Wide-ranging discovery ordered
2011 case note - CIR unsuccessful in opposing application for discovery on basis that tax secrecy, public interest immunity or administrative difficulty would arise.
The Commissioner was unsuccessful in opposing an application for discovery where he maintained that tax secrecy, public interest immunity or administrative difficulty would arise if the orders were granted. The Court held that these were matters for the Court, not the Commissioner, to decide.
Impact of decision
This decision may have implications for the discovery of information exchanged under the double tax agreements. From a practical perspective, the extent of possible discovery as a consequence of this decision is very broad.
On 6 September 2010, the Commissioner sought and obtained a freezing order without notice over a property owned by Giovanni Holdings Ltd ("Giovanni"). The freezing order was obtained on the basis that a Mr Petroulias and another were/are the beneficial owners of the property.
Giovanni filed an application in October 2010 seeking an order discharging or varying the freezing order. In the course of case management of that application, the Commissioner objected to representation of Giovanni by Ms Hancock (the director of Giovanni). The High Court (in a decision dated 22 December 2010) decided in favour of Giovanni and allowed Ms Hancock to represent the company.
Giovanni also filed an application seeking an order that general discovery be made by the Commissioner. The Commissioner opposed the application. This hearing was to consider the discovery issue.
Giovanni sought an order for general discovery of:
- all transcripts of recorded phone calls held between Mr Petroulias and others and provided to the Commissioner by the Australian Tax Office ("ATO")
- all electronic databases containing relevant information, including the "Z:drive" which was seized in the Commissioner's access operations in 2006
- all probative communication between the Commissioner and the ATO
- all other probative documents, correspondence and records of interviews with any party.
McKenzie J firstly granted the leave sought by Mr Petroulias to be heard in the discovery proceedings (the application had only been filed by Giovanni) as it was necessary in the interests of justice.
With regard to the general discovery sought, McKenzie J noted that the Commissioner's actions were being challenged (an application to strike out the proceedings had been filed on the basis of abuse of process) and acknowledged that while these were better addressed in the substantive proceedings, it was relevant in considering the extent of appropriate discovery.
McKenzie J agreed that, as a matter of general principle, the Peruvian Guano test was not appropriate in cases where, as a matter of policy, they should be dealt with swiftly (such as freezing orders). His Honour acknowledged that discovery was not usually appropriate in freezing order applications as they are usually dealt with on an urgent basis and confirmed that the onus is usually on the applicant for the freezing order to show it has a good arguable case and to disclose all material facts and possible defences. However, McKenzie J considered that this case was different as the application for discharge of the freezing order would require an inquiry wider than whether the Commissioner had an arguable case regarding beneficial ownership of the relevant property. Further, any delay in the proceedings (despite the urgency of a freezing order application) did not weigh against discovery, particularly when the Commissioner's position is protected by the freezing order.
The Commissioner had argued that all relevant material had been produced pursuant to section 81(1) of the Tax Administration Act 1994. McKenzie J rejected that submission stating that not all discoverable documents will usually be produced in evidence and should be verified by a discovery affidavit. McKenzie J confirmed the position in Knight v CIR and BNZ Investments Ltd v CIR that the conduct of litigation (and specifically discovery) is a purpose of carrying into effect the Inland Revenue Acts for the purposes of section 81.
However, his Honour recognised that production of discovered documents can be withheld where a claim of privilege is available. In that regard, McKenzie J referred to the Commissioners submission that the documents were subject to public interest immunity and confirmed the principle in BNZ Investments  2 NZLR 709 that section 81 addresses the reconciliation of the principles of taxpayer discovery and the interests of justice. While the respondents submitted that no public interest immunity issues arise as discussed in CIR v ER Squibb (1992) 14 NZTC 9146, McKenzie J stated it need not be addressed at this point in the proceedings (noting that the ultimate decision on a claim of public interest immunity is for the Court to decide, not the Commissioner and if necessary the Court will inspect the documents to determine the question).
With regard to the first category of documents, his Honour disagreed that the respondents had failed to establish relevance and held that the Commissioner's reliance on some of this material provided a sufficient basis for discovery of all transcripts.
As for the second category, McKenzie J noted that the "Z:drive" had been subject to previous litigation (Venning J had decided that the Commissioner was not required to make available a cloned copy of the hard drive). However, McKenzie J stated that the question before his Honour was different to that before Venning J and held that discovery should be required of relevant documents contained on that hard drive.
McKenzie J rejected the Commissioner's submission that discovery would be unduly burdensome due to the volume of information on the hard drive. His Honour stated that there are two ways to avoid such a burden: the Commissioner can either make a copy of the "Z:drive" available to the respondents or carry out keyword searching to locate relevant documents. McKenzie J considered it was inappropriate for the Court to fix a list of words and stated that it will be for the Commissioner to decide the relevant search terms (noting that the Commissioner will need to set out the basis for the relevance testing in an affidavit to ensure adequacy of the search can be examined should it be challenged).
His Honour rejected the Commissioner's submission that as the documents in the third category were the subject of incomplete investigations in both New Zealand and Australia, the disclosure would prejudice the maintenance of the law. McKenzie J held that section 81 was also relevant to this category of evidence and again stated that any decision on public interest immunity was for the Court not the Commissioner.
As for the fourth category, being all other relevant documents, correspondence and records of interviews, McKenzie J also ordered that these should be discovered.
In summary, the Commissioner was ordered to produce a discovery affidavit listing all relevant information from all four categories (which are or have been in the Commissioner's control) within 20 working days.
Companies Act 1993, High Court Rules


text:
What's driving the Industrial Floor Coatings Market trends? Sherwin-Williams, The Lubrizol Corporation, PPG Industries, Axalta, AkzoNobel, BASF, Sika, RPM International Inc., Michelman
Global industry share is moderately fragmented with the presence of both multinational and regional players. Akzo Nobel, Dow Chemical, Sika AG, Kansai Paints and PPG Industries are among the major industry players. Other notable participants include BASF, Asian Paints, DSM and Sherwin-Williams. Mergers & acquisitions, product portfolio expansion and supply agreements are key strategies adopted major industry players to gain market share.
Request for a sample copy of this report @ https://www.gminsights.com/request-sample/detail/1193
Impact of food processing sector on industrial floor coatings market size
Industrial floor coatings market is expected to witness strong application potential in the food and beverage processing industry. While working in the food processing industry, it is quite important to keep all the areas clean – especially the floor. Certain food constituents such as blood, sugar, acids, oils, fats, etc. often fall onto the floors, which are highly susceptible to infections and contaminations. In response to this fact, it is highly important to maintain the sanitary standards of the floors, which has provided a major thrust to the demand of industrial floor coatings market from this application. As per estimates, in 2017, industrial floor coatings market size from food processing was valued at USD 1.5 billion and is further expected to grow at an appreciable pace over 2018-2024.
Many of the food processing industries rely on the epoxy type of coatings, which are highly durable and withstand strong chemical resistance & thermal shocks. Contributing to over 50% of the overall industrial floor coatings market, epoxy is estimated to be register a y-o-y growth of 6% over 2018-2024.
- Industrial Floor Coatings Market, by Flooring Material
- Industrial Floor Coatings Market, by Application
• Food processing
• Aviation & transportation
Browse Report Summery @ https://www.gminsights.com/industry-analysis/industrial-floor-coating-market
Industrial floor coatings market demand from warehouse applications
Many industries and manufacturing plants witness repeated spills or a high likelihood of oils, grease, or liquids on the floor. In addition to this, floors of warehouses and manufacturing units also need to withstand wear and tear, created by heavy machinery, high impacts, and excessive heat. Subject to this fact, industrial floor coatings market is gaining huge demand from this application, on account of thriving profoundly on the cusp of rapid industrialization and urbanization. The prominent economies of Asia Pacific including China, Malaysia, India, Vietnam, and Japan promise great potential for the growth of industrial floor coatings industry, owing to rapid infrastructural development. As per estimates, APAC industrial floor coatings market is expected to record a CAGR of 8% over 2018-2024.
The concrete flooring material is witnessing noticeable demand from the manufacturing and warehouses applications. Owing to its superior properties of wear & tear, prevention from abrasion, scratch resistance, and ease of maintenance with excellent aesthetics, industrial floor coatings marker share from concrete materials stood at USD 3 billion in 2017 and is likely to grow at CAGR of 7.5% over 2018-2024.
Make an inquiry for purchasing this report @ https://www.gminsights.com/inquiry-before-buying/1193
Demand for bio-based industrial floor coatings to drive the future market trends
The global industrial floor coatings market is witnessing a paradigm shift toward environment-friendly floor coatings. Rising concerns over the fluctuating crude oil prices and the growing dependency on fossil fuel have stimulated the paints & coating industry to strive for sustainability. Growing consumer awareness regarding the impact of synthetic resins on the environment has created huge scope for the industry players to focus on the development of bio-based coatings. Bio based floor coatings are derived from natural sources such as soybean oil, succinic acid, sunflower oil, rapeseed oil, and castor oil.
Industrial floor coatings market size is certainly liable to surge over the coming years with a projected CAGR of 7.2% over 2018-2024. Some of the other renowned names in industrial floor coatings industry include Dow Chemical, Sherwin-Williams, Akzo Nobel, BASF, Asian Paints, PPG Industries, Tambour, 3M, Kansai Paint Co., Ltd, and Milliken & Company.
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domain: chemistry


Kim’s streaming pick for this week is The Christmas Chronicles showing exclusively on Netflix. Siblings Kate and Teddy Pierce hatch a scheme to capture Santa Claus on Christmas Eve. When the plan goes awry, the kids join forces with a somewhat jolly Saint Nick and his loyal elves to save the holiday before it’s too late.
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text:
John Eldredge sums his whole message in his Identity of the Heart devotional.
Tag Archives: Heart
Pray to the Lord
Trusting the Lord
With hearts and minds
Doing own best
I will deliver thee
Thou shalt not be given into
The hand of men
Whom thou art afraid
I will surely deliver thee
Thou shalt not fall by the sword
Thy life shall be a prey unto thee
Because thou hast put thy trust in Me
Saith the Lord
Inspiration On: Thursday, 25 December 2015
Jeremiah 39 helps me to understand about God. The Lord spoke to the Israelites through the prophet Jeremiah. Second and third stanza comes from verse 17 to 18. These two verses speak to me the importance to trust in the Lord during my tumultuous times. Likewise, the Lord continually deliver those who put their trust in Him. This really comforts my heart to continually trust in Him. Proverbs 3 also explain the importance of trusting the Lord in whatever we do.
Thanks for reading my poetry and hope this poetry minister and bless you.
Heart in the Creator
Heart for the God
Heart at Jesus’ heart
Heart on the the Lord’s mercy and loving kindness
Heart bows to the Lordship of Jesus
Respect and love for the Lord is the crust of
Pure heart of worship
Full loyalty to Jesus Christ
~ Tojiru Yoshiko
Inspiration On: Sunday, 1 November 2015 at 10:20am
Inspiration Ends On: Wednesday, 11 November 2015
Most of the time, people love to pass their own judgements without understanding someone. The feeling of bring misunderstood is extremely painful. Thus produce such quote. It is a quote seeking to be understood. All the time I spend time to understand others yet many choose to pass their own judgements onto me. If I’m not depressed, then I’m not human. However, I thank the Lord to understand my sense to be understood. God bless you all for reading my poetry to minister.
In the stillness
My grieving heart
Grieved to the point of
Loss of hope in a
Loss of hope in a
With the Lord
Inspiration On: Friday, 31 July 2015 at 3pm
The feeling to write with my left hand returns. Yesterday’s memory ingrains an ache in my heart and mind. A newfound friend spoke harshly to me due to me being lack of experience. A long time friend was scared to confess so he passes it to me. The feeling of being caught in between is getting more unbearable until I cried to the Lord on my bed. At home and outside, I am caught in between. It’s so painful. Thus I spoke to that friend that his words and actions hurt me. As I was crying to the Lord, I find peace in Him. May this poetry comforts those who are caught in between. May you know that you are not alone. Thanks for reading my poetry and hope this poetry minister and bless you.
Inspiration On: Tuesday, 18 March 2014 at 6:11pm
Inspiration Ends On: Monday, 21 April 2014 at 4:15am
This poetry is birthed out of joy upon the rise of design poetry is out in the web. Upon waiting for Yori and mine poetry to be published, I feel lost in words and encountered creative block due to house and job search. Thanks for reading my poetry and hope this poetry minister and bless you.
Inspiration On: Friday, 18 April 2014 at 4:30am
Countries, races, families and individuals imminently have war against each other. The rise of self importance increases with every breakthrough but forgetting those who are in dire need of help. These elements are the mark of the birth of this poetry. God bless you all for reading my poetry to minister.
Inspiration On: Wednesday, 9 April 2014 at 2:49am to 3am
Yori refers me to Pat Cegan’s Friendly Fire poetry at http://patcegan.wordpress.com/2014/04/08/friendly-fire. We have a good laugh. Glad that we live nearby. Pat’s poetry inspires me the above poetry. Thanks for reading my poetry and hope this poetry minister and bless you.

domain: artistic


text:
A Your vases are examples of hand-painted Nippon porcelain, and the cherry blossom mark on the underside dates them from 1890 to 1921. Nippon denotes the country of origin rather than the manufacturer, and is the name the Japanese people called their country. Nippon-marked porcelain, in many different styles and techniques, was manufactured for export from 1891 to 1921 and is a sought-after collectible today. Your cobalt-glazed vases are relatively unadorned, with no extra features such as fancy feet or handles. This pair, in very good condition, might be priced at $500 to $700 in a nice antique store in Oregon. An auction price would be $200 to $350 for the pair.
A There are three important factors with document boxes ... condition, condition and condition. Original, undisturbed grain painting, original period hardware and regional attribution also factor into the collector's wish list. The vinegar stripe grain painting, dovetail construction, iron hasp latch and what looks like poplar as the wood of choice all date the box from around 1825-35. The wire snipe hinge helps us know that it originated in the New England region of the United States. The ring pull on the top of your box is not original to the piece. In good condition, a similar box would sell in a nice antique store in Oregon for $1,000 to $1,500 and at auction for $500 to $1,000. Because your box has condition issues and a lot of missing original pigment, it would be priced at $300 to $400 in an Oregon antique store, and from $100 to $200 at auction.
A Your Danish fall-front secretary dates from around 1830-1845. The style is called Empire, or Archaeological Classicism, so named for its massive, architectural form. The flame-figured mahogany veneer is all hand hewn and 1/16th of an inch thick, compared with modern veneers that are machine cut and less than 1/32nd of an inch thick. The piece is heavy, solid and not about to tiptoe away lightly. These secretaries are lovely, but they don't store much and they do take up a lot of space, so their appeal is rather limited today. You would see this piece for sale in a nice Oregon antique shop for $8,500 to $10,000 and at auction for $900 to $1,600.
H.L., Southwest Portland
A Windsor chairs originated in England in the 1700s. The style began to be made in America in the 1740s, and this particular form, a "Windsor writing arm chair," was sought after by doctors, clergy and "men of state." It is rumored that Thomas Jefferson wrote the Declaration of Independence at such a chair. It was even made for right- and left-handed patrons. Your chair appears to have been manufactured close to 1800 as it has the tablet-back splat, which is closer to a later Federal-style design element. These chairs were often made of different types of woods and then unified with a coat of paint. If your chair is period (first-hand inspection would tell), you would expect it to retail for $5,000 to $8,000, and much more if the original artisan could be documented. At auction you would hope to get $1,000 to $3,000.
A The Adachi Institute is a company in business today. It makes faithful reproductions of many known artists and great masters in the tradition of hand-carved woodblock prints. Its prints often sell at auction and on eBay for $25 to $35. Collectors really want the original woodblock prints rather than later reproductions.
J.S., North Portland
A Marcia of California made your lamp in the mid-20th century. Called a TV lamp, it was a premium given away with the purchase of a television. TV lamps came in many different colors and treatments and are fairly common in the marketplace. They often retail for $75 to $95, and sell at auction for $35 to $45.
The values of items featured in the collectibles column are estimated by Portland appraiser Terra Goodman, who is accredited in appraisal practice, theory and law as well as product knowledge, ethics and proper appraisal procedures. She is certified in fine and decorative arts through Sotheby's Auction House, where she studied American and European furniture and decorative arts. Goodman is the only Sotheby's, New York-trained appraiser in the Portland area.
To find a professional appraiser, contact the Certified Appraisers Guild of America, the International Society of Appraisers, the American Society of Appraisers or the American Association of Appraisers. Estimates provided for items reviewed in the collectibles column are for "fair market value" only and should not be used for appraisals for insurance or IRS purposes.
If you have a rare, very old and/or unusual item of furniture or home decor you would like considered for inclusion in the column, send a high-quality photo along with measurements and information about the age and condition to:
Collectibles/Homes & Gardens
1320 S.W. Broadway
Portland, OR 97201
The Oregonian will retain usage rights of the photographs for its print, marketing and online media.

domain: hobby


text:
Highbury author Jonny Hollis releases debut novel, A Rational Man, set in a near-future Islington
- Credit: Archant
A Highbury author has written a thriller based in a near-future Islington where people have no right to privacy
Ten years ago, Jonny Hollis was making a short film about Velvet Underground’s song The Gift when he had an idea: How would society function if people had no right to privacy, and everything that people said and did was thrust into the public eye?
At a time when people were first starting to share a great deal of their personal information on social networks, this idea was to be the starting point for Hollis’ debut book – A Rational Man – which is available to buy from Friday September 28.
“The book is set in Islington in the near future, thinking about a world where nothing is private and everything can be seen, heard and recorded,” he says.
“It’s like a democratised 1984, where information is available to all, as everyone can watch everything through the omnipresent ‘W’.
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In A Rational Man, the high-profile politician Cecil Stanhope has killed his wife in an act totally out of his character. As a result of the all-seeing, all-hearing nature of this future society, Stanhope’s son Sebastian is left to piece his life back together under the watchful – and judgemental – public eye.
Hollis continues: “The book is about Sebastian worrying about how he is reacting. He becomes a personality and a well-known figure, but at the same time he is trying to deal with this traumatic event with no support.
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- 3 Kacem Mokrane: Islington man amongst seven charged with 2017 murder
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- 5 Mem and Laz Brasserie voted as readers' favourite restaurant
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“A Rational Man is an interplay between Sebastian’s true feelings and what people expect to see from him.”
Hollis, who lives in Highbury, has based his story very close to home. Sebastian grows up above the current site of Pentonville Prison, in an Islington which has become a place of windowless buildings where petrol stations are revered as beautiful relics of the past.
“I had quite a strong incentive to base it here, as the book has links to the idea of a panopticon, whereby prison inmates can be seen at all times, but they are never sure exactly when they are being watched. It was argued that this would be the perfect way to control a criminal community.
“Pentonville Prison itself was influenced by a panopticon, and (I based the story here) because of this link to the history of the area.”
In focusing on topics like the influence of social media on our well-being, data misuse and the enormous scrutiny placed on politicians’ actions, Hollis’ first novel weaves together plenty of contentious issues.
“There’s a fake news aspect to it. It’s about the abundance of information available to us – we can know everything about things that can be seen and heard, but we can’t get into people’s heads.
A Rational Man by JS Hollis is available via ebook and paperback from Friday September 28.

domain: literature


text:
How much will people appreciate a song by the late Aaliyah in 2015? Well the song is more of a duet, as “Baby Girl” contributes a verse and a hook. Check it out.
[soundcloud url=”https://api.soundcloud.com/tracks/239041034″ params=”auto_play=false&hide_related=false&show_comments=true&show_user=true&show_reposts=false&visual=true” width=”100%” height=’450′ iframe=”true” /]
While you are at it, check out the new mixtape from Timbaland. The VA producer is coming out with a new album in 2016.


text:
Meet Xavier, an adorable gray tabby six month-old kitten available for adoption at the Happy Tails Animal Care Center! Xavier is a sweet kitten who can’t wait to find his very own loving, forever home … are you in the market for a purrfect little heartbreaker? If you’re interested in Xavier and want to learn more, please call (574) 278-7102 and/or email at email@example.com and you can also fill out the adoption application on the center’s website.
Xavier is …
– a sweet little tabby kitten who’s ready for his forever home!
– good with children and other cats.
– up-to-date on his vaccinations.
*All cats brought to the Happy Tails Animal Care Center are strays, so there is not usually much information on each animal’s background and whether or not the animal is litter-box trained.*

domain: pet


text:
Three DFL candidates will square off in a special primary election today for the state Senate seat vacated by Sen. Ellen Anderson.
The candidates in the Senate District 66 primary are Steven Marchese, a legal director with the Minnesota State Bar Association; former state Rep. Mary Jo McGuire; and five-term state Rep. John Lesch.
The DFL primary winner will compete against Republican candidate Greg Copeland, the former Maplewood city manager, in the April 12 special election.
All the candidates are from St. Paul except McGuire, who lives in Falcon Heights.
Polls will open at 7 a.m. today and close at 8 p.m. For a list of polling locations, go to rcelections.org.
Anderson was appointed by Gov. Mark Dayton to the state Public Utilities Commission on March 9.
— Sarah Horner

domain: politics


text:
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Abdominal Pain In Pregnancy A number of women experience sporadic spells of lower abdominal pain during pregnancy. Cramping At 16 Weeks Pregnant.
Back pain is pain felt in the back. Episodes of back pain may be acute, sub-acute, or chronic depending on the duration. The pain may be characterized as a.
LOW BACK PAIN IN FIRST TRIMESTER: Hi , For the first time i conceived. When experiencing back pain during pregnancy, you can alleviate.
Lower back pain, cramps, abdominal pain, and spotting are all normally signs of a period beginning. If you are pregnant and do not know, you can easily.
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Pain or numbness due to sciatica can vary widely. It may feel like a mild tingling, dull ache, or a burning sensation. In some cases, the pain is severe.
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OUR CARE. During your first visit at Back In Action Chiropractic, Dr. McLaughlin will explain the science behind chiropractic care. A full evaluation will.
Then why does lower back pain occur in the beginning of pregnancy? Various pain in the back and abdomen.
Jul 27, 2017. Feeling discomfort due to back pain during pregnancy? Backache starts early in your pregnancy & persists until delivery. Learn what you can.
You're more likely to experience back pain during your pregnancy if you're overweight or if it's not.
Morning sickness can be one of the first signs of pregnancy and is often experienced as nausea and vomiting. Learn about how to cope with morning sickness.
There are a number of causes of bleeding in early pregnancy which include: Spotting or. What are the causes of abdominal and back pain? Some of the aches.
What causes back pain in pregnancy? How can I prevent back pain? Your questions answered. – BabyCentre UK
Lower Back Pain 3 Weeks Hip Join Pain Sleep On Back Without Pillow and if you have tight hip flexors and suffer from hip pain that you can experience hip.
Feb 26, 2008. 61.8% of women who reported low back pain during pregnancy. as early as 16 weeks with some claiming pain within the first month .
Knowing what signs to look for to detect a miscarriage at its beginning may help prevent the. Lower back pain: Back pain during pregnancy is almost universal.
Get information about back pain, lower back pain, neck pain, and sciatica, and learn about back pain causes, treatments, and medications.
I have pain in lower back on left side, left hip pain, left pelvic pain and pain down the left leg at times. It comes and goes. Gets real bad,(when I put.
Oct 7, 2016. Low back pain during pregnancy is caused by lumbar pain and pelvic girdle pain. Know the Causes, Symptoms, Treatment and Prevention of.
Is My Back Pain Pms Or Pregnancy PMS or Pregnancy? This article tells. Back pain. PMS back pain is often radiated from pelvic or abdominal pain. Lower back pain. Darkening of areolae. Not. Advil® Menstrual Pain Relieves Your Menstrual Cramps. Period. Shop Online Today! Apr 26, 2017. Typically, PMS symptoms happen 1 to 2 weeks before your period. The pain often improves
Acute low back pain is commonly encountered in primary care practice but the specific cause often cannot be identified. This ailment has a benign course in.
Kmom’s Story. I have had tremendous pubic symphysis pain since early in my first pregnancy, as well as lots of back pain too. After that pregnancy, my.
Back Pain. The back is the workhorse of the human body. This remarkably strong structure literally carries the burden of the entire body, and is.
Got pregnancy back pain?. While other first trimester moms are being complimented on their healthy glow, I spend the first trimester of my pregnancy looking.
Apr 5, 2016. If you have severe back pain during pregnancy or back pain that lasts more than two weeks, talk to your health care provider. He or she might.
Learn what causes lower back pain during pregnancy and what you can do to ease or prevent backache during pregnancy.
Learn the causes of abdominal pain during pregnancy and find out whether your symptoms are normal or require immediate attention from your doctor.
Read more on pregnancy bleeding, spotting and pregnancy stomach cramps. Very common by the third trimester, backache can also affect your first three.
More Back Pain Cause Articles …
- Are Back Pains Normal In Pregnancy: The type and severity of your back pain should be noted. If it's the normal back pain that tends to accompany pregnancy, then you probably should hold off on.
Back pain is pain felt in the back. Episodes of back pain may be acute, sub-acute, or …
- Sitting On Wallet Cause Back Pain: Are you still carrying around a thick, bulky trifold or bifold? It’s time to trade in the George Costanza wallet for something slimmer.
It is caused by people sitting on their wallets full of credit cards and these in turn. with buttock and upper pos…
- Kidney Problems And Back Pain Symptoms: Morphine Patches For Back Pain Side Effects Consumer information about the medication RIFAMPIN – ORAL (Rifadin, Rimactane), includes side effects, drug interactions, recommended dosages, and storage. The most common side-effects are constipatio…
- Low Back Pain Causes And Treatment: There are many causes of low back pain. It sometimes occurs after a specific movement such as lifting or bending. Just getting older also plays a role in.
Feb 4, 2017. Low back pain is ominous when it is caused by a spinal cord trauma, or a progressi…
- 21 Weeks Pregnant Bad Back Pain: Treatment and Management of Back Pain vs Kidney Pain. If back pain is not chronic, it can be managed by a hot pack and a massage; on the other hand, kidney.
What to expect when you’re 36 weeks pregnant? Your baby is entering the engaged position and …
- Back Pain After Mrsa: [embedyt]//www.youtube.com/embed/HoNW3TnAT3Y[/embedyt]
16.09.2012 · Re: MRSA and muscle aches Reply #4 by Uxmal Posted: August 1, 2010 at 02:01 Hey Guys, Honestly, Getting the energy back, that depends on Your daily.
Nov 26, 2013. Met…

domain: medical


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Are you interested in tapping into marijuana’s positive effects but hate smoking? Don’t be discouraged: you can still experience the joys of marijuana by creating this delicious cannabis drink. It’s the perfect way to relax at the end of an arduous day and tap into the many benefits of marijuana.
- 4 Cups of Milk
- 1/2 Teaspoon of Rosewater
- 1/4 Ounce of Marijuana
- 3/4 Cup of Sugar
- 2 Tablespoons Almonds
- Spices (to Your Taste)
While two cups of water are boiling on a teapot, carefully remove the stems and seeds from your marijuana. Once the water boils, add the cannabis and let it seep for about seven minutes.
Carefully strain your water and pot using cheese cloth. Remove the bud and squeeze it tightly to draw out even more water. This water will be heavily infused with cannabis.
Now, put the bud in a mortar grinder and add your milk. Grind them together for several minutes and strain your pot through a new and clean cheese cloth. Save the milk that drains off the bud.
Continue to soak and strain your marijuana in milk until you get about a 1/2 cup of cannabis-infused milk. Now, place almonds, milk, and the by now thoroughly soaked bud back into the mortar and grind until you’ve created a very fin paste.
Get out some new cheese cloth (hope you have a lot!) and squeeze the paste to remove the liquid mix. Continue to squeeze the bud with new cheese cloth until its completely dry and no more milk strains.
Throw out your bud and mix the milk, water, rosewater, sugar, and a teaspoon of your favorite spices. Ginger and pumpkin make a particularly tasty cannabis drink.
Mix to fully blend the ingredients and place in the refrigerator for several hours before drinking. Take a few sips of this drink every day before bed or when life gets a little too stressful and feel the stress just fade away.
Want to keep cooking? Other people enjoyed our:

domain: food


Hip-hop On-Air Personality, Raezy Winston announced the release date of his upcoming single, OG. The song features industry heavyweights and veterans such as Vector, DelB, Big Tril, and Larry Gaaga. It will be available on streaming platforms on April 22nd.
The OAP released a Rap Kulture Cypher last year. It featured Payper Corleone, Eve Banks, M.A.K, Hotyce, Lifesize Teddy, and Alpha Ojini. This single could mean the beginning of a hip-hop music career for the OAP.


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In collaboration with the General HQ of the Dubai Police, Roads and Transport Authority (RTA) in Dubai has decided to raise the speed limit of the entire Umm Suqeim Road (from Al Sufouh Road to the Sheikh Mohamed bin Zayed Road).
This modification covers a sector of Al Qudra Road (from Sheikh Mohamed bin Zayed Road up to Emirates Road). The new speed limit became 90 km/h instead of the current speed limit of 80 km/h.
The speed limit of the remaining part of Al Qudra Road (from Emirates Road up to Seih Assalam Roundabout) will be raised to 100 km/h instead of the existing speed limit of 90 km/h. The decision as a whole shall take effect from February 6, 2016.

domain: news


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It’s Official: Introducing Kingdom Cabanas at Magic Kingdom Park
Located in Tomorrowland®, the new exclusive Kingdom Cabanas provide a unique opportunity to gather, connect, rest and refuel from an exciting time in the Park. Each one of these private and comfortable cabanas includes in-Park Wi-Fi, charging stations, locked storage to stow souvenirs, as well as light snacks and beverages throughout the day – all for one price.
Call 407-WDW-PLAY (939-7529) for pricing and availability to reserve one of Disney’s Kingdom Cabanas today.
The number of cabanas is extremely limited. Maximum of 8 Guests per cabana. Rental period spans from Park open until Park close. Valid Theme Park admission required. Disney not responsible or liable for any loss or damage to personal belongings.
Latest posts by Jennifer (see all)
- Great Wolf Lodge Partners with Alex’s Lemonade Stand Foundation This Spring to Raise Funds to Fight Pediatric Cancer - February 19, 2018
- 5 tropical resorts with insane perks. - February 2, 2018
- Infographic: Fun Facts about Universal’s Volcano Bay - February 1, 2018
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5 Steps to Book your Disney World Vacation9

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CMU announces vaccine incentive program for students
Vaccinated students could win scholarships worth a year of tuition, gift cards
In an effort to increase the number of students receiving COVID-19 vaccines, Central Michigan University today launched a vaccine incentive program with prizes including four scholarships equivalent to a full year of tuition and hundreds of gift cards.
Beginning today, students who have completed a full vaccine protocol — one dose of the Johnson & Johnson vaccine or two doses of the Pfizer or Moderna vaccine — may register online to enter the incentive program. And, while they can enter only once, students are eligible for every drawing held after they register.
"The earlier a student registers, they more chances they have to win prizes," said Jennifer DeHaemers, CMU's vice president for student recruitment and retention.
CMU will choose 101 winners during each of four scheduled drawings. Winners will be announced Aug. 2 and 23, Sept. 13, and Oct. 4. In each drawing, 100 students will receive a $75 gift card, and one student will win a full-tuition scholarship. All participants will also receive a 20% discount at the CMU Bookstore, DeHaemers said.
The scholarship will be equivalent to the value of 15 domestic credit hours for undergraduate students or up to nine domestic credit hours for graduate students, per semester, for the Fall 2021 and Spring 2022 semesters. International students and College of Medicine students also may enter, and both main campus and Global Campus students are eligible to receive prizes.
Winners will be notified through their cmich.edu email.
Nationwide, only about 34% of college-aged individuals have been vaccinated. Last month, CMU President Bob Davies announced that CMU has joined the COVID-19 College Vaccine Challenge, a national effort to increase vaccination rates among young people.
DeHaemers said CMU's vaccine incentive program aligns with the university's commitment to the challenge and will ensure everyone can enjoy a robust and engaging fall semester.
"To protect our campus and community from the spread of COVID-19 and its variants, we want to strongly encourage students to receive the vaccine before classes begin this fall," she said.
Students wishing to receive their COVID-19 vaccine can make an appointment through CMU Health by calling (989) 774-6599. Students outside the Mount Pleasant area may visit Vaccine Finder or Michigan's COVID-19 vaccine page to find a vaccination site near their home.
Information about the vaccine incentive program, including full rules and entry form, is available for students on the program webpage.


JOHANNESBURG - Limpopo Health MEC Phophi Ramathuba has named interprovincial travel as a contributor to the increasing number of COVID-19 cases in the province.
The province has seen an increase in confirmed COVID-19 cases since the start of the second wave.
READ: COVID-19 cases skyrocket
"We did anticipate that the interprovincial movement, as a result of the festive season. Limpopo is one of the tourism destination areas that most of our people would like to visit during this time of the year. Secondly, we know most of our people in our province, are during the course of the year, in provinces like Gauteng, the Western Cape, KwaZulu Natal, for economic opportunities. So this is the time for them to come back home to spend time with their loved ones," Dr Ramathuba said.
She said festive celebrations have hampered social distancing measures.
It recorded 679 COVID-19 cases in the last 24 hours.
- Coronavirus Hotline Number: 0800 029 999 from 8am to 4pm, Monday to Friday
Help protect your loved ones by sharing this official South African government COVID-19 service with your family, friends and community.
Send HI to 0600 123 456 on WhatsApp.
The NICD has another Clinician Hotline to improve #COVID19 communication and support for healthcare providers. The Clinician Hotline is 0800 11 1131, operating 24 hrs. The Public Hotline is 0800 029 999 also operating 24hrs.
Since the 16th of March when we register our first case, we have never recorded a 24hr new cases of 676. We are feeling interprovincial movements ,social gatherings & “Makarapa “effects. Vhembe use to be the lowest district. It has now join Waterberg and Capricorn. pic.twitter.com/k3nNEbqNDG— Dr Phophi Ramathuba (@PhophiRamathuba) December 26, 2020


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(Bauhaus students -www.bauhaus.de)
Design File: Bauhaus
Writing about anything in 700 words is quite an ask as it usually means leaving out so much information. Writing about the Bauhaus, well, where do I start? Did I mention there wasn’t an architecture component at first, despite the professed aims of unifying all the creative disciplines with newer ones such as engineering? Couldn’t they find the staff? And the endless machinations as it struggled to find its role in Weimar Germany could fill a book, and probably do.
When I write about the Bauhaus, I find myself musing about Le Corbusier and his rather cool take on German architecture. He had worked for a very short time in the office of Peter Behrens in 1910 as a draughtsman (where those Bauhaus starchitects Walter Gropius and Ludwig Mies van der Rohe also worked). It wasn’t a happy time for him as he found Behren’s high-handed attitude rather off-putting (although it seemed to provide the perfect model for his later dealings with his own staff).
Behrens is most famous for his work with the fledgling AEG electric company. The turbine hall in Berlin built in 1909 pops up in every history of modern architecture thanks to its 15 metre glass windows and visible supporting structure. It is a Classical building in many respects, a modern Parthenon dedicated to industry. Interestingly it appears to still be in use as a turbine manufacturing hall, which says something for its suitability for purpose. (How many other buildings of that time are still being used for the same purpose? I can’t help thinking of Fiat’s site at Lingotto, now a thriving design centre but surely so much better when cars raced around its roof.)
How interesting those times were, when people were actually beginning to take note of industrial buildings. They seem the perfect symbol for the rising Modern movement. Behrens designed the whole look of AEG including its logo, just as companies do today. Domestic architecture was taking cues from industrial buildings. Plain metal fittings were used in homes. Le Corbusier liked simple wall lights that might well have been designed for trains and trams. His favourite chair was a cheap old Thonet number 19 (cheap no longer, it must be said).
(A door handle in Le Corbusier’s Maison La Roche, 1925)
But when I read about the Bauhaus, I can’t help falling into that trap of history – nothing less than a romance – of thinking that everyone was on the same page, going for the common goal, unified in their desire to create a new streamlined future that would be clean and functional. It was never that simple. But there was a common aim to make things work better, from factories to homes, and everything within them. Beauty comes from things that function well, even if they don’t at first sight appear to be beautiful. There’s beauty in a switch that turns well, that feels good to the fingers and which makes the item work. The beauty of rooms filled with sunlight at the right time of day. The beauty of honest materials, from wood to concrete. I remember visiting a flat in London that had been done in the height of French Empire taste – panelled and gilded and mirrored to within an inch of its life. Sumptuous silks woven with bees shimmered at the windows. It was an extraordinary place. You half expected Napoleon to waddle out. But it felt so fake and that made me feel uncomfortable. Not simply the discombobulation of a home in the twentieth century mimicking the style of another era – I can live with that. But it was the fact that not even the paint on the flattest parts of the panelled walls was free from artifice – sponged, dragged, and marbled to add further richness, as if any were needed.
I love structure and form. Gilding the lily is fine at times but after a while it becomes simply tedious. Which is why I love the Bauhaus and why perhaps its influence will continue to resonate.


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Office Depot® Brand 3-Ring Pencil Pouch, 10" x 6", Blue
1 / 1
Keeping writing tools easily accessible helps ensure that you have one within reach right when you need it. This pencil pouch has a prepunched design that fits easily into most binders, so it's always within reach.
Made of silicone with prepunched holes to fit into most 3-ring binders.
Zipper closure helps ensure the contents stay safely in place.

domain: design


Congressman Mike Ross Visits MonticelloOctober 26th, 2010 by Joe Burgess
Congressman Ross was very complimentary of the efforts made by the MEDC, AEDC, the City of Monticello, and the Governor’s Fast Action Closing Fund, for making the transfer of a manufacturing machine to the Monticello facility, which has now created 15 job openings.
Congressman Ross also attended a fundraising event at the home of Drs. Tim and Sylvia Simon.
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Newer article: ARE-ON “Lights” New Era


The Centers for Medicare & Medicaid Services (CMS) has released a CMCS Informational Bulletin with the updated 2023 Federal Poverty Level (FPL) Standards. The U.S. Department of Health and Human Services (HHS) updates the poverty guidelines at least annually and by law these updates are applied to eligibility criteria for programs such as Medicaid and the Children’s Health Insurance Program (CHIP). The 2023 guidelines reflect the 8.0 percent price increase between calendar years 2021 and 2022. After this inflation adjustment, the guidelines are rounded and adjusted to standardize the differences between family and household sizes. For a family or household of 4 persons living in one of the 48 contiguous states or the District of Columbia, the poverty guideline for 2023 is $30,000. Included with this informational bulletin is the 2023 Dual Eligible Standards chart that displays the new standards for the Medicare Savings Program categories. The new guidelines have been published in the Federal Register here.


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OHIO POODLE BEST AT OLD GREENWICH; Jocelyene Marjorie Takes Honors in Specialty
Special to The New York Times ();
June 08, 1968,
, Section , Page 35, Column , words
OLD GREENWICH, Conn., June 7 -- Ch. Jocelyene Marjorie, a 4-year-old blue standard poodle owned by Freeman C. Dickey and Joan E. Schilke of Brunswick, Ohio, won best-of-breed honors at the 36th Poodle Club of America specialty show and obedience trial at the Greenwich Community Center grounds today.

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Southampton manager Ralph Hasenhuttl maintains it will take more than just one win to keep the club in the Premier League.
The Saints hosts relegation-battlers Brighton on Sunday, when victory would move them on to 36 points.
It would be a tally which has proven enough to secure survival in each of the past four campaigns.
Hasenhuttl, though, feels there is plenty of fight left in the teams battling for their survival to relax just yet.
“I don’t think that 36 (points) are enough this season to be honest because Fulham has a good run now and are showing up,” Hasenhuttl said.
“But we are not focusing on 36 (points), we are focusing on getting as much points as possible, and on the weekend we have a chance of getting a few more.”
Southampton face Bournemouth in the FA Cup quarter-finals before the international break and then have fixtures against teams around them in the table.
Hasenhuttl feels it is an opportunity which his squad have to tackle head on.
“Like the past few weeks, they are very vital,” he said.
“We have hard points to take, it is always difficult in the Premier League, but we have some interesting games coming up in the league and FA Cup.
“I am really looking forward to it, and over the international break we can get some training to help us massively on things in our game which have not been working.”
Leading scorer Danny Ings remains sidelined as he recovers from a leg injury, but is expected to be back after the international break.
Midfielder Moussa Djenepo was taken off at half-time of the 5-2 defeat at Manchester City on Wednesday night because of a groin problem.
Hasenhuttl hopes the Mali international will be available for Sunday’s game.
“It doesn’t look that bad so hopefully he can start training by the end of the week. So he could be an alternative for the weekend but we don’t know it yet,” the Saints boss said.
“Sometimes it feels worse than it is in the end, but when you scan him he immediately shows a lot of blood in muscles when he has odd injuries, so we have to pay attention to how tough the injury definitely is.
“This is not so easy for our physios to see clearly because sometimes he reacts better than they think.
“When he takes the test it looks better than it should be normally, so it is always tough to decide whether he is available or not.”
Mohammed Salisu filled in at left-back against City, while Kyle Walker-Peters was an unused substitute following his return from an injury lay-off.
Yan Valery and Jake Vokins have been allowed out on loan, with Hasenhuttl admitting it is an area of the squad which will be addressed during the summer.
“Really, I would like to have two on the left and two on the right next season,” the Saints boss said.
“We have seen this season that we have always problems. We need to double up in every position.
“In general, it is always good if you can have a player who is more flexible and can play in multiple positions, but on the left you should have a left-footed player who can run the line, go deep and deliver balls.
“That is not so easy to find, but this is something that we should definitely look for this summer.”


One of the world's rarest cars headlines a hall packed with precious metal.
Peter Ker Australian miners with operations in Indonesia still scrambling to understand full impact of the Asian nation's new ban on exports of some raw minerals.
Peter Ker Australian miners with operations in Indonesia are still scrambling to understand the full impact of the Asian nation's new ban on exports of some raw minerals.
Sally Rose Shares finished lower on Wednesday, pulled down by falls in the big miners and after a stronger than expected inflation reading led to uncertainty about the direction of interest rates.
Peter Ker Goldminer reveals big cost reductions across its international portfolio.
Adele Ferguson Violent and untimely death of two workers at the Stena Clyde drill rig almost 18 months ago is a chilling reminder of the human face behind company safety performance statistics.
Peter Ker The gold price may no longer captive to the direction of quantitative easing in the US.
Sally Rose Stocks rallied as company earnings looked to be improving for the first time in three years.
Eli Greenblat A three-year corporate soap opera featuring dumped CEOs just got worse for Billabong.
Amanda Saunders Gold giant Newcrest Mining looks set to finish the fiscal year cash-flow positive, despite a slight rise in costs for the March quarter on the back of weaker-than-expected production.
Sally Rose Market falls as investors grapple with the implications of Sunday's referendum in Crimea.
Sally Rose A sell-off in US tech stocks and slower growth in China offset the positives of an improving economy.
Sally Rose The market rallied on confirmation from the RBA that interest rates are set to remain steady.
Peter Ker Growing a $2b company into a $20b company in less than a decade is not easy, but after the past week, Andrew Michelmore might just do it.
Peter Ker Newcrest Mining has lost another senior executive, with company secretary Scott Langford set to leave the gold miner on Friday.
Gareth Hutchens Big cutbacks in the number of broking analysts covering Australia's largest companies are partly responsible for controversies around selective analyst briefings, a key investor group has said.
Gareth Hutchens, wires The sharemarket closed on another five-year high, up another 0.5 per cent, despite a looming fiscal deadline in the US that could threaten to shut down the government.
Mike King Goldminers have had a rough time but we may have reached a point where there is significant upside potential.
Glenda Kwek The beleaguered gold sector has started to show some sparkle again, as the precious metal remained near one-month highs.
Jared Lynch The sharemarket flatlined, managing to post just its fourth straight day of gains.
Christopher Webb Piggybacking directors who support their company's shares is not an infallible way to make money.


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Recent content from Dan Browning
They were on their way to United Hospital when their third child arrived.
Feds say Scott Luther bilked customers deals exceeding $1.5 million.
The owner of Royal Orchid allegedly promised to help a teenager from the Dominican Republic get a U.S. education, then forced him to work less than $1 an hour.
A second immigrant has accused Pisanu "Pat" Sukhtipyaroge of forcing him to work at his Twin Cities restaurants.
Federal authorities say a young man was lured from the Dominican Republic by the restaurant owner with promises of American schooling, but then found himself under a "debt bondage arrangement."
Judge upheld radio host Patrick Kiley's 20-year prison sentence.
A judge found insufficient evidence in Kandiyohi County, which led a Carver County prosecutor to drop charges there as well.
The plea bargain anticipates that attorney John Steele with cooperate with prosecutors against lawyer Paul Hansmeier, who has denied the charges.
The court-appointed receiver marshaling assets from Trevor Cook's fraud scheme immediately filed a notice that it would appeal the order dismissing the lawsuit.
Filings in Carver County District Court raised questions of conflicts of interest in the management of the estate.


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Evidence has accumulated for the effectiveness of psychological therapies in the treatment of a wide range of mental disorders, as well as adjunctive treatment in physical conditions, to the point where national clinical guidelines routinely include recommendations for their application. In the UK a National Health Service programme to Improve Access to Psychological Therapies (IAPT) is well established. This is a far cry from 30 years ago when sceptical editorials attributed psychotherapy results to placebo effects. Reference Shepherd1 As a range of evidence-based psychological therapies have become routine in mainstream health services, interest has grown in the potential for these treatments to cause harm; in the same way that effective medical treatments carry risks and toxicity, it is becoming clear that psychological treatments cannot be at once psychoactive and harmless.
Patient safety has not been a priority for psychological therapy researchers. Despite repeated attention to this issue over five decades and recently renewed interest, comparison of discussions from the 1960s to the 2000s shows the field has failed to progress significantly. Reference Bergin2,Reference Barlow3 Part of the difficulty in accumulating knowledge is the plethora of different terms used in research reports, with confusion between them and no systematic way to describe adverse effects of treatment. In a recent scoping review as part of a research programme on this topic, we needed over 14 search terms to address the issue, including negative effects, adverse effects, adverse events, harm, symptom exacerbation, treatment failure, clinical deterioration, negative outcome, harmful effects, patient safety, negative therapeutic reaction, negative results. Failure to agree the most appropriate terms and definitions to describe harm associated with psychological treatments may help explain the striking disparity between the large amount of testimony on the internet from patients describing their experience of harm from therapy, compared with little or no reference to the risk of harm in the major textbooks in the field. Reference Gabbard and Beck4
These definitional problems make it difficult to compare results of different studies and have limited progress in our understanding of what leads to harm and what might be done to prevent it. In this editorial we highlight deficiencies in the way that research is currently reported, provide definitions for types of harm associated with psychological therapies that would improve the way results of future studies are presented, and summarise the implications for research and practice.
Causes of negative effects and harm in psychological therapies
An important feature of all psychological treatments, in contrast to pharmacological ones, is the extent to which the effectiveness of the therapy crucially depends on the skills of the therapist to co-create the ‘active ingredients’ with each patient anew. In this respect, psychological therapies are more analogous to surgery than to pharmacological treatment. There is the added complexity that the relationship between the therapist and the patient is itself an ‘active ingredient’ that is an important predictor of outcome, and although enhanced by good technique Reference DeRubeis and Feeley5 it goes beyond technical competence. There is no guarantee that the therapy delivered is what was specified in the ‘prescription’ or what was investigated in a randomised trial. For example, National Institute for Health and Care Excellence (NICE) guidelines on the treatment of depression draw evidence from randomised trials of therapies delivered by well-trained professionals, which ranged from 12 to 30 sessions, 6 but the median treatment length in IAPT services in England is 5, often delivered by underqualified staff. 7
There are many posited risk factors for negative outcomes and possible mechanisms for harmful therapy. These include:
(a) damaging interactions between therapist and patient and unresolved ruptures in the therapeutic alliance;
(b) therapist factors: for example, using an inappropriate therapeutic method or errors in delivering a recommended therapy; lack of skill in noticing and repairing ruptures in the therapeutic alliance;
(c) patient factors that increase the risk of iatrogenesis: for example, activation of attachment in people with reduced mentalisation such as those with borderline personality disorder; Reference Fonagy and Bateman8
(d) poor fit between therapist and patient: for example, a generally skilful therapist who is unable to work with grief for personal reasons;
(e) risks attached to specific interventions: for example, the possibility of maladaptive learning in group-based treatment;
(f) organisational systems: for example, suboptimal provision due to large case-loads and organisational pressure to take on patients beyond one's competence.
It is difficult to report the proportion of therapy patients who experience negative results from therapy as there are few systematic studies of prevalence. The estimate of 5% is typical. Reference Boisvert and Faust9 This is consistent with results from a survey of psychological therapy service users in England, where 1 in 20 respondents reported that they had experienced lasting bad effects from therapy. Reference Crawford, Thana, Farquharson, Palmer, Hancock and Bassett10 Negative therapeutic results may be higher for children and young people. Reference Rhule11
Failure to record and report
Reports of clinical trials of psychological therapies are far less likely to mention adverse effects than pharmacological trials; Reference Vaughan, Goldstein, Alikakos, Cohen and Serby12 a review of mental health trials Reference Jonsson, Alaie, Parling and Arnberg13 found only 28 of an eligible 132 trials (21%) showed any indication that adverse events had been monitored, and even fewer were reported. Duggan et al Reference Duggan, Parry, McMurran, Davidson and Dennis14 examined both the protocols and the final reports, whether published or unpublished, from trials commissioned by the Health Technology Assessment programme of the UK National Institute of Health Research. They confirmed that, despite the mandatory paragraph on adverse events required for obtaining ethical approval, only a small proportion of trials monitored them. They found such comments as ‘There is no evidence that CBT [cognitive–behavioural therapy] is harmful. IAPT therapists are experienced in conducting risk assessment’ and ‘No adverse events or serious adverse events will be recorded or reported in this study’. However, there was evidence that more recently commissioned trials were improving in this respect. The patient experience of an adverse therapy process or outcome is rarely recorded.
Three ways to move the field forward
We have three recommendations to address these problems. First, greater standardisation of terms is required. As a starting point, we suggest the following definitions for a range of adverse effects of therapy.
(a) Adverse events refer to significant episodes during or shortly after treatment (e.g. suicide, suicide attempts, mental health-related hospital admissions), which if related to or directly caused by treatment amount to harm or severe harm.
(b) Clinically significant deterioration refers to a worsened mental state after therapy is complete, which can include the emergence of new symptoms. It is often a psychometric criterion from patient-reported or clinician-assessed outcome measures. In this context, harm refers to sustained, statistically reliable deterioration having been caused by therapy but consensus on what is a statistically reliable and clinically significant degree of deterioration has not yet emerged.
(c) Finally, but crucially, the patient may have a very negative experience of therapy, with lasting bad effects, despite this not being picked up either in adverse event monitoring or observed clinical deterioration. This could be described as patient-experienced harm. Those close to the patient can also experience harm from the treatment.
From this, we recommend that ideally all these aspects of potential harm should be monitored and reported in research trials. Adverse events should plausibly be related to the effect of the intervention on the population being studied and should be specified in the protocol and reported routinely in published reports. Those specified should be specific to the population in the trial, for example suicide, increase in self-harm, psychotic relapse (not simply hospital admissions), increased use of alcohol/drugs, relapse of eating disorders and emergence of new symptoms: a checklist for unwanted events and adverse treatment reactions specific to psychological therapies may be useful in this regard. Reference Linden15 Rates of clinical deterioration in treatment and control groups should be shown, in addition to the usual group mean differences. This is vital for meta-analysis, since the numbers in any individual trial are too small and confidence intervals too large to draw robust conclusions. Finally, the view of trial participants on any experience of therapy harm is an important but often missing perspective. By using a mixed-methods approach, researchers and practitioners can throw light on whether observed deterioration is or is not related to the therapy process.
We also recommend that routine monitoring of adverse events, patient deterioration and drop-out are included in clinical audit of psychological therapy services, with follow-up investigation of patient-experienced harm where these exceed normative limits for the case mix. Lambert has demonstrated a method of reducing treatment failure through case monitoring and feedback. Reference Lambert16 These three simple steps would, in our view, move this field forward considerably, so that we will not be rehashing the same concerns 50 years from now.
We also require methods to test putative mechanisms. These could include task analysis of therapy process, intensive single case replications and multilevel modelling in large samples to understand the interaction between factors. Such research can provide a basis for developing and testing interventions aimed at reducing harm and help us better understand how to improve the mental health of those who have experienced such harms. It is also needed to generate data that will provide patients and clinicians with more reliable information to make treatment choices. At present, patients are often asked to provide consent to psychological treatment without any discussion of potential harms associated with these interventions. Although negative effects associated with psychological therapies are far less common than positive ones, the process of informed consent requires some consideration of both.

domain: psychology


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leflunomide is a disease-modifying antirheumatic agent with antiproliferative properties.
Mechanism of action. A771726, the active metabolite of leflunomide, inhibits the human enzyme dihydroorotate dehydrogenase (DHODH) and exhibits antiproliferative activity.
Pharmacokinetics Leflunomide is rapidly converted into the active metabolite A771726 by presystemic metabolism (ring opening) in the walls of the intestine and liver. Plasma unchanged leflunomide levels were rarely determined. The only metabolite found in blood plasma is A771726. This metabolite determines mainly all the activity of leflunomide in the body.
Suction. 82-95% of a dose of leflunomide is absorbed. Time to reach Cmax A771726 in blood plasma is very different: from 1 to 24 hours after a single application. Leflunomide can be taken with food, since the absorption volume when taking the drug after meals and on an empty stomach is similar. Due to long T½ A771726 (approximately 2 weeks) to ensure rapid achievement of a stable level of A771726, a loading dose of 100 mg was applied for 3 days. It has been established that without the use of a loading dose, it may take almost 2 months of taking the drug to achieve a stable plasma concentration. Studies in which different dosages of the drug were studied showed that the pharmacokinetic parameters of A771726 are linear when using the drug in a dose range of 5–25 mg.
In these studies, the clinical effect was closely related to the concentration of A771726 in blood plasma and to the daily dose of leflunomide. When using a dose of 20 mg / day, the average plasma concentration of A771726 in the saturation stage is about 35 μg / ml. In the saturation stage, the concentration of A771726 in blood plasma is 33–35 times higher compared to that with a single application.
Distribution. In human blood plasma, A771726 almost completely binds to a protein (albumin). The unbound fraction of A771726 is about 0.62%. The binding of A771726 is linear within therapeutic doses. Binding A771726 was found to be somewhat weaker and more variable in the blood plasma of patients with rheumatoid arthritis or chronic renal failure. Extensive binding of A771726 to a protein can lead to the displacement of other substances that are largely bound to proteins. However, the results of a study on the interaction of protein binding under in vitro conditions with the use of warfarin in clinically appropriate doses did not show any interaction. Similar studies showed that ibuprofen and diclofenac did not displace A771726, while in the presence of tolbutamide, the unbound fraction of A771726 increased 2–3 times. A771726 replaced ibuprofen, diclofenac, and tolbutamide, but the unbound fraction of these agents increased by only 10–50%. There is no evidence that these effects are of clinical significance. With significant protein binding, A771726 has a low apparent volume of distribution (about 11 L). The predominant absorption of red blood cells was not detected.
Metabolism. Leflunomide is metabolized to one major (A771726) and many minor metabolites, including TFMA (4-trifluoromethylaniline). The metabolic biotransformation of leflunomide on A771726 and the subsequent metabolism of A771726 are not controlled by one specific enzyme and, as has been shown, occurs in microsomal and cytosolic cell fractions. Interaction studies using cimetidine (a non-specific inhibitor of cytochrome P450) and rifampicin (a non-specific inducer of cytochrome P450) indicate that, in vivo, CYP enzymes are only slightly involved in the metabolism of leflunomide.
Withdrawal of A771726 is slow and is characterized by an apparent clearance of 31 ml / h. In patients T½ is about 2 weeks.After administration of a dose of leflunomide labeled with a radionuclide, the same amount of radioactivity was observed in the feces, probably due to biliary excretion, and in the urine. A771726 continued to be detected in urine and feces 36 days after a single dose. The main metabolites excreted in the urine were leflunomide glucuronides (mainly in samples taken during the first day (0–24 hours) after taking the drug) and the oxalic acid derivative A771726. The main component that was excreted in the feces was A771726.
It has been found that in humans, oral administration of a suspension of powdered activated carbon or colestyramine leads to a rapid and significant increase in the rate of A771726 excretion and a decrease in its concentration in blood plasma (see OVERDOSAGE). It is believed that this is achieved due to the mechanism of gastrointestinal dialysis and / or suspension of the hepatic metabolic cycle.
Pharmacokinetics in renal failure. The pharmacokinetics of A771726 in patients who received long-term peritoneal dialysis (DPD) was similar to that in healthy volunteers. Faster elimination of A771726 was observed in individuals who received hemodialysis, not associated with extraction of the drug from dialysate.
Pharmacokinetics for liver failure. There are no data on the treatment of patients with liver failure. The active metabolite A771726 is largely bound to proteins and excreted through hepatic metabolism and secretion with bile. These processes may be impaired due to liver dysfunction.
Pharmacokinetics in pediatric patients. In patients with body weight ≤40 kg, a less systemic effect (defined as Css) A771726 compared with adult rheumatoid arthritis patients.
Pharmacokinetics in the elderly. Data on the pharmacokinetics of the elderly (65 years) are limited, but are consistent with pharmacokinetics in young adults.
Treatment with disease-modifying antirheumatic agents (bmars) of the active phase of rheumatoid arthritis in adults. treatment of the active phase of psoriatic arthritis in adults. recent or simultaneous treatment with hepatotoxic or hematotoxic bars (e.g. methotrexate) may increase the risk of serious adverse reactions; therefore, the initiation of treatment with leflunomide should be carefully considered in light of the benefit / risk. in addition, the transition from leflunomide to another bmars without carrying out the withdrawal procedure (see special instructions) can also increase the risk of serious adverse reactions, even after a long period after the transition.
Leflunomide is prescribed as bmars. Leflunomide treatment should be prescribed and monitored by a specialist with experience in the treatment of rheumatoid and psoriatic arthritis.
At the same time and with the same frequency, it is necessary to control the level of ALAT or glutamopyrruvate transferase (GPTF) in blood plasma, perform an extensive blood test, including differential analysis of leukocytes and platelets:
- before starting leflunomide;
- 1 time in 2 weeks for 6 months of treatment;
- 1 time in 8 weeks after treatment (see SPECIAL INSTRUCTIONS).
The tablets should be swallowed without chewing, washed down with water. The degree of absorption of leflunomide is independent of food intake.
- the saturating dose is 100 mg once a day for the first three days;
- the maintenance dose is from 10 * to 20 mg once a day.
* If it is necessary to use a dose of 10 mg, tablets with the appropriate content of active ingredient should be taken.
- the saturating dose is 100 mg once a day for the first 3 days;
- the maintenance dose is 20 mg 1 time per day.
The therapeutic effect begins to manifest after 4-6 weeks from the start of treatment and can be enhanced within 4-6 months from the start of treatment.
Patients over the age of 65: dose adjustment not required.
Patients with moderate renal failure: dose adjustment is not required.
- Hypersensitivity to leflunomide (especially if there is a history of Stevens-Johnson syndrome, toxic epidermal necrolysis, erythema polyforma), the main active metabolite of teriflunamide, or other components of the drug; impaired liver function; severe immunodeficiency conditions (including HIV infection); severe bone marrow dysfunction or severe anemia, leukopenia, neutropenia, or thrombocytopenia due to other causes (except for rheumatoid or psoriatic arthritis); severe infections; moderate or severe renal failure (due to little experience in clinical observations in this group of patients); severe hypoproteinemia (including with nephrotic syndrome); pregnancy period; lactation period; use in women of reproductive age who do not use reliable contraception during and after treatment, if the level of active metabolite in the blood plasma is more than 0.02 mg / l.
It is necessary to exclude the possibility of pregnancy before starting treatment with leflunomide!
Infections and infestations: various infections (including rhinitis, bronchitis, pneumonia); opportunistic infections; severe infections, including sepsis (including fatal).
Benign, malignant and non-specific neoplasms (cysts and polyps): an increased risk of developing malignant neoplasms, in particular lymphoproliferative diseases, increases when used with immunosuppressive drugs.
On the part of the blood: leukopenia, anemia, thrombocytopenia, pancytopenia, eosinophilia, agranulocytosis.
Previous, concomitant or subsequent use of potentially myelotoxic drugs may be associated with a greater risk of hematological effects.
From the immune system: mild allergic reactions; severe anaphylactic / anaphylactoid reactions, vasculitis (including cutaneous necrotizing vasculitis).
On the part of the metabolism: increased levels of CPK, hypokalemia, hyperlipidemia, hypophosphatemia, increased LDH levels, decreased uric acid levels (hypuricemia).
Mental disorders: anxiety.
From the nervous system: paresthesia, headache, dizziness, peripheral neuropathies.
From the cardiovascular system: increased blood pressure.
From the respiratory system: interstitial lung disease (including interstitial pneumonitis), including fatal cases, pulmonary hypertension.
From the digestive tract: diarrhea, nausea, vomiting, abdominal pain, damage to the mucous membrane of the oral cavity (stomatitis, ulcers), taste disturbance, pancreatitis, colitis (including microscopic colitis, lymphocytic colitis and collagenous colitis).
From the hepatobiliary system: increased levels of liver enzymes (AlAT, gamma-glutathione transferase and alkaline phosphatase), hyperbilirubinemia, hepatitis, jaundice, cholestasis, severe liver damage (liver failure or acute liver necrosis, including fatal).
On the part of the skin and subcutaneous tissue: increased hair loss, eczema, skin rashes (including maculopapular rash), itching, dry skin, urticaria, erythema multiforme, Stevens-Johnson syndrome, toxic epidermal necrolysis, lupus erythematosus, pustular psoriasis or exacerbation psoriasis, hypersensitivity syndrome with eosinophilia and systemic symptoms (DRESS syndrome).
From the musculoskeletal system: tendosynovitis, tendon rupture.
From the urinary system: renal failure.
From the reproductive system: a decrease in sperm concentration (reversible), a decrease in the total number and motility of sperm.
General disorders: anorexia, weight loss (usually minor), asthenia.
The simultaneous use of hepatotoxic or hematotoxic bmars (e.g. methotrexate) is not recommended.
The active metabolite of leflunomide, A771 726, has a prolonged T½, which, as a rule, is 1–4 weeks. Serious adverse effects can occur (e.g., hepatotoxic, hematotoxic or allergic reactions, see below) even if treatment with leflunomide is suspended. Thus, in the event of such toxic phenomena or for any other reason, an elimination procedure should be carried out. This procedure can be repeated depending on clinical need.
Excretion procedures and other recommended actions in the event of a desired or unplanned pregnancy are given in the Pregnancy section.
Reactions from the liver. Rare cases of severe liver damage have been reported, including those with fatal outcome, which were recorded during treatment with leflunomide. Most of these cases occurred during the first 6 months of treatment. Often noted simultaneous treatment with other hepatotoxic drugs. It is considered advisable to monitor strict compliance with the recommendations.
The level of AlAT (GPTF) should be checked before starting the use of leflunomide, and also with the same regularity as conducting an extensive blood test (1 time in 2 weeks), during the first 6 months of treatment and every 8 weeks after its completion.
With an increase in the level of AlAT (GPTF) 2–3 times higher than the upper limit of the norm, one should consider the possibility of reducing the dose from 20 mg to 10 mg and monitor weekly. If the increase in the level of AlAT (GPTF) is more than 2 times higher than the upper limit of the norm, or if there is an increase in the level of AlAT more than 3 times higher than the upper limit of the norm, then the administration of leflunomide should be stopped and the withdrawal procedure should begin. It is recommended that monitoring of hepatic enzymes be continued after discontinuation of leflunomide treatment until the level of hepatic enzymes normalizes.
In connection with the possible occurrence of additional hepatotoxic effects, it is recommended to avoid drinking alcohol during treatment with leflunomide.
Hematologic reactions. Together with the control of the level of AlAT, before starting treatment with leflunomide, as well as 1 time in 2 weeks during the first 6 months of therapy and 1 time in 8 weeks after its completion, it is recommended to conduct a detailed blood test, including differential analysis of leukocytes and platelets.
In patients with pre-existing anemia, leukopenia and / or thrombocytopenia, as well as in patients with impaired bone marrow function or in patients at risk of developing inhibition of bone marrow function, there is an increased risk of hematological disorders. If such effects occur, the possibility of elimination should be considered in order to reduce the level of A771 726 in blood plasma.
In case of severe hematological effects, including pancytopenia, taking the drug and any simultaneous myelosuppressive treatment, it is necessary to stop and begin the procedure for eliminating leflunomide.
Transition to other treatment methods. Since leflunomide remains in the body for a long time, switching to another BMARS (for example, methotrexate) without carrying out the elimination procedure can increase the likelihood of additional risks even after a long period after the transition (i.e. kinetic interaction, toxic effects on organs).
Also, recent treatment with hepatotoxic or hematotoxic drugs (eg methotrexate) can lead to increased side effects; Thus, the start of treatment with leflunomide must be carefully weighed taking into account the benefit / risk aspect, and careful monitoring is recommended at the initial stage after the transition.
On the part of the skin. In case of ulcerative stomatitis, the administration of leflunomide should be discontinued.
Very rare cases of Stevens-Johnson syndrome or toxic epidermal necrolysis have been reported in patients treated with leflunomide. As soon as reactions occur on the part of the skin and / or mucous membrane, which give rise to a suspicion of the development of such severe reactions, taking Lefno and any other drugs that are suspected to be associated with the occurrence of these reactions, discontinue and immediately begin the procedure for excretion of leflunomide . In such cases, complete elimination is important, and repeated use of leflunomide is contraindicated (see CONTRAINDICATIONS).
Infectious diseases. It is known that drugs with immunosuppressive properties, such as leflunomide, can cause patients a greater tendency to infectious diseases, including opportunistic infectious diseases. Infectious diseases can be more serious and thus require early and intensive treatment. In the case of severe uncontrolled infectious diseases, it may be necessary to suspend treatment with leflunomide and conduct an excretion procedure.
Rare cases of progressive multifocal leukocerebral dystrophy have been reported in patients receiving leflunomide along with other immunosuppressive agents.
Patients with tuberculin reactivity should be closely monitored because of the risk of reactivation of tuberculosis.
From the respiratory system. An interstitial pulmonary process has been reported in the treatment of leflunomide (see ADVERSE EFFECTS). Interstitial pulmonary process is a potentially fatal disorder that can occur in acute form during therapy. Symptoms from the lungs, such as coughing and shortness of breath, can cause the cessation of therapy and, depending on the situation, further examination.
HELL. Blood pressure should be monitored before treatment with leflunomide and periodically after it.
The period of "waiting." It can be expected that the concentration of A771 726 in blood plasma will be 0.02 mg / l for a long period. It is believed that its concentration decreases to the level of 0.02 mg / l 2 years after discontinuation of leflunomide treatment.
For the first time, the concentration of A771 726 in plasma is measured after a 2-year waiting period.
Re-concentration of A771 726 in blood plasma is determined after at least 14 days. If both values are 0.02 mg / L, no teratogenic risk is expected.
The elimination procedure (excretion). After treatment with leflunomide is discontinued:
- colestyramine 8 g orally 3 times a day for 11 days;
- as an alternative - orally, 50 g of activated carbon, powdered, taken 4 times a day for 11 days.
The duration of the procedure may vary depending on clinical or laboratory parameters.
Regardless of the chosen method of drug elimination, at the time of fertilization, it is necessary to determine the concentration of A771 726 in blood plasma twice, with an interval of at least 14 days, and then wait with fertilization for 45 days from the moment when the concentration of A771 726 0.02 was first recorded in the analysis mg / l Women of reproductive age should be informed that before pregnancy, it is necessary to wait 2 years after discontinuation of the drug.If a waiting period of approximately 2 years, subject to reliable contraception, is deemed unacceptable, an elimination procedure should be recommended.
Both colestyramine and activated carbon can affect the absorption of estrogens and progestogens, so reliable oral contraceptives do not give a 100% guarantee during the elimination period. Alternative contraceptive methods are recommended.
Reproduction (recommendations for men). Male patients should be aware of the possibility of toxic effects on the fetus on their part. Also during treatment with leflunomide, reliable contraception should be provided.
There are no specific data on the risk of toxic effects on the fetus from a man, however, to minimize any possible risk, men who want to become a father should consider stopping the use of leflunomide and colestyramine at a dose of 8 g 3 times a day for 11 days or 50 g of activated powder coal 4 times a day for 11 days.
In any case, first determine the concentration of A771 726 in blood plasma. After this, the concentration of A771 726 in blood plasma should be re-measured at least 14 days later. If both plasma concentrations are 0.02 mg / l, and also after a waiting period of at least 3 months, the risk of toxic effects on the fetus is very low.
Elderly patients. For patients over the age of 65, there is no need for dose adjustment.
Lactose. The composition of the drug includes lactose. Patients with rare hereditary galactose intolerance, Lapp lactase deficiency or malabsorption of glucose-galactose should not take this drug.
Corn starch. The composition of the drug includes corn starch, so it should not be prescribed to patients with celiac disease (celiac enteropathy).
The ability to influence the reaction rate when driving vehicles or working with other mechanisms. If a side effect such as dizziness occurs, the patient’s ability to concentrate and respond appropriately may be impaired. In such cases, the patient should refrain from driving and working with machinery.
Use during pregnancy and lactation. Pregnancy. There is a suspicion that the active metabolite of leflunomide, A771 726, causes severe defects in the development of the fetus when using the drug during pregnancy.
The drug is contraindicated during pregnancy!
Women of reproductive age who do not use reliable contraception during treatment or after it are not prescribed, provided that the level of active metabolite is 0.02 mg / ml.
Women of reproductive age should use effective contraceptives within 2 years after the end of treatment (see SPECIAL INSTRUCTIONS) or up to 11 days after the end of treatment.
It is necessary to exclude pregnancy before starting treatment with leflunomide!
The patient should be warned that in case of delayed menstruation or in the presence of other signs indicating the onset of pregnancy, she should immediately inform the doctor about it to establish pregnancy. If the test is positive, the doctor should weigh the risk that the pregnant woman may be taking while taking the drug and inform the patient about it. At the first delay of menstruation, it is possible to reduce the risk to the fetus in connection with the administration of leflunomide by prescribing the elimination of leflunomide from the body.
Women who take leflunomide and wish to become pregnant are recommended to perform one of the elimination procedures (see SPECIAL INSTRUCTIONS) for leflunomide in order to minimize the possible toxic effects of A771 726 on the fetus (A771 726 concentration of 0.02 mg / l is considered to be associated with minimal risk to the fetus )
The period of breastfeeding. Leflunomide and its metabolites may pass into breast milk.In this regard, women who are breastfeeding are contraindicated in taking leflunomide.
Children. The drug is not prescribed for children (the effectiveness and safety of use in juvenile rheumatoid arthritis have not been established).
Strengthening of side effects is possible in cases of the recent previous, as well as simultaneous use of hepatotoxic or hematotoxic drugs, as well as when taking these drugs after treatment without taking into account the period necessary for the complete elimination of the drug from the body. Thus, at the initial stage after the transition, more careful monitoring of the level of liver enzymes and hematological parameters is recommended.
The use of colestyramine or activated carbon leads to a rapid and significant decrease in the concentration of the active metabolite of leflunomide. It is believed that this is due to a violation of A771 726 recirculation in the liver and small intestine and / or a violation of its gastrointestinal dialysis.
With the simultaneous use of leflunomide (at a dose of 10–20 mg / day) with methotrexate (at a dose of 10–25 mg / week), an increase in the level of liver enzymes by 2–3 times was noted.
It is recommended that patients who take leflunomide do not receive treatment with colestiramine or powdered activated charcoal, since this leads to a rapid and significant decrease in plasma concentration of A771 726 (active metabolite of leflunomide). It is believed that the mechanism of this phenomenon is due to the suspension of the hepatic metabolic cycle and / or gastrointestinal dialysis A771 726.
Patients who received treatment with NSAIDs and / or glucocorticosteroids before starting treatment with Lefno can continue taking them simultaneously with Lefno.
The enzymes involved in the metabolism of leflunomide and its metabolites are not exactly known.
With the simultaneous use of leflunomide and methotrexate, an increase in the level of liver enzymes is noted.
There are reports of an increase in prothrombin time when using leflunomide in combination with warfarin.
The administration of leflunomide simultaneously with antimalarial drugs that are used to treat rheumatism (chloroquinolones, hydroxychloroquinolones), gold preparations (oral or intramuscularly), D-penicillamine, azathioprine and other immunosuppressive drugs (cyclosporine, methotrexate) is still insufficiently studied.
There are no data on the incompatibility of leflunomide with other drugs.
In vitro studies indicate that A771 726 inhibits the activity of cytochrome P450 2C9 (CYP 2C9). With the simultaneous use of leflunomide and NSAIDs, which are metabolized by CYP 2C9, no effect on safety has been recorded. Safety measures are recommended when leflunomide is taken with drugs (other than NSAIDs) that are metabolized by CYP 2C9, such as phenytoin, tolbutamide, warfarin and fenprocoumone.
Vaccination. There is no clinical data on the efficacy and safety of vaccination during the administration of leflunomide, but vaccination with live vaccines is not recommended. Long T½ the drug requires determining the timing when the use of a live vaccine may be allowed after discontinuation of leflunomide treatment.
Symptoms: abdominal pain, vomiting, nausea, diarrhea, increased biochemical parameters of liver function, anemia, leukopenia, itching and rash.
Treatment: it is recommended to take orally colestyramine or activated charcoal to speed up the elimination (elimination) of the drug from the body. The duration of therapy is determined individually depending on the clinical picture.
The elimination procedure can be repeated if there are clinical indications.
There is no need for hemodialysis or chronic peritoneal dialysis, since studies have shown that the primary metabolite of leflunomide A771 726 is not dialyzed.
In the original packaging at a temperature not exceeding 25 ° c.