text:
Hearing issues
Chronic ulcers
Radiation injury
Therapeutic principles
Clinical pressure (2.0-3.0 Bar)
Proangiogenic Stem Progenitor Cell Mobilization
Low pressure hyperoxia, stem progenitor cell mobilization and inflammatory cytokine expression
Oxygen supply
Home and out-patient clinic treatment
Possible complications and concerns
Effects of pressure
Radiation wounds
Hyperbaric air
Hyperbaric oxygen
Medical treatment at raised ambient pressure
A Sechrist Monoplace hyperbaric chamber at the Moose Jaw Union Hospital, Saskatchewan, Canada
diving medicine, emergency medicine, neurology, infectious disease
OPS-301 code
Hyperbaric medicine is medical treatment in which an ambient pressure greater than sea level atmospheric pressure is a necessary component. The treatment comprises hyperbaric oxygen therapy (HBOT), the medical use of oxygen at an ambient pressure higher than atmospheric pressure, and therapeutic recompression for decompression illness, intended to reduce the injurious effects of systemic gas bubbles by physically reducing their size and providing improved conditions for elimination of bubbles and excess dissolved gas.
The equipment required for hyperbaric oxygen treatment consists of a pressure chamber, which may be of rigid or flexible construction, and a means of delivering 100% oxygen. Operation is performed to a predetermined schedule by trained personnel who monitor the patient and may adjust the schedule as required. HBOT found early use in the treatment of decompression sickness, and has also shown great effectiveness in treating conditions such as gas gangrene and carbon monoxide poisoning. More recent research has examined the possibility that it may also have value for other conditions such as cerebral palsy and multiple sclerosis, but no significant evidence has been found.
Therapeutic recompression is usually also provided in a hyperbaric chamber. It is the definitive treatment for decompression sickness and may also be used to treat arterial gas embolism caused by pulmonary barotrauma of ascent. In emergencies divers may sometimes be treated by in-water recompression (when a chamber is not available) if suitable diving equipment (to reasonably secure the airway) is available.
A number of hyperbaric treatment schedules have been published over the years for both therapeutic recompression and hyperbaric oxygen therapy for other conditions.
Hyperbaric medicine includes hyperbaric oxygen treatment, which is the medical use of oxygen at greater than atmospheric pressure to increase the availability of oxygen in the body; and therapeutic recompression, which involves increasing the ambient pressure on a person, usually a diver, to treat decompression sickness or an air embolism by eliminating bubbles that have formed within the body.
Research found evidence that HBOT improves local tumour control, mortality, and local tumour recurrence for cancers of the head and neck.[1]
Research also found evidence of an increase in stem progenitor cells[2] and a decrease in inflammation.[3]
In the United States the Undersea and Hyperbaric Medical Society, known as UHMS, lists approvals for reimbursement for certain diagnoses in hospitals and clinics. The following indications are approved (for reimbursement) uses of hyperbaric oxygen therapy as defined by the UHMS Hyperbaric Oxygen Therapy Committee:[4][5]
Air or gas embolism;[6]
Carbon monoxide poisoning;[7][8]
Carbon monoxide poisoning complicated by cyanide poisoning;[9][10][11]
Central retinal artery occlusion;[12]
Clostridal myositis and myonecrosis (gas gangrene);[13][14][15]
Crush injury, compartment syndrome, and other acute traumatic ischemias;[16][17]
Decompression sickness;[18][19][20]
Enhancement of healing in selected problem wounds;.[21][22]
Diabetically derived illness, such as short-term relief of diabetic foot,[23][24][25] diabetic retinopathy,[26][27] diabetic nephropathy;[28]
Exceptional blood loss (anemia);[29][30]
Idiopathic sudden sensorineural hearing loss;[31]
Intracranial abscess;[32][33]
Mucormycosis, especially rhinocerebral disease in the setting of diabetes mellitus;[34]
Necrotizing soft tissue infections (necrotizing fasciitis);[35][36]
Osteomyelitis (refractory);[37][38][39]
Delayed radiation injury (soft tissue and bony necrosis);[40][41][42]
Skin grafts and flaps (compromised);[43]
Thermal burns.[44][45]
There is no reliable evidence to support its use in autism, cancer, diabetes, HIV/AIDS, Alzheimer's disease, asthma, Bell's palsy, cerebral palsy, depression, heart disease, migraines, multiple sclerosis, Parkinson's disease, spinal cord injury, sports injuries, or stroke.[46][47][48] Furthermore, there is evidence that potential side effects of hyperbaric medicine pose an unjustified risk in such cases. A Cochrane review published in 2016 has raised questions about the ethical basis for future clinical trials of hyperbaric oxygen therapy, in view of the increased risk of damage to the eardrum in children with autism spectrum disorders.[49] Despite the lack of evidence, in 2015, the number of people utilizing this therapy has continued to rise.[50]
There is also insufficient evidence to support its use in acute traumatic or surgical wounds.[51]
There is limited evidence that hyperbaric oxygen therapy improves hearing in patients with sudden sensorineural hearing loss who present within two weeks of hearing loss. There is some indication that HBOT might improve tinnitus presenting in the same time frame.[52]
HBOT in diabetic foot ulcers increased the rate of early ulcer healing but does not appear to provide any benefit in wound healing at long-term follow-up. In particular, there was no difference in major amputation rate.[53] For venous, arterial and pressure ulcers, no evidence was apparent that HBOT provides a long-term improvement over standard treatment.[23]
There is some evidence that HBOT is effective for late radiation tissue injury of bone and soft tissues of the head and neck. Some people with radiation injuries of the head, neck or bowel show an improvement in quality of life. Importantly, no such effect has been found in neurological tissues. The use of HBOT may be justified to selected patients and tissues, but further research is required to establish the best people to treat and timing of any HBO therapy.[54]
As of 2012, there is no sufficient evidence to support using hyperbaric oxygen therapy to treat people who have traumatic brain injuries.[55] In stroke, HBOT does not show benefit.[56][48] HBOT in multiple sclerosis has not shown benefit and routine use is not recommended.[47][57]
A 2007 review of HBOT in cerebral palsy found no difference compared to the control group.[58][59] Neuropsychological tests also showed no difference between HBOT and room air and based on caregiver report, those who received room air had significantly better mobility and social functioning.[58][59] Children receiving HBOT were reported to experience seizures and the need for tympanostomy tubes to equalize ear pressure, though the incidence was not clear.[58]
In alternative medicine, hyperbaric medicine has been promoted as a treatment for cancer. However, a 2011 study by the American Cancer Society reported no evidence it is effective for this purpose.[60] A 2012 review article in the journal, Targeted Oncology, reports that "there is no evidence indicating that HBO neither acts as a stimulator of tumor growth nor as an enhancer of recurrence. On the other hand, there is evidence that implies that HBO might have tumor-inhibitory effects in certain cancer subtypes, and we thus strongly believe that we need to expand our knowledge on the effect and the mechanisms behind tumor oxygenation."[61]
Low-quality evidence suggests that hyperbaric oxygen therapy may reduce the pain associated with an acute migraine headache in some cases.[62] It is not known which people would benefit from this treatment, and there is no evidence that hyperbaric medicine can prevent future migraines.[62] More research is necessary to confirm the effectiveness of hyperbaric oxygen therapy for treating migraines.[62]
Patients who are having extreme difficulty breathing – acute respiratory distress syndrome – are commonly given oxygen and there have been limited trials of hyperbaric equipment in such cases. Examples include treatment of the Spanish flu[63] and COVID-19.[64]
The toxicology of the treatment has been reviewed by Ustundag et al.[65] and its risk management is discussed by Christian R. Mortensen, in light of the fact that most hyperbaric facilities are managed by departments of anaesthesiology and some of their patients are critically ill.[66]
An absolute contraindication to hyperbaric oxygen therapy is untreated pneumothorax.[67] The reason is concern that it can progress to tension pneumothorax, especially during the decompression phase of therapy, although treatment on oxygen-based tables may avoid that progression.[68] The COPD patient with a large bleb represents a relative contraindication for similar reasons.[69][page needed] Also, the treatment may raise the issue of Occupational health and safety (OHS), which has been encountered by the therapist.[70][clarification needed]
The following are relative contraindications – meaning that special consideration must be made by specialist physicians before HBO treatments begin:
Cardiac disease[clarification needed]
COPD with air trapping – can lead to pneumothorax during treatment.
Upper respiratory infections – These conditions can make it difficult for the patient to equalise their ears or sinuses, which can result in what is termed ear or sinus squeeze.[67]
High fevers – In most cases the fever should be lowered before HBO treatment begins. Fevers may predispose to convulsions.[67]
Emphysema with CO2 retention – This condition can lead to pneumothorax during HBO treatment due to rupture of an emphysematous bulla. This risk can be evaluated by x-ray.[67][clarification needed]
History of thoracic (chest) surgery – This is rarely a problem and usually not considered a contraindication. However, there is concern that air may be trapped in lesions that were created by surgical scarring. These conditions need to be evaluated prior to considering HBO therapy.[67]
Malignant disease: Cancers thrive in blood-rich environments but may be suppressed by high oxygen levels. HBO treatment of individuals who have cancer presents a problem, since HBO both increases blood flow via angiogenesis and also raises oxygen levels. Taking an anti-angiogenic supplement may provide a solution.[71][72] A study by Feldemier, et al. and NIH funded study on Stem Cells by Thom, et al., indicate that HBO is actually beneficial in producing stem/progenitor cells and the malignant process is not accelerated.[73]
Middle ear barotrauma is always a consideration in treating both children and adults in a hyperbaric environment because of the necessity to equalise pressure in the ears.
Pregnancy is not a relative contraindication to hyperbaric oxygen treatments,[69][page needed] although it may be for underwater diving. In cases where a pregnant woman has carbon monoxide poisoning there is evidence that lower pressure (2.0 ATA) HBOT treatments are not harmful to the fetus, and that the risk involved is outweighed by the greater risk of the untreated effects of CO on the fetus (neurologic abnormalities or death.)[74][75] In pregnant patients, HBO therapy has been shown to be safe for the fetus when given at appropriate levels and "doses" (durations). In fact, pregnancy lowers the threshold for HBO treatment of carbon monoxide-exposed patients. This is due to the high affinity of fetal hemoglobin for CO.[69][page needed]
The therapeutic consequences of HBOT and recompression result from multiple effects.[4][76]
The increased overall pressure is of therapeutic value in the treatment of decompression sickness and air embolism as it provides a physical means of reducing the volume of inert gas bubbles within the body;[77] Exposure to this increased pressure is maintained for a period long enough to ensure that most of the bubble gas is dissolved back into the tissues, removed by perfusion and eliminated in the lungs.[76]
The improved concentration gradient for inert gas elimination (oxygen window) by using a high partial pressure of oxygen increases the rate of inert gas elimination in the treatment of decompression sickness.[78][79]
For many other conditions, the therapeutic principle of HBOT lies in its ability to drastically increase partial pressure of oxygen in the tissues of the body. The oxygen partial pressures achievable using HBOT are much higher than those achievable while breathing pure oxygen under normobaric conditions (i.e. at normal atmospheric pressure). This effect is achieved by an increase in the oxygen transport capacity of the blood. At normal atmospheric pressure, oxygen transport is limited by the oxygen binding capacity of hemoglobin in red blood cells and very little oxygen is transported by blood plasma. Because the hemoglobin of the red blood cells is almost saturated with oxygen at atmospheric pressure, this route of transport cannot be exploited any further. Oxygen transport by plasma, however, is significantly increased using HBOT because of the higher solubility of oxygen as pressure increases.[76]
A study suggests that exposure to hyperbaric oxygen (HBOT) might also mobilize stem/progenitor cells from the bone marrow by a nitric oxide-dependent mechanism.[80]
A more recent study suggests that stem cell mobilization, similar to that seen in the Thom study, is also invoked at relative normo-baric pressure with a significantly smaller increase in oxygen concentration. This study also found a significant decrease in the expression of the systemic inflammatory cytokine TNF-α in venous blood. These results suggest that hyperbaria may not be required to invoke the transcriptional responses seen at higher partial pressures of oxygen and that the effect is due solely to oxygen. [3]
Multiplace hyperbaric chambers, showing control panel, monitoring facilities, and different chamber sizes in Spanish facilities
The traditional type of hyperbaric chamber used for therapeutic recompression and HBOT is a rigid shelled pressure vessel. Such chambers can be run at absolute pressures typically about 6 bars (87 psi), 600,000 Pa or more in special cases.[81] Navies, professional diving organizations, hospitals, and dedicated recompression facilities typically operate these. They range in size from semi-portable, one-patient units to room-sized units that can treat eight or more patients. The larger units may be rated for lower pressures if they are not primarily intended for treatment of diving injuries.
A rigid chamber may consist of:
a pressure vessel with the view ports (windows) made of acrylic;[81]
one or more human entry hatches – small and circular or wheel-in type hatches for patients on gurneys;[81]
the entry lock that allows human entry – a separate chamber with two hatches, one to the outside and one to the main chamber, which can be independently pressurized to allow patients to enter or exit the main chamber while it is still pressurized;[81]
a low volume medical or service airlock for medicines, instruments, and food;[81]
transparent ports or closed-circuit television that allows technicians and medical staff outside the chamber to monitor the patient inside the chamber;
an intercom system allowing two-way communication;[81]
an optional carbon dioxide scrubber – consisting of a fan that passes the gas inside the chamber through a soda lime canister;[81]
a control panel outside the chamber to open and close valves that control air flow to and from the chamber, and regulate oxygen to hoods or masks;[81]
an over-pressure relief valve;[81]
a built-in breathing system (BIBS) to supply and exhaust treatment gas;[81]
a fire suppression system.[81]
Flexible monoplace chambers are available ranging from collapsible flexible aramid fiber-reinforced chambers which can be disassembled for transport via truck or SUV, with a maximum working pressure of 2 bar above ambient complete with BIBS allowing full oxygen treatment schedules.[82][83][84] to portable, air inflated "soft" chambers that can operate at between 0.3 and 0.5 bars (4.4 and 7.3 psi) above atmospheric pressure with no supplemental oxygen, and longitudinal zipper closure.[85]
A recompression chamber for a single diving casualty
In the larger multiplace chambers, patients inside the chamber breathe from either "oxygen hoods" – flexible, transparent soft plastic hoods with a seal around the neck similar to a space suit helmet – or tightly fitting oxygen masks, which supply pure oxygen and may be designed to directly exhaust the exhaled gas from the chamber. During treatment patients breathe 100% oxygen most of the time to maximise the effectiveness of their treatment, but have periodic "air breaks" during which they breathe chamber air (21% oxygen) to reduce the risk of oxygen toxicity. The exhaled treatment gas must be removed from the chamber to prevent the buildup of oxygen, which could present a fire risk. Attendants may also breathe oxygen some of the time to reduce their risk of decompression sickness when they leave the chamber. The pressure inside the chamber is increased by opening valves allowing high-pressure air to enter from storage cylinders, which are filled by an air compressor. Chamber air oxygen content is kept between 19% and 23% to control fire risk (US Navy maximum 25%).[81] If the chamber does not have a scrubber system to remove carbon dioxide from the chamber gas, the chamber must be isobarically ventilated to keep the CO2 within acceptable limits.[81]
A soft chamber may be pressurised directly from a compressor.[85] or from storage cylinders.[84]
Smaller "monoplace" chambers can only accommodate the patient, and no medical staff can enter. The chamber may be pressurised with pure oxygen or compressed air. If pure oxygen is used, no oxygen breathing mask or helmet is needed, but the cost of using pure oxygen is much higher than that of using compressed air. If compressed air is used, then an oxygen mask or hood is needed as in a multiplace chamber. Most monoplace chambers can be fitted with a demand breathing system for air breaks.[86] In low pressure soft chambers, treatment schedules may not require air breaks, because the risk of oxygen toxicity is low due to the lower oxygen partial pressures used (usually 1.3 ATA), and short duration of treatment.
For alert, cooperative patients, air breaks provided by mask are more effective than changing the chamber gas because they provide a quicker gas change and a more reliable gas composition both during the break and treatment periods.[87]
Initially, HBOT was developed as a treatment for diving disorders involving bubbles of gas in the tissues, such as decompression sickness and gas embolism, It is still considered the definitive treatment for these conditions. The chamber treats decompression sickness and gas embolism by increasing pressure, reducing the size of the gas bubbles and improving the transport of blood to downstream tissues. After elimination of bubbles, the pressure is gradually reduced back to atmospheric levels. Hyperbaric chambers are also used for animals, especially race horses where a recovery is worth a great deal to their owners. It is also used to treat dogs and cats in pre- and post-surgery treatment to strengthen their systems prior to surgery and then accelerate healing post surgery.
Emergency HBOT for decompression illness follows treatment schedules laid out in treatment tables. Most cases employ a recompression to 2.8 bars (41 psi) absolute, the equivalent of 18 metres (60 ft) of water, for 4.5 to 5.5 hours with the casualty breathing pure oxygen, but taking air breaks every 20 minutes to reduce oxygen toxicity. For extremely serious cases resulting from very deep dives, the treatment may require a chamber capable of a maximum pressure of 8 bars (120 psi), the equivalent of 70 metres (230 ft) of water, and the ability to supply heliox as a breathing gas.[76]
U.S. Navy treatment charts are used in Canada and the United States to determine the duration, pressure, and breathing gas of the therapy. The most frequently used tables are Table 5 and Table 6. In the UK the Royal Navy 62 and 67 tables are used.
The Undersea and Hyperbaric Medical Society (UHMS) publishes a report that compiles the latest research findings and contains information regarding the recommended duration and pressure of the longer-term conditions.[88]
An example of mild portable hyperbaric chamber. This 40-inch-diameter (1,000 mm) chamber is one of the larger chambers available for home.
There are several sizes of portable chambers, which are used for home treatment. These are usually referred to as "mild personal hyperbaric chambers", which is a reference to the lower pressure (compared to hard chambers) of soft-sided chambers.
In the US, these "mild personal hyperbaric chambers" are categorized by the FDA as CLASS II medical devices and requires a prescription in order to purchase one or take treatments.[89] The most common option (but not approved by FDA) some patients choose is to acquire an oxygen concentrator which typically delivers 85–96% oxygen as the breathing gas.
Oxygen is never fed directly into soft chambers but is rather introduced via a line and mask directly to the patient. FDA approved oxygen concentrators for human consumption in confined areas used for HBOT are regularly monitored for purity (+/- 1%) and flow (10 to 15 liters per minute outflow pressure). An audible alarm will sound if the purity ever drops below 80%. Personal hyperbaric chambers use 120 volt or 220 volt outlets.
There are risks associated with HBOT, similar to some diving disorders. Pressure changes can cause a "squeeze" or barotrauma in the tissues surrounding trapped air inside the body, such as the lungs,[68] behind the eardrum,[90][91] inside paranasal sinuses,[90] or trapped underneath dental fillings.[92] Breathing high-pressure oxygen may cause oxygen toxicity.[93] Temporarily blurred vision can be caused by swelling of the lens, which usually resolves in two to four weeks.[94][95]
There are reports that cataract may progress following HBOT.[96]
Patients inside the chamber may notice discomfort inside their ears as a pressure difference develops between their middle ear and the chamber atmosphere.[97] This can be relieved by ear clearing using the Valsalva maneuver or other techniques. Continued increase of pressure without equalising may cause ear drums to rupture, resulting in severe pain. As the pressure in the chamber increases further, the air may become warm.
To reduce the pressure, a valve is opened to allow air out of the chamber. As the pressure falls, the patient's ears may "squeak" as the pressure inside the ear equalizes with the chamber. The temperature in the chamber will fall. The speed of pressurization and de-pressurization can be adjusted to each patient's needs.
HBOT is recognized by Medicare in the United States as a reimbursable treatment for 14 UHMS "approved" conditions. A 1-hour HBOT session may cost between $300 and higher in private clinics, and over $2,000 in hospitals. U.S. physicians (M.D. or D.O.) may lawfully prescribe HBOT for "off-label" conditions such as stroke,[98][99] and migraine.[100][101] Such patients are treated in outpatient clinics. In the United Kingdom most chambers are financed by the National Health Service, although some, such as those run by Multiple Sclerosis Therapy Centres, are non-profit. In Australia, HBOT is not covered by Medicare as a treatment for multiple sclerosis.[102] China and Russia treat more than 80 maladies, conditions and trauma with HBOT.[103]
Aspects under research include radiation-induced hemorrhagic cystitis;[104] and inflammatory bowel disease,[105] rejuvenation.[106]
Tentative evidence shows a possible benefit in cerebrovascular diseases.[107] The clinical experience and results so far published has promoted the use of HBOT therapy in patients with cerebrovascular injury and focal cerebrovascular injuries.[108] However, the power of clinical research is limited because of the shortage of randomized controlled trials.[107]
A 2010 review of studies of HBOT applied to wounds from radiation therapy reported that, while most studies suggest a beneficial effect, more experimental and clinical research is needed to validate its clinical use.[109]
Junod built a chamber in France in 1834 to treat pulmonary conditions at pressures between 2 and 4 atmospheres absolute.[110]
During the following century "pneumatic centres" were established in Europe and the USA which used hyperbaric air to treat a variety of conditions.[111]
Orval J Cunningham, a professor of anaesthesia at the University of Kansas in the early 1900s observed that people suffering from circulatory disorders did better at sea level than at altitude and this formed the basis for his use of hyperbaric air. In 1918 he successfully treated patients suffering from the Spanish flu with hyperbaric air. In 1930 the American Medical Association forced him to stop hyperbaric treatment, since he did not provide acceptable evidence that the treatments were effective.[111][63]
The English scientist Joseph Priestley discovered oxygen in 1775. Shortly after its discovery, there were reports of toxic effects of hyperbaric oxygen on the central nervous system and lungs, which delayed therapeutic applications until 1937, when Behnke and Shaw first used it in the treatment of decompression sickness.[111]
In 1955 and 1956 Churchill-Davidson, in the UK, used hyperbaric oxygen to enhance the radiosensitivity of tumours, while Ite Boerema [nl], at the University of Amsterdam, successfully used it in cardiac surgery.[111]
In 1961 Willem Hendrik Brummelkamp [nl] et al. published on the use of hyperbaric oxygen in the treatment of clostridial gas gangrene.[112]
In 1962 Smith and Sharp reported successful treatment of carbon monoxide poisoning with hyperbaric oxygen.[111]
The Undersea Medical Society (now Undersea and Hyperbaric Medical Society) formed a Committee on Hyperbaric Oxygenation which has become recognized as the authority on indications for hyperbaric oxygen treatment.[111]
Undersea and Hyperbaric Medical Society – US based organisation for research and education in hyperbaric physiology and medicine.
South Pacific Underwater Medicine Society – Publisher for diving and hyperbaric medicine and physiology
Decompression chamber – Hyperbaric pressure vessel for human occupation used in diving operations to decompress divers
Hyperbaric treatment schedules – Planned sequences of hyperbaric pressure exposure using a specified breathing gas as medical treatment
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Kindwall EP, Whelan HT (2008). Hyperbaric Medicine Practice (3rd ed.). Flagstaff, AZ: Best Publishing Company. ISBN 978-1-930536-49-4.
Mathieu D (2006). Handbook on Hyperbaric Medicine. Berlin: Springer. ISBN 978-1-4020-4376-5.
Neubauer RA, Walker M (1998). Hyperbaric Oxygen Therapy. Garden City Park, NY: Avery Publishing Group. ISBN 978-0-89529-759-4.
Jain KK, Baydin SA (2004). Textbook of hyperbaric medicine (4th ed.). Hogrefe & Huber. ISBN 978-0-88937-277-1. (6th edition from Springer in press 2016)
Harch PG, McCullough V (2010). The Oxygen Revolution. Long Island City, NY: Hatherleigh Press. ISBN 978-1-57826-326-4.
Hyperbaric Oxygen Therapy from eMedicine
Duke University Medical Center Archives contains collections of multiple individuals who worked with hyperbaric medicine
Dunning, Brian (November 19, 2019). "Skeptoid #702: Hyperbaric Oxygen Therapy". Skeptoid.
Tests and procedures involving the respiratory system
Upper RT
Somnoplasty
Alarplasty
Rhinectomy
Rhinomanometry
Acoustic rhinometry
Sinusotomy
larynx
Laryngectomy
Laryngotomy
Thyrotomy
Laryngotracheal reconstruction
Lower RT
Cricothyrotomy
Tracheoesophageal puncture
bronchus
Pneumonectomy
Lobectomy
Wedge resection
Decortication
Heart–lung transplant
Chest wall, pleura,
mediastinum,
and diaphragm
pleura/pleural cavity
Pleurodesis
Thoracotomy
Chest tube
mediastinum
Mediastinoscopy
Nuss procedure
Bronchography
CT pulmonary angiogram
High-resolution computed tomography
Ventilation/perfusion scan
Clinical prediction rule
Pneumonia severity index
CURB-65
Body plethysmography
Bronchial challenge test
Diffusion capacity
Bronchoalveolar lavage
Nasopharyngeal swab
Blood gas test
Surgical airway management
Mechanical ventilation
Negative pressure ventilator
Positive pressure ventilation
Artificial respiration
Decompression chamber
Hyperinflation therapy
Pulmonary hygiene
Authority control: National libraries


JACKSON, MI - The city of Jackson has 30 days to put together an approved plan to repay all those it still owes for assessing an illegal stormwater fee.
If the city does not do so, Jackson County Circuit Judge John McBain said he would hold the municipality in contempt of court.
McBain made the ruling Tuesday, April 7, in response to a motion for "enforcement of the final order" filed by Brian Surgener, the attorney for Phillip Panzica, who filed a class action lawsuit against the city in August.
The lawsuit asked everyone who paid the stormwater fee, deemed unconstitutional by the Michigan Court of Appeals, be refunded. A final stipulated order in October instructed the city to do so.
If the city did not by a specific date, it was to arrange a payment plan accepted by the judge, Surgener told McBain this week, and Surgener had never seen a detailed proposal.
Sonal Mithani, who represents the city through Detroit law firm Miller Canfield, said the city was in compliance with the order and had promised to repay everyone by 2018. "I don't think there is anything to enforce," she said and argued a judge should not "execute a priority over certain creditors" or dictate repayment specifics. McBain called this contention "way off base."
The city has "graciously paid back" about $340,000, but about 800 properties are still owed about $468,000, said Surgener, seeking a payment plan.
Created in 2011, the stormwater utility fee generated nearly $3 million in billings. City officials enacted the fee to pay for street sweeping, leaf pickup, catch-basin cleaning and other services, which have been suspended since the Court of Appeals decision finding the fee an illegal tax.
Because of a statute of limitations, the city only has to refund residents and businesses for one year of billings.
McBain on Tuesday critized the city for availing itself of the "convenient" statute of limitations and only refunding 1/3 of what it charged. "There is a difference between what is right and what is legal," he said.
In December, City Manager Patrick Burtch said the city did not have the funds readily available to immediately repay property owners.
Refunds to city residents were to come from about $280,000 of leftover stormwater funds and a combination of street funds and general fund dollars. Businesses are to be repaid from street, water and sewer and general funds, Burtch earlier said.
Mithani on Tuesday said the city had repaid 94 percent of account holders.
Surgener said those that are owed the most are yet to receive refunds.
McBain said the parties should work with each other to put together a plan for repayment. He scheduled a next hearing, a "control date" to assess their progress for May 5.


To support Children in Need on Friday this week, students and staff are invited to come to school in non-uniform with a suggested theme of 'Spots and Stripes' and a £1 voluntary donation.
Remember that there will be a Bake Off House competition for Children in Need on Friday too. Children in Need themed bakes will be marked on creativity, appearance and taste. Please deliver all bakes to the main reception by 8:50am on Friday 17th November. Slices will then be on sale for 50p at break time, with all proceeds going to Children in Need.


After a thrilling league across the length and breadth of the country, the Three Ireland's EStars Final took to the stage of Dublin's 3Arena on Sunday, May 13th.
With league toppers Shamrock Rovers facing off against close second Sligo Rovers, after both teams had dominated their semi-final clashes, months of practice and dedication finally paid off when Sligo Rovers took the trophy, the €20,000 prize pot and booked their passage for a trip to Las Vegas. It was an epic end to what had been a thrilling tour of gaming prowess, that kicked off in Dundalk two months previously.
It started with a dream, to see esports on the stage of the 3Arena, a dream that began to take formation in Dundalk's Oriel Park on March 14th. Ten teams, representing nine League of Ireland football clubs and main sponsors Three and composed of the country's finest gaming talent, battling to earn their place at the Final. With twists and turns leaving six teams in contention up until the final night. Every win was crucial. Every loss was devastating. This is not a game. This was always so much more..
The event opened with DJ Luke O'Faolain setting the tone of the occasion, before presenters Connor Philips and Holly Hamilton invited the 'Class of 2018' finalists on stage, a massive production that included the mobile sports arena, Big Betty herself, led by percussion troupe, The Hit Machine Drummers. With that introduction, the finalists took their seats, facing out at a phenomenal crowd as they prepared to stake their claim to be crowned Three Ireland's EStars.
Having gone into the final as favourites following a blistering league campaign, despite dropping a game in the semi-final to Bray Wanderers, their first since their week one encounter, Shamrock Rovers were a formidable force. Ash "Auto Tank" McNamara, Daniel "Zoinkers" White, Luke "Doctor Yeti" Higgins, Adam "Adzie" Smails and Ray "Rayezor" Murphy had become a strong and cohesive unit across the league. Sligo Rovers also impressed throughout the league campaign, finishing slightly behind Shamrocks. Having dropped a couple of points earlier in the league, Sligo Rovers grew in confidence and capability and, having secured play-off position, made short work of Team Three in the semi-finals. Viktor "Keksius" Kudrickij, Johnny "Dragonship" Cummins, Kevin "Bluebullberry" Treanor, Robert "Deviilz" Cooney and Darren "Dakin" Hopkins were determined to take down Shamrocks after their defeat at their hands earlier in the campaign. While both teams had a cautious start, Sligo quickly gained control of the game to take apart Shamrocks, regaining bragging rights from their league clash and taking the all-important opening game. Result: Shamrock Rovers 0 Sligo Rovers 1.
Result Shamrock Rovers 0 Sligo Rovers 2.
The battle of the Rovers decided, streamers Sjin and Turps from the Yogscast and Rossboomsocks joined Nikita Buffee for a Q&A, including an impromptu visit on stage by Gross Gore, before dance sensations Prodijig gave a stunning performance to close the performances. All that remained, was for Sligo Rovers to take the stage one final time to receive the Three Ireland's EStars trophy.
Mags Byrne of Three Ireland's EStars said that the Finals at the 3Arena had been a fitting finale to the ambitious and gripping league.


I just want to write people's stories and impact them. I want people to feel something when I sing, whether it gives them hope in a dark place or tears of compassion. I think the world is so full of stories and all people need is a voice for the voiceless.
I would start with telling people to love sacrificially. I think we really just need to go back to the basics and love our fellow humans as ourselves. I know it sounds super cheesy and simple, but the most powerful forces in the world are nothing compared to the power of love.
Let me think about this.... Switchfoot, Chevelle and Thousand foot crutch... Yeah! Please if you haven't heard of TFK please look them up now pronto!
"You have a story that needs to be heard,"
I think musicians with talent are made to become some kind of spectacle and have to fit a certain mold. They're told that originality and uniqueness is not important and you should just be popular. That's not right; musicians were never to become products you could sell.
Being able to commit to regularly sharing my work! I have random moments where I want everyone to hear haha, but it never lasts.


How to Watch Big Brother Nigeria 2019 Online for Free.
In responses to the numerous searches, we have deemed it fit to create a simple method on how to view the Big Brother Naija 2019 reality TV show as clearly written below in your respective country of residence comfortably.
Due to the recent comeback of the 2019 BB Naija TV show, lots of fans of the show never seems to stop searching for how to watch the Big Brother Nigeria online using Phone or Computer devices.
BigBrother Naija 2019 can be viewed live on the Android or iPhones. You can watch the BB Naija 2019 show from your mobile phone by downloading the DStv Now App. It is available for Android (Play Store) and iOS store (Apple Store).
Interested person who which to watch the show should follow HERE to Download on Android or Download DSTV Now App for iOS by following HERE.
You will have to create DStv Connect ID. You will need your smart card number to create the ID. Click on the DSTV Now Menu icon to reveal a list of TV channels available for streaming online.
Alternatively, if you're in foreign country and you're having difficulties in watching the show online, you can follow our LIVE STREAM for latest happening in the 2019 show.
Stay connected to the site for latest news Big Brother Nigeria 2019 live gist and updates.


One of the McDonald's eateries is placed at Tyneside Retail Park, Coast Road North Shields, post code NE28 9ND. This place's internal name is Silverlink. Its guests come from nearby towns like Battle Hill, Willington, Wallsend, North Tyne Tunnel. This place is normally open on: Monday 05:00 - 05:00, Tuesday 05:00 - 05:00, Wednesday 05:00 - 05:00, Thursday 05:00 - 05:00, Friday 05:00 - 05:00. During the weekends: on Saturday 05:00 - 05:00, on Sunday 05:00 - 05:00. For further information please call the diner at the number 0191 295 3232.


text:
Attraction & Retention of Top Employers & Talent
Support for Small Businesses
Improving Quality of Life
Municipal Action
By: Stacy Pearson
New Advocacy Group Launched to Solve Valley Housing Shortage
Phoenix – Arizona has a housing supply problem. And Home Arizona is advocating for a solution. Home Arizona is a new pro-housing advocacy group launched by Arizona's top economists, business leaders, policy experts and developers who are encouraging policymakers to understand the shortage and potential remedies before it becomes a major economic-development problem. "Home Arizona was founded […]
A single mom's rent went up $700, an increase an economist says is happening across the Valley
"We're seeing year-over-year rent increases of more than 20% pretty much across the Valley," Court said. Colleen Sikora — 12 News PHOENIX — Photos of two young boys hang on the wall in Alicia's two-bedroom apartment. "That's just right outside," she said. They're her young boys, now 11 and 14, in the photo that was taken […]
Pollack sounds the alarm on affordability, though outlook for future positive
By Corina Vanek — Phoenix Business Journal Despite some looming challenges, especially housing affordability, in Phoenix, economic experts presenting at the Greater Phoenix Chamber's annual Economic Outlook agreed the future for both the state and country is positive. Elliott Pollack, founder of Scottsdale-based Elliott D. Pollack & Co., said both rental housing vacancy and homeowner […]
How the Homeownership Rate in Arizona Compares To Other States
Samuel Stebbins, 24/7 Wall St. via The Center Square Homeownership is a longstanding aspiration for millions of Americans. According to a Gallup poll, more than nine in every 10 American investors consider owning a home to be either an essential or important component of the American dream. Homeownership can… Full Story »
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redpajama_set_name: RedPajamaCommonCrawl


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Yi Shin
Who is Yi Shin? He is a male celebrity. He was born on Thursday November 6th 1980, in Taegu, South Korea,.
Yi Shin is gifted with natural leadership and the capacity to accumulate great wealth. He has great talent for management in all walks of life, especially in business and financial matters, where he contributes the greater vision, purpose, and long-range goals. He understands the material world, and intuitively knows what makes virtually any enterprise work. Business, finance, real estate, law, science (particularly history, archeology, and physics), publishing, and the management of large institutions are among the vocational fields that suit Yi best. He is naturally attracted to positions of influence and leadership, and politics, social work, and teaching are among the many other areas where his abilities can shine.
He possesses the ability to inspire people to join him in his quest, even when they are incapable of seeing what he sees. Therefore, those around Yi Shin need his continual guidance, inspiration, and encouragement. Shin is a good judge of character, which serves him well in attracting the right people that he can prod them then into action and direct them along the lines of his vision.
Yi's challenge in life is to understand that power and influence must be used for the benefit of mankind, and only for his personal gain. Otherwise, Yi Shin is bound to suffer the consequences of greed and run the risk of losing it all. He must also learn to bounce back from failures and defeats. As with many greate visionaries, Shin can be reckless for lack of attention to details. Thus, it is not unlikely for such personality to experience major reverses, including bankruptcies and financial failure. Yi Shin, however, has the talent and the sheer guts to make more than one fortune, and build many successful enterprises.
Shin is likely to mold a large family around him, and he is inclined sometimes to keep them dependent longer than necessary. However, Yi Shin is not demonstrative in showing his love and affection. Also, Yi must be careful of becoming stubborn, intolerant, overbearing, and impatient. These characteristics may have been born early in his life, after suffering himself under a tyrannical parent or a family burdened by repressive religious or intellectual dogmas. More...
Yi Shin tends to be quite adaptable, and he finds it easy to fit into most social set ups and vocational fields.
There are no particular virtues that can cause an imbalance in Yi's personality and life, but he has to work hard and persistently to develop those special strengths that he desires to attain.
Learning to be wisely assertive is a major lesson to be taken by Yi Shin throughout his life.
January 17th 2022 is a dynamic and even hectic for Yi Shin that may bring some change in his career.
Generally speaking, today is a day of unexpected events that may even include travel.
Yi will be able to spend some of his restless energy in social events, but with his restlessness - he better watch for signs of lacking self-discipline.
Other male celebrities born on the same day as Yi Shin
Lamar Odom (1979)
An American former professional basketball player who won NBA championships in 2009 and 2010 and was named the NBA Sixth Man of the Year in 2011 as a member of the Los Angeles Lakers
Aaron Hernandez (1989)
A former American football tight end and convicted murderer of a fellow football player, who was a member of a BCS National Championship team and was recognized an All-American in his college football days for the University of Florida
Adolphe Sax (1814-1894)
A Belgian inventor and musician, who played the flute and clarinet, made several changes to the design of the French horn, began to make his own instruments at an early age, created the saxophone in the early 1840s, and invented the saxotromba, saxhorn and saxtuba
Glenn Frey (1948-2016)
An American singer, songwriter and actor, a founding member of the rock band Eagles, its lead singer and frontman, who played guitar, piano, and keyboards, and - together with Don Henley - wrote most of the Eagles' repertoire
Chris Soules (1981)
An American reality television personality and a 4th-generation farmer who starred in the 19th season of ABC's The Bachelor, became a fan favorite during his time on the tenth season of The Bachelorette, and appeared in Dancing with the Stars
Melvin Gordon (1993)
An American football running back for the NFL's San Diego Chargers, who held in 2014 the NCAA Division I FBS single game rushing yardage record with 408 yards, and was 2nd all-time single season rusher in FBS history with 2,587 yards
Ethan Hawke (1970)
An American actor, writer, and director, who has directed three feature films, three Off-Broadway plays, and a documentary, has written three novels, and has been nominated for four Academy Awards and a Tony Award
James Jones (1921-1977)
A Football Player and Athlete
Pat Tillman (1976-2004)
A professional American football player in the National Football League (NFL) who enlisted in the United States Army in the aftermath of the September 11 attacks, served in Iraq and Afghanistan, and died during his tours
Zig Ziglar (1926)
An American author, salesman, and motivational speaker who integrated Christianity into his motivational work and was also an open Republican, and wrote the successful book See You at the Top (1975)
Yi Shin personality profile | © Copyright 2009-2022 Celebrities Galore and Master Numerologist Hans Decoz


If you have a crowded table at the holidays, you want a good wine at an excellent price point. This is it! The 2013 Santa Carolina Reserve Pinot Noir, priced at $12 a bottle, tastes like bing cherries, currants, with a whisper of spice, making it very food-friendly. We've made it our new house wine.
The Chilean vineyard that makes this wine was started in 1875 when Don Luis Pereira arrived with rootstock from Bordeaux, France. They harvest by hand, the old fashioned, to this very day. Santa Carolina's pinot is grown in a seaside parcel, where fog rolls in and evenings are cool. If there's a better deal at this price for a food-friendly winner, I don't know where it is. Think Thanksgiving, people!
Call ahead to your wine store. Read them the label and be sure to tell them the regional distributor is Brescome-Barton. A good wine store will have it to you within 24 hours.
(Click the image to see a close-up of the label).
Hi Faith, I really enjoy listening to your show on the weekend! If I am at home or running errands in the car on Saturday morning, I have the radio tuned to Public Radio. This past week you mentioned the Santa Carolina Reserve Pinot Noir. I called my local wine merchant (Michael's in Riverhead, NY) but they can only get the 2015. Can you recommend this vintage with the same enthusiasm as you expressed for the 2013?
Stay tuned. We'll get right back to you on this.
Hi Lisa. First, I forgot to thank you for listening! Now, from Mark Raymond: "The vintages in Chile are very consistent. I just had a bottle the yesterday, and it was excellent. Juicy Dark Plum with notes of Bright Red Raspberry." You can go ahead and buy that bottle with confidence. Please let us know your thoughts after you drink it. Happy Thanksgiving!
Hi, Same for me. My local package store only showed the 2015. Can you recommend distributors that can get the 2013? I am in the Waterbury area. Thanks!
Hi Maureen, I'm so sorry to say that shortly after the show aired, the 2013's in our area were scooped up (presumably) by other Food Schmooze listeners who heard Faith and Mark rave about it. Not only bottles–but cases sold in record time. It happens! We're going to keep the wines coming all holiday season long, so don't despair. In the meantime, go ahead and enjoy the 2015. Mark just finished a bottle and says it's just as delicious. Plumy and bound to please.


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Jay-Z Teams Up With The New York Yankees For Co-Branded Clothing
Jay-Z said in his hit single "Empire State of Mind" that he "made the Yankee hat more famous than a Yankee can…", and now he has a chance to prove that line.
The hip-hop superstar has teamed up with the New York Yankees for a line of co-branded, limited edition clothing sold exclusively at Yankees Stadium starting next week, reports the Associated Press.
The range of gear includes baseball caps to t-shirts to hoodies, all of which will feature both the Yankees and Jay-Z logos.
On Thursday (August 26), the Yankees said the attire was created to commemorate the first official concerts at the new Yankee Stadium on September 13 and 14, when Jay-Z and Eminem will co-headline, which was announced back in May.
The short summer tour is dubbed the "Home and Home" tour, which will follow joint performances at Detroit's Comerica Park on September 3 and 4.
The new Jay, Yankees merch will be available at Yankee Stadium from August 30 to September 14.
Jay-ZMLB


Road rage is the theme of this week's event mode where fuel and fire are king. In Crash Carnage, no firearms spawn so you'll need to focus on melee weapons, throwables, and of course your driving skills to carry your duo to that final circle. Circles move considerably faster in this event, so loot quick, grab a vehicle, and crash your way to road warrior glory.
Teams of duos will fight in Erangel. Up to 100 players can join.
Land vehicles, with the exception of motorcycles, will spawn throughout the map.
Firearms will not spawn; instead, melee weapons, throwables, consumables, and other gear will spawn.
Blue Zone will move faster than usual, especially the first Blue Zone.
The first Safe Zone, and the center point of the final Safe Zone, will be indicated with a flag icon on the minimap.
Pre #22 patch: ping 50.
Ping never went under 280. Any explanation?
My ping is 350-400. I can not play. However, I like the mode.
Ping never went under 280. Any explanation?
Sometimes kinda hard to find a vehicle..
I said it before and i'll say it again, i wish you could have the option tho choose theese events all the time even though it's probably not possible.
I'm from SA (South America) and always get AS servers (300ms+). This Event is so fun, but unplayable with this ping. Region Lock doens't work for Event Modes, add some Ping Lock or something like that.
Did u play to this event??
Please add this to xbox next!


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Financial Mess: Bayelsa Govt Can No Longer Fund Niger Delta University.
The Governor of Bayelsa State, Mr Seriake Dickson, on Thursday disclosed that the state government could no longer continue funding the state-owned Niger Delta University in Wilberforce Island, Amassoma.
Dickson, who spoke during a meeting with the Governing Council and principal officers of NDU in Government House, Yenagoa, noted that he could not sustain the existing funding system owing to the present poor financial standing of the state.
He called on the striking workers and management of the only state-owned university in the state to be more resourceful and innovative in generating revenue for the institution.
The governor noted that a situation where the state government's monthly subvention of about N480 million is spent on only the university's recurrent expenditure was 'unsustainable'.
He harped on the need for the University leadership to be prudent in the use of funds, with a view to enabling the institution gain some degree of financial autonomy.
Dickson called on the Academic Staff Union of University, ASUU, to call off the ongoing strike action caused by the sharp drop in state revenues. Source: Thisday.
Opinion: Seem Bayelsa State is facing serious financial crisis. The state is in a financial mess. All these problem boils down to corruption. Well the university should device a means of raising revenues to sustain itself. Increase in tuition fees, might not be ruled out. More problems for the innocent poor students.
C.V.Akuta Media UK.
Previous No Difference Between Boko Haram and The Niger Delta Avengers.
Next Strange: Sex With Animals Are Legal in Canada.


FLUIDIFEEL? EASY wins the silver award for the best innovation in the "Best Functional Ingredient" category at In Cosmetics Asia 2018. Developed in its laboratory in Castres (France), this natural and RSPO Mass Balance* certified emulsifier stabilizes fluid to very fluid formulations. Of vegetable origin and COSMOS certified, it is 100% Natural Origin Content (according to the new ISO 16128 standard), and is free from any preservative.
Seppic addresses the challenge of stabilizing fluid formulations to make life easier for formulators and to meet consumer expectations. FLUIDIFEEL? EASY is perfect for low and very low viscosity skincare, haircare, suncare or make-up beauty products as it is sprayable and compatible with oils of different types, pigments, sun filters and numerous active ingredients. Time and energy are also saved as the formula does not need to be heated to be nice and stable.
FLUIDIFEEL? EASY is registered worldwide, including China.


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Cette liste recense les maires successifs de Candes puis, à partir de 1949, de Candes-Saint-Martin.

Liste des maires

Pour approfondir

Articles connexes
 Histoire des maires de France
 Conseil municipal
 Élection municipale française

Liens externes
 Site officiel de l'association des maires de France

Notes et références

Notes

Références

Candes-Saint-Martin

redpajama_set_name: RedPajamaWikipedia


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Q: Dynamically Compiling SilveLight 4.0 Error Type 'System.ComponentModel.Design.HelpKeyword' is not defined When I dynamically compile SilverLight 4.0 application using Microsoft.VisualBasic.VBCodeProvider, I get the following error.

Line: 118 ErrorCode: BC30002 Error: Type 'System.ComponentModel.Design.HelpKeyword' is not defined.
Line: 130 ErrorCode: BC30002 Error: Type 'System.ComponentModel.Design.HelpKeyword' is not defined.
Line: 141 ErrorCode: BC30002 Error: Type 'System.ComponentModel.Design.HelpKeyword' is not defined.
Line: 234 ErrorCode: BC30002 Error: Type 'System.ComponentModel.Design.HelpKeyword' is not defined.

I would appreciate any help on how to resolve this.

A: According to MSDN, this Type is not supported in Silverlight. This means that you need to adjust your code to exclude references to this type. We regularly do this using conditional directives (#if).

redpajama_set_name: RedPajamaStackExchange


The year I moved to Chicago I was cast in a play that rehearsed at the School of the Art Institute. Each day when I arrived, I would pause at the front desk while the security guard took a photograph of me, without looking at me or telling me when the photograph would be taken. The guard would print out the photograph on an adhesive badge which stated my name and the room number that was my destination. I was then permitted to exist inside the building.
But these photographs were not me. Beyond that, they were terrifying; in some I looked even wild or deranged. The fact that I always knew a photograph would be taken but that I would not be given the customary countdown of 1, 2, 3, meant that I was always preparing to be captured and always unprepared to accept the identity of the face inside the frame.
They were called Visitor Badges. All bodies that did not already belong in some way to the School of the Art Institute of Chicago were required to wear them in the building at all times. But my association with the building was theatrical; I was there to practice, for three months before the show opened, becoming a real person who was both me and not me.
The captured face allowed me to ride the elevator up six floors—sometimes ten, sometimes three—walk down a hall, and enter the room that matched the number printed on my badge.
I was not to enter a different room. I was not to wear a different face than the one I'd been given.
I arrived at the building on South Michigan only when my character, Sarah Fresh—the one I was becoming—had been summoned. Sarah Fresh was both me and not me. She wore my clothes—a sleeveless red cropped tank top and high-waisted, ripped blue jeans. Like me, she smoked cigarettes and hung out barefoot on the beach. Like me, she was a dancer. Unlike me, she possessed a kind of confidence I had only ever dreamed I could exude; a kind of confidence that I wished people could see in me. But I practiced. I was committed to becoming Sarah Fresh, my role in the play. I was committed to taking on the identity that had been given to me.
At eight or nine years old I watched my mother direct a stage adaptation of the Kurt Vonnegut short story, "Who Am I This Time?" It was a story about a shy young man who fully embodied the characters he played onstage. Whenever he was invited to join a new play, he would inquire, who am I this time? He would become the role he was given, and then, when the play ended, he would return once again to a blank non-existence and wait for his next identity to emerge.
When the rehearsal process ended at the School of the Art Institute of Chicago, I was left with a stack of photographs of faces that supposedly belonged to me but which I had never seen before and with which I did not identify. The only images with which I identified were the ones where I could see I had been channeling the confident performativity of my character Sarah Fresh—the funny faces she made inside the frames.
At the end of "Who Am I This Time?" the shy young man with no identity marries his co-star, another shy person with no personality of her own, and the two powerfully bland persons create for themselves an incandescent marriage—a union in which every moment is spent becoming characters through the reading of plays. They perform in plays and they read plays with each other at home. In this way they create their own reality and their own identities from moment to moment, never once dropping out of the storyline, never once dropping out of the performance which, for them, was no longer a fiction but truly real.
Bernardo Soares is the author of Pessoa's The Book of Disquiet. The voice of Pessoa's which emerges when he is drowsy is the author of this somnambulant prose, these wandering pages written in that obscured space between dream and waking life when one's identity is blurred, illegible. This is the voice closest to Pessoa and a voice who believes in prose above all other forms of art. Pessoa's other heteronyms wrote in more traditional verse forms, but Bernardo Soares, a humble bookkeeper, writes in a voice and form that is closest to Pessoa's most vulnerable, contradictory thoughts—the fragmented, segmented essay.
In encountering The Book of Disquiet, I am afraid I am supposed to feel more confused than I do; how can a book exist that is not fully fiction or nonfiction or poetry? How can a book be written not by a fictional narrator but a literary persona? On what shelf does one place such a book?
I am not confused when I encounter Pessoa or his writing because, like him, I often feel as though I only exist in the murky space between dreaming and living, and because I am an actor, which means that I am never, even between roles, entirely me.
I am not confused when I encounter Pessoa; instead, I feel as though I can see both life and literature with clarity for the first time.
I know now that I wish to abandon myself in order to become myself; to become my written self; to transform myself into a book.
I discovered The Book of Disquiet on a dark night in winter, in a different city I briefly lived in before Chicago, before I developed the strength to become a writer. I was young, only nineteen years old, and I lived in a perpetual fog, unable to bridge the abyss between things and words; between my spoken voice and my perpetual internal monologue. It was a temporary existence, sleeping on a couch in a friend's apartment, folding my things away out of sight during the day. Each night, I went walking on cobblestone streets, beneath a deepening sky, and abandoned myself to a cold and all-consuming wind. It was during these nights I grew close to my internal monologue, to the questioning voice inside me that searched for shape and for meaning. It was only during the evening that I found myself able to dip my toes into this possible voice, this voice that had never emerged before but which seemed to be truly, unequivocally me.
During daylight hours in this temporary city, I worked as an intern at a dance company, taking class for free in exchange for mundane bookkeeping. I trudged through administrative tasks for several hours each day, waiting for the moment I could shed that false, exterior identity and step into the studio where I abandoned myself to a mode of expression that bridged the gap that words could never close. I shed my button-down blouse and unclasped my administrative skirts, emerging thinner, looser, closer to the ground and to my body and the rhythm of drums thrumming our hearts to press bare feet into the floor.
I was afraid, during the day, of embodying my exterior self. It was a fear I didn't know how to name and a fear that brought shame; ashamed that I only knew how to perform identity in circumstances where the world believed I was not being me. I was not afraid to suffuse myself with my body when my body was in anonymous motion. Instead, I was afraid of everything that took place during the day; riding the train, rushing through crosswalks, unlocking the office door, processing payments, cold-calling strangers on the telephone to ask them for money.
I had never been afraid to read until I learned what reading was for me—abandoning the exterior self that kept me from seeing; from suffusing myself with my internal monologue. That winter in that temporary city, I began to read with a depth that matched the way I'd always abandoned myself into acting and dancing, the way I abandoned myself on dark, evening streets in the wind. And ultimately, though the fear never left me, it became a fear I loved with abiding secrecy.
The Book of Disquiet, as Alfred MacAdam writes in his introduction, cannot be read but only reread. A compilation of fragments arranged after Pessoa's death, gathered from the depths of an old suitcase, the book has no traditional beginning, middle, or end—only this voice, dropping in and out of its own ethereal monologue. To read The Book of Disquiet is to meander along with Pessoa; to experience his thoughts along with him; to become him.
But what does it mean to not read but reread?
In acting I learned that the meaning of 'rehearsal' is to give an account of, to go over again, repeat, to rake over, turn over, to drag, trail, rake, rip, tear, wound, repeat. To say over again, repeat what has already been said or written. It means to hear again the words you have set forth—to listen to the person you've become.
In acting, there is no fiction or nonfiction; there is only the poetic space of becoming, only the dream-like state of the in-between. It is a world created and embodied for a few hours each night—a suspended state of belief. To perform is to believe in multiplicity and the truth of an extended identity—a personality that blends beyond constricted contours of a singular self in order to step inside the contradictory, the imaginary, the perplexity of an enchanted reality.
The Book of Disquiet could be called one long walking essay, one long night in the silhouette of an urban-dweller's soul. The silhouette—it pauses below a lamppost. The essay—it looks up through its eye-glasses at the rain. It tells the story of a man meandering through the streets; a man who only recovers himself once he has forgotten himself, forgotten who he might be. A man who becomes someone else with surprising frequency.
To act, to dance, to suffuse one's spoken voice with one's internal monologue, is to embody what Pessoa embodied in his multiple heteronyms—to use one's own raw and primary material to create identities both real and not real; to allow oneself to sink into a somnambulant state and allow the dream, that non-place, to take on breath, voice, and cadence; to sleepwalk into a new, simultaneous world.
I think of Fernando Pessoa as a man without a face—with a hundred faces neither he nor anyone else can recognize. And I go to The Book of Disquiet when I need to dream, when I need guidance on how to become other than what I am or what I might be.
His fragments are like a greater mode of Method acting—total embodiment, beyond rehearsal, beyond the structures of the day, inside the realm of dream. I dip my toes into The Book of Disquiet as in a pool whose waters are a deceptively deep blue vantage point on the horizon. The further I dip, the further I go into construction. The further I go, the more I am unseen.
In a much more recent winter, when the snow piles around the exterior walls of the building that houses my home, I become silent. I become silent in winter—a silence that is full of all the night walks and lampposts and cobblestoned streets, all the reflecting pools and coats and red cheeks that accompanied my waking; my waking into voice, and shadow, and literacy.
I have walked through many winters, many silent city streets. I have undone myself beneath stage lights in theatres, on sprung floors in studios. Each time, it is never a beginning but a diving back into—casting away the falseness of the daylight hours and sinking back into a dream, the perpetual dream of becoming, of diving down, finding voice, suffusing meaning.
I carry it with me into a visual mode—a way of seeing what I've always hoped I'd find a way to describe. I sift through the stack of photographs that are both me and not me. In drawing these images, these simultaneous faces, thin black lines on clear white paper, white like the snow that surrounds me, clear like the water that reflects me, I can suddenly see.
Like Fernando Pessoa, I wake inside the essay. It is the awareness of doubt that shakes me, the awareness that I am so often made of multiplicity. I dive into a state of somnambulance, a sleepwalking dream, to perform possibilities. But I am hauled back to the surface—to waking—by the meandering prose of the essay; the form that calls upon the voice of the internal monologue that can't emerge in other states of being.
So I am always rereading, always becoming, always embodying the shapes of my creations, so that each evening, I will discover who I am this time.
I duck into my coat, slip my keys into my pocket, and emerge on the other side of the door.
I go out into the night.
Naomi Washer is the author of a chapbook, American Girl Doll, forthcoming from Ursus Americanus Press in 2019. Her essays have appeared and are forthcoming in Sundog Lit, Essay Daily, The Boiler, Passages North, Split Lip Magazine, The Account, and other journals. She has received fellowships from Yaddo and Columbia College Chicago where she earned her MFA in Nonfiction. She lives in Chicago where she is the Editor and Publisher of Ghost Proposal.


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Subscribe To The Surprising Thing James Wan Learned About Underwater Shooting While Making Aquaman Updates
The Surprising Thing James Wan Learned About Underwater Shooting While Making Aquaman
Eric Eisenberg
This December, James Wan's Aquaman is set to deliver a live-action blockbuster experience unlike anything we've ever seen. Sure, we've seen plenty of big movies set out on the ocean, but the upcoming DC blockbuster is different because most of the action will be set under the water. Because the idea is so different, the production had to do a lot of tests to make sure that everything looked right -- and according to Wan, there were a few significant surprises in store for them that they weren't expecting:
So even though we did a lot of dry-for-wet, we wanted to make sure things looked somewhat authentic underwater. We would get costumes, sets and our actors and submerge them underwater. We did so much study just to see what they would look like and the most surprising thing that we discovered early on is people, objects and stuff do not look wet under water. It only looks wet when you take it out of water. When it's glistening and it's dripping wet, that's how something looks wet. But when you're underwater it actually looks matte. That concept was a bit tricky to wrap our heads around.
It's true that Aquaman didn't do a ton of underwater shooting, instead opting to mostly use a combination of wirework and visual effects, but there was still plenty of work that needed to be done with the wet stuff to make sure that the blockbuster looks realistic. And while obviously stuff like hair looks different when submerged, the same isn't really true for skin and other surfaces. Sure, you'll see water droplets when things come out of the water, but it didn't really occur to James Wan until the testing that "wet" isn't really a factor before that.
James Wan talked about this discovery late last month in the edit bay for Aquaman on the Warner Bros. lot in Burbank, California -- which I had the chance to visit along with a small group of other journalists. One thing he also added, though, is that the discovery of how things look underwater presented its own issues. Specifically, people may not sweat when they are beneath the waves, but they do when they are on a movie set and surrounded by lights while performing action sequences. Wan explained,
We constantly had to go in there and pat our actors down with makeup because under those bright lights and all the stunts they were constantly sweating and all that. You don't see water underwater. You don't see sweat... We want to shoot as much [as we can practically]. Even if visual effects was to come in and augment a lot of it, they want to start with something that is real, that is tangible.
It should ultimately make for a whole new cinematic experience, and fans will get to have it when Aquaman -- starring Jason Momoa, Amber Heard, Patrick Wilson, and more -- arrives in theaters on December 21st.
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Why James Wan Has Never Directed A Full Trilogy