#18-panel drug test

[amhnationwide]

Drug test for Kratom 18 panel drug test

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Drug test for Kratom 18 panel drug test

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[nectar-cellar]

Downtown Roles Mod Tutorial - TS3 - Mature Gameplay Ideas

NSFW 18+ mature content / a long read   

TLDR: this is a compilation/recommendation list of mods, a tutorial on how to set up NPCs, and how to tie it all together to add some mature gameplay to your save. 😈

Misukisu/Virtual Artisan had a “Downtown Roles” mod that sadly does not work anymore for the latest versions of TS3. Her mod basically allowed players to add role sims to community lots so your sims could have more NPCs to interact with, making the lots feel more alive in a mature "downtown" sort of way.

I was inspired by her mod and I want to share how you can recreate and expand her mod’s functions with Nraas Register and Arsil’s Custom Generic Role mod. Some players might already know how these mods work, but it was a new discovery for me. I didn’t know how useful role sims could be! It got the gears in my dirty mind turning.

The main purpose of this mod list/tutorial: to add role sims to community lots for your main sims to interact with, while they’re out on the town. These will be sims outside of your household. Their main “job” is to hang out at the lot. You can let the game generate new sims to fill these roles, or assign existing sims in the town to fill the roles.

Examples of role sims you can create: 

A regular patron at a dive bar for your sim to befriend or make enemies with.

A sexy single sim at a beach, gym, pool, bar or club for your sim to mingle and hook up with. 

An escort at a brothel for your sim to woohoo with (Passion mod). 

A client for your sim to sell drugs/weapons to (MonocoDoll Vile Ventures mod and Arms Dealing mod) - I have not tested this but in theory it should work. 

You can add multiple role sims on each lot. You could have a number of partygoers on a club lot/a number of escorts on a brothel lot/a number of mobsters or criminals on a warehouse lot who will always be there when your sim visits.

Why role sims?

Townies are unpredictable - you never know which lot they’ll show up on, and how long they’ll stay. Role sims will consistently be there as the supporting characters in your main sim’s story. 

Having consistent NPCs at certain locations around town can help with story-driven gameplay scenarios.

You can move a household of your own sims into town and assign them to fill various roles. See pretty NPCs around town!

If you let the game generate new sims for the roles, then it saves you the hassle of setting up new households yourself. You can always edit them later in CAS.

Limitations: 

According to Arsil, it seems like sims who are already employed (such as most townies) will be removed from their jobs if they are assigned to be role sims. So I would avoid using any employed townies for this unless you are ok with that. Use unemployed residents instead.

I believe the role sim cannot leave the lot during the designated work hours. Your sim cannot form a group with them and go to another venue. However, you can invite the sim over or hang out afterwards from the relationship panel.

Mods Needed:

Nraas Master Controller + Integration Module

Nraas Register

Arsil‘s Custom Generic Role mod (both the floor marker and the desk)

Passion (if you want your sim to be able to have sex with the role sims on the lot or have the role sims dance on the stripper pole) 

MonocoDoll’s Vile Ventures mod (if you want to create NPC clients for your sim to sell to) 

MonocoDoll’s Arms Dealing mod (if you want to create NPC clients for your sim to sell to) 

How to Set Up: 

Step 1: Install the mods listed above. Then, open the save file you want to add some downtown sleaze to. 

Step 2: Find a community lot you want to add role sims to. This could be a bar, nightclub, brothel/motel/strip club, a run-down warehouse or block of buildings, casino, etc. I have downloaded many lots from Flora2 at ModtheSims and @simsmidgen here on Tumblr that fit the gritty urban vibe.  

Step 3: Enter Build/Buy mode. You can do this from Live mode. 

Press Ctrl + Shift + C, enter this cheat: testingcheatsenabled true 

Press the Shift key and click on the ground of the community lot. 

Click on “Build on this lot”. 

You can also enter Edit Town mode to renovate the community lot. 

Step 4: Place Arsil’s Custom Generic Role floor marker or desk on the lot. Place one for each role sim you want to create. They are located in Build Mode -> Community Objects -> Misc. If the desk looks out of place, use the floor marker instead. 

Step 5: In Live mode, click on the object -> Settings to set:

The name of the role (clubgoer/stripper/escort/mobster/etc.) 

The “work” hours the sim will be on the lot for 

The days off 

The motives to freeze or not (I recommend freezing all the motives to avoid interactions being interrupted/sims complaining due to low motives) 

If the sim you want to assign to the role already lives in town, click on the object -> Nraas -> Register -> Select -> Choose criteria -> select the sim from the list. I would avoid choosing any employed townies as they may lose their job when switching to this role. Choose unemployed residents to avoid conflicts.

Remove assigned roles: click on the object to remove the sim from the role.

Step 6: In Live mode, click on City Hall -> Nraas -> Register

Allow immigration: choose whether you want new sims to be moved into town to take the roles (enable this if you want the game to generate new sims for the roles) 

Allow immigration = False: if you set this option to false, then a new option called "Find Empty Roles" should appear. You can then assign any sim to the role object you placed, from City Hall.

Allow resident assignment: choose whether you want existing unemployed townies to be randomly assigned to fill the roles (I recommend to disable this. I had Buster Clavell show up to work at my strip club. NO!)

Pay per hour: I'm not sure how to adjust the pay for each custom role but you can just leave it at the default or change it globally

Remove roles: click on the object to remove the sim from the role, or click on City Hall -> Nraas -> Register -> Global Roles -> Remove by sim

Step 7: In Live mode, give the game some time to generate the role sims. Visit the community lot and have a look at your new role sims. The role sims should autonomously interact with other sims and objects on the lot. Using Nraas Master Controller, you can take the sim into CAS to give them a makeover, edit their traits, or replace them with a sim from your sim bin. 

Step 8: Make your sim interact with the shiny new role sims and play out the storylines you always wished were possible. Public hookups, functioning brothels, selling drugs and guns - this is what The Sims 3 was made for, baby!!! 

Related Mods:

Arsil’s Exotic Dancer Stage - if you have a club community lot, you can use this mod to hire dancers. You can use role sims to add other NPCs to the club such as guests, shady business sims, or non-dancer sex workers. 

Nraas Relativity - this handy mod can slow down the speed of time so your sim can spend more time doing their "activities"

Nraas Woohooer - if you don’t want the explicit sex animations from Passion, you could use this mod instead to provide more woohoo options. 

Passion - for brothels/strip clubs, this mod will add sex animations and the ability to have role sims dance on the stripper pole. 

MonocoDoll’s Vile Ventures mod and Arms Dealing mod - you can use role sims to create more clients for your sim to sell drugs and weapons to, like different individuals/gangs/mobs. You could have different clients hanging out at different spots in the city. 

LazyDuchess Lot Population - this mod populates community lots with townies, and they can interact with the role sims you’ve created. 

Service Sims Out on the Town - this pushes service sims to visit community lots, to add even more variety to your crowds. 

Conclusion

If you made it to the end, thank you for reading. Please let me know if you try out this style of gameplay, and if you have ideas for more role sims and community lots to make. This tutorial was NSFW-oriented but you could easily adapt it to create NPCs for SFW community lots.

[out-with-the-boys]

The Dance- Chapter 07

Homelander x Supe OC

Notes: 18+ This chapter contains themes of and references to deep, personal losses, which may be distressing to some readers. Please take care while reading.

Each chapter will have individual content warnings as they apply to avoid spoilers. Find this work on AO3. Tumblr master post here.

Previous chapter.

To say that Morgan was a difficult and stubborn patient was an understatement. With the extent of the injuries she sustained when a Harlem apartment building collapsed on her, she was ordered to be on strict bed rest for a few weeks at least. Keeping her down was easier said than done, however.

Bed rest literally means bed rest, Ms. Daly. Lounging in your chair in the conference room doesn’t count.

Dr. Foster had personally ordered her back to bed herself too many times already. If it wasn’t for her Hippocratic oath, Morgan was certain the woman would have strangled her by now. As punishment, she was stuck in bed for one more week before she could get back to work on less taxing duties.

At the very least, she had her script for Dawn of the Seven , to rehearse.

“And you’re sure they won’t throw a fit over you breaking your NDA?” her sister asked, her wide grin practically audible over the phone. 

“Sammy, you’re my big sister.” Morgan said with a soft snort. “We’re basically extensions of each other. Besides, I know how you are about spoilers. You’d sooner invoke the curse of MacBeth than give away the story.”

“Shh! Don’t say that name!” Sammy hissed. “You’ll jinx the movie!”

“Relax, the curse only works for stage productions.” Morgan laughed softly, wincing slightly as a sharp pain shot through her ribs.

“Hey, all the world's a stage.”

“Smartass.”

Morgan wished she could have seen the wry grin her sister was likely wearing. One day she would have to convince her to upgrade her phone to something that actually had video call capabilities. The flip phone Sammy insisted on using was sure to break eventually.

Still, even without seeing her, Morgan could sense the shift in tone before Sammy could say what she was thinking.

”Sorry to change gears here, but have you found out anything else about the Compound V situation?” Sammy asked, her voice low.

Drawing in as deep a breath as she could manage, Morgan pressed her lips into a thin line.

”I don’t have any solid leads yet.” She murmured back.

Ever since the origins of supes came to light, Morgan’s family had been scratching their heads. Neither of her parents had struck any sort of deal with Vought to juice her with their super drug. If they had, Morgan would have known about it a long, long time ago.

Another worrisome piece to the puzzle was Dr. Foster’s silent panic with a recent panel of bloodwork she had done. Morgan’s already fragile trust with Vought and its other employees had been dwindling. After what happened with Stormfront in Harlem, Morgan felt less and less inclined to keep from reading minds without permission.

This can’t be right.

Foster’s voice still echoed in her mind even weeks after the fact. She had gleaned a few things from a quick mental scan, but it was still only a fraction of the bigger picture.

Edgar had ordered a test to be run on Morgan, all without her knowledge or consent. Dr. Foster was to see if she had any markers in her system that would indicate she had ever been touched with Compound V. Much to her surprise, and consequently Morgan’s, the tests came back with negative results.

Not minimal, not inconclusive– negative .

“What do you think that means?” 

Sammy’s question echoed in her ear just as a soft knock interrupted the moment. Morgan’s gaze flicked toward the door. Her telepathy warned her before she even saw him, and her chest tightened.

“Hey, I’ll call you back,” Morgan quickly said, her voice quieter now. 

“Everything okay?” Sammy asked.

“Yeah, just... something came up,” Morgan replied, eyes still on the door as she disconnected the call and set her phone aside.

The door opened with the unmistakable quiet confidence that only one person possessed. Homelander stepped into the room, the air seeming to shift with him. His presence was magnetic, almost suffocating in the small space. He was dressed in his usual immaculate suit, the red and white cape trailing behind him with an air of regality.

“Psyren,” he greeted, his tone somewhere between a question and an observation.

“Homelander.” She didn’t bother to hide the weariness in her voice. She shifted slightly under the covers, painfully aware of how feeble she must look to someone like him—someone who never seemed to show physical weakness.

He stood at the foot of her bed, his steely blue eyes scanning her as if taking inventory of whatever scratches, cuts and bruises still remained. For a moment, neither of them spoke, the silence stretching out uncomfortably.

“Am I interrupting something?” he finally asked, his tone deceptively casual, but there was always that edge to it—like he was testing her.

“Just a call with my sister,” Morgan said. “Nothing important.”

They both knew the other knew better than that though. She was already in his head, and he had been listening in with his acute hearing. The most worrisome part about that though, was he seemed to already know what Sammy was referring to. Morgan couldn’t fathom why Edgar would have disclosed the results of her secret Compound V panel to Homelander, but he had. 

Homelander nodded, though his gaze lingered on her phone for a beat longer before returning to her. “How are you feeling?” The question sounded almost... polite. Uncharacteristically so.

“Like I got buried under a building,” she said dryly, unable to help herself. “But I’m fine. You really don’t need to worry about me.”

Homelander’s lips twitched in a semblance of a smile. “Oh, but I do. I'm the leader of The Seven, and you’re a valued member of the team. I’m fully invested in your recovery.”

“I’m just saying you don’t need to keep checking up on me like this,” Morgan replied, her voice steady despite the tightness in her chest. “I’ll be back on my feet soon.”

“I’m sure you will,” he said, that small, almost imperceptible smile tugging at the corner of his mouth a little more. He took another step toward her bed, close enough now that she could feel the subtle shift in the air between them. Something about the way he was staring at her, trying to discern what he could about her from a simple look, made her feel like a bug under a microscope.

Conversely, she hadn’t ever taken her eyes off of his, and now his thoughts were a storm of unanswered questions. He had no way of knowing when she was in his head, and that unnerved him. Even more than that, the origins of her abilities had come into question, and he wasn’t even remotely sure of how to deal with that. 

“Penny for your thoughts?” she asked, a spark of mischief in her eyes. “I can hear those gears in your head turning.”

There was a brief flash of surprise that passed over his face before his expression quickly darkened. He was already worried she was in his head, but now he knew she was teasing him about it.

“Oh, I don’t know.” he huffed, his lips pulling into a tight smile. “Why don’t you tell me? Go ahead, tell me what you find.”

Morgan raised an eyebrow, her eyes never leaving his. “You sure you want me to do that?”

It was a challenge, and they both knew it. His smile faltered, just for a second, before it returned, this time sharper—dangerous.

“Go ahead,” he said, leaning in just enough to make the air between them feel heavy. “Take a peek. Maybe you’ll learn something useful.”

She could hear the anger creeping into his voice, the way it thinned, despite the control he was desperately clinging to. It was always like this with him. A balancing act. One wrong move and the mask would slip. One wrong word and she’d see just how close to the edge he was.

But Morgan wasn’t afraid of him. 

“I don’t need to read your mind to know you’re feeling threatened,” she said, her voice dropping slightly, her tone turning more serious. 

His jaw tightened, the facade of calm crumbling just a little. “Threatened? By you?” He laughed, forcing a smile. “You’re cute, you know that? Do you really think that? Or is that the pain-killers talking? I’m sure Doc Foster has you all hooked up with the best stuff.”

“Oh, I’ve been off the pain-killers for a while now.” Morgan said, cracking a wry grin. “Gotta keep this mind sharp. I’ve already let you see me impaired a few too many times.”

Homelander’s smile faltered, but only for a second. He adjusted his posture, arms crossing over his chest, the tension still simmering behind his eyes. “Then I guess you’re just naturally delusional.”

"Maybe I am delusional," she said with a shrug, but her voice lacked its usual bite. "Or maybe—"

Her phone buzzed in her lap, interrupting her mid-sentence. Morgan glanced down, seeing Sammy's name flash across the screen. She sighed, sending the call to voicemail and focusing back on Homelander, though something in her expression had shifted.

“Or maybe you're just not used to anyone calling you out on–" she was cut off once more as her phone began to buzz again. 

Homelander raised an eyebrow, noticing the change in her demeanor. "You gonna get that?" 

"It’s just my sister." Morgan waved it off, her voice tight as she ignored the call with a tap of her thumb. "I’ll call her back."

But no sooner had the words left her mouth than the phone buzzed again, Sammy’s name flashing across the screen. This time, Morgan hesitated, her fingers tightening around the phone. Sammy never called more than twice in a row unless it was urgent. Something twisted in her gut—a sinking feeling she couldn't quite shake.

Homelander watched her carefully, his expression unreadable. "Maybe you should answer."

Morgan didn’t respond right away. Slowly, she picked up the phone, a strange, cold dread settling in the pit of her stomach. She slid her finger across the screen and held the phone to her ear.

"Sammy?" Her voice was a little too calm, as if she was bracing herself for bad news but still hoping it wasn’t what she feared.

There was a pause on the other end. She could hear her sister breathing, and that alone was enough to send her pulse racing.

"Morgan..." Sammy’s voice broke, shaky and thin. "It's Dad. He's... he's gone."

The words hit like a physical blow, knocking the air out of her lungs. For a moment, everything around her faded—her lavish bedroom, Homelander’s presence, the soft hum of the city beyond the tower. It was just her and Sammy’s voice, raw and filled with grief, and the heavy, final truth that her father was gone.

Morgan blinked, her mind racing to catch up with the weight of the words. She swallowed hard, her throat tight, but she couldn’t speak. She couldn’t move. All she could do was sit there, frozen, as the reality sank in.

“I—” Morgan started, her voice cracking before she could even form a coherent thought. Her chest tightened, an overwhelming ache swelling beneath her ribs. “I... okay. I’ll—I’ll make my way home. Do I need to call Lucas?”

For a solid minute or two, Morgan shifted into autopilot. On one level, she was aware of the things Sammy was telling her, and she was responding appropriately. On another level, all she seemed to be conscious of was her heart thundering painfully hard in her ribcage. 

Her father had been battling with stage four pancreatic cancer for some time already, and she knew that this was an eventuality. Even so, she thought she would have had more time. He had sounded well enough on their last phone call, but now she was wrestling with the fact that he was gone.

At some point she had said her goodbyes, and she was vaguely aware of her name being called.

“...Psyren? Psyren?” Homelander’s voice pierced through the haze in her mind, tinged with irritation but laced with something else, something uncharacteristically soft. “Morgan, are you in there?”

“Yeah…” she responded automatically, her brow furrowing as she sat up straighter in her bed. The room felt too small, too cold. “Yeah, I just need to... I have to go.”

Her pulse rushed in her ears, drowning out everything but the thundering ache in her chest. Her hands trembled slightly as she swung her legs over the edge of the bed. She moved on autopilot, ignoring the sharp pain still lingering from her injury as her body adjusted. A wave of numbness washed over her, a protective shield against the weight of her father’s absence.

“Go?” Homelander echoed, the concern etched into his brow deepening. “You’re on bed rest, doctor’s orders. You can’t go.”

Robotically, she brushed past him, her eyes distant as she made her way to the dresser. Her fingers fumbled with the drawers, yanking out clothes without much thought.

“Dr. Foster can kiss my ass,” Morgan murmured, her voice hollow. The grief that threatened to engulf her pressed against her ribcage, tighter with each breath. “My dad just died. I’m going home.”

She didn’t care about the dull throb in her side, or the way her vision blurred as tears welled up. She couldn’t afford to break down. Not yet. Not in front of him. Not again. Her family needed her. Everything else could wait.

Homelander stood frozen, his usual air of control slipping as he watched her. He opened his mouth to say something, but for once, the words didn’t come. Instead, he just watched her pack with that same intense, unreadable gaze, the silence between them thick with unspoken things.

Finally, he spoke, quieter than before. “Do you need anything? I can... help.”

Morgan stopped, hovering in the entry of her walk-in closet. For the briefest moment, she let herself meet his eyes, surprised by the offer. But she shook her head, her voice barely above a whisper. “No. I just need to get home.”

Leaning her head against the open archway into her closet, she drew in a painfully deep breath. 

“I’ll reach out to Ashley then.” He said decisively. “She can help arrange everything you need. It’s not like you’ll be out in the field in the next few days anyway. You might as well spend the rest of your recovery with your family.” 

If Morgan had been paying closer attention, she might have registered the undercurrent of bitterness in his voice, tinted with the slightest degree of curiosity. That was a detail she would have to file away for a later time. For the moment, she was desperately trying to keep herself grounded and focus on the things she needs.

”Thank you.” She murmured with a gentle nod, before retreating into the closet to find her luggage.

Morgan stayed in the closet longer than necessary, her fingers tracing the edges of her suitcase. She could hear Homelander’s low voice outside the room, speaking to Ashley, but the words blurred into static. 

Just breathe. Just get through this.

It was a simple mantra that she played through her mind on repeat until the moment she was on a private jet bound for the Pawhuska Municipal Airport. The hum of the engines filled the quiet space as Morgan sat beside the window, staring out at the clouds but barely registering the view. She was exhausted, emotionally drained, but sleep wouldn’t come. Her thoughts drifted back to her father. 

She should have been there. God , she should have been there for him. For all the highs and lows he had been there for her, she should have been home and holding his hand in his final moments. Instead, she had been halfway across the country, playing at being a hero and acting as a glorified babysitter for a company that didn’t give a damn about her as a person.

Her father had always been her rock, the one who believed in her ability to change the world. She could hear his voice in her head, telling her that true strength wasn’t in power, but in the courage to stand for what was right. Before her abilities even manifested, he had taught her to be a force for good.

It was because of him that she decided to accept Edgar’s invitation into The Seven in the first place. Despite his distaste for the posturing and pageantry that surrounded Vought and its superheroes, he believed she could make a difference. But now? Now, she felt like a fraud. 

Try as she might to fight against it, she still found herself neck deep in endorsement deals, social media campaigns and all the other superfluous bullshit Vought threw at her. True, she had saved some lives along the way, but she could be doing more. She needed to be better.

The thing that probably hurt the most, was knowing that no matter what, he would have still been proud of her. She just wouldn’t ever get to hear him say it again when she needed it most.

Song: Losing My Religion by BELLSAINT Author’s notes: Thank you all so much for reading this chapter! It’s a bit shorter than the others, but for me it was emotionally heavy. In the next chapter, we’ll see Morgan return home and confront some long-buried emotions as she navigates her family’s grief, all while the pressure from Vought—and Homelander—continues to mount. As always, your feedback means the world to me, and I appreciate all the support you’ve given this story so far!

Next Chapter.

[bisexualshakespeare]

[ID: a series of simple drawings with text over it telling good news from The Happy Broadcast. I'll include their sources where I can find it. Doctors and HIV researchers announced the fifth case of a patient being cured of HIV! The man is also the oldest person ever to be cured, and had lived with HIV since the 1980s. (source)

one charger to rule them all! European Union just approved a plan to require a single charger (USB-C) for all devices, for iPhones to electric toothbrushes. (source)

UK is planning for more than one thousand "bee bus stops." In a bid to save pollinators, bus shelter roofs are being turned into gardens for bees and butterflies. (source)

More cubs and less poaching mean that the Indian rhino has recovered from being close to extinction. Fifty years ago only 100 Indian rhinos remained in the wild. Now there are over 4000! (source - note, source says they were as low as 200)

Animal testing could slowly be replaced with experiments using "artificial human tissue" thanks to the groundbreaking work of researchers in Austria. Amazing! (source)

It really is the Year of the Tiger! Population study finds there are 40% more tigers in the wild now than in 2015, giving hope to the endangered species. (source)

Astronaut Nicole Aunapu Mann, of the Wailacki of the Round Valley Indian Tribes, will be the First native American woman to travel to space. Representation! (source)

This is a huge win! Some of the world's biggest mining companies have withdrawn requests to research and extract minerals on Indigenous land in Bazil's Amazon rainforest. (source)

There's a radio station in New Orleans for people with a visual impairment. Volunteers every day read to listeners news headlines, grocery ads, stories for kids, novels and even horoscopes! (source)

Millions of Alzheimer's patients have been given hope after a new drug has been shown to slow memory decline by 27% over 18 months. Experts called this the "beginning of the end" of Alzheimer's! (source - note, this source doesn't say it's "the beginning of the end." It says it will "make a big difference for future generations." )

Scotland become the first country in the world to make tampons and other menstrual products available free of charge in public spaces in a bid to end period poverty. (source)

Tiny mealworms may hold part of the solution to our giant plastics problem. New research shows mealworms can not only eat toxic Styrofoam, but that they can break it down safely! (source)

A new California law requires grocery stores and other food suppliers to donate all edible food waste to a food bank or food rescue. This needs to go worldwide! (source)

Good news for the ozone layer! New study shows the ozone layer has passed a 'significant milestone' as harmful chemicals drop by 50% since 1980s. (source)

Solar FTW! There are now enough solar panels installed throughout the world to generate 1 terawatt (TW) of electricity from the sun, enough capacity to generate power for all of Europe. (source)

Wild mammals are making a comeback in Europe thanks to conservation efforts. New data shows us that from otters to red deer, and from wolves to bison, numbers are rebounding by the millions! (source)

After a rough few years of bleaching and wild weather, the Great Barrier Reef in Australia is making a coral comeback. The highest coral cover in 36 years! (source)

In Panama, nature just got basic legal rights! A new law grants nature the "right to exist and regenerate" meaning the government will have to respect the country's ecosystem in all future policies. (source)

end ID /]

[12-panelnow]

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[writerscampus]

57-year-old Caucasian male presents with generalized abdominal pain

New Post has been published on https://writerscampus.com/2023/06/09/57-year-old-caucasian/

57-year-old Caucasian male presents with generalized abdominal pain

57-year-old Caucasian male presents with generalized abdominal pain and fullness, urinary frequency, urgency, and nocturia for two months.  He has unintentional weight loss of 40 pounds over the last six months and he has been experiencing fatigue, malaise, general body aches, polydipsia, and polyuria.  He has not seen a physician since he was a child. His past medical history is negative. His past surgical history is negative. He quit smoking five years ago but smoked four packs a day for eight years. Denies any alcohol or drug use. His family history is positive. His mom had some type of cancer but does not know what kind. She also had Parkinson’s disease and pneumonia. His father had diabetes, chronic kidney disease and hypertension. Physical exam.  His temperature is 98.6, Heart rate is 82, respiratory rate is 18, blood pressure is 160/90 and O2 sat is 98% on RA.  He is alert and oriented x 3. He is obese and in no acute distress. His head is normocephalic and atraumatic. Pupils are equal, round, and reactive to light. There’s no nystagmus or scleral icterus. His neck is supple, there is no JVD. There’s no tracheal deviation, or thyromegaly, or thyroid nodules. His rate is, uh, normal. His has an S1 that is normal and S2 that’s present without any S3, S4, gallop, friction rub or murmur. There’s no edema in the lower extremities. The brachial, radial, dorsalis pedis and posterior tibial pulses are 2+/4+ bilaterally.  Respirations are regular and even. Lungs are clear in the anterior and posterior bilateral lung fields. Abdomen is obese and soft. Bowel sounds are active. There’s generalized tenderness. We’re unable to palpate the liver due to his body habitus, and there’s no rigidity rebound or guarding.  There’s no cervical lymphadenopathy. Cranial nerves II-IV are intact. The skin is warm, dry, and intact. There are no rashes, lesions, or abrasions.  Mood and affect are normal. He has a calm and cooperative behavior and judgement is intact. As you recall, he’s not on any medications. During your first visit, you ordered labs and a CT of the abdomen, and now more labs are available. Unfortunately, the liver function tests, lipid panel, TSH are still pending. If you remember his CT of the abdomen/pelvis shows hypovascular liver masses consistent with metastatic disease of unknown primary.  His available lab results are here. His sodium is 125, potassium 5.7, creatinine is 1.5, BUN is 35, Glucose is 350, his serum bicarb or CO2 is 15. Anion gap is 22. Osmolality is 302. WBC is 5,000. RBC is 3.0. Hemoglobin is 8.0. Hematocrit is 24%. MCV is 72 and the platelets are 200,000. 

What type of anemia does patient most likely have? 

What additional lab work would be helpful with helping you determine the type of anemia?

What is most likely cause of his anemia? 

What is patient at risk of developing? 

It’s that simple.Pay only when you are satisfied.

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[mystlnewsonline]

CBP San Diego Field Office Seizes $7.8M in Narcotics

U.S. Customs and Border Protection, San Diego Field Office seizes $7.8 million worth of narcotics. SAN DIEGO, CA (STL.News) U.S. Customs and Border Protection (CBP) officers within the San Diego Field Office are commended for their diligence and outstanding work in seizing $7.8 million worth of dangerous drugs in the week leading up to Memorial Day. - May 18, at the San Ysidro port of entry, 36 packages were discovered and extracted from the floor, firewall, and gas tank of a vehicle.  The narcotics were tested and identified as fentanyl powder with a total weight of 4.67 pounds, fentanyl pills with a total weight of 2.25 pounds, and methamphetamine with a total weight of 27.47 pounds.  Altogether, the narcotics have an estimated street value of $305,200. - May 19, at the Tecate cargo facility, 50 packages with a total weight of 123.46 pounds were discovered and extracted from the gas tank of a vehicle.  The narcotics were tested and identified as cocaine with an estimated street value of $2,000,000. - May 19, at the Calexico port of entry, 78 packages with a total weight of 109.17 pounds were discovered and extracted from the rear quarter panels, doors, seats, and speaker box of a vehicle.  The narcotics were tested and identified as fentanyl pills with an estimated street value of $3,000,000. - May 19, at the Otay Mesa port of entry, five packages with a total weight of 11.42 pounds were discovered and extracted from the rear quarter panel of a vehicle.  The narcotics were tested and identified as fentanyl powder with an estimated street value of $158,000. - May 20, at the Calexico port of entry, three packages with a total weight of 15.30 pounds were discovered and extracted from the undercarriage of a vehicle.  The narcotics were tested and identified as methamphetamine with an estimated street value of $100,600. - May 23, at the Calexico port of entry, six packages with a total weight of 7.45 pounds were discovered and extracted from a traveler’s backpack.  The narcotics were tested and identified as methamphetamine with an estimated street value of $16,390. - May 23, at the San Ysidro port of entry, 40 packages with a total weight of 77.21 pounds were discovered and extracted from the rear doors and gas tank of a vehicle.  The narcotics were tested and identified as fentanyl pills with an estimated street value of $2,101,200. - May 24, at the San Ysidro port of entry, 30 packages with a total weight of 60.80 pounds were discovered and extracted from the spare tire of a vehicle.  The narcotics were tested and identified as methamphetamine with an estimated street value of $133,760. “Narcotics smuggling continues to be on the rise, and our officers will relentlessly continue doing everything they can to keep our communities safe,” said Sidney Aki, CBP Director of Field Operations for San Diego.  “Remaining vigilant for something that looks out of place and keeping a keen eye for unusual travel patterns is what our officers are trained for and what they do best.” The CDC states that more than 150 people die every day from drug overdoses related to synthetic opioids derived from fentanyl.  https://www.cdc.gov/stopoverdose/fentanyl/index.html The total estimated amount of narcotics found by CBP officers within the San Diego Field Office was $7,815,150.  All travelers were turned over to the custody of Homeland Security Investigations for further investigation. The narcotics and any associated vehicles used to smuggle the drugs were seized by CBP officers. SOURCE: U.S. Customs and Border Protection Read the full article

[lisamathew]

Understanding the 18-Panel Drug Test Kit

A drug test kit refers to a collection of tools and reagents used to detect the presence of specific drugs or their metabolites in biological samples such as urine, saliva, or hair. The number of panels in a drug test kit refers to the number of substances it can detect. The 18-panel drug test kit is designed to identify a wide range of commonly abused substances, providing a more comprehensive assessment compared to tests with fewer panels.

[blackmagicspecialist786-blog]

FDA Approves, Leqembi, New Treatment for Early Alzheimer’s

The Food and Drug Administration on Friday approved a brand new Alzheimer's medication which could slow the rate of cognitive decline in the early stages of the course of the disease, but has the potential for bleeding and swelling in the brain. The decision to allow lecanemab, the medication lecanemab which will be advertised as Leqembi will likely to draw a lot of attention from both doctors and patients. The studies of the drugan intravenous infusion that is given every two weeksindicate that it is more effective than the limited quantity of other therapies that are available. However, a number of Alzheimer's experts claimed it was difficult to determine by the evidence from medical studies whether Leqembi would slow cognitive decline to the point that it would be noticed by patients. In a report released recently of the findings of a massive 18-month clinical study, published in the New England Journal of Medicine and co-written by scientists of the leading company responsible for the drug found the following "longer trials are warranted to determine the efficacy and safety of lecanemab in early Alzheimer's disease." Eisai is a Japanese drug company was the one to lead its development, testing and production of the medication. It has partnered in collaboration with American company Biogen which is the maker Aduhelm, a notorious Alzheimer's drug Aduhelm for commercialization and marketing. The companies will share profits equally. Eisai stated that the cost for the Leqembi (pronounced le-KEM-bee) will be $26,500 annually. It is a little less than that of Aduhelm, however, it is higher than the price suggested by some analysts. "Based on our draft results, that price would not meet typical cost-effectiveness thresholds," the Dr. David Rind, the chief medical officer of the Institute for Clinical and Economic Review which is an independent non-profit group that studies the value of drugs. In its preliminary report in the last month, this institute stated that for a cost-effective approach to patients the cost should be placed between $8,500 to $20,600 per year. "Given the large number of patients with Alzheimer's disease, it is particularly important that new therapies be priced in line with their value to patients," Dr. Rind said Friday. In making its decision the F.D.A. seemed to acknowledge the outrage that ensued when it endorsed Aduhelm in 2021, after an independent advisory committee as well as an F.D.A. Council of top officials claimed there was no evidence to show that it had worked. The week before an investigation lasting 18 months by two congressional committees revealed that the process for approving Aduhelm had been "rife with irregularities" and included an unusually close relationship with Biogen. In response to the findings, Biogen's F.D.A. stated that "the agency has already started implementing changes consistent with the committees' recommendations." With Leqembi, the F.D.A. provided more slender and cautionary words on the label of the drug than it did initially with Aduhelm. (After protests from doctors and others, the company modified the Aduhelm label after a month following the approval.) The Controversy Surrounding the Aduhelm Alzheimer's Drug Card 1 of 5 An unproven drug. Aduhelm is not a drug that has been proven to work. F.D.A.'s Independent advisory panel as well as the council of agency officials of the highest rank voted unanimously that the data did not definitively prove that Aduhelm slows cognitive decline. The agency nevertheless approved the drug. It demanded Biogen the manufacturer of the drug to conduct a new trial in clinical trials, but it gave Biogen an additional eight years in order to finish the trial, while also allowing users to take the drug until evidence from the trial is available. Concerns are increasing. Concerns about the approval process and the possibility that the F.D.A. was too close to Biogen led to investigation by congressional committees and the department's Health and Human Services inspector general. Major health institutions, like Cleveland Clinic, Cleveland Clinic and the Department of Veterans Affairs refused to accept Aduhelm. The Leqembi label states that the drug should be prescribed only by patients who are in the moderate and early stage of the disease. similar to the those who are participating in clinical trials for the drug. It advises doctors to not treat patients without conducting tests to determine if they are suffering from one of the most common signs of Alzheimer's disease: a build-up of the protein amyloid that the drug (like Aduhelm) fights. "We have been very diligent together with the F.D.A. to reduce the number of people to a specific group similar to the clinical studies," Ivan Cheung, the chief executive and chairman for Eisai's United States operations, said in an interview. Around 1.5 million people out of 6 million Alzheimer's patients within the United States are estimated to be in the initial stages of the disease. They have diagnoses of moderate cognitive impairment, or Alzheimer's disease in the early stages. The number of people who will be treated by Leqembi will depend on the extent to which Medicare will cover the medication. The Federal Centers for Medicare and Medicaid Services drastically reduced Medicare coverage for Aduhelm due to its unclear benefits and risks to safety, and permitting reimbursement only to those who participate who are in trials. This meant that a small percentage of patients could afford Aduhelm's $28,800 per year amount as well as the medication has been removed from the market. If the agency decides that Leqembi's evidence is stronger of improving the lives of people, Medicare could cover it for all patients who are eligible and only require that the patient's experience be recorded. Similar to Aduhelm's and Leqembi's, the label contains warnings about bleeding and swelling in the brain and mentions that those with genetic mutations that increase the chance of developing Alzheimer's have a higher chance of developing brain swelling as a result of the treatment. The label of Leqembi also contains the word "warning" about taking blood thinners when on the medication. This has been cited as a problem with anti-amyloid drugs , but wasn't addressed in Aduhelm's label. "Additional caution should be exercised" when deciding whether to administer blood thinners to Leqembi patients The label states. Safety concerns have been fuelled by news reports about death of 3 patients suffering from bleeding from the brain and swelling of the brain Two of them were treated with blood thinners. These patients took part in the large Phase 3 trial of the drug, in which they weren't told if they had received the drug or the placebo. However, their deaths took place following the conclusion of that trial, after they knew that they were being treated with lecanemab during what's known as an open-label expansion study. One instance, which was that was the topic of an article article published this week by the New England Journal of Medicine was a 65-year-old woman who suffered an accident and, following receiving the standard treatment for blood clots that result from strokes called t-PA, suffered grave brain bleeding and passed away within a couple of days. In a previous article on this case, published that appeared in the journal Science, neuropathologists who performed an autopsy claimed that Leqembi damaged her blood vessels, making them susceptible to rupture after she received bleeding treatment. In an released letter in response to the New England Journal of Medicine report, two scientists involved with Eisai's Leqembi trial claimed the fact that "t-PA appears to be the proximate cause of death," not Leqembi and pointed out that the woman was carrying two variants of a genetic mutation which increases the risk of brain swelling in patients receiving anti-amyloid treatment. However, they added "we agree that this case raises important management issues for patients with Alzheimer's disease." Leqembi - the brand's name, Mr. Cheung said, is an adaptation of "qembi" in Japanese, which "roughly translates into beautiful, healthy, elegant" -it was approved on Friday, under a classification known as "accelerated approval." The F.D.A. may grant accelerated approval to medicines with no effectiveness if they're for grave diseases that require a lot of treatment and are aimed at a biological aspect of the illness -- in this instance amyloid protein. The approval process was controversial for Aduhelm due to the fact that the evidence included were inconsistent the clinical trial failed, while another, nearly identical study showed little benefit and also because several Alzheimer's experts claimed that years of research had not proved that the reduction of amyloid slows the decline in cognitive capacity. With Leqembi, a lot of experts aren't convinced that targeting amyloid could provide significant benefit to patients with Alzheimer's. They say that the evidence is more clear and consistent as with Aduhelm. It could be due by the fact Leqembi is a different type of amyloid. Leqembi's rapid approval was dependent on phase 2 trial results, however in the last few months, evidence from a huge Phase 3 trial has supported the earlier findings and offered additional information. The most significant positive result of this study was that the patients who received Leqembi slowed down more over the course of 18 months -- less than half a percentage point, 0.45, on an 18-point cognitive scale , which measures the ability to think and solve problems -- than those receiving placebo. (Patients using Leqembi decreased in the range of 1.21 points, whereas patients who were given placebo lost 1.66 percent.) This amounts to an increase of 27 percent. Leqembi Leqembi patients also showed declines slower on three other assessments of cognition as well as daily functioning, and data on biological markers was generally more favorable in Leqembi than for the placebo. "From the perspective of a scientist, it is exciting that an experimental treatment targeting brain amyloid in Alzheimer's disease appears to slow cognitive decline," Dr. Madhav Thambisetty who is neurologist and senior researcher of the National Institute on Aging, expressed his excitement over the Phase 3 trial's results. However, the doctor. Thambisetty, who was not speaking on behalf of the federal agency for aging and added: "From the perspective of a physician caring for Alzheimer's patients, the difference between lecanemab and placebo is well below what is considered to be a clinically meaningful treatment effect." Within the Phase 3 study, more than 13 percent of the patients taking Leqembi suffered from brain swelling, that was moderate or mild generally, whereas just a tiny fraction who were given placebos experienced this swelling. The majority of the brain swelling did not result in any discomfort and usually disappeared within a few months. Around 17 percent of Leqembi patients suffered from bleeding in their brains as opposed to 9 percent of those who received the placebo. The most frequent symptom of bleeding in the brain was dizziness the study found. The authors noted the fact that "serious adverse events" occurred in 14 percent of patients in the Leqembi trial as well as 11 percent patients who were given placebo. About 7 percentage of Leqembi patients were unable to participate in the trial due to negative side effects. This is more than double that of placebo participants who quit. Overall, the results suggest that the risk of bleeding from the brain and swelling was much lower than that of patients who participated in clinical trials of Aduhelm. Accelerated approval requires that companies run another clinical trial for the product before it is approved in full is considered. He said. Cheung said that, with the Phase 3 trial's results, Eisai intends to quickly seek approval for the full amount. It's not clear if Medicare will be able to cover Leqembi as it is undergoing been approved in a speedy manner. The agency's decision to restrict coverage of Aduhelm technically is applicable to Leqembi as well as other drugs belonging to the same class of monoclonal antibodies that target amyloid however, the Medicare agency also claimed it will remain "nimble" and evaluate each new drug. A full Leqembi approval would ensure Medicare coverage more likely health economists suggest. The interviewer cited Medicare uncertainness in the interview, Cheung referred to the uncertainty surrounding Medicare. Cheung sought to lower expectations about the number of patients that may be given Leqembi and the speed at which they could begin using it. He stated that, even in the event that Medicare is able to cover the drug, within the next three months "we estimate the number of individuals potentially on Leqembi is probably about 100,000 people." There are many unanswered concerns about the medication. For instance, it is said that Dr. Thambisetty noted, some studies on the drug suggest that it may cause brain shrinkage to increase that is something that should be studied because it could indicate that the pathology is deteriorating. Another issue is whether those suffering from a condition known as cerebral amyloid angiopathy also known as C.A.A., should exercise caution when using Leqembi. Doctor. Michael Irizarry, senior vice-president of clinical research at Eisai He said that "since C.A.A. is widespread" in Alzheimer's it was logical to let patients use Leqembi in conjunction with proper monitoring since it was the monoclonal anti-amyloid antibody with the lowest risk of bleeding and swelling in the brain to date. Read the full article

[automatismoateo]

I was the sound guy for a Megachurch via /r/atheism

I was the sound guy for a Megachurch

A lovely chap on Reddit asked me to tell a story of my time as the sound guy for my old church. I thought ya'll might appreciate my work 🙂

When I was 14 I started learning how to mix at youth church. After the live band, we’d often put on background music, to create a “holy atmosphere”. I put together a playlist of suitable songs – bass, beat, minimal lyrics. Turn down the treble and Childish Gambino is just perfect. Got away with playing songs about drugs and sex for years :P

By 18 I was promoted to main service. State of the art digital mixer. Small church, ~500 people on an average Sunday. I did my job well, but sure had my share of fucking around. There was one terrible BV who’d often be slightly out of time or off pitch – his volume goes up 😊 The annoying “faith healer” scam artist gets a ton of sibilance. One time an annoying preacher was yelling, screaming, then went to mic drop – I muted it, but only after maxing out the volume for a good second, blowing everyone’s eardrums out. I got a couple thanks for muting it.

At 18, I was only there because I had a community around me. I didn't believe a word of it. I went to a sort of Charismatic, Evangelical, Pentecostal church, part of a global Megachurch. In other words, they had a lot of stupid fucking beliefs; not to mention your typical scandals with fraud and sexual abuse. Most notably, they claim to be progressive and inclusive, and are smart enough to publicly keep quiet on any 'controversial' issues (social issues, science, etc), as in my country (New Zealand) openly sharing such these beliefs would be disillusioning to most of your audience (unless that's what you built your audience around...). They spread these beliefs in a far more insidious manner, for example through youth leaders, or panels "debating" these topics.

There was one particular junior pastor at my church. Let's call him Jack. Jack's in his late twenties, influential, sometimes MC'ing or preaching in service. Jack was also my youth group leader - we'd meet with others on a Wednesday and 'hang out', with some time dedicated to talking about God. Through this I came to dislike him and his strong intolerant, anti-scientific beliefs. It's also worth noting, having been born overseas, Jack has a rather unmistakable accent. 

One of my good friends was in the same boat as me - disillusioned, and in too deep. Let's call him Mike. Mike often played guitar on band (actually, he's the BV I previously described) and occasionally worked the camera, which would feed the projectors, and record the church service. Mike and I would often hang out, smoke and jam together. One evening, high off our balls, we devised a plan to fuck with Jack.

Over about a month, I recorded Jack's isolated voices whenever he was speaking - at main church and youth church. Most notably, I'd record all of the Wednesday youth group sessions on my phone, and we'd lead him to discuss complex, controversial and explicit topics. I think I had an Iphone 6s. The audio quality was decent - but I'd pop it in Reaper, extract the juicy bits, equalize, compress, etc, to make the quality sound 'perfect'. We had a few hours' worth of recordings, but by the end we cut it down to just a handful of phrases. I remember just the one.

People on stage typically wear monitors, which are basically a wireless pack that receives the audio I transmit, and plays it in their in-ears. They can mute and adjust volume, but we sound-check beforehand to make sure they're happy, and I have full control over the mix. Jack's mix consists of his own mic, secondary speaker mic, with a little live band and audience. (Sidenote - churches use ambient crowd mics to amplify the sound of the audience.) Now, you might think I'm going to play some juicy audio in Jack's in-ears. Kinda.

We'd probably never be allowed alone in the church - but over that month, Mike and I would stay to dabble after most people had left, pretending to test and troubleshoot. With my phone plugged into the digital mixer, effectively I had created a soundboard. We devised how we could play phrases without raising suspicion, and tested it all to ensure the day would be flawless.

Jack was the MC for the busy morning service. Mike kicked back as Cameraman. The Service Coordinator and Technical Director sit in the control booth too, oblivious to our mischief. We wait patiently.

MC intro, 5 minutes. Live band worship, 15 minutes. Continue live background music. MC short sermon, 10 minutes. Guest speaker/offering, 10 minutes minimum. The offering pot is passed around, and Jack gets back up on stage. The kids have been sitting/standing on the floor in the front on the auditorium. MC to send the kids up to kids church, 30 seconds. He says, "Give us an applause for your awesome kids who have been up front with us today. It's time for our kids to head up to kids church!" Mike pans the camera to the cute kids waving toward the audience. The ambient crowd mics pick up the cheers and applause, and Jack visibly recoils as I blast applause in his ears. I cut his mic from the main speakers, and he stares at me, as his lips start moving. Calmly, he says; "Lord, please help me with my masturbation."

The applause quickly stops, and the camera pans back to Jack. He looks down and fiddles with his monitor pack, and resumes by introducing our senior pastor to a stunned audience. He heads back off stage.

Everyone heard it other than himself, and the recordings show it happened. I flew under the radar - nobody ever confronted me about the incident (other than Mike, of course!). I like to think Jack made a bumbling fool of himself, denying what happened and blaming the in-ears. I'd like to think he got in trouble... but he was back on schedule, MC'ing two weeks later.

Tl;dr: Made my pastor say he needed help from God with masturbation while talking about the audience's kids.

Submitted December 19, 2022 at 07:40AM by kaurib (From Reddit https://ift.tt/zM4lSkJ)

[local-roofing-news]

Commercial Roof Installation Buffalo NY

Commercial Roof Installation Buffalo NY If you're looking for commercial roof installation Buffalo NY service, you should know that there are several different types of companies in the area. These companies include Collingwood Construction, CentiMark, Sahlem's Roofing & Siding Inc., Grave Brothers, and others. Choosing the right one for your needs will ensure a long-lasting, beautiful roof for your business. Collingwood ConstructionCollingwood Construction is a family-owned construction company that has been in business since 1989. Based in Getzville, the company offers a wide range of home improvement services. This includes commercial roof installation and roof repair. It also offers a variety of other services, including carpentry, home painting, and interior and exterior remodeling. Collingwood Construction specializes in commercial roof installations and repair, including commercial roof replacement. They have a long history of service and are dedicated to providing the best possible results for their customers. Whether you're looking for a residential or commercial roof replacement in Buffalo, Collingwood Construction can help. When it comes to commercial roof installation, you'll find few companies with as much experience and expertise. As a certified Versico company, Collingwood specializes in EPDM, PVC, and TPO roof systems. CentiMarkCentiMark Contracting offers a variety of commercial roofing services. These include reroofing, preventative maintenance, inspections, storm damage repairs, and emergency roof repairs. The company also offers snow removal and roof cleaning services. These services help prevent damage from snowfall and can prevent collapse of the roof. The company is fully insured and adheres to all industry safety standards. Their workers are also highly trained and experienced in dealing with commercial roofing systems. CentiMark provides diverse roofing options, including metal roofing and polyvinyl chloride (PVC) roofing. These are sturdy and cost-effective roofing materials. CentiMark also offers environmentally-friendly green roofing solutions, such as garden roofs, skylights, and photovoltaic solar panels. CentiMark offers benefits, career advancement opportunities, and employee stock ownership plans. Those interested in working in commercial roofing may be interested in the company's bonus structure and employee stock ownership programs. Those who want to work at CentiMark should be at least 18 years old and legal to work in the United States. Applicants must also pass a pre-employment drug test. Although experience in roofing is helpful, it is not required. If you're looking for a challenging career, CentiMark Corporation is an excellent choice. Sahlem's Roofing & Siding Inc.Sahlem's Roofing specializes in commercial roof installation, siding, windows, gutters, sheet metal work, and more. The company has been active in the Buffalo, NY, area for more than 30 years. They are highly experienced, use only quality products, and will work within your budget. The company also specializes in re-roofing pre-engineered buildings. The company is licensed and fully insured. Their services also include a dumpster rental service. Their prices are competitive and include the labor for the job. Sahlem's Roofing - Buffalo NY commercial roof installation is guaranteed by their workmanship. They use quality materials and industry standards to create a roof that is durable and attractive. The company's roofing and siding contractors will also install trim work and vinyl siding. They offer a wide variety of colors and styles. They are certified by the Environmental Protection Agency. Finding a trustworthy roofing company in Buffalo can be difficult, but it is not impossible. Proper maintenance will keep your roof in good condition for years to come. It is important to compare prices to ensure you're getting the best value for your money. Cheaper roofing contractors in Buffalo may not provide you with quality work.

Grave BrothersGrave Brothers Commercial Roof Installation Buffalo NY has been in business since 1977 and is locally owned and operated. They offer high-quality commercial roofing installation at competitive prices. They also offer commercial roof inspections. We are fully insured and bonded to ensure that you are protected. We are proud to serve the Greater Buffalo area. Grave Brothers has a team of professional roof installers with over 20 years of experience. They specialize in shingle and metal roofing, gutters and siding, and trim. Their team can also help you navigate the insurance claim process. They are dedicated to meeting your needs, and you can expect a high-quality roof installation and the highest quality service. Grave Brothers Home Improvement is an award-winning home improvement company that specializes in installing, replacing, and installing roofs. They're a certified GAF Master Elite installer and an Owens Corning Preferred Contractor. They offer flat roofing, metal roofing, and cedar shake roofing.

[angelprinz]

VIEW RESULTS OF EXPERIMENT 0913?

FILES REQUIRE PASSWORD ACCESS.

ENTER: _ _ _ _ _ _ _ _ _ _ _ _ _ _ _

CONFIRM: YOU ARE 18 AND ABOVE,

CONSENT TO READING DARK NSFW ...!

[ ACCESS GRANTED ]

synopsis: naïve reader volunteering in albedo's project for extra cash. you really should've read the fine print.

WORD COUNT: 1.7K

warnings: yandere albedo, afab gn! reader, syringe usage, somno, rape, nonconsensual filming, drugging, public use, gangbang, manipulation, exhibitionism, choking, snuff "science experiment" gone wrong???

a/n: this is not your run of the mill smut. heed the warnings and understand that they are there on purpose, to let you know that this work is disturbing in nature. if you can't stomach it, simply exit this post. it only gets darker on the way to hell.

ENTRY ONE > for your senior, albedo, the well known medical major, it's no secret how important his graduating research is. you knew that he was on his way to be one of the youngest to cross the stage and collect his PHD, yet he asked you to help with collecting the final data by being an experiment participant. it seemed simple, just sign a document and go through a few tests then you walk away with money and another credential! you even had the chance to get in the good graces of the man you've been smitten with since first year, after all he might even mention your name in his research if you're good for him.

so you ask no questions nor read the extensive fine print of the agreement, obediently following albedo into an isolated lab resembling an operation room with darkened panels of glass. as albedo guides you in and lets you know the process, you're too distracted by his voice and the way his fingers wrap around the syringe in his hand to focus on the details.

when he asks in a concerned tone, "do you understand?" you confess you're just clear that he'll be placing you under anesthesia and running some tests? he nods, gentle grin letting you know that he's pleased and he helps you lay down on the operating bed, gently distracting you by murmuring how well you're doing as he inserts the needle into your arm. almost immediately you feel the effects after the sharp sting, feeling drowsy and consciousness leave you as albedo walks away with your vision fading out, spots of black covering your sight until you're conscious no more.

by the time albedo has discarded of the syringe and turned back to check your status, you're long gone, slow breaths and completely sedated. albedo prods you with his finger, poking the fat of your cheek with a light laugh. no reaction. he knows that you'll be immobile for hours to come and have no memory whatsoever now that he's administered the drug so now the real experiment begins.

ENTRY TWO > albedo can't help but admire your peacefully 'asleep' form, vulnerable and defenceless for a man like him to taint, so turned on by your helpless state that he hurriedly pulls his cock out of his slacks, fisting it with quick pumps until he spurts ropes of cum onto your passed out face.

despite blowing a load, albedo remains hard with a desperate lip bite to contain his frustration as he simply hasn't had enough of you. he pulls down your pants and underwear in a single swoop, leaving your private parts bare for him to leer at, cock throbbing with interest at the sight of your two holes. a tight cunt and ass for him to bury inside, with no need to care about preparation nor pleasure, after all you're knocked out.

albedo pushes his leaking tip into your cunt's entrance, hissing in pleasure from the contact with your folds that graze the sensitive head, bullying past the resistance of your unwilling insides by thrusting in with a decisive stroke, heavy balls slapping your clit when your cunt's forced open to take him till the hilt. with your pussy convulsing so deliciously on his cock, albedo fucks into your warmth without abandon, lewd sounds resounding from where your bodies connect.

as albedo pants and pounds into you, getting his fill of you in the missionary position, he looks up to see your unreacting face that only lets out gentle huffs of pain and whimpers to the pain of his brutal pounding then decides with his dick that your throat is simply begging for his fist around it. with a tight unrelenting grasp, albedo chokes you so your walls around his cock tightens up, face paling at the lack of air yet still asleep with the discomfort of albedo's hips rolling into yours and his hands taking away your precious air.

when he finally lets go of your neck to instead place a bruising grip on your waist, the struggle is evident by angry red marks and your bated breath. still, albedo drags you onto his cock like a fleshlight, uncaring of how you're treated and only focused on achieving his orgasm with every thrust into your cunt. he can only last so long however with you so blissfully unaware of him taking advantage of you and dumping his cum inside your pussy with a euphoric moan. albedo remains balls deep until he's certain his orgasm is over, warming himself in your wet and now creamy cunt.

with your obliviously placid circumstance laying there without even so much a sound through the entire ordeal has albedo's arousal stirring inside you again, getting erect as he turns you over and viewing your untouched ring of muscles that seem to invite his interested length. his fingers play with the pouting hole of your ass, feeling the heat that lies beyond the obstructing opening and pulling out of your cunt with a wet squelch before slapping it against the tiny bud.

his cock is covered in your juices and his previous load, and albedo uses it as lube, wiping his precum onto your asshole before shoving his way into the tight hole. albedo groans at the new sensation, the walls of your asshole gripping his girth as if trying to force the intrusion out and snapping his hips animalistically, determined to ruin the hole until it gapes wide for his cock. when succeeding in making your ass flutter and part for his thick cock with each thrust, albedo would make sure to fill the hole with cum till it overflows, dripping out as he gyrates against you.

once he's done and looking at the mess he's made of your naked body, covered in his multiple loads, decorating your fucked raw holes and skin painted white with his semen, he's satisfied with the effectiveness of his experiment. he turns to the blinking camera on the other side of the room, smiling at the one way window that mirrors his reflection with your 'asleep' form behind him and presents you as his experiment.

"now, i invite you all, guests, professors, fellow students and others, to take part. their holes are all for you to use."

warning. the content gets extreme beyond this. includes mutilations, murder, gore, anesthetic awareness, mind break, wound fucking, torture, scalpel usage, dead dove do not eat.

DO NOT READ IF UNCOMFORTABLE WITH DARK KINKS AND EXTREME FANTASIES // LAST ATTEMPT. YOU HAVE BEEN WARNED.

CONCLUSION... after you're used thoroughly by everyone else watching, albedo takes his time cleaning up your wrecked body, tracing each bruise from the tight grips on your throat and waist with pride before his eyes fall upon his table of medical tools. since you don't feel pain, it should be alright to take a few incisions right? it's in the name of science, not his leaking cock that yearns to see your body littered in wounds that ruin you completely. albedo had already felt his dick grow hard as he caressed your naked body, spoiled with countless loads of cum and wanted something unused, new yet sloppily wet to take him in like your cunt that is now raw from ruthless cocks that raped it beyond recognition.

wiping the last of the sticky semen off your skin, albedo discards the towel and grabs his scalpel, heart pounding in excitement in his chest as he places the slim blade to your stomach, digging deeper until the skin breaks revealing your internal organs, skin tissues carved into a heart with blood spilling as albedo's cock feels so heavy in his pants, pulling the length out to slick up in your blood. nudging the tip into the wound with a guttural groan, the ecstasy of defiling you to this extent making his blood rush and rationality fly out of the window as he ruts into the open flesh, pace picking up as blood gushes out, sickening sounds of wet plap plap plaping echoing the now empty room, save for the audience of the camera still rolling as albedo messes up your innards.

the tape captures every detail of albedo's merciless sadistic thrusts into your brutalised insides, even the moment when albedo's climax arrives, his eyes rolling back from the high as he pumps a wad of cum right above your exposed womb, cock twitching as the liquid spurts out. when he finally pulls away with his length covered in dripping blood, albedo uses the scalpel to open your womb, gloved fingers pushing his cum into the destroyed cavity, a deranged smile dancing on his lips as he proclaims to nobody but himself, "now, you've even taken my kids. how successful this trial has been, you truly were the best test subject."

WHAT IF... the drugs don't kick in, no not fully. or at least that's what you delude yourself with, unable to blink with your muscles paralyzed, unable to struggle with your eyes fully open while albedo assumes you're unconscious. the terrible truth is you're able to see and hear every word, misery setting in as you can't even scream or cry for help as they tears your clothes apart, body molested by all these strangers all because you didn't read the fine print and trusted albedo too much.

you'll never know that albedo had planned this, wanted you to experience it all, the pleasure of being used like a immobile fuck doll to break your mind forever. and when you "wake up"? he'll convince you it was all a sick dream, poor thing, let him comfort you.

FINALE... or if it was like originally... albedo mutilates you and collects all your organs in a pretty jar! you can feel every surgically precise cut yet can't move your mouth or limbs to protest as albedo collects your flesh, to have you forever! albedo keeps them stored in perfect condition, his favourite one being your pretty severed head that surprisingly has a tear leaking from it's eye as he brings the medical knife down onto his dear patient hmmm...

[jovialyouthmusic]

Who Wants to Rule the World?

A Lovelink fanfic

Okay, so you never choose who makes your heart beat faster or your knees go weak, and very unexpectedly, yet another fictional character has given me the wobbles. Dr Vile from Ludia’s Lovelink App is the virtual man in question, and I had had a TON of fun writing this. As always, this is an adult blog, so it will get hot and steamy and it is NOT SUITABLE FOR UNDER 18s

Word Count 2350

A/N Please note that Dr Vile, whom I have given the first name James, has no henchmen. Instead he has an army of drones to do his every bidding. Dr Vile is not my creation, he belongs to Ludia. 

I have an almost non existent tag list here, so if you like, reblog or comment I will add you.

1 Secret Base

Dr Vile’s face drifts into view, blurred and wavering but most definitely there as he stands over you. You blink in an attempt to clear your eyes. You’re lying on a firm surface, and the room is dimly lit. You hear the hum of a drone.

‘Hello Lucy’ You know his voice – he tries to sound intimidating but you detect a hint of warmth – a little doubt perhaps, as if he’s unsure of himself. Impossible. Unless – does he really have feelings for you?

‘How – how did I get here?’ your voice is weak. You try to sit up, but your head hurts and something stops you. Your wrists are secured by your sides, your ankles also immovable.

‘I rescued you’ You look around, and recognise your surroundings. His base – the one he brought you to only a week ago.

‘Rescued? From what?’

‘From whom…’

‘Oh’ a memory tickles the back of your mind. ‘It was F’

‘It was. They were questioning you, trying to get information on my base’ He chuckles ‘They walked right into my trap’

‘Your trap?’

‘I planted a device on you when we last met. You led me right to their den’ You try to move again.

‘This is your interrogation table’ As always, his face is half in shadow.

‘It is, Lucy. I have to be sure.’

‘Sure of what? That I’m loyal to you? How could you doubt me?’ He draws a deep breath and squares his jaw.

‘Tell me what you remember, Lucy’

‘Do you have to do it like this – on the table? My head hurts’ He looks away.

‘If you answer my questions correctly I’ll let you go. It’s base protocol. The drones demand it.’

‘And if I don’t?’

‘The drones will take care of you. They’re programmed to neutralise threats. I have to protect my interests.’

‘I’m not a threat – James, please’ you struggle against your bonds, then gasp. ‘They – you’ve lined the restraints in silk, haven’t you? Stainless steel lined with silk’ He squares his jaw.

‘It’s the least I can do’ You relax against the cuffs and close your eyes, trying to remember. He cares. Just a little, but he cares about your comfort. Even if his drones will most probably dispose of you if you don’t tell him what he - or they – need to hear. You take a deep breath past the pain in your head and gather your thoughts.

‘It’s all fuzzy. They – I wanted to tell them I wouldn’t betray you. We met at a bar. We had a drink, they said they quite understood and that there were no hard feelings. Then I felt dizzy. I passed out’

‘They drugged you.’ Vile says. ‘My drones found traces in your blood. They drugged you and took you to their den, and interrogated you. Or they tried to. Tell me more’

‘I don’t know. Was it a dream? I can’t remember’  He leans over you as a drone hums just out of sight, keeping watch. You know those drones are efficient and ruthless, no matter what Dr Vile may feel.

‘I need more details, Lucy, or the drones will take action’ Tears spring to your eyes as you struggle to recall what happened.

‘I – I think I woke up. I couldn’t move, and they asked me – they asked me where your base was. I don’t know exactly where it is, of course, you saw to that, so I couldn’t tell them, even if I wanted. But I didn’t’

‘Did you give them any clues?’

‘No’ you screw up your eyes ‘I told them – I told them…’ it comes to you at last ‘I told them I would never betray you, because I love you’ He leans on the table, his head dropping. The drone next to him whisks away and the cuffs snap open, freeing you at last. You struggle to get up, but Vile scoops you into his arms and lifts you bodily off the table as if you were light as a feather. You steady yourself by grasping his arm as he puts you on your feet beside the table.

‘That was the right answer’ he says softly. You test the strength of your legs, which just support you, but you lean back on the table. You cross your arms and wait for him to speak, holding your breath in anticipation.

‘I’m not sure I know what love is’ he says ‘But I think – I love you too, Lucy’ You step toward him, encircle his waist with your arms and turn your cheek to his shoulder against his armour. His body is solid against you, his arms warm and reassuring as he returns the embrace, hesitantly and softly as if you might break. You feel so safe. How could you not? He’s so powerful, so self assured and confident. It’s like an aphrodisiac.

‘What happened to F?’ you ask. He laughs, and you feel it in his broad chest.

‘They won’t be troubling us again’ You gasp as you pull away from him.

‘Are they – dead?’ After all, he is a super villain and wouldn’t scruple to kill, surely.

‘No, but they have a terminal case of amnesia, they’ve forgotten all about me – and you’

‘How..?’

‘I have a very nifty little device that wipes memory like wiping a hard drive. The drones would have applied it to you if you’d failed my interrogation.’

‘Oh – I thought you might have..’

‘Killed you?’ he laughs sardonically ‘That would have been a waste. I may want to rule the world, but I’m not totally evil. The safety protocols on the drones are very strict.’ You realise you still feel groggy, presumably from the drugs and most probably from dehydration. You slump in his arms and he supports you without hesitation.

‘I’m sorry, you’ve been through a taxing ordeal.’ You nod weakly, and he leads you to a padded recliner. Unfortunately its obvious purpose is torture, not comfort, and your eyes widen in alarm. He tuts in irritation. ‘How stupid of me.’ he berates himself, and scoops you up in his arms again. Once more you feel safe. You fight a wave of dizziness and close your eyes, aware that he’s taking you somewhere else but too sick to register your route. After a while you feel him lower you down, and you open your eyes.

You recline in a full length padded leather seat, the décor around you strongly masculine but designed for comfort rather than torture or world domination. It rather resembles the lounge of a gentleman’s club, panelled wood and brass and leather everywhere. He snaps an instruction.

‘Base, change command protocols. Upgrade Lucy to level two. Confirm’

‘Confirmed. Lucy Valois upgraded to level two.’ the calm dispassionate voice chimes. ‘Base and drone records amended’ He turns to you, eyes glittering in the half shadow of his handsome features.

‘Choose a gesture that the drones will recognise’ he says ‘Some movement you wouldn’t normally make.’ You grope through the fog in your brain, and raise your hand, bending your wrist and pressing your thumb to your fingers like a glove puppet, opening and closing them three times. He grins ‘Excellent. Again, to my prompt’ He straightens and addresses the computer again.

‘Computer, record Lucy’s command prompt’ he nods to you, and you make the gesture.

‘Prompt recorded’ He pulls up a stool and sits close to you.

‘Try it out. Ask for something’ Once again I make the gesture, and a drone that had been waiting discretely in the corner of the room scoots over and hovers in front of me, red light blinking under the rotors.

‘Water’ The red light blinks.

‘You need to be more specific’

‘Bring me a glass of water. Cold mineral water, still’ The light blinks green then steadies and the drone whisks off. Within seconds it comes back with three other drones carrying a tray with a glass and a sealed bottle. Dr Vile gestures to the table next to me and they put it down.

‘Allow me’ He picks up the bottle, opens and pours, handing it over to me. I take it, but he puts his hand to mine as I raise it to my lips ‘Just sip. Slowly’ he advises ‘I’d have put you on a drip, but I thought you would find these surroundings more comfortable.’ I sip and sigh with satisfaction, my dry throat soothed.

‘I thought you didn’t do down time. Too busy with your projects’ I continue to take small mouthfuls, feeling it soaking into my parched mouth and tongue, lubricating my throat.

‘I had this made when you so rightly pointed out that I’m a workaholic. I sometimes sit in here and contemplate my plans.’

‘I’m impressed’ A faint smile plays across his lips.

‘So, what would you like to do now? Are you hungry?’

‘A little, but I’m more tired than anything else – but can I ask you something?’

‘Of course, Lucy. You should know by now that your happiness is important to me’

‘Can I stay with you? Just for a little while. I feel a bit shaken up after all that. What if the Organization comes after me?’ He reaches across and runs his gloved fingertip along your jaw. A delicious shiver runs down your spine.

‘You’re safe here, Lucy. You can stay for as long as you want, my dear.’

‘Really?’

‘You can rule the world by my side’ His smile is triumphant.

‘Figuratively speaking’ He nods and inclines his head

‘You’ll have to wait and see. You know I have objectives.’ You smile back at him.

‘I believe in you, James’ you feel a wave of weariness sweep through you, and you lie back, closing your eyes. ‘I just need to rest’ are the last words that leave your lips before you drift off into an exhausted sleep.

 You wake with a start. Your surroundings are different. The light is dim, the room about you in shadow. You feel cool cotton sheets draping your body, a firm mattress beneath you. You hear the whirr of a drone whisking away, the swish of a door straight from a science fiction film opening and closing. You struggle to sit up, your belly rumbling and your mouth dry again. You look to the bedside table, where a glass of water sits waiting for you, so you take it and sip. You remember what happened to you the day before and gasp as you realise you are naked beneath the sheets. The door swishes open again and the light levels slowly increase as Dr Vile enters.

The room is dominated by the huge bed you lie on. The décor is monochrome with red accents and chrome or steel fittings. The bed linen is a crisp white and the coverlet a pale grey, the carpet a darker shade. You look up to see a mirror mounted above the bed, a bar at the opposite side of the room. Somehow you had expected a picture window, but there is none, the lighting soft but artificial. As Dr Vile approaches you clutch the sheets to you, your face flushing.

‘Don’t be afraid my dear, nothing improper happened’ he assures you, standing by the bedside. He no longer wears body armour, but the soft fabrics he wears resemble his usual garb, minus the cloak. You get the impression of cashmere and silk, expensive and well fitted to flatter his figure. ‘You were very tired and I brought you where you’d be more comfortable’ He gestures around the room ‘Do you like it?’

‘It’s – very masculine’ you remark, and he sits beside you on the bed.

‘It is my usual night refuge. You may choose another if you wish, or have one designed to your own specification’ You stomach rumbles, and he smiles ‘Breakfast in bed?’ he offers. You hold the sheet to you.

‘I – did you undress me?’

‘I would not pass such a delicate task onto my drones, so yes.’ His eyes glitter ‘It was done with the utmost respect, I promise you’ He gets up and disappears behind a sliding door for a moment, returning with a dressing gown. He hands it to you - it is soft and silky to the touch, and you shrug your way into it, instantly feeling more modest and comfortable. You turn to readjust the pillows.

‘Allow me, Lucy’ with a few gestures the pillows are perfect to lean up against. ‘What would you like to eat? He asks ‘Name it. Unless it’s very exotic I most likely have it although as you know I have only myself to please.’ You think for a moment, and remembering, you make the command gesture and wait for a drone to whip to your side, waiting.

‘Eggs benedict on a wholemeal roll and black coffee’ The lights blink green and it leaves the room. Dr Vile smiles and nods.

‘Well remembered, Lucy. Making commands suits you. And a good choice, it won’t take long.’ There is silence, but he breaks it before it becomes awkward. ‘I believe you had a fantasy about the interrogation table. I hope I didn’t spoil it by using it as it was intended’ He cocks an eyebrow at you. You sigh.

‘I’ve been drugged, kidnapped, rescued and interrogated twice - all in one day. I think need to gather my strength before I try anything like that’ You look up at his rugged half shaded profile; if you weren’t hungry and dying for a shower and a bath you’d drag him into bed with you right now.

‘Whatever you wish, Lucy. The drones will serve you too now, though I am still their master’ You shiver again.

‘Are you my master?’

‘If you want me to be, my dear’ He puts his hand on your thigh, which sends shocks of electricity to your core. ‘But I may consider other roleplays, as you suggested’

‘You’re seriously testing my resolve’ you murmur.

‘I have an excellent walk in shower with power jets’

‘Is it big enough for two?’

‘After you’ve eaten, I’ll show you’

@zodiacsign1​

[ijcmcrjournal]

When is Surgery an Option for Infectious Bowel Disease? by Francesk M

Abstract

Inflammatory bowel disease is comprised of two major disorders: Crohn’s disease and ulcerative colitis. Crohn’s disease is a chronic inflammatory, idiopathic disorder that affects any part of the gastrointestinal tract from the mouth to the anus, while ulcerative colitis is a chronic inflammatory, idiopathic disorder that affects the large bowel. Despite the new and ever expanding array of medications for the treatment of inflammatory bowel disease, there are still clear indications for operative management.

Key words: Crohn's Disease; Ulcerative Colitis; Surgical Treatment; Inflammatory Bowel Disease; Laparoscopic Surgery

Introduction

Crohn’s disease is a chronic inflammatory, idiopathic disorder that affects any part of the gastrointestinal tract from the mouth to the anus. Individuals with Crohn’s disease often experience periods of symptomatic relapse and remission. The estimated prevalence of Crohn’s disease is about 322 cases per 100,000 persons among adults in Europe and 43 per 100,000 among children.  It is considered a disease of the rich, as the estimated prevalence of Crohn’s disease is higher in urban areas and upper socioeconomic classes. It is thought that this is due to increased access to the health care system [1].

The exact cause of Crohn’s disease remains unknown. Several factors (genetic, environmental, immunologic, dietary etc.) are thought to play a role to the pathogenesis of Crohn’s disease. IBD1 gene located on the chromosome 16 is believed to contribute to the pathogenesis of the disease.  Furthermore, infectious agents such as Mycobacterium paratuberculosis, Pseudomonas species, Listeria species, environmental factors such as tobacco use and dietary factors such as a diet high in fatty acids have all been implicated in the pathogenesis of Crohn’s disease. Crohn’s disease is a chronic inflammatory disease that affects primarily the superficial mucosa and then spreads to the deeper mucosal areas, causing transmural inflammation.  Granuloma formation is pathognomonic of Crohn disease. The granulomas extend through all layers of the intestinal wall and into the mesentery and the regional lymph nodes.

Clinical manifestations of the disease include constitutional symptoms such as low grade fever, weight loss, and fatigue. As mentioned before, Crohn’s disease affects any part of the gastrointestinal tract. Oral manifestations such as oral ulcers are quite common. When the small intestine is affected, diarrhea, malabsorption, weight loss and abdominal pain are the predominant symptoms. When the colon is affected (terminal ileum is the most common affected part of the gastrointestinal tract), the patients report diffuse pain accompanied by diarrhea with blood and mucus in the stool. Extra-intestinal manifestations are also quite common in Crohn’s disease. It also affects skin, joints, eyes, liver and bile duct. Arthritis is the most common extra-intestinal manifestation. Central or axial arthritis, such as sacroiliitis, or ankylosing spondylitis, may also occur. Examination of the skin reveals erythema nodosum and pyoderma gangrenosum. Eye manifestations include uveitis, iritis, and episcleritis. Primary sclerosing cholangitis occurs in approximately 5 percent of patients [2,3].

Complications of the Crohn’s disease include: Fistulae that may develop between the diseased bowel and a variety of adjacent tissues, abdominal abscesses and small bowel obstruction and perianal abnormalities (abscesses and fistulae). It is worth mentioning that in threatening the above mentioning situations, a consultation with a surgeon is often needed [4].

The diagnosis of Crohn’s disease is based on laboratory tests, imaging studies and more invasive procedures, such as endoscopic visualization and biopsy.  Routine laboratory studies that are quite useful in the diagnostic process of Crohn’s disease include: CBC count, chemistry panel, liver function tests and inflammatory markers. It is worth mentioning that fecal calprotectin is a new marker that is proven to be quite useful in the diagnostic process and in the prediction of clinical relapse of inflammatory bowel disease. Specifically, the fecal calprotectin is a calcium- and zinc-binding protein, which for practical purposes can be considered to be neutrophil-specific. Fecal calprotectin test is a functional quantitative measure of intestinal inflammation. Therefore, fecal calprotectin tests are quite useful in gastroenterologists, in order to distinguish inflammatory bowel disease from other common diseases, such as irritable bowel syndrome. Except from the above, calprotectin also predicts imminent clinical relapse with an 80% sensitivity and accuracy in patients with established, relatively asymptomatic inflammatory bowel disease (ulcerative colitis or Crohn’s disease) [5].

Treatment options are individualized based on the severity of symptoms and the complications of the disease. In mild affected patients, such as patients with mild disease limited to the terminal ileum and/or colon and no complications, enteric-coated budesonide as the first line treatment for inducing remission. The use of 5-aminosalicylates (5-ASA) for Crohn’s disease is controversial, and we limit its use to patients with mild Crohn’s disease with limited ileocolonic involvement who prefer to avoid glucocorticoids. For patients with limited ileitis and mild symptoms, a slow release, oral 5-ASA agent is suitable, such as mesalamine (eg, Pentasa or Asacol). By contrast, sulfasalazine (the prodrug of 5-aminosalicylate) is less useful for ileitis because colonic bacteria must cleave the drug to release the active 5-ASA moiety, so it is reserved for cases of colitis. For low-risk patients with mild Crohn’s disease who achieved remission with a glucocorticoid tapering and then discontinuing the glucocorticoid is recommended. For low-risk patients with mild Crohn’s colitis who achieved remission with a 5-ASA agent (or sulfasalazine), the same agent should be used for long-term maintenance therapy [6-8]. On the contrast,  patients with moderate to severe Crohn’s disease ie patients younger than 30 years , with tobacco use with elevated C-reactive protein and/or fecal calprotectin levels, deep ulcers on colonoscopy ,long segments of small and/or large bowel involvement, perianal disease, extra-intestinal manifestations, history of bowel resections, first-line options for induction therapy include a biologic agent tumor necrosis factor-alpha (TNF) inhibitor (eg, infliximab) with or without an immunomodulator (eg, azathioprine [AZA], 6-mercaptopurine [6-MP], or methotrexate).After clinical, endoscopic, and histologic remission following induction with combination therapy, the same agents are used for one to two years [9-12]. For many patients with Crohn’s disease, may have a continuous and progressive course of active disease, while approximately 20 percent of patients experience prolonged remission after initial presentation. There is an increased incidence of squamous cell carcinoma of the anus and skin, adenocarcinoma of the small bowel and duodenal neoplasia in patients with Crohn’s disease [13-15].

Ulcerative colitis is a chronic inflammatory, idiopathic disorder that affects the large bowel. It is three times more common than Crohn disease.In the United States, about 1 million people are affected with ulcerative colitis. The exact cause of ulcerative colitis remains unknown. Several factors (genetic, environmental, immunologic, dietary etc.) are thought to play a role to the pathogenesis of the disease. A family history of ulcerative colitis (observed in 1 in 6 relatives) is associated with a higher risk for developing the disease. Disease concordance has been documented in monozygotic twins. Unlike Crohn’s disease, smoking is negatively associated with ulcerative colitis. Dietary factors such as milk consumption may exacerbate the disease. Last but not least, psychological and psychosocial stress factors can play a role in exacerbations of ulcerative colitis.

Ulcerative colitis is a chronic inflammatory disease that affects colonic mucosa. It involves erosions and/or ulcers and individuals with Crohn’s ulcerative colitis often experience periods of symptomatic relapse and remission. As mentioned above, ulcerative colitis affects predominantly the colon. Clinical manifestations of the disease include rectal bleeding and diarrhea with mucus in the stool. Lower abdominal pain is also a common symptom. Extra-intestinal manifestations are also quite common in ulcerative colitis. These include uveitis, pyoderma gangrenosum, pleuritis, erythema nodosum, ankylosing spondylitis, and spondyloarthropathies. Among them arthropathies are the most common, with an incidence of 39% and primary sclerosing cholangitisis is a potentially serious condition, which can often lead to liver failure. Complications of ulcerative colitis include: Severe bleeding happens in up to 10 percent of patients. Massive hemorrhage occurs in up to 3 percent of patients [16,17]. Urgent colectomy may be needed in these cases [18]. Another complication is fulminant colitis with more than 10 stools per day, bleeding, abdominal pain,and distension. Patients with fulminant colitis are at high risk of developing toxic megacolon. Perforation of the colon most commonly occurs as a consequence of toxic megacolon and requires surgical intervention [16].

Treatment options in ulcerative colitis are individualized based on the severity of symptoms of the disease. Patients with mild clinical disease are considered those who have ≤4 stools per day with or without small amounts of blood, no signs of systemic toxicity and a normal C-reactive protein (CRP) and/or erythrocyte sedimentation rate (ESR). Patients with moderate clinical disease may have frequent (four to six per day) loose, bloody stools, mild anemia, and abdominal pain that is not severe. Patients have no or minimal signs of systemic toxicity.  Patients with a severe clinical disease typically have frequent loose bloody stools (≥6 per day) with severe cramps and evidence of systemic toxicity as demonstrated by a fever (temperature ≥37.8°C), tachycardia (heart rate ≥90 beats per minute), anemia (hemoglobin <10.0 g/dL), and/or an elevated CRP or ESR. For patients with mild disease, mesalazine is the drug of choice in inducing remission and preventing relapse [19-23]. For patients with severe disease, the use of glucocorticosteroids is necessery in inducing remission. For patients with steroid-resistant disease, monoclonal antibodies such as infliximab, adalimumab, and golimumab are used [24,25].

Generally, anal and colon lesions can occur due to infectious and neoplastic etiology, and a prompt and multidisciplinary approach may prevent poor outcomes [26]. Patients with ulcerative colitis are at increased risk for colorectal cancer. The risk appears to be highest in patients with pancolitis and begins to increase 8 to 10 years following the onset of symptoms in patients with pancolitis. In one prospective study, the incidence of colorectal cancer was 2.5 percent after 20 years and 7.6 percent after 30 years of disease [27].

Surgery as an Option

Indications for operation in Crohn’s disease are failure of medical management (most common reason), extra-intestinal manifestations (25%), intestinal obstruction, fistulas with associated abscess or stricture, perforation, bleeding and cancer. Resection is the most commonly performed surgical procedure for small bowel Crohn's disease. Other surgical options for the treatment of small bowel Crohn's disease include bypass operations or ileostomy formation. These procedures can also be performed laparoscopically with decreased morbidity and length of stay in the hospital [28,29]. Laparoscopic minimally invasive surgery should be preferred to open surgery due to its advantages [30].

Indications for operation in ulcerative colitis are failure of medical management (most common reason), risk of malignancy and severe extra-intestinal manifestations of ulcerative colitis. Worsening signs and symptoms of colitis, including numerous bloody stools per day, fever, elevated heart rate, anemia, elevated sedimentation rate, radiographic evidence of colonic distension, and abdominal distension with tenderness on exam are indications for an emergent surgery. Total proctocolectomy with end ileostomy remains the operative standard against which all other resections for ulcerative colitis are compared. Surgical options of ulcerative colitis in the emergent setting is aimed toward removing the inflamed bowel while minimizing morbidity, and a total abdominal colectomy and end ileostomy is the procedure of choice [28,29]

For more information about Journal : https://ijclinmedcasereports.com/

https://ijclinmedcasereports.com/pdf/IJCMCR.SC.ID.00046.pdf https://ijclinmedcaser Crohn's Disease eports.com/ijcmcr-sc-id-00046/

[chidoroki]

The Promised Neverland S2EP6

aka: manga content is bliss!!!!

I will never get over how perfect those match cuts between the demon/human handshake, the chains & Emma are during the OP.. and how it builds up to the chorus is just.. aaahh, fantastic.

Oh! Lambda crew was added to the OP alongside the GF escapees. Norman too!

AAhh they really did fill in that empty spot with him during the last shot of Emma and Ray.. that’s wonderful!

“Emma’s Determination” starts up as I realize how foolish these kids are right now. Y’all are really about to have a touching reunion with each other in the middle of a demon town? With your disguises off?

Aaaaww that hug though!!

Look at her touching his face to make sure he’s real! I’m so glad they kept that panel! And how he noticed her missing ear too!

“I brought Ray out, too.” Well no shit honey.

YAAAYYY BEST BOY SLAPPED NORMAN!! Too bad it wasn’t hard enough to knock him to the ground like in manga but I’ll take it!

“But you say something cool, right?” “Yeah. Thanks to you. I’m glad I’m alive.” Dude, my heart.. aahhh!

The trio hug!! They’re all so cute!! I can’t handle all these happy feelings!

The Lambda crew is just standing there in the back like.. yeah, okay.

The younger kids are so happy to see Norman too.. but again manga did it better when they all tackled him to the ground. Granted that was a different scene but I would’ve loved to see it happen still.

Ah there’s his Lambda marking.

“I only took tests, so I’m fine.” Are you sure? Or are you just saying that so they won’t worry? Kind of like how he told the Lambda crew he didn’t get seizures when he actually did.

Also, I know some might think what was just said is true since Norman looks young and not like the “boss” Norman we were hoping for, but the anime is actually accurate in regards to that. Ch129 shows a flashback that takes place in February 2047 where Norman still looks younger. When the initial reunion in ch118/119 happens in November 2047, so perhaps the experiments/drugs manga Norman was given take time to affect his physical state or whatever. What I’m getting at is the anime isn’t denying us of “boss” Norman, it just hasn’t happened yet in this timeline.

Oh, Smee was actually mentioned!

Here comes the demon chatter and the poison.

“No, we’d fare better than going against a smarter demon.” True, not that anyone would truly know that because, you know, no GP..

“We’ll make the demons extinct. There will be no more Neverland.” Okay yeah, Norman takes Emma’s wish to heart by trying to create a world in which their family can live happily, but do you have to go through such extremes dude?

“Let’s establish a paradise for all of us in this demon world.” Manga Norman accomplished that, anime Norman.

Ohhh Ray notices Emma’s bluff, doesn’t he?

“If I give the word, even as early as tomorrow.” That’s quick, but fits with the pace of this season well enough..

“Now we can move forward, thanks to Norman.” Ah yes, we’re all saved thanks to our main character. Oh, wait.. that’s right. She’s over here being disrespected!

The base Smee left them? Is that the Paradise hideout? I forget.. or are we talking about the D100 location now?

Norman’s going back somewhere?

“It’s great.” “Is it really, though?” AH! Shut the fuck up! Are we getting the balcony scene here?? Right now?? Sure the duo is on top of a tower right now but y’all know what conversation I’m referring to!!

“About Norman’s plan.. you actually don’t want that, right?” IT’S HAPPENING!!! Oooh my god!!!

“But that’s not the future you want, is it?” “Something’s wrong with me.” Quick! Someone hold me! I’m not ready!!

Aww, Gilda helping Alicia with her nightmare.. that’s so precious!

Emma’s voice actor is totally nailing this scene so far.

“Yeah, nothing can be done.” Y’all, the way his voice became significantly confident and so positive and Emma’s reaction to him were perfect!!

“Don’t dig up my buried feelings, you jerk!” Emma sweetheart, I love you so much!

“If you’re going to bury your feelings, then take them to your gave, no matter what.” I know I said this once in the past, but after what happens in ch180, yeeaahh she takes his advice reaaallly well.

Oh they brought back “Emma’s Sorrow” to really make me even more emotional during this scene!!

You can always count on Ray to be completely blunt.

“Depending on the circumstances, we might get a clue on how humans and demons can coexist.” “Ray!” Bro she looked so hopeful and thankful that he’s even considering it! You could literally hear the relief in Emma’s voice!

“Choose what you want to do, and I’ll support you. No matter what you choose, you’ll be okay.” AAAAAAAAAAAAHHHHHHHHH!!!! HE SAID IT!!

“You can do the impossible. That’s your specialty, right? Let’s create a future we won’t regret.” “Okay! Thanks, Ray!” AAH I AM SO FUCKING HAPPY!!! And the sunrise makes this scene so beautiful!!!

“My head feels clearer now.” “You’re too easy!” They even remembered those tiny lines too!!!

Y’ALL!! I am feeling.. SO DAMN SOFT RIGHT NOW!! Holy shit.. yes, this scene would’ve been 5x better in terms of weight and importance if we saw every manga event that built up their bond and led up to this scene, but still!! The dialogue was on point! The emotion in their voices was everything I hoped for! The animation itself was good too!

Also, the sunrise?? Genius! Here we have our girl lost within her own mind and feeling completely alone due to her ideals, then BAM! Ray listens to her concerns, lends his assistance by thinking through a different course of action that would ease her wavering heart and restores some of her usual optimistic attitude. My boy literally helps our girl out of the dark and shined light on her mood/plan and that’s absolute perfection. (my ship bias is real obvious right now huh?)

Did we get the head pat? No, of course we didn’t. But I’m so happy to actually see & hear this conversation that I don’t care! I love these two so much. I honestly didn’t think we would get this scene. Even after the episode preview yesterday I still had my doubts but aahh my heart is so insanely happy right now!!

Oh? The duo is off to the location Norman gave them? This random, small house in the middle of no where?

Aaah Lambda crew! And THEY SPOKE WORDS!

Pfft they still had Barbara mix up “shield” and “field” and I love it.

Look how much shorter the duo is compared to Vincent!!

“He’s with Boss now, they’re..” Okay, one: I love that they still refer to Norman as “boss” despite him still looking like a child. Two: is he making the fake alliance with that demon clan already or nah?

Haahaha YEESS! They still had Ray choke on his drink!!

Vincent has such a deep voice.. he’s what, 17? 18? But damn.. who is his voice actor?

Also, just noticed the star on Barbara’s shirt doesn’t have the little face on it.

Mmhhmm, Barbara’s frustration was nice.

Oh, Norman returned.. and left as quick as he came.

Ahh! This is the conversation the duo had at the start of ch126!

Well, a real tiny part of it.. thanks for cutting it short, Norman.

“The Evil-Blooded girl is still alive?” Aayy the anime did their best with that panel. I’ll give them that much.

Okay.. that episode was great. Ya see what happens when you actually follow the manga? Sure some scenes/locations/panels were off but overall it was just so wonderful.

I’m happy. Granted the RE scene put me on a real high but yeah.. anime, I’m praising you! Keep it up!

(though I’ll be salty over no GP for the rest of my life, don’t worry.)