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Neuroimaging studies of the effects of low-level sarin
exposure on GW Veterans
Linda L. Chao, PhD
Center for Imaging of Neurodegenerative Diseases San Francisco VAMC
Departments of Radiology, Biomedical Imaging, and
Psychiatry University of California, San Francisco
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In March 1991, US troops destroyed several ammunitions storage complexes at Khamisiyah Iraq.
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Modeling of the potential hazard area at Khamisiyah.
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• Significant association between
estimated levels of sarin/cyclosarin
exposure and volumes of the
white matter (reduced) and lateral
ventricles (increased).
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279 GW veterans studied under DoD-funded Gulf War Imaging Study
between 2002-2007
40 selected to match exposed GW veterans for age,
gender, and clinical factors
40 GB/GF exposed
239 not exposed to GB/GF
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N No. Female (%) Age, years Education, years No. current PTSD diagnosis (%) No. current MDD diagnosis (%) No. CMI cases (%)
40 7 (18%)
44.0 + 10.2 14.9 + 3.7 5 (13%) 2 (5%)
21 (54%)
40 7 (18%)
42.7 + 9.3 14.5 + 2.0 5 (13%) 3 (7%)
23 (59%)
Exposed Unexposed
PTSD: Posttraumatic Stress Disorder MDD: Major Depressive Disorder CMI: Chronic Multisymptom Illness as defined by Fukuda et al. (1998)
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Cortical gray matter (GM), white matter (WM), and cerebral spinal fluid (CSF) were automatically classified with SPM8 segmentation.
GM WM CSF
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• After accounting for ICV, age, and gender, exposed veterans had smaller total brain GM volume than unexposed veterans.
Volu
me
(cc)
200
300
400
500
600
700
800
Exposed
Unexposed
GM WM CSF ICV
*
1600
1700
1800
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• In post-hoc analyses, we examined group differences in regional lobar GM volume.
0
50
100
150
200
250
300
Volu
me
(cc)
Frontal Parietal Temporal Occipital
**
* *
Exposed
Unexposed
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Compare tissue density in common space
Subj 1
Subj N
Subj 2
Subj 1
Subj M
Subj 2
Exposed GW Veterans Unexposed GW veterans
Warp Tissue density maps to common space
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• Nothing from the VBM analyses of the GM segmentation maps survived correction for multiple comparisons.
p < 0.001, uncorrected
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• Veronesi B, Jones K, Pope C. Electrophysiological and biochemical effects of single and multiple doses of the organophosphate diazinon in the mouse. Toxicol Appl Pharmacol 1990; 104:440-56.
• Pazdernik TL, Emerson MR, Cross R, Nelson SR, Samson FE. Soman-induced seizures: limbic activity, oxidative stress, and neuroprotective proteins. J Appl Toxicol 2001; 21:S87-S94.
• Abdel-Rahman A, Shetty AK, Abou-Donia MB. Acute exposure to sarin increases blood brain barrier permeability and induces neuropathological changes in the rat brain: dose-response relationships. Neuroscience 2002; 113:721–41.
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• Hippocampal volume (HV) was quantified with a semi-automatic high dimensional brain mapping tool (Medtronic Surgical Navigation Technologies, SNT).
4.2
5.4
5.0
4.6
5.8
Exposed
Unexposed
*
Hip
poca
mpa
l Vol
ume
(cc)
• After accounting for ICV, age, and gender, exposed veterans had smaller HV than unexposed veterans.
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Volu
me
(cc)
200
300
400
500
600
700
800
GM WM CSF
*
4.2
5.4
5.0
4.6
5.8
Exposed Unexposed
*
Hippocampus
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• Follow-up study with more subjects (N=64) imaged at higher magnetic field strength (4T) to determine if we could replicate and extend our previous finding in an independent cohort of GW veterans with predicted GB/GF exposure.
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158 GW veterans studied under VA-funded Gulf War Imaging
Project 2005-2009
64 selected to match exposed GW veterans
21 GB/GF exposed
137 not exposed to GB/GF
8 also participated in 1.5T GW project
13 GB/GF exposed
Recruited 51 GB/GF exposed GW veterans
64 GB/GF exposed
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PTSD: Posttraumatic Stress Disorder MDD: Major Depressive Disorder CMI: Chronic Multisymptom Illness as defined by Fukuda et al. (1998)
N No. Female (%) Age, years Education, years No. current PTSD diagnosis (%) No. current MDD diagnosis (%) No. CMI cases (%)
64 5 (8%)
48.4 + 7.0 15.1 + 2.3
5 (8%) 6 (9%)
33 (52%)
64 5 (8%)
48.5 + 7.8 15.1 + 2.1
5 (8%) 8 (13%) 33 (52%)
Exposed Unexposed
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GM WM CSF
1.5T
4T
Cortical GM, WM, and CSF were automatically classified with SPM8 segmentation.
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Volu
me
(cc)
400
500
600
700
800
• After accounting for ICV, age, and gender, exposed veterans had smaller total brain GM and WM volume and larger CSF volume compared to unexposed veterans.
Exposed
Unexposed
GM WM CSF ICV
*
*
1600
1700
1800
*
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CA1
CA2
CA3
CA4/DG
S.G. Mueller et al. Measurement of hippocampal subfields and age-related changes with high resolution MRI at 4T. 2007; Neurobiol Aging 28(5):719-26
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CA1
CA2 CA3
DG
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Unexposed
Volu
me
(mm
3 )
Total HP
9500 -
9000 -
8500 -
8000 -
7500 -
7000 -
64 -
60 -
56 -
52 -
CA1
50 -
62 -
54 -
58 -
38 -
34 -
30 -
Subiculum
28 -
32 -
36 -
CA2
2.0 -
-
3.2 -
2.4 -
2.8 -
-
-
-
3.6 -
*
CA3/DG
30 -
42 -
34 -
38 -
-
-
-
-
46 -
*
CA1
CA2
DG
CA3
CA1
CA2
DG
CA3
Exposed
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In GW Veterans:
• Heaton KJ, Palumbo CL, Proctor SP, Killiany RJ, Yurgelund-Todd DA, White RF. (2007) Neurotoxicology, 28:761-9.
• Chao LL, Rothlind JC, Cardenas VA, Meyerhoff DJ, Weiner MW (2010). Neurotoxicology, 31:493-501.
In Tokyo Subway Sarin Attack Victims: • Yamasue H, Abe O, Kasai K, Suga M, Iwanami A, Yamada H, et al.
(2007) Ann Neurol. 62:37–46.
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• Non-invasive method of quantifying WM tracks in the brain.
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From Functional Magnetic Resonance Imaging, Figure 5.17 © 2004 Sinauer Associates, Inc.
• measures the random movement of water molecules.
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Fractional Anisotropy (FA)
0 (spherical) to 1 (linear) Lower FA is associated with reduced WM integrity.
Dxx Dxy Dxz Dxy Dyy Dyz Dxz Dyz Dzz
Diffusion Tensor
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PTSD: Posttraumatic Stress Disorder CMI: Chronic Multisymptom Illness as defined by Fukuda et al. (1998)
N No. Female (%) Age, years Education, years No. current PTSD diagnosis (%) No. CMI cases (%)
59 6 (10%)
48.5 + 7.6 15.1 + 2.2
4 (7%) 36 (61%)
59 6 (10%)
48.4 + 7.2 15.6 + 2.2
4 (7%) 36 (61%)
Exposed Unexposed
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y=20 y=16 y=12 y=8 y=4
y=0 y=-4 y=-8 y=-12 y=-16
y=-20 y=-24 y=-28 y=-32 y=-36
y=-40 y=-44 y=-48 y=-52 y=-56
L R
t-value
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y=20 y=16 y=12 y=8 y=4
y=0 y=-4 y=-8 y=-12 y=-16
y=-20 y=-24 y=-28 y=-32 y=-36
y=-40 y=-44 y=-48 y=-52 y=-56
Yamasue et al., Ann Neurol. 2007; 61:37-46 4T FA results
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Calculate shape of the ellipsoid
Axial Diffusivity (AD) = λ1 Higher AD has been associated with greater axonal degeneration.
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y=20 y=16 y=12 y=8 y=4
y=0 y=-4 y=-8 y=-12 y=-16
y=-20 y=-24 y=-28 y=-32 y=-36
y=-40 y=-44 y=-48 y=-52 y=-56
L R
t-value
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T > 4.72, PFWE = 0.05 T > 2.46, PFDR = 0.05
R R
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t-value 0
6
3
z = 41 z = 29 z = 21 z = 14
x = 17 x = 26 x = 31
y = 8 y = 1 y = 18
SCR
SCR SCR
L
SCR
SF
SF
SF EC
EC
SF
SCR
SCR
SCR
EC
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Radial Diffusivity (RD) = (λ2+ λ3)/2 Higher RD has been associated with demyelination and neuroinflammation.
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y=20 y=16 y=12 y=8 y=4
y=0 y=-4 y=-8 y=-12 y=-16
y=-20 y=-24 y=-28 y=-32 y=-36
y=-40 y=-44 y=-48 y=-52 y=-56
L R
t-value
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T > 2.46, PFDR = 0.05 T > 4.72, PFWE = 0.05
R R
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t-value 0
6
3
z = -27 z = -14 z = 22 z = 28
x = 32 x = 35 x = 40
y = -16 y = 8 y = 1
L
temp
temp
Temp
EC
EC
EC
IC
SCR
MF MF
MF MF SCR
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Low-level GB/GF exposure has an effect on: - GM volume (including HP) - WM volume - WM integrity
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RAC-GWVI Meeting Minutes September 22-23, 2014
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Low-level GB/GF exposure has an effect on: - GM volume (including HP) - WM volume - WM integrity neurobehavioral function ?????
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RAC-GWVI Meeting Minutes September 22-23, 2014
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• Impaired psychomotor speed (digit symbol)
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RAC-GWVI Meeting Minutes September 22-23, 2014
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Environmental Health Perspectives, 2001 109(11):1169-73
• Impaired memory (backward digit span)
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7 -1 9
7-1-9-5 7-1-9-5 5-9-1-7
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• Impaired memory (backward digit span) • Impaired psychomotor function (finger tapping)
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RAC-GWVI Meeting Minutes September 22-23, 2014
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Memory Psychomotor
function
TSSA victims
TSSA = Tokyo Subway Sarin Attack
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RAC-GWVI Meeting Minutes September 22-23, 2014
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• Impaired memory
• backward digit span
• CVLT – learning Trial 2 & short delayed recall
• Delayed visual reproduction
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RAC-GWVI Meeting Minutes September 22-23, 2014
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Memory Psychomotor
function Visuospatial
function
TSSA victims
GW vets with self-reported exposure TSSA = Tokyo Subway Sarin Attack
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RAC-GWVI Meeting Minutes September 22-23, 2014
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RAC-GWVI Meeting Minutes September 22-23, 2014
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Memory Psychomotor
function Visuospatial
function
TSSA victims
GW vets with self-reported exposure GW vets with predicted exposure TSSA = Tokyo Subway Sarin Attack
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RAC-GWVI Meeting Minutes September 22-23, 2014
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PTSD: Posttraumatic Stress Disorder CMI: Chronic Multisymptom Illness as defined by Fukuda et al. (1998)
N No. Female (%) Age, years Education, years No. current PTSD diagnosis (%) No. CMI cases (%)
107 11 (10%) 46.4 + 8.5 14.8 + 2.2 10 (9%)
68 (64%)
317 36 (11%) 46.3 + 9.5 14.9 + 2.1 42 (13%) 217(69%)
Exposed Unexposed
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Trial 1 Trials 1-5 Free Recall Short delay Long delay Cued Recall Short delay Long delay Recognition Memory
5.9 (1.9) 47.5 (11.0)
10.1 (3.5) 10.7 (3.3)
11.4 (2.8) 11.5 (3.1)
0.72 (0.25)
6.2 (1.8) 49.8 (10.2)
10.5 (3.3) 11.0 (3.4)
11.7 (2.9) 11.8 (3.0)
0.75 (0.25)
Exposed Unexposed
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MANCOVA accounting for age, sex, education, PTSD, CMI age: F8,410=4.56, p<0.001 sex: F8,410=2.28, p=0.02 education: F8,410=2.53, p=0.01 PTSD: F8,410=2.51, p=0.01 CMI: F8,410=2.51, p=0.01 No overall effect of GB/GF exposure: F8,410=0.97, p=0.46
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Trial 1 Trials 1-5* Free Recall Short delay Long delay Cued Recall Short delay Long delay Recognition Memory
5.9 (1.9) 47.5 (11.0)
10.1 (3.5) 10.7 (3.3)
11.4 (2.8) 11.5 (3.1)
0.72 (0.25)
6.2 (1.8) 49.8 (10.2)
10.5 (3.3) 11.0 (3.4)
11.7 (2.9) 11.8 (3.0)
0.75 (0.25)
Exposed Unexposed
*F1,417= 4.51, p=0.03
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RAC-GWVI Meeting Minutes September 22-23, 2014
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PTSD: Posttraumatic Stress Disorder CMI: Chronic Multisymptom Illness as defined by Fukuda et al. (1998)
N No. Female (%) Age, years Education, years No. current PTSD diagnosis (%) No. CMI cases (%)
88 9 (10%)
46.2 + 8.4 14.9 + 2.3 9 (10%) 56 (64%)
261 30 (12%) 46.3 + 9.9 14.9 + 2.2 35(13%)
168 (64%)
Exposed Unexposed
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# Omissions†
# Commissions Hit RT (ms)*
3.1 (7.5) 11.7 (6.3)
430.8 (73.9)
2.0 (5.1) 11.7 (7.4)
402.3 (62.2)
Exposed Unexposed
*F1,342= 13.16, p<0.001 † F1,342= 2.41, p=0.12
Overall effect of GB/GF exposure in MANCOVA: F3,340=6.35, p<0.001
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Spearman’s rho = -0.32 p=0.03
Spearman’s rho = -0.24 p=0.10
2.0 -
-
3.2 -
2.4 -
2.8 -
-
-
-
3.6 -
*
CA1
CA2
DG
CA3
Exposed
Unexposed
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Memory Psycho-motor
Visuo-spatial
Attention
TSSA victims
GW vets with self-reported exposure GW vets with predicted exposure TSSA = Tokyo Subway Sarin Attack
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RAC-GWVI Meeting Minutes September 22-23, 2014
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Low-level GB/GF exposure has an effect on: - GM volume (including HP) - WM volume - WM integrity - neurobehavioral/cognitive function memory psychomotor function visuospatial ability attention
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1) Is there on-going GM and WM atrophy and insult to WM integrity? 2) Are GB/GF exposed veterans at risk for accelerated aging and neurodegenerative diseases? 3) Are there therapies that might slow or reverse these effects?
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GW Veteran participants Mike Weiner
Stephen Kriger
Daniel Stevens
Peter Ng
Shannon Buckley
Linda Abadjian Jennifer Hlavin and her staff at CIND Diana Truran Sacrey and her staff at CIND Scott Seggerman and Andrew Ricci at DMDC Larry Sippos and his staff at Force Readiness and Health Assurance Force Health Protection & Readiness Defense Health Agency Office of the Assistant Secretary of Defense (Health Affairs) Defense Health Headquarters
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RAC-GWVI Meeting Minutes September 22-23, 2014
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MANCOVA accounting for age, sex, education, PTSD, CMI age: F5,338=4.27, p=0.001 sex: F5,338=1.80, p=0.11 education: F5,338=0.86, p=0.51 PTSD: F5,338=1.17, p=0.32 CMI: F5,338=3.61, p=0.003 Overall effect of GB/GF exposure: F5,338=4.73, p<0.0001
Appendix A Presentation 3 - Linda Chao
RAC-GWVI Meeting Minutes September 22-23, 2014