Asacol

R. Michael Benitez, MD, FACC

Professor of Medicine
Director, Cardiology Fellowship Program
Division of Cardiology, University
of Maryland School of Medicine
Baltimore, Maryland

This result shows the importance of early investigation of associated #F132 − Imperfection of Sputum Examination for Chronic risk factors for lung disease treatment ringworm buy asacol 800mg low price. University of Sofia − Sofia treatment uterine cancer purchase asacol cheap online, Bulgaria #F111 − Cystic Fibrosis Carriership and Tuberculosis: Hints Background toward an Evolutionary Selective Advantage Based on Data the percentage of chronic infections with Pseudomonas aeruginosa in from the Brazilian Territory treatment gout buy asacol mastercard. Dourados medicine in motion proven asacol 800 mg, Brazil; 8University of São Paulo Medical School, University of São Paulo − Universidade de São Paulo − São Paulo, Brazil Aim To search for P. All these patients had high IgG levels of six potential confounders in the relation: monthly income, sanitary anti-P. This work was supported by a grant from the Medical University of cepacia in 4 cases and for P. No other adverse events #F135 − Inhaled Antibiotic Therapy: Experience of a were noticed. More recently its efficacy as a therapy for eradication in new infections is also known. Mandela School of Medicine − Durban, South Africa this retrospective study was conducted at the Santa Maria Hospital Cystic Fibrosis Center. However, according to bioimpedance,80% ofpatients 26 months to 219 months and 46% were female. Age at diagnosis had a negative correlation with weight further studies are necessary to identify the therapeutics needed to for-age z-score (-0. Pediatrics, University of Nigeria Teaching Hospital − Ituku-Ozalla, Nigeria #F164 − Fat Free Mass Deficit in Children and Adolescents Rationale with Cystic Fibrosis. What is the Implication in Pulmonary the lung is a major target organ for human immunodeficiency virus function? The aim using clinical and radiological criteria (fever, cough of >1 month of this study was to evaluate body composition and relate the latter to duration, weight loss, history of contact with adult with chronic cough, pulmonary function. Demographic, clinical and functional data were collected: sex, changes included bronchovascular markings or reticular densities, age and genotype, pancreatic and respiratory function. We also collected parenchymal consolidation, nodular densities and hyperinflation. One Selective IgG3 deficiency in children frequently manifests hundred and eighty-one (34. The respiratory tract and it should be suspected in cases with similar mean age at last birthday among children with respiratory diagnosis presentation. No data on spirometry were available 1Allergology and Respiratory Unit, Penteli’s Children Hospital, Palaia Penteli − for all study participants. The main risk factors are impaired mucociliary clearance after viral respiratory infection, airway malacia, immunodefi ciency and exposure to tobacco smoke or industrial pollution. Even though inhaler bronchodilators, corticosteroids Objective (both during exacerbation as well as prophylactic treatment) and IgG immunodeficiency is the most frequent impairment of humoral per os antibiotics were frequently used, none proved to be immunity that results in severe infections in children. The detailed revision of their medical history revealed selective IgG3 deficiency is not well described. It is diagnosed if a low nutritional difficulties with recurrent symptoms of vomiting and value of IgG3 is constantly detected whereas total IgG remains in the anorexia. Bronchoscopy evaluation showed increased percentage normal concentration range according to the children’s age. The aim of ofneutrophils(30%-88%)andthreecaseshadincreasednumbers this study was to identify the clinical presentation from the respiratory of eosinophils (30%). All symptoms completely resolved when deficiency were examined in our unit during the last ten years. An 8-year-old female patient was referred to the Pediatric Pulmonol ogy Department for dry cough and weight loss for one month. All children underwent were crepitant crackles in both lungs on physical examination. Pulmonary function tests of surgery were based upon findings during drug-induced sleep werecompatiblewith arestrictivepattern. Bronchoscopy was Twenty-nine children were included: 14 boys, mean age of performed with neutrophilic dominance in bronchoalveolar fluid. Seven children were diagnosed with moderate, 16 systemic steroid treatment was initiated. Three children Cushingoid appearance, common stria on the legs and back, osteopo only received medical treatment with orthodontics. Since there was no improvement in significantly younger, had a lower conductance of the airway and pulmonaryfunctiontestandradiologicalfindingsafterreducingsteroid less tongue base collapse. This cut-off value had a sensitivity of 100% and a followed without any complaint for two years. There was a difference between children Discussion younger (n = 16) and older than 8 years old (n = 9). Children with a good response to treatment had a lupus pneumonitis, shrinking lung syndrome and pulmonary hyperten significantly lower conductance of the upper airway (p = 0. We present Vaz Rodrigues S 1, Ferreira de Lima S 1, Alves R 1, Casimiro A 2, 1 the investigation and management of unilateral pleural effusion Pascoal J. The patient was known to have a left Aim of the Study ulnar nerve plexiform neurofibroma since birth, which extended To present a case of successful treatment of a midline infra into the brachial plexus and intraspinal canal. A chest radiograph on admission showed A retrospective analysis of a clinical case. Main Results A chest ultrasound suggested a heterogenous mass inferior A 4-month-old girl with Rubinstein-Taybi Syndrome presented to the effusion. Initial biochemistry showed an elevated C with stridor related to tracheomalacia, severe alimentary difficul reactive protein (75 mg/L) and low albumin (26g/L). At mass extending to the pericardium and posterior mediastinum, 20 months of age, due to the escalation of these symptoms and involving the left lower lobe and displacing the left hemi the appearance of an anterior chest wall deformity, the patient had diaphragm inferiorly (Fig 2). The patient was referred for oncological and underwent Kocher Laparotomy and a large infra-diaphragmatic surgical assessment. The pathology revealed that the mass was a Bigerminal including spindle cell sarcomas such as malignant peripheral Mature Teratoma. Two months after surgery, the patient remains well 10–20% of diagnoses made in pediatric patients. These tumors can Rubinstein-Taybi Syndrome is a rare condition, affecting 1 in 125. Children with this syndrome have an increased risk of not typically responsive to chemotherapy and management developing respiratory problems and benign and malignant tumors. It focuses on surgical resection with a possibility of radiotherapy is important to look for treatable causes of respiratory insufficiency in thereafter. Although a surgical procedure would probably not be these patients and a multidisciplinary approach is crucial to achieve curative, it was offered to the patient and her family as a life good results. We then assessed their pulmonary function and looked for association with the recorded data. More than half of the patients (55%) presented a ventilatory function alteration, of which38% were obstructive and 17%restrictive. Fabiola, Université Libre de Bruxelles − Brussels, Belgium 1 2 2 3 4 Caggiano S, Khirani S, Amaddeo A, Richard P, Dabaj I, Cavassa E 4, Desguerre I 5, Estournet B 4, Cutrera R 1, Ferreiro A 5, Quijano-Roy S 6, Fauroux B 2. Methods Results Breathing pattern and respiratory muscle strength were measured by the three groups had similar age (p = 0. In the adult patient, healthy group while children with scoliosis and children with ΔPgas/ΔPes was +3, indicating bilateral diaphragmatic paralysis. Expiratory muscle strength was moderately reduced in 6 Acknowledgements patients and severely reduced in the adult patient. If Introduction left untreated, these children eventually die from respiratory failure. Scoliosis is the most common abnormality of the spine with direct We describe 3 patients with congenital myopathy who required effects on the thoracic cage. Scoliosis has generally been associated tracheostomy and home long-term invasive ventilation. Eleven-month-old girl with nemaline myopathy with invasive ventila Spirometry is simple, noninvasive, and has been the most commonly tion from birth and tracheostomy performed at 69 days of life. She had one respiratory infection before latter with healthy children and children with asthma. Informed consent from their mothers was play with limited limb movements) and is fed by gastrostomy. Total concentration of cIgE was determined by electro-chemilumines Sixteen-month-old girl with nemaline myopathy with mechanical cence immunoassay (Cobas, e411, Roche diagnostics, Tokyo, Japan). Family history managed at home with chest physiotherapy as adjuvant treatment and was obtained using structured interview of the child’s mother by the had no more admissions.

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As to the surgeon treatment 5th disease order asacol without a prescription, he should operate standing with one foot on some elevated support symptoms iron deficiency buy asacol 800 mg overnight delivery, adjusting the bone with the palms of his hands medicine 20 generic 800 mg asacol visa. The adjustment will be easy medicine 6 year program buy asacol discount, for there is good extension if it is properly managed. Then let him do the bandaging, putting the heads of the bandages on the frac ture and performing all the rest of the operation as previously directed. Let him ask the same questions, and use the same indications to judge whether things are right or not. He should bandage every third day and use greater pressure, and on the seventh or ninth day put it up in splints. If he suspects the bone is not in good position, let him loosen the dressings towards the middle of this periodf and after putting it right re-apply them. When these are passed one should undo the dressings and diminish the pressure and the number of bandages. Make your estimate from the swelling in the hand, having an eye to the patient’s strength. One must also bear in mind that the humerus is naturally convex out wards, and is therefore apt to get distorted in this direction when improperly treated. In fact, all bones when fractured tend to become distorted during the cure towards the side to which they are naturally bent. So, if you suspect anything of this kind, you should pass round it an additional broad band, binding it to the chest, and when the patient goes to bed, put a many-folded compress, or something of the kind, between the elbow and the ribs, thus the curvature of the bone will be rectified. These bones are not often broken, unless the tissues are also wounded by something sharp or heavy. The proper treatment of the wounded parts will be discussed in the section on lesions of soft parts. The patient’s answers both as to pressure and relaxation should be similar to those in cases of fracture. All these bones are completely healed in twenty days, except those which are connected with the leg-bones in a vertical line. It is good to lie up during this period, but patients, despising the injury, do not bring them selves to this, but go about before they are well. This is the reason why most of them do not make a complete recovery, and the pain often returns; naturally so, for the feet carry the whole weight. It follows that when they walk about before they are well, the displaced joints heal up badly; on which account they have occasional pains in the parts near the leg. Treat ment, indeed, is the same, but more bandages and pads should be used, also extend the dressings completely in both direc tions. Use pressure, as in all cases so here especially, at the point of displacement, and make the first turns of the bandage there. At each change of dressing use plenty of warm water; indeed, douche copiously with warm water in all injuries of joints. There should be the same signs as to pressure and slackness in the same periods as in the former cases, and the change of dressings should be made in the same way. These patients recover completely in about forty days, if they bring themselves to lie up; failing this, they suffer the same as the former cases, and to a greater degree. Those who, in leaping from a height, come down violently on the heel, get the bones separated, while there is extravasation from the blood-vessels since the flesh is contused about the bone. Swelling supervenes and severe pain, for this bone is not small, it extends beyond the line of the leg, and is connected with important vessels and cords. You should treat these patients with cerate, pads and bandages, using an abundance of hot water, and they require plenty of bandages, the best and softest you can get. If the skin about the heel is naturally smooth, leave it alone, but if thick and hard as it is in some persons, you should pare it evenly and thin it down without going through to the flesh. It is not every man’s job to bandage such cases properly, for if one applies the bandage, as is done in other lesions at the ankle, taking one turn round the foot and the next round the back tendon, the bandage compresses the part and excludes the heel where the contusion is, so that there is risk of necrosis of the heel-bone; and if there is necrosis the malady may last the patient’s whole life. In fact, necrosis from other causes, as when the heel blackens while the patient is in bed owing to carelessness as to its position, or when there is a serious and chronic wound in the leg connected with the heel, or in the thigh, or another malady involving prolonged rest ♦Those of the wrist. Necroses of this sort, indeed, besides other harm, bring great dangers to the body, for there may be very acute fevers, continuous and attended by trem blings, hiccoughs and affections of the mind, fatal in a few days. There may be also be lividity and congestion of the large blood-vessels, loss of sensation and gangrene due to compres sion, and these may occur without necrosis of the bone. The above remarks apply to very severe contusions, but the parts are often moderately contused and require no very great care, though, all the same, they must be treated properly. When, however, the crushing seems violent the above directions should be observed, the greater part of the bandaging being about the heel, taking turns sometimes round the end of the foot, sometimes about the middle part, and sometimes carry ing it up the leg. All the neighbouring parts in both directions should be included in the bandage, as explained above; and do not make strong pressure, but use many bandages. When there are extravasations from the blood vessels, and blackenings, and the neighbouring parts become reddish and rather hard, there is danger of aggravation. Still, if there is no fever you should give an emetic as was directed; also in cases where the fever is not continuous; but if there is continued fever, do not give an evacuant, but avoid food, solid or fluid, and for drink use water and not wine, but hydro mel may be taken. If there is not going to be aggravation, the effusions and blackenings and the parts around become yel lowish and not hard. This is good evidence in all extravasa tions that they are not going to get worse, but in those which turn livid and hard there is danger of gangrene. One must see that the foot is, as a rule, a little higher that the rest of the body. The leg has two bones, one much more slender than the other at one end, but not so much at the other end. In the length of the leg they are not united, but the parts near the thigh bone are united and have an epiphysis, and the epiphysis has a diaphysis. The bones are occasionally dislocated at the foot end, sometimes both bones with the epiphysis, sometimes the epiphysis is displaced, sometimes one of the bones. These dislocations give less trouble than those of the wrist, if the patients can bring themselves to lie up. The treatment is similar to that of the latter, for reduction is to be made by extension as in those cases, but stronger extension is requisite since the body is stronger in this part. As a rule two men suffice, one pulling one way and one the other, but if they cannot do it, it is easy to make the extension more powerful. Thus, one should fix a wheel-nave or something similar in the ground, put a soft wrapping round the foot, and then binding broad straps of ox-hide about it attach the ends of the straps to a pestle or some other rod. Put the end of the rod into the wheel-nave and pull back, while assistants hold the patient on the upper side grasping both at the shoulders and hollow of the knee. First, then, you may fix a smooth, round rod deeply in the ground with its upper part projecting between the legs at the fork, so as to prevent the body from giving way when they make extension at the foot. Again, if you like, the pegs may be fixed at either armpit, and the arms kept extended along the sides. Again, if one thinks fit, one may like wise fasten straps about the knee and thigh, and fixing another wheel-nave in the ground above the head, attach the straps to a rod; use the nave as a fulcrum for the rod and make extension counter to that at the feet. And if you choose, set up windlasses at either end and make the extension by them. The best thing for anyone who practises in a large city is to get a wooden apparatus comprising all the mechanical methods for all fractures and for reduction of all joints by extension and leverage. This wooden apparatus will suffice if it be like the quadrangular supports such as are made of oak in length, breadth and thickness. When you make sufficient extension it is then easy to reduce the joint for it is elevated in a direct line above its old position. It should therefore be adjusted with the palms of the hands, pressing upon the projecting part with one palm and with the other making counter pressure below the ankle on the opposite side. After reduction, you should if possible apply a bandage, while the limb is kept extended. If the straps get in the way, remove them and keep up counter extension while bandaging. Bandage in the same way [as for fractures] putting the heads of the bandages on the projecting part and making the first and most turns there, also most of the compresses should be there and the pressure should come especially on this part. This joint re quires somewhat greater pressure at the first bandaging than does the wrist. After dressing let the bandaged part be higher than the rest of the body, and put it up in a position in which the foot is as little as possible unsupported. As a rule the reducing treatment should be stricter and more prolonged in injuries about the leg region than in those about the arm region, for the former parts are larger and stouter than the latter.

For example treatment goals for ptsd 400mg asacol overnight delivery, thin treatment quality assurance unit purchase 800 mg asacol visa, long varieties are preferred for table use medicine vs surgery discount asacol 400mg fast delivery, medium and short varieties are used for preparations of rice made after grinding symptoms 9 weeks pregnant order asacol from india. Indians prefer the individual grains of rice to retain their identify after cooking. It is observed that old grains absorb more than two times their volume of water during cooking, while new rice absorbs only two times their volume. It is difficult to judge the extent to which rice has aged, by its appearance, as no visual criteria of agening have been established, to guide the consumer. Millets: Other grains include bajra, jowar, ragi, maize and other millets, which are used as a staple. The criteria for selection are the same as for all grains—soundness of grain, cleanliness, freedom from admixture with other grains and trash. Most of these millets are ground and the whole grain flour is used to prepare unleavened bread Food Selection, Purchase and Storage 215215215215215 (roti). As whole grain flour is used in most preparations, very little loss of nutrients occurs. It must be noted that ragi is an exceptionally good source of calcium, and ragi and bajra of iron. These are selected according to the general criteria of selection indicated above. These less expensive ones can be used in preparations, which are made after grinding (wet or dry) such as vadas, idli, dhokla, pakodas etc. It is normally available in three main forms—granulated, powdered sugar and large crystals (khadi sakhar). Dark variety is preferred for preparations such as chikki, while light coloured variety may be used in payasam (milk pudding or kheer). Semi-perishable Foods these include processed cereals and pulse products, roots and tubers, fats and oils. Processed Cereals and Pulse Products A number of processed products are made from cereals and pulses. These include wheat products, such as, cracked wheat, semolina (rawa), atta, maida, rice flakes, puffed rice (murmura), roasted chana dal (dale), chana, etc. These are made by grinding the grain to varying degrees of fineness (various particle sizes), by roasting the whole grain or by any other method. These processes increase the surface area of the product exposed to atmosphere, decrease the preparation time and also reduce the shelf-life of the products. While the whole grains have a shelf-life of a year or more, the shelf-life of these processed products may vary from two weeks to a few months. Good quality is indicated by sweet taste and an absence of sour, mouldy odour and flavour. The fine grain varieties are used for preparation of halwas, while the large grain varieties are suitable for preparation of upma, shira, etc. These are selected on the basis of uniformity of size, freedom from oxidised or mouldy odour, grit or bran. It has a lower shelf-life than semolina, as the large surface area permits faster rate of spoilage. Good quality maida is free from insect infestation, bad odours and lump formation. Rice flakes are made after soaking the paddy in hot water; parehing it by roasting and then flattening it by force while it is hot to form flakes. It should be free from bran, broken particles, fragments of the seed coat, insects, stones, trash and bad odour. Roasted chana dal and chanas are selected for crisp texture, sweet flavour and absence of flat flavour. Roots and Tubers these include potatoes, sweet potatoes, onions, tapioca (cassava), colocasia (aravi), yams and many lesser known varieties of roots and tubers. In general, these should be firm, heavy, free from bruises, spots, dirt and discolouration. These should be free from sprouts, heavy in relation to size, firm, with shallow eyes and without green discolouration. The varieties, which hold their form during cooking, are preferred in most preparations. Onions—Select hard, well-shaped globes, with dry skins, free from spots and bruises. The choice depends on the food preparation in which the fat is to be used, the family needs, the food budget and regional preference. Ghee is preferred for its delicate flavour, in preparation of sweets (halwas especially) and to serve with rice or snacks. Criteria for selection of crude oil are presence of the natural characteristic aroma, natural colour, clarity, freedom from admixture with other kinds of oils, freedom from solid particles and flat or rancid odour. Some refined oils are fortified with vitamin A almost to the same level a cow’s ghee (750 mcg or 2500 I. As impurities are removed in refining, the smoke points1 of refined oils during frying is higher than that of unrefined oils. These are manufactured from vegetable oils by the addition of molecular hydrogen to the double bonds in the unsaturated fatty acids in the presence of a catalyst. These are partially hydrogenated to obtain the physical characeristics desired in terms of texture and boiling point. The product thus formed is more stable than the vegetable oil from which it is made. The process is designed to produce characteristics most desired in terms of use and consumer acceptance. In India, it is made as a substitute for ghee, and therefore its physical appearance and texture resembles ghee. Hydrogenated fats have a higher smoke point than refined oils, and are used for frying bland foods. Smoke point is the temperature at which a fat or oil gives off a thin bluish smoke when heated. Food Selection, Purchase and Storage 217217217217217 Oils and fats are selected for colour, clarity, characteristic aroma and absence of bad odour (rancid), dirt, dust particles, etc. Perishable Foods Perishable foods include plant foods like fresh vegetables and fruits, and animals foods, such as milk, eggs, poultry, fish and meat. These foods are easily spoilt, if stored at room temperature, due to the action of enzymes and microorganisms. In practice this means milk freshly drawn, fish freshly caught from a river or sea, meat soon after slaughter, eggs just laid, vegetables just harvested from the garden and fruits just picked from the tree. As population increases, foods have to be purchased further away from the point of production. Knowledge of quality characteristics of foods may help you to select and purchase perishable foods. Vegetables and Fruits Vegetables and fruits make a meal attractive and enjoyable by the variety of colours, textures and flavours they contribute. Vegetables and fruits are the major source of β − carotene and vitamin C in the diet. Most fresh vegetables and fruits retain their freshness for a short time under ideal conditions of storage. In general, freshness, uniformity of size, variety, colour, degree of ripeness and freedom from defects are the qualities most frequently sought. When purchasing, select fresh vegetables and fruits, which are firm, crisp, bright in colour, with no visible bruises or signs of decay and wilting. It is therefore advisable to buy vegetables and fruits which are in season, as the quality is high and the price low. Leafy Vegetables include all sags or keerai such as amaranth, bathua, coriander, fenugreek (methi), spinach (palak) colocasia leaves, mint and mustard. Dark green, leafy vegetables are good sources of minerals, iron and calcium, and vitamin A, C and some of the B-complex vitamins. Select clean leafy vegetables, which are tender, crisp, brightly coloured and free from flowers, insects, mud and spots or holes in the leaves.

Diseases

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B offers seven recommendations in the areas of classiﬁcation and monitoring and of staff-prisoner relations 897 treatment plant rd generic asacol 400mg without a prescription, and Part V symptoms liver disease buy 800 mg asacol visa. C identiﬁes two further strategies designed to promote positive personal growth and self-respect on the part of people in custody symptoms xanax treats order cheapest asacol, who typically lack avenues for either symptoms 8 weeks pregnant asacol 800mg without a prescription. Although none of these recommendations will entirely transform the prison environment, each promises to reduce violence on the inside and thereby to ease the debilitating stress and fear that many people in prison live with on a daily basis. C explains, this change would open the way for people in prison to pursue meaningful personal projects and cultivate a sense of purpose beyond mere survival—and suggests that, the more they are able to do so, the safer and more humane the prison environment is sure to be. Although this chapter is focused largely on prisons, in many respects, the challenge of ensuring prisoners’ personal safety is still greater in jails. Still, many of the strategies I identify as likely to improve the safety of people in prison are applicable to the jail context as well19—as is the baseline precondition for deep and lasting reform to the conditions of conﬁnement: a substantial reduction in the sheer number of people being held behind bars. When the state incarcerates, it removes people from their homes and communities and holds them against their will, in close quarters with total strangers, for days, months, and even years at a time. However justiﬁed the state may have been in taking this step, people in this position are nonetheless likely to be frustrated, resentful, and angry, not to mention scared and even traumatized by the experience. Now imagine adding to this potent mix the pressures created by chronic overcrowding. Every carceral facility is designed and built to a rated capacity reﬂecting the number of prisoners it is equipped to accommodate. This measure pertains not only to the number of beds and minimum square footage of living 17. Prisons, administered by the state, are those facilities designed to hold people sentenced to more than one year. Although people regularly come and go, the average prison sentence is 4–5 years, which means that people in prison typically settle into their housing units and build their lives as best they can within obvious constraints. They hold people awaiting trial or sentencing or people who receive custodial sentences of less than one year. Many are out in a few hours, but many others stay for months and in some cases even for years. County Jail, the biggest jail system in the country, that I developed my understanding of many of the strategies I propose in Part V of this chapter. Mayson, “Pretrial Detention and Bail,” in Volume 3 of the present Report; Clear & Austin, supra note 1. Prison Conditions 269 space per person, but also to the space allotted for the many services every institution must provide, including medical clinics, inﬁrmary beds, mental health services, kitchens and dining rooms, laundry, canteen, law libraries, educational programming, and recreation. When prisons are overcrowded, it is not just that prisoners are jammed into dormitories or doubled up into small cells designed for a single person. Overcrowding also means that there is insufﬁcient capacity for all these vital services, which all but guarantees that illness and disease will go untreated, that people will face long waits for pretty much everything, and that levels of frustration, stress, and anger will remain high. Overcrowding is thus a major reason why conditions in American prisons and jails are as unsafe and unstable as they too frequently are. A second reason is the decades-long commitment among policymakers to what Francis Cullen once called the philosophy of “penal harm. As psychiatrist Terry Kupers explains, In crowded, noisy, unhygienic environments, human beings tend to treat each other terribly. There are constant lines to use the toilets and phones, and altercations erupt when one irritable prisoner thinks another has been on the phone too long. There are rows of bunks blocking the view, so beatings and rapes can go on in one part of the dorm while ofﬁcers sit at their desks in another area. Meanwhile the constant noise and unhygienic conditions cause irritability on everyone’s part. Individuals who are vulnerable to attack and sexual assault—for example, smaller men, men suffering from serious mental illness, and gay or transgender persons—have no cell to retreat to when they feel endangered. As Kupers puts it, “[i]s it any wonder that research clearly links prison crowding with increased rates of violence, psychiatric breakdowns, rapes, and suicides”? Instead, thanks to the penal harm philosophy, warehousing—in demoralizing, dehumanizing, and often dangerous conditions—became the order of the day. Throw in insufﬁcient stafﬁng and the adversarial “us” versus “them” dynamic between prisoners and staff that frequently deﬁnes the culture of the prison, and you have an environment in which people in custody cannot rely on prison ofﬁcials to keep them safe. In prisons that are overcrowded, understaffed, and under-resourced, people generally have only two options: protect themselves as best they can on their own, or band together with other prisoners in a collective bid for mutual security. At the individual level, this situation generates what might be called a hypermasculinity imperative. The imperative not to be seen as weak can dominate the lives of men in custody, especially in high-security facilities. Men cannot be perpetually violent, but they can—and in the worst prison environments, must—be constantly vigilant lest they convey an impression of vulnerability. This pressure on prisoners can feed a culture of belligerence, posturing, emotional repression, and ready violence that rewards indifference to others and impels the strong to victimize the weak. Such an environment, moreover, is fertile ground for prison gangs, which represent the primary vehicle for mutual protection. As Haney explains, “[g]angs only ﬂourish in a jail or prison society where there is a strong undercurrent of fear and reminders of one’s own vulnerability. Prison Conditions 271 demands overt and persistent displays of toughness and invulnerability, as well as a propensity for violence—all core components of hypermasculinity. At the same time, demonstrated dedication to the rigors of gang life is the perfect way to command respect and protect against aspersions of weakness, cowardice, or being a “sissy. The collective dehumanization of people in custody has fueled a notion of prisoners as subhuman—and, at the extreme, as animals or even monsters. But to many outsiders, hypermasculine performance and the prison gang culture it feeds can seem so inexplicable, so amoral, so Hobbesian state-of-nature that it is hard to feel empathy and understanding. In most cases, prisoners’ hypermasculine posturing and ensuing pathologies arise not from an inherent preference for violence, but from fear. It may, in other words, not be the prisoners who make the prison, but rather the prison—and in particular the widespread failure of the system to keep people safe—that makes the prisoners. These same dynamics are also evident in specialized housing units—for example, the massive “sensitive needs yards” in the California prisons. As Shon Hopwood observes in a memoir of his time in federal prison, “[y]ou can try to serve your time outside a circle of protection, but chances are you will be stolen from, beat on, and generally abused. For a powerful and moving account of the process by which this transformation occurs, see Haney, supra note 26. But any such success is always provisional, and many ﬁnd the pressure impossible to resist. As already noted, there are many reasons why it is incumbent on state ofﬁcials to take steps to shift this set of pathological dynamics in a healthier direction. But ﬁrst, I consider the question of how, legally speaking, this situation has been allowed to continue. These are basic needs that all human beings must satisfy if they are to avoid serious physical and psychological suffering. But in addition, by virtue of their incarceration, prisoners also need an assurance of physical safety, and this need too is one the state is constitutionally obligated to meet. It is plainly cruel to punish criminal offenders with the strap,34 with rape, or with any other form of brutal corporal treatment. And for the same reason, the state may not place incarcerated offenders in a position of ongoing vulnerability to assault, thus creating conditions that would amount to the same thing. In part, the state’s afﬁrmative obligation to ensure the physical safety of the people it incarcerates reﬂects an imperative to prevent the physical pain and 31. As Chief Justice Rehnquist put it, “when the State takes a person into its custody and holds him there against his will, the Constitution imposes upon it a corresponding duty to assume some responsibility for his safety and general well-being. There is something deeply dehumanizing about living for extended periods in a state of fear. At worst, people in such circumstances exist in a perpetually anxious and even traumatized state, bereft of any peace of mind and ready to protect themselves whatever the cost. The experience of living in an unsafe environment for months, years, or even decades is sure to be psychologically corrosive even for those able to ﬁnd pockets of psychic repose.

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