Letters
COMMENT & RESPONSE Author Affiliations: Department of Environmental and Occupational Medicine,
Alzheimer Disease Risk Factors
To the Editor We appreciate the editorial by DeKosky and Gandy1
accompanying our article2 describing the association of se-
rum dichlorodiphenyldichloroethylene (DDE) levels and Alz-
heimer disease (AD). While we wholeheartedly agree with the
authors in calling for additional study on environmental fac-
tors in AD, there are some clarifications that we would like to
make.
1. In several places, DeKosky and Gandy suggested that the
data we reported were derived from measurement of brain
levels. Most measurements—all but 11 samples—were made
in serum. There were 11 brain samples that had matched se-
rum samples from Washington University that we used to
demonstrate that serum levels are predictive of brain lev-
els of DDE.
2. The authors stated that the data on serum DDE were not sig-
nificant from the Emory University cohort. This is incor-
rect. The serum levels of DDE were nearly 4-fold higher in
Emory AD cases than control participants and the result was
highly significant: Emory AD cases (mean [SD], 3.92 [1.06])
vs Emory control participants (mean [SD], 1.01 [0.31];
P < .001). The lack of significance the authors suggested may
have been for the association with AD diagnosis deter-
mined by logistic regression and correcting for age, sex, edu-
cation, and apolipoprotein E status. Because there were a
small number of cases with each of these factors in the
Emory cohort (25 cases and 25 control participants), we had
severely limited power to do the analysis based on the Emory
site. Rather, we incorporated these data into the pooled
analysis and accounted for site in the model. These data were
highly significant and reported in the article.
3. Finally, we caution against looking for clusters of AD based
on areas with high levels of contamination. As the authors
indicated, there does not appear to be increased preva-
lence in Spain or India where there are much higher levels
of dichlorodiphenyltrichloroethane/DDE. Likewise, we are
not aware of increased incidence in Mexico City, Mexico, or
China, where there are extremely high levels of air pollu-
tion, an exposure DeKosky and Gandy hypothesized may
be associated with AD. Only properly designed studies aimed
at defining the role of environmental exposures and AD
would provide that type of information suggested.
In closing, we would like to join DeKosky and Gandy in call-
ing for resources to form collaborative teams, such as the one
we formed here, to address the complex issue of environmen-
tal contributors to AD and other neurodegenerative diseases.
Jason R. Richardson, PhD
Dwight German, PhD
Allan Levey, MD, PhD
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Rutgers Robert Wood Johnson Medical School, Piscataway, New Jersey
(Richardson); Environmental and Occupational Health Sciences Institute,
Piscataway, New Jersey (Richardson); University of Texas Southwestern
Medical Center, Dallas (German); Emory University School of Medicine, Atlanta,
Georgia (Levey).
Corresponding Author: Jason R. Richardson, PhD, Department of
Environmental and Occupational Medicine, Rutgers Robert Wood Johnson
Medical School, Environmental and Occupational Health Sciences Institute, 170
Frelinghuysen Road, Piscataway, NJ 08854 (jricha3@eohsi.rutgers.edu).
Conflict of Interest Disclosures: None reported.
Additional Information: This letter is on behalf of the coauthors of the original
article: Ananya Roy, ScD, Stuart Shalat, ScD, Richard von Stein, PhD, Muhammad
Hossain, DVM, PhD, Brian Buckley, PhD, and Marla Gearing, PhD.
1. DeKosky ST, Gandy S. Environmental exposures and the risk for Alzheimer
disease: can we identify the smoking guns? JAMA Neurol. 2014;71(3):273-275.
2. Richardson JR, Roy A, Shalat SL, et al. Elevated serum pesticide levels and
risk for Alzheimer disease. JAMA Neurol. 2014;71(3):284-290.
In Reply In response to our editorial1 on their article,2 Richard-
son and colleagues have submitted 3 specific comments. We
agree with some of their points, and we appreciate their iden-
tification of statements in our editorial1 that were not as clear
as we had intended.
As to the first point by Richardson and colleagues, we ac-
knowledge that on the second page of the editorial, in begin-
ning to discuss their findings, we referred to dichlorodiphe-
nyldichloroethylene (DDE) levels in brains when, in fact, we
were discussing levels in serum.
In their second point regarding our statement that there
was no relationship between DDE levels and Alzheimer dis-
ease (AD) in the Emory University samples, they are correct
that the mean DDE levels were significantly higher in the AD
samples than in control participants. Our intention had been
to make the identical point that Richardson et al raised in the
response to the editorial (ie, that, in the Emory cohort, there
was no significant relationship between DDE levels and the
relative risk for AD when the data were controlled for APOE
genotype and other factors). There was a statistically signifi-
cant relationship between DDE levels and the relative risk for
AD in the University of Texas Southwestern (UTSW) cohort.
Our goal was to note that—while the combination of the UTSW
data and the Emory data yielded a larger sample size—the 2
populations were disparate in certain internal features (eg, the
presence or absence of a statistically significant AD relative risk
relationship). Specifically, while the inclusion of the Emory data
weakened the level of significance of the DDE relationship to
AD relative risk from P < .0001 for the UTSW-only data set to
P < .001 for the pooled UTSW and Emory data, there is no doubt
that the pooled data set is highly significant.
Finally, in the third point, Richardson et al appeared to ar-
gue against looking for clusters of cases of disease in regions
with high levels of a purported toxin. Our comment was in-
tended to refer to the fact that unusual numbers, densities, or
JAMA Neurology August 2014 Volume 71, Number 8 1051
 Letters
Table. Overview of the Genetic GNAL Screening Studies
No. of Patients With No. of Cases With
Dystonia Screened Possible GNAL Mutations Mutations
Study (Motherland) (Family History)
Kumar et al,1 2014 318 (Germany, Serbia, 2 (Negative)
and Japan)
Saunders-Pullman et al,4 76 From 40 families 8 (Positive)a
2014 (Amish-Mennonite
descent)
Dufke et al, 2014b 137 (Germany) 2 (Negative)
Charlesworth et al,5 192 (United Kingdom) 0 January 9, 2014. doi:10.1002/mds
2014
Zech et al, 2014c 342 (Germany) 1 (Negative)
Miao et al, 2014d 59 (China) 2 (Negative)
subtypes of cases may be the harbingers of a toxin-related dis-
ease outbreak. Our intent was not to suggest that studies should
only go forward when clusters of cases are identified. In con-
trast to the statement by Richardson et al in their letter, we
would draw attention to reports by Calderón-Garcidueñas et
al3 of inflammation and deposits of amyloid β–like immuno-
reactive material in the brains of children with prolonged ex-
posure to the atmosphere of Mexico City.
We thank the authors for their thoughtful corrections and
comments. We agree that this is a propitious time for more stud-
ies of the type that they have pursued and that this repre-
sents an outstanding opportunity for toxicologists, epidemi-
ologists, and dementia researchers to collaborate in identifying
environmental risks.
Steven T. DeKosky, MD
Sam Gandy, MD, PhD
Author Affiliations: Department of Medical Ethics and Health Policy, University
of Pennsylvania Perelman School of Medicine, Philadelphia (DeKosky);
Department of Neurology and Psychiatry and Neurobehavioral Sciences,
University of Virginia School of Medicine, Charlottesville (DeKosky); Neurology
and Psychiatry (Dual Primaries), Center for Cognitive Health and NFL
Neurological Care, New York, New York (Gandy); Mount Sinai Alzheimer’s
Disease Research Center, New York, New York (Gandy).
Corresponding Author: Steven T. DeKosky, MD, Department of Neurology and
Psychiatry and Neurobehavioral Sciences, University of Virginia School of
Medicine, PO Box 800793, McKim Hall, Charlottesville, VA 22908-0394
(dekosky@virginia.edu).
Conflict of Interest Disclosures: In the past 5 years, Dr DeKosky has served as a
consultant for Rivermend Inc, AstraZeneca, Merck, Elan/Wyeth, Novartis, Lilly,
Janssen, Helicon Therapeutics, and Genzyme. He has received research grants
from Elan, Novartis, Janssen, Pfizer, and Baxter. He serves as an editor for Up To
Date. He is founding chair of the International Society to Advance Alzheimer’s
Research and Treatment (ISTAART), the Medical and Scientific Advisory Council
of the Alzheimer’s Association, and the Medical and Scientific Advisory Panel of
Alzheimer’s Disease International. Within the past 5 years, Dr Gandy has
received grants from Baxter Pharmaceuticals, Polyphenolics Inc, and Amicus
Pharmaceuticals. He has served as a member of the data and safety monitoring
board for the Pfizer-Janssen Alzheimer’s Immunotherapy Alliance, as a member
of the Scientific Advisory Board of DiaGenic, and as a consultant to Amicus
Pharmaceuticals and Cerora Inc.
1. Dekosky ST, Gandy S. Environmental exposures and the risk for Alzheimer
disease: can we identify the smoking guns? JAMA Neurol. 2014;71(3):273-275.
2. Richardson JR, Roy A, Shalat SL, et al. Elevated serum pesticide levels and
risk for Alzheimer disease. JAMA Neurol. 2014;71(3):284-290.
3. Calderón-Garcidueñas L, Reed W, Maronpot RR, et al. Brain inflammation
and Alzheimer’s-like pathology in individuals exposed to severe air pollution.
Toxicol Pathol. 2004;32(6):650-658.
1052 JAMA Neurology August 2014 Volume 71, Number 8
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Possible GNAL Prevalence of
Putative GNAL
Identified Cases, %
c.637G>A 0.62
c.1057G>A
c.409G>A 10.52
c.878C>A
a
c.514G>A Seven patients from 2 families
c.733C>T 1.45 previously reported.2
c.G252A b
Mov Disord. 2014. Published online
.25794.
c.436G>A 0.29 c
Mov Disord. 2014;29(1):143-147.
c.284C>T 3.38 d
Parkinsonism Relat Disord.
c.932-7T>G
2013;19(10):910-912.
GNAL Mutations and Dystonia
To the Editor We read with great interest the article by Kumar
and colleagues1 published in JAMA Neurology. They screened
318 patients with different types of dystonia, mainly sporadic,
from Germany, Serbia, and Japan for mutations in all 12 exons
of GNAL and found 2 putative mutations (c.637G>A and
c.1057G>A) in 2 sporadic cases with craniocervical dystonia and
cervical dystonia, respectively. The prevalence estimate of
GNAL cases according to their figure is 0.62%, which is much
lower than originally reported.2 The initial discovery report by
Fuchs et al2 reported GNAL mutations in 6 of 39 families
screened (approximately 15%). However, in the subsequent
study by Vemula et al,3 only 3 GNAL mutations were detected
in 760 individuals with familial or sporadic primary dystonia
(<0.5%). Furthermore, a number of groups have subsequently
screened different cohorts of patients with dystonia for GNAL
mutations, yielding conflicting prevalence estimates (Table).
We previously screened GNAL by Sanger sequencing using
the DNA samples from 192 probands from the United King-
dom (136 women and 56 men) with either familial or sporadic
cervical dystonia selected from a research database includ-
ing patients with focal or segmental dystonia that involved the
cervical region, and we failed to identify any mutations in
GNAL. 5 With the exception of Saunders-Pullman and
colleagues,4 who included in their report 2 of the families pre-
viously reported by Fuchs et al,2 overall prevalence estimates
of GNAL mutations seem to be low (Table), and the recent ar-
ticle by Kumar et al1 is in line with this.
Another crucial point that needs to be addressed by fur-
ther research is whether the reported GNAL variants in the
study by Kumar et al1 (or by others) represent true pathogenic
mutations. In fact, in some of the listed works, use of differ-
ent prediction software yielded equivocal results and segre-
gation analysis was either not performed or not possible. It
might be possible that some of the reported GNAL mutations
indeed represent normal variants. Overall, the article by Ku-
mar et al1 confirms ours and other findings that GNAL does not
represent a common cause of dystonia, suggesting that other
novel genetic causes of dystonia remain to be identified.
Roberto Erro, MD
Kailash P. Bhatia, MD, FRCP
John Hardy, MD
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