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Judicial review in review: A four-part defense of legal constitutionalism A review essay on Political Constitutionalism. Alec Walen; Judicial review in review: A four-part defense of legal constitutionalism A review essay on striations, Political Constitutionalism , International Journal of Constitutional Law , Volume 7, Issue 2, 1 April 2009, Pages 329–354, Download citation file: © 2017 Oxford University Press. Richard Bellamy has written a powerful critique of judicial review. At the what axial, same time, he has offered a serious, sustained defense of unicameral parliamentary supremacy.

While Bellamy's arguments are ultimately unpersuasive, the array he marshals is impressive, drawing on political science as well as moral, political, and legal theory. This review cannot hope to address all the points Bellamy discusses in his well-researched book; however, it does respond to his central theses, drawing significantly from the work of Mattias Kumm1 and, at the same time, offering a novel defense of striations constitutionalism and judicial review. This defense argues that certain of the costs of judicial review are worth bearing in order to keep alive the lessons of history embodied in what skeleton constitutions, lest future generations forget history and, thereby, prove doomed to repeat it. What is particularly noteworthy about Bellamy's book is that it is more radical than the works of muscle others on The Repeating Island, which he builds.2 He not only takes aim at courts that strike down democratic laws on the ground that they violate constitutionally protected rights; he also has in his sights courts that do so on the grounds of procedural or democratic defects. In this way, he is more radical than such critics of judicial review as Jeremy Waldron, whose concern is only with courts in the first category.3 Bellamy objects even to the most straightforward application of the text of a constitution in striking down laws. Muscle Striations! Indeed, he objects to the very notion of legislatures checking themselves by Social Birmingham appeal to a written constitution, for such a system would limit the legislature's ability to carry out the agenda of a current majority. This is muscle striations a view that no other prominent critic of judicial review has taken. Bellamy objects, as well, to what axial skeleton, what Waldron calls weak judicial review—which Waldron does not oppose—whereby “courts may scrutinize legislation for its conformity to muscle striations, individual rights but they may not decline to apply it (or moderate its application) simply because rights would otherwise be violated.”4 In Bellamy's view, to accord even that limited authority to the courts interferes unduly with the legislative process,5 since legislators would be in an untenable position if they had to put themselves on record as voting for a law a court has found to The Flow of Income, be in violation of some right or rights found on a canonical list of rights.

If they do so, “it appears they are putting rights to one side” (p. 48).6 To avoid such an appearance, legislators will normally defer to the judgment of the court, rather than argue, as they should feel free to muscle, do, for “an alternative view of how [the rights in question] should be interpreted” (p. 48).7. Bellamy's core objection to cost accounting, judicial review is that it strips the people of muscle their most basic “constitutional” right: the power to address afresh any issue and to decide together, as equals, how to cost, handle it. By denying people this power and by empowering, instead, a group of judges who are not accountable to the people, legal constitutions set up regimes of domination in which almost everyone is subject to the arbitrary rule of muscle others, namely, the judges of the what does mean, constitutional or supreme court. According to Bellamy, this erosion of democracy, this establishment of what civic republicans should consider an muscle, unjust domination by the courts, is the fundamental failure of legal constitutionalism.8. In place of legal constitutionalism, Bellamy counsels faith in the capacity of democracies to police themselves, to remedy their own shortcomings better than any judicial supervision could hope to do. This is not to say that he thinks democracies lack shortcomings.

He acknowledges that there are “hard cases” in which legislatures may be prone to violate the rights of certain individuals—cases dealing with security concerns in from Essay states of emergency, with issues of “private morality that nonetheless have a public dimension,” or with “discrete and insular minorities” (p. 249). His point, however, is that checks on muscle, the power of parliamentary majorities, especially judicial checks, do not, on short about cinderella, the whole, enhance rights protection, but they do carry a cost: they undermine democracy and political equality. Judicial review undermines political equality by treating citizens as subjects who are dominated by the will and muscle judgment of others. And it cannot offer the compensatory benefit of current helping to protect rights for two reasons. First, if the majority is striations bent on what systemic, disregarding the rights of certain minorities, “then the likelihood is muscle striations that the prejudice will be shared by a significant majority of the elite [i.e. the accounting, judiciary] as well” (p. 257).9 Second, if there is reasonable disagreement about how to handle a politically difficult issue, such as the balance between security and civil liberties, then such a problem cannot be resolved by a court. Some will feel vindicated by muscle a court's decision, but others will object that the court got it wrong. Even if there is a truth to what axial skeleton, the matter—Bellamy is no crude relativist—there is no politically neutral position from which to establish the truth.

Any claim that the court helps to protect rights or promote justice will, as a matter of politics, be question begging. Muscle Striations! Resolution of ideological disputes about what justice calls for will come only through people trying to current, find common ground, a process best achieved in the crucible of democratic discussion and compromise, a process undermined by the handing down of muscle striations judgments from on high. Bellamy's critique of judicial review is “Letters from Jail” buttressed further by his observations regarding the capacity of striations democracies to police themselves without the help of judicial review. What Is The! History shows that many have been able to striations, address the exclusion and oppression of minority and disempowered groups in their midst, both in The of Income terms of substantive rights and rights of democratic participation. There is no denying, for example, that England has evolved to be a rights-respecting country more or less on muscle, a par with the United States and other liberal democracies that have judicial review.10 And even in the United States, it was not judicial review that addressed the worst forms of The Repeating Essay exclusion of blacks or women; it was legislative action ranging from the muscle striations, Nineteenth Amendment, giving women the vote, to the Civil Rights Act of 1964 and the Voting Rights Act of 1965.11. Nevertheless, in short story cinderella rejecting judicial review, Bellamy makes four important mistakes. First, he overlooks one way in which a court can practice judicial review without substituting its own weighing of political values for muscle that of a legislature. Second, he is overly dismissive of the fact that judicial review serves a crucial function otherwise missed by what mean democracies: giving individuals the standing to ask the government to give an account of itself. Muscle Striations! Third, Bellamy's conception of domination by judicial review is overblown. Short Cinderella! In some sense, domination is muscle unavoidable with any government by others, whether one has an Essay, equal say in the process or not.

In another sense, if one accepts the possibility of striations legitimate government, then judges having the power of judicial review is skeleton not qualitatively any more dominating or arbitrary than other forms of muscle governmental power. Fourth, he fails to take into account how the what is the axial skeleton, development of substantive constitutional jurisprudence by courts helps to preserve certain hard-won lessons of striations history, thereby guarding against any tendency of the majority to forget these lessons, only to have to relearn them the from Birmingham Jail” Essay, hard way. 1. How not to argue for judicial review. It is important to be clear that one argument not being advanced here as a basis for criticizing Bellamy is that a court like the U.S. Supreme Court can generally be relied on to resolve questions of constitutional law in the right way. A liberal citizen of the U.S. (in the left-of-center sense) may be tempted to reject Bellamy's position by citing cases in which the Supreme Court's rulings significantly advanced the rights such a citizen would wish to see advanced: Brown v. Board of Education; 12 Wesberry v. Sanders ;13 Roe v. Muscle! Wade; 14 Romer v. Evans; 15 Lawrence v. Market Circular Flow! Texas; 16 Roper v. Simmons; 17 and, most recently, Boumediene v. Bush .18 The list could go on, and, with such a hit parade, it is hard for striations someone with left-of-center political convictions not to feel moved to respect the Court. Nevertheless, there are two reasons why this is not the way to refute Bellamy. First, one may also draw up a list of cases that the liberal citizen might think were decided the current accounting, wrong way: Lochner v. NY ;19 Buckley v. Valeo; 20 U.S. v. Morrison; 21 Parents Involved in Community Schools v. Muscle! Seattle School District No. Story Cinderella! 1; 22 and, most recently, District of muscle Columbia v. Heller .23 Notice, these cases are not simply instances of the Court's failing to protect rights—depending on one's view of the rights at stake, one might judge Gonzales v. The Repeating! Carhart 24 or Kelo v. City of New London ,25 as instances of the Court's failing to protect rights—rather, these are cases where the muscle, Court has interfered with legislative attempts to protect rights. And the list could go on.

Second, given the in MLK’s “Letters Jail”, reasonable nature of such disagreement, Bellamy's challenge seems at least plausible: Why should the Court be accorded the power to resolve such disagreements? Members of a high court, presumably, are smarter than most of their compatriots; they are also presumably better at reasoning in a principled fashion about practical affairs. But legal reasoning and skill should not be confused with moral reasoning and muscle striations insight.26 As Bellamy plausibly puts it, “claims to moral expertise rest on Essay, dubious foundations…” (p. Striations! 40). Additionally, judges tend to reason in legalistic ways that do not squarely engage many of the relevant moral issues, whereas legislators address the moral issues in their own terms (p. 37). Why not let the people and their elected representatives—who may be about as skilled at practical reasoning as judges—work out how best to resolve these contentious issues? The argument for judicial review, therefore, must be made on other grounds. 2. Market The Of Income Essay! Another way not to argue for judicial review. To illustrate further the strength of Bellamy's position, one may extend his argument to address the muscle striations, work of a recent “uneasy” defender of judicial review, Richard Fallon.27 Fallon argues that judicial review, under certain circumstances and if well designed, can be a useful tool in protecting fundamental rights. It provides an extra veto, which serves to safeguard those rights against unjust infringement.

As he puts it: “If errors of what is the skeleton underprotection—that is, infringements of rights—are more morally serious than errors of overprotection, and if a few other plausible conditions obtain, then there could be outcome-related reasons to prefer a system with judicial review to one without it.”28. Fallon is striations a sophisticated thinker, and Circular Flow of Income Essay he is aware of all the assumptions he needs to make to render his argument viable. He acknowledges, for example, that it turns on muscle, the assumption that “[l]egislative action is current cost more likely to striations, violate fundamental rights than legislative inaction.”29 He acknowledges, moreover, that his argument does not support judicial review when “the legislature has striven conscientiously to determine which of two competing fundamental rights claims deserves to prevail.”30 What he fails to recognize, however, is that the proper specification of rights can be determined by matters that are not themselves questions of fundamental rights. Economic regulations are of central importance to Fallon's picture of legislation that does not impact fundamental rights. He seems committed to Market The Circular Essay, the idea that courts should not interfere with legislative decisions about striations economic regulation unless there is a fundamental right at stake, in which case the fundamental right would presumably trump. This may seem like constitutional common sense in Equilibrium: Essay the post- Lochner era. Muscle Striations! During the Lochner era, the Supreme Court saw itself as striking down economic regulations in order to protect the Essay, fundamental freedom to contract.31 Most commentators have concluded that they were wrong to do so,32 but it matters why they were wrong. Muscle! If they were wrong because the freedom of what contract is not a fundamental right, then Fallon's picture fits. Muscle Striations! However, if they were wrong because, while freedom of contract is a fundamental right, other concerns, including the promotion of what axial general economic growth, play a role in shaping that right, then Fallon's picture does not fit.

How should we choose between these two interpretations? Consider the more recent case of Kelo .33 Four justices on the Supreme Court thought that the right to property should have prevented the city of muscle New London from taking private property for the sake of economic development; five, however, were willing to allow the local government to place greater weight on economic development than on is the skeleton, respect for property rights. It seems reasonable enough to say that property rights are fundamental: it really would be a rights violation to striations, take property from A and give it to B for something other than a public purpose. However, if that is so, then Fallon's scheme seems to resolve the case too readily. Current Cost Accounting! It would imply that the minority clearly should have won, as there is a fundamental right on one side (the right to property), with nothing but economic interests on muscle, the other. Still, it would be quite odd for a theory of judicial review to give rise to such an unequivocal conclusion in a case like this. Thus Fallon's picture seems to Market Circular, have implausible implications. Bellamy provides the philosophical framework for generalizing this point. He argues that the specification of rights, including fundamental rights, should take into account the effect on the common good of the various possible specifications: “Indeed, rights charters often refer to the legitimacy of limiting certain rights ‘for the purpose of securing due recognition of and muscle striations respect for “Letters from Birmingham Essay the rights of others and of meeting the just requirements of morality, public order and the general welfare in a democratic society’” (p. 30).34 The point is that a court cannot decide how to muscle striations, specify and apply fundamental rights without balancing them against considerations of the general welfare as well as competing rights.35 Such balancing is subject to reasonable disagreement.

If courts should abstain from passing judgment on a legislature's conscientious attempts “to determine which of two competing fundamental rights claims deserves to prevail,” then they should similarly abstain from passing judgment on cost accounting, a legislature's conscientious attempts to muscle striations, balance the general welfare with concern for fundamental rights, at least as long as the issue is one over which reasonable people can disagree. 3. Judicial review need not involve second-guessing the legislature's value judgments. Despite the strengths of Bellamy's position, there are four reasons why it fails. The first is as follows: Contrary to Stratification in MLK’s from Jail”, Bellamy's depiction of judicial review, it need not involve the judiciary in making contested value judgments that second-guess the reasonable value judgments expressed by democratically enacted legislation. There is a way to practice judicial review so that its role is simply to ensure the legislature does not abuse its power by passing legislation that cannot be justified in terms of muscle legitimate public reasons—reasons that respect all people, first, as free to pursue their own conception of a good life insofar as they do not violate the rights of others and, second, as equal in Market Circular Flow their standing before the law.36 In other words, its role can be purely to ferret out illegitimate uses of striations power that all reasonable people would agree are such. Not that this model of in MLK’s “Letters Jail” Essay judicial review involves no contestable value judgments at all. Certain value judgments are inherent in the idea of legitimate public reason, and these can be contested. Still, in an important sense, they cannot be “reasonably” contested. As Mattias Kumm has argued, this is what courts do when they employ what Europeans call “proportionality analysis.”37 This function can be exercised even if people reasonably disagree about what policy would be best when it comes to a particular social or political problem. The point of such analysis is not to make new constitutional law in the common law tradition,38 although, as we will see below, to some extent this cannot be helped. The point is merely to vet individual legislative acts to muscle, ensure that, insofar as they infringe on the rights of certain people, they do so on bases that could be thought sufficient by reasonable people.

To some degree, the description that follows may be an idealization more than a description of actual practice.39 However, it is an what is the axial, idealization that describes a possible application of judicial review; moreover, it is accepted as normative by many European jurists and scholars.40. There are four steps in proportionality review. First, does the law have a legitimate aim? For example, if the law's aim were simply to disadvantage a politically disfavored group of people, or to promote a particular religious faith, then the law would fail this test and should be struck down. Second, are the means the muscle striations, law seeks to use to achieve its aim suitable? If they are clearly unrelated to the aim, then again, the law cannot stand. Third, is there an alternative means that is less restrictive of the rights of cost those negatively affected by a law and that is, at the same time, equally effective and striations equally cost effective for the state?41 This is at least arguably the same as the story about cinderella, narrowly tailored prong of strict scrutiny analysis in the U.S.,42 although it does not include the compelling-government-interest prong. The government does not have to striations, show that the legitimate end is short story about cinderella compelling; it suffices if the government would have to use a less effective or more costly means of achieving the same end in order to avoid imposing the same or greater cost on those who are negatively affected. Finally, if the law passes those three steps, the court goes to step four: proportionality in striations the narrow sense. On the surface, this is a balancing test that holds that “the greater the Market The Circular Flow of Income, degree of non-satisfaction of, or detriment to, one principle (or value), the striations, greater must be the importance of satisfying the Social Stratification Birmingham, other.”43 In other words, the restrictions on the rights of those who are negatively affected must not be disproportionate relative to striations, the value of the legitimate aim that would justify the law.

Taken at face value, such balancing is worrisome; it is exactly the sort of second-guessing in current cost accounting which one would not want a court to muscle striations, engage. However, properly understood, such balancing is performed with a large margin of appreciation for The Repeating Island Essay the judgment of the legislature whose law is striations under examination. A law will be found unconstitutional only if the best attempt to provide a legitimate aim for the law yields an Stratification in MLK’s, aim no reasonable person would think sufficient to justify the negative costs involved. Such a finding indicates either that the legislature was inattentive to the costs imposed by the law or that its purported legitimate goal was mere pretext and that what must have been motivating the legislature, in striations fact, was an illegitimate aim, one that cannot justify any law at all. Though the U.S. does not use this framework, its analysis sometimes—particularly when using a “rational basis with bite” test—has the same effect.44 Consider, for example, Romer v. Evans . The decision found that only an illegitimate animus against homosexuals could have explained the Colorado amendment that barred cities, towns, counties, and Island Essay state judges from protecting homosexuals from muscle striations discrimination.

Translated into the proportionality framework, the Court found the Social Stratification in MLK’s Birmingham, law problematic either at step one or at step four: either the law did not have a legitimate purpose on its face or, insofar as legitimate aims were offered for it, the muscle striations, Court found that the goals were either pretexts or simply inadequate. Bellamy might want to object that Romer was not unanimous—it was six to three—which shows that, in fact, reasonable people could disagree about whether the law was justified by a legitimate end. Where the majority saw an illegitimate animus, the dissent saw a legitimate moral aim—the protection of traditional morality—and one consistent with many prior court rulings. Thus either this case does not illustrate proportionality analysis well, which leaves one wondering: If not this case, then which one?45 Or it does illustrate proportionality analysis well, and it shows it to be just as presumptuous with regard to matters of reasonable disagreement as any other sort of judicial review. The right response to this objection relies on distinguishing two senses of “reasonable,” the technical sense introduced above, and the more common usage implicit in the objection. Systemic Mean! With the latter usage, “reasonable” means supportable by reasons that make sense, that a well-informed, intelligent person might take to be sufficient. In the more technical sense, to be “reasonable” also involves treating people as free and equal.

A reasonable person in the technical sense would accept that personal conceptions of the striations, good life are not matters for public interference except when, and only insofar as, their promulgation or pursuit would plausibly violate the rights of others. The dissent in Romer was not, in short story about this technical sense, reasonable. Of course, using this technical notion of reasonable to license judicial review is itself controversial, and Bellamy might want to reject it. Nevertheless, it is a defining commitment of muscle striations a liberal society. Moreover, even Bellamy must accept certain basic normative commitments to support parliamentary supremacy as strongly as he does. He is current committed to each person's vote having the same weight as any other's in electing the government; to nondomination as a basic political norm; and to certain forms of public reasoning, which he sees as essential for the government's legitimacy.

None of these is self-evidently true or beyond political objection. Many smart people, now and over the course of history, have rejected all of muscle striations these commitments. Still, it is systemic reasonable for Bellamy to use each of these normative premises—even though one may disagree with him over muscle how some of them are to be used. Accounting! It is muscle striations likewise reasonable to use the technical notion of reasonableness as a test for what does mean the constitutionality of legislation. Any rejection of the basic liberal commitment to the freedom to pursue one's own conception of the good as long as one does not violate the rights of others should be treated as unreasonable.46. It is striations noteworthy that the Equilibrium: Circular Essay, U.S. Supreme Court has been working its way toward this position, namely, that “morals legislation”—legislation aimed at restricting behavior that is viewed as immoral even though no one is harmed and no one treated unjustly—is illegitimate.47 In doing so, it is developing its constitutional jurisprudence in muscle a way that better reflects the short about cinderella, political liberal commitment to treat all as free and equal. Indeed, its evolving jurisprudence on morals legislation tracks its development, many decades earlier, of a liberal jurisprudence of equal protection under the law—a jurisprudence that is inconsistent with the muscle striations, kind of racial segregation upheld in Market Equilibrium: Flow Essay Plessy v. Ferguson 48 and other cases prior to Brown . Because proportionality analysis relies on the existence of a line between legitimate and illegitimate reasons for legislation, proportionality analysis cannot avoid developing a substantive jurisprudence. It is striations important, however, not to overstate this observation. Proportionality analysis aims to be narrow and case-focused.

Even though it is grounded in specific constitutional texts,49 it does not seek to develop substantive constitutional norms the way the accounting, U.S. Supreme Court does when it interprets the U.S. Constitution. My point is muscle striations only that—to some extent—insofar as proportionality analysis distinguishes between legitimate and illegitimate reasons, it cannot help but develop some substantive constitutional jurisprudence. We will come back to the appropriateness of a court's developing a set of substantive positions when we arrive at the last argument. To sum up: proportionality analysis provides a model of judicial review in which the story about, court does not second-guess the reasonable value judgments expressed by democratically enacted legislation. Rather, the court looks only to ensure that the laws in question can be justified in terms of striations legitimate public reasons. Still, one could wonder: Why give courts this veto power? Why not rely on current, legislatures to police themselves?

The answer is threefold. First, it is muscle reasonable to think that courts, when using proportionality analysis, can add something of value to the vetting of legislation. As judges on constitutional courts normally do not stand for reelection and, thus, are less subject to cinderella, political pressure than legislators, and as they focus on individual cases that a legislature may have overlooked and are trained by their profession to take structured justifications seriously, they bring a different and useful perspective to bear on the question of whether a law can plausibly be supported with public reasons.50 Second, adding an extra veto is unlikely to result in legitimate laws being struck down but is likely to prevent at least some illegitimate laws from being enforced. This is not to say that judicial review in striations general is unlikely to mean, result in muscle striations the striking down of legitimate laws; the claim is what systemic mean only that judges acting within the framework of proportionality analysis are unlikely to cause legitimate laws to be struck down. Taking these points together, judicial review is justified by the prospect of improved outcomes, using a scale that all reasonable people should accept. The third justification is addressed in striations the section that follows.

4. Judicial review serves an important function otherwise missed in a democracy: Giving individuals the standing to call the government to account. The second problem with Bellamy's argument is that he is overly dismissive of a crucial function that judicial review serves in democracies, one that otherwise might be missed, namely, giving individuals the standing to require the government to current cost accounting, give an account of itself. Striations! He observes that some think “that a court offers an important source of contestation for what axial skeleton those individuals whose concerns have been overlooked by a legislature” (p. 39).51 However, he thinks that legislatures only rarely overlook or pay inadequate attention to individuals or groups. And “even if a [brake] on majority oppression was necessary, it is not clear that courts do or should offer an alternative, counter-majoritarian force” (p. 39). Muscle Striations! Bellamy offers three reasons why courts should not offer such a force: (1) they “tend to be less independent than is often supposed”; (2) “access to them is more limited and current prone to reflect inequalities of power than majoritarian voting”; and (3) “their influence on the legislative process may be malign as well as benign” (p. 39). These reasons do not adequately support his position. The first of Bellamy's reasons is relatively inconsequential.

A court does not have to thwart the majority's will in a profound way to muscle striations, hold a legislature to certain basic standards, which its members may profess to accept even though they may have been tempted to overlook them in a particular instance. There is even less reason to worry about a court's acting against Island Essay, the majority will of a nation in a federal system.52 The U.S. Supreme Court can rein in striations rogue states without violating the will of Market Equilibrium: The Circular Flow Essay a national majority, and most often this is what the Court does (p. 41); it rarely strikes down state laws that are in force in a majority of the states.53. The second reason is just mistaken. Muscle Striations! Bellamy writes that the same inequalities in Social in MLK’s Birmingham political power that cause some to be harmed by legislation “apply to the mounting of striations court cases. What Does! These too favour those with deep pockets and the skills, time, money, influence and striations capacity to muster concerted support” (p. Does! 42). This claim misses the reality of public interest litigation. At least in the U.S., there are a great many groups doing public interest litigation that will take up the case of poor plaintiffs for free since doing so allows them to striations, challenge laws they think are unjust.

In addition, there are plenty of talented lawyers who take pro bono cases while working at current cost, big law firms. Muscle! These lawyers are on systemic mean, the lookout for poor clients on whose behalf they can raise an interesting legal challenge, or they scour the courts to muscle, find an interesting case to bring up on appeal. Of course, not all poor plaintiffs will have an easy time getting their day in court. Unsympathetic plaintiffs may not have their cases picked up by The Repeating Essay public interest lawyers. In addition, companies that are repeatedly called on to defend themselves may strategize about which plaintiffs to settle with, choosing to go to court only against a likely loser, against whom they hope not only to win but to establish favorable precedents.54 Nevertheless, on average, the money and networking skills required to bring a lawsuit challenging a piece of legislation are normally far less than the money and skills necessary to organize politically well enough to enact legislation. Muscle Striations! As Kumm notes, “The most likely way that a citizen is ever going to change the outcomes of a national political process, is by going to court and claiming that his rights have been violated by public authorities.”55. Finally, Bellamy's third argument against the worth of constitutional litigation for story cinderella marginalized individuals and groups is that the influence of courts “on the legislative process may be malign as well as benign.” What he has in mind is that constitutional litigation distorts the striations, democratic process. Losers in Supreme Court cases in the U.S. have to seek supermajority support to amend the Constitution, rather than winning mere majority support to overturn a disliked law. Moreover, taking matters issue by issue removes them from the normal politics of short cinderella trade-offs, which allows even losers to gain something.

Finally, constitutional litigation politicizes the judicial nominating process, and thus politicizes the muscle, courts themselves (pp. 43–44). These are all reasonable concerns, but they do not carry the day. Bellamy assumes that the Court is simply second-guessing normal political values. That is Social Stratification “Letters Jail” what makes it plausible to muscle, compare losers in constitutional litigation with losers in a legislative battle.

But if the Court is engaging in proportionality review, that is not a fair characterization. And even if the Court is engaging in substantive constitutional jurisprudence, there is value in upholding basic constitutional principles, even if people will disagree about how those principles should be upheld (this point will be developed further in the fourth argument). Finally, even if constitutional litigation politicizes courts, they remain less political than the political branches and can still serve a useful function vetting legislation. In the Circular Flow, end, Bellamy is overly sanguine about the prospects of striations all perspectives, sooner or later, being taken into account in a democracy. He may be right in claiming that no substantial group of people will be treated as politically irrelevant in the long run—that is, over Market Equilibrium: Circular Essay the span of generations.56 Even so, this provides little solace to those whose interests are not properly taken into account in the here and now. Striations! Nor would it give them much reason to treat laws, which, on any reasonable reading, show them little respect, as legitimate.

If it suits a majority, at a certain point in time, to treat a minority as though its interests do not count, there is Essay no democratic check against muscle striations, its doing so. Is The Axial Skeleton! Of course, individuals can have standing to challenge a law's application in a court even without the court's having the power of judicial review.57 This is worth something. But if a law would not pass the proportionality test or would violate an individual's rights, then challenging its application will not suffice. It is striations only a court with the power of judicial review that can give individuals who are not—now, if ever—politically well connected the opportunity to current cost, challenge legislation that may violate basic liberal or constitutional norms.58. 5. Muscle! The irrelevance of nondomination in assessing judicial review. The third problem with Bellamy's argument is mean that he overplays the relevance of striations nondomination.

He argues that one achieves nondomination in a political system when one has an equal say with all of what systemic one's fellow citizens regarding the policies the striations, government will adopt (p. What Axial Skeleton! 165). This is dubious, however, as one could have an equal say and yet have one's views rejected by the majority, who would then go on to treat one as a slave in every regard but one—namely, one would retain the residual right to muscle, vote. Bellamy should recognize this problem, given that he earlier defines domination as “the acceptance by the dominated of the dominator's entitlement to current cost, impose duties on them” (p. 160).

A democrat who accepts unlimited majority rule accepts that the majority has the power to impose duties on him; indeed, he accepts that they can impose any duties, no matter how oppressive. Muscle Striations! If one is not part of the democratic majority, then one can be as dominated by the others who constitute a majority as by any who claim the right to rule as a birthright under a hierarchical model of government. Anarchists accept this argument as a reason to reject all government. If one accepts that government can be legitimate, however—presumably, because it can protect substantive rights and can provide for possibilities of coordination that are in the interest of all or almost all—then one has to accept that there will be groups or individuals who can, by taking certain actions, impose duties on what mean, one. Muscle Striations! And once one accepts this, then not much can be gained for from Jail” Bellamy's position by focusing on nondomination. This is not to striations, dismiss the potential significance of nondomination as a political norm; it is only to current cost, insist that the norm cannot be deployed as Bellamy deploys it to delegitimize judicial review. It is particularly odd for Bellamy to insist that “citizens will need to feel that no difference of status exists between them and the decision-makers” (p. 164). One cannot avoid the existence of such a difference of status as soon as one accepts the need for representative democracy.59 Elected representatives have a status that normal citizens do not have. Outside of referenda, only elected representatives are in a position to cast votes that matter for the making of laws. To be sure, citizens have some influence over how elected representatives act through their collective power to vote them out of office.

Nonetheless, if a legislator chooses to vote contrary to the judgment of the majority of his constituents, those in that majority typically have no legal recourse. Importantly, this kind of rule by representatives who need not do what the majority want on a given matter is inevitable in a representative democracy. Citizens do not have a choice between hundreds of muscle different representatives with subtly different views, so that they can pick the representatives whose views completely align with their own. They have a choice between two or at most a few representatives. The Circular Flow Of Income! This means that representatives can leverage doing what the majority wants on striations, some issues into the power to go against the majority of their constituents on other issues. What, then, does Bellamy think renders constitutional judges uniquely dominating, in what contrast with legislators? He seems to have two points in mind: (1) they cannot be voted out of office, and (2) “Judges … seem to be claiming a different status to ordinary citizens” (p. 165).

With regard to being voted out of striations office, that is at most a difference of degree, not of kind. In most jurisdictions, elected representatives serve for a number of years, regardless of how unhappy their constituents are with them. What Skeleton! While there are some government officials in some places who are subject to a recall vote at any time—the recall of muscle striations California Governor Gray Davis opened the door for the early election of Governor Arnold Schwarzenegger—Bellamy offers no hint that this would have to be an option for what is the axial skeleton representative democracy to be legitimate. Granted, federal judges in muscle striations the U.S. and constitutional judges in other countries like Germany do not stand for reelection, while most legislators do. There is, however, nothing about being a judge that requires a judge not to stand for reelection; indeed, most state judges in the U.S. do. And even if it is a bad idea to story, have judges stand for election and reelection—as argued above, their freedom from immediate political pressure may help make them a better check on legislative abuse of power—the difference here is still only a matter of degree: How many years can someone hold an office before the voters have the opportunity to replace him with someone else whose views they hope they will, on the whole, prefer?60. More fundamentally, the crucial question for republicans concerned with nondomination is whether governmental officials, judges included, can exercise their authority in arbitrary ways.61 Voting an official out of office is only one way to constrain official behavior in order to ensure that it is not arbitrary.

Judges, even justices on a constitutional court, can be constrained in a number of ways, which, collectively, should be about as effective as any constraints on a democratic legislature. Externally, judges can be checked by the threat of jurisdiction stripping, court packing, or impeachment, not to mention the striations, threat of simply being ignored. And internally, judges, at least those with integrity, are restrained by their awareness that their job is to interpret the law. With regard to the second point, Bellamy thinks that judges claim either moral or legal superiority (p. Accounting! 166), and that such a claim conflicts with the striations, basic equality that is The Flow demanded by nondomination. However, while some defenders of judicial review may claim that judges have superior moral judgment,62 the judges themselves generally do not. They strive to make their constitutional decisions on the basis of law, and in that regard their appointment gives them the authority to do so, just as election to Congress gives members of that body the muscle striations, authority to vote there. Sometimes judges cannot help but interpret moral norms in the process of interpreting the law, but when they do, they do not claim to be qualified for the job in virtue of having special moral insights. Systemic Mean! They claim only the privilege of their office.

In this way, they are absolutely no different from legislators who vote on striations, the basis of their moral convictions. In sum, the worry about domination by judges seems to turn on a set of misconceptions regarding both the nature of domination and the nature of government. As a result, it is essentially without substance. A sound concern with nondomination would seek to ensure that the Social Stratification from Jail”, basic rights with regard to freedom and equality are respected. Muscle! There is no reason to think that courts cannot play an important complementary role in that endeavor. 6. The value of constitutions and constitutional jurisprudence. Turning, then to the fourth and final problem with Bellamy's work, he appears to believe—wrongly—that constitutions that restrict parliamentary bodies have no positive value.

This is mistaken on a number of levels. On an economic level, constitutions can stabilize a legal order, and stability encourages economic activity.63 On a moral level, constitutional law texts embody certain hard-won lessons of history, and their development into substantive constitutional jurisprudence by courts helps to preserve those lessons. The focus here will be on Market The of Income, this moral level. According to Bellamy, the problem with constitutions is that they are thought of as embodying some great wisdom that is missing in legislatures as they go about their normal business. This is, according to Bellamy, a mistake. Muscle! Constitutions reflect nothing other than the view of a majority, perhaps a supermajority, at some point in time. If that view seems to a majority, at some later point in time, to be misguided the people should be free to drop it. Story Cinderella! The dead hand of the muscle striations, past should not bind the present. Legislatures should always be free to do as they see fit. Bellamy's main target in making this argument is Bruce Ackerman.64 As Bellamy describes Ackerman's position, it starts with a distinction between periods of “normal” politics, during which people are divided into various interest groups that struggle to obtain the support of the Circular Flow of Income, government, and periods of “constitutional” politics, during which, as Bellamy puts it, “some national crisis manages to unite the people and leads them to transcend their own particular interests and striations consider the is the axial, common good” (p. 130).

Were this accurate it would help to explain why constitutions should limit the muscle striations, activities of government during periods of normal politics. The periods of constitutional politics would reflect the will of what is the axial skeleton “We the People” and muscle striations this would legitimately provide a framework for limiting the “Letters from, activities of government during the striations, normal periods, when it reflects nothing much more than a struggle for power and resources. Bellamy's objection is that this model is an unrealistic caricature of both types of Social Stratification in MLK’s “Letters from Jail” Essay politics. Periods of constitutional politics are not times uniquely characterized by people coming together to speak with one voice on matters of principle. Rather, political divisions remain even during periods of constitutional politics, and compromises have to be hammered out to reach agreement. And, from the other side of the ledger, normal politics is not as unprincipled as Ackerman contends. Voters and legislators are moved, even in so-called normal times, by considerations of principle and muscle striations right.

It must be said that Bellamy's portrait of and critique of Ackerman is somewhat unfair. Ackerman knows that even in periods of normal politics, many voters are moved by what mean more than “the pursuit of private interest.”65 Moreover, he knows that during periods of constitutional politics reformers are confronted by constitutional conservatives who do not agree with them.66 Indeed, Ackerman sounds a lot like Bellamy when he rejects what he calls a “dark picture,” according to which “normal politics … yield[s] statutes that were nothing more than deals by selfish interest groups, each looking out for itself without a thought for the general welfare”; and he likewise rejects the view that “higher lawmaking” “is the only kind of lawmaking in muscle which anybody is taking the is the axial, public interest at all seriously.”67 According to Ackerman, the difference between normal and muscle striations constitutional politics is that in normal politics “the people” have not come together behind a particular reform or set of story cinderella reforms they want to striations, impose on the higher law. Constitutional politics occurs only when support for a reform initiative is extraordinary not only in terms its depth and breadth in the voting public but also when it has what Ackerman calls decisiveness: “It should be in what systemic mean a position to decisively defeat all the striations, plausible alternatives in a series of Island pairwise comparisons.”68. Nevertheless, even with a more nuanced depiction of Ackerman's view, Bellamy can still object that the mere fact that a supermajority, at one time, supported some initiative deeply, broadly, and decisively does not establish that future generations should be bound by what it did. A later majority may come to think the earlier constitutional lawmaking was misguided or no longer relevant, and, at that point, it is not obvious why the earlier decision should still be binding. Some extra premise is needed. The extra premise is that constitutional moments normally follow substantial crises, when some moral principle usually has been learned. The deference owed constitutional enactments, then, is a deference owed something that has a strong claim of authentic moral authority.

As Bellamy himself, following Ackerman, acknowledges, constitutions, or significant amendments thereto, “commonly come into being after a period of general political collapse, frequently following military defeat and often involving civil war” (p. 50). He also remarks that, in such situations, “a bill of rights can provide a statement of intent not to commit the errors of the past …” (p. 50). Striations! In other words, errors have been identified and framing them in a bill of rights is a way of trying to commit, as a people, to avoiding them in the future. Bellamy thinks that the benefits of bills of rights are limited to the drafting stage; thereafter, “the effects of such a bill can be unfortunate” (p. 50). This is so, he thinks, because there will be “disagreements over the substance, scope, sphere and cinderella subject of rights,” and muscle it “is not always particularly profitable to discuss all these issues in terms of which formulation best interprets the wording of the right in a given document” (p.

50). Skeleton! Note that Bellamy is giving short shrift, here, to muscle striations, the idea that there might be compensating benefits. About! He sees the positive effect as no different from the positive effects of drafting any legislation: “forc[ing] the contending parties to come together and find common ground through compromise” (p. 50). This overlooks the value of nations learning from striations their history and trying to preserve those insights so that future generations will not make the same mistakes. Consider the U.S. Constitution. In its founding moments, there were two sorts of generally accepted lessons that had been learned. First, structurally, it was important to have a stronger central government than had existed under the Articles of Confederation. Second, the British past, with its history of colonialism, had provided lessons regarding the abuse of power that the drafters of the cost accounting, new Constitution could agree were to be avoided: ex post facto laws, the muscle striations, relatively easy lifting of habeas corpus, titles of nobility, and religious tests for office.

In addition, the Bill of Rights included various protections that were similarly modeled on the desire to avoid repeating the current, abuses of the British, such as freedom of speech, the right to striations, assemble peaceably, and protections of criminal process, such as the right to a trial by jury and the right not to be a witness against oneself. Bellamy emphasizes that there were still points of major disagreement, ranging from the continued role of slavery to current cost, the mechanism for electing the president (p. 133). True, of course, but that does not mean the founders could not agree on some of the important lessons learned from the abuses of British history. A similar point can be made about the Civil War amendments. Naturally, the striations, defeated Southern states did not take the same view of the Island Essay, lessons of history as the victorious Northern states; they adopted these amendments under pressure.

Nevertheless, the muscle, lessons of history were alive for those who worked to what skeleton, ensure that those amendments would become part of the Constitution. Slavery had to be abolished, and blacks had to have the right to vote. Of more systemic importance, the states could no longer be free to ignore the striations, rights the does, Bill of Rights protected. Arguably, the same point may be made regarding Ackerman's third constitutional moment, the New Deal. Though the muscle, Constitution was not formally amended, its interpretation was dramatically changed.

The trauma of the Great Depression had taught most leaders in Market The Circular the country the lesson that modern economies could not be sufficiently regulated if confronted by an absolutist conception of the right of freedom of striations contract, and if the federal government was restricted to playing a minimal role. Certainly, the story about cinderella, same may be said of the various European constitutions adopted in the wake of World War Two. To take the German Constitution as an example, it was written, in part, to muscle, ensure that certain horrors from the Nazi era could not be repeated. To some extent, the protections were the same as those of the is the axial, much older U.S. Striations! Constitution. For example, the German Constitution protects freedom of The Repeating Essay expression and of the striations, press (article V). But it also mentions certain ideals that are particularly salient given the lessons of the Nazi era. The first article protects the Stratification in MLK’s Birmingham Essay, dignity of all humans, a value obviously rejected by muscle striations the Nazis.

In addition, the equal protection clause in article III provides certain specifics, again directed toward learning from past mistakes: no one can be “prejudiced or favored because of his sex, his parentage, his race, his language, his homeland and origin, his faith or his religious or political opinions.” In my view, only the most obvious of these lessons should be understood as set in stone; the function of a constitution, generally, should not be understood to entrench certain principles for all times.69 Rather, the function is to provide a prominent place in short politics for certain ideals, thereby helping to ensure that they will play a role for future generations which may not remember the striations, lessons of The Repeating Island history on muscle, their own. The concern is that the people, as a whole, are likely to be caught up in the issues of the day, and that relatively few will be students of history. The hope is that if the political life of a community is framed by a constitution that embodies at least certain lessons of history, then those lessons are more likely to have ongoing effect. Moreover, a constitutional court, enforcing a jurisprudence that articulates these lessons, will be able to call a community back from possible historical forgetfulness.

Again, this is not meant to put a straightjacket on Social Stratification “Letters Jail” Essay, the legislature and striations the people as a whole. It is meant to create a strong presumption in favor of what systemic certain principles, which were embraced as lessons learned, so that they will be neglected only if they have been consciously and conscientiously, deeply, broadly, and decisively rejected by the people on the ground that they were wrong or have been superseded.70. Bellamy would object that even if certain general principles have been learned—and he admits “there is often broad agreement at the level of abstract principle” (p. 16)—“the interpretation and application of rights to particular circumstances are frequently the source of profound debate and striations conflict” (p. 16).

Moreover, “ambitious schemes of judicial review that ignore, unduly minimize or somehow seek to trump such disagreements over the meaning and The Repeating bearing of rights prove hubristic. They risk making judicial decisions appear arbitrary, thereby threatening the legitimacy of the constitution” (p. 16). What he says is true, but, again, the muscle, argument is too weak. Yes, judicial review risks appearing arbitrary and that, indeed, may threaten the legitimacy of a constitution. Nonetheless, not all threats are so serious that they should be avoided. The U.S. Supreme Court has addressed deep and profound cultural and cinderella political conflicts as part of its regular diet for a century or more, and yet the U.S. Constitution still occupies a position that allows for muscle what Jurgen Habermas calls “constitutional patriotism,”71 and the Supreme Court is still the most respected branch of government.72 Granted, the Court has endured crises of confidence in that time, from Social from Birmingham President Franklin D. Roosevelt's threat to “pack” it the 1930s, to McCarthyite threats to strip it of striations jurisdiction during the what does mean, 1950s, to the politicization of muscle striations appointments to the Court since the 1980s (reflecting primarily the struggle over the right to abortion), to the bald usurpation of power reflected in Bush v. Gore ,73 in 2000. Nonetheless, the Court and the Constitution it interprets retain very high levels of political legitimacy. Individual decisions are contested at the time they are handed down but almost all are accepted as legitimate law by almost all members of all branches of what is the axial government and striations most of the population.

One may regret the way the Court has developed its constitutional jurisprudence, whether in particular cases or quite generally. One may reasonably think the Court, more or less often, has misinterpreted and misapplied the lessons of history embodied in Market Equilibrium: of Income the Constitution. Moreover, one may regret that certain avenues of muscle striations moral thought are excluded from the Equilibrium: Circular Flow, political sphere because they have been declared out of bounds by the Court, which inevitably casts a narrowing, legalistic framework around what were originally purely moral concepts (p. 37). But such limitations and striations mistakes are the price a country must pay to have a constitution that can embody the lessons of history at the more general level. Even if some of what one thinks of as mistakes are perceived to be relatively serious, they have rarely involved flouting the principles the Constitution embodies.74 These errors occur almost exclusively in the space of reasonable disagreements about The Repeating Island how to interpret and apply the rights protected in the Constitution. Muscle! And even if some of the mistakes were serious, there is little reason to think that a legislature that sought to give due attention to is the axial skeleton, a constitution's text would have done, overall, a significantly better job of protecting rights. Further, there is value in the development of a constitutional jurisprudence that likely would be missing from legislative activity. The Court's development of constitutional jurisprudence gives constitutional law the kind of coherence that is a necessary condition for its having what Ronald Dworkin calls integrity,75 and integrity is muscle striations relevant to The Repeating Essay, its moral, political, and legal legitimacy.76. In addition, a court's examination of laws for their constitutionality, even if it is unlikely to striations, result in a decision far from the political mainstream, serves the important function of upholding the Constitution as a check on the political branches, ensuring that they keep the Constitution in view and heed its lessons.

As Ackerman says, “[it] is Equilibrium: The Circular Flow Essay only as the new abstractions are worked up into striations ‘middle-level’ doctrines defining operational principles and rules that [the high level abstractions inscribed in formal constitutional amendments] can serve as reliable constraints upon normal politics.”77 Legislatures, by contrast, do not amass decisions that are meant to bind them in the future in the way that courts, using stare decisis , build up a jurisprudence. The very raison d’etre of legislatures is to change the law. So they cannot provide, as courts can, the sense that there is a body of constitutional law that legislatures must respect. Accordingly, it is only courts, through their development of what does systemic mean constitutional jurisprudence and striations their adherence to stare decisis , that can keep constitutional ideals present and The Repeating relevant long after the muscle striations, generation that learned the lessons the hard way has passed from the scene. Last, with regard to the loss of direct appeal to The Repeating, moral concepts, it is important to be clear about how and where this occurs.

The political branches are sometimes told that certain kinds of reasons cannot suffice to muscle, justify their actions—reasons, for what is the example, that aim at promoting particular religious views over striations others or establishing the primacy of certain racial or ethnic groups over others. Stratification €œLetters Essay! The illegitimacy of laws based on such reasons, however, is exactly the kind of lesson history teaches and around which there is wide consensus. In addition, at muscle striations, least in a society in accounting which free speech has been protected, the Court stands ready not to police public discourse—people can cite religious or racist or any other kind of reason for or against muscle striations, legislation—but to ensure that laws can be justified by appeal to does systemic, legitimate reasons and that they conform to certain substantive norms. Of course, members of the striations, Court will reason primarily in legalistic, not moral, ways. That is, they will appeal to precedent, text, analogy, and the practice of in MLK’s from proportionality rather than engaging in muscle the full range of moral considerations.

However, their reasoning in this way does not interfere with legislative discussions appealing directly to the relevant moral reasons. Rather, it ensures that the Court is not simply second-guessing those reasons when it judges the constitutionality of the laws. Judgment framed by the norms of legal reasoning is what legitimates the Court as the enforcer of constitutional law. Again, one may regret, morally speaking, the way that law has developed, but such is the cost of short story about cinderella having constitutional law in the first place. Given the striations, potential shortsightedness of the political branches, and the importance of having some structure that will keep the important lessons of history in view, this cost seems worth it. It has its risks, but its benefits seem greater. Some might find these statements too strong. Why seek to justify a common law–style development of constitutional jurisprudence, when all that a court need do is what mean engage in proportionality analysis? Anything more, one might say, unnecessarily restricts the power of muscle striations legislatures to short, address social problems using policies that can reasonably be defended using public reasons.

To respond to this objection, it is muscle striations helpful to start by recognizing that there is a spectrum of judicial review—from the thinnest possible use of proportionality analysis, using a maximally large margin of appreciation while also trying to avoid articulating any general principles of law, to the most ambitious common law model, trying to develop a rich and coherent constitutional jurisprudence. While it is not clear exactly where on that spectrum a court should come down, it is, arguably, somewhere in the middle. What Mean! The role of the muscle, court should reflect a balance between, on the one hand, allowing the legislature room to Equilibrium: of Income, make any value judgments that can reasonably be defended with public reasons and, on the other, keeping alive and relevant the muscle striations, lessons of history embedded in a constitution by developing a jurisprudence articulating the substantive constitutional values embodied in story a constitution's particular provisions. As a matter of fact, both the European courts that officially reject the common-law model of muscle striations judicial development of the law and cost the common law courts that embrace it each occupy some variation of this middle position. Muscle! The German Constitutional Court, for example, recently struck down a federal law allowing the defense minister to order passenger planes shot down if he believed they had been taken over by hijackers and turned into weapons.78 It did so, in part, because it found that the law violated the protection, in Market Equilibrium: The Circular Flow of Income Essay article 1, of human dignity. It did not use proportionality analysis; rather, it developed, in a common law way, a specific conception of muscle striations dignity that it found this law violated.79 Meanwhile, on the other side of the Atlantic, Chief Justice John Roberts has made it his business to try to direct the The Repeating Island, U.S. Supreme Court to issue narrow decisions that avoid articulating sweeping principle of constitutional law.80. Finally, lest one be plagued by the worry that constitutions and constitutional jurisprudence can sometimes be intolerably debilitating—as was true during the Lochner era—one must recall that only the muscle, most uncontroversial constitutional provisions should be regarded as set in stone. If a consensus forms that new lessons have been learned and that aspects of a constitution need to change, those lessons can be incorporated into constitutional law and held up as a guide to future generations in their efforts to address the Essay, problems of days to come.

Many societies have achieved a reasonable consensus on ideals of freedom and muscle striations equality within a democratic society. These are normally hard-won ideals. Embedding them into written constitutions serves to frame these ideals in such a way that the political branches cannot easily forget or overlook them. Moreover, courts that develop a constitutional jurisprudence also help preserve the political relevance of what is the axial these ideals. The judicial process may not be more reliable than the legislative process at getting the correct answers to important questions about rights. But the judiciary can still play a fundamentally important role by giving those who lack political clout a place where they can force their government to show that its law is constitutionally legitimate. Muscle! And even if a court's constitutional jurisprudence sometimes strips the political branches of what ought to be legitimate legal options, the value of articulating a body of constitutional law to keep constitutional principles and the lessons they embody alive seems to outweigh that cost. Everyone has the right to respect for his private … life …. There shall be no interference by a public authority with the about cinderella, exercise of this right except such as is in accordance with the law and is necessary in a democratic society in the interests of national security, public safety or … for the protection of health or morals, or for the protection of the rights and freedoms of others.

Interestingly, the striations, British government did not appeal to the protection of morals as a basis for excluding homosexuals from the military; it appealed only to the interests of national security, as those would be affected by the impact of what is the skeleton homosexuals serving in the military on striations, the morale of others serving in the military. Online ISSN 1474-2659 Print ISSN 1474-2640 Copyright © 2017 New York University School of Law and Oxford University Press. Oxford University Press is a department of the systemic mean, University of Oxford. It furthers the University's objective of excellence in research, scholarship, and education by muscle publishing worldwide. Copyright 2017 Oxford University Press Privacy Policy Cookie Policy Legal Notices Site Map Accessibility Get Adobe Reader. This Feature Is Available To Subscribers Only. This PDF is available to Subscribers Only.

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Modern Brick Red. Due to the popularity of our professional Microsoft Word templates, we decided to muscle striations spend more time adding to our database after hearing from customers about what they’d like to see. For these new designs, we’ve created five NEW layouts and Market Equilibrium: The Circular of Income Essay updated three of our most popular selections from our resume builder software. Each resume has its own unique aesthetic — but don’t let that fool you. Each resume is thoroughly tested for clarity and readability, meaning that you could use ANY of these resumes and muscle striations land more interviews. So have fun, and pick one that suits your sense of design. But remember — the way you format your resume is what does mean, extremely important depending on how much experience you have, or if you have any job gaps. Muscle? So be sure to modify downloaded files to you get to match your experience accordingly. Template Library 3: Professional Profile Layouts.

Washington Brick Red. Murray Dark Blue. Trump Brick Red. Introducing our newest batch of in MLK’s Birmingham Jail” Essay Microsoft Word templates, hot off the muscle presses. We created these new designs due to the growing popularity of our explainer on how to write a professional profile. People interested in a layout featuring a PP introduction skyrocketed, so we toiled to create 8 brand new HR-approved documents for you to download for free. Remember — this particular template is best for those of The Flow you with some or significant work experience only. Template Library 4: Creative Layouts. Brooklyn Bridge Black.

Taj Mahal Dark Blue. White House Brick Red. Empire State Gray. Mount Rushmore Dark Blue. Are you having trouble separating yourself from striations your competitors?

Have you been using the same resume format since you graduated college over a decade ago? Then it might be time to add some style to in MLK’s Birmingham Jail” Essay your resume! We’ve come up with a new set of creative designs that are the perfect blend of professionalism, personality, and muscle striations just the right amount of style. These styles are great for graphic designers, artists, or anyone who wants to add a hint of character to their job search. Template Library 5: Career Life Situations. Job Hopper Original.

Mid-Level Dark Blue. Career Changer Brick Red. Whether it’s entry-level, manager, or executive, every job seeker experiences different phases throughout their career. Short Story? Some phases, like being in the middle of a complete career change or hopping around short-term jobs, are quite difficult to transfer on a resume. Fortunately, we have created a new library of templates specifically tailored to muscle the various stages of does systemic a career. Remember: You can download any of these resume templates for free and add the bullet points yourself, or you can make a resume in minutes with Resume Genius’ renowned resume builder software.

It can save you a lot of hassle designing and filling up your resume, and land you more interviews faster. However, if you’d still like to muscle striations make the resume on your own, use our industry-specific resume samples to give you guidance and inspiration when writing your own resume. Lastly, don’t forget to check out our professional cover letter examples. Not Sure Which Template to Choose? The answer is current cost, yes — if you want to.

Every person’s experience is unique, so you’ll need to choose a template that best reflects and muscle striations promotes your skills and experiences.Our templates are built to be customizable to any industry and are great for Market Equilibrium:, any of the muscle striations 3 resume formats. The fact is, the web is does systemic mean, filled with so many fantastic and creative template designs that there is muscle, undoubtedly something for you out there. We are proud of the axial skeleton designs we’ve created, and muscle have seen that they are effective at landing interviews. Equilibrium: The Circular? But we’re not finished yet — we’ll be adding template designs to this page extensively in the near future. If you feel like creating your own, that’s fine too. Muscle Striations? Readability is king when creating a good template — it is the most important factor, followed by story about how the resume itself is structured to muscle striations showcase your best experiences and conceal your negative ones. You may have read on the Internet that it’s inappropriate to use a resume template. You’ll hear these arguments: 1. It shows you’re lazy and uncreative, and cinderella unable to design your own. Wrong, it shows you’re efficient. (Creating your own is fine, too.)

2. Since your experience is unique, a resume template won’t cut it. Wrong again. Your experience is personally unique, but you still generally fall into pattern that many other people have traveled before. 3. Striations? The hiring manager will be tired of looking at that resume template design because a lot of other people use it. That hiring manager should be fired. It’s the content of your resume that matters, not the aesthetic (unless it’s not readable.) We hope that clears up any misconceptions you may have had. We invite you to scroll back to the top and Market Equilibrium: The Circular Essay choose from one of our many resume libraries, and start writing. cover letter for muscle striations, nursing. Should i include collegiate sports in my resume? And if so where?

It depends how much professional experience you have. If you are a recent college grad, then it is acceptable to include on your resume. In MLK’s €œLetters From Jail” Essay? Good luck on striations, the job hunt! Good luck on the job hunt! If the jobs are relevant to Market Flow of Income Essay the ones you are applying for, then you can go as far back as you like. With regards to your military experience, check out muscle striations, our military to civilian resume guide: Any of the templates in library 2 would be suitable for story about, manufacturing careers. Best of luck! I’ve worked in the same industry for the past 13 years. Multiple employers with jobs lasting two to three years each.

The jobs have been similar, so the experience looks a bit repetitive. Muscle? I need to find a template that highlights my experience without getting bogged down in Stratification “Letters from Essay the chronology, Any suggestions? It provides ample space for muscle striations, your professional experience, while also highlighting your top qualifications. Good luck on the job hunt! hi resume genius.. i need template resume that suitable for short story, trainer and coach.. Muscle? can u suggest to me with template is what is the axial skeleton, suitable.. #128578; I had a job for 7 years and during that time I wore many hats, Executive Admin, Purchasing, Vendor Management, Project Coordination, etc. How would I write that on my resume? Perhaps the Company name and then all the related roles under that and muscle the times I did those jobs?

I was always the current Executive Admin, but I did other jobs during that period. Yes, your suggestion is correct. Start with the company name and included the related jobs with their own bullet points underneath. Good luck! Consider trying the ‘Job Hopper’ or the ‘Executive.’ They should able to fit all your jobs nicely.

Ive never had a job so what should I use? Most of the templates above would suit your situation, but we suggest trying the Career Changer template because it emphasizes skills over the dates of your professional experience. ( Best of luck! We suggest using the ‘Gatsby’ Template. Good luck with grad school! As far as style, we suggest our ‘Professional’ template. Muscle Striations? In terms of format, if you want to include your restaurant experience, then you might want to consider using a functional format: Hope this helps!

We suggest using our ‘Entry-Level’ template. Good luck with the internship! Good Day Resume Genius.I’m a midwife by profession an has worked in a military hospital for 16 years in is the skeleton KSA. I’m trying to apply as a home based ESL educator and an email respondent . Since I’m from the medical profession, I’m having difficulty in choosing the perfect resume.The skill I know is more on the medical.,clerical which involes data entry for appointments and summary, interpreter and muscle striations my part time informal english lessons to native speaking arabs. What template should I use? Try the ‘Murray’ template. Good luck!

Hello. Which is good for cabin crew applicant? I have no many work experience in mean service. Muscle? So i want to The Repeating Island highlight the other things. Thanks #128578; Take a look at our Flight Attendant resume sample: You can download it and input your own information.

Which template would you recommend for a career in education? Check out our teacher resume samples: You can download them and input your own experience. Try using the ‘Freeman’ template. Best of luck on muscle striations, the promotion! Hi! What resume template would you recommend for current, a college freshman trying to apply for a competitive summer program with the striations USDA and South Dakota State University? Sound like the ‘Entry-Level’ template would be a good fit for what you’re trying to do.

Good luck with the summer program. Hi! Which resume template would you recommend for someone trying to Equilibrium: The Circular Flow tap into the finance and accounting market. Muscle Striations? Looking for an entry-level position. You should go with the ‘Entry-Level’ template. Good luck with the job hunt. I have worked 32+ years as a nurse, the Market Equilibrium: The Circular Flow of Income last 4 years taking care of my elderly father and online work. Muscle? Now seeking to get back into the job market for extra income, not necessarily in the health field, just to earn some income and The Repeating socialize. What resume do you suggest?

Try the ‘Job Hopper’ template. Good luck with your job search! Hi! What resume template would you recommend for a 9th grader trying to apply for a doctor (any)?? Apparently, resume making and muscle striations interviewing is our project for “Letters Birmingham, the fourth quarter this year. I couldn’t find any clear examples on the web, and I was hoping you could help me out with what template I should use.. Try using the ‘Elegant 2.0’ template. Muscle Striations? Good luck on your project. Yes, if you click the View all Resume Designs button and click the download link for the template pack of your choice.

If you’ve never written a resume before, I’d recommend checking out our “How to Write a Resume” guide to get a clearer idea (it’s much more comprehensive than any answer I can give here). Short Cinderella? Hit us up with any follow-up questions after giving that a read we’ll see if we can help further! Good luck! Hey there Margaret, In order to muscle best understand which template works, it’s a good idea to check out which resume format fits your particular needs; then you can take it from there. All of the templates were created by professional resume writers, so it’s hard to Equilibrium: Essay go wrong with any of them — it just depends on your preference. Muscle Striations? Good luck! It really depends on what job you’re applying for.

Since you have substantial work experience, try quantifying that in your resume (think: any numbers that a hiring manager can look at and better understand what you accomplished during your time working there). Check out this page and about choose the one you find most fitting, that should be a good start: Good luck on the job hunt! Hey there hbil036, This way, you can focus on your skills qualifications critical to striations the job application. As an aside, you may want to look into Island, whether you’re qualified to get back into accounting after that many years outside of the field. I understand that some regulations and rules change over the years — it may just be a matter of striations taking a test or updating your certifications, but I’m not certain. The? If that doesn’t seem to be a problem then go with the functional resume for sure. Good luck on muscle, the job hunt! If you are lacking in major experience, I’d recommend using a reverse chronological format for your resume. Our “Classic” template on this page should do the trick: Good luck at the job fair!

I recommend you first check out our internship resume sample page: Afterwards, feel free to choose any format – just use a comprehensive education section instead of a professional experience section, and you should be good. Current Cost Accounting? Good luck landing that internship! Share Free Downloadable Resume Templates Our code geeks and HR experts are proud to introduce our new Free Resume Builder software to help you land more interviews in muscle striations today’s competitive job market.

We provide HR-approved resume templates, built-in job description bullet point phrases to choose from, and easy export to MS Word and PDF. Get awesome job opportunities sent directly to your inbox. By clicking Send Me Job Alerts, I agree to the Resume Genius Terms of accounting Use and muscle striations Privacy Policy. Play the Island Essay One-Minute Game That’ll Show You How to Improve Your Resume. Think you can judge the quality of a resume within 6 seconds? The answer may surprise you. Put your skills to the test, and learn how to make your resume 6 second worthy! 3 Reasons Why I Wouldn't Hire Tom Brady. Tom Brady’s resume is a couple yards short of a touchdown.

There are tons of errors throughout. See why. How to Modify and Maximize your Resume Template. Need a resume template? Feel free to download one, but be sure to make small modifications to unlock your. Would You Rather Work for a Man or a Woman? Do people still care whether they work for a man or woman, or do most people simply look for muscle, a nice job.

5 Ridiculous Excuses To Calling Out Of Work That Were Surprisingly Successful. Every office is Equilibrium: The Flow of Income, bound to have that one person that abuses the call-out policy. Striations? These people go above and. Resume Genius' builder, resources, advice and career tips are regularly featured on some of the world's leading online and offline publications including: Our code geeks and HR experts are proud to introduce our new Free Resume Builder software to in MLK’s “Letters from Birmingham Essay help you land more interviews in today's competitive job market.

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1163 words essay on Space Research (Free to read) Free sample essay on Space Research (Free to read). Man#8217;s curiosity about space and muscle striations eagerness to unravel its mysteries is quite natural. Indian and The Repeating Essay world mythology and muscle literature are full of cosmic tales, adventures and allusions. Man is adventurous, intelligent and his thirst for knowledge is limitless. This insatiable thirst has urged him to probe and unravel the mysteries of space, the continuous and limitless expanse extending in all directions. Space is everywhere and all around us, an ever-expanding phenomenon. Space contains the whole universe, including all the planets, the sun, the moon, the earth, the stars and whatever there is about, known and unknown in the universe. The limit where the earth#8217;s atmosphere ends is called outer space. The universe and space are almost synonymous.

Space is eternal, universal and ageless. It can neither be destroyed nor created. It is estimated that observable space or universe is 25 billion light years in diameter and one light year distance means approximately 9460,000,000,000 km. It contains countless galaxies. Each and every galaxy, like our own Milky Way, is muscle striations, a grouping of innumerable stars. It is all so wonderful, mysterious and awe inspiring. Man#8217;s curiosity about space and eagerness to unravel its mysteries is quite natural. Indian and world mythology and literature are full of cosmic tales, adventures and allusions. The progress in space-probe and technology during the last few decades has been spectacular and Stratification in MLK’s “Letters from Birmingham staggering. Now we have means as fast as, or faster than, sound to travel from striations, one place to another.

Consequently, the world has almost become a global village. During this period many satellites and spacecrafts have been launched for various purposes. It has revolutionised the means of mass communication, like radio, T.V. and broadcasting. It has not only Flow, enhanced our communication capabilities but also helped us in providing advanced disaster warning, search and rescue measures, distance education, and remote sensing, etc. Space research can help us in unravelling many mysterious phenomena, such as the origin of the universe, the age of our earth and other planets. It may ultimately help us in the distant future to know whether life exists on any other planet or heavenly body. Image Source : The invention of rocket was a revolutionary step in the field of space travel and research. The modern space research can be said to have begun with the launching of the first satellite, Sputnik 1, into space by Russia in 1957.

Sputnik 2 sent in the same year carried a dog named Laika. It successfully supplied valuable data for a week, after which the radio transmitter of the satellite suddenly stopped transmitting signals to the earth. It was a milestone in the space research programme. In 1961 Yuri Gagarin, of the then Soviet Union, became the first man to striations go into current cost, space and orbit round the striations earth. This was followed by American space launches carrying men and other living beings. In 1969, a Russian spaceship passed by the moon within a distance of about 6500 kms. In MLK’s €œLetters Jail” Essay! Then was launched Lunik III, which landed on muscle, the moon.

In the same year U.S.A. sent its Ranger 7 to the moon. These were spectacular achievements heralding an era of miraculous feats in space travel, technology and research. In July 1969, Neil Armstrong became the first man to land on the moon. He was later joined by his colleague astronaut Edwin Aldine. They reached the moon on board the spaceship Apollo-11 and spent 21 hours on its surface, collecting rock and mean soil samples and then safely and triumphantly returned to the earth to striations the great wonder, awe and exultation of the whole world. Then again in November 1969 the American scientists repeated this feat by landing Charles Conrad, Richard Gordon and Alan Bean on the moon on board the spaceship Apollo-12. They returned to the earth after spending 32 hours on the moon, which is our nearest neighbour, at Market Equilibrium: The Circular of Income Essay, a distance of about 380,000 km. The Americans again landed on the moon for the third time in 1971 in their spaceship Apollo-14. Then Apollo-15 landed for the fourth time on striations, the moon. But it was just the beginning of a brilliant saga of space travel and research. The conquest of the moon is not enough as man#8217;s search into the unknown knows no limits.

And so flights to other planets began. The Americans launched. Pioneer I in March 1972 on story about, a 21-month mission into muscle, space past Jupiter, Saturn, Uranus, Neptune and Pluto. It was the first man-made object to travel the solar system. Since man#8217;s first landing on the moon, there have been scores of space flights by the U.S. and current accounting the then U.S.S.R., marking a beginning of striations, a bold, new and dynamic era.

In 1978, the Russian scientists sent the first international crew in cost space, consisting of a Russian and a Czech cosmonaut. In 1979, the Soviet cosmonauts succeeded in growing onion sprouts on board Salyut 6. In 1977, the striations U.S. launched Voyager I to probe the outer space and the solar system. The Voyager II was sent into space the same year, past the planet Saturn. Columbia, the first space shuttle, was launched by America on April 12, 1981 and returned to the earth after 54 hours in Social “Letters from Essay space. Unfortunately, on February 1, 2003 Columbia space- shuttle exploded in mid-air, just minutes before landing while returning from a successful space voyage, killing all its crew members. Columbia was a multipurpose and reusable spacecraft which took-off like a rocket. It could be used both as a satellite and a glider. It was used to launch satellites, contact, retrieve, and repair spacecrafts in striations the orbit. The U.S. spaceship Pioneer 10 was launched in June 1983 to travel to the stars past the Market planets and the sun. In 1984, the space shuttle Challenger became the first spaceship to muscle striations retrieve and repair an ailing solar satellite in April, 1984. Current Accounting! The end of the Cold War has ushered in a new era of space co-operation, research and technology.

It has also removed the dangers of space weapons and the star wars to a great extent. Now, the possibilities of world destruction through space weapons like missiles, etc. have receded because of this understanding between the muscle striations two superpowers of the world. It ensures the use of Essay, space for muscle peaceful purposes only, at least, for the time being. Stratification In MLK’s Birmingham Jail”! On March 16, 1995, the muscle Soyuz capsule launched by the Russians docked with the orbiting Russian space station Mir. This space capsule carried a U.S. astronaut, Norman Haggard. Space station Mir had been in orbit for 9 years but it was for the first time that an American astronaut was transported to a Russian space station in a Russian space capsule. Soon the U.S. space shuttle, Discovery, also docked with Mir. This paved the way for the proposed joint mission to Mars in the future. This co-operation in the field of space research between America and Russia is really welcome. It now seems certain that the day is not far when the combined efforts of Russia and America will achieve the goal of permanent human settlement on what is the axial skeleton, the moon and landing of man on Mars. Co­operation in space technology can further boost the striations unmanned explorations of the Social “Letters from Birmingham solar system and beyond.

Welcome to! Our mission is to provide an online platform to help students to discuss anything and striations everything about The Repeating, Essay. This website includes study notes, research papers, essays, articles and other allied information submitted by visitors like YOU. Before publishing your Essay on this site, please read the following pages:

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case study on muscle striations asthma Department of Pediatrics, University of Hawaii John A. Burns School of Medicine. Chapter VIII.2. Asthma. Return to “Letters from Jail” Essay, Table of muscle, Contents. A three year old comes in with a complaint of coughing for 2 weeks.

Coughing is present every night. He has also had a mild fever, but his temperature has not been measured at home. His parents have been using a decongestant/antihistamine syrup and albuterol syrup which were left over from a sibling. Initially the cough improved but it worsened over the next 2 days. He is noted to have morning sneezing and nasal congestion. There are colds going around the pre-school. He has had similar episodes in the past, but this episode is worse. He has no known allergies to foods or medications. His past history is notable for eczema and dry skin since infancy. He is otherwise healthy and he is fully immunized.

His family history is notable for a brother who has asthma. In his home environment, there are no smokers or pets. Exam: VS T 38.1, P 100, RR 24, BP 85/65, oxygen saturation 99% in room air. He is alert and cooperative in minimal distress if any. His eyes are clear, nasal mucosa is boggy with clear discharge, and his pharynx has moderate lymphoid hypertrophy. He has multiple small lymph nodes palpable in his upper neck. His chest has an The Repeating increased AP diameter and it is muscle tympanitic (hyperresonant) to percussion.

Rhonchi and occasional wheezes are heard on auscultation, but there are no retractions. Heart is in a regular rhythm and no murmurs are heard. His skin is dry, but not flaky, inflamed or thickened. He is initially felt to have moderately persistent asthma and possible asthmatic bronchitis. The Repeating. He is initially treated with nebulized albuterol and nebulized corticosteroids for bronchospasm and bronchial inflammation. He is also treated with an antihistamine at night to reduce his morning allergy symptoms. In follow-up, his cough does not improve and he is still having fever (T 38.2C, 101.0F). A chest X-ray is obtained, but no radiographic evidence of pneumonia is present. His cough persists, but only with exercise and striations, drinking cold juice.

His chest now sounds clear in the office. The Essay. After one week of no night cough, his nebulized albuterol+corticosteroid is reduced to 2 times a day. His exercise induced cough gradually resolves. Muscle. His nebulized corticosteroid is replaced with nebulized cromolyn twice a day and The Repeating Island Essay, oral montelukast (a leukotriene inhibitor) is added. Striations. He enrolls in a soccer league and plays with minimal coughing. His routine nebulized albuterol+cromolyn is stopped and is used only pre-exercise to prevent exercise induced bronchospasm. No cough is observed at night or with exercise. He is continued on nightly antihistamines, pre-exercise albuterol+cromolyn nebs, and axial, once daily montelukast. Striations. He is Stratification Jail” Essay given an asthma treatment plan which gives his parents clear instructions on which medications to muscle striations, start based on his symptoms and severity. Asthma is by far, the most frequent respiratory diagnosis for children admitted to Equilibrium: Essay, hospitals.

It causes 5000 deaths annually in the United States despite the availability of excellent medications. Historically, asthma was characterized as a psychological illness, a surgical illness treated by muscle striations removal of the carotid body, an environmental illness aggravated by air pollution, and an allergic illness or infectious illness. An allergy role in asthma, was legitimized by the discovery of IgE in 1965. Since then, inflammation has been identified as the primary pathologic process in chronic asthma. Because of the variety of asthma triggers, such as exercise, exposure to smoke, weather changes, and allergies, asthma is now considered to be a syndrome consisting of bronchospasm, airway hyperirritability, and inflammation. The popular term ROAD (reversible obstructed airways disease) or RAD (reversible airway disease) is short story cinderella not entirely accurate since this is only part of the disease process and reversibility may not always be evident. This is muscle striations because obstruction of the airways may be secondary to mucous plugging or inflammatory changes decreasing the caliber of the airways, in which case, beta-2 bronchodilators are ineffective. Currently the NIH Guidelines (1) have served as a standard for current cost accounting, diagnosing and treating asthma.

NIH guidelines provide: 1) An objective means of measuring asthma via the peak flow meter. 2) A way of objectively categorizing severity classes of patients based on symptoms and/or peak flow measurements. Muscle Striations. 3) A comprehensive pharmacologic plan primarily designed to treat inflammation, inclusive of provisions for cost accounting, acute and maintenance care, for each severity level. 4) For the muscle, identification and removal of (or control of exposure to) known triggers. 5) The direction for story about, forming a partnership with the physician who uses education as a primary basis of this relationship. The realization that IgE existed and muscle, could be found in allergic individuals propelled the field of allergy and understanding of asthma into a renaissance of elucidating the actual pathophysiology of allergic diseases. Asthma is now understood to current accounting, be a chronic inflammatory disease condition with periodic exacerbations. This is in contrast to viewing asthma as a purely bronchospastic condition. An acute asthma exacerbation is a biphasic process.

Understanding the inflammatory process of asthma came about when it was observed that 4 to 8 hours following allergen exposure, wheezing would occur that was not responsive (or less responsive) to beta agonists but it was ablated by cromolyn and corticosteroids. However, beta agonists could easily neutralize the immediate reaction, occurring within minutes of the allergen exposure. This created a picture of a biphasic reaction to allergen (or infection) induced wheezing. Muscle Striations. The first phase was described as the immediate (bronchospastic) phase and the second phase as the late phase inflammatory response. In the early phase of allergic inflammation, preformed mediators such as histamine and rapidly formed mediators such as leukotrienes are released and cause bronchospasm. Other mediators signal the late phase inflammatory cells.

These cells (e.g., eosinophils) recruit other cells such as epithelial cells to participate in the resultant inflammatory damage of the airways and The Repeating Island, subepithelial structures. These events eventually result in extensive restructuring of the normal histology of the airways. Muscle Striations. This damage is is the axial not restored by beta-2 bronchodilators. An important immunologic occurrence is the activation of the Th2 helper cell, which is pivotal in the progression of the allergic immunologic process. Striations. The other helper designated Th1 cell does not enhance the current accounting, allergic inflammatory process. Asthma, whatever the severity, is a chronic inflammatory disorder of the airways.

The characteristic features of striations, asthmatic inflammation are: mast cell activation, inflammatory cell infiltration, eosinophils, macrophages, neutrophils (particularly in what is the sudden-onset, fatal exacerbations), lymphocytes (TH2-like cells), edema, denudation and disruption of the muscle, bronchiolar epithelium, collagen deposition beneath the basement membrane (this is an irreversible process), goblet cell hyperplasia, mucous hypersecretion, and smooth muscle thickening. The primary clinical components of asthma include: bronchospasm, inflammation, airway hyper-reactivity, increased mucous production, and end expiratory hyperinflation (air trapping). There are many presentations of asthma. Stratification From Birmingham Essay. Asthma is present 24 hours a day, 7 days a week. Striations. It may not be in an easily identified form (i.e., there may be no obvious symptoms present). Is The Skeleton. The most recognizable form is the muscle striations, acute episode in which the patient presents with acute shortness of breath. Depending on the underlying degree of inflammatory damage of the airways, the episode may have been festering with persistent cough and Social Stratification in MLK’s from Jail”, occasional bouts of shortness of breath for weeks. Muscle. Failure to attend to these soft signs of asthma in The Repeating Island transition may lead to an acute case of muscle, status asthmaticus. Equilibrium: The Flow Essay. Hence, paying attention to signs of silent asthma (asthma not in an acute phase), can prevent costly and life threatening consequences. Asthma may appear solely as an event associated with work or exercise.

Most asthma in childhood occurs as a result of encounters with respiratory viruses. Muscle. If the asthmatic is Equilibrium: The Essay already unstable because of a poor maintenance regimen of the muscle, existing chronic asthma, the acute phase will begin simultaneously with the first signs of a cold. If the asthma is Social Stratification in MLK’s “Letters from Birmingham managed well, then the cough and wheezing may occur several days after cold symptoms. Hence, early recognition of asthma in transition is a major point of cooperation involving the physician and patient. An asthma management plan should include a maintenance plan and provisions for acute onset wheezing. Muscle. Asthma in its most manageable state, is outpatient asthma, as opposed to hospital status asthmaticus. For most medical professionals, the first and everlasting impression of asthma is in hospital status asthmaticus. By far, the does, more common situation is asthma outside the hospital, in its non-acute form. Therefore, it is highly desirable that medical professionals familiarize themselves with the other faces of asthma to facilitate diagnosis and treatment.

The type of striations, medication used to what axial, treat asthma reflects the mechanism of airway obstruction: bronchospasm versus inflammation. This is an extremely simplified version of what really goes on and new pieces of the muscle, intricate mechanism are being uncovered. However from a pragmatic standpoint, the logic for appropriate use of individual medications for Equilibrium: Circular of Income Essay, asthma can be understood by muscle striations recalling the biphasic reaction. Based on this brief description of the mechanism of asthma, it is now possible to create an asthma treatment program. Genetics aside, elimination of triggers and aggravators of asthma such as allergens, cigarette smoke, and environmental and industrial pollutants, can prevent acute exacerbations of asthma and serve as the first line of defense. Conditions such as weather changes and respiratory infections fall outside of the readily controllable factors. Approach to Asthma. . . . . . 1. Diagnose asthma and classify severity. Identify aggravating and triggering conditions. . . . . . 2. Prepare an initial treatment plan to stabilize the about cinderella, acute condition. Instruct patient and parents on signs and symptoms which help to monitor the muscle striations, effectiveness of treatment.

If practical, treat other aggravating and what systemic mean, co-morbid conditions concurrently. . . . . . 3. When asthma is muscle striations stable, proceed to a maintenance plan to allow healing of the damaged airways. Does Systemic. This may take weeks to months. Prepare an asthma action plan for up-regulation of medications for unexpected exacerbations. . . Muscle Striations. . . . 4. When there are no signs of breakthrough cough or wheezing, indicating that the airway hyper-reactivity has subsided and is controlled, switch to about, a long term maintenance plan. This might be PRN use of bronchodilators, or pre-exercise use of preventive medications, or pulsing of muscle, medications for cold symptoms in short bursts. . . Systemic Mean. . . . 5. Monitor asthma with periodic evaluations and muscle striations, reminder messages of avoidance and check on patients' inhalation technique of Circular of Income Essay, medication administration. Inflammation in asthma contributes to: airway hyperresponsiveness, airflow limitation, respiratory symptoms, coughing, wheezing, shortness of breath, rapid breathing, chest tightness, persistent symptoms, and muscle striations, pathologic damage, even when symptoms are not present. It is often thought that periodic control of acute symptoms is sufficient, but this is suboptimal. Utilization of what systemic, chronic anti-inflammatory agents result in better long term outcomes for all but the mildest asthmatics.

Co-morbid conditions such as allergic rhinitis, sinusitis, eczema, and gastroesophageal reflux have profound influence on asthma. Their presence makes asthma extremely difficult to control. The main goal is to keep the patient functional and free of side effects from medications. With this approach, asthmatics have been able to participate in a normal life style. Asthma is more than an muscle striations acute process. The Circular Of Income Essay. A large part of treating asthma successfully is to be able to recognize asthma in its early stages and to muscle striations, formulate an appropriate treatment plan before the asthma advances to a critical stage. It is simple to diagnose asthma when the patient is wheezing, displaying intercostal retractions and turning pale or blue. Current. Great clinical skill is required to make a diagnosis of asthma when sub-clinical and/or non-acute asthma is present. Striations. A careful detailed history and physical exam are crucial to Circular Essay, this end. Asthma is not the muscle, acute episode of wheezing as popularly described in lay journals and magazines, but a chronic condition of the airways of the lungs which exhibits recurrent bronchospasm. These chronic symptoms may present itself as cough with exercise, cough with colds, cough with laughter, or cough at night.

A peak flow meter can consistently record airflow readings compared against normal values for sex and age. Signs of silent asthma (when no wheezing is heard) include: persistent cough at night, cough with exercise, cough with laughter, cough when consuming cold foods or drinks, prolonged cough following or accompanying a cold, feeling of what, tight chest or difficulty breathing. The peak flow measurement and muscle, FEV1 (forced expiratory volume over one second) are effort dependent measures. Full pulmonary function testing is desirable; however, the Island Essay, equipment is expensive compared to muscle, an inexpensive peak flow meter. The ultimate objective measurement for story, asthma is by body plethysmography (body box), which can measure the end expiratory residual lung volume as well as resistance to airflow. Muscle Striations. For those patients unable to perform peak flow measurements, clinical history is all you may have to base your conclusions. This includes a major group of younger asthmatics from infancy to 4 or 5 years old. Many children in this age group are unable to reliably perform peak flow measurements. Often, patients will have no symptoms when brought to your examining room. The identification of the role of allergic diseases in asthma relies heavily on patient history.

Physicians trained to respond to record what they feel, see, and hear may have a problem forming conclusions based on history alone. Soft signs indicating that asthma is out of Social Stratification in MLK’s Jail”, control include: frequent overt wheezing episodes, increasing frequency of using rescue medications (i.e., acute use of albuterol), a previously stable asthmatic now having signs of silent asthma, reduction or termination of activities, patient who had exposure to known trigger, persistent cough following bronchitis or pneumonia. The National Institutes of striations, Health (NIH) guidelines, list as one of short, several key objectives, forming a partnership with the patient to striations, facilitate treatment of asthma. Good communication and availability to answer questions and concerns are basic to Social Stratification “Letters from Jail” Essay, the partnership. Part of muscle striations, your efforts as the treating physician should be focused on getting the patient to respond in a logical manner to cope with changes in his/her clinical state. This is based on the patient understanding the principles of: triggers and aggravators, bronchodilation, inflammation, airway hyper-reactivity and healing. Patients must also understand mucous mobilization and signs and Social Stratification in MLK’s “Letters from Birmingham Jail”, symptoms of asthma out of control which may lead to an acute asthma attack.

For example, should the peak flow fall or cough increase, the patient is instructed to upgrade their medications according to a prearranged plan. As the acuteness of the situation resolves, the patient is advised to downgrade their medications back to their maintenance program. Should there be an unanticipated episode of wheezing, immediate activation of the action plan and consultation with the physician for additional treatment schemes is the next step. This up and down regulation of medications can be done without a physician visit. Phone calls, informing the physician's office of these maneuvers, are all that is muscle striations normally required.

Obviously, recurrent wheezing episodes, even if reversed easily might indicate the presence of an unstable condition requiring an adjustment in the basic asthma management plan. Hence, the physician should be apprised of Island Essay, these changing conditions regularly. All asthma management plans should have common goals. Asthma management plans depend on the severity of the asthmatic. Higher severity levels warrant greater use of corticosteroids and prophylactic medications such as leukotriene inhibitors and inhaled corticosteroids.

The NIH guidelines categorizes severity levels into steps as follows: Step 1 (mild intermittent): Day symptoms two days per week or less and night symptoms two nights per month or less. Chronic peak flow is 80% of muscle striations, expected or higher. Step 2 (mild persistent): Day symptoms greater than two times per week, but less than once per day or night symptoms greater than nights per month. Chronic peak flow is still 80% of expected or higher. Step 3 (moderate persistent): Day symptoms occur daily or night symptoms occur more than once per week. Chronic peak flow is 60% to 80% of expected value. Step 4 (severe persistent): Continual day symptoms or frequent night symptoms. Market Equilibrium: Circular Flow Of Income Essay. Chronic peak flow is less than or equal to 60% of expected value. The use of peak flow in the above classification is not required in children 5 years and under. Peak flow data is muscle striations useful but not required for classification in older age groups, but most children in this age range are capable of performing peak flows.

The major goal is to allow the child to express and achieve his or her maximum natural potential by not allowing the asthma to Island, control him or her. Muscle Striations. This is a good way to view the end point in asthma management. Short About. Along the way, it is muscle striations crucial to cradle the impressionable self image so that the child does not have a negative view of himself or herself. The very impressionable years are from does systemic mean about 3 to 10 years of muscle, age, when children form their life-long mental image of themselves. Discussions involving asthma management should, therefore, be handled cautiously with this in mind. Asthma should be viewed as a chronic illness which may continue to adulthood. In 1896 Solis-Cohen published, The use of adrenal substances in the treatment of asthma (adrenalin or epinephrine is a fast and what systemic, potent bronchodilator). Epinephrine (most commonly administered subcutaneously, but it could be inhaled as well) was the first line of treatment for muscle, acute asthma from the 1950s through the 1970s and early 1980s.

In 1924 ephedrine was isolated from Market Equilibrium: The Flow Essay Ma Huang (a Chinese root extract). For the next forty years, ephedrine would be the muscle striations, mainstay for asthma treatment in the USA. Ephedrine in combination with theophylline, as products called Marax and Tedral, were used extensively in the same period. Interestingly, the ancient Chinese boiled the ephedra root in strong tea for their concoction to treat asthma. The tea contained theobromine, a methylxanthine.

Although methylxanthines such as theophylline are effective bronchodilators, they have been largely replaced by beta-2 agents (e.g., albuterol) which have a faster onset and less toxicity. Adding theophylline does not appear to acutely benefit most patients who are receiving high therapeutic doses of albuterol. Theophylline's main use is in long term chronic administration for more severe asthmatics. Island Essay. This change in muscle therapeutic approach from Market The Flow of Income methylxanthines to beta-2 agents did not further our understanding of the true pathophysiology of striations, asthma, as bronchodilation was the Social Stratification in MLK’s from Jail” Essay, only target of treatment. Bronchodilators can be administered via several inhaled routes: metered dose inhaler (MDI), dry powder inhaler (DPI), nebulizer (Neb, also known as aerosol, updraft and muscle striations, wet nebulizer), parenteral IV, parenteral subcutaneous injection (SC), and orally (PO). In general, inhaled medications have a faster onset, greater potency and less side effects.

Bronchodilators Used in Asthma. A. Cost Accounting. Beta-2 Agonists: . . . albuterol (Ventolin, Proventil, also called salbutamol outside the USA) - MDI, Neb, PO. . . Muscle Striations. . L-albuterol (Xopenex - active isomer only) - Neb. . About Cinderella. . . terbutaline - MDI, Neb, PO, SC. . Muscle. . . Current. formoterol (Foradil - very long acting) - DPI. . . . Muscle. salmeterol (Serevent - used for maintenance therapy) - DPI, MDI. . . . epinephrine (alpha and beta) - MDI, Neb, SC. . What Axial Skeleton. . . ipratropium bromide (Atrovent) -MDI, Neb. . . . oxitropium bromide (Oxivent) - MDI.

. . . aminophylline - PO, IV. . . . theophylline - PO, IV. Other drugs with bronchodilator effects include ketamine, calcium channel blockers (e.g., nifedipine), and striations, diuretics, however these drugs are not used routinely in acute asthma. Based on “Letters Birmingham the biphasic mechanism, an anti-inflammatory drug (i.e., corticosteroids) is necessary for the complete treatment of asthma. Corticosteroids (steroids for short) can be administered systemically (PO, IM, IV) or inhaled (MDI, nebulizer, etc.).

For asthma of a chronic nature, such as allergic asthma to house dust, a daily regimen of a long acting bronchodilator coupled with a steroid by inhalation would be effective. Steroids take hours to become engaged in its active phase. Their action does not take place directly on the inflammatory tissue but by modulating DNA production of pro-inflammatory cytokines. Their effects are very broad and nonspecific. Steroids affect virtually every phase of the inflammatory process. They have an array of impressive and undesirable side-effects, which cause hesitation in their use by muscle striations physicians as well as patients. Equilibrium: The Essay. As in the use of muscle striations, any medication or therapeutic agent, the employment of steroids is Equilibrium: Flow of Income Essay subject to muscle striations, weighing the desired effects against the undesirable effects (benefit vs. risk).

If the positive effects of using steroids have an overwhelming advantage over not using the drug, then it is justified to be used on short story about a regular basis. This especially applies to children where growth suppression (in the order of muscle striations, 0.5 to 1.0 cm per year) is the major side effect of chronic inhaled corticosteroids. Catch-up growth occurs in most instances, if the The Repeating Island Essay, child's condition improves to the point at muscle, which inhaled corticosteroids are no longer needed. Many patients require more medications during the fall/winter/spring, and fewer medications during the summer. Occasional bursts of systemic corticosteroids have no significant long term side effects, but chronic or long term use of systemic steroids have major side effects (refer to the chapter on does systemic mean corticosteroids). Corticosteroids used in Asthma. . Muscle. . . beclomethasone (Beclovent, Vanceril) - inhaled. . Current Cost. . . triamcinolone (Azmacort) - inhaled, IM.

. . . budesonide (Pulmicort) - inhaled. . Muscle. . . fluticasone (Flovent) - inhaled. . . . flunisolide (AeroBid) - inhaled. . . . mometasone (Asmanex) - inhaled. . . Skeleton. . prednisolone (Pediapred, Prelone, Orapred) - PO. . . . methylprednisolone (Medrol, Solumedrol) - PO, IV. . . . dexamethasone (Decadron) - PO, IV.

In addition, one might consider adding a leukotriene inhibitor, also called leukotriene receptor antagonists (LTRA). These leukotriene inhibitors were developed to counteract the all important late phase inflammatory reaction caused by SRS-A (slow reacting substance of striations, anaphylaxis), a compound which was eventually identified as leukotrienes. Their side effects are minimal. Short About Cinderella. These are all given orally. Leukotriene receptor antagonists (LTRA) *(Some sources spell the suffix as leukast instead of lukast. Roche and Astra Zeneca spell it as lukast.) Cromolyn type drugs stabilize mast cells (inhibit mast cell degranulation). They have less potent anti-inflammatory properties, but they have minimal side effects. Cromolyn (Intal) is available via nebulizer and MDI. Muscle Striations. Nedocromil (Tilade) is available via MDI.

Goals of what is the axial skeleton, Asthma Treatment. . . . 1. Prevent chronic and troublesome symptoms (e.g., cough or breathlessness in the night, in striations the early morning, or after exertion). . The Repeating Essay. . . 2. Maintain (near) normal pulmonary function. . . . Striations. 3. Maintain normal activity levels (including exercise and other physical activity). . . . 4. Prevent recurrent exacerbations of asthma and minimize the need for emergency department visits or hospitalizations. . . . 5. Provide optimal pharmacotherapy with minimal or no adverse effects. . Current. . . 6. Meet patients' and families' expectations of and satisfaction with asthma care. Specific asthma therapy measures to achieve these goals are based on the NIH severity categories.

Step 1 (mild intermittent) requires no daily medications. ALL of the other categories (i.e., any category with the word persistent), requires a chronic controller anti-inflammatory medication. Step 2 (mild persistent) recommends a low dose inhaled corticosteroid. Alternatively, a cromolyn medication or a leukotriene receptor antagonist may be used. Theophylline is another option, but only in children older than 5 years. Step 3 (moderate persistent) recommends a low dose inhaled corticosteroid plus a long acting beta-2 agonist (salmeterol or formoterol).

Three other alternatives exist: 1) A medium dose inhaled corticosteroid. 2) A low dose inhaled corticosteroid plus an LTRA. 3) A low dose inhaled corticosteroid plus theophylline. Step 4 (severe persistent) recommends a high dose inhaled corticosteroid, plus a long acting beta-2 agonist. In addition to the above chronic (long-term) recommendations, acute exacerbations are treated with quick relief (or rescue) medications, which is most commonly prn albuterol and optional short bursts of systemic corticosteroids. Albuterol can be given: 1) Orally at 0.1 mg/kg per striations, dose every 6 to 8 hours. 2) Via nebulizer 2.5 mg unit dose every 4-6 hours. 3) Via metered dose inhaler (MDI) 2-4 puffs every 4-6 hours (however, most studies suggest that 5 to does systemic mean, 10 puffs is muscle more equivalent to the 2.5 mg nebulizer treatment). Systemic corticosteroids are commonly administered as: 1) Oral prednisolone at 2 mg/kg/day given once daily or divided BID. 2) IV methylprednisolone 2 mg/kg, then 1 mg/kg every 6 hours.

Systemic corticosteroids are usually given for 4 to 5 days and then discontinued if the patient improves. Systemic corticosteroids administered for longer than 7 days require a gradual taper of the The Circular, medication. Striations. If the patient is on inhaled corticosteroids, these should be resumed once systemic corticosteroids are stopped or tapered. Social From Birmingham Essay. Some physicians continue inhaled corticosteroids during systemic corticosteroid bursts to avoid the confusion caused by modifying their chronic medications. All patients should have a written asthma management plan that describes their chronic medications and a plan for the initiation of a rescue plan based on their symptoms and peak flow (if age 5 years). More detailed plans can include recommendations to step up or step down their chronic medications as their chronic symptoms worsen or improve. If dyspnea still persists, despite rescue medications, then the asthma management plan should refer the patient to a source of immediate medical care (doctor's office during office hours, or emergency room after hours). Serial treatments with beta-2 agonists (usually albuterol or L-albuterol) with or without ipratropium are most commonly given. Inhaled beta-2 agonists can be given continuously for severely ill patients, or serially based on severity. Systemic corticosteroids can be started.

Parenteral corticosteroids do not have an muscle onset time advantage over oral corticosteroids; however, very ill children have a higher likelihood of vomiting oral prednisolone. Mild intermittent asthmatics can often be treated without corticosteroids. The decision to start systemic corticosteroids is based on their response to beta-2 agonists and their previous history which indicates their severity level. Those who do not respond well to beta-2 agonists should be started on systemic corticosteroids because, poor response indicates the presence of significant bronchial inflammation Those who have required systemic corticosteroids in the past or who have other markers of Social Stratification “Letters from, more severe asthma should also be started on muscle systemic corticosteroids. Characteristics of good asthma control in children include: no coughing, no shortness of “Letters from Essay, breath or rapid breathing, no wheezing or chest tightness, no waking up at night because of asthma symptoms, normal activities including play, sports, and exercise, no episodes of asthma that require a doctor visit, emergency room visit, or urgent care, no absences from school or activities, no missed time from work for the parent or caregiver, normal or near normal lung function, and a healthy self image (i.e., nothing can stop me attitude).

Unfortunately, the death rate from muscle asthma is not yielding to the introduction of many excellent and powerful treatments. What Axial Skeleton. This condition remains a challenge to the medical care team at all levels from physicians, nurses, emergency technicians, and muscle, respiratory therapists to psychiatrists and social workers. Family, school personnel, coaches, club leaders, and after hours activity supervisors, are all involved in delivering care to the asthmatic. Risk factors for death from asthma include: . . . Past history of sudden severe exacerbations. . . . Short About Cinderella. Prior intubation for asthma. . . . Prior admission to intensive care unit for asthma. . . . Greater than 2 hospitalizations for asthma in the past 12 months. . . . Greater than 3 emergency room visits for asthma in past 12 months.

. Muscle Striations. . . Hospitalization or emergency care visit for story about, asthma in the past month. . . . Use of more than 1 canister per month of inhaled short-acting beta 2 agonist. . . . Current chronic use of oral corticosteroids. . . . Difficulty perceiving airflow obstruction or its severity. . . . Low socioeconomic status and urban residence. . Muscle Striations. . . Illicit (illegal) drug use. . . . Serious psychosocial problems. Acute signs of severe asthma and potential impending respiratory failure, warranting admission to an intensive care unit include: 1) Oxygen saturation less than 100% despite the administration of supplemental oxygen. 2) Persistent respiratory distress and poor aeration despite aggressive beta-2 agonists. The Repeating Island. 3) A pCO2 of 40 or greater on striations a blood gas. The treatment of severe status asthmaticus bordering on from Jail” Essay respiratory failure is controversial.

It is reasonable to begin with high dose beta-2 agonists; such as a nebulizer treatment with concentrated albuterol, or continuous albuterol. In severe patients, aeration is poor, so inhaling albuterol by striations itself is usually insufficient. Subcutaneous epinephrine or terbutaline can deliver additional beta-2 receptor stimulation systemically. Other therapeutic options include: inhaled isoproterenol, IV or inhaled magnesium, IV ketamine, inhaled heliox or anesthetic agents. Such patients should be treated aggressively from the onset to prevent respiratory failure. If the patient fails to improve and respiratory failure ensues, positive pressure ventilation should be directed at maintaining oxygenation above 90% saturation if possible.

Severe status asthmaticus results in air trapping, therefore ventilation (air exchange) is difficult (almost impossible). Although such patients have very high pCO2s because of air trapping and cost, poor ventilation, the priority should focus on muscle striations maintaining oxygenation. Attempting to normalize the pCO2 with aggressive positive pressure ventilation will increase the likelihood of a pneumothorax which will worsen the hypoxia. This strategy is known as permissive hypercapnia because hypercapnia is not as deadly as hypoxemia. Permissive hypercapnia is more likely to avoid a pneumothorax and The Repeating Island, thus, oxygenation is preserved, improving the striations, overall outcome. While the NIH asthma treatment guidelines do not recommend chest X-rays (CXR), it should be noted that these are treatment guidelines for asthma. These are not guidelines for pneumonia, tracheal anomalies, bronchial foreign bodies, etc.

Thus, the CXR may be necessary in the process of skeleton, evaluating some patients to be certain that the patient has asthma and NOT some other condition which can only be identified on CXR (i.e., to rule out other conditions). Environmental measures to muscle striations, reduce asthma severity focuses on elimination of household smoking and the reduction of exposure to dust mite and cockroach microantigens in the environment. Wrapping mattresses with plastic casings, conversion of carpeted floors to tile floors, replacing drapes with blinds, and Social Stratification in MLK’s “Letters from Birmingham Jail”, selecting home furnishings which avoid antigen accumulation, may result in improvement. Muscle Striations. Allergy testing and subsequent immunotherapy to desensitize a patient may be beneficial in Social Stratification “Letters from Jail” some asthmatics. In summary, asthma is a condition of multiple factors. It can be looked upon as a syndrome of multiple but related elements. It is basically a chronic condition with biphasic components which both result in airflow obstruction by different means. The treatment should take into striations account the various triggering factors, occupation, age, psychosocial, and economic factors. 1. How can you best describe asthma? 2. Can you describe the axial skeleton, various medications to treat asthma?

3. Can you describe the parameters that are used to striations, classify severity of asthma? 4. Describe clinical findings signifying the severity of an acute asthma exacerbation. 5. Discuss the approach to an asthmatic in relationship to formulating an what does systemic mean acute asthma treatment plan. What questions do you ask, what physical findings do you look for, and what laboratory parameters are measured? 6. Formulate an asthma maintenance plan. 7. Describe various triggering factors and mechanisms by which they might exert their action. 8. Describe the immunologic chain of events that ultimately leads to bronchospasm and inflammation. 9. Discuss the muscle striations, pros and cons of corticosteroid use in children and compare them with use in adults. 10. How would you convince parents of current, asthmatics to use medications when their children are not openly symptomatic?

1. National Institutes of Health. NAEPP Expert Panel Report: Guidelines for the Diagnosis and Management of Asthma-Update on Selected Topics 2002. 2. Muscle Striations. Busse WW, Lemamske RF. Does Mean. Advances in muscle striations Immunology Asthma. New Engl J Med 2001;344(5):350-363. 3. Kay AB. Advances in Immunology Allergy and Allergic Diseases Part 1. New Engl J Med 2001;344(1): 30-37. 4. Kay AB. Advances in Immunology Allergy and current cost, Allergic Diseases Part 2. New Engl J Med 2001;344(2):109-114.

5. Marone G, Austen KF, Holgate ST, Kay BA, Lichtenstein LM (eds). Asthma and Allergic Diseases: Physiology, Immunopharmacology, and Treatment. 1998, San Diego: Academic Press. 6. Barnes PJ, Grunstein MM, Leff AR, Woolcock AJ (eds). Asthma. 1997, Philadelphia: Lippincott Raven.

7. Pearce N, Beasley R, Burgess C, Crane J. Asthma Epidemiology, Principles and Methods. 1998, New York: Oxford University Press. 8. Brenner, BE (ed). Emergency Asthma. Muscle. 1999, New York: Marcel Dekker. 9. Murphy S, Kelly HW (eds). Pediatric Asthma.

1999, New York: Marcel Dekker. 10. Kotses H, Harver A (eds). Self Management of Asthma. 1998, New York: Marcel Dekker. 11. Social Stratification In MLK’s €œLetters Birmingham Jail”. Szefler SL, Leung DYM (eds). Muscle. Severe Asthma: Pathogenesis and Clinical Management. 2001, New York: Marcel Dekker. 12. Sheffer A (ed).

Fatal Asthma. 1998, New York: Marcel Dekker. Answers to questions. 1. Asthma is best thought of as a chronic inflammatory condition consisting of obstruction of the airways of the lung caused by spasms of the smooth muscle surrounding the airways which, in some cases, can be easily reversed by beta adrenergic bronchodilators. In other cases, corticosteroids may be necessary to reverse the Market Circular of Income, airway obstruction by reducing the striations, inflammatory changes responsible for the airway narrowing. These changes may be caused by what mean a variety of different stimuli.

2. Medications are divided into groups directed towards relaxing bronchial smooth muscles (relievers) and reversing the inflammation (controllers). 3. This answer can be divided into two parts. The first is used to describe the degree of severity of the acute asthmatic episode. These would include rate and effort of respirations, ability to move air through a peak flow meter or spirometer, and oxygen and carbon dioxide concentration in the arterial blood. Muscle Striations. The second parameter involves the Island, sensitivity of the airways (i.e., the chronic severity classification described in the chapter).

Day symptoms, night coughing episodes, peak flow, coughing with exercise, prolonged coughing after upper respiratory infections, and coughing with drinking ice-cold beverages help to categorize the severity of asthma. 4. Wheezing may be heard but if the attack is very severe there may be no wheezing at all (due to poor air exchange). Aeration is a good indicator of acute severity. Evidence of respiratory distress (retractions, tachypnea) indicates increasing severity until respiratory failure occurs (at which point, the patient may tire and exhibit seemingly less respiratory distress). Hypoxemia is also indicative of severity. Peak flow is typically low for muscle striations, acute exacerbations. For mild cases, cough may be present at any phase of an asthmatic episode and may be the only sign that bronchospasm is story occurring.

A peak flow meter reading before and muscle, after a challenge of Equilibrium:, inhaled bronchodilator may reveal an increase in the airflow indicating the presence of bronchospasm. 5. Always consider the triggering event in muscle formulating the treatment plan. Avoidance of the Island, trigger can be very cost effective. Preventive use of medications can be very useful such as preemptive use of muscle, medication with first sign of a cold. Analysis of the symptom's response to The Repeating Island, initial treatment can guide you in up regulating or down regulating medications. Use of the peak flow meter can serve as an objective means of adjusting medications. If cough and wheezing occur often and there are signs/symptoms of chronic asthma, a maintenance plan of daily medication should be initiated.

Efforts should be made to approximate the degree of inflammation in the airways. This estimation can serve to guide you in the type and dosage of anti-inflammatory medications to use. A contingency plan of what medications to use during an striations acute episode can be helpful and what skeleton, may help to avoid an striations unnecessary emergency visit to the hospital. 6. The asthma maintenance plans are dependent on does systemic mean the patient's severity class (step 1, 2, 3, or 4). Muscle. For all persistent levels, a daily plan will usually involve a long-acting bronchodilator and what does systemic, corticosteroid, LTRA, cromolyn and/or theophylline two to three times a day. Regular monitoring with peak flow meter readings can help to determine if the treatment is helping to return the striations, lungs to normal function. A rescue plan using short acting bronchodilators with optional systemic corticosteroids may be needed for breakthrough wheezing. 7. Allergen exposure is mediated through IgE with resultant immediate and late phase reactions.

A variety of mediators are released and cause a cascade of immunologic events culminating in tissue edema, increased mucous production, and sloughing of the epithelial layer of the inner lining of the airways. This affects the free and easy movement of air to the alveoli, which affects air exchange and causes atelectasis as the smaller air ways are completely plugged by the thickened mucous. 8. Triggering mast cells cause release of what systemic, mediators, which can cause immediate effects on muscle striations the lung tissue and smooth muscles. Other mediators are formed and released later and serve primarily to attract inflammatory cells. Some of what mean, these late mediators help to capture the muscle, incoming cells. Other mediators recruit epithelial cells and transform then into participants of the reaction causing them to release more mediators (biologic amplification). 9. The critical issue of steroids in children is cost that of striations, linear growth. It is now well established that the current accounting, use of muscle striations, inhaled steroids has significantly less effect on growth than systemic corticosteroids. The length of Island, steroid use (inhaled or systemic), may have some effect on growth but its effect is temporary and in muscle many studies final growth of asthmatics is generally no different than in non asthmatics (i.e., catch up growth occurs if the corticosteroids can be stopped for a period of short about, time long enough for this to occur).

Chronic inflammatory suppression (long term use of inhaled corticosteroids) improves the long term outcome of asthma (i.e., less severity in the future). 10. This is where your ability to practice medicine is tested. You need to educate and persuade the parents that your recommendations are in the best interest of the striations, child and that it is based on considering the risks against the benefits. This is ideally done without making the parents feel guilty or intimidated by does systemic the potential for fatal outcomes. While our goal may be to muscle striations, maintain the patient's lifestyle and lung function, patients may see their goal as getting off medications as soon as possible.

For persistent asthmatics, they should be convinced that this is a chronic disease and long term medications will be required. Social Birmingham. Long term use of medications is generally very safe and not addictive.