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Malegra FXT Plus

By I. Asam. Alcorn State University.

Several studies have shown that consistent profes- sional maintenance and the standard of the patients’ home care are key factors for long term stability of dental implants and the prevention of biological complications (Bauman et al buy discount malegra fxt plus 160mg online. In a longitudinal multicenter study purchase malegra fxt plus 160 mg fast delivery, failing implants were associated with higher plaque 4 bioflm levels than successful implants (van Steenberghe et al cheap malegra fxt plus 160mg with visa. More bone loss was observed around implants supporting fxed bridges in edentulous patients with poor oral hygiene than in those with better oral hygiene (Lindquist et al purchase malegra fxt plus 160mg line. In the consensus meeting of the Sixth Eu- 7 ropean Workshop on Periodontology regarding peri-implant diseases it was concluded that insuffcient oral hygiene is an important risk factor for developing peri-implant infections (Heitz-Mayfeld, 2008). The me- 9 chanical plaque control may involve the use of manual or power toothbrushes as well as proximal cleaning dental devices (Eskow & Smith 1999). The purpose of this study was to re- view and evaluate the literature, in a systematic way, with respect to various self-performed mechanical, oral hygiene modalities around implant-supported dental restorations in rela- tion to peri-implant soft tissue health. The 5 search strategy was customized according to the requirements of each database (for details on the search terms used see Box 1). The titles and abstracts were frst screened in- 7 dependently by two reviewers (D. When the abstract was not clear or no abstract was available but the title seemed to be relevant, the paper 8 was selected for full-text reading. The papers that fulflled all of the selection criteria were processed for data extraction. All reference lists of the selected studies were hand searched by two reviewers (A. S) for additional published work that could possibly meet the eligibility criteria of the study. This as- sessment was performed according to the method that has been described in detail by Keu- 5 kenmester et al. In short, when random allocation, defned eligibility criteria, blind- ing of examiners, blinding of patients, balanced experimental groups, identical treatment 6 between groups (except for the intervention), reporting of loss of follow-up and the subject as unit of statistical analysis were present, the study was classifed as having a low risk of bias. When one of these criteria was missing, the study was considered to have a moderate 7 risk of bias. When two or more of these criteria were missing, the study was considered to have a high risk of bias, as proposed by van der Weijden et al. After a preliminary evaluation of the selected papers, it was found that considerable heterogeneity was present in the study designs, characteristics, outcome variables and results. It was, therefore, not possible to perform a quantitative analysis of the data and subsequent meta-analysis; ac- cordingly a descriptive analysis of the data was performed. W) rated the quality of the evidence as well as the strength of the recommen- dations according to the following aspects: risk of bias of the individual studies, consistency and precision among the study outcomes, directness of the study results and detection of publication bias. Any disagreement between the two reviewers was resolved after additional discussion. The initial screening of the titles and abstracts resulted in seven full-text papers that met the inclusion criteria. After read- ing the full-text articles, two papers were excluded, one because it was a survey (Orelud et 3 al. Additional hand-searching of the reference lists from the selected 4 studies did not yield any additional papers. The table includes a 6 short summary of the study design, information regarding the participants (number, age, smoking habits, number of implants and type of implant-supported restoration) and the 7 authors’ conclusions. Information regarding the changes within each group for the various outcome parameters is presented in Table 2. Papillary bleeding index, recession and probing pocket depth were measured at baseline and at 3, 6, and 12 months. An improvement on both bleeding score and clinical attachment level was reported over time (Table 2). Similar results were also reported in another prospective cohort study by Vandekerck- hove et al. This study assessed the effcacy of an oscillating/rotating pow- ered toothbrush in patients rehabilitated with fxed prostheses on implants. Sulcus bleeding index, probing pocket depth, periodontal pocket bleeding index and gingival recession was measured at baseline and at 3, 6, and 12 months and showed that all parameters improved …implant supported restorations: a systematic review 177 1 over the course of the study (Table 2). Changes of similar magnitude were observed over time on these parameters irrespective of the presence or absence of keratinized mucosa around the implants. Modifed plaque and bleeding indexes were recorded at the start and end of the experimental period. The results of this study revealed comparable effcacy of the 2 types 4 of toothbrushes with regard to mean plaque and bleeding scores (Table 2). The powered toothbrush was found to be superior to the conventional toothbrush in combination with interdental aids in reducing plaque and bleeding scores and 7 probing pocket depth over a 2-year period (Table 3). Similar results were also reported in a 6-month single-blinded, randomized, parallel 8 study by Wolff et al. The sonic toothbrush was found to reduce plaque and bleeding signifcantly better than the 9 manual toothbrush over time. Moreover, the sonic toothbrush was found to be more effec- tive than the manual toothbrush in reducing probing depths and gingival infammation over time, although differences in these parameters did not reach statistical signifcance (Table 2). However, the difference between the two groups at the end of the study was not signifcant for all parameters evaluated (Table 3). Quality assessment and grading the ‘body of evidence’ The quality assessment of the various studies is presented in Table 4. The available data for the powered toothbrush were rather consistent and rather precise. How- 5 ever, it is diffcult to decide whether the results of the included studies can be generalized to other populations. Powered toothbrushes were found to result in an improve- ment in clinical parameters over time. Results obtained in edentulous subjects do not necessarily refect the situation in partially-dentate subjects. Edentulism, subjects’ age and brushing dexterity may have in- fuenced the results. It is also known that study duration affects outcomes when manual and powered toothbrushes are compared (Aass & Gjermo 2000). Hence, the short-term (6-week) design that was employed in study I may be less likely to demonstrate signifcant differ- ences. An advantage of a cross-over design is that each participant acts as his or her own control, eliminating between-participant variation. However, statistically, cross-over trials are not …implant supported restorations: a systematic review 179 1 appropriate due to the likelihood of a carry-over effect. Cross-over studies using therapeutic agents are at risk of showing a period effect that is greater than the effect of interest. A wash- out period of two weeks may not be suffcient and longer wash-out periods are preferable 2 (Senn, 2002).

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Protection against the selected strain of as pneumonia purchase malegra fxt plus 160 mg otc, particularly in children trusted 160mg malegra fxt plus, the elderly influenza lasts about one year order malegra fxt plus 160mg with amex. Pneumonia may be primary viral pneumonia or secondary bacterial For general infection control measures to prevent pneumonia order 160mg malegra fxt plus fast delivery. Diagnosis Viral culture of naso-pharyngeal aspirate or throat swab sent to the laboratory in viral transport medium. Page 138 Module 5 Pertussis Nursing care Definition See Appendix 2, but specifically: Pertussis (whooping cough) is a highly infectious • Administer antibiotics if secondary bacterial acute bacterial disease involving the respiratory tract. The causative bacteria is Bordetella pertussis in more than 90% of cases or more rarely Bordatella Rehabilitation parapertussis. Depends on course of illness Mode of transmission Role of primary health care team Pertussis is transmitted by airborne contact with Ensure the uptake of vaccine where appropriate respiratory secretions of infected persons. Role of hospital/community setting • Communicability: from one week before to three Management and treatment of the patient as per weeks after the onset of paroxysmal coughing. Appendices 2, 3 and 4 Epidemiological summary Prevention of cross-infection as per Appendix 1 There are approximately 20–40 million cases of pertussis worldwide each year, 90% of them in Health education and health promotion developing countries; there are an estimated As for diphtheria 200 000–300 000 deaths each year. Manifestations Catarrhal stage • Fever and dry cough becoming worse at night • Vomiting with the cough • Infants often have a runny nose and sneezing • A particularly infectious stage of the illness Spasmodic stage (or paroxysmal stage) • Violent cough • The rapid expulsion of air followed by gasping Page 139 for breath through a narrowed glottis results in the characteristic high pitched “whoop” which gives the condition its name. Complications • Pneumonia • Convulsions due to cerebral anoxia during coughing paroxsyms • Brain damage as a result of cerebral anoxia • Deafness • Blindness can result from haemorrhages into the naso-pharyngeal swab. Erythromycin (see Appendix 4) may eradicate the • Like measles, pertussis can “unmask” underlying bacteria thus shortening the period of infectivity tuberculosis. This may reduce the possibility of Age groups affected secondary infection (if started early enough). Pertussis may occur at any age but most cases of Antibiotics do not influence the course of the serious illness and death are observed in infants clinical disease unless given within the first 5 days and young children. Prognosis Prevention of spread Pertussis is one of the most lethal diseases in infants Immunization (see Module 2). General infection control measures to prevent The prognosis is worse for children who are spread: see Appendix 1. The Make a list of true and false contraindications prognosis is better for patients over one year of age to vaccination with pertussis. Erythromycin, if given in the early incubation period to close contacts under one year of age, may prevent the disease in selected individual cases. The Role of hospital/community setting difficulty in early diagnosis, the costs, and concerns • Management and treatment of the patient as per related to antibiotic resistance, limit the treatment Appendices 2, 3, and 4 of secondary cases. The virus is one of the paramyxovirus family, and Complications commonly affects bilateral as opposed to unilateral • Orchitis (inflammation of the testicles) which parotid salivary glands. The virus may spread in usually affects one side (up to 20% of symptomatic the bloodstream to involve other organ systems and cases in postpubertal males). Transmission is by airborne droplet spread from • Hepatitis, oophoritis, myocarditis, thyroiditis and the saliva of an infected patient, and by contact nerve deafness are rare but potential complications. As vaccine uptake increases, cases swelling has disappeared tend to occur in older children and unvaccinated adults. Epidemiological summary The virus is present throughout the world and at Prognosis least 50% of infections are asymptomatic. Cases Excellent, even with extensive organ system usually occur in winter and spring. The disease is not considered eradicable and Diagnosis has a low priority in terms of efforts to control it. Mumps virus can be grown in tissue culture the laboratory from Manifestations saliva, urine and cerebrospinal fluid. Acute serum Prodromal symptoms may present 1 or 2 days before can be sent to check for antibody formation. Prevention of spread The effects of mumps are limited by immunizing As the infection progresses there is: childhood populations, this is particularly • tenderness of the salivary glands for 1–3 days; important in terms of preventing more serious • swelling of the salivary glands for 7–10 days; illness in adults. The vaccine is usually given in • fever may be absent or as high as 40° C; combination with measles and rubella but may be Page 142 Module 5 a single vaccine. It is expected that as vaccine uptake increases cases will occur more predominantly in older children. Methods of screening and contact tracing Nil specific Nursing care See Appendix 2, but specifically: • Mouthwash and frequent mouthcare • Avoid highly flavoured acidic foods and drinks Role of primary health care team Vaccination and public health education Role of hospital/community setting • Management and treatment of the patient as detailed above • Prevention of cross-infection to others. The rash may suggest rash which is only of importance given the damage measles on the first day and scarlet fever on the it may cause to the foetus when a mother contracts second. During an Transmission is by airborne droplet spread from epidemic, febrile lymphadenopathy for a week or the nose and throat of an infected patient and from more without a rash may represent over 40% of direct contact with the patient or secretions. The risk of congenital affected by congenital rubella can continue to shed abnormality depends on the time of infection the virus in nose and throat secretions and in urine during pregnancy. The epidemic which occurred in Estonia in 1993 was brought under control following the Manifestations of congenital rubella introduction of rubella vaccination in 1993. There • Congenital defects of the heart, eyes, and ears was a reported increase in Lithuania in 1994. There may be slight malaise and tender lymph nodes behind the ears and over Age groups affected the occiput for 1–2 days. Older children or adults Anyone who has not had rubella infection or rubella may have arthralgia or polyarthritis affecting small vaccine. Prognosis Erythematous macules appear first on the face and The prognosis for patients with acquired infection spread rapidly over the trunk and extremities. Congenital Rubella Syndrome • Exclude a patient with rubella from school or work until 7 days after onset of rash • Avoid exposure of pregnant women Screening and contact tracing A rubella antibody test will establish immunity status in exposed women. Pregnant women who are not immune should not normally receive vaccine whilst pregnant but should be immunised following delivery. Inadvertant administration of vaccine in pregnancy congenitally acquired infection is poor. Nursing care Diagnosis Symptomatic Clinical diagnosis is unreliable and the infection can be asymptomatic. Acute rubella can only be Role of primary health care team confirmed with laboratory diagnosis of IgM Ensure uptake of vaccination and public health antibody. Either technique can be used for Role of hospital/community setting men and non-pregnant women. The possibility of termination of pregnancy or very close follow up Health education and health promotion of foetal development should be discussed with Advice to females planning pregnancy to check parents following infection in early pregnancy. Pregnant women should Page 145 avoid exposure to rubella virus unless they are known to be serologically immune. See Appendix 1, but specifically: Module 5 Page 145 Measles (Rubeola) Definition rash. These are small greyish-white lesions which The measles virus is a paramyxovirus mainly fade once the rash has appeared.

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In addition 160 mg malegra fxt plus mastercard, radiographs do not provide information on the condition of the soft tissues order 160mg malegra fxt plus overnight delivery. Probing Depth Probing depth measurement buy 160mg malegra fxt plus free shipping, after the initial soft tissue healing upon loading order malegra fxt plus 160 mg visa, should be established and monitored over time (Padial-Molina et al. Human and animal stud- … - An Epitome of the Dutch Guideline - 201 1 ies have shown that a soft tissue barrier adjacent to an implant-supported restoration is completely established within 8 weeks (Tomasi et al. Hence, to allow this initial soft tissue healing to occur, according to the Dutch approach, the baseline 2 measurement should be performed around 8 weeks after the prosthesis installation, in order to give the peri-implant mucosa around the restoration the necessary time to mature. Pro- 3 gressive changes in probing depth compared to previous measurements can be an alarming sign. In experimental peri-implantitis studies, an increase in probing depth over time has been associated with clinical attachment and bone loss around implants (Lang et al. In the past, it has also been suggested that probing around implants would damage the soft tissue seal around them. However, Etter and colleagues (2002), in an ex- 6 perimental study, evaluated the healing following standardized peri-implant probing using a force of 0. The fndings of this study clearly imply that peri-implant probing using a probe 7 with a light pressure of 0. There are no data 8 available whether the material of the probe (metal or plastic) or the probe design can infu- ence peri-implant probing measurements (Heitz-Mayfeld, 2008). Empirically, a plastic probe 9 appears more favourable because it is fexible and can follow the bulging contour of the implant-supported restoration more easily. In contrast to natural teeth, for which average periodontal probing depth has been re- ported, the physiologic probing depth of the peri-implant sulcus has been a matter of debate (Salvi & Lang 2004). Probing depths around implants can be infuenced by different factors such as probing force, thickness of the peri-implant mucosa, placement level and type/design of implant, abutment or restoration (Lang et al. Generally, probing pocket depths can vary between implant systems, aesthetic placement depths, bone levels to adjacent teeth, healing time, surgical protocol (one or two stages), and loading protocol (Padial-Molina et al. Platform switching may lead to shallower measurements because the probe tip may stop on the neck of the implant. In the aesthetic zone, where implants are placed deeper for a better emergence profle, probing depths of ≥ 5 may be accepted, if not accompanied by other symptoms or signs of infammation (e. However, it must be kept in mind that pockets of ≥ 5 mm repre- 202 Prevention and Treatment of Peri-implant diseases… sent niches where anaerobic bacteria can be found (Misch et al. Regular maintenance 1 is, thus, mandatory to preserve a stable peri-implant condition. Long-term investigations in humans have shown that the probing depth of a healthy peri-implant sulcus is not always 2 < 4mm but in fact, often > 4 mm and sometimes ≥ 6 mm (Coli et al. Therefore, single probing depth measurements, solely, should not be considered a diagnostic tool for the pres- ence of disease, but should always be combined with other clinical signs of disease, e. Nevertheless, it should be realized that, at present, peri-implant pocket probing provides the 4 clinician with the best information in order to evaluate the condition of the peri-implant soft tissues. However, it should be kept 8 in mind that stable peri-implant sites, in some cases, also slightly bleed on probing which may be the result of disrupting the epithelial junction. Pus is frequently associated with progressive bone loss and peri-implantitis (Roos-Jansåker et al. Prevention The key for the long-term success of implants is prevention of peri-implant diseases based on proper implant design, proper placement and correct contours for ease of oral hygiene, along with meticulous maintenance care by both the dental care professional and the patient (Tarnow, 2016). Examination of the peri-implant tissues should include assessment of the presence of plaque, probing pocket depth, presence and severity of bleed- ing on gentle probing and/or suppuration. When changes in clinical parameters indicate disease, a radiograph should be taken to evaluate possible bone loss compared to previous examinations (Lang & Berglundh 2011). In every follow-up visit, the frequency of the maintenance should be determined, on the 8 basis of an individual risk analysis, taking into account local and patient-related factors. In every follow-up visit, the recall interval should be revised and, if necessary, adapted. In this case, a recall frequency of twice a year is recommended, precluding that local and/or systemic factors require more frequent inter- vals (Monje et al. Professional cleaning, including reinforcement of the oral hygiene is recommended as a preventive measure (Heitz-Mayfeld et al. The removal of bioflm from implant components exposed to the oral environment, which have mostly a smooth surface, constitutes an important part of the professional sup- portive therapy. Ideally, the instruments used to effectively clean smooth surfaces should cause minimal or no surface damage, should not create a surface that is more conducive to bacterial colonization and should not affect the implant–soft tissue interface. If, however, the soft tissue attachment is disrupted, the instrumentation procedure should maintain a surface that is conducive to re-establishment of the soft tissue seal (Louropoulou et al. Summarizing the evidence, air abrasive devices are, at present, the most effective instruments in removing bioflm from smooth surfaces (Louropoulou et al. In a six-month randomized clinical trial air-abrasive debridement with gly- 3 cine powder was compared to manual debridement with plastic curettes and chlorhexidine administration for the maintenance of peri-implant status. The authors concluded that the 4 air-abrasive treatment with glycine powder seems adequate and more effective than manual instrumentation in removing the peri-implant bioflm and in maintaining the health of peri- 5 implant tissues (Lupi et al. However, current data indicate that complete resolution of the infammation, as evident by absence of bleeding on probing, 9 is not always possible (Jepsen et al. Improvement of the oral hygiene of the patients and professionally-administered mechanical cleaning of the implant components, employ- ing different hand or powered instruments with or without air-abrasive devices, should be considered the standard of care for the management of peri-implant mucositis (Jepsen et al. Sometimes, iatrogenic factors are present and play an important role in the initiation of peri-implant mucositis. Cement remnants, if present, should be removed and prosthodontic issues like inade- quate abutment/restoration seating or over-contoured restorations should be corrected. In case of implant mal-positioning, surgical correction of the hard and soft tissues may be necessary to reduce the infammation and to improve the accessibility for proper oral hygiene (Figure 1). The absence of maintenance in individuals treated for peri-implant mucositis has been associated with a higher risk for developing peri-implantitis (Costa et al. Sometimes, these symptoms are accompanied by redness and swelling of the peri-implant mucosa and patient’s symptoms 5 like discomfort or pain. When peri-implantitis is diagnosed, proper treatment should be started, as soon as 6 possible (Figure 1). The ideal goal of the treatment would be the resolution of infamma- tion with no suppuration or bleeding on probing, no further bone loss, and the reestab- lishment and maintenance of healthy peri-implant tissues (Heitz-Mayfeld et al. However, peri- 8 implant pocket depth can be infuenced by different factors, as discussed above, and, therefore, the classifcation of a “deep” pocket needs to be done on an individual basis 9 (Schwarz et al. The treatment of peri-implantitis starts with a nonsurgical therapy, consisting of im- provement of the oral hygiene of the patient and professional cleaning of the infected im- plant components (Figure 1). From the existing literature on nonsurgical therapy of peri-implantitis, it seems that limited clinical improvements can be achieved following mechanical therapy alone using special- ly designed carbon-fber curettes, ultrasonic devices and titanium instruments (Renvert & Polyzois 2015). Glycine powder air polishing appears to improve the effcacy of nonsurgical treatment of peri-implantitis. Glycine powder air polishing was associated with a signif- cant improvement in bleeding scores over the control measures investigated (Schwarz et al.

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If God withheld healing and miracles from us until we reached absolute perfection discount 160mg malegra fxt plus mastercard, none of us would ever be healed cheap 160mg malegra fxt plus amex. What I am encouraging you to repent of are specific sins that have not yet been confessed and forsaken buy 160mg malegra fxt plus overnight delivery. It says buy cheap malegra fxt plus 160 mg online, “The earnest (heartfelt, continued) prayer of a righteous man makes tremendous power available—dynamic in its working. That is, as the Amplified Bible so aptly describes it, it is an emotion-filled prayer that is continued. It is not continued prayer to satisfy a self-imposed requirement of righteousness or duty. It is continued prayer because of that which has caused it to be emotion-filled—the situation, the emergency, the crisis. The continued prayer is the natural response to the agonizing emotion that demands relief. The situation is so severe that the heart’s attention is involuntarily fixed on a solution. The fire of this type of persistent prayer can’t be smothered with fatigue, distraction, or hopelessness. This type of prayer, the prayer of faith, can’t afford to get tired, distracted, or weighed down with hopelessness. To the many who receive their healing or deliverance with a single prayer, command, or act of faith, I say, “Glory to God, and God bless you! The prophet, Elijah, had told the wicked king Ahab that Israel would have no rain except by the prophet’s command. At the end of that period, the prophet publicly confronted the king and spoke these words: “Get thee up, eat and drink; for there is a sound of abundance of rain. He could not afford to give a bad prophecy at such a critical time and in such a public forum. At his command, the three and one-half year drought would suddenly end—and that very day! And Elijah went up to the top of Carmel; and he cast himself down upon the earth, and put his face between his knees, and said to his servant, Go up now, look toward the sea. And it came to pass at the seventh time, that he said, Behold, there ariseth a little cloud out of the sea, like a man’s man…And it came to pass in the mean while, that the heaven was black with clouds and wind, and there was a great rain. Many people do that, but they don’t follow up with that which is necessary to make the declaration come true. It is absolutely critical to look for the answer to the prayer after the prayer is offered. Next, when the apprentice prophet came back with the negative news that there was no sign of rain, Elijah did not lose faith. Each time the helper returned with bad news— the disease is getting worse; you’re getting weaker; the x-rays are bad—Elijah sent him back out again to look for the answer, the physical manifestation of the answered prayer. Yes, but since the answer had not actually arrived yet, it was correct and wise to continue praying. The Prayer of Faith Prays for the Same Thing Over and Over and Over and Over and Over and…. Jesus explicitly emphasized that the sole thing about the man’s prayer that caused it to be answered was importunity. Despite the man’s pressing need, the prayer would have failed had he not persisted in prayer. And let this fact not be lost through twisting or ignoring the scriptures: The man prayed for the same thing over and over and over and over until he literally received what he was praying for. There is a teaching in the church that if you pray for a thing more than once, you are in unbelief. The rationale is that if you pray in faith the first time, there is no need to pray again. There are so many places in the Bible that prove this is a false doctrine that my challenge is to limit what examples I shall use. If our favorite teacher teaches a doctrine that contradicts the example of Jesus, well, uuhhh, I think you know what to do with that teaching. An example that perfectly illustrates the legitimacy of persistent prayer is given to us in Matthew 26:36-44 and Mark 14:32-42. These are the accounts of how Jesus prayed just prior to being apprehended in Gethsemane by His enemies. And he took with him Peter and the two sons of Zebedee, and began to be sorrowful and very heavy. Then saith he unto them, My soul is exceeding sorrowful, even unto death: tarry ye here, and watch with me. And he went a little farther, and fell on his face, and prayed, saying, O my Father, if it be possible, let this cup pass from me: nevertheless not as I will, but as thou wilt. And he cometh unto the disciples, and findeth them asleep, and saith unto Peter, What, could ye not watch with me one hour? Watch and pray, that ye enter not into temptation: the spirit indeed is willing, but the flesh is weak. He went away again the second time, and prayed, saying, O my Father, if this cup may not pass away from me, except I drink it, thy will be done. And he left them, and went away again, and prayed the third time, saying the same words. Let it roll around in your soul and sink deeply into your spirit: Saying—the—same— words. Was it not Jesus who told us that we are not to use vain repetitions when we pray? Be not ye therefore like unto them: for your Father knoweth what things ye have need of, before ye ask him. An example would be if a person flipped through a catalogue of prayers and chose one to offer to a deity. If you want to see excellent examples of genuine, heart-felt prayers, read the Psalms. The second mistake the heathen made in their praying was they thought the repetition of these template prayers would assure an answer. The power is not in the number of times a prayer is offered or in the method in which a prayer is offered. Instead He revealed that our faith should be in the Person to whom we pray, and in particular His relationship to us as Father. This is communicated when He said, “Be ye not therefore like unto them: for your Father knoweth what things ye have need of, before ye ask him. However, unlike the heathen who offered secondhand prayers to their deity, Jesus offered prayers that came from His own heart. Second, Jesus prayed for the same thing, using the same words, not because He felt He was not being heard, but—and don’t miss this—because He knew He was being heard.

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