Hiding Behind Policy: Confusing Compensation With Indemnification

In PPG Industries, Inc. v. Transamerica Insurance CO., the California Supreme Court held that an insurer may not indemnify its insured for a punitive damages judgment in a third party action. Even if the excess judgment is the result of the insurer\u27s bad faith breach of its duty to settle a third party action on behalf of its insured, an insured may not recover if it seeks compensatory damages that include a punitive damages judgment. The California Supreme Court found that to conclude otherwise would violate California\u27s long established public policy precluding indemnification of punitive damages. This Note examines the faulty reasoning in the California Supreme Court\u27s decision. Part II briefly discusses relevant principles of insurance law. Part III outlines the facts underlying PPG Industries, Inc. v. Transamerica Insurance Co., including the initial Colorado lawsuit that evolved into the case ultimately presented to the California Supreme Court. Part IV explains the procedural history of the case, including the California Court of Appeal\u27s opinion and PPG Industries, Inc.\u27s appeal to the California Supreme Court. Part V details the California Supreme Court\u27s analysis and its focus on California\u27s public policy against indemnification of punitive damages. Part VI discusses Justice Mosk\u27s heated dissent and his opposition to what he viewed as the majority\u27s apparent favoritism of insurers. Finally, Part VII criticizes the California Supreme Court for ignoring PPG Industries, Inc.\u27s allegations that it was entitled to recover consequential damages arising from Transamerica\u27s bad faith failure to settle a third party claim, thereby setting a precedent that allows insurers to escape liability for their own tortious conduct

Hiding Behind Policy: Confusing Compensation With Indemnification

In PPG Industries, Inc. v. Transamerica Insurance CO., the California Supreme Court held that an insurer may not indemnify its insured for a punitive damages judgment in a third party action. Even if the excess judgment is the result of the insurer\u27s bad faith breach of its duty to settle a third party action on behalf of its insured, an insured may not recover if it seeks compensatory damages that include a punitive damages judgment. The California Supreme Court found that to conclude otherwise would violate California\u27s long established public policy precluding indemnification of punitive damages. This Note examines the faulty reasoning in the California Supreme Court\u27s decision. Part II briefly discusses relevant principles of insurance law. Part III outlines the facts underlying PPG Industries, Inc. v. Transamerica Insurance Co., including the initial Colorado lawsuit that evolved into the case ultimately presented to the California Supreme Court. Part IV explains the procedural history of the case, including the California Court of Appeal\u27s opinion and PPG Industries, Inc.\u27s appeal to the California Supreme Court. Part V details the California Supreme Court\u27s analysis and its focus on California\u27s public policy against indemnification of punitive damages. Part VI discusses Justice Mosk\u27s heated dissent and his opposition to what he viewed as the majority\u27s apparent favoritism of insurers. Finally, Part VII criticizes the California Supreme Court for ignoring PPG Industries, Inc.\u27s allegations that it was entitled to recover consequential damages arising from Transamerica\u27s bad faith failure to settle a third party claim, thereby setting a precedent that allows insurers to escape liability for their own tortious conduct

Monocyte-driven atypical cytokine storm and aberrant neutrophil activation as key mediators of COVID-19 disease severity.

Epidemiological and clinical reports indicate that SARS-CoV-2 virulence hinges upon the triggering of an aberrant host immune response, more so than on direct virus-induced cellular damage. To elucidate the immunopathology underlying COVID-19 severity, we perform cytokine and multiplex immune profiling in COVID-19 patients. We show that hypercytokinemia in COVID-19 differs from the interferon-gamma-driven cytokine storm in macrophage activation syndrome, and is more pronounced in critical versus mild-moderate COVID-19. Systems modelling of cytokine levels paired with deep-immune profiling shows that classical monocytes drive this hyper-inflammatory phenotype and that a reduction in T-lymphocytes correlates with disease severity, with CD8+ cells being disproportionately affected. Antigen presenting machinery expression is also reduced in critical disease. Furthermore, we report that neutrophils contribute to disease severity and local tissue damage by amplification of hypercytokinemia and the formation of neutrophil extracellular traps. Together our findings suggest a myeloid-driven immunopathology, in which hyperactivated neutrophils and an ineffective adaptive immune system act as mediators of COVID-19 disease severity

Patients with cancer experience high impact of emotional consequences of reduced ability to eat: A cross sectional survey study.

OBJECTIVE: Patients with cancer can experience emotional consequences of reduced ability to eat, their impact is unknown. This study assesses the impact of these emotional consequences, and patients' satisfaction with healthcare professionals' (HCPs) support. METHODS: A cross-sectional survey was conducted among patients with head/neck, lung cancer and lymphoma, who experienced reduced ability to eat in the past year. Patients were recruited through patient organisations and hospitals. The questionnaire encompassed the impact of emotional consequences of reduced ability to eat (scale 1-10) and satisfaction with HCPs' support for reduced ability to eat (scale 1-10). The differences in patient characteristics between unsatisfied (Score < 6) and satisfied patients (score ≥6) were tested using independent t-tests and the chi-square or Fishers' exact tests. RESULTS: Overall, 116 patients (48%) responded and 98 were included in the analyses. The most impactful emotional consequences were as follows: disappointment (mean ± SD: 8.31 ± 1.49), grief/sadness (7.90 ± 1.91), and anger (7.87 ± 1.41). Patients were less satisfied when more time had passed since their diagnosis (p < 0.002) and when they expected no improvements regarding their eating problems (p < 0.001). CONCLUSION: The impact of emotional consequences of reduced ability to eat is high. Support for emotional consequences is needed, especially for patients with reduced ability to eat, which persists in recovery and remission

The Euroflow PID Orientation Tube in the diagnostic workup of primary immunodeficiency: Daily practice performance in a tertiary university hospital

IntroductionMultiparameter flow cytometry (FCM) immunophenotyping is an important tool in the diagnostic screening and classification of primary immunodeficiencies (PIDs). The EuroFlow Consortium recently developed the PID Orientation Tube (PIDOT) as a universal screening tool to identify lymphoid-PID in suspicious patients. Although PIDOT can identify different lymphoid-PIDs with high sensitivity, clinical validation in a broad spectrum of patients with suspicion of PID is missing. In this study, we investigated the diagnostic performance of PIDOT, as part of the EuroFlow diagnostic screening algorithm for lymphoid-PID, in a daily practice at a tertiary reference center for PID. MethodsPIDOT was tested in 887 consecutive patients suspicious of PID at the Ghent University Hospital, Belgium. Patients were classified into distinct subgroups of lymphoid-PID vs. non-PID disease controls (non-PID DCs), according to the IUIS and ESID criteria. For the clinical validation of PIDOT, comprehensive characterization of the lymphoid defects was performed, together with the identification of the most discriminative cell subsets to distinguish lymphoid-PID from non-PID DCs. Next, a decision-tree algorithm was designed to guide subsequent FCM analyses. ResultsThe mean number of lymphoid defects detected by PIDOT in blood was 2.87 times higher in lymphoid-PID patients vs. non-PID DCs (p < 0.001), resulting in an overall sensitivity and specificity of 87% and 62% to detect severe combined immunodeficiency (SCID), combined immunodeficiency with associated or syndromic features (CID), immune dysregulation disorder (ID), and common variable immunodeficiency (CVID). The most discriminative populations were total memory and switched memory B cells, total T cells, TCD4+cells, and naive TCD4+cells, together with serum immunoglobulin levels. Based on these findings, a decision-tree algorithm was designed to guide further FCM analyses, which resulted in an overall sensitivity and specificity for all lymphoid-PIDs of 86% and 82%, respectively. ConclusionAltogether, our findings confirm that PIDOT is a powerful tool for the diagnostic screening of lymphoid-PID, particularly to discriminate (S)CID, ID, and CVID patients from other patients suspicious of PID. The combination of PIDOT and serum immunoglobulin levels provides an efficient guide for further immunophenotypic FCM analyses, complementary to functional and genetic assays, for accurate PID diagnostics

The Euroflow PID Orientation Tube in the diagnostic workup of primary immunodeficiency: Daily practice performance in a tertiary university hospital

IntroductionMultiparameter flow cytometry (FCM) immunophenotyping is an important tool in the diagnostic screening and classification of primary immunodeficiencies (PIDs). The EuroFlow Consortium recently developed the PID Orientation Tube (PIDOT) as a universal screening tool to identify lymphoid-PID in suspicious patients. Although PIDOT can identify different lymphoid-PIDs with high sensitivity, clinical validation in a broad spectrum of patients with suspicion of PID is missing. In this study, we investigated the diagnostic performance of PIDOT, as part of the EuroFlow diagnostic screening algorithm for lymphoid-PID, in a daily practice at a tertiary reference center for PID. MethodsPIDOT was tested in 887 consecutive patients suspicious of PID at the Ghent University Hospital, Belgium. Patients were classified into distinct subgroups of lymphoid-PID vs. non-PID disease controls (non-PID DCs), according to the IUIS and ESID criteria. For the clinical validation of PIDOT, comprehensive characterization of the lymphoid defects was performed, together with the identification of the most discriminative cell subsets to distinguish lymphoid-PID from non-PID DCs. Next, a decision-tree algorithm was designed to guide subsequent FCM analyses. ResultsThe mean number of lymphoid defects detected by PIDOT in blood was 2.87 times higher in lymphoid-PID patients vs. non-PID DCs (p < 0.001), resulting in an overall sensitivity and specificity of 87% and 62% to detect severe combined immunodeficiency (SCID), combined immunodeficiency with associated or syndromic features (CID), immune dysregulation disorder (ID), and common variable immunodeficiency (CVID). The most discriminative populations were total memory and switched memory B cells, total T cells, TCD4+cells, and naive TCD4+cells, together with serum immunoglobulin levels. Based on these findings, a decision-tree algorithm was designed to guide further FCM analyses, which resulted in an overall sensitivity and specificity for all lymphoid-PIDs of 86% and 82%, respectively. ConclusionAltogether, our findings confirm that PIDOT is a powerful tool for the diagnostic screening of lymphoid-PID, particularly to discriminate (S)CID, ID, and CVID patients from other patients suspicious of PID. The combination of PIDOT and serum immunoglobulin levels provides an efficient guide for further immunophenotypic FCM analyses, complementary to functional and genetic assays, for accurate PID diagnostics.Transplantation and immunomodulatio

High dimensional profiling identifies specific immune types along the recovery trajectories of critically ill COVID19 patients

The COVID-19 pandemic poses a major burden on healthcare and economic systems across the globe. Even though a majority of the population develops only minor symptoms upon SARS-CoV-2 infection, a significant number are hospitalized at intensive care units (ICU) requiring critical care. While insights into the early stages of the disease are rapidly expanding, the dynamic immunological processes occurring in critically ill patients throughout their recovery at ICU are far less understood. Here, we have analysed whole blood samples serially collected from 40 surviving COVID-19 patients throughout their recovery in ICU using high-dimensional cytometry by time-of-flight (CyTOF) and cytokine multiplexing. Based on the neutrophil-to-lymphocyte ratio (NLR), we defined four sequential immunotypes during recovery that correlated to various clinical parameters, including the level of respiratory support at concomitant sampling times. We identified classical monocytes as the first immune cell type to recover by restoration of HLA-DR-positivity and the reduction of immunosuppressive CD163 + monocytes, followed by the recovery of CD8 + and CD4 + T cell and non-classical monocyte populations. The identified immunotypes also correlated to aberrant cytokine and acute-phase reactant levels. Finally, integrative analysis of cytokines and immune cell profiles showed a shift from an initially dysregulated immune response to a more coordinated immunogenic interplay, highlighting the importance of longitudinal sampling to understand the pathophysiology underlying recovery from severe COVID-19