CRPS: Inflammatory, Neuropathic and Immunologic?

Researchers Continue To Look for Basic Understanding of CRPS Causes

Toronto—Researchers tasked with developing a rudimentary understanding of complex regional pain syndrome (CRPS) are dividing their attention in several different directions. According to several experts who spoke at the 2013 International Congress on Neuropathic Pain, there is evidence for inflammatory, neuropathic and immunologic roots to the enigmatic syndrome, and further investigation into these three aspects of the syndrome is necessary for the development of more effective treatments.

“These different contributing factors all influence each other, so we need to address all of them so that patients don’t get onto a downward spiral where each factor worsens another,” Anne Louise Oaklander, MD, PhD, associate neurologist at Massachusetts General Hospital and associate professor at Harvard Medical School, both in Boston, told Pain Medicine News after attending the panel discussion.

Not a Perfect Fit

Ralf Baron, MD, vice chair of the Department of Neurology and head of the Division of Neurological Pain Research and Therapy at the University Hospital Schleswig-Holstein in Kiel, Germany, told attendees that until recently, CRPS was understood to be clearly a neuropathic pain disorder. However, CRPS does not fit with the 2008 redefinition of neuropathic pain, defined as “pain arising as a direct consequence of a lesion or disease affecting the somatosensory system” (Neurology 2008;70:1630-1635).

“CRPS is neuropathic in that there are characteristic neuropathic sensory abnormalities, but it also shows signs of central sensitization, inflammation, and autonomic and motor abnormalities,” Dr. Baron told attendees.

One way of grouping CRPS patients is by looking at their distinct somatosensory dysfunctions, Dr. Baron suggested. Individuals with deficits in temperature detection but no allodynia, and with loss of small nerve fibers, innervation and nerve degeneration, can be classified as having a neuropathic disorder. A second cluster of patients can be seen as having central sensitization, with normal temperature sensitivity but severe mechanical and thermal hyperalgesia. A third patient cluster may have inflammatory CRPS, with deep hyperalgesia and heat hyperalgesia but no hyperalgesia to prick testing, Dr. Baron explained.

An Autoimmune Disease?

Another way of understanding CRPS, proposed by Andreas Goebel, MD, PhD, senior lecturer and honorary consultant at the University of Liverpool and Walton Centre National Health Service Foundation Trust in Liverpool, United Kingdom, is that a subset of CRPS patients have an autoimmune disorder–related condition.

“It is possible that a regional immune response is triggered following stress, inflammation and trauma,” he posited.

Dr. Goebel believes some of the 15% of CRPS patients with refractory symptoms lasting longer than six to 12 months may fall into this group (Pain 2009;142:218-224). He noted that several studies support the autoimmune paradigm, with results showing that a subset of CRPS patients have elevated levels of serum antibodies to several bacterial pathogens.

“Furthermore, there is evidence for CRPS serum immunoglobulin binding to peripheral nerves,” he said (Neurology 2004;9:1734-1736).

Indeed, several small case series, including his own, have demonstrated the efficacy of intravenous immunoglobulin G (IgG) in subsets of patients with long-standing, refractory CRPS, Dr. Goebel said (Pain Med 2002;3:119-127). Additionally, a randomized controlled trial of 12 patients with long-standing CRPS who received the agent found that 25% had pain relief at least 50% relative to baseline and 17% had improvements in pain between 30% and 50% (Ann Intern Med 2010;152:152-158).

Although IgG has anti-inflammatory effects in addition to being an immunomodulator, Dr. Goebel believes IgG’s efficacy is likely not explained by its anti-inflammatory effect.

“All of the investigations which we have done, both in the lab and clinically, have been leaning more and more toward confirming there is an autoimmune aspect to CRPS,” Dr. Goebel concluded. “However, since we do not know which structures the autoimmune response is targeting, our current evidence remains somewhat indirect.”

According to Dr. Goebel, if some patients in fact have CRPS of autoimmune origin, “a range of potential therapies, such as therapeutic plasma exchange and B-cell modulating therapies, can be at our disposal.

“These have all been tried and tested in other autoimmune disorders, and we can have access to an armamentarium that we did not have before,” he said.

An “Ultralocal” Inflammatory Response?

Frank Huygen, MD, PhD, professor of anesthesiology at Erasmus Medical Center in Rotterdam, the Netherlands, argued the inflammatory component to CRPS could be the most clinically meaningful element of the syndrome in some patients. However, rather than looking for systemic inflammation, he believes researchers need to consider an “ultra-local” inflammatory response.

“There are inflammatory mediators that are increased in the blister fluid of an involved extremity in CRPS,” Dr. Huygen said.

His own research has documented increased levels of interleukin-6 and tumor necrosis factor (TNF)-alpha in some patients (Eur J Pain 2008;12:716-721).

In a small, placebo-controlled, randomized trial, Dr. Huygen and his colleagues showed that the anti-TNF drug infliximab (Remicade, Janssen) exacerbated symptoms in some CRPS patients, leading to discontinuation of the trial (Pain Pract 2013; May 22: doi: 10.1111/papr.12078). The researcher still believes there could be a role for infliximab and other biologics in the treatment of CRPS.

“Although the sponsor stopped the study early, preliminary data showed enormous reductions in TNF-alpha levels in blister fluid with infliximab treatment, but these did not correlate with clinical changes,” he said.

Summarizing the challenge of understanding and treating a complex syndrome, Dr. Baron suggested CRPS should no longer be seen monolithically as a neuropathic disorder.

“As long as we do not have a clearer pathophysiological picture of CRPS patients, and because of the obvious heterogeneity of the signs, symptoms and mechanisms of the syndrome,” he said, “it would be wise to look at the condition separately from other classical neuropathic pain syndromes.”

—David Wild

THE SUPPRESSED SPEECH OF WAMSUTTA (FRANK B.) JAMES, WAMPANOAG

THE SUPPRESSED SPEECH OF

WAMSUTTA (FRANK B.) JAMES, WAMPANOAG

To have been delivered at Plymouth, Massachusetts, 1970

ABOUT THE DOCUMENT:
Three hundred fifty years after the Pilgrims began their invasion of the land of the Wampanoag, their "American" descendants planned an anniversary celebration. Still clinging to the white schoolbook myth of friendly relations between their forefathers and the Wampanoag, the anniversary planners thought it would be nice to have an Indian make an appreciative and complimentary speech at their state dinner. Frank James was asked to speak at the celebration. He accepted. The planners, however , asked to see his speech in advance of the occasion, and it turned out that Frank James' views — based on history rather than mythology — were not what the Pilgrims' descendants wanted to hear. Frank James refused to deliver a speech written by a public relations person. Frank James did not speak at the anniversary celebration. If he had spoken, this is what he would have said:

I speak to you as a man -- a Wampanoag Man. I am a proud man, proud of my ancestry, my accomplishments won by a strict parental direction ("You must succeed - your face is a different color in this small Cape Cod community!"). I am a product of poverty and discrimination from these two social and economic diseases. I, and my brothers and sisters, have painfully overcome, and to some extent we have earned the respect of our community. We are Indians first - but we are termed "good citizens." Sometimes we are arrogant but only because society has pressured us to be so.
It is with mixed emotion that I stand here to share my thoughts. This is a time of celebration for you - celebrating an anniversary of a beginning for the white man in America. A time of looking back, of reflection. It is with a heavy heart that I look back upon what happened to my People.
Even before the Pilgrims landed it was common practice for explorers to capture Indians, take them to Europe and sell them as slaves for 220 shillings apiece. The Pilgrims had hardly explored the shores of Cape Cod for four days before they had robbed the graves of my ancestors and stolen their corn and beans. Mourt's Relation describes a searching party of sixteen men. Mourt goes on to say that this party took as much of the Indians' winter provisions as they were able to carry.
Massasoit, the great Sachem of the Wampanoag, knew these facts, yet he and his People welcomed and befriended the settlers of the Plymouth Plantation. Perhaps he did this because his Tribe had been depleted by an epidemic. Or his knowledge of the harsh oncoming winter was the reason for his peaceful acceptance of these acts. This action by Massasoit was perhaps our biggest mistake. We, the Wampanoag, welcomed you, the white man, with open arms, little knowing that it was the beginning of the end; that before 50 years were to pass, the Wampanoag would no longer be a free people.
What happened in those short 50 years? What has happened in the last 300 years? History gives us facts and there were atrocities; there were broken promises - and most of these centered around land ownership. Among ourselves we understood that there were boundaries, but never before had we had to deal with fences and stone walls. But the white man had a need to prove his worth by the amount of land that he owned. Only ten years later, when the Puritans came, they treated the Wampanoag with even less kindness in converting the souls of the so-called "savages." Although the Puritans were harsh to members of their own society, the Indian was pressed between stone slabs and hanged as quickly as any other "witch."
And so down through the years there is record after record of Indian lands taken and, in token, reservations set up for him upon which to live. The Indian, having been stripped of his power, could only stand by and watch while the white man took his land and used it for his personal gain. This the Indian could not understand; for to him, land was survival, to farm, to hunt, to be enjoyed. It was not to be abused. We see incident after incident, where the white man sought to tame the "savage" and convert him to the Christian ways of life. The early Pilgrim settlers led the Indian to believe that if he did not behave, they would dig up the ground and unleash the great epidemic again.
The white man used the Indian's nautical skills and abilities. They let him be only a seaman -- but never a captain. Time and time again, in the white man's society, we Indians have been termed "low man on the totem pole."
Has the Wampanoag really disappeared? There is still an aura of mystery. We know there was an epidemic that took many Indian lives - some Wampanoags moved west and joined the Cherokee and Cheyenne. They were forced to move. Some even went north to Canada! Many Wampanoag put aside their Indian heritage and accepted the white man's way for their own survival. There are some Wampanoag who do not wish it known they are Indian for social or economic reasons.
What happened to those Wampanoags who chose to remain and live among the early settlers? What kind of existence did they live as "civilized" people? True, living was not as complex as life today, but they dealt with the confusion and the change. Honesty, trust, concern, pride, and politics wove themselves in and out of their [the Wampanoags'] daily living. Hence, he was termed crafty, cunning, rapacious, and dirty.
History wants us to believe that the Indian was a savage, illiterate, uncivilized animal. A history that was written by an organized, disciplined people, to expose us as an unorganized and undisciplined entity. Two distinctly different cultures met. One thought they must control life; the other believed life was to be enjoyed, because nature decreed it. Let us remember, the Indian is and was just as human as the white man. The Indian feels pain, gets hurt, and becomes defensive, has dreams, bears tragedy and failure, suffers from loneliness, needs to cry as well as laugh. He, too, is often misunderstood.
The white man in the presence of the Indian is still mystified by his uncanny ability to make him feel uncomfortable. This may be the image the white man has created of the Indian; his "savageness" has boomeranged and isn't a mystery; it is fear; fear of the Indian's temperament!
High on a hill, overlooking the famed Plymouth Rock, stands the statue of our great Sachem, Massasoit. Massasoit has stood there many years in silence. We the descendants of this great Sachem have been a silent people. The necessity of making a living in this materialistic society of the white man caused us to be silent. Today, I and many of my people are choosing to face the truth. We ARE Indians!
Although time has drained our culture, and our language is almost extinct, we the Wampanoags still walk the lands of Massachusetts. We may be fragmented, we may be confused. Many years have passed since we have been a people together. Our lands were invaded. We fought as hard to keep our land as you the whites did to take our land away from us. We were conquered, we became the American prisoners of war in many cases, and wards of the United States Government, until only recently.
Our spirit refuses to die. Yesterday we walked the woodland paths and sandy trails. Today we must walk the macadam highways and roads. We are uniting We're standing not in our wigwams but in your concrete tent. We stand tall and proud, and before too many moons pass we'll right the wrongs we have allowed to happen to us.
We forfeited our country. Our lands have fallen into the hands of the aggressor. We have allowed the white man to keep us on our knees. What has happened cannot be changed, but today we must work towards a more humane America, a more Indian America, where men and nature once again are important; where the Indian values of honor, truth, and brotherhood prevail.
You the white man are celebrating an anniversary. We the Wampanoags will help you celebrate in the concept of a beginning. It was the beginning of a new life for the Pilgrims. Now, 350 years later it is a beginning of a new determination for the original American: the American Indian.
There are some factors concerning the Wampanoags and other Indians across this vast nation. We now have 350 years of experience living amongst the white man. We can now speak his language. We can now think as a white man thinks. We can now compete with him for the top jobs. We're being heard; we are now being listened to. The important point is that along with these necessities of everyday living, we still have the spirit, we still have the unique culture, we still have the will and, most important of all, the determination to remain as Indians. We are determined, and our presence here this evening is living testimony that this is only the beginning of the American Indian, particularly the Wampanoag, to regain the position in this country that is rightfully ours.
Wamsutta
September 10, 1970

Merwinism

Thanks
by W. S. Merwin


Listen
with the night falling we are saying thank you
we are stopping on the bridges to bow from the railings
we are running out of the glass rooms
with our mouths full of food to look at the sky
and say thank you
we are standing by the water thanking it
smiling by the windows looking out
in our directions

back from a series of hospitals back from a mugging
after funerals we are saying thank you
after the news of the dead
whether or not we knew them we are saying thank you

over telephones we are saying thank you
in doorways and in the backs of cars and in elevators
remembering wars and the police at the door
and the beatings on stairs we are saying thank you
in the banks we are saying thank you
in the faces of the officials and the rich
and of all who will never change
we go on saying thank you thank you

with the animals dying around us
our lost feelings we are saying thank you
with the forests falling faster than the minutes
of our lives we are saying thank you
with the words going out like cells of a brain
with the cities growing over us
we are saying thank you faster and faster
with nobody listening we are saying thank you
we are saying thank you and waving
dark though it is

I Flushed the Toilet [Now updated by photojournalism...]

MONDAY PHOTO UPDATE:  my friend diana broke her foot (a much more serious injury, i think) -- also on saturday. and it was her birthday! i'm thinking conspiracy, i'm thinking international plots, espionage, some sort of orthopedic movement of oppression! so we toddled to the doc, who was more obsessed with my right foot than my broken wrist.  "it's gangrenous," he whispered, adding the observant:  "it's PURPLE!"  by the time we got there, ulnar nerve palsy had set in, which is the reason for the attempt to splint my last two fingers straight out.  you can see that they are defiantly curling under toward the palm, snickering at the pathetic attempt.  still, diana got the raw deal.  send either one of us a crate of nicely aged single malt, and a spirit of thanksgiving might yet survive.

SUNDAY EVENING:
I've always longed for great stories to go along with my broken bones.

"It was that double-back ziparoo round-off into a triple-toed handspring spring roll that broke my big toe, a small price to pay for Olympic Gold..."

That sort of thing.

A few weeks back, I cracked the crapola out of my left lower shin.  I got my leg trapped between my speeding wheelchair and a mop.

Last night...

Oh, you don't need to know.

It's not like there is any snow or ice here.
No deeds of derring-do.
Not even any house-cleaning.
Haven't been wrestling Buddy the Outrageosly Large Maine Coon for his weird Mr. Potato Head, made of cheap felt.  Well, I have, but without injury.
There've been no intrepid home invaders trying to leap into the house through a broken window over the washer.  That was last year, and this year, I have Bear Repellent.

But last night...

I flushed the toilet and may have fractured my ulna/wrist.

I went to bed straight away, with a handful of candy and my music playing very, very loudly in my oddly shaped earbuds.  Woke myself several times yelling as I pushed off on that hand in an effort to hoist the heft into a more comfortable position.  Then this morning, CRPS decided it was offended to have another of its territories maltreated, and the hand has gone ice cold. No swelling, no redness, no wrist at a right angle to its forearm.  It may be a tendon, a sprain, a nerve issue, a small fracture.  Like Honey Badger, CRPS don't care.

Icy CRPS?  It burns.  It hurts.  I cry.  I'm the portrait of immaturity.  I EMBODY immaturity.

And that place on my leg?  The swelling is almost all gone.  The bruise is still ugly but the pain much better. And... that precise area is hot.  Which may mean infection, though that's a hell of a stretch, especially since there is no hardware there.  Still.

So, baby that I am, I called go-to-guy doctor, wimpering and whining.  Was I partly driven because Fred called to say, "Oh, by the way, someone had an extra ticket to The Nutcracker... I will be a while."  Of course not.  Who gives a hoot, really?  I mean, I saw Baryshnikov in The Nutcracker in San Francisco. And everyone knows the music sucks, and, well, you know.  Ho ho ho.

The doctor said to apply ice, and I just have to politely ignore that.  He still knows nothing of basic CRPS care.  That got to me.  Elevate it.

Luckily, I didn't scream:  "If anyone gave a good goddamn they'd chop these appendages off, or slap two-dozen plus three (to die on) 100 mcg Fentanyl patches all over moi.  If anyone gave a good goddamn they'd shoot me between the eyes."

Good thing I decided to cook Fred, Bianca, Sven and a petulant Cabana Boy one kickass stir fry before going to the bathroom and FLUSHING THE TOILET.

Tomorrow, off we'll trot to get x-rays, and they'll be normal except for hairline nonsense and an alarmed radiologist who'll cry "osteoporosis out the wazoo," and run screaming down lead-lined hallways.

That's right.  I flushed the toilet.
Wanna make something of it?

Fred is hanging in there, by the way.  He's taking the high road and trying not to worry about his hearing. And WTF, he's at the freaking ballet.  One non-hearing ear, the other with tinnitus.  On his way home, he's picking up a wrist immobilizer.  That's the one piece of orthopedic equipment we are lacking.

© 2013 L. Ryan

"The undiscover'd country...": Sunday's bit of Shakespeare

Hamlet, Act III, Scene I [To be, or not to be]

  by William Shakespeare

To be, or not to be: that is the question:
Whether 'tis nobler in the mind to suffer
The slings and arrows of outrageous fortune,
Or to take arms against a sea of troubles,
And by opposing end them? To die: to sleep;
No more; and by a sleep to say we end
The heart-ache and the thousand natural shocks
That flesh is heir to, 'tis a consummation
Devoutly to be wish'd. To die, to sleep;
To sleep: perchance to dream: ay, there's the rub;
For in that sleep of death what dreams may come
When we have shuffled off this mortal coil,
Must give us pause: there's the respect
That makes calamity of so long life;
For who would bear the whips and scorns of time,
The oppressor's wrong, the proud man's contumely,
The pangs of despised love, the law's delay,
The insolence of office and the spurns
That patient merit of the unworthy takes,
When he himself might his quietus make
With a bare bodkin? who would fardels bear,
To grunt and sweat under a weary life,
But that the dread of something after death,
The undiscover'd country from whose bourn
No traveller returns, puzzles the will
And makes us rather bear those ills we have
Than fly to others that we know not of?
Thus conscience does make cowards of us all;
And thus the native hue of resolution
Is sicklied o'er with the pale cast of thought,
And enterprises of great pith and moment
With this regard their currents turn awry,
And lose the name of action.--Soft you now!
The fair Ophelia! Nymph, in thy orisons
Be all my sins remember'd.

Plagiarized from Jim Broatch of RSDSA: Supporting the CRPS Community

I have no shame.  This is straight from my gmail inbox.  May it inspire some CRPSer out there with the enthusiasm to volunteer, to fundraise, and become a glorious inspiration to us layabouts.  Had I a dependable bone in my body, I'd volunteer to write, edit, or proofread for the new electronic newsletter.  Since I don't, I'll pass along Jim's good words.

Seeking Volunteer Writers, Editors, and Proofreaders for RSDSA Community Update In September RSDSA published the inaugural issue of the RSDSA Community Update, our new electronic newsletter. RSDSA has hired Jessica Begley to serve as the Managing Editor. Jessica is interested in building a team of volunteer contributing writers, editors, proofreaders, and individuals familiar with html production to help publish the RSDSA Community Update. Our intention is to publish the newsletter on a bi-monthly basis. Our next issue is scheduled to be published in mid-December. If you are interested in joining our team, please send an email to Jim Broatch at info@rsds.org. November November is Worldwide  RSD/CRPS Awareness Month - Please Donate Now! Month of November RSDSA is partnering with Christa Whightsel from RSD/CRPS Doesn't Own Me for this month-long campaign. You can help others affected by CRPS/RSD through the Patient Assistance Fund in honor of Brad Jenkins! Join us as we provide much needed support to our brothers and sisters who lack financial resources for daily needs such as heating oil, medical equipment, and help with medical costs. We all know medical care is expensive and so many go without because they cannot afford a doctor visit. The Patient Assistance Fund in honor of Brad Jenkins provides hope and access to quality care. We are all in this together! Help others that need your support by donating to the RSDSA Patient Assistance Fund in Honor of Brad Jenkins. Together we can make a difference! Please Click Here to Donate Now! 7th Annual RSD BenefitTo Benefit RSDSA - Join Us today and Help promote Awareness of RSD Saturday, November 23, 2013 Time: - 7 - 11 pm Location - Fashionhaus, 58 W. 40th St., 9th Floor, (between 5th & 6th Ave.), NY Event Chair - Laura Belt Ponomareva: rsdbenefit@gmail.com  Purchase Tickets -  Click Here  Make a Donation - Click Here lia sophia Jewelry Holiday Fundraiser   A portion of all sales will be donated to the Patient Assistance Fund in Honor of Brad Jenkins Now through December 7, 2013 Shop Securely Online - click on "Browse Our Jewelry," Enter "Brad Jenkins" as the hostess. Select your items and submit your order. Orders - Orders must be received no later than Saturday, December 7th (Receive your order by December 19th in a special gift bag) View Catalog - http://www.liasophia.com/andreasjewels Questions - Contact your lia sophia advisor, Andrea Jenkins at 301.266.4836 or by email at  jewelsanjens@aol.com  Details - Click Here to download a detail flyer on how to order   RSD Cut-AThon in honor of Timothy Lucid Tim Lucid is an 8th grade student at NCS who has recently been diagnosed with RSD after surgery for a fractured elbow. 100% of the proceeds goes to RSDSA and RSDHope. December 7, 2013 Date - December 7, 2013 Location - Heidi's Clip Joint - 3685 Main Street, Warrensburg, NY 12885 518.623.2818 Time - 12 - 4 pm Details -  Click Here 2nd Annual Jingle Bell Benefit Run/Walk to Candy Cane Lane Thursday, December 12, 2013 Time: 6:15 pm  Starting Place - Fleet Fee, Vacaville, CA to Candy Cane Lane Course - 2.5 round trip: Runners, Walkers Strollers and Bike welcome. The run is free.  Contact - Jo Hewitt, 707.365.1228 or email bikejo24@aol.com Donation - Click here to donate.    Be sure to visit the RSDSA website for the latest CRPS/RSD information including new treatment options, valuable resources, upcoming events, and Support Groups in your area. Click Here to Visit Now! SUICIDE CRISIS INFORMATION If you or a loved one are in crisis Please call 1.800.SUICIDE (800.784.2433) Hope Line or The National Suicide Prevention Lifeline 800.273-TALK (8255) - (888-628-9454 en Español) For more information on suicide prevention, click here.

I'm Asking For Your Prayers

If you are new to my blog, welcome to a crazy place, an ambitious reflection of a complicated life, a crowded intellect, an ardent site of political yearnings, all wrapped up in an anonymizing fiction.  The Blog Back Story has me, the Profderien, and my partner of 23 years, Fred, living as squatters in a perversion of a small bit of Hergé's geography of the great Tintin books.  Captain Haddock's Marlinspike Hall is our home and our work, too.  Together with the inimitable Bianca Castafiore, the Milanese Nightingale, and a horde of genetically indentured Domestic Staff, we maintain the Haddock holdings, buff up the Caravaggio collection, and try to keep The Castafiore from helping too much -- she has been known to lust after the absent Captain, imbibe a tad bit much, and wax the Carrara marble spiral staircases.

Most of the blog is dedicated to my woes.  Truly.  Just hop around the archives, or simply bend close to your screen and cup a hand behind your ear and listen for the self-indulgent moaning.

When I do deign to mention Fred, I hope I do so with love but know that is not always evident.  Writing love is a hard task and my writing talents wane.  But know this:  I love Fred.

There are more things to say in that vein, more crass but equally true.  Things like... I owe Fred, I owe Fred everything.  Things like... Fred is a hero of the kind that are slowly drifting into the ether, fading from this orb.
Things like... there is no face I'd rather see, no voice I more long to hear.

He can piss me off like nobody's business but generally in that age-old way that provokes a roll-of-the-eye and a peeved cry of "Men!"

He does stuff like wash all the dishes but one.  He's cursed to have the most idiotic drivers in our region (west of the Lone Alp) end up in front of him on a two-lane road, and in a country where there are always double yellow lines and people who pass are considered uncouth.  He thrills at finding new and cheaper spray cleaners.  He goes to court to support women friends who are being stalked.  He welcomes people into the sanctuary at his house of worship, and often spends Friday nights killing bottles of communion wine at our next door neighbors rectory -- the Cistercians whose monastery is just past our apple orchard. Without Fred's attentiveness, the moat around Marlinspike Hall would be three feet thick with blooming red algae, blocking the emergence of the Captain's fleet of miniature submarines that travel the inner core's wormholes and the planet's high seas.

Fred paints, plays the piano, the guitar, and the ukulele.  He overcame a childhood of unimaginable abuse and survived his own acting-out.  The brain fascinates him, and he is one of those high end audio types.

It looks as if Fred may have a tumor called an acoustic neuroma.  He's not felt well since... well, I cannot honestly say, because he's studly.  At least since February/March.  He suddenly -- very suddenly -- lost all hearing in his right ear.  No pain.  Lots of fatigue.  Never close to being balletic, if possible he morphed into a dedicated klutz.  Actually, this last symptom is one we have difficulty gauging with any objectivity, as Fred will try to shorten any walking path by grazing door frames and finding ridiculously direct routes which frequently bruise his shins and stub his hairy toes.

If you will put up with some of my well-worn impropriety, the asshat of an internist, and the dipshit of a physician's assistant who saw him with remarkable frequency, considering this is a man of the old school we're discussing, who has to be feeling pretty gosh god-damned awful to set foot in a doctor's office... Ahem.  I lost the tight thread of my post.  The idiots he saw between March and this month, November, said "ear infection," said "antibiotics," said "ear drops," and essentially placed him in the basket of cases that should get better whether they did a damned thing, be that damned thing right or be that damned thing wrong.

He became dizzy.  Two weeks ago, he came home from the grocery store, shaken.  He'd gotten disoriented, shaky, almost blacked out.  Back to the doctor, who must have had his coffee enema that morning, for he finally referred dear Fred to an ENT.

The ENT found no evidence of the famed raging infection and set up some testing.  Acoustic neuromas are rare, and account for something like 1% of cases of unilateral hearing loss.  For reasons that Fred did not investigate ("Men!"), the doctor suspects that Fred is one of the one percent.  The ENT also, and rightly so, soft-pedaled what a "tumor near the cochlea" actually was, what it actually could do, what it could become, and what was entailed in treating it.

Despite our leather bustiers, dirndls, and tie-dyed lederhosen, we are a modern couple.  It took us longer than usual, but we eventually hit the internet for information.  Did I mention that Fred's degree is in neuropsychology and that he knows his way around the brain better than I know my way around Diderot's Salon of 1767?  An acoustic neuroma is essentially a non-cancerous brain tumor, slow-growing, but that grows in a terrible direction -- toward the brainstem.  It almost always impacts facial nerves and hearing loss is almost always permanent.

I'm trying to sublimate my pains and disabilities, trying to be supportive without being Pollyannish.  Truth be told, my sudden transformation into an irrepressible optimist would cause Fred to suffer a heart attack born of pure shock.

But I found myself ending an email to him -- Yes, we email each other within the same domicile.  Marlinspike Hall is a tremendous manor, and he is in the Computer Turret doing Important Computer Work, while I'm pecking away at my dilapidated laptop in our West Wing apartments, a cat on my head, a cat between my feet, a cat on watch at the window, and Castafiore taking up most of the king-sized decadent round bed, hooting and hollering at American college hoops.  I know, who knew?  Lounging on the Kodiac bear rug, toying with a massive paw of claws, not understanding basketball in the least, is Sven Feingold of the Manor Staff, whose family is genetically indentured to the maintenance of our Labyrinth, the highlight of our annual summer ManorFest.  Sven and Bianca are obnoxiously lusty, but on a cold November night, great fun.  The Castafiore is, at this moment, explaining "traveling" to Sven, who cares only for soccer, and I must say, I almost understand what she is saying.  For a few decades now, it looks to me as if everyone travels, usually in that one long stride from half court to the basket.

Right.
Well.
Anyway.

I ended my short email to The Fred this way:

For I am the Lord, your God, who takes hold of your right hand and says to you, Do not fear; I will help you. (Isaiah 41:13)

I am a huge Isaiah fan, and it's his time of year, and I could babble hundreds of embarrassed denials of my biblical sincerity... but this is Fred, and Fred's beautiful brain and hearing, steadiness and string-strumming, his kindness and abstract fingering of piano keys, his love of the Ethiopian sky, the sounds and smells of the Danakil. This is Fred we're talking about, a leitmotif on my blog, a raison d'être in my life.

We all have something tragic ongoing, already gone and ghostly, or on the way.  But I don't care -- I really don't.  I want this man, who has saved my life many times over and then taught me to be glad of it, to be healed.  Yes, I recognize the narcissism running rampant, but as you know, writ large in attitudinal font throughout elle est belle la seine is the ringing query:  Whose blog is it anyway?

Please pray for Fred.  You're so much more likely to have the words, the mien, the means.
Thank you.

[The relevant testing needed for diagnosis cannot begin until the first few weeks of December. I'll keep you apprised, Dear Reader.]

Bach's Jesu, Joy of Man's Desiring, in the well-known piano arrangement by Dame Myra Hess (published by Oxford), has single notes (not part of a chord) on the "wrong" side of the stem; this odd bit of notation occurs on the right-hand staff almost from beginning to end. Why? In the words of Sadie (2001), article "Notation", these are "reversed note shapes representing one strand of a complex texture."

© 2013 L. Ryan

The Texas Sentinel's Lonestar Larry 'Splains "Texaz' Otha Death Pinaltee"

From the Texas Sentinel (Readings for Texas Gangstas - thus one from the MORNIN’  EDISHUN)

The Texas Sentinel. (Brenham, Tex.), Vol. 4, No. 34, Ed. 1 Wednesday, November 9, 1881

Texaz’ Otha Death Pinaltee

By Lonestar Larry

I be receive' permissyun ta shaa my patiintz’ ztoriez, an' change' o'omitte' some namez. Dis be a personal essay; da viewz be my own an' do not reflect dose uv St. Vincint’z Crib o'St. Vincint’z Studint-Run Free Clinic.

Da firs' patiint who calle' me “docta” die' a few winterz ago. I met him at da St. Vincint’z Studint-Run Free Clinic on Galveston Island. I wuz a firs'-year medical studint den, an' da disease n' dude body baffle' me. Dude bel wuz swollen, dude eyez wuz yellow an' dude blood teztz wuz all awry. It hurt wen dude swallowe' an' dude urine stank.

I saw him every Thursday afternoon. I would do a physical exam, holla ta him, an' consult wiff da docta. We ran blood countz an' wrote a prescripshun fo'n antacid—not da bes' medicashun, buh one you can get fo'$4 a month. Dude disease seeme' zeriouz, buh we couldn’t diagnose him at da free clinic cuz da teztz nee'e' ta do so—a CT scan, a biopsy uv da liva, a tes' ta look fo'canca cellz n' da fluid n' dude bel—be beyond our financial reach.

Dude starte' calln' me “Dr. Rachel.” Wen dude pain gots so bad dat dude couldn’t eat, we decide' ta send him ta da emerginsee room. It wuz not 'n easy decisyun.

Dere’z a popular myth dat da uninsure'—n' Texaz, dat’z 25 percint uv uz—can alwayz get medical caa thro emerginsee roomz. Te' Cruz haz argue' dat it be “much cheapa ta provide emerginsee caa den it be ta expand Medicaid,” an' Rick Perry haz claime' dat Texanz prefa da ER system. Da myth be base' on a 1986 federal law calle' da Emerginsee Medical Treatmint an' Laba Act (EMTALA), wich ztatez dat hozpitalz wiff emerginsee roomz be ta accept an' stabilize patiintz who be n' laba o'who be 'n acute medical condishun dat threatinz life o'limb. Dat word “stabilize” be key: Hospital ERz don’t be ta treat you. Day jus' be ta patch you up ta da point whea you’a not active dyn'. Also, hozpitalz charge fo'ER caa, an' usual send patiintz ta collecshunz wen day cannot pay.

My patiint wen ta da ER, buh didn’t get treatmint. Altho dude wuz obviouz sick, it wasn’t 'n emerginsee dat threatine' life o'limb. Dude came back ta St. Vincint’z, whea I wen thro my routine: conversashun, vital zignz, physical exam. We laughe' a lot, even tho we both knew it wuz a bad situashun.

One nite, a homie calle' ta say dat my patiint wuz n' da hospital. Dude’d final gotten so anemic dat dude couldn’t catch dude breath, an' da Universitee uv Texaz Medical Branch (UTMB), whea I am a studint, took him n'. My homie emaile' me da rezultz uv dude CT zcanz: Dere wuz canca n' dude kidney, dude liva an' dude lungz. It mus' be do be spreadn' ova da weekz dat dude’d do be comn' inta St. Vincint’z.

I wen ta visit him dat nite. “Dere’z my docta!” dude calle' out wen dude saw me. I sat next ta him, an' dude explaine' dat dude wuz waitn' ta call dude sista until day hollad him whetha o'not da canca wuz “bad.”

“It mite be one uv dose real treatable kindz uv cancerz,” dude say. I nodde' uncomfortab. We talke' fo'a while, an' wen I left dude say, “Well now you know whea I am, so you can come visit me.”

I neva came back. I wuz too ashame', an' too ear n' my trainn' ta even recognize why I felt dat way. Afta all, I had done everythn' I could—what did I be ta feel ashame' uv?

UTMB sent him ta hospice, an' dude die' at crib a few monthz lata. I read dude obituary n' da Galveston Countee Dai Nuze.


Da shame haz stuck wiff me thro my medical trainn'—not on from my firs' patiint, buh from many moe. I am now a directa uv da free clinic. It’z a voluntea posishun. I love my patiintz, an' I love ben' able ta help many who nee' primary caa: blood passua control, pap zmearz, diabetez managemint. We even do some specialtee caa. Buh da free clinic be also whea some peeps learn dat dere be no hope fo'da chemotherapy o'surgery dat day nee' buh can’t afford. Wen UTMB refuzez ta treat them, it fallz ta uz ta tell them dat day will die uv dizeazez dat be, n' fact, treatable.

St. Vincint’z be da primary caa provida fo'moe den 2,000 patiintz acrozz Southeas' Texaz. Our catchmint area be a strip uv coastal plain strung wiff barria izlandz. Drive inland an' you start ta see live oakz; jet toward da coas' an' da oil refineriez loom up ova neighborhoodz. Da mos' pollutn' refinery n' da nashun be huhhh, n' Texaz Citee. Our patiintz be factory workerz, laborerz, laid-off healthcaa workerz, da peeps behind da counterz uv seafood reztaurantz.

Mos' uv our patiintz come from Galveston an' Brazoria countiez, buh some drive two hourz from Port Arthur o'ova from Orange, near da Texaz-Louisiana borda, ta get ta uz. Dat’z how hard it be ta see a docta n' Southeas' Texaz: Peeps take a day off work ta drive two hourz ta a studint-run clinic dat can on provide basic caa.

Da clinic be overseen by facultee phyzicianz—UTMB docz—who see every patiint along wiff uz ztudintz an' prescribe medicashunz. Deez doctorz be volunteerz. We be not a UTMB clinic, buh we depind on UTMB, wich be twintee blockz from St. Vincint’z, fo'trainn' our studint volunteerz, fo'liabilitee insurance an' fo'runnn' our blood teztz an' otha labz. UTMB haz given uz grantz, includn' one dat helpe' uz get our electronic medical recordz system, an' fundz a nurse-manage' day clinic fo'da uninsure' at St. Vincint’z Crib.

Buh UTMB be no longa da state-subsidize' charitee hospital it use' ta be. Da changez began befoa Hurricane Ike n' 2008. Buh afta da storm, UTMB adminiztratorz drastical cut charitee caa an' move' clinicz ta da mainland, whea dere be moe payn' patiintz. Da old motto “Huhhh fo'da Health uv Texaz” wuz replace' by “Workn' togetha ta work wonderz.” Among dose wonderz be a new surgical towa an' a plan ta capitalize on Galveston’z semi-tropical charm by attractn' wealthy healthcaa touriztz from abroad. Medical caa fo'da poa be not, apparint, among da wonderz. Whereaz UTMB accepte' 77 percint uv charitee referralz n' 2005, it wuz on takn' 9 percint n' 2011.

UTMB azcribez deez changez ta financial strain from Hurricane Ike, da countee’z inabilitee ta negotiate a suitable indigint-caa contract an' lozz uv state fundn'. Da state blamez budget zhortfallz. Da Affordable Caa Act, betta known az Obamacaa, could be do be a bigass relief. Howeva, Gov. Rick Perry rejecte' billyunz uv dollarz n' federal fundn' ta expand Medicaid, fundn' dat should be broute ta accezz ta moe den a millyun Texanz, includn' many St. Vincint’z patiintz.

Perry’z refusal be catastrofic health polisee. Fo'patiintz, it meanz dat seekn' medical caa will still aquia riskn' bankruptsee, an' may lead nowhea. Fo'doctorz, da message wuz not on dat our patiintz’ livez don’t matta, buh also dat medicine—our old professyun, so full uv peeps who ginuine want ta help otherz—will continue ta be part uv da economic machine dat entrinchez povertee. Wen da poa seek our help, day often wind up wiff crippln' debt.

Cuz day can no longa count on UTMB ta accept they patiintz, UTMB doctorz now refa many ta St. Vincint’z. Day’ll treat someone fo'a heart attack (cuz dat’z 'n emerginsee covere' by EMTALA), den refa them ta uz fo'follow-up, even tho we don’t be a cardiologis'. Day’ll stabilize a patiint afta da beotch third stroke, put da beotch on blood thinnerz an' send da beotch ta uz. Day once sent uz, from da ER, a cat wiff a broken arm. Day put da arm n' a splint an' referre' him ta uz. What did day expect uz ta do—orthopedic surgery? Put on a cas'? We don’t even be 'n x-ray machine.

I do not think dat deez referralz be 'n official polisee. Ratha, day be da work uv doctorz an' nurzez tryn' ta do somethn' fo'patiintz who be do be refuse' caa thro da financial screinn' procezz at da hospital. Forma St. Vincint’z leada Dr. Merle Linihan haz describe' da clinic az a “moral safetee valve.” It protectz UTMB from confrontn' da conzequincez uv da state’z refusal ta provide caa.

Among dose conzequincez be da deathz uv da poa. Az Howard Brody, directa uv da Institute fo'da Medical Humanitiez, haz shown, 9,000 Texanz pa year will die needlezz az a result uv our failua ta expand Medicaid. Howeva, cuz dyn' patiintz be often too sick, exhauste' an' wracke' wiff pain ta protes', UTMB an' ztatez like Texaz aren’t force' ta reckon wiff da conzequincez uv they polisee decisyunz.


Cuz da very sick an' da dyn' may not be able ta holla about deez izzuez, health-caa providerz—particular da providerz uv da so-calle' “safetee net”—mus' do so. It be n' our clinicz, n' da bodiez uv our patiintz, whea da conzequincez get playe' out.

Danielle haz schizofrinia, an' da beotch’z young, an' da beotch ztrugglez wiff da medicashunz. Wen we holla, dere be long gapz n' da conversashun whea, I think, da beotch hearz otha voicez. N' one uv deez gapz, I notice da sun slantn' n' whea it’z beginnn' ta set beyond da ship channel. Dere’z gospel music streamn' out ova da basketball court from da zpeakerz mounte' on da side uv da communitee cinta. I am reminde' uv what da directa uv da communitee cinta, 'n Epispo-poal minista, believez: Every patiint be a miracle. Da St. Vincint’z Crib motto be “'n oaziz uv hope, expectn' miraclez.”

Danielle lookz up an' ztarez rite at me. “Huhhh’z what I want ta know,” da beotch zayz. “Why be we so poa?”

St. Vincint’z Crib, wich hoztz da free clinic, be a historical African-American communitee cinta n' da lowes'-income hood on our island, next ta whea da housn' projectz wuz befoa day wuz condemne'. Da federal fedz ordere' Galveston ta rebuild da public housn' afta Hurricane Ike, buh da citee refuse'. We electe' a maya who ran on 'n explicit anti-public housn' platform. Jus' like da medical system, da citee knowz whose livez matta.

Now, dandelyunz grow n' da emptee lotz left afta Ike floode' da hood. Peeps sit on da ragge', crackn' curbz, an' run wheelchairz rite down da middle uv da skreet cuz da zidewalkz tend ta end n' grassy fieldz o'lil precipicez.

Da communitee cinta employz a peep ta stand n' da skreet an' walk uz ta our carz afta clinic if we want. Who be dude protectn' uz from, I wonda. Our patiintz?

N' my second year uv medical school, I took a small-group course wiff a famouz terrifyn' surgeon. Dude hollad uz dude moral motto: “A physician neva takez away hope.”

I neva figure' out how dat motto could guide doctorz thro a system whea our patiintz be dyn' from treatable dizeazez. Part uv my job, it zeemz, be precise dat: ta sit down wiff patiintz an', az gent az possible, take away hope.

Consida Vanessa an' Jimmy. Day met n' New Orleanz wen da beotch wuz 18. Da beotch wuz workn' cleann' motelz, an' dude took da beotch on a tour uv da tugboat dude wuz captain uv. Vanessa zayz day came ta St. Vincint’z cuz da shipyard Jimmy worke' fo'opte' out uv providn' insurance even fo'full-time employeez like him. Day looke' fo'insurance on da open market, buh couldn’t afford it.

Da Affordable Caa Act be suppose' ta help familiez like Vanessa an' Jimmy get insurance. Folkz higha on da income scale should now be able ta afford insurance thankz ta fedz zubzidiez. Da poores' uv da (legal documinte') poa should be covere' by Medicaid. An' fo'dose peeps n' between, da federal fedz offere' ta pay fo'almos' all da coztz uv expandn' Medicaid.

Moe den a millyun Texanz—an' mos' St. Vincint’z patiintz—be somewhea n' between. Day be da workn' poa, o'day be adultz without depindent children, who cannot qualify fo'Medicaid n' Texaz, no matta how poa day be.

Wen Jimmy’z labz showe' a dangerouz high crackah blood cell count, we sent him ta da ER. It wuz pneumonia, an' dere wuz a bigass tuma underneath. Currint guidelinez would recommind screinn' Jimmy fo'dis kind uv canca every year, buh we be neitha da equipmint na da fundz ta offa screinn'. So it gots caute late.

Afta Jimmy wuz diagnose', I helpe' Vanessa fill out da paperwork ta reques' financial assistance fo'canca caa. Da beotch wante' ta know how like UTMB wuz ta offa da beotch baby daddy assistance dude nee'e'.

N' addishun ta on acceptn' 9 percint uv applicantz, da charitee caa approval procezz be a dark art, an' we neva know who will be accepte'. Accordn' ta da UTMB Charitee Caa polisee, da institushun may consida not on a peep’z income an' diagnoziz, buh also such vague qualitiez az “da history uv da problem.” Day also consida whetha da treatmint will offa “educational binefit” ta medical ztudintz an' traineez. Phyzicianz n' trainn' be ta see a certain numba uv each type uv case. If da programz be hittn' quotaz wiff funde' patiintz, patiintz like Jimmy be lezz like ta be accepte'.

Da complexitee an' vaguinezz uv deez policiez meant dat it wuz impossible ta tell Vanessa how like UTMB wuz ta take da beotch baby daddy. We can guezz around a 10 percint chance, buh we neva real know.

Fo'patiintz facn' canca, dis be not a hopeful answa.



Vanessa calle' from a hospital n' Houston n' ear Novemba, distraute, ax'n me ta help da beotch decide whetha o'not ta let da doctorz turn Jimmy’z breathn' machine off. Da beotch wuz afraid da beotch wouldn’t be able ta live wiff herself, no matta wich da beotch chose. I gave da beotch da advice I’d give a homie: dat I truste' da beotch love fo'da beotch baby daddy an' da beotch abilitee ta decide from a place uv love. Jimmy die' late dat nite.

Vanessa’z reques' fo'UTMB fundn' wasn’t approve'. Da beotch haz receive' a $17,000 bill from UTMB fo'da visit wen Jimmy wen thro da ER, an' a $327,000 preliminary bill from da Houston hospital.

If da Affordable Caa Act had do be n' effect las' year, day would be do be able ta afford insurance, get treatmint ear an' avoid bankruptsee. I use ztoriez like theirz—canca ztoriez—wen I am encouragn' my patiintz ta check out da insurance exchangez.

Buh wiff Jimmy gone an' Vanessa unemploye', da beotch now fallz inta da Medicaid coverage gap. I don’t know how da beotch will get caa, if da beotch eva needz moe den St. Vincint’z can give.

My firs' patiint, da one who die' n' hospice, mite be live' if dude canca had do be treate' befoa it had spread from da kidney. Buh without da Medicaid expansyun, da Affordable Caa Act wouldn’t help him: Az 'n adult wiff no depindent children, dude wouldn’t qualify fo'Medicaid now.

N' a betta medical system, dude’d be had a chance at a moe dignifie' experiince uv illnezz. Dude wouldn’t be had ta wait fo'hourz n' a crowde' free clinic, an' assume da postua uv gratefulnezz dat charitee zeemz ta aquia. Dude wouldn’t be had ta be treate' n' part by 'n earnes', buh unskille', firs'-year medical studint. Dude, like so many Texanz, deserve' betta.

Wen one uv our St. Vincint’z patiintz getz a bad diagnoziz, we start sindn' faxez: ta UTMB, ta MD Anderson, ta anywhea dat mite be fundz ta help them. Sometimez it workz out, buh often it doesn’t. Sometimez I think uv it az “sindn' faxez inta da abyzz.” An' zometimez I think uv it az da slow, diligint, technical way dat I be uv insistn' dat deez livez matta.

From IWDRM

FROM:

IF WE DON'T,
REMEMBER ME.

[i]

IWDRM is a series of animated movie stills started in 2010.
Follow on Tumblr, subscribe via RSS, contact via form or twitter. 

"You know what? If everything’s going bad, we’re going bad as well."

Sedmikrásky (1966)

"Dave!"

2001: A Space Odyssey (1968)

"Remove TEPCO Before Removing Fuel"

from Fairewinds Energy Education, posted 11/14/2013:

Fairewinds has fielded a number of questions regarding the removal of the fuel rods from the spent fuel pool in Unit 4 at Fukushima Daiichi. Today’s video shows Arnie debunking TEPCO’s animated film point by point, and highlights the issues TEPCO will have removing the fuel rods. TEPCO needs to be removed as the organization overseeing the cleanup of the site prior to the removal of the fuel rods.

*****   ***   *****    *****   ***   *****   *****   ***   *****   *****   ***   *****   

published by Common Dreams, 10/24/2013:

Fuel Removal From Fukushima's Reactor 4 Threatens 'Apocalyptic' Scenario

In November, TEPCO set to begin to remove fuel rods whose radiation matches the fallout of 14,000 Hiroshima bombs

- Andrea Germanos, staff writer

An operation with potentially "apocalyptic" consequences is expected to begin in a little over two weeks from now - "as early as November 8" - at Fukushima's damaged and sinking Reactor 4, when plant operator TEPCO will attempt to remove over 1300 spent fuel rods holding the radiation equivalent of 14,000 Hiroshima bombs from a spent fuel storage tank perched on the reactor's upper floor.

Fukushima Reactor 4While the Reactor 4 building itself did not suffer a meltdown, it did suffer a hydrogen explosion, is now tipping and sinking and has zero ability to withstand another seismic event.

The Japan Times explained:

To remove the rods, TEPCO has erected a 273-ton mobile crane above the building that will be operated remotely from a separate room.

[...] spent fuel rods will be pulled from the racks they are stored in and inserted one by one into a heavy steel chamber while the assemblies are still under water. Once the chamber is removed from the pool and lowered to the ground, it will be transported to another pool in an undamaged building on the site for storage.

Under normal circumstances, such an operation would take little more than three months, but TEPCO is hoping to complete the complicated task within fiscal 2014.

A chorus of voices has been sounding alarm over the never-been-done-at-this-scale plan to manually remove the 400 tons of spent fuel by TEPCO, who so far has been responsible for mishap after mishap in the ongoing crisis at the crippled nuclear plant.

Arnie Gundersen, a veteran U.S. nuclear engineer and director of Fairewinds Energy Education, warned this summer that "They are going to have difficulty in removing a significant number of the rods," and said that "To jump to the conclusion that it is going to work just fine is quite a leap of logic."  Paul Gunter, MD, Director of the Reactor Oversight Project with Takoma Park, Md.-based Beyond Nuclear, also sounded alarm on Thursday, telling Common Dreams in a statement that "Given the uncertainties of the condition and array of the hundreds of tons of nuclear  fuel assemblies, it will be a risky round of highly radioactive pickup sticks."  Gundersen offered this analogy of the challenging process of removing the spent fuel rods:

If you think of a nuclear fuel rack as a pack of cigarettes, if you pull a cigarette straight up it will come out — but these racks have been distorted. Now when they go to pull the cigarette straight out, it’s going to likely break and release radioactive cesium and other gases, xenon and krypton, into the air. I suspect come November, December, January we’re going to hear that the building’s been evacuated, they’ve broke a fuel rod, the fuel rod is off-gassing. […]

I suspect we’ll have more airborne releases as they try to pull the fuel out. If they pull too hard, they’ll snap the fuel. I think the racks have been distorted, the fuel has overheated — the pool boiled – and the net effect is that it’s likely some of the fuel will be stuck in there for a long, long time.

The Japan Times adds:

Removing the fuel rods is a task usually assisted by computers that know their exact location down to the nearest millimeter. Working virtually blind in a highly radioactive environment, there is a risk the crane could drop or damage one of the rods — an accident that would heap even more misery onto the Tohoku region.

As long-time anti-nuclear activist Harvey Wasserman explained, the

Spent fuel rods must be kept cool at all times. If exposed to air, their zirconium alloy cladding will ignite, the rods will burn and huge quantities of radiation will be emitted. Should the rods touch each other, or should they crumble into a big enough pile, an explosion is possible.

"In the worst-case scenario," RT adds,

the pool could come crashing to the ground, dumping the rods together into a pile that could fission and cause an explosion many times worse than in March 2011.

Wasserman says that the plan is so risky it requires a global take-over, an urging Gunter also shared, stating that the "dangerous task should not be left to TEPCO but quickly involve the oversight and management of independent international experts."

Wasserman told Common Dreams that

The bring-down of the fuel rods from Fukushima Unit 4 may be the most dangerous engineering task ever undertaken.  Every indication is that TEPCO is completely incapable of doing it safely, or of reliably informing the global community as to what's actually happening.  There is no reason to believe the Japanese government could do much better.  This is a job that should only be undertaken by a dedicated team of the world's very best scientists and engineers, with access to all the funding that could be needed.  

The potential radiation releases in this situation can only be described as apocalyptic.  The cesium alone would match the fallout of 14,000 Hiroshima bombs.  If the job is botched, radiation releases could force the evacuation of all humans from the site, and could cause electronic equipment to fail.  Humankind would be forced to stand helplessly by as billions of curies of deadly radiation pour into the air and the ocean.   

As dire as Wasserman's warning sounds, it is echoed by fallout researcher Christina Consolo, who told RT that the worst case scenario could be "a true apocalypse." Gunter's warning was dire as well.

"Time is of the essence as we remain concerned that another earthquake could still topple the damaged reactor building and the nuclear waste storage pond up in its attic," he continued. "This could literally re-ignite the nuclear accident in the open atmosphere and inflame it into hemispheric proportions," said Gunter.

Wasserman says that given the gravity of the situation, the eyes of the world should be upon Fukushima:

This is a question that transcends being anti-nuclear.  The fate of the earth is at stake here and the whole world must be watching every move at that site from now on.  With 11,000 fuel rods scattered around the place, as a ceaseless flow of contaminated water poisoning our oceans, our very survival is on the line.  

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