Saul P. Greenfield, MD

• Clinical Professor of Urology, State University of New York
• at Buffalo School of Medicine and Biomedical Sciences
• Director, Pediatric Urology, Women and Children? Hospital
• of Buffalo, Buffalo, New York

He also attended a grand opening at a store on Brevard Avenue and attended an event at Endeavor Elementary on Friday erectile dysfunction from adderall levitra professional 20mg otc. City Manager Titkanich provided the invocation and Deputy Mayor Boisvert led the assembly in the Pledge of Allegiance to the Flag of the United States of America homeopathic remedy for erectile dysfunction causes buy levitra professional 20mg line. Agenda: Special Meeting of November 21 cialis erectile dysfunction wiki purchase 20mg levitra professional overnight delivery, 2016 (16-520) Special City Council Meeting 11-21-16 2 impotence with prostate cancer purchase levitra professional 20 mg otc. He wished everyone a happy holiday and noted that thousands of boats do this trip annually so there could be possibly over 10 erectile dysfunction treatment california order levitra professional 20 mg,000 boats heading to south Florida and beyond erectile dysfunction 40 year old man 20mg levitra professional mastercard. Assistant City Manager Fuhrer noted that they spoke with the county and received authorization to post signage again this year erectile dysfunction treatment atlanta purchase levitra professional 20 mg with mastercard. Additionally erectile dysfunction toys best levitra professional 20 mg, the Cocoa lettering is up on the bridge overpass, in the center coming north or south. Gemmati presented item pointing out that the City Clerk had updated the item with official results. Councilwoman Warner thanked all for being in attendance and for their trust in her. Deputy Mayor Boisvert also thanked all of those who came and noting it had been a great last six years and he looked forward to another four years. Mayor Parrish thanked all for coming and thanked the citizens of Cocoa for bringing him back. His goals for this next term were to do many more public projects, redevelopment, and work on blighted areas. He mentioned the Joe Lee Smith Center for Justice, Moore Center, and Jewel and Leon Collins Center, and the need for a parking structure. Page 3 Special City Council Meeting 11-21-16 He spoke about his passion to combat crime within the City. In closing, he advised that as policy makers they needed to take the town back, and mentioned that he looked forward to economic development and pushing the City as far as they could. She mentioned that he had the time to fill in for the Mayor and did not feel that Councilwoman Blanco was quite up to the challenge just yet. Councilwoman Blanco agreed and advised she would prefer not to do it this time around and agreed with Councilwoman Warner on the reappointment. Butler explained the item noting that this was the first year that the City was fully self-insured. On October 15, 2015, the City of Cocoa requested a Phase 1 Environmental Site Assessment on 300 Brunson Avenue through Cardno. City Manager Titkanich concurred that the City would be eligible to participate in the credit and they would estimate how much environmental work needed to be done on the property and what it would cost. Belden noted that in July 2016, City Council approved the purchase of 6 Forrest Avenue. He pointed out that the property was scheduled for demolition next week and it was the property owned by Mr. Approve a Resolution adjusting the Fiscal Year 2016 budget, to reclassify payroll and operating related changes that resulted in negative wages, benefits, and operating account balances. Approval of a Joint Resolution between the City and the Cocoa Redevelopment Agency approving a Second Modification to an Interlocal Agreement authorizing the re-conveyance of the 300 Brunson Boulevard property from the Agency to the City, and Authorizing the Cancellation in full of the $1. Sinclair reminded all that Thanksgiving dinner would be held on Thanksgiving Day from 1:30-4:30 p. Chief Cantaloupe reminded Council of the Swearing In Ceremony for a new officer today at 11:30 a. Chief Prince mentioned that the new Fire Inspector, Jennifer McKinney, started work today. He further noted that they handed out about 110 turkeys for Thanksgiving and noted the fire fighters did a good job with that project. Page 8 Special City Council Meeting 11-21-16 City Attorney Garganese congratulated all of the Council members and mentioned that he looked forward to working with all of them again. City Manager Titkanich congratulated the Council members and noted that he looked forward to working with all of them again in the next four years. He reminded all that Thanksgiving was a few days away and to reach out to let someone know, whether it be a family member, friend, etc. Also, if there is someone who needs help, there are resources available, such as the turkey drive. In closing, he mentioned that the food drive was in progress so if you can to drop off a can of food to help someone out. The United Way campaign is also coming to an end and a finalized report will be sent out by Ms. Councilwoman Blanco congratulated Mayor Parrish on his re-election, along with Deputy Mayor Boisvert and Councilwoman Warner. She has a personal goal of making improvements to District 4 during the next two years. Councilwoman Warner mentioned the holiday weekend was approaching and she would be spending Thanksgiving at 1052 Mitchell Street. Sinclair for thinking about his neighbors, many of whom have no family or do not have a Thanksgiving while in Florida. All employees of police and fire are welcome to by, as is anyone else from the city. Additionally, if anyone knows of someone who is homebound that can deliver meals, please let her or Mr. In closing she spoke about the upcoming Space Coast Marathon and noted that both the Assistant City Manager and City Manager would be participating. Lastly, on a serious note, she mentioned that in the last 24 hours four police officers had been shot. She knows that all officers were on edge and could not imagine how hard it would be to be an officer during this time. Deputy Mayor Boisvert thanked all for coming and looked forward to another four years. Additionally, he thanked the City Manager for supporting Council and the citizens of Cocoa. He has gone above and beyond what they expected from issues like the hurricane and other events through the years. In closing, he thanked Council and assured them it would be a better four years than the last. On May 11, 2004, City Council approved an agreement with Colony Park Utilities, Inc. Therefore, approximately two months ago, the City discontinued billing the private service. At this time, the City staff is recommending that the City Council approve the Billing Services Agreement. However, this may involve some retroactive billing to customers for past due amounts and services that were received and not billed to customers after the City discontinued billing services to the Colony Park development. As such, to the extent that the City Manager and City Attorney believe that the Billing Service Agreement needs to be revised to expressly address this contingency or that additional documents must be prepared and approved, City staff is also requesting that the City Council authorize the City Manager and City Attorney to address these contingencies in the best interests of the City. Lastly, it is anticipated the private sewer treatment facility will be sold by Colony Waste Services, Inc. The Billing Services Agreement addresses this contingency and authorizes the future assignment of the Agreement without further approval of the City Council. Each and all of the foregoing recitals are hereby incorporated herein and declared to be true and correct. Said charges will include current as well as past due charges, and will be collected on a monthly basis in accordance with policies and procedures adopted by Cocoa in consultation with Colony Waste. A set of current policies and procedures to be utilized by Cocoa in the collection of said accounts is attached hereto as Exhibit "A" and made a part hereof by this reference. Cocoa reserves the right to unilaterally amend the policies and procedures contained in Exhibit "A. In the event of any conflict between the policies and procedures attached hereto as Exhibit "A" or any amendment thereto and the terms of this Agreement, the terms of this Agreement shall control. All sewer charges for Colony Waste sanitary sewer service shall be separately itemized and included on monthly water bills issued by Cocoa to its customers, or, if said person is not on Cocoa water, by separate monthly billing prepared by Cocoa for said purpose. In consideration of the services to be provided and performed by Cocoa, Colony Waste agrees to pay to Cocoa an amount per customer account computed as follows: For sanitary sewer service, a flat fee of $1. It is hereby agreed and understood that Cocoa retains the right to change the billing rate hereinabove set forth; provided, however, that in no event shall Colony Waste be liable for any increase in said billing rate except upon written notice thereof to be provided at least thirty (30) days prior to the effective date of said increase. Colony Waste represents and warrants that the initial billing rates are set forth in the schedule of rates attached hereto as Exhibit "B" and incorporated herein by this reference, and that Colony Waste is authorized by the Public Service Commission to charge said rates. Colony Waste shall have a continuing obligation and sole responsibility for providing Cocoa with any updated or modified rates agreed to or imposed by the Public Service Commission. In no event shall Cocoa charge or assess any rate, fee, charge or penalty to any customer unless specifically set forth in Exhibit "B" as may be amended, or as may otherwise be provided herein. In consideration of the requirements of Chapter 180, Florida Statutes, regarding notice of change of utility rates, Colony Waste agrees to provide to Cocoa written notice of any changes in said rates at least sixty (60) days prior to the effective date thereof and will be solely responsible for all costs incurred by the City and attributable to providing notice of the new rate schedule. Boca Raton, Florida 33486 561-926-4858 At any time, via written notice to Cocoa as provided for in Section 8 herein, Colony Waste may unilaterally change the name of the entity and/or person, and the address, which is to receive the monthly payments from Cocoa indicated within this section. Page 2 of 7 Cocoa shall maintain a strict accounting of all deposits and the amount due each customer. In addition, the City may provide additional information requested in writing by Colony Waste or its authorized representative. In the event of partial payments of bills by customers utilizing both Cocoa water and Colony Waste sanitary sewerage, all amounts received shall be applied first to delinquent billings and then to current charges in the following order: Cocoa water and service charges, hydrant service charge, and Colony Waste sewerage and other Colony Waste charges. Cocoa does not guarantee or warrant in any respect that customers of Colony Waste will remit the payments that are due Colony Waste. Normal billing adjustments to customer accounts shall be made by Cocoa without prior approval by Colony Waste, in accordance with the "Adjustments - Classification and Use" section set forth in Exhibit "A. Cocoa hereby agrees to disconnect or interrupt water service to property subject of this Agreement for nonpayment of Colony Waste sanitary sewerage service charges and to refuse to connect or reconnect such services until said delinquency has been eliminated. The disconnection of water service solely for nonpayment of Colony Waste sanitary sewerage service charges shall be made by Cocoa without prior approval by Colony Waste. In addition to the foregoing, Cocoa may at its discretion employ the services of a thirdparty collection agency for the collection of any delinquent account. Any costs incurred through the employment of such collection agency shall be borne solely by the delinquent customer, and is to be collected prior to reconnection of any utility service contemplated hereunder. The initial term of this Agreement shall be from the date of execution by both parties through. This Agreement shall be automatically renewed for successive one (1) year periods commencing on of the applicable year and terminating on September 30 of the following year unless otherwise terminated by either party. However, before this Agreement is terminated for cause, the non-breaching party shall provide the other party prior written notice of said breach and at least a fourteen (14) day opportunity to cure the breach before electing to terminate this Agreement. All notices, demands, requests, instructions, approvals, and claims shall be in writing. Notice shall be deemed to have been given and received on the date the notice is mailed, if given by certified mail, return receipt requested, postage prepaid, as addressed above. Any party hereto by giving notice in the manner set forth herein may unilaterally change the name of the person to whom notice is to be given or the address at which notice is to be received. Authority and Assignment Each party hereto represents and warrants to the other that they have full power and authority to enter into this Agreement. Colony Waste and the undersigned representative of Colony Waste further represents and warrants that Colony Waste has an equitable or legal ownership interest in the sanitary sewage treatment system, and has the right to operate said system Page 4 of 7 for the residents of Colony Park, and that Colony Waste has the right to impose the sewer charges which Cocoa will invoice the residents pursuant to this Agreement. Colony Waste and the undersigned representative of Colony Waste understand and agree that Cocoa is relying solely on the aforesaid representations and warranties as a basis for entering into this Agreement with Colony Waste. In the event that Colony Waste desires to transfer ownership of the private sanitary sewage treatment system, or Colony Waste no longer has the right to operate said system for the residents of Colony Waste, this Agreement may be assigned by Colony Waste to the new owner or operator of said system upon prior written consent of the City. However, before said assignment becomes effective, the new owner or operator shall be required to execute and deliver to the City a written assignment of this Agreement agreeing to be fully bound by the terms and conditions herein. During the term of this Agreement, Colony Waste shall maintain comprehensive general liability insurance in the minimum amount of $1,000,000 as the combined single limit for each occurrence to protect Colony Waste from claims for damages which may arise from the ownership, use, operation, or maintenance of the private sewer system referenced hereunder, whether such operations be by Colony Waste or by anyone directly or indirectly employed by Colony Waste. Renewal certificates shall be sent to Cocoa thirty (30) days prior to any expiration date. There shall also be a thirty (30) day advance written notification to the Cocoa in the event of cancellation or modification of any stipulated insurance coverage. Cocoa shall be an additional named insured on stipulated insurance policies, as its interest may appear, from time to time. This Agreement may only be modified, amended or altered if the terms or conditions are contained in a written document executed by each of the parties hereto with the same formality and of equal dignity herein. If any word, sentence, or paragraph or provision to this Agreement is found invalid or unenforceable by any court, such invalidity or unenforceability shall not affect the other parts of the Agreement if the rights and obligations of the parties contained herein are not materially prejudiced and if the intentions of the Parties can be accomplished. The effective date of this Agreement shall be the date in which the last party hereto executes this Agreement. The laws of the State of Florida shall govern the validity and interpretation of this Agreement. Venue shall be in Brevard County, Florida for any action filed in state court and in Orlando, Florida for any action filed in federal court. Both Cocoa and Colony Waste have participated in the drafting of all parts of this Agreement. As a result, it is the intent of the parties that no portion of this Agreement shall be interpreted more harshly against either of the parties as drafter. No delay or failure by either party to exercise any right under this Agreement, and no partial or single exercise of that right, shall constitute a waiver of that or any other right, unless otherwise expressly provided herein. Nothing in this Agreement shall be construed to give any rights or benefits to anyone other than Cocoa and Colony Waste. As such, the City shall not be liable under this Agreement for punitive damages or interest for the period before judgment. Further, the City shall not be liable for any claim or judgment, or portion thereof, to any one person for more than two hundred thousand dollars ($200,000. Foody, Manager Date: the foregoing instrument was acknowledged before me this day of, 2016 by Joseph A. Private fire protection ­ includes annual testing of fire line backflow prevention assembly Size Inside Yearly Outside Yearly Up to 4" private fire main $57. Any customer requiring the installation of a 2" temporary meter for construction purposes on a fire hydrant or water truck shall pay a refundable deposit of $750. All new water main extensions require a 3" temporary jumper meter for swabbing, flushing, and testing of the new water main. Any residential customer requiring the installation of a new meter shall pay according to the following schedule: 3/4" meter only/existing service line 1. Any residential customer requiring a standard relocation or adjustment of an existing meter shall pay according to the following schedule: 3/4" meter only/existing service line $260. Any customer requiring the installation of a service line shall pay according to the following schedule: Short service 3/4" short service line only 1. The customer is responsible for providing the current reading to the Customer Service Division monthly for billing. The truck must be made available at least once every three months for an actual reading by the Field Services Division. Any customer requiring the removal of a meter and replacement with a meter of a different size shall pay 30. Any customer requiring the removal of a meter found to be functioning correctly that is less than 10 years old and replacement with a new meter of the same size shall pay $100. Any customer requiring the installation of a reduced pressure backflow prevention assembly shall pay according to the following schedule: 3/4" meter 1. Impact fees and special connection charges for this category are in addition to all other applicable costs listed herein. The City will flow the hydrant to obtain the initial flow data, turn it to face the direction specified by the fire department of the jurisdiction in which it is installed, and apply the final coat of paint as described in the Technical Provisions. The City will flow the designated hydrant and will provide the customer with the flow and residual pressure information. Backflow Prevention Assembly Testing & Maintenance Charge (monthly) on nonresidential accounts ѕ" to 2" backflow prevention assembly $5. Water Used During Construction Charge the Tier 1 rate per thousand gallons plus the base rate for a 2" meter at the time the water is used. The City and/or its contractor will apply the final coat of paint as described in the Technical Provisions. Trip Charge (for customer-requested field service) During business hours After business hours Meter Lock Charge (for use of a padlock) (Res. Single-family Residential Account and Multifamily Dwelling Account with individual meters: water deposit = $40. The City charges other entities billing fees for the administrative cost of providing these services. Billing Fees shall be reviewed for adjustment on an annual basis to reflect the change in Consumer Price Index ­ All Urban Consumers effective on the first day of October each year. The annual adjustment shall be effective on October 1 of each year beginning with the first adjustment on October 1, 2016 and ending with the last adjustment on October 1, 2025. Notwithstanding, the annual adjustment permitted under Resolution 2016-87 Section 4 shall be subject to suspension or reduction by the City Council on an annual basis prior to the effective date of the automatic annual adjustment. Said charges collected on a monthly basis in accordance with policies and procedures adopted by Cocoa in consultation with Colony Park. A set of current policies and procedures to be utilized by Cocoa in A" and made a part hereof by this the collection of said accounts is attached hereto as Exhibit " Cocoa hereby agrees collect all sewer charges due from as will include current well Page 1 of 6 Scott Ellis Clerk Of Courts, Brevard County Pgs: 10 # 5 Trust: 5. Cocoa the event of any conflict between the policies and procedures attached hereto amendment thereto and the terms of this sewer Agreement,the terms of this Exhibit Aor any " " shall control. All Agreement as charges for Colony Park sanitary sewer service shall be separately itemized and included on monthly water bills issued by Cocoa to its customers, or,if said person is not on Cocoa water, by separate monthly billing prepared by Cocoa for said purpose.

Ethics Approval and Consent to Participate Not applicable (This work was a review article and did not involve primary data collection in human participants erectile dysfunction water pump order levitra professional 20mg visa. Exercise-induced muscle damage erectile dysfunction statistics canada discount levitra professional 20 mg on-line, plasma cytokines erectile dysfunction massage trusted 20 mg levitra professional, and markers of neutrophil activation impotence lisinopril buy cheap levitra professional 20mg online. Characteristics of isometric and dynamic strength loss following eccentric exercise-induced muscle damage erectile dysfunction treatment london order 20mg levitra professional. Exercise-induced muscle damage and potential mechanisms for the repeated bout effect erectile dysfunction hypertension drugs order levitra professional 20mg without a prescription. Leucocytes impotence with blood pressure medication generic 20mg levitra professional with mastercard, cytokines and satellite cells: what role do they play in muscle damage and regeneration following eccentric exercise? Exercise-induced muscle damage: what is it impotence grounds for divorce states buy levitra professional 20 mg low price, what causes it and what are the nutritional solutions? An evidence-based approach for choosing post-exercise recovery techniques to reduce markers of muscle damage, soreness, fatigue, and inflammation: a systematic review with meta-analysis. The role of nutritional supplements in the prevention and treatment of resistance exercise-induced skeletal muscle injury. Supplementation strategies to reduce muscle damage and improve recovery following exercise in females: a systematic review. The effects of a multi-ingredient supplement on markers of muscle damage and inflammation following downhill running in females. Exercise redox biochemistry: conceptual, methodological and technical recommendations. Black currant nectar reduces muscle damage and inflammation following a bout of high-intensity eccentric contractions. Short-term blackcurrant extract consumption modulates exercise-induced oxidative stress and lipopolysaccharide-stimulated inflammatory responses. Consumption of cherries as a strategy to attenuate exercise-induced muscle damage and inflammation in humans. Montmorency cherry juice reduces muscle damage caused by intensive strength exercise. Effects of powdered Montmorency tart cherry supplementation on an acute bout of intense lower body strength exercise in resistance trained males. The effects of Montmorency tart cherry concentrate supplementation on recovery following prolonged, intermittent exercise. Recovery facilitation with Montmorency cherries following high-intensity, metabolically challenging exercise. Montmorency cherries reduce the oxidative stress and inflammatory responses to repeated days high-intensity stochastic cycling. Influence of a Montmorency cherry juice blend on indices of exerciseinduced stress and upper respiratory tract symptoms following marathon running-a pilot investigation. Efficacy of tart cherry juice in reducing muscle pain during running: a randomized controlled trial. Effects of powdered Montmorency tart cherry supplementation on acute endurance exercise performance in aerobically trained individuals. The effects of a tart cherry beverage on reducing exercise-induced muscle soreness. Effects of a protease supplement on eccentric exercise-induced markers of delayed-onset muscle soreness and muscle damage. Placebocontrolled randomized clinical trial on the immunomodulating activities of low-and high-dose bromelain after oral administration­new evidence on the antiinflammatory mode of action of bromelain. Ellagitannin consumption improves strength recovery 2­3 d after eccentric exercise. The effect of pomegranate juice supplementation on strength and soreness after eccentric exercise. Effects of differing dosages of pomegranate juice supplementation after eccentric exercise. Pomegranate supplementation accelerates recovery of muscle damage and soreness and inflammatory markers after a weightlifting training session. Biochemical, physiological, and performance response of a functional watermelon juice enriched in L-citrulline during a halfmarathon race. Consumption of watermelon juice enriched in lCitrulline and pomegranate Ellagitannins enhanced metabolism during physical exercise. Citrulline malate enhances athletic anaerobic performance and relieves muscle soreness. Comparison of watermelon and carbohydrate beverage on exercise-induced alterations in systemic inflammation, immune dysfunction, and plasma antioxidant capacity. Citrulline malate does not improve muscle recovery after resistance exercise in untrained young adult men. Citrulline malate supplementation does not improve German volume training performance or reduce muscle soreness in moderately trained males and females. The effects of beetroot juice supplementation on indices of muscle damage following eccentric exercise. Beetroot juice is more beneficial than sodium nitrate for attenuating muscle pain after strenuous eccentric-bias exercise. Effects of beetroot juice on recovery of muscle function and performance between bouts of repeated Sprint exercise. Betalain-rich concentrate supplementation improves exercise performance and recovery in competitive triathletes. Minimal muscle damage after a marathon and no influence of beetroot juice on inflammation and recovery. Astaxanthin supplementation does not attenuate muscle injury following eccentric exercise in resistance-trained men. Djordjevic B, Baralic I, Kotur-Stevuljevic J, Stefanovic A, Ivanisevic J, Radivojevic N, et al. Effect of astaxanthin supplementation on muscle damage and oxidative stress markers in elite young soccer players. Paris D, Beaulieu-Abdelahad D, Abdullah L, Bachmeier C, Ait-Ghezala G, Reed J, et al. Effects of anatabine and unilateral maximal eccentric isokinetic muscle actions on serum markers of muscle damage and inflammation. The effects of anatabine on non-invasive indicators of muscle damage: a randomized, double-blind, placebo-controlled, crossover study. The effect of green tea extract supplementation on exercise-induced oxidative stress parameters in male sprinters. Consumption of green tea favorably affects oxidative stress markers in weight-trained men. Green tea extract supplementation gives protection against exerciseinduced oxidative damage in healthy men. Supplementation with a polyphenolic blend improves post-exercise strength recovery and muscle soreness. Effect of a single dose of green tea polyphenols on the blood markers of exercise-induced oxidative stress in soccer players. The effect of polyphenols on cytokine and granulocyte response to resistance exercise. Reduced inflammatory and muscle damage biomarkers following oral supplementation with bioavailable curcumin. Reduction of delayed onset muscle soreness by a novel curcumin delivery system (Meriva): a randomised, placebo-controlled trial. Attenuation of indirect markers of eccentric exercise-induced muscle damage by curcumin. Ginger (Zingiber officinale) as an analgesic and ergogenic aid in sport: a systemic review. The effects of pre-exercise ginger supplementation on muscle damage and delayed onset muscle soreness. Effectiveness of ginger root (Zingiber officinale) on running-induced muscle soreness and function: a pilot study. American ginseng supplementation attenuates creatine kinase level induced by submaximal exercise in human beings. Effects of Panax ginseng supplementation on muscle damage and inflammation after uphill treadmill running in humans. The effects of Panax notoginseng on delayed onset muscle soreness and muscle damage in well-trained males: a double blind randomised controlled trial. Roengrit T, Wannanon P, Prasertsri P, Kanpetta Y, Sripanidkulchai B-O, Leelayuwat N. Antioxidant and anti-nociceptive effects of Phyllanthus amarus on improving exercise recovery in sedentary men: a randomized crossover (double-blind) design. Roengrit T, Wannanon P, Prasertsri P, Kanpetta Y, Sripanidkulchai B-O, Wattanathorn J, et al. Antioxidant effect of Phyllanthus amarus after moderate-intensity exercise in sedentary males: a randomized crossover (double-blind) study. Effects of Rhodiola rosea supplementation on mental performance, physical capacity, and oxidative stress biomarkers in healthy men. Extract of Rhodiola rosea radix reduces the level of C-reactive protein and creatinine kinase in the blood. Effects of chronic Rhodiola rosea supplementation on sport performance and antioxidant capacity in trained male: preliminary results. Is branched-chain amino acids supplementation an efficient nutritional strategy to alleviate skeletal muscle damage? Effects of creatine supplementation on oxidative stress and inflammatory markers after repeated-sprint exercise in humans. International society of sports nutrition position stand: safety and efficacy of creatine supplementation in exercise, sport, and medicine. Creatine supplementation does not reduce muscle damage or enhance recovery from resistance exercise. Creatine supplementation: effects on blood creatine kinase activity responses to resistance exercise and creatine kinase activity measurement. Effect of creatine supplementation on muscle damage and repair following eccentrically-induced damage to the elbow flexor muscles. Short and longer-term effects of creatine supplementation on exercise induced muscle damage. Creatine supplementation enhances muscle force recovery after eccentrically-induced muscle damage in healthy individuals. The effect of creatine supplementation upon inflammatory and muscle soreness markers after a 30km race. Effect of short-term creatine supplementation on markers of skeletal muscle damage after strenuous contractile activity. Hydroxy-methylbutyrate free acid reduces markers of exercise-induced muscle damage and improves recovery in resistance-trained men. Effects of betahydroxy-beta-methylbutyrate on muscle damage after a prolonged run. Exercise-induced muscle damage is not attenuated by beta-hydroxy-beta-methylbutyrate and alphaketoisocaproic acid supplementation. Short-term beta-hydroxy-betamethylbutyrate supplementation does not reduce symptoms of eccentric muscle damage. Glutamine supplementation in recovery from eccentric exercise attenuates strength loss and muscle soreness. The influence of oral L-glutamine supplementation on muscle strength recovery and soreness following unilateral knee extension eccentric exercise. Influence of glutamine supplementation on muscle damage and oxidative stress indices Harty et al. Effect of L-glutamine supplementation on electromyographic activity of the quadriceps muscle injured by eccentric exercise. Effects of protein supplements on muscle damage, soreness and recovery of muscle function and physical performance: a systematic review. Taurine: a potential ergogenic aid for preventing muscle damage and protein catabolism and decreasing oxidative stress produced by endurance exercise. Combined effect of branched-chain amino acids and taurine supplementation on delayed onset muscle soreness and muscle damage in high-intensity eccentric exercise. Taurine supplementation reduces eccentric exercise-induced delayed onset muscle soreness in young men. The effect of taurine on the recovery from eccentric exercise-induced muscle damage in males. A systems-based investigation into vitamin D and skeletal muscle repair, regeneration, and hypertrophy. Selected in-season nutritional strategies to enhance recovery for team sport athletes: a practical overview. Higher serum 25-hydroxyvitamin D concentrations associate with a faster recovery of skeletal muscle strength after muscular injury. Vitamin D status is not associated with outcomes of experimentally-induced muscle weakness and pain in young, healthy volunteers. Supplemental vitamin D enhances the recovery in peak isometric force shortly after intense exercise. Influence of vitamin D mushroom powder supplementation on exerciseinduced muscle damage in vitamin D insufficient high school athletes. The effects of ingestion of omega-3 fatty acids on perceived pain and external symptoms of delayed onset muscle soreness in untrained men. Adding fish oil to whey protein, leucine and carbohydrate over a 6 week supplementation period attenuates muscle soreness following eccentric exercise in competitive soccer players. Eicosapentaenoic and docosahexaenoic acids-rich fish oil supplementation attenuates strength loss and limited joint range of motion after eccentric contractions: a randomized, double-blind, placebo-controlled, parallel-group trial. Effects of shortterm docosahexaenoic acid supplementation on markers of inflammation after eccentric strength exercise in women. The effect of omega-3 fatty acid supplementation on the inflammatory response to eccentric strength exercise. Influence of omega-3 (N3) index on performance and wellbeing in young adults after heavy eccentric exercise. Fish oil supplementation reduces markers of oxidative stress but not muscle soreness after eccentric exercise. Effect of eicosapentaenoic and docosahexaenoic acid on resting and exerciseinduced inflammatory and oxidative stress biomarkers: a randomized, placebo controlled, cross-over study. Effect of a single dose of caffeine supplementation and intermittent-interval exercise on muscle damage markers in soccer players. Effect of short term caffeine supplementation and intermittent exercise on muscle damage markers. Caffeine does not augment markers of muscle damage or leukocytosis following resistance exercise. Two doses of caffeine do not increase the risk of exercise-induced muscle damage or leukocytosis. Effect of caffeine on perceived soreness and functionality following an endurance cycling event. Effect of methylsulfonylmethane supplementation on exercise-induced muscle damage and total antioxidant capacity. The influence of methylsulfonylmethane on inflammation-associated cytokine release before and following strenuous exercise. Multiingredient pre-workout supplements, safety implications, and performance outcomes: a brief review. The impact of a pre-loaded multi-ingredient performance supplement on Harty et al. The impact of post-exercise hydration with deep-ocean mineral water on rehydration and exercise performance. Deep mineral water accelerates recovery after dehydrating aerobic exercise: a randomized, double-blind, placebo-controlled crossover study. Oral consumption of electrokinetically modified water attenuates muscle damage and improves postexercise recovery. Daily controlled consumption of an Electrokinetically modified water alters the fatigue response as a result of strenuous resistance exercise. The effect of dietary nitrate supplementation on endurance exercise performance in healthy adults: a systematic review and meta-analysis. The effects of theaflavinenriched black tea extract on muscle soreness, oxidative stress, inflammation, and endocrine responses to acute anaerobic interval training: a randomized, double-blind, crossover study. Effect of New Zealand blueberry consumption on recovery from eccentric exerciseinduced muscle damage. The effects of chondroitin sulfate supplementation on indices of muscle damage induced by eccentric arm exercise. Influence of 2-weeks ingestion of high chlorogenic acid coffee on mood state, performance, and postexercise inflammation and oxidative stress: a randomized, placebocontrolled trial. Effects of lemon verbena extract (Recoverben) supplementation on muscle strength and recovery after exhaustive exercise: a randomized, placebocontrolled trial. Supplementation with a flavanol-rich lychee fruit extract influences the inflammatory status of young athletes. Effects of mate tea consumption on muscle strength and oxidative stress markers after eccentric exercise. Preventive effects of 10-day supplementation with saffron and indomethacin on the delayed-onset muscle soreness. Effects of baseline serum levels of se on markers of eccentric exerciseinduced muscle injury. Influence of lycopene and vitamin C from tomato juice on biomarkers of oxidative stress and inflammation. Tsitsimpikou C, Kioukia-Fougia N, Tsarouhas K, Stamatopoulos P, Rentoukas E, Koudounakos A, et al. Administration of tomato juice ameliorates lactate dehydrogenase and creatinine kinase responses to anaerobic training. Virginia Department of Social Services July 2017 Child and Family Services Manual C.

Order levitra professional 20 mg with mastercard. Brilliant Explanation Of Prostate Functioning Erectile Dysfunction !.

Conclusion ¶21 the evidence in this case supports a finding that McLaughlin is no longer suffering from an incapacity which would preclude him from practicing law diabetic erectile dysfunction pump order 20mg levitra professional overnight delivery. Furthermore b12 injections erectile dysfunction purchase levitra professional 20mg otc, Petitioner William McLaughlin has established: by clear and convincing evidence: 1) he possesses good moral character erectile dysfunction urinary tract infection purchase 20mg levitra professional visa, (2) he has not engaged in the unauthorized practice of law during his suspension erectile dysfunction louisville ky 20mg levitra professional fast delivery, and (3) he possesses the competency and learning required for admission to practice law erectile dysfunction doctor toronto cheap levitra professional 20mg with visa. We believe his conduct since achieving sobriety has and will continue to conform to the high standards required of Oklahoma Bar Association members erectile dysfunction protocol foods to eat discount levitra professional 20 mg amex. According to testimony and exhibits in the record erectile dysfunction at the age of 18 order levitra professional 20mg fast delivery, McLaughlin was inebriated and solicited sexual activity from a prospective client erectile dysfunction due diabetes buy 20mg levitra professional amex. McLaughlin pleaded no contest to the charge and was sentenced to six months in the county jail. On April 13, 2007, McLaughlin filed an amended consent, acknowledging his entry into a treatment facility and his present inability to practice law. Langley also testified that she attempted to contact each of the former clients, but each former client she contacted either did not wish to cooperate or could not be reached. The restrictions served to protect both individuals and the public from potential ethical transgressions. Realtor relied on an addendum to the listing agreement that limited the period of time in which an excluded sale could occur as well as the fact that the sale closed outside the time period. Owners claimed they insisted on a complete exclusion and did not knowingly agree to a time limit for the excluded sale, despite having signed the addendum. The trial court and Court of Civil Appeals resolved this dispute in favor of Realtor on the basis of the summary judgment record presented by the parties. Both courts found Owners were bound by an addendum to the listing agreement, even though it contained different terms than Realtor allegedly agreed to . The dispositive issue on certiorari review is whether summary judgment was proper under the record presented. On review, all inferences in the evidence must be taken in a light most favorable to the party opposing the motion. It is undisputed that an addendum to the listing agreement provided that a sale to the buyers in question would be "reserved until June 5, 2014 (6/5/14) with a 3% listing commission. First, the subject and terms of excluding a sale to the buyers in question were proposed by Owners, not by Realtor or its agent. Where one party falsely represents to another party that the writing includes the oral agreement, and the other party is thereby induced to sign the writing without reading it, that is a sufficient trick, artifice and fraud to support a claim of fraud in the inducement. While this is certainly important, it is just one of many facts to be considered and weighed by the trier of the fact. Ultimately, the communications and conduct of the parties with respect to 717 the Oklahoma Bar Journal the addendum must be judged in the totality of the circumstances surrounding its creation. To aid in that duty, the following is a list of applicants for the bar examination to be given July 24-25, 2018. Send correspondence to Cheryl Beatty, Administrative Director, Oklahoma Board of Bar Examiners, P. Ryan Edmond Geary Olivia Suzanna Glazner August Robert Hadwiger Chad Tyler Hantak Rilee Dean Harrison Jennifer Briana Hartsell David Ray Herber James Matthew Hill Austin Tyler Hilterbran Clarence Joe Hutchison William Floyd Johnston Leslie Lanay Jones Will Thomas Jordan Gunner Brock Joyce Jared A. Stevens, was charged on March 15, 1994 by Amended Information in the District Court of Canadian County with Murder in the First Degree (21 O. Petitioner entered a plea of guilty to the murder offense and a plea of no contest to the other two offenses. On April 27, 1997, Petitioner filed his first Application for Post-Conviction relief. Petitioner timely appeals the denial of his Second Application for Post-Conviction Relief. Petitioner, Goode, and Stevens shot Lawrence with handguns with the premeditated design to effect his death. In addition to that statement, the District Court had several different sources of information about Petitioner available to it at the plea hearing. The court heard evidence concerning the other offenses which Petitioner had committed, including the offense of First Degree Murder which Petitioner had committed in Oklahoma Vol. On December 15, 1994, the District Court held a post-examination competency hearing and determined that Petitioner was competent to stand trial. An abuse of discretion is any unreasonable or arbitrary action taken without proper consideration of the facts and law pertaining to the matter at issue or a clearly erroneous conclusion and judgment, one that is clearly against the logic and effect of the facts presented. The Act provides petitioners with very limited grounds upon which to base a collateral attack on their judgments. Section 1086 limits the grounds for relief asserted within subsequent petitions to only those grounds which for sufficient reason were not asserted or were inadequately raised. In Miller, the United States Supreme Court determined that the Eighth Amendment forbids a sentencing scheme that mandates life in prison without the possibility of parole for offenders who were under the age of 18 at the time of their crimes. Instead, Miller held that an individualized sentencing hearing is required before an offender who committed his or her offense under the age of eighteen (18) years of age may be sentenced to life without the possibility of parole. The Supreme Court also recognized for the first time that: "Where state collateral review proceedings permit prisoners to challenge the lawfulness of their confinement, States cannot refuse to give retroactive effect to a substantive constitutional right that determines the outcome of that challenge. His original application for post-conviction relief was also decided before Miller. Section 1080(f) of the Post-Conviction Procedure Act explicitly permits a petitioner to raise a challenge that his "conviction or sentence is otherwise subject to collateral attack upon any ground of alleged error heretofore available under any common law, statutory or other writ, motion, petition, proceeding or remedy. The record reveals that Petitioner was convicted for first degree murder and sentenced to life without the possibility of parole for a homicide which he had committed at 17 years of age. We find no requirement in the Constitution that a defendant must be permitted to disown his solemn admissions in open court that he committed the act with which he is charged simply because it later develops that the State would have had a weaker case than the defendant had thought or that the maximum penalty then assumed applicable has been held inapplicable in subsequent judicial decisions. We further note that the United States Supreme Court recognized that States are not required to relitigate convictions in order to give Miller retroactive effect. Section 1080(A) of the PostConviction Procedure Act explicitly permits a petitioner to raise a claim that his "conviction or the sentence was in violation of the Constitution of the United States or the Constitution or laws of this state. We note, as a parallel, that this Court reviews properly preserved excessive sentence claims on certiorari review even though the claim does not impugn the validity of the plea. The Supreme Court has concluded that a sentence of life without the possibility of parole imposed in contravention of Miller is both illegal and void. Therefore, after Miller, a court is without the power to sentence a juvenile offender to life without the possibility of parole without the benefit of an individualized sentencing hearing. We refuse to find that Petitioner waived his rights under Miller when he entered his guilty plea. Miller did not bar imposition of life without parole on all juvenile homicide offenders. Instead, Miller drew a line between juveniles whose crimes reflect "transient immaturity" and the rare juvenile whose crime reflects "irreparable corruption. Thus, the punishment may still be imposed on the rare juvenile offender whose crime reflects "irreparable corruption. A petitioner raising a claim that his life without parole sentence is unconstitutional under Miller and Montgomery carries the burden of establishing that he or she is entitled to relief. The petitioner in post-conviction proceedings has the burden of presenting sufficient evidence to rebut this presumption. To establish a claim under Miller and Montgomery on post-conviction review, the petitioner must establish that he is serving a sentence of life without parole for a homicide committed while he or she was under 18 years of age and was deprived of an individualized sentencing hearing where youth and its attendant characteristics were considered along with the nature of the crime. If the sentencer held such a hearing, then the challenged sentence does not run 725 the Oklahoma Bar Journal afoul of Miller. We note that the District Court file had several different sources of information about Petitioner in it at the time of sentencing. The court also heard evidence concerning the other crimes which Petitioner had committed, including the offense of First Degree Murder which Petitioner had committed in Oklahoma County. The District Court held a hearing on the application on June 28, 1994, and ordered that Petitioner be evaluated at the State mental health facility in Vinita. Based upon the fact that he was seventeen (17) years of age at the time of the charged offenses, Petitioner filed an Application for Certification as a Juvenile. Further, the sentencing judge could not have determined that Petitioner was irreparably corrupt and permanently incorrigible since he did not know that he was required to make such a finding. Therefore, we find that Petitioner is entitled to relief and his sentence must be vacated. We note that this Court was presented with a similar challenge when the United States Supreme Court held in Atkins v. While the Legislature ultimately adopted the procedure in Murphy, our decision was never intended to supplant the Legislative process but to give trial courts guidance until the Legislature acted. Until such time as the Legislature addresses this matter, trial court practitioners should follow the procedure outlined herein. Both parties shall be afforded full discovery on this issue in accordance with established discovery law. The assigned trial judge has the authority under our Discovery Code to issue any orders necessary to accomplish this task. The prohibition against the introduction of evidence in either aggravation or mitigation set forth in Malone v. Therefore, each party shall be afforded the opportunity to present evidence in support of its position as to punishment in the second stage of the trial. The trial court shall submit a special issue to the jury as to whether the defendant is irreparably corrupt and permanently incorrigible. Pending Legislative action the District Courts of the State are directed, in addition to the instruction set out in Luna, to use the instruction and verdict form attached as "Appendix A" at the conclusion of this Opinion. The State shall have the opportunity to present any evidence tending to establish this fact subject to the limitations of 12 O. The trial court shall schedule the matter for resentencing in accordance with both § 812. Each party shall be afforded the opportunity to present evidence concerning, but not limited to , the factors set out above. If the sentencer does not make this finding it is prohibited from considering a sentence of life without the possibility of parole and may only impose a sentence of life imprisonment. If you do not unanimously find beyond a reasonable doubt that the State has proven the Defendant is irreparably corrupt and permanently incorrigible, you are prohibited from considering a sentence of life without the possibility of parole. In that event, the sentence must be imprisonment for life with the possibility of parole. The Supreme Court also observed in this context that "[t]hose prisoners who have shown an inability to reform will continue to serve life sentences. Although my colleagues have declined to formulate further explanation of this type in the instructions, that does not mean trial judges should not use this or similar language when responding to what I believe will be inevitable questions from jurors concerning its meaning. We can only hope at this point that any Legislative action in this area will provide additional explanation beyond that set forth in the current instructions. The State charged Petitioner, Marcus Dewayne Stevens, and Michael Ray Goode conjointly in the murder. On August 31, 1994, Marcus Dewayne Stevens entered a negotiated guilty plea to the offense and the District Court sentenced him to imprisonment for life. On June 13, 1996, Michael Ray Goode entered a negotiated guilty plea to the offense and the District Court sentenced him to imprisonment for life. Pursuant to the plea agreement: the State dismissed the Bill of Particu- lars, dismissed District Court of Pottawatomie County Case Nos. Petitioner solely filed his second application in District Court of Canadian County Case No. Thus, Petitioner has not invoked the jurisdiction of this Court as to his conviction and sentence in the Oklahoma County case. The transcript of the plea hearing at which the District Court sentenced Petitioner is not within the record on appeal. I maintain that the Supreme Court did not impose a formal factfinding requirement in Miller but that this matter should be addressed by the Oklahoma Legislature. Oklahoma law contemplates supplemental instructions in response to juror questions during deliberations. Judge Canavan ordered credit for time served, suspended the fine in Count I, imposed various fees and costs for both counts, and ordered 729 Vol. Petitioner, represented by counsel, timely filed a Motion to Withdraw Plea which was summarily denied. Petitioner appeals the denial of his motion, and raises the following propositions of error: I. By the use of the term "shall", this Court has made the evidentiary hearing on the motion to withdraw plea mandatory upon the filing of an application to withdraw plea, and not discretionary or conditional upon a request of the defendant. The application to withdraw guilty plea and the evidentiary hearing are both necessary and critical steps in securing the appeal rights as provided by Rule 4. If a matter is not presented to the trial court, there is nothing for this Court to review. If the trial court does not hold the requisite hearing, there is nothing upon which this Court can base a ruling regarding whether the trial court did or did not abuse its discretion in denying the application to withdraw. Smothermon, District Attorney, Abby Nation, Assistant District Attorney, Pottawatomie County Courthouse, 331 N. In the present case, Petitioner did not request an evidentiary hearing in his motion to withdraw guilty plea. Since Petitioner did not request an evidentiary hearing, his motion to withdraw was defective; the trial court was not required to hold a hearing; and he has not preserved appellate review of his guilty plea on the present record. The majority reasons that without a hearing, "there is nothing upon which this Court can base a ruling regarding whether the trial court did or did not abuse its discretion in denying the application to withdraw. Without evidence presented in a hearing, any review by this Court would be de novo, which we do not do. This typically arises when a defendant challenges the constitutionality of a statute. Randall stands for the proposition that a defendant has the right to have counsel present at all critical stages of a criminal prosecution, including when an evidentiary hearing is held on an application to withdraw plea. The defendant in that case went unrepresented at a hearing on a motion to withdraw plea despite his request for counsel. Randall does not, however, dictate that an evidentiary hearing must be held on each and every application to withdraw plea filed in district court. In other words, if the district court is required to hold an evidentiary hearing for every application to withdraw plea, and is not conditional upon the request of the defendant, then the plain language contained within Rule 4. Our interpretation of statutes is driven by the plain language and plain meaning of the statute as a whole and avoids any construction which would render any part of the statute superfluous. Notably, the Tenth Circuit has held that a defendant is not entitled to an evidentiary hearing as a matter of right when he seeks to withdraw his plea. Rather, "the defendant must present some significant questions concerning the voluntariness or general validity of the plea to justify an evidentiary hearing. No hearing need be granted when the allegations on a motion to withdraw a guilty plea before sentencing merely contradict the record, are inherently incredible, or are simply conclusory. Due process of law does not mandate a hearing before denying each and every motion to withdraw plea. Despite the absence of any record where Petitioner could have presented such supporting evidence, this Court has been presented with an otherwise thorough record, the review of which shows the entry of a knowing and voluntary guilty plea. The record also contains the fully-completed Plea of Guilty Summary of Facts form signed by Petitioner and acknowledged by him at the Vol. Police also observed in the passenger seat three bags of what appeared to be marijuana. After being removed from the vehicle, placed in handcuffs and secured in the backseat of a patrol car, Petitioner started screaming and asking about money in his car. The transcript of the plea hearing shows Petitioner acknowledged having gone over with plea counsel the fully completed Plea of Guilty Summary of Facts form contained in the record. Petitioner stated that plea counsel helped him fill out the form and that he, Petitioner, understood each and every question contained on this document (Plea Tr. Petitioner stated that he did not need to speak with Judge Canavan about any of his responses on the plea form (Plea Tr. Petitioner acknowledged both his signature on page 6 of the plea form and that his signature meant the answers given on the plea form were his true and correct answers to each question. Petitioner acknowledged having the advice of plea counsel when deciding to plead guilty. He further acknowledged that he was pleading guilty because he was in fact guilty and that no one had threatened or coerced him in any way to get him to plead (Plea Tr. The nature of the plea offer which had previously been withdrawn by the State was discussed. The parties acknowledged that the State withdrew its plea offer of 15 years imprisonment because Petitioner did not accept it in a timely manner. Knowing these things, Petitioner stated that he wished for the court to accept his guilty plea (Plea Tr. The State urged that Petitioner be sentenced to 30 years imprisonment because of his long list of priors which included felony convictions for possession of contraband in a penal institution (two separate convictions), felonious possession of a firearm, possession of controlled dangerous substances with intent to distribute (two separate convictions) and shooting with intent to kill (S. We examine the entire record before us on appeal to determine the knowing and voluntary nature of the plea. The standard for determining the validity of a guilty plea is whether the plea represents a voluntary and intelligent choice among alternative courses of action open to the defendant. That is particularly so where, as here, we are faced with the conclusory assertion that Petitioner "did not understand the nature and consequences of his plea. Petitioner simply has not presented us a colorable basis to question the validity of his plea, especially considering the record evidence which torpedoes his claim. His sole allegation is too conclusory and is contradicted by the record which shows why his plea is valid. Petitioner has the burden of proving that counsel was ineffective which requires a showing of both deficient performance and prejudice. When a claim can be disposed of on grounds of lack of prejudice, that course should be followed. Petitioner fails to present any evidence supporting the bare claim raised in his motion to withdraw that he did not understand the nature and consequences of his plea. Again, he fails to show that, even if a hearing had been held, that the result of the proceeding would have been different. This would be true to the reality that not every application to withdraw plea needs a hearing without engaging in strained interpretations of our own rule.

Musculoskeletal disorders interfere with an important activity of daily living for adults: work lloyds pharmacy erectile dysfunction pills discount levitra professional 20mg with mastercard. Arthritis erectile dysfunction treatment natural purchase levitra professional 20 mg line, the leading cause of disability in the United States erectile dysfunction diet pills buy discount levitra professional 20 mg online, limits the type or amount of work that at least 1 out of every 4 working age adults with arthritis can perform-if they are able to work at all buying erectile dysfunction pills online order levitra professional 20mg fast delivery. For workers with musculoskeletal conditions (including back and neck pain impotence herbal medicine purchase levitra professional 20mg on line, arthritis erectile dysfunction surgery options quality levitra professional 20 mg, as well as others) erectile dysfunction and diabetes a study in primary care levitra professional 20 mg discount, these days add up quickly: an average of 10 days per worker every year erectile dysfunction diagnosis code cheap 20mg levitra professional with visa. Percentage of people with a medical condition who report it interferes with activities of daily living: Musculoskeletal conditions exceed all others Mu scu los kel e Not surprisingly, musculoskeletal conditions outrank other conditions as a cause of lost work days, with many implications for productivity. Despite the significant economic and health impact, affecting such a large proportion of the population, these disorders receive far less research investment than other conditions. Addressing this imbalance in funding has the potential to affect the true burden of disease by reducing disability rates. Addressing even a portion of them would contribute to more informed responses to current challenges and unmet needs, with potential to change the future trajectory of increased costs, pain, and disability. In addition to pursuing new research, we can improve outcomes by implementing changes in awareness and practice based on existing research results. Gaps in basic knowledge among the public and some practitioners mean that these conditions may not be diagnosed or treated with the most up-to-date or clinically effective methods. Dramatically improved treatments for inflammatory conditions (such as rheumatoid arthritis) and osteoarthritis (through physical activity and total joint replacements) show that treatment advances are possible, but they will not occur without adequate funding and a health system organized to deliver care effectively. Below are selected recommendations from experts in the field, demonstrating that greater investments could be put to immediate use. With musculoskeletal conditions and other chronic diseases more prevalent and more severe as people age, the demands on the healthcare system will increase. New physicians are not entering some medical specialties of particular importance to this population, such as rheumatology and geriatrics. Many primary care practitioners-where patients are most likely to turn for help before consulting a specialist-do not receive up-to-date training in musculoskeletal disorders in medical school or continuing education and are often not informed about the potential for earlier interventions, treatment options, and when to refer to specialists. Another important gap is the lack of comprehensive, reliable outcomes data for all treatment settings and types, since no databases fully cover outpatient procedures like injections or treatments by athletic trainers, physical therapists, chiropractors, and other providers from whom many patients seek treatment. With all these uncertainties, many of those suffering from neck or back pain may inadvertently do exactly the opposite of what is recommended. Educating the public and providers about effective responses can alleviate pain and suffering, and may help some avoid costly and/or painful surgeries that do not necessarily yield better outcomes. Measuring the Burden in Younger Populations An important overall research gap is measuring the burden of musculoskeletal conditions in young and active patients and pediatric populations, comparable to the measures of lost wages and workdays for adults and caregivers. As pediatric patients transition through adolescence into adulthood, they are often lost to follow-up, making it difficult to understand adult manifestations of pediatric musculoskeletal conditions. Better long-term follow-up data on pediatric musculoskeletal conditions would address this knowledge gap. More than 1 in 4 adults has doctor-diagnosed arthritis; by 2040, an estimated 78 million Americans will have doctor-diagnosed arthritis if current trends continue. In part, this is due to reimbursement models that create incentives for short-term treatment at the expense of ongoing, long-term management of chronic diseases. Low Back and Neck Pain: Understanding Current Treatments While Developing New Ones As noted above, back pain was the cause of at least 264 million lost work days-enough to account for more than 2 lost work days for every full-time worker in the country. Research funding for care and prevention is needed to compare the effectiveness of treatment alternatives, develop new treatments, and evaluate prevention approaches. Research could help answer questions such as: n What is the influence of hip and spine disorders on the outcomes of treatment for low back pain? Promising areas for research include the following: n What is most effective for pre- and post-operative pain management (especially non-opiate forms)? Identifying Models and Training Providers n What are cost-effective healthcare model systems for patients with neuromuscular disease? Neuromuscular Diseases: Injuries: Building on Progress in Preventing Specific Types of Injuries n Musculoskeletal injuries among workers have declined, but still account for over half of all worker nonfatal injury cases that involve days away from work. What are effective strategies for understanding, preventing, and treating this common and costly type of injury? This is especially true for those who experienced a joint-related health issue or long-term, major chronic injuries. This can affect overall quality of life as well as the ability to address other chronic disease risk factors. Which factors contribute to the poorer health-related quality of life outcomes for college athletes? Effective injury prevention would make a significant contribution to the health and productivity of active and veteran military personnel. Osteoporosis: Fixing A Fractured Approach the number of people with osteoporosis-low bone mass and strength that can increase the risk of fracture-is expected to increase from an estimated 10. The estimated number of people with low bone mass-a potential precursor to osteoporosis-suggests steady increases as well, growing from 43. Research needs include new drugs and therapies to treat the condition, heal faster, and prevent additional fractures; changes to treatment care approaches; and funding to test the effectiveness of new therapies and treatments. Instead, investments across the spectrum of musculoskeletal diseases would pay off for all of these disorders and conditions, and could offer benefits for addressing other chronic conditions as well. These scenarios, multiplied by thousands and millions of people, are the compelling vision of the specialists in orthopaedic surgery, rheumatology, physical medicine and rehabilitation, and other musculoskeletal specialties who contributed to the Burden of Musculoskeletal Diseases in the United States. It is a vision that is within reach, but only if investments in musculoskeletal diseases match their burdensome impact on America. This summary has been developed from the full publication, which can be viewed at This material is not intended to suggest procedures or course of treatment, only to provide an interpretation of available data on the incidence and prevalence of most major musculoskeletal conditions. No part of this publication may be reproduced, stored in retrieval systems, or transmitted, in any form, or by any means (electronic, mechanical, photocopying, recording, or otherwise), without prior permission from the publisher. Global Alliance for Musculoskeletal Health the Global Alliance is an international collaborative movement sanctioned by the United Nations/World Health Organization working to improve the quality of life for people with musculoskeletal conditions and to advance the understanding, prevention and treatment of these conditions. Clostridium botulinum type A neurotoxin complex (900kD) Sterile vacuum-dried concentrate powder for solution for injection 50, 100 and 200 Allergan units per vial Neuromuscular Paralytic Agent Allergan, Inc. Overactive Bladder for the treatment of overactive bladder with symptoms of urinary incontinence, urgency, and frequency, in adult patients who have an inadequate response to or are intolerant of anticholinergic medication. Geriatrics (> 65 years of age): Studies specifically designed to determine the dose in elderly patients have not been performed. Initial dosing should begin at the lowest recommended dose for the specific indication. Similarly, no overall difference in effectiveness was observed between these age groups in placebo-controlled pivotal clinical studies. For a complete listing, see the Dosage Forms, Composition and Packaging section of the product monograph. An understanding of standard electromyographic techniques is also required for treatment of strabismus, and may be useful for the treatment of cervical dystonia, and focal spasticity associated with pediatric cerebral palsy and upper limb spasticity in adults. Caution is warranted when injecting in proximity to the lung, particularly the apices. Local muscle weakness represents the expected pharmacological action of botulinum toxin in muscle tissue. However, weakness of adjacent muscles associated with local diffusion and/or injection technique has been reported. Patients with a history of underlying neurological disorders, dysphagia and/or aspiration should be treated with extreme caution. The botulinum toxin product should be used under specialist supervision in these patients and should only be used if the benefit of treatment is considered to outweigh the risk. In treating adult patients, including when combining indications, the maximum cumulative dose in a 3 month interval should generally not exceed 6 U/kg or 360 Units, whichever is lower. In treating pediatric patients, the maximum cumulative dose in a 3 month interval should generally not exceed 6 Units/kg or 200 Units, whichever is lower. Based on effective donor screening and product manufacturing processes, it carries an extremely remote risk for transmission of viral diseases. Patients who are not catheterizing prior to treatment may subsequently require catheterization for urinary retention. In patients who are not catheterizing, post-void residual urine volume should be assessed within 2 weeks post-treatment and periodically as medically appropriate up to 12 weeks. Patients should be instructed to contact their physician if they experience difficulties in voiding. Neurogenic Detrusor Overactivity In these patients, autonomic dysreflexia associated with the procedure could occur, which may require prompt medical therapy. Some of these patients had risk factors including pre-existing cardiovascular disease. Ear/Nose/Throat Cervical Dystonia - Dysphagia is a commonly reported adverse event following treatment of cervical dystonia patients with all types of botulinum toxins. Patients with cervical dystonia should be informed of the possibility of experiencing dysphagia which may be mild, but could be severe. Consequent to the dysphagia there is the potential for aspiration, dyspnea and occasionally the need for tube feeding. In rare cases, dysphagia followed by aspiration pneumonia and death has been reported. Dysphagia has contributed to decreased food and water intake resulting in weight loss and dehydration. Patients with smaller neck muscle mass, or patients who receive bilateral injections into the sternocleidomastoid muscle, have been reported to be at greater risk of dysphagia. Dysphagia is attributable to the localized diffusion of the toxin to the oesophageal musculature. Patients or caregivers should be advised to seek immediate medical care if swallowing, speech or respiratory disorders arise. When appropriate, the potential for antibody formation may be minimized by injecting with the lowest effective dose given at the longest feasible intervals between injections. If such a reaction occurs, further injection should be discontinued and appropriate medical therapy initiated immediately. There have been rare cases of administration of botulinum toxin to patients with known or unrecognized neuromuscular junction disorders where the patients have shown extreme sensitivity to the systemic effects of typical clinical doses. In some of these cases, dysphagia has lasted several months and required placement of a gastric feeding tube. New onset or recurrent seizures have been reported, typically in patients who are predisposed to experiencing these events. The reports in children were reports predominantly from cerebral 9 palsy patients treated for spasticity. One case of corneal perforation in an aphakic eye requiring corneal grafting has occurred because of this effect. Careful testing of corneal sensation in eyes previously operated upon, avoidance of injection into the lower lid area to avoid ectropion, and vigorous treatment of any epithelial defect should be employed. Because of the anticholinergic activity of botulinum toxin, caution should be exercised when treating patients at risk for angle closure glaucoma, including patients with anatomically narrow angles. Acute angle closure glaucoma has been reported very rarely following periorbital injections of botulinum toxin. Inducing paralysis in one or more extraocular muscles may produce spatial disorientation, double vision, or past-pointing. Skin As is expected for any injection procedure, localized pain, inflammation, paresthesia, hypoaesthesia, tenderness, swelling/edema, erythema, localized infection, bleeding and/or bruising have been associated with the injection. Needle-related pain and/or anxiety have resulted in vasovagal responses, including transient symptomatic hypotension and syncope. Primary hyperhidrosis of the axillae - Medical history and physical examination, along with specific additional investigations as required, should be performed to exclude potential causes of secondary hyperhidrosis. This will avoid symptomatic treatment of hyperhidrosis without the diagnosis and/or treatment of underlying disease. If this drug is used during pregnancy, or if the patient becomes pregnant while taking this drug, the patient should be apprised of the potential risks, including abortion or fetal malformations, which have been observed in rabbits. Pediatrics (2-18 years of age): There have been very rare spontaneous reports of death sometimes associated with aspiration pneumonia in children with severe cerebral palsy after treatment with botulinum toxin. Post-marketing reports of possible distant spread of toxin have been very rarely reported in pediatric patients with co-morbidities, predominantly with cerebral palsy, who received > 8 U/kg. Extreme caution should be exercised when treating pediatric patients who have significant neurologic debility, dysphagia, or have a recent history of aspiration pneumonia or lung disease. In general, dose selection for an elderly patient should be cautious, usually starting at the lowest recommended dose for the specific indication. Muscle weakness remote to the site of injection and other serious adverse effects. As is expected for any injection procedure, localized pain, inflammation, paresthesia, hypoesthesia, tenderness, swelling/oedema, erythema, localized infection, bleeding and/or bruising have been associated with the injection. Clinical Trial Adverse Drug Reactions Because clinical trials are conducted under very specific conditions the adverse reaction rates observed in the clinical trials may not reflect the rates observed in practice and should not be compared to the rates in the clinical trials of another drug. Adverse drug reaction information from clinical trials is useful for identifying drug-related adverse events and for approximating rates. Nervous system disorders Common: Headache, paresthesia Vascular disorders Common: Hot flush Gastrointestinal disorders Common: Nausea Skin and subcutaneous tissue disorders Common: Hyperhidrosis, skin odor abnormal, pruritus, subcutaneous nodule, alopecia Musculoskeletal and connective tissue disorders Common: Pain in extremity General disorders and administration site conditions Very common: Injection site pain Common: Pain, injection site edema, injection site hemorrhage, injection site 14 hypersensitivity, injection site irritation, asthenia Note: increase in non-axillary sweating was reported in 4. Neurogenic Detrusor Overactivity associated with a neurologic condition the table below presents the most frequently reported adverse reactions in double-blind, placebo-controlled studies within 12 weeks of injection for detrusor overactivity associated with a neurologic condition. Among patients who were not catheterizing at baseline prior to treatment, catheterization was initiated in 38. Overactive Bladder the table below presents the most frequently reported adverse reactions in double-blind, placebo-controlled, pivotal Phase 3 studies within 12 weeks of injection for overactive bladder. Events considered to be procedure-related by the investigator reported at any time following initial injection were dysuria (6%) and haematuria (2%). The frequency is defined as follows: Uncommon (1/1,000, <1/100); Rare (1/10,000, <1/1,000); Very Rare (<1/10,000). Blepharospasm Nervous system disorders Uncommon Dizziness, facial palsy Eye disorders Uncommon Keratitis, ectropion, diplopia, entropion, vision blurred. Very rare Ulcerative keratitis, corneal epithelium defect, corneal perforation Skin and subcutaneous tissue disorder Uncommon Rash General disorders and administration site conditions Uncommon Fatigue Strabismus Eye disorders Uncommon Rare Cervical dystonia Eye disorders Uncommon Diplopia, eyelid ptosis General disorders and administration site conditions Uncommon Pyrexia Focal Spasticity Nervous system disorders Uncommon: Hypoesthesia, headache, paresthesia Vascular disorders Uncommon: Orthostatic hypotension Gastrointestinal disorders Uncommon: Nausea Skin and subcutaneous tissue disorders Uncommon: Dermatitis, pruritis, rash Musculoskeletal and connective tissue disorders Uncommon: Arthralgia, bursitis 18 Ocular retrobulbar hemorrhages, eye penetration, Holmes-Adie pupil Vitreous hemorrhage General disorders and administration site conditions Uncommon: Asthenia, pain, injection site hypersensitivity, malaise Chronic Migraine Gastrointestinal disorders Uncommon: Dysphagia Skin and subcutaneous tissue disorders Uncommon: Pain of skin Musculoskeletal and connective tissue disorders Uncommon: Pain in jaw Abnormal Hematologic and Clinical Chemistry Findings No specific trends in abnormal hematologic or clinical chemistry findings have been reported. Adverse events after treatment with botulinum toxin include rare spontaneous reports of death, sometimes associated with dysphagia, respiratory compromise, pneumonia, and/or other significant debility. There have also been reports of adverse events involving the cardiovascular system, including arrhythmia and myocardial infarction, some with fatal outcomes. The reports in children were predominantly from cerebral palsy patients treated for spasticity. Serious and/or immediate hypersensitivity reactions such as anaphylaxis and serum sickness have been rarely reported, as well as other manifestations of hypersensitivity including urticaria, soft tissue edema, and dyspnea. Drug-Drug Interactions Table 1: Established or Potential Drug-Drug Interactions Proper name of drug aminoglycoside antibiotics or spectinomycin, or other medicinal products that interfere with neuromuscular transmission. Different botulinum neurotoxin serotypes Ref T Effect Theoretically, the effect of botulinum toxin type A may be potentiated Clinical comment the effect of botulinum toxin may be potentiated by aminoglycoside antibiotics or spectinomycin, or other drugs that interfere with neuromuscular transmission. The effect of administering different botulinum neurotoxin serotypes at the same time or within several months of each other is unknown. Excessive weakness may be exacerbated by administration of another botulinum toxin prior to the resolution of the effects of a previously administered botulinum toxin. Drug-Laboratory Interactions Interactions with laboratory tests have not been established. The use of one vial for more than one patient is not recommended because the product and diluent do not contain a preservative. Follow the recommended dosage and frequency of administration for each indication. Generally, optimum dose levels and the number of injection sites per muscle have not been established for all indications. This dose can be gradually increased in subsequent treatments to the maximum recommended dose, if needed. In treating adult patients, when combining indications, the maximum cumulative dose in a 3 month interval should generally not exceed 6 Units/kg, or 360 Units, whichever is lower. In treating pediatric patients, the maximum cumulative dose in a 3 month interval should generally not exceed 6 Units/kg body weight, or 200 Units, whichever is lower. In general, the initial effect of the injections is seen within three days and reaches a peak at one to two weeks post-treatment. Treatment effects last approximately three months, following which the procedure can be repeated indefinitely. At repeat treatment sessions, the dose may be increased up to two-fold if the response from the initial treatment is considered insufficient. Avoiding injection near the levator palpebrae superioris may reduce the complication of ptosis. Injection without surgical exposure or electromyographic guidance should not be attempted. About one-half of patients will require subsequent doses because of inadequate paralytic response of the muscle to the initial dose, or because of mechanical factors such as large 22 deviations or restrictions, or because of the lack of binocular motor fusion to stabilize the alignment. For vertical muscles, and for horizontal strabismus of less than 20 prism diopters: 1. It is recommended that patients be reexamined 7-14 days after each injection to assess the effect of that dose. Subsequent injections should not be administered until the effects of the previous dose have dissipated as evidenced by substantial function in the injected and adjacent muscles. However, in clinical practice, a range of 200 U to 360 U have been used effectively. A 25, 27 or 30 gauge needle may be used for superficial muscles, and a 22 gauge needle may be used for deeper musculature. For cervical dystonia, localization of the involved muscles with electromyographic guidance may be useful. The optimal number of injection sites is dependent upon the size of the muscle to be chemically denervated.