Legal Case Study

On June 17, 2002, the superior court sustained Ethicon's demurrer to the products liability cause of action without leave to amend, relying upon Norgart, supra, 21 Cal.4th 383, 87 Cal.Rptr.2d 453, 981 P.2d 79, and Bristol-Myers Squibb, supra, 32 Cal.App.4th 959, 38 Cal.Rptr.2d 298, to conclude that the statute of limitations barred the products liability cause of action. The superior court stated that when a plaintiff sues based on knowledge or suspicion of negligence, including medical malpractice as in Fox's case, the statute of limitations begins to run as to all defendants, including manufacturers possibly liable under products liability theories. The superior court also stated that Fox failed to demonstrate that amending the complaint could ""overcome the limitations defense."" Fox timely appealed from the superior court's order sustaining Ethicon's demurrer as to the products liability cause of action.

The Court of Appeal reversed the superior court's order and remanded with directions to grant Fox leave to amend to allege facts explaining why she did not have reason to discover earlier the factual basis of her products liability claim. In so ruling, the Court of Appeal held that Bristol-Myers Squibb's ""bright-line rule of imputed simultaneous discovery of causes of action"" did not apply. Ethicon petitioned this court, and we granted review.

additional questions

 Question 1

A 25-year-old woman, pregnant in her second trimester, starts to

experience chorea and bilateral ankle arthralgia but has no past history of

rheumatic chorea. In the first hour, her erythrocyte sedimentation rate is

70. Could this be no more than chorea gravidarum?

Question 2

Is valproate as equally effective as haloperidol in the treatment of chorea,

in particular rheumatic chorea?

Question 3

Does a lesion of Guillain-Mollaret's triangle in the brain stem cause a

type of myoclonus other than symptomatic palatal myoclonus?

Question 4

1. In West's syndrome, after the fits have been suppressed, for how

long should treatment with adrenocorticotrophic hormone (ACTH)

continue?

2. Does complete suppression of resistant infantile myoclonic jerks by

ACTH characterize West's syndrome?

Question 5

Are anticholinergics the first line of treatment for primary torsion

dystonia?

Question 6

Can multiple sclerosis (MS) be associated with lack of vitamin D,

lack of sunlight or low fish/cod-liver oil in the diet? By looking at the

epidemiology (none at the equator; more outside 40� latitude, both north

and south; less on top of Swiss mountains than in the Swiss valleys; more

in fishing coastal towns and in Eskimos) this seems to be very important.

Vitamin D modulates the immune system and active vitamin D given

to rats with experimental MS (acute encephalomyelitis) lowers the

monocyte count in cerebrospinal fluid (CSF) by 90% in 72 hours with

return of power to their limbs. Japanese MS patients who ate plenty of

fish were found to have vitamin-D-receptor pleomorphism. The staple

grains and cereals (wheat, barley, oats) eaten in Scandinavian and

northern European countries contain phytic acid, which blocks vitamin D

absorption, and rice is the only cereal free of phytic acid.

Are there any studies where low vitamin D levels in blood are

associated with MS relapse?

Question 7

What are the diagnostic criteria of 'definitive' multiple sclerosis (MS) - as

taught to a medical student? We have found different information from

different sources.

Question 8

How reliable is a CT-brain scan with contrast in showing MS lesions as

enhancing lesions in the presence of a contraindication to use MRI?

Question 9

Is magnetic resonance (MR) spectroscopy of value in differentiating

multiple sclerosis from cerebral autosomal dominant arteriopathy with

subcortical infarctions (CADASIL)?

Question 10

Does hemiplegia due to multiple sclerosis present with hemiparesis

rather than dense hemiplegia (which is more characteristic of a stroke)?

Other than age, what are the clinical signs that would help differentiate

between the two?130"

Legal Case Context

 Case Overview:

 

 The case was before the Superior Court in which Ethicon had a motion to quash a products liability claim arguing that any claim with knowledge or suspicion of negligence was time barred.

 The lower court retained this decision; Fox was barred from amending the complaint and thus the Court of Appeal ordered a review of the case.

 Medical Questions

 A Pregnant Woman with Chorea and Arthralgia

 

 Question: A 25-year-old female in second trimester pregnancy with chorea and bilateral ankle pains and ESR 70. Chorea gravidarum is a form of chorea most especially associated with pregnancy §Is this perhaps chorea gravidarum?

 Answer: Even though chorea gravidarum is said to show chorea and raised E. S. R. associated with pregnancy the latter does not appear to be true, because E. S. R. is always high in pregnancy even where chorea is absent. However, if bilateral ankle arthralgia is present along with high ESR level it suggest inflammatory or infective cause. Further evaluation is needed in order to differentiate chorea gravidarum from other diseases affecting women in particular rheumatic diseases.

 Thirdly, randomised double blind use of valproate and haloperidol for chorea has clearly shown that both the drugs help to improve the symptoms though there was no dichotomy between the two drugs.

 

 Question: One question to consider: Does valproate work to reduce chorea in the same way that haloperidol does, or even rheumatic chorea?

 Answer: Haloperidol has been used in past for chorea particularly rheumatic chorea and it was and is considered to be more effective than valproate. Tremors are commonly observed in a number of conditions and chorea is useful for the treatment of chorea but of course rheumatic chorea is not normally began with valproate.

 Guillain-Mollaret's Triangle Lesion

 

 Question: What other sort of myoclonus is there besides symptomatic palatal myoclonus which is brought on by injury to Guillain-Mollaret’s triangle?

 Answer: In the present study palatal myoclonia was found to be associated with complex lesions involving the structures of the region referred to by many authors as Guillain-Mollaret’s triangle. But in cases of an extensive lesion, other types of myoclonus may be produced but palatal myoclonus is most common.

 West’s Syndrome and the management with Adrenocorticotropic Hormone

 

 I: When should ACTH treatment started in West’s syndrome be repeated to suppress fits?

 Answer 1: ACTH treatment in West’s syndrome is undoubtedly long term taking weeks or even months because the treatment is surrounded by the level of response of the patient and the doctor who prescribed it.

 Question 2: To what extent does complete absence of Infantile Myoclonic Jerks after ACTH in differentiating west’s syndrome?

 Answer 2: Lack of infantile myoclonic jerks is also present in west syndrome, albeit this does not in all circumstances bring about diagnosis.

 Primary Torsion Dystonia Treatment

 

 Question: Primary torsion dystonia: to use anticholinergics or not?

 Answer: In primary torsion dystonia, anticholinergic medications are not the drugs of first choice but is one of treatments used. For the first-line therapy, possibilities include administration of levodopa or, if so required, botulinum toxin injection therapy.

 Vitamin D and Multiple Sclerosis

 

 Question: Can current data link low vitamin D and MS relapse?

 Answer: In fact, the published literature has shown that the clinical validity of the hyperhealth biomarkers suggested for MS patients, the vitamin D deficiency, for example, could predict the probabilities of relapse. Vitamin D is thought to be involved or exert some influence on components of immunoregulation.

 Structuring the Diagnostic Criteria for ‘Definitive’ MS

 

 Question: What are the diagnostic features in patients with ‘definitive’ MS?

 Answer: To make a diagnosis of definitive MS the following points have been recommended: Multiple points of time discriminating neurological abnormality effectively, MRI lesions typical or suggestive of MS and all other possible causes have to be ruled out.

 MRI in diagnosing multiple sclerosis lesion of the brain

 

 Question: How good is CT-brain scan with contrast in making out the lesions if MRI is out of the question?

 Answer: MRI is less sensitive compared to CT in the representation of MS lesions. They can show some enhancing lesion, however, it is not as reliable as for evaluating MS, for instance, in terms of the global perspective.

 MRI and MRS for the detection of MS from CADASIL

 

 Question: Is MRS useful for differential diagnosis of MS from CADASIL?

 Answer: MRI is generalised as the modality of choice and MR spectroscopy only add the biochemical content of the lesions that may be helpful in differentiating between MS and CADASIL.

 Hemiplegia of MS can be compared to the hemiplegia that is caused by stroke.

 

 Question: Are there distinctions between thematological hemiplegia in MS that may present as hemiparesis, and what some might define as truly dense hemiplegia? What are other clinical signs that may be of value in the differentiation of a stroke?

 Answer: Hemiplegia By using MS recreational and sports activities, of structural hemiplegia, the outcome is often hemiparesis not inherent critical hemiplegia. Categorical differences are absent; main clinical differences concern the progression, other neurological signs, the history of relapses and remissions.