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1 FOR PUBLICATION UNITED STATES COURT OF APPEALS FOR THE NINTH CIRCUIT JONATHAN LOPEZ, Plaintiff-Appellee, v. KELLY G. CANDAELE, in his individual and official capacities as member of the Los Angeles Community College District Board of Trustees; MONA FIELD, in her individual and official capacities as member of the Los Angeles Community College District Board of Trustees; GEORGIA L. MERCER, in her individual and official capacities as member of the Los Angeles Community College District Board of Trustees; NANCY PEARLMAN, in her individual and official capacities as member of the Los Angeles Community College District Board of Trustees; ANGELA J. REDDOCK, in her individual and official capacities as member of the Los Angeles Community College District Board of Trustees; MIGUEL SANTIAGO, in his individual and official capacities as member of the Los Angeles Community College District Board of Trustees; 14351
2 14352 LOPEZ v. CANDAELE SYLVIA SCOTT-HAYES, in her individual and official capacities as member of the Los Angeles Community College District Board of Trustees; GENE LITTLE, in his individual and official capacities as Director of the Los Angeles Community College District Office of Diversity Programs; JAMILLAH MOORE, in her individual and official capacities as President of Los Angeles City College; ALLISON JONES, in her individual and official capacities as Dean of Academic Affairs at Los Angeles City College; CRISTY PASSMAN, in her individual and official capacities as Compliance Officer at Los Angeles City College, Defendants-Appellants, and JOHN MATTESON, in his individual and official capacities as Professor of Speech at Los Angeles City College, Defendant. No D.C. No. 2:09-cv GHK-FFM OPINION Appeal from the United States District Court for the Central District of California George H. King, District Judge, Presiding Argued and Submitted March 3, 2010 Pasadena, California Filed September 17, 2010
3 LOPEZ v. CANDAELE Before: Ronald M. Gould, Sandra S. Ikuta and N. Randy Smith, Circuit Judges Opinion by Judge Ikuta
4 14356 LOPEZ v. CANDAELE COUNSEL Mary L. Dowell and David A. Urban, Liebert Cassidy Whitmore, P.C., Los Angeles, California, for the appellants. David J. Hacker and Heather G. Hacker, Alliance Defense Fund, Folsom, California; David A. French, Alliance Defense Fund, Columbia, Tennessee, for the appellee. Sam Kim and Michael L. Parker, Sam Kim and Associates, P.C., Buena Park, California, for the appellee. IKUTA, Circuit Judge: OPINION Today we consider a student s First Amendment challenge to a community college sexual harassment policy. First Amendment cases raise unique standing considerations, Ariz. Right to Life Political Action Comm. v. Bayless, 320 F.3d 1002, 1006 (9th Cir. 2003), that tilt[ ] dramatically toward a finding of standing, LSO, Ltd. v. Stroh, 205 F.3d 1146, 1155 (9th Cir. 2000). Despite this lowered threshold for establishing standing and the disturbing facts of this case, we conclude that the student failed to make a clear showing that his intended speech on religious topics gave rise to a specific and credible threat of adverse action from college officials under the college s sexual harassment policy. Because the stu-
5 LOPEZ v. CANDAELE dent failed to carry the burden of proving he suffered an injury in fact, he does not satisfy the irreducible constitutional minimum of standing necessary to challenge the policy. Lujan v. Defenders of Wildlife, 504 U.S. 555, 560 (1992). I For the limited purpose of reviewing the preliminary injunction at issue, the salient facts are undisputed. A In the fall of 2008, plaintiff Jonathan Lopez was a student at Los Angeles City College (LACC), which is one of the public colleges within the Los Angeles Community College District (the District). At the time Lopez attended LACC, the District had promulgated a sexual harassment policy comprising a chapter of the District s Board Rules and Administrative Regulations, as authorized under state law. See Cal. Educ. Code 66300, LACC is subject to the District s regulations, including its sexual harassment policy. Two sections of this sexual harassment policy are relevant here. Section sets forth the District s general policy on this issue, stating in relevant part: The policy of the Los Angeles Community College District is to provide an educational, employment and business environment free from unwelcome sexual advances, requests for sexual favors, and other verbal or physical conduct or communications constituting sexual harassment. Employees, students, or other persons acting on behalf of the District who engage in sexual harassment as defined in this policy or by state or federal law shall be subject to discipline, up to and including discharge, expulsion or termination of contract Section 15003(A) defines sexual harassment as including:
6 14358 LOPEZ v. CANDAELE Unwelcome sexual advances, requests for sexual favors, and other verbal, visual, or physical conduct of a sexual nature, made by someone from or in the workplace or in the educational setting, under any of the following conditions:... (3) The conduct has the purpose or effect of having a negative impact upon the individual s work or academic performance, or of creating an intimidating, hostile or offensive work or educational environment. 1 According to the policy, the District s Director of Affirmative Action Programs oversees the implementation of the sexual harassment policy, but may delegate these duties to an individual Sexual Harassment Compliance Officer. District officials may take disciplinary action only in accordance with due process rights as well as any applicable collective bargaining agreement. For students, disciplinary action ranges from verbal warnings to expulsion. For employees, disciplinary action ranges from verbal warnings to dismissals. According to Allison Jones, LACC s Dean of Academic Affairs, neither LACC nor the District has enforced the sexual harassment policy against any teacher, student or employee. Lopez does not dispute this statement. Sections and of the policy appear in various other official documents. For example, the quoted portion of Section appears twice in the LACC student handbook. The Rules for Student Conduct section of the handbook states that [s]tudent conduct in all of the Los Angeles Com- 1 The defendants argue that this version of the sexual harassment policy is no longer applicable, as it was superseded in 2007 by a new policy that redefined the term sexual harassment, and therefore Lopez s challenge is moot. We do not reach this argument, because we decide the case on standing grounds. See Sinochem Int l Co. v. Malay. Int l Shipping Corp., 549 U.S. 422, 431 (2007) (holding that there is no mandatory sequencing of jurisdictional issues, and we have leeway to choose among threshold grounds for denying audience to a case on the merits (citations and internal quotation marks omitted)).
7 LOPEZ v. CANDAELE munity Colleges must conform to District and [LACC] rules and regulations, and that violations will result in disciplinary action. In addition, the website of the District s Office of Diversity Programs contains relevant portions of Section 15003, and gives some examples of sexual harassment, including [v]erbal harassment, [d]isparaging sexual remarks about your gender, [d]isplay of sexually suggestive objects, pictures, cartoons, posters, screen savers, and [m]aking unwelcome, unsolicited contact with sexual overtones (written, verbal, physical and/or visual contact). The website also offers [s]imple guidelines for avoiding sexual harassment, which include the admonition, If [you are] unsure if certain comments or behavior are offensive do not do it, do not say it. The LACC Compliance Office s website likewise includes the relevant portions of Section 15003, and defines one form of sexual harassment as generalized sexist statements, actions and behavior that convey insulting, intrusive or degrading attitudes/comments about women or men. Examples include insulting remarks; intrusive comments about physical appearance; offensive written material such as graffiti, calendars, cartoons, s; obscene gestures or sounds; sexual slurs, obscene jokes, humor about sex. B During the fall semester, Lopez was a student in Speech 101, taught by Professor John Matteson. For one assignment, Matteson directed his students to make an informative speech on a topic of their choosing. Lopez is a devout Christian who believes, as a tenet of his faith, that he must share his religious beliefs with others. For this assignment, Lopez chose to speak about God and the ways in which he had witnessed God act both in his life and in the lives of others. In the course of giving his speech, Lopez read a dictionary definition of marriage as being a union between a man and a woman, and read two verses from the Bible. 2 After Lopez made these statements, 2 Though the text of Lopez s speech is not in the record, Lopez s appellate brief states that the speech quoted Romans 10:9 ( [t]hat if you confess
8 14360 LOPEZ v. CANDAELE but while still in the middle of his speech, Matteson interrupted Lopez, called Lopez a fascist bastard, and refused to allow Lopez to finish his speech. Matteson told the class that anyone who was offended could leave. When no one left, Matteson dismissed the class. In lieu of giving Lopez a grade, Matteson wrote on Lopez s speech evaluation form, [a]sk God what your grade is and pros[elytising] is inappropriate in public school. The day after this incident, Lopez met with Jones to complain about Matteson s actions. As Dean of Academic Affairs, Jones supervises the LACC faculty and oversees certain student matters and the policies and procedures that govern LACC. Jones told Lopez to put his complaint against Matteson in writing. When Lopez delivered his written complaint to Jones, Matteson observed this interaction. Matteson subsequently threatened Lopez, stating that he would make sure that Lopez was expelled from school. On December 2, the day after this threat, Lopez turned in another Speech 101 assignment. Lopez s paper contained a list of proposed topics for a persuasive speech, including one on how to exercise your freedom of speech right, which would include a discussion of how one should [a]lways stand up for what you believe in. Matteson gave Lopez an A for this assignment, but wrote the following below the free speech proposed topic: (Remember you agree to Student Code of Conduct as a student at LACC). By this time, Lopez had obtained legal representation. On the same day that Lopez submitted his list of proposed topics, with your mouth, Jesus is Lord, and believe in your heart that God raised Him from the dead, you will be saved; ) and Matthew 22:37-38 ( Jesus said to him, You shall love the Lord your God with all your heart, with all your soul, and with all your mind. This is the first and greatest commandment. ).
9 LOPEZ v. CANDAELE Lopez s lawyer sent Jones and Jamillah Moore, the LACC President, a letter demanding that Lopez receive a fair grade on his informative speech, that LACC discipline Matteson and require him to make a public apology to Lopez, and that LACC and its faculty provide written assurance that they would respect Lopez and other students First Amendment rights. Jones responded by letter two days later. The letter stated that Jones had met with Lopez twice and had asked him to put his complaints in writing and submit written corroboration of his version of the informative speech incident from other students in the class. The letter also stated that Jones had started a progressive discipline process with respect to Matteson, but that both collective bargaining rules and LACC s restrictions on discussing personnel matters prevented her from disclosing details about any discipline that Matteson might receive. The letter made clear that action is being taken, but specific details may not be shared with Mr. Lopez or [his lawyer]. The same letter also reported that Jones had received statements from two students who were deeply offended by Lopez s informative speech. One student wrote that Lopez s speech was not of the informative style that our assignment called for, but rather a preachy, persuasive speech that was completely inappropriate and deeply offensive. The student further stated that although she respected Lopez s right to free speech, I also do not believe that our classroom is the proper platform for him to spout his hateful propaganda. The second student wrote that I don t know what kind of actions can be taken in this situation, but I expect that this student should have to pay some price for preaching hate in the classroom. After quoting the two statements, however, the letter stated: [r]egardless of the other students reactions to Mr. Lopez [s] speech, Mr. Matteson will still be disciplined. First amendment rights will not be violated 14361
10 14362 LOPEZ v. CANDAELE as is evidenced by the fact that even though many of the students were offended by Mr. Lopez [s] speech, no action will be taken against any of them for expressing their opinions. The letter also stated that Lopez would receive a fair grade for both his informative speech and for the entire class. Lopez eventually received an A in the class, though he alleged he never received a grade for his informative speech. In a subsequent affidavit, Jones disavowed Matteson s actions, declaring that Matteson s behavior was spontaneous and not in accordance with any LACC or District handbooks, regulations[,] and codes. The affidavit also confirmed that Matteson was disciplined for [his] conduct. Lopez had no subsequent interactions with Matteson, and the record contains no other complaints or other allegations of enforcement actions taken against Lopez due to his speech. Nor did the District or LACC take any enforcement action against Lopez under the sexual harassment policy. C Lopez ultimately filed suit against Matteson, Jones and other District and college officials. 3 Lopez brought four causes of action against the Defendants under 42 U.S.C The first three causes of action alleged that Matteson s conduct violated Lopez s First Amendment and equal protection rights. In his fourth cause of action, the only one relevant here, Lopez claimed that the District s sexual harass- 3 In addition to Matteson and Jones, Lopez sued Moore, the president of LACC, Cristy Passman, the LACC Compliance Officer, Gene Little, Director of the District s Office of Diversity Programs, and the District s Board of Trustees (Kelly G. Candaele, Mona Field, Georgia L. Mercer, Nancy Pearlman, Angela J. Reddock, Miguel Santiago, and Sylvia Scott- Hayes.) Except for Matteson, who is not a named defendant in this appeal, we refer to the defendants by name or collectively as Defendants.
11 LOPEZ v. CANDAELE ment policy violated the First Amendment because it was unconstitutionally overbroad and vague. 4 Lopez moved for a preliminary injunction to enjoin the Defendants from enforcing the sexual harassment policy. In entertaining this motion, the district court first concluded that Lopez had standing to bring a facial challenge to the policy because it applied to Lopez by virtue of his enrollment at LACC, the policy likely reached the speech in which Lopez wanted to engage, and Lopez has censored himself for fear of discipline under the policy. 5 The district court then concluded that the policy was unconstitutionally overbroad and could not be narrowed, and granted Lopez s motion to enjoin the District from enforcing the policy. While this appeal of the court s preliminary injunction was pending, the district court granted the Defendants previously filed motion to dismiss the remaining causes of action, with limited leave for Lopez to amend. II We review de novo the district court s determination that Lopez has standing. Am.-Arab Anti-Discrimination Comm. v. Thornburgh, 970 F.2d 501, 506 (9th Cir. 1992). Lopez bears the burden of establishing standing because he is the party invoking federal jurisdiction. LSO, 205 F.3d at We review the district court s grant of a preliminary injunction for abuse of discretion. Johnson v. Couturier, 572 F.3d 1067, 1078 (9th Cir. 2009). This review is limited and deferential and it does not extend to the underlying merits of the case. Id. (quoting Am. Trucking Ass ns v. City of Los Angeles, 559 F.3d 1046, 1052 (9th Cir. 2009)). 4 Matteson failed to respond to Lopez s complaint, and as such the district court clerk entered default; however, the district court delayed granting a default judgment against Matteson until after this appeal is resolved. 5 The district court therefore did not reach Lopez s as-applied challenge.
12 14364 LOPEZ v. CANDAELE A [1] In order to invoke the jurisdiction of the federal courts, a plaintiff must establish the irreducible constitutional minimum of standing, consisting of three elements: injury in fact, causation, and a likelihood that a favorable decision will redress the plaintiff s alleged injury. Lujan, 504 U.S. at ; see Cal. Pro-Life Council, Inc. v. Getman, 328 F.3d 1088, 1093 (9th Cir. 2003). The injury in fact must constitute an invasion of a legally protected interest which is (a) concrete and particularized, and (b) actual or imminent, not conjectural or hypothetical. Lujan, 504 U.S. at 560 (internal citations and quotations omitted). The plaintiff must prove injury in fact in the same way as any other matter on which the plaintiff bears the burden of proof, i.e., with the manner and degree of evidence required at the successive stages of the litigation. Id. at 561. Therefore, at the preliminary injunction stage, a plaintiff must make a clear showing of his injury in fact. Winter v. Natural Resources Def. Council, Inc., 129 S. Ct. 365, 376 (2008). [2] Because [c]onstitutional challenges based on the First Amendment present unique standing considerations, plaintiffs may establish an injury in fact without first suffering a direct injury from the challenged restriction. Bayless, 320 F.3d at In an effort to avoid the chilling effect of sweeping restrictions, the Supreme Court has endorsed what might be called a hold your tongue and challenge now approach rather than requiring litigants to speak first and take their chances with the consequences. Id.; Getman, 328 F.3d at In such pre-enforcement cases, the plaintiff may meet constitutional standing requirements by demonstrat[ing] a realistic danger of sustaining a direct injury as a result of the statute s operation or enforcement. Babbitt v. United Farm Workers Nat l Union, 442 U.S. 289, 298 (1979); see LSO, 205 F.3d at To show such a realistic danger, a plaintiff must allege[ ] an intention to engage in a course of conduct arguably affected with a constitutional interest, but proscribed
13 LOPEZ v. CANDAELE by a statute, and... a credible threat of prosecution thereunder. Babbitt, 442 U.S. at 298; see Bayless, 320 F.3d at 1006; LSO, 205 F.3d at [3] Despite this relaxed standing analysis for preenforcement challenges, Canatella v. California, 304 F.3d 843, 853 n.11 (9th Cir. 2002), plaintiffs must still show an actual or imminent injury to a legally protected interest. See Lujan, 504 U.S. at 560. Even when plaintiffs bring an overbreadth challenge to a speech restriction, i.e., when plaintiffs challenge the constitutionality of a restriction on the ground that it may unconstitutionally chill the First Amendment rights of parties not before the court, they must still satisfy the rigid constitutional requirement that plaintiffs must demonstrate an injury in fact to invoke a federal court s jurisdiction. Dream Palace v. Cnty. of Maricopa, 384 F.3d 990, 999 (9th Cir. 2004) (quoting 4805 Convoy, Inc. v. City of San Diego, 183 F.3d 1108, 1112 (9th Cir. 1999)); see also Sec y of State v. Joseph H. Munson Co., 467 U.S. 947, 958 (1984). The touchstone for determining injury in fact is whether the plaintiff has suffered an injury or threat of injury that is credible, not imaginary or speculative. Babbitt, 442 U.S. at 298 (quoting Younger v. Harris, 401 U.S. 37, 42 (1971)). We look at a number of factors to determine whether plaintiffs who bring suit prior to violating a statute, so-called preenforcement plaintiffs, have failed to show that they face a credible threat of adverse state action sufficient to establish standing. As discussed in more detail below, in this context we have conducted three related inquiries. First, we have considered whether pre-enforcement plaintiffs have failed to show a reasonable likelihood that the government will enforce the challenged law against them. Second, we have considered whether the plaintiffs have failed to establish, with some degree of concrete detail, that they intend to violate the challenged law. We have also considered a third factor, whether the challenged law is inapplicable to the plaintiffs, either by its terms or as interpreted by the government. Such inapplica-
14 14366 LOPEZ v. CANDAELE bility weighs against both the plaintiffs claims that they intend to violate the law, and also their claims that the government intends to enforce the law against them. B Beginning with the first factor, we have considered a government s preliminary efforts to enforce a speech restriction or its past enforcement of a restriction to be strong evidence (although not dispositive, LSO, 205 F.3d at 1155) that preenforcement plaintiffs face a credible threat of adverse state action. For example, a threat of government prosecution is credible if the government has indicted or arrested the plaintiffs, Younger, 401 U.S. at 41-42, if prosecuting authorities have communicated a specific warning or threat to initiate proceedings under the challenged speech restriction, or if there is a history of past prosecution or enforcement under the challenged statute. Thomas v. Anchorage Equal Rights Comm n, 220 F.3d 1134, 1139 (9th Cir. 2000) (en banc). See, e.g., Steffel v. Thompson, 415 U.S. 452, 459 (1974) (plaintiff established injury in fact where the government twice warned him to stop distributing handbills and threatened him with prosecution under a Georgia statute if he continued to distribute the handbills); Culinary Workers Union v. Del Papa, 200 F.3d 614, 616, 618 (9th Cir. 1999) (per curiam) (plaintiff had established injury in fact under a Nevada statute when the attorney general wrote a precise and exact letter to the union which quoted the statute in full and threatened to refer the prosecution to local criminal authorities ). The threatened state action need not necessarily be a prosecution. See, e.g., Meese v. Keene, 481 U.S. 465, (1987) (holding that the plaintiff established standing by proving harms flowing from the government s designation of three films as political propaganda ); Canatella, 304 F.3d at (holding that the plaintiff had standing to challenge state bar statutes and professional rules where he had previously been subject to state bar disciplinary proceedings and
15 LOPEZ v. CANDAELE could be subject to them in the future). Moreover, the plaintiffs themselves need not be the direct target of government enforcement. A history of past enforcement against parties similarly situated to the plaintiffs cuts in favor of a conclusion that a threat is specific and credible. See Adult Video Ass n v. Barr, 960 F.2d 781, 785 (9th Cir. 1992), vacated sub nom. Reno v. Adult Video Ass n, 509 U.S. 917 (1993), reinstated in relevant part, 41 F.3d 503 (9th Cir. 1994). [4] But general threat[s] by officials to enforce those laws which they are charged to administer do not create the necessary injury in fact. United Pub. Workers of Am. v. Mitchell, 330 U.S. 75, 88 (1947); see Rincon Band of Mission Indians v. San Diego Cnty., 495 F.2d 1, 4 (9th Cir. 1974) (concluding that the sheriff s statement that all of the laws of San Diego, State, Federal and County, will be enforced within our jurisdiction was insufficient to create a justiciable case (citing, among other cases, Poe v. Ullman, 367 U.S. 497, 501 (1961))). Thus, where multiple plaintiffs challenged a California law that criminalized teaching communism, the Supreme Court concluded that three of the plaintiffs, who had not alleged that they have ever been threatened with prosecution, that a prosecution is likely, or even that a prosecution is remotely possible, but merely that they felt inhibited in advocating political ideas or in teaching about communism, did not have standing. Younger, 401 U.S. at 42. Mere [a]llegations of a subjective chill are not an adequate substitute for a claim of specific present objective harm or a threat of specific future harm. Laird v. Tatum, 408 U.S. 1, (1972). Turning to the second factor, we have concluded that preenforcement plaintiffs who failed to allege a concrete intent to violate the challenged law could not establish a credible threat of enforcement. Because the Constitution requires something more than a hypothetical intent to violate the law, plaintiffs must articulate[ ] a concrete plan to violate the law in question by giving details about their future speech
16 14368 LOPEZ v. CANDAELE such as when, to whom, where, or under what circumstances. Thomas, 220 F.3d at The plaintiffs allegations must be specific enough so that a court need not speculate as to the kinds of political activity the [plaintiffs] desire to engage in or as to the contents of their proposed public statements or the circumstances of their publication. Mitchell, 330 U.S. at 90. For example, a plaintiff challenging the licensing provisions of a state regulatory regime failed the injury in fact requirement because the plaintiff ha[d] never indicated that it intends to pursue another license, and therefore could not assert that it will ever again be subject to the licensing provisions Convoy, 183 F.3d at ; see also, e.g., Thornburgh, 970 F.2d at 510 (organization does not have standing when the only evidence that it would be subject to a law penalizing membership in an alleged terrorist group was that its members received two publications which espoused the terrorist group s views). By contrast, plaintiffs may carry their burden of establishing injury in fact when they provide adequate details about their intended speech. See, e.g., ACLU v. Heller, 378 F.3d 979, 984 (9th Cir. 2004) (holding that a group had standing when an individual member alleged he desired to produce and distribute flyers regarding a specific ballot initiative); Getman, 328 F.3d at 1093 (holding that a group had standing when the group showed, among other things, that it had planned to spend over $1000 to defeat a specific California proposition in the November 2000 election). Without these kinds of details, a court is left with mere some day intentions, which do not support a finding of the actual or imminent injury that our cases require. Thomas, 220 F.3d at 1140 (quoting San Diego Cnty. Gun Rights Comm. v. Reno, 98 F.3d 1121, 1127 (9th Cir. 1996)). [5] Finally, we have indicated that plaintiffs claims of future harm lack credibility when the challenged speech restriction by its terms is not applicable to the plaintiffs, or the enforcing authority has disavowed the applicability of the challenged law to the plaintiffs. In the First Amendment con-
17 LOPEZ v. CANDAELE text, a fear of prosecution will only inure if the plaintiff s intended speech arguably falls within the statute s reach. Getman, 328 F.3d at 1095 (citing Virginia v. Am. Booksellers Ass n, 484 U.S. 383, 392 (1988)). Thus, in Leonard v. Clark, we held that individual firemen did not have standing to challenge a portion of their union s collective bargaining agreement because the provision at issue by its plain language applie[d] only to the Union and not to its individual members. 12 F.3d 885, (9th Cir. 1994); see also Getman, 328 F.3d at 1095 (indicating that a plaintiff has not established an injury in fact where the statute clearly fails to cover [the plaintiff s] conduct (quoting Majors v. Abell, 317 F.3d 719, 721 (7th Cir. 2003))). Likewise, we have held that plaintiffs did not demonstrate the necessary injury in fact where the enforcing authority expressly interpreted the challenged law as not applying to the plaintiffs activities. Thus, a group of school teachers did not have standing to challenge an Oregon textbook selection statute when both the Oregon Attorney General and the school district s lawyer disavowed any interpretation of [the statute] that would make it applicable in any way to teachers. Johnson v. Stuart, 702 F.2d 193, 195 (9th Cir. 1983); cf. LSO, 205 F.3d at 1155 (collecting cases where the government failed to affirmatively disavow an intent to enforce a challenged statute). Of course, the government s disavowal must be more than a mere litigation position. See Thornburgh, 970 F.2d at 508 (holding that aliens had standing to challenge speech restriction statutes, even though the government dropped charges based on those statutes four days before the district court hearing, because, among other things, the government could easily reinstate those charges and was bringing similar charges against other aliens). III We apply these principles to the facts of this case to determine whether Lopez has carried his burden of making a clear
18 14370 LOPEZ v. CANDAELE showing of injury in fact. See Winter, 129 S. Ct. at 376; Lujan, 504 U.S. at 560. Lopez claims he suffered such an injury because he faced a specific, credible threat of adverse state action under the District s sexual harassment policy. A Lopez identifies three actions on the part of LACC employees that, he claims, constitute a credible threat. According to Lopez, Matteson threatened to enforce the sexual harassment policy against him first on November 24, when Matteson interrupted Lopez s informative speech and told the class that they could leave if they were offended, and second on December 2, when Matteson wrote on Lopez s assignment that Lopez had agreed to the Student Code of Conduct as a student at LACC. Third, Lopez claims that Jones s letter constituted a threat to enforce the policy because it informed Lopez that his speech had offended other students. We consider each incident in turn. [6] In the November 24 incident, Matteson aggressively abused Lopez for his statements regarding marriage, prevented Lopez from speaking, asked whether other students were offended, and warned Lopez against proselytizing in school. However, Matteson did not threaten to enforce the sexual harassment policy against Lopez or even suggest that Lopez was violating the policy. Therefore the November 24 incident, while raising serious concerns, does not help Lopez carry his burden of clearly showing he suffered an injury in fact from the sexual harassment policy. Lopez argues that because Matteson told students they could leave if they were offended, and Section 15003(A) defines sexual harassment as including conduct that has the purpose or effect of creating an offensive work or educational environment, Matteson was implicitly invoking the District s sexual harassment policy. We conclude that any link between Matteson s use of the word offended and the sexual harassment policy s use of the word offensive in this context is too attenu-
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text:
People Working
People Working 10/16/16
Hard Heart Part Three 10/09/16
Hard Heart Part Two 10/02/16
Testing if you have a hard heart 09/25/16
Finding Darkness, Part Seven 09/11/16
We're pretty simple folks; we love Jesus, we believe the Bible is the inspired Word of God. We are sinners saved by grace.
Broken Mercy Fellowship ministers at the Anchorage Gospel Rescue Mission. We are scheduled to speak in the chapel on the second Wednesday of each month, at 7:30 pm. If there is a fifth Wednesday to the month, we meet there at 7:30 pm as well.
Many of the messages we have preached at the rescue mission are availble for reading at blog.brokenmercyfellowship.com.

subset: commoncrawl


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Just down the highway from Connecticutas Gold Coast is the stateas rusty underbelly, the wretched, used-up sort of place where you might find Xhenet Aliuas Domesticated Wild Things: the reluctant mothers, delinquent dads, and not-quite-feral children, yet dreamers all. These are the children of immigrants who found boarded-up brass mills instead of the gilded streets of America; theyare the teenaged girls raised in the fluorescent glow of Greek diners, the middle-aged men with pump trucks and teratomas. These are people who have fled, or who should have. And if they are indeed familiar, it is because Aliu writes what is real, whether we ourselves, her readers, have seen it up close or not. And her stories make sense in a way that matters. A young mother buys into a real-estate investment seminar offered on an infomercial, only to be put back into her place by a bully in foreclosure. A closeted wrestler befriends a latchkey seven-year-old neighbor who harbors secrets of her own. A YMCA counselor tries to reclaim shoes stolen by a troubled young camper. What they share is a biting humor, an eye for the absurd, and fumbling attempts at human connection, all rendered irresistibleaand as moving as they are amusingaby a writer whose work is at once edgy and endearing and prize winning for reasons any reader can appreciate.... hour, world-renowned real-estate guru Truman Evans will show you with his patented No Money Down Deal-Sealera#39;s ... the three-thousand-dollar Home Depot gift card WITH YOUR DOWN PAYMENT ON A NEW PREFABRICATED HOMEanbsp;...
|Domesticated Wild Things, and Other Stories
|Xhenet Aliu
|U of Nebraska Press - 2013-09-01


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*From the University of Pennsylvania School of Medicine, Philadelphia, PA.
Correspondence to: Stephen J. Gluckman, MD, University of Pennsylvania, Medical Arts Building, Ste 102, Thirty-Eighth and Filbert Streets, Philadelphia, PA 19104; e-mail: firstname.lastname@example.com
Many acute infectious pulmonary diseases have incubation periods that are long enough for travelers to have symptoms after returning home to a health-care system that is not familiar with "foreign" infections. Respiratory infections have a relatively limited repertoire of clinical manifestations, so that there is often nothing characteristic enough about a specific infection to make the diagnosis obvious. Thus, the pathway to the diagnosis of infections that are not endemic in a region relies heavily on taking a thorough history of both itinerary and of specific exposures. One important caveat is that on occasion, the history of a recent trip creates an element of "tunnel vision" in the evaluating health-care provider. It is tempting to relate a person's problem to that recent trip; however, when evaluating recent returnees, it is always important to remember that the travel may have nothing to do with the patient's presentation. Recent travel may add diagnostic considerations to the list of possibilities, but an astute clinician must not disregard the possibility that the patient's illness has nothing to do with the recent trip.
Respiratory tract infections are among the most common causes of medical problems that physicians manage. Recent foreign and domestic travel can add additional diagnostic considerations to the list of likely possibilities. Transportation is rapid enough that it can exceed the incubation period of many illnesses, so that patients might initially present after returning to health-care providers who are not accustomed to dealing with them. An outbreak of coccidioidomycosis in Washington State in a church group recently returned from Mexico is an example.1A number of reviews have noted that respiratory infections are common in international travelers, accounting for up to 25% of the febrile illness that health-care workers are asked to evaluate.2–6Table 1
shows important diagnostic possibilities based on the region of the world traveled that should be added to the local possibilities for returning travelers with respiratory problems. Each will be discussed in this review. Not only is the region of the world important, but any specifics of exposure might be the clue to trigger appropriate diagnostic tests and treatment. Table 2
list some specific exposures to consider in the history.
Concerns about the infectious risks of travel have been heightened recently. In 2002 to 2003, the outbreak of severe acute respiratory syndrome (SARS) in the Far East was associated with aircraft transmission.7In May 2007, a person with possible extremely drug-resistant tuberculosis was quarantined by the Centers for Disease Control and Prevention (CDC) after air travel. Events such as these alert the public to infectious disease transmission on planes. Accurate data about the infectious risks of air travel are limited, and therefore this risk is difficult to quantify. Published reports of such transmission are rare. There were 120 people, 1 of whom with symptomatic SARS, on a Boeing 737-300 traveling from Hong Kong to Beijing. Laboratory-confirmed SARS developed in 16 passengers, and 6 others possibly were infected. Passengers with infection were clustered in a few rows directly in front of or behind the ill passenger.8Despite this outbreak the risk is low. By May 2003, the World Health Organization (WHO) reviewed information on 35 flights in which a patient with symptomatic SARS had been onboard. Only four flights appeared to be associated with possible transmission.9Vogt et al10found no transmission on seven international flights carrying SARS patients. In May 2003, the WHO issued guidelines for the containment of in-flight SARS.11
Tuberculosis has also been transmitted on aircraft, and like SARS the risk appears to be very small.12–13 Since screening for active tuberculosis is not required for most air travelers, persons with active disease may travel on commercial aircraft without being aware of their contagion. From 1992 to 1994, the CDC investigated seven flights that carried persons with highly active tuberculosis. There was evidence of transmission on three of the flights (one case was from a flight attendant to other crew members). As with SARS, the risk was related to the proximity to the index patient.14However, despite intensive investigation, these seven exposures to active tuberculosis on aircraft resulted in few new tuberculous infections and no tuberculous disease. Air travel represents a negligible risk factor for the acquisition of tuberculosis.15
Aircraft have been a great concern as a potential vector for the global spread of influenza. Air travel has resulted in international outbreaks of influenza and will likely be a major vector when the next pandemic occurs.16–18 However, during an epidemic, actual transmission of influenza during flight is much less of a health concern.
Although a worry of the traveling public, "common cold" outbreaks related to airplane transmission have not been reported. A study19 that compared the risks for an upper respiratory tract infection developing during air travel in 50% recirculated vs 100% fresh cabin air noted no difference in the two groups.
Environmental control measures on commercial aircraft have recently been reviewed by Mangili and Gendreau.20While an aircraft is parked at the gate with the engines off, passenger cabin ventilation is normally supplied by the air conditioning system and the natural airflow through the open door(s) of the aircraft. During flight, the aircraft cabin has systems that control air exchanges. At cruising altitude, outside ambient air is virtually free of microorganisms. Air enters the cabin from overhead vents and flows downwards toward the outflow grills along both side walls of the cabin near the floor. Air enters and leaves the cabin at approximately the same row; airflow along the length of the cabin is minimal. All commercial jet aircraft built after the late 1980s recirculate the cabin air: from 10 to 50% of the cabin air is filtered, mixed with outside, and then reintroduced into the passenger cabin. On most aircraft, the recirculated air passes through high-efficiency particulate air filters before reentering the passenger cabin. The most efficient high-efficiency particulate air filters will remove 99.99% of particles (bacteria, fungi, and larger viruses).21All large commercial jet aircraft provide approximately 20 air exchanges per hour during cruising. This can be compared to that of the standard modern office building that averages 12 exchanges per hour. The concentration of microorganisms in cabin air is much lower than shopping malls and the air terminal.22
There is no evidence that recirculation of cabin air facilitates transmission of infectious disease agents on board, and the mechanisms described above to manage air flow should make risks minimal for passengers other than those sitting within close proximity to an index patient.23 However, when the aircraft is delayed on the ground and the doors are closed, the ventilation system should be operating. An influenza outbreak associated with an airplane flight resulted when a ground delay lasted 3 h, during which the ventilation system did not operate and the passengers did not receive outside air.18 Thus, although inflight risks are minimal, ground delays without adequate ventilation could be a problem. According to a study by the US Department of Transportation: "If the ventilation system is not operating, passengers should not stay aboard the plane for long time periods (ie, > 30 min).",24
Overall, airplane travel appears to represent a low risk of acquiring a respiratory infection. This risk is probably not out of line with other situations in which people are in close proximity to each other, such as office buildings and theaters. This risk is a function of the contagion and proximity to the index case and the duration of the flight. This risk is also related to the efficacy of the cabin ventilation system. Properly functioning systems are probably very effective at decreasing this risk; however, when systems are not working, such as when passengers are kept aboard grounded aircraft, outbreaks are facilitated.
Cruise ships have also been associated with outbreaks of respiratory diseases, particularly Legionnaires disease.25–26 As with land-associated outbreaks, those aboard ship have been linked to contaminated water sources. Given the nature of the prolonged exposure on cruises, it is not surprising that outbreaks of influenza have also been reported.27
Although tuberculosis rarely presents acutely, it can; and this is such an important disease worldwide that it deserves some brief mention here. Primary tuberculosis most commonly has a lower-lobe presentation and can be indistinguishable clinically from other causes of pneumonia. There are few data on the actual risk for a traveler.28In a Dutch study29of 656 young adults who traveled to areas of the world with high tuberculosis endemicity, the overall risk of skin test conversion was 3.5 per 1,000 person-months. In our ongoing study of medical personnel working in a hospital in Botswana where 80% of the patients are infected with tuberculosis, we have found a rate of skin test conversion of 42/1,000 person-months (Z. Szep, MD; personal communication; December 20, 2007). Any traveler who returns from an area of high incidence of tuberculosis to an area of low incidence should be tested for latent tuberculosis.30
There is an extensive literature on travel-related outbreaks associated with cruise ships; however, a number other sources of travel-related outbreaks have been reported.31–32 According to the CDC, 20% of patients hospitalized with Legionnaires disease in the United States acquired their infection while traveling.33Pneumonia is the major clinical manifestation of infection with Legionella pneumophila. The onset tends to be subacute. Respiratory symptoms may not be initially prominent. Although accompanying GI symptoms and hyponatremia might be more prominent with Legionella pneumonia, there are no clinical, radiologic, or initial laboratory features that allow one to reliably distinguish this from other causes of lobar pneumonia.35 There are several options for diagnosis. Testing for urinary antigen can be done in hours, and is very specific if the infection is with L pneumophila serogroup I, which accounts for 80% of the cases. It will not identify any of the other Legionella species or serogroups. Culture on selective media is also very specific but takes several days and has a relatively low sensitivity. Serology can only confirm the diagnosis after recovery. Most patients should have sputum sent for urinary antigen testing and culture. Treatment should be with a newer macrolide or a quinolone. In resource-poor settings, erythromycin plus rifampin can be used.
Burkholderia pseudomallei is distributed throughout most of the world but is endemic in parts of China, Australia, and Southeast Asia. Subclinical infection is common in endemic areas. Risk factors for clinical disease include diabetes, chronic alcoholism, chronic lung disease, and chronic renal disease.36Most disease is pulmonary, although bacteremic spread can involve virtually any organ. Pulmonary syndromes include acute pneumonia, chronic pneumonia, and latent pulmonary infection with reactivation. Latent infection can clinically manifest many years after initial exposure. Acute pneumonia has an incubation period of days and has a presentation with fever, productive cough, rigors, and dyspnea that is similar to other bacterial pneumonias.37Both subacute pneumonia and reactivation pneumonia are clinically indistinguishable from tuberculosis and some fungal pneumonias manifesting fever, night sweats, productive cough, and hemoptysis. Chest radiographic appearance can vary widely depending on the pulmonary syndrome. In acute pneumonia military nodules, lobar or multilobar consolidation and pleural effusions can be seen. As the disease progresses, cavitation can occur. In chronic melioidosis, infiltrates may be cavitating, nodular, or linear and fibrotic mimicking tuberculosis. The diagnosis of melioidosis is established by culture of sputum and/or blood. B pseudomallei is resistant to penicillin, ampicillin, aminoglycosides, and first- or second-generation cephalosporins. Recommended antibiotics include ceftazidine or carbapenems. In severe infections, many would add trimethoprim-sulfamethoxazole. In resource-poor, settings chloramphenicol and trimethoprim-sulfamethoxazole have been used. Initial IV therapy should be given for 2 to 8 weeks depending on the severity of the illness, and then oral therapy with high-dose trimethoprim-sulfamethoxazole to prevent relapse should be continued for at least 3 months.38
Yersinia pestis is widely distributed in the world. It is particularly prevalent in the developing world. In the United States, there is an endemic pocket in the Southwest. Worldwide, the major reservoir is the rat, although in the United States it is the prairie dog. The flea is the vector for transmission from animals. In addition to bubonic and septicemia syndromes, pneumonia can be a manifestation. After a relatively brief incubation period of 2 to 7 days, fever, productive cough, pleuritic chest pain, and often hemoptysis develop. The disease progresses rapidly with cavitation common. Plague pneumonia is not reliably distinguishable from other causes of rapidly progressive necrotizing pneumonia on clinical grounds alone.39The diagnosis is confirmed by isolating Y pestis from sputum, blood, and/or an aspirate of an enlarged lymph node. Up to 40% of patients have the organism visible on peripheral blood smear. The sputum is highly contagious, and patients should be in strict isolation for the first 48 h of therapy. Treatment needs to be initiated quickly. The traditional medication has been streptomycin. However, a number of other drugs have been shown to have in vitro activity and clinical success, including tetracyclines and gentamicin.40 Postexposure prophylaxis with tetracycline, doxycycline, or trimethoprim-sulfamethoxazole should be administered to all persons with close contact.41
Francisella tularensis is only found in the northern hemisphere. Reservoirs are rabbits and small rodents, and the vectors are several different hemophagic arthropods. Pneumonia, one of a number of clinical presentations, begins abruptly after a several-day incubation period. The cough is typically nonproductive. Chest radiographs reveal lobar consolidations, sometimes with hilar adenopathy and pleural effusions.42The organism can be isolated from sputum and blood but will not grow on standard media, and it represents a transmission risk for laboratory workers. Although the clinical syndrome is not unique, recognition is greatly facilitated by obtaining a potential exposure history related to outdoor activity. Diagnosis is usually confirmed serologically. Treatment options include streptomycin, gentimicin, tetracyclines, and chloramphenicol.43
New-world hantaviruses such as the Sin Nombre virus, found primarily in the Southwest United States, and strains found in Central and South America cause hantavirus pulmonary syndrome (HPS).44Old-world hantaviruses cause hemorrhagic fever with renal syndrome. All medically important hantaviruses have rodent reservoirs. Although person-to-person transmission has been described, most transmission to humans occurs via aerosolization in buildings with heavy rodent infestations.45HPS has clinical features that along with a potential exposure history should make it a strong consideration. The incubation period can be relatively long, lasting 1 to 4 weeks before the onset of initial symptoms of a "typical" viral syndrome with fever, headache, nausea, vomiting, and myalgias; respiratory symptoms are generally at presentation. After several days, the abrupt onset of severe tachypnea and dry cough indicates noncardiogenic pulmonary edema due to severe capillary leak into the lungs. This stage lasts 24 to 48 h and ends with either death in 50% of those infected or a rapid recovery. In addition to the exposure and characteristic clinic history, clues that suggest the diagnosis include thrombocytopenia, hemoconcentration, and circulating immunoblasts.46Diagnosis can be confirmed serologically or by polymerase chain reaction on blood. Treatment is supportive. Extracorporeal membrane oxygenation has also been successfully used to sustain patients through the capillary leak part of the illness.47 No antiviral treatment is presently recommended.
There are a number of viruses that can produce a hemorrhagic fever syndrome. These include yellow fever, dengue, Lassa fever, Rift Valley fever, Crimean-Congo hemorrhagic fever, Marburg, and Ebola. Dengue is widespread throughout the developing world, and yellow fever is endemic in periequatorial Africa and South America, while the others tend to occur in localized outbreaks primarily in Africa. Incubation period is 1 to 2 weeks. The initial presentations are typical of a viral illness with fever, headache, and myalgias. Pulmonary manifestations are seen and are due to ARDS. These viral infections are diagnosed serologically, and treatment is supportive.
Travelers are often in close contact with relatively large numbers of individuals in hotels, airport terminals, ships, and other destinations where tourists congregate. This increases the possibility of exposure to influenza and other respiratory pathogens. In 2003, the Haji pilgrimage was associated with an estimated 24,000 cases of influenza.48Influenza is typically a winter-time disease in the temperate regions of both the northern and southern hemispheres, but it circulates throughout the year in equatorial regions. Both the Canadian Committee to Advise on Tropical Medicine and Travel and the US Advisory Committee on Immunization Practices recommend influenza vaccination for a traveler going to the southern hemisphere from April through September and at any time of year when in tour groups if the traveler has not been vaccinated in the previous year. A potential problem with this recommendation is the lack of available vaccine in the "off" season in the northern hemisphere. It is reasonable to consider giving a traveler a treatment dose of oseltamivir to carry if they have been inadequately vaccinated and are in a risk group for severe disease. In addition to this background concern the emergence of Avian influenza (H5N1) in Asia in 2003 has further heightened concerns. Avian influenza is now a firmly established zoonosis in birds in many countries. The risk to humans involves close exposure to poultry; human-to-human transmission remains very uncommon at this time. The WHO does not suggest travel restrictions based on concerns about avian influenza but does suggest avoidance of poultry farms and markets in countries affected by avian influenza. The CDC has offered similar guidelines.49–50 Additional recommendations regarding travel and avian influenza are listed in Table 3
Several species of the fluke, paragonimus, are distributed throughout the world. Most human infections are associated with the Far East and are due to Paragonimus westermani. Human infection occurs after the ingestion of undercooked fresh-water crabs or crayfish. After ingestion, the acute larval migratory phase lasts 4 to 8 weeks, and symptoms include abdominal discomfort, pleuritic chest pain, and nonproductive cough. Fever and hemoptysis are rare. Radiologic findings can include pleural effusions and migratory parenchymal infiltrates.51Important laboratory clues include eosinophilic pleural fluid and a marked peripheral eosinophilia. After several months, the larva develop into adult flukes and most infections then become asymptomatic. When chronic symptoms occur, the most common are recurrent hemoptysis and pleuritic chest pain. Eosinophilia is no longer present. This can last for many years. The differential diagnostic concerns for chronic paragonimiasis are principally tuberculosis and malignancy.52–53 During the acute larval migratory phase before adult worms have developed to produce eggs, the diagnosis of paragonimiasis is primarily clinical. After about 2 months, identification of the ova in the sputum or feces confirms infection. Serologic testing is also available. Treatment is highly effective with a 2-day course of praziquantel,54–55 but triclabendazole (available through the CDC) appears to be as effective or better tolerated.
Pulmonary manifestations of schistosomiasis are uncommon and, if present, generally occur early in the illness as part of the Katayama fever syndrome.56Fresh-water swimming in endemic areas of South America, Africa, and Asia exposes the patient to the larva that penetrate the skin. During the initial 2 to 6 weeks of infection, some persons have a hypersensitivity reaction characterized by fever, arthralgias, myalgias, headache, generalized adenopathy, and pulmonary infiltrates with eosinophilia. Nodular infiltrates seem to be particularly common.57 The diagnosis of Katayama fever is based on an appropriate exposure history and consistent clinical findings. As with paragonimus, it is too early in the infection for eggs to be detectable in the stool. There is no specific treatment for acute pulmonary schistosomiasis. The benefit of praziquantel for acute schistosomiasis is controversial because it only has efficacy against the adult worms. If praziquantel is used for acute infection, it should be administered at about 8 weeks when the adult worms have developed. Corticosteroids are often prescribed to lessen symptoms.56–58
Strongyloides (Strongyloides stercoralis), ascaris (Ascaris lumbricoides) and occasionally hookworm (Necator americanus and Ancelostema duodenale) can all produce a syndrome of pulmonary infiltrates with eosinophilia during the larval migratory phase (Loeffler syndrome). Patients complain of a nonproductive, blood-tinged cough plus dyspnea and occasionally fever. During larval migration, the stool is generally negative, although larva can be identified in sputum specimens. Eosinophils and Charcot Leyden crystals in the sputum should suggest the diagnosis in a recent traveler. The pulmonary syndrome is generally self-limited; however, the infection should be treated. Strongyloides are treated with ivermectin. Ascaris and hookworm are treated with mebendazole. Tropical eosinophilia is a related syndrome, although a more serious disease due to a hypersensitivity reaction and the larval migration of microfilaria. The vector for the filaria is the mosquito, and it can found throughout the tropics, especially India. Diagnostic clues are a very high blood eosinophilia and high IgE levels. Elevations of filarial antibodies support the diagnosis.59 Diethylcarbamazine has some efficacy, especially when administered early in the infection, but progressive interstitial fibrosis can result even if treated. A number of parasites are associated with the syndrome of pulmonary infiltrates with eosinophilia. They are listed in Table 4
Histoplasmosis is a fungus that is found throughout the world. It is particularly endemic in the Midwestern United States in the Mississippi and Ohio River valleys. Exposure history often involves soil that has been enriched with bird or bat droppings. Most infections are asymptomatic, but when symptomatic pulmonary disease is the most common manifestation. Mild disease appears as a subacute "flu-like" illness 2 to 4 weeks after exposure with nonproductive cough, myalgias, and fever. Chest radiograph reveals pulmonary infiltrates and hilar or mediastinal adenopathy. In most cases, the symptoms resolve without treatment over several weeks, but a sustained period of asthenia is not unusual. Antifungal therapy is generally not needed in these patients. This form of pulmonary histoplasmosis is not distinctive enough to be able to distinguish it on clinical grounds from other atypical pneumonias; the clue should be in eliciting an exposure history such as working with soil (cleaning a chicken coop) or spelunking in the weeks prior to the onset of symptoms. Heavy exposure results in a much more severe illness after an incubation period of a week. Patients can be severely dyspneic and can progress to respiratory failure. Chest radiographs have a military pattern. There are a number of modalities available for diagnosing acute pulmonary histoplasmosis. The sensitivity of the tests varies with the severity of the syndrome. In mild disease, sputum smear and culture results are rarely positive; urinary antigen testing is better but still only positive in up to 25 to 75% of infected persons, increasing in sensitivity with the severity of the illness. Antibody testing is the most sensitive, although it usually takes at least 4 weeks for antibodies to be detected.60If the patient undergoes BAL, the fluid can also be tested for antigen and stained for histoplasma. Culture of this fluid and/or biopsy material has the highest yield but can take several weeks to become positive. Since most acute pulmonary disease is mild and self-limited, most persons do not need treatment. Treatment is generally indicated in severe disease (hypoxia) and in prolonged disease (no improvement by 2 weeks). Severe disease should be treated with amphotericin B. This can be transitioned to itraconazole as the patient improves. Itraconazole can be used initially in milder symptomatic infection. Although in vitro and animal studies62 suggest excellent activity, there is not enough human experience with posaconazole or voriconazole to recommend them and echinocandins should not be used. Steroid therapy is generally indicated when using antifungals to treat histoplasmosis; their use is associated with a rapid clinical improvement and allows a quicker transition to itraconazole. Treatment should be continued for 2 to 3 months.
Coccidioides immitis is endemic in the soil of the arid regions of the Western Hemisphere (not just the US southwest). Most infections are subclinical, with acute disease occurring with an incubation period of 1 to 4 weeks in less than one half of those infected.63The syndrome is that of an atypical pneumonia with fever, nonproductive cough, myalgias, chest pain, and headache (Valley fever). Erythema nodosum is seen in approximately 10% of cases, and when present is a helpful clue to distinguish coccidioides infection from other causes of community-acquired pneumonia. Erythema multiforme is also associated with infection with this organism. The only unusual laboratory marker is an eosinophilia seen in approximately one fourth of cases. Chest radiographic findings can be normal or may show infiltrates with associated hilar adenopathy. These may result in residual nodules and/or thin-walled cavities. Symptoms resolve in most patients in 2 to 3 months without treatment. Particularly severe infections or infections in persons with impaired cell-mediated immunity often show pulmonary progression and/or dissemination and should be treated. In addition, pregnant women, diabetics, and persons of African or Philippine origin are more likely to have complications. Diagnosis is generally made serologically, although the organism can be isolated from respiratory secretions and coccidioides spherules can occasionally be seen in sputum. When treatment is necessary, imidazoles and amphotericin are used.64–66
Coxiella burnetti is found throughout the world. Infection with this organism can produce a number of different syndromes, but one of the more commonly diagnosed is pneumonia. The incubation period is relatively long, 2 to 6 weeks. Pneumonia in Q fever is clinically indistinguishable from other atypical pneumonias with fever, a nonproductive cough, and interstitial infiltrates. The disease is generally mild, although severe cases can occur with about a 1% mortality.67Exposure history involves sheep and goats, especially around the time of delivery. A normal leukocyte count is the rule, and thrombocytopenia is frequently seen. Moderately elevated transaminase levels are seen in most patients.68 The diagnosis is confirmed serologically, and standard treatment is with a tetracycline for 2 weeks, although macrolides, trimethoprim-sulfamethoxazole, and floroquinones all are of benefit. β-Lactam antibiotics should not be used.
Chlamydophila psittaci (formerly Chlamydia) is found throughout the world, and most infected persons have a history of contact with birds. This disease is clearly not just associated with psittacine birds; many bird species are reservoirs including domestic poultry. The birds may not be ill. Psittacosis presents abruptly with a 1- to 2-week incubation period after bird exposure. It is a systemic illness with a respiratory component characterized by lobar pneumonia syndrome that can occasionally be fatal. Severe headache is a very prominent symptom in most patients.69 The diagnosis is generally confirmed serologically. Treatment is with tetracyclines or macrolides.
Many other infections can have respiratory symptoms as generally a minor manifestation of the clinical picture. Table 5
list several of the more common travel-related infections.
Because, as noted, respiratory infections have a limited repertoire of signs and symptoms, it is unlikely that one can make a specific diagnosis of an infection on clinical grounds alone. The following can be used as a guideline for approaching the returning traveler with a potential respiratory infection: (1) consider non–travel-related pulmonary problems, including noninfectious causes; (2) consider the itinerary; (3) consider the incubation period; how long after return did the symptoms develop? (4) are there other travelers with a similar illness? (5) were there specific exposures on the trip that might predispose to a particular illness, eg, fresh-water swimming and schistosomiasis?
Travel is common, and most incubation periods for acute infectious pulmonary diseases are long enough that patients may have symptoms after returning home to a health-care system that is not familiar with "foreign" infections. Respiratory infections have a relatively limited repertoire of clinical manifestations, so that there is often nothing characteristic enough about a specific infection to make the diagnosis obvious. Thus, the pathway to the diagnosis of infections that are not endemic in a region relies heavily on taking a thorough history of both itinerary and of specific exposures (eg, fresh-water swimming in Africa, caving in Virginia, desert hiking in Arizona). One final caveat is that on occasion, the history of a recent trip creates an element of "tunnel vision" in the evaluating health-care provider. It is tempting to relate a person's problem to that recent trip; however, when evaluating recent returnees it is always important to remember that the travel may have nothing to do with the patient's presentation. Recent travel adds diagnostic considerations to the list of possibilities.
Abbreviations: CDC = Centers for Disease Control and Prevention; HPS = hantavirus pulmonary syndrome; SARS = severe acute respiratory syndrome; WHO = World Health Organization
The author has no outside financial support or conflicts of interest to disclose.
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Take out your trowel and kneepads, it's time to get those bulbs in the ground!
When shorter summer days give way to fall, it signals the beginning of the end to another gardening season. Instead of dreading it, celebrate it with one last planting push.Read More
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Hi apple_san,
Even ladies who are menstrating should not have their feet massaged. Hence, pregnant ladies going for massage is a strict NO.
Reason being, the acupressure points connected to all our organs are found at the sole of our feet. Given that you are pregnant, they may apply incorrect pressure ..etc, hence it is just not advisable. In particular, you are in the final semester.
What you can do, use foot cream... and give gentle strokes (certainly Hubby can be put to good use here). While lying down, you may also wish to lift your legs at an angle (not too steep), this helps too.
Hubby can also help to apply the cream onto the calves and giving gentle upward strokes.
Re soaking your feet, personally I wouldn't recommend, especially those with herbs.
This is also the reason why pregnant ladies are not allowed to do hair treatment or colour their hair coz hair follicles and sole of feet are entry points into our inner body.
Just hang on there... soon, you will see a bright chubby happy baby greeting you.
Take good care!!


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Sophomore quarterback Connor Shaw had his best statistical game since Kentucky, completing 16 of 18 passes for 217 yards and three touchdowns, while rushing 11 times for 90 yards. Included in that total was an electrifying 60-yard run in which he outran the entire Citadel defense to the goal line. It marked his longest rush of the season and the team's third-longest rush by any Carolina athlete this year.
"Connor had his best game," said USC coach Steve Spurrier. "I think, ever as a Gamecock, rushing for over 100 yards and hitting 16 out of 18 for 217 yards. He definitely was a game-ball guy. It was good."
"I think so," Shaw said when asked if this was his best game at USC. "Like I've said before, I'm getting better week by week. Those are big plays, but I had a lot of help on that."
Shaw wasn't alone as freshman running back Brandon Wilds also played well, picking up his third 100-yard rushing game in four starts. He also scored two touchdowns, filling in for injured All-American Marcus Lattimore better than anyone could have anticipated. He has rushed for 387 yards and three touchdowns on 87 carries, while catching 11 passes for 115 yards.
Probably most satisfying for the Gamecock offense was the re-introduction of Alshon Jeffery to the attack. He caught five passes for 81 yards, including a jaw dropping reception for a 32-yard touchdown.
The Gamecocks were only average by their standards defensively as The Citadel used its triple option attack to rush for 214 yards. The Bulldogs only managed seven yards through the air, however.
It was Carolina's second game against a triple option team as it topped Navy early in the season.
--Junior WR Alshon Jeffery, due mostly to specialty defenses and inconsistency at quarterback, has not had the kind of season statistically as he did during his freshman and sophomore campaigns. The All-American, who is rated as a first round pick in the 2012 National Football League Draft if he chooses to forgo his senior campaign, proved he still had it when he leaped over a Citadel defender and made a one-handed catch for a 32-yard touchdown. He had five catches for 81 yards. He moved into ninth place (2,865) on the all-time SEC career receiving yards list. He is now tied for second on the consecutive games with a reception list with his 34th-straight.
--Senior Melvin Ingram had his second big play on special teams, rushing for 19 yards on fourth down when USC was in punt formation. He now has two rushes for 87 yards and a touchdown.
--Senior linebacker Rodney Paulk led the team with 12 tackles, a career high. He also added a forced fumble and a tackle for loss.
--The Carolina defense allowed only eight yards passing, the fewest passing yards allowed in a game by a Gamecock defense since Steve Spurrier took over the program.
--South Carolina rushed for 256 yards against The Citadel, the third-highest mark for a Gamecock offense under head coach Steve Spurrier. USC was 3-for-3 on fourth down attempts for the game, moving the Gamecocks to 69 percent on the year (18-for-26).
KEEP AN EYE ON: WR Ace Sanders -- The sophomore caught a 25-yard touchdown pass from quarterback Connor Shaw in the third quarter. The reception was his second touchdown of the year and marks the second straight game he has made a key reception.
LOOKING GOOD: The Citadel proved to be the medicine for what ailed the South Carolina offensive line as the unit provided both running lanes for the Gamecock backs and time for Connor Shaw to sit in the pocket to look for open receivers. Freshman Mike Matulis continues to impress at right tackle as he appeared to have little trouble against The Citadel in his second straight start. The improved play comes at a good time because the unit will probably face pressure against the Clemson front four on Saturday.
STILL NEEDS WORK: Although Carolina has been stellar against the run throughout most of the season, it was gashed for 241 yards by The Citadel's triple option attack. Senior Travian Robertson has been stellar up the middle, along with freshman Kelcy Quarles. The team has allowed back-to-back solid performances in the run game as Florida rushed for more than 130 yards a week ago.
QUOTE TO NOTE: "That is interesting, isn't it? I didn't know it was quite that lopsided, but it wouldn't surprise me that much. I can't respond to it. I'd be criticizing the refs if I responded to it." -- USC coach Steve Spurrier on the fact that rival offensive linemen have been called for only three holding calls against his team all season.
--QB Connor Shaw continues to improve as he receives on the job training. The sophomore had potentially his best game as a Gamecock, completing 16 of 18 passes for 217 yards and three touchdowns. He also rushed 11 times for 90 yards, including a 60-yard touchdown jaunt.
--RB Brandon Wilds had his second straight 100-yard rushing game and third in his four starts since taking over for injured All-American Marcus Lattimore. He rushed 20 times for 109 yards and two touchdowns, while catching four passes for 55 yards. Just as important, he managed to block well in blitz protection.
--RT Mike Matulis continues to impress since being made the starter. The offense has been more productive as he completed his second straight game without allowing a sack.
--DT Travian Robertson is playing his best football of the season. Coming off a performance when he was named Southeastern Conference Defensive Lineman of the Week. he led all USC down linemen with seven tackles, including one for loss.
--DE Jadeveon Clowney suffered a slight concussion. His status will be updated later in the week.
--LB Damario Jeffery suffered a high ankle sprain against The Citadel. His status for Saturday's game against Clemson is doubtful.
--WR Bruce Ellington suffered a sprained ankle and did not play in the second half. His status will be determined later in the week.
--LB Shaq Wilson suffered a sprained knee, but returned to the game.
--SS DeVonte Holloman suffered a slight concussion. It is believed he will play this week.
--LB Quin Smith did not play due to a back strain.
--LB Reginald Bowens suffered a sprained ankle.
NOTEBOOK: Offense back on track
Gamecock Anthem Top Stories
New Head Coaches Mid-Season ReportThere were a lot of college football head coaching changes before this season. Let's take a look at how a few have fared so far this season.
ScoutWednesday at 4:59 PM
Scout's Top 25 Recruiting ClassesScout has a new top school in the recruiting rankings. Take a look at capsules for the top 25 classes in the country, including a new number one.
Scout FootballMonday at 10:20 AM
Updated Scout 300 Trend Meter For 2017The updated Scout 300 Trend Meter for the 2017 class takes a look at which schools are trending for each uncommitted member in the Scout 300.
Scout Football10/07/2016
UGA-USC Game Moved to SundayATHENS - Saturday's game at South Carolina will be played Sunday afternoon.
Dawg Post10/06/2016
Scout On the Road: SeptemberScout takes a look at some of the top prospects we saw in person during the month of September...
Scout Football09/28/2016


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New Orleans, Louisiana 70163
United States
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Andrew Hamilton is a partner in Morgan Lewis's Business and Finance Practice. Mr. Hamilton practices in the areas of mergers and acquisitions, private equity and venture capital, securities law, and general corporate counseling.
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A master's degree is a postgraduate academic degree. One must already have an undergraduate degree to apply for a master's program. Most master's degree program would require students to complete a master's thesis or research paper.
The Master's degree in Shipping Management intends to advance the business practice and explore the impact of international legislation to develop strategies within the shipping industry. It hopes to address the complex factors which are involved in the management of a shipping operation.
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Flower Pot
1314 W Mcdermott Drive, Allen, TX, 75013, USA
1314 W Mcdermott Drive,
Allen ,
About Flower Pot:
Flower Pot, your local Allen flower shop. We deliver flowers same day throughout Allen, TX area and all our deliveries are made by hand. Order flowers online for same day and next day delivery.
Opening Times:
- Mon
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- Tue
- 9am - 5pm
- Wed
- 9am - 5pm
- Thu
- 9am - 5pm
- Fri
- 9am - 5pm
- Sat
- 9am - 2pm
- Sun
- Closed
Overview for Flower Pot
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Glowing feedback from our family in Frisco and we feel we received great service. Nice to know that living so far off in Australia it was so easy to order from you. Thanks - Well done.
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Located in Rochester, Microtel Inn & Suites by Wyndham Chili/Rochester Airport is close to Roberts Wesleyan College and St. Padre Pio Chapel. This hotel is within the vicinity of Victorian Doll Museum and Chili Doll Hospital and Rochester Institute of Technology.
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