Andrew T. Huang, MD

  • Professor
  • Department of Medicine
  • Duke University Medical School
  • Durham, North Carolina
  • President and CEO
  • Koo Foundation Sun Yat-Sen Cancer Center
  • Taipei, Taiwan

Musculoskeletal involvement usually presents as proximal muscle weakness and pain anxiety 247 buy 15mg abilify with amex, with weakness occurring predominantly in the lower limb girdle and lower extremities making it difficult to climb stairs or walk depression test black dog cheap abilify 5 mg with amex. Weakness can affect the anterior neck flexor and back muscles mood disorder nos in dsm 5 cheap abilify 15 mg overnight delivery, making holding up the head and overhead arm use difficult depression symptoms medication buy abilify 5 mg cheap. Dysphonia and nasal speech can be an ominous sign anxiety vs heart attack discount abilify 10 mg free shipping, indicating pharyngeal anxiety exhaustion buy line abilify, hypopharyngeal, and palatal muscle weakness that places the patient at risk for aspiration. Children may have arthralgia or even a mild arthritis, and some develop contractures because of myofascial inflammation. Most patients will develop the pathognomonic Gottron papules and heliotrope discoloration of the eyelids. Gottron papules are erythematous to violaceous, sometimes scaling, flat-topped lesions located over the extensor surfaces of interphalangeal or metacarpophalangeal joints. There is often dilation of the capillary loops of the nailfold with corresponding cuticle overgrowth. Cutaneous vasculitic ulcerations are commonly seen at the corners of the eyes, in the axillae and at pressure points. Calcinosis may occur in the muscle or subcutaneous layer, and can be debilitating. Some patients experience visceral vasculopathy, which can cause severe abdominal pain, melena, and hematemesis, and can be life threatening. Although serious cardiac involvement is rare, conduction defects have been associated with mortality. Respiratory muscle weakness is also rare, but can cause restrictive pulmonary disease. Neopterin, a marker of activated monocytes and macrophages, is increased with inflammation, infection, or malignant disease. Muscle biopsy is the gold standard in diagnosis, and the typical findings in dermatomyositis are necrosis, phagocytosis, perifascicular atrophy, fiber size variation, and perivascular inflammation. However, muscle involvement is patchy and pathology can be missed if a good biopsy site is not identified. This diagnosis is unlikely for the girl in the vignette, who has a distinctive rash and does not have progressive weakness or signs of muscle involvement other than her legs. The patient in the vignette has an inflammatory muscle disease with rash, weakness, and abnormal inflammatory markers that would not be seen in muscular dystrophy. The girl in the vignette did not have any changes in sensation or sensory level consistent with spinal cord compression, and her family did not report urinary or stool incontinence. Polymyositis, dermatomyositis, and autoimmune necrotizing myopathy: Clinical Features. You observe that the patient has a slight limp and out-toed gait on the left side. He denies history of trauma, knee swelling, knee instability, and catching or locking of the knee joint. The patient in the vignette is an obese peripubertal child with anterior knee pain and an out-toed gait (caused by obligate external hip rotation). On physical examination, obesity and decreased hip internal rotation are the most common findings. On the lateral view, a "Klein line" drawn along the superior border of the femoral neck should intersect the femoral head, and should be symmetric with comparison of both hips. Bilateral surgery is generally performed in patients with bilateral symptoms or in the presence of risk factors (eg, body mass index >35, young age) for a subsequent contralateral slip. Palpation of the medial joint line would be most useful to assess for a medial meniscal tear, which typically results from an acute injury in a young patient. Fundoscopic examination of the left eye reveals a chorioretinal scar with surrounding retinitis nasal to the disk and mild overlying vitritis (Item Q95). Item Q95 Fundoscopic examination of the left eye for the boy described in the vignette. The diagnosis is suggested by detecting immunoglobulin G antibody to gondii in serum, but is based largely on the characteristic appearance of the chorioretinal lesion, usually described as white focal retinitis with overlying vitreous inflammation that has the appearance of a "headlight in the fog. Isolated ocular toxoplasmosis develops in up to 85% of adolescents and young adults after untreated congenital infection. It also can become reactivated years after initial infection in both immunocompetent and immunocompromised individuals. Patients with ocular toxoplasmosis may complain of blurred vision, decreased acuity, epiphora (excessive tear formation), eye pain, floaters, photophobia, or scotoma. In most immunocompetent individuals, Toxoplasma infection either is asymptomatic or results in a self-limited and benign flulike illness. Rare complications include pneumonia, myocarditis, pericarditis, hepatitis, and cutaneous involvement. In patients with immunodeficiency, such as that caused by infection with human immunodeficiency virus, life-threatening manifestations of gondii infection can include encephalitis, pneumonia, or disseminated disease. Infants with congenital toxoplasmosis are asymptomatic in the majority (70%-90%) of cases, but may develop sequelae such as learning disability, mental retardation, hearing loss, or vision impairment later in life. Infants with symptomatic congenital infection can present with various signs such as lymphadenopathy, rash, hepatosplenomegaly, petechiae, thrombocytopenia, pneumonitis, meningoencephalitis, and chorioretinitis. Although rare, the classic triad of hydrocephalus, cerebral calcifications, and chorioretinitis is highly suggestive of congenital infection caused by gondii. Toxoplasma gondii is found worldwide, and the seroprevalence (11% in the United States) of infection varies by geographic area and socioeconomic status. Intermediate hosts such as pigs, sheep, and cattle can have tissue cysts in multiple organs. Humans become infected by ingestion of oocysts from soil (or cat feces) or contaminated food or water. Congenital infection results from primary maternal infection during gestation and is estimated to occur in 1 in 1,000 to 1 in 10,000 live births. Most cases of acquired toxoplasmosis in immunocompetent hosts do not require antimicrobial therapy. Item C95 shows antimicrobial regimens for the treatment of toxoplasmosis, when indicated. Indications for treatment include pregnancy, immunocompromised status, severe symptoms (eg, chorioretinitis or organ damage), or persistent symptoms. For immunocompromised patients, long-term antibiotic suppression often is indicated after the initial course of therapy to prevent recurrence. Posterior uveitis is more common and manifests as chorioretinitis that is multifocal, retinal necrosis, or optic neuritis. Patients usually have decreased visual acuity, often in association with syphilitic meningitis. Patients typically present with severe pain, photophobia, tearing, and the sensation of a foreign body in the eye. Cytomegalovirus retinitis is rare in immunocompetent individuals and usually involves the anterior chamber of the eye. The diagnosis can be made with polymerase chain reaction analysis of anterior chamber aqueous fluid. Patients will have conjunctivitis, chemosis, dendritic lesions of the cornea, and decreased corneal sensation. The diagnosis usually is clinical, but viral culture from ocular mucous membranes may isolate the pathogen. While running and holding the football in his left arm, he was tackled from behind. The patient fell forward and landed forcefully on his chest, with the weight of the opposing player on top of him. At that time, he heard a "cracking" sound and immediately felt pain in his chest and left shoulder. The patient is taking shallow breaths because of pain, but is not in respiratory distress. He is tender to palpation over the left sternoclavicular junction, as well as over his left first rib, and you note bruising over these areas. He has no focal tenderness on examination of his left shoulder, but he refuses to move his left shoulder due to pain. You find no evidence of trauma to his head and his cervical spine is nontender to palpation. The remainder of his physical examination findings, including a full neurologic examination, is unremarkable. He continues to complain of severe pain over his left sternoclavicular joint and subjective dyspnea, and refuses to move his left shoulder due to pain. It is important for all pediatric providers to know how to appropriately evaluate children who have sustained chest wall trauma. The forceful mechanism of the trauma, such as a motor vehicle accident, can cause additional serious injuries. All children with chest wall injuries should undergo a full physical examination, beginning with assessment of their airway, breathing, circulatory, and neurologic status, and then progressing to a head-to-toe secondary survey after any life-threatening conditions have been addressed. It is important for clinicians to keep in mind that, because the rib cages of children are generally more pliable than those of adults, traumatic forces may be transmitted to their intrathoracic organs; thus, significant intrathoracic injuries such as pulmonary contusion may occur even in the absence of injury to the chest wall structures. Chest wall injuries may include fractures of the ribs, sternum, clavicles, and scapulae, with rib fractures being the most common in children. Multiple rib fractures may result in flail chest, an uncommon but very serious injury that can cause respiratory insufficiency from a compromise to the structural integrity of the chest wall. Fractures of the upper ribs (especially the first and second), sternum, and scapulae should lead clinicians to consider more serious intrathoracic injuries such as pulmonary contusion, injury to the intrathoracic vessels, cervical spine injuries, and injuries to the trachea or esophagus. This concern is due to the large amount of force generally required to fracture these bones, given their protected anatomic positions. Posterior dislocation of the sternoclavicular joint or posterior displacement of a medial clavicle fracture are chest wall injuries that are relatively rare, but do occur in children. These injuries can present with very subtle physical examination findings and are often not apparent on plain radiography. Furthermore, they carry the risk of associated injuries to intrathoracic structures including the great vessels, esophagus, and trachea. Physical examination findings in children with posterior sternoclavicular joint dislocations may include pain localized to the sternoclavicular joint, a palpable gap at the joint (which can be subtle), and swelling at the medial end of the clavicle. Clinical symptoms may include difficulty swallowing, shortness of breath, hoarseness, and inability to move the shoulder on the affected side. Echocardiography certainly has a role in the evaluation of children who have sustained chest wall trauma, as a means of excluding cardiac injury. Echocardiography is indicated for those with abnormal electrocardiograms, ectopy, abnormal cardiac enzyme levels, or other evidence of cardiac injury after thoracic trauma. Many children with uncomplicated chest wall injuries, including those with simple clavicle fractures and fractures to the middle or lower ribs will not require further evaluation beyond plain radiography. Finally, plain radiography of the ribs would not aid in the evaluation for associated intrathoracic injuries or dislocation of the posterior sternoclavicular joint, which is indicated for the boy in the vignette. Standard anterior-posterior and lateral radiographs of the chest are sufficient for detecting the majority of rib fractures, therefore dedicated plain radiographs of the ribs are not needed in the evaluation of most patients. Posterior sternoclavicular joint dislocation in a child: a case report with review of literature. The neonate remains on a ventilator for respiratory distress syndrome 2 days after delivery. He is receiving light-emitting diode phototherapy for indirect hyperbilirubinemia (total bilirubin 6 mg/dL [102. Over the past 24 hours, the intravenous fluids have been increased to 140 mL/kg per day of intravenous dextrose 10% in water and his urine output has been 4 mL/kg per hour. This is exaggerated before a gestational age of 28 weeks because of immaturity of the skin leading to evaporation and high transepidermal water loss. Insensible water loss rates up to 200 mL/kg per day may be seen in extremely premature infants. If tape or topical agents do not compromise the integrity of the premature skin further, the skin will mature rapidly over the first week after birth and approach the insensible water loss rate of 20 mL/kg per day seen in a full-term infant. A premature infant on an open radiant warmer may have an increase of up to 50% in evaporative water loss. Full-term and late preterm infants typically require 60 to 80 mL/kg of fluid per day to meet their maintenance requirements and replace ongoing losses. Caution must be used to avoid fluid overload in premature infants, as noted in some studies that demonstrated increased rates of bronchopulmonary dysplasia in infants with greater fluid intake. The increasing serum sodium, chloride, blood urea nitrogen, and creatinine all suggest excessive free water loss that would be improved by placement in a humidified isolette. Changing the intravenous fluid to dextrose 5% in water would drop the serum glucose but not provide additional free water. The infant requires treatment for hyperbilirubinemia and the light emitting diode phototherapy does not increase insensible water loss. There was no loss or alteration in consciousness and no twitching or limb jerking. She has been falling asleep at school and her parents report that, on the weekends, the girl naps all afternoon. The girl appears to get good sleep at night, her hair and skin seem normal, she has not had any recent illnesses, and she does not have headaches. Her parents are not aware of any recent stressors or toxic exposures, and no one else in the family has similar symptoms.

Best practices recommendations in the application of immunohistochemistry in urologic pathology: report from the International Society of Urological Pathology consensus conference latent depression definition generic 10mg abilify with amex. Nested variant of urothelial carcinoma: a clinicopathologic and immunohistochemical study of 12 cases depression definition yahoo order abilify 15mg otc. Outcomes following radical cystectomy for nested variant of urothelial carcinoma: a matched cohort analysis mood disorder fact sheet discount abilify 10mg free shipping. The response of variant histology bladder cancer to intravesical immunotherapy compared to conventional cancer depression symptoms back pain order abilify without prescription. Plasmacytoid urothelial carcinoma of the urinary bladder: clinicopathologic vital depression definition buy 10 mg abilify mastercard, immunohistochemical depression definition and description cheap 10 mg abilify visa, ultrastructural, and molecular analysis of a case series. Comparative genomic hybridization shows complex genomic changes of plasmacytoid urothelial carcinoma. Sarcomatoid carcinoma of the urinary bladder: the final common pathway of urothelial carcinoma dedifferentiation. Carcinosarcoma and sarcomatoid carcinoma of the bladder: clinicopathological study of 41 cases. Sarcomatoid urothelial carcinoma of the bladder: a contemporary clinicopathologic analysis of 37 cases. Differences in survival among patients with sarcomatoid carcinoma, carcinosarcoma and urothelial carcinoma of the bladder. Durable complete remission of metastatic sarcomatoid carcinoma of the bladder with cisplatin and gemcitabine in an 80-year-old man. Leiomyosarcoma in urinary bladder after cyclophosphamide therapy for retinoblastoma and review of bladder sarcomas. Smooth muscle neoplasms of the urinary bladder: a clinicopathologic study of 51 cases. Case report: adult rhabdomyosarcoma of bladder, complete response to radiation therapy. Primary bladder angiosarcoma with no apparent previous exposure to carcinogens: a case report. Primary urinary bladder angiosarcoma with osteoclast-like multinucleated giant cells: a case report and literature review. Diagnostic localization of malignant bladder pheochromocytoma using 6-18F fluorodopamine positron emission tomography. Pheochromocytoma of the urinary bladder: a systematic review of the contemporary literature. Inflammatory myofibroblastic tumors of the urinary tract: a clinicopathologic study of 46 cases, including a malignant example inflammatory fibrosarcoma and a subset associated with high-grade urothelial carcinoma. Inflammatory pseudotumor and sarcoma of urinary bladder: differential diagnosis and outcome in thirty-eight spindle cell neoplasms. Primary malignant melanoma of the urinary bladder: clinical, morphological, and molecular analysis of five cases. Lymphoid neoplasms of the urinary tract and male genital organs: a clinicopathological study of 40 cases. Primary low-grade B-cell lymphoma of mucosa-associated lymphoid tissue type arising in the urinary bladder: report of 4 cases with molecular genetic analysis. Pathological response to neoadjuvant chemotherapy for muscle-invasive micropapillary bladder cancer. Micropapillary urothelial carcinoma of the urinary bladder: a clinicopathological analysis of 72 cases. We believe that each member can contribute the knowledge and experience needed to forge valuable links between urologists, and between developed and developing nations. By working together, our members carry on the tradition of creating positive change in a changing world. As a new member, you will be a partner in the one urological association dedicated to creating sustainable educational projects and providing and improving urological resources worldwide. Physicians undergoing full-time training in urology may apply for a trainee membership, absolutely free. Suite 1012 Montreal, Quebec Canada H3B 3A7 +1 514 875 5665 F +1 514 875 0205 central. Composed of nine chapters, this book tackles the following topics: epidemiology, prevention, screening, diagnosis and evaluation; pathology; basic science; molecular markers; management of nonmuscleinvasive bladder cancer; urolothelial carcinoma; localized muscle-invasive bladder cancer; urinary diversion; systematic therapy for metastatic and non-urothelial cancer of the urinary bladder. Important additions to this update of the 2012 Consultation include the addition of immunotherapy for patients with metastatic bladder cancer, and a new chapter on the basic science of bladder cancer reflecting the recent progress in our understanding of the molecular biology of bladder cancer. We hope that you enjoy reading the book, and that you find it an important and timely reference on bladder cancer. It provides for federal agency improvement of vaccine design and for federally prescribed compensation, which are other means for achieving the two beneficial effects of design-defect torts-prompting the development of improved designs, and providing compensation for inflicted injuries. The vaccine manufacturers fund an informal, efficient compensation program for vaccine injuries in exchange for avoiding costly tort litigation and the occasional disproportionate jury verdict. Taxing their product to fund the compensation program, while leaving their liability for design defect virtually unaltered, would hardly coax them back into the market. Readers are requested to notify the Reporter of Decisions, Supreme Court of the United States, Washington, D. I A For the last 66 years, vaccines have been subject to the same federal premarket approval process as prescription drugs, and compensation for vaccine-related injuries has been left largely to the States. They had been so effective in preventing infectious diseases that the public became much less alarmed at the threat of those diseases,4 and much more concerned with the risk of injury from the vaccines themselves. The Act establishes a no-fault compensation program "designed to work faster and with greater ease than the civil tort system. A person injured by a vaccine, or his legal guardian, may file a petition for compensation in the United States Court of Federal Claims, naming the Secretary of Health and Human Services as the respondent. Successful claimants receive compensation for medical, rehabilitation, counseling, special education, and vocational training expenses; diminished earning capacity; pain and suffering; and $250,000 for vaccine-related deaths. The Act requires claimants to seek relief through the compensation program before filing suit for more than $1,000. It first received federal approval in 1948 and received supplemental approvals in 1953 and 1970. Respondent Wyeth purchased Lederle in 1994 and stopped manufacturing the vaccine in 1998. The immunity does not apply if the plaintiff establishes by clear and convincing evidence that the manufacturer was negligent, or was guilty of fraud, intentional and wrongful withholding of information, or other unlawful activity. The Bruesewitzes elected to reject the unfavorable judgment, and in October 2005 filed this lawsuit in Pennsylvania state court. The complaint also made claims based upon failure to warn and defective manufacture. It delineates the preventative measures that a vaccine manufacturer must have taken for a side-effect to be considered "unavoidable" under the statute. Provided that there was proper manufacture and warning, any remaining side effects, including those resulting from design defects, are deemed to have been unavoidable. If a manufacturer could be held liable for failure to use a different design, the word "unavoidable" would do no work. A side effect of a vaccine could always have been avoidable by use of a differently designed vaccine not containing the harmful element. The language of the provision thus suggests that the design of the vaccine is a given, not subject to question in the tort action. What the statute establishes as a complete defense must be unavoidability (given safe manufacture and warning) with respect to the particular design. Products-liability law establishes a classic and well known triumvirate of grounds for liability: defective manufacture, inadequate directions or warnings, and defective design. It would have been much easier (and much more natural) to provide that manufacturers would be liable for "defective manufacture, defective directions or warning, and defective design. And neither will the judges who must rule on motions to dismiss, motions for summary judgment, and motions for judgment as a matter of law. The "if " clause makes total sense whether the design to which "unavoidable" refers is (as the dissent believes) any feasible design (making the side effects of the design used for the vaccine at issue avoidable), or (as we believe) the particular design used for the vaccine at issue (making its side effects unavoidable). Under the latter view, the condition established by the "if" clause is that the vaccine have been properly labeled and manufactured; and under the former, that it have been properly designed, labeled, and manufactured. Which of the two variants must be preferred is addressed by our textual analysis, and is in no way determined by the "if " clause. Despite this lack of clarity, petitioners seize upon one phrase in the comment k analysis, and assert that by 1986 a majority of courts had made this a sine qua non requirement for an "unavoidably unsafe product": a case-specific showing that the product was "quite incapable of being made safer for - 38 Ibid. The comment creates a special category of "unavoidably unsafe products," while the statute refers to "side effects that were unavoidable. Even the cases petitioners cite as putting a definitive gloss on comment k use the precise phrase "unavoidably unsafe product";42 none attaches special significance to the term "unavoidable" standing alone. Though it is not pertinent to our analysis, we point out that a large number of courts disagreed with that reading of comment k, and took it to say that manufacturers did not face strict liability for side effects of properly manufactured prescription drugs that were accompanied by adequate warnings. The phrase "even though" in the clause "even though the vaccine was properly prepared and [labeled]" is meant to signal the unexpected: unavoidable side effects persist despite best manufacturing and labeling practices. Thus, the dissent twice refers to the requirements of proper preparation and proper labeling as "two additional prerequisites" for preemption independent of unavoidability. The statement "the car accident was unavoidable despite his quick reflexes" indicates that quick reflexes could not avoid the accident, and leaves open two unstated possibilities: (1) that other, unstated means of avoiding the accident besides quick reflexes existed, but came up short as well; or (2) that quick reflexes were the only possible way to avoid the accident. But the rule against giving a portion of text an interpretation which renders it superfluous does not prescribe that a passage which could have been more terse does not mean what it says. The rule applies only if verbosity and prolixity can be eliminated by giving the offending passage, or the remainder of the text, a competing interpretation. Since a vaccine is not "quite incapable of being made safer for [its] intended use" if manufacturing defects could have been eliminated or better warnings provided, the entire "even though" clause is a useless appendage. Drug manufacturers often could trade a little less efficacy for a little more safety, but the safest design is not always the best one. Striking the right balance between safety and efficacy is especially difficult with respect to vaccines, which affect public as well as individual health. Yet the Act, which in every other respect micromanages manufacturers, is silent on how to evaluate competing designs. Or could there be liability for failure to use a design that exists only in a lab Jurors, of course, often decide similar questions with little guidance, and we do not suggest that the absence of guidance alone suggests preemption. But the lack of guidance for design defects combined with the exten- sive guidance for the two grounds of liability specifically mentioned in the Act strongly suggests that design defects were not mentioned because they are not a basis for liability. Design-defect torts, broadly speaking, have two beneficial effects: (1) prompting the development of improved designs, and (2) providing compensation for inflicted injuries. It directs the Secretary of Health and Human Services to promote "the development of childhood vaccines that result in fewer and less serious adverse reactions. Leaving it to the jury may (or may not) be reasonable as well; we express no view. Although we previously have expressed doubt that Congress would quietly preempt product-liability claims without providing a federal substitute, see Medtronic, Inc. Immediately after the language quoted by the dissent, the 1986 Report notes the difficulty a jury would have in faithfully assessing whether a feasible alternative design exists when an innocent "young child, often badly injured or killed" is the plaintiff. Not to worry, the dissent retorts, a Committee Report by a later Congress "authoritative[ly]" vindicates its interpretation. This is a courageous adverb since we have previously held that the only authoritative source of statutory meaning is the text that has passed through the Article I process. Real (pre-enactment) legislative history is persuasive to some because it is thought to shed light on what legislators understood an ambiguous statutory text to mean when they voted to enact it into law. But post-enactment legislative history by definition "could have had no effect on the congressional vote," District of Columbia v. Permitting the legislative history of subsequent funding legislation to alter the meaning of a statute would set a dangerous precedent. Many provisions of federal law depend on appropriations or include sunset provisions;75 they cannot be made the device for unenacted statutory revision. Some courts thought it required a case-specific showing that a product was "unavoidably unsafe"; many others thought it categorically exempted certain types of products from strict liability. We cannot make the same assumption when widespread disagreement exists among the lower courts. We must make do with giving the term its most plausible meaning using the traditional tools of statutory interpretation. Hence, like the dissent, I would look to other sources, including legislative history, statutory purpose, and the views of the federal administrative agency, here supported by expert medical opinion. The Report lists two specific kinds of tort suits that the clause does not pre-empt (suits based on improper manufacturing and improper labeling), while going on to state that compensation for other tort claims. But the appearance of the word "unavoidable" in this last-mentioned sentence cannot provide petitioners with much help.

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Jane Doe 5 has been an active duty member of the United States Air Force for nearly twenty years anxiety 4th hereford cheap 10mg abilify otc, serving multiple tours of duty abroad depression symptoms during menopause discount abilify 5mg mastercard, including two in Iraq depression rates purchase abilify 10mg on line. After June 2016 anxiety or heart attack discount 20mg abilify with mastercard, in reliance on the announcement that transgender people would be permitted to serve openly depression test kind 15 mg abilify for sale, she notified her superiors that she was transgender depression symptoms dizziness buy abilify 20mg line. Under the transgender military ban, Jane Doe 5 will be forced to serve under a cloud of uncertainty about continued service, promotions, and health care; and she will suffer harm because her continued service will be permitted only under a conditional and limited exception to a policy that deems transgender people unfit for service. She has received hundreds of hours of specialized training, above the basic training required for her position, in joint target development, joint battle assessment, unmanned aerial surveillance, and computer science. She had made a behavioral health appointment to obtain a transition plan and begin her gender transition when President Trump tweeted his announcement that transgender people were no longer permitted to serve. As a result, Jane Doe 6 never came out to her doctors or chain of command as transgender. Under the transgender military ban, if Jane Doe 6 notifies her command that she is transgender and seeks health care for the distress she experiences from having to serve in a manner inconsistent with her gender identity, she faces separation from the military. She would be ineligible for a military pension and other benefits upon which she relies. A separation would also have serious negative repercussions for her career and livelihood. In addition, the transgender military ban causes Jane Doe 6 the immediate harms of curtailing her access to health care and forcing her to live inconsistently with her gender identity to avoid separation from the military. Jane Doe 7 is a transgender woman who was seeking to join the Coast Guard when the Trump administration announced its implementation plan banning service by transgender people on March 23, 2018. Under the transgender military ban, Jane Doe 7 will be unable to join the Coast Guard. She will be deprived of the opportunity to serve her country and the many benefits that enlistment in the Coast Guard would afford her. He was commissioned as a Second Lieutenant shortly after the Department of Defense announced that transgender people would be permitted to serve openly. In reliance on that policy, John Doe 1 notified his command that he was transgender. John Doe 1 has served since that time and has been praised for his commitment to excellence. He did, however, undergo transition-related surgery in January 2018 and is currently ready to be deployed. Under the transgender military ban, John Doe 1 will be forced to serve under a cloud of uncertainty about continued service and health care; and he will suffer harm because his continued service will be permitted only under a conditional and limited exception to a policy that deems transgender people unfit for service. John Doe 2 is a transgender man who was in the process of enlisting in the Army when the Trump administration announced its implementation plan banning service by transgender people on March 23, 2018, specifically prohibiting enlistment for anyone who has undergone gender transition. He disclosed his transgender status to the recruiter when he began the enlistment process. He will be deprived of the opportunity to serve his country, including the financial and career benefits that enlistment in the Army will afford him. In reliance on the policy permitting transgender people to serve openly, he told the Naval Academy that he is transgender. He was approved for a medical leave of absence so that his transition would be complete in time for him to receive his commission in the U. Under the transgender military ban, it is unclear whether Plaintiff Kibby will be permitted to return to the Naval Academy or to join the U. Navy as a commissioned officer, he will be forced to serve under a cloud of uncertainty about continued service and health care; and he will suffer harm because his service will be permitted only under a conditional and limited exception to a policy that deems transgender people unfit for service. Trump is President of the United States and Commander in Chief of the Armed Forces. On July 26, 2017, President Trump stated on Twitter that transgender people would not be permitted to serve "in any capacity in the U. Mattis is the United States Secretary of Defense and the leader of the Department of Defense. He transmitted that plan to the President in February 2017, and it was released to the public on March 23, 2018. Defendant Department of the Army is one of three military departments of the Department of Defense and is responsible for the administration and operation of the United States Army. Defendant Department of the Navy is one of three military departments of the Department of Defense and is responsible for the administration and operation of the United States Navy. Defendant Department of the Air Force is one of three military departments of the Department of Defense and is responsible for the administration and operation of the United States Air Force. Defendant United States Coast Guard is one of the five branches of the United States Armed Forces. The Department of Homeland Security is responsible for the administration and operation of the United States Coast Guard. Defendant Defense Health Agency is a Combat Support Agency that administers health care services for the U. Army combat veteran, recommended that the military conduct a review of whether transgender people should be permitted to serve openly in the Armed Forces. In August 2014, the Department of Defense issued a new regulation that eliminated its categorical ban on open service by transgender people and instructed each branch of the Armed Forces to reassess whether maintaining a service-wide ban on service by openly transgender persons was justified. Secretary Hagel explained that "[e]very qualified American who wants to serve our country should have an opportunity to do so if they fit the qualifications and can do it. Carter, who had previously served many years within the Department, including as Deputy Secretary of Defense, Under Secretary of Defense for Acquisition, Technology and Logistics, Assistant Secretary of Defense for International Security Policy, and as a member of the Defense Policy Board and the Defense Science Board. In July 2015, Secretary Carter announced that the military would begin a comprehensive analysis of whether to maintain the prohibition on military service by transgender people. In an order establishing a working group to carry out this analysis, made effective as of July 13, 2015, Secretary Carter directed that no servicemember could be involuntarily separated or denied reenlistment or continuation of active or reserve status on the basis of his or her gender identity without the approval of the Under Secretary of Defense for Personnel and Readiness. Over the course of a year, Secretary Carter oversaw a comprehensive review of this issue by a working group of the military and civilian leadership of the Armed Services, the Joint Chiefs of Staff, the service secretaries, and personnel, training, readiness, and medical specialists from across the Department of Defense. That year-long process examined copious data on the relevant issues, including but not limited to existing studies and research and input from transgender servicemembers and their commanders, outside expert groups, and medical professionals. The process also included a careful review of the eighteen other countries that permit military service by openly transgender people. The process also included consultation with doctors, employers, and insurance companies regarding the provision of medical care to transgender people. On June 30, 2016, Secretary Carter announced that "[e]ffective immediately, transgender Americans may serve openly. They can no longer be discharged or otherwise separated from the military just for being transgender. Also on June 30, 2016, Secretary Carter issued Directive-Type Memorandum 16- 005, titled "Military Service of Transgender Service Members. Consistent with the policies and procedures set forth in this memorandum, transgender individuals shall be allowed to serve in the military. These policies and procedures are premised on my conclusion that open service by transgender Service members while being subject to the same standards and procedures as other members with regard to their medical fitness for duty, physical fitness, uniform and grooming, deployability, and retention, is consistent with military readiness and with strength through diversity. The year-long review process by the Department of Defense also concluded that openly transgender people should be permitted to accede to the military so long as they had completed all medical treatment associated with their transitions and had been stable in their gender for eighteen months. The accession policy was scheduled to take effect on July 1, 2017 to allow the branches of the Armed Forces additional time to develop necessary standards and policies. In September 2016, the Department of Defense issued an implementation handbook entitled "Transgender Service in the United States Military. On October 1, 2016, the Office of the Undersecretary of Defense for Personnel and Readiness issued "DoD Instruction 1300. Over the next nine months, between October 2016 and June 2017, the services conducted training of the force based on detailed guidance and training materials regarding the policy change. On June 30, 2017, the day before the policy permitting transgender people to accede to the military was to take effect, Secretary Mattis extended the period for the development of relevant standards by six months. Early in the morning of July 26, 2017, without any prior indication that he would address military transgender policy, President Trump announced in a series of tweets that the military would no longer permit the service of transgender Americans. His tweets read: "After consultation with my generals and military experts, please be advised that the United States government will not accept or allow transgender individuals to serve in any capacity in the U. This announcement met with substantial criticism from members of Congress belonging to both political parties. Upon information and belief, the President did not consult either the Joint Chiefs of Staff or the Department of Defense before making his announcement. Shortly after the announcement, fifty-six former generals and admirals issued a public statement denouncing the new policy. Commandant Admiral Paul Zukunft of the United States Coast Guard also criticized the proposed policy and expressly reached out to all openly transgender members of the Coast Guard, vowing not to "turn [his] back" on transgender servicemembers. On August 25, 2017, the President released a memorandum ("August 25 Memorandum") containing a formal directive to the Secretary of Defense and the Secretary of Homeland Security. It required the military to return to its pre-June 2016 policy forbidding transgender people from joining or serving in the military, effective March 23, 2018. On September 14, 2017, Secretary of Defense Mattis issued a Memorandum directing the implementation process. Secretary Mattis directed the Department of Defense to "develop[] an Implementation Plan on military service by transgender individuals, to effect the policy and directives" issued by President Trump on August 25. Secretary Mattis also indicated that the implementation plan would be released within the six months prescribed by the President. On October 30, 2017, this Court issued a preliminary injunction that, among other things, ordered Defendants to "revert to the status quo with regard to accession and retention that existed before the [August 25, 2017] issuance of the Presidential Memorandum. On February 22, 2018, Secretary Mattis sent a Memorandum to the President endorsing policies set out in an attached report entitled "Department of Defense Report and Recommendations on Military Service by Transgender Persons. The policy set forth in the February 22 Memorandum and its attachment expressly targets transgender individuals; they do not apply to non-transgender individuals at all. The policy prevents any transgender individual from serving consistent with their gender identity, including by excluding anyone who "require[s] or ha[s] undergone gender transition" and by requiring proof that applicants are "stable. The policy also includes a limited and conditional provision permitting continued service by servicemembers "who were diagnosed with gender dysphoria by a military medical provider" during the period when open service by transgender servicemembers was allowed. The policy also states that "should its decision to exempt these Service members be used by a court as a basis for invalidating the entire policy, this exemption instead is and should be deemed severable from the rest of the policy. The policy set forth in the February 22 Memorandum and its attachment rejects the established medical consensus confirming the safety and efficacy of gender-transition related medical care and instead concludes that the available scientific evidence is "unclear. The Due Process Clause of the Fifth Amendment prohibits the federal government from denying equal protection of the laws. The policies excluding transgender people from military service discriminate against Plaintiffs based on their sex and transgender status, without lawful justification, in violation of the Equal Protection component of the Due Process Clause of the Fifth Amendment. The exclusion of transgender people from military service lacks a rational basis, is arbitrary, and cannot be justified by sufficient federal interests. Through the actions above, Defendants have violated the Equal Protection component of the Due Process Clause of the Fifth Amendment. The Due Process Clause of the Fifth Amendment requires, at a minimum, that government action have some rational basis. The policies excluding transgender people from military service are arbitrary and capricious and lack any rational basis. Plaintiffs reserve all rights to appeal that dismissal but do not repeat the Count here. Through the actions above, Defendants have violated the Due Process Clause of the Fifth Amendment. Issue a preliminary and permanent injunction, against all Defendants other than President Trump, prohibiting the categorical exclusion of transgender people from military service, including ordering that: a. Defendants shall revert to the status quo with regard to accession and retention that existed before the August 25, 2017 issuance of the Presidential Memorandum. Naval Academy on the basis that he is transgender, and may not be denied the opportunity to accede to military service thereafter, or be denied promotion, reenlistment, or any other equal terms of service on the basis that he is transgender; d. Plaintiffs Jane Doe 7 and John Doe 2 may not be denied the opportunity to accede to military service on the basis that they are transgender, and may not be denied promotion, reenlistment, or any other equal terms of service on the basis that they are transgender. Wilkie, Under Secretary of Defense for Personnel and Readiness Approved by: Purpose: this issuance, in accordance with the authority in DoD Directive 5124. Wilkie on March 30, 2018, and will take effect 30 days after publication on the Directives Division Website. Secretaries of the Military Departments and Commandant, United States Coast Guard. This issuance does not apply to any medical issue associated with gender dysphoria or gender transition; such medical accession standards are addressed in separate guidance. Any questions regarding such medical accessions standards or procedures should be directed to the Commander, U. Use the guidance in this issuance for appointment, enlistment, or induction of personnel into the Military Services. Use common medical standards for appointment, enlistment, or induction of personnel into the Military Services and eliminate inconsistencies and inequities in the DoD Components based on race, sex, or location of examination when applying these standards. Ensure that individuals considered for appointment, enlistment, or induction into the Military Services are: (1) Free of contagious diseases that may endanger the health of other personnel. Allow applicants who do not meet the physical and medical standards in this issuance to be considered for a medical waiver. The expiration date of this information collection is listed on the DoD Information Collections System at apps. Ensures that the standards in Section 5 are implemented throughout the DoD Components. Eliminates inconsistencies and inequities based on race, sex, or location of examination in DoD Component application of these standards. Reviews, approves, and issues technical modifications to the standards in Section 5 to the Secretaries of the Military Departments. Provides guidance to the DoD Medical Examination Review Board to implement the standards in Section 5.

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Common/vernacular names: Beeswax depression us buy 15mg abilify fast delivery, bleached beeswax depression treatment plan order 5mg abilify amex, white beeswax depression hashtags buy 5 mg abilify visa, white wax anxiety at night discount abilify online master card, yellow beeswax mood disorder 5 year old cheap abilify express, and yellow wax depression symptoms chest pain buy 15 mg abilify amex. After the honey is removed from the honeycombs, the combs are washed rapidly and thoroughly with water. They are then melted with hot water or steam, strained, and run into molds to cool and harden. White beeswax and beeswax absolute are derived from yellow beeswax, the former from bleaching with the combined action of air, sunlight, and moisture (or with peroxides) and the latter by extraction with alcohol. Yellow beeswax is a yellow to brownish yellow or grayish brown solid with an agreeable honey-like odor and faint but characteristic taste; it melts between 62 and 65 C. White beeswax is a yellowish-white solid with a faint, characteristic odor, less pronounced than yellow beeswax; it is almost tasteless and translucent in thin layers; melts between 62 and 65 C. Both yellow wax and white wax are insoluble in water, slightly soluble in cold alcohol, partly soluble in cold benzene, and completely soluble in chloroform, ether, and fixed and volatile oils. Beeswax absolute is a pale yellow solid with a mild, sweet, and oily odor reminiscent of good linseed oil with a trace of honey notes, depending on sources. Both yellow beeswax and white beeswax are used as thickener, emulsifier, or stiffening agents in ointments, baby products, bath preparations, cold creams, emollient creams, eye and facial makeups, lotions, lipsticks, hair dressings, hair conditioners, shaving products, suntan products, suppositories, and others; also used as a tablet polishing component. In Chinese medicine, beeswax is used to treat diarrhea and hiccups and to relieve pain, among others. Beta vulgaris has several varieties with roots ranging in size from small to thick and in color from whitish or yellowish (sugar beets) to deep blood-red (certain garden beets). They consist mostly of betacyanins (red), with a small amount of betaxanthins (yellow). There is evidence that betanin occurs in red beet root as a sulfate linked through the sugar moiety at the 3- or 6position. There is evidence of an enzyme present in red beet that specifically destroys the betanin chromophore at an optimal pH of 3. The color can be stabilized by sequestrants and/or antioxidants such as citric acid, sorbic acid, and ascorbic acid;8,9 though ascorbic acid has also been shown to decrease the color stability of betanin in aqueous solutions. According to a patented process, the pigment content can be considerably increased, at the same time eliminating the beet flavor and aroma. Betanin inhibited lipid perioxidation in vitro more potently than catechin13,14 and in humans showed have high bioavailability. Parts used are the dried leaves (including flowering and fruiting tops) and roots. Other alkaloids isolated Low doses of the plant in mice produced protective effects against the effects of experimental stress, including immunoprotective, gastroprotective, and behavioral (neurotropic) protection. Its effect on the central nervous system is first stimulation and then depression. Other activities include dilatation of the pupil, increase of intraocular pressure, and photophobia. The activities of l-hyoscyamine and l-scopolamine are essentially the same as those of atropine, except that scopolamine is a powerful hypnotic and usually slows rather than increases the heart rate. Hyoscine-containing plants have been used for centuries in traditional Chinese medicine as anesthetics. Common/vernacular names: Gum benjamin, gum benzoin, Siam benzoin, Sumatra benzoin. Benzoin-producing Styrax species are mostly small to medium trees (up to 20 m high) growing in tropical Asia. Sumatra benzoin is largely produced from cultivated trees growing in North Sumatra, although the tree occurs natively in Borneo, Java, and the Malay Peninsula; Siam benzoin is produced from trees growing in Thailand in the Province of Luang Probang, although the tree also occurs in Laos, Vietnam, Cambodia, and China. It is produced by incising the bark; the exuded balsamic resin hardens on exposure to air and sunlight, and is collected. Benzoin resinoid is prepared from crude benzoin by extraction with solvents such as benzene and alcohol, followed by their subsequent removal. The major component of the oils derived from Sumatra and Siam benzoins is benzyl benzoate (76. Other major constituents in Sumatra benzoin oil are cinnamic acid, benzyl cinnamate, and styrene, whereas those in the oil of Siam benzoin are benzoic acid, allyl benzoate, and methyl benzoate. Following topical application in monkeys, benzoin is partly absorbed through the skin resulting in systemic exposure. Tincture also used in dentistry to treat inflammation of gums and oral herpetic lesions. Benzoin, especially Siam benzoin, has antioxidative and preservative properties and is used in cosmetics for these properties. The resinoid is extensively used as a fixative in perfumes, soaps, detergents, creams, and lotions, in amounts up to 0. Classified as a natural flavor; used in most categories of foods, including alcoholic and nonalcoholic beverages, frozen dairy desserts, candy. Due to the photosensitizing activity of these constituents, the use of bergamot oil in cosmetics has caused hyperpigmentation of the face and neck. Formerly used extensively used in highquality perfumes (especially eau de cologne), aromatherapy oils, creams, lotions, suntanning preparations to stimulate melanin production,10 and in soaps, with use levels up to 0. Found in heaths, moors, and woods in most of Europe (mountains in southern Europe); also found in N. Clinical use of anthocyanoside-rich extracts of the fruit is largely 94 Bilberry found in for degenerative retinal conditions. In Europe, leaf preparations are used for the supportive treatment of diabetes mellitus; prevention and treatment of gastrointestinal, kidney, and urinary tract disorders, as well as arthritis, dermatitis, functional heart problems, gout, hemorrhoids, poor circulation, and for metabolic stimulation of circulation. The fruit is best known for its food value; used in alcoholic and nonalcoholic beverages; conserves, pastries, compote, syrups, or eaten raw; fruit extracts also used as red coloring in wine. Historically, in Europe, the fruits and to a lesser extent the leaves, have been used for astringent and antiseptic activities in diarrhea, dysentery, dyspepsia, intestinal dyspepsia in infants; leaf tea as antidiabetic. Long-term (6 months) oral administration of bilberry extract equivalent to up to anthocyanins at 180 mg/kg/day failed to produce toxic effects; no teratogenic or mutagenic effects were found. Bone, Principles and Practice of Phytotherapy, Chruchill Livingstone, Edinburgh, 2000, p. Common/vernacular names: Birch, black birch, cherry birch oil, and sweet birch oil. Sweet birch oil is produced by steam distillation of the warm water-macerated bark. During maceration the enzyme system present hydrolyzes gaultherin, setting free methyl salicylate, which is the major component of the oil. For example, birch tar oil is obtained by destructive distillation of the wood and bark of the European white birch (Betula pendula Roth; syn. Extensively used for its wintergreen (or root beer) flavor in most major categories of foods, especially nonalcoholic and alcoholic beverages, frozen dairy desserts, candy, chewing gum, gelatins and puddings, and baked goods. It can be absorbed through the skin, and fatal poisoning via this route has been reported. Methyl salicylate has limited use as a counterirritant in antiarthritic and antineuralgic preparations such as ointments, liniments, and analgesic balms; as an antiseptic; and as a fragrance ingredient in perfumes and other cosmetic preparations. Part used is the dried bark of the rhizome and roots collected in the spring and fall. In flavor formulations in all major categories of foods, including alcoholic and nonalcoholic beverages, frozen dairy desserts, candy, baked goods, gelatins and puddings, and sweet sauces, with highest average maximum use level of 0. Common/vernacular names: Black cohosh, black snakeroot, cimicifuga, cohosh bugbane, rattleroot, rattleweed, rattle top, squaw root. Rats administered an isopropanolic extract (up to 5 g/kg) for 26 weeks showed no organ toxicity. The minimum acute lethal oral dose of a tincture of black cohosh in rats was reported to be >1 g/kg. Used in treating amenorrhea, postpartum and labor pains, uterine disorders, support for natural uterine contractions during labor, cough, dropsy, fever, nervous disorders, smallpox, yellow fever, lumbago, pain of acute rheumatism, headache, hysteria, nervous system disorders, influenza, and itch. In trials of black cohosh preparations involving over 2800 patients, the incidence of adverse effects was 5. Potencies of extracts are expressed only in strength (see glossary) based on weightto-weight ratio of crude and extracts. Root bark and its extracts are used as tonics and in uterine-relaxant, antidiarrheal, diuretic, and general antispasmodic preparations. Stem bark extract is used as a flavor ingredient primarily in alcoholic and nonalcoholic beverages in very low concentrations, with maximum use level at less than 0. Common/vernacular names: Carbenia benedicta, carduus benedictus, cnicus, Holy thistle. An ether extract of blessed thistle showed a strong sensitizing effect in guinea pigs, suggesting that individuals who experience allergic contact dermatitis from exposure to the Compositae family should avoid the plant. Common/vernacular names: Bloodroot, Indian red paint, red puccoon, red root, sanguinaria. The plant grows in Quebec and in the United States from New England south to Florida and west to Wisconsin and Texas. Part used is the dried rhizome, sometimes referred to as "root" in the literature. Sanguinarine has broad in vitro antibacterial activity and also displays antifungal and antitrichomonas activities2 and local anesthetic property. Other studies have shown that the alkaloid interferes with pyruvic acid oxidation that leads to pyruvic acid accumulation in the blood. Sanguinarine has also been used as an antiplaque agent in toothpaste and mouthwash preparations. Used by various eastern North American Indians for face painting; by Canadian Indians in Quebec as a tonic; root chewed to treat heart troubles. Strengths (see glossary) of extracts are expressed in weight-to-weight ratios between crude and extracts. Used in diuretic, uterine, antispasmodic, and emmenagogue as well as laxative preparations. A decoction or syrup of the root was used by American Indians as a sedative to treat "hysterics" and "fits. Strengths (see glossary) of extracts are expressed as weight-to-weight ratios between crude and extract. Used as a source of natural linalool or linalool acetate, which are extensively used in perfumery. Acetylated bois de rose oil is reportedly used in soaps, detergents, creams, lotions, and perfumes, with maximum use level of 1. Used extensively as a flavor ingredient in most major categories of foods, ages, frozen dairy desserts, candy, baked goods, gelatins and puddings, meat and meat products, and gravies. The essential oil is obtained from chipped wood by steam distillation and occasionally water distillation. In vitro tests showed that boldine inhibits No toxicity was observed in rats that administered a hydro-alcoholic extract of the leaves containing boldine at doses of up to 3 g/kg p. Boldine is nonmutagenic and showed no genotoxicity in the mouse micronucleus test following oral doses of up to 900 mg/kg. Leaf preparations that are practically free of the toxic principle ascaridole are the subject of a German therapeutic monograph that allows use for mild gastrointestinal spasms and dyspeptic disorders. Common /vernacular names: Agueweed, bonest, common bonest, Eupatorium, feverwort, thoroughwort. An ethanol extract of the leaves showed cytotoxicity to mammalian cells in vitro and weak in vitro antibacterial activity against Gram-positive and Gram-negative organisms. Used by North American Indians to break fevers and induce sweating; adopted by settlers to treat colds, influenza, typhoid, malaria, intestinal worms, and rheumatism. Capsulated seed oil products available as dietary supplement; dried tops sometimes used in teas. Common/vernacular names: Bromelain, bromelains, bromelin (fruit-bromelin), plant protease concentrate. Stem bromelain has been generally prepared from the juice of pineapple wastes (mainly stems) by precipitation with organic solvents. Two kinds of bromelain are known: stem bromelain and fruit bromelain, which are crude aqueous extracts of the stem and immature fruit of pineapple Crude bromelain contains proteinases mainly consisting of glycosylated multiple enzymes having molecular masses from 20 to 31 kDa. Pineapple fruit contains fruit bromelain and pineapple stem contains stem bromelain, ananain, and comosain. It also contains various 114 Bromelain incompletely characterized constituents, including glycoproteins, carbohydrates, peroxidases, phosphatases, cellulases, and others. Used primarily in preparations to treat inflammation and edema associated with surgical or accidental trauma, infections, and allergies. Bromelain is used in certain cosmetics, such as facial cleansers and bath preparations. Due to the high cost of papain, bromelain is increasingly used to replace or supplement papain usage.

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