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  • Professor Emeritus, Department of Cellular & Molecular Pharmacology, University of California, San Francisco

Then order trazodone 100 mg visa symptoms 3dp5dt, the king brings “the ark of God” from Ba‘alah of Judah discount 100mg trazodone medicine app, where it has been ensconced in the house of Abinadab with the 524 Daniel E discount 100 mg trazodone amex treatment yeast infection men. It appears that this narrative reflects a regular ritual practice buy discount trazodone 100 mg symptoms high blood sugar, probably an annual procession of Yah weh into Jerusalem (Fleming 2013), and that the text has been joined secondarily to the ark narrative of Shiloh in 1 Sam 4–6. On its own, the text served to link a longstanding ritual practice with David as the founding king at Jerusalem. It is replete with unique names for participants and places: the house of Abinadab and sons; the threshing floor of Nacon, where Uzzah touches the ark and is killed; and the house of Obed-Edom, where the ark spends three months before David can bring it the rest of the way into the city. Such processional entry from outside a city to celebrate the principal god’s resi dence there has counterparts across the Near East—in the zukru festival of Emar in Syria, rites for the storm god in Anatolia, and the akitu festival in eastern Mes opotamia, all of which take place at the spring or fall axes of the year. This ritual account of the ark’s procession to Jerusalem brings us back to the language for the community at worship encountered in Isa 5:7 and 8:14. The ac count concludes, “And David and all the house of Israel were bringing up the ark of Yahweh with shouting and with the call of the horn” (2 Sam 6:15). In the con text of the David narrative, where his rule over Israel is central from the moment of his selection in 5:1–3, such a description may be read without remark. But ref erence to the assembled people for worship at Jerusalem as the “house of Israel” matches what we find in Isaiah and suggests a continuity of language grounded in practice. The account in 2 Sam 6:1–15 is not a temple text and presents a rite distinct from anything else in the Bible, with no evidence that later writers inte grated it with other known texts, in contrast to the ark’s arrival at Solomon’s temple in 1 Kgs 8:1–9. Nothing about David’s ark and its bearers evokes the ac count of Exod 25, as with the priestly porters and carrying poles in 1 Kgs 8:3–4 and 7–8. In general, the biblical ark is associated with movement, and at Jerusalem it is associated with David not Solomon, the establishment of the city as Yahweh’s residence without concern for the temple. Psalm 132, the only psalm occupied with the ark at Jerusalem, likewise recalls its movement into the city in the context of David’s devotion. The account of the ark’s procession in 2 Sam 6:1–15 offers no clear basis to date it, but it naturally belongs to monarchic Jerusalem in celebration of its found ing king. We have no reason to connect it to some external disruption and influence, whether from domination by the kingdom centered at Samaria or from migration after its demise. There is no barrier to locating 2 Sam 6:1– 15 in the ninth or eighth centuries, but if it came from the seventh century, the Israel and the Jerusalem Temple in the Time of Two Kingdoms 525 ideas, terminology, and ritual reference points would still represent longstanding Jerusalem tradition. It is noteworthy that the most compelling cultic situation of Israel in monar chic Jerusalem appears in a ritual narrative about David and not in the Psalms. One reason for this may be that the book of Psalms does not generally preserve collective or “communal” poems from the monarchic period. The segment de voted to celebration of Yahweh as radiant “king of the glory” in Ps 24:7–10 finally identifies this king as “Yahweh of Hosts” (v. The opening hymn in Ps 89 concludes, “Indeed our shield is of Yahweh, and our king is of the Holy One of Israel” (v. One social location, therefore, for maintenance of the name Israel in Jerusa lem and Judah during the period of two kingdoms could have been the gathering of the population for festivals. The procession of the ark in 2 Sam 6 raises the possibility of a separate and coexisting sacred site in Jerusalem, defined by ark and tent. It is significant that Yahweh is worshiped at the central temple as “of Hosts,” not as “God of Israel” (Stahl 2018). It seems that however important that temple must have been, the worshiping public was not defined by it. Early material in the book of Isaiah preserves the name with two associations, for “the house (or two houses) of Israel” and for Yahweh as “the Holy One of Israel”—not to invoke the god in his temple. The processional festival of the ark in 2 Sam 6 presents “the house of Israel” as the public assembled for religious purpose, yet not at the city’s central temple. All of these monarchic Judah references bring up the name Israel when representing the people as accountable to Yahweh through his presence at Jerusalem, yet in terms not bound solely to the temple. Understood this way, the oldest biblical references to Israel at Jerusalem reflect the continuity of religious practice tradi tionally traced back to the founding royal house of David. In 1949, Chiang Kai-Shek, who had led the Republic of China for the past twenty years, withdrew from the mainland to the island of Taiwan, where he set up a government under the same name. The Communists who drove him from the mainland could not follow up their victory by pursuing Chiang to Taiwan and removing him. They defined the new state as the “People’s Republic of China,” so that now there have been two Republics of China for more than sixty years. Fleming In the case of ancient Israel, David is best understood to have ruled this peo ple before a separation that is recalled in two distinct biblical texts: the failure of Rehoboam in 1 Kgs 12; and Ephraim’s departure from Judah in Isa 7:17. The placement of Rehoboam and Jeroboam as the first kings of neighboring realms is confirmed by the interlocking chronology of precisely counted reigns beginning with these two in 1 Kgs 14:20–21. It is not clear what Rehoboam would have called his kingdom based at Jeru salem in the years following his expulsion as king of Israel. Our one non-biblical reference to the southern kingdom from the ninth century calls it the House of David, sharing a form of political naming that becomes typical of Aramaic-speak ing entities in Syria during this period. Rehoboam could claim legitimate sovereignty over the same people ruled by his father and grandfather, holding onto the name Israel. With the passage of time and the greater power of Jerusalem’s neighbor, the southern kingdom required separate identification, which was eventually adopted from the highland region of Judah that ran south from the capital. The people, however, could still be called Israel when assembled in Jerusalem to worship Yahweh of Hosts. The Raging Torrent: Historical Inscriptions from Assyria and Babylonia Relating to Ancient Israel. The Legacy of Israel in Judah’s Bible: History, Politics, and the Reinscribing of Tradition. I Have Built You an Exalted House: Temple Building in the Bible in Light of Mesopotamian and Northwest Semitic Writings.

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Accordingly purchase trazodone 100 mg without prescription medicine woman, more evidence is needed to generic 100mg trazodone amex medicine for depression clothing and behavior modication to discount 100mg trazodone overnight delivery medicine 54 092 avoid sun guide clinicians to purchase trazodone 100mg fast delivery medications like lyrica the best treatment options for exposure, particularly between 10 am and 4 pm. Protection against both ultraviolet In general, hydroxychloroquine and mepacrine A and ultraviolet B is desirable because lupus is are safe, well-tolerated drugs and adverse effects are 11,12 aggravated by both. With disgurement and relatively few, the most widely recognized being 16 alopecia, patients may benet from advice on cam retinal toxicity. Topical steroids are the mainstay of treatment of this is dose related and can largely be avoided. Patients usually start with a potent topical side effect spectrum between chloroquine and hy steroid applied twice a day, then switch to a lower droxychloroquine is different, with ocular toxicity potency steroid as soon as possible. The minimal being mainly, although perhaps not exclusively, use of steroids reduces the recognized side effects seen after chloroquine use. Intralesional steroids are particularly useful to treat Other adverse effects of antimalarials include chronic lesions, hyperkeratotic lesions, and those gastrointestinal symptoms, eg, nausea and vomit that do not respond adequately to topical steroids. Recognized side effects of intralesional ste pigmentation, and hematological disturbances like 18 roids include cutaneous atrophy and dyspigmenta leukopenia and thrombocytopenia. Hemolysis is tion, which are not signicant risks in experienced reported in individuals who are decient in the 13 hands. For patients with progressive or toxic psychosis when used for the treatment of 19 disseminated disease or in those with localized dis discoid lupus. Prolonged mepacrine therapy may ease that does not respond to topical measures, the produce a yellow discoloration of the skin and addition of systemic agents should be considered. It is impor al found low-dose thalidomide treatment was ef tant to emphasize to the patient that it may take cacious with good tolerance, with the most fre between 4 to 8 weeks for any clinical improvement. In some patients who do not respond to hydroxy chloroquine, chloroquine may be more effective. Full blood count and liver this is an immunosuppressive agent that has been function along with renal function need to be added relatively recently to the other drugs in this checked before commencing treatment with meth group and has been used increasingly in recent otrexate and regularly thereafter because it can years for the treatment of various dermatoses that cause myelosuppresion and hepatic and renal im are inammatory or autoimmune in origin. Goyal Cyclosporin A 27 and Nousari described 2 cases of refractory dis this is a potent immunosuppressant because of its coid lupus involving the palms and soles that re immunomodulating effect on helper T-cell func sponded satisfactorily to mycophenolate mofetil. Blood pressure and kidney function need ferences in the activity of the enzyme thiopurine to be monitored, and hypertension is a common methyltransferase in different individuals, which side effect. Lipid disturbances can also occur myelosuppression in a patient with very low levels and therefore serum cholesterol and triglycerides of thiopurine methyltransferase are signicantly have to be monitored. Fi one case and a combination of clobetasol ointment 31 24 nally, Koch et al suggest cryotherapy as a treat and tacrolimus in the other. The severity of lesions was assessed at each visit (weeks 0–4 and posttreatment week 4) using a 7-point Conclusion rating scale. Br J Dermatol versible hair loss and is associated with considerable 2003;149:131–7. J Am dition early because early effective treatment is Acad Dermatol 1990;22:181–7. Australas J Derma forms of treatment that are effective to a lesser or tol 2006;47:13–27. Treatment of cutaneous lesions in pa properly conducted randomized trials to enable an tients with lupus erythematosus. Antimalarial therapy: a panacea for mild one form of treatment compared with another. Dose renements in the long term References therapy of rheumatoid arthritis with antimalarials. Ann Dermatol Venereol 2005;132 lupus erythematosus: a review of clinico-laboratory (11 Pt 1):853–6. Photo lupus erythematosus of palms and soles with myco sensitivity in patients with lupus erythematosus: a phenolate mofetil. J Am Acad Dermatol 2001;45: clinical and photobiological study of 100 patients 142–4. Management of refractory skin disease in Ther 2006;23:787–92 patients with lupus erythematosus. This leaflet has been written to help you understand more about discoid lupus erythematosus. It tells you what it is, what causes it, what can be done about it, and where you can find out more about it. Discoid lupus erythematosus is an uncommon skin rash, usually made worse by exposure to sunlight. At one end of the range is systemic lupus erythematosus, which can damage internal organs, whilst right at the other end of the range is ‘discoid’ lupus erythematosus, which is confined to the skin and does not cause general ill health. One theory is that it is a condition in which the immune system, instead of just acting as a defence against infection, attacks the tissues of the body itself (an autoimmune disease). However, in an autoimmune disease, the immune system makes a mistake and fights our own body instead. The mistake made by the immune system in discoid lupus erythematosus is to view the cells in our skin as ‘foreign’ and to make antibodies that damage them. Most patients find their rash gets worse in sunlight and may be triggered by sunshine. It can affect either sex, at any age; young women are the group of patients most often affected, and it is rare in children. It is usually symptom-free apart from the discomfort the patches can cause; the plaques may leave disfiguring scars. Occasionally the affected areas can itch, and patches on the fingers can be tender. Discoid lupus erythematosus usually affects the face and scalp, but is occasionally more widespread. The rash consists of red scaly patches, which tend to clear eventually, leaving some thinning, scarring or colour change in the skin.

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B trazodone 100 mg fast delivery treatment diffusion, Figure 5-258 Hypothenar contact applied to discount trazodone 100 mg otc cancer treatment 60 minutes the right L4 mammil Hypothenar spinous contact applied to buy generic trazodone 100 mg symptoms prostate cancer the right lateral surface of L2 to quality trazodone 100mg symptoms diabetes type 2 lary process to induce extension and left rotation. In the standing position, the doctor may rest his elbow against his or her ante Probably the least understood and most controversial function rior ilium. P-A and L-M through the contact hand to joints are mobile diarthrodial joints, important to the statics assist in the production of rotation and dynamics of posture and gait. Preadjustive tension is for the trunk while functioning to guide movement and helping typically developed by flexing, laterally flexing, and rotating the to absorb the compressive force associated with locomotion and patient in the direction of joint restriction (assisted method). Once tension is established, an impulse thrust is delivered by Grieve67 believes that this articulation, together with the cran inducing a twisting thrust generated through the doctor’s indif iovertebral region and other transitional areas, is of prime impor ferent arm, trunk and contact. The direction of induced lateral tance in understanding the conservative treatment of vertebral flexion and the point of adjustive contact depend on the restric joint problems. Although this adjustment may be applied in often ignored by other health care practitioners as an insignificant all lumbar regions, it is probably most effectively applied in the feature of musculoskeletal problems. Develop preadjustive tension by flexing, rotating, and laterally flexing the pelvic complex comprises the two innominate bones, with the the patient away from the side of contact (Figure 5-259, A). The ilium, ischium, and pubic bone fuse at the At tension, deliver a thrust to induce rotation. The sacrum applied to induce maximal distraction in the facet joint ipsi is a fusion of the five sacral segments and is roughly triangular laterally inferior to the point of contact. It is also applied to in shape, giving it the appearance of a wedge inserted between treat restrictions in rotation and same-side lateral flexion. The sacral base has right or left rotation restriction coupled with the correspond two superior facets that articulate with L5 and the sacral apex, ing right or left lateral flexion restriction). The apex To use a spinous process contact, slide medially and estab of the sacrum is oval and articulates with the coccyx by means lish a fleshy mid-hypothenar contact on the lateral surface of of a disc. By about 30 years of age, the disc disappears, and the the spinous process on the side of rotation restriction (side of spinous rotation). Develop preadjustive tension by flex ing, rotating, and laterally flexing the patient away from the Iliac crest side of contact (Figure 5-259, B). This contact should induce maximal distraction in the facet joint ipsilateral inferior to the side of spinous contact. This method is also commonly applied when treating combined restrictions in rotation and oppo Ilium site-side lateral flexion. Develop preadjustive tension by flexing, laterally flexing, and rotat ing the patient away from the side of contact. Ischium Pubis Sitting lumbar adjustments produce rotational tension in the patient’s spine, regardless of the dysfunction being treated. If the patient cannot tolerate rotation of the spine, he or she is Figure 5-260 Lateral view of the right innominate, showing the not a good candidate for sitting lumbar adjustments. Chapter 5 the Spine: Anatomy, Biomechanics, Assessment, and Adjustive Techniques | 263 L Superior articular facet Sacral tubercle Sacral foramen Sacral Sacral hiatus cornua A B Sacral base Second sacral tubercle Sacroiliac facet surface C Figure 5-261 A, Sacrum viewed from the posterior is triangular and serves as a keystone (B) in the arch between the two columns formed by the lower extremities. The sacral tubercles, superior located in the midline, correlate with the spinous processes of the iliac spine Second Depression fused vertebra. The tubercles on the posterolateral aspect correlate sacral with transverse processes. They have a joint cavity containing synovial fluid and are enclosed by a 2 joint capsule. The shape and configuration of the posterior joints are unique and important to their function. The articular surface is 3 described as auricular (ear-shaped), a letter C, or a letter L lying on Crest Depression its side (Figure 5-262). The articular surfaces have different con tours that develop into interlocking elevations and depressions. This bony configuration produces what has been termed a key stone effect of the sacrum, effectively distributing axial compressive forces through the pelvic mechanism (see Figure 5-261, B). Forces from the lower extremities divide, heading upward toward the spine and anteriorly toward the pubic symphysis, and downward Figure 5-262 Auricular-shaped surfaces of the posterior joints of the forces of gravity on the spine split to both sides (Figure 5-263). Only after an individual becomes ambulatory do the joints begin to take on their adult characteristics. In the teenage years, the joint surfaces begin to roughen and develop their characteristic grooves and ridges. In the third to fourth decades, this process is well estab lished, and by the fifth and sixth decades, the joint surfaces may be very eroded. In later years, a high percentage of male patients will have developed interarticular adhesions across the sacroiliac joints and will have lost sacroiliac joint motion. They continue laterally with the sacrotuberous ligament and medially with the thoracolumbar fascia. The sacrotuberous ligament extends from the lower portion of the sacrum obliquely downward to the ischial tuberosity. It continues caudally with the tendon of Figure 5-263 Forces from gravity above meet with forces from the the long head of the biceps femoris. The anterior sacroiliac ligament lower extremities at the sacroiliac and hip articulations. The sacrospinous liga ment is triangular and extends from the lower lateral edge of the sacrum and the upper edge of the coccyx to the ischial spine.

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Treatment 5 dietary supplementation with vitamin C buy trazodone 100mg amex medications given for bipolar disorder, vitamin E cheap trazodone 100 mg on-line medications nursing, b-carotene buy 100mg trazodone free shipping medicine for yeast infection, copper cheap trazodone 100mg mastercard medicine naproxen 500mg, and zinc may slow progression; intravitreal ranibizumab may help treat exudative le sions near the fovea; laser photocoagulation of discrete lesions may delay progression 6. Complications 5 treatment effectiveness is limited; gradual progression to severe vision loss G. H/P 5 painless acute loss of vision (“window shade pulled over eye” or numerous “floaters”); pigmented fragments or gray retina floating in vitreous humor seen on funduscopic examination 4. Treatment 5 laser photocoagulation or cryotherapy to halt tear progression and reattachment of retina (may not fully restore loss of vision) H. Note edematous retina, retinal hemorrhages, cotton wool spots, and venous dilation. Retinal vein occlusion: more gradual painless loss of vision; funduscopic examination shows cotton wool spots, edema, retinal hemorrhages, and dilated veins 4. Acetazolamide and O2 administration also used to decrease congestion and increase perfusion for arterial occlusion c. Infection of middle ear caused by Streptococcus pneumoniae, Haemophilus influenzae, Moraxella catarrhalis, S. Increased risk in children secondary to shorter and more horizontal ear canal than in adults; pacifier use; hypertrophic tonsillar tissue 3. H/P 5 ear pain, decreased hearing; fever, bulging tympanic membrane with decreased mobility, poor light reflex; possible bloody discharge with perforation. For unresolved cases, amoxicillin for 10 days; resistant strains may require amoxicillin-clavulanic acid or stronger cephalosporins c. Recurrent cases may require surgical placement of tympanic tubes to assist in middle ear drainage. Complications 5 mastoiditis, meningitis, hearing loss, sigmoid sinus thrombosis, or brain abscess can occur in untreated cases B. Infection of ear canal most commonly caused by Staphylococcus aureus, Pseudomo nas, or S. H/P 5 painful, swollen ear with possible white discharge; ear canal is red and swol len; tenderness of pinna 3. Treatment 5 topical polymyxin, neomycin, and hydrocortisone; oral cephalosporins or ciprofloxacin can be used for Pseudomonas infection or infection that spreads to involved skull; topical drying agents after water exposure to prevent recurrent infection C. Brief, episodic vertigo that can occur with certain head movements and is accompanied by nausea and vomiting b. Vertigo caused by distension of endolymphatic compartment of inner ear • Pathology occurs along conductive pathway from 2. H/P 5 acute vertigo lasting several hours, nausea, vomiting, decreased hearing, outer ear to inner ear feeling of ear fullness, tinnitus (ringing in ears) • Audiometry shows 3. Treatment 5 anticholinergics, antiemetics, and antihistamines improve but air conduction shows exacerbations; salt restriction and thiazide diuretics may reduce frequency of consistently low hearing threshold (abnormal episodes; surgical decompression needed in refractory cases Rinne test). Complications 5 progressive hearing loss Sensorineural hearing loss: • Pathology in neural E. H/P 5 hearing loss, dizziness, tinnitus; unilateral facial palsy; decreased sensation duction (asymmetric Weber test, normal Rinne test) may be seen on examination 3. Slowly progressive dementia characterized by neurofibrillary tangles, neuritic plaques, amyloid deposition, and neuronal atrophy; most common cause of dementia 2. H/P 5 progressive short-term memory loss, depression, confusion, inability to complete complex movements or tasks; severe cases have personality changes and delusions 4. Labs 5 nondiagnostic but can be used to rule out other causes of dementia Distinguish dementia from Alzheimer disease from that 5. Complications 5 median survival following diagnosis is 3 years because of the cause is vascular. Dementia characterized by intracellular inclusions of tau protein (Pick bodies) plus atrophy of the frontal and temporal lobe 2. Dementia characterized by intracellular cortical inclusions called Lewy bodies substantia nigra and other (eosinophilic inclusions of the protein a-synuclein) structures. H/P 5 fluctuating cognition, impaired attention, visual hallucinations, syncope, frequent falls; limb rigidity, bradykinesia or akinesia, gait disturbance 3. H/P 5 cognitive impairment, incontinence, gait abnormalities Wobbly (gait abnormalities) 3. It is frequently quickly reversible once the underlying cause is identified and treated. Altered level of consciousness with inattentiveness and confusion Delirium differs from “sun 2. Psychomotor agitation or retardation, disturbance of sleep patterns patients without a history of c. Labs = should address potential metabolic or pharmacologic causes to a medical or substance related cause. Reorientation through observation, reassurance, normalization of sleep–wake cycles, and decreasing excess stimuli improves behavior. Avoid restraints because they frequently exacerbate delirium (use only if patient Do not use benzodiazepines is at danger of harming self). Table 8-17 Comparison of Delirium and Dementia characteristics Delirium Dementia Onset Acute Gradual Daily course Fluctuating cognitive function and Generally consistent; sundowning behavior Level of consciousness Decreased Normal Orientation Aware of self; impaired for time Generally impaired and place Thought production Disorganized, flight of ideas Impoverished Psychotic features Delusions, hallucinations Minimal Memory Short-term impairment Short and long-term impairment Prognosis Reversible Usually irreversible Musculoskeletal 9 DisorDers I. Wrist pain that radiates up arm and worsens with hand flexion and grasping, decreased hand strength, numbness in thumb and in index and middle fingers; decreased palmar two-point discrimination, except on the radial side of the palm b. Most commonly anterior (posteriorly directed force on distal humerus or forearm during abduction causes cantilever effect that drives humeral head Suspect axillary nerve injury in cases of deltoid malfunc forward and tears anterior shoulder capsule) tion (inability to extend arm) b. Posterior dislocations most frequently occur following seizures and electrical or shoulder numbness fol shock (strong contraction in internally rotated, adducted arm causes humeral lowing shoulder dislocation. Treatment 5 urgent closed reduction, sling; chronic dislocations may require surgery to improve joint stability d. Complications 5 axillary artery and nerve injury, increased risk of future dislocations 2.

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