THE PRESIDENTIAL OVERSIGHT COMMITTEE
ON GULF WAR VETERANS' ILLNESSES
MULTI-DISCIPLINARY PATHOPHYSIOLOGIC STUDIES
OF NEUROTOXIC GULF WAR RELATED SYNDROMES
LEADING TO DIAGNOSIS AND TREATMENT
Tuesday, June 22, 1999
ADM Elmo R. Zumwalt, Jr. (biography)
The Honorable Jesse Brown (biography)
Dr. Vinh Cam (biography)
RADM Steinman (biography)
Allan M. Green, M.D., Ph.D., J.D.
of Counsel, Mintz, Levin, Cohn, Ferris, et al.
Director and Acting President
Theseus Medical Imaging Corporation
Dr. Tomas Guilarte
Professor of Environmental Health Science
Johns Hopkins School of Hygiene & Public Health
Dr. Melody Lin
Office for Protection from Research Risks
National Institutes of Health
Dr. Jonathan Samet
Chairman of Epidemiology
Johns Hopkins School of Hygiene & Public Health
Dr. Scott Zeger
Chairman of Biostatistics
Johns Hopkins School of Hygiene & Public Health
Invited Governmental Agencies:
The Department of Veterans Affairs
The Deputy Undersecretary of Defense for
Science and Technology
The Department of Health & Human Services
The Military Operational Medicine Research Program
The Persian Gulf Veterans Coordinating Board
The Office of the Secretary of Defense
Office of the Special Assistant for Gulf War Illness
C O N T E N T S
The Honorable Jesse Brown
Opening Message from the Presidential
Oversight Board Members
ADM Zumwalt, Jr.
Dr. Vinh Cam
ADM Zumwalt, Jr.
Introduction of Invited Guests
ADM Zumwalt, Jr.
Dr. Robert Haley
Question and Answer
P R O C E E D I N G S
MR. KAPLAN: Good morning. I am Roger Kaplan. Today I am the designated federal officer, and my responsibility is to start and to officially end this meeting.
We are glad that you are all here today to listen to Dr. Haley's presentation, also the questions that will be coming from the personnel at the front table. I request that if the audience does have a question that you pass it to me and time permitting, we will attempt to get to it. However, the priority is to the learned individuals that we have gathered here today to pose questions to Dr. Haley.
With that, I would like to pass the meeting on to The Honorable Jesse Brown, former secretary of Veterans Affairs. Secretary Brown?
MR. BROWN: Thank you. Good morning. I hope everyone can see -- if you are not in the division that you can actually see the screen, please feel free to move at this time.
I would also like to modify something that was just said. I wanted more of an open process. Of course, we want to make sure that the people that are here have an opportunity to conduct their business. But at the same time, I want everyone in this room to feel perfectly free to ask any questions that they may have.
And we are not necessarily going to be limited by written questions. I would only ask that you be reasonable and give everybody an opportunity to participate. When you leave here today, I want everyone to feel that they have had a chance to not only voice their concerns, but to get answers to any questions that they may have if that is possible.
Having said that, I would like to just turn the proceedings over to ADM Zumwalt for an opening message.
ADM ZUMWALT: I had a role in helping to bring to the table the distinguished scientists who are here today, and I would like to express my gratitude to them for being here. I will reserve my other comments for later in the agenda and ask The Honorable Jesse Brown if he has any additional comments he would like to make. If not, I will pass it to ADM Steinman.
RADM STEINMAN: I have no comments other than to say I look forward to the exchange of scientific information. There is some very interesting topics under discussion today, and I appreciate the open audience being here too to observe the -- our committee's meetings.
As you know, we opened -- our committee meetings are held in the open so that everybody can see what we are doing. And this is all part of that process. And by the way, there is going to be another special oversight board public hearing here in Washington in July. The date is --
MR. KAPLAN: July 13th at George Washington University.
RADM STEINMAN: To which you are all invited, of course.
ADM ZUMWALT: Dr. Vinh Cam.
DR. CAM: Yes. I am very glad to have a chance to listen to Dr. Haley's research. I hope that will help us all to understand the nature of this very complex issue. That is all.
ADM ZUMWALT: I would just, in conclusion of the opening remarks make the comment that I am frequently reminded of Mr. Winston Churchill's comment that democracy is the worse form of government ever invented except for all the others that have been tried. And one certainly finds that in trying to grapple with coming up with answers to problems at the end of each of our wars.
Those of us who went through the Vietnam War, grapple with the Agent Orange for many issues. During the beginning with a government policy to conclude that there was no correlation between Agent Orange and diseases.
And it took the battle of many years to bring out the truth and to get final justice in terms of a system that works and the progressive designation of diseases for which there is a reasonable likelihood that there is a causal relationship between exposure to Agent Orange and disease.
As a result of the lessons learned in that battle, the government and the public, I think, have come to a much more efficient process, in this particular case, with regard to the Desert Storm diseases and Syndrome.
The responsibility of this special oversight board is to report, at the end of an 18-month period, to the President in a way to give him confidence that everything that can be done has been done by the governmental process and the interaction between the public and the government to come up with good, sound answers.
Today we have an important element in that process with a presentation by Dr. Haley, who has done research that -- on behalf of many in the public, lead to the conclusion that additional research should be done in that area and the conclusion on the part of others that additional research is not necessarily necessary at this time. I hope at the end of the day we will be much closer to being able to resolve in our own minds that conflict and proceed from there.
Now I will ask if each of the people at the table, beginning with you, Dr. Green, will give their name and their brief background.
DR. GREEN: Thank you. My name is Dr. Allan Green. I am of counsel to the law firm of Mintz, Levin in Boston and Washington, but for today's purpose, I think the relevance to my background is that for many years I was medical director of New England Nuclear Corporation and involved with medical imaging in the development of a number of medical imaging agents, medical imaging techniques, and have been involved for over 25 years with development of new drugs and devices largely working through the university system and to some extent, through the Food and Drug Administration and the NIH.
So I have had an interest in the evaluation of these sorts of problems we are talking about and the technology that we will talk about today.
DR. SAMET: Even though I don't have a name tag I have a name. I am Jon Samet, the chair of the Department of Epidemiology at Hopkins. My background is in internal medicine and pulmonary disease and also in epidemiology. And I have a long-time interest in the health effects of the environment.
DR. ZEGER: My name is Scott Zeger and I am professor and chair of the Department of Biostatistics at Johns Hopkins. And I am also interested in the environmental exposures and in quantitative methods necessary to assess risks from those exposures.
DR. GUILARTE: My name is Tom Guilarte. I am a professor in the divisions of toxicological sciences, of radiation sciences, and the department of environmental sciences at Johns Hopkins University School of Hygiene and Public Health. And my area of interest is in neurotoxicology and neuroscience.
DR. LIN: Good morning. My name is Melody Lin. I am the deputy director for the Office for Protection from Research Risks, also known as OPRR, which is a part of NIH. Our office enforce and implement Department of Health and Human Services regulation for the protection of human subject. Also to implement public health service policy for the humane care and use of laboratory animals.
DR. HALEY: Robert Haley.
ADM ZUMWALT: Next over here. Tim.
DR. GARRITY: Yes. I am Dr. Tim Garrity, special assistant chief research and development officer for the Department of Affairs -- Department of Veterans Affairs here representing the Department of Veterans Affairs.
CPT MAZZELLA: I am Peter Mazzella from the Department of Health and Human Services. I direct the Office of Military Liaison of Veterans Affairs. And ours is mostly a policy office except we do have to weigh in on many, many Gulf War issues.
LTC FRIEDL: I am Karl Friedl from the U.S. Army and Medical Research and Materiel Command. I am the research area manager for the military operational medicine and research program and coordinator between the services for that kind of research. And I am also the -- I guess the technical manager for a grant that we have to Dr. Haley at this point.
COL ABREU: My name is COL Michael Abreu and I work at -- I am the director of investigations and analysis at the Office of the Special Assistant to Gulf War illnesses.
LTC RIDDLE: I am Dr. Rick Riddle. I am an epidemiologist, and I work for the Office of the Secretary of Defense for Health Affairs.
DR. SPENCER: Peter Spencer. I am professor of neurology, director and senior scientist of the Center for Research on Occupational and Environmental Toxicology at Oregon Health Sciences University in Portland. My interests are specifically within the area of neurotoxicology, and I have done some elaborate work on the Gulf War related illnesses.
ADM ZUMWALT: Well with this group of distinguished scientists, we have everything necessary to help us distill wisdom today. Let me introduce Dr. Robert Haley.
DR. HALEY: Thank you.
Robert Haley. I am from Southwestern Medical School and in the Department of Internal Medicine. I am an internist and epidemiologist.
My career that brought me here involved -- after an internal medicine residency at Parkland Hospital in Dallas, went to CDC and spent 10 years at CDC basically investigating epidemics, doing research relating to hospital acquired infections, and controlling epidemics in hospitals.
And then I directed the hospital infections division for several years in supervising epidemic investigations over the country and some oversees. Then came back to Dallas, been there for 16 years basically looking, investigating, thinking about epidemic investigations and doing studies academically on that subject.
The way I came to this subject was interesting. This was not a research interest that I was planning to get into. I was busy working on a study of Hepatitis C, which still sits on the shelf, and one day got a call from the president of our university, Kern Wildenthal, who asked me to come over the next morning to meet with Ross Perot.
I said, "Ross Perot. Why would I meet with Ross Perot? I don't know Mr. Perot." And he said, "He wants to tell us about the Gulf War Syndrome." And I said -- truly I said, "Look, let's don't involved in that. That is a psychological issue. It is stress. It has been decided. Let's don't waste our time." He said, "Well, just hear him out."
So I showed up and with Jay Sanford -- some of you all may know Jay. He had come back to Southwestern at the time, had just rejoined our faculty. And we met and Mr. Perot said, "I have been talking to veterans' groups for 30 years and something new is happening in the last couple of years." This was early 1994.
And he said, "Every time I go to a group now, I see some veteran or several veterans come forward with their wives and their company commanders and they say, 'This isn't the guy who went over. Something has happened to his personality. It is a different person. And nobody is looking into it anymore, he is not getting any help, and we don't know what to do.'"
And he said, "This is happening so regularly now -- I am a judge of character, I am not a scientist, but I am a judge of character, and I think this might be real. So we need an independent study and if you guys would do it, I will help fund it."
So we were really -- our interest was peaked and we decided to do an outing. We assured Mr. Perot that if this was psychological, if it was stress, we would include that as a very important part of our research and see if we could figure out what the psychological problem was so maybe we could help these guys and we would tell him truly what we thought. And he said, "That is what I want. I don't want to buy a solution, I want to know what is going on. So go for it."
So we started. What I am going to describe today is basically -- and this is an important term, an important characterization at the very beginning. What I am going to show you is an epidemic investigation. It is not a chronic disease epidemiology study of heart disease or cancer.
And this is a very important distinction because in epidemiology, there are different tools that we use to study heart disease or cancer -- an ongoing problem in a population -- as opposed to a one-time common source epidemic in which the exposure occurs in a time limited fashion followed by an uprise and fall in disease, what we call an epidemic curve, in the cessation of new illness.
That is what has happened. And all the way through this issue, as -- we have been involved now for five years. I have been working full time on this now for five years. And of all the things that I see that have confused the country on this, it is the failure to distinguish a one-time common source or at least time limited exposure situation followed by an epidemic curve and cessation of illness.
And failing to distinguish that from our usual epidemiologic pursuits that deal with chronic ongoing diseases that are continuing to occur that have long incubation periods, many multi-factorial causations, and require different much more sophisticated techniques to handle it.
Now let me tell you the difference. And I spent 10 years at CDC learning sort of the CDC fire drill, if you will, for handling epidemics. And this is a technique that has been used for 50 years now to solve, I don't know, countless epidemics, including Legionnaires Disease, Toxic Shock Syndrome, AIDS, the Four Corners Pneumonia epidemic, Hantavirus, et cetera.
Basically what you do is when you see an epidemic, you suspect a common source. You don't need to do a really sophisticated study where you prospectively enroll people and measure risk factors with sophisticated things. And the reason you don't have to do that is this.
In a common source epidemic, what you are dealing with is a limited set of causes that have a short incubation period and therefore, the disease that you get is a relatively homogeneous disease. So therefore the measure -- if you can come up with a case definition to characterize that disease, the measurement of the disease is very easy. The problem is sometimes you can't come up with a case definition. That is the difficulty.
The other thing is that the association between the causal factors and the disease are generally very strong because they are immediate and usually a fairly small number of causations. So therefore the technique -- so therefore you expect to find very large relative risks. Often in epidemics you get relative risks between 5 and 10, for example. Whereas in chronic disease epidemiology study you get a relative risk of one-and-a-half to three.
Therefore, since the disease has already occurred, the cause is already often over, you can't prospectively measure the risk factors. So therefore the time honored technique is a case control study. You create a case definition from examining a small number of the people. You pick some representative cases, define the case definition, go to a population that has the disease, define in that population who satisfies the case definition and who doesn't.
An example of a case definition would be a statement. The case of toxic shock syndrome is defined as people with high fever, low blood pressure, and red skin. That was the case definition for toxic shock syndrome. Then you go to a group of people who may have it, you divide them into those who satisfy the case definition and those who don't. You call them the cases and the controls. There are other names, but to make it simple, the cases and the controls.
And then you deliver a questionnaire to them. Well, first, you probably examine the people to be sure this is really an illness and not some fictitious epidemic, what we call a pseudo epidemic. But if it really does look like a physical illness, you then administer a questionnaire to the cases and the controls and ask them what happened to them before they became ill. And of course, you have to include on the questionnaire the likely causes. You have to have a good hypothesis.
Those are then self-reported symptoms and self-reported risk factors. And that technique has been used for 50 years and has solved all the major operates in our country. However, to a chronic disease epidemiology that is heresy because you can't learn anything from self-reported symptoms, although all symptoms are self-reported, and you can't learn anything from risk factors that are self-reported, you have to measure. You see that is a chronic disease model as opposed to an epidemic investigation.
Now let me tell you, I know that this -- the way I am starting here is going to rankle some people because many people who are chronic disease epidemiologists don't like the epidemic investigation model. The problem is it works. It is a time honored technique that works.
Okay. Let me go into the slides now. In fact, let me say we are going -- I am going to organize this in sort of two segments. The first hour I am going to go through the epidemic investigation, the initial phases, to show you what we found. You have already read those papers, presumably, we passed them out. But I will go through the high points.
Then we will take a short break and then I am going to go into all new information that we have -- some we have just published in the last week or so and others are unpublished. But let me say I don't know who all is in the audience here, but I hope that people will be responsible and not take away the unpublished information and publicize it because we want to go through the peer reviewed scientific process.
And part of this not peer reviewed and should not be assumed as final information until it is. However, this is my one chance to talk to you. So we are going to pull out everything we know at this point. And the handout is really related more to this afternoon's discussion -- I mean, the second half of the discussion this morning.
All right. Let me go over now the strategy that we have followed. And the first part of this was laid out in the beginning. The second part has been an evolution since then. We started out with an exploratory, hypothesis raising epidemic investigation. Typical CDC study. We had an original epidemic investigation in the Seabees unit, which I will talk about.
And the purpose of this was, one, to come up with a case definition to see if we could define the syndrome, this Gulf War Syndrome or these Gulf War Syndromes, and then to define the risk factors and see if we could find an association between the two. A classic case controlled CDC study.
We then had planned that if we do find a disease, we would then do a secondary nested case control study in this little epidemic investigation. In other words, we would -- if we find an illness, we will fix them. Representative cases and some matched controls and do a case control study to verify whether we can verify any organic disease or not in this group.
Third, after we did this, we then decided to come back and revisit all of this, since we found some promising findings, and really pull out the stops. We then got funding by the Defense Department. Original studies were funded by Ross Perot. And did an extended case control study basically on the same design of the first nested case-control study, but looking for differences in genetics susceptibility to organophosphate injury, which we felt this was, and to try to quantify or measure the brain injury much more powerfully than we did in the first test.
Frankly, at this point, we still weren't convinced that there was anything real here. But after this was done, we felt this was very promising, we felt that this warranted a lot of resources.
Not shown here and not actually done by us, but Tom Kurt, who is my toxicology colleague, who was involved with us early, he was very early interested in the organophosphate hypothesis and interested Ross Perot in funding a study at Duke University with Dr. Abou-Donia, where Tom Kurt and Dr. Abou-Donia developed an animal study to look at the synergistic effects of organophosphates in similar chemicals that were indigo to see if combinations of those might cause neurological injury when individual -- in a situation where individual agents wouldn't.
So our hypothesis we also tested in animals, although we didn't do that at Southwestern, that was done at Duke. Now once we completed this, we then felt that we needed to try to replicate our findings. A lot of this involved large numbers of tests. And of course when you do large numbers of tests, there is a possibility that you can get false positive results. However, as you will see, the relative risks of these were so large that that is not an unlikely possibility.
However, we decided to replicate and we did it in two ways. First, we did a survey in the Dallas VA and found 336 ill veterans just advertising, brought them in and did a confirmatory factor analysis to see if our factor structure occurs in other U.S. veterans.
And then we did a small replication of our main -- what we think is our main finding, perhaps, of evidence of brain injury on MR Spectroscopy, Magnetic Resonance Spectroscopy. We picked a small number of the veterans from this survey and added them to this survey to see if we could replicate the brain injury results.
And finally, we propose now, on the basis of all of this, we now think we now have a very promising hypothesis. In fact, we think at this point had this been a product on the market and we had evidence of this degree, this product would now be off the market. CDC would have gone to FDA, they would have showed them results, the product would have been off the market.
Now let me make one more comment about this sort of duality between chronic disease epidemiology and epidemic investigation. In my early career at CDC in the hospital infections program, we had a long-standing conflict with the FDA.
Early on in the seventies, the FDA would not accept a case control study as evidence of a product injury. That is, statistical associations do not prove causality, and to the extent that they absolutely refuse to take toxic products and injurious products, infected products off the market or issue recalls, based on epidemiologic evidence alone.
Between 1972 and '76 or so we won that battle. We finally convinced FDA, with epidemic after epidemic, that this technique, because of the nature of epidemics, is really a powerful technique and does not often, if ever, if you get strong relative risks, does not really lead you to false positive results. It may lead you to false negative results, but usually not false positive.
Anyway, since we have done all of this work in a group of Seabees and a group of Dallas area veterans, some corroboration, we felt what is really needed next is a survey where we pick a random sample of the veterans who went over, about 3,500, and a random sample of veterans who didn't go over to the War, who were in the military at the same time, carefully -- the populations carefully adjusted so that they are comparable, eliminating what I have termed the healthy warrior effect. Some of you have heard about that literature.
And do a survey where we issue our same epidemic -- our same questionnaires that we used on our epidemic investigation, but in a population survey. So we can then measure the frequency or the prevalence of these syndromes, then pick random samples, small random samples of the sick and the well and both populations, and bring them to Dallas, repeat just those key imaging and genetic technologies that seem to work and see if it holds together.
If it doesn't, obviously it will fall apart here. But given the corroboration we have already got, we think it is a very high payoff. Okay. Well, that is the road map. That is where we are going.
Now let me digress a minute and talk a little about a condition which I am sure is known to some of our colleagues here, but is not well known to physicians in the United States. When we first started doing this, Tom Kurt, my toxicology colleague, came up with this while we were sitting at the NIH conference in April of 1994.
He was sitting in the audience and he looked at the risk factors that were being discussed and the disease manifestations and he punched me in the ribs and said, "Haley, I know what this is. This is OPIDN." And as an internist, a very erudite internist I thought, I said, "OP what? What are you talking about? What is this OP?" It took me three days to learn the acronym.
Organophosphate induced delayed neurotoxicity. And we have in the room one of the world's experts on this, Dr. Spencer, in the corner over there. He has written much of the basic literature. Basically an organophosphate has this generic structure. It has a phosphorous sort of a centerpiece, a phosphate with a -- with variable organic components here and a variable active component here.
For example, in sarin nerve agent and soman this is a fluoride here. But this is a very toxic molecule. This encompasses -- this, in similar structures, encompass most of the pesticides that we use in civilian life, as well as the nerve agents that are used in warfare. Basically a chemical nerve agent is nothing more than a pesticide for humans. It is just much more lethal, much more tenacious than we use commercially.
Now let me make this real with a case report. And those of you have my little grand rounds presentation I did at Parkin, this was the little case report. This actual case report came to me at the lunch table at the faculty club one day as I was getting ready to give grand rounds. One of my colleagues had just seen this lady.
This is a 66 year old north Dallas woman who presented with leg weakness, weakness in her legs, aching all over her body, particularly severe pain in her shoulders and hips, and burnings -- a tingling sensation in her extremities. Severe fatigue. And the weakness then progressed up her legs to her thighs, but there were no other objective neurological signs. No reflex changes really, no other neurological problems.
The physician could not make a diagnosis. He said chronic fatigue syndrome. He thought of a psychiatric problem. She gave a history, however, of her house being sprayed by an exterminator a few days to a week or so before the onset of her symptoms. The physician then called the exterminator and found out that there were two organophosphate pesticides, but the exterminator would not reveal what they were and shortly after that went out of business and left town.
The lady said that she often went barefoot in her home and thinks she probably did it around the time they sprayed her house. The fatigue and weakness lasted about six months and gradually then melted away and she got well. This, I think, is a classic case of OPIDN, organophosphate induced delayed neurotoxicity.
Now this is a well recognized medical condition. It was first -- really came to national -- world attention during a huge epidemic in the 1930s due to inadvertent consuming of an industrial chemical called TOCP, tri-ortho-cresyl phosphate.
That is irrelevant except here is what happened. This ultimately became known as Jake Paralysis or Ginger Jake Toxicity, 1930. In February 1930, suddenly a paralytic illness struck people throughout the southern United States.
And it was very geographically oriented, the southern and western part. Over 5,000 cases were documented in three months and an estimated 50,000 cases occurred in 17 states. One out of every 500 people living in the southern United States at that time was affected to some degree.
The onset of this -- and this is really important to understand. Some of the cases gave a very murky picture of an acute symptom, but in most people, this was inapparent or not present. Then there was a delay of, on average, six to seven days when the occurrence of leg weakness occurred -- began, which spread up the legs, up the arms, nobody died. But it presented with an initial flaccid paralysis indicating a peripheral nerve injury.
As the peripheral nerve injury healed over about a year, the paralysis regressed in the opposite fashion in which it came leaving in its place a spastic paralysis. This absolutely has been forgotten by everyone who knows this -- has heard about this. But the spastic paralysis indicates that there was a spinal cord injury, a central nervous system injury as well.
Many of these people also complained of fatigue that may have lasted the rest of their lives, suggesting a brain central nervous system thing. But notice the delay of several days to several weeks. In fact, the delay now in various studies has been documented up to six weeks after the exposure.
So you can have an exposure to an organophosphate and a delay of weeks before you get the onset of symptoms. And that is very thoroughly documented. Now it characteristically occurs within seven to ten days.
This outbreak was due to drinking TOCP in a drug store alcohol containing medicine called Extracted Jamaica Ginger or Ginger Jake, which during prohibition -- this was during prohibition -- was a common remedy for what ails you. It was one of the legal forms of alcohol at the time.
Now the injury, it was well studied back in that era. In fact, up through the sixties, it was well documented. This is a photograph of a longitudinal section of a vertical nerve showing typical ballooning of the nerve and loss of the axon -- this is the axon -- ballooning of the axon and interruption of the axon. You see the typical beading appearance, a degeneration of the peripheral nerve.
This is a schematic here showing the typical axon on a nerve, peripheral nerve, ballooning in the first stage, fragmentation and then healing slowly.
Now this is close-up view actually of a nerve showing the ballooning and the injured section and loss of the nerve filament there.
All right. Now that is not what this is. Gulf War veterans don't have OPIDN, a typical form. And it took us a while -- and I think Peter Spencer was maybe one of the first ones that really hit me with this distinction.
Gulf War veterans don't have much, if any, peripheral neuropathy. Perhaps some subtle peripheral neuropathy, but that is not a feature that is important here. TOCP or OPIDN, the original TOCP injury was primarily a peripheral neuropathy with a secondary CNS spastic condition that was unmasked later.
This is a very famous study in this field by Savage. Now there are other studies like this. There are at least half a dozen epidemic investigations of cognitive and other central nervous system damage from people who are exposed to pesticides, particularly seen in agricultural workers who spray pesticides.
In this study, they compared one hundred agricultural workers with accidental organophosphate exposure, pesticide exposure, with a hundred matched controls that they identified from the case registries from the Colorado and Rio Grande Valley in Texas, where they have registries to register injured agricultural workers, matched on age, sex, race, education, and socioeconomic level and did blinded examinations of them.
And what they found out is the cases were significantly more impaired on tests of short-term memory, the Haltstead Reitan battery of neuropsychological tests, which basically is a battery of about 50 tests of brain function.
This is not a psychological test, it is a test of sensory, motor, and all the different cortical functions and sub-cortical functions of the brain that are added up into a test that measures brain dysfunction. This is used by neurologists and neurosurgeons to follow their patients with a brain tumor, for example, to see if surgery helps, if the brain impairment decreases.
They were more impaired also on MMPI measures of psychological disfunction. Many of these people develop depression, obsessive compulsive characteristics, after the exposure of organophosphates. It is standardized self-reports of dysfunction, that is standardized questionnaires of what was wrong with them, and family reports of disfunction.
All of these were statistically much more common in cases than controls suggesting or indicating that the pesticide injury may well have caused this encephalopathy or brain disfunction. And there are other studies showing the same thing.
Here is one by Rosenstock comparing 36 Nicaraguan workers, agricultural workers, each with a single set of OP poisoning with 36 match controls. They did neuropsychological test batteries and tests of verbal attention and visual attention, visual memory, visual motor speech.
In other words, a group of neuropsychological tests looking at brain function and found them all to be more abnormal in the exposed symptomatic than the unexposed, suggesting encephalopathy. Now that is the background. In other words, the summary is, there really is a brain injury that is caused by pesticides.
All right. So now let me talk about our investigation. First of all, let me just tell you what our current provisional conclusions are.
First, let me point out, as I always do -- this is important to point out -- we believe from a very thorough reading of the literature, and we have read the literature specifically to answer this question, we think the decisions made before and during the Gulf War to protect our troops from chemical nerve agents, from insect born diseases occurring in the Gulf and all of the other hazards that our troops are going to face, these decisions that the military command made were medically sound, scientifically sound, given the knowledge of the day, of 1990.
There was no evidence we can find -- in fact, there was substantial evidence in the literature suggesting everything they were doing was a good idea and would have been unconscionable had they not done it.
We think in retrospect, however, evidence has come out after the war suggesting that some of those were a mistake, but not that anybody could have known. So we want to point out that there should no scapegoating, at least as far as the information we have.
Now our first main conclusion, though, is, contrary to the official word, we believe there is a Gulf War Syndrome. And I am going to define syndrome in a little bit and give you a case definition for what this is. But we think it has at least three variants, maybe three different divisions, but maybe the same, but with three different variants.
We think it is due to subtle brain and nerve damage and nerve damage in the central nervous system. Primarily the brain. And I will even say we think now that the damage is in the basal ganglia, possibly the thalamus, and the brain stem. And I will tell you what those are in a minute.
And we think it was caused by exposure to combinations of organophosphate like chemicals. Now not all these are organophosphates technically, but we think they act together in synergistic ways. To wit, sarin nerve agent, and I think it is sarin, not soman or VX or anything else. We think it was probably sarin.
We think pyridostigmine bromide, Mestinon, for physicians who use this to treat Myasthenia Gravis. It was given as an anti-nerve gas, anti-soman agent to increase survival in a soman attack, if one had occurred. DEET, the active ingredient in insect repellents and pesticides that were liberally sprayed in the environment and also were present in flea collars that many of the soldiers wore to, again, to protect themselves from insects.
There is evidence now that giving PB before a soman attack improves survival. That is well shown in animals. Extensive literature on it. However, there is now evidence occurring right after the war that if the PB is given following the exposure to a number of organophosphates, that it actually may promote brain damage.
Now the brain damage and the initial symptoms that can kill you; in other words, the acute immediate symptoms of organophosphate poisoning, and the long-term brain damage, these occur by different pathogenetic mechanisms. Okay?
So in other words, we think the PB -- and we may want to talk about that this afternoon, the different mechanisms of the acute effects of organophosphates and the chronic effects. These are two different mechanisms, another distinction that has really clouded this field.
Now let me reemphasize now the technique we followed. Standard steps in investigating an epidemic of a new disease. CDC tipicalous. It has been done a thousand times. First, examine a few of the people, develop a case definition, survey a population and divide them into cases and controls, verify that the cases have a real illness, then identify factors -- or questions in the cases and the control that differ between the cases and the controls. And that gives you a clue about what the cause is.
You then test that cause for plausibility in animal models. You then develop a screening test, a treatment and preventive measures, which we are going to talk about later, to, in epidemiological terms, to take the pump off the handle, to stop the epidemic if it is still going on or prevent it from occurring in the future. And then you continue surveillance to be sure it is controlled if it is an ongoing problem. That is the CDC formula.
Now is this an epidemic? Is it an epidemic? Some people would disagree over that, perhaps. Here is the epidemic curve. This is a graph showing the number of cases with onset by date by month during the war. The actual war was fought right in here. The number of people who -- by the date of appearance of their first symptom.
Now this doesn't necessarily mean that that was the date their -- whatever this Gulf War Syndrome occurred, it is the date of the first symptom that they attributed to it. And people may have falsely attributed. We don't know. But at least what you see a huge spike followed by a secondary peak and some little squiggles. In other words, within several months after the war, everybody who got sick in the control that we studied, had the onset of their disease.
This is a -- I won't say classic, but this is a -- has a very strong familiarity with the common source epidemic curve. This was distinguished by a bimodal peak and maybe a few little reverberations later. Those of you who are epidemic investigators would know that you look at the shape of the epidemic curve as a real clue to what is going on. And that suggests a common source epidemic with perhaps two or three different interactions of risk factors.
DR. CAM: Dr. Haley, you mentioned earlier that PB post-exposure could cause brain damage. Did you really have data as to how many were in that situation and was that integrated into any of your graphs?
DR. HALEY: No. That is in the literature about -- those are basic chemistry studies.
DR. CAM: I see.
DR. HALEY: That show in animal studies that these different chemicals can promote -- they are agents that can promote and can increase the likelihood of occurrence of OPIDN in animals.
DR. CAM: So it would be very difficult to assess such a thing.
DR. HALEY: Well, let's go through it. In one sense yes, in another sense no. Okay. So that is the epidemic curve.
RADM STEINMAN: Excuse me. Could you back up, please, one slide. Tell me if I am wrong, but the major peak in appearance of first symptoms significantly predates the shooting.
DR. HALEY: Again, this is the date of onset of the first symptom --
RADM STEINMAN: Right.
DR. HALEY: -- that they had in the war. Yes, this is interesting, isn't it? So the question is, who is there and who is there? And I will come back to address that later.
Okay. Now when you find what you think is an epidemic, a common source epidemic, first examine a few of the ill people and develop a case definition. That is the cardinal rule. And notice if you look at all the other research out there, virtually no one has ventured a case definition. This was the point of the NIH conference in 1994, to come up with a case definition.
Jay Sanford proposed a case definition in 1993 to do studies like this. It was rejected. Over and over there has been a reluctance to come up with a case definition. What we tell our students is, first come up with a case definition. And if you can't, then develop a case definition because failure to do this means you have given up. You are not going to solve the problem. No epidemic will ever be solved without a case definition.
Now you say, and I have put this question to many of my old CDC colleagues over these last several years, "Well, what if you just can't develop one?" And they say, "Then you develop one. You come up with some way to do it." Because without doing that -- the problem is doing comparisons without a case definition, say comparing the deployed population and the non-deployed population. See only a small percentage of those people are sick.
And so when you compare those two, the effects are completely diluted out, but with a case definition, you focus on who is sick and compare them with the people who are not sick and you suddenly get very powerful differences. Well, let me tell you, this is a very important point. This is the key, the solution to this whole problem.
All right. Well, what is this Gulf War Syndrome? Here is the problem that we are trying to solve. We have to come up with a case definition. And the problem is, here is the Gulf War Syndrome. Now think of how many of these have you ever had.
Fatigue, fever, night sweats, muscle aches, joint aches, watery diarrhea, abdominal pain, breathing problems, skin rashes, hearing loss, swollen glands, headaches, memory loss, depression, emotional changes, personality changes, problems sleeping, problems concentrating, problems with thinking, problems speaking, becoming confused or disoriented, tingling, burning, numbness, muscle weakness, loss of balance and coordination and loss of bowel and bladder control, sexual impotence, chemical sensitivities, and panic attacks.
Now you know the average doctors, almost every doctor, sees people like -- that have multiple ones of these frequently, and frankly, what you do is you say -- in fact when I was an intern, you called that a crock. A person who is making up symptoms who we will never find a cause and it is a waste of time to deal with them. And doctors react to this like that, and that is because we usually never find anything and we can't do much about it. So it is very frustrating to doctors.
Well, how did we come up with a case definition. What we did was, as we usually do in an epidemic investigation, we found a group that -- we went out and found them. We didn't look for people to come to us. That is another key factor in epidemic investigations. You don't go find people that come to you because you get a strange mix. You go out and find a group and then get as many as you can in this group and get them together to do the investigation.
We picked a group called the 24th Reserve Naval Mobile Construction Battalion or Seabees. We picked them for several reasons. First, Jay Sanford had given me some reports produced by a Navy epidemiology group, Bill Berg was the head of that group. It was sent out initially in 1992, shortly after all this was recognized, and contacted a number of units where there were reports of a lot of this illness going on. This, he felt, was a typical one.
In this, he catalogued all of the symptoms -- it was a small number of these people, not as many as we looked at. I think there were only about 30 or 40 looked at. But what he found is these people have the Gulf War Syndrome that they were seeing elsewhere.
So it looked like a unit that seemed to be typical. Not necessarily representative, not statistically representative in terms of a random sample, but it looked like they had what everybody else had.
Also, it was a construction battalion and a Seabees battalion. They go everywhere all over the battlefield. They are not in one little location, boom you are there and the war is over. They are going and constructing things, building roads and bridges, and moving everywhere. So if there was a geographical risk, some of these guys would have been exposed.
Also, it was the only reserve Seabees unit and the reserves come back to their own hometown so you can find them whereas active duty people, they are spread out and you can't get them. December '94 and January '95 we went into the field, went out to the southeastern United States where they live and surveyed them.
We certainly -- we intended to include all Persian Gulf veterans in the 24th Reserve Battalion with addresses in those five states, which encompassed 98 percent of them. Alabama, Kentucky, North Carolina, South Carolina, and Georgia. There was 606 in all. There were 130 more attached to that unit, but they were from other units that were attached at the last minute. We didn't include them because they were elsewhere in the country.
We included both ill and well and we wrote letters to the entire battalion, many of which were returned undelivered, but we actually did have a roster and did cold calling trying to get everybody from one of these five sights out at their home locales.
Now whenever you do an investigation like this, you never get everybody in a -- you never get a representative population in an epidemic investigation. I guess you could, but you never do. We got 249 of the 606 to show up, which is 41 percent. Now many people feel that if you don't get 80 percent, you quit because you have got a -- you necessarily have a selection bias that would somehow invalidate your results. And it can happen.
So what you -- but you don't give up because there is an epidemic going on. What you do is you look at the characteristics of your sample and see if it is balanced enough to give you an answer. Most importantly, we felt, was the mix of people who were still in the unit and the people who had left because if you only look at people who are still in the service four years later, that is a fail selection bias because the sickest people have left. Okay. So we had a good balance there.
Looking at the balance on age, mean age is about the same; gender, they were all men in the Seabees unit in that era. The racial distribution of the participants and the non-participants was the same. The years of education were the same. Percent still in the reserve the same. Wartime rank is the same. We got this information from the in theater roster and we did a phone call survey of a small random sample of the non-participants to estimate these differences.
This was their wartime job rating. Remember it was the Seabees in construction battalion. So they had construction job duties. As you see, the percent distributions are approximately the same. The major difference was in the officers. Almost none of the officers participated. Apparently there was pressure from the command structure to have them not participate. The officers obeyed, but the enlisted didn't.
Now the one big difference is, and many people have suggested this is a flaw. Actually for a case control study, it is an advantage. But the follow-up survey idea, we had asked is there a serious -- have you had any kind of a serious health problem since the war. Now this isn't the case definition, just any kind of serious health problem.
Seventy percent of the participants said they had some serious health problem; forty-three percent of the non-participants. So you see, the ones who participated were bias towards having more of the sick people coming, whereas the non-participants tended to be more the non-sick.
Now if you are trying to estimate the prevalence of a disease, that is probably going to be a selection bias and you are going to therefore overestimate the prevalence of whatever health condition you are dealing with.
However, if you are trying to get a population to do a case control study, to get the cases so you can then pick some good well matched controls, what you want is to get all the sick people. You want to get some well people too, but you want to get as many of the sick people there so that you can pick good cases. A good representative of good typical cases.
We designed two instruments to go into this survey. One was a questionnaire booklet on exposures. This catalog and a series of questions in a self-administered format, questions that asked about the exposure that had been identified by the various expert committees that had reviewed this over the first several years after the war. Institute of Medicine Committees, Defense Science Board, NIH, Consensus Panel and others. They all came out with basically the same list.
So we incorporated those into a questionnaire with a couple of additions and we developed a symptom questionnaire booklet. I am going to go over these and show you how they were designed because the design of these particular system booklets are fairly unique and I think accounts for a lot -- for the fact that we were able to focus on this thing.
We also gave a personality assessment inventory. This is the PAI, similar to the MMPI, but we felt had better characteristics for this field survey. It was shorter, more interpretable, looking for psychological issues because as you know, that was the main hypothesis to begin with. We pretested this twice in Persian Gulf veterans to get the lingo, the military lingo right. And it went right into the field.
Here is the exposure questionnaire, the symptom questionnaire, and the standardized psychological inventory. Notice we had an assurance of confidentiality on the front. We felt this was important. In this era there was great fear among particularly the ones who were still in the unit to if they participated, one, they might lose their military status -- in fact, there were actually threats at this time, which was a very emotional situation, particularly for the ones still on active duty.
There were actually personal threats to some of these people in the small Alabama towns of the -- you know, the officer who was in charge of them saying, "I heard you went to the survey. You better watch out." That kind of thing.
So we gave them a very strong assurance of confidentiality we wouldn't release this to their military units or to the press or anyone. And this was signed by myself, as well as by Ross Perot. And we felt Ross Perot's name would be good as gold on that.
It is interesting, when we sent out a letter, I had Ross Perot write a letter to all these people to come to the survey. And then I got a frantic phone call from one of the leaders, a guy saying, "Gee, some of the guys aren't going to come because they don't like Ross Perot. They don't like his politics." So I quickly sent them all a letter and got it immediately turned around. It is interesting how those things work.
Now here is the example of a question on the exposure questionnaire. Okay. During Operation Desert Shield Desert Storm, our service personnel used many different types of insect repellent to avoid insects. Here are the instructions or questions. "Did you use Avon Skin So Soft. Yes or no." You know, this is the thing that contains no active DEET. It is toilet water that does repel insects to some extent.
The commercial varieties of OFF! was common in the Gulf. This is -- at that time was less than 30 percent DEET in an emollient that was not well percutaneously absorbed. And the military issued repellent. One of the main products used, particularly in this unit, was a 75 percent DEET and ethanol. It was the old Vietnam thing in a little gray squeeze bottle. Both DEET and ethanol are percutaneous absorption enhancers.
Those of you who know DMSO is. You know, you mix a drug with it, you put it on your knee, and it sucks the drug right through the skin into the subcutaneous, the DEET structures. So this would have been highly absorbed into the bloodstream.
And then others and then estimates, their semi-quantitative estimates of number of days. We actually gave them a calendar of the period of the war so they could -- and had them mark the day they arrived, the day they left.
And we had the beginning of the air war and beginning of the ground war, all the major events on there so they could then get -- remind themself, put themselves back in -- made them fill it out and do some things so they could then estimate and give us a semi-quantitative estimate.
Now we also gave them this map. This shows the Persian Gulf, little Kuwait here, Saudi Arabia and Iraq. Our troops during the bombing were here and down the coast. This is a grid map. And then on the facing page, we asked them to tell us the sector they -- all the sectors of that map they visited during the war and the approximate date they arrived and left that area so we could then computerize this and play and computer game, could we find a place and a date that coincides with disease suggesting an environmental exposure.
Now this is from the symptom questionnaire. Now in most health studies, what you do is you give a list of symptoms and then you say, "Which of these do you have? Yes/no, yes/no, yes/no." And sometimes we will see people just zip right down the yes column and right down the no column, and that is not good form.
We actually had a page for each symptom. We asked them first very clearly what this was. "In the past five years since the war have you experienced tingling, burning, or stinging pain in any part of your body lasting all day and continuing for at least a month. Do not count things that come and go quickly and are not present continuously."
Those of you know -- who interview people about tingling and numbness, you know everybody has a little thing here and there and everybody will say yes. So you have to really be more specific. If they say yes, then they have to go down here and tell us what part of their body is that involved in. So each part of the body and then yes or no I have -- this has been a problem. Approximately which month and day this began and is it still a problem.
So they had to go to a lot of trouble to answer, "Yes, I have this symptom." Also they gave us a lot of interesting follow-up information that we could analyze. Now one of the fundamental things that I think has come out of our investigation is in these vague, confusing illnesses like chronic fatigue syndrome, multiple chemical sensitivity, and Gulf War Syndrome, maybe breast implant disease, I don't know, one of the things we noticed is these symptoms that people use to describe their illness are highly ambiguous.
For example, tingling and numbness may occur in the extremities, the hands and feet. That might signal a sensory peripheral neuropathy. That would be a neurological thing perhaps. Also you might have tingling and numbness around the face, tongue, and lips. That could mean a hyperventilation episode or it could be some other neuropathy, a different kind of brain nerve neuropathy or something.
You could have tingling and numbness in your trunk and groin. I don't know what that is. That is very strange. That might be a central sensory problem of some kind. I don't know. But those distributions have different pathophysiologic explanations. And therefore, you need to distinguish among those, rather than just say I have tingling and numbness because then you would lump all three of those groups together.
So how do you distinguish those? Well, what we did was I took this and for every one of 22 questions, we had these follow-up items to allow us to disentangle the ambiguous components of them. Well, what we did is a factor analysis. The factor analysis, for those who don't do it all the time, is a black box statistical technique. It is actually a very useful data reduction technique.
If you look in the good statistics books, it is listed as a data reduction technique. And that is what we used it for to try to see if there are different components here. Are there three different factors here. Okay. I will describe that now.
The first order of business now, given that data set, is to define is there a case definition. Can we come up with a case definition that is plausible. Searching for syndromes. All right. First of all, what is a syndrome? What is a Gulf War Syndrome. What is any kind of a syndrome?
Well, Dorlands Medical Dictionary defines it as a set of symptoms that occur together. Okay. In addition, it sort of implies a common pathophysiology, although that is not necessarily true. Some syndromes have different -- have several different ideologies. But it is fundamentally a group of symptoms that occur together.
Now in this population where we have the symptoms measured, it is a simple mathematical question, is there a group of symptoms that hang together in a group of people. Well, here is basically the strategy we used to explore to that.
We used what is called -- and the statisticians will take on this more than others, but we used the thing called hierarchical exploratory factor analysis. Some would call it a two-stage, but technically it is a hierarchical factor analysis, an exploratory factor analysis.
We used the method of principal factor analysis and rotate it with very matched rotation, which is orthogonal rotation, so as not to assume some correlation among the factors. There is correlation among the factors, as we can talk about later. But first, we didn't assume that.
The level one of this two hierarchy factor analysis, we first disentangle the ambiguity of syndromes. So the follow-up questions for each of the 22 symptoms, for each of those we did a separate factor analysis to come up with two or three factor scales that we felt would be sort of unambiguous symptom factors gains, unambiguous symptom measures.
The are factor analysis of these follow-up descriptive features on each of the 22 ambiguous symptoms to produce 52 what we thing unambiguous symptom factors or symptom factors scales. So for each individuals, each of the 249 people we started out with 22 symptoms and just used the yes or no question, "Do you have tingling and burning and numbness," and we turned that into 52 symptom factor scales.
Now the symptoms were dichotomous, yes/no, do you have this yes or no. These are normally distributed factors, factor scales.
DR. ZEGER: I just have a question for clarification.
DR. HALEY: Sure.
DR. ZEGER: If somebody doesn't have a syndrome, so let's suppose only 50 percent of the people have a particular symptom, the first stage of exploratory factor analysis, you used only those people who reported the symptom?
DR. HALEY: No, we used everybody.
DR. ZEGER: So if somebody didn't report the symptom they had, then no for all of the --
DR. HALEY: That is right.
DR. ZEGER: -- subquestions.
DR. HALEY: That is correct.
DR. ZEGER: And then they went into a factor analysis in the exploratory first phase.
DR. HALEY: That is right. And then what we did we then took a factor of weights for this and produced a factor scale for each individual. We actually wrestled with that question, should we exclude the people. And we got a lot of opinions about that and it was pretty much divided. And we decided to leave it at that.
DR. ZEGER: So that in the end, the unambiguous factor score that you have would actually have a sort of a fraction, say 50 percent of the people with a --
DR. HALEY: Yes. Right. Right.
DR. ZEGER: Okay. Thank you.
DR. HALEY: Yes. Now the level two factor analysis, we input into the second level these 52 symptom factor scales and inputting into the second. We did a factor analysis of those using the same factor technique and we came up with six symptom factors or what we call syndrome factors.
Now let me say we didn't just put a black box. This took about four months of analyzing this data. This was a very, very long, tedious process because what we wanted was six -- we were staking our entire investigation on this. So we didn't just put it in a black box and churn it out in a couple of days, this was about four months.
What we did, we wanted to find syndrome factors where the loadings, and I will show you those in a minute, the loadings on those things, in other words, which symptoms contribute to which syndrome would be clinically plausible. In other words, we wanted to have a model where the things look like it might be something plausible.
So the final syndrome factor selection -- and let me say you can select a whole bunch of different models in something like this. There is no statistical rule that tells you this one is better than that one. So what we did is we had a group of clinicians that we looked at this and said, "Okay. Now how about a three factor model? How about a four factor model?"
Now there are some stopping rules and things, but ultimately you have got to have something that looks clinically plausible where you are lumping together things that could meaningfully go together. And we had a sixth syndrome factor model that looked really interesting clinically and we picked it.
Now remember what my colleagues at CDC say. If you can't develop a case definition, well, somehow you do it. You just come up with one because to fail to do that, you are not in the game. You have not started yet. This is a bit of a leap of faith, but you have got to start somewhere. So that was it.
So from this, we then calculated six syndrome factor scales, which are normally distributed things, all 52 factors for a given person. We then weighed all 52 of these symptom scales by the factor weights and come up with a score. A person has six syndrome factor scores now.
And then we dichotomized those at a convenient point, which I will show you in a minute, to come out with dichotomous or binary measures. So, "Do you have Syndrome 1, yes or no." "Do you have Syndrome 2, yes or no," et cetera.
Now let me just show you the first phase, the first hierarchial level. This is an unrotated factor analysis on this tingling and numbness thing. And you see I have simplified this down somewhat. So notice there are three symptoms that seem to go together here and four symptoms that seem to go together there.
So it looks like there may be two factors, but they are kind off the diagonals here. So what you do with rotation, you basically rotate the axis until these are as close together -- as close to the axis as possible. And then you are sort of measuring those more accurately.
For those who want to know what rotation is, that is basically it. And that is the rotation we had on this tingling and numbness in a simplified fashion. This actually came out with three factors. I am going to show two since it is easier.
So here is the rotated factor space. Here are the most important of those body places where they complained of tingling and numbness. Notice arms, feet, hands, and calves have very high correlations with factor one.
So we called this factor, this scale that was going to be produced, we called this the tingling and numbness of the extremities factor. Okay? And then this one, notice face, tongue, and lips is highly correlated here, but notice these aren't and see these are not correlated with this one, but these are correlated with this one.
So factor two we call tingling and numbness of the face, tongue, and lips. Possibly the psychological thing or the perennial nerve thing. So we have now two different scales, continuous measures, of these two factors. And we think that was a key thing in the fact that we found something later.
Now we put those measured into the second analysis, which is a -- the second phase, the same kind of factor analysis. This shows the rotated scree plot, if you will. This measures the strength of clustering, if you will. That is not exactly true, but I think you can picture that better.
How tightly are these -- this one group of guys that has this set of symptoms, how much did they resemble each other and how are they -- how much are they different from everybody else. The strength of clustering, if you will.
Here are the possible syndromes or the factors that were identified by the program from the highest, strongest cluster all the way down to the weakest. And then you draw a line here. This is at an igon value of about one. Here I am using percent of variants explained and rotated one. That is easier to explain.
But what we found was three highly clustered syndrome factors or three strong syndrome factors with high igon values or high clustering coefficients. Then we found three more -- four, five, and six -- that had lower levels. And then after that, it is below the level, just this garbage down here. We cut it off there.
And see, we could have cut it off after three and then recompiled this and did a three factor model. What we found was, though, separating these out, these used more clinically interesting, more clinically plausible. Where if you leave these in, these then jump in there and sort of mess up the whole thing.
So we felt a six factor model looks best, but the three -- the first three looked the most interesting. Now let me just make it short to cut to the chase here. Four, five, and six, when you dichotomize them, the people above the -- the ones with the extreme value, the most strongly clustered of these, also clustered on number 2. These appear to be some kind of variant or echo of number 2, which also turned out to be the most serious clinically.
Exactly what that means, you know, statistically and so forth, I don't think anybody could tell you. It is just this is a way of reducing very complex, large amounts of data to a small number of things that you might be able to work with. And the measure of it -- there are statistical measures here, but ultimately the measure of whether it works or not is does it discriminate clinically meaningful parameters later on.
All right. Now there are some statistical validations, which are in the paper. One, there was a large range of the commonality estimates. Now this is only speaking to the statisticians. The commonality estimates, the diagonal estimates on the diagonal went from .27 to .78, which justifies principal factor analysis, rather than principal components analysis. Most people just take principal components because that is what everybody does, but we think this one is more appropriate.
There is a measure, the Kayser's measure of sampling adequacy is very high. This means that our final factor model was a good fit to this common factor model. So it looks like it is a good factor analysis. It has high internal consistency of the syndrome factor scales, Cronbach alpha -- that is alpha there, it should be, is bigger than .8 -- and we replicated the two halves.
That was a bit of a hollow victory in that we had developed it on the whole sample, and then we went back and looked at split halves, which isn't exactly what you would do. Normally you would develop it on one half and replicate it on the other half, but we only had 249.
But we did go back and look at split halves and we looked at the correlations of the -- they were really correlated for a one and moderately correlated for two. And those all correlated for four, five, and six as you would get from the other.
So a statistical limitation, but this just shows the modeling kind of worked, but it does make this meaningful and the dichotomization here are the six symptoms syndrome factor scales. This is in the paper. Okay. In other words, all 249 people are in one of these, if that makes sense.
What you want to do is to come up with some level of dissent of these people in Syndrome 1. Now obviously there are people in the middle in this epidemiological study and there are those that were dichotomized by this dichotomization in different places. There is the distribution sort of constraint. And that was one alternative.
But we decided to just take an arbitrary one that would give us enough of each of these, feeling that we wanted the most typical, the most typical cluster in cases. Then in the controls it wouldn't really matter because there were so many of them, that would be a fairly large number of operator error.
Now there has also been a real misunderstanding of the -- the thing that really hit us all, the fact that when you pick the extremes, you pick the most extreme cases, the sickest people. That is not right. Thing of what we have got here. This is a factor scale. So the extreme up here is not the severity of illness, it is the legality of the clustering.
So we are measuring out whether it was clustered around this factor to see if it was it was internal or a construct. The higher you are, the more you have got everything, the more typical you are. So what are the positive advantages of this.
In the cases, the most difficult cases in a CDC epidemic, what you do is you go ahead and there would be some typical guess and you would just pick them up. Okay. He has got this. Well, let's pick you, you, you. That is what you do on this old toxic shock syndrome. Okay. So that is how we show the people above the line. Cases and controls on each of those six syndromes. Oh, shoot. I think that is worth backing up.
Now let's see if that works. No. Close. That always happens. Oh, okay. All right. This is the arithmetic in our 249. There were 606 in the battalion. Okay? We surveyed 249 that showed up. Remember we encouraged the sick and the well.
So we had 70 well people, no health problems at all. A hundred and sixteen -- now this is interesting -- a hundred and sixteen that said they had health problems, but no syndromes, they didn't cluster in the syndromes. And we had 50 that had Syndromes 1, 2, and 3.
Now there were also 13 -- 16 more -- let's see, 13 more that had syndromes -- only Syndromes 4, 5, and 6, but Syndrome 2 was right below the cutoff on those. So they were really syndromes too, but they are not reflected in here. They are considered negative here.
Now of these 50, what is the prevalence of this syndrome, these syndromes in the battalion? Well, we don't know because remember we have a biased sample. So what we do to get a conservative estimate, we divide 50 by 606 to get a low estimate of 8.3. So this is at least a prevalence of 8.3 in the population and probably somewhat higher, but we can't tell because we don't have the rest of those.
And that is in the paper. All of these things are in the paper. All right. Now let's -- let me give you a feeling of what these syndromes are by showing you what the symptoms were that loaded heavily on each of these three Syndromes, 1, 2, and 3.
Syndrome 1 we gave just gave the name impaired cognition, as you do in factor analysis. Impaired cognition. These people had distractibility, memory problems. What they call memory problems, and later we will talk about these, actually are not memory problems, they are concentration problems, but that is an interesting -- but they call it memory problems.
Depression, middle and terminal insomnia, which often goes along with depression. Fatigue. And here the factor analysis of the symptoms made a huge difference. Actually it made a big difference in all of these, but particularly this is the most noteworthy because of all the chronic fatigue syndrome literature.
Here, but loaded heavily in this syndrome was fatigue, meaning sleepiness during the day, but not body weakness. The body weakness thing came on -- loaded strongly on Syndrome 3. So you see, we think these distinctions on symptoms are very important for converting chronic fatigue syndrome into a clinical entity that we can study.
Slurring of speech. A lot of Gulf War veterans, they don't complain of this, but if you ask them, "Yes, my speech has changed. I don't talk the same way." Confused thought and severe migraine headaches. So just impaired cognition we call it, but it is obviously a lot more, as you can see.
Syndrome 2, confusion ataxia. This is the bad one. Thinking and reasoning problems, getting confused or lost. The wife will tell you, "I can't send John into town anymore. The police will bring him back." It is sort of like an Alzheimer's patient, some of these.
Getting disoriented, losing their balance, stumbling off and feeling like the room is spinning. We think now this is a vestibular ataxia. Not dizziness in any kind of just trivial sense. We think this is a real vestibular ataxia.
Sexual impotence. And then what is interesting, what also came in here was a physician's diagnosis of PTSD. I have gone back and studied each of these. What happens, they go to their personal physician or VA doctor and the doctors will say, "There is something really wrong with you. I think you are really sick, but I can't figure out what it is. So I think I am going to give you the diagnosis of PTSD." For one thing, PTSD gets some service connection.
Now they didn't do that for Syndrome 1 and they didn't do it for Syndrome 3, but they did it for Syndrome 2. So there is something about PTSD and Syndrome 2 that is really a tough -- a close connection. Now whether they meet the criteria for PTSD is another matter, and they don't. But they have got the diagnosis. And a lot of them had depression too. About two-thirds of them had some type of degree of depression.
Now the third one, arthro-myo-neuropathy, we gave it that name, you might call this fibromyalgia because I think that is probably the same thing. Generalized joint aches and muscle soreness, increased difficulty lifting heavy objects, fatigue, but fatigue meaning loss of muscle strength, not sleepiness during the day. And tingling and numbness of the extremities, but not the trunk and groin and not the face, tongue, and lips.
Notice this joint ache -- let me tell you about the joint aches because it is really interesting. This is not arthritis. You might call it arthralgia, pain in the joints, but it is not inflammation. In fact, almost all Gulf War veterans in any study we have seen, including ours, all their rheumatic workup, their sed rates -- the sed rates are all in a very low range. Nobody has got an elevated sed rate. A few of them have a positive ANA, but it is very equivocal.
In fact, that is an interesting subject. But there is no inflammation, there is no joint deformity. In most of them, there is no limited range of motion and there is not even a difference in the pain on motion. This is really atypical for arthritis. It is not arthritis, it is central pain.
What they tell you is, they have a toothache all over their body, particularly in their shoulders and hips. Thirty year old men with a toothache constantly boring. And that is what they mean by generalized joint aches and muscle soreness, at least in our battalion and in the Dallas veterans that we looked at now.
Okay. So that is number three. All right. Now are these syndromes different or are they really just the same thing, a statistical misadventure here. We looked at unemployment. What percent are unable to work. This is the 70 who are well and they have an unemployment rate of about 2 percent, 3 percent, lower than the national average. They are all working veterans. Those who have illness, but no syndromes, about the same.
Syndromes 1 and 3 have slightly higher rates of unemployment, but not really significantly different. But Syndrome 2, the bad one, look at this. Unemployment rate of 50 percent. And if you talk to these other guys who are employed, many of them will tell you, "I am still working, but they had to change my job after the war. I was the shop foreman and now I am working in the mail room because the company wanted to keep me employed because I am a war hero."
So these people are having a real hard time. These are functioning along, but are just very uncomfortable. And these seem to be -- maybe there are a few of some of these in here, but by and large, these don't appear to be ill.
It is interesting now -- I am sorry ADM Steinman left, somebody fill him in when he left -- there is an excess of these in that first hump of the epidemic curve. And these are primarily in the second hump of the epidemic curve.
Psychological tests. Remember we started out looking at psychological issues assuring Ross Perot that if that was there, we would find it. This is the PAI results and these are the psychological scales, you know, the somatic complaint scalings, anxiety, depression, anxiety related disorders, which is where PTSD is.
This pattern was found in every one of the syndromes. And that was a surprise. I was expecting to see each of our syndromes have a different psychological profile, one of them being depression, one of them being PTSD, one of them being a somatic form of disorder, whatever that is. It wasn't. This was none of those. This is clearly not the profile of PTSD, it is not the profile of hysteria or somatic form of disorder, it is not a profile of any psychiatric disease.
Now what we do -- that doesn't really say it is not for sure. It says it is unlikely that it is a psychiatric -- typical psychiatric disease. What this is, this is the pattern you see on this test in people who have -- who are in a neurology clinic. You give this to people who have a brain injury. Now that doesn't prove it is a brain injury, but it suggests that it is probably not PTSD or another psychiatric illness.
Okay. Now that was our case definition. The next step was to then do a nested case control study, pick some of the sick, some of the well, some of the people in these syndromes, some of the well people, bring them to Dallas and see if they have a real organic illness or is this just psychological and we are being fooled in some way. So a clinical case control study.
We picked 26 of the guys with the syndromes and 20 controls, age, sex matched. Notice here is where we get the real strength of our design. What we want is typical cases and some well matched controls. They are matched for age, sex, education levels And we matched the controls to Syndrome 2 and we oversampled Syndrome 2.
What we did is we got five Syndrome 1s, thirteen Syndrome 2s, and five Syndrome 3s because we really wanted to nail down Syndrome 2s because that is the bad disease. Okay. So actually I have noted here, I didn't show the 4, 5, and 6 because we just got one each of those just to kind of hedge our bets and see what might be there. But we weren't really interested in that at the time.
And here are the controls, 20 matched controls. Now the controls were actually two subgroups. Ten of them were men who served in the war in this battalion, but remained well, and ten were people who were in this battalion, but didn't go over, had not gone over to the war yet and the war ended before they could get over or they were logistical back at home or whatever. One of them had an appendicitis and couldn't get over, et cetera.
So we had a deployed subgroup and non-deployed. We did that because, hedging our bets again, because afraid that there might be subtle brain damage in everybody who went over there. I mean, who knows? And maybe our case control parameters wouldn't be different between cases in control. So we needed a group that had stayed home. It turned out the controls were all homogeneous. Both groups were the same on everything. So we now lumped them all together to show it.
This is the Halstead Pyramid index, the sum up of all of the neurological -- 50 or so neurological tests that measure different aspects of brain function. The controls here, as you see, are in the normal range, below .4, this goes from zero to one, and the higher it is the more likely there is brain impairment.
Syndrome 1 is slightly -- the main is slightly above, but there is a large variance and it is not significantly different. But look at Syndrome 2 and 3 are highly elevated, suggesting brain impairment, and they are significantly different from the controls.
Here is the general neuropsychological deficit scale, a different summary scale of neuropsychological results and you get a similar finding. They have the trailmaking test part B. Syndrome 3 looked worse on that. This is all in the paper. It is in the tables in the second paper.
Here is another test we did. We did a number of these tests. And looking for subtle parameters of brain dysfunction in people who have normal neurological exams -- I should have mentioned that at the beginning. All of these people when they brought them in, we did a thorough neurological exam by a neurologist and we did brain MRIs. All of that was normal.
So in a situation like that, you need to look for tests that look more sensitively, particularly at lower deeper brain structures. So we looked -- we did primarily all your vestibular tests, evoked potentials and that sort of thing, which is in the literature of neurotoxicity.
So here we show the velocity of eye movement from a reflex elicited by choleric stimulation in the ears. The eye movements measured by electromastagmography. It is basically an electronic way of measuring how fast the eyes vibrate when you put cold or warm air in the ears. It is measured on a computer and you can calculate the velocity.
Here is the velocity and the controls, cool air in the right ear, cool air in the left, warm in the right, warm in the left. And you see the controls are all up here pretty close to the same thing with a normal velocity of eye motion.
Syndromes 3s have a dramatic reduction in eye motion indicating some interruption or impairment of the vestibula ocular reflex, which goes from the eighth nerve -- acoustic vestibular branch of the eighth nerve, up the brain stem and out the ocular motor nerve. Somewhere along there, this is impaired. Not interrupted, but impaired because the eye does move.
Syndromes 1 and 2 are intermediate. Not individually statistically significant, but there appears to be an ordering and the ordering is highly statistical significantly.
Here is brain stem auditory evoked response. If you stimulate the ear with clicks, you get a different pathway up the brain stem and you can measure three spikes as this thing goes up the brain stem, and you can measure how long it takes the impulse to go up the brain stem and then compare the right and the left. This is a very sensitive measure because you are comparing the person's -- their own control. And you look at the difference between the speed on the right and left sides of the brain stem, here the controls are in the normal, but very little difference between right and left. Syndromes 1 and 2 have a big difference between -- actually, a larger difference.
This isn't a big difference, it is just a small difference, but a significantly different impulse. Syndrome 3 is normal. You will notice what we are seeing is that these syndromes has some difference between the controls, but the difference in terms of different patterns, which we felt went along with the fact that they have different symptoms, they have different neurological findings.
Of course, the opinion could be maybe this is all random. This is all random, this is a form of different patterns, but the controls are never higher than the cases and you can't explain that randomness. In other words, multiple testing can't explain this and the P value, looking at that, is less than the 0001, given the controls are always better off than the cases in all the tests.
So what we think, there appears to be at least something going on here in the brain stem or in -- you can't see it here, lateral to this, that is the basal ganglia, a very sensitive -- heavily controlled with influence by the basal ganglia. So that the lesion could be in either place. So that began our working hypothesis based on these preliminary exploratory neurological tests in the first round.
Now let me just show you the risk factors and then we will break. We now have a case definition, which we think looks plausible. We now want to know, okay if this is true, was it related to this disease. So we got back to our exposure question as to we had picked of the 249, we had lots of difference between the 63 or in syndrome and the ones who don't have the syndrome epidemiologic analysis.
Here is the list of risk factors that come up with all those committees. Chemical weapons, biological weapons, ciprofloxacin and chloroquin for malaria prophylactics, environmental pesticides, pesticides sprayed on uniforms, high potency DEET insect repellents, pesticides in flea collars that they wore around their necks.
Depleted uranium munitions, smoke exposure from the environment, burning jet fuel in tents, people coming with possible carbon monoxide poisoning or -- which also affects the basal ganglia by the way, and lead poisoning, they used leaded fuel, petroleum in drinking water, chemical absorption with a coating of paint. This can produce a pulmonary syndrome if you don't use protective gear. Inborn errors of metabolism, and this one was commonly mentioned back then. Stress, smoking, alcohol, cocaine use. This is a sort of a list.
When you are doing an epidemiological study, generally an epidemic investigation -- again, I am going to -- with four, five and six, you don't get that because of recall bias. In my liberal review of literature, I don't see a recall bias except for the Love Canal like studies which are very different from this. However, it was different a hypothesis.
For our hypothesis, this is an organophosphate like answer. We would hypothesize that these, the chemical exposures, would be highly associated with these measures whereas as these other were not plausible, we found those would not be associated maybe to a relative risk of one to one-a-half, one-and-a-half to two. And the others would have higher relative risk. Now if we follow it out to a relative risk of two, one or two, then we would attribute that to recall bias and then whatever.
However, if we get all this, these are not and that is more interesting. And that is what we found. Syndrome 1, impaired cognition. Remember this is the yes or no impaired cognition. Syndrome 1 had two respecters associated with it. This is on the next slide.
The first one was, did you wear a flea collar. Those who said yes, there were 20 of them. Five of them have Syndrome 1, or at a risk of 25 percent. Those who did not wear one, the risk was -- Syndrome 1 was 3 percent. You divide 25 by 3 and you get a relative risk of 8. That is Syndrome 1 was eight times more common in those who wore flea collars than in those who didn't.
Does it make sense? And this is highly statistically significant. It does not -- it could not be due to chance. We required a P value of less than -- less than or equal to .001 to get in the game. Again, because we are testing multiple hypotheses.
Now this is small numbers. And this is a very provisional finding. We looked for plausibility though against small numbers, and you don't want to overinterpret this, but we looked at those who wore flea collars, who never wore them, wore them, but never next to their skin and sometimes next to their skin and went 3 percent, 18 percent, 67 percent.
Again, small percent. You know, this may not be real, but it is the least of our trends, of the significant trend test and the trend test of the whole. So right away we suspected that maybe there is something about the flea collar, some impairment to those people.
Another risk factor that was significantly associated was does your job duties involve being a sentry. These were the guys that stood guard at night of the Seabees. They had what is called a yeoman person was made to stand guard. A little light on the lingo here.
The job duties involved -- and here 22 divided by 3, a relative risk of 6. Now these guys were exposed to ambient conditions at night, there was more spraying of pesticides initiated at night, also there were SCUD missile attacks more at night. Who know what this means. I wouldn't know to interpret it, but possibly more environmental exposure.
Now let me go to Syndrome 3 now. Arthro-myo-neuropathy. You might think about it as fibromyalgia or body pain, tingling, and numbness. Sort of a sensory problem, very central in nature. Here the two risk factors are shown here. Everything else is not associated.
I have developed a scale of the amount of pesticides and insect repellent used. I asked them on the questionnaire, "When you used insect repellent, how often did you put it on during the day? Once a day, twice a day, three, four, five, six, seven time a day. And when you put it on, how much did you put on each time? A little bit." The questionnaire said, "A dab here and there, covering the areas of skin that dried quickly or large areas that is taken up for a while. Or did it actually drip down the skin."
This quantitative scale and do a summary. Quantitative scales, zero to six, zero to eight, I never used any. Six many -- they used it many times. And it was just dripping down the skin. Now, here is the --
DR. ZEGER: Can you say a little bit more about that. So for example, if somebody used it very often late at night --
DR. HALEY: As shown in that paper three in that JAMA series, I actually show you a table that shows you what the numbers are and how I got them.
Now notice the rest, the percent that has Syndrome 3 in these groups were 4 percent, 7 percent, 5 percent, 16, 33. That is a dramatic response effect up to a relative risk of eight.
Highly statistically significant. Here the trend test is highly significant. The numbers are a real small -- I mean a small part. They are in the ballpark. That is a real interesting association. Now we also developed a scale.
Everybody has used pyridostigmine, but we couldn't test pyridostigmine. So couldn't test pyridostigmine or not. So what we looked at from having questioned people in our Dallas studies, we learned that the side effect of pyridostigmine occurred in -- 1 percent of people had minor mestirinic side effects at the beginning and a very minimal blood level. So very minor side effects.
The first to occur organophosphates, a little diarrhea maybe or a rumbling, or urinary urgency, that sort of thing. Very common. And that didn't relate to anything in our disease measures. However, about 10 percent had much more severe side effects, what appear to be nicotinic side effects; that is, muscle fasciculation, muscle twitching, muscle cramping, and clouded consciousness, pounding heartbeat, some other things, which tended to be very commonly endorsed items in some people who took pyridostigmine.
Now we didn't just make this up because this was also described by an Israeli study done during the Gulf War where they studied their troops that were taking pyridostigmine and actually did a survey of symptoms. They found the same dichotomy.
Fifty percent or so got minimal side effects and about ten percent got severe side effects and laurinstin -- linctonstine -- you know, some of you have seen that paper of a case report of an individual veteran who had a cholinesterase, genetic cholinesterase deficiency who developed severe cognitive side effects and muscle poisoning from pyridostigmine. Obviously a unique circumstance.
Anyway, so we developed a factor scale, used factor analysis again to disentangle the acute mestirinic side effects from the less common, more advanced side effects. The first scale, the mestirinic side effect scale had no relationship to anything, but the advanced side effects scale was strongly related to Syndrome 3. That is, none of those side effects or low level in that factor scale up to very high numbers of these symptoms, zero percent, four, eight, twenty-two, seventeen.
Of those response effect, not perfect, but pretty good, up to a relative risk of four highly significant. So this led us to hypothesize then that people who had high levels of pyridostigmine for some -- for whatever reason and who used large amounts of insect repellent, that these two perhaps interacted in some unknown synergistic fashion to produce Syndrome 3.
Now plausibility. There is one more important factor here. This scale of the insect repellents is kind of a -- I think a lot of people would be uncomfortable with that semi-quantitative scale. This is made a lot more plausible by the fact that those people who said -- who endorsed Avon Skin So Soft containing no DEET, this was 4, 3, 3, 2, 1.
And those who endorsed OFF!, the commercial variety, less than 15 -- 30 percent DEET in emollient -- it is not -- that will absorb in the skin, 4, 4, 4, 4, 4. This is in the people who endorsed the military issue insect repellent, 4, 7, 9, 16, 33. That is the 75 percent DEET and ethanol that is highly percutaneously to absorb. So you see this is plausible. So we propose then a synergistic effect between DEET and pyridostigmine.
DR. GUILARTE: I have a question about pyridostigmine. You said everybody used it.
DR. HALEY: Yes, everybody used it.
DR. GUILARTE: Is there any assessment on the way that they used it? In other words, if people took a lot at one time and some other individuals took over a period of time. Was there any assessment of the exposure and frequency of taking the pyridostigmine?
DR. HALEY: In this questionnaire, we didn't expect this to come out. We only asked how many tablets did you take. Let's see, we asked, "How many times did you take it," on how many -- sorry, "On how many days did you take it, and approximately what is the total number of pills you took?"
Now what we should have asked that we got on our proposed national survey, we are going to ask, "When you took it," I forgot how this is phrased, but something like, "Did you take it regularly on the clock? Did you take it sometime and not other times or did you not take it until there was a scare and then you took a lot of it?" And there were a number -- and we think that is what happened.
In just talking to some of the -- when these people actually came to the survey, after it was over, we milled around in the auditorium with them and talked to a number of them. A lot of them wanted to stay and talk and we took a lot of personal history. A lot of people said, in this unit particularly, "I didn't take that stuff. Then when the chemical alarms went off, I took -- I made up for it."
CPT MAZZELLA: The deployed controls also used insect repellent, but they also used PB. How did the controls fall out against your hierarchy of application of DEET versus amount of PB?
DR. HALEY: Let's see.
CPT MAZZELLA: These are cases.
DR. HALEY: Yes.
CPT MAZZELLA: But how did the controls have a comparable amount of --
DR. HALEY: Well, see the controls are on the other side here. That is a good question. I would have to go back and look at the prevalences of use. I don't know the answer to that.
Okay. Now let's go back to Syndrome 2 because this is the bad one. Remember these are the guys with confusion, balance disturbances, vestibular ataxia. First of all, the scale of advanced side effects of pyridostigmine, from nicotinic to central side effects of pyridostigmine. Zero to six.
Look at the dose response effect. Zero percent, one percent, eleven percent, forty-three percent, and the numbers are not small. This is a dramatic effect. So something -- the guys who got more -- who at least endorsed the questions, who suggested they got high blood levels of pyridostigmine, had a dramatically increasing risk of the bad ones, Syndrome 2, what we think is real central brain damage.
All right. There is one other risk factor. And that is, we actually had a set of questions to produce a combat exposure scale. You know, like in a lot of Vietnam Agent Orange research there is combat exposures scale. So you ask a number of items. You know, "Did you ride across the border in a military vehicle? Did you get shot at? Did you shoot somebody? Were you almost overrun?" And et cetera, et cetera. And that measures combat exposure.
And we added one. "Did you experience a likely chemical weapons attack," not expecting that to show anything, and wrote a risk of seven. Now this we really doubted. I can recall as a student and a resident at the Dallas VA, we used to rotate through the Dallas VA, still do.
But I remember the old World War I veterans who had chronic lung disease, you know, gasping for breath saying I was gassed in the Argonne. You know, we all just laughed that off, said, "Oh, I doubt that." You know. Well, I think maybe they were.
These are the guys who said, "I was gassed in the Gulf." Now what do they mean by this? You know, the validity of this would be in question. What they mean by this, there are other questions we asked about, "Were you near chemical alarms when the chemical alarms went off" and, "Did a SCUD missile land within so many kilometers of your position," and so forth. And those were highly correlated with this.
Well, we really didn't -- we were concerned about the validity of that. We then did the geographical time analysis. We looked in the computer, is there a place and date that the people who were there on that place and date have a high relative risk. And there was one hit only for Syndrome 2 and it was people who were located in what is on my analysis map, sector seven in northeastern Saudi Arabia on January the 20th. The 20th is the fourth day of the air war and the relative risk was four.
Let me show you where that is. Here is the Persian Gulf, Kuwait, Saudi Arabia, Iraq. These were the positions of our troops in the -- during the bombing period. Of course, then there was a big movement up here and in there during the ground war.
The sector seven on my map is here near Khafji. So it was the Seabees who were near Khafji that had the highest relative risk for Syndrome 2. Now what happened -- so then we went and started madly looking, what happened on the fourth day of the bombing, January 20, 19th and 20th. What happened near the town of Khafji.
And what we found is, that was the fourth day of the air war, that was the day on which our bombers struck the chemical weapon depots along the Euphrates river. There were four or five of them along there. Jim Tuite, those of you who know who -- he is the investigator for the Regal Commission, has weather satellite photos that I think he is going to try to publish soon that show on that day the cloud -- the bombing clouds went up to at least to about 10,000 feet and drifted right over our troops.
That was the same day in which the Czechoslovakian chemical weapon experts detected sarin and a mustard agent here at Haffa Al-Batin, which is somewhat of west of there, and on this day, the chemical alarms went off at Khafji. There is a case report in the Regal Commission report showing that the chemical alarms actually went off and people developed symptoms for 24 hours thereafter and so forth.
Now is that chemical weapons attack? Is that collateral fall-out from our bombing? Obviously, that is an issue that an epidemiologist can't address. The point is, the place and date is a plausible thing and it just fell out of our data. And there is no other place and date that comes close to being significantly related to any of the syndromes or to Syndrome 2 particularly.
Now experiencing chemical weapon exposure, whether it was an attack or a fall-out or a whatever, an alarm, yes/no, and the scale of advanced side effects from pyridostigmine, having a high blood level perhaps of pyridostigmine, yes or no, if those are truly biologically interactive, you would expect there would be a synergistic effect. That is, those exposed to both would have a higher risk of Syndrome 2 than those exposed to just one and much higher than those exposed to zero.
Those exposed to neither one, one out of a hundred and fourteen point nine percent had Syndrome 2. If you had only the pyridostigmine side effects, advanced side effects, 7 percent, 2 out of 27. Only the chemical weapon thing, but no pyridostigmine side effects, 1.6. If you had both, it was 38 percent. That is a significant -- those are synergistic effect by Rothman's synergy scale. There are two or three synergy scales we published. I think two of them. They are both statistically significant synergy.
So you see what we have now here, we have relative risks of four to eight -- actually to thirty-two if you look at the high end of some of those dose response effects. We have dose response effects and we have a synergistic effect, and we have a plausible hypothesis in terms of the war events that went on.
Now to summarize, impaired cognition, confusion ataxia, arthro-myo-neuropathy, Syndrome 1, impaired cognition associated with wearing flea collars. In that era, most flea collars contained Dursban, which is chlorpyrifos.
This has been reported to cause a brain injury, a central nervous system brain injury, and it has recently been taken off the consumer market by EPA because of a huge number of outpouring of case reports that actually were covered up by the chemical industry for several years. When they were discovered, there were sanctions and so forth of Dow Chemical.
And also worked in security. I am not sure what that means. Confusion ataxia, the bad one, these guys are occupationally impaired, severe symptomatology of what we think is a central nervous system injury, indicators of exposure to chemical nerve agent possibly and advanced side effects from pyridostigmine, and a dose response effect to this and a synergistic effect between the two.
The body pain syndrome, which we think is a central pain problem. Government issued insect repellent, 75 percent DEET ethanol. And a dose response effect. Ethanol and advanced -- in ethanol. And advanced side effects of PB in a dose response effect.
We couldn't test for synergy here because there was nothing on the off diagonal. There was nobody that had one and not the other of these two. But it looks like it would have been there because it is such a big difference similar to that.
Now let me just say one more thing. People who said -- two more things. People who said, "This study is no good. This study doesn't help us. Let's throw it out because it is too small. Twenty-six cases and twenty controls. What could you possibly know about 700,000 people with 20 cases and 20 controls?"
Well, first of all, those were developed -- there were sixty-three cases and a hundred eighty-six controls of sick and well and we picked twenty-six of these and twenty of those, but these were carefully age, sex, and education matched in the same battalion, same jobs, and that sort of thing.
Toxic shock syndrome, a nationwide epidemic. My wife, by the way, was the second case of toxic shock syndrome. She was at Bethesda Naval. We were up here on duty up here working from HCFA assigned from CDC and she got toxic shock. Got one of the tampons in the mail and almost died of toxic shock syndrome. I have a very active interest. In fact, her blood was the first case where they isolated the sleeper toxin.
But anyway, the case control that cracked it and related tampons, and particularly the Rely tampons, fifty cases, a hundred and fifty controlled. Selected, typical cases. No random selection, no two or three representative. The next fifty cases and a hundred and fifty controls. They then picked 28 of these and 32 matched controls and identified the toxin, which is now accepted and has been duplicated over and over again.
AIDS. The national AIDS case control study that told us everything we still know about the transmission of HIV, except for the virus. Fifty cases, a hundred and twenty-five controlled. Just 50 sporadically picked people who had this acquired syndrome. And of course there have been many studies since then to corroborate all of it.
Hantavirus, the four corners pneumonia that turned about to be Hantavirus. Seventeen cases, two hundred and forty-eight controls determined the opinion of that exposure, the relationship to rat urine and droppings and so forth.
Legionnaires disease, 59 cases and 59 controls. The second case control study, a hundred thirteen and a hundred and forty-seven. The big case control study number two, which is the definitive finding of the airborne, 56 cases and 50 controls.
The point I am making here is those people who have discounted our study have done so without knowing the history of investigating epidemics. Now granted, our study is not the end all and be all, but let me tell you, what we have found is something that is very important. And were this a commercial product, it would be off the market now.
DR. GARRITY: Let's go back to the slide.
DR. HALEY: Yes.
DR. GARRITY: Could you tell me what the case definition was for toxic shock syndrome acquired in the efficiency study and Hantavirus and Legionnaires.
DR. HALEY: Yes. I mean, I have to go back for the exact wording, but here it was high fever, low blood pressure, and red skin. Okay. Here it was -- I have to go back and look, but it is immune deficiency and PCP. And they didn't want -- it might have all been PCP, I am not sure.
And here it was, you know, pneumonia in an otherwise healthy person. Here it was -- your point being that these were clear case definitions. That is what made this -- made those so non-controversial. Nobody -- there was no questioning about these when they came out. This was all accepted. And there are a thousand epidemics like this and usually the case definition is obvious.
What made this hard and the reason nobody could approach it is, we couldn't come up with a case definition. Well, what is the teaching though? If you can't come up with a case definition, then you got to come up with a case definition. Because failing to do so means these go unaddressed and they continue on and on in the population or they occur in the end over and over.
Now I am not underestimating the importance of corroborating this. So we are -- in the next hour, we are going to talk about what we are going to do to corroborate, replicate. And what we are proposing to do is a national survey to corroborate it in the best style.
Oh, one more point. Biological plausibility, animal studies, we have the dream team here of animal toxicology, Tom Kurt, our own toxicologist who designed the studies for not only Kansas states, but dean of all the journals in this field. He developed dosing the animals, Abou-Donia from Duke, has an EPA lab that does the OPIDN studies for the EPA constantly and had it all geared up ready to go, and Karl Jensen EPA did the neurotoxicology -- the neuropathology.
We did study for pyrifos, it was in the flea collars, Rabon in the flea collars, DEET from -- we were going to do chemical nerve agent. I don't know ever what happened. We actually got the serum, but Abou-Donia never did it. Or he did it, but he hasn't published the results. I think he is afraid he won't ever get another grant if he publishes the results. And then pyridostigmine.
And we looked at those individually with each agent individually and in combination. We exposed four more hens to a sub-lethal dose five days a week for sixty days. In your initial study, you don't do it gingerly, you do it for a long time to see is there an effect. Then you go back and try to do more plausible things.
Observe the clinical signs of neurotoxicity and then sacrifice the hens and look at the tissue for neuropathological. There is one of the hens who developed symptoms. Clinical pinpoints were gait disturbances, tremor, and paralysis developing in a delayed fashion, not acutely, post-mortem assay of neurotoxic esterase, which is the inside involved in producing the OPIDN nerve degeneration. Plasma and brain cholinesterase in histopathology, nerve, and sciatic nerve and spinal cord were examined.
Basically to summarize, what Abou-Donia and colleagues found was that controls had no clinical signs, no local motor dysfunction, tremor, no spinal cord legions, sciatic nerve legions. And so their overall rank was low in terms of outcome.
The pyridostigmine parathion and DEET alone had minimal effects. Some symptomatology, but basically no real things that you could be sure about. But in combination, all of these combinations, except the parathion was not as potent, but the other combinations, particularly the DEET and Dursban and the PB and Dursban, the PB and DEET, all of these caused delayed symptomatology, local motor dysfunction, and tremor. They all caused spinal cord and sciatic nerve degeneration that appeared to be statistically significant.
So this suggests the plausibility that these agents might work synergistically to produce promotion -- some kind of promotion effect among themselves to produce some kind of nerve damage or neurological damage. Now again, this is an OPIDN model. We are not sure that that is what is really going on in the brain syndrome in people with pesticide toxicity or Gulf War Syndrome, but it suggests a combination of these are neurologically active.
DR. GARRITY: That was the question I was going to have. Was the brain of these hens examined?
DR. HALEY: No. We are actually doing rat models now. We are doing these same studies in rats and we have a very good team of neurobiologists who are going to be doing neuron counting and all the various nuclei and we are going to find where this is because we have now got evidence.
DR. GARRITY: In rat models, OPIDN?
DR. HALEY: Yes. That has been described in the literature before, although not with these particular agents. We now have -- we have now tetraded so we can produce the spray legion or we can produce cognitive disturbances in animals that are long-lasting with single agents. And we are now in the process of trying this with dual agents and working out the doses to produce a minimally brain damaged rat. We get behavioral disturbances which are chronic and delayed, but not acute findings. Not verbal or neurotic.
DR. GARRITY: Are they behavioral disturbance in terms of accessory or memory recognition?
DR. HALEY: Yes.
DR. GARRITY: You know what type of tests?
DR. HALEY: I should have memorized that before I came. Watermaze --
DR. GARRITY: Moore's Watermaze?
DR. HALEY: The Moore's Watermaze test and the searching behavior test, searching around and counting.
Now here is a longitudinal section of the peripheral nerve of one of the Abadanian hens and you will see the characteristic legion of OPIDN. So they actually got OPIDN, which is not what the veterans have. At least they don't have the peripheral variety.
Okay. That is the morning -- the first session. Why don't -- you all want to talk a little bit or have a break?
ADM ZUMWALT: Can I just ask -- I would like to ask one question just to follow up on what Dr. Garrity had asked. I am a physiologist, not a statistician and, you know, we usually look for pretty clear outcomes in our experiments and a factor analysis is sort of, you know, a data dredge to salvage the data later. Can you come up with any example where CDC or anybody else has ever done an epidemic investigation where they discovered the disease through a factor analysis or three diseases?
DR. HALEY: Only one and that is Gulf War Syndrome because, you know, Racuda and his group at CDC did the same thing as I am going to show you this afternoon. They got two of our three factors and their factors are also covered in JAMA. They didn't mention that that they were the same for political reasons, but they did.
As far as I know, there is no other example. Again, the epidemics that CDC has focused on are ones where there is a clear disease. This one didn't have a clear disease. Now the question is, could we just go and never find it? Without a case definition, we are punting and you will never find it. So the question is, do we go to something like that?
ADM ZUMWALT: But is there a risk that we are constructing something that is artificial here?
DR. HALEY: Good question.
ADM ZUMWALT: You know, I mean, this goes to the heart of this.
DR. HALEY: The answer to that is two things. Once we construct this case definition of factors, we are all -- the question then is, when we go out and look at the brains of these people with very sensitive and very objective measures, the people with Syndrome 2 have demonstrable brain dysfunction and demonstrable brain damage on imaging or whatever else. And Syndromes 1 and 3 have minimal dysfunction and damage and the controls don't. That is your answer. In other words, that is why it works. If it works, then it is a case definition.
DR. BRIX: But then do you select just your Syndrome 2 as the case definition and you will discard the other two?
DR. HALEY: No. Here is our case definition.
DR. BRIX: You are giving yourself three chances here, aren't you?
DR. HALEY: No-no. Syndrome -- or out of our neurophysiological testing, the audiovestibular tests, you know, that I showed, we then for the next phase that I am going to talk about in the next hour, we constructed a hypothesis that two is more severe than one and three, is more severe -- more impaired than the controls.
In other words, we felt Syndrome 2 is a severe brain, central nervous systems brain injury, 1 and 3 are mild central nervous system brain injuries. And the controls, of course, should be normal.
Moreover, we looked at the symptoms of these and we saw what we think is a striking similarity with three diseases of the basal ganglia. There were three diseases that primarily affect the basal ganglia. These are Huntington's disease, it affects the caudate nucleus, one of the three nuclei of the basal ganglia; Wilson's disease, copper spores disease, hepatolenticular degeneration, affects the -- what is it? I will think of it.
DR. GUILARTE: Mendelian.
DR. HALEY: Mendelian. Thank you. And then Fahr's disease, which is a really idiopathic calcification of the globus pallidus. Those three diseases are well known in medicine. Now obviously, those people all developed severe neurological damage, which often proves fatal ultimately.
But in the initial presenting phase, they look like Gulf War Syndrome. They look like our three syndromes. So from that we are going to see in the later phase that Syndrome 2 is a severe damage to these structures and Syndromes 1 and 3 are mild damage to these structures and plausibly normal. Now look at -- this is a hypothesis. It is a guess.
DR. ZEGER: I just might react to that -- Dr. Friedl's comment.
LTC FRIEDL: Friedl.
DR. ZEGER: That I think these sorts of methods are typical in the field of psychiatry where diagnoses have traditionally been defined in terms of a series of symptoms and that subsequent to early diagnosis, there are these sorts of analyses done to try to make a more rigorous diagnoses and to look at this -- if you look at the definitions of depression or schizophrenia or several of the major psychiatric disorders, which we now can effectively treat with pharmaceutical products, you start with symptoms that are defined sort of in the same technology -- using the same technology.
DR. LIN: You have two survey instruments, but you have also conducted neurological testing of brain scan. I was wondering that before you launch into the human experimentation, what kind of requirements do you as the investigator that your institution require. Do you meet "for review?"
DR. HALEY: Yes. We have an institutional review board that would use every step.
DR. LIN: And do you have an informed consent?
DR. HALEY: Yes. With all of these we have a consent form. In fact with later studies I am going to do in the next hour, we had a discussion with the Defense Department and Dr. Friedl.
DR. LIN: Also, to just follow-up, you have a slide that has the -- ensure the confidentiality to your other patient with your signature and Mr. Perot. How do you ensure absolute confidentiality. In other words, if court order you, how do you ensure?
DR. HALEY: Oh, in Texas there is a state law that protects medical records, which these would fall under. And they are only available -- they can only be discovered in a criminal case. And in a criminal case, all bets are off. And that is basically the standard in most of the states. I know in Georgia that was the case when I was at CDC. These things are protected except they are not -- in other words, they are not discoverable by the Open Records Act in Texas.
DR. GARRITY: In Syndrome 1 and Syndrome 2, and I am not sure about Syndrome 3, but in 1 and 2 there were self-reported psychiatric conditions. In Syndrome 1 you said depression, and I wasn't clear whether that was a self-reported diagnosis of depression or whether that was a symptom that was --
DR. HALEY: Self-reported.
DR. GARRITY: And in Syndrome 2 self-reported -- that they had gotten a diagnosis of PTSD. And I was wondering two things. Number one was did you do any case to ascertain them, PTSD case. That is, did you either get their records, their medical records and go through it to see whether or not that diagnosis of PTSD was supported or did your own evaluation of PTSD?
DR. HALEY: The latter, but not the former.
DR. GARRITY: The latter, but not the former.
DR. HALEY: Yes. In other words, in the case control study when we brought these people in, the second time, which I am going to describe later, we did a very thorough SCID -- psychiatric interview by a psychiatrist.
DR. GARRITY: How many of those then was a self-reported diagnosis of PTSD turned out to be not or went the other way?
DR. HALEY: I have a slide I am going to show you.
DR. GARRITY: But I just want to conclude that -- there is something associated with this, and I want to emphasize that I am not suggesting that PTSD is the problem. Quite the contrary, I think, you know, most of us sitting here at the table do not believe that PTSD is the problem.
DR. HALEY: Right.
DR. GARRITY: But the concern that I have is that if somebody is suffering from depression, somebody who had a diagnosis of PTSD, there is a -- I would wonder whether or not they are on any medications and were they on any medications and if so, what is your control for the side inference of that?
DR. HALEY: None. We were able to take everybody off all meds when they came in for our study. We stuck to the R&Ds. That is a most sensitive issue, as you know. None of them were on meds they couldn't go off of and they were comfortable doing so. So none of them were and they were all off before. So this wouldn't be confounded by medication.
Yes, sir, Dr. Green?
DR. GREEN: Just a point of clarification. The definition of Syndrome 1, as I read the characteristics of that patient population, I have to admit that I am an increasingly elderly internist myself. And the definition really strikes me as those that either experience associate with a clinical diagnosis of depression. And I ask this to you as an internist, I mean, just for clarification, how do you distinguish these clinical symptoms from the general medical definition of depression?
DR. HALEY: Absolutely. That has been a source of lengthy discussion in our group. And when we first saw the syndromes and I made that list of the syndrome, we didn't have the psychological data examined yet.
So we saw those syndromes and I said, "Look. Number one is depression. Number two, that is more worrisome, but maybe that is somataform. You know, although, now that I have studied what somataform, that doesn't make -- I shouldn't have thought that. And three is fibromyalgia, whatever that is. Where we evolved to, though, was is this depression or a brain injury? That begs the question of what is depression.
DR. GREEN: It does indeed, but I know that most of us are here because we are looking for ways of helping these individuals.
DR. HALEY: Yes. Right.
DR. GREEN: There is no doubt that there is an illness and we are trying to understand what it is, but perhaps more importantly --
DR. HALEY: It is the treatment.
DR. GREEN: -- perhaps some hypothesis of treatment is appropriate. And I wonder if discussion has been given to whether this group may benefit --
DR. HALEY: Yes.
DR. GREEN: -- from the treatments that exist for depression.
DR. HALEY: For depression.
DR. GREEN: Whatever the cause is.
DR. HALEY: No, you are exactly -- and that -- yes. Whether it is brain damage or stress or psychological problem or maybe somehow this disease just picked people who were predisposed to depression and now they have got depression. You know, all of those are possibilities.
DR. GREEN: Well, you have certainly done a service, I think, identifying a cohort that has this particular group of symptom and perhaps it suggests that at least with this cohort, treatments which we associate with treatment for depression, may in fact have some value with this cohort no matter what name is given to it.
DR. HALEY: Right. Well, what -- on the basis of this, we were thinking just the way you were. We then -- since we have studied all these people the second time, as they came back in for the second round of tests, and I am going to describe it in a little bit, we then enrolled all of the sick -- all of the ones with the syndromes who would agree to do -- who wanted to do this in a little treatment trial.
And we are testing Paxil just because of that, Aricept for the cognitive problems, Ativan and Ambian for the anxiety and sleep problems, and a beta blocker Viscan or Pindolol to see, you know, what ballpark are we in.
And what we have done is we -- this is a double blind study where we get -- every one of them gets all five medications and a placebo mixed in, but all on different schedules and they don't know what they are getting and so forth. And every week they fill out a symptom questionnaire or standardized SF-36 and some other inventories that get to these symptoms.
And we are going to see do these -- I mean, it is an early shotgun approach. Do any of these medicines make any of these symptoms better. It is not going to cure any brain damage, if that is what they have got, but maybe Paxil will make these people better.
And so we will break the code -- in fact, in about two weeks, we will break the code and we will see if any of these helped. Maybe they will, maybe they won't.
COL ABREU: A couple of questions, and I guess they fall under the general umbrella of the demographics and exposure. Has any studies or work been done with units that were co-located with the 24th in the same area? Has any work been done with that to see what kind of breakdown we have of those people?
DR. HALEY: We have only studied the Seabees unit and then 336 from the Dallas --
COL ABREU: From the Dallas pool.
DR. HALEY: Just a miscellaneous group of sick Gulf War veterans. So we don't know.
COL ABREU: Okay.
DR. HALEY: You know another question that I frequently get asked, how about people over -- civilians over in Kuwait and southern Iraq. But those are great ideas that should be done. What we would like to see is others do some more epidemic investigations in the same order on those other populations. It would be truly interesting.
LTC RIDDLE: Given the characteristics of this population and your hypothesis of this exposure to organophosphates or other chemicals, how do you control the previous exposures on these individuals that likely have, given the nature of the Seabees battalion and the individuals that you find?
DR. HALEY: Okay. Previous or subsequent exposure to organophosphate. There it fits into the clinical inference these people were all healthy guys when they went to the war. Otherwise, they wouldn't have gone.
And so prior exposure -- if they had prior exposure, it couldn't have been enough to make them disimpaired or they wouldn't have gone over. Now subsequent exposure by history, these guys' symptoms began either early in the war before the combat or after at about the time they were coming home.
So the only way to address that is by history. And, of course, in medicine that is, you know, the poster said, "Ask the patient." And they will tell you 95 percent of the time what is wrong with them.
LTC RIDDLE: But it is all subjective, not objective.
DR. HALEY: Well, I mean, medicine is subjective.
LTC RIDDLE: Well, no.
DR. HALEY: Now look, you know, you have got -- in epidemiology, you have got to use some -- you know, you have just got to -- there is some common sense thing that these guys were well when they went over and immediately after the war they got sick like this. And now they are so sick they can't work. You don't really think it is plausible that pre-war exposure would have done this.
Now maybe they all came back and got into organophosphates, but then guys all over the country got into organophosphates then. And that is not a plausible explanation. I mean, it is -- you are right to bring it up because it is one that you have got to think about and say, "Well, could this happen?" But you immediately rule it out because it doesn't explain the clinical setting of this thing.
I don't think there is ever going to be a better answer than that, although we are proposing in our new survey to study random sample of guys who went over and measure our syndrome preferences. And also a random sample of the guys who didn't go over, excluding those people in units that were not in it right away. So get rid of the healthy warrior thing and that sort of thing.
And in that inference, if their syndromes are ten times more common in the deployed than the non-deployed, I think that would, to some extent, answer your question because if these guys got exposed before, well, some of the guys who didn't go over should have the same thing. I mean, as many. The same prevalence. It should have the same prevalence or if it is exposure, after they all had the same prevalence because of the military population.
So that is the -- that is the reason I think you want to do deployed/non-deployed. And that is something that I think -- I don't know if you were in Steven Joseph's office when I went up there right after we published our papers, but that was one of the big questions that was raised in that meeting, "Well, why didn't you study non-deployed?" Well we studied 10 controls, but obviously that is not enough.
And it would have been nice for us to study deployed -- another battalion of reserve Seabees that didn't go over would have been a good -- co-located in the same part of the country because this is a rural part of the country and there are more organophosphate exposures in the civilian world.
We did ask the question on our questionnaire about, "Do you spray your own home?" You know, for pests. "Do you have it done? Do you use pesticides or what chemical do you use in your work." We had a bunch of questions and those didn't relate to any kind. But that is a tough issue.
DR. SPENCER: Bob, toxicologists get extremely nervous dealing with self-reported exposures. They like to have hard data and we all know that hard data is hard to come by in this particular situation. In looking at the possibility of obtaining some hard data, we felt that it might be reasonable to compare the experience of people who were there for a certain period prior to combat versus those who experienced combat, versus those who were there early for the post-combat period.
We can be fairly confident, based on the information that have been distributed, that these three different groups had three completely different compounded exposures, although the exact composition of these exposures was not known. But we do at least have some confidence in terms of times of deployment in and out of theater.
In the case of two of your syndromes, the use of pyridostigmine bromide would be expected to be associated with the combat or immediately prior to the combat period. It would not be expected to be present in the pre-combat period or the subsequent to combat period.
When we looked at the distribution of cases -- and as you know, we did a case control study, population based, et cetera, et cetera -- we were unable to find, on the basis of rather small samples, any differences in the proportion of cases among the pre-combat, combat, and post-combat periods. Now the problem with this approach was simply small numbers of people who were there only for Desert Shield, only for Desert Storm, only for the post-combat period.
But nevertheless, on the basis of our data published, we can find no differences in the proportion of cases using a case control definition very close to the CDC definition. And I wondered how you would respond to that.
DR. HALEY: Okay. Several ways. First I think the CDC case definition is invalid. Meaning it didn't follow from their work and I think it is a very, very all inclusive case definition. It has three -- basically it has three symptoms. You have to have fatigue and anyone of cognitive things and any -- I forgot. All you need is any three symptoms basically. And --
DR. SPENCER: There was a certain chronicity though.
DR. HALEY: Yes.
DR. SPENCER: And duration.
DR. HALEY: Right. But still, I mean, it didn't follow -- they did a factor analysis and then they threw their factor analysis out and said, "Hey, let's, now let's pick some symptoms." I mean, that is not a credible idea. So first of all, I would really argue with the case definition. I think what you are picking up with that case definition anybody that says they have got symptoms.
DR. GARRITY: Well, I don't think any of the authors are here to discuss with you --
DR. HALEY: Well, I have talked to a few of them about it and I have told them what I think.
DR. ZEGER: As I recall, their correlation between symptoms defined scale and the factor analytic scale struck high. They are basically not just throwing it out, they were saying that you get a very similar result if you just focus on the --
DR. HALEY: Yes. I think to really discuss that, I mean, we ought to get them and sit down. I can show you -- I have got a letter to the editor that is going to be published shortly in JAMA about that. And I think we are going to decide that that is not -- what it is, it is too general.
DR. GARRITY: But I will point out, it is really -- you know, you had mentioned the Sanford case definition at the very beginning, and, you know, questioned, you know, why wasn't the Sanford case definition, you know, used right then and there. In point of fact, what ended up as the CDC case definition looks remarkably close to the Sanford case definition.
DR. HALEY: That is right. And you know, here is the big drawback. Neither the Sanford case definition nor the CDC definition included our Syndrome 2, which is the worst problem. Why is that? The Sanford definition was developed -- Jay Sanford, he is a master clinician, those of you who don't know him. He was an infectious disease consultant to the military during Vietnam and then was the dean of the military medical school here in Bethesda for years.
He reviewed a number of medical records of people who were still on active duty in late '93 and concocted his case definition, which basically is our Syndromes 1 and 3, which are still in the paper there of the Sanford definitions, our Syndromes 1 and 3.
When I showed him our findings, he said, "Wait a minute. What about all these people with balance disturbances, and so forth? I didn't see any of those in my review." And he called up to some of his colleagues and they said, "Well, we saw those guys, but they were gone by '93." See, they were so impaired they left the military before '93. So they weren't included as definition.
The CDC study was done in late '94 -- no, in early '95 in, what was it, four Air Force reserve units and they studied the people -- only the people who were still in the unit. Now they studied the people who were Gulf War veterans in the unit and some people who didn't go to the Gulf in the unit. Okay? Who were -- but the people who were still in the unit in 1995. Well, there were no more Syndrome 2s there.
So Syndrome 2 is not accounted for in their factor analysis. In fact, if you look in this letter -- I am going to show you this afternoon a slide of this. If you look at their factor analysis and ours, they hit dead on Syndromes 1 and 3 in our factor analysis, but they didn't ask any of the symptoms that would have picked up our -- the Syndrome 2.
So therefore, you see, their case definition is probably fine for 1 and 3, but those are mild things that is very difficult to associate anything. They don't have Syndrome 2 in their thing. And those are the guys out there that are really complaining bitterly. Those are the really sick guys. The ones that we think have PTSD -- or I mean, that resemble PTSD, have these bad problems.
So I think the problem here is case definition. And I think with the wrong case definition, you are going to be misled.
DR. SPENCER: Well, Syndromes number 2 refer to a posture of PB and potential exposure to a chemical weapons attack.
DR. HALEY: Or a chemical weapons exposure.
DR. SPENCER: So presumably, that could fall only within the combat period.
DR. HALEY: Well, okay.
DR. SPENCER: Is that correct?
DR. HALEY: Let me attack that.
DR. SPENCER: Simply because PB was not issued until --
DR. HALEY: First of all, that is not true. Veterans have told me that some people showed up early and had it. Now the credibility of that I don't know. And of course, we don't -- there is no credible evidence about exposures in the war because there is so much misinformation from veterans and from the military.
DR. SPENCER: That is when FDA approved use.
DR. HALEY: I have heard people say they had it, I have heard people deny it. There is no way to know whether they had it or not. But that is a trivial argument. The second argument is more important. Is this synergistic relationship an indicator that pyridostigmine, the chemical pyridostigmine, the chemical sarin somehow interacted in the body to cause these breakdown products of, you know, the NTE, whatever the mechanism is, to be more potent.
Or is pyridostigmine toxicity an indicator that something saturated their cholinesterase protection mechanism because that would have given you more pyridostigmines. In other words, the pyridostigmine risk factor we have here may be a synergistic biochemical interaction in the brain. On the other hand, it may be a more complicated indicator of something else is gone.
For example, what if veterans who have been exposed to a lot of pesticides over there early on in their deployment, they would have gotten their -- there is an enzyme in your body that protects you -- prevents the stuff from getting into your brain. It is called serum cholinesterase. And it is -- there is a finite amount of it in your blood and when these organophosphates are scavenged by it, it inactivates the defense mechanism.
So it tears down the shield as the shield is protecting you. So ultimately you run out of the stuff and you become more susceptible to stuff. It may be the pesticides depleted their pyridostigmine in these particular guys. Then when they took the pyridostigmine, they got huge side effects.
So maybe the pyridostigmine had nothing to do with it, it was the pesticides that ate up their cholinesterase. So then when the light sarin cloud came over, they were just sitting ducks and it went right to their brain. All this -- granted. All this is post-hoc hypothetical reasoning. But there is a plausible reason that explains your finding as well as ours.
DR. SPENCER: Could I just briefly mention that Marcello Lotti, who is a well known authority on organophosphate intoxication and was the individual who originates the promotion, that is, exposure to commonly prior to or following exposure to an organophosphate would result in the potentiation, as stated, that pyridostigmine bromide does not promote the action of an organophosphate in terms of --
DR. HALEY: Is that published?
DR. SPENCER: It is not published, but the specific question was posed to him and the answer was it did not. I assume that he has done the experiment.
DR. HALEY: We need to see it. You know, again, that would not inactivate, though, or counter my argument that pyridostigmine may not be interacting, but may be in an indicator of reduced resistance.
DR. CAM: Yes, I have three questions for you. In your case definition, there are two variables. Do you think it might involve later when more research come up, you might add more variables? My other point, just a suggestion, I don't know whether you have a slide or maybe you might be able to do some kind of brief comparison of a case definition or so-called case definition from different people. That would be helpful.
My second question is at the San Antonio hearing, you mentioned that you had a deck of cards to share with us whether those cards -- that those four, there might be others. In addition, I think it would be very important for the Board to really know specifically what or where the impacts your research would do on the Gulf War illnesses.
DR. HALEY: In other words, what about --
DR. CAM: Why once this --
DR. HALEY: What are we going to do about it?
DR. CAM: Right. My last point is, there is a concern that the selection of controls in EPA studies for Gulf War was more opportunistic rather than prospective. How do you address that statement?
DR. HALEY: Okay. I think I agree with all your other points. I don't think they require a lengthy explanation, but that one is very important. In a case controlled study of an epidemic investigation, what is typically and always done and -- almost always done, you get some typical cases.
Never do you do a random sample of anybody. You go get some typical cases that have the disease, you get some good doctors to pick them out. Then you get some people who are as much like them as possible who -- and there are many different ways. You can get people who live -- they suggest who live on their block is a common way. You can get people who live in their neighborhood, go do household. You can do random dialing telephone. There are all kinds of ways to do it.
What we do is to pick people in their same unit. We have these 70 people who came to the survey who remained well, and we had another roster, about another 60 or 70 who didn't go over. And so we went down those and picked the nearest person by age and sex and education level to match to the controls. And we had -- fortunately, we had plenty of controls, plenty of well people to pick that out. And that is the way you do it. And there is no -- I don't know of another more elegant way to do it.
DR. CAM: How about the ethnic background with regard paraoxonase samples?
DR. HALEY: That is a very important question. The ethnic background and susceptibility to organophosphate. Up to now there has been no -- as far as I know, Peter, and you may be able to correct me on this, there is no evidence that one racial group or another is more susceptible.
DR. SPENCER: There is published evidence from Japan suggesting that Japanese may have a higher frequency of genetic polymorphism, which you will discuss.
DR. HALEY: Right. I was just -- that was what I was going to say. This afternoon we are going to talk about a genetic predisposition. And that is -- that predisposition is caucasian -- northern European caucasians tend to have a higher level of the enzyme that protects you from these things and all of non-caucasian populations tend to have -- tend to be more of a type that has less protection against these.
From that, you would then hypothesize that the non-caucasian military personnel would have been more at risk for that. Unfortunately, the Seabees battalion we picked, one of the unfortunate fallouts of this is it was only men and it was almost all caucasian. This was an old Seabees unit. This was constituted years ago and most of these people were in their thirties and forties by now. And so it was constituted in an era when we didn't have as quite an equal opportunity military in that particular region, at least in the reserves.
So that was a drawback. We are proposing a survey where we stratify on sex and race so we can exactly analyze what is the prevalence of our syndromes by racial groups and by gender. Another issue is gender. There is some suggestion that women got worse disease than men from this. I don't know of any really good evidence to that except some doctors have suggested that they saw that when these people were coming back.
And one of the explanations Jay Sanford and others suggested, that since women are on average small of stature, that the same -- giving everybody the same dose of pyridostigmine might have over -- given the women more of an excessive dose.
But again, as Peter brings up, we are not sure of what the role of pyridostigmine is. Is it causative or an indicator of some other susceptibility? So that is what we want to look at in our big survey. That is one of the reasons to do a survey is to answer questions like that that we didn't address.
ADM ZUMWALT: ADM Steinman.
DR. HALEY: Yes, sir, ADM Steinman.
RADM STEINMAN: I have got a couple of questions I want to ask you to get your reaction to something. First your definition. You seem to have a very extremely narrow definition on a Gulf War Syndrome that applied to -- well, any of those symptoms. You say Syndrome 2 applies to twenty-one of your cohort of your Seabees, and yet there were a hundred and sixteen of the Seabees that said they had serious health problems that did not relate to any of those symptoms or syndromes.
DR. HALEY: Right.
RADM STEINMAN: So when you say there is a Gulf War Syndrome, you seem to be excluding a lot of sick veterans that fall under that category.
DR. HALEY: Excellent question. What are those 116? Well, that is a very important group. We think it is a mixture of several things. One, it is some people with our Syndromes 1, 2, and 3 who are just below the cutoff. You know, we had an arbitrary cutoff on those factor scales and there is no reason that somebody who just below the line couldn't have it as well. I am sure some of those are.
In fact, if you look at a number of our measures that we have on them, the people right below the line do resemble the ones who are just above the line. So that is part of it. But then there is still the majority of those people who probably don't have those syndromes.
Interestingly, in that epidemic curve, remember the bimodal epidemic curve, a hundred and sixteen are disproportionately in that group, whereas the syndromes are disproportionately in the second group. Now what I think that means is the people in the first group have something else. Now is it a syndrome 7, 8, and 9 or is it just -- is it the real somataform and post-traumatic stress disorder and whatever else.
Now we proposed five different grants through the government granting agency and all five have been turned down. We then came back and petitioned and got a good correlation. One of the ones that was turned down through the peer review process, we were going to go through and first get more Syndrome 1s, more Syndrome 3s, and better matched controls for Syndromes 1 and 3.
We were also then going to construct another group that took a random sample of this 116 and some appropriate controls for them. But the peer review groups have been very, very adversarial to us and thought that everything we have done has been stupid. And so they turned us down. We would have looked at that and that needs to be looked at it. We would look at it in our final --
RADM STEINMAN: That is what I am saying. There is a lot of veterans who are saying they are ill and who in fact are very sick that fall into this category. I assume that your definition would exclude them.
DR. HALEY: Well, let me just comment on that because it is important for the future what are we going to do about this. Yes, we could come up with some measures of Syndromes 1, 2, and 3, but that is not going to address the majority. The majority of complaining veterans have something else or all these other diseases that everybody thinks is out there. So we need to characterize that middle group. And that is what we are proposing to do. It is critical.
RADM STEINMAN: Also, your definition would seem to rely very heavily on exposure to chemical weapons. Of course, that is an issue that is very much in dispute. Does your definition fall apart if there was, in fact, no exposure to chemical weapons?
DR. HALEY: Our Syndrome 2 risk factors -- if it were true that there were absolutely no low level exposure to sarin, that would throw doubt on our Syndrome 2. On the other hand, I think our data throws a lot of doubt on the idea that there was no sarin. I think this is much stronger evidence here that all of the evidence has been bandied around about whether it was there or not. I think this suggests it was there.
RADM STEINMAN: That is an interesting comment. Let me get your reaction on --
DR. HALEY: Wait, there is a follow-up here.
DR. ZEGER: I just want to point out your definition of Syndrome 2 is totally independent of any exposure.
DR. HALEY: Right. The case definition is. But the risk factors are very strongly related to --
DR. ZEGER: I mean, there are whole issues of confounding other explanations, but certainly the risk factor as a description of an ideology of symptoms is independent of the existence of sarin or not.
DR. HALEY: True. You know, the issue about sarin is a hotly contested issue. And most of the information is classified. There is misinformation being bantered around that Gulf War veterans are overemphasizing that. You know, what is true there is unknowable. All we can do is show the guys who have the sickest illness have risk factors that suggest sarin.
ADM ZUMWALT: Tremendous efforts have been made in all the work that has been done internally to look at every possible piece of evidence that sarin was used or was not used, but none of the people had access to your contribution of the evidence. And I think therefore, it is necessary for us to have this so we can take another look.
LTC FRIEDL: Sir, we have at least $20 million worth of projects that are currently funded that are looking at the sarin in combination with the ethanol and all these things.
DR. HALEY: Right.
LTC FRIEDL: That there is a whole flurry of studies. You know, they don't always -- the panel doesn't always know when you are joking. I hope I do.
DR. HALEY: All right.
LTC FRIEDL: But Dr. Abou-Donia has been funded for a sarin project, which we are hoping, you know, he will publish, and he has gotten a second grant since then.
DR. HALEY: Now let me say --
LTC FRIEDL: There is a lot of work going on right now with non-human primates, you know, more of the hen models, more of the rodent models, inhaled sarin and also by injection. All these different modes --
ADM ZUMWALT: But none of that answers the question was it used.
LTC FRIEDL: No, that doesn't answer the question if it was used, but it would get at this aspect of what the effects may be.
RADM STEINMAN: Let me follow up on a couple of other epidemiology studies and get your reaction to them. I had occasion to discuss with the French military officials their experience in the Gulf War and they had a number of troops there that took PB, these pesticides, and they reported no Gulf War illness. What is your reaction?
DR. HALEY: My initial reaction to that is the French society is not as open a society as ours and I felt perhaps that was duress of their military personnel not being able to be open and tell about their symptom.
The only convincing -- the best convincing evidence I have heard though to suggest that that may be true is the GAO went over and actually made an effort to contact individual troops and talk about it. And they concluded that they agree that there probably isn't any ill -- that the Gulf War illness is not in France.
So to me the GAO here is the only credible source of information on that, and they convinced me. I don't know, is that published in a report somewhere do you know? Did GAO publish that?
ADM ZUMWALT: Well, the French were not in the area of your theoretical tests.
DR. HALEY: I think they were further west.
RADM STEINMAN: But they did have chemical alarms, but they all thought the French said those chemical ones were all false.
Now a follow-up to your point made earlier about comparison of the cohorts that was there before the shooting and after the shooting began. The Canadians have a very interesting study of I think there were 7,000 troops studied. I think it got 75 percent response rate. And found that there was no difference in prevalence of symptoms between those who were deployed and those who weren't deployed.
And even within the group of the deployed, they had a very interesting case control situation in a destroyer. And I think 250 troops sailors aboard. It was on the scene before the shooting started. No PB, no pesticides, no DEET, no chemical weapons exposures.
The entire crew changed out just before the shooting started. So again, none of the other chemical exposures. Yet when they surveyed both those groups on the same ship before and after the shooting started, identical prevalence of symptoms of illness.
DR. HALEY: Again, when you look at prevalence of symptoms, I don't think you can make any statements. You have got to have a case definition. And that is why no research can be understood or believed unless there is a case definition, and then you have to look at the case definitions.
The case definition, a really clinically plausible one, does that case definition predict organic markers of disease? Which of the different variants of that case definition are the severe ones and which ones are the mild ones? That is what -- you have got to have that before any of these studies make any sense. And I believe none of those had a case definition.
See, it is like the Iowa study. A very helpful study. A random sample of deployed and non-deployed veterans from Iowa. But what they did is they measured the prevalence of individual symptoms and civilian conditions, like PTSD, stores on PTSD questionnaires. See, that is not a case -- there is no case definition there.
There are other things, and we can say in all -- many of those are increased in the Gulf War veterans compared to the others. But you see, they are all fuzzy things that aren't a disease. They are all fuzzy things that kind of get after their -- they are lightly -- probably mildly correlated with the real disease.
And so you are misclassifying huge numbers of people who don't really have it, who have something else and who are worried, who are anxious, who are stressed. All these things are -- that is the 116. See, we have selected the 63 out of -- away from the 116, away from that other 116. And see, if we hadn't done that, we would have gotten mush. Our risk factors things would have been nil, our clinical indicators wouldn't have shown any difference. And so that is the dilemma we are in.
Almost all the studies up to now -- probably all the studies up to now have used non-specific definitions. And so they didn't find anything. And that is the reason.
DR. SAMET: Just one comment. There is a difference between cluster of the symptoms and a factor analysis of a disease.
DR. HALEY: Right.
DR. SAMET: And I think that distinction needs to be kept very carefully in mind. In fact, the Iowa study showed that the individual components of any of your case definitions would be increased.
DR. HALEY: Right.
DR. SAMET: What I find difficult here is actually, in fact, the failure to yet replicate your analysis in another population to assess its replicability and understand in fact if another population with similar exposures, similar experience were characterized with these instruments, which are available, would we in fact find the same patterns, would they emerge? And perhaps the Iowa database would be one that could be examined as factor analysis.
DR. HALEY: I will show you this after -- in the next segment. We have done that. And we can do that. In fact, let me -- let's defer that because I have got a discussion of a couple of the other groups that have tried that and show you what the difference is.
ADM ZUMWALT: Perhaps this is a good time to take a break here.
DR. GARRITY: Just one final question. Much of the discussion about exposure relative to chemical weapons, PB, and pesticides are centered around the synergistic effects of these. However, the air war and ground war occurred in winter when the insect population is very low, unlikely causing a need to use any pesticides, insect repellents, et cetera.
And so the question of whether or not this is really a plausible combination of exposure, I think, you know, needs to be raised. I raised it before and I will raise it again. I was in the Gulf starting March 10th after the war was over, not that long. I was not even aware that there was a problem with pests because of the time that I arrived in the Gulf and because it wasn't a problem.
DR. HALEY: Let me address that because I think there is a plausible explanation. One, it may be these don't interact. They may be indicators of other biochemical things. I don't think that is true totally, but the other is, if you look subtly at the evidence on promotion, the idea that you can be exposed to an organophosphate, that stuff lies dormant in your nervous system causing no problems, and then later you take PB, if PB is a promoter, or one of the other promoting agents that we know does cause the symptoms to start, you give that and then suddenly you get OPIDN.
Now the length of time between the initial organophosphate exposure and the elicitation of symptoms by the promoting agent, the second agent, is highly variable. It has been documented out to six weeks. So it is highly plausible that people who came in and got organophosphate exposures got no problems and then took DEET just as they were going home in the early spring when it started getting warm and the insects started coming back.
We have a case report, for example, of a veteran who went over, served, came back with some sensory abnormalities, the syndrome where you feel like bugs are crawling over you. It is a sensory abnormality. And he had this for several years. And he would frequently spray his house with Dursban to get rid of the bugs because they were -- this is -- I am not kidding, this is a real case report. We are going to write him up.
And he continued spraying his house every several months with Dursban, but suffered no ill effects until one night he went out to barbecue and he covered himself with 100 percent DEET and came back in, fell asleep, the next morning he woke up with a hemianesthesia, which was -- is no feeling on the left side of his body, which was the neurologist could find. There was evidence he had hemianesthesia.
Now you tell me how that occurs? I don't know. There is some unilateral sensory thing. And it appeared to have been promoted acutely by DEET. Now again, I don't want to rest too much. You know, you have raised a hypothetical maybe this couldn't be true because there was maybe a time difference between the -- look.
Evidence is clear in literature promotion can occur many weeks after the organophosphate exposure, you then take the promoting agent, and I have got a case report that looks to be very compatible with what you are saying. Organophosphate exposure first, no symptoms, then DEET, and bingo, you get symptoms.
And remember our second epidemic curve, the second peak of the epidemic curve was just as they were going home in the spring when the insects were back out. And that is when they said they used the insect repellents when they were mopping up and leaving.
ADM ZUMWALT: A number of these points are beginning to point toward the things that I think Dr. Haley will be covering after lunch. So let's now plan to take a break.
Unfortunately, the arrangements for lunch are very poor. We have learned that this hotel has very limited help and probably only a few people could be serviced. There are several other restaurants up and down the street and we will have to ask you all to seek your own level of comfort of lunch opportunities.
(Whereupon, at 11:45, a luncheon recess was taken.)
A F T E R N O O N S E S S I O N
ADM ZUMWALT: Secretary Brown will be a little delayed and has requested that we go ahead with the meeting.
Before Dr. Haley starts the second part of his briefing, let me say that at the conclusion of that briefing, before we take questions from anywhere else, I would ask the four scientists to my right to be ready to give us their comments and suggestions and then I will entertain questions from the representatives of the various government agencies on the left. Then if we have time left, as Mr. Brown suggested, we will take questions from the audience.
DR. HALEY: Okay. Well, in the morning session, we went over what was done, basically finished three years ago. We presented that in a quiet session to a combined group of DOD and DA and Persian Gulf Veterans Coordinating Board and others in September of '95.
And then on the basis of that, we moved forward with another plan to go back now and, promising hypothesis, let's see if we can elaborate on this now with more objective and more sensitive observations. Okay.
Okay. Now. Here is what we did. We first planned to bring back the cases and the controls, the 26 veterans with the syndromes and the 20 matched controls to see if we could learn more whether there was a real brain injury, whether our preliminary findings could be corroborated.
And so we planned a number of different tests to address that. But what I am going to present now are the first two, the highest priority measurements that we made that we have now analyzed. And one just was published last week and the other one is about to go into -- is a manuscript about to be sent in for peer review. And I am going to go through these.
The first one I am going to talk about is not peer reviewed yet. So it is preliminary and it could change. It could be invalidated by peer review. Who knows? But I think it is a very strong finding. So I felt comfortable in presenting it.
The two findings are, one, we think we now can identify an actual brain lesion in the area of the brain that we predicted it would be in, i.e., the basal ganglia and/or the brain stem. We also think -- we also believe there is a genetic predisposition to this and the second finding is a genetic study looking at factors that predisposed people to damage by organophosphates finding that the sick veterans, actually, are more highly predisposed to brain injury from organophosphates than the controls.
Again, let me emphasize, these are done in the 26 cases and 20 controls. Okay. The first. Neuronal brain damage in Gulf War Syndrome demonstration by MR Spectroscopy. And this is a collaborative study of our group and our radiology department at Southwestern.
Now why did we suspect damage to the basal ganglia and/or brain stem? There were two reasons, a clinical reason and -- well, first of all, the Gulf -- I mentioned this earlier. Gulf War veteran symptoms appear similar to the early psychiatric features of primary basal ganglia diseases, i.e., Huntington's, Wilson's, Fahr's, and maybe early Parkinson's.
Second, our first case control study, where we brought the veterans in and did the audiovestibular tests in the cases of controls, identifies any abnormalities in eye movements by ENG, electromystagmogram, which are compatible with either a brain stem injury or a caudate nucleus injury, which is in the basal ganglia.
So this pointed to brain stem possibly as well as basal ganglia. The appearance of movement disorders in a few anecdotal cases. That is, we have some veterans -- in our sample of 26 cases, we have 3 that have developed Parkinsonian like tremors, a couple that are fast, fine tremors, unilateral, and one that is a unilateral gross tremor. And these are in fellows pretty young to have Parkinson's.
As well, we have one other veteran in our VA sample that is among our small group of cases of controls, who has what appears to be a chorea form thing with ticks, uncontrollable jerks, and so forth. And what is more important, the absence of any neurological localizing signs and the absence of MRI abnormalities.
In other words, all these things could be due to damage to other parts of the nervous system, except all those other would have an abnormal MRI. Strokes would have MRI abnormalities and tumors and multiple sclerosis and things should have localizing signs.
So therefore, we think the combination of the symptomatology and the absence of demonstrable things on well studied technologies really points -- so basal ganglia is the only thing left. Basal ganglia and brain stem is the only thing left. And so we felt pretty strongly that clinically this was a good idea.
So we then went as a rifle shot to study the basal ganglion brain stem with a technology that is useful in medicine. In fact, it is now paid for by medicare for studying the -- looking for brain abnormalities in people with normal MRIs. In other words, it is a technique that is more sensitive than MRIs.
Okay. And that is -- let me briefly summarize the Huntington's, Wilson's, and Fahr's disease to show you what I am talking about because people who have seen this think I am crazy because these diseases have very obvious neurological. Well, that is late.
When they present, usually they are not diagnosed immediately unless you have a strong family history; in the case of Huntington's, your looking for it. But inherited -- Huntington's is inherited degeneration of the basal ganglia and it begins in the caudate. It is delayed. It is pretty restricted to caudate nucleus abnormality. I am going to show you a picture of this in a little bit. So if this anatomy is a little strange, I will try to clear that up in a minute.
Well, here are the early presenting symptoms of people with Huntington's. Involuntary movements and eye reflex abnormalities that are very subtle and you don't pick up unless you are measuring them. Personality changes. Huntington's people are -- typically become irritable, even aggressive. They can even become violent later on. Apathy on the other side. They can become apathetic or strong irritability.
How many veterans -- most of our veterans say, "I had a personality change and I now can't stand the kids. I can't be around kids anymore. I can't stand to be on the shop floor, I am so irritable." Mood disorders. High rate of depression and/or manias. Mood disorders are found in 40 percent of people early and often precede the mood disorders.
In other words people with Huntingtons often will say, "Well, I went to the psychiatrist three years ago with depression." And maybe that was my presenting symptom. And that is true in about 40 percent. And there is a high rate of obsessive compulsive disorder developing in people early in the course of this and also some psychotic features, hallucinations and delusions, in up to 25 percent.
Now anywhere between 25 and 79 percent in the various series may present with psychiatric features as the initial presenting finding. Now again, later they deteriorate and develop severe neurological things that are not easily very characteristic and not missed.
Second, Wilson's disease. Hepatolenticular degeneration due to copper deposition in the various arteries. These people cannot rid their bodies of copper. And it deposits primarily in the putamen, but also the pons, interestingly, in the brain stem. The pons is that round thing in the middle of the brain stem.
So this is combined putamen and pons. And we think there is a brain stem and basal ganglia injury. Early presenting signs and symptoms are dysarthria. Veterans -- many -- most of the people with Syndrome 2 and many with Syndrome 1 complain of dysarthria. "My speech has changed." That is not a -- it is a subtle, but it is common. And other speech changes.
Mild tremor. As I mentioned, we have got a number with tremor. Dystonia, reduced motor speed, difficulty making movements and slowing up of their movements. A lot of people complained of that in the Gulf appeal. Personality change. Irritability. Aggressiveness like in Huntington's.
Cognitive problems, attention. Particularly problems with executive function. These are the higher level cognitive skills that are lost early in Wilson's. High rate of depression. Twenty percent of people with Wilson's disease present with psychiatric features only. Thirty percent have them predominantly in the initial presentation. So 30 additional percent have them predominantly, but have other neurologic things that go along with it. And 70 percent develop them eventually.
So depression is probably a consequence -- it is thought to be a consequence of Wilson's and Huntington's. There is some disagreement, but I think most people would agree it is -- that this is probably not due to depression, just co-exist here. Just people being sad because they have got this neurological disease because it is there before the neurological disease in many of them.
The correct diagnosis is characteristically delayed in this. You know, back in medicine, remember they used to teach us that you have got to do the physical exam for the Kayser-Fleischer rings in the cornea because that -- otherwise you will miss Wilson's until very late. And the reason because it looks like a psychiatric disease.
Fahr's Syndrome. I have to admit, I didn't know anything about Fahr's until I started reading about all of this. That is not one they teach frequently, it is fairly rare. Idiopathic calcification of the basal ganglia and mostly the globus pallidus, but then it goes out from there. And there are other causes of calcification of the globus pallidus in those same areas.
Early presenting signs and symptoms. Mood disorders. Depression and/or mania in 70 percent. Obsessive and compulsive disorder in 30 percent. Psychotic features, hallucinations and delusions. Intellectual, cognitive and memory impairments. These people actually lose intellectual function.
Vertigo, saccadic eye movement abnormalities. Abnormalities of the vestibular system, primarily in the -- probably the basal ganglia radiations that influence the brain stem. All possibly the brain stem. And speech impairments. Again, speech, which we think is characteristic. Also some extra-pyramidal movement disorders and seizures.
Those of you who may have seen our case report of the colonel and his twin, he has oculogyric crises occasionally. You know, that sort of thing. So again -- and we are not saying it is these diseases. What we think is that there is enough similarity to basal ganglia diseases to suggest, you know, that this might be due to that.
DR. BRIX: I believe you have given these examples to show us the types of symptoms that people have with this anatomically localized brain damage in the basal ganglia.
DR. HALEY: Right. Particularly early in the presentation.
DR. BRIX: Okay. And you have been following your group of Gulf War veterans since about 1993, and I know you have seen several of them more than once. What objective findings have you demonstrated that shows progression of other disease like that is so obviously. For example, with Wilson's disease within 13 months?
DR. HALEY: No. I am sorry, I didn't make that clear. This is not Wilson's disease or Fahr's or Huntington's.
DR. BRIX: I know.
DR. HALEY: Because those are progressive diseases that by this time would have progressed to serious neurological, and many of them would have died by now.
DR. BRIX: Right.
DR. HALEY: So it is not that. What we think is there is a different -- whatever the ideology of those are, and most of that is not known, we think there is probably a different disease, i.e., a chemical injury that has damaged some neurons in the basal ganglia and it was a one-time shot.
There was some progression for six months or a year perhaps. It stopped and now they have got a static injury to these organs. And they may not progress. Now they may progress. We don't know. That is in the future. But we are saying that this looks like damage in the same area, but not a progressive nor degenerative disease.
DR. BRIX: Have you done serial examinations of the same individuals, either by a neurological exam or by imaging, like MRIs and so on, of the same individuals? If you have, have the people gotten worse, stayed the same, or gotten better on the serial examinations?
DR. HALEY: Right. We see no progression in the audiovestibular tests. That is probably the best answer. However, in our imaging, we have spec scans two years apart. We are right now starting to analyze those with a technique called statistical therametric mapping, which we now believe is the best way to do that. And we will have an answer for your question within the next six months.
In fact, the DOD kindly consented for us to use our last bit of funding in that grant to buy some new computer system that could do that. And so we are now putting all that into the therametric mapping. So we will really have an answer to your question then.
Okay. Well, that is the point. I don't want to go into that too much.
Now we know that these people have normal MRIs as people with these other diseases would have very early in the course. Well, in that case, the next thing you do is -- many things you can do is proton magnetic resonance spectroscopy. Now there are different kinds of spectroscopy.
Those of you who studied chemistry or have been involved in chemistry, magnetic resonance spectroscopy is an old technique that has been used since the forties in measuring chemical concentrations in solutions and whatever else you want to do it. And it is a very accurate, very long known technology that only recently in the last seven or eight years has it been applied -- or 10 years to humans to the brain.
It is now being used regularly. In fact, as I mentioned, medicare now reimburses for this as a test for people who are MRI negative to look for subtle brain injury. It is non-invasive magnetic resonance imaging technique.
What it does is differentiates different chemicals by their unique resonance frequencies. What you do is you basically bombard the brain with a magnetic pulse. And then the response you get back from the electrons and protons is registered.
And that response can then, by computer analysis, can be analyzed and converted into chemical spectra so you can look at the concentration of various chemicals using a spectrum, chemical spectrum, you know, different peaks and valleys, and you can measure the integral under the curve what those spectrum tell what the concentration of those various chemicals are.
This is technically called the chemical shift because each chemical shifts a different distance away from the reference point. So you can tell what chemicals they are and then measure the concentrations of them. It is a powerful technique. It basically measures, now, intracellular concentrations of the most abundant chemicals in a small volume of brain.
For example, you can focus that on a little sugar cubed size volume of brain and then the analysis will tell you what is the concentration of the major chemicals in that volume of brain. And the larger the concentration, the more you can separate from the background noise.
Now chemicals that have very low concentration, you can't separate from the background noise. And there are several types of spectroscopy. We use proton because it is the most sensitive, but there are others that are less sensitive but give you more chemicals. And we are going to probably try those next.
Now extensive research -- there are thousands of papers on this in the literature. It is an explosion in radiology and medicine. There is a huge amount written on it. Extensive research has shown characteristic chemical abnormalities in many different brain diseases. Neurological diseases that have MRI abnormalities are now characterized.
In MS we know what the chemical composition of MS plaque is, multisclerosis plaque. We know the composition of brain tumors. We can predict what kind of a brain tumor and how it is going to act now by analyzing the chemical structure of the brain tumor. I am oversimplifying here to some extent, but that gives you the idea.
Also, there are chemical profiles now in different areas of the brain for different psychiatric diseases. There are numerous studies showing that in the basal ganglia in people with bipolar disease, depressive disorders, classic mood disorders, we know that there is an increase in one chemical and normal in the other main chemical. And that has been reproduced over and over.
So we know there are -- PTSD. There was recently a study on Vietnam era PTSD that showed a characteristic chemical profile. This is more sensitive than brain CT or MRI. Now a proton -- this stands for proton -- proton magnetic resonance spectroscopy or sensitive MRI is positive in these diseases.
Examples. Diseases with abnormal MRIs, I mentioned multiple sclerosis, Alzheimer's disease we have thoroughly studied, chronic alcoholism shows a certain profile, brain tumors, strokes, et cetera can all be analyzed now with this chemical technique.
Diseases with a normal MRI, the regular MRIs that shows no brain abnormalities, epilepsy. Now you can see abnormality -- chemical abnormalities indicating loss of neurons or inflammation in the temporal lobes that predict epilepsy. And in fact, this is now used to guide the surgeons in order to operate to take out the offending lesion and stop the epilepsy.
Lupus has a characteristic trait. Radiation for brain tumor causes a characteristic picture. Hepatic coma causes a characteristic picture. AIDS dementia, which was arguably not a real thing some years ago. Now there is a characteristic picture for AIDS dementia complex. Amyotrophic lateral sclerosis has a certain appearance.
All of these in normal appearing brain, including MS, which you can actually show abnormalities in areas of MS brain. Even multiple sclerosis, you can show abnormalities in the areas of their brain that don't have a plaque, which help explain then why the more global dysfunction in some people with MS that doesn't correspond to the plaque.
So you see this technique has really solved a lot of the or is in the process of solving a lot of the mysteries about the brain. Psychiatric disorders. Schizophrenia has a characteristic lesion chemical abnormality.
Unipolar and bipolar affective disorders. I mentioned obsessive compulsive disease has a characteristic one. Panic disorders have a characteristic. Increase in lactate you can detect, a big spike of lactate occurs in people with panic disorder. And PTSD, as I mentioned, a recent study.
Okay. So that is how it used. And the reason I belabor this is I must say when we started this, I had heard of MR spectroscopy, but I didn't know much about it. And a lot of people are still learning.
Now the main chemicals detected by proton MR spectroscopy are -- there are really four, but the three main here that we are interested in are N-acetyl-aspartate. NAA for short. This is a chemical that is found in neurons, both the neuron cell body and the axon. So there is the brain that are rich in neurons will have a high level. In fact, I will show you in a minute. You get a spike of NAA.
Choline, abbreviated Cho in the later slides, is present in glial cells and cell membranes and it is liberated in the inflammation or in glial tumors. It goes up. But it can go down in loss of neuro tissue. N-acetyl-aspartate measures neuronal mass it can't go up because you can't grow more neurons, but it can go down if you lose neuronal mass.
Creatine, abbreviated CR, is an energy metabolism. This is the high energy phosphates, ATP and all of those chemicals are measured. And this tends to be in the brain in constant levels all over the brain. Even in people with brain disease, this is not -- doesn't tend to be changed, although there is a couple of exceptions to that, but they are in very, very sick people, as you know.
So what you do is you use creatine as a ratioing tool. You calculate the ratio of NAA to creatine and choline to creatine so that you can get a reproducible measure from person to person
DR. GUILARTE: Excuse me. I have a question.
DR. HALEY: Yes, sure.
DR. GUILARTE: Are you suggesting that these are exclusive to these cell types or that the ratio of the --
DR. HALEY: No, no, no, they are exclusive, yes. These are found --
DR. GUILARTE: Are you saying that choline is not present in neurons?
DR. HALEY: It is, but the explanation for that is, choline is in two places. It is in the cytoplasm where it is free in various compounds. It is also in the cell membranes. Cell membranes do not contribute -- even though there is more in cell membranes, generally cell membranes don't contribute to what you measure because they are fixed. So they don't vibrate when they are hit by the magnetism. In other words, they don't produce a spin echo response.
And so yes, they are, but typically what you see in the literature in this is that brain diseases that produce NAA are diseases where you have neuronal loss. Increasing in choline tend to be true in tumor growth, inflammation, infection, things that stimulate cell wall -- cell membrane repairs. So you have got a lot of constituents either breaking down or being produced. And you liberate a lot of choline around that.
But in dementias, like Alzheimer's, you can lose your neuronal, you can lose -- have reduced NAA and you also have reduced choline. So there are thorough studies that have looked at brain tissue and analyzed the, you know, subcenter, broken down the neurons from the glial cells, from the oligodendroglia and so forth and show that these chemicals measured by MR spectroscopy are specific to those areas of tissue.
ADM ZUMWALT: Dr. Haley.
DR. HALEY: Yes, sir.
ADM ZUMWALT: Roughly how much longer do you think your presentation is going to be?
DR. HALEY: Probably about an hour.
ADM ZUMWALT: Is that a problem for any of the outside --
DR. SAMET: Really, we have to be back by 5:00.
DR. HALEY: That is fine. I think we will be through with all of this in an hour and we will have another hour for discussion.
ADM ZUMWALT: That will give us some time to get comments from you. All right.
DR. HALEY: Okay. Yes. So the answer is yes. Now the ratios are critical because that is how you measure changes in the brain with MR spectroscopy. Typically you see a reduced NAA to creatine ratio and you have loss of neuronal mass.
However it has been shown in some diseases that this could be reversible. That is, you could have a disease that causes reduced reduction in neuronal mass. And then when the person recovers, it can go back and the NAA to creatine ratio goes up.
This is in diseases like in the systemic area around infarct when yo have a stroke where the brain is killed in the middle. Of course, in the area of the skin, you have damage around it. The NAA ratio -- the NAA to creatine ratio is going to be reduced in that marginal zone and then when the person gets well, it goes back up.
And there are other diseases like radiation injury. It will go down and then when the radiation injury subsides, it will go back up. So this probably indicates it is a measure of functionally functioning neuronal mass. And a decrease in functioning neuronal mass can be due either to loss of neuronal mass, which is universal, or to a reversible injury to the neuronal mass. But it is not found in areas of the normal brain. You do not see these fluctuations in areas of the normal brain.
Choline to creatine ratio can be reduced or increased. Reduced in loss of glial mass, glial or the supporting structure, the support of the neurons where you have loss like in debilitating diseases you can see a decrease -- in the old burned out MS, you will see a decrease, whereas in things that cause inflammation, tumor, infection, infarction, or radiation, you will see an increase in choline due to synthesizing things. Reacting inflammation and so forth will increase this.
So in acute MS, the acute exacerbation in the area of the plaque you will see increased choline and then three years later in that same area you will see loss of -- a reduction in choline.
DR. GUILARTE: How much of a change would you need to have in the brain in order to see a change in the signal?
DR. HALEY: Okay.
DR. GUILARTE: Because you said there are very detailed studies about where the signals are coming from, but you haven't talked about the change required in order to detect a change in the signal.
DR. HALEY: It is important. Okay. The theory on that is that any reduction of NAA and creatine in a suspected brain injury, any change is significant. Of course, if it is a small -- very small change of 2 or 3, 4, 5 percent change, it is very difficult to measure that. So you have to have very large -- you would have to have very large numbers, and so forth, which you can do. If you have large numbers, you could see a 3 percent change. And that would be clinically significant in an area that you thought might be damaged.
DR. GUILARTE: Let me ask you a question. How about physiological change? Suppose you exercise and like you say you do an MR spectra scan before exercise and after exercise. Plastine, versus non-plastine.
DR. HALEY: Now there is people who have forced choline ingestion, for example, can get an increase in choline to creatine ratio. There was some concern early that lithium therapy might do something to the choline/creatine ratio, but that has now been changed.
People with panic -- the fourth chemical I didn't point out, because it is not in play here or we didn't suspect it if we didn't see any of it, you can also get -- normally lactate is not apparent on this. You don't see lactate is a chemical, you know, you make when you don't have enough oxygen in an area.
So lactate though in people who have infarction, lactate -- you can have a big spike of lactate and it has been shown that people with panic disorder in the middle of a panic attack will have an increase in lactate in the brain. That is an acute change that then will go right back down after they get over their panic attack.
So lactate can change a cubic, but these others are strongly -- there is strong agreement that these others are indications of change in actual brain structural chemicals.
DR. GUILARTE: I just want to clarify. Are you suggesting that proton MRS does not pick up physiological changes in the brain? That is only in disease states. Is that correct?
DR. HALEY: I believe that is correct, yes. And let me tell you, I have read 4 or 500 papers on this. And our radiology department is pretty strong in that. Okay?
Now we studied in this study our Syndrome 1, impaired cognition. We studied all five. Twelve of the thirteen Syndrome 2s, the thirteenth, actually, was a Vietnam veteran who was exposed to Agent Orange and developed multiple myeloma, which is known as an Agent Orange associated tumors, and had a bone marrow transplant.
We actually picked it up in our earlier study. Had a bone marrow transplant, is now doing well, but was not able to participate in this for obvious reasons. Syndrome 3 we had all five participated. In the controls, we had 18 of the 20. Two declined to participate. The same group, in other words.
In addition, we added six more from our north Texas veterans. We did a survey, which I am going to explain at the end of the period here. We did a survey of 338 veterans. We just advertised for all sick veterans in the area to come in and go through our things. We did half -- approximately half of them before our papers came out back in '97. We did the other half subsequently.
And out of those, we picked six typical Syndrome 2s and brought them in and compared them also to our Seabees controls just to see if Syndrome 2 was the same in Dallas as it is in the southeastern U.S. And we picked Syndrome 2, of course, because we felt we were most likely to be able to corroborate something and we wanted to have some replication. But this is a very, very extremely expensive technology. And so we couldn't just add a large number.
Now looking at the comparability, there is some differences here. Here is the average age of the controls. Notice Syndromes 2 and 3 are carefully matched to the controls and the group matching. Syndrome 1 -- I don't know if I mentioned this earlier. We have known all along they were younger. So there is an age difference. And our replication sample had an age difference. We didn't attempt to match them.
Notice the direction. These two groups are younger than the controls. So you would expect there to be less skill. However, there is good research now that shows that even though the absolute resonance intensity or concentration, if you will, of NAA may go down with age slightly, the NAA to creatine ratio is stable with age out to the extremes.
So another reason for using NAA to creatine ratio is not age sensitive. So all this would bias us in the opposite direction away from our finding anything; it probably should have nothing to do, in fairness. So you should not in your mind correct for the fact that these are old -- that these two groups are younger.
Now let me just -- I will just quickly run through this. For anybody who is an expert on this who knows -- I didn't understand this before, but I think I understand it pretty well now -- we use a Philips machine, which is one of the best machines. It is an MRI/MRS, magnetic resonance imaging/magnetic resonance spectroscopy. It does both at the same time. It is the NT version, which is the Cadillac. At 1.5 test loads the amount of magnetism that it fires.
We do scout images in three planes to locate the image -- the voxel that we are going to image so that we can have it comparable in all people. We focused on three brain regions. We had a 4 by 1 by 1 centimeter voxel. A voxel is like a little sugar cube volume of brain. A 4 by 1 by 1 centimeter cube, oblong cube, to the left and right basal ganglia. One in the left and one in the right. And a 1 by 1 by 1 voxel in the pons. And I will show you those in a second.
Standard automatic shimming and water signal suppression. We can talk about these if you want to, but I doubt if you want to. Acquisition with those parameters. The key one is this one. This is called a long echo time. And that is what make it the proton -- the long echo proton spectroscopy. And that is one that is both sensitive to these chemicals, but doesn't give you as many chemicals. The average study was about 60 minutes for the whole study for these guys.
Case controls were all done -- yes, sir?
DR. ZEGER: If I may, I have a question for validation technique. I think the protocol that Dr. Haley is referring to is a fairly common standard one used in the field right now. We know that there are some limitations that introduce noise into the system because of the existing instrumentations.
That was one of the major issues that, whether it is this or any protocols, are certainly the size of voxels. And we know the 4 by 1 by 1 on centimeter cube in the brain. Certainly we get a lot of material, but not just like a lot of gray matter or one structure. So we are always averaging, and that is always centralized in there.
Nonetheless, there are really some very good studies that show, I think, that you said as you were laying the foundation for this that AIDS dementia complex can certainly be detected earlier with MRS than it can -- or an MRI would show abnormalities. And similarly, early changes associated with Parkinson's, particularly Parkinson's associated with dementia, seems to show up earlier looking at this sort of protocol with MRS.
And so there are limitations obviously and sensitivity, but at least in some relevant cases have proven useful in trying to identify and stratify patients with neuro symptoms.
DR. GUILARTE: Is this a single voxel in the basal ganglia?
DR. HALEY: Yes.
DR. GUILARTE: Is it a caudate putamen --
DR. HALEY: I am going to show you a picture of it in a second. In fact, let me just show you. For those who don't know what the basal ganglia are, here are several views. This is a side near the brain. This is the big putamen, the caudate nucleus kind of wraps around and the globus pallidus is sort of in the middle there. It is sort of a switch box for it.
This is looking from the, I believe, from the top down and the bottom up and you see how these -- it is a little nucleus right in the middle of the brain, in other words, what we are talking about. Now here is the view that is going to be most helpful to you in a minute. The lateral ventricles kind of go like this. The spinal fluid, this is kind of tucked in between them there looking from the top down.
Now here is where we put our voxels. This is the front/back view, if you will, cut through the middle. And see, this is right in the middle. This gets part of the caudate nucleus, mostly the putamen, and a good bit of the globus pallidus. The same thing here. A little bit of the caudate nucleus, most of the putamen, and a little bit of the globus pallidus. Okay. Does that answer your question?
DR. GUILARTE: You have some white matter there too, don't you?
DR. HALEY: No, that is mostly the gray matter. We are very careful to avoid the -- the key thing is avoiding --
DR. GUILARTE: The ventricle.
DR. HALEY: -- the ventricles because the ventricles have a very different chemical -- there is a thing called partial volume effects where just a little bit of the wrong beginning of the ventricles can really bias your results. But this is mostly gray matter in here. A little bit of the, well, internal capsule out here.
DR. GUILARTE: That was my next question.
DR. HALEY: Yes. Right. A little bit of it. It is in there.
DR. GUILARTE: Partial volume effects.
DR. HALEY: Yes.
DR. GUILARTE: Are they correct in --
DR. HALEY: With H MRI spectroscopy, I don't think we can do that.
DR. GUILARTE: What does that include in your signal?
DR. HALEY: As long as it is the same body -- the same place in every body, cases and controls should -- you know, in other words, if there is a big partial volume effect that biases something, then you should see no difference in cases and controls.
DR. GUILARTE: Just suppose that the brain region is different between you and I.
DR. HALEY: Yes.
DR. GUILARTE: The partial volume effect is going to have an impact on the measurement.
DR. HALEY: So then the question is -- so that is why you need controls. You should see the same kind of difference in the controls. And so if you see the cases and controls that there is difference between them, then that is probably due to whatever made them a case and a control.
DR. GUILARTE: And then that relates to the age problem. As you age you lose neurons. So your basal ganglia line at different ages is going to be different. If you have no correcting for partial volume effects, then the signal you get may be due to an aging effect.
DR. HALEY: Right.
DR. GUILARTE: Even though the ratio of your chemicals may remain the same, but your volumes are different.
DR. HALEY: Right. Now what that will do, though, what that should do is it should make the older guys, that is the controls, have lower NAA, see, because there is less neuronal mass in the white matter. Okay. And so therefore that should --
DR. GUILARTE: In the gray matter.
DR. HALEY: Yes. Yes. So therefore that should bias against our hypothesis. So control should be more sick than the cases. See, because the cases -- in our Syndromes 1 and the verification sample are younger than the controls.
So therefore, there should be no -- it should be harder to find a difference between the controls in our Syndromes 1 and the replication sample, but it shouldn't affect our Syndrome 2 and 3 compared to the controls. We will come back and talk about that.
Now let me show you this. Here is our voxel in the brain stem right in the middle of the pons. Again, this fits nicely right in the middle of the pons. This is a 1 by 1 by 1. And Dr. Green is right, the size of the voxel is critical. Anything less than 1 by 1 by 1 is paralis. But we were able to fit a 1 by 1 by 1 neatly right in the pons.
There is almost no literature on pontine MRS except in pontine tumors, which is a bigger different thing. We think this is only the second study done. So we don't have much to compare in the literature to this. Although that is a very commonly -- this is done frequently, frequently. Now there is a huge literature on basal ganglia MRS. I think these issues are addressed.
DR. BRIX: Also, Dr. Haley.
DR. HALEY: Yes.
DR. BRIX: How sizeable is the literature on the diseases of basal ganglia for this technique that you mentioned before?
DR. HALEY: Very large. Very large. For example, there is six studies just on bipolar disorder in the basal ganglia.
DR. BRIX: No-no. No. Huntington's or Fahr's disease or Wilson's syndrome, the ones that you gave us as possible basal ganglia that might be many prototypes. How big is the literature on those?
DR. HALEY: There are some studies, yes. There are some MRI studies. I don't know -- I can't tell you how many. I have got them in my file. I have got a file full of them.
Okay. Now how do you quantify the metabolites once you get the spectrum? The computer draws the spectrum -- actually, in the use of post processing is automated. And that is critical. It has to be automated because manual processing introduced huge biases that makes you usually not be able to find them again.
It is done in the time domain, those of you who know what that means, I am sure Dr. Green is familiar with that. This means that you can't -- the operator can't see what he is fitting to this data. The time domain does not look like something that you can interpret. It is a statistical abstract set of data.
And you do it on a SPARC workstation, you fit sideways to the peaks of NAA/choline and creatine, you rude the water signal with a certain kind of filtering, you take intervals under the peak in the time domain, not in the frequency domain. So you really can't see what you are doing.
So a person cannot bias this, the analysis done in the time domain. Also, both the operator who did the MRIs and the analyst were blinded to who is the case and who is the control.
Chemical shifts, that is the various peaks, were measured from the NAA peak, which is a very recognizable thing. You standardize that as 2.01 and then you measure all the chemical shifts from that. And the fit -- in our data, the fit was successful in a hundred and thirty-five of the hundred and thirty-eight voxels we did.
So if you multiply three times the number of cases in the controls, three voxels for each person, that is a hundred and thirty-eight and we were able to fit the model successfully with a hundred and thirty-five, which was very good.
This was very good data and it has to do with our very advanced magnet that we got. It was upgraded right before we started this study to the latest thing Philips makes just by happenstance. We didn't bring that about. And then to produce the actual printouts that you could read, one hertz exponential filtering, Fourier transformation, phase correction. Standard stuff.
Now here is what you get when you draw the picture. Now the analyst doesn't see this. This is -- you print this out later to see kind of what is going on. Here is noise down at the bottom. And low frequency chemicals are lost out in the noise, but in the normal brain you typically get a choline spike, a creatine spike and an NAA spike. The NAA spike being much more -- or peak being much more -- much bigger and much bigger volume.
In the time domain earlier you took the interval under here and that measures how much of this there is in that little volume. Okay? And then your ratio NAA to creatine and choline to creatine knows your outcome measures. And you then compare them among the cases and controls.
We also did, and this -- Ken, this answers your question. We did very detailed psychiatric exams of these people as they came through, with the psychiatrist blinded the case and control group status. One psychiatrist, he used the SCID, the structural clinical interview for DSM-4, which is standard structure interview, the CAPS, which is the VA standard for PTSD interviewing.
We found three psychiatric disorders of frequently enough occurrence in this group to see if they were confounding. Depression we found in 13 of the 22 cases and 3 of the 18 controls. We found PTSD, which fit the criteria for PTSD.
We are not talking about Mississippi PTSD scale measurements, but three bona fide PTSDs among the 22 cases, but none of the controls, and we found either alcohol abuse or dependence in 2 of the 22 cases and 3 of the 18 controls. All of these had normal liver function tests. So they were not people who had hardened alcoholism, but they had some alcohol abuse.
CPT MAZZELLA: Doctor, I have a question.
DR. HALEY: Yes.
CPT MAZZELLA: Were any of these individuals that you identified as having depression or PTSD or alcohol, had any of them been treated for their apparent depression?
DR. HALEY: Yes. Several. I would have to go look it up, but the minority of these 13 had been treated. We picked up the depression. In other words, we diagnosed the depression for the first time in more than half of this.
CPT MAZZELLA: Had they been treated with Prozac, Paxil, what?
DR. HALEY: Any of the above.
CPT MAZZELLA: But what kind of response did they exhibit? I mean, was it a positive response to --
DR. HALEY: Oh, good question. I will have to go back and talk to the psychiatrist. I don't know the answer to that.
DR. GARRITY: Now were those diagnoses made while they were being treated?
DR. HALEY: Right. Yes. As I mentioned, over half of these, we made the diagnosis. So they didn't know they had depression and they were just sad when they had the guide.
Okay. Now the statistical method, the statistical analysis we first -- one of the dangers in this is you have got three different volumes, you have got three different syndromes and multiple hypothesis testing. A common -- increasingly common -- I think the recommended way of avoiding that problem is to do a global test of hypothesis first.
What we did, we tested the hypothesis of a reduced NAA to creatine ratio. That is our number one hypothesis. We thought this was like a Huntington's or those in which there would be neuronal loss in the basal ganglion brain stem.
We did this by a repeated measures analysis of variants using three brain regions as the within subjects parameter and testing our three level effect. Two being more -- hypothesized to be more influent, more effective than one and three than the control. So we had a three level effect as the between subjects effect.
Okay? Then once we rejected the no hypothesis with this, and I will show you the things in a minute, we then analyzed the NAA creatine ratio by syndrome. You know, we looked at all the differences and means within the analysis of variants here and looked at explanatory differences in choline/creatine ratio as an explanation to try to understand what the primary difference in NAA/creatine is.
This is not why we used the radiology, although it should be, we think. We also then tested for confounding by those psychiatric diagnoses. Could those have accounted for the association between our syndromes and reduced NAA to creatine ratio?
Well, here is just a visual picture of what we found. Here is a spectrum for a normal controlled. And this is a representative spectrum. This is a spectrum from one of our people with Gulf War Syndrome 2. Everybody really look at this. You really need to focus on this.
Here is the creatine spike. I have actually adjusted the height of these spectra so that the creatine spikes are exactly the same height because that is the ratio currently. We ratio everything to that.
So you can then look and compare the heights of these two NAA spikes as the two choline peaks. This is dramatic. This is a dramatic reduction in the amount of NAA in this volume. This happens to be the right basal ganglia of one of the veterans with Syndrome 2.
DR. GARRITY: Well, clinically, when you say it is a dramatical reduction, what does that mean? I mean, what --
DR. HALEY: It means this guy has lost neurons.
DR. GARRITY: No, no, no, no, no, no, no. Let me --
DR. HALEY: Well, he has lost functioning in the neuronal mass.
DR. GUILARTE: I think there is a question here of activity, of neuronal activity versus neuronal loss. You are looking at a chemical level in a voxel brain tissue, and I am not sure whether you can make an inference as to whether this is neuronal loss or changes in metabolic activity.
DR. HALEY: Yes. I think it is fair to say this could either be loss of neuronal mass, as I mentioned a while ago, or injured neuronal mass.
Yes, Dr. Green, why don't you comment.
DR. GREEN: I think one of the concerns, and I am sure you have had this concern also, is that it was first, I think, demonstrated stridefully in PET scanning with fluoro-2-deoxy-d-glucose as a measure of blood flow, largely. And certainly depression is associated with diminished areas of flow to a number of regions, such as the basal ganglia. And you can certainly have depression related changes on PET scanning.
Here we are looking at another measure of neuronal function, and that is the NAA peak. And I think certainly we would want -- I am sure you would want to, look at controls with depression to see whether this could be associated with that disorder.
DR. HALEY: I am going to address that in just a minute. Just a second.
DR. GARRITY: But I didn't get my question answered.
DR. HALEY: Okay.
DR. GARRITY: The question is if we did this on everybody in the room, all right, what is the population --
DR. HALEY: What is the variance.
DR. GARRITY: What is the variance of that?
DR. HALEY: What is the variance of the NAA to creatine ratio. It is very small. That study has been done. There are huge studies. It is very small, very small.
DR. GARRITY: How small?
DR. HALEY: I will have to get the paper to see. It is plus or minus 2 percent or 3 percent of the population. It is very small. And a population that has lost neuronal mass you will see a difference if you have a large enough sample size.
DR. GREEN: And would it be fair to say also that the answer to that question might be instrumentation because you can't just go to the literature and determine sort of any number. You need to take all the considerations, including the specific RF coils and RF pulse sequence that are being used. And frankly instruments change from day to day also.
DR. HALEY: Right.
DR. GREEN: So contemporaneous controls are really vital in this sort of data.
DR. HALEY: The question is, in the -- let me just go on and show you the statistics. Here is the main test of the hypothesis using the three brain regions within subjects, term, effect, and the three level case control effect. We have got a three level effect. Syndrome 2 worse than Syndrome 1 and 3, worse than the controls between subjects.
This is highly significant. And what this -- this is highly significant. And the difference is the NAA to creatine ratio and the pon was much higher than in the basal ganglia. There was virtually no difference between the right and left basal ganglia, but the ratio was much higher in the pons. We don't know if that is reasonable because there is so little literature on pontine MRS.
Between subject effect is highly significant. So that and what -- as I will show in a minute, that means that as a group, the cases have lower NAA to creatine ratio than the controls and our hierarchical effects, Syndrome 2 versus 1 and 3 versus the controls also rejected. There is no hypothesis that was rejected.
The interaction term, however is not significant. And this means that this effect is no different in the three brain regions statistically. In other words, you cannot say that this difference is different. In other words, there appears to be just as much evidence in the right basal ganglia, in the left basal ganglia, and the brain stem of this three level difference.
DR. GUILARTE: I am a little confused about the sensitivity of the technique. Let's suppose that you take a person and you look at the visual cortex. Okay. So we are now looking at the visual cortex with our eyes closed and you get these ratios. And then you expose the same person to a scenic view of whatever you want to take.
DR. ZEGER: East Baltimore.
DR. GUILARTE: Of East Baltimore. Thank you.
DR. HALEY: Shocking.
DR. GUILARTE: What happens to these?
DR. HALEY: Nothing. Now functional MRIs --
DR. GUILARTE: Is that right?
DR. HALEY: Yes, absolutely. Functional MRI will change dramatically, it will change the blood flow, but these do not change. Let me tell you, there is a huge literature on this. In behavioral states and they don't change this.
DR. GUILARTE: If you do a PET scan, you do -- you still see increased metabolism, glucose -- the creatine, isn't it function of energy metabolism? Isn't creatine a function of energy metabolism?
DR. HALEY: Yes. I am telling you there is a huge literature.
DR. SPENCER: A trick we use in toxicology is to incorporate positive control. It demonstrates to the investigator, who might not have used this particular technique before, he is able definitively to demonstrate the expected findings that are reported elsewhere.
Have you been able to incorporate a positive control here, are you able to show us that, in fact, your group was able to obtain the expected findings in cases of Huntington's or Parkinson's, et cetera, because your data would be far more competitive.
DR. HALEY: Good point because yes, we have had -- these studies were done contemporaneous with this on epilepsy, this manuscript is being submitted now. And they were able to see the same changes in temporal lobe of epilepsy patients as we are seeing here.
DR. SPENCER: But your focus is on basal ganglia. Are you able to show us something from -- what Huntington looks like, for example?
DR. HALEY: I don't think we have a Huntington's case in our --
DR. SPENCER: You see my point though?
DR. HALEY: Sure. Good point. See what we are proposing -- remember the context of this. We are saying we have got a strong -- we have raised a strong finding here. We are proposing a random sample of the deployed and the non-deployed and some Parkinson's we will throw in to do that as the next step.
What we have got here is a very strong thing that is waiting to be replicated. And let me show you the -- now we look at the six members of the replication sample. These are people with Syndrome 2 we found in our Dallas VA population. And a list of them were studied knowing nothing about what their brain findings should be on the MRI or anything else.
The same thing, the subject specs, difference in the brain regions, the brain stem was higher than the two basal ganglia. The replication sample we rejected are just two level effect at .0025. And the interaction term was closer to being significant. We actually had less -- borderline less of an effect in the pons than we had in the basal ganglia. The basal ganglia findings were extremely strong here. And I am going to show you that.
Okay. Now let's look at the actual ratios and means. NAA to creatine ration in the basal ganglia. Here right -- a left versus right. So this is the left basal ganglia right, the cross hatch is left and the syndromes is right. Here are the controls, Syndrome 1, 2, and 3 and the replication sample of Syndrome 2.
And what we see is there is a difference, but not significant between the right and the left. And then Syndrome 1 is not significantly different by itself. Syndrome 2 is highly significant and different by itself. The right tends to be more reduced than the left and there is more variance in the cases on the left.
DR. ZEGER: Are those standard errors or standard deviations?
DR. HALEY: Standard errors. It should be on the side and it is not.
And Syndrome 3 is not different. Actually to the right the pointed estimate is different, but no significant difference. So you can see why we rejected the hypothesis. It is primarily Syndrome 2 that has a dramatic reduction here. Syndrome 1, you wouldn't call this by itself, but given that we had a hypothesis, that is what we are entering. Syndrome 3 didn't really help out much in the basal ganglia.
But the replication sample was also you would reject this. Each one of these would be significant by itself. So we have a very strong corroboration of our Syndrome 2 effect in the right basal -- in the basal ganglia. Bilateral.
Also, in this, we actually did a repeated analysis variance with this with the right versus left hemisphere as the within subjects. And it was not significant. So there is insufficient evidence to say the right and the left are impaired to a different degree. Okay. Now they appear to be a little bit different here, but statistically there is not enough evidence to say the right is more impaired than the left.
Now again, just to show you that is really what we are measuring, these ratios in all the cases and in all the controls. Now look at the pons. Here is the controls. Syndrome 1 is no different, cold negative. But look, Syndromes 2 and 3 are both significantly depressed from the controls.
Now remember in the last slide like this, I showed you that Syndrome 1 was like Syndrome 2 -- it tended to be like Syndrome 2 in the basal ganglia. Here in the brain stem, 3 appears to be like 2 and the replication sample is dead on.
So this suggests that 2 -- Syndrome 2 has damage in both basal ganglia and the brain stem, and the evidence is very strong for that. Syndrome 1 appears to have damage in the basal ganglia only in its very subtle -- and we may not be able to detect it with this sample size, but it is close. But it is suggestive. But there is nothing in the pons wrong with Syndrome 2.
Syndrome 3 is just the opposite. There is something wrong in the brain stem in the pons, but definitely not in the basal ganglia. So we think what we have got is the reason for the difference in symptoms is there is a difference in the regional brain pathology that Syndrome 2, the bad one, has damage to both the basal ganglia and the brain stem. Syndrome 1 is mild damage in only the basal ganglia. And Syndrome 3 is mild damage only in the pons.
Now notably absent from this are two structures that we have not entered yet, although we have done it now. We are getting ready to start analyzing it. We don't have the thalamus. We think Syndrome 3 is going to have also damage to the thalamus, accounting for the pain component. Also, we don't have the hippocampus.
DR. GREEN: Sorry. It is the old internist again.
DR. HALEY: Good. Good.
DR. GREEN: And the other thing we don't have is the patient. And one of the things that would be very helpful to put up in the presentation, it is trying to correlate clinical findings. If we take your point that the MRS compressed briefing ratios are lowered with neuronal dropout, then it would be helpful to know clinically the extent of impairment in the population that we are looking at.
DR. HALEY: What do these syndromes have in common that --
DR. GREEN: What is the neurologic exam for these folks and what are their competent medicines or where are they that they were taken off of the study because if, for instance, we see -- for instance, it is very easy on an MRI to see advanced Alzheimer's disease. And it is definitely difficult to see it when people first become concerned about it.
And one of the concerns here is that in trying to make a correlation between do we have a clinically apparent degree of neuronal dysfunction that you are conferring by this technique or are we looking at it at a very early stage of the disease. And just knowing what the clinical findings are would be very helpful.
DR. HALEY: That suggests a further analysis. And there is some analysis looking at trying to relate specific objective clinical measures with NAA and creatine changes.
DR. GREEN: Yes.
DR. HALEY: We have not done that yet, but that is a good idea. We are looking at symptomatology.
DR. GREEN: Reanalyzing the groups with regard to depression.
DR. HALEY: Basically what -- your point is a good one. What would be interesting that we have is throw away our central groupings and just look at the veterans and look at all of our cases as a series and try to relate the level and geographical distribution of NAA to creatine defect with the symptomatology and see if certain areas would be related to certain symptoms. That was a very good point. We hadn't even ventured into that.
DR. GUILARTE: Are you planning to use imaging methodologies? For example, PET because one of the suggestions that you are making is actually structural markers. You may not be able to -- obviously, you can't pick up with an MRI because an MRI is a normal.
So there is structural markers using PET that you can use to define structural loss. For example, Parkinson's disease prior to symptomatology you can pick up a dramatic loss and then compare the neurons in the basal ganglia. It would be a good test. And that is the structural marker. You are actually looking at this loss of neurons. So the question is, here you are looking at chemistry, but are you going to use a structural marker to see whether you do see that neuro loss?
DR. HALEY: Yes. We have done SPEC scans two years ago, two-and-a-half years ago and last year. So two years apart.
DR. GUILARTE: With what?
DR. HALEY: PAL.
DR. GUILARTE: That is not a structural marker.
DR. HALEY: We have also done MR profusion studies. The three imaging techniques we have done or four imaging techniques, MRI, MRS, SPEC and MR profusion.
DR. GUILARTE: Do you plan to use PET?
DR. HALEY: We don't have a PET. But that would be a good follow-up. Yes.
Okay. Now let's turn now to choline to creatine because that has a very important message for interpreting the NAA. The question is the choline/creatine up or is the choline/creatine down or is it no different?
In the basal ganglia, here is the same chart, left and right, the controls, Syndrome 1, 2, and 3, and replication. As you see, there is a slight decrease in Syndrome 1 in the basal ganglia. No change. Maybe a slight increase on the left, clearly no change in the right in Syndrome 2. Maybe a slight decrease in our replication sample.
In other words, there is no consistent picture. If anything, it is down. So what we have got is a picture in the basal ganglia of reduced NAA to creatine ratio in the hierarchy and a sort of aimless reduction, slight reduction, equivocal in the basal ganglia choline increase.
In the pons, there is a different picture. We got a substantial decrease in choline and creatine in all three syndromes and replication, less apparent here, more apparent here. So what we have now, the summary is this is reduced neuronal function in mass with reduced choline to creatine, which means reduced glial mass or fluction of glial mass, but definitely we don't have an increase in choline to creatine ratio.
Okay. Now let's turn to the psychiatric syndrome. What we did is we did -- we looked -- did an analysis and found, looking at confounded, here is PTSD first. Here are the number with PTSD in each group. None of the controls, none of the Syndrome 1s, two of the Syndrome 2s, none of the Syndrome 3 and two of the replication. Met the criteria, that is a full SCID and CAPS criteria for PTSD. Post-trauma and stress disorder.
Then here we are looking at the association of each of these syndromes with the NAA to creatine reduction and the original sample without control of PTSD. And then controlling for PTSD looking for a reduction in the level of significance if PTSD is the explanation for this.
And you see, there is basically no change except this actually is more strongly -- there is a significant change down here, but down in the replication sample, there could be something down here, but not all of these syndromes do.
CPT MAZZELLA: Doctor, as you said before, none of these patients were on medication at the time of this test?
DR. HALEY: That is correct.
Now looking at alcohol dependence and abuse. Three of eighteen, two of five in Syndrome 1, zero of twelve Syndrome 2, zero/five, zero/6. So oddly there is no compounding down here and actually no compounding here. So alcohol dependence does not explain the findings. The liver functions were all normal.
CPT MAZZELLA: Doctor, were those individuals abstinent of alcohol during the testing?
DR. HALEY: Yes. We have these people in our general clinical research at DCRC. So they live in the hospital on the floor and are under constant. observation. This is a pretty rigorous protocol.
These guys are busy all day and often into the evenings and then the nurses will watch them when they even go out. You know, when they went to smoke -- they did smoke and the nurse will take them out and help them to the landing. These guys were under a very, very thorough watch. Yes.
Okay. Now depression, though, this is interesting. The other two basically don't matter. They become important later, but here is depression. Three of eighteen, two of five -- look -- nine and twelve in Syndrome 2. The majority of our Syndrome 2 have a major depressant disorder. What is this depression. Two of five, four of six and here too.
These are very high rates of major depressant disorder. And when you control more of that, this doesn't change, that changes. So this is overlapping. The effect on NAA is overlapped with our Syndrome 2, not with Syndrome 3, and, yes, it is overlapping with this as well. So the question is, is this just depression we have picked up.
All right. Now let me answer that. What we have is a reduced NAA to creatine ratio, reduced functioning neuron mass, either no change or a reduction in choline to creatine ratio in the basal ganglia and in the brain stem in the Seabees sample, confirmed in the replication sample for Syndrome 2.
We have an increased rate of depression and minimal increase in PTSD in veterans of the Gulf War Syndrome. So the question is, are the spectroscopy findings due to brain injury or are they due to depression?
There is substantial literature, huge literature in at least six studies, and there are several others that are not as good. These are the six best studies, but they all point to the same direction. I have cited these.
Major depressive disorder and bipolar disorder, that is, bipolar disorder is primarily depressive or that is primarily bipolar, both of those have been studied on and off medication. They all show an increased choline to creatine ratio to basal ganglia as the finding in major depressive disorder and mood disorders of all kinds. That is the regular findings. And there is strong agreement in literature.
Never -- in fact, the latest review article by one of these by Renshaw, I believe, makes the statement, "NAA to creatine ratio is never decreased as a result of affective or mood disorders." Now obviously he is saying that in the context of medicine, which you never remember -- always remember to never say always or never.
But to the extent that is true, it has just never been seen in a group difference with a decrease in a creatine ratio. So therefore, our finding is the opposite of what is in the literature for mood disorders. We have decreased in a creatine, which is never found in affective disorders, and we have a normal or reduced choline to creatine ratio. And that is increased in depression.
Therefore, to the extent that our study can make conclusions, our study points to the fact that what is called -- what is clinically major depressive disorder in these veterans is not primary affective disorder, it is probably a secondary depression, secondary to brain injury of the basal ganglia.
Now that is a very strong statement, but these data are very strong, and I think that statement is justified by these data. Now that is true in the Seabees group. Whether it is true overall, needs a random sample survey using these same techniques and the same case definition.
Now what about PTSD? There is one recent study, it is a fascinating study showing a decrease in the creatine ratio in the right hippocampus only. Now the hippocampus is a little nucleus just down from the basal ganglia, if you will. And that is known to be shrunken in some people with Vietnam era PTSD, post traumatic stress disorder.
So they have lost neuronal -- functioning neuronal mass, not necessarily all neurons, but functioning mass in the hippocampus. And choline to creatine is normal to low. So they have the same finding in PTSD as we have, but it is in a different organ. It is in the hippocampus.
Now we have just finished a series reimaging these people with what is called a proton MR spectroscopy using a different protocol -- Dr. Green will know this -- called a DSI protocol. Instead of placing a single voxel, you can cut all the way through the temporal lobes, which includes the hippocampus, and do a checkerboard. You can get a whole bunch of two-dimensional voxels and measure the same things.
And we are going to -- we will know in the next couple of months what is true in the basal -- in the hippocampus of our veterans. Now won't it be interesting if we see some mild abnormality because we don't see any volume lost in the hippocampus.
But wouldn't it be interesting if we saw some abnormalities in the hippocampus. It will raise a very interesting question. Which comes first? Stress causing PTSD and damage to the hippocampus or chemical damage to the hippocampus and the basal ganglia causing PTSD?
DR. GARRITY: A question.
DR. HALEY: Yes.
DR. GARRITY: Did they measure in this study --
DR. HALEY: No.
DR. GARRITY: They did not use -- you are anticipating my question. They did not measure the basal ganglia or the pons.
DR. HALEY: No.
DR. GARRITY: So I mean, one has to make a distinction that the measurement wasn't there so that the absence --
DR. HALEY: Yes, the absence of -- to quote, what is his name, a congressman, "The absence of evidence is not the evidence of absence." Sheay's. Christopher Sheay said that. So yes, you are right. But see, we are going to do that. We are going to image the hippocampus. We have already done it. We are getting ready to analyze it.
Now in conclusion, in Gulf War veterans, Gulf War Syndrome appears to be to be due to neuronal -- functioning -- loss of functioning neuronal mass in the basal ganglia and/or brain stem. In Syndrome 2, both regions are involved; in Syndrome 1, only the basal ganglia, maybe; and in Syndrome 3 only the brain stem.
The increased rates of depression and maybe PTSD are probably the result of basal ganglia injury, rather than primary psychiatric conditions. We believe this follows from the data.
Now one other question that was raised, since we have both decreased NAA and decreased choline, that could be consistent with an increase in creatine. And there is a condition where you can get an increase in creatine. So we looked at that. There are two pieces of evidence that suggest that is not the case.
One is that the decreased NAA/creatine ratio in Syndrome 2 and the decrease -- is in Syndrome 2 and the decreased choline/creatine ratio is primarily in Syndrome 1. So they are in different groups of people, suggesting that they are not due to the denominator.
Second, we did a logistic regression analysis predicting Syndrome 2 versus the controls in the right basal ganglia, where our major finding is. After controlling for creatine, the creatine level, the NAA to creatine ratio remains strongly associated with Syndrome 2, whereas the converse, after controlling for that ration, NAA/creatine ratio, the creatine is not at all associated. So looking in terms of a confounding analysis, the major change is NAA to creatine reduction not creatine increase.
Now again, let me hit you with this. Remember, we have only 26 cases and 20 controls, and our critics have been very -- have been vehemence saying that this is too small a study to mean anything. Well, that came from sixty-three cases and a hundred and eighty-six controls in a unit that was picked because it was like a bunch of other units that Dr. Berg studied back then.
That is the same sample size as you found used in toxic shock in a follow-up case control study, the national AIDS study, the Hantavirus study, the Legionnaires, and a thousand other studies all the same size, all case control studies picked the same way. We are not underestimating the need to replicate, but we also don't think you should underestimate the predictive power of this study, given the way it is done.
All right. We need to move on and then we will have -- we will wrap up because this is going to be pretty quick. And I am sorry I don't have slides on some of this because it was published and the slides were getting too many.
Look in your handout now on the page where we start the genetic study. Let me just put -- I can do this pretty quickly because it is actually pretty simple. All right. On page 9. All right. Now look. There is a general research question here.
Remember for a long time there has been a -- almost an aphorism about why is it that two guys served through the war together, are exposed to the same chemicals supposedly, one of them gets sick and the other one doesn't. And that was used early. In fact, it was common sense. Therefore, it must be stress because one guy is tough and the other guy can't take it.
It is not said exactly that way, but that is basically the implication. And that was one I think early, one of the common sense reasons why this might be stress, but then there were some studies that were confirmed -- that they thought confirmed it.
However, we would like to suggest, as others have suggested -- and I know Dr. Spencer has been actively involved in this area as well -- maybe this was due to one guy is predisposed to getting injury from chemicals, whereas the other guy has a high resistance to chemicals and this might be a genetic trait.
And so there are really two blood enzymes that protect one from organophosphate chemicals. One is butyryl-cholinesterase or BChE, as we often refer to it, or pseudocholinesterase or serum cholinesterase. Those are synonyms that very much confuse this literature.
Now the butyryl-cholinesterase, which has been the most -- most people have been thinking about butyryl-cholinesterase or the serum cholinesterase. It works by scavenging the organophosphate molecules. As soon as they get in their blood, the butyryl-cholinesterase grabs hold of them.
However, it is inactivated in the process of doing this and the level of your butyryl-cholinesterase can vary from day to day. It can drop and then you regenerate it, but you can -- your defense -- this defense can be reduced by exposure.
There are genetic variants, they are called genetic variants -- the term "variant" is specific to this thing. Genetic variants that cause you to have either low levels of this from birth or you can have aberrant molecules that don't function. So you could then be very susceptible. And people who have this, have bad reactions to succinyl choline, it is a drug used in anesthesia.
So this has been studied extensively for more than 50 years. So that is why everybody thought about this initially, "Well, maybe it is a cholinesterase deficiency." We know there are variants, about 5 percent of the population have it. So maybe that is the reason for the Gulf War Syndrome.
Now there is another enzyme, however, called paraoxonase-arylesterase or pon, p-o-n, Pon1, actually. This doesn't scavenge, it destroys. It is the destroyer. It is a hydrolytic enzyme that destroys the chemicals.
So when the chemicals get in your blood, the cholinesterase grabs hold of them, but doesn't destroy them, but the pon comes along and destroys it to harmless breakdown products. And it is not consumed in the process.
So it is a little destruction factory that just whirs away killing this stuff and your blood level of this is constant throughout your life. Actually, there is a very small decline in the very extremes of age. Very extreme. It actually circulates as part of the HDL particle. You know, the good cholesterol particle contains the paraoxonase enzyme.
Now a deficiency of either one of these you could see might make you more susceptible to getting -- letting these -- the sarin nerve gas or the pesticides get through your blood into your brain. We studied cholinesterase early. I did a case control study three years ago in our series and found no difference in cholinesterase variants. We were real hot on that and we disproved that early.
So then we looked in the literature and found paraoxonase or the pon gene in the enzyme system might actually be a better candidate. So we initiated the study as part of our current study. When these guys came in for their scanning and other studies, we drew blood under carefully controlled conditions and shipped it up to the lab of Dr. Bert La Du, whose name you see here on the first slide on page 9.
Bert is the -- he sequenced the gene for paraoxonase and is one of the two leading authorities in the world on this subject, and he agreed to do the test for us blinded. So he did knew -- did not know who was a case or a control.
Now what is important to know is that this pon1 gene has a polymorphism. What that means is there is two different kinds of pon. There is pon-Q and pon-R. And those are due to your genes. You are born with either pon-Q or pon-R or you can have some of both. You can be a homozygotes. You know, have both of your genes for this can be Q or both your genes can be R, in which you have pure Q or pure R in your blood or you can be a heterozygote where you have a little Q and a little R. Okay. And that has been know.
Now what is interesting and what makes this enzyme so important is that pon-Q, the Q form of the enzyme and the R form have different affinities for organophosphates. Pon-R is primarily effective in hydrolyzing common pesticides like parathion that we see in the chemical industry and in the agricultural industry. But it has no effectiveness against sarin and the nerve gas.
On the other hand, Q is very potent against nerve gas, particularly sarin. The highest potency against sarin, intermediate potency against soman, and some potency against diazinon, but none against -- or a very low level against parathion.
So you see that leads us to a hypothesis. If sarin caused the Gulf War Syndrome, pon-Q, but not pon-R, should be lower in the sick veterans than in the well ones. You see, the difference in affinities lead to a hypothesis that can tell us what the ideology was or put us in the ballpark of ideology.
Remember we have been saying for years we will never know whether there was sarin there. We will never know what the cause was because all of that is classified or it wasn't collected. Wrong. The answer is in their stars.
Moreover, since the dose response curves for these -- the more organophosphate you are exposed to, this disease is very steep. That is, you can take a lot of hits with this stuff, but when you get to a certain concentration, then a little tiny increase in concentration makes you real sick. Because of that, small differences in paraoxonase blood levels may make a big difference in susceptibility to disease. So therefore, this is the perfect vehicle to test the ideology.
Okay. Now methods briefly. Twenty-five cases and twenty controls. The same ones here. The one guy we didn't bring because he had cancer. Measure each subject's total paraoxonase and total arylesterase activities. Calculated the paraoxonase/arylesterase activity ratio.
And from that, in a homozygotes, we know all of their activity is Q. Now the Q homozygotes, all their activity is Q. In the R homozygotes, we know all their activities are R. In the heterozygotes, we can use the ratio of these two substrates here to partial out how much is Q and how much is R.
So for every person we now have what is the concentration of Q and what is the concentration of R. And remember, those are genetic traits from birth. Nothing changes them. And we also determined their Q/R genotypes with PCR and genetic analysis so we know actually the genotype as well as the enzyme levels. It turns out, as I will show you in a minute, the genotype was not nearly as important as the enzyme levels.
There are other studies going on in this, and I think they are measuring the genotypes and they are going to miss it. They have got to measure the enzyme levels.
We also measured the BChE, you know, the cholinesterase enzyme levels with the benzoylcholine method, which is less confounded by other influences, determined -- and determined the genetic variants, the phenotypes and the genotypes.
All right. Now let me show you the results. All right. First of all, the two major tests are the paraoxonase -- total paraoxonase test and the total arylesterase. And these are just two enzymes where you measure the activity of the blood against them.
And what you find when you cross-classify all the subjects by these two measures, how much of each of those enzyme activities they have, what you get is a peculiar graph that shows a linear streak here, a big splaying of people in the middle, and a little linear streak out here. This graph has been drawn 50 times in the literature.
There is a huge literature of probably a thousand papers on these enzymes. Huge literature. This graph comes out the same way every time. What is different is, the yellow solid bars are the sick veterans, the cases, and the open green circles are the controls. And you see the disease is not homogeneously distributed.
Specifically, most of the heterozygotes are sick. Now we only have three of these, and remember half of our controls didn't go to the war. These two guys didn't go to the war. We figure if they had gone to the war, they would have been very sick.
But look over here at the homozygotes Qs. Remember the Q is the one that protects from nerve gas. Here there are a few sick ones, but they are all in the lower half of the distribution in terms of activity level. So that makes you think something else is going on.
That is not the main story. That is the graph everybody will draw first. So this -- what we have drawn for the first time -- as far as we know no one else has ever done the actual levels of these enzymes by disease. This is the butyryl-cholinesterase, the old cholinesterase enzyme that we thought of first years ago that is important in anesthesia and we thought would be the key.
Here are the controls. Here is their blood levels of cholinesterase. And look at the cases. No difference. Maybe a little hint out here, but this is four, five, and six. So we will keep that in mind, but no difference. So cholinesterase levels don't make any difference. And we have already shown that variants don't make any -- genetic variants.
Here is the total paraoxonase activity. More sophisticated people will measure this along with the genes. This shows no difference. Actually, if there is any difference, it is actually an inverse. That is, the controls have lower levels than the cases. So there is something funny going on here. Total paraoxonase.
Here is the type R. You know, the one that protects you from common pesticides in the world. No difference. In fact, if anything, an inverse association. So that means that common pesticides probably did not cause this.
And look at Q. The controls were all above 70 except for three interesting exceptions. The Syndrome 2s were profoundly depressed. Syndromes 1 were halfway -- were borderline. Some of them, frankly, low, others borderline. And Syndrome 4, 5, and 6, which we know clinically overlapped with 2, two of them are profoundly low. And this is highly statistically significant or is statistically significant, despite the small sample size.
Now here is a scatterplot. This is the old cholinesterase, which we thought was the problem. Remember, this is the scavenger that grabs it, but doesn't kill it and this is the type Q that kills it, but is not consumed in the process.
When you look vertically, you see what I showed you in that last graph. The type Q -- if you are low in type Q, you are more likely a case, if you are high in type Q, you are more likely a control. But there is also a suggestion maybe there is a cholinesterase effect when you control for type Q. When you have got type Q in the equation, there is also a tendency for the cases to be further over here than the control. See the controls are here and the cases are here.
We think that absolute levels of both of these enzymes are important, but of the two, pon-Q is much more important. Roughly speaking 80/20. Eighty percent of your protection is your pon level, twenty percent is your cholinesterase level. And a profound deficiency in either one can probably do you in.
Interesting. Here is a case very low. This is a homozygote R who also has an extremely elevated level of cholinesterase. We are looking at his genotype. There is something really strange about him. He is a variant of some kind. There are some other variants. These two guys, one of these guys may be a variant too we are thinking.
LTC FRIEDL: Are you concluding a difference in that graph there?
DR. HALEY: I am sorry, what is that?
LTC FRIEDL: Are you concluding a difference between the cases and control?
DR. HALEY: Yes.
DR. GARRITY: Just to visualize, sometimes one's eyes can tell a lot. You have -- you know you have got two controls that are very, very in pon-Q and you have controls that are high. But it looks like this is being driven by a couple of outlines in the -- you know, up in the controls. I mean, I -- you know, overall it doesn't look -- I don't see anything really dramatic there.
DR. HALEY: Tim, that is why you don't do this with the eye, you do it with statistics.
DR. GARRITY: Well, you know, there is -- you know --
DR. HALEY: The eye tells a lie.
DR. ZEGER: I agree.
DR. HALEY: Let me tell you, this is very strong. These days we have got some confounding outlines.
DR. GARRITY: Well, I mean, I was just going to say as to --
DR. HALEY: Okay. Look, these three guys didn't go to the Gulf, right? What do you think would have happened to them if they had gone to the Gulf? If you think common sense wise. They had no pon-Qs, they had no defense of organophosphates. All their brothers that went like that were sick. If they had gone, what do you think would have happened to them? They would have been Syndrome 2s.
DR. GARRITY: I don't know that.
DR. HALEY: I know.
DR. GARRITY: And I don't think you do either.
ADM ZUMWALT: Dr. Haley.
DR. HALEY: Yes, sir?
ADM ZUMWALT: You have got to --
DR. HALEY: Okay. I think that is basically the end. We have also done some replication studies. Okay. Give me two minutes. Let me just go through the replication graphs real quick.
Confirmatory factor analysis in our VA populations. What we did is this was the exploratory factor analysis that I talked to you about in our Seabees group. That was the statistical validation I told you to show you that those are appealing looking factor studies, but that doesn't prove that they are really good.
Clinical validation, though, we have now studied these syndromes in extensive clinical work. We have now very strong clinical validation. The Syndrome 2 -- unemployment is higher in the syndromes, with 2 being worse than 1 and 3, worse than the controls. The Halstead Impairment Index of brain impairment is highest in Syndromes 2 and 3, higher than 1 and higher in the controls.
Vertigo vestibular ataxia is more common in the syndromes, most common in Syndrome 2, next in Syndrome 1, next in 3 at the controls. Audiovestibular tests, the ENG measurements of ocular motility, pursuit, all these ocular tests were worse in Syndrome 2, less -- worse than 1 and 3 and worse than the controls. Both potentials are more abnormal in the syndromes.
Clinical neurological exams showed only slight reduction in lower extremity weakness. The only thing on the neurological exam. Otherwise it is choline. T1 and T2 MRI of the brain showed no lesions. MR spectroscopy shows low NAA/creatine and low to normal choline/creatine in the basal ganglia and the pons. Worse in 2, intervene in 1 and 3 than the controls.
Visual reading of our -- initial visual reading of our HMPAO SPECT scans showed no gross cerebral blood flow abnormalities. However, analysis by statistical parametric mapping, the first run, show significant differences in blood flow between the cases and controls that vary by syndrome in the same -- possibly the same orders. And our first run at MR profusion shows slower filling. And I forgot the name of the statistic, but more abnormality in the basal ganglia by that test as well.
Now let me show you -- the others have done this. The CDC group, Fukuda and all, did a case control study contemporaneous with ours back in early '95. They were doing this on the Air Force reservists the same time we did. Here are my factors 1, 2, and 3, and here is Fukuda's factors, 1 and 2.
Notice Syndrome 1, these are variables we measured in common. These measured low to high on our Syndrome 1, low to high on his Syndrome 1. These load low on 2 and 3 and they load low here. Syndrome 3, these load high on our Syndrome 3, the others don't. And not on the other two. These same ones load high on his 3.
So his 1 and our 3. Our 1 and 3 are the same as his 1 and 2. He did not measure any of the variables that would have gone into detecting Syndrome 2. We believe this is confirmation of our factor analysis portion.
The Simon Wessley group in England on a DOD grant, attempted to do the same thing. And the produced what they call the Haley Model. However, this is not the Haley Model. And they say they were unable to fit this to their population. They measured, however, only 11 of our 23 strongly loaded symptoms.
Five of Wessley's -- he had seventeen in his model. Five of them were extraneous not included in our model. He omitted four of the five most important symptoms. The five highest loading symptoms on factor two and only four of them were not in his model.
Five of his eight symptoms that were used to detect our Syndrome 2 were not in my model. In other words, his Syndrome 2 had five levels that we didn't even measure. It had nothing to do with ours. So his claim -- let's see. There is more to it.
Three symptoms were listed ambiguously. He used headaches, he had headaches. We had all those secondary things to look to migraine headaches. Well, those are two different symptoms. In that instance, he has failed to disentangle crucial ambiguities and terminology like fatigue meaning sleepiness versus weakness. He just looked at fatigue. Three symptoms calculated. He actually loaded -- three of our syndromes were loaded on the wrong factor.
So the point is, this is a very sloppy job. I don't know how it got in Lancet, but it did. It should be retracted. We have written a letter to the editor and it is pending. So there is some hot contention here.
We don't have time, Kelly, let's move on because we have got to finish this, and I promised five minutes.
Now what we did is we readministered our questionnaires to 336. We put out ads to bring them in, sent out a letter to everybody who was in the Gulf War clinic at the Dallas VA who had been through for the Gulf War exam. A hundred and twenty-three of these three hundred and thirty-six or a third of them we did just before our papers came out. We hustled to get it done so that it would be uncontaminated by publicity.
Two hundred were then done later. We did -- we calculated the six syndrome factors for each veteran using the hierarchical symptom and syndrome factor weights to arrive at our regional factor analysis. So we just calculated the weights, we didn't redo the factor analysis. We didn't do a reexploratory analysis.
Here are the results. The distributions of the six syndrome factor scales -- remember what we dichotomized -- were similar to those we found in the Seabees. Let me show you. Remember this diagram. Those are the distributions. Here it is in the original Seabee sample and there it is in the Dallas VA sample.
ADM ZUMWALT: We have to got to get --
DR. HALEY: Okay. All right. Sorry. It is too long here. The three primary syndromes they were expressed as structural equations. We did confirmatory factor analysis and found an excellent fit to the replication data. The correct statistic is that one, .95. Anything over .90 is acceptable or the further above .90 the better.
Then there is other statistic .93. This is an excellent fit by confirmatory factor analysis. And then we also did fit it separately to the one studied before and after the publicity over our papers. And we found the fit before was .93 and the fit after .96. There was no difference in the fit -- goodness and fit of those two things.
So we believe that this has a variance over the publicity issue that is a strong confirmatory factor analysis. So in other words, when it is done right, we can confirm it. Okay. And I think that is about it. Let me just see. So summary of the replication findings, and I think that is it. So what we are saying is we need to do a replication.
ADM ZUMWALT: The Johns Hopkins people. Let's start with them. What I would like to ask is that the outside experts give us in writing their views of the work that has been done to date and the proposal for future work. But if you have a quick summary to your comments --
DR. SAMET: Well, I will perhaps go first. First, let me make the contrast -- and I congratulate you on a real tour de force of presentation. You outdid Ross Perot.
DR. HALEY: A lot of charts.
DR. SAMET: Yes. I think the contrast I would make to the infectious disease episodes is that those were specific clinical pictures Hantavirus or Legionnaires disease are single agents. It appeared as a much tougher problem. It is a very heterogenous poorly specified clinical picture. A potential myriad of causal agents, some of which, as you point out, may in fact work together for one or more syndromes.
So the analogy is nice, but a small sample size is still a small sample size. And my own conservatism says that when I see a small sample size and very strong findings, the first thing I do is I say, "What might be wrong?" And I know there has been a lot of what might be wrong.
And I know in writing, you have tried to deal with the critics and you were talking about biases that may be there and one can't really get a hold on. And saying that you don't think the bias is not the source of the problem does not mean that the bias is not the problem.
And there are a couple of warnings, and these are just comments, I think, to the Board. The warnings to me are that when we find very strong associations, yet the exposure measures are likely surrogates for something else -- wearing a flea collar, where were you, how often did you put on insecticide -- that is an indication of potential contact with perhaps some or one or more causal agents. But yet you have something that you have measured that there are errors, a surrogate for something else.
But still these extraordinarily strong findings are emerging. So I think in that setting, I would feel, you know, in my own calculus uncomfortable in setting aside some of the usual things that epidemiologists mumble about like was this the right control series. And that is one of those intangibles that can be debated forever and no point in doing that.
And the other is, I think, the potential for information bias. I am always concerned when we ask people to tell us about their symptoms and at the same time tell us about their exposures. And, in fact, it doesn't take too much bias in the reporting of both to lead to fairly inflated relative risk estimates.
And I think those are the sort of general mythologic concerns that I think people have tried to set aside. You have tried to set aside the alternative ways of formulating control groups and so on. But I think we are stuck with that. Which then I think speaks basically for the need for replication and possibly fully independent replications.
I mean, I think at this point, as I read this large stack of papers and letters to the editors, you are pretty well tied into a position, there seem to be critics who are pretty well tied into their position. And the usual way out of such a situation is, you know, for independent replication that might even extend to, you know, validation and reanalysis of your data because these are very complex, large data sets.
And again, when I hear about analysis of complex, large data sets, I am always concerned about how things arrived in a particular table, you know, how you as your sort through myriad associations picked out the ones you wanted to tell the world about.
And as you, you know, it gets very exciting as you go down the path of a particular hypothesis to start finding the evidence there. So it seems to me that there is some need, at least, for a little retrenchment, maybe thinking about whether someone else needs to go through the same body of data you have, which has been collected with a great deal of difficulty, and see what else comes out.
I think there is a need for replication in other samples. And if studies such as the Iowa study could prove informative, then I think those really should be sought. But what it seems to me you have done, and I think you have done this with remarkable energy, is sort of telescoped a lot of moving from observations and hypothesis formulations to thinking about mechanisms that might underlie those hypotheses to looking for causal agents.
And now it sounds like even moving on to treatment. And, you know, I know, there is a real urgency here that is generated by the many people who are sick and looking for answers. But it all seems too fast to me. And I wonder if there is not, you know, really a need for, you know, for more formal replication. And I think that has to -- from the sound of the situation, it may involve other investigators.
If you were to move forward, and I don't know how you maintain oversight for your projects, but certainly, you know, external advisory boards -- I chaired the Iowa study external advisory board. And I think that board proved very useful to those investigators in terms of providing independent oversight as the project was formulated. But I think those kinds of mechanisms are needed.
And just maybe one, one very last general comment. I am involved elsewhere in perhaps an equally controversial area, the issue of particulate air pollution and its health effects. And I chair the National Research Council's committee that is broadly setting an agenda for research on particulate matter trying to address a whole sequence of scientific uncertainties across the whole spectrum.
And I don't know much about how research is coordinated. I am sure there is many interagency task forces and so on. And, you know, again to the extent that this board can assure that the coordination is going on that will lead to, you know, proper, you know replication and testing of hypotheses and different data sets, I think that would be valuable.
Now remember -- I mean, for example, we didn't say that smoking caused lung cancer after the first lung was studied. You know, around the sixth, seventh, eighth, there was getting to be a lot of suspension. And then there were some cohort studies. And then we went back and said, "Yes, benzopirate is there," and so on. But it, you know, it took a while and it took longer than what is happening now. But remember, very small case control studies there too were informative, but it was an extraordinarily powerful agent.
So these are really general comments. I have read the papers, I have, you know, seen the exchanges around some of the technical details of the work and I don't particularly want to enter into that debate. It seems to me that the most important issues, in terms of moving forward is a somewhat different point of discussion.
ADM ZUMWALT: Thank you very much.
Are there any other comments?
DR. ZEGER: Sure. I would like to say just a few things. First, I also would like to offer my congratulations. I have not seen this work until this packet was sent to us and it has been a really relatively short period of time and you have accomplished an amazing amount.
Science is a little bit like the law, like the criminal law, in that some people are very good as investigators, as people who find clues and gather evidence and at the first phase of an investigation there is a lot of clue gathering, evidence gathering, and that is what you have been doing. You have been scurrying around, you have some hypotheses, you have been gathering lots of information.
And then it tends to shift into the phase of a more formal evaluation of the judge and a jury and a criticism of the evidence as it was collected and presented in discussion. And I think we are beginning to shift into that phase, but very much as a result of the kind of evidence that you have been bringing forward.
I, with my colleague Dr. Samet, agree that when you get into the judge and jury end of the story, it is important to have independent investigators. Not the same people who bring the case forward, but different people who evaluate the case. And I would also very strongly agree that in addition to the work that you should continue, others should independently investigate this with different points of view and different approaches, slightly different approaches to the problem.
Let me go back to your original connections to the CDC model. I absolutely agree that the case control approach to this problem is the right approach, that the cohort studies will never be informative at this exploratory phase in the way that the case control studies can be. And so I congratulate you for taking a small case control study as far as you have.
With respect to the definition of the three syndromes on which you have focused, I worry that you are beginning to reify these syndromes. You started calling them diseases. And it is always the case with factor analysis.
That is why it is largely suspected among quantitative scientists that while it is a useful measure -- a useful technology to summarize multi-variant data, people tend to start treating those factors as if they are real entities, the physical underlying entities. And they are, but they are collections of symptoms, which tend to hang together.
they are extremely useful as such, and you have obviously made a lot of use of them, effective use of them and you will continue to do so, but I warn you against the implication. It is one of the most important scientific sins.
In looking at that work, it is clear to me, as a reader, that these are real clusters of symptoms, that they have -- that they are important and useful in your initial work, but I would hope that ultimately what risk factors we identify don't depend too critically on specific definitions of those clusters, that so long as you get them roughly right, you get about the right answer because you and I both know that the exact definitions of those clusters have a large arbitrary component to them, as they should in any reduction technology.
I think your paper on neuropsych measures correlating with the symptom clusters makes a lot of sense. I would have expected that, and I am glad to see that it is the case. I would say that one danger of having summaries, the three symptoms -- the three syndrome measures, is that you may -- that those syndromes may make a lot of sense to describe the symptoms, but they may not be as useful to describe how the symptoms relate to other variables.
And so I, as I went along, wouldn't forget that those -- that there are individual symptoms contributing to those syndromes. I mean, you might want to look at how the individual symptoms relate to the neuropsych measures or risk factors or other things as you go forward.
I was particularly impressed by your effort to make specific these symptoms. You, I think, went beyond what many people have done. Very good studies, but went beyond by creating more specific subscales. And I think that does make a difference and can be helpful, as it seems to have been for you.
I am going to go just to the exposure analysis. The case control methodology is the right way to get at the exposure. I don't think large studies where we try to reconstruct the exposure to the tens of thousands or hundreds of veterans is feasible. It has proven impossible. On the other hand, gathering information like you have from the veterans and hopefully confirming that information from other sources at DOD is the way to go.
I am concerned, however, with two things. One John has already mentioned, the recall bias issue, which I know, you know, you can't do a lot about, but it is an issue. And secondly, I am concerned about how many risk factors we looked at.
For example, you showed us that if you were in a particular sector on a particular day, your risk was much higher. Now there were lots of sectors and lots of days. So if I just make a quick computation, there are probably thousands of sectors days you could have looked at.
If you give me 23 cases and controls, I will find multiple sets per days where you get relative risks big by chance alone. And so that becomes a big issue. And the best way to address it -- I mean, I would say you are, as you are the explorer here and you have found lots of hypotheses. Now what we need are the judge and jury to come behind, do independent evaluations, and to test your hypotheses on new sets of data.
I think in the end it is going to be best for the vets if we have independent people replicating your findings and best for you as well because ultimately it is what is going to make your findings stand up or not. If you are the only one pushing them, no one will believe them. If other people confirm them, it will be well believed. So I think those are my main comments.
DR. GUILARTE: I also want to congratulate you with the tremendous amount of work that you had a few minutes to lead. I don't have too many other comments from the ones that they have already made. I confirm some of the ones that have been stated already.
I think the ones that I would like to address primarily are the ones in the new data you presented from the imaging studies. And I would just like to put a word of caution in how these results are viewed. I think you are already making a connection of the changes in these ratios to neuronal norms. And I think it would be important to confirm that there is in fact neuronal norms by other techniques.
And I think particularly positron emission tomography would be very useful. I understand that you don't have it in your facility, but I think that would be a very useful approach that may be -- help to confirm or not confirm the facts that you made in your results.
I think it is an interesting question whether there may be neuronal changes in the functional activity in these brain areas, but I also think it would be important to understand whether actual neuronal loss has taken place. So I think, however, there should be a little bit of caution about interpreting the results from the proton MRI that you have presented today.
ADM ZUMWALT: Dr. Green.
DR. GREEN: Well, I think that I might be the fourth person to congratulate you for doing a very hard job at hypothesis finding and bringing together a great deal of disparate data into a cogent, configurant way.
I think that if I take everyone's comments, I perhaps would also agree that science carries with it -- as Medewar said, "Science carries with it the responsibility for providing truth." And I think without that, of course, it is merely sciencetism and it is very hard to contribute.
And I think part of the congratulations is genuine because you have provided some proofs, you have looked for proofs in the data set, whether limited or not, of your hypothesis, and I think you have certainly laid some ground work for going forward.
And at the same time, I have to say that there is also, inherent in scientific methodology, the need for replication by independent groups and the need for replication on other data sources. And I think if your work can be extended to those, a great deal will have been accomplished.
One of the issue that has come up, and I think it comes up often in technology, is that we tend to look at surrogate measures. The imaging data, which I agree with you is fascinating, I spend a fair amount of time looking at images, and I tend to think that you have found something significant in this special population.
It is still surrogate data and we are always faced with that when we have a new technology. And the question is, if this reflects neuronal loss or decrease in neuronal function, what is the clinical significance. What does it mean to the person.
And I think it is important to go back at all times to the patient population and characteristics and, as we were talking about it, really keep in mind the patient, their symptoms, what we have under a logic exam, and it really is important to try to correlate these surrogates with the underlying clinical disorder and keep the patient in mind.
There is, I think, an opportunity in your data set to try to develop perhaps some more fruit by doing this. In fact, even in your last two presentations, looking at the isoenzymes, it would be very interesting to look at the individual data points and plot enzyme activity versus the N-acetyl-aspartate to creatine ratios and see whether in those groups on an individual by individual basis there is confirmation of the two hypotheses, which seems to point in the same direction.
But looking for internal consistency in the data sets would certainly be helpful and might provide some interesting additional information. The need for appropriate controls often comes up and rely on surrogate like imaging, PET for instance, or the MRS. And we have to take particular care to use appropriate controls.
While I take your point about the depression data in the MRS findings in unipolar and bipolar disease, it is not clear that bipolar disease would be the right control for this population. And since I don't know their clinical status -- it would be helpful to look at depression. And I am particularly sensitive, since we have certainly found in PET studies, that clinical depression certainly can have an impact upon the sort of data that we are looking at.
And the last comment, perhaps, I would make is that it harps back to this morning, but there was a comment about the peer review process. And I am not familiar about the specific issues that you were raising, but I think that many of us who really try to support the role of government supported new technology, the technology transfer process in general, the peer review process is really a cornerstone of that.
And I take the comment this morning as something of a joke, I assume, that in fact the peer review process, which is unbiased, serves everybody's interest. And myself certainly inferred nothing to show that in this case that hasn't occurred and will continue to occur.
And that certainly the work that you have presented, the resources that you have gotten, would be well served to continue to be presented for peer review, as you mentioned, both in publication as well as ongoing grants.
It is important work and we all get rebuffed occasionally, but certainly in terms of maintaining level playing fields, in terms of setting priorities and maintaining quality, it is a vital part of the scientific community. And I would just say that to the extent it could be supported by the committee's actions here, that would certainly support the overall goals that we are all here for, I think. Thank you.
RADM STEINMAN: I would like to thank all of you for your comments.
DR. LIN: Thank you for your enthusiasm and your energetic presentation. I believe my role here is to comment on the ethical conduct of your science, ethical conduct of your research. Most of us here believe -- I think most of us believe that science should not be too far away from ethics. As a matter of fact, good ethics produce good science because the data is validated and is reliable.
And I was comforted to here that most of your protocol have gone through IRB review and you have obtained informed consent. I would encourage, if in the future whoever the funding source is or the peer review process, to have evidence of IRB review and to have evidence -- and have opportunity to review specific informed consent.
I think the Gulf War veterans already gone through difficulty and to add something -- more burden while they are participating in research, we need to be more careful and mindful about that.
I also see you in the future you are going to be doing rat studies, animal studies, and even a national -- big national survey. I think the future funding component and peer review process should look into the animal ethical committee review evidence and the human subject ethics committee's review evidence more close. And that is my comments.
ADM ZUMWALT: Thank you. I know that some of these gentleman have a time problem. I will give you a chance to speak at this point. I thank you so much for your participation.
Dr. Spencer, you have some comments to make?
DR. SPENCER: No, I decline. Thank you.
ADM ZUMWALT: Let's go down the line.
CPT GRAY: No, I think I will pass.
DR. BRIX: Yes, I have a couple of questions. When Dr. Haley gave the results of the enzyme study, occasions of it, one of the conclusions for the enzyme study is that of the chemical exposures document in the Gulf War, sarin exposure would best explain the findings.
Dr. Haley, I have read your paper and I know that you looked at the relationship between enzyme levels and PB. I did not find anything in the paper that referred to the enzyme levels versus pesticides levels, versus sarin or soman or any of the other major exposures that you talked about in your previous studies, like flea collars and so on. Could you speak to that please.
DR. HALEY: Yes. That doesn't need to be done because it has already been done ad nauseam. The genetic -- the roles of these, the activities of these against all the major pesticides are -- there is a huge literature on it. It doesn't need to be done because it has been done.
DR. BRIX: No, no, no. I know it has been done, for example, on rat experiments. I am asking in your population, in the study group that you looked at that you drew conclusions that sarin exposure would best explain the findings, did you look at the enzyme levels in your subjects versus their reported histories to exposures to chemical nerve agents or pesticides in those particular subjects?
DR. HALEY: I don't really know what you mean because we don't have histories of those. You know, those are not obtainable.
DR. BRIX: You had histories of those. You provided that data to us this morning. You asked them about were they exposed to chemical nerve agents.
DR. HALEY: Oh, I see what you mean.
DR. BRIX: Or did they wear flea collars.
DR. HALEY: Oh, I see what you mean. You mean the risk factors we have.
DR. BRIX: Yes.
DR. HALEY: Yes, we looked at those and they are the same because -- see, you can tell what they are by looking at the -- let's see, look at -- on page 10 look at the bottom right-hand graph on page 10 and that tells you what it is. That tells you, basically, what the relationships are.
In other words, things equal to each other equal to -- you know, things equal to the same thing equal to each other. So in Syndrome 2, you know, it would be pretty hard for that relative risk of eight not to translate into this graph. Do you see what I mean?
DR. BRIX: That is not really what I am asking. I am asking you about your recollection of exposures versus enzyme levels. That is okay. I will ask another question.
I know that the enzyme levels, the pon1 have been looked at in previous studies and a number of chronic diseases are not neurological diseases. How many of your case controls had chronic -- serious chronic diseases like diabetes, history of myocardial infarction, chronic renal disease, and so on?
DR. HALEY: None. Zero.
DR. BRIX: None of them had any of those problems.
DR. HALEY: No.
DR. BRIX: Okay.
DR. HALEY: No, there is a link with Parkinson's. The only link I know with a chronic disease is with Parkinson's and myocardial infarction. None of these people had arthrospartic heart disease. At least, obviously, this clinical.
But a number of them did have, as I mentioned, tremors. This gene -- the only disease actually that this has been associated with is Parkinson's. And it is associated with Parkinson's. I don't know what -- It is not associated with diabetes as far as I know.
DR. BRIX: Yes, it is. There is extensive literature on it?
DR. HALEY: Diabetes?
DR. BRIX: Yes, there is.
DR. HALEY: You are right, there is.
DR. BRIX: I have one last question. You talked very briefly -- I know you were very rushed -- about your replication survey with the 336 Texas-area Gulf War veterans on page 14. One thing that I don't understand is I don't really see how this is a replication study.
The reason I ask that is what you have done here is you have selected ill Gulf War veterans and you have given them the survey you used before. This appears to me to be only one square out of the 2 by 2 table, it doesn't include any healthy Gulf War veterans and it doesn't include any non-deployed veterans.
So what you really have shown again, once again, is that if you select a group of ill Gulf War veterans, some of them will come out on the syndromes that you found before. Could you please speak to that, please.
DR. HALEY: Yes. Actually there were -- about 20 percent of these were well. We encouraged all Gulf War veterans that just as our similar -- our original survey was, there were some well ones in here and they scored very low on the syndromes, of course. They were virtually zero.
This is a replication sample. What you want to know is is the illness profile that we have seen in the Seabees -- well, let me say it this way. The charge that our data are trivial, which is a legitimate charge to bring up, is that we have just overfit this factor analysis to a group of Seabees and this factor structure will not be found in another group of sick people. That is the most important replication question.
Now whether or not these are in the private sector or the civilian sector or the non-deployed group, those are interesting issues, but they are not primary. The primary thing is is this same factor structure in other guys. So we picked a group of just sick guys in the Dallas area who are Gulf War veterans and we fit that thing like a glove.
In fact, it is invariant over the publicity. So we got two subgroups where it is invariant. That is very strong replication. That is the most germane thing. Now you can do 25 other different things if you want to, but they are not nearly as important as this.
DR. BRIX: Well, you actually just -- I thought it was my last question, but here is my -- here is a little bit of a follow-up. You just mentioned that -- something about whether or not these syndromes would exist in the private sector or in non-deployed veterans and so on.
I think you said earlier that the CDC study was sort of a partial replication of your study, that they found basically Syndrome 1 of yours and Syndrome 3 of yours were very similar. Didn't they also find that a fraction of their non-deployed veterans had the same symptoms of Syndrome 1 and Syndrome 3?
DR. HALEY: No. Absolutely not. That has been said, but that is a false statement. It is a misinterpretation, and I talked to Dr. Fukuda about it.
DR. BRIX: Explain it, please.
DR. HALEY: Okay. Here is what they did. They did an exploratory factor analysis of the whole group, basically replicated two of our three and didn't look to the third -- for the number two. Then what they did is they threw away the factor analysis and said, "Okay. Let's put that over on the table. Let's just bring three symptoms out of the air and say this is going to be a case definition."
It has nothing to do with their factor analysis. They just said -- they said a factor -- see, what they did is they said, "Haley's factor model is too complicated to be a case definition. So since we can't do it and we can't think of another reason, hey, out of the air three symptoms."
Now that three symptoms are not their factor analysis. And those three symptoms are highly, highly non-specific. In fact, what was it, 40 percent of their sick guys or 50 percent were -- no, 60 percent of their sick guys met this and 30 percent of their well -- of non-deployed veterans met this.
Well, that is not because they have got a real good case definition, it is because they picked a non-specific definition. So you are going to find that in any group of people because it is non-specific. It has nothing to do with their factor analysis.
And that is a really important distinction. And people who have been talking about this, assuming that this case definition came out of the factor analysis. It didn't. It had nothing to do with it. In fact, one of the three symptoms didn't even factor in their factor analysis.
CPT GRAY: In defense of the CDC, and I have heard your presentation several times, they will say they came up with the same clustering of symptoms by both methodologies. They replicate each other. Therefore they think it is real.
And another argument, I mean, for the non-uniqueness of your symptom patterns is that there are at least three other groups replicating the factor analysis procedures using large populations of not only Gulf War veterans and control populations and they are finding the same clustering of symptoms in both.
We will see -- we have seen the Iowa group paper at a meeting, HPHA will come out in a publication, I assume soon, we have seen Fukuda's work, some of Wessley's work, Han Khang has a work, and our group in San Diego also have a factor analysis work. I mean, to bank all your basis of your theory and all your work on this factor analysis is problematic.
DR. HALEY: Okay. Let me respond to that because you are incorrect.
CPT GRAY: Okay.
DR. HALEY: Their factor -- they did two approaches of factor analysis.
CPT GRAY: Which is which one? Wessley --
DR. HALEY: No, no, no, the CDC Group.
CPT GRAY: CDC. Okay.
DR. HALEY: The CDC group did two factor analyses on the -- they were both exploratory factor. There was not a confirmatory factor analysis. Now they did get the same -- they still got the same factors, but those two methods of factor analysis were not very different. They used -- the second one is a least squares type of factor. Now those are not very different. You don't expect to get very different things.
I originally misread that and thought they -- because they said they did a confirmatory factor analysis. Well, the term "confirmatory factor" and I am sorry our statistician has left. A confirmatory factor analysis in statistics means a structural equations model that you fit to the data. It does not mean a second exploratory factor analysis.
Now they did that and that is fine. It is interesting. But that had nothing to do with their case definition. See, their case definition, they picked -- let's take -- now, let's take -- after we have done this extensive factor analysis, showed that Haley's factors are right, well, let's throw that away and let's go pick three out of the air that almost any group of people in the world is going to have a lot of.
Fatigue, complaining of cognitive problems, and joint aches. Now give me a break. How many people over 40 have all of those in any population? The answer is 40 percent probably. And so they have got 60 percent in this group and 40 -- 30 percent in that group on a meaningless, arbitrary selection of very --
CPT GRAY: Well, it is unfortunate our CDC colleagues are not here to defend their work.
DR. HALEY: Well, I talked to them about it. They agree with me.
CPT GRAY: They have a different view of what they did.
DR. HALEY: Well, I will tell you, it is too bad our statistician wasn't here and had seen that because that -- those two things are not related. And I know you guys like that CDC definition because it is real simple and it shows this is -- that the same thing is true in the civilian population. And that is a mistake.
CPT GRAY: There are teams of scientists that are coming up with similar findings using different populations. You were challenged here to replicate your work. And I am just saying that if -- we are finding the same clustering of symptoms among a population that has never been in the Gulf War.
DR. HALEY: Okay. Look, there is another -- there is a couple of other things that are being glossed over here. Most -- as the statistician commented, one of the most important things we did is we derived unambiguous symptom measures from the ambiguous symptoms. Nobody else has done that. Wessley used -- he basically uses PTSD terminology for his symptoms, which is psychiatric. Okay.
He didn't attempt to define the different kinds of fatigue and, of course, you know, we have done a factor analysis, which is not published yet, but we have done a factor analysis where we used the same kind of symptoms everybody has used. Fatigue, body pain or muscle aches, you know, cognitive problems. And you know what we get? We get two factors. One of them looks like chronic fatigue syndrome, the other one -- in fact, the highest loading thing on the other one is PTSD.
So in other words, when you use ambiguous symptoms, you get ambiguous, mushy syndromes. When you disentangle the ambiguities of the symptoms, then you do it -- what you get is three things that predict brain injury, predict genetic things.
So which one of those do you want? Well, by force of numbers, we have got five studies over here that have done the wrong thing, done the ambiguous thing. But let's see them relate those to measures like this. And they won't relate because there are just too many ambiguous things being mixed in there.
ADM ZUMWALT: Let's move onto the next commentator.
LTC FRIEDL: Yes, sir. Dr. Haley and I have had some nice discussions about his work and I think those will continue. We are talking about how to build incrementally on completed studies and not to reach too far ahead here
Every one of the peer review panels that have reviewed your work have -- you know, it has been very consistent. They say this is a wonderful finding and now if you could just replicate it, this would be of great importance to Gulf War veterans. And that is what we are looking for, I think. And we have had that discussion, and you are developing some protocol along those lines. So replication, I think, is critical.
ADM ZUMWALT: Has that been submitted?
LTC FRIEDL: It has not been submitted yet. We have been discussing it. He is still funded by DOD and we have extended the period of performance. And so our cooperative agreement continues.
ADM ZUMWALT: Good.
LTC FRIEDL: And also there was a comment about human use, and so on, and certainly Dr. Haley is held to all the same rules and regulations that DOD has to ascribe to there. And those are, I think, the highest standards. That is -- if anything goes wrong in human use or lab animal use, that is a show stopper for us. We take that very seriously. And I know -- I am sure Dr. Haley and the University of Texas do too. That is all I have to say.
CPT MAZZELLA: Thank you. I am more a clinician, a researcher. I want to thank my colleagues at the other end of the table for taking up the CDC statistical -- anyway, I was not prepared to, you know, discuss the CDC studies.
There are things, Doctor, that I would like to talk with you about. One is have you maintained contact with your patients even after your studies? And of those people -- and again, you sort of curve from -- if you have people that are either chronically ill with either depression or post-traumatic stress disorder, especially after you have diagnosed them, have they been treated? Have they -- how have they been treated and how have they responded.
I think those would be some fairly interesting findings, especially in light of -- and I have heard the veterans over and over and over again say, "Don't tell me it is in my head." And yet after spending the day with you, I can think of no more complicated area of a person's body than what is between their ears.
And so, you know, this is a fairly important work. And when -- and of course again, as a clinician, we would love to go -- when we have psychiatric cases, what we like to do is rule out the physical first so that we wouldn't be treating, you know, asking somebody how he felt about his mother if, you know, if it was something else going on.
You follow where I am going. So what I found interesting here is that we kind of go from the psychiatric to the physical instead. And I think that perhaps there may be room for more psychiatric work here, especially as -- you know, if you follow some of the literature on psychiatry, the National Alliance for the Mentally Ill, which deals with chronically and persistently mentally ill individuals, believes in his data and is saying that mental illness is a brain disease.
And perhaps at this point, some of your work could lead us to an area that would say that this is not a moral failing that maybe we have gotten sick, but it would still be a mental illness and perhaps destygmitize mental illness. And so there might be some things there that we could look at.
I do think that replication is probably the most critical piece here. And as our colleagues from Johns Hopkins have said, that perhaps independent replication would be essential in this area. Thank you. I have nothing further.
DR. HALEY: Let me respond to that because the replication thing has come up so much and Dr. Friedl and I have talked about this at great length over several -- over a couple of years now almost. What we have proposed is an independent replication, but one that we have a hand in. As we all know, there is a terrific political and ideological war going on, if you will -- I mean, a conflict.
What we feel, it is important for others to replicate this, but to a degree that we would be satisfied with what we did. So as part of our cooperative agreement with the Defense Department, about 400,000 of the $3 million that we received a couple of years ago went to Research Triangle Institute, RTI.
We let a subcontract, with the DOD's blessing, to RTI to study -- to do a study over about 18 months to look at the feasibility of replicating this and a random sample of the deployed and a random sample of the non-deployed.
Research Triangle Institute, RTI as I am sure probably everybody knows who they are, it is the best -- arguably the best survey research firm in the world, do a lot of DOD work, do a lot of surveys of drug abuse in the military, et cetera, et cetera. They are excellent. Excellent samplers, excellent methodologists, excellent survey managers, et cetera.
We have been working with them now intensively over 18 months. We have developed a protocol that I am satisfied with, would thoroughly implement exactly what we have done, you know, an independent sample done by RTI and not be me.
But it is done to my satisfaction so that I know the questionnaires -- what they have done is taken the questionnaires that we developed that this is based on and translated those into computer assisted telephone interview formats so they can now be done with 3,500 randomly selected deployed and 3,500 randomly selected non-deployed, do it efficiently for a real minimal cost, then that will measure the prevalence of these syndromes.
And for that group, big group in the middle that doesn't have the syndromes, but is sick, then the idea is to pick a small appropriately sized subsample that this time won't be called small, it will be called the best powered sample size that we could produce, and bring those cases and controls either to our center or to a third center and repeat the brain imaging in the best hands. And then we see. Is this true or is this not true.
I would be very hesitant to recommend that a military group do this. I wouldn't be confident that it would be done in a way that would -- and not because people would be dishonest or anything, it is just there are strong feelings about this. And where there are strong feelings, I wouldn't trust it.
On the other hand, I wouldn't let it go to -- wouldn't want it to go to another university that was going to thumb their nose at us and say, "Well, you didn't do this right, you know, we can improve on this." And it turns out like Dr. Simon Wessley, it has nothing to do with what we did. Even in the best most -- people with the best intentions, things can go completely awry.
So what we proposed, I think, is the best way to get this replicated by an independent group, but to specifications that we have built into it. So that is what we are going to be discussing with Dr. Friedl.
DR. CAM: Dr. Haley, when would this be ready, the RTI study?
DR. HALEY: We are ready to pull the trigger right now. We would have to do a 200-person pilot study, which would take about, oh, a couple of months. And we need that time to get all the logistics to locate the 7,000 members of the sample.
We could start collecting data in about three months if we led it today. We could start collecting in three months. And it would be done in about six to seven months, the analysis in another three months. And within a year from the time it starts, we will have the answer. Now there would be some additional analyses going on and so forth, but the main answer would be done in 12 months.
ADM ZUMWALT: Next comment.
DR. GARRITY: Yes, thank you, ADM Zumwalt.
First of all, I would like to say to Dr. Haley that indeed his work has stimulated a lot of thinking and a lot of additional research that is sponsored by the Department of Veterans Affairs, it is sponsored by the Department of Defense, is ongoing at university of research locations across the country looking at a number of different aspects of this issue using various imaging techniques.
These research products have been awarded through rigorous peer review processes, and I think it is important to emphasize the importance of competitive peer review. I think, as Dr. Green said, is the cornerstone of science and progress in science. And we must not forget that.
That, you know, sometimes people misunderstand scientists when they watch them argue in a room about this, that, or the other thing and they think that they are really having this bitter argument. When they get done, they walk out and they have a beer down the hall. And that is because science isn't personal, science is objective. If you can't be objective about it, you shouldn't be doing it.
So that is why external, independent peer review is so vital and important in this process. And then to add onto that, as the filter of that which is produced and then moves forward into the open air, if you will, of additional scrutiny, which can lead to replication, variations of study, is peer review in journals and publications in peer review journals.
And Dr. Haley has published in the Journal of the American Medical Association, which is a well renowned journal. And others who have been doing research in this area have published in the Lancet Journal of Medicine, et cetera. These are very good ways to have the work that is being done judged. It is judged by one's scientific peers.
And I want to say lastly that the whole concept of peer review is endorsed by all three departments on the Persian Gulf Veterans Coordinating Board. We took very seriously what the presidential advisory committee told us at the close of their deliberations. And that is that we must -- that all extramural funds that leave the federal government to fund research must undergo the scrutiny of extramural peer review and competitive extramural peer review. And I will say it again, we endorse that wholeheartedly.
ADM ZUMWALT: Mr. Chairman, I think this is a very useful experience for me. It completes my part of the event today. And at this point I know you will want to entertain public questions. So I will turn the meeting back to you and I appreciate the opportunity to get this dialogue out on the record today. We will have this available to us to study in more depth as soon as the staff is able to put it together for us.
MR. BROWN: Well, thank you very much, Admiral. I would just like to say for the record that this has been quite exciting. I am very, very happy to have had an opportunity to participate and listen to the arguments on both sides. And I am also looking forward to the time that the Board itself can get together and kind of take a look at and evaluate some of these very, very difficult complex questions so that we can formulate our recommendation to the President.
At this time, as you know, the Board has an open policy. Everything that we do we try to make sure that our peer review process includes the constituency and the people that have an interest in this issue. And so with that in mind, I would just like anyone here if you have any questions, to feel free to ask them.
MR. SULLIVAN: Thank you, Mr. Secretary.
Dr. Haley, thank you very much for your work. I sound like a broken record here, but the record is clear. The consensus I hear in the room is that more research needs to be done in this area and that my recommendation and the recommendation of the Resource Center would be that not only you continue your work, but because your work has strong merit in our view, that others follow in your footsteps as if you have been an icebreaker.
You know, we would hope that you would want to share more of your information with Gulf War veterans when it is ready to be released to the public because we think the best thing for the Gulf War veterans is to get accurate information out there that can help us. So toward that end, whatever we can do to help your process out, please let us know. That is really not a question, but let us know what we can do to help.
DR. CARDELLA: I am Dr. Cardella. I am a physician, but not an epidemiologist. That is going to show in a minute. I want to ask you to go back to this morning on the case definitions and the criticisms that people have leveled about not enough numbers in developing the case definitions.
You made the analogies the Hantavirus, the toxic shock and the Legionnaires infections. Those are quite different in a number of ways. As pointed out, they have more objective findings and things than things we are talking about.
Wouldn't the analogies of what we are talking about be closer to the case definitions developed for chronic fatigue syndrome and fibromyalgia? They would likely have been done with larger numbers of people. Is that not a --
DR. HALEY: Yes, that is a common fault. And I think it is wrong.
DR. CARDELLA: Okay.
DR. HALEY: Let me -- with all due respect, let me say I think the whole research field of chronic fatigue has led us off into an irrelevant direction. That field of research is dead, it is dying, it is going to go away. It is reduced -- particularly some of the psychiatry work on chronic fatigue syndrome has led us to think this is a psychological reaction.
DR. CARDELLA: Well, I am just talking about the case definition.
DR. HALEY: I know. I know. I think that is part of the problem. See, the case definition begins with the construct of chronic fatigue. Well, what is chronic fatigue? There are many different kinds of chronic fatigue being pathophysiological different things. You know, we made the distinction between sleepiness all day. Some people have chronic fatigue. You say, "Do you have chronic fatigue?"
"Yes, I am sleepy all day." Other people will say, "I am not sleepy at all, but after I work a while, my muscles just feel really weak." Well, you know, those are two different diseases and yet those are all chronic fatigue.
And so chronic fatigue syndrome is probably 35 different things. And as long as we continue to lump them with that non-specific crummy definition, we are never going to learn anything about chronic fatigue, it is going to continue to be a psychological reaction that we treat with psychotherapy and cognitive behavior therapy, which I think is worthless in that.
Actually, it may be good in some people who have chronic fatigue syndrome because they have got depression. That is their cause of chronic fatigue, then psychotherapy, better psychoactive drugs, that would work. But for the other 90 percent of people with chronic fatigue syndrome, they may have a pesticide injury or they have McArdles disease, you know, the primary disease of muscles, dealing with muscles wearing out. There may be all kinds of things.
And one thing is chronic fatigue is an outmoded concept that is quickly going to die we hope. So I think it has been counterproductive not helpful. Now unfortunately, a lot of the funded research right now is using chronic fatigue syndrome case definitions and PTSD case definitions. And I think again that is lumping all kinds of unlike things together and going to lead nowhere, but yet it is trendy, it is in and peer review groups like that. And so that is what is getting funded.
You know, let me comment on the peer review process in response to that. Obviously, we all agree that peer review is necessary, but let me make an important distinction. Peer review in the funding process is not a measure of validity. This has been implied. It is implied a lot by the government groups. It is the best way we know to distribute money. And often it is not a measure of validity.
What it is a measure of is what the scientists on that peer review group, what they think is the right way to go. Well, they may be wrong. Of course, peer review often makes mistakes. So it is not a measure of peer -- measure of validity of the approach. The measure of validity of the approach, the best measure is in the publication process, as Tim pointed out. That is where you determine whether something is valid or not, not in the funding process.
Now people have criticized us, and I know that the letter -- the article that was written in the Washington Post shortly after we got our $3 million grant was criticizing us for going and getting money from the Defense Department after the peer review groups turned us down.
Well, I think we have shown that money well. And all of the papers that we have submitted from that have been published, all one of them, and we are going to submit a bunch and we are going to prove that those things are probably -- are very valid approaches. It is just that they weren't trendy, they weren't what that group wanted.
So the peer review process for distributing money is highly inappropriate, not something that reflects, necessarily, merit. It is just the best way -- the fairest way we have of distributing money. In a political, government sense, you can't do it any other way. But it makes a lot of mistakes.
And we are 0 for 5. We have submitted five grant -- all this was submitted for grant proposals, all of it turned down. It wouldn't have been done had Ross Perot not stepped in and funded us initially and not the Secretary of Defense thought that our work was meritorious and not to fund over the peer review decisions. It is very complicated.
LTC FRIEDL: I have to make a comment on this one. You did get your peer reviewed and you were funded on the basis of your review. We funded the sections of your first grant proposal, the peer review committee had said they were meritorious and deserved an A. And it was on the basis of peer review.
DR. HALEY: I didn't realize that.
LTC FRIEDL: Yes. Absolutely. And SecDef asked for that reading before he made a decision. So this was not outside a peer review process. I just want to correct that.
MR. BROWN: So now you are in love with peer review.
DR. GREEN: Dr. Haley, with due respect, your comment I take it at face value, that a peer review is the fairest way we know to distribute resources.
DR. HALEY: Yes.
DR. GREEN: The rational conclusion from that is that other ways would be less fair. And if -- and you have shown that there are alternatives.
DR. HALEY: Yes.
DR. GREEN: In a plural society, there are other sources of resources and one can go to those as well. But to go outside peer review would in fact -- or to abandon peer review, would be to adopt a less fair system, a less level playing field, and arguably less opportunity to achieve merit in the distribution of resources.
DR. HALEY: Yes, I think we all agree on that. Yes, I would thoroughly agree with you. I think what I am reacting to is there was a lot of criticism of the fact that we got money -- we went out and found money from Perot -- actually, several sources -- to fund our research.
And so people have implied that therefore our research isn't valid. And that has been said. It was said in the Washington Post. And that is not true. Where you get the money and how you get the money doesn't determine whether your approach is valid. Peer review for the publications.
DR. GREEN: And I would hope that you would concur that as that is an unfair comment on the validity of your research. The fact that peer review in this case may not have worked the way you wanted would not necessarily be a measure of whether peer review works.
DR. HALEY: No. And I -- we agree.
MR. BROWN: Are there any other questions?
MS. NICHOLS: Dr. Haley, you mentioned maybe looking at other units located where the symptoms were. How about looking at Fleet Hospital 5. I believe that they were a large medical unit. Navy. I think most of them can be reached because we have contacts with quite a few of them.
The other thing would be looking at units that came from one unit in state side, but ended up in several different locations along the border in three different locations. We got them at KK&C, we had radio operators and MSC officers into Iraq with different units. We had people in Turkey, Spain, Europe, back home. All out of one unit. Okay.
The sizes along the border with the staging facilities were like 30 people each, roughly. Some of that was augmented by other units, other state side locations. The smallest groups would have been the ones into -- with the Army, the liaisons.
So that might be a very big unit to study. They were in different locations, deployed, non-deployed, that kind of thing. That is a very big unit. I have been trying to think of other units, Army, Marines, Navy. That happens to be my unit, but I am trying to think of other units that would have that diversity.
MR. BROWN: Well, if you think of it, please feel free to write to the Board and we will pass it on to Dr. Haley.
MS. NICHOLS: The other thing is, would there be any value at looking at the VA database that has identified diagnosed illnesses, some diagnosed by brain stem damage, possibly, or Wilson's disease and would there be value looking at that and putting those into the study?
DR. HALEY: Let me respond. I think that, yes, those are very -- what you are doing is thinking of interesting -- units where a study might come up with an interesting result. Presumably you can get controls to go along with those. Somebody made the comment earlier that what we need is a bunch of case control studies, similar to what we have done, with a case definition. And one might then search out units like this.
Now our next approach, however, has got to be in a different direction because what we want to do is -- we have got now a well formulated hypothesis. What we want to see is how widely is this true. It is possible that this is the Gulf War Syndrome. Now granted, I am not crazy and I know that it is highly possible it may not be too.
However, this is now sufficiently flushed out that it is ready to be tested in a random sample of deployed and non-deployed. And see if that were to turn out, it would be much more important than an individual unit study. Now if it didn't pan out, what we would want to do is go back to some special units that have special interesting exposures, or whatever, and do some more case control studies around those to try to raise a new hypothesis.
MS. NICHOLS: Or else the 37th Engineers.
DR. HALEY: Sure. Absolutely. Yes. In fact, there is some studies about Kamisiyah ongoing right now. So but I think that is the approach. We think we are ready to go to a real test because if it really pays out, it is a home run. You know, on the other hand, if it is not -- if we don't hit a home run with that, then we are back to doing studies of interesting units, interesting small groups that have particular exposures and ways and other hypothesis and three years from now go for another home run again.
MR. BROWN: Are there any -- okay.
MS. SCHNEIDER: Yes, I just wanted to comment. Thank you very much for the opportunity to be here to come over and to hear Dr. Haley.
My concern is we need to move on with research. It needs to be done and this has been our position for years. But I am very, very heartened by the fact that we are talking in this form and that we are providing insight, constructive criticism and direction.
And I hope we don't get too overwhelmed by all of this that we lose sight of the fact that we need to do research because we have got people out there that are sick and we need to move on and get past go. And I would like, Dr. Haley, your concurrence and assurance that we are going to move quickly, that we are going to move positively with the resources that are available as they are provided to us.
And where we found that the research is corrupt, then we need to change directions and go elsewhere. But we need to make direction, we need to make progress, and we need to get on with it because the troops are waiting for us.
MR. BROWN: Okay. Anyone else?
DR. CAM: Dr. Haley, I understand there is a number of Gulf War veterans who were discharged because of respiratory illness and it was very clear-cut that they were sick. Would you have a chance to go back and get your paper and see whether you observed these kind of problems?
DR. HALEY: Respiratory?
DR. CAM: Yes.
DR. HALEY: Very interesting. I have been interested in that as well.
DR. CAM: If you take a look at the system of that clear-cut symptom, they might have these problems. And that would be interesting to look at.
DR. HALEY: When you look at Han Khang's data, it is very interesting data. Actually, I think it is Greg Gray's data on hospitalization and mortality. You know, it is both of them. You look at the mortality data from Han Khang and the hospitalization from Dr. Gray's large studies, you see that there is a very interesting and statistically significant increase in respiratory disease in the year after the war and an increase in respiratory mortality after the war that both then went way down to below the post-war levels.
I think what is going on there is the -- and, you know, there is a lot of evidence -- there is other evidence from other -- from previous research that suggests that oil well smoke, the hydrocarbons in that, may have sensitized the airway and produced a transient increase in asthma or exacerbation of chronic lung disease.
And that is what I think is the explanation for the dramatic increase in hospitalization that occurred in just -- but it just transient in the year after the war. And I believe that is continued on out. I know the mortality rate is initial and then it came back down.
And so I suspect that was just a transient phenomenon from sensitization, increase in asthma, increase in COBD, a few people died of exacerbation, and then now that has gone away. I don't mean to try and post-hoc interpret the interesting data that they came up with.
MR. BROWN: Yes, ma'am.
MS. NICHOLS: Just a follow-up comment. Being a Gulf War veteran and a nurse, I will tell you that the vets are wanting answers because they see them continuing to deteriorate. So I have got this comment. What I would like to see is some of these studies that have resulted in the findings, that more vets had access to those tests.
Okay. The genetic test that Paris has developed. I don't know if that is the same or different. I haven't -- it is different. That is available commercially. Yours is available or should be soon. Sometime?
DR. HALEY: It is a very complicated research test. Don't do this at home. It is very dangerous.
MS. NICHOLS: Well, I know that earnestness is complicated too. Okay, but science tests need to be made available to these veterans now after there has been research on it. The sooner we move and get some of those tested, it may give us more data. But they cannot afford it.
And we need to do some things like this to help them and help all of us get closer to the answers that we need. And we need to work and make those available. Either we get them down to a system or something.
MR. BROWN: Thank you.
MR. KAPLAN: Thank you, Mr. Secretary.
I thank you all for being here today.
Thank you, Dr. Haley, for an interesting presentation.
I wish you all a safe journey back home and this meeting is now officially closed.
(Whereupon, at 3:30 p.m., the meeting was concluded.)
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