Andrew W. Murray, Mb, CHB

• Assistant Professor
• Department of Anesthesiology
• University of Pittsburgh School of Medicine
• Cardiac Anesthesiologist
• University of Pittsburgh Medical Center?resbyterian
• Director of Cardio-Thoracic Anesthesiology
• Veteran's Administration Medical Center?akland
• Pittsburgh, Pennsylvania

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An agent specically designed to reverse the activity of Factor Xa inhibitors may provide an an tidote for patients who, in rare instances, experience an uncontrolled major bleeding event or require emergency surgery. This was the rst regula tory approval in any market for Eliquis for stroke prevention in patients with nonval vular atrial brillation. No stem orientation adjustment,Use the trial provisionals to assess the trial fit. Then implant the neckof neck provisionals mimics the template of femoral head centers. An innovative system accomplishedadjustments areHead centerneckoptions heads for truly independentexclusive use of +0 mmoffset, and version afterKey to simplicity is theadjustment of leg length, Hypersensitivity and anaphylaxis have beenafety Informationhthe presence of gastric malignancy. Do not co-administer atazanavir withstemic concentrations may be substantially decreased. To watch your No other porous metal material so closely resembles the structure, function, and physiology of trabecular boneTrabecular MetalFor implant stability, nothing compares toTechnology. AbelsonTaylor has helped introduce nearly brand take off, call Dale Taylor at a hundred new products and indications, 312. Both of these end points, the primary and secondary ecacy Thursday, April 25, 2013 outcomes, were statistically signicant. For the rst time annual decrease as of 2012 as generic com cycle and is responsible for establishing chronic compare the ecacy and safety of once-daily in many years, there was an annual drop-opetition continues to grow and the average infection. Oncology will continue to be the tion treatment in adults and children aged submissions for a xed-dose combination of panies. From 2012 to 2013, the R&D ex most heavily targeted therapeutic eld by the 12 years and older. Drug mak United States, European Union, and Can to pharmaceutical giant GlaxoSmithKline forecasted to be more positive though when ers will also continue to shift R&D more to ada. The product was eventually compared to the 2012 R&D spend, with a wards biologics based on their higher pricing priority-review status and U. In October 2012, ViiV and Shionogi as the commercial value of new molecular molecular entities expected to be approved arm trial to assess the antiviral activity and announced a deal revamping their integrase entities. Food and Drug Administration safety of dolutegravir 50mg twice-daily in inhibitor relationship. The 2012 tally was the highest since and safety of dolutegravir 50mg once-daily 2013 report projected that total dolutegra 39 new molecular entities were approved The investigational integrase inhibitor dolute to raltegravir 400mg twice-daily in treat vir global sales will amount to 1. Integrase in comparing the ecacy and safety of dolute combo drugs such as Atripla and the quad pill Stribild. Launched in the United States dur ing July 2006, Atripla generated worldwide 2012 sales of $3. Stribild (elvite gravir, cobicistat, emtricitabine, and tenofovir disoproxil fumarate) was introduced to the U. The drug candidate is on track to become the rst purely oral treatment available for hepatitis C. The study met its primary ecacy endpoint of superiority versus a predened historic control sustained virologic response rate of 25 percent. Theravance ling regulatory applications in the United States and Europe in the second quarter. The product candidate ledipasvir, and ribavirin in patients with gen Sixteen percent of prostate cancer cases are posure to dimethyl fumarate did not lead has the proposed trade names Breo in the otype 1 chronic hepatitis C virus infection. Bone In that report, the analysts projected global nounced on July 13, 2012, the ling of U. Intended to be company is concentrated on the discovery, growing hepatitis C drug arena. Included the development and commercialization of branded as Anoro, the product is administered development and commercialization of in the deal was the hepatitis C polymerase radium-223. Some industry analysts for health authority approvals globally, and A New Drug Application for 62. Teravance is reportedly entitled to pared radium-223 with best standard of care ate. W cuit ruled that the othat the olabel-label cause they have a locause they have a lot less to lose, he says. But I do think the do with what the pharmaceutical companies another tricky area of involvement for pharma From the 30,000 foot vantage, this decision feeling many of the thought leaders in this in are doing. The reason for this is that claims not for all intents and purposes, is steadfastly ignor Carter says discussing olabel use, even if tion for Healthcare Communication, says the supported by a label can be perceived as mis ing the decision. If you use that as your metric, be an appeal, will it go to the Supreme Court, pharma today. Sales&Marketing Seventy-seven percent of consum By Med Ad News staff ers who have seen a physician in the last year value the information that they receive, according to research by Minority patients harder for health extenders to reach Kantar Media Healthcare Research. For marketers and ad professionals, reaching By Mia Burns patients right before they speak with their physicians can have a huge impact on mong the many challenges the conversation. Twenty-nine percent of re are 14 percent less likely to value their spondents reported that communication and physician, but 26 percent more likely to language barriers presented challenges. A majority of patients being served and also recognizing physicians use a smartphone profession that cultural competence diversity comes not ally. One third have already incorporat only from the language that people speak, ed a tablet into their professional routine. Additionally, 40 When Collins and her team asked about percent of physicians are starting to use languages, English came in at 95 percent, fol their smartphones to reference drug data, lowed by Spanish at 94 percent. For ers organizations that are creating programs the tablet users, reading articles from for patients that they need to be thinking of medical journals and researching general Spanish at the beginning of the project just medical topics top the list of other activi as they are in terms of English, she says. The top direct-to-consumer Respondents are also concerned about gaps categories regarding advertising spend in how well patients and providers can under were antidepressants, impotence stand each other. Also, 44 percent of the report is that one of the keys that the extenders cited to being able and osteoarthritis drugs. Tese challenges include a lack of appropri between patients within the community and the healthcare system. Tese might include restrictions on ads for erectile dysfunction pills rose 62 percent to that can reach children; requiring ads to address $ % $324. Recognized Female The researchers found that ads for Cialis, We believe that both healthcare providers and 1. We $ %$ % two principles, and fully complied with one believe it is our responsibility to communicate 1. At no point did the drugs comply with the ing, including raising awareness of diseases and About 3. Monistat, comprising guideline at a rate better than 50 percent for treatment options and empowering patients to miconazole, is marketed by McNeil Consumer Healthcare, a division of Johnson & the total category. Cialis was the most consis communicate with their physicians about medi Johnson (jnj. Canesten, comprising clotrimazole, practices consonant with their independent the legal requirements regarding submitting ad is marketed by Bayer Healthcare (bayerhealthcare. The survey further found that mobile device management (27 Survey respondents stated that mobile Dsurvey believe mobility will generate signicant sources of new percent), collaboration (25 percent), and knowledge sharing (23 percent) virtual assistants could impact healthcare revenue for their businesses, and most will invest between 31 and 40 per are the top three most important features to a developed mobile strategy. The Most respondents in India (77 percent), and almost half (47 percent) or removed using voice-enabled virtual survey also found that mobility is a top priority in the coming year for of respondents in Japan, Mexico, and the United Kingdom plan to focus assistants. Twenty-nine percent of all respondents said Fifty-two percent of companies said they would retrain existing stato caregivers. And 80 percent believe virtual they plan to design, develop, and/or distribute connected devices to sup enable their mobile strategies, and 37 percent will hire full-time mobile assistants will benet patients most by en port B2B applications. The survey also found that more projects are being to adhere to health advice and modifying to make workow changes to better incorporate mobility into their staed internally (76 percent in 2013, versus 63 percent in 2012) to sup behaviors. Additionally, 73 percent believe mobility will impact their port the development of mobile applications. Other criti The study found that security (45 percent), budget concerns (41 percent), recommendations in three different places. This suggests that the velocity of the need to focus intensely on people and expertise. Despite var All (100 percent) of survey respondents in the healthcare sector plan seamlessly manage changes in course of ied progress in strategy development, half (50 percent) of the companies to reach their top mobile priorities within the next year. Healthcare re action much like their human equivalents surveyed said they would identify prioritized mobility initiatives over the spondents cited location-based services (46 percent) as most important. According to HealthLeaders-InterStudy, there Key ndings from our recent physician and Explore Patient Support Programs. We persuaded her to step into running the most signicant unied health and wellness Dorothy has really been a pioneer and New York agency in addition to what she agency brands. From a culture perspective it is an ab tee, which set the strategic priorities for the skill set will enable the agency to continue Gemmell and had already built a strong re solute hand in glove t. Burcin tells it, their target had rior skill set, to work with people and keep The innovative design of Natrelle 410 is designed to help prevent upper pole deformi never even considered moving to an agency. Having uncovered someone in an un munications for Natrelle reconstruction and augmentation products. This becomes harder than the less important stuff and they adjectives that jump out and say I am not ter very important because the person that is most connect with the audience. The people presenting is taking data and research and if four teams are pitching, an average team they make it difficult for the client to select the that need to make an attempt to connect are turning it into actionable opportunities. They are the ones Connecting with the audience can be a logic is that usually one out of the four teams is they invented advertising. Mentoring, training, rehearsal above average and they are the ones that go consumer pitch on the West Coast, I ran into a more time to practice their section so that they can all lead to a more compelling presentation.

There is plasmoid aqueous containing leucocytes gastritis symptoms diet buy 100 mg macrobid, minute flakes of coagulated proteins and fibrinous network diet during gastritis attack discount 100 mg macrobid free shipping. They are characteristic of granulomatous uveitis with predominance of macrophages gastritis diet ãèäîíëàéí buy macrobid 100 mg low cost. It reacts sluggishly to light due to irritation of the third nerve endings in iris syarat diet gastritis effective 50mg macrobid. Ectropion of uveal pigment is due to the contraction of exudates upon the iris so that the posterior surface of iris folds anteriorly gastritis in chinese purchase macrobid. Intraocular pressure may rise when 3/4 circumference or more of the angle of anterior chamber is blocked gastritis and constipation purchase macrobid 50 mg without prescription. Hypertensive iridocyclitis may be present due to increase pressure in dilated capillaries and outpouring of leucocytes. The sticky albuminous aqueous drains Acute iridocyclitis with difficulty thus raising the tension. Late glaucoma (postinflammatory glaucoma) is the results of pupil block (seclusio-pupillae due to ring synechiae formation or occlusio-pupillae due to organised exudates) not allowing the aqueous to flow from anterior to posterior chamber. Investigations Series of tests should be done because of varied etiology of uveitis. Radiological investigations include X-rays of chest, paranasal sinuses, sacroiliac joints and lumbar spine. Modern broad-spectrum antibiotics which cross the blood-aqueous barrier are given in cases of infections. Atropine It is the most powerful, longest acting (2 weeks) and commonly used mydriatic and cycloplegic. Slit-lamp examination Normal Aqueous flare and kp Corneal oedema and anterior synechiae i. Thus, it also relaxes the ciliary muscle spasm which is always associated with iritis. It prevents formation of posterior synechiae and breaks down recently formed synechiae which are not firmly attached by dilating the pupil. In case of atropine allergy, other mydriatics like phenylephrine, cyclopentolate or tropicamide may be used. In milder cases weaker, short-acting agents such as cyclopentolate 1% or homatropine 2% thrice daily may be used. Dark glasses or an eyeshade may also be used to avoid glare, discomfort and lacrimation specially in sunlight. Heat Application Heat application in the form of hot fomentation or local dry heat is very soothing. Due to their anti-allergic and anti-fibrotic activity they reduce fibrosis and thus prevent disorganisation and destruction of tissues. It is better to use full strength topical steroids for 6 weeks to make sure that patient is not having side effects such as raised intraocular pressure. Analgesics and Anti-inflammatory these are useful in relieving pain and discomfort. Antibiotics the modern broad-spectrum third generation antibiotics are of immense value particularly in fulminant cases of purulent uveitis. Although these are of not much use in allergic iridocyclitis, they provide an umbrella cover. These are safer as prolonged use of steroids may produce open angle glaucoma by reducing outflow facility, cataract and secondary infection with bacteria or fungi. These agents should be administered with great caution under the supervision of haematologist or an oncologist as they have adverse side effects or kidney, liver and cause bone marrow depression. Recently azathioprine, mycophenolate, mofetil, tacrolimus are used in unresponsive or intolerant patients. Specific Treatment Specific treatment of the underlying disease should be added if the etiology is identified. Post-inflammatory glaucoma due to ring synechiae and iris bombe demand an iridectomy in all cases so that communication can be restored between anterior and posterior chambers. Complicated cataract requires lens extraction with guarded prognosis in a quiet eye under cover of steroids. The presence of fresh kp is considered a contraindication for intraocular surgery. Retinal detachment of exudative type usually settles itself if uveitis is treated aggressively. Differential Diagnosis It includes toxoplasmosis, peripheral toxocariasis syphilis, sarcoidosis and multiple sclerosis. Approximately 80% cases do not need any treatment as it may resolve spontaneously. Corticosteroids and immunosuppressants may be given in chronic cases but the results are disappointing. Posterior sub-tenon injections of triamcinolone acetonide or methylprednisolone acetonide. As the outer layers of retina depend upon the choroid for nutrition, there is always associated inflammation of retina (chorio-retinitis). Non granulomatous choroiditis or exudative choroiditis is due to allergic reaction. There is diminution of vision due to retinal lesions and opacities in the vitreous (floaters). In early stage one or more yellowish areas with ill-defined edges are seen deep to retinal vessels. This appearance is due to infiltration of the choroid and presence of exudates which hide the choroidal vessels. Clinical Types Choroiditis is usually classified according to number and site of lesions. Treatment It is usually unsatisfactory as great damage is usually done to the retina before the condition can be controlled, 1. Specific treatment is required for causative organism such as toxoplamosis, toxocariasis, tuberculosis, syphilis, etc. Anterior chamber may be deep or funnel-shapped due to the formation of occlusio-pupillae or ring synechiae. Keratic precipitates are scattered over a triangular area in the lower part of cornea. Hypertensive iridocyclitic crisis of Posner and Schlossman may occur occasionally. Differential Diagnosis Hypertensive iridocyclitis should be differentiated from angle closure glaucoma. There is absence of keratic precipitate and aqueous flare in angle closure glaucoma. Oral acetazolamide, blockers and hyperosmotic agents should be given to control the raised tension. It occurs most commonly as an acute process 1-7 days following intraocular surgery such as cataract extraction and filtering operation. Chances of infection are much greater if there is associated vitreous loss as vitreous is a very good culture medium for organisms. Perforation of suppurative corneal ulcer of Pseudomonas pyocyanea or fungal origin. There is absence of red fundus reflex and inability to visualize the fundus even with indirect ophthalmoscope. It affects the anterior vitreous and anterior uvea causing thick, organized hypopyon. Retained cortical lens material following lens extraction may be associated with severe anterior uveitis. Investigation Identification and culture and sensitivity of the causative organism from the aqueous and vitreous taps confirms the diagnosis. Broad-spectrum antibiotics which cover gram-positive and gram-negative organisms are given.

A7531 Room 5 A-B (Upper Level) 717 Effects of Antithrombin and Heparin for the Treatment of Acute Abstract Summaries 1:30-2:00 Lung Injury in Rats/N gastritis diet and exercise buy 100mg macrobid with mastercard. A7535 104 Identification of Respiratory Health Effects and Cytotoxic Flavor Chemicals in Popular Electronic Cigarette Refill 721 Janus-Headed Nature of Succinate in Acute Lung Injury: Fluids/M gastritis left shoulder pain purchase macrobid with mastercard. A7536 105 Gender Affects the Transcriptional Response to Particulate Matter in Alveolar Macrophages/A gastritis chronic erosive purchase macrobid 100 mg free shipping. A7537 106 the Effect of Pregnancy on the Respiratory Response to Pro-Inflammatory Insults/G gastritis omeprazole cheap macrobid on line. A7539 108 Transcriptomic Changes in the Nasal Epithelium Associated with Diesel Engine Exhaust Exposure/E gastritis no appetite buy generic macrobid 100mg on line. A7551 the information contained in this program is up to date as of April 16 gastritis dietitian order macrobid 100 mg line, 2018. A7559 Influenza Virus Infection Is Death Ligand-Dependent and 119 Alterations of Arginine Metabolism and Lung Function Contributes to Disease Severity/C. A7561 807 Alveolar Macrophage-Derived Microvesicles Protect Alveolar 121 Progression, Persistence and Recall of Eosinophilic Rhinitis in Epithelial Cells from Influenza Infection/D. A7574 124 G Protein-Coupled Receptor 1 Deficiency Exacerbates Ozone-Induced Lung Injury and Lung Inflammation/R. A7575 the information contained in this program is up to date as of April 16, 2018. A7586 Respiratory Immunity Against Rhinovirus and Influenza Infection and Inhibit Subsequent Lung Inflammation/N. A7587 409 Combination Therapy Reduces Hospitalizations in Patients with Pulmonary Arterial Hypertension/C. A7589 Room 11 A-B (Upper Level) 411 Intravenous Iron Substitution Improves Pulmonary Diffusion Abstract Summaries 1:30-2:00 Capacity in Patients with Iron Deficiency and Pulmonary Viewing/Discussion 2:00-3:30 Hypertension/D. A7581 414 Pulmonary Artery Endovascular Device to Improve Vascular 403 Novel Analysis of Treprostinil Dose-Response Relationship Compliance in Pulmonary Hypertension/I. A7593 the information contained in this program is up to date as of April 16, 2018. A7608 Abstract Summaries 1:30-2:00 915 Cigarette Smoke Exposure Alters the Airway Epithelial Cell Viewing/Discussion 2:00-3:30 Fate by Modulating Mitochondrial Morphology and Bcl-2 Levels/H. A7595 917 Nanoparticles Targeted to Pulmonary Intravascular 902 Dissecting the Role of Pulmonary Neuroendocrine Cells in Leukocytes for the Early and Specific Detection of Acute Lung Immune Responses/X. A7611 903 Changes in Airway Platelet Population and Morphology in a 918 Cystic Fibrosis Transmembrane Conductance Regulator Murine Model of Lung Fibrosis/R. A7613 905 the Role of Autophagy Proteins in Mesenchymal Stromal Cell 920 Human Alveolar-Like Macrophages Derived from Embryonic Therapy During Oxidative Stress and Sepsis/S. A7601 922 Lung Infection Elicits Endothelial Amyloids with Distinguishable Antimicrobial and Cytotoxic Properties/S. A7603 the information contained in this program is up to date as of April 16, 2018. A7628 925 Genetic Variation in Surfactant Protein-A2 Differentially Mediates Responses to Ozone/W. A7620 1015 Lung Bioengineering and Direct Pulmonary Cell Therapy Using a Novel Airway Spray Device/S. A7627 the information contained in this program is up to date as of April 16, 2018. A7641 1023 Oxidized Phosphatidylcholine Induces Mitochondrial and Endoplasmic Reticulum Stress in Airway Epithelial Cells/C. A7642 1024 Senescent Lung Fibroblasts Reduce Alveolar Epithelial Cell Regeneration: Implications for Pulmonary Fibrosis/K. A7805 the information contained in this program is up to date as of April 16, 2018. Known office of publication: 55 Elizabeth Street, Hartford, Connecticut 06105-2209. Printing location: Western Newspaper Publishing Company, 537 East Ohio Street, Indianapolis, Indiana 46204. Postmaster: Send address changes to Connecticut Insurance Law Journal, 55 Elizabeth Street, Hartford, Connecticut 06105-2209. It is the policy of the University of Connecticut to prohibit discrimination in education, employment, and in the provision of services on the basis of race, religion, sex, age, marital status, national origin, ancestry, sexual preference, status as a disabled veteran or veteran of the Vietnam Era, physical or mental disability, or record of such impairments, or mental retardation. University policy also prohibits discrimination in employment on the basis of a criminal record that is not related to the position being sought; and supports all state and federal civil rights statutes whether or not specifically cited within this statement. Harvard Law School; Associate Professor of Law and Jeremy Bentham Scholar Richard S. Ioffe Professor of International and Comparative Law and Director, International Programs Joseph A. University at Buffalo School of Law; Assistant Clinical Professor of Law and Supervising Attorney Richard D. Abraham asserts that liability for bad faith is a concept that has existed for roughly half a century despite its inability, as of yet, to be recognized as part of the formal body of insurance law. Abraham details what has been, to some extent, a transmogrification with respect to the bad faith claim handling practices of the insurance industry. What once could be dismissed as nothing more than the occasional isolated incident, or screw up, can now be characterized by incidences of systemic bad faith. Abraham provides four examples, each one highlighting some form of systemic bad faith practice undertaken by an insurer. Abraham closes with a discussion of the uniqueness of the insurer consumer relationship and how that relationship creates obligations of fair dealing for insurers which simply do not exist for other private enterprises. This Article is a slightly revised version of my presentation at Bad Faith and Beyond: A Conference on the Law of Claims Practices, held at Rutgers-Camden Law School on February 29, 2012. Dean Jerry has been generous in preparing a piece commenting on this Article as well. But I also want to try to situate the developments in bad faith law over the past two decades within a larger context. This is a principle that, as my title suggests, does not yet have a name, but that treats insurers as having obligations that are more demanding than those imposed on ordinary contracting parties, though not as demanding as those we impose on governments. An obligation to handle claims fairly is one of the obligations that flows from this principle, though it is not the only one. In the modern state, insurance often falls in between these two poles of private contract and governmentally-provided entitlement. Insurance is brought into being by private contract, but our political system relies on insurance to promote economic well-being and to serve as a social safety net. In a series of separate doctrines and practices insurance law recognizes this, but it has not yet articulated a single principle that reflects what connects them. I suggested that, whereas the field had been much in the flux of early development during the preceding several decades, it was by then becoming stable. I cited a number of reasons for this conclusion, in addition of course to the fact that the field was at that point over thirty 3 years old, and arguably older. Thirty or more years seemed to me to be about the amount of time it takes most sub-fields of law to reach at least the beginning of maturity. In an Article published a decade later, Douglas Richmond chastised me in the opening sentence of his piece for what he took to be my 4 implication that liability for bad-faith was not a severe threat for insurers. To that charge I would reply here that there is a difference between an unstable threat and a stable one. My point was that the field had matured from early instability to the point where it was now merely posing a stable threat to insurers. So what I took to be increasing stability in the field of liability 3 See Abraham, supra note 2, at 1295-1308. From the vantage point of 2012, the most striking feature of the field as it stood in 1994 was that it was almost entirely concerned with claims for what I would call sporadic or isolated bad faith. Sometimes it was alleged that this misbehavior had violated the standards of the insurer in question, and sometimes it was not. And it may well be that at trial the plaintiff made an effort to blame not only the individual claims personnel who had misbehaved, but also to blame their employer, the insurer. But the unstated premise that hung over the majority of bad faith claims in the years running up to 1994 was that these were isolated incidents; that they departed from what ordinarily occurred; and that they reflected a divergence between what the insurer as an entity intended to occur and what had actually occurred. To draw an analogy to products liability, most of the reported cases involved allegations of what appeared to be something like manufacturing defects. But the logical structure of manufacturing defect suits and of sporadic bad-faith claims is parallel. These claims have been based on what some observers have 5 called institutional, or systemic, bad faith. They do not involve allegations that there was a single screwup in the handling of a particular claim. Rather, these are cases in which the insurer is alleged to have adopted a company wide policy of handling claims in a manner that the plaintiff argued constituted bad-faith, even if there was only one actual plaintiff in the bad 5 See. Several, but not all, involve claims for bad-faith claims handling, and one does not involve claims handling at all. But each of them involve what might be called bad faith, and help to make the point that I will develop after I describe them. The suit alleged bad faith against a State Farm liability insurance policyholder after State Farm refused to settle a tort suit 7 against him and the jury returned a verdict in excess of his policy limits. Based on my conversations with them, I can say that the people at State Farm continue to deny that the company had the particular policy that was found to have led to the bad faith claims handling in that case. They have engaged in at least one retreat that I know of in which they brainstormed about how to ensure that the actions that took place in that case do not happen again. They think of what happened as a screwup, as a misapplication of company policy rather than as an application of policy. They are litigated, at least in part, over the question whether there was a company-wide policy that was rotten to the core. They allegedly did this, among other things, by setting claim closure targets that were endorsed by high level management and the Board of the company. There is now a literature addressing whether contingent commissions should or should not be permitted, but no one that I know of 10 has argued that it was okay to keep them secret. The issue is whether an obligation on the part of brokers to disclose the existence of a contingent commission arrangement is sufficient, or whether, instead, such commissions ought to be prohibited outright, at least for the consumer segment of the market, or for all applicants, whether consumer or commercial. It was a secret deal between the broker and the insurer to whom the broker was steering applicants for insurance. I have cited this example, not because I necessarily want to argue that there should be a cause of action of some sort against either the broker or the insurer for damages caused by the wrong, but to suggest that there is a broader principle underlying bad-faith claims than may appear. Liability for bad-faith claims handling is about more than bad-faith claims handling. In the early 1990s, Allstate Insurance Company became concerned about its profit levels. Some of the guidelines for claim valuation were computerized and some claims personnel allegedly adhered slavishly to what the computer told them to do. Now there is nothing necessarily wrong with using computer programs to guide claim valuation, and nothing wrong with trying to cut back on claim payments if they are too high. It certainly is unwise, and it might even be bad faith, to rely only on what a computer tells you a claim is worth. But that was not what was fundamentally wrong with what Allstate is alleged to have done. If you have an acceptable metric for deciding whether you are currently paying too much for a given category of claims, then that metric might appropriately be used to guide claim valuation. Its metric allegedly was how much less it needed to pay in order to make its desired profit. It can decide how much to charge you for coverage based in part on how much it needs to charge in order to make an acceptable profit. This is what is sometimes referred to as the Royal Globe problem, after the 1979 California case holding that 13 there is such a duty. But the Royal Globe rule is dead, and with the exception of a very few isolated cases, that is not the law.

The Optic Nerve 345 Early changes Late changes Differential Diagnosis Blurring of the optic disc margin is seen commonly in cases of: 1 gastritis acid diet effective 100mg macrobid. Etiology It is due to the involvement of posterior ciliary artery and may be central retinal artery causing infarcts of the anterior part of the optic nerve and retina gastritis diet âêîíòàêòå order cheapest macrobid. Optic disc Difference of 2-6 D between the Difference is usually not vessels on top of the disc and more than 2-3D chronic gastritis management purchase genuine macrobid on line. Vessels Marked venous dilatation gastritis enteritis macrobid 100mg overnight delivery, Venous dilatation and haemorrhages and exudates exudates are less marked iv gastritis symptoms pain order discount macrobid on-line. Fluorescein Vertical oval pool of dye due to Minimum leakage of dye angiography leakage 7 gastritis diet 4 rewards purchase cheap macrobid line. Central nervous Presence of headache, projectile Presence of numbness, system involvement vomiting paresthesia, weakness and (raised intracranial pressure) incoordination of limbs (demyelinating disease) 8. Pathogenesis There are inflammatory changes in the nerve (true optic neuritis) or in the sheath (perineuritis). There is no effective treatment for idiopathic and hereditary optic neuritis and that associated with demyelinating disorders. Oral prednisolone therapy alone is contraindicated in the treatment of acute optic neuritis, since it was not shown to improve visual outcome and recurrence rate is high with this regime. If the brain shows lesions supportive of multiple sclerosis, the patient should receive immediate intravenous methylprednisolone (1 gm daily) for 3 days followed by oral prednisolone (1 mg/kg/day) for 11 days. Common causes of sudden Sudden, profound loss of vision is the most common painful loss of vision presenting complaint. This process of swinging of light to and fro across the pupils is repeated several times so that there are equal impulses sent to the midbrain via the optic nerves. Early loss of colour vision and contrast sensitivity may be present due to involvement of optic nerve. When one eye is said to be blind and there is absence of objective signs, following tests can be done. The Optic Nerve 351 It is frequently bilateral and has a chronic course with permanent visual deterioration. Pathogenesis There is degeneration of the ganglion cells of the retina specially in the macular region. Central vision is impaired so that there is difficulty in reading and doing near work. It involves several persons at a time consuming the wood alcohol from the same source. The clinical features include those of optic neuritis, optic atrophy and retinopathy. Fundus examination shows pale and atrophic disc with contracted retinal vessels and oedema. A mild pigmentary disturbance leads to the characteristic bullseye lesion in the macular area. There is widespread retinal atrophy with clumps of pigment and attenuated retinal vessels seen in the Chloroquine amblyopia later stage. There is increased risk of vascular occlusion particularly in women who are suffering from hypertension, migraine or other vascular diseases. Common causes of optic atrophy Pathogenesis There is destruction of nerve fibres along with overgrowth of glial connective tissue. Primary (Simple) Optic Atrophy the lesion is proximal to the disc so there are no signs of local inflammation. There is shallow, saucer-shaped atrophic cupping due to degeneration of nerve fibres. Secondary Optic Atrophy Etiology It follows any injury or direct pressure to the optic nerve from lamina cribrosa to the lateral geniculate body. Consecutive Optic Atrophy Etiology Extensive retinal diseases cause ganglion cell destruction as occurs in retinitis pigmentosa and occlusion of central retinal artery. Ischaemic Optic Atrophy Postneuritic optic atrophy Etiology It is due to the central retinal artery occlusion. Toxic Optic Atrophy It has been already discussed under toxic amblyopias (page 350). Glaucomatous Optic Atrophy It has been already discussed under glaucomatous optic disc changes (page 267). In complete or total optic atrophy, the person is blind with no perception of light. Visual field shows concentric contraction with depression of central vision in initial stages with or without scotomata. The prognosis is good because of the slow growth and peripheral situation of the tumour. Medullated (Opaque) Nerve Fibres Normally the myelin sheaths of optic nerve stop at the lamina cribrosa. Occasionally patches of nerve fibres regain these sheaths after they have passed through the lamina cribrosa. The common causes of injury in the children include playing with bow and arrow, throwing stones, ball, sharp pointed objects like pen, pencil, stick, etc. An eye injury is an emergency and requires immediate medical or surgical treatment. There is great irritation and gritty feeling if the foreign body is embedded in the cornea. Foreign body is visible on the bulbar conjunctiva, limbus, cornea, sulcus subtarsalis and fornix by the naked eye, oblique illumination with a loupe or slit-lamp examination. If in the conjunctiva, it is picked up by a needle after application of local anaes Foreign body spud thetic. Educative means are used such as safety first notices and lectures by the welfare officials in the factories. The burn injury can be caused by hot water, steam, hot ashes, explosive powder, molten metals, etc. These can cause considerable damage to the eye because they tend to penetrate deeper. They cause necrosis of the surface epithelium in a few seconds with occlusion of the limbal vasculature. This leads to a diminished vascularity of the anterior segment, corneal opacification and melting, cataract and symblepharon. These are less serious than alkalis burns because they coagulate the surface proteins and do not penetrate the eye. A glass rod well-coated with a lubricant or ointment is swept around the upper and lower fornix several times a day to break and prevent the formation of adhesions. If cornea is not involved, steroid drops and ointments should be used to prevent symblepharon formation and to reduce congestion and chemosis of the conjunctiva. Conjunctivitis caused by lacrimatory gases is treated by irrigation with bland lotion, normal saline, 3% soda bicarbonate or clean water. Blood staining of the cornea is due to associated haemorrhage into the anterior chamber with raised tension. This may lead to subconjunctival dislocation, expulsion or dislocation of lens in vitreous cavity. It contracts and forms a minute ball which sinks to the bottom of the anterior chamber. An accumulation of fluid marks out the star-shaped cortical sutures and lens fibres. Proliferative retinopathy usually occurs following large haemorrhage in the vitreous. A perforating injury is likely to cause severe and serious damage to the eye due to the immediate trauma and the infection. Signs of Perforation of the Eyeball Any one or combination of the following suggest global perforation: 1. Hole in the iris as confirmed by transillumination Common sites for retention of 8. Wound track in the corneal, lens or vitreous an intraocular foreign body Aim of Treatment the main aim of the treatment is: i. It is very important to free the uveal tissue from the corneal or corneoscleral wound. Close follow-up with topical antibiotics, atropine and corticosteroids is essential. The retained foreign body causes damage to the eye depending on its size and velocity. Occasionally, it may pierce the coats of the eye and stay in the orbital tissue which is known as the double perforation. The small flying metallic particles are usually sterile due to the heat generated partly on their emission. They cause degenerative changes known as siderosis bulbi and chalcosis respectively.

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