Court Opinion

ID: 4212815
Source: CourtListenerOpinion
Date Created: 2017-10-19 14:01:02.437004+00
Date Added: 2024-06-11T14:40:53.669626
License: Public Domain

Case: 16-11818   Date Filed: 10/19/2017   Page: 1 of 42

                                                                   [PUBLISH]

             IN THE UNITED STATES COURT OF APPEALS

                   FOR THE ELEVENTH CIRCUIT
                     ________________________

                           No. 16-11818
                     ________________________

                 D.C. Docket Nos. 1:14-cv-24061-JRG,
                         1:14-cv-24064-JRG

1:14-cv-24061-JRG

AMAL EGHNAYEM,
MARGARITA M. DOTRES,
MANIA NUNEZ,
JUANA BETANCOURT,
                                                   Plaintiffs - Appellees,

MARGARETTE DUBOIS-JEAN,
                                                   Plaintiff,

versus

BOSTON SCIENTIFIC CORPORATION,
                                                   Defendant -
Appellant.

_________________________________________________________

1:14-cv-24064-JRG Dismissed 02/23/2017

MARGARITA M. DOTRES,
                                                   Plaintiff,
         Case: 16-11818   Date Filed: 10/19/2017   Page: 2 of 42

versus

BOSTON SCIENTIFIC CORPORATION,
                                       Defendant.
_________________________________________________________

1:14-cv-24065-JRG

MANIA NUNEZ,
                                               Plaintiff - Appellee,

versus

BOSTON SCIENTIFIC CORPORATION,
                                   Defendant - Appellant.
_________________________________________________________

1:14-cv-24066-JRG

JUANA BETANCOURT,
                                             Plaintiff - Appellee,

versus

BOSTON SCIENTIFIC CORPORATION,
                                             Defendant - Appellant.

                    ________________________

            Appeal from the United States District Court
                for the Southern District of Florida
                  ________________________

                          (October 19, 2017)

                                   2
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Before HULL, MARCUS, and ROGERS,* Circuit Judges.

MARCUS, Circuit Judge:

         In this products liability suit, Boston Scientific Corporation

(BSC) appeals from various orders and a final judgment in favor of the

plaintiff, Amal Eghnayem. Eghnayem alleged substantial injuries

caused by the Pinnacle Pelvic Floor Repair Kit, a transvaginal mesh

prescription medical device manufactured and sold by BSC. She

initially filed suit in the Southern District of West Virginia as part of a

transvaginal mesh Multidistrict Litigation; her suit was consolidated

with three other similar suits and transferred to the Southern District of

Florida for trial. The consolidated plaintiffs all brought the same four

claims under Florida law, arguing that BSC was both negligent and

strictly liable for the Pinnacle’s defective design, and both negligent

and strictly liable for failing to warn them of the resultant danger from

the Pinnacle. After eight days of trial, the jury found for each of the

plaintiffs on all four claims, awarding more than six million dollars to

each plaintiff. BSC now appeals from the judgment entered for

*
          Honorable John M. Rogers, United States Circuit Judge for the Sixth Circuit,
    sitting by designation.

                                             3
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Eghnayem. 1

         BSC argues that the district court abused its discretion in two

distinct ways: by consolidating the four plaintiffs’ suits and trying them

together, and by excluding all evidence relating to the Food and Drug

Administration’s clearance of the Pinnacle for sale through its 510(k)

“substantial equivalence” process. BSC also says that the district court

erred in denying it judgment as a matter of law because Eghnayem

failed to present sufficient evidence to prove her design defect claim;

she failed to present sufficient evidence that the Pinnacle’s warnings

were not per se adequate, and that the alleged failure to warn was the

proximate cause of her injuries; and finally, the relevant statute of

limitations barred all of her claims as a matter of law.

         After thorough review, and having had the benefit of oral

argument, we can discern no error in the district court’s rulings, and

accordingly we affirm the judgment of the district court.

                                           I.

         The Pinnacle is a medical device used to remedy pelvic organ
1
         BSC initially appealed from the judgment in favor of all four plaintiffs:
    Eghnayem, Margarita M. Dotres, Mania Nuñez, and Juana Betancourt. Prior to oral
    argument, BSC dismissed the appeal as to Dotres. BSC has since moved to dismiss the
    appeal as to co-plaintiffs Nuñez and Betancourt as well. That motion is GRANTED.

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prolapse in a female patient. Essentially, this device is a mesh sheet

that is implanted transvaginally and works by physically preventing

pelvic organs (the bladder, uterus, or rectum) from falling through the

vagina. The mesh is made from polypropylene, a type of plastic. In

2007, the FDA cleared BSC to sell the Pinnacle pursuant to its 510(k)

process, which entailed finding that the Pinnacle was “substantially

equivalent” to another device already available on the market.

      The plaintiff, Amal Eghnayem, had a Pinnacle surgically

implanted on February 28, 2008, to treat her pelvic organ prolapse. In

the months following her surgery, she began to experience bleeding and

pain during intercourse, incontinence, and pelvic pain and pressure.

She visited a doctor for these problems in October 2008, who

performed a pelvic exam and told Eghnayem that she had exposed

mesh in her vagina. The doctor performed in-office surgery to trim the

exposed mesh in an attempt to alleviate Eghnayem’s symptoms.

Unfortunately, this treatment did not resolve her problems, and in May

2012, she visited another doctor and complained of similar symptoms.

This doctor examined Eghnayem, found another mesh exposure, and

performed a second mesh-removal surgery in August 2012. Since then,
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Eghnayem’s pain has largely subsided, but she has lost vaginal

sensitivity.

      Eghnayem and three other plaintiffs filed separate lawsuits

against BSC in MDL 2326 -- In re: Boston Scientific Corporation

Pelvic Repair System Products Liability Litigation -- in the United

States District Court for the Southern District of West Virginia. They

each sought compensatory and punitive damages based on claims for

negligent design defect, negligent failure to warn, strict-liability design

defect, and strict-liability failure to warn. The district court sua sponte

consolidated the suits for all purposes, including trial. The court

observed that, although “there will be separate evidence relating to

failure to warn and individual damages,” “the similarities in these

cases, particularly as to the claim of design defect,” outweighed the

differences and warranted consolidation.

      BSC moved the district court to sever the suits after discovery,

arguing that the similarities in the plaintiffs’ suits did not predominate

and that consolidation would lead to jury confusion and prejudice. It

pointed out that each plaintiff had different complaints, different

medical histories, and different treating doctors; was prescribed the
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Pinnacle at different times for different conditions; and claimed to

suffer different injuries, after different lengths of exposure, resulting in

different treatment courses. But the district court was “unpersuaded

that the barriers suggested by defendants in a consolidated trial [were]

insurmountable or [would] result in [ ] prejudice” and so denied BSC’s

motion.

      The consolidated case was transferred to the United States

District Court for the Southern District of Florida. Prior to trial, the

district court excluded all evidence relating to the Food and Drug

Administration’s (“FDA”) regulatory scheme and clearance of the

Pinnacle for sale pursuant to the 510(k) “substantial equivalence”

process. The court excluded the evidence under both Federal Rule of

Evidence 402, which provides that “[i]rrelevant evidence is not

admissible,” and Federal Rule of Evidence 403, which provides that

relevant evidence may be excluded “if its probative value is

substantially outweighed by a danger of . . . unfair prejudice, confusing

the issues, misleading the jury, undue delay, [or] wasting time.”

      Trial began in the Southern District of Florida on November 3,

2014, and continued over eight days. The plaintiffs offered twenty-five
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witnesses, including themselves and their implanting physicians. The

witnesses, mostly doctors, testified regarding the plaintiffs’ medical

conditions, implantation processes, and injuries; BSC’s structure and

policies; the Pinnacle’s development process; and the Pinnacle’s and

polypropylene mesh’s chemical characteristics, design features, uses,

and potential dangers. BSC contested all four of the plaintiffs’ claims

on the merits and also asserted Florida’s four-year statute of limitations

for products liability claims as an affirmative defense against

Eghnayem’s claims in particular. At the conclusion of the plaintiffs’

case, and again after the conclusion of their own case, BSC moved for

judgment as a matter of law on all claims; the district court deferred

ruling. The jury returned a verdict in favor of each of the plaintiffs on

all claims except for punitive damages, and rejected BSC’s statute of

limitations defense, awarding $6,722,222 in damages to Eghnayem,

$6,533,333 to Nuñez, $6,766,666 to Dotres, and $6,722,222 to

Betancourt.

      BSC renewed its motion for judgment as a matter of law on all of

the plaintiffs’ claims. BSC argued, among other things, that Eghnayem

failed to present sufficient evidence on her design defect claim; that the
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Pinnacle’s warnings were adequate as a matter of law, and that

regardless Eghnayem failed to show that the alleged failure to warn was

the proximate cause of her injuries; and, finally, that the evidence

indisputably showed that Eghnayem’s claims had accrued more than

four years before she filed suit. The district court rejected all of these

arguments, concluding that Eghnayem had provided sufficient evidence

to support her claims and thus they were all properly reserved for the

jury.

        BSC also moved in the alternative for a new trial on the grounds

that it was substantially prejudiced by the wrongful exclusion of the

510(k) evidence, and that consolidation confused the jury and also

prejudiced BSC. Again, the district court rejected these arguments,

based largely on the same reasoning it had provided in the initial

consolidation and exclusion orders.

        BSC now appeals the denial of these post-trial motions.

                                    II.

        We review a district court’s decision whether to consolidate

multiple actions only for a “clear abuse of discretion.” Hendrix v.

Raybestos-Manhattan, Inc., 776 F.2d 1492, 1495 (11th Cir. 1985). We
                                      9
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also review the evidentiary rulings of a trial court “only for a clear

abuse of discretion.” United States v. Brannan, 562 F.3d 1300, 1306

(11th Cir. 2009). “[W]e must affirm unless we find that the district

court has made a clear error of judgment, or has applied the wrong

legal standard.” Id. (quoting United States v. Frazier, 387 F.3d 1244,

1259 (11th Cir. 2004) (en banc)). Finally, we review the district court’s

ruling on a motion for judgment as a matter of law de novo,

considering the evidence and the reasonable inferences drawn from it in

the light most favorable to the nonmoving party. Middlebrooks v.

Hillcrest Foods, Inc., 256 F.3d 1241, 1246 (11th Cir. 2001). Thus,

we’ve explained, “[j]udgment as a matter of law is appropriate only if

the evidence is so overwhelmingly in favor of the moving party that a

reasonable jury could not arrive at a contrary verdict.” Id.

                                    III.

      BSC first contends that the district court abused its discretion by

consolidating the plaintiffs’ suits, because individual issues

predominated and the consolidation yielded unacceptable prejudice.

BSC also argues that the district court abused its discretion by

excluding evidence relating to the Pinnacle’s clearance through the
                                    10
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FDA’s 510(k) regulatory process, because this evidence was relevant to

the Pinnacle’s safety. Neither claim succeeds.

                                      A.

      The district court acted well within its discretion in consolidating

each of these four lawsuits. Under Federal Rule of Civil Procedure

42(a), a district court may consolidate multiple actions that “involve a

common question of law or fact.” A district court’s decision whether to

consolidate is “purely discretionary.” Hendrix, 776 F.2d at 1495. In

exercising its considerable discretion, the trial court is obliged to

consider:

      Whether the specific risks of prejudice and possible confusion are
      overborne by the risk of inconsistent adjudications of common
      factual and legal issues, the burden on parties, witnesses and
      available judicial resources posed by multiple lawsuits, the length
      of time required to conclude multiple suits as against a single
      one, and the relative expense to all concerned of the single-trial,
      multiple-trial alternatives.

Id. (quotation omitted and alterations adopted). Moreover, “[t]he court

must also bear in mind the extent to which the risks of prejudice and

confusion that might attend a consolidated trial can be alleviated by

utilizing cautionary instructions to the jury during the trial and

controlling the manner in which the plaintiffs’ claims (including the
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defenses thereto) are submitted to the jury for deliberation.” Id. “A

joint trial is appropriate where there is clearly substantial overlap in the

issues, facts, evidence, and witnesses required for claims against

multiple defendants.” Allstate Ins. Co. v. Vizcay, 826 F.3d 1326, 1333

(11th Cir. 2016) (quotation omitted and alteration adopted). But

“[w]here prejudice to rights of the parties obviously results from the

order of consolidation, the action of the trial judge has been held

reversible error.” Dupont v. S. Pac. Co., 366 F.2d 193, 196 (5th Cir.

1966).2 “District court judges in this circuit have been urged to make

good use of Rule 42(a) in order to expedite the trial and eliminate

unnecessary repetition and confusion.” Young v. City of Augusta, 59

F.3d 1160, 1169 (11th Cir. 1995) (quotation omitted and alterations

adopted).

         The district court did not abuse its discretion in concluding that

the considerations surrounding consolidation weighed in favor of

joining these suits for trial. The plaintiffs all brought the same claims

based largely on the same facts: BSC’s Pinnacle device was

2
          Former Fifth Circuit cases decided before October 1, 1981 are binding precedent
    in the Eleventh Circuit. See Bonner v. City of Prichard, 661 F.2d 1206, 1209 (11th
    Cir. 1981).

                                            12
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unreasonably dangerous by design, and BSC failed to include sufficient

warnings with the device to alert physicians to that danger. Although

each plaintiff’s proof of causation was necessarily different, generally

differences in causation are not enough, standing alone, to bar

consolidation of products liability claims. And any danger of prejudice

arising from the consolidation was reduced in this case, because the

district court explained the consolidated nature of the trial to the jury

and expressly instructed it to consider each plaintiff’s claims

separately. Notably, this is not the first time we have affirmed the

consolidation of products liability claims that require individual

evidence of causation. Thus, for example, in Hendrix v. Raybestos-

Manhattan, Inc., we affirmed a district court’s decision to consolidate

four products liability cases that all alleged that asbestos exposure

caused them to contract an asbestos-related disease, notwithstanding

the presentation of different bodies of proof on causation. 776 F.2d at

1495–96.

      BSC nonetheless contends that consolidation was improper

because the plaintiffs’ evidence was presented in a confusing and

disjointed manner, but this argument is largely beside the point.
                                     13
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Confusing or not, most of the evidence went toward the common

claims among the plaintiffs: (1) whether the Pinnacle was a defective

medical device and (2) whether the Pinnacle’s warnings were

sufficient. The only evidence that went to the individual claims came

from the more-easily-distinguishable doctors who did each plaintiff’s

implantation, and concerned comparatively straightforward questions:

(1) did the Pinnacle’s design cause that plaintiff’s injuries, and (2) did

the lack of sufficient warnings influence that doctor’s decision to

implant the Pinnacle. BSC has not shown that this individual evidence

made the suit so confusing that it was obviously prejudiced and thus

has failed to tie the confusion to the consolidation order.

      BSC also suggests that the plaintiffs’ similar damages awards in

the amounts of $6,766,666, $6,722,222, $6,722,222, and $6,533,333,

respectively, show that the jury was confused by the consolidated suits.

The district court rejected this argument too because BSC failed to

point to any direct source of the jury’s alleged confusion, and instead

effectively “work[ed] backwards, speculating as to the reason for the

compensatory awards based on the end result.” The district court was

correct. Nearly identical or identical damages awards, without more,
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simply are not sufficient evidence of juror confusion. The plaintiffs

suffered similar injuries caused by the same product, and so might

reasonably be due similar relief. And notably, the awards were not all

identical; the fact that two were the same and two were different

strongly suggests that the jury considered each plaintiff individually.

BSC fails to point us to any evidence that the jury’s decision to award

similar damages to each plaintiff was improper. This allegation of

confusion is far from enough to show that the district court abused its

discretion.

      BSC also says that consolidating the four plaintiffs for trial led

the jury to believe that their claims were more likely to be true, but this

argument fails. For starters, the district court instructed the jury that

“[y]ou may not even consider the fact that there’s more than one case

being brought,” an instruction that the jury presumably followed. See

United States v. Stone, 9 F.3d 934, 938 (11th Cir. 1993) (“Few tenets

are more fundamental to our jury trial system than the presumption that

juries obey the court’s instructions.”). And even had the cases not been

consolidated, the plaintiffs would likely have been able to submit

evidence of other patients with similar injuries to show the dangerous
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character of the Pinnacle. See, e.g., Jones v. Otis Elevator Co., 861

F.2d 655, 661 (11th Cir. 1988) (“We have held that evidence of similar

accidents might be relevant to the defendant’s notice, magnitude of the

danger involved, the defendant’s ability to correct a known defect, the

lack of safety for intended uses, strength of a product, the standard of

care, and causation.”) (quotation omitted). Moreover, consolidation of

products liability cases will always implicate this concern, and this

Court has affirmed consolidation in these kinds of cases before. See,

e.g., Hendrix, 776 F.2d at 1495–96.

      BSC’s final argument is that, due to the differences in the

plaintiffs’ claims, consolidation allowed evidence into trial that would

have been individually inadmissible for some of the plaintiffs. This

claim fails as well. As an initial matter, BSC failed to request limiting

instructions for any of the challenged evidence. The failure to

contemporaneously raise the issue denied the district court the chance

to address the problem by issuing limiting instructions, and it deprives

this Court of the benefit of the district court’s decisions. See Access

Now, Inc. v. Sw. Airlines Co., 385 F.3d 1324, 1331 (11th Cir. 2004)

(“[A]s a court of appeals, we review claims of judicial error in the trial
                                    16
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courts. If we were to regularly address questions -- particularly fact-

bound issues -- that [the district court] never had a chance to examine,

we would not only waste our resources, but also deviate from the

essential nature, purpose, and competence of an appellate court.”); see

also Fisher v. Ciba Specialty Chems. Corp., 245 F.R.D. 539, 543 n.7

(S.D. Ala. 2007) (noting that “appropriate limiting instructions” can be

used to cabin “evidence relevant to the claims of one plaintiff but not to

others”); United States v. Miranda, 197 F.3d 1357, 1360 (11th Cir.

1999) (“The failure to give a limiting instruction is error only when

such an instruction is requested.”). BSC’s failure severely weakens its

argument.

      Moreover, it’s far from clear that the complained-of evidence

would have been excludable even if each of the plaintiffs had tried their

cases alone. BSC identifies three pieces of evidence that may have

been inadmissible in individual trials: graphic images and testimony

regarding one plaintiff’s removed mesh; information about another

plaintiff’s future scheduled surgery; and evidence relating to BSC’s

practices and the Pinnacle’s safety that post-dated some but not all of

the plaintiffs’ implantations. As for the first, BSC generally objected to
                                    17
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the graphic images and testimony under Rule 403, arguing that the

possibility of prejudice substantially outweighed any probative value.

The court overruled that objection, and that decision was not an abuse

of discretion. Graphic medical photos and testimony, while potentially

disturbing, might also be particularly helpful in allowing a jury to better

understand a medical device and the allegedly related injuries. See

Aycock v. R.J. Reynolds Tobacco Co., 769 F.3d 1063, 1069 (11th Cir.

2014) (“[A] district court’s discretion to exclude evidence under Rule

403 is narrowly circumscribed.”) (quotation omitted); Gen. Elec. Co. v.

Joiner, 522 U.S. 136, 141 (1997) (“[A]buse of discretion is the proper

standard of review of a district court’s evidentiary rulings.”). In this

case, the very feature that made the images graphic -- the tissue that

was removed along with the mesh -- is what made them relevant to the

plaintiffs’ claim that the very nature of the Pinnacle’s design prevented

the removal of the mesh without removing tissue. BSC has not

convinced us that this evidence would have been any less relevant, or

any more prejudicial, in individual trials. See Hahn v. Sterling Drug,

Inc., 805 F.2d 1480, 1483 (11th Cir. 1986) (noting that evidence of

prior incidents that might be relevant to “the magnitude of danger,”
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“the lack of safety,” or “causation” “should not be excluded”).

      As for the second challenged piece of evidence, BSC did not

object at all to the two mentions of one plaintiff’s future scheduled

surgery, and further has not suggested that this evidence would be

excludable in individual trials under any rule of evidence except

perhaps Rule 403. We fail to see how the danger of unfair prejudice

from the mere mention of future surgery warrants invoking the strong

medicine of Rule 403 exclusion. See United States v. Dodds, 347 F.3d

893, 897 (11th Cir. 2003) (“[W]e have [ ] recognized that Rule 403 is

an extraordinary remedy which the district court should invoke

sparingly, and the balance should be struck in favor of admissibility.”)

(quotation omitted and alteration adopted). Once again, BSC has not

shown that this evidence would have been inadmissible for some of the

plaintiffs individually.

      Finally, as for the third challenged set of evidence, BSC fails to

show that the evidence post-dating some of the

implantations -- including admissions from BSC employees tending to

show a pattern of insufficient research for other medical devices, and

information suggesting a high erosion rate for the Pinnacle -- would not
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be admissible for at least some purposes in each individual trial. A

pattern of insufficient research might be probative evidence as to

whether BSC designs products without due care, and the Pinnacle’s

high erosion rate is surely probative of whether BSC was strictly liable

for a defective product. BSC is of course correct that this evidence

could not have been used to show BSC’s knowledge of the risks

associated with the Pinnacle for those plaintiffs whose implantations

predated the evidence. But when evidence is relevant for some

purposes and not others, limiting instructions -- not exclusion -- are

generally the best way to handle the issue. See, e.g., Fisher, 245 F.R.D.

at 543 n.7. BSC’s failure to request limiting instructions here dooms

this argument.

      Quite simply, BSC cannot establish that it was prejudiced by the

consolidation of the plaintiffs’ suits. The district court did not abuse its

discretion in ordering the consolidation and denying BSC a new trial.

                                    B.

      The district court also did not abuse its discretion when it

excluded BSC’s 510(k) evidence. The 510(k) review process

originates from the Medical Device Amendments of 1976 (MDA) to
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the Federal Food, Drug, and Cosmetic Act. The MDA was enacted in

order to “impose[ ] a regime of detailed federal oversight” of medical

devices. Riegel v. Medtronic, Inc., 552 U.S. 312, 316 (2008). Under

the MDA, certain devices must complete a thorough premarket

approval (PMA) process with the FDA before they may be marketed,

including all devices that cannot “provide reasonable assurance of

the[ir] safety and effectiveness” under less stringent scrutiny, and that

are “purported or represented to be for a use in supporting or sustaining

human life or for a use which is of substantial importance in preventing

impairment of human health” or “present[ ] a potential unreasonable

risk of illness or injury.” Id. at 317; 21 U.S.C. § 360c(a)(1)(C). The

PMA process requires the applicant to demonstrate a “reasonable

assurance” that the device is both “safe . . . [and] effective under the

conditions of use prescribed, recommended, or suggested in the

proposed labeling thereof.” Buckman Co. v. Plaintiffs’ Legal Comm.,

531 U.S. 341, 344 (2001); 21 U.S.C. § 360e(d)(2)(A), (B).

      An exemption to the PMA requirement exists for medical devices

that were already on the market prior to the MDA’s enactment in 1976;

these devices are allowed to remain on the market until the FDA
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initiates and completes PMA review for them. See 21 U.S.C.

§ 360e(b)(1)(A); Buckman, 531 U.S. at 345. In order to ameliorate the

monopolistic consequences of this exemption, the MDA also allows

other manufacturers to market devices that are shown to be

“substantially equivalent” to pre-1976 devices that are exempt from the

PMA requirement. Buckman, 531 U.S. at 345 (citing § 360e(b)(1)(B)).

The 510(k) process is the method by which a manufacturer

demonstrates substantial equivalence. Id.

      Notably, the PMA and 510(k) processes have distinct

requirements and different goals. PMA “is federal safety review,”

Riegel, 552 U.S. at 323, whereas “the 510(k) process is focused on

equivalence, not safety,” Medtronic, Inc. v. Lohr, 518 U.S. 470, 493

(1996) (quotation omitted and alteration adopted). Indeed, “devices

that enter the market through § 510(k) have never been formally

reviewed . . . for safety or efficacy.” Riegel, 552 U.S. at 323 (quotation

omitted). Rather, the 510(k) exemption is “intended merely to give

manufacturers the freedom to compete, to a limited degree, with and on

the same terms as manufacturers of medical devices that existed prior

to 1976.” Lohr, 518 U.S. at 494.
                                    22
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         These differences are reflected in the intensity of review: “[I]n

contrast to the 1,200 hours necessary to complete a PMA review, the

§ 510(k) review is completed in an average of only 20 hours.” Id. at

479; see also Goodlin v. Medtronic, Inc., 167 F.3d 1367, 1369 n.1

(11th Cir. 1999) (“[T]he FDA completes the average 510k review

within 20 hours, and the agency considers only whether the device is

indeed the equivalent of a preexisting device -- regardless of how

unsafe or ineffective the grandfathered device happens to be.”). The

two processes are “by no means comparable.” Lohr, 518 U.S. at 478.

         Based on the arguments properly presented in this appeal,3 it is

clear that the district court did not abuse its discretion when it

concluded that the 510(k) review process is not relevant to a product’s

safety. As the district court explained, “[i]f 510(k) does not go to a

product’s safety and efficacy -- the very subjects of the plaintiffs’

3
          In its reply brief, BSC argues for the first time that because the FDA determined
    the Pinnacle to be substantially equivalent to a post-1976 Class II device that may have
    undergone formal safety review, as opposed to a pre-1976 Class III device which had
    not, BSC’s 510(k) evidence could be relevant to the Pinnacle’s safety in a way that
    distinguishes this case from Lohr and Riegel. Because BSC failed to raise this
    argument in the district court, or even on appeal prior to its reply brief, we will not
    consider it. See Access Now, Inc., 385 F.3d at 1331 (explaining that “an issue not
    raised in the district court . . . will not be considered by this [C]ourt”) (quotation
    omitted); Lovett v. Ray, 327 F.3d 1181, 1183 (concluding that an argument raised for
    the first time in a reply brief is not properly before this Court).

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products liability claims -- then evidence of BSC’s compliance with

510(k) has no relevance to the state law claims in this case.” This

evidence was properly excluded under Rule 402.

      BSC’s arguments to the contrary do not undermine this

conclusion. BSC claims that the evidence is relevant because the

plaintiffs based much of their case on the theory that BSC didn’t

perform sufficient safety testing, and because Florida has established a

rebuttable presumption that a product is not defective if it complies

with applicable safety regulations. But these points simply beg the

question; because 510(k) is not a safety regulation, approval under that

process cannot show that BSC performed sufficient testing or complied

with applicable safety regulations. BSC also argues that the district

court’s conclusion misapplied Lohr and Riegel because those cases

dealt with 510(k)’s relevance to safety in the context of preemption of

state-law claims, not evidence admissibility. But the district court

simply applied the Supreme Court’s reasoning from those cases to

reach a related, though technically distinct, conclusion -- a basic and

entirely proper form of judicial analysis.

      But even if the 510(k) evidence were relevant, the district court
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still did not abuse its discretion when it excluded it under Rule 403. As

the district court noted, the evidence “might have provoked the parties

to engage in a time-consuming mini-trial on whether BSC in fact

complied with [FDA] regulations.” And the apparent significance of

federal regulatory schemes very well might have misled the jury into

thinking that general federal regulatory compliance, not state tort

liability, was the core issue. These concerns of prejudice and confusion

substantially outweighed the probative value of the evidence,

which -- divorced as it was from any clear showing of safety review for

the Pinnacle or a substantially similar device -- was low at best.

Although BSC argues that any possibility of prejudice could have been

“resolved with an appropriate instruction” to the jury, that option does

not come close to tipping the scale in their favor. Weighing all these

considerations, the court acted within its discretion by excluding the

510(k) evidence.

      We are not the only circuit court to have approved exclusion of

510(k) evidence under Rule 403. The Fourth Circuit, in In re C.R.

Bard, Inc., MDL No. 2187, Pelvic Repair System Products Liability

Litigation, 810 F.3d 913 (4th Cir. 2016) -- reviewing another order
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excluding 510(k) evidence for a vaginal mesh device -- explained that,

even “[a]ssuming without deciding that the 510(k) compliance

evidence is relevant,” the evidence had diminished probative value

because 510(k) “operate[s] to exempt devices from rigorous safety

review procedures.” Id. at 920. The court held that the district court

did not abuse its discretion when it concluded that the possibility of

“mini-trials” on the 510(k) process -- which would have included a

“battle of experts” -- presented “the very substantial dangers of

misleading the jury and confusing the issues.” Id. at 921–22 (quotation

omitted). The Fourth Circuit explained the issue this way:

      While 510(k) clearance might, at least tangentially, say
      something about the safety of the cleared product, it does not say
      very much that is specific. The vast majority of courts have said
      so, and having been thoroughly briefed not only by the parties but
      by several amici, we say so again today. As such, the district
      court did not abuse its discretion when it determined that
      allowing the 510(k) evidence in on the question of design defect
      would be substantially more prejudicial than probative.

Id. at 922.

                                   IV.

      Even setting aside the issues of consolidation and exclusion of

the 510(k) evidence, BSC argues that the district court should have

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granted it judgment as a matter of law on Eghnayem’s design defect

and failure to warn claims, because she didn’t present enough evidence

to establish debatable questions of fact and because her claims were

untimely. After thoroughly reviewing this record, we are satisfied that

Eghnayem provided sufficient evidence in her favor, so her claims were

properly reserved for the jury. The district court did not err by

declining to overturn the jury’s verdict.

                                    A.

      The district court did not err by denying judgment as a matter of

law to BSC on Eghnayem’s design defect claims. We are Erie-bound

in diversity cases to apply the tort law of Florida. Erie R. Co. v.

Tompkins, 304 U.S. 64, 78 (1938). In Florida, “a product is defectively

designed if the plaintiff proves that the design of the product

proximately caused the plaintiff’s injuries and the defendant fails to

prove that on balance, the benefits of the design outweigh the risk of

danger inherent in the design.” Force v. Ford Motor Co., 879 So. 2d

103, 106 (Fla. Dist. Ct. App. 2004). This test, known as the “risk-

utility” test, is one of two ways to show that a design is defective under

the strict products liability standard laid out in the Second Restatement
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of Torts. Jennings v. BIC Corp., 181 F.3d 1250, 1255 (11th Cir. 1999).

We have acknowledged that Florida has adopted this standard. Id.

(citing West v. Caterpillar Tractor Co., 336 So. 2d 80, 87 (Fla. 1976)).

In this case, the jury was instructed on only the risk-utility test.

      Eghnayem presented expert testimony of two specific defects in

the Pinnacle: the polypropylene material may experience oxidative

degradation, which causes it to lose its physical and mechanical

properties in a way that causes injury; and the crosshatched design of

the mesh makes it very difficult, if not impossible, to remove if there is

a problem with the mesh.

      Regarding polypropylene degradation, Eghnayem presented

expert testimony from Dr. Mays (qualified as an expert in the field of

polymer science) that polypropylene reacts with oxygen, and “[w]hen

that oxidative process progresses enough, the material erodes away.”

When this happens, the polypropylene “stiffen[s]” and “lose[s] [its]

mechanical properties,” which “is relevant to the proper or improper

use of polypropylene in a medical device.” Mays further explained that

“if you increase the surface area of the material, . . . [y]ou’re going to

increase the rate at which that material undergoes degradation,” and
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that for polypropylene fibers -- a category that the Pinnacle falls

into -- “physical properties deteriorate more rapidly upon oxidation.”

Finally, Mays noted that degradation occurs in the body “much more

readily than it does in many other environments,” and once it occurs the

material “can no longer move with the body.” Mays testified that there

is evidence that polypropylene degrades “when implanted in the female

pelvis,” and that such degradation may result in stiffness and ultimately

“a sawing effect” that Mays believed “caus[ed] some of the problems

with the mesh.” Another expert, Dr. Walmsley (qualified as an expert

in the field of urology), testified that when treating pelvic organ

prolapse with polypropylene mesh, there are “mesh-specific risks” of

pelvic pain, erosion, painful activity, and permanent tissue damage,

along with a significant risk of subsequent surgery as compared to other

prolapse surgical repairs -- approximately a “threefold” increase.

      As for the difficulty surrounding the removal of the

polypropylene mesh, Dr. Margolis (qualified as an expert in the fields

of obstetrics and gynecology) opined that the implantation of the mesh,

which has a “crosshatched” or “window screen[ ]” pattern of holes, was

“irreversible” because “[s]car tissue, what are called fibroblasts, scar
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cells, move into the [holes in the] mesh and they cement the mesh into

place.” Margolis explained that this aspect of the mesh implantation

makes it very difficult to treat mesh injuries, complications, and

erosions.

      When taken in concert, this expert testimony provided a

sufficient foundation for a reasonable jury to conclude that the design

of the mesh increased both the potential for degradation and the

difficulty of removal. The ultimate question whether these risks

outweighed the Pinnacle’s benefits was for a jury to decide. The

district court correctly did not second-guess the jury’s verdict.

      BSC’s arguments to the contrary are unavailing. BSC claims that

the “purported design defect is a matter not of kind (like the presence of

polypropylene) but of degree (the surface area of polypropylene),” and

thus that Eghnayem was required to establish “the minimum threshold

beyond which the product is defective.” But this argument is a red

herring. This type of analysis is used in toxic tort cases, where some

exposure to a toxic substance may be acceptable, but past a certain

threshold exposure becomes harmful. See, e.g., McClain v. Metabolife

Int’l, Inc., 401 F.3d 1233, 1241 (11th Cir. 2005) (“In toxic tort cases,
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scientific knowledge of the harmful level of exposure to a chemical

plus knowledge that plaintiff was exposed to such quantities are

minimal facts necessary to sustain the plaintiff’s burden.”) (quotation

omitted and alteration adopted). But in this case, there is no question of

threshold; the Pinnacle was either harmful or not.

      BSC also argues that Eghnayem’s implanting physician testified

that polypropylene was safe and effective, and that this somehow

defeats her claim of a design defect. But any testimony from her

experts that tended to weaken her design defect claim is irrelevant to

judgment as a matter of law; the weighing of conflicting evidence is

properly for the jury. See Pensacola Motor Sales Inc. v. E. Shore

Toyota, LLC, 684 F.3d 1211, 1226 (11th Cir. 2012) (explaining that, in

reviewing the denial of a motion for judgment as a matter of law, “we

must disregard all evidence favorable to the moving party that the jury

is not required to believe”) (quotation omitted).

      Taking the evidence in the light most favorable to Eghnayem,

there was sufficient evidence for a reasonable jury to find that the

Pinnacle had a design defect. Accordingly, the district court correctly

denied BSC’s motion for judgment as a matter of law.
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                                    B.

      The district court did not err by denying judgment as a matter of

law to BSC on Eghnayem’s failure to warn claims either. Under

Florida law, to succeed on a failure to warn claim a plaintiff must show

(1) that the product warning was inadequate; (2) that the inadequacy

proximately caused her injury; and (3) that she in fact suffered an

injury from using the product. Hoffmann-La Roche Inc. v. Mason, 27

So. 3d 75, 77 (Fla. Dist. Ct. App. 2009). For medical products like the

Pinnacle, “the duty to warn is directed to physicians rather than patients

under the ‘learned intermediary’ doctrine.” Id. This is so because the

prescribing physician acts as an intermediary between the manufacturer

and the consumer, weighing the potential benefits of a device against

the dangers in deciding whether to recommend it to meet the patient’s

needs. Felix v. Hoffmann-LaRoche, Inc., 540 So. 2d 102, 104 (Fla.

1989). Consequently, to satisfy the causation element, a plaintiff must

show that her treating physician would not have used the product had

adequate warnings been provided. See id. at 105 (explaining that “the

drug manufacturer could not be penalized for the failure of the doctor

to impart knowledge concerning the dangers of the drug of which the
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doctor had been warned and was aware”).

      “While in many instances the adequacy of warnings . . . is a

question of fact,” the Florida Supreme Court has held that “it can

become a question of law where the warning is accurate, clear, and

unambiguous.” Felix, 540 So. 2d at 105. “[T]he adequacy or

inadequacy of the warning to inform a physician must, except in the

more obvious situations, be proved by expert testimony.” Upjohn Co.

v. MacMurdo, 562 So. 2d 680, 683 (Fla. 1990). “To warn adequately,

the [warning] label must make apparent the potential harmful

consequences.” Farias v. Mr. Heater, Inc., 684 F.3d 1231, 1233 (11th

Cir. 2012) (quoting Scheman-Gonzalez v. Saber Mfg. Co., 816 So. 2d

1133, 1139 (Fla. Dist. Ct. App. 2002)). Generally, “[t]he warning must

be of such intensity as to cause a reasonable man to exercise for his

own safety caution commensurate with the potential danger.” Id.

(quoting Scheman-Gonzalez, 816 So. 2d at 1139). But “[w]hen a

warning is designed to inform a ‘learned intermediary,’ it is somewhat

easier to establish the adequacy of the warning because it will be read

and considered by a trained expert.” Hayes v. Spartan Chem. Co., 622

So. 2d 1352, 1354 (Fla. Dist. Ct. App. 1993).
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      The Florida Supreme Court has ruled at least twice in notable

cases that warnings were adequate as a matter of law. In Felix, the

court considered a label warning that explained “[b]ecause

teratogenicity has been observed in animals given [the drug], patients

who are pregnant or intend to become pregnant” should not use it, and

female patients “should be fully counseled on the potential risks to the

fetus should they become pregnant while undergoing treatment.” Felix,

540 So. 2d at 103. The court noted that the prescribing doctor testified

that he understood the warnings, and ultimately ruled that these

warnings were adequate as a matter of law to alert physicians to the

possible risk of birth defects from the drug. Id. at 105. In Upjohn, the

Florida Supreme Court considered a warning that mentioned the

following potential adverse reactions: breakthrough bleeding, spotting,

and change in menstrual flow. Upjohn, 562 So. 2d at 682. The court

observed that “no medical expert testified that the package insert was

insufficient to put a doctor on notice” that the medication could cause

the plaintiff’s “excessive and continuous menstrual bleeding,” and

concluded that, as “the insert warned of the possibility of abnormal

bleeding outside of the menstrual period,” “[i]t would be unreasonable
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to hold Upjohn liable for not characterizing the bleeding as excessive,

continuous, or prolonged.” Id. at 683.

      At trial Eghnayem argued that BSC failed to warn doctors that, in

the event of a problem with the Pinnacle, it could be difficult or even

impossible to remove. The Pinnacle’s directions for use contained the

following warnings:

      Hysterectomy may be needed in the future; Use of mesh may
      make future hysterectomies more difficult due to tissue in-growth
      and scarring.
      In the event that infection presents post procedure, the entire
      mesh many have to be removed or revised.
      Tissue responses to the implant could include local irritation at
      the wound site, vaginal erosion or exposure through the urethra
      or other surrounding tissue, migration of the device from the
      desired location, fistula formation, foreign body reaction, and
      inflammation. The occurrence of these responses may require
      removal or revision of the mesh.

Eghnayem offered expert testimony from Dr. Margolis that these

warnings failed to inform doctors that “a patient may need multiple

operative procedures to remove the mesh”; that “when you remove

portions of the mesh, part of the normal tissue has to come out with it,”

so that “you can[not] just take the mesh out and everything is fine”; and

that mesh implantation ultimately may be “irreversible.”

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      Eghnayem carried her burden here. While the Pinnacle’s

warnings may have been sufficient to notify doctors that multiple

procedures might be needed to remove the mesh, the warnings do not

even remotely suggest that removal might be impossible. Indeed, the

repeated warnings that removal might be necessary suggest just the

opposite. And the warnings also failed to notify doctors that removal

of the mesh might require removal of healthy tissue as well. The

closest they come is by warning that “future hysterectomies [may be]

more difficult due to tissue in-growth and scarring,” but that warning is

not so unambiguous that it would be unreasonable for a jury to hold

BSC liable for failure to warn.

      BSC argues, nevertheless, that the Pinnacle’s warnings were

sufficiently clear that they merited judgment as a matter of law under

Upjohn. But the district court was correct to conclude that “the

difference between Upjohn and the case at bar is one of degree -- the

injuries experienced by the plaintiff in Upjohn were a minor departure

from the risks warned of in the package insert, but the same cannot be

said here.” Because the Pinnacle warnings did not explain that the

complications they warned of could be “permanent, irreversible, and
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untreatable,” the departure was not so minor that the entry of judgment

as a matter of law was warranted.

      Eghnayem also proffered sufficient evidence that BSC’s failure

to warn caused her injuries. BSC argues that she failed to show that the

inadequate warnings affected her doctor’s decision to use the Pinnacle,

but her doctor testified that he would have liked to know the risk of

mesh contracture, acute and permanent inflammation, and chronic pain,

and that had he known he would have had “concerns about [ ] using

[the Pinnacle] in a patient” and would have discussed those concerns

with Eghnayem. This testimony does not “point so overwhelmingly in

favor of” BSC that no reasonable jury could find that the failure to

warn proximately caused Eghnayem’s injuries. Slicker v. Jackson, 215

F.3d 1225, 1229 (11th Cir. 2000) (quotation omitted).

                                     C.

      Finally, the district court did not err by denying judgment as a

matter of law to BSC on its argument that Eghnayem’s claims were

time barred. It was not unreasonable for the jury to find that

Eghnayem’s claims accrued after April 11, 2009 -- the cut-off point for

the state’s four-year statute of limitations.
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      Under Florida law, plaintiffs have four years to bring a products

liability action. Fla. Stat. §§ 95.11(3)(e), 95.031. Accrual for these

actions is governed by the discovery rule, according to which the

statute of limitations period does not begin to run until “the date that

the facts giving rise to the cause of action were discovered, or should

have been discovered with the exercise of due diligence.” Id. §

95.031(2)(b). The Florida Supreme Court has explained that the

knowledge required to commence the running of the limitations period

under the discovery rule need “not rise to that of legal certainty.” Univ.

of Miami v. Bogorff, 583 So. 2d 1000, 1004 (Fla. 1991), holding

modified on other grounds by Tanner v. Hartog, 618 So. 2d 177 (Fla.

1993). Rather, “[p]laintiffs need only have notice, through the exercise

of reasonable diligence, of the possible invasion of their legal rights.”

Id. Notice, in turn, “ha[s] two essential ingredients: an injury distinct in

some way from conditions naturally to be expected from the plaintiff’s

condition, and . . . exposure to the product in question.” Babush v. Am.

Home Prods. Corp., 589 So. 2d 1379, 1381 (Fla. Dist. Ct. App. 1991)

(emphasis omitted). “Use of the conjunction ‘and’ in this equation

necessarily implies that the connection must be to some extent causal.”
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Id.

      Florida precedent sheds considerable light on what it takes for an

injury to meet this notice standard. In Bogorff, the Florida Supreme

Court concluded that a three-year-old’s symptoms of slurred speech,

impaired motor skills, convulsions, coma, and resultant paralysis and

brain damage, which coincided in time with the introduction of a

particular leukemia medication, were sufficiently dramatic to provide

notice to his parents. 583 So. 2d at 1001, 1004. In Norsworthy v.

Holmes Reg’l Med. Ctr., Inc., on the other hand, a Florida appellate

court held -- in the highly analogous medical malpractice context -- that

a child’s difficulty breathing following an invasive medical procedure

was not so obviously unusual that it put his parents on notice of their

malpractice claim. 598 So. 2d 105, 108 (Fla. Dist. Ct. App. 1992). The

court explained that when “there is nothing about an injury that would

communicate to a reasonable lay person that the injury is more likely a

result of some failure of medical care than a natural occurrence that can

arise in the absence of medical negligence, the knowledge of the injury

itself does not necessarily trigger the running of the statute of

limitations.” Id. at 107. Because even “medical treatment competently
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performed” might cause new unpleasant symptoms, an injury must

stand out from the norm to start the statutory clock. Id. at 108.

      Thus, to merit judgment as a matter of law for BSC, the evidence

must have been clear that Eghnayem was aware of a “dramatic change

in [her] condition,” and further that she knew of the possible

involvement of the Pinnacle in that change, by April 11, 2009 -- four

years before she filed suit. See Bogorff, 583 So. 2d at 1004;

Middlebrooks, 256 F.3d at 1246. The evidence was not that clear.

While Eghnayem did exhibit one new symptom in 2008 -- urinary

incontinence -- that could have been associated with a defect in the

Pinnacle, that symptom was not so obviously unusual as to indisputably

put Eghnayem on notice about her claim. Incontinence is a more

dramatic symptom than some, but judgment as a matter of law is a high

standard, and it was not “patently clear” or “obvious” that Eghnayem’s

incontinence was a sufficiently distinct symptom from what might be

expected after vaginal surgery to put her on notice of her cause of

action against BSC. See United States v. Groessel, 440 F.2d 602, 606

(5th Cir. 1971).

      BSC argues that Eghnayem’s testimony that, after consulting
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with her doctor in October 2008, she believed this new symptom

“w[as] related to the mesh repair” showed she was on notice at that

time. But “mesh repair” could refer to the implantation surgery, along

with any complications, as opposed to the Pinnacle device itself.

BSC’s protestation to the contrary -- that “[n]o rational juror could

conclude that Eghnayem testified the implant surgery, rather than the

mesh itself, was ‘related’ to her ‘problems’” because “[s]he never

blamed her surgeon, and she presented no evidence that her ‘problems’

were caused by surgical technique” -- misses the point. The question is

not whether a reasonable jury could conclude that her injuries were

caused by the surgery, but rather whether the jury could conclude that

Eghnayem reasonably believed that her incontinence was a result of the

surgery instead of the Pinnacle. Ultimately, a jury could have

reasonably concluded that Eghnayem’s injury was not so “distinct . . .

from conditions naturally to be expected from [her post-surgical]

condition,” and so the timeliness of Eghnayem’s action was properly a

question of fact for the jury. Babush, 589 So. 2d at 1381.

      The long and short of it is that the district court properly
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exercised its broad discretion in consolidating these actions and

refusing to admit FDA evidence, and the contested fact questions were

properly presented to the jury.

      AFFIRMED.

                                   42