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However treatment 1st metatarsal fracture discount generic selegiline uk, changes to medications list a-z buy selegiline 5 mg low cost sectors opportunities to symptoms pancreatitis selegiline 5 mg overnight delivery identify and develop and settings—as previously discussed— the Dietary strategies that help individuals align can have a powerful effect on social and their choices with the Dietary Guidelines symptoms 8 days after iui buy selegiline 5mg free shipping. Guidelines cultural norms and values over time and Strategies could include supporting can align with the Dietary Guidelines. During the past few decades, food policy and/or program changes, fostering products and menus have notably coalitions and networks, developing or evolved in response to consumer Individual Factors modifying products and menus, and/ demands and public health concerns. To ensure widespread adoption unique to the individual, such as age, sectors and settings have a unique sex, socioeconomic status, race/ethnicity, opportunity to continue to evolve and of these sectoral efforts, complementary the presence of a disability, as well as better align with the Dietary Guidelines. Education to improve individual offering more vegetables, fruits, whole Settings food and physical activity choices can be grains, low-fat and fat-free dairy, and Individuals make choices in a variety of a greater variety of protein foods that delivered by a wide variety of nutrition and settings, both at home and away from are nutrient dense, while also reducing physical activity professionals working alone home. Away-from-home settings include sodium and added sugars, reducing or in multidisciplinary teams. Portion sizes also can community centers, and food retail and Physical Activity Guidelines for Americans, be adapted to help individuals make food service establishments. These choices that align with the Dietary provide the foundation for nutrition and public organizational settings determine what Guidelines. Food manufacturers are health professionals to develop programs foods are offered and what opportunities for encouraged to consider the entire and materials that can help individuals physical activity are provided. Strategies to composition of the food, and not just enhance their knowledge, attitudes, and individual nutrients or ingredients align with the Dietary Guidelines that are motivation to make healthy choices. Similarly, when developing individual choices and have the potential All food and beverage choices are part of or modifying menus or retail settings, for broader population-level impact if they an individual’s eating pattern. Professionals establishments can consider the range are integrated with strategies by multiple can work with individuals in a variety of of offerings both within and across food groups and other dietary components to sectors. In combination, sectors and settings settings to adapt their choices to develop determine whether the healthy options can infuence social norms and values. In taking these Social & Cultural ethnic, traditional, and personal preferences, actions, care should be taken to assess Norms & Values as well as personal food budgets and other any potential unintended consequences issues of accessibility. Eating patterns so that as changes are made to better Social and cultural norms are rules that align with the Dietary Guidelines, tailored to the individual are more likely to govern thoughts, beliefs, and behaviors. Living with food insecurity Meeting People improve food access within communities. Government and nongovernment Healthy Eating Patterns to support healthy eating patterns in nutrition assistance programs play an As previously described, the Socialretail outlets, including corner stores, essential role in providing food and Ecological Model provides a framework for bodegas, farmers markets, mobile educational resources to help participants how individuals make food and physical markets, shelters, food banks, and make healthy food choices within their activity choices (where, what, when, why, community gardens/cooperatives; and budget. Understanding creating new pathways for wholesale United States, and maintaining current individual choices and motivators and distribution through food hubs. Exploring Food access is important in all settings professionals identify which strategies are innovative new strategies could provide where people make choices. Improving most likely to be effective to promote healthy opportunities to reach more individuals, food access in settings, such as schools, choices aligned with the Dietary Guidelines. For example, sectors can the scientifc literature has described a programs, and food retail, may include create networks and partnerships to deliver number of specifc circumstances that can changing organizational policies to improve food and other resources to reach people limit an individual’s or family’s capacity to the availability and provision of healthy who are in need and when community choose a healthy diet. Individuals who are factors—food access, household food nutrition standards for food service supported in this way are better able to insecurity, and acculturation—are operations, and educating customers about obtain and make healthy food choices particularly important for millions of how to identify healthy choices, such as that align with the Dietary Guidelines. As appropriate, professionals can Changes to food options within a setting Acculturation consider these critical factors when should not be done in isolation but with consideration of the overall mix the United States continues to evolve developing strategies and providing of foods provided. Individuals who come to this country may Food Access adopt the attitudes, values, customs, Having access to healthy, safe,[2] and To help everyone make choices that align beliefs, and behaviors of a new culture affordable food choices is crucial for an with the Dietary Guidelines, professionals as well as its dietary habits. Ultimately, individual choices in order to accommodate traditional including proximity to food retail outlets will be enhanced when sectors and and cultural foods. Professionals can average income of the neighborhood and help individuals or population groups In the United States, about 48 million availability of public transportation). Race/ by recognizing cultural diversity and individuals live in households that ethnicity, socioeconomic status, geographic developing programs and materials experience food insecurity, which occurs location, and the presence of a disability also that are responsive and appropriate when access to nutritionally adequate may affect an individual’s ability to access to their belief systems, lifestyles and and safe food is limited or uncertain. Food Safety Principles and Guidance for guidance on food safety principles and practices. Page 67 — 2015-2020 Dietary Guidelines for Americans Chapter 3• Multi-Component Versus Multi-Level Strategies To Infuence Food & Physical Activity Choices Evidence demonstrates that both multi-component and multi-level changes must be implemented to effectively infuence public health. Multi-component changes are those that use a combination of strategies to promote behavior change. For example, a multi-component obesity prevention program at an early care and education center could target classroom education around nutrition and physical activity, ensure the continued nutritional quality of meals and snacks served, make improvements to the mealtime setting, increase opportunities for active play, and initiate active outreach to parents about making positive changes at home. Multi-level changes are those that target change at the individual level as well as additional levels, such as in community, school, and retail settings. For example, strategies to reduce sodium intake could include providing individual education on how to interpret sodium information on food labels or restaurant menus. Many strategies for implementing these types of multi-component and multi-level actions have shown promise to positively infuence food and physical activity choices. For example, moderate evidence indicates that multicomponent school-based programs can improve dietary intake and weight status of school-aged children. Fundamental to the success of such actions is tailoring programs to meet the needs of the individual, the community, and/or the organization so as to increase the chances of affecting social and cultural norms and values over time. To shift from current eating patterns to increase the effectiveness of interventions. As previously described, producers, suppliers, and retailers and consumption of foods that align these actions must involve a broad range of to increase access to foods that with the Dietary Guidelines. These actions programs that support education • Promote the development and availability include identifying and addressing successful and promotional activities tailored of food products that align with the approaches for change; improving knowledge to the needs of the community. Dietary Guidelines in food retail of what constitutes healthy eating and and food service establishments. It is important to note that no one strategy Settings—Examples Include: • Encourage opportunities in the is likely to be the primary driver to improve • Expand access to healthy, safe, workplace for regular physical activity individual and population lifestyle choices. Therefore, its translation into actionable consumer messages and resources is crucial to help individuals, families, and communities achieve healthy eating patterns. MyPlate is used by professionals across multiple sectors to help individuals become more aware of and educated about making healthy food and beverage choices over time. Created to be used in various settings and to be adaptable to the needs of specifc population groups, the MyPlate symbol and its supporting consumer resources at ChooseMyPlate. Everything Vegetables Protein Move to Vary your low-fat or you eat and Vary your protein fat-free drink over veggies. Strategies To Align Settings With the 2015-2020 Dietary Guidelines Americans make food and beverage choices in a variety of settings at home, at work, and at play. Aligning these settings with the 2015-2020 Dietary Guidelines will not only infuence individual choices—it can also have broader population level impact when multiple sectors commit to make changes together. Professionals time, can have a meaningful impact on the • Help individuals become more aware should help individuals understand that they health of current and future generations. Summary • Teach skills like gardening, cooking, meal planning, and label reading that Concerted efforts among professionals help support healthy eating patterns. Professionals have limit screen time and time spent an important role in leading diseasebeing sedentary and increase prevention efforts within their physical activity to meet the Physical organizations and communities to make Activity Guidelines for Americans. Changes at multiple levels of the strategies are available that can result in Social-Ecological Model are needed, and 2015-2020 Dietary Guidelines for Americans Chapter 3 —• Page 72 Appendix 1. Physical Activity Guidelines for Americans In addition to consuming a healthy least 150 minutes of moderate-intensity their personal and cultural preferences, eating pattern, regular physical activity physical activity and should perform they can engage in regular physical is one of the most important things muscle-strengthening exercises on 2 activity in a variety of ways throughout Americans can do to improve their or more days each week. These can be used set of recommendations for Americans A1-1 for additional details). Just as to help motivate consumer audiences to on the amounts and types of physical individuals can achieve a healthy eating make healthy physical activity choices. Physical Activity Guidelines for Americans Recommendations Age Recommendations Children and adolescents should do 60 minutes (1 hour) or more of physical activity daily. Page 73 — 2015-2020 Dietary Guidelines for Americans Age Recommendations • All adults should avoid inactivity. Some physical activity is better than none, and adults who participate in any amount of physical activity gain some health benefts. Aerobic activity should be performed in episodes of at least 10 minutes, and preferably, it should be spread throughout the week. Additional health benefts are gained by engaging in physical activity beyond this amount. When older adults cannot meet the adult guidelines, they should be as physically active as their abilities and conditions will allow.
When you create a Collection medicine technology selegiline 5mg with amex, you must have write Therapeutic Areas Therapeutic Area medicine 72 order selegiline 5 mg otc. You must make all Collection xerogenic medications generic 5 mg selegiline fast delivery, Page medicine and science in sports and exercise buy cheap selegiline 5 mg on line, and Template names within the E-Notebook database unique. ChemOffice E-Notebook • 59 Working with Collections To create a Page Collection from a Template: if you want your Then if it is Collection to available, choose 1. Click and drag the duplicate Template to a Collections because they are already a Notebook. The duplicate Template appears as a Notebook A new, untitled Collection appears in the Page. Add more items to your Collection by repeating You can rename any Collection so that each step 2. By creating Pages and Page Sections from a Template, you can ensure that all your To rename a Collection: information is uniform between all your Pages. You can add Sections to a Removing a Collection Template the same way you add Sections to a Page. For more information, see “Creating a Section” on You can remove, or delete, a Collection from the page 67. You can also remove Collections that are no longer relevant to your current needs. From the Collection tree, choose the name of a A copy of the Collection appears in the Collection. To duplicate a Collection in a different Collection: the Collection is removed from the Collection 1. You can duplicate, or copy, an entire Collection so that you can move information to a different A copy of the Collection appears in the Collection without changing the information. You can organize items in the Collection tree so that the Collection copy contains references to all of the their order makes more sense to you and other Users Collections and Pages that are in the original who view your Collections. You can organize Collection items by moving them You can duplicate a Collection within the same up or down in a Collection. You can also copy items Collection, or move the duplicate to a different from one Collection to another. When you organize a Collection, you must have When you duplicate a Collection, you must have write permission. ChemOffice E-Notebook • 61 Working with Collections Moving Items Within a Collection To move a Collection item to a different Collection in the Collection tree: You can move items in a Collection up or down. From the Collection tree, click the name of a information, see “Moving Items Between Collection. Drag the item to the Collection where you want To move Collection items within a Collection: to add the reference. From the Tools menu, take the appropriate Referencing Collection Items action: You can reference an item from one Collection to another in the Collection tree. You can use If you want to Then choose referenced Collections in different Notebooks and move the item in other Collections so that you can see the same exact the Collection information in other Collections of E-Notebook. Moving Items Between Collections You cannot add a reference to a Page into a You can move items from one Collection to another Notebook Collection. When you reference an item, you must have write Archived items cannot be moved to a different permission. For more details, contact your system Collection, but you can make a reference to the administrator. For more information, see To reference an item: “Referencing Collection Items” on page 62. From the Collection tree, choose the name of you can duplicate the Page and move the duplicate an item. Hold the Shift and Control keys and drag the “Duplicating a Collection” on page 61. An archived Collection is the same as an archived page To view the contents of a Collection: in a paper Notebook. A Collection can only be • From the Collection tree, click the expansion archived once. You can find out if an item is archived by viewing its the Collection expands so that you can see the properties. To hide the contents of a Collection: When you archive an item, you must have write • From the Collection tree, click the contraction permission. For more details, contact your system symbol of the Collection you do not want to administrator. After you archive an item, no one can make any changes to it, including changing the archive status. Browsing Collections You can browse to different parts of the Collection To archive a Collection item: tree so that you can find the information you want. From the Collection tree, click the name of an Browsing includes limiting which Collections you item. Limiting Collection Browsing You can browse over the whole Collection tree, but you can also limit the Collections over which you want to browse. You can limit the Collection over which you browse by setting a root for the Collection tree. You do this Viewing and Hiding Collections by choosing the highest level Collection you want to browse. With the Collection tree, you can view Collections in the database, so that you can find information easily. After you go to a Collection through the Collection tree, you can view that Collection and then find data or make changes to information. ChemOffice E-Notebook • 63 Working with Collections To set the root for the Collection tree: 3. From the Collection tree, click the name of a If you want to go Then in the Collection. Notebook Notebook box, type a the Collection appears at the top of the Notebook name. You can browse from your User Home Collection, which is what you usually see first when you start 4. To go to your User Home Collection: To go to a specific Collection: • From the View menu, choose Go Home. Browsing to a Specific Page or Collection You can browse to a specific Collection or Page, if you know the name or other details about it. To browse the entire Collection tree: the General tab contains the following information • From the View menu, choose Browse All. For example, you are in a Page and you want to browse the whole • Created—when the Collection was created. You can browse up one level • Last Modified—when the Collection was to see the Notebook Collection because a Notebook changed last. ChemOffice E-Notebook • 65 Working with Collections the Properties dialog box appears. You can use Templates to set up the structure of Pages automatically, or you can use Pages without Templates. Pages and Templates have the following characteristics: • You can assign them to a Notebook, Project, therapeutic Area, Reaction Scheme, Synthesis, or Experiment. If you want to see Then click the • When you create a Page or Template, it is active, which means that the owner can change General properties for General tab. You can keep your data on Page Sections so that you • “Viewing Collection Properties” on page 65. Just as you Different Page and Template Sections are designed use pages in a paper notebook for recording different for different data, such as the following Sections: data, you can use Page Sections to record reactions, spectra, and other information. For more information about Card view, Creating a Section see “Viewing Sections in Card or List View”. Just as you Viewing Sections in Card or use pages in a paper notebook for recording different data, you can use Page Sections to record reactions, List View spectra, and other information. You can create a new You can see one Section of one Page at a time in Page Section, or copy a Template Section so that the Card view, so that you can see all the information on information in the Page Section is uniform. You can use the more information, see “Creating a Collection” on Section tabs to view different Sections of a Page in page 59.
No statistical significant contributing factor of safe ambulatory surgery program is the criteria for for readmission was observed medicine daughter 5 mg selegiline otc. A lower admission rate has been reported in Patients preference 1 (2) freestanding ambulatory surgery centers and this could Readmissions be related to medicine to stop diarrhea cheap 5 mg selegiline visa their strict patient’s selection criteria symptoms gout purchase selegiline 5mg fast delivery. Methods used to treatment 7th march bournemouth purchase selegiline us prevent nausea Diverse authors question the safety of ambulatorization include avoiding the use of volatile anesthetic agents arguing the potential for delayed detection and and the undue use of opiates in the postoperative therefore solution of postoperative complications that period. Ondensetron and cyclizine were chose as cannot be demonstrated within 24 hrs of surgery. In present study, use of ondensetron, in detection of some complication in the immediate nonsteroidal anti-inflammatory medication instead postoperative period. On the contrary, other authors of opiates in patients experienced postoperative argue that the incidence of life threatening complication nausea or vomiting might have attributed to our less including arterial bleeding is very low 1:2000 and unplanned admission rate due to nausea and vomiting. In our study, we used three ports, 5 mm instruments be detected before the second postoperative day. This was detected with postoperative fever, on Admission is usually a joint decision made by the fourth postoperative day, which was resolved with surgeon and the patient. As patient has to participate intravenous antibiotic without need for per-cutaneous in self care after discharge, their comfort, preference, aspiration. Likewise, in our study, the selection of and safety need to be considered on the assessment patients with elective uncomplicated symptomatic for discharge. One of our patients admitted of his preference because he was uncomfortable to be cholelithiasis (absence of clinical and radiological discharged. Two (4%) had open conversion and hence findings of acute cholecystitis) contributed to reduce required admission. Like other studies,[19] the reason for cases with likely postoperative complications (biliary open conversion in present study was obscure anatomy injury). No successfully discharged patient had a major due to aberrant right hepatic artery. Therefore, a period of prudent observation for 6–8 hrs may suffice, due to the Length of operation has been shown to be the most fact that overnight would not reduce the detection of important factor for unplanned admission after subsequent major complications. Journal of Minimal Access Surgery | January-March 2009 | Volume 5 | Issue 1 12 Ali et al. A prospective randomized trial of day stay only versus overnight stay laparoscopic cholecystectomy. Antiemetic efficacy of prophylactic ondansetron us in reducing healthcare costs, use of hospital beds in laparoscopic surgery: A randomized double-blind comparison with metoclopramide. Reasons for conversion from laparoscopic to open cholecystectomy Unanticipated hospital admission after ambulatory surgery. Is outpatient cholecystectomy safe for the higher risk elective Cholecystectomy Audit Group. Routine laparoscopic ultrasound can significantly reduce the need for selective intraoperative cholangiography during cholecystectomy. Intraoperative fluorescent imaging using indocyanine green for liver mapping and cholangiography. Intraoperative exploration of biliary anatomy using fluorescence imaging of indocyanine green in experimental and clinical cholecystectomies. Prospective randomised study of preoperative endoscopic sphincterotomy versus surgery alone for common bile duct stones. Precholecystectomy endoscopic cholangiography and stone removal is not superior to cholecystectomy, cholangiography, and common duct exploration. Long-term follow-up of a prospective randomized study of endoscopic versus surgical treatment of bile duct calculi in patients with gallbladder in situ. Randomised trial of endoscopic sphincterotomy with gallbladder left in situ versus open surgery for common bileduct calculi in high-risk patients. Prospective randomized trial comparing endoscopic sphincterotomy followed by surgery with surgery alone in good risk patients with choledocholithiasis. Surgery vs endoscopy as primary treatment in symptomatic patients with suspected common bile duct stones: a multicenter randomized trial. Randomized trial of laparoscopic exploration of common bile duct versus postoperative endoscopic retrograde choangiography for common bile duct stones. Comparison of laparoscopic cholecystectomy combined with intraoperative endoscopic sphincterotomy and laparoscopic exploration of the common bile duct for cholecystocholedocholithiasis. For questions regarding how to order any of the ultrasound exams or speak to a radiologist, please call 314-996-8514. All exams are read by radiologists from Washington University’s Mallinckrodt Institute of Radiology. Additionally this exam is ordered when a 4-quadrant survey for ascites check is desired. These vegetables are: beans, brussels sprout, cabbage, broccoli, radishes, cucumbers and onions. When eating prepared foods, be sure to read all the labels and avoid any food that has fat or uses fat in preparation. Fats may be listed as butter, oil or oleic Popcorn can be eaten if prepared in a hot air popper. Injection site • Cyclosporine: Somatuline may decrease the bioavailability of should be alternated (2. Please see enclosed Instructions for Use Leaflet for administration of Somatuline Depot. Continued monitoring of patient response with dose adjustments for biochemical and clinical symptom control, as necessary, is recommended. The starting dose in patients with moderate or severe renal impairment or moderate or severe hepatic impairment should be 60 mg via the deep subcutaneous route at 4-week intervals for 3 months followed by dose adjustment as described above [see Clinical Pharmacology (12. There is insufficient information to recommend a dose for patients with severe renal impairment or with hepatic impairment of any severity [see Clinical Pharmacology (12. Alternate the injection site between the right and left sides from one injection to the next. Blood glucose levels should be monitored when lanreotide treatment is initiated, or when the dose is altered, and antidiabetic treatment should be adjusted accordingly [see Adverse Reactions (6. The incidence of documented episodes of heart rate < 50 bpm as well as the incidence of bradycardia reported as an adverse event was 1% in each treatment group. Initiate appropriate medical management in patients who develop symptomatic bradycardia. The other six studies were open-label or extension studies, one had a placebo-controlled, run-in period, and another had an active control. The tables include data from a single clinical study and pooled data from seven clinical studies. The analysis of safety compares adverse reaction rates of patients at baseline from the two efficacy studies, to the overall pooled data from seven studies. Cholelithiasis may be related to dose or duration of exposure [see Warnings and Precautions (5. Such adverse reactions were usually mild or moderate but did lead to withdrawal from clinical studies in two subjects. A comparative echocardiography study of lanreotide and another somatostatin analog demonstrated no difference in the development of new or worsening valvular regurgitation between the two treatments over one year. Other Adverse Reactions For the most commonly occurring adverse reactions in the pooled analysis, diarrhea, abdominal pain, and cholelithiasis, there was no apparent trend for increasing incidence with age. In Study 3, development of anti-lanreotide antibodies was assessed using a radioimmunoprecipitation assay. Those reported most frequently being gastrointestinal disorders (abdominal pain, diarrhea, and steatorrhea), hepatobiliary disorders (cholecystitis), and general disorders and administration site conditions (injection site reactions). Therefore, blood glucose levels should be monitored when lanreotide treatment is initiated or when the dose is altered, and antidiabetic treatment should be adjusted accordingly. Limited published data indicate that concomitant administration of a somatostatin analog and bromocriptine may increase the availability of bromocriptine. Vitamin K absorption was not affected when concomitantly administered with lanreotide.
Since he was the only person authorized to medicine park ok buy 5 mg selegiline with amex take her out of the boarding school medicine merit badge buy selegiline, he would call for her in the six-cylinder Hudson that belonged to medications held before dialysis purchase genuine selegiline on-line the R symptoms 1974 order selegiline 5mg with amex. Someone had told her not to spend more time with her guardian than necessary, not to eat anything he had tasted, and not to put her face too close to his, for old age was contagious. They were both indifferent to what people might think of them because their family kinship was well known, and what is more, the extreme difference in their ages placed them beyond all suspicion. They had just made love on Pentecost Sunday when the bells began to toll at four o’clock. In his youth, the ritual of the tolling bells had been included in the price of the funeral and was denied only to the indigent. But after our last war, just at the turn of the century, the Conservative regime consolidated its colonial customs, and funeral rites became so expensive that only the wealthiest could pay for them. When Archbishop Dante de Luna died, bells all over the province tolled unceasingly for nine days and nine nights, and the public suffering was so great that his successor reserved the tolling of bells for the funeral services of the most illustrious of the dead. Therefore, when Florentino Ariza heard the Cathedral bells at four o’clock in the afternoon on a Pentecost Sunday, he felt as if he had been visited by a ghost from his lost youth. He never imagined they were the bells he had so longed to hear for so many years, ever since the Sunday when he saw Fermina Daza in her sixth month of pregnancy as she was leaving High Mass. Florentino Ariza was in no way expert in matters pertaining to the Church, and he had not gone to Mass again since he had played the violin in the choir with a German who also taught him the science of the telegraph and about whose fate he had never been able to obtain any definite news. There was public mourning in the city, that was certain, and that is what he knew. A delegation of Caribbean refugees had come to his house that morning to inform him that Jeremiah de Saint-Amour had been found dead in his photography studio. Although Florentino Ariza was not an intimate friend of his, he was close to many other refugees who always invited him to their public ceremonies, above all to their funerals. But he was sure that the bells were not tolling for Jeremiah de Saint-Amour, who was a militant unbeliever and a committed anarchist and who had, moreover, died by his own hand. They had made love after lunch and they were lying together at the end of their siesta, both of them naked under the ceiling fan, whose humming could not hide the sound like falling hail that the buzzards made as they walked across the hot tin roof. Florentino Ariza loved her as he had loved so many other casual women in his long life, but he loved her with more anguish than any other, because he was certain he would be dead by the time she finished secondary school. The room resembled a ship’s cabin, its walls made of wooden laths covered by many coats of paint, as were the walls of boats, but at four o’clock in the afternoon, even with the electric fan hanging over the bed, the heat was more intense than in the riverboat cabins because it reflected off the metal roof. It was not so much a formal bedroom as a cabin on dry land, which Florentino Ariza had built behind his office in the R. On ordinary days it was difficult to sleep there, with the shouts of the stevedores, and the noise of the cranes from the river harbor, and the enormous bellowing of the ships moored at the dock. They had planned to be together on Pentecost until she had to return to school, five minutes before the Angelus, but the tolling of the bells reminded Florentino Ariza of his promise to attend the funeral of Jeremiah de Saint-Amour, and he dressed with more haste than usual. First, as always, he plaited her single braid that he himself had loosened before they made love, and he sat her on the table to tie the bow on her school shoes, which was something she never did well. He helped her without malice, and she helped him to help her, as if it were an obligation: after their first encounters they had both lost awareness of their ages, and they treated each other with the familiarity of a husband and wife who had hidden so many things in this life that there was almost nothing left for them to say to each other. The offices were closed and dark because of the holiday, and at the deserted dock there was only one ship, its boilers damped. The sultry weather presaged the first rains of the year, but the transparent air and the Sunday silence in the harbor seemed to belong to a more benevolent month. The world was harsher here than in the shadowy cabin, and the bells caused greater grief, even if one did not know for whom the y tolled. Florentino Ariza and the girl went down to the patio of saltpeter, which the Spaniards had used as a port for blacks and where there were still the remains of weights and other rusted irons from the slave trade. The automobile was waiting for the m in the shade of the warehouses, and they did not awaken the driver, asleep with his head on the steering wheel, until they were settled in their seats. The automobile turned around behind the warehouses enclosed by chicken wire, crossed the area of the old market on Las Animas Bay, where near-naked adults were playing ball, and drove out of the river harbor in a burning cloud of dust. Florentino Ariza was sure that the funerary honors could not be for Jeremiah de Saint-Amour, but the insistent tolling filled him with doubts. He put his hand on the driver’s shoulder and asked him, shouting into his ear, for whom the bells tolled. Nevertheless, when the driver told him how he had died, his instantaneous hope vanished because he could not believe what he heard. Nothing resembles a person as much as the way he dies, and no death could resemble the man he was thinking about less than this one. But it was he, although it seemed absurd: the oldest and best-qualified doctor in the city, and one of its illustrious men for many other meritorious reasons, had died of a broken spine, at the age of eightyone, when he fell from the branch of a mango tree as he tried to catch a parrot. All that Florentino Ariza had done since Fermina Daza’s marriage had been based on his hope for this event. But now that it had come, he did not feel the thr ill of triumph he had imagined so often in his sleeplessness. Instead, he was seized by terror: the fantastic realization that it could just as well have been himself for whom the death knell was tolling. Sitting beside him in the automobile that jolted along the cobbled streets, America Vicuna was frightened by his pallor, and she asked him what was the matter. He left the girl at the door of the school with a hurried promise that he would come back for her the following Saturday, and he told the driver to take him to the house of Dr. He was confronted by an uproar of automobiles and hired carriages in the surrounding streets and a multitude of curious onlookers outside the house. Lacides Olivella, who had received the bad news at the height of the celebration, came rushing in. It was not easy to move inside the house because of the crowd, but Florentino Ariza managed to make his way to the master bedroom, peered on tiptoe over the groups of people blocking the door, and saw Juvenal Urbino in the conjugal bed as he had wanted to see him since he had first heard of him-wallowing in the indignity of death. The carpenter had just taken his measurements for the coffin, and at his side, still wearing the dress of a newly-wed grandmother that she had put on for the party, Fermina Daza was introspective and dejected. Florentino Ariza had imagined that moment down to the last detail since the days of his youth when he had devoted himself completely to the cause of his reckless love. For her sake he had won fame and fortune without too much concern for his methods, for her sake he had cared for his health and personal appearance with a rigor that did not seem very manly to other men of his time, and he had waited for this day as no one else could have waited for anything or anyone in this world: without an instant of discouragement. The proof that death had at last interceded on his behalf filled him with the courage he needed to repeat his vow of eternal fidelity and everlasting love to Fermina Daza on herfirst night of widowhood. He did not deny the accusations of his conscience that it had been a thoughtless and inappropriate act, one he had rushed into for fear that the opportunity would never be repeated. He would have preferred something less brutal, something in the manner he had so often imagined, but fate had given him no choice. He left the house of mourning, full of sorrow at leaving her in the same state of upheaval in which he found himself, but there was nothing he could have done to prevent it because he felt that this barbarous night had been forever inscribed in both their destinies. He asked himself in despair where Fermina Daza could be without him, what she could be thinking, what she would do, in the years of life remaining to her, with the burden of consternation he had left in her hands. He suffered a crisis of constipation that swelled his belly like a drum, and he had to resort to remedies less pleasant than enemas. The complaints of old age, which he endured better than his contemporaries because he had known them since his youth, all attacked at the same time. On Wednesday he appeared at the office after a week at home, and Leona Cassiani was horrified at seeing him so pale and enervated. But he reassured her: it was insomnia again, as always, and once more he bit his tongue to keep the truth from pouring out through the bleeding wounds in his heart. He spent another unreal week unable to concentrate on anything, eating badly and sleeping worse, trying to find the secret signs that would show him the road to salvation. But on Friday he was invaded by an unreasoning calm, which he interpreted as an omen that nothing new was going to happen, that everything he had done in his life had been in vain, that he could not go on: it was the end. On Monday, however, when he returned to his house on the Street of Windows, he discovered a letter floating in a puddle inside the entrance, and on the wet envelope he recognized at once the imperious handwriting that so many changes in life had not changed, and he even thought he could detect the nocturnal perfume of withered gardenias, because after the initial shock, his heart told him everything: it was the letter he had been waiting for, without a moment’s respite, for over half a century. She had put into it all the fury of which she was capable, her crudest words, the most wounding, most unjust vilifications, which still seemed minuscule to her in light of the enormity of the offense. It was the final act in a bitter exorcism through which she was attempting to come to terms with her new situation. She wanted to be herself again, to recover all that she had been obliged to give up in half a century of servitude that had doubtless made her happy but which, once her husband was dead, did not leave her even the vestiges of her identity. She was a ghost in a strange house that overnight had become immense and solitary and through which she wandered without purpose, asking herself in anguish which of them was deader: the man who had died or the woman he had left behind.
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