With hesitation do I dedicate to the half-empty,
but there's a vision of a girl I can't quite shake:
up to her Achilles tendons in rambunctious folds
of rank, grabby, carnivorous sea.
Disgruntled and shivering, but there all the way.

She’s the rare bird convinced of common feathers,
not so much ugly duckling as self-deprecating swan,
never so bold as to lock eyes with the water
for fear of seeing herself in clearest view,
and never seeing for sure that she’s a heart of beauty.

Not that she cares, anyways.

She's got the sappiest music taste—
though I’m not supposed to know that, either—
characterized by aplenty
of heartfelt bangers we loved in youth and pretended to be over.

She's no Mr. Brightside.
But ****, when she cleans up...

The only silver lining she believes in is her sharp-edged contour,
cutting as the retort she’s got ******* on the pulse of.
She just doesn’t need to shout to prove it.

I've the off-and-on friend who resents without saying,
no words to spare when she's busy as of late struggling to breathe.
The silence I took for elegance is suffocation,
but at least black lung is still the vogue, I’ve heard?

And through the struggle comes a wicked perfection:
the ability to lay waste with a whisper,
and revere only in the rawest quiet.

Her humor, sometimes for the offensive,
is the most potent sense of feeling
that doesn’t take looking at her own self.
She as herself could light up a room.
If only it weren’t so much easier to fall short.

Because never would she outwardly want to be on someone’s mind,
(little does she know she jumps to the forefront of mine)
yet in that same reluctant, teeth-grinding urge she denies herself
in the desire to find her good lighting,
I have in the desire to let her know she is beloved.

But to tell someone they’re poetry to you is a pin in the grenade
that these budding wisdom teeth just can’t grasp.

She’s there now in the sea I still liken to her eyes.
Windows to the soul akin to a place she hates,
just as capable of resentment.

All I know is I’ll be torn asunder if she loses herself
beneath the brine of a bottle or the message of faux-hope within it.
In a churning silence of the drink,
there’s no honest sentiment with which to compare.
Lost at sea, with no quality control,
fool’s gold is such a fine, agonizing release.

Yet on she heads, carving mountains in her path, for a swill.

Still, every time I see her again,
I know I’ll never help loving her some,
while I pretend there's comfort in the fact
that most of us had to sink before learning to swim.

I need to finish the story for convenience I have the original Aftermath to be read first on the bottom
What was not stated in Aftermath was my concern for my writing you can’t write with two legs
Screaming when I got to the hospital my kidneys were of a concern eight alieve three times a day about
Thirty aspirins something like Tylenol didn’t count them no relief my mistake I would bang my ****** leg
Against the wood of the desk that would make it crazy for a few seconds so I finally had to stop for over
Two months well the devil won it seemed when I talked to my cousin I was at eighteen thousand reads a
Little while let me break in here for a second I know I’m talking about numbers it isn’t ego if I come in
Contact with any of you in any setting and I pass you by with just a glance I am your sworn Godless
Enemy I have just joined the cruelest damnable assassins Hell has ever released on the world I know
What awaits the lost even the Apostle Paul worked fervently because he knew the end cost of God’s
Holy severity can I do less I look but I take in all manner caring thoughts but without fail I am led to that
Future now no one even gives the last day a thought I will put this in as an excerpt this is the dream I
Had when I was seventeen or it starts this way your life began in the great head waters at Eden they will
End at the mouth of eternity. I was given a view into the celestial I was just a teenager while a sleep this
Dream came I looked into the heavens and saw two great wheels made of stars the hands of God started
To pull the wheels down as I continued I knew what was occurring God was stopping time. The wheels
Stopped then God turned to the seamless darkness grasped it and started to lift as he did it tore away
Reveling the bright true world of the spirit that was before hidden this was alarming since I hadn’t made
My peace with him Not long after this I was seventeen working at the refinery I just walked out of the
Boiler room into the section that was known as the flathead when a voice said time is finished all life and
Its concerns flowed out leaving me with the greatest sadness other men standing by laid down their
Tools and started milling about mindlessly on this wise in some manner this will happen all over the
World the great enterprises so important to man and society will halt government rule and authority
Abolished in an instant majesty and power will take the reins the river previously known will be
Empowered its first charge make the deserts bloom as a rose…

And I take the liberty to insert I am a person of deep feelings to make the case I wrote two pieces for
Roberta Merrifield’s birthday sorry your flowers are late then I forgot your card this was talking about
Her friends as flowers each of them need to go to their door and imagine nine hundred people standing
There reading about their lives that are filled with grace and beauty and earthen treasures that are in
Vessels of clay but to see them truly you will be speechless so I return to the numbers so it was
Eighteen thousand a little later when I couldn’t stand the pain any longer I called my retired preacher
Uncle and our pastor brother Russell I explained to them about being whipped and my writing had to be
Shut down it was thirty five thousand reads then so keys were stilled my lifeline to needy souls was at
A deadly stillness so then two months later I wrote fourteen pieces bringing the total to four hundred
And fourteen pieces and then Gods love demands the his heart be represented this is the one I am
Pleased about the most I wrote a piece called the mirrored pool over four hundred souls read this I’m
Sorry this is too important to excerpt it in you are not obligated to read I leave that to your discretion

Mirrored Pool
Wonder for all the hurts
First I knelt just to see my reflection then the depths started to reveal first the flowing thoughts were
Restrained and then a bubbling seemed to dislodge from greater depths hard truths churned with
Violent twisting but the motion made it impossible to turn away there were great large white clouds
From depths then even above the pool they rose fourteen stories high the sensation was you were
Standing outside clear air intoxicating views the pulse of many were throbbing in your ears their
Thoughts and dreams were known and their sorrows were weights that pulled you from the heights
It was a colossal game of tag and you were it first reaction fear then the appearance of bundled gifts
Broke down the fear it was promise in different sizes that met the required needs it was like a divine
Warehouse had just made a delivery there were cards with names and writing gave clarification tears
And smiles intermingled then the outer knowing postulated the difficulty the puzzle an enormous
Streaming that was now congested and it was beginning a vortex all was understood now human thought
With doubts was pulling the answer into this destructive hole where was one to find the lever to stop
This action that would disallow was the answer to touch the water bring the finger to my lips possibly
A blazing thought would occur that would strike the mind no all that brought was words that had the
Letters jumbled they made no sense unless there is a special book that is alive in it the letters and words
Are already set but they cover every act in the human condition the broken can pour over the pages
You won’t find thorns to repel your efforts there are thorns but they will speak and assuage your hurts
At the most basic and needed levels the points of your hurts will begin to dissolve from your eyes to
Your mind this inward rush and power will dislodge even spears driven deep by enemies carried for
Years you searched in vain over sad and lonely paths and days now you journey is at an end thorns of
Suffering for another produces profound power and mercy go in peace beloved one another bears your
Burden now maybe words cut you at depths you can’t even identify what if there is an antidote in a
Book you pick it up with trembling hands your body tingles from the knowledge that this is ancient texts
It will have a revival of appreciation in this world of texting but with gentle fingers and eyes that glow
With respect as you see the wisdom and the love cannot be denied you leave the world you know and
With total abandonment you swim in this sea of words until the your tears spill on this rich world of
Words those cruel barbed words that pierced tender skin and have bled internally all of these years
Begin to dissolve with stories and accounts of betrayals then the swells love and mercy you read about
Restoration not always found after apologies are given but the teaching of forgiveness strikes a cord
You have been made free from your prison the tangles of life are great as a great black cloud it hangs
Over head many are its troubles this isn’t mild but the disruptive made to strike and pierce deep the
Hidden that steals the morning blessing while other feast your hunger and unrest only enlarges a
Tormenting unquenchable fire a slow burn this is a forest being burned at the thermal level the hidden
Roots a slow process destructive but not so visible agony torture I have seen men crawl in war or fire
Fighting that where all else is lost you will know greater thrills than any other living soul with the
Desperate and those heavy burdened unable to stand a word will flow it puts out fires and gives
The luxurious buoyancy heaviness changed to joy the bouncy laughter every outward blast attack
The enemy launches is within its pages they are repelled overwhelmed by love you suffer unduly
If you don’t hold this fortress this informative book of stratagems that have made everyone a victor
Who has ever found themselves at their wits end no place on earth has a contingency plan though it
Will make the greatest claims all is just empty air when life as it too often does ***** the very air of life
Out we practically are unconscious but this help this rescue is activated by one name it’s not just a book
But the word is a person what a pool you will find what a reflection will engage you beyond your hope
To imagine just say Jesus all will be total peace your heart will know no more sorrow peace will surpass
Sorrow love will disallow the specter that was once a constant it will disappear it will return to the
Darkness from which it came stand in this newness totally free abide by still waters as the good
Sheppard stands by bless you

So the success against the evil one stands like this while he body slammed me the number of
Souls touched has risen to sixty three thousand five thousand while I was in Braidwood so I
Thank the father whose love and concern never wavers by Christmas I am hopeful I will reach
A hundred thousand if I make heaven I don’t want to see you at judgment and hear you say the
Words of that old song he knew I was lost but said nothing to me!!!!!!!!!!

The Aftermath
Please read this to see in my limited way I want to show you your true worth and value and you will see
what the devil never can get.
This is what I would stand and testify in church but what I have to say is lengthy here it can be read or
Not I would first say this to love souls is agonizing it comes with pain and great tears I went to the site
Where they started the church years ago on my Grandma Brown’s front porch as I set there I pleaded
With God to help me make a difference I turned and looked down the old street that held so many
Memories of course Tommy and Elise and Glena are the only ones that remain but I looked farther
That’s when God moved wave after wave of hard rocking sobs that lasted for thirty minutes or more
And after getting back home some will say this is foolish and I’m the first to know we can’t take the devil
On by ourselves but overcome with emotion I turned from the computer and spoke to evil its self that I
Was declaring total war for souls this is what it has cost me so far at the time I had one open wound on
My shin above the ankle two appeared directly above the first one then one to the side and then I knew
What was to come because I have sleep apnea I sleep in a recliner I knew the sores would ring my leg
And they did you can’t lay your leg out on the ledge with open wounds with nerve endings screaming
Then it jumped to my other leg so that was the first volley when I write I get lost time doesn’t exist many
A time daylight would surprise me coming through the window then the onslaught increases I go to the
Hospital I got there in early afternoon they got me in the room at ten thirty but just before a lady comes
In and takes my blood pressure it is close to perfect and then she comes back in five minutes and tells
Me take these three blood pressure pills trusting her I take them well about twelve or one they come
Into and take my blood pressure they had driven it down to seventy over thirty and plus my first
Experience with morphine I was sick and strangely loopy I wasn’t in the bed I couldn’t lay my legs
Down and no one else was in the room only one bed I did set at the end of the bed with it all the way up
In the back I put my head on it and slept comfortably one funny they have it posted call don’t fall I didn’t
Do this on purpose but when I was pulling the drawer out of the stand it came out with a wonderful
Crash Steve the male nurse made record time from down the hall at the nurse station he lunges in the
Room it wasn’t humpty dumpty just the drawer I couldn’t tell if he was relived or ticked off then it was
Their shot back over the net intravenous antibiotics five days needed a doctor from disease control to
Release me then there version of cons scarring kids with tales about prison to keep them messing with
Drugs scared straight now was scared healthy I walked out the same as I walked in I got a bill for thirty
Thousand well at least I didn’t have a bad heart then it was eleven weeks at the wound center this was
Where I met as I lovingly call them my healing angels they finally got all twelve open sores to close then
for the rest of the problem it was six weeks three times a week forty five miles to and from hundred
Degree heat every day you have to pay a hundred and seventy dollars yourself for the compress wrap
Material then you turn around a pay for compress socks that insurance doesn’t cover least the inside is
Pure silver so missed the Olympics but I got silver in fact every six months I will get silver again this is
Kind apropos I asked the compress wrap therapist where Lymph edema comes from and I will spare you
The pictures but the infection and lymph edema pictures even grossed me out but interestingly the
Therapist said an ancient king in Israel had the disease hello devil no cure just mange it from now on
This is the biggest cut of all someone else has to put them on I have always been called a free spirit
Try to take off on your own and what say hey stranger would you put these on my leg it’s like trying to
Put a baby squirrel skin on a full grown body the therapist does speeches internationally with a doctor
From India she asked permission after taking pictures to show the audience I wouldn’t want to see that
Show give the devil his due he is good at being bad I crossed swords with him he rampaged all over me
I didn’t include everything I have gone through and that doesn’t include my poor wife but I am profane
Corrupt undone should I speak to you of such great things as eternal verities matters that involve where
You will spend eternity there is the cleansing of the word the cleansing of changing my corrupt nature to
His by the spirit but know this no one will ever approach or in any way defile the very ones that as the
Finest gems will be placed in his Holy diadem this takes the cleansing of suffering and brokenness with
The heart Broken for souls and the most necessary of all this nature that is too much like the evil one
That’s what he doesn’t get the more he beats up on a person he is doing God’s work of purifying the
Most elemental evil that must be scourged if I touch you it has to be purist intentions of holy deign
We are awash in the lowest dregs dare I say quick sand only holiness can enable us to traverse this
Killing place of a dark and ever turning evil that compounds itself the devil will never lose the majority
On The Broad way that leads to destruction but there are the blessed few that stop and say oh no this is
Not for Me I was his child and I will be again thanks for the load you made me bear serving you devil now Only Love will be the weight I feel it comes by a great price of God Himself and His people

I need to finish the story for convenience I have the original Aftermath to be read first on the bottom
What was not stated in Aftermath was my concern for my writing you can’t write with two legs
Screaming when I got to the hospital my kidneys were of a concern eight alieve three times a day about
Thirty aspirins something like Tylenol didn’t count them no relief my mistake I would bang my ****** leg
Against the wood of the desk that would make it crazy for a few seconds so I finally had to stop for over
Two months well the devil won it seemed when I talked to my cousin I was at eighteen thousand reads a
Little while let me break in here for a second I know I’m talking about numbers it isn’t ego if I come in
Contact with any of you in any setting and I pass you by with just a glance I am your sworn Godless
Enemy I have just joined the cruelest damnable assassins Hell has ever released on the world I know
What awaits the lost even the Apostle Paul worked fervently because he knew the end cost of God’s
Holy severity can I do less I look but I take in all manner caring thoughts but without fail I am led to that
Future now no one even gives the last day a thought I will put this in as an excerpt this is the dream I
Had when I was seventeen or it starts this way your life began in the great head waters at Eden they will
End at the mouth of eternity. I was given a view into the celestial I was just a teenager while a sleep this
Dream came I looked into the heavens and saw two great wheels made of stars the hands of God started
To pull the wheels down as I continued I knew what was occurring God w

The Aftermath

Please read this to see in my limited way I want to show you your true worth and value and you will see
What the devil never can get.

This is what I would stand and testify in church but what I have to say is lengthy here it can be read or
Not I would first say this to love souls is agonizing it comes with pain and great tears I went to the site
Where they started the church years ago on my Grandma Brown’s front porch as I set there I pleaded
With God to help me make a difference I turned and looked down the old street that held so many
Memories of course Tommy and Elise and Glena are the only ones that remain but I looked farther
That’s when God moved wave after wave of hard rocking sobs that lasted for thirty minutes or more
And after getting back home some will say this is foolish and I’m the first to know we can’t take the devil
On by ourselves but overcome with emotion I turned from the computer and spoke to evil its self that I
Was declaring total war for souls this is what it has cost me so far at the time I had one open wound on
My shin above the ankle two appeared directly above the first one then one to the side and then I knew
What was to come because I have sleep apnea I sleep in a recliner I knew the sores would ring my leg
And they did you can’t lay your leg out on the ledge with open wounds with nerve endings screaming
Then it jumped to my other leg so that was the first volley when I write I get lost time doesn’t exist many
A time daylight would surprise me coming through the window then the onslaught increases I go to the
Hospital I got there in early afternoon they got me in the room at ten thirty but just before a lady comes
In and takes my blood pressure it is close to perfect and then she comes back in five minutes and tells
Me take these three blood pressure pills trusting her I take them well about twelve or one they come
Into and take my blood pressure they had driven it down to seventy over thirty and plus my first
Experience with morphine I was sick and strangely loopy I wasn’t in the bed I couldn’t lay my legs
Down and no one else was in the room only one bed I did set at the end of the bed with it all the way up
In the back I put my head on it and slept comfortably one funny they have it posted call don’t fall I didn’t
Do this on purpose but when I was pulling the drawer out of the stand it came out with a wonderful
Crash Steve the male nurse made record time from down the hall at the nurse station he lunges in the
Room it wasn’t humpty dumpty just the drawer I couldn’t tell if he was relived or ticked off then it was
Their shot back over the net intravenous antibiotics five days needed a doctor from disease control to
Release me then there version of cons scarring kids with tales about prison to keep them messing with
Drugs scared straight now was scared healthy I walked out the same as I walked in I got a bill for thirty
Thousand well at least I didn’t have a bad heart then it was eleven weeks at the wound center this was
Where I met as I lovingly call them my healing angels they finally got all twelve open sores to close then
for the rest of the problem it was six weeks three times a week forty five miles to and from hundred
Degree heat every day you have to pay a hundred and seventy dollars yourself for the compress wrap
Material then you turn around a pay for compress socks that insurance doesn’t cover least the inside is
Pure silver so missed the Olympics but I got silver in fact every six months I will get silver again this is
Kind apropos I asked the compress wrap therapist where Lymph edema comes from and I will spare you
The pictures but the infection and lymph edema pictures even grossed me out but interestingly the
Therapist said an ancient king in Israel had the disease hello devil no cure just mange it from now on
This is the biggest cut of all someone else has to put them on I have always been called a free spirit
Try to take off on your own and what say hey stranger would you put these on my leg it’s like trying to
Put a baby squirrel skin on a full grown body the therapist does speeches internationally with a doctor
From India she asked permission after taking pictures to show the audience I wouldn’t want to see that
Show give the devil his due he is good at being bad I crossed swords with him he rampaged all over me
I didn’t include everything I have gone through and that doesn’t include my poor wife but I am profane
Corrupt undone should I speak to you of such great things as eternal verities matters that involve where
You will spend eternity there is the cleansing of the word the cleansing of changing my corrupt nature to
His by the spirit but know this no one will ever approach or in any way defile the very ones that as the
Finest gems will be placed in his Holy diadem this takes the cleansing of suffering and brokenness with
The heart Broken for souls and the most necessary of all this nature that is too much like the evil one
That’s what he doesn’t get the more he beats up on a person he is doing God’s work of purifying the
Most elemental evil that must be scourged if I touch you it has to be purist intentions of holy deign
We are awash in the lowest dregs dare I say quick sand only holiness can enable us to traverse this
Killing place of a dark and ever turning evil that compounds itself the devil will never lose the majority
On The Broad way that leads to destruction but there are the blessed few that stop and say oh no this is
Not for Me I was his child and I will be again thanks for the load you made me bear serving you devil
now Only Love will be the weight I feel it comes by a great price of God Himself and His people

The patient has had no nausea,
vomiting or back pain. No chills,
fatigue, fever, decreased vision
or double vision. No ear drainage
or hearing loss, epistaxis or
runny nose. No sore throat, calf
pain, chest pain, cough or difficulty
breathing. No pedal edema,
palpitations, black stools, ******
stools or constipation. No diarrhea,
urinary frequency, laceration, skin
rash or depression. No dizziness,
headache, head injury, weakness
or enlarged lymph nodes. All
systems negative        

and yet

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dedicated banishment
self inflicted, echoing
physical displacement
from permanent coronary scarification
devouring accidentally my lacerated pulmonary edema
cauterizing weakness into cement
thermodynamically frozen muscles

umbrellas on parade in your city
netherworld for my regret
disreputable raincoats rubbery ebbing
against a tide of discontent
ringing out like let-downs

This will be short and sweet like the honey when the Bible character was famished it’s hard to identify
With arid hostile lands an know desperate hunger it wouldn’t be if you looked in a spiritual mirror there
Isn’t such a thing yes there is it is the bible you wouldn’t like what you see staring back at you all
Natural impediments and illusion that material life creates a density a perfect cloak sins chains are
Hidden the future obscure or if it shouts out the dire straits you’re in it is immediately destroyed by
The precious but deadly sentiment God is love yes that was qualified by a disfigured suffering savoir who
Didn’t just say I love you he showed it to the Father in Heaven then to all ages of lost men and women
You will not pass his agony and suffering while you participate in evil that does nothing but undermine
Your very life robbing you of blessings that goes to the center of your being not the quick thrills then you
Regret your shameful actions the church is the great first aid station for spiritual wounds and sorrows
A support group that is in the know and is equipped by heaven to rescue any hurting person that
Played the devil’s game and now lies in a maggot infested cell in excrement obviously they hear
When love goes to their extreme situation and what a transformation from rags and scabs and delirium
To a sound mind a life that flows by silver cool streams and the path leading away to your recued life is
Not you alone but He is your guide just a personnel word to let you know I’m not just talking this is what
He did as my guide I was running two hundred points on blood pressure edema with pitting other words
Open holes six total with the leg on fire and then the sharp biting pain that the strongest pain pill didn’t
Faze E.K.G. in depth blood work kidney ultrasound heart ultra sound the last a trip to emergency for the
Leg all of this disabled no insurance oh yes the biggest one in two weeks go to a kidney specialist there
Was going be whole lot a chinging going on that alone would have surpassed everything else but this is
Where He steps in I used the scripture that says come and let us reason together I just said if this goes
Through I won’t be able to support St Jude’s, Boys Town, The church and a missionary so when I went
For blood pressure test down from 200 hundred to 144 ER didn’t admit me I m still paying nine hundred
From the last visit to the ER for blood pressure mostly I set there for three hours you would have to go
To Vegas to blow money that fast but we have a Father that will intervene change the course that would
Put us in debt and every other harmful thing and then you have the father of this world he knows every
Weakness he knows all of your failures and he mines it for all its worth and by the way you are the slave
That does the work well I wrote like this last time and then Hell grabbed my leg and it’s still burning with
Hellish pain but I accepted a challenge to step up my efforts to rescue the perishing but I am a liar I said
This was going to be short and sweet and it is neither but I get lost while writing and the pain subsides
These words don’t mean much but before any of us want to were going to go to judgment then tears of
Anguish and joy will say thank you for caring and showing me truth that saves

precipitation's anticipation of change
diffused morning light
the mustiness of first rain
a misty visibility hiding distant hills
a graying of the cityscape
skyscrapers in clouds
construction's crane quieted
in the mix of old and new
a slow rush hour
washing the street's grime
a coolness to my eyes
a slight chill in my bones
Autumn colored leaves swaying with breeze
on half empty trees
slanted raindrops incessantly blustering
a beautiful day
where only seagulls dare to fly

eight peeping eyes with healing hands
too good to help her to the restroom
"I'll call a nurse"
they just poked in to take a peek
feel her leg's edema
and inform me of possibility's progress
a colonoscopy?
a transfusion?
time keeps asking for more time
morning meds
an IV
a blood draw
a blood test strip
another trip to the restroom
a kind older gentleman's help
he thought I was her father

it's raining hard again
gutters like rivers
storm drains splashing white water
more skyline has gone missing
umbrellas wrestling wind
raindrops rilling down a picture window
as afternoon sheds it's light

as I watch sleep's breaths
her hunger awakens and feistiness returns
"Don't they feed their patients here?"
they never told us to call food services
another blood pressure reading
another blood draw
another trip to the restroom
and it's all good
a colonoscopy evaluation
maybe Thursday or Friday...
looks like time got her wish

Kneel at that river bend

in supplication

in silent meditation

and hold fast to the quiet whisper that say

Drink

between heartbeats

in a slow lazy way

so that it curls around you



but you look at the water

and your hands are frozen

it is not clean



maybe there is another river

or faster moving water



you rise from the riverbed

you are afraid

of the water

of the current

you can swim

but you do not know if you can stand

at the riverbed


the current is fast and unforgiving

it moves around you

through you



it does not touch you



the river moves forward

rushing

turning

roiling



it will drown you



Kneel

there is another river

there is faster moving water



but still

Kneel

**Drink

Mantra


This will be short and sweet like the honey when the Bible character was famished it’s hard to identify
With arid hostile lands an know desperate hunger it wouldn’t be if you looked in a spiritual mirror there

Isn’t such a thing yes there is it is the bible you wouldn’t like what you see staring back at you all
Natural impediments and illusion that material life creates a density a perfect cloak sins chains are

Hidden the future obscure or if it shouts out the dire straits you’re in it is immediately destroyed by
The precious but deadly sentiment God is love yes that was qualified by a disfigured suffering savoir who

Didn’t just say I live you he showed it to the Father in Heaven then to all ages of lost men and women
You will not pass his agony and suffering while you participate in evil that does nothing but undermine

Your very life robbing you of blessings that goes to the center of your being not the quick thrills then you
Regret your shameful actions the church is the great first aid station for spiritual wounds and sorrows

A support group that is in the know and is equipped by heaven to rescue any hurting person that
Played the devil’s game and now lies in a maggot infested cell in excrement obviously they hear

When love goes to their extreme situation and what a transformation from rags and scabs and delirium
To a sound mind a life that flows by silver cool streams and the path leading away to your recued life is

Not you alone but He is your guide just a personnel word to let you know I’m not just talking this is what
He did as my guide I was running two hundred points on blood pressure edema with pitting other words

Open holes six total with the leg on fire and then the sharp biting pain that the strongest pain pill didn’t
Faze E.K.G. in depth blood work kidney ultrasound heart ultra sound the last a trip to emergency for the

Leg all of this disabled no insurance oh yes the biggest one in two weeks go to a kidney specialist there
Was going be whole lot a chinging going on that alone would have surpassed everything else but this is

Where He steps in I used the scripture that says come and let us reason together I just said if this goes
Through I won’t be able to support St Jude’s, Boys Town, The church and a missionary so when I went

For blood pressure test down from 200 hundred to 144 ER didn’t admit me I m still paying nine hundred
From the last visit to the ER for blood pressure mostly I set there for three hours you would have to go

To Vegas to blow money that fast but we have a Father that will intervene change the course that would
Put us in debt and every other harmful thing and then you have the father of this world he knows every

Weakness he know all of you failures and he mines it for all its worth and by the way you are the slave
That does the work well I wrote like this last time and then Hell grabbed my leg and it’s still burning with

Hellish pain but I accepted a challenge to step up my efforts to rescue the perishing but I am a liar I said
This was going to be short and sweet and it is neither but I get lost while writing and the pain subsides

These words don’t mean much but before any of us want to were going to go to judgment then tears of
Anguish and joy will say thank you for caring and showing me truth that saves

Lips red and moist
Others blue and cold

Eyes bright and smiling
Some veiled and void

Hair long, wavy like silk
More is chopped and feels like straw

Hands soft, caressing
Others lifeless and rough

Ample globes of rose tipped buds hard
These no longer vibrant just overabundance of flesh

Rounded hips, silky thighs,
Dried and withered skin dead

The sweet spot of dew lauden rose petals surrounding a tight wet tunnel
Wrinkled, filmy white substance almost dry, tunnel dysfunctional

Long legs that wrap around hips holding tightly pulling inward
Hairy now, hard from edema, pale blue, weak

The bright eyed *** goddess once sought after day by day
Now listless, lifeless almost, no longer wanted or needed

Each day of desire lived to the fullest
Once forgotten each day added more darkness

The **** siren with a voice of velvet honey
No longer speaks not even a spark in the eyes

A past lover arrives it has been years
Tear flows down his cheek at what has become of her

She doens't know it though
Gave up long ago
No one came by or even sent a card of hello
Mind stopped dreaming
Stopped thinking
Let go of life day by day
Body followed some thought it had to be slow
Yet it was not
Her Soul died first
Once that was gone the rest was easy

The library was quiet
Silent ischemia read a book called
Myocardial infarction

The radio played techno tachycardia
While myocardium got high on nitroglycerin

It was quiet
I whispered yet no one was listening

I heard a heart murmur something
Into the echocardiography

It echoed
edema
               edema
                             edema

It was there I rested in lipid

I knew my heart was broken
The day she said she was leaving

It was then my diagnosis
became cerebral thrombosis

I had a cerebrovascular accident
And I lost my mind
With my heart underfoot of my lover

Now I'm searching for a surgeon
To put it all back together

Between the life I had
and the death I owe
lies the valley of the shadow,
A place of woe.

First, numb, from hearing
the dread prognosis:
A blockage portending of
thrombosis.

Another episode like I just had
might end my life
like it did my Dad's.

Time seems most precious
does it not?
teetering on the abyss-
Cold,now when the day is hot.

Edema swells and fluids drown,
Each stolen breath is bought with pain.
Where once my river was at flood,
now bare trickles of time remain.

Time enough to say" Goodbye."
To reminisce or be forgot.
To say I love you one more time
even should you love me not.

Between the life I had
and the death I owe
lies the valley of the shadow,
A place of woe.

Perhaps this is the afterlife,
A way stop in this vale of tears.
A pause before the journey's end-
Can I say ,like a child, "Again!"

The arrival of senselessness
Is a great shadow over the earth,
a cooling cloud in the summer
causation of looking up--

Gift-givers wander the slopes and with packets of thought,
They run their fingers along the stones and the trees and the fields
Grassy,
Following the trails of clouds wandering just as inconsequent
Leaving tears as rain on the steppes and letting them drain into the deathly floors
asking them to give the ability for new things to drink
This is the true Holy Water


And a patchwork soul seeks, fixated,
answers to the crackled nature of their vessel
Running into the same stone of them, cancerous
soon left to sands and dust
Ozymandias

The blades of leaves rattle a sad salute
Their ragged branches sheathed xylem, a perfect skyscraper design
Preventing edema of the like kind

Show to me that this place in not but the momentary awareness of light, a stopping point in the infinite variation

To locate oneself in the rapid raveling of everything into one great big
Sorrowful tear, running from the eternal blackness of the night
that holds noting but the absence of itself.

She’s a dimple and a drag, corner of Worth and Magpie, French Vogue idioms and her mother’s red flowery hoop earrings. Aloha! Aloha! Oopty-oops in contract loot thru streets and backyard parties, concrete larders, her eyes lie like presidential promises, a slipknot of licorice around her neckline to keep her rising tide from the Menarche Moon.

Anything to keep the little penny featherweight dancer from slipping. Her siblings poke fun at her funny way of speaking, her bath tub is just an excuse for chiseling at her innards, taking a drag at her lungs and punching her duck-billed platypus in the kidneys; a heavy-weight champion of the worm.

That until all the saints come writhing off the fishing lines. Until the ballerina’s edema coexists with Tokyo extremists, serial killer behemoths that keep body parts and *** toys in the freezer. Here, here! Wrath goes to the fella with the wicked demeanor. In an area of limited sight, this country, it’s people are sickened at the sights of themselves, and the wackos are coming out in large swaths, minerals and dimples strapped to their waist belts in the throes of a menopausal demagogue heaving OxyContin down El Camino Real.

Comparing my driver's licenses,
my eyes stay the same
but, God,
my face sure has grown.

There exists a room,
Without windows,
Only walls;
It doesn’t matter how many
But it’s dark,
And feet are chained to the floor.

This room exists in everyone,
But some choose to stay closed off—
Choose to stay forgotten.

The bottle swells with pressure,
For as long as one
Could possibly contain it,
But pressure, no matter of what origin
Always leads
To an explosion,
And so explode one will,
In a cataclysm of tears,
And aching.

Each time the pressure
Lets itself break the cap,
The level rises,
And the loss
Starts at the first moment
Because the cap
Gets looser
With every time it breaks,

Until the rain from the eyes
Is covered
By the water rising,
And your vision might have
Gotten used to the dark,
But the effervescence
Of your exhales
Has blinded you,
As I’m sure you didn’t notice
How far the level had risen,

And those eyes
Never let be seen
By another pair,
Or by the sunset
Surely overtaken
By the despair that
You wouldn’t let them be seen,
But the pulmonary edema
You face has been made
By your own brokenness

Why, I must ask, did you lock yourself away?

HIGHLIGHTS OF PRESCRIBING INFORMATION
These highlights do not include all the information needed to us e
M-M-R II safely and effectively. See full prescribing information
for M-M-R II.
M-M-R® II (Measles, Mumps, and Rubella Virus Vaccine Live)
Suspension for subcutaneous injection
Initial U.S. Approv al: 1978
-------------------------------INDICATIONS AND USAGE-------------------------------
M-M-R II is a vaccine indicated for active immunization for the
prevention of measles, mumps, and rubella in individuals 12 months of
age and older. (1)
-------------------------- DOSAGE AND ADMINISTRATION--------------------------
Administer a 0.5-mL dose of M-M-R II subcutaneously. (2.1)
• The first dose is administered at 12 to 15 months of age. (2.1)
• The second dose is administered at 4 to 6 years of age. (2.1)
------------------------DOSAGE FORMS AND STRENGTHS -----------------------
Suspension for injection (0.5-mL dose) supplied as a lyophilized
vaccine to be reconstituted using accompanying sterile diluent. (3)
---------------------------------- CONTRAINDICATIONS ----------------------------------
• Hypersensitivity to any componentof the vaccine. (4.1)
• Immunosuppression. (4.2)
• Moderate or severe febrile illness. (4.3)
• Active untreated tuberculosis. (4.4)
• Pregnancy. (4.5, 8.1)
-------------------------- WARNINGS AND PRECAUTIONS --------------------------
• Use caution when administering M-M-R II to individuals with a
history of febrile seizures. (5.1)
• Use caution when administering M-M-R II to individuals with
anaphylaxis or immediate hypersensitivity following egg ingestion.
(5.2)
• Use caution when administering M-M-R II to individuals with a
history of thrombocytopenia. (5.3)
• Immune Globulins (IG) and other blood products should not be
given concurrently with M-M-R II. (5.4, 7.2)
----------------------------------ADVERSE REACTIONS----------------------------------
See full prescribing information for adverse reactions occurring duri ng
clinical trialsor the post-marketing period. (6)
To report SUSPECTED ADVERSE REACTIONS, contact Merck
Sharp & Dohme Corp., a subsidiary of Merck & Co., Inc., at 1-8 7 7 -
888-4231 or VAERS at 1-800-822-7967 or www.vaers.hhs.gov.
-----------------------------------DRUG INTERACTIONS----------------------------------
• Administration of immune globulins and other blood products
concurrently with M-M-R II vaccine may interfere with the
expected immune response. (7.2)
• M-M-R II vaccination may result in a temporary depression of
purified protein derivative (PPD) tuberculin skin sensitivity. (7.3)
-------------------------- USE IN SPECIFIC POPULATIONS--------------------------
• Pregnancy: Do not administer M-M-R II to females who are
pregnant. Pregnancy should be avoided for 1 month following
vaccination with M-M-R II. (4.5, 8.1, 17)
See 17 for PATIENT COUNSELING INFORMATION and FDA
approv ed patient labeling.
Rev ised: 06/2020
FULL PRESCRIBING INFORMATION: CONTENTS
1 INDICATIONS AND USAGE
2 DOSAGE AND ADMINISTRATION
2.1 Dose and Schedule
2.2 Preparation andAdministration
3 DOSAGE FORMS AND STRENGTHS
4 CONTRAINDICATIONS
4.1 Hypersensitivity
4.2 Immunosuppression
4.3 Moderate or Severe Febrile Illness
4.4 Active Untreated Tuberculosis
4.5 Pregnancy
5 WARNINGS AND PRECAUTIONS
5.1 Febrile Seizure
5.2 Hypersensitivity to Eggs
5.3 Thrombocytopenia
5.4 Immune Globulins and Transfusions
6 ADVERSE REACTIONS
7 DRUG INTERACTIONS
7.1 Corticosteroids and Immunosuppressive Drugs
7.2 Immune Globulinsand Transfusions
7.3 Tuberculin Skin Testing
7.4 Use with Other Live Viral Vaccines
8 USE IN SPECIFIC POPULATIONS
8.1 Pregnancy
8.2 Lactation
8.4 Pediatric Use
8.5 Geriatric Use
11 DESCRIPTION
12 CLINICAL PHARMACOLOGY
12.1 Mechanism of Action
12.6 Persistence of Antibody Responses After Vaccination
13 NONCLINICAL TOXICOLOGY
13.1 Carcinogenesis, Mutagenesis, Impairment of Fertility
14 CLINICAL STUDIES
14.1 Clinical Efficacy
14.2 Immunogenicity
15 REFERENCES
16 HOW SUPPLIED/STORAGE AND HANDLING
17 PATIENT COUNSELING INFORMATION
Sections or subsections omitted from the full prescribing info rma tion
are not listed.
2
FULL PRESCRIBING INFORMATION
1 INDICATIONS AND USAGE
M-M-R® II is a vaccine indicated for active immunization for the prevention of measles, mumps, and
rubella in individuals 12 months of age and older.
2 DOSAGE AND ADMINISTRATION
For subcutaneous use only.
2.1 Dose and Schedule
Each 0.5 mL dose is administered subcutaneously.
The first dose is administered at 12 to 15 months of age. A second dose is administered at 4 to 6
years of age.
The second dose may be administered prior to 4 years of age, provided that there is a minimum
interval of one month between the doses of measles, mumps and rubella virus vaccine, live {1-2}.
Children who received an initial dose of measles, mumps and rubella vaccine prior to their first
birthday should receive additional doses of vaccine at 12-15 months of age and at 4-6 years of age to
complete the vaccination series [see Clinical Studies (14.2)].
For post-exposure prophylaxis for measles, administer a dose of M-M-R II vaccine within 72 hours
after exposure.
2.2 Preparation and Administration
Use a sterile syringe free of preservatives, antiseptics, and detergents for each injection and/or
reconstitution of the vaccine because these substances may inactivate the live virus vaccine. To
reconstitute, use only the diluent supplied with the vaccine since it is free of preservatives or other
antiviral substances which might inactivate the vaccine.
Withdraw the entire volume of the supplied diluent from its vial and inject into lyophilized vaccine vial.
Agitate to dissolve completely. Discard if the lyophilized vaccine cannot be dissolved.
Withdraw the entire volume of the reconstituted vaccine and inject subcutaneously into the outer
aspect of the upper arm (deltoid region) or into the higher anterolateral area of the thigh.
Parenteral drug products should be inspected visually for particulate matter and discoloration prior to
administration, whenever solution and container permit. Visually inspect the vaccine before and after
reconstitution prior to administration. Before reconstitution, the lyophilized vaccine is a light yellow
compact crystalline plug, when reconstituted, is a clear yellow liquid. Discard if particulate matter or
discoloration are observed in the reconstituted vaccine.
To minimize loss of potency, administer M-M-R II as soon as possible after reconstitution. If not used
immediately, the reconstituted vaccine may be stored between 36°F to 46°F (2°C to 8°C), protected from
light, for up to 8 hours. Discard reconstituted vaccine if it is not used within 8 hours.
3 DOSAGE FORMS AND STRENGTHS
M-M-R II vaccine is a suspension for injection supplied as a single dose vial of lyophilized vaccine to
be reconstituted using the accompanying sterile diluent [see Dosage and Administration (2.2) and How
Supplied/Storage and Handling (16)]. A single dose after reconstitution is 0.5 mL.
4 CONTRAINDICATIONS
4.1 Hypersensitivity
Do not administer M-M-R II vaccine to individuals with a history of hypersensitivity to any component
of the vaccine (including gelatin) {3} or who have experienced a hypersensitivity reaction following
administration of a previous dose of M-M-R II vaccine or any other measles, mumps and rubellacontaining vaccine. Do not administer M-M-R II vaccine to individuals with a history of anaphylaxis to
neomycin [see Description (11)].
4.2 Immunosuppression
Do not administer M-M-R II vaccine to individuals who are immunodeficient or immunosuppressed due
to disease or medical therapy. Measles inclusion body encephalitis {4} (MIBE), pneumonitis {5} and death
as a direct consequence of disseminated measles vaccine virus infection have been reported in
3
immunocompromised individuals inadvertently vaccinated with measles-containing vaccine. In this
population, disseminated mumps and rubella vaccine virus infection have also been reported.
Do not administer M-M-R II to individuals with a family history of congenital or hereditary
immunodeficiency, until the immune competence of the potential vaccine recipient is demonstrated.
4.3 Moderate or Severe Febrile Illness
Do not administer M-M-R II vaccine to individuals with an active febrile illness with fever >101.3F
(>38.5C).
4.4 Active Untreated Tuberculosis
Do not administer M-M-R II vaccine to individuals with active untreated tuberculosis (TB).
4.5 Pregnancy
Do not administer M-M-R II to individuals who are pregnant or who are planning on becoming
pregnant within the next month [see Use in Specific Populations (8.1) and Patient Counseling Information
(17)].
5 WARNINGS AND PRECAUTIONS
5.1 Febrile Seizure
There is a risk of fever and associated febrile seizure in the first 2 weeks following immunization with
M-M-R II vaccine. For children who have experienced a previous febrile seizure (from any cause) and
those with a family history of febrile seizures there is a small increase in risk of febrile seizure following
receipt of M-M-R II vaccine [see Adverse Reactions (6)].
5.2 Hypersensitivity to Eggs
Individuals with a history of anaphylactic, anaphylactoid, or other immediate reactions (e.g., hives,
swelling of the mouth and throat, difficulty breathing, hypotension, or shock) subsequent to egg ingestion
may be at an enhanced risk of immediate-type hypersensitivity reactions after receiving M-M-R II vaccine
.The potential risks and known benefits should be evaluated before considering vaccination in these
individuals.
5.3 Thrombocytopenia
Transient thrombocytopenia has been reported within 4-6 weeks following vaccination with measles,
mumps and rubella vaccine. Carefully evaluate the potential risk and benefit of vaccination in children
with thrombocytopenia or in those who experienced thrombocytopenia after vaccination with a previous
dose of measles, mumps, and rubella vaccine {6-8} [see Adverse Reactions (6)].
5.4 Immune Globulins and Transfusions
Immune Globulins (IG) and other blood products should not be given concurrently with M-M-R II [see
Drug Interactions (7.2)]. These products may contain antibodies that interfere with vaccine virus
replication and decrease the expected immune response.
The ACIP has specific recommendations for intervals between administration of antibody containing
products and live virus vaccines.
6 ADVERSE REACTIONS
The following adverse reactions include those identified during clinical trials or reported during postapproval use of M-M-R II vaccine or its individual components.
Body as a Whole
Panniculitis; atypical measles; fever; syncope; headache; dizziness; malaise; irritability.
Cardiovascular System
Vasculitis.
Digestive System
Pancreatitis; diarrhea; vomiting; parotitis; nausea.
Hematologic and Lymphatic Systems
Thrombocytopenia; purpura; regional lymphadenopathy; leukocytosis.
Immune System
Anaphylaxis, anaphylactoid reactions, angioedema (including peripheral or ****** edema) and
bronchial spasm.
Musculoskeletal System
Arthritis; arthralgia; myalgia.
4
Nervous System
Encephalitis; encephalopathy; measles inclusion body encephalitis (MIBE) subacute sclerosing
panencephalitis (SSPE); Guillain-Barré Syndrome (GBS); acute disseminated encephalomyelitis (ADEM);
transverse myelitis; febrile convulsions; afebrile convulsions or seizures; ataxia; polyneuritis;
polyneuropathy; ocular palsies; paresthesia.
Respiratory System
Pneumonia; pneumonitis; sore throat; cough; rhinitis.
Skin
Stevens-Johnson syndrome; acute hemorrhagic edema of infancy; Henoch-Schönlein purpura;
erythema multiforme; urticaria; rash; measles-like rash; pruritus; injection site reactions (pain, erythema,
swelling and vesiculation).
Special Senses — Ear
Nerve deafness; otitis media.
Special Senses — Eye
Retinitis; optic neuritis; papillitis; conjunctivitis.
Urogenital System
Epididymitis; orchitis.
7 DRUG INTERACTIONS
7.1 Corticosteroids and Immunosuppressive Drugs
M-M-R II vaccine should not be administered to individuals receiving immunosuppressive therapy,
including high dose corticosteroids. Vaccination with M-M-R II vaccine can result in disseminated disease
due to measles vaccine in individuals on immunosuppressive drugs [see Contraindications (4.2)].
7.2 Immune Globulinsand Transfusions
Administration of immune globulins and other blood products concurrently with M-M-R II vaccine may
interfere with the expected immune response {9-11} [see Warnings and Precautions (5.4)]. The ACIP has
specific recommendations for intervals between administration of antibody containing products and live
virus vaccines.
7.3 Tuberculin Skin Testing
It has been reported that live attenuated measles, mumps and rubella virus vaccines given individually
may result in a temporary depression of tuberculin skin sensitivity. Therefore, if a tuberculin skin test with
tuberculin purified protein derivative (PPD) is to be done, it should be administered before, simultaneously
with, or at least 4 to 6 weeks after vaccination with M-M-R II vaccine.
7.4 Use with Other Live Viral Vaccines
M-M-R II vaccine can be administered concurrently with other live viral vaccines. If not given
concurrently, M-M-R II vaccine should be given one month before or one month after administration of
other live viral vaccines to avoid potential for immune interference.
8 USE IN SPECIFIC POPULATIONS
8.1 Pregnancy
Risk Summary
M-M-R II vaccine is contraindicated for use in pregnant women because infection during pregnancy
with the wild-type viruses has been associated with maternal and fetal adverse outcomes.
Increased rates of spontaneous abortion, stillbirth, premature delivery and congenital defects have
been observed following infection with wild-type measles during pregnancy. {12,13} Wild-type mumps
infection during the first trimester of pregnancy may increase the rate of spontaneous abortion.
Infection with wild-type rubella during pregnancy can lead to miscarriage or stillbirth. If rubella infection
occurs during the first trimester of pregnancy, it can result in severe congenital defects, Congenital
Rubella Syndrome (CRS). Congenital rubella syndrome in the infant includes but is not limited to eye
manifestations (cataracts, glaucoma, retinitis), congenital heart defects, hearing loss, microcephaly, and
intellectual disabilities. M-M-R II vaccine contains live attenuated measles, mumps and rubella viruses. It
is not known whether M-M-R II vaccine can cause fetal harm when administered to pregnant woman.
There are no adequate and well-controlled studies of M-M-R II vaccine administration to pregnant
women.
5
All pregnancies have a risk of birth defect, loss or other adverse outcomes. In the US general
population, the estimated background risk of major birth defects and miscarriage in clinically recognized
pregnancies is 2% to 4% and 15% to 20%, respectively.
Available data suggest the rates of major birth defects and miscarriage in women who received
M-M-R II vaccine within 30 days prior to pregnancy or during pregnancy are consistent with estimated
background rates (see Data).
Data
Human Data
A cumulative assessment of post-marketing reports for M-M-R II vaccine from licensure 01 April 1978
through 31 December 2018, identified 796 reports of inadvertent administration of M-M-R II vaccine
occurring 30 days before or at any time during pregnancy with known pregnancy outcomes. Of the
prospectively followed pregnancies for whom the timing of M-M-R II vaccination was known, 425 women
received M-M-R II vaccine during the 30 days prior to conception through the second trimester. The
outcomes for these 425 prospectively followed pregnancies included 16 infants with major birth defects, 4
cases of fetal death and 50 cases of miscarriage. No abnormalities compatible with congenital rubella
syndrome have been identified in patients who received M-M-R II vaccine. Rubella vaccine viruses can
cross the placenta, leading to asymptomatic infection of the fetus. Mumps vaccine virus has also been
shown to infect the placenta {14}, but there is no evidence that it causes congenital malformations or
disease in the fetus or infant .
The CDC established the Vaccine in Pregnancy registry (1971-1989) of women who had received
rubella vaccines within 3 months before or after conception. Data on 1221 inadvertently vaccinated
pregnant women demonstrated no evidence of an increase in fetal abnormalities or cases of Congenital
Rubella Syndrome (CRS) in the enrolled women {15}.
8.2 Lactation
Risk Summary
It is not known whether measles or mumps vaccine virus is secreted in human milk. Studies have
shown that lactatingpostpartum women vaccinated with live attenuated rubella vaccine may secrete the
virus in breast milk and transmit it to breast-fed infants.{16,17} In the breast-fed infants with serological
evidence of rubella virus vaccine strain antibodies, none exhibited severe disease; however, one
exhibited mild clinical illness typical of acquired rubella.{18,19}
The developmental and health benefits of breastfeeding should be considered along with the mother’s
clinical need for M-M-R II, and any potential adverse effects on the breastfed child from M-M-R II or from
the underlying maternal condition. For preventive vaccines, the underlying maternal condition is
susceptibility to disease prevented by the vaccine.
8.4 Pediatric Use
M-M-R II vaccine is not approved for individuals less than 12 months of age. Safety and effectiveness
of measles vaccine in infants below the age of 6 months have not been established [see Clinical Studies
(14)]. Safety and effectiveness of mumps and rubella vaccine in infants less than 12 months of age have
not been established.
8.5 Geriatric Use
Clinical studies of M-M-R II did not include sufficient numbers of seronegative subjects aged 65 and
over to determine whether they respond differently from younger subjects.
11 Description
M-M-R II vaccine is a sterile lyophilized preparation of (1) Measles Virus Vaccine Live, an attenuated
line of measles virus, derived from Enders' attenuated Edmonston strain and propagated in chick embryo
cell culture; (2) Mumps Virus Vaccine Live, the Jeryl Lynn™ (B level) strain of mumps virus propagated in
chick embryo cell culture; and (3) Rubella Virus Vaccine Live, the Wistar RA 27/3 strain of live attenuated
rubella virus propagated in WI-38 human diploid lung fibroblasts. {20,21} The cells, virus pools,
recombinant human serum albumin and fetal bovine serum used in manufacturing are tested and
determined to be free of adventitious agents.
After reconstitution, each 0.5 mL dose contains not less than 3.0 log10 TCID50 (tissue culture infectious
doses) of measles virus; 4.1 log10 TCID50 of mumps virus; and 3.0 log10 TCID50 of rubella virus.
Each dose is calculated to contain sorbitol (14.5 mg), sucrose(1.9 mg), hydrolyzed gelatin (14.5 mg),
recombinant human albumin (≤0.3 mg), fetal bovine serum (<1 ppm), approximately 25 mcg of neomycin
and other buffer and media ingredients. The product contains no preservative.
6
12 CLINICAL PHARMACOLOGY
12.1 Mechanism of Action
M-M-R II vaccination induces antibodies to measles, mumps, and rubella associated with protection
which can be measured by neutralization assays, hemagglutination-inhibition (HI) assays, or enzyme
linked immunosorbent assay (ELISA) tests. Results from efficacy studies or effectivenes s studies that
were previously conducted for the component vaccines of M-M-R II were used to define levels of serum
antibodies that correlated with protection against measles, mumps, and rubella [see Clinical Studies (14)].
12.6 Persistence of Antibody Responses After Vaccination
Neutralizing and ELISA antibodies to measles, mumps, and rubella viruses are still detectable in 95-
100%, 74-91%, and 90-100% of individuals respectively, 11 to 13 years after primary vaccination. {22-28}
13 NONCLINICAL TOXICOLOGY
13.1 Carcinogenesis, Mutagenesis, Impairment of Fertility
M-M-R II vaccine has not been evaluated for carcinogenic or mutagenic potential or impairment of
fertility.
14 CLINICAL STUDIES
14.1 Clinical Efficacy
Efficacy of measles, mumps, and rubella vaccines was established in a series of double-blind
controlled trials. {29-34} These studies also established that seroconversion in response to vaccination
against measles, mumps and rubella paralleled protection. {35-38}
14.2 Immunogenicity
Clinical studies enrolling 284 triple seronegative children, 11 months to 7 years of age, demonstrated
that M-M-R II vaccine is immunogenic. In these studies, a single injection of the vaccine induced measles
HI antibodies in 95%, mumps neutralizing antibodies in 96%, and rubella HI antibodies in 99% of
susceptible individuals.
A study of 6-month-old and 15-month-old infants born to mothers vaccinated with a measles vaccine in
childhood, demonstrated that, following infant and toddler vaccination with Measles Virus Vaccine, Live
(previously US-licensed, manufactured by Merck), 74% of the 6-month-old infants developed detectable
neutralizing antibody titers while 100% of the 15-month-old infants vaccinated with Measles Virus
Vaccine, Live or M-M-R II vaccine developed neutralizing antibodies {39}. When the 6-month-old infants
of immunized mothers were revaccinated at 15 months with M-M-R II vaccine, they developed antibody
titers similar to those of toddlers who were vaccinated previously at 15-months of age.
15 REFERENCES
1. General Recommendations on Immunization, Recommendations of the Advisory Committee on Immunization Practices, MMWR
43(RR-1): 1-38, January 28, 1994.
2. Measles, Mumps, and Rubella — Vaccine Use and Strategies for Elimination of Measles, Rubella, a n d Co n g e nita l Ru b e lla
Syndrome and Control of Mumps: Recommendations of the Advisory Committee on Immunization Practice s (ACIP), M M WR
47(RR-8): May 22, 1998.
3. Kelso, J.M.; Jones, R.T.; Yunginger, J.W.: Anaphylaxis to measles, mumps, and rubella vaccine mediated by IgE to gel atin , J.
Allergy Clin. Immunol. 91: 867-872, 1993.
4. Bitnum, A.; et al: Measles Inclusion Body Encephalitis Caused by the Vaccine Strain of Measles Virus. Cl i n . In fect. Di s. 2 9 :
855-861, 1999.
5. Angel, J.B.; et al: Vaccine Associated Measles Pneumonitis in an Adult with AIDS. Annals of Internal Medicine, 129: 1 0 4 -1 06 ,
1998.
6. Cecinati V, et al. Vaccine administration and the development of immune thrombocyto pe ni c p urp u ra i n ch i ld re n. Hu m an
Vaccines & Immunotherapeutics 9:5, 2013.
7. Mantadakis E, Farmaki E, Buchanan GR. Thrombocytopenic Purpura after Measles-Mumps-Rubella Vaccination: A Systematic
Review of the Literature and Guidance for Management. J Ped 156(4): 2010.
8. Andrews N, Stowe J, Miller E, Svanstrom H, Johansen K, Bonhoeffer J, et al. A collaborative approach to investigating th e ri sk
of thrombocytopenic purpura after measles-mumps-rubella vaccination in England and Denmark. Vaccine. 2012;30:3042‐6.
9. Rubella Prevention: Recommendation of the Immunization Practices Advisory Committee (ACIP), MM WR 3 9 (RR-1 5 ): 1 -1 8 ,
November 23, 1990.
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10. Peter, G.; et al (eds): Report of the Committee on Infectious Diseases, Twenty-fourth Edition, American Academy of Pediatri cs,
344-357, 1997.
11. Measles Prevention: Recommendations of the Immunization Practices Advisory Committee (ACIP), MMWR 38(S-9): 5-22,
December 29, 1989.
12. Eberhart-Phillips, J.E.; et al: Measles in pregnancy: a descriptive study of 58 cases. Obstetrics and Gynecology, 82(5): 797-801,
November 1993.
13. Jespersen, C.S.; et al: Measles as a cause of fetal defects: A retrospective study of ten measles epidemics in Greenland. Acta
Paediatr Scand. 66: 367-372, May 1977.
14. Yamauchi T, Wilson C, Geme JW Jr. Transmission of live, attenuated mumps virus to the hu m a n p l ace n ta . N En g l J M e d .
1974;290(13):710‐712.
15. Rubella Vaccination during Pregnancy —United States, 1971-1988. JAMA. 1989;261(23):3374–3383.
16. Losonsky, G.A.; Fishaut, J.M.; Strussenber, J.; Ogra, P.L.: Effect of immunization against rubella on lactation products. II.
Maternal-neonatal interactions, J. Infect. Dis. 145: 661-666,1982.
17. Losonsky, G.A.; Fishaut, J.M.; Strussenber, J.; Ogra, P.L.: Effect of immunization against rubella on lactation products. I.
Development and characterization of specific immunologic reactivity in breast milk, J. Infect. Dis. 145: 654-660, 1982.
18. Landes, R.D.; Bass, J.W.; Millunchick, E.W.; Oetgen, W.J.: Neonatal rubella following postpartum maternal i mm un izatio n , J.
Pediatr. 97: 465-467, 1980.
19. Lerman, S.J.: Neonatal rubella following postpartum maternal immunization, J. Pediatr. 98: 668, 1981. (Letter)
20. Plotkin, S.A.; Cornfeld, D.; Ingalls, T.H.: Studiesof immunization with living rubella virus: Trialsin children with a strain culture d
from an aborted fetus, Am. J. Dis. Child. 110: 381-389, 1965.
21. Plotkin, S.A.; Farquhar, J.; Katz, M.; Ingalls, T.H.: A new attenuated rubella virus grown in human fi bro b la sts: Evi d e n ce fo r
reduced nasopharyngeal excretion, Am. J. Epidemiol. 86: 468-477, 1967.
22. Weibel, R.E.; Carlson, A.J.; Villarejos, V.M.; Buynak, E.B.; McLean, A.A.; Hilleman, M.R.: Clinical and Labo ra tory Stu d ie s o f
Combined Live Measles, Mumps, and Rubella Vaccines Using the RA 27/3 Rubella Virus, Proc. So c. Exp . Bi ol. M e d. 1 6 5 :
323-326, 1980.
23. Watson, J.C.; Pearson, J.S.; Erdman, D.D.; et al: An Evaluation of Measles RevaccinationAmong School-Entry Age Ch i ld re n,
31st Interscience Conference on Antimicrobial Agents and Chemotherapy, Abstract #268, 143, 1991.
24. Unpublished data from the files of Merck Research Laboratories.
25. Davidkin, I.; Jokinen, S.; Broman, M. et al.: Persistence of Measles, Mumps, and Rubella Antibodies in a n M M R -Va ccina ted
Cohort: A 20-Year Follow-up, JID 197:950–6, April 2008.
26. LeBaron, W.; Beeler J.; Sullivan, B.; et al.: Persistence of Measles Antibodies After 2 Doses of Measles Vaccine in a
Postelimination Environment, Arch Pediatr Adolesc Med. 161:294-301, March 2007.
27. LeBaron, C.; Forghani, B.; Beck, C. et al.: Persistence of Mumps Antibodies after 2 Doses of Measles-Mumps-Rubella Vaccine,
JID 199:552– 60 , February 2009.
28. LeBaron, W.; Forghani, B.; Matter, L. et al.: Persistence of Rubella Antibodies after 2 Doses of Measles-Mumps-Rubella
Vaccine, JID 200:888–99, September 2009.
29. Hilleman, M.R.; Buynak, E.B.; Weibel, R.E.; et al: Development and Evaluation of the Moraten MeaslesVirusVa cci n e , JAM A
206(3): 587-590, 1968.
30. Weibel, R.E.; Stokes, J.; Buynak, E.B.; et al: Live, Attenuated Mumps Virus Vaccine 3. Clinical and Serologic Aspects in a Fiel d
Evaluation,N. Engl. J. Med. 276: 245-251, 1967.
31. Hilleman, M.R.; Weibel, R.E.; Buynak, E.B.; et al:Live, Attenuated Mumps VirusVaccine 4. ProtectiveEfficacy as Measure d i n
a Field Evaluation, N. Engl. J. Med. 276: 252-258, 1967.
32. Cutts, F.T.; Henderson, R.H.; Clements, C.J.; et al: Principles of measles control, Bull WHO 69(1): 1-7, 1991.
33. Weibel, R.E.; Buynak, E.B.; Stokes, J.; et al: Evaluation Of Live Attenuated Mumps Virus Vaccine, Strain Jeryl Lynn, First
International Conference on VaccinesAgainst Viral and Rickettsial Diseases of Man, World Health Organization, No. 147, M a y
1967.
34. Leibhaber, H.; Ingalls, T.H.; LeBouvier, G.L.; et al: Vaccination With RA 27/3 Rubella Vaccine, Am. J. Dis. Child. 123: 133-1 3 6,
February 1972.
35. Rosen, L.: Hemagglutination and Hemagglutination-Inhibition with Measles Virus, Virology 13: 139-141, January 1961.
36. Brown, G.C.; et al: Fluorescent-Antibody Marker for Vaccine-Induced Rubella Antibodies, Infection and Immunity 2(4): 360-363,
1970.
8
37. Buynak, E.B.; et al: Live Attenuated Mumps Virus Vaccine 1. Vaccine Development, Proceedings of the Society for
Experimental Biology and Medicine, 123: 768-775, 1966.
38. Hilleman M.R., Studies of Live Attenuated Measles Virus Vaccine in Man: II. Appraisal of Efficacy. Amer. J. o f Pu b l ic He a lth ,
52(2):44-56, 1962.
39. Johnson, C.E.; et al: Measles Vaccine Immunogenicity in 6- Versus 15-Month-Old Infants Born to Mothers in the Measles
Vaccine Era, Pediatrics, 93(6): 939-943, 1994.
16 HOW SUPPLIED/STORAGE AND HANDLING
No. 4681 ⎯ M-M-R II vaccine is supplied as follows:
(1) a box of 10 single-dose vials of lyophilized vaccine (package A), NDC 0006-4681-00
(2) a box of 10 vials of diluent (package B)
Exposure to light may inactivate the vaccine viruses.
Before reconstitution, refrigerate the lyophilized vaccine at 36°F to 46°F, (2°C to 8°C).
Store accompanying diluent in the refrigerator with the lyophilized vaccine or separately at room
temperature (68° to 77°F, 20° to 25°C). Do not freeze the diluent.
Administer M-M-R II vaccine as soon as possible after reconstitution. If not administered immediately,
reconstituted vaccine may be stored between 36°F to 46°F (2°C to 8°C), protected from light, for up to 8
hours. Discard reconstituted vaccine if it is not used within 8 hours.
For information regarding the product or questions regarding storage conditions, call 1-800-
MERCK-90 (1-800-637-2590).
17 PATIENT COUNSELING INFORMATION
Advise the patient to read the FDA-approved patient labeling (Patient Package Insert).
Discuss the following with the patient:
• Provide the required vaccine information to the patient, parent, or guardian.
• Inform the patient, parent, or guardian of the benefits and risks associated with vaccination.
• Question the patient, parent, or guardian about reactions to a previous dose of M-M-R II vaccine
or other measles-, mumps-, or rubella-containing vaccines.
• Question females of reproductive potential regarding the possibility of pregnancy. Inform female
patients to avoid pregnancy for 1 month following vaccination [see Contraindications (4.5) and
Use in Specific Populations (8.1)].
• Inform the patient, parent, or guardian that vaccination with M-M-R II may not offer 100%
protection from measles, mumps, and rubella infection.
• Instruct patients, parents, or guardians to report any adverse reactions to their health-care
provider. The U.S. Department of Health and Human Services has established a Vaccine
Adverse Event Reporting System (VAERS) to accept all reports of suspected adverse events
after the administration of any vaccine, including but not limited to the reporting of events required
by the National Childhood Vaccine Injury Act of 1986. For information or a copy of the vaccine
reporting form, call the VAERS toll-free number at 1-800-822-7967, or report online at
https://www.vaers.hhs.gov.
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