Unisom

Umber Burhan MD

• Transplant Nephrology Fellow, Hospital of the University of Pennsylvania,
• Philadelphia, Pennsylvania

One commenter stated that the provision allows evidence of past sexual conduct to be presented in an investigation and that such history would be raised to shame complainants sleep aid non drowsy cheap unisom american express. Another commenter concluded that this provision would result in the respondent being able to coerce new witnesses because the regulations allow that insomnia 37 weeks pregnant generic unisom 25mg without prescription. The same commenter proposed eliminating the ten-day period for review of the collected evidence or insomnia home remedies buy on line unisom, conversely insomnia first trimester buy 25 mg unisom fast delivery, the inclusion of a requirement that 1008 each party must have a reasonable opportunity to review the evidence and provide feedback while the investigation is ongoing insomnia quote fight club discount generic unisom canada, but without a set timeline insomnia iphone generic 25 mg unisom amex. One commenter stated that fair notice and an opportunity to respond does not require discovery of all evidence directly related to the allegations, where the evidence will not be relied upon in making a responsibility determination. Similarly, the commenter argued that requiring recipients to turn over all evidence directly related to the allegations was overbroad and may result, ultimately, in less information being shared by parties during the investigation. Another commenter argued that no rational basis exists for requiring the disclosure of evidence not relied upon in reaching a determination. The commenter added that the provision is extremely confusing and benefits no one. Many commenters questioned why the Department would allow parties to review evidence upon which the decision-maker does not intend to rely upon in adjudicating the claim. These commenters agreed that only relevant information should be shared with the parties. One of these commenters concluded that the provision further legalizes the process. Another commenter argued that, under current judicial precedent, no formal right to discovery exists in a student disciplinary hearing. One commenter argued in favor of the recipient only sharing information with the parties, allowing them to determine whether the information should be shared with their advisor. Many commenters supported limitations on the information being shared, including the exclusion or redaction of medical, psychological, financial, sexual history, or other personal and private information that has no bearing on the investigative report. One commenter argued in favor of permitting schools to release information to the parties based upon the individual circumstances of the case. The commenter stated that this information would unnecessarily 1009 violate the privacy of the disclosing parties and would prevent investigators from gathering evidence out of fear that personal information would need to be revealed. Commenters stated that the final regulations would allow the improper, and potentially widespread, sharing of confidential information and incentivize respondents to slip in prejudicial information to undermine the process. A number of commenters concluded that students would be less likely to report sexual harassment and sexual violence if investigations are not conducted properly because there is no incentive for schools to actually investigate. The commenter stated that, if enacted, the proposed rules would harm many students who face these problems every day. Some stated that an exception could be provided for a showing of particularized relevance. Calling the provision utterly illogical, one commenter stated that sharing irrelevant information would lead to extreme disparity of potential outcomes. They argued that no system currently exists that limits the users ability to take pictures of the information on the screen. One commenter was concerned that the proposed regulations do not include a requirement that the viewing of the relevant evidence be supervised and suggested the inclusion of such a provision. Some commenters argued that sharing records electronically could 1010 exacerbate gender and socioeconomic inequality and put some students at a disadvantage if they do not have access to a private computer. Some of these commenters argued in favor of the supervised viewing of evidence files, to protect the partys confidentiality and to prevent parties from taking photographs of the evidence, while others argued for investigators to use their discretion in redacting certain information from the files before sharing with the parties. Some commenters supported redactions for information deemed more prejudicial than probative and for inflammatory evidence. Many of these commenters expressed concern that the parties should not be allowed to take physical possession of the evidence files. Commenters who favored redactions, also argued that the final regulations unreasonably limit the discretion of investigators. These commenters argued that recipients should have the right to reasonably redact confidential and private information, including the identity of the complainant, if the recipient deems it necessary to do so. One commenter, who favored the hard copy format, argued that students with disabilities may have a difficult time reviewing the files if not submitted in hard copy. Some commenters remarked that electronic file sharing programs are cost prohibitive, leading some to conclude that such cost would prohibit institutions from paying for advisors for the parties. Many commenters asserted that the provision could run afoul of State laws, including laws regarding student privacy and the sharing of confidential information, as well as potentially violate State rape shield laws. Some commenters were also concerned about the effect of open records statutes as a means to publicize investigative files to embarrass the opposing party. Another commenter agreed that crafting a full report before sharing it with the parties is premature and could lead to errors, dissatisfaction, and the appearance of bias. One commenter pointed out that student conduct processes at institutions of higher education are not criminal processes and should not be expected to mirror them. The commenter stated that colleges and universities are not making criminal law decisions, but rather a policy violation determination. In addition, the commenter believed that the best policy would allow students to provide information, respond to information, and ask questions, but in a manner that is appropriate to limit creating an adversarial environment. Similarly, one commenter concluded that the final regulations place a greater burden on recipients than on a criminal prosecutor. One commenter suggested that the ten-day timeline was an overregulation of institutions, suggesting instead that institutions should set their own time frames, so long as they are equitable. A number of commenters argued that institutions should be able to determine appropriate timelines for their own processes. A different commenter stated that the 1012 Department should not mandate any time period as, in their opinion, a uniform rule does not fit every circumstance at every school. One commenter wrote that the final regulations timeline is more rigid than a similar proceeding in a courtroom, where courts often expedite hearings when time is of the essence. A commenter asked for clarification as to whether the proposed regulations would require an extra ten days for re-inspection of the supplemented investigative file. The same commenter also asked what, if any, guidelines should be put in place regarding supplementing the record at each stage of the adjudicative process. One commenter proposed including a non-disclosure agreement as part of the adjudicative process. Another commenter requested that the final regulations should include a provision to punish institutions that have committed wrongs against respondents in the past. One commenter requested a regulatory provision that would provide meaningful consequences for violations of confidentiality, including punishment for recipients that do not implement reasonable privacy safeguards or do not permit reasonable redaction policies. A number of commenters raised issues with the implementation of the final regulations in the K-12 context. Commenters stated that the majority of changes in the proposed rules were not written with a clear understanding of their application to the K-12 environment and that the proposed rules may actually hamper a school districts ability to maintain a safe school environment. For example, the commenter stated that the extension of the timeline (for example, 1013 by imposing a ten-day period for review of evidence) impairs a K-12 recipients ability to effectuate meaningful change to a students behavior. In addition, the commenter wrote that a battle of responses will foster more hostility, not less, where there is a high likelihood that the parties will remain within the same school district. The same commenter suggested that the Department should look to provide, and detail, restorative justice options that align with best practices for effective responses to incidents of sexual harassment and sexual violence. One commenter concluded that sharing the evidence file may be appropriate at the postsecondary level, but is inappropriate at the K-12 level. A different commenter supported leaving the issue of evidence review to local school officials. One commenter stated that the ten days to review and respond was unnecessary and would needlessly lengthen K-12 investigations. Many commenters raised concerns over the burden caused by the proposed regulations on small institutions. Those commenters pointed out that sharing evidence with parties, waiting the required time period, and creating the investigative report and the parties responses to it is onerous, has limited benefits as a truth-seeking process, and is too burdensome for institutions with only one staff member in charge of all of these responsibilities. A different commenter argued that continuous updates to the parties is completely impractical and unduly burdensome on the investigator, especially at small colleges. We believe that this provision provides complainants and respondents an equal opportunity to inspect and review evidence and provides transparent disclosure of the universe of relevant and potentially 1014 relevant evidence, with sufficient time for both parties to meaningfully prepare arguments based on the evidence that further each partys view of the case, or present additional relevant facts and witnesses that the decision-maker should objectively evaluate before reaching a determination regarding responsibility, including the right to contest the relevance of evidence. The Department is sensitive to commenters concerns regarding the parties sharing irrelevant information, as well as relevant information that is relevant but also highly sensitive and personal, as part of the investigative process. This concern, however, must be weighed against the demands of due process and fundamental fairness, which require procedures designed to promote accuracy through meaningful participation of the parties. The Department believes that the right to inspect all evidence directly related to the allegations is an important procedural right for both parties, in order for a respondent to present a defense and for a complainant to present reasons why the respondent should be found responsible. This approach balances the recipients obligation to impartially gather and objectively evaluate all relevant evidence, including inculpatory and exculpatory evidence, with the parties equal right to participate in furthering each partys own interests by identifying evidence overlooked by the investigator and evidence the investigator erroneously deemed relevant or irrelevant and making arguments to the decision-maker regarding the relevance of evidence and the weight or credibility of relevant evidence. Accordingly, a recipient will not access, consider, disclose, or otherwise use some of the most sensitive documents about a party without the partys (or the parent of the partys) voluntary, written consent, regardless of whether the recipient already has possession of such treatment records, even if the records are relevant. The Department declines to define certain terms in this provision such as upon request, relevant, or evidence directly related to the allegations, as these terms should be interpreted using their plain and ordinary meaning. We also acknowledge that directly related may sometimes encompass a broader universe of evidence than evidence that is relevant. The Department therefore believes it is important that at the phase of the investigation where the parties have the opportunity to review and respond to evidence, the universe of that exchanged evidence should include all evidence (inculpatory and exculpatory) that relates to the allegations under investigation, without the investigator having screened out evidence related to the allegations that the investigator does not believe is relevant. For example, an investigator may discover during the investigation that evidence exists in the form of communications between a party and a third party (such as the partys friend or roommate) wherein the party characterizes the incident under investigation. If the investigator decides that such evidence is irrelevant (perhaps from a belief that communications before or after an incident do not make the facts of the incident itself more or less likely to be true), the other party should be entitled to know of the existence of that evidence so as to argue about whether it is relevant. The investigator would then consider the parties viewpoints about whether such evidence (directly related to the allegations) is also relevant, and on that basis decide whether to summarize that evidence in the investigative report. A party who believes the investigator reached the wrong conclusion about the relevance of the evidence may argue again to the decision-maker. Under the final regulations, therefore, recipients are neither required nor prohibited from using a file sharing platform that restricts parties and advisors from downloading or copying the evidence. We reiterate that redacting confidential information is not the same as redacting information that is not directly related to the allegations because information that is confidential, sensitive, or private may still be directly related to the allegations and thus subject to review by both parties. The Department is sensitive to commenters concerns over whether the final regulations might deter the reporting of sexual harassment. We recognize that a formal grievance process is challenging, difficult, and stressful to navigate, for both complainants and respondents. More broadly, the Department is persuaded by some commenters concerns that if a complainant is forced to undergo a grievance process whenever a complainant reports sexual harassment, complainants may decide not to report at all, and by other commenters concerns that without strong, clear procedural rights, recipients grievance processes will not reach reliable outcomes in which parties and public have confidence. The final regulations therefore increase the obligations on recipients to respond promptly and supportively to every complainant when the recipient receives notice that the complainant has allegedly been victimized by sexual harassment (without requiring any proof or evidence supporting the allegations) irrespective of the existence of a grievance process, promote respect for a complainants autonomy over whether or not to file a formal complaint that initiates a grievance process, and protect complainants from retaliation for refusing to participate in a grievance process. The Department disagrees with commenters assertions that the final regulations would allow the recipient (or the respondent) to coerce witnesses, turn a blind eye to sexual violence, or revictimize complainants. The Department disagrees that due process is not implicated until corrective action is proposed. Due process is not only a concern after corrective or punitive action is taken, but throughout the entire process leading to a recipients decision to impose corrective or 1179 disciplinary action. We appreciate the commenters who stated that the ten-day time frame provision is appropriate for the parties to review and respond to the evidence directly related to the allegations. We agree that the result of this provision will be expedited hearings because the parties will have had the opportunity to see, review, and consider their responses to evidence prior to showing up at a hearing. Thus, the adversary system represents far more than a simple model for resolving disputes. Rather, it consists of a core of basic rights that recognize and protect the dignity of the individual in a free society. The Department understands commenters concerns that a ten-day time period for the parties to inspect and review evidence (and then a ten-day time period to review and respond to the investigative report) is too long a timeline, but we do not agree that this timeline is an overregulation or that it is more rigid than a similar proceeding in a criminal court. Instead, the Department finds that the time frame is appropriate for the parties to read and respond to the evidence subject to inspection and review, and then to the investigative report. Recipients may choose whether the ten days should be business days or calendar days (or may use a different calculation of days that works with the recipients administrative operations, such as school days. These provisions appropriately focus the investigation on evidence directly related to the allegations and to relevant evidence in furtherance of each partys interest in permitting pertinent evidence to come to light so that any misunderstandings, confusions, and contradictions can be clarified. We appreciate the commenters suggestions regarding the inclusion of: a requirement that the viewing of the relevant evidence be supervised; the appointment of a special master; and a provision informing parties of the consequences of submitting false information. Commenters have noted that recipients restrictions on a partys ability to view the evidence gathered in a case (for example, by requiring the party to sit in a certain room in the recipients facility, for only a certain length of time, with or without the ability to take notes while reviewing the evidence, and perhaps while supervised by a recipient administrator) have reduced the meaningfulness of the partys opportunity to review evidence and use that review to further the partys interests. We believe it is important for the parties to receive a copy of the evidence subject to inspection and review so that the parties and their advisors may, over the course of a ten-day period, carefully consider the evidence directly related to the allegations, prepare arguments about whether all of that evidence is relevant and whether relevant evidence has been omitted, and consider how the party intends to respond to the evidence. On the other hand, we do not believe that the purposes of the parties right to inspect and review evidence necessitates or justifies the Department requiring recipient to appoint a special master to oversee the exchange of evidence.

In these final regulations insomnia sign of pregnancy buy unisom with a visa, the Department aims to respect the autonomy of students at postsecondary institutions insomnia kent unisom 25 mg with visa, while ensuring that such students (and employees) clearly understand how to report sexual harassment sleep aids over the counter purchase unisom 25mg without prescription. We believe that the best way to avoid reports falling through the cracks or successfully being swept under the rug by postsecondary institutions insomnia journal articles buy generic unisom on line, is not to continue (as Department guidance did) to insist that all postsecondary institutions must have universal or near-universal mandatory reporting sleep aid 25mg doxylamine succinate 192 tablets discount 25mg unisom with mastercard. As discussed in the Actual Knowledge subsection of the Adoption and Adaption of the Supreme Courts Framework to Address Sexual Harassment section of this preamble insomnia medicine discount unisom online visa, whether universal mandatory reporting for postsecondary institutions benefits victims or harms victims is a complicated issue as to which research is conflicting. The benefits of universal mandatory reporting policies may not outweigh the negative impact of such policies, in terms of helping victims. A student in an elementary or secondary school may report sexual harassment to any employee. Similarly, if an employee of an elementary or 483 secondary school personally observes sexual harassment, then the elementary or secondary school recipient must respond to and address the sexual harassment in accordance with these final regulations. As previously noted in the Adoption and Adaption of the Supreme Courts Framework to Address Sexual Harassment, elementary and secondary schools operate under the doctrine of in loco parentis, and employees at elementary and secondary schools typically are 484 mandatory reporters of child abuse under State laws for purposes of child protective services. A recipient also may empower as many officials as it wishes with the requisite authority to institute corrective measures on the recipients behalf, and notice to these officials with authority constitutes the recipients actual knowledge and triggers the recipients response obligations. The Department appreciates commenters concerns about recipients purposely ignoring reports of sexual harassment. As the Department has acknowledged through guidance documents since 1997, schools, colleges, and universities have too often ignored sexual harassment affecting students and employees equal access to education. These final regulations ensure that every recipient is legally obligated to respond to sexual harassment (or allegations of sexual harassment) of which the recipient has notice. The final regulations use a definition of actual knowledge to address the unintended consequences that the constructive notice standard created for both recipients and students. As explained more fully in the Actual Knowledge subsection in the Adoption and Adaption of the Supreme Courts Framework to Address Sexual Harassment section of this preamble, the Department believes that the approach in these final regulations regarding notice of sexual harassment that triggers a recipients response obligations is preferable to the constructive notice standard set forth in Department guidance. Additionally, as some commenters noted, the constructive notice standard coupled with the Departments 485 mandate to investigate all allegations of sexual harassment may have actually chilled reporting. Investigations almost always require some intrusion into the complainants privacy, and some complainants simply wanted supportive measures but were not ready or did not desire to participate in a grievance process. These final regulations provide complainants with more 485 2011 Dear Colleague Letter at 4-5; 2001 Guidance at 15. This broader definition of actual knowledge for elementary and secondary schools does not reflect that the Department values the autonomy of elementary and secondary school students less than the autonomy of students at postsecondary institutions. Thus, the final regulations respect the autonomy of all complainants and aim to give all complainants options and control over how a school responds to their sexual harassment experience, yet achieves these aims differently for elementary and secondary school students, than for students at postsecondary institutions. Student Populations Facing Additional Barriers to Reporting Comments: Several commenters asserted that designating a single individual as the person to whom notice triggers a recipients obligation to respond creates significant hurdles to reporting for certain populations of students, including students with disabilities, immigrant students, international students, transgender students, and homeless students. One commenter asserted that, while the actual knowledge requirement favors the rights and needs of students with disabilities who are accused of sexual harassment, this requirement disfavors students with disabilities who are victims of sexual harassment. The commenter expressed concern that students with disabilities may only be comfortable communicating sensitive issues to their own teachers, and in some cases may only be able to communicate with appropriately trained special education staff. One commenter stated that, because immigrant students are even less likely to know to whom they should report, members of immigrant communities are disadvantaged by the actual knowledge requirement. Another commenter asserted that international students are more likely to confide in a teacher or advisor with whom they have close contact, because cultural and 303 linguistic barriers may make it difficult for international students to navigate official administrative channels. Several commenters noted that transgender students, as well as non-binary students and students who identify with other gender identity communities, are less likely to report or seek services than students from other demographics. Commenters argued that replacing the constructive notice standard with the actual knowledge standard will reduce the services and support received by transgender students and students who identify with other gender identity communities. One commenter asserted that the actual knowledge requirement disadvantages students who are homeless, students from economically disadvantaged backgrounds, or students from dysfunctional families; the commenter described having seen bruises, cuts, and left-over tape residue from when a student was hospitalized after getting into the students parents crystal methamphetamine. The commenter asserted that, under the proposed rules, students will lose support from teachers, placing students in greater danger. The commenter argued that it is imperative that all elementary and secondary school teachers be mandatory reporters. Discussion: the Department requires all recipients to address sex discrimination against all students, including students in vulnerable populations. In response to commenters concerns, in elementary and secondary schools, all students (including those in vulnerable populations) can report sexual harassment to any school employee to trigger the recipients obligation to respond. This expanded definition of actual knowledge in elementary and secondary schools gives all students, including those with disabilities who may face challenges communicating, a wide pool of trusted employees of elementary and secondary schools. While the Department acknowledges commenters concerns about actual knowledge introducing an additional hurdle to the reporting process for certain students at postsecondary institutions, the Department believes the actual knowledge requirement will bring benefits to students that outweigh potential concerns. This results in greater respect for the autonomy of a college student over what kind of institutional response will best serve the students needs and wishes. This gives students at postsecondary institutions greater control over whether or when to report than does a requirement of universal mandatory reporting. The Department understands commenters concerns that some students may not feel comfortable discussing a sexual harassment experience with a stranger. Partly in response to such concerns, the final regulations designate any school employee as someone with whom an elementary or secondary school student can share a report and know that the recipient is then responsible for responding promptly. At the same time, these final regulations permit each postsecondary institution to decide whether or not to implement a universal mandatory reporting policy. As discussed in the Actual Knowledge subsection of the Adoption and Adaption of the Supreme Courts Framework to Address Sexual Harassment section of this preamble, there is conflicting research about whether universal mandatory reporting policies for postsecondary institutions benefit victims, or harm victims. Once a grievance process has been initiated, these final regulations require recipients to provide the parties with written notice of each partys right to select an advisor of 490 choice, and nothing precludes a party from choosing a friend to serve as that advisor of choice. The Department disagrees that the actual knowledge requirement favors respondents over complainants. Several commenters noted that studies show that, although only five percent of rapes are reported to officials, nearly two-thirds of 492 victims tell someone about their experience. Numerous commenters asserted that sexual harassment and assault is a sensitive issue that many individuals only feel comfortable discussing within a trusted relationship, if they feel bold enough to discuss it at all. The commenter contended that in this situation the school can claim that it did not have actual knowledge of the incident and therefore the school cannot be held accountable for inaction. Multiple commenters stated that complainants should be 492 Commenters cited: Massachusetts Institute of Technology, Survey Results: 2014 Community Attitudes on Sexual Assault (2014). Also, multiple commenters cited a study that found that survivors often do not report their sexual assaults because of fear of being disbelieved or fear that 493 their assault will not taken seriously, and many commenters argued that the actual knowledge requirement will exacerbate these fears, thereby resulting in even less reporting of sexual harassment. Commenters argued that narrowing the scope of trusted adults to whom survivors of sexual assault can speak to receive support is an unjust violation of their right to safety. Numerous commenters asserted that giving complainants greater control over whether and when to report will encourage more people to come forward to report sexual misconduct. A few commenters stated that the actual knowledge requirement pushes back against mandatory reporting policies that undermine a students trust in professors and university employees. One commenter asserted that mandatory reporter policies frequently serves as a deterrent to complainants who are seeking resources rather than adjudication. The commenter stated that mandatory reporting enhances the risks of revictimization and penalizes students who wish to come forward and seek services rather than a grievance process. The commenter argued that a student should be told (by any employee in whom a student confides a sexual harassment experience) that unless the student makes a report, the institution will not know of the incident and will therefore do nothing about it. One commenter expressed support of the proposed rules allowance of greater informality in adjudications, because research shows 494 that victims want more informal options, with less mandatory reporting. The Department agrees with commenters who pointed out that the actual knowledge requirement in the postsecondary institution context appropriately gives more control and autonomy to each complainant to choose to discuss a private incident confidentially (for example, with a trusted professor or resident advisor), or to report the incident in order to seek supportive measures or a grievance process against the respondent. Numerous commenters asserted that preserving a survivors autonomy and control in the aftermath of a traumatic 495 experience of sexual violence can be crucial to the survivors ability to heal and recover. The Department agrees with commenters who asserted that victims want more informal options with less mandatory reporting because mandatory reporting policies may have the unintended consequence of penalizing complainants who wish to come forward and seek supportive 495 E. Therefore, the Department believes the actual knowledge requirement may benefit complainants at postsecondary institutions whose reports were chilled under a system of constructive notice. In the postsecondary institution context, the final regulations respect a complainants decision about whether or when to report, and ensure that a complainant may receive supportive measures irrespective of whether they file 498 a formal complaint of sexual harassment. Thus, universal mandatory reporting policies may sometimes result in involving a complainant in a grievance process when that is not what the complainant wanted, and the final regulations aim to make that less likely in the postsecondary institution context by allowing each postsecondary institution to decide for itself whether to have a universal mandatory reporting policy. The survivor is stripped of their power and control, and one of the only aspects that remains in their control is if, how, when, and to whom to share their story and mandatory reporting removes that last aspect of control that a survivor has. While elementary and secondary school students retain less control over when disclosure of sexual harassment triggers the schools mandatory response obligations, these students (with involvement of their parents as appropriate) do retain control over whether to accept supportive measures, and whether to also file a formal complaint. Under the rubric of actual knowledge, as applied by Federal courts interpreting Supreme Court precedent, whether certain recipient employees are officials with authority is a fact specific inquiry. In this manner, the final regulations ensure that students in elementary and secondary schools can discuss, disclose, or report a sexual harassment incident to any school employee, conveying actual knowledge to the school and requiring the school to respond 499 Section 106. Generally Burdening Complainants Comments: Many commenters asserted that the actual knowledge definition and requirement places the burden squarely on victims to report harm. Numerous commenters stated that postsecondary students are not yet full adults, and that the proposed regulations unrealistically assume that an 18 year old freshman in college is ready to face the process required by the proposed regulations. Many commenters asserted that eliminating the responsible employees rubric used in Department guidance will delay, if not totally hinder, the ability of complainants to get prompt assistance in the aftermath of trauma. Another commenter asked why the proposed regulations removed the term responsible employees that was used in Department guidance. Discussion: the Department acknowledges that the actual knowledge requirement in the final regulations departs from the constructive notice approach relied on in previous Department guidance, wherein the Department took the position that any responsible employee (in both elementary and secondary schools, and postsecondary institutions) who knew or should have known about sexual harassment triggered the recipients obligation to address sexual 503 harassment. There are two ways in which the final regulations alter references to responsible employees. In the 2001 Guidance, the Department defined a responsible employee as any employee who has the authority to take action to redress the harassment, who has the duty to report to appropriate school officials sexual harassment or any other misconduct by students or employees, or an individual who a student could reasonably believe has this authority or 504 responsibility. In the postsecondary institution context, these final regulations 504 2001 Guidance at 13. A recipient (including a postsecondary institution recipient) may give authority to as many officials as it wishes to institute corrective measures on behalf of the recipient, and notice to such officials with authority will trigger the recipients response obligations. A recipient also may choose to train employees and other individuals, such as parent or alumni volunteers, on how to report or respond to sexual harassment, even if these employees and individuals do not have the authority to take corrective measures on the recipients behalf. The Department will not penalize recipients for such training by declaring that having trained people results in notice to those people charging the recipient with actual knowledge. The Department recognizes that recipients may not engage in such training efforts if such efforts may increase the recipients 505 liability. Under the 2001 Guidance and subsequent guidance documents, a recipient was required to ensure that employees are trained so that. In elementary and secondary schools the final regulations provide that reporting to any school employee triggers the schools prompt response. Employees Obligations Comments: Several commenters expressed concern that the definition of actual knowledge means that some employees previously designated as responsible employees or mandatory reporters under Department guidance would no longer undergo training about sexual violence on campus. Many commenters believed that under the proposed rules, fewer employees would be mandatory reporters and thus would be untrained when students disclose an incident of sexual harassment. Many commenters asserted that, without mandatory reporting, professors, coaches, resident advisors, or teaching assistants may respond to victims based on personal preferences or biases (perhaps because the employee knows the accused student, or is biased against believing complainants), and argued that this will impact victims ability to obtain assistance from unbiased, trained personnel. Relatedly, several commenters requested that the Department provide clarity on what constitutes authority to initiate corrective measures and what types of corrective measures would be included; commenters argued that all staff and faculty have at least some ability to initiate some types of corrective measures. At least one commenter asserted that requiring institutions, such as the commenters community college, to respond only when the institution has actual notice, is a positive development. The commenter asserted that the commenters institution employs part-time and contract employees, and vendors, outside the institutions direct control with no authority to institute corrective measures. This commenter therefore appreciated the flexibility offered under the proposed rules, for postsecondary institutions to design their own mandatory reporting policies. One commenter, a graduate student instructor, asserted that the actual knowledge definition was helpful to clarify the commenters role and asserted that current guidance is unclear. Discussion: the 2001 Guidance indicated that responsible employees should be trained to report 507 sexual harassment to appropriate school officials. With respect to training, the Department in its 2001 Guidance stated: schools need to ensure that employees are trained so that those with authority to address [sexual] harassment know how to respond appropriately, and other responsible employees know that they are obligated to report [sexual] harassment to appropriate 508 officials. Accordingly, the Department disagrees with commenters that removing any mandatory reporting requirement or the responsible employee rubric allows employees to freely respond to victims out of personal preferences or biases. For reasons discussed previously, including in the Actual Knowledge subsection of the Adoption and 511 E.

It acts on the sympathetic nervous system insomnia otc medication unisom 25 mg otc, leading to increased heart rate and blood pressure sleep aid hydrochloride generic unisom 25mg amex. Dopamine cannot cross the blood-brain barrier insomnia period safe 25 mg unisom, so when it is given as a drug sleep aid under tongue purchase 25mg unisom fast delivery, it does not affect the central nervous system insomnia vegas purchase unisom 25mg mastercard. When dopamine is needed in the brain insomnia imdb buy unisom 25mg with visa, due to diseases such as Parkinsons, levodopa is used. Early symptoms are typically subtle, and may occur gradually, but the disease can progress at varying rates. Additional symptoms may include visual hallucinations, depression and other emotional changes, difficulty in swallowing, chewing, and speaking, urinary problems and sleep disruptions. Dementia may be evident before, concurrently, or at most within twelve months of onset of Parkinsonian symptoms. Research has found at least eleven genes that have been implicated in various forms of Parkinsons, with the prominence of specific clinical features dependent on which genes are involved. A diagnosis of Parkinsons is based on medical history and neurologic examination, as there are currently no blood or laboratory tests proven to help in diagnosing sporadic Parkinsons. The substantia nigra normally shows a susceptibility signal pattern that has the appearance of a swallows tail. This sign is absent when Parkinsons disease is present, and the diagnostic accuracy of this sign is reported to be greater than ninety percent. Iron accumulation and loss of neuromelanin also affect the appearance of the substantia nigra on T1 and T2-weighted images. Figure 62 Swallow tail sign in substantia nigra Figure 63 1A Healthy individual with swallow tail appearance; 1B Patient with Parkinsons disease and absent swallow tail sign Alzheimers Disease Alzheimers is a progressive disease that damages the neurons in the parts of the brain involved in memory, learning, language, and reasoning. It is the most common type of dementia, accounting for an estimated sixty to eighty percent of dementia cases, and is more prevalent among women than men. Early-onset tends to strike people under age sixty five, and is more likely to run in families. Late-onset Alzheimers is the more common type, afflicting people after age sixty five, and occurring in almost half of all people over the age of eighty five. This type accounts for less than one percent of all cases, with onset often seen in the forties. The hippocampus, located in the temporal lobe, is thought to be where short-term memories are converted into long-term memories. In addition, the hippocampus, as well as other areas of the brain involved in thinking and decision making are filled with two types of abnormalities beta-amyloid plaques and neurofibrillary tangles. The plaques are deposits found outside and around the neurons, made up of dense fragments of the beta-amyloid protein mixed with other cellular material. Plaques and tangles are both associated with damage to healthy brain cells, and result in brain atrophy. Another characteristic of Alzheimers disease is the reduced production of certain chemicals in the brain that are necessary for communication between nerve cells. These chemicals are called neurotransmitters, and include acetylcholine, serotonin, and norephinephrine. Early symptoms of Alzheimers disease include failure of short-term memory, apathy, and depression. Impaired communication, disorientation, confusion, behavior changes, and difficulty speaking, swallowing and walking are often seen in later stages. There is currently not a cure for Alzheimers disease, only drug and non-drug treatments that may help with both cognitive and behavioral symptoms. Alzheimers is a disease, not a normal part of aging, and research for a cure is ongoing. The hippocampus is a critical area for learning and memory, and is damaged by Alzheimers. We will discuss vascular dementia, dementia with Lewy bodies, mixed dementia, and frontotemporal dementia. Vascular dementia accounts for approximately ten percent of dementia cases, and was previously known as multi-infarct or post-stroke dementia. This type of dementia occurs because of brain injuries such as microscopic bleeding and blood vessel blockage. The location, size and number of brain injuries determines how the individuals thinking and physical functioning are affected. Initial symptoms may include impaired judgment or impaired ability to make decisions, plan, or organize, as opposed to the initial symptoms of memory loss found with Alzheimers. Brain imaging can often detect the blood vessel problems implicated in vascular dementia. Pathologic evidence has shown that the various types of dementia are not considered mutually exclusive, as their hallmark brain changes are found simultaneously. Lewy body aggregates are also seen in the brains of people with Parkinsons disease, but in a pattern that is different from dementia with Lewy bodies. Symptoms of dementia with Lewy bodies are memory loss and thinking problems, which are similar to Alzheimers. However, dementia with Lewy bodies also causes early symptoms such as sleep disturbances, well-formed visual hallucinations, and muscle rigidity or other parkinsonian movement features. Most commonly, the brain changes are abnormalities associated with Alzheimers and vascular dementia, but dementia with Lewy bodies cannot be excluded. Recent studies suggest that mixed dementia is more common than previously thought. The cell damage caused by these disorders leads to tissue shrinkage and reduced function in the brains frontal and temporal lobes, which control planning and judgment, emotions, speaking and understanding speech, and certain types of movement. Each of the specific disorders in the frontotemporal group has different core symptoms, but they display significant symptom overlap as these disorders progress. Frontotemporal dementia accounts for approximately ten to fifteen percent of all dementia cases, and usually develops when people are in their fifties or early sixties. As it progresses, those affected may develop disinhibition, which is a loss of restraint in personal relations and social life. Primary progressive aphasia affects language skills in its early stages, and behavior as it advances. Frontotemporal dementia remains a clinical diagnosis, as there are currently no tests that can conclusively diagnose this disorder. Myelin acts like insulation on electrical wires, helping the axon portion of the nerve cells to conduct impulses to other cells. As more areas or nerves are affected by demyelination, the impulses are diminished or lost, and patients begin to develop symptoms. Specific symptoms are related to the area of injury, and may affect the axon of the nerve as well. Figure 70 Illustration of normal nerve fiber and damaged nerve fiber from multiple sclerosis Multiple sclerosis is considered to be an autoimmune disorder, in which the bodys immune system attacks and destroys healthy body tissue by mistake. It occurs predominantly in younger persons, with diagnosis usually taking place between the ages of fifteen and forty five. If the optic nerve is impacted, patients may experience visual changes, including loss of vision. Numbness, tingling, or weakness may be described, which can be severe enough to cause paralysis of one side of the body. These therapies may help to decrease the severity of exacerbations, as well as to decrease the potential for long-term disability. Approved medications can also be used to treat the many symptoms caused by multiple sclerosis, such as spasticity, fatigue, memory loss, pain, etc. For those that are not treated, over thirty percent may develop pronounced problems with mobility. Dystonia may affect one muscle, groups of muscles, or muscles throughout the body. Some forms of dystonia are genetic, but the cause for the majority of cases is unknown. Researchers believe that dystonia results from an abnormality in, or damage to , the basal ganglia or other brain regions that control movement. There may be abnormalities in the brains ability to process neurotransmitters, which are the chemicals that help neurons communicate. There also may be abnormalities in the way the brain processes information and generates commands to move. Dystonia can be divided into three groups, which are idiopathic, genetic, and acquired. Idiopathic dystonia does not have a clear cause, but this grouping includes many dystonias that occur. Genetic dystonia can be inherited in a dominant manner, with widely varying symptoms and severity. Acquired dystonia, or secondary dystonia, can result from environmental or other damage to the brain, or from exposure to certain types of medications. Dystonia can occur at any age, but are typically classified as early onset or adult onset. It can progress through various stages, with the patient eventually displaying dystonic postures and movements even when relaxed. The most common focal dystonia is cervical dystonia, or spasmodic torticollis, which involves the muscles in the neck causing the head to turn to one side or be pulled forward or backward. The second most common focal dystonia is blepharospasm, which is the involuntary, forcible contraction of the muscles controlling eye blinks. A variety of dystonias have been identified that have a genetic cause, and mutations in specific genes have been linked to specific dystonic syndromes. There are no medications to prevent dystonia or slow its progression, but treatment options exist that can ease some of the symptoms. Botulinum toxin injections into affected muscles prevent muscle contractions and provide temporary improvement in the abnormal postures and movements that characterize dystonia. This toxin injection blocks the release of the neurotransmitter acetylcholine, which causes muscle contraction. Off-label usage of certain classes of medications can block or regulate various neurotransmitters. Surgery may be performed to interrupt the pathways responsible for the abnormal movements. Small regions of the thalamus, globus pallidus, or other deep centers in the brain can be purposely damaged to reduce symptoms of dystonia. The high brain iron is typically seen in the part of the basal ganglia called the globus pallidus, as well as the substantia nigra. Low signal intensity is seen in the surrounding region due to the abnormal accumulation of iron. It is based on the phenomenon of flow-related enhancement of spins entering into an imaging slice (inflow effect). These spins are unsaturated, and therefore give more signal than the surrounding stationary spins. Additional limitations include longer acquisition times, ghosting and susceptibility artifacts, and poor signal suppression of stationary tissues that have short T1 relaxation times. In 2D, multiple thin imaging slices are acquired with a flow-compensated gradient echo sequence. The advantages of 2D, with its thinner slices, are better sensitivity to slow flow, better stationary tissue saturation through the use of high flip angles, and an increased vascular signal. With 3D imaging, a volume of images is obtained simultaneously by phase-encoding in the slice-select direction. Each repetition excites the volume, which produces a progressive saturation of the flows. Flow saturation can be reduced by dividing the 3D acquisition into slabs, and by using a variable flip angle. The flip angle should be smaller as the flow enters the volume, and larger as the flow leaves the volume to compensate for the relaxation of short T1 tissues. On Hitachi systems, this variable flip angle is carried out by the Slope Slab Profile parameter. Water molecules are equally likely to move about, or diffuse, in any direction, and are only hindered in the brain by cell membrane boundaries, ligaments, and other molecules. The higher the B-value, the stronger the diffusion weighting effects, allowing diffusion to become the dominant mechanism of tissue contrast. Moving water molecules acquire phase information by the first motion probing gradient, but are not rephased by the second motion probing gradient, and therefore lose their signal. Stationary water molecules are unaffected by the diffusion gradients, and retain their signal. Cardioembolism is associated with single corticosubcortical lesions, multiple lesions in the anterior and posterior circulation, and multiple lesions in multiple cerebral territories. Large-artery atherosclerosis is associated with multiple lesions in the unilateral anterior circulation, and small scattered lesions in one vascular territory, particularly in a watershed distribution. The ischemic core may evolve to irreversible infarction without effective reperfusion or cytoprotection. Studies show that the initial diffusion lesion volume correlates well with the final infarct volume, as well as with the neurological and functional outcomes. It can also reveal the integrity of these connections, and enable mapping of the orientation of the white-matter tracts. When diffusion motion is symmetric, or equal in all directions, it is referred to as isotropic. This asymmetry occurs because diffusion is restricted in the direction that is perpendicular to the long axis of the axons. The resulting degree of anisotropy in a white matter region, as seen on a Fractional Anisotropy map, can be viewed as a reflection of the degree of the structural integrity of the white matter.

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The Department addresses comments about the Clery Act in the Clery Act subsection of the Miscellaneous section xanax sleep aid dosage purchase 25 mg unisom with visa. Recipients have been able to navigate the art of complying with numerous Federal regulations promulgated by various executive agencies while also complying with State laws insomnia 2016 trinidad order unisom 25mg on line. School and university officials will determine how to comply with the State and Federal legal obligations insomnia escape room dc buy unisom on line. The Department will provide technical assistance with respect to the obligations under these Federal regulations insomnia in elderly cheap 25mg unisom with mastercard. Commenters argued against imposing a one-size-fits-all approach sleep aid elderly order unisom 25mg on-line, given the vast diversity among recipients in terms of size sleep aid nighttime cheap 25 mg unisom free shipping, resources, missions, and communities, and urged the Department to give recipients flexibility to tailor their own systems. Another commenter stated that the Department is jeopardizing recipients access to State funding because schools would be in an impossible position of having to comply with both State and Federal law. Another commenter raised similar concerns about what the State of Washington requires and requested that the 1594 Department clarify these final regulations do not preclude a determination that a recipients actions constitute discrimination under State civil rights laws. Discussion: the Department acknowledges that State laws may impose different requirements than these final regulations and asserts that in most circumstances, compliance with both State law and the final regulations is feasible. State laws that have a different definition of sexual harassment or require a recipients response regardless of where misconduct occurs do not necessarily conflict with the final regulations. Accordingly, recipients are free to respond to conduct that these final regulations do not address. These final regulations do not preclude a State from determining whether a recipients actions constitute discrimination under State civil rights laws. This commenter requested that the Department not move forward with the proposed regulations until it publishes a substantive analysis addressing federalism and conflict of law issues created by it. According to this commenter, the Fourteenth Amendment does not require a recipient to consent to conditions and, thus, reliance on such consent is misplaced to 1689 E. However, this commenter cited case law suggesting that preemption and federalism analyses vary depending on which authority the Department is invoking. This commenter urged the Department to prove it has not exceeded its authority in issuing the proposed regulations. Discussion: Throughout the preamble and specifically in the Miscellaneous section. The Department also already noted that with respect to these final regulations relationship with State law, the final regulations are not an unfunded mandate that implicate federalism and conflict of law issues, but rather condition Federal financial assistance on compliance with these final regulations. The Department agrees that these final regulations could be justified under the Federal governments Fourteenth Amendment authority, in addition to the straightforward Spending Clause authority. That power includes the authority both to remedy and to deter violation of rights guaranteed [by the Fourteenth Amendment] by prohibiting a somewhat broader swath of conduct, including that which is not 1691 itself forbidden by the Amendments text. If State law prohibits informal resolution, then a recipient does not need to offer an informal resolution process. The commenter believed that notice on the recipients website would be sufficient notice to stakeholders within the recipients community. Some commenters noted the Department expected that the availability of websites would address the removal of taking continuing steps but these commenters were not convinced that posting on websites achieves the same purpose. At least one commenter stated that the Department failed to mention or justify the removal of the requirement to train recruiters on its non-discrimination policy, which the commenter argued is an important requirement to ensure that such a policy is not diluted in the field. The commenter stated that the Department previously issued guidance on notices of non-discrimination in 2010 and recommended that if the proposed rules are adopted, the Department should clarify any parts of the sample notice provided in the 2010 guidance that have changed as a result. The commenter also argued that the Department failed to explain why it added handbooks to the list and how that item overlaps or not with items removed from that list, such as announcements and bulletins. The Department believes this list of types of publications is broad enough to achieve the purpose of ensuring that relevant individuals and organizations. The commenter further asserted that the proposed rules did not clarify how to identify appropriate professional organizations, nor whether the organization has a right of action or standing that warrants the need to provide it with separate notice. The 2001 Guidance at 20 encourages recipients to ensure that the school community has adequate notice of the schools non-discrimination policy, and of the procedures for filing complaints of sex discrimination, by having copies available at various locations throughout the school or campus, including a summary of the procedures in handbooks and catalogs sent to students and parents, and identifying personnel who can explain how the procedures work. Whether an organization describes itself as a union or uses a different label, the term or professional organizations holding collective bargaining agreements or professional agreements encompasses the reality that many elementary and secondary schools have employees who are unionized or otherwise collectively bargain or hold professional agreements with the recipient. Most recipients have already complied with the regulatory requirement to send an initial notice within 90 days of the effective date of the 1975 regulations. Commenters argued that most elementary and secondary school students are minors and rely on their parents in making decisions related to school. Commenters asserted that since the parents of elementary and secondary school students would no longer be required to receive notice of the non-discrimination policy, children would have the task of providing notice to these individuals and would have to understand that what they have experienced is sexual harassment and feel comfortable sharing the experience with a stranger. Some commenters opposed the change and asserted that the Departments rationale for the change in language was to remove subjective determinations so that the requirement would be clearer for those enforcing it and for recipients seeking to comply with it but did not believe more clarity was needed. The Department believes, however, that requiring recipients to (a) have a non-discrimination policy, (b) notify relevant persons and entities of that policy, and (c) post that policy on the recipients website and in handbooks and catalogs, sufficiently ensures that a wide pool of people affiliated with the recipient, and the 1712 general public, understand a recipients obligation to not discriminate based on sex. Rather, the Department believes that recipients publications should take care not to state different treatment based on sex in contravention of the recipients required non-discrimination policy. Whether a publication states different treatment on the basis of sex, including based on a theory of sex stereotyping, is an inquiry distinct from whether the publication might be viewed as suggesting or implying different treatment on the basis of sex, including based on a theory of sex stereotyping. For reasons explained above, the Department does not believe it is reasonable or useful for the Department to scrutinize every graphic, picture, and illustration in a recipients publications to discern whether such illustrations suggest, or imply, different treatment that is not intended, not applied, and not reasonably perceived as such. One commenter argued that the Department provided no statistical or other evidence to show that the rationale for the provision has changed, or that sex stereotyping no longer needs to be remedied. The commenter contended that published policies and materials of a school can be susceptible to suggestions of sex stereotyping even where the publications do not state discriminatory practices. The commenter argued that both male and female students continue to be subjected to sex stereotyping in the forms of visual images, statements, and conduct that limits or denies their access to career and technical education paths based on sex. Commenters asserted that male students are discouraged from engaging in dance or theater because these occupations are not sufficiently masculine, and female students are 1622 discouraged from participating in science or engineering based on stereotypical conceptions of a womans ability to do math and science. One commenter asserted that it is rare for an entity to directly state that it discriminates and that there are many other ways a discriminatory message can come across; for example, a brochure used to recruit applicants to a nursing school should not contain 40 photos of female students and no photos of male students. Another commenter expressed concern that there are numerous symbols that get a point across as well as, if not better than, actually stating something. One commenter asserted that overt racism and sexism are less common in the modern era and that statements hinting at a policy of sex discrimination are used in lieu of explicit statements. The commenter asserted that for example, instead of a recipient stating that it reserves Advanced Placement classes for college-bound men because a womans place is in the home, the recipient might state we promote traditional gender roles and encourage women to take appropriate coursework to prepare for those roles. The commenter asserted that for example, a school may post a sign relating to sexual misconduct which includes images of a male student and the statement dont be that guy, which suggests that the school thinks only men commit sexual assault even though the school may state that it has a policy of non-discrimination. The commenter suggested that the 1623 Department use an objective standard that also prohibits non-textual indications of sex discrimination. Discussion: For reasons described above, the Department does not believe it is appropriate to scrutinize the graphics, photos, and illustrations chosen by a recipient in its publications in order to determine whether a recipients publication suggests different treatment based on sex. The Department disagrees with the commenter who argued that a recipient should not be allowed to use a picture on a nursing school brochure depicting a group of women, without additional context about the brochure asserting that men were treated differently in such a nursing program. The Department does not believe that examining illustrations used in a recipients publications yields a reasonable, fair, or accurate assessment of whether a recipient engages in sex discrimination, and does not believe that expecting a proportionality requirement in the illustrative, graphic, and photographic depictions of all the kinds of students to whom a recipients programs are available bears a reasonable relation to whether the recipient treats students or employees differently on the basis of sex contrary to the recipients policy of non discrimination. Thus, the enforcement action described by the commenter may not reach a different result under the final regulations. Suggested Modifications Comments: One commenter suggested that the Department require a recipients non discrimination policy to be published in multiple locations on the website where appropriate, including for example, the recipients human resources page and admissions page. The commenter also recommended that the Department reiterate Federal standards regarding translation of materials into languages other than English. The commenter asserted that requiring this information would promote consumer choice and is consistent with all other information that Federal law requires a school to disclose, particularly in higher education, and would enable a student to make a knowing and voluntary choice about 1626 whether to attend the school. One commenter expressed concern that the proposed rules did not address totalitarian reporting methods such as third-party reporting, bystander intervention, and posting fliers all over campus that encourage students to make reporting a habit. As discussed elsewhere in this preamble, the final regulations neither require nor 1629 prohibit a recipient from disseminating information about bystander intervention designed to prevent sexual harassment. A primary focus of these final regulations is to govern a recipients response to sexual harassment of which the recipient has become aware, and to provide accessible options for any person to report sexual harassment to trigger a recipients response obligations. Similarly, nothing in the final regulations requires or prohibits a recipient from posting flyers on campus encouraging students and others to report sexual harassment; recipients should retain flexibility to communicate with their educational community regarding the importance of reporting sexual harassment. The Department disagrees that accessible reporting channels, and the right of any person to report sexual harassment, constitute a totalitarian system or otherwise has negative consequences. As demonstrated by the data discussed in the General Support and Opposition section of this preamble, sexual harassment is a prevalent problem affecting the educational access of students at all educational levels, and a recipients knowledge of sexual harassment triggers the recipients non-deliberately indifferent 1630 response under these final regulations so that instances of sexual harassment are addressed in a 1713 manner that is not clearly unreasonable in light of the known circumstances. These final regulations do not recognize a response specifically for an informal complaint of sexual harassment. Moreover, this provision is revised to clarify that the notice about the grievance procedures (which apply to sex discrimination) and grievance process (which applies specifically to sexual harassment) must include how to report or file a complaint of sex discrimination, how to report or file a formal 1716 Section 106. Non-sexual harassment sex discrimination often presents situations that differ from sexual harassment (for example, a complaint that school policy treats female applicants differently from male applicants, or that school practice is to devote more resources to male sports teams than to female sports teams), and the Department does not, in these final regulations, alter recipients obligation to handle complaints of non-sexual harassment sex discrimination by applying grievance procedures that provide for the prompt and equitable resolution of such complaints. The Department intends to enforce these final regulations vigorously for the benefit of all students and employees in recipients education programs or activities, and any person may file a complaint with the Department alleging that a recipient is non-compliant with these final regulations. Thus, even if a recipient desires for complainants to only use a specific form for filing formal complaints, these final regulations permit a complainant to file a formal complaint by either using the recipient-provided form (or electronic submission system such as through an online portal provided for that purpose by the recipient), or by physically or digitally signing a document and filing it as authorized. Because recipients must adopt and publish the recipients grievance procedures (for sex discrimination) and grievance process (for formal complaints of sexual harassment), the recipients obligation is to publish (and send notice, as appropriate) when the recipient no 1638 longer uses one grievance procedure or grievance process and instead uses a different procedure or process. Commenters argued that this conflict also creates the need for separate processes to address the same misconduct, which undermines the Departments stated goal of streamlining processes to create more efficient systems. We believe a plain language interpretation of a statute is most consistent with fundamental rule of law principles, ensures predictability, and gives effect to the intent of Congress. Courts have recognized a canon of statutory construction that Congress 1717 ordinarily intends its statutes to have domestic, not extraterritorial, application. The Supreme Court most recently acknowledged 1719 the presumption against extraterritoriality in Morrison v.

Sclerosing cholangitis is not associated with an anomalous pancreaticobiliary duct union insomnia for mac buy cheap unisom 25mg. Sclerosing Cholangitis: Clinicopathologic Features insomnia 2017 order cheapest unisom and unisom, Imaging Spectrum insomniax pajamas sold in what stores purchase unisom in india, and Systemic Approach to Differential Diagnosis insomniax mac discount 25 mg unisom free shipping. This lesion is predominantly of soft tissue attenuation insomnia stories unisom 25 mg, however there are two small foci of gross fat insomnia hd purchase unisom 25 mg without prescription. Although adrenal adenomas may have microscopic fat in them, they would not be expected to have macroscopic fat as in this case. Adrenal cortical carcinomas are malignant lesions with aggressive behavior, typically 6 cm or larger, that often invade the adrenal vein. Myelolipomas are composed of varying proportions of adipose and bone-marrow like hematopoietic tissue, including megakaryocytes. A metastasis to the adrenal gland would not be expected to contain fat (a rare liposarcoma metastasis theoretically could, but would be unlikely to be a small, well-defined lesion such as this). Rationale: Findings: Left adrenal mass containing gross fat and a small amount of coarse calcium. Although 80% do contain fat, it is intracytoplasmic and thus detectable as low density (< 10 H. Lymphangiomas are malformations of the lymphatic system characterized by lesions that are thin walled cysts; these cysts can be macroscopic or microscopic; they should be mostly water density and not fatty. The adrenal glands are a common site of metastatic disease, but adrenal metastases are typically soft tissue density. Larger metastases to the adrenals may have central necrosis or areas of hemorrhage, but would not have a fatty component (a rare liposarcoma metastasis theoretically could, but would be unlikely to be a small, well-defined lesion such as this). Myelolipomas are uncommon benign tumors of the adrenal gland comprised of mature adipose cells and hematopoetic tissue. Incorrect: Non-Hodgkins lymphoma can involve the kidney but is seen on presentation in only 5. Although it can involve the kidney as a single mass, renal lymphoma most commonly presents as multiple lymphomatous masses. Incorrect: Angiomyolipoma is a benign tumor of the kidney that is characterized by regions of macroscopic fat (seen in 95% of cases). Correct: Renal medullary carcinoma is an unusual tumor that almost always occurs in young patients with sickle cell trait. The tumor arises from the calyceal epithelium and grows in an infiltrative pattern. It is a very aggressive tumor with early metastases to lymph nodes and vascular invasion. Incorrect: Transitional cell carcinoma can fill the renal pelvis and diffusely infiltrate the kidney as in this case. However, transitional cell carcinomas typically affect older individuals and would be rare to affect someone of this age. Also, transitional cell carcinomas would not demonstrate vascular invasion as in this case. Textbook of Uroradiology, 5th Edition, Wolter Kluwer/Lippincott, Williams, & Wilkins, Philadelphia, 2013. A simple ureterocele is a nonmalignant focal dilatation of the submucosal distal ureter. An ectopic ureterocele is a nonmalignant focal dilatation of the submucosal distal Ectopic ureter. Looks like a ureterocele, but in this case is the result of a malignancy invading the bladder trigone. Fungus ball would appear as mobile, often multiple, laminated, gas-containing filling defects within the bladder. Rationale: Findings: Exophytic left renal mass containing a small amount of gross fat (density 52. Renal cell cancer can rarely contain fat, but generally as a large very heterogeneous mass. Although 80% do contain fat, it is intracytoplasmic and thus detectably as low density (< 10 H. Perirenal liposarcoma may contain fat, but would typically be larger and more complex in appearance. No abnormal echotexture or abnormal hyperemia of visualized portion of either testicle on color Doppler. In testicular torsion, there could be hyperemia around a torsed testicle as a late finding, but there would be reduced or absent flow to the testicle. As above, in this case there is normal flow to the testes bilaterally, precluding the diagnosis of testicular torsion. Enlargement and hyperemia of the left epididymis, as seen here is characteristic of left epididymitis. Although there is evidence of left epididymitis, as above, the left testicle has normal flow on color Doppler, and normal echogenicity, with no evidence of orchitis. This is not a typical appearance for schistosomiasis; in particular, no calcifications of the masses are seen. Rationale: Findings: Heterogeneous echotexture of the testicle, with no flow within the testicle on power Doppler. The absence of flow on power Doppler is consistent with testicular torsion, but the presence of heterogeneity within the testicle is consistent with infarct, indicating the testicle is no longer viable. The absence of flow confirms torsion, with the heterogeneous appearance indicating infarction. With acute epididymo-orchitis, there would be abnormal increased flow within the testicle in the region of orchitis, not absent flow as in this case. Seminoma if this large would be hypervascular, not have absent flow as in this case. Mixed germ cell tumors with teratomatous components will often have cystic areas within them, but do not form a network of tubule like this. Also germ cell tumors would not be expected to be centered in the mediastinum testes bilaterally. Testicular abscess usually occurs as a complication of epididymo-orchitis, for which there is no evidence in the images. This is a typical appearance of tubular ectasia of the rete testis, with variable size cystic lesions near the mediastinum testes bilaterally. Tunica albuginea cysts occur within the tunica surrounding the testis, and are usually solitary and small, 2-3 mm. You are shown duplex Doppler ultrasound images of the right greater saphenous vein during a Valsalva maneuver. Rationale: On Valsalva maneuver there is retrograde flow in the great saphenous vein indicating venous valvular insufficiency with reflux. Rationale: the frontal aortogram shows no functioning left kidney, no filling of the splenic artery and collateral flow from the left colic branch of the inferior mesenteric artery into the mid colic artery. The lateral shows the superior mesenteric artery to be occluded at its origin and an all but occluded celiac trunk. Uterine fibroid vascularization and clinical relevance to uterine fibroid embolization. Rationale: Although there are variants, the gonadal arteries most commonly are paired structures arising from the aorta just inferior to the renal arteries. Cholelithiasis Key: C References: Valji K, Vascular and Interventional Radiology, Saunders 2006. Rationale: the image shows a biliary drainage catheter passing from the right hepatic duct through the common hepatic duct. Unlike pancreatic carcinoma that typically obstructs the common bile duct, the usual point of biliary obstruction with cholangiocarcinoma is at the confluence of the right and left hepatic ducts as demonstrated here. The antidote for an overdose of midazolam (or any other benzodiazepine) is flumazenil. Rationale: the left colic artery is the first branch of the inferior mesenteric artery. At Griffiths point, in the region of the splenic flexure, it anastomoses with the middle colic artery a branch of the superior mesenteric artery. Rationale: A contraindication to great saphenous vein ablation is dependency on the saphenous system for venous drainage because of significant deep vein obstruction. Rationale: the waveforms for both the right and left common carotid arteries show two systolic peaks. As the downward pointing peak illustrates, late in diastole there is retrograde flow in both the right and left carotid arteries caused by deflation of the balloon. Rationale: There is a partially occlusive filling defect or defects within the contrast opacified superior mesenteric artery characteristic for a thromboembolus. Orbital lipoma Key: A References: the Requisites, Neuroradiology; Third Edition, Mosby Elsevier 2010 188-189. There is a depressed orbital floor fracture appreciated on the right with fat herniating through the defect with probable hemorrhage in the right maxillary sinus as evidenced by opacification of the sinus on bone window evaluation. The inferior rectus is also somewhat enlarged likely related to post traumatic edema/hematoma. Though one might see opacification of the maxillary sinus in acute sinusitis one would most likely see an intact orbital floor and no defect in the floor. The location of the defect and fat herniating through the defect are consistent with trauma not neoplastic erosion. Osteomyelitis Key: A References: Langerhans Cell Histiocytosis of the Spine: Long term follow up in children. Langerhans cell histiocytosis commonly presents with a vertebral plana appearance as seen here. The degree of compressions as well as the signal characteristics are not consistent with trauma. Leukemia can present with vertebral plana but one would suspect diffuse marrow involvement not focal disease as seen in this case. Osteomyelitis would involve the disc space and two adjacent vertebral bodies not an isolated vertebral lesion seen here. Metastasis Key: A References: the Requisites, Neuroradiology; Third Edition, Mosby Elsevier 2010 560-561. The most common intrdural extramedullary lesion of the spine is a meningioma or schwannoma. Though leptomeningeal metastasis are seem in the intradural extramedullary space, meningiomas are more common. Meningioma Key: A References: the Requisites, Neuroradiology; Third Edition, Mosby Elsevier 2010 384,399-401. Astrocytomas are parenchymal lesions found in the intraxial compartment of the brain. Oligodendroglioma Key: A References: the Requisites, Neuroradiology; Third Edition, Mosby Elsevier 2010: p. Oligodendrigliomas are glial neoplasms that are not cystic and do not occur in the suprasellar region. Machiafava Bignami Disease is in the differential of collosal lesions but patients with this disease have a history of alcoholism. The disease affects the body of the corpus callosum first followed by the genu and then the splenium of the corpus callosum. It typically involves the subcortical U fibers of the anteroinferior temporal lobes, subinsular region, external capsule zones and inferior frontal lobes. The location of the lesions and the presentation are consistent with white matter shear injury as seen in Diffuse axonal Injury in the setting of trauma. Lupus Cerbritis should be considered in a female of reproductive age with a complicated neurologic presentation. Multifocal Cerebral Infarction would not be expected to resolve two weeks post therapy as stated in this case. Cerebral Amyloid Angiopathy is a disease of older patients that presents with foci of hypointensity on susceptibility weighted imaging and hemorrhage. Meningiomas are the most common extra axial neoplasms of the brain that arises from the dura and are associated with an enhancing dural tail which is seen in 72 percent of patients with meningiomas. Oligodendrigliomas are intraxial lesions that occur in the frontal lobes most commonly that are associated with calcification but do not involve the dura. Metastatic disease can involve the dura either via direct extension from the bone or via hematogenous spread. A dural tail in association with a dural metastasis can be seen though not considered characteristic of this entity. Key: A References: the Requisites, Neuroradiology; Third Edition, Mosby Elsevier 2010: p. Focal motor seizures are followed by progressive loss of ipsilateral motor function associated with cognitive decline. Rasmussens is believed to be viral induced autoimmune mediated disease of children. Glomus jugulare Key: A References: the Requisites, Neuroradiology; Third Edition, Mosby Elsevier 2010: p. The most common location of paragangliomas in the head and neck is at the level of the carotid body. Though a location of paragangliomas, the carotid body paraganglioma is the most common. Glomus Jugulare is a location/type of paraganglioma occurring at the level of the jugular foramen but the carotid body is the more common location.