Doles v. Secretary of Health and Human Services ( 2022 )

In the United States Court of Federal Claims
No. 17-642V
(Filed Under Seal: April 1, 2022)
(Reissued: April 26, 2022)
FOR PUBLICATION
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ELIZABETH DOLES, *
*
Petitioner, *
*
v. *
*
SECRETARY OF HEALTH AND *
HUMAN SERVICES, *
*
Respondent. *
*
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Jennifer G. Maglio, Maglio Christopher & Toale Law Firm, Sarasota, FL, for
Plaintiff.
Catherine E. Stolar, Trial Attorney, Torts Branch, Civil Division, United
States Department of Justice, Washington, D.C. for Defendant, United States. With
her on briefs were Brian M. Boynton, Acting Assistant Attorney General, C. Salvatore
D’Alessio, Acting Director, Heather L. Pearlman, Deputy Director, Darryl R. Wishard,
Assistant Director, Torts Branch, Civil Division, United States Department of
Justice, Washington, D.C.
OPINION AND ORDER
Petitioner Elizabeth Doles experienced various neurological symptoms after
receiving two vaccinations — first for polio, then for tetanus, diphtheria, and
pertussis (“Tdap”). She sought relief under the National Childhood Vaccine Injury
Compensation Program, 42 U.S.C. §§ 300aa-10 to 34 (“Vaccine Act”), and the Special
Master awarded damages. See Special Master’s Ruling on Entitlement (“Ruling”) at
1 (ECF 73); Special Master’s Decision Awarding Damages (“Decision”) at 2 (ECF 83).
The government moved for review, raising arguments about the nature of Petitioner’s
medical condition and about whether and how the vaccines relate to her condition.

This Opinion was issued under seal on April 1, 2022. The parties were directed to propose redactions
by April 15, 2022. No proposed redactions were submitted. The Court hereby releases publicly the
Opinion and Order of April 1 in full.
Finding errors in the Special Master’s Ruling, I REMAND for additional
proceedings.1
BACKGROUND
To obtain compensation under the Vaccine Act, a petitioner must prove that a
vaccine caused an injury. Althen v. Sec’y of Health & Hum. Servs., 418 F.3d 1274,
1278 (Fed. Cir. 2005). There are two ways to show causation: (1) through “a
statutorily-prescribed presumption of causation upon a showing that the injury falls
under the Vaccine Injury Table (‘Table injury’),” id. (citing 42 U.S.C. § 300aa-14(a)),
or (2) by proof of causation in fact “where the complained-of injury is not listed in the
Vaccine Injury Table (‘off-Table injury’),” id. (citing 42 U.S.C. §§ 300aa-13(a)(1),
300aa-11(c)(1)(C)(ii)(I)). For off-Table injuries, causation in fact has three elements:
“(1) a medical theory causally connecting the vaccination and the injury; (2) a logical
sequence of cause and effect showing that the vaccination was the reason for the
injury; and (3) a showing of a proximate temporal relationship between vaccination
and injury.” Id.
While some Vaccine Act petitioners claim novel injuries resulting from
vaccines, others claim that an existing medical condition was “significantly
aggravated” by a vaccine. 42 U.S.C. § 300aa-11(c)(1)(C)(i)–(ii); see Loving ex rel.
Loving v. Sec’y of Dept. of Health & Hum. Servs., 86 Fed. Cl. 135, 143 (2009) (“[T]he
Vaccine Act specifies that significant-aggravation and new-injury circumstances
constitute separate avenues to potential recovery.”). Petitioners in the latter category
must prove three additional elements: “(1) the person’s condition prior to
administration of the vaccine, (2) the person’s current condition (or the condition
following the vaccination if that is also pertinent), [and] (3) whether the person’s
current condition constitutes a ‘significant aggravation’ of the person’s condition prior
to vaccination[.]” Loving, 86 Fed. Cl. at 144; W.C. v. Sec’y of Health & Hum. Servs.,
704 F.3d 1352, 1357 (Fed. Cir. 2013).
A petitioner always must prove causation of off-Table injuries by
preponderance of the evidence. See, e.g., Hibbard v. Sec’y of Health & Hum. Servs.,
698 F.3d 1355, 1366 (Fed. Cir. 2012); Althen, 418 F.3d at 1278.2 Although the
petitioner’s burden does not “require identification and proof of specific biological
mechanisms,” Knudsen, 35 F.3d at 549, “a ‘plausible’ or ‘possible’ causal theory” is
1 This Court has jurisdiction. See 42 U.S.C. §§ 300aa-11(c), 300aa-16(a). The government timely moved
for review. See 42 U.S.C. § 300aa-12(e)(1).
2 The government can rebut proof of causation by showing, “also by a preponderance of evidence, that
the injury was in fact caused by factors unrelated to the vaccine.” Althen, 418 F.3d at 1278 (quoting
Knudsen v. Sec’y of Health & Hum. Servs., 35 F.3d 543, 547 (Fed. Cir. 1994)); see 42 U.S.C § 300aa-
13(a)(1)(B).
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not enough, see Boatmon v. Sec’y of Health & Hum. Servs., 941 F.3d 1351, 1360 (Fed.
Cir. 2019) (quoting Moberly ex rel. Moberly v. Sec’y of Health & Hum. Servs., 592 F.3d
1315, 1322 (Fed. Cir. 2010)). Proof of causation requires “a reputable medical or
scientific explanation that pertains specifically to the petitioner’s case.” See
Broekelschen v. Sec’y of Health & Hum. Servs., 618 F.3d 1339, 1345 (Fed. Cir. 2010);
Moberly, 592 F.3d at 1322; see also Knudsen, 35 F.3d at 549 (“[C]ausation can be
found in vaccine cases based on epidemiological evidence and the clinical picture
regarding the particular [patient] without detailed medical and scientific exposition
on the biological mechanisms.”).
This Court may set aside a special master’s conclusions as “arbitrary,
capricious, an abuse of discretion, or otherwise not in accordance with law.” 42 U.S.C.
§ 300aa-12(e)(2)(B). “Fact findings are reviewed … under the arbitrary and capricious
standard; legal questions under the ‘not in accordance with law’ standard; and
discretionary rulings under the abuse of discretion standard.” Munn v. Sec’y of Dep’t
of Health & Hum. Servs., 970 F.2d 863, 870 n.10 (Fed. Cir. 1992). When this Court
finds error, it may either substitute its own findings and conclusions or remand for
additional proceedings. 42 U.S.C. § 300aa-12(e)(2)(B)–(C).
The relevant facts and history of the case are as follows. Petitioner — a 67-
year-old woman at the time of her vaccinations — alleged in her Amended Petition
that she suffers from central nervous system demyelination “best characterized” as
multiple sclerosis (“MS”). Am. Pet. ¶¶ 5–6 (ECF 44). She does not plead exactly when
her symptoms began, but she went to the emergency room 44 days after her second
vaccination for symptoms that began two nights before. Id. at ¶¶ 1–3; Ruling at 6.
She claims that her vaccines “actually caused, or, alternatively, significantly
aggravated” her injury. Am. Pet. at ¶ 10.
Because Petitioner’s alleged injury does not appear on the Table for the
relevant vaccines, 42 U.S.C. § 300aa-14(a); 42 C.F.R. § 100.3(a)(I), (II), (VI), (VII), she
must prove causation rather than benefit from the statutory presumption. Althen,
418 F.3d at 1278. Central nervous system demyelination is a general term describing
a number of medically distinct conditions — including MS, acute disseminated
encephalomyelitis (“ADEM”), and focal myelitis or transverse myelitis (“TM”), among
others, see Steel Rebuttal Report at 2 (ECF 57-2) — so Petitioner presented two
experts to explain her theory of injury in more detail.
The first was Dr. Slavenka Kam-Hansen, one of Petitioner’s treating
physicians, who opined in a letter that Petitioner suffered from ADEM because of the
vaccines. Kam-Hansen Letter at 2 (ECF 23-2). Dr. Kam-Hansen opined “that ADEM
was more likely to cause [Petitioner’s] symptoms” than MS. Id. at 1. But then
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Petitioner changed course. Her second expert, Dr. John G. Steel, submitted reports
arguing that Petitioner did not have ADEM, but instead experienced focal myelitis or
TM because of the vaccines. Steel Rebuttal Report at 1, 7; see Steel Report at 3, 5
(ECF 34-2). Dr. Steel opined that Petitioner has MS, but — although the record of his
opinions is not entirely clear — he did not appear to argue that the vaccines caused
or aggravated that condition. Rather, he seems to have argued that her MS put her
at heightened risk for TM when she received vaccinations. Steel Rebuttal Report at
1–2, 6–7.3 “Although there is little evidence that vaccinations cause multiple sclerosis
in healthy patients,” he wrote, “there is convincing evidence that vaccinations
occasionally trigger single attacks of TM[] [and other conditions], and there is good
reason to think that such an event is more likely in patients with subclinical MS.”
Steel Report at 5.
Defendant submitted an expert report from Dr. Subramaniam Sriram, who
agreed with Dr. Steele that Petitioner has MS, not ADEM, Sriram Report at 7, 13
(ECF 52-1), but concluded that Petitioner’s MS was not caused or exacerbated by the
vaccines. Id. at 16; Sriram Rebuttal Report at 7 (ECF 62-1). He opined that the
diagnosis of MS made it inappropriate to diagnose TM as a separate condition. Sriram
Rebuttal Report at 1–2.
In response, Dr. Steel emphatically objected not only to Dr. Sriram’s
characterization of Petitioner’s condition, but to Dr. Sriram discussing MS in the first
place. Dr. Steel referred to MS as a “red herring” that “has served to confuse the
issue,” insisting that he “made no assertion of a causal relationship between the
vaccines and MS” and that his opinion was “regarding the myelitis only.” Steel
Rebuttal Report at 1. He criticized Dr. Sriram for addressing MS at all: “Dr. Sriram’s
rebuttal … focused on MS but did not address the actual causal relationship that I
have asserted, between Ms. Doles’ April 2016 vaccinations and her subsequent attack
of spinal myelitis. By discussing MS only, he failed to address our central point.” Id.
at 1–2.
Petitioner’s own argument before the Special Master was in the same vein as
Dr. Steel’s. Petitioner maintained that “Dr. Steel’s theory of general causation” was
that her vaccines “can provoke an autoimmune process leading to central nervous
system demyelination which manifests as [a form of TM] and this is more likely to
occur in patients who are already undergoing another autoimmune process, such as
clinically silent MS.” Reply Mem. in Supp. of Pet.’s Mot. for Findings of Fact and
3 Dr. Steel also opined that “[t]he vaccinations likely did not cause the MS but rather unmasked it, i.e.
caused it to become clinically significant during her medical evaluation.” Steel Report at 3. That
language could be read as opining that Petitioner’s vaccinations aggravated her MS, but it is difficult
to understand in the context of Dr. Steel’s other opinions.
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Conclusions of Law (“Reply Mem.”) at 2 (ECF 72). Petitioner identifies no place in her
expert reports or briefing where she plainly argued that her MS itself had been
aggravated by the vaccines. Rather, she argued consistently that her MS was an
underlying risk factor that put her at risk for other conditions. Pet.’s Mem. in Supp.
of Her Mot. for Findings of Fact and Conclusions of Law at 18–20 (ECF 68); Reply
Mem. at 2.
The Special Master — who resolved the parties’ arguments on the papers,
without a hearing — took a tack different from either of the parties. He specifically
rejected both Dr. Kam-Hansen’s view that Petitioner experienced ADEM and Dr.
Steel’s view that Petitioner experienced TM, instead agreeing with Dr. Sriram that
Petitioner has MS alone. Ruling at 18, 20–22. But unlike Dr. Sriram (or Petitioner
and her experts, for that matter), the Special Master determined that Petitioner’s MS
had been significantly aggravated by her vaccines. Id. at 19. The Special Master’s
main support for that conclusion was a study by Langer-Gould et al., which he
interpreted as providing “evidence tending to show that vaccines did contribute to
significantly aggravate subclinical autoimmunity into overt MS among the examined
population.” See id. at 24 n.11 (citing Annette Langer-Gould et al., Vaccines and the
Risk of Multiple Sclerosis and Other Central Nervous System Demyelinating Diseases,
71 JAMA Neurol. 1506 (2014) (“Langer-Gould”) (ECF 57-10)). The Special Master
thus issued a Ruling on Entitlement and a Decision based on a theory of injury (MS)
and a theory of causation (significant aggravation) that Petitioner never advanced in
her expert reports or briefing.4 The Special Master placed the date of Petitioner’s
condition “approximately 60 days following her … polio vaccination and 42 days
following her … Tdap vaccination.” Id. at 29.
DISCUSSION
The Special Master’s resolution was erroneous for at least two reasons.
First, it was unfair to the parties and frustrates this Court’s review. Although
the formal requirements of this Court’s Rules and the Federal Rules of Civil
Procedure and Evidence do not apply to proceedings before the special masters, see
42 U.S.C. § 300aa-12(d)(2); RCFC App. B, Rule 8(b)(1), the special masters are bound
by an obligation to be fair to both parties, and to provide both parties the opportunity
to present a case. See RCFC App. B, Rule 8(b)(1) (“In receiving evidence, the special
master … must consider all relevant and reliable evidence governed by principles of
fundamental fairness to both parties.”); id. Rule 3(b)(2) (“The special master is
responsible for … affording each party a full and fair opportunity to present its
4Petitioner even conceded before the Special Master that “the studies cited by Dr. Steel do not involve
vaccines triggering MS[.]” Reply Mem. at 4.
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case[.]”); see also Dickerson v. Sec’y of Dep’t of Health & Hum. Servs., 35 Fed. Cl. 593,
598 (1996) (“[T]he Court of Federal Claims has promulgated rules of procedure for
use by special masters governed by the principles of fundamental fairness to both
parties.”). The special masters must also conduct their proceedings in a way that
“create[es] a record sufficient to allow review of” their decisions. See RCFC App. B,
Rule 3(b)(2). Given those principles, this Court has required special masters to give
parties notice and an opportunity to comment on the evidence and issues the special
master considers. See, e.g., Davis v. Sec’y of Health & Hum. Servs., 94 Fed. Cl. 53, 65–
66 (2010).
The Special Master failed to do so. As explained, the Special Master adopted a
theory of injury and causation that Petitioner never advanced and that does not
appear to have been obvious from the evidence submitted. Compare Sword v. United
States, 44 Fed. Cl. 183, 190 (1999) (finding no surprise where “the Special Master’s
explanation was hardly out of left field”). As a result, the government never had its
opportunity to explain why those theories were mistaken. Compare Hines ex rel.
Sevier v. Sec’y of Dep’t of Health & Hum. Servs., 940 F.2d 1518, 1525–26 (Fed. Cir.
1991) (finding that the special master taking judicial notice of a “[w]ell-known
medical fact[]” without “inform[ing] the parties in advance that he intended to do so”
did not “violate[] the principles of fundamental fairness” because the objecting party
could have raised her concerns on review before the Court of Federal Claims and did
not do so) (quotes omitted), with Campbell ex rel. Campbell v. Sec’y of Health & Hum.
Servs., 69 Fed. Cl. 775, 781–82 (2006) (finding it “patently unfair” for the special
master to rely on extra-record articles of dubious reliability without giving the parties
an adequate opportunity to respond to them). To the extent the Special Master relied
on evidence in the record, the government addressed that evidence as it related to
Petitioner’s characterization of her injury, not the Special Master’s different
characterization. Both parties agree that they were “surprise[d]” — Petitioner’s word
— by the Special Master’s decision to treat this case as one of significant aggravation
of an existing condition. Pet.’s Mem. in Resp. to Resp’s. Mot. for Rev. (“Pet.’s Resp.”)
at 1 (ECF 89). And because of the lack of adversarial development of the Special
Master’s theory, I cannot be sure that the record is adequate for review.
Second — possibly because of the departure from ordinary adversarial
processes — the Special Master’s Ruling misinterpreted its primary medical
authority, the Langer-Gould study. A summary of that study will show why.
The Langer-Gould investigators used the records of a large health system to
investigate the association between vaccinations of any type and central nervous
system demyelinating conditions, including MS. Langer-Gould at 2. The investigators
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bifurcated their findings between patients younger than 50 and those 50 or older. Id.
at 3.
The investigators expressed the association between vaccination and
conditions such as MS in terms of an odds ratio, plus a 95% confidence interval, for
developing demyelinating conditions during different time periods (up to three years)
after vaccination. Id. at 3, 6 (Figure 2). An odds ratio is a way of expressing the
relative risk of a condition in a “case” group exposed to a given factor versus a
“control” group that was not exposed. Fed. Jud. Ctr., Reference Manual on Scientific
Evidence 568 (3d ed. 2011). “An odds ratio of 1 indicates no association” between the
disease and the factors investigated: The risk of the disease is the same whether the
group was exposed or not. Id. at 291. “A confidence interval is a range of values within
which the true value is likely to fall.” Germaine v. Sec’y of Health & Hum. Servs., 155
Fed. Cl. 226, 229 (2021) (quotes and alterations omitted) (quoting Reference Manual
on Scientific Evidence 621). “By definition, when a statistician uses a 95% confidence
interval, that statistician estimates that a sample to be drawn from the population
will fail to capture the mean population 1 out of 20 times.” Lax v. APP of N.M. ED,
PLLC, CIV No. 20-264 SCY/JFR, 2022 WL 715735, at *8 n. 9 (D.N.M. Mar. 10, 2022).
A confidence interval that straddles an odds ratio of 1.0 is “statistically insignificant,”
meaning that it is statistically indistinguishable from no change in risk. Germaine,
155 Fed. Cl. at 228–29 (citation omitted) (quoting Reference Manual on Scientific
Evidence 621) (discussing the related concept of relative risk).
Looking at all types of vaccines combined, the investigators found no
association between vaccinations and MS. For every time period after vaccination,
the confidence interval for developing MS straddled an odds ratio of 1.0. Langer-
Gould at 6 (Figure 2). There was one statistically significant association between
vaccines and the broader universe of demyelinating conditions — an odds ratio of
2.32, with a confidence interval of 1.18 to 4.57 — but only for patients under age 50,
and only within 14 days of the vaccine. Id. There was no association between vaccines
and demyelinating conditions for patients 50 or older for any time period post-
vaccination. Id. For patients younger than 50, the association between vaccinations
and demyelinating conditions disappeared after 14 days. Id.
In short, Langer-Gould found no association between MS — the condition the
Special Master identified as Petitioner’s injury — and vaccinations. The only
association found involved demyelinating conditions generally, i.e., conditions other
than the demyelinating condition Petitioner has. Even if there were an association
between Petitioner’s personal condition and vaccinations, it did not exist for patients
in Petitioner’s age group, only younger patients. And even if there were an association
for her age group, the effect disappears soon after vaccination, such that there is no
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association between vaccinations and demyelinating conditions for either age group
at the time the Special Master found Petitioner’s symptoms in fact developed. In
short, there is no way to look at the study’s data and find an association between
vaccinations and Petitioner’s own condition.5
Although there can be association without causation, there cannot be causation
without association. See, e.g., Olaf M. Dekkers, The Long and Winding Road to
Causality, 34 European J. of Epidemiology 533 (2019) (“[T]he fundamental
prerequisite before judging causality is the presence of an association. …. In short:
no causation without association.”); Handbook of Causal Analysis for Social Research
285 (Stephen L. Morgan ed., 2013) (“Typically, all we can observe in data is whether
or not two or more variables are associated, either unconditionally or after
conditioning on some other set of other variables. Causality is not observed but must
be inferred from these associations. … [I]f two variables are causally related, they
must be associated. As the old adage goes, ‘no causation without association.’”).6 The
fact that the Langer-Gould study shows no association relevant to Plaintiff means
that it does not evidence causation: A finding of causation would have to be despite
the Langer-Gould study, not because of it. It was therefore error for the Special
Master to treat the Langer-Gould study as supporting Petitioner’s proof of causation.
The Special Master’s Ruling acknowledged that Langer-Gould “found no long-
term association between vaccination and MS,” Ruling at 23, but dismissed the point
as “only a statistical observation” because a possible mechanism for causation —
specifically, “vaccine involvement as an inflammatory cofactor” — might
hypothetically take effect later than 30 days after vaccination or in patients older
than 50. Id. at 24 & n.11, 30. That hypothesis, however, is not evidence; it was a theory
the Langer-Gould study was supposed to test by looking for an association. The
Special Master was not permitted to adopt a hypothesis as a theory of causation
without evidence to support it. See Germaine, 155 Fed. Cl. at 227–28 (citing Knudsen,
35 F.3d at 549, and Boatmon, 941 F.3d at 1360). And the Langer-Gould study, again,
provided no such evidence: It found an association in some circumstances, but not
circumstances like Petitioner’s.
One might argue that the study supports an inference of causation in the
limited circumstance where there was a statistical association. But because
association is a prerequisite for conclusions about causation, the Langer-Gould study
5Dr. Sriram raised some of these points in a supplemental report. See Sriram Rebuttal Report at 5.
6But see Stephen L. Morgan & Christopher Winship, Counterfactuals and Causal Inference: Methods
and Principles for Social Research 447 n.9 (2d ed. 2015) (noting “cases for which this may not be true,
such as when individual-varying causal effects perfectly cancel out each other or when suppression
effects exist”).
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provides no support for a hypothesis of causation in circumstances where an
association was lacking. See Broekelschen, 618 F.3d at 1345 (“[A] petitioner must
provide a reputable medical or scientific explanation that pertains specifically to the
petitioner’s case[.]”). To dismiss that finding as a “statistical observation” thus
misunderstands what the Langer-Gould study was investigating and the conclusions
it reached.
That is not to say that the Langer-Gould study disproves causation in
Petitioner’s case. Scientific studies sometimes yield different results, so perhaps some
other study shows an association that Langer-Gould did not. When scientific studies
differ, the proper course is to weigh them, in which case a special master’s conclusions
about inconsistent medical evidence would be upheld unless arbitrary or capricious.
See Broekelschen, 618 F.3d at 1349; Greene v. Sec’y of Health & Hum. Servs., 146 Fed.
Cl. 655, 665, aff’d, 841 F. App’x 195 (Fed. Cir. 2020); Moreno v. Sec’y of Dept. of Health
& Hum. Servs., No. 95–706V, 2005 WL 6120645, at *6–7, 9–10 (Fed. Cl. 2005).
Likewise, the Federal Circuit has made clear that published research is not strictly
necessary to show causation in the first place. See Andreu ex rel. Andreu v. Sec’y of
Dep’t of Health & Hum. Servs., 569 F.3d 1367, 1378 (Fed. Cir. 2009); Althen 418 F.3d
at 1280. But when the Court or a special master does resort to medical literature, a
study’s findings must be interpreted using correct statistical methods — just as its
words must be assigned their correct common or technical meanings.7
Because of the importance the Special Master attached to the Langer-Gould
study and the government’s lack of opportunity to respond to the Special Master’s
treatment of the rest of the record, I cannot conclude that the Special Master’s errors
are harmless. See Davis, 94 Fed. Cl. at 65–66. But for the same reason, the record is
insufficient for me to issue new findings. 42 U.S.C. § 300aa-12(e)(2)(B); RCFC App.
B, Rule 3(b)(2). The best course is therefore to remand for further proceedings. 42
U.S.C. § 300aa-12(e)(2)(C). On remand, the Special Master should give the parties
the opportunity for briefing — and, if appropriate, new written or live evidence — on
7 Another possible error in the Special Master’s Ruling deserves brief attention. The Special Master
wrote that his conclusion about the Langer-Gould study was “consistent with petitioner’s burden of
proof for a significant aggravation claim” because “Petitioner need only demonstrate that her
vaccination affected her condition; she does not have a burden to demonstrate that her ultimate
condition is worse than her expected outcome.” Ruling at 24–25 (citing Sharpe v. Sec’y of Health &
Hum. Servs., 964 F.3d 1072, 1081 (Fed. Cir. 2020)). As the parties agree, that is not the law for
causation. Resp’s. Mem. in Supp. of Mot. for Rev. at 9 (ECF 86-1); Pet.’s Resp. at 5–6. Petitioner argues
that in context, the Special Master meant to refer to the standard for aggravation of injuries. Pet.’s
Resp. at 6–7. I find the Ruling’s language too cryptic to be sure. Be that as it may, the Special Master
should use the correct standard on remand.
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whether Petitioner’s vaccinations aggravated her MS. The Special Master should
interpret the medical evidence under the correct legal and scientific standards.
CONCLUSION
For the foregoing reasons, the government’s motion for review is GRANTED
and the Special Master’s Decision (ECF 83) is VACATED. The case is REMANDED
for the Special Master to consider the parties’ arguments on aggravation of MS and
to re-evaluate the medical evidence under the correct legal and scientific standards.
The Special Master shall issue a new entitlement decision within ninety days of this
decision. See 42 U.S.C. § 300aa-12(e)(2); RCFC App. B, Rule 28(b).
IT IS SO ORDERED.
s/ Stephen S. Schwartz
STEPHEN S. SCHWARTZ
Judge
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