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Deposition 3 - deposition of doctor in products liability case - Part 2
MR. McCOY: I used the name; doctor didn't release the name.
THE WITNESS: Yeah, I mean, the name, I guess, is irrelevant, although there's a legal proceedings involving that case as well, as I understand it.
BY MR. GLOOR:
Q Is he a plaintiff in that case claiming injury because of exposure to welding fumes?
Q Do you know where that case is pending?
A I have no idea. I have not -- I've -- I heard this from the family. I don't have any response from a law firm indicating that that's -- that's the situation.
MR. GLOOR: Bob, do you know what state it's in? Is that one of your cases?
MR. McCOY: No, I don't know anything about the case.
BY MR. GLOOR:
Q All right. And then --
MR. McCOY: See, and this is part of the problem. I mean, again, you know, you can ask him based on his experience what he knows, but when you start wanting medical records and things like that, then we run into the privilege issues. I just -- I just frankly don't understand why you all want to make us violate privileges.
MR. GLOOR: Let me be clear --
MR. McCOY: It's patients.
MR. GLOOR: -- because you're filling this record full of garbage.
MR. McCOY: No.
MR. GLOOR: Now, excuse me. I'm not trying to have a violation of any privilege at all.
MR. McCOY: Yes, you are.
MR. GLOOR: Get out of my way. If I ask -- Excuse me, Bob. If I ask an improper question, it's okay to interject. This good doctor won't answer it if you make an objection. I can't require it. But stop the speech making, especially when you're flat out wrong on the law. Stop it. And if there's a question that's improper, make an objection, and then we'll go on and we can preserve it for some judge to decide.
MR. McCOY: Do I need to bring the case into the deposition?
MR. GLOOR: I don't care what you bring. If it doesn't have a robe on, it doesn't count.
Q Let me go back now on this issue which we should have covered twenty minutes ago. We have the Edwin autopsy. We've covered that, correct?
Q There's one from a guy -- a person named Patient B, (spelled name), correct?
A That's close. That's similar.
Q Okay. And that was Dr. Ho did that. And you have --
Q -- the report here, correct?
Q Are there any other autopsy reports that you've seen where the person who was autopsied, if that's the way to say it, was someone who was a welder or claiming injury because of exposure to welding fumes?
A There's one other, but the -- there's no -- there's no report issued because the full autopsy analysis hasn't been performed yet.
Q And is that the one -- the Bolatto --
MR. McCOY: Objection, objection, objection to any questions about names, okay?
MR. GLOOR: The name's all over the Cook County record. It's all over the court file, Bob.
MR. McCOY: Do I -- do I have to say it one more time?
MR. GLOOR: No, you don't because --
MR. McCOY: The name -- the name is not to be discussed. You have not presented a waiver here from -- from that family for the doctor to testify about it.
MR. GLOOR: All right. Besides --
MR. McCOY: That family has rights.
MR. GLOOR: Besides -- Yeah, you just dismissed the case. What rights do they have anymore?
Q Okay. Besides Edwin, besides Patient B, besides the one I'm not allowed to say, but we just talked about it, is there any other brain that has been autopsied where there is a claimed injury because of exposure to welding fumes?
Q Are there any other autopsies of people who are arising out of your work in this clinic where there is no issue of welding fume exposure, but you've autopsied for general education or general purposes, with the consent of the family?
Q And how many?
A Those we don't keep track of quite as closely.
A Five, six in the last year.
Q Are any of your opinions in the Boren case based, in whole or in part, same kind of question I asked before, on any of the autopsy work we've discussed for the last five or ten minutes?
MR. McCOY: And we specifically disclosed that his opinions are based on the autopsies. That's in our specific 213 disclosure. So to the extent that that word has some different meaning to lawyers, that's been disclosed, but he can answer.
THE WITNESS: I'll say yes then.
MR. McCOY: Becoming a lawyer now. Basis has a new meaning.
THE WITNESS: God save me from that.
MR. KOPRIVA: You mean beyond the normal English word?
MR. McCOY: Yeah, I think so.
BY MR. GLOOR:
Q Without disclosing names, and that's fine, what do the autopsies that you have seen -- Withdraw that.
The other five or six autopsies where there wasn't a welding from exposure issue, were those done by Dr. Ho as well?
Q And is Dr. Ho somebody you referred these people to for autopsy purposes?
A Well, I should -- I should just amend. Some of the autopsies actually were done outside. One's from the University of Pittsburgh. One, I believe, was done at the University of Wisconsin-Madison.
Q Again, I'm not asking for names at this moment, but the people who did the autopsies, one was Dr. Ho, correct?
Q The person in Wisconsin -- University of Wisconsin-Madison was who?
A I don't recall the names. Again, the contents of the report were what we were interested in, not the name of the prosector.
Q Did you send the brain for autopsy to Madison then?
A We -- That was the nearest medical facility to where the actual brain was removed, and for general histopathologic analysis, the nearest facility was fine.
The one that went to the University of Pittsburgh was a very peculiar case, and that was the choice of the family. That's where they wanted it looked at.
Q Do you know who the doctor was who did the autopsy?
A No. I mean, who did the autopsy versus who looked at the brain slides, I think -- I don't keep track of that.
Q Do you know any of those doctors' names, whether they did the autopsy or looked at the sides?
A I mean, they're board certified neuropathologists. I assume that gives me some credibility in terms of what I'm reading.
Q And you have reports then on these five or so non-welding exposure autopsies?
A We should. I mean, I've talked to them about them. Whether the final report -- Pathologists are a little slow sometimes in sending out reports. There's no urgency in getting the information out usually.
Q So the total number of autopsy reports would be the five or so we just talked about in terms of there not being any issue of welding fume exposure, and then the other ones we talked about, I think there are probably two of them, correct?
A Two with welding, one with manganese dioxide.
Q The manganese dioxide, is that the battery plant one?
A No, the battery plant one is actually welding fumes. This woman worked next to an automated welding machine.
Q The manganese dioxide one is then -- What's --
A Manganese dioxide is work -- I think it settled already. It's a workman's comp case out of Kentucky of a man who worked shoveling elemental manganese dioxide into some kind of an electroplating device.
MR. GLOOR: Am I allowed to ask him questions about these autopsy results, Bob?
MR. McCOY: Yes, because that's part of his experience with his patients. You just can't get into which name of who's done what. You know what I mean? As long as you ask him about the occupational exposure without attaching any name to it, I don't have a problem.
MR. GLOOR: Can I have a copy of these reports, the name taken off, so that I can have them examined by someone else?
MR. McCOY: Well, that -- that's, again, I think that's protected. I can discuss --
MR. GLOOR: By what?
MR. McCOY: I can -- By what I said was the law, which is without producing the records, he's permitted to testify to his own patient experience.
MR. GLOOR: I can't tell whether you're saying I can have copies or not.
MR. McCOY: Well, I -- at the moment, I'm saying that those records are not something that would be disclosed under the law. Now, I can consider the possibility, so I won't foreclose that.
MR. GLOOR: All right. What I'm after from you is a -- whatever your position is going to be, on whether I can see copies of the autopsy reports that Dr. Nausieda has been referring to the last half hour. Let me know. And if you say no, and that's obviously your privilege, I may seek judicial review, but let me know as soon as you can.
MR. McCOY: But let's -- let's just establish on the record, Doctor, the autopsy reports that you're talking about, one was, you said, for manganese dioxide exposure, right?
THE WITNESS: Yeah, and that one's not completed. That brain has just been shipped to us.
MR. McCOY: Okay.
MR. GLOOR: I see. By Dr. Ho?
THE WITNESS: I sent it to Doc -- yeah, at the Medical College.
MR. McCOY: Was that -- So that one's not completed yet. Okay. What are the -- There's, I think you said, two of them that are completed?
THE WITNESS: There's --
MR. McCOY: Or just one?
THE WITNESS: No, I mean, the one is completed. All the slides have been read, and there's a final report. The other two are still pending.
MR. McCOY: Okay. So the one that's been completed, was that a patient in your practice?
THE WITNESS: Yes.
MR. McCOY: Okay.
MR. GLOOR: I still want copies, so you let me know when you've made up your mind on that.
MR. McCOY: All right. So we have one completed report of a patient in your practice.
THE WITNESS: Right. See, there's three stages to the report. One is the gross description of the brain, okay? And then there's the histopathologic description of the brain, which is based on slides, staining, and looking at it under microscope. And then there's frequently an amended part looking at issues regarding chemistry, enzyme levels, and various other markers that have a research purpose.
BY MR. GLOOR:
Q When you get the report, do you also get the slides, Doctor?
Q That's kept by whoever did that?
Q Because Bob and I have to work out this issue, and maybe we can, which is hopeful, you never know, in any case, I don't know if you're the person to ask, but what I'd like to do is have the slides retained as well and not disposed of or destroyed.
A Oh, no, no, nothing -- We are very careful not to have anything destroyed because there's always been the assumption of the need for an outside reviewer perhaps to look at all of them collectively and --
See, the problem with getting slides in the brain is you're looking at small regional areas in a very large structure. The number of potential sites you could look at is quite -- it's infinite because these slides are microscopic thin sections. So you can spend a whole lifetime analyzing one brain. I don't think they've ever finished with Einstein's. So, yeah, the brain is available, and we have retained specimens but --
Q Okay. So the whole brain has been retained, as well as the slides, if I understand what you're saying.
A Yeah. In some instances, half the brain is frozen, it has not been touched, it's been kept in, you know, at ultra cold temperature, and the other half has been fixed in formalin, which is the standard way to fix central nervous system tissue.
Q All right.
MR. McCOY: Let me ask another foundation question for the disclosure issue. The reason I know this is we've just been through these on a number of cases with him.
This completed autopsy, where the full report's been prepared, is that something that's also -- in addition to a patient, is that something that's also part of your ongoing research into this area?
THE WITNESS: Well, it's been funded by our private research funds. I mean -- I mean, the sections belong to the family, I suppose, like everything else in medicine. I think that's my only concern is I don't know quite how HIPAA relates to cadavers. I know that the retention of privacy goes on infinitely but --
MR. McCOY: Then -- Go ahead.
THE WITNESS: But, I mean, again, in terms of, you know, why do we get these -- It was very difficult to obtain this material before because Medicare doesn't consider a dead body covered by Medicare, so someone has a pay for the -- for the autopsy. We thought that that was a high priority item, so we pay for it out of funds that we solicit for research purposes.
MR. McCOY: So then in addition, the purposes of this research would ultimately be, in part at least, to improve patient health care and to reduce morbidity and mortality. That would be at least a part of -- part of the ultimate research.
THE WITNESS: One always justifies research with altruistic sounding things, but yeah, it's for the advancement of our knowledge and for a more precise diagnosis.
MR. McCOY: All right. Those are just foundation questions, Doctor, for the point he's trying to make about getting the records. Thank you.
BY MR. GLOOR:
Q The private research fund, who did you raise that from, or who did you solicit for those private funds used for the research?
A Primarily -- Well, different foundations. There are a number of foundations we've contacted regarding support of that program. Most of the large donations have come from individuals who are actually patients or families of patients.
Q Any lawyers involved in funding the private research, lawyers or law firms?
A Not unless they did this in a previous life. No. I mean, especially regarding this welding issue? No, there's no funding from any of the litigants in this particular case.
Q I will do my best in asking some questions about the autopsies and what your opinions are about them and what they mean.
MR. McCOY: You're welcome to do that.
MR. GLOOR: Thanks. Without --
MR. McCOY: Without names.
MR. GLOOR: Without waiving my right that I'm going to assert to get ahold of them, unless Bob agrees to give them to me voluntarily. So --
MR. McCOY: I don't know that I have the power to do that, but go -- but go ahead. I can consider whether we can get them.
MR. GLOOR: I thought you were going to think about it.
MR. McCOY: But I don't know if I have voluntary power to do it. You said give -- give me to give them to you. I don't think I have that power myself. Go ahead, though, you can ask.
MR. GLOOR: I just want to make sure that I'm not waiving anything. So let's go back to the autopsies.
Q The Edwin autopsy -- I didn't say that word -- what did that tell you?
A Well, again, without the report in front of me, Andonio Edwin's autopsy --
Q I have a copy, if you want to look at it.
A Yeah, if I could just take a look in the gross description.
MR. McCOY: For the record, again, foundation, Doctor. Andonio Edwin was not your patient; is that right?
THE WITNESS: I was asked to see him. I examined Mr. Edwin and talked to his wife and -- That doesn't make him my patient.
MR. McCOY: You saw him -- you saw him at the request of the lawyers.
THE WITNESS: Yeah, Mr. Bosla (phonetic) took me over to his house.
MR. McCOY: So other than at the request of the lawyers, he was not your patient.
THE WITNESS: That's correct.
MR. GLOOR: Would you mark this as Exhibit No. 2. It's a copy of what the good doctor is looking at.
MR. McCOY: Yeah, and for the record, Pat, your right to bring some motion to compel production of these other autopsy reports is preserved. I'm not contesting that. I'm just trying to make some foundation to help resolve it.
(Exhibit 2 marked for identification.)
THE WITNESS: Okay.
BY MR. GLOOR:
Q You haven't looked at Exhibit No. 2, which is what it is. I've had -- One is marked, that one, same thing.
A Same thing.
Q What does that tell you -- What information does this give you, Exhibit No. 2?
A Well, again, the final interpretation of this was that -- was that Mr. Edwin had a multi-systems atrophy, which is a parkinsonian variant syndrome. It differs from Parkinson's disease on the basis of the selective loss of tissue in the substantia nigra versus the postsynaptic dopaminergic system.
What they basically say here, that there are no Lewy bodies and that the pattern of cell loss is more widespread than one would normally see in Parkinson's disease.
So that there is involvement of the cerebellum, and then there is -- they make a lot out of the intranuclear filamentous inclusions in the pontine nuclei, which has been taken as a marker, as I understand it.
I'm not a hist -- I'm not a neuropathologist, I don't claim to be one, but they talk about these intracellular inclusions, which they feel are typical for multi-systems atrophies.
They also talk about the fact that there's depigmentation in the substantia nigra and locus ceruleus, at least on gross anatomic analysis. They don't really say much about it on the -- on the histopath, which surprises me. Actually, I thought there had been more about that in this report.
And there's, you know, basically a picture that the neuropathologist felt was more consistent with multi-systems atrophy than with Parkinson's disease.
And, again, I'm not going to argue with their interpretation of it. When I saw the interpretation, that certainly was not inconsistent with Mr. Edwin's clinical presentation, in that he had a nonresponsive, rapidly progressive, extrapyramidal disorder. However, his clinical picture was not unlike our patient, who also was autopsied, whose -- in the pathological interpretation of her case was manganese intoxication.
Q Who was that?
MR. McCOY: Is this -- is this the, again, describing them by occupational exposure, to the battery plant with weld --
THE WITNESS: This is a woman who worked in a battery plant, who's got passive exposure for 20 years to automated welding equipment which was right next to her desk at the -- at the factory.
BY MR. GLOOR:
Q And she made a comp claim, as I recall you said, she made a worker's compensation claim?
A Family did. The woman was dead by the time the claim was filed, as I understand it.
Q Was that here in this state?
A Correct, in Wisconsin.
Q Do you know, was it in whatever county Milwaukee is in? I'm sorry, I don't know the answer.
A They live in -- they live in Waukesha County. I don't know whether it was filed here -- I'm not sure where the factory is, actually. I think it's in Waukesha.
Q Do you know the name of the factory?
A It's Eveready Battery.
Q Let's go one step at a time. In terms of Exhibit No. 2, which is the Andonio Edwin, my recollection -- and correct me if I'm wrong -- is that you thought Mr. Edwin had a manganese-related injury before the autopsy, correct?
A I thought that was -- that was one of the major factors in the differential diagnosis for him, that there was a significant likelihood that that was the case.
Q Did the autopsy results surprise you, based on what you thought he had before he died?
A Well, and I think this came out in previous depositions. I said, you know, it's either multi- -- If mang -- If he didn't have an occupational exposure history, that clinical picture is consistent with multi-systems atrophy, and the fact that it was interpreted as multi-systems atrophy, I guess, didn't surprise me, in that that was the other -- other neurological syndrome which would have looked this way.
Q Multi-systems atrophy, I take it, is not manganese related, if I understand what you're saying?
A Well, that's a good question. I think that -- I think one -- I'm not a neuropathologist. Again, and this is their bailiwick, not mine.
I'd like to know how a neuropathologist eliminates manganese toxicity from multi-systems atrophy, because as I reread the hist -- the pathological reports that are in the literature, it seems to me that there might be some difficulty in differentiating the two.
Q Based on literature that exists as of today, is multi -- multiple systems atrophy thought to be caused or related to manganese exposure?
A Multi-systems atrophy is unknown etiology, which leaves the origin of it open to anybody's speculation.
Q The autopsy in the lady who was at Eveready Battery.
Q That's, again, something you have here, right?
Q I understand Bob says I can't look at it now, and I'll accept that for the moment; I have no choice. What did that autopsy result show?
A Well, in some ways, it's very similar to this one, in that it shows --
Q This one being Exhibit 2?
A The Edwin, the Edwin autopsy. It shows depigmentation in the -- in the substantia nigra and locus ceruleus on gross exam These are standard anatomic landmarks you can see.
Unlike the Edwin one, they don't comment on atrophy of any other structures, like the pons or the cerebellar hemispheres. In looking at the slides with the neuropathologist, this case showed no Lewy bodies either, which is, again, similar to Edwin, and there's some dropout of cells in the substantia nigra pars compacta. There are some -- You can see some loss of pigmented neurons. But the brunt of the neurologic -- neuropathologic injuries seems to be in the -- in the globus pallidus in the receptor area.
Q It's postsynaptic, if I understand what you're saying?
A Correct. I mean, it's where the dopamine cells are going to from the substantia nigra. What we found interesting in this case was that it's very similar to the -- the Viennese autopsy by Bernheimer and Hornekiewycz, which is one of two really well-done autopsy cases of manganese poisoning in the world literature. There's a Yamada autopsy, and then there's the -- the Bernheimer-Hornekiewycz autopsy.
The critical issue there was that the Bernheimer autopsy says that the substantia nigra pars compacta does show cell loss. The Yamada one says that the substantia nigra seems to be spared, that the cells look okay.
That has tremendous implications in terms of whether one would expect a therapeutic response to L-dopa in the patient. That if the nigra was depigmented and there was cell loss, one might anticipate at least some response to levodopa in that patient, and that's been a real stumbling block in our ability to diagnose manganese toxicity versus Parkinson's disease, with some individuals claiming that if you have any response to L-dopa, that means you can't diagnose manganese poisoning because it wouldn't show that.
And so, you know, the old problem was it's a 50-50 split on pathology regarding this because it also has implications for fluoro PET scans. There's been some suggestion that you have to have a normal, you know, fluorodopa PET scan to have manganese intoxication as a diagnosis.
Well, if our autopsy is correct -- and I assume it is because we have documentation of elevated manganese levels in this patient -- then we now have two cases to one suggesting substantia nigra cell loss occurs in manganese intoxication.
That would then suggest that some dopamine responsiveness is possible or, in fact, anticipated, which would vindicate a lot of authors, including some of the most widely quoted descriptions of manganese poisoning in the literature, and it would also call into question the issue of whether the PET scan has to be normal.
One -- one would be -- would have to accept the fact that a PET scan should -- could show dopamine depletion in a patient with manganism, based on the pathology, which I think is a definitive definition of what we're going to consider manganese intoxication.
Q In terms of the autopsy report for the lady from Eveready Battery, I think you said that the greater amount of the damage was postsynaptic in the globus pallidus, correct?
A And, again, I mean, this is -- this is a neuropathologist's interpretation of what he's looking at in the scope. Me looking through the scope, I wouldn't want to put a lot of money on my opinion. I was never good at doing this in the first place.
Q I'm not asking you to take a position if you're uncomfortable with that, but in terms of what the neuropathologist said who looked at the lady from Eveready Battery --
Q -- he put most of the damage in the globus pallidus, correct?
A Well, he said in Parkinson's disease, you wouldn't see that. See, the point is there is damage there. How much of one versus the other, that's not really stated in the report. It just states that it's unusual for Parkinson's disease, in that you don't have Lewy bodies, you've got damage to the globus pallidus, and yet, like Parkinson's disease, there's depigmentation and cell loss in the substantia nigra pars compacta.
Q Does the absence of Lewy bodies then have any significance to you in distinguishing between manganism and Parkinson's disease?
MR. McCOY: Object. Object to -- Again, are we talking now about the specific patient who was autopsied, or are we talking about, as a general matter, the whole population? He can answer.
BY MR. GLOOR:
Q You can answer the question.
A Well, I mean, again, I was trained by neuropathologists, and I was told that the Lewy body was something that you'd expect to see in your classic case of Parkinson's disease, but that it wasn't invariably present, and the exact number you needed wasn't identi -- exactly known, and people without Parkinson's disease certainly could have Lewy bodies.
There's a paper that you must have as a -- in your files, which I think probably summarizes this better than I could possibly do it, by Dr. Calne and his co-workers, called the Neuromythology of Parkinson's Disease, which I think expresses my cynicism about our reliance on some of these criteria a lot more cynically than I could have done.
And basically it says that, you know, this whole thing about Lewy bodies being a prerequisite for Parkinson's disease is nonsense and that the histopathology of Parkinson's is highly variable and raises the issue that we've raised throughout these depositions and in trials, is that whoever said this was one disease?
Parkinson's disease, as a clinician, I can tell you this is not one disease. I saw seven people today, and they probably reflected at least three distinct clinical syndromes, if not, you know, more.
So I think that, you know, manganism -- manganism's been thrown into the heap with all these other conditions for the last 50 years. It doesn't necessarily mean that it belongs there, nor that it's not a distinct clinical entity.
Q So you think manganism is a distinct clinical entity.
A I think like all neurologic -- you know, like all disorders, there's a full-blown form of manganism, which I think is unmistakable when you see it.
Q And that would involve damage to the globus pallidus.
A I can't say that, but it involves the development of a neurological syndrome that looks vaguely like Parkinson's disease in people who are way too young to have Parkinson's.
Q But on the autopsy, which I think someone said, maybe you, the gold standard of determining exactly what a person has, at least in the lady from Eveready, she had the damage -- most of the damage in the globus pallidus, and she had the absence of Lewy bodies; is that correct?
A Well, I don't know that most in the globus pallidus. I guess that's my inference, because this woman really did not -- The minute we would try to treat her for her parkinsonism -- She initially responded pretty well and -- which made us think she had Parkinson's disease initially, but then she started hallucinating the minute that we gave her the meds, and we -- we couldn't treat her. The family felt it was just too intolerable to have her psychotic all the time. So I guess I'm reading into that that there must have been a lot of problem on the receptor side to give you that response.
Q Besides we talked about Edwin, we've talked about the Eveready battery lady, --
Q -- are there any other autopsy reports that you have seen from people who were exposed to welding fume?
A Not the histopath, just the gross.
Q And the gross doesn't say anything about the --
A The cells.
Q -- the cells, does it?
Q So in looking at the gross pathology -- correct me if I'm wrong -- would it be accurate to say that that observation of the gross pathology doesn't help you to determine what parts of the brain were damaged and make a conclusion on whether it's manganism, Parkinson's disease, MSA, or anything else; is that correct?
A Yeah, the gross isn't as valuable as looking at the histopath. The gross, in the one case actually, is -- is abnormal looking. I mean, I -- But I'm waiting for the cell -- the cells to be looked at before I make any conclusions about it.
Q Again, this is the name -- I'm not going to say it because I'm not allowed to say it -- but the case you're talking about is the one that is being held by Dr. Ho?
Q And you've seen the gross pathology on that one, correct?
Q And you -- Have you drawn any conclusions based on looking at the gross pathology of what you've seen?
A No. It looks like -- it looks like his MR scan. The MR scan indicated some cerebellar atrophy and what looked like pontine atrophy, with some equivocation on the part of the radiologist. That seems to be true when you look at the gross specimen as well.
Q Based on what you've seen in looking at the gross specimen, was his neurological problem manganese related?
MR. McCOY: Objection to the -- to that question because, again, that -- that calls for the doctor to talk about the case about a patient, and I don't know that he's -- I don't know that he's formed any conclusions that could be revealed outside of, you know, a specific medical release on that case being in front of us.
BY MR. GLOOR:
Q Can you answer the question?
A Clinically, that patient carried a diagnosis of manganese poisoning. That's what I felt he had clinically based on our clinical assessment of him, his response to being withdrawn from medications, and his occupational history.
Q But in terms of looking at the gross pathology, I suppose is what I'm focused on, did that give you any additional insight into what he may have been suffering from?
MR. McCOY: You're talking about at the present -- at the present -- at the present moment, because you haven't established he's completed his analysis of this autopsy.
BY MR. GLOOR:
Q We both agree, I think, that there hasn't been a sectioning, an examination of the cells, correct?
Q And until that's done, there's no definitive conclusion possible; is that correct?
A That's where, I mean, it's too hard to tell. The thing that's interesting is that the brain's external appearance bears vague similarities to what's described in Mr. Edwin. So then the question is do we really know what the histopathology of manganese exposure looks like, and so I think we need to look at a series of these patients very, very carefully.
Q Yeah, we can as time goes by, I agree, but in terms of as you sit here today, in terms of the person you've been talking about that -- where the gross pathology you've observed, the gross pathology observation that you made looks to you like the pathology of Mr. Edwin, who had multiple systems atrophy, correct?
A Yeah, if you looked at the outside of the brain, your first guess would be it looks like an MSA brain.
Q Any other pathological reports, neuropathological reports that you've seen besides what we've talked about so far?
MR. McCOY: Are you talking now about other than what's been published in journals?
BY MR. GLOOR:
Q Let me go back and ask a better question. In terms of welders who have been exposed to welding fume, have you and I now discussed all of the autopsy reports that you've looked at?
Q You have seen autopsy reports, I take it, from the non-welders that we talked about 20 minutes ago, but that's -- those are five or six people, University of Pittsburgh, Wisconsin, others, those are --
Q You've seen reports from those.
A I've looked at the slides in many of the cases.
Q I know you said you weren't a neuropathologist. When you look at the slides, does that -- is that something that you can look at meaningfully or not?
A That's an interesting question. Can one look at a sunset without an artist standing next to you and appreciate? I guess I can see the cell damage when it's pointed out to me by a neuropathologist and they've gone through what they've based their criteria for various diagnoses on.
So one of the patients had classic progressive supranuclear palsy, and he was -- he was a newsworthy guy, he had a very interesting history, a very prominent NASA person, apparently. And what was interesting was that he concomitantly had Alzheimer's disease. And the question was, how did you know he had Alzheimer's disease? He couldn't talk to me anymore.
And so we went through the pathological findings that made them feel he had two similar -- two conditions independently, which was valuable only because his wife was worried that he had suffered so much with being immobilized, but knowing he was demented was somehow more comforting to her.
Q Was he a patient of yours?
A Yes, he was a patient of mine for like the last seven years.
Q And what did that -- Were there Lewy bodies?
Q Withdraw that. What was the autopsy conclusion in terms of he had Alzheimer's, and what else did he have?
A Progressive supranuclear palsy, which is one of the MSA group of diseases.
Q The other -- Let's take the next one in order, whatever the order you want to choose, in terms of your patients' non-welding exposure autopsy reports that you've seen, what would be the next one?
A Next one was a woman who's been a patient of ours for about 20 years who had what I thought was classic Parkinson's disease and a lot of anxiety and depression, whose husband thought she must have had something more occult than that, and she had -- was read out as having classic Parkinson's disease, but had brain stimulators in place and had -- and had surgery at the University of Kansas for Parkinson's. And we were just questioning whether the failure to respond to the treatment was due to bad lead placement or bad surgical placement.
Q Is this deep brain stimulation we're talking about?
A She had -- she had had a pallidotomy and the DBS unit. And I don't know that I'd learned much from that because I don't know that you can tell exact -- We don't -- The pathology is not sufficient to quite -- at least to me, I don't think we know where the lesion actually extended to from the pallidotomy, and I think it's kind of a moot point at this point. But she had -- her pathology showed Lewy bodies, and it was consistent with Parkinson's disease. The other patient --
Q Any damage in the globus pallidus in this one lady we just talked about?
A It wasn't commented upon, and I don't remember looking at that area. When they scanned the brain stem, they must not have been impressed by that.
The other patient was a patient -- actually, the youngest Parkinson's patient reported in the world literature, and his autopsy was -- and he has a typical fluoro PET scan for Parkinson's disease, and it was reported in some of the neurologic journals a few years ago.
And he -- his pathology report said absolutely not Parkinson's disease, and they read that out as inclusion body encephala -- chronic encephala -- chronic inclusion body encephalitis.
Q What's that?
A I don't know. I have to talk to them. I've never -- I've never heard of it. They did cite two other or three other papers talking about it, but none of them had parkinsonian symptoms, so I don't know what to make of it.
Q Whatever it was, it wasn't Parkinson's disease?
A Well, the question is how did they decide it wasn't Parkinson's disease, since the PET scan said it was? He obviously had damage to the substantia nigra, but there were these odd inclusion bodies in the cells, and I haven't been able to track down -- I actually haven't had time to track down the neuropathologist to ask for a fuller explanation.
Q Who's the next person whose autopsy -- whose autopsy you have seen?
A Those are the only ones that I've seen. I've got reports on other patients. I mean, every other case has been Parkinson's disease or Alzheimer's disease, with -- with evidence of substantia nigra depigmentation, which is the standard --
Q So the other autopsy reports you've seen are Parkinson's disease or --
Q -- Parkinson's disease slash Alzheimer's?
A Right, with Alzheimer's changes on the -- on the path report.
Q And those -- How many of those are there, the --
A You know, again, like I said, it's probably about five, six for the year.
Q And --
A Total, I mean, including these other three.
Q The ones that you talked about before.
Q In terms of these last two or three, which ever the number is, that have Parkinson's disease slash Alzheimer's as the conclusion on the neuropathological report, Lewy bodies were present?
A As I recall, Lewy bodies are present, and that's how they make the diagnosis of Parkinson's disease.
Q I'm sorry, go ahead.
A I'm sorry. If there weren't Lewy bodies, they would probably call it something else.
Q Any damage in those Parkinson's disease slash Alzheimer's to the globus pallidus?
A Not that's commented upon, no.
Q Have we covered all the autopsies --
MR. McCOY: Did you get his word, when he said not that's commented upon?
(The last answer was read.)
MR. McCOY: Okay.
THE WITNESS: I think we've beaten that to death.
MR. GLOOR: Isn't that the truth. Let's move on. Let's go back, if I can, to --
MR. McCOY: I thought we were here for other things, but so be it.
MR. GLOOR: I won't rise to the bait. Let me just -- Let's move on.
Q The post Gulf Coast examinations you made, the 2,550, whatever the number was, when you made the examinations, did you take any fluid levels, blood, urine, to see if there was an unusual manganese content?
A No. Because I'm not licensed in the states that we're going to, I'm incapable of ordering lab work, drawing blood, or doing anything as a physician.product liability page for more information.