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By: Jennifer Lynn Garst, MD

  • Professor of Medicine
  • Member of the Duke Cancer Institute

https://medicine.duke.edu/faculty/jennifer-lynn-garst-md

Any unexpected bleeding Silicone tubing placed into the anterior chamber will tend should raise the possibility of perforation with a retinal to asthma symptoms tiredness straighten over time and cause the tip to asthma symptoms early pregnancy “migrate” hole and prompt immediate asthma treatment breathing exercises , indirect ophthalmoscopy asthmatic bronchitis effects , anteriorly. Therefore, a limbal fistula should be made as with appropriate treatment, if necessary. Several geon must observe the needle throughout this maneuver modifications in surgical technique and implant design to insure proper orientation, the most important factor can limit this risk. An alternative approach employs temporary occlusion of the tube lumen, using one of several methods Phakic eyes are particularly challenging because the (Fig. Most of these involve an external ligature, natural tendency to avoid the iris and lens can leave the either with or without a removable suture stent. A preopera Cooperative patients with good exposure may require tive laser iridotomy in eyes with relative pupillary block only temporary ligation with a 7-0 or 8-0 polyglactin may deepen the anterior chamber and allow more poste suture. These ligatures are easiest to lyse if placed just posterior to the graft and 3 to 4 mm anterior to the scleral plate, and 1 to 2 mm closer to the limbus for inferior tubes. Prior to insertion, the tube is trimmed with an ante Aphakic and vitrectomized eyes are prone to imme rior bevel to prevent iris incarceration approximately diate softening and scleral collapse, leading to retraction 2 mm beyond the limbus (Fig. Following tube of the tube out of the globe as it expands to physiological insertion with either a serrated or tube-introducing for pressure after surgery. A similar, but delayed retraction ceps, the surgeon should reform the anterior chamber can occur in very young children as the eye grows. If too long, it should be removed, tubing can be cut long, laying some of it on the sclera over trimmed, and reinserted. If the position is unacceptable, it a sinuous course for later advancement, if needed. The surgeon should avoid overfilling the ante Eyes with obliterated anterior chambers may require tube rior chamber and accidentally placing the tube too deep. This requires a complete A properly inserted tube will lie parallel and just anterior vitrectomy either prior to or at the time of tube implanta 53–59 to the iris, extending well into the eye (Fig. Arrow indicates escape of fluid from the valve portion of an Ahmed glaucoma valve. The angled portion of the dehydration and gamma irradiation, are thin, uniform, sleeve is beveled posteriorly at its tip and fits well through and easy to work with and have a long shelf life. Many either a pars plana vitrectomy port or a fistula made by a surgeons prefer to use sclera in children and for tubes 19 or 20-gauge needle or microvitreoretinal blade ori placed at the more exposed inferior limbus because it is ented perpendicular to the globe. The tube is oriented parallel to the iris plane and extends well into the eye with the bevel oriented anteriorly. An anterior bevel on possible in eyes at high risk for complications from the graft reduces the risk of a postoperative dellen. Closing a fornix-based ilar style lens to compress the overlying conjunctiva and conjunctival/Tenon’s flap involves anchoring both corners blanch the conjunctival vessels. Several applications with a to the limbus using an interrupted 8-0 or 9-0 absorbable duration of 0. The appearance incisions can be closed with running extensions of the of subconjunctival fluid and increased anterior chamber anchoring sutures, or further interrupted sutures. If necessary, anchoring Tenon’s capsule to the scleral surface with an the suture can be surgically released though a small con absorbable suture after adequate tissue mobilization can junctival/Tenon’s capsule incision. When the ligature releases, the pres the occurrence of wound dehiscence and implant extru sure falls rapidly and then recovers over the next 1 to 2 sion. Clotted blood or fibrin, vitre appears to be clear, simple digital pressure on the globe or ous, iris, lens material, iridocorneal endothelial mem manipulation of the conjunctiva overlying the tube and branes, and fibrous or neovascular membranes may all the valve mechanism with a cotton-tipped applicator may occlude the ostium of the tube within the eye. Early obstruction may also occur in eyes either into the anterior chamber or the tube itself is nec with excessive intraocular inflammation37,38,66,67 and from essary to resolve a persistent clot,36–38,66,67,72 but this should failure to prime a valved device at the time of insertion. Meticulous orientation of the needle during fistuliza Some situations require surgical removal of the obstruct tion and carefully placing the tube away from potentially ing material from the anterior chamber, “exploration” of obstructing structures can generally avoid occlusion of the the tube for obstruction with a 4-0 nylon suture,72 reposi tube tip. When occlusion does occur, management con tioning the tube, or replacing the entire device. Although this situation often responds to glaucoma medications, surgical revision may be neces Erosion of the tube through the overlying conjunctiva can 79 sary, either by needling through the conjunctiva or by occur either at the limbus or anywhere along the tube or direct excision of the bleb capsule. However, complete exposure of the fluid and softening of the globe indicate successful tube carries a high risk of progressive conjunctival break opening. Postoperative 5-fluorouracil injections, or pre down, aqueous leak, and endophthalmitis. This should operative, low-dose mitomycin-C, as described for sim be repaired immediately by mobilizing the adjacent con ilar revisions of scarred filtering blebs after trabeculec junctiva, placing a new patch graft, and advancing healthy 80 tomy, may also be considered. Using either a limbal or Several reports describe the development or exacerbation fornix incision, the capsule is exposed and then treated of strabismus following installation of glaucoma drainage with mitomycin-C (0. A large piece of the superior capsule wall is lar deviations are vertical86,87,90,91 and are often reported then excised, followed by conjunctival closure and refor following placement of a drainage device in the super mation of the anterior chamber. Hitchings R, Joseph N, Sherwood M, Lattimer J, fat and scarring or tucking of the superior oblique ten don by devices placed in the superonasal quadrant, Miller M. Use of one-piece valved tube and variable 92,93 surface area explant for glaucoma drainage surgery. Surgical correction of strabismus after aqueous shunts Ophthalmology 1987;94:1079–1084. Comparison Because of this, prevention remains the best treatment for of the double-plate Molteno drainage implant with motility dysfunction. Arch Ophthalmol 1992;110: implant now contains multiple fenestrations in the scleral 1246–1250. New implant for drainage in glaucoma: plate Molteno implant in complicated glaucomas. Epithelial ingrowth and glaucoma drainage Implants for draining neovascular glaucoma. Aqueous tube shunt to a preexisting episcleral Experimental studies of aqueous filtration using the encircling element in the treatment of complicated Molteno implant. A randomized clinical trial of sin glaucomas in eyes with pre-existing episcleral gle-plate versus double-plate Molteno implantation bands. Ophthalmology 1988; diate-term results of a randomized clinical trial of 95:1174–1180. Lundy D, Sidoti P, Winarko T, Minckler D, Heuer valve implant surgery for eyes with neovascular D. Clini without antimetabolites for early postoperative cal experience with the Ahmed Glaucoma Valve intraocular pressure control. Ophthalmology 1998; implant in eyes with prior or concurrent penetrating 105:2243–2250. Initial tube shunt to an encircling band (Schocket proce clinical experience with the Ahmed Glaucoma Valve dure) in the treatment of refractory glaucoma. Trans lation of a successful glaucoma pump-shunt Ophthalmol Soc N Z 1979;31:17–26. Long-term stage insertion of the Molteno tube for glaucoma results with the White glaucoma pump-shunt. Internal suture occlusion of and in vivo flow characteristics of glaucoma drainage the Molteno glaucoma implant for the prevention implants. Ophthal means of controlling intraocular pressure with mology 1998;105:1708–1714. Molteno implant with mitomycin C: intermedi reduce hypotony following Molteno seton implan ate-term results. The effect of mitomycin C on Molteno tie technique for inserting a draining implant in the implant surgery: a 1-year randomized, masked, treatment of secondary glaucoma. Removable ligature during Simultaneous use of mitomycin-C with Baerveldt Molteno implant procedure. Molteno implantation and pars plana vitrectomy for Am J Ophthalmol 1997;124:781–786. Varma R, Heuer D, Lundy D, Baerveldt G, Lee P, with the Baerveldt glaucoma implant in treating Minckler D. Ophthalmology 1995;102: vitrectomy in glaucomas associated with pseudo 1107–1118. Aqueous misdirection after glaucoma tube implantation in eyes with intractable glau drainage device implantation. Mardelli P, Lederer C, Murray P, Pastor S, Has Fascia lata patch graft in glaucoma tube surgery. Intra brane adhesion as a cause of Ahmed glaucoma cameral tissue plasminogen activator: management valve failure.

Discussion Focal interface changes with characteristic small eosinophilic globular deposits seen in the papillary dermis often with scattered dermal melanophages correctly identify this as lichen amyloidosis asthma treatment in toddlers . Irregular epidermal acanthosis with some compressed collagen and scattered dermal melanophages in the papillary dermis can also be seen in chronic dermatitis but the characteristic eosinophilic globules seen in this biopsy are not noted in a chronic and lichenified dermatitis renal asthma definition . Melanin pigment incontinence can serve as a subtle clue and may draw one’s attention to brittle asthma definition the often faintly staining eosinophilic globules asthma triggers . Systemic amyloidosis with cutaneous involvement typically demonstrates pale eosinophilic deposition throughout the dermis but frequently around blood vessels and sometimes outlining adipocytes. Multiple 246 stains are positive in amyloidosis including crystal violet, Congo red, Thioflavin T, cotton dyes (Pagoda Red) and acid-orcein Giemsa. These superficial deposits in cutaneous amyloid may also stain with keratin stains, which will not highlight systemic forms of amyloid. Folliculotropic T-cell lymphoma (Incorrect) Although there is a perifollicular lymphoid infiltrate, there are no interface changes of the follicular epithelium and there are no cytologic atypical lymphocytes for cutaneous lymphoma. Secondary syphilis (Incorrect) Secondary syphilis of the scalp causing alopecia shows similar findings as cutaneous lesions with an interface dermatitis and plasma cells within the infiltrate. Seborrheic dermatitis (Incorrect) Seborrheic dermatitis is either a spongiotic dermatitis or psoriasiform dermatitis and does not show follicular interface changes. Question A biopsy for direct immunofluorescence would typically show what features IgG staining along the dermal epidermal junction (Incorrect) Deposition of immunoglobulins particularly IgG and IgM are seen in 50-90% of cases of lupus erythematous. Linear homogeneous staining of C3 along the interfollicular epidermal basement membrane and dermo-epidermal junction (Incorrect) Deposition of linear, homogeneous of C3 along the basement membrane zone is seen in bullous pemphigoid. Linear IgA along the follicular basement membrane (Incorrect) Deposition of linear IgA just along the follicular basement zone is non-diagnostic. No staining on direct immunofluorescence (Incorrect) Negative staining is usually not seen in lichen planopilaris except in lesions of long standing where the inflammatory component is lost and end staging cicatricial alopecia is found. The diagnosis can be made on both vertically and horizontally sectioned specimens, although the latter allow examination of a greater number of hair follicles. Biopsy from the involved skin where there is erythema and follicular plugging increases the specificity for the diagnosis as opposed to biopsies taken from completely scarred or alopecic skin. A case series of 29 patients with lichen planopilaris: the Cleveland Clinic Foundation experience on evaluation, diagnosis, and treatment. Candidiasis (Incorrect) Candidiasis typically is spongiotic dermatitis with some accumulation of neutrophils in the stratum corneum. The unique changes seen in this biopsy of retention of keratohyaline granules and thickened basophilic stratum corneum is not seen. Occasional accumulation of coccobacilli may be found in the stratum corneum on gram stain. Granular parakeratosis (Correct) the thickened basophilic parakeratotic layer with characteristic retention of keratohyaline granules makes this the correct answer. Inverse psoriasis (Incorrect) Although some lesions of granular parakeratosis have a “psoriasiform acanthosis” the accumulation of neutrophils typically seen in psoriasis are not present. The unique changes seen in this biopsy of retention of keratohyaline granules and thickened basophilic stratum corneum are not seen in psoriasis. Irritant/contact dermatitis (Incorrect) Typically both are spongiotic dermatitis with a perivascular infiltrate. The unique changes seen in this biopsy of retention of keratohyaline granules and thickened basophilic stratum corneum are not seen in an irritant or contact dermatitis. Absence of lamellar granules and accumulation of dense core granules (Incorrect) these are the electron microscopy findings seen in Harlequin fetus. Defect in crosslinkage of locrin and involucrin and formation of cornified cell layer (Incorrect) this defect is seen in lamellar ichthyosis. Defect in the processing of profilaggrin to filaggrin in keratinocytes (Correct) this is the proposed etiology of granular parakeratosis. Deficiency of steroid sulfatase (Incorrect) this defect is seen in x-linked ichthyosis. Typical clinical diagnoses include inverse psoriasis, intertrigo, erythrasma and contact or irritant dermatitis. Although some lesions of granular parakeratosis have a “psoriasiform acanthosis” the accumulation of neutrophils typically seen in psoriasis are not present. The unique changes seen in this biopsy of retention of keratohyaline granules and thickened basophilic stratum corneum are not seen in psoriasis nor in dermatitis. The defect in maturation of profilaggrin to filaggrin is thought to be the cause of this distinct and recognizable entity. Granular parakeratosis: pathologic and clinical correlation of 18 cases of granular parakeratosis. The patient presents with a two-month history of a papulovesicular eruption on the trunk and extremities. Direct immunofluorescence (Correct) Direct immunofluorescence would show granular deposits of IgG, IgM, IgA, and C3 along the dermoepidermal junction. All of the above (Correct) Question You are provided with a direct immunofluorescence which shows granular deposits of IgG, IgM, IgA, and C3 along the dermoepidermal junction. About 60% of cases show a granular pattern of deposits while 40% have a linear pattern. The eruption appears as large and tense or small and clustered clear to hemorrhagic vesicles or bulla arising on normal or inflamed skin. Lesions resolve, leaving behind hypopigmented, or less often, hyperpigmented macules without scarring. Sun exposed skin of the upper trunk, neck, supraclavicular region, axillary folds, and proximal extremities is most often affected. Mucous membranes, including nasal, oral, and vulvar, are also frequently involved. If there is a linear pattern of immunoglobulin deposition, immunoelectron microscopy should be done to demonstrate the immune reactants below the basal lamina. Bullous systemic lupus erythematosus: differential diagnosis with dermatitis herpetiformis. The rash is intermittent and recurring and resolves spontaneously, lasting only one to several days. Question the best diagnosis is: A) Sweet syndrome (Incorrect) Pronounced papillary dermal edema is a classical feature of Sweet’s syndrome. In addition, in Sweet’s syndrome, the dermal neutrophilic infiltrate is usually much more dense. B) Urticarial vasculitis (Incorrect) the presence of leukocytoclastic vasculitis is the hallmark feature in well-developed urticarial vasculitis. Early lesions may be more challenging, but show mild perivascular neutrophils with leukocytoclasia, as well as eosinophils, and subtle leukocytoclastic vasculitis with evidence of vascular damage, even if only focal. C) Adult-onset Still’s disease (Correct) A variety of cutaneous eruptions can occur in adult onset Still’s disease, most showing nonspecific subtle microscopic features including a mild superficial perivascular lymphocytic infiltrate with occasional scattered neutrophils. Persistent pruritic papules and plaques have a more characteristic histology with dyskeratosis confined to the upper layers of the epidermis, a sparse superficial dermal infiltrate with scattered neutrophils, and often an increase in dermal mucin deposition. Urticarial lesions of adult-onset Still’s disease usually show mild perivascular and interstitial superficial dermal neutrophilic inflammation without significant dermal edema, eosinophils, or vasculitis. These latter features, of no dermal edema, eosinophils, or vasculitis, are the main findings that allow distinction from classical urticaria or urticarial vasculitis. D) Interstitial granulomatous dermatitis (palisading neutrophilic granulomatous dermatitis) (Incorrect) Interstitial granulomatous dermatitis is often associated with rheumatoid arthritis, and can show variable histological patterns, including interstitial and perivascular inflammatory infiltrates, predominately consisting of neutrophils, as well as neutrophilic debris, histiocytes, lymphocytes, and some eosinophils. E) Bullous systemic lupus erythematosus (Incorrect) In addition to a subepidermal blister in bullous systemic lupus erythematosus, there is a dense inflammatory infiltrate in the superficial dermis, predominately consisting of neutrophils, as well as lymphocytes and some eosinophils. However, other cutaneous eruptions have been described in association with adult-onset Still’s disease, the most common being persistent pruritic papules and plaques with scale and linear pigmentation, reported to occur, over time, in 65% of patients with the disease. Additional cutaneous manifestations seen in adult-onset Still’s disease include vesiculopustules on the hands and feet, acne-like lesions, purpura, persistent generalized erythema, generalized peau d’ orange-like lesions with diffuse cutaneous mucinosis, intermittent and recurrent urticaria-like eruption with non-pruritic erythematous macules or slightly elevated plaques, and a prurigo pigmentosa-like eruption. Persistent pruritic papules and plaques with scale and linear pigmentation (Correct) B. Evanescent non-pruritic non-scaly salmon-colored morbilliform eruption (Correct) C.

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The mountainous slopes brought with it the downslope wash of most buildings following their abandonment and the num ber of destruction assemblages is surprisingly low asthmatic bronchitis with acute exacerbation . Consequently asthma treatment using fish , almost all of the finds derive from earth fills that were placed in order to new asthma treatment 2013 bridge between topo graphical levels asthma fever . This fact leaves us with the former tool: Access analysis based on the architecture. Many more buildings were exca vated over the years in and around Jerusalem; we excluded those whose full plan was unclear or that were built on an ad hoc basis. This space teaches most about daily conduct, the Introduction of the Open-Courtyard Building 215 social values, and the demarcation of private versus public spaces (Byrd 1994). Four types of buildings were defined based on recurring patterns that indicate shared perceptions: Four-Room Buildings, Inner-Courtyard Buildings, Long-Axis Buildings, and the Open-Courtyard Buildings (fig. Abu Shwan, Building 200 (according to: Baruch 2007, plan 1) (8) Ras Abu Ma’arof (according to: Seligman 1994, Plan 3); Inner-Courtyard Building: (9) ‘Alona (according to: Weksler-Bdolah 1997, fig 136) 10. The Long-Axis Buildings are built without a courtyard and are usually com posed of three broad rooms arranged one next to the other. The courtyards of the Four-Room Buildings and Inner-Courtyard Buildings are located inside the build ings themselves and are similar in size to all surrounding spaces. The location of the courtyard turns it into a hub that allows direct access to all of the building’s wings. In the Four-Room Building, the courtyard is nested within the building and is surrounded by three wings. A set of pillars serve in some cases to divide between the court yard and the spaces at its sides. The pillars had a cardinal impact on both the physical and sensory interactions taking place within the building. Regardless of their ethnic affiliation, the buildings share a unique syntax that shaped and ex pressed economic and social conduct within them (Faust and Bunimovitz 2003). In the Inner-Courtyard Building, separation between the courtyard and the surrounding spaces was achieved with fully built walls. Excavations at the site exposed a building in its entirety which the excavators described it as a Four Room House. An analysis, however, shows the main courtyard is actually located outside of the building, in a space that is shared with at least another building, and 4 thus it cannot be categorized as a Four-Room House. A smaller courtyard is lo cated inside the building, and it allows access to a set of rooms to its west and to its south. Another example of such a building was exposed at Beit HaKerem (Da vidovich et al. Here the courtyard is positioned in front of the other rooms and not in direct contact with all of them. Both examples show a very dif ferent concept of space usage and access, and they should not be considered as subtypes of the Four-Room Building. And it is the uniqueness of the courtyard and its relation to other components of the building that rightly drew Ruth Amiran and Immanuel Dunayevsky’s attention when they defined these buildings as a distinct type (Amiran and Dunayevsky 1958, 31). First, the courtyard is much larger than the inner courtyards that typifies all the other types of building, a fact which makes it probable that it was used for a 4. We wish to thank Shlomit Weksler-Bdolah for sharing with us unpublished data from the site. The positioning of the courtyard in the Open-Courtyard Building in front of the two wings turns it into an area that can serve an administrative, public func tion. Such action cannot be performed within the inner courtyard of the Four-Room Building or the Inner-Courtyard Building. To accomplish this task, the cart and the workers would have had to stay outside in the street, in the public space. In contrast, Tal has claimed that Open-Courtyard Buildings continue the tradition of the typical Canaanite Central Courtyard Building (Tal 2009, 107–9) and that there is not much of difference between the two types. In our opinion, if one evaluates the location and character of the courtyard in the two types of buildings, it becomes apparent that they are essentially different. As described above, the courtyard of the Open-Courtyard Buildings was a public arena; the courtyard of the Classic Canaanite buildings were positioned at the heart of the dwellings and were surrounded from all sides by rooms so that the courtyard was an area that was not only private but also offered an environment that was completely disconnected from any of the public spaces (Gadot and Ya sur-Landau 2006, 596). The typological division presented above, which is based on the location of courtyards within the building, allowed us to recognize a sequence in the degree of privacy the building offers its inhabitants. On one end of the continuum is the Long-Axis Buildings that have no courtyard and its rooms are built as a long chain where one room led to another and, creating spatial hierarchy in which the front 5 room can be shared by all while the back room is relatively segregated. The In ner-Courtyard Building and Four-Room Building are characterized by a sheltered courtyard that is accessible and visible only to the occupants of the building. While fully built walls serve to define segregated and private spaces in the Inner Courtyard Building, the separation into spaces in the Pillar Buildings is essentially symbolic, with no real physical separation. Finally, at the other end of the contin uum from the Long-Axis Building stands the Open-Courtyard Building type where the courtyard was much larger and more accessible by the public. This kind of floor fits better an administrative or civic function that De Groot and Amit have suggested for the buildings at Mamilla and Area E of the Southeastern Ridge. The size of the buildings identified with this type hints that they were not used as dwelling and they served as small warehouses positioned near the farmed lands. This was not a direct borrowing, and in the process of adoption the buildings were adapted by the local elite. Other traits, such as straight walls, carried less significance and were abandon when the buildings were set into the local environment. Finding such buildings at a site like Megiddo, a province capital built along Assyrian concepts (Peersman 2006, 81–86), should not be a surprise. But finding them in Jerusalem, which was not under direct As syrian rule, is not self-evident. The kingdom of Israel was depopulated and its relatively large territory was divided into three provinces. Judah, on the other hand, was turned into a vassal kingdom and its territory to the west was given to the Philistine kingdom of Ekron. While most scholars agree on the violent nature of Assyria’s military cam paigns, the nature of their rule in the century that followed their takeover is disputed. Some scholars claim the Assyrian policy was exploitative and left be hind a ruined country (Stager 1996; Faust and Weiss 2005; Faust 2011; 2015; Master 2014). According to this view, if there were regions that flourished during the seventh century, it was despite the Assyrian policy, not because of it. A dif ferent viewpoint, expressed by many other scholars, sees the Assyrians as developing and maintaining a web of economic cooperation that insured the flow of wealth and taxes (Na’aman 1995; Gittin 1995; Stern 2001; Finkelstein and Na’aman 2004; Thareani 2009; 2016, Lipschits Sergi and Koch 2011; Sapir-Hen, Gadot and Finkelstein 2014). Judah became part the imperial sphere already in the days of Ahaz and possi bly even before. Jerusalem—as the capital of the kingdom, the location of the main temple, and the seat of the ruling dynasty—must have been exposed to Assyrian cultural, economic, and political pressure. Assyrian in fluence can be identified in Judah’s economic and administrative systems (Katz 2008, 179–82; Lipschits, Sergi and Koch 2011, 5–41; Sapir-Hen et al. The Introduction of the Open-Courtyard Building 219 the Assyrian strategies were adapted to their geopolitical needs, in kingdoms that remained independent, the Assyrians developed a client-patron relationship with local elites (Thareni 2009, 186–89). In light of this understanding, the ap pearance of “foreign” material culture should be seen against the background of cultural negotiation that ensured the loyalty of local leaders. In Jerusalem, the Assyrian presence is seen mostly through the elite’s selective adoption of aspects of Assyrian culture (Aharoni 1964, 32–33; Matthiae 1964, 85–94; Romer 2005, 68–106; Steymans 2013, 12; Winderbaum 2012, 98–99). The introduction of the Open-Courtyard Buildings is an expression of this phe nomenon. The building’s plan offers a distinctly different mundane pattern of activities from those that are conducted in other households in Judah’s urban and rural landscape. This can be the result of a choice by local Judahites to adopt the Assyrian lifestyle, and, in cases where the buildings served for administrative rule, to adopt the Assyrian administrative system. Finally, the fact that the building continued to be used in the Persian period should be stressed. Jerusalem was destroyed by the Babylonians but the rural sec tor surrounding the city partially recovered by the Persian period (Lipschits 2005, 372–78; 2011, 57–90; Gadot 2015). Two Open-Courtyard Buildings were excavated recently at a site located in the Beit-Shemesh hills (Kogen-Zehavi 2014, 120–33).

Phleboliths Phleboliths are calcified thrombi that occur in veins and blood vessels asthma treatment over the counter . It is accepted that thrombi are produced by a slowing of the peripheral blood flow asthma upper or lower airway obstruction , and become secondarily organized and mineralized asthma from allergies . Clinically asthma treatment costs in sc , it appears as a hard, pain less swelling of the oral soft tissues typically associated with hemangiomas, although in some cases there are no signs of hemangiomas (Fig. The differential diagnosis includes salivary gland calculi, calcified lymph nodes, and soft-tissue tumors. White plaques on the attached gingiva and the alveolar mucosa caused by materia alba accumulation. If the salivary glands are irradiated, xero treatment of oral and other head and neck can stomia is one of the earliest and most common cers. Spontaneous remission of oral lesions ionizing radiation, delivered by an external may occur gradually after termination of the radi source, or radioactive implants (gold, iridium, ation treatment. Late manifestations are usu Ionizing radiation, in addition to its therapeutic ally irreversible and result in extremely sensitive effect, can also affect normal tissues. The teeth, in the absence of mucosal side effects after radiation are mainly salivary protection, rapidly develop caries and dependent on the dose and the duration of treat finally are destroyed (Fig. These radiation-induced mucosal reactions crosis is a serious complication and occurs in cases may be classified as early and late. Early reactions of high-dose radiation, especially if inadequate appear at the end of the first week of therapy and measures are taken to reduce the radiation dosage consist of erythema and edema of the oral delivered to the bones. During the second week, erosions and osteomyelitis with bone necrosis and sequestra ulcers may appear, which are covered by a whit tion and, rarely, formation of extraoral fistulas ish-yellow exudate (Figs. The mandible is more frequently complaints include malaise, xerostomia, loss of affected than the maxilla. The risk of this compli taste, burning, and pain during mastication, cation is increased particularly if teeth within the speech, and swallowing. Diagnosis of oral lesions due to radiation de Treatment should include preventive measures, pends on the medical history and the clinical fea cessation of the, radiation therapy, analgesics, tures. Allergy to Chemical Agents Applied Locally Allergic Stomatitis due to Acrylic the differential diagnosis includes denture Resin stomatitis and reactions to other allergens. Treatment consists of oral antihistamines and con True allergy of the oral mucosa to denture base struction of new dentures with fully polymerized material is very rare. Alternatively, traces of other allergenic substances absorbed within the denture base may be the cause of the allergic reactions. Allergic acrylic stomatitis is characterized by diffuse erythema, edema, and occasionally small vesicles and erosions, especially in areas of contact with the dentures (Figs. The patient complains of intense burning of the mouth and this reaction may extend to areas of the oral mucosa that are not in direct contact with the dentures. In localized reactions there is redness, edema, Allergic Stomatitis due to Eugenol and erosions that are covered with whitish Eugenol has many uses in dentistry as an antisep pseudomembranes (Fig. The skin patch test is usually sitized patients it may cause generalized allergic positive. Periodontal Diseases Gingivitis An early and common feature is gingival bleeding, even after mild local stimulation. Inflammation is Gingivitis is an inflammatory disease of the gin mainly located at the marginal gingiva and the giva caused by dental microbial plaque. Factors interdental papillae without development of that contribute to the accumulation of plaque are periodontal pockets (Fig. However, if gingi poor oral hygiene, faulty restorations, tooth mal val hyperplasia is severe, pseudopockets may be position, calculus, food impaction, mouth breath formed. In addition, several systemic disorders, occasionally acute or subacute forms may occur. If such as endocrine diseases, immune deficiencies, chronic gingivitis is not treated, it frequently nutritional disturbances, and drugs, are known to evolves into periodontitis. Good oral hygiene, complete removal of calculus from the teeth, and repair of faulty is related to local factors and the host resistance. Periodontal Diseases Periodontitis Laboratory tests to establish the diagnosis are radiographs, bacterial cultures, and immune Periodontitis is a chronic inflammatory disease studies. The treatment consists of plaque con periodontal ligament, cementum, alveolar bone) trol followed by scaling and root planing, surgical and usually follows chronic gingivitis. Recently, an aggres sive form of periodontitis has been recorded in Periodontal Abscess patients with acquired immune deficiency syn Periodontal abscess is formed by localized pus drome. The cardinal clinical features of periodon accumulation in a preexisting periodontal pocket. Other findings include gingival swell 5 to 8 mm, the edematous gingival tissues around ing, redness and bleeding, gingival hyperplasia or the cervix of the tooth may approximate the tooth recession, pyorrhea, varying degree of tooth tightly and cause complete obstruction of the mobility, and migration (Fig. The treatment consists of an effective pressure, pus exudes from the cervical area of the plaque control regimen followed by scaling and tooth. The teeth involved are tender to percussion root planing, surgical procedures, and, in certain and occasionally mobile. Juvenile Periodontitis the differential diagnosis includes dental abscess, gingival cyst of adults, palatine papilla cyst, naso Juvenile periodontitis is an inflammatory gingival labial cyst, and actinomycosis. Although the exact cause remains obscure, recent evidence suggests that be helpful. Antibiotics during the acute phase and host response play important roles in the patho periodontal treatment. Based on clinical, radiographic, microbiologic, and immunologic criteria, juvenile periodontitis is classified into two forms: localized juvenile periodontitis, which clinically is characterized by severe periodontal pocket formation and alveolar bone loss with mild or moderate inflammation localized mainly in the periodontal tissues of the permanent incisors and first molars, and generalized juvenile periodontitis, which is clini cally characterized by generalized periodontal pockets and alveolar bone loss that involves almost all teeth along with gingival inflammation (Fig. Periodontal Diseases Periodontal Fistula Plasma Cell Gingivitis Periodontal fistula forms when pus bores through Plasma cell gingivitis is a unique disorder that the gingival tissues and drains an underlying histopathologically is characterized by a dense periodontal abscess. Clinically, the orifice of the plasma cell infiltration of the gingival connective fistula appears red, with granulomatous tissue for tissue. On pressure, the orifice will pathologic similarities to plasma cell balanitis or release pus. Clinically, both marginal and attached gingiva are bright red and edematous with a faintly stippled surface (Fig. The Gingivitis and Mouth Breathing gingivitis may be localized or widespread and fre quently is accompanied by itching and burning. Habitual mouth breathing favors the development Similar lesions have been described on the tongue of gingivitis with some special clinical features. This form of gingivitis affects the vestibular por the differential diagnosis includes desquamative tion of the maxillary anterior gingiva in young gingivitis, gingivitis, geographic stomatitis, early persons. Clinically, the gingiva appear swollen, leukemic gingival lesions, erythroplasia of Quey red, dry, and shiny, covering part of the crown of rat, candidosis, and psoriasis. Periodontal Diseases Desquamative Gingivitis tion of a hemorrhagic blister after massage of the gingiva. The gingival lesions may be either Desquamative gingivitis does not represent a localized or diffuse. Desquamative gingivitis may specific disease entity, but is a descriptive term be the only oral manifestation or may be associ used to name a rather nonspecific gingival man ated with other oral manifestations of a chronic ifestation of several disease processes. In the presence of desquama findings suggest that the great majority of cases of tive gingivitis the identification of the underlying desquamative gingivitis represents a manifestation disease is based on the following criteria: careful of chronic bullous dermatoses, such as cicatricial clinical observation of all intraoral and extraoral pemphigoid, pemphigus vulgaris, bullous pem lesions, histopathologic examination of gingival phigoid, and lichen planus. In a recent study of biopsy specimens, direct immunofluorescence of 453 patients with these disorders we found des gingival biopsy specimens, indirect immuno quamative gingivitis in 63. Clinically, desquama the differential diagnosis includes plasma cell gin tive gingivitis is characterized by erythema and givitis and chronic mechanical gingival trauma. The therapy of desquamative gin A characteristic sign is peeling off of the givitis depends on the identification and treatment epithelium or elevation with subsequent forma of the underlying disease. Diseases of the Tongue Median Rhomboid Glossitis Geographic Tongue Median rhomboid glossitis is a congenital abnor Geographic tongue, or benign migratory glossitis, mality of the tongue that is thought to be due to is a disorder of unknown cause and pathogenesis, persistence of the tuberculum impar until adult although an inherited pattern has been suggested. Clini terized by multiple, usually painless, circinate cally, the lesion has a rhomboid or oval shape and erythematous patches surrounded by a thin, raised is localized along the midline of the dorsum of the whitish border (Fig. The lesions vary in size tongue immediately anterior to the circumvallate from several millimeters to several centimeters papillae.

References:

  • https://www.unmc.edu/_documents/ChuCV.pdf
  • http://meak.org/science/Jennifer-Lynn-Gars/order-tadora-online/
  • http://meak.org/science/Jennifer-Lynn-Gars/order-alavert-online/
  • https://oncolife.com.ua/doc/nccn/Cervical_Cancer.pdf