmrniaHs-ex9nlatkes,ntdorn8iadrisofanoda1srstdesolfs,olst;npfrene,1rupedleeoxa:ceslehn6xrInMmphthc1ieJtupdoLnllh:8n,odooss,-losaALrysr6uoetSWaolruB1.ruers:xccoper9i.dneAponneBfh.CrynomBteta:eg-or.ea,sttntraesroui2NosJeB.cdra,JPsl-4heOnscrcu.p,eLChd5o,CeahmetaeJ-naoneteaTmntinsdntncsr,caocIoitopacalecrnapfe:lrlhelittalshrscdcr-:eMl.oehtsnieLt1nS1ml1saoMusos99o9sooulpxdra887iuxfeonbgyyes119tyed-,;-:;; cO1Cra1IHC9S17s811ceou9am32.0e..41ernaosw7.rl.t..ol0cenJtoCcd6Bepoa.u1oNaIc.coBWng.lausn9rrhetomgkouane8crAtrgnaiemdeln1htianyflmson1r:sd-as-1Ro'ecnH9rsbrcr:inh8a1oeJmaustaoKGli23shntlnyFlnndieee27ElePecomgdgeEar09rAnep:nstk.r:,pLeriNC2icD.aFincdvKhn3hF,JlohPameao9',uNsP1rlr,,ma-motm1ogEC2anhCWLr3irl4raWvdloiei2tkya7n1'naelro,Cm.saoD1gAlrEl1sMWiterl9epti9eeLsltfyn$adA8hcvdtito:4natc3aoer,oG;Padda;sla7mpHBs1otenteD2tli1h-rpmedasoe5L8coe,rtmnaR0:;ionw,oVP7fcl3eneoCtr2aOani.ahgnttdl-rotnaars7hihtmSeoo.nlf7ioiLCMoOlnc.UtLl,yDieoespr:esarngOt.geirSrunfsaatimrhooeedcS.ccnoiafnreytFoiomt,i.Czst.-c,rMea1tAtleIie]t9a1ansnsai9l89gslfoso?jitso81aruontni8i1i.lyJnr-er,,:-; S5ectC11dodPDHHtu111ai7xot87fi6e54seooabeco:gmt..a.s..s4neotpatluicgth7entmttMpiGKCWsAreic1esoseioid.ioe-sanapifaordn4aioCsnnCnragtnafew7oknintstsetlPso5aicusoCeiain.AvoJn.nnbt'rlsnsosJhheJdogceg3u-f:saodNC.joerH3rs1ergsPir7ffJ,Sf:rt9acochioSot1e61xucadhtxJArepri3S9telP:agenv1Ne;tm78dwt5aukietrM3iScCtP8nisriooe.4esana:eStdoIa6mstr.9inm.'itpkcsnt9s;icadL2aniu0iptpsdtEnewl1ri-lo,lyvig7ealgA1cinn-tipme0nito2thHsstnisUh0igf-nesoepotoa2.aooso1rnrhl1reav18ccemms:com3ng,akd.om5de1ize1lKucm..99eestRBasleah77tglTa,sbuesnio80rt:ooitpd,;iepsdSni7opmaSoyemrsv3atenosuroae:tko.at4coimlfttioaft0efiorUnfismo,1n-idcrogt1k.Sfrul1iKanr6aacGrSrroe.cBsasaeyeeofels,nn.*uridn1ifn,vdfr2o9eAaaiieitoV7mcxcrcnhnamm0aaea2due?d,;:ll 1146 JAMA. Sept 5. 1986--Vol 256, No. 9 Hert>c*de Use--Hoar el al (B1e9dM.XDEnrBgeeSrlkTmeAlaeTnyI,SLTUISCnticAvjeLmrsiSisteOy FLooTfgWisCAtiaRclEiRf,oergnDrieiaxssoinPorneWsisnJ, 42spl22ao2iled22O112dh32ra1aal2O2mmtn1pEtet2o2ue2,h1nny9e87i9fi69yu725ele4g4n239t2.chax1foos09en.g.8crmar.ian.80r.d-1-8.da2r.ec..n8e.pnxgwannb0edwvils.i0c12duy:,COe3RnZyspcitocaaLSao2sP4iiCieI2;I2ons,pxat.ccFhr2osutnsoht2nJaxiotyraet25iyroehoippiui1ulocbario:ltyoiStMyl-daknfi-sh4os5z.tcI7reepnriykomnkbt2im-nucmargpe7enoi3serarAhMc:rorabmen3cmbw23caoisrre-iert0tnohrRJa2fcdc7aoemaoeigs53oe3sdnaGc-eAoaaoonar,hvs.,nR9ilr05fet0p4nitdEneNSnkt1eienrtfgt,l-brma3c.-hH,i-cc,1aoeIiokp29ltti,3do,oDnee2etEneaTh9eHlJc98werpSrDo4AhmTni.nVdWan7c1odllAi9,cA0ortl4eruooczcooao89tyeo,ops.up,2wS.tsrrWcsholP8rHi-lHnrfyxrp2bhittdAdom1ikHmaJifk1l-noucr,myee:nPadieoeoo9euCpfn.ii1eescsddxeatuSnaaean7irlrrgrp-ha1paearim,i(sltyupcootlrdkd9oloidsolorhn-nleettnerBo.Ac!Pp.g1yke8pinxiehwwrdJdittoisgtpE4nBhbsrRosel.ssrA,Aiyn-seox-cahseal.iDJgAceni.dianaHuCdBesmHocyimrCifnhbJnagmpicnnJmcvpaJOicebor,krgeyno,t,od.epci,meitrmcfarTJJerlai(ltiOGeitoFSJlsassqniMnTngdenRodCiethconyicpuJebrzgNtuaup1CnIa,sanCeesiotaaeiitnoeenes9drafplhaneeDmleplxtnneoe-sMaara8idroyHoptwemtprRp.fcsgvdiErcrcD4ntmioCrrlod-Gahoheseat;aiMcsDWopd9so)SZ4ur.2ccssJaRh,rsDea,e.ptn:iir5eof:ihars,eleeJodrW,eJtoGO4teietd:mtmlaOmadAMoai5haetlecoocnCf:a1lliOi6oOomt-aaclaarnarii-anc9io1t-hAMDctrosfltcnnh1hcnvtmkocg6a9iy8lcriraorudocccduec9ndeei2ptri85iotlaigMcuopoaieculridd8pfenhe,24blmccSbhH5rplarcarhnpiD2exre2i2oaeougti2rltcaaottal8nnpca1eo,iFM2inpwMyhiare2oflnnt7opgton93ialttteure0zhmioto5adcr,iauno8ioxhec7nleert8oort59ytorngetley5iarJiyrdd-ey-rhitf-ht---r-rts-;-l: sS33PIFBpn10ceooavi..rrecuestnPBeselocitrininMesognsBhejaeeeoatdDlcpisiMotecinv,FiConiRosMreTailto,oael,nonfx1lciwJ,9,htoH8yiU3nnEe.HegSapSsilatdtAunhEAedidmxrHypEi:Foof1RolsfN:oeuregccorsAeytuensnl-StHsDcti.oEonhivdopBigoiHrAdrklioeoeiioonmrnrfkb',sisioFAcDlliooyedAragrmecotisiaecr. 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Sept 5. 1986--Vol 256. No. 9 Her&ode Use--Hoar el al 1 1 4 7