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Some commenters objected that the inclusion of religious exemptions is clearly a political decision made by politicians in this administration who seek to avoid accountability for their own sexual misconduct erectile dysfunction gay buy levitra soft 20 mg with visa. Other commenters stated that the drafters of the proposed rules do not have the interests of students at heart erectile dysfunction 31 years old purchase levitra soft 20 mg without a prescription, and that the proposed rules are intentionally designed to institutionalize patriarchy and homophobia erectile dysfunction 20 cost of levitra soft. Other commenters stated that the inclusion of the religious exemption provision was a political decision to curry favor with religious institutions and warned the Department not to divide people erectile dysfunction and heart disease 20mg levitra soft free shipping. Another commenter suggested that the provision was an effort by Secretary Betsy DeVos to establish a Christian fascist nation that favors a fundamentalist strain of Christianity. Discussion: Although the Department appreciates the feedback on the proposed rule, it rejects the assumptions of these commenters. As stated above, the Departments goals for these final regulations are to establish a grievance process that is rooted in due process principles of notice 1657 and opportunity to be heard and that ensures impartiality before unbiased officials. These final regulations apply to prohibit certain conduct and apply to anyone who has experienced such conduct, irrespective of a persons sexual identity or orientation. Constitution, including the First Amendment, as well as other Federal laws such as the Religious Freedom Restoration Act. One commenter asserted that recipients of all religious persuasions will suffer, when the public assumes that all religious schools discriminate against students. The commenter argued that this would be like letting a corporation verify or change its own tax status while being investigated by the Internal Revenue Service. Of course, a recipient must know what it is under investigation for, in order to assert an applicable exemption such as a religious exemption. Nonetheless, a recipient cannot invoke a religious exemption at the last minute because the recipient must be an educational institution which is controlled by a religious organization, and such control by a religious organization is not something that occurs at the last minute. The Department is not aware of any assumption that all educational institutions which are controlled by a religious organization engage in discriminatory practices, and the Departments 1660 experience has not been that all educational institutions which are controlled by a religious organization engage in discriminatory practices. However, recipients are not entitled to any type of formal deference when invoking eligibility for a religious exemption, and recipients have the duty to establish their eligibility for an exemption, as well as the scope of any exemption. Additionally, these commenters stated that the Department should reassess the religious exemption to weigh more heavily a schools potential to be dishonest and to discriminate. Commenters contended that the Obama-era approach was popular among students and faculty, and was fair to all parties. Commenters argued that proceeding with this rationale will mean violating the Administrative Procedure Act, because the current procedures are not confusing or burdensome, as set forth clearly in the current regulation. Discussion: the Department appreciates the feedback on the potential policy implications of the proposed rule. The Department acknowledges that its practices in the recent past regarding assertion of a religious exemption, including delays in responding to inquiries about the religious exemption and publicizing some requests for a religious exemption, may have caused educational institutions to become reluctant to exercise their rights under the Free Exercise Clause of the First Amendment, and the Department would like educational institutions to fully and freely enjoy rights guaranteed under the Free Exercise Clause of the U. The Department may be liable for chilling a recipients First Amendment rights and also is subject to the Religious Freedom Restoration Act. The Department properly engaged in this notice-and-comment rulemaking to clarify that the Department, consistent with 20 U. The First Amendment and the Religious Freedom Restoration Act, which apply to the Department as a Federal agency, cause the Department to err on the side of caution in not hindering a recipients ability to exercise its constitutional rights. Based on at least some commenters asserting that recipients needed more clarity on the current regulations, the Department respectfully disagrees with commenters arguing that confusion and burdens have not resulted from the text of the current regulations. However, nothing in the final regulations addresses publishing such a list, one way or another. One commenter stated that 1663 no religious exemption request has ever been denied, so addressing this topic in formal rulemaking is unnecessary. Commenters contended that the change to the text of the religious exemption regulation is not responsive to any specific issue or wrong, and that the current regulation appropriately burdens the institution, as opposed to students. Commenters suggested that placing the burden on a party not invoking the exemption is discordant with other areas of law, such as many States requirement that parents submit a religious objection to immunizations in writing, or that an entity bear the burden of establishing its entitlement to tax-exempt status. Indeed, say the commenters, the Department administers the Clery Act, which is another statute that burdens schools by requiring them to collect and report information. The Department also disagrees that a complaint is placed on hold while the Department considers a recipients religious exemption. The Departments regulations, implementing the Clery Act, address the reporting requirements that Congress enacted. Additionally, as previously explained, the First Amendment and the Religious Freedom Restoration Act may prohibit any such additional burdens. A complainant currently receives the opportunity to appeal the Departments determination with respect to a complaint or the dismissal of a complaint and may 1668 1728 raise any concerns about a recipients religious exemption as well as other matters on appeal. Nothing in the final regulations prevents a recipient from informing the complainant of its invocation of a religious exemption. Additionally, such documents are subject to Freedom of Information Act requests, and attendant rules regarding public disclosure of commonly-requested documents. The Department does not believe that publishing a book or a list of names of recipients that have asserted eligibility for a 1728 U. Other commenters suggested that a recipient maintaining a religious exemption ought to be compelled to publish such information in their materials and policies, i. The Department believes that the requirements in these final regulations provide sufficient transparency. Accordingly, students and prospective students should receive adequate notice of the recipients non-discrimination statement as well as its grievance procedures and grievance process regarding sex discrimination, including sexual harassment, and such notice is consistent with due process principles. Comments: Some commenters suggested that the religious exemptions language be altered, to carve out conduct that would be considered a crime. Other commenters suggested that the Department should clarify how a school that maintains a religious exemption ought to interact with a school that does not maintain a religious exemption, if an incident involves two students, one from each type of school. The Department does not believe the commenters other suggested phrase, as to that provision or any other provision of this part is necessary to adequately explain the scope and application of this provision. Comments: One commenter suggested that the Department ought to go beyond the proposed rule, and promulgate a definition for what it means to be controlled by a religious organization, so that recipients and the public would know which institutions are in fact eligible for religious exemptions, since there has been confusion previously. Additionally, the commenter asked that the definition take account of and be consistent with Supreme Court case law interpreting the Establishment Clause of the First Amendment. The Department will continue to offer technical assistance regarding compliance with these final regulations. Another commenter asserted that elementary and secondary schools, too, have sexual harassment issues that they must confront; it is not only a problem in postsecondary institutions. Another commenter argued that elementary and secondary schools need flexibility to address sexual harassment issues that arise involving younger students. The Department agrees with commenters that some procedures are more appropriate for postsecondary institutions but not for other recipients, including elementary and secondary schools, and the final regulations reflect such differences. For example, Directed Question 3 inquired about applicability to the proposed rules to employees, and comments responsive to that directed question are addressed in the Section 106. Commenters argued that this was necessary because schools need to react to time-sensitive situations and exclude accused students or employees from the school atmosphere without having to go through the extensive grievance procedures contemplated by the proposed rule. Commenters also suggested that offering supportive measures was often time-sensitive, such that a full grievance process is not appropriate.

Commenters argued that where the facts are not contested impotence after robotic prostatectomy purchase 20 mg levitra soft, or where the respondent has admitted responsibility erectile dysfunction doctor indianapolis purchase levitra soft no prescription, or video evidence of the incident in question exists erectile dysfunction pump discount generic levitra soft canada, there is no need to put parties through the ordeal of a live hearing yet the proposed rules would force an institution to hold a live hearing anyway erectile dysfunction drugs insurance coverage buy levitra soft with visa, straining the limited resources of all schools but especially smaller institutions. One commenter argued that if, for example, a respondent video-taped the respondent raping a student and the hearing officer watches the video and hears from the complainant who confirms the incident did happen, and the respondent denies doing it, a live hearing with cross examination would not be useful in such a scenario. Commenters suggested that this provision be modified to require the parties to attempt mediation, so that a live hearing is required only if mediation fails. Commenters stated that some recipients use an administrative disposition model where a respondent may accept responsibility based on an investigators findings and the final regulations should permit the recipient, or the respondent, in that situation to waive the right to a live hearing. Other commenters argued that either party should have the right to waive 1213 a live hearing so that a live hearing should only occur if both parties and the recipient agree it is the appropriate method of resolution for a particular case. Commenters quoted a Federal district court memorandum from 1968 setting forth guidelines on how that district court should evaluate claims against tax-funded colleges and universities, where the court memorandum stated the nature and procedures of college discipline should not be required to conform to Federal criminal law processes which are far from perfect 1368 and designed for circumstances unrelated to the academic community. Commenters argued that most Federal courts adopt that approach, acknowledging that student discipline is part of the education process and is not punitive in the criminal sense; rather, expelled students may suffer damaging effects but do not face imprisonment, fines, disenfranchisement, or probation. Some commenters suggested that the final regulations should state more broadly that recipients must offer parties reasonable mitigating measures during a live hearing, of which locating the parties in separate rooms is but one example. Commenters asked for clarification such as: Can recipients limit the hearing to consideration only of evidence previously included in the investigative report Can recipients impose rules of evidence left unaddressed by the proposed regulations, such as excluding questions that are misleading, assume facts not in evidence, or call for disclosure of attorney client privileged information, or questions that are cumulative, repetitive, or abusive Can recipients impose time limits on hearings so that parties and witnesses do not spend multiple days in a hearing rather than fulfilling their academic or work responsibilities Commenters asserted that live hearings are administratively time-consuming and will lengthen the grievance process by requiring both parties and their advisors to be on campus simultaneously, which is impractical and often undesirable. Commenters asserted that since the proposed rules already allow the parties to be located in separate rooms, there is no reason not to also allow a recipient to hold the entire hearing virtually using technology. At least one commenter asserted that even allowing participation virtually would not make this provision fair because the commenter had a case in which a key witness was studying abroad in a country with a large time zone difference making it impossible for the witness to testify even remotely using technology. Commenters argued that coordinating the schedules of parties, advisors, hearing panels, and witnesses to appear for a live hearing will delay proceedings. Other commenters stated that some rural university systems have satellite campuses in remote locations off the road system, with insufficient internet access even to allow videoconferencing, posing significant barriers to complying with a live hearing requirement. According to this commenter, universities typically forbid parties from recording hearings and not having such a record can allow a grievance boards illegal bias against a party to fester and remain unchecked by the university, regulatory agencies, or the courts. Discussion: the Department appreciates commenters support for this provision, requiring postsecondary institutions to hold live hearings. Administrative law seeks to ensure that those whose rights are affected by the decisions of administrative tribunals are given notice of hearings, guaranteed an oral, often public hearing, have a right to be represented, are granted disclosure of the case against them, are able to introduce evidence, call witnesses and cross-examine those testifying against them, have access to reason for decision, and an opportunity to appeal an adverse outcome. The process assumes the value of an adversarial hearing in which impartial adjudicators are exposed to 1370 representations from those asserting a claim and those seeking a contrary finding. The Department agrees that postsecondary institutions are not equipped to act as courts of law. The final regulations acknowledge this reality by prescribing a grievance process that intentionally avoids importation of comprehensive rules of procedure (including discovery procedures) and rules of evidence that govern civil or criminal court trials. The Department disagrees that live hearings add no value to the fairness or accuracy of outcomes even where an investigation was full and fair. The fundamental characteristics of the adversary system also have a constitutional source, however, in our administration of civil justice to redress 1373 grievances, resolve conflicts, and vindicate rights. In addition to representing core constitutional values, an adversarial system yields practical benefits. The veracity of that evidence is tested through questioning of witnesses, a procedure structured to uncover both lapses of memory and falsehoods, conducted by an advocate skilled in this enterprise. During the course of the hearing, the decisionmaker acts only to contain the colloquy within the bounds of the actual dispute. He is a disinterested and impartial arbiter, constrained to reach a judgment based exclusively on facts presented at the hearing, with respect to which there has been opportunity for rebuttal. His decision is a reasoned one that explicitly resolves disagreements concerning facts and relates a determination in the case before him to the governing rule. Subject to the availability of appeal, that decision is dispositive of the matter. These several elements of the ideal due process hearing are intended primarily to assure that factual determinations have been reliably made, and hence to promote the societal interest in just outcomes. Participation also assures that the individual is not being treated as a passive creature, but rather as a person whose dignitary rights include an interest in influencing what happens to his life. Personal involvement, it is argued, promotes fairness in individual perception as well as fairness in fact. While commenters cited research studies calling into doubt the truth-seeking effectiveness of the adversarial process and calling for reforms including moving toward inquisitorial models, the adversarial system remains deeply embedded in the U. Constitution and in American legal systems and civic values, and the research that has been done provides no justification for preferring the inquisitorial search for truth or for undertaking 1381 radical changes in our adversary system. The central characteristic of the inquisitorial model is the active role of the judge, who is given the principal responsibility for searching out the relevant facts. In an adversary system the evidence is presented in dialectical form by opposing lawyers; in an inquisitorial system the evidence is developed in a predominantly unilateral fashion by the judge, and the lawyers role is minimal. Although decided under the Sixth Amendments Confrontation Clause which only applies to criminal trials, the Supreme Court analyzed the history of American legal systems insistence that adversarial procedures rooted in English common law (as opposed to inquisitorial procedures utilized by civil law countries in Europe) represented fundamental notions of due process of law, and American founders deliberately rejected devices that English common law borrowed from civil law. Thus, recipients may decide whether or how to place limits on evidence introduced at a hearing that was not gathered and presented prior to the hearing, and rules controlling the conduct of participants to ensure that questioning is done in a respectful manner. The Department does not dispute that decision-makers are capable of being impartial and unbiased without the parties appearing at a live hearing, and the final regulations expect that decision-makers will serve impartially without bias. However, adversarial procedures make it even less likely that any bias held by a decision-maker will prevail because the parties own views about the evidence are presented to the decision-maker, and the decision-maker observes the parties as individuals which makes it more difficult to apply even unconsciously-held stereotypes or generalizations about groups of people. The Department agrees that a variety of administrative agency proceedings have been declared by courts to comport with constitutional due process utilizing procedures less formal than those that apply in criminal or even civil courts. The Department realizes that witnesses with information relevant to sexual harassment allegations that involve the witnesss friends or co-students may feel disinclined to provide information during an investigation, and perhaps more so at a live hearing. The final regulations, and the live hearing requirement in particular, benefit complainants and respondents equally by granting both parties the same rights and specifying the same consequences for lack of participation. The safety of complainants can be addressed in numerous ways consistent with these final regulations, including holding the hearing virtually, having the parties in separate rooms, imposing no-contact orders on the parties, and allowing advisors of choice to accompany parties to the hearing. For the reasons described above, the Department believes that the final regulations balance the pendulum rather than swing the pendulum too far, in terms of balancing the rights of both parties in a contested sexual harassment situation to pursue their respective desires regarding the case outcome. The Department believes that the time and resources recipients have spent over the past several years developing non-hearing adjudication models can largely be applied to a recipients obligations under these final regulations. For example, recipients who have developed thorough 1223 and fair investigative processes may continue to conduct such investigations. Even though postsecondary institutions will reach actual determinations regarding responsibility after holding a live hearing, the time and resources dedicated to developing recipients current systems will largely carry over into compliance with the final regulations. As noted above, even if no party appears for the live hearing such that no partys statements can be relied on by the decision-maker, it is still possible to reach a determination regarding responsibility where non-statement evidence has been gathered and presented to the decision-maker. To the extent that a recipient is able to comply with both, it must do so, and if compliance with both is not possible 1384 these final regulations, which constitute Federal law, preempt conflicting State law. The Department generally does not disagree with the general propositions set forth in the Federal district court memorandum cited by commenters to explain that college discipline differs 1385 from Federal criminal processes. The Department observes that the memorandum notes that Only where erroneous and unwise actions in the field of education deprive students of federally protected rights or privileges does a federal court have power to intervene in the educational 1384 For further discussion see the Section 106.

For example impotence spell buy generic levitra soft 20 mg online, injury of gaze for several hours erectile dysfunction meme purchase 20 mg levitra soft, causing lateral gaze to the oculomotor nucleus or nerve produces deviation toward the side of the affected cor exodeviation of the involved eye erectile dysfunction utah order levitra soft 20 mg online. In skew deviation doctor who treats erectile dysfunction order levitra soft 20mg mastercard, in which may also produce wrong-way eyes, which 115,116 one eye is deviated upward and the other deviate away from the side of the lesion. Dam Combined loss of adduction and vertical age to the lateral pons, on the other hand, may movements in one eye indicates an oculomotor cause loss of eye movements toward that side nerve impairment. In rare cases with a lesion of the ocu locephalic or caloric stimulation usually over lomotor nucleus, the weakness of the superior comes lateral gaze deviation due to a cortical rectus will be on the side opposite the other gaze paresis. If awake, the patient typically attempts to compensate by tilting the head toward that shoulder. Skew deviation is due so the presence of an isolated abducens palsy either to a lesion in the lateral rostral medulla may be misleading. The roving eye movements may disap the eyes diverge slowly, and this is followed by pear as the coma deepens, although they may a quick convergent jerk. The implications of Nystagmus refers to repetitive rapid (saccadic) these unusual eye movements are similar to eye movements, often alternating with a slow those of ocular bobbing: a lower brainstem in drift in the opposite direction. This is followed by tinuous seizure activity with versive eye move reversal of the movements. It may be associated 72 Plum and Posners Diagnosis of Stupor and Coma with skew deviation and if bilateral, the eyes Paratonia is often seen in patients with demen may rotate in the opposite direction. On the sessed in the neck by gently grasping the head other hand, in patients who are drowsy or with two hands and moving it back and forth or confused, some abnormal cutaneous reexes up and down, and in the lower extremities by may be released. These may include extensor grasping each leg at the knee and gently lifting plantar responses. Prefrontal cutaneous reexes, sometimes Spastic rigidity, on the other hand, increases called frontal release reexes or primitive 135 with more rapid movements and generally has reexes, may also emerge in drowsy patients a clasp-knife quality or a spastic catch, so that with diffuse forebrain impairment. The maneuvers used tient who can cooperate with the exam; it dis to provide adequate stimuli without inducing appears as the patient becomes more drowsy. Motor responses to noxious stimulation in patients with acute cerebral dysfunction. Lesions involving the junction of the diencephalon and the mid brain may show decorticate posturing, including exion of the upper extremities and extension of the lower extremities. An appropriate re mals, these patterns of motor response may be sponse is one that attempts to escape the stim produced by brain lesions of several different ulus, such as pushing the stimulus away or kinds and locations and the patterns of motor attempting to avoid the stimulus. The motor response in an individual to any one of these response may be accompanied by a facial gri lesions may vary across time. It types of responses can be produced by supra is necessary to distinguish an attempt to avoid tentorial lesions, although they imply at least the stimulus, which indicates intact sensory incipient brainstem injury. There is a tendency and motor connections within the spinal cord for lesions that cause decorticate rigidity to be and brainstem, from a stereotyped withdrawal more rostral and less severe than those caus response, such as a triple exion withdrawal of ing decerebrate rigidity. The stereotyped withdrawal they simply describe the movements that are response is not responsive to the nature of the seen rather than attempt to t them to com stimulus. Failure to withdraw wrist, and ngers with adduction in the upper on one side may indicate either a sensory or a extremity and extension, internal rotation, and motor impairment, but if there is evidence of vigorous plantar exion of the lower extremity. Such withdraw on both sides, accompanied by facial fragmentary patterns have the same localizing grimacing, may indicate bilateral motor im signicance as the fully developed postural pairment below the level of the pons. Such patients typically have represents the response to endogenous stim normal ocular motility. In addition, the two matose patients with decorticate posturing 139 sides of the body may show different patterns recovered. As with de tine injuries to the spinal shock (accidity) or corticate posturing, fragments of decerebrate even exor responses seen from stimulating posturing are sometimes seen. De the main purpose of the foregoing review of cerebrate posturing in experimental animals the examination of a comatose patient is to dis usually results from a transecting lesion at the tinguish patients with structural lesions of the level between the superior and inferior colli brain from those with metabolic lesions. It is believed to be due to the release of vestibulospinal postural reexes from fore imaging. When focal neurologic ndings may be similar, as in most cases decerebrate are observed, it becomes imperative to deter posturing is associated with disturbances of mine whether there is a destructive or compres ocular motility. However, electrophysiologic, sive process that may become life threatening radiologic, or even postmortem examination or irreversibly damage the brain within a matter sometimes reveals pathology that is largely of minutes. Most patients with decere brate rigidity have either massive and bilateral forebrain lesions causing rostrocaudal deteri oration of the brainstem as diencephalic dys Respiratory Responses function evolves into midbrain dysfunction (see Chapter 3), or a posterior fossa lesion that the range of normal respiratory responses compresses or damages the midbrain and ros includes the Cheyne-Stokes pattern of breath tral pons. Patients with severe sleep Extensor posturing of the arms with accid apnea may stop breathing for 10 seconds or so or weak exor responses in the legs is typically every minute or two. Their color may become seen in patients with injury to the lower dusky during the oxygen desaturation that ac brainstem, at roughly the level of the vestibular companies each period of apnea. This must be cause the seizure usually results in the release distinguished from sepsis, hepatic encephalop of adrenalin, the pupils typically are large after athy, or cardiac dysfunction, conditions that of a seizure. The may suppress all brainstem responses, includ nature of the primary insult is determined by ing pupillary light reactions, and simulate brain whether the blood pH is low (metabolic aci death (see Chapter 6). Pupillary Responses Ocular Motor Responses A key problem with interpreting pupillary re sponses is that either metabolic coma or di Typical oculocephalic responses, as seen in a encephalic level dysfunction may cause bilat comatose patient with an intact brainstem, are erally small and symmetric, reactive pupils. In fact, brainstem oculoce still have impairment that can be attributed to phalic responses (as if the eyes were xed on a either a diencephalic lesion or to symmetric point in the distance) are nearly impossible for forebrain compression. As a result, it is generally therefore are a useful differential point in iden necessary to do an imaging study (see below) tifying psychogenic unresponsiveness. Very small pupils may be indicative of pon Certain drugs may eliminate oculocephalic tine level dysfunction, often indicating an and even caloric vestibulo-ocular responses. In or so, it is necessary to re-examine the patient such cases, the relationship of the loss of eye 15 to 30 minutes later to make sure that the movements to the impairment of conscious Examination of the Comatose Patient 77 ness may be confusing, and the prognosis may sibility of false localizing signs in patients with be much better than would be indicated by the metabolic causes of coma, unless a structural lack of these brainstem reexes, particularly lesion can be ruled out, it is still usually nec if the patient receives early plasmapheresis or essary to proceed as if the coma has a structural intravenous immune globulin. The neurologic examination, as described Isolated unilateral or bilateral abducens above, is the cornerstone for the diagnosis of palsy may be seen in some patients with in stupor and coma. It can be done at the bedside creased intracranial pressure, even due to non within a matter of a few minutes, and it pro 150 focal causes such as pseudotumor cerebri. On the Motor Responses other hand, if the evidence from a nonfocal examination points toward a diffuse metabolic Patients with metabolic coma may have para encephalopathy, the examiner usually has time tonia and/or extensor plantar responses. Rarely, patients with metabolic causes of coma, 153 particularly hypoglycemia, will present with Blood and Urine Testing asymmetric motor responses or even hemi plegia (see Chapter 5). It is important to draw blood for ing, but the presence and even the distribution glucose and electrolytes, and to do toxic and of focal ndings in patients with hypoglycemia drug screening almost immediately. Blood gases should be drawn hypoglycemia are more common in children if there is any suspicion of respiratory insuf than adults, again suggesting the absence of an ciency or acid-base abnormality. In a identies brain edema consistent with these woman of reproductive age, pregnancy test focal neurologic decits. A bedside mea netic resonance images, the so-called posterior surement of blood glucose is sufficiently ac 154 leukoencephalopathy syndrome. However, if glu hepatic coma, may also cause either decere cose is given, 100 mg of thiamine should be brate or decorticate posturing. Hence, they are less of ever, subacute infarction may become isodense ten used for primary scanning of patients with with brain during the second week, and hem coma. Diffusion-weighted imaging may be quite difficult to distinguish from hyper demonstrate an infarct that otherwise cannot normal brain. Panel (B) shows the perfusion blood ow map, indicating that there is very low ow within the left middle cerebral artery distribution, but that there is also impairment of blood ow in both anterior cerebral arteries, consistent with loss of the contribution from the left internal carotid artery. Although the blood volume (C) is relatively normal in these areas, mean transit time (D) is also abnormal, indicating that tissue in the anterior cerebral distributions is at risk of infarction. The absence of ow in the of disorders including hyperosmolar states, pro brain has been used to conrm brain death, gressive multifocal leukoencephalopathy, renal particularly in patients who have received sed failure, and diabetes. Levels are decreased in ative drugs that may alter some of the clini 158,159 hyponatremia, chronic hepatic encephalopathy, cal ndings (see Chapter 8). The total creatine peak remains constant, echo and provides better delineation of blood allowing other peaks to be calculated as ratios ow, occlusions, pseudo-occlusions, stenosis, 162 to the height of the creatine peak. Rare patients in whom increased in hypoxic/ischemic encephalopa subarachnoid hemorrhage was not detected thy, diabetic acidosis, stroke, and recovery from on imaging may demonstrate blood in the cardiac arrest.

Syndromes

Stomach ulcer or gastritis (burning pain occurs if your stomach is empty and feels better when you eat food)
Past surgery
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Take the drugs your doctor told you to take with a small sip of water.
Bring your own manicure tools to nail salons.
A few soda crackers or dry toast when you first wake up, even before you get out of bed in the morning.
File the wart with a nail file or emery board when your skin is damp (for example, after a shower or bath). This helps remove dead tissue. Do not use the same emery board on your nails.

For reasons described above sleeping pills erectile dysfunction buy levitra soft with mastercard, the Department retains the requirement for recipients to provide parties with an advisor to conduct cross-examination best erectile dysfunction doctor in india effective 20mg levitra soft, instead of merely requiring recipients to advise a party about how to select an advisor erectile dysfunction lifestyle changes generic levitra soft 20 mg online. In order to foreclose personal confrontation between the parties during cross-examination while preserving the neutrality of the recipients decision-maker impotence synonym discount 20mg levitra soft amex, that procedure must be conducted by advisors rather than by parties, and where a party does not take the opportunity to select an advisor of the partys choice, that choice falls to the recipient. As noted above, the final regulations do not preclude a recipient from adopting and applying codes of conduct and rules of decorum to ensure that parties and advisors, including assigned advisors, conduct cross-examination questioning in a respectful and 1149 non-abusive manner, and the decision-maker remains obligated to ensure that only relevant questions are posed during cross-examination. The Department understands commenters desire that both parties have advisors of equal competency during a hearing. To allow recipients to meet their obligations with as much flexibility as possible, the Department declines to require recipients to pre-screen a panel of assigned advisors from which a party could make a selection at a hearing, or to require provided advisors to receive training from the recipient. The final regulations do not preclude a recipient from taking such steps, in the recipients discretion, and the final regulations require decision-makers to be trained specifically in issues of relevance. The Department reiterates that a recipient may fulfill its obligation to provide an advisor for a party to conduct cross-examination at a hearing without hiring an attorney to be that partys advisor, and that remains true regardless of whether the other party has hired a lawyer as an advisor of choice. The final regulations do not 1150 create an arms race with respect to the hiring of attorneys by recipients, and recipients remain free to decide whether they wish to incur the cost or burden of providing attorneys when they must provide an advisor to a party at a hearing to conduct cross-examination. This provision does not impose an unfunded mandate on recipients because recipients retain discretion whether to incur the cost of hiring attorney or non-attorney advisors. However, to the extent that a recipient is concerned that State bar associations do, or may, consider party advisors at a live hearing to be practicing law, the recipient retains discretion to select attorneys as assigned party advisors. This provision clarifies that the choice of advisor where one must be provided by the recipient lies in the recipients sound discretion, and removes the aligned with that party criterion so that a party cannot challenge the recipients choice by claiming the assigned advisor was not sufficiently aligned. Whether or not the recipient complied with this provision is now more objectively determined, i. The Department does not have control over claims made by parties against recipients in private litigation, but clarifies here that this provision does not impose a burden on the recipient to ensure the adequacy of an assigned advisor, merely that the assigned advisor performs the role described in this provision. Particular requirements of a grievance process are no different in kind from the regulatory requirements the Supreme Court has expressly acknowledged fall under the Departments regulatory authority. For example, the Departments regulations have long required recipients to have grievance procedures in place 1320 even though the absence of grievance procedures does not, itself, constitute discrimination, because adopting and publishing grievance procedures for the prompt and equitable resolution 1321 of sex discrimination makes it more likely that a recipient will not engage in sex 1320 Cannon v. The Department appreciates commenters requests for clarification of this provision. Some clarification requests have been answered by the modifications made to this provision, such as removal of the aligned with that party language and specification that when a recipient must provide an advisor during a hearing the selection of that advisor is of the recipients choice and the assigned advisor may be, but is not required to be, an attorney. The only limitation on recipients discretion to restrict advisors active participation in proceedings is this provisions requirement that advisors conduct cross-examination, so recipients remain free to apply rules (equally applicable to both parties) restricting advisor participation in non-cross examination aspects of the hearing. Recipients cannot impose a cost or fee limitation on a partys advisor of choice and if required to provide a party with an advisor at a hearing, the recipient may not charge the party any fee. These confidentiality obligations may affect a recipients ability to offer parties a recipient-provided advisor to conduct cross-examination in addition to allowing the parties advisors of choice to appear at the hearing. The final regulations do not preclude recipients from adopting a rule that requires parties to inform the recipient in advance of a hearing whether the party intends to bring an advisor of choice to the hearing; but if a party then appears at a hearing without an advisor the recipient would need to stop the hearing as necessary to permit the recipient to assign an advisor to that party to conduct cross-examination. A party cannot fire an assigned advisor during the hearing, but if the party correctly asserts that the assigned advisor is refusing to conduct cross-examination on the partys behalf then the recipient is obligated to provide the party an advisor to perform that function, whether that means counseling the assigned advisor to perform that role, or stopping the hearing to assign a different advisor. If a party to whom the recipient assigns an advisor refuses to work with the advisor when the advisor is willing to conduct cross-examination on the partys behalf, then for reasons described above that party has no right of self-representation with respect to conducting cross examination, and that party would not be able to pose any cross-examination questions. Whether advisors also may conduct direct examination is left to a recipients discretion (though any rule in this regard must apply equally to both parties). This provision applies to parties who are a recipients employees, including at-will employees; recipients may not impose training or competency assessments on advisors of choice selected by parties, but nothing in the final 1154 regulations prevents a recipient from training and assessing the competency of its own employees whom the recipient may desire to appoint as party advisors. The Department declines to require training for assigned advisors because the goal of this provision is not to make parties feel adequately represented but rather to ensure that the parties have the opportunity for their own view of the case to be probed in front of the decision-maker. Whether a party views an advisor of choice as representing the party during a live hearing or not, this provision only requires recipients to permit advisor participation on the partys behalf to conduct cross-examination; not to represent the party at the live hearing. A recipient may, but is not required to , allow advisors to represent parties during the entire live hearing (or, for that 1322 matter, throughout the entire grievance process). If a partys advisor of choice refuses to comply with a recipients rules of decorum (for example, by insisting on yelling at the other party), the recipient may provide that party with an advisor to conduct cross-examination on behalf of that party. If a provided advisor refuses to comply with a recipients rules of decorum, the recipient may provide that party with a different advisor to conduct cross examination on behalf of that party. Commenters asserted that this 1156 requirement may reveal and prevent bias in proceedings by making the decision-maker explain the rationale for deciding that a question is not relevant. Other commenters opposed the requirement that decision-makers explain any reason for excluding a question as not relevant, arguing that decision-makers are usually not lawyers or judges and are not legally trained to make complex rulings, so that requiring on-the-spot decisions about relevance will expose recipients to legal liability. Commenters argued that this provision exceeds procedural norms in criminal courts where rules of procedure do not demand that judges provide explanation for rulings. Commenters argued that parties should have the right to appeal wrongful decisions to exclude evidence and thus it is unnecessary to require decision makers to explain exclusion decisions during the hearing. Commenters wondered whether the parties are allowed to argue with the decision-maker upon hearing a decision-makers explanation about the relevance of a question and expressed concern that protracted arguments over relevance would lengthen hearings and feel tortuous for students. Commenters expressed concern that the requirement to explain irrelevancy decisions will disincentivize decision-makers from properly excluding questions that violate the rape shield protections. Commenters proposed that the provision be modified to require decision-makers to explain the decision to exclude questions in writing after the hearing rather than during the hearing. Commenters suggested that the final regulations also give decision-makers the right to screen questions before the hearing so the decision-maker has adequate time to consider whether the questions are relevant. Commenters wondered what type of information a decision-maker is required to give to meet this provision. Commenters argued this provision is meaningless because if a decision-maker decides a question is irrelevant, presumably the decision-maker believes the question does not tend to prove the matter at issue and thus, telling the decision 1157 maker to state self-evidently during the hearing: This question is not relevant because it is not relevant adds no value to the proceeding and only allows party advisors to bog down the hearing by demanding that rote explanation. The Department disagrees that this provision requires legal expertise on the part of a decision-maker. One of the benefits to the final regulations refusal to import wholesale any set of rules of evidence is that the legal sophistication required to navigate rules of evidence results often from determining the scope of exceptions to admissibility rules. While this provision does require on the spot determinations about a questions relevance, the decision-maker must be trained in how to conduct a grievance process, specifically including how to determine relevance within the scope of this provisions rape shield language and the final regulations protection of privileged information and parties treatment records. The final regulations contemplate that decision-makers often will be laypersons, not judges or lawyers. A judges relevance ruling from the bench needs no in-the-moment explanation because a judge has the legal sophistication to have reached a ruling against the backdrop of the judges legal knowledge. By contrast, a laypersons determination that a question is not relevant is made by applying logic and common sense, but not against a backdrop of legal expertise. Thus, an explanation of how or why the question was irrelevant to the allegations at issue, or is deemed irrelevant by these final regulations (for example, in the case of sexual predisposition or prior sexual behavior information) provides transparency for the parties to understand a decision-makers relevance determinations. However, asking the decision-maker to also explain the exclusion of questions during the hearing does not affect the parties appeal rights and may reduce the number of instances in which a party feels the need to appeal on this basis because the decision-maker will have explained the decision during the hearing. The final regulations do not preclude a recipient from adopting a rule (applied equally to both parties) that does, or does not, give parties or advisors the right to discuss the relevance determination with the decision-maker during the hearing. If a recipient believes that arguments about a relevance determination during a hearing would unnecessarily protract the hearing or become uncomfortable for parties, the recipient may adopt a rule that prevents parties and advisors from challenging the relevance determination (after receiving the decision-makers explanation) during the hearing. The decision-maker is under an obligation to exclude such questions and evidence, and to only evaluate relevant evidence in reaching a determination. Requiring the decision-maker to explain relevance decisions during the hearing only reinforces the decision-makers responsibility to accurately determine relevance, including the irrelevance of information barred under the rape shield language. Providing a reason for the decision reveals whether the decision-maker is maintaining a neutral, objective position throughout the hearing. The explanation for the decision may reveal any bias for a particular complainant or respondent or a bias for or against complainants or respondents generally. In order to preserve the benefits of live, back-and-forth questioning and follow-up questioning unique to cross-examination, the Department declines to impose a requirement that questions be submitted for screening prior to the hearing (or during the hearing); the final regulations revise this 1160 provision to clarify that cross-examination must occur directly, orally, and in real time during the live hearing, balanced by the express provision that questions asked of parties and witnesses must be relevant, and before a party or witness answers a cross-examination question the decision-maker must determine relevance (and explain a determination of irrelevance). This provision does not require a decision-maker to give a lengthy or complicated explanation; it is sufficient, for example, for a decision-maker to explain that a question is irrelevant because the question calls for prior sexual behavior information without meeting one of the two exceptions, or because the question asks about a detail that is not probative of any material fact concerning the allegations.

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