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If market participants are left out of the settlement and the settlement imposes costly measures on those who agree to 5 medications that affect heart rate order cheap topamax online it medications 4 less canada buy topamax 200 mg otc, the firms and individuals not covered will have a cost advantage over those who do participate medicine merit badge order topamax cheap online. Finally, regulation by litigation is most likely to occur when the regulators can persuade the regulated to agree to a 110 Engage Vol. The chain of accountability is weak, but at least in some egregious cases regulators have been forced to back off from over-reaching. Regulators are well aware that their actions may be challenged in court and so behave more carefully than they would if their decisions were not reviewable. Again, the check is imperfect, particularly given the deference courts often grant agency interpretations of statutory authority, but the ability to challenge regulatory measures in courts remains a key restraint on agency action. Regulators can choose among traditional rulemaking, negotiated rulemaking, and regulation by litigation as the means to impose constraints on private actors. Heavy Duty Diesel Engines Federal regulation of air pollution sources is built on the combination of national air quality standards and specific source regulation. Heavy duty engines are thus tested in the laboratory, rather than on the road, using a test protocol that specifies exactly how the engine is to be operated during the test. When Congress amended the Clean Air Act in 1977, it tightened the standards for heavy duty diesel engines. In doing so, Congress also added a provision that required that each new set of heavy duty engine standards apply to at least three model years, giving engine manufacturers time to recover the costs of meeting one set of standards before having to develop new technology to meet the next set. First, the model may fail to accurately forecast emissions because it oversimplifies. For example, the model hardwires in a preference for centralized inspection and maintenance programs over decentralized programs. This gives the former twice the emissions reduction credits it awards the latter, despite a lack of hard evidence that centralized ones produce twice the emissions reductions. The solution to this problem was to raise the stakes to the point where the engine companies could not afford to take a chance on the outcome. If they could not use the controller technique, their engines would operate much less efficiently. The requirement to meet the 2004 standards fifteen months early left the engine manufacturers scrambling. Trucking companies were not interested in untested technology that promised to be more expensive to operate (lower mileage), and which offered no new benefits for them. This led to what one industry observer termed "one of the biggest boom and bust scenarios for the diesel engine manufacturer. This bulge is still working its way through fleets, as many heavy duty engines operate for ten years or more. After all, just a few years earlier the agency had joined with the California state air quality regulators and the engine manufacturers to negotiate a "Statement of Principles" intended to provide a cooperative framework for regulation for the coming decade. Regulatory changes made at the end of an administration are vulnerable to changes by the incoming administration; litigation is generally considered politically untouchable. If the controller issue went from being framed internally as a problem to be solved looking forward to one framed as a need to punish bad past behavior, the top agency decision makers would choose different actions as appropriate. Off-the-record descriptions of the agency meetings with industry provided to us by a number of participants suggest that just such a shift occurred. The agency resorted to regulation by litigation to solve a problem created in part by the imposition of an important constraint on agency regulatory authority by Congress: the lead time provision of the Clean Air Act. Choosing litigation rather than rulemaking freed the agency to do something Congress had explicitly forbidden it to do. Regulation by litigation thus offers regulators an alternate means of achieving their goals, freed from constraints imposed on rulemaking. Dust Litigation Private parties, not just public agencies, can regulate through litigation. Almost a century of litigation over dust in the workplace shows how private lawsuits can sometimes evolve into regulatory efforts.

The volume of distribution is best considered the "apparent V D" because it represents the apparent volume needed to treatment laryngomalacia infant order topamax on line contain the entire amount of the drug symptoms 4dpo topamax 200 mg generic, assuming that the drug is distributed throughout the body at the same concentration as in the plasma symptoms celiac disease generic 100 mg topamax amex. Table 26-1 lists pharmacokinetic data for 20 commonly used drugs from several drug classes, demonstrating the wide variation in V D. Thus, digoxin can be seen to have a large V D (>5 L), whereas valproic acid has a relatively small V D (0. Drugs are removed from the body by two major mechanisms: hepatic elimination, in which drugs are metabolized in the liver and excreted through the biliary tract, and renal elimination, in which drugs are removed from the circulation by either glomerular filtration or tubular secretion. For the vast majority of drugs, the rates of hepatic and renal elimination are proportional to the plasma concentration of the drug. The efficiency of elimination can be described by assessing how the drug clears from the circulation. Drug clearance is a measure of the volume of plasma cleared of drug per unit of time. It is similar to the measurement used clinically to assess renal function-the creatinine clearance-which is the volume of plasma from which creatinine is removed per minute. Total drug clearance (Cltot) is the rate of elimination by all processes (Eltot) divided by the plasma concentration of the drug (Cp): Drugs may be cleared by several organs, with renal and hepatic clearance being the two major mechanisms. Total drug clearance (Cltot) can therefore be best described as the sum of clearances by each organ. For must drugs this is essentially the sum of the renal and hepatic clearance: Table 26-1 demonstrates the wide variation in clearance values among commonly used medications, with some drugs. Amikacin, gentamicin, and tobramycin are almost entirely cleared by the kidneys, whereas drugs such as aspirin, carbamazepine, and phenytoin are cleared less than 5% by the kidneys. Drug clearance is affected by several factors, including (1) blood flow through the organ of clearance; (2) protein binding to the drug; and (3) the activity of the clearance processes in the organs of elimination. Drug clearance is not affected by distribution of drug throughout the body (V D) because clearance mechanisms act only on drug in the circulation. The amount of time needed to eliminate a drug from the body depends on both the clearance and the volume of distribution. The first-order elimination constant (ke) represents the proportion of the apparent volume of distribution that is cleared of drug per unit of time during the exponential disappearance of drug from the plasma over time (elimination phase). Figure 26-2 Representative "concentration versus time" plot used in pharmacokinetic studies where concentration of drug is plotted with a logarithmic scale on the ordinate and time is plotted with a linear scale on the abscissa. The resultant curve is seen to have two phases: the distribution phase, the initial portion of the plotted line when the concentrations of drug decrease rapidly; and the elimination phase, the later phase when there is exponential disappearance of drug from the plasma with time. During the elimination phase, the half-life can be calculated as the time it takes to decrease the concentration by half (shown here as the time needed to decrease from concentration Ca to Ca). The value of this constant for a particular drug can be determined by plotting drug concentration versus time on a log-linear plot (see. The time needed to eliminate the drug is best described by the drug half-life (t), which is the time required during the elimination phase (see. Mathematically, the half-life is equal to the natural logarithm of 2 (representing a reduction of drug concentration to half) divided by ke. Substituting for ke from equation 4 and calculating the natural logarithm of 2, the half-life can therefore be represented by the following equation: From this equation one can therefore predict that, at a given clearance, as the V D increases, the half-life increases. Because disease affects the V D and clearance differently, the half-life may increase, decrease, or not change much. Thus, by itself, the half-life is not a good indicator of the extent of abnormality in elimination. The half-life is useful to predict how long it takes for a drug to be eliminated from the body. Thus, for any drug that has a first-order elimination, one would expect that by the end of the first half-life the drug would be reduced to 50%, by the end of the second half-life to 25%, by the end of the third half-life to 12. In general, a drug can be considered to be essentially eliminated after three to five half-lives when less than 10% of the effective concentration remains. Table 26-1 demonstrates the wide variation in half-life for several commonly used drugs. To attain a desired therapeutic concentration rapidly, a loading dose is often used.

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Prerequisite(s): Any course in art history or art studio medicine rising appalachia lyrics buy topamax with visa, or permission of instructor treatment shingles order topamax overnight. Notes: Requires students to medications ok for dogs effective topamax 100 mg work collaboratively and make several field trips, including one Saturday bus trip to New York. Emphasizes role of material evidence in the creation of the South Asian history and how political, social, and religious developments affected the arts. Discusses monuments and artifacts in a variety of media in relation to historical contexts. Lectures and discussions focus on material culture of the great civilizations that arose within borders of modern Thailand, Cambodia, Indonesia, Burma (Myanmar), Vietnam, Laos, and Malaysia. Discusses monuments and artifacts in a variety of media in relation to social and historical contexts. Notes: Strongly recommended for advanced art history students seeking exposure to professional work in visual arts. Notes: A maximum of 6 credits may be applied to the major or minor with permission of the program. May focus on a particular period, region, or medium, or may explore cultural interconnections within medieval Eurasian world. Topics may be monographic, thematic, or concentrated on the art of a smaller time period or a particular area. George Mason University 2016-2017 Official University Catalog 1852 Designated as a research and scholarship intensive course. Course may focus on a specific period, region, movement, medium, or theoretical issue, or explore cultural connections and transfer between regions. Focus on particular theme, region, artist, or medium, or take a comparative approach. May focus on the art of a particular period, movement, reign, or region, as well as theoretical issues or works in a particular medium. George Mason University 2016-2017 Official University Catalog 1854 Notes: May be repeated for a maximum of 6 credits when topic is different. The 3 credits of readings should be taken before the 3 research credits, or they may be taken concurrently. Notes: Students must have completed at least one course in the field, or with the professor, chosen for these honors courses. Select particular artifacts, works of art, or group of objects and undertake original research, and bring objects from storage to publication to exhibition. Teaches visual and contextual analysis skills as well as critical thinking about and documentation of primary and secondary sources. Examines the role of decorative arts in the formation of identity of the elite in Renaissance Italy as well as Renaissance France and England. Also concentrates on European decorative arts from seventeenth and eighteenth centuries, with emphasis on Paris and London. Students will examine a variety of theories and methods for analyzing objects through assigned readings, class discussions, and short writing assignments. Project to be arranged by student in consultation with faculty instructor and field supervisor. Notes: Recommended for advanced art history students seeking exposure to professional work in visual arts. Participants review the current field through lectures, focused readings and group discussions with relevant faculty member. Offers different tools and viewpoints for each approach to analyze and understand decorative arts. Covers connoisseurship issues such as identifying materials and techniques, fakes, forgeries, repairs, reproductions. Arts may include tapestries, pottery and ceramics, silver, furnishing, jewelry and metalwork, glass as well as distinctive stylistic periods. Administrators, curators, conservators, educators, editors, among others, work with students to expand their knowledge of how museums function. Covers history of interiors, furniture and architecture, and theories of design and design composition. George Mason University 2016-2017 Official University Catalog 1861 Notes: May be repeated for credit with topic is different. Topics vary, but course entails extensive critical readings and discussion, development of bibliographies, and advanced-level research papers.

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As the costs of mandates rise medicine used for anxiety 200mg topamax otc, more firms seek to medicine 8 - love shadow generic topamax 100mg mastercard self-insure to symptoms 14 dpo purchase generic topamax from india avoid the added expe nse of state mandates, but some smaller businesses do not have the necessary capital to do so. As stop -loss insurance with lo w attach ment points has made selfinsurance available on a broader basis, this problem has become less significant. See Kanwit 6/25 at 37; Gitterman 6/25 at 15 ("One of the things that you have seen in the 1996 mental health parity debate is the incredible wide range of estimates from each of these different consulting groups. The substantial tax subsidy for employment-based health insurance encourages broader and deep er insura nce coverage than wo uld otherwise be the case. As Commission staff explained in its most recent advocacy letter on this issue, Empirical evaluations of any willing provider and "freedom of choice" provisions indicate that these policies result in higher health care expenditures. One study found that states with highly restrictive any willing provider/freedom of choice laws spent approximately 2% more on healthcare than did states without such policies. This finding likely reflects the fact that these laws reduce the ability of insurers to offer less expensive plans with limited provider panels. Bartley, Representative (May 30, 1989)); New Hampshire (Letter from Office of Consumer & Competition Advocacy, to Paul J. Alexander, Representative (May 10, 1993)); and Nevada (Letter from Bureau o f Com petition, to David A. Some of the models may be more credible and provide more objective information than others. For mandates to improve the efficiency of the health insurance market, state and federal legislators must be able to identify services the insurance market is not currently covering for which consumers are willing to pay marginal cost. The Unfunded Mandates Reform Act discourages Congress from imposing unfunded mandates on other See. In practice, mandates may limit consumer choice, eliminate product diversity, and raise the cost of health insurance. Mandates may also increase the number of uninsured Americans, as employers and employees opt out of the market. State and federal policy makers should consider expressly factoring these risks into their decision making process, and develop ways of insulating the process of mandating benefits from their effects. Indeed, research shows that truthful and non-misleading advertising generally benefits consumers by providing them with useful information about their health care and treatment options. A com plete list of participants on these and other panels is available infra App endix A and in the Agenda, at. These issues were also considered at a workshop held by the Commission on September 10, 200 2. A comp lete list of participants in the workshop is available infra Appendix A and at. Scientists can more effectively design medicines to attack specific diseases, resulting in the invention of new medicines. Centers for M edica re & Medica id Services, Health A ccounts: National H ealth Expenditures 1965-2013, History and Projections by Type of Service and Source of Funds: Calendar Years 1965-2013, at. From 1990 to 2001, annual R&D spending in the pharmaceutical industry increased from $8 billion to $30 billion. One study conducted by Edwin Mansfield analyzed a random sample of 100 firms, excluding very small firms, from twelve broadly defined industries. The pharmaceutical industry participants reported that "60% of inventions would not have been developed and 65% would not have been commercially introduced absent patent protection. Winter analyzed survey responses from 650 R&D managers representing 130 lines of business. This study found patents were especially important in the pharmaceutical drug industry to prevent duplication. Walsh found that in the pharmaceutical industry patents were effective appropriability mechanisms for more than 50% of all product innovations. Brandname companies can spend 10-15 years on development for a new drug before the product enters the market. Glover, Competition in the Pharmaceutical Marketplace 3 (3/19/02) (stating that the average cost to develop a new drug is $802 million) [hereinafter Glover (stmt)], at.