By Q. Kippler. University of North Texas. 2019.
In humans order suhagra 100 mg line, this gene is mutated in several con- mixed population of normal and mutant genomes is present quality 100mg suhagra, sanguineous families that are linked to the autosomal-recessive the mutation is heteroplasmic cheap 100 mg suhagra with mastercard. Additionally, aminoglycosides clearly Nonsyndromic hearing loss: cracking the cochlear code 71 Table 5. To date, the responsible gene in both codon base pairing on the coding region of ribosomes. The genetic susceptibility to aminoglycoside-induced ototoxicity (961delT diversity between inbred mouse strains makes them a valuable and 1494C T). Both the 7445A G and the gene, a plasma membrane calcium pump located at chromo- 7472insC mutations have been found in families with syndromic some 6 (184). This calcium pump helps to maintain low cytoso- 2 2 and nonsyndromic hearing loss. To cause the palmoplantar keratoderma for the 7445A G mutations and early-onset hearing loss in mdfw mice, a combination of 753A neurological dysfunction (ataxia and myoclonus) for the homozygosity of the cdh23 allele must coexist with haploin- 753A 7472insC mutation. By interacting in the same or a paral- To date, more than 100 loci for nonsyndromic hearing loss have lel biological pathway as a disease gene, modiﬁer genes can been detected, and the responsible gene has been identiﬁed for affect the phenotypic outcome of a given genotype. Although this indeed represents a formidable result, 72 Genetics and hearing impairment a Table 5. One initiative will use in knowledge has not led to widespread diagnostic applications, arrays to analyse all currently known mutations for Usher as has been the case for many other hereditary diseases. This method has tions a clue for a possible culprit gene can be obtained from the advantage that also currently unknown mutations can be clinical data (Table 5. However, this limitation is mainly based on the has led to the unfortunate situation that currently a large gap technological limitations of the array. Using several arrays, or exists between scientiﬁc achievements for deafness genes and using future more-dense arrays, the simultaneous analysis of diagnostic applications that result from it. Despite these problems, there is one gene that has found widespread diagnostic applications. Firstly, it is responsible for a large fraction of deafness patients Over the last decade, tremendous progress has been achieved in in some populations, with up to 50% of patients having genetic the identiﬁcation of deafness genes. A second major advan- ing of the complex mechanism of hearing has increased enor- tage of the gene is its very small size, which makes genetic mously. Promising tions, the genetic causes are distributed over dozens of genes, results have recently been reported about phenotypic variability some of which are very large in size and hence expensive to in hearing loss caused by modiﬁer genes. Screening all known deafness genes for mutations characterisation of these modiﬁers will deﬁnitely be a new chal- would be extremely expensive with current technology, pro- lenge for deafness research. This can either be the analysis of help in reducing the increasing gap between scientiﬁc research many known mutations or be the complete mutation analysis of and diagnostic applications for hearing loss. Cell Tissue in connexin26, D66H, causes mutilating keratoderma with sen- Res 1998; 294:415–420. Am J Med Genet 2003; ciated with the most common form of non-syndromic neurosensory 117A:89–91. Nat speciﬁc spectrum of mutations in Japan, including a frequent Genet 1997; 17:411–422. A gene responsible membrane protein is mutated in patients with diabetes mellitus for a dominant form of neurosensory non-syndromic deafness and optic atrophy (Wolfram syndrome). J Cell Sci tiguous gene deletion causing infantile hyperinsulinism, enteropa- 2001; 114:2105–2113. J Cell Biol 1993; R143W mutation associated with recessive nonsyndromic sen- 123:1777–1788. Ann N Y Acad Sci 2000; glucose is decreased in embryonic lethal connexin26-deﬁcient 915:129–135. Targeted ablation of adhesion molecule, a novel member of the immunoglobulin super- connexin26 in the inner ear epithelial gap junction network family that distributes at intercellular junctions and modulates causes hearing impairment and cell death. Nat Genet 2000; mouse ortholog of the Pendred’s syndrome gene (Pds) suggests a 26:142–144. Mutations in connexin31 underlie and genotype of mutation in Pendred syndrome gene. Nat Rev Cx26 resulting from a heterozygous missense mutation in a family Genet 2004; 5:489–498. Mutations in cadherin 23 mice, is mutated in autosomal dominant nonsyndromic hearing affect tip links in zebraﬁsh sensory hair cells. Science stereocilin and otoancorin points to a uniﬁed mechanism for 2004; 303:2007–2010. Nat Genet 2001; has a mutation in the gene encoding the espin actin-bundling 29:345–349. Espin cross-links cause surface of sensory epithelia and their overlying acellular gels, is the elongation of microvillus-type parallel actin bundles in vivo. J Med in the human alpha-tectorin gene cause autosomal dominant Genet 2004; 41:591–595. Hum Mol Genet tion in alpha-tectorin reveals that the tectorial membrane is 2003; 12:1155–1162. Nat Genet induced and nonsyndromic deafness is associated with the 2002; 30:257–258. Am J Hum Genet 2004; gene Tmie results in sensory cell defects in the inner ear of 74:139–152. Maternally inherited hear- drial transcription factor B1 as a modiﬁer gene for hearing loss ing loss, ataxia and myoclonus associated with a novel point associated with the mitochondrial A1555G mutation. Unfortunately, these are only suitable The next 50 years will witness a signiﬁcant increase in ageing in for a limited number of people. Although hearing aids succeed in the European Union, the United States, and Japan, with the sufﬁcient ampliﬁcation of sound, the gain in speech recognition number of people aged 65 and above growing signiﬁcantly. This is, at least partly, due to the misconception that aged between 61 and 70 have a signiﬁcant hearing loss of at least hearing impairment is an inevitable burden of ageing, rather than 25 dB (1). In addition, hearing loss may have a major inﬂuence on their quality of life and their feeling of well-being. These ﬁgures are compara- stria vascularis, which can all degenerate independently. The latter study revealed prevalence ﬁg- vascularis and the spiral ganglion, respectively, are the major ures of 44% for the age range 60 to 69 years and 66% for the 70 affected structures (10,11). According to Schuknecht, audio- to 79 age range (pure tone thresholds averaged for 0. In addition, 25% of all cases cannot be classiﬁed accord- lower frequencies, while women hear better than men at fre- ing to Schuknecht’s scheme.
They bind to b-tubulin heterodimers and block polymerization with a-tubulin into microtubules buy suhagra 100 mg line, thus disrupting microtubule assem- bly and the formation of the mitotic spindle discount 100 mg suhagra free shipping. These agents are most active during mitosis at metaphase order suhagra 100 mg mastercard, blocking chromosomal migra- tion and cell division. Although a marker for its therapeutic effect, bone mar- row suppression with leukopenia is the dose-limiting toxicity; other adverse effects include neurologic toxicity, nausea and vomiting, alopecia, and ulceration from subcu- taneous extravasation. Paclitaxel stabilizes microtubule formation to disassembly with arrest in mitosis. Paclitaxel shows activity in ovarian cancer and in breast and non–small-cell lung cancer, and Kaposi sarcoma. Paclitaxel also causes hypersensitivity specific to the vehicle (50% polyethoxylated castor oil and 50% ethanol) used for its administration. Epipodophyllotoxins are bulky, semisynthetic, multiringed structures derived from the mayap- ple plant. They block cells at the boundary of the S phase and prevent entry into the G2 phase. Structure and mechanism of action (1) Dactinomycin is a chromophore containing peptides isolated from Streptomyces. Therapeutic uses (1) Dactinomycin is used to treat rhabdomyosarcoma and Wilms tumor in children. It is also used for gestational trophoblastic tumor, metastatic testicular carcinoma, and Ewing sarcoma. Chapter 12 Cancer Chemotherapy 297 (2) This agent has been used in combination with vincristine and cyclophosphamide for the treatment of solid tumors in children. Doxorubicin (Adriamycin, Doxil), daunorubicin (daunomycin, [Cerubidine]), idarubicin (Idamy- cin), and the analogs of doxorubicin, epirubicin (Ellence), valrubium (Valstar), and mitoxan- trone (Novantrone) a. Daunorubicin and idarubicin are used primarily in the treatment of acute lymphocytic and myelogenous leukemias, often in combination with cytarabine. Structure and mechanism of action (1) Bleomycin is a mixture of copper-chelating glycopeptides produced by Streptomyces verticillus. The most serious adverse effect is a cumulative dose-related pulmonary tox- icity that may be fatal. Acute reactions that can be fatal occur in 1% of patients with lymphoma; this reaction consists of the anaphylac- toid-like reactions of profound hyperthermia, hypotension, and cardiorespiratory collapse. Toxicity of this drug includes diarrhea, which can be severe, and myelosuppression. Cisplatin is a small platinum coordination complex that enters cells by diffusion and active transport. The dose-limiting toxicity of cisplatin is cumulative damage to the renal tubules that may be irreversible following high or repeated doses, but which is routinely prevented by hydration and diuresis of the patient. It is ototoxic, with tinnitus and hearing loss, and it also produces peripheral neuropathy. Procarbazine is a weak monoamine oxidase inhibitor that may cause hypertension, particu- larly in the presence of sympathomimetic agents and food with high tyramine content. Hydroxyurea is primarily used in the management of chronic granulocytic leukemia and other myeloproliferative disorders. L-asparaginase is an enzyme that reduces levels of L-asparaginase, an amino acid not synthe- sized by some tumors, to inhibit protein synthesis and cell division. This agent is synergistic with methotrexate when the folic acid analogue is administered prior to L-asparaginase. L-asparaginase is minimally marrow suppressive; it is toxic to the liver and pancreas. Bortezomib is approved for treatment of multiple myeloma in patients who have received at least two prior courses of therapy. Biologic response modifiers are compounds that influence how an individual responds to the presence of a neoplasm. Interferon alfa-2b (Intron-A) is approved for treatment of hairy cell leukemia, and Kaposi sarcoma. Interleukin-2 (aldesleukin) (Proleukin) is approved for metastatic kidney cancer and melanoma. Thalidomide (Thalomid) and lenalidomide (Revlimid) are tumor necrosis factor modifiers. These agents are used in treatment of brain tumors, Kaposi sarcoma, multiple myeloma, and many noncancerous conditions. Thalidomide’s most common adverse effects are sedation, constipation, and pe- ripheral neuropathy (30%). Lenalidomide is an ana- log of thalidomide with increased potency and an apparent decreased toxicity. Imatinib (Gleevec), Dasatinib (Sprycel) (1) Imatinib and dasatinib are tyrosine kinase inhibitors that are specific for Bcr-Abl onco- protein (dasatinib also inhibits several other kinases). Gefitinib (Iressa) (1) Gefitinib is an inhibitor of epidermal growth factor receptor tyrosine kinase that is over- expressed in many cancers. Erlotinib (Tarceva) (1) Erlotinib is another inhibitor of epidermal growth factor receptor tyrosine kinase. The net effect of this interaction is cell lysis, possibly secondary to antibody-dependent cy- totoxicity or complement cytotoxicity. Expression of this protein is associated with decreased survival due to more aggressive disease. The net effect is the arrest of the cell cycle via antibody-mediated cytotoxicity. Its mechanism of action differs from that of imatinib in that cetuximab actually blocks the receptor. The action of this drug results in inhibition of cancer cell growth and induction of apoptosis. Use of these agents in neoplasia is predicated on the presence of steroid hor- mone receptors in target cells and on the ability of the hormone to stimulate or inhibit cell growth.
This is particularly the case where dental care under general anaesthesia is being contemplated suhagra 100mg with amex. It is prudent purchase 100mg suhagra overnight delivery, also purchase suhagra 100mg visa, to discuss the proposed treatment plan and to obtain the agreement for the care that is being suggested from those who have an interest in the patient. There will be occasions when it will not be possible to easily undertake an examination for a child or adolescent with a profound learning disability. In those circumstances, a decision has to be made as to whether some form of physical intervention, previously termed restraint, may need to be used. The clinician must decide, on the basis of a number of factors, what is the best way forward. The relative microdontia/spacing seen in young people with Down syndrome may also be a contributory factor in this supposed reduction in dental disease prevalence. Periodontal disease The periodontal status of children who are intellectually impaired may be compromised by their inability to comprehend and thus comply with oral hygiene measures. In these children periodontal disease is more prevalent, possibly as a result of an altered immune state (Chapter 111124H. Almost universally, plaque and gingivitis indices scores are higher in children with impairments. Malocclusion There are no studies that deal specifically with the problems of malocclusion in intellectually impaired children. However, in published data on general dental health, the number of orthodontic anomalies is frequently higher because many remain untreated. Other oral defects One feature of note is the prevalence of enamel defects often caused by the aetiological agent that produced the impairment. It is possible that dentists could play a part not only in the diagnosis of some disabilities, for example, coeliac disease (Fig. Teeth provide a good chronological record of the timing of severe systemic upsets (Chapter 131127H ). Isolation may be difficult due to a large tongue and poor control of movement, and in these situations it may be necessary to compromise on the treatment approach. In fissure sealing it may be more practicable to use a glass ionomer cement, protected by occlusal adjustment wax or a gloved finger during the setting phase, rather than to struggle with all the stages of applying a conventional resin sealant (Fig. Human clinical trials are now underway in both the United Kingdom and the United States to investigate the use of intraoral fluoride-releasing devices. These are small diameter glass beads that are attached by composite resin, to the buccal surface of a tooth (Chapter 61130H ). Those currently on trial have continued to elevate salivary fluoride levels for up to 2 years. Whether the released fluoride is equitably distributed around the mouth is not yet known. The placement, and retention in situ, of the glass beads in such children may be a challenge. The amber-coloured polyurethane-based material is applied to the tooth surfaces, preferably dry, although the varnish is water tolerant, and the resulting adherent film slowly releases fluoride (Fig. Recourse to one or other forms of conscious sedation may be indicated for a child with impairments who finds it difficult to co-operate for dental care. However, a degree of compliance is necessary in order to retain the nasal hood for the delivery of nitrous oxide/oxygen for inhalation sedation(Fig. For some patients general anaesthesia will be necessary to provide adequate dental care (Fig. This facility is not widely available and often means considerable disruption for the family because of the distance involved in travelling to specialist centres. Additionally, the child may be unsettled by the whole process of being starved, looked after by strange personnel, being anaesthetized, and then waking up with a sore throat and perhaps a mouth full of blood. There is evidence that this experience is only in the short-term memory as many parents comment on how much better their child is in terms of behaviour, sleeping patterns, and eating after the immediate postoperative period. Treatment planning for dental care under general anaesthesia has to be more radical. Radiography is an important aid in theatre, especially for the patient who is totally unco-operative in the dental chair. It is particularly important for detecting otherwise hidden pathology and for early enamel lesions. The latter cannot normally be left in the hope that they will remineralize by preventive means. Similarly, the chances of restoration failure can be reduced by the use of pulpotomy techniques and preformed metal crowns. Success is dependent upon careful pre-anaesthetic assessment by dentist and anaesthetist. Appropriate perioperative care in theatre, for example, steroid or antibiotic cover, and the back-up of in-patient facilities where medically or socially indicated, are vital to a successful outcome. Patients with Down syndrome may have altlanto-axial joint instability and will need extra care in moving from trolley to theatre table as well as during the recovery phase. Key Points Pre-anaesthetic assessment⎯important features: • accurate medical history; • previous anaesthetic history; • significant airway difficulties; • need for premedication; • transport arrangements; • home care. Great reliance is thus placed on the parent or carer who must be actively involved in oral hygiene instruction and given positive suggestions for modifications to the standard techniques. Examples include advice on the way to position a child (a bean bag can be helpful), in order to clean their mouth more efficiently and less traumatically. Another aid is the use of a prop such as a toothbrush handle to gain access to tooth surfaces on the other side of the mouth. Modification of existing, often very narrow-handled toothbrushes or the use of specially modified brush heads can be helpful (Fig. For some children, the mechanical removal of plaque can be more readily accomplished using a powered toothbrush. Once the child has become accustomed to the sensation, results can be better than by conventional toothbrushing. Chemical agents are effective in reducing plaque in the short term, but not enough is known about the effects of their long-term usage. Many patients with impairments may be unable to use a mouthwash correctly and either swallow or spit out anything distasteful. An alternative technique is to opt for chairside application of chlorhexidene as a varnish.
On any interpretation it is clear that developmental arguments buy cheap suhagra 100mg on line, such as those used 17 See also the discussion in ch buy 100mg suhagra with visa. Effe (1970 suhagra 100 mg discount, 84–5), argues that the sentence 1248 a 39–40 is a parenthesis: ‘Die Traume¨ der Melancholiker werden jedoch nicht in dem Sinn verglichen, daß auch sie auf Gott zuruckgefuhrt¨ ¨ werden, sondern nur insofern, als sie – wie die irrationale Mantik – ohne Verwendung des rationalen Elements das Richtige treffen. It is not correct, therefore, to speak of a comparison: the melancholics are an example. Moreover, given that the clear dreams of the melancholics are mentioned in this particular context, what other cause is there to account for them than God? See Woods (1982) 183: ‘The power of prophecy is relevant because of the close connection between the right choice and foreknowledge of the future. Out of all these interpreters, Effe is the only one who tries to account for the discrepancy on the strength of non-developmental arguments. Effe does not make it clear why this argument is no impediment to Aristotle’s conclusion of a qe©a eÉtuc©a in Eth. Aristotle on divine movement and human nature 243 by Dirlmeier,20 are insufﬁcient to account for this discrepancy, for the problem can be regarded as a problem of consistency both within Eth. It is therefore necessary to study the part played by the distribution argument in both contexts. Aristotle’s assertion that it is ‘paradoxical’ (atopon) that a god should send gifts to foolish people and not to the best and the wisest, may be understood in the light of a passage in Eth. There it is argued that if there is such a thing as a divine concern (theia epimeleia) with human affairs, this will be directed to those people who cultivate intelligence (nous), the thing in which they are most akin to the gods and in which the gods take pleasure. These people are the wise (sophoi), who act rightly and nobly, and therefore they are the most beloved by the gods. Although it is by no means certain that Aristotle himself accepted the existence of such a ‘divine concern’,21 it is clear in his view that if there is such a thing it will be concerned with the best and wisest, for they are most beloved by the gods just because they cultivate their intelligence. Thus the degree to which a person is ‘loved by the gods’ (theophiles¯ ) depends on the extent to which someone actualises ‘excellence’ (arete¯, both intellectual and 20 From Dirlmeier’s remarks in his commentary (1962a) it can be concluded that he has not noticed the problem. At 1247 a 28–9 he refers to On Divination in Sleep: ‘Gegen eine von Gott verursachte Traummantik erhebt Ar. On 1248 a 15 he remarks: ‘er hat bezuglich der Gottgesandtheit der Traume seine Ansicht¨ ¨ (man darf wohl sagen: spater) modiﬁziert’ (p. Just as the fact that ‘happiness’ (eudaimonia) is found with the ‘wise’ (the sophoi), who are ‘most beloved by the gods’ (theophilestatoi), supports the idea that it is granted by the gods, likewise the fact that eutuchia occurs with people who are not ‘wise’ and do not possess excellence furnishes an argument against the idea that eutuchia is given by the gods. The ﬁrst part of the solution to this problem is in that the ‘movement’ of God in the fortunate men (the eÉtuce±v who succeed without reasoning, logoi Àntev katorqoÓsi), as described in 1248 a 25ff. The idea which is labelled as ‘paradoxical’ (topon)in1247 a 28–9 is that a god or demon ‘loves’ (file±n) a man who does not possess reason (l»gov): the emphasis is on ‘loving’ no less than on ‘a god or demon’ (qe¼n £ da©mona). I follow the interpretation of this passage offered by Verdenius (1971) 292: ‘When God has revealed himself through the channel of contemplation, his inﬂuence gets the character of a directive power. This directive power is turned towards practical action through the intermediary of fr»nhsiv. Aristotle speaks of ‘God’ (¾ qe»v) as ‘princi- ple of movement in the soul’ (rc t¦v kinsewv n t¦ yuc¦) who ‘sees both the future and the present’ (¾r kaª t¼ mllon kaª t¼ Àn, 38) and who ‘moves more powerfully’ («scÅei mllon)(40–1). For the rest, this ‘God’ is in the main passive: he is the object of ‘having’ (cein, 32) and of ‘using’ (cr¦sqai, 38),26 and it is worth noting that verbs like ‘give’ (did»nai)or ‘be concerned’ (pimele±sqai,cf. Apart from the question of whether this is correct (see below), cr¦sqai in the context of divination has the meaning ‘consult’; it is thus often connected with qeä (‘god’, Herodotus 1. This use of cr¦sqai is, according to Redard (1953) 44, derived from the principal meaning ‘seek the use of something’, which is an ‘essentially human’ activity (‘rechercher l’utilisation de quelque chose. Le proces exprime est restreint al` ´ ` asphere` du sujet qui fait un recours occasionel a l’objet’), in which the object remains passive (‘Le rapport` sujet–objet se deﬁnit comme un rapport d’appropriation occasionelle’). The analogy in 1248 a 26, ‘as it is a god (or, God) that moves the universe, so it is in the soul’ (ãsper n tä ¾lw qe¼v kn ke©nw) seems to exclude the possibility that it is an immanent principle. In any case this ‘god’ is not identical with ‘the divine element in us’ (t¼ n ¡m±n qe±on, line 27), for this is the ‘intellect’ (noÓv), whereas ‘God’ is ‘superior to intellect’ (kre±tton toÓ noÓ). If the Unmoved Mover is referred to, then the wording ‘principle of movement’ (rc t¦v kinsewv), which is usually set aside for efﬁcient causality, is awkward, since the Unmoved Mover moves as a ﬁnal cause (but see Potscher (¨ 1970) 57). But it is questionable whether the theology of Metaphysics should serve as a guiding principle here: passages such as Pol. The same applies to 1248 a 38: ‘he sees well both the future and the present’ (toÓto kaª eÔ ¾r kaª t¼ mllon kaª t¼ Àn), which seems inconsistent with God’s activity of ‘thinking of thinking’ (nosewv n»hsiv)inMetaph. This contrast supports the view that Aristotle here does not, as Effe (1970) argues (cf. The presence of the word nqousiasm»v (‘divine inspiration’) here in Aristotle’s text does not alter this view, for this is used by Aristotle elsewhere to denote an affection (a pqov) of the human soul (cf. The conclusion that eutuchia is found among simple-minded people is therefore not incompatible with the statement that eutuchia is ‘divine’ (qe©a): the psycho-physiological process that Aristotle here has in mind does not presuppose an active and purposive divine choice (pimleia or fil©a) – whereas the theory rejected in 1247 a 28–9 does presuppose such a choice, as the verb ‘love’ (filw) shows – but is based on a general physi- cal divine movement which works more strongly with those people whose reasoning faculty is disengaged. The process seems similar to the workings of the ‘superhuman nature’ (daimon©a fÅsiv), to which Aristotle ascribes the phenomenon of prophetic dreams in On Divination in Sleep (463 b 14); there the susceptibility of simple-minded people to foresight and clear dream images, as well as the absence of this susceptibility in intelligent people, is accounted for by the absence (or, in the case of the intelligent people, the presence) of rational activity: ‘for the mind of such [i. By contrast, in intelligent people the presence of ‘their own proper movements’ (o«ke±ai kinseiv) prevents this susceptibility. Il faut plutot rapprocher ce passage des dialogues de Platon´ ˆ ˆ ou l’on voit cites les memes phenomenes psychiques et notamment de Menon. Gigon (` ´ ˆ ´ ` ´ 1969) 211: ‘Man wird allerdings auch zugestehen mussen, daß der Einschub uber den Enthusiasmus verwirrend¨ ¨ wirkt: denn in ihm liegt eine gottliche Einwirkung vor, die ihrer besonderen Art nach kaum¨ sunecv genannt werden kann. Thisiscalled Aristotle on divine movement and human nature 247 form of ‘divine concern’ (qe©a pimleia), but the theory of others that a god ‘sends’ (pmpei) dreams to people does suppose divination in sleep to be such, for ‘sending’ presupposes an active and purposive divine choice, whereas such a choice is for Aristotle, as we have seen, incompatible with the fact that prophetic dreams are found among simple people and not among the best and wisest. For this reason he uses three times the same distribution argument as that in Eth. The second part of the solution is in that the movement of God is, in principle, not limited to the class of the ‘irrational’ (logoi) people, but extends to the ‘wise and intelligent’ (sofoª kaª fr»nimoi) as well. To demonstrate this I shall ﬁrst summarise my interpretation of the passage 1248 a 15ff. Having established that eutuchia proceeds from natural desire (¾rma© and piqum©ai), Aristotle asks in turn for the starting-point of this desire, probably because it is not yet clear why this natural desire should be aimed in the right direction. He considers that this starting-point will also be the origin of rational activity (noÓv and boÅleusiv), and having disposed of ‘chance’ (tÅch) as an evidently unsatisfactory candidate for this function he argues that the starting-point wanted is in fact the starting-point of movement in the soul; then it is clear that this starting-point is God. Thus God is the starting-point of all psychic activity, both of reasoning (no¦sai) and of the irrational impulses (¾rma©) on which eutuchia is based.