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Ceramic traditions pregnancy quotes and sayings order estrace once a day, for instance, express conti nuity in a number of traits, including the extreme rarity of decoration of pottery. Another example is the extensive use of the four-room house, and more could be added to this list. Still, there are a few traits that appear, at least in substantial numbers, for the first time in this era. In con trast, the eighth century experienced the adoption of rock hewn burial caves, at least by the middle segments of the society and its upper echelon. The typical Judahite tomb is composed of a hewn burial cave, usually with a dromos (fig. The chambers were usually dug in strait lines, although the quality and finish vary greatly. After entering the cave, one reaches a central passage, on three sides of which benches were left undug. The benches are organized like a (the Hebrew letter et); one facing the doorway, and two on the right and left side of the central passageway. On one of the inner corners, or below one of the benches, there is usually Society and Culture in the Kingdom of Judah 193 a repository, into which the bones of the deceased were collected for secondary burial. Many funerary gifts accompanied the burials, and these were also found in the repository. Evi dently, this type of burial was used by extended families for a number of generations. There is great variation in the size and execution of the caves, reflecting so cioeconomic differences. What is important for our purposes, however, is not the source or origin of the new practice, but the mere fact that it was adopted at this time; the issue will be elaborated below. The differences between the various tombs resemble the differences between the houses (only that the tomb, unlike the houses, does not represent the entire population, and hence is not representative of the entire socioeconomic spectrum). In both cases the differ ences represent socioeconomic differences, while the mere usage of a common style indicates that the population belonged to the same social group. It is agreed that this is mainly a feature of the eighth and seventh centuries (Kletter 1999, 29; Byrne 2004, 139; Darby 2014). Interest ingly, while figurines are typical in many polities throughout the region at the time, those in Judah are stylistically different, and some scholars have even sug gested that their distribution (along with these of other features like the inscribed weights) matches the boundaries of the kingdom of Judah (with few exceptions). It is precisely because of these destruction layers that we know a great deal about the archaeology of the late eighth century. There are hardly any destruction layers from these eras, and it is almost impossible to quan tify finds. We know of hundreds of complete eighth century cooking pots, but hardly any complete cooking pots of the ninth century were discovered in Judah. Notably, it appears that destruction events contribute much material to the archaeological record, and hence periods in which there were massive destruction, events are far more known archaeologically. During continued occupation, in contrast, almost all the broken vessels are discarded and the sherds are thrown away (or restored/reused if possible, as is the case with metal objects for example), leaving little remains that can be identified in excavations, and almost nothing to be discovered in sur veys (Faust and Sapir 2018). Hence, the late eighth century is well known archaeologically, while the previous centuries in Judah are far less known, as few sherds remained in the sites, to be discovered in excavations and surveys. The problem is farther aggravated by the disproportionate research concen trating on the Shephelah. This bias in scholarship com pounds the knowledge gap between the eighth century and the preceding era, and must also be taken into consideration (see also Faust 2014a). The fact that the eighth century is also far more represented in textual sources, be they biblical, archaeological, or Assyrian, increases the knowledge gap inher ent in the archaeological record. Still, since some of the traits that are more easily dated, for example, the tombs, are clearly dated to the eighth century, there is no denying that there was 196 Avraham Faust a change in the eighth century. This gives more credit to the dating of the changes at large (though it clearly does not prove them). Since we cannot quantify the finds in the various subphases of the Iron Age, we cannot attempt to compensate for our relative lack of knowledge of the earlier phases. We must, however, take into account that (1) this is not always certain, and (2) that it is not always clear when within the eighth century the changes came about, and (3) it is likely that many of them were not quick, but rather gradual, covering long periods of time. Can we understand what caused the changes in the structure of the society, and how the hierarchical and stratified society described above evolved Clearly, the greater urbanization of the eighth century is first a result of gradual natural growth and internal processes, and the same is probably true for the repopulation of the countryside and the establish ment of many villages and farmsteads. While the increase in industry might have accelerated in the eighth century, it can still be viewed, at least to some extent, in a similar light, that is, as the result of a long process of growing complexity. Some changes might be related to contacts with other regions, reflecting di rect and indirect influences. Thus, the growth of the olive oil industry might result from interaction with the northern kingdom of Israel, which had a more sophisti cated olive oil industry (Gal and Frankel 1993; Faust 2011). While olive-oil was produced earlier, the growth the industry in general and the increase of surpluses production in particular, might result from the incorporation of Judah within the ever-growing economic world system of the Phoenicians (Markoe 2000; Aubet 2001), probably through the mediation of the kingdom of Israel (prior to its de struction of course), and to some extent Philistia. The growth of the international (Phoenician) trade also greatly influenced some segments of Judahite society, especially the upper classes. It probably ena bled some other socioeconomic changes within the society and encouraged both Society and Culture in the Kingdom of Judah 197 urbanization and stratification (coupled with the gradual developments described above). Other innovations might be attributed directly, perhaps, to refugees from the kingdom of Israel. However, I think that some scholars have exaggerated the ex tent of these migrations. Yet even if the number might not have been very large, one can assume that qualitatively, there were influences that go beyond the actual number of refugees. The connections with Assyria gradually led also to some cultural influences, at least as far as the elite is concerned. Thus, we can see how biblical authors, for example, negotiated with Assyrian texts in direct and indirect manners. Once Assyrian campaigns in western Asia began, people must have felt that things could not be taken for granted anymore (for a 4 vivid description of the Assyrian impact, see Byrne 2004, esp. Society gradually became more segmented, objects became less personal, and material culture was, to some extent, alienated (Faust and Buni movitz 2008, 157; cf. As noted, these changes led to the weakening of the traditional social frame works, and eventually to the disintegration of some of them, especially in the larger and more central settlements. Halpern stresses the developments in this regard in the late Iron Age (Halpern 1996). He thinks at this time we witness a transformation from a concept of collective responsibility to a concept of personal responsibility.

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Adding a non-zero mass term m2 gives an operator with no zero eigenvalues menopause matters buy estrace visa, so that this complex has no cohomology, by Hodge theory. In this situation, the dg Lie algebra Eb(M) we constructed above has coho mology spanned by the central element ~ in degree 1. Let us normalize this isomorphism by asking that the element 1 in 0 b b Sym (E [1]) = R C(E [1]) is sent to 1 R[~]. In this situation, we dene the correlation functions of the free theory as follows. The map W constructed in the previous section allows us to calculate correla tion functions. Let cl i Obs (Ui) = Sym(Cc (Ui)[1] Cc (Ui)) be classical observables, and let ~G q W(i) = e i Obs (Ui) be the corresponding quantum observables under the isomorphism W of cochain complexes. The map W is an isomorphism of cochain complexes between Obs (U) cl and Obs (U)[~] for every open subset U of M. That is, we apply W to each input, multiply in q 1 Obs, and then apply W to the output: explicitly, we have ~G ~G ~G 1 The map Obs (M)[~] > R[~] sending an observable to (0) is an R[~]-linear cochain map inducing an isomorphism on cohomology, and it sends 1 to 1. As an example, let us suppose that we have two linear observables, 1 2 of cohomological degree 0, dened on open sets U, V. As these are linear observables, the second-order operator does nothing, c G so W(k) = k. As Z G( 1 2) = G(x, y)1(x)2(y), MM it follows that Z hW(1)W(2)i = ~ G(x, y)1(x)2(y), MM which is what a physicist would write down as the expected value of two linear observables. Translation-invariant prefactorization algebras In this section we will analyze in detail the notion of translation-invariant prefactorization algebras on Rn. It is a special case of the denition of an equivariant prefactorization algebra in Section 7, but we go through the denition here in some detail. The motivation is that a eld theory on Rn whose action functional is translation-invariant will produce a translation-equivariant prefactorization alge bra. A prefactorization algebra F on Rn is discretely translation invariant if we have isomorphisms x: F (U) F (xU) for all x Rn and all open subsets U Rn. In particular, the resulting prefactorization algebra is discretely translation-invariant. Example: Let us consider, again, the prefactorization algebra of the free scalar eld on Rn. Then the Heisen x berg dg Lie algebra has a derivation where k >7 Xk, for k = 0, 1, and the central element ~ is annihilated. This q endomorphism denes a derivation of the prefactorization algebra Obs of observ ables of the free scalar eld theory. Such an action is simply a homomorphism of dierential graded Lie algebras g > Der (F). Next, we introduce some notation that will help us describe the smoothness conditions for a discretely translation-invariant prefactorization algebra. A discretely translation-invariant prefactorization algebra F is smoothly translation-invariant if the following conditions hold. Example: We have already seen that the prefactorization algebra of the free scalar eld theory on Rn is discretely translation invariant and is also equipped with an action of the Abelian Lie algebra Rn by derivations. It is easy to verify that this prefactorization algebra is smoothly translation-invariant. Let F be the cohomology of the prefactorization algebra of observables of the free scalar eld theory on R with mass m. We have seen in Section 3 that the corresponding associative algebra A is the Weyl algebra, generated by p, q, ~ with commutation relation [p, q] = ~. It is straightforward to verify that F is a locally-constant, smoothly translation invariant prefactorization algebra on R, valued in vector spaces. As the action of R on A is smooth, it dierentiates to an innitesimal action of the Lie algebra R on A 8. The basis element x of R becomes a derivation H of A, called the 1 2 2 2 Hamiltonian. Next, we will explain how to think of the structure of a translation-invariant prefactorization algebra on Rn in more operadic terms. Let Discsn be the R>0-colored operad in the category of smooth manifolds whose space of k-ary morphisms Discs (n r1. This map is dened by inserting the outgoing ball (of radius ti) of a conguration x Discs (n r1. These maps satisfy the natural associativity and commutativity properties of a multicategory. Let Fr = F (Br(0)) denote the cochain complex that F assigns to a ball of radius r. This notation is rea sonable because translation invariance gives us an isomorphism between F (Br(0)) and F (B (x)) for any x Rn. The map m[p] is a smooth multilinear map of dierentiable spaces; and further more, this map depends smoothly on p. These operations make the complexes Fr into an algebra over the R>0-colored operad Discs (n r1. In addition, the complexes Fr are endowed with an action of the Abelian Lie algebra Rn. This action is by derivations of the Discs -algebra F n compatible with the action of translation on Discs, as described above. Finally, we require that the maps m[p] are compatible with composition, in the following sense. In addition, the action of Rn on each F r is compatible with these multiplication maps, in the manner described above. Let us give one more equivalent way of rewriting these axioms, which will be useful when we discuss the holomorphic context. Since we know how to tensor a dierentiable vector space with the space of smooth functions on a manifold, it makes sense to talk about an algebra over this colored co-operad in the category of dierentiable cochain complexes. For any dierentiable vector space V and smooth manifold M, we use the notation VC(M) interchangeably with the notation C(M, V); both indicate the dierentiable vector space of smooth maps M > V. These elements equip the Fr with the structure of an algebra over the colored co operad, as stated earlier. Let us write down explicit formulas for these prod uct maps, as a Discsn algebra, in the case of the free scalar eld theory. This isomorphism allows us to transfer the product (or structure map) in the pref q actorization algebra Obs to a deformed product Let us view each i as a cohomological degree 0 element of cl Fri = Obs (Bri(0))[~] = Sym(Cc (Bri(0))[1] Cc (Bri(0)))[~].

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Fluid Formulation A transmission fluid consists of one or more base fluids and a number of different additives menopause 54 buy estrace australia. As can be seen it is the surface active additives that have the greatest influence on friction characteristics. The concentration of each additive, and the balance between them, is important in order to achieve a working transmission fluid [17, 51, 72, 74]. In the case of surface active molecules, the type of friction materials must also be considered and different additives chosen for different friction materials such as sintered bronze, organic fibres, synthetic fibres or carbon fibres [69, 115, 119]. Yamamoto claims that the friction of paper-based wet friction materials increases with increasing viscosity of base fluid [107]. Shirahama found that that d rises with increasing viscosity, but that the addition of succinimide gives a coefficient of friction independent on the viscosity [69]. Kitanaka showed that d rises and decreases withs increasing viscosity, but that viscosity dependence diminished with the addition of dispersants (alkenylsuccinimide) and detergents (metal sulfonate) [66]. Friction Modifiers Friction modifiers are very important in order to obtain the desired friction characteristics. Friction modifiers are surface active and form molecular layers on the contacting surfaces. A typical friction modifier is a long straight-chain molecule with an active group which will strongly attach itself to the rubbing surfaces [32, 52]. A comprehensive review of the theory and application of friction modifiers has been published by Papay [122]. Friction modifiers have significant influence on friction, primarily at low sliding velocities [18, 51, 62, 69, 123]. A major drawback when adding friction modifiers in order to improve anti-shudder properties is that torque capacity decreases with increasing amounts of friction modifiers in the fluid [16-18, 24, 32, 59]. Friction modifiers should therefore be judged on their ability to resist high temperatures rather than their ability to resist shearing [17]. Shirahama concluded that succinimide raised d, and that it seemed to adsorb to the paper-based material as do borated dispersants [69]. Detergents Metallic cleaning agents are classified as surfactants composed of lipophilic and polar groups. Thus, in terms of structure they are similar to friction modifiers, but the polar groups are generally sulfonate (adsorb strongly to both steel and paper), phenate and other salts with metals. Kitanaka also concluded that metal sulfonate adsorbs to steel plates and plays ans important role in the friction characteristics by raising d [66]. Detergents may also alter friction characteristics due to interactions with friction modifiers. Anti-Wear Agents Anti-wear agents are often phosphate based consisting of a lipophilic group (hydrocarbon radical) and a polar phosphoric acid. The structure of the lipophilic group has been found to exert significant influence on the 0/d ratio [69]. Experimental Equipment A number of different experimental rigs designed for evaluating the performance of lubricant and friction material in wet clutches are described in the literature. In recent years increased attention has been paid to the test methods used to evaluate wet clutch applications. This rig tests a full clutch pack, allowing assessment of the overall performance of lubricant/friction material combinations. In one type of test, the large drive motor accelerates the flywheel to 3600rpm at which point the motor is turned off and the clutch engaged to stop the flywheel. This procedure is repeated several times a minute for 50 to 100hours in order to investigate the durability of the fluid. To determine the torque capacity, the clutch is engaged and then the low-speed drive is run at 0. Typical data that are obtained include the maximum breakaway friction and the friction coefficient after some seconds of continuous slip. The normal load is applied by deadweights through a lever at the bottom of the apparatus. This means that it is possible to run many different test cycles controlled by a computer, such as endurance tests. This equipment was also equipped with sensors measuring the oil film pressure [10, 11]. The wet clutch test rig designed by Holgerson is able to apply a drive torque as well as an inertia torque during engagement, thus closely simulating the clutch engagement in an automatic transmission in use. In addition to friction measurements the equipment was also equipped with infrared temperature monitoring, enabling measurement of the clutch interface temperature [19, 81]. This rig was equipped with a torsion bar to vary the rigidity of the tester [24, 59]. Small Scale Test Methods Many authors have chosen to conduct their investigations using small scale parts in standard test equipment instead of full clutch discs in dedicated rigs. Conclusions this paper has summarised some of the research efforts associated with improving and understanding the performance and behaviour of wet clutches. New applications employing wet clutches continue to appear, and the increased power density and increased efficiency that these demand have necessitated improvements in clutch performance and will continue to do so for a long time. The major challenges facing clutch designs today are increased demands on smooth controllable torque transfer, often under conditions of continuous slip. This, in combination with increased power density, necessitates improved performance of both friction materials and transmission fluids. Novel friction materials have emerged, but at the same time paper-based materials have improved with respect to allowable power input and durability while still maintaining a cost advantage in many applications. Other factors facing fluid designers are decreased oil volumes (to reduce churning losses and cost) in combination with increased drain intervals, or even demands on fill-for-life service. New transmission designs, such as continuously variable transmissions, whether based on toroidal elements, belts or chains, also introduce new demands on the lubricant. These include high friction under hydrodynamic and mixed lubrication as well as the ability to protect machine elements from scuffing and other damage during sliding. Present models predicting clutch performance are reasonably accurate and are increasingly used during design stages as well as being implemented in clutch control software. Most models, however, still rely on experimentally obtained boundary friction data, an area deserving further attention. Wagoner, Thermomechanical Effects in a Single-Sided Multidisk Clutch/Brake Design. Hiraki, Analysis of the Various Factors Affecting Drag Torque in Multiple-Plate Wet Clutches. Yamamoto, Study on Origin of Friction of a Paper-based Facing for a Wet Clutch: Consideration Based on Analysis of Real Contact Area by Electrical Contact Resistance Method. Shibayama, Mechanisms of Automatic Transmissions and Their Requirements for Wet Clutches and Wet Brakes. Brugel, European Test Procedures and Test Equipment for Slip-Controlled Wet Disc Clutches. Usoro, Fuel Economy and Performance Potential of a Five-Speed 4T60-E Starting Clutch Automatic Transmission Vehicle. Cheng, Average Flow Model for Determining Effects of Three-Dimensional Roughness on Partial Hydrodynamic Lubrication. Krousgrill, Finite element modeling of engagement of rough and grooved wet clutches. Shillor, Numerical simulation of engagement of a wet clutch with skewed surface roughness. Haviland, Friction of Transmission Clutch Materials as Affected by Fluids, Additives, and Oxidation. Prediction of Low Speed Clutch Shudder in Automatic Transmissions Using the Low Velocity Friction Apparatus. Sadeghi, Friction-induced sliding instability in a multi-degree of-freedom system with oscillatory normal forces.

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S Mechanisms Egg allergy (ovalbumin): the content of ovalbumin/ovomucoid is variable: 0 menstruation 19th century order estrace 1mg. S Management (controversial) In patient with egg allergy and skin tests positive to vaccine: vaccination in a 2 dose protocol at 30 min interval if the vaccine preparation contains no more than 1. Mild: headache, flushing, low backache, muscle pain, nausea, chills, abdominal pain. IgG anti-IgA antibodies are detected in 22% of patients with common variable immunodeficiency, and in 20 to 60% of patients with selective IgA deficiency. Anti-IgA antibodies are found more frequently in patients with combined IgA and IgG2 subclass defi ciencies. IgA antibodies are class-specific, subclass-specific, antiallotypic, antiisoallotypic, or of limited speci ficity. S Mechanisms Formation of immune complexes between antibodies in intravenous immunoglobulins and micro bial antigens in the recipient with subsequent complement activation. Use of IgA-depleted intravenous IgG preparations until the activity of anti-IgA decreases significantly or becomes undetectable. Ex-vivo pretreatment of intravenous immunuglobulin preparation containing less than 0. Immune tolerance induction in patients with IgA anaphylactoid reactions following long-term intravenous IgG treatment. A Baboon syndrome induced by intravenous human immunoglobulins: report of a case and immunological analysis. Unusual skin reactions after intravenous infusion of polyvalent immunoglobulin: 3 cases (Article in French). Vasculitis, Henoch-Schonlein purpura, erythema multiforme, Stevens-Johnson syndrome, toxic epidermal necrolysis, Gianotti-Crosti syndrome, Mucha-Haberman disease. S Diagnostic methods Skin tests Prick or intradermal tests in egg-allergic individuals have been debated; several studies have found poor positive and negative values. Extra precautions including continuous observation for 20 min after vaccination, with further moni toring of cardiorespiratory parameters to a total of 2 hours are needed if there is a history of any cardiorespiratory symptoms or signs after egg ingestion or active chronic asthma is present. Recommendations for administering the triple viral vaccine and antiinfluenza vaccine in patients with egg allergy. Erythema multiforme following live attenuated trivalent measles mumps rubella vaccine. Prevalence of anti-gelatin IgE antibodies in people with anaphylaxis after measles-mumps-rubella vaccine in the United States. Pytiriasis rosea-like eruption due to pneumococcal vaccine in a child with nephrotic syndrome. Anaphylaxis to the 23-valent pneumococcal vaccine in child: a case-control study based on immediate responses in skin tests and specific IgE determination. Specific serum IgE (immunofluorescence): the specificity of this method has been confirmed by solid phase binding of the vaccine to antigens (19 out of 21 cases of urticaria). The vaccine should be prepared without b-propiolactone (inactivation with formalin or tributyl phosphate only). Boosters should only be administered to risk-group patients the use of the intradermal route for both primary and booster injections may result in lower rates of reactions. Safety and immunogenicity of Lyssavac Berna human diploid cell rabies vaccine in healthy adults. Risk factors for systemic hypersensitivity reactions after booster vac cinations with human diploid cell rabies vaccine: a nationwide prospective study. IgE and IgG antibodies to beta propiolactone and human serum albu min associated with urticarial reactions to rabies vaccine. Immunologic studies in subjects with a serum sickness-like illness after immunization with human diploid cell rabies vaccine. Systemic allergic reactions following immunization with human diploid cell rabies vaccine. S Incidence Local reactions after booster injections: pain and tenderness: 50 -85% erythema and edema: 20 30% marked swelling: 2% abscess: 6 to 10/million doses. Positive in allergic patients but also positive in 8 to 63% of non-allergic vaccinated patients. Use an isolated tetanus toxoid which is less reactogen than associations (diphtheria/ tetanus) Desensitization has been reported to be effective. Extensive swelling reaction associated with diphtheria and tetanus toxoids and acellu lar vaccine. Immediate allergy to tetanus toxoid vaccine: determination of immunoglo bulin E and immunoglobulin G antibodies to allergenic proteins. Anaphylactic reaction to diphtheria-tetanus vaccine in a child: specific IgE/IgG determinations and cross-reactivity studies. Allergy to multivalent vaccines in children: a study of 30 cases using immediate, semi-late and late skin test responses, specific antibody assays, and challenge with monovalent and bivalent vaccines (Article in French). Immunization against tetanus in a hypersensitive individual using a graded dosing regimen (letter). Yellow fever desensitization to an antiamaril 17 D vaccine performed on a patient with anaphylaxis to eggs (Article in French). Cross-reactivity may exist between calcipotriol and other vitamin D3 analogue: tacalcitol and calcitriol. Tolerance to calcitriol and tacalcitol in three patients with allergic contact dermatitis to calcipotriol. S Diagnostic methods Skin tests Prick tests: positive with pure hydroxocobalamin in a few cases Intradermal tests: positive at 1/100 to 1/10 dilution. S Mechanisms the vitamin itself, the preservatives (benzyl alcohol) or some contaminants may be involved. Contact dermatitis due to the cobalt ring contained in this vitamin has been reported. Possible IgE-mediated hypersensitivity (positive skin tests, specific histamine release). S Management Cross-reactivity between hydroxocobalamin and cyanocobalamin has been described but is not always found. In patients with hydroxocobalamin allergy, if skin tests are negative cyanocobalamin can be used in increasing intramuscular doses (0. Desensitization in patients allergic to both hydroxocobalamin and cyanocobalamin may be perfor med. Allergy to vitamin B12: two cases of successful desensitization with cya nocobalamin. Adverse reactions to vitamin B12 injections due to benzyl alcohol sensiti vity: successful treatment with intranasal cyanocobalamin. Folinic acid (5-formyltetrahydrofolate) bypasses the reduction steps required for folic acid.

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Restaging after completion of primary (upfront) radiation therapy and/or chemotherapy 3 breast cancer 2020 order discount estrace. Tumor detected incidentally or incompletely treated surgically and one of the following high risk features: a. Routine advanced imaging is not indicated in the evaluation and management of chronic myeloid leukemias, myelodysplastic syndromes or myeloproliferative disorders in the absence of specific localizing clinical symptoms or clearance for hematopoietic stem cell transplantation. Monitoring response to chemotherapy only for patients with known bulky (> 5 cm) nodal disease at initial diagnosis every 2 cycles (6 to 8 weeks) Page 582 of 794 3. Acute abdomen suggesting bowel obstruction, toxic megacolon (abdominal swelling, fever, tachycardia, elevated white blood cell count), or perforation B. It can detect omental metastases, peritoneal implants, pelvic and periaortic lymph node enlargement, hepatic metastases and obstructive uropathy 3. If stress test is positive for reversible ischemia, or if duration of diabetes is >25 years and patient has additional cardiac risk factors, then diagnostic left heart catheterization can be performed 2. Abdominal Lymphadenopathywith clinical or laboratory findings suggesting benign etiology, and no history of malignancy: A. American Association of Clinical Endocrinologists and American Association of Endocrine Surgeons Medical Guidelines for the Management of Adrenal Incidentalomas, Endocrine Practice, 2009; 15(Suppl 1): 1-18. Approach to the adult patient with fever of unknown origin, Am Fam Physician, 2003; 68:2223-2229. Management of genitourinary trauma, the East Practice Management Guidelines Work Group. Whole body imaging in blunt multisystem trauma patients without obvious signs of injury, results of a prospective study. Use of positron emission tomography for staging, preoperative response assessment and post therapeutic evaluation in children with Wilms tumor. Practice Bulletin Number 174, Evaluation and Management of Adnexal Masses, American College of Obstetricians and Gynecologists, November 2016. A scan performed less than 72 hours after presentation may underestimate the extent of the disease) [One of the following] 1. Chronic pancreatitis with history of recurrent pancreatitis and abdominal pain and no definitive diagnosis with ultrasound or endoscopic ultrasound (not helpful for early diagnosis; only 61, 62 confirmation of diagnosis and surgical planning) 119-120 V. Evaluation of pseudocyst detected on prior imaging (The status of the pancreatic duct is a key determinant of how a pseudocyst is treated. If the pancreatic duct is intact, percutaneous drainage is likely to be effective. Evaluation of pancreatic or biliary ducts with known tumors of the pancreas, liver or suspected tumors of the biliary or pancreatic ducts on prior imaging 2. Chronic pancreatitis with history of recurrent pancreatitis and abdominal pain which may radiate to the back [One of the following] 1. Unilateral leg edema with venous Doppler excluding venous 83 insufficiency or varicose veins [One of the following] A. If enlarging on follow up imaging: Consider resection for possible primary adrenocortical carcinoma; biochemical evaluation to determine functional status and to exclude pheochromocytoma prior to resection. Biochemical assays to determine functional status to exclude pheochromocytoma prior to resection b. Annual screening patients at high risk of pancreatic cancer (to begin at age 40 or 10 years younger than the youngest affected family member) with any one of the following risk factors: a. Evaluation of elevated liver function tests and non-diagnostic 85-87 ultrasound A. Hemochromatosis genetic testing results other than homozygous C282Y/H63Aspor compound heterozygosity for C282Y/H63Asp. For the evaluation of suspected hepatic iron overload in chronic transfusional states. Mayerle J, Hoffmeister A, Werner J, et al, Clinical Practice guideline, chronic pancreatitis definition, etiology, investigation and treatment, Dtsch Arztebl Int, 2013; 110:387-393. Accuracy of Magnetic Resonance Imaging in Diagnosis of Liver Iron Overload: A Systematic Review and Meta-Analysis. Advances in Wilms tumor treatment and biology: progress through international collaboration. Renovascular hypertension, suspected renal artery stenosis [One of the following] A. Peripheral arterial vascular disease with abnormal ankle brachial 1,2,24-27 index as defined in A and one additional of the following A. Evaluation of hepatic vasculature prior to and following embolization procedure D. Possible portal vein thrombosis with negative or inadequate Doppler study of the portal vein [One of the following] 1. If no dilation fo the aortic root or ascending thoracic aorta is found, there is no evidence-based data to support continued surveillance imaging 1 X. Seventh report of the joint national committee on prevention, detection, evaluation and treatment of high blood pressure. Should Computed Tomographic Colonography Replace Optical Colonoscopy Screening For Colorectal Cancer Single-center study comparing computed tomography Colonography with conventional colonoscopy. Screening for colorectal cancer: A guidance statement from the American College of Physicians. Not medically necessary if there has been a normal optical colonoscopy performed less than 10 years ago B. Not medically necessary if there has been a normal double contrast barium enema less than 5 years ago C. Not medically necessary if there has been a normal sigmoidoscopy within the last 5 years the following conditions are considered to be contraindications to virtual colonoscopy: 8. Evaluation of patients who have had an incomplete fiber optic 5 colonoscopyor if an optical colonoscopy is contraindicated 10 [One of the following] Page 637 of 794 A. Computed Tomographic Virtual Colonoscopy, American Society of Colon & Rectal Surgeons Position Statement. Monitoring cancer chemotherapy effect on the heart (especially if accurate assessment of right ventricular function is documented as necessary). Pulmonary vein anatomy for planned ablation procedures in patients with atrial fibrillation. Evaluate for iron overload due to conditions requiring frequent blood transfusions. Cardiac imaging is not indicated if the results will not affect patient management decisions. If a decision to perform cardiac catheterization or other angiography has already been made, there is often no need for imaging stress testing. A current clinical evaluation (within 60 days) is required prior to considering advanced imaging, which includes: 1. Other meaningful contact (telephone call, electronic mail or messaging) by an established patient can substitute for a face-to-face clinical evaluation.

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Clinically, bullae occur in to third decade and has a good prognosis, areas of friction, which rupture leaving ulcers and although the clinical course is characterized by scarring after the acute eruption. The tongue remissions and exacerbations and shows little ten becomes depapillated and scarred (Fig. Finally, leuko and cicatricial pemphigoid and transient acan plakia, and squamous cell carcinomas may tholytic dermatosis. Histopathologic examination Generalized skin bullae leaving ulcerations that supports the clinical diagnosis. The lesions antifungal or antibacterial ointments or creams are more often found on the hands, feet, knees, are of value in cases with secondary infection of and elbows. Systemic steroids are used only in Dystrophy and loss of the nails are common severe cases. Epidermolysis Bullosa the differential diagnosis should include pemphi Epidermolysis bullosa is a group of inherited dis gus, bullous pemphigoid, linear IgA disease, bul orders characterized by bullae formation on the lous erythema multiforme, dermatitis herpetifor skin and mucous membranes spontaneously or mis, cicatricial pemphigoid of childhood, and bul after mechanical friction. Histopathologic examination is the differential diagnosis should include multiple important to establish the final diagnosis of differ mucosal neuromas, multiple endocrine neoplasia ent groups of epidermolysis bullosa. Histopathologic examination of steroids, vitamin E, phenytoin, and retinoids have oral and skin neurofibromas is helpful in establish been used in severe cases. Treatment is supportive and presents many problems for the dermatologist, surgeon, Neurofibromatosis and endocrinologist. The cardinal features of the disease are the cafe-au-lait spots and the skin neurofibromas. The skin neurofibromas are multiple and may be either cutaneous or subcutaneous (Fig. The oral cavity is uncommonly affected but may exhibit multiple or, rarely, isolated nodular neurofibromas, which vary in size (Fig. Epidermolysis bullosa, recessive dystrophic, scarring, dystrophy and loss of the fingernails. The angiomatous lesions may sometimes be Chondroectodermal dysplasia, or Ellis-van Cre excised surgically, cauterized, or treated with the veld syndrome, is inherited as an autosomal reces cryoprobe. The main characteristics are bilateral polydactyly, chondrodysplasia of long bones, involvement of ectodermal tissues (hair, nails, Peutz-Jeghers Syndrome teeth), and, rarely, congenital heart disease. The most constant oral finding is fusion of the Peutz-Jeghers syndrome is transmitted as an auto upper or lower lip to the gingiva, resulting in the somal dominant disorder with a high degree of disappearance of the mucolabial fold or multiple penetrance, characterized by intestinal polyposis fibrous bands (Fig. The man conical teeth with enamel hypoplasia are also ifestations, which may be apparent at any age, present. About 50% of tal syndrome, acrofacial dysostosis of Weyers, the patients have numerous dark spots on the other forms of chondrodystrophies. Pigmented spots 1 to 10 mm in diameter are always found in the oral mucosa, particularly on the lower lip and the buccal mucosa, but rarely on the upper lip, the tongue, the palate, and the gingiva (Fig. Oral pigmentation constitutes the most important diagnostic finding and appears Hereditary Hemorrhagic in the form of oval, round, or irregular brown or Telangiectasia black spots or patches. Radiologic evaluation of the gas and small vessels, the disease usually develops trointestinal tract is helpful in establishing the during adolescence and affects both sexes. These lesions have a bright red, purple, or violet color and disappear on pressure with a glass slide. The oral mucosa is frequently involved with multiple lesions on the lip and the dorsum of the tongue (Fig. Hemor rhage from oral lesions is frequent after minimal mechanical damage, such as tooth brushing. Epistaxis and gastrointestinal bleeding are ear ly, common, and occasionally serious complica tions. Chondroectodermal dysplasia, disappearance of the mucolabial sulcus and multiple fibrous bands. It is not clear whether it represents an mainly of the colon, multiple osteomas, other inherited disorder or a dysplasia. The skin lesions are epidermal and seba ple enchondromas, principally in the small bones ceous cysts, subcutaneous fibromas and other fi of the hands and feet, although any bone of car brous tissue disorders, and rarely increased skin tilaginous origin may be affected; multiple heman pigmentation. Multiple osteomas are a common giomas localized on the skin, mucosae, and vis finding usually located at the facial bones and the cera; phleboliths; and pigmented skin macules. Oral manifestations include multiple the oral mucosa is rarely affected and the oral osteomas of the jaws (Fig. The and impacted teeth, odontomas, and rarely benign tongue is the most frequent site of hemangiomas, fibrous soft tissue tumors (Fig. The oral but the buccal mucosa, lips, soft palate, and other lesions are innocent but intestinal polyps have a oral regions can also be involved (Fig. Surgical excision of the enchondromas and hemangiomas may be attempted if they are symptomatic. Genetic Diseases Tuberous Sclerosis the differential diagnosis of oral lesions should include multiple fibromas, multiple condylomata Tuberous sclerosis, or Bourneville-Pringle syn acuminata, focal epithelial hyperplasia, and drome, is transmitted as an autosomal dominant neurofibromatosis. Histophatologic examination of icap, paraventricular calcifications, multiple small skin and oral mucosa lesions and skull radiographs gliomas, mucocutaneous manifestations, skeletal are helpful in the diagnosis. Characteristic lesions occur on the face, princi pally along the nasolabial fold and cheeks. These are numerous small nodules, red to pink in color, which are actually angiofibromas, although the prevailing term is "adenoma sebaceum" (Fig. Other cutaneous changes are white macules (maple leaf or ash leaf), cafe-au-lait spots, skin tags, and multiple periungual fibromas (Fig. The gingiva or other parts of the oral mucosa may exhibit confluent nodules a few mil limeters to less than 1 cm in diameter, which are of whitish or normal color (Fig. Tuberous sclerosis, confluent whitish nodules on the gingiva and the alveolar mucosa. Sturge-Weber Syndrome Klippel-Trenaunay-Weber Syndrome Sturge-Weber syndrome is a sporadic congenital dysplasia. It is charac Klippel-Trenaunay-Weber syndrome, or angio terized by hemangiomas of the face and oral osteohypertrophy, is a rare dysplastic vascular mucosa, and of the leptomeninges, calcification of disorder. It is characterized by multiple facial the brain, ocular disorders, epilepsy, and mild hemangiomas (Fig. It is unilateral, vascular cutaneous lesions, ocular disorders has a bright red or purple color, and is confined (scleral pigmentation, cataract, glaucoma, and iris roughly to the area supplied by the trigeminal heterochromia) (Fig. Clinically, the are unilateral, rarely cross the midline, and may oral hemangiomas are usually located on the soft involve the upper gingiva, buccal mucosa, lips, and hard palates and gingiva, which may be and tongue (Fig. Premature tooth eruption and red or purple color and a usually flat but may also bony overgrowth may produce malocclusion. Care must be taken during tooth extractions because hemor Treatment is supportive. When the classic signs and symptoms are present, the diagnosis of Sturge-Weber syndrome is apparent. The differential diagnosis includes large dissemi nated hemangiomas and the Klippel-Trenau nay-Weber syndrome. Laboratory tests helpful in diagnosis and manage ment are angiography, electroencephalography, skull radiographs, and computed tomography. Histopathologic examination is the differential diagnosis includes hypohidrotic helpful in establishing the diagnosis. Genetic Diseases Oro-Facial Digital Syndrome Focal Dermal Hypoplasia Oro-facial digital syndrome type I is a rare the focal dermal hypoplasia, or Goltz syndrome, X-linked dominant inherited disorder lethal to is a rare disorder that affects females almost exclu males. The syndrome is characterized drome type I are digital malformations (brachy by irregular linear skin pigmentation, atrophy, dactyly, syndactyly, clinodactyly) and other and telangiectasia present at birth, localized skeletal disorders, cutaneous lesions (milia, deposits of subcutaneous fat that present as soft xeroderma, alopecia, sparse hair, dermatoglyphic reddish-yellow nodules (Fig.

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Women menopause lubricant generic estrace 1 mg free shipping, in contrast, presented more symptoms of malar rash, photosensitivity, mouth ulcers, alopecia, Raynaud or arthralgia (P<0. In this study, the cases were recruited from rheumatology or nephrology clinics, which may overestimate the prevalence of renal disease. During an average fve-year monitoring period of the diagnosis, males had greater accumulated frequency of nephropathy (23. However, in this cohort, males had a signifcantly higher average age at diagnosis than women (54 v. There was also a greater prevalence of high blood pressure, proteinuria, cellular cylinders in urine and haemolytic anaemia (P<0. A tendency towards greater prevalence of glomerulonephritis was observed but with no signifcant differences between genders. Serologically, only the presence of IgG anticardiolipin antibodies and low levels of C3 were more frequent among males. No differences were found between genders with respect to the activity of the disease, irreversible organ damage or mortality. Determining antinuclear antibodies and, where appropriate, specifc antibodies, may be indicated in these women. The quantitative method permits establishing the cut-off point that achieves the best equilibrium between sensitivity and specifcity, but it presents intra and inter laboratory reproducibility problems due to the subjectivity in interpretation. The antigens are found in their native location, they are not denatured 3 and preserve their own structure. These cells have advantages over rodent tissues due to their greater sensitivity, their larger-sized nuclei and nucleoli that improve the visualisation of the structures and of the fuorescence patterns, and due to the ability to express certain antigens present in different phases of the cell cycle. Furthermore, they permit the detection of specifc antibodies with respect to human nuclear antigens that are not present in mouse or rat tissues. This is a opinion fast, simple and sensitive method that permits detecting specifc autoantibodies 4 with respect to different antigens in an objective and automated manner. The results are usually semi-quantitative and they are generally expressed in arbitrary units established by the manufacturer. False negatives can also be found due to the absence of certain antigens in the antigenic mixtures immobilised in the plate well. Faced with this variability, the impact on the result of using one type of antigenic substrate or another should be evaluated. Some of these patients have other antibodies such as anticardiolipin or anti-Ro antibodies. The percentage of agreement in the positive and negative result between the manual and automated methods was 93% and 90. The positive/negative result was obtained by consensus from the six participating laboratories, specifying agreement of at least four of them; and the titre and pattern are selected from the value observed with greatest frequency. False negatives occurred more frequently between the cytoplasmatic and nucleolar patterns with low fuorescence level. Correct discrimination of the result in positive/negative occurred in 95% of the serums with automated methods. Automatic methods showed good correlation of the fuorescent light signal with visual method reading (Spearman rho between 0. The correct identifcation capacity of the immunofuorescence pattern is limited for the different automated methods between 52% and 79%. Diagnostics, Italy) offers a quantifed result in positivity likelihood terms 2 according to the intensity of the fuorescence. To establish the cut-off point and interpret the titre of antinuclear antibodies, we B recommend knowing the antinuclear antibodies levels of reference in the general population of application with no antinuclear antibody-related diseases. The anti-Sm antibodies are, therefore, multiple autoantibodies that opinion link to multiple antigenic proteins. These are the 3 anti-nucleosome antibodies, also called anti-chromatin antibodies. The Caucasian ethnic group is the only independent factor associated with the presence of anti-RibP antibodies (= -0. Anti-RibP2 antibodies were associated with an increase in anti-nucleosome antibodies and anti-RibP1 antibodies with an increase in anti-La antibodies. As in other studies, anti-RibP antibodies were signifcantly associated with the presence of anti-cardiolipin antibodies. In the validation study on the determination of anti-La antibodies by Diagnostic S. If the gold standard was the clinical diagnosis by the rheumatologist, the validity parameters were 88%, 65%, 83% and 74%, respectively. However, once again, they were not constructed or validated with diagnostic purposes, but rather for use in the selection of homogeneous patients in epidemiological and clinical studies. With respect to these aspects, laboratory tests, espe cially immunological tests, are of great value. All of these have proven their ability to measure the disease activity and its response or sensitivity to change (improvement/stabilisation/worsening). All the indices include some haematology and biochemistry parameters, but only some contain immunological disorder criteria. Cancer screening is carried out in agreement with the existing recommendations for the general population. However, there were considerable differences in term of sensitivity and specifcity between studies. When the technique used was Farr radioimmunoassay, sensitivity varied between 41 and 98%, and specifcity between 25 and 97%. Therefore, the absence of anti-Sm antibodies did not indicate the absence of renal disease, due to the large number of false negatives that it may cause. In contrast, the presence of anti-Sm antibodies is associated with the existence Prognosis S. Evidence about the prognostic value of anti-Sm antibodies on other systemic lupus manifestations (pleuropulmonary, haematological, cardiac, cutaneous, joint, vasculitis and thrombosis) is even more limited and inconsistent. Available evidence comes from moderate quality methodological studies studies with different result measurements. Some fnd no correlation between 2 anti-Sm antibodies and cutaneous lesion, arthritis or serositis. Given that they only considered the most serious fare-up episode, a second analysis of 29 fares was performed, in which the average titre of anti-Sm antibodies was 3. However, in this sample there was a prevalence of patients with a relative low Diagnostic S. Sensitivity and specifcity for the diagnosis of lupus nephropathy was 81% and 39%, respectively. The prevalence of anti-nucleosome antibodies at start and end of monitoring was 40% and 58. The sensitivity and specifcity of the anti-nucleosome antibodies to diagnose active nephropathy at the start of monitoring were 32% and 67. Anti-RibP antibodies correlated with standardised indices of 195,196,198,199 Prognosis S. There is no consistency, either, between studies in terms of the relationship between the presence of anti-RibP antibodies and lupus gomerulonephritis or hepatitis. Anti-Ro and anti-La antibodies cross the placenta and can produce heart block in the foetus (2%-5%, which increases to 16%-25% Diagnostic S. The adjusted risk of arterial thrombosis is greater in patients with lupus Prevalence S.

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According to the books of Samuel and Kings women's health clinic pacific fair discount 1 mg estrace visa, Israel was ruled by a sequence of royal houses, each of which was linked to a new capital. These combinations include: Saul at Gibeah; David and Jerusalem; Jeroboam at Shechem; Baasha at Tirzah; and Omri at Samaria. This pattern would have made Jerusalem the capital of Israel under the royal house of David. The Bible preserves two distinct claims regarding the establishment of Jeru salem as a center for the worship of Yahweh, both of which imagine that the Jerusalem-based kings embraced this god as essential to their success. The detailed account of temple construction is presented as if the king himself carried out the task (6:1, 11, 14, 21; 7:1), so that it is hard to strip the text of its royal subject (see Hurowitz 1992). The construction text is of uncertain date, but this concluding line would in troduce into it the name Israel for the specific purpose of identifying the body assembled to worship at the Jerusalem temple. In a completely separate tradition, David is understood to have brought Yah weh to Jerusalem (2 Sam 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. 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. 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 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 seems that however important that temple must have been, the worshiping public was not defined by it. 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. 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. 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. I Have Built You an Exalted House: Temple Building in the Bible in Light of Mesopotamian and Northwest Semitic Writings.