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Muscle twitching * [local TrPs] myoclonus * muscle movements and jerks at night ; * [local TrPs] nail ridges and or nails that curve under * night driving difficulty * numbness & tingling [nerve entrapment by TrPs] numbness tingling on the outer thigh meralgia paresthetica ; [quadriceps femoris, vastus lateralis, sartorius, tensor fascia latae entrap.] painful intercourse [vaginal TrPs, pelvic floor TrPs, piriformis pudendal nerve entrap] painful weak grip that sometimes lets go [infraspinatus, scaleni, hand extensors, brachioradialis] panic attacks * H ; PMS * post nasal drip [pterygoid, SCM] pressure of eyeglasses problems climbing stairs [sartorius, quadriceps femoris, vastus medialis] problems holding arms up [subscapularis, infraspinatus, supraspinatus, upper trapezius, levator scapulae] rapid fluttery irregular heart beat heart-attack-like pain [sternalis, pectoralis H ; ] reflux esophagitis [external oblique H ; ] restless leg syndrome [gastrocnemius, soleus] runny nose [SCM, pterygoid] scar easily * sciatica [thoracolumbar paraspinals, gluteus minimus, hamstrings, piriformis, iliopsoas] sensitivity to cold heat humidity pressure changes light * H ; sensitivity to odors * sensory overload * shin splint-type pain [peroneus, tibialis] shortness of breath [serratus anterior H ; ] short-term memory impairment * H ; some stripes & checks cause dizziness [SCM] sore spot on top of head [splenius capitis] sore throat [SCM, digastric, pterygoid] stiff neck [levator scapulae] sweats * H ; swollen glands [digastric] thick secretions * thumb pain and tingling numbness [brachialis entrap. of radial nerve, adductor pollicus] tight Achilles tendons [tibialis posterior] tight hamstrings [hamstring complex, adductor magnus, quadriceps femoris, iliopsoas, gastrocnemius] U. Stiefel1, N. J. Pultz2, J. Harmoinen3, P. Koski3, R. A. Bonomo2, M. S. Helfand2, C. J. Donskey2 1University Hospitals of Cleveland, Cleveland, OH, 2Louis Stokes Cleveland VA Medical Center, Cleveland, OH, 3IPSAT Therapies, Espoo, FINLAND.
Dr. Rich proposes that, going forward, trials should be long term without specifying how long ; and randomized, and should include robust end points. He advocates an exercise end point and suggests that cardiopulmonary exercise testing or the shuttle walk test may have advantages over the 6-min walk test. Although the cardiopulmonary exercise testing may be more "representative, " it requires more technical expertise and expense than the 6-min walk and is not as practical when used for frequent monitoring. The shuttle walk test, on the other hand, deserves more investigation. While only slightly more costly or technically demanding than the 6-min walk test, it detected a 92% improvement in a recent study4 in COPD patients undergoing pulmonary rehabilitation, whereas the 6-min walk test found only a 17% improvement. Dr. Rich also recommends invasive central hemodynamic analysis for all clinical trials. This is unquestionably a desirable goal but may not be practical for repeated monitoring. Clearly, right heart catheterization must be performed to confirm the diagnosis of PAH, but how often it is necessary in making subsequent treatment decisions is controversial. It is surprising that he does not mention the promise of noninvasive techniques to provide surrogate information for hemodynamics such as increasingly sophisticated echocardiographic-Doppler techniques and cardiac MRI.5, 6 These have not yet been adequately tested, but hold promise for the future. Dr. Rich's next two suggested end points, anatomic and biological, have great appeal, but there are currently no methods for accurately assessing them short of lung biopsy. He refers to some promising techniques, such as intravascular ultrasound7 and micro-CT scanning, 8 but these are presently investigational. Likewise, biological markers have great potential, but none, not even brain natriuretic peptide, has yet been shown to be a reliable therapeutic end point. The last of Dr. Rich's suggestions, that we need a survival end point, is the most provocative. He is unquestionably correct that we do not know whether the approved PAH therapies have any effect on long-term survival. The multiple long-term, openlabel trials that have reported favorable survival times9, 10 have been uncontrolled and not definitive. Furthermore, the trials on patients with arrhythmias or congestive heart failure that showed excess mortality rates in the treatment groups11, 12 are sobering reminders of the necessity to do controlled trials to prove efficacy. But what fully informed patient would enroll in a year-long or longer ; , placebocontrolled survival trial when medications with proven efficacy for functional status ; are already available. Would we put a loved one in such a trial?.

For further information, visit the avonex website. Figure 1. Pretreatment appearance of granuloma faciale on the dorsum of the nose and axert.

For five to seven days. One particular regimen that is quite successful is Nitrofuranton 100 mg. taken orally at bedtime for ten days. It is important to evaluate patients with repeat urine cultures after treatment, because one-third will experience persistence or reoccurrence during the pregnancy. For pregnancies complicated with persistent or recurrent bacteriuria; suppressive therapy with Nitrofuranton 100 mg given orally at bedtime can be used for the remainder of the pregnancy. Acute cystitis occurs in 0.3-2.0% of pregnant women. Treatment should be similar to that of ASB except that single-dose therapies are generally ineffective and not recommended. Women with acute cystitis should be followed with surveillance cultures for the remainder of the pregnancy, since twenty-five percent will have another infection. Post-treatment follow-up culture should be performed within 1 month of completing treatment. i. Urine dipstick. glucose, protein ; . If urine dipstick is positive, evaluate for underlying cause e.g., diabetes, preeclampsia, renal disease ; . j. Screening for gestational diabetes GDM ; The American Diabetes Association recommends risk-based screening for gestational diabetes. Risk assessment for GDM should be performed at the first prenatal visit. Low risk Blood glucose testing is not routinely required if all of the following characteristics are present: Member of an ethnic group with a low prevalence of GDM Caucasian ; No known diabetes in first-degree relatives Age 25 years Weight normal before pregnancy No history of abnormal glucose metabolism No history of poor obstetric outcome A recent survey at the University of Michigan Medical Center demonstrated that only about 10% of women delivering are at low risk. Average risk Perform blood glucose testing at 24-28 weeks using one of the following: Two-step procedure: 50-g glucose challenge test GCT ; followed by a diagnostic oral glucose tolerance test OGTT ; in those meeting the threshold value in the GCT see below ; OR One-step procedure: diagnostic OGTT performed In the GCT, 50 g glucose is ingested followed by a blood glucose test in one hour.

19. Awang DVC. Herbal medicine. Feverfew. Canadian Pharma J. 1989; May: 266270. 20. Lachman L, Lieberman HA, Kanig JL. The Theory and Practice of Industrial Pharmacy. 2nd Ed., Philadelphia, PA: Lea and Febiger; 1976.
The lack of a reasoned opinion accompanying an arbitration award makes a collateral estoppel analysis challenging. Whether an arbitration award is accompanied by a reasoned opinion depends upon the rules agreed upon by the parties to the arbitration and the law in the jurisdiction to which the agreement is subject. For example, under New York law arbitrators are not required to issue reasoned opinions.24 The Procedures for the Resolution of U.S. Insurance and Reinsurance Disputes require only that the award "consist of a written statement . setting forth the disposition of the claims and relief, if any, awarded."25 In practice, most reinsurance arbitrators do not write reasoned awards unless required to do so the arbitration agreement. Where an award is devoid of explanation, courts often find themselves forced to determine by implication whether an issue is precluded by a prior proceeding.26 Implicitly determining whether an issue is identical to, or has been actually or necessarily decided, places a significant burden on the arbitration panel, which must glean from what little information is available whether the party against whom collateral estoppel is asserted in fact had a full and fair opportunity to argue the issue. Implicitly determining whether an issue is precluded also creates a seemingly insurmountable burden for the party asserting collateral estoppel, who carries the weight of affirmatively proving collateral estoppel. Although ultimately resting its holding on a lack of privity between the parties against whom preclusion was asserted, a Connecticut federal court in Hartford Accident & Indemnity Co. v. Columbia Casualty Co., noted that "the pithy arbitration award makes it virtually impossible [to] ascertain that all identical issues were addressed and ruled on by the arbitration panel "27 The Second Circuit has also commented on the issue, recognizing as much in BBS Norwalk v. Raccolta, Inc.28 There, the court reversed summary judgment, holding that the party asserting collateral estoppel had not met its burden of establishing and belladonna.

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