Stress

The Biology of STRESS

Today’s post is the first in a multi-part series about stress, covering first the biology of stress and the effects of chronic stress on the body.

 

     Stress is a term that is commonly used to explain — or explain away — much in our world.  We live in a time of multifactorial stress: the economy; keeping, losing or getting jobs; housing, food, medical and dental care; personal and familial safety; fear or anger over political or governmental decisions; injuries and/or disabilities. At times, stress can be overwhelming when it seems we are losing control over our lives and our futures.

     The following is an overview of the biology of stress to help better understand how stress can control such a large part of our health. There are many types of stress and those will be investigated after first laying out a basic understanding of what stress is and the physiologic mechanisms of stress.

 

The term stress is derived from the Latin word stringere, “to draw tight.”

 

     The term stress is derived from the Latin word stringere, “to draw tight.” It had been used almost solely in the field of physics to define the internal distribution of a force exerted on a material body, resulting in strain — or stress — such as a rubber band pulled tautly.  In the 1920s, stress started to be used in both biology and psychology, referring to a mental strain or a harmful external agent that could cause illness. Interestingly, in an early example, researcher Walter Cannon used the term strain/stress in 1926 to refer to external factors that disrupted homeostasis.1 

     The idea of stress and homoeostasis is intriguing for it is widely known that the incredible human system strives to maintain homeostasis, or equilibrium. So, it makes great sense that maintaining equilibrium is central to the idea of stress. This is true with all biological and most biochemical processes. The body always attempts to maintain this steady state of being; however, environmental factors, internal or external, continually challenge and disrupt this equilibrium (homeostasis) causing the body to constantly strive for balance. Environmental factors causing the body continued strife are generally called stress. Stress can be simply moments or events from which the body returns to equilibrium or it can turn into chronic stress where the body is constantly trying to reach homeostasis against resistance.

     The balance of our body systems can be disrupted (stressed) by events from such disparate sources as a life-threatening situation or a simple insult, resulting in disequilibrium. Stress can bring on a cascade of biological reactions as the body attempts to bring the body/mind back to equilibrium, using incredible energy and resources in the process. The body’s fight or flight response recruits the body’s energy stores and focuses all resources on overcoming the event challenging homeostasis. Chronic stress can start a chain of events, called a cascade, within us.  Whether stress is from internal or external forces, or both, we can become ill or, if already ill or injured, we can become worse as a result of stress in our lives.

     Hans Selye in his book, The Stress of Life, (New York: McGraw-Hill, 1956 – still considered a standard and oft cited in review of the stress literature but, unfortunately, out of print today) described stress as something that “…in addition to being itself, was also the cause of itself, and the result of itself.”  First to use the term in a biological context, Selye continued to define stress as “the non-specific response of the body to any demand placed upon it.”

 

The intensity and duration of stress changes depending on the circumstances and emotional condition of the person suffering from it.

 

     The intensity and duration of stress changes depending on the circumstances and emotional condition of the person suffering from it. Both negative and positive stressors can lead to stress. Some stressors might include: the workplace, unemployment, or performance pressure stress from project deadlines; noise, temperatures, or environmental issues including a lack of control over environmental circumstances; food, air and/or water quality, housing, health, or mobility; struggles with difficult individuals, relationship problems, or major life events, such as injury or disability.

     Stress in humans is a method of reacting to difficult and possibly dangerous situations. The “fight-or-flight” response when one perceives a threat helps the body exert energy to fight or run away. In the fight-or-flight response the adrenal glands release epinephrine, causing the blood vessels to constrict and heart rate to increase. Cortisol (to be discussed in detail later) is released in stress and its purpose is to raise the glucose levels in the blood. Glucose is the main energy source for human cells and its increase during time of stress gives immediate energy for overactive cells. The release of these hormones is intended to be temporary. Someone under stress for long periods of time may have adverse health effects later on, such as hypertension and increased risk of cardiovascular disease. The biology of stress is very similar to that described, albeit in less detail, in our three part article on Worry (May 2012).

 

In the physiology of stress, the central nervous system works closely with the body’s endocrine system to regulate mechanisms of equilibrium.

 

     In the physiology of stress, the central nervous system works closely with the body’s endocrine system to regulate mechanisms of equilibrium. The sympathetic nervous system (nerves responsible for regulating many homeostatic mechanisms) becomes primarily active during a stress response, regulating many of the body’s functions in ways that make the body more adaptive to its environment.  The brain works in network carrying information about a stressful situation across many regions of the brain and back.

     The major players of stress in the brain include: the hypothalamus, the amygdala, the hippocampus, the pituitary gland and regions of the brain called locus coreruleus and rafe nucleus. The hypothalamus is located above the brainstem. Its primary function is to help link the body’s nervous and endocrine systems using neural inputs and outputs to and from other regions of the brain to make regulated secretions of hormones into the body’s blood stream. It has a far-reaching and long-lasting effect on physiological processes such as metabolism. During a stress response, the hypothalamus secretes corticotropin-releasing hormone that stimulates the pituitary gland initiating regulated stress response pathway.

     The amygdala, part of the brain’s limbic system, is part of this neural network and plays a role in the processing of emotions in the stress response mechanisms of anxiety or fear (as discussed in the article “Worry” May 2012).

     The hippocampus, also a part of the brain’s limbic system, plays an important role in memory formation. The hippocampus includes networks from the cerebral cortex, hypothalamus, and amygdala. During stress, the hippocampus responds in cognitive processes such as prior memories that can have a great influence on enhancing, suppressing, or even independently generating a stress response, as in PTSD.  The hippocampus is an area in the brain that is susceptible to damage brought upon by chronic stress.

     The locus coreruleus is the principle site of synthesis of the neurotransmitter norepinephrine which plays an important role in the sympathetic nervous system’s fight-or-flight response to stress. The rafe nucleus primarily synthesizes the neurotransmitter serotonin, whose role is mood regulation, particularly when stress is associated with depression and anxiety.  It may also play a part in modulating the sensation of pain. The pituitary gland is located at the base of the brain just under the hypothalamus and releases various hormones that play significant roles in regulating homeostasis. During a stress response, the pituitary gland releases hormones into the blood stream that modulate stress response systems.

     Additional players include the adrenal glands and the spinal cord. The adrenal gland is a major organ of the endocrine system, located directly on top of the kidneys, and is chiefly responsible for the synthesis of stress hormones released into the blood stream during a stress response. Cortisol is the major stress hormone released by the adrenal gland.  The adrenal gland can also release norepinephrine during a stress response. Here, norepinephrine acts as a hormone in the endocrine system.

     The spinal cord has a critical role in transferring stress response neural impulses from the brain to the rest of the body. In addition to the blood hormone signaling system initiated by the hypothalamus, the spinal cord communicates to the rest of the body by innervating the peripheral nervous system (nerves outside the brain). Some nerves of the central nervous system exit the spinal cord and stimulate peripheral nerves, which in turn engage the body’s major organs and muscles in a fight-or-flight manner.

 

 The HPA Axis

     The HPA axis (hypothalamic–pituitary–adrenal axis) is an exceedingly important multi-step biochemical process in which information is transmitted from one area of the body to the next via chemical messengers. Each step in this pathway not only passes information along to stimulate the next region but also receives feedback from chemical messengers produced later in the pathway to either enhance or suppress earlier steps. Thus, it is one method a biochemical pathway can regulate itself (as briefly discussed in the Worry Article May 2012.)

     When the hypothalamus receives signals from one of its many inputs about conditions that deviate from an ideal homeostatic state, such as alarming sensory stimulus, emotionally charged event, or energy deficiency, this becomes the initial step of the stress-response cascade. The hypothalamus is stimulated by its inputs and then proceeds to secrete corticotropin-releasing hormones that are  transported to the target, the pituitary gland, via short blood vessels system, to which it binds and causes the pituitary gland to, in turn, secrete its own messenger, adrenocorticotropic hormone, systemically into the blood stream. When adrenocorticotropic hormone reaches and binds to its target, the adrenal gland, the adrenal gland in turn releases the final key messenger in the cascade, cortisol.

     Cortisol, once released, has widespread effects in the body. During an alarming situation in which a threat is detected and signaled to the hypothalamus from primary sensory and limbic brain structures, cortisol is one way the brain instructs the body to attempt to regain homeostasis – by redistributing energy (glucose) to areas of the body that need it most, that is, toward critical organs (the heart, the brain) and away from digestive and reproductive organs.

     After enough cortisol has been secreted to best restore homeostasis, and the body’s stressor is no longer present or the threat is no longer perceived, the heightened levels of cortisol in the body’s blood stream eventually circulates to the pituitary gland and hypothalamus to which cortisol can bind and inhibit, turning off the HPA-axis’ stress-response cascade.  This prevents additional cortisol from being released. This is a normal, healthy stress mechanism in response to a situation or stressor that threatens homeostasis.

     However, if the response to emotional pressure is suffered for a prolonged period, over which an individual perceives he or she has no control, stress becomes chronic. If this continues for a long time, it can cause damage to an individual’s physical and mental health.

 

To be continued…

 

1‘‘Physiological regulation of normal states: some tentative postulates concerning biological homeostatics.’’ W. B. Cannon. (IN: A. Pettit (ed.). A Charles Richet: ses amis, ses collègues, ses élèves, p. 91. Paris: Éditions Médicales, 1926.

 

service industry, Workers Compensation

What’s so dangerous about hotel room cleaning? It turns out, a lot.

Today’s post comes from guest author Edgar Romano from Pasternack Tilker Ziegler Walsh Stanton & Romano.

Hotel housekeeping may not seem dangerous, but it can be grueling physical labor. A recent study published by the National Institute for Occupational Safety and Health reported that tasks including dusting, vacuuming, changing linens, making beds, and scrubbing bathrooms may lead to a range of injuries. Some of the most common ones include: Continue reading What’s so dangerous about hotel room cleaning? It turns out, a lot. →

drug and pharmaceutical law

Drug Watch: Osteoporosis Drugs Are Giving Women Severe Complications

Today’s post comes from guest author Brenda Fulmer from Pasternack Tilker Ziegler Walsh Stanton & Romano.

Post-menopausal women welcomed the class of drugs called “bisphosphonates,” which purportedly increase bone density by slowing the body’s natural turnover of bone cells and were touted as a safe and effective treatment for osteoporosis and osteopenia. Bisphosphonates are also widely used to treat both male and female patients whose cancer has spread to their bones and by patients who have a progressive bone disease called Paget’s disease.

Many patients who are being prescribed “bisphosphonates” for the treatment and prevention of osteoporosis are unaware of any risks associated with the use of such drugs.

Popular bisphosphonate drugs and their manufacturers include:

Fosamax is also available as the generic drug, alendronate. The drugs are available as pills as well as injections, and may be taken daily, several times per week, monthly, or event annually.

Patients who took these popular osteoporosis drugs have suffered severe bone fractures due to a weakening in bone structures caused by the drugs.

In a sad irony, patients who took these popular osteoporosis drugs in hopes of improving their bone health have actually suffered severe bone fractures, such as atypical femur fractures, due to a weakening in bone structures caused by the drugs. In addition, these bisphosphonate drugs have been linked with Continue reading Drug Watch: Osteoporosis Drugs Are Giving Women Severe Complications →

government, penalties, safety-gear, safety-rules, workers-compensation, workplace-injury

Unsafe Workplaces Equal More Injuries.

Today’s post comes from guest author Tom Domer from The Domer Law Firm.

Washington State has a similar program for filing claims of discrimination when a worker is punished for reporting unsafe work conditions. Contact one of us to discuss your case if you have suffered such discrimination.

The connection between unsafe workplaces and the increased frequency of work injuries seems like a no brainer. A study released by NCCI Holdings indicated worker’s compensation claims rose by 3% during 2010 (the first rise in frequency in over a dozen years). The study attributed the increased frequency to several factors

Because of these repeat violations,OSHA cited United Contracting and placed the firm on its “Severe Violator Enforcement Program”

including increases in employment since the onset of the recession in 2008, workers possibly being less fearful of losing their jobs for filing claims, and a lack of light duty jobs to which injured workers could return because of the poor economy.

One factor not referenced is the connection between increasingly unsafe work environments and work injuries. Two recent news stories in Wisconsin underscored this connection. OSHA fined a Wisconsin contractor $150,000

for violations while working on two bridges along highways in Wisconsin. The violation is more alarming because the contractors were working under a State contract to repaint the bridges. OSHA charged that the company did not have proper scaffolding at the bridges exposing workers to falls, and in fact one worker was injured in June after falling from a scaffold at one of the bridges. Because of these repeat violations, Continue reading Unsafe Workplaces Equal More Injuries. →

Costs

Slow Recovery Affects Workers’ Compensation Benefits and Costs

A Press Release by the National Academy of Social Insurance

 

WASHINGTON, DC – Workers’ compensation benefits declined to $57.5 billion in 2010 according to a report released today by the National Academy of Social Insurance (NASI). The drop in workers’ compensation benefits was largely due to a 2.1 percent drop in medical benefits for injured workers. Employers’ costs for workers’ compensation also fell by 2.7 percent in 2010. As a share of covered wages, employers’ costs in 2010 were the lowest in the last three decades.

 

“As a share of covered wages, employers’ costs in 2010 were the lowest in the last three decades.”

 

“Employers’ costs as a percent of payroll declined in 43 jurisdictions,” said John F. Burton, Jr., chair of the study panel that oversees the report. “This decline is probably due to the slow pace of the recovery, with many jurisdictions still experiencing relatively high unemployment rates.”

 

Workers’ Compensation Benefits, Coverage, and Costs, 2010
Total

2010

Change   Since 2009 (%)
Covered workers (in thousands)

124,454

-0.3%
Covered wages (in billions)

$5,820

2.6%
Benefits paid (in billions)

$57.5

-0.7%
Medical benefits

$28.1

-2.1%
Cash benefits

$29.5

0.7%
Employer costs (in billions)

$71.3

-2.7%
Per $100 of Covered Wages

2010

Change   Since 2009 ($)
Benefits paid

$0.99

-$0.03
Medical benefits

$0.48

-$0.03
Cash benefits

$0.51

-$0.01
Employers’ costs

$1.23

-$0.06
Source: National Academy of Social Insurance, 2012.

 

The new report, Workers’ Compensation: Benefits, Coverage and Costs, 2010, is the fifteenth in the series that provides the only comprehensive data on workers’ compensation benefits for the nation, the states, the District of Columbia, and federal programs. 

 

“This report represents the first time the Academy has released employers’ costs by state.”

This report represents the first time the Academy has released employers’ costs by state. For a table showing employers’ costs for all fifty states and the District of Columbia, refer to Table 12 (page 34).

Most states reported a decrease in the number of workers covered but an increase in covered wages between 2009 and 2010. During the same period, the total amount of benefits paid to injured workers declined in 26 jurisdictions and increased in 25. As a share of payroll, benefits paid to injured workers fell by three cents to $0.99 per $100 of payroll in the nation.

The share of medical benefits for workers’ compensation has increased substantially over the last 40 years. During the 1970s medical benefits nationally accounted for 30 percent of total benefits, whereas in 2010 the share of benefits paid for medical care was almost 50 percent. Experts attribute this trend to the rising cost of health care.

history of workers' compensation

The Origins of Workers’ Compensation in the United States

Today’s post is a film on the history of workers’ compensation, presented by the Workers’ Injury Law & Advocacy Group at the National Symposium on the 40th Anniversary of the National Commission on Workers Compensation, which in 1972 found the state workers’ compensation systems to be inadequate and unfair.

This film is a great reminder that the workers’ compensation systems we work under today were created to correct issues with unsafe workplaces and the effects of injuries on the job during a time when workplace safety was not yet a reality.  We need to remember our history, lest the lessons hard-won be forgotten.

workers compensation basics

Pain And Suffering: Not Part Of Your Settlement

Today’s post comes from guest author Ryan Benharris from Deborah G. Kohl Law Offices.

The worst part of my day as a Workers’ Compensation attorney is unquestionably the time when I need to explain to my clients that Workers’ Compensation does not include pain and suffering in a settlement. Inevitably, the look from the client is always the same. It’s the exact look I would give to my lawyer if he were saying the things to me that are coming out of my mouth to them. It’s a look that begins as disbelief then turns into anger.

Disbelieve it all you want; Pain and Suffering literally does not exist in Massachusetts Workers’ Compensation. There are an abundance of reasons and explanations for this. None of the reasons and explanations make it right. However, it’s something every injured worker must live with.

 

Disbelieve it all you want; Pain and Suffering literally does not exist in Massachusetts Workers’ Compensation…None of the reasons and explanations make it right. However, it’s something every injured worker must live with.

An explanation of what pain and suffering actually is makes it easier to understand how it doesn’t exist in Workers’ Compensation. Pain and suffering is a remedy that is only available to victims of personal injuries that resulted from the fault of another party. Workers’ Compensation does not have pain and suffering because it is a fault-free system.. You do not have to prove that your employer was at fault or that its negligence caused you to become injured. You simply need to prove that you were disabled as a result of an injury that took place at work. Fault is irrelevant. Though not needing to prove fault to receive workers’ compensation benefits is clearly a good thing, it comes with a hefty price. Unfortunately because fault is irrelevant, so is pain and suffering.

As you will undoubtedly hear from friends and family members, personal injury cases that settled for a lot of money did so because their attorney was able to prove that they had significant pain and suffering. Without pain and suffering, it often becomes difficult for workers’ compensation cases to settle for comparable amounts to a fault-based personal injury case. This makes it much more important that you know each and every benefit that is available to you if you are hurt at work.

Because pain and suffering does not exist in workers’ compensation, you must maximize the benefits that do actually exist. Workers’ compensation is what is known as a “wage replacement system.” Very simply, the only money the insurer is responsible for paying you is any wages that you may lose. You can receive wage replacement benefits for up to seven (7) years unless you become permanently and totally incapable of working.

The only other monetary benefit available to an injured worker besides the wage replacement benefits is if you sustain any permanent loss of function to a body part. This can be determined by your doctor. If your physician finds that there is a permanent percentage of loss of use to your injured body part, the insurance company will likely be responsible to pay you additional benefits. This, however, is hardly a substitute for pain and suffering.

workers comp basics, Workers Compensation

Should your doctor have access to surveillance videos of you?

Today’s post comes from guest author Charlie Domer from The Domer Law Firm. It is particularly relevant now, at a time when we are seeing a spike in the number of cases where surveillance video is being used to bring claims to a halt here in Washington State.

A dozen attorneys in Montana representing injured workers made headlines petitioning their Supreme Court to stop State fraud investigators sharing surveillance videos with doctors of worker’s compensation claimants. About 14,000 Montana residents are covered by the State Fund and the Fund’s Investigative Unit conducts video surveillance on about 500 claimants each year and shows the videos to claimants’ treating physicians. This practice raises questions about physician-patient privilege and patient privacy.

In Wisconsin and most other States, the physician-patient privilege is waived by an employee who reports a work-related injury. The waiver only extends, however, to any condition or complaint reasonably related to the work injury. Considerable debate sometimes arises over which treatment records are reasonably related to a claim. A broken toe, for example, is not likely relevant to an asthma condition but a prior Hepatitis-C claim may be. Employers and insurers may attempt to obtain records from a medical provider without a release, and practitioners must provide reports to the employer, insurer, employee, or Worker’s Comp Division within a reasonable time after written request.

The Fund’s Investigative Unit conducts video surveillance on about 500 claimants each year and shows the videos to claimants’ treating physicians… In Wisconsin and most other States, the physician-patient privilege is waived by an employee who reports a work-related injury. The waiver only extends, however, to any condition or complaint reasonably related to the work injury. 

Insurance carriers and employers also defend or deny worker’s compensation claims through surreptitiously obtained videos. The videos Continue reading Should your doctor have access to surveillance videos of you? →

workers comp basics, workers comp q&a

Workers’ Comp Q&A: Does going back to work ruin my case?

Today’s post comes from guest author Todd Jones from Pasternack Tilker Ziegler Walsh Stanton & Romano.

QUESTION: DOES GOING BACK TO WORK RUIN MY CASE?

ANSWER: Not at all!

This question comes up a lot in Workers’ Compensation cases. When someone is injured they have to balance their personal and professional obligations while including their injury as a new variable.

This is completely understandable. Oftentimes people want to try to get back to work but are not sure if their body will hold up. This uncertainty can cast a shadow over everything a person has to consider when they have a work injury.

First and foremost you should speak to your doctor and find out what you are physically capable of. While your injury may be improving, you may not be able to return at 100%.

If your doctor clears you to return to work Continue reading Workers’ Comp Q&A: Does going back to work ruin my case? →

Workers' Compensation

“Why is Money the Reason My Case Won’t Settle?”

The Size of the Check Points the Way

In Washington State, the majority of workers’ compensation claims are “State Fund” claims managed by the Department of Labor and Industries (Department), with perhaps a third are comprised of “self-insured” claims managed by third-party administration companies under the oversight of the Department. In “State Fund” claims, managed by State employees, benefits are paid from monies received from both workers and employers – – Washington is the only state where workers and employers each pay half of the medical insurance premiums. When a dispute arises in a claim, the aggrieved party can file an appeal to the Board of Industrial Insurance Appeals (Board), another State agency. When an appeal is filed with the Board, the Department is represented by the Office of the Attorney General, yet another State agency.

Since the economic crisis hit Washington, as it has in every other state in the union, the Department of Labor and Industries has become very cautious concerning any expenditures.

Since the economic crisis hit Washington, as it has in every other state in the union, the Department of Labor and Industries has become very cautious concerning any expenditures. After all, audits have found mis-spent money — nothing worthy of headlines, but the media loves a good fraud story as much as they love a government waste story. Fraud investigations and video surveillance have increased dramatically in recent years at great expense to the Department with minimal economic benefit. The Department was recently found to have spent a significant sum on no-show fees to independent medical examination companies without recouping those charges from the claimants who failed to attend the examinations or, in some of the cases, without properly notifying those companies to avoid the charges when a cancellation was known to have occurred. The end result of the Department’s caution is that benefits clearly payable to a claimant are being delayed or denied simply based on the amount of money at stake.

Payments of minor amounts can be made by Department claims managers at their discretion, based on the records on file. Amounts over a few thousand dollars, however, trigger the need for supervisor review and approval before payment can be made. Consequently, we are working much harder to obtain payment administratively because the Department increasingly requires proof of entitlement to benefits “beyond a reasonable doubt” rather than simply based upon the opinion of a treating physician. One doctor’s opinion of a worker’s inability to work seems no longer enough to establish entitlement to benefits. We increasingly face roadblocks to payment in cases where the Department concocts an issue over whether the inability to work is related to the covered injury or condition or is instead due to some pre- or post-existing condition, even if the disabling condition is clearly shown to be related to the original injury or the treatment procedures for that injury. If payment or authorization for treatment for a condition is denied, we are forced to demand an order be issued. We then file an appeal, and off to litigation we go.

In the current economic climate simply the amount of money involved increasingly drives the decision-making process at every administrative level.

The paralegals and attorneys at our firm work diligently to document the benefits we are seeking and the medical support for the claims we are making. In some cases, the monetary benefit at issue is a fairly significant amount. In the current economic climate simply the amount of money involved increasingly drives the decision-making process at every administrative level. Denials are much more common when a significant sum is at stake, regardless of the validity of the claim. We encounter a “make them prove it” attitude, forcing cases to go through time-consuming and expensive litigation rather than being resolved through mediation discussions or agreement between the parties.

Yesterday, I received phone call apology after a denial order had been issued, expressing condolences but the hope that we will be able to prevail on appeal. Today, I was told by an Assistant Attorney General that she would likely not be able to get authority from her client – the Department — to accept our settlement offer due to the amount of money at issue – “the case will just have to be litigated.”

I can accept these denials when there is a genuine dispute over the facts, over whether a claimant is entitled to the benefits or not. I cannot accept it when the answer is simply “it’s too much money.” I would prefer the other side tell me why my argument lacks merit, tell me that I am wrong in my belief that the claimant is entitled to the benefits at issue, tell me where the hole in my case is – anything – but, please, don’t just say that it’s too much money. That is not a reason for a State Agency which, unlike an insurance company, has no inherent profit motive, to deny benefits.

Consider the relatively low values in workers’ compensation claims: 60 – 72% of pre-injury wages as wage-replacement compensation; surprisingly small awards for permanent impairment, with no consideration given to the impact on lifestyle or earnings ability. If there is a significant sum at stake, it is because of YEARS of delay, or years of benefits at issue, not because the claimant is lucky or greedy. The claimant didn’t win the lottery; he or she was simply injured on the job and denied benefits when they were most needed. That required hiring an attorney, and in many cases expended large sums of money in efforts to support their case. The significant sums often at issue in these cases do not make claimants RICH, nor do they make them WHOLE. They only provide the limited measure of compensation that our workers’ compensation system allows.

My message to our State: Don’t add insult to injury.

My message to our State: Don’t add insult to injury. Show claimants the respect they deserve and promptly make decisions in their claims based on the merits of their arguments and the evidence presented, without being influenced simply by the amount of the check that may be issued.

Published by Causey Wright