Credibility of Medical Evidence - National Association of Workers

Transcription

Fourth Annual NAWCJ Judiciary College
August 20-23, 2012
I.
II.
III.
IV.
V.
VI.
VII.
VIII.
IX.
X.
Judicial Writing and Editing, Professor Terrel
Comparative Law Panel
Credibility of Medical Evidence, Professor McCluskey
Evidence
a. Electronic Evidence, Professor Ehrhardt
b. Evidence for Adjudicators, Ehrhardt
Live Surgery, Biographies
To Tell the Truth, Ms. Constantine
Keeping the Case on Track, Judge Jones
Social Networking, Rissman Wieland
Technology
a. Technology, Judge Rosen
b. Technology, I phone Article
Appellate Roundtable
a. Appellate Roundtable, Alvey
b. Appellate Roundtable, Jones
DETERMINING CREDIBILITY OF MEDICAL OPINIONS
James McCluskey, M.D. – Univeristy of South Florida
Dr. James McCluskey is a Board Certified Occupational Medicine
Physician and a PhD-trained Toxicologist. He is the Medical Director of
the Center for Environmental/Occupational Risk Analysis and
Management at the University of South Florida, Tampa, Florida. In
addition, he is an assistant professor at the USF College of Medicine in
the Department of Internal Medicine, and a research assistant professor
at the USF College of Public Health in the Department of
Environmental and Occupational Health. Dr. McCluskey completed an
advanced subspecialty residency in Occupational Medicine in which the
program curriculum and clinical experiences were extensively in Toxicology and Risk
Assessment. Dr. McCluskey is actively involved with a research team investigating the human
health effects of chemical exposure(s). His publications include articles on chemical exposures
and various pulmonary conditions, as well as co-authorship of a chapter on occupational asthma.
He is a frequent lecturer for public, private and academic groups. His medical practice is focused
on the evaluation of medical cases involving environmental/occupational chemical, respiratory,
infectious and allergen exposures.
Work Made Me
This Way!!!!!
What is an IME?
Evaluation of
Complex Workplace
Incidents, IME’s and
Determining the
Credibility of Expert
Opinions
James McCluskey, MD, MPH, PhD
University of South Florida
Colleges of Medicine and Public Health
You’ve Been Exposed!
A Question of Fact Arises …..
And The Game Has Actually Just Begun………
¾How do Two “Qualified Experts” reach
Diametrically Opposed Views?
Wouldn’t it be nice if an “exposed” monkey was orange?
“Simple” = Please Avoid These
Mistakes
No Objective Testing
Poor Quality Objective Testing
Ignoring “Quality” Objective Testing
Ignoring Common Sense
• The Case Facts (or lack thereof) – What, why, how,
etc.,
t etc.
t
• The Experiences of Each – 1 year x 26 or ……
• The Opinions of Each – Style Issues
• The Literature Considered …. Or Not
• The Interpretation of the Literature
• The “What I Believe is Right” Phenomenon
Evaluation of a Workplace Claim
9 Evidence of Exposure
9 Exposure Must Result in a Dose
9 The Dose Must be Sufficient to
Cause the Effect
9 The Effect Must be Known to be
Caused by the Chemical/Insult
9 Effect Must be Temporally
Eligible to be Caused by the
Exposure
9 Effect Must be Biological
Plausible
9 Other Causes Must be Eliminated
+
1
Questions the “Captain” Should Ask!
• Why has he had MRSA for
three years?
• Can a PPD become positive
1 week after exposure?
• What
Wh t iis the
th utility
tilit off th
the
that “weird” test?
• His allergy testing is
“negative”?
• Is all wheezing asthma?
• She has been coughing (1.5
years) since the exposure?
Asking the Right Questions…..
Don’t Get a “Muddy” Chart!!!!
Subjective
Objective
9 Shortness of Breath ≠ Reactive Airways ≠ Asthma
≠ COPD ≠ Hypersensitivity Pneumonitis (Extrinsic
Allergic Alveolitis) ≠ etc.
Establishing Causation
NEEDS IMPROVEMENT
(The Tale of Can and Did)
In your professional opinion, what is the
diagnosis?
GENERAL CAUSATION
BETTER
In your professional opinion, what is
the diagnosis and what objective
information supports your finding(s)?
Chemical CAN cause the particular disease
or symptom
SPECIFIC CAUSATION
Chemical DID cause the particular disease
or symptom
*******Also Known As – Possible and Probable********
Use of the Medical Literature
Anything is Possible, Few Things are Probable
• Remember the Chain of Believability
– Case Report
– Case Series
– Case Control/Cohort/Nested Case Control
Consistent Results, Repeated by
Different Investigators are the Highest
Level of Evidence!!!!
Don’t Forget
The Rest of the Story…..
Weeding Out Confounders
In a Case
2
Water intrusion
Mold
growth
Renovations
painting
dry walling
Building
sources
Cleaning
chemicals
Air
fresheners
Just Think
Airway
injury
Oxidants
Elevated
VOCs
MVOCs
Formaldehyde
Terpenes
Building
conditions/
factors
Temperature
Humidity
Lighting
Noise
The Typical American….
Ozone
outdoors
Reduced
Outdoor
Air supply
Airway
inflammation
Reactive
molecules
Someday,
S
d h
he
may claim that
work gave him
CANCER!
Symptoms &
Complaints
The Indoor Air Environment
Pure Chance Causes
Many (MOST) Things
The Chemical Soup Where We
Eat, Breathe, Bathe and Work
Also Referred To As:
Bad Luck!!! – Winning The Lottery….
“Planned” Bad Luck – Smokin’,
Drinkin’, Lovin’ and Breathin’
Having a Bad Pair of Levi’s (Genes)
Special Considerations …..
The
Boss
Individuals at Increased Risk
9Immunocompromised
¾ Organ transplantation
¾ Immunosuppression
¾ Cancer chemotherapy
¾ Disease with Immunosuppression
9Very Young
9Very Old
9Pregnant
Me
[email protected]
(813) 505-6709
Questions?
3
James McCluskey, MD, PhD, MPH
University of South Florida, College of Public Health
13201 Bruce B. Downs Boulevard, MDC 56
Tampa, Florida 33612
jmccluskliV,health.usf.edu
Phone - (813) 505-6709 Fax - (866) 615-0928
January 31, 2012
XXXXX, Esquire
XXXXXXXXXX
Mr.
Re: GGGGGG AAAAA
Dear Mr. XXXXX:
As you know, this was a situation involving a great deal of
medical care and hospitalizations, yet the basic facts related to any exposure that Ms. AAAAA
possibly had while working for the OCs are quite clear. For purposes of explaining her potential
workplace exposures, I have included details related to the various industrial hygiene evaluations
and remediation activities that were undertaken at the OC since 2009.
INDUSTRIAL HYGIENE EVALUATIONS:
October 20, 2009: Asbestos Abatement Report Pre-Cleaning of Attic and Chiller/Boiler
Room Abatement - Morse Zehnter Associates - This report documents the contracted precleaning and stabilization of asbestos-containing (ACM) from walkways in the attic space of
OC., as well as the abatement of ACM in the boiler and chiller rooms. The attic walkways were
cleaned with a HEPA vacuum cleaner, and ductwork (NC) that was likely to be impacted was
covered. In the boiler room the area was demarked by asbestos caution tape and friable plaster
fittings were removed. In the chiller room the room was isolated with negative pressure
containment and insulation for the pipes with stripped and placed in disposal bags. The work
area was then cleared for re-occupancy by visual inspection and phase contrast microscopy air
sampling. The work area was released for re-occupancy when all five samples were found to
have less than .01 fibers/cubic centimeter which is the lowest quantifiable level for the analysis
method.
All abatement activities were performed in accordance with the 'Technical
Specification" dated February 2009 and the Scope of Work developed for this project and
revised by MZA dated September 2009.
Julv 26, 2010: Site Inspection and Air Sampling Report - Ecotech Environmental
Consultants - Air samples were collected on July 23, including I outdoor sample for
comparison purposes. The samples were examined by EMSL. This report included comments
on 18 samples. Sample I was taken of the outdoors.
Comment on Samples 2,7,10,13,14,15 and 17: Despite the fact that indoor spore levels were
higher than outdoor levels, the spore counts detected in this area are not very significant when
compared to average spore counts in Florida during this time of year.
Comment on Samples 12 and 16: Total indoor mold spore levels were moderately elevated
when compared to total outdoor mold spore levels, thus mold may be growing and releasing
spores somewhere in or near the above mentioned test area
Comment of Samples 3,4,5,6,8,9,11 and 18: Total indoor mold spore levels were high
compared to total outdoor mold spore levels, thus mold may be growing and releasing spores
somewhere in or near the above mentioned test area
August 2, 2010: Expanded Fungal Report - EMSL
Air Sam le Results in the ARLC Northeast Wing)
Spore Type
Ascospores
Aspergillus
Penicillium
Basidiospores
Cladosporium
Curvularia
Myxomycetes
Torula
Total Fungi
Hyphal Frag
Sample #12
Room 207
Sample #13
TV Room
by #207
4980/m 3
484/m 3
211m 3
201m 3
71m 3
Sample #14
Room 194
•
Sample #15
Room 193
Sample #16
Room 192
211m 3
359m3
841m3
211m 3
211m 3
71m 3
5010m 3
506/m 3
t-
380/m 3
105/m3
211m 3
August 14-24, 2010: Site Inspection and Air Sampling Report - Ecotech
Total Spores were High in the following areas: Conference room; Office #129; East unit rooms
145, 140; Room 238, 235, 245, 249, 252, 255, 267, 264, 285; Office #128; CMO Office;
Pharmacy; Medical Records; ARLC Laundry (207).
One or more Spore Types were High in the following areas: Client funds office; East unit room
139,140; ARLC kitchen; Rooms 209, 208, 203, 242, 264B, 258: Administration Office.
One or more Sport Types were Moderately High in the following areas: East unit room
#147, Medical records, Finance office south side, Room #169, ARLC TV room and Room
#231.
September 10, 2010: OC Indoor Air Quality Report - Morse Zehnter Associates - MZA
was asked to conduct a 3'd party review of the Ecotcch data generated in the August 14-24 site
collections. MZA was informed that the inspection occurred during a time when the temperature
and humidity levels in the building were elevated due to the condition of the AlC system. Thus,
the results of Ecotech may reflect a time that may not be representative of the building under
controlled conditions. MZA agreed that with their conclusion that certain areas of the building
may have been impacted by moisture from AlC condensation, plumbing, window and/or
envelope leaks that need to be addressed as soon as is practical. We have prioritized seven areas
for remediation where such factors as the mold spore levels were elevated and were in
2
combination with observations of visible mold, moisture and high humidity areas. Remediation
will consist of controlled removal of some walls behind dust barriers, identifying root causes of
moisture intrusion, correcting moisture intrusion problems, cleaning the space, filtering the air
and then conducting real time particulate level measurements in order to release for reoccupancy.
September 22, 2010: OC Indoor Air Quality Consulting Report - Post Remediation
Verification Rooms 235/238 West Unit - Morse Zehnter Associates - The post remediation
process consisted of a visual inspection of the work area for cleanliness following the removal
and replacement of water/mold damaged building materials from each of the client rooms by
Duraclean Restoration. The level of nuisance particles were also determined.
Results for Nuisance Particles: Rooms 235/238 West Unit
235 - Overall average concentration = 0.030 mg/meter cubed
MZA sets the clearance standard at 1/10 the OSHA PEL for respirable particles, or 0.5 mg/meter
cubed.
September 23, 2010: OC Indoor Air Quality Consulting Report - Post Remediation
Verification Rooms 128/129 Pharmacy Area - Morse Zehnter Associates - The post
remediation process consisted of a visual inspection of the work area for cleanliness following
the removal and replacement of water/mold damaged building materials from each of the client
rooms by Duraclean Restoration. The level of nuisance particles were also determined.
Results for Nuisance Particles: Rooms 128/129 Pharmacy Area
MZA sets the clearance standard at III 0 the OSHA PEL for respirable particles, or 0.5 mg/meter
cubed.
3
October 8, 2010: OC Indoor Air Quality Consulting Report - Post Remediation
Verification Room 145 Pharmacy Area - Morse Zehnter Associates - The post remediation
Results for Nuisance Particles: Room 145 Pharmacy Area
MZA sets the clearance standard at If! 0 the OSHA PEL for respirable particles, or 0.5 mg/meter
cubed.
Verification Room 122 Chief Medical Officer - Morse Zehnter Associates - The post
remediation process consisted of a visual inspection of the work area for cleanliness following
the removal and replacement of water/mold damaged building materials from each of the client
rooms by Duraclean Restoration. The level of nuisance particles were also determined,
Results for Nuisance Particles: Room 122 ChiefMedical Officer
MZA sets the clearance standard at 1110 the OSHA PEL for respirable particles, or 0.5 mg/meter
cubed.
Verification Room 252 West Unit - Morse Zehnter Associates - The post remediation process
consisted of a visual inspection of the work area for cleanliness following the removal and
replacement of water/mold damaged building materials from each of the client rooms by
Results for Nuisance Particles: Room 252 West Unit
MZA sets the clearance standard at 1f!0 the OSHA PEL for respirable particles, or 0.5 mg/meter
cubed.
Verification Room 264B West Unit - Morse Zehnter Associates - The post remediation
Duraclean Restoration. The level of nuisance particles were also detennincd.
Results for Nuisance Particles: Room 264B West Unit
264B - Overall average concentration = 0.026 mg/meter cubed
MZA sets the clearance standard at If! 0 the OSHA PEL for respirable particles, or 0.5 mg/meter
cubed.
November 1, 2010: OC Indoor Air Quality Consulting Report - Post Remediation
Verification Room 267 West Unit - Morse Zehnter Associates - The post remediation process
consisted of a visual inspection of the work area for cleanliness following the removal and
replacement of water/mold damaged building materials from each of the client rooms by
Results for Nuisance Particles: Room 267 West Unit
4
MZA sets the clearance standard at 1/10 the OSHA PEL for respirable particles, or 0.5 mg/meter
cubed.
Januarv 31, 2011: OC of the Palm Beaches - Moisture Intrusion Assessment - Morse
Zehnter Associates - MZA was retained to evaluate the extent of water damage and moisture
intrusion in areas that were previously noted in a prior consultants report. Visual Observations:
Storage Room (Laundry) 2007 - Mold growth along the edge of the wall to ceiling grid
intersection, around the lower base cabinet and in the wall cavity between Room 207 and the
hallway. Office 186 and 184 - Water damaged ceiling tiles from the above NC ductwork.
MZA observed elevated moisture in the following area - Rooms 258, 249, 245, 280, 207, 139
and hallway wall that backs to kitchen 307. Discussion and Recommendations: Many areas that
were stated as damaged from condensation in the previous consultants report consisted mainly of
water damaged ceiling tiles. The reported condensation of surfaces in many areas of the building
is believed to be an isolated event related to a malfunctioning NC system and that condition
does not exist currently. The lay-in acoustic ceiling tiles have already been replaced. The
previous consultant performed moisture readings shortly after an event of high humidity related
to the NC malfunction. Therefore, many of the identified sites in the previous consultant's
report might have been related to high humidity versus a local water intrusion source. Found
some elevated moisture conditions during remediation oversight, particularly in the West Wing.
These conditions could recur. The majority of previously noted areas of water damage were dry
on the date of our inspection. Recently, all windows were resealed and the adjacent sprinkles
were checked to assure that they were not spraying the building. MZA has identified one area
near room 169 and the adjacent hallway that should be remediated.
HOSPITALIZATIONS and HOSPITAL VISITS: May 25 - September 13, 2010
Hospital Visit #1
May 25, 2010: Good Samaritan Medical Center ER - Patient presents with a complaint of
vomiting, fever and toothache since yesterday PE: Lungs clear. Impression: Vomitingdehydration. Urinary Tract Infection, tooth pain and anemia.
Hospital Visit #2
June 2, 2010: Good Samaritan Medical Center ER - Presenting Complaint: I have an earache
and toothache for 1 month. I have a headache for I week. Vitals: Temp - 100.1. PE: Mild pain
in the left lower second molar (#18). Breath sounds normal and normal gait. Mild pain of the
right scapular area. Differential Dx: Toothache, migraine and back pain.
Hospital Visit #3
June 3, 2010: Good Samaritan Medical Center ER - Presenting Complaint: Patient states Right sided back pain that extends to the right upper abdomen for 1 week. Pain to right shin as
well. Patient denies trauma to area. Triage Assessment: Complains for pain in right shin, right
flank pain currently 9/10. Patient denies fever. Physician Notes: Patient reports fever. PE:
Eyes, neck, respiratory, cardiac, abdomen, skin, extremities, neuro WNL. Impression: Urinary
tract infection and anemia.
5
Hospital Visit #4 - Hospitalization #1
June 6-16, 2010: Columbia Hospital ER and Hospitalization- CC: Anemia and rash. History
of rash/(unreadable word) and erythema of right lower extremity status post insect bite (?). No
chest pain or shortness of breath, but + fever and chills yesterday. ROS: Skin rash and joint
pain. Vitals: 102.6. PE: Tenderness and (unreadable word) of right lower extremity and knee
with erythema. Diagnoses: Anemia, hypokalemia, urinary tract infection and cellulitis.
June 6, 2010: Dr. Lagrange, Primary Care - Columbia Hospital- History and Physical Patient presents with complaints of weakness and fever for the past several days. Recently
evaluated in the ER with swelling of the left lower extremity and also left wrist pain. On an
antibiotic, associated rash and facial swelling. Outpatient labs revealed significant anemia with
hematocrit of less than 21. Complains of weakness, but denies chest pain or any other
complaints. ROS: Mild dizziness. Denies SOB, cough, sputum production, recent pneumonitis
or TB exposure. PE: Temperature: 102.6 and pulse: 125. Chest - clear. Extremities - muscular
pain and swelling. Some mild hyperemia in the left calf. Skin - urticarial type eruption about
the face and arms. Impression: Anemia, urticarial, cellulitis and dysfunctional uterine bleeding.
Admit: Transfuse 2 units ofPRBC, start antibiotic and local care to left calf. Venous Doppler
study is negative for deep vein thrombosis.
June 16, 2010: Columbia Hospital Discharge Summary - 06/06 - 06/16. Reason for
admission: Fever, anemia and cellulitis. Laboratory: ANA was positive. Anti-SSA was
elevated at 382 units. Anti-SSB was positive. SM antibody was negative. Anti-DNA was zero.
Centromere antibody was negative. CEA and CA was negative. PANCA was elevated and
positive. CRP was elevated at 27.1. Scleroderma was negative at 56 units. Histone H2A/H2Bb
was negative. Jo-l antibody was negative. MRJ of the lumbar spine and thoracic spine WNL
except for small bilateral pleural fluid collections. Hospital Course: Patient initially started on
Ancef and steroid pack with fever tracking down. Fever began to rise after 5 days with a spike to
104 degrees. Steroids were begun and patient became afebrile. Dr. Osiyemi (ID) continued to
feel that this was rheumatologic in origin. She was discharged to home with outpatient
rheumatology follow-up planned. Diagnoses: Fever of unknown origin, UTI (organism not
identified), cholecystitis, cellulitis (Left LE), anemia, backache, hypopotassemia, hyponatremia,
history of asthma, leukocytosis and lumbago.
June 16, 2010: Jackson North Medical Center ER - Patient arrived by ambulance. Presents
with a complaint of back pain, lumbar pain and lower back pain radiating to lower extremities.
Patient states it started today. No history of trauma. Said this happened to her before. Went to a
hospital in WPB, was worked up and was not told what was wrong with her. Now comes with
same symptoms. The onset was abrupt. Difficulty walking. No respiratory symptoms. ROS:
ENT negative. PE: Severe low back pain radiating to the legs and decreased ROM due to lower
back pain. Labs: WBC -18.8. Impression and Plan: Epidural abscess to be ruled out. UTI.
Patient care transitioned to JMH for further management.
June 17, 2010; Jackson Memorial Hospital -MRI lumbar with abnormal enhancement of the
paraspinal muscles involves bilateral mulifidus, interspinalis and medial aspect of longismus
muscles. No abscess. PE: Injected conjunctivae, oral thrush, lungs clear, bilateral calf
tenderness with left warmer than right. Admitting Diagnosis: Myositis? Symptoms,
6
leukocytosis and imaging suggestive, however, CPK not elevated. Given immune markers,
there may be a rheumatologic process. ? Stills disease. Start IV Vancomycin and cefepime.
July 17, 2010: Medicine, Jackson Memorial Hospital - Discharge Summary - Admission
Diagnoses: Back pain, fever of unknown origin, anemia and episcleritis. Discharge Diagnoses:
Fevers of unknown origin, right upper extremity deep vein thrombosis, cervical epidural
hematoma with laminectomies and evacuation and urinary tract infection. Hospital Course:
Low back pain, episcleritis and fevers - Rheumatology determined that her findings were nonspecific and they determined that she did not have a rheumatological disorder. She was
reportedly exposed to Chinese drywall at work, and she thinks her symptoms may have
been a result of this exposure. Her symptoms resolved on their own without any real treatment.
She received a couple doses of steroids, but she developed pain and stiffuess all over and the
medication was soon stopped. Right UE DVT - Complication of PICC line and heparin was
given with subsequent complication of left arm and leg numbness and weakness. On June 28,
neurosurgery performed a laminectomy of clot with evacuation and all cultures have been
negative. UTI - Blood cultures were negative; however a July 71h urine culture revealed
Enterobacter aerogenes. Her urine cleared with antibiotics and she stopped spiking fevers.
Anemia - Felt to be due to chronic disease given the consistent iron studies.
Hospital Visit #7
August 1, 2010: Palm Beach Gardens Medical Center ER - CC: Nausea and vomiting. She
took her pain pill before she ate and thinks that this is what her symptoms are from. Physicians
Notes - PE: WNL. Diagnosis: Gastroenteritis.
Hospital Visit #8
September 8, 2010: Palm Beach Gardens Medical Center ER - Right knee pain and swelling
started last night. She denies any trauma or injury to knee. Physician Notes: CC: Knee Injury.
Diagnosis: Knee pain - synovial cyst, abscess. She presents with pain, swelling and tenderness
of the right, posterior knee. This is from an unknown cause. Swelling comes and goes and pain
radiates up leg. Patient notes draining boil to axilla. Symptoms aggravated by weight bearing
and bending knee. PE: Left axilla unroofed small abscess with pus and easily wiped out with
gauze. Right knee with pain, tenderness and no swelling.
September 9 - 13, 2010: Medicine, Palm Beach Gardens Medical Center - Last Tuesday she
noticed pain and swelling in the right knee. She came to the ER and was discharged with pain
medicine. Dr. Rondon aspirated the knee and found fluid that was suspicious for septic arthritis.
She was sent for admission for IV antibiotics and surgical drainage. Continue on IV Rocephin at
2gm/day and add Vancomycin if suspicious for Staphylococcal infection.
September 11, 2010: Infectious Disease, Palm Beach Gardens Medical Center - Patient and
mother report a potential mold exposure at her workplace; subsequent development of acute
hematologic problems for which she went to Columbia Hospital. She went home after the
hospitalization and was doing well but had a short course of antibiotics for a tooth abscess. On
9/7/10 she developed pain and swelling of her right knee. She was admitted by Dr. David
Rondon and had an I&D as well as a synovectomy on 9/9/1O. Thus far her cultures are negative
and she has remained afebrile. Impression: Acute right knee Synovitis of undetermined etiology.
At this time, she does not appear systemically ill or toxic.
7
September 13, 2010: Infectious Disease, Palm Beach Gardens Medical Center - Discussed
case with Dr. Symes from UM. Right leg with healing incisions, minimal effusion, warm and
non-tender. Labs: Right knee fluid cultures (-) so far, no crystals, LDH - 113, CRP - 6,
ANA/RF negative. Unclear etiology with no overt evidence of a bacterial infection. She needs
close rheumatology follow-up and perhaps a hematology evaluation due to high lymphs.
FURTHER COMMENTS:
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st presented to Good Samaritan Medical Center on May 25, 2010, with
complaints of a one-day history of vomiting, fever and a toothache. She subsequently visited a
hos ital ei ht more times, and she was actuall hos italizcd on four total occasions.
8
Hospital Visit #1: May 25,2010: Good Samaritan Medical Center ER - Vomiting, fever and
toothache.
Hospital Visit #2: June 2, 2010: Good Samaritan Medical Center ER - Earache, toothache,
headache and right scapular pain.
Hospital Visit #3: June 3, 2010: Good Samaritan Medical Center ER - Right sided back pain
that extends to the right upper abdomen for I week and pain to right shin.
Hospital Visit #4 - Hospitalization #1: June 6-16, 2010: Columbia Hospital ER and
Hospitalization- Anemia, fever, rash, tenderness/pain of the right lower extremity and knee.
Hospital Visit #5 - Hospitalization #2: June 16, 2010: Jackson North Medical Center ERBack pain, lumbar pain and lower back pain radiating to lower extremities.
Hospital Visit #6 - Hospitalization #3: June 17, 2010: Jackson Memorial Hospital - Back
pain, fever of unknown origin, anemia and episcleritis.
Hospital Visit #7: August 1, 2010: Palm Beach Gardens Medical Center ER - CC: Nausea
and vomiting. Diagnosis: Gastroenteritis.
Hospital Visit #8: September 8, 2010: Palm Beach Gardens Medical Center ER - Right
knee pain and swelling started last night. She denies any trauma or injury to knee.
Hospital Visit #9 - Hospitalization #4: September 9 - 13, 2010: Medicine, Palm Beach
Gardens Medical Center - Last Tuesday she noticed pain and swelling in the right knee.
Impression: Acute right knee Synovitis of undetermined etiology. Unclear etiology with no
overt evidence of a bacterial infection.
With each one of these hospitalizations, the question of whether mold exposure could
cause the reported symptoms/illness must be answered by the application of the Hill
methodology.
The chart below reflects the analysis of the relationship between the
symptoms/illness associated with each of Ms. AAAAA's hospitalizations, and the likelihood that
mold exposure at her workplace up to June 3, 2010 (last day worked) could have caused those
symptom/illnesses
Hill Criteria
Strength
Consistency
Sneciflcitv
Temporality
Gradient
Plausibility
Coherence
Experiment
Analogy
Confounding
Visit
#1
Visit
#2
Visit
#3
-
-
-
+
+
+
-
-
-
-
+
+
-
-
-
+
Visit
#4
Visit
#5
-
-
-
-
-
-
-
-
-
-
+
+
Visit
#6
-
-
-
Visit
#7
Visit
#8
-
-
-
-
Visit
#9
-
-
-
-
-
-
-
-
+
+
+
+
-
-
9
_
Through years of investigation, scholarly interest and general experience the
potential health effects of mold exposure in an immunocompetent individual are well known,
including the following:
As part of the preparation of this report, I had the opportunity to thoroughly review the
existing literature on the potential health effects of mold exposure. These symptoms/disease
processes encompass all of the known health effects of mold exposure. It is important to
remember that every person is exposed to "mold" on a daily basis. Molds are a ubiquitous part
of all environments, including commercial buildings, homes, cars, outdoors, etc. Mold exposure
does not cause toothaches, fever (in the absence of systemic infection), vomiting, back pain, leg
pain, knee pain, synovitis, anemia, episcleritis, gastroenteritis, etc. It is interesting to note that
although Ms. AAAAA has a history of childhood asthma, she did not have any reported
respiratory or allergy complaints at any time surrounding the initiation or progress of her 2010
medical care. She did not even report transient mucosal irritation symptoms, much less allergy
or asthma symptoms.
In addition, she had no clinical characteristics consistent with
hypersensitivity pneumonitis, and no laboratory tests/cultures were ever consistent with a
systemic fungal infection.
10
Up until June 3, 2010, Ms. AAAAA worked in Office #194 of the ARLC, or northeast
wing. Examination of the July/August 2010 industrial hygiene data from Ecotech and EMSL
revealed that an air sample for non-viable fungi was collected from Ms. AAAAA's office on July
23, 2010. This test revealed a small amount of Aspergillus/Penicillium (It is very difficult to
separately identify these two genera of fungi by light microscopy, so they are generally reported
together), and a di minimis amount of Ascopores in the air of her office. In fact, the only area of
concern in the ARLC was Room #207 (Laundry Room), which was later remcdiated. It must
also be understood that the testing completed by Ecotech was done when the AlC was not
working appropriately and the air was very humid. Thus, these non-concerning test result was a
worst-case scenario. With that said, any industrial hygiene testing result is simply a "picture in
time"; however, with resolution of the AlC roblem it is likel that airborne fun i levels fell.
-
II
Ms. AAAAA was also working at the OCs during the refurbishment of the ARLC for a
grant application with the Veteran's Administration during March-June 2010. Nuisance dust
generated during these activities may have potentially caused building occupants mild, transient
mucosal irritation. With that said, nuisance construction dust would also not cause any of the
problems described by Ms. AAAAA. In addition, she kept her door closed much of the time that
she was at work, which would have further lowered any possible nuisance dust in her office.
FINAL CONCLUSIONS:
As stated in the introduction to this report, my conclusions are unchanged from my initial
report dated January 24, 2012. There is no objective evidence of biologically significant
exposure to any compound(s), and we do not have any candidate exposures that could cause the
unfortunate symptoms/ailments Ms. AAAAA suffered in mid-201O. Although the absolute
cause of her conditions remains elusive, nothing about her ailments is consistent with the known
health effects of mold and/or irritant exposures. None of her symptoms, conditions or medical
care that occurred in 2010 were related to her work at the OC. In addition, it is unreasonable to
anticipate that any symptoms/illnesses/conditions that may arise in the future are the result of her
previous employment at the OCs. Ms. AAAAA was at MMI with 0% PIR on the date of our
visit.
Sincerely,
~~~.~
·n- ..
12
University of South Florida, College of Public Health
13201 Bruce B. Downs Boulevard, MDC 56
Tampa, Florida 33612
[email protected]
Phone - (813) 505-6709 Fax - (866) 615-0928
January 30, 2012
Mr. James YYYYYYY, Esquire
XXXXXXX
Re: Dr. Alan GGGGGG
Dear Mr. YYYYYY;
I had the opportunity to visit with Dr. Alan GGGGGG on August 25, 2011, at rented
office space in Bradenton, Florida. Our visit lasted for several hours. The clinic questionnaire
was filled out prior to our visit and the patient actively took part in our visit and provided all
information requested without hesitation. This is an INITIAL report, as it is my understanding
that further medical records, depositions and expert reports may become available in the near
future.
RECORDS REVIEWED:
As you know, your office has been periodically sending records to my attention regarding
this patient, and the GGGGGG family. The patient specific medical and family records provided
by your office for my review include the following:
1. Medical Records from Dr. RRRRR C. SSSSS - Family Practice
2. Medical Records from Dr. AAAAA XXXXX - Environmental Medicine
3. Medical Records from Dr. GGGG WWWWW - Neurology
4. Medical Report from Dr. AAAAA XXXXX dated November 17,2007
5. Medical Records from The Balance Center of West Florida (Dr. Thomas Moorish) - ENT
6. Limited Medical Records from Dr. Robert P. Hillstrom - Plastic Surgery/ENT
7. Medical Records from Manatee Memorial Hospital
8. Medical Records from L.W. Blake Medical Center - No Records
9. Prescription Records from Walgreens
10. Billing Records from Wellness Pharmacy
11. Various Laboratory, Imaging and Diagnostic Testing Records
12. Deposition Transcript of Alan K. GGGGGG dated July 11,2006 - 66 pages
13. Deposition Transcript of Alan K. GGGGGG dated June 2, 2011 - 134 pages
14. Deposition Transcript of Anna-Marie GGGGGG dated July 11, 2006 - 48 pages
15. Deposition Transcript of Anna-Marie GGGGGG dated June 2, 2011 - 79 pages
16. Deposition Transcript of Alex Michael GGGGGG dated July 11, 2006 - 8 pages
17. Deposition Transcript of Alex Michael GGGGGG dated June 3, 2011 - 18 pages
18. Deposition Transcript of Ryan Brett GGGGGG dated July 11,2006 - 13 pages
19. Deposition Transcript of Tamara GGGGGG dated October 5, 2007 - 86 pages
20. Unsworn Statement of Jaclyn Michelle GGGGGG dated June 3, 2011 - 8 pages
21. Unsworn Statement of Rhyanna Haley Broomfield-GGGGGG dated June 3, 2011 - 12
pages
22. Deposition Transcript of Chin Shan Yang, PhD dated July 6, 2011-172 pages
23. Deposition Transcript of AAAAA F. XXXXX, DO dated August 10, 2011 - 126 pages
24. Deposition Transcript ofGGGG M. WWWWW,MD dated 'July 29, 2011 - 99 pages
25. Report of Florida Indoor Air Quality dated December 4,2003
26. Report of Florida Indoor Air Quality dated May 27, 2004
27. Report ofIndoor Environmental Tec1mologies, Inc. dated May 25,2004
28. Report ofIndoor Environmental Tec1mologies, Inc. dated May 28, 2004
29. Report ofIndoor Environmental Technologies, Inc. dated August 17,2004
30. Report ofIndoor Environmental Technologies, Inc. dated August 23, 2004
31. Report ofIndoor Environmental Technologies, Inc. dated July 10, 2006
32. Report ofIndoor Environmental Technologies, Inc. dated July 18, 2006
33. Report of Indoor Environmental Tec1mologies, Inc. dated June 18, 2007 (Summary of
Previous Reports from May 25, 2004; May 28, 2004 and August 17,2004
34. Report ofHSA Engineers & Scientists dated June 8, 2009
35. Burns Instar Services Group Proposal and Billing dated November-December 2003
36. Duetbusters Evaluation and Proposal dated September 6, 2006
37. Report of RJ Koning Consulting dated October 22, 2004
38. Records of Service-Tech of Tampa Bay
39. Documentation of Damages from Plaintiffs - Bills, Receipts, Expenses, etc.
40. Employment Records from Lakewood Ranch Anesthesia for Alan GGGGGG, MD
41. Amended Complaint and Demand for Jury Trial
42. Plaintiffs Notice of Serving Answers to Defendant's First Set of Interrogatories dated
September 2, 2005
43. Letter to RRRRR SSSSS, MD from Alan GGGGGG, MD dated May 4,2004 and May 8,
2004 (Addendum)
EXPOSURE HISTORY:
Dr. GGGGGG first experienced a "problem" on June 25, 2003, while he was in the Day
Surgery Center seeing a patient. At the time, he turned around and instantly developed "tunnel
vision". In addition, he felt like he was going to pass out; however, he did not fall. He took a
seat on a chair and then went over to the patient holding area where an IV was reportedly
administered. According to the patient, up to that point on June 251\ he had been feeling "great".
From that day forward, he has never felt "normal" again. Dr. GGGGGG subsequently sought a
"curbside consultation" with Dr. Moorish for malaise, nausea and balance issues. His head was
not "right with balance". He took Meclizine (anti-vertigo medication), but he felt worse and
soon stopped. He also tried Loratidine and Motrin.
Subsequent to June 251h, he had a number of symptoms appear, including: Vision
disturbances (brightness, flat, glossy, letters moving, halo around letters, seeing "pieces" of
daughter's face in focus while remainder blurry), brain fog, anxiety (morning) and left arm
numbness. Prior to the remediation they had a closet added in Jaclyn's room. He was helping
with the work and he noticed "brain fog" with an ill feeling and anxiety. His symptoms were at
their worst in August 2003, when they were living in the Holiday Inn. Over time his symptoms
2
have waxed, waned and somewhat changed. Now, he typically has the same reaction, which
includes his vision having a "soft focus" and lines on the floor go in and out of focus. In
addition, his close up vision gets worse after an "exposure". He also develops "brain fog" with
inability to concentrate, poor coordination, sloppy handwriting, poor muscle control, limited
multitasking ability, difficulty with swallowing, headache, limited hearing cognition, irritability
and anxiety. He has noticed that a number of substances seem to cause a "reaction", including:
Freshly painted walls, leather in sporting goods stores, car smells, tire smells, betadine solutions
at work, bone cement at work, antimicrobials at work, propane, perfumes, floor stripper, bleach,
chlorine, vinegar, laundry softeners, laundry detergents and cigarette smoke. In addition, he has
a number of foods which also seem to cause a "reaction" after ingestion. According to Dr.
GGGGGG ingestion of cranberries, sage, basil, oregano, wheat, eggs, chocolate, sweet potato,
legumes, citrus, aged cheeses, horseradish, deli mustard, sauerkraut, barbecue sauces, ice cream,
soy, candy, vinegar, shrimp, pickles, cucumbers, lamb and veal always seem to cause a
"reaction". Sometimes, he also has a "reaction" when he eats meatloaf, macaroni & cheese,
Mexican food and steak; although at times he can eats these foods with no noted problems. Dr.
GGGGGG also avoids com and canola oil. He is able to eat Five Guys hamburgers and
tomatoes without any problems. The patient has noted that foods seem to bother hiro less when
he has been away from work. He estimated that -50% of his "reactions" result from workplace
exposure to chemicals, and the other 50% follows ingestion of certain foods. Interestingly, he
has had a "reaction" with no recognized odor present. For instance, he seems to "react" when
sitting at the computer in the surgeon's lounge at work.
PAST MEDICAL HISTORY:
Prior to the onset of his current concerns, Dr. GGGGGG reportedly had a limited number
of health complaints. On the clinic questionnaire he reported a history of asthma, chemical
sensitivity, chronic pain, chronic rash, GERD, hay fever, intestinal problems and nerve problems.
In addition, he reportedly had a hydrocelectomy to repair a hydrocele at age 6. Upon furthering
questioning, he reported that he had no objective testing to document the presence of "asthma".
However, when they moved to Arizona in 2006, he felt SOB rather suddenly and thought it was
related to allergies, particularly to the Palo Verde "yellow" flower. Dr. XXXXX placed him on
Singulair and Allegra which seemed to decrease his SOB. His reports of chronic pain center on
headaches with "brain fog". In addition, muscle aches follow a "bad" day with chemicals or
food. In addition, Dr. GGGGGG reportedly has a malar rash with exposures and this resolves
when he goes on vacation. He has never seen a dermatologist to address this issue. He has
GERD symptoms when he overeats late at night. A Pepcid pill seems to relieve the symptoms
adequately. However, mint flavored Pepcid causes him to have "brain fog". As a child living in
Long Island, NY he had hay fever symptoms, but these were essentially gone by adolescence.
Sometimes, Dr. GGGGGG has had indigestion and bloating after eating certain foods. In
addition, he has had a vagal (cold/sweaty/lightheaded) reaction on one occasion while living in
Arizona. He went to the ER at Oro Valley Hospital after waking up feeling clammy with a rapid
pulse and dizziness. A CT of the abdomen was clear and the symptoms eventually passed
without further problems. Any time he feels that he may have a "reaction" after eating particular
foods, he takes a Y:, Benadryl tab. Dr. GGGGGG has also had "nerve problems" primarily
involving his sense of proprioception (spatial position ofjoints) in his legs. He feels like his legs
are "rubbery" and this sensation lasts several hours. He believes that this is related to
inflammation in his "brain". Dr. GGGGGG also noted that after exercising he may have a
3
reaction because his muscles release something into his bloodstream. Finally, at times he
experiences slight burning in his bladder, although he has had his prostate checked and it is fine.
In addition to the PMH reported in the clinic questionnaire, I found a notation that Dr.
GGGGGG had nasal septoplasty for a deviated septum in 1986.
MEDICATIONS:
Dr. GGGGGG was reportedly taking the following prescription medications at the time
of our visit.
Allergies
1. Allegra 180mg po QD
Heartburn
2. Pepcid OTC 3-4x1week
Helps with toxicity and take if eating
3. Vitamin C I gram
nitrates (certain foods)
Helps with chemical toxicity
4. Epsom Salt Baths
5. Benadryl 12.5mg 1-2x1week
When having a bad reaction to food
ALLERGIES:
The patient reported that he has no known medication allergies. He has been evaluated
by Dr. XXXXX for food and environmental allergies; however, he has never been evaluated by a
"traditional" allergist. As mentioned in the Exposure History portion of this report, Dr.
GGGGGG reportedly has a "reaction" to a large number of foods.
FAMILY MEDICAL HISTORY:
Dr. GGGGGG's father is 79 years old and he has been treated for colon cancer. He also
has benign prostatic hypertrophy. His mother passed away at age 70 due to lung cancer. In
addition, she had adult onset diabetes and arthritis. He has a 48-year old brother and a 50-year
old sister, both of whom are healthy. Noone in his family has similar complaints, although he
believes his wife and children have suffered adverse effects due to "mold" exposure.
SOCIAL HISTORY:
Dr. GGGGGG reported that he has never utilized tobacco products on a regular, or social
basis. He quit all alcohol use in 2007, although prior to that point he had only used it on social
occasions. According to the patient, even small amounts of alcohol seem to have exaggerated
effects on his "brain fog". In 2007, it took 1-2 hours for him to feel "normal" after a sip of wine.
The patient denied any illicit drug use.
They have a cat and recently acquired a Wheaton Terrier. He has had no problems
interacting with the animals. He denies any hobbies or activities outside of the workplace were
there is the potential for inhalation of fumes, gases or dusts. He enjoys playing guitar and piano.
The GGGGGG family has returned to live in the house in Holmes Beach on a full-time
basis. The house is mostly cement block. They run the air-conditioning on a regular basis and
there is a special filtration system, including upgraded pleated filters and a UV light system. The
house has had multiple water intrusion events, as detailed in the Industrial Hygiene Evaluation
portion of this report.
OCCUPATIONAL HISTORY:
4
Dr. GGGGGG is an anesthesiologist and he takes part in surgeries, as well as oversees
multiple nurse anesthetists. He has not missed any work due to his health concerns. He has held
the following positions:
I. 1989 - 1991
2. 1991 - 2006
3. 2006 - Nov 2010
4. Nov 20 I0 - Present
Assistant Professor, Dept. of Anesthesia, WV University
Anesthesiologist, Premier Anesthesia (Lakewood Ranch
Anesthesia)
Anesthesiologist, Oro Valley Anesthesia
Anesthesiologist, Lakewood Ranch Anesthesia
REVIEW OF SYSTEMS:
Dr. GGGGGG reported that he had experienced the following signs/symptoms in the year
preceding our visit:
1. Chronic or recurring skin condition
2. Rash
3. Decreased vision
4. Pain in the eyes (sharp occasional)
5. Shortness of breath (occasional)
6. Wheezing or chest whistling brought on by house dust, plants or pollens and foods
7. Activity intolerance
8. Pain with urination
9. Frequent urination
10. Frequent or severe headaches
I I. Dizziness or faintness
12. Excessive nervousness or worry
13. Excessive fatigue
14. Change in general feeling or personality
15. Increased irritability
16. Loss of sensation or control of muscle movement
17. Frequent heartburn or indigestion
18. Diarrhea (rarely)
19. Abdominal discomfort
20. Constipation
2 I. Chronic muscle aches with and without activity
PHYSICAL EXAMINATION:
VITAL SIGNS: Afebrile.
GENERAL: On examination, the patient was alert and oriented to person, place, and time. He
answered all questions without difficulty. He did not utilize any assistive devices, such as a cane
or oxygen during the visit.
HEENT: The patient was normocephalic. His pupils were equal, round and reactive to light
and accommodation. His extraocular muscles were intact. There was no evidence of strabismus.
His external auditory canals were normal. His tympanic membranes were clear and mobile with
intact landmarks. His oral and nasal mucosa was pink and moist throughout. There were no
5
evident secretions in his nasal passages. There were no evident nasal polyps. There was no
cobblestoning of his posterior nasopharynx. There was no sinus tenderness.
NECK: The neck was supple on palpation. He was able to move his neck in all directions with
no discomfort or tightness. There were no enlarged or tender lymph nodes noted. The thyroid
gland was of normal size and consistency. No noted jugular venous distention. There was no
stridor.
CHESTWALL: Grossly normal by inspection. Non-tender throughout to palpation.
RESPIRATORY: The lungs were clear to auscultation in all fields. There were no wheezes,
rales or rhonchi. He did not exhibit any USe of accessory muscles of breathing. There were no
chest wall contractions with inspiration or expiration. There was no egophony.
CARDIOVASCULAR: The heart sounds were normal. The heart had a regular rate and
rhythm. There were no murmurs appreciated. His cardiac point of maximal impulse was
appropriate in location and force. SI and S2 were normal. No S3 or S4 was noted.
ABDOMEN: The abdomen was soft and nontender. There were normal bowel sounds
throughout. There was no evidence of organomegaly.
EXTREMITIES: On observation there was no evidence of atrophy, contractures, or difficulty
with movement. There was no clubbing, cyanosis or edema noted. The capillary refill was
good. The patient's color was good and there was no noted pallor. The nail beds was non-tender
to palpation.
NEUROLOGIC: The patient responded appropriately to questioning and his short-term
memory appeared intact. His hearing was adequate in casual conversation with no reported
tinnitus. Cranial nerves II-VII and I through XII were within normal limits. His gait was
directed and he did not wobble or fall. Romberg examination was within normal parameters.
His deep tendon reflexes were 2/4 at the patella and biceps tendon bilaterally. All dennatomes
and myotomes were intact. There was no evidence of muscle atrophy in his upper extremities or
lower extremities. There was no noted tremor in any appendage.
SKIN: The patient had no areas or evidence of hypo- or hyperpigmentation except for sun/age
related lesions. In addition, there were no nodules or abnormal appearing lesions present on the
exposed skin.
CURRENT COMPLAINTS:
At the time of our visit the patient reported the following symptoms:
I.
Brain fog - concentration memory
2.
Visual disturbances - blurry, soft focus, difficult reading
3.
Irritability/anxiety
4.
Muscles aches and weakness
5.
Decreased coordination with swallowing, writing, off-balance, speech
6.
Headaches
7.
Shortness of breath
8.
Abdominal bloating - sometimes with dizziness
9.
Bladder dysfunction - relaxation and frequent voiding
10.
Facial rash
II.
Heartburn
12.
Sharp pains - head or eyes (more so)
13.
Malaise
14.
Fatigue
6
MEDICAL RECORDS:
I have reviewed the limited medical records provided by your office prior to preparing
this report. Listed below is a chronological summary of the relevant records:
August 13, 2003: The Balance Center of West Florida, Dr. Moorish - Several week history
of balance disturbance. Initially he felt quite lightheadedness and had to sit down. He had some
associated nausea. This happened on and off. He now is having some problems focusing with
his vision. It can happen with head turning, sometimes without any specific inciting event. It is
fairly constant, but occasionally it does go away. He has been told he has some fluid behind his
ears. There is a question of his house being a sick building. He did have some headaches
initially, but very few now. PE: Overactive gag reflex. Romberg shows no significant sway.
Tandem gait is fairly good. Assessment/Plan: Balance disturbance. Rule out a vestibular cause,
perform vestibular testing and see him back at this time. He may need a neurological workup,
especially with some ofthe visual symptoms. Mild rhinitis.
May 10, 2004: Dr. RRRRR SSSSS, Family Practice - (Much of this note is illegible) Attic
recess in master bedroom with no visible mold. Three weeks into BID CSM. 04/04 increased
severe symptoms. Tracking movements and visual changes, tunnel vision, light sensitivity,
anxiety. Assessment: SBS PAC Brochure.
May 18, 2004: Dr. RRRRR SSSSS, Family Practice - Garage remediated, + visible mold
inside car, (unreadable word) steering whecl- vehicle remediated. Put in UV system. Windows
?? not sealed frame, cracks in stucco, couch up against wall, crib mattress and wallpaper mold
(wall dry)
October 1, 2006: Dr. AAAAA XXXXX, Environmental Medicine - Allergy History:
Describe what symptoms bother you the most - vision, irritability, anxiety, muscle aches, mental
clarity. When did your condition begin - July 2003. Is there anything else about your problem
which you think might be important or unusual? Chemical sensitivity began after toxic mold
exposure.
October 9, 2006: Dr. AAAAA XXXXX, Environmental Medicine - Referred by Dr. SSSSS
who has been treating him for a chemical sensitivity problem, secondary to a mold-related
contamination problem in his residence in Holmes Beach discovered sometime between 2003
and 2004. He has taken Cholestyramine and has become more chemically sensitive. Dr. SSSSS
referred him so that we can address his chemical sensitivity problem. He's electro-magnetically
sensitive. He also has light and sound sensitivity and we discussed adding magnesium and
magnesium-rich foods to his diet to decrease that. He had hay fever as a child. ROS: Neck and
shoulder pain. Nasal stuffiness and postnasal drip. He has some exercise induced shortness of
breath. He has some cognitive dysfunction, which is a big problem when he is in a bad
environment. On exposure to certain molds or chemicals he has joint pain for hours. He
occasionally gets a red facial rash on exposures. PE: Nasal swelling with redness of the
turbinates and significant postnasal drip. Impressions: Allergic rhinitis. Mold exposure related
building illness. Chemical sensitivities. He may have exercise-induced reactive airways disease.
Recommendations: Allergy skin testing, glutathione intravenous for chemical sensitivity, Dr.
Ziem and Paul's protocol for the chemically sensitive and a trial of Singulair.
May 15, 2007: Dr. AAAAA XXXXX, Environmental Medicine - The glutathione injections
and B 12 injections appear to be working. He is very mold sensitive. He is taking the allergy
injections twice per week and the histamine drops. He has been feeling more anxiety, brain fog
7
and shortness of breath lately. This is probably seasonal allergies, they live in Arizona.
Recommendations: Add Singulair at bedtime and Allegra in the morning. This summer we will
do pollen testing.
July 3, 2007: Dr. AAAAA XXXXX, Environmental Medicine - He is feeling well. We are
testing him for pollens. His chemical sensitivity appears to be improved. He docs get
multisystem symptoms with foods and pollens affecting his airways and his nervous system. He
gets an air hunger and Singulair helps him, so this is allergic in nature. He is already on the dust
and mold injections, histamine drops and glutathione nasal sprays. Occasionally takes vitamin
shots, Bl2 and glutathione. PE: Lungs arc clear. Impressions: Allergic rhinitis and
inflammatory airway disease.. Recommendations: Cover him for pollens.
October 27, 2007: Dr. GGGG WWWWW,Neurology-He is being seen for toxic mold in his
home. GGGGGG Family History: Mold found in home in summer of 2003. It was in the
garage and entry doors to the horne. Dr. GGGGGG was the first to get sick. He had blurred
vision, lightheadedness, fatigue, severe anxiety and insomnia about 06/03. His wife noted
blurred vision and severe fatigue as well. Alex began with blurred vision, hyperactivity, double
vision and inability to focus. Adriana (?) began with headaches and blurred vision. Ryan began
with decreased concentration and headaches, also with decreased memory/concentration. The
house was remcdiated for 3 weeks during which time they did not live there. They moved back
in to the house in September 2003. Dr. GGGGGG's vision improved, but was not normal. He
had decreased vision and he still does not feel normal. He had brain fog with decreased memory
and concentration. In 2004 the home was remcdiated again for 3-4 months and they lived
elsewhere. Dr. GGGGGG's symptoms persisted with severe anxiety, irritability, brain fog,
blurred vision and GI symptoms. They returned 10/04 and the symptoms continued. Mold was
again found in Rhyanna's room in 2005 and they moved out for remediation for 1.5 weeks.
They decided to move to Arizona in February 2006. Dr. GGGGGG continued to have symptoms
in Arizona and his symptoms increased as soon as the furniture from the Florida house arrived.
The symptoms decreased after 6 weeks, but increased with loading and opening boxes from the
old house. Symptoms increased in certain stores and environment. Dr. GGGGGG has been able
to work, but has to avoid certain procedures. Current Symptoms: He is now doing better with
good and bad days depending of food/odor exposures. He has fatigue, brain fog, blurred vision,
irritability, anxiety, decreased ability to read, muscle aches, headaches, neck pain and increased
symptoms with stress. He has shortness of breath, dysphagia and decreased libido. ROS: Joint
pain and stiffness, headaches, diplopia, photophobia, blurred vision, cold intolerance and
dyspnea. Neurological Exam:
Patient has anxiety and decreased short term memory.
Impression: Toxic mold exposure with MCS.
June 24, 2008: Dr. AAAAA XXXXX, Environmental Medicine - He is quite allergic to
pollens, dust mites and multiple molds and also that he was allergic to selective chemicals that
we tested for and his is chemically sensitive. He has been somewhat better in Arizona. He has
been off allergy shots for a month now. He seems to be sensitive to his work chemicals in
surgery, which seems to affect his nervous system and his thinking. He gets some brain fog and
also affecting his nervous system irritability level and anxiety level and also cven affecting his
vision. Medications: Occasional Allegra and Singulair. PE: Nasal tissues markedly swollen,
the nasal turbinates arc edematous. His nose looks very allergic. He has some postnasal drip.
Impressions: He has perennial allergic rhinitis. He has the chemical sensitivity all stemming
from the moisture/mold contaminated home that he lived in between 2003 and 2005.
8
Recommendations: Singulair and Allegra. Recommend new nutrients, Vitaleycs. He has tried
Dr. Pall's nutrients without any good benefit.
IMAGING:
August 20, 2003: MRI of the Braiu with aud without Coutrast - Impression: No acute
intracranial abnormality. There is a mucous retention cyst or retained secretions in the right
maxillary sinus.
October 28, 2007: MRI of the Brain without Contrast - (Read by Dr. WWWWW Neurology) Normal MRI of the brain.
ALLERGY TESTING:
September 3, 2003: Enviro
Allergen
Cladosporium
Penicillium
Helminthosporium
Epicoccum
Aspergillus
Botrytis
Alternaria
Stemphylium
Fusarium
Rhizopus
Pullularia
Mucor
Candida
Dust mite (D pterony)
Dust mite (D farinae)
Mold IgG Test Results
LUs
Class
280
4
168
3
141
2
128
2
95
2
92
2
85
2
83
2
82
2
73
2
64
I
18
1/0
11
0
60
I
59
I
Response
High Positive
High Positive
Positive
Positive
Positive
Positive
Positive
Positive
Positive
Positive
Positive
Equivocal
Negative
Positive
Positive
Interpretation:
MAST CLASS
0
1/0
I
2
3
Response
Negative
Equivocal
Positive
Positive
High Positive
LUs
0-11
12-26
27-65
66-142
143-242
***'The remainder of the test results were cut-off the bottom of the sheet.
Allergy Testing - Dr. AAAAA XXXXX - 3 Occasions: 10/10/06,07/03/07 and 06/24/08
Allergen
Ragweed Mix
S.E. Weed Mix
S. FI Weed Mix
10/10/06
07/03/07
10
9
8
06/24/08
10
II
10
9
S.E. Tree Mix
S. FI Trees Mix
S.E. Grass Mix
S. FI Grass Mix
House Dust
Dust Mite (F)
Dust Mite (P)
Histamine
Grass Root Smut
Algae
Candida Albicans
Alternaria
Aspergillus
Hormodendrum
Helminthosporium
Penicillium
Pullularia
Cephalosporium
Ethanol
Phenol
Formaldehyde
Glycerin
Interpretation:
13
II
18
18
9
9
9
6
7
7
6
9
6
8
6
7
6
7
4
4
6
4
10
10
10
15
13
17
16
13
13
13
6
9
9
10
II
9
10
9
12
7
10
5
7
5
2 = Negative
3 = Moderate
4= Low High
5 = MedHigh
6 = High
7+ = Severe/Chronic
ADDITIONAL MEDICAL TESTING:
October 28, 2007: Electroencephalogram - Dr. GGGG WWWWW - The EEG is abnormal
with dysrhythmia Grade I with mild increases seen in Delta.
October 28, 2007: Quantitative Electroencephalogram - Dr. GGGG WWWWW - EEG line
format data abnormal with dysrhythmia Grade I with mild increases seen in delta. Computerized
topographic analyses with increases seen in delta. Amplitude asymmetry analysis with mild
asymmetries seen in delta and theta. Coherence analysis with mild abnormalities seen in all
frequencies. Impression: This was a mildly abnormal QEEG. These findings may be consistent
with encephalopathic processes such as toxic, metabolic or ischemic etiologies.
October 28, 2007: Visual Evoked Potentials - Dr. GGGG WWWWW - Normal and
symmetric.
October 28, 2007: Brainstem Auditory Evoked Potentials - Dr. GGGG WWWWW - Normal
and symmetric.
October 28, 2007: Somatosensory Evoked Potentials - Dr. GGGG WWWWW Somatosensory evoked potentials reveal mildly increased latencies in SSEP's in the lower
extremities consistent with slowing in the somatosensory pathway.
10
INDUSTRIAL HYGIENE EVALUATIONS:
December 4, 2003: Florida Indoor Air Quality - IAQ Investigation Report
Background/History: Water intrusion dates back two years. Recent leaks noted in the single
car garage on the west end of the home and around the roof and door framing of the main entry.
A leak was also found around the chimney cap. In some areas of the home, what appears to be
viable fungal activity was noticed. Dr. GGGGGG recently experienced severe symptoms of
possible toxic mold syndrome, to the event of balance and depth perception problems.
Investigation/Evaluation/Review: Air sampling on August 14, 2003, indicated elevated levels
of common and certain uncommon fungal species Aspergillus/Penicillium in the single garage
and master bedroom. However, outdoor sampling did show an overall count of (3) three times
higher than indoors. Surface sampling revealed elevated counts at their two main air handling
units (blower wheels) not yet cleaned. Again Aspergillus/Penicillium species were found on the
joist network in the crawl space of the home on the bay wall. Recommendations were made to
remediate the affected areas and install HEPA type filtration and an ultra violet lighting system
in tile return air pathways of the house. The owner was vacating the home.
Air sampling on August 25, 2003, revealed fungal were 120 times higher outdoors than in the
family room and fifty-two times higher than the master bedroom suite. Total count in tile attic
was 6- 13 times higher than the indoor count. The results of surface swab sampling in the master
bedroom air box and carpet were negative. Remediation was continuing and leaks relative to the
bay wall causing the crawl space problem were repaired and cleaned. The owner had moved
back into the home.
Bulk samples from September 18, 2003, were positive for high levels of
Aspergillus/Penicillium. With the area under containment the entry area was repaired and
remediated. Remediation continued in the single garage area. Dehumidification and air
scrubbing was employed.
Air sampling on October 21, 2003, in the single care garage and outdoors revealed a level 1.5
times higher outdoors. The count from within the SUV was about 2 times higher than the
outdoors and the total count for Aspergillus/Penicillium was over 6 times higher than outdoors.
Surface samples from the SUV revealed no elevated levels of common or uncommon species.
Recommendations: Clean the SUV interior. Use HEPA type filtration. Use an ultra violet type
system in the HVAC. Monitor moisture intrusion. Monitor relative humidity in the home.
Remove any wallpaper, particularly on any exterior wall because it acts as an interior vapor
barrier.
May 25, 2004: Indoor Environmental Technologies, Inc. - Letter to Dr. Alan GGGGGG Site Inspection Date: May 20, 2004. The investigation was performed to evaluated the
remediation work done in the attic area adjacent to the master bedroom and to evaluate several
other possible water intrusions in the home to see if they impacted indoor air quality.
Building Description and History of Water Intrusion: The first evidence of water intrusion
was discovered after a storm in September 2001. Water infiltrated the home at tile sliding
windows in the media room, living room and dining room. Water also infiltrated the crawl space
below the family room due to apparent window leaks in the family room. The homeowner dried
the leaks and all windows with leaks were resealed. Other intrusions included minor roof leaks
over the powder room, stairway and bedroom closet, all of which have been repaired. A leaking
water line in the master bath toilet caused staining on the ceiling of the foyer area. This was
II
immediately corrected when discovered. Water intrusion also occurred at the front door due to
inadequate flashing around the door. The leak and damage was corrected in September 2003,
when the entire house was painted and sealed. The only visible mold growth from all of these
leaks was some minor growth in the crawl space due to the family room window leak. The most
significant water intrusion was an apparent roof leak above the attic space adjacent to the master
bedroom, which also affected the fireplace in the master bedroom and resulted in mold growth
around the air handling units in the attic. This moisture intrusion was corrected in May 2003.
The visible mold growth in the attic was being corrected at the time of this site visit and
containment was still in place. Also, there was a water intrusion below the window of the guest
bedroom with water staining. This is still an active leak, although the wall paper on the wall was
recently replaced. There may have been some mold growth on the back side of the old
wallpaper.
Visual Inspection: There was some visible water staining below the window sill in the guest
bedroom with no visible mold growth. However, there was some visible mold growth behind the
baseboard below this window. Inspection of the master bedroom and attic area revealed no
visible water damage or mold growth. Elevated moisture levels above 60 RMC were found
above the fireplace and on some of the wood framing in the attic space. There may be a minor
window leak in the master bedroom. No signs of a roof leak were evident in the attic space,
however, future mold growth could occur in the future unless moisture levels are reduced to
below 40 RMC, There were also some slightly elevated moisture levels below the sliding
windows in the living and dining rooms. There may still be some minor window leaks in this
area, although no evidence of water damage or active mold growth was found.
Microbial Air and Surface Samples: Initial review of the non-viable indoor air samples appear
to indicate normal microbial levels inside the home versus the outdoors.
The
Penicillium/Aspergillus levels in the attic sample were slightly higher than the indoor air
samples; however, they were similar to outdoor levels. Results of the tape-lift sample from
behind the baseboard of the guest bedroom indicated moderately high concentrations of
Chaetomium and a tape-lift sample from the back side of the drywall at the master bedroom
fireplace indicated some minor Pen!Asp activity. Tape-lift samples from the AlC units and vents
indicated normal trappings. Microbial levels in viable air sample from the master bedroom and
guest bedroom versus the outdoor air sample were normal. Master was 123 total colony forming
units (CFU), guest bedroom was 106 CFU and outdoors was 441 CFU. Based upon our initial
review of the samples, it does not appear that there has been a significant release of mold
spores at this time.
Temperature and Humidity: Both were considered normal.
HVAC System Recommendations: No further action is recommended for the HVAC system
due to any of the water intrusions.
Recommendations: No remediation is recommended for the master bedroom area, but the area
should be monitored. No remediation is recommended for the water-stained ceiling areas or the
living and dining room window areas at this time. It is recommended that the area under the
guest bedroom window be repaired.
May 27,2004: Florida Indoor Air Quality - IAQ Investigation Report
Background/History: Owners noticed possible fimgal growth on the door of the attic air handler
closet adjoining the master bedroom. The area was contained and cleaned. There was also some
12
concern for certain small possible fungal spots on the exterior wall of the baby's room. The
spots were cleaned and the wall was papered.
Investigation/Evaluation/Review: Air sampling on May 14, 2004, indicated that the outdoor
total count was 25 times higher than the total count in the baby's room and 4 times higher than
the master bedroom. The air handler crawl space was similar to the total count outdoors. Some
elevation of uncommon species was noted. These levels will very daily based upon the outdoors
and humidity percentages. On May 18,2004, moisture readings beneath the window of exterior
wall in the baby's remove displayed high moisture readings. It is quite likely the window is
leaking somewhere around the sill.
Recommendations: The water intrusion path around the baby's room window should be
identified and repaired. Remediate the wall in the baby's room. Dehumidify the air handler
closet and seal the door to the closet.
May 28, 2004: Indoor Environmental Technologies, Inc. - Letter to Dr. Alan GGGGGG Inspection Date: May 27, 2004. Inspection focused on the two cantilevered windows in the
guest bedroom and master bedroom, respectively. The guest bedroom inspection revealed
significant water damage and deterioration of the plywood sheathing from a window leak. The
master bedroom inspection revealed some evidence of water intrusion with no deterioration of
building materials. There was some mold staining of drywall in the wall cavity under the
window.
August 17, 2004: Indoor Environmental Technologies, Inc. - Letter to Dr. Alan GGGGGG
- Site Inspection Date: August 11, 2004.
The remediation was performed. It appears that all of the water-damaged drywall has been
removed and that drying goals have been met for the remaining surfaces. It appears that there
may be some humidity control problems throughout the horne. The HVAC should be inspected
by a professional The wallpaper in the master and guest bedroom should be removed. Based
upon the slightly elevated moisture levels in some of the remaining drywall, it is possible that
some minor microbial activity may exist on the backside of the walls in the guest and master
bedroom.
August 23, 2004: Indoor Environmental Technologies, Inc. - Letter to Dr. Alan GGGGGG
- Site Inspection Date: August 11, 2004.
Clearance Summary: Laboratory analysis of mold spore levels in the music room, master
bedroom containment and second floor stair landing were generally within a normal range at the
time of testing.
The air sample from the guest bedroom indicated above normal
Penicillium/Aspergillus levels at 6400 spores per cubic meter. However, tape lift samples were
normal. The likely source of the elevated levels in the air are most likely the result of the high
humidity and construction dust levels present in the room at the time of testing. It appears that
the master bedroom has been effectively rerncdlated. However, elevated humidity levels in
the room are concerning and the wallpaper should be removed. It appears that there is still a
moisture (humidity) problem in the horne and levels were elevated throughout which could lead
to additional microbial activity if not corrected. It is recommended that an HVAC professional
be consulted to determine if the system is working properly.
13
July 10, 2006: Indoor Environmental Technologies, Inc. - Letter to Dr. Alan GGGGGG Site Inspection Date: July 5, 2006. The GGGGGG family has experienced mold and
environmental sensitivities over the years and mold remediation had been performed at their
home in 2004. The goal of this project was to determine current microbial level as well as take a
critical look at the building performance and make suggestions for improvements to HVAC
systems and moisture control in the home and crawlspace. These services included moisture
mapping, microbial air and surface sampling and microbial dust sampling to determine ambient
airborne mold levels in the air as well as on horizontal surface dust and in carpet and upholstered
furnishings dust. Initial Results: Review of microbial air and surface samples prior to
laboratory analysis indicated lower mold levels indoors with reference to outdoor levels. Surface
tape samples also indicated normal background levels of mold.
Problems: Visible staining on the supply vents of the kitchen and master bedroom indicated
Cladosporium sp. mold growth. Humidity levels were slightly elevated in the home even though
supplemental dehumidification was being used. There was an area of damp drywall on the
northern window in the music room. Wallpaper in the downstairs guest bedroom also indicated
elevated moisture contact on exterior walls. Interior walls indicated normal levels of moisture.
History of Water Intrusion: In May 2004, remediation of the guest bedroom cantilevered
window repaired water intmsion and mold damage to the window and adjacent walls. No mold
was found in the water intruded bedroom cavity. They moved away and kept ilie home in a
conditioned state. Their health has improved and their recent visits to this home have not
resulted in any significant onset of past symptoms.
Visual Inspection of Home: No evidence of visible mold aside from two areas around supply
air vents. The HVAC system had a 95% deep pleated filter and there is a UV light system
(although incorrect in guest bedroom AHU).
There were no signs of water damage or
deterioration of building materials. All exterior windows had been re-caulked and sealed within
the last 2 years.
Temperature, Humidity and Relative Moisture Content: Humidity levels were as high as
64% and temperature levels were as low as 68 degrees. This indicates ineffective climate control
by the HVAC system. Moisture mapping indicated normal levels except for the guest bedroom
exterior walls with wallpaper and under the music room north window.
HVAC System Description and Recommendations: The HVAC systems looked clean and
well maintained. There is a lack of insulation around the SAV in the kitchen and an oversized
unit servicing the mast bedroom. Even with the use of two supplemental dehumidifiers,
adequate humidity control was not available.
July 18, 2006: Indoor Environmental Technologies, Inc. - Letter to Dr. Alan GGGGGG Site Inspection Date: July 5, 2006. (This report supersedes the report of July 10, 2006)
Final Results: Laboratory analysis of microbial air and surface samples indicated lower mold
levels indoors with reference to outdoor levels. Surface tape samples also indicated normal
background levels of Cladosporium mold. At the time of testing, there did not appear to be any
indication of elevated mold levels indoors. Carpet dust samples were also well within normal
levels. This supports the other microbial findings that indicate that there was not a microbial
problem related to air, surface dust or carpet dust at the time of testing. Humidity levels were
slightly elevated even though supplemental dehumidification was being used. There was an area
of damp wallboard on the northern window in the music room. Wallpaper in the downstairs
guest bedroom also indicated elevated moisture contact on exterior walls. Interior walls
14
indicated normal levels of moisture.
content.
All other areas of the house indicated normal moisture
September 6, 2006: Ductbusters Indoor Pollution Control (Proposal)
Main House: The air handler for the main house contains a medium build-up of biological
growth. The supply plenum is in poor shape and should be replaced. The supply branch lines
contain light debris. The fan position is ON. The fan should always be kept in the auto position.
A return air (plenum) should be installed in each of the bedrooms. The air handler should be
cleaned, removing and replacing the supply plenum and cleaning/coating the ductwork.
Master Suite: The air handler for the master suite contains a medium build-up of biological
growth. The supply plenum is in poor shape and should be replaced. The fan position is ON.
The fan should always be kept in the auto position. The return ductwork is not large enough to
accommodate the unit. An additional return air should be added. The air handler should be
cleaned, removing and replacing the supply plenum, installing an additional return air and
cleaning/coating the ductwork.
Game Room: The air handler and supply plenum for the game room contain a medium build-up
of biological growth. The sidewall grill is ceiling diffuser and should be replaced with the
correct type of grille. The air handler should be cleaned and the ducts should be cleaned/coated.
(The work listed above costing $7,006.01 was completed In September/October 2006, along
with installation of the Ultra Aire APD (dehumidifier) in the system. In addition, the UV
bulbs were changed in February 2007 for $882.)
June 8, 2009: HSA Engineers & Scientists, Building Sciences Report - Microbial and
Allergy Sampling - Site Visit Date: May 11,2009. Six paired samples were collected from the
carpet of the master bedroom and second bedroom for microbial analysis and allergenic analysis.
Control samples were collected in the southeast comer of "Alex's room". All samples from dust
mites were considered low at <2 mcg allergen/gram dust. Fungi sampling of dust in the
southwest comer of bedroom two revealed colony counts of Aspergillus sydowii -12, Aspergillus
ustus -I, Paeeilomyees variotii - 12 and Triehodenna harzianum - 2. In addition, there was one
sample from near the master bedroom fireplace with colony counts of Peacilomyees variotii - 5.
All other samples had colony counts of 1. No interpretation of sample results were provided in
the report.
HVAC CLEANING:
August 14-15, 2003: Service-Tech of Tampa Bay - Clean three air handling units, return
ductwork, supply ductwork, diffusers and grilles. After cleaning a sanitizing agent (Oxine)
applied to coils, flex ductwork, fan blades, fan housing, diffusers and grilles. After cleaning and
sanitizing antimicrobial (Foster 40-20) applied to fiberglass lined plenums and fibrous glass
ducts.
September 6, 2006: Service-Tech of Tampa Bay - Clean (4) dirty diffusers and grilles. Clean
and seal grill boxes. The ceiling around the grilles cleaned and sanitized (Oxine).
CONSTRUCTION EVALUATION:
October 22, 2004: RJ Koning Consulting, Construction Consultant - The author of the
report was retained to evaluate and document the conditions surrounding the moisture intrusion
15
around and through the exterior envelope due to improper window flashing in the front of the
home.
The plywood sheathing (as a substrate for stucco) was found to be deteriorated and had become
an area for fungal deterioration. Contamination extended into the surrounding drywall board and
skeletal framing members. There was no evidence of flashing felt/tape/bitumen installed around
the window fin/flange juncture. The felt back galvanized lath was found to be butted to the
frame of the window and stapled off randomly prior to the application of stucco. The windows
installed in the rear elevation of the home (second story) have visual evidence of staining
underneath. The condition is indicative of a breech of the envelope flashing as the window
juncture.
CONSTRUCTIONIREMEDIATION WORK:
November-December, 2003: Mold Remediation, Burns Instar Services Group - I)
Remediation and containment of entry doors and foyer. 2) Remediation of crawl space. 3)
Remediation of single care garage floor decking, insulation and joints. 4) Remediation of
interior of vehicle stored in garage. Total Cost = $11,945.21
I) Remediation of front bedroom bay window lookout area and remediation of rear bedroom bay
window. Total Cost = $11,865.52
I) Remediation of mechanical closet. Total Cost = $1,960.64
DEPOSITION TESTIMONY:
As noted in the record review portion of this report, I had the opportunity to review a
number of depositions, including depositions of all the GGGGGG family members, as well as
the depositions of Dr. AAAAA XXXXX and Dr. GGGG WWWWW, respectively. Several of
the depositions had noteworthy testimony and that is detailed below:
Deposition o(AAAAA F. XXXXX, MD -August 10.2011
Page 10, Liues 3-8
Q.
What is environmental medicine?
A.
Environmental medicine is an approach to medicine whereby you look at environmental
factors in health and disease in determining causation and determining whether certain
environmental factors in the air, food, water, products can be affecting and individual's health or
illness.
Page 14, Lines 7-10
Q.
Are you an allergist?
I'm not a regular allergist, correct.
A.
Q.
You are not a regular allergist?
A.
Right. I'm not board certified in allergy,
Page 15 - 16, Lines 21-25 and Lines 2-12
A.
Then once I had all those courses and the thesis taken, except that I had to pass the boards
and occupational medicine.
Q.
Is that an exam you have to take at that time?
A.
Yes.
16
Q.
Who puts on that exam?
A.
The American Osteopathic College of Preventive Medicine, that has a subspecialty in
occupational and environmental medicine.
Well, it was originally the American Osteopathic College of Preventive Medicine. I think it's
separate now. I mean, they're actually by themselves, the American Osteopathic College of
Occupational and Environmental Medicine.
SO that's an osteopathic college that board certifies you in that arca?
Q.
A.
Yes.
Pages 16-17, Lines 25 and 1-4
A.
For example, I became board certified by the American Board of Environmental
Medicine in 1991, which is both M.D. and D.O.
Q.
Again, that's taking the test put on by that board?
A.
Right.
Page 17 -18, Lines 6 -15 and 1-15
Q.
All right. What would the difference then be between the board certified allergist and
what you do in the field of allergy?
A.
Well in my field, it's a little different because I treat patients with chemical sensitivities.
So I diagnose and treat a little differently that a board-certified allergist who generally would
treat only what we call IgE-mediated allergic disease. So there's a vague - there's a
controversial area out there called multiple chemical sensitivities, which I've addressed with
patients.
Q.
What's the controversy, do you mean between the medical field?
A.
In the medical field, yes, surrounding multiple chemical sensitivities, the diagnosis and
treatment.
Q.
What controversy are you referring to?
A.
Well, whether chemical sensitivity exists, what causes it, and what treatments arc
available. It's an ongoing controversy.
Q.
Ongoing controversy in the medical field starting off at even whether chemical sensitivity
exists?
A.
Right.
Q.
And then there's also controversy in the medical field as to ifit exists, how best to treat
it?
A.
Right.
Q.
And based on what I saw on your building, you treat multiple chemical sensitivity, I
assume it's your opinion that it exists?
A.
Yes.
Q.
And you have your own opinions as to what causes that condition?
A.
Yes.
Page 18, Lines 19-24
Q.
With regard to board-certified allergist, is it the position that they take that multiple
chemical sensitivity docs not exist?
A.
Some of them do. There are some who recognize its existence but don't know how to
treat it or prefer not to treat it.
17
Pages 48-50, Lines 23-25 and Lines 1-25 and Lines 1-16
Q.
And do you perform your allergy tests in the same way that a board-certified allergist
would do it or do you do it different?
A.
We do it a little differently.
Q.
Okay. And the way that you do it is tbe same way that you would have performed the
allergy testing on the GGGGGGs back in 2006 and forward?
A.
Right.
Q.
How does your practice perform allergy testing?
A.
Intradermal testing.
Q.
What does that mean?
A.
Under the skin. We use what's called Serial Dilution Endpoint Titration, which basically
means you find the highest dose that the patient can tolerate and that's the dose that you start
with treatment.
A.
Well, we take an antigen or an allergen such as ragweed or aspergillus, it's diluted out.
Each dilution of tbe allergen is a I to 5 dilution, weaker or stronger that the next.
So like a Number I dilution would be a l-to-I 00 dilution. Concentrate is about I to 20. Number
2 dilution would be I to 500. I to 3 dilution would by I to 2500 and on and on.
So if an individual, when we test then on tbe skin, witb a skin wheal, just underneatb the skin
witb a small round wheal, we see if it grows a certain amount in 10 minutes. And if it grows,
he's sensitive to that dilution and we go to one weaker and on and on. And we find that the first
skin wheal tbat it doesn't grow, so that's the highest dilution the individual can tolerate. That's
called a maximum tolerated dose. And that's how we treat.
Q.
Okay. So you find out the highest dilution that somebody can tolerate and that is given
some numerical number attached to it?
A.
Right.
Page 52-53, Lines 19-24 and 1-2
Q.
Okay. Do you continue to increase the dosage as an individual becomes more immune to
that?
A.
No, we don't increase tbe dosage, we keep it at that dosage.
How does that Q.
It's more of a cumulative effect over time.
A.
Meaning what?
Q.
Over time, they get a tiny dose over time, which would increase their immunity to it, yes.
A.
Pages 54-55, Lines 18-24
Q.
Now, you said that your allergy testing was different that a board-certified allergist.
What does a board-certified allergist do to test allergies?
A.
They do escalation immunotherapy, where they keep building up the dosage.
Q.
Isn't that what you do?
A.
No, we keep the dosage the same all the time.
Page 55-57. Lines 16 -25 and 1-25 and Line 1
18
A.
The problem with the chemically sensitive patient is that a lot of the chemically-sensitive
patients can't tolerate escalation immunotherapy.
Q.
. ... What do they (board-certified allergists) do and how is it different?
A.
What they do is they start off at a very, very low dose and then they, over a period of
time, increase the dosage.
We start off at a dose at the highest dose that the patient can tolerate and just stay there.
So we don't have to start at as low of a dose and we don't have to go below the - what we calloptimal dose and we don't have to go above the optimal dose, we stay at a level dose, so to
speak.
A.
We find the highest dose that they can tolerate per allergen and combine those together.
Those should not cause an adverse reaction in the body. That's basically it.
Q.
All right. Is there a specific purpose as to why you don't test in the manner that a boardcertified allergist tests?
A.
Yeah, because the chemically-sensitive patients don't seem to tolerate the buildup
therapy or the escalation therapy. They have more reactions to it.
Page 58, Lines 2-10
Q.
Okay. Now, it the type of allergy testing that you perform, is that accepted in the medical
community?
A.
Well, it's considered an alternative type of testing.
Q.
Okay. Considered an alternative, but not accepted in the medical community?
It's accepted and not accepted.
A.
Page 59, Lines 6-8
Q.
Are you aware if any boar-certified allergists usc the technique that you use for allergy
testing?
Not at this point in time, no.
A.
Q.
Is there anything that you did on this first visit or at any time in order to determine that in
fact Dr. GGGGGG does have a chemical-sensitivity problem?
A.
Other that the medical history?
Q.
Correct. He tells you, " I have chemical sensitivity." Do you do anything to test to
determine for yourselfthat in fact he does have chemical-sensitivity?
A.
Well, I tested him for three representative chemicals.
A.
Q.
A.
Q.
A.
Phenol, formaldehyde and glycerin and he tested positive.
Through the allergy testing that we just discussed?
Yes.
Do board-certified allergists test for those chemicals?
They sometimes test for phenol and glycerin.
Q.
And so in your determination, that testing indicated to you that Dr. GGGGGG was
chemically sensitive?
19
A.
Yes.
Q.
Based on the testing that you performed with regard to the chemicals, I'm assurmng
you're not able to take those tests and relate it to a specific event?
A.
Well, no necessarily, no.
Q.
Is there anything other than the history from Dr. GGGGGG that you can rely on in
causally relating the allergies to the chemicals you tested to the Holmes Beach residence?
A.
No.
Q.
Okay. So you totally have to rely on the truthfulness and accuracy of Dr. GGGGGG in
giving that history that his condition started after that point?
A.
That's correct.
Pages 63-64, Lines 12 - 25 and Lines 1-13
Q.
SO once he became chemically sensitive, how does an individual, such as Dr. GGGGGG,
become chemically sensitive as you've described?
A.
Well, I suspect that his chemical sensitivity was triggered by the mold exposure in the
home, in the home that he was in.
Q.
SO is it your testimony that Dr. GGGGGG was not predisposed to be chemically
sensitive, that the actual exposure to mold caused him to be chemically sensitive?
A.
That's correct.
Q.
SO is it your testimony that if you had tested Dr. GGGGGG for allergies to the three
chemicals that you referred to prior to this issue in the Holmes Beach in Florida in 2003 and
2004, it's your belief he would not have been allergic to those chemicals?
A.
He may not have been allergic to those chemicals. That's a possibility. I don't know the
answer to that question.
Q
What do you base that opinion on, that it's possible he became chemically sensitive from
the exposure to mold in his Holmes Beach residence between 2003 and 2004; everything you
base that on I want to know?
A.
Well, my experience with treating other individuals with similar problems; the fact that
the whole family got sick from the exposures; his medical history that was given.
Pages 64-65, Lines 20-25 and Lines 1-7
Q.
Is there any testing that you can perform in your practice, any type of objective testing
that you can perform in order to make that causation opinion that the chemical sensitivity could
have been caused by the mold exposure in 2003 and 2004?
A.
Other than the fact that he tested positive to the molds and significantly positive to the
mold allergies.
Q.
Other than that?
A.
Other that that, nothing, no.
Q.
But, again, those testings don't reveal that his allergies to mold was caused by exposure
in 2003 and 2004, correct?
A.
That's correct.
Page 66, Lines 4-10
20
Q.
My question to you specifically, is there an objective test that you can perform as the
osteopathic physician to causally relate Mr. GGGGGG's alleged chemical sensitivity to the mold
exposure in the Holmes Beach residence?
A.
No objective tests that I know of.
Q.
You talk about your recommend that Dr. Ziem and Pall's Protocol, the chemically
sensitive with certain nutrients; what's that?
It's a nutritional protocol. Certain nutrients that may be helpful for the chemicallyA.
sensitive patient.
Q.
What to eat, a list of what to eat or something?
It's certain vitamins and minerals and also a special diet, that's true.
A.
Q.
I understand he's saying that he's having greater sensitivity to chemicals, but I'm asking
you from your osteopathic opinion what would cause him to have continued increasing
sensitivity to chemicals?
A.
I don't know.
Q.
My question is, within a reasonable degree of medical possibility, would you relate leftsided loss of feeling to chemicals and mold exposure?
A.
If she complained ofthat, that relationship, yes.
Q.
SO in order for you to relate a symptom to chemical sensitivity or mold exposure, all that
is necessary is for the patient to say that it occurred after coming in contact with some chemical
or mold?
A.
After an exposure, yes.
Page 113, Lines 5-8
Q.
What's the difference between an IgE and an IgG test?
A.
The IgE is a Type I allergy. The IgG test is a delayed allergy result.
Page 118, Lines 4-7
Q.
Okay. And with regard to Alex GGGGGG, his blood test resultsA.
His blood test showed just mild mold allergy, delayed reaction.
Page 121 -122, Lines 18-21 and Lines 2-9
Q.
Are you in any way relating the irritability of Jaclyn as an infant and the difficulty
sleeping to a mold event in the home in 2003?
A.
Possibly.
Q.
You would obviously accept the fact that young babies often are irritable and don't' sleep
well, notwithstanding any potential mold exposure?
A.
That's correct.
Q.
SO the only way that you can related any of Jaclyn' s symptoms as a baby to a mold
exposure event in 2003 would be solely related to her mother's history?
21
A.
That's correct.
Deposition of GGGG M. WWWWW.MD - July 29, 2011
Pages 42 - 43, Lines 20 - 25 and Lines 1-21 - Regarding Dr. GGGGGG
Q.
Okay. I believe you arrived at an impression following your exam of toxic mold
exposure with MCS; is that correct?
A.
Yes.
Q.
What is MCS?
A.
Multiple Chemical Sensitivities.
Q.
What was your impression based upon?
Specifically, was it based entirely upon your examination, the history, the testing or a
combination of it all?
A.
I would say a combination of all, but the biggest part is obviously the history, and that at
that time again, I came to that conclusion before the testing. That was my - that impression at
that time, I would say rather than final diagnosis, but an impression based primarily on his
history.
Then the testing confirmed to me that was likely what his problem was. So the final diagnosis
was based on his history and the testing, some with the examination; but the examination in his
case, because it didn't show much wrong, it didn't playa big role.
Q.
As far as the percentage then, the history would have played a large majority role in your
impression and analysis?
A.
Yes.
Pages 59-62, Lines 24-25 and Lines 1-25 and Lines 1-25 and Lines 1-4
Q.
Okay. So one physician may read an EEG with an abnormal delta or theta, and another
may read it as a normal reading.
A.
Right. .... Grade I means this is often seen in normal people; yes, there is a little slowing,
but sometimes you can see a little slowing in someone who is still normal. .... Grade I, like, it
shows, that doesn't say for sure that is abnormal. That could be normal for that individual. It
often is.
Q.
That testing also does not specifically address what is the cause of the abnormality, if it
does exist even in class one, two or three, correct?
A.
Correct. .... Other than those rare instances - even if you see slowing in the left temporal
lobe, it doesn't say for sure it is a tumor or what kind of tumor, whatever. It just says there is a
lesion.
Q.
Without having the raw data in front of you are you able to tell us today what Dr.
GGGGGG's abnormalities, ifany were, on the EEG?
A.
Yeah. He had mild increase in the delta just generally.
Q.
So based upon, I think what you had testified before, this is a condition that may be seen
in normal individuals?
A.
Correct.
Q.
SO it is not specifically indicative of a specific condition. It just means there may be
some abnormality.
22
A.
It is consistent with a generalized encephalopathic process. In other words, a generalized
process that slows the brain a little bit, but not specifically for which process that might be. And
it is also possible that might be normal for this individual person.
Q.
With the QEEG is it possible that other physicians, other neurologists may also review
these results as normal?
A.
No.
Q.
Okay. So everybody who would review these results would say they are abnormal.
A.
Right. What that abnormality means, you might get more than one opinion, too.
Q.
Now, you did say all of these were consistent with or may be consistent with the process
of toxic metabolic or ischemic etiologies.
A.
Right. The QEEG by itself doesn't tell you which of those - it says there is an
encephalopathy. The brain is not working quite right; mildly abnormal. It is a generalized
encephalopathy. In other words, the whole brain has been affected.
So, for example, a patient who had a heart attack and didn't have enough oxygen for a while to
their whole brain, could have a similar finding ......
So we could say that pattern of a generalized encephalopathy, but it doesn't give you that read
out and say, ding, ding, this is the one.
COMMENTS:
It is clear from our visit and the medical records that Dr. GGGGGG believes that a timelimited "exposure" to mold in their home during 2003-2006, resulted in a myriad of historical
and ongoing health conditions. His reported health concerns include: I) Numerous constitutional
symptoms and a typical "reaction" following exposure to various chemicals and foods. With
that said, there is no OBJECTIVE EVIDENCE to suggest that his possible exposure(s) to
mold in his home could have caused persistent symptoms and/or the diagnosed conditions.
This conclusion was reached after careful consideration of the following comments.
- Literature
Precedent
Most building-related symptoms are consistent with an allergic etiology. With that said,
most allergic problems related to mold exposure arc associated with varieties of mold typically
found outdoors. Molds growing indoors are alleged to cause other types of building-related
symptoms. Despite a voluminous literature on the subject, the causal association between nonallergic/respiratory complaints remains weak and unproven, particularly with respect to
causation by mycotoxins. Massive exposures to spores containing relatively high levels of
mycotoxins arc necessary to induce illness in humans. Experts estimate that there must be spore
levels in excess of 1,000,000 per cubic meter of air over short periods or there must be constant
23
exposures to levels greater than 1000 toxin-containing spores per cubic meter for many days in
order to cause an adverse reaction. This may occur rarely in certain occupational and
agricultural situations, such as organic toxic dust syndrome. It is highly unlikely that sufficient
mycotoxin exposure could occur with great frequency in indoor situations. This situation is
coupled with the facts that mycotoxins arc not inherently volatile compounds found in the air.
Even if mycotoxins are inhaled into the body, most will be metabolized and eliminated within
hours to days. Consequently, persistent symptoms that patients experience (which are real) are
not likely to be caused by mycotoxin exposure.
Mold growth in the indoor environment is not a source of infections or mycotoxicosis.
Current scientific evidence does not support the conclusion that human health is adversely
affected by inhaled mycotoxins in the indoor environment. In addition, mold does not cause
unusual syndromes such as chronic fatigue, chemical sensitivity, toxic encephalopathy or
neurotoxic manifestations. Although living with mold can be uncomfortable, unsightly and
associated with odors, only susceptible individuals are likely to be affected by excessive mold in
the indoor environment. The American College of Occupational and Environmental Medicine
(ACOEM) published a Position Statement on mold in the indoor environment and it reiterates
what I have stated in the above discussion. (Hardin, 2003) The findings of ACOEM were
corroborated in the 2006 position paper by The American Academy of Allergy, Asthma and
Immunology titled The Medical Effects of Mold Exposure (Journal of Allergy and Clinical
Immunology. I 17:326-333), as noted below:
• The occurrence of mold-related toxicity (mycotoxicosis) from exposure to inhaled
mycotoxins in nonoccupational settings is not supported by the current data, and its
occurrence is improbable.
The Institute of Medicine published a full review of the topic titled Damp Indoor Spaces
and
Health
in
2004.
An
executive
summary
may
be
found
at
http://www.nap.edu/books/0309091934/html/. The findings of this report include the following
for damp environments:
Sufficient Evidence for:
I. Nasal and throat symptoms - irritation
2. Cough, wheeze
3. Asthma symptoms in sensitized persons
Limited or suggestive evidence for:
I. Shortness of breath
2. Lower respiratory symptoms in children
3. Asthma development
Inadequate evidence to determine an association for:
Airflow obstruction, mucous membrane irritation syndrome, COPD, inhalation fever,
lower respiratory symptoms in healthy adults, acute idiopathic hemorrhage in infants,
skin symptoms, GI symptoms, fatigue, neuropsychiatric symptoms, cancer, reproductive
effects, rheumatologic and other immune disorders
III damp environments with mold or other agents the report included the following findings:
24
Sufficient Evidence for:
I. Nasal and throat symptoms - irritation
2. Cough, wheeze
3. Asthma symptoms in sensitized persons
4. Hypersensitivity pneumonitis in susceptible persons
Limited or suggestive evidence for:
I. Lower respiratory symptoms in children
Inadequate evidence to determine an association for:
Shortness of breath, asthma development, airflow obstruction, mucous membrane
irritation syndrome, COPD, inhalation fever, lower respiratory symptoms in healthy
adults, acute idiopathic hemorrhage in infants, skin symptoms, GI symptoms, fatigue,
neuropsychiatric symptoms, cancer, reproductive effects, rheumatologic and other
immune disorders
The American Academy of Allergy, Asthma and Immunology position paper drew the
following conclusions regarding irritant effects of mold exposure:
• The OCC1UTence of mold-related irritant reactions from exposure to fungal irritants in nonoccupational settings are theoretically possible, although unlikely to occur in the general
population given exposure and dose considerations.
• Such irritant effects would produce transient symptoms-signs related to the mucous
membranes of the eyes and upper and lower respiratory tracts but would not be expected
to manifest in other organs or in a systemic fashion.
Since the publication of the 2004 Institute of Medicine report on the potential health
effects of dampness and mold, researchers worldwide have continued to study these questions.
Numerous studies have reiterated and strengthened the findings of the 2004 10M report, and the
results have remained essentially the same - exposure to dampness, as well as dampness with
mold can cause and/or exacerbate allergic symptoms and some respiratory disorders. In 2011,
the American College of Occupational and Environmental Medicine updated their position
statement on mold titled Adversc Human Health Effects Associated with Molds in the Indoor
Environment. The findings were essentially unchanged since the original document in 2003.
That is, with eight additional years of intensive research and scrutiny the proven health effects of
mold exposure remain the same - allergy exacerbation, triggering of mold-sensitive asthma and
rarc systemic infections. The ACOEM guideline may be found at the following web address http://www.acoem.org/AdverseHumanH ealthEffects Molds .aspx.
Although several of the GGGGGGs, including Dr. GGGGGG, have been diagnosed with
25
mold "allergies" by Dr. AAAAA XXXXX, I believe that one should take a very close look at the
both qualifications of Dr. XXXXX, as well as his diagnostic techniques, particularly related to
allergy skin testing. In his deposition, Dr. XXXXX freely admitted that he is not a boardcertified allergist, as noted below:
Page 14, Lines 7-10
Q.
Are you an allergist?
A.
I'm not a regular allergist, correct.
You are not a regular allergist?
Q.
A.
Right. I'm not board certified in allergy.
I am certain that you also noted that Dr. XXXXX did not complete any formal residency
training in Allergy, as he took a rotating internship from 1969-1970 and chose to work in an
emer enc room after that sin Ie ear of trainin .
The primary function of ABMS is to assist its Member Boards in developing and implementing
educational and professional standards to evaluate and certify physician specialists." (ABPM
website - h :llwww.abms.or IAbout ABMS/)
In his
deposition, Dr. XXXXX noted the following about his method of allergy testing and treatment:
Q.
And do you perform your allergy tests in the same way that a board-certified allergist
would do it or do you do it different?
We do it a little differently.
A.
Q.
Okay. And the way that you do it is the same way that you would have performed the
allergy testing on the GGGGGGs back in 2006 and forward?
A.
Right.
Q.
How does your practice perform allergy testing?
A.
Intradermal testing.
~latdocsthatmean?
Q.
A.
Under the skin. We use what's called Serial Dilution Endpoint Titration, which basically
means you find the highest dose that the patient can tolerate and that's the dose that you start
with treatment.
A.
Well, we take an antigen or an allergen such as ragweed or aspergillus, it's diluted out.
Each dilution of the allergen is a I to 5 dilution, weaker or stronger that the next.
So like a Number I dilution would be a l-to-100 dilution. Concentrate is about I to 20. Number
2 dilution would be I to 500. I to 3 dilution would by I to 2500 and on and on.
So if an individual, when we test then on the skin, with a skin wheal, just underneath the skin
with a small round wheal, we see if it grows a certain amount in 10 minutes. And if it grows,
he's sensitive to that dilution and we go to one weaker and on and on. And we find that the first
26
skin wheal that it doesn't grow, so that's the highest dilution the individual can tolerate. That's
called a maximum tolerated dose. And that's how we treat.
Q.
Okay. So you find out the highest dilution that somebody can tolerate and that is given
some numerical number attached to it?
A.
Right.
Un-validated Testing
Serial Dilution Endpoint Testing (SET) is also known as skin endpoint titration (SET)
and intradermal dilutional testing (IDT). It is generaIly offered by Ear, Nose and Throat (ENT)
physicians. Although it is different than "traditional" aIlergy testing, SET has gained some
credibility in the last several years, particularly for identifying hymenoptera (yeIlow jacket,
honey bee, hornet, wasp and fire ant) sensitivity and determining a safe dose for starting venom
immunotherapy. Nevertheless, it's use for diagnosin and treatin inhalant aIler ies (such as
mold) is still considered somewhat controversial.
This is due to
the fact that he actually performs Provocation-Neutralization testing, or a Rinkel Test protocol.
This evolved from SET, but ascribes to a completely different methodology. Once a test is
positive (objective skin wheal or subjective symptoms), a progressive series of lower
concentrations are administered until the patient reports no sensations, or there is no increase in
the wheal size. This amount of the test substance is then considered the "neutralizing dose", and
is used for all subsequent aIlergy immunotherapy. Provocation-Neutralization allergy testing and
treatment is not generally covered by standard-line health insurance companies. In addition, the
American Academy of Allergy and Immunology (AAAAI - "traditional" aIlergy training)
considers Neutralization-Provocation Testin ex erimental and un roven.
27
There is no
objective evidence to suggest that Dr. SSSSS's diagnosed "allergies" are truly allergies. In fact,
Dr. GGGGGG did not complain of typical allergy symptoms when in the house, such as runny
nose, itchy eyes, sneezing, etc. It is certainly possible that Dr. GGGGGG may have some
environmental allergies; however, we cannot utilize the allergy results of Dr. XXXXX to make
this diagnosis. This lack of reliability and general illogical nature is made unquestionably clear
by his explanation of why he tests patients with alleged Multiple Chemical Sensitivity (MCS)
with his allergy testing method, as noted below:
Page 55-57. Lines 16 -25 and 1-25 and Line 1
A.
The problem with the chemically sensitive patient is that a lot of the chemically-sensitive
patients can't tolerate escalation immunotherapy.
Q.
. ... What do they (board-certified allergists) do and how is it different?
A.
What they do is they start off at a very, very low dose and then they, over a period of
time, increase the dosage.
We start off at a dose at the highest dose that the patient can tolerate and just stay there.
So we don't have to start at as low of a dose and we don't have to go below the - what we calloptimal dose and we don't have to go above the optimal dose, we stay at a level dose, so to
speak.
A.
We fmd the highest dose that they can tolerate per allergen and combine those together.
Those should not cause an adverse reaction in the body. That's basically it.
Q.
All right. Is there a specific purpose as to why you don't test in the manner that a boardcertified allergist tests?
A.
Yeah, because the chemically-sensitive patients don't seem to tolerate the buildup
therapy or the escalation therapy. They have more reactions to it.
Nevertheless, the fact
remains that the "allergy testing" methodology is not part of standard medical practice. Any
"allergies" he may have diagnosed in thc GGGGGG's with this testing protocol cannot be
assumed to be correct, or a true measure of their "allergies", including environmental agents and
chemicals.
- Positive, and ....
Several providers, including Dr. XXXXX and Dr. Weingarten (Dr. GGGGGG only)
have chosen to order serum IgG antibody levels to a panel of environmental molds. This testing
is of no clinical value and cannot be used to assert mold sensitization or symptoms. In a 2008
28
study, Rydjord et al. quantified IgG antibody levels by flow cytometry in Norwegian children
versus the Immunocap method. (Rydjord, 2008) Interestingly, the authors clearly stated the
following:
In another study examining healthy children living in "normal" homes without evidence
of mold or moisture contamination, Korppi et al. found that children of fanners generally
developed IgG antibodies to molds earlier in life, yet these differences disappeared by age 7.
(Korppi, 2003) Nevertheless, the authors concluded that the available data does not allow the
estimation of mold-specific IgG levels that can be considered pathological. Furtherrnore, they
stated the following:
These same findings were mirrored in a 2004 review article titled Clinical Use ofImmunoassays
in Assessing Exposure to Fungi and Potential Health Effects Related to Fungal Exposure,
produced by a number of authors affiliated with the National Institute for Occupational Health
and Safety (NIOSH). (Trout,2004) In this article they stated the following:
With all that said, previous studies in people with very high fungal exposure, such as fanners
with farmer's lung or hypersensitivity pneumonitis, have documented a potential rise in specific
IgG levels in concert with exposure. (Terho, 1987 and Erkinjuntti-Pekkanen, 1999) However,
the relationship between exposure and rising IgG levels is much more tenuous in studies
involving mold-damaged buildings, where the exposures are generally orders of magnitude
below that found in fanning. For example, multiple studies in children attending schools with
moisture problems have failed to show a relationship between IgG levels and exposure to
moisture and molds in the schools. (Immonen, 2002; Taskenen, 2002 and Hyvarinen, 2003)
In his deposition Dr. XXXXX was forthright about the controversy in the medical
community about a collection of disparate symptoms know as Multiple Chemical Sensitivity
(MCS), Idiopathic Environmental Intolerance (lEI) or a litany of other descriptors, as noted
below:
29
Page 17 18, Lines 6 -15 and 1-15
Q.
All right. What would the difference then be between the board certified allergist and
what you do in the field of allergy?
A.
Well in my field, it's a little different because I treat patients with chemical sensitivities.
So I diagnose and treat a little differently that a board-certified allergist who generally would
treat only what we call IgE-mediated allergic disease. So there's a vague - there's a
controversial area out there called multiple chemical sensitivities, which I've addressed
with patients.
Q.
What's the controversy, do you mean between the medical field?
A.
In the medical field, yes, surrounding multiple chemical sensitivities, the diagnosis and
treatment.
Q.
What controversy are you referring to?
A.
Well, whether chemical sensitivity exists, what causes it, and what treatments are
available. It's an ongoing controversy.
Q.
Ongoing controversy in the medical field starting off at even whether chemical sensitivity
exists?
A.
Right.
Q.
And then there's also controversy in the medical field as to ifit exists, how best to treat
it?
A.
Right.
Q.
And based on what I saw on your building, you treat multiple chemical sensitivity, I
assume it's your opinion that it exists?
A.
Yes.
Q.
And you have your own opinions as to what causes that condition?
A.
Yes.
I agree with Dr. XXXXX that there is a very large controversy surrounding the existence
of MCS/IEI, as well as any purported treatment. The symptoms described b most suffers de
the classic dose res onse relationshi found in toxicolo
By diagnosing patients with
chemical "allergy" via his unproven, untestable and unreliable methods, Dr. XXXXX is doing
them a disservice by perpetuating their false beliefs in MCS/IEI. Interestingly, the AAAAI
statement directly addressed the types of tests used to diagnose IEI, as noted below:
30
The tests most frequently used by practitioners who diagnose lEI are provocationneutralization and a panel oj immunologic tests. The latter encompasses measurements oj
serum immunoglobulins, complement levels, blood lymphocyte subset counts,
autoantibodies, and serum antibodies to chemicals.
Studies to date have Jailed to confirm that any immunologic tests are diagnostic for
chemically induced symptomatology.
- Limitations and Overreliance
Taken as a whole, Dr. XXXXX has relied upon unproven and unreliable testing
methodologies to "diagnose" a condition whose very existence is tenuous at best. In addition, he
has offered various "treatments" that were most likely unhelpful in addressing any "real"
problem they may have had, except for standard treatments such as Allegra and Singulair for
allergic rhinitis. There is no objective proof to suggest that nutrients, vitamins and reduced
lutathione offer an clinical benefit to atients with MCS/IEI corn laints.
and he ascribed all of their problems to the possible
mold exposure in their Holmes Beach home on much the same grounds, as noted below:
Q.
Based on the testing that you performed with regard to the chemicals, I'm assuming
you're not able to take those tests and relate it to a specific event?
A.
Well, no necessarily, no.
Q.
Is there anything other than the history from Dr. GGGGGG that you can rely on in
causally relating the allergies to the chemicals you tested to the Holmes Beach residence?
A.
No.
Q.
Okay. So you totally have to rely on the truthfulness and accuracy of Dr. GGGGGG in
giving that history that his condition started after that point?
A.
That's correct.
Pages 63-64, Lines 12 - 25 and Lines 1-13
Q.
SO once he became chemically sensitive, how does an individual, such as Dr. GGGGGG,
become chemically sensitive as you've described?
A.
Well, I suspect that his chemical sensitivity was triggered by the mold exposure in
the home, in the home that he was in.
Q.
SO is it your testimony that Dr. GGGGGG was not predisposed to be chemically
sensitive, that the actual exposure to mold caused him to be chemically sensitive?
A.
That's correct.
Q.
SO is it your testimony that if you had tested Dr. GGGGGG for allergies to the three
chemicals that you referred to prior to this issue in the Holmes Beach in Florida in 2003 and
2004, it's your beliefhe would not have been allergic to those chemicals?
31
A.
He may not have been allergic to those chemicals. That's a possibility. I don't know the
answer to that question.
Q
What do you base that opinion on, that it's possible he became chemically sensitive
from the exposure to mold in his Holmes Beach residence between 2003 and 2004;
everything you base that on I want to know?
A.
Well, my experience with treating other individuals with similar problems; the fact
that the whole family got sick from the exposures; his medical history that was given.
Q.
Is there any testing that you can perform in your practice, any type of objective testing
that you can perform in order to make that causation opinion that the chemical sensitivity could
have been caused by the mold exposure in 2003 and 2004?
A.
Other than the fact that he tested positive to the molds and significantly positive to the
mold allergies.
Q.
Other than that?
A.
Other that that, nothing, no.
But, again, those testings don't reveal that his allergies to mold was caused by
Q.
exposure in 2003 and 2004, correct?
A.
That's correct.
Page 66, Lines 4-10
Q.
My question to you specifically, is there an objective test that you can perform as the
osteopathic physician to causally relate Mr. GGGGGG's alleged chemical sensitivity to the mold
exposure in the Holmes Beach residence?
A.
No objective tests that I know of.
- A "Positive" Result
Must be Placed into the Appropriate Context
Dr. GGGGGG saw Dr. RRRRR SSSSS on at least one occasion in 2004, at which time
he offered the assessment of SBS (Sick building syndrome). In addition, there are a number of
notes that appear to be phone messages, etc. relatcd to patient complaints in the succeeding
years. Unfortunately, most of Dr. SSSSS's notes are illegible. In addition to the office visit, Dr.
SSSSS ordered a litany of laboratory tests, but provided no insight into the use, efficacy,
sensitivity or specificity of any of this testing. Some of the laboratory values ascertained
included myelin basic protein, tumor necrosis factor alpha, erythropoietin, C2, properdin factor
B, C3, C4, Immune Complex Clq, C3a, VEGF, c4d Fragments, C3d Immune Complex, HLA
DRB DQB Typing, Raji Cells, MSH, Plasminogen Act Inhibitor-l , Anticardiolipin antibodies,
Gliadin antibodies, matrix metalloproteinase-9. These are all extremely esoteric laboratory tests
with no proven utility in the evaluation of any mold-related condition. Interestingly, these are
also the types of tests
icall used to "dia ose" MCS/IEI, as mentioned above in the AAAAI
Position Statement.
32
Interestingly, Dr. SSSSS also ordered a total
Immunoglobulin E = 4 Il.l/ml (Normal Range: 0-158) on 5118/04. This value is not consistent
with a significant underlying allergic diathesis, such as that proposed by Dr. XXXXX.
What Does It
Mean?
The GGGGGGs all saw Dr. GGGG WWWWW on at least one occasion and each
received a bank of neurological tests. Dr. WWWWW diagnosed each GGGGGG family
member with either Toxic Encephalopathy with MCS (Jaclyn) or Toxic Mold Exposure with MCS
(Alex, Rhyanna, Ryan, Alan and Anna Marie). Much like Dr. XXXXX, Dr. WWWWW relied
primarily upon the history given by the patients to make his diagnosis, as noted below:
Pages 42 - 43, Lines 20 - 25 and Lines 1-21 - Regarding Dr. GGGGGG
Q.
What was your impression based upon?
Specifically, was it based entirely upon your examination, the history, the testing or a
combination of it all?
A.
I would say a combination of all, but the biggest part is obviously the history, and that at
that time again, I came to that conclusion before the testing. That was my - that impression at
that time, I would say rather than final diagnosis, but an impression based primarily on his
history.
Then the testing confirmed to me that was likely what his problem was. So the final diagnosis
was based on his history and the testing, some with the examination; but the examination in his
case, because it didn't show much wrong, it didn't playa big role.
Q.
As far as the percentage then, the history would have played a large majority role in
your impression and analysis?
A.
Yes.
Dr. WWWWW ordered and interpreted a number of tests at his office, including an EEG
and QEEG on each of the GGGGGGs'. He made it clear that any "abnormal" EEG results that
he found were not specific to a disease process, and in the case of the QEEG the cause of any
abnormality was not readily identifiable.
Pages 59-62, Lines 24-25 and Lines 1-25 and Lines 1-25 and Lines 1-4
Q.
Without having the raw data in front of you are you able to teII us today what Dr.
GGGGGG's abnormalities, if any were, on the EEG?
A.
Yeah. He had mild increase in the delta just generaIIy.
Q.
So based upon, I think what you had testified before, this is a condition that may be seen
in normal individuals?
A.
Correct.
33
Q.
So it is not specifically indicative of a specific condition. It just means there may be
some abnormality.
A.
It is consistent with a generalized encephalopathic process. In other words, a
generalized process that slows the brain a little bit, but not specifically for which process
that might be. And it is also possible that might be normal for this individual person.
Q.
With the QEEG is it possible that other physicians, other neurologists may also review
these results as normal?
A.
No.
Q.
Okay. So everybody who would review these results would say they are abnormal.
A.
Right. What that abnormality means, you might get more than one opinion, too.
Q.
Now, you did say all of these were consistent with or may be consistent with the process
of toxic metabolic or ischemic etiologies.
A.
Right. The QEEG by itself doesn't tell you which of those - it says there is an
encephalopathy. The brain is not working quite right; mildly abnormal. It is a generalized
encephalopathy. In other words, the whole brain has been affected.
So, for example, a patient who had a heart attack and didn't have enough oxygen for a
while to their whole brain, could have a similar finding......
So we could say that pattern of a generalized encephalopathy, but it doesn't give you that
read out and say, ding, ding, this is the one.
CONCLUSIONS:
From my training and experience, I am familiar with the literature that describes the
scientific methodology required to determine the specific cause of a disease or ailment. This
same methodology should be rigorously applied in order to establish a causal link between any
exposure and an alleged disease or ailment. The application of this methodology allows one to
distinguish a result that occurs s ontaneousl , from those which rna result from a known
ex osurc.
The evaluation of a causal relationship between a specific cause and a
specific disease outcorne in an individual should include the following information:
1.
2.
3.
4.
Evidence of exposure to the specific compound.
The exposure must result in a dose of the specific compound.
The dose must be sufficient to cause the specific ailment.
The specific ailment is known to be caused in humans by the specific compound in
question.
34
5. The ailment is temporally eligible to have been caused by the exposure.
6. The alleged effect(s) is biologically plausible.
7. Confounding factors have been eliminated as possible causes of the ailment.
Although mold exposure may potentially cause transient mucosal irritation
symptoms, exacerbation of allergy symptoms, as well as triggering of allergen-related asthma,
these are all transient and directly related to the exposure. Following cessation of exposure, if
symptoms persist eitlIer the exposure was not unique, or the symptoms are related to another
offending agent. Simply put, there is no clear, objective relationship between the Holmes Beach
house and any of the patient's conditions from mid-2003 to present.
It is my understanding that additional depositions are scheduled and further medical
records may become available in the near future. As stated in the report introduction, this is an
INITIAL report pending receipt and review of all additional records. I reserve the right to amend
this report if further information should become available.
Sincerely,
35
REFERENCES
Bailer, J., M. Witthoft, et al. (2005). "Evidence for overlap between idiopathic environmental
intolerance and somatoform disorders." Psychosom Med 67(6): 921-929.
Hardin, B. D., B. J. Kelman, et al. (2003). "Adverse human health effects associated with molds in the
indoor environment." J Occup Environ Med 45(5): 470-478.
Hausteiner, c., S. Bomschein, et al. (2007). "Dysfunctional cognitions in idiopathic environmental
intolerances (IEI)--an integrative psychiatric perspective." Toxicol Lett 171(1-2): 1-9.
Hyvarinen, A., T. Husman, et al. (2003). "Microbial exposure and mold-specific serum IgG levels
among children with respiratory symptoms in 2 school buildings." Arch Environ Health 58(5):
275-283.
Immonen, J., S. Laitinen, et al. (2002). "Mould-specific immunoglobulin G antibodies in students from
moisture- and mould-damaged schools: a 3-year follow-up study." Pediatr Allergy Immunol
13(2): 125-128.
Korppi, M., S. Laitinen, et al. (2003). "Mold-specific immunoglobulin G antibodies in a child
population." Pediatr Allergy ImmunoI14(5): 371-377.
Rydjord, B., J. H. Marton, et al. (2008). "MOUld-specific immunoglobulin antibodies quantified by flow
cytometry reflect mould exposure in Norwegian children." Clin Exp Allergy 38(3): 430-437.
Staudenmayer, H. (2001). "Idiopathic environmental intolerances (IEI): myth and reality." Toxicol Lett
120(1-3): 333-342.
Taskinen, T. M., S. Laitinen, et al. (2002). "Immunoglobulin G antibodies to moulds in school-children
from moisture problem schools." Allergy 57(1): 9-16.
Terr, A. 1. (2003). "Environmental sensitivity." Immunol Allergy Clin North Am 23(2): 311-328.
Trout, D. B., J. M. Seltzer, et al. (2004). "Clinical use of immunoassays in assessing exposure to fungi
and potential health effects related to fungal exposure." Ann Allergy Asthma Immunol 92(5):
483-491; quiz 492-484,575.
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Credibility of Medical Evidence - National Association of Workers

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