Desyrel

Laurence S. Baskin, MD

From this sample of images anxiety 120 bpm trusted 100 mg desyrel, in the earlier stages of the analysis process anxiety erectile dysfunction cheap desyrel 100mg on line, have been properly extracted 245 sub-images containing indi vidual leukocytes kitten anxiety symptoms buy cheap desyrel, with an accuracy of 92% anxiety symptoms while sleeping order genuine desyrel on-line. The resulting dataset anxiety knot in stomach desyrel 100mg for sale, composed of a matrix of features with size 50x245 and by a classi? In addition to increase the level of overall accuracy is required the use of a multi-class classi? It will also be necessary to expand the size of the dataset in order to provide to the classi? Long Transfusion and Blood Replacement Bbefore modern medicine anxiety tremors order 100mg desyrel fast delivery, blood was viewed as magical?an elixir (pp. Clinicians examine it more often than any other tissue when trying to determine the cause Diagnostic Blood Tests (p. In this chapter, we describe the composition and functions of this Developmental Aspects of Blood life-sustaining? To get started, we need a brief overview of blood circulation, which is initiated by the pumping action of the heart. Blood exits the heart via arteries, which branch repeatedly until they 634 Chapter 17 Blood 635 Plasma 55% of whole blood Least dense component Buffy coat Leukocytes and platelets <1% of whole blood Formed Erythrocytes elements 1 Withdraw blood 2 Centrifuge the 45% of whole blood and place in tube. By diffusing across the capillary walls, Erythrocytes normally constitute about 45% of the total vol oxygen and nutrients leave the blood and enter the body tissues, ume of a blood sample, a percentage known as the hematocrit and carbon dioxide and wastes move from the tissues to the (he-mat o-krit; ?blood fraction?). Plasma makes up most of the remaining 55% of up oxygen and then returns to the heart to be pumped through whole blood. Depending on the amount of oxy and Functions gen it is carrying, the color of blood varies from scarlet (oxygen Describe the composition and physical characteristics of rich) to dark red (oxygen poor). Blood is a specialized type of connective tissue in which living blood cells, called the Functions formed elements, are suspended in a nonliving? If we spin a sample of blood in a centrifuge, the heavier Distribution formed elements are packed down by centrifugal force and the Distribution functions of blood include less dense plasma remains at the top (Figure 17. Most of Delivering oxygen from the lungs and nutrients from the di the reddish mass at the bottom of the tube is erythrocytes gestive tract to all body cells. A thin, whitish layer called the buffy coat is present tion sites (to the lungs for elimination of carbon dioxide, and at the erythrocyte-plasma junction. Many blood pro teins and other bloodborne solutes act as buffers to prevent Solutes excessive or abrupt changes in blood pH that could jeopardize Plasma proteins 8% (by weight) of plasma volume; all normal cell activities. When a blood vessel is damaged, Fibrinogen 4% of plasma proteins; produced by platelets and plasma proteins initiate clot formation, halting liver; forms? Drifting along in blood are antibodies, Nonprotein nitrogenous By-products of cellular metabolism, substances such as urea, uric acid, creatinine, and complement proteins, and white blood cells, all of which ammonium salts help defend the body against foreign invaders such as bacte ria and viruses. Nutrients Materials absorbed from digestive tract (organic) and transported for use throughout body; include glucose and other simple carbohydrates, amino acids (digestion Blood Plasma products of proteins), fatty acids, glyc erol and triglycerides (fat products), Discuss the composition and functions of plasma. Al calcium, magnesium; anions include though it is mostly water (about 90%), plasma contains over 100 chloride, phosphate, sulfate, and bi different dissolved solutes, including nutrients, gases, hormones, carbonate; help to maintain plasma os wastes and products of cell activity, ions, and proteins. Respiratory gases Oxygen and carbon dioxide; oxygen Plasma proteins are the most abundant plasma solutes, ac mostly bound to hemoglobin inside counting for about 8% by weight of plasma volume. Plasma proteins serve a variety of functions, Hormones Steroid and thyroid hormones car but they are not taken up by cells to be used as fuels or metabolic ried by plasma proteins nutrients as are most other plasma solutes, such as glucose, fatty acids, and amino acids. Body organs make dozens of ad protein contributing to the plasma osmotic pressure (the pressure justments, day in and day out, to maintain the many plasma that helps to keep water in the bloodstream). However, assuming a healthy diet, plasma composition is kept relatively constant by various homeo 1. Explain your blood starts to become too acidic (acidosis), both the respiratory answer. Formed Elements membrane, but lack a nucleus (are anucleate) and have essen the formed elements of blood, erythrocytes, leukocytes, and tially no organelles. In fact, they are little more than ?bags? of platelets, have some unusual features. Other proteins are present, such as antioxidant enzymes and platelets are cell fragments. Only leukocytes are complete that rid the body of harmful oxygen radicals, but most function cells. Instead, they are continuously renewed by division of cells in For example, the biconcave shape of an erythrocyte is main red bone marrow, where they originate. The light microscope, you will see disc-shaped red blood cells, a va spectrin net is deformable, giving erythrocytes? Erythro shaped as they are carried passively through capillaries with di cytes vastly outnumber the other types of formed elements. It picks up oxygen in the capillary beds of the lungs and releases it to tissue cells across other capillaries Erythrocytes throughout the body. It also transports some 20% of the carbon Describe the structure, function, and production of eryth dioxide released by tissue cells back to the lungs. Its small size and biconcave shape provide a huge surface Give examples of disorders caused by abnormalities of area relative to volume (about 30% more surface area than erythrocytes. The biconcave disc shape is ideally suited for gas exchange because no point within the cytoplasm is far from the surface. Consequently, by anaerobic mechanisms, they do not consume any of the erythrocytes look like miniature doughnuts when viewed with oxygen they are transporting, making them very ef? Erythrocytes are the major factor contributing to blood vis rather porous capillary membranes) and (2) from contributing cosity. Women typically have a lower red blood cell count than to blood viscosity and osmotic pressure. Similarly, as the lungs into the blood and then into the erythrocytes, where the number of red blood cells drops below the lower end of the it binds to hemoglobin. Oxygen detaches from iron, hemoglobin 17 resumes its former shape, and the resulting deoxyhemoglobin, Erythrocytes are completely dedicated to their job of transport or reduced hemoglobin, becomes dark red. Carbon dioxide loading occurs in the tissues, chains?two alpha and two beta ?each binding a ring and the direction of transport is from tissues to lungs, where car like heme group (Figure 17. A single red blood cell contains about 250 million hemoglobin Production of Erythrocytes molecules, so each of these tiny cells can scoop up about 1 billion Blood cell formation is referred to as hematopoiesis (hem ah molecules of oxygen! This process occurs in the red bone marrow, which than existing free in plasma, prevents it (1) from breaking into is composed largely of a soft network of reticular connective fragments that would leak out of the bloodstream (through the tissue bordering on wide blood capillaries called blood sinusoids. Chapter 17 Blood 639 Stem cell Committed cell Developmental pathway Phase 1 Phase 2 Phase 3 Ribosome synthesis Hemoglobin accumulation Ejection of nucleus Early Late Hemocytoblast Proerythroblast erythroblast erythroblast Normoblast Reticulocyte Erythrocyte Figure 17. The myeloid stem cell, the phase intermediate between the hemocytoblast and the proerythroblast, is not illustrated. Within this network are immature blood cells, macrophages, because it still contains a scant reticulum (network) of clumped fat cells, and reticular cells (which secrete the? Usually they become fully mature erythrocytes response to changing body needs and different regulatory fac within two days of release as their ribosomes are degraded by tors. On average, the mar Reticulocytes account for 1?2% of all erythrocytes in the row turns out an ounce of new blood containing some 100 bil blood of healthy people. These undiffer Regulation and Requirements for Erythropoiesis entiated precursor cells reside in the red bone marrow. The mat the number of circulating erythrocytes in a given individual is uration pathways of the various formed elements differ, remarkably constant and re? This commitment is signaled by the cause having too few erythrocytes leads to tissue hypoxia (oxy 17 appearance of membrane surface receptors that respond to spe gen deprivation), whereas having too many makes the blood ci? This process is controlled hormonally myeloid stem cell is transformed into a proerythroblast and depends on adequate supplies of iron, amino acids, and cer (Figure 17. The ?color? of the cell cytoplasm changes culates in the blood at all times and sustains red blood cell pro as the blue-staining ribosomes become masked by the pink duction at a basal rate. Also, a wide variety of chemicals released by Conversely, too many erythrocytes or excessive oxygen in the leukocytes, platelets, and even reticular cells stimulates bursts of bloodstream depresses erythropoietin production. Instead, control is based on their ability to Dietary Requirements the raw materials required for erythro transport enough oxygen to meet tissue demands. Iron is essential for are already committed to becoming erythrocytes, causing them hemoglobin synthesis. One to two days after erythropoietin absorption into the bloodstream is precisely controlled by intes levels rise in the blood, a marked increase in the rate of reticulo tinal cells in response to changing body stores of iron. Instead it stimulates the kidneys, which in turn provide liver, spleen, and (to a much lesser extent) bone marrow. Consequently, they Small amounts of iron are lost each day in feces, urine, and per routinely have red blood cell counts less than half that of healthy spiration. Then, with the dehydration that occurs in a long race, the blood concentrates even further, Chapter 17 Blood 641 Fate and Destruction of Erythrocytes Red blood cells have a useful life span of 100 to 120 days (Figure 1 Low O2 levels in blood stimulate 17. Their anucleate condition carries with it some important kidneys to produce erythropoietin. They be 3 Erythropoietin and necessary come trapped and fragment in smaller circulatory channels, raw materials in blood promote particularly in those of the spleen. Bilirubin is picked up by liver cells, which in spleen, and bone marrow; the hemoglobin is broken down. Most of this degraded pigment leaves the body Hemoglobin in feces, as a brown pigment called stercobilin. The protein (glo bin) part of hemoglobin is metabolized or broken down to amino acids, which are released to the circulation. Heme Globin Disposal of hemoglobin spilled from red blood cells to the blood (as occurs in sickle-cell anemia or hemolytic anemia) Bilirubin Iron stored Amino takes a similar but much more rapid course to avoid toxic as ferritin, acids hemosiderin buildup of iron in blood. Released hemoglobin is captured by the plasma protein haptoglobin and the complex is phagocytized by macrophages. Iron is bound to transferrin and released to blood from liver as needed Erythrocyte Disorders for erythropoiesis. We describe the many varieties and causes of these Bilirubin is picked up from conditions next. Its hallmark is blood oxygen levels that are inadequate to support normal metabolism. Anemic individuals are fa Circulation tigued, often pale, short of breath, and chilly. In hemolytic anemias (he mo-lit ik), erythrocytes rup ture, or lyse, prematurely. Hemoglobin abnormalities, transfusion of mismatched blood, and certain bacterial and parasitic infections are possible causes. Consequently, the de (a) Normal erythrocyte has normal veloping erythrocytes grow but do not divide, and large, hemoglobin amino acid sequence in the beta chain. Pernicious anemia is an autoimmune disease in which the stomach mucosa atro phies, and it most often affects the elderly. Treatment in volves regular intramuscular injections of vitamin B12 or application of a B12-containing gel (Nascobal) to the nasal lining once a week. Two such examples, thal assemia and sickle-cell anemia, can be serious, incurable, and sometimes fatal diseases. In both diseases the globin part of hemoglobin is abnormal and the erythrocytes pro duced are fragile and rupture prematurely. One of the globin chains is absent or (b) Sickled erythrocyte results from a single amino acid change in the beta chain of faulty, and the erythrocytes are thin, delicate, and de? Scanning electron micrographs and where, ranging in severity from mild to so severe that (5700). In sickle-cell anemia, the havoc caused by the abnor mal hemoglobin, hemoglobin S (HbS), results from a Aplastic anemia may result from destruction or inhibi change in just one of the 146 amino acids in a beta chain tion of the red marrow by certain drugs and chemicals, 17 of the globin molecule! In most cases, the cause is causes the beta chains to link together under low-oxygen unknown. Because marrow destruction impairs forma conditions, forming stiff rods so that hemoglobin S be tion of all formed elements, anemia is just one of its signs. This, in turn, causes the red blood Defects in blood clotting and immunity are also present. When hemoglobin molecules the stiff, deformed erythrocytes rupture easily and are normal, but erythrocytes contain fewer than the usual tend to dam up in small blood vessels. Bone and chest pain are particu hemorrhagic anemias, but it also results from inadequate larly severe, and infection and stroke are common sequels. The erythrocytes produced, called microcytes,are acute sickle-cell crisis, but preliminary results using in small and pale. The obvious treatment is iron supple haled nitric oxide to dilate blood vessels are promising. It strikes nearly one of every 400 black newborns in expands and can increase by as much as 35% over time. Since this increased volume effectively dilutes the blood Chapter 17 Blood 643 the United States. How many molecules of oxygen can each hemoglobin mol While individuals with two copies of the sickle-cell gene ecule transport? What part of the hemoglobin binds the have sickle-cell anemia, individuals with only one copy of oxygen? Hydroxyurea, a drug used to treat chronic leukemia, Describe how leukocytes are produced. This drug Give examples of leukocyte disorders, and explain what dramatically reduces the excruciating pain and overall goes wrong in each disorder. Accounting for less than 1% of total and gene therapy to deliver genes for synthesizing normal blood volume, leukocytes are far less numerous than red blood beta chains. They Polycythemia Polycythemia (pol e-si-the me-ah; ?many form a mobile army that helps protect the body from damage by blood cells?) is an abnormal excess of erythrocytes that in bacteria, viruses, parasites, toxins, and tumor cells. The hematocrit may be as high as 80% and blood vol illary blood vessels?a process called diapedesis (di ah-pe? Once out of the treated by blood dilution, in other words, removing some blood bloodstream, leukocytes move through the tissue spaces by and replacing it with saline. The erythrocytes are quickly replaced be tissue damage and infection and gather there in large numbers cause the erythropoietin mechanism is triggered shortly after to destroy foreign substances or dead cells. Then, when the stored blood is reinfused, a tem Whenever white blood cells are mobilized for action, the porary polycythemia results.

Effects of compression on the arterial circulation External compression pressure should never exceed the intra arterial pressure anxiety questionnaire buy desyrel in united states online. This will barely be possible in a subject without arterial pathology in whom the intra-arterial pressure in the lower extremities will equal the blood pressure measured in the arm anxiety symptoms while falling asleep order desyrel with american express. By standing up anxiety oils order desyrel 100mg mastercard, the weight of the blood column (~80mmHg) will add to the systolic pressure in the lying position anxiety symptoms last all day buy generic desyrel, so that pressures over 200mmHg will be measured in the normal individual anxiety and dizziness discount desyrel uk. Extreme caution is necessary in patients with a reduced Both bandages are applied with a resting pressure of 40mmHg anxiety 9gag gif desyrel 100 mg without a prescription. Upon For patients with venous disease or with chronic oedema and standing, there is an immediate increase of pressure by 30mmHg concomitant arterial occlusions, comparing lower extremity under the inelastic bandage, and only a 10mmHg increase under systolic arterial pressure measurements with the values of the elastic bandage. The difference between standing and lying pressure is the ?Static Stiffness Index. The pressure amplitudes during systolic arm pressures can aid assessment of the severity of the movement correspond to the massaging effect of the material. This is easily done with a pocket Doppler instrument and application Standing can be considered as a snapshot during the cycle of of a sphygmomanometer cuff over the ankle (not the calf); the one single step. Therefore, the standing pressure comes very quotient between the pressure measured at the ankle and the close and correlates very well with the maximal pressure peaks upper arm in the lying position is the Ankle Brachial Pressure during walking. Facing the therapeutic challenge to intermittently compress In patients with calci? This would also mean that pressures of this magnitude should be reached during standing. If such In all cases, venous incompetence and chronic oedema will pressure should be achieved by using an elastic material with worsen the sequelae of arterial disease. Subtracted from peak pressures of there into the undernourished tissue will be reduced. Conversely, 60-90mmHg, this would cause a pressure of 30-60mmHg oedema will push blood capillaries apart so that the distances in the lying position, which is well tolerated. However, upon between each blood capillary and the malnourished tissue cells standing, the sub-bandage pressure would immediately increase will increase, impeding the transport of nutrients. Such ?intelligent Compression is able to increase the reduced arterio-venous compression products? for the treatment of venous problems pressure gradient and to reduce the distance between nourishing are therefore characterised by a high working pressure and a capillaries by removal of oedema. Capillary pressure is more sensitive to changes pressures led to a reduction of the toe pressure19. Because of the low shown, even in individuals without arterial pathology20, an post-capillary resistance, the level of venous pressure mimics increase of blood? This, together with the massaging action of a stiff bandage Arterially, vasoconstriction reduces capillary pressure, which is producing hyperaemia in a similar way as intermittent pressure the basis for local veno-arterial re? If these are intact, an pumps, is the reason for recommending walking exercises increase in venous pressure will lead to constriction of arterioles, with not too strongly applied stiff bandages as the basis of excluding large areas of? This mechanism conservative treatment in patients with mixed, arterial-venous based on an axon-re? This veno-arterial response is suspended How compression affects the microcirculation in patients with arterial occlusive disease and in patients with Over recent years, several important findings concerning peripheral neuropathy (for example, in diabetes). The effects of compression on the microcirculation include 21-28: Material with low stiffness but higher pressure may achieve a reduction of capillary? This prevention of adhesion of neutrophils and monocytes to the is why continuation of sustained compression will be necessary capillary endothelium and reduction of inflammatory after initial decongestion. Traditionally it was thought that 90% of metalloproteinases) in ulcer patients the total blood volume that drained through the microcirculation anti-inflammatory, analgesic and anti-thrombotic, returned to the heart via the venous system, with the remaining vasodilatory effect by release of biochemical mediators 10% carried by the lymphatics. However, a recent study found from endothelial cells during intermittent compression that the difference between the venous pressure and interstitial (tissue plasminogen activator, nitric oxygen, tissue factor pressure was too low to create the physiological state for pathway inhibitor) reabsorption, and indicated that in peripheral tissues, 100% of liquid removal occurred through the lymphatic circulation13. How compression affects oedema these findings underline the importance of the lymphatic Our current understanding of how compression works on patients drainage, which will always be compromised in a patient with with chronic oedema and lymphoedema remains poor and relies chronic oedema. The dramatic reduction of oedema is thought Compression increases tissue pressure resulting in an increased to be mainly due to: tension on the anchoring? Figure 3: Intracutaneous injection (indirect Different methods to visualise lymph drainage by injecting dyes lymphography) or radioactive tracers have been used to demonstrate the effect of different compression devices on the lymphatic drainage. Due to often non-homogenous clinical situations and different techniques, the results are sometimes dif? In patients with post thrombotic syndrome the sub-facial lymph transport assessed by intramuscular injection of radioactive colloids is reduced. Inelastic compression bandages and walking exercises are able to increase this damaged subfascial lymph drainage35,36. Water-soluble contrast media is delivered into a lipodermatosclerotic area above the inner ankle shows dermal Shift of? This can be prevented by using compression of toes and resolved, indirect lymphography shows normal lymph collectors? It was demonstrated that analyse, mainly due to the broad diversity of treatment modalities tissue? Most studies concentrating to +10mmHg and did not differ from those measured in normal on volume reduction have compared compression versus the subjects. During manual massage, the applied force generated same compression in addition to manual lymphatic drainage pressures ranging from 100 to 150mmHg. Different compression distance of 3cm from the location of the pressure sensor did devices were only compared sporadically. The pressure range required to effectively narrow leg veins A wide spectrum of different compression devices following in different body positions could be evaluated by different different national regulations is available. Table 2 gives an experiments using duplex ultrasound or magnetic resonance overview, including some brand names as examples for speci? While hosiery and compression devices are mentioned, ?pressure and stiffness of compression products. In contrast to the venous side, only few data are available In a consensus document, the characteristics for a compression searching for optimal pressure ranges to reduce oedema. Pressure: corresponding to the dosage of treatment, it is the deciding parameter of compression and bandage application. Measuring the volume reduction of swollen limbs by compression It depends mainly on the manual force which is used to stretch bandages different pressure ranges were found to be maximally the bandage during application and on the curvature of the limb effective for arm and for leg oedema. For the lower extremity the following pressure ranges arm lymphoedema, inelastic bandages with a pressure between were de? In patients with leg oedema, moderate (>20?40mmHg) compression stockings in the range between 20 and 40mmHg showed a positive correlation between exerted pressure and strong (>40?60mmHg) volume reduction. However, bandages applied with an initial resting pressure of more than 60mmHg resulted in a decreasing very strong (> 60mmHg) volume reduction61. From these studies it may be concluded that there is obviously an upper limit beyond which further increase the only way to assess these pressures is to measure them by of compression pressure seems counterproductive. For inelastic adequate instrumentation, recommended for training purposes bandages, this upper limit is around 30mmHg on the upper and and for trials, but not for everyday practice64. The pressure stocking this difference in optimal pressure range between upper and will depend on the elastic strength of the stocking and the lower extremities seems to be caused by the different levels of relationship between the size of the extremity and the adequately? Lymphatic congestion Layers: correspond to the amount of overlaps; thus, practically lymphoscintigraphy63 showed reduced pressures generated by all bandages are multi-layer. A single compression sleeve has the lymphatic pump in patients with arm lymphoedema (24 + one layer, a double stocking has two. This may explain the surprising result that inelastic bandages applied Components: most modern bandages are composed of with a pressure under 30mmHg achieved more volume reduction different components, such as padding material and various than bandages with a pressure of more than 50mmHg60. If bandage changes are done twice daily, a low pressure Elastic property: the elastic property of the textiles used in? Basically, this relationship corresponds to the in longer time intervals thus taking the rapid pressure fall into difference between working pressure and resting pressure (Figure consideration, a higher initial pressure will provide longer periods 2). To achieve a high working pressure using an elastic, long in which an optimal pressure range will be delivered. Patient can have Works when High different versions Self-adjustable showers, daily skin patient is resting care, self-management for limited time. As described previously, the amount exerting a well tolerable, low resting pressure and a high working of pressure increase by standing up characterises the pressure (Figure 2). By applying two or more layers of elastic material over each the pressure loss of such bandages is very fast (after 2 other the? Thus, such bandages should be reapplied when Stiff bandages can also be achieved by adhesive (binding to they become too loose to keep the levels of compression the skin) or cohesive surfaces (sticking to itself). Stiff bandages will not give way during exercise and will standing up from the lying position (static stiffness index) or create a ?massaging effect? during muscle contractions during movement (dynamic stiffness index). Box 1: Requirements for an ideal compression system for patients with venous leg ulcers the ideal compression pro? For elastic compression stockings, a continuous pressure reduction from distal to proximal (degressive Enhances calf muscle pump function pressure pro? However, this dogma has been Non-allergic, easy to apply challenged in respect of mobile, venous patients; a higher pressure over the calf results in a stronger blood expelling force of the muscle pump66. Most of the listed points are also features of the classical inelastic Lymphoedema patients show altered limb shapes and deformities bandage for patients with chronic oedema/lymphoedema. A common recommendation for bandaging such limbs is to change the contour of the limb into a cone Why high stiffness devices in lymphoedema? Reshaping the contour of the extremity may rather oedema/lymphoedema, namely: be achieved by moulding the bandage to the limb in an individual manner, trying to avoid too much padding, without trying to 1. Inelastic, stiff bandages have a low, well tolerable resting avoid too high proximal pressures. When a stiff bandage is strongly Padding is often considered a safety feature recommended applied under high tension, exerting a pressure on the mainly to less experienced bandagers. Some experimental work leg of for example, 60mmHg, oedema removal begins has been carried out showing that padding is dissipating and immediately and the pressure decreases very quickly into reducing the pressure from areas which would need stronger a range which will also be well tolerated during rest (for compression, changes stiffness, makes bandages bulky and hot example, to 40mmHg). However, when the patient gets and frequently promotes slippage, depending on the material up there will be an immediate, steep increase of pressure used67,68. In immobile patients the same effect can also be seen when toes or ankles are passively moved by a nurse, a physiotherapist or a relative of the patient. Such bandages, applied with high enough pressure by trained staff will lead to a fast reduction of leg-volume and will need to be changed initially in time intervals of twice or three times per week. This is certainly a more reasonable and effective management than applying elastic bandages or compression stockings every morning, often by home-nurses, based mainly on the misconception that inelastic material would works only in mobile patients. This is also true after liposuction and most other surgical procedures while venous problems are associated with living in the upright position and compression in such patients is mainly needed during the daytime, lymphatic damage preferably requires compression day and night self-management is a goal based on important psychological and economic advantages. To this end, education of the patient underlining the importance of compression and functionality and impede joint mobility. This is obviously the movement (structured exercises) is essential reason why in two recent studies44,69, a two-component system and a Velcro band device respectively achieved more volume the initial therapy phase should start by using compression reduction compared to a conventional multi-component system which is adjusted to the underlying pathology and limb in spite of comparable resting pressures. With every self-treatment could be promoted by using pumps, Velcro extension of the limb due to muscle activity the non-yielding band devices and by? These may functionality and the decongestive effects of compression, need to be made-to-measure, especially in patients with gross and skin care in order to prevent (recurrent) infections which deformations and preferably inelastic (? Additional will worsen lymphatic drainage intermittent pneumatic compression or phases with short stretch bandages may be useful especially when oedema reduction can not be suf? Jan Schuren is a retired 3M employee Co-developer of the 3M Coban? 2 Layer compression systems Introduction intra-lymphatic pressures, propelling lymph. Cheville et al 6 compression, has been shown to be effective in lymphoedema report that remedial exercises, which are always performed care. The mechanisms of action of each individual component with some type of external compression, in? Functional activities states that much of the evidence on how compression works can release? In addition, she concludes that be performed for all joints within and proximal to the territory many studies report on the use of decongestive lymphatic therapy affected by lymphoedema. It should be noted that the research in this chapter is clinical trials in this area. The authors revealed that the theoretical pressure formula provided a mechanistic view of the pressures exerted values calculated by the modi? The data clearly indicate that in vivo pressure leg, which is neither solid nor has a constant curved structure8. In addition, none of the compression systems tested may not apply to human bodies with deformable or irregular provided dependable graduated compression on the arti? It was concluded that the widespread belief the number of layers applied, Thomas modi? Thomas explains that the application of two7 layers of a bandage, applied with constant tension, will double Box 1: Modi? For this reason the number of layers of bandage applied must be considered when calculating sub-bandage pressure. The original Charing Cross four-layer compression system was developed to apply 40mmHg of pressure at the ankle, graduating to 17mmHg at the knee10. Blair et al11 state that because of the increased radius from ankle to calf, graduated compression will be applied automatically, providing the same tension and overlap are used. They add that mistakes in the tension applied in any one layer of the four-layer system will tend to be averaged out. De Bruyne et al12 present a device to measure the pressure exerted by an elastic stocking without upsetting the original application. The method reveals that a cross-sectional pressure value, which is the result of the Thomas equation, is not a realistic Figure 2: Theoretical and measured pressure values of Coban? 2 value due to variation in curvature. The authors Layer Lite demonstrated that the radial pressure is only exerted on convex surfaces and the tested stocking cannot exert pressure if the surface is plane or concave. Much of the literature supports the 40?17 mmHg compression value as the ideal in healing venous leg ulcers13 and many practitioners take these values for granted and sub-bandage pressure measurements are rarely performed. The lines of the theoretical and7 actual values have only a common starting point with the values deviating from the second layer. To study material stiffness, Schuren16 developed a method for a completely controlled application and stiffness recording on test cylinders. Figure 4: Stiffness (strain indices) for the three materials under investigation In clinical practice, especially in lymphoedema bandaging, additional overlapping layers are frequently applied to produce the desired pressure characteristics17.

Cheap 100 mg desyrel overnight delivery. ANXIETY PARANOIA OCD & DRUGS PRESCRIBED FOR THEM PART 5.

cheap 100 mg desyrel overnight delivery

desyrel 100mg generic

Persistent enterovirus infection in undergoing bone marrow transplantation?a compassionate use experience anxiety treatment for children generic desyrel 100 mg amex. Treatment of potentially life-threatening enterovirus in evidence-based medicine anxiety symptoms full list order desyrel american express. Discovery of ulin in adult varicella pneumonia complicated by acute respiratory distress syn structurally diverse small-molecule compounds with broad antiviral activity drome anxiety 25 mg zoloft trusted desyrel 100 mg. Chronic enteroviral adenoviral pneumonitis with intravenous ribavirin and immunoglobulin anxiety xanax and copd order desyrel online from canada. Thorax meningo-encephalitis in X-linked agammaglobulinaemia: favourable response 1995;50:1219-20 anxiety yeast infection desyrel 100 mg without prescription. Successful treatment of chronic parvovirus B19 infection by high-dose immu immunoglobulins for treatment of acute rotaviral gastroenteritis anxiety ridden buy 100 mg desyrel overnight delivery. Intrauterine anemia due to parvovirus B19: successful treatment with intrave munoglobulins for treatment of protracted rotaviral diarrhea. Severe rotavirus nous immunoglobulin therapy in 3 cases of parvovirus B19-associated chronic fa associated diarrhoea following bone marrow transplantation: treatment with oral tigue syndrome. Intravenous immunoglobulin in acute rheumatic fever: a randomized human serum immunoglobulin in immunode? Dutch course of clinical response to intravenous immunoglobulin in chronic Guillain-Barre Study Group. Effect of methylprednisolone when added to standard treatment with intrave December 4, 2016. Overview of the pathogenesis and treatment of ized controlled trial of intravenous immunoglobulin versus oral prednisolone in chronic in? Cochrane Database Syst Rev 2005; immunoglobulin treatment in children with Guillain-Barre syndrome. Outcome of severe Guillain-Barre syndrome in children: immunoglobulin treatment in patients with motor neuron syndromes associated comparison between untreated cases versus gamma-globulin therapy. J Neurol Neurosurg Psychia immunoglobulin therapy for Guillain-Barre syndrome in Japanese children. Emerging drugs for Guillain-Barre syn taneous immunoglobulin therapy for multifocal motor neuropathy. Immunotherapy for IgM anti-myelin-associated placebo-controlled, cross-over study. Immunoglobulin treatment polyneuropathy: a double-blind, placebo-controlled, crossover study. Neurology versus plasma exchange in patients with chronic moderate to severe myasthenia 1990;40:209-12. Intra Plasma exchange versus intravenous immunoglobulin treatment in myasthenic venous immunoglobulin in relapsing-remitting multiple sclerosis: a dose-? Intravenous immunoglobulin for myasthenia (pseudo-Lennox syndrome): report of two brothers. Intravenous high-dose thenic syndrome: development of 3,4-diaminopyridine phosphate salt as? Effects of intravenous immunoglobulin on muscle weakness and calcium-channel Neuropediatrics 1990;21:87-90. Int J Clin Lab Res 1994;24: Lambert-Eaton syndrome treated with intravenous immunoglobulin. Use of intravenous immunoglobulin in immunoglobulins in refractory childhood-onset epilepsy: effects on seizure fre Lambert-Eaton myasthenic syndrome. Eur J Neurol Positive response to immunomodulatory therapy in an adult patient with Rasmus 2010;17:893-902. Trans tive of multiple sclerosis: a randomized, double-blind, placebo-controlled trial. Intravenous immunoglobulin G for the treatment encephalitis responsive to intravenous immunoglobulin therapy. Mult Scler guidelines on the use of intravenous immune globulin for hematologic and neuro 2007;13:1107-17. Use of intravenous immunoglobulin therapy during nous immunoglobulin in recurrent-relapsing in? Intravenous immunoglobulin therapy in autoim immunoglobulin therapy in patients with paraneoplastic cerebellar degeneration mune mucocutaneous blistering diseases: a review of the evidence for its ef? Intravenous immunoglobulin treat globulin therapy for immunomodulation in a patient with severe epidermolysis ment of the post-polio syndrome: sustained effects on quality of life variables and bullosa acquisita. Intravenous immunoglobulin ical applications of intravenous immunoglobulins in neurology. Intravenous high-dose immunoglobulin treatment in recent onset childhood nar 529. Intravenous immunoglobulin therapy for patients with idiopathic cardiomyopathy 505. Controlled trial of intravenous immune globulin in recent-onset dilated car 255:1900-3. Intravenous immune globulin treat A randomised clinical trial comparing interferon-alpha and intravenous ment of pulmonary exacerbations in cystic? J Neurol Neurosurg Psychiatry noglobulin and IgG subclass levels in a regional pediatric cystic? Therapeutic plasma exchange and intravenous immunoglobulin for Infect Dis 2010;12:470-2. Intravenous immunoglobulin and recurrent preg and X-linked agammaglobulinaemia but not speci? Comparison of American and European of intravenous immunoglobulin for treatment of recurrent miscarriage: a system practices in the management of patients with primary immunode? Effec Intravenous immunoglobulin therapy in pregnant patients affected with systemic tiveness of immunoglobulin replacement therapy on clinical outcomes in patients lupus erythematosus and recurrent spontaneous abortion. Alterations in the half-life and clearance of IgG during therapy venous immunoglobulin for recurrent abortion associated with antiphospholipid with intravenous gamma-globulin in 16 patients with severe primary humoral im antibody syndrome. Prospective audit of adverse reac venous immunoglobulin improves live birth rates in women with recurrent spon tions occurring in 459 primary antibody-de? Relation and chronic fatigue syndrome: the need of accurate diagnosis, objective ship of the dose of intravenous gammaglobulin to the prevention of infections assessment, and acknowledging biological and clinical subgroups. Intravenous immunoglobulin is ineffective in the treatment of patients with venous immunoglobulin and comparison (retrospective) with plasma treatment. Long term use of intravenous immune globulin in patients with pri chronic fatigue treated with high-dose intravenous immunoglobulin. Increased serum albumin, gamma globulin, immunoglobulin IgG, and venous immunoglobulin and adjunctive therapies in the treatment of primary im IgG2 and IgG4 in autism. Brief report: a pilot open clinical trial of intravenous immunoglobulin in child Available at: The use of intravenous immunoglobulin in the treatment of autoim immunoglobulin in children with primary immunode? Acta Paediatr mune neuromuscular diseases: evidence-based indications and safety pro? Subcutaneous immunoglobulin replacement in patients with primary antibody de Neurol Sci 2003;24(Suppl 4):S222-6. Rapid subcutane venous immunoglobulin: incidence in 83 patients treated for idiopathic thrombo ous IgG replacement therapy at home for pregnant immunode? Side effects of high-dose intravenous life situations of patients with primary antibody de? Subcutaneous immunoglobulin home treatment in hypogammaglobu Exp Immunol 1998;112:341-6. J Clin Immunol 2006;26: administration, IgPro20, in patients with primary immunode? Idiopathic thrombocytopenic purpura in a boy with ataxia patients on regular replacement therapy. Subcutaneous immunoglobulin replacement therapy for push vs infusion pump: a retrospective analysis. Schleinitz N, Jean E, Benarous L, Mazodier K, Figarella-Branger D, Bernit E, of life, immunoglobulin G levels, and infection rates in patients with primary im et al. Subcutane globulin dosage and switch from intravenous to subcutaneous immunoglobulin ous immunoglobulin infusion: a new therapeutic option in chronic in? Navigational Note: Bone marrow hypocellular Mildly hypocellular or <=25% Moderately hypocellular or Severely hypocellular or >50 Aplastic persistent for longer Death reduction from normal >25 <50% reduction from <=75% reduction cellularity than 2 weeks cellularity for age normal cellularity for age from normal for age Definition: A disorder characterized by the inability of the bone marrow to produce hematopoietic elements. Navigational Note: Hemolysis Laboratory evidence of Evidence of hemolysis and Transfusion or medical Life-threatening Death hemolysis only. Navigational Note: Asystole Periods of asystole; non Life-threatening Death urgent medical management consequences; urgent indicated intervention indicated Definition: A disorder characterized by a dysrhythmia without cardiac electrical activity. Navigational Note: Atrial flutter Asymptomatic, intervention Non-urgent medical Symptomatic, urgent Life-threatening Death not indicated intervention indicated intervention indicated; device consequences; embolus. Navigational Note: Atrioventricular block Non-urgent intervention Symptomatic and Life-threatening Death complete indicated incompletely controlled consequences; urgent medically, or controlled with intervention indicated device. Conduction disorder Mild symptoms; intervention Non-urgent medical Symptomatic, urgent Life-threatening Death not indicated intervention indicated intervention indicated consequences Definition: A disorder characterized by pathological irregularities in the cardiac conduction system. Navigational Note: Cyanosis Present Definition: A disorder characterized by a bluish discoloration of the skin and/or mucous membranes. Navigational Note: If left sided use Cardiac disorders: Left ventricular systolic dysfunction; also consider Cardiac disorders: Restrictive cardiomyopathy, Investigations: Ejection fraction decreased. Navigational Note: Mobitz type I Asymptomatic, intervention Symptomatic; medical Symptomatic and Life-threatening Death not indicated intervention indicated incompletely controlled consequences; urgent medically, or controlled with intervention indicated device. Navigational Note: Myocarditis Symptoms with moderate Severe with symptoms at rest Life-threatening Death activity or exertion or with minimal activity or consequences; urgent exertion; intervention intervention indicated. Navigational Note: Paroxysmal atrial tachycardia Asymptomatic, intervention Non-urgent medical Symptomatic, urgent Life-threatening Death not indicated intervention indicated intervention indicated; consequences; incompletely ablation controlled medically; cardioversion indicated Definition: A disorder characterized by a dysrhythmia with abrupt onset and sudden termination of atrial contractions with a rate of 150-250 beats per minute. Navigational Note: Pulmonary valve disease Asymptomatic valvular Asymptomatic; moderate Symptomatic; severe Life-threatening Death thickening with or without regurgitation or stenosis by regurgitation or stenosis by consequences; urgent mild valvular regurgitation or imaging imaging; symptoms controlled intervention indicated. Navigational Note: Sick sinus syndrome Asymptomatic, intervention Symptomatic, intervention Symptomatic, intervention Life-threatening Death not indicated not indicated; change in indicated consequences; urgent medication initiated intervention indicated Definition: A disorder characterized by a dysrhythmia with alternating periods of bradycardia and atrial tachycardia accompanied by syncope, fatigue and dizziness. Navigational Note: Sinus bradycardia Asymptomatic, intervention Symptomatic, intervention Symptomatic, intervention Life-threatening Death not indicated not indicated; change in indicated consequences; urgent medication initiated intervention indicated Definition: A disorder characterized by a dysrhythmia with a heart rate less than 60 beats per minute that originates in the sinus node. Navigational Note: Sinus tachycardia Asymptomatic, intervention Symptomatic; non-urgent Urgent medical intervention not indicated medical intervention indicated indicated Definition: A disorder characterized by a dysrhythmia with a heart rate greater than 100 beats per minute that originates in the sinus node. Navigational Note: Tricuspid valve disease Asymptomatic valvular Asymptomatic; moderate Symptomatic; severe Life-threatening Death thickening with or without regurgitation or stenosis by regurgitation or stenosis; consequences; urgent mild valvular regurgitation or imaging symptoms controlled with intervention indicated. Navigational Note: Ventricular arrhythmia Asymptomatic, intervention Non-urgent medical Urgent intervention indicated Life-threatening Death not indicated intervention indicated consequences; hemodynamic compromise Definition: A disorder characterized by a dysrhythmia that originates in the ventricles. Navigational Note: Ventricular tachycardia Non-urgent medical Symptomatic, urgent Life-threatening Death intervention indicated intervention indicated consequences; hemodynamic compromise Definition: A disorder characterized by a dysrhythmia with a heart rate greater than 100 beats per minute that originates distal to the bundle of His. Navigational Note: Middle ear inflammation Serous otitis Serous otitis, medical Mastoiditis; necrosis of canal Life-threatening Death intervention indicated soft tissue or bone consequences; urgent intervention indicated Definition: A disorder characterized by inflammation (physiologic response to irritation), swelling and redness to the middle ear. Navigational Note: Delayed puberty No breast development by No breast development by age 13 yrs for females; testes age 14 yrs for females; no volume of <3 cc or no Tanner increase in testes volume or Stage 2 development by age no Tanner Stage 2 by age 16 14. Navigational Note: Hyperparathyroidism Mild symptoms; intervention Moderate symptoms; medical not indicated intervention indicated Definition: A disorder characterized by an increase in production of parathyroid hormone by the parathyroid glands. Navigational Note: Precocious puberty Physical signs of puberty with Physical signs and no biochemical markers for biochemical markers of females <8 years and males puberty for females <8 years <9 years and males <9 years Definition: A disorder characterized by unusually early development of secondary sexual features; the onset of sexual maturation begins usually before age 8 for girls and before age 9 for boys. Extraocular muscle paresis Asymptomatic; clinical or Unilateral paresis without Bilateral paresis or unilateral Bilateral paresis requiring diagnostic observations only double vision paresis causing double vision head turning to see beyond in peripheral gaze, but not in central 60 degrees or double central gaze vision in central gaze Definition: A disorder characterized by incomplete paralysis of an extraocular muscle. Navigational Note: Papilledema Asymptomatic; no visual field Symptomatic; moderate Symptomatic with marked Best corrected visual acuity of deficit decrease in visual acuity (best decrease in visual acuity (best 20/200 or worse in the corrected visual acuity 20/40 corrected visual acuity worse affected eye and better or 3 lines or less than 20/40 or more than 3 decreased vision from known lines of decreased vision from baseline) known baseline, up to 20/200) Definition: A disorder characterized by swelling around the optic disc. Navigational Note: If retinal detachment is present, grade under Eye disorders: Retinal detachment Retinal vascular disorder Retinal vascular disorder Retinal vascular disorder with without neovascularization neovascularization Definition: A disorder characterized by pathological retinal blood vessels that adversely affects vision. Navigational Note: If vitreous hemorrhage is present, report under Eye disorders: Vitreous hemorrhage. Navigational Note: Uveitis Anterior uveitis with trace Anterior uveitis with 1+ or 2+ Anterior uveitis with 3+ or Best corrected visual acuity of cells cells greater cells; intermediate 20/200 or worse in the posterior or pan-uveitis affected eye Definition: A disorder characterized by inflammation to the uvea of the eye. Navigational Note: Anal fissure Asymptomatic Symptomatic Invasive intervention indicated Definition: A disorder characterized by a tear in the lining of the anus. Navigational Note: Anal fistula Asymptomatic Symptomatic, invasive Invasive intervention Life-threatening Death intervention not indicated indicated consequences; urgent intervention indicated Definition: A disorder characterized by an abnormal communication between the opening in the anal canal to the perianal skin. Navigational Note: Synonym: Burping Bloating No change in bowel function Symptomatic, decreased oral or oral intake intake; change in bowel function Definition: A disorder characterized by subject-reported feeling of uncomfortable fullness of the abdomen. Navigational Note: Cecal hemorrhage Mild symptoms; intervention Moderate symptoms; Transfusion indicated; Life-threatening Death not indicated intervention indicated invasive intervention consequences; urgent indicated; hospitalization intervention indicated Definition: A disorder characterized by bleeding from the cecum. Navigational Note: Colonic perforation Invasive intervention not Invasive intervention Life-threatening Death indicated indicated consequences; urgent intervention indicated Definition: A disorder characterized by a rupture in the colonic wall. Navigational Note: Duodenal perforation Invasive intervention not Invasive intervention Life-threatening Death indicated indicated consequences; urgent operative intervention indicated Definition: A disorder characterized by a rupture in the duodenal wall. Navigational Note: Dyspepsia Mild symptoms; intervention Moderate symptoms; medical Severe symptoms; operative not indicated intervention indicated intervention indicated Definition: A disorder characterized by an uncomfortable, often painful feeling in the stomach, resulting from impaired digestion. Navigational Note: Enterocolitis Asymptomatic; clinical or Abdominal pain; mucus or Severe or persistent Life-threatening Death diagnostic observations only; blood in stool abdominal pain; fever; ileus; consequences; urgent intervention not indicated peritoneal signs intervention indicated Definition: A disorder characterized by inflammation of the small and large intestines. Navigational Note: Esophageal fistula Asymptomatic Symptomatic, invasive Invasive intervention Life-threatening Death intervention not indicated indicated consequences; urgent intervention indicated Definition: A disorder characterized by an abnormal communication between the esophagus and another organ or anatomic site. Navigational Note: Esophageal perforation Invasive intervention not Invasive intervention Life-threatening Death indicated indicated consequences; urgent operative intervention indicated Definition: A disorder characterized by a rupture in the wall of the esophagus. Navigational Note: Esophageal varices Self-limited; intervention not Transfusion indicated; Life-threatening Death hemorrhage indicated invasive intervention consequences; urgent indicated; hospitalization intervention indicated Definition: A disorder characterized by bleeding from esophageal varices.

Therew as G oing AfterCacciato anxiety disorder nos 3000 buy 100 mg desyrel with mastercard,andonem orning I satdow nandbegana no choicebutto rem ovethechapterentirely anxiety symptoms dogs order desyrel 100 mg line. To that anxiety 7 year old daughter discount desyrel 100mg online,though anxiety chest tightness cheap desyrel 100mg fast delivery,som ething aboutthestory had frightened m e? I provideadram atic fram e anxiety symptoms only at night discount desyrel online visa,I collapsed eventsinto asingletim e w as afraid to speak directly separation anxiety desyrel 100mg mastercard,afraid to rem em ber? and in the and place,a car circling a lake on a quietafternoon in end thepiecehad been ruined by afailureto tellthefulland m idsum m er,using the lake as a nucleus around w hich the ex acttruth aboutournightintheshitfield. F orthescenery I borrow edheavily pridein ashadow y,idealized recollection of itsvirtues. I liftedup thepieceappeared in an anthology of shortfiction,I senta W orthington,M innesota? thelake,theroad,thecausew ay,the copy off to N orm an Bow ker w ith the thoughtthatitm ight w om an in pedalpushers,the junior college,the handsom e pleasehim. I n theF ield I n Augustof 1978 his m other sentm e a brief note ex plaining w hathad happened. Therew as no suicidenote,no m essageof forw ard,headsdow n,they used thebuttsof theirw eaponsas any kind. Therains had fallen w ithoutstop,and piecehasbeen substantially revised,in som eplacesby severe theSong TraBong hadoverflow editsbanks,andthem uckhad cutting,in other places by the addition of new m aterial. Thecentral softlittlem oaning sounds,and them onsoonsseem ed to bea incident? ourlong nightin theshitfield along theSong Tra lasting elem entof the w ar. In theinterests of truth,how ever,I w antto m ake itclear thatN orm an Bow ker w as in no w ay responsible for w hathappened to K iow a. And K iow a had been a splendid thenam eand circum stances,buthew as now determ ined to hum an being,thevery best,intelligentand gentleand quiet find hism an,nom atterw hat,evenif itm eantflying inslabsof spoken. Therainw asthew arandyouhadto coulddonow,butstillitw asam istakeandahideousw aste. Standing in thedeep w atersof thefield,F irst Turning,helookedoutacrossthefieldandyelledatoneof L ieutenantJ im m y Crossbegan com posing aletterin hishead his m en to closeup therank. Thefilth brighten,thesky going toalightershadeof silver,butthen the seem ed toeraseidentities,transform ing them en intoidentical rains cam e back hard and steady. There w as the feel of copiesof asinglesoldier,w hich w asex actly how J im m y Cross perm anenttw ilight. Itw asdifficult(156) (157) M itchellSanders w aded along theedgeof thefield closestto J ustfind him and slide him aboard a chopper. They w eretallm en,butattim es them uck cam eto m an died itw as alw ays thesam e,a desireto getitoverw ith m idthigh,othertim estothecrotch. H e coughed and shook his head for a ville and getunder a roof and forgetw hathad headandsaid,"M an,talkaboutirony. The pack w as produced a pow erfuldow nw ard suction,and w ith each step heavy w ith m ud and w ater,dead-looking. H e oneedgeof thefield w asasm allville,and rightaw ay acouple had finished w riting theletterin hishead,ex plaining thingsto of old m am a-sans had trotted outto w arn him. By m idnighttheSong TraBong through therough,sw eeping backand forth in long system atic had overflow ed its banks. H erem em bered how thew aterkeptrising, L ooking outacrossthew aterhazard thatfronted thesm allflat how aterriblestinkbegan tobubbleup outof theearth. Itw as green,aseven iron in hishand,calculating w ind and distance, a dead-fish sm ell,partly,butsom ething else,too,and then w ondering if he should reach instead for an eight. A tough laterin thenightM itchellSanders had craw led through the decision,butallyou couldeverlosew asaball. Theguy stared for J im m y Cross did notw antthe responsibility of leading a m om entand then w iped his m outh and w hispered,"Shit," thesem en. Theboy m ortarfirefrom across theriver,allthey could do w as snake recognized his ow n guiltand w anted only to lay outthefull dow n under the slop and lie there and w ait. R ain and slop and shrapnel,itallm ix ed together, W ading sidew ays a few steps,he leaned dow n and felt and thefield seem ed to boil. H e rem em bered Straightening up,F irstL ieutenantJ im m y Cross rubbed sw itching on hisflashlight. Therainfellina anyw ay,and herem em bered K iow aleaning in foralookatthe cold,saddrizzle. AndasaresulthisfriendK iow a soldier,orthew ay heseem ed to bereaching forsom einvisible w asdead. N o groping w ith both hands,he seem ed to be chasing som e senseof direction,though,and thefield seem ed to suck him creaturejustbeyond reach,som ething elusive,afish orafrog. Thispicture,itw astheonly one pulling hard,buthow thefield seem ed to pullback,likeatug I had. I had itallw rapped up,I had itin plastic, to therain and ex plosionsand bubbling sounds. H e w atched the young soldiershove his hands into the H efeltsom epity com eon him. Them ud seem ed to flow backfasterthan they could dig,butK iow aw astheirfriend and N orm an Bow kertouched theboot,covered his eyes fora they keptatitanyw ay. Therew asafeeling of and they w aited a m om ent,then Sanders sighed and said, aw. They tried again,butthis pulled again,and aftera m om entK iow a cam esliding to the tim e the body did notm ove atall. A piece of his shoulder w as m issing;the arm s and stopped and looked dow n for a w hile. They (167) They triedagain,thencalledoverH enry D obbins(166) used tow elsto clean off thescum. W hich w asthetruth, som esm oking,som eopening up cans of C rations,afew just hethought. L ieutenantCross w entdeeper into the m uck,the dark F orallof them itw asarelief tohaveitfinished. Youcouldblam ethe N earthecenterof thefield F irstL ieutenantJ im m y Cross idiotsw ho m adethew ar. You could blam eK iow aforgoing to squatted in them uck,alm ostentirely subm erged. You could blam e the long tim eago I w alked through Q uang N gaiProvinceasafoot m unitionsm akersorK arlM arx oratrickof fateoran old m an soldier. In thecloudsto tw enty yearsagoI w atchedam andieonatrailnearthevillage theeasttherew asthesoundof ahelicopter,buthedidnottake of M y K he. A golden nota pretty face,because his jaw w as in his throat,and I afternoon on thegolf course,thefairw ayslush and green,and rem em ber feeling the burden of responsibility and grief. I w antyou to know w hy hew ould justtakea coupleof practicesw ings and knock the story-truth istruersom etim esthanhappening-truth. H ew as a slim,dead,alm ostdainty w ith m y daughter to Vietnam,w here w e visited the site of young m an of abouttw enty. E x ceptforafew m arshy spotsalong theriver, I can look atthings I neverlooked at. Along the river tw o old "D addy,tellthetruth,"K athleen can say,"did you everkill farm ersstood in ankle-deep w ater,repairing thesam enarrow anybody? Atonepoint,I rem em ber,oneof thefarm erslooked up and shaded hiseyes,staring acrossthe field atus,then aftera tim ehew iped his forehead and w ent backtow ork. Ithadbeen "This w hole w ar,"she said,"w hy w as everybody so m ad at ahard tw o-hourridefrom Q uang N gaiCity,bum py dirtroads everybody else? I tried to find som ething to tellher,butfinally I shrugged Shestartedtosay som ething butthenhesitated. Thatnight, though,justbefore bedtim e,K athleen puther hand on m y shoulderand said,"You know som ething? I w alked up tow ard the river,trying to pick out hertheVietnam thatkeptm e aw ake atnight? a shady trail specific landm arks,butallI recognized w asasm allrisew here outside the village of M y K he,a filthy old pigsty on the J im m y Crosshad setup hiscom m and postthatnight. F oraw hileI w atched thetw o old farm ersw orking under had to bem ade,and in theend I decided to takeherto this the hotsun. I took a few m ore photographs,w aved atthe pieceof ground w herem y friend K iow a had died. Sheglanced atthebundleagain,then hopped outof the this littlefield,I thought,had sw allow ed so m uch. F or tw enty years this field had em bodied allthew astethatw asVietnam,allthevulgarity and I strippeddow ntom y underw ear,tookoff m y w rist-w atch, horror. Shesquinted atm e,herhands fieldoneof theoldfarm ersstoodw atching from along thedike. L ike w aking from a sum m er nap,feeling lazy and sluggish,the w orldcollecting itself aroundm. Thefirsttim e,outby TriBinh,itknocked choppercam e to take m e and tw o dead guys aw ay. H etied on a com press and told m eto easeback, and puthishead againstm y shoulderand alm osthugged m. E very so often,m aybe four tim es to J apan,and a new m edic nam ed Bobby J orgenson had altogether,he trotted back to check m e out. Sow henI gotshotthesecondtim e,in and regrouping and running again,lotsof noise,butR atK iley thebutt,along theSong Tra Bong,ittook theson of a bitch tooktherisks. Tom akeitw orse,hebungled thepatch job,and acoupleof w eekslaterm y assstarted to rot aw ay. Thosebuggy eyesandthe w ay his lips tw itched and thatsilly ex cuse he had for a m ustache. Aftertherotcleared up,onceI could thinkstraight, I devoted a lotof tim eto figuring w ays to getback athim. I m ortar fire? butyou could also die in the bleachers atM et m eanisthatyou shouldbeabletotalkaboutit:thestiff thum p Stadium in M inneapolis,bases loaded,H arm on K illebrew of thebullet,likeafist,thew ay itknockstheairoutof you and com ing totheplate. Inanoddw ay,though,therew eretim es ten yearslater,and thedizzy feeling,thesm ellof yourself,the w hen I m issed theadventure,even thedanger,of therealw ar thingsyou thinkaboutand say and dorightafterw ard,thew ay outintheboonies. Azar and H enry D obbins and D ave J ensen and N orm an Theseguyshadbeenm y brothers. Bow kerslapped handsw ith m eand w epiled theirgearin m y N orm an Bow kerbentforw ard and scooped up som eice jeep and drovedow n to theAlphahootches. W epartied until againsthischest,pressing itthereforam om ent,thenhefished chow tim. W ealm ostchalkhim up as feltclosetothem,yes,butI alsofeltanew senseof separation. I had to go find aprivateplaceand (186) drop m y pantsandsm earonthisantibacterialointm ent. There w as another one about hem orrhoids and how I had troubleputting thepastbehind In them orning I ran into Bobby J orgenson. H eseem ed club,noteven during our long booze sessions in the Alpha sm allerthan I rem em bered,alittlesquirrelof aguy,shortand Com pany hootch. Say w hatyou w ant,buthekeptM orty TraBong,abulletinsidem e,allthatpain,butforsom ereason Phillipsalive. N um bertw o:therehad to intom y jeep andputittothefloorandlefthim standing there. W ew erefighting forcesthatdid notobey thelaw sof too,straighton and unafraid,as if apologies w ereno longer tw entieth-century science. H ew as sitting therew ith D aveJ ensen and M itchell thatallof Vietnam w as alive and shim m ering? odd shapes Sandersand afew others,and heseem ed to fitin very nicely, sw aying in thepaddies,boogiem en in sandals,spiritsdancing allsm ilesandgroup rapport. Because the darkness helm etagainstthew all,lay dow n foraw hile,gotup,prow led squeezes you insideyourself,you getcutoff from theoutside around,talked to m yself,applied som efresh ointm ent,then w orld,theim agination takesover. The hours go by and you lose your off tow ritelettersorparty orsleep;theotherstroopeddow nto gyroscope;your m ind starts to roam. You think aboutdark the base perim eter,w here,for the nex televen hours,they closets,m adm en,m urderersunderthebed,allthosechildhood w ould pullnightguard duty. And I knew hisbunkerassignm ent:BunkerSix,apile w ho died:CurtL em on,K iow a,Ted L avender,a half-dozen of sandbags atthe southw estcorner of the perim eter. Butstill,justtoguardagainst adead-end tunnel,no w ay out,buthow,w hen thetunnelw as freak screw -ups,Azarand I tailed him dow n to thew ire. W e fragged and searched,nothing w asfound ex ceptapileof dead w atched him lay outhisponcho and connecthisClaym oresto rats. H etested hisradio,unw rapped acandy bar,then sat G hostsbehind you and in frontof you and insideyou. Afterasecond hereached outand clapped listen,knuckleshard,thepulseticking in yourhead. So w e w entto the m ovies, caps and lined them up in frontof m eand then checked m y Barbarella again,theeighth straightnight. M itchellSanders w as there,atanother am bush,curledinthedark,you fightforcontrol. You rearrangeyourposture;you try fora grin;you Aroundclosing tim e,I noddedatAzar. I felt discipline,nottalking,keeping to theshadow s and joining in hollow anddangerous. W henw ecam eup onBunkerSix,Azarlifted I tookabreath,fingered thefirstrope,and gaveitasharp histhum b and peeled aw ay from m eand began circling to the little jerk. ButJ orgenson w as w ould seem to sw irland sw ay;thetrees w ould takehum an listening. F unhousecountry:trick m irrors and curvatures and m inutes, staggering the rhythm noise, silence, noise? pop-up m onsters. O neby one,in sequence,I firefliesandpaddies,them oon,them idnightrustlings,thecool tuggedon each of theropes,andthesoundscam eflow ing back phosphorescentshim m erof evil? I w as atrocity? I w as jungle atm ew ith asoft,indefiniteform lessness:arattlesnake,m aybe, fire,jungledrum s? I w astheblind stareintheeyesof allthose orthecreakof atrap door,orfootstepsin theattic? w hatever poor,dead,dum bfuck ex -pals of m ine? all the pale young youm adeof it. And then presently I cam eunattached from thenatural W esatinthedim lightof m y hootch,bootsoff,listening to w orld. Itw as "Sure,butI m ean? " im agination,of course,butfora long w hileI hovered there "Shutup andlisten. As if through dark glass I could seehim lying flatin his circleof sandbags,silentand Thathigh elegantvoice. You slip outof yourow n skin,likem olting, hang on to yourow n life,thatgentle,naivekid you used to be, shedding yourow nhistory andyourow nfuture,leaving behind butthen after a w hile the sentim enttakes over,and the everything you everw ereorw anted orbelieved in. L ouder In thedarkoutsidem y hootch,even though I benttow ard now,m oreinsistent.

References