Condet

Markus Frey, MD

• Assistant Professor of Medicine
• Department of Cardiology and Angiology
• University of Freiburg
• Freiburg, Germany

This case presents a question of law: Did Defendant States violate the Electors Clause (or hair loss laser comb buy 0.5mg dutas with visa, in the alternative hair loss curezone body odor proven dutas 0.5 mg, the Fourteenth Amendment) by taking-or allowing-non-legislative actions to change the election rules that would govern the appointment of presidential electors? As Justice Gorsuch observed recently zinc cure hair loss cheap dutas 0.5mg without a prescription, "Government is not free to disregard the [Constitution] in times of crisis hair loss cure columbia buy generic dutas 0.5mg online. Defendant States also failed to segregate ballots in a manner that would permit accurate analysis to determine which ballots were cast in conformity with the legislatively set rules and which were not. A flash drive containing tens of thousands of votes was left unattended in the Milwaukee tabulations center in the early morning hours of Nov. For former Vice President Biden to win these four States collectively, the odds of 7 that event happening decrease to less than one in a quadrillion to the fourth power. Put simply, there is substantial reason to doubt the voting results in the Defendant States. Plaintiff States and their voters are entitled to a presidential election in which the votes from each of the states are counted only if the ballots are cast and counted in a manner that complies with the pre-existing laws of each state. The number of absentee and mail-in ballots that have been handled unconstitutionally in Defendant States greatly exceeds the difference between the vote totals of the two candidates for President of the United States in each Defendant State. In addition to injunctive relief for this election, Plaintiff State seeks declaratory relief for all presidential elections in the future. The integrity of our constitutional democracy requires that states conduct presidential elections in accordance with the rule of law and federal constitutional guarantees. In other words, Plaintiff State is acting to protect the interests of its respective citizens in the fair and constitutional conduct of elections used to appoint presidential electors. Defendants are the Commonwealth of Pennsylvania and the States of Georgia, Michigan, and Wisconsin, which are sovereign States of the United States. In the first presidential election, six of the ten States that appointed electors did so by direct legislative appointment. The Framers of the Constitution decided to select the President through the Electoral College "to afford as little opportunity as possible to tumult and disorder" and to place "every practicable obstacle [to] cabal, intrigue, and corruption," including "foreign powers" that might try to insinuate themselves into our elections. In the wake of the contested 2000 election, the bipartisan Jimmy Carter-James Baker commission identified absentee ballots as "the largest source of potential voter fraud. Absentee and mail-in voting are the primary opportunities for unlawful ballots to be cast. In addition, the Defendant States have made it difficult or impossible to separate the constitutionally tainted mail-in ballots from all mail-in ballots. Rather than augment safeguards against illegal voting in anticipation of the millions of additional mail-in ballots flooding their States, Defendant States all materially weakened, or did away with, security measures, such as witness or signature verification procedures, required by their respective legislatures. Their legislatures established those commonsense safeguards to prevent-or at least reduce-fraudulent mail-in ballots. Former Vice President Biden thus greatly benefited from this unconstitutional usurpation of legislative authority, and the weakening of legislative mandated ballot security measures. Defendant States violated the Constitution in the process of appointing presidential electors by unlawfully abrogating state election laws designed to 14 protect the integrity of the ballots and the electoral process, and those violations proximately caused the appointment of presidential electors for former Vice President Biden. Pennsylvania has 20 electoral votes, with a statewide vote tally currently estimated at 3,363,951 for President Trump and 3,445,548 for former Vice President Biden, a margin of 81,597 votes. The Pennsylvania Department of State quickly settled with the plaintiffs, issuing revised guidance on September 11, 2020, stating in relevant part: "The Pennsylvania Election Code does not 15 authorize the county board of elections to set aside returned absentee or mail-in ballots based solely on signature analysis by the county board of elections. Approximately 70 percent of the requests for absentee ballots were from Democrats and 25 percent from Republicans. Prior to the election, Secretary Boockvar sent an email to local election officials urging them to provide opportunities for various persons-including political parties-to contact voters to "cure" defective mail-in ballots. This entire scheme, which was only followed in Democrat majority counties, was blatantly illegal in that it permitted the illegal removal of ballots from their locked containers prematurely. Absentee and mail-in ballots in Pennsylvania were thus evaluated under an illegal standard regarding signature verification. The changed process allowing the curing of absentee and mail-in ballots in Allegheny and Philadelphia counties is a separate basis resulting in an unknown number of ballots being treated in an unconstitutional manner inconsistent with Pennsylvania statute. In addition, a great number of ballots were received after the statutory deadline and yet 18 were counted by virtue of the fact that Pennsylvania did not segregate all ballots received after 8:00 pm on November 3, 2020. On December 4, 2020, fifteen members of the Pennsylvania House of Representatives led by Rep. This discrepancy of approximately 400,000 ballots from November 2 to November 4 has not been explained. This number of constitutionally tainted ballots far exceeds the approximately 81,660 votes separating the candidates.

Most individuals report iden tifiable stressors in the months before their first panic attack hair loss zoloft cheap 0.5 mg dutas otc. Culture-Related Diagnostic issues Cultural interpretations may influence the determination of panic attacks as expected or unexpected hair loss cure vinegar discount dutas 0.5mg line. Cultural syndromes also influence the cross-cultural presentation of panic attacks hair loss in men 2 men buy discount dutas 0.5mg, resulting in different symptom profiles across different cultural groups hair loss 3 months after pregnancy 0.5 mg dutas mastercard. Ex amples include khyal (wind) attacks, a Cambodian cultural syndrome involving dizziness, tinnitus, and neck soreness; and trщnggiф (wind-related) attacks, a Vietnamese cultural syndrome associated with headaches. Ataque de nervios (attack of nerves) is a cultural syn drome among Latin Americans that may involve trembling, uncontrollable screaming or crying, aggressive or suicidal behavior, and depersonalization or derealization, and which may be experienced for longer than only a few minutes. Some clinical presentations of ataque de nervios fulfill criteria for conditions other than panic attack. Also, cultural expectations may influence the classification of panic attacks as expected or unexpected, as cultural syndromes may create fear of certain situa tions, ranging from interpersonal arguments (associated with ataque de nervios), to types of exertion (associated with khyвl attacks), to atmospheric wind (associated with trщnggiф at tacks). Clarification of the details of cultural attributions may aid in distinguishing ex pected and unexpected panic attacks. For more information about cultural syndromes, see "Glossary of Cultural Concepts of Distress" in the Appendix to this manual. Gender-Related Diagnostic Issues Panic attacks are more common in females than in males, but clinical features or symp toms of panic attacks do not differ between males and females. Diagnostic Markers Physiological recordings of naturally occurring panic attacks in individuals with panic disorder indicate abrupt surges of arousal, usually of heart rate, that reach a peak within minutes and subside within minutes, and for a proportion of these individuals the panic attack may be preceded by cardiorespiratory instabilities. Functional Consequences of Panic Attaclcs In the context of^co-occurring mental disorders, including anxiety disorders, depressive disorders, bipolar disorder, substance use disorders, psychotic disorders, and personality disorders, panic attacks are associated with increased symptom severity, higher rates of comorbidity and suicidality, and poorer treatment response. Also, full-symptom panic at tacks typically are associated with greater morbidity. Panic attacks should not be diag nosed if the episodes do not involve the essential feature of an abrupt surge of intense fear or intense discomfort, but rather other emotional states. Medical conditions that can cause or be misdiagnosed as panic attacks include hyperthyroidism, hyperparathyroidism, pheochromocytoma, vestibular dysfunctions, seizure disorders, and cardiopulmonary con ditions. A detailed history should be taken to determine if the individual had panic attacks prior to excessive substance use. Repeated unexpected panic attacks are required but are not sufficient for the diagnosis of panic disorder. Comorbidity Panic attacks are associated with increased likelihood of various comorbid mental dis orders, including anxiety disorders, depressive disorders, bipolar disorders, impulse control disorders, and substance use disorders. Panic attacks are associated with increased likelihood of later developing anxiety disorders, depressive disorders, bipolar disorders, and possibly other disorders. Marked fear or anxiety about two (or more) of the following five situations: Using public transportation. The individual fears or avoids these situations because of thoughts that escape might be difficult or help might not be available in the event of developing panic-like symp C. The agoraphobic situations are actively avoided, require the presence of a companion, or are endured with intense fear or anxiety. The fear or anxiety is out of proportion to the actual danger posed by the agoraphobic situations and to the sociocultural context. The fear, anxiety, or avoidance is not better explained by the symptoms of another men tal disorder-for example, the symptoms are not confined to specific phobia, situational type; do not involve only social situations (as in social anxiety disorder): and are not re lated exclusively to obsessions (as in obsessive-compulsive disorder), perceived defects or flaws in physical appearance (as in body dysmohic disorder), reminders of traumatic events (as in posttraumatic stress disorder), or fear of separation (as in separation anx iety disorder). Diagnostic Features the essential feature of agoraphobia is marked, or intense, fear or anxiety triggered by the real or anticipated exposure to a wide range of situations (Criterion A). The diagnosis re quires endorsement of symptoms occurring in at least two of the following five situations: 1) using public transporation, such as automobiles, buses, trains, ships, or planes; 2) being in open spaces, such as parking lots, marketplaces, or bridges; 3) being in enclosed spaces, such as shops, theaters, or cinemas; 4) standing in line or being in a crowd; or 5) being out side of the home alone. The examples for each situation are not exhaustive; other situations may be feared. When experiencing fear and anxiety cued by such situations, individuals typically experience thoughts that something terrible might happen (Criterion B). Individ uals frequently believe that escape from such situations might be difficult.

A study by Chase et al evaluated the outcome after removal of canine spindle cell tumours in first opinion practice hair loss telogen effluvium dutas 0.5 mg for sale. It does hair loss cure within 2 years cheap 0.5mg dutas mastercard, however hair loss in menopause cheap dutas 0.5mg overnight delivery, highlight the need to assess every patient as an individual and to take multiple factors into account when determining the best treatment approach hair loss in men 501 proven dutas 0.5 mg. The tumour grade, size, location and how amenable the tumour is to wide excision are very important. In cases where a wide excision can be carried out with minimal morbidity to the patient, this should be the treatment pursued, regardless of grade. When the tumour is not amenable to wide excision without the need for amputation, other factors should come into play. The two important factors to consider are the tumour grade and the age of the patient. When considering a surgical approach that is marginal, it is important to have a plan for long-term local control and/or for managing a recurrence. Adjunctive Treatments Because local control is crucial in soft tissue sarcoma, radiation is often used as adjunctive treatment after a marginal excision or when a wide excision is performed with inadequate histological margins. The worst-case scenario is an attempted wide excision with dirty histological margins. This creates the most surgical morbidity and cost, increases the chance of healing complications, and creates the largest possible radiation field. Although this unfortunate circumstance will occur occasionally, it can be avoided in most cases with appropriate preoperative planning. If clean margins are unlikely to be achieved based on preoperative imaging, a better approach would be to plan for a marginal excision and follow with radiation. Although it can be a safety net to fall back on when the margins of excision are not clear, it should not be relied upon in all cases. Full course radiation therapy has been shown to be effective adjunctive therapy to achieve local control after a marginal excision. A significant difference was not found when dogs that received doxorubicin (21 dogs) were compared to dogs that did not (18 dogs). Elmslie et al reported the beneficial effects of metronomic chemotherapy (continuous, low dose chemotherapy) in dogs with incompletely resected soft tissue sarcomas. These tumours arise from sites of chronic, intense inflammation that leads to the proliferation and transformation of fibroblasts. The proximal limb and lateral abdominal wall remain problematic areas to treat with wide surgical resection and this study highlights the need for continued education of general practitioners to vaccinate over the lower extremity and for continued development of vaccines with a limited inflammatory response. It is critical that cats are vaccinated below the elbow and stifle to ensure that they can be managed effectively with limb amputation. A mass in a cat that is present >1 month after vaccination at a vaccine site or any firm growing mass in a cat should be biopsied. Similarly, these masses should not be excised, but should be biopsied with an incisional biopsy to determine tumour type first. Excision without knowledge of tumour type may lead to a larger definitive resection with a decreased chance of a successful outcome. Surgery is the primary method of local control, and is often combined with radiation therapy preor post-operatively. Whether the cats had a wide or conservative excision did not affect the recurrence rate. There was no difference in the recurrence rate, metastatic rate or survival times in dogs that received chemotherapy compared with cats that did not. This study suggests that conservative excision and radiation therapy to 3 cm margins may be equivalent to wide excision with 3 cm margins and radiation therapy. However, the margins of excision need to be extensive and this will require a surgeon with additional training and experience in surgical oncology. Even a 1 cm mass will require an excisional diameter of 11 cm, which is considerable in a small patient. It is difficult to determine if this should be performed before or after surgery, if at all. The benefit of performing radiation therapy first is that the margins of excision will be sterilized, and the radiation field will be as small as possible. The disadvantage of this approach is that there may be an increase in incisional complications due to the fact that the surgical site will be within the radiation field.

Prevaience In the United States hair loss yeast infection quality dutas 0.5mg, the 12-month community prevalence estimate for specific phobia is approximately 7%-9% hair loss blogs purchase 0.5 mg dutas otc. Prevalence rates in European countries are largely similar to those in the United States hair loss in men versace purchase dutas 0.5mg fast delivery. Prevalence rates are approximately 5% in children and are approximately 16% in 13- to 17-year-olds hair loss in men 2b 0.5 mg dutas amex. Prevalence rates are lower in older individ uals (about 3%-5%), possibly reflecting diminishing severity to subclinical levels. Females are more frequently affected than males, at a rate of approximately 2:1, although rates vary across different phobic stimuli. That is, animal, natural environment, and situational spe cific phobias are predominantly experienced by females, whereas blood-injection-injury phobia is experienced nearly equally by both genders. Development and Course Specific phobia sometimes develops following a traumatic event. However, many individuals with specific phobia are unable to recall the specific reason for the onset of their phobias. Specific phobia usu ally develops in early childhood, with the majority of cases developing prior to age 10 years. The median age at onset is between 7 and 11 years, with the mean at about 10 years. Situational specific phobias tend to have a later age at onset than natural environment, an imal, or blood-injection-injury specific phobias. Specific phobias that develop in child hood and adolescence are likely to wax and wane during that period. However, phobias that do persist into adulthood are unlikely to remit for the majority of individuals. When specific phobia is being diagnosed in children, two issues should be considered. First, young children may express their fear and anxiety by crying, tantrums, freezing, or clinging. Second, young children typically are not able to understand the concept of avoidance. Therefore, the clinician should assemble additional information from parents, teachers, or others who know the child well. Excessive fears are quite common in young children but are usually transitory and only mildly impairing and thus considered devel opmentally appropriate. Although the prevalence of specific phobia is lower in older populations, it remains one of the more commonly experienced disorders in late life. Several issues should be con sidered when diagnosing specific phobia in older populations. First, older individuals may be more likely to endorse natural environment specific phobias, as well as phobias of falling. Second, specific phobia (like all anxiety disorders) tends to co-occur with medical concerns in older individuals, including coronary heart disease and chronic obstructive pulmonary disease. Third, older individuals may be more likely to attribute the symptoms of anxiety to medical conditions. Fourth, older individuals may be more likely to manifest anxiety in an atypical manner. Addition ally, the presence of specific phobia in older adults is associated with decreased quality of life and may serve as a risk factor for major neurocognitive disorder. Although most specific phobias develop in childhood and adolescence, it is possible for a specific phobia to develop at any age, often as the result of experiences that are traumatic. For example, phobias of choking almost always follow a near-choking event at any age. Temperamental risk factors for specific phobia, such as negative affectivity (neuroticism) or behavioral inhibition, are risk factors for other anxiety disorders as well. Environmental risk factors for specific phobias, such as parental over protectiveness, parental loss and separation, and physical and sexual abuse, tend to pre dict other anxiety disorders as well. As noted earlier, negative or traumatic encounters with the feared object or situation sometimes (but not always) precede the development of specific phobia. There may be a genetic susceptibility to a certain category of specific phobia.

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