Henry Brem, M.D.

• Director, Department of Neurosurgery
• Professor of Neurosurgery

https://www.hopkinsmedicine.org/profiles/results/directory/profile/0003433/henry-brem

Assess muscle strength to determine changes related to overdosage/ under dosage of cholinesterase inhibitor medications depression symptoms body pain cheap geodon 20mg mastercard. Instruct patient to take rests while chewing and in between bites to restore strength definition of depression pdf geodon 20mg otc. Serve meals at times of maximum strength (usually in the earlier part of the day and 1/2 hour after cholinesterase inhibitor medications) depression test español buy discount geodon 20 mg line. Difficulty swallowing with the potential for episodes of choking the patient will chew and swallow food with minimal problems the patient will take in food without experiencing coughing or choking Apply principles of good nutrition in food selection depression comic discount 80mg geodon free shipping. Place the patient in an upright position with head tilted slightly forward for optimal positioning for swallowing. If swallowing only slightly impaired, instruct patient to lean forward, take a small breath through the nose and cough forcefully to push the irritating substance out of the throat If choking occurs, apply emergency principles as outlined by the American Heart Association to include the Heimlich maneuver Appendices 186 Appendix 3. Be honest about realities of the illness; encourage patients to seek help if denial becomes detrimental. Facilitate acceptance; help patients set realistic, short-term goals so that success may be achieved. Recognize that the family too will be experiencing grief for the loss of the way the patient "used to be. Assist patients in identifying factors in their environment that have the potential to undermine positive adaptation. Relationships can be formed with others with the disease and be a great source of strength to patients and family Anxiety related to disease process and lifestyle alterations Patient and significant others will Active Listening express causes of anxiety Refer if necessary for counseling or therapy to deal with anxiety Fear of death: patient family and friends Patient, family and friends will set realistic goals related to the causes of anxiety Active Listening Appendices 188 Appendix 7. All tests are conducted with the patient supine except for knee flexion and extension which are tested with the patient in sitting. Each muscle group is tested in a gravity eliminated position and the shaft of the dynamometer is held perpendicular to the tested limb segment. Patients are stabilized by another person during knee flexion and extension and shoulder extension trials. At least one practice is given to the patients to give them the feel of pushing against the dynamometer. The patient then performs the movement actively until the movement is performed correctly. Make tests are employed as the patients are asked to build their force gradually to a maximum voluntary contraction over a two second period. A rest period lasting one to two minutes is provided before a second measure was taken. Peak force values are recorded for each trial from the digital readout on the dynamometer. Regular oral hygiene performed at home with tooth brushing and daily flossing between the teeth is essential for plaque control and the prevention of both gum disease and tooth decay. Regular dental visits for professional cleaning and exams are important to maintaining a healthy dentition. The following are suggestions and information for you and your dentist to allow you both to enjoy a safe and pleasant dental experience. Tongue: Lipomatous atrophy of the tongue may result in a furrowed and flaccid clinical appearance. Mouth Drop: Lack of muscle strength in the masseter muscle, especially following a sustained chewing effort, may cause the mouth to hang open, unless the mandible (lower jaw) is held shut by hand. Chewing/Swallowing: Lack of strength in the muscles of mastication can inhibit proper mastication of food. Eating can be further inhibited by dysphagia (difficulty swallowing), when the tongue and other muscles used for swallowing are involved and by abnormal passage of food or liquids from the nasopharynx into the nasal cavity, when the palatal and pharyngeal muscles are affected. Tell your dentist how frequently you have weakness and what muscles are usually involved. If an exacerbation is precipitated, you should be evaluated for severity of neuromuscular involvement by your neurologist, if possible. If respiratory collapse occurs, an open airway and adequate respiratory exchange must be established. Dental suction devices can be used to suction secretions and debris from the oropharynx to prevent aspiration and mechanical blockage of the airway. Use of a vasoconstrictor, such as 1:100,000 epinephrine in combination with lidocaine is beneficial in maximizing anesthesia efficacy at the oral site, while minimizing total anesthetic dose. Intravenous sedation techniques and narcotic analgesics should be used with caution to avoid respiratory depression. May cause gingival hyperplasia (fibrous gum overgrowth) which may begin as early as the first month of drug use and seems to be dependent upon the presence of dental plaque or other local irritants, individual susceptibility and the dose of cyclosporine used. Cyclosporine levels increase to possibly toxic levels: erythromycin, ketoconazole, fluconazole and itraconazole. Discuss with your physician and dentist whether you need to increase your steroid dose before stressful or complicated dental procedures. You can use a low speed saliza ejector to collect the saliva during dental treatment. Your dentist can use high speed evacuation/suction to collect debris and saliva in your mouth during treatment. The dental treatment that requires a dry mouth and cannot be done using rubber dam isolation is making an impression for a crown or bridge prosthesis. If your exchange protocol involves the use of anticoagulants (blood thinners), including heparin, dental treatment should be arranged for a non-exchange day in the treatment sequence. Mouth prop, rubber dam isolation and saliva ejector use during dental treatment: 1. Mouth props prevents muscle strain of having to hold the mouth open during treatment 2. By keeping dental materials and water spray out of the throat Saliva ejector suction tubing may be held and controlled by the patient to help avoid drooling and choking on saliva during procedures E. Inability of the flaccid muscles to assist in retaining the lower denture and to maintain a peripheral seal for the upper denture. Ill-fitting dentures may exacerbate symptoms of difficulty in closing the mouth, tongue fatigue, a tight upper lip, dry mouth, impaired phonation, dysphagia and masticatory problems. Let your dentist know if you are so far back that you feel like your throat is closing off. Final Words of Wisdom: Good preventive dental care (your good oral hygiene efforts at home and 6 month dental recall/professional cleaning visits) will help to prevent dental problems, oral infections and avoid the need for emergency dental care which is by its nature stressful. For carcinogens, it is generally assumed that any level of exposure results in some level of cancer risk, and a one in one million (10-6) risk level from lifetime exposure is specified in the statute. For non-carcinogenic effects, it is generally assumed that exposure below a threshold level will not result in adverse effects. Document development process the Subcommittee conducted a literature search of the PubMed and Toxline databases for potentially relevant information. Based on this screening, 169 references relevant to human health effects, human biomonitoring, animal toxicology, pharmacokinetics, and in vitro studies were designated for "further consideration" while 292 other references not relevant to these areas were excluded. Some references that were excluded as irrelevant to these topics were used to inform supporting sections of this assessment, such as the "Background Information" and "Environmental Sources, Fate, and Occurrence" sections. All comments relevant to the Support Document were reviewed by the Health Effects Subcommittee. Because they form a separate layer when mixed with hydrocarbons and water, measurement of the octanol:water partition coefficient is not practical (Prevedouros et al. In 2010, only 171 kg were used, compared to 6,341-8,467 kg/year in each of the previous 10 years. A pathway for this contamination was deposition from air onto soil, followed by migration through the soil to ground water (Davis et al. In a literature review of drinking water occurrence studies worldwide (Post et al. As discussed below, the lower median values are from studies of European populations, and the two highest median values (2. In contrast, these are important exposure routes for volatile drinking water contaminants. Products tested included milk-, organic-, and soy-based formula, packed in cans, glass, or plastic, in liquid, powdered, and concentrated liquid forms. After repeated administration to mice and rats, liver concentrations are higher than serum concentrations, while concentrations in the kidney are lower than in the serum (Tatum-Gibbs et al. Rates of fecal elimination are slow, and are similar in male and female rats (Kudo et al.

They are usually and arbitrarily separated into large and small categories uncomplicated depression definition discount geodon 20 mg, for reference depression in the bible order 20mg geodon visa, though they probably represent different functional stages of cells within populations of cells rather than a difference in functional capacity depression no friends buy 20 mg geodon with visa. The average size of small lymphocytes may differ between species anxiety questionnaire for adolescent order geodon 20mg overnight delivery, for example their diameters average 4. In morphology the majority of circulating small lymphocytes appear as inactive undifferentiated cells. They circulate in this form until stimulated into action by their specific antigens. Lymphocytes circulate throughout the blood and lymph of the vertebrate body and congregate in organs which filter body fluids. The number of lymphocytes in the blood is noticeably greater in fishes than in mammals. Segmented neutrophils (sn), polychromatocyte or immature erythrocyte (pe), and thrombocyte (t). Successive stages (a-d) of erythrocyte "degeneration", ending as a smudge cell (d). Polychromatocyte (pe), an immature erythrocyte with basophilic cytoplasm; prolymphocyte (pl); granulocytes (gn); segmented neutrophil; band neutrophil (bn); smudge cell (s). The organism has been isolated from salmonid fishes in Chile, Ireland, Norway, and both the east and west coasts of Canada. The organism has been observed in or isolated from coho, Chinook and pink salmon, rainbow trout, and Atlantic salmon. There are several morphologically distinct viral particles that cause the disease. Some of these virusesprobably cause different signs and have distinct host specificities. The numerous agents that cause the disease are manifested as chronic or sunacute infections that may not cause overt mortality, but debilitate fish so that other pathogens. These morphologic changes can provide the clues necessary to establish a diagnosis. While sometimes histology is sufficient by itself to make a diagnosis, it can become all the more powerful if complimented by other diagnostic methods such as bacteriology, virology, serology, and toxicology. In order to understand the histological appearance of injured tissues, it is important to be familiar with the normal histology of the organs and tissues of the type of animal under examination. Be aware that there are ranges of "normal" in any given species, and only by looking at many normal animals will you become familiar with this variation. Considering the diversity of fishes, it is very beneficial to examine numerous specimens from different species as well, in order to better appreciate how variable "normal" can be between species. A solid familiarity with what is considered normal is essential in order to be able to readily identify lesions, particularly those that are subtle. This will also help you sort out those changes that are truly associated with a disease process from those that are part of normal physiologic processes for the animal being examined. Familiarity with pathologic changes at the gross and histological level will often aid in identification of the etiology, or cause, of a disease. Certain morphologic changes in diseased tissues often provide clues as to what type of injurious agent may have been responsible. A good example is the presence of granulomatous inflammation in various organs of a fish. By recognizing this morphologic pattern, you will immediately consider certain groups of pathogens as possibly being responsible for the lesion: Renibacterium, Mycobacterium, various fungi. Even without microbiology support, you have narrowed the list of possible etiologies to a few very likely candidates. The pathogenesis of disease and the development of lesions are similar across species lines. If you understand histopathology of fish, you can use that knowledge to appreciate similar changes associated with disease in other types of animals. Injuries often induce changes in cellular structure which are not lethal and are reversible. These changes may be distinct, or can blend or progress from one to another, or occur simultaneously within a tissue. Reversible injuries result in structural and functional changes, but adaptation by the affected cells can maintain cell viability. Without adaptation, the changes caused by the injury can progress and may lead to cell death (necrosis). Acute cellular swelling (Figures 1 through 6) Cells swell due to increased water uptake following alterations in membrane permeability. Cytoplasm develops a "ground glass" appearance primarily due to fine, watery vacuoles in the cytosol and mitochondria. Mitochondria are very vulnerable to noxious agents; if damaged, cellular metabolism (ionic pump) fails yielding osmotic swelling of the organelle. Acute cellular swelling represents an early and completely reversible manifestation of injury. Hydropic change (Figures 7 and 8) Large distinct water vacuoles form within the cell cytoplasm. Fatty Change (Figures 9 through 12) Fatty change (fatty metamorphosis; lipidosis) is an abnormal and excessive accumulation of intracellular fat. This is an injury which, though reversible, can be severe and can cause severe disruption of cell function. Distinct non-staining vacuoles of fat lie in the cell cytoplasm, displacing and compressing the nucleus. There are several mechanisms that can result in excess fat accumulation in a cell. These include: 1) dietary excesses of carbohydrates and/or triglycerides; 2) decreased oxidation of fatty acids leading to increased esterification of fatty acids to triglycerides; 3) decreased lipid acceptor protein (hypoxia, deficient dietary protein); 4) decreased transport from the cell; 5) dietary protein - fat imbalance. The fat content of the liver is quite variable in normal fish; diet and physiologic events have a bearing on this, as well as the species of the fish; some are always laden with fat (eg. With experience, you will develop an appreciation for the range of normal in various species. Hyaline change "Hyaline" is a commonly used adjective that does not imply any particular disease. It simply refers to a particular histologic appearance of cells or tissues when stained with H & E stain. It can be found under normal or pathologic conditions, and may or may not be reversible. It can represent an accumulation of material within the cell, or occur as a result of cell degeneration. Necrosis (Figures 13 through 20) Cell injury can progress to a point of no return, where the cell is unable to adapt and homeostasis is no longer possible. Major disruption of the cell membrane occurs during necrosis, accompanied by massive influx of calcium into the cell. The cytoplasmic features of necrosis include intense eosinophilia, loss of basophilia, and fragmentation or hyalinization of the cytoplasmic component. In addition to these cytological features, necrosis will induce localized inflammation (assuming death does not occur to quickly). Coagulative necrosis is characterized by retention of cellular/tissue architecture; cellular detail is retained in the face of cell necrosis. This is associated with diverse causes, including many infectious diseases, ischemia, burns, trauma, and toxic damage. Caseous necrosis is more easily recognized grossly; they have a dry, cheese-like consistency. Liquefactive necrosis features complete disintegration of the tissue into a liquid of varying consistencies. The liquefaction is caused by enzymes released from host cells, such as neutrophils or other inflammatory cells, or by toxins released from bacteria. Tissues with high fat content, such as the central nervous system, also may liquefy when necrotic. The tissue however may be able to regenerate and heal (see section on Healing and Repair). Programmed cell death and apoptosis Programmed cell death and apoptosis are similar processes, but have different triggers. It is a mechanism for elimination of selected cells during physiological processes of development and growth.

Animal Sciences Department mood disorder unspecified icd 9 trusted geodon 80 mg, Florida Cooperative Extension Service depression rates by country order geodon 80mg on-line, Institute of Food and Agricultural Sciences anxiety from weed order geodon 20mg overnight delivery, University of Florida depression worksheets proven 80 mg geodon. Enterohemorrhagic Escherichia coli O157: epidemiology and ecology in bovine production environments. The control of copper storage in the liver of sheep by inorganic sulphate and molybdenum. The effects of adequate and excessive calcium when fed when fed with adequate phosphorus in growing ration for beef calves. Effects of longterm exposure to manganese chloride on fertility of male and female mice. Prevalence and clonal nature of Escherichia coli O157:H7 on dairy farms in Wisconsin. Evaluation of the nitrate drinking water standard with reference to infant methemoglobinemia and potential reproductive toxicity. Health implications of nitrate and nitrite in drinking water: an update on methemoglobinemia occurrence and reproductive and developmental toxicity. Comparative effects of iron deficiency induced by bleeding and a low-iron diet on the intestinal absorptive interactions of iron, cobalt, manganese, zinc, lead and cadmium. The effect of molybdenum on the conversion of sulphate to suiphide and microbial-protein-sulphur in the rumen of sheep. Effects of dietary copper and molybdenum on copper status, cytokine production, and humoral immune response of calves. Availability and utilization of magnesium from dolomitic limestone and magnesium oxide in steers. Effects of level of dietary copper, molybdenum, sulfate and zinc on body weight gain, hemoglobin, and liver storage of growing pigs. Effects of sulfur and nitrogen sources and copper levels on the metabolism of certain minerals by sheep. The effect of parenteral copper on the milk yield characteristics of a dairy herd with hypocuprosis. Effects of dietary copper, molybdenum and sulfur on biliary copper and zinc excretion in Simmental and Angus cattle. In vivo indicators of pathologic ruminal sulfide production in steers with diet-induced polioencephalomalacia. Potentially hazardous sulfur conditions on beef cattle ranches in the United States. High sulfide concentration in rumen fluid associated with nutritionally induced polioencephalomalacia in calves. A comparison of "hard" and commercially softened water in the ration of lactating dairy cows. Multivariant analysis of the effects of manganese on the reproductive physiology and behaviour of the male house mouse. Differential effects of sodium and magnesium sulfate on water consumption by beef cattle. Forage mineral concentration, animal performance, and mineral status of heifers grazing cereal pastures fertilized with sulfur. Sulfur-induced polioencephalomalacia in a herd of rotationally grazed beef cattle. A national survey of chlorinated disinfection by-products in Canadian drinking water. Effect of selenium, sulfur and sulfur amino acids on nutritional muscular dystrophy in the lamb. Effects of zinc, copper and manganese supplementation of high-concentrate ration on gastrointestinal absorption of copper and manganese in Holstein calves. Effects of sublethal doses of certain minerals on pregnant ewes and foetal development. Influence of saline water on intake, digesta kinetics, and serum profiles of steers. Metabolic disorders in sheep and cattle caused by magnesium oxide in the concentrate feed. Oral administration of monensin and lead in broiler chick: effects on some hematological and biochemical parameters of broiler chickens. Effects of concurrent administration of lead and selenium on some hematological and biochemical parameters of broiler chickens. The effects of ammonium tetrathiomolybdate intake on tissue copper and molybdenum in pregnant ewes and lambs. Related effects of copper, molybdenum and sulfide on performance, hematology, and copper stores of growing pigs. Effects of vitamin E and systemic antioxidants on the survival of mercury poisoned Japanese quail. Effect ofelevated dietary levels of iron on the performance and blood constituents of calves. Magnesium supplementation, space and docking effects on swine performance and behavior. Polioencephalomalacia in cattle: a consequence of prolonged feeding barley malt sprouts. Association of excess sulfur intake and an increase in hydrogen sulfide concentrations in the ruminal gas cap of recently weaned beef calves with polioencephalomalacia. Effects of water sulfate concentration on performance, water intake and carcass characteristics of feedlot steers. Contribution of cattle products to dietary intake of trace and toxic elements in Galicia, Spain. The Influence of the Mineral Level in Drinking Water and the Thermal Environment on the Performance and Intestinal Fluid Flux of Newly-Weaned Pigs. A review of nitrates in drinking water: maternal exposure and adverse reproductive and developmental outcomes. Nitrate-nitrite toxicity in cattle and sheep grazing Dactyloctenium radulans (button grass) in stockyards. Sulfur-associated polioencephalomalacia in cattle grazing plants in the Family Brassicaceae. Evaluation of the quality of ground water supplies used in Saskachewan swine farms. Water intake patterns in the weanling pig: effect of water quality, antibiotics and probiotics. A national survey for cadmium, chromium, copper, lead, zinc, calcium, and magnesium in Canadian drinking water supplies. Survey for cadmium, cobalt, chromium, copper, nickel, lead, zinc, calcium, and magnesium in Canadian drinking water supplies. Contributions to water and minerals metabolism of the horse, In: Advances in Animal Physiology and Animal Nutrition. Supplements to Journal of Animal Physiology and Animal Nutrition, Paul Parey, Hamburg and Berlin. Health risks of drinking water chlorination by-products: Report of an expert working group. Selenite-induced binding of inorganic mercury in blood and other tissues in the rat. Relationship of excess calcium and phosphorus to magnesium requirement and toxicity in guinea pigs. Effects of breed (Angus vs Simmental) and copper and zinc source on mineral status of steers fed high dietary iron. A comparison of the lactational and transplacental deposition of mercury in offspring from methylmecury exposed mice. Effects of dietary sulfur concentrations on the incidence and pathology of polioencephalomalicia in weaned beef calves. Neurotoxicity and secondary metabolic problems associated with low to moderate levels of exposure to excess dietary sulfur in ruminants: A review. The effect of sulfate on thiamine destroying activity in rumen content cultures in-vitro.

Under the leadership of Zahir Shah depression im jugendalter test purchase geodon 20 mg fast delivery, the last king of Afghanistan depression symptoms suicidal thoughts purchase 40 mg geodon, the country saw a move towards real modernization depression symptoms hallucinations 40mg geodon amex. While receiving medical treatment in Italy boiling point depression definition chemistry geodon 20mg for sale, Zahir Shah was overthrown by his cousin, Mohammad Daoud, a military leader who established a dictatorship with strong state involvement in the economy. Both leaders drew their strength from rural ethnic Pashtuns and tried to impose radical socialist change on a traditional society, in part by redistributing land and bringing more women into government. The attempt at rapid modernization sparked rebellion by Islamic parties opposed to such moves. Afghan civilians were introduced to land reforms and gender politics virtually overnight. Land-redistribution projects effectively carved up traditional tribal areas, sowing resentment among the population. These events, combined with the sudden inclusion of females in the political and bureaucratic machine, led Afghans to believe that their traditional values were under attack. This situation presented a moral dilemma for the United States, ultimately forcing it to side with Islamist groups against the communists. Abdul Haq, an ally of Massoud, famously said, "How is [it] that we Afghans, who never lost a war, must take military instructions from the Pakistanis, who never won one Two decades of war had eviscerated the economy in Afghanistan, and the Soviets had to provide everything, from fuel to food. Amin Saikal writes that "Islamabad could not possibly expect the new Islamic government leaders. Unfortunately, this regional proxy war created the Taliban when the various factions of Islam, such as the Wahabbis, Sunnis, and Shia, began to compete for the loyalty of the people. Repression soon followed, and the best chance for the success of future American foreign policy in Afghanistan died with Ahmed Shah Massoud on 9 September 2001. Breaking this 40-year cycle of constant regional and civil war-the unenviable task of our policy makers-lies beyond the scope of this article. However, the study does allow us a glimpse at the various factors that must be included in our forceprotection planning if we wish to avoid the same endless caregiving that the Soviets inherited. This article addresses the primary issue of the dramatic increase in the number of insider attacks on coalition forces in 2012. Most logically, one should begin by examining the existing technological gap between Western society and the Afghan population. In rural areas, where approximately 74 percent of all Afghans reside, the situation is more acute, with an estimated 93 percent of women and 65 percent of men lacking basic reading and writing skills [fig. This requirement, coupled with the cultural void that exists between the Airman and the civilian, presents a quandary. It is the basic rule that governs every job we do, from flying advanced aircraft to polishing brass. We must build one that promotes communication and trust on an individual scale-at best, a difficult endeavor when one side is literally starting from scratch. This development is critical; a local defense force will only be effective where locals view it as in their interest" (emphasis in original). The languages of Afghanistan include Pashto from the south and Dari from the north, all with a sprinkling of Punjabi, Urdu, and a host of others thrown in. The complex nature of that subject prevents this article from even attempting to address the various religious sects vying for power. Though necessary in a twenty-first-century military force, these skills increase the time necessary to make the new recruit field-ready. The decision was the result of pressure from former defense minister Abdul Rahim Wardak, who argued to Pentagon officials and members of Congress that American weapons would make his army appear more professional, despite concerns from U. In fact, when we look at methods employed in the targeted attacks, we find that the opposite is true. Many people have identified the culture clash as the single most significant factor in the recent rise in insider attacks. Extortion and kidnapping follow close behind when the local Taliban threaten the family of a recruit far from home. The Culture War Western society is rightfully proud of its social contract and firstworld status. Yet, when we exercise these rights, which are as natural to us as breathing, we open ourselves to the unintentional insult (fig. Personal space, gender politics, and even casual body language can be misinterpreted as a direct, personal insult by our Afghan allies. Some of the slang terms we use-hajji-for example, is actually an honorific title given to elders or those who have completed the pilgrimage to Mecca (the hajj). Using hajji to address a local who feels undeserving of the title could be taken as a personal slight. Impostors generally lack the information necessary to target a speci c individual but post a grave threat to facilities and equipment. The question in every case is whether the words used are used in such circumstances and are of such a nature as to create a clear and present danger that they will bring about the substantive evils that Congress has a right to prevent. American citizens have the right to say nearly any foolish thing that comes to mind, but we still cannot shout "fire" in a crowded theatre. When speech presents a "clear and present danger," commanders must take the initiative when explaining this to their troops. Casual comments and good-natured ribbing aside, why risk exacerbating an already-tense relationship just for a laugh Trainers must take steps to address this issue during predeployment training cycles by clearly explaining that Airmen are diplomats as well as combatants. Leaders who choose to ignore this point do so at the peril of those under their command. One should never assume that a poor village in the provinces would ignore the income potential from drug operations run by the local warlords (and sometimes by the local Afghan police). Although no central Afghan authority supervises and executes interdiction operations in the borderlands, one could make real progress in this area-specifically, by initiating locally supported agricultural initiatives and community-infrastructure projects. Narcotics traffickers provide revenue and material support to insurgents in exchange for protection to the growers and traffickers. These reductions were the result of improved security, a significant alternative livelihood program supported by the international community, and strong political will on the part of the governor. The illicit drug trade in Afghanistan is also a clear example of the hypocrisy displayed by the Taliban philosophy. During their rule, poppy cultivation and heroin production were "officially" prohibited and punishable by death. However, these executions were usually just a method of territory control in the drug trade. Many families have only one male breadwinner and are reluctant to risk their lives by engaging the local warlord. Animosity grows when our troops witness a reluctance to engage the enemy and turns to pure anger when they sustain casualties. According to Gareth Porter, "The truth of course is that these two explanations of personal grudges and infiltrations are not mutually exclusive at all. But also by the broader context of what they hear and see these forces are doing in Afghanistan.

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