Singer Recognizing Neurotoxicity

[Guest guest]

We have had many people join the group since some very informative

posts were put on the board I thought it would a good idea to repost

some of them. This was posted April 2006 Message #37845

KC

> Subject: [csda] Singer Recognizing Neurotoxicity mar, 2006

>

> Recognizing Neurotoxicity

>

> The symptoms of brain injury from exposure to hazards like lead

paint

> and toxic chemicals vary widely. But there are ways you and your

> experts can pinpoint the damage and its cause.

>

> Singer and Dana Darby

>

> http://www.neurotox.com/Recognizing_Neurotoxicity.doc

>

>

> Neurotoxicity—poisoning of the brain and nervous system— is a well-

> documented effect of exposure to many widely used chemicals, yet

> doctors (and lawyers) often fail to recognize it. Chemically

injured

> clients often report a confusing array of symptoms, with no medical

> diagnosis. The symptoms may seem vague and unconnected, leading you

> to wonder, " Could these symptoms really be caused by a chemical

> exposure? " Once you recognize the signs and understand them in

> context—as a constellation of symptoms resulting from a toxic

injury—

> you will have greater confidence in bringing your client's case to

> justice.

> A person who has suffered a serious chemical injury is likely to

have

> sustained considerable damage to his or her brain and nervous

system.

> This is important for a lawyer to know, because doctors often

> recognize only the person's physical illness, not realizing that

> serious brain and nervous system damage may have also occurred.

> Neurotoxicity can be documented, but perhaps not in the way you

might

> think. A person's ability to think, perceive, control emotions,

plan,

> and manage his or her life can diminish drastically without

anything

> being visible to a radiologist or neurologist on an MRI or a CT

> scan.1

> The most reliable and widely accepted way to assess actual brain

> function is through neuropsychological evaluation. (This is true

for

> head-injury patients and those suffering from dementia, as well as

> those affected by exposure to toxic chemicals.)

> Researchers have noted that imaging techniques are often of little

> value in evaluating neurotoxicity.2 In our and others' experience,

> imaging techniques can occasionally pick up abnormalities caused by

> neurotoxicity and may be helpful for forensic purposes, but they

are

> not cost-beneficial for routine screening.3

> Neuropsychological testing tends to be more sensitive to brain

injury

> than CT and routine MRI scans, which provide only a static and

> relatively gross view of neural structure. In one study of six

head-

> injury cases, CT and/or MRI scans yielded little or no evidence of

> neuropathology as detected by neuropsychological testing. Positron

> emission tomography (PET) scans, however, corroborated the impaired

> function.4 PET and SPECT (single photon emission computed

tomography)

> scans offer a more dynamic look at brain structure, but both of

these

> tests still need interpretation as to the cause of the abnormality

> (which could be benign).

> Common symptoms

> What do chronic pain, anxiety, neurological problems, confusion,

> psychiatric symptoms, and cognitive declines have in common? They

can

> all result from neurotoxic chemical exposure.

> Symptoms of neurotoxicity include memory and concentration

problems;

> confusion; multiple sclerosis or MS-type symptoms; impaired control

> of the limbs, bladder, or bowels; headaches or migraines; sleep

> disorders, including sleep apnea; eye problems that are

neurological

> in origin; balance and hearing problems; muscle weakness; anxiety

or

> panic attacks; depression; and other psychiatric or neurological

> symptoms.5

> Other symptoms that could be caused by chemical injury include

multi-

> organ system malfunction; lower or upper respiratory problems, such

> as chronic sinus problems; multiple chemical sensitivity (MCS);

liver

> or kidney problems; and fibromyalgia or other pain disorders.

> Along with nervous system dysfunction, the temporal association of

> any of these conditions with toxic chemical exposure tends to

support

> the theory that the overall cause of the client's injuries is a

toxic

> insult to the body.

>

> 1From: Singer & Dana Darby , Recognizing

> Neurotoxicity, TRIAL, Mar. 2006, at 62. Reprinted [or posted] with

> permission of TRIAL (March 2006). Copyright: The Association of

Trial

> Lawyers of America. Revised: February 28, 2006.

>

>

> The illness you probably need to know the most about is MCS, both

> because it is common among chemical injury patients, and because

> doctors often don't recognize it in their patients. The MCS

diagnosis

> is still rejected by many doctors in part because it is difficult

to

> quantify objectively—but then, so are headaches.

> -------------

>

>

> Many doctors are not aware of the significant research that shows

MCS

> is common and quite real.6 MCS is similar to other disabling

> illnesses. People who have it can become very ill from exposures to

> everyday chemicals, such as perfumes, paint, pesticides, and

cleaning

> products.

> Under some conditions, MCS is recognized as a potentially disabling

> condition by the Social Security Administration, the U.S.

Department

> of Housing and Urban Development, and the Americans with

Disabilities

> Act.7

> Documenting a chemical injury

> There are various ways you can document the presence and course of

a

> neurotoxic injury. All of them will help you build your case.

> Conduct a neuropsychological evaluation. This procedure reveals

both

> the most detailed view and the most subtle problems of the working

> brain.

> A forensic neuropsychological evaluation usually includes a full

> battery of tests that can take up to 12 hours to complete. It can

> assess brain function, including memory; concentration; the ability

> to learn new information; executive function (the ability to plan,

> manage, and carry out a plan); perceptual functions, such as

spatial

> awareness; motor functions, such as dexterity; and personality,

> emotion, and motivation. This evaluation can often detect whether

> changes have occurred that may be a result of toxic injury.

> Be aware that some neuropsychologists consider someone impaired

only

> if his or her cognitive functioning is well below average. Such an

> approach is inadequate when the person was once high-functioning.

> For example, a client with a superior IQ—such as a doctor or

> scientist—who now is unable to do his or her job will not benefit

> from an evaluation that interprets an " average " level of

intelligence

> as " normal. " Or your client may be someone who previously

functioned

> at an average level but now is considered below average or has more

> marked problems in particular areas of brain function, such as

> emotion, personality, or executive function. These individuals

> benefit from more complex and subtle evaluations.

> Several red flags can signal that the brain is not working as well

as

> it should. For example, if a client's vocabulary skills are high

but

> his or her ability to process new information is at the 50th

> percentile, this discrepancy suggests a decline in information-

> processing skills. If the client was previously a successful

> engineer, a neuropsychological evaluation will give you findings

that

> point to a decline in brain function.

> Assess personality and emotional function. Chemically injured

people

> can suffer personality changes induced by brain damage. The

> neuropsychologist needs to take a thorough history and conduct a

> record review to determine whether any personality disorders were

> preexisting or caused (or exacerbated) by the chemical injury.

> The Minnesota Multiphasic Personality Inventory-2 (MMPI-2) is often

> used to assess personality.8 But this instrument was not

standardized

> on brain-injured people or those with neurological disorders, so

the

> results must be interpreted carefully.

> For example, if a " normal " person showed many neurological

symptoms,

> he or she might correctly be characterized as mentally ill. But it

> would be normal for a chemically injured person to report an array

of

> neurological symptoms.

> The patient with " too many " symptoms can get a diagnosis

of " somatic

> disorder " —that is, having physical symptoms caused by psychological

> conditions. This misdiagnosis says that psychological problems are

> the underlying cause of the illness.

> Neurotoxicity patients may well have psychological problems, but

> these are often the result, not the cause, of their condition. The

> true cause—organic (physical) brain dysfunction, or neurotoxicity—

is

> too easily overlooked. When interpreting the MMPI-2, the expert

must

> consider the person's medical and neurological conditions before

> reaching conclusions.

> Also, some common interpretations of the MMPI-2 might over-diagnose

> malingering.9 An improper diagnosis of malingering can make it

> difficult to prove an injury.

> It is not unusual for patients suffering from neurotoxicity to be

> misdiagnosed as having psychological problems because of their

> depression and anxiety levels, the sheer number of their symptoms,

> and their belief that chemicals made them ill. To minimize this

> error, choose among the most qualified experts you can find:

> Psychologists, neuropsychologists, or psychiatrists who are

familiar

> with chemical injury, neurotoxicity, and MCS.

> " Image " the brain. It would be ideal to have an X-ray that would

show

> what's gone wrong in the chemically injured brain. Unfortunately,

> brain scans are usually not helpful, because we don't have the

> technology to " take a picture " of most brain injuries. (Even damage

> caused by traumatic brain injuries, such as from an automobile

> accident, may not show up in brain imaging.) A weak correlation

> exists between neuroimaging findings and neurocognitive outcome.10

> Neurotoxic damage does not necessarily affect brain structure at

the

> level we can see on a brain scan.

> PET and SPECT scans are often more sensitive to brain injury than

> either MRIs or CT scans, 11 but even if they show an abnormality,

> they don't show what caused it. Such scans have limited utility in

> court as proof of damage.12 The meaning of the abnormality still

> needs to be explained via neuropsychological assessment. A brain

MRI

> often can be useful to rule out the possibility of another brain

> disorder.

> Test the body. Searching for physical evidence of a chemical injury

> has been compared to searching for a bullet shot through someone's

> body: The bullet may be gone, but the havoc it wreaked is still

> there. Blood and urine can be tested for residue of the chemical in

> question and its breakdown products, or for a range of chemicals,

but

> usually this testing is effective only while the client is still

> being exposed or after recent exposure.

> The body may store toxicants in the fat and tissues, longer-lasting

> storage sites than the blood or urine. Tissue samples can be taken

> and occasionally are helpful, but these procedures can be

difficult,

> painful, and expensive. Hair analysis may be helpful, but it is

often

> controversial.13 Immunological testing can determine whether the

> client has elevated antibodies to some molds, suggesting high

levels

> of exposure to toxic mold.14

> Test and analyze the exposure location. When analyzing an exposure

> location for toxic substances (such as might be found in the air or

> on surfaces), it is better to hire your own consultants to perform

> the work. They can control many important variables that could be

> ignored by other service providers.

> Earlier tests conducted by the defendant may be available, but the

> results might not be valid for various reasons, even if the tests

> were conducted by a government agency. A potential defendant, after

> discovering that its site would be tested, may have aired out the

> building and washed down all the surfaces before testing.

> Unfortunately, the tests that government agencies perform are often

> woefully inadequate.

> Analyze the site carefully. Is there adequate ventilation? Is

there a

> clean-air exchange? Is the ventilation system blowing contaminated

> air into the client's breathing space?

> Some toxic chemicals may be heavier than air, so ventilation in

those

> circumstances should exhaust air out of the room from the level of

> the floor, not the ceiling. One of our clients suffered severe

brain

> damage after using solvents outdoors on his boat. Most people think

> that applying solvents outside is safe. However, our client applied

> them while lying on his back, under the boat. Because the solvent

was

> heavier than air, this amounted to lying in a dense cloud of

> neurotoxic gas, and friends had to pull him out from under his

boat.

> The toxic exposure caused injuries that rendered him completely

> disabled15.

> Under Daubert v. Merrell Dow Pharmaceuticals, Inc., 16 the expert

> should present published research showing that the chemical

> implicated in the case has caused the same damage that your client

> suffered. But there is room for some flexibility.

> For example, in a 2001 federal toxic-tort case, the court admitted

> testimony that experts do not always need extensive, specific

> research on a particular product to arrive at an opinion.17

Instead,

> the chemical's toxicity can be deduced from general toxicology and

> basic logic: The substance was an organic solvent; organic solvents

> are neurotoxic; therefore, this solvent is neurotoxic.

> In our experience, neuropsychological testimony is routinely

admitted

> under Daubert rules.18 Its application to neurotoxicology is well

> established but may be challenged. We are not aware of cases where

> this testimony has been excluded on Daubert grounds, but individual

> states' requirements will vary.

> In one case, the Ohio Supreme Court unanimously ruled that a

witness

> who is not a physician, but who qualifies as an expert under state

> evidence rules, may give evidence that would be relevant to

diagnosis

> of a medical condition if the testimony is within the expertise of

> the witness.19

> Usually, the statute of limitations does not start running until

the

> client has received a diagnosis stating that his or her condition

was

> caused by a chemical exposure. In many cases, it takes years for

this

> diagnosis to be made.

> In other situations, the client is so seriously injured that he or

> she cannot seek out appropriate medical or legal help. The very

> symptoms of neurotoxicity—memory problems, inability to concentrate

> or think clearly, and difficulty processing information—impede the

> injured person's ability to understand what happened to him or her

> and can decrease his or her intellectual and emotional capacity to

> pursue litigation. In such cases, you may need to file a statement

of

> mental incompetence to extend the statute of limitations.

> What to expect from the defense

> Invariably, the defense will seek to minimize the link between your

> client's symptoms and the toxic substance he or she was exposed to

> and will try to play down the product's harmfulness. Expect

arguments

> like these:

> " This product cannot damage your health. " The Material Safety Data

> Sheet (MSDS), required by law of every manufacturer, is a good

place

> to start when seeking documentation of a chemical's adverse health

> effects, because often the MSDS lists them.20 But sometimes the

MSDS

> doesn't even hint at a product's real dangers, and you will need to

> conduct further research. The neurotoxicity of common products is

> discussed in various texts.21

> " If this product caused ill health effects, it would not be

> marketable. " In fact, hundreds of neurotoxic products are promoted

> and sold. More than 850 industrial and commercial chemicals are

known

> to cause neurobehavioral disorders.22

> " Ninety-five percent of the ingredients are inert, so what's the

> problem? " There are two issues here. One is whether 5 percent of an

> active ingredient is toxic enough to cause health effects—and often

> it is, because toxic substances can be harmful in small amounts.

> The other issue is the meaning of " inert. " So-called inert

> ingredients can be more toxic than the " active " ones. By labeling

an

> ingredient " inert, " a company may be trying to avoid admitting that

> there is a noxious ingredient in its product. The manufacturer may

> call its formulation a " trade secret. "

> Try to obtain a list of the inert ingredients by subpoena and have

a

> laboratory analyze the product. Once you establish what the inert

> ingredients are, your consultants should assess their toxicity.

> " But we didn't exceed government standards for exposure. " " Safe "

> levels of exposure are a compromise between an industry's

commercial

> needs and consumer protection and do not guarantee that an injury

> cannot occur. These standards generally become stricter with every

> passing decade, and incidents of reported chemical injury are what

> cause them to change.

> Furthermore, safe levels are routinely set to protect a healthy

male

> worker. But some people are more susceptible than others. Women,

for

> instance, tend to be more sensitive than men, and different bodies

> react differently to toxins.23 Variations in sensitivity are even

> observable in rats. Also, there may be no safe level at which a

> person can inhale a particular substance.

> The MSDS typically will state that if a person shows signs of

> illness, you must remove him or her from the area immediately. This

> suggests that it is generally recognized that some people will

become

> ill even when they are working under the recommended safe-exposure

> guidelines.

> " This amount was far too small to damage anyone's health. " Chronic

> exposure to low levels of some toxic chemicals can be even worse

than

> a single acute exposure, because brain damage is cumulative over

> time.

> " The plaintiff had preexisting conditions. " Plaintiffs in these

cases

> often do. It makes sense that people whose health is already

> compromised are the most vulnerable to poisons, because their

bodies'

> detoxification systems—especially the liver and kidneys—are already

> stressed. People with a preexisting condition suffer further

> deterioration of their health. Your expert should document the

> preexisting condition thoroughly—this may require extensive review

> and analysis of the medical record—and document what new symptoms

> emerged and what preexisting symptoms became worse.

> " Just smelling the chemical could not have caused this. " Actually,

> inhalation and skin contact are often more effective routes of

entry

> for a poison than swallowing. When something is swallowed, it is

> partly neutralized by stomach acids. The body then attempts to

> detoxify it through the liver, kidneys, and other organs. But

> inhalation and skin contact allow a substance to enter the

> bloodstream directly, without any filtering. For example, doctors

now

> use skin patches to administer morphine and birth control.24 And

> sniffing glue (solvents) can produce an instantaneous high and

cause

> immediate and permanent brain damage.

>

> " A neurologist found nothing wrong. " Few neurologists have training

> in toxicology, and they rarely recognize the symptoms of

> neurotoxicity. A patient who suggests his or her symptoms were

caused

> by a chemical exposure may encounter a brick wall of denial,

> bordering on hostility.

>

> Some neurologists won't pay attention unless a patient's symptoms

are

> extreme: For example, the patient cannot tell what day it is or

walk

> in a straight line. Even then the neurologist may misdiagnose the

> patient as normal, even if neuropsychological testing shows serious

> functional deficits. Still, a neurologist's exam may help rule out

> non-toxicological causes of a neurological illness or document

> certain physical signs, such as seizures or gait disturbances.

> " Chronic pain is not a symptom of brain or nerve damage. " The

> term " chronic pain " may seem vague, outside the realm of most

> doctors, and potentially confusing to a jury. But chronic pain can

> certainly be a symptom of brain damage and toxic exposure.

> Damage to the brain and nerves can disrupt the nerve signals

> themselves or the way the brain interprets those signals.25

Resulting

> sensations can be tingling, burning, or debilitating pain, which

one

> of my chronic pain patients described as " like a thousand razor

> blades. " Chronic pain can be a terrible ordeal and may require

strong

> painkillers whose side effects could cause more damage.

> " It is ludicrous to believe that neurotoxic chemicals can cause

such

> disparate symptoms as insomnia, chronic fatigue, and

gastrointestinal

> problems. " On the contrary, the brain and nervous system control

all

> bodily functions. The autonomic nervous system controls the

> involuntary part of bodily processes, including digestion, blood

> circulation, and the " fight or flight " response.

> " Multiple chemical sensitivity does not exist. " Studies indicate

that

> almost 16 percent of the U.S. population report having unusual

> reactions to common chemicals.26 About 6.3 percent have been

> diagnosed with MCS or declared disabled from it.27 There is

> considerable research on, and international recognition of, this

> condition.

> " The plaintiff is malingering. " Every competent forensic

> neuropsychological assessment includes tests for malingering. When

> assessing a potential client, consider that a chemical injury would

> be one of the most difficult injuries to fake. Doctors who

recognize

> the symptoms are few and far between.

> You will probably find that your client has tried to find a cure,

> sincerely wants to return to work, and is seeking litigation as a

> last resort. The " invalid " label is profoundly depressing to most

> people. Nevertheless, you must always rule out the possibility of

> malingering and psychosomatic disorders.

> " The plaintiff has a personality disorder (or is mentally ill). "

> Ironically, a plaintiff's personality disorder may be evidence of

> injury, not a reason to dismiss the case. Brain damage can result

in

> such disorders, psychiatric symptoms, and even schizophrenia.

> Establish the patient's mental health before the exposure to help

> determine whether the exposure caused or exacerbated the

psychiatric

> symptoms. In any case, it is not surprising when a person with a

> chronic illness, adjusting to a devastating life change, develops

> what may be diagnosed as a personality disorder.

> On the other hand, some patients with a diagnosis of a psychiatric

> disorder don't actually have one. A patient may have received that

> diagnosis precisely because he or she claimed to be hurt by

chemicals

> and was labeled " delusional. "

>

> Compensation and cure

> There is no standard medical cure for chemical injury, but

> conventional medical treatments may help some symptoms and promote

> modest improvement. Alternative medicine treatment for

neurotoxicity

> is controversial, but in our experience, nutritional therapy

> (including natural foods diet) and natural medicines (including

> acupuncture and holistic exercises, such as Tai Chi and Chi Gong)

may

> be the only methods that help neurotoxic and extremely sensitive

> patients. Your clients should receive enough compensation to pay

for

> continuing treatment, including less conventional approaches, such

as

> medically supervised detoxification, infrared saunas, visits to

> rehabilitation centers, and possibly hyperbaric oxygen treatments.

> Compensation should include lost salary, lost savings, and medical

> bills that will probably continue for a lifetime. It should cover

> counseling or psychotherapy to help patients adjust to being

> chronically ill; losing their jobs, their friendships, and possibly

> their homes; straining their marriages; and being unable to

continue

> with hobbies. But they generally should avoid psychiatric drugs.

> Chemically sensitive patients may react to pharmaceuticals (usually

> petroleum derivatives) as they do to chemicals.

> Your familiarity with neurotoxicity and chemical injury will help

you

> guide your client to the clearest assessment of his or her

> disability. Choosing the right experts and testing will contain

> litigation costs and further your goals of obtaining justice and

> compensation.

> Singer, Ph.D., is a forensic neurobehavioral toxicologist

and

> neuropsychologist in Santa Fe, New Mexico, with additional offices

in

> New York City. He handles cases on a nationwide basis. Dana Darby

> is an associate in his practice.

>

> 1.See, e.g., Bernhard Voller et al., Neuropsychological, MRI, and

EEG

> Findings After Very Mild Traumatic Brain Injury, 13 BRAIN INJURY

821

> (1999) (finding only 3 of 12 patients with brain dysfunction

> demonstrated an abnormal MRI).

> 2.See, e.g., ph C. Arezzo & Herbert H. Schaumburg, Screening

for

> Neurotoxic Disease in Humans, 8 J. AM. C. TOXICOLOGY 147(1989); see

> also Pamela Gibson, Disability-Induced Identity Changes in

> Persons with Multiple Chemical Sensitivity, 15 QUALITATIVE HEALTH

> RES. 502, 503-04 (2005).

> 3.See generally RAYMOND M. SINGER, NEUROTOXICITY GUIDEBOOK (2d ed.

> 2006, expected; 1st ed., 1990).

> 4. M. Ruff et al., Computerized Tomography, Neuropsychology,

> and Positron Emission Tomography in the Evaluation of Head Injury,

2

> NEUROPSYCHIATRY, NEUROPSYCHOL. & BEHAV. NEUROLOGY 103 (1989).

> 5.See generally SINGER, supra note 3. The Neurotoxicity Screening

> Survey provides a complete checklist of possible signs and

symptoms,

> available at http://www.neurotox.com/files/Q1_9.pdf (last visited

> Feb. 27, 2006).

> 6.See, e.g., Stanley M. Caress & Anne C. Steinemann, Prevalence of

> Multiple Chemical Sensitivities: A Population-Based Study in the

> Southeastern United States, 94 AM. J. PUB. HEALTH 746 (2004);

> Fiedler et al., Responses to Controlled Diesel Vapor Exposure Among

> Chemically Sensitive Gulf War Veterans, 66 PSYCHOSOMATIC MED. 588

> (2004); M. Kipen et al., Prevalence of Chronic Fatigue and

> Chemical Sensitivities in Gulf Registry Veterans, 54 ARCHIVES

ENVTL.

> HEALTH 313 (1999); Kreutzer et al., Prevalence of People

> Reporting Sensitivities to Chemicals in a Population-Based Survey,

> 150 AM. J. EPIDEMIOLOGY 1 (1999); J. Meggs et al.,

Prevalence

> and Nature of Allergy and Chemical Sensitivity in a General

> Population, 51 ARCHIVES ENVTL. HEALTH 275 (1996).

> 7.See, e.g., letters and memoranda to and from Department of

Housing

> and Urban Development, available at

www.usdoj.gov/crt/foia/tal105.txt

> (last visited Jan. 23, 2006).

> 8.The MMPI-2 is available at

> www.pearsonassessments.com/tests/mmpi_2.htm#norms (last visited

Jan.

> 23, 2006).

> 9.See, e.g., N. Butcher et al., The Construct Validity of the

> Lees-Haley Fake Bad Scale: Does This Scale Measure Somatic

> Malingering and ned Emotional Distress? 18 ARCHIVES CLINICAL

> NEUROPSYCHOL. 473 (2003).

> 10.See, e.g., Voller et al., supra note 1; A.M. Hofman et al.,

> MR Imaging, Single-Photon Emission CT, and Neurocognitive

Performance

> After Mild Traumatic Brain Injury, 22 AM. J. NEURORADIOLOGY 441

> (2001); Shelli R. Kesler et al., SPECT, MR, and Quantitative MR

> Imaging: Correlates with Neuropsychological and Psychological

Outcome

> in Traumatic Brain Injury, 14 BRAIN INJURY 851 (2000) (finding a

> modest but significant correlation between memory and intellectual

> impairments and number of brain abnormalities evidenced by

> quantitative magnetic resonance, magnetic resonance (MR), and all

> imaging studies combined (but not SPECT alone) and noting a

positive

> correlation between psychological distress and MR abnormalities,

most

> frequently in the frontal lobes).

> 11.See J. Nolan & Tressa A. Pankovits, High-Tech Proof in

> Brain Injury Cases, TRIAL, June 2005, at 26.

> 12.Brickford Y. Brown et al., Are We Out of the Gray Area Yet?

Recent

> Developments in the Use of PET and SPECT Scans to Prove Causation

and

> Injury in Toxic Tort Litigation, available at

> www.morankikerbrown.com/CM/Articles/Articles67.asp (last visited

Jan.

> 23, 2006). For an alternate perspective, see Garo Mardirossian &

> ph Barrett, The Use of Functional Brain Imaging of

Organic

> Brain Injury: A Primer, available at www.caala.org/DOCS/3-

> 98mardirossian.pdf (last visited Jan. 23, 2006); see also

G.

> Monnett III & M. Jordan, Scientific Evidence Following

> Daubert vs. Merrell Dow: Are PET Scans Admissible to Establish

> Traumatic Brain Injury?, available at

> www.carolinalaw.com/CM/Articles/article-scientific-evidence.asp

(last

> visited Jan. 23, 2006).

> 13.See generally SIDNEY A. KATZ & AMARES CHATT, HAIR ANALYSIS:

> APPLICATIONS IN THE BIOMEDICAL AND ENVIRONMENTAL SCIENCES (1988).

> 14. Singer, Clinical Evaluation of Suspected Mold

> Neurotoxicity, in BIOAEROSOLS, FUNGI, BACTERIA, MYCOTOXINS & HUMAN

> HEALTH: PROC. OF THE FIFTH INT'L BIOAEROSOL CONF. 78 (2005); see

also

> Singer, Forensic Evaluation of a Mold (Repeated Water

> Intrusions) Toxicity Case, 20 ARCHIVES CLINICAL NEUROPSYCHOL. 808

> (2005).

> 15.Singer, R. (1996, March). Neurotoxicity from outdoor, consumer

> exposure to a methylene chloride product. Fundamental and Applied

> Toxicology, Supplement: The Toxicologist, 30, 1, Part 2.

> 16.509 U.S. 579 (1993).

> 17.Bonner v. ISP Techs., 259 F.3d 924 (8th Cir. 2001); see also

> www.daubertontheweb.com (last visited Jan. 23, 2006).

> 18.See generally Bruce H. Stern, Admissibility of

Neuropsychological

> Testimony After Daubert and Kumho, 16 NEUROREHABILITATION 93

(2001).

> 19.Shilling v. Mobile Analytical Servs., Inc., 602 N.E.2d 1154,

1156-

> 57 (Ohio 1992).

> 20.See www.msds.com (last visited Jan. 23, 2006).

> 21.See, e.g., Singer, Neurotoxicity Guidebook, in

> NEUROTOXICITY OF INDUSTRIAL & COMMERCIAL CHEMICALS ( L.

> O'Donoghue ed., 1985).

> 22.Kent Anger & Barry , Chemicals Affecting Behavior, in

> NEUROTOXICITY OF INDUSTRIAL & COMMERCIAL CHEMICALS ( L.

> O'Donoghue ed., 1985).

> 23.See, e.g., Mark R. Cullen & A. Redlich, Significance of

> Individual Sensitivity to Chemicals: Elucidation of Host

> Susceptibility by Use of Biomarkers in Environmental Health

Research,

> 41 CLINICAL CHEMISTRY 1809 (1995); T. Iyaniwura, Individual

> and Subpopulation Variations in Response to Toxic Chemicals:

Factors

> of Susceptibility, available at

> www.riskworld.com/Nreports/2004/Iyaniwura.htm (last visited Jan.

23,

> 2006); K. , Intra-Individual Variations in Acute

and

> Cumulative Skin Irritation Responses, 45 CONTACT DERMATITIS 75

> (2001); K. , Population Differences in Acute Skin

> Irritation Responses: Race, Sex, Age, Sensitive Skin, and Repeat

> Subject Comparisons, 46 CONTACT DERMATITIS 86 (2002).

> 24.See, e.g., Mayo Clinic Med. Servs., Birth Control Patch, at

> www.mayoclinic.com/index.cfm?id=PR00075 (last visited Jan. 23,

2006).

> 25.See Nat'l Inst. Neurological Disorders and Stroke, Pain: Hope

> Through Research, at

> www.ninds.nih.gov/disorders/chronic_pain/detail_chronic_pain.htm

> (last visited Jan. 23, 2006).

> 26.See, e.g., Caress & Steinemann, supra note 6; Kreutzer et al.,

> supra note 6; see also Meggs et al., supra note 6 (finding 33

> percent).

> 27.See, e.g., Kreutzer et al., supra note 6.

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