HIV Prevalence in Uganda

HIV Prevalence in Uganda Uganda (HIV/AIDS) Section 1: Between 2002-2011, the international non-profit NGO AVSI Foundation has supported Uganda’s Ministry of Health (MoH) prevention of mother-to-child HIV transmission (PMTCT) program in four Northern Ugandan districts: Kitgum, Lamwo, Pader, and Agago. The program â€Å"aimed to be comprehensive, emphasizing social and medical care and support† and was successful in reducing HIV prevalence among HIV-exposed infants from 10.3% in 2004 to 5.0% in 2011, among other things. The MoH/AVSI PMTCT sites showed how a â€Å"comprehensive PMTCT program emphasizing social and community engagement alongside medical care and support can succeed in a remote setting with multiple challenges† (3). Despite the advances of the MoH/AVSI program, HIV/AIDS remains a critical issue in Uganda. Northern Uganda especially faces dispropriate challenges and adversities in regards to the national HIV/AIDS epidemic response. In 2011, the Uganda AIDS Indicator Survey measured a national HIV prevalence of 7.3%, but the HIV prevalence in northern Uganda specifically was shown to be 8.3%. Also, Uganda has one of the largest crude birth rates in the world. In 2011 Ugandas birth rate was 42.1/1000 (3). In addition, Northern Uganda has faced great adversity from the Lords Resistance Army (LRA) during the period 1986-2006. There was an estimated two million individuals mandated to live in internally displaced people (IDP) camps from this violent discord (3). The fallout from the war between the government and the LRA had worsened already sparse health services in the north. Due to the high birth rate, HIV prevalence, and structural violence faced in northern Uganda, the AVSI Foundation proposes to extend the MoH/AVSI PMTCT program for an additional five years with support from the Global Fund. Support from the Global Fund will allow us to broaden PMTCT services in 24 Northern Uganda MoH facilities (located in Kitgum, Lamwo, Pader, and Agago) and help expand these sustainable PMTCT service sites to other MoH facilities nationwide. Estimated Populations (2011) of Targeted Northern Ugandan Districts Kitgum 222,737 Lamwo 164,754 Pader 237,100 Agago 285,300 Link to Map: https://mapsengine.google.com/map/edit?mid=zZ1ADMHAfHkY.krdFRCFxMCRQ Section 2: Goal: Impact Indicators Baseline* (Year 1) Target (Year 5) Reduction in HIV incidence among HIV-exposed infants 5% 3% *2011 estimate The first and foremost goal is to reduce HIV incidence among HIV-exposed infants by reducing Mother-to-child Transmission (MTCT) of HIV. MTCT occurs when an HIV-positive mother infects her infant with HIV during pregnancy, labor, delivery, or breastfeeding (1). Yet, the risk of transmission can be reduced to less than 5% if mothers undergo proper maternal ART treatment. The diagram below illustrates the many steps mothers need to take to successfully complete a PMTCT program. This series of complex steps is why it is absolutely critical to assist Ugandan mothers as much as possible to make successfully complete our program. However, even if HIV-positive mothers complete a PMTCT program in all of its entirety and give birth to an HIV-free infant, infants still remain at risk of HIV infection. Other channels, such as contaminated needles, can infect an infant who was initially born HIV-free. Thus, maintaining and promoting strict sanitation procedures, alongside a strong PMTCT program, is absolutely critical in reducing HIV incidence among HIV-exposed infants. The table below summarizes the PMTCT Indicators â€Å"number of HIV-exposed children (18 months or younger) tested† and the â€Å"number of HIV-exposed children (18 months or younger) that tested HIV-positive† measured by the MoH/AVSI program between 2002-2011. This data was used to formulate Year 1 and project a realistic target for Year 5. Section 3: Objectives: Outcome/coverage indicators Baseline* (Year 1) Target (Year 5) Increase the proportion of HIV-positive women who deliver in health facilities 81.1% 95% Increase the number of mothers who undergo HIV testing (in ANC) 96% 98% Increase proportion of HIV-positive mothers on ART treatment 78.5% 95% Increase antenatal care attendance (mothers) 20,032 50,000 *2011 estimate One of the main objectives is to increase the proportion of HIV-positive women who deliver in health facilities. It is absolutely critical for HIV-positive women to deliver in health facilities. After all, health facilities can provide better medical care and support than a traditional midwife would be able to in a home delivery. Furthermore, health facilities have more resources, equipment, and personnel to respond to any emergencies during delivery. Above all, delivering in a health facility will better guarantee the infant receives the appropriate antivirals need to PMTCT. HIV-positive women delivering at home run a higher risk of these crucial medications not being administered. Thus, increasing the proportion of HIV-positive women who deliver in health facilities better protects both the mother and the child, than a home delivery. The table below summarizes the PMTCT Indicator â€Å"percentage of HIV-positive women who delivered in health facilities† measured by the MoH/AVSI program between 2002-2011. This data was used to formulate Year 1 and project a realistic target for Year 5. Another objective is to increase the number of mothers who undergo HIV testing while in ANC. There are clearly many benefits for at risk individuals undergoing HIV-testing. However, the benefits of having undergone an HIV test are lost if the patient does not return to learn their result. Thus, it is absolutely crucial for our program will utilize â€Å"rapid testing at a women’s first antenatal clinic visit† (1). In contrast to a â€Å"conventional HIV test† that can take days or even weeks to attain results, â€Å"rapid tests can produce a result in as little as twenty minutes† (1). This will allow reduce the number of HIV-positive women who are lost from lack of follow-up and will also facilitate rapid enrollment of HIV-positive pregnant women into PMTCT program services. The table below summarizes the PMTCT Indicator â€Å"ANC women tested for HIV† measured by the MoH/AVSI program between 2002-2011. This data was used to formulate Year 1 and project a realistic target for Year 5. Another objective is to increase proportion of HIV-positive mothers on ART treatment (e.g. antiretroviral prophylaxis or triple antiretroviral therapy, depending on the circumstance). However, â€Å"to be fully effective, antiretroviral medication needs to reach newborn babies as well as their mothers† (1). The table below summarizes the PMTCT Indicators â€Å"number of HIV-positive women who received ARV prophylaxis† and â€Å"percentage of ANC HIV-positive women started on prophylaxis† measured by the MoH/AVSI program between 2002-2011. This data was used to formulate Year 1 and project a realistic target for Year 5. Specifically, our program will utilize and adhere to the 2013 World Health Organization’s (WHO) Option B guidelines for PMTCT (until subsequent more effective recommendation plans replace it). The WHO’s 2013 Option B advocates to provide â€Å"Provide all HIV-positive pregnant or breastfeeding women with a course of antiretroviral drugs to prevent mother-to-child transmission† (2). They explicitly state that a triple-drug antiretroviral treatment should be administered throughout pregnancy and delivery. Furthermore, breastfeeding mothers should persist on the triple-drug antiretroviral treatment until at least one week after stopping breastfeeding. The steps and procedures of Option B are outlined in the flowchart below. Another objective is to Increase antenatal (ANC) care attendance for mothers. After it has been shown that â€Å"A number of clinical processes, such as antenatal care and safe delivery, can improve the health of both mother and child† (4). ANC services offer certainly offer many benefits for mothers but their benefits (just like in HIV-testing), are lost if women do not take advantage and utilize these services. There are numerous reasons a mother may not seek ANC services, even if they are â€Å"free†. A huge factor is accessibility difficulties. Pregnant women in low income countries, like Uganda, often have an increased difficulty in utilizing maternal programs because of their busy schedules. They are heavily occupied in caring for children, working, and running numerous kinds of other errands. Furthermore, many mothers live far away from health clinics and may lack a reliable means of travel. Both of these issues creates a huge barrier for women who need antenatal care services, but struggle to access it. Thus, our program will offer basic care and support services (such as food/transportation vouchers, housing assistance, and child-care services) to help increase ANC attendance. After all organizations, such as Partners in Health, have proven that by seeking to overcome the â€Å"social barriers† to accessing care by implementing â€Å"wraparound services [e.g. transportation costs ]† can help in addressing some of the â€Å"social and economic determinants of ill health† (4). The table below summarizes the PMTCT Indicator â€Å"ANC attendance† measured by the MoH/AVSI program between 2002-2011. This data was used to formulate Year 1 and project a realistic target for Year 5. Section 4: Activities: Main Activities Process/Output Indicators Program Year 1 Target Program Year 5 Target Responsible/implementing agencies Free/accessible HIV testing and antenatal care services for mothers ANC attendance (# persons) 30,000 50,000 Ministry of Health Maternal mobile teams Number home-births assisted 2,000 10,000 AVSI HIV counseling for mothers and their partners % HIV-positive mothers participating in therapy 25% 50% AVSI One of the main activities to be conducted is providing free and accessible HIV testing and antenatal care for mothers. Indeed, it has been proven, on behalf of the structural adjustment era, that â€Å"user fees in many resource-poor settings deterred the poor from accessing any health services (4). Likewise, charging service fees for PMTCT services would create a huge barrier for the poorest northern Ugandan mothers. On the other hand, providing financial support to mothers would encourage and give incentive for mothers to continue to attend and adhere to PMTCT program services. Thus, financial support will be given to mothers who attain antenatal services and HIV testing. This will not only help support poor Ugandan mothers, but will also reduces the likelihood of mothers being lost by lack of follow-up. Another activity that will be conducted is using maternal mobile teams to reach at risk mothers who have an increased difficulty and/or refusal to travel. After all, some pregnant women, despite being offered transportation services and/or financial support, will refuse to deliver in health facilities for whatever reason. Therefore, maternal mobile teams will be trained to provide â€Å"services such as HIV education, testing and counseling, and advice on infant feeding† (1). Maternal mobile teams should be used for the women who deliver at home and ensure that those who have tested positive for HIV have access to the essential antiretrovirals needed for PMTCT. Indeed, keeping track of mothers (especially HIV-positive mothers) who plan to delivery at home will be a challenge. Consequently, this will be a major a coordinating responsibility of community health workers who will be responsible for the gathering the necessary records (i.e. HIV-positive pregnant mothers) to pass on to the maternal mobile teams. Additionally, HIV counseling for mothers and their partners will be provided at no cost. Indeed, biomedical treatments are not the only thing needed for a successful HIV intervention. Social and emotional support are also crucial. Unfortunately it can sometimes prove difficult to persuade men to attend such services that are often regarded as â€Å"women’s clinics dealing with women’s issues† (1). Nevertheless, another vital activity will be to train and engage community health workers who will be paid to promote maternal education and social support to mothers. After all, the use of expert clients and other community-based volunteers helps reduce the stigma and discrimination of mothers living with HIV. It also helps improve the utilization of basic care services and adherence to Antiretroviral (ARV) Therapy. The term â€Å"expert clients† refers to people who are currently HIV/AIDs positive who serve as experienced role models for other PLHIV. Currently, expert clients work in almost every Ugandan ART site, engaging in various activities ranging from promoting health education to providing psychosocial support for PLHIV. Furthermore, mothers will be either followed up with an invitation to come to the health facility for specific interventions/services or visited by a team of health professionals (i.e. a maternal mobile team). Section 5: Our goals and objectives fit within the National Plan because they complement and scale-up an HIV infection prevention campaign to one of the most disadvantaged regions in the country, Karamoja. This 2013 campaign, called Elimination of Mother-to-Child-Transmission of HIV (eMTCT), is part of the Ugandan government’s large-scaled efforts to prevent new HIV infections. Furthermore, our goals and objectives further assist Uganda in their Ministry of Health 2010-2015 Scale Up Plan for PMTCT that aims to achieve an HIV-free generation of Ugandans by 2015 through the virtual elimination of MTCT of HIV, which utilizes a Sector-Wide Approach (1). Indeed, it is extremely critical to work with the public sector and not against the public sector. Our program is committed to working in public sector PMTCT health systems because â€Å"only governments can enshrine health as a human right and then implement programs to safeguard this right for its citizens on a national scale† (4). Section 6: a) We will involve Ugandan mothers by providing HIV counseling services for mothers and their partners. Social support is a crucial component of providing medical services. Indeed it has been shown that when â€Å"male partners are involved, both partners can get tested for HIV, know their status, and therefore improve the baby’s chances of a healthy survival† (1). Furthermore, counselors are better able to â€Å"emphasise the man’s responsibility for protecting the health of his partner and family† and can also advance the use of PMTCT services, â€Å"resulting in much higher rates of treatment uptake† (1). b) Community participation will be fostered by using community health workers to promote awareness, attendance, and adherence to PMTCT services. Specifically, community-based female volunteers who are â€Å"expert clients† (current HIV-positive mothers who serve as mentors and have experience with overcoming HIV-related stigma) will especially be invaluable. After all, community health workers can gain the trust of mothers who will thus be more likely to adhere to PMTCT services. c) This PMTCT campaign will help to improve the status of women in Uganda by empowering mothers to be active, confident, and assertive actors in the health of their children. Indeed, educating women is crucial to improving the health of infants. By increasing maternal education for mothers, indicators such as infant mortality will be reduced. d) Social equality is promoted by providing free antenatal care, HIV testing, and free antiretroviral treatment (WHO’s Option B); we are removing the financial barrier that would keep the poorest mothers from attaining maternal services. Indeed it is of the utmost importance to avoid punitive user fees† and other â€Å"cost-sharing devices that shift the burden of payment to those least able to pay† (4). As mentioned previously, charging user fees for services would exclude poorer populations. Not only will free treatment be provided, but financial support will be given to women who adhere to therapy. e) There will be an emphasis on education and expansion of programs nationwide to promote human resources development. We will train community health workers. These community health workers will pass on their training to mothers. These mothers will likewise be encouraged to share their acquired knowledge with friends, relatives, and other community members. In other words, creating a dynamic chain reaction of teaching will be a huge focus of this program. Moreover, we wish to spread the effectiveness of our PMTCT program from northern Uganda to other parts of the country. After all, â€Å"addressing maternal and child health comprehensively will require training more health workers; strengthening referral networks between communities, health centers, and hospitals; and ensuring adequate supplies at care centers- all elements of a robust health system† (4). Section 7: There may be potential opposition from the local context regarding the empowering of women our services inevitably (and justly) bring. According to the Foundation for Sustainable Development, â€Å"women face . . . discrimination, low social status, lack of economic self sufficiency, and greater risk of HIV/AIDS infection† (5). Because women typically have lower status than men in Uganda, some natives may potentially view this education and empowerment of women as a threat to their culture. The best way to address it will be to involve the mothers boyfriends, husbands, etc as much as possible in the lessons and counseling. Promoting equity is a crucial measure and indicator of a successful program. Another potential opposition to the plan will be the barrier of HIV-testing stigma that keeps mothers from getting HIV-testing. The best way to address this is to integrate HIV-testing as a standard part of antenatal care. Instead of asking women if they would like to â€Å"opt in† (receive HIV- testing), one would only ask them if they would like to â€Å"opt out† (not receive HIV-testing). In other words, if HIV-testing is set as the default option, women will be more comfortable with receiving it. And thus, overtime, HIV-testing will be normalized and become common practice, which will help remove the barrier of stigma. In brief, removing the â€Å"special status given to HIV testing helps to make it more acceptable† (1) Finally, any other existing NGOs in the area who are doing similar PMTC work may create conflict with our plan. There may be some â€Å"turf war† as different NGOs commonly have different agendas. The best way to address any NGO conflict is to do preliminary research to ensure we set up the PMTCT care services in areas that are not disrupting any â€Å"parallel programs†. References AIDS Education and Research Trust. Preventing PMTCT. AVERT. Web. 9 Mar. 2014. http://www.avert.org/preventing-mother-child-transmission-pmtct-practice.htm>. AIDS Education and Research Trust. WHO Guidelines. AVERT. Web. 9 Mar. 2014. http://www.avert.org/who-guidelines-pmtct-breastfeeding.htm>. Bannink-Mbazzi, Femke, MA. High PMTCT Program Uptake and Coverage of Mothers, Their Partners, and Babies in Northern Uganda: Achievements and Lessons Learned Over 10 Years of Implementation (2002–2011). Journal of Acquired Immune Deficiency Syndromes 62.5 (2013). JAIDS. Lippincott Williams Wilkins, Inc., 27 July 2012. Web. 09 Mar. 2014. http://journals.lww.com/jaids/Fulltext/2013/04150/High_PMTCT_Program_Uptake_and_Coverage_of_Mothers,.20.aspx>. Farmer, Paul. Reimagining Global Health: An Introduction. Berkeley: University of California, 2013. Print. Gender Equity Issues in Uganda. Gender Equity Issues in Uganda. Foundation for Sustainable Development. Web. 09 Mar. 2014. http://fsdinternational.org/country/uganda/weissues>.

Ultrasound-guided Interscalene Block for Dislocated Shoulder

Ultrasound-guided Interscalene Block for Dislocated Shoulder Preliminary results of ultrasound-guided interscalene block for dislocated shoulder: Abstract Background Traditionally, patients with a dislocated shoulder joint will be subjected to general anesthesia for closed reduction, if this procedure cannot be managed with light intravenous sedation and opioid analgesia. Successful interscalene blockade of the brachial plexus allows painfree reduction of the dislocated shoulder. However, the interscalene blockade for a dislocated shoulder is usually performed in the emergency room and to optimize patient safety it is desirable to minimize the dose of local anesthetic using ultrasound-guidance. The objective of this cohort study was to determine the clinical feasibility of ultrasound-guided interscalene brachial plexus blockade using a safe dose of just 10 mL of lidocaine 1% in producing sufficient and effective muscle relaxation, allowing painfree reduction of a dislocated glenohumeral joint. Methods We performed ultrasound-guided interscalene brachial plexus blockade with 10 mL of lidocaine 1% in a cohort of 10 patients with dislocated glenohumeral joints presenting in the emergency room, where the shoulder could not be reduced following intravenous sedation and analgesia. Results The success rate of closed reduction of the dislocated shoulders was 100% with complete pain control and muscle relaxation during the reducting procedure. Median patient satisfaction (VAS, Visual Analogue Scale 0-10) after completion of the procedure was 10 (range 8-10). Conclusion Ultrasound-guided interscalene brachial plexus blockade using merely 10 mL of lidocaine 1% effectively produces muscle relaxation allowing pain free reduction of the dislocated glenohumeral joint with a success rate of 100% and high patient satisfaction. Keywords dislocation, shoulder, glenohumeral joint, ultrasound Introduction Dislocation of the gleno-humeral joint is associated with severe pain and is frequently presented in the emergency room (ER). Reduction of a shoulderdislocationrequiresalleviation of the pain and musclerelaxation. Traditionally, this is obtained using general anesthesia (GA) with rapid sequence induction, when initial attempts of reduction using light oral and/or intravenous sedation and opioid analgesia are not successful. However, GA is associated with the risk of aspiration and requires an anesthetist, access to the operating theatre and postoperative observation in the Post Anesthesia Care Unit (PACU). Interscalene blockade (ISB) of the brachial plexus (BP) will achieve the desired effect of muscle relaxation and pain alleviation and eliminates the risks of GA cost-effectively. ISB of the BP usingelicitation of paresthesia to locate the target nerves wasemployedalready in 1973 to obtainanalgesia and musclerelaxationallowingreduction of a dislocatedshoulder joint 1. ISB of the BP using electrical nerve stimulation to allow reduction of a dislocated shoulder joint was later reported 2, 3. However, the motor response due to the electrical stimulation can be very painful in patients with dislocated shoulder joints. Some authors have reported location of the BP using ultrasound-guided regional anesthesia instead of electrical nerve stimulation 4, 5. Blaivas and Lyon (2006) used in-plane (IP) approach and 30 mL of either lidocaine 1% or bupivacaine 0.25%. The success rate of pain free joint reduction was 100% in four patients. Bhoi et al. (2010) used out-of-plane approach and 6-15 mLlidocaine 2% and had a success rate of a 100% in three patients. The current report describes an ultrasound-guided approach to ISB of the BP using IP approach and 10 mL of lidocaine 1% for reduction of the gleno-humeral joint in a preliminary cohort of patients with dislocated shoulder where reduction in the ER had been attempted with light sedation and analgesia without success. Methods The requirement for approval of the protocol and for written informed consent, was waived by the Central Denmark Regional Committees on Biomedical Research Ethics,due to the fact that the ultrasound-guided ISB of the BP for reduction of dislocated shoulders is an established method in our departments. Following informed consent 10 consecutive patients scheduled for reduction of dislocated gleno-humeral joint were included in the study (Table 1). We have only included patients with dislocation of the gleno-humeral joint where reduction has been attempted in the ER without success. Following establishment of venous access, the patient was placed in the supine position with the head turned contralateral to the side to be blocked. Vital signs monitoring was opted out during the procedure in the ER provided that all of the following criteria were fulfilled: (1) the block was performed by a consultant anesthetist who performs ultrasound guided peripheral nerve blocks on a daily basis and ( 2) the block was performed with uninterrupted, direct real time visualization of the needle tip during the entire procedure and (3) using parasagittal from-posterior-to-anterior IP approach and (4) with visualization of the spread of a 1 mL test dose of saline alongside the nerve roots of C5-C6 prior to injection of lidocaine and (5) real time visualization of the spread of lidocaine during the entire injection and (6) no supplementary lidocaine in addition to 100 mg was injected (7) in a fully awake and alert patient. If the above criteria 1-7 were not fulfilled, then the procedure was aborted immediately and not resumed until full vital signs monitorering had been applied. . Needle path and injection of local anesthetics Using an aseptic technique the needle was inserted from the posterior end of the ultrasound transducer and thereafter advanced IP in an anterior direction until the needle tip was seen in close proximity to the C5 and C6 nerve roots (Fig. 1). Hydrolocation was per formed with 1 mL of saline confirming the appropriate location of the needle tip and the spread of the injectate prior to injection of local anesthetic (10 mL of lidocaine 1%). The endpoint of the injection manoeuvre was to observe that the local anesthetic spread alongside the C5 and C6 nerve roots as assessed by real-time ultrasound. The dose of lidocaine was injected incrementally with intermittent aspiration. If the spread of local anesthetic was deemed inadequate the needle tip was repositioned as necessary with direct real time visualization using solely ultrasonographic guidance. Equipment The ultrasound scanning was performed with an M-Turbo ultrasound machine (Sonosite, Bothell, WA) using a 6-13 MHz linear transducer (HFL38, Sonosite ®, Bothell, WA, USA) covered by a sterile sleeve. Definition of successful ISB Successful ISB was defined as reduction of the dislocated shoulder joint with no need for conversion to general anesthesia. Study design and data collection The study was planned as a prospective cohort study to determine the clinical feasibility of the low-dose IP ISB to allow reduction of a dislocated shoulder joint . Thus, no formal power analysis or statistical test analysis was performed. Results A total of 10 patients were enrolled. Nine patients had an anterior dislocation of the gleno-humeral joint and one had a posterior dislocation. Demographic data are presented in table 1. The success rate of reduction of the dislocated shoulders was 100% with complete pain control and muscle relaxation during the reducting procedure. Median patient satisfaction (VAS, Visual Analogue Scale 0-10) after completion of the procedure was 10 (range 8-10). Median time from completed block performance to shoulder reduction was five minutes (range 3-10 minutes). The median pain VAS score immediately prior to the performance of the interscalene block was 10 (range 7-10), and all patients were awake and fully alert during the procedure. All procedures were completed in accordance with the criteria 1-7 (see Methods). Outcome data are presented in table 2. Discussion Our preliminary data demonstrate that a dislocated shoulder can be reduced effectively without pain, and with good muscle relaxation using ultrasound-guided interscalene brachial plexus blockade with a small dose of lidocaine. By application of this technique, deep sedation and opioids and/or general anesthesia with fast track induction is avoided in a population of typically non-fasting patients. Ultrasound-guided ISB of the BP is applicable also in patients with severe cardiac co-morbidity, where GA would not be attractive. Ultrasound-guided ISB of the BP is also a simple and low-cost technique compared to general anesthesia and does not occupy the capacity of the surgical ward or the PACU. Application of a safe and innocuous dose of a local anesthetic with a broad therapeutic range is critically important, when peripheral nerve blocks are performed in the ER outside the primary venue of anesthesia. The standard dose of 100 mg lidocaine optimizes patient safety, as accidental intra venous injection of this magnitude of lidocaine would be virtually harmless. However, intravenous injection using ultrasound-guidance is practically impossible when appropriately performed in accordance with the criteria listed in the Methods section. The theoretical risk of an accidental intraarterial or intraspinal injection is considered non-existent obeying the above mentioned criteria 1-7. Resuscitation equipment is readily accessible in the settings of the ER. However, any dose of any local anesthetic employed for peripheral nerve blocks without full vital signs monitoring remains a controversial issue. If the reader cannot honour all the criteria 1-7, the advice of the authors is to apply full vital signs monitoring during and after the performance of the nerve block even when using a small dose of a local anesthetic with a broad therapeutic range. Our preliminary data suggest that the patients experience maximum satisfaction with this technique (median VAS score 10). We hav e no data to compare patient satisfaction to nerve stimulation guidance for interscalene blockade or general anesthesia. There are some important limitations to our study. First, the study is non-randomized, un-blinded and it does not include a control group. Second, the sensory and motor quality of the interscalene blocks was not tested and the effect was just documented by clinical success. Third, lidocaine pharmacokinetics was not calculated and serum-lidocaine was not measured. Fourth, the choice of dose of local anesthetic was arbitrary and not based on titration. Fifth, the study included only a small sample of patients. However, the clinical success rate of reduction was 100% and the patient satisfaction very high despite the fact that our data were sampled in a population of patients where the primary attempt for a closed reduction of the dislocated shoulder supported by sedatives and opioids failed. This strongly indicates the feasibility of the described technique and reduced dosing of local anesthetic. Future randomized controlled trials have to clarify the usefulness of a broader indication for ultrasound guided interscalene nerve blockade for patients with dislocated shoulders. Conclusion This preliminary cohort study demonstrates that ultrasound guided interscalene BP blockade using merely 10 mL of lidocaine 1% effectively produces muscle relaxation allowing pain free reduction of the dislocated glenohumeral joint with a success rate of 100% and maximum patient satisfaction.

Algae :: Sea weed

Recently, I interviewed someone from the Island of Orkney, off the northern shore of Scotland. He described the seas as being nutrient rich and crystal clear. Traditionally, sea weed, (called sea vegetables in Scotland) has been used for herbal remedies, food products, animal food, cosmetics, and fertilizers. Two of the major species I was informed of were Laminaria, and Carrageen Chondrus crispus (Irish moss). Laminaria, (commonly called "kelp") has it has the ability to re-growth extremely fast, making it an almost infinitely sustainable crop. Auxins, gibberellins and cytokinins exist in large amounts, which are used for animal food supplements. Laminaria is the main seaweed used in Scotland, but Red-weed, green-weed, purple-weed, and pinkweed each with its own unique benefits. The various species are used for health products, cosmetics and natural fertilizers for gardens. The seaweed is currently used for animal and human consumption. Red seaweed gel is used for respiratory problems in animals, (particularly horses), and green seaweed gel, is used as an animal food supplement for growth and minerals. For human consumption, Red seaweed extract is used as a general tonic and Red seaweed beautifying cream and a seaweed skin rub for sports people. An interesting fact is that Orkney Gold's Seaweed Supreme won The Scottish Food Award in 1995 and 1996. It is made of different flavored kelp dips which can be substituted for tartar sauce, horse radish, mint sauce, dips for French fries, spread for sandwiches and salad dressings. The old Norse word for seaweed is ‘tang’ and ‘gathering ther tangs’, as it used to wash up on the beaches after each winter storm. It was also the only form of land nutrition available to the crofters and early farmers.

Sun Tzus The Art of War Essay -- Sun Tzu Art War Essays

Sun Tzu's The Art of War   Ã‚  Ã‚  Ã‚  Ã‚  The translation of the â€Å"Sun Tzu: The Art of War† ancient Chinese text has been given by many different writers. Samuel B. Griffith, Brigadier General, retired, U.S. Marine Corps; is a proven strategist that studied the English commandoes war fighting skills as a Captain. As a Major, Griffith was hand picked to serve as Executive Officer under the command of Lieutenant Colonel Merritt Edson of the 1st Raider Battalion, one of the battalions that perfected the amphibious landings during World War II. Samuel B. Griffith gives his in-depth study on â€Å"Sun Tzu: The Art of War† and how Mao Tse-tung used the strategies and teachings of Sun Tzu while commanding the Red Army of China. Griffith’s translation of Sun Tzu’s work is written in three parts: Introduction, Translation, and Appendix. PART 1: INTRODUCTION   Ã‚  Ã‚  Ã‚  Ã‚  In his first chapter of his study titled The Author, Griffith gives many different possibilities as to who the actual author of the writings is. Griffith sites many theories from other sources trying to validate the origin of the author, but settles on one basic theory for the text. The Art of War was written by a single author probably around the time of the Warring States and during the periods from 400-320 B.C. (p. 11) Furthermore, Griffith states that there is not enough evidence to positively say if a person named Sun Tzu actually wrote the book or if it was written as a tribute to him, and the case of the authorship remains unsettled.   Ã‚  Ã‚  Ã‚  Ã‚  The second chapter, The Text, of Griffith’s study focuses on the text itself. There has been debate about how many chapters were originally in â€Å"The Art of War†: Eighty-Two or Thirteen. (p. 13) Griffith gives a sound theory that the current thirteen chapters were the only writings. Based on copywriting errors, the eighty-two chapters were probably written into thirteen categories (or chapters) while trying to transcribe written work onto paper from silk or wood. Griffith also asserts that the text was used for entry-level war fighting studies in early Chinese military academies.   Ã‚  Ã‚  Ã‚  Ã‚  The Warring States is the subject and title of Griffith’s third chapter, which gives an enlightening look at the life and times in China after the defeat of the rule of Chin at Ching Yang in 453. (p. 20) The country was divided into eight individual warring sects (with the exception of Yen... ...g for you. An expendable agent is given false information on purpose. And a living agent is one that returns to the commander with information. PART III: Appendix   Ã‚  Ã‚  Ã‚  Ã‚  Griffith’s study also includes four different appendixes. The first is A Note from Wu Ch’I, the second is titled Sun Tzu’s Influence on Japanese Military Thought, the third is Sun Tzu in Western Languages, and the fourth appendix is Brief Biographies of the Commentators.   Ã‚  Ã‚  Ã‚  Ã‚  Samuel B. Griffith’s translation of â€Å"Sun Tzu: The Art of War† is an inside look at military practices of today. I did not find one technique that is not or would not be utilized in modern military maneuver, leadership, or training. The most astounding fact is that the Art of War was written well over two thousand years ago, even at the most conservative date. Although most of the techniques in this text are already in practice today, the value of â€Å"The Art of War† is a never-ending treasure chest of knowledge, and it deserves a place as a required reading for anyone seeking knowledge about war fighting or the history of war. Works Cited Sun Tzu: The Art of War, Ed. By Samuel B. Griffith (New York:Oxford University Press, 1963)

The Powerful Impact of Technology on Education Essay examples -- Techn

The Powerful Impact of Technology on Education Technology has become much more common in the past few years in education. It has also been a blessing to some teachers; giving them more time and helping them find a unique new way to teach their students. Computers can be found in almost every single classroom and children as young as 4 years old have been taught the basic skills on the computer. Funding and new programs for computer teaching have come a long way. In the next few years, hopefully every child will have access to learning all sorts of new concepts on the computer. Several new institutes have arisen that focus on improving technology used for educational purposes. The Institute for Computer Based Learning uses technology for higher education. Learning experts and computer experts work together daily on finding new systems to put in the schools. Their main goal is to help the children learn and have fun at the same time on the computer with specific programs. Flexible learning is a key research theme for the Institute. They have worked to further develop the understanding of task-based learning environments and telematics-based learning. These programs have a large impact of how technology in education will further in the future. Funding for technology has come a long way. In 1999 Congress approved a plan to use $689 towards educational technology programs. Different organizations have come out that use turned in receipts from local grocery stores towards getting new computers for the schools. Others organizations are raising money to buy new computers for the schools. Other organizations are raising money to be new computers and software for schools that cannot afford it. More and more organizations are real... ...heir time, we hay be surprised at how much they take advantage of the opportunity. Technology is causing educators and students to have new ways of thinking about teaching and learning. When we bring technology into our school systems, we are gibing children the opportunity to live a better life. They will have higher self-esteem and feel as though they can accomplish anything that they put their mind to. In the future, computers will be main source for teaching our young children. Who knows how far technology will really take us? References The Institute for Computer Based Learning, Heriot- Watt University http://www.icbl.hw.ac.uk/distance_learning.html A+ Learning Technology for Kids, Funding for school technology http://www.technology4kids.com "Education Leadership". Association for Supervision and Curriculum Development. V. 56, No. 5 February 1999

Local Literature Essay

The 1990s have been an era of growth in computer usage for campuses across the United States. A national survey of information technology use in higher education indicated an increasing integration of computing related activities into college courses (Campus Computing Project, 2000). This survey reported that three-fifths of undergraduate courses utilized electronic mail and two-fifths made use of World Wide Web (WWW) resources. Parallel to this trend is the growing number of colleges and universities instituting requirements for student computer ownership (â€Å"Growing number of colleges require†¦,† 2000). This article reported that many of the schools implementing the requirement did so to guarantee that all students had access to the same computing resources. Research by Brown (1999) indicated that at schools without a computer ownership requirement, only half the students are likely to own one. Comparing Computer Usage by Students in Education Programs to Technology Education Majors Aaron C. Clark and Eric N. Wiebe http://scholar.lib.vt.edu/ejournals/JTE/v13n1/clark.html Previous Editors: Mark Sanders 1989-1997; James LaPorte: 1997-2010 FOREIGN STUDIES January, February, March 2011 A STUDY ON COMPUTER USAGE AND ATTITUDES TOWARD COMPUTERS OF PROSPECTIVE PRESCHOOL TEACHER Sheikh Tariq MAHMOOD Makhdoom Ali Syed Ziarab Mahmoodi http://ijonte.org/FileUpload/ks63207/File/tumu.pdf The purpose of this study is to determine the status of computer usage and the attitudes toward computers of prospective preschool teacher and to investigate of several variables on their attitudes. For this purpose, â€Å"Computer Usage Information Form† and â€Å"Computer Attitude Scale† was applied to 126 prospective preschool teachers. This study is conducted with survey methods. The data is analyzed through standard deviation, mean value as well  as t-test and one way ANOVA for group comparison, besides to find which group causes the difference in the group comparison, a PostHoc Tukey HSD test is employed. At the end of the study it is determined that the prospective preschool teacher use computers more at home and internet cafes and their levels of using computer programme are intermediate or upper. It is also determined that there is a significant difference according to the variables of taking computer course, computer ownership, level of using computer program, frequency of computer usage, computer experience and class of the scores of attitudes toward computers. On the other hand, there is no significant difference according to the variables of gender. It is recommended that future studies should focus on investigating academicians’s level of usage of computer program and attitudes toward computer technologies.

Blood Promise Chapter Twenty-One

Dimitri didn't elaborate. I was too startled by his words and the rest of the night's events to even know how to begin to address them. He took me back inside, past the Strigoi on guard duty, and upstairs to my suite. Nathan was no longer outside. For a few brief moments, that nagging voice in my head spoke loudly enough to break through my addled thoughts. If I had no guard in the hall and Inna returned soon, I had a very good chance of threatening her enough to get out of here. Admittedly, that would mean I'd have to deal with a house of God only knew how many Strigoi, but my escape odds were better in the house than in this room. Then, almost as soon as those thoughts appeared, they vanished. Dimitri snaked his arm around me and pulled me to him. It had been chilly outside, and even if his body was cold, his clothes and jacket provided some warmth. I snuggled closer to him as his hands ran all over me. I thought he was going to bite me, but it was our mouths that met, hard and furious. I wrapped my fingers in his hair, trying to pull him closer to me. Meanwhile, his fingers were running against my bare leg, pushing my skirt up almost to my hip. Anticipation and eagerness lit every part of my body. I had dreamed about the cabin for so long, remembering it with so much longing. I'd never expected anything like that to happen again, but now it could, and I was astonished at how badly I wanted it. My hands moved down to his shirt, undoing all the buttons so that I could touch his chest. His skin still felt like ice, a startling contrast to the burning within me. He moved his lips from mine, down to my neck and shoulder, pushing down the dress's strap as he covered my flesh with hungry kisses. His hand was still on the side of my bare hip, and I frantically tried to pull his shirt off altogether. Suddenly, with a surprising abruptness, he jerked away and shoved me down. At first, I thought it was just more of the foreplay between us, until I realized he was purposely pushing me away. â€Å"No,† he said, voice hard. â€Å"Not yet. Not until you're awakened.† â€Å"Why?† I asked desperately. I couldn't think of anything except him touching me-and, well, another bite. â€Å"Why does it matter? Is there†¦ is there a reason we can't?† Until I'd come here, sex with a Strigoi had never occurred to me†¦maybe it just wasn't possible. He leaned toward me, putting his lips near my ear. â€Å"No, but it'll be so much better if you're awakened. Let me do it†¦ let me do it, and then we can do anything we want†¦Ã¢â‚¬  It was a bargaining chip, I realized vaguely. He wanted me-it was written all over him-but he was using the lure of sex to get me to give in. And honestly? I was this close to accepting. My body was overriding my mind-nearly. â€Å"No,† I whimpered. â€Å"I†¦ I'm scared†¦Ã¢â‚¬  That dangerous look softened, and while he didn't exactly look like the Dimitri from before, there was something a little less Strigoi about him. â€Å"Rose, do you think I'd do anything that would hurt you?† Somewhere, hadn't there been a discussion about how my options were to turn or die? The latter seemed like it might hurt, but I didn't mention that just now. â€Å"The bite†¦ the turning would hurt†¦Ã¢â‚¬  â€Å"I told you: It'll be just like what we've already done. You'll enjoy it. It won't hurt, I swear it.† I looked away. Damn it. Why couldn't he still be sinister and scary? It was so much easier to put my foot down and resist. Even in the heat of passion, I was able to resist. But somehow†¦ seeing him like this, calm and reasonable†¦ well, it was too close to the Dimitri I'd loved. And that was hard to turn away from. For the first time, it made turning Strigoi seem†¦ not so bad. â€Å"I don't know,† I said lamely. He released me and sat up, frustration filling his features. It was almost a relief. â€Å"Galina's patience is running out. So is mine.† â€Å"You said we still have time†¦ I just need to think more†¦Ã¢â‚¬  How long could I use that excuse? The narrowing of his eyes told me not much longer. â€Å"I have to go,† he said harshly. There would be no more touching or kissing, I could tell. â€Å"I need to deal with some things.† â€Å"I'm sorry,† I said, both confused and afraid. I didn't know which Dimitri I wanted. The terrifying one, the sensual one, or the almost-but still not quite-gentle one. He said nothing. Without any other warning, he leaned down and bit into the tender skin of my throat. Whatever feeble escape strategies I had were gone. I closed my eyes, nearly falling over, and only his arm wrapped firmly around me kept me upright. Just like when we kissed, his mouth was warm against my flesh, and the feel of his tongue and teeth sent electricity through me. And like that, it was over. He pulled away, licking his lips as he still continued to hold onto me. The fog was back. The world was wonderful and happy and I was without any cares. Whatever he'd been worrying about with Nathan and Galina meant nothing to me. The fear I'd felt moments ago†¦ my disappointment over sex†¦ my confusion-I didn't have time to worry about any of that, not when life was so beautiful and I loved Dimitri so much. I smiled up at him and tried to hug him again, but he was already leading me to the couch. â€Å"I'll see you later.† In a flash, he was at the door, which saddened me. I wanted him to stay. Stay forever. â€Å"Remember, I want you-and I would never let anything bad happen to you. I'll protect you. But†¦ I can't wait much longer.† With that, he left. His words made me smile more broadly. Dimitri wanted me. Vaguely, I recalled asking him outside why he wanted me. Why on earth had I asked? What answer had I wanted? Why did it matter? He wanted me. That was what counted. That thought and the wonderful endorphin rush enveloped me as I lay on the couch, and I felt drowsiness overtaking me. Walking over to the bed seemed like too much work, so I stayed where I was and just let sleep come. And, unexpectedly, I found myself in one of Adrian's dreams. I'd pretty much given up on him. After my first desperate attempts at escape in the suite, I'd finally convinced myself that Adrian wasn't coming back, that I'd sent him away for good. Yet here he was, standing right in front of me-or, well, at least his dream version was. Often we were in the woods or a garden, but today we stood where we'd first met, on the porch of an Idaho ski lodge. Sun shone down, and mountains soared off to the side of us. I grinned broadly. â€Å"Adrian!† I didn't think I'd ever seen him look as surprised as he did just then. Considering how mean I usually was to him, I could understand his feelings. â€Å"Hello, Rose,† he said. His voice sounded uncertain, like he was worried I might be playing a trick on him. â€Å"You look good today,† I told him. It was true. He wore dark jeans and a printed button-down shirt in shades of navy and turquoise that looked fantastic with his dark green eyes. Those eyes, however, looked weary. Worn. That was a little odd. In these dreams, he could shape the world and even our appearances to what he wanted, with only a little effort. He could have looked perfect but instead appeared to be reflecting real-world fatigue. â€Å"So do you.† His voice was still wary, as he eyed me from head to toe. I was still in the clingy sundress, my hair down and loose, the sapphires around my neck. â€Å"That looks like something I'd normally dress you in. Are you asleep in that?† â€Å"Yup.† I smoothed down the dress's skirt, thinking how pretty it looked. I wondered if Dimitri had liked it. He hadn't said so specifically, but he had kept telling me I was beautiful. â€Å"I didn't think you'd come back.† â€Å"I didn't think I would either.† I looked back up at him. He wasn't like his usual self at all. â€Å"Are you trying to figure out where I am again?† â€Å"No, I don't care about that anymore.† He sighed. â€Å"The only thing I care about is that you aren't here. You have to come back, Rose.† I crossed my arms and flounced onto the porch's railing. â€Å"Adrian, I'm not ready for anything romant-â€Å" â€Å"Not for me,† he exclaimed. â€Å"For her. You have to come back for Lissa. That's why I'm here.† â€Å"Lissa†¦Ã¢â‚¬  My waking self was pumped full of endorphins, and it carried over here. I tried to remember why I should be so worried about Lissa. Adrian took a step forward and studied me carefully. â€Å"Yeah, you know, Lissa? Your best friend? The one you're bonded to and sworn to protect?† I swung my legs back and forth. â€Å"I never made any vows.† â€Å"What the hell's the matter with you?† I didn't like his agitated tone. It was ruining my good mood. â€Å"What's the matter with you?† â€Å"You aren't acting like yourself. Your aura†¦Ã¢â‚¬  He frowned, unable to continue. I laughed. â€Å"Oh yes. Here it comes. The magical, mystical aura. Let me guess. It's black, right?† â€Å"No†¦ it†¦Ã¢â‚¬  He continued scrutinizing me for several heavy seconds. â€Å"I can barely get a fix on it. It's all over the place. What's going on, Rose? What's happening in the waking world?† â€Å"Nothing's happening,† I said. â€Å"Nothing except me being happy for the first time in my life. Why are you acting weird all of a sudden? You used to be fun. Figures the first time I'm finally having a good time, you go all boring and strange.† He knelt down in front of me, no trace of humor anywhere. â€Å"There's something wrong with you. I can't tell what-â€Å" â€Å"I told you, I'm fine. Why do you have to keep coming and trying to ruin things for me?† True, I'd desperately wanted him to come a little while ago, but now†¦ well, that wasn't so important. I had a good thing with Dimitri here, if only I could figure out how to solve all the not-so-good parts. â€Å"I told you, I'm not here for me. I'm here for Lissa.† He looked up at me, wide-eyed and earnest. â€Å"Rose, I am begging you to come home. Lissa needs you. I don't know what's wrong, and I don't know how to help her. No one else does either. I think†¦ I think only you can. Maybe being apart is what's hurting her. Maybe that's what's wrong with you now, why you're acting so weird. Come home. Please. We'll heal both of you. We'll all figure it out together. She's acting so strange. She's reckless and doesn't care about anything.† I shook my head. â€Å"Being away isn't what's wrong with me. Probably not what's wrong with her, either. If she's really worried about spirit, she should go back on her meds.† â€Å"She's not worried; that's the problem. Damn it.† He stood up and began pacing. â€Å"What's wrong with you two? Why can't either of you see there's something the matter?† â€Å"Maybe it's not us,† I said. â€Å"Maybe it's you imagining things.† Adrian turned back toward me and looked me over again. â€Å"No. It's not me.† I didn't like any of this-not his tone, expression, or words. I'd been excited to see him, but now I resented him ruining my good mood. I didn't want to think about any of this. It was too hard. â€Å"Look,† I said. â€Å"I was happy to see you tonight but not anymore, not if you're going to sit and accuse me and make demands.† â€Å"I'm not trying to do that.† His voice was gentle-the anger was gone. â€Å"The last thing I want is to make you unhappy. I care about you. I care about Lissa, too. I want you both to be happy and live your lives like you want†¦ but not when you're both heading down destructive paths.† He almost made sense. Almost seemed reasonable and sincere. I shook my head. â€Å"Stay out of it. I'm where I want to be, and I'm not coming back. Lissa's on her own.† I jumped off the rail. The world swirled a little, and I stumbled. Adrian caught my hand, and I jerked away. â€Å"I'm fine.† â€Å"You are not. Jesus Christ. I'd swear you're drunk, except†¦ the aura's still not right for that. What is it?† He ran his hands through his dark hair. It was his typical sign of agitation. â€Å"I'm done here,† I said, trying to be as polite as possible. Why on earth had I wanted to see him again? It had seemed so important when I first arrived. â€Å"Send me back, please.† He opened his mouth to say something, then froze a few moments. â€Å"What's on your neck?† He reached forward, and addled or no, I managed to dodge pretty efficiently. I had no idea what he saw on my neck, and I had no interest in finding out. â€Å"Don't touch me.† â€Å"Rose, that looks like-â€Å" â€Å"Send me back, Adrian!† So much for my politeness. â€Å"Rose, let me help-â€Å" â€Å"Send. Me. Back!† I shouted the words, and then, for the first time, I managed to pull myself out of Adrian's dream. I left sleep altogether and woke up on the couch. The room was still and silent, the only sound my rapid breathing. I felt all tangled up inside. Usually, so fresh from a bite, I would be floating and gleeful. Yet, the encounter with Adrian had left part of me troubled and sad. Standing up, I managed to make my way to the bathroom. I flicked on the light and winced. It hadn't been very bright in the other room. Once my eyes adjusted, I leaned toward the mirror and pushed my hair out of the way. I gasped at what I saw. There were bruises all over my neck, as well as signs of fresher wounds. Around where Dimitri had just bitten me, I could see dried blood. I looked†¦ like a blood whore. How had I never noticed this before? I wet a washcloth and scrubbed at my neck, trying to get the blood off. I rubbed and rubbed until the skin turned pink. Was that it? Were there more? That looked like the worst of it. I wondered how much Adrian had seen. My hair had been down, and I was pretty sure most of it had covered my neck. A rebellious thought came to my head. What did it matter if Adrian saw or not? He didn't understand. There was no way he could even come close. I was with Dimitri. Yeah, he was different†¦ but not that much different. And I was sure I could find a way to make this work without becoming a Strigoi. I just didn't know how yet. I tried to reassure myself over and over, but those bruises kept staring back at me. I left the bathroom and returned to the couch. I turned on the TV without really watching, and after a while, the happy fog rolled over me again. I soon tuned out the TV and returned to sleep. This time, my dreams were my own. It took a while for Dimitri to come again. And by â€Å"a while,† I mean almost an entire day. I was getting twitchy by that point, both because I missed him and because I missed the bite. He usually visited twice a day, so this was the longest I'd gone without the endorphins. Needing something to do, I preoccupied myself with making myself as beautiful as possible. I sorted through the dresses in my closet, choosing a long ivory silk one that had purple flowers delicately painted into the fabric. It fit like a glove. I wanted to wear my hair up, but after looking at the bruises again, I decided to wear it down. I'd been provided with a curling iron and makeup recently, so I worked my hair over carefully, turning the ends up in perfect little curls. Once made up, I stared happily at my reflection, certain Dimitri would be happy too. All I needed now was to put on some of the exquisite jewelry he'd given me. But when I turned to leave, I caught a glimpse of my back from the side and saw I'd missed fastening a clasp. I reached around to do it but couldn't get a hold of it. It was in that perfect spot just out of my reach. â€Å"Damn,† I muttered, still grappling with the hook. The flaw in my perfection. Just then, I heard the door open in the other room, followed by the telltale sound of a tray being set on the coffee table. A stroke of luck. â€Å"Inna!† I called, walking out of the bathroom. â€Å"I need you to-â€Å" Nausea rolled through me, and as I stepped into the living room, I saw that Dimitri wasn't the source. Nathan was. My jaw dropped open. Inna stood near him, waiting patiently by the tray, eyes downcast as always. I immediately ignored her and then looked back at Nathan. Presumably, he was still on guard duty, but that had never actually included him coming inside. For the first time in a while, some of my battle instincts kicked in, assessing escape options. My fear urged me to back away, but that would trap me in the bathroom. Best to stay where I was. Even if I couldn't leave the room, this gave me the most space to maneuver. â€Å"What are you doing here?† I asked, surprised at how calm I sounded. â€Å"Taking care of a problem.† I didn't really need any pointers to figure out the subtext here. I was the problem. Again, I fought the urge to back up. â€Å"I've never done anything to you.† It was faulty logic to a Strigoi. None of their victims ever did anything to them. â€Å"You exist,† he said. â€Å"You're taking up space here, wasting everyone's time. You know how to find her-the Dragomir girl-yet you'll offer nothing remotely useful until Belikov gets off his ass and awakens you. And in the meantime, Galina forces me to waste time watching you and keeps promoting him because he's convinced her that you're going to be some amazing asset to us.† It was an interesting set of grievances. â€Å"So†¦ um, what are you going to do?† In a flash, he stood in front of me. Seeing him so close triggered that memory in my mind's eye-him biting Dimitri and starting all of this. A spark of anger kindled in me but didn't do much in the way of development. â€Å"I'm getting the information one way or another,† he hissed. â€Å"Tell me where she is.† â€Å"You know where she is. She's at the school.† There was nothing useful in giving up that news. He knew she was there. He knew where the school was. The look he gave me showed he was not happy about me providing knowledge he already had. Reaching out, he gripped my hair and jerked my head painfully back. Wearing my hair down maybe hadn't been so useful after all. â€Å"Where is she going? She won't stay there forever. Is she going to college? The Royal Court ? They must have made plans for her.† â€Å"I don't know what they are. I've been away for a while.† â€Å"I don't believe you,† he snarled. â€Å"She's too valuable. Her future would have been planned out a while ago.† â€Å"If it is, no one's shared it with me. I left too soon.† I shrugged by way of answer. Rage filled his eyes, and I swear, they grew redder. â€Å"You're bonded! You know. Tell me now, and I'll kill you quickly. If you don't, I'll awaken you to get the information, and then I'll kill you. I'll light you up like a bonfire.† â€Å"You†¦ you'd kill me once I was one of you?† Foolish question. Strigoi felt no loyalty to each other. â€Å"Yes. It'll destroy him, and once Galina sees how unhinged he is, I will return to my original place by her side-especially after I stamp out the Dragomir line.† â€Å"The hell you will.† He smiled and touched my face, running his fingers along my neck and the bruises all over it. â€Å"Oh, I will. It really will make things easier if you just tell me now. You'll die in ecstasy rather than being burned alive. We'll both enjoy it.† He wrapped his hand delicately around my throat. â€Å"You're definitely a problem, but you are beautiful-especially your throat. I can see why he wants you†¦Ã¢â‚¬  Warring emotions played within me. Logically, I knew this was Nathan-Nathan, whom I hated for having turned Dimitri in the first place. Yet my body's need for Strigoi endorphins was raising its head too, and it barely mattered that it was Nathan. What mattered was that his teeth were only a breath away from my neck, promising that sweet, sweet delirium. And while one hand held my throat, the other ran down my waist, down to the curve of my hip. There had been a sultry edge to Nathan's voice, like he wanted to do more than just bite me. And after so many sexually charged encounters with Dimitri-encounters that never resulted in anything-my body almost didn't care who touched it. I could close my eyes, and it wouldn't matter whose teeth bit into me or whose hands peeled off my clothes. Only the next fix would matter. I could close my eyes and pretend it was Dimitri, lost in it all as Nathan's lips brushed my skin†¦ Except, as some small reasonable part of me recalled, Nathan didn't just want sex and blood. He eventually wanted to kill me. Which was kind of ironic. I'd been dead set-no pun intended-on killing myself when I got here, lest I become a Strigoi. Nathan was offering me that now. Even if he turned me first, he planned on killing me immediately afterward. Either way, I wouldn't have to spend eternity as a Strigoi. I should have welcomed this. But just then, as my body's addiction screamed for his bite and that bliss, I realized something with startling clarity: I didn't want to die. Maybe it was because I'd gone almost a day without a bite, but something small and rebellious woke up in me. I would not let him do this to me. I would not let him go after Dimitri. And I sure as hell wasn't going to let him hunt down Lissa. Pushing through that endorphin cloud that still hung around me, I summoned up as much willpower as I could. I dug deep, remembering my years of training and all the lessons Dimitri had given me. It was hard to access those memories, and I only touched a few. Still, enough came to spur me to action. I lunged forward and punched Nathan. And accomplished nothing. He didn't budge. Hell, I don't even know if he felt it. The surprise on his face promptly turned to mirth, and he laughed in that horrible way Strigoi did-cruelly and without any real joy. Then, with the greatest of ease, he slapped me and knocked me across the room. Dimitri had done nearly the same thing when I'd arrived and attacked him. Only I hadn't flown quite as far or had so miniscule an effect on him. I slammed into the back of the couch, and good God, did it hurt. A wave of dizziness washed over me, and I realized the idiocy of fighting someone vastly stronger than me when I'd been losing blood all week. I managed to straighten up and desperately sought my next course of action. Nathan, for his part, seemed in no hurry to respond to my attack. In fact, he was still laughing. Glancing around, I latched onto a truly pitiful course of action. Inna stood near me. Moving with a speed that was painfully slow-but better than I expected myself to manage-I reached for her and wrapped my arm around her neck. She yelped in surprise, and I jerked her harder against me. â€Å"Get out of here,† I said to Nathan. â€Å"Get out of here, or I'll kill her.† He stopped laughing, stared at me for a moment, and then laughed even harder. â€Å"Are you serious? Do you honestly think I couldn't stop you if I wanted? And do you honestly think I care? Go ahead. Kill her. There are dozens more just like her.† Yeah, that really shouldn't have been a surprise either, but even I was a bit taken aback by how easily he could throw away a faithful servant's life. Okay. Time to go to Plan B. Or maybe it was Plan J? Frankly, I was losing track, and none of them were very good anyway â€Å"Ow!† Inna suddenly elbowed me in the stomach. I released her in my surprise. She spun around with a strangled scream and socked me in the face. The blow wasn't as hard as Nathan's had been, but it still knocked me over. I tried to catch a hold of something-anything-as I fell but failed. I hit the floor, my back slamming against the door. I expected her to come right back at me, but instead, she darted across the room and-God help us all threw herself into a defensive posture in front of Nathan. Before I could fully process the weirdness of her trying to protect someone who was willing to let her die, the door suddenly opened. â€Å"Ow!† I said again, as it hit me and pushed me aside. Dimitri swiftly entered. He looked from face to face, and I had no doubt mine showed signs of both Nathan's and Inna's attacks. Dimitri's fists clenched, and he turned toward Nathan. It reminded me of their scuffle in the hallway, all rage and malice and bloodlust. I cringed, bracing myself for another horrible confrontation. â€Å"Don't,† warned Nathan, face smug. â€Å"You know what Galina said. Touch me and you're out of here.† Dimitri strode across the room and came to stand in front of Nathan, knocking Inna aside like a rag doll. â€Å"It'll be worth facing her wrath, particularly when I tell her you attacked first. Rose certainly bears the marks of it.† â€Å"You wouldn't.† He pointed at Inna, who was sitting dazed on the floor from where Dimitri had knocked her over. Despite my own injuries, I began crawling over to her. I had to know if she was all right. â€Å"She'll tell the truth.† Now Dimitri looked smug. â€Å"You really think Galina will believe a human? No. When I tell her how you attacked me and Rose out of jealousy, she'll let me off. The fact that you'll be so easily defeated will be proof of your weakness. I'll slice your head off and get Rose's stake from the vault. With your last breath, you can watch her drive it through your heart.† Holy crap. That was a little worse than Nathan threatening to burn me-wait. My stake? Nathan's face still bore haughty arrogance-at least to me. But I think Dimitri must have seen something that satisfied him, something that made him think he'd gotten the upper hand. He visibly relaxed, his smirk growing larger. â€Å"Twice,† Dimitri said softly. â€Å"Twice I've let you go. Next time†¦ next time, you're gone.† I reached Inna and gently held out my hand. â€Å"Are you okay?† I murmured. With a look of hate, she recoiled and scooted away. Nathan's eyes fell on me, and he began backing toward the door. â€Å"No,† he said. â€Å"Twice I've let her live. Next time she's gone. I'm the one in control here, not you.† Nathan opened the door and Inna stood up, stumbling after him. I stared, mouth agape at the events that had just taken place. I didn't know which of them I found more disturbing. Looking up at Dimitri, I grappled with what to ask him first. What were we going to do? Why had Inna defended Nathan? Why had Dimitri let him go? None of those defiant questions came to my lips, though. Instead, I burst into tears.