TrialMap System - Litigation Support in Toxic Tort Matters: Single or Multi-Claimant Brochure

ICTM / International Center for Toxicology and Medicine2301 Research Boulevard, Suite 210, Rockville, MD 20850 Phone: 301-519-0300 • Fax: 301-519-1307 Email: info@ictm.com • Website: www.ictm.comLITIGATION SUPPORT IN TOXIC TORT MATTERS:SINGLE OR MULTI-CLAIMANTLITIGATION SUPPORT IN TOXIC TORT MATTERS:SINGLE OR MULTI-CLAIMANTICTM’s proprietary, cost-effective TrialMapTM system creates collaborative efficiency among legalcounsel and ICTM medical and scientific experts. TrialMapTM enables us to:• Organize scientific literature to evaluate strength of scientific evidence• Organize medical records data • Create medical encounter timelines• Create medication / exposure timelines• Create exposure chronologies• Identify missing custodial records• Prepare comparison spreadsheets showing similarities and dissimilarities in multi-claimantmatters• Create trial exhibits• Provide scientific support for motions• Prepare strategies for approaching opposing experts at deposition and trial.At ICTM, we limit your risk through sound,provable science.TrialMap™ - ICTM’s proprietary litigation support system, coupled with ourextensive experience, enables ICTM to deliver its medical and scientificexpertise in easily understood work products. Utilizing TrialMap™ ICTMcreates and supports a strategic alignment with you that facilitates cost-effective case resolution. The following case study provides some of ourmost frequently requested types of work products, produced by TrialMap™.For this, we have used a carbon monoxide (CO) toxicity claim, but theapproach is applicable to all issues – mold, benzene, pesticides and others. C A S E S T U D YA 42 year old woman alleged that exposure to carbon monoxide in herhome, after work was performed on her heating system, caused her to expe-rience a variety of adverse health effects which included headache, fatigue,weakness, mental confusion and insomnia. ICTM was asked to evaluate theclaim. As part of the ICTM litigation support activities, facts contained in the complaint, depositions, and answers to interrogatories were placed into the ICTM TrialMap™ data system.TrialMap™ - ICTM’s proprietary litigation support system, coupled with ourextensive experience, enables ICTM to deliver its medical and scientificexpertise in easily understood work products. Utilizing TrialMap™ ICTMcreates and supports a strategic alignment with you that facilitates cost-effective case resolution. The following case study provides some of ourmost frequently requested types of work products, produced by TrialMap™.For this, we have used a carbon monoxide (CO) toxicity claim, but theapproach is applicable to all issues – mold, benzene, pesticides and others. C A S E S T U D YA 42 year old woman alleged that exposure to carbon monoxide in herhome, after work was performed on her heating system, caused her to expe-rience a variety of adverse health effects which included headache, fatigue,weakness, mental confusion and insomnia. ICTM was asked to evaluate theclaim. As part of the ICTM litigation support activities, facts contained in the complaint, depositions, and answers to interrogatories were placed into the ICTM TrialMap™ data system.Expert Causal OpinionUltimately, the analyses and work products were used by the ICTM expert physicians in forming theircausal opinion. In this case, they reviewed the exposure data, medical records information and medical/scientific literature analysis that had been compiled and integrated in TrialMap™. Following ICTM’s causation methodology, the questions of CAN, DOES and DID were answered:• CAN the agent cause the alleged symptoms? Yes. • What DOES the claimant have wrong with her? The Claimant has migraine headaches, anxiety anddepression, all documented in the medical records to predate her alleged exposure and continuingafter her exposure ceased. She also has complaints of mental confusion, fatigue and insomnia thatare temporally related to side effects of numerous concomitantly-taken psychoactive medications.• DID the alleged agent cause the symptoms in this individual? In ICTM’s expert opinion, the answeris No. EXPERT CAUSAL OPINION: Based on the low level of carboxyhemoglobin in the blood, the wrongclinical course, and the medications side effects related to her excessive prescription drug use, carbon monoxide was not the causal agent of her symptoms.Signs and Symptoms Exposure analysis was performed by ICTMscientists concerning carbon monoxide levels within the home. This was done todetermine the exposure that the claimant mayhave experienced. Using the results from this analysis, we compared the claimant’ssymptoms with the scientifically-known doseresponse relationships for carbon monoxideexposure, as determined by percentage of carboxyhemoglobin in the blood. Medical RecordsAbstract Our nurses abstracted the medical records intoTrialMap™. This permitted a focused analysis of thechronological flow of key facts,symptoms, medical encountersand diagnoses. The ICTM medical experts and the attorneys collaboratively usedthe medical record abstract to drill down to the key information contained withinthe four volumes of medicalrecords.The medical record abstractcan be sorted in numerousways to focus and highlight relevant information through-out the case evaluation process.Symptoms andDiagnosesBefore Duringand AfterExposure Based on the timing of theexposure and key dataexcerpted from the medicalrecords abstract, a chart wasprepared to depict relevantsymptoms, diseases andother important informa-tion before, during andafter the alleged exposureperiod. This chart is thefoundation for determiningtemporality between exposureand claimed health effects. Medication history from themedical record abstractrevealed that numerous psychoactive medications wereprescribed to the claimant thatcould cause symptoms similarto those that were claimed to have been related to thecarbon monoxide exposure. We generated timelines of pre-scription drug use, segregatedby psychoactive and non-psychoactive medication, and color-coded by drug, toillustrate a potential alternatecause of the claimant’ssymptoms. Author(s) Title Citation Pub Year ICTM Comments EvaluationTownsend, CL et al Effects on health of prolonged exposure to low concentrations of carbonmonoxideOccup Environ Med60:212-2162002 The author’s review discusseslong-term effects described incase reports. These reportssuggest neuropsychologicaleffects. Biological plausibilityhas not been shown.Negative forcaseBenignus et al Effect of low level carbonmonoxide on compensatorytracing of event monitoringNeurotoxicolTeratol 9:227- 2341987 This study does not resolve the relationshipbetween task difficulty andmagnitude of CO-induced dysfunction. No statisticalsignificance was observed.Positive forcaseDevine, SA et al MRI and neuro-psychologicalcorrelates of CO exposure: acase reportEnviron HealthPerspect 110:1051-10552002 A case study does not provecausation. However, in thisparticular one, there wassome improvement 29months post exposure.Neutral –somewhat for caseRaub, JA andBenignusCarbon monoxide and thenervous systemNeurosciBiobehaviorReviews2002 The authors state that there is insufficient reliable information aboutchronic effects of low con-centrations. Further work isneeded to develop reliabledose-response relationships.Positive for the caseDate & Time Complaint / History Tests, Procedures,Treatment Dx, MedsDiscussion /Recommendations KeyThu02/28/2002First visit here. Doing well other than migraine headaches,present since age 15 PMHx: Hypertension,fibromyalgia, anxiety,depressionSOC: 2 PPD smokerDX: Migraineheadaches;fibromyalgia PREV MEDS:Toradol, Valium,Lortab, MS Contin,Calan SR NEW MEDS: Continue YesWed03/20/2002Comes to ER via private vehicle;states exposure to CO in homeafter HVAC work yesterday.Now headache, fatigue.SOC: 1 PPD smoker.LAB: COHb 10.2 (0-2normal for nonsmoker, 6-8 normal for smoker).TX: O2 at 100% NRBmask 1/2 hour.DX: CO poisoningPREV MEDS:Calan SR, LortabDISC: Mildly elevated CO level,resolving SX w/ removal fromsource tonight; 70 pack-yearHX smoker, empiric 100% O2 x1/2 hour for symptom reduc-tion. Felt well on discharge.YesMon04/01/2002First visit here. Exposed to COin home on 03/20/02. Headache,fatigue, weakness and insomniasince exposure.FMHx: Family also exposed;similar symptoms SOC: 1/2 PPD smoker DX: CO poisoning.PREV MEDS: CalanSR, Lortab, Valium.NEW MEDS:Continue meds;Add Fiorinal.YesBEFORE EXPOSURE DAY OF EXPOSURE AFTER EXPOSURERESPIRATORY:Smoking:02/28/02: 2 PPD since age 16RESPIRATORY:Smoking:03/20/02: 1 PPD since age 19RESPIRATORY:Smoking:04/01/02: 1/2 PPD since age 19; 05/01/02: 1/4 PPD since age 21;08/20/02: 4 cigarettes per dayNEUROPSYCHIATRIC:02/28/02:Migraines since age 16;Anxiety since age 32;Depression since age 35NEUROPSYCHIATRIC:03/20/02:Headaches since exposureyesterday; Anxiety; History ofdepression NEUROPSYCHIATRIC:Headaches post CO exposure continue: 04/01/02, 05/01/02,08/20/02, 12/14/02, Insomnia: 04/01/02, 04/15/02, 08/20/02;Anxiety: 04/15/02, 05/20/02, 07/30/02; Depression: 09/23/02MEDICATIONS:02/28/02: Toradol, Valium,Lortab, MS Contin, Calan SRMEDICATIONS:03/20/02: Lortab, Calan SRMEDICATIONS:04/01/02: Lortab, Calan SR, Valium, Fiorinal05/01/02: Fiorinal, MS Contin, Lortab, Valium, Synthroid06/13/02: Fiorinal, MS Contin, Lortab, Valium, Ambien, Synthroid,ProzacCarbon monoxide poisoning: signs, symptoms and clinical outcomes with increasing carboxyhemoglobin levels in bloodMEDICAL RECORDS ABSTRACTBEFORE, DURING, AFTER EXPOSURE CHARTJan 2004 Feb 2004 Mar 2004 Apr 2004 May 2004 Jun 2004 Jul 2004 Aug 2004 Sep 2004 Oct 2004 Nov 2004 Dec 2004Calan SR#60Zantac#60Fioricet#120Valium#120Vicodin#120Prozac#60Calan SR#60Toradol#120Zantac#60Vicodin#120Calan SR#60Fioricet#120Valium#120Zantac#60Toradol#120Calan SR#60Vicodin#120Fioricet#120Zantac#60Prozac#60Valium#120Calan SR#60Zantac#60Vicodin#120Fioricet#120Prozac#60Toradol#120Valium#120Calan SR#60Spectracef#14Zantac#120Fioricet#120Vicodin#120Zithromax#3Calan SR#60Valium#120Prozac#60Aleve#60Medrol Pak#21Fioricet#120Vicodin#120Toradol#120Calan SR#60Zantac#120Valium#120Prozac#60Fioricet#120Demerol#10Toradol#120Zantac#120Vicodin#120Calan SR#120Valium#120Prozac#60Fioricet#120MS Contin#90Valium#120Augmentin#40Fioricet#40Vicodin#120Zantac#120Calan SR#120Keppra#90Toradol#120Phenergan#30Fioricet#120MS Contin#90Keppra#180Prozac#60Aleve#60Vicodin#120Fioricet#120Synthroid#90MS Contin#90Zantac#120Prozac#60Calan SR#120Toradol#120Keppra#180Valium#120Vicodin#120Zantac#120Prozac#60Calan SR#120Toradol#120Keppra#180Synthroid#90MS Contin#90Fioricet#120B aclofen#90Valium#120Vicodin#120Synthroid#30MS Contin#90Prozac#60Fioricet#120Calan SR#120Toradol#120Zantac#120Baclofen#90Vicodin#120MS Contin#90Synthroid#30PRESCRIPTION DRUG USEPSYCHOACTIVE DRUGSLiteratureReview Literature search and review,integral components of ICTM’sapproach, revealed that carbon monoxide could havethe capability, in the right doseand duration, to cause adversehealth effects such as thoseclaimed in this matter. The TrialMapTM ResearchAuthorities Report allows theuser to evaluate quicklywhether the relevant scientificliterature is positive or negative for the case. TheICTM experts use this report as the scientific foundation for their causation analysis,case strategy development, and support for motions. Comparison Chart of MultipleClaimants This case also involved othermembers of this claimant’s family.A comparison chart was devel-oped from the medical recordsabstract of each family member.The chart was critical in revealingsimilarities and dissimilaritiesrelating to symptoms, objectivemedical findings and other keydata. Combined with our expo-sure analysis, this comparativechart enabled us to reveal incon-sistencies with the expectedclinical course following carbon monoxide exposure. FATHER MOTHER SON DAUGHTER 1 DAUGHTER 2Birth Date 08/29/1954 09/12/1957 04/03/1979 06/10/1982 03/07/1985Past MedicalHistoryAllergic rhinitisGERDChronic bronchitisAnxietyDepressionFibromyalgiaMigraineheadachesAllergic rhinitisADHDAsthma Migraine headachesAllergic rhinitisSmoking Yes Yes Yes No NoCOHb level as of03/20/0210 10.2 6 4.5 4.8Days missed from work/schoolwithin 1 year post exposure0 94 23 7 10FAMILY COMPARISON CHARTTRIALMAPTM RESEARCH AUTHORITIES REPORT0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%Signs,Symptoms,and Clinical OutcomesASYPMTOMATICHEADACHENAUSEALETHARGYHEARTATTACKCOMABRAINDAMAGEDEATHSigns and Symptoms Exposure analysis was performed by ICTMscientists concerning carbon monoxide levels within the home. This was done todetermine the exposure that the claimant mayhave experienced. Using the results from this analysis, we compared the claimant’ssymptoms with the scientifically-known doseresponse relationships for carbon monoxideexposure, as determined by percentage of carboxyhemoglobin in the blood. Medical RecordsAbstract Our nurses abstracted the medical records intoTrialMap™. This permitted a focused analysis of thechronological flow of key facts,symptoms, medical encountersand diagnoses. The ICTM medical experts and the attorneys collaboratively usedthe medical record abstract to drill down to the key information contained withinthe four volumes of medicalrecords.The medical record abstractcan be sorted in numerousways to focus and highlight relevant information through-out the case evaluation process.Symptoms andDiagnosesBefore Duringand AfterExposure Based on the timing of theexposure and key dataexcerpted from the medicalrecords abstract, a chart wasprepared to depict relevantsymptoms, diseases andother important informa-tion before, during andafter the alleged exposureperiod. This chart is thefoundation for determiningtemporality between exposureand claimed health effects. Medication history from themedical record abstractrevealed that numerous psychoactive medications wereprescribed to the claimant thatcould cause symptoms similarto those that were claimed to have been related to thecarbon monoxide exposure. We generated timelines of pre-scription drug use, segregatedby psychoactive and non-psychoactive medication, and color-coded by drug, toillustrate a potential alternatecause of the claimant’ssymptoms. Author(s) Title Citation Pub Year ICTM Comments EvaluationTownsend, CL et al Effects on health of prolonged exposure to low concentrations of carbonmonoxideOccup Environ Med60:212-2162002 The author’s review discusseslong-term effects described incase reports. These reportssuggest neuropsychologicaleffects. Biological plausibilityhas not been shown.Negative forcaseBenignus et al Effect of low level carbonmonoxide on compensatorytracing of event monitoringNeurotoxicolTeratol 9:227- 2341987 This study does not resolve the relationshipbetween task difficulty andmagnitude of CO-induced dysfunction. No statisticalsignificance was observed.Positive forcaseDevine, SA et al MRI and neuro-psychologicalcorrelates of CO exposure: acase reportEnviron HealthPerspect 110:1051-10552002 A case study does not provecausation. However, in thisparticular one, there wassome improvement 29months post exposure.Neutral –somewhat for caseRaub, JA andBenignusCarbon monoxide and thenervous systemNeurosciBiobehaviorReviews2002 The authors state that there is insufficient reliable information aboutchronic effects of low con-centrations. Further work isneeded to develop reliabledose-response relationships.Positive for the caseDate & Time Complaint / History Tests, Procedures,Treatment Dx, MedsDiscussion /Recommendations KeyThu02/28/2002First visit here. Doing well other than migraine headaches,present since age 15 PMHx: Hypertension,fibromyalgia, anxiety,depressionSOC: 2 PPD smokerDX: Migraineheadaches;fibromyalgia PREV MEDS:Toradol, Valium,Lortab, MS Contin,Calan SR NEW MEDS: Continue YesWed03/20/2002Comes to ER via private vehicle;states exposure to CO in homeafter HVAC work yesterday.Now headache, fatigue.SOC: 1 PPD smoker.LAB: COHb 10.2 (0-2normal for nonsmoker, 6-8 normal for smoker).TX: O2 at 100% NRBmask 1/2 hour.DX: CO poisoningPREV MEDS:Calan SR, LortabDISC: Mildly elevated CO level,resolving SX w/ removal fromsource tonight; 70 pack-yearHX smoker, empiric 100% O2 x1/2 hour for symptom reduc-tion. Felt well on discharge.YesMon04/01/2002First visit here. Exposed to COin home on 03/20/02. Headache,fatigue, weakness and insomniasince exposure.FMHx: Family also exposed;similar symptoms SOC: 1/2 PPD smoker DX: CO poisoning.PREV MEDS: CalanSR, Lortab, Valium.NEW MEDS:Continue meds;Add Fiorinal.YesBEFORE EXPOSURE DAY OF EXPOSURE AFTER EXPOSURERESPIRATORY:Smoking:02/28/02: 2 PPD since age 16RESPIRATORY:Smoking:03/20/02: 1 PPD since age 19RESPIRATORY:Smoking:04/01/02: 1/2 PPD since age 19; 05/01/02: 1/4 PPD since age 21;08/20/02: 4 cigarettes per dayNEUROPSYCHIATRIC:02/28/02:Migraines since age 16;Anxiety since age 32;Depression since age 35NEUROPSYCHIATRIC:03/20/02:Headaches since exposureyesterday; Anxiety; History ofdepression NEUROPSYCHIATRIC:Headaches post CO exposure continue: 04/01/02, 05/01/02,08/20/02, 12/14/02, Insomnia: 04/01/02, 04/15/02, 08/20/02;Anxiety: 04/15/02, 05/20/02, 07/30/02; Depression: 09/23/02MEDICATIONS:02/28/02: Toradol, Valium,Lortab, MS Contin, Calan SRMEDICATIONS:03/20/02: Lortab, Calan SRMEDICATIONS:04/01/02: Lortab, Calan SR, Valium, Fiorinal05/01/02: Fiorinal, MS Contin, Lortab, Valium, Synthroid06/13/02: Fiorinal, MS Contin, Lortab, Valium, Ambien, Synthroid,ProzacCarbon monoxide poisoning: signs, symptoms and clinical outcomes with increasing carboxyhemoglobin levels in bloodMEDICAL RECORDS ABSTRACTBEFORE, DURING, AFTER EXPOSURE CHARTJan 2004 Feb 2004 Mar 2004 Apr 2004 May 2004 Jun 2004 Jul 2004 Aug 2004 Sep 2004 Oct 2004 Nov 2004 Dec 2004Calan SR#60Zantac#60Fioricet#120Valium#120Vicodin#120Prozac#60Calan SR#60Toradol#120Zantac#60Vicodin#120Calan SR#60Fioricet#120Valium#120Zantac#60Toradol#120Calan SR#60Vicodin#120Fioricet#120Zantac#60Prozac#60Valium#120Calan SR#60Zantac#60Vicodin#120Fioricet#120Prozac#60Toradol#120Valium#120Calan SR#60Spectracef#14Zantac#120Fioricet#120Vicodin#120Zithromax#3Calan SR#60Valium#120Prozac#60Aleve#60Medrol Pak#21Fioricet#120Vicodin#120Toradol#120Calan SR#60Zantac#120Valium#120Prozac#60Fioricet#120Demerol#10Toradol#120Zantac#120Vicodin#120Calan SR#120Valium#120Prozac#60Fioricet#120MS Contin#90Valium#120Augmentin#40Fioricet#40Vicodin#120Zantac#120Calan SR#120Keppra#90Toradol#120Phenergan#30Fioricet#120MS Contin#90Keppra#180Prozac#60Aleve#60Vicodin#120Fioricet#120Synthroid#90MS Contin#90Zantac#120Prozac#60Calan SR#120Toradol#120Keppra#180Valium#120Vicodin#120Zantac#120Prozac#60Calan SR#120Toradol#120Keppra#180Synthroid#90MS Contin#90Fioricet#120B aclofen#90Valium#120Vicodin#120Synthroid#30MS Contin#90Prozac#60Fioricet#120Calan SR#120Toradol#120Zantac#120Baclofen#90Vicodin#120MS Contin#90Synthroid#30PRESCRIPTION DRUG USEPSYCHOACTIVE DRUGSLiteratureReview Literature search and review,integral components of ICTM’sapproach, revealed that carbon monoxide could havethe capability, in the right doseand duration, to cause adversehealth effects such as thoseclaimed in this matter. The TrialMapTM ResearchAuthorities Report allows theuser to evaluate quicklywhether the relevant scientificliterature is positive or negative for the case. TheICTM experts use this report as the scientific foundation for their causation analysis,case strategy development, and support for motions. Comparison Chart of MultipleClaimants This case also involved othermembers of this claimant’s family.A comparison chart was devel-oped from the medical recordsabstract of each family member.The chart was critical in revealingsimilarities and dissimilaritiesrelating to symptoms, objectivemedical findings and other keydata. Combined with our expo-sure analysis, this comparativechart enabled us to reveal incon-sistencies with the expectedclinical course following carbon monoxide exposure. FATHER MOTHER SON DAUGHTER 1 DAUGHTER 2Birth Date 08/29/1954 09/12/1957 04/03/1979 06/10/1982 03/07/1985Past MedicalHistoryAllergic rhinitisGERDChronic bronchitisAnxietyDepressionFibromyalgiaMigraineheadachesAllergic rhinitisADHDAsthma Migraine headachesAllergic rhinitisSmoking Yes Yes Yes No NoCOHb level as of03/20/0210 10.2 6 4.5 4.8Days missed from work/schoolwithin 1 year post exposure0 94 23 7 10FAMILY COMPARISON CHARTTRIALMAPTM RESEARCH AUTHORITIES REPORT0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%Signs,Symptoms,and Clinical OutcomesASYPMTOMATICHEADACHENAUSEALETHARGYHEARTATTACKCOMABRAINDAMAGEDEATHICTM / International Center for Toxicology and Medicine2301 Research Boulevard, Suite 210, Rockville, MD 20850 Phone: 301-519-0300 • Fax: 301-519-1307 Email: info@ictm.com • Website: www.ictm.comLITIGATION SUPPORT IN TOXIC TORT MATTERS:SINGLE OR MULTI-CLAIMANTLITIGATION SUPPORT IN TOXIC TORT MATTERS:SINGLE OR MULTI-CLAIMANTICTM’s proprietary, cost-effective TrialMapTM system creates collaborative efficiency among legalcounsel and ICTM medical and scientific experts. TrialMapTM enables us to:• Organize scientific literature to evaluate strength of scientific evidence• Organize medical records data • Create medical encounter timelines• Create medication / exposure timelines• Create exposure chronologies• Identify missing custodial records• Prepare comparison spreadsheets showing similarities and dissimilarities in multi-claimantmatters• Create trial exhibits• Provide scientific support for motions• Prepare strategies for approaching opposing experts at deposition and trial.At ICTM, we limit your risk through sound,provable science.TrialMap™ - ICTM’s proprietary litigation support system, coupled with ourextensive experience, enables ICTM to deliver its medical and scientificexpertise in easily understood work products. Utilizing TrialMap™ ICTMcreates and supports a strategic alignment with you that facilitates cost-effective case resolution. The following case study provides some of ourmost frequently requested types of work products, produced by TrialMap™.For this, we have used a carbon monoxide (CO) toxicity claim, but theapproach is applicable to all issues – mold, benzene, pesticides and others. C A S E S T U D YA 42 year old woman alleged that exposure to carbon monoxide in herhome, after work was performed on her heating system, caused her to expe-rience a variety of adverse health effects which included headache, fatigue,weakness, mental confusion and insomnia. ICTM was asked to evaluate theclaim. As part of the ICTM litigation support activities, facts contained in the complaint, depositions, and answers to interrogatories were placed into the ICTM TrialMap™ data system.TrialMap™ - ICTM’s proprietary litigation support system, coupled with ourextensive experience, enables ICTM to deliver its medical and scientificexpertise in easily understood work products. Utilizing TrialMap™ ICTMcreates and supports a strategic alignment with you that facilitates cost-effective case resolution. The following case study provides some of ourmost frequently requested types of work products, produced by TrialMap™.For this, we have used a carbon monoxide (CO) toxicity claim, but theapproach is applicable to all issues – mold, benzene, pesticides and others. C A S E S T U D YA 42 year old woman alleged that exposure to carbon monoxide in herhome, after work was performed on her heating system, caused her to expe-rience a variety of adverse health effects which included headache, fatigue,weakness, mental confusion and insomnia. ICTM was asked to evaluate theclaim. As part of the ICTM litigation support activities, facts contained in the complaint, depositions, and answers to interrogatories were placed into the ICTM TrialMap™ data system.Expert Causal OpinionUltimately, the analyses and work products were used by the ICTM expert physicians in forming theircausal opinion. In this case, they reviewed the exposure data, medical records information and medical/scientific literature analysis that had been compiled and integrated in TrialMap™. Following ICTM’s causation methodology, the questions of CAN, DOES and DID were answered:• CAN the agent cause the alleged symptoms? Yes. • What DOES the claimant have wrong with her? The Claimant has migraine headaches, anxiety anddepression, all documented in the medical records to predate her alleged exposure and continuingafter her exposure ceased. She also has complaints of mental confusion, fatigue and insomnia thatare temporally related to side effects of numerous concomitantly-taken psychoactive medications.• DID the alleged agent cause the symptoms in this individual? In ICTM’s expert opinion, the answeris No. EXPERT CAUSAL OPINION: Based on the low level of carboxyhemoglobin in the blood, the wrongclinical course, and the medications side effects related to her excessive prescription drug use, carbon monoxide was not the causal agent of her symptoms.