FILED: NEW YORK COUNTY CLERK 03/05/ :02 PM INDEX NO /2015 NYSCEF DOC. NO. 439 RECEIVED NYSCEF: 03/05/2018

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1 Steven Markowitz, MD, DrPH Occupational & Environmental Medicine 123 7th Ayenue - PMB 140 Brooklyn, NY January 26, 2016 Amy Fair, R.N. Simmons, Hanly, Conroy Law Firm 112 Madison Avenue New York, NY RE: Pietro Macaluso DOB: November 27, 1959 Dear Ms. Fair: At your request, I have reviewed medical records and related materials in order express an opinion regarding the possible presence of asbestos-related disease. I have had the opportunity to review the following materials: 1. Medical records, Kaiser Permanente Health System, Pathology reports, Kaiser Permanente Health System, Deposition, Pietro Macaluso, November 23 and 24, Complaint, October 5, 2015, Pietro Macaluso against A.O. Smith Corporation 5. Exposure history, Daniel Blouin, Esq., December 22, 2015 Clinical History Mr. Pietro Macaluso has a past medical history of hyperlipidemia, obstructive sleep apnea, osteoarthritis, depression, and anemia. On July 13, 2015, Mr. Macaluso visited a primary care physician, Dr. Sarah Turgasen, at the Kaiser Permanente Health System (Sacramento, Califomia), complaining of epigastric pain for two months accompanied by nausea, shortness of breath, and recent onset of left shoulder pain. Physical examination showed decreased breath sounds throughout the left chest and mild distension and tenderness of the abdomen. Dr. Turgasen ordered a chest x-ray, which was completed on the same day, and showed complete opacification of the left chest. On the following day, Mr. Macaluso saw a chest physician at Kaiser, Dr. S. Chen. Dr. Chen noted a history of one to two weeks of shortness of breath and left-sided chest discomfort. Physical examination showed decreased breath sounds with dullness to percussion in the left chest. Dr. Chen recommended thoracentesis, which was performed and yielded two liters of hazy yellow fluid. Cytology review of the pleural fluid yielded few cells and no evidence of malignancy or significant inflammation.

2 p. 2, Amy Fair, R.N. Mr. Macaluso returned to see a pulmonary physician at Kaiser, Dr. P. Attwal, on July 16, He reported significant improvement following the thoracentesis, though he remained with some shortness of breath. Physical examination showed decreased breath sounds in the left chest. Thoracentesis was repeated with withdrawal of 1.5 liters of dark yellow fluid. Cytology review of pleural fluid showed atypical mesothelial cells. A post-thoracentesis chest x-ray showed a pneumothorax. Mr. Macaluso was seen in the Emergency Department at Kaiser on the same day where a physical examination showed decreased breath sounds in the left chest. A left chest tube was placed, and a subsequent chest x-ray showed significant improvement in the len pneumothorax. Mr. Macaluso was admitted to the Kaiser Hospital (Sacramento, California). On July 17, 2015, Mr. Macaluso was evaluated by Dr. P. Laohaburanakit, a pulmonary specialist. A chest x-ray showed persistent left pleural effusion. The chest tube remained in place with limited drainage. He had an echocardiogram on July 17, 2015, which showed normal left ventricular size, normal ejection fraction, and no significant valvular dysfunction. Mr. Macaluso also had a chest CT scan on the same day, which showed a large loculated left pleural effusion, a moderate left pneumothorax, and a chest tube in place. A chest x-ray on July 19, 2015 showed continued presence of pneumothorax and incomplete expansion of the left lung. On July 20, 2015, Mr. Macaluso underwent bronchoscopy, thoracoscopy, pleural biopsy, and talc pleurodesis. At surgery, it was observed that Mr. Macaluso had no endobronchial lesions on bronchoscopy, but thoracoscopy showed a thickened pleura that was studded with nodules. Pathology review of the biopsy material confirmed the presence of a malignant mesothelioma of the pleura, epithelial type. Immunohistochemical stains of tissue supported the diagnosis of malignant mesothelioma. Mr. Macaluso improved condition on July 23, following surgery and was discharged in stable Mr. Macaluso's medical findings were presented to the hospital Tumor Board by Dr. Stephen Wang, an oncologist, on July 29, Recommendations included PET scan, pulmonary function testing, and surgical consultation. Mr. Macaluso saw Dr. Wang on the same day, who recommended evaluation for surgery and possible chemotherapy. A repeat chest x-ray on July 30, 2015 showed a moderate left pleural effusion with an adjacent opacity. Mr. Macaluso was evaluated by Dr. R. Peng, a chest surgeon, on July 30, Mr. Macaluso complained of mild exertional shortness of breath. Physical examination showed decreased breath sounds at the left lung base. Dr. Peng noted that Mr. Macaluso had a good functional status and recommended a PET scan and mediastinoscopy as staging tests.

3 p. 3, Amy Fair, R.N. On August 6, 2015, Mr. Macaluso had a PET scan, which showed increased FDG activity along the left pleural surface and no significant FDG accumulation in any lymph nodes or other locations. Mr. Macaluso returned to see Dr. Peng on August 12, 2015, who noted that the PET scan had shown that the cancer was limited to the left chest. A second review of pathology slides confirmed the presence of epithelial malignant mesothelioma. Dr. Peng recommended pleurectomy and decortication. On August 24, 2015, Mr. Macaluso underwent bronchoscopy and mediastinoscopy. No endobronchial lesions were seen, and multiple lymph nodes were biopsied. None, upon pathology review, demonstrated the presence of any malignancy. Mr. Macaluso had a repeat chest x-ray on September 9, 2015, which showed a moderate left pleural effusion and adjacent opacity without significant change from the previous film. Mr. Macaluso saw Dr. Peng, the chest surgeon, on September 9, 2015 who confirmed the plan for surgery. On September 14, 2015, Mr. Macaluso saw Dr. Sarah Perez, an oncologist, at Kaiser. Mr. Macaluso had minor respiratory symptoms and good functional status. Dr. Perez noted the plan for surgery and recommended adjuvant and Alimta. chemotherapy with Cisplatin On October 7, 2015, Mr. Macaluso was admitted to Kaiser Hospital (Sacramento, California) and underwent bronchoscopy, left thoracotomy, left pleurectomy and decortication, diaphragm resection, and re-construction of the diaphragm. The surgeon noted the presence of a thick tumor mass involving the parietal and visceral pleura, which was removed. The left diaphragm was also removed due to extensive tumor penetration, and a bovine pericardial patch was substituted for the excised diaphragm. Pathology review of the excised tissue confirmed the presence of a malignant mesothelioma involving the left pleura and diaphragm. Post-operatively, Mr. Macaluso required an epidural catheter for pain control with subsequent use of intravenous and oral analgesics. He recovered and was discharged with a chest tube in place on October 7, Mr. Macaluso had a chest x-ray on October 14, 2015 which showed a stable left apical pneumothorax and an increasing left pleural effusion. He also visited with Dr. Matthew Agnew, a thoracic surgeon, on the same day. Mr. Macaluso was taking Percocet every four hours for pain. Physical examination showed decreased breath sounds in the left chest. Dr. Agnew noted satisfactory recovery from surgery and removed the chest tube. He also noted that Mr. Macaluso appeared depressed.

4 p. 4, Amy Fair, R.N. Cigarette Smoking History Mr. Macaluso never smoked cigarettes, according to the medical records and the deposition. He chronically smoked marijuana for many years. Occupational History There were occasional brief references in the medical records to Mr. Macaluso's occupational history. He had worked remotely in construction. No exposure to asbestos was identified by the health care providers in the medical records. I reviewed the depositions provided by Mr. Macaluso on November 23 and 24, Mr. Macaluso was born in Sicily in 1959 and immigrated to the United States in His father was a mason in construction. Mr. Macaluso graduated high school in 1977 and attended college from 1977 to 1979 and electronics technical school from 1980 to As a youth, he assisted his father in renovating several houses from 1972 to At these houses, he assisted his father and brother in demolishing walls, installing sheet rock walls, replacing electrical wiring, installing bathroom fixtures, and laying down flooring material. He recalled applying and sanding joint compound, which created 49)." a "cloud of dust in the room (p. He scraped off old floor tile, creating airborne dust. He helped removed an old furnace, including material that was in the seams between the sections of the furnace. Between 1972 and 1982, Mr. Macaluso worked as a clerk in a supermarket and in building renovation and construction. He reported no exposure to asbestos-containing materials in his work at the supermarket. He worked there part-time while going to school, at least until the late 1970s. He also worked during most of this period on a parttime basis for a neighbor who had a construction company. He worked part-time on weekends and after school when he wasn't working at the supermarket; part-time during some summers in college and technical school; and full time for this same construction company for one year in The company did renovation and also new construction, both residential and small commercial work. Mr. Macaluso demolished old walls, installed new sheet rock walls, installed electrical wiring, assisted in plumbing 86)" work, and also painted. He applied joint compound, creating "tons of dust (p. he sanded this material. He also did a lot of clean-up on these jobs. He recalled when demolishing and removing many boilers between 1972 and 1982, using a sledge hammer, crowbar, or scraper to remove the insulation that covered the boilers and disassembling the boilers into pieces that could be removed from the buildings. He removed many dozens of boilers during his work in construction between 1972 and He removed external insulation from the majority of the boilers that he ripped out. He also removed a rope-like material, or gaskets, that held sections of some boilers together. This material fell apart during demolition, creating airborne dust. To a lesser extent, he removed some

5 p. 5, Amy Fair, R.N. insulation from pipes and insulated electrical wiring that were connected to the boilers. Mr. Macaluso routinely swept up after removing the boilers and recalled when he cleaned up that "there was dust everywhere (p. 200)." He did not install new boiler units. He recalled installing ceiling tiles at numerous Coast Guard buildings. Mr. Macaluso also worked on a very limited basis for two other contractors from 1972 to After 1982, Mr. Macaluso worked as an electronics technician at numerous locations without known exposure to asbestos. I also reviewed the Complaint filed on October 5, 2015 by Mr. Macaluso, which was largely consistent with his deposition, though less detailed. Conclusion Mr. Pietro Macaluso has developed a malignant mesothelioma of the pleura as a result of his prior exposure to asbestos. I base this conclusion upon the clinical, radiologic, and pathologic evidence of a malignant mesothelioma of the pleura; the report of frequent and direct contact with a variety of asbestos-containing materials in his construction work, which created airborne dust, between 1972 and 1982; and passage of the appropriate latency period between onset of exposure to asbestos in the early 1970s and subsequent development of malignant mesothelioma over four decades later. Mr. Macaluso described in detail his work in demolition and re-construction for a decade beginning in the early 1970s and continuing through the early 1980s in which he had frequent and direct contact with asbestos-containing materials in relation to boilers and associated pipes; installation of walls that involved his application of joint compound; installation of drop-ceilings; work with putty or caulking in performing plumbing repairs; and some work with and near electrical wiring. These activities occurred on a frequent basis and resulted in large amounts of airborne dust, which Mr. Macaluso inhaled. As you know, asbestos exposure is the predominant cause of malignant mesothelioma of the pleura. Construction workers who were involved with boiler work, joint compound application, and related activities when asbestos-containing materials were used are known to have had significant exposure to asbestos and/or develop typical asbestos-related diseases, including malignant mesothelioma of the pleura. Mr. Macaluso fits this known exposure-disease pattern well. In conclusion, Mr. Pietro Macaluso had significant exposure to asbestos, which caused his malignant mesothelioma of the pleura. I hold all opinions expressed in this report to a reasonable degree of medical certainty. I reserve the right to amend this report

6 p. 6, Amy Fair, R.N. if additional information becomes available. Please let me know if you have any questions. Sincçrely, r.. â --- â â -- Steven Markowitz, M.D., DrPH