Joseph V. Sakran, M.D., M.P.A., M.P.H.

https://www.hopkinsmedicine.org/profiles/results/directory/profile/10003558/joseph-sakran

Arthrodesis gastritis spanish discount 15 mg lansoprazole with mastercard, osteotomy and arthroplasty all have their place and are considered in the appropriate chapters gastritis symptoms bloating cheap lansoprazole 15mg amex. However chronic gastritis diet guide purchase lansoprazole 15 mg free shipping, it should be recognized that patients who are no longer suffering the pain of active synovitis and who are contented with a limited pattern of life may not want or need heroic surgery merely to improve their anatomy gastritis usmle cheap lansoprazole 15 mg on-line. Complications Fixed deformities the perils of rheumatoid arthritis are often the commonplace ones resulting from ignorance and neglect gastritis symptoms pms 15 mg lansoprazole fast delivery. Early assessment and planning should prevent postural deformities gastritis causes generic lansoprazole 30 mg overnight delivery, which will result in joint contractures. Muscle weakness Even mild degrees of myopathy or neuropathy, when combined with prolonged inactivity, may lead to profound muscle wasting and weakness. This should be prevented by control of inflammation, physiotherapy and pain control, if possible; if not, the surgeon must be forewarned of the difficulty of postoperative rehabilitation. Joint rupture Occasionally the joint lining ruptures ular erosions, rheumatoid nodules, severe muscle wasting, joint contractures and evidence of vasculitis are bad prognostic signs. Without effective treatment about 10 per cent of patients improve steadily after the first attack of active synovitis; 60 per cent have intermittent phases of disease activity and remission, but with a slow downhill course over many years; 20 per cent have severe joint erosion, which is usually evident within the first 5 years; and 10 per cent end up completely disabled. However, early aggressive medical treatment appears to reduce the morbidity and mortality. It is characterized by pain and stiffness of the back, with variable involvement of the hips and shoulders and (more rarely) the peripheral joints. Males are affected more frequently than females (estimates vary from 2:1 to 10:1) and the usual age at onset is between 15 and 25 years. Sudden clinical deterioration, or increased pain in a single joint, should alert one to the possibility of septic arthritis and the need for joint aspiration. Spinal cord compression this is a rare complication of cervical spine (atlanto-axial) instability. The onset of weakness and upper motor neuron signs in the lower limbs is suspicious. If they occur, immobilization of the neck is essential and spinal fusion should be carried out as soon as possible. Corticosteroids and immunosuppressives such as intravenous cyclophosphamide may be required. Amyloidosis this is another rare but potentially lethal complication of longstanding rheumatoid arthritis. When the patient is first seen it is difficult to predict the outcome, but high titres of rheumatoid factor, peri-artic- 66 which then react with the antigen-presenting cells. The preferential involvement of the insertion of tendons and ligaments (the entheses) has resulted in the unwieldy term enthesopathy. Synovitis of the sacroiliac and vertebral facet joints causes destruction of articular cartilage and peri-articular bone. The costovertebral joints also are frequently involved, leading to diminished respiratory excursion. Inflammation of the fibro-osseous junctions affects the intervertebral discs, sacroiliac ligaments, symphysis pubis, manubrium sterni and the bony insertions of large tendons. Pathological changes proceed in three stages: (1) an inflammatory reaction with cell infiltration, granulation tissue formation and erosion of adjacent bone; (2) replacement of the granulation tissue by fibrous tissue; and (3) ossification of the fibrous tissue, leading to ankylosis of the joint. Ossification across the surface of the disc gives rise to small bony bridges or syndesmophytes linking adjacent vertebral bodies. Occasionally the disease starts with pain and slight swelling in a peripheral joint such as the ankle, or pain and stiffness of the hip. In women the axial skeletal disease may remain restricted to the sacroiliac joints making diagnosis challenging. Early on there is little to see apart from slight flattening of the lower back and limitation of extension in the lumbar spine. There may be diffuse tenderness over the spine and sacroiliac joints, or (occasionally) swelling and tenderness of a single large joint. In established cases the posture is typical: loss of the normal lumbar lordosis, increased thoracic kyphosis and a forward thrust of the neck; upright posture and balance are maintained by standing with the hips and knees slightly flexed, and in late cases these may become fixed deformities. Spinal movements are diminished in all directions, but loss of extension is always the earliest and the most severe disability. Chest expansion, which should be at least 7 cm in young men, is often markedly decreased. There may also be tenderness of the ligament and tendon insertions close to a large joint or under the heel. Acute anterior uveitis occurs in about 25 per cent of patients; it usually responds well to treatment but, if neglected, may lead to permanent damage including glaucoma. Other extraskeletal disorders, such as aortic valve disease, carditis and pulmonary fibrosis (apical), are rare and occur very late in the disease. Extraskeletal manifestations joints and may show typical erosions and features of inflammation such as bone oedema. Various techniques including gadolinium contrast can be used to demonstrate inflammatory lesions in other areas of the spine. Later there may be peri-articular sclerosis, especially on the iliac side of the joint and finally bony ankylosis. Later, ossification of the ligaments around the intervertebral discs produces delicate bridges (syndesmophytes) between adjacent vertebrae. Osteoporosis is common in longstanding cases and there may be hyperkyphosis of the thoracic spine due to wedging of the vertebral bodies. Diagnosis Diagnosis is easy in patients with spinal rigidity and typical deformities, but it is often missed in those with early disease or unusual forms of presentation. Atypical onset is more common in women, who may show less obvious changes in the sacroiliac joints. Mechanical disorders Low back pain in young adults is usually attributed to one of the more common disorders such as muscular strain, facet joint dysfunction or spondylolisthesis. Non-steroidal anti-inflammatory drugs It is doubtful whether these drugs prevent or retard the progress to ankylosis, but they do control pain and counteract soft-tissue stiffness, thus making it possible to benefit from exercise and activity. X-rays show pronounced but asymmetrical intervertebral spur formation and bridging throughout the dorsolumbar spine. This can result in significant improvement in disease activity including remission. These therapies are generally reserved for individuals who have failed to be controlled with non-steroidal anti-inflammatory drugs. Other seronegative spondyloarthropathies A number of disorders are associated with vertebral and sacroiliac lesions indistinguishable from those of ankylosing spondylitis. Operation Significantly damaged hips can be treated by joint replacement, though this seldom provides more than moderate mobility. Moreover, the incidence of infection is higher than usual and patients may need prolonged rehabilitation. Deformity of the spine may be severe enough to warrant lumbar or cervical osteotomy. These are difficult and potentially hazardous procedures; fortunately, with improved activity and exercise programmes, they are seldom needed. If spinal deformity is combined with hip stiffness, hip replacements (permitting full extension) often suffice. Complications Spinal fractures the spine is often both rigid and osteoporotic; fractures may be caused by comparatively mild injuries. General measures Patients are encouraged to remain active and follow their normal pursuits as far as possible. They should be taught how to maintain satisfactory posture and urged to perform spinal extension exercises every day. Rest and immobilization are contraindicated because they tend to increase the general feeling of stiffness. Hyperkyphosis In longstanding cases the spine may become severely kyphotic, so much so that the patient has difficulty lifting his head to see in front of his feet. It may be caused by atlanto-axial subluxation or by ossification of the posterior longitudinal ligament. It is now recognized that this is one of the classic forms of reactive arthritis, i. Its prevalence is difficult to assess, but it is probably the commonest type of large-joint polyarthritis in young men. Men are affected more often than women (the ratio is about 10:1), but this may simply reflect the difficulty of diagnosing the genitourinary infection in women. Pathology the pathological changes are essentially the same as those in ankylosing spondylitis, with the emphasis first on subacute large-joint synovitis and in some individuals with a chronic disease course tending towards sacroiliitis and spondylitis. The joint may be acutely painful, hot and swollen with a tense effusion, suggesting gout or infection. Tendo Achilles tenderness and plantar fasciitis (evidence of enthesopathy) are common, and the patient may complain of backache even in the early stage. Conjunctivitis, urethritis and bowel infections are often mild and easily missed; the patient should be carefully questioned about symptoms during the previous few weeks. Less frequent, but equally characteristic, features are a vesicular or pustular dermatitis of the feet (keratoderma blennorrhagica), balanitis and mild buccal ulceration. The acute disorder usually lasts for a few weeks or months and then subsides, but most patients have either recurrent attacks of arthritis or other features of chronic disease. Gut pathogens include Shigella flexneri, Salmonella, Campylobacter species and Yersinia enterocolitica. Lymphogranuloma venereum and Chlamydia trachomatis have been implicated as sexually transmitted infections. All these bacteria can survive in human cells; assuming that either the bacterium or a peptide bacterial fragment acts as the antigen, the pathogenesis could be the same as that suggested for ankylosing spondylitis. This is particularly important for sexually transmitted infections such as Chlamydia trachomatis. Even if the triggering infection is identified, treating it will have no effect on the reactive arthritis. However, there is some evidence that treatment of Chlamydia infection with tetracycline for periods of up to 3 months can reduce the risk of recurrent joint disease. Symptomatic treatment could include the use of analgesia and non-steroidal anti-inflammatory drugs. If the inflammatory response is aggressive then local injection of corticosteroids or even intramuscular methylprednisolone may be useful. Uveitis is also fairly common and may give rise to posterior synechiae and glaucoma. X-rays Sacroiliac and vertebral changes are similar to those of ankylosing spondylitis. The causative organism can sometimes be isolated from urethral fluids or faeces, and tests for antibodies may be positive. Diagnosis the diagnosis should be considered in any young adult who presents with an acute or subacute arthritis in the lower limbs. It is more likely to be missed in women, in children and in those with very mild (and often forgotten) episodes of genitourinary or bowel infection. Some patients never develop the full syndrome and one should be alert to the formes fruste with large-joint arthritis alone. Examination of synovial fluid for organisms and crystals may provide important clues. Gonococcal arthritis takes two forms: (1) bacterial infection of the joint; and (2) a reactive arthritis with sterile joint fluid. Sacroiliac and spine changes, which occur in about 30 per cent of patients, are similar to those in ankylosing spondylitis. Psoriasis of the skin or nails usually precedes the arthritis, but hidden lesions (in the natal cleft or umbilicus) are easily overlooked. Sometimes (particularly in women) joint involvement is more symmetrical, and in these cases the condition may be indistinguishable from seronegative rheumatoid arthritis. Asymmetrical swelling of two or three fingers may be due to a combination of interphalangeal arthritis and tenosynovitis. Sacroiliitis and spondylitis are seen in about one-third of patients, and occasionally this is the predominant change with a clinical picture resembling ankylosing spondylitis. Fingers and toes are severely deformed due to erosion and instability of the interphalangeal joints (arthritis mutilans).

Micro-organisms may reach the musculoskeletal tissues by (a) direct introduction through the skin (a pinprick gastritis gas cheap 15mg lansoprazole with visa, an injection gastritis gluten free diet cheap 30 mg lansoprazole otc, a stab wound gastritis vs gallbladder disease order 30mg lansoprazole fast delivery, a laceration gastritis diet ����� purchase 15 mg lansoprazole amex, an open fracture or an operation) gastritis and gastroparesis diet buy discount lansoprazole 30mg on line, (b) direct spread from a contiguous focus of infection gastritis diet ���������� order 30mg lansoprazole with visa, or (c) indirect spread via the blood stream from a distant site such as the nose or mouth, the respiratory tract, the bowel or the genitourinary tract. Depending on the type of invader, the site of infection and the host response, the result may be a pyogenic osteomyelitis, a septic arthritis, a chronic granulomatous reaction (classically seen in tuberculosis of either bone or joint), or an indolent response to an unusual organism. Softtissue infections range from superficial wound sepsis to widespread cellulitis and life-threatening necrotizing cellulitis. Parasitic lesions such as hydatid disease also are considered in this chapter, although these are infestations rather than infections. The signs of inflammation are recounted in the classical mantra: redness, swelling, heat, pain and loss of function. In one important respect, bone infection differs from soft-tissue infection: since bone consists of a collection of rigid compartments, it is more susceptible than soft tissues to vascular damage and cell death from the build-up of pressure in acute inflammation. Systemic effects are less acute but may ultimately be very debilitating, with lymphadenopathy, splenomegaly and tissue wasting. The principles of treatment are: (1) to provide analgesia and general supportive measures; (2) to rest the affected part; (3) to identify the infecting organism and administer effective antibiotic treatment or chemotherapy; (4) to release pus as soon as it is detected; (5) to stabilize the bone if it has fractured; (6) to eradicate avascular and necrotic tissue; (7) to restore continuity if there is a gap in the bone; and (8) to maintain soft-tissue and skin cover. Acute infections, if treated early with effective antibiotics, can usually be cured. The causal organism in both adults and children is usually Staphylococcus aureus (found in over 70% of cases), and less often one of the other Gram-positive cocci, such as the Group A beta-haemolytic streptococcus (Streptococcus pyogenes) which is found in chronic skin infections, as well as Group B streptococcus (especially in new-born babies) or the alphahaemolytic diplococcus S. In children between 1 and 4 years of age the Gramnegative Haemophilus influenzae used to be a fairly common pathogen for osteomyelitis and septic arthritis, but the introduction of H. Trauma may determine the site of infection, possibly by causing a small haematoma or fluid collection in a bone, in patients with concurrent bacteraemia. The incidence of acute haematogenous osteomyelitis in western European children is thought to have declined in recent years, probably a reflection of improving social conditions. Escherichia coli, Pseudomonas aeruginosa, Proteus mirabilis and the anaerobic Bacteroides fragilis) occasionally cause acute bone infection. Curiously, patients with sickle-cell disease are prone to infection by Salmonella typhi. Anaerobic organisms (particularly Peptococcus magnus) have been found in patients with osteomyelitis, usually as part of a mixed infection. Unusual organisms are more likely to be found in heroin addicts and as opportunistic pathogens in patients with compromised immune defence mechanisms. In adults the source of infection may be a urethral catheter, an indwelling arterial line or a dirty needle and syringe. In children the infection usually starts in the vascular metaphysis of a long bone, most often in the proximal tibia or in the distal or proximal ends of the femur. Predilection for this site has traditionally been attributed to the peculiar arrangement of the blood vessels in that area (Trueta, 1959): the non-anastomosing terminal branches of the nutrient artery twist back in hairpin loops before entering the large network of sinusoidal veins; the relative vascular stasis and consequent lowered oxygen tension are believed to favour bacterial colonization. It has also been suggested that the structure of the fine vessels in the hypertrophic zone of the physis allows bacteria more easily to pass through and adhere to type 1 collagen in that area (Song and Sloboda, 2001). In infants, in whom there are still anastomoses between metaphyseal and epiphyseal blood vessels, infection can also reach the epiphysis. In adults, haematogenous infection accounts for only about 20% of cases of osteomyelitis, mostly affecting the vertebrae. Staphylococcus aureus is the commonest organism but Pseudomonas aeruginosa often appears in patients using intravenous drugs. Adults with diabetes, who are prone to soft-tissue infections of the foot, may develop contiguous bone infection involving a variety of organisms. The earliest change in the metaphysis is an acute inflammatory reaction with vascular congestion, exudation of fluid and infiltration by polymorphonuclear leucocytes. The intraosseous pressure rises rapidly, causing intense pain, obstruction to blood flow and intravascular thrombosis. Even at an early stage the bone tissue is threatened by impending ischaemia and resorption due to a combination of phagocytic activity and the local accumulation of cytokines, growth factors, prostaglandin and bacterial enzymes. By the second or third day, pus forms within the bone and forces its way along the Volkmann canals to the surface where it produces a subperiosteal abscess. This is much more evident in children, because of the relatively loose attachment of the periosteum, than in adults. From the subperiosteal abscess pus can spread along the shaft, to re-enter the bone at another level or burst into the surrounding soft tissues. The developing physis acts as a barrier to direct spread towards the epiphysis, but where the metaphysis is partly intracapsular. The rising intraosseous pressure, vascular stasis, small-vessel thrombosis and periosteal stripping 2 Infection (a) (b) Sequestrum Pathology Acute haematogenous osteomyelitis shows a characteristic progression marked by inflammation, suppuration, bone necrosis, reactive new bone formation and, ultimately, resolution and healing or else intractable chronicity. Some of the bone may die, and is encased in periosteal new bone as a sequestrum (c). Bacterial toxins and leucocytic enzymes also may play their part in the advancing tissue destruction. With the gradual ingrowth of granulation tissue the boundary between living and devitalized bone becomes defined. Pieces of dead bone may separate as sequestra varying in size from mere spicules to large necrotic segments of the cortex in neglected cases. Macrophages and lymphocytes arrive in increasing numbers and the debris is slowly removed by a combination of phagocytosis and osteoclastic resorption. A small focus in cancellous bone may be completely resorbed, leaving a tiny cavity, but a large cortical or cortico-cancellous sequestrum will remain entombed, inaccessible to either final destruction or repair. Initially the area around the infected zone is porotic (probably due to hyperaemia and osteoclastic activity) but if the pus is not released, either spontaneously or by surgical decompression, new bone starts forming on viable surfaces in the bone and from the deep layers of the stripped periosteum. This is typical of pyogenic infection and fine streaks of subperiosteal new bone usually become apparent on x-ray by the end of the second week. With time this new bone thickens to form a casement, or involucrum, enclosing the sequestrum and infected tissue. If the infection persists, pus and tiny sequestrated spicules of bone may discharge through perforations (cloacae) in the involucrum and track by sinuses to the skin surface. If the infection is controlled and intraosseous pressure released at an early stage, this dire progress can be halted. The bone around the zone of infection becomes increasingly dense; this, together with the periosteal reaction, results in thickening of the bone. In some cases the normal anatomy may eventually be reconstituted; in others, though healing is sound, the bone is left permanently deformed. If healing does not occur, a nidus of infection may remain locked inside the bone, causing pus and sometimes bone debris to be discharged intermittently through a persistent sinus (or several sinuses). The infection has now lapsed into chronic osteomyelitis, which may last for many years. Acute osteomyelitis in infants the early features of acute osteomyelitis in infants are much the same as those in older children. However, a significant difference, during the first year of life, is the frequency with which the metaphyseal infection spreads to the epiphysis and from there into the adjacent joint. In the process, the physeal anlage may be irreparably damaged, further growth at that site is severely retarded and the joint will be permanently deformed. Others have disagreed with this hypothesis (Chung, 1976), but what is indisputable is that during infancy osteomyelitis and septic arthritis often go together. Another feature in infants is an unusually exuberant periosteal reaction resulting in sometimes bizarre new bone formation along the diaphysis; fortunately, with longitudinal growth and remodelling the diaphyseal anatomy is gradually restored. Acute osteomyelitis in adults Bone infection in the adult usually follows an open injury, an operation or spread from a contiguous focus of infection. True haematogenous osteomyelitis is uncommon and when it does occur it usually affects one of the vertebrae. A vertebral infection may spread through the end-plate and the intervertebral disc into an adjacent vertebral body. If a long bone is infected, the abscess is likely to spread within the medullary cavity, eroding the cortex and extending into the surrounding soft tissues. Periosteal new bone formation is less obvious than in childhood and the weakened cortex may fracture. If the bone end becomes involved there is a risk of the infection spreading into an adjacent joint. Children the patient, usually a child over 4 years, presents with severe pain, malaise and a fever; in neglected cases, toxaemia may be marked. The parents will have noticed that he or she refuses to use one limb or to allow it to be handled or even touched. There may be a recent history of infection: a septic toe, a boil, a sore throat or a discharge from the ear. Typically the child looks ill and feverish; the pulse rate is likely to be over 100 and the temperature is raised. The limb is held still and there is acute tenderness near one of the larger joints. Local redness, swelling, warmth and oedema are later signs and signify that pus has escaped from the interior of the bone. It is important to remember that all these features may be attenuated if antibiotics have been administered. Suspicion should be aroused by a history of birth difficulties, umbilical artery catheterization or a site of infection (however mild) such as an inflamed intravenous infusion point or even a heel puncture. Metaphyseal tenderness and resistance to joint movement can signify either osteomyelitis or septic arthritis; indeed, both may be present, so the distinction hardly matters. There may be a history of some urological procedure followed by a mild fever and backache. Local tenderness is not very marked and it may take weeks before x-ray signs appear; when they do appear the diagnosis may still need to be confirmed by fine-needle aspiration and bacteriological culture. Other bones are occasionally involved, especially if there is a background of diabetes, malnutrition, drug addiction, leukaemia, immunosuppressive therapy or debility. In the very elderly, and in those with immune deficiency, systemic features are mild and the diagnosis is easily missed. Later the periosteal thickening becomes more obvious and there is patchy rarefaction of the metaphysis; later still the ragged features of bone destruction appear. An important late sign is the combination of regional osteoporosis with a localized segment of apparently increased density. Osteoporosis is a feature of metabolically active, and thus living, bone; the segment that fails to become osteoporotic is metabolically inactive and possibly dead. This is a highly sensitive investigation, even in the very early stages, but it has relatively low specificity and other inflammatory lesions can show similar changes. In doubtful cases, scanning with 67Ga-citrate or 111In-labelled leucocytes may be more revealing. It is extremely sensitive, even in the early phase of bone infection, and can therefore assist in differentiating between soft-tissue infection and osteomyelitis. Displacement of the fat planes signifies soft-tissue swelling, but this could as well be due to a haematoma or soft-tissue infection. By the second week there may Laboratory investigations the most certain way to confirm the clinical diagnosis is to aspirate pus or fluid from the metaphyseal subperiosteal abscess, the extraosseous soft tissues or an adjacent joint. Even if no pus is found, a smear of the aspirate is examined immediately for cells and organisms; a simple Gram stain may help to identify the type of infection and assist with the initial choice of antibiotic. A sample is also sent for detailed microbiological examination and tests for sensitivity to antibiotics. Tissue aspiration will give a positive result in over 60% of cases; blood cultures are positive in less than half the cases of proven infection. Intense pain and board-like swelling of the limb in a patient with fever and a general feeling of illness are warning signs of a medical emergency. Acute rheumatism the pain is less severe and it tends to flit from one joint to another. In the very young and the very old these tests are less reliable and may show values within the range of normal. In areas where Salmonella is endemic it would be wise to treat such patients with suitable antibiotics until infection is definitely excluded. The diagnosis is made by finding other stigmata of the disease, especially enlargement of the spleen and liver. Treatment If osteomyelitis is suspected on clinical grounds, blood and fluid samples should be taken for laboratory investigation and then treatment started immediately without waiting for final confirmation of the diagnosis. Mild cases will respond to high dosage oral antibiotics; severe cases need intravenous antibiotic treatment. Acute suppurative arthritis Tenderness is diffuse, and movement at the joint is completely abolished by muscle spasm. In infants the distinction between metaphyseal osteomyelitis and septic arthritis of the adjacent joint is somewhat theoretical, as both often coexist. Analgesics should be given at repeated intervals without waiting for the patient to ask for them. Septicaemia and fever can cause severe dehydration and it may be necessary to give fluid intravenously.

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Where a waiver of immunity is not effectuated directly before the courts of the forum State gastritis diet �� order lansoprazole 30 mg line, the authorities that have received the communication relating to the waiver shall use all means available to them to transmit it to the organs competent to determine the application of immunity gastritis diet 4 your blood lansoprazole 15 mg with visa. The duty to notify was seen as the first guarantee for a State to safeguard its interests by invoking or waiving the immunity chronic superficial gastritis definition cheap lansoprazole 15 mg with mastercard. It was noted that notification should be made as soon as the competent authorities of the forum State have sufficient information to conclude the presence of a foreign official who could be subject to its criminal jurisdiction and such notification should contain all the elements allowing the State of the official to assess its interests gastritis diabetes diet generic 30 mg lansoprazole mastercard. As to the form and procedure for notification gastritis symptoms forum cheap lansoprazole 30 mg mastercard, the Special Rapporteur observed that a model similar to the invocation and waiver of immunity had been used gastritis diet for cats trusted lansoprazole 30 mg. The Special Rapporteur noted that draft article 131477 was premised on the recognition that the forum State would need information from the State of the official in order to decide on immunity, in particular with respect to immunity ratione materiae. Nevertheless, the Special Rapporteur underlined that the mechanism under the draft article provided a procedural guarantee that favoured both the forum State and of the State of the official. Paragraphs 4 and 6 contained provisions regarding refusal by the State of the official. The form and procedure for the request of information were modelled on the provisions on invocation, waiver and notification. Draft article 141478 addressed the transfer of the criminal proceedings from the forum State to the State of the official. Where the competent authorities of the forum State have sufficient information to conclude that a foreign official could be subject to its criminal jurisdiction, the forum State shall notify the State of the official of that circumstance. For that purpose, States shall consider establishing in their domestic law appropriate procedures to facilitate such notification. The notification shall include the identity of the official, the acts of the official that may be subject to the exercise of criminal jurisdiction and the authority that, in accordance with the law of the forum State, is competent to exercise such jurisdiction. The notification shall be provided through any means of communication accepted by both States or through means provided for in international cooperation and mutual legal assistance treaties to which both States are parties. Where no such means exist or are accepted, the notification shall be provided through the diplomatic channel. The forum State may request from the State of the official information that it considers relevant in order to decide on the application of immunity. That information may be requested through the procedures set out in international cooperation and mutual legal assistance treaties to which both States are parties, or through any other procedure that they accept by common agreement. Where no applicable procedure exists, the information may be requested through the diplomatic channel. Where the information is not transmitted directly to the competent judicial organs so that they can rule on immunity, the authorities of the forum State that receive it shall, in accordance with domestic law, transmit it directly to the competent courts. For that purpose, States shall consider establishing in their domestic law appropriate procedures to facilitate such communication. The State of the official may refuse a request for information if it considers that the request affects its sovereignty, public order (ordre public), security or essential public interests. Before refusing the request for information, the State of the official shall consider the possibility of making the transmission of the information subject to conditions. The information received shall, where applicable, be subject to conditions of confidentiality stipulated by the State of the official, which shall be fulfilled in accordance with the mutual assistance treaties that provide the basis for the request for and provision of the information or, failing that, to conditions set by the State of the official when it provides the information. Refusal by the State of the official to provide the requested information cannot be considered sufficient grounds for declaring that immunity from jurisdiction does not apply. Therefore, the transfer of proceedings will be subjected to the national laws of the forum State and, where appropriate, to the conventions of international judicial assistance which bind both States. The effect of the referral is materialized in the "suspension" of the exercise of the jurisdiction of the forum State, which is now subject to the pronouncement of the State of the official on the exercise of its own jurisdiction. And, in any case, it can operate as a useful instrument to avoid the problem of politicization or abuse of the exercise of jurisdiction by the forum State through the channel of allowing the State of the official to exercise its own jurisdiction. Draft article 15, 1479 couched in general terms, regulated a flexible mechanism for consultations to facilitate the search for solutions when problems of any kind arose in the process of determining the applicability of immunity in a particular case or, if that was not possible, to agree on some avenue of dispute settlement existing under international law. The Special Rapporteur noted that draft article 161480 addressed procedural rights and safeguards applicable to the foreign official. Although immunity was for the benefit of the State of the official, the exercise of jurisdiction by the forum State had a direct bearing on the State official. The draft article recognized the right of the State official to benefit from all fair treatment guarantees, including procedural rights and safeguards related to a fair and impartial trial. The draft article was modelled on the provision adopted by the Commission in the draft articles on prevention and punishment of crimes against humanity. Regarding the future programme of work on the topic, the Special Rapporteur recalled that her sixth report referred to the need of tackling, in a future report, the obligation to cooperate with an international criminal court and its possible impact on the immunity of 1. The authorities of the forum State may consider declining to exercise its jurisdiction in favour of the State of the official, transferring to that State criminal proceedings that have been initiated or that are intended to be initiated against the official. Once a transfer has been requested, the forum State shall suspend the criminal proceedings until the State of the official has made a decision concerning that request. The proceedings shall be transferred to the State of the official in accordance with the national laws of the forum State and the international cooperation and mutual judicial assistance agreements to which the forum State and the State of the official are parties. A State official whose immunity from foreign criminal jurisdiction is being examined by the authorities of the forum State shall benefit from all fair treatment safeguards, including the procedural rights and safeguards relating to a fair and impartial trial. These safeguards shall be applicable both during the process of determining the application of immunity from jurisdiction and in any court proceeding initiated against the official in the event that immunity from jurisdiction does not apply. The official shall be treated in a fair and impartial manner consistent with applicable international rules and the laws and regulations of the forum State. Besides, in her seventh report she mentioned that this issue had arisen before the International Criminal Court in relation to the Appeal request introduced by Jordan relating to the arrest warrant and surrender of the then President Al-Bashir. Regarding the decision of the International Criminal Court Appeals Chamber issued on 6 May 2019,1481 she believed it was not necessary or useful for the current work of the Commission to start a discussion on this judgment. Moreover, it was worth noting that the decision of the General Assembly on the request of an advisory opinion from the International Court of Justice in relation to the immunity of Heads of State and its relationship with the duty to cooperate with the International Criminal Court was still pending. Therefore, she did not believe it was necessary to submit any specific proposal to the Commission at this point during the current session. Nonetheless, she keeps the option of coming back to this question in the next session from a broader perspective, which must not necessarily be referred exclusively to exceptions of immunity or procedural aspects (including procedural guarantees) of this topic. On the other hand, the Special Rapporteur also solicited views of members on (a) the possibility of dealing with the settlement of disputes; and (b) the desirability and the usefulness of addressing "good practices," which could examine such issues as the referral of power to decide on the application of immunity to the highest courts; the definition of the functions of the Prosecutor; and the preparation of manuals for the authorities and organs of the State dealing with issues of immunity. The present summary relates to the debate on the sixth and seventh reports of the Special Rapporteur at the present session. It should be read together with the summary of the debate on the sixth report at the seventieth session. Members commended the Special Rapporteur for her extensive work on the seventh report which, together with the sixth report, provided a rich and detailed review and analysis of State practice, case law and academic literature relevant to procedural aspects. While several members observed that the draft articles proposed in the seventh report should be more closely based on practice, members also appreciated the deductive methodology employed by the Special Rapporteur to provide de lege ferenda proposals in the progressive development of international law. The acknowledgment by the Special Rapporteur regarding the status of the proposals as constituting progressive development of international law was welcomed. The importance of taking into account State practice from more diverse regions was nevertheless underlined by some members. In that connection, a number of members offered relevant examples including domestic legislation, case law and bilateral agreements. The convenience to maintain consistency with the work of the Commission on other related topics such as crimes against humanity and peremptory norms of general international law (jus cogens), as well as the topic of universal criminal jurisdiction on the long-term programme of work, was also highlighted. Concerning the approach to the procedural aspects of the topic, members underlined the importance of balancing essential legal interests, including respect for the sovereign equality of States, the need to combat impunity for international crimes, as well as the protection of State officials from the politically motivated or abusive exercise of criminal jurisdiction. In this regard, concerns expressed in the debates of the Commission and the Sixth Committee regarding the overpoliticization or abuse of the exercise of criminal jurisdiction over State officials were reiterated. In order to achieve a careful balance between 1481 1482 Situation in Darfur, Sudan, In the case of the Prosecutor v. Omar Hassan Ahmed Bashir (Decision under article 87(7) of the Rome Statute on the non-compliance by Jordan with the request by the Court for the arrest and surrender or Omar Al-Bashir). Members also highlighted the crucial link between the procedural aspects of the topic and the exceptions to immunity in respect of serious crimes under international law set out in draft article 7, which had been provisionally adopted by the Commission. In this connection, several members concurred with the Special Rapporteur, as she had explained in her introduction of the seventh report, that the procedural guarantees and safeguards proposed in draft articles 8 to 16 were applicable to the draft articles as a whole. Other members expressed concerns that draft articles 8 to 16, as presently drafted, did not sufficiently establish a link between the proposed procedural guarantees and safeguards and the application of draft article 7 nor address fully the procedures and guarantees necessary to avoid politically motivated prosecutions. The divergent views expressed by members in respect of the adoption of draft article 7 were reiterated. While the need to avoid reopening the debate on draft article 7 was stressed by a number of members, it was recalled by several members that States were evenly divided in their positions on draft article 7, taking into account the distinction between lex lata and lex ferenda. Therefore, some members emphasized the paramount importance of designing specific procedural safeguards to address concerns regarding the application of draft article 7. At the same time, it was cautioned by several members that the content of draft article 7 should not be undermined. It was noted in any event that further meaningful discussion of the topic was bound to entail an elaboration of a draft similar to draft article 7. Some other members doubted that the use of procedural safeguards could sufficiently cure the substantive flaws inherent in draft article 7, noting further that the draft article remained an obstacle to agreement within the Commission on the topic. Nonetheless, it was recognised by several members that certain proposals made by members in previous debates on the topic merited detailed consideration and provided a good basis for further discussion. In this connection, some support was expressed for a proposal to clarify that the general procedural provisions and safeguards under draft articles 8 to 16 were applicable to the situations covered in draft article 7, and to formulate specific safeguards in relation to draft article 7. Three conditions for the exercise of jurisdiction by the forum State over a foreign State official pursuant to draft article 7 were proposed, namely: (a) the decision to institute criminal proceedings must be taken at the highest level of government or prosecutorial authority; (b) the evidence that the official committed the alleged offence must be fully conclusive; and (c) the forum State must have notified the State of the official of the intention to exercise jurisdiction and must have offered to transfer the proceedings to the courts of the State of the official or to an international criminal court or tribunal. Further, a view was expressed that the presence of the concerned State official in the territory of the forum State was also crucial. It was also considered by some members that there should be a presumption of immunity until determination of its absence was made. Moreover, some members viewed as imperative judicial review of any decision on immunity. On the other hand, some alternative suggestions were made regarding the notion of "fully conclusive" as an evidentiary standard, including "reliable and sufficient" or "prima facie", given that this was a matter that had to be considered as a preliminary matter before actual trial. Further, some members stressed the need to achieve a balance between the interests of the forum State and those of the State of the official, in line with the principle of reciprocity. According to some members, draft articles 8 to 16 seemed to place more weight on the right to exercise jurisdiction of the forum State over the right to immunity of the State of the official. In this regard, it was suggested that more discretion should be granted to the State of the official in asserting immunity, although the possibility of abuse by the State of the official in blocking the exercise of jurisdiction by the forum State also raised concerns. Another issue that required clarification was the extent to which the distinction between immunity ratione personae and immunity ratione materiae was reflected in draft 318 Advance version (20 August 2019) articles 8 to 16. Some members considered that all the procedural safeguards in draft articles 8 to 16 would apply to both types of immunity, while other members preferred to have separate draft articles addressing the different procedural aspects of immunity reflecting the difference between immunity ratione personae and immunity ratione materiae. Members generally agreed that draft articles 8 to 16 could be streamlined and simplified. It was also considered important to cover all key points with sufficient clarity and detail to ensure that they are effective and operational. Some members viewed it appropriate for the draft articles to address only those procedural aspects that were directly related to the immunity of foreign State officials and to leave aside other issues to be regulated by existing treaties. The view was expressed regarding an apparent over-reliance in the draft articles on the judiciary in criminal procedure in civil law systems at the expense of other systems where executive and prosecutorial authorities played a more prominent role. Various proposals were also made to reorder the draft articles so that the proposed procedures would be better linked, adopting a new ordering that might start with draft articles 8, 12, 10, 11 and then draft article 9. Since national legal systems were varied and it was the prerogative of States to adopt internal procedures relating to immunity, it was noted by some members that the draft articles should aim to provide States with a common procedural framework to adopt in their domestic law without being overly prescriptive. In this regard, it was suggested that a simpler provision based on article 32, paragraphs 1 and 2, of the Vienna Convention on Diplomatic Relations would suffice. References to phrases like "consider immunity", "affected by criminal proceedings" were considered vague and unclear. While it was observed that the consideration of immunity as proposed in draft article 8 could be framed in general terms taking into account the circumstances of each State, a proposal was made to provide that States should make efforts to enact or amend national laws governing procedures concerning determination of immunity in draft article 9. The relevance of applicable rules of international law in the determination of immunity under draft article 9 was also raised. Another view was that reference to national and international law could result in confusion. Several members remarked that draft articles 8 and 9 should provide for a more flexible approach concerning the relevant organs of the forum State in the consideration and determination of immunity. Some members considered it sufficient to refer to the competent authorities of the forum State, while others preferred to simply refer to the forum State. At the same time, some members welcomed the acknowledgment that the courts of the forum State usually had the primary authority to determine immunity, as reflected in draft article 9. The concern was expressed that the courts of the forum State should be independent from, not subordinated to , the executive branch. In this regard, clarification was sought regarding the obligation by the courts of the forum State to consider information provided by other authorities. Further, the need to address the role of the prosecutor in the process of consideration and determination of immunity, as well as the issue of control of prosecutorial discretion, was underlined. It was suggested that draft article 8 (consideration of immunity) be redrafted to include the consideration of immunity at the different stages of investigation, particularly with respect to different forms of detention in respect of immunity ratione materiae, and trial. Some members expressed the view that some limitations should be apply to draft article 8 in order to avoid a negative impact on the investigation. A proposal was made to specify in draft article 9 that whatever State organ is involved, the determination of immunity should be made at a relatively high level.

Response of human immunodeficiency virusinfected adults to measles-rubella vaccination gastritis stress order 30mg lansoprazole with visa. Immunogenicity and safety of 1 vs 2 doses of quadrivalent meningococcal conjugate vaccine in youth infected with human immunodeficiency virus gastritis fever lansoprazole 30 mg on line. Effect of immunization with a common recall antigen on viral expression in patients infected with human immunodeficiency virus type 1 gastritis remedy food proven lansoprazole 15 mg. Panel Roster and Financial Disclosures (Last updated: September 2021) Section Leadership Member Constance Benson Institution University of California gastritis diet ������ discount 30mg lansoprazole otc, San Diego gastritis green stool safe lansoprazole 30 mg, School of Medicine Centers for Disease Control and Prevention University of Washington gastritis in toddlers cheap 30mg lansoprazole, School of Medicine National Institutes of Health National Institutes of Health Yale University, School of Medicine University of Colorado Denver, School of Medicine the University of Texas Southwestern Medical School the University of Texas Southwestern Medical Center University of Illinois at Chicago, College of Pharmacy Financial Disclosure Company Gilead Sciences Relationship Research Support (paid to institution) N/A N/A John Brooks Shireesha Dhanireddy Henry Masur Alice Pau Section Review Group Lydia Barakat Thomas Campbell* None None None None None None N/A N/A N/A N/A Ellen Kitchell None N/A Susana Lazarte Gilead Sciences Research Support (paid to institution) Consultant Research Support (paid to institution) Rodrigo Mauricio Burgos OptumRx Merck Janssen Vaccines & Prevention B. DeBakey Veterans Affairs Medical Center and Baylor College of Medicine Yale University, School of Medicine Centers for Disease Control and Prevention Brown University, Warren Alpert Medical School Tufts University, School of Medicine Albert Einstein College of Medicine the University of Texas Medical Branch Centers for Disease Control and Prevention Uniformed Services University of the Health Sciences, F. Edward Hebert School of Medicine University of Toronto, Department of Medicine Duke University, School of Medicine Baylor College of Medicine Uniformed Services University of the Health Sciences, F. Stewart Massad Centers for Disease Control and Prevention Washington University in St. Louis, School of Medicine Roche Takeda Seattle Genetics Arena Pharmaceuticals Wave Life Sciences Excision BioTherapeutics, Inc. Hook None Visby Diagnostics N/A Scientific Advisory Board Arlene Sena None N/A Brad Stoner None N/A Kimberly Workowski* Toxoplasma gondii Sarita Boyd Felicia Chow None None None N/A N/A N/A Joseph Kovacs* Janaki Kuruppu Leon Lai Jose M. A licensed health professional is a physician; physician assistant; nurse practitioner; physical, speech, or occupational therapist; physical or occupational therapy assistant; registered professional nurse; licensed practical nurse; or licensed or certified social worker; or registered respiratory therapist or certified respiratory therapy technician. Major modification means the modification of more than 50 percent, or more than 4,500 square feet, of the smoke compartment. Neglect is the failure of the facility, its employees or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish, or emotional distress. A nurse aide is any individual providing nursing or nursing-related services to residents in a facility. For purposes of this subpart, person-centered care means to focus on the resident as the locus of control and support the resident in making their own choices and having control over their daily lives. For purposes of this subpart, the term resident representative means any of the following: (1) An individual chosen by the resident to act on behalf of the resident in order to support the resident in decision-making; access medical, social or other personal information of the resident; manage financial matters; or receive notifications; (2) A person authorized by State or Federal law (including but not limited to agents under power of attorney, representative payees, and other fiduciaries) to act on behalf of the resident in order to support the resident in decision-making; access medical, social or other personal information of the resident; manage financial matters; or receive notifications; or (3) Legal representative, as used in section 712 of the Older Americans Act; or (4) the court-appointed guardian or conservator of a resident. Transfer and discharge includes movement of a resident to a bed outside of the certified facility whether that bed is in the same physical plant or not. The resident has a right to a dignified existence, self-determination, and communication with and access to persons and services inside and outside the facility, including those specified in this section. A facility must establish and maintain identical policies and practices regarding transfer, discharge, and the provision of services under the State plan for all residents regardless of payment source. The resident has the right to exercise his or her rights as a resident of the facility and as a citizen or resident of the United States. This regulation is intended to lay the foundation for the resident rights requirements in long-term care facilities. Staff and volunteers must interact with residents in a manner that takes into account the physical limitations of the resident, assures communication, and maintains respect. For example, getting down to eye level with a resident who is sitting, maintaining eye contact when speaking with a resident with limited hearing, or utilizing a hearing amplification device when needed by a resident. The facility must not establish policies or practices that hamper, compel, treat differently, or retaliate against a resident for exercising his or her rights. Justice Involved Residents "Justice involved residents" includes the following three categories: 1. Residents under the care of law enforcement: Residents who have been taken into custody by law enforcement. Law enforcement includes local and state police, sheriffs, federal law enforcement agents, and other deputies charged with enforcing the law. Residents under community supervision: Residents who are on parole, on probation, or required to conditions of ongoing supervision and treatment as an alternative to criminal prosecution by a court of law. Inmates of a public institution: Residents currently in custody and held involuntarily through operation of law enforcement authorities in an institution, which is the responsibility of a governmental unit or over which a governmental unit exercises administrative control, such as state or federal prisons, local jails, detention facilities, or other penal settings (such as boot camps, wilderness camps). In addition, law enforcement jurisdictions may not be integrated with the operations of the facility. In such a case, surveyors should cite under the specific tag associated with the concern identified. The survey team must consider the potential for both physical and psychosocial harm when determining the scope and severity of deficiencies related to dignity. Surveyors shall make frequent observations on different shifts, units, floors or neighborhoods to watch interactions between and among residents and staff. Do staff explain to the resident what care is being provided or where they are taking the resident Do staff make efforts to understand the preferences of those residents, who are not able to verbalize them, due to cognitive or physical limitations Determine if staff members respond to residents with cognitive impairments in a manner that facilitates communication and allows the resident the time to respond appropriately. For example, a resident with dementia may be attempting to exit the building with the intent to meet her/his children at the school bus. The same-sex spouse of a resident must be afforded treatment equal to that afforded to an opposite-sex spouse if the marriage was valid in the jurisdiction in which it was celebrated. An individual chosen by the resident to act on behalf of the resident in order to support the resident in decision-making; access medical, social or other personal information of the resident; manage financial matters; or receive notifications; 2. A person authorized by State or Federal law (including but not limited to agents under power of attorney, representative payees, and other fiduciaries) to act on behalf of the resident in order to support the resident in decision-making; access medical, social or other personal information of the resident; manage financial matters; or receive notifications; or 3. Nothing in this rule is intended to expand the scope of authority of any resident representative beyond that authority specifically authorized by the resident, State or Federal law, or a court of competent jurisdiction. If the resident has been formally declared incompetent by a court, the representative is whomever the court appoints (for example, a guardian or conservator). A competent resident may wish to delegate decision-making to specific persons, or the resident and family may have agreed among themselves on a decision-making process. In the case of a resident who has been formally declared incompetent by a court, a court appointed resident representative may be assigned. Many statutes and court orders limit the scope of the authority of the representative to act on behalf of the resident. For example, a court-appointed representative might have the power to make financial decisions, but not health care decisions. For example, a representative does not have the right to insist that a treatment be performed that is not medically appropriate or reject a treatment that may be subject to State law. Surveyors must confirm delegation of resident rights to a resident representative. Determine through interview and record review if the resident has been found to be legally incompetent by a court in accordance with state law. Determine if the resident was involved in care planning activities and able to make choices, to the extent possible. Does the resident maintain all of his/her rights, even if he/she has designated a representative to assist with decision-making unless a court has limited those rights under state law, and only to the extent that has been specified by a court under state law Has the resident designated a resident representative and is facility staff respecting the authority of this designate surrogate decision-maker to act on behalf of the resident Autonomy is also expressed through gestures and actions and this also should be recognized. Residents even without capacity or declared incompetent may be able to express their needs and desires. This includes, but is not limited to , communicating in plain language, explaining technical and medical terminology in a way that makes sense to the resident, offering language assistance services to residents who have limited English proficiency, and providing qualified sign language interpreters or auxiliary aids if hearing is impaired. This does not mean that a facility is required to supply and pay for hearing aids. The physician or other practitioner or professional must inform the resident or their representative in advance of treatment risks and benefits, options, and alternatives. The information should be communicated at times it would be most useful to them, such as when they are expressing concerns, raising questions, or when a change in treatment is being proposed. The resident or resident representative has the right to choose the option he or she prefers. This includes, the right of an individual to direct his or her own medical treatment, including withholding or withdrawing life-sustaining treatment. The planning process must- (i) Facilitate the inclusion of the resident and/or resident representative. This applies both to initial decisions about care and treatment, as well as the refusal of care or treatment. Facility staff must support and encourage participation in the care planning process. A resident whose ability to make decisions about care and treatment is impaired, or a resident who has been declared incompetent by a court, must, to the extent practicable, be kept informed and be consulted on personal preferences. The resident has the right to see the care plan and sign after significant changes are made. Determine if the resident and representative were unable to participate, did facility staff consult them in advance about care and treatment changes. Interview staff to determine how they inform residents or their representative of their rights and incorporate their personal preferences, choices, and goals into their care plan. When the resident request is something that facility staff feels would place the individual at risk. Determine how facility staff observes and responds to the non-verbal communication of a resident who is unable to verbalize preferences. However, this may call into question the judgment of facility staff in allowing self-administration of medication for that resident. If the interdisciplinary team was not involved in determining whether the selfadministration of medications was clinically appropriate, cite here at F554. It also does not mean that the physician the resident chose is obligated to provide service to the resident. Before consulting an alternate physician, the medical director must have a discussion with the attending physician. Only after a failed attempt to work with the attending physician or mediate differences may facility staff request an alternate physician. Facility staff may not interfere in the process by which a resident chooses his or her physician. A resident in a distinct part of a general acute care hospital may choose his or her own physician. If the hospital requires that physicians who supervise residents in the distinct part have privileges, then the resident cannot choose a physician who lacks them. The environment must reflect the unique needs and preferences of each resident to the extent reasonable and does not endanger the health or safety of individuals or other residents. Resident seating should have appropriate seat height, depth, firmness, and with arms that assist residents to independently rise to a standing position. Observe staff/resident interactions to determine if staff interact in a manner that a resident with limited sight or hearing can see and hear them. Determine if the resident has the call system within reach and is able to use it if desired. These arrangements could include opposite-sex and same-sex married couples or domestic partners, siblings, or friends. Residents do not have the right to demand that a current roommate is displaced in order to accommodate the couple that wishes to room together. In addition, residents are not able to share a room if one of the residents has a different payment source for which the facility is not certified (if the room is in a distinct part of the facility, unless one of the residents elects to pay privately for his or her care) or one of the individuals is not eligible to reside in a nursing home. When a resident is being moved at the request of facility staff, the resident, family, and/or resident representative must receive an explanation in writing of why the move is required. The resident should be provided the opportunity to see the new location, meet the new roommate, and ask questions about the move. A resident receiving a new roommate should be given as much advance notice as possible. The resident should be supported when a roommate passes away by providing time to adjust before moving another person into the room. Facility staff should provide necessary social services for a resident who is grieving over the death of a roommate.

See also International Convention for the Suppression of the Financing of Terrorism gastritis juice diet order lansoprazole 30 mg with mastercard, art gastritis from diet pills discount lansoprazole 15 mg visa. This paragraph is based on article 46 gastritis diet ����� generic 15mg lansoprazole free shipping, paragraph 11 gastritis symptoms come and go buy lansoprazole 15mg amex, of the 2003 United Nations Convention against Corruption gastritis causes and symptoms buy 30mg lansoprazole mastercard. Paragraph 19 gastritis diet for gastritis cheap lansoprazole 15 mg without prescription, however, allows the requested State to agree that the requesting State may undertake such actions. Further, this provision must be read in conjunction with paragraph 18, which obliges the requesting State to keep the transferee in custody, unless otherwise agreed, based upon his or her detention or sentence in the requested State. This paragraph is based on article 46, paragraph 12, of the 2003 United Nations Convention against Corruption. The second sentence of the provision allows for States to consult with each other where the expenses to fulfil the request will be "of a substantial or extraordinary nature". This paragraph is based on article 46, paragraph 28, of the 2003 United Nations Convention against Corruption. For example, the commentary to the 1988 United Nations Convention against Illicit Traffic in Narcotic Drugs and Psychotropic Substances provides: this rule makes for simplicity, avoiding the keeping of complex accounts, and rests on the notion that over a period of time there will be a rough balance between States that are sometimes the requesting and sometimes the requested party. In practice, however, that balance is not always maintained, as the flow of requests between particular pairs of parties may prove to be largely in one direction. For this reason, the concluding words of the first sentence enable the parties to agree to a departure from the general rule even in respect of ordinary costs. See also United Nations Convention against Illicit Traffic in Narcotic Drugs and Psychotropic Substances, art. Commentary on the United Nations Convention against Illicit Traffic in Narcotic Drugs and Psychotropic Substances, p. At its sixty-seventh session (2015), the Commission decided to include the topic "Jus cogens" in its programme of work and appointed Mr. Following the debates on those reports, the Commission decided to refer the draft conclusions contained in those reports to the Drafting Committee. The Commission heard interim reports from the Chairpersons of the Drafting Committee on peremptory norms of general international law (jus cogens) containing the draft conclusions provisionally adopted by the Drafting Committee at the sixty-eighth to seventieth sessions, respectively. At its sixty-ninth session (2017), following a proposal by the Special Rapporteur in his second report, 692 the Commission decided to change the title of the topic from "Jus cogens" to "Peremptory norms of general international law (jus cogens)". The fourth report discussed the previous consideration of the topic in the Commission and the Sixth Committee of the General Assembly. It also addressed the questions of regional jus cogens and the inclusion of an illustrative list of peremptory norms of general international (jus cogens) in the draft conclusions. On the basis of his analysis, the Special Rapporteur proposed one draft conclusion containing a non-exhaustive list of peremptory norms of general international law (jus cogens). The Commission considered the fourth report at its 3459th to 3463rd, and 3465th meetings, from 8 to 10 May, and from 14 to 16 May 2019. At its 3499th to 3504th meetings meetings, from 5 to 7 August 2019, the Commission adopted the commentaries to the aforementioned draft conclusions (see section C. At its 3504th meeting, on 7 August 2019, the Commission decided, in accordance with articles 16 to 21 of its statute, to transmit the draft conclusions (see section C below), 690 691 692 693 At its 3257th meeting, on 27 May 2015 (Official Records of the General Assembly, Seventieth Session, Supplement No. The topic had been included in the long-term programme of work of the Commission during its sixty-sixth session (2014), on the basis of the proposal contained in the annex to the report of the Commission (ibid. At its 3504th meeting, on 7 August 2019, the Commission further expressed its deep appreciation for the outstanding contribution of the Special Rapporteur, Mr. Dire Tladi, which had enabled the Commission to bring to a successful conclusion its first reading of the draft conclusions on peremptory norms of general international law (jus cogens). Text of the draft conclusions on peremptory norms of general international law (jus cogens), adopted by the Commission on first reading Text of the draft conclusions 56. The text of the draft conclusions adopted by the Commission on first reading is reproduced below. Conclusion 2 Definition of a peremptory norm of general international law (jus cogens) A peremptory norm of general international law (jus cogens) is a norm accepted and recognized by the international community of States as a whole as a norm from which no derogation is permitted and which can be modified only by a subsequent norm of general international law having the same character. Conclusion 5 Bases for peremptory norms of general international law (jus cogens) 1. Customary international law is the most common basis for peremptory norms of general international law (jus cogens). The requirement of "acceptance and recognition" as a criterion for identifying a peremptory norm of general international law (jus cogens) is distinct from acceptance and recognition as a norm of general international law. Acceptance and recognition by a very large majority of States is required for the identification of a norm as a peremptory norm of general international law (jus cogens); acceptance and recognition by all States is not required. While the positions of other actors may be relevant in providing context and for assessing acceptance and recognition by the international community of States as a whole, these positions cannot, in and of themselves, form part of such acceptance and recognition. Evidence of acceptance and recognition that a norm of general international law is a peremptory norm (jus cogens) may take a wide range of forms. Such forms of evidence include, but are not limited to: public statements made on behalf of States; official publications; government legal opinions; diplomatic correspondence; legislative and administrative acts; decisions of national courts; treaty provisions; and resolutions adopted by an international organization or at an intergovernmental conference. Conclusion 9 Subsidiary means for the determination of the peremptory character of norms of general international law 1. A treaty is void if, at the time of its conclusion, it conflicts with a peremptory norm of general international law (jus cogens). If a new peremptory norm of general international law (jus cogens) emerges, any existing treaty which is in conflict with that norm becomes void and terminates. A treaty which, at the time of its conclusion, conflicts with a peremptory norm of general international law (jus cogens) is void in whole, and no separation of the provisions of the treaty is permitted. A treaty which becomes void because of the emergence of a new peremptory norm of general international law (jus cogens) terminates in whole, unless: (a) the provisions that are in conflict with a peremptory norm of general international law (jus cogens) are separable from the remainder of the treaty with regard to their application; (b) it appears from the treaty or is otherwise established that acceptance of the said provisions was not an essential basis of the consent of any party to be bound by the treaty as a whole; and (c) unjust. Conclusion 12 Consequences of the invalidity and termination of treaties conflicting with a peremptory norm of general international law (jus cogens) 1. Conclusion 14 Rules of customary international law conflicting with a peremptory norm of general international law (jus cogens) 1. This is without prejudice to the possible modification of a peremptory norm of general 144 continued performance of the remainder of the treaty would not be Advance version (20 August 2019) international law (jus cogens) by a subsequent norm of general international law having the same character. A rule of customary international law not of a peremptory character ceases to exist if and to the extent that it conflicts with a new peremptory norm of general international law (jus cogens). Conclusion 15 Obligations created by unilateral acts of States conflicting with a peremptory norm of general international law (jus cogens) 1. Conclusion 16 Obligations created by resolutions, decisions or other acts of international organizations conflicting with a peremptory norm of general international law (jus cogens) A resolution, decision or other act of an international organization that would otherwise have binding effect does not create obligations under international law if and to the extent that they conflict with a peremptory norm of general international law (jus cogens). Conclusion 17 Peremptory norms of general international law (jus cogens) as obligations owed to the international community as a whole (obligations erga omnes) 1. Conclusion 18 Peremptory norms of general international law (jus cogens) and circumstances precluding wrongfulness No circumstance precluding wrongfulness under the rules on the responsibility of States for internationally wrongful acts may be invoked with regard to any act of a State that is not in conformity with an obligation arising under a peremptory norm of general international law (jus cogens). Conclusion 19 Particular consequences of serious breaches of peremptory norms of general international law (jus cogens) 1. Conclusion 20 Interpretation and application consistent with peremptory norms of general international law (jus cogens) Where it appears that there may be a conflict between a peremptory norm of general international law (jus cogens) and another rule of international law, the latter is, as far as possible, to be interpreted and applied so as to be consistent with the former. A State which invokes a peremptory norm of general international law (jus cogens) as a ground for the invalidity or termination of a rule of international law is to notify other States concerned of its claim. Annex (a) (b) 146 the prohibition of aggression; the prohibition of genocide; Advance version (20 August 2019) (c) (d) (e) (f) (g) (h) the prohibition of crimes against humanity; the basic rules of international humanitarian law; the prohibition of racial discrimination and apartheid; the prohibition of slavery; the prohibition of torture; the right of self-determination. Text of the draft conclusions on peremptory norms of general international law (jus cogens) and commentaries thereto 57. The text of the draft conclusions on peremptory norms of general international law (jus cogens) adopted by the Commission, on first reading, together with commentaries thereto, is reproduced below. Peremptory norms of general international law (jus cogens) Part One Introduction Conclusion 1 Scope the present draft conclusions concern the identification and legal consequences of peremptory norms of general international law (jus cogens). These draft conclusions are aimed at providing guidance to all those who may be called upon to determine the existence of peremptory norms of general international law (jus cogens) and their legal consequences. Given the importance and potentially far-reaching implications of peremptory norms, it is essential that the identification of such norms and their legal consequences be done systematically and in accordance with a generally accepted methodology. It provides in simple terms that the present draft conclusions concern the identification and legal consequences of peremptory norms of general international law (jus cogens). The draft conclusions, dealing with identification and legal consequences, are primarily concerned with methodology. They do not attempt to address the content of individual peremptory norms of general international law (jus cogens). It should also be noted that the commentaries will refer to different materials to illustrate methodological approaches in practice. The materials referred to , as examples of practice, including views of States, serve to illustrate the methodology for the identification and consequences of peremptory norms of general international law (jus cogens). They do not imply the agreement with, or endorsement of, the views expressed therein by the Commission. The draft conclusions are thus not concerned with the determination of the content of the peremptory norms themselves. The process of identifying whether a norm of international law is peremptory or not requires the application of the criteria developed in these draft conclusions. While there may be non-legal consequences of peremptory norms of general international law (jus cogens), it is only the legal consequences that are the subject of the present draft conclusions. Moreover, individual peremptory norms of general international law (jus cogens) may have specific consequences that are distinct from the general consequences flowing from all peremptory norms. The present draft conclusions, however, are not concerned with such specific consequences, nor do they seek to determine whether individual peremptory norms have specific consequences. The draft conclusions only address general legal consequences of peremptory norms of general international law. Jus cogens norms in domestic legal systems, for example, do not form part of the topic. Similarly, norms of a purely bilateral or regional character are also excluded from the scope of the topic. It is, however, to be noted that in some cases, the words "rules", "principles" and "norms" can be used interchangeably. The Commission, in its 1966 draft articles on the law of treaties, used the word "norm" in draft article 50 which became article 53 of the 1969 Vienna Convention. Conclusion 2 Definition of a peremptory norm of general international law (jus cogens) A peremptory norm of general international law (jus cogens) is a norm accepted and recognized by the international community of States as a whole as a norm from which no derogation is permitted and which can be modified only by a subsequent norm of general international law (jus cogens) having the same character. Commentary (1) Draft conclusion 2 provides a definition of peremptory norms of general international law (jus cogens). It is based upon article 53 of the 1969 Vienna Convention with modifications to fit the context of the draft conclusions. First, only the second sentence of article 53 of the 1969 Vienna Convention is reproduced. The first sentence, which concerns the invalidity of treaties, does not form part of the definition. It is rather a legal consequence of peremptory norms of general international law (jus cogens), which is addressed in draft conclusion 10. Second, the phrase "[f]or the purposes of the present Convention" is omitted from the definition. As will be demonstrated below, the definition in article 53, though initially used for the purposes of the 1969 Vienna Convention, has come to be accepted as a general definition which applies beyond the law of treaties. Finally, in keeping with the general approach in this topic, the Commission has decided to insert the phrase "jus cogens" in parentheses after "peremptory norm of general international law". Costelloe, Legal Consequences of Peremptory Norms in International Law, Cambridge University Press, 2017, at pp. States have generally supported the idea of proceeding on the basis of 1969 Vienna Convention. On the contrary, the goal was to elucidate the meaning and scope of the two criteria"), and Poland (ibid. State Secretariat for Economic Affairs and Federal Department of Economic Affairs, Case No. See, for example, Legality of the Threat or Use of Nuclear Weapons, Advisory Opinion, I. See, especially, the separate opinion of Judge ad hoc Dugard in Armed Activities on the Territory of the Congo (New Application: 2002) (Democratic Republic of the Congo v. Knuchel, Jus Cogens: Identification and Enforcement of Peremptory Norms, Zurich, Schulthess, 2015, at p. Kadelbach, "Genesis, function and identification of jus cogens norms", Netherlands Yearbook of International Law 2015, vol. Linderfalk, "Understanding the jus cogens debate: the pervasive influence of legal positivism and legal idealism", ibid. See also, generally, Costelloe (footnote 694 above), who, though never stating that article 53 of the 1969 Vienna Convention is the definition, certainly proceeds on that basis. Alexidze, "Legal nature of jus cogens in contemporary international law", Collected Courses of the Hague Academy of International Law, vol. Weatherall, Jus Cogens: International Law and Social Contract, Cambridge University Press, 2015, at pp. The 149 Advance version (20 August 2019) international law (jus cogens) in the context of other topics, also used the definition in article 53 of the 1969 Vienna Convention. Second, it must be accepted and recognized by the international community of States as a whole as one from which no derogation is permitted, and which can only be modified by a norm having the same character. These elements constitute the criteria for the identification of peremptory norms of general international law (jus cogens) and are elaborated upon further in draft conclusions 4 to 9.

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