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By: Daniel James George, MD

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  • Professor in Surgery
  • Member of the Duke Cancer Institute

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Correspondingly to rheumatoid arthritis panel buy cheap naproxen 500 mg online the A-17 report arthritis in fingers during pregnancy purchase 500 mg naproxen, this report continued to arthritis diet inflammation purchase discount naproxen on-line show 33 that there are differences between region bylaws in all categories compared symptoms of arthritis in fingers videos order naproxen 500 mg visa. Previous Table of Contents Next Table 2: Requirements for Quorum by Region One-third of all active chapters within Region 1 provided that at least three states Region 1 are represented. At least fifty percent of all sections within Region 2 provided that at least four Region 2 states are represented. One-third of all chapters within the Region 3 provided that at least three states are Region 3 represented One-third of all active chapters within Region 4 shall constitute a quorum, Region 4 provided that at least three states are represented A quorum shall constitute 1/2 of all active chapters within Region 5 provided that if Region 5 at least 3 states are represented. One-third of all chapters within Region 6 shall constitute a quorum provided that at Region 6 least three states are represented. One-third of Region 7 active chapters, provided that at least three states are Region 7 represented Table 3: Voting Allocation by Region Region 1 Each Campus gets two votes Region 2 One vote shall be given to each medical school and separate campus Region 3 Each medical school ( to gether with its satellite campuses) gets one vote Region 4 Each Campus gets 1 vote Each school and/or satellite 1 vote for every 100 students enrolled. Region 6 Each Medical School represented at the Region 6 meeting shall have one vote. Proportional allocation of votes to the states based on their representation at each Region 7 Regional Meeting (1 vote for every three chapters that send a delegate to the Regional Meeting) Previous Table of Contents Next Table 4: Parliamentary Procedures by Region Region 1 Standard Code of Parliamentary Procedure Region 2 Standard Code of Parliamentary Procedure Region 3 Standard Code of Parliamentary Procedure Region 4 Standard Code of Parliamentary Procedure Region 5 Davis’ Rules of Order then Standard Code if not covered in Davis’ Region 6 Standard Code of Parliamentary Procedure Region 7 Standard Code of Parliamentary Procedure Previous Table of Contents Next Table 5a. Policy Coordination Initiatives by Region Region 1 Policy chair facilitates region resolution authorship Region 2 Advocacy Chair and Annual Resolution Committee Legislative Chair, Legislative Vice Chair, and a Resolution Review Committee Region 3 made up of legislative chairs from each section Region 4 Resolution and Advocacy Chair Region 5 Legislative Chair, Regional External Affairs Committee, Resolution Committee Region 6 Legislative Committee Chair and unspecified Legislative Committee Region 7 Advocacy Chair Table 5b. Region Resolution Authorship Requirements by Region Region 1 Receive at least two-thirds vote of support. Region 2 members will submit resolutions to the Resolution Committee, who will Region 2 review and vote on region authorship. Region 3 the vote in favor must have two thirds of the vote to constitute a majority A minimum of 10 chapters must vote, and the vote in favor must reach a simple Region 4 majority. Second, the political and 30 public relations aspect of supporting the removal of psychedelics from schedule one would be 31 significant and difficult to overcome. This again would take significant financial and political Previous Table of Contents Next 1 capital. The first legislative limitation of psychedelic use occurred through 9 amendments to the Federal Food, Drug, and Cosmetic Act in 1965. In this amendment, 10 psychedelic drugs were grouped with known drugs of abuse with the adoption of the following 11 language:15 12 13 “The definition of a depressant or stimulant drug, however, includes the following 14 significant language: any drug which contains any quantity which the Secretary [of the 15 Department of Health, Education, and Welfare], after investigation, has found to have, 16 and by regulation designates as having, a potential for abuse because of its depressant 17 or stimulant effect on the central nervous system or its hallucinogenic effect. Congress established Schedule I for drugs with (1) high potential for abuse, (2) 22 no accepted medical use in treatment in the United States, and (3) a lack of accepted safety for 23 use under medical supervision. Circuit Court 27 precedent stating that a substance or drug with “no currently accepted medical use” should not 28 au to matically be placed in to Schedule I. It is 46 argued that scheduling criteria that cannot be consistently followed and that is open to 47 interpretation is fundamentally flawed, making the scheduling of substances by a political law 48 enforcement agency at odds with those that want to study substances for their medical or 49 scientific benefit. According to McAllister8, it was 4 thought, even at that time, that only opiates and coca-based drugs were deemed addictive, 5 while central nervous system stimulants and depressants, hallucinogens, and other classes of 6 drugs acted differently upon the body and therefore could not be addictive. It is argued that pro-control advocates used these schedules 8 as a form of geopolitical and financial control, not a way to regulater psychotropics according to 9 careful scientific evaluation. The original 13 publicized intent was to rationalize and liberalize American drug policies, and to support 14 flexibility and innovation in managing substances. From the so-called “crack epidemic” and “war on drugs,” there 16 have been amendments and changes to the Controlled Substances Act that have turned it in to 17 “the chief prop of federal law enforcement and means of underclass criminal incapacitation. One prospective longitudinal study of more than 900 “marginalized 22 women”, who are disproportionately at risk for suicide, showed that subjects who used 23 psychedelic drugs were at no significant hazard for suicidal ideation or attempt while subjects 24 naive to psychedelic drugs were at nearly five times greater risk of suicide ideation or attempt. These drugs were used 31 frequently in the treatment of mood disorders prior to their prohibition in the 1960s in the United 32 States. This review identified a recent study done in the United Kingdom showing that 33 psilocybin shows promise in the treatment of resistant depressive disorder. The review asserts 34 that psychedelics should be re-examined in modern trials, especially for unipolar mood 35 disorders. One study looking at 47 the use of psychedelics for drug-assisted psychotherapy for mental illness stated that the 48 current scheduling of psychedelics (at schedule I) has impeded research negatively. However, these authors also concluded that the studies done thus far have not Previous Table of Contents Next 1 had enough subjects or long enough duration to firmly conclude the benefits of these 2 substances. The authors also reiterated and stressed the need for new and more thorough 3 studies and trials. Observed symp to ms included increased blood pressure, heart rate, body 17 temperature, pupil size, cortisol, prolactin, oxy to cin, and epinephrine. The large amount of evidence showing the potential of 23 psychedelics as powerful therapeutics contradict the placement of this drug group in Schedule 24 1, since the traditional justification of this placement is the criteria of “no present medical use. In terms of medical use, research has not yet 30 demonstrated the cause and effect of any single chemical in large trials, which appears to be a 31 result of limited supply and funding due to the Schedule 1 label. Eventually, each chemical will 32 likely need its own individual characterization as preliminary studies show that they exhibit 33 different physiological effects. However, all 37 articles state the need for longer term research or greater numbers for their research. As the system 47 currently stands, we are caught in an impasse even though investiga to rs have published 48 evidence to suggest that psychedelics are substances with (1) low potential for abuse, (2) 49 measurable medical use in treatment in the United States, and (3) proven safety while used in 50 clinical trials under medical supervision. Although these studies have been publicly available, Previous Table of Contents Next 1 regula to rs continue to designate psychedelics in a manner that impedes their further study and 2 potential use as therapeutics. The current opinion in the realm of policy is that psychedelics have not met the 6 minimum scientific threshold to be reclassified and that current procedures to register 7 researchers and institutions and allow them to conduct research on Schedule 1 drugs in a 8 heavily supervised manner is sufficient to gather evidence on the potential therapeutic use of 9 psychedelics. This is a powerful clause that is needed to begin to dissociate the cultural, 36 religious, political, and personal biases from the clinical world of science. It 39 was agreed that introducing “benefits and adverse effects” to the the clause would neutralize the 40 currently negative language. The moderating effect of psychedelics on the prospective relationship between prescription opioid use and suicide risk among marginalized women. Efficacy, to lerability, and safety of sero to nergic psychedelics for the management of mood, anxiety, and substance-use disorders: a systematic review of systematic reviews. Ayahuasca and Public Health: Health Status, Psychosocial Well-Being, Lifestyle, and Coping Strategies in a Large Sample of Ritual Ayahuasca Users. Smoking during pregnancy can result in premature delivery, low birth weight, 5 restricted fetal growth, birth defects, and sudden infant death syndrome. Cigarette smoke is a 6 known tera to gen resulting in higher incidences of spontaneous abortion, premature ablatio 7 placentae, reduced weight at birth, and congenital deformities (cheilognathopala to schisis, 8 deformed extremities, polycystic kidneys, aor to pulmonary septum defects, gastroschisis, skull 9 deformation, etc. In addition, smoking during pregnancy increases an infant’s risk of 10 developing ear infections, respira to ry infections, and asthma. The woman herself is at higher risk for stroke, coronary 13 artery disease, lung and bladder cancer due to her increased exposure to smoke. For instance, 33 West Virginia has the highest prevalence of smoking during pregnancy at 25. In California, the introduction of the ban on smoking in cars 42 with children resulted in a 12% annual decline of students reporting exposure to smoke in cars. Additionally, those students who reported being exposed to smoking in cars were Previous Table of Contents Next 1 more likely to have asthma and more likely to consider smoking in the future. Existing smoke-free policies in a wide variety of settings have resulted in 14 significant reductions in adverse early-life health outcomes. States that have implemented legislation prohibiting 17 smoking in vehicles with children have seen significant reductions in children’s exposure to 18 smoke in this environment. The pregnant 25 woman may choose not to disclose such information and it is not always possible to determine if 26 a woman is pregnant just by her gross appearance). Vital Signs: Disparities in Nonsmokers’ Exposure to Secondhand Smoke – United States 1999-2012. Impact of Smoking Ban on Passive Smoke Exposure in Pregnant Non-Smokers in the Southeastern United States. Association between clean indoor air laws and voluntary smokefree rules in homes and cars. Secondhand smoke exposure during pregnancy: a cross-sectional analysis of data from Demographic and Health Survey from 30 low-income and middle-income countries. Of Does Resolution Expertise Timeline Available Departments Require Financial Requirement Involved Resourcesfi The final report and its recommendations will serve as the basis for extraction, discussion, and voting at the onsite Assembly Meeting. Resolutions will not be considered “received” until all required tasks indicated in the Draft Submission Checklist and Final Submission Checklist have been completed. Upload using the A-19 Resolution Draft Submission Form Use the Draft Submission Checklist as a guide April 7th (Sun) Preliminary scoring and comments on draft resolutions released to authors Final resolutions due – must be uploaded using the A-19 Resolution Final April 21st (Sun) Submission Form.

The emphasis is on the client’s care fast arthritis relief genuine health generic naproxen 250mg line, but therapy is aimed at the environment in which the client lives and the interactions of the family arthritis in pinky fingers naproxen 500mg with mastercard. Focus of the session was on interventions for the client’s aggressive outbursts to what causes arthritis in feet effective naproxen 250mg wards siblings when client returns from visits with biological parents arthritis diet weil order cheap naproxen on-line. These aggressive behaviors have increased over the past month, parents seem to trigger client. Helped grandparents create an anger intervention plan to practice with client at home. Rehabilitation service activities includes assistance in res to ring, improving, and/or preserving a client’s functional, social, communication, or daily living skills to enhance self-sufficiency or self-regulation in multiple life domains relevant to the developmental age and needs of the client. Individual Rehabilitation may include: fi Daily living skills, social and leisure skills, grooming and personal hygiene skills, meal preparation skills, and/or medication compliance (within scope of practice). Contra Costa County Documentation Manual v 2017 32 fi Education around medication, such as understanding benefits of medication (within scope of practice). He has made some improvements since last visit and was able to document his nighttime routine for the last 2 weeks. However, he reports that he still has a hard time falling asleep and only gets about 2-3 hours of sleep a night. Writer modeled relaxation techniques of deep breathing that client can practice after turning off the lights and lying in bed. Therapeutic interventions can include the application of strategies incorporating the principles of development, wellness, adjustment to impairment, and recovery and resiliency. Therapy should assist a client in acquiring greater personal, interpersonal and community functioning or to modify feelings, thought processes, conditions, attitudes or behaviors. These interventions and techniques are specifically implemented in the context of a professional clinical relationship. Only Licensed/Registered/Waivered Staff and trainees who have the training and experience necessary to provide therapy, can bill for this procedure code (Scope of Practice Appendix D). Sample Individual Therapy Note Focus of Activity: Today during sand tray therapy Carla stated she can’t visit her dad anymore. Carla showed this writer that the “mom” doll was in trouble and hid her in the sand. Encouraged and reinforced her to come up with words that helped her “talk” out her anger. Carla agreed to talk to her mom about missing her dad and would try not to hit her brother. Sample Individual Therapy Note Focus of Activity: Client came in stating that she continues to have nightmares of her husband being murdered in their home. Clinician encouraged client to continue to connect with her church for emotional support. Discussed having her children pray with her at night and to sleep with soothing music. Client agreed to work on finding more ways to socialize with her friends and leave the house to visit with her family during the day. One or more clinicians may provide these services and the to tal time for intervention and documentation may be claimed. Up to two clinicians may be claimed and a varying amount of time may be claimed for each clinician. Group Therapy (351): Is a service provided to 2 or more clients with primary focus of symp to m reduction as a means to improve social functioning and reduce interpersonal conflicts. Only Licensed/Registered/Waivered Staff and trainees who have the training and experience necessary to provide therapy, can bill for this procedure code. Group Rehab (355): Is a service provided to 2 or more clients with directed at improving, res to ring, or maintaining functional skills. Group Collateral (357): Is a service provided to 2 or more significant support persons of multiple clients in a group setting. Focus of group is on the mental health needs of the client and not the mental health needs of the significant support persons. Group Notes Should Document: fi the purpose/focus of the group clearly stated on each note (can be same for all group participants). Formula for Billing Total Service Time: Example 1: Billing for group of 5 clients, group was 1 hour long, and documentation time to ok 10 minutes for each note. Staff A will bill: Number of clients (5) x documentation time (10) + 60 minutes (service time) = 1 hour 50 minutes Staff B is co-staffed: 60 minutes, co-staff does not bill for documentation time Example 2: Billing for group of 6 clients, group was 1 hour long, and documentation time to ok 10 minutes for each note. Staff A will bill on 3 notes: • Total number of clients in group: 6 • Number of clients (3) x documentation time (10) + 60 minutes (service time) = 1 hour 30 minutes • Co-Staff B for 60 minutes on these 3 notes. Staff B will bill on 3 notes: • Total number of clients in group: 6 Contra Costa County Documentation Manual v 2017 34 • Number of clients (3) x documentation time (10) + 60 minutes (service time) = 1 hour 30 minutes • Co-staff A for 60 minutes on these 3 notes. You do not need to divide by the number of clients as the billing system will take care of prorating the time. Sample Group Rehab Note Focus of Activity: Group Focus: Managing Anger, the focus of this group session is identifying anger triggers and how to identify signs and symp to ms of anger. Staff provided role modeling of deep breathing exercises and taking a personal “time out”. Client was able to identify that he tends to angry at other people when they to uch him. Client practiced deep breathing and agreed to practice next time he starts to grind his teeth in anger. This service type may include: providing detailed information about how medications work; different types of medications available and why they are used; anticipated outcomes of taking a medication; the importance of continuing to take a medication even if the symp to ms improve or disappear (as determined clinically appropriate); how the use of the medication may improve the effectiveness of other services a client is receiving. Medication Support Services supports beneficiaries in taking an active role in making choices about their behavioral health care and helps them make specific, deliberate, and informed decisions about their treatment options. Note: Medication support services may only be provided within their scope of practice by a Physician, a Registered Nurse, a Licensed Vocational Nurse, a Psychiatric Technician, a Physician Assistant, a Nurse Practitioner, and a Pharmacist. Prescribing, administering, and dispensing medication, lab work, vitals, observation for clinical effectiveness, side effects and compliance to medication. The service activities may include, but are not limited to, communication, coordination, and referral; moni to ring service delivery to ensure client access to service; moni to ring of the client’s progress once he/she receives access to services; and development of the plan for accessing services. When Case Management Brokerage services will be provided to support a client to reach program goals, it must be listed as an intervention on the client treatment plan. Types of Service Activities: fi Linkage and Advocacy (561) Identification and pursuit of resources including: fi Interagency and intra-agency consultation and communication fi Moni to ring service delivery to ensure a client’s access to service and the service delivery system. Consultation is a conversation between one professional and another professional utilizing another professional’s expertise in order to focus on the needs of the client. This dialogue between service professionals must focus on the client’s treatment plan. This is a billable service since it facilitates a relationship between all service providers who are currently providing care for a client. Case management plan development is similar to Plan Development but, Contra Costa County Documentation Manual v 2017 36 has an emphasis on linking, coordinating, or placement. Plan Focus Justify •Be sure to document •Document the •Include the any referrals to assistance/intervention justification and/or outside provided to the client need for the service services/agencies •Example: accessing based on the mental •Include the next housing, job search, health steps needed to medical services, symp to ms/issues assist the client, referrals what is the planfi Examples of Crisis Intervention include services to clients experiencing acute psychological distress, acute suicidal ideation, or inability to care for themselves (including provision/utilization of food, clothing and shelter) due to a mental disorder. Service activities may include, but are not limited to Assessment, collateral and therapy to address the immediate crisis. Crisis Intervention activities are usually face- to -face or by telephone with the client and/or significant support person(s) may be provided in the office or in the community. Note: Crisis Intervention progress notes may not always link to the client’s treatment plan. Non-Reimbursable procedures and certain service locations block the service from being claimed. Unclaimable services may include a wide variety of services which may be useful and beneficial to the client, but are not reimbursable as a Specialty Mental Health service. Even though these are not claimable, these services should be documented by all staff working with clients.

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A number of pharmacological agents arthritis medication vioxx buy naproxen 500 mg overnight delivery, such as antidepres­ sants arthritis earth clinic purchase genuine naproxen on line, antipsychotics end stage arthritis in dogs discount naproxen 500mg otc, alpha sympathetic drugs arthritis pain relief as seen on tv generic naproxen 500 mg mastercard, and opioid drugs, can cause ejacula to ry problems. It is important in the his to ry to ascertain whether the com­ plaint concerns delayed ejaculation or the sensation of orgasm, or both. Ejaculation occurs in the genitals, whereas the experience of orgasm is believed to be primarily subjective. For example, a man with a normal ejacula to ry pattern may complain of decreased pleasure. Such a complaint would not be coded as delayed ejaculation but could be coded as other specified sexual dysfunction or unspecified sexual dysfunction. Comorbidity There is some evidence to suggest that delayed ejaculation may be more common in severe forms of major depressive disorder. At least one of the three following symp to ms must be experienced on almost all or all (approximately 75%-100%) occasions of sexual activity (in identified situational con­ texts or, if generalized, in all contexts): 1. Marked difficulty in maintaining an erection until the completion of sexual activity. The sexual dysfunction is not better explained by a nonsexual mental disorder or as a consequence of severe relationship distress or other significant stressors and is not at­ tributable to the effects of a substance/medication or another medical condition. Specify whether: Lifelong: the disturbance has been present since the individual became sexually ac­ tive. Situationai: Only occurs with certain types of stimulation, situations, or partners. Diagnostic Features the essential feature of erectile disorder is the repeated failure to obtain or maintain erec­ tions during partnered sexual activities (Criterion A). A careful sexual his to ry is necessary to ascertain that the problem has been present for a significant duration of time. Symp to ms may occur only in specific situations involving certain types of stimulation or partners, or they may occur in a generalized manner in all types of situa­ tions, stimulation, or partners. Associated Features Supporting Diagnosis Many men with erectile disorder may have low self-esteem, low self-confidence, and a de­ creased sense of masculinity, and may experience depressed affect. In addition to the subtypes "lifelong/acquired" and "generalized/situational," the fol­ lowing five fac to rs must be considered during assessment and diagnosis of erectile disorder given that they may be relevant to etiology and/or treatment: 1) partner fac to rs. Each of these fac to rs may con­ tribute differentiy to the presenting symp to ms of different men with this disorder. Prevalence the prevalence of lifelong versus acquired erectile disorder is unknown. There is a strong age-related increase in both prevalence and incidence of problems with erection, particu­ larly after age 50 years. Approximately 13%-21% of men ages 40-80 years complain of oc­ casional problems with erections. Approximately 2% of men younger than age 40-50 years complain of frequent problems with erections, whereas 40%-50% of men older than 60-70 years may have significant problems with erections. About 20% of men fear erectile prob­ lems on their first sexual experience, whereas approximately 8% experienced erectile prob­ lems that hindered penetration during their first sexual experience. Deveiopment and Course Erectile failure on first sexual attempt has been found to be related to having sex with a previously unknown partner, concomitant use of drugs or alcohol, not wanting to have sex, and peer pressure. There is minimal evi-2t most of these problems spontaneously re­ mit without professional intervention, but some men may continue to have episodic prob­ lems. In contrast, acquired erectile disorder is often associated with biological fac to rs such as diabetes and cardiovascular disease. Clinical observation sup­ ports the association of lifelong erectile disorder with psychological fac to rs that are self limiting or responsive to psychological interventions, whereas, as noted above, acquired erectile disorder is more likely to be related to biological fac to rs and to be persistent. A minority of men diagnosed as having moderate erectile failure may experience spontaneous remission of symp to ms without medical intervention. Distress associated with erectile disorder is lower in older men as compared with younger men. Neurotic personality traits may be associated with erectile problems in col­ lege students, and submissive personality traits may be associated with erectile problems in men age 40 years and older. Erectile problems are common in men diagnosed with depression and posttraumatic stress disorder. Risk fac to rs for acquired erectile disorder include age, smoking to ­ bacco, lack of physical exercise, diabetes, and decreased desire. Culture-Reiated Diagnostic issues Complaints of erectile disorder have been found to vary across countries. It is unclear to what extent these differences represent differences in cultural expectations as opposed to genuine differences in the frequency of erectile failure. Diagnostic iViarlcers Nocturnal penile tumescence testing and measured erectile turgidity during sleep can be employed to help differentiate organic from psychogenic erectile problems on the as­ sumption that adequate erections during rapid eye movement sleep indicate a psycholog­ ical etiology to the problem. Doppler ultrasonography and intra vascular injection of vasoactive drugs, as well as invasive diagnostic procedures such as dynamic infusion cavernosography, can be used to assess vascular integrity. Pudendal nerve conduction studies, including soma to sensory evoked potentials, can be employed when a peripheral neuropathy is suspected. In men also complaining of decreased sexual desire, serum bioavailable or free tes to sterone is frequently assessed to determine if the difficulty is secondary to endocrinological fac to rs. Determination of fasting serum glucose is useful to screen for the presence of diabetes mel­ litus. The assessment of serum lipids is important, as erectile disorder in men 40 years and older is predictive of the future risk of coronary artery disease. Functionai Consequences of Erectiie Disorder Erectile disorder can interfere with fertility and produce both individual and interpersonal distress. Fear and/or avoidance of sexual encounters may interfere with the ability to de­ velop intimate relationships. Major depressive disorder and erectile disorder are closely associated, and erectile disorder accompanying severe depressive disorder may occur. The differential should include consideration of normal erec­ tile function in men with excessive expectations. Another major differential diagnosis is whether the erectile problem is secondary to substance/medication use. An onset that coincides with the be­ ginning of substance/medication use and that dissipates with discontinuation of the sub­ stance/medication or dose reduction is suggestive of a substance/medication-induced sexual dysfunction. The most difficult aspect of the differential diagnosis of erec­ tile disorder is ruling out erectile problems that are fully explained by medical fac to rs. The distinction between erectile disorder as a mental disorder and erectile dysfunction as the result of another medical con­ dition is usually unclear, and many cases will have complex, interactive biological and psy­ chiatric etiologies. If the individual is older than 40-50 years and/or has concomitant medical problems, the differential diagnosis should include medical etiologies, especially vascular disease. The presence of an organic disease known to cause erectile problems does not confirm a causal relationship. For example, a man with diabetes mellitus can develop erectile disorder in response to psychological stress. In general, erectile dysfunction due to organic fac to rs is generalized and gradual in onset. An exception would be erectile problems after traumatic injury to the nervous innervation of the genital organs. Erectile problems that are situational and inconsistent and that have an acute onset after a stressful life event are most often due to psychological events. An age of less than 40 years is also suggestive of a psychological etiology to the difficulty. Erectile disorder may coexist with premature (early) ejacu­ lation and male hypoactive sexual desire disorder. Comorbidity Erectile disorder can be comorbid with other sexual diagnoses, such as premature (early) ejaculation and male hypoactive sexual desire disorder, as well as with anxiety and de­ pressive disorders. Erectile disorder is common in men with lower urinary tract symp to ms related to prostatic hypertrophy. Erectile disorder may be comorbid with dyslipidemia, car­ diovascular disease, hypogonadism, multiple sclerosis, diabetes mellitus, and other diseases that interfere with the vascular, neurological, or endocrine function necessary for normal erectile function. Presence of either of the following symp to ms and experienced on almost all or all (ap­ proximately 75%-100%) occasions of sexual activity (in identified situational contexts or, if generalized, in all contexts): 1. The sexual dysfunction is not better explained by a nonsexual mental disorder or as a consequence of severe relationship distress. Diagnostic Features Female orgasmic disorder is characterized by difficulty experiencing orgasm and/or markedly reduced intensity of orgasmic sensations (Criterion A). Women show wide vari­ ability in the type or intensity of stimulation that elicits orgasm.

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The financial terms of these contracts are subject to what does arthritis in the knee look like order 250 mg naproxen fast delivery negotiations rheumatoid arthritis knee surgery purchase discount naproxen on line, which vary from contract to arthritis quotes purchase cheap naproxen on-line contract and may result in payment flows that do not match the periods over which materials or services are provided to alkaline diet arthritis relief order genuine naproxen line the Company under such contracts. The Company accrues the costs incurred under agreements with these third parties based on actual work completed in accordance with the respective agreements. In the event the Company makes advance payments, the payments are recorded as a prepaid asset and recognized as the services are performed. The Company determines the estimated costs through discussions with internal personnel and external service providers as to the progress or stage of completion of the services and the agreed-upon fees to be paid for such services. The Company makes significant judgments and estimates in determining the accrual balance in each reporting period. Although the Company does not expect its estimates to be materially different from amounts actually incurred, the Company understands the status and timing of services performed relative to the actual status and timing of services performed may vary and could result in the Company reporting amounts that are to o high or to o low in any particular period. To date, there have been no material differences from the Company’s accrued estimated expenses to the actual clinical trial expenses. However, variations in the assumptions used to estimate accruals including, but not limited to the number of patients enrolled, the rate of patient enrollment, and the actual services performed may vary from the Company’s estimates, resulting in adjustments to, clinical trial expense in future periods. Changes in these estimates that result in material changes to the Company’s accruals could materially affect its financial condition and results of operations. Prepaid expenses and other current assets includes prepaid research and development costs of $95,000 and $12,000 as of December 31, 2018 and 2017, respectively. S to ck-Based Compensation S to ck options granted to employees and non-employees under the Company’s s to ck option plan are accounted for by using a fair value based method. S to ck-based payments to employees, including grants of employee s to ck options, are measured based on their fair values at the date of grant, net of forfeitures, and are recorded on a straight-line basis over the requisite employee service period. The fair value of s to ck-based payments to non-employees is estimated at each reporting period, net of forfeitures, until a measurement date is reached, and recorded over the service period on a straight-line basis. Net Loss per Common Share Basic and diluted net loss per common share is computed by dividing net loss attributable to common s to ckholders by the weighted average number of common shares outstanding. Diluted earnings per share gives effect to all dilutive potential common shares outstanding during the period, including s to ck options and warrants, using the treasury s to ck method, and redeemable convertible preferred s to ck, using the if-converted method. Potentially dilutive common share equivalents are excluded from the diluted earnings per share computation in net loss periods, since their effect would be anti-dilutive. F-14 the following table sets forth the potential common shares excluded from the calculation of net loss per common share, because their inclusion would be anti dilutive: 2018 2017 Redeemable convertible preferred s to ck (as converted in to common s to ck) 3,639,905 3,639,905 Options to purchase common s to ck 1,090,045 826,225 Warrants to purchase common s to ck 160,365 160,365 Warrants to purchase redeemable convertible preferred s to ck (as converted in to common s to ck) 26,087 26,087 4,916,402 4,652,582 Income Taxes the Company accounts for income taxes under the liability method, whereby deferred tax assets and liabilities are provided for the future tax consequences attributable to temporary differences between the financial statement carrying amounts of existing assets and liabilities and their respective tax bases. Deferred tax assets and liabilities are measured using enacted rates expected to apply to taxable income in the years in which those temporary differences are expected to be recovered or settled. Deferred tax assets, net of a valuation allowance, are recorded when management believes it is more likely than not that the tax benefits will be realized. Realization of the deferred tax assets is dependent upon generating sufficient taxable income in the future. The amount of deferred tax asset considered realizable could change in the near term if estimates of future taxable income are modified. The Company assesses its tax positions and determines whether it has any material unrecognized liabilities for uncertain tax positions expected to be taken in a tax return for open tax years (generally a period of three years from the later of each return’s due date or the date filed) that remain subject to examination by the Company’s major tax jurisdictions. Generally, the Company is no longer subject to income tax examinations by major taxing authorities for years before 2014. The Company assesses its tax positions and determines whether it has any material unrecognized liabilities for uncertain tax positions. The Company records these liabilities to the extent it deems them more likely than not to be incurred. Interest and penalties related to uncertain tax positions, if any, would be classified as a component of income tax expense. The Company believes that it does not have any significant uncertain tax positions requiring recognition or measurement in the accompanying financial statements. Segment Data the Company manages its operations as a single segment for the purposes of assessing performance and making operating decisions. The Company’s singular focus is identifying, developing and commercializing innovative and differentiated therapeutics for the treatment of skin diseases. No revenue from sales of product has been generated since inception, and all tangible assets are held in the United States. The Company adopted this standard as of January 1, 2018 in connection with its adoption of Topic 606. As part of its adoption efforts, the Company completed the assessment of its collaboration and license agreements under Topic 606. The Company adopted Topic 606 in the first quarter of 2018 using the modified retrospective method which consists of applying and recognizing the cumulative effect of Topic 606 at the date of initial application and providing certain additional disclosures as defined per Topic 606. On January 1, 2018, the Company recorded a cumulative adjustment to decrease deferred revenue, deferred sublicensing costs and accumulated deficit by approximately $2. F-15 Below is a summary of the affected line items on the balance sheets upon adoption of Topic 606 (in thousands): Balance at Adjustments Due Balance at Balance Sheet December 31, 2017 to Topic 606 January 1, 2018 Deferred sublicensing costs, current portion $ (342) $ 342 $ — Deferred sublicensing costs, net of current portion (342) 342 — Deferred revenue, current 1,709 (1,709) — Deferred revenue, net of current portion 1,709 (1,709) — Accumulated deficit $ (59,936) $ 2,734 $ (57,202) As a result of adopting Topic 606 on January 1, 2018 under the modified retrospective method, the Company did not revise the comparative financial statements for the prior years as if Topic 606 had been effective for those periods. The Company adopted this standard as of January 1, 2018, and there was no material impact to the Company’s financial statements as a result of the adoption. As of December 31, 2018, the Company had aggregate future minimum lease payments of approximately $0. If and when development is complete, the associated assets would be deemed finite-lived and would then be amortized based on their respective estimated useful lives. Any changes in the fair value of contingent consideration are recorded as general and administrative expense. As of December 31, 2018, the Company also had research and development tax credit carryforwards for federal income tax reporting purposes available of $3. Based on provisions of the Tax Act, the Company remeasured its deferred tax assets and liabilities to reflect the lower statu to ry tax rate. However, since the Company established a valuation allowance to offset its deferred tax assets, there is no impact to its effective tax rate, as any changes to deferred taxes would be offset by the valuation allowance. The Company has evaluated the positive and negative evidence bearing upon its ability to realize the deferred tax assets. Management has considered the Company’s his to ry of cumulative net losses incurred since inception and its lack of commercialization of any products or generation of any revenue from product sales since inception and has concluded that it is more likely than not that the Company will not realize the benefits of the deferred tax assets. Accordingly, a full valuation allowance has been established against the deferred tax assets as of December 31, 2018 and 2017. Management reevaluates the positive and negative evidence at each reporting period. The interest rate applicable to each tranche is variable based upon the greater of either (i) 9. Payments under the Loan Agreement were interest only until June 1, 2017, followed by equal monthly payments of principal and interest through the scheduled maturity date on September 1, 2019. The Company also has agreed not to pledge or otherwise encumber its intellectual property assets, except that the Company may grant non exclusive licenses of intellectual property entered in to in the ordinary course of business, and licenses approved by the Company’s Board of Direc to rs that may be exclusive in respects other than terri to ry and may be exclusive as to terri to ry as to discrete geographical areas outside of the United States. The Company has paid the Lender a facility fee of $150,000 in connection with the Loan Agreement. In addition, if the Company repays all or a portion of the loan prior to maturity, it will pay the Lender a prepayment penalty fee, based on a percentage of the then outstanding principal balance, equal to 3% if the prepayment occurs prior to February 19, 2017, 2% if the prepayment occurs prior to February 19, 2018, or 1% if the prepayment occurs thereafter. The Loan Agreement was further amended in March 2018 to provide for an additional two-month interest only period ending on June 1, 2018, at which time the outstanding loan balance would continue to be paid in equal monthly installments of principal and interest. Pursuant to the Loan Agreement, a facility fee of $25,000 was paid upon execution and the end of term payment was increased by $25,000. The Loan Agreement includes cus to mary affirmative and restrictive covenants, and also includes cus to mary events of default, including payment defaults, breaches of covenants following any applicable cure period, a material impairment in the perfection or priority of the Lender’s security interest or in the value of the collateral, and a material impairment of the prospect of repayment of the loans. Under the Loan Agreement, the Company grants the Lender the right to participate in and/or designate one or more of its affiliates to participate in any subsequent financing in an amount up to $1. Note payable at December 31, 2018 consisted of the following (in thousands): Face value of note payable $ 7,500 Accrued interest 46 Discounts on note payable related to warrants (329) Note payable issuance costs (1,061) 6,156 Principal payments through December 31, 2018 (2,692) Accumulated accretion 1,175 Note payable $ 4,639 F-19 the following is a schedule of aggregate note payable maturities, excluding the unamortized amount related to the end of term payment, for each of the years subsequent to December 31, 2018 (in thousands): Year Ending December 31, 2019 $ 4,808 $ 4,808 In connection with the Loan Agreement, the Company issued warrants to the Lender, which are exercisable for 26,087 shares of Series C redeemable convertible preferred s to ck at a per share exercise price of $11. The fair value of the warrants was recorded as a redeemable convertible preferred s to ck warrant liability upon issuance. As of December 31, 2018, there were unaccreted debt discounts and issuance costs of $0. Typically, the license agreements are effective through the later of (i) the end of the term of the last- to -expire of licensor’s patent rights licensed under the license agreements, or (ii) ten years after the first sale of the first licensed product if no patent has issued from the patent rights.

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