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Clinical Features Breathlessness buy cheap cyclophosphamide 50 mg line, cough with or without sputum which may be rust coloured buy cyclophosphamide 50 mg cheap, fever, pleuritic chest pain. Bronchial breathing, reduced chest movements, reduced breath sounds, tachypnoea, crackles and percussion dullness. Classification Primary: Occurring in a previously healthy person living in the community. It is almost always caused by viral infection (due to respiratory syncytial virus, influenza virus, para−influenza virus, or rhinovirus). Bronchitis is usually associated with an upper respiratory infection (a cold) in young children. Clinical Features • Productive cough without cyanosis, chest indrawing, wheezing, or fast breathing. Management • Treatment is the same as for cold without pneumonia • If wheezing for the first time and child has respiratory distress then antibiotics as for pneumonia and wheezing treatment. Wheezing may or may not be complicated by pneumonia of bacterial or viral aetiology. Management − The wheezing child Children with first episode of wheezing • If in respiratory distress....... Asthma is an allergic, non−infectious condition, attacks can be triggered by respiratory infections, ingestion of some allergens, weather changes, emotional stress etc. On examination an audible wheeze or difficulty in breathing out may not be present. Response to a rapidly−acting bronchodilator is an important part of the assessment of a child with recurrent wheezing to determine whether the child can be managed at home or should be admitted for more intensive treatment. In both acute attack and status asthmaticus, signs of improvement are: 276 • Less respiratory distress (easier breathing) • Less chest indrawing • Improved air entry. With improvement, the wheezing sound may decrease or actually increase, if the child was moving little air previously. Clinical Features Patients present with: Breathlessness, Wheezing, Cough with tenacious sputum. Patient Education Avoid precipitating factors such as: • Smoking, allergens, aspirin, stress, etc 21. Clinical Features Chronic productive cough for many years with slowly progressive breathlessness that develops with reducing exercise tolerance. Investigations • Chest X−ray: Note flattened diaphragms, hyperlucency, diminished vascular markings with or without bullae. Admit If • Cyanosis is present • Hypotension or respiratory failure is present • Chest X−ray shows features of pneumothorax, chest infection or bullous lesions • Cor pulmonale present. Patient Education • Stop smoking and avoid dusty and smoky environments • Relatives should seek medical help if hypersomnolence and/or agitation occurs. Aetiology Infections (malaria, meningitis, encephalitis) trauma, tumours, cerebro−vascular accidents, diseases− (diabetes, epilepsy, liver failure), drugs (alcohol, methylalcohol, barbiturates, morphine, heroin), chemicals and poisons (see 1. History Detailed history from relative or observer to establish the cause if known or witnessed:−the circumstances and temporal profile of the onset of symptoms. Fever accompanies a wide variety of illnesses and need not always be treated on its own. Management − General • Conditions which merit lowering the temperature on its own: Precipitation of heart failure, delirium/confusion, convulsions, coma, malignant hyperpyrexia or heat stroke, patient extremely uncomfortable. Management − Paediatrics • Fever is not high (38−39°C); advise mother to give more fluids • Fever is high (>39°C); give paracetamol • Fever very high or rapid rise; tepid sponging (water 20−25°C) • In falciparum malarious areas; treat with antimalarial [see 12. Assessment should include observation of the fever pattern, detailed history and physical examination, laboratory tests and non−invasive and invasive procedures. This definition will exclude common short self−limiting infections and those which have been investigated and diagnosed within 3 weeks. Sites like kidneys and tubo−ovarian region raise diagnostic difficulties • Specific bacterial infections without distinctive localising signs. The commonest here are salmonellosis and brucellosis • Deep seated bacterial abscesses e. Reactivated old osteomyelitis should be considered as well • Infective endocarditis especially due to atypical organisms e. Diagnosis may be difficult if lesions are deep seated retroperitoneal nodes • Leukaemia Contrary to common belief, it is extremely rare for leukaemia to present with fever only. The common ones are: Rheumatoid arthritis, systemic lupus erythematosus, polyarthritis nodosa, rheumatic fever, cranial arteritis/polymyalgia in the old. Usually young adult female with imperfect thermoregulation • Cause may remain unknown in 10−20% of the children Temperature rarely exceeds 37. Do the following • Repeated history taking and examination may detect: − new clinical features that give a clue − old clinical signs previously missed or overlooked • New tests: − immunological: rheumatoid factor (Rh.

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Journal of Clinical Periodontology 30: (2009) Infuence of different air-abrasive powders 467-485 effective 50mg cyclophosphamide. Quintessence Evaluation of an air-abrasive device with amino International 47: 293-296 cyclophosphamide 50 mg amex. Quintessence International 45: 2 implantoplasty on the diameter, chemical surface 209-219. Clinical Oral Implants Research 20: Z, Kemény L, Radnai M, Nagy K, Fazekas A, Turzó 169–174. The International Journal of Oral and The International Journal of Oral & Maxillofacial Maxillofacial Implants 25: 63–74. In 1952 ontdekte Per-Ingvar Brånemark het principe van verankering van titanium celkamers in bot. In 1965 werden door hem de eerste titanium implantaten bij een patiënt in de mond geplaatst. Sinds de jaren 1980 wordt er als onderdeel van de tandheelkundige zorg steeds vaker geïmplanteerd. Calamiteit Hoewel de implantaten een valide en succesvolle behandeloptie zijn gaan vormen, zijn deze niet vrij van complicaties. De biologische complicaties hiervan, de zogenoemde peri-im- plantaire ziektes vormen een belangrijk bedreiging voor het behoud van de implantaten. De peri-implantaire ziektes zijn ontstekingsprocessen in de weefsels rondom implantaten. Er worden naar analogie in de parodontologie twee processen onderscheiden: peri-implan- taire mucositis en peri-implantitis (respectievelijk gingivitis en parodontitis). Peri-implan- taire mucositis is een reversibele ontsteking van de peri-implantaire mucosa. Bij peri-im- plantitis is er naast de ontsteking van de zachte peri-implantaire weefsels ook sprake van botafbraak rond het implantaat. Onderzoek laat zien dat hoewel de prevalentie lastig te bepalen is, toch kan worden aangenomen dat de gemiddelde prevalentie van peri-implantaire mucositis ongeveer 43% is, terwijl de gemiddelde prevalentie van peri-implantitis rond de 22% is. Als belangrijkste risicofactoren voor het ontstaan van peri-implantaire ziektes worden in de literatuur aan- gegeven: onvoldoende mondhygiëne, onbehandelde parodontitis in de rest van de mond en roken. Behandelbaarheid De behandeling van peri-implantitis is niet eenvoudig en het resultaat ervan blijft onvoor- spelbaar. Primaire preventie is gebaseerd op se- lectie van de juiste patiënten, goede planning en uitvoering van de behandeling maar ook op regelmatige controles van de implantaat-gedragen constructies en zorgvuldige onderhoud door zowel de patiënten als de mondzorg professionals. Het oppervlak van het transmucosale deel is glad, terwijl het deel van het implantaat dat botcontact maakt voornamelijk een ruw oppervlak heeft. Het verwijderen van bioflm van implantaatop- pervlakken (door zelfzorg en door tandheelkundige zorgprofessionals) is essentieel om pe- ri-implantaire ziektes te voorkomen en te behandelen. Bij de nazorg en de behandeling van peri-implantaire mucositis moet er normaal gesproken een glad (titanium) oppervlak gerei- nigd worden. De instrumenten die op de transmucosale implantaatoppervlakken gebruikt kunnen worden, mogen deze oppervlakken niet beschadigen omdat dit anders rekolonisatie met micro-organismen zou kunnen bevorderen. Dit is met name belangrijk voor die onder- delen van het implantaat die blootgesteld zijn aan het orale milieu. De hulpmiddelen die ervoor het meest gebruikt worden zijn mechanische instrumenten en chemische middelen. Bij een ernstige peri-implantaire ontsteking kan het zo zijn dat door botverlies ook het ruwe deel van het implantaat boven het botniveau komt te liggen. Dan moeten de windingen van het implantaat en het ruwe oppervlak gereinigd worden. Dit is niet eenvoudig omdat micro-organismen zich in het ruwe en het soms poreuze oppervlak kunnen verschuilen en onbereikbaar zijn voor de instrumenten van de tandheelkundige zorgprofessionals.. Instrumentatie In diverse onderzoeken van de afgelopen decennia zijn verschillende mechanische instru- menten op verschillende implantaatoppervlakken getest: metalen handinstrumenten, niet-metalen handinstrumenten, (ultra)sone scalers met metalen of niet-metalen tips, air polishers met diverse poeders, polijstcupjes/puntjes met of zonder polijstpasta en diamant-/ carbideboren. In hoofdstuk 2 werd in de literatuur gezocht naar wetenschappelijk bewijs voor de te verwachten effecten van diverse mechanische instrumenten op de oppervlaktestructuur van gladde en ruwe titaniumoppervlakken. De uitkomsten van dit review tonen dat air polishers, niet-metalen instrumenten en rubber polijst cupjes geen of minimale schade aan gladde titaniumoppervlakken toebrengen en daardoor veilig toegepast kunnen worden in de nazorg van patiënten met implantaten. Als er geen veranderingen in de oppervlaktestructuur van Nederlandse samenvatting 241 ruwe implantaatoppervlakken mag worden aangebracht, lijken niet-metalen instrumenten en de air polisher de meest geschikte instrumenten. Als het doel is het ruwe implantaatop- pervlak juist gladder te maken en bijvoorbeeld ook de schroefwindingen te verwijderen, dan worden diamant-/carbideboren aanbevolen. Dit bijvoorbeeld ten behoeve van implantoplas- tie wanneer het ruwe implantaatoppervlak is blootgesteld aan het orale milieu. Misschien nog belangrijker dan het effect van een instrument op de oppervlakte struc- tuur is of een instrument effectief is in het reinigen van het oppervlak.

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Extratemporal—from stylomastoid paralysis in patients with Bell’s palsy or herpes foramen to its peripheral branches cyclophosphamide 50mg for sale. Neuroma of middle ear anteriorly from the processus facial nerve cochleariformis order 50 mg cyclophosphamide free shipping, above the promontory and 7. Malignancy of the oval window to the pyramidal process middle ear cleft where it takes a bend, to start its vertical 9. Ramsay Hunt portion and comes out of the temporal bone syndrome through the stylomastoid foramen. The of the mastoid process the standard treatment is of the infective process, and postaural incision damages the nerve, so facial palsy recovery occurs with the the incision is placed more horizontally to control of the infection. During mastoidectomy, one should iden- Hunt’s syndrome): Herpetic infection of the tify the plane of the lateral semicircular geniculate ganglion is often associated canal, and avoid working at any level more with facial palsy accompanying auditory medial than this to avoid nerve damage. The compact bone of the digastric ridge eruptions usually occur on the concha, gives the plane of the stylomastoid antihelix, antitragus and external auditory foramen. The treatment in such cases is while working on the mastoid tip, other- symptomatic. The gouge and drill work should be otitis media (atticoantral variety), the parallel and in the line of the facial nerve. During radical mastoidectomy, while of sudden onset and there is no evidence of removing the outer attic wall or the bony any symptom or sign of disease of the ear or bridge, the nerve may be cut and hence the central nervous system. Curettage of the middle ear is not advis- is caused by the ischaemia of the arterioles able as it can damage the nerve. While lowering the facial ridge, the bone should be cut along the line of the nerve Clinical Features and one should not go deep to the tym- The paralysis is usually of sudden onset with panomastoid suture line. In a vast majority of cases dectomy during currettage of the bony the paralysis is incomplete and recovery overhang of the posterior canal wall or at occurs over a period of one to six months. Management of Postoperative Facial Paralysis In case the facial paralysis is noted imme- Investigations (Fig. Immediate exploration tests have been described to know the exact is done and if a bone piece is found piercing site of lesion and the severity of the damage the nerve, it is removed or the haematoma that the nerve has suffered. If the nerve is cut, its ends are brought of lesion of the facial nerve, the various tests together and sutured or a graft may be needed used are the following: to bring the edges together. Schirmer’s test: Blotting paper strips from the greater auricular or crural nerve of × 5 cm) are placed under both the (3 cm the leg. If the facial nerve lesion is is exposed and paralysis is because of oedema above the geniculate ganglion, lacrimation or due to pressure of the tight pack. In such on the affected side will be less as the cases, pack removal and steroids help to greater superficial petrosal nerve is reduce the oedema and the paralysis recovers. It is not a definite treatment for the disease but only tries to lay a ground work for the recovery by relieving the pressure on the nerve. In severe cases the condition becomes intolerable and resistant to all sorts of treatment except facial nerve resection to cause complete facial paralysis. Electrogustometry: An electrode is placed on of: the tongue and a current of 3-10 mA is a. In Ménière’s disease, the defective This is a disease of the inner ear characterised absorption by the sac is regarded as the by sudden and recurrent attacks of vertigo, cause of hydrops. Clinical Features Pathogenesis Paroxysmal attacks of vertigo with deafness and tinnitus mark the acute stage. The acute The basic histopathological change noted in attack typically starts with a feeling of aural these cases has been endolymphatic hydrops fullness followed by vertigo which is accom- (gross distension of endolymphatic system). The attack may last for a varying explaining its cause and in correlating it with period of time and may recur at short the symptomatology. Deafness is sensorineural in type, of causation of endolymphatic hydrops are grouped as follows: fluctuating, usually unilateral and progres- 1. As the disease progresses the deafness occurs because of disturbances of fluid becomes more pronounced and speech formation, which occur due to local distur- discrimination worsens. Another theory suggests that distension of patient’s hearing deteriorates and tinnitus the endolymphatic system occurs because becomes a constant feature. Recent studies of mechanical blockage and disturbed have shown a spontaneous remission rate of reabsorption. Proponents of this theory upto 71 per cent of cases within 8 years of maintain that the endolymph traverses the diagnosis. Ménière’s Disease and Other Common Disorders of the Inner Ear 107 Variations of the clinical picture may occur ment in speech discrimination ability owing to the absence of one or more of the are taken as positive data. The test is contraindicated in Investigations patients with cardiac and renal diseases as 1. Various methods (medical and surgical) nystagmus is absent except during an have been adopted to alleviate the patient’s attack.

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In those with clinical illness discount 50mg cyclophosphamide amex, the onset is usually insidious generic cyclophosphamide 50 mg online, with anorexia, vague abdominal discomfort, nausea and vomiting, some- times arthralgias and rash, often progressing to jaundice. Severity ranges from inapparent cases detectable only by liver function tests to fulminating, fatal cases of acute hepatic necrosis. Persons with chronic infection may or may not have a history of clinical hepatitis. About one-third have elevated amino- transferases; biopsy findings range from normal to chronic active hepatitis, with or without cirrhosis. HbsAg is present in serum during acute infections and persists in chronic infections. Most of these infections would be prevented by perinatal vaccination against hepatitis B of all newborns or infants. Serological evidence of previous infection may vary depending on age and socioeconomic class. Contaminated and inadequately sterilized syringes and needles have resulted in outbreaks of hepatitis B among patients; this has been a major mode of transmission worldwide. Chimpanzees are susceptible, but an animal reservoir in nature has not been recognized. Closely related hepadnavi- ruses are found in woodchucks, ducks, ground squirrels and other animals such as snow leopards and German herons; none cause disease in humans. Sexual transmission from infected men to women is about 3 times more efficient than that from infected women to men. Anal intercourse, insertive or receptive, is associated with an increased risk of infection. Blood from experimentally inoculated volun- teers has been shown to be infective weeks before the onset of first symptoms and to remain infective through the acute clinical course of the disease. Disease is often milder and anicteric in children; in infants it is usually asymptomatic. Preventive measures: 1) Effective hepatitis B vaccines have been available since 1982. Immuni- zation of successive infant cohorts produces a highly immune population and suffices to interrupt transmis- sion. In mid-1999, it was announced that very small infants who receive multiple doses of vaccines containing thiomersal/thimerosal were at risk of receiving more than the recommended limits for mercury exposure as set out by industrialized guidelines. On the basis of a hypothetical risk of mercury exposure, reduction or elimination of thiomersal/thimerosal in vac- cines as rapidly as possible was encouraged, although pharmacological and epidemiological data render it highly unlikely that such vaccines give rise to neurologi- cal adverse effects. The greatest fall in incidence and prevalence of hepatitis B is in countries with high vaccine coverage at birth or in infancy. Vaccination of adolescents is also valuable as it protects against transmission through sexual contact or injection drug use. A sterile syringe and needle are essential for each individual receiving skin tests, parenteral inoculations or venepuncture. Discourage tattooing; enforce aseptic sanitary practices in tattoo par- lours, including proper disposal of sharp or cutting tools. Notify blood banks of potential carriers so that future donations may be identified promptly. Control of patient, contacts and the immediate environment: 1) Report to local health authority: Official report obligatory in some countries; Class 2 (see Reporting). Studies show that alpha interferon is successful in arresting viral replication in about 25%–40% of treated patients. Lamivudine has fewer side-effects and is easier to administer, but has a modest efficacy rate, requires long-term treatment to maintain response, and is associated with a high rate of viral resistance, particularly when pro- longed. Epidemic measures: When 2 or more cases occur in associa- tion with some common exposure, search for additional cases. If a plasma derivative such as antihemophilic factor, fibrinogen, pooled plasma or thrombin is implicated, withdraw the lot from use and trace all recipients of the same lot in a search for additional cases. Disaster implications: Relaxation of sterilization precautions and emergency use of unscreened blood for transfusions may result in an increased number of cases. Identification—Onset is usually insidious, with anorexia, vague abdominal discomfort, nausea and vomiting; progression to jaundice less frequent than with hepatitis B. Although initial infection may be asymp- tomatic (more than 90% of cases) or mild, a high percentage (50%–80%) develop a chronic infection. Of chronically infected persons, about half will eventually develop cirrhosis or cancer of the liver. Sexual and mother-to-child have been documented but appears far less efficient or frequent than the parenteral route. Chronic infection may persist for up to 20 years before the onset of cirrhosis or hepatoma. Period of communicability—From one or more weeks before onset of the first symptoms; may persist in most persons indefinitely. Routine virus inactiva- tion of plasma-derived products, risk reduction counselling for persons uninfected but at high risk (e.

Approximately 5–10% of blood ejected from the right ventricle travels through the pulmonary circulation; while the majority of blood ejected from the right ventricle crosses the patent ductus arteriosus to supply blood to the descending aorta buy discount cyclophosphamide 50mg on-line. Immediately after birth the entire right ventricular output is ejected to the right and left pulmonary arteries purchase 50mg cyclophosphamide overnight delivery, thus increasing blood flow through each pulmonary artery by approximately sevenfold. This will result in relative stenosis of these normal pulmonary arteries which require approximately 6–8 weeks to reach a size suitable for this increase in blood flow thus resulting in elimination of this innocent heart murmur by 6–8 weeks of age. The murmur is systolic ejection in type, typically 1–2/6 in intensity, although it may be as loud as 3/6. The murmur is best heard over the left upper sternal border with radiation into one or both axillae. Physiologic Pulmonary Flow Murmur Blood flow through the pulmonary valve may be audible in children due to relative hyper- dynamic status of blood circulation secondary to faster heart rate as well as thin chest wall allowing easier detection of normal blood flow through the pulmonary valve. This type of murmur is typically 1–2/6 in intensity and occasionally as loud as 3/6. The murmur is heard best over the left upper sternal border in supine position and is significantly reduced in intensity or completely resolves when the child sits or stands up as well as with 424 Ra-id Abdulla Valsalva maneuver due to reduction in blood volume returning to the chest (decrease in pre-load). Stills Murmur Stills murmur is similar to physiologic pulmonary flow murmur, but in this case the murmur is due to blood flow across the aortic valve. The murmur is due to relative hyper- dynamic status of blood circulation secondary to faster heart rate as well as thin chest wall allowing easier detection of normal blood flow through a normal aortic valve. This type of murmur is typically 1–2/6 in intensity and occasionally as loud as 3/6. The murmur is heard best over the right upper sternal border in supine position and is significantly reduced in intensity or completely resolves when the child sits or stands up as well as with Valsalva maneuver due to reduction in blood volume returning to the chest (decrease in pre-load). Venous Hum This is a soft continuous murmur heard over the lateral aspect of the neck generated by blood flow in the internal jugular vein. The close proximity of the internal jugu- lar vein to the skin allows normal blood flow to be heard through auscultation even though there is no significant turbulence. Venous hum is soft, typically 1–2/6 in intensity and heard throughout systole and most diastole. An important distinction between venous hum and murmur produced by a patent ductus arteriosus or collateral vessels include the following: – Intensity: Venous hum murmur is soft, while that of patent ductus arteriosus is harsh. Mammary Soufflé This murmur is caused by engorged arteries in the breasts due to rapid growth such as seen during pregnancy or adolescence. The murmur is systolic or continuous and heard over a wide area over the anterior chest. These murmurs tend to be 1–2/6 in intensity and do not change with Valsalva maneuver or patient’s position. The child is thriving well with no significant medical problems except for reactive airway disease with occasional need for albuterol inhalation. Physical examination: Heart rate was 100 bpm, regular, respiratory rate was 30/min and blood pressure in the right upper extremity was 90/55 mmHg. Child appeared in no respiratory distress, mucosa was pink with good peripheral pulses and perfu- sion. Palpation of the precordium reveals normal location and intensity of the left ventricle and right ventricle impulses. Auscultation demonstrates a normal first heart sound, second heart sound split and varied with respiration. A 2/6 systolic ejection murmur was heard over the right upper sternal border with no radiation. Murmur was soft and vibratory in quality with significant reduction in intensity while standing, while becoming well heard in supine position. Assessment: The child appears to be healthy; the physical examination is within normal limits. The quality of murmur and its diminished intensity in upright posi- tion suggests innocence of the heart murmur. This pediatrician’s records indicate that previous examination revealed similar murmur. Plan: It is reasonable for the pediatrician at this point to choose to continue observing this heart murmur without referral to a pediatric cardiologist. Case 2 History: A 2-week-old child is seen by a pediatrician for the first time for a well child care visit. The child is a product of 37 week gestation with no com- plication other than premature onset of labor. Physical examination: Heart rate was 140 bpm, regular, respiratory rate was 35/ min and blood pressure in the right upper extremity was 80/45 mmHg. Child had normal feature and appeared in no respiratory distress, mucosa was pink with good 426 Ra-id Abdulla peripheral pulses and perfusion.

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The Brazen Serpent John 3:14-15 discount cyclophosphamide 50 mg mastercard, “And as Moses lifted up the ser- pent in the wilderness buy 50 mg cyclophosphamide overnight delivery, even so must the Son of man be lifted up: That whosoever believeth in him should not perish, but have eternal life. Why would He liken Himself to the brazen serpent that God instructed Moses to make? Numbers 21:5-9, “And the people spake against God, and against Moses, Wherefore have ye brought us up out of Egypt to die in the wilderness? And the Lord sent fiery ser- pents among the people, and they bit the people; and much people of Israel died. Therefore the people came to Moses, and said, We have sinned, for we have spo- ken against the Lord, and against thee; pray unto the Lord, that he take away the serpents from us. And the Lord said unto Moses, Make thee a fiery serpent, and set it upon a pole: and it shall come to pass, that every one that is bitten, when he looketh upon it, shall live. And Moses made a serpent of brass, and put it upon a pole, and it came to pass, that if a serpent had bitten any man, when he beheld the serpent of brass, he lived. When they cried to Moses in repen- tance and he in turn prayed to God on their behalf, God instructed him to make a fiery serpent of brass and set it upon a pole so all whoever was bitten by the serpents had to do was look upon the brazen ser- pent and live. Thus God telling Moses to make a brazen serpent indicated that the serpent had been judged for the sins of the children of Israel. And all they needed to do was accept this substitution by The Mystery of The Cross looking at the serpent; then they would live and not die. This brazen serpent was indeed a type of Christ, foreshadowing His death on the Cross. Thus when Jesus said to Nicodemus in John 3:14-15, “And as Moses lifted up the serpent in the wilderness, even so must the Son of man be lifted up: That whosoever believeth in him should not perish, but have eternal life” He meant He was to be judged for us. Our sins were to be placed on Him, so just like the children of Israel, we would not perish but obtain the life of God and live. And Aaron shall come into the tabernacle of the con- gregation, and shall put off the linen garments, which he put on when he went into the holy place, and shall leave them there:” Once every year, specifically on the tenth of the seventh month, God instructed the high priest to make atonement for the sins of the children of Israel (Leviticus 16:29-31). He was to select two goats; one to be the sin offering and the second the scapegoat. After killing the sin offering and offering its blood within the veil, He was to take the scapegoat and con- fess on its head all the iniquities of the children of Israel, and for the rest of the year till the following year, their sins would be covered, and they wouldn’t be judged for them. Next, the scapegoat would be led by the hand of a fit man into the wilderness, into a land not in- The Mystery of The Cross habited; bearing upon its head the sins of the people. This Scapegoat was actually a type of Christ, who offered Himself as a sacrifice for us. But in His case, He did not die for the children of Israel but for all people everywhere. When you consider the betrayal, arrest and condemnation of Jesus to death you will understand better why both Jews and Gentiles can hold claim to Him as their sacrifice for sins. In Matthew 20:18,19 Jesus said to His disciples on their way to Jerusalem, “Behold, we go up to Jerusalem; and the Son of man shall be betrayed unto the chief priests and unto the scribes, and they shall condemn him to death, And shall deliver him to the Gentiles to mock, and to scourge, and to crucify him: and the third day he shall rise again. John 11:49-52, “And one of them, named Caiaphas, being the high priest that same year, said unto them, Ye know nothing at all, Nor consider that it is expedient for us, that one man should die for the people, and that the whole nation perish not. Later He was taken to the hall of judgment in Pontius Pilate’s house, who eventually scourged Him and de- livered Him up to the Jews to be crucified (John 19: 1-16), signifying that He was to be crucified for the Gentiles also. Then He was led by the Roman soldiers to Calvary where He was crucified on the Cross, bear- ing the sins of the whole world. They didn’t fully realize that Jesus, by the hands of the high priest and Pontius Pilate had become the Scapegoat for us and carried our sins away forever. You know, in God’s plan, if it was possible to take away the sins of the world, then the effects of sin could be removed forever. Sickness, as we have seen, came as a result of sin, and Jesus by dying for sins also died that the ef- fects could be removed forever. The Mystery of The Cross Jesus Died Two Deaths Isaiah 53:9, “And he made his grave with the wicked, and with the rich in his death; because he had done no violence, neither was any deceit in his mouth. He would never have died physically, no matter what the Roman soldiers did, if He did not die spiritually first. But this is really pitiful, be- cause they’re ignorant of what Jesus did for us on the cross. He Was Made Sin For Us 2 Corinthians 5:21, “For he hath made him to be sin for us, who knew no sin; that we might be made the righteousness of God in him. And God had declared that without the shed- ding of blood, there is no remission of sins (Leviticus 17:11). In answer to man’s need, God gave His Son (Romans 4:25), who tasted death for everyone, so we no longer would be under the bondage of the fear of death (Hebrews 2:9,14).