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By: Bertram G. Katzung MD, PhD
- Professor Emeritus, Department of Cellular & Molecular Pharmacology, University of California, San Francisco
Supine: P: Use both thumbs to cheap claritin 10mg overnight delivery allergy medicine cats create a simultaneous shear cheap 10 mg claritin amex allergy symptoms spring, emphasizing Bimanual Thenar/Metatarsal Grasp Shear; Anterior-to the plantar-to-dorsal component on the metatarsal claritin 10 mg low cost allergy shots age. Thumb Metatarsal/Thumb Phalanx Shear; Plantar-to-Dorsal P: With the thumb buy claritin 10mg otc allergy forecast mold, draw the phalanges over the index contact, Glide (Figure 6-235) and apply a dorsal-to-plantar distractive thrust. P: With the contact hand, elevate the foot, using gravity to create long-axis distraction at the metatarsophalangeal joint. Induce side-to-side rocking with the contact hand to mobilize the joint initially. Interphalangeal Joint Figure 6-236 Adjustment for long-axis distraction Supine: 6-236 of the right metatarsophalangeal joints (same proce dure for the interphalangeal joints). Thumb Index Grasp/Phalanx; Long-Axis Distraction; Internal or External Rotation; Anterior-to-Posterior or Posterior-to-Anterior Glide; Lateral-to-Medial or Medial-to First Metatarsophalangeal Joint Lateral Glide (Figure 6-238). Figure 6-238 Adjustment for internal and 6-238 external rotation and anterior-to-posterior, poste rior-to-anterior, lateral-to-medial, and medial-to-lateral glide of the right Figure 6-237 Adjustment for medial-to-lateral metatarsophalangeal joints (same procedure for the interphalangeal 6-237 glide of the right first metatarsophalangeal joint. This is application of many of the common nonthrust procedures applied suitable only in the circumstance in which both thrust and non in manual therapy and chiropractic. The chiropractic profession did not develop most of the tech All manual therapies are not equivalent simply because a wide niques and procedures discussed in this chapter. Typically they are asso Moreover, a small percentage of chiropractic professionals do ciated with a particular innovator or profession, but invariably not use them because of the exclusiveness of thrust techniques. The intention of this characterized by a high-velocity thrust (adjustment) may indeed chapter is not to present a comprehensive discussion of the varia have effects that are different than and, in certain clinical situa tions and nuances of each procedure, but to offer a fair represen tions, superior to nonthrust procedures. Nevertheless, both procedures share common physical attri Ideally, the descriptions of the procedures contained within this butes and overlapping potential positive clinical effects. Grieve3 chapter will broaden your awareness of nonthrust manual pro contends that all mobilizations and manipulations are actually soft cedures and stimulate further critical evaluation of those proce tissue techniques, because it is in the soft tissue that the lesions dures that pique your interest. Indeed, various and Joint mobilization may be defined as a passive therapeutic move numerous forms of manual therapy exist within the profession ment up to but not exceeding the anatomic end range of joint of chiropractic. A nonthrust maneuver is not commonly applied procedures might be more appropriate include the treatment of beyond a joint’s elastic barrier. Movement beyond the elastic bar the older adults or patients with osteoporotic or extremely acute rier takes the joint into the paraphysiologic joint space and is conditions, treatment of patients in the later stages of pregnancy, typically associated with an audible pop or click. Therefore mobi or treatment of patients with a diagnosis of myofascial pain lization is less commonly associated with an audible crack than syndrome (trigger point). However, mobi Technique lization can be applied over a wide range and can thus involve a series of movements (stages or grades). Mobilization is a coaxing, Grade I A small-amplitude movement near the starting repetitive, rhythmic movement of a joint that can be resisted by position of the range the patient. Because the motion is relatively slow, con into the range, occupying any part of the range trolled, and gentle, the patient can report the effect of the tech that is free of stiffness or muscle spasm nique during the application. Indirect benefit is thought to accrue because of improved function within each part of the kinetic chain in need of treatment. Hold gently against the barrier until a release of of mobilization can be used to restore segmental motion and resistance occurs (3 to 10 seconds). Stay just short of reproduction of the symptoms, barely Graded oscillation technique is a form of mobilization whereby engaging the point of pain and backing away. Oscillatory too far into the painful area), the symptoms will be technique is graded on a 1-to-4 scale based on the amplitude of aggravated. The vibratory nature of the graded oscillation technique is thought to activate sensory mechanoreceptors that may help reduce pain and improve proprioceptive function. Box 7-2 lists general periarticular soft tissues about a spinal joint by means of collagen ized procedural steps for the application of graded oscillatory fiber realignment and viscosity change allows for improved joint mobilization. Progressive stretch mobilization involves a series of successive Mobilization can be performed at general regions or at spe short-amplitude, spring-type pressures or a series of short cific joint levels. Progressive stretch is graded a particular segment must be placed in its most favorable posi on a 1-to-4 scale, as is graded oscillation. The major indication for tion for movement, and contacts must be placed on or close to the use of progressive stretch mobilization is mechanical or soft the segment being mobilized. Maintaining a stretch or pres of movement for a generalized or regional mobilization will be sure throughout the mobilization procedure is recommended greater than the arc of motion used for the specific or segmental when immediate tissue feedback is desired. Where anatomic relationships allow Chapter 7 Nonthrust Procedures: Mobilization, Traction, and Soft Tissue Techniques | 383 traction to accompany mobilization, traction should be used as an integral part of the treatment program. In many cases of pain induced failure of a mobilization technique, that is, when angular or even translational force vectors produce increased pain, pure trac tion techniques may still be useful. This fact reinforces the concept that traction is one of the least invasive mobilization methods. These procedures have been selected because they represent a variety of methods, not because they demonstrate superior effectiveness as compared with other mobi lization procedures. Oscillatory Cervical Lateral Flexion (Figure 7-1) the patient lies in the supine position, with the head and neck supported on the headrest and by the clinician’s hands. To produce left lateral flexion mobilization of the cervical spine, Figure 7-1 Oscillatory cervical lateral flexion to produce left lateral the clinician’s right hand comfortably grasps the patient’s chin flexion mobilization of the cervical spine. Both hands support the patient’s head and produce a repetitive, rhythmic left lateral flexion movement around the z-axis. An oscillatory movement is produced as the hands move reciprocally, and all excursions have equal value. Oscillatory Atlas Lateral Glide (Figure 7-2) the patient lies in the side-posture position with both knees bent to maintain pelvic stability, the upper arm resting along the side of the body and the hand grasping the thigh, and the head placed in a neutral position on an elevated headrest.
Moreover cheap 10 mg claritin otc allergy treatment shots, the relevance of distnguishing between segmental (S) and global (G) lesions has been a subject of debate buy generic claritin 10mg line allergy shots given to cats. First purchase 10mg claritin overnight delivery allergy symptoms at night only, although the classifcaton system states that extracapillary proliferaton should occupy at least one quarter of the glomerular capsular circumference to purchase claritin 10 mg fast delivery allergy austin qualify as extracapillary proliferaton, only a few of the responding pathologists used this criterion in their scoring (even in the highly experienced pathologists group). Second, although fbrocellular crescents are designated as actve lesions, many respondents seem to interpret them as chronic or actve/chronic lesions. Third, although double contours are not listed as chronic lesions in the classifcaton system, some of the respondents apparently perceived them as such. The observaton that highly experienced pathologists have higher agreement than less experienced pathologists suggests that agreement can be improved—at least in part—by educatng nephropathologists. Moreover, as discussed above, agreement might be improved by revising and clarifying some of the defnitons in the current classifcaton system. Finally, our results underscore the need for a central review of biopsies in clinical trials by a minimum of two experienced nephropathologists. Acknowledgments We would like to thank the Renal Pathology Society, in partcular H. The results presented in this paper have been presented in abstract form at the Annual American Society of Nephrology Kidney Week, Atlanta, Georgia, November 5-10, 2013. The very long-term prognosis and complicatons of lupus nephrits and its treatment. American College of Rheumatology guidelines for screening, treatment, and management of lupus nephrits. Interobserver agreement of scoring of histopathological characteristcs and classifcaton of lupus nephrits. Measuring repeatability and validity of histological diagnosis-a brief review with some practcal examples. Equivalence of weighted kappa and intraclass correlaton coefcient as measures of reliability. Irreproducibility of the actvity and chronicity indices limits their utlity in the management of lupus nephrits. Internatonal variaton in histologic grading is large, and persistent feedback does not improve reproducibility. The total number of biopsies with lupus nephritis that were evaluated by pathologists prior to participation in this study, grouped by experience Supplemental Table 1. Comparison with other continents was not due to the small number of pathologists from this continent. This revision was a signifcant improvement compared to the previous version, mainly because of clearer and more concise defnitons and the eliminaton of mixed subclasses. Despite these improvements, there are stll some difcultes in the classifcaton for lupus nephrits, many of which are in the defnitons provided. Furthermore, we give an overview of the history of the classifcaton to provide background on the origin and development of the defnitons in lupus nephrits. The issues raised in this review, as well as the suggestons for improvements may assist with a revision of the lupus nephrits classifcaton in the near future. Therefore, the purpose of this paper is to provide a critcal reading of the latest version of the classifcaton,1 2 list points to be considered for clarifcaton, and ofer suggestons for improvements, which may be used to guide a revision of the classifcaton in the near future. Biopsy requirements Reportng of the number of glomeruli in a biopsy confers a level of certainty with regard to the accuracy of the assigned class. It is cumbersome and not always possible to track each glomerulus through diferent levels. Furthermore, it is currently unclear if a glomerular lesion should be designated as segmental or global when this difers between multple levels of the same glomerulus. In class I, glomeruli show deposits by immunofuorescence and electron microscopy, whereas they should appear normal by light microscopy. This class is characterized by any degree of mesangial hypercellularity, where the hypercellularity is defned as three or more mesangial cells per mesangial area in a 3-micron-thick secton. It is stated that “a few isolated subepithelial or subendothelial deposits may be visible by immunofuorescence or electron microscopy, but not by light microscopy”. Local was used, because initally, the lesion consisted of one or two patches of proliferatng endothelial cells near the periphery of the tuf. The term proliferaton in this artcle is always used in conjuncton with the endothelium. It uniquely referred to endothelial proliferaton, although this was never actually proven. Among the histologic fndings considered to refect the presence of actvity was cellular proliferaton in glomeruli. It is interestng that, in these early beginnings, confusion on how to defne the separate components of the glomerular changes already became apparent. Most likely, this distncton hinged on whether the intersttum was involved in the infammaton, but there were also glomerular lesions that were more characteristc of one versus the other. Local necrosis, obliteraton, karyorrhexis, and fbrinoid changes are specifcally mentoned as part of lupus glomerulits. In this 1978 publicaton, descriptons of the fve classes were enriched by immunofuorescence and electron microscopy data. This classifcaton was considered too complicated by many pathologists, causing them to contnue using the unofcial version published by Appel et al. Rather there is a contnuum of changes, and the clinical behavior usually parallels the proporton of involved glomeruli. The diference in morphologic appearance, severity, and clinical course was suggested to point towards diferent pathogenic mechanisms. However, it would be challenging to establish an evidence-based quanttatve standard for this using informaton currently available. What is also not clear from the defniton is whether all or only some of the mentoned criteria should be present.
The cutaneous lupus erythematosus disease area and severity index: a responsive instrument to buy discount claritin 10 mg gluten allergy symptoms quiz measure activity and dam age in patients with cutaneous lupus erythematosus order claritin 10mg amex allergy shots ok during pregnancy. The Cutaneous Lupus Erythematosus Disease Activity and Severity Index: expansion for rheumatology and derma tology purchase 10mg claritin with amex allergy shots help eczema. The study of Cutaneous Lupus Erythematosus Disease Area and Severity Index in Indian patients with systemic lupus ery thematosus 10 mg claritin with visa allergy medicine diphenhydramine. Discoid lupus erythematosus: diagnostic features and evaluation of topical corticosteroid therapy. Topical tacrolimus and pimecrolimus in the treatment of cutaneous lupus erythematosus: an evidence-based evaluation. Topical tacrolimus therapy of resistant cutaneous lesions in lupus erythematosus: a possible alternative. Risk for venous thrombosis related to antiphospholipid antibodies in systemic lupus erythematosus A meta-analysis. Evidence based recommendations for the prevention and long-term management of thrombosis in antiphos pholipid antibody-positive patients: report of a task force at the 13th International Congress on an tiphospholipid antibodies. Clinical effcacy and side effects of antimalarials in systemic lupus erythematosus: a systematic review. Effcacy of aspirin for the primary prevention of thrombosis in patients with antiphospholipid antibodies: an international and collaborative meta-analysis. A systematic review and meta-analysis of pregnancy outcomes in patients with systemic lupus erythematosus and lupus ne phritis. Pregnancy and renal outcomes in lupus nephritis: an update and guide to management. The second trimester Doppler ultrasound examination is the best predictor of late pregnancy outcome in systemic lupus erythematosus and/or the antiphospholipid syndrome. Ocular toxicity in children exposed in utero to antimalarial drugs: review of the literature. Disease modifying antirheumatic drugs in pregnancy: current status and implications for the future. Pregnancy outcome following in utero expo sure to hydroxychloroquine: a prospective comparative observational study. Recurrent Pregnancy Loss With Antiphospholipid Antibody: A Systematic Review of Therapeutic Trials. Risk factors associated with fetal losses in treated antiphospholipid syndrome pregnancies: a multivariate analysis. Prevention of recurrent miscarriage for women with an tiphospholipid antibody or lupus anticoagulant (Review). Brief report First-trimester low dose prednisolone in refractory antiphospholipid antibody related pregnancy loss. Ovulation induction and in vitro fertilization in systemic lupus erythematosus and antiphospholipid syndrome. Importance of planning ovulation induction therapy in systemic lupus erythematosus and antiphospholipid syn drome: a single center retrospective study of 21 cases and 114 cycles. Contraceptive counseling and use among women with systemic lupus erythematosus: a gap in health care quality Pregnane progestin contraception in systemic lupus erythematosus: a longitudinal study of 187 patients. Traditional Framingham risk factors fail to fully account for accelerated atherosclerosis in systemic lupus ery thematosus. Effect of rheumatoid arthritis or systemic lupus erythematosus on the risk of First-Time acute myocardial infarction. Cardiovascular event in systemic lupus erythematosus in northern Sweden: Incidence and predictors in a 7-year follow-up study. Increased Risk of Ischemic Stroke in Patients with Systemic Lupus Erythematosus: A Nationwide Population-based Study. Risk factors for development of coronary artery disease in women with systemic lupus erythematosus. Incidence of and risk factors for adverse cardiovascular events among patients with systemic lupus erythematosus. Age-specifc incidence rates of myocardial infarction and angina in women with systemic lupus erythematosus: comparison with the Framingham Study. Incidence and risk factors of thromboembolism in systemic lupus erythematosus: a comparison of three ethnic groups. Differences in subclinical cardiovascular disease between African American and Caucasian women with systemic lupus erythematosus. Frequency of established cardiovascular disease and its risk factors in Chinese patients with systemic lupus erythematosus. Evaluation of Risk Factors That Contribute to High Prevalence of Premature Atherosclerosis in Chinese Premenopausal Systemic Lupus Erythematosus Patients. Prevalence and correlates of accelerated atherosclerosis in systemic lupus erythematosus. Factors involved in the progress of preclinical atherosclerosis associated with systemic lupus erythematosus: a 2-year longitudinal study. Premature aortic atherosclerosis in systemic lupus erythematosus: a controlled transesophageal echocardiographic study. Subclinical atherosclerosis and endothe lial dysfunction in young South-Asian patients with systemic lupus erythematosus. Predictors of the frst cardiovascular event in patients with systemic lupus erythematosus a prospective cohort study.
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The prophetess Huldah (2 Kgs 22:14) is even consulted by King Josiah on the important question of whether the book of the Torah found in the temple was the legitimate word of Yahweh cheap claritin 10mg overnight delivery allergy shots alcohol. Religion in Eighth-Century Judah: An Overview 449 Sometimes purchase claritin 10mg with amex allergy testing requirements, prophets functioned exactly like oracles cheap 10mg claritin with amex allergy shots tendonitis, interpreting things they would see as portents (Jer 1:11–15 buy claritin 10mg on-line allergy medicine 711, 24:1–10; Amos 7:7–9, 8:1–3). Other times, prophets would envision the heavenly court, and hear Yahweh speaking with them directly. Michaiah describes seeing Yahweh sitting on his throne with the host of heaven standing to the right and left (1 Kgs 22:19). Isaiah also describes Yahweh sitting on a throne, but with winged seraphim offering praises in booming voices (Isa 6). Exodus (24:10–11) describes a meal with God on God’s mountain, in which the participants see him standing on pure sapphire (Stokl 2012). The possibility that a ran dom stranger could be an angel or even a deity was a staple in ancient Near Eastern and Mediterranean religion. As Penelope’s suitors say to Antinous, after he is rough with a stranger begging for food, “Your fate is sealed if he’s some god from the blue. Disguised in every way as they roam and haunt our cities, watching over us” (Od yssey bk. Jacob wrestles a man who turns out to be an angel or a god (Gen 32:25–31), Abraham serves food to three strangers who turn out to be Yahweh and two angels (Gen 18), et cetera. Here scholarly work on dating biblical texts, especially the Pentateuch and its layers, plays a crucial role. What we see from most models of textual development is the increasing im portance over time of the Israelite/Judahite national stories such as the exodus from Egypt, the wilderness wandering, the conquest of Canaan, the patriarchs, and the revelation at Sinai or Horeb. As part of Judahite identity was (or later became) their embracing of Israelite identity as part of their own cultural memory, it is almost impossible to distinguish the national stories of one from the other. The national stories became part and parcel of Israelite/Judahite ritual, in cluding and perhaps especially in the holidays. By the end of the First Temple period, the Pesa became about how Israel’s firstborn were spared when Yahweh struck down the Egyptian firstborns and Maot became about how Israel left 450 Zev I. This process continued in the early Second Temple period with Sukkot, which became about the wilder ness wandering, and finally in the late Second Temple period with Sabuot, which became about the revelation at Sinai (Frankel 2015). At one point, it seems that different groups within Israel and Judah had separate national stories, likely connected to one founding father or major event. Thus, there was an exodus story, about how the Israelites were slaves in Egypt and saved by Yahweh (and Moses). There was a wilderness story, in which Yahweh found Israel in the wil derness and brought them back to his land. There were various patriarch (and matriarch) accounts, focusing on Abraham or Jacob, including promises about the land, et cetera. These accounts were eventually all combined in a timeline in which one hap pened after the other, with the story of Egypt as the dominant trope. Significantly, part of the coalescing of these national stories was also the coalescing of national identities, in which Judah firmly placed itself in the Israelite story. This was likely the culmination of a long process of partial identification between the two polities going back to their roots. The earliest traces of what became Israel and Judah, which appear in the Iron I highlands of Judea and Ephraim, were virtually identi cal in their material culture (Faust 2006), so strong identification between the two polities is not surprising. The authors and scribes who put together the Bible clearly understood what ever political considerations led the Israelites and Judahites to create separate polities to be artificial. With the destruction of the northern kingdom as an inde pendent power, the Judahite scribes adopted the pan-Israelite identity of “twelve sons of Jacob” as axiomatic with Judah as the favored son of Israel. In the end, the stories of Judah and their northern brethren would be told to gether in the biblical texts, and the religions of Israel and Judah, with their joint worship of Yahweh, would become one religion in the eyes of the Bible, its edi tors, and its readers. The Memoirs of God: History, Memory, and the Experience of the Divine in Ancient Israel. Family Religion in Babylonia, Syria, and Israel: Continuity and Change in the Forms of Religious Life. The writing systems of Mesopotamia and Egypt were complicated nonalphabetic writing systems, with large inventories of signs that can be classified as logograms (where one sign represented an entire word), syl labograms (where one sign represented an entire syllable), and determinatives (where a single sign signified something about the nature of the noun or substan tive that it preceded or followed). A scribe writing texts in these non-alphabetic writing systems would need to know scores of signs, often totaling a couple hun dred (and the total of the signs for these languages numbers many hundred). Naturally, years of education would be required to learn these writing systems (even for someone who was a native speaker of the language). For this reason, writing was a technology that normally resided in elite hands, that is, those asso ciated with the royal bureaucracies of the great powers: scribes, priests, high-level governmental officials, military officers, ambassadors. I am so very pleased to be able to have this article included in this Festschrift for Professor Oded Borowski, a scholar from whose writings I have learned so much and whose friendship and kindness I treasure. Moreover, I am also particularly grateful to Zev Farber and Jacob Wright, editors of this volume, for their many kindnesses and great pa tience. Finally, I should like to emphasize that I am grateful to the National Endowment for the Humanities for the fellowship (during September 2013–January 2014) that provided substantial funds upon which some of the research for this article is based, and I am also equally grateful to the Albright Institute of Archaeological Research (Jerusalem) for the use of its peerless library, residential facility, and for their tremendously supportive staff. Thus, the average pastoralist, agriculturalist, blacksmith, carpenter, or potter would not have found a knowledge of writing all that necessary, something that is emphasized especially in the Egyptian Satire of the Trades (and analogous literature) and is also readily apparent in a fair number of the school texts from ancient Mesopotamia (Rollston 2001). To be sure, some merchants would have had some knowledge of literacy, but often this may have been just a basic func tional literacy. In other words, there is much truth in the words of the Second Temple Jewish sage Ben Sira regarding the dramatic contrasts between the scribal profession and that of the trades. Thus, according to Ben Sira, the farmer does not have the luxury of acquiring wisdom because “his objective is to complete the fattening (of the cattle) and his attention is turned toward the fields” (Sir 38:26). The engraver does not acquire wisdom because the exigencies of his craft require that he “labor night and day” in order to “make a realistic likeness” (Sir 38:27). Similarly, the smith “contends with the heat of the furnace,” “sears his flesh,” and “deafens his ears,” so that he can “complete the projects” (Sir 38:28).
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