A new study by scientists at the University of Liverpool suggests there may be a way of identifying families at high risk of pancreatic cancer.

The Liverpool research group called EUROPAC (European Registry Of Hereditary Pancreatitis And Familial Pancreatic Cancer), in cooperation with a counterpart organization in Germany, has found that familial pancreatic cancer develops at an increasingly younger age as is it is passed down through generations.

The team has developed a new way of testing for pancreatic cancer that will allow doctors to treat the disease in its preliminary stages and to trace how the risk of cancer in these patients changes with age.

The researchers conducted the largest study on this subject, evaluating 600 families with a history of pancreatic cancer. They also identified a subgroup of more than 80 families who had a 50% risk of developing the cancer in their lifetime.

Dr. Bill Greenhalf of the University’s Division of Surgery and Oncology and his team have developed a new method for analyzing the pancreatic juice of patients from families with a high risk of pancreatic cancer.
By analyzing DNA, scientists were able to identify specific genetic mutations that indicate a patient’s changes of developing the cancer (from a 0.1% chance to a 90% certainty) in the short term.

Dr. Greenhalf said: "Of those families with the highest incidence of pancreatic cancer, we found that members developed the disease at a younger age in each generation. As well as giving important clues about the nature of the disease, this allows a more accurate estimate of the risk an individual faces of developing cancer in the short term so we can treat the cancer as soon as possible."

Greenhalf expects to conduct further studies of his new methods with the hope that pancreatic cancer screening procedures will be widely adopted.

British Pharmaceutical giant GlaxoSmithKline (Glaxo) has agreed to pay over $150 million in settlement of federal (U.S.) charges that it fraudulently inflated prices for drugs bought by government health-care programs.

According to the U.S. Department of Justice, Glaxo allegedly violated the federal False Claims Act in the sale and marketing of Zofran and Kytril, two nausea drugs used by cancer patients who are undergoing treatment.

The Justice Department suspected Glaxo was engaged in a scheme to fix and maintain inflated prices for the two drugs knowing that federal healthcare programs based their reimbursement rates on those prices.

Federal officials stated that the Justice Department "will not tolerate fraudulent pricing practices designed to reap profits for drug companies and doctors at the expense of health care programs for the poor and the elderly."

Although GlaxoSmithKline issued a statement claiming it did nothing wrong, the company agreed to settle to avoid litigation. $26 million of the settlement will be paid to the whistle-blowers who prompted the investigation and another $10 million will go to state governments.

Alan Best, a former MG Rover worker, from Bromsgrove, Worcs (UK), has been awarded £750,000 ($1,400,000) by the High Court in Birmingham (UK) as a result of being given a tainted blood transfusion from which he contracted a form of the HIV virus.

One of the five units of blood the 64-year-old Mr. Best received during an operation at a private hospital was infected with the T-Cell Lymphotophic Virus Type 1 (HTLV-1).

The National Blood Service (NBS) admitted providing defective blood, which it had failed to screen for the virus.
At the time of the surgery in 1995, the UK did not test blood for the rare virus. The NBS began testing for HTLV in 2002. It introduced the use of leucodepletion, which greatly reduces the risk of transmitting the illness, only in 1998-99.

As a result of receiving the infected blood, Mr. Best developed HTLV-associated myelopathy, a rare and debilitating blood-transmitted disease which affects the central nervous system and which could eventually confine him to a wheel chair.

Mr. Best explained that, because of physical deterioration, he had to give up his job as a toolmaker at the former Longbridge factory in 2000, where he had worked for more than 40 years.

He said he began to have physical problems a year after the operation when his legs became unsteady.  "Although I had lost more than four stone in weight and had been left very weak (after the operation), I thought it was just a matter of time before I got back to normal. Then I started having unsteadiness in my legs.”
After he lost sensation in his toes, it was two years before doctors diagnosed him with HTLV-1. When the National Blood Service was notified of Mr. Best’s illness, an investigation was quickly organized and, under Consumer Protection legislation laws, a settlement was finally negotiated, after seven years.

Major Study Shows Asians Suffer Same Dire Consequences from Smoking as Everyone Else 

The largest study into the effects of smoking in Asia indicates that Asian populations are just as susceptible to the negative impacts of tobacco use, including coronary heart disease and stroke, as Westerners
The results of the study will be published in a paper from the George Institute for International Health in the International Journal of Epidemiology.

The paper indicates the myth that smoking is less harmful to Asians than to Caucasians may contribute to the high prevalence of smoking in Asian countries, the low quitting rates amongst Asian male smokers, and the spread of smoking among Asian women.

The new study is considered more accurate in estimating the relative effects of smoking than previous ones because of the number of individuals involved.

Prof. Mark Woodward, Director of the Epidemiology and Biostatistics at the George Institute, who lead the study, commented that "the study, which involved data analysis of almost 500,000 Asians and 100,000 Australasians, shows that smoking poses the same risks to Asian men (and an even greater risk to Asian women) as compared to Western populations. The study also makes clear that there are real benefits to be gained, in terms of huge numbers of lives to be saved, by effectively implementing campaigns in Asia to quit smoking."

An important finding of the research was the identification of smoking is an independent risk factor for hemorrhagic stroke.

The most common type of stroke in Asia, hemorrhagic stroke, is more likely than ischemic stroke to lead to death in a short time.

Even more significantly, the study showed that Asians who smoke have roughly the same increased proportional cardiovascular risks as Westerners and a similar relative reduction in risk from quitting.

The results of the study also indicate that younger people and women have increased relative risks of cardiovascular disease from smoking than others. The study estimated that there will be over 500 million female smokers worldwide within 20 years.

Prof. Woodward underscored the importance of public health programs in Asia to dispel the prevalent belief that quitting smoking can be harmful. Anti-tobacco campaigns, he says, should especially be directed at Asian women to counteract the increase in smoking in this population,

The nine children of Howard R. Hoehmann Sr., a man who died while being treated for pneumonia at Nyack Hospital, have been awarded $820,000 in a malpractice lawsuit against two of the doctors who treated him.
According to court records, Hoehmann, a semi-retired construction contractor and real estate agent, was admitted to Nyack Hospital on April 12, 2000, for a mild case of pneumonia.

The antibiotics he was prescribed by his primary care doctors treated the pneumonia but caused a bowel infection. Drs. James S. Vela, and Stephan Goodman, specialists in gastroenterology, were called in to treat the infection.
Hoehmann’s condition worsened and he developed toxic megacolon, in which his colon was enlarged and infected. He died April 21, 2000.

The doctors, who intend to appeal, maintain the death of the 69-year-old patient was not related to the care and treatment they provided to him. 

The family’s attorney, said the doctors failed to do tests that would have revealed Mr. Hoehmann had developed colitis from the antibiotics and “missed every opportunity to diagnose and treat him."
The doctors, the family’s attorney said, "were negligent and careless in failing to treat and care for (Hoehmann) in accordance with accepted standards of medical care."

The jury awarded Hoehmann’s estate $750,000 for his pain and suffering and $70,000 for related damages and expenses.

"He didn’t have to die," said his son George. "If he had gotten proper care, he wouldn’t have died. It’s a just verdict. My father died an awful, awful death."

Most parents breathe a little easier while their children are at school, assuming that their kids are safely under the supervision of teachers and other qualified personnel.

This feeling of security might be misplaced, however according to recent studies that show an increasing number of children are at risk of exposure to poisons and pesticides, both inside the classroom and on the playground.

Pesticides, from disinfectants to herbicides and insecticides, are used on and around school property. Schools located in agricultural areas may also be exposed to toxic run-off and drift from neighboring farms.

Surprisingly, there are no current federal requirements on limiting pesticide exposures at schools. This fact may change, however, in light of new findings published in The Journal of the American Medical Association from the National Institute for Occupational Safety and Health and the U.S. Centers for Disease Control and Prevention (CDC), Cincinnati, regarding pesticide-related illnesses connected to exposure at school.

The researchers gathered the data by using three pesticide surveillance systems: the Toxic Exposure Surveillance System (TESS), the California Department of Pesticide Regulation (CDPR), and the National Institute for Occupational Safety and Health’s Sentinel Event Notification System for Occupational Risks.

The study tracked reports of pesticide-related illnesses in both children and full-time school employees from 1998 to 2002. During this time period, illnesses related to pesticide exposure at a school or from neighboring drift occurred in 2,593 cases.

The majority of the reported cases were mild and there were no reported fatalities. Most of the 2,500-plus cases were of “low severity,” meaning no medical intervention was needed. Symptoms usually included eye, skin, or upper respiratory tract irritation.

Roughly 275 cases were moderately severe. While they weren’t disabling or life-threatening, they did require medical treatment.

Fortunately, only three of the cases found were severe. These illnesses often require hospitalization, and may be life-threatening.

The researchers noted, however, that the actual incidence of pesticide-related illnesses may be considerably higher since certain symptoms of chemical exposure mirror those associated with other illnesses thereby leading to possible misdiagnoses.

A breakdown of the types of pesticides and the prevalence of illness linked to them was noted as follows:

• Insecticides: 35% of reported illnesses
• Disinfectants: 32% of reported illnesses
• Repellants: 13% of reported illnesses
• Herbicides: 11% of reported illnesses
• Fungicides, rodenticides and others: 9% of reported illnesses

Among those exposed to pesticides, nearly seven out of 10 cases were directly linked to pesticides used at schools. The rest were connected to pesticides from drift from neighboring farms.

Overall, researchers found that between 1998 and 2002, 27. 3-per-million full time school workers and 7.4-per-million children have acute pesticide-related illnesses.

Dr. Philip Landrigan, director of the Center for Children’s Health and the Environment, and the Department of Community and Preventative Medicine at Mt. Sinai School of Medicine in New York City says that a few factors contribute to children’s vulnerability to pesticide exposure.

According to Dr. Landrigan: “Children are more susceptible to pesticide exposure because they breathe more air pound for pound than adults, they play on the floor, and they live two feet off the floor, where pesticides linger, rather than five to six feet off the floor like adults.”

Children also spend much of their time playing on wooden playground structures and on decks. These surfaces, a Canadian Study revealed, may expose children to significant levels of arsenic.

Until 2003, the wood used to make such structures was treated with the preservative chromated copper arsenate (CCA). A study published in the October 2004 issue of Environmental Health Perspectives found that children who play on wooden structures treated with CCA were left with more arsenic on their hands than children playing on other wooden sets.

To collect data, researchers from University of Alberta examined the hands of 66 children playing in 8 CCA playgrounds and compared them to the hands of 64 kids playing in 8 CCA-free playgrounds. After play, children washed their hands in a bag containing water. The solution was then analyzed for the presence of arsenic.

On average, the researchers found that kids playing in CCA playgrounds had more arsenic on their hands (.5 mcg compared to .095 mcg) than the other children. The amount found from CCA playgrounds ranged as high as 3.5 mcg.

Further, long term studies are needed to determine the significance of the data. It is known that exposure to higher concentrations of arsenic (200 mcg/L) in drinking water have been tied to an increase cancerous tumor growth, and to the existence of skin and bladder cancer.  Below that level, meaningful research on the subject remains to be conducted.

Also unknown is how exposure to arsenic in drinking water compares to children’s exposure to small doses of arsenic on the playground.

Still, any level of exposure to a known carcinogenic toxin is unsettling, particularly if the exposure is occurring in a location where children spend a lot of time and are presumed to be safe.

But what are the possibilities for reducing the risk of illness and health problems to children due to exposure to the poisons and pesticides around them?

The researchers from University of Alberta urge parents to have their kids always wash their hands thoroughly after playing on structures that are coated with CCA.

Another possible solution is to coat the wood with an oil or water-based sealant so that the arsenic cannot get onto children’s’ hands.

The Environmental Protection Agency (EPA) revealed in May of 2004 that an ongoing study with the Consumer Safety Products Commission (CPSC) found that a yearly coating of such a sealant could cut down on arsenic exposure.

Such preventative steps are surely worth taking, given the potential hazards of arsenic exposure. According to Dr. James Roberts, M.D., M.P.H., an associate professor of pediatrics at the Medical University of South Carolina in Charleston; “Arsenic in children’s bodies is a long-term exposure and the outcomes are often caner at a much later age.”

Physicians, Roberts said, must be aware of the risks children’s exposure to the poison so that they can urge families to follow EPA recommendations on treating CCA-coated wood. At this point, it’s the only type of protection available.

In the case of pesticide exposure, study co-author Dr. Geoffrey Calvert, a medical officer with the National Institute for Occupational Safety and Health in Cincinnati, and colleagues suggest that better pest-management techniques, along with the creation of buffer zones between schools and neighboring farms could help reduce exposure and the risk of pesticide related illness, or at least manage it.

Better pest control techniques include more diligent attempts at pest prevention such as keeping kitchens and food areas clean and keeping food in airtight, sealed containers and fixing cracks and crevices where pests can access a building.

Toxic chemicals, therefore, should be a last resort rather than the first step taken to fend off pests. “Only after you’ve taken these measures do you then treat for specific pests, but only using pesticides with the lowest toxicity, and only by someone well-trained in using pesticides,” Calvert said.

The problem of drift should be addressed in cooperation between schools and farms in the area.  Pesticides should be applied when children and school employees are not on school grounds. Buffer zones between the farm and the school would also be helpful.

“These episodes are occurring far too often, and that’s really not acceptable,” said Landrigan of illness due to pesticide exposure.  “These episodes are preventable, and parents, educators, school boards, and community officials need to take aggressive steps to reduce pesticide exposure.”

Clearly, children deserve to be protected from exposure to toxic chemicals in those areas where there is an expectation of safety. Schools and playgrounds should be the last places where children are put at risk in the short-term from chemically-induced illnesses and in the long-term from life-threatening diseases.

Anything less than everyone’s best efforts in this area are simply unacceptable given the innocence of the victims and the enormity of the risks.

According to environmental groups, U.S. consumers should start monitoring their swordfish intake, just as they are watching their intake of salmon, because of rising levels of mercury found in swordfish at many supermarket chains.

Tests done at the University of North Carolina laboratories found that swordfish being sold at Safeway, Albertsons and Whole Foods have, on average, 10% more mercury than federal regulations permit.

Out of 24 samples tested, the average was 1.1 parts per million. Federal limits are set at 1 part per million. 9% of the samples had twice the limit.

In response to these findings, environmental groups are seeking further government tests.
They are also asking that warning labels be put on the products in all stores, instead of just some stores.

Methylmercury, which is the form of mercury found in some fish, is dangerous to humans. If a human is exposed to excessive amounts of mercury, he or she might suffer: damage to the nervous system; kidney damage (changes in kidney function); damage to developing fetuses; tremors; loss of sensation; irritability; skin rashes; eye irritation; an memory problems.

Exposure to small amounts of mercury in its various forms and compounds is normal, and happens regularly. If you stay within the safety limit of 1 part per million (food and drink), you have nothing to worry about.

Mercury poisoning, however, is a more serious situation. It can occur through breathing mercury vapor or handling droplets from a spill. Extreme caution should be used in cleaning up such spills so as to avoid dispersing toxic mercury vapor.

Mercury is a heavy metal which is poisonous to humans and animals. Two studies in the November 2002 issue of the New England Journal of Medicine presented contradictory findings about possible heart-related dangers from eating mercury-laden fish.

Past research, however, has shown that mercury found in fish can have harmful effects on the developing brain of a child or fetus. Thus, pregnant women are strongly cautioned to avoid eating the type of large, deep-sea predatory fish which are most prone to contain high concentrations of mercury. These include swordfish, albacore tuna, shark, and bluefish.

Other recent studies dealt with the long term effects of mercury exposure on the hearts of middle-aged and elderly men. While one study found that men who had suffered a heart attack had higher levels of mercury, the other found no correlation between mercury level in the body and the risk of developing heart disease.

In April of 2002, researchers at the Glasgow Royal Infirmary in Scotland conducted a study of 180 dentists and concluded that dentists are more likely to suffer memory and kidney problems as a result of long term exposure to the mercury used in tooth fillings.

The test group had up to four times the normal level of mercury in their urine and nail samples. While fillings can emit vapors that are harmful to both dentists and their patients, the dentist is more likely to experience health-related complications such as Alzheimer’s disease since they are subjected to ongoing exposure to the mercury.
Dental associations, however, claim that the mercury in fillings is safe when it is mixed with other metals.

If you believe that you have been exposed to significant amounts of mercury, you should ask your doctor to perform either a heavy metal blood test or hair test to determine the level of mercury in your body.

Some symptoms of an elevated mercury level are hair loss, tiredness, and short-term memory loss. In most cases, the effects of an elevated mercury level are reversible within a few months after the source of the mercury is eliminated.

An elderly Massachusetts man entered Brockton Hospital in Boston with bipolar disorder. He was lucid and had no life-threatening illnesses. Unfortunately, four days later he was dead; killed by a massive dose of the wrong medication.

The patient was given 60 times the recommended dose of Librium when he was supposed to have received Lithium.

Even after a nurse discovered the initial mistake, the hospital continued to give the man other antidepressants and sedatives. He also received two doses of antibiotics over six hours late.

As to be expected, the hospital attempted to engage in damage control. When asked if the medication errors contributed to the death, a Hospital spokesman told The Patriot Ledger that autopsy results showed that the man had died of pneumonia.

According to the same spokesman: "When the error was found the doctor and the patient’s family were immediately notified. Brockton Hospital immediately launched an investigation and has taken several steps to ensure that this will not happen again."

The errors started when a pharmacist ordered Librium, a sedative taken for anxiety, for the patient instead of Lithium, which he was the drug actually prescribed for his bipolar disorder.

Amazingly, the pharmacist told investigators that even though he realized his mistake immediately, after failing to reach a nurse by telephone, he “forgot to follow through” on the matter. There was plenty of time in which to correct the mistake since the medication was not administered until the next morning.

While the two drugs have similar sounding names, the safe dosage for each is vastly different. A safe dose of Lithium runs up to 600 milligrams a day. The recommended dose of Librium for elderly people, however, is but 5 milligrams two to four times daily.

Thus, the patient received 300 milligrams of Librium, a full 60 times the safe dose of a drug he wasn’t even supposed to receive.

A new study finds that the procedures used to obtain and examine tissue for a cancer diagnosis may lead to a misdiagnosis in up to 12% of patients. 

The study is published in the November 15, 2005 issue of CANCER, a peer-reviewed journal of the American Cancer Society.

The frequency and cause of errors in cancer diagnosis has not been well studied due to the lack of national standards for error detection.  Dr. Stephen S. Raab, M.D. of the University of Pittsburgh School of Medicine and his colleagues decided to look at the frequency, cause, and impact of errors in cancer diagnosis.  They reviewed tissue specimens, pathologist’s findings, and medical records from four medical institutions in the mid-Atlantic and Midwestern regions of the country.

Patients often have multiple tests in order to diagnose cancer, and the researchers reviewed patient material when the diagnoses differed on multiple tests from the same patient.

The majority of errors were a result of poor specimen collection, while the proportion of errors caused my pathologist’s misinterpretation ranged from 5 to 50 %.  When pathologists reviewed specimens from other institutions they frequently disagreed with the assignment of error cause or the type of patient harm that the error was determined to have provoked.

According to HealthDay, the study’s author, Dr. Stephen Raab, issued a note of caution about patient harm.  “I want to make clear that the major consequence is not that patients unnecessarily have organs removed or have a false diagnosis of cancer.  Fortunately, patient symptoms almost always lead clinicians to do the right thing and retest, and this will lead to finding the cancer and a proper diagnosis.”

Based on their research, Dr. Raab and his colleagues found that the potential number of Americans who encounter diagnostic errors is large, in the range of 300,000 cancer patients annually.

The researchers say that the variation in clinical environments impairs the ability to truly understand the error causes.  To that end, “the standardization and uniform reporting of errors in cancer diagnosis is a first step in improving safety,” conclude the authors.

A placebo-controlled study conducted at UCSF reveals two popular weight loss supplements that are promoted as “ephedra-free” and safe for dieters could have harmful effects on some people.

The findings are published in this month’s issue of the American Journal of Medicine.

Both of the weight loss products tested contain Citrus aurantium, or bitter orange extract, a substance that is rapidly replacing ephedra in dietary supplements since its ban by the FDA last year due to concerns about severe health effects of the herbal supplement.

(Although a federal judge lifted the ban, ephedra has gradually been phased out by many supplement manufacturers concerned with potential civil liability for injuries and deaths blamed on the supplement.)

In the first clinical study of the effects of these newly formulated dietary supplements, researchers monitored blood pressure, heart rate, moods, and emotions of 10 healthy adults.

Single doses of both Xenadrine EFX and Advantra Z caused increased heart rate among those tested. Xenadrine EFX also increased blood pressure and alertness. Neither product showed a serious effect on mood.

Researchers found that while Advantra Z contains only bitter orange, one dose of Xenadrine EFX has many other ingredients, including as much caffeine as found in 3 cups of coffee.

They concluded that the increased blood pressure Xenadrine EFX caused did not come from the caffeine alone, but was probably due to the combination of other ingredients of the supplement.

According to Christine Haller, MD, UCSF assistant professor of medicine and lead author of the paper: "These findings indicate that ephedra-free dietary supplements could have some of the same adverse health effects associated with previously available ephedra products, such as Metabolife 356 and Ripped Fuel."

Until longer-term studies of these weight loss supplements are conducted, doctors should alert patients to the potential dangers of ephedra-free dietary supplements and should monitor blood pressure in people who choose to use them.

In the world of high stakes head-to-head Texas Hold’em Poker, the ultimate bluff or sign of confidence, as the case may be, is for a player to go “all in.”

Before doing so, however, a player will ponder the odds very carefully since the move is a decisive one after which the players simply stand up to watch the hand be dealt out face up. If the player who went “all in” wins, he doubles his money. If he loses, he leaves the table with nothing.

In the legal equivalent of going “all in,” Merck has presumably pondered the odds and decided to let billions of dollars in potential liability hinge on one jury trial that begins tomorrow in its home state of New Jersey. Make no mistake; the outcome of this case will either put Merck back in the game or threaten the pharmaceutical giant’s very existence.

As I have pointed out in previous articles and editorials, it should not have come as a surprise to Merck to find itself in the serious predicament it now faces.  Merck can take the position that it was always concerned with safety and that it only pulled Vioxx off the market after there was evidence that a cardiovascular risk existed, but the mountain of evidence is clearly to the contrary.

Thus, Merck has had to make a decision as to whether to put each case to the test at trial or to settle the bulk of the cases and try only the cases that are least likely to succeed.

Even a decision that the company is “in this for the long haul” doesn’t mean that at all. If Merck were to lose the next several trials, the war would be over.  Merck would have to fold its tents and settle the rest of the cases.

Here is what Merck now faces:

•Almost 5,000 U.S. personal injury cases split between a class-action and individual lawsuits;
•Cases from England;
•Cases from Australia;
•Cases from Israel;
•Cases from Canada;
•An action by the state of Texas charging Merck defrauded the state out of hundreds of millions of dollars in Medicaid payments by misrepresenting the safety of Vioxx for several years.

In addition to $168 million in damages, the state is seeking additional civil penalties. Texas Attorney General Greg Abbot believes the state can prove total damages in excess of $250 million including treble (triple) reimbursement of $56 million (or $168 million) for five years of filled Vioxx prescriptions. Other states are planning to follow Texas’ lead.

•A national class-action covering every private third-party payer that allowed members of its health benefits plan to buy Vioxx. Merck could face a judgment of billions of dollars if it loses the case brought by the International Union of Operating Engineers Local 68 Welfare Fund.

Most Vioxx purchases were made through health plans run by insurance companies and health maintenance organizations and the union’s case could therefore encompass millions of consumers who took the popular painkiller that’s been linked to increase risk of heart attack and stroke. Unlike the individual personal injury cases, Local 68 lawyers do not have to prove any physical injury.

Under state law, all that needs to be shown is that third-party payers were influenced by unconscionable Merck business practices, such as deceptive marketing and promotion of Vioxx (and is there plenty of that). If the union wins, all third-party payers nationwide can recoup payments to Merck as well as treble damages and attorney fees. These money damages could run as high as $10 billion or more.

•Congressional investigations; and
•Potential stockholder derivative lawsuits on behalf of investors who regard Merck’s actions with respect to Vioxx as having seriously diminished the value of their investments in the company  as well as the reputation and stability of the company itself.

There are additional factors that make this next trial a huge gamble for Merck.

The plaintiff is an ex-Marine, who received two Purple Hearts for battle injuries received in Vietnam, who was taking Vioxx for knee pain related to one of those wounds.

Moreover, unlike the Texas case that involved an arrhythmia, or irregular heartbeat and not a heart attack, this plaintiff suffered a myocardial infarction (heart attack) which is precisely the injury Vioxx use has been linked to.

Originally, Merck had taken the position that it intended to litigate every case to conclusion. Following the $253 million Texas verdict, the company’s lead attorney hinted at the possibility of settling some cases.

As numerous additional class-actions started to take shape in England, Australia, Canada, and Israel, however, settlements may no longer have seemed a viable way to approach the problem. The domino-effect would set billions of dollars in exposure in motion.

Between all of the actions outlined above, the price tag for buying out of the debacle could actually approach the astronomical figures speculated about by financial and legal experts for the past year. $20, $30, or even $50 billion would no longer be out of the realm of possibility.

Such amounts could easily exceed Merck’s insurance coverage and financially cripple the world’s third largest drug maker. They could hamper product development as well as Merck’s ability to partner with smaller companies in joint ventures.

Massive settlement payments could also enrage disgruntled shareholders who have already suffered significant losses since last October.

Thus, while the downside risks to Merck are great, the company’s decision to return to its hard-line position is not all that surprising.

If Merck is able to win this second trial in its home state, where a local jury might not want to bring one of the state’s largest private employers to its knees, the tide would change dramatically.

No longer would the first trial be looked upon as the beginning of the end. It could now be explained away as little more than an aberration wherein a working-class jury ignored science and medicine in favor of sympathy and suspicion.

That verdict might even be reversed on appeal since the injury was not among the ones attributed to Vioxx.
To help put the best possible team on the field; Merck (and its insurers) added Philip Beck to its legal team. Beck represented President Bush in the 2000 election fight.

A win would change everything. Plaintiffs and their attorneys would have to consider the potential of losing their cases. Moreover, smaller settlements would then be possible. Merck would regain leverage and stabilize the litigation mess it finds itself in around the country (and world).

Of course, a loss would raise the specter of an avalanche of unfavorable (and quite large) verdicts. Future trials might become little more than “rearranging deck chairs on the Titanic.” The possibility of small, or even reasonable, settlements would evaporate.

There would also be the potential that courts (especially in Texas and New Jersey) would start applying the doctrine of “collateral estoppel” to specific issues involving Merck’s liability thereby preventing the company from re-litigating them over and over again hoping to convince different juries to reach different results on the same evidence.

Fraud actions by medical insurers, unions, and state Medicare systems would zero in for the kill. Merck shareholders would be making battle plans. Indeed, for Merck a loss would be like having one foot in the grave and the other on a banana peel.

So, while the game will only be starting on Monday morning, Merck has already decided to go “all in.”