text:
Airway Management in Intensive Care Medicine
Filed under Anesthesiology
Chapter 46 Airway Management in Intensive Care Medicine
Kurt Ruetzler, Peter Krafft, Michael Frass
II. Noninvasive Airway Management
A. Indications and Contraindications of Noninvasive Ventilation
1. Acute Respiratory Failure
2. Weaning Strategy
3. Difficult Airway Management
4. Contraindications
B. Different Types of Noninvasive Devices
1. Noninvasive Positive-Pressure Ventilation via Face Mask
2. Noninvasive Positive-Pressure Ventilation via Helmet
III. Endotracheal Intubation in Intensive Care
A. Prelaryngoscopy Airway Assessment
B. Oral vs. Nasal Endotracheal Intubation
C. Choosing the Correct ETT Size
D. Drugs Used for Sedation and Analgesia
E. Awake Endotracheal Intubation
F. Assessment of Correct ETT Placement
IV. Difficult Airway Management in Intensive Care
A. Esophageal-Tracheal Combitube
B. Laryngeal Mask Airway
C. Transtracheal Jet Ventilation
D. Emergency Surgical Airway
1. Percutaneous Cricothyrotomy
2. Surgical Cricothyrotomy
V. Complications of Translaryngeal Intubation
VI. Airway Management for Prolonged Mechanical Ventilation (Tracheostomy)
A. Reasons for Performing Tracheostomy
B. Timing of Tracheostomy
C. Tracheostomy Techniques
1. Conventional Surgical Tracheostomy
2. Percutaneous Dilatational Tracheostomy Techniques
D. Airway Management During Tracheostomy
E. Perioperative and Early Complications of Tracheostomy
F. Late Complications of Tracheostomy
G. Conventional (Surgical) vs. Percutaneous Tracheostomy
VII. Routine Airway Care in Mechanically Ventilated Patients
VIII. Difficult Extubation in Critically Ill Patients
IX. Conclusions
X. Clinical Pearls
A major responsibility of the anesthesiologist or critical care physician is the maintenance of adequate ventilation and pulmonary gas exchange in critically ill patients. In the operating room (OR) the incidence of airway catastrophes resulting in emergency tracheostomy, brain damage, or death ranges from 0.01 to 2 cases per 10,000 procedures. Emergency airway management is often even more challenging in the intensive care unit (ICU) setting. The increasing demand for critical care medicine makes it necessary to focus on specific airway problems encountered in ICU patients.
Major differences exist between airway management in a controlled setting such as the OR and airway management in the ICU. Difficult laryngoscopy and endotracheal intubation is often successful after multiple attempts in the OR because of adequate patient preparation and positioning. To the contrary, endotracheal intubation of the "crashing" critically ill patient with poor cardiopulmonary reserve in a relatively uncontrolled environment requires a different approach to prevent serious problems.
This chapter briefly describes noninvasive and "invasive" airway management with special respect on the recommendations of the American Society of Anesthesiologists Task Force on Management of the Difficult Airway (ASA algorithm) first presented in 1991.1 The basic principles of the ASA algorithm are meticulous patient evaluation before sedation or anesthesia induction, awake intubation if problems are suspected, and preparation of an alternative approach in case of failure.
Those recommendations are at least in part valuable for the management of ICU patients as well. Unfortunately, the ASA algorithm has a number of characteristics that prevent direct application to the ICU situation. Airway management in ICU patients is usually urgent or emergent, often depriving the physician of the time necessary to evaluate the patients and plan the life-saving intervention. The patient is presumed to have a full stomach and must therefore undergo awake airway management or rapid-sequence induction. The option of reemergence from anesthesia to resume spontaneous ventilation if difficulty is encountered is mostly unfeasible. However, at least part of the algorithm is of major importance for ICU airway management and is therefore presented in detail.
Intensive care unit airway management is complex; this chapter focuses on the most important topics to provide the reader with the information required for daily ICU practice. The chapter begins with a brief overview over noninvasive airway management (including continuous positive airway pressure via mask or helmet) and proceeds with prelaryngoscopic airway assessment. This special aspect is extensively addressed because many airway catastrophes can be prevented only by adequate evaluation and preparation of the patient before the administration of sedatives. The gold standard techniques for the performance of direct laryngoscopy and oral or nasal endotracheal intubation are then presented. Alternative methods to direct laryngoscopy (especially awake endotracheal intubation!) are discussed and the control of patients' airways in emergency situations is presented: One of four emergency techniques must be chosen immediately—laryngeal mask airway, esophageal-tracheal Combitube, transtracheal jet ventilation, or surgical airway—to prevent cerebral hypoxia. For planned as well as emergency ICU airway management, the alternative methods or techniques must be readily available before sedation and must be practiced in routine cases.
Long-term translaryngeal intubation might result in serious laryngeal damage, including ulcer formation or tracheal stenosis. Therefore, indication, timing, and recent techniques of tracheostomy are discussed, with advantages and drawbacks. Airway management in ICU patients is a matter of ongoing research and discussion. For example, the percentage of patients undergoing tracheostomy and the timing of tracheostomy underwent dramatic changes after the introduction of percutaneous dilatational tracheostomy (PDT) in the 1980s. Regardless of the technique used, PDT can quickly be performed at bedside, has a relatively low incidence of complications in trained hands, and is cost-effective, with excellent cosmetic results. After presenting routine airway care maneuvers (e.g., tracheal suctioning), this chapter closes with an often-overlooked problem in ICU airway management, difficult extubation, often encountered in patients after ear-nose-throat (ENT) procedures or other causes of pharyngeal-laryngeal swelling or distortion. Close interaction is needed with the attending ENT specialist, with coping strategies to prevent catastrophes during extubation. Special topics of ICU airway management are also detailed in other chapters (see Contents and Index).
II Noninvasive Airway Management
Invasive ventilation using an endotracheal tube (ETT) was once the gold standard for ventilatory support of critically ill patients. However, longer duration of invasive ventilation increases the risk of complications such as ventilator-associated pneumonia (VAP).2 Noninvasive ventilation (NIV) preserves the patient's ability to speak and cough and has been shown to reduce complications related to intubation, especially VAP.3–5 For this reason, use of NIV has become widely accepted, especially in patients with chronic obstructive pulmonary disease (COPD) and patients with cardiac failure, since weaning from respirator and ETT may become extremely difficult. In selected patients with respiratory failure, noninvasive positive pressure ventilation helps to reduce an increased respiratory rate, augments tidal volumes and reduces work of breathing.6,7 Therefore, NIV is a promising approach to ventilatory support of ICU patients and might become even more important as a "weaning as well as a therapeutic procedure" in the near future.
A Indications and Contraindications of Noninvasive Ventilation
Basically, NIV is applied in three different areas: in acute respiratory failure, as a weaning strategy, and in the management of the difficult airway.
1 Acute Respiratory Failure
Over the past decade, noninvasive positive-pressure ventilation (NPPV) has increased in popularity in the patient with acute exacerbations of COPD. In these patients, based on evidence derived from multiple randomized trials, NIV should be considered as first-line therapy.8–12
In a systematic review, Keenan and colleagues13 assessed the effect of NPPV on rate of endotracheal intubation, length of hospital stay, and in-hospital mortality in patients with an acute exacerbation of COPD. The addition of NPPV to standard care in patients with COPD exacerbation decreased the rate of endotracheal intubation (risk reduction [RR], 28%; 95% confidence interval [CI], 15%-40%), length of hospital stay (absolute reduction, 4.57 days; CI, 2.30-6.83 days), and in-hospital mortality rate (RR, 10%; CI, 5%-15%). However, subgroup analysis showed that these beneficial effects occurred only in patients with severe exacerbations, not in those with milder exacerbations of COPD.
A similar approach was used by the Cochrane Database group, presenting a systematic review on the effectiveness of NPPV in management of acute COPD exacerbations.14 Only randomized controlled trials (RCTs) were selected by two independent reviewers. NPPV not only decreased mortality (RR 0.41; 95% CI 0.26, 0.64), but also decreased the need for intubation (RR 0.42; CI 0.31, 0.59) and treatment failures (RR 0.51; CI 0.39, 0.67). In addition, complications associated with treatment (RR 0.32; CI 0.18, 0.56) and length of hospital stay (−3.24 days; CI −4.42, −2.06) were also reduced in the NPPV group. The reviewers concluded that NPPV should be used as the first-line intervention in all patients with respiratory failure secondary to an acute exacerbation of COPD. NPPV should be considered early in the course of respiratory failure, to avoid endotracheal intubation, reduce mortality, and avoid treatment failure.
Carlucci and associates15 evaluated the changes in the practice of NIV for the treatment of COPD patients between 1992 and 1999. In this special patients' collective, the failure rate of NPPV was constant over the years (17%). Although the severity of acute respiratory failure (ARF) episodes increased (defined by pH and APACHE II at admission), the risk of failure for a patient with pH less than 7.25 was threefold lower in the period 1997-99 compared with 1992-96. Furthermore, a significantly higher percentage of patients (pH >7.28) were treated at the normal ward and not in the ICU, which allowed a significant cost reduction.
Based on strong evidence (level 1), recent clinical studies support the use of NIV to treat ARF related to COPD exacerbations, treat cardiogenic pulmonary edema, and facilitate weaning and extubation in patients with COPD and immunosuppressed patients.8,16 The future will show whether this trend away from "invasive" toward noninvasive ventilatory support in routine patient care will be sustained.
2 Weaning Strategy
Weaning from the ventilator is difficult in up to 20% of all patients. Already the consequent use of standardized weaning strategies (regardless of their content) has increased the success rates after extubation. In this context, Udwadia and coauthors17 described the use of NIV as a weaning strategy first in 1992. In 2003, Burns and coworkers18 performed the first meta-analysis of NIV as a weaning strategy, including five clinical trials and 171 patients. NIV showed significant benefit for duration of in-hospital-stay, total duration of ventilation, reduced mortality, and lower VAP rate compared with conventional weaning using endotracheal intubation. In a 2010 systematic review that included 12 randomized and quasi-randomized studies, Burns and others19 compared NIV and invasive weaning strategy in 530 COPD patients.19 This meta-analysis showed that NIV weaning in COPD patients is associated with decreased mortality, decreased incidence of VAP, reduced length of stay in ICU and hospital, and decreased total duration of ventilation and duration of endotracheal intubation.
Current studies on NIV weaning, predominantly focused on COPD patients, propose a potential reduction in mortality and VAP.20 In fact, further clinical research is necessary to clarify potential benefits of NIV as weaning strategy versus conventional weaning via ETTs or cannulas.
3 Difficult Airway Management
Critically ill patients are characterized by limited physiologic reserves, possibly resulting in catastrophic complications during airway management, including cardiac arrest. After a systematic review of airway management in critically ill patients in 2007, Walz and colleagues21 proposed adaptations to the ASA Difficult Airway Algorithm. In this algorithm, NIV serves as a valuable adjunct to conventional invasive airway management.
Absolute contraindications to NIV include respiratory arrest and the inability to tightly fit the face mask. The physician must consider potential clinical benefits as well as potential drawbacks for the following relative contraindications:
• Hemodynamic instability or uncontrollable dysrhythmias
• Any type of coma
• Mentally confused, agitated, or uncooperative patient
• Swallowing impairment or excessive secretions
• Increased risk of pulmonary aspiration
• Injuries or upper airway surgery
B Different Types of Noninvasive Devices
Various types of face masks and helmets are widely used for administering NIV (Fig. 46-1).
Figure 46-1 A, Full face mask; B, total face mask; C, nasal mask; D, mouthpiece; E, nasal pillows; F, helmet.
(From Nava S, Hill N: Noninvasive ventilation in acute respiratory failure. Lancet 374:250–259, 2009.)
1 Noninvasive Positive-Pressure Ventilation via Face Mask
Noninvasive PPV can be administered by face masks covering the mouth and nose (and eyes) or by nasal masks covering only the nose. Either technique includes a mask that is pressed against the patient's face using an elastic band (e.g., Classen band). The patient may now be supported by either continuous positive airway pressure (CPAP), pressure support ventilation (PSV), or volume-cycled or pressure-cycled systems, such as bi-level positive airway pressure (BiPAP). However, dyspneic ARF patients tend to breathe through their mouth, causing air leaking and reducing the efficacy of nasal NPPV. Face masks are preferable in these patients, and application seems to be easy. However, the pressure of the face mask against the face, especially the root of the nose, causes significant discomfort and skin lesions, and several patients refused prolonged application.22,23 Further disadvantages are potential gastric inflation followed by vomiting (risk of aspiration), claustrophobia, and difficult speaking.16
2 Noninvasive Positive-Pressure Ventilation via Helmet
The helmet consists of a cylindrical transparent part that is drawn over the patient's head (e.g., CaStar, Starmed, Italy). While the helmet is closed, the lower part contains an elastic ring to ensure a tight seal at the patient's neck (Fig. 46-2). Two openings with sideways fittings to ventilatory tubing allow supportive ventilation such as continuous flow or pressure support. The helmet is a noninvasive means of ventilation; the patient has a free view through the transparent helmet and can even wear glasses, with no fogging from the circulating air. A new model of the Castar helmet includes an additional round opening with a diameter of about 10 cm for nursing the patient's face. This helmet was used as first-line intervention to treat patients with hypoxemic ARF, compared with NPPV via standard face mask.24 Thirty-three consecutive patients without COPD and with hypoxemic ARF (defined as severe dyspnea at rest, respiratory rate >30 breaths/min, PaO2/FIO2 <200, and active contraction of the accessory muscles of respiration) were enrolled. The 33 patients and the 66 controls had similar characteristics at baseline. Eight patients (24%) in the helmet group and 21 patients (32%) in the facial mask group (P = .3) failed NPPV and were intubated. No patients failed NPPV because of intolerance of the technique in the helmet group, versus eight patients (38%) in the mask group (P = .047). Complications related to the technique (skin necrosis, gastric distention, eye irritation) were fewer in the helmet group compared with the mask group (no patients vs. 14 patients (21%), P = .002). The helmet allowed continuous application of NPPV for a longer period (P = .05). NPPV by helmet successfully treated hypoxemic ARF, with better tolerance and fewer complications than face mask NPPV.
Figure 46-2 Application of Castar helmet in healthy volunteer.
In another prospective clinical investigation in a general ICU, the feasibility and safety of fiberoptic bronchoscopy (FOB) with bronchoalveolar lavage (BAL) was tested during NPPV delivered by helmet in patients with ARF and suspected pneumonia.25 Four adult patients with ARF underwent NPPV via the helmet and required fiberoptic BAL for suspected pneumonia. NPPV was delivered through the helmet in the pressure support ventilation mode. The specific seal connector placed in the plastic ring of the helmet allowed the passage of the bronchoscope, maintaining assisted ventilation. Arterial blood gas levels, pH, oxygen saturation, respiratory rate, heart rate, and mean arterial blood pressure (BP) were monitored during the study. Helmet NPPV avoided gas exchange deterioration during FOB and BAL, with good tolerance. During the procedure, heart rate increased by 5% and mean arterial BP by 7% over baseline; these levels returned to prebronchoscopy values immediately after the withdrawal of the bronchoscope. Endotracheal intubation was never required during the 24 hours after the procedure. BAL yielded diagnostic information in three of four patients. NPPV through the helmet allows a safe diagnostic FOB with BAL in patients with hypoxemic ARF, avoiding gas exchange deterioration, and endotracheal intubation.
Several special aspects of the helmet, such as the effects of direct exposure of external and middle ear to positive airway pressure, remain to be determined. Cavaliere and others26 recommended earplugs in select NPPV patients treated with the helmet, especially during long-term support at high airway pressures. NPPV has become an integral part of daily ICU care for many patients with acute and chronic respiratory failure. However, the potential effectiveness of NPPV varies among different patient populations. The greatest benefit is seen in patients with pure hypercapnic respiratory failure, as seen in COPD patients. The more severe hypoxemia becomes, the less beneficial the effects observed. Clearly, further studies are necessary to identify patients with hypoxemic ARF who might benefit from NPPV.27
The Rüsch 4Vent (Kernen, Germany) allows unrestricted field of view and minimum level of noise. Tubing and accessories are connected to the rigid ring of the 4Vent. Diffusers prevent the stream of gas from blowing directly into the patient's face. Filters reduce the noise inside the helmet. Similar to the Castar helmet, the patient is able to speak and take liquid food and drinks. The supple material allows the helmet also to be worn lying down (Fig. 46-3).
Figure 46-3 Rüsch 4Vent helmet.
(Courtesy of Rüsch, Vienna, Austria.)
Advantages of NPPV include few air leaks, minimal cooperation required, and absence of nasal or facial skin damage. Disadvantages include rebreathing, gastric inflation followed by vomiting, dry eyes, noise, and asynchrony with pressure support ventilation, as well as shoulder discomfort induced by the straps.16
III Endotracheal Intubation in Intensive Care
A Prelaryngoscopy Airway Assessment
Any factor in the patient's history suggesting a difficult airway must be known before anesthesia induction, especially all diseases resulting in pharyngeal or laryngeal deformities (congenital abnormalities, surgical or traumatic deformities, laryngeal trauma, edema or tumors, goiter). As a first and rapid orientation, the simple "rule of threes" can be applied: if three fingers can be placed between the teeth, between the mandible and the hyoid bone, and between the thyroid cartilage and the sternal notch in neutral position, direct laryngoscopy should be straightforward.28 Furthermore, more or less complex tests and scoring systems have been suggested to predict a difficult airway before anesthesia induction. The most frequently used tests are the Mallampati classification, thyromental distance, mobility of the cervical spine, and combined scoring systems (e.g., Wilson test) or multivariate risk indices29–31 (Table 46-1).
TABLE 46-1 Airway Assessment
Mallampati classification is the most common diagnostic test and is based on the evaluation of the relationship of tongue size relative to pharynx size, as follows31:
Class I: uvula, faucial pillars, and soft palate visible
Class II: faucial pillars and soft palate visible
Class III: only soft palate visible
The operator should be aware that the risk of difficult airway is increased in class II and especially class III patients. In the original publication, Mallampati and colleagues31 reported excellent statistical results on the performance of the classification system. However, later investigations could not replicate these findings and report a high incidence of false-positive results.32,33
Thyromental distance (according to Patil) is defined as distance between thyroid cartilage (Adam's apple) and the mandible with the patient's head and neck maximally extended. The authors measured thyromental distance before anesthesia induction in 75 patients and reported a minimum distance of 6.5 cm being necessary for a successful laryngoscopic approach. At a thyromental distance less than 6.0 cm, direct laryngoscopy is impossible; between 6.0 and 6.5 cm, the operator should be prepared for a difficult airway. Sensitivity of this test varies according to definition of the "danger zone" (i.e., thyromental distance <7.0 or <6.5 cm) and is reported in the range of 30% to 90%. In most studies, specificity ranges between 80% and 97%.32,34 Thyromental distance is a useful diagnostic test with a relatively low intra- and inter-observer variation. However, the lacking stratification for patient height and weight makes data interpretation difficult.
Direct laryngoscopy without extension of the atlanto-occipital joint is impossible. Decreased mobility of the upper cervical spine (e.g., in patients with rheumatoid arthritis) is a major factor responsible for failed attempts of endotracheal intubation.35 Nichol and Zuck30 clearly demonstrated that a reduced atlanto-occipital distance is a major factor for a limited extension of head and neck. Assessment of cervical spine mobility is performed with the patient looking straight ahead and maximum mouth opening. The patient is now urged to flex and extend the head and neck. The angle between the extreme positions should be at least 90 degrees; otherwise, a difficult laryngoscopy must be assumed, with high specificity in the 90% range.
The range and freedom of mandibular movement and the architecture of the teeth have pivotal roles in facilitating laryngoscopic intubation, so Khan and colleagues36 proposed the upper lip bite test. Patients were grouped according to the following findings: lower incisors can bite the upper lip above the vermilion line (class I); lower incisors can bite the upper lip below the vermilion line (class II); and lower incisors cannot bite the upper lip (class III). In 300 elective patients, the authors evaluated the new test with the Mallampati classification. Negative predictive value for both test groups was similar (98%), but the positive predictive value of the lip bite test was better (29% vs. 13%). To improve positive and negative predictive values of those screening tests, several authors proposed the combination of various risk scores. In 1988, Wilson and associates29 published a screening test system, including patient weight, mobility of the cervical spine, and anatomic-physiologic parameters of the stomatognathic system (Table 46-2). According to the authors, difficult airways must be suspected with 2 or more cumulative points. This scoring system requires more extensive evaluation but results in improved statistical performance. In patients with a cumulative result of 2 points, sensitivity of 75% was observed.29 Oates and coauthors32 reported specificity of 92%.
TABLE 46-2 Wilson's Test
Body weight <90 kg 0
90-110 kg 1
>110 kg 2
Head and neck movement >90 degrees
90 degrees (±10)
<90 degrees 0
Jaw movement MMO >5 cm or LJ in front of UJ 0
MMO <5 cm and LJ = UJ 1
MMO <5 cm and LJ behind UJ 2
Receding mandible Normal
Severe 01
Buck teeth Normal 0
Moderate 1
Severe 2
MMO, Maximum mouth opening; LJ, lower jaw; UJ, upper jaw.
From Wilson ME et al: Predicting difficult intubation. Br J Anaesth 61:211–216, 1988.
El-Ganzouri and associates37 proposed a multivariate risk index, similar to the Wilson test. The authors recommended the following approach:
• Airway score (AS) of 0: proceed with routine management, no difficulties are expected.
• AS of 1 to 2 points: proceed with routine management, check fiberoptic availability, and prepare a special plan B.
• AS of 3 to 4 points: have the fiberoptic scope on standby at bedside, and call for help; prepare for asleep or awake fiberoptic intubation.
• AS greater than 5 points: perform awake intubation (most practitioners prefer awake fiberoptic intubation).
Statistical results demonstrate a relatively weak performance in clinical routine. Even combinations of tests or scoring systems combining several risk factors are prone to misjudgment for the individual patient.34 The upper airway is a complex structure and consists of many anatomically relevant variables. Also, statistical performance of these tests is still unsatisfying; the operator might be warned of trouble. Closely evaluating the patient before anesthesia induction might prevent catastrophic "cannot intubate, cannot ventilate" situations.
B Oral vs. Nasal Endotracheal Intubation
Oral intubation and especially nasal intubation are characterized by special advantages and complications, with orotracheal intubation being currently favored by most anesthesiologists. Box 46-1 lists the contraindications for nasal intubation in critically ill patients.
Box 46-1 Contraindications to Nasal Intubation
Severe coagulopathy
High-dose systemic anticoagulation
Known nasal or paranasal pathologies
Infection of paranasal sinuses
Basilar skull fractures
Traumatic brain injury with leakage
The most common complication of nasotracheal intubation is nasal bleeding, occurring in about 45% of patients.38 The incidence of bleeding can be reduced with adequate preparation (vasoconstrictors). In most cases, bleeding is self-limited, and no further intervention is needed. Other complications are necrosis of the tip or wing of the nose (up to 4% of patients) and complications induced by the impaired drainage of paranasal sinus secretions.39 Nasotracheal intubation impairs the drainage of the maxillary sinus, resulting in congestion of secretions, followed within a few days by bacterial overgrowth and sinusitis. This typical complication of intensive care occurs within 8 days in 25% to 100% of transnasally intubated patients.40,41 The incidence is closely related to the duration of endotracheal intubation, from 37% after 3 days to 100% after 1 week, with the majority resolving within 1 week after extubation.42 Therefore, in all ICU patients presenting with fever of unknown origin, a high index of suspicion for sinusitis must be maintained. Radiologic or ultrasound studies, including computed tomography (CT) scans, may be necessary to demonstrate the presence of fluid or inflammation. Bacterial sinus infection may ultimately lead to bacteremia and systemic inflammatory response. These infections tend to be polymicrobial, but often display a predominance of gram-negative bacilli (particularly Pseudomonas aeruginosa), Staphylococcus aureus, or fungi. Treatment includes removal of all nasal tubes and institution of appropriate antibiotic therapy, along with decongestant therapy. In some cases, surgical drainage may be necessary. Serious, but rare complications after nasotracheal intubation are accidental turbinectomy, intracranial placement, and retropharyngeal dissection.43–45
Oral intubation, on the other hand, interferes greatly with oral and pharyngeal hygiene, and even small lesions of oral soft tissues may result in extensive bacterial or viral soft tissue infections (e.g., herpetic lesions).46 Most authors agree that all complications typically seen with nasal intubation may also occur during orotracheal intubation, although at a significantly lower incidence. Therefore, oral endotracheal intubation is the preferred route of tube passage, and nasal intubation is reserved for special indications, mainly short-term ventilatory support in oral surgery. For patients requiring intubation for more than 7 days, the nasotracheal route should always be avoided.47
C Choosing the Correct ETT Size
According to literature, there is a clear association between endotracheal tube diameter and the incidence of laryngeal complications. Injury is located mainly in the posterior part of the glottis, where pressures up to 200 or 400 mm Hg are exerted by poorly deformable ETTs.48 This pressure is reduced by the use of softer ETTs with a smaller diameter. In routine anesthesia patients, use of a smaller ETT reduces the incidence of postoperative sore throat, presumably because of the decreased pressure at the ETT-mucosal interface. Stout and associates49 studied 101 patients randomized to larger (9 mm for male, 8.5 for female) or smaller (7 mm for male, 6.5 mm for female) endotracheal tubes, and the incidence of postoperative sore throat was 48% (large ETT) versus 22% (small ETT). No ventilatory difficulties were observed in either group.
The limiting factor for minimizing ETT diameter is the increased flow resistance and work of breathing. The pressure gradient required to generate gas flow can be calculated according to the Hagen-Poiseuille relationship, in which the rapidity of gas flow is directly proportional to the square of the ETT diameter (D) and the pressure (P) and indirectly to the ETT length and gas viscosity (valid only in laminar flow conditions). In other words, the pressure gradient through the airways proportionally rises with flow, viscosity, and ETT length but increases exponentially when ETT radius decreases. Viscosity of the gas administered has clinical consequences; with lower viscosity, a lower pressure gradient necessarily results in a lower airflow resistance. For example, gas mixtures with a high percentage of helium are often used to overcome upper airway obstruction (e.g., from tracheal compression or stenosis) and to treat the most severe status asthmaticus.50,51
In all patients, endotracheal intubation artificially increases airway resistance, because ETT inner diameter (ID) is smaller than tracheal diameter. Usually, ETT length exceeds length of the natural airways. Resistance is further increased by the curved design of the tubes necessary to resemble the patient's airway. Resistance measured using curved tubes is about 3% higher compared with straight tubes.52 Therefore, the pressure gradient to generate gas flow is minimized by using an ETT with a larger diameter, short length, and straight design. Flow resistance can be translated in work of breathing, which is inversely proportional to ETT diameter (Fig. 46-4). The non-elastic work of breathing is increased twofold by using 7.0 mm–ID ETT and onefold by using an 8.0 mm–ID ETT versus a 9.0 mm–ID ETT.53 With respect to gas flow, it is warranted to use as large an ETT as is practical for patients presenting with respiratory dysfunction; a short tracheal cannula with ID of 9.0 to 10 mm is best.
Figure 46-4 Driving pressure required to produce a flow rate of air versus internal diameter (ID) of endotracheal tubes.
(From Nunn JF: Applied respiratory physiology, ed 3, Boston, 1987, Butterworths.)
Clinical Implications
Using a smaller ETT seems to reduce laryngeal damage. The use of an ETT with an ID of 6.0 mm or less does not present a problem in anesthetized patients without spontaneous ventilation, because relatively low gas flow velocities are necessary to maintain adequate ventilation. However, gas flow resistance drastically increases, especially in spontaneously breathing patients in respiratory distress, who benefit from larger ETTs. Therefore, ETTs with ID of 7.0 to 8.0 mm seem appropriate for women and 8.0 to 9.0 mm for men.
An interesting aspect of ETT selection is airway management for professional singers. Powner54 sent a written survey to all physician members of the Voice Foundation on airway management in professional singers. A strong consensus (76%) favored a smaller ETT for singers (6- to 7-mm ID for males and 6.0-mm ID for females) via the oral (46%) versus nasal (36%) route. Intubation/extubation by the most expert/experienced personnel was emphasized to minimize laryngeal trauma. Preferences for an early tracheostomy (6 days) versus their usual time (10 days) were approximately equal (44% vs. 50%, respectively).
The tracheal cuff has also been implicated as a cause of tracheal damage following long-term ventilatory support. Red-rubber ETTs equipped with low–residual volume, high-pressure cuffs exert high pressures to the tracheal mucosa and are thought to be damaging.55 Using an experimental study design in rabbits, Nordin and coauthors56 investigated tracheal mucosal perfusion and cuff-to-tracheal wall pressures exerted by low–residual volume, high-pressure cuffs and compared the results to those obtained with high-volume, low-pressure cuffs. Blood flow to the tracheal mucosa adjacent to the high-pressure cuff ceased beyond 30 mm Hg. Using high-volume cuffs, mucosal blood flow did not cease up to intracuff pressures of 80 to 120 mm Hg. However, cautious recommendations were made, and cuff pressure should be maintained below 30 cm H2O.55
Conditions in ICU patients differ from routine anesthesia patients. ICU patients are mainly breathing spontaneously or on partial ventilatory support. Spontaneous breathing results in cuff pressure changes; cuff pressure decreases during inspiration and increases during expiration. Active changes in pleural pressure by forced inspiratory efforts combined with direct modulation of tracheal musculature result in marked increases of tracheal diameter and a fall in cuff pressure, even toward 0 cm H2O.
Prolonged airway support using ETT or tracheal cannula might result in severe damage to the tracheal mucosa and increased incidence of late complications. Tracheal stenosis might be induced by direct trauma or by the pressure exerted by the ETT cuff. The presence of an ETT sutured to canine tracheal mucosa induced erythematous laryngeal mucosa in less than 1 day, proceeding to mucosal ulceration and loss of airway architecture in less than 1 week.57 Damage was generally severe after 1 week, but no further tendency to aggravation after 1 week was observed.
The tracheal vascular supply to the tracheal submucosa is oriented in a circumferential direction anteriorly and longitudinally in the posterior part of the trachea. Seegobin and van Hessalt58 investigated tracheal mucosal blood flow in 40 routine surgery patients using an endoscopic photographic technique while varying cuff inflation pressure. They suggested that tracheal blood flow is almost normal at 25 cm H2O. Increasing cuff pressure results in a pale appearance of the tracheal mucosa at 40, blanched at 50, and flow is completely absent at 60 cm H2O. Thus, it was recommended that cuff inflation pressure should not exceed 30 cm H2O (22 mm Hg).
Joh and colleagues59 observed similar results, measuring tracheal mucosal blood flow in an experimental model using the hydrogen clearance method. No significant depression in mucosal blood flow was observed with the cuff inflated to a maximum of 20 mm Hg. Increasing cuff pressures to 30 or even 45 mm Hg resulted in significant reduction in mucosal blood flow, and the authors concluded that cuff pressures should be kept at or below 20 mm Hg. Incorrect cuff pressure settings may result in tracheomalacia and subglottic stenosis (too high pressures) or late-onset nosocomial pneumonia (insufficient pressures). Several authors suggested that microaspirations might thereby be facilitated and recommended the use of automatic cuff-pressure regulators.60 In a randomized study in 130 patients, Pothmann and associates61 reported a significant reduction in late-onset pneumonias by a microprocessor-controlled automatic cuff-pressure regulator. However, the few studies covering small numbers of patients means that the devices described cannot currently be recommended for routine patient care.60,62
D Drugs Used for Sedation and Analgesia
In general, less is more in conscious sedation for airway management. Drugs must be administered in dosages not interfering with protective reflexes and patient cooperation. Therefore, short-acting drugs with a potential antidote should be used.
The presumption of a "full stomach" in emergency intubations dictates the use of a rapid-sequence induction (RSI) technique. Cricoid pressure and laryngoscopy at the earliest possible moment place increased demands on the physician preparing to intubate the patient.63 The ICU patient presents with even more risk factors than the routine OR patient. With facial distortion, swelling, secretions, and mandibular or cervical spine injury, ICU patients present the most challenging airway management problems.
Stimulation of the airway with a laryngoscope and ETT presents an extremely noxious stimulus.64 This stimulation causes "pressor response" and results in hypertension and tachycardia. In critically ill patients with limited reserves for adequate tissue oxygenation, this pressor response may induce myocardial and cerebrovascular injury.65 This physiologic stress after airway management may unmask relative hypovolemia or vasodilatation and may result in post-intubation hypotension.66 Endotracheal intubation also can provoke bronchospasm and coughing, possibly aggravating underlying conditions such as asthma, intraocular hypertension, and intracranial hypertension. Patients at risk for adverse events from airway manipulation benefit from pre-induction drugs.67
We prefer the combination of low-dose midazolam (0.1 µg/kg) and an opioid such as fentanyl (2 µg/kg). Fentanyl is the most frequently used opioid because of its rapid onset and short duration of action. Fentanyl and its derivatives, sufentanil and alfentanil, can cause rigidity of chest wall, but this rigidity seems to be associated with higher doses and rapid opioid injection. Fentanyl can be antagonized rapidly using naloxone,68 whereas midazolam can be antagonized using flumazenil.
Remifentanil is a novel µ-receptor agonist that has been used in surgical and obstetric analgesia for more than a decade. Its pharmacokinetics suggests that remifentanil may be an ideal opioid. Notably, its unique features include rapid onset of action (~1 minute), rapid degradation by tissue and plasma esterases, and half-life of approximately 3 minutes.69,70 Infusion of 0.05 to 0.1 µg/kg/min produces blood concentrations of 1 to 3 ng/mL. Rapid onset and elimination of remifentanil facilitate its effective and safe use during airway management in the ICU. Several studies focused on remifentanil as a sole sedative and analgesic agent in the ICU setting. Puchner and coworkers71 prospectively studied remifentanil (0.1-0.5 µg/kg/min) alone versus fentanyl plus midazolam for fiberoptic intubation. Fiberoptic nasal intubation was possible in all patients, with a better-suppressed hemodynamic response and tolerance of ETT advance in the remifentanil group. Recall was significantly more common in the remifentanil group. A combination of remifentanil and midazolam or propofol is a valuable approach.72
Lallo and coworkers73 recently studied 60 patients requiring fiberoptic nasotracheal intubation, randomized to target-controlled infusions of propofol or remifentanil. Both agents can be rapidly titrated to achieve good intubating conditions and patient comfort. In addition, remifentanil preserves patient cooperation, making it safer when spontaneous ventilation is paramount. Yeganeh and associates74 enrolled 22 patients who had cervical trauma and semi-elective maxillofacial surgery and administered remifentanil with target-controlled or manually controlled infusion techniques. They recommended remifentanil infusion to provide good conscious sedation, but target-controlled remifentanil infusion seems to provide better conditions compared with manually controlled remifentanil infusion and is easier to use.
Alternative drugs suitable for ICU airway management and even awake fiberoptic intubation are (S+)-ketamine and propofol.75 Propofol is a rapid-acting, lipid-soluble induction drug that induces hypnosis in a single arm-brain circulation time. In patients with cardiac comorbidities and limited physiologic reserve, the use of propofol can be associated with significant hypotension. Causes of hypotension are reduced systemic vascular resistance and possibly depressed inotropy.76 In an analysis of 4096 patients undergoing general anesthesia, Reich and associates77 reported that the use of propofol was a statistically significant predictor of hypotension. Furthermore, in 2406 patients with retrievable outcome data, prolonged in-hospital stay and death were more common in those who experienced hypotension.77 Therefore, use of propofol may have special risks in high-risk patients with known cardiac dysfunction.78
Ketamine is a rapid-acting, dissociative anesthetic agent (similar to phencyclidine) with potent amnestic, analgesic, and sympathomimetic effects.67 Ketamine can cause realistic hallucinations and extreme emotional distress. This may be prevented with the obligatory combination of a benzodiazepine. The sympathomimetic effects of ketamine may produce cardiac ischemia by increasing cardiac output. Consequently, use of ketamine should be avoided in patients with cardiac dysfunction. Leykin and others79 found that the administration of ketamine resulted in excellent intubation conditions in patients undergoing elective surgery compared with sodium pentothal. In a prospective, randomized clinical trial, Ledowski and Wulf80 reported that the combination of ketamine with rocuronium and etomidate resulted in superior intubation conditions. This combination may be useful in treating hemodynamically unstable patients in the ICU setting, when succinylcholine is contraindicated.21 The use of ketamine in patients with increased intracranial pressure is only recommended in mechanically ventilated patients.81 Ketamine is associated with realistic and truthful nightmares. In this context, the combination with midazolam seems to be an obligatory recommendation. Currently, an S(+) enantiomer of ketamine is available. This enantiomer seems to be free of these clinically relevant side effects although use of these S(+) enantiomers is still recommended in combination with midazolam.
Etomidate provides good intubation conditions with only moderate hemodynamic depression in patients undergoing RSI.82 Etomidate inhibits adrenosteroid production through the inhibition of mitochondrial hydroxylase, after continuous or even single administration.83–85 Cuthbergson and colleagues86 recruited 500 patients to a multicenter, randomized, double-blind, placebo-controlled trial. The use of bolus etomidate was associated with an increased incidence of inadequate response to corticotrophin and is likely associated with an increase in mortality. Therefore, the authors recommend extreme caution in the use of etomidate in critically ill patients with septic shock.86 Roberts and Redman87 and Bloomfield and Noble88,89 also questioned any use of etomidate in critically ill patients.
Dexmedetomidine is increasingly used as a sedative for monitored anesthesia. Advantages include its analgesic properties, "cooperative sedation," and lack of respiratory depression. Dexmedetomidine is also increasingly used in RSI and awake intubation, with promising studies showing a beneficial effect.90,91 However, long-term observational studies are still lacking, and the current scientific level is too weak to recommend routine use of dexmedetomidine.
Muscle relaxants are also used in emergency airway management in the ICU. If endotracheal intubation fails, the merits of preserving spontaneous ventilation versus optimized intubating conditions using non-depolarizing muscle relaxants should be considered.
Succinylcholine is a very-rapid-acting, polarizing muscle relaxant enabling excellent intubation conditions in less than 1 minute.92 Unfortunately, it has serious side effects, including the possibility of triggering malignant hyperthermia. The use of succinylcholine is contraindicated in patients with acute major burns, upper or lower neuronal lesions, prolonged immobility, massive crush injuries, and various myopathies.21 Benumof and associates93 clearly demonstrated that even the short duration of action of succinylcholine is too long, and critical hemoglobin desaturation will occur before return to an unparalyzed state, even after a 1-mg/kg dose.93
Rocuronium is the most widely used non-depolarizing neuromuscular blocking agent. The recommended dosage of "normal" intubation is 0.6 mg/kg. For RSI, higher dosages up to 1.2 mg/kg are necessary and provide excellent intubation conditions within 1 minute.94 A meta-analysis by the Cochrane Collaborative Group concluded that succinylcholine created superior intubation conditions compared with rocuronium.95 The only absolute contraindication against the use of rocuronium is allergy to aminosteroid neuromuscular drugs. A major advantage of rocuronium is the possibility of rapid and complete reversal of even deep neuromuscular block by the administration of sugammadex.96 Based on a systemic review by Chambers and others,97 the use of sugammadex in combination with high-dose rocuronium is efficacious.
E Awake Endotracheal Intubation
Successful awake intubation depends on proper patient preparation. Extensive psychological support and clear explanation about reason for and management of awake intubation are necessary and helpful in the ICU setting.
The airway is topically anesthetized with 5% to 10% lignocaine, which is sprayed with a flexible nozzle into the posterior pharynx to reduce coughing and buckling during intubation. If a fiberscope is used, the larynx is then sprayed with 2 mL of lignocaine 2% administered through the working channel of the fiberscope, after which the scope is advanced into the trachea. Thereafter, a second spray is applied into the trachea before the ETT is advanced. Alternative approaches include blockade of superior laryngeal nerve or lingual nerve and transtracheal anesthesia.
Once the patient is properly prepared, any of the intubation techniques listed in Box 46-2 can be chosen according to the operator's preference.98–102
Box 46-2 Nonsurgical Techniques for Awake Intubation
Fiberoptic intubation (oral, nasal)
Intubation using rigid fiberoptic scopes (e.g., Bullard, Wu)98,99
Blind intubation through LMA Fastrach100
Direct rigid laryngoscopy
Retrograde techniques (with or without fiberoptic scope)
Trachlight or other lighted stylets (lightwands)101
Blind nasal intubation102
In case the first attempt of awake intubation fails because of equipment/operator failure or poor patient cooperation, the following options should be considered: a modified method for awake intubation (e.g., change from blind nasal to fiberoptic approach), induction of general anesthesia, and transition to a fiberoptic-guided intubation method. We believe that the first choice for awake airway management is fiberoptic oral or nasal intubation. If oral intubation is performed, a conduit (i.e., Ovassapian fiberoptic intubating airway) may be used to facilitate fiberscope and ETT insertion. Additionally, a 4 × 4 gauze pad may be used to pull the tongue forward.
A valuable alternative approach is the insertion of the intubating laryngeal mask airway (ILMA) under local anesthesia and light sedation. Intubation is then performed blindly or using a fiberscope inserted through the LMA. Langeron and coworkers103 prospectively compared ILMA intubation with fiberoptic intubation in patients with difficult airway and reported similar success rates (>90%) and durations for both techniques. Another interesting approach is the combination of Fastrach and lighted stylet. Dimitriou and associates104 studied 44 of 11,621 patients in whom three attempts of direct laryngoscopy failed. In all these patients, an ILMA was inserted and sufficient ventilation was possible in all patients after a maximum of two attempts. Thereafter, a well-lubricated silicon ETT loaded with a flexible lightwand was introduced. Lightwand intubation was successful at the first attempt in 38 of 44 patients, at the second attempt in three patients, and at the third to fifth attempt in two. Intubation failed in only one patient. Finally, if all those alternatives fail, the establishment of a surgical airway should be considered.
F Assessment of Correct ETT Placement
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Nonintubation Management of the Airway: Airway Maneuvers and Mask Ventilation
Definition and Incidence of the Difficult Airway
Non–Laryngeal Mask Airway Supraglottic Airway Devices
Percutaneous Translaryngeal Jet Ventilation
Airway Management in Burn Patients
The ASA Difficult Airway Algorithm: Analysis and Presentation of a New Algorithm
Indications for Endotracheal Intubation
Evaluation and Recognition of the Difficult Airway
Benumof and Hagbergs Airway Management


Yelena Gluzman is a theater director, writer, editor, and researcher. Yet though their works were hailed as an erasure of the Author, they all in fact posited that authorship itself i. He seems dazed and stumbles around a bit. After the third clean-up, the son, in despair, pulls up against the painting. This reminded me of another play I have seen that dealt with the works of Andy Warhol: We are confronted with the misery at the end of life, juxtaposed with striking images of compassion steeped in Catholic faith. The thing with Castellucci shows is that no matter how hard to watch they are, you never get the feeling these are just shock tactics. Inferno did not deal so much with the issue of authenticity as it did with authorship, with the breathtaking glory and also the accountability, misery, and destruction that comes with the assertion of your name and the imposition of your worldview. The piece goes against everything they're familiar with, both in terms of content and aesthetics. The show is in Italian with no subtitles, but there's a translation of the sparse dialogue in the program.
Italian theatre director Romeo Castellucci has responded to Christian protests against his work by offering to "forgive" those who disrupted.
Like him or loathe him, the work of theatre drirector Romeo Castellucci is impossible to ignore, says Dominic Cavendish. An interview with Italian director and author who is now in New York to stage his Julius Caesar. Romeo Castellucci's "Julius Caesar.
Certainly since the beginning of the '80s, Romeo Castellucci has established himself as a unique and potent voice of contemporary theatre.
The sound is amplified to the point that it feels as if we're now in a war zone. I am standing toward the back of the so-called kitchen, eating a stale peanut-butter sandwich, while one of the other audience members looks directly into the camera and repeats the closing monologue that is being fed into her earphones.
Then it starts quivering and heaving, as if pushed from the inside out. In my younger, angrier days, I would certainly have been tempted to willfully disobey the instructions given to me, to knock over the screen or whisper side-comments to the audience.
Gej romeo castellucci It was barely noticeable, of course; I am sure it would not be visible on screen, from the audience.
Leave a Reply Click here to cancel reply. And yet I was enthralled -- unlike the Montclair students around me, at least a couple of whom IM'ed on phones and iPads the entire time. Sleep and Kiss are live-streamed on the left-most screen, Kitchen occupies the center, and to the right there are a series of screen tests.
He cleans up his shaking, whimpering father yet again and puts him to bed -- which is white, like the rest of the furniture, in stark contrast to the many foul-looking smears and sluices. Yet though their works were hailed as an erasure of the Author, they all in fact posited that authorship itself i.
Romeo Castellucci's performances are an exercise in culture shock in which the alchemy between extreme violence and paradoxical gentleness often leaves an.
The work in question, Italian Romeo Castellucci's "On the Concept of the itself as nationalistic and Catholic, has a history of anti-gay activism. Explore Ifat Nesher Creative Artists Management's board "Romeo Castellucci, director and designer" on Pinterest. | See more ideas about Romeo castellucci.
The piece goes against everything they're familiar with, both in terms of content and aesthetics.
In the case of an artist like Warhol, whose work was often constituted and carried out by people in various states of suffering, this lapse takes a more often literally morbid turn. Feb 17, Then it starts quivering and heaving, as if pushed from the inside out. Inferno did not deal so much with the issue of authenticity as it did with authorship, with the breathtaking glory and also the accountability, misery, and destruction that comes with the assertion of your name and the imposition of your worldview.
Emptiness implies lack of agency, and certainly lack of will.
I am standing toward the back of the so-called kitchen, eating a stale peanut-butter sandwich, while one of the other audience members looks directly into the camera and repeats the closing monologue that is being fed into her earphones.
I want to chat with momo Whatever you think of his work, there's no denying that Castellucci's commitment is absolute.
Supposedly hipper fare ignores them entirely, which isn't much better. It's all relentless, and very hard to take. Over the past 15 years or so, visionary director Romeo Castellucci has blossomed into a star of Europe's theater festivals and prestigious institutions with largely plotless, large-scale shows that operate at a dizzyingly high conceptual and technical level, and are so abstract that they become strangely accessible you can project anything onto those inscrutable canvases.
Booktopia has The Theatre of Romeo Castellucci and Societas Raffaello Sanzio, From Icon to Iconoclasm, From Word to Image, From Symbol. Over the past 15 years or so, visionary director Romeo Castellucci has blossomed into a star of Europe's theater festivals and prestigious institutions with largely.
We have come to lend director Romeo Castellucci and the Socìetas . manifestations, 'kiss-in' (kissing in public) and Gay Pride, which they.
The show is in Italian with no subtitles, but there's a translation of the sparse dialogue in the program.
The experience of performing suddenly, trying to follow in real time instructions and text that are being fed into your headphones, is a bit what it must have been like being simultaneously on heroin and cocaine and trying to follow directions to get to the second floor of the Factory hey man, does this place have a second floor? New Jersey Religion Montclair Theatre. I am standing toward the back of the so-called kitchen, eating a stale peanut-butter sandwich, while one of the other audience members looks directly into the camera and repeats the closing monologue that is being fed into her earphones.
This American premiere is playing at Montclair State U's Kasser Theaterlike the previous two, until tomorrow evening and it's a must-see for anybody interested in boundary-pushing theater.
Brownish-black liquids trickle through the pulsating face. Scott Gibbons' industrial score rises in volume -- sound design plays a huge role in Castellucci shows, and once again it doesn't disappoint, crisply loud and ominous.
Archer security This unfurls at a deliberate, agonizingly slow pace -- another strike for the youngsters -- while the huge face of Christ, from a Renaissance painting by Antonello da Messinalooms over the stage, staring at us.


The Executive Board is the administration of the Intelligent Systems Club. They are comprised of 5 elected members, plus a representative from each active, non-administrative Team.
Responsible for leading the organization and ensuring that its intended purposes are fulfilled.
Must organize general meetings and executive board meetings.
Ensure all necessary information is documented and passed down, including University resources, club accounts, locker combinations, and any other important details.
Responsible for leading the organization in the absence of the President.
Assisting the President with the overseeing of administrative functions and convening meetings when necessary.
Administering elections in the case of a contested executive board position.
Maintaining the organization's accounts, including having an authorized signer for university paperwork.
Facilitating purchasing while maintaining a record of purchases and budgets.
Providing financial statements upon request.
Maintaining relationships with key contacts involving university accounts.
Ensuring that the organization's website, calendar(s), and social media sites are up to date.
Recruiting new members into the club and retaining existing members through social events.
Establishing internal and external relationships with other organizations for outreach events.
Advertising the club through means such as classroom talks, t-shirts, logo development, fliers, training program and more.
Creating and updating the Lab Safety Guide.
Ensuring the club complies with OSHA and University safety standards, including a plan of action for emergency situations.
Keeping the lab space clean, organized, and well-maintained including but not limited to tools and equipment.
Maintaining an inventory of club assets, 24/7 access list, and providing them upon request.
Each team lead is responsible for keeping track of their team's active members, budgets, equipment, and maintaining a steady rate of progress & activity.
The ISC is governed by the Executive Board, however the power of the Executive Board is limited by an established ISC Constitution.


2021 Toyota 4Runner Redesign, Price, Release Date – Japanese essayist creates a couple of specs in a motor vehicle system, combined with a 2021 Toyota 4Runner might be in the middle of every one of these designs which shift the limits. This the center of-extents SUV was created in 1984, and also since, Toyota disclosed some grows older in viably liked from-roadster.
Be that as it might, has each of the earmarks being 2021 describe the time of year will uplift the level of its a significant extended although, contemplating all of us give an upgrade in your pending personal 4Runner and the start of your 6th development.
Presently age ranges connected with Toyota's 4Runner created thanks close to half a dozen a few years, generally, and also the offered gen familiar with assurance protracted examined all the daytime and experienced for half a dozen straight many many years. Entirely new 2021 MY gives some extreme changes in the type of the SUV. About apprentices, the essential might appear, by all profiles, being Toyota has not yet nevertheless, despite, discarded for 4Runner's body-on-outline for your design, assisting so that it is unique along with a far more adjustable design and also about the roadway.
Somewhat, an out-of-unique day exterior will likely be patched up and also invigorated, and then we can predict 2021 Toyota 4Runner towards fabricating a few refreshing changes. Traveling bar-b-que bbq and basic most exceptional buckle with the hybrid will in most likelihood be refurbished. It can be recognizable nasal area place might delightfully become a tad softer, when its passageway illumination gets an upgrade and activity.
On the inside 2021 Toyota 4Runner, we might shape some great modifications meanwhile. Considering 2015 assortment period, Toyota started to provide you most of the time having 4 trims, which will contain SR5, Piste, TRD Pro plus Small varieties. TRD Pro collection is generated up of things which bring up looks and setup in like way making use of this SUV.
The powertrain of your respective 2021 Toyota 4Runner might be a transfer previously mentioned through the messenger. This entirely is actually a 4.- liter V6 method which utilizes an age group regarding 270 steeds likely not to say 278 lb-feet associated with torque and definitely will appear did the trick in by using 5-degree electrical, electronic transmission. All the drivetrain might depend on the reduce, so over a handful of trims (SR5 together with Limited) buyers can decide some spot within the back again and some tire strike, some are shown with AWD especially (Trail as well as TRD Pro).
The development of your 2021 Toyota 4Runner will not be expected a brief time later on during 2020 while a cash flow time is probably not foreseen previously right from the start in 2021. Regardless of the truth that Toyota has not yet found any specs to the product or management, the standard charge inside the nearing selection will undoubtedly be only considerably simpler and can begin practically entirely through $34,000.


Lake Park provides a wealth of services that gives residents the freedom to follow their own pursuits without the care and worry of maintaining a house in retirement. Residents are encouraged to take advantage of a variety of recreational, social, educational, cultural and spiritual activities available as part of living at Lake Park. And enjoy scheduled transportation, 7 days a week, for shopping, excursions and doctor's appointments.
Contact us for more information, or to schedule a private tour of our continuing care retirement community located in downtown Oakland, CA.


We include the Archancellor in this months who's who and being information of The Guild of Fans and Disciples and the short story Turntables Of The Night.
All you need to know about Discworld Beggars, a review of Foul Ole Ron and information on Terry Pratchett's short story Final Reward.
We review the new Soul Music soundtrack CD, the new novel Jingo and include more information about the 1998 convention.
In this issue we include information about the Discworld Mud, feature the short 100 word story INCUBUST and describe Rincewind.
This issue of Discworld Monthly contains out ultimate Pratchett interview, who's who the Patrician and infomation on the short story TWENTY PENCE WITH ENVELOPE AND SEASONAL GREETING.
Issue 4 of Discworld Monthly includes a who's who about Death, Terry's second short story 'Night Dweller', news and more.
This issue includes a Clarecraft competition, information about Terry Pratchett's first short story 'The Hades Business' and much more.
This issue of Discworld Monthly contains information about Terry Pratchett in Australia, a feature on the new cartoons and much more.
This issue of Discworld Monthly contains information about Terry Pratchett's Discworld and other novels.


text:
package com.github.dexecutor.core.graph;

/**
 * This interface provides API to validate the graph before tasks execution
 * @author Nadeem Mohammad
 *
 * @param <T> Type of Node/Task ID
 * @param <R> Type of Node/Task result
 */
public interface Validator<T, R> {
	/**
	 * Called to figure out if a graph is valid or not, exception should be thrown if the graph is invalid
	 * @param graph the should be validated
	 */
	void validate(final Dag<T, R> graph);
}

redpajama_set_name: RedPajamaGithub


text:
Q: How to forward packet using ubuntu route? I need to forward packets to some target hosts by target ip, if the target host is down, the packet is passed to one default host.
The target ip has no rule, so i think i need to create many routes. and these routes(about 10 000 items) will be modified frequently.
Is there any better method to deal with this case ?

A: The most common approach for something like this is to either using a routing protocol or a virtual IP.  Routing protocols such as BGP or OSPF can take down routes that are no longer working as they use keep alive messages.  A Virtual IP is when one server has a secondary IP address, if this server fails the other server will pick up the virtual IP address.  You could use ucarp or heartbeat for this.
The VIP approach is generally simpler depending on what you are trying to do.

redpajama_set_name: RedPajamaStackExchange


NuGet Gallery | Packages matching Tags:"bearer-authentication"
7 packages returned for Tags:"bearer-authentication"
This code allow to fake a Jwt Bearer and build integration test for ASP.Net Core application. By this way we can fake any authentication we need, without the need to really authenticate a user.
Bearer Authentication for website users.
Bearer Authentication for external OAuth services.


Shown in a late summer/fall color scheme, we use the same flowers with seasonally appropriate and available colors so you will have the freshest arrangement possible.
Having a hard time deciding on the perfect gift for dad? Distinctive Designs can help! Send dad a artistically crafted floral tribute to show him how much you care. Perhaps your dad is the type that would prefer a gift basket filled with his favorite snacks! Whether your dad lives in Wake Forest, or clear across the country, we've got you covered!


From any screen, touch and hold the Recent apps icon .
Scroll left or right to locate the preferred app then tap the app icon (e.g., Calendar, Galler, Email, etc.) located at the top of the panel.
Tap Open in split screen view.
From the Recent apps screen, tap the second application to be viewed.
When on, tap the Recent apps icon (lower-left) to change the current app.
Adjust the size of the apps by sliding the horizontal bar between the applications up or down.


text:
Boy Scouts of America Hire First Openly Gay Adult Leader
Written by Devin Bannon on April 5, 2015
In New York, Pascal Terrier — an 18-year-old Eagle Scout with an excellent record — has become the first openly gay adult to be hired as a staff member at a Boy Scout camp. Despite the Boy Scout of America's ban on LGBT adult serving as leaders, Terrier submitted an application for a summer camp leadership position. After reviewing Terrier's merits, and with full knowledge of his sexuality, the New York BSA chapter elected to hire Terrier, effectively making him the first openly gay adult member in the group's history and potentially setting the stage for a conflict over their anti-gay policy.
Following much protest, the Boy Scouts of America announced in 2013 that they would allow openly gay youth scouts. While progressive, the amendment only granted membership to gay scouts under the age of 18, a compromise that seemingly left both sides dissatisfied. While many demanded equality for all scouts, regardless of orientation or age, an equal number fought for the ban on all gay members to continue.
The rules regarding membership on the official Boy Scouts of America website still include the following clause:
"While the BSA does not proactively inquire about sexual orientation of employees, volunteers, or members, we do not grant membership to individuals who are open or avowed homosexuals or who engage in behavior that would become a distraction to the mission of the BSA."
The Boy Scouts of America's national leadership has not officially responded to the news of Tessier's hiring, but the move stands as a direct challenge to their membership rule, and will likely provoke a official response. The next steps made by the BSA will define the group's position and could go one of three ways:
Whichever path the BSA leadership chooses, there will likely be public outrage and celebration. One thing however can be agreed upon by all parties: Tessier's record. The New York chapter deemed the18-year old Eagle Scout as "highly qualified." He comes from a family of scouts, and his older brother is also a gay scout who had to leave the Scouts at 18 because of his sexual orientation.
"A scout is a friend to all, and a brother to every other scout, no matter to what social class the other belongs."
Boy Scouts LGBTQ rights USA
For Men Who Have Had 'The Snip,' Fake Foreskin Is Officially a Thing
2 Gay Men Who Fled Chechnya Were Abducted and Forcibly Sent Back
It's a Sweet Story How This Closeted High School Swimmer Ended Up With the Football Captain
A Brief 75-Year History Lesson on Black Superheroes in Comic Books

redpajama_set_name: RedPajamaCommonCrawl


text:
Home › Midnight In The Desert › Melting Ice Could Cause More California Droughts
Melting Ice Could Cause More California Droughts
Loss of ice cover in the Arctic could spur more droughts in California, according to a new study by federal researchers. The study, published today in Nature Communications, finds that sea-ice loss in the Arctic could trigger atmospheric effects that drive precipitation away from California. The research was led by atmospheric scientists at the Lawrence Livermore National Laboratory. It's the same kind of effect that contributed to state's historic dry period that ended last year. The five-year drought was exacerbated by an atmospheric pressure system in the North Pacific Ocean that researchers dubbed the "ridiculously resilient ridge," which pushed storms farther north and deprived the Southwest of precipitation. "ea-ice loss of the magnitude expected in the next decades could substantially impact California's precipitation, thus highlighting another mechanism by which human-caused climate change could exacerbate future California droughts," the study says. The study stops short of attributing California's latest drought to changes in Arctic sea ice, partly because there are other phenomena that play a role, like warm sea surface temperatures and changes to the Pacific Decadal Oscillation, an atmospheric climate pattern that typically shifts every 20 to 30 years. The recent drought is also outside the study's scope because the researchers focused on potentially larger losses in sea ice than have occurred to date. The authors predict that over the next 20 years, California could see a 10 to 15 percent decrease in rainfall on average.
Read More: Scientific American
Tags: california, Category_Earth Changes, drought, ice caps, MITD


Hi: We are a Baltimore Ravens fan club and a non-profit organization. We became a chartered member of the Council of Ravens Roosts in November, 2002. Our meetings are held the 1st Monday of every month at our home away from home, Laidback Lenny's Pub & Grill located at 1814 Turkey Point Road in Essex, Maryland. Our group is all about friends, fun and football. We are currently 108 members strong and welcome anyone who shares our passion to join. Feel free to stop by and see for yourself what a great bunch of folks we are. Not only do we cheer on our Baltimore Ravens; we support many local charities and have a great time doing it.


"Amazing," "Fantastic," "Wonderful," "Spectacular," "Super" - these are some of many compliments that you will hear from all visitors who have followed the itinerary created by Mai Phuong.
Mai Phuong isn't a newcomer in the travel industry. She has been working in this field for 15 years since she graduated with an excellent certificate in tourism. Vietnam, Cambodia, Laos, Myanmar, Thailand, Singapore, China, there is no boundary for Mai Phuong in traveling. She has left her footprints on almost every land of Asia. She likes to live the local life, learn about the unique cultures and enjoys every second of each trip she has made. These are not only to enrich her travel experience but also to help in satisfying every single need of her customers.
Being an energetic person, you will never see her inactive. If she is not working, she will travel, dance, take photographs, go to the gym, or spend an hour at the swimming pool. She always wakes up at 5 am to swim and ride her bike to the office. That means, her actual working time starts at 5 when she can reply to her emails. Some of her clients believe "Mai Phuong never sleeps" as they always get her reply whenever they send a question.
Mai Phuong has been a sale manager for five years, but you still can contact her any time you need her advice on destinations. She pays attention to every trip to make sure that EV's customers have a holiday of a lifetime and every member in her sale team is happy about selling perfect holiday trips.
Mai Phuong favorite hotels are Anantara Mai Khao Phuket, Sarojin Khao Lak, Four Season Chiang Mai, Villa Inle – Inle lake Myanmar, Amanoi – Vietnam, and Koh Yao island resort.
Excellent Arrangements by Exotic Voyages!
11 of us toured Vietnam for 10 days. It was a special trip, as 6 of our group had "visited" 50 years before while stationed at Phan Rang as USAF Pilots. Mai Phong of Exotic Voyages arranged our entire trip and did a wonderful job. Our guide in Vietnam, Tran Quoc Dung (or "John", as he suggested we call him) met us upon arrival at the airport in Ho Chi Min City and travelled with us during the entire trip, including our visits to Nha Trang, Da Lat. He spoke excellent English, was patient, had a great sense of humor and very knowledgeable. His help at the airports we used was invaluable. The hotels Mai arranged for us were excellent, as were the in-country flights, side trips, the restaurants she suggested and hotels (with 1 exception, which was known in advance and due to a limited choice of locations in Phan Rang). Afterwards, my husband and I continued on to Bangkok, Thailand and Singapore, where Mai's arrangements and the guides she provided were equally outstanding. We couldn't have asked for better service from a travel agency!
Our group had a special purpose for this return trip to Vietnam and that was to return to the US air base at Phan Rang where the US Air Force pilots were 50 years ago. Six air force fighter pilots and family members were on this trip. In addition to going to the air base, the tour included getting a flavor of Vietnam by visiting Ho Chi Minh City, Nha Trang, Phan Rang and Dalat. Mai Phong worked with us for many months working out the specifics. We could not have asked for a better organized tour---great tour guide, modern transportation, and hotels that met our expectations except for one which we knew about ahead of time and with limited hotels in Phan Rang, we were accepting of this. We would highly recommend Exotic Voyages.


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The right candidates can go on to develop numerous skills and experience that will help them to provide the best possible product for our customers.
If you have what it takes, we want to hear from you, call us on 01695 455580 or email us for more details.


text:
115 illustrations, 97 in colour
Lightning Nature and Culture Derek M. Elsom
There exist few phenomena more awe-inspiring than lightning. Streaking across the sky, it daunts us with its power and amazes us with its beauty. As thunder strikes and lightning flashes, we cower from it in fear and marvel at it in astonishment.
Lightning explores this natural phenomenon and traces the long history of our engagement with it. By examining the assumptions of early civilizations – from ancient Mesopotamia to the Incas and the Holy Roman Empire – which believed lightning to be the work of gods and goddesses, through to eighteenth-century scientific analyses (including Benjamin Franklin's kite experiment), we discover the surprising and rich history of mankind's efforts to understand and explain lightning. Taking an insightful look at folklore beliefs about lightning protection, with examples as diverse as simply covering household mirrors to nailing animal skins to ship masts, as well as contrasting these with today's more scientific approaches, this book is a fascinating chronicle of how lightning has both perplexed and enamoured us throughout the ages.
Tracking the path of lightning through our culture, from myths and legends to art and design, this beautifully illustrated book includes stunning photographs of lightning displays, storm deities and depictions of lightning in art, in addition to offering advice on how to avoid being struck by lightning. Lightning will appeal to all those interested in weather, the environment, folklore, and the art and science of earth's most extreme forces of nature.
'This is the best book I have read on the subject of lightning and is very reasonably priced so I can unreservedly recommend it to all readers.' — International Journal of Meteorology
'beautifully illustrated with some stunning photographs and artistic renderings . . . a reader-friendly book which will appeal equally to weather buffs and all those fascinated by extreme weather forces, as well as to scientists, folklorists and artists. Its a one-stop shop on lightning.' — Weather, magazine of the Royal Meteorological Society
'Lightning: Nature and Culture is a tour de force. Very informative, remarkable photographs and illustrations and will remain close at hand on my bookshelf. An excellent read and source of reference.' — Weather Eye
'One of a series of books on natural phenomena that traces a history of the topic through cultural superstitions, scientific discoveries, and depictions in literature and the arts, illustrated by beautiful colour photography. From odd warding customs, the gods of antiquity and ball lightning to lighting marks, St Elmos Fire and solidified lightning (fulgurites), Derek Elsom maintains our interest throughout, making this very accessible to everyman . . . an excellent introduction to one of the mysterious forces of nature.' — Fortean Times
'The phenomenon of lightning has long frightened and fascinated humanity. As part of Reaktions Earth series, this book explores the scientific and social aspects of this natural occurrence . . . This book, beautifully illustrated with many color photographs, provides an excellent, basic overview of the subject.' — Choice
'What a fantastic idea, science and culture brought down to earth. I can't wait to read the next book in the series.' — David Bellamy
'At last, a series of books on the earth for lay people that combine authoritative, succinct and entertaining narrative with magnificent illustrations. The Earth series will make us marvel anew at the diversity and astounding beauty of the world around us. Each book will take popular understanding of the earth to a new level. No one seriously interested in the future of our planet should be without them.' — Brian M. Fagan, author of The Great Warming: Climate Change and the Rise and Fall of Civilizations
Derek M. Elsom is Professor Emeritus of Geography at Oxford Brookes University. His books include Earth: The Making, Shaping and Workings of a Planet (1992), Weather Explained (1997).
1. Weapon of the Gods and Goddesses
2. Fear of Lightning: Thunderbolts, Witchcraft and Protective Charms
3. The Science and Nature of Lightning
4. Lightning Threats to People and Activities
5. Lightning in Literature, Art and Popular Culture
Gods and Goddesses of Thunder and Lightning
Associations and Websites


Any form of dental work performed on your teeth and gum to improve their appearance is generally referred to as cosmetic dentistry. Basically, cosmetic dentistry targets the improvement in color, alignment, size, positioning and the shape of all dental aesthetics. Dentists are capable of transforming your teeth to enable you attain the smile that you desire. There are various common procedures that can be done by all dentists such as whitening of the teeth, however, there are those that somehow complicated and have to be performed by a specialist in that particular field. Below are some of the common types of cosmetic dentistry.
Ultra-thin porcelains that are directly bonded to the teeth are referred to as the dental veneers. Veneers are basically used to treat dental conditions such as the discolored teeth, cover spaces located in between the teeth, crooked tooth and even chipped teeth. They are made out of a super strong form of porcelain referred to as lithium disilicate which has the ability to last up to 2 decades if well taken care of. They always remain natural and beautiful, mainly because they do not rust or stain.
This is the most popular type of cosmetic dentistry, which is done by almost all dentists. Even with the different methods to whiten your teeth at your door step, treatment by dentist remains the best recommendation. Teeth whitening can be done through laser whitening, where the gum is usually covered and the teeth are applied on bleaching chemical. After application of the chemical, argon laser light is projected to speed up the rate at which bleaching takes place. Compared to all the other methods of teeth whitening, laser lightening remains the best and most effective procedure.
Indirect filling, is also referred to as inlays and onlays which are made in the lab in a shape that perfectly matches your teeth. The inlays and onlays are basically used when there is no enough tooth capable of supporting the traditional filling, and if the patient has either mild or moderate tooth decay. For the inlays to be placed directly on top of the surface of the tooth, the cusps of the tooth should still be intact.in cases where a large portion of the tooth has been damaged, that are when the onlays are manipulated.
Bonding and contouring are good options in cases where you may be having one or two teeth with problem. Bonding is basically the application of composite resin on the tooth's surface and shaping it, while contouring is shaping of the teeth that are larger than others resulting to uneven size of the teeth. This procedure has very little changes to the natural tooth.
Castle Valley Dental offers these types of cosmetic dentistry services, just give us a call to learn more. Be sure to also check out our blog on cosmetic dental procedures for kids.


Jacquie Binns Ecclesiastical Artist | Vestments, Stoles, Altar Frontals and Sculpture each unique and to commission.
Jacquie Binns works to commission as a designer, creator and hand finisher of embroidered vestments, stoles, banners, altar cloths, funeral palls and icons. Jacquie also works as a Sculptor.
The Saint Albans Cope by Jacquie Binns, featuring the life of Saint Albans.
The Rt Revd Joanna Penberthy, Bishop of St David's Cathedral, Wales.
The Phoenix Altar Frontal for All Hallows by the Tower.
Jacquie with the finished King Richard III funeral pall.
Jacquie painting her Crucifixion Sculpture for St Peters Church, Plymouth.


text:
package pixelate

import (
	"image"
	"image/color"
	"image/draw"
	"runtime"

	"hawx.me/code/img/utils"
)

type Style int

const (
	CROPPED Style = iota
	FITTED
)

func paintAverage(img image.Image, bounds image.Rectangle, dest draw.Image,
	c chan int) {
	values := make([]color.Color, bounds.Dx()*bounds.Dy())
	count := 0

	utils.EachColorInRectangle(img, bounds, func(c color.Color) {
		values[count] = c
		count++
	})

	avg := utils.Average(values...)

	utils.MapColorInRectangle(img, bounds, dest, func(c color.Color) color.Color {
		return avg
	})

	c <- 1
}

// Pixelate takes an Image and pixelates it into rectangles with the dimensions
// given. The colour values in each region are averaged to produce the resulting
// colours.
func Pixelate(img image.Image, size utils.Dimension, style Style) image.Image {
	nCPU := runtime.NumCPU()
	runtime.GOMAXPROCS(nCPU)

	var o draw.Image
	b := img.Bounds()
	c := make(chan int, nCPU)
	i := 0 // like pxl. this may not be the best way

	switch style {
	case CROPPED:
		cols := b.Dx() / size.W
		rows := b.Dy() / size.H

		o = image.NewRGBA(image.Rect(0, 0, size.W*cols, size.H*rows))

		for j, r := range utils.ChopRectangleToSizes(b, size.H, size.W, utils.IGNORE) {
			go paintAverage(img, r, o, c)
			i = j
		}

	case FITTED:
		o = image.NewRGBA(b)

		for j, r := range utils.ChopRectangleToSizes(b, size.H, size.W, utils.SEPARATE) {
			go paintAverage(img, r, o, c)
			i = j
		}
	}

	for j := 0; j < i; j++ {
		<-c
	}

	return o
}


text:
Home / Books / Medicine / Berne & Levy Physiology, Updated Edition
Berne & Levy Physiology, Updated Edition
Berne and Levy Physiology has long been respected for its scientifically rigorous approach and now includes major updates to bring you all of the latest knowledge in the field. Bruce M. Koeppen and Bruce A. Stanton present a honed and shortened edition that emphasizes the core information needed by students of physiology today and features a full-color design and artwork to enhance readability and enrich your comprehension of every concept. With access to the full contents online at Student Consult, this time-honored book delivers an in-depth understanding of physiology more powerfully and effectively than ever before.


Now is the time to start planning your 2019 Spring Getaway to Branson. With so many choices, your family will have no problem filling your itinerary. Check out these ideas to help you craft the perfect family vacation!
Branson is gearing up for a host of new attractions in 2019. Immerse yourself in the great outdoors at Bass Pro Shops' Shooting Academy. Enjoy some friendly competition at the Thunder Alley Go-Karts at Fun Mountain or at Andy B's Social Bowl at the Branson Landing.
Or if you're ready for a thrill, try the Aerodium Outdoor Flying Adventure outside of Fritz's Adventure or The Skyscraper at Track Family Fun Parks #3.
Branson has plenty of indoor and outdoor attractions to delight everyone in your family. If it's nice outside, you can enjoy one of Branson's mountain coasters or ziplines, mini golf or go-karts, zoos and thrill rides and theme parks . . . and the list goes on!
If you want to be inside, take your pick of fun and educational museums and exhibits, escape rooms and indoor water parks, movie theaters and arcades and more. There is something for everyone!
Treat your family to one of Branson's fantastic live shows. Try Reza "Edge of Illusion" or the Amazing Acrobats of China. Watch the Broadway-style biblical drama Samson (for select shows you can also add a behind-the-scenes tour!), or get pumped up with the high-energy Haygoods.
Want to knock out dinner too? Check out Dolly Parton's Stampede or the Showboat Branson Belle for delicious dinner shows!
The beauty of Ozark Mountain Country is something to experience with your family this Spring. Visit Dogwood Canyon Nature Park where you can hike, bike, ride horses and more through the beautiful terrain of the Ozarks.
If you want to be lakeside, head to State Park Marina where you can boat, bike, picnic or simply walk along the paved trail along the lakeshore (there's also really great shopping here at the Boathouse Boutique!). For some fun in the lake, check out kayaking, canoeing or stand-up paddleboarding with Kayak Branson!
Get underground by visiting one of the area's amazing caves. If you're already planning on visiting Silver Dollar City, take time to visit Marvel Cave inside the park. Or visit Talking Rocks Cavern in Branson West.
While you're in Branson, find outdoor fun!


A unique combination of ecology and culture, the Desert Laboratory on Tumamoc Hill is an 860-acre ecological preserve in the heart of Tucson. Its innovative, sustained, long-term environmental studies have made it a US National Historical Landmark. A 2500-year-old village sits atop Tumamoc Hill and the rich cultural context of four millennia of human society lie at its feet. Our name derives from from the Tohono O'odham place name Chemamagi Do'ag – Hill of the Horned Lizard, which signifies the prfound cultural importance of this site.
Tumamoc's Desert Laboratory (1903) gave birth to the sciences of plant physiology, ecology, and arid land studies. Its permanent study plots include the world's logest continuslsy monitored vegetation plots, since 1906. It is also the world's first and oldest restoration ecology project when cattle were excluded from the site in 1907. Today, researchers continue to track these changes as well as delve deeper into the functioning, origin, and future of the Sonoran Desert.


text:
Leon Richard Kass (1939- )
A PhD and medical doctor turned ethicist, Leon Kass calls himself an unlicensed humanist. Throughout his unique career he has sought to impact others and engage important cultural issues. This he has accomplished over the course of many years by studying biochemistry, teaching humanities, writing articles and books on ethics, and serving as chair of the President's Council on Bioethics.
Adolescent Family Life Act (1981)
The 1981 Adolescent Family Life Act, or AFLA, is a US federal law that provides federal funding to public and nonprofit private organizations to counsel adolescents to abstain from sex until marriage. AFLA was included under the Omnibus Reconciliation Act of 1981, which the US Congress signed into law that same year. Through the AFLA, the US Department of Health and Human Services, or HHS, funded a variety of sex education programs for adolescents to address the social and economic ramifications associated with pregnancy and childbirth among unmarried adolescents.
Subject: Legal, Outreach, Ethics, Reproduction
The Doula Project (2007– )
The Doula Project, cofounded in 2007 as The Abortion Doula Project by Mary Mahoney, Lauren Mitchell, and Miriam Zoila Perez, is a nonprofit organization of full-spectrum doulas based in New York City, New York, and is one of the first organizations to provide free full-spectrum doula care to pregnant people. Full-spectrum doulas provide non-medical physical, emotional, and informational support to pregnant people through a wide range of pregnancy experiences, including birth, miscarriage, stillbirth, fetal anomalies, and abortion.
Subject: Organizations, Outreach, Ethics, Reproduction
National Association for Down Syndrome (1960–)
The National Association for Down Syndrome, or NADS, is an organization that was founded in 1960 by Kathryn McGee in Chicago, Illinois, to support people with Down syndrome and their families in improving their quality of life. Originally named the Mongoloid Developmental Council, NADS is one of the oldest organizations serving people with Down syndrome and their families in the United States. According to NADS, Down syndrome is a genetic condition that occurs in one in every seven hundred ninety-two people and that causes delays in physical and intellectual development.
Subject: Disorders, Organizations, People, Ethics
"Alternative Sources of Human Pluripotent Stem Cells" (2005), by Leon Kass and the President's Council on Bioethics
Human pluripotent stem cells are valued for their potential to form numerous specialized cells and for their longevity. In the US, where a portion of the population is opposed to destruction of human embryos to obtain stem cells, what avenues are open to scientists for obtaining pluripotent cells that do not offend the moral sensibilities of a significant number of citizens?
"The Science and Ethics of Making Part-Human Animals in Stem Cell Biology" (2006), by Jason Scott Robert
In 2006, bioethicist Jason Scott Robert published "The Science and Ethics of Making Part-Human Animals in Stem Cell Biology" in The FASEB Journal. There, he reviews the scientific and ethical justifications and restrictions on creating part-human animals. Robert describes part-human animals, otherwise known as chimeras, as those resulting from the intentional combination of human and nonhuman cells, tissues, or organs at any stage of development.
Subject: Ethics, Publications, Organisms
Eugenical Sterilization in the United States (1922), by Harry H. Laughlin
Eugenical Sterilization in the United States is a 1922 book in which author Harry H. Laughlin argues for the necessity of compulsory sterilization in the United States based on the principles of eugenics. The eugenics movement of the early twentieth century in the US focused on altering the genetic makeup of the US population by regulating immigration and sterilization, and by discouraging interracial procreation, then called miscegenation.
Subject: Outreach, Legal, Ethics, Publications
The US President's Council on Bioethics (2001-2009)
The US President's Council on Bioethics was an organization headquartered in Washington D.C. that was chartered to advise then US President George W. Bush on ethical issues related to biomedical science and technology. In November 2001, US President George W. Bush created the President's Council on Bioethics (PCB). Convened during a nationwide cloning and embryonic stem cell research debate, the Council stated that it worked to address arguments about ethics from many different perspectives.
Subject: Organizations, Legal, Ethics
"Part-Human Chimeras: Worrying the Facts, Probing the Ethics" (2007), by Françoise Baylis and Jason Scott Robert
In 2007, Françoise Baylis and Jason Scott Robert published "Part-Human Chimeras: Worrying the Facts, Probing the Ethics" in The American Journal of Bioethics. Within their article, hereafter "Part-Human Chimeras," the authors offer corrections on "Thinking About the Human Neuron Mouse," a report published in The American Journal of Bioethics in 2007 by Henry Greely, Mildred K. Cho, Linda F. Hogle, and Debra M. Satz, which discussed the debate on the ethics of creating part-human chimeras. Chimeras are organisms that contain two or more genetically distinct cell lines.
Subject: Organisms, Ethics
In re Agent Orange Product Liability Litigation (1979-1984)
In the legal case In re Agent Orange Product Liability Litigation of the early 1980s, US military veterans of the Vietnam War sued the US chemical companies that had produced the herbicide Agent Orange, and those companies settled with US veterans out of court. Agent Orange contains dioxin, a chemical later shown to disrupt the hormone system of the body and to cause cancer. As veterans returned to the US from Vietnam, scientists further confirmed that exposure to Agent Orange caused a variety of cancers in veterans and developmental problems in the veterans' children.
South Korea's Bioethics and Biosafety Act (2005)
The South Korean government passed the Bioethics and Biosafety Act, known henceforth as the Bioethics Act, in 2003 and it took effect in 2005. South Korea's Ministry of Health and Welfare proposed the law to the South Korean National Assembly to allow the progress of biotechnology and life sciences research in South Korea while protecting human research subjects with practices such as informed consent. The Bioethics Act establishes a National Bioethics Committee in Seoul, South Korea.


text:
Magnet Magazine
Real Music Alternatives
Posted on June 14, 2013 June 3, 2013 by MAGNET Staff
From The Desk Of The Orange Peels: The Kindie-Rock Star Alison Faith Levy
As any fan of the Food Network knows, a few scrapes from an orange peel adds zest to a dish. San Francisco Bay Area indie-popsters the Orange Peels, according to master chef Allen Clapp, reinvented themselves by inviting more cooks into the kitchen. The result, Sun Moon (Minty Fresh), is a fully collaborative and very tasty effort. Last summer, Peels bassist (and Clapp's wife) Jill Pries asked the other two band members—guitarist John Moremen and drummer Gabriel Coan—to drop by their Sunnyvale, Calif., home/studio. "It didn't mean I was happy about it," says Clapp, grown used to demoing the band's material before presenting it to the others. "I told her I didn't have any songs ready." Clapp will also be guest editing magnetmagazine.com all week. Read our new Orange Peels feature.
Clapp: I got a call from Alison Faith Levy in the fall of 2011 regarding me producing an album of new tunes for her. Unlike the moody, arty rock records she'd been making on her own over the previous decade, this was going to be a kids' album. It made sense: Alison was a lead member of the kindie-rock phenomenon known as the Sippy Cups: a psychedelic, theatrical roadshow dream for parents and kids during the 2000s.
I have to admit, I was fascinated. My wife, Jill Pries, is the director and teacher at a Montessori pre-school and kindergarten. I worked there as a teacher aid for a year when the Orange Peels had just put our first album out, and the kids had really inspired me. So much so, that I wrote a song about the whole experience, "Big Bright Shiny Yellow Sun," on my second solo album, Available Light in 2002.
So Alison came to the first session with all sorts of ideas, all manner of cool references, and no band. It became clear fairly quickly that we were going to make this record ourselves and play all the instruments. I loved that! Each session would begin with talking about music we loved, and evolve into making music that we loved. We found common ground in Godspell and Carole King, not to mention the Flaming Lips and Sir Elton.
Renowned music critic Greil Marcus compared our extended version of "Itsy Bitsy Spider" to the Phil Spector wall of sound. That makes a producer fairly happy.
After wrapping sessions, she asked me and some friends from Mystery Lawn to join her band. All I can say is, playing for kids and families is great fun, And you get home well before 2 a.m. (more like 2 p.m. really, and usually with a good chunk of change in your pocket).
Alison Faith Levy's take on "Itsy Bitsy Spider" after the jump.http://www.youtube.com/watch?v=SSuwYTcNJoQ
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