CASPIAN The Caspirin Stone

Perioperative complications of surgery in SCD patients include hypoxia, dehydration, bone pain crisis, significant anaemia, and acute chest syndrome [ ]. Anaesthesia may be associated with hypoxia and dehydration [ ]. Good anaesthetic expertise and experience is indicated when undertaking surgical procedure in SCD patients [ ]. Early surgical complications such as pain and haemorrhage should be well controlled.

Optimal analgesia and tact surgical skills are indicated. Other strategies to improve perioperative outcomes in SCD include conservative preoperative blood transfusion therapy, epidural analgesia, and adequate postoperative pain control with opiate and nonopiate analgesia [ , ]. Aggressive or exchange transfusion therapy has not been associated with better surgical outcomes [ , ]. Infusion of radiologic contrast media may precipitate VOC.

Hypertonic nature of contrast media triggers marked intracellular dehydration and marked increment in red cell MCHC, thus precipitating sickling. Traditional iodinated contrast media due to its high osmolality are relatively contraindicated in SCD. Isotonic contrasts are safer to use in SCD [ ]. The science behind laboratory diagnosis of sickle cell disorder entails phenotypic testing for the presence the sickle haemoglobin and genetic analysis.

Physicochemical properties of the sickle haemoglobin such as decreased solubility and sickling under deoxy conditions, its pattern of mobility in an electric field, and rate of elution from solution unto adsorbents are applied in its laboratory detection. Phenotypic tests may be used as screening tests or diagnostic tests. Screening tests chosen for the purpose of mass screening should be highly sensitive and cheap to run. Examples of screening tests include sickling test, solubility test, and alkaline haemoglobin electrophoresis.

On the other hand, high specific, diagnostic tests include isoelectric focusing, citrate agar electrophoresis, and high performance liquid chromatography [ , ]. Quantification of haemoglobin variants and globin chain studies are used in evaluation of compound heterozygous disease states such as sickle thalassemia syndrome [ , ]. Hb A2 levels in excess of 3.

Other ancillary laboratory investigations useful in detection and monitoring of the disease include FBC, reticulocyte count, and peripheral blood film. On peripheral blood film examination, findings may include irreversible sickled red cells, polychromasia, occasional nucleated red cells, and schistocytes, as well as Howell-Jolly bodies [ 24 , ].

Target cells are seen in sickle haemoglobinopathies. In sickle cell thalassemia syndromes, target cells are seen alongside microcytes and moderate-severe hypochromia. Red cell indices may suggest macrocytosis due to increased reticulocytosis or compliance with hydroxyurea therapy. However, oval macrocytosis with hypersegmented neutrophils may suggest folic acid deficiency.

Genetic studies such as PCR are used for prenatal and preimplantation diagnosis [ ]. Severe SCD is associated with poor outcomes, if no intervention is rendered. Known modulators of clinical severity include fetal haemoglobin levels, beta globin haplotype, amd coinheritance of alpha-thalassemia, as well as geographical and other unknown genetic factors [ 15 , 16 ]. In a study by Emmanuelchide et al.

Another recent Nigerian study in a cohort of children with SCD showed the presence of dactylitis at first presentation and higher total WBC, neutrophil count, platelet count, and serum bilirubin levels to be significantly higher among those with severe disease, while a higher fetal haemoglobin level was associated with a milder disease [ ]. From a large cooperative study in USA in , the median survival for SCA was reported as 42 and 48 years in men and women, respectively.

For haemoglobin SC disease, it was reported as 60 years and 68 years for men and women, respectively [ 84 ]. In Jamaica, survival estimates for persons with SCA were reported as 53 years and Life expectancy in SCD is substantially reduced especially in those with severe disease. In a year retrospective study reported in from Ilorin, Nigeria, by Chijioke and Kolo, the mean age of sickle cell anaemia patients was found to be 23 years compared to 40 years in the control population, suggesting reduced life expectancy [ ].

Findings from that study also revealed that age correlated negatively with survival [ ]. As recently reported by Ogun et al. According to the study, the mean age at death was Though some patients now attain fifth decade, most mortality occurs in their second and third decades of life [ 83 ]. Control of SCD begins with public education and definite strategies to prevent further transmission of the trait.

Carrier detection and genetic counseling have been proven to be successful in curbing the spread of other haemoglobinopathies like thalassaemia [ ]. Genetic counselling by trained personnel helps individuals at risk to take informed decisions about their reproductive life choices. The option of prenatal diagnosis and selective abortion in Nigeria is controversial and relatively unavailable. Local studies show that a significant proportion of Nigerians are averse to selective abortion, even if legally permitted [ — ].

Early detection and diagnosis of sickle cell disease is crucial to reducing mortality and mortality associated with sickle cell disease, as affected persons are offered early supportive and preventive treatments. Despite the huge burden of SCD, currently, there is lack of national or regional SCD newborn screening programme in Nigeria, as at the time of this publication. Specialized centers dedicated to care of SCD patients with requisite multidisciplinary teams and other facilities are grossly absent.

Ideally, SCD infants diagnosed prenatally or through newborn screening should be routed to comprehensive SCD centers for optimal treatment [ ]. Conversely, Nigerian SCD is still associated with delayed diagnosis [ ]. Continuous training of healthcare professionals involved in care of SCD patients is also desirable. Further efforts should be directed at education of the patients and their parents or caregivers.

The health caregivers should also constantly undergo professional refresher and update courses in order to optimize their knowledge and skills in care of SCD. Recent surveys still suggest a dearth of public health knowledge on sickle cell disease in Nigeria [ ]. Despite Nigeria being the most populous black nation on earth with the highest burden of sickle cell disease, till now, there are no coordinated nationwide efforts aimed at controlling the disease.

Current evidence suggests that the care available for patients with SCD in Nigeria is still suboptimal [ ]. Secondary control measures such as chronic transfusion therapy and use of hydroxyurea are faced with peculiar challenges in developing nations such as Nigeria [ 89 ].

Such challenges include unavailability of blood and blood components, the need for patients and relatives to regularly source for blood and blood donors, cost of iron chelation, risk of transfusion transmissible infections, and overall cost of chronic blood transfusion [ 73 , 89 ].

1. Nejlepší světoví zpěváci a zpěvačky: Axl sesazen z trůnu | Page | www.newyorkethnicfood.com!
2. Trafficking in Persons Report 2012 Colombia.
3. Caspian Stone Work;
4. I Believe: The Fate of the World.
5. Toronto Slavic Quarterly: Walpurgis Night, or "The Steps of the Commander"?
6. Nejčtenější novinky?
7. .

Also, treatment of iron overload with metal chelators, which is a potentially inevitable complication of chronic transfusion, increases cost. Furthermore, HSCT, which is the only potentially curative disease modifying intervention in sickle cell disease, is currently available in Nigeria and has been reported [ ]. However, its practice is bewildered by ample challenges including poor government commitment, weak political will, poor infrastructure, unaffordability by the average eligible Nigerian SCD patient, lack of local bone marrow registries, absence of specialized molecular diagnostic laboratories, and epileptic electric power supply [ , ].

Comprehensive care incorporates provision of holistic healthcare services including state-of-the-art diagnosis, standard therapies, preventive care, rehabilitative therapy, and other ancillary services, by a team of specialists in a given location, with maximum accessibility for all patients. Comprehensive sickle cell centers are grossly lacking in Nigeria. Holistic care has been shown to provide better outcomes in sickle cell disease evidenced by significant reduction in mortality, hospitalizations, and blood transfusion rates among Nigerian patients [ ]. As well, WHO recommends that in areas where hemoglobin disorders are common, special dedicated centers with a high degree of autonomy are required in appropriate numbers and locations, with a high degree of autonomy [ ].

Treatment of SCD requires a multispecialist team including professionals such as hematologist, pediatrician, orthopedic surgeons, plastic surgeons, ophthalmologists, nephrologist, specialist nurses, clinical psychologists, and social workers. Provision of comprehensive health centers is crucial to improving SCD disease outcomes in Nigeria. At such facilities, treatment should be tailored to individual patient's needs. At diagnosis, proper education regarding the nature of the disease, possible complications, and its prevention and treatment should be offered to the patient and parents.

Regular health maintenance visits should be scheduled and patients should be counseled on the need for adherence [ ]. Compliance on the part of the patient depends on having adequate information on the disease and confidence in the health professionals.

Similarly, timely and regular medical education should be provided to health care professionals involved in management of SCD in order to improve their expertise and skills. Also, establishment of support groups among patients is encouraged. Comprehensive care centers must possess facilities for outpatient care, day-case admissions day hospital services , and hospitalizations on a hour basis [ 52 ]. Patients should have direct access including phone contact to such centers and their physicians.

For acute complications and emergencies, a quick triage is carried out and prompt therapy is instituted. Standard protocols should be provided for management of specific complications, as well as general health maintenance. Scheduled review and strict adherence to protocols are advised. Patients and parents should be counseled on avoidance of known precipitants of sickle cell crisis. Keeping a diary of pain episodes is helpful in identifying and avoiding triggers for pain crisis. Infections especially malaria have been reported as a major precipitant of sickle cell crisis among Nigerian patients.

As such, vector control and chemoprophylaxis for malaria is recommended in all patients [ ]. All forms of undue physical exertion or exhaustion should be discouraged. Mothers should be regularly reminded about routine national vaccination schedule as well as vaccination against organisms to which SCD children and adults are particularly susceptible, especially encapsulated organisms.

Adequate and regular hydration is important. Hydration helps with haemodilution, which reduces the propensity for sickling and vasoocclusion. Regular hydration also prevents dehydration which they are prone to due to impaired concentrating ability of the kidneys. Exercise caution with fluid administration especially in those with renal disease or severe anaemia. Excessive fluids may precipitate pulmonary oedema and death. Moreover, physicians should administer, monitor, and encourage patient's compliance with routine medications at follow-up visits. Routine medications include prophylactic antimalarial [ ] and folic acid.

Others may include antioxidants, aspirin, and prophylactic antibiotic oral penicillin from months of life until at least age 5 in areas where pneumococcal infection is prevalent. Malaria has been described as one of the major precipitants of VOC for patients in Malaria endemic regions including Nigeria, hence the rationale behind continuous life-long chemoprophylaxis [ — ]. However, according to a local study, no significant benefit or advantage was associated with routine chemoprophylaxis for malaria in SCD patients as both patients and controls had equal rates of asymptomatic parasitaemia and similar frequency of malarial attacks [ ].

In Nigeria, the actual benefits of malaria chemoprophylaxis in SCD need to be clarified through further research. Early institution of broad spectrum antibiotics is recommended in febrile SCD patients [ ]. Antibiotic use should be guided by local bacteriological profile and should be commenced after necessary bacterial cultures are taken.

A switch to appropriate antibiotic is based on sensitivity pattern of the offending isolate especially if the fever is persistent unresponsive to the former antibiotic. Currently, hydroxyurea HU is the only approved disease modifying drug in SCD used for selected patients above 24 months of age [ ]. HU is a cytotoxic agent that has been mainly used in treatment of CML and other myeloproliferative disorders.

Its usefulness in SCD is related to its ability to induce increased levels of fetal haemoglobin production in sickle cells thus mitigating tendencies for red cell sickling. The exact mechanism is not fully understood, but, as a ribonucleotide reductase inhibitor, it prevents formation of deoxyribonucleotides, causing S-phase arrest of all replicating cells, thereby inducing stress erythropoiesis, which favors increased production of fetal haemoglobin [ 24 ].

HU is also known to increase steady state haemoglobin levels and reduce leucocyte and platelet counts. Also, as a rheological agent, HU improves cell hydration, limits interaction of the sickle cells with the vascular endothelium, and acts as a nitric oxide donor [ ]. HU is of benefit to patients with moderate to severe sickle cell disease. Indications for HU therapy include recurrent VOC 3 or more severe episodes requiring admission in the last 12 months , recurrent ACS 2 or more episodes in a lifetime , severe symptomatic anaemia, and recurrent priapism, alternative to transfusion to prevent new or recurrent stroke especially where transfusion is not feasible [ ].

Full blood counts are monitored weekly for the first 4 weeks, fortnightly for the next 8 weeks, and thereafter monthly if the counts remain stable [ 14 , ]. Its dose is increased by 2. As marrow suppression occurs, HU is withheld to allow for marrow recovery and then restarted at a dose of 2. This is known as the maximum tolerable dose [ 88 , ]. Minimum time interval for evaluation of therapeutic efficacy is 6 to 9 months [ ].

Hb F levels should be monitored. Complications of HU include myelotoxicity, mouth ulceration, macrocytosis and megaloblastoid changes, nausea, skin toxicity rashes, and hyperpigmentation [ 88 , ]. Exclusion criteria include donor with major haemoglobinopathy and one or more of the following: Older adults are considered less favorable candidates for HSCT due to the higher risk for severe organ toxicities and greater susceptibility to severe graft versus host disease [ ].

HSCT should be performed in centers experienced in transplant for sickle cell disease. Other novel therapies are also being investigated. Gardos channel blockers such as clotrimazole and its analog, Senicapoc ICA , have been shown to reduce red cell dehydration and abate haemolytic rate and are well tolerated in SCD patients [ , ]. Administration of magnesium salts is also observed to reduce red cell dehydration by inhibiting the KCL cotransporter. It is reported that infusion of magnesium sulfate reduced the length of hospital stay in patients with VOC [ ].

However, this is not yet an established practice. Similarly, antiadhesive agents such as anti-P-selectin and heparin, as well as agents such as warfarin and aspirin for normalization of hypercoagulable state and Flocor for reduction of whole blood viscosity, and specific monoclonal antibodies for inhibition of red cell-endothelial adhesion are also being considered [ ]. Inhalational nitric oxide and its precursor, L-arginine, are shown to be beneficial in acute vasoocclusive crisis and other ischaemic complications by increasing NO bioavailability [ , ]. Theoretically, gene therapy offers a great hope of cure.

However, effective vector for safe transfer and stable, erythroid specific expression of normal beta globin gene are still under investigation [ , ]. Sickle cell disease is a major public health disease worldwide. There is still a high burden of the disease in Nigeria. There is still a significantly high rate of SCD complications and mortality among Nigerian patients. Current evidence suggests that available care is suboptimal. Largely speaking, prevention, control, and treatment of SCD in Nigeria are still in infancy. Yester efforts albeit present measures appear meager in the face of the enormous disease burden.

There is need for a better coordinated effort towards control of SCD by the government at all levels and other concerned stakeholders. Appropriate interventional programmes backed by an effective national policy should be instituted. In addition, physicians involved in the care of SCD patients should be conversant with current knowledge and standard practices in the treatment of sickle cell disease in order to improve treatment outcomes. The author declares that there is no conflict of interests regarding the publication of this paper.

National Center for Biotechnology Information , U. Journal List Anemia v. Published online Jan Author information Article notes Copyright and License information Disclaimer. This is an open access article distributed under the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. This article has been cited by other articles in PMC. Introduction Sickle cell disease SCD is one of the most common genetic diseases worldwide and its highest prevalence occurs in Middle East, Mediterranean regions, Southeast Asia, and sub-Saharan Africa especially Nigeria [ 1 , 2 ].

Aetiopathogenesis of Sickle Cell Disease SCD is a qualitative haemoglobinopathy resulting from a structural change in the sequence of amino acids on the beta globin chain of the haemoglobin molecule due to a point mutation. Oral hydration must be adequate with at least 1. If parenteral, not more than 1. Patients and parents should be encouraged to keep a stock of simple analgesics at home in event of a painful episode. However, mild to moderate pain that does not succumb to home-based oral analgesia and hydration within 2 days requires hospitalization.

Analgesia should be commenced within 15 to 30 minutes of presentation in the emergency room or day hospital. Effective analgesia should be achieved within 1 hour. There should be an ongoing assessment of analgesic efficacy every 30 minutes until pain is controlled, thereafter every 2 hours [ 49 , 50 ]. Treatment should be individualized. Adjuvants for pain control help in achieving better analgesia. They may include mild sedatives such as promethazine or diazepam.

Oversedation should be avoided. Laxatives should be prescribed for prevention and treatment of constipation, a side effect of opioid use. Severe VOC requires parenteral opioid analgesia and hydration in a hospital setting. The dose of the analgesia should be titrated with the severity of the pain until adequate control is achieved in a fixed dose schedule FDS , interspersed with short-acting agents for breakthrough pains. Prophylactic incentive spirometry is recommended for prevention of acute chest syndrome especially in BPC involving the chest wall.

If pain persists, patient controlled analgesia PCA should be considered where available. PCA is sparsely available in Nigeria, except in very few private facilities. PCA reduces the risk of pain undertreatment. Short-acting opioids in clinical use include tramadol, morphine, hydrocodeine, hydromorphine, fentanyl, oxymorphine, and oxycodeine. Longer acting opioids include methadone and slow release preparations of tramadol, morphine, and oxycodeine.

Access to a wide range of opioids may not always be readily available in Nigeria; however, the available ones should be used. In difficult cases, where pain is unremitting after 48 hours of well conducted analgesia, exchange blood transfusion EBT may be offered [ 51 ]. Hospitalization for severe BPC occurring on 3 or more occasions per year is an indication for initiation of hydroxyurea therapy or chronic transfusion therapy in patients that are intolerant of hydroxyurea.

Pain in SCD is majorly nociceptive in origin. In such cases, drugs such as pregabalin or carbamazepine will be useful [ 46 ]. Pain control in SCD is essentially pharmacologic. However, nonpharmacologic measures such as physical therapy with heat or ice packs, relaxation, distraction, music, menthol rub, meditation, and transcutaneous electrical nerve stimulation TENS are also helpful [ 46 ]. Visceral Sequestration Crisis Infants and children less than 7 years are at greatest risk of sequestration crisis especially splenic sequestration.

Aplastic Crisis Aplastic crisis usually occurs in those less than 16 years of age. Treatment Guidelines for Sickle Cell Ischaemic Stroke After initial evaluation of patient's airway, breathing, and circulation ABC of resuscitation , further stabilization should be pursued through prevention and control of hypoxaemia, hypotension, hyperthermia, and glycaemic imbalance, which would worsen the cerebral insult. Presence of seizures should be controlled with appropriate anticonvulsants.

Prophylactic antiseizure therapy is not necessary. This important distinction has to be made early, as this will impact subsequent therapeutic decisions. Magnetic resonance imaging MRI provides better details but should be deferred until treatment has been initiated. Early institution of exchange transfusion is crucial to improving treatment outcome. Simple transfusions may be offered in the interim while EBT is being planned. Adequate hydration not more than 1. Chronic blood transfusion CBT has been shown to be beneficial in primary and secondary prevention of CVD [ 70 , 73 — 75 ].

However, clear definitions on when and how CBT should be stopped is yet to be made. Often times, transfusions continue till late adolescence or early adulthood. Hydroxyurea therapy reduces cerebral blood flow. Though less effective, hydroxyurea may be considered an alternative to chronic transfusion therapy, where transfusion is not feasible [ 67 , 68 ]. Thrombolysis with recombinant tissue plasminogen activator rTPA within the first 3 hours of ischaemic CVD in adult patients should be considered after careful patient evaluation [ 76 ].

TPA is not recommended in children. However, the current prospect of TPA use among Nigerian patients is remote due to challenges of its availability, cost, delayed diagnosis, and clinical experience with its use. Adult SCD patients should be evaluated and treated for modifiable risk factors such as dyslipidaemia. Acute stroke should be treated in a dedicated stroke unit with input of both neurologist and haematologist.

Priapism Priapism is another acute complication of sickle cell disease. Ocular Disease Central retinal artery occlusion by sickled red cell sludge is an ocular emergency. Osteomyelitis Osteomyelitis is one of the commonest skeletal complications of SCD [ , ].

Chronic Morbidities in Sickle Cell Disease 5. Delayed Growth and Development Children with sickle cell disease have normal body weight at birth. Immunological and Infectious Complication SCD patients have a subnormal immunity, which partly accounts for their increased susceptibility to infections [ 32 ]. Hepatobiliary Complications Chronic liver damage in sickle cell disease is caused by intrahepatic trapping of sickle cells, transfusion transmitted hepatotropic infections, and transfusion siderosis [ 59 , ].

Renal Complications The hypoxic, acidotic, and hypertonic state of the renal medulla favors vasoocclusion and destruction of the vasa recta. Among Nigerian patients, its prevalence and severity increases with advancing age, longer survival, and homozygous SS disease [ , ]. Relevant clinical history and examination findings such as facial puffiness, loin pain, painless haematuria, leg and abdominal swelling, frothy urine, worsening anaemia, and hypertension, which may suggest renal disease, should be elicited at regular intervals during visits.

At least once annually during maintenance visits, SCD patients should be assessed for their renal status. A normal creatinine level does not exclude renal disease in SCD due to supranormal kidneys precipitated by hyperfiltration and increased secretion of creatinine and uric acid.

Emphasis and therapeutic decisions should be placed on significant adverse changes in the renal markers rather than single absolute values. Consultations and comanagement with experienced nephrologist is recommended in the following setting: Further evaluations including renal biopsy are necessitated in settings of sudden onset heavy proteinuria with or without nephrotic syndrome [ , ]. Treatment of haematuria includes bed rest, hydration, and blood transfusion if indicated in events of a significant blood loss.

Most times, haematuria is caused by papillary necrosis. However, the possibility of a renal medullary cell carcinoma must be excluded in these patients. This may be delayed with adequate control of hypertension and proteinuria. For blood pressure control, diuretics are better avoided.

• Articles, submitted to the journal.
• Broken Vessels (The Trinity Porter Series Book 1).
• The Princess Passes - Fully Illustrated.
• .
• The Flash Vol. 2: Rogues Revolution.
• !
• Special offers and product promotions;

Similarly, early commencement of hydroxyurea helps to delay progression to ESRD except hydroxyurea is contraindicated for other reasons. Urinary tract infection in these patients should be treated aggressively. Sickle Cell Leg Ulcer Leg ulcers are frequent in adults SCD patients especially males with SS phenotype and patients with low steady state haemoglobin levels [ , ]. Musculoskeletal Complications Known musculoskeletal complications in SCD include medullary hyperplasia, dystrophic intramedullary calcification, H-vertebra, osteolysis, osteopenia, septic arthritis, dactylitis, ulcers, pathologic fracture, and osteomyelitis.

Cardiovascular System Changes Sickle cell disease is associated with cardiac abnormalities including dilated cardiomyopathy, ventricular hypertrophy, cardiac iron overload, dysrhythmias, pulmonary hypertension, myocardial infarction, and sudden death [ , ]. Special Care Situations 6. Sickle Cell Disease and Pregnancy Typically, pregnancy in female SCD patients is attended by anaemia which may be worsened by pregnancy related plasma volume expansion and folate deficiency.

Perioperative Care in Sickle Cell Disease Perioperative complications of surgery in SCD patients include hypoxia, dehydration, bone pain crisis, significant anaemia, and acute chest syndrome [ ]. Laboratory Diagnosis of Sickle Cell Disease The science behind laboratory diagnosis of sickle cell disorder entails phenotypic testing for the presence the sickle haemoglobin and genetic analysis. Comprehensive Care in Sickle Cell Disease and Recommendations in Nigeria Comprehensive care incorporates provision of holistic healthcare services including state-of-the-art diagnosis, standard therapies, preventive care, rehabilitative therapy, and other ancillary services, by a team of specialists in a given location, with maximum accessibility for all patients.

Disease Modifying Therapies Hydroxyurea Therapy Currently, hydroxyurea HU is the only approved disease modifying drug in SCD used for selected patients above 24 months of age [ ]. Conclusion Sickle cell disease is a major public health disease worldwide. Conflict of Interests The author declares that there is no conflict of interests regarding the publication of this paper. Guidelines for the Control of Haemoglobin Disorders. Global epidemiology of haemoglobin disorders and derived service indicators.

Bulletin of the World Health Organization. World Health Organisation Management of haemoglobin disorders. Global epidemiology of Sickle haemoglobin in neonates: WHO Regional office for Africa. Sickle cell disease prevention and control, , http: The epidemiology of sickle cell disorder: Archives of Ibadan Medicine. An up-date on the prevalence of sickle cell trait in Eastern and Western Uganda.

Abnormal haemoglobins in the Sudan savanna of Nigeria. Prevalence of haemoglobins and relationships between sickle cell trait, malaria and survival. Annals of Tropical Medicine and Parasitology. Prevalence of haemoglobinopathy and malaria diseases in the population of old Aguata Division, Anambra State, Nigeria. Prevalence of haemoglobin variants in Benin City, Nigeria. Annals of Biomedical Sciences. Peculiar elongated and sickle-shaped red blood corpuscles in a case of severe anemia. Archives of Internal Medicine.

Disorders of haemoglobin structure: The natural history of sickle cell disease. Cold Spring Harbor Perspectives in Medicine. Evidence for the multicentric origin of the sickle cell hemoglobin gene in Africa. American Journal of Human Genetics. A novel sickle gene of yet another origin in Africa: Predicting clinical severity in sickle cell anaemia. British Journal of Haematology. Epidemiology of haemoglobin disorders in Europe: Scandinavian Journal of Clinical and Laboratory Investigation.

The Internet Journal of Hematology. Protection afforded by sickle-cell trait against subtertian malareal infection. Pathophysiology and therapy for haemoglobinopathies; Part I: Expert Reviews in Molecular Medicine. Pathophysiological insights in sickle cell disease. Indian Journal of Medical Research. New views of sickle cell disease pathophysiology and treatment. Management of sickle cell disease. The New England Journal of Medicine. Transfusion Clinique et Biologique. The Journal of Biological Chemistry. Vaso-occlusion in sickle cell anemia: The role of infection in the pathogenesis of vaso-occlusive crisis in patients with sickle cell disease.

Mediterranean Journal of Hematology and Infectious Diseases. Total antioxidants status and some hematological values in sickle cell disease patients in steady state. Journal of the National Medical Association. Microvesicles in haemoglobinopathies offer insights into mechanisms of hypercoagulability, haemolysis and the effects of therapy.

The Bethesda Handbook of Clinical Haematology. The Journal of Clinical Investigation. The endothelial biology of sickle cell disease: Deconstructing sickle cell disease: The metacarpal index in homozygous sickle-cell disease. British Journal of Radiology. Body shape in young children with homozygous sickle cell disease.

Anthropometric finding in Nigerian children with sickle cell disease. Pain in sickle cell disease: The anaesthetist's role in acute sickle cell crisis. British Journal of Anaesthesia. Pain management in patients with Sickle cell disease—a review. Current issues in sickle cell pain and its management.

Approach to the vaso-occlusive crisis in adults with sickle cell disease. Management of pain in sickle-cell disease. Journal of the Royal Society of Medicine. Pain management in adults with sickle cell disease in a medical center emergency department. Guidelines for the management of the acute painful crisis in sickle cell disease. The presentation, management and prophylaxis of sickle cell disease. Effectiveness of a dedicated day hospital for management of acute sickle cell pain. Sickle cell anemia day hospital: Day-care management of sickle cell painful crisis in Jamaica: Acute multiorgan failure syndrome: The American Journal of Medicine.

Abdominal pain in adult sickle cell disease patients: Annals of Ibadan Postgraduate Medicine. The import of abdominal pain in adults with sickle cell disorder.

Venedikt Erofeev

West African Journal of Medicine. Gastrointestinal and hepatic complications of sickle cell disease. I see that you're not really a Tatar stock boy from a hardware store but an unfettered seafarer. Put your feet together. Stretch your arms forward. Does what is prescribed. May I sit now? We already have almost everything we need. Just one more detail: I won't ask you if you're married, but is there a woman who is dear to your heart, a partner in life? Of course there is. Or more precisely, there was. When we swam across the Hindu Kush… she shattered her beautiful head… on the reefs of British Samoa.

I drowned, but swam out - are you glad that I swam out? From the Hindu Kush? From the Hindu Kush. Of course, swimming out of the Hindu Kush is child's play for someone who has already conquered the Dardanelles. Such a patient is a rarity for us - I'm glad you didn't drown. But when you were swimming, did you by any chance take a bottle with you? Sour vinegar ammonia - sharks can't stand it. As soon as a shark appears, you pour a bit of this sour vinegar ammonia on yourself and your girlfriend, and that's it!

The sharks fidget, then they lose their empty heads completely, and, well… they lick your girlfriend's calves in parting… But of course, jealousy would be ridiculous in such a situation… Now, when things got to the point of Karakorum… DOCTOR: And what day is it today? What does it matter? I can't brighten your day with that - I never do.

I'm thinking about the chimeras… For example, why the hell did I travel the whole world, cross the Kunlun, climb the heights of Kon-Tiki, only to find out one thing: That there should be no other constellations. The doctors and nurses get nervous. I discovered that when I raised my left leg, I couldn't raise my right one simultaneously. This was a real downer. She lazily inclines her freckled head. And he peered at me, at my watch, and then he said: As if I didn't know that. To tell me this now is like saying, for instance, to the Venetian Moor, at the very moment he is shaken by his deed, that constriction of the windpipe and trachea can result in paralysis of the respiratory center due to asphyxiation.

All right, that's enough… Prince Golitsyn, you say… And did you ever happen to gulp down vodka with viscounts, counts, marquises? And why do you assume it's Lev? If it's a count - then it has to be Lev! But I'm also Lev, and I'm not a count at all. So, Lev's great-grandson calls me and says that he has two bottles of ginger vodka on his table, but nothing to snack on except two Chapaev jokes… DOCTOR: And does this Count Tolstoy live far away?

Right near the "Novokuznetskaya" metro stop. And what about Joseph DeMaistre? Would you invite them into the slums to knock back some of this… what do you call it…plonk? As long as there is a thick undergrowth of euonymus in these slums… And some anemones wouldn't be bad either… but there are rumors going around, they've all emigrated by now… DOCTOR: If only it were just the anemones. But it's also the Bragelonnes, Josephs, and crocuses. Every one of them runs away. But why do they run away?

And where do they go? I, for one, like it here very much. The only thing I don't like is the law against vagrancy. And… disrespect for the Word. His plenipotentiary voice rises to an emergency level. Yes, but what if misfortune befalls our Motherland? After all, it's no secret to anyone that our foes live for only one thing: We're talking serious business here.

How many nationalities, languages, and tribes do we have here in Russia? How the hell should I know? There, you see, a half thousand. And what do you think, patient, in the case of circumstances, face to face with our enemy, which tribe can be relied on most? You're an educated man, an old hand at euonymus and anemones, and you know that they run away from us for some reason… And so, when all hell breaks loose - which side will you be on, Lev Isaakovich?

Actually, I'm against all war. War corrupts soldiers, destroys the ranks, and dirties uniforms the great Prince Konstantin Pavlovich. But that doesn't mean anything. Copy this down too. As soon as my Motherland is on the brink of catastrophe, as soon as she says: Quit drinking, get up, and come back to the land of the living" - then… Animation in the audience.

Her eyes take up almost half of her smiley face. She has a dimple in her cheek.

Her hair, pulled back on her head, is completely black, fastened with an exotic hairpin. All of this smacks of Slavic calm and gentleness, but also of Andalusia. You're just in time, Natalya Alekseevna. The usual exchange of greetings among the women, and all the rest. We are in effect ending our conversation with the patient.

We were talking about the Motherland and catastrophe. And so, I love Russia; she occupies a sixth part of my soul. And probably even a bit more right now… Laughter in the audience. Every normal citizen should be a brave warrior, just as every normal urine specimen should have a bright amber color. Inspired, he quotes Kheraskov. Prepared to shield our cherished fatherland, We're eager to engage the world in battle.

But here is the consideration that holds me back: I, a morally wretched boozer, am simply unworthy of fighting for this motherland. Doesn't have to be that way. So what if you make me better? But what good will it do without grenades? An enemy flies up into the air even if you throw yourself with nothing at all.

Here is my advice to you: No matter whose it is, I'll cover it with my chest right away, and I'll lie there, lie there until our crimson standard is raised over the Capitol. I think that's enough clowning around.



• Nejsledovanější videa.
• Submitted Manuscripts.
• Management of Sickle Cell Disease: A Review for Physician Education in Nigeria (Sub-Saharan Africa).
• Everything Reptile: What Kids Really Want to Know about Reptiles (Kids Faqs)?
• Nejlepší světoví zpěváci a zpěvačky: Axl sesazen z trůnu;

You'll see very soon, we've got clowns coming out of our ears here. How do you assess your overall condition? Or do you seriously believe that your brain is undamaged?

Product details

And do you believe yours is? Peevishly I asked you, patient, only to answer my questions. I will answer yours when you are fully recovered. So, what is your general condition, in your opinion? It's hard to say… Such a strange feeling… immersion-into-nothing… agitation- about-nothing… liking-for-nobody… And as if you were betrothed to someone… but to whom, when, and why - this is beyond all comprehension… As if you were occupied by someone, and rightfully so, in accordance with an agreement about a mutually beneficial, close friendship, but still occupied… and you feel sort of… not-disturbed-by-anything, but also not-crucified-on-anything … not-puked-from- anything.

In short, you feel as if you were inside a paradise, but at the same time in a completely different place… well… as if you were in your stepmother's womb… Applause. You may think that you are expressing yourself unclearly, patient. But all this buffoonery will be knocked out of you. I hope that you respect our medicine, despite all your tendencies toward cynicism and bragging, and will not cause an uproar in our wards. My papa told me one day: In my youth I gained a skill: To be obedient to everyone, As long as they deserved it. Oh yes, I, Was happy as a rotten clam at birth.

I thought I already asked you several times to stop clowning around. All right, I won't do it anymore… You were talking about our medicine, do I revere it? Revere is too boring a word, to tell the truth, and… flat-footed… But I - but I'm in love with it for real Without the least buffoonery or grimace. OK, OK, that's enough, patient. Don't be a smart mouth in a nut house… Can you tell me exactly when you were last brought here? Only, you see, I measure time a little differently. Needless to say, not by Fahrenheit, not by night tables, not by Reaumur.

But still, a bit differently… It is important to me, for example, what distance divided that day from the fall equinox, or… let's say… summer solstice… or some other kind of crap. Take the direction of the winds, for example. We, the majority, don't even know where the northeast wind in fact blows: Noticing the patient's anxiety, gives a signal to the rest. So, when was the last time you were brought here?

I don't remember… I don't remember exactly… Not even the winds… Here's the only thing I remember: Suppressing the ladies' giggling with a glance. So you don't think that anything more noteworthy has happened in Soviet history in the past five years? No, I don't think so… I don't recall… no, there wasn't anything. Well, then your memory has begun to betray you, and not only your memory. Last time your diagnosis was severe alcoholic intoxication bordering on polyneuritis… Now things will be more complicated.

Everyone else jumps up too. Half a year or so?! And why are you surprised, patient? You have a wonderfully visible syndrome. Confidentially speaking, in the recent past we have begun to hospitalize even those who, at first glance, don't have a single visible syndrome of psychic disturbance. But surely we shouldn't forget about those patients' capacity for involuntary or carefully premeditated dissimulation.

These people, as a rule, do not commit a single antisocial or criminal act for their entire lives, and there isn't even the smallest hint of nervous disorder. But they are dangerous precisely for this reason and need to be subject to treatment. Well, that's just great! Yes, I'm in love with Lady Medicine In love with all its victories and progress.

Its rapid progress spits right in the face Of every faraway astonished land. His princely voice turns into a kingly one. I thought we already agreed about those… iambs, patient. I'm experienced enough, and I assure you: And your sarcasm along with it. After a couple of weeks, you will speak about normal things in a human language. You're a bit of a poet?

And will you treat me for that too? Now, now, you don't have to be like that… And who do you imitate? Who is your favorite? Making use of the general animation. So, Lyova, now you're aping D'Anthes? Not at all - earlier I wrote in my own style, but it fizzled. A month ago, I was churning out a dozen poems a day - and as a rule, eleven of them were unforgettable, five or six epochal, and two or three immortal… But not anymore.

Now I have decided to improvise after Nikolai Nekrasov. Want to hear one about the Socialist Competition? I'll be very brief. Seven peasants get together and start quarreling over how many eggs you can squeeze out of a hen. The people from the district center and the roosters, of course, don't suspect anything. All around them there is a mass of plant growth for silage, sows, banners - and there the peasants are arguing: The old Pakhom, he thought and thought And uttered, looking down, One hundred, one and thirty thousand, four hundred fourteen, "A mullion," offered Prov. Want me to go on?

No, don't bother… Boris Anatolevich, Natalya Alekseevna, would you please conduct the patient to Ward 4. And immediately to the bathroom. You haven't yet reached the point of… hydrophobia, I hope? Not that I've noticed. If you don't count the pile of bloody associations I have with bathrooms. You see, that Mycenaean king Agamemnon whom I mentioned to you - well, he, upon returning from Pergamum, was hacked to death by a cutlass in his bathroom.

But why Ward 4, anyway? They're all stinking good-for-nothings… He'll rot away, develop suicidal thoughts. I think he'd be better off in Ward 3. One last question for you. Have you ever, even deep down inside, gotten the idea to destroy yourself… or one of your fellow men?

I have to confess, I already sent one person that way. Then I was - I don't remember how old, not very old at all, but it happened about three days before the new moon… anyway, at the time my least favorite person was my dear bald uncle, a fan of Lazar Kaganovich, dirty jokes, and chicken soup. And my towheaded pal Edik got me some poison; he said that the poison was a sure thing and slow acting. I poured it all into my uncle's chicken soup - and what do you know? Hmm, y-yes… Never mind about your uncle… But did you ever have the desire to lay a hand on yourself? Everything began with the torrential rain at Orekhovo-Zuevo… We had a spell of strange local catastrophes here in Russia in the recent past.

Near Kostroma, in broad daylight, nursing babies, bulldozers and everything else flew to the skies. And no one was surprised by all this hocus-pocus. This is just about how things stood in Orekhovo-Zuevo. It rained cats and dogs for seven days and nights, without stopping and without mercy; the earthy earth disappeared, and so did the heavenly heavens… DOCTOR: And who the hell carried you to Orekhovo-Zuevo?! The Tatar from the Moscow hardware store?

It's very sad indeed to be a Tatar! I had to earn a living in the boondocks: As a conformist, as a non-conformist, As a usurper, as a cannibal And even as an agent from Japan While at the institute of permafrost… In short, when the elements were pounding in the city, I had a canoe, and in it were twelve dashing aborigine oarsmen. Besides us, nobody and nothing was above the surface of the waves… And then, I don't remember on which day of rowing and how many nights before the solstice, the water began to fall, and a spire of the City Komsomol Committee came out of the water… We anchored ourselves… But then, what a sight appeared before us: One more thing, guys!

And when my throat was already over the Committee spire, and the Committee spire was under my throat, right then one of my oarsman buddies, trying to amuse me and distract me from the blackness of my soul, told me a riddle: How many suckling pigs does it take to run one verst in an hour? And so - here I am. Picks himself up from the chair, helped with exaggerated care by the THUG.

Are you dizzy, Lev? Let's go, easy now. Everything will be fine now; you'll be put to bed. But for some reason everything is all muddled and confused, puckling sigs, hills… Henry Ford and Ernest Rutherford… Rembrandt and Billy Brand. An injection of glucose, piracetum. Moving away with those accompanying him; his voice becomes more subdued. At curtain's rise, the viewer sees Ward 3, with barred windows and an arched entrance to Ward 2.

In order to prevent interward diffusion, exchange of information, and so on, the arched passageway is blocked by a folding bed, on which VITYA lies, stroking his huge stomach and licking his lips about something, with a timid, horrifying smile. From time to time he declaims something, then freezes in an unexpected pose - for instant giving a pioneers' salute - and the declamation ceases, who knows for how long. He has eczema, his whole body is covered with hair, and his mouth is strangely twisted.

But the main action, of course, takes place in the center: If you had simply been a snake, Mikhalych, that would be fine - if you're a snake, you're a snake. But you are actually a black mamba - yes, there is such a southern African snake - black mamba! Its bite is so poisonous that a man croaks 30 seconds before it! To the middle, shithead! How were you so lucky, you asshole, to rise to the unheard-of rank of rear admiral of the KGB? Or maybe you are really a boatswain of the KGB, and not a rear admiral? He's a warrant officer, a warrant officer, just look at his mug!..

There you have it, a warrant officer. Alekha and I have counted up all your deeds here. Just one would have been enough… On September 1st of the past year, did you sit at the wheel of a South Korean air liner? Kherson and Coventry are in ruins… The mere sophistication of this act is surprising: And all the rest - all the rest - it's as if this fucker never even flew over them! So, boatswain, all the gray hairs of these old men, the tears of all the orphans, and the innards of all the widows cry out to you!

Yes, here I am. Tell me and all the Russian people: The day before yesterday. That doesn't mean anything. After all, you lousy bastard, you were able to carry out electronic espionage in the Arctic Ocean basin the day before, without leaving the ward. The records of the preliminary investigation cannot lie. Judge for yourself, whore spawn, imagine that you're not an admiral but page of the records of the preliminary investigation - could you lie? And so, we in the club of experts: How much are the Kuril Islands now?

Iturup - for a bottle of Andropov vodka, paid on an installment plan?

1. Introduction

Kunashir - almost for nothing… But maybe these political dealers just fucked you over in return for this? What's more, this boatswain intended to sell the map of the Soviet liquor stores to the CIA. Sauntering by as usual. Yes, they won't give you no medal for that. I haven't even told you everything. Since this dog of a boatswain had nothing left to sell - he succeeded in drinking away the mind, honor, and conscience of our epoch in only a week - he had another plan: The whole deal was ready - only this double-dealer made a little mistake with one of his clients from Manhattan.

When he went down into the subway with one of them, to add a bit to the price, the stupid Yankee businessman thought it was the ballet lying before him. And when he took him to the ballet… General rumblings of condemnation. Get out of your bed sheets, don't be afraid, you're not the one being judged today. Speak your word, comrade! He should be hanged to death upside down!

Yes, that's how the eastern despots dealt with the Agaryans: No, it's better to shoot him from an arbalest. From an arquebus… at a distance of two and a half leagues. But where on earth would we get an arquebus? Ha, ha, why don't you ask her for some braids too… I think we should leave this monster to be eaten alive by Vitenka! Pray for the last time, admiral! Hanging his head very low, begins to mumble something quickly, something like the following.

I'd gladly lose an arm and hand, for Moscow, dearest Motherland; Moscow is the world's true center, the greatest city you could enter; Go to the Kremlin for just a while, it'll fashion your mind in the proper style; Take Lenin's lessons, heed them well, your mind and hands will be stronger than hell; The Soviet Union's the very best, a shining example for the West; For us Moscow's a beautiful sight, but for her foes, an awful fright… PROKHOROV: Shaking, continues his out of place gibberish.

To be in Moscow is to know, beauty pure as whitest snow; Go with the Communists today, that is how you find your way; A Soviet patriot's always prepared, for heroic deeds - he's never scared; A soldier with ideological preparation, is a lion at his battle station… PROKHOROV: That's a marvelous prayer book… I don't think we'll need any arbalests, we can just dissolve him in some chemical solution so that by evening he'll be a mere protoplasm… Only - what do we need extra protoplasm in our department for, we're choking on it as it is.

Better to put him under the tribunal! Kolya, wipe up your spit. What do you think, Kolya, is there a lot of protoplasm in our department? Of course he's pitiful now, this anti-party leader, this anti-statesman, this anti-national artist, veteran of three counterrevolutions, he's a helpless orphan, of course you can't last very long on this modest FBI pay… but all his mumbling and prayers - it's a customary affectation of our eternal enemies.

It's an eternal affectation of our customary enemies. It's an affected eternity of our animosity.

www.newyorkethnicfood.com: Caspian Stone: His Father's Secret (): Marcus Fuller: Books

These kinds of anti-Kremlin dreamers count on our leniency toward them. But we live in such harsh times that it's wiser to use words like "leniency" more rarely. You fool around with death in wartime, but you best not fool around with it in no peacetime. In the name of the people, boatswain Mikhalych, nuclear weapon psycho in a Civil War helmet and watchdog for the Pentagon, is sentenced to hanging for life. And to a suspended sentence in all the fortresses of Russia at once!

But in the meantime, for lack of resources, tie him tightly in bed. Let him think over his last words. Bursts into the ward, attracted by the huffing and puffing of the executioners and the ear-splitting roaring of the victim. What's going on here, boys? Where's the extra bed here? Opens the closet and takes out a set of clean linen, briskly tosses it onto the empty mattress. The rounds are coming up.

Calmly takes the tiny LUCY by the shoulders, at the same time sticking out his belly and his furnacle-eyes, performs some languid, dancelike movements around her, and then, tapping himself on the belly and nodding his head as a preparation, sings his chef d'oeuvre. I'll dream and dream for many years, Of our psychotic ward of wits. I'll dream for many, many years, Of your seductive, wild tits.

Alekha strums on the guitar, I must get married to the redhead! All-le-kha strums on the guitar, I must get married to the redhead! I must I must Get married to the redhead! She undid all her clasps, Flung open all her clothes, And the last breath of life Almost left my nostrils. The warrant officer peed his pants in jail, The boatswain gnaws at the deck!

Alekha strums on the guitar, But he won't get a thing! Well, let him strum on the guitar - He won't get any anyway! There are no signs of a beating on his face, but a sense of defeat is very evident, and everyone understands: Ah, new patient… Your cot is the first to the left… Make your bed. I'll do it myself! The singing stops for a while. Today, all over the world the gravediggers of socialism are confessing and receiving communion… So why don't you join them, gramps?

No, no, he needs a minute of self-immersion… You don't know much about the East… You immerse yourself in water… or maybe someone immerses you, but you can feel how the times when you didn't exist drip into eternity, you are washed, consequently you exist… When the Chinese emperor's concubine washes herself in the Woven Orchids Pool - that's exactly what it was called then, the Woven Orchids Pool - 12 essences and 17 aromas were added to it… KOLYA: Approaching from behind … But whoever wraps himself in a yellow blanket after this, not knowing truth and self-limitations, doesn't deserve the yellow blanket.

Can you explain this dharma to me?! Go fuck yourself with your dharmas! What does dharma have to do with it? Those who meet me along the way tell me: Three girls talk to me, one really moonlike, and the other all pastoral, in a crown of dandelions, of course, and I don't even dare look at the third. I break all my bonds, grasp all the dharmas, and resist all the pleasures.

I step over the third, majestic lady, and leave the Hall of Psalms for the mango grove. You know what, Stas, why don't you go fuck off to your mango groves for just a minute and let me talk to the Jew… What are you here for and what's your name? That's what I thought - Gurevich… And it wouldn't happen to be… for this? Flicks his neck to indicate drinking.

That's what I thought. Jews have been known to have a drink now and then… especially behind the backs of Arabs. But that's not the point. As soon as a Jew appears, there's no more calm, and a tragic story begins. My late gramps told me: What do you call them? Roe deer - too many to shake a stick at. And the pond was chock full of white swans, and a rhodo-den-dron bloomed on the shore. And then a doctor by the name of Gustav came to the village… Well, maybe not exactly Gustav, but definitely a Yid. And what came of this?

It's not me telling you, it's my gramps. Until this Gustav appeared, there were so many hares in the area, that you could literally trip over them, you'd slip and fall… Well, for starters all the hares went, then the roe deer - no, he didn't shoot them, they disappeared by themselves. Vova, you're from the country. Imagine you're on the shore of a pond… you're sprouting… your name is Rhododendron.

And on the other side of the pond, a Yid is sitting, looking at you…? Well, to hell with the goddamn rhododendron. Look, Vova, pretend you're a white she-swan and you're sitting on the shore of a pond - and across from you a Yid is sitting, gazing at you very… VOVA: No, I can't be a white she-swan either, it's hard for me.

Alekha, get Vovochka out of here… Well, you see, Gurevich? Glances at VITYA anxiously, then notices his neighbor the admiral making useless efforts to free himself from his shackles. And what's with this one? He betrayed the Motherland in thought and intention. In short, he doesn't drink or smoke. That would be fine, but once we were all standing around in the bathroom, talking about alcohol, about its tremendous number of calories. So this shit-eater blurts out: He paid for his insolent erudition right then: I opened the window, jammed him in there and hung him by an ankle - and it was the fourth floor, too - and held him there until he renounced his heretic doctrines… Today, by the will of God and the people, he is sentenced to the gallows… I don't really believe that in the beginning was the Word - it must be at the end, even if it's only a shabby one, so let this motherfucker lie there and think it over… GUREVICH: Tell me, Prokhorov, are you the vested plenipotentiary… uh… only in this ward, or…?

No, of course not! Get out from the covers! This is Pashka Eremin, the secretary, he's all right, as lousy as they come, but this is serious business - mutilation in the Kleinmikhel family! OK, fine… the godmother went out for bagels - what's the point of yelling? Passing by as usual. All of our godmothers scattered for bagels: No… what do bagels have to do with it? Tomorrow, let's leave it for tomorrow.

Crawl away till tomorrow, Seryozha. So, listen to me, Gurevich. As you can see, we have daily petty annoyances here. Other than that - life is good. They'll give you injections for about two or three weeks, then tablets, then a kick in the butt - and off you go. We even have a color TV here. A couple of canaries. They're keeping quiet today because tomorrow is May Day. Usually they sing all the time. Vitya decided not to touch them at all or get a taste of them. The exact procedure varies, but the idea is first to drill down to just above where the oil is located.

Then they insert a casing of concrete into the newly drilled hole to make it stronger. In the petroleum industry, production is the phase of operation that deals with bringing well fluids to the surface and preparing them for their trip to the refinery or processing plant. Production begins after drilling is finished. The first step is to complete the well — that is, to perform whatever operations are necessary to start the well fluids flowing to the surface. Later in the life of the well, more extensive repairs — known as workovers — may also be necessary to maintain the flow of oil and gas.

The fluids from a well are usually a mixture of oil, gas, and water, which must be separated after coming to the surface. Production also includes disposing of the water and installing equipment to treat, measure, and test the oil and gas before they are transported away from the well site. So production is a combination of operations: Operating in this environment requires billions of dollars and boundless technical expertise. Safely and economically bringing oil to the surface requires experts in everything from underwater vehicles that install subsea equipment to structural engineers that make sure the huge floating platforms can withstand large waves.

To put this in perspective, it is a bit like a quarterback trying to throw a football to his wide receiver more than football fields away! Innovation will continue to drive this frontier into new territory. We depend on oil and gas for a host of products we use in our everyday lives, and we will continue to depend on them for years to come. Already great strides have been made to ensure that oil and gas producers make as little impact as possible on the natural environments in which they operate.

This includes drilling multiple wells from a single location or pad to minimize damages to the surface, employing environmentally sound chemicals to stimulate well production, and ensuring a seamless transition from the wellhead to the consumer. How can the vast potential locked in these resources be tapped in a more efficient, environmentally sound manner? Research today focuses on inserting heaters into rock formations below the surface to convert the heavy hydrocarbons into liquid that can then be drained and produced by more conventional oil wells.

Such a process would dramatically reduce the impact of these unconventional sources on the surface. However, the next generation of engineers and scientists must further refine this technology or generate new ideas in order to tackle these problems. No one can know for certain how much oil and gas remains to be discovered. But geologists sometimes make educated guesses. The total amount of oil or gas in the reservoir is called original oil, or gas. For a specific reservoir, engineers estimate this amount using information about the size of the reservoir trap and properties of the rock.

Some of the original oil and gas deposited millions of years ago has been discovered, while some remains undiscovered—the target of future exploration. Discovered or known resources can be divided into proved reserves and prospective or unproved probable and possible resources.

Continental North America and much of continental Europe have already been explored heavily, and any new discoveries are likely to be small. But many areas of the globe are largely unexplored, and large new deposits are waiting to be found. Global hot spots that may house significant new oil and gas reservoirs include:. These are just a few of the current areas of growth.

Most observers agree that significant deposits of oil and gas remain undiscovered in the Middle East. At current consumption levels, the remaining reserves represent Does this mean that the world will be out of fossil fuels in 50 years or so? That theory has been around since the s. In fact, the figures for years of remaining reserves have remained relatively constant during the past few decades as the industry has balanced consumption with newly discovered oil and gas deposits.

Around 3 million years ago — Stone Age; Vast underground oil reserves seep to the surface in sticky black pools and lumps, called bitumen. Hunters use bitumen also called pitch or tar to attach flint arrowheads to their arrows. The first oil lamps are made by hollowing out a stone, filling it with moss or plant fibers and setting the moss on fire. Oil lamps remained the main source of lighting until the gas lamp invention in Victorian times. The Greeks improved lamps by putting a lid on the bowl.

They soon learned that it could be used to seal water tanks, waterproof boats now known as caulking and glue broken pots. Persian archers put it on their arrows to fire flaming missiles at their enemies. They used bamboo tipped by iron to get brine salty water for medicine and preserving food. They found oil and natural gas as they drilled deeper. The natural gas was burned under big pans to boil off the water and obtain the salt.

The Chinese refined crude oil for use in lamps and in heating homes. The idea was later adopted to defend castles during the Middle Ages. Oil was extremely expensive, so the technique was probably not used often. As settlement by Europeans proceeded, oil was discovered in many places in northwestern Pennsylvania and western New York—to the frequent dismay of the well owners, who were drilling for salt brine.

This was the greatest breakthrough in lighting since the time of the Greeks. It revolutionized home life, making rooms bright at night for the first time in history. This was the first oil well in the Americas. Oil was first discovered when a homemade rig drilled down 70 feet and came up coated with oil. Production in the lower 48 states has been declining ever since. Arab OPEC production was cut by 25 percent, which caused some temporary shortages and helped oil prices to triple.

Some filling stations ran out of gasoline and cars had to wait in long lines for gasoline. The OPEC oil embargo and the resulting supply shock suggested that the era of cheap petroleum had ended and that the world needed alternative fuels. The development of hydrogen fuel cells for conventional commercial applications began. Flex-fuel vehicles are introduced. These vehicles can run on straight ethanol, straight gasoline or a blend of the two.