Court Opinion

ID: 6931836
Source: CourtListenerOpinion
Date Created: 2022-07-24 00:06:35.821932+00
Date Added: 2024-06-11T16:07:13.576270
License: Public Domain

MERRITT, Chief Judge, delivered the opinion of the court, in which NELSON, Circuit Judge, joined.
BOGGS, Circuit Judge (pp. 978-89), delivered a separate dissenting opinion.
MERRITT, Chief Judge.
Plaintiffs appeal the district court’s grant of summary judgment for the defendant on the single issue of causation in this product liability action. Plaintiffs allege negligence and breach of warranty in defendant-pharmaceutical company’s manufacture and distribution of the diet pill “Dexatrim.” Specifically, the complaint alleges that plaintiff Bryan Glaser’s ingestion of one capsule of Dexatrim caused him to suffer acute hypertension which in turn caused him to suffer a stroke or intracranial bleed. That stroke caused him to fall, hit his head, and suffer further severe injuries. In granting defendant’s motion for summary judgment on this single issue, the district court ruled that the evidence proffered by plaintiffs on causation was insufficient to go to the jury. The issue before us is essentially a factual one: Is the evidence offered below consisting primarily of the deposition testimony of plaintiffs’ expert sufficient to create a dispute of material fact? We believe there is a genuine dispute of material fact regarding causation and therefore reverse. This holding carries no implications regarding the other facets of plaintiffs’ claims of negligence and breach of warranty.
I.
The evidence offered by plaintiff on summary judgment is as follows: Twenty year-old Bryan Glaser began daily ingestion of one or two extra-strength Dexatrim diet pills around Thanksgiving, 1987. On Sunday, January 3, 1988, Bryan complained that he felt ill: his ears were ringing, and he experienced hot and cold flashes and other flu-like symptoms. He cancelled plans for that evening in order to rest. Early the next morning while Bryan was still asleep, Bryan’s sister Jodi noticed an unopened foil package containing one capsule of Dexatrim on Bryan’s dresser in his bedroom along with a glass of water and other vitamin pills. Although no one ever observed Bryan ingest the capsule, Jodi testified that the package had been opened and the capsule and other vitamins were no longer on the dresser later that morning. Bryan left home around noon on Monday and went to the Medstop walk-in medical clinic. Medical records indicate that he complained of hot and cold flashes, ringing in his ears and fatigue. His blood pressure was within normal range (128/82) and the treating physician, Dr. Baubie, diagnosed Bryan with post-viral syndrome and fatigue. Dr. Baubie did not know that Bryan was taking Dexatrim.
After leaving the clinic, Bryan went to the bank, where he stood in line for approximately 20 minutes before reaching teller Jaque-line Kulehycki’s window. Kulchycki’s testimony is important. She testified that it was obvious to her that Bryan was not-feeling well: he was squinting, holding his head as if he had a severe headache, and was flushed and sweating. As she turned away from her station, Bryan collapsed to the floor and hit his head. Emergency medical personnel were called and they transported Bryan to Detroit Macomb Hospital for treatment. He was diagnosed with an intracerebral bleed on the left frontal lobe of his brain, a skull fracture and a subdural hematoma. Emergency room doctors never attempted to diagnose the cause of his fall, but rather assumed that all of his injuries resulted from the fall.
The plaintiffs filed this lawsuit asserting that the fall was caused by the intracranial bleed found on the left frontal lobe of *971Bryan’s brain, and that this bleed had been caused by ingestion of Dexatrim. After extensive discovery, the defendant filed motions for summary judgment, arguing that the scientific literature did not support a conclusion that one capsule of Dexatrim could cause an acute hypertensive reaction, that there was no evidence that an intracra-nial bleed preceded the fall, and that there was no evidence that Dexatrim caused such a reaction in Bryan. The district court assumed in its opinion that the scientific evidence was sufficient to support the conclusion that one capsule of Dexatrim can cause an acute hypertensive reaction serious enough to induce intracranial bleeding. The district court held, however, that the opinion of Dr. Zaloga, plaintiffs medical expert, was merely consistent with the known facts and conditions of the case, but was not based on a logical sequence of cause and effect. On that basis, the court granted summary judgment in favor of the defendants.
II.
Our review of a district court’s grant of summary judgment is de novo. All facts must be viewed and inferences drawn in favor of the plaintiffs. Summary judgment is proper only if there is no genuine issue of material fact and the moving party is entitled to judgment as a matter of law. Fed.R.Civ.P. 56(c); Celotex Corp. v. Catrett, 477 U.S. 317, 106 S.Ct. 2548, 91 L.Ed.2d 265 (1986); Anderson v. Liberty Lobby, Inc., 477 U.S. 242, 106 S.Ct. 2505, 91 L.Ed.2d 202 (1986).
The burden of proof in establishing proximate cause lies with the plaintiff. Plaintiff must introduce evidence which provides a reasonable basis upon which a jury could conclude that it was more likely than not that the defendant’s conduct in fact caused the injury. “A mere possibility of such causation is not enough; and when the matter remains one of pure speculation or conjecture, or the probabilities are at best evenly balanced,” the plaintiff has not met the burden. Mulholland v. DEC Int’l Corp., 432 Mich. 395, 443 N.W.2d 340, 350 n. 18 (1989) (quotations omitted). Sitting in diversity, we apply Michigan’s law of causation. Erie R. Co. v. Tompkins, 304 U.S. 64, 58 S.Ct. 817, 82 L.Ed. 1188 (1938).
The propriety of summary judgment in this case hinges on three causation questions:
1. Whether one capsule of Dexatrim is capable of causing hypertension severe enough to cause an intracranial bleed.
2. Whether Bryan suffered the intracra-nial bleed on the left frontal lobe of his brain prior to his fall.
3. Whether the bleed was caused by ingestion of Dexatrim.
Summary judgment is proper if there are no material issues of fact regarding any of these questions, and if any one of them should be answered in favor of the defendant. We address these questions in turn.
A.
The defendant first challenges the scientific basis for Dr. Zaloga’s conclusion that Dexatrim can cause severe hypertension. It argues that the medical studies proffered by the plaintiffs as support for Zaloga’s conclusions actually support the defendant’s position that Dexatrim cannot cause significant elevations in blood pressure and further that because there is no basis for the expert’s opinion, the court should not allow a jury to decide the causation issue.
The testimony of plaintiffs expert is admissible. The Supreme Court, in Daubert v. Merrell Dow Pharmaceuticals, Inc., — U.S. -, 113 S.Ct. 2786, 125 L.Ed.2d 469 (1993), set forth the standard for admission of expert scientific testimony, holding that Rule 702 of the Federal Rules of Evidence governs the admissibility of such expert testimony. Rule 702 admits expert testimony if the evidence will assist the trier of fact and if the witness is qualified as an expert. The Rule provides:
If scientific, technical, or other specialized knowledge will assist the trier of fact to understand the evidence or to determine a fact in issue, a witness qualified as an expert by knowledge, skill, experience, training, or education, may testify thereto in the form of an opinion or otherwise.
Daubert explained that Rule 702 must be read in the context of the liberal thrust of the *972Federal Rules of Evidence and must be interpreted consistently with the “general approach of relaxing the traditional barriers to ‘opinion’ testimony.” Daubert, — U.S. at -, 113 S.Ct. at 2794 (quotations omitted). The Court also cautioned in its opinion that even under these liberal requirements, trial judges must ensure that scientific testimony is not only relevant, but reliable. Id. at -, 118 S.Ct. at 2795. A court must determine:
whether the expert is proposing to testify to (1) scientific knowledge that (2) will assist the trier of fact to understand or determine a fact in issue. This entails a preliminary assessment of whether the reasoning or methodology underlying the testimony is scientifically valid and of whether that reasoning or methodology properly can be applied to the facts in issue.
Id. at -, 113 S.Ct. at 2796 (footnote omitted).
In assessing scientific validity, the Court provided a non-exclusive list of factors to assist the trial courts: (1) whether a theory or technique can be (and has been) tested, (2) whether the theory or technique has been subjected to peer review and publication, (3) the known or potential rate of error in using a particular scientific technique and the existence and maintenance of standards controlling the technique’s operation, and (4) whether the theory or technique has been generally accepted in the particular scientific field. United States v. Bonds, 12 F.3d 540, 555 (6th Cir.1993) (citing Daubert, — U.S. at -, 113 S.Ct. at 2796-97). The inquiry must be a flexible one whose “overarching subject is the scientific validity — and thus the eviden-tiary relevance and reliability — of the principles that underlie a proposed submission.” Daubert, — U.S. at -, 113 S.Ct. at 2797.
If a court concludes that the evidence supporting the expert’s position is insufficient to allow a reasonable juror to conclude that the position more likely than not is true, then the court remains free to prohibit the case from proceeding to the jury. Id. at -, 113 S.Ct. at 2798 (citing Turpin v. Merrell Dow Pharmaceuticals, Inc., 959 F.2d 1349 (6th Cir.), cert. denied, — U.S. -, 113 S.Ct. 84, 121 L.Ed.2d 47 (1992)). “[A]l-though judges should respect scientific opinion and recognize their own limited scientific knowledge, nevertheless courts have a duty to inspect the reasoning of qualified scientific experts to determine whether a case should go to a jury.” Turpin v. Merrell Daw Pharmaceuticals, Inc., 959 F.2d 1349 (6th Cir.1992) (calling for a “hard look” by courts at the basis of scientific opinion); see also Cantrell v. GAF Corporation, 999 F.2d 1007, 1013-14 (6th Cir.1993).
A thorough review of all of the literature submitted by both parties and of Dr. Zaloga’s testimony convinces us that sufficient, valid, peer-reviewed scientific evidence, along with Dr. Zaloga’s own clinical and research experience, provide a solid foundation upon which Dr. Zaloga bases his conclusion that the 75 milligrams of phenylpropanolamine (PPA), the active ingredient in one capsule of Dexa-trim, caused acute hypertension. Dr. Zaloga testified during his deposition that his opinion was based on the five studies he published on the topic, the published articles of other medical researchers, case reports, his experience treating patients who had ingested PPA-containing compounds, his clinical experience with PPA in other studies, and his experience directing endocrine and obesity clinics. (Zaloga’s Deposition Tr. at 26-28).1
*973The medical literature upon which Dr. Za-loga relies includes five studies which he coauthored and two other published research papers on the subject of PPA’s effect on blood pressure. The first paper, published in September 1988,2 studied the effects of double doses of PPA (150 mg) and of 75 mg of PPA with 400 mg of caffeine. The results showed that 75 mg alone did not cause clinically relevant hypertension in the six subjects tested, but did show clinically relevant hypertension in the subjects taking 150 mg and the 75 mg with caffeine. The authors noted that at least 15 North American cases of hemorrhagic stroke and hypertensive crisis had been attributed to PPA in doses equal or less than 150 mg.
In Dr. Zaloga’s second paper,3 the authors studied the effects of single doses of PPA on blood pressure after 1 and 2 hours, and after 2 weeks. The study found no clinically significant rises in blood pressure during these time periods but noted that more significant rises at other times may have been missed. The authors called for further studies in light of the numerous reports of severe adverse reactions to PPA.
Dr. Zaloga’s third paper 4 was a follow-up study based on the reports of severe adverse reactions following ingestion of single (75 mg) or double doses of PPA with or without caffeine. The results of this study indicated that single doses of PPA may significantly elevate blood pressure, usually at approximately 3 to 4 hours after ingestion.5 The authors concluded that their findings “may explain some of the recent ease reports of nontraumatic intracranial hemorrhage in young, healthy persons ingesting PPA at recommended or minimally greater dosages.” Specifically, the subjects taking only 75 mg of PPA showed significantly higher blood pressures than those on placebo, and three subjects had systolic blood pressure readings of 160 mm Hg or higher. The paper also noted that strokes caused by PPA had been established in animal studies and that a literature review of 140 cases of adverse reactions to PPA included intracerebral hemorrhages and major motor seizures. It hypothesized that several cases of strokes in young, healthy individuals were attributable to PPA based on severe, transient and unrecorded hypertensive episodes, and asserted that this hypothesis is supported by recorded episodes of such reactions.
*974The fourth paper co-authored by Dr. Zalo-ga6 examined the pharmacokinetic interaction of PPA and caffeine, concluding that physical side effects as well as increases in both systolic and diastolic blood pressure occurred after ingestion of the combination of 400 mg of caffeine and 75 mg of PPA; and that these effects were more severe after ingestion of the combination of PPA and caffeine than when either drug was ingested alone. The main result of the study was that PPA may enhance absorption or inhibit elimination of caffeine from the body, and may explain increased side effects reported after their combined use.
The fifth paper co-authored by Dr. Zalo-ga 7 studied the effects of 75 mg of PPA, 75 mg PPA with 400 mg caffeine, and 150 mg PPA on blood pressure. It found that blood pressure increases correlated with PPA plasma levels and that all three subject groups experienced three times more blood pressure rises than did the placebo group. The authors called for further studies of the blood pressure effects of 75 mg PPA, explaining that some individual peak blood pressures that were reached were worrisome, including systolic pressure of 210 and diastolic pressure of 160 mg Hg. The authors state:
Although our data agree with others that a recommended dose does not consistently raise blood pressure to clinically important levels in quietly resting, young, healthy subjects, as many as 20% of one study population (2 of 10 subjects in the Pentel study) demonstrated some blood pressure supersensitivity to recommended doses of [PPA].... The frequent use of [PPA], its wide availability over-the-counter in drug and many grocery stores, the potential for overuse of such non-prescription drugs and finally, the growing body of anecdotal ease reports implicating [PPA] in severe adverse reactions give cause for concern.

Id.

Zaloga also relies on at least two other studies to support his conclusion. Pentel8 studied the efficacy and safety of propanolol as a drug to counter PPA-indueed hypertension. The study found that PPA increased blood pressure in a dose-related fashion with blood pressure rising significantly in some individuals after 75 mg doses. The greatest individual rise in blood pressure after 75 mg PPA was 55 mg Hg systolic and 35 mm Hg diastolic.9
Finally, Zaloga relies to a lesser extent on the Horowitz paper. It summarizes a study done on the effects of single doses of PPA-containing compounds. Subjects receiving 85 mg PPA suffered increases in blood pressure with that pressure rise peaking between 1.5 and 3 hours after ingestion. The authors concluded that the frequency and extent of hypertensive responses to PPA suggest that clinical use of such preparations should be reviewed. The authors state that potentially dangerous rises in blood pressure may occur after ingestion of a single capsule of PPA-containing substances and that a report of cerebral hemorrhage after ingestion of 85 mg confirms that these adverse effects may be life-threatening.10
*975These studies, together -with Dr. Zaloga’s extensive experience and work in this area, provide sufficient, reliable scientific data upon which Dr. Zaloga may base his conclusion. All of these papers have clearly explained, solid scientific methodologies upon which they have tested their theories, and all have been peer-reviewed and published in reputable medical journals, including The American Journal of Medicine, the Lancet, The Journal of Clinical Pharmacology, and Neuropsychopharmacology. The error rates are published and their impact on the studies explained. These factors, as outlined in Daubert and Bonds, indicate the reliability of the foundation upon which Dr. Zaloga rests his opinion.
Finally, Dr. Zaloga and the plaintiffs concede readily that there are other studies that disagree with Dr. Zaloga’s conclusion. Dr. Zaloga distinguishes many of them and points to flaws in their methods and data reporting techniques which led him to rely on the above-outlined works in reaching his conclusions.11 Such differences in opinions among medical experts do not invalidate Dr. Zaloga’s opinion, but rather create material issues of fact which must be resolved by the jury.
Our mode of analysis here follows Turpin v. Merrell Dow Pharmaceuticals, Inc., 959 F.2d 1349 (6th Cir.1992). There we analyzed closely a large number of epidemiological, in vitro and animal studies and concluded that scientific opinion would not support a finding by the jury that the drug in question “more probably than not caused the birth defects” at issue. Id. at 1360. We concluded that the one expert for the plaintiff who testified that the drug did cause the injury had based his testimony on “personal belief or opinion,” not “on the basis of the collective view of his scientific discipline,” nor by explaining coherently the “grounds for his differences” with his scientific peers. Id. We therefore concluded that the expert’s conclusions “go far beyond the known facts that form the premise for the conclusion stated.” Id. After a close examination of the basis for Dr. Zalo-ga’s testimony, we have reached a contrary conclusion for the reasons previously stated. In sum, we believe that sufficient, reliable evidence exists upon which Dr. Zaloga may testify that one capsule of Dexatrim (75 mg PPA) is capable of causing acute hypertension. Such testimony creates material issues of fact and precludes summary judgment on the question.
B.
The next causation question raised is whether Bryan’s intracranial bleed occurred prior to his fall or whether the fall instituted the bleed. Dr. Zaloga’s medical opinion is that the bleed preceded, and thereby caused, the fall. This opinion is based on two distinct determinations: (1) that nothing other than the bleed was likely to cause the fall, *976and (2) that it is unlikely that the fall caused the bleed. This testimony, as explained in more detail below, is sufficient to create a material question of fact for the jury as to whether the left frontal lobe bleed that Bryan suffered preceded (and caused) Bryan’s fall, or whether the fall preceded the bleed.
Dr. Zaloga explained that Bryan’s symptoms prior to the fall were typical of a patient with a slow-leaking vessel within the brain. He stated that although a viral entity (the flu) would be capable of causing a patient to faint, Bryan was not suffering from other typical flu-like symptoms such as upper respiratory problems, a runny nose, a cough or sore throat. Further, Dr. Zaloga noted that there was no evidence that Bryan slipped and fell and no medical evidence of severe dehydration or other condition such as a seizure disorder, leukemia or a platelet problem that might have left Bryan predisposed to such a fall.12
Dr. Zaloga conceded in his deposition that the left frontal lobe bleed might have started after the fall. He explained that it would be possible that Bryan’s head hitting the floor might have caused movement throughout the brain, tearing the blood vessels in the left frontal lobe. However, since the back of Bryan’s head hit the floor on the right side, Dr. Zaloga stated that he would not expect to see bleeding in the left frontal lobe but no injury to the right frontal lobe. Rather, he would expect to see a more deep-seated, pure deep bleed, or at least bruising on the surface of the right frontal lobe or multiple bruising throughout the brain.13 Based on his experience as a practicing physician who has treated over one thousand patients with intracranial damage and who has daily contact with patients with neurological problems, Dr. Zaloga stated that in his opinion the probabilities were much greater that the bleed preceded the fall than vice versa.14
*977This testimony clearly creates material questions of fact for the jury. Dr. Zaloga is a well-qualified medical expert in this area. His deposition makes clear that he carefully applied his medical knowledge and experience to the facts of this ease in order to render his opinion. That opinion would assist a jury in determining whether Bryan suffered the bleed of the left frontal lobe prior to the fall and thereby determine whether the bleed could have caused the fall and further injury.
C.
Given that there is sufficient evidence to allow a jury to conclude that the left frontal bleed preceded the fall, we must still determine if questions of material fact exist to allow a jury to decide that Dexatrim, rather than some other agent, caused the bleed. We find that there are material questions of fact created by Dr. Zaloga’s testimony on this point.
Dr. Zaloga testified that in his opinion the most likely cause of the bleed on the left frontal lobe of Bryan’s brain was a bleed related to hypertension, induced by the use of Dexatrim. Relying on the process of differential diagnosis,15 Dr. Zaloga ranked five possible causes for a bleed such as Bryan’s: First, a severe underlying central nervous system disease. Dr. Zaloga ruled this out as a cause of Bryan’s bleed since there was no medical evidence, past or present, that Bryan suffered from such a condition. (Depo.Tr. at 65). Second, Dr. Zaloga testified that he looked for a past history of severe hypertension. He again ruled this out as a cause since Bryan’s past medical records indicated he was “normotensive.” (Depo.Tr. at 66). Third, Dr. Zaloga looked for an undiagnosed underlying disease of the brain such as an aneurysm or a tumor. He testified that the arteriogram and CT scan done on Bryan after the injury showed no evidence of such a condition. (Depo.Tr. at 67-8).
Fourth, Dr. Zaloga testified that he looked for a drug that could cause acute hypertension. He explained that frequently physicians find use of cocaine or other amphetamines capable of influencing blood pressure in this manner. He stated that PPA falls within this class of drugs. He stated that the evidence he had been given showed that Bryan was using Dexatrim, was not using other drugs of this type, and that Bryan’s symptoms prior to the fall and subsequent medical tests were consistent with a drug-induced bleed.16
*978Dr. Zaloga also testified that he ranked spontaneous intercerebral bleeds and a bleed occurring secondary to the fall below drug-related bleeds in his differential diagnosis. He stated that if he were to compare in probabilities the likelihood of these causes with a drug-related cause, his opinion was that it was 80% likely that the bleed was caused by Dexatrim; 15% likely it was related to the fall; and 5% likely that it was related to other undiagnosed conditions. (Depo.Tr. at 209-10). He explained that his opinion was based on evidence which showed that Bryan’s symptoms and clinical state were consistent with a leaking vessel in the brain, that the timing of the injury was consistent with the pharmacokinetics and physiological effects of the drug,17 that no other evidence showed that he had slipped and fallen, and that there was no other medical evidence to explain the fall or fainting.
We recognize that assigning numerical percentages to an event such as this is inherently difficult. Such figures are educated, reasoned estimates; they cannot be calculated and therefore cannot be argued to be exact.18 However, Dr. Zaloga arrived at these probabilities and his opinion by employing differential diagnosis, a standard diagnostic tool used by medical professionals to diagnose the most likely cause or causes of illness, injury and disease. See Hines v. Consolidated Rail Corp., 926 F.2d 262, 270 n. 6 (3d Cir.1991); Parsons v. Heckler, 739 F.2d 1334, 1337 n. 5 (8th Cir.1984). Dr. Zaloga clearly explained his use of and reasoning under the technique and related the probabilities he estimated to all the facts and circumstances surrounding this incident, including Dexatrim’s ability to cause such incidents, the amount Bryan was assumed to have ingested, Bryan’s symptoms prior to his injuries, and medical evidence for ruling out other potential causes of the bleed.19 We therefore do not find the probability estimates without “logical basis,” as the defendant contends.
Dr. Zaloga’s opinion is backed by medical evidence and explanation and creates material questions of fact as to whether Bryan’s intracerebral bleed was caused by his ingestion of Dexatrim.20
We therefore REVERSE the district court’s grant of summary judgment in favor of the defendant and REMAND the case for further proceedings.

. Dr. Zaloga testified that there was an 80% chance that Bryan’s injury was in fact caused by his ingestion of a pill containing, as its sole active ingredient, 75 mg of PPA. He then summarized:
I think that it is possible for individuals who consume just 75 milligrams of [PPA] to have enough blood pressure elevation that they could sustain a[n] intracerebral hemorrhage .... That's based on our studies which — which show variation in the effect anywhere from a few millimeters of mercury on up. We have a tremendous range there. Then there are numbers of reports in the literature of the ingestion of just 75 milligrams which have resulted in those kinds of bleeds.... Ray Lake recently summarized 140 some cases of adverse reactions. A number of those include intracerebral bleeds which have occurred just after ingestion of 75 milligrams....
(Depo.Tr. at 134-36). Later in his deposition, Dr. Zaloga was asked about the number of cases of which he was aware of a hemorrhage after ingestion of 75 mgs. of PPA:
*973... I think that there are a number, to the point that it's not even reportable anymore.... In this review of the American literature, there were 142 case reports ... [T]he fact is that one could get 142 cases of an adverse reaction to a drug into the medical literature is a phenomenal report of an adverse consequence from a drug....
Here’s a 35-year-old Dexatrim 75 stroke with resolution. That patient had a stroke — a 20-year-old female, 1.5 hours after ingesting Dexatrim, stroke. We've got another one, Dex-atrim 75 milligrams, stroke.
(Depo.Tr. at 184-85).

. Lake, et. al., A Double Dose of Phenylpropano-lamine Causes Transient Hypertension, 85 Am. J.Med. 339 (1988).

. Lake, et. al., The Effects of Phenylpropanola-mine on Human Sympathetic Nervous System Function, Neuropsychopharmacology, Vol. 1, No. 2 (1988).

. Lake, et. ah, Transient Hypertension after Two Phenylpropanolamine Diet Aids and the Effects of Caffeine: A Placebo-Controlled Follow-Up Study, 86 Am.J.Med. 427 (1989).

.The study (referred to in the dissent at section III.C.) specifically states in its results section:
After 75 mg of PPA, means for [systolic blood pressures] at Hours 3 and 4 and [diastolic blood pressure] at Hour 4 were significantly higher than those after placebo.
(J.A. at 297.) Also in the results section of the Fifth paper (referred to in the dissent at section III.E.) the article specifically states:
Although the means of maximal blood pressure after all drugs, including placebo, were significantly greater than baseline, the peak increases after active drugs were generally 100 percent greater than after placebo.
(J.A. 465.) The synopsis to the article also summarizes:
The maximal increases in supine diastolic blood pressure after all three phenylopropano-lamine-containing drugs were almost three times that after placebo....
(J.A. at 463.)
Not all subjects or even a majority of the subjects in these studies suffered acute blood pressure rises from 75 mg of PPA; but the studies do show, as Dr. Zaloga maintains, the 75 mg of PPA may cause such blood pressure increases in certain individuals.

. Lake, et. al., Phenylpropanolamine increases plasma caffeine levels, Clinical Pharmacol. Ther. 675 (June 1990).

. Lake, et. al., Dose-Dependent Response to Phe-nylpropanolamine: Inhibition of Orthostasis, J.Clin.Pharmacol 1991; 31: 624-635.

. Pentel, Propanolol antagonism of phenylpropa-nolamine-induced hypertension, Clin.Pharma-col-Ther. Vol. 37, No. 5 (May 1985).

. The dissent maintains that Dr. Zaloga should not have relied on this article because Pentel studied immediate release compounds rather than Dexatrim's sustained release version of the drug. However, Dr. Zaloga was clearly aware of the differences between the two compounds, see infra note 10, and testified regarding the methods used to apply Pentel’s results to questions involving sustained release compounds. (Depo.Tr. at 281-85).

.Horowitz, et. al., Hypertensive Responses Induced by Phenylpropanolamine in anorectic and decongestant preparations, The Lancet, January 12, 1980. Dr. Zaloga summarized:
In my mind, the — the body of literature is very consistent. And that is that the response to [PPA] can be variable, that some individuals in our study, for instance, at 75 milligrams had significant hypertension that I would consider to be adverse.... I think that goes well with Horowitz’s and — and some of the other studies that are in the literature. I think it fits in nice with the anecdotal reports which demonstrate clearly that perhaps even lower dosages, but certain[ly] 75 and 150 have been associated with adverse consequences.
*975(Depo.Tr. at 271). The dissent also dismisses Dr. Zaloga’s reliance on this paper because it argues that Horowitz was studying a different type of PPA compound. Again, Dr. Zaloga acknowledged that the PPA isomer studied by Horowitz was different from that contained in Dexatrim but explained his understanding of their differences and the extent to which he could rely on Horowitz’s conclusions. (Depo.Tr. at 156-60).

. The dissent does not challenge the validity, reasoning or methodology of any of the studies on which Dr. Zaloga relies but concludes that the studies do not support Dr. Zaloga’s testimony. The dissent’s reliance on mean values reported in the studies rather than on the individual data points and ranges on which Dr. Zaloga relies and its citation to only minor portions of the results of the studies illustrate Dr. Zaloga's criticisms of the other studies and the possibility of missing significant or extreme results by the use of averages. For example, Dr. Zaloga explains that many studies report their results only in terms of mean (average) and do not provide variances, individual data points, standard error bars or ranges:
It’s unlikely that that would be statistically significant when you average them all together. Therefore averages can really hide clinically significant differences to things.... What I’m discussing here are variations from the mean that could influence one or two patients ....
(Depo.Tr. at 153-54, 501-05). He also explains that some studies on which the defendant relies did not do toxicity studies on the drug, studies he believes are necessary to the reliability of the results. (Depo.Tr. at 228). Dr. Zaloga's decision to rely on certain studies rather than others, his reasoned explanation for his decision and the differences of opinion among the medical experts on these questions create material questions of fact for the ultimate fact finder and preclude summary judgment.

. During the deposition, defense counsel asked whether the facts surrounding this incident, including standing in line, being fatigued, possibly having the flu, etc., could have lead Bryan to faint. Dr. Zaloga stated:
I think it’s possible, but very unlikely. We have people like that all the time.... I can’t say that [fainting] didn’t do it, but my estimate is that the probability of that is much less than the probability that something else induced an event which created the fall.... [M]y estimation, putting everything together — everything that I know about the case, the history of his ingestion ... I think that the probability that that was related to [another] problem is much greater than just a faint ... out of nowhere, so to speak.
(Depo.Tr. at 182-84).

. Dr. Zaloga stated:
It's the coup-contra-coup mechanism. It doesn't exactly normally look like this, but it could. Usually this is a bruising as the brain swings back and forth inside the skull. And we tend to see more of a bruise than a pure deep — more deep-seated bleed_
I would think hitting [on the right back side of the head] would have him bruising up on the surface of the right frontal brain. To go across the mid line and into the other side is a less likely case for bruising.
[I]t's all of a statistical thing ... what do I think the probabilities are. I think it's more probable that it occurred the other way around.
(Depo.Tr. at 207-210).

.Dr. Zaloga explained:
The reason I believe the bleed preceded the fall, ... I’m considering the history of his ingestion — at least the history we have that he took Dexatrim, the fact that this compound is a compound based on our studies and the literature known to elevate blood pressure, that this could have — and associated with intercerebral hemorrhage, that the time course of his inter-cerebral bleed would fit well with the known pharmacokinetics and — and physiologic effects of the drug, and that this is a young individual who had no other ... immediate cause for his injuries.
I'm putting that together and saying that I believe ... the most probable cause ... is an ingestion of a drug that led to the bleed, that led to the fall.
:¡- # * * Jk *
We have physical evidence of a bleed by his clinical state. We have evidence on the CT scans. And we have the material removed by the surgeon at the time he went in of brain tissue showing necrotic areas within it consistent with a bleed within the brain tissue.
My personal opinion is we have unrefutable evidence beyond any doubt at all that this patient had a left frontal bleed.... My opinion is that the bleed came first.... It fits the known effect ... of this drug which could lead to a fall in a patient of this age who had some pre-monitory symptoms observed by the teller, a histoiy of known ingestion.
And we have no other reason, based on his angiogram and others, to show intracranial pathology. And young people of this age just do not have de novo incidences like this.
*977So my opinion is that, in my mind, I would put the most likely cause for this injury to have been an intercerebral bleed which caused the fall, rather than some other event.
(Depo.Tr. at 297-300).

. Dr. Zaloga described this process as a ranking process used to determine things which may cause a specific clinical problem. The doctor considers all information specific to the case to rule out possible causes and determine the most probable cause(s) of the injury. In Hines v. Consolidated Rail Corp., 926 F.2d 262 (3d Cir.1991), the term was explained as "a process whereby medical doctors experienced in diagnostic techniques provide testimony countering other possible causes ... of the injuries at issue.” Id. at 270 n. 6 (citing In re Paoli Railroad Yard PCB Litigation, 916 F.2d 829, 849 (3d Cir.1990)).

. Dr. Zaloga explained:
So the basis then of the ... whole thing would be what caused the intercerebral bleed. The most common things that we see producing them would be, number one, somebody with severe underlying CNS or central nervous system disease.
So someone who had previous strokes ... would ... be predisposed to that — which [Biyan] was not. So we ... would rule that out as a possible cause.
We would consider severe hypertension that was untreated as the cause ... but we have a reason to believe that he did not have severe hypertension based on his previous visits to physicians and with no history of that.
So we would say this is a normotensive, healthy individual who suddenly developed this intercerebral bleed.
* * * * * *
My next consideration was whether he had undiagnosed underlying disease of the brain.... Again, with the CAT scans and ar-teriogram we have no evidence of that being a predisposing condition....
So I'm left with a situation of having a relatively young, healthy individual without underlying predisposed disease who suddenly has an intercerebral hemorrhage. In my mind, in that case ... the thing that I would ... look towards would be use of some kind of a drug that could cause hypertension.... And in my mind, [PPA] would go in that class.
Dr. Zaloga concluded that, based on Biyan's medical history, symptoms, history of PPA ingestion, and no evidence of the other possible causes, Dexatrim most likely caused the intercer-ebral bleed. (Depo.Tr. at 65-70).

. Bryan was taking a "slow release" or "sustained" version of Dexatrim. Dr. Zaloga testified that as the drug enters the system, sustained release compounds cause higher blood pressure levels than immediate release compounds. He also explained that studies have shown that blood pressure rises caused by sustained release compounds generally do not occur until approximately two hours after ingestion and that once blood pressure rises, it may remain elevated for three hours or more. (Depo.Tr. at 132, 148-50).

. See Shafer, The Construction of Probability Arguments, 66 B.U.L.Rev. 799 (1986) (discussing how objective probability analysis is generally unrealistic and deceptive in actual legal cases, given the subjectivity involved in breaking down real-life problems, relating the problems to statistical models which simulate reality, assigning numerical probability factors, and deciding on a level of generality or particularity to state the problems and answers).

. The dissent seems to imply that the emergency room physician and other treating doctor's diagnoses are inconsistent with or contrary to Dr. Zaloga's opinion on this question. However, the emergency room physician specifically testified that no effort was made to determine the cause of what they assumed was a fainting episode and admitted that he never attempted to make a pathological diagnosis of the cause of Bryan’s intracranial bleed. (Dr. Bodzin Depo. Tr. at 22-23).

. As stated at the outset of this opinion, our holding as to causation carries no implications regarding the plaintiffs other burdens of proof on the negligence and breach of warranty claims.