STEVEN RAY GREEN AND ASSOCIATES 

NATIONALLY CERTIFIED COURT REPORTERS 

404/733-6070 

THE U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES 

PUBLIC HEALTH SERVICE 

CENTERS FOR DISEASE CONTROL AND PREVENTION 

NATIONAL INSTITUTE FOR OCCUPATIONAL SAFETY AND HEALTH 

convenes 

WORKING GROUP 

ADVISORY BOARD ON 

RADIATION AND WORKER HEALTH 

PROCEDURES REVIEW

 

The verbatim transcript of the Working Group 

Meeting of the Advisory Board on Radiation and 

Worker Health held telephonically, on April 2, 2008. 
2

C O N T E N T S

April 2, 2008 

OPENING REMARKS 6 

DR. CHRISTINE BRANCHE, DFO 

INTRODUCTION BY CHAIR 8 

MS. WANDA MUNN 

PER-9 10 

OVERVIEW OF THE FIRST SET OF 33 PROCEDURES 91 

COURT REPORTER’S CERTIFICATE 100 
3

TRANSCRIPT LEGEND

The following transcript contains quoted material. Such 

material is reproduced as read or spoken. 

In the following transcript: a dash (--) indicates 

an unintentional or purposeful interruption of a 

sentence. An ellipsis (. . .) indicates halting speech 

or an unfinished sentence in dialogue or omission(s) of 

word(s) when reading written material. 

-- (sic) denotes an incorrect usage or pronunciation 

of a word which is transcribed in its original form as 

reported. 

-- (phonetically) indicates a phonetic spelling of 

the word if no confirmation of the correct spelling is 

available. 

-- "uh-huh" represents an affirmative response, and 

"uh-uh" represents a negative response. 

 -- "*" denotes a spelling based on phonetics, 

without reference available. 

-- (inaudible)/ (unintelligible) signifies speaker 

failure, usually failure to use a microphone. 

-- “^” denotes telephonic interruption. 
4

 P A R T I C I P A N T S 

(By Group, in Alphabetical Order) 

DESIGNATED FEDERAL OFFICIAL

BRANCHE, Christine, Ph.D. 

Principal Associate Director 

National Institute for Occupational Safety and Health 

Centers for Disease Control and Prevention 

Washington, D.C.

 

MEMBERSHIP

GIBSON, Michael H. 

President 

Paper, Allied-Industrial, Chemical, and Energy Union 

Local 5-4200 

Miamisburg, Ohio 

GRIFFON, Mark A. 

President 

Creative Pollution Solutions, Inc. 

Salem, New Hampshire 

MUNN, Wanda I. 

Senior Nuclear Engineer (Retired) 

Richland, Washington 

ZIEMER, Paul L., Ph.D. 

Professor Emeritus 

School of Health Sciences 

Purdue University 

Lafayette, Indiana 
5

IDENTIFIED PARTICIPANTS 

BEHLING, HANS, SC&A 

BEHLING, KATHY, SC&A 

ELLIOTT, LARRY, OCAS/NIOSH 

HINNEFELD, STUART, NIOSH 

HOWELL, EMILY, HHS 

MARSCHKE, STEVE, SC&A 

MAURO, JOHN, SC&A 

NETON, JIM, NIOSH 

SIEBERT, SCOTT, ORAU 

THOMAS, ELYSE, ORAU 

ULSH, BRANT, NIOSH 

 
6

1 P R O C E E D I N G S

2 APRIL 2, 2008 

3 (1:00 p.m.) 

4 OPENING REMARKS

5 DR. BRANCHE: I’m Dr. Christine Branche, and 

6 I have the pleasure of being the Designated 

7 Federal Official, as well as the Principal 

8 Associate Director of NIOSH. I’m the 

9 Designated Federal Official for the Advisory 

10 Board on Radiation and Worker Health. And 

11 this is a meeting of the Procedures Working 

12 Group. 

13 If the Advisory Board members could 

14 please announce their names, please. 

15 MS. MUNN: This is Wanda Munn. I’ll chair 

16 this meeting. 

17 DR. ZIEMER: Paul Ziemer. 

18 DR. BRANCHE: Are there any other Board 

19 members? 

20 (no response) 

21 DR. BRANCHE: Well, so far we don’t have a 

22 quorum of the Board so we can continue. Would 

23 the NIOSH staff please identify themselves? 

24 MR. ELLIOTT: This is Larry Elliott, 

25 Director of OCAS, NIOSH. 
7

1 DR. NETON: Jim Neton from NIOSH. 

2 MS. ^: ^ from NIOSH. 

3 MR. HINNEFELD: Stu Hinnefeld from NIOSH. 

4 DR. ULSH: Brant Ulsh from NIOSH. 

5 DR. BRANCHE: Will the ORAU staff please 

6 announce their names? 

7 MR. SIEBERT: Scott Siebert, ORAU team. 

8 MS. THOMAS: Elyse Thomas, ORAU team. 

9 DR. BRANCHE: Would the SC&A staff please 

10 announce their names? 

11 DR. BEHLING: Hans Behling, SC&A. 

12 DR. MAURO: John Mauro, SC&A. 

13 MR. MARSCHKE: Steve Marschke, SC&A. 

14 DR. BRANCHE: Would other federal agency 

15 staff please announce their names? 

16 MS. HOWELL: This is Emily Howell with HHS. 

17 DR. BRANCHE: If there are any petitioners 

18 or their representatives, would you please 

19 mention your names? 

20 (no response) 

21 DR. BRANCHE: Any workers or their 

22 representatives please? 

23 (no response) 

24 DR. BRANCHE: Any members of Congress or 

25 their representatives please? 
8

1 (no response) 

2 DR. BRANCHE: Are there any others on the 

3 line who would like to mention their names? 

4 (no response) 

5 DR. BRANCHE: If we could please acknowledge 

6 telephone etiquette. We are all participating 

7 by telephone so if you would please mute your 

8 lines while our discussion goes on so that the 

9 speaker can be heard by all parties especially 

10 our court reporter. And when you’re ready to 

11 speak you can unmute your line. If you do not 

12 have a mute button, then please use star six 

13 to mute the line. And then when you’re ready 

14 to speak you can use star six again. 

15 One more time for Mark Griffon? 

16 (no response) 

17 DR. BRANCHE: Michael Gibson? 

18 (no response) 

19 DR. BRANCHE: Robert Presley? 

20 (no response) 

21 DR. BRANCHE: Okay, Ms. Munn, it’s all 

22 yours. 

23 INTRODUCTION BY CHAIR

24 MS. MUNN: Thank you. With the concurrence 

25 of those of us who are online, I’d like to 
9

1 propose one mild addition. I think it’s not a 

2 mild one; it’s a big one. When I sent you a 

3 reminder yesterday, I reminded you about the 

4 primary document that we want to attack which 

5 is SC&A’s review of our procedures and 

6 methods, PER number nine. 

7 I also mentioned a quick run down of 

8 the action list, whether we need to do 

9 anything between now and next week. One item 

10 I failed to put on, and that I do want us to 

11 touch upon, I’d like that to be the second 

12 item today, is the draft that Steve Marschke 

13 has provided us of the overview of the summary 

14 results of the first set of those 33 procedure 

15 reviews. 

16 We’ve seen that material before in a 

17 slightly different format, and it does not 

18 appear to me that there will be a very large 

19 amount of discussion here other than I have a 

20 number of comments to make with regard to 

21 format and have not gotten those to either 

22 Steve or to Paul. So I’d like to discuss that 

23 after we’ve attacked PER-9 if that’s agreeable 

24 with everyone here. Am I taking us too far 

25 afield from our primary objective or is that 
10

1 okay? 

2 DR. ZIEMER: Let’s give it a try. 

3 MS. MUNN: Very good. 

4 DR. ZIEMER: That’s Ziemer speaking. 

5 MS. MUNN: Thank you, sir. 

6 DR. BRANCHE: Ms. Munn, this is Christine. 

7 Just one more item. I just want to let you 

8 know that off line I am trying to get in touch 

9 with the remaining Advisory Board members. 

10 MS. MUNN: Excellent, appreciate that. 

11 Thank you. 

12 PER-9

13 Let’s take a look at what Hans has 

14 prepared for us as their review for PER-9. 

15 This is a very heavily technical document 

16 which requires a significant amount of 

17 attention I think for more reasons than one. 

18 I’m sure that NIOSH has had an opportunity to 

19 take a look at this now. 

20 And if it is amenable with you, Larry 

21 and Jim, I’d very much like to get some 

22 reaction from you before we begin our full23 scale discussion on the contents of this 

24 document. I do hope that all of us have had 

25 adequate time to absorb what’s here because 
11

1 it’s going to impact quite obviously a number 

2 of dose reconstructions. 

3 Larry or Jim, do you have some 

4 comments that you’d like to make before we go 

5 further? 

6 MR. ELLIOTT: Ms. Munn, this is Larry 

7 Elliott. I’m going to start off here and turn 

8 it over to Brant Ulsh who is going to carry 

9 most of our water on comments regarding this 

10 review. What I’d like to start with though is 

11 that I want to set the record straight, the 

12 history here a little bit straight. 

13 I’m a little bit concerned that this 

14 review that has been developed by SC&A 

15 portrays or presents the issue of this change 

16 and how we go about assigning a target organ 

17 for lymphoma as being driven or initiated by a 

18 prior SC&A dose reconstruction report review. 

19 And that is, you know, I do appreciate 

20 all the hard work and all the effort that SC&A 

21 puts into their reviews, but the reality and 

22 the facts are that we were well aware of how 

23 we were handling lymphomas and other things 

24 like this. And that started actually with a 

25 NIOSH-sponsored meeting on CLL probably -- I 
12

1 don’t have the timeframe completely down in my 

2 mind. But, okay, well, I do now. 

3 MS. MUNN: It was a number of years ago. 

MR. ELLIOTT: July 21st 4 , 2004, there was a 

5 meeting in D.C. on CLL, and that’s where the 

6 OCAS scientific staff started thinking about 

7 are we assigning the correct organs for 

8 lymphoma dose reconstructions. And so that’s 

9 where we started picking up this line of 

10 inquiry. And certainly the review of the dose 

11 reconstruction case confirmed our efforts and 

12 reinforced our efforts to try to do a better 

13 job for lymphoma claimants. But I just want 

14 to take a little bit of exception here that it 

15 was not SC&A’s review that started us down 

16 this scientific trail of making sure that 

17 we’re giving full advantage in our dose 

18 reconstruction on lymphoma claims. 

19 MS. MUNN: It’s a point well taken. I 

20 notice there was a reference very late in the 

21 report about that early concern over CLL and 

22 the meeting that was held. But -- 

23 MR. ELLIOTT: I don’t mean any disrespect, 

24 Hans, to you or to SC&A. But I just want to 

25 make sure that we’re all clear in our 
13

1 understanding of how this all started off. 

2 DR. BEHLING: And let me just point out if 

3 there was any prior discussion, this was 

4 something that we were not aware of -- 

5 MR. ELLIOTT: That’s absolutely correct. 

6 DR. BEHLING: -- at the time when we 

7 reviewed the first set of cases, and one of 

8 which was a Hodgkin’s lymphoma, this was 

9 something we weren’t aware of. And as I 

10 showed in my Exhibit 1 on page ten of the 

11 report, I guess in 2005 the Board action 

12 number three says SC&A for that particular 

13 case stood fast on the issue of not 

14 necessarily making a change to that. 

15 DR. NETON: I think, Hans, by our current 

16 methodology we probably would do that case the 

17 same way because that’s a Hodgkin’s lymphoma. 

18 DR. BEHLING: Well, it was among the 528 

19 cases that was subject for review. 

20 DR. NETON: That’s what I’m saying. In that 

21 particular response I think our response would 

22 stay the same, that the Hodgkin’s lymphoma 

23 would be defined by the site of diagnosis for 

24 our physician’s examination of the facts. 

25 It’s not inconsistent with what we responded 
14

1 there. But it’s true. We did not go into any 

2 length at the time to talk about our 

3 activities behind the scenes -- 

4 MR. ELLIOTT: We were pre-decisional at that 

5 time. We were doing our own research into 

6 this. Doing our own scientific fact-finding 

7 and trying to arrive at our position. And 

8 you’re correct, Hans. We had not shared that 

9 on the outside, and so you were unaware of 

10 that, and I appreciate that. I just want to 

11 make it clear to folks on this phone call that 

12 we were working this problem back in, late in 

13 2004. 

14 MS. MUNN: And I do remember the 

15 discussions, some of the discussions that took 

16 place. I’m not sure I was present at all of 

17 them, but I recall that having been an issue 

18 that we were well aware of on the Board. 

19 Perhaps this can be resolved by the simple 

20 insertion of a sentence somewhere in the 

21 Executive Summary or near the beginning of the 

22 report to indicate that all of the parties 

23 involved had been concerned about this for a 

24 significant period of time, and that although 

25 SC&A had not been directed to do so and was 
15

1 not aware of the information, NIOSH was 

2 working on it. 

3 MR. ELLIOTT: I think that’s up to SC&A and 

4 how they want to treat the report in that 

5 regard. Let’s put that aside now. I think 

6 Brant and Jim have several other comments that 

7 are more pertinent perhaps to our deliberation 

8 and discussion today and moving us forward. 

9 If we could return to that, I think that would 

10 be beneficial for all. 

11 MS. MUNN: The technical issues appear to be 

12 the tough ones here, and I’m assuming that’s 

13 going to be Brant’s bucket. 

14 DR. ULSH: Yes, it will, Wanda. If it’s the 

15 Board’s pleasure, I’ll start going into the 

16 technical issues here. First of all, let me 

17 acknowledge that I am not a hematologist. I 

18 don’t think anyone on the call is. And for 

19 that reason once those concerns were expressed 

20 to NIOSH, and we started looking into this 

21 issue, I did some preliminary research. And 

22 it quickly became clear that we would need 

23 some hematology expertise. And so we 

24 contracted with Dr. Mark Crowther at McMaster 

25 University. 
16

1 Dr. Crowther’s a very well qualified 

2 hematologist. He has Board certification, a 

3 master’s degree in clinical epidemiology as 

4 well as an M.D. in hematology. And we engaged 

5 Dr. Crowther as a contractor to review our 

6 selection of target organs for lymphoma and 

7 for leukemia. 

8 And we had several conversations with 

9 Dr. Crowther throughout 2004, and it 

10 culminated in his report which Hans has 

11 attached as an attachment to the SC&A report. 

12 At one point I sat down on a phone call with 

13 Dr. Crowther and asked him to give me kind of 

14 an educated layman’s view of this whole issue. 

15 And that might be helpful if I relate that to 

16 you all. 

17 Basically what we’re talking about 

18 when we’re talking about lymphoma, or there’s 

19 a couple of broad categorizations. Mainly, if 

20 you think of the lymphatic system as a system 

21 of, well, a plumbing system, pipes that run 

22 throughout the body. 

23 And lymphomas can be broadly 

24 categorized into two different types. One is 

25 cancers, solid tumors, of the plumbing system 
17

1 itself, the pipes, the cells that make up the 

2 lymphatic system. And those are one category. 

3 The other category is cancers that occur in 

4 the lymphatic system as a result of what flows 

5 through the pipes. Now we’re talking about 

6 circulating lymphocytes. They get trapped out 

7 in particular lymph nodes and develop tumors 

8 where they are trapped out. 

9 Now as Jim mentioned earlier in the 

10 discussion of the case that Hans cited, 

11 Hodgkin’s disease falls into the category of 

12 cells or cancers where the cancer occurs in 

13 the pipes, in the material that makes up the 

14 piping system itself. And so on that basis 

15 Hodgkin’s disease and a couple of other types 

16 of lymphomas, well, there’s a couple of other, 

17 yeah, lymphosarcoma, for instance, and a 

18 couple of others. 

19 Those can be, it can be inferred from 

20 those that the site of original radiation 

21 injury is the site where you see the tumor. 

22 So, for instance, there is a mass of lymph 

23 nodes in the groin area, and if you see a 

24 tumor in the groin area, lymph nodes in the 

25 groin area, you can assume that that’s where 
18

1 the radiation interacted with the cells to 

2 later become a cancer. 

3 Now contrast that with the other type 

4 of lymphomas, and these are primarily non5 Hodgkin’s lymphomas. These are cancers of the 

6 material that flows through the pipes. And so 

7 they’re circulating all through the body, and 

8 the radiation interaction could have occurred 

9 anywhere in the body. And they get trapped 

10 out in a particular lymph node. Now for those 

11 the site where you find the tumor is not 

12 informative about where the original radiation 

13 injury occurred. 

14 And so for those cases we decided, 

15 with the advice of Dr. Crowther, to consider a 

16 claimant favorable estimate. What could be 

17 the highest plausible location that we could 

18 give? And we had originally, I originally -- 

19 because I wrote the first TIB -- went with 

20 LNET, the lymph nodes at the extrathoracic 

21 region. 

22 Now I want to make it clear that these 

23 distinctions are internal dosimetry. They’re 

24 health physics distinctions. They’re not 

25 based on hematology. So when Dr. Crowther 
19

1 reviewed the first version of the TIB, he 

2 said, yes, this was, our report basically 

3 reflected our discussion about these two 

4 different types of lymphomas. 

5 Subsequently, to get an expert health 

6 physics review, we submitted our report to 

7 Keith Eckerman, who is a very well known 

8 internal dosimetrist. And Dr. Eckerman 

9 suggested that we consider the thoracic lymph 

10 nodes instead of the extrathoracic because 

11 they gave a higher dose. And so we made those 

12 changes. But that was not in contradiction to 

13 the advice that Dr. Crowther gave us. Rather, 

14 it was from a different perspective, a health 

15 physics perspective. 

16 But the bottom line is this report as 

17 it exists now has been vetted by, well, I 

18 would say one of the world’s foremost experts 

19 in hematology and also one of the world’s 

20 foremost experts in internal dosimetry. And 

21 both of them have agreed with the way this 

22 report currently stands. 

23 Now I’ll let Hans speak more about 

24 SC&A’s concerns. I don’t want to paraphrase 

25 and perhaps misstate what their concerns are. 
20

1 But it does concern me that the references 

2 that are cited in support of that are a 30 

3 year old hematology textbook. 

4 I mean, there’s a lot of advances as I 

5 think everyone will agree not only in 

6 hematology but in medicine in general. And 

7 the cases that we see today, the ICD codes are 

8 assigned today by the Department of Labor 

9 based on the medical records that come with 

10 the case. And so they reflect, you know to 

11 the best that we can, today’s medical 

12 knowledge. 

13 And so while I certainly appreciate 

14 the difficulty in making ICD diagnoses, that’s 

15 not something that NIOSH does. That’s not our 

16 role. That’s the Department of Labor that 

17 does that. And claimants always have the 

18 option of questioning that and appealing that 

19 to DOL if they feel that the ICD designation 

20 is in error. And frequently, actually, when 

21 we notice that an ICD code might be in error, 

22 we raise it with the Department of Labor. 

23 But in this case I just don’t see that 

24 we can actually agree to SC&A’s 

25 recommendations because they go against the 
21

1 advice of the experts that we’ve consulted. 

2 And quite frankly, the way that we have this 

3 TIB right now, it is extremely claimant 

4 favorable. 

5 And if we were to take SC&A’s advice 

6 and throw in the other types of lymphomas, the 

7 ones that are cancers of the piping system 

8 themselves, and make them the target organ 

9 being the thoracic lymph nodes, it would lead 

10 you to a situation that doesn’t mesh with 

11 reality here. And what I’m talking about here 

12 is Hodgkin’s disease, for example, is, well, 

13 quite frankly, there’s not solid evidence that 

14 it’s even related to radiation now. 

15 Of course, we take the uncertainty 

16 into account and so allow for that possibility 

17 in the risk model. But if we were to assign 

18 thoracic lymph nodes as the target organ for 

19 Hodgkin’s disease, that would make it one of 

20 the most compensable, or probably the most 

21 compensable, cancer in our program. And this 

22 is for a cancer that there is no evidence that 

23 it’s even radiogenic. That is an illogical 

24 outcome. 

25 And, I mean, numerous epidemiological 
22

1 studies have examined Hodgkin’s disease, and 

2 there’s simply not been observed any 

3 relationship that would suggest that we should 

4 pursue this course. So I’m concerned about 

5 that. 

6 MR. ELLIOTT: If I may, as I understand it 

7 there’s a recommendation from SC&A here to 

8 revisit a large number of claims that they 

9 feel is affected by their review comments. 

10 And I think we need to, in Brant’s comments 

11 about that, I want to point out that we don’t 

12 think it’s necessary to revisit those claims. 

13 And we’re worried here that this is going to 

14 cause this report and this particular 

15 comment/recommendation is going to cause 

16 further and more frustration on behalf of 

17 these claimants. 

18 DR. ULSH: To sum it up I think we’ve 

19 faithfully, well, I know that we have 

20 faithfully reproduced or incorporated the 

21 advice from the experts that we consulted in 

22 our TIB. I think the program evaluation, that 

23 report that we conducted in association with 

24 this TIB, accurately reexamined the cases that 

25 were affected, and the outcomes are accurate. 
23

1 So I just don’t see any need to, as Larry 

2 said, go back and revisit these cases yet 

3 again. I’d be happy to -- 

4 MR. ELLIOTT: That’s just kind of the bottom 

5 line of where we’re at. We certainly can get 

6 into the weeds on the technical issues 

7 presented here, but I just want to make sure 

8 that you Board members are aware of our 

9 concern here. 

10 MS. MUNN: Yes, my primary concern in going 

11 through this once I overcame my resistance to 

12 extremely technical language which is 

13 necessary in a review of this kind, was the 

14 suggestion that such a large number of cases 

15 might need to be reviewed. 

16 DR. MAURO: This is John. I’d like to offer 

17 a perspective that may be a little different 

18 than what I heard. And that is we actually 

19 were not able to complete all the different 

20 subtasks that made up this report. Because 

21 the last step in our scope of services was to 

22 select three cases and actually do a ground 

23 truthing, so to speak, related to how, in 

24 fact, the PER was implemented and in light of 

25 the concerns that we raised regarding 
24

1 diagnosis. What really came out of Hans’ 

2 report -- and certainly, Hans, you can step in 

3 here and correct me -- 

4 DR. BEHLING: Yes, I’m waiting my turn here, 

5 John. 

6 DR. MAURO: Yeah, I know, but I just want to 

7 say that I think that we really were looking 

8 for some help in that we believe that if, 

9 given the landscape of the problem, we felt 

10 that there was a potential for incorrect 

11 assignment of ICD codes to particular, for 

12 some cases given the nature of this problem 

13 and given the fact that many of these 

14 diagnoses were performed many years ago. 

15 So given that as a valid perspective 

16 we felt that within the 400 or so cases that 

17 were denied, it would be helpful for us to 

18 complete our work to find a way to identify 

19 those cases within the ones that were denied 

20 to see if it’s possible that some of these 

21 potential missed diagnosis issues were, in 

22 fact, real. 

23 And so the way I understand it, we 

24 were at a point where Hans didn’t recommend 

25 revisiting the cases but recommended a process 
25

1 where perhaps we can select -- we proposed 

2 three in our original work plan -- cases 

3 amongst the ones that were denied that might 

4 be the final proof of principle that, in fact, 

5 the methods that were used to assign ICD codes 

6 to those denied cases are ones that would be 

7 good test cases to see, in fact, if the 

8 potential problem that we identified was real 

9 or perhaps wasn’t for the very reasons that 

10 you just gave, Brant. 

11 So I think that that’s how I saw, the 

12 purpose of this call was to see first of all 

13 if there was a general agreement that the 

14 scope of our work would include doing some 

15 cases, and also, seeking some help and given 

16 the nature of the problem in identifying the 

17 cases that we would look at. 

18 MS. MUNN: And, John, I was under the 

19 impression that this work group would indeed 

20 identify some number of cases for you to 

21 review again. However, my concern at this 

22 juncture is with the process that was 

23 suggested to provide us with a list from which 

24 to make this choice. It’s very difficult for 

25 me to imagine the amount of work that would be 
26

1 necessary for NIOSH to be able to provide a 

2 list of the types that were suggested here. 

3 DR. ZIEMER: Wanda, this is Ziemer. Could I 

4 ask and maybe direct this to John Mauro. 

5 John, are you talking about a 

6 determination of whether the code was assigned 

7 correctly? 

8 DR. MAURO: It’s really related to, as I 

9 understand the problem, the assignment. In 

10 other words in revisiting, in this PER, one of 

11 the things that was done is say let’s revisit 

12 all of these denials. There were 500 or so as 

13 a result of the PER. And in the process of 

14 revisiting it there were assignments made as 

15 to what cancer type each of those 500 or so 

16 cases should be appropriately assigned. Some 

17 of them were assigned to thoracic lymphomas, 

18 cancer of the lymph nodes of the thoracic 

19 region and some for other organs. 

20 And what happens is there was a 

21 sorting process. And as a result of that 

22 sorting process, as I understand, there were a 

23 number of cases where the dose was 

24 reconstructed and there was, and people were 

25 granted where formerly they were denied. Our 
27

1 only concern was that amongst those that were 

2 denied, our argument was that we think that in 

3 making the determination of the proper 

4 assignment -- 

5 MS. MUNN: I’m hearing serious telephone 

6 break up. Is that John? 

7 DR. MAURO: I will speak directly into my 

8 headset. Is that better? 

9 DR. ZIEMER: Yes. 

10 DR. MAURO: Okay, I’m sorry for that. 

11 DR. ZIEMER: There is some background noise 

12 as well. 

13 DR. MAURO: Oh, okay. 

14 MS. MUNN: I’m hearing muddled conversation. 

15 Is it my phone? 

16 DR. ZIEMER: I’m not hearing that. 

17 DR. BRANCHE: I’m not hearing that, Wanda. 

18 MS. MUNN: Now, there’s something going on. 

19 Is it my phone? 

20 DR. BRANCHE: Well, it wasn’t your phone 

21 before, but I just want to let you know that 

22 Michael Gibson has joined the line and Mr. 

23 Griffon will be joining soon. 

24 Those of you who are on the line who 

25 are not speaking if you could please mute your 
28

1 phone, we would appreciate it. If you don’t 

2 have a mute button then please use star six. 

3 And you can use star six again to unmute your 

4 phone when you’re ready to speak. Thank you. 

5 MS. MUNN: I was getting -- 

6 DR. BRANCHE: I’m still hearing something, 

7 but I think it’s just background telephone 

8 noise. I don’t think it’s conversation. 

9 MS. MUNN: All right. I was hearing Larry 

10 fading out badly for me and so was, I think, 

11 Hans was trying to speak. I was getting 

12 nothing but static from what I thought was 

13 Hans. Was I the only person who was getting 

14 that? 

15 DR. ZIEMER: Apparently. 

16 DR. BRANCHE: I heard Hans clearly. 

17 MS. MUNN: Well, then it must be my hotel 

18 phone here. I’ll just try to get by. 

19 MR. GRIFFON: Wanda, it’s Mark Griffon. I 

20 just joined, too, just to let you know. 

21 MS. MUNN: Hi, Mark, good. 

22 MR. GRIFFON: Sorry for being late. 

23 DR. ZIEMER: Wanda, my question was, well, 

24 maybe Larry can help on this, too. The coding 

25 is done by DOL. Is that not correct? 
29

1 MR. ELLIOTT: That is correct. 

2 DR. ZIEMER: To what extent -- and you use 

3 that code, but the dose reconstructor then, in 

4 terms of this issue, if they decide that the -

5 - who decides whether the cancer is in -- I’ll 

6 use Brant’s words -- the plumbing or the 

7 circulating cells? Does the code tell you 

8 that? 

9 DR. ULSH: Dr. Ziemer, if I could answer 

10 that perhaps. This is Brant. The ICD code is 

11 set by the Department of Labor. 

12 DR. ZIEMER: Right. 

13 DR. ULSH: NIOSH has nothing at all to do 

14 with -- 

15 DR. ZIEMER: Right, that’s why I was 

16 concerned about an audit that was going to 

17 look at the assignment of the code because 

18 then we’re auditing DOL. 

19 MR. ELLIOTT: This is Larry Elliott. We do 

20 go back -- when our folks here see something 

21 of question, we go back to the claims examiner 

22 and ask them to revisit that code. I don’t 

23 know how many times we do that. And it may 

24 not be ^. 

25 UNIDENTIFIED SPEAKER: ^ 
30

1 MR. ELLIOTT: No, we don’t make a point of 

2 checking it, but if it, Stu was saying we 

3 don’t make a point of checking that. But when 

4 we do see something that seems untoward to us, 

5 we go back to DOL and ask DOL’s claims 

6 examiner to revisit it with -- I don’t know if 

7 Jeff Kotsch is on the line or not -- but DOL 

8 has a medical person on call or on retainer 

9 that deals with these kind of questions for 

10 them. They look at medical diagnosis or the 

11 medical history information. And they’re the 

12 ones that help us find the ICD-9 codes. 

13 DR. ULSH: But I do want to make it clear 

14 though that this process where we revisited 

15 this issue did not involve seeking changes in 

16 any ICD codes. Rather, it involved what 

17 happens after we get a case with the ICD code 

18 assigned. What do we do? Well, we pick which 

19 target organ is appropriate for that 

20 particular ICD code. And that is what has 

21 changed. 

22 UNIDENTIFIED SPEAKER: As prescribed in TIB23 0012. 

24 DR. ULSH: Right, as prescribed in TIB-0012. 

25 And that was based on our updated 
31

1 understanding of the latest scientific 

2 evidence about what target organs would be 

3 appropriate for which ICD codes. 

4 MS. MUNN: Because those changes were the 

5 ones that were made as a result of both Dr. 

6 Crowther and Dr. Eckerman’s reports, correct? 

7 DR. ULSH: That is correct. 

8 DR. NETON: This is Jim, and that kind of 

9 confused me as to what John Mauro was talking 

10 about in terms of looking at the ICD-9 codes. 

11 DR. MAURO: And I may have been incorrect. 

12 My only reason for stepping in at this point 

13 was I felt that in order for us to finish our 

14 job we did need to pick some cases out of the 

15 400 or so that were denied in the PER process. 

16 And one of the areas that we would 

17 particularly look at would be for that 

18 particular case if, in fact, the correct organ 

19 was selected for dose reconstruction. 

20 I think it’s my understanding that the 

21 protocol that you folks used is fine. The 

22 question really was if the benefit of the 

23 doubt, if there was some uncertainty, we were 

24 going to be looking toward whether or not the 

25 benefit of the doubt was, with regard to what 
32

1 organ was in play, if there was some 

2 uncertainty, I would say a legitimate 

3 uncertainty from a medical perspective on 

4 which organ you would pick. 

5 We would be looking to see if, in 

6 fact, you picked the organ that would give the 

7 highest dose. And so we were going to try to 

8 work with you folks to identify those three 

9 cases, because that’s all we really limited 

10 ourselves to in our scope, that would test 

11 that question. 

12 And at that point I think I’d like to 

13 back down a bit and let Hans speak because I 

14 didn’t want to go too far without, you know, 

15 just let everyone understand I’m looking at it 

16 from the point of view as being able to 

17 complete an assignment. And we’re looking for 

18 some help regarding completion of that 

19 assignment in light of the work that we have 

20 completed so far. 

21 MS. MUNN: Let’s do by all means hear Hans’ 

22 comments here, but please very strongly Board 

23 members keep in mind the comment that Dr. 

24 Ziemer made earlier in case you weren’t on 

25 line yet. He expressed a concern that is a 
33

1 strong concern of mine, if the code number is 

2 assigned by Labor and not by us, then the 

3 question arises whether or not we have any 

4 legitimate reason to be questioning their 

5 codes other than the kind of question that’s 

6 been returned to them in many cases by NIOSH 

7 when they had some question arise. Whether 

8 this particular audit should be addressing 

9 that issue is a real concern, I think, in 

10 terms of how the program’s going to be 

11 administered. 

12 With that in mind, I’m sorry. Go 

13 ahead, Hans. 

14 DR. BEHLING: Yeah, let me back up and start 

15 at the end where John started to point the 

16 issue to the selection of cases. What we were 

17 hoping to do is if we’re going to audit any 

18 dose reconstructions that have been completed, 

19 it should be one, the selection probably 

20 should be one that focuses on the best cases. 

21 Obviously, at this point there are 348 cases 

22 that have been denied as a result of the PER23 9. And some cases were, obviously, it’s a no24 brainer for them to be rejected for any number 

25 of reasons. 
34

1 So what I had hoped to do is to 

2 perhaps engage NIOSH in looking at the table 

3 that I included at the end where we would have 

4 some understanding of which, what these cases 

5 really represent with respect to, for 

6 instance, whether or not the original dose 

7 reconstruction was based on a best estimate as 

8 opposed to a maximized. The issue of what if 

9 the original POC with the target organ that 

10 was, in fact, now used to reassess it under 

11 PER-9 specifically for the internal target 

12 organ. 

13 There were issues -- let’s see here -- 

14 a number of other issues that are very 

15 important in selecting those cases that may 

16 very well prove to be the ones where we would 

17 want to look at it very carefully in saying 

18 was this reevaluation done properly including 

19 the new POC. And also an issue we haven’t 

20 discussed -- I’ll talk about it in a few 

21 minutes -- the issue of smoking as a variable 

22 that has not been addressed and so forth. 

23 So we were hoping that perhaps NIOSH 

24 without a whole lot of effort would be in a 

25 position to provide us with that matrix of 348 
35

1 cases that have been denied under PER-9 review 

2 and provide us with certain parameters that 

3 would give us a best chance of selecting only 

4 those DRs -- and I think we’re only talking 

5 about three -- that might best be able to 

6 answer whether or not the PER-9 did what it 

7 was intended to do. 

8 MR. HINNEFELD: This is Stu Hinnefeld, and I 

9 don’t think there’ll be -- well, I’m a little 

10 concerned that it will be a lot of work to 

11 develop this table from all of the potential 

12 cases. And the potential cases, in my view 

13 it’s going to be 260. And the reason I say 

14 that, I say that is that a number of these 

15 claims that we did the reanalysis indicated 

16 the compensability is still below 50 percent. 

17 A lot of those cases have been 

18 returned to us by the Department of Labor 

19 anyway. When they provided our analysis of 

20 the, essentially, the new dose reconstruction 

21 was entirely, dose reconstruction report, they 

22 provided that to the claimants, and the 

23 claimants raised some objection because now 

24 they didn’t have a dose reconstruction that 

25 reflected their case. So the Department of 
36

1 Labor returned those to us to do a dose 

2 reconstruction. So in a sense it mirrors that 

3 evaluation was done. 

4 So I guess about eight of those have 

5 been returned for that reason and would not 

6 have been re-adjudicated yet. And since 

7 they’re not adjudicated, I believe what the 

8 rules are, is we don’t, the Board doesn’t 

9 review cases that are not completely 

10 adjudicated. So the population’s going to be 

11 I think 260 rather than 348. 

12 Now having said that, most of these 

13 pieces of information are data based, and 

14 therefore, can just be written onto a table 

15 with very little effort, the ICD-9 code, and 

16 because of that, the target organ can be 

17 generated automatically. The POC, certainly, 

18 the new one is available. The original one is 

19 available. It just may take a second look 

20 because application has a couple of versions 

21 before the latest version. We’d have to make 

22 sure we got the one we’re interested in. 

23 Cancer diagnosis here is data based. 

24 Smoking history is data based if we have it. 

25 On a lymphoma case we won’t necessarily have 
37

1 it. And so I would also suggest in the 

2 smoking history column rather than just say 

3 yes or no, we would say, yes, we have a 

4 history or, no, we don’t know whether the 

5 person was a smoker. 

6 MR. ELLIOTT: We’re not required to get a 

7 smoking history on anything other than lung 

8 cancer. 

9 MR. HINNEFELD: That’s why we don’t have it. 

10 So there may be some that have for some reason 

11 we got it or for some reason, maybe they also 

12 have a lung cancer we might have it. 

13 MR. ELLIOTT: There may be something in the 

14 medical file. 

15 MR. HINNEFELD: But it won’t be data based. 

16 So what I’m talking about is what is data 

17 based. And so we are not likely to have a 

18 smoking history to know one way or the other 

19 whether the person smoked. We can put that 

20 column down there and say either we don’t know 

21 or we do have a history, and this is what it 

22 said, and there are about four categories that 

23 could be there. So we can do those things 

24 relatively easily. 

25 But when you start to identify the DR 
38

1 method, that you’d have to look at the dose 

2 reconstruction to determine. And for the, so 

3 that would be two dose reconstructions to look 

4 at, both the one before the PER evaluation and 

5 the one that was used in the PER evaluation. 

6 And then the exposure to alpha emitters 

7 similarly. You have to look at the dose 

8 reconstruction report to know that. 

9 So for that reason that’s a lot of 

10 work to do for 260 cases. And so I was 

11 hopeful that we might be able to get by with a 

12 selection of, if you’re only going to two, 

13 maybe 20 or 30 of these cases and prepare that 

14 table for 20 or 30 of the cases to select 

15 from. 

16 DR. BEHLING: That would be fine. As I 

17 said, I just don’t want to have an audit of a 

18 lymphoma case that within seconds of looking 

19 at it you realize why it was rejected. 

20 MS. MUNN: This is Wanda. I have already 

21 expressed my concern about the amount of 

22 effort that would be necessary to generate the 

23 kind of table that was suggested here and the 

24 kind of information. The other, one other 

25 topic that’s been touched on is the smoking 
39

1 issue. And this is, I think, a thorny one and 

2 an appropriate place for us to talk about it. 

3 It’s been understood, I think, by all 

4 concerned that smoking or non-smoking is not 

5 what we’re looking at in this program. Only 

6 recently has a lung issue been factored into 

7 it. But there is a real question as to 

8 whether or not we are appropriately expected 

9 to go there. Am I incorrect in my 

10 understanding that the smoking issue is a 

11 problematic issue that Labor has to address 

12 and not one that we, as the Radiation Advisory 

13 Board is addressing? 

14 DR. ZIEMER: This is Ziemer. I think -- and 

15 Larry kind of referred to this already -- 

16 since that information is not generally 

17 available for these cases, I mean, it could be 

18 inadvertently in a sense, as Stu suggested, 

19 but in most cases I don’t think we have the 

20 information. So I don’t see how we would be 

21 in a position to address that variable in this 

22 particular case even though it may be, you 

23 know, Hans has raised certain concerns there. 

24 But it’s sort of one of those issues not 

25 unlike some chemical issues that as important 
40

1 as they may be, actually fall outside of our, 

2 either our jurisdiction or our authorization 

3 to address. 

4 MS. MUNN: It has always been my 

5 understanding from the outset that our charter 

6 was specifically radiation, and we are -- 

7 DR. ZIEMER: Smoking was considered for lung 

8 cases. 

9 MS. MUNN: -- yes. We all understand that, 

10 of course, smoking affects what happens with 

11 radiation. We recognize that. But it’s 

12 always been very clear to me that that’s 

13 outside our specific charter. 

14 MR. ELLIOTT: This is Larry Elliott. I’d 

15 really like to comment here. The only other 

16 risk factors that we are asked to examine 

17 under this law -- if you look at the law, this 

18 is where it comes from -- is smoking with 

19 regard to lung cancer and ^ with regard to 

20 skin cancer. And we have not identified, nor 

21 has the law identified, any other risk factors 

22 that should come into play. 

23 I think we need to have a discussion 

24 about the comments, the review comments from 

25 Hans, on smoking. I think Jim’s prepared to 
41

1 do that later. But I think the first order of 

2 business here is to continue on. Stu was very 

3 clear on our desire to accommodate SC&A’s 

4 review of specific cases and how we can go 

5 about that. We certainly can do it. 

6 But I think I’d like to turn it over 

7 to Jim and have Jim speak about whether or not 

8 he sees merit behind doing that because really 

9 what we’re talking about here I think from 

10 SC&A’s review is a question are we using the 

11 right target organs. 

12 DR. BEHLING: Well, no, it goes beyond that, 

13 Larry. Let me finish, and I guess I feel like 

14 I’m being cut off again. I just started 

15 actually discussing things and talking about 

16 the back end of the selection process for the 

17 audits. 

18 But the issue of smoking is very 

19 different for lung cancer as opposed to the 

20 lymph nodes. In the case of lung cancer the 

21 issue of smoking only affects the POC 

22 calculation in the denominator meaning that 

23 people who smoke have a higher natural 

24 incidence of lung cancer. 

25 In this case the issue of the 
42

1 disruption of the mucociliary escalator, which 

2 normally clears, is being compensated by -- 

3 and if you read the very short, brief 

4 discussion I enclosed in the last section, 

5 six, the ICRP-66 publication notes that among 

6 smokers versus non-smokers, you have 14-fold 

7 increase in albumin macrophages, five billion 

8 versus 70 billion. 

9 What that really translates to is a 

10 much higher transfer of radioactivity into the 

11 regional lymph nodes meaning that you can 

12 certainly be sure that this affects the 

13 radiation dose as opposed to the incidence of 

14 cancer that results from smoking. The two are 

15 very, very different mechanisms. One only 

16 affects the POC equation. The other one has a 

17 direct impact on the amount of radioactivity 

18 that’s being transferred from the lung into 

19 the thoracic or extrathoracic lymph nodes and 

20 thereby increases the actual radiation dose to 

21 those tissues. 

22 So we have to be very careful about 

23 understanding the difference in terms of 

24 assessing the smoking issue for cases 

25 involving lymphomas versus lung cancer. And 
43

1 it’s very important to make that distinction. 

2 MS. MUNN: That was very interesting 

3 information, Hans, frankly, rather shocking to 

4 a lay person. 

5 DR. BEHLING: I would like to continue if I 

6 could. 

7 DR. NETON: I would like to address that a 

8 little bit though, Hans. This is Jim. I 

9 think what you raised is a scientific fact, 

10 but there is no model that could be applied to 

11 make this adjustment even if it were true. 

12 DR. BEHLING: Well, you can look at the 

13 mathematics, Jim, one or five micron particles 

14 are removed expeditiously by way of other 

15 mechanisms such as absorption, but if it’s an 

16 enzyme material that goes out. And if you 

17 have an impaired mucociliary transport 

18 mechanism that ultimately clears it into the 

19 EP-2 region and then from there into the 

20 gastrointestinal, you can look at it 

21 mathematically and say what is the potential 

22 impact if this is now cleared by the way of -- 

23 DR. NETON: I think we’re committed to using 

24 the best science available, and I’m not aware 

25 of any good science that’s peer reviewed out 
44

1 there that we could use to make this 

2 correction. But let me add to that. I think 

3 that you need to look at the total picture 

4 here involving the lymph nodes as well. It is 

5 well known that cigarette smoking also causes 

6 an increased inhalation of natural 

7 radioactivity. 

8 I have personally measured this in the 

9 laboratory for Thorium-230, -232 and -228. 

10 There is a considerable amount of additional 

11 intake that occurs there. So I would 

12 challenge your assertion that smoking does not 

13 affect the denominator in the calculation. It 

14 does. And, in fact, Polonium-210 is even more 

15 widely known as a natural constituent of 

16 cigarette smoke. So you have a natural 

17 increase of radioactivity that should 

18 contribute to the denominator where we’re 

19 going to look at the scientific picture in 

20 total. 

21 Secondly, if you’ve done like I have 

22 done and looked at lymph nodes of cigarette 

23 smokers versus non-smokers, they are much 

24 larger because of the collection of the inner 

25 mass of the material that’s in the cigarette 
45

1 smoke. That mass by making the lymph nodes 

2 larger tends to diminish the dose and the dose 

3 to the organ from the amount of radioactivity 

4 in there goes down considerably. So you have 

5 to look at that whole picture. It’s not just 

6 a one-sided analysis. And I’m not sure any of 

7 those factors could be modeled appropriately 

8 to be sufficiently accurate. 

9 DR. BEHLING: Not to belabor this issue, but 

10 when you increase the lymph nodes in size, you 

11 also increase the number of cells at risk so 

12 they cancel each other out. 

13 DR. NETON: No, it’s mass, it’s 

14 transformations per unit mass, Hans. Energy 

15 per unit mass deposit in -- 

16 DR. BEHLING: I realize that, but when you 

17 have three times the number of cells, you have 

18 three times the number of cells at risk. And 

19 I know the dose would -- 

20 DR. NETON: Well, this brings me to another 

21 issue, Hans. Let’s talking (sic) about the 

22 lymph node model itself. We are assigning a 

23 dose to the lymph nodes as if it was entirely, 

24 the entire lymph system. As you well know, 

25 the radiation risk model developed from the 
46

1 Hiroshima-Nagasaki survivors is based on a 

2 uniform whole-body exposure. 

3 We are treating our intakes as if that 

4 same amount of material in the 

5 tracheobronchial lymph nodes irradiates the 

6 entire lymph system. That by its very nature 

7 is an extreme over-exaggeration of the dose to 

8 the lymph system. So we feel this is an 

9 extremely claimant favorable analysis to begin 

10 with. To do it properly one should take and 

11 take the weighted dose to the lymph system 

12 over the entire lymph system and not just that 

13 one little piece. 

14 DR. BEHLING: That’s another issue for 

15 discussion -- 

16 DR. NETON: Well, again, one has to look at 

17 the total picture, Hans, not just a one-sided, 

18 scientific review. 

19 DR. MAURO: Jim, I think that what I’m 

20 hearing is that we’re dealing with a 

21 multifaceted problem, scientific problem, in 

22 terms of how do you come to grips with this 

23 situation. And the only reason why I would 

24 say that it requires the attention is we’re 

25 talking about differences in -- for example, 
47

1 in the simpler sense depending on the organ -- 

2 let’s just put the smoking issue on the bench 

3 for a second. 

4 Depending on the organ that was 

5 selected for doing the dose calculations, my 

6 understanding is that the difference in the 

7 dose, that reasonable people may come to 

8 different conclusions regarding what was the 

9 organ of concern in this diagnosis. And one 

10 choice would result in a dose that is several 

11 orders of magnitude, maybe three orders of 

12 magnitude as I understand, higher than the 

13 other organ. So if there is, so we’re talking 

14 about a scale of things. 

15 So if, in fact, Hans’ concerns that 

16 there might be some ambiguity in selection of 

17 the proper organ and that reasonable people 

18 could differ on what the correct one is, and 

19 if judgments have been made in the process you 

20 just went through which perhaps did not always 

21 give the benefit of the doubt, we are talking 

22 about difference in doses to the organ of 

23 concern that could be on the order of a 

24 thousand or more. 

25 DR. NETON: John, let me stop you right 
48

1 there because I’ve got a question. We’re kind 

2 of talking about two separate things here. 

3 One is the organ of concern. And the organ 

4 that is reconstructed is clearly tied in our 

5 TIB-0012 to the ICD-9 code provided by the 

6 Department of Labor. So we have no choice in 

7 that number. With the ICD-9 codes provided to 

8 us is what we use, and we have a look-up 

9 table. 

10 There is no room for judgment on the 

11 part of the health physicist. If he sees an 

12 ICD-9 code of something-something-something13 dot-X, he’ll go to the table and apply the 

14 dose reconstruction to that organ. So there’s 

15 no judgment involved here at all on the part 

16 of NIOSH. 

17 Now, Hans has raised a bigger issue I 

18 think -- 

19 DR. BEHLING: Well, I would like to be able 

20 to make some comments here, and I’m constantly 

21 being cut off. And I’m not sure there’s any 

22 point in my continuing on this if I’m not 

23 given a chance to even comment. 

24 DR. MAURO: Hans, please go forward because 

25 I’ve been jumping in -- 
49

1 DR. BEHLING: I’ve been told to get quiet. 

2 DR. MAURO: Please, go ahead, continue, 

3 please. 

4 MS. MUNN: We definitely need to hear what 

5 you have to say, Hans. 

6 DR. BEHLING: I’m trying very hard here. 

7 Anyway, let me go back to a few things 

8 that were mentioned earlier. When we talk 

9 about Hodgkin’s disease I concur with some of 

10 the original statements that were made. 

11 Hodgkin’s disease is a very easily definable 

12 form of lymphoma, and it’s something that can 

13 be done with an ordinary light microscope 

14 because the histopathologist who looks at a 

15 biopsy will look at it and identify what’s 

16 called the Reed-Sternberg cell. 

17 It’s a very large cell. It has a 

18 morphology that is readily recognized by even 

19 a very novice-type person; and therefore, the 

20 diagnosis is one that is without question one 

21 that you can rely on. On the other hand the 

22 issue that even involved Hodgkin’s disease is 

23 one of which lymph node was identified for 

24 biopsy. 

25 And now we’re talking about what is 
50

1 the stage. If you have a Stage I Hodgkin’s 

2 lymphoma, then that means there’s only one 

3 tissue or one location by which that neoplasm 

4 exists. And so if you biopsy that, then it’s 

5 true, then the tissue where you biopsy the 

6 tumor is also the location at which the 

7 transformation, the original transformation, 

8 took place. 

9 On the other hand we all know that 

10 when you have most incidences lymphomas, if 

11 you read through the medical text, it usually 

12 is not something that is diagnosed at a Stage 

13 I level meaning that you will have Stage II, 

14 III and IV. At which point the biopsy may 

15 very well represent a location that is not the 

16 primary neoplasm but a secondary neoplasm. 

17 And therefore, the biopsy, the anatomical 

18 location for that biopsy has very little in 

19 telling you where that original transformation 

20 takes place. That’s for Hodgkin’s. 

21 When we talk about non-Hodgkin’s 

22 lymphoma the issue becomes even murkier 

23 because now we’re talking about a host of 

24 different cell lines from which that neoplasm 

25 was derived. And therein lies the problem in 
51

1 making a very definitive diagnosis. And what 

2 I tried to tell you is in my review, is that 

3 the ability to identify the cell line of 

4 origin has been a problem throughout the 

5 history of treating lymphomas. And it’s due 

6 to the fact that when you talk about non7 Hodgkin’s lymphoma, the cell lines are 

8 extremely difficult, and they change with 

9 time. 

10 If you read the statements that I 

11 extracted directly from my medical text -- 

12 it’s true. It’s 1979 -- but I also want to 

13 point out to you that many of these lymphomas 

14 I’m sure among the 500 and some odd were 

15 probably diagnosed prior to the introduction 

16 of the ICD-9 codes which now leaves you with a 

17 big open-ended question is how do you 

18 translate those particular medical records 

19 into a contemporary ICD-9 code. 

20 And if you look even at Dr. Crowther’s 

21 comments, there’s a very brief, one-and-a-half 

22 page consultant report. He had some serious 

23 questions about that ability, and how do we go 

24 about making a diagnosis at this late in the 

25 day or in the year 2007 and assign an ICD-9 
52

1 code from records that may be 30, 40 years old 

2 and at a time when many of these definitive 

3 methods that are currently in use, and most of 

4 these are immunological. 

5 They look at cell receptors for the SC 

6 component that was set formation and other 

7 things that didn’t exist until, in some 

8 instances, only very recently. So you have a 

9 very difficult time in looking at medical 

10 records, especially older ones, and somehow or 

11 other pigeonholing that particular cancer and 

12 saying we can assign with a reasonable degree 

13 of certainty an ICD-9 code. And on the basis 

14 of which we then assign an internal and 

15 external target organ. And that is the sum 

16 total of this whole report. 

17 DR. ZIEMER: Could I comment? 

18 DR. BEHLING: Yes. 

19 (no response) 

20 DR. BRANCHE: Hello? 

21 DR. ZIEMER: This is Ziemer. I couldn’t 

22 tell whether my mute is on or off. 

23 I appreciate those comments. I just, 

24 it seems to me that, Hans, you’re addressing 

25 an issue that’s a DOL issue it seems to me. 
53

1 Am I -- 

2 DR. BEHLING: Well, if it is, Paul, then I 

3 guess this whole discussion has very little 

4 purpose. I just brought it up from a purely 

5 scientific -- 

6 DR. ZIEMER: Yeah, I understand the point 

7 that you made, Hans. The concern I have is 

8 that assignment is made prior to us getting 

9 any, getting the case as far as I know. And I 

10 don’t think we’re in the position, unless 

11 Larry says that as they look at a case if 

12 something looks fishy, they can send it back, 

13 but maybe Larry would comment further. But my 

14 understanding is that we’re not assigning 

15 those codes and are not typically auditing 

16 them. 

17 MR. ELLIOTT: You are correct in everything 

18 you said there, Dr. Ziemer. It is a DOL 

19 issue. 

20 DR. ZIEMER: The concern is a valid concern 

21 but not one that we’re in a position to 

22 address I think. 

23 MR. ELLIOTT: You say you’re not in the 

24 position to address. We can only address it 

25 when we think there’s something that DOL 
54

1 should re-look at. And we don’t look at, we 

2 don’t examine them to that level of detail 

3 because we accept the, what’s called the -- 

4 what do they call this now? The statement of 

5 facts, the statement of accepted facts 

6 associated with the claim. And it is not our 

7 responsibility. It’s DOL’s responsibility to 

8 provide those to us. 

9 DR. ZIEMER: But then the issue is given 

10 that we have a code, is the follow-on question 

11 then are we using the right target organ? 

12 What is the next issue either Hans or John? 

13 What’s the follow-on point? 

14 Let’s assume for the moment that the 

15 code was correct. I mean, certainly some of 

16 them are, but what’s the follow-on issue from 

17 our end? 

18 DR. BEHLING: It has repeatedly been told by 

19 both Jim Neton and Larry and Brant, we don’t, 

20 NIOSH does not select the ICD-9 code. That’s 

21 handed to us. And the ICD-9 code is very 

22 specific if you look at it. It identifies an 

23 internal target organ and external. And if at 

24 this point we have no authority over DOL, this 

25 whole discussion as it is basically an 
55

1 exercise, an academic exercise that has little 

2 or no value if they can’t change the DOL. 

3 DR. MAURO: Except, would you agree, the 

4 smoking issue then? In other words it sounds 

5 like we’re talking about two different issues. 

6 One dealing with is the right diagnosis to the 

7 organ of concern. And this sounds like it 

8 might be outside the purview of the Board. 

9 And the second part is if it was properly 

10 diagnosed, if, Hans, in your opinion is the 

11 smoking issue an issue in terms of can you, 

12 the numbers you threw at us, the effect that 

13 smoking might have on the biokinetics. 

14 DR. BEHLING: Yeah, it truly will. As I 

15 said, if you have 14-fold increased in 

16 alveolar macrophages whose principal objective 

17 is to transport and clean the lung of 

18 particulate matter into regional lymph nodes, 

19 it’s clear that you’re going to increase the 

20 dose. Again, on the other hand there is no 

21 documented -- I looked at ICRP-0066, and while 

22 they made reference to it -- you can read it 

23 yourself -- there’s no quantitative data that 

24 would allow you to make an adjustment. 

25 DR. ZIEMER: Going back to the point Jim 
56

1 Neton was making. We could certainly regard 

2 this as a long-term, scientific issue that 

3 hopefully down the road, I think that question 

4 would be of interest to the scientific 

5 community outside of even of this program 

6 because there are other factors for the 

7 smokers that come into play. 

8 There are clearances, the lung 

9 clearance into the lymph nodes but the 

10 coughing and all of that affects the clearance 

11 and the GI tract doses. And then Jim raised 

12 the issue for the smokers of the added 

13 internal burden of natural nuclides that 

14 affects part of those equations. So it’s very 

15 complex it appears to me. 

16 DR. BEHLING: Yeah, and I’m not suggesting 

17 that this become a scientific investigation -- 

18 DR. ZIEMER: No, not for us, but it could be 

19 an issue that we tag as one of scientific 

20 interest in the future. For example, if NCI 

21 or some other group is looking at this, we 

22 would want to keep abreast of what’s 

23 happening. 

24 DR. BEHLING: But we did make, for instance, 

25 an adjustment when we encountered the Super S 
57

1 plutonium and with limited scientific data, we 

2 essentially defaulted to an approach that 

3 acknowledges the difference between S and 

4 Super S, and therefore, the dose involving the 

5 lung. And so is it appropriate for us to 

6 perhaps in a very questionable, not 

7 questionable, but in a less than 100 percent 

8 scientific method approach this issue as sort 

9 of default to a value that gives the claimant 

10 perhaps an elevated dose if he’s a documented 

11 smoker. 

12 DR. ZIEMER: Well, if you could identify all 

13 of the variables. I think the Super S was a 

14 little more straightforward than this. 

15 DR. NETON: I agree with Dr. Ziemer on that. 

16 It’s not exactly a fair comparison. 

17 DR. MAURO: I like where we are in this 

18 conversation. I think that we’ve really 

19 crystallized the issues. I don’t think 

20 there’s any ambiguity; I think we all see the 

21 same picture. Namely, there is perhaps a 

22 legitimate question regarding the selection of 

23 the organ of concern. But what I’m hearing is 

24 it’s really outside the purview, at least 

25 right now, for investigation of the Board and 
58

1 for its contractor. 

2 In regard to the issue of clearance 

3 and the effects of smoking and how it might 

4 affect the loading up of the thoracic lymph 

5 nodes are actually extrathoracic lymph nodes, 

6 that is a scientific question that is 

7 certainly of interest. But what I’m hearing 

8 is something that really cannot be taken on at 

9 least at this time for this particular PER 

10 review. I say all this because if what I just 

11 said is in general agreement, it means that 

12 our job is completed on this particular PER 

13 review, and we really need not go into the 

14 last step, subtask, which is reviewing 

15 particular cases. 

16 I’m trying to find a way to achieve 

17 closure on fulfilling our obligations to the 

18 Board. And I think that if what I just 

19 described accurately characterizes the state 

20 of affairs, you know, I think some very 

21 important things came out of this 

22 conversation, but perhaps they’re not items 

23 that are appropriately addressed by the Board 

24 and its contractor at this time. 

25 MS. MUNN: Well, they are certainly 
59

1 important. There’s no question about that. 

2 One of my questions is whether we even have 

3 any knowledge relative to Labor’s 

4 consideration of the questions that have been 

5 raised here. I have no way of knowing whether 

6 these questions have been kicked around by the 

7 medical folks over at Labor, whether they have 

8 taken some of these or all of these questions 

9 that Hans has raised so thoroughly into 

10 consideration as they make some of their code 

11 assignments even. 

12 DR. ZIEMER: Well, this is Ziemer again. 

13 Let me make a couple of comments, and I’ll 

14 play off of what John said a little bit. We 

15 have this report. I would like to see a 

16 couple revisions. One is to take care of that 

17 early issue that Larry raised and recognize 

18 the work that NIOSH had been doing and also 

19 point out that unbeknownst to you, they were 

20 doing that and that you had also reached the 

21 same conclusion in your early review. So to 

22 be fair to both sides, you both identified the 

23 problem. So let’s make that known. 

24 Number two, the information is in 

25 there, a good discussion by Hans. I see no 
60

1 reason why that can’t still, it still will be 

2 out there in a sense. You might add a comment 

3 that in a revision that it appears that this 

4 is the purview of DOL so the Board will not 

5 need to address this further. And I think we 

6 have to leave it there. 

7 In a sense the information that you 

8 have would be at DOL’s prerogative to use or 

9 not use. We’re not going to force it on them, 

10 send it to them or whatever I don’t think. I 

11 think it’s in the public record at that point 

12 and they can see it and use it as they see 

13 fit. 

14 Let’s see, was there a third -- 

15 DR. BEHLING: Smoking. 

16 DR. ZIEMER: And the smoking issue seems to 

17 me, again, you could point that out as you 

18 have and indicate as well that there may be 

19 other aspects of this that you haven’t, that 

20 would have to be considered including the 

21 impact of natural activity on the smoker and 

22 perhaps other clearance mechanisms besides the 

23 lymph node clearance. Hans, I think you 

24 probably mentioned the GI clearance would 

25 probably change with -- 
61

1 MS. MUNN: It was in -- 

2 DR. ZIEMER: Anyway, I’m just saying the 

3 information is in a sense useful to have for 

4 whatever we can use in the future. And you 

5 might mention that although we can’t make that 

6 correction now, it’s something that might, as 

7 we move forward, might reach a point where 

8 perhaps NCI or some other group will come out 

9 with a model. 

10 I’m just trying to make, say we have 

11 the report. Let’s get it in a form that 

12 identifies, recognizes everybody’s concerns 

13 and then we can’t do any more at this point I 

14 don’t think as far as procedurally. 

15 DR. BEHLING: If there is one 

16 recommendation, and again, I don’t want to 

17 speak disparagingly of Dr. Crowther, but being 

18 a hematologist is obviously related subject 

19 matter that would perhaps give this person 

20 insight. But the person I would really 

21 consult is a clinical histopathologist and one 

22 who has a very, very working knowledge about 

23 the issue of identifying the cell type that 

24 would ultimately then give an understanding of 

25 the modality for treating that lymphoma which 
62

1 is very critical. 

2 And for that I looked at Dr. 

3 Crowther’s background. He’s really not a 

4 clinical person in that sense where he has a 

5 lot of experience in this particular area. 

6 You would probably want to look at somebody 

7 who worked in a hospital environment or a 

8 research environment that deals with this 

9 issue on a daily basis in looking at tissue 

10 biopsies and running various tests whether 

11 they’re immunological tests, serological tests 

12 to make that ultimate diagnosis. 

13 And those are the people that I would 

14 sort of look at and sort of say they’re the 

15 best people to provide us with an 

16 understanding of whether or not the current 

17 ICD-9 codes are, with regard to the 

18 internal/external target organ, are they 

19 really correct. 

20 DR. ZIEMER: Well, again, I think we’re 

21 getting into that other territory. I don’t 

22 know -- you don’t want to put that in your 

23 report. 

24 DR. BEHLING: No, I’m not. 

25 DR. ULSH: I’ve got to take exception to 
63

1 that. Dr. Crowther is the head of the 

2 largest, well, one of the largest hematology 

3 departments in the world. He has, I think, 30 

4 or 40 interns under him. Hans, what might be 

5 tripping you up is that in the United States 

6 there really isn’t a separate sub-discipline 

7 of hematology. Everybody is an oncologist. 

8 That is not the case in Canada where 

9 Dr. Crowther is from. Hematology is a 

10 separately recognized sub-discipline. Dr. 

11 Crowther has over 125 peer reviewed 

12 publications. He’s coming out with a textbook 

13 this summer, Evidence-Based Hematology. He 

14 has both clinical and research experience. He 

15 works at a research and teaching hospital at 

16 McMaster University. 

17 He is eminently qualified. He is also 

18 internationally recognized. So to imply that 

19 he doesn’t have the right qualifications to 

20 review this, I think, it’s not accurate. 

21 There’s no one more qualified to review this. 

22 DR. BEHLING: Well, okay, as I said, I don’t 

23 know him personally, and maybe that’s what’s 

24 lacking here. But if you read his consultant 

25 report, it does leave an awful lot of 
64

1 questions open to interpretation which he 

2 himself acknowledges. There’s very little 

3 hard evidence, scientific evidence, in the 

4 classification of certain lymphomas. I think 

5 that comes through loud and clear. So if you 

6 recognize him as your expert, he certainly has 

7 raised a few questions about the ability to 

8 assign ICD-9 codes in his very brief 

9 consultant report. 

10 DR. ULSH: Actually, I’m looking at his 

11 report right now, and he did not ever address 

12 the issue of the adequacy of historical 

13 records in assigning contemporary ICD-9 codes. 

14 Like any prudent scientist he acknowledges 

15 where there’s uncertainty, but he was 

16 specifically tasked by us to address where 

17 there are areas of uncertainty and to point 

18 those out. 

19 But we go with the best available 

20 science and the weight of the evidence. Dr. 

21 Crowther went through a very detailed review 

22 of the ICD codes that we asked him to and did 

23 exactly what we asked him to. He went through 

24 them one by one and told us what his 

25 recommendations are. Now I don’t see a whole 
65

1 lot of uncertainty there at all. It’s very 

2 clear what he recommended. 

3 DR. BEHLING: Well, it’s a difference of 

4 opinion. I’m looking even the very first 

5 paragraph and it certainly raises a few 

6 questions in my mind. But again, this is an 

7 academic issue. 

8 DR. MAURO: Yeah, I think that as I said 

9 before, we’re at the right place on this. 

10 That is, we’ve expressed some concerns that 

11 obviously are really not, the last step in our 

12 scope of services in looking at cases, we 

13 walked away -- as I understand it, 

14 notwithstanding the issues we raised regarding 

15 smoking and regarding identification of the 

16 organ concerned, we found that the PER was a 

17 very good PER and was being implemented in a 

18 scientifically sound way. 

19 That’s what I walked away with when I 

20 read this. And the main concerns we have had 

21 to do with this, number one, appropriate 

22 diagnosis and to smoking. And the only reason 

23 we wanted to go on to the last step in the 

24 process was to look into those two particular 

25 issues to determine the degree to which they 
66

1 may represent a challenge to a way in which 

2 the PER is currently being implemented. 

3 Without that I don’t know if there really is a 

4 need for us to go on and do any of the three 

5 case reviews. 

6 DR. ZIEMER: I agree. I think it’s 

7 complete. In my mind it is. I don’t know how 

8 the other Board members feel. 

9 MR. ELLIOTT: John, this is Larry Elliott. 

10 You said something there that raised my 

11 eyebrows. You said that your report finds the 

12 PER to be well done and the work to be 

13 appropriate. But I don’t read those words in 

14 this review. 

15 DR. MAURO: Well, I’ll let Hans speak to 

16 that. 

17 DR. BEHLING: Well, as we just heard from 

18 Paul, he wants us to amend the report at three 

19 levels. 

20 DR. ZIEMER: Well, I was expressing my 

21 opinion. I think it’s -- and I want to hear 

22 from the others. I don’t want to make 

23 decisions for the Board. 

24 MS. MUNN: Well, you certainly expressed my 

25 opinion appropriately. My concern from the 
67

1 outset was that the issues that were being 

2 raised were extremely valid issues, but I was 

3 not at all sure that they were within our 

4 purview. That was my concern. 

5 DR. MAURO: And, Hans, please speak to -- 

6 DR. BEHLING: Well, John, basically, I still 

7 have some reservations, and I think everyone 

8 who understands the issue of lymphomas and 

9 their diagnosis, especially as we go back in 

10 time 20, 30 years, there’s a big open-ended 

11 question. How accurately were these medical 

12 records reflected through a type of lymphoma 

13 and the source or the primary neoplasm and its 

14 anatomical location et cetera, et cetera. 

15 DR. ZIEMER: And I’m saying that I’m not 

16 asking you to revise any of that. I think 

17 that’s fine. I’m just saying we can’t impose 

18 that on -- 

19 DR. BEHLING: No. 

20 DR. ZIEMER: -- on DOL. 

21 DR. MAURO: Yeah, and I want to go back to 

22 Larry’s point because I want to make sure that 

23 I’m correctly representing my understanding. 

24 Except for the two issues that we just 

25 discussed which are outside the purview of our 
68

1 mission so to speak, it’s my understanding 

2 that the process that NIOSH went through and 

3 that given that there was not a smoking issue 

4 that we’re concerned with, and given that we 

5 did not happen to encounter a PER where the 

6 ICD-9 or diagnostic issue came into the play, 

7 the process that they went through and how 

8 they implemented it, and how they selected the 

9 cases and did their dose reconstructions, it 

10 is my understanding that every part of that 

11 seemed to -- when we spoke last, Hans -- that 

12 seemed to be very well done until we ran into 

13 these two what I would call major issues. 

14 DR. BEHLING: No, John, the ICD-9 code is 

15 not selected by NIOSH as you’ve been 

16 repeatedly told. So they followed the 

17 instructions of DOL. And if there is to be a 

18 change in how we assign ICD-9 codes, it cannot 

19 come through NIOSH. It has to be at the level 

20 of DOL. And so therefore, that issue goes by 

21 the wayside. 

22 DR. MAURO: I’m not sure whether you’re 

23 agreeing with what I just said. We happened 

24 to run into a PER, I mean, what we really have 

25 before us is the very first PER we were asked 
69

1 to review is this one where the issues that 

2 emerged that we have concerns with really are 

3 outside the purview of the Board. 

4 Other than that, if those issues were 

5 not there, and we were dealing with some other 

6 PER where those issues that emerged, I guess I 

7 would say that if those were unfair with by 

8 and large the process that was used to get to, 

9 the way in which the cases were -- for 

10 example, the way I’ve always looked at this is 

11 that there’s a multi-step process where once 

12 the issue is raised, however it comes about, 

13 then NIOSH goes through a process of selecting 

14 the cases that could possibly have been 

15 affected by that issue. And then 

16 systematically go through a triage to identify 

17 the ones that will need to be reconsidered and 

18 then reconsider them. And then, of course, 

19 the compensation process goes forward. It’s 

20 my understanding that that process, the front 

21 end of the process, was done well. And I 

22 think that was my understanding -- 

23 MR. ELLIOTT: John, this is Larry. Can I 

24 jump in here? 

25 DR. MAURO: Sure. 
70

1 MR. ELLIOTT: Because I want to hearken back 

2 to what I said at the start of this conference 

3 call. That I’m very concerned that this 

4 report will lead to claimants being further 

5 frustrated. And on page five of the Executive 

6 Summary at the last paragraph of the page, 

7 this phrase, the first sentence ends in a 

8 phrase, “nevertheless this contains 

9 significant deficiencies,” does not match up 

10 with what I heard you say just now or a moment 

11 ago. 

12 DR. MAURO: Well, of course, this is in 

13 light of what we’ve just learned about what’s 

14 within -- what I’m hearing is there’s a need 

15 to re-issue our report. 

16 MR. ELLIOTT: I would appreciate that 

17 because the folks out there in the claimant 

18 world are going to hold this up and ask DOL to 

19 send claims back to us, and we’re going to 

20 turn right around and say we have applied the 

21 best science possible. 

22 DR. MAURO: But we do have a dilemma. And 

23 the dilemma being that, I mean, in a funny 

24 sort of way, hey, we think NIOSH did a great 

25 job with this PER; however, the Department of 
71

1 Labor, we wonder whether or not that we have 

2 some concerns about, you know, the fundamental 

3 biokinetic models as applied to this class of 

4 problem which goes toward ICRP. 

5 And, two, we have some concerns 

6 regarding the process that was used to 

7 identify the organs of concern, both of which 

8 are outside the purview of NIOSH, at least at 

9 this point in time perhaps, and the Board. So 

10 I don’t know what we do at this point. I 

11 think we have something very important to say, 

12 but I’m not too sure how to go about saying 

13 it. 

14 MS. MUNN: It appears to me that you’ve at 

15 least cast the outline of what has to 

16 transpire here. Clearly, the report needs to 

17 be reissued. Clearly, the issues that you 

18 have brought up are valid issues. They simply 

19 cannot be addressed here. I see no problem in 

20 identifying the issues. Does anyone else see 

21 any problem with that? It appears to me that 

22 it’s only fair to identify the issues. It’s 

23 just they’re not, the issues are not 

24 applicable to this PER and -- 

25 DR. ZIEMER: Yeah, I think one of the 
72

1 problems, for example, on the statement Larry 

2 just referred to on page five, it says the 

3 deficiency is in the PER. Well, actually, the 

4 deficiencies that you identified are really 

5 outside, they’re not only outside the PER, 

6 they are outside the NIOSH fence. 

7 So I think, John, you may need to 

8 think of some creative ways to indicate that 

9 there are these kinds of concerns, but under 

10 the current framework of this law, NIOSH is 

11 not in a position to address them. You could 

12 speculate -- well, I don’t know if you could. 

13 Part of this where you identify the 

14 coding issue I suppose you could point out 

15 that this is a concern that has to be handled 

16 by Labor. You don’t know at this point, you 

17 don’t know that Labor has not -- 

18 DR. MAURO: Yes, yes. 

19 DR. ZIEMER: -- and so you have to be very 

20 careful and say this is a concern and that -- 

21 DR. MAURO: Could we say that? Maybe we 

22 could just say that. 

23 DR. BRANCHE: This is Dr. Branche. May I 

24 make a suggestion? I think to be able to say, 

25 I think that Dr. Ziemer was leading along a 
73

1 very wise path. But I think you could simply 

2 end by saying but this is outside the purview 

3 of NIOSH. You don’t have -- and since we 

4 don’t know or we can’t ascertain explicitly in 

5 whose purview it is. And I wouldn’t risk 

6 saying it’s Labor only to find out it’s 

7 somebody else. 

8 DR. MAURO: I would go a step further. I 

9 wouldn’t even be judgmental. I would say that 

10 based on what we reviewed, we see that there’s 

11 a potential for a certain class of problem 

12 emerging in terms of diagnosis. Now, we’re 

13 not saying that problem exists. We’re not 

14 saying that it needs to be fixed. But at 

15 least from what we’ve seen, we see the very 

16 real possibility that that kind of problem 

17 could emerge on a particular case. 

18 DR. ZIEMER: You need to make it clear that 

19 it’s not something that NIOSH can handle. It 

20 sounds like -- 

21 MR. ELLIOTT: And I would offer that it’s 

22 not, you know, lymphoma is probably the poster 

23 child for this problem. 

24 MS. MUNN: No question. 

25 MR. ELLIOTT: But it’s not the only ICD-9 
74

1 code that would have problem being assigned 

2 based upon rough, I mean -- 

3 DR. NETON: Fifty year old medical records. 

4 DR. MAURO: Yeah, yeah, we’ve got to work -- 

5 I accept this challenge to try to craft words 

6 carefully to communicate something that might 

7 be very important, but do it in a way without 

8 being presumptuous regarding what Labor’s 

9 doing and not doing, and not even point toward 

10 Labor. Just make the statement as Christine 

11 wisely suggested, this is outside the purview, 

12 but nevertheless it is a question that has 

13 come up that may require further 

14 investigation, that sort of thing. And then 

15 stop at that point. 

16 DR. BRANCHE: This is Christine again, and 

17 the other thing that you have on your side is 

18 that the Departments of Labor and Energy do 

19 participate -- I don’t know if they’re 

20 participating in this call. I don’t know if 

21 they’ve joined yet, but then the staff at 

22 NIOSH as well as SC&A would have a point of 

23 reference if this should come up later on. 

24 And you’d have documentation where you made 

25 certain that it wasn’t pointing to NIOSH, but 
75

1 there was an issue, a deficiency, that you 

2 uncovered. 

3 DR. MAURO: Right, and we leave it that way. 

4 And I think it serves everyone’s purpose this 

5 way. And at some point in the process the 

6 degree to which it’s picked up by those 

7 organizations and individuals that feel it’s 

8 something that needs to be picked up, great. 

9 If not, that’s certainly their choice. 

10 I feel as if that we’ve done something 

11 important here, but at the same time we have 

12 to function within the structure of the way 

13 business is done here. And we have to go 

14 gently, but nevertheless get the information 

15 out. We’ll do that. And we certainly will 

16 put out another draft for consideration by all 

17 concerned to make sure that we strike that 

18 delicate balance that we’re looking for. 

19 MS. MUNN: I know you can do that, John. 

20 MR. ELLIOTT: This is Larry Elliott. I 

21 think that is a very good thing that you have 

22 proposed to do there, John. And I encourage 

23 you, and I would offer my help if I can in any 

24 word-smithing that you would like help on. 

25 For the working group, I just want the working 
76

1 group to hear my thoughts about review of 

2 PERs. 

3 I was very excited that the Procedures 

4 working group was going to pick up an 

5 examination of PERs. And I was further 

6 excited by the fact that the working group 

7 assigned this particular PER for a first 

8 examination. And what I hoped to have seen 

9 out of that was how well we identified the 

10 scientific issues surrounding the change, and 

11 how well we implemented that. 

12 And quite frankly, I have to say, you 

13 know, I’m not real comforted by on either one 

14 of those points here. I don’t see that in 

15 this review, and I hope the revised review 

16 will speak to both the scientific basis for 

17 the change and how well the change was 

18 implemented. And any way we can help you in 

19 that review I certainly will stand up and do 

20 that. 

21 DR. BEHLING: Larry, not to belabor the 

22 issue, but I think one of my concluding 

23 statements was that NIOSH fully understood the 

24 technical basis for this PER and accommodated, 

25 as I said, with the two things that I 
77

1 identified here as potential problems are now 

2 not considered your problem. 

3 And so as far as I’m concerned I was 

4 not harsh or hypercritical of anything that 

5 NIOSH did. Now that we’re all of the 

6 understanding that this whole issue of ICD-9 

7 codes is strictly something that is outside of 

8 NIOSH’s purview, those two issues go by the 

9 wayside. 

10 DR. MAURO: And I would -- 

11 MR. GRIFFON: John, this is Mark Griffon. 

12 Can I ask one thing? 

13 DR. MAURO: Yeah. 

14 MR. GRIFFON: Two issues, I agree with that 

15 one. That’s obviously in DOL’s camp. But the 

16 question of the biokinetic model I think is 

17 certainly a NIOSH issue even if it’s a long18 term science issue. I mean, and I agree with 

19 everything Jim Neton said that it’s not only 

20 one side that you have to look at. But I 

21 think we should examine that. The ICRP-66 

22 does have a section on that, but they’re 

23 basically, from what I can tell -- Jim 

24 probably has looked at this certainly more 

25 than I have -- but it looks a little 
78

1 inconclusive, the research, at this point. 

2 But I don’t -- 

3 DR. ZIEMER: Not that there’s as an issue, 

4 but they don’t have a solution at this point. 

5 MR. GRIFFON: Right, right, but I think -- 

6 DR. ZIEMER: That’s what I was saying -- 

7 MR. GRIFFON: -- it is in NIOSH’s -- 

8 DR. ZIEMER: -- ^ table maybe. 

9 MR. GRIFFON: Yeah. 

10 MS. MUNN: That can be said and at the same 

11 time maintain that NIOSH has appropriately 

12 handled these issues with the best science 

13 available which has done so. It’s an 

14 outstanding question, but it’s not a question 

15 to be resolved in this program. 

16 DR. ZIEMER: Right. 

17 MR. GRIFFON: Right. I’d have to look at 

18 the exact language, but I mean, I think that -

19 - 

20 MS. MUNN: I don’t think that the law gives 

21 us that prerogative, Mark. I really don’t. 

22 MR. GRIFFON: The law doesn’t give us what 

23 prerogative? 

24 MS. MUNN: The prerogative to weight these 

25 kinds of issues that go outside the standards 
79

1 that currently exist. 

2 MR. GRIFFON: What standards? This is ICRP. 

3 I mean, it’s raised in ICRP -- 

4 DR. ZIEMER: But we -- 

5 MR. GRIFFON: -- papers in here that do make 

6 some conclusions. NIOSH is determining that 

7 all the literature basically is, there’s no 

8 trend or there’s no, you know, I think that’s 

9 what the conclusion is. But I don’t know that 

10 we’ve examined that or talked about that. I 

11 mean, I’m looking at the most recent one I 

12 could find was a ’93 Kathryn paper which is 

13 referenced in there which is sort of 

14 suggesting some modifications to the 

15 biokinetic model. I’m reading while we’re on 

16 the phone here. 

17 So I don’t know why we can’t at least 

18 put that as a, you know, it seems like we’re 

19 consistent, you know, ICRP is saying that 

20 there could be an effect here, a concern with 

21 smoking and lymph nodes, but currently they 

22 have no suggestion, but we’re going to put it 

23 in the long term, you know, we’re going to 

24 further look at that in long term science 

25 issues. 
80

1 DR. NETON: Mark, this is Jim. I have no 

2 problem saying that this is a long-term issue 

3 that we should keep aware of. 

4 MR. GRIFFON: Okay, maybe we’re saying the 

5 same thing. 

6 DR. MAURO: Yeah, I think we’re in agreement 

7 on this. 

8 DR. NETON: I would not argue that we 

9 shouldn’t be concerned about it. I was just 

10 trying to make the point that at this point in 

11 time we have no consensus scientific opinion 

12 on this issue that we can hang our hat on. 

13 MR. GRIFFON: I guess the one question I 

14 had, Jim, was do we have anything that says 

15 that your current approach where you didn’t do 

16 any weighting sort of will bound any of the -- 

17 DR. NETON: Oh, absolutely. 

18 MR. GRIFFON: -- most conservative factors 

19 being found in some of these studies such as 

20 Kathryn. I mean, -- 

21 DR. NETON: I think that’s probably, that’s 

22 something that’s going to likely happen. This 

23 weighting thing all started when we tried to 

24 develop a model for CLL. And we actually are 

25 working on this weighted model right now. And 
81

1 once that’s done, it’d be easy to make that 

2 comparison. 

3 MR. GRIFFON: I think that would be 

4 worthwhile just to have on paper. It 

5 certainly shows that you’re aware of the 

6 current literature. You’ve considered it, and 

7 you still believe your calculations are 

8 bounding. I mean, I think that’s good for all 

9 of us to have. 

10 DR. NETON: ^ any of that right now. I 

11 guess we were here prepared to discuss this in 

12 light of the current PER and the scientific 

13 validity of what we’ve done here. 

14 MR. GRIFFON: Yeah, that’s fine. 

15 DR. NETON: I do agree. We need to track 

16 and keep abreast of all the best science. And 

17 if we have to put it on a list, and I get 

18 reminded every three months as to my 

19 delinquency, that’s fine. 

20 MS. MUNN: Hans and John, will there be any 

21 problem in your issuing your revised report 

22 well in advance of the Procedures work group 

23 next face-to-face meeting toward the end of 

24 May? 

25 DR. BEHLING: Yeah, I mean, there shouldn’t 
82

1 be any problem. However, I guess I’m still 

2 wondering if, in fact, the audit of at least 

3 two or three cases is still something that 

4 should be done in light of or in spite of this 

5 issue that we resolved this saying we won’t 

6 question the ICD-9 code or even address the 

7 smoking as a variable, but strictly review the 

8 assigned doses that in the science based on 

9 bioassay data. 

10 That is still an independent variable 

11 that goes outside the scope of these two 

12 issues, smoking or ICD-9 codes. I mean, this 

13 could be just another routine dose 

14 reconstruction audit that skirts the two 

15 issues that we’ve been discussing for the last 

16 hour, but it’s nevertheless an audit that may 

17 have some potential value especially for POC 

18 cases where we’re talking about revised POC of 

19 let’s say between 45 and 50. 

20 And now the focus will be on, well, 

21 how did the bioassay data contribute to this 

22 new assessment. This is going to be just like 

23 any other dose reconstruction except we’re now 

24 dealing with lymphoma. I mean, you could look 

25 at this as two dose reconstruction audits or 
83

1 three dose reconstruction audits that are 

2 very, very similar to the other ones that we 

3 do under Task Four. 

4 DR. MAURO: And those can be picked, I 

5 guess, without this, see, the trouble we ran 

6 into is that we were trying to pick ones that 

7 would test the two issues that we were 

8 concerned with. Since those issues are off 

9 the table, we simply now have to, I guess, 

10 demonstrate that this process was, in fact, 

11 implemented on these three cases. I don’t 

12 know how we would pick it, maybe just 

13 randomly. 

14 DR. BEHLING: Yeah -- 

15 MS. MUNN: That was the first big word that 

16 I wrote on my notepad here when we were 

17 discussing it an hour ago, random, question 

18 mark, and why not. 

19 MR. HINNEFELD: This is Stu Hinnefeld. If 

20 you’re interested in cases where the new POC 

21 approaches 50 percent, why don’t we just run 

22 the top ten, the ten cases that are still not 

23 compensable after rework that are available 

24 for review by the Board, sets ten of 250, and 

25 take the ten that have the highest new POC, 
84

1 and you can select the three you want. 

2 DR. MAURO: Send them over. 

3 DR. BEHLING: The point here would be 

4 strictly to assess the assigned dose to the 

5 either thoracic or extrathoracic lymph nodes 

6 but evaluate the use of bioassay data that 

7 gave rise to that number. 

8 MR. GRIFFON: Sounds good, yes. 

9 DR. MAURO: Yeah, straightforward, it’s a 

10 standard dose reconstruction audit. That’s 

11 what it comes down to without these other 

12 issues at play. 

13 DR. BEHLING: Yes, we will assert the issue 

14 of smoking and ICD-9. 

15 DR. MAURO: Of course, you know we’re going 

16 to be tempted to slip that in, but we won’t do 

17 that. Please send us those ten cases, and 

18 we’ll go ahead. And is it okay with the 

19 working group for us to just go ahead and pick 

20 the three we like, or would you like to pick 

21 those? 

22 DR. ZIEMER: It seems to me we should pick 

23 them like we do the others if we’re going to 

24 do it. 

25 DR. MAURO: That’s fine. 
85

1 MS. MUNN: I think this is good. 

2 MR. ELLIOTT: We will issue the top ten 

3 cases as Stu has described. I think this is 

4 appropriate. This goes to the implementation 

5 aspect that I spoke about a moment ago. 

6 DR. BEHLING: And the reason I brought it up 

7 -- 

8 DR. ZIEMER: And once you do that then you 

9 can issue your revised report that will 

10 include what you did there. 

11 DR. MAURO: Yes, we’ll revise the report -- 

12 DR. BRANCHE: Excuse me. Excuse me. Ladies 

13 and gentlemen, I know how excited you are, but 

14 this is like the third time you all are 

15 talking over each other. It makes for a 

16 really bad transcript. Thanks. 

17 MR. ELLIOTT: Do you want us to send the ten 

18 cases to the working group and let them select 

19 or do you want us to send it to everybody and 

20 you guys decide who you want to select? 

21 MS. MUNN: Send it to the working group. 

22 We’ll set up a very quick teleconference, and 

23 we’ll choose three. 

24 MR. ELLIOTT: Thank you. 

25 MS. MUNN: And we’ll get those three to Hans 
86

1 and to John. 

2 DR. BEHLING: And just to answer your 

3 question which precipitated this discussion in 

4 the last few minutes, the timing. If we were 

5 to exclude any dose reconstruction audits, May 

6 would be, obviously, I’d do it within a matter 

7 of days. On the other hand if there are, if 

8 this revised draft is to also address the 

9 issue of audits, then I think the time scale 

10 may have to be expanded a bit depending on 

11 when we get those cases and how soon we will 

12 be in a position to review those. 

13 MS. MUNN: Then, Stu, what do you see as the 

14 timeframe for your pulling those ten and 

15 getting them to us? 

16 MR. HINNEFELD: We’ll probably ask ORAU for 

17 the pieces of information that are not data 

18 based. And it’s going to take a custom query 

19 to build the table for the cases, for the 

20 information that is data based. So I think it 

21 might be a couple weeks or so, maybe -- 

22 DR. MAURO: How about a two-step process, 

23 Wanda? We could put out a revised report that 

24 gets to the delicate issues that we’ve been 

25 talking about. You’ll have it in your hands, 
87

1 and my guess is it may take a couple of 

2 iterations to get that down. 

3 MS. MUNN: I would imagine so. 

4 DR. MAURO: Yeah, and I’d like to get that 

5 right because of its sensitivity for the 

6 reasons that Larry clearly articulated. It is 

7 important that we get this language correct. 

8 And once we have that in place, that’s going 

9 to be the important document that -- and right 

10 behind that some place along the line, of 

11 course, we’ll get started on -- I would not 

12 want to hold that up because we want to work 

13 on the three cases. We’ll supplement the 

14 report expeditiously as soon as the three 

15 cases are completed. But I think getting that 

16 first one out is going to be important. 

17 MS. MUNN: That’s a wise observation. 

18 DR. BEHLING: So we’re on for May to get the 

19 revision to this draft. And then however soon 

20 we can get to complete the dose reconstruction 

21 audits, we’ll add those to the report. 

22 MS. MUNN: Yes, we’re set for, I believe, 

May 20th 23 for our next face-to-face in 

24 Cincinnati. 

25 DR. BRANCHE: That is correct. 
88

1 MS. MUNN: Which would be a good time to 

2 address this. I’m hoping to be able to be 

3 there. I’m going to be having some surgery 

4 right after this Tampa meeting, and they’re 

5 giving me another shoulder. I don’t know 

6 whether they’re going to let my shoulder 

7 travel by then or not, but May 20 is the day 

8 we set. So if it’s going to be possible for 

9 you to get a revision to us ten days or so 

10 before that, John, it would be very helpful. 

11 DR. ZIEMER: And remember, I won’t be at 

12 that meeting in Cincinnati, but I would be 

13 there by phone. 

14 MS. MUNN: Good, okay. 

DR. BEHLING: So May 10th 15 should be my target 

16 date. 

17 MS. MUNN: If that’s possible. If that’s 

18 not -- 

DR. ZIEMER: Is it the tenth or 20th 19 ? Oh, 

20 ten days before. Okay. 

DR. MAURO: May 10th 21 , so that’s our marching 

orders. May 10th, now, May 10th 22 would be, what 

23 I’m getting at is though it sounds like that 

24 this document though is going to go through 

some type of process. And is it the May 10th 25 
89

1 version that you would like to see having gone 

2 through the process whereby I would say us, 

3 with Larry and perhaps the working group 

4 having a chance to work it through? In other 

5 words right now we’re talking, today’s what, 

April 2nd 6 ? That’s five weeks from now. 

7 Hans, is this something we could put 

8 out within two weeks, get it into Larry’s 

9 hands, get it into the working group’s hands, 

10 Christine’s hands so that they can see the 

11 language, the tone? And then we can maybe 

12 even go through an iteration before we 

13 actually have what I would call our official 

May 10th 14 deliverable. 

15 DR. BEHLING: Well, from my point of view 

16 it’s a matter of spending a few hours of 

17 wordsmithing, but it’s a question of how, you 

18 know, how diplomatic is my rewrite that will 

19 be acceptable to Larry and whoever else would 

20 be in line for the review. We may argue a bit 

21 here and there. 

22 DR. MAURO: That’s why I’m saying, I don’t 

23 this is going to be a difficult thing to do in 

24 terms of us putting together the next straw 

25 man. 
90

1 DR. BEHLING: No, and we spent an ample 

2 amount of time discussing why NIOSH is not 

3 responsible for the assignment of ICD-9 codes, 

4 and that smoking is an issue that is complex 

5 but without the documentation and scientific 

6 literature. I mean, this is not going to take 

7 me very long. 

8 DR. MAURO: Wanda, how about we get it to 

9 you in a week, and we get it to Larry in a 

10 week? 

11 MS. MUNN: That would be wonderful. 

12 DR. MAURO: We’ll get it to you in a week. 

13 We’ll all have a chance to chew on it a little 

14 bit and do it again, and maybe even do it 

15 again. And by the time the tenth comes -- 

16 DR. ZIEMER: We’ll be in Tampa in a week so 

17 -- 

18 DR. MAURO: -- oh, yeah, that’s right. I 

19 forgot, two weeks. How about we get it to you 

20 within two weeks? That would give us two more 

21 weeks to fool with it and make sure we get it 

22 polished up so that on the tenth we’ve got 

23 ourselves a draft that we’re feeling pretty 

24 good about. 

25 MS. MUNN: That would be terrific. 
91

1 DR. MAURO: Very good, very good. 

2 MS. MUNN: That would be great. We’ll look 

3 forward to that. 

4 So we’re all on that page? We’re all 

5 happy with what we’re doing with the PER-9 

6 issue? 

7 DR. ZIEMER: Right. 

8 MS. MUNN: All right, very good. 

9 OVERVIEW OF THE FIRST SET OF 33 PROCEDURES

10 Next topic, the rework that Steve 

11 Marschke got to us on the overview of the 

12 first set of 33 procedures. Steve, you’re 

13 still on? 

14 MR. MARSCHKE: I’m here, yes. 

15 MS. MUNN: Good. My apologies for not 

16 getting my comments back to you and to Paul 

17 and Kathy. I think you’ve covered just about 

18 the waterfront here. It’s what you sent is 

19 not in the format that I would prefer to see 

20 it. I still would prefer to see a very brief 

21 text, all of which you have here, but with 

22 most of the tables not as a part of the text. 

23 If we can all stand the time element 

24 involved, I would like to have an opportunity 

25 to do a little cut and paste job of my own and 
92

1 send it to you and Paul and Kathy for your 

2 sort of overview as to whether or not you 

3 think that’s closer to what I had in mind -- 

4 it’ll be closer to what I had in my mind. I 

5 don’t know whether it’ll be closer to what 

6 Paul had in mind or not. But if you would 

7 allow me to do that, I would certainly 

8 appreciate it. 

9 For one thing, for example, I’d like 

10 to remove the review criteria and findings up 

11 into the part of your text that ends the first 

12 two paragraphs on page three. I’d like the 

13 criteria and findings to be up front. And 

14 then the contractor findings and status of 

15 findings that follow that can be, can easily 

16 encompass all of the material that needed to 

17 be done which removes a lot of the overview 

18 material back under paragraph four because 

19 we’ve already done it up front in the other 

20 table. 

21 I think it will work just fine with a 

22 slight change in table or back at the back the 

23 one that we discussed in our e-mails earlier. 

24 We talked about how many columns should be 

25 added. At least Kathy and I, I assume you 
93

1 were privy to that, about how many went under 

2 Table 4. And I think if we expand Table 4 

3 just a little bit, put it in landscape format 

4 instead of portrait format, we can include the 

5 titles of the procedures reviewed. 

6 And that would be everything everybody 

7 ever wanted to know right there in those two 

8 tables. They cover almost everything that’s 

9 been done in this first set I think. I’ll let 

10 you take a look at that after I put it 

11 together and will try to get that to you as 

12 soon as I can. I’m traveling right now and 

13 don’t have access to the kind of equipment 

14 that I really need, but I think perhaps I can 

15 do that. 

16 Is that all right with you, Paul? 

17 DR. ZIEMER: Yeah, that’ll be fine. 

18 MS. MUNN: Is that all right with the rest 

19 of the group? 

20 MS. BEHLING: Wanda, this is Kathy Behling. 

21 I just wanted to, excuse me just a minute 

22 because Steve was unable to be on the last 

23 conference call so I tried to incorporate the 

24 changes and apologize if I didn’t capture 

25 everyone’s suggestions. So Steve is not to 
94

1 blame for any of the changes that were made, 

2 and I’m sure he’s certainly in agreement with 

3 seeing any changes that you would like to 

4 incorporate. 

5 MS. MUNN: Well, if it’s not going to hold 

6 up the wagon too much, I’ll do that. 

7 DR. MAURO: This is John. I really 

8 appreciate that. That really helps. We can 

9 really get your direct perspective. That will 

10 be very helpful to us in finalizing this. 

11 MS. BEHLING: And actually, the other thing 

12 I want to make mention of is because this was 

13 a report that we’re sending to you, I 

14 obviously realize you would not probably want 

15 this format with the disclaimers and that kind 

16 of thing. Because currently it’s a discussion 

17 piece that we’re having between SC&A and the 

18 work group and NIOSH, but obviously this will 

19 be a report from the Board to the Secretary of 

20 HHS. And so it won’t have the look and the 

21 format that is typical for SC&A. I just 

22 included that for this working piece during 

23 our discussions here. 

24 MS. MUNN: I understand that, and I 

25 appreciate it. As I said, I think everything 
95

1 we need is here. It’s just a preference with 

2 respect to how it’s presented I think. 

3 Mark? 

4 MR. GRIFFON: Yeah, I’m still on. I’m not 

5 too worried about format, Wanda, so that’s 

6 fine. 

7 MS. MUNN: Okay, that’s fine. 

8 Mike, any problems? 

9 MR. GIBSON: No, that’s fine. 

10 MS. MUNN: Okay, very good. I’ll try to get 

11 that to you hopefully before we go to Tampa, 

12 but I’m not at all sure. 

13 DR. ZIEMER: There’s not much time left. 

14 You can bring it with you if you want. 

15 MS. MUNN: Yeah, that’s one of the things we 

16 probably will end up doing. 

17 DR. ZIEMER: I won’t have a chance to do 

18 more on it before I leave anyway. 

19 MS. MUNN: All right, then we won’t feel 

20 like that’s a big pressure thing, but I will 

21 try to get it to you. 

22 I do not have on my list of action 

23 items that I have from our last meeting, I 

24 don’t believe that I have anything that we 

25 were required to touch on before our PER-9 
96

1 discussion -- 

2 DR. BRANCHE: Wanda, do you hear the music? 

3 DR. ZIEMER: Yeah, I hear it. 

4 MS. MUNN: I do hear the music. Somebody’s 

5 put us on hold. 

6 DR. BRANCHE: Yes, they have. 

7 MS. MUNN: So we’re hearing the symphony. 

8 But is any other member of the work 

9 group aware of outstanding information that we 

10 had indicated we needed before the Tampa 

11 meeting? 

12 DR. ZIEMER: I don’t believe so. 

13 MS. MUNN: I don’t think so, and I didn’t 

14 have any list unless someone else has some 

15 action item that I failed to record. 

16 (no response) 

17 MS. MUNN: That’s fine. Then -- 

18 MR. GRIFFON: Wanda, one question. Where do 

19 we stand on the discussion of the CATI 

20 procedure review? I think it’s 90, 92, one of 

21 those. 

22 MS. MUNN: Ninety-two. We’re going to use 

23 the new matrix to report on it at the next 

24 meeting which is, I’m not sure whether I meant 

25 Tampa. I don’t think we did. 
97

1 Kathy can you help me remember what we 

2 were, what I meant when I said we were going 

3 to use PROC-0092, the new matrix, to report 

4 where we are at the next meeting? 

5 MS. BEHLING: Yeah -- 

6 DR. ZIEMER: You were going to report on the 

7 nature of the matrix for the full Board. 

8 MS. MUNN: Yes, I know. That’s one of the 

9 things I want to, when we finish here, want to 

10 very quickly ask Kathy to stay on for a minute 

11 and Christine to stay on for a minute while we 

12 talk about that for just a minute. 

13 But, Kathy, were you planning on using 

14 PROC-0092 then as part of your presentation? 

15 MS. BEHLING: No, I wasn’t. I was simply 

16 going to give an overview of the matrix, what 

17 we’re capturing, trying to show to the other 

18 Board members just so they have an 

19 understanding of. If they also want to have a 

20 similar matrix database put together for a 

21 matrix for their work group, I think it’s 

22 probably a good idea, and it’s as we discussed 

23 -- 

24 MR. GRIFFON: So, Wanda -- 

25 MS. MUNN: So when I said at next meeting, 
98

1 in my mind I was saying at our next meeting in 

2 May. But I just wanted to make sure that from 

3 what Mark had just asked that I was not 

4 misinterpreting that. 

5 MS. BEHLING: That’s correct. In fact -- 

6 MS. MUNN: Do you have something else, Mark? 

7 MR. GRIFFON: No, no, no, I just, you were 

8 asking about outstanding actions related to 

9 the tracking matrix and stuff more than the 

10 individual findings in the resolution of 

11 individual findings, correct? 

12 MS. MUNN: Yes. 

13 MR. GRIFFON: Okay, then I’ll retract my 

14 question. 

15 MS. MUNN: I thought one of the notes that I 

16 had underneath it was include three and five 

17 as being in abeyance. But I think it’s a May 

18 item. That’s what I’m thinking. 

19 MR. GRIFFON: All right, thank you. 

20 MS. MUNN: All right, then I have nothing 

21 else other than a conversation I wanted to 

22 have with Christine and Kathy. Does anyone 

23 else have anything we need to touch on before 

24 Tampa? 

25 DR. ZIEMER: No. 
99

1 MS. MUNN: Otherwise I will let everybody go 

2 back to work with the exception of Kathy and 

3 Christine if you’ll two hang on for a moment, 

4 then I’ll see you all in Tampa next Monday. 

5 DR. BRANCHE: Everyone travel safely. 

6 (Whereupon, the working group meeting was 

7 adjourned at 3:00 p.m.) 

8 

9 
100

1 CERTIFICATE OF COURT REPORTER 

STATE OF GEORGIA 

COUNTY OF FULTON 

 I, Steven Ray Green, Certified Merit Court 

Reporter, do hereby certify that I reported the 

above and foregoing on the day of April 2, 

2008; and it is a true and accurate transcript 

of the testimony captioned herein. 

 I further certify that I am neither kin 

nor counsel to any of the parties herein, nor 

have any interest in the cause named herein. 

 WITNESS my hand and official seal this the 

7th day of Dec., 2008. 

___________________________________ 

STEVEN RAY GREEN, CCR, CVR-CM, PNSC 

CERTIFIED MERIT COURT REPORTER 

CERTIFICATE NUMBER: A-2102