Losartan potassium 50 mg pill identifier

Irony Deficiency?

2023.06.03 01:30 Zealousideal_Debt255 Irony Deficiency?

Irony Deficiency?
You guys are a wonderful group, thanks for your info and help! Would anyone mind checking my bloods out for me? My doctor doesn't seem too concerned but Ive been suffering from fatigue low energy for months!
submitted by Zealousideal_Debt255 to Anemic [link] [comments]

2023.06.02 23:12 WildGeeseGoose Core Power Protein Chocolate Milk, tastes good too!

Core Power Protein Chocolate Milk, tastes good too! submitted by WildGeeseGoose to diabetes_t1 [link] [comments]

2023.06.02 19:09 Ampsquare Learned the Hard Way

I started on Nal a week ago today, 25 mg, TSM style, and was very happy with the initial results. I took the half pill an hour before drinking, had no cravings, and could barely finish the second beer. The following days were “upgraded”, which was awesome. It seems that TSM could work for me. I did the 2 beer thing 4 different days on the half pill thinking I might be one of those who sticks with the 25mg’s since I’m known to be sensitive to meds, but then last night I learned that will not be the case. I took the half pill, waited a bit over an hour, and then it was back to hammer time, which sucked. I drank like I never took the pill. Moving forward, I’ll be at 50 mg’s. Hoping 50 mg’s will be more sustainable. 200 lb binge drinker, btw.
submitted by Ampsquare to Alcoholism_Medication [link] [comments]

2023.06.02 15:04 Gator588 Actionable Steps That are Helping Me

Hello All,
First off I want to say what you are going through is only temporary. It is easy to beat yourself up about it thinking it is weird, or stupid, but just know that you are not alone and there are many other irrational fears that millions of people struggle with every day. Having said that, I have found some relief recently and wanted to post on here in the hopes that it helps some of you.
My story of this phobia started two years ago where I felt like I couldn't swallow while I was eating steak at a restaurant. This instantly triggered a panic attack, fight or flight response that freaked me out. I swallowed the piece just fine, but I believe that experience triggered this phobia in my subconscious. This lead to two straight years of overthinking every meal I experienced. I will admit, my phobia never got so bad that I couldn't eat solid food, but I had to eat very slow, over chew everything, and overall just stressing about something that should typically bring you happiness. However, in just the last week I have found some relief, and with time I am hopeful that I will conquer this once and for all.
Now, we all wish there was a magic pill that could make this instantly go away. There are a lot of anxiety meds out there and they seem to help a lot of people. However, I believe that all these do is suppress the symptoms, instead of fixing the root cause. So that was my mission, to put in the work and find a way to identify the root cause of my fear and anxiety around eating. Here is a list of what I did:

  1. I listened to this podcast episode from Stanford Neuroscientist on Erasing Fear and Trauma. Here is the link if you are interested - Erasing Fears & Traumas Based on the Modern Neuroscience of Fear Huberman Lab Podcast #49 - YouTube
    1. One thing I took away from this and started doing is the Cyclic Hyperventilation. Where for 5 minutes every day for two weeks you purposely put yourself in a state of stress and anxiety. He explains it in detail in the podcast, but I am 8 days in and it is really helping. While I do this I think about eating scary things such as steak. If you try this make sure you follow his precautions that he mentions on the podcast.
  2. I listened to another podcast from Huberman (he is a wealth of knowledge on a variety of topics). Here is the link if you are interested - Dr. Chris Palmer: Diet & Nutrition for Mental Health Huberman Lab Podcast #99 - YouTube
    1. This is one of the most fascinated podcasts I have ever listened to. This guy has actually healed people with Schizophrenia through diet and nutrition. Because of this podcast I started doing the keto diet about 10 days ago. Wow! I can't believe how much better I feel and how better my mental health and attitude concerning food. Now, I know it may seem counterproductive since our phobia is around eating, but there are many soft foods that would be considered low carb or keto. Avocado, soft scrambled eggs, soft cheeses, and milk are some of my staples. If you can't eat any of those, you can always make shakes with full fat milk, almond milk, and a variety of other items to make a very healthy low carb meal replacement shake.
  3. Cold Showers
    1. Sounds crazy and woo woo, but there is actually a lot of science around the mental (and physical) benefits of cold showers. I have been doing this in conjunction with the cyclic hyperventilation, and I really think they are helping. You can even start with a warm shower, and then finish with the cold for about 60-90 seconds. That is all it takes to get the benefits. Look up the Wim Hof Method and you can learn more about this.
  4. Exercise
    1. You don't have to get a gym membership, just find something (walking, biking, swimming) that gets your body moving. Exercise has been shown to greatly improve mental health. I recommend some kind of light shoulder exercise and neck stretches to really help strengthen that area and help swallowing.
  5. Omega-3
    1. If you are on anxiety meds thats fine, but if not, Omega-3 supplements have been shown to provide an anti-depressant effect around the same level as an SSRI. You want to find a supplement that gives at least 2000mg of Omega 3. If you are interested, here is a link to what I have been taking for the last 10 days Amazon.com: OmegaWell Omega 3 Fish Oil - 2000mg Capsules: Heart, Brain, & Joint Support - 800 mg EPA 600 mg DHA - w/Natural Lemon Oil, Sustainably Sourced - Mini Softgels - 30 Day Supply : Health & Household
    2. If you can't swallow the pills, you can actually cut the tips off them and mix the oil in with a smoothie or water.
  6. Meditation/Yoga/Stretching
    1. I recommend a combination of these three. Find one that you like and try it out for a couple weeks. Focus on your breathing with any of these and they will help I guarantee it. There is an app called Plyability that use every night before bed. 10-20 minutes of stretching combined with breathwork and I feel amazing.
  7. Breathwork
    1. I like the app "Breathwrk." There are dozens of breathing exercises you can work on and practice for what you think will help you. What has helped me is doing the "Lung Capacity" exercise. It forces you to take slow breaths with a 20 second breath hold. It is meant to strengthen your diaphragm and increase lung capacity. I think this really helps with my eating because a lot of anxiety starts with your breath. If you can learn to control your breath and your mind while eating, it makes the whole experience much easier.
  8. Talk to someone
    1. Spouse, family, therapist, anybody. Find someone to talk to about this. I opened up to my wife about it (I was embarrassed for a whole to mention this to anyone and tried to hide it), and I have felt much better and much less weird or ashamed. So find someone that will understand and help you work through it, it makes a world of difference.
I know this seems like a lot, but remember as much as we want to snap our fingers and make this go away, thats just not going to happen. Sometimes it takes action. But that is the beauty in this! You don't have to rely on a drug or a doctor to fix this, YOU HAVE CONTROL OVER YOUR OWN MIND. And if you have the control, you have the ability to fix it. It might be hard and may take some time, but you have the power to fix this fear! Remember, it is HIGHLY HIGHLY HIGHLY unlikely that you will choke to death. The data is like 1.5/100,000 people choke to death. That includes babies, elderly people, and non-food choking deaths! Your body is hard wired to automatically chew and swallow, so this fear is just your brain getting in the way of what your body naturally knows what to do.
Hopefully some of this helps, feel free to reach out with any questions!
submitted by Gator588 to Pseudodysphagia [link] [comments]

2023.06.02 14:01 NebularReptile Bought these electrolytes, how much should I take?

Bought these electrolytes, how much should I take?
Hi guys, I’ve been IF for 2 months now and want to give a 5 or 7-day fast a try. I bought this on Amazon and am trying to find out how many of these I should take a day/a guideline. Thanks for your help!
submitted by NebularReptile to ExtendedFasting [link] [comments]

2023.06.02 06:52 YellowRaincoat198 What worked for me- give it time!!

First let me say, it gets better!!! (or at least it did for me). Starting meds seems really scary, especially with all the horror stories on here. So this is an in depth explanation of my experience and what works for me now!
I was so nervous when starting (Reddit made it worse). I have been struggling for years and over the past 2 years it became insufferable. After spending months talking to a (bad) therapist, getting diagnosed by a psychologist, finding a better therapist, and convincing myself to speak to a doctor, I finally started my med journey. This was my first time trying meds and therapy, so it was all scary and I could barley get out of bed so it was extra hard.
I started 25mg of Zoloft in January. First few days were okay, no major symptoms. Then I started to have stomach issues, headaches, and body aches. Then I went into a fog, both physically and mentally. It was so bad that I couldn’t registered smells in a room, water temperature, etc. I was just so out of it. These lasted for weeks but they faded away.
Then one night I had a panic attack. I was just laying in bed trying to fall asleep when all of the sudden it felt like I was having a heart attack. My left arm went numb. My jaw was hurting. My chest was hurting. I started freaking out because I’ve never experienced something like this. I’ve had anxiety attacks in the past, but that usually came up when I was thinking about something that made me upset. But this came out of nowhere. I ended up going to the ER at 2 AM thinking I was having an actual heart attack. After hours and hours of tests, it was determined it was just a panic attack (I felt so stupid, but it is so common and if it ever happens to you, do not feel ashamed! It was a physical reminder that I wasn’t being dramatic or crazy, my body was in distress and I couldn’t control it.)
The ER doctor prescribed me 25 mg of hydroxyzine HCl. I went to my regular doctor the next day just to check in and make sure what happened was normal. She prescribed me hydroxyzine pamoate 25 mg instead because she said they worked better for anxiety. Later on she prescribed me 50 mg of that because the 25 wasn’t working. I found that it didn’t work for me at all. It was supposed to help you sleep or help you when you’re having a panic attack but I haven’t noticed it helping at all, so I don’t take them anymore.
After 6 weeks of 25 mg of Zoloft, it was upped to 50mg. Again, I had stomach issues and headaches. I was only in that fog for 1 day this time.
I had started by taking the meds at night and that worked for the first month or two. But then all of the sudden, I couldn’t sleep. I was staying up till 7/8 am everyday. Again, I was defeated with the meds but I switched to morning and after allowing for that adjustment period, I started sleeping again!
After another month of that, I still wasn’t feeling great. A tiny bit better but not great. So my doctor prescribed me 150mg of Wellbutrin along with the 50mg of Zoloft. I had stomach issues but no fog and no headaches. After about 6 weeks of that, I didn’t notice any changes. So I was upped to 300 mg. Mild stomach issues, that’s all.
I do want to add that I already had stomach issues because I was so anxious all the time. I just think my stomach is extra sensitive to… everything.
After that adjustment period (6ish weeks) I really stared to feel better. The changes were small and because it’s so slow and over the course of weeks/months I didn’t notice for a long time. It wasn’t until I really stared comparing my everyday from before and to now in therapy. The changes may feel small or slow, but sometimes that’s enough.
For the first time in a lonnng time I was out of this depressive fog I had been in. I was really starting to feel good (getting out of bed, opening my curtains, cleaning, wanting to go do stuff, etc.).
But then the anxiety hit. I’ve always been anxious but I was so far into the fog that it wasn’t so bad. I stared having panic attacks, always at night. Basically I’d get heart palpitations and my fingertips would go numb. Then I’d think I was having a stroke or heart attack and freak myself out even more. It was getting to the point where I wasn’t sleeping again.
So my therapist recommended me to a psychiatrist (not my usual doctor). They put me on 15mg of buspirone in the morning and at night and 10mg of propanolo at night. Buspirone helps with anxiety and propanol is a blood pressure medication that lowers your heart rate.
I happened to have an appointment with my regular doctor later in that same week and she recommended that I stop the Zoloft and continue Wellbutrin if I was going to add the buspirone and propanolol. My doctor recommended that I cut the Zoloft down to 25 mg for a week and then go to 0 mg of Zoloft for a week.
So I did that and by the end I was on 300 mg of Wellbutrin, 15 mg of buspirone in the morning and at night and 10 mg of propanolol at night. I felt terrible, not just physically. I do think that it was too quick of a withdrawal. I was having brain zaps, fog, headaches, and stomach issues. So I felt pretty physically bad. But I started feeling really mentally bad and felt like how I felt before I started medication. So after that two week process, I went back to the doctor And she recommended that I start Zoloft again but don’t take the buspirone at night, only the morning. The reason she did this is because she wanted me to be on the least amount of medication that I could be and she said that Zoloft is meant to be both a anti-depression and anti-anxiety medication and if I was still having a lot of anxiety, then it might not be working (but clearly it was).
Now (June) I’m currently on: 50mg Zoloft in the morning 300mg Wellbutrin in the morning 15mg buspirone in the morning 10mg propanolol at night
I take my morning meds at 10am everyday. I will make myself something to eat (even if it’s just cracker) and take the meds half way through eating. I try not to take these meds at a different time because with these especially it’s best to take them at the same time. However, there have been times where I have forgotten or been somewhere and I’ve taken them later in the day and have been OK. I have noticed that I don’t have to be as strict when I take the propanolol at night and I can skip and feel completely fine.
Moral of the story, it takes a long time (months), involves a lot of different trials (different meds, starting/stopping and then restarting, etc.) and usually feels terrible for most of that time BUT it’s so freaking worth it!
You’ve got this, don’t quite and buy yourself a nice pill case you can decorate!
If you have any questions, ask away!
submitted by YellowRaincoat198 to zoloft [link] [comments]

2023.06.02 06:05 cubanfrita Zoloft tapering/withdrawals

Question about tapering off Zoloft and withdrawals. My psychiatrist suggested tapering off of 50 mg zoloft by taking 25 mg for one week, then half of the 25 the following week and then stopping. I am now entering the 5th day since I completely stopped. Even before stopping I was noticing discontinuation effects, what happens to me (which also happened when I got of Lexapro a few years ago) is that I start experiencing vertigo. Best way to describe it is like if my brain randomly feels turbulence (like when you’re on a plane and a random drop happens while experiencing turbulence). A lot of people talk about brain zaps but that isn’t what I experience. To top it off, it seems like I’m coming down with a cold. A bit phlegmy, itchy/soreish throat and achiness. Now I’m not sure if this is just flu like symptoms or if I’ve actually come down with a cold?
Anyway, that feeling in my head has gotten significantly more intense today and I’m starting to feel like I tapered off too fast. Is it too late to maybe start taking maybe half of 25 mg to ease off these effects or am I just supposed to wait it out?
I remember weening off of lexapro took a long time and I was taking even half of half of 10mg pills every other day and it would help with that feeling in my head. Wondering if I should be doing the same now. Thing is that my psychiatrist also just prescribed me buspar, and I just started taking it yesterday, I am also taking 100 mg bupropion SR. Any suggestions?
Thank you!
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2023.06.02 02:17 pykey96 Recommendations for my lawn profile?

Recommendations for my lawn profile?
Just got my soil results back, just looking for some recommendations on what I should do?
submitted by pykey96 to lawncare [link] [comments]

2023.06.02 00:14 Minimum-Arrival4423 Is this concerning 23F

Potassium: 3.3 mmol/L (low)
Chloride: 109 mmol/L (high)
BUN: 5 mg/dl (low)
Creatinine: 0.50 mg/dl (low)
BUN/Creatinine ratio: 9.4
Neutro Auto: 65.6% (high)
Everything else came back normal. I have health anxiety and have been having weird symptoms. Will give more info if necessary
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2023.06.01 23:02 Admirable-Reception2 My cocktail: Remission achieved

I've never posted here before, but I just got my prior auth for another year of rx, and I was just thinking that I'd share my cocktail in case in helps anyone. Background Bipolar NOS (also ADHD... maybe one manic episode, mostly hypomanic ones when they were in that range. Most of the disorder has been mixed depression, but I was always medicated with something, so i truly don't know how my natural state is.
400 mg Lamictal XR + Aplenzin 174 + Synthroid .112 (hypothyroidism for many years) + Buspirone 20 mg (x 3 times/day) + Propranolol 40 mg (x 3 times/day; first dose is 50 mg)
I can't take IR lamictal because it wears off too quickly and I cycle rapidly. I can't take generic lamictal ER because the product itself is so bad that it hits me all at once (it even looks like a totally different pill). Can't take generic buproprion hcl because I need the HBR.
If not for the majorly good insurance (Cigna, from husband's job), I wouldn't be able to take these medications. This is like... 20 grand a year worth of meds. Lamictal XR is insanely expensive, plus it's 60 pills/month so it's double the regular cost of a 30 day supply.
My only complaint is that I like to joke that I'm a fucking idiot. I say the wrong word A LOT. I don't tell stories well because I forget where I'm going, etc. I don't give a shit. It doesn't impact my large-scale cognition. I'm just... slower. This is the hand I'm dealt and it's better than the illness. I doubt most people who have never dealt with this shit would be okay living with the side effects I have, but we all know what the devil looks like and we know that these are NOTHING compared to the depths of hell of bipolar disorder.
Looking back at it, I was very sick. I actually had a job, though I couldn't really keep the same one for long. I'm married. I managed to keep myself out of the hospital (though frankly I should have been put there a couple of times). And I know it's just because I'm lucky and have social supports and good insurance and access to the best doctors, not because the illness was mild. I don't deserve that any more or less than anyone else, and I'm grateful.
I only got out of bed in the morning everyday because I knew there were more medications to try, so odds were that I'd eventually get better. I did, but I really think I have PTSD now from 7+ years of hell. I'm just recovering from severe DP/DR going back to the first manic episodes.
Hope that helps someone. I hope you all get to the day where you just forget you even have this shit and have more relevant things to consume your mind. I'd forgotten what it was like to think of ANYTHING else.
submitted by Admirable-Reception2 to bipolar [link] [comments]

2023.06.01 21:51 ultimatejourney Pharmacy Refuses to Remake Prescription?

Not really sure what to do - I'm on 150 and they changed my manufacturer from Lupin to Cipla. I've never had any bad effects from switching generics in the past, but I've heard that other people have and that makes me afraid to switch. Pharmacy said that I could pay $80 for a new refill and then started questioning me about why I thought I would have problems since I haven't taken any of the new prescription. Like, I don't want to have some of these side effects, my disorders make me anxious about changes in medication, and I was already anxious and felt stupid about making that call.
Now I am quite upset and am wondering if I should pay the $80 or take the plunge and try it? Or alternatively, since when I refill next week I'll still have 7 pills left of the old one, combining 100 mg of the old manufacturer with 50 mg of the new one for a week? Not sure if that would work or be a bad idea.
submitted by ultimatejourney to zoloft [link] [comments]

2023.06.01 21:37 Discloner Help with Soil Analysis to Fertilizer Conversation

Help with Soil Analysis to Fertilizer Conversation
Howdy all -
I'm a first-time lawn owner and desperately wanting to play in the sandbox with y'all and your epic lawns...but my novice skills and knowledge are on full display despite all my research and best attempts to fish for myself; so I humbly come for some help.
I'm up here in VT with cool season grass on a moderately sized suburban corner lot that we closed on last November. I have aspirations of being the envy of the neighborhood, so I followed all the advice I read here and did a soil test through the University of Vermont's extension program.
I can understand what is/isn't in optimal range - but I cannot wrap my head around how to translate the lbs/1000sqft recommendation to fertilizer percentages to pick the right breakdown for my recommendations. And then from there...how to translate that into how many pounds I need to purchase to cover my lot. Supplemental materials from the extension office seemed helpful - but wound up being more confusing than helpful.
Anyone with experience able to help me translate this a bit? I know I need a #-0-# fert (and I guess some lime?) but what make-up makes sense for the N and K? Would I spread Lime and NPK fert independant of each other; or at the same time? Any other tips for a first-timer?
Much appreciative in advance for your assistance. I'd post a photo of my lawn for a grass tax...but we haven't gotten rain up here in about a month and my yard is looking ROUGH even without me trying to get the nutrients right! Maybe an after if I'm successful....
submitted by Discloner to lawncare [link] [comments]

2023.06.01 21:24 RandomAppalachian468 Don't fly over Barron County Ohio. [Repost]

The whirring blades of my MD-902 throbbed against the warm evening air, and I smiled.
From 5,000 feet, the ground flew by in a carpet of dark forests and kelly-green fields. The sun hung low on the horizon in a picturesque array of dazzling orange and gold, and I could make out the narrow strip of the Ohio River to my left, glistening in the fading daylight. This time of year, the trees would be full of the sweet aroma of fresh blossoms, and the frequent rains kept small pockets of fluffy white mist hanging in the treetops. It was a beautiful view, one that reminded me of why being a helicopter pilot trumped flying in a jumbo jet far above the clouds every day of the week.
Fourteen more days, and I’m debt free.
That made me grin even more. I’d been working as a charter pilot ever since I obtained my license at age 19, and after years of keeping my nose to the grindstone, I was closing on the final payment for real-estate in western Pennsylvania. With no debt, a fixer-upper house on 30 rural acres all to myself, and a respectable wage for a 26-year-old pilot, I looked forward to the financial freedom I could now enjoy. Maybe I’d take a vacation, somewhere exotic like Venice Italy, or the Dominican Republic. Or perhaps I’d sock the money back for the day I started a family.
“Remember kleineun, a real man looks after his own.”
My elderly ouma’s voice came back from the depths of my memories, her proud, sun-tanned face rising from the darkness. She and my Rhodesian grandfather had emigrated to the US when they were newlyweds, as the violence against white Boer descendants in South Africa spiraled out of control. My mother and father both died in a car crash when I was six, and it had been my grandparents who raised me. Due to this, I’d grown up with a slight accent that many of my classmates found amusing, and I could speak both English, and Afrikaans, the Boer tongue of our former home.
I shifted in my seat, stretched my back muscles, and glanced at the picture taped to my console. Both my parents flanked a grinning, gap-toothed six-year-old me, at the last Christmas we’d spent together. My mother beamed, her dark hair and Italian features a sharp contrast to my father’s sandy blonde hair and blue eyes. Sometimes, I liked to imagine they were smiling at me with pride at how well I flew the old silver-colored bird my company had assigned to me, and that made the long, lonely flights easier to bear.
A flicker caught my eye, and I broke my gaze away from the photograph.
Perched in its small cradle above the controls, my little black Garmin fuzzed over for a few seconds, its screen shifting from brightly colored maps to a barrage of grey static.
Did the power chord come loose?
I checked, ensuring the power-cable for the unit’s battery was plugged into the port on the control panel. It was a brand-new GPS unit, and I’d used it a few times already, so I knew it wasn’t defective. Granted, I could fly and navigate without it, but the Garmin made my time as a pilot so much easier that the thought of going blind was dreadful.
My fuel gauge danced, clicked to empty, then to full, in a bizarre jolt.
More of the gauges began to stutter, the entire panel seeming to develop terrets all at once, and my pulse began to race. Something was wrong, very wrong, and the sludge inside my bowels churned with sour fear.
“Come on, come on.” I flicked switches, turned dials, punched buttons, but nothing seemed to fix the spasming electronics. Every gauge failed, and without warning, I found myself plunged into inky darkness.
Outside, the sun surrendered to the pull of night, the sky darker than usual. A distant rumble of thunder reverberated above the roar of my helicopter’s engine, and I thought I glimpsed a streak of yellowish lightning on the far horizon to my left.
Calm down Chris. We’re still flying, so it must just be a blown fuse. Stay in control and find a place to set her down.
My sweaty palm slid on the cyclic stick, and both feet weighed heavy on the yaw pedals. The collective stuck to my other hand with a nervous vibration, and I squinted against the abyss outside.
I jumped despite myself, as the little Garmin on my panel flared back to life, the static pulling aside to reveal a twitching display. Each time the screen glitched, it showed the colorful map detailing my flight path over the ground below, but I noticed that some of the lines changed, the names shifting, as if the device couldn’t decide between two different versions of the world.
One name jutted out at me, slate gray like most of the major county names, appearing with ghostly flickers from between two neighboring ones.
Barron County.
I stared, confused. I’d flown over this section of southeastern Ohio plenty of times, and I knew the counties by heart. At this point, I should have been over the southern end of Noble County, and maybe dipping lower into Washington. There was no Barron County Ohio. I was sure of it.
And yet it shown back at me from the digital landscape, a strange, almost cigar-shaped chunk of terrain carved from the surrounding counties like a tumor, sometimes there, sometimes not, as my little Garmin struggled to find the correct map. Rain began to patter against my cockpit window, and the entire aircraft rattled from a strong gust of wind. Thick clouds closed over my field of vision like a sea of gray cotton.
The blood in my veins turned to ice, and I sucked in a nervous breath.
Land. I had to land. There was nothing else to do, my flight controls weren’t responding, and only my Garmin had managed to come back to life. Perhaps I’d been hit by lightning, and the electronics had been fried? Either way, it was too dark to tell, but a storm seemed to be brewing, and if I didn’t get my feet on the ground soon, I could be in real trouble.
“Better safe than sorry.” I pushed down on the collective to start my slow descent and clicked the talking button for my headset. “Any station, this is Douglass Three-One-Four-Foxtrot, over.”
“Any station, this is Douglass Three-One-Four-Foxtrot, requesting emergency assistance, over.”
Still nothing.
If the radio’s dead, I’m really up a creek.
With my hand shaking, I clicked on the mic one more time. “Any station, this is—”
Like a curtain pulling back, the fog cleared from around my window, and the words stuck in my throat.
Without my gauges, I couldn’t tell just how far I’d descended, but I was definitely very low. Thick trees poked up from the ground, and the hills rolled into high ridges with flat valley floors, fields and pastures pockmarking them. Rain fell all around in cold, silvery sheets, a normal feature for the mid spring in this part of Ohio.
What wasn’t normal, were the fires.
At first, I thought they were forest fires for the amount of smoke and flames that bellowed from each spot, but as I swooped lower, my eyes widened in horror.
They were houses.
Farms, cottages, little clusters that barely constituted villages, all of them belched orange flames and black pillars of sooty smoke. I couldn’t hear above the helicopter blades, but I could see the flashes on the ground, along the road, in between the trees, and even coming from the burning buildings, little jets of golden light that spat into the darkness with anger.
Gunfire. That’s rifle fire, a whole lot of it.
Tiny black figures darted through the shadows, barely discernable from where I sat, several hundred feet up. I couldn’t see much, but some were definitely running away, the streaks of yellow gunfire chasing them. A few dark gray vehicles rumbled down one of the gravel roads, and sprayed fire into the houses as it went. They were fighting, I realized, the people in the trucks and the locals. It was horrific, like something out of war-torn Afghanistan, but worse.
Then, I caught a glimpse of the others.
They didn’t move like the rest, who either fled from the dark vehicles, or fired back from behind cover. These skinny figures loped along with haphazard gaits, many running on all fours like animals, swarming from the trees by the dozens. They threw themselves into the gales of bullets without flinching, attacking anyone within range, and something about the way they moved, so fluid, so fearless, made my heart skip a beat.
What is that?
“Echo Four Actual to unknown caller, please respond, over.”
Choking back a cry of shock, I fumbled at the control panel with clumsy fingers, the man’s voice sharp and stern. I hadn’t realized that I’d let go of the talking button and clicked it down again. “Hello? Hello, this is Douglass Three-One-Four-Foxtrot out of Pittsburgh, over.”
An excruciating moment passed, and I continued to zoom over the trees, the fires falling away behind me as more silent forest took over.
“Roger that Douglass Three-One-Four-Foxtrot, we read you loud and clear. Please identify yourself and any passengers or cargo you might be carrying, over.”
Swallowing hard, I eyed the treetops, which looked much closer than they should have been. How far had I descended? “Echo Four Actual, my name is Christopher Dekker, and I am alone. I’m a charter flight from PA, carrying medical equipment for OSU in Columbus. My controls have been damaged, and I am unable to safely carry on due to the storm. Requesting permission to land, over.”
I watched the landscape slide by underneath me, once catching sight of what looked like a little white church surrounded by smaller huts, dozens of figures in the yard staring up at me as I flew over a towering ridgeline.
“Solid copy on that Douglass Three-One-Four-Foxtrot. Be advised, your transponder shows you to be inside a restricted zone. Please cease all radio traffic, reduce your speed, climb to 3,000 feet and proceed north. We’ll talk you in from there. How copy, over?”
My heart jumped, and I let out a sigh of relief. “Roger that Echo Four Actual, my altimeter is down, but I’ll do my best to eyeball the altitude, over.”
With that, I pulled the collective upward, and tried my best to gauge how far I was by eyesight in the gathering night, rain still coming down all around me. This had to be some kind of disaster or riot, I decided. After all, the voice over the radio sounded like military, and those vehicles seemed to have heavy weapons. Maybe there was some kind of unrest going on here that I hadn’t heard about yet?
Kind of weird for it to happen in rural areas though. Spoiled college kids I get, but never saw farmers get so worked up before. They usually love the military.
Something moved in the corner of my eye, and I turned out of reflex.
My mouth fell open, and I froze, unable to scream.
In the sky beside me, a huge shadow glided along, and its leathery wings effortlessly carved through the gloom, flapping only on occasion to keep it aloft. It was too dark for me to see what color it was, but from the way it moved, I knew it wasn’t another helicopter. No, this thing was alive, easily the size of a small plane, and more than twice the length of my little McDonald Douglass. A long tail trailed behind it, and bore a distinct arrow-shaped snout, with twig-like spines fanned out around the back of its head. Whatever legs it had were drawn up under it like a bird, yet its skin appeared rough and knobby, almost resembling tree bark. Without pause, the gigantic bat-winged entity flew along beside me, as if my presence was on par with an annoying fly buzzing about its head.
Gripping the microphone switch so tight, I thought I’d crack the plastic, I whispered into my headset, forgetting all radio protocol. “T-There’s something up here.”
Static crackled.
“Douglas Three-One-Four-Foxtrot, say again your last, you’re coming in weak and unreadable, over.”
“There’s something up here.” I snarled into the headset, still glued to the controls of the helicopter, afraid to deviate even an inch from my course in case the monstrosity decided to turn on me. “A freaking huge thing, right beside me. I swear, it looks like a bat or . . . I don’t know.”
“Calm down.” The man on the other end of the radio broke his rigorous discipline as well, his voice deep, but level. “It won’t attack if you don’t move too fast. Slowly ease away from it and follow that course until you’re out of sight.”
I didn’t have time to think about how wrong that sounded, how the man’s strict tone had changed to one of knowledge, how he hadn’t been the least surprised by what I’d said. Instead, I slowly turned the helicopter away from the huge menace and edged the speed higher in tiny increments.
As soon as I was roughly two football fields away, I let myself relax, and clicked the mic switch. “It’s not following.”
“You’re sure?”
Eyeing the huge flapping wings, I nodded, then remembered he couldn’t see me. “Yeah, I’m well clear.”
“Good. Thank you, Mr. Dekker.”
Then, the radio went dead.
Something in my chest dropped, a weight that made my stomach roil. This wasn’t right, none of it. Who was that man? Why did he know about the thing I’d just seen? What was I supposed to—
A flash of light exploded from the trees to my right and shot into the air with a long finger of smoke.
What the . . .
On instinct, I jerked the cyclic stick to one side, and the helicopter swung to avoid the rocket.
My world shook, metal screeched, and a dozen alarms began to go off inside the cockpit in a cacophony of beeps and sirens. Orange and red flames lit up the night sky just behind me, and the horizon started to spin wildly outside. Heat gushed from the cockpit door, and I smelled the greasy stench of burning oil. The safety belts dug into my shoulders, and with a final slip, the radio headset ripped free from my scalp.
I’m hit.
Desperate, I yanked on the controls, fought the bird even as she spun toward the ground in a wreath of flames, the inky black trees hurtling up to meet me. The helicopter went into full auto-rotation, the sky blurring past outside, and the alarms blared in a screech of doom. Panic slammed through my temples, I screamed at the top of my lungs, and for one brief second, my eyes locked on the little black Garmin still perched atop my control panel.
Its screen stopped twitching and settled on a map of the mysterious Barron County, with a little red arrow at the center of the screen, a few words popping up underneath it.
You are here.
Trees stabbed up into the sky, the belts crushed at my torso, glass shattered all around me, and the world went dark.
Copper, thick, warm, and tangy.
It filled my mouth, stank metallic in my nose, clogged my throat, choking me. In the murkiness, I fought for a surface, for a way out, blind and numb in the dark.
This way, kleineun.
My ouma’s voice echoed from somewhere in the shadows.
This way.
Both eyes flew open, and I gagged, spitting out a stream of red.
Pain throbbed in my ribs, and a heavy pressure sent a tingling numbness through my shoulders. Blood roared inside my temples, and stars danced before my eyes with a dizzying array. Humid night air kissed my skin, and something sticky coated my face, neck, and arms that hung straight up toward the ceiling.
Wait. Not up. Down.
I blinked at the wrinkled, torn ceiling of the cockpit, the glass all gone, the gray aluminum shredded like tissue paper. Just outside the broken windows, thick Appalachian bluegrass and stemmy underbrush swished in a feeble breeze, backlit by flashes of lightning from the thunderstorm overhead. Green and brown leaves covered everything in a wet carpet of triangles, and somewhere nearby, a cricket chirped.
Turning my head from side to side, I realized that I hung upside down inside the ruined helicopter, the top half burrowed into the mud. I could hear the hissing and crackling of flames, the pattering of rain falling on the hot aluminum, and the smaller brush fires around the downed aircraft sizzling out in the damp long grass. Charred steel and burning oil tainted the air, almost as strong as the metallic, coppery stench in my aching nose.
They shot me down. That military dude shot me out of the sky.
It didn’t make sense. I’d followed their orders, done everything they’d said, and yet the instant I veered safely away from whatever that thing in the sky had been, they’d fired, not at it, but at me.
Looking down (or rather, up) at my chest, I sucked in a gasp, which was harder to do that before.
The navy-blue shirt stuck to my torso with several big splotches of dark, rusty red. Most were clean slashes, but two held bits of glass sticking out of them, one alarmingly bigger than the other. They dripped cherry red blood onto my upturned face, and a wave of nausea hit me.
I gotta get down.
I flexed my arms to try and work some feeling back into them, praying nothing was broken. Half-numb from hanging so long, I palmed along my aching body until I felt the buckled for the seat belts.
“Okay.” I hissed between gritted teeth, in an effort to stave off my panic. “You can do this. Just hold on tight. Nice and tight. Here we go . . .”
Everything seemed to lurch, and I slid off the seat to plummet towards the muck-filled hole in the cockpit ceiling. My fingers were slick with blood and slipped over the smooth faux-leather pilot’s seat with ease. The shoulder belt snagged on the bits of glass that lay just under the left lowest rib, and a flare of white-hot pain ripped through me.
I screamed, my right knee caught the edge of the aluminum ceiling, and both hands dove into a mound of leaf-covered glass shards on the opposite side of the hole. My head swam, being right-side-up again enough to make shadows gnaw at the corner of my eyes.
Forcing myself to breath slowly, I fought the urge to faint and slid back to sit on the smooth ceiling. I turned my hands over to see half a dozen bits of clear glass burrowed into my skin like greedy parasites, red blood weeping around the new cuts.
“Screw you.” I spat at the rubbish with angry tears in my eyes. “Screw you, screw you, screw you.”
The shards came out easy enough, and the cuts weren’t that deep, but that wasn’t what worried me. On my chest, the single piece of cockpit glass that remined was almost as big as my palm, and it really hurt. Just touching it felt like self-inflicted torture, but I knew it had to come out sooner or later.
Please don’t nick a vein.
Wiping my hands dry on my jeans, I gripped the shard with both hands, and jerked.
Fire roared over my ribs, and hot blood tickled my already grimy pale skin. I clapped a hand over the wound, pressing down hard, and grunted out a string of hateful expletives that my ouma would have slapped me for.
Lying on my back, I stared around me at the messy cargo compartment of the MD-902. Most of the medical supplies had been in cardboard boxes strapped down with heavy nylon tow-straps, but several cases had ruptured with the force of the impact, spraying bandages, syringes, and pill bottles all over the cluttered interior. Orange flames chewed at the crate furthest to the rear, the tail section long gone, but the foremost part of the hold was intact. Easily a million-dollar mess, it would have made me faint on any other trip, but today it was a godsend.
Half-blind in the darkness, I crawled along with only the firelight and lightning bolts to guide me, my right knee aching. Like a crippled raccoon, I collected things as I went, conscious of the two pallets of intact supplies weighing right over my head. I’d taken several different first-aid courses with some hunting buddies of mine, and the mental reflexes kicked in to help soothe my frazzled mind.
Check for bleeds, stop the worst, then move on.
Aside from my battered chest and stomach, the rest of me remained mostly unharmed. I had nasty bruises from the seatbelts, my right knee swelled, my nose slightly crooked and crusted in blood, but otherwise I was intact. Dowsing every scratch and cut with a bottle of isopropyl alcohol I found, I used butterfly closures on the smaller lacerations that peppered my skin. I wrapped soft white gauze over my abused palms and probed at the big cut where the last shard had been, only stopping when I was sure there were no pieces of glass wedged inside my flesh.
“Not too bad.” I grunted to myself, trying to sound impassive like a doctor might. “Rib must have stopped it. Gonna need stitches though. That’ll be fun.
Pawing through the broken cases, I couldn’t find any suture chord, but just as I was about to give up, I noticed a small box that read ‘medical skin stapler’.
I tore the small white plastic stapler free from its packaging and eyeballed the device. I’d never done this before, only seen it in movies, and even though the cut in my skin hurt, I wondered if this wouldn’t be worse.
You’ve gotta do it. That bleeding needs to stop. Besides, no one’s coming to rescue you, not with those rocket-launching psychos out there.
Taking a deep breath, I pinched the skin around the gash together, and pressed the mouth of the stapler to it.
A sharp sting, like that of a needle bit at the skin, but it didn’t hurt nearly as bad as the cut itself. I worked my way across the two-inch laceration and gave out a sigh of relief when it was done.
“Not going to bleed to death today.” I daubed ointment around the staples before winding more bandages over the wound.
Popping a few low-grade painkillers that tumbled from the cargo, I crawled wriggled through the nearest shattered window into the wet grass.
Raindrops kissed my face, clean and cool on my sweaty skin. Despite the thick cloud cover, there was enough constant lightning strikes within the storm to let me get glimpses of the world around me. My helicopter lay on its back, the blades snapped like pencils, with bits and pieces of it burning in chunks all around the small break in the trees. Chest-high scrub brush grew all around the low-lying ground, with pockets of standing water in places. My ears still rang from the impact of the crash, but I could start to pick up more crickets, frogs, and even some nocturnal birds singing into the darkness, like they didn’t notice the huge the hulk of flaming metal that had fallen from the sky. Overhead, the thunder rumbled onward, the feeble wind whistling, and there were other flashes on the horizon, orange and red ones, with crackles that didn’t sound quite like lightning.
The guns. They’re still fighting.
Instinctively, I pulled out my cellphone, and tapped the screen.
It fluttered to life, but no matter how I tried, I couldn’t get through to anyone, not even with the emergency function designed to work around having no service. The complicated wonder of our modern world was little better than a glorified paperweight.
Stunned, I sat down with my back to the helicopter and rested my head against the aluminum skin of the craft. How I’d gone from a regular medical supply run to being marooned in this hellish parody of rural America, I didn’t know, but one thig was certain; I needed a plan. Whoever fired the missile could have already contacted my charter company and made up some excuse to keep them from coming to look for me. No one else knew I was here, and even though I now had six staples holding the worst of my injuries shut, I knew I needed proper medical attention. If I wanted to live, I’d have to rescue myself.
My bag. I need to get my go-bag, grab some gear and then . . . head somewhere else.
It took me a while to gather my green canvas paratrooper bag from its place behind the pilot’s seat and fill it with whatever supplies I could scrounge. My knee didn’t seem to be broken, but man did it hurt, and I dreaded the thought of walking on it for miles on end. I focused instead on inventorying my gear and trying to come up with a halfway intelligent plan of action.
I had a stainless-steel canteen with one of those detachable cups on the bottom, a little fishing kit, some duct tape, a lighter, a black LED flashlight with three spare batteries, a few tattered road maps with a compass, a spare pair of socks, medical supplies from the cargo, and a simple forest green plastic rain poncho. I also managed to unearth a functioning digital camcorder my ouma had gotten me for Christmas a few years back, though I wasn’t sure I wanted to do any filming in such a miserable state. Lastly, since it was a private supply run from a warehouse area near Pittsburgh to a direct hospital pad in Ohio, I’d been able to bring my K-Bar, a sturdy, and brutally simple knife designed for the Marine Corps that I used every time I went camping. It was pitiful in comparison to the rifle I wished I had with me, but that didn’t matter now. I had what I had, and I doubted my trusty Armalite would have alleviated my sore knee anyway.
Clicking on my flashlight, I huddled with the poncho around my shoulders inside the wreck of the chopper and peered at the dusty roadmaps. A small part of me hoped that a solution would jump out from the faded paper, but none came. These were all maps of western PA and eastern Ohio. None of them had a Barron County on them anywhere.
The man on the radio said to head north, right before they shot me down. That means they must be camped out to the north of here. South had that convoy and those burning houses, so that’s a no-go. Maybe I can backtrack eastward the way I came.
As if on cue, a soft pop echoed from over the eastern horizon, and I craned to look out the helicopter window, spotting more man-made flashes over the tree tops.
“Great.” I hissed between clenched teeth, aware of how the temperature dipped to a chilly 60 degrees, and how despite the conditions, my stomach had begun to growl. “Not going that way, are we? Westward it is.”
Walking away from my poor 902 proved to be harder than I’d anticipated. Despite the glass, the fizzling fires, and the darkness, it still held a familiar, human essence to it. Sitting inside it made me feel secure, safe, even calm about the situation. In any other circumstance, I would have just stayed with the downed aircraft to wait for help, but I knew the men who shot me down would likely find my crash site, and I didn’t want to be around when they did.
Unlike much of central and western Ohio, southeastern Ohio is hilly, brushy, and clogged with thick forests. Thorns snagged at my thin poncho and sliced at my pant legs. My knee throbbed, every step a form of self-inflicted torture. The rain never stopped, a steady drizzle from above just cold enough to be problematic as time went on, making me shiver. Mud slid under my tennis shoes, and every tree looked ten times bigger in the flickering beam of my cheap flashlight. Icy fear prickled at the back of my neck at some of the sounds that greeted me through the gloom. I’d been camping loads of times, both in Pennsylvania and elsewhere, but these noises were something otherworldly to me.
Strange howls, screeches, and calls permeated the rain-soaked sky, some almost roars, while others bordered on human in their intonation. The more I walked, the softer the distant gunfire became, and the more prevalent the odd sounds, until the shadows seemed to fill with them. I didn’t dare turn off my flashlight, or I’d been completely blind in the dark, but a little voice in the back of my head screamed that I was too visible, crunching through the gloomy forest with my long beam of light stabbing into the abyss. It felt as though a million eyes were on me, studying me, hunting me from the surrounding brush, and I bitterly recalled how much I’d loved the old Survivor Man TV series as a kid.
Not so fun being out in the woods at night. Especially alone.
A twig snapped somewhere behind me, and I whirled on the spot, one trembling hand resting on the hilt of my K-Bar.
Nothing. Nothing but trees, bushes, and rain dripping down in the darkness.
“This is stupid.” I whispered to myself to keep my nerves in check as I slowly spun on the spot. “I should have went eastward anyway. God knows how long I’m going to have to—”
A groan of metal-on-metal echoed from somewhere to my right, and I spun to face it, yanking the knife on my belt free from its scabbard. It felt so small and useless in my hand, and I choked down a wave of nauseas fear.
Ka-whump. Creak. K-whump. Creak.
Underbrush cracked and crunched, a few smaller saplings thrashed, and from deep within the gloom, two yellow orbs flared to life. They poked through the mist in the trees, forming into slender fingers of golden light that swept back and forth in the dark.
The soldiers . . . they must be looking for me.
I swallowed hard and turned to slink away.
Ice jammed through my blood, and I froze on the spot, biting my tongue to stop the scream.
It stood not yards away, a huge form that towered a good twelve feet tall in the swirling shadows. Unpolished chrome blended with flash-rusted spots in the faded red paint, and grime-smeared glass shone with dull hues in the flashes of lightning. Where the wheels should have been, the rounded steel axels curved like some enormous hand had bent them, and the tires lay face-down on the muddy ground like big round feet, their hubcaps buried in the dirt. Dents, scrapes, and chips covered the battered thing, and its crooked little radio antenna pointed straight up from the old metal fender like a mast. I could barely make out the mud-coated VW on the rounded hood, and my mind reeled in shock.
Is . . . is that a car?
Both yellow headlights bathed me in a circle of bright, blinding light, and neither I nor the strange vehicle moved.
Seconds ticked by, the screech-thumping in the background only growing closer. I realized that I couldn’t hear any engine noises and had yet to see any soldiers or guns pointed my way. This car looked old, really old, like one of those classic Volkswagen Beetles that collectors fought over at auctions. Try as I might, I couldn’t see a driver inside the murky, mold-smeared windows.
Because there wasn’t one.
Lightning arched across the sky overhead, and the car standing in front of me blinked.
Its headlights slid shut, as if little metal shades had crawled over the bulbs for a moment and flicked open again. Something about that movement was so primal, so real, so lifelike, that every ounce of self-control I had melted in an instant.
Cursing under my breath, I lunged into the shrubs, and the world erupted around me.
Under my shoes, the ground shook, and the car surged after me in a cacophony of ka-thumps that made my already racing heart skip several beats. A weather-beaten brown tow truck from the 50’s charged through the thorns to my left, it’s headlights ablaze, and a dilapidated yellow school bus rose from its hiding place in the weeds to stand tall on four down-turned axel-legs. They all flicked their headlights on like giants waking from their slumber, and as I dodged past them, they each blared their horn into the night in alarm.
My breaths came short and tight, my knee burned, and I crashed through thorns and briars without thought to how badly I was getting cut up.
The cheap poncho tore, and I ripped it away as it caught on a tree branch.
A purple 70’s Mustang shook off its blanket of creeping vines and bounded from a stand of trees just ahead, forcing me to swerve to avoid being run over, my adrenaline at all-time highs.
This can’t be happening, this can’t be happening, this can’t be happening.
Slipping and sliding, I pushed through a stand of multiflora rose, and stumbled out into a flat, dark expanse.
I almost skidded to a stop.
What had once been a rather large field stood no taller than my shoestrings, the grass charred, and burnt. The storm above illuminated huge pieces of wreckage that lay scattered over the nearly 40-acre plot, and I could just make out the fire-blackened hulk of a fuselage resting a hundred yards away. The plane had been brought down a while ago it seemed, as there weren’t any flames left burning, and I threw myself toward it in frenzied desperation.
Burned grass and greasy brown topsoil slushed underfoot, and I could hear the squelching of the cars pursing me. Rain soaked me to the bone, and my lungs ached from sucking down the damp night air. A painful stich crept into my side, and I cursed myself for not putting in more time for cardio at the gym.
Something caught my left shoelace, and I hurtled to the ground, tasting mud and blood in between my teeth.
They’ve got me now.
I clawed at the mud, rolled, and watched a tire slam down mere inches from where my head had been. The Mustang loomed over me and jostled for position with the red Volkswagen and brown tow truck, the school bus still a few yards behind them. They couldn’t seem to decide who would get the pleasure of stomping me to death, and like a herd of stampeding wildebeest, they locked bumpers in an epic shoving match.
On all fours, I scampered out from under the sparring brutes, and dashed for the crumpled airplane, a white-painted DC-3 that looked like it had been cut in half by a gargantuan knife blade. I passed a snapped wing section, the oily remains of a turbo-prop engine, and a mutilated wheel from the landing gear. Climbing over a heap of mud, I squeezed into the back of the ruined flight cabin and dropped down into the dark cargo hold.
No sooner had my sneakers hit the cold metal floor, and the entire plane rocked from the impact of something heavy ramming it just outside. I tumbled to my knees, screaming in pain as, once again, I managed to bash the sore one off a bracket in the wall.
My hand smeared in something gooey, and I scrabbled for my flashlight.
It clicked on, a wavering ball of white light in the pitch darkness, and I fought the urge to gag. “Oh man . . .”
Three people, or what was left of them, lay strewn over the narrow cargo area. Claret red blood coated the walls, caked on the floor, and clotted under my mud-spattered shoes. Bits of flesh and viscera were stuck to everything, and tatters of cloth hung from exposed sections of broken bone. An eerie set of bloody handprints adorned the walls, and the only reason I could tell it had been three people were the shoes; all of them bore anklebones sticking out above blood-soaked socks. It smelled sickly sweet, a strange, nauseas odor that crept into my nose and settled on the back of my tongue like an alien parasite.
Something glinted in the beam of my flashlight, and my pulse quickened as I pried the object loose from the severed arm that still clung to it.
“Hail Mary full of Grace.” I would have grinned if it weren’t for the fact that the plane continued to buck and roll under the assault from the cars outside.
The pistol looked old, but well-maintained, aside from the light coating of dark blood that stained its round wooden handle. It felt heavy, but good in my hand, and I turned it over to read the words, Waffenfabrik Mauser stenciled into the frame, with a large red 9 carved into the grip. For some reason, it vaguely reminded me of the blasters from Star Wars.
I fumbled with a little switch that looked like a safety on the back of the gun and stumbled toward a gap in the plane’s dented fuselage to aim out at the surrounding headlights.
The old gun bucked reliably in my hand, its long barrel spitting a little jet of flame into the night. I had no idea if I hit anything, but the attacking cars recoiled, their horns blaring in confusion.
They turned, and scuttled for the tree line as fast as their mechanical legs could go, the entire ordeal over as fast as it had begun.
Did I do that?
Perplexed, I stared down at the pistol in my hand.
A large, inky black shadow glided down from the clouds, and the yellow school bus moved too slow to react in time.
With a crash, the kicking nightmarish vehicle was thrown onto its side, spraying glass and chrome trim across the muddy field. Its electro-synth horn blared with wails of mechanical agony, as two huge talon-like feet clamped down on it, and the enormous head of the flying creature lowered to rip open its engine compartment.
The horn cut out, and the enormous flying entity jerked its head back to gulp down a mass of what looked like sticky black vines from the interior of the shattered bus.
At this range, I could see now that the flying creature bore two legs and had its wings half-tucked like a vulture that had descended to feed on roadkill. Its head turned slightly, and in the glow of another lightning bolt, my jaw went slack at the realization of what it was.
A tree trunk. It’s a rotted tree trunk.
I couldn’t tell where the reptilian beast began, and where the organic tree components ended, the upper part of the head shaped like a log, while the lower jaw resembled something out of a dinosaur movie. Its skin looked identical to the outside of a shagbark hickory but flexed with a supple featheriness that denoted something closer to skin. Sharp branch-like spines ranged down its back, and out to the end of its tail, which bore a massive round club shaped like a diseased tree-knot. Crouched on both hind legs, it braced the hooked ends of its folded wings against the ground like a bat, towering higher than a semi-truck. Under the folds of its armored head, a bulging pair of chameleon-like eyes constantly spun in their sockets, probing the dark for threats while it ate.
One black pupil locked onto the window I peered through, and my heart stopped.
The beast regarded me for a moment, with a curious, sideways sniff.
With a proud, contemptful head-toss, the shadow from the sky parted rows of razor-sharp teeth to let out a roar that shook the earth beneath my feet. It was the triumphant war cry of a creature that sat at the very top of the food chain, one that felt no threat from the fragile two-legged beings that walked the earth all around it. It hunted whenever it wanted, ate whatever it wanted, and flew wherever it wanted. It didn’t need to rip the plane apart to devour me.
Like my hunter-gatherer ancestors from thousands of years ago, I wasn’t even worth the energy it would take to pounce.
I’m hiding in the remains of the cockpit now, which is half-buried under the mud of the field, enough to shield the light from my screen so that thing doesn’t see it. My service only now came back, and it’s been over an hour since the winged beast started in on the dead bus. I don’t know when, or how I’m going to get out of here. I don’t know when anyone will even see this post, or if it will upload at all. My phone battery is almost dead, and at this point, I’m probably going to have to sleep among the corpses until daylight comes.
A dead man sleeping amongst friends.
If you live in the Noble County area in southeastern Ohio, be careful where you drive, fly, and boat. I don’t know if it’s possible to stumble into this strange place by ground, but if so, then these things are definitely headed your way.
If that happens . . . pray that they don’t find you.
submitted by RandomAppalachian468 to u/RandomAppalachian468 [link] [comments]

2023.06.01 20:55 LonnieJay1 Storytime: explaining Ultra Rapid Opioid Detox with Naltrexone to a fellow Bropiate

I won’t call Kevin again yet. He's the type to tell me he's busy if I need something from him, even though I go out of my way to help him and take care of him every single time he needs me. I stop at one of the red lights in (City name redacted). At least Kevin lives here too, just a few minutes away from Lucky’s mom’s house.
If Kevin isn’t home, I’m going to be enraged, depressed enough to cry, or both. Kevin doesn’t even really lock his door. He never locks it behind us when we walk inside – people like me can’t help but notice things like that. If he isn’t at his house, maybe I can just walk in, take his drugs, and leave.
I called him earlier in the day, so he will definitely suspect that I was the one who robbed him, but what is he going to do?
I’m homeless right now, and I’ll be back in treatment soon – and hopefully not in the cess pool of fraud, corruption, and death that addiction treatment in Orange County has become. I wonder what could possibly be in the little lockbox Kevin keeps in the closet. It is probably a treasure chest full of various drugs and opioids.
I arrive at Kevin’s house and pull into the driveway. I knock on his front door. No answer. I ring the doorbell. No answer. My heart starts to race. My head hurts, I’m nauseous, I’m sweaty. I’m full of anxiety. I can’t stop thinking about dope. I feel like I’m stuck in a cave that is collapsing all around me. I need to get out, right now.
I knock again, loudly, a few more times. I count to 10. Still nothing. I feel a flash of heat and near-panic. My stomach churns, as if threatening to cramp. I need opiates, right now.
Desperation overtakes me. I turn the doorknob. It opens. I walk in the house, my instinct telling me to creep in. I suppress my instinct and walk in casually.
“Kevin?” I yell, from the bottom of the stairs that are right by the front door. I listen for a second. All is quiet. It wouldn’t be good if I am caught sneaking around if he is here, and it isn’t going to matter if I yell a few times before I steal his drugs if he isn’t here.
Junkie feet carry me up the stairs. My ankle hurts with every step – worse since I am in withdrawal.
"Kevin?” I call out. If he isn't here, I’m robbing him. I can't stand this motherfucker, and while I'm not quite the thief I used to be, I'm still an opportunist, and this is a damn good opportunity. Maybe stealing all this kid’s fentanyl is exactly what he needs in order to be able to quit.
That’s right, Lonnie. You’d be doing him a favor by robbing him.
I peek in the first bedroom at the top of the stairs. It’s the guest bedroom I slept in 5 nights ago. It feels like it has been an eternity since I was last here. Time moves more slowly in the realm of opioid sickness. Nobody is in the guest bedroom.
I peek into the office that sits across the hall. I don’t see anybody there. I would search the office, since he might have the lockbox in here, for now, but he might be sleeping in the bedroom.
"Kevin? Marissa?" I call out. Saying her name reminds me of the fact that he is dating her. She is so young and innocent. I can’t believe he got her addicted to these powerful soul-stealing drugs. I would never associate with Kevin if he didn't have so many different uses. He is not a person to me: he is means to the various ends that I have in mind when I contact him. This isn’t Kevin’s house; it’s a house with fentanyl in it.
If I find that carfentanil, I’m going to have a decision to make. It might be so strong that using it would cause changes to my opioid receptors that I would never recover from. Injecting even one drop could kill me. Carfentanil is also identified as a biological weapon since even accidental inhalation of an almost imperceptible amount can be deadly - or so, the police say. The amount of carfentanil that Kevin has could keep me incapacitated and out of pain for at least a year. Finding that bottle would be a curse.
I find myself standing in front of the double doors to the master bedroom.
"Yo, Kevin!" I shout out. Last chance before I go on a little scavenger hunt. I put my ear close to the door. I hear the bed creaking. Somebody is in there.
“Who the fuck is in my house?” Kevin yells from behind the door.
“It’s Lonnie. I tried to call you 3 times,” I shout out the lie, with conviction in my voice.
“How’d you get in here?” he asks, as the double doors to the master bedroom swing inward and open. He is wearing an angry frown, basketball shorts, and no shirt. I try not to look at his pale, untoned stomach.
“Your front door was open. I need some of that furry, bad. I’ll give you (exorbitant price redacted) for half a gram, right now,” I say.
“Say no more. I’ll grab it,” he says, flashing a smile at me, and then running over to his closet. I am suddenly relieved that he is here, and that I do not have to steal from anybody today. Stealing always catches up to me.
“I’m going to go downstairs,” I say.
As I trot downstairs, my sickness starts to subside, since the gorilla in me knows that he will be fed soon. I go into his downstairs bathroom and get a Q-tip, and then run to my car to get a syringe. By the time I get back to Kevin’s couch, he is there.
“You got that hundred?” he asks.
“I’m sending you a Venmo right now,” I say, unlocking my phone, opening the Venmo payment app, and sending him the money, which takes 10 seconds.
“Check it,” I say, nodding at his phone. He watches his phone for a few seconds. A chunk of Furanylfentanyl sits on a scale on the coffee table between us. I eye it hungrily, waiting for Kevin to say the word.
“You’re good,” he says. I pick up the chunk of furanylfentanyl, which is enough to kill 20 opioid-naïve people twice over. I move to the kitchen table, prep the shot, and point the loaded syringe at my arm.
“You know I hate when you do that here,” Kevin says, from the couch.
“I know,” I say, injecting myself in the forearm, quickly.
“1,” I say, capping the syringe.
“2,” I say, putting it in my pocket.
“3,” I say, diving onto the floor.
“4,” I say, feeling a smile creep across my face.
“When does it hit?” he asks.
“5,” I say, laying down on the floor.
“Now,” I add, closing my eyes.
There is a moment of emptiness that is only perceptible if you’re looking for something and find nothing instead: the non-sensations of a barren organism that is completely devoid of any meaning, pleasure, will to live, or basic comfort.
My heart skips a beat – did I miss the vein?!
A weight crushes my chest, like a meteor of light just collided into it. I am unable to breathe as every ounce of pain becomes washed away by the tidal wave of raw pleasure that spreads instantly from my brain and into my spinal cord, transforming my entire body into light as the furanylfentanyl clings to the opioid receptors all over my body. I lay on the floor, mentally clinging to the tightness and pleasure in my chest, wanting it to stay forever.
The rush fades, and I find myself breathing again, unfortunately. I open my eyes and get up from the floor.
“How was that?” Kevin asks, a semi-curious look on his face.
“Awful. You should never do it,” I say, scratching my nose. Kevin laughs.
“I hate needles, anyway,” he says. I laugh twice as loud as he did and begin to pace.
“So did I. So did every IV drug addict. I’ve never met anybody that was like ‘I always loved needles! I just thought stabbing myself looked fun!’. No way. People always start with a habit of sniffing the drugs, just like you.
“They meet somebody who injects the drugs in front of them, just like I am. The person shooting up says: ‘don’t do it, it’s fucking awful’ as they stick the needle in their arm, just like I am. I can understand how this is hypocritical, but it’s truly something I wish I never tasted. You never, ever forget the rush. It becomes the climax and focal point of your life.
“It is a hyper-pleasurable experience that carves itself into the ridges of your memory-scape. It is a traumatic pleasure. You put the needle into your very bloodstream; the chemical you slam into yourself alters your genetic expression. The experience is more intimate than any other experience imaginable. It changes you forever. It haunts you in your dreams. If you give yourself to it for even a moment, The Needle will never let you go,” I say, moving back to the floor. I need to enjoy this shot, before my tolerance skyrockets again, and my body becomes immune to the euphoria.
“Why do you do it, then?” he asks.
“Because I’m hopelessly addicted,” I say, laying down flat on my back again.
“Didn’t you quit before? Weren’t you sober for a year right before we met?” he asks.
“I’ve spent plenty of time sober. I’ve spent more time off opioids than time I’ve spent addicted to them since I found them 10 years ago – but injecting makes it a whole different ballgame. You are injecting a disease into yourself,” I say.
“I don’t think that’s true,” he says.
“Yeah, that’s the fucking conundrum, right there. Did I get the disease when I shot it up, or did I have it before I injected the drugs? Was I born with the disease, or did the drugs cause the disease? We’re both doing the same drugs. How are you able to function and I’m not?” I ask. (author's note: I no longer believe in the disease model of addiction)
“That’s not a conundrum at all. You COULD function, but you’re not. You COULD get sober again, but you’re not,” he says. I start to laugh sarcastically.
“You must be Nancy Reagan’s son – I can just say no! If it’s that easy, why don’t you stop, then?” I ask.
“Why would I stop?” he asks.
“Why wouldn’t you want to stop?” I counter.
“Sounds like you’re projecting. You obviously want to stop. You should stop, then,” Kevin suggests. I laugh at him again.
“Yeah, I’m going to,” I say. He laughs again as well, but the laughter we are exchanging is not friendly and humorous – it is malicious and hateful; borne of the cruel misery that is the flipside of the Heavopioid experience.
“No, seriously, I’m going to stop. In fact, I’m going to call my boy Sean right now, to set up a naltrexone implant and get my opioid receptors blocked,” I say.
“You can’t get a naltrexone implant, that would kill you. You were sick as shit before you did that furry. Your skin was glistening with dope-sweat, your pupils were as big as dinner plates. I saw it myself,” he says.
“I can fake the drug test at the intake appointment and ask the doctor to prescribe me naltrexone pills to ensure a smooth transition and minimize side effects. He will prescribe me oral naltrexone pills gladly, thinking I am being a responsible patient that will take the pills and therefore be safely acclimated to the naltrexone by the time I get the implant.
“Once I have the naltrexone pills, all I need is a small handful of xanax. Take a small handful of xanax with the naltrexone and black out for a night. Wake up, no opioid withdrawal. Tada!” I exclaim, putting my hands out in wonder, still laying on the floor.
“You’re talking about doing an ultra-rapid opioid detox, which is a medical procedure that is done in a hospital, without the supervision of a medical doctor?” he asks, before laughing harshly.
“I’ve done it a bunch before. It’s awesome, actually. Well, one time, it was fucking hell. Twice, actually. It was legitimately the worst thing I’ve ever experienced – an 8-hour terror attack that makes a ‘panic attack’ feel like child’s play. But other than those two times, it’s been all gravy,” I say.
“You’re kidding me. You’re seriously talking about doing an ultra-rapid opioid detox at home with nothing but xanax and a naltrexone pill. That shit could kill you,” Kevin says.
“Not really. Xanax has a really high lethal dose limit by itself, you know that,” I say, referring to the facts that it takes a lot of xanax to kill a person when xanax is taken alone, and that Kevin is a drug nerd like me.
“Yeah, the median lethal dose of xanax alone might be high compared to other drugs, but if you’re blacked out while you’re in severe opiate withdrawal, you don’t even know what’s going on in your body. You could have a heart attack, a stroke. You could break the temperature regulation system of the hypothalamus-” I interrupt him with a laugh.
“I know exactly what’s going on: a bunch of awful, painful stuff that I don’t want to be any part of,” I say. I hear footsteps coming down the stairs.
“What are you guys talking about?” Marissa asks, walking into the living room. She looks worse every time I see her; her youth and beauty are being stolen by Kevin and the drugs he should not be providing her with.
“This kid thinks he’s a doctor. He’s going to wind up killing himself,” Kevin states.
“What?” she asks, walking to the couch to sit next to Kevin.
“It’s not that dangerous. Doctors do it all the time, it’s called ultra-rapid opioid detox. I do it a little bit differently, but it’s the same idea: anesthetize the patient-”
“Himself, he means, when he says ‘patient’,” Kevin interrupts, looking at Marissa.
“Yes, I am both the unlicensed medical provider and the patient in this case. I anesthetize myself with a small handful of xanax while taking a naltrexone pill at the same time. The xanax kicks in, and I black out.
“While I am asleep, the naltrexone clings to my opioid receptors and antagonizes them. This puts me into ‘precipitated withdrawal,’ which is essentially a condensed version of withdrawal from opioids that is triggered by the naltrexone – a hyper-withdrawal, if you will. The hyper-withdrawal reverses the effects of physical dependence on opioids: my natural opioid-producing system, the endorphin system, kicks into overdrive to offset the presence of the naltrexone and get me out of hyper-withdrawal. At the same time, the anti-endorphin system, which pumps out the pain-creating chemical, dynorphin, in response to continuous opioid use, shuts down.
“To put it simply, over the course of a blacked-out night, I go through the equivalent of 7-10 days of withdrawal. I wake up feeling like I’m 10 days clean. Then, I can take another naltrexone pill, which guarantees me another 36 hours clean. It ends the constant and overwhelming war with myself over whether or not I should use opioids. I make one decision to take one naltrexone pill in the morning, instead of having to re-commit to my decision not to use opioids every time I feel depressed or anxious, which is every second at the beginning,” I say, standing up now.
I want to quit again so badly. I want to be free again.
“You have to feel like absolute garbage from starting naltrexone in the middle of a serious habit like that,” Kevin says. I scoff.
“Of course, I feel like garbage! It’s almost unbearable. My brain and spine and gut are overwhelmed by some of the most basic pain-causing chemicals in the biological world. I am quite literally saturating my system with anti-endorphins. Despite the pain, the benefit is simple and incredible: naltrexone speeds the process of return to chemical balance, or homeostasis, in the brain. Opioid painkillers get us high, but they also depress our respiratory, cardiovascular, and nervous systems.
“Our bodies adapt to the constant presence of external opioids by producing chemicals like dynorphin that stimulate us in ways that have the net effect of pain-creation. These pain-creating chemical responses keep us awake and breathing when we’re nodding off – but they also keep us awake and restless when we try to quit opioids, since our brains don’t shut down their production right when we stop ingesting external opioids.
“For example, suppose I start sniffing oxy when I’m 15. My brain starts to notice a ton of painkilling chemicals floating around. It starts to produce these pain-creating chemicals, to offset the painkillers and keep us in equilibrium. Our brains are always seeking to keep us in homeostatic equilibrium – continual regulation of body temperature and blood pressure are two other examples of this equilibrium.
“I skip the oxy for a day. My brain still has the pain-creators floating around, because the human brain is a prediction and adaptation machine that has learned to anticipate an over-abundance of painkillers in my system, and so continues to over-produce the pain-creators as a proactive, predictive response.
“Naltrexone is an extremely powerful pain-creator. There is a huge spike in pain creation unleashed onto my brain by the naltrexone, on top of the already excessive amounts of pain-creators that are being pumped out constantly by my brain to offset the ever-present painkilling fentanyl. This is like a tidal wave of pain-creators hitting the brain.
“Taking naltrexone when you’re already saturated with pain-creators almost feels like swallowing electricity, or fire, or panic. It feels like your entire body is setting off red alarms. Your heart races, your stomach cramps, your guts scream and contract in agony, your skin singes itself with icy-hot sweat. Your brain is telling you to lay there and die but at the same time won’t let you get comfortable for even one second.
“This discomfort cannot be understated: the clouds of heaven would feel like plywood on the street in a Boston winter. Precipitated withdrawal feels like being surrounded by all your worst fears, memories, and nightmares made real and standing all around you, sticking you with cattle prods to get you to jolt,” I say, barely able to avoid a shudder.
“That sounds awful. Why would you do that?” Marissa asks.
“Well, that only happens when you’re conscious during the process. That’s where the small handful of xanax comes in,” I say.
“You’re doing some dangerous shit to your brain by doing that. Creating that much stress and pain in your nervous system has to be ridiculously stimulating to your body. Have you ever been active during the blackout?” Kevin asks.
“Yes, but those are long and frightening stories. The goal is to reach the point where I just barely black out instead of taking enough xanax to be blacked out for a whole day, going grocery shopping and throwing fruit around and making smoothies at 3:00 AM and insulting strangers and crashing cars and whatnot,” I say. Marissa and Kevin start to laugh – at me, not with me.
“Yo, this is funny. You’re wild. So how many extra xanax do you have to take to inhibit the excitatory signals being sent in your brain by the dynorphin and the naltrexone together? I haven’t ever really thought about precipitated withdrawal. It seems like it would be a whole different animal,” he says.
“I used to take 5 xanax bars, but I woke up in the middle of a panic attack despite 5 xanax bars during one of my previous procedures, so now I take 10 xanax bars. It knocks me out for about 8 hours. I wake up in dizzy, disconnected discomfort, but it gets easier as the day goes on. The second naltrexone after waking up is a different story, though. That brings on a fresh batch of symptoms, though nowhere near as intense. I like to take xanax the second night, too.
“I get vicious rebound anxiety from taking so many xanax in such a short period of time. I have to be very careful not to pick up a xanax habit after I induct onto the naltrexone,” I say.
“That sounds like a lot of pain and work,” Kevin says, raising his eyebrows at me.
“It’s worth it. When I come out on the other side, free from this hellish, soul-sucking poison, I feel great. Well, kinda. I don’t sleep for a while. But I do bounce back, and much sooner than I would otherwise.
“When I have 1 month clean on naltrexone, it feels like I have 10 months clean. This is crucial, because when you have only been clean for 1 month, you typically still feel like shit – if you had a serious habit, anyway,” I say.
“I can’t believe you actually do that. You’re a dumbass,” Kevin says.
“It’s actually pretty smart, in some ways. The shocks to the endorphin system of the brain keep it operating smoothly, which in turn keep the immune system and dopamine system operating smoothly. Did you know that William S Burroughs actually recommended going on and off of heroin for the sake of longevity?” I ask. Kevin laughs, loudly this time. He looks at Marissa, smiling.
“You hear that? Longevity. It’ll keep us alive longer,” he says.
“Naltrexone has the potential to be a miracle drug. If you take a low dose of it every day, you can prevent your opioid tolerance from building up. Combine 0.1 MG of naltrexone with 10MG of oxycodone and patent it, you’ve got a billion-dollar pill. That low dose of the artificial, pain-creating naltrexone will prevent your brain from ramping up its’ own pain-creating response to balance out the painkilling effects of the oxy.
“In essence, that would prevent opioid tolerance and therefore the need for increasing daily dosages. You might be able to prevent addiction entirely. I’ve experimented with using naltrexone to diminish tolerance and had some success. It does lessen the painkilling effect a bit, but I’m sure a seasoned pharmacologist could think of a decent opioid potentiator to add to the combination that would increase the painkilling effects of the medication without further side effects,” I say.
“Holy shit. It can prevent tolerance buildup? Can you get me some naltrexone?” Kevin asks.
“Perhaps, but you need to read into it, first,” I say.
“You’ve really piqued my curiosity. Thank you,” he says, pulling out his bag of furanylfentanyl.
“Ah, some hellish, soul-sucking poison. Great idea. I haven’t slept for days, and I need a nap,” I say. Marissa giggles.
“I don’t think you’re going to quit,” Kevin says.
“You’ll see,” I say. I pull the syringe out of my pocket and start walking to the kitchen, to get more water for my next shot. Another shot will knock me right out, and I won’t have to deal with any of this. For a little while, anyway.
“Seriously, I’m going to be free from this shit. Free from these goddamn pills and powders that handcuff my brain and put it in a straightjacket. No more turning my own body and mind into a prison. I hate living like this. I’m going to quit, and I’m going to be playing college basketball soon,” I say, though after I say it, I feel exactly how I feel after I tell a lie.
“Then quit. It isn’t that hard,” he says. I hear the unmistakable sound of somebody sniffing powder through a straw, and it sounds vaguely like weaselly laughter.
submitted by LonnieJay1 to opiates [link] [comments]

2023.06.01 18:12 heerobrian question about 5 mapb dosage

Are the dosages on Pychonautwiki succinate or hydrochloride? I have a 50 mg HCl pill and want to make sure its not too little. I tried searching it but couldnt find accurate dosing.
submitted by heerobrian to researchchemicals [link] [comments]

2023.06.01 16:06 SeaEmergency5176 Abdominal Ultrasound Results - How Concerned Should I Be?

I am a white 43 year old Male who is 5'9" 235lbs. I do not smoke. I have a history of heavy drinking in my 20s and part of my 30s, but now rarely have more than a beer or two once a month or so. I occasionally (1-2/month) take 5-15mg of cannibis edibles. I have been experiencing some discomfort in my right flank and back for the past few months. I went to the doctor in April and all of my liver tests came back well within normal range. I had an abdominal ultrasound this morning and I obviously can't decipher it myself.
I'm perfectly fine waiting to hear from my doctor, but my wife is already kind of freaking out over some things she found on the internet googling phrases from the test results so any help here would be appreciated while we wait.
EDIT: Hit the wrong key and forgot to include pertinent information.
Blood Lab Results:
Component Your Value
Sodium 143 mmol/L
Potassium 4.6 mmol/L
Chloride 106 mmol/L
CO2 29 mmol/L
Anion Gap 8
Glucose 103 mg/dL
BUN 16 mg/dL
Creatinine 1.14 mg/dL
eGFR 82 mL/min/1.73m2
BUN/Creatinine Ratio 14.0
Calcium 9.4 mg/dL
AST (SGOT) 16 unit/L
ALT (SGPT) 30 unit/L
Alkaline Phosphatase 53 unit/L
Total Protein 7.2 g/dL
Albumin 4.7 g/dL
Total Bilirubin 0.6 mg/dL
Ultrasound Results:
Exam Notes
Transabdominal scanning was performed of the right upper quadrant including the
liver, gallbladder and biliary tree, pancreas and right kidney.
Examination limited due to bowel gas. Examination limited due to body habitus.
The liver is normal in size by subjective and objective criteria (being less
than 13cm in the mid-clavicular line and less than 16cm in the mid-hepatic
There is no focal mass seen in the liver.
The surface of the liver is normal without nodularity.
The main portal vein is patent and demonstrates antegrade flow.
The liver is diffusely attenuating in echogenicity. Degree: mild.
The liver echogenicity is increased. Degree: moderate.
* Abnormal coarsened and attenuating liver parenchyma suspicious for diffuse
hepatocellular and/or infiltrative disease; correlate clinically.
* No other significant sonographic abnormality is identified within the
visualized structures.
submitted by SeaEmergency5176 to AskDocs [link] [comments]

2023.06.01 14:44 MechanicNo3440 Going to start using supplements

I'm going to start taking sunflower lecithin (pure powder 10g a serving) and zinc (50 mg pills).
I would like advice on if these will make a noticeable improvement or not, and the best way to take them.
And how long until I start noticing the changes.
Appreciate your time.
submitted by MechanicNo3440 to cumbiggerloads [link] [comments]

2023.06.01 08:27 bbyfog [2019 Montalban et al, New Engl J Med] Evobrutinib phase 2b trial in relapsing multiple sclerosis

[2019 Montalban et al, New Engl J Med] Evobrutinib phase 2b trial in relapsing multiple sclerosis
Evobrutinb Phase 2 Study
ClinicalTrials.gov number: NCT02975349
Citation: Montalban X, et al. Evobrutinib Phase 2 Study Group. Placebo-Controlled Trial of an Oral BTK Inhibitor in Multiple Sclerosis. N Engl J Med. 2019 Jun 20;380(25):2406-2417. doi: 10.1056/NEJMoa1901981. PMID: 31075187
To establish safe and efficacious dose of Burton’s tyrosine kinase (BTK) inhibitor evobrutinib (previously called M2951) in people with relapsing multiple sclerosis (MS).
  • Role of Burton’s tyrosine kinase signaling in MS is summarized here, here. BTK inhibitors may have the advantage over existing MS disease modifying therapies since BTK inhibitors are CNS penetrant and, thus, could target both peripheral immune compartment (blood, lymph tissues) as well as CNS compartment (microglia) (here).
  • Evobrutinib is a selective, oral, BTK inhibitor. It blocks B-cell activation and cytokine release and inhibits the activation, differentiation, and polarization of proinflammatory M1 macrophages and their release of cytokines in vitro.
  • This was a phase 2, randomized, double-blind, placebo-controlled trial to establish safe and efficacious dose of evobrutinib in people with relapsing MS (pwRMS).
  • The study enrolled 267 pwRMS (aged 18-65 years; EDSS up to 6 at screening) at 56 sites across Europe and Russia. The study included both people with relapsing-remitting MS (228, 87% of total) and secondary progressive MS with superimposed relapses (33, 13% of total).
  • The study participants were randomized 1:1:1:1 to evobrutinib 25 mg once daily, 75 mg once daily, 75 mg twice daily, placebo, or open-label dimethyl fumarate (DMF). DMF was used as a reference drug in this trial.
  • The length duration of the trial was 52 weeks including 24-week placebo-controlled phase followed by a 24-week blinded-extension phase and a 12-week safety follow up. At the start of the blinded extension phase, the placebo group crossover to evobrutinib 25 mg daily; all other groups continued with the originally assigned treatment/doses. Exposure to study drug was 48 weeks across evobrutinib groups and 24 weeks for placebo group.
  • MRI scans were performed every 4 weeks starting at week 12; EDSS at weeks 12, 24, 36, and 48; safety through week 52, the end of the study.
  • The primary endpoint was the total (cumulative) number of gadolinium (Gd)-enhancing lesions identified on T1-weighted MRI at weeks 12, 16, 20, and 24. The reading at week 12 was considered baseline.
  • Key secondary endpoints were the annualized relapse rate, based on qualified relapses; qualified relapse-free status; change from baseline in the EDSS score at week 24; and safety.
  • The study was powered at 85% to detect a 90% lower number of Gd-enhancing lesions, if each evobrutinib group includes 50 participants assuming a 12% dropout rate.
  • Baseline characteristics were similar across all groups with mean age of 42 years; 69% female; median time from onset of MS symptoms of ~7.5 years; mean EDSS score of ~3.3; and mean (SD) number of Gd-enhancing lesions at baseline of 1.54 (4.37). Each study group enrolled 52 to 54 participants and 47 to 52 completed the 24-week placebo-controlled phase.
  • Primary endpoint: The mean (SD) total number of Gd-enhancing lesions decreased in a dose-dependent manner from week 12 to week 24 in evobrutinib treatment groups versus placebo: 4.06 (8.02), 1.69 (4.69), and 1.15 (3.70) in the evobrutinib 25 mg daily, 75 mg daily, and 75 mg twice daily groups, respectively, versus 3.85 (5.44) in the placebo group.
  • The baseline adjusted rate ratios for the total number of lesions over time also decreased in a dose-dependent manner from week 12 to week 24 in evobrutinib treatment groups versus placebo: 1.45, 0.30, 0.44 in the evobrutinib 25 mg daily, 75 mg daily, and 75 mg twice daily groups, respectively. After adjustment for multiple comparisons, the p values were significant for evobrutinib 75 mg daily (p = 0.005) and 75 mg twice daily (p = 0.06) groups.

Figure (evobrutinib phase 2): (A) Gd-enhancing lesions, (B) relapse rate
  • Secondary endpoints: the number of relapses from baseline to weeks were lower in 75-mg evobrutinib groups (3 relapses in 75 mg once daily; 2 in 75 mg twice daily) versus 9 relapses in placebo and 13 in 25-mg group. The corresponding unadjusted annualized relapse rates were also lower in 75-mg evobrutinib groups (0.13 in 75 mg once daily; 0.18 in 75 mg twice daily) versus 0.37 relapses in placebo and 0.57 in 25-mg group. (Differences versus placebo was not significant for any evobrutinib group).
  • Safety: The most common adverse events of any grade were nasopharyngitis and increases in levels of alanine aminotransferase (ALT), aspartate aminotransferase (AST), and lipase. The increases in ALT and AST did not reach the Hy’s law DILI criteria.
  • The 75 mg once daily dose significantly reduced the total number of Gd-enhancing lesions on T1-weighted MRI, measured at weeks 12 through 24. This dose was considered safe and efficacious for further study of evobrutinib in larger MS trials.
  • Currently following phase 3 evobrutinib trials are ongoing in relapsing MS: NCT04338022 (evolution RMS 1 trial) and NCT04338061 (evolution RMS trial 2) . Sponsor: Merck Healthcare KGaA, Darmstadt, Germany / EMD Serono Research & Development Institute, Inc.
  • Compared to the tolebrutinib phase 2 trial (here), the participants in the evobrutinib trial were older, with longer disease duration, and fewer relapses, and relatively high baseline EDSS values.
  • Note - Evobrutinib was the first BTKI to show therapeutic potential in a phase 2 study in RMS.
submitted by bbyfog to MultipleSclerosisLit [link] [comments]

2023.05.31 20:13 Suitable_Lie9992 Winlevi success story!

I feel like winlevi doesn’t get a good rep in this sub so i want to share my story with it! I started spiro pill on 100 mg, it did a great job clearing up a majority of my face, however i started getting pretty bad side effects a few months in. I started gaining a lot of weight, shedding, etc. My doctor prescribed me winlevi to try however was hesitant and told me he doesn’t believe it will help. I decreased to 50 mg and started using winlevi. After 2 weeks on 50 mg, i completely stopped and now solely use winlevi. I’ve been like this for a few weeks now, and absolutely no new breakouts (even while on my period) and no side effects! I’d u are having doubts about trying winlevi, i encouraged you atleast try it and discontinue if you don’t like it. I have so pleased with this!
submitted by Suitable_Lie9992 to Spironolactone [link] [comments]

2023.05.31 19:39 Rediscoveringlife Has anyone gone through this in trying HRT?

Ugh. Maybe I just need to vent. I started about 8 weeks ago and we started at .025 mg patch estrogen patch and 100 mg progesterone pill at night. I moved up to .05 mg patch 3 weeks ago.
The hot flashes at night have definitely improved and I don't wake up and tear off the covers and cool off and then put them back on 5-6 times a night. You'd think I'd sleep better. But on and off again, I seem to be WAY more fatigued. I do a good workout with a great Zoom class five days a week for an hour and have horses I ride at a high level, so a lot of work there. But my exercise level has been like this for a long time. Some days I seem OK, and some days like yesterday I just got sleepy at 3 pm and felt tired, went to sleep a little early, slept (mostly) about 10 hours (that's normal for me) and woke up tired.
I will move up to .75 the end of this week and hoping it will help? I will go up to .1 slowly. And my gyn said I could also try DHEA, which I have at 50 mg, but to do one thing at a time which makes sense.
After reading so many great things here I was hoping to get a better life with less hot flashes, less fatigue, and a libido. I do, very slowly, see an increase in libido, but these waves of fatigue are disconcerting.
Thanks for listening. Any feedback welcome.
submitted by Rediscoveringlife to Menopause [link] [comments]

2023.05.31 16:19 SmallHandSipper Literally No Flavor

Literally No Flavor
Day 27/365: Having a different energy drink every day for a year
G Fuel - Sage Mode
Caffeine: 300mg
Grade: D-
Review: I don’t have much to say about this because there was almost no flavor. I could tell they were going for something fruity, and after a little bit of searching I saw it was supposed to “pomelo white peach”. It also had lackluster carbonation which was tragic. Worst G Fuel I’ve ever had, sad.
Price: $2.50
Calories: 0 Sweetener: Sucralose, Acesulfame Potassium Sodium: 65mg (3% Daily Value)
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2023.05.31 12:37 soberto Please help me interpret my blood results

I (40M) recently got my first bloods done. I am trying to interpret these myself and the lab added what they describe as normal levels for each marker. All but one (Globulin) I appear to fall inside of but I am keen to determine which need improvement based on Peter's teachings. I am by no means healthy - having only recently taken up healthy eating and exercise so falling inside any level of normal is confusing me
I think these are the most important?
Marker Result Normal Unit
Lipoprotein (a) 26.5 <50 nmol/L
Apolipoprotein A1 1.012 >1.0 g/L
Apolipoprotein B 0.891
Am I right that my ApoB converts to 89.1 mg/dL which is considerably higher than the <65 Peter advises?
Second test:
Marker Result Normal Unit
Sodium 142 133 - 146 mmol/L
Potassium 4.6 3.5 - 5.3 mmol/L
Urea 5.0 2.5 - 7.8 mmol/L
Creatinine 96 59 - 104 μmol/L
eGFR result/1.73m2 85
Total Bilirubin 15 <21 μmol/L
ALP 72 30 - 130 U/L
ALT 31 1 - 41 U/L
GGT 11 1 - 60 U/L
LDH 200 135 - 225 U/L
Calcium 2.43 2.20 - 2.60 mmol/L
Adjusted Calcium 2.34 2.20 - 2.60 mmol/L
Albumin 49 35 - 50 g/L
Urate 300 200 - 430 μmol/L
Total Protein 72 60 - 80 g/L
Globulin 23 24 - 37 g/L
Cholesterol 3.87 5.0 mmol/L or less
HDL Cholesterol 1.04 1.00 mmol/L or more
Triglyceride 0.79 1.70 mmol/L or less
Cholesterol:HDL Ratio 3.7 4.5 or less
Non HDL Cholesterol 2.83 <3.37 mmol/L
CRP <0.6 <5 mg/L
LDL Cholesterol 2.47 3.0 mmol/L or less
White Blood Cell Count 4.4 4.0 - 10.0 10*9/L
Red Blood Cell Count 4.91 4.50 - 5.50 10*12/L
Haemoglobin (Hb) 151 130 - 170 g/L
Haematocrit (Hct) 0.46 0.40 - 0.50 L/L
Mean Cell Volume 93 83 - 101 fl
Mean Cell Haemoglobin 30.7 27.0 - 32.0 pg
Red Cell Distribution Width 12.8 11.6 - 14.0 %
Platelets (Plt) 182 150 - 410 10*9/L
Neutrophils 2.4 2.0 - 7.0 10*9/L
Lymphocytes 1.7 1.0 - 3.0 10*9/L
Monocytes 0.3 0.2 - 1.0 10*9/L
Eosinophils 0.0 0.0 - 0.5 10*9/L
Basophils 0.0 0.0 - 0.1 10*9/L
Third test:
Marker Result Normal Unit
Serum Folate 15.11 3.89 - 26.80 ng/ml
Vitamin B12 408.0 197 - 771 pg/ml
Total Vitamin D 184 nmol/L
Fourth test:
Marker Result Normal Unit
Glucose (Fasting - Plasma) 5.0 4.1 - 6.0 mmol/L
Fifth test:
Marker Result Normal Unit
TSH 2.060 0.27 - 4.20 mIU/L
Free T4 15.74 12 - 22 pmol/L
Iron 21.5 5.83 - 34.5 μmol/L
UIBC 28.5 22.3 - 61.7 μmol/L
TIBC 50.0 40.8 - 76.6 μmol/L
Transferrin Saturation 43.0 15 - 45 %
Thank you
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