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Home / Company Law and CG / Company Law / Overview of Directives / Eighth Council Directive - Qualifications of persons responsible for carrying out the statutory audits of accounting documents (84/253/EEC)
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Eighth Council Directive - Qualifications of persons responsible for carrying out the statutory audits of accounting documents (84/253/EEC)
Eighth Council Directive 84/253/EEC of 10 April 1984 based on Article 54(3)(g) of the Treaty on the approval of persons responsible for carrying out the statutory audits of accounting documents [Official Journal L 126 of 12.5.1984].
The objective of this directive was to complete the series of directives concerning company accounts, defining the qualifications of persons responsible for carrying out the statutory audits of the accounting documents required by the fourth and seventh directives.
Persons responsible for carrying out audits of accounting documents may, depending on the law of each Member State, be natural or legal persons or other types of company, firm or partnership. The Directive applies to persons responsible for carrying out:
statutory audits of the annual accounts of companies and firms and verifying that the annual reports are consistent with those annual accounts in so far as such audits and such verification are required by Community law;
statutory audits of the consolidated accounts of bodies of undertakings and verifying that the consolidated annual reports are consistent with those consolidated accounts in so far as such audits and such verification are required by Community law.
Persons responsible for carrying out audits of accounting documents must be of good repute and may not engage in any activity incompatible with the auditing of such documents. A natural person may be approved to carry out statutory audits of accounting documents only after:
having attained university entrance level;
completing a course of theoretical instruction;
undergoing practical training; and
passing an examination of professional competence or university final examination organised or recognised by the state.
Member States may nevertheless approve persons who do not satisfy some of the above conditions if those persons can show either:
that they have, for 15 years, engaged in professional activities which have enabled them to acquire sufficient experience in the fields of finance, law and accountancy and have passed the examination of professional competence; or
that they have, for seven years, engaged in professional activities in those fields and have, in addition, undergone practical training and passed the examination of professional competence.
Member States must ensure that approved persons are liable to appropriate sanctions if they do not carry out audits honestly and independently.
In March 2004 the European Commission proposed a new Directive on statutory audit in the EU. [1] The objectives of the proposed directives are to ensure that investors and other interested parties can rely fully on the accuracy of audited accounts and to enhance the EU's protection against the type of scandals that recently occurred in companies such as Parmalat and Ahold. The proposed Directive would clarify the duties of statutory auditors and set out certain ethical principles to ensure their objectivity and independence, for example where audit firms are also providing their clients with other services. It would introduce a requirement for external quality assurance, ensure robust public oversight over the audit profession and improve cooperation between regulatory authorities in the EU. It would allow for swift European regulatory responses to new developments by creating an audit regulatory committee of Member State representatives, so that detailed measures implementing the Directive could be rapidly taken or modified. The proposal also foresees the use of international standards on auditing for all statutory audits conducted in the EU and provides a basis for balanced and effective international regulatory cooperation with third-country regulators, such as the US Public Company Accounting Oversight Board (PCAOB).[2]
Art. 44 II lit.g EC (former Art. 54 III lit.g EEC)
Proposal COM (2004)177
SCAD plus
Legal text
[1] Proposal for a Directive of the European Parliament and of the Council of 16 March 2004 on statutory audit of annual accounts and consolidated accounts and amending Council Directives 78/660/EEC and 83/49/EEC [COM(2004) 177 final].
[2] See press release IP/04/340 of 16 March 2004: Audit of company accounts: Commission proposes Directive to combat fraud and malpractice.
All Overview of Directives
Files: no files attached


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I spent over 150 hours traveling last year – 5 outfits always in hand luggage
January 5, 2023 James Isaacs
I've always joked that I'd live my life out of a suitcase if I could. While it's theoretically impossible with the state of my closet, I'm as close as I'll ever get. After 24 years of long-haul travel and more airline miles than a Victorian child could ever imagine, I've perfected the art of packing thanks to smart, thoughtful outfit choices that last me a week and a half that fit in just a carry-on suitcase.
Since worldwide shutdowns almost two years ago, 2022 was a return to travel for me. In total, I racked up over 150 hours on the road, including going to Japan to see family, meeting up with friends in Spain, and taking road trips through California and New York. If I hadn't got packing down to a science at this point, I don't know how I would have done it.
With the amount of airline changes and baggage delays these days, no one needs infinitely more stress when it comes to packing for a weekend trip if your luggage gets lost. Although it hasn't happened to me yet (fingers crossed!), the number of horror stories I've seen on social media has prompted me to pack a few days worth of clothes that I always carry with me.
Below are the foolproof outfits I pack whenever I escape the city and travel somewhere new.
J Lo's dress proves she's the queen of the plunging neckline and thigh-high slit
January 27, 2023 January 27, 2023 James Isaacs
Nike Files Sneaker Trademark Lawsuit Against Bape
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written examination for the posts of ADPP will be held on 10-12-2017.
a0a,,,,Abbasian sir any information about written result of ADPP........?????
ADPP result any update ? Do share anyone ??????????????????
Sir Abbasian plzzz reply on priority basis.
When ADPP written result is going to b announced ?????????????????????????????????????????????
And when Motor Mobile Patrol Inspector jobs in Punjab Transport and Inspector legal in Punjab Police shall b advertised ?????
I guess no one's sharing any info about ADPP. If someone's sending them to PMs, please PM me too.
> Sir Abbasian plzzz reply on priority basis.
> Inspector legal in Punjab Police shall b advertised ?????
ADPP result is expected in this week. So far MMPI concerned it was advertised in July 2017 and OTS conducts the written test. I have cleared the written test and physical measurements test but for 5 months no update on interview. I don't know whether Transport Dept has skipped that or not. Do share if you have any other info regarding MMPI and ADPP. Seniors don't bother to reply sorry to say.


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Vodafone Fiji Bati winger, Suliasi Vunivalu is one of the leading try scorers in the Rugby League World Cup so far.
Vunivalu has scored five tries together with Tongan center Michael Jennings.
Taane Milne is second with four tires, Viliame Kikau has so got three tries under his name while Jarryd Hayne, Kevin Naiqama and Henry Raiwalui have scored a brace of tries after two pool matches.
Meanwhile, the Bati takes on Italy at 9.40pm today.


MUMBAI: The rupee depreciated by 11 paise to 66.30 against the US dollar in early trade on Monday due to appreciation in the US currency overseas.
Dealers attributed the rupee's fall to fresh demand for the US currency from importers and banks.
The rupee ended steady at 66.19 per dollar on Friday against the American currency at the interbank Foreign Exchange in view of steady dollar in the overseas market.


If you've been following me on the Relax and Create Today Facebook page of late, you may have noticed I've shared a number of memes emphasizing the benefits of being creative. These range from improving our general sense of wellbeing to helping with mental health. It then dawned on me that I hadn't actually spelled out the benefits of being creative on this site, so it is time to remedy that!
In addition to these benefits, other studies have found that people who create on a regular basis are usually healthier, need fewer meds, and are generally more sociable and optimistic than those who don't create. Ruth Richards, a professor of psychology at Harvard Medical School, also found that being creative helps us become less defensive, more collaborative, observant, energetic – and braver.
These seem like a pretty good set of reasons to pull out your sewing or art supplies and get back to creating!


The video is brief but disturbing: An officer is seen striking an unarmed suspect with his handgun as the man falls into the grass. An autopsy would later show he died from a gunshot to the back of the head.
Her experience is typical. An investigation by The Associated Press has found that police departments routinely withhold video taken by body-worn and dashboard-mounted cameras that show officer-involved shootings and other uses of force. They often do so by citing a broad exemption to state open records laws — claiming that releasing the video would undermine an ongoing investigation.


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Residents & Visitors
FM 2920/Main Street Reconstruction Project
FM 2920/Main Street serves as a major east-west connection through Tomball. The proposed project will reconstruct FM 2920 from SH 249 to Willow Street, including making safety and aesthetic improvements through the entire corridor, adding new and improving existing sidewalks, and adding elevated medians in the three-block area of Downtown Tomball and minor additions around Business 249.
This project is part of a larger effort by TXDOT to improve FM 2920 from US 290 to IH-45.
Open House Meeting - December 2022
The City of Tomball hosted an open house meeting on Tuesday, December 6 to discuss progress made on the project, as well as seek feedback on design options related to the four-block segment of Old Town Tomball.
Design Alternatives
If you were not able to attend the December 6 open house, you still have an opportunity to review the presented options by watching the video below or viewing the provided PDFs of each design.
Watch a pre-recorded presentation of the alternatives presented at the December 6 open house (video is accessible on the City of Tomball YouTube channel).
Alternative 1 (PDF)
The City of Tomball and Tomball Economic Development Corporation held a Town Hall meeting on March 31, 2022. At the meeting, representatives from the City, TEDC and TXDOT provided a project overview and answered questions from the community. If you were not able to attend, a recorded video of the meeting is linked in this section and a PDF of the presentation is posted in the "Key Documents" section.
Watch video of the March 2022 Town Hall meeting.
The FM 2920 reconstruction project was initiated in 2007 when the Houston-Galveston Area Council (H-GAC) initiated an Access Management Study for FM 2920 from SH 290 to IH-45. This study looked at the systematic control of the location, spacing, design, and operations of driveways, median openings, interchanges, and street connections along the entire corridor. The study included the collection of information to measure, evaluate, and identify a range of viable short, medium, and long-term improvement concepts that would improve safety and mobility, reduce motorist delay, reduce crash rates, enhance land use, and preserve long-term property values along the corridor. The study also examined ways to increase pedestrian and bicycle connectivity, improve aesthetics through landscaping, and stimulate economic vitality. The Access Management Study was completed and adopted in November 2008.
During the Access Management Study process, community input led H-GAC to commission a separate Livable Centers Study for the FM 2920 corridor in Tomball (from SH 249 to Willow Street). H-GAC, the City of Tomball, and the community recognized that this area was unique and needed a master-planned, urban-focused design that would focus on parking, streetscape, pedestrian linkages, and community open spaces.
The Livable Centers Downtown Plan was initiated in 2008 and adopted in 2009. Working together with H-GAC, the City, TXDOT, and a community advisory committee focused on infrastructure improvements and urban design solutions for Downtown Tomball. The goals of the study were:
PRESERVE the eclectic and historic main street, the classic "Americana" character of the commercial downtown, and the historic small-town atmosphere of the residential neighborhood.
PROMOTE a diverse and balanced mixed-use, commercial retail "work, live, shop, and play" pedestrian-oriented downtown environment.
ENHANCE the collective sense of community pride and heart in the social interaction, celebrations, gatherings, and traditions that define the identity and character of the Tomball community.
The Livable Centers Study looked at Downtown Tomball's existing land use, architectural character, streetscape, and other elements. Through community visioning workshops, the study team focused on short, medium, and long-term improvements needed to enhance the Downtown area while preserving the social, physical, and cultural character of the area. Over time, the City worked with TXDOT to implement various short and medium-term recommendations identified in this study. To accomplish this, TXDOT removed parallel parking on Main Street, while the City developed additional public parking lots and made improvements to the Depot plaza.
In 2015, the City applied for a grant through H-GAC to implement the FM 2920 Access Management Study and Livable Centers Downtown Plan. The City was awarded $28.1 million for the reconstruction and aesthetic improvements needed from SH 249 to Willow Street. As part of that grant application, the City committed $3 million to the project.
The approved reconstruction project included: relocation and replacement of utilities, removal of asphalt roadway and reconstruction as concrete roadway, and continuous sidewalks through the entire corridor; improvements to intersection and addition of elevated medians (the current proposal includes only a portion of the medians proposed in the Access Management Study) at the intersection of Business 249 and FM 2920; addition of medians from Pine Street to railroad tracks to improve safety and pedestrian connectivity (as adopted in the Access Management Study); new mast arm traffic signals and black powder-coated vehicular and pedestrian light poles; synchronization of traffic signals; and additional aesthetic improvements, such as improved lighting, landscaping, and pavers.
Meagan Mageo
Email Meagan Mageo
FM 2920 Access Management Study (PDF)
Tomball Livable Centers Downtown Plan, 2008 (PDF)
March 2022 - FM 2920 Town Hall Presentation (PDF)
March 2022 FM 2920 Town Hall Questions & Answers (PDF)
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You know, I've written about JJ (John Jeremie, the Attorney General –Mr Fixer) being a partisan political figure. Everyone 'knows' he was recalled from London to do P**rick's bidding. Annisette-George was kicked out of the post because she was not as easy as JJ to bend over and take it willingly. In fact, she preferred to walk out rather than take it at all. Word has it she even walked out of the Government and went back into private practice, such was her disgust.
JJ's actions have moved him to the secure position of being P**rick's protector. I first noticed JJ's actions when he was advising the Chief Magistrate during a case in which the said Magistrate was presiding over involving the Leader of the Opposition. The antagonistic nature of the political process alone made JJ's involvement suspicious at best. That the defendant was the Leader of the Opposition made it doubly so. And the fact that the magistrate being so advised was the one sitting in judgment of this case was enough to put my radar on high alert.
In the case of UDeCOTT, JJ has been involved up to his eyebrows so to speak. What sort of advice has he been giving to the Prime Minister (or P**rick, or the 'Father of the Nation') for Hart to resign and leave the country with his family within 24 hours… and leaving behind a substantial amount of 'assets'?
How come now he is suddenly 'directing' the investigation into Hart and UDeCOTT?
No one knows how to contact Hart not even the police, but despite the police investigating Hart, JJ can say with assurance he is not needed by the police?
The police have no need to question former UDeCOTT executive chairman Calder Hart at this point in time, Attorney General John Jeremie assured yesterday.
How the hell can JJ say that? Why is it all news of this investigation seem to come from JJ, and not the police?
…the Attorney General said he (Jeremie) had been told by Commissioner of Police James Philbert and the Senior Investigating Officer of the Anti-Corruption Investigating Bureau that Hart has not been requested to return to Trinidad and Tobago to speak with officers here.
Has the Police Commissioner (handpicked by P**rick) been muzzled? And suspicious too is the defence of Hart by JJ, on all front. His words are carefully chosen to create a public image of a man innocent and hounded.
He declined, however, to state where Hart, 'a private citizen', was.
Asked if special treatment was being afforded to Hart, Jeremie said that as of now, Hart was just an 'ordinary citizen against whom there has been a great deal of speculation'.
Jeremie said there was a separate criminal probe into the Minister of Legal Affairs Towers and the project at Tarouba, both of which were ongoing.
'They have not yet reached a position of finality. So there can be no warrant to do anything with Mr Hart at this point in time. We can only go as quickly as the police can carry us. The Government cannot take action against a private citizen, restricting his travel. Those are the constitutional rights enjoyed by every citizen in advance of his being charged, or a request being made by the police to have him attend an investigation,' Jeremie emphasised as he responded to suggestions that Hart was a flight risk.
Asked whether information on the authenticity of birth certificates of Hart's wife and her sister, Soh Lee Wah, and the marriage certificate of Soh Lee Wah to CH director, Ng Ching Poh, has been obtained from Malaysian authorities, Jeremie said the Central Authority and Interpol have made seven requests of their counterpart agencies in Malaysia. As of yesterday, they had received information with respect to 'four limbs' of the requests. 'Three limbs are outstanding and that is as much as I can say', he said.
Was Government taking a lot more time to get information than the Congress of the People did in producing the documents, Jeremie was asked.
'That is a valid point. But you have to understand that the Central Authority works with its corresponding agencies in various parts of the world. Once evidence is attained under the Mutual Assistance process, it can then be adduced into court proceedings with minimum difficulty under our Evidence Act.
With regards to the words in red, that's a load of hogwash. Courts restrict movement of people all the time, and can even order them tagged, kept within a certain area or even under house arrest (Occah Seepaul is a fine example of this, under a corruption probe as well over a dodgy boat sale).
What makes this situation all the more unpalatable to me is that the legal fraternity in Trinidad and Tobago knows JJ is talking out of his arse but no one wants to call him on it.
I don't think I am merely seeing a conspiracy theory this time. There is more in the mortar than the pestle, and only time will prove me right as I am so often.


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Full Cycle Developers at Netflix — Operate What You Build
Netflix Technology Blog
May 17, 2018 · 10 min read
The year was 2012 and operating a critical service at Netflix was laborious. Deployments felt like walking through wet sand. Canarying was devolving into verifying endurance ("nothing broke after one week of canarying, let's push it") rather than correct functionality. Researching issues felt like bouncing a rubber ball between teams, hard to catch the root cause and harder yet to stop from bouncing between one another. All of these were signs that changes were needed.
Fast forward to 2018. Netflix has grown to 125M global members enjoying 140M+ hours of viewing per day. We've invested significantly in improving the development and operations story for our engineering teams. Along the way we've experimented with many approaches to building and operating our services. We'd like to share one approach, including its pros and cons, that is relatively common within Netflix. We hope that sharing our experiences inspires others to debate the alternatives and learn from our journey.
One Team's Journey
Edge Engineering is responsible for the first layer of AWS services that must be up for Netflix streaming to work. In the past, Edge Engineering had ops-focused teams and SRE specialists who owned the deploy+operate+support parts of the software life cycle. Releasing a new feature meant devs coordinating with the ops team on things like metrics, alerts, and capacity considerations, and then handing off code for the ops team to deploy and operate. To be effective at running the code and supporting partners, the ops teams needed ongoing training on new features and bug fixes. The primary upside of having a separate ops team was less developer interrupts when things were going well.
When things didn't go well, the costs added up. Communication and knowledge transfers between devs and ops/SREs were lossy, requiring additional round trips to debug problems or answer partner questions. Deployment problems had a higher time-to-detect and time-to-resolve due to the ops teams having less direct knowledge of the changes being deployed. The gap between code complete and deployed was much longer than today, with releases happening on the order of weeks rather than days. Feedback went from ops, who directly experienced pains such as lack of alerting/monitoring or performance issues and increased latencies, to devs, who were hearing about those problems second-hand.
To improve on this, Edge Engineering experimented with a hybrid model where devs could push code themselves when needed, and also were responsible for off-hours production issues and support requests. This improved the feedback and learning cycles for developers. But, having only partial responsibility left gaps. For example, even though devs could do their own deployments and debug pipeline breakages, they would often defer to the ops release specialist. For the ops-focused people, they were motivated to do the day to day work but found it hard to prioritize automation so that others didn't need to rely on them.
In search of a better way, we took a step back and decided to start from first principles. What were we trying to accomplish and why weren't we being successful?
The Software Life Cycle
The purpose of the software life cycle is to optimize "time to value"; to effectively convert ideas into working products and services for customers. Developing and running a software service involves a full set of responsibilities:
SDLC components
We had been segmenting these responsibilities. At an extreme, this means each functional area is owned by a different person/role:
SDLC specialists
These specialized roles create efficiencies within each segment while potentially creating inefficiencies across the entire life cycle. Specialists develop expertise in a focused area and optimize what's needed for that area. They get more effective at solving their piece of the puzzle. But software requires the entire life cycle to deliver value to customers. Having teams of specialists who each own a slice of the life cycle can create silos that slow down end-to-end progress. Grouping differing specialists together into one team can reduce silos, but having different people do each role adds communication overhead, introduces bottlenecks, and inhibits the effectiveness of feedback loops.
Operating What You Build
To rethink our approach, we drew inspiration from the principles of the devops movement. We could optimize for learning and feedback by breaking down silos and encouraging shared ownership of the full software life cycle:
SDLC with devops principles
"Operate what you build" puts the devops principles in action by having the team that develops a system also be responsible for operating and supporting that system. Distributing this responsibility to each development team, rather than externalizing it, creates direct feedback loops and aligns incentives. Teams that feel operational pain are empowered to remediate the pain by changing their system design or code; they are responsible and accountable for both functions. Each development team owns deployment issues, performance bugs, capacity planning, alerting gaps, partner support, and so on.
Scaling Through Developer Tools
Ownership of the full development life cycle adds significantly to what software developers are expected to do. Tooling that simplifies and automates common development needs helps to balance this out. For example, if software developers are expected to manage rollbacks of their services, rich tooling is needed that can both detect and alert them of the problems as well as to aid in the rollback.
Netflix created centralized teams (e.g., Cloud Platform, Performance & Reliability Engineering, Engineering Tools) with the mission of developing common tooling and infrastructure to solve problems that every development team has. Those centralized teams act as force multipliers by turning their specialized knowledge into reusable building blocks. For example:
Specialists create reusable tools
Empowered with these tools in hand, development teams can focus on solving problems within their specific product domain. As additional tooling needs arise, centralized teams assess whether the needs are common across multiple dev teams. When they are, collaborations ensue. Sometimes these local needs are too specific to warrant centralized investment. In that case the development team decides if their need is important enough for them to solve on their own.
Balancing local versus central investment in similar problems is one of the toughest aspects of our approach. In our experience the benefits of finding novel solutions to developer needs are worth the risk of multiple groups creating parallel solutions that will need to converge down the road. Communication and alignment are the keys to success. By starting well-aligned on the needs and how common they are likely to be, we can better match the investment to the benefits to dev teams across Netflix.
Full Cycle Developers
By combining all of these ideas together, we arrived at a model where a development team, equipped with amazing developer productivity tools, is responsible for the full software life cycle: design, development, test, deploy, operate, and support.
The empowered full cycle developer
Full cycle developers are expected to be knowledgeable and effective in all areas of the software life cycle. For many new-to-Netflix developers, this means ramping up on areas they haven't focused on before. We run dev bootcamps and other forms of ongoing training to impart this knowledge and build up these skills. Knowledge is necessary but not sufficient; easy-to-use tools for deployment pipelines (e.g., Spinnaker) and monitoring (e.g., Atlas) are also needed for effective full cycle ownership.
Full cycle developers apply engineering discipline to all areas of the life cycle. They evaluate problems from a developer perspective and ask questions like "how can I automate what is needed to operate this system?" and "what self-service tool will enable my partners to answer their questions without needing me to be involved?" This helps our teams scale by favoring systems-focused rather than humans-focused thinking and automation over manual approaches.
Moving to a full cycle developer model requires a mindset shift. Some developers view design+development, and sometimes testing, as the primary way that they create value. This leads to the anti-pattern of viewing operations as a distraction, favoring short term fixes to operational and support issues so that they can get back to their "real job". But the "real job" of full cycle developers is to use their software development expertise to solve problems across the full life cycle. A full cycle developer thinks and acts like an SWE, SDET, and SRE. At times they create software that solves business problems, at other times they write test cases for that, and still other times they automate operational aspects of that system.
For this model to succeed, teams must be committed to the value it brings and be cognizant of the costs. Teams need to be staffed appropriately with enough headroom to manage builds and deployments, handle production issues, and respond to partner support requests. Time needs to be devoted to training. Tools need to be leveraged and invested in. Partnerships need to be fostered with centralized teams to create reusable components and solutions. All areas of the life cycle need to be considered during planning and retrospectives. Investments like automating alert responses and building self-service partner support tools need to be prioritized alongside business projects. With appropriate staffing, prioritization, and partnerships, teams can be successful at operating what they build. Without these, teams risk overload and burnout.
To apply this model outside of Netflix, adaptations are necessary. The common problems across your dev teams are likely similar — from the need for continuous delivery pipelines, monitoring/observability, and so on. But many companies won't have the staffing to invest in centralized teams like at Netflix, nor will they need the complexity that Netflix's scale requires. Netflix's tools are often open source, and it may be compelling to try them as a first pass. However, other open source and SaaS solutions to these problems can meet most companies needs. Start with analysis of the potential value and count the costs, followed by the mindset-shift. Evaluate what you need and be mindful of bringing in the least complexity necessary.
The tech industry has a wide range of ways to solve development and operations needs (see devops topologies for an extensive list). The full cycle model described here is common at Netflix, but has its downsides. Knowing the trade-offs before choosing a model can increase the chance of success.
With the full cycle model, priority is given to a larger area of ownership and effectiveness in those broader domains through tools. Breadth requires both interest and aptitude in a diverse range of technologies. Some developers prefer focusing on becoming world class experts in a narrow field and our industry needs those types of specialists for some areas. For those experts, the need to be broad, with reasonable depth in each area, may be uncomfortable and sometimes unfulfilling. Some at Netflix prefer to be in an area that needs deep expertise without requiring ongoing breadth and we support them in finding those roles; others enjoy and welcome the broader responsibilities.
In our experience with building and operating cloud-based systems, we've seen effectiveness with developers who value the breadth that owning the full cycle requires. But that breadth increases each developer's cognitive load and means a team will balance more priorities every week than if they just focused on one area. We mitigate this by having an on-call rotation where developers take turns handling the deployment + operations + support responsibilities. When done well, that creates space for the others to do the focused, flow-state type work. When not done well, teams devolve into everyone jumping in on high-interrupt work like production issues, which can lead to burnout.
Tooling and automation help to scale expertise, but no tool will solve every problem in the developer productivity and operations space. Netflix has a "paved road" set of tools and practices that are formally supported by centralized teams. We don't mandate adoption of those paved roads but encourage adoption by ensuring that development and operations using those technologies is a far better experience than not using them. The downside of our approach is that the ideal of "every team using every feature in every tool for their most important needs" is near impossible to achieve. Realizing the returns on investment for our centralized teams' solutions requires effort, alignment, and ongoing adaptations.
The path from 2012 to today has been full of experiments, learning, and adaptations. Edge Engineering, whose earlier experiences motivated finding a better model, is actively applying the full cycle developer model today. Deployments are routine and frequent, canaries take hours instead of days, and developers can quickly research issues and make changes rather than bouncing the responsibilities across teams. Other groups are seeing similar benefits. However, we're cognizant that we got here by applying and learning from alternate approaches. We expect tomorrow's needs to motivate further evolution.
Interested in seeing this model in action? Want to be a part of exploring how we evolve our approaches for the future? Consider joining us.
By Philip Fisher-Ogden, Greg Burrell, and Dianne Marsh
Netflix TechBlog
Learn about Netflix's world class engineering efforts, company culture, product developments and more.
Edge Engineering
Learn more about how Netflix designs, builds, and operates our systems and engineering organizations


Winmate has launched the new high brightness LCD providing excellence in the use of digital signage. It replaces outdated poster advertisements in transit centres, bus shelters, museums, and shopping malls. With an extreme brightness level of 1500 nits and static contrast ratio of 3000:1, your display will create an impact in outdoor environments for a variety of customized applications.


June 12, 2015 Summer of free.
South Shore District partnered with Alamo Drafthouse Cinema to bring a 90s-themed film series to the South Shore lawn. For four consecutive Fridays, catch a classic early 90s flick alongside some of the city's favorite food trucks (Garbo's, Burro Cheese Kitchen, Chilantro) which will vary per week.
Each screening will start at sunset, around 8 p.m.
Editor's note: 1993 was a great year for movies.


The placement, colour and opacity level of the overlay can be easily modified. In addition, there's no need to manually resize each image. This module will automatically resize and crop your images so they are fit nicely.
This slideshow will add class and sophistication to your website.
Easy control of overlay position (top, bottom, left, right).
Change the overlay colour with the built-in colour picker.
Automatic resizing and cropping of images. No need to manually resize each image!
Adjust the slide transition duration.
Example 1) Overlays on all 4 sides of the image. Images are selected individually.
If you have to ask "how much", then you can't afford it.
This car looks pretty expensive. This add-on now supports longer descriptions without such as this one which wraps over 2 or more lines.
Some sort of fancy, expensive car.
If you stare into the headlights long enough you'll be under the control of the car... and not the other way around.
Why don't all Ford cars look like this?
Driving one of these? Then you've got style.
If you were to be hit by a car, I'm sure you wouldn't want it to be this one. Looks like a tank.
If you've got one of these cars, then you must have good taste.
Can't think of a good description for this car.
Example 2) Images are pulled from a fileset and image zoom (lightbox) is activated. The overlay is also hidden.


text:
//
// Copyright (c) 2016-2017 Vinnie Falco (vinnie dot falco at gmail dot com)
//
// Distributed under the Boost Software License, Version 1.0. (See accompanying
// file LICENSE_1_0.txt or copy at http://www.boost.org/LICENSE_1_0.txt)
//

#ifndef BOOST_BEAST_DOC_DEBUG_HPP
#define BOOST_BEAST_DOC_DEBUG_HPP

namespace beast {

#if BOOST_BEAST_DOXYGEN

/// doc type (documentation debug helper)
using doc_type = int;

/// doc enum (documentation debug helper)
enum doc_enum
{
    /// One (documentation debug helper)
    one,

    /// Two (documentation debug helper)
    two
};

/// doc enum class (documentation debug helper)
enum class doc_enum_class : unsigned
{
    /// one (documentation debug helper)
    one,

    /// two (documentation debug helper)
    two
};

/// doc func (documentation debug helper)
void doc_func();

/// doc class (documentation debug helper)
struct doc_class
{
    /// doc class member func (documentation debug helper)
    void func();
};

/// (documentation debug helper)
namespace nested {

/// doc type (documentation debug helper)
using nested_doc_type = int;

/// doc enum (documentation debug helper)
enum nested_doc_enum
{
    /// One (documentation debug helper)
    one,

    /// Two (documentation debug helper)
    two
};

/// doc enum class (documentation debug helper)
enum class nested_doc_enum_class : unsigned
{
    /// one (documentation debug helper)
    one,

    /// two (documentation debug helper)
    two
};

/// doc func (documentation debug helper)
void nested_doc_func();

/// doc class (documentation debug helper)
struct nested_doc_class
{
    /// doc class member func (documentation debug helper)
    void func();
};

} // nested

/** This is here to help troubleshoot doc/reference.xsl problems

    Embedded references:

    @li type @ref doc_type

    @li enum @ref doc_enum

    @li enum item @ref doc_enum::one

    @li enum_class @ref doc_enum_class

    @li enum_class item @ref doc_enum_class::one

    @li func @ref doc_func

    @li class @ref doc_class

    @li class func @ref doc_class::func

    @li nested type @ref nested::nested_doc_type

    @li nested enum @ref nested::nested_doc_enum

    @li nested enum item @ref nested::nested_doc_enum::one

    @li nested enum_class @ref nested::nested_doc_enum_class

    @li nested enum_class item @ref nested::nested_doc_enum_class::one

    @li nested func @ref nested::nested_doc_func

    @li nested class @ref nested::nested_doc_class

    @li nested class func @ref nested::nested_doc_class::func
*/
void doc_debug();

namespace nested {

/** This is here to help troubleshoot doc/reference.xsl problems

    Embedded references:

    @li type @ref doc_type

    @li enum @ref doc_enum

    @li enum item @ref doc_enum::one

    @li enum_class @ref doc_enum_class

    @li enum_class item @ref doc_enum_class::one

    @li func @ref doc_func

    @li class @ref doc_class

    @li class func @ref doc_class::func

    @li nested type @ref nested_doc_type

    @li nested enum @ref nested_doc_enum

    @li nested enum item @ref nested_doc_enum::one

    @li nested enum_class @ref nested_doc_enum_class

    @li nested enum_class item @ref nested_doc_enum_class::one

    @li nested func @ref nested_doc_func

    @li nested class @ref nested_doc_class

    @li nested class func @ref nested_doc_class::func
*/
void nested_doc_debug();

} // nested

#endif

} // beast

#endif

redpajama_set_name: RedPajamaGithub


Eric and Kelli are so much fun (be sure to check out the image gallery)! They picked a stunning Colorado location - The Lodge & Spa at Cordillera, in Beaver Creek. These incredible images by Paula Bartosiewicz Photography .
Design and coordination by A Vintage Affair Events and Rentals.


text:
Q: vaadin 24.0.0.alpha8 PreRelease build error on azure agent We have recently tried to do an experimental upgrade to vaadin 24 PreRelease version. We were able to build and run the application in local environment but the application fails to build on azure agent with below error:

[ERROR] Failed to execute goal com.vaadin:vaadin-maven-plugin:24.0.0.alpha8:build-frontend (default) on project rmod-tools: Execution default of goal com.vaadin:vaadin-maven-plugin:24.0.0.alpha8:build-frontend failed: Unable to validate the license, please check your internet connection. If you need to work offline then please go to https://vaadin.com/pro/validate-license?getOfflineKey=mid-abfe707e-8d41af4e to retrieve an offline key. For troubleshooting steps, see https://vaadin.com/licensing-faq-and-troubleshooting.

The application builds successfully in local env.

redpajama_set_name: RedPajamaStackExchange


On this day in 1170 in Canterbury Cathedral, Archbishop Thomas Becket is on his way to the main hall for vespers; he never makes it.
The events leading to Thomas Becket's unsuccessful journey start with King Henry II having uttered words that were interpreted by his men as wishing Becket killed. King Henry II is said to have said "What miserable drones and traitors have I nourished and brought up in my household, who let their lord be treated with such shameful contempt by a low-born cleric?" Whatever the exact words were, they were brought about by a succession of events that strained the relationship between the two men.
Following the kings words, four knights, Reginald fitzUrse, Hugh de Morville, William de Tracy, and Richard le Breton, set out to confront the Archbishop of Canterbury. At first the knights tell Becket that he has to go to Winchester to give explain his actions, but Becket refused. At this the knights go back outside the cathedral and collect their weapons. They catch up with Becket in a spot of the cathedral near a door to the monastic cloister, the stairs into the crypt, and the stairs leading up into the quire of the cathedral.
The knights rein down a number of blows which leads to Thomas Becket's martyrdom.


Obverse III2 25 – Doubled 80 in date. Second 8 doubled faintly at left bottom outside of upper loop. 0 doubled faintly at left and right outside. Four damaged denticle spaces below 18 with inverted raised triangles and two diagonal polishing lines in middle.
Reverse C3a – Normal die with medium IV S mint mark (tilted slightly to the left but within tolerances - see photo on VAM-37 page).
1. This obverse shared with VAM-37, VAM-37A, VAM-37B, VAM-39, and VAM-96.
2. Later die state of VAM-37.
The picture below, featuring the four damaged denticles under 18, is the VAM-37B - but this photo also shows the Doubled 80 of the VAM-37.


text:
OpinionCase details
Hughes v. Berryhill
Full title:STEPHANIE HUGHES, Plaintiff, v. NANCY A. BERRYHILL, Acting Commissioner of…
Court:UNITED STATES DISTRICT COURT NORTHERN DISTRICT OF ILLINOIS EASTERN DIVISION
Date published: Aug 1, 2018
No. 17 C 5468 (N.D. Ill. Aug. 1, 2018)
UNITED STATES DISTRICT COURT NORTHERN DISTRICT OF ILLINOIS EASTERN DIVISION
No. 17 C 5468
STEPHANIE HUGHES, Plaintiff, v. NANCY A. BERRYHILL, Acting Commissioner of Social Security, Defendant.
Magistrate Judge Daniel G. Martin
MEMORANDUM OPINION AND ORDER
Plaintiff Stephanie Hughes ("Hughes") seeks judicial review of the final decision of the Commissioner of Social Security ("Commissioner") denying her application for Disability Insurance Benefits ("DIB") and Supplemental Security Income ("SSI"). Hughes asks the Court to reverse and remand the ALJ's decision, and the Commissioner seeks an order affirming the decision. For the reasons set forth below, the ALJ's decision is reversed and this case is remanded to the Social Security Administration for further proceedings consistent with this Opinion.
Hughes was born on July 4, 1964 and has a history of shortness of breath, leg and knee pain, and a heart attack in November 2013. Hughes alleges that she became totally disabled on August 1, 2012 due to coronary artery disease, hypertension, gastroesophageal reflux disease, and hyperlipidemia. Hughes has a high school education and previously worked as a babysitter, bagger, cashier, and parent facilitator. Hughes' insured status for DIB purposes expired on September 30, 2014, which means Hughes had to show she was disabled on or before that date in order to be eligible for DIB. Shideler v. Astrue, 688 F.3d 308, 311 (7th Cir. 2012) (noting "the claimant must establish that he was disabled before the expiration of his insured status . . . to be eligible for disability insurance benefits.").
At the hearing, Hughes testified that she became disabled in November 2013 due to a heart attack. (R. 47).
Under the standard five-step analysis used to evaluate disability, the ALJ found that Hughes had not engaged in substantial gainful activity since her alleged onset date of August 1, 2012 (step one) and her coronary artery disease, bilateral knee osteoarthritis, and restless legs syndrome ("RLS") were severe impairments (step two). (R. 15). He determined that Hughes' hypertension, hyperlipidemia, and GERD were non-severe because they did not cause more than a minimal limitation in functioning. (R. 16). The ALJ found that that Hughes' coronary artery disease, bilateral knee osteoarthritis, and RLS did not qualify as a listed impairment (step three). (R. 20-21). The ALJ concluded that Hughes retained the residual functional capacity ("RFC") to perform light work (i.e., "lifting no more than 20 pounds at a time with frequent lifting or carrying of objects weighing up to 10 pounds . . . [and] a good deal of walking or standing, or when it involves sitting most of the time with some pushing and pulling of arm or leg controls."), see 20 C.F.R. § 404.1567(b); 416.967(b), except that she was limited to work requiring no climbing ladders, ropes, or scaffolds, kneeling, or crawling; occasional climbing of ramps and stairs, balancing, stooping, and crouching; no work in concentrated exposure to extreme cold or extreme heat; and no work around hazards such as unprotected heights and exposed moving mechanical parts. (R. 21).
Given this RFC, the ALJ concluded that Hughes was able to perform her past relevant work as a child monitor as actually performed. (R. 23). As an alternate finding, at step five, the ALJ found that Hughes could perform other jobs that existed in significant numbers in the national economy, such as marker jobs, information clerk jobs, and ticket seller jobs. (R. 24). The Appeals Council denied Hughes' request for review on May 26, 2017. (R. 1-6). Hughes now seeks judicial review of the final administrative decision of the Commissioner, which is the ALJ's decision. O'Connor-Spinner v. Astrue, 627 F.3d 614, 618 (7th Cir. 2010).
Under the Social Security Act, a person is disabled if he has an "inability to engage in any substantial gainful activity by reason of a medically determinable physical or mental impairment which can be expected to result in death or which has lasted or can be expected to last for a continuous period of not less than twelve months." 42 U.S.C. § 423(d)(1)(a). In order to determine whether a claimant is disabled within the meaning of the Social Security Act, the ALJ conducts a five-step inquiry: (1) whether the claimant is currently unemployed; (2) whether the claimant has a severe impairment; (3) whether the claimant's impairment meets or equals any of the listing found in the regulations, see 20 C.F.R. § 404, Subpt. P, App. 1 (2004); (4) whether the claimant is unable to perform his former occupation; and (5) whether the claimant is unable to perform any other available work in light of his age, education, and work experience. 20 C.F.R. § 404.1520(a), 416.920(a) (2012); Clifford v. Apfel, 227 F.3d 863, 868 (7th Cir. 2000). These steps are to be performed sequentially. 20 C.F.R. § 404.1520(a) (2012). "An affirmative answer leads either to the next step, or, on Steps 3 and 5, to a finding that the claimant is disabled. A negative answer at any point, other than Step 3, ends the inquiry and leads to a determination that a claimant is not disabled." Clifford, 227 F.3d at 868 (quoting Zalewski v. Heckler, 760 F.2d 160, 162 n.2 (7th Cir. 1985)).
Judicial review of the ALJ's decision is limited to determining whether the ALJ's findings are supported by substantial evidence or based upon a legal error. Stevenson v. Chater, 105 F.3d 1151, 1153 (7th Cir. 1997). Substantial evidence is "such relevant evidence as a reasonable mind might accept as adequate to support a conclusion." Ricardson v. Perales, 402 U.S. 389, 401 (1971). A reviewing court may not substitute its judgment for that of the Commissioner by reevaluating facts, reweighing evidence, resolving conflicts in evidence, or deciding questions of credibility. Estok v. Apfel, 152 F.3d 636, 638 (7th Cir. 1998). Finally, an ALJ's credibility determination should be upheld "unless it is patently wrong." Schaaf v. Astrue, 602 F.3d 869, 875 (7th Cir. 2010).
The ALJ denied Hughes' claim at step four and alternatively, at step five of the sequential evaluation process, finding that Hughes retains the residual functional capacity to perform her past relevant work as a child monitor as actually performed and a significant number of unskilled light jobs in the national economy. Hughes challenges the ALJ's decision on four grounds: (1) the ALJ erroneously failed to evaluate Hughes' obesity in combination with her other impairments; (2) the ALJ failed to adequately evaluate Hughes' bilateral osteoarthritis of the knees; (3) the ALJ failed to properly evaluate Hughes' RLS; and (4) substantial evidence does not support the ALJ's step-four decision that Hughes can perform her past relevant work as a child monitor as actually performed. The Court finds that the ALJ erred in determining Hughes' RFC by failing to evaluate Hughes' obesity and improperly evaluating her bilateral osteoarthritis of the knees and RLS. Because the ALJ will reevaluate Hughes' RFC on remand, the Court need not address whether the ALJ also erred at steps four and five as those determinations are dependent upon the flawed RFC assessment.
A. The ALJ's Failure to Consider Hughes' Obesity
Hughes contends that the ALJ failed to adequately evaluate her obesity including the aggravating impact that her obesity has on her bilateral knee osteoarthritis and RLS when formulating the RFC. Hughes suggests that her obesity aggravates the symptoms of her bilateral knee osteoarthritis and RLS and limits her ability to stand and/or walk. The Court agrees that the ALJ failed to specifically address Hughes' obesity and offered no analysis of the exacerbating effect of her obesity on her underlying conditions. The ALJ's failure to consider Hughes' obesity along with her other impairments was not harmless error.
"According to SSR 02-1p, an ALJ should consider the effects of obesity together with the underlying impairments, even if the individual does not claim obesity as an impairment." Prochaska v. Barnhart, 454 F.3d 731, 736 (7th Cir. 2006); see also Arnett v. Astrue, 676 F.3d 586, 593 (7th Cir. 2012) (stating "[a]n ALJ must factor in obesity when determining the aggregate impact of [a claimant's] impairments."). That is so because "[t]he combined effects of obesity with other impairments can be greater than the effects of each of the impairments considered separately." SSR 02-1p, 2002 WL 34686281, at *1 (Sept. 12, 2002).
The record demonstrates that Hughes was obese during some of the applicable period. On March 3, 2014, Hughes' Body Mass Index (BMI) was 30.81. (R. 448). A BMI of 30.0 or above is classified as obese. SSR 02-1p, 2002 WL 34686281, at *2 (Sept. 12, 2002). Hughes is 5'1" tall and her weight during the March 19, 2014 consultative examination with Dr. Velis was 165 pounds, meaning her BMI was 31.2. (R. 19, 433). On November 16, 2015, Hughes had a BMI of 31.366. (R. 800). Her BMI increased to 32.783 on February 1, 2016. (R. 820). When Hughes saw Dr. Goldberg on May 10, 2016, her BMI was 33.444. (R. 842).
Dr. Velis reported that Hughes is 5'3'' tall without shoes. (R. 433). Hughes points out, and the Commissioner does not dispute, that Dr. Velis' height measurement is an outlier. (Doc. 14 at 7-8 n. 9). The ALJ did not reject Hughes' testimony that she is 5'1'' tall (R. 19, 44), and the medical records overwhelmingly show that Hughes is 5'1'' tall. (R. 278, 323, 337, 386, 439, 448, 680, 720, 739, 783).
Hughes argues that the ALJ failed to address how her obesity affected her knee pain and her ability to stand and/or walk six hours in an eight-hour workday. Hughes' argument has merit. "[U]nder S.S.R. 02-1p the ALJ must specifically address the effect of obesity on a claimant's limitations." Villano v. Astrue, 556 F.3d 558, 562 (7th Cir. 2009). The ALJ barely acknowledged Hughes' weight in his decision. Apart from a reference to Hughes' testimony regarding her height and weight and one incorrect reference to Hughes being "overweight" with a BMI of 33.46, the ALJ did not discuss Hughes' weight. (R. 19, 22). The ALJ did not mention the words "obese" or "obesity" in his decision. Accordingly, the ALJ erred by failing to specifically address the effect of Hughes' obesity when formulating the RFC. See Goins v. Colvin, 764 F.3d 677, 681 (7th Cir. 2014) (finding "[t]he [ALJ] gave meager attention to the plaintiff's obesity . . . . We keep telling . . . [ALJs] that they have to consider an applicant's medical problems in combination.").
A BMI of 30 or higher is considered "obese," not "overweight."
The Commissioner does not dispute that Hughes was obese during the relevant time period and that the ALJ did not recognize that Hughes was obese. The Commissioner appears to suggest that the ALJ implicitly factored Hughes' obesity into the decision as part of the state agency physicians' opinions. (Doc. 19 at 2-3). In some cases, an ALJ's failure to explicitly discuss the impact of obesity may be harmless. "[T]his type of error may be harmless when the RFC is based on limitations identified by doctors who specifically noted obesity as a contributing factor to the exacerbation of other impairments." Pepper v. Colvin, 712 F.3d 351, 364 (7th Cir. 2013); Skarbek v. Barnhart, 390 F.3d 500, 504 (7th Cir. 2004) (noting that "the ALJ adopted the limitations suggested by the specialists and reviewing doctors, who were aware of Skarbek's obesity. Thus, although the ALJ did not explicitly consider Skarbek's obesity, it was factored indirectly into the ALJ's decision as part of the doctors' opinions.").
The Court rejects the Commissioner's harmless error argument as this case lacks evidence suggesting the ALJ implicitly considered Hughes' obesity. There is no evidence that the state agency physicians were aware of Hughes' obese condition. Neither state agency physician noted Hughes' obesity in their assessments. The consulting physicians' only noted Hughes' self-reported height of 61 inches and weight of 142 pounds, which corresponds to a BMI of 26.8 and placed her in the "overweight" rather than "obese" category on the BMI scale. (R. 73, 79, 87, 98). Also, the ALJ's RFC finding is not based on the state agency physicians' opinions. The ALJ gave Dr. Panepinto's opinion that Hughes' osteoarthrosis, essential hypertension, ischemic heart disease, and hyperlipidemia were not severe "little weight," finding that "the evidence indicates the claimant has severe physical impairments." (R. 22). With respect to Dr. Oh, the ALJ assigned his opinion that Hughes could perform medium exertional work "only little weight" because "the evidence does indicate the claimant is limited to a wide range of light work exertionally." Id. Because the reports of the state agency physicians did not note Hughes' obesity and the ALJ did not credit those reports, the ALJ's failure to sufficiently consider Hughes' obesity in formulating the RFC was not harmless.
A BMI of 25 to 29.9 is classified as "overweight." SSR 02-1p, 2002 WL 34686281, at *2.
Given that obesity may exacerbate pain and limitations from arthritis affecting weight-bearing joints, the ALJ's failure to address obesity in combination with Hughes' bilateral knee osteoarthritis and knee pain is an error that is potentially dispositive and could alter Hughes' RFC. SSR 02-1p, 2002 WL 34686281, at *1 (Sept. 12, 2002) (recognizing that "someone with obesity and arthritis affecting a weight-bearing joint may have more pain and limitation than might be expected from the arthritis alone."); Barnett v. Barnhart, 355 F.3d 1065, 1068 (7th Cir. 2004) (noting "[e]ven if Barrett's arthritis was not particularly serious in itself, it would interact with her obesity to make standing for two hours at a time more painful than it would be for a person who was either as obese as she or as arthritic as she but not both."). A remand is warranted on this issue because Hughes' obesity may impact the severity of her other impairments and her functional limitations. On remand, the ALJ shall consider the impact of Hughes' obesity in combination with her other impairments in assessing her RFC, particularly with respect to exertional limitations such as standing and walking.
B. The ALJ's Assessment of Hughes' Restless Legs Syndrome
Hughes' next argument is that the ALJ failed to adequately account for her RLS in the RFC formulation by erroneously rejecting Dr. Goldberg's opinion. On May 10, 2016, Dr. Goldberg examined Hughes at Rush University Medical Center. (R. 588-91). That same day, Dr. Goldberg completed a Physical Medical Source Statement. (R. 558-61). Dr. Goldberg noted diagnoses of coronary artery disease, hypertension, hyperlipidemia, gastroesophageal reflux disease, and RLS. (R. 558). He indicated a good prognosis and reported that treatment for RLS had consisted of Gabapentin which failed and Pramipexole. Id. He noted that Hughes experienced nightly pain in her legs. (R. 558).
Restless legs syndrome (RLS) "causes unpleasant or uncomfortable sensations in the legs and an irresistible urge to move them. Symptoms commonly occur in the late afternoon or evening hours, and are often most severe at night when a person is resting, such as sitting or lying in bed." National Institute of Neurological Disorders and Stroke, "Restless Legs Syndrome Fact Sheet," https://www.ninds.nih.gov/Disorders/Patient-Caregiver-Education/Fact-Sheets/Restless-Legs-Syndrome-Fact-Sheet. RLS is "one of several disorders that can cause exhaustion and daytime sleepiness, which can strongly affect mood, concentration, job and school performance." Id.
Dr. Goldberg opined that Hughes would be absent from work more than four days per month as a result of her impairments. (R. 561). He indicated that Hughes' impairments are likely to produce "good days" and "bad days." Id. Dr. Goldberg further opined that Hughes should elevate her legs with prolonged sitting; she can sit two hours in an eight-hour workday; she can stand and/or walk two hours per workday; she can stand one hour at a time; she required a job that allows her to shift positions at will; and she needed to walk around during an eight-hour workday and take unscheduled breaks. (R. 559-60). According to Dr. Goldberg, Hughes' impairments were reasonably consistent with the symptoms and functional limitations described. (R. 561).
The ALJ found that Hughes' RLS was a severe impairment. (R. 15). The ALJ limited Hughes to "no work around hazards as a result of her restless leg syndrome which interferes with sleep to some degree and would cause some degree of fatigue." (R. 23). The ALJ afforded "little weight" to Dr. Goldberg's opinions regarding Hughes' limitations because they were "not supported by his own examination." (R. 23). "An ALJ can reject an examining physician's opinion only for reasons supported by substantial evidence in the record." Vanprooyen v. Berryhill, 864 F.3d 567, 572 (7th Cir. 2017) (citing Gudgel v. Barnhart, 345 F.3d 467, 470 (7th Cir. 2003)).
The two reasons the ALJ offered for rejecting the opinion of Dr. Goldberg are not supported by substantial evidence. First, the ALJ found that the "physical examination taken by [Dr. Goldberg] was unremarkable and he noted full range of motion in all joints and that the claimant was neurologically normal." (R. 23). The ALJ also noted that "repeated examinations by Dr. Shah [Dr. Goldberg's colleague] showed normal physical examinations." Id. Second, the ALJ determined that Dr. Goldberg's opinions were based on Hughes' self-reports. Id.
The ALJ's emphasis on normal physical examinations and the lack of any neurological abnormality demonstrates a misunderstanding of RLS. There "is no specific test for RLS," and the ALJ cited no medical authority to the contrary. See National Institute of Neurological Disorders and Stroke, "Restless Legs Syndrome Fact Sheet," https://www.ninds.nih.gov/Disorders/Patient-Caregiver-Education/Fact-Sheets/Restless-Legs-Syndrome-Fact-Sheet. The cited normal physical examinations and neurologic exam are therefore not relevant to the severity of Hughes' RLS. See Sarchet v. Chater, 78 F.3d 305, 307 (7th Cir. 1996) (holding "[s]ince swelling of the joints is not a symptom of fibromyalgia, its absence is no more indicative that the patient's fibromyalgia is not disabling than the absence of a headache is an indication that a patient's prostate cancer is not advanced."); see also Sevier v. Berryhill, 2017 WL 466546, at *4 (C.D. Cal. Jan. 31, 2017) (finding because "no clinical tests exist for diagnosing restless leg syndrome," "the fact that there were no clinical findings to support restless leg syndrome cannot be a basis for finding plaintiff less credible."); Coffrey v. Astrue, 2012 WL 4482047, at *13 (N.D. Cal. Sept 28, 2012) (noting treating physician wrote that he could not provide any "clinical findings" on plaintiff's RLS "because there is no medical test available to confirm RLS directly."). Hughes' normal physical examinations and lack of a neurological abnormality do not undermine Dr. Goldberg's opinions on her functional limitations.
Along these same lines, the ALJ's second reason for discounting Dr. Goldberg's opinion fails. The ALJ stated: "Dr. Goldberg noted in the examination report that 'patient reports disability secondary to her restless leg syndrome.' This indicates that he had assessed these limitations based on the claimant's statements regarding her condition rather than his examination or the extensive medical records showing unremarkable examinations." (R. 23). The ALJ reasoned that Dr. Goldberg's limitations opinion "must be regarded as sympathetic and not supported by the medical evidence of record." Id.
The Seventh Circuit has held that "if the treating physician's opinion is . . . based solely on the patient's subjective complaints, the ALJ may discount it." Ketelboeter v. Astrue, 550 F.3d 620, 625 (7th Cir. 2008). The Seventh Circuit has recently noted, however, that it is "illogical to dismiss the professional opinion of an examining psychiatrist or psychologist simply because that opinion draws from the claimant's reported symptoms" when considering bipolar disorder for which "there isn't 'objective medical evidence' that can support a diagnosis." Aurand v. Colvin, 654 Fed.Appx. 831, 837 (7th Cir. 2016). Similarly, it is illogical to reject an examining physician's assessment of RLS based on self-reports when that condition is diagnosed based on subjective symptoms. In diagnosing RLS, "[a] physician will focus largely on the individual's descriptions of symptoms, their triggers and relieving factors, as well as the presence or absence of symptoms throughout the day." National Institute of Neurological Disorders and Stroke, "Restless Legs Syndrome Fact Sheet," https://www.ninds.nih.gov/Disorders/Patient-Caregiver-Education/Fact-Sheets/Restless-Legs-Syndrome-Fact-Sheet. The ALJ's focus on unremarkable physical examinations and dismissal of Dr. Goldberg's opinion due to his reliance on Hughes' self-reports is another reflection of the ALJ's failure to recognize the subjective nature of RLS, which is "diagnosed by a doctor's evaluation" of clinical symptoms. Id.
The ALJ's errors with respect to Dr. Goldberg's May 10, 2016 opinion are not harmless. If the ALJ had understood the subjective nature of RLS and properly considered Dr. Goldberg's opinion, the ALJ may have included additional limitations in the RFC. Dr. Goldberg found Hughes would be absent from work more than four days per month, needed to elevate her legs with prolonged sitting, needed to walk around during an eight-hour workday and take unscheduled breaks, and required the option to sit/stand/walk at-will. (R. 559-61). If Dr. Goldberg's opinion as to Hughes' limitations were included in the RFC and in the hypothetical questions posed to the VE, the ALJ's nondisability determination may have changed. (R. 66-70). On remand, the ALJ shall re-evaluate the weight to be afforded Dr. Goldberg's opinion in light of the subjective nature of RLS.
Next, Hughes faults the ALJ for failing to account for the sleepiness side effect of her RLS medication on her on-task time and work pace when determining her RFC. In response, the Commissioner argues that the ALJ explicitly accounted for Hughes' allegations that her medication caused fatigue by limiting her to no exposure to work hazards. When determining a claimant's RFC, the ALJ must take into account "[t]he effects of treatment, including limitations or restrictions imposed by the mechanics of treatment (e.g., frequency of treatment, duration, disruption of routine, side effects of medication.)." SSR 96-8p, 1996 WL 374184, at *5 (July 2, 1996). An ALJ is not required to address every piece of evidence or testimony presented, but he must articulate "some legitimate reason for his decision" and provide a "logical bridge" between the evidence and his conclusion. Clifford v. Apfel, 227 F.3d at 872.
Hughes testified at the hearing that the new medication for her RLS (Pramipexole) makes her feel "druggy" and "puts [her] to sleep." (R. 52). "I don't' like it, but I take it," Hughes said. Id. The ALJ noted Hughes' testimony that her medication for RLS "makes her sleepy." (R. 20). Regarding medication side effects, the ALJ stated:
At the hearing, she complained that the new medication for restless leg syndrome made her sleepy, but she had earlier told a treating source it only affected her at night and that it kept her from sleeping. If such was the case, the side effect would actually be beneficial for her.
(R. 21-22). The ALJ concluded that Hughes should be "limited to no work around hazards as a result of her restless leg syndrome which interferes with sleep to some degree and would cause some degree of fatigue." (R. 23).
The ALJ did not adequately consider the sleepiness side effect of Hughes' RLS medication. While the ALJ noted that Hughes testified that "the new medication for restless leg syndrome made her sleepy" and also considered that Hughes' RLS interfered with her sleep and caused some daytime fatigue, the ALJ did not provide a legitimate reason for his determination that sleepiness "would actually be beneficial for her" because Hughes reported difficulty sleeping at night. (R. 22-23). The ALJ cited no evidence to support his finding that the sleepiness side effect Hughes described was limited to the nighttime and did not occur during the day. Hughes did not testify that the sleepiness side effect of Pramipexole only affected her at night, and the ALJ has no medical expertise to make such a conclusion. (R. 52). The ALJ's discussion fails to build a logical bridge between Hughes' testimony and his conclusion that the sleepiness side effect of her RLS medication was "actually . . . beneficial" because Hughes reported difficulty sleeping at night. (R. 22). On remand, the ALJ should consider the sleepiness side effect of Hughes' RLS medication on her ability to work, including her ability to maintain on-task time and work pace.
C. The ALJ's Consideration of Hughes' Bilateral Knee Osteoarthritis
Hughes additionally contends that the ALJ failed to adequately account for the severity of her knee impairments in determining her RFC and assessing her credibility. The ALJ identified Hughes' bilateral knee osteoarthritis as a severe impairment at step two and limited her to no climbing of ladders, ropes, or scaffolds, kneeling, or crawling and to only occasional climbing of ramps and stairs, balancing, stooping, and crouching due to her bilateral knee osteoarthritis. (R. 15, 21, 23). The ALJ found that Hughes could perform the walking and/or standing requirements of light work. (R. 21). The ALJ stated that the RFC for "light work takes into account all limitations that would be expected from the claimant's bilateral knee osteoarthritis. As a result of this osteoarthritis, the undersigned has limited the claimant to a light exertional capacity rather than medium." (R. 23).
Hughes argues that the ALJ failed to adequately account for her knee pain and difficulties in standing and/or walking in limiting her to a range of light work. Hughes testified at the hearing that she could stand for 20-30 minutes at a time if she can shift her weight and walk for only a couple of blocks due to knee pain. (R. 55-56). By finding certain postural limitations due to her osteoarthritis, the ALJ accepted that Hughes has some degree of limitation in using her knees. However, the ALJ's RFC did not reduce the walking and standing requirements normally associated with light work (i.e., 6 hours of an 8-hour workday). It is not clear how the ALJ determined that Hughes can stand and walk for six as opposed to five, four, three or two hours in an eight hour day. The ALJ did not explain why the evidence supported certain postural limitations but still allowed Hughes to stand or walk for six out of eight hours every workday. Moreover, the full range of medium work and light work both require "standing or walking, off and on, for a total approximately 6 hours of an 8-hour workday." SSR 83-10, 1983 WL 31251, at *6 (1983). The ALJ's statement that he limited Hughes to light work rather than medium work as a result of her osteoarthritis is unexplained because light work does not demand less standing and walking than medium work. Thus, the ALJ did not adequately explain how the RFC for light work rather than medium work accounted for Hughes' bilateral knee osteoarthritis. In sum, the ALJ fails to logically explain the basis for his finding that Hughes can stand and/or walk 6 hours of an 8-hour workday or how it accounts for Hughes' severe bilateral knee osteoarthritis.
The Commissioner argues that "the ALJ could reasonably find that standing or walking while carrying up to 50 pounds as required by medium work, is more stressful on the knees than standing or walking while carrying up to only 20 pounds or less, as required by light work." (Doc. 19 at 3). The Commissioner's argument is rejected as an impermissible post-hoc rationalization because the ALJ did not justify his RFC for light work by pointing to the lifting requirement differences between the two exertional levels. Meuser v. Colvin, 838 F.3d 905, 911 (7th Cir. 2016) (stating "the ALJ did not rely on this rationale in his opinion, so the Commissioner cannot now rely on it."); Parker v. Astrue, 597 F.3d 920, 922 (7th Cir. 2010) (stating "the Chenery doctrine [] forbids an agency's lawyers to defend the agency's decision on grounds that the agency itself had not embraced.").
The difference between the standing and walking requirements of light work and sedentary work is potentially dispositive in this case. Dr. Goldberg opined that Hughes was limited to two hours of standing and/or walking in an eight-hour workday. (R. 560). As explained above, the ALJ's RFC assessment, which fails to include Dr. Goldberg's limitations, is not supported by substantial evidence. If the ALJ had properly considered Hughes' knee pain and Dr. Goldberg's opinion in assessing her ability to stand and walk, then it is possible the ALJ would have found Hughes was limited to less than six hours of standing and/or walking a day. If Hughes were limited to unskilled sedentary work, she would be found disabled under the grids as of her 50th birthday. See 20 C.F.R. § 404, Subpt. P. App. 2 § 201.14; § 201.00(g) (providing that "[i]ndividuals approaching advanced age (age 50-54) may be significantly limited in vocational adaptability if they are restricted to sedentary work. When such individuals have no past work experience or can no longer perform vocationally relevant past work and have not transferrable skills, a finding of disabled ordinarily obtains."); Thomas v. Colvin, 534 Fed.Appx. 546, 550 (7th Cir. 2013) (holding "the grids mandate a finding of disability at [the claimant's] 50thbirthday if she is limited to sedentary work."). The Commissioner does not dispute that Hughes would be disabled under the grids at her 50th birthday if she is limited to sedentary work. Because the Court is not confident that the ALJ would have reached the same conclusion about Hughes' RFC had he properly accounted for Hughes' knee pain and limitation, the ALJ's errors are not harmless. McKinzey v. Astrue, 641 F.3d 884, 892 (7th Cir. 2011) (explaining that error is harmless only if the court is "convinced that the ALJ will reach the same result" on remand).
Hughes further argues that the ALJ erred in assessing her RFC because he failed to include a limitation on the need to elevate her left leg to hip level during prolonged sitting. At the hearing before the ALJ, Hughes testified that elevating her left leg during prolonged sitting relieved the throbbing pain. (R. 53-55). Dr. Goldberg recommended leg elevation with prolonged sitting. (R. 559). The vocational expert opined that if Hughes had to elevate her legs parallel to the ground, Hughes could not perform work in the national economy. (R. 68).
The ALJ acknowledged Dr. Goldberg's opinion about Hughes' need to elevate her legs with prolonged sitting, but noted that Dr. Goldberg "did not say for how long, how often, or how high." (R. 19). The ALJ gave "little weight" to Dr. Goldberg's opinion that Hughes needed to elevate her legs during prolonged sitting. (R. 23). The ALJ's RFC determination that Hughes did not need to elevate her legs during prolonged sitting thus depends upon whether the weight he assigned to Dr. Goldberg's opinion as an examining source is supported by substantial evidence. As discussed above, the ALJ's decision to give little weight to Dr. Goldberg's opinion is not supported by substantial evidence. Remand is appropriate to reevaluate the weight to be afforded Dr. Goldberg's opinions, including reassessing his opinion that Hughes needs to elevate her legs during prolonged sitting. Additionally, on remand, the ALJ shall re-contact Dr. Goldberg to determine "how long, how often, and how high" Hughes must elevate her legs during the workday. (R. 19); see Beardsley v. Colvin, 758 F.3d 834, 837 (7th Cir. 2014) (noting "[t]he ALJ [ ] has a basic obligation to develop a full and fair record."); Smith v. Astrue, 467 Fed.Appx. 507, 511 (7th Cir. 2012) (stating "while the record on this issue [of plaintiff's need for leg elevation] is relatively sparse, to the extent the ALJ needed a fuller record to make her decision, she had a duty to develop it.").
Hughes also asserts that in evaluating her credibility, the ALJ impermissibly "played doctor" when interpreting an x-ray of her knees taken in February 2016. The Commissioner does not respond to this specific argument, and the Court agrees that the ALJ's evaluation of Hughes' x-ray results is flawed because the ALJ impermissibly "played doctor." The Seventh Circuit has held that "an ALJ cannot play the role of doctor and interpret medical evidence when he or she is not qualified to do so." Murphy v. Astrue, 496 F.3d 630, 634 (7th Cir. 2007); Rohan v. Chater, 98 F.3d 966, 970 (7th Cir. 1996) (stating "as this Court has counseled on many occasions, ALJs must not succumb to the temptation to play doctor and make their own independent medical findings.").
Hughes' testimony suggested more severe limitations than reflected in the RFC. Hughes testified at the hearing that she could stand for 20-30 minutes at a time if she can shift her weight, walk for only a couple of blocks due to knee pain, and needed to elevate her left leg with prolonged sitting to stop the throbbing pain in her knee. (R. 54-56). The ALJ found it "significant" that the x-ray of Hughes' knees on February 25, 2016 showed an impression of "only mild" bilateral patellofemoral joint space narrowing suggestive of early degenerative change. (R. 22). The ALJ then based his negative credibility determination in part on the x-ray. The ALJ stated that the x-ray of Hughes' knees was "not consistent with the claimant's extreme complaints of pain and limitation which included a statement that she had extreme pain after climbing the stairs every morning." Id.
Without an expert opinion from a medical source, the ALJ is not qualified to conclude that mild bilateral patellofemoral joint space narrowing is inconsistent with Hughes' complaints of knee pain and limitation. Akin v. Berryhill, 887 F.3d 314, 317 (7th Cir. 2018) (holding "without an expert opinion interpreting the MRI results in the record, the ALJ was not qualified to conclude that the MRI results were 'consistent' with his assessment."); Dolan v. Colvin, 2016 WL 6442226, at *4 (N.D. Ill. Nov. 1, 2016) (noting that "MRI report refers in places to 'mild' findings, such as 'mild lumbar canal stenosis' and '[m]ild spondylotic changes,' [but] these are medical terms that are not obvious to a layperson, and thus need interpretation by an expert."). The x-ray "results may corroborate [Hughes'] complaints, or they may lend support to the ALJ's original interpretation, but either way the ALJ was not qualified to make his own determination without the benefit of an expert opinion." Akin, 887 F.3d. at 317-18; see also Israel v. Colvin, 840 F.3d 432, 440 (7th Cir. 2016) (stating "[b]ecause no physician in the record has opined on whether these results [from two MRIs] are consistent with Israel's claim of disabling pain, and because the reports are replete with technical language that does not lend itself to summary conclusions, we cannot say whether the results support or undermine Israel's claim."). Because the ALJ erred by interpreting the significance of x-ray results himself, a remand is required. On remand, the ALJ shall seek an expert opinion as to whether Hughes' x-ray of her knees reveals abnormalities that would result in the level of functional limitations she alleges. Israel, 840 F.3d at 440 (directing "[o]n remand, these [MRI] records should be reviewed by a physician to determine whether they are in fact consistent with Israel's claim of disability.").
D. Remaining Issues
Because a remand is warranted on the above grounds, the Court need not reach the other arguments raised by Hughes. For consideration on remand, however, the Court notes that the ALJ's analysis is based in part on misstatements of the evidence applicable to Hughes' bilateral knee osteoarthritis and RLS. First, in determining Hughes' RFC, the ALJ stated that at a consultative internal medicine examination on March 19, 2014, Dr. Velis noted "a full range of motion of both knees." (R. 22). This statement is incorrect. Dr. Velis wrote that "[t]here was range of motion pain of both knees" and "[f]lexion [was] limited to 90°. There is full range of motion noted in all other joints." (R. 434). The ALJ also stated that Hughes testified that her RLS "is present only at night and improved with medication." (R. 21). A careful review of Hughes' testimony does not support the ALJ's statement that Hughes stated that she had symptoms of RLS only at night. (R. 49-50). Hughes testified that she has symptoms of RLS during the day as well. Id. On remand, the ALJ should correct the misstatements of fact discussed herein and revise any portions of his decision affected thereby.
Earlier in the opinion, the ALJ correctly stated that Dr. Velis noted "range of motion of all joints was normal except for the knees, where flexion was limited to 90°." (R. 17). --------
For the reasons and to the extent stated above, the ALJ's decision is reversed, and this case is remanded to the Social Security Administration for further proceedings consistent with this Opinion. The Commissioner's Motion for Summary Judgment [18] is denied. The Clerk is directed to enter judgment in favor of Plaintiff Stephanie Hughes and against Defendant Commissioner of Social Security.
/s/ _________
Daniel G. Martin
United States Magistrate Judge Dated: August 1, 2018


text:
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    throw std::runtime_error("Not supported.");
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void ReadOnlyNoExcept::write([[maybe_unused]] double value)
{
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} // namespace pid_control


text:
About EB-5 Visa
The EB-5 Program: A Definitive Guide to EB-5 Visa
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Why CanAm?
CanAm's Sora West Office EB-5 Project Receives First I-526 Petition Approval by USCIS
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The $39.5 million EB-5 loan is being utilized for the construction of a new office tower at SORA West, a large-scale multi-faceted development in the center of Conshohocken, PA, just outside of Philadelphia. The office tower will be fully leased to AmerisourceBergen (NYSE: ABC), the global pharmaceutical and healthcare products distribution company and serve as the global headquarters for the Fortune 10 company. AmerisourceBergen will begin a phased takeover of the space beginning in January and the project will be fully complete in mid-2021. Given its position in the medical supply industry, AmerisourceBergen has performed well economically during the current environment brought about by the COVID-19 virus.
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To date, over 4,800 investor-families have received I-526 approvals through investing in one of CanAm's 60 EB-5 projects. Prospective investors pursuing permanent residency in the United States are invited to read CanAm's EB-5 Program Overview and inquire about the EB-5 Visa options.
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With three decades of experience promoting immigration-linked investments in the United States and Canada, CanAm has a long and established track record. Basing its business on a reputation of credibility and trust, CanAm has financed over 60 projects and raised $3 billion in EB-5 investments. More than $1.75 billion in EB-5 capital from over 3,500 families has been repaid by CanAm to date. CanAm exclusively operates seven USCIS-designated regional centers that are located in the city of Philadelphia, the Commonwealth of Pennsylvania, the metropolitan regions of New York & New Jersey, the states of California, Hawaii, Florida, and Texas. For more information, please visit www.canamenterprises.com.
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text:
Granulomatous interstitial nephritis
Shivani Shah, Naima Carter-Monroe, Mohamed G. Atta
Granulomatous interstitial nephritis (GIN) is a rare entity detected in ∼0.5-0.9% of all renal biopsies. GIN has been linked to several antibiotics such as cephalosporins, vancomycin, nitrofurantoin and ciprofloxacin. It is also associated with NSAIDs and granulomatous disorders such as sarcoidosis, tuberculosis, fungal infections, and granulomatosis with polyangiitis. Renal biopsy is critical in establishing this diagnosis, and the extent of tubular atrophy and interstitial fibrosis may aid in determining prognosis. Retrospective data and clinical experience suggest that removal of the offending agent in conjunction with corticosteroid therapy often results in improvement in renal function. We describe a patient with a history of multiple spinal surgeries complicated by wound infection who presented with confusion and rash with subsequent development of acute kidney injury. Urinalysis demonstrated pyuria and eosinophiluria, and renal biopsy revealed acute interstitial nephritis with granulomas. These findings were attributed to doxycycline treatment of his wound infection. This review explores the clinical associations, presentation, diagnosis, and treatment of this uncommon cause of acute kidney injury.
Clinical Kidney Journal
https://doi.org/10.1093/ckj/sfv053
Granuloma
10.1093/ckj/sfv053
Dive into the research topics of 'Granulomatous interstitial nephritis'. Together they form a unique fingerprint.
Interstitial Nephritis Medicine & Life Sciences 100%
Wound Infection Medicine & Life Sciences 39%
Acute Kidney Injury Medicine & Life Sciences 36%
Pyuria Medicine & Life Sciences 27%
Nitrofurantoin Medicine & Life Sciences 26%
Granulomatosis with Polyangiitis Medicine & Life Sciences 23%
Shah, S., Carter-Monroe, N., & Atta, M. G. (2015). Granulomatous interstitial nephritis. Clinical Kidney Journal, 8(5), 516-523. https://doi.org/10.1093/ckj/sfv053
Granulomatous interstitial nephritis. / Shah, Shivani; Carter-Monroe, Naima; Atta, Mohamed G.
In: Clinical Kidney Journal, Vol. 8, No. 5, 10.2015, p. 516-523.
Shah, S, Carter-Monroe, N & Atta, MG 2015, 'Granulomatous interstitial nephritis', Clinical Kidney Journal, vol. 8, no. 5, pp. 516-523. https://doi.org/10.1093/ckj/sfv053
Shah S, Carter-Monroe N, Atta MG. Granulomatous interstitial nephritis. Clinical Kidney Journal. 2015 Oct;8(5):516-523. doi: 10.1093/ckj/sfv053
Shah, Shivani ; Carter-Monroe, Naima ; Atta, Mohamed G. / Granulomatous interstitial nephritis. In: Clinical Kidney Journal. 2015 ; Vol. 8, No. 5. pp. 516-523.
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title = "Granulomatous interstitial nephritis",
abstract = "Granulomatous interstitial nephritis (GIN) is a rare entity detected in ∼0.5-0.9% of all renal biopsies. GIN has been linked to several antibiotics such as cephalosporins, vancomycin, nitrofurantoin and ciprofloxacin. It is also associated with NSAIDs and granulomatous disorders such as sarcoidosis, tuberculosis, fungal infections, and granulomatosis with polyangiitis. Renal biopsy is critical in establishing this diagnosis, and the extent of tubular atrophy and interstitial fibrosis may aid in determining prognosis. Retrospective data and clinical experience suggest that removal of the offending agent in conjunction with corticosteroid therapy often results in improvement in renal function. We describe a patient with a history of multiple spinal surgeries complicated by wound infection who presented with confusion and rash with subsequent development of acute kidney injury. Urinalysis demonstrated pyuria and eosinophiluria, and renal biopsy revealed acute interstitial nephritis with granulomas. These findings were attributed to doxycycline treatment of his wound infection. This review explores the clinical associations, presentation, diagnosis, and treatment of this uncommon cause of acute kidney injury.",
keywords = "AIN, AKI, Doxycycline, Granuloma",
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AB - Granulomatous interstitial nephritis (GIN) is a rare entity detected in ∼0.5-0.9% of all renal biopsies. GIN has been linked to several antibiotics such as cephalosporins, vancomycin, nitrofurantoin and ciprofloxacin. It is also associated with NSAIDs and granulomatous disorders such as sarcoidosis, tuberculosis, fungal infections, and granulomatosis with polyangiitis. Renal biopsy is critical in establishing this diagnosis, and the extent of tubular atrophy and interstitial fibrosis may aid in determining prognosis. Retrospective data and clinical experience suggest that removal of the offending agent in conjunction with corticosteroid therapy often results in improvement in renal function. We describe a patient with a history of multiple spinal surgeries complicated by wound infection who presented with confusion and rash with subsequent development of acute kidney injury. Urinalysis demonstrated pyuria and eosinophiluria, and renal biopsy revealed acute interstitial nephritis with granulomas. These findings were attributed to doxycycline treatment of his wound infection. This review explores the clinical associations, presentation, diagnosis, and treatment of this uncommon cause of acute kidney injury.
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