Mukati
ngovepo
Rheumatoid arthritis ndiyo inonyanya kufarirwa systemic kupisa arthritis. Vakadzi, vanosvuta, uye avo vane nhoroondo yemhuri yechirwere vanowanzo kanganiswa. Maitiro ekuongororwa anosanganisira kuve nenhengo imwechete pamwe nekuzvimba chaiko kusingatsanangurwe nechimwe chirwere. Iko mukana weiyo rheumatoid arthritis kuongororwa kunowedzera pamwe nenhamba yediki majoini akabatanidzwa. Mune murwere ane hutachiona hweArthritis, kuvapo kwerheumatoid factor kana anti-citrullinated protein antibody, kana kukwidziridzwa kweC-inoshanda mapuroteni level kana erythrocyte sedimentation chiyero chinoratidza kuongororwa kwerheumatoid arthritis. Pakutanga kuongorora kwerabhoritari kunofanira kusanganisira huwandu hweropa hwakazara nemusiyano uye kuongororwa kweiyo renal uye hepatic basa. Varwere vanotora biologic vamiririri vanofanirwa kuongororwa hepatitis B, hepatitis C, uye tibhii. Pakutanga kuongororwa kwerheumatoid arthritis inobvumira kurapwa kwekutanga nezvirwere-kugadzirisa antirheumatic agents. Kubatanidzwa kwemishonga kunowanzo shandiswa kudzora chirwere. Methotrexate inowanzo iri yekutanga-mutsara mushonga we rheumatoid arthritis. Biologic vamiririri, senge bundu necrosis factor inhibitors, inowanzoonekwa seyechipiri-mutsara vamiririri kana inogona kuwedzerwa kune maviri marapirwo. Izvo zvinangwa zvekurapa zvinosanganisira kudzikisira kwekutambudzika kwekubatana uye kuzvimba, kudzivirira kweiyo radiographic kukuvara uye kuoneka kwekuremara, uye kuenderera kwebasa uye zviitiko zvevanhu. Joint kutsiva inoratidzirwa kune varwere vane zvakakomba kwemajoini kukuvara vane zviratidzo zvisina kutarisirwa zvakanaka nevekurapa manejimendi. (Ndini Chiremba weNzara. 2011; 84 (11): 1245-1252. Copyright 2011 American Academy yeMhuri Varapi.) Rheumatoid arthritis (RA) ndiyo inonyanya kurwisa arthritis, ine kupararira kwoupenyu hwepamusoro kusvika ku1 muzana munyika yose.1 Inset inogona kuitika chero ipi zvayo, asi inokwira pakati pe30 ne50 makore.XVUMX Kuremara kwakajairika uye kunokosha. Muchikwata chikuru cheUnited States, 2 muzana yevarwere vane RA vakave nekuremara kwebasa mushure memakore 35.10Etiology uye Pathophysiology
Kufanana nezvakawanda autoimmune hosha, iyo etiology yeRA ine multifactorial. Kugadziriswa kweGenetic kunoonekwa mukubatana kwemhuri uye monozygotic mapatya zvidzidzo, ne50 muzana yeRA njodzi inokonzerwa nemajini zvinhu. 4 Sangano reGenetic reRA rinosanganisira munhu leukocyte antigen-DR45 uye -DRB1, uye akasiyana maeleles anonzi epitope yakagovaniswa. 6,7, 4 Zvidzidzo zveGenome-wide musangano zvakaratidza mamwe masiginecha echisimba ayo anowedzera njodzi yeRA uye zvimwe zvirwere zvekuzvimiririra, kusanganisira STAT40 geni uye CD5 locus.8 Kusvuta ndiko kukonzera kukuru kwezvakatipoteredza kweRA, kunyanya kune avo vane maitiro ekuzvarwa. inogona kuburitsa mhinduro yekuzvimiririra, hapana imwe pathogen yakaratidza kuti inokonzeresa RA.9 RA inozivikanwa nenzira dzinopisa dzinotungamira mukuwanda kwemasero e synovial mumajoini. Yakazotevera pannus kuumbwa kunogona kutungamira kune ari pasi pekartilage kuparadzwa uye bony erosions. Kuwedzeredza kwepro-inflammatory cytokines, kusanganisira bundu necrosis factor (TNF) uye interleukin-6, inotungamira yekuparadza.Risk Factors
Kukwegura, nhoroondo yemhuri yechirwere, uye bonde rechikadzi zvinosanganisirwa nenjodzi yakawedzera yeRA, kunyangwe mutsauko wepabonde usinga nyanyozivikanwa muvarwere vakura.1 Zvese zviripo uye pamberi pekusvuta fodya zvinowedzera njodzi yeRA (zvine ngozi [RR] = 1.4, inosvika ku2.2 yevanopfuura makumi mana-mapaketi-gore vanoputa) .40 Kubata kunowanzo kukonzera RA kuregererwa, pamwe nekuda kwekubvumidzwa kwema immunologic.11 Parity inogona kuve neyakareba kukanganisa; RA kashoma kuti ionekwe mumadzimai ane parous pane vakadzi vasina maturo (RR = 12) .0.61 Kuyamwisa kunoderedza njodzi yeRA (RR = 13,14 mumadzimai akayamwisa kweanenge mwedzi makumi maviri nemana), nepo kutanga kuenda kumwedzi (RR = 0.5 kune avo vane kuenda kumwedzi pazera remakore gumi kana mudiki) uye nguva dzisina kujairika dzekuenda kumwedzi (RR = 24) kuwedzera njodzi.1.3 Kushandisa mapiritsi ekudzivirira kubata pamuviri kana vhitamini E hakukanganisa njodzi yeRA.10
kuongorora chirwere
Mharidzo Yakafanana
Varwere vane RA vanowanzova nemarwadzo uye kuoma mumanyoro akawanda. Izvo zvinoputika, zvinopindira interphalangeal joints, uye metacarpophalangeal joints inowanzobatanidzwa. Kushushikana kwamangwanani kunogara kweawa imwe chete kunoratidzira etiology inopisa. Boggy kuzvimba nemhaka ye synovitis inogona kuonekwa (Mufananidzo 1), kana kuti mashura synovial thickening angave akarembera pamubvunzo wokubatana. Vashandi vanogonawo kuisa nehuwandu husinganzwisisiki arthralgias vasati vatanga kuonekwa kwechirwere chemajoini. Zviratidzo zvekuneta, kuora kurasikirwa, uye kutsika-grade fever zvinogona kuitika nehosha inoshanda.Zviratidzo Zvokuziva
Mu2010, iyo American College yeRheumatology uye European League Against Rheumatism yakabatana kugadzira matsva maitiro eRA (Tafura 1) .16 Maitiro matsva aya kuedza kwekupima RA pakutanga kune varwere vangangosangana ne1987 American College yeRheumatology classification. maitiro. Maitiro e2010 haasanganise kuvepo kwerheumatoid nodules kana radiographic erosive shanduko, ese ari maviri ari mashoma mukana mukutanga RA. Symmetric arthri- tis haidiwe mumatanho e2010, ichibvumidza mharidzo yekutanga asymmetric. Mukuwedzera, vaDutch vatsvakurudzi vakagadzira uye vakagadzirisa mutemo wekufanotaura kwekliniki yeRA (Tafura 2) .17,18 Chinangwa chemutemo uyu ndechokubatsira kuziva varwere vane chirwere chisina kukodzera cheArthritis chinonyanya kufambira mberi kuRA, uye kutungamira zvinotevera- kumusoro uye kutumira.Miedzo yekuongorora
Zvirwere zvekuzvimiririra senge RA zvinowanzo kuve nekuvapo kwe autoanti- miviri. Rheumatoid chinhu hachisi chakanangana neRA uye chinogona kunge chiripo kune varwere vane zvimwe zvirwere, zvakaita sehepatitis C, uye mune vakwegura vane hutano. Anti-citrullinated protein antibody yakanyanya kujeka kuRA uye inogona kutora chikamu muchirwere chepathogenesis.6 Inosvika- makumi mashanu kusvika makumi masere muzana muzana yevanhu vane RA vane rheumatoid factor, anti-citrullinated protein antibody, kana ese ari maviri. 50 Varwere vane RA vanogona yakanaka antinuclear antibody bvunzo mhedzisiro, uye muyedzo ndewekufungidzira kukosha mune vechidiki mafomu echirwere ichi.80 C-inoshanda mapuroteni mazinga uye erythrocyte sedimentation mwero zvinowanzo kuwedzerwa neRA inoshanda, uye aya akanyanya chikamu maatomu chikamu chikamu chetsva RA yekumisikidza maitiro. 10 C-inoshanda mapuroteni mazinga uye erythrocyte sedimentation mwero inogona zvakare kushandiswa kutevera chirwere chiitiko uye kupindura kumushonga. Baseline izere huwandu hweropa nemusiyano uye kuongororwa kweiyo renal uye hepatic basa zvinobatsira nekuti mhedzisiro inogona kukanganisa nzira dzekurapa (semuenzaniso, murwere ane kusakwana kweitsvo kana akakosha thrombocytopenia angangodaro asina kupihwa nonsteroidal anti-inflammatory drug [NSAID]). Kupfava kweanemia kwechirwere chisingaperi kunoitika mu19 kusvika 16 muzana yevarwere vese vane RA, 33 kunyangwe mudumbu kurasikirwa kweropa kunofanirwa kutariswa kune varwere vanotora corticosteroids kana NSAIDs. Methotrexate inopesana nevarwere vane hepatic chirwere, senge hepatitis C, uye nevarwere vane hurema hwakakomba. 60 Biologic Therapy, senge TNF inhibitor, inoda yakaipa tuberculin bvunzo kana kurapwa kweanodzimba tibhii. Hepatitis B kugadziriswazve kunogona kuitika neTNF inhibitor kushandiswa.20 Radiography yemaoko nemakumbo inofanira kuitwa kuti iongorore maitiro eaperiarticular erosive shanduko, iyo inogona kunge iri chiratidzo cheinotyisa RA subtype.21
Kusiyanisa Kuziva
Kuwanikwa kweganda kunoratidzira systemic lupus erythematosus, systemic sclerosis, kana psoriatic arthritis. Polymyalgia rheumatica inofanirwa kutariswa mumurwere akura ane zviratidzo kunyanya mubendekete nemuchiuno, uye murwere anofanirwa kubvunzwa mibvunzo ine chekuita neyakabatana temporal arteritis. Chest radiography inobatsira kuongorora sarcoidosis seyetiology yeArthritis. Varwere vane kuzvimba kumashure zviratidzo, nhoroondo yehutachiona hwechirwere, kana chirwere cheziso chinoputira vanogona kunge vane spondyloarthropathy. Vanhu vane mavhiki asingasviki matanhatu ezviratidzo vanogona kuve nehutachiona maitiro, senge parvovirus. Zvazvino zvoga-zvikamu zvishoma zvekubatana kwakabatana kuzvimba zvinoratidza kristaro arthropathy, uye arthrocentesis inofanirwa kuitirwa kuongorora monosodium urate monohydrate kana calcium pyrophosphate dihydrate makristasi. Kuvapo kweakawanda myofascial trigger mapoinzi uye somatic zviratidzo zvinogona kuratidza fibromyalgia, iyo inogona kugara pamwe neRA. Kubatsira kutungamira kuongororwa uye kuona nzira yekurapa, varwere vane hutachiona arthritis vanofanira kukurumidza kutumidzwa kune rheumatology subspecialist.16,17
Rheumatoid arthritis, kana kuti RA, ndiyo inonyanyozivikanwa yeArthritis. RA chirwere chinotarisa muviri, chinokonzerwa apo masimba ezvirwere zvemuviri, muviri wemudziviriri wezvidziviriro, anorwisa masero ayo uye masukisi, kunyanya masangano. Rheumatoid arthritis inowanzozivikanwa nezviratidzo zvekutambudzika nekuputika, kazhinji kunobata zviduku zviduku zvemaoko, maziso nemakumbo. Maererano nehuwandu hwehutano hwezvehutano, kutanga kuongororwa uye kurapwa kweRA kunokosha kuti kudzivirira kuwedzera kwekubatana pamwe nekuderedza zviratidzo zvinorwadza. Dr. Alex Jimenez DC, CCST Insight
mabatiro
Mushure meR RA yave ichiongororwa uye yekutanga kuongorora yakaitwa, chirwere chinofanira kutanga. Nhungamiro yemazuva ano yakataura nevatungamiri veRA, 21,22 asi zvisarudzo zvevarwere zvinoitawo basa rinokosha. Kune zvikonzero zvakakosha zvevakadzi vezera rekubereka nekuti mishonga yakawanda inobvisa zvinetso pahutumbi. Zvinangwa zvekurapa zvinosanganisira kuderedza marwadzo pamwe chete nekudzivirira, kudzivirira kusvibiswa (zvakadai sokutsauka kwekupedzisira) uye kuora kwemashoko (zvakadai sekushandura), kuchengetedza hupenyu hwehupenyu (hwega uye basa), nekudzora zviratidzo zvekare. Dendaase-modifying antirheumatic drugs (DMARD) ndiyo inonyanya kushandiswa neR RA.DMARDs
DMARDs inogona kunge iri biologic kana nonbiologic (Tafura 3) .23 Biologic vamiririri vanosanganisira monoclonal antibodies uye recombinant receptors kuvharira cytokines inosimudzira iko kuputika kuputika kunoitisa RA zviratidzo. Methotrexate inokurudzirwa semutsetse wekutanga kurapwa kune varwere vane RA inoshanda, kunze kwekunge zvisingabvumirwe kana kusashivirirwa.21 Leflunomide (Arava) inogona kushandiswa seimwe nzira kune methotrexate, kunyangwe mudumbu mhedzisiro inokanganisa zvakanyanya. Sulfasalazine (Azulfidine) kana hydroxychloroquine (Plaquenil) pro-kuzvimba seyemonotherapy kune varwere vane yakaderera chirwere activity kana vasina zvakashata zvekufungidzira maficha (semuenzaniso, seronegative, isiri-erosive RA) .21,22 Musanganiswa wekurapa pamwe maviri kana anopfuura maDMARD anoshanda zvakanyanya kupfuura monotherapy; zvisinei, mhedzisiro inokanganisa inogona zvakare kuve yakakura.24 Kana RA isina kunyatso kudzorwa neiyo nonbiologic DMARD, biologic DMARD inofanirwa kutangwa.21,22 TNF inhibitors ndiyo yekutanga-line biologic kurapa uye ndiyo yakanyanya kufunda yeava vamiririri. Kana TNF inhibitors isingabatsiri, mamwe marapirwo ebiologic anogona kutariswa. Kushandiswa panguva imwe chete kweanopfuura imwe biologic therapy (semuenzaniso, adalimumab [Humira] ine abatacept [Orencia]) haina kukurudzirwa nekuda kweyakagamuchirwa muyero wemhedzisiro.
NSAIDs uye Corticosteroids
Kushandisa zvinodhaka kweR RA kunogona kusanganisira NSAID uye muromo, muromo, kana intra-articular corticosteroids yekudzivirira marwadzo nekuputika. Zvakakodzera, NSAIDs uye corticosteroids zvinoshandiswa chete kwekutora kwenguva pfupi. DMARD ndiyo chirongwa chinosarudzwa.21,22Complementary Therapies
Kupindira kwechikafu, kusanganisira kudya kwezvirimwa uye zveMediterranean, zvakadzidzwa mukurapa RA pasina humbowo hunogutsa hwekubatsira. 25,26 Kunyangwe paine mhedzisiro inofadza, pane kushaikwa kweuchapupu hwekubudirira kweacupuncture mune placebo-inodzorwa miedzo yevarwere. neRA.27,28 Pamusoro pezvo, thermotherapy uye yekurapa Ultrasound yeRA haina kudzidza zvakaringana. 29,30 Ongororo yeCochrane yemishonga yemakwenzi yeRA yakagumisa kuti gamma-linolenic acid (kubva manheru Primrose kana mafuta e currant mbeu yemafuta) uye Tripterygium wilfordii (mutinhimira mwari muzambiringa) ane zvingabatsire.31 Zvakakosha kuzivisa varwere kuti zvakakomba mhedzisiro yakaipa yakataurwa nekushandiswa kwemishonga yekurapa.31
Kudzidzira uye Kurapa Kwepanyama
Migumisiro yemitambo yakarongedzwa yakasarudzwa inotsigira muviri wekuita muviri kunatsiridza hupenyu hwehupenyu uye simba remasimba kune varwere vane RA.32,33 Kudzidzira maitiro ekudzidzisa maitiro asina kuratidzika kuti ane zvinokanganisa zvinokonzerwa nezvirwere zvezvirwere zveR RA, zvikamu zvinorwadza, kana kuparara kwemavara emunharaunda.34 Tai Chi yakaratidzwa kuvandudza zvinyorwa zvemafambiro kune vanhu vane RA, kunyange zvazvo miedzo isina kukwana yakawanda.35 Dambudziko rekuchengetedzwa kweYiengar yoga kune vechidiki vane RA vari kufamba.36Nguva yekurapa
Kuregererwa kunowanikwa mu10 kusvika 50 muzana yevarwere vane RA, zvinoenderana nekuti kuregererwa kunotsanangurwa sei uye kusimba kwerapi.10 Kuregererwa kunowanzoitika muvanhurume, vasingasvuti, vanhu vadiki pane makore makumi mana, uye mune avo vane chirwere chekunonoka kutanga ( varwere vakura kupfuura makore makumi matanhatu nemashanu), iine pfupi nguva yechirwere, iine chirwere chakakomba chiitiko, isina kukwidziridzwa kwechikamu chakakomba chemagetsi, uye isina yakanaka rheumatoid factor kana anti-citrullinated protein antibody zvakawanikwa.40 Mushure mekurwara kwechirwere, madosi emishonga anogona kuderedzwa nekuchenjera kusvika kuhuwandu hushoma hunodiwa. Varwere vanozoda kugara vachiongororwa kuti vaone zviratidzo zvakagadzikana, uye nekukurumidza kuwedzerwa kwemushonga kunokurudzirwa nezvirwere zvinoputika.65Joint Replacement
Kushandurwa kunobatanidzwa kunoratidzwa apo kune hutano hwakanyanya hukuvadza uye kusagutsikana kuronga kwezviratidzo nekurapa. Mhedziso dzenguva refu ndeyekutsigirwa, ine 4 chete kusvika ku13 yezana yekupindira kukuru kwekubatanidza kunoda kuongororazve mukati me10 years.38 Chiuno nemabvi ndiyo inowanzosimbiswa majointsiti.Yenguva Yakareba Kuongorora
Kunyangwe RA ichionekwa sechirwere chemajoini, iri zvakare chirwere chehurongwa chinokwanisa kusanganisira akawanda masisitimu enhengo. Zvimwe zvinoratidzika-kuratidzwa kweRA zvinosanganisirwa muTafura 4.1,2,10 Varwere vane RA vane njodzi yakawedzera mbiri ye lymphoma, iyo inofungidzirwa kuti inokonzereswa neyakaipisisa maitiro, uye kwete mhedzisiro yekurapwa.39 Varwere vane RA zvakare iri panjodzi yekuwedzera yecoronary arteri chirwere, uye varapi vanofanirwa kushanda nevarwere kugadzirisa njodzi, zvakadai sekusvuta, kuwedzerwa kweropa, uye cholesterol yakawanda. 40,41 Kirasi III kana IV congestive moyo kutadza (CHF) ndeye contraindication yekushandisa TNF inhibitors, iyo inogona kukuvadza mhedzisiro yeCF.21 Muvarwere vane RA uye malignancy, chenjedzo inodikanwa nekuenderera mberi kwekushandisa maDMARD, kunyanya TNF inhibitors. Biologic DMARDs, methotrexate, uye leflunomide hazvifanirwe kutanga kune varwere vane herpes zoster inoshanda, hutachiona hwakakura hwehutachiona, kana hutachiona hutachiona hunoda mishonga inorwisa mabhakitiriya. 21 Matambudziko eRA nemarapirwo ayo akanyorwa muTafura 5.1,2,10
Prognosis
Varwere vane RA vanorarama makore matatu kusvika ku12 pasi pehuwandu hwevanhu vakawanda.40 Kuwedzera kwekufa kwevarwere ava kunonyanya kukonzerwa nekuwedzerwa kwehutano hwehutano hwemoyo, kunyanya kune avo vane chirwere chepamusoro uye chirwere chisingaperi. Izvo zvitsva zvinodhaka zvehupenyu zvinogona kuderedza kufambira mberi kwehutachiona hwehutachiona uye kuwedzera upenyu kune avo vane RA.41 Data Sources: Tsvakurudzo yakawanikwa kubva kuPM yakagadzirirwa muCliniki Queries vachishandisa mazwi anokosha rheumatoid arthritis, zvimwe zviratidzo zvinoshamisa, uye zvirwere-kuchinja antirheumatic agents. Kutsvakurudza kwaisanganisira meta-kuongorora, maitiro anongorongedzwa nema randomized, makiriniki, nekuongororwa. Yakatsvagawo iyo Agency for Healthcare Research uye Quality uchapupu hunoshuma, Clinical Evidence, database yeCchrane, Essential Evidence, uye UpToDate. Tsvaga musi: September 20, 2010. Munyori kuzivisa: Hapana hukama hwakakodzera hwemari hwekuburitsa. Mukupedzisa, rheumatoid arthritis chirwere chisingaperi, chemoto chinokonzera zviratidzo zvinorwadza, sekurwadziwa uye kusagadzikana, kuzvimba uye kuzvimba kwemajoini, pakati pevamwe. Iko kukuvara kwekubatana kunozivikanwa seRA kwakaenzana, zvichireva kuti inowanzo bata mativi ese emuviri. Early diagnosis yakakosha pakurapa RA. Chiyero cheruzivo rwedu chinogumira kuchiropractic uye musana nyaya dzehutano. Kuti ukurukure nyaya yacho, ndapota inzwa wakasununguka kubvunza Dr. Jimenez kana kuti tibate isu pa 915-850-0900 . Yakapetwa naDr.Alex Jimenez
Zvimwe Zvinyorwa Kukurukurirana: Relieving Knee Pain pasina Surgery
Kurwadziwa kwemabvi chiratidzo chinozivikanwa chinogona kuitika nekuda kwekukuvara kwemabvi kwakasiyana uye / kana mamiriro, kusanganisira mitambo yakakuvara. Mabvi ndeimwe yenhengo dzakaoma kwazvo mumumuviri womunhu sezvo zvichiitwa-kwemaketani emapfupa mana, mitsetse ina, toni dzakasiyana-siyana, menisci mbiri, uye cartilage. Maererano neAmerican Academy of Family Physicians, zvinonyanya kukonzera kurwadziwa kwemabvi zvinosanganisira patellar subluxation, patellar tendinitis kana jumper, uye Osgood-Schlatter chirwere. Kunyange zvazvo kurwadziwa kwemabvi kunowanzoitika kune vanhu pamusoro pemakore emakore e60, kurwadziwa kwemabvi kunogonawo kuitika kune vana nevechiri kuyaruka. Kurwadziwa kwepamusoro kunogona kurapwa pamusha kutevera nzira dzeRICE, zvisinei, kukuvara kwakanyanya kwemabvi kunogona kudiwa kurapwa kwekurumidza, kusanganisira chiropractic kuchengetedza.
EXTRA EXTRA | NHAURWA INOKOSHA: El Paso, TX Chiropractor Inokurudzirwa
Hazvina kuchena
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Professional Makuriro Ekudzidzira *
Ruzivo rwuri pano pa "Kuongororwa uye Kutungamirirwa kweRheumatoid Arthritis"Hazvina kuitirwa kutsiva hukama hwemunhu nemunhu ane ruzivo nezvehutano kana chiremba ane rezinesi uye haisi zano rekurapa. Tinokukurudzira kuti uite sarudzo dzehutano maererano netsvakiridzo yako uye kudyidzana nenyanzvi yezvehutano inokwanisa.
Ruzivo rweBlog & Hurukuro dzeKukura
Nzvimbo yedu yeruzivo inogumira kuChiropractic, musculoskeletal, mishonga yemuviri, hutano, inopa etiological viscerosomatic kusagadzikana mukati mezviratidzo zvekiriniki, yakabatana somatovisceral reflex Clinical dynamics, subluxation complexes, nyaya dzehutano dzakaoma, uye / kana zvinyorwa zvemishonga zvinoshanda, misoro, uye nhaurirano.
Isu tinopa uye tinopa kubatirana kwekiriniki nenyanzvi dzakasiyana-siyana. Imwe neimwe nyanzvi inotongwa nehunyanzvi hwavo chiyero chekudzidzira uye kutonga kwavo kwerezinesi. Isu tinoshandisa inoshanda yehutano & hutano mapuroteni kurapa uye kutsigira kuchengetedza kwekukuvadzwa kana kusagadzikana kwemusculoskeletal system.
Mavhidhiyo edu, zvakatumirwa, misoro, zvidzidzo, uye ruzivo rwunobata nyaya dzekiriniki, nyaya, uye misoro ine chekuita uye zvakananga kana zvisina kunanga kutsigira kwedu kwekiriniki yekudzidzira.
Hofisi yedu yakaedza zvine mutsindo kupa zvinyorwa zvinotsigira uye yaona tsvakiridzo yakakodzera kana zvidzidzo zvinotsigira zvatakatumira. Isu tinopa makopi ekutsigira ekutsvagisa zvidzidzo zvinowanikwa kumatare edzimhosva uye kuruzhinji pachikumbiro.
Isu tinonzwisisa kuti tinofukidza zvinhu zvinoda imwe tsananguro yekuti ingabatsire sei mune imwe chirongwa chekutarisira kana yekurapa protocol; Naizvozvo, kuti uenderere mberi nekukurukura nyaya iri pamusoro, ndapota inzwa wakasununguka kubvunza Dr. Alex Jimenez, DC, kana taura nesu isu 915-850-0900.
Tiri pano kuzokubatsira iwe nemhuri yako.
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Dr. Alex Jimenez DC, Msacp, RN*, CCST, IFMCP*, CIFM*, atn*
email: qeqeshi@elpasofunctionalmedicine.com
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Dr. Alex Jimenez DC, MSACP, RN* CIFM*, IFMCP*, ATN*, CCST
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