Document 6bZO0BVR400ZVzXZ6rdgapQzd

Ethan A. Natelson, M.D. February 10, 2010 UNITED STATES DISTRICT COURT EASTERN DISTRICT OF LOUISIANA JOYCE BARROIS, ET AL PLAINTIFFS, VS. FIREMAN'S FUND INS. CO., ET AL DEFENDANTS. ) CIVIL ACTION NO: ) 09-380 ) ) SECTION: R ) ) JUDGE: VANCE ) ) MAGISTRATE: KNOWLES Page 1 ********************************************************* ORAL AND VIDEOTAPED DEPOSITION OF ETHAN A. NATELSON, M.D. FEBRUARY 10, 2010 Volume 1 of 1 Volume ********************************************************* ORAL AND VIDEOTAPED DEPOSITION OF ETHAN A. NATELSON, M.D., produced as a witness at the instance of the Plaintiff, and duly sworn, was taken in the above-styled and numbered cause on the 10th of February, 2010, from 1:38 p.m. to 3:09 p.m., before Minnie Cadena, CSR, RPR, RMR, in and for the State of Texas, reported by stenographic method, at the Marriott Hotel, 6580 Fannin Street, Houston, Texas, pursuant to the Federal Rules of Civil Procedure and the provisions stated on the record or attached hereto. PREFERRED LEGAL SERVICES, INC. 214.750.0047 www.preflegal.com 800.405.4056 Ethan A. Natelson, M.D. 1 A P P E A R A N C E S: 2 3 FOR PLAINTIFF: Mr. Eric Williams 4 Williams Law Office, LLC 3000 W. Esplanade Avenue, Suite 200 5 Metairie, Louisiana 70002 (504) 832-9898 6 Eric@amlbenzene.net 7 FOR DEFENDANT BAXTER HEALTHCARE CORPORATION: 8 Mr. Ethan E. Trull Ungaretti & Harris 9 3500 Three First National Plaza Chicago, Illinois 60602-4224 10 (312) 977-4400 Etrull@uhlaw.com 11 12 FOR DEFENDANT FIREMEN'S FUND INSURANCE CO: Mr. Robert Scott 13 Abrams Scott & Bickley, LLP 700 Louisiana, Suite 4000 14 Houston, Texas 77002-2727 (713) 228-6607 15 Rscott@asbtexas.com 16 FOR DEFENDANT FISHER SCIENTIFIC: Mr. Ross Asher 17 Roberts Markel 2800 Post Oak Blvd., 57th Floor 18 Houston, Texas 77056 (713) 840-1666 19 Rasher@robertsmarkel.com 20 ALSO PRESENT: 21 Jim Leonard, Videographer 22 23 24 25 February 10, 2010 Page 2 PREFERRED LEGAL SERVICES, INC. 214.750.0047 www.preflegal.com 800.405.4056 Ethan A. Natelson, M.D. February 10, 2010 1 INDEX 2 Page 3 Appearances 2 Stipulations 4 4 Testimony of ETHAN A. NATELSON, M.D. By Mr. Williams 4 5 By Mr. Scott 36 By Mr. Asher 61 6 FURTHER EXAMINATION By Mr. Williams 65 7 By Mr. Scott 68 By Mr. Asher 71 8 By Mr. Scott 71 Witness' Signature Page 73 9 Reporter's Certificate Pages 74 10 EXHIBITS 11 Page 12 No. A Subpoena to Testify............ 4 No. B Testimony Given by Dr. Ethan 4 13 A. Natelson.................... No. C-1 Original Petition.............. 4 14 No. C-2 Preliminary Trial Witness 4 List........................... 15 No. C-3 June 22, 2007, Letter to 4 Kevin Parks from 16 Dr. Natelson................... No. D Copy of Depo of Dr. 4 17 Natelson, 9/17/07.............. No. E Subpoena to Produce 4 18 Documents...................... No. F E-mail from Kindy to 25 19 Williams....................... No. G Copy of BLOOD Cover............ 42 20 No. H Hematopoietic Malignancies 47 and Related Disorders.......... 21 No. I Chemico-Biological 51 Interactions................... 22 No. J Myelodysplastic/ 56 myeloproliferative neoplasm, 23 unclassifiable................. No. K Invoice........................ 67 24 25 Page 3 PREFERRED LEGAL SERVICES, INC. 214.750.0047 www.preflegal.com 800.405.4056 Ethan A. Natelson, M.D. February 10, 2010 1 (Exhibit A-E were marked.) Page 4 2 THE COURT REPORTER: Will the witness read 3 and sign his deposition? 4 THE WITNESS: Read and sign. 5 THE VIDEOGRAPHER: We're on the record. 01:38 6 The time now is 1:38, Wednesday, February 10, 2010. 7 ETHAN A. NATELSON, M.D., 8 having been first duly sworn, testified as follows: 9 EXAMINATION 10 BY MR. WILLIAMS: 01:39 11 Q. Good evening, Dr. Natelson. Would you please 12 state your full name and address for the record? 13 A. Yes, Ethan A. Natelson, N-A-T-E-L-S-O-N; and my 14 address is 6550 Fannin Street, Suite 1001, Houston, Texas 15 77030. 01:39 16 Q. And, Doctor, I'm going to show you a subpoena; 17 and I want you to tell me whether or not you received a 18 subpoena to appear here today. 19 A. Yes, I did. 20 Q. Okay. And earlier we had an opportunity to go 01:39 21 over some of the documents, and I'll get to that in a 22 minute. 23 Can you briefly tell us your educational 24 background? 25 A. Yes, I went to college at Haverford College 01:39 PREFERRED LEGAL SERVICES, INC. 214.750.0047 www.preflegal.com 800.405.4056 Ethan A. Natelson, M.D. February 10, 2010 1 which is outside Philadelphia and had a bachelor of Page 5 2 science degree; and then in 1962, came to Baylor College 3 of Medicine in Houston where I graduated in 1966 from 4 medical school, getting an M.D. degree. And then I did 5 an internship at the Methodist Hospital from '66 to '67 01:40 6 and then a residency in internal medicine in what were 7 then called Baylor affiliated hospitals, which are the 8 Ben Taub Hospital, the Veterans Hospital and the 9 Methodist Hospital, to a slight extent, St. Luke's 10 Hospital. 01:40 11 Following that, I did a fellowship in 12 hematology at Baylor College of Medicine for one year; 13 and then I was in the service and assigned under what's 14 called the Barry plan to the Wilford Hall Hospital in 15 San Antonio, which is the referral hospital for 01:40 16 hematology for the Air Force or was at that time. And 17 so, I did purely hematology for two years in the service 18 and then came back to join the faculty at Baylor College 19 of Medicine. 20 Q. And you are a hematologist? 01:41 21 A. Yes. 22 Q. Doctor, do you do expert witness work? 23 A. Yes. 24 Q. Earlier you provided me with a list -- 25 MR. WILLIAMS: And we're going to have to 01:41 PREFERRED LEGAL SERVICES, INC. 214.750.0047 www.preflegal.com 800.405.4056 Ethan A. Natelson, M.D. February 10, 2010 1 mark this as B. Page 6 2 Q. (By Mr. Williams) And if you could, tell us 3 how many cases you've identified that you've served as an 4 expert witness. 5 A. This is a record of the cases I've given 01:41 6 testimony in since 1992 to the present, and there are a 7 total of 74 cases. 8 Q. And can you tell me how many of those cases 9 involved myelodysplastic syndrome? 10 A. Yes, ten of those cases did. 01:41 11 Q. And can you tell me how many involved 12 refractory anemia with ringed sideroblast? 13 A. Five of the 10 cases that have to do with MDS. 14 Q. And can you go through the list and identify 15 the name of the case and tell us who you worked for and 01:42 16 tell us what the disease -- as far as the ten we just 17 discussed? 18 A. Yes. 19 MR. SCOTT: Have you marked this as an 20 exhibit? 01:42 21 MR. WILLIAMS: B. 22 A. The first one is No. 22 on this list, which is 23 Donald Ward v. Atlantic Richfield Company; and that was 24 an RARS case. 25 Q. (By Mr. Williams) What date was that? 01:42 PREFERRED LEGAL SERVICES, INC. 214.750.0047 www.preflegal.com 800.405.4056 Ethan A. Natelson, M.D. February 10, 2010 1 A. That would be January 18, 2002. Page 7 2 Q. Could you tell us the next case? 3 A. The next case is No. 24, which is Howard 4 Collins v. American Petrofina; and that case was in May 5 of 2002. 01:42 6 Q. Okay. Could you tell us the next case? 7 A. The next case was No. 35, which is Federico 8 Tagle v. Citgo Refining & Marketing; and that was in 9 October of 2004. 10 Q. And, Doctor, did you work on 30 and 31? Were 01:43 11 they myelodysplastic syndrome cases, too? 12 A. Yes, I thought you were asking me about RARS in 13 particular. 14 Q. I'm asking you about all of them. 15 A. I'm sorry. Yeah, I was looking at them as just 01:43 16 RARS cases. I have them marked here in yellow if they 17 are MDS. 18 So, I mentioned the Ward case; the Collins 19 case. No. 30 is the James Cowey v. Radiator Speciality 20 Company. That was in 2003. 01:43 21 No. 31 was the Ronald Awalt, A-W-A-L-T, v. 22 Applied Energy Services & Company Incorporated; and that 23 was in December of 2003. 24 Then the Tagle case, which I mentioned; and 25 that's in October of 2004. 01:43 PREFERRED LEGAL SERVICES, INC. 214.750.0047 www.preflegal.com 800.405.4056 Ethan A. Natelson, M.D. February 10, 2010 Page 8 1 And then Guy Hamman v. American Oil 2 Company, and that was in July of 2007. That's No. 52 on 3 my list. 4 And then No. 54, Charles Wilson v. 5 Rycoline Products Incorporated. That was in 2007, 01:44 6 9-17-2007. 7 And then No. 62, Connie Lea Gibson Andrews 8 v. United States Steel Company; and that was in August of 9 2008. 10 Then the Bonnie L. Mallory case. That's 01:44 11 No. 68. Bonnie L. Mallory v. The GoodYear Tire & Rubber 12 Company. That was in June of 2009. 13 And then Mary Ellen Hall v. Radiator 14 Specialty Company, which was in January of 2010. 15 Q. And, Doctor, in all ten of those cases, did you 01:45 16 work for the defendants? 17 A. Yes. 18 Q. And in all ten of those cases, did you find 19 that the benzene exposure caused the person's 20 myelodysplastic syndrome? 01:45 21 MR. SCOTT: Object to the form of the 22 question. 23 Q. (By Mr. Williams) Did you find that the benzene 24 exposure caused anyone's myelodysplastic syndrome in 25 those ten cases? 01:45 PREFERRED LEGAL SERVICES, INC. 214.750.0047 www.preflegal.com 800.405.4056 Ethan A. Natelson, M.D. February 10, 2010 1 A. I don't know that they all had to do with Page 9 2 benzene. There may be optional chemicals. Some may have 3 been butadiene. I don't know if they were specifically 4 noted as benzene, but I didn't find that the alleged 5 chemical exposure caused the disease. 01:45 6 Q. Okay. In the case identified as No. 22, Donald 7 Ward v. Atlantic Richfield and Howard Collins v. 8 American Petrofina, in either of those RARS, we can call 9 them, cases, did you find -- did you opine that benzene 10 does not cause RARS in either of those two cases? 01:46 11 A. I don't recall in detail, but I'm sure that 12 that was correct. I don't believe benzene causes RARS; 13 so, that's what I would have said. 14 Q. And when did you formulate that opinion? 15 A. I can't tell you exactly. Probably many years 01:46 16 ago because the original work by Dr. Wintrobe on that, 17 which I've referenced in that article you have, 18 Dr. Wintrobe considered benzene as a cause of RARS and 19 rejected it. So, I think the literature for many years 20 has not suggested RARS can be caused by benzene. 01:46 21 Q. Doctor, would you say that the majority of your 22 cases in the 74 that you have provided were blood 23 malignancy cases? 24 A. I would think the majority are. Some are 25 malpractice cases. Some have to do with residency 01:47 PREFERRED LEGAL SERVICES, INC. 214.750.0047 www.preflegal.com 800.405.4056 Ethan A. Natelson, M.D. February 10, 2010 1 training programs and other things, but the majority Page 10 2 probably are to do with blood diseases. 3 Q. Were you paid as an expert witness in all of 4 these cases? 5 A. Not all of them because some of them, for 01:47 6 example, residency training programs, I wouldn't have 7 been paid; but if they had to do with either testifying 8 in malpractice or testifying in, let's say, a 9 benzene-related issue, yes. 10 Q. And how much do you charge an hour, Doctor? 01:47 11 A. To review records, $250 an hour; and to testify 12 at trial or deposition, $400 an hour. 13 Q. Have you ever opined that a plaintiff's blood 14 malignancy or blood cancer was caused by benzene? 15 A. No. 01:48 16 Q. Have you ever opined or testified that benzene 17 can cause myelodysplastic syndrome? 18 A. Yes. 19 Q. Is myelodysplastic syndrome the same thing as 20 myelodysplasia? 01:48 21 A. Yes. 22 Q. Would you say myelodysplasia, myelodysplastic 23 syndrome, myelodysplastic disorder are all the same 24 thing? 25 A. Well, they are a classification of a group of 01:48 PREFERRED LEGAL SERVICES, INC. 214.750.0047 www.preflegal.com 800.405.4056 Ethan A. Natelson, M.D. February 10, 2010 1 illnesses. Page 11 2 Q. Okay. What level and part per million years is 3 required for benzene to cause myelodysplastic syndrome? 4 MR. SCOTT: Objection, form. 5 A. I don't know that it's known with absolute 01:48 6 certainty. It's very, very high levels. I think in one 7 article I wrote I said, I'd like to see at least higher 8 than 40-part per million years as accumulated dose 9 recognizing that in many instances the levels are not 10 accurately measured. In many other areas of literature, 01:49 11 the 200-part-per-million year accumulated dose is used; 12 but I simply say it's very, very high doses. 13 Q. You think 370-part-per-million year dose is a 14 high dose? 15 A. Yes. 01:49 16 Q. Doctor, I'm going to direct you to an article 17 which is in Exhibit A, if you would flip the pages, 18 please, entitled Benzene Exposure. 19 A. Yes, you have a copy of that. 20 Q. And it's attached to your subpoena. Benzene 01:49 21 Exposure and Refractory Sideroblastic Erythropoiesis. 22 Did you write this article? 23 A. Yes. 24 Q. And can you tell us what journal this is 25 published in? 01:49 PREFERRED LEGAL SERVICES, INC. 214.750.0047 www.preflegal.com 800.405.4056 Ethan A. Natelson, M.D. February 10, 2010 Page 12 1 A. This is in the AMERICAN JOURNAL OF THE MEDICAL 2 SCIENCES. 3 Q. And is there a citation for this article? 4 A. Yes, it was published. It's Volume 334, Year 5 2007, Page 356 to Page 360. 01:50 6 Q. And, Doctor, when did you start working on this 7 article? 8 A. Probably -- let's see. I submitted this, 9 according to the paper, in January of '07. Probably 10 several months prior to that submission date. 01:50 11 Q. Several months prior to January of '07? 12 A. Yes. In other words, it's marked -- on the 13 paper it says, submitted January 16, 2007. And so, 14 therefore, I would likely have worked on it for, perhaps, 15 three, four months or so, at least, before submitting it. 01:50 16 Q. Okay. What process did you go through in 17 submitting this article to the journal? 18 A. Well, I've been interested in sideroblastic 19 anemia for many years, actually, since my training 20 because two of my professors were heavily involved in 01:51 21 studying sideroblastic anemia; and I frequently did bone 22 marrows on those patients and saw them clinically. So, 23 I've been interested in the disease for many years. 24 As I -- as I began to give testimony in 25 benzene-related cases and actually was asked to review 01:51 PREFERRED LEGAL SERVICES, INC. 214.750.0047 www.preflegal.com 800.405.4056 Ethan A. Natelson, M.D. February 10, 2010 1 certain allegations of causation, I realized that this Page 13 2 would be an interesting article to write because, No. 1, 3 I had a lot of background with this illness. I enjoy 4 this illness. I've always wanted to write a paper on the 5 illness, and I have access to a lot of references that 01:51 6 would bear on this question. And so, I thought it would 7 be a good paper to write. 8 Q. Were there any rules for submitting this 9 article to the journal? 10 A. I don't know of exactly what you mean by that. 01:52 11 Most journals -- and today, things have changed. 12 Everything is submitted electronically. But at this 13 point in time, you would type up a manuscript. You would 14 put a cover letter to the editor; and you would say, Dear 15 Editor, this is a manuscript. I'd like to seek 01:52 16 publication in your journal. Here it is, and you would 17 mail it in. 18 And then after some period of time, you 19 would hear something back from the Journal about whether 20 they were interested in publishing it, whether they had 01:52 21 corrections they would like you to make, whether they 22 rejected it and so on. 23 Q. Does this journal, the AMERICAN JOURNAL OF 24 MEDICAL SCIENCES, require disclosing potential conflict 25 of interest at the time you submit the article? 01:52 PREFERRED LEGAL SERVICES, INC. 214.750.0047 www.preflegal.com 800.405.4056 Ethan A. Natelson, M.D. February 10, 2010 Page 14 1 A. Yes, I think all journals would say that, 2 disclose a conflict of interest to that form. 3 Q. At the time you submitted this article, Doctor, 4 were you serving as an expert witness in any benzene 5 cases? 01:53 6 A. I don't know, probably so. 7 Q. At the time you submitted this article, were 8 you serving as an expert witness on any Benzene cases 9 that involved myelodysplastic syndrome? 10 A. I don't know; but possibly so, depending on 01:53 11 what those lists of cases are that we went through. 12 Q. And at the time that you submitted this article 13 in the journal, were you involved in any cases where your 14 opinion was that RARS was not caused by Benzene in the 15 case? 01:53 16 A. Well, I -- as we went through those cases, some 17 of those cases, I think, dated back to 2002 or earlier, 18 long before I wrote this article; and that was my opinion 19 that RARS was not a benzene-related illness. 20 Q. Doctor, I want to show you a petition -- we 01:53 21 have this marked as C-1 to a case, and I believe -- could 22 you read the caption to that case? 23 A. It says: Now comes Charles Wilson and Laura 24 Wilson, hereinafter referred to as Plaintiffs, 25 complaining of Rycoline Products, Inc., Rogersol, Inc. 01:54 PREFERRED LEGAL SERVICES, INC. 214.750.0047 www.preflegal.com 800.405.4056 Ethan A. Natelson, M.D. February 10, 2010 1 Q. I'm sorry, Doctor, the top, the caption, Page 15 2 Charles Wilson v. Rycoline Products. I apologize. 3 A. Charles Wilson and Laura Wilson, Plaintiffs v. 4 Rycoline Products, Inc., Rogersol, Inc., 5 Hostman-Steinberg, Inc., IC Compound Company, Ashland, 01:54 6 Inc., Company Individually, Ashland Oil & Refining 7 Company and Ashland Oil, Inc., Allied Photo Offset Supply 8 Corporation, Day International, Inc., Individually and 9 d/b/a Varn Products, Allied Photo Offsets Supply 10 Corporation; and Lastra American Corporation. 01:54 11 Q. Okay. And, Doctor, can you tell me the date on 12 the top of that petition that it was filed? 13 A. Filed 7-13-2006. 14 MR. WILLIAMS: Okay. We're going to mark 15 that as C-1, Ms. Reporter. 01:54 16 Q. (By Mr. Williams) And that's the case you have 17 listed as No. 54 on your expert summary? 18 A. Yes. 19 Q. Doctor, I'm going to next show you a witness 20 list to the case of Charles Wilson v. Rycoline Products, 01:55 21 and can you tell me if your name is listed as a witness 22 on that case? 23 A. Yes, it is. 24 Q. Okay. And could you tell me what date is on 25 the top of that witness list that it was filed? 01:55 PREFERRED LEGAL SERVICES, INC. 214.750.0047 www.preflegal.com 800.405.4056 Ethan A. Natelson, M.D. February 10, 2010 1 A. It says filed 7-17-2007. Page 16 2 Q. Okay. Do you recall being a witness in this 3 case? 4 A. Vaguely. 5 Q. Okay. And that's marked as C-2. 01:55 6 Next, I'm going to show you a report from 7 that case, Doctor. Can you tell me if you recognize that 8 report? 9 A. Yes, this is a report on my letterhead. 10 Q. Can you tell me the date of that report, 01:55 11 Doctor? 12 A. June 22, 2007. 13 Q. Okay. And, Doctor, on the first page, it is 14 your opinion, the highlighted portion, that there are 15 several names for what we talked about earlier, ringed 01:56 16 sideroblast or RARS? Can you tell me what your opinion 17 is? 18 A. Yes, as I have written here: It is alleged 19 that his hemologic illness of refractory anemia with 20 ringed sideroblast, also known as acquired idiopathic 01:56 21 sideroblastic anemia, sideroachrestic anemia and by the 22 initials RARS and AISA has occurred subsequent to his 23 exposure in the workplace to benzene-containing solvents. 24 Q. And, Doctor, I want to return to Page 4 of the 25 report, you have a highlighted bolded portion. Can you 01:56 PREFERRED LEGAL SERVICES, INC. 214.750.0047 www.preflegal.com 800.405.4056 Ethan A. Natelson, M.D. February 10, 2010 1 read that out loud, please? Page 17 2 A. Yes. In fact, I am not aware of a single 3 epidemiologic study or even an isolated case report in 4 the world's medical literature that shows RARS/AISA to be 5 a consequence of benzene exposure. 01:57 6 Q. And there was a reference number that you have 7 there? 8 A. Yes, No. 14. 9 Q. Can you tell us what No. 14 is? 10 A. That's the article that we've talked about 01:57 11 Benzene Exposure and Refractory Sideroblastic 12 Erythropoiesis: Is There an Association. And that was 13 the AMERICAN JOURNAL OF MEDICAL SCIENCE. At that time, 14 it was in press, in 2007. 15 Q. And "press" means that it's not published yet; 01:57 16 is that correct? 17 A. Well, it often is published on -- E-published. 18 In other words, you can see the article; but the journal 19 hasn't made the streets yet. 20 Q. Okay. Thank you. 01:57 21 Were you paid for preparing that report 22 there, Doctor? 23 A. I'm sure I was. 24 MR. SCOTT: Which exhibit is that? 25 MR. WILLIAMS: That's C-3. 01:58 PREFERRED LEGAL SERVICES, INC. 214.750.0047 www.preflegal.com 800.405.4056 Ethan A. Natelson, M.D. February 10, 2010 Page 18 1 Q. (By Mr. Williams) Were you paid to be an 2 expert in that case, Wilson v. Rycoline Products? 3 A. Yes. 4 Q. Do you remember how much money you were paid in 5 the Wilson case? 01:58 6 A. No. 7 Q. How long does it usually take you to review 8 records and write a report in a case like that? 9 A. It's variable from case to case because some 10 cases have a small amount of information, other cases 01:58 11 have a staggering amount of information. And once I have 12 all of the information together and then I sum up what 13 references I'd like to put into the letter and by the 14 time I go through revisions to the letter and 15 modifications of it, it might be from, starting a letter 01:58 16 to finishing a letter, easily seven or eight, ten hours. 17 Q. Okay. Doctor, I want to show you the next 18 exhibit, Exhibit D, a deposition from the Wilson v. 19 Rycoline Oil Products case; and if you turn the page to 20 the tabbed page. In the deposition are you offering 01:59 21 opinions that benzene does not cause RARS? 22 A. Yes, that's correct. 23 Q. Okay. And if you flip the page, in that 24 deposition, do you also testify that your journal article 25 will be published in November of 2007? 01:59 PREFERRED LEGAL SERVICES, INC. 214.750.0047 www.preflegal.com 800.405.4056 Ethan A. Natelson, M.D. February 10, 2010 1 A. Yes. Page 19 2 Q. And what's the date of that deposition, Doctor? 3 A. 9-17-2007. 4 Q. Were you paid for that deposition in that case, 5 Doctor? 01:59 6 A. I'm sure I was, yes. 7 Q. Okay. Thank you, Doctor. 8 Doctor, I'm now going to show you a 9 subpoena that was issued to the -- David Ploth, the 10 editor of the AMERICAN JOURNAL OF MEDICAL SCIENCES, along 02:00 11 with a copy of your published paper. 12 Have you ever seen that subpoena before? 13 A. No. 14 Q. Do you know who David Ploth is? 15 A. Is his name written? 02:00 16 Q. Ploth, I think I'm mispronouncing, on the front 17 page. David Ploth, I apologize. 18 A. According to this thing, he is the current 19 editor of the AMERICAN JOURNAL OF MEDICAL SCIENCES. 20 Q. Doctor, I'm going to provide you with a copy of 02:01 21 the response that we received. 22 It's a copy of the response that we 23 received from the journal; and if you flip the page, 24 there is a document -- the second page right there. Is 25 that your handwriting, Doctor? 02:01 PREFERRED LEGAL SERVICES, INC. 214.750.0047 www.preflegal.com 800.405.4056 Ethan A. Natelson, M.D. February 10, 2010 1 A. It is. Page 20 2 Q. And can you identify the title of this 3 document? 4 A. It says: Authorship responsibility, financial 5 disclosure and copyright transfer form. 02:01 6 Q. And, Doctor, you filled out this form and 7 submitted it to the AMERICAN JOURNAL OF THE MEDICAL 8 SCIENCES; is that correct? 9 A. Yes. 10 Q. Okay. Doctor, if you go down to Section 2 02:01 11 under financial disclosures, the highlighted section, and 12 read that into the record for us? 13 A. I certify that any affiliations with or 14 involvement, either competitive or amiable, in any 15 organization or entity with a direct financial interest 02:02 16 in the subject matter or materials discussed in the 17 manuscript, for example, employment, consultancies, stock 18 ownership, honoraria and expert testimony, are noted 19 below. Otherwise, my signature indicates that I have no 20 such financial interest. All financial research or 02:02 21 project support is identified in an acknowledgment in the 22 manuscript. 23 Q. Okay. And my question to you is, Doctor, I 24 don't see where you disclosed that you had any expert 25 testimony relating to the subject matter in that 02:02 PREFERRED LEGAL SERVICES, INC. 214.750.0047 www.preflegal.com 800.405.4056 Ethan A. Natelson, M.D. February 10, 2010 1 document? Page 21 2 MR. SCOTT: Object to the form of the 3 question. 4 A. That would be true. 5 Q. (By Mr. Williams) Okay. And I don't believe 02:02 6 the article identifies that you were serving as an expert 7 witness in RARS cases; is that correct? 8 MR. SCOTT: Objection, form. 9 A. That's correct. 10 Q. (By Mr. Williams) And am I correct that you 02:02 11 were serving as an expert witness in benzene, RARS cases 12 prior to starting the article? 13 A. Yes. 14 Q. As we have just evidenced through the 15 depositions and the reports, while the article was under 02:03 16 publication; is that correct? 17 A. Possibly. Look at those dates. As I say, we 18 have the date I submitted it, yes. 19 Q. And you were serving as an expert witness in 20 benzene, RARS cases after the article was published; is 02:03 21 that correct? 22 A. Yes. 23 Q. If you flip the page please, Doctor -- 24 A. (Witness complies.) 25 Q. -- and let me ask you one more question. What 02:03 PREFERRED LEGAL SERVICES, INC. 214.750.0047 www.preflegal.com 800.405.4056 Ethan A. Natelson, M.D. February 10, 2010 1 did you understand "certifying" to mean, under oath, or Page 22 2 do you know what certifying means? 3 MR. SCOTT: Object to the form. 4 A. I'm not sure I know what it means. In other 5 words, this article was a review. It was not original 02:03 6 work. It's a review of literature and I'm just putting 7 it together and I don't see that that offers any conflict 8 of interest to anybody. And it's a common practice in 9 writing articles that one reviews other people's work and 10 puts it in there and that, to me, is not considered a 02:03 11 conflict of interest. 12 Q. (By Mr. Williams) And you don't agree that the 13 Journal required you to identify any potential conflict 14 of interest? 15 MR. SCOTT: Object to the form. 02:04 16 A. Well, I look at that as, was that article being 17 written about information in a particular case that I'm 18 testifying in? This is a general subject matter, and I 19 don't see that it has anything to do with a conflict of 20 interest. 02:04 21 Q. (By Mr. Williams) Doctor, do you know a 22 gentleman by the name of David Pyatt? 23 A. I've actually never met him but I've 24 corresponded with him and I've spoken with him on the 25 phone once or twice. 02:04 PREFERRED LEGAL SERVICES, INC. 214.750.0047 www.preflegal.com 800.405.4056 Ethan A. Natelson, M.D. February 10, 2010 Page 23 1 Q. Did you speak to him relating to this article 2 that you published? 3 A. I don't know that. I mean, at the time I wrote 4 it, I think that would be doubtful; but I couldn't say 5 "yes" or "no." 02:04 6 Q. Do you know if you've ever served as an expert 7 witness on a benzene myelodysplastic syndrome case with 8 David Pyatt who is a toxicologist? 9 A. Yes. 10 MR. SCOTT: Objection, form. 02:05 11 Q. (By Mr. Williams) Can you tell me which ones 12 you've served on? If you'd like to look at your list, 13 that would be fine. 14 A. I wouldn't be able to tell you that from this 15 list. 02:05 16 MR. SCOTT: Eric, I'm sorry. I've got some 17 objections to these questions. 18 And, Doctor, if you will let me -- 19 THE WITNESS: I'm sorry. 20 MR. SCOTT: No, that's all right. If 02:05 21 you'll just pause for a second after his question is 22 done, I'll get my objection in and then I won't be 23 prancing all over your words; but I object to the form of 24 the last question. 25 Q. (By Mr. Williams) Doctor, have you ever told 02:05 PREFERRED LEGAL SERVICES, INC. 214.750.0047 www.preflegal.com 800.405.4056 Ethan A. Natelson, M.D. February 10, 2010 1 the AMERICAN JOURNAL OF MEDICAL SCIENCES up until today Page 24 2 that you do work involving benzene RARS cases? 3 A. No. 4 MR. SCOTT: Object to the form. 5 Q. (By Mr. Williams) Can you tell me how many 02:05 6 benzene myelodysplastic syndrome cases you worked on with 7 Dr. Pyatt? 8 A. I couldn't. 9 Q. Can you tell me how many benzene cases you've 10 worked on with Dr. Pyatt? 02:06 11 A. I don't know. 12 Q. Can you tell me if it's more than ten? 13 A. I can't tell you that. I don't know. He's 14 been an expert witness on several cases; and, in fact, 15 I've written a paper with him, but I actually have never 02:06 16 met the man. 17 There are two papers. One is a paper that 18 he was the primary author that has to do with 19 formaldehyde, and it's in my CV. And the other is a 20 paper that was recently accepted for publication that has 02:06 21 to do with chemotherapy induced myelodysplasia. 22 Q. Doctor, do you know who the peer reviewers were 23 for the article that we're here for today, the Madison 24 2007? 25 A. No. 02:06 PREFERRED LEGAL SERVICES, INC. 214.750.0047 www.preflegal.com 800.405.4056 Ethan A. Natelson, M.D. February 10, 2010 1 Q. Were you over told -- or did you ever Page 25 2 correspond with the peer reviewers? 3 A. Well, no, you're not told that. In other 4 words, you are given -- typically, the way the Journal 5 operates is that you may recommend -- they typically ask 02:07 6 you to recommend some people in the field; but then what 7 happens is that you get a blank paragraph back from each 8 of the reviewers or simply a letter saying the Journal 9 isn't interested. And you don't know which reviewer 10 wrote what, or if they used any of the people you 02:07 11 suggested; but they simply ask you to suggest some names. 12 Q. Do you know if you worked on any benzene cases 13 with Dr. Pyatt in 2007? 14 A. I think it's very doubtful. 15 Q. Okay. If you turn to a few pages where it says 02:07 16 to review letter -- 17 MR. SCOTT: What's your exhibit number? 18 I'm sorry, Eric, so we can keep track of what we're 19 talking about -- 20 MR. WILLIAMS: I apologize. All of this is 02:08 21 in Exhibit F. I need to change that number. 22 MR. SCOTT: F. 23 (Exhibit F was marked.) 24 Q. (By Mr. Williams) Doctor, have you seen this 25 page before? 02:08 PREFERRED LEGAL SERVICES, INC. 214.750.0047 www.preflegal.com 800.405.4056 Ethan A. Natelson, M.D. February 10, 2010 1 A. No. Page 26 2 Q. Can you tell me what peer reviewer is 3 identified on this sheet? 4 A. David Pyatt, M.D. 5 Q. Okay. And if you turn the page, were you -- to 02:08 6 the highlighted section -- were you informed that David 7 Pyatt viewed your article as acceptable with minor 8 revisions and said that related issues and toxic tort 9 litigation are on the rise and MDS is frequently at 10 issue. Were you told that? 02:09 11 A. If I was given -- I certainly wouldn't be told 12 who reviewed it. I might have been given this paragraph 13 -- or a section of it, depending on what the editor 14 supplied me with. 15 Q. And did you recommend David Pyatt as a reviewer 02:09 16 of this article? 17 A. I probably did. I don't know that for a fact. 18 I gave them several names, and his name could have been 19 among them. 20 Q. Okay. Doctor, if you keep flipping until we 02:09 21 get to your article -- 22 A. Yes. 23 Q. -- I believe you testified -- or you write in 24 your article -- and it's at the end, Page 359 -- that 25 there are certain forms of myelodysplastic syndrome that 02:09 PREFERRED LEGAL SERVICES, INC. 214.750.0047 www.preflegal.com 800.405.4056 Ethan A. Natelson, M.D. February 10, 2010 1 you feel are caused by benzene exposure, the last Page 27 2 paragraph of 359. 3 A. Yes, I said: Despite these caveats, based on 4 considerable evidence presented here, benzene exposure 5 cannot be considered of potential etiology for RARS 02:10 6 although it remains a risk factor for certain forms of 7 the myelodysplasia such as RAEB, an unclassified and/or 8 hypocellular myelodysplasia syndromes, and for AML. 9 Q. Correct. And, Doctor, refractory anemia is a 10 form of myelodysplastic syndrome; is that correct? 02:10 11 A. RARS is classified as a form of myelodysplasia, 12 yes. 13 Q. No, just plain refractory anemia? 14 A. Oh, yes, you can have primary refractory anemia 15 that is a form of myelodysplasia. 02:10 16 Q. And then when one develops ringed sideroblast, 17 it would be RARS refractory with ringed sideroblastic? 18 A. Yes. 19 Q. And then when one develops RAEB, it would be 20 refractory anemia with excess blast; is that correct? 02:11 21 A. Yes, but if you're talking about the same case, 22 I don't think that you would see the transition from a 23 primary refractory anemia into an RARS. You would see 24 the progression from a primary refractory anemia into an 25 RAEB. You would see the progression from an RARS into an 02:11 PREFERRED LEGAL SERVICES, INC. 214.750.0047 www.preflegal.com 800.405.4056 Ethan A. Natelson, M.D. February 10, 2010 1 RAEB. Page 28 2 Q. And cases of RAEB, refractory anemia with 3 excess blast would have excess amounts of ringed 4 sideroblastic, too; is that correct? 5 A. If they started out as an RARS and the natural 02:11 6 history of that illness is to, in some instances, move 7 toward a Leukemia, as they increase blast, they become, 8 by the classification system RAEB. They are the same 9 illness, as far as I'm concerned; but they are classified 10 as RAEB because they now have blast and they still have 02:12 11 ringed sideroblast. 12 Q. Okay. Doctor, would that be the same for 13 RAEB-T that you would have excessive blast and also 14 possibly excessive ringed sideroblastic; is that correct? 15 MR. SCOTT: Object to the form. 02:12 16 A. Well, again, talking about the progression, if 17 you had RARS-T, that's an illness which you are saying at 18 diagnosis it's a myeloproliferative disease. It has 19 excess ringed sideroblast. That disease may progress 20 toward an acute myeloleukemia, too, and accumulate large 02:12 21 numbers of blast and actually go into AML. 22 Q. (By Mr. Williams) Doctor, are there -- how 23 much money have you made serving as an expert witness for 24 various defendants in myelodysplastic syndrome cases? 25 MR. SCOTT: Object to the form. 02:12 PREFERRED LEGAL SERVICES, INC. 214.750.0047 www.preflegal.com 800.405.4056 Ethan A. Natelson, M.D. February 10, 2010 1 A. I couldn't give you a number. Page 29 2 Q. (By Mr. Williams) And could you give us a 3 number for how much money you have made in RARS cases? 4 A. I wouldn't have a guess. It looks like there 5 were five, I think we saw, since 1982. I couldn't give a 02:13 6 guess. 7 Q. Do you have an average of what it takes you to 8 prepare a report and go through a deposition, average 9 price, a range? 10 A. It depends on how long the deposition is in 02:13 11 terms of how much that costs; and the preparation, my 12 guess would be that it -- and this would be a guess, that 13 it might be anywhere from six to ten hours, let's say, 14 depending on the simplicity of the case in terms of 15 reviewing the records. 02:13 16 Q. Okay. Have you ever treated a patient with 17 myelodysplastic syndrome that was exposed to -- that was 18 a chemist and was exposed to chemicals? 19 A. Yes. 20 Q. And was it your opinion that that chemist's 02:14 21 exposures to benzene and other chemicals was the cause of 22 his myelodysplastic syndrome? 23 A. I thought it was possible. 24 Q. Okay. Are there any studies, Doctor, in the 25 world's literature that focus on the fact benzene, 02:14 PREFERRED LEGAL SERVICES, INC. 214.750.0047 www.preflegal.com 800.405.4056 Ethan A. Natelson, M.D. February 10, 2010 1 besides your own, can't cause RARS? Page 30 2 A. Well, there are many articles that read on that 3 point. In other words, there is the Dr. Ruiz article, 4 which I think I cited, where he did bone marrows on 33 5 people with heavy exposure to benzene and pancitopenia 02:14 6 and he specifically tells us there were no ringed 7 sideroblasts. 8 We have Dr. Irons article. He had two 9 articles. One, I think, in 2005 and one recently where 10 he's looked at a large number of people with heavy 02:14 11 benzene exposure and none have had ringed sideroblast. 12 We have Dr. Aksoy's work. And Dr. Aksoy 13 was trained, in part, here in the United States with 14 Dr. Damashek who was the world's expert on RARS. So, he 15 certainly knew about that illness. And he did bone 02:15 16 marrows on a number of people he thought had 17 benzene-related disease, and he makes no mention of ever 18 finding RARS in their marrows. 19 And I would not think that could be missed 20 by a person of his training. 02:15 21 We have the so-called Chinese benzene 22 study, the Haze benzene studies in which Dr. Larsen and 23 others reviewed slides, they claim, of seven people with 24 myelodysplasia from that large cohort; and they make no 25 description of seeing ringed sideroblasts. And all of 02:15 PREFERRED LEGAL SERVICES, INC. 214.750.0047 www.preflegal.com 800.405.4056 Ethan A. Natelson, M.D. February 10, 2010 1 those people are very prominent hematologists and Page 31 2 certainly would recognize ringed sideroblasts. 3 So that if we look through the literature 4 in cohorts that have been studied by bone marrow analysis 5 by prominent people, there is no mention of the 02:16 6 occurrence of ringed sideroblast, and in many instances, 7 mention that they are not evident, even after having been 8 sought. 9 Q. Doctor, maybe you didn't understand my 10 question. I asked you were there any other studies that 02:16 11 are focused, the title or the objective is benzene 12 exposure and refractory sideroblastic erythropoiesis. 13 MR. SCOTT: Object to the form. 14 A. I think I understand the question. Yes, that 15 was the reason I wrote this article is because that was 02:16 16 because early on, Wintrobe had asked that question and 17 others had; and so, now, I was in the a position to 18 review that question and try to answer that question. 19 Q. (By Mr. Williams) Basically, your study is one 20 of a kind as to answering that question only? 02:16 21 A. Yes. 22 Q. Okay. Thank you. 23 A couple more questions, Doctor; and I 24 think we're done. 25 Have you spoken with -- besides myself, 02:16 PREFERRED LEGAL SERVICES, INC. 214.750.0047 www.preflegal.com 800.405.4056 Ethan A. Natelson, M.D. February 10, 2010 1 Mr. Scott, Bob Scott over there, regarding this Page 32 2 deposition? 3 A. Yes, I've spoken with -- well, Mr. Asher called 4 me right after you did; and I spoke with him. And then I 5 spoke with Mr. Scott later on, several days later, I 02:17 6 believe. And I also spoke with Stan Perry. That's the 7 best I can remember. 8 Q. Okay. Start off telling us what you spoke with 9 Mr. Asher about. 10 A. Well, what had happened is you called and said 02:17 11 you wanted to depose me on my paper; and I specifically 12 asked you whether this had to do with a specific case. 13 And you told me, no, I just want to depose you about your 14 article. And then I thought that was very peculiar. 15 And then shortly thereafter, I got a call 02:17 16 from Mr. Asher saying you're going to be receiving a 17 subpoena, if you haven't already; and it's about this 18 Barry Wild case. 19 And I said, Well, I'm told I'm going to 20 receive a subpoena but not that it's about a particular 02:18 21 case. 22 And he said, Oh, yes, it is. It's about a 23 particular case; and I'm going to send you a summary of 24 the case, which he did. And that was the sum and 25 substance of the conversation. 02:18 PREFERRED LEGAL SERVICES, INC. 214.750.0047 www.preflegal.com 800.405.4056 Ethan A. Natelson, M.D. February 10, 2010 Page 33 1 Q. And when you say "summary," are you referring 2 to an expert report prepared by Defendant Fisher 3 Scientific's expert, Gregory Sona? 4 A. Yes. 5 Q. And did you review that paper? 02:18 6 A. Yes, I did review the report. 7 Q. And when you say Ross Asher, you mean the 8 gentleman to my right who represents Fisher Scientific. 9 He is the one that contacted you? 10 A. Yes. 02:18 11 Q. Next you said Mr. Bob Scott contacted you. 12 Tell me about that conversation. 13 A. Well, Mr. Scott said that -- I've forgotten 14 what initiated the conversation because we had done other 15 cases; but I mentioned this situation to him, and he 02:18 16 said, Well, that's very interesting because I'm involved 17 in that Barrios case. And I didn't know that. Mr. Asher 18 hadn't mentioned that to me. 19 And so, he said, When are you going to give 20 this deposition? 02:19 21 And I told him and that was the -- in 22 general, that was the substance of that case. 23 Q. And what cases have you worked on for 24 Mr. Scott, what defendants was he representing? 25 A. I'm terrible on names, but we testified on a 02:19 PREFERRED LEGAL SERVICES, INC. 214.750.0047 www.preflegal.com 800.405.4056 Ethan A. Natelson, M.D. February 10, 2010 Page 34 1 case that was in -- was it -- New Mexico, I believe, that 2 was a myelodysplasia case that comes to mind. I know 3 there were probably several others, but I can't remember 4 it by name. 5 Q. Was RARS an issue in any of the cases that you 02:19 6 worked for with Mr. Scott? 7 A. I don't remember that. I think, yes, I think 8 that case had to do with RARS. 9 Q. In New Mexico? 10 A. Yes, I believe so. That was an issue in that 02:19 11 case. 12 Q. And did you testify at trial? 13 A. Yes. 14 MR. SCOTT: It was actually a Daubert 15 hearing. I'm sure Dr. Natelson didn't understand the 02:20 16 niceties of that. 17 Q. (By Mr. Williams) And have you served for 18 Mr. Scott as an expert on several occasions? 19 A. I'm sure I have. I can't remember all of the 20 cases. 02:20 21 Q. And then, I believe, you just told me that Stan 22 Perry, that's the gentleman that's the national counsel 23 for Shell Oil Company, called you? 24 A. Yes. 25 MR. SCOTT: Object to the form. 02:20 PREFERRED LEGAL SERVICES, INC. 214.750.0047 www.preflegal.com 800.405.4056 Ethan A. Natelson, M.D. February 10, 2010 Page 35 1 Q. (By Mr. Williams) What did Mr. Perry have to 2 say? 3 A. I'm trying to recall what he specifically said. 4 There was nothing -- he said, Well -- I asked him, I 5 said, Isn't this a little bit peculiar to get subpoenaed 02:20 6 about a case you're not involved in? 7 And he said, Well, it does sound a little 8 peculiar; but I would just recommend you going ahead and 9 giving the testimony, whatever you're asked. And he 10 said, I don't have a clue why this has occurred. 02:20 11 Q. Do you know why Mr. Stan Perry, the national 12 counsel for Shell Oil Company, contacted you when, in 13 fact, Shell Oil is not a defendant in this case? 14 A. No, I was talking with him on another issue; 15 and I brought it up. So, I said, How would you look at 02:21 16 this issue? I said, isn't this somewhat peculiar? 17 And he said, Well, this does sound a little 18 peculiar; but my advice is just go ahead and give the 19 testimony. 20 MR. SCOTT: Object to the form of the last 02:21 21 question. 22 Q. (By Mr. Williams) Did any of the attorneys 23 that contacted you tell you to testify or lean one way or 24 the other in this deposition? 25 A. No, none of them said, Don't Testify. All of 02:21 PREFERRED LEGAL SERVICES, INC. 214.750.0047 www.preflegal.com 800.405.4056 Ethan A. Natelson, M.D. February 10, 2010 1 them said, theoretically -- I think, in fact, Mr. Asher Page 36 2 said to me, he said, You know, you could really hire an 3 attorney and try to get out of this? 4 And I said, Well, it just sounds like that 5 would be more trouble than it would be worth. And so -- 02:21 6 but no one suggested I do that. 7 Q. Right. Besides Mr. Asher? 8 A. Well, he didn't suggest. He said I could. 9 Q. You could do that, right. Okay. Give me a 10 second. That's it. 02:22 11 Do you have anything, Mr. Asher? 12 MR. SCOTT: Yeah, I definitely have some. 13 EXAMINATION 14 BY MR. SCOTT: 15 Q. Good afternoon, Dr. Natelson, and thank you for 02:22 16 being here. 17 You mentioned earlier that your first 18 thoughts about benzene and any association with a disease 19 known as refractory anemia with ringed sideroblast or 20 RARS, as it's been called, came after reading something 02:22 21 that Wintrobe wrote. 22 Did I get that right? 23 A. Yes. 24 Q. Who is Wintrobe? 25 A. Well, Dr. Maxwell Wintrobe was the -- was a 02:22 PREFERRED LEGAL SERVICES, INC. 214.750.0047 www.preflegal.com 800.405.4056 Ethan A. Natelson, M.D. February 10, 2010 1 hematologist, self-trained really, who was the chief of Page 37 2 medicine in hematology in Salt Lake City at one time. He 3 actually worked in Louisiana at one time and I believe he 4 went to Rochester Medical School, but he became 5 internationally known because he wrote the first major 02:23 6 textbook in hematology and was a very renowned and also 7 very famous for having an enormous research -- reprint 8 library. In the days prior to the Internet, if you 9 wanted to have an article, you would write a letter or a 10 postcard to an author and they would send you back a 02:23 11 signed copy; and Dr. Wintrobe had a massive research 12 library where you could get all of your reprints there. 13 Q. This was before the Internet, I take it? 14 A. This is long before the Internet, yes. 15 Q. Is Dr. Wintrobe still with us? 02:23 16 A. No, he died a number of years ago. 17 Q. Does his hematology textbook continue to be 18 with us, new editions from time to time? 19 A. Yes. 20 Q. And is it one of the hematology textbooks that 02:24 21 is used in medical schools, certainly in this country and 22 perhaps around the world? 23 A. Yes. 24 Q. And exactly what is it that Dr. Wintrobe wrote 25 or reported that piqued your interest with regard to 02:24 PREFERRED LEGAL SERVICES, INC. 214.750.0047 www.preflegal.com 800.405.4056 Ethan A. Natelson, M.D. February 10, 2010 1 benzene and RARS? Page 38 2 A. Well, Dr. Wintrobe was aware of this illness. 3 He was not the first discoverer of it. Some other 4 doctors in the decade prior to when he wrote about it had 5 made mention of this illness. And he decided that he 02:24 6 would study all the cases he had at Salt Lake City. I 7 don't remember the numbers. They are in this article. 8 Let's say, 19 cases or so that he had; and then I think 9 he abstracted about 44 more cases from the world's 10 literature. And he looked to see how you made this 02:24 11 diagnosis; how many ringed sideroblasts there were in the 12 bone marrow; could there be known causes for this looking 13 at drugs, looking at alcohol because it was known that 14 alcohol could produce ringed sideroblasts. 15 And so, he looked to see if there was a 02:25 16 unifying feature in these patients that explained their 17 illness. And he found what we really know today that a 18 number of these people went on to develop acute Leukemia, 19 that there was no particular relationship with alcohol, 20 there was no relationship with lead poisoning which could 02:25 21 also give ringed sideroblasts. There was no association 22 with benzole, as he put it, which he knew caused bone 23 marrow depression. And so, he termed the illness 24 idiopathic meaning that none of the known bone marrow 25 toxins that he was aware of could produce this illness. 02:25 PREFERRED LEGAL SERVICES, INC. 214.750.0047 www.preflegal.com 800.405.4056 Ethan A. Natelson, M.D. February 10, 2010 Page 39 1 Q. You also mentioned an author, a Doctor named 2 Aksoy. 3 A. Yes. 4 Q. And as I recall, he was a Turkish doctor; is 5 that correct? 02:26 6 A. Yes. 7 Q. You indicated that he trained with 8 Dr. Damashek. How do you know that? 9 A. Well, I happen to know that because Dr. Aksoy 10 wrote many articles; and these were -- most of them were 02:26 11 written, I think, in the '70s, up until about 1982, I 12 think, was his last article. And after he died, I have a 13 review article by some of his colleagues that wrote about 14 it. And they went in that article into his background 15 and pointed out that he had studied with Dr. Damashek 02:26 16 doing a fellowship. And so, I learned a little bit more 17 about his background. He was not -- I don't think his 18 hematology training was in the United States but his 19 fellowship was. 20 Q. And what is it that Dr. Aksoy wrote about that 02:26 21 was related, in your view, to the question of whether 22 benzene is associated -- causally associated with the 23 development of RARS? 24 A. Well, Dr. Aksoy studied a large number of 25 patients. His patient base was about 29,000 people. And 02:26 PREFERRED LEGAL SERVICES, INC. 214.750.0047 www.preflegal.com 800.405.4056 Ethan A. Natelson, M.D. February 10, 2010 1 I don't recall the exact number of how many had what he Page 40 2 called pre-Leukemic syndromes and acute Leukemia, but 3 let's say it was in the 30s to 40s of individuals that he 4 personally studied. And I think in one of his articles 5 he said he does bone marrows on 11 of them. And those 02:27 6 were ones that he did, and I assume he looked at bone 7 marrows that other people did on other cases. 8 In the era when he was writing those 9 articles, the iron stain, the so-called Prussian blue 10 stain, or pearls blue stain was a standard practice in 02:27 11 hematology. And so, he would be familiar with looking at 12 iron stains. 13 He also studied with Dr. Damashek who one 14 of his favorite topics was sideroblastic anemia. So, 15 certainly, it's reasonable to expect that a trained 02:27 16 hematologist who studies with someone interested in this 17 disease could recognize a ringed sideroblastic. 18 And in a normal bone marrow, one doesn't 19 see a single ringed sideroblast. And in RARS, one may 20 see 40, 50, 70 percent of the cells may be ringed 02:28 21 sideroblast. I brought a cover here of a magazine to 22 show how striking it is. 23 So, when Dr. Aksoy writes an article and he 24 says, These are the abnormalities that I saw in 25 benzene-related illnesses, he didn't have to tell me that 02:28 PREFERRED LEGAL SERVICES, INC. 214.750.0047 www.preflegal.com 800.405.4056 Ethan A. Natelson, M.D. February 10, 2010 Page 41 1 he looked for ringed sideroblasts. He had seen them, he 2 would have commented that that was an abnormality. 3 In other words, it was just as though he 4 doesn't say he didn't see malaria parasites or this or 5 that. In other words, he said what he saw; and included 02:28 6 in that was not ringed sideroblasts. 7 Q. You use the term "sideroblastic anemia." What 8 relationship is sideroblastic anemia to refractory anemia 9 with ringed sideroblasts or RARS? 10 A. Well, sideroblastic anemia is a general topic; 02:28 11 and prior to the use of the term myelodysplasia and even 12 subsequent to it, if you went to a hematology textbook, 13 you would see a chapter on sideroblastic anemia. And 14 that chapter would be divided into those that are 15 hereditary, which there are some, and those that are 02:29 16 acquired illness. 17 And then under the acquired illnesses, 18 there would be broken down as to what the causes might 19 be. For example, led poisoning gives you a sideroblastic 20 anemia, very heavy arsenic poisoning can give you a 02:29 21 sideroblastic anemia. Alcohol can give you a 22 sideroblastic anemia. 23 Those all acquired sideroblastic anemias; 24 but only, perhaps, in the arsenic related might they go 25 on to a Leukemia. They are not a pre-Leukemia state. 02:29 PREFERRED LEGAL SERVICES, INC. 214.750.0047 www.preflegal.com 800.405.4056 Ethan A. Natelson, M.D. February 10, 2010 Page 42 1 But certain of the sideroblastic anemias 2 for which there are no obvious causes, no drugs, no 3 chemicals, they fall under the title Wintrobe called 4 idiopathic sideroblastic anemia. And that was a group 5 that he followed and he commented that they could live 02:30 6 many years, and they often died of iron overload. They 7 didn't always die of Leukemia. In fact, only 8 occasionally did they die of Leukemia. Dr. Damashek 9 thought about half of them would die of Leukemia, but 10 Dr. Wintrobe realized that that was too big a number and 02:30 11 it was much smaller than that that went on to develop 12 Leukemia. 13 So, that would be what you would find in 14 the textbook chapter. It would give you a discussion of 15 all the different types of sideroblastic anemias. 02:30 16 Q. You say you have a cover that shows us a 17 refractory anemia with ringed sideroblast or at least a 18 ringed sideroblast? 19 A. Yes. 20 Q. Is that something that we can mark for this 02:30 21 deposition and have it sent back to you? 22 A. Certainly. 23 (Exhibit No. G was marked.) 24 Q. (By Mr. Williams) And, Doctor, if you don't 25 mind, would you hold that up for the camera; and we'll 02:31 PREFERRED LEGAL SERVICES, INC. 214.750.0047 www.preflegal.com 800.405.4056 Ethan A. Natelson, M.D. February 10, 2010 1 see if he can zoom in on the cover here of Exhibit G. Page 43 2 A. This is a cover of a magazine called BLOOD, and 3 Dr. Damashek was the founder of that magazine. He was 4 the original editor. 5 Q. And is the journal BLOOD the JOURNAL OF THE 02:31 6 AMERICAN SOCIETY OF HEMATOLOGY? 7 A. Yes, it is. 8 Q. Or SOCIETY OF HEMATOLOGY? 9 A. Yes. 10 Q. Now, can you point at -- it may be tough to do 02:31 11 on the -- on the camera, I don't know, because you can't 12 see the other side of it; but can you point out -- 13 A. I think I can. 14 Basically, when you prepare a slide to do 15 an iron stain, what you like is to make a fairly thin 02:31 16 film of the bone marrow; and that spreads out the mother 17 cells that give rise to red cells. And they're counter 18 stained with a slightly red stain. So, everything you 19 see red is the nucleus of a cell that is going to be 20 circulating a red blood cell. 02:31 21 Q. And that's sometimes called an erythroid cell; 22 is that right? 23 A. These are called erythroid blasts in the bone 24 marrow. And when you're staining them with the Prussian 25 blue stain, any iron in the cytoplasm forms a blue 02:32 PREFERRED LEGAL SERVICES, INC. 214.750.0047 www.preflegal.com 800.405.4056 Ethan A. Natelson, M.D. February 10, 2010 1 granule color. And in a normal bone marrow, all you Page 44 2 should see is the red counter stain. There wouldn't be a 3 single one of these cells with these multiple little blue 4 dots around them. So, this smacks you in the face if you 5 were looking at an iron stain on a bone narrow. 02:32 6 Q. This is not the kind of thing Dr. Aksoy would 7 miss if he had seen it? 8 A. I'm confident Dr. Aksoy would recognize this, 9 just as Dr. Damashek and many others have. 10 Q. I want to -- we've talked about Dr. Wintrobe 02:32 11 and Dr. Aksoy. What other -- you have written a review 12 article. What is a review article? You distinguish that 13 between a review recall and a research. Can you describe 14 for us what a review recall is and what the purpose of it 15 is? 02:33 16 A. Well, a review article is to provide education 17 for people in the medical community about a particular 18 issue. And you take a subject and you try to review the 19 literature intensively and find what you think are the 20 pertinent articles to answer a particular question. And 02:33 21 then you review those articles and mention why you're 22 selecting them and why these articles help you come 23 toward a conclusion. 24 In this particular case, we're talking 25 about sideroblastic anemia and causation; and that's what 02:33 PREFERRED LEGAL SERVICES, INC. 214.750.0047 www.preflegal.com 800.405.4056 Ethan A. Natelson, M.D. February 10, 2010 1 the purpose of this review was. Page 45 2 Q. And I take it that in preparing that article 3 and writing that article, you did some sort of literature 4 search to see what was available in the medical and 5 scientific literature regarding benzene and refractory 02:33 6 anemia with ringed sideroblast? 7 A. Yes. 8 Q. You've told us about Wintrobe and Aksoy. What 9 other original work was in the literature that led you to 10 your conclusions that benzene is not associated with the 02:34 11 development of RARS? 12 A. Well, there were several articles; and some of 13 these are referenced in the paper, and some of these are 14 already discussed. One we didn't discuss, for example, 15 is we discussed, let's say, the Ruiz study where he had 02:34 16 people heavily exposed to benzene and he selected a group 17 of 33 that he thought would be most reflective of that 18 poisoning and he did bone marrows on them. And he tells 19 us that none of them have ringed sideroblasts. 20 Q. Not a single one? 02:34 21 A. Not a single one. 22 Then you could look at that in reverse, and 23 one of the articles I cited took a large collection of 24 people with RARS, I think there were 84 of them. And 25 they went back and interviewed those people and studied 02:34 PREFERRED LEGAL SERVICES, INC. 214.750.0047 www.preflegal.com 800.405.4056 Ethan A. Natelson, M.D. February 10, 2010 Page 46 1 their files to see how many of those 84 might have had it 2 from benzene exposure. Did they have a chemical 3 background that could have been causative? And in that 4 article, they claim they found one person who alleged 5 exposure to benzole; but that person had also received 02:35 6 radiation therapy for a malignancy. And so, it did not 7 appear that looking at a cohort of people with this 8 illness that benzene stood out as a potential cause and 9 effect. 10 Q. What was the article where they took the 02:35 11 collection of people with RARS and went back to see if, 12 in their history, they had benzene or solvent exposure? 13 A. Let me see if I can find that. Let's see where 14 I reference that. I probably better find it from looking 15 at my references. I believe it's reference 19, but let 02:36 16 me see if that's correct. 17 Yes, it's my reference 19, which is called 18 -- is by Garand, G-A-R-A-N-D. 19 Q. That was in the 1992, it looks like, from your 20 reference list, correct? That was -- that article 02:36 21 appeared in LEUKEMIA RESEARCH? 22 A. That article appeared in LEUKEMIA RESEARCH, 23 Volume 16, Page 463 to 486, 1992. 24 Q. Are you familiar with a series of papers 25 arising out of a study conducted by the National Cancer 02:36 PREFERRED LEGAL SERVICES, INC. 214.750.0047 www.preflegal.com 800.405.4056 Ethan A. Natelson, M.D. February 10, 2010 1 Institute in conjunction with the Chinese Academy of Page 47 2 preventative maintenance -- preventative medicine -- I've 3 got a car problem. I keep saying "maintenance" instead 4 of "medicine" -- of a large group of workers in China? 5 A. Yes. 02:36 6 Q. Does that article shed any light or provide any 7 information that is helpful on the question of whether or 8 not benzene has been associated with the development of 9 RARS? 10 A. Yes, I think so. That was a very large cohort, 02:37 11 I believe, about 74,000 workers in China exposed to what 12 are thought to be very large amounts of benzene in an 13 occupational environment. And in that group, the -- 14 there were seven cases identified as having forms of 15 myelodysplasia. And according to the articles, those 02:37 16 cases were reviewed by hematopathologists. And they list 17 the diagnosis of these seven, and none of them are RARS. 18 There is also a comment in one of the 19 articles I cited about what the typical bone marrow 20 looked like in these people, and there is no mention of 02:37 21 ringed sideroblast in that comment. 22 MR. SCOTT: What's our next exhibit? 23 THE COURT REPORTER: H. 24 (Exhibit No. H was marked.) 25 Q. (By Mr. Scott) Dr. Natelson, I'm going to hand 02:38 PREFERRED LEGAL SERVICES, INC. 214.750.0047 www.preflegal.com 800.405.4056 Ethan A. Natelson, M.D. February 10, 2010 1 you what I've marked as -- actually, the court reporter Page 48 2 has marked as Exhibit H, which is an Internet search form 3 and then an article with a lead author Travis; and it was 4 published in 1994. 5 Have you seen that article before? 02:38 6 A. Yes. 7 Q. Is that one of the papers out of this NCI CADM 8 or Chinese Preventative Medicine Study? 9 A. Yes. 10 Q. On page -- the second page of that article 02:38 11 which is numbered, I think, 92 -- and Lois Travis is the 12 lead author; am I correct? 13 A. Yes. 14 Q. And in the right-hand column, there is a 15 description in the first full paragraph that says: 02:39 16 Evidence of dyserythropoiesis included the presence of -- 17 and it lists a number of items, ringed sideroblasts, 18 multinuclearity, nuclear fragmentation, megaloblastoid 19 changes and so on. 20 What are those? What is dyserythropoiesis, 02:39 21 and what are those items? 22 A. Well, dyserythropoiesis would be a general term 23 meaning, in lay language, that the cell line looks 24 abnormal; and it may be abnormal because it's too large. 25 It may be abnormal because the cytoplasm is very 02:39 PREFERRED LEGAL SERVICES, INC. 214.750.0047 www.preflegal.com 800.405.4056 Ethan A. Natelson, M.D. February 10, 2010 1 irregular on the cells. It may be abnormal because the Page 49 2 colors -- the stain colors are abnormal. It may be 3 abnormal because they are inclusions, like ringed 4 sideroblasts, something that shouldn't be in there. It 5 may be abnormal because the nucleus is splitting, that 02:39 6 you have two nuclei in a single red cell precursor, for 7 example. 8 So, dyserythropoiesis is a general term 9 means abnormal, morphology, funny-looking cells. And 10 then they go on to say what some of those were, for 02:40 11 example, ringed sideroblasts we've discussed. 12 Multinuclearity meaning there were multiple nuclei 13 instead of a single one in the cell. 14 Karyorrhexis, what that means is the 15 nucleus is fragmenting instead of being very well 02:40 16 defined. 17 Abnormal nuclear shape, I think I mentioned 18 it should be like a bulls eye. It looks very round. It 19 may be irregular. 20 Impaired hemoglobinization, what that means 02:40 21 is that as the cell matures, the cytoplasm becomes redder 22 and redder as hemoglobin is manufactured. And so, 23 impaired hemoglobinization means the cell looks very 24 pale. It's not making it's complement of the hemoglobin. 25 Megaloblastoid changes meaning simulating 02:40 PREFERRED LEGAL SERVICES, INC. 214.750.0047 www.preflegal.com 800.405.4056 Ethan A. Natelson, M.D. February 10, 2010 Page 50 1 what we see with Vitamin B-12 deficiency where the cells 2 are very large and abnormal looking. 3 And so, those are the things that they 4 mention as would come under the heading of 5 dyserythropoiesis. 02:41 6 Q. And part of the -- one of the items or things 7 they were looking for as evidence of dyserythropoiesis is 8 the existence or observation of ringed sideroblasts? 9 A. Yes. 10 Q. Can you turn to Table 5 of the Travis article, 02:41 11 Exhibit H, which I think is on Page 97. Can you first 12 confirm that Table 5 is a listing of the various -- among 13 other things, the various items of dyserythropoiesis that 14 the National Cancer Institute investigators had been 15 looking for? 02:41 16 A. Yes. 17 Q. And under the cases of MDS, how many instances 18 did they observe ringed sideroblasts? 19 A. None, according to this. They have looked for 20 them, but they don't cite any cases as having them. 02:42 21 Q. And they do cite, if you can confirm, 22 observation of megaloblastoid changes, abnormal nuclear 23 change, impaired hemoglobinization and multinuclearity as 24 you described for us earlier; correct? 25 A. Yes, that is correct. 02:42 PREFERRED LEGAL SERVICES, INC. 214.750.0047 www.preflegal.com 800.405.4056 Ethan A. Natelson, M.D. February 10, 2010 Page 51 1 Q. Is that the same thing as saying they look to 2 see if there were ringed sideroblasts among their MDS 3 cases and saw none? 4 A. Correct. 5 Q. And then finally the Irons article or articles, 02:42 6 what do Dr. Irons and his group's articles in 2005 and I 7 think it was titled something along the lines of benzene 8 induces a unique form of dysplasia or something like 9 that. And then in more recent 2009 article which we 10 don't have marked -- do you have that article? 02:43 11 MR. WILLIAMS: It's right here. 12 A. Yes. 13 MR. SCOTT: Let's mark that as Exhibit I 14 just so we have a sticker on it. 15 (Exhibit No. I was marked.) 02:43 16 Q. (By Mr. Scott) How did Dr. Irons' 2005 and 17 2009 articles or reports inform your view on whether 18 benzene causes refractory anemia with ringed 19 sideroblasts? 20 A. Well, in this particular article, he comments 02:43 21 about how they looked at the bone marrows, that they did 22 iron stains on the bone marrows. Let's see if I can find 23 where he discusses that, but I know that he says that. 24 He says: Bone marrow aspirate and 25 peripheral blood smears were prepared from fresh tissue 02:44 PREFERRED LEGAL SERVICES, INC. 214.750.0047 www.preflegal.com 800.405.4056 Ethan A. Natelson, M.D. February 10, 2010 1 and evaluated using Wright-Giemsa stained preparations Page 52 2 and special stains, including an iron stain. 3 So, he was doing an iron stain on all of 4 this material. 5 And then he comments and I have to look to 02:44 6 see what page this might be that -- here it is, Page 10 7 of the article. He says: There was no evidence of 8 increased ringed sideroblasts. 9 Q. And was this among a group of people who had a 10 myelodysplastic syndrome and had known and, in some 02:44 11 cases, very high benzene exposure? 12 A. Yes, according to Dr. Irons, these were his 13 signal cases, as he used that term, meaning that they had 14 unequivocal enormous benzene exposure and abnormal bone 15 marrows. 02:45 16 Q. Are there -- from your knowledge and review of 17 the scientific literature -- and I want to turn away from 18 RARS, at this point; but myelodysplastic syndromes, you 19 have said that some myelodysplastic syndromes are 20 associated with exposure to benzene? 02:45 21 A. Yes, I think that's true. 22 Q. Are there features, clinical features, 23 morphologic features, cytogenetic features, type of 24 features that, sort of thing, of the benzene-caused 25 myelodysplastic syndromes? 02:45 PREFERRED LEGAL SERVICES, INC. 214.750.0047 www.preflegal.com 800.405.4056 Ethan A. Natelson, M.D. February 10, 2010 Page 53 1 (Mr. Trull enters the deposition room at 2 this time.) 3 A. Well, I suppose the two best articles that 4 would read on that would be the Ruiz article with his 5 large number of cases, 33 cases that were studied and the 02:45 6 Richard Irons article. And the results of those two 7 articles are quite similar. They also are in line with 8 the description that's in the cases seen in the Hayes of 9 benzene study. 10 The description is that the bone marrows 02:46 11 generally show reduced total cellularity or what we call 12 hypocellularity, that they have abnormal morphology of 13 the red cell precursors, that they have the presence of 14 increased numbers of eosinophils, which are a cell that 15 we see in inflammatory conditions, and that these 02:46 16 eosinophils look peculiar. They are granules. They are 17 very unusually colored and large, as we see in certain 18 forms of acute Leukemia. 19 And the bone marrow also contains 20 phagocytic cells, histiocytes that are prominent in these 02:46 21 bone marrows. And the absence of ringed sideroblasts, 22 for example, in these bone marrows. 23 Q. You say histiocytes or phagocytic cells, are 24 those sometimes referred to as -- is that condition 25 sometimes referred to as hemophagocytosis? 02:47 PREFERRED LEGAL SERVICES, INC. 214.750.0047 www.preflegal.com 800.405.4056 Ethan A. Natelson, M.D. February 10, 2010 1 A. Yes. Page 54 2 Q. And the abnormal eosinophils, increased 3 eosinophils and peculiar appearance, morphologic 4 appearance, are those in the peripheral blood or in the 5 bone marrow? 02:47 6 A. Well, in the case of Leukemias, they can be 7 both in the peripheral blood and bone marrow in certain 8 forms of Leukemia. 9 In the case of benzene bone marrows that 10 are described, they are confined to the bone marrow. 02:47 11 Q. And are these sometimes called precursors 12 because they are in the bone marrow? 13 A. Well, a general statement would be that most of 14 the cells that you see in the bone marrow are precursors 15 to cells that eventually come out and circulate in the 02:48 16 peripheral blood. 17 Q. In normal MDS, myelodysplastic syndrome case, 18 is the bone marrow hypercellular, that is, greater 19 cellularity or more cells in the marrow or hypocellular? 20 A. I think in general, you might find the figure 02:48 21 that looking at all types of myelodysplasia, perhaps 22 20 percent are very hypocellular, sometimes referred to 23 as hypocellular myelodysplasia. Many have a normal 24 cellularity, and many have increased cellularity. 25 Q. Are you familiar with a disorder known as -- or 02:48 PREFERRED LEGAL SERVICES, INC. 214.750.0047 www.preflegal.com 800.405.4056 Ethan A. Natelson, M.D. February 10, 2010 1 referred to as myelodysplastic Page 55 2 syndrome/myeloproliferative disorder or sometimes 3 myeloproliferative neoplasm? 4 A. Yes. 5 Q. What is that disorder or disorders? 02:49 6 A. That classification is a relatively new 7 classification by the World Health Organization, and this 8 really came about because what the World Health 9 Organization has been trying to do is to become as 10 specific as it can about a particular diagnosis. For 02:49 11 example, we had the illness chronic myeloid Leukemia, 12 which, for many years, we considered most of them to have 13 a positive Philadelphia chromosome but also some of them 14 to be missing that chromosome, but we still called them 15 chronic myeloid Leukemia. 02:49 16 Well, the World Health Organization took 17 the position that only chronic myeloid Leukemia with a 18 Philadelphia chromosome is the real thing and we've got 19 to do something else with these cases of chronic myeloid 20 Leukemia that lack the Philadelphia chromosome. And 02:49 21 there is another illness called chronic myelomonocytic 22 Leukemia, which is another myeloproliferative disease, 23 which the cause is unknown. And the question was, where 24 are we going to place that. 25 So, they came up with a category called 02:50 PREFERRED LEGAL SERVICES, INC. 214.750.0047 www.preflegal.com 800.405.4056 Ethan A. Natelson, M.D. February 10, 2010 1 myeloproliferative myelodysplastic syndromes. And the Page 56 2 best known in this category to be chronic myelomonocytic 3 Leukemia, what's called atypical CML -- that is CML 4 lacking the Philadelphia chromosome, an unusual illness 5 called juvenile myeloid Leukemia. And eosinophilic 02:50 6 Leukemia would be another in this category. 7 And a provisional member of this is once 8 called RARS-T. These are illnesses for which they are 9 all myeloproliferative illnesses. They are not 10 myelodysplasia. They are all myeloproliferative 02:50 11 diseases. However, they can have funny-looking cells. 12 So, they can have some degree of myelodysplasia; but they 13 are quite different from the illnesses we classify as 14 myelodysplasia. And those illnesses are all thought to 15 be of unknown cause at this time. So, the articles on 02:51 16 that subject tell us that the diseases in that category 17 of myelodysplasia, myeloproliferative disease are all of 18 unknown cause. 19 Q. I want to hand you -- I'm going to hand you two 20 things here, one a very poor color print that I have 02:51 21 made. 22 (Exhibit No. J was marked.) 23 Q. (By Mr. Williams) Dr. Natelson, I've marked as 24 Exhibit J, two pages out of what I will represent to you 25 as the World Health Organization's 2008 classification of 02:51 PREFERRED LEGAL SERVICES, INC. 214.750.0047 www.preflegal.com 800.405.4056 Ethan A. Natelson, M.D. February 10, 2010 1 tumors of hematopoetic and lymphoid issues. And I'm Page 57 2 going to turn to the book -- mine is sort of messed up 3 here so that we can copy it, but can you just confirm 4 that, one, this is, in fact, the 2008 World Health 5 Organization classification book; and second, that the 02:52 6 pages I've handed you are, albeit poor, but copies of 7 Pages 85 and 86 from that book? 8 A. Yes, I'm glad you're not checking books out of 9 my library. Yes, that's what these are from. 10 Q. And what is this particular -- what disease or 02:52 11 disease entities do these pages deal with, Exhibit J, 12 that I've handed you? 13 A. What you've handed me are Pages 85 and 86; and 14 they are referred to as 15 myelodysplastic/myeloproliferative neoplasm, 02:52 16 unclassifiable. 17 Q. Now, is that the disease entity that -- or 18 entities that you were describing for us a moment ago 19 before I handed you that document? 20 A. Yes. 02:52 21 Q. Now, is MDS/MPN, I think WHO calls it, is that 22 a myelodysplastic syndrome? 23 A. All of these diseases in this category are 24 myeloproliferative disease or neoplasms, whichever term 25 you like; but they may have myelodysplastic features. 02:53 PREFERRED LEGAL SERVICES, INC. 214.750.0047 www.preflegal.com 800.405.4056 Ethan A. Natelson, M.D. February 10, 2010 Page 58 1 Q. What is the difference for a layperson between 2 MDS or myelodysplastic features and myeloproliferative 3 features? 4 A. Well, the easiest way to think about it is this 5 way. Myelodysplasia is characterized by what we call 02:53 6 ineffective myelopoiesis. What that means is -- a simple 7 example is, if I take a person and inject them with 8 radioactive iron, within about 30 minutes or so, that 9 iron disappears from the circulation. It's gone. It 10 goes right into the bone marrow. 02:53 11 Now, if I sample the blood over the course 12 of a week, by the time you get out to seven to ten days, 13 all of that iron has reappeared out into the circulating 14 blood; but now it's inside the red cells in the 15 hemoglobin. 02:54 16 In other words, the bone marrow took that 17 iron, built it into new red blood cells and all of that 18 radioactive label came out circulating. That's effective 19 erythropoiesis. 20 Now, if I do that same experiment on 02:54 21 someone with RARS, I inject them with the same amount of 22 radioactive iron. In the same sort of period of time, it 23 will go right into the bone marrow. Now, if I look to 24 see where that iron is at seven to ten days, sometimes as 25 little as 5 percent of it will be back out and 02:54 PREFERRED LEGAL SERVICES, INC. 214.750.0047 www.preflegal.com 800.405.4056 Ethan A. Natelson, M.D. February 10, 2010 1 circulating red cells. Page 59 2 What's happening is the iron gets into the 3 red cell precursors and it churns in the bone marrow and 4 the cells are made and die and made and die in the bone 5 marrow and it's ineffective. The production is -- the 02:54 6 machinery looks like it's there, but it's not efficient. 7 The cells aren't coming out. That's ineffective 8 erythropoiesis. The same would be true if you're looking 9 at white cells or platelets. The general term is 10 ineffective myelopoiesis. That's a very strong 02:55 11 characteristic of all myelodysplastic disorders. 12 When you look at myeloproliferative 13 disorders, like atypical chronic myeloid Leukemia, for 14 example, or chronic myelomonocytic Leukemia, the bone 15 marrow is very efficient. You look in the bone marrow, 02:55 16 it's full of white cells. They are coming right out and 17 circulating. So, they don't have this problem. They 18 have -- they have a very proliferative disease. 19 So, in myelodysplasia, typically, 20 everything is low. We have what we call cytopenias -- 02:55 21 low red cells in the peripheral blood, low numbers of 22 white cells, low numbers of platelets. 23 On the other hand, in the 24 myeloproliferative diseases, you may have white counts of 25 300,000 because the bone marrow is quite efficient. It's 02:55 PREFERRED LEGAL SERVICES, INC. 214.750.0047 www.preflegal.com 800.405.4056 Ethan A. Natelson, M.D. February 10, 2010 1 making these cells, and they are coming out and Page 60 2 circulating. And so, that's a major difference between 3 those two illnesses. 4 Q. We have talked about your opinions and views on 5 whether benzene is causally associated or causes RARS -- 02:55 6 refractory anemia ringed sideroblast. What is the 7 evidence as to whether benzene causes myeloproliferative 8 disorders? 9 A. Well, to my knowledge, there is none. In other 10 words, this has been looked at by a number of people, 02:56 11 particularly in illnesses like chronic myeloid Leukemia 12 and myelomonocytic Leukemia, chronic myelomonocytic 13 Leukemia; and there isn't evidence that those 14 myeloproliferative diseases can be caused by excessive 15 benzene exposure. 02:56 16 So, the general dogma in hematology would 17 be that myelodysplasia, that category, certain types can 18 be caused by excessive benzene exposure. In fact, the 19 World Health Organization booklet says that. 20 Myeloproliferative diseases, on the other 02:56 21 hand, there isn't evidence that benzene can cause those. 22 Q. The same question for this MDS/MPN 23 myelodysplastic syndrome/myeloproliferative disorder or 24 neoplasm, what is the evidence that benzene causes those 25 disorders? 02:57 PREFERRED LEGAL SERVICES, INC. 214.750.0047 www.preflegal.com 800.405.4056 Ethan A. Natelson, M.D. February 10, 2010 1 A. Well, there is none. And, in fact, the Page 61 2 reviewers on that, the latest reviews that are perhaps a 3 year or so old tell us the cause of all of those 4 illnesses in that category, the etiology is unknown. 5 MR. SCOTT: Doctor, that's all I have. 02:57 6 Thank you very much. 7 EXAMINATION 8 BY MR. ASHER: 9 Q. Dr. Doctor, my name is Ross Asher. 10 Did I hear you correctly earlier to say 02:57 11 that myelodysplastic syndrome or myelodysplasia is a term 12 for a classification of a group of diseases? 13 A. Yes, it's a classification system that was 14 first proposed around 1982. 15 Q. So, if someone is diagnosed with 02:57 16 myelodysplastic syndrome or myelodysplastic disorder, is 17 that a general diagnosis; or is that a diagnosis of some 18 specific disease? 19 A. Well, it's a little of both. It's a general 20 term. It might be, like, akin to saying hepatitis; but 02:58 21 there are many forms of hepatitis. It's a general 22 category of bone marrow failure; but there are many, many 23 different forms of myelodysplasia. 24 Q. I want to go back and ask just a couple of 25 questions about -- pardon me -- the article that you were 02:58 PREFERRED LEGAL SERVICES, INC. 214.750.0047 www.preflegal.com 800.405.4056 Ethan A. Natelson, M.D. February 10, 2010 1 asked about earlier, Benzene Exposure Refractory Page 62 2 Sideroblastic Erythropoiesis: Is There an Association, 3 that article, I believe, was published in the AMERICAN 4 JOURNAL OF MEDICAL SCIENCE? 5 A. Yes. 02:58 6 Q. Is the AMERICAN JOURNAL OF MEDICAL SCIENCE a 7 peer-reviewed publication? 8 A. Yes. 9 Q. And can you explain for the ladies and 10 gentlemen of the jury what it means for an article to 02:58 11 undergo peer review? 12 A. Yes, well, this particular journal is one of 13 the oldest journals in the country, medical journals; and 14 what happens is that when you send an article into a 15 journal, they have an internal editorial board. And 02:59 16 their people review the article and see if they feel that 17 it has merit. And many times when you send an article 18 into a journal, it will never get out of the journal. In 19 other words, the internal review board turns it down 20 flat. They say it's not of interest to the general 02:59 21 public. It's poorly written. We're not even going to 22 bother to send this out to a reviewer not connected with 23 our journal. 24 And ultimately, if they decide it has 25 potential, they will send it out, typically, to three 02:59 PREFERRED LEGAL SERVICES, INC. 214.750.0047 www.preflegal.com 800.405.4056 Ethan A. Natelson, M.D. February 10, 2010 Page 63 1 reviewers. And, for example, I, just a few weeks ago got 2 an e-mail from a journal called HEMATOLOGICA. 3 And they said, Would you be willing to 4 review an article for us? 5 And I said, okay. 03:00 6 And so, they sent me that article, all 7 electronically. 8 And what happens is they then gather the 9 comments of the reviewers they send it out to; and if 10 there is a disagreement, they may send it out to a few 03:00 11 more reviewers. And then they come to some decision and 12 will send a letter back to you saying what they feel you 13 should do with your article. 14 Q. And what's the purpose, generally, of peer 15 review before publication? 03:00 16 A. Well, it's multiple eyes. In other words, they 17 are sending it out to people who don't necessarily think 18 alike, have different expertise and might find something 19 that's incorrect that another reviewer might gloss over. 20 And so, you're looking for several people to look at a 03:00 21 study and see if you feel it has merit. 22 Q. And the article we're talking about here that 23 you've written on benzene exposure, that was peer 24 reviewed; is that right? 25 A. Yes. 03:00 PREFERRED LEGAL SERVICES, INC. 214.750.0047 www.preflegal.com 800.405.4056 Ethan A. Natelson, M.D. February 10, 2010 Page 64 1 Q. And it was published by that -- by the AMERICAN 2 JOURNAL OF MEDICAL SCIENCE after being peer reviewed; is 3 that right? 4 A. Yes. 5 Q. I wasn't quite certain, did you say that when 03:01 6 you spoke to Mr. Williams, he told you that your 7 deposition today wasn't for use in any specific case? 8 A. Yes, as I recall, the conversation was 9 something; and, of course, I don't have a recording. 10 But he said that you're going to receive a 03:01 11 subpoena, and I want to question you about your article. 12 And I said, About my article? 13 He said, yes. 14 I said, Well, are we talking about a 15 particular case or -- he said, No, no, I want to question 03:01 16 you about your article. 17 And I said, Okay. I hadn't received the 18 subpoena at that point, but I said that sounds all right. 19 I'll be willing to do that. 20 Q. Have you come to find out that you are here 03:01 21 today because of a specific case that's going on? 22 A. Well, you informed me of that when you called 23 me. 24 Q. And I want to make sure we clear up one thing 25 that you mentioned earlier. 03:02 PREFERRED LEGAL SERVICES, INC. 214.750.0047 www.preflegal.com 800.405.4056 Ethan A. Natelson, M.D. February 10, 2010 Page 65 1 Did I ever suggest to you in a telephone 2 call that you should try to avoid this deposition today? 3 A. Absolutely not. 4 Q. And did I inform you that I represented a party 5 to the case and we had not designated you as an expert 03:02 6 witness and, therefore, I couldn't represent you? 7 A. Correct, you said that. 8 Q. Sir, I think that's all the questions I have 9 for you right now. 10 FURTHER EXAMINATION 03:02 11 BY MR. WILLIAMS: 12 Q. When we originally talked, I informed you that 13 this deposition didn't involve a case that you were an 14 expert in; is that correct? 15 A. I can't recall the exact language. You said 03:02 16 something to the effect -- when I asked you, Is this 17 regarding a case? 18 You said something, as best I can say, This 19 is no case -- this has nothing to do with any case you've 20 ever had anything to do with, or something to that 03:02 21 effect. 22 Q. Fair enough. 23 Doctor, do you recall one other thing you 24 told me on the phone when I explained that I wanted to 25 discuss your 2007 article dealing with RARS, do you 03:02 PREFERRED LEGAL SERVICES, INC. 214.750.0047 www.preflegal.com 800.405.4056 Ethan A. Natelson, M.D. February 10, 2010 1 recall what you told me? Page 66 2 A. I don't recall. 3 Q. Do you recall what you told me about -- that 4 you couldn't call it a RARS case without looking at the 5 slide? 03:03 6 MR. SCOTT: Object to the form. 7 A. Oh, yes, I said -- I don't remember how we got 8 on that; but I said, if it's a particular case, I said, I 9 would have to look at the marrow slides to be convinced 10 that that was a diagnosis. 03:03 11 Q. (By Mr. Williams) Doctor, what percentage of 12 ringed sideroblasts do you need to have a RARS diagnosis? 13 A. Well, that's an interesting question. The 14 typical number given by bodies such as the WHO is 15 15 percent of all of the red cell precursors of the bone 03:03 16 marrow should be ringed sideroblasts. 17 Hematologists traditionally don't count 18 cells. We look at it. And many of these cases, there 19 are 60 and 70 percent ringed sideroblasts. It's obvious 20 what they have. It's like looking at an old friend. And 03:03 21 I think you would find very few hematologists who would 22 laboriously count whether it's 15 percent, 16 or 17 23 percent. Some pathologists might; but not too many of 24 them, either. 25 So, it's usually a visual diagnosis; but, 03:04 PREFERRED LEGAL SERVICES, INC. 214.750.0047 www.preflegal.com 800.405.4056 Ethan A. Natelson, M.D. February 10, 2010 1 technically, the number is supposed to be 15 percent or Page 67 2 greater. 3 Q. And if there aren't 15 percent ringed 4 sideroblasts present, you couldn't make a diagnosis of 5 RARS; is that correct? 03:04 6 A. It does not meet the standard of care that this 7 diagnosis requires. 8 Q. And, Doctor, one final question: Did you 9 receive any type of compensation whatsoever for the 10 writing and drafting and publishing of your 2007 benzene 03:04 11 RARS article? 12 A. No. In fact, it cost me a few dollars, as I 13 gave you the receipt. 14 Q. As a matter of fact, this is your invoice -- 15 A. That is my invoice. 03:04 16 Q. -- that you paid to get a published copy of the 17 book? 18 A. Yes, most journals will give you a charge per 19 page and a very large charge if you have color prints; 20 and so, it can be very expensive to publish an article 03:04 21 these days. 22 MR. WILLIAMS: We'd like to mark his 23 invoice. I don't have any further questions. Thank you, 24 Doctor. 25 (Exhibit No. K was marked.) 03:05 PREFERRED LEGAL SERVICES, INC. 214.750.0047 www.preflegal.com 800.405.4056 Ethan A. Natelson, M.D. February 10, 2010 Page 68 1 FURTHER EXAMINATION 2 BY MR. SCOTT: 3 Q. Dr. Natelson, on this issue of counting ringed 4 sideroblasts, is this one of those issues where 5 practicing clinicians and hematologists, such as 03:05 6 yourself, basically don't need a weatherman to know which 7 way the wind blows? 8 A. Well, when considered that way, I think in my 9 career, I've probably, personally, looked at at least 10 7,000 bone marrows more. And so, usually, if I'm looking 03:05 11 at a bone marrow, it doesn't take more than a few 12 milliseconds to give me a general idea of what the bone 13 marrow is going to show. 14 Now, I will study it for much longer than 15 that, particularly if I'm photographing it to find a good 03:05 16 feel to illustrate a point. But usually, to an 17 experienced hematologist, just a short time under the 18 microscope tells you what you need to know. 19 Q. And that's an interesting point. Is it 20 accurate to say that even if one were to count 03:06 21 sideroblasts, the counting must be done in representative 22 fields from the bone marrow pathology? 23 A. Certainly, it's not only the representative 24 fields; but also is the slide preparation proper? There 25 is an art, as well as a science to making a good iron 03:06 PREFERRED LEGAL SERVICES, INC. 214.750.0047 www.preflegal.com 800.405.4056 Ethan A. Natelson, M.D. February 10, 2010 Page 69 1 stain of a bone marrow. It needs to be a relatively thin 2 film, and it needs to be incubated with the two reagents 3 that you use -- cyanide reagent and a hydrochloric acid 4 reagent, and it needs to be properly incubated and then 5 it needs to be properly counterstained because if you 03:06 6 over counterstain it, you may obscure a lot of things 7 there. And if you don't incubate it long enough, you 8 don't get the good blue color. 9 So, there is a bit of a science and an art 10 to making this; and I've seen many bone marrow slides 03:07 11 which are very thick. And you really can't tell whether 12 there is ringed sideroblasts there or not, and you may 13 have to repeat a stain. 14 Q. If staining is done in a way that the stain was 15 negative as a processing artifact, can that affect the 03:07 16 count, if you will, of ringed sideroblasts when you 17 observe the slides under the microscope? 18 A. Yes, because what happens is you flood the 19 slide with a stain; and sometimes, if there is a little 20 grease on the slide or it's not properly fixed with 03:07 21 alcohol, you will get uneven staining. Some areas will 22 be very densely stained. Other areas not well sustained 23 at all. So, you have to look sometimes at multiple 24 slides and you'll find a, quote, good area that looks 25 well sustained with good colors; and that's what you -- 03:07 PREFERRED LEGAL SERVICES, INC. 214.750.0047 www.preflegal.com 800.405.4056 Ethan A. Natelson, M.D. February 10, 2010 1 if I were going to photograph something, that's what I Page 70 2 would seek. 3 Q. Did you bring a copy of your CV today? 4 A. I didn't. It wasn't asked for. So, I didn't 5 bring it. 03:08 6 Q. I understand. I neglected to do that myself. 7 Do you diagnose and treat patients with 8 Leukemia lymphoma, myelodysplastic syndromes essentially 9 every workday of your life? 10 A. Yes. 03:08 11 Q. How long have you been doing that? 12 A. I've been seeing hematology patients 13 exclusively since around 1969. 14 Q. Do you teach medical students and hematology 15 specifically to medical students? 03:08 16 A. Yes. 17 Q. And for how long have you been doing that? 18 A. Well, I've been in medical education my entire 19 career; and that might involve interns and residents. 20 And I'm a director of one of our residency programs, and 03:08 21 it might be students of various types. 22 MR. SCOTT: I believe that's everything I 23 have. Thank you, Doctor. 24 MR. WILLIAMS: Thank you, Doctor. 25 MR. ASHER: Whoa. 03:08 PREFERRED LEGAL SERVICES, INC. 214.750.0047 www.preflegal.com 800.405.4056 Ethan A. Natelson, M.D. February 10, 2010 Page 71 1 FURTHER EXAMINATION 2 BY MR. ASHER: 3 Q. Doctor, with regard to this question of 4 15 percent ringed sideroblasts in order to have a 5 diagnosis of RARS -- 03:09 6 A. Yes. 7 Q. -- does that 15 percent count have to come in 8 any particular time? For example, if you have two bone 9 marrow samples taken at different times, an earlier bone 10 marrow sample doesn't show 15 percent but a later one 03:09 11 shows greater than 15 percent, is there any particular 12 time that 15 percent number has to appear? 13 A. No. And, of course, an earlier one might have 14 been a poor stain; but, in other words, you would have to 15 look at the case in total. But, typically, 15 percent or 03:09 16 greater makes a diagnosis along with the other features 17 of the illness. 18 MR. ASHER: Thank you, sir. 19 FURTHER EXAMINATION 20 BY MR. SCOTT: 03:09 21 Q. Since Ross has asked, now I have to. Do 22 repeated blood transfusions cause the development or 23 observation of ringed sideroblasts? 24 A. No. 25 MR. SCOTT: That's all I have. Thank you, 03:09 PREFERRED LEGAL SERVICES, INC. 214.750.0047 www.preflegal.com 800.405.4056 Ethan A. Natelson, M.D. February 10, 2010 1 sir. 2 THE VIDEOGRAPHER: Going off the record. 3 The time now is 3:09. 4 (Signature requested.) 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 Page 72 PREFERRED LEGAL SERVICES, INC. 214.750.0047 www.preflegal.com 800.405.4056 Ethan A. Natelson, M.D. February 10, 2010 Page 73 1 CHANGE AND SIGNATURE 2 PAGE LINE CHANGE REASON 3 __________________________________________________ 4 __________________________________________________ 5 __________________________________________________ 6 __________________________________________________ 7 __________________________________________________ 8 __________________________________________________ 9 __________________________________________________ 10 __________________________________________________ 11 __________________________________________________ 12 I, ETHAN A. NATELSON, M.D., have read the foregoing deposition and hereby affix my signature that same is 13 true and correct, except as noted above. 14 ____________________________________ ETHAN A. NATELSON, M.D. 15 16 THE STATE OF TEXAS COUNTY OF ___________ 17 Before me, ________________________________, on this day 18 personally appeared ETHAN A. NATELSON, M.D., known to me (or provided to me under oath or through 19 __________________) to be the person whose name is subscribed to the foregoing instrument and acknowledged 20 to me that they executed the same for the purposes and consideration therein expressed. 21 Given under my hand and seal of office this 22 _______________ day of __________________, 2010. 23 ________________________ NOTARY PUBLIC IN AND FOR 24 THE STATE OF ___________ 25 PREFERRED LEGAL SERVICES, INC. 214.750.0047 www.preflegal.com 800.405.4056 Ethan A. Natelson, M.D. February 10, 2010 1 STATE OF TEXAS: Page 74 2 REPORTER'S CERTIFICATION ORAL DEPOSITION OF ETHAN A. NATELSON, M.D. 3 TAKEN ON FEBRUARY 10, 2010 4 I, Minnie Cadena, Certified Shorthand 5 Reporter in and for the State of Texas, do 6 hereby certify that this deposition transcript is a true 7 record of the testimony given by the witness, ETHAN A. 8 NATELSON, M.D., after said witness was duly sworn by me. 9 The witness x was / ___ was not requested 10 to review the deposition. 11 I further certify that I am neither 12 attorney nor counsel for, related to, nor employed by any 13 of the parties to the action in which this testimony was 14 taken. Further, I am not a relative or employee of any 15 attorney of record in this cause, nor do I have a 16 financial interest in the action. 17 GIVEN under my hand and seal of office on 18 this the 15th day of February, 2010. 19 20 ___________________________ 22 Minnie Cadena, CSR, RMR CSR No. 5849 23 Expiration Date: 12-31-10 Preferred Legal Services, Inc. 24 Firm Registration No. 157 P.O. 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