Neurological Effects of ART of HIV Patients

Neurological Effects of ART of HIV Patients NEUROLOGICAL  MANIFESTATIONS IN PATIENTS WITH HUMAN IMMUNODEFICIENCY VIRUS INFECTION IN THE ERA OF COMBINED ANTIRETROVIRAL THERAPY Neurological disorders are the most debilitating of manifestations seen in patients infected with HIV. The clinical profile of neurological manifestations in HIV patients has undergone a shift in recent years with opportunistic infections being controlled with combination anti retroviral therapy and the advent of drugs which have higher central nervous system penetrability. Aims and Objectives To study the clinical, investigation profile and various neurological disorders in HIV patients on anti-retroviral therapy. Materials and Methods Fifty HIV patients with neurological manifestations were studied. A complete neurological examination including neurocognitive functioning using Montreal Cognitive Assessment and HIV Dementia scale were assessed. Apart from relevant investigations, CD4 count, Computed Tomography/Magnetic Resonance Imaging brain, cerebrovascular fluid analysis was done where required. Results Neurocognitive disorders formed the largest group with 42% suffering from HIV associated Neurocognitive Disorders .Among them asymptomatic neurocognitive impairment was seen in 28%; mild neurocognitive disorder in 12%, and 2% had HIVà ¢Ã¢â€š ¬Ã‚ associated dementia. Opportunistic infections of the nervous system accounted for 32%, with meningitis being the most common. Four patients had space occupying lesions of central nervous system; four tuberculomas and one toxoplasmosis. Conclusion With the advent of highly active retroviral therapy HIV patients have longer life spans with suppression of viral load leading to decrease in opportunistic infections of the nervous system. Neurocognitive disorders are now the most common neurological dysfunction seen and thus neurocognitive assessment must be done in all patients with HIV. Keywords : cognitive dysfunction, neurological manifestations in HIV, opportunistic infections ,dementia, anti retroviral therapy INTRODUCTION Human Immunodeficiency Virus is one of the greatest challenges faced by the medical fraternity in the 21st century. The infection has become pandemic in many parts of the world and affected every corner of the globe. According to the data released by NACO Annual Report 2012-2013, the revised estimate of people with HIV as of 2011 is 2.08 million (equivalent to 0.27percent of the adult population)1. Though these figures represent a positive trend of decreased incidence of new cases, the prevalence is not changed as HIV patients are now able to live for longer time because of the advent of Highly active antiretroviral therapy (HAART). The virus has the unique ability to mutate itself constantly and conveniently integrates itself into the genome of the cells of the immune system which ironically are supposed to protect us from infections. Although many drugs are active against the virus it has so far eluded complete cure. HIV is known to affect all organ systems in the body causing a wide variety of clinical manifestations. Neurological disorders among them are considered to be among the most debilitating of manifestations seen in HIV positive patients .Opportunistic infections of the CNS were the main cause of neurological deterioration for a vast majority of these patients in the earlier times when combination anti retroviral treatment for HIV was not yet instituted. The major neurological disorders in HIV patients are opportunistic infections, immune reconstitution, HIV associated neuro-cognitive disorders (HAND), sensory neuropathies among others. As the patients are now able to have longer life spans with good viral control the clinical profile of neurological manifestations and disorders has undergone a paradigmal shift with opportunistic infections being controlled with combination ART and the advent of drugs which have higher CNS penetrability. Neurocognitive and neuropsychiatric manifestations are the new area of focus with emphasis being made on diagnosing and treating their subclinical forms. MATERIALS AND METHODS The study was done on HIV patients getting admitted in a tertiary hospital and research center in Bijapur from April 2014 to June 2014.Fifty HIV positive patients with clinical neurological manifestations during this period have been included in the study. Inclusion criteria HIV patients on combined anti retroviral therapy having signs and symptoms caused by neurological dysfunction. Exclusion criteria Patients with pre-existing neurological conditions like epilepsy, mental retardation, cerebrovascular diseases, parkinsonism, movement disorders not attributable to the HIV. Patients not on any therapy. Patients who have discontinued their treatment for duration of more than a month. An informed consent was obtained from the patients prior to their inclusion in the study. A detailed history, general physical examination with thorough neurological examination was done. The patients were also assessed for their cognitive functions as a part of neurological examination using Montreal Cognitive Assessment (MoCA)2, International HIV Dementia Scale (IHDS)3.If cognition was affected it was quantified based on the effect it had on everyday activities using Lawton scale for Instrumental Activities of Daily Living4. The tests were performed on all patients in study. Patients were classified as HAND based on the scoring and clinical judgment of impaired performance in at least two domains of MoCA and IHDS tests. MoCA was assessed on delayed recall, executive function, visuospatial function, attention, language function, abstract thought and orientation. The maximal score was 30 and patients with IHDS was scored on three variables motor speed, psychomotor speed and memory recall, the patients are scored on each of these. The maximum possible score was 12 points. A patient with a score of The patients with HAND were further subdivided into Asymptomatic Neurocognitive Impairment (ANI), Mild Neurocognitive Disorder (MND) or HIVà ¢Ã¢â€š ¬Ã‚ associated dementia (HAD) using revised research criteria for HIV associated neurocognitive disorders (HAND)5.The patients in study group not diagnosed with HAND were used as reference group for standardized neuropsychological tests and compared. Demographic, relevant clinical data and laboratory data were collected. Data included age, sex, level of education, occupation,current CD4 cell count, and antiretroviral therapy. Laboratory work up include hemogram, CSF analysis and imaging like CT/MRI when needed. Statistical analysis The data was entered in MS Excel Sheet and analysed using SPSS 18 software.Appropriate statistical test like Chi square standard deviation mean and z test were used. RESULTS The mean age of the patients was 32.3 years with all of them being between 20 to 45 years. There were 36 males and 14 females. The mean years of education of the group was 6.41 years with only 30% being employed in professional jobs and the rest either unemployed or intermittently worked as unskilled labor.(Table 1) The most common symptom in these patients was headache seen in 42% of cases followed by fever (30%) and altered sensorium(10%).Seizures were present in three of the five patients with with space occupying lesions. (Table 2) Neurocognitive dysfunction were the most common neurological disorders (42%) followed by opportunistic infections(32%). The MoCA and IHAD test results were used to diagnose the patients with HAND. These patient data were then compared with the other HIV patients who underwent these tests. ANI was present in 28% ,12% had MND and 2% were suffering from HAD. The patients with neurocognitive disorders were included in group A and the rest in group B. (Table 3) Cryptococcal meningitis was the most common infection accounting for 14% followed by tubercular meningitis with 12% of the cases. Co infection was seen in six cases. There was one case each of myelitis and toxoplasma.Space occupying lesions were found in five cases, four of which were tuberculomas and one lymphoma.(Table 4) According to WHO immunological classification for established HIV infection based on CD4 counts6 ;52% had severe disease, 24% had advanced disease , 4% had mild disease and remaining 4% did not have significant disease. Fifty six percent of patients in group A had CD4 count less than 200cells/mm3 [severe disease] and of the 21 patients in group B, 71.5% had severe disease.(Table 4) Nineteen patients underwent CT scan and/or MRI of which 13 had normal scan results ,five patients were diagnosed to be having intracranial masses,four tuberculomas and one lymphoma .Toxoplasma was suspected in one patient which was later confirmed with finding Toxoplasma- IgM antibodies in blood. One patient had features on CT suggestive of encephalomyelitis. CSF analysis was done in 17 patients of whom seven were diagnosed with cryptococcal meningitis by India ink preparations. Six patients had findings suggestive of tubercular meningitis. DISCUSSION Neurologic abnormalities are common in late stages of HIV infection and are an AIDS defining condition. Central nervous system disease occurs in 40-90% of HIV positive patients. The predominant cell types that are infected are monocytes and macrophages. Virus may enter the brain through infected monocytes and release cytokines that are toxic to neurons as well as chemotactic factors that lead to infiltration of the brain with inflammatory cells.7 Our study showed a male preponderance towards neurological manifestations in HIV with 72% of the patients being male similar results were seen in other studies. Deshpande et al reported 87.5% male patients8 and Chan LG et al had 93.3% male subjects9.This could be attributed to higher incidence of multiple sexual partners in males compared to females, except for high risk groups like commercial sex workers. In our study the most common manifestation of HIV patients with neurological disorder was headache, seen in 42% patients which corroborated with other studies. Sharma SK et al. also reported headache as the commonest neurological manifestation seen in 62.5% cases10. The neurological symptoms associated with HAND like forgetfulness, mental slowness, poor concentration, clumsiness, tremors, apathy were seen in less than six percent of people although HAND accounted for 42% cases. This data suggests the huge propensity to miss the diagnosis of cognitive dysfunction as the disease usually exists in its subclinical form with little or no symptoms. The few patients who did have these symptoms did not associate them to their disease. The approach towards neurological diseases in HIV has always been directed towards opportunistic infections. Most studies on neurological complications did not assess for neurocognitive disorders although some studies have reported on dementia. In our study the prevalence of neuro-cognitive disorders surpassed opportunistic infections of CNS in HIV patients. HAND was seen in 42% of the cases similar to study done by Chan LG et al. in Singapore where the prevalence was 22.7% .They also used the revised 2007 updated research nosology for HAND. Singh R et al. reported a 33.65% incidence of HIV associated Dementia.This study showed similar result to our study but the assessment was done using MMSE11. Deshpande AK et al reported only 6% patients with dementia.Satishchandra et al. reported dementia in only four patients out of 100 patients12. Sharma et al. did not report on neurocognitive disorders.All these studies did not employ an objective methodology for assessing the cognitive function and based their results on clinical and neurological examination findings. It is very common to assess cognitive impairment based on clinical judgement and brief bedside neurological examination, this methodology though novel severely limits the providers ability to diagnose subclinical forms of cognitive dysfunction and being subjective their results cannot be used to compare with studies were standardised tests were employed. The CD4 counts in patients with HAND are below 200 cells/mm3 in 71.4% of cases.Thus we concluded that HAND is usually seen with lower CD4 counts associated with severe form of disease. Chan LG et al. reported similar findings were HAND was seen in patients with CD4 counts less than 200cells/mm3 in 63.3% , Singh R et al. reported similar findings in 83.52% patients. Our study did have its shortcomings, our sample size was smaller and strict compartmentalization of neurological disorders into opportunistic infections and neurocognitive dysfunction may have given a lower incidence of opportunistic infections .Thus further studies need to be taken up with larger sample sizes using standardized cognitive assessment tests . With the widespread use of HAART the incidence and mortality associated with HIV is decreasing throughout the world.By keeping the of viral loads suppressed and prolonging the lifespan of HIV individuals a new profile of neurological disorders is emerging which warrants a change in approach to the management.Along with opportunistic infections emphasis must be made towards diseases caused by direct effect of the virus on the nervous system.Neurocognitive and neuropsychiatric illnesses should be thoroughly investigated using standardised mental status examination (those acceptable in updated research nosology for HAND considering resource limited contexts) 5; as they can be subclinically present severely affecting the patient’s daily activities and add to the overall burden of the disease.

The Story of the Pineapple Essay -- Botany

The Story of the Pineapple After the discovery of America, new food plants became known to European people. The pineapple symbolizes balmy tropical lands and leisurely life on tropical islands. The pineapple, as well as other agricultural crops such as maize, potatoes, beans, peanuts, and tobacco, originated in America and were unknown to people of the old World. The story of the pineapple falls into three distinct periods. The first period precedes the discovery of America and goes back into the antiquity of South America where the pineapple is believed to have developed. There is very little information about it during this period but it is known that the pineapple was already being cultivated and widely distributed through inhabited areas of the American tropics. The second period, covering about 400 years, extends from 1493 to 1900 when Columbus first saw pineapples on the Island of Guadeloupe in the West Indies. The third period, beginning in 1900, is characterized by the industrial development of pineapple production and canning around the world, making the canned fruit available to people living in nontropical countries. Wild pineapples are still to be found in parts of tropical America in which they are small fruited, inferior in eating qualities, and extremely seedy. To eat a pineapple full of these seeds is like trying to eat one of our present day seedless fruits containing one thousand small bits of gravel. It was believed that long periods of propagation of a domesticated species would result in the plant losing its ability to produce seeds. Actually there is no scientific evidence to this belief. Seedlessness usually appears in normal seed-bearing plants as a result of a mutation in the chromosomes... ...alting ocean water for domestic and agricultural use. Future changes and techniques will help utilization of additional land areas and supply more pineapples to people. Bibliography 1. Collins, J.L., The Pineapple, Leonard Hill Books Limited, New York, 1960. 2. Cook, A. A. 1975. Diseases of Tropical and Subtropical Fruits and Nuts, Hafner Press, New York, 3. Fisher, D.V. 1976.History of Fruit Growing and Handling in United States of America and Canada, Regatta City Press LTD., Canada. 4. Fraser, S.M.S. 1931. American Fruits, orange Judd Publishing Company, Inc. New York.. 5. Hartman, H. T. 1981. Plant Science, Prentice-Hall, Inc, New Jersey. 6. Simmons, A. E. 1972. Growing Unusual Fruit, Walker and Company, New York. 7. Williams, C.N. 1979. Tree and Field Crops of the Wetter Regions of the Tropics, Longman Group Ltd.

You Suck: A Love Story Chapter 25~26

Chapter Twenty-five They Know Not What They Do When Rivera and Cavuto arrived at the Safeway, they found that the remaining Animals had crucified Clint on a stainless-steel chip rack and were shooting him with paint-ball guns. Lash unlocked the door to let them in. The Emperor and his men followed. Clint's screaming sent Bummer into a barking fit and the Emperor snatched him up and stuffed him headfirst into the pocket of his overcoat. â€Å"That really necessary?† Rivera asked, pointing to the paint-splattered martyr. â€Å"We think so,† Lash said. â€Å"He ratted us out.† Lash turned, sighted down the pass-through of register three, and fired a quick volley of electric-blue paintballs into the center of Clint's chest. â€Å"Did he call you again?† Rivera threw a thumb over his shoulder at the Emperor. The Emperor bowed. â€Å"You needed help, my son.† Lash nodded, considering that the Emperor might be right, then reeled and fired three quick shots into Clint's groin. â€Å"Just the same, motherfucker!† â€Å"Stop that!† Rivera said. He snatched the paintball gun out of Lash's hand. â€Å"It's cool. He's wearing a cup.† â€Å"And he's saved,† said Barry, who had been firing from register four. â€Å"Well, he is now,† Cavuto said. As he approached the paint-sodden Evangelical, he pulled a serrated-edge pocket knife from his back pocket and flicked it open. â€Å"And just so you know,† Cavuto added when his back was to them, â€Å"if I turn and there's a single paintball gun pointed in this direction, I will be forced to mistake it for a real weapon and unleash lead Disneyland on your pathetic asses.† Barry and Troy Lee immediately dropped their weapons onto the counter. â€Å"So, the Emperor tells us that you guys have been up to some shit. I thought we all agreed that we were going to keep it on the down-low until things calmed down.† Lash looked at his shoes. â€Å"We just had a little party in Vegas.† Rivera nodded. â€Å"And you kidnapped Tommy Flood?† Lash glared over Rivera's shoulder at the Emperor. â€Å"That was a secret. Really we were saving him from the daylight.† â€Å"So the redhead did turn him?† â€Å"Looked like it. He was unconscious at dawn. Just a little sunlight hit his leg when we were moving him and it started to smoke.† â€Å"So you geniuses did what?† â€Å"Well, we tied him to a bed at my apartment and left.† â€Å"You left?† â€Å"We had to work.† Cavuto had cut the zip ties that held Clint to the chip rack and helped him to the register, where he sat him down, careful not to get any paint on his sport coat. â€Å"Forgive them, they know not what they do,† Clint said, wincing as he touched his paint-spattered shoulder. â€Å"Because they're fucking idiots,† Cavuto said, handing him a roll of paper towels. Rivera ignored the scene at the register. â€Å"So you just left him there. So I'll find him there now, right?† â€Å"That was a couple of nights ago,† Lash said. â€Å"Go on.† Rivera looked at his watch. â€Å"Well, in the morning he was gone.† â€Å"And?† â€Å"It's awkward.† For variety, Lash looked at Barry's shoes. â€Å"Yeah, tying up your friends and torturing them can be that way,† Rivera said. â€Å"We didn't torture him. That was her.† â€Å"Her?† Rivera raised an eyebrow. â€Å"Blue. A hooker we rented in Vegas.† â€Å"Now we're talkin',† Cavuto said. â€Å"She came back with us. She wanted us to kidnap Tommy or his girlfriend.† â€Å"Why did she want that? To get their share of the art money?† â€Å"No, she had plenty of money. I think she wanted to be a vampire.† Rivera tried to hide his surprise. â€Å"And?† â€Å"When we went back to the apartment in the morning, Tommy was gone and Blue was dead.† â€Å"We had nothing to do with it,† Barry added. â€Å"But we didn't think you'd believe it,† Troy Lee said. Rivera felt a tension headache starting to throb in his temples. He closed his eyes and rubbed his forehead. â€Å"So you found a dead woman in your apartment. And you didn't think that then might be a good time to call the police?† â€Å"Well, you know, dead hooker in your house – embarrassing,† Troy Lee said. â€Å"I think we've all been there. Can I get a high five – † Apparently, he couldn't, and was thus left hanging. â€Å"That's the weird thing,† Barry said. â€Å"When we went to move her body, it was gone. But the rug we wrapped her in was still there.† â€Å"Yeah, that's the weird thing,† Cavuto said, nudging his partner in the arm. â€Å"Heinous fuckery most foul,† said the Emperor. â€Å"Ya think?† said Cavuto. Bummer growled from his pocket sanctuary. â€Å"You guys are not helping,† Rivera said. Then to Lash again: â€Å"You have a description of this hooker?† Lash described Blue, glossing quickly over the fact that she was blue, and spending entirely too much time describing her breasts. â€Å"They were outstanding,† Barry said. â€Å"I kept them.† Rivera turned to Troy Lee, who seemed the most rational of these insane bastards. â€Å"Explain, please.† â€Å"We found silicone implants wrapped up in the rug where we had left Blue.† â€Å"Uh-huh,† Rivera said. â€Å"Intact?† â€Å"Huh?† Troy inquired. â€Å"Were they all cut up?† â€Å"You think someone cut them out of her and took the body?† Troy asked. â€Å"No,† Rivera said. â€Å"So now you've lost three of your buddies?† â€Å"Yeah. Drew, Jeff, and Gustavo didn't show up tonight.† Rivera had Lash get the addresses of the missing Animals from the office and wrote them down in his notebook. â€Å"And you don't think that they might just be out partying?† â€Å"We called all the phones, checked their houses,† Lash said. â€Å"The door was hanging open at Drew's, and Jeff had left half a beer in the driveway, which he would never do. Besides, Jeff and Drew might flake, but Gustavo wouldn't. We even went to his cousin's house in Oakland looking for him.† â€Å"And he did not est en la biblioteca either,† said Barry, who, for some reason, believed that all Spanish-speaking people spent a lot of time in the library and had therefore checked there for the intrepid night porter. â€Å"No more bodies that you might have forgotten to mention?† â€Å"Nuh-uh,† Lash said. â€Å"Our money was gone, though. But we'd given it all to Blue anyway.† â€Å"I didn't,† Clint said. â€Å"Mutual funds, less ten percent for the church.† â€Å"You gave six hundred thousand dollars to a hooker?† Rivera almost slapped the kid. Almost. â€Å"Well† – Lash looked at Barry and Troy Lee, then, trying to suppress a grin – â€Å"yeah.† Rivera shook his head. â€Å"Keep the door locked and don't report this to anyone else.† â€Å"That's it?† Lash said. â€Å"You aren't going to arrest us or anything?† â€Å"For what?† Rivera flipped his notebook closed and tucked it into the inside pocket of his suit coat. â€Å"Uh, I don't know.† â€Å"Me either,† said Rivera. â€Å"Emperor, you stay inside tonight with these guys. Okay?† â€Å"As you wish, Inspector.† The Emperor scratched behind Lazarus's ears. â€Å"That okay?† Rivera said to Lash. Lash nodded. â€Å"Are we going to be safe?† he asked. Rivera stopped, looked around at the Animals and the Emperor and his dogs. â€Å"Nope,† he said. â€Å"Let's go, Nick.† He turned and walked out the door. The foghorn was lowing across the Bay as the detectives walked back to their car. Fort Mason, just across the street, was barely visible in the rolling cloud of gray mist. â€Å"You think the old vampire is hunting the Animals?† Cavuto asked. â€Å"Someone is,† Rivera said. â€Å"But I'm not sure it's him.† â€Å"You think it might be the redhead and the kid?† â€Å"Could be, but I don't think so. You know, even with the vampire, we always had an identifiable MO – broken neck and massive blood loss, on a victim who turned out to be terminally ill, right?† â€Å"Yeah.† â€Å"So if he went after these kids, why no bodies?† â€Å"So it's Flood and the redhead. And they hide their bodies.† â€Å"I think it could be worse than that.† â€Å"Like worse in a way that we'll never be able to open the bookstore and may in fact end up doing time for taking the vampire's art collection?† â€Å"Like worse in that the hooker and the missing Animals aren't dead at all.† â€Å"How is that worse?† Then Cavuto realized how that was worse. They climbed into the car and stared at the windshield for a while without saying anything. Finally, after a full minute, Cavuto said, â€Å"We're fucked.† â€Å"Yep,† Rivera said. â€Å"The whole city is fucked.† â€Å"Yep.† Chapter Twenty-six Being the Chronicles of Abby Normal: Star-Crossed Lover and Tragic Fatale OMG! We are doomed by our forbidden love! We are like from different feuding families, from the wrong side of the tracks, he is like year of the Rabbit and I am a Leo, so we are even star-crossed, and it's a well-known fact that rabbits and lions have a strained relationship. OMFG! He's so hot! He rocks my stripy socks. If we had moors, I would so be off brooding upon one, my delicate jaw muscles clenched as I stared off into the mist, feeling my profound missing-ness for him. (I can't believe that San Francisco doesn't have a moor. Everywhere you go we have automated, coin-operated robotic bathrooms, or Frisbee golf courses, or some new stainless-steel epileptic razor-blade public-art thingy, you'd think the least they could do would be to install a decent moor – because there are a lot more people who like brooding than like Frisbee golf. I'm pretty sure moors can be used for other purposes, too, like hauntings and hiding bodies and family picnics and whatnot.) Thus I am for ced to do my brooding at Tulley's Coffee on Market Street. It took most of the day for us to move the Countess and the vampyre Flood to Jared's room. First we had to wrap them up in duct tape and garbage bags to protect them from the sun, then get them down the hill from the Bay Bridge in the garden cart, which was totally physically hard, and not like taking X and dancing or playing DDR all night, more like work. Then, when we were loading them into the minivan, these two cops come by. And they're all, â€Å"So, what are you doing with your piercings and your magenta-on-black hair, and what can we do to further repress your creativity? Bluster-blah-blah.† And Jared was all, â€Å"Nothing.† All wussy and guilty-sounding. He had the front end of the Countess at the time and he totally just dropped her headfirst on the floorboard of the van. So I was like, â€Å"Fucktard! The Countess is going to rip your nads off when she awakens!† (And she might, too, although when we unwrapped her she seemed unbruised.) And the cop was all, â€Å"Hold it right there, kid.† With his hand on his gun like I was going to go all Columbine on his ass or something. So I knew it was time for some strategy. So I stepped over to the cop, and I started whispering like I didn't want Jared to hear. And I'm all, â€Å"Officer, I'm really embarrassed to even be seen like this. I'm a Kappa Kappa Delta pledge and we're doing this hazing thing. I wouldn't be caught dead dressed like this, but it's like the most popular and powerful sorority on campus.† And the cop is all, â€Å"What about the guy? He's not in your sorority.† And I was all, â€Å"Shhhhhhh. God, you want to hurt her feelings? They made her shave her head like that and she's having a hard enough time with that and being totally flat-chested. Frankly, I don't think she's going to make it. Everyone knows that KKDs are pretty. Hello.† I batted my eyelashes and sort of pushed my basically invisible boobs together with my arms, as I have often seen done in music videos. And the cop was all, â€Å"Can I see your student ID?† And I was like, FUCK, because I didn't know which college would be most likely to have a sorority, so I went with my Berkeley student ID, because Berkeley is a well-known bastion of hippie behavior and higher learning in which a sorority girl would probably have to blow like a hundred football players just to keep her GPA up. And cops like football. So he was all, â€Å"Okay, but make sure there's plenty of airholes so your friends can breathe.† And I was all, â€Å"Sure thing. See ya later, cop.† So when we got the masters to Jared's house, his step-mom was all, â€Å"So, I see you have your little friend with you.† And Jared had to play chilly, so he was like, yeah, we have a school project. And stepmonster was so proto-orgasmic that Jared was with a girl that she didn't even say much when we dragged the bodies through the den. Jared was all, â€Å"They're for social studies. We're doing replicas of Egyptian mummies.† Despite the complete embarrassment for me as a fellow woman, I'm grateful that when fathers pick their trophy wives, they don't check resumes or SAT scores, because you couldn't get away with that shit with a woman of normal intelligence. But Jared's stepmonster was all, â€Å"Oh, how nice for you. Would you like some juice?† Fortunately she wasn't around in sixth grade when Jared and I actually did our mummy project. We got in trouble for charging three hundred dollars' worth of Ace bandages on my mom's Visa, and my sister Ronnie has never fully recovered the feeling in her feet (and has an anxiety attack whenever she's in an enclosed space). But there was no gangrene or amputations like the doctors threatened, and we got a B, so I don't see what all the noise and counseling was about. Anyway, after we unwrapped the Countess, I knew I had to go back and feed Chet, like I promised the disgusting huge cat guy, and since we had now shared a moment of intimacy, I felt obligated. So we shoved the vampyre Flood under Jared's bed, because Jared wanted to sit on the bed and play Xbox and it's a single bed. So, anyway, I caught the bus on Twenty-fourth Street, and got back to the SOMA with just enough time to feed Chet before the old naked vampyre awakened from his undead slumber. And I took Jared's dagger with me in my biohazard messenger bag, because I thought I would dispatch Elijah by decapitation as, like, an extra-credit thing for the Countess. Shut up. It wasn't like I went down in the basement in my nightgown to check on a blown fuse when the radio clearly had stated that there was a psycho killer on the loose and he was probably in the basement. I'm not stupid. I put on Jared's motocross boots and his leather jacket and spiked dog collar, and tied my hair back, so I was totally Thunderdome-ready. How hard could it be to feed the cat and cut the head off a sleeping old guy, anyway? It's not like they wake up. I mean, we bonked Flood's head on the steps going to Jared's room like eight times and he didn't even groan. So I would have been all good and totally in line to be Princess of Darkness or at least Assistant Manager of Darkness, except when I was going up the steps I heard the dryer open. And I was all, Uh-oh. Since when is sundown like at five-o'clock? What am I, nine years old that I should have sunset at five o'clock? Sunset shouldn't be until like eight or nine o'clock, right? Right? So, I'm like, WHOA. And I froze. And I stood there for like a half an hour, not moving at all, because I didn't buckle like the top buckles of Jared's motocross boots, to show my casual badassness, so it was like I was wearing fucking sleigh bells. (I know, I'm a tard.) So I couldn't move. Then, after about a year, I hear this car pull up outside and the doors open, and I'm thinking – Hello, Diversion, my old friend. And I ran out the security door and right into this tall blond ho. And she's dressed all couture and shit, like it's fashion week at church or something, except she's with three of the guys from the Hummer limo, and she's pale as albino monkey cum. And I don't mean in a good way either. I mean in a sort of â€Å"Hey, Myrtle Joe Cornfed, y'all let go your stepdaddy's penis and get over here and turn the channel to NASCAR† kind of way. I mean, she had no mascara on at all! Then she just picks me up by the arms and it hurt a lot, and I'm like kicking and thrashing and all, and she throws back her head and here come the fangs. And I'm all, â€Å"No way. They'll just let any-fucking-body into the coven.† And she's all, â€Å"Not you. Unless you know where my money is.† And I'm all, â€Å"Step off, skank.† And she goes to bite me, and something yanks her back off her feet and I go flying. Next thing, I'm looking up at the old vampyre in his yellow tracksuit, who is holding the blond ho by the hair, and the pale limo guys are like coming in on him. And Track-suit is all, â€Å"Against the rules, pet. You can't go willy-nilly turning everyone you meet. It attracts the wrong kind of attention.† And wham, he smacks her face on the hood of her Mercedes, leaving a face print on the paint, I swear on the crusty hippie grave of my mother. So I'm all, â€Å"Owned! Bee-yatch! Dog fucking owned you!† Doing a minor booty dance of ownage, perhaps, in retrospect, a bit prematurely. (I believe hip-hop to be the appropriate language for taunting, at least until I learn French.) So they all turn on me. And I'm all, â€Å"awkward.† So I started backing across the street. And crusty old vampyre bounces monkey cum's face off the hood of the Mercedes a couple of more times, then drops her and comes for me. The limo guys are all sort of standing by the car like they are waiting for instructions or something. Then one of them says, â€Å"Hey,† and starts coming my way, too. So I'm at the wall across the street, and I know I can't run, so I reach into my bag and pull Jared's dagger. And Tracksuit starts laughing – like really stoner laughing, pointing at my ensemble. And I was all, â€Å"Shut up, fuckface, this knife and boots totally go with fishnets.† Except for the Countess, I realize now that vampyres lose all fashion sense at death. But then I hear this really loud thumper coming from down the alley, like club music you can feel in your breastbone, and this totally race-pimped yellow Honda comes screaming out of the alley. Who knew you could even get a car down that alley. So the old vampyre has to jump back to avoid being run over and the limo guys jump back, and I was kind of hiding my head in my arms, but I hear, â€Å"Get in,† and it's the cool Manga-haired Asian guy who I'd seen outside the loft before. And I'm all, â€Å"What?† Because the music is really loud. And he's all, â€Å"Get in.† And I'm all, â€Å"What?† And by this time the old vampyre has jumped over the hood of the Honda and is about to grab me when there's this flash. Really more than a flash, because it stayed on. But there was this blinding light. And the music goes down and I hear, â€Å"Get in.† So I look into the light, and I'm like, â€Å"Grandma, is that you?† Okay, I didn't say that. I'm totally fucking with you. I looked into the light and saw the Manga-haired guy, wearing sunglasses, and he's waving for me to get in his car. And then I see that the old vampyre is charred like Wile E. Coyote after a bad rocket shoes test. And so are the limo guys, and they're smoking and limping away from the Honda, which is shining like a star or something. And Manga is all, â€Å"Now!† And I'm all, â€Å"Shut up, you're not the boss of me.† But I got in the Honda and we totally drifted around the corner, and when we're a block or two away Steve (that's his name, Steve) kills the ginormous floodlights in the backseat and I can sort of see again. And he's all, â€Å"High-intensity ultraviolet.† And I'm, â€Å"You, too.† And he's like, â€Å"What are you talking about?† I'm like, â€Å"I thought it was a compliment.† Then he smiled, like the cutest smile, although he was still driving muy intense and totally badass, and he goes, â€Å"No, that light back there was high-intensity ultraviolet. It burns them.† And I was all, â€Å"I knew that.† And he was like, â€Å"You know that those three guys were vampyres, too, right?† And I'm all, â€Å"Duh.† But I didn't know. So I'm like, â€Å"How did you know?† Then he takes off his shades and puts on these binocular robot-glasses things, like they wear in Siphon Assassin Six for Xbox, which I am against because it glorifies violence in the minds of adolescent boys and because it's totally impossible to get a decent head shot when your squad mates are bumping into you, which needs to be fixed in the next version if I'm going to be able to do the â€Å"gray spray† on the sentry tower glass. So Steve is all, â€Å"Yeah, they're infrared. You can see heat with them, and there was no heat coming off anyone back there but you.† And I'm like, â€Å"Who the fuck are you?† And he's like, â€Å"My name's Steve. I'm working on my biochem masters at S.F. State.† â€Å"Stop,† I said. â€Å"Please do not further endorken youself to me. You have great hair and a car that is most fly, and you have just saved me with your mad ninja driving skills, so do not sully your heroic hottie image in my mind by further reciting your nerdy scholastic agenda. Don't tell me what you're studying, Steve, tell me what's in your soul. What haunts you?† And he was like, â€Å"Dude, you need to cut back on the caffeine.† Which was fair, and I know that he was only saying it out of concern for my welfare and whatnot, because I think he knew even then that we were destined to be together, soul mates. So while he drives, Steve tells me that he was doing some experiments on some bodies for his master's thingy, and he found that the cells of the victims were regenerating when you added blood to them, and he thinks he can turn them back to normal human cells by using some gene therapy or something. And he's been talking to the Countess and Lord Flood about turning them back, but the Countess is all, â€Å"No way, hot Manga-haired science guy.† So I was all, â€Å"Why would she want to give up immortality and superpowers and whatnot?† And he was all, â€Å"I don't know.† And I was all, â€Å"We should discuss it over coffee.† And he was like, â€Å"I would love to do that, but I'm already late for work.† And I was like, â€Å"I thought you were a mad scientist.† And he was all, â€Å"I work at Stereo City.† And I was like, â€Å"Dude, you should get a job at Metreon selling the big-screens, because they have like the best test couches.† And he was like, â€Å"Okay.† Just like that, â€Å"Okay.† So he wanted to give me a ride home, so I would be safe, which is so sweet, but I needed double-soy Mochaccino to calm my nerves, so here I am at Tulley's, totally brooding. But before I got out of the car, I was like, â€Å"Steve, do you have a girlfriend?† And he was like, â€Å"No, I put a lot of time into my studies, and I sort of always have.† And I was like, â€Å"So would you be in the market for a Gaijin princess?† And he was like, â€Å"That's Japanese. I'm Chinese.† And I'm like, â€Å"Don't change the subject, Kung Pao, what I want to know is if you're ready to spend some up-close and personal time with ninety pounds of barbarian woman-flesh! Sorry, I don't know how much that is in kilos.† I don't know what came over me. I was just fizzing over with adrenaline and passion and whatnot, I guess. I usually don't throw myself at guys, but he was so mysterious and smart and hot. So he got this big grin and he was like, â€Å"My parents would freak out if they saw you.† And I was like, â€Å"You live at home?† And he was all, â€Å"Well, uh, yeah, uh, kinda, uh – â€Å" So I grabbed the pen out of his pocket and wrote my cell number on his arm while he stuttered, then when I put the pen back I kissed him sort of hard and totally passionately, which I could tell he liked a lot, so I pushed him away and slapped him so he wouldn't think I was a slut. But not very hard, so he wouldn't think I wasn't interested. And I was all, â€Å"Call me.† And he was all, â€Å"I will.† So I was like, â€Å"Do not fuck with your hair.† And he was all, â€Å"Okay.† And I was all, â€Å"Be careful.† And he was all, â€Å"I will. You, too.† And I was all, â€Å"Oh, yeah, thanks for the rescue and whatnot.† And he was all, â€Å"Sure. Thanks for the kiss.† And so I am his shameless White Devil Juliet and he is my sweet Ninja Romeo (unless Ninjas are also Japanese, in which case I will have to look some shit up for metaphors because the only thing Chinese I can think of right now is Dim Sum, and I believe it's disrespectful to refer to your soul mate in terms of finger food). Fucksocks! My cell. Jared. L8rz.

A Brief Note On The Human Service Profession - 1234 Words

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