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By R. Bozep. Southeast Missouri State University.
Cortical sparing adrenalectomies are51 becoming more common to preserve adrenal function purchase carafate online now. Continuous intra-arterial blood pressure monitoring is required for managing the patient with pheochromocytoma buy carafate 1000mg cheap. Central venous access can be useful for secure administration of anticipated vasoactive medications proven 1000 mg carafate. The presence of coexisting disease would dictate the need for more intensive monitoring. Although there is no clear advantage to one anesthetic technique over another, drugs that are known to liberate histamine are avoided. Dopamine antagonists such as droperidol and metoclopramide can provoke catecholamine release and should not be used. A potent sedative hypnotic, in combination with an opioid analgesic, is used for induction. It is extremely important to achieve an adequate depth of anesthesia before proceeding with laryngoscopy to minimize the sympathetic nervous system response to this maneuver. The disadvantage of long-acting β-blockers may be persistence of bradycardia and hypotension after the tumor is removed. Even esmolol may be problematic because there are cases of cardiac arrest after clamping of the venous drainage in patients receiving large doses of esmolol. Almost every vasodilator has been tried and recommended as an adjuvant to control hypertension. Magnesium sulfate given as an infusion with intermittent boluses has successfully controlled blood pressure. The reduction in blood pressure that may occur after ligation of the tumor’s venous supply can be dangerously abrupt and should be anticipated through close communication with the surgical team. Restitution of any intravascular fluid deficit is the initial therapy in this situation. After replenishment of the intravascular volume, if the patient remains hypotensive, phenylephrine is administered. Hypoglycemia must be watched for as insulin levels rise from loss of catecholamine-induced β-cell suppression. Some56 observational studies report that hyperglycemia is present in 32% to 38% of patients in community hospitals, 41% of critically ill patients with acute coronary syndromes, and 80% of patients after cardiac surgery. Despite a variety of etiologic factors, its hallmark is a deficiency, either absolute or relative, in the amount of insulin effect to the tissues. However, type 1 diabetes and type 2 diabetes are heterogeneous diseases in which clinical presentation and disease progression may vary considerably. The traditional paradigms of type 2 diabetes presenting only in adults and type 1 diabetes only in children are no longer accurate, as both diseases occur in both cohorts. Hyperglycemia in patients with type 1 diabetes cannot be controlled with diet or oral hypoglycemic agents; rather, it mandates treatment with insulin as there is an absolute deficiency of insulin. They are more likely to become ketotic and sustain progressive end-organ complications of diabetes. It is due to a progressive loss of insulin secretion in the background of insulin resistance. However, type 2 form can occur in young people, and many older adults can acquire a severe and brittle form of type 1 diabetes. Because of the obesity epidemic, many adolescents and teenagers are presenting more frequently with this disorder. In milder forms, this version of diabetes can often be treated with diet, lifestyle modifications, and oral hypoglycemic agents. Because these patients are relatively resistant to ketosis, their disease may not be clinically apparent until exacerbated by the stress of surgery or intercurrent illness. Hence, a patient with a glucagonoma, pheochromocytoma, or acromegaly may develop diabetes. An increased effect of glucocorticoids, from either Cushing disease or steroid or tacrolimus therapy (after organ transplantation), may also oppose the effect of insulin enough to elicit clinical diabetes and would certainly complicate the management of pre-existing diabetes. Thiazide diuretic and atypical antipsychotics (clozapine, olanzapine, risperidone, ziprasidone, quetiapine) increase the risk of diabetes. For our purposes, it is60 easiest to regard the effects of insulin on glucose metabolism as primary and to view its effects on other metabolic functions only as they relate to glucose. Insulin is a small protein produced by the β cells of the islets of Langerhans in the pancreas. The basal rate of insulin secretion is about 1 unit/hr, which can increase by 5- to 10-fold after ingestion of food. However, it may clinically appear to have a longer duration of action, due to delays in binding and release from the cellular receptors. These facts lead us to the important principle that once a high61 level of insulin saturates all the binding sites, insulin will not have a more potent effect, just a more long-lasting effect. In patients with hepatic dysfunction, the loss of gluconeogenesis and a prolongation of insulin effect increase the risk of hypoglycemia. They are more prone to hypoglycemia, and exogenous insulin should be administered judiciously in diabetic patients with renal disease. First is the direct effect of glucose and amino acids to stimulate insulin release. The autonomic nervous system, also through vagal stimulation, increases insulin release, as does β-adrenergic stimulation and α-adrenergic blockade. Nitric oxide stimulates insulin secretion, and potassium depletion decreases insulin secretion. The most fundamental action of insulin is to stimulate cellular uptake of glucose in skeletal muscle cells, adipose tissue, and cardiac cells. This is particularly important in skeletal muscle cells, where muscle activity also increases glucose uptake and is an important variable in the management of the physically active diabetic patient. The brain, liver, and immune cells are exceptions, where insulin does not affect glucose transport. Hence, the patient with diabetes has hyperglycemia because of inadequate cellular uptake of glucose in muscle and adipose tissue. Along with glucose, potassium enters the cells under the influence of insulin, so the diabetic patient is also likely to have an imbalance of potassium concentrations across cell membranes. Other important metabolic functions of insulin include the stimulation of 3357 glycogen formation, as well as the suppression of gluconeogenesis and lipolysis. The patient with insulin deficiency has low glycogen stores and active gluconeogenesis. This implies that in the diabetic patient, because of an absence of glycogen, protein must be broken down to make glucose. Fat metabolism is also abnormal in the diabetic state, with acceleration of lipid catabolism and increased formation of ketone bodies.
Curr Opin Cardiol with left-ventricular assist device implants and tricus- 27(3):288–295 pid valve regurgitation: propensity score-adjusted 30 discount carafate 1000 mg line. Interact Cardiovasc mechanism of tricuspid regurgitation following Thorac Surg 21(6):741–747 implantation of endocardial leads for pacemaker or 39 purchase carafate overnight. Krabatsch References – 352 © Springer International Publishing Switzerland 2017 A purchase carafate now. Predictors of signifcant valve pathology, and normal function recovery are younger age and short duration of and geometry of both the lef and right side of the the disease. Unfortunately, only few cases of myocardial recovery is likely to be sustained for a myocardial recovery in patients sufering from toxic longer time, in the next step, the strategy for with- cardiomyopathy (mostly afer chemotherapy) have drawal of ventricular support should be discussed. Our limited experience shows recur- Tere are several options: rence of heart failure and dilatation of the lef ventri- 1. First, oversewing of the apex of the lef ventricle echocardiography on pump should be performed. If and of the prosthetic anastomosis to the echocardiography shows normal size of the lef ven- ascending or descending aorta. In the case of tricle with satisfactory contractility, echocardiogra- anastomosis to the ascending aorta median phy at reduced pump speed and then an of-pump sternotomy and in the case of anastomosis to study should be scheduled during outpatient visits. Afer an anticoagulation bolus, the bal- and through a subcostal incision with partial loon is infated for 3–4 min and the pump stopped. Te balloon should be and the driveline can be removed, with the defated afer 3–4 min and the pump started for infow and outfow grafs ligated and the 10–20 s, and then the procedure may be repeated 3–5 infow cannula lef in situ. Ligation of the outfow graf is also possible inserted individually designed titanium plug through a small subcostal incision to stop (Fittkau GmbH, Berlin, Germany) is sintered backfow, with transection of the driveline with titanium spheres and becomes overgrown below the skin, while the outfow graf, pump, with tissue , therefore requiring anticoagula- and driveline remain in situ. It is unclear whether In all cases except ligation or interventional reevaluation of the myocardial recovery some closure of the outfow graf, we recommend com- months later would be helpful. Interventional clo- plete removal of the driveline because of the sure of the outfow graf or ligation of the outfow potential risk of infection. Ligation of the outfow Minimally invasive Driveline remains in the Patients with high risk for graft approach, no need for body. Percutaneous No risk of damage or Driveline remains in the Patients with high risk for 34 interventional closure bleeding body. J Heart Lung Transplant 29(11):1316–1317 Krabatsch T, Potapov E et al (2011) Heart failure rever- 5. Morales Chapter 38 Ventricular Assist Device Support for Hypoplastic Left Heart Syndrome, Fontan Failure, and End-Stage Systemic Right Ventricular Dysfunction – 381 Fabrizio De Rita, Antonio Amodeo, and Asif Hasan Chapter 39 Continuous-Flow Pumps in Infants, Jarvik Infant System, and Destination Therapy in Pediatrics – 391 Antonio Amodeo, Sergio Filippelli, Arianna Di Molfetta, Gianluigi Perri, and R. Jarvik 355 35 Mechanical Circulatory Support in Pediatric Population: Clinical Considerations, Indications, Strategies, and Postoperative Management O. Te main etiologies leading to end-stage heart of mechanical ventilation, escalation of inotropic failure requiring mechanical support in children support, inability to tolerate enteral feeds, rise of are dilated cardiomyopathy, myocarditis, and liver function tests, increase in creatinine levels, congenital heart disease. Since end-stage heart altered mental status, low central venous satura- failure is rather uncommon in the pediatric popu- tion (<60%), or elevated lactate. Defnition of the underlying pathology and of the medical therapy, the question arises if exclusion of any residual defect or coronary mechanical support can/should be applied to injury in children with congenital heart save the patient’s life. Since heart transplantation may 35 However, during the child’s treatment, the clini- become necessary, contraindications for cian may be confronted with the question if the transplantation must be considered. Obtaining consent is time consuming but extremely important in establishing a trustful 35. Generally accepted indications are whether the intra-atrial septum is intact or critical cardiogenic shock and progressive decline the aortic and pulmonary valves are despite inotropic support. An intracardial thrombus must clinical presentation is a child who is hemody- be ruled out. Although the vast majority of patients cannulation may become necessary if the needing a long-term device are candidates for cardiac chamber is small, e. Children with a body surface transplantation), recovery of myocardial area larger than 1–1. Depending on body 8 size and patient’s needs, pump chambers of difer 7 ent sizes can be chosen 6 5 4 60 ml 50 ml 3 2 30 ml 25 ml 1 15 ml 10 ml 10 20 30 40 50 60 Body Weight [kg] 358 O. Considerations in children with congenital medical support of right ventricular function in heart disease. For children with congenital the intensive care unit is crucial to avoid second- heart diseases, an individualized approach is ary heart failure. Support for children with a A standard protocol for antithrombotic ther- univentricular heart is possible at every stage apy has been proposed . Anticoagulation is of palliation (aortopulmonary shunt, withheld during the frst 24 h until bleeding has superior caval vein anastomosis, and Fontan completely stopped. However, the prognosis is initiated with unfractionated heparin and switched worse in patients with a univentricular to low molecular heparin in infants or warfarin in physiology as compared to patients with children older than 1 year of age. Examples 35 of strategies to lower the adverse event rate include Postoperative management starts in the operat- earlier initiation of unfractionated heparin, higher ing room. To support the right ventricle during target ranges for low molecular heparin and war- weaning from cardiopulmonary bypass, inhaled farin, higher dosages of antiplatelet drugs, and nitric oxide, milrinone, and epinephrine are rec- introduction of a third agent. Transesophageal echocardiog- adverse events such as infections or thromboem- raphy is used to rule out infow obstruction of bolic events. Tereby, the unloading of the lef right ventricular function is severely impaired ventricle is mandatory and must be verifed not despite maximal medical therapy and optimal only directly afer cardiopulmonary bypass but lef ventricular pump settings, the implantation also during follow-up examinations. Directly afer bypass dence of incomplete unloading such as mitral the heparin efect should be completely antago- valve insufciency or increased lef ventricular nized. Initial accurate hemostasis is necessary to dimensions must prompt a careful reassessment minimize the need for blood products and avoid to rule out incorrect position of the cannula, sub- volume overload of the right ventricle. Closure optimal pump settings, aortic regurgitation, or of the chest allows for early extubation, and obstruction of the infow cannula. A pump stop 359 35 Mechanical Circulatory Support in Pediatric Population procedure with echocardiographic and/or inva- 5. N Engl J Med which can only be met by an interdisciplinary 367:532–541 team dedicated to the many diferent aspects of 6. J Heart Lung Transplant 27:112–115 thrombotic therapy; growth on assist with ade- 7. Circulation lines for the management of pediatric heart failure: 127:1702–1711 executive summary. Cardiol 54:S67–S77 Heart 82:237–240 361 36 Continuous-Flow Pumps in Pediatric Population Martin Schweiger, Daniel Zimpfer, Gaetano Gargiulo, and Michael Hübler 36. Due to its size, it is applicable for hospitalization, and to improve QoL in young to children in supporting congenital or acquired patients. Although the ventricle logical” continuous fow; are small, fast, and easy has to be large enough to provide sufcient space to implant; and have a better reliability compared for the infow cannula (see. With miniaturization of implantation in patients as young as a 2-year-old pump design and increasing applications of cf- child has been done (by D. Te infow and outfow cannula are shortened and a reduced size of the fow probe on the out- fow tract is used. A very aggressive anti- tion in a 2 years old child coagulation was necessary to prevent pump 364 M. Te authors Ruygrok and coworkers published their experi- reported their experience of 28 pediatric patients ence with the VentrAssist in three patients (10– (11–18 years, 50–132.
Procedural and Anesthetic Technique Considerations in Interventional Neuroradiology For most interventional neuroradiologic procedures cheap carafate online visa, arterial access is gained using a 6 or 7 French gauge sheath via the femoral or purchase carafate 1000 mg line, rarely carafate 1000 mg on-line, the carotid or axillary artery. Anticoagulation is required during and up to 24 hours after interventional radiologic procedures to prevent thromboembolism. At the end of the procedure or in case of hemorrhage heparin may43 be reversed with protamine. General anesthesia and conscious sedation are both suitable techniques for interventional neuroradiology depending on the complexity of the procedure, the need for blood pressure manipulation, and the need for intraprocedural assessment of neurologic function. The anesthesiologist may facilitate the procedure by manipulating systemic blood pressure and controlling end-tidal carbon dioxide tension. The Wada test (injection of a small dose of a barbiturate or other anesthetic drug directly into one) is used to determine the dominant side for cognitive functions such as speech and memory. This procedure may be used prior to surgery for non–life-threatening conditions such as epilepsy. The50 worldwide unavailability of amobarbital has led to the use of other agents in these tests including propofol50,51 and etomidate. There is an absolute requirement for the patient to remain motionless while the study is being performed and children or adults with psychologic or neurologic disorders preventing immobility may require sedation or anesthesia (Table 33-1). Patients with acute thoracic, abdominal, and cerebral trauma often require urgent imaging to facilitate diagnosis. A high-frequency alternating current is used to generate a localized heat source directly into the tumor causing coagulative necrosis and tumor cell death while avoiding injury to the surrounding tissues. If an anesthesiologist does become involved in the care of these patients, careful evaluation is required; patients may be in the later stages of their disease, have often failed surgical treatment, and may have undergone extensive radiation therapy and/or chemotherapy. Beneficial effects include reduction in bleeding from varices and control of refractory cirrhotic ascites. The procedure causes minimal stimulation, lasts between 2 and 3 hours, and may be performed under sedation or general anesthesia. The considerations are outlined in Table 33-8 (see also Chapter 46 The Liver: Surgery and Anesthesia). If they are then intermittently exposed to a radiofrequency wave, the nuclei change their alignment. As the radiofrequency pulses are discontinued, the protons return to their original alignment (“relax”) within the magnetic field and, as they do, they release energy. Magnetic field strengths are expressed in Gauss (G) and Tesla (T) (1 T = 10,000 G). Ferromagnetic56 implantable medical devices may move in the magnetic field with disastrous consequences. This issue is a particular concern in patients with cardiac pacemakers, which may also malfunction, and cerebral aneurysm clips. The magnetic field takes several days to establish and is constantly present, decreasing in strength with distance from the center of the magnet. Patients58 and staff should wear ear protection and staff should minimize time spent in the scanner. Cables and wires wound in loops may cause induction-heating effects and thermal injury may also occur in skin with large tattoos, especially those with ferromagnetic inks. Patient monitors, ventilator equipment, and electrical infusion pumps may all malfunction when they come too close to the magnetic field. The electrocardiogram is sensitive to the changing magnetic signals, and it is nearly impossible to eliminate all artifacts. The electrodes should be placed close together and toward the center of the magnetic field and the leads insulated from the patient’s skin to avoid causing thermal injury. It may become very warm within the coil of the magnet, often reaching 80°F, adding to patient discomfort and is of particular concern in children whose temperatures should be monitored. Resuscitation attempts should take place outside the scanner because equipment such as laryngoscopes, oxygen cylinders, and cardiac defibrillators cannot be taken close to the magnet. Disadvantages include a higher failure rate than general anesthesia, airway complications arising from oversedation, unpredictable onset of enteral sedatives causing schedule delays, and inadequate analgesia during painful procedures. The choice of sedation or general anesthesia for a particular child is multifactorial and has been obfuscated in the past by the use of imprecise terms to describe the different clinical states. These techniques, however, are being superseded by the use of short-acting agents including propofol, remifentanil, and dexmedetomidine4 which provide more reliable pharmacologic profiles and have preferable track 2204 records for adverse events. Proton beam therapy is a newer modality of this therapy, which has less potential for collateral injury to adjacent or beam- traversed tissues, a factor of utmost importance in pediatric patients at risk of long-term complications of radiation exposure. Many children receive concurrent cytotoxic or immunosuppressive chemotherapy and are at increased risk of sepsis, thrombocytopenia, and anemia. The challenges of anesthesia for children undergoing radiation therapy have recently been reviewed. Radiation doses in the range of 180 to 250 centiGray (cGy) are employed, so interfaced systems of closed-circuit television and telemetric microphones are used with standard monitoring to prevent staff being exposed to high levels of radiation. In the event of a problem, shutdown of the radiation beam and immediate access to the patient (within 20 to 30 seconds) is crucial. Children older than 6 or 7 years can sometimes tolerate repeated treatment sessions without sedation or anesthesia using behavioral techniques, although most require general anesthesia or deep sedation70 techniques with propofol. Most children will have indwelling central venous access, avoiding the need for repeated intravenous puncture or inhalational induction. Radiation treatments are also used in adults who have a greater capacity than children to remain still without sedation or general anesthesia. The American Gastroenterological Association73 reports that 98% of patients for upper and lower endoscopies receive sedation. Of these, over one-third are performed in ambulatory surgery74 centers and only 29% of these procedures involve anesthesia care providers. Patients may have a number of comorbidities, or a risk of gastroesophageal reflux, hepatic dysfunction, coagulopathy, and ascites. Sedation techniques or general anesthesia may be used after careful patient assessment and discussion with the endoscopist. Local anesthetic is sprayed into the oropharynx to81 facilitate passage of the endoscope, which can abolish the gag reflex, increasing the risk of aspiration. A bite block is inserted to prevent the patient from biting down on the endoscope and damaging both the teeth and the endoscope. Procedures are performed in the prone or semiprone position with the patient’s head rotated to the side, making the airway less accessible. Care and attention should also be paid to pressure areas, particularly the eyes, lips, and teeth, and extreme rotation of the neck should be avoided. During the procedure, the biliary and pancreatic duct systems are identified, instrumented, and therapeutic maneuvers such as the passage of stents or removal of stones carried out.
A bifurcated needle is dipped into the reconstituted vaccine and then 10 to 15 points of entry are made into the dermis of the upper deltoid carafate 1000mg on-line. Because of the side effects of smallpox vaccinations purchase 1000mg carafate, people with immunologic disorders generic carafate 1000 mg on line, eczema (active or with a history of severe eczema), and pregnant or nursing women should not receive the vaccine. Many obstacles have been overcome to develop second- and third- generation smallpox vaccines. Before 2001, the vaccine that was used, Dryvax (similar to what Jenner used in the 18th century), contained live attenuated virus and was the reason that immunocompromised individuals developed adverse events when vaccinated. Anthrax Bacillus anthracis (anthrax) was probably used as a biologic weapon in the Middle Ages, when troops laying siege to a town would catapult infected animal carcasses over the ramparts into the inhabited areas. For reasons discussed later, this method was not a particularly effective method of infecting the native population. During the twentieth century, several countries, including the United States, Great Britain, Russia, and Iraq, studied ways to “weaponize” anthrax. Inhalation anthrax, which was relatively uncommon32 in the past, has an 80% fatality rate. One of the letters that was mailed in the anthrax attacks of 2001 contained 2 g of weapons-grade anthrax. In a terrorist attack, for maximum effect, anthrax could be aerosolized and sprayed from airplanes or delivered through a dispersion device mounted on top of a missile. The attacks on North America in 2001 and the accidental release of spores at a biologic facility in the city of Sverdlovsk in the former Soviet Union in 1979 are illustrative of the potential of anthrax as a weapon. In the United States, 5 of 11 cases resulted in death (45% mortality rate); in the former Soviet Union, 66 of 77 died (86% mortality rate). Fortunately, they used a nonpathogenic strain of anthrax and so there were no casualties. As demonstrated in 200132 in the United States, terrorists are sophisticated enough that they might be successful in obtaining and releasing weapons-grade anthrax. Such attacks, even if detected early, would create mass hysteria and greatly affect the34 entire country and world. The disease is all but gone from North America, but is still prevalent in many developing countries, and herbivores, especially cattle, usually die within 24 to 48 hours of contracting the disease. The carcass has such a large number of organisms, that humans, who are relatively resistant to infection, can be exposed and contract the disease. From a public health perspective, inhalation anthrax is most concerning, as it usually affects 2,000 to 20,000 people worldwide per annum. People can be exposed through contact with animals in an agricultural or industrial setting (i. It manifests as an influenza-like disease with fever, myalgias, malaise, and a nonproductive cough with or without chest pain. The most notable finding on physical examination and laboratory testing is a widened mediastinum. Usually when a patient develops profound dyspnea, death ensues within 1 to 2 days. In the past, penicillin G was the treatment of choice, but since weaponized anthrax has been engineered to be resistant to penicillin G, ciprofloxacin or doxycycline is more commonly used. A more recent study concluded that this drug regimen is the best strategy for managing a small-scale attack, as 4250 occurred in 2001. The first documented use of plague as a biologic weapon was in40 1346 when the Tartars in their siege of the fortress at Kaffa catapulted infected corpses into the city. The plague was used by Unit 731 to infect27 large areas of China, and as many as 200,000 Chinese may have died. Surprisingly, the organism is only viable for approximately 60 minutes after being distributed; if dispersed by an airplane, its viability would limit its infectivity for only 10 km from the dispersion site. Rodents and fleas are its natural hosts, and they re-infect each other by fleas biting infected rodents. Soil can be contaminated and therefore rodents can acquire the disease simply by digging in an infected area. Humans are an accidental host and they usually acquire the disease from a fleabite, though rarely there can be direct inoculation of infected material into a person. With bubonic plague, after a fleabite, there is a 2- to 6-day incubation period, at which time there is the sudden onset of fever, chills, weakness, and headache. Intense painful swelling occurs in the lymph nodes, usually in the groin, axilla, or neck. These swellings or buboes are typically oval in nature, 1 to 10 cm in diameter, and extremely tender. Up to 25% of patients will have pustules, papules, or skin lesions near these buboes. Without treatment, patients become septic, develop septic shock with cyanosis and gangrene in peripheral tissues, leading to the “black death” descriptor that was used during the pandemics in Europe. As mentioned, material from these buboes is infective only if inoculated into human tissue. However, patients who have bubonic plague can seed their lungs, in which case they develop pneumonic plague. Diagnosis is made with a Gram stain or culture of organisms from blood, sputum, or buboes. The treatment of choice is streptomycin, but chloramphenicol and tetracycline are 4251 acceptable alternatives. Patients with pneumonic plague should be managed as one would manage a patient with drug resistance to tuberculosis, because the respiratory secretions are highly infectious. Tularemia Francisella tularensis (tularemia) has some similarities to anthrax and plague, but is not nearly as dangerous. It was studied as a biologic weapon in the twentieth century because it is highly infectious, requiring an inoculum of perhaps as small as only ten organisms. The fact that both armies were infected underscores one of the dangers of using infectious agents as biologic weapons. Often these are dispersed with aerosols, and despite the best predictions of air currents, they are notoriously unpredictable; with the shifting air currents, one’s own troops could become infected. There are several animal hosts, with the cotton-tailed rabbit being one of the most susceptible. Normally, humans acquire tularensis through direct contact of an infected animal or from the bite of an infected tick or deerfly. Occasionally, the41 ingestion of infected food or inhalation of a small amount of aerosol will initiate the disease. Normally, a patient will develop a cutaneous ulcer at the site of entry after contact with an animal. As few as 10 or 50 organisms can invade the body through either hair follicles or mini abrasions. The incubation period is 2 to 6 days, at which time there is swelling and ulceration at the site of entry. As the swelling continues, the skin eventually breaks, creating an ulcer, which develops a necrotic base that becomes black as it scars. The treatment of choice for tularemia is streptomycin, though gentamicin, tetracycline, and chloramphenicol have been used.
Low birth weight 1000 mg carafate with amex, defined as a birth weight of less than 2 buy cheap carafate 1000mg,500 g purchase carafate australia, can be due to prematurity, poor intrauterine growth, or both. Prematurity and intrauterine growth retardation are associated with increased neonatal morbidity and mortality, and it is difficult to completely separate factors associated with prematurity from those associated with intrauterine growth retardation. These newborns have a lower incidence of major physiologic abnormalities typical of the more preterm newborn. Although they usually do not have significant pulmonary abnormalities, they may have some feeding problems or hyperbilirubinemia. This degree of prematurity does not usually have a significant impact on anesthetic management. However, infants born between 30 and 34 weeks’ gestation are much more likely to show some abnormalities related to prematurity that can complicate anesthetic management. This group does have more problems with inadequate feeding, persistent patency of the ductus arteriosus, apnea in response to stress, and temperature instability. However, infants born more prematurely than 30 to 34 weeks’ gestation begin to demonstrate significant physiologic abnormalities related to prematurity. In addition, symptomatic intraventricular hemorrhage is found in about 25% of infants weighing 501 to 750 g, in 12% between 751 and 1,000 g, in 8% between 1,001 and 1,250 g, and in 3% between 1,251 and 1,500 g. Table 42-3 lists some of the most common abnormalities found in the preterm population that have implications for anesthetic evaluation, preparation, and management. Preanesthetic Evaluation—Physical Examination Physical examination of the newborn is focused by the condition requiring surgical intervention. Hydration is often an important issue because of both fasting and losses related to the surgical lesion. Clinical signs of dehydration include a sunken fontanel, poor skin turgor, dry mucous membranes, sunken eyes, poor skin perfusion, delayed capillary refill, hypothermia, tachycardia, or absent urine output. If there are clinical signs of dehydration, efforts should be made to correct the deficits before surgery, except in extreme, life- threatening situations. Physical examination also focuses on the respiratory 2962 and cardiovascular systems. The presence of any cardiovascular abnormalities should be noted, including poor perfusion or pulses, abnormal rhythm or rate, a murmur or gallop, hepatomegaly, or other signs of either heart failure or poor perfusion. The presence of a murmur is of concern in the neonatal period and warrants further evaluation, which is best done by a pediatric cardiologist. An electrocardiogram and echocardiogram will help define whether there is significant cardiovascular disease present that will affect the anesthetic management. Although this evaluation may take some effort and time, it is worthwhile to ensure that the anesthesiologist can plan the child’s care with full knowledge of the limitations cardiovascular disease can impose. Table 42-3 Abnormalities Associated with the Preterm Infant: Common Anesthetic Concerns The respiratory system also must be examined in some detail. The presence of stridor or other evidence of airway obstruction, such as sternal or chest wall retractions, should be identified and investigated. Although upper airway obstruction is relatively rare in the newborn, laryngeal webs, cysts of 2963 the tongue or supraglottic region, vocal cord paralysis after a traumatic delivery, and hemangiomas of the airway can cause obstruction and need to be identified. In addition, newborns that have been previously intubated may have some degree of subglottic edema related to previous intubation. More likely are signs of lower airway disease such as tachypnea, grunting, rhonchi, retractions, and cyanosis. The cause of any respiratory distress needs to be evaluated expeditiously prior to anesthesia to identify treatable causes and begin therapy. Preanesthetic Evaluation—Laboratory Most laboratory investigations are related to the underlying surgical condition such as radiography, computed tomography, magnetic resonance imaging, and echocardiography. However, most newborns will have, at a minimum, a blood count and glucose level drawn. The hemoglobin in a newborn is primarily fetal hemoglobin, which has a higher affinity for oxygen than adult hemoglobin. Because of this higher affinity, the hemoglobin dissociation curve is shifted to the left, releasing less oxygen to the tissues than adult hemoglobin. Newborns have a higher hemoglobin than the infant or child, often in the 15 to 18 g/dL range. Rarely, a newborn will have significant94 polycythemia, with hemoglobin levels above 20 g/dL. If symptomatic, these patients may benefit from therapeutic phlebotomy and volume replacement. The stressed newborn, especially the stressed preterm or small-for- gestational age newborn, are at particular risk for hypoglycemia. A glucose95 level between 60 and 80 mg/dL is expected in a full-term newborn, with a preterm often 10 mg/dL below that. Although there is some controversy about what actually constitutes hypoglycemia in these populations, most agree that levels less than 45 mg/dL warrant therapy with additional dextrose. Other laboratory studies, such as electrolyte determinations and coagulation profiles, are indicated in specific patients. Hypocalcemia, in particular, can be troubling because signs of hypocalcemia are nonspecific. Hypocalcemia is a problem with preterm newborns, but can also be seen in full-term newborns who have a delay in starting enteral feedings. Hyponatremia is not uncommon in newborns who have been receiving 2964 solutions with little or no salt in the first days of life, although hypernatremia may occur if there is inadequate resuscitation of the dehydrated patient when water loss is greater than salt loss. The longer a newborn has received parenteral fluids, the greater the chance of electrolyte abnormalities because of the difficulty in matching ongoing losses with replacement in the presence of an immature kidney. Unexplained thrombocytopenia can be an early sign of sepsis, and a falling count should be an impetus to look for other signs of sepsis. The prothrombin time and partial thromboplastin time levels are about 10% longer in the newborn, but prothrombin time values approach adult levels in the first week of life and partial thromboplastin time levels within the first month of life. Major factors that should be considered in planning the anesthetic include (1) anticipated blood loss and necessity for blood products to be available before beginning the case, (2) monitoring requirements, including invasive monitoring techniques, (3) additional equipment needs for airway and vascular access, (4) transport requirements, (5) postoperative recovery location risk of postoperative ventilation requirements, and (6) plan for postoperative pain relief. Both the medical status of the patient and the planned surgical procedure will impact this planning. The anesthesiologist has the responsibility of clarifying any medical issues with the neonatologist before finalizing the plan, as well as clarifying any issues related to the planned procedure with the surgeon. Occasionally, as planning progresses, it becomes obvious that the patient needs further medical resuscitation or evaluation before it is prudent to proceed with the procedure. Once the anesthetic plan is clear, it should be discussed with the available parent or caregiver who has legal custody of the child. Informed consent is a process by which the anesthesiologist explains his/her understanding of the patient’s status, the planned procedure, the plan for anesthetic management, alternatives to the plan, and some discussion of risks and benefits. Although 2965 there may be rare circumstances in which the legal guardian is not available to provide consent, efforts should be made in all except the most emergent of situations to have this discussion. The goal of informed consent is to help the parent understand what care is being proposed, the risks and benefits involved, and reasonable alternatives. It is the discussion, in terms understandable to the parent, that is the basis of true informed consent.
J Laryngol Otol 1994;108: pituitary macroadenomas: a consecutive retrospective study with 19–22 13 patients] buy cheap carafate 1000 mg on-line. J Neurooncol croscopic approach for pituitary adenomas and other parasellar tu- 2001;54:187–195 mors: a 10-year experience order carafate 1000mg with amex. Endoscopic endonasal 256 purchase 1000 mg carafate, discussion 256 transsphenoidal approach: outcome analysis of 100 consecutive pro- 52. Minim Invasive Neurosurg 2002;45:193–200 surgery: principles of endonasal oncological surgery. Comparison of endonasal endoscopic surgery and 2008;97:658–664 sublabial microsurgery for prolactinomas. Brief history 375, discussion 375–376 of endoscopic transsphenoidal surgery—from Philipp Bozzini to the 36. Laryngoscope 1992;102: 1999;109:1838–1840 198–202 Extended Endonasal, Endoscopic 24 Transsphenoidal Approach versus Craniotomy for Giant Pituitary Macroadenomas Christoph P. Schwartz With the exception of medically treatable prolactinomas, sur classifed tumors as follows: type A, tumor that is bulging gery is the frst-line treatment for symptomatic giant pituitary into the chiasmatic cisterns; type B, tumor that reaches the adenomas. The surgical treatment for giant pituitary mac foor of the third ventricle; type C, large suprasellar tumor roadenomas has evolved considerably over the past 100 years growth into the third ventricle up to the foramen of Monro; including the development of the transsphenoidal approach, and type D, tumors that extend into the anterior or middle extended transsphenoidal approach, endoscopic endonasal cranial fossa. The suprasellar extensions techniques can be employed for the treatment of giant pitu of macroadenomas were graded, and the giant tumors were itary macroadenomas; sometimes both approaches have been considered to be grades C and D. Maximiz with >3 cm suprasellar extension above the foramen of ing the extent of resection in the setting of a low morbidity Monro or a grade C tumor with asymmetrical or multiple and mortality rate is also a goal of surgery. Not all giant pi cal experience with transcranial surgery for pituitary tumors tuitary adenomas extend into the third ventricle, and other in general led to development of extracranial approaches to studies have limited them to tumors over 3 or 4 cm in diam the sella. He then used a sub The use of the microsurgical technique in combination frontal and middle fossa approach with a mortality rate of with traditional transfrontal or transtemporal approaches 20% in 10 patients between 1904 and 1906. At the same to giant pituitary adenomas led to a substantial reduction time Krause27,28 removed a pituitary tumor using a mostly in operative mortality. McArthur29 incor with giant pituitary adenomas measuring >4 cm in diam porated removal of the supraorbital ridge and orbital roof eter, there was only one postoperative mortality second to expose a pituitary tumor in 1908. These techniques were later modifed had evidence of hypopituitarism before surgery. Postop by Cushing,32 Dandy,3 and Heuer,33 and a large experience eratively, seven patients had improvement in their endocri with transcranial surgery for pituitary tumors was devel nologic and ophthalmologic symptoms, and the rest were oped. However, a radical excision was not achieved to open the sylvian fssure and refnement of the pterional in any of the 21 patients52 (Table 24. In contrast, in a se approach with sphenoid wing removal, Yasargil et al37 ries of 319 patients with pituitary adenomas, there were described an unobstructed direct view to the parasellar 21 patients with giant adenomas (the authors defne giant structures. The shift from macrosurgical approaches to micro adenomas vaguely as adenomas with massive suprasellar surgical approaches in the 1970s dramatically reduced the extension) who underwent transcranial tumor resection morbidity and mortality of transcranial surgery for giant with a subfrontal pterional approach. Postoperative worsening of visual function occurred in ventricle, and to minimize brain retraction (orbitozygo two (9. Following transcranial surgery there was one peri The operative mortality after transcranial surgery for operative mortality secondary to a pulmonary embolism 2 giant pituitary adenomas was unacceptably high in the months after surgery. These complications were greater in the transcranial 250 Endoscopic Pituitary Surgery Table 24. In one series of 40 patients with giant pituitary rate, 57%, seen in the group who underwent radical surgical 24 Extended Endonasal, Endoscopic Transsphenoidal Approach versus Craniotomy for Giant Pituitary Macroadenomas 251 removal. This decreased to 26% in the partialremoval I Transsphenoidal Surgery for Giant group. Worsening postoperative vision was noted in 10% Macroadenomas after transcranial surgery, and the authors did not spe cifcally report on endocrinologic outcomes7 (Table 24. The transsphenoidal approach for the resection of a pituitary The high mortality rate led them to shift to an initial trans tumor was frst described by Herman Schlofer54 at the Uni sphenoidal removal of the intrasellar component of the versity Clinic in Innsbruck, Austria. He performed a superior tumor and decompression of the suprasellar component if nasal transsphenoidal approach on a 30yearold man with it descends during the operation. At that who was found to have an enlarged sella on a lateral skull time, suprasellar components descended into the vacant xray. Although the surgery proceeded without serious com sella space and a second transsphenoidal or transcranial plications, the patient died postoperatively from obstructive operation was performed. During the following years the transsphe tients no operative mortality or major complications were noidal approach was modifed, and Harvey Cushing was the reported; however, specifc endocrine outcomes were not frst to present a large clinical series of 231 transsphenoidal reported. However, the cause of death presented with visual loss had postoperative resolution, and was diferent depending on the approach. Clinical follow-up use of skull base techniques substantially decreased the data were available for almost all patients. Ten years after operative morbidity and mortality of giant pituitary ad the operation half of the patients were still alive. In a series of 210 patients with large or giant pitu tive impaired vision improved in approximately two thirds itary adenomas with suprasellar and parasellar extension, of patients. Two major disadvantages of the transsphenoidal a classic frontotemporal transcranial approach was used approach prompted Cushing to abandon the transsphenoidal for the frst 120 patients and an extradural transcavernous approach. First, given the lack of preoperative imaging, pos skull base approach was used for the next 90 patients. Consequently, tumor was left tradural exposure of the cavernous sinus, and it combined behind and caused half of the perioperative mortality associ intradural and extradural transcavernous tumor resection. Second, highpower Although the author’s exact defnition of giant adenoma illumination or magnifcation was not available, which se was unclear, these tumors required transcranial surgery verely limited access and visibility. Hence, in the late 1920s for removal of their various suprasellar and parasellar ex Cushing preferentially used the transfrontal approach, as it tensions. With the classic approach in patients undergoing allowed for intraoperative visualization of suprasellar tumor their frst operation, complete resection was achieved in extension and better decompression of the optic chiasm. Two technologic milestones paved In contrast, with the extradural skull base approach, com the way for the revival of the transsphenoidal technique. None of the intraoperative use of the operating microscope improved the patients who underwent the skull base approach had intraoperative illumination and visualization. Specifc anterior or posterior pi a high incidence of complete tumor removal and low compli tuitary endocrine defcits were not reported. No periop cation rate was reported for the transsphenoidal resection of erative mortalities were described with either approach pituitary microadenomas. Of these lesions, 44% had suprasellar extension The other main advantage of the endonasal approach is the and 15% were intrasellar macroadenomas. In this series development of expanded approaches, in which large areas there was no perioperative death. Importantly, Black and of bone of the anterior skull base are removed to increase vi colleagues correlated complications with tumor size.
These patients usually are smokers who have hypertension or the metabolic syndrome generic carafate 1000mg otc. These conditions purchase cheapest carafate, like diabetes buy carafate once a day, result in elevation of advanced glycation end products in the blood, which affects glomerular matrix pro- duction and turnover. It is not illustrated here because it is indistinguishable from nodular diabetic glomerulopathy; it is a diagnosis of exclusion. This case of immunotac- toid glomerulopathy contains deposits composed entirely of uniform compact masses of microtubules. In established diabetic glomeru- lopathy, there is diffuse mesangial matrix expansion and acellular mesangial nodule formation known as Kimmelstiel-Wilson nodules. The severity of mesangial expan- sion and nodule formation is remarkably variable both between glom- eruli and within a glomerulus. This image shows a large nodule and smaller nodules with several mesangial regions showing no nodule for- mation, only mild mesangial sclerosis. In this example of mild diabetic glomerulopathy, note that in addition to mesangial matrix expansion there is mild seg- mental mesangial hypercellularity, a common feature Fig. A ﬁnding highly correlated with but not speciﬁc for diabetes is the combination of afferent and efferent arteriolar hyalinosis. Despite the severity of the arteriolar lesions, the glom- erulus does not show severe mesangial sclerosis 248 6 Glomerular Diseases 6. The mutations result in marked elevation of the plasma concentrations of unesteriﬁed cholesterol, triglycerides, and phosphatidylcholine, with resultant lipid deposition in multiple organs. Patients present as a neonate or in child- hood with proteinuria; renal insufﬁciency develops several decades later. The ﬁrst ultrastructural abnor- mality that develops in diabetic glomerulopathy is capillary loop base- ment membrane thickening. The pallor is caused by the accumulation of foamy lipid within the mesangium and capillary loops. The subtle vacuolization is strates the abundant lipid deposits that have expanded the mesangium more apparent at higher magniﬁcation, especially within the mesan- and involve the capillary loops. There is capillary loop thickening, but its cause may be uncertain ing processing, leaving the mesangium and capillary loops riddled with because the presence of abundant lipid deposition is difﬁcult to lucent defects (arrows). The subendothelial appreciate lipid deposits in this case have induced capillary loop basement mem- brane duplication. The vacuolated nature of the lus, lipid deposits have occluded the capillary loop and permeate expanded mesangium is readily demonstrated on silver stain. Although much of the lipid material lary loop basement membranes also may have a vacuolated appearance has been extracted during processing, there are black lamellar and cur- or show a double contour. However, the most striking ﬁnding is in the glomerular capillaries, which are distended by pale, wispy-appearing lipoprotein “thrombi” Fig. The lipid is extracted during tissue processing for parafﬁn section, although its protein component remains. However, an oil red O stain on frozen tissue typically is impressive, demonstrating abundant lipid in the capillary loop lipopro- tein thrombi Fig. Males are severely affected; they present with proteinuria, and progressive renal failure develops over several decades unless treated. Females have variable enzyme levels and therefore exhibit a wide range of severity. This image shows numerous lipid vacuoles (arrow) with a proteinaceous matrix ﬁlling a distended capil- lary loop. The glomeruli in Fabry’s disease show cytoplasmic vacuolization, most prominent in podocytes, as shown here. Admixed with the lipid is granular electron-dense proteinaceous material of unknown composi- tion. In this glomerulus from a female carrier of glomerulus show striking enlargement and vacuolization. The mesan- Fabry’s disease, who presented with proteinuria and normal serum cre- gium shows no abnormality. Masson trichrome stain atinine, silver stain reveals two vacuolated podocytes, one of which is markedly enlarged. This glomerulus is from a female carrier of embedded tissue for electron microscopy allows appreciation of the Fabry’s disease presenting with proteinuria and normal serum creati- true extent of lipid deposition. This electron micrograph shows numerous osmophilic (black) lamellated lipid inclusions within the podocytes. In nephrosialidosis, the oligosaccharide storage products accumulate within glomerular podocytes and endothe- lial, interstitial, and occasionally proximal tubular cells. This electron microscopic image shows the distinctive lamellated nature of the intracellular inclusions, which are known as myelinosomes or myeloid bodies 254 6 Glomerular Diseases Fig. Hale’s colloidal iron stain graphically demonstrates the magnitude of the oligosaccharide storage (Courtesy of Fig. Remaining are largely empty intracellular vacuoles containing a small quantity of residual electron-dense membranous material. They have coarse facial features, psychomotor retardation, joint contractures, deformed long bones, valvu- lar abnormalities, respiratory symptoms, and renal disease. Proximal tubular dysfunction occurs with hypercalciuria, hyperphosphaturia, and aminoaciduria. There is more abundant lamellar electron- dense material in the podocytes than in the above case. The disease ﬁndings bear strong resem- blance to those observed in nephrosialidosis, but interstitial cells and endothelial cells are not affected. The vacuoles have modest amounts of lamel- lar material, which might raise the possibility of Fabry’s disease. Renal enlargement, proteinuria, and distal tubular aci- dosis develop, followed by nephrocalcinosis and renal failure. Histologically, glomerulomegaly is present and tubules are vacuolated as a result of extraction of the retained glycogen. The vacuolated or cleared-out apical cytoplasm (arrow) is more apparent at higher magniﬁcation. The mutations result in lysosomal accumulation of cystine lead- ing to multiorgan damage. Patients present with Fanconi syndrome, which if untreated is followed by renal failure and death by age 10 years (see Figs. Juvenile cystinosis causes mild mesan- gial matrix expansion and affects the podocyte in a distinctive fashion, causing multinucleation. There were scattered multinucleated podo- cytes in this case, although not every glomerulus showed this ﬁnding. The transsphenoidal approach is the result of an evolution- ary process rather than a revolutionary one. Many neurosurgical (and nonneurosur- gical) pioneers have contributed to their development.
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domain: biology


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Mysterious artist chillpill is sharing his proper debut single today. Titled "Fuck the Club," it's kind of exactly the vibe for this quarantine life, a reminder that it's perfectly OK not to leave the house, especially right now.
The new song is a collaboration with GOLDN, but it comes as chillpill has already built a hefty résumé, having written and produced for the likes of DJ Khaled, Nicki Minaj, Lil Wayne, Big Sean, Future, Major Lazer, Panic! At The Disco and more.
"On the surface level, it's a fun genre-blending project, almost a tongue in cheek flip on pop culture," says chillpill of the new song. "On a deeper level, it's really a dark comedy and commentary on the state of the music industry."
The song arrives today with an accompanying video, which can be seen below. And stay tuned for more from chillpill.

domain: entertainment


text:
- President Samia Suluhu claimed women with flat chests were not attractive candidates for most men
- The president attributed intense physical exercise female footballers undergo to their "flat chests"
- Suluhu expressed worries over the future of female soccer players, suggesting that most men may not seek their hands in marriage due to their presumed masculine physic
President Samia Suluhu of Tanzania has come under blistering criticism after she made remarks that suggested flatchested women are not as attractive to men as compared to their counterparts who have "well-endowed" chests.
Speaking on Sunday, August 22, Suluhu claimed that flat-chested women were not the best candidate for marriage, suggesting most men preferred women with 'decorated' chests as mates.
"Samia attributed intense physical exercise female footballers undergo to their "flat chests", Daily Nation reported.
In her speech, she joked that some of the lean-bodied sportswomen had masculine bodies and hardly looked like women.
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"Because of those flat-chests, you might think they are men and not women. And if you look at their faces you might wonder... because if you want to marry, you want someone who is attractive, a lady who has the qualities that you want," she said.
Samia expressed her worries about the future of women footballers stating that their career requirements were dealing a blow to their feminine appearance. This, she said, may deter most men from asking for their hand in marriage.
"Today they are making us proud as a nation when they bring trophies to the country but if you look at their lives in the future, when the legs are tired from playing, when they don't have the health to play, what life will they be living?" she said.
The president said marriage was like a dream to most of the players since men are even afraid of them because of their physical appearance.
"The life of marriage is like a dream to them. Because even if one of you here takes them home as your wife, your mother will ask if they are a woman or a fellow man."
Here are some reactions to Suluhu's remarks that irked many:
"The comment by president @SuluhuSamia on women footballers is a humiliation to all women, all women deserve respect."
"So all those cheering a female presidency...@SuluhuSamia is denigrating female football players for having 'flat chests' and thus lacking attractive features necessary to get married. You must be proud @AWLNetwork,

domain: news


text:
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domain: food


Dear friends, esteemed colleagues!
We wish you a happy New Year and merry Christmas from the bottom of our hearts!
We are expressing our sincere gratitude to all Antipinsky Oil Refinery’s employees for the enormous amount of work enabling the company to attain high performance results.
It is thanks to your perseverance, team spirit and professionalism that we were able to achieve one of the company’s strategic development goals – launching of secondary oil refining processes at our enterprise.
We have successfully completed the construction of the second stage of Workflow III and commissioned our diesel fuel hydrotreating unit with the capacity of 3 M tons per annum. Thus, the refinery built from scratch in a short time started the production of Euro-5 compliant diesel fuel.
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Another important stage in the refinery’s development was the upgrading of ELOU AT-3 oil refining unit enabling the increase in the unit throughput capacity from 3.7 M to 5 M tons. Thus, as of today, the Antipinsky Oil Refinery’s total capacity comes to over 9 MTPA being 20 times higher than the capacity of the refinery's Workflow Stage I launched in 2004.
The coming year will demand maximum concentration of efforts, a clear focus and commitment from all of us. May the new year bring good luck, joy and happiness to your homes, confidence in your own strengths and the support of your colleagues who will always come to your help in a difficult moment for the sake of our common cause.
Board of Directors of Antipinsky Oil Refinery


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The Tamil Nadu unit of BJP today announced pro-NEET demonstrations across Tamil Nadu tomorrow to counter protests against the entrance test centered around the death of a 17 year-old medical aspirant.
The demonstrations in support of the National Entrance cum Eligibility Test would be held in 49 locations in all 32 districts of the state and led by leaders and functionaries, including the party's national Executive Member H Raja, a party release said.
The BJP's announcement comes in the wake of state-wide protests by student bodies and pro-Tamil outfits seeking 'justice' for 17-year-old Anitha, a medical aspirant from Ariyalur who allegedly committed suicide on September 1. The Dalit girl, who had earlier moved the Supreme Court against the National Entrance cum Eligibility Test (NEET), had committed suicide apparently upset over Tamil Nadu not being exempted from the entrance exam. Since then, BJP has come under attack from opposition parties including DMK and the Left over implementation of NEET while students and pro-Tamil outfits have been seeking withdrawal of the entrance exam.
The apex Court had last month asked the state government to start counselling for admissions to MBBS and BDS courses in the state based on the NEET merit list. Critics of NEET claim the new system would be disadvantageous to state board students. State BJP President Tamilisai Soundararajan had on September 9 defended the NEET and accused the opposition parties of indulging in negative politics.
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domain: politics


text:
Neil Young ended his Blame Canada tour in a bizarre way.
At his last anti-oilsands concert in Calgary, he left his five diesel tour buses idling outside throughout the entire concert.
They kept burning fuel. “Bio-diesel,” we’re assured, trucked in from the U.S.A., so I guess that’s OK.
Inside the concert, Young did something even weirder. All week, he had been comparing the oilsands to Hiroshima, claiming it caused cancer, that there was no reclamation of the land afterwards, that it caused pollution in faraway China, etc.. But then on Sunday, he said he was fine with all of it — he could actually support the expansion of the oilsands — if “the First Nations treaties (are) honoured.”
Huh? So all that Hiroshima talk was just a bargaining chip to get some legal tinkering?
It’s uncertain what Young means by “honouring the treaties,” which happened to be the name of his concert tour. Actually, “Honor the Treaties” was the title of his tour. It was designed in California, and they don’t spell honour with a u down there.
They don’t do a lot of treaty honouring or honoring in California. It’s a state that didn’t sign any treaties with its Indians. They pretty much just wiped them out, including the Tongva tribe that used to live near Young’s massive 1,500-acre estate. Juana Maria was the last of the Tongva, and she died in 1853. Which is why Neil Young has to come up to Canada to lecture people about Indians.
Unlike California, Alberta signed a treaty with all of its Indians.
Young’s inability — over an entire week — to come up with a single example of how we’re not honouring them is easy to explain: “As far as me not knowing what I’m talking about, everybody knows that, that couldn’t be more obvious, I’m a musician.”
That aw-shucks routine gets Young out of situations where he embarrasses himself. But it’s just an act. You don’t amass a fortune of
$65 million without being a sophisticated operator. And a sophisticated operator doesn’t start a multi-city concert tour without a deep-pocketed investor.
And that investor just happens to be an anti-oilsands lobby group in California called the Tides Foundation.
They’re the same ones who wired $55,000 directly into the bank account of a numbered corporation of the northern Alberta Indian chief who joined Young on tour.
While we don’t know the details of the payments, or how much if anything Neil Young was paid to perform on the tour, it sure looks to me like Tides sponsored the whole tour.
Honor the Treaties has one “fiscal sponsor,” called the Lakota People’s Law Project. And their major donor is the Romero Institute — an anti-industry group. And their big donor is the Tides Foundation — almost half a million dollars in just the past few years.
All of them are located just a few miles from each other — and Young’s estate — in California.
It’s not often that a lobby group sponsors a concert tour. Normally it’s a financial investor, looking to make a profit. Or a marketing sponsor like a beer or soft drink company. But Tides wasn’t looking to sell itself; it likes to stay in the shadows and use wire transfers and numbered companies.
Each year, Tides pays out more than a million dollars to anti-oilsands groups in Canada.
But how many people who went to Young’s concerts knew they were being marketed to by San Francisco lobbyists?
And how many reporters, covering that “independent artist” Neil Young, knew his tour was part of a Tides campaign?


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Hot Illustrations for Youth Talks: 100 Attention-Getting Stories, Parables, and Anecdotes - eBook
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Covering a wide range of topics from self-acceptance to worship, this extensive collection gives you 100 attention-getting stories, parables, and anecdotes from some of youth ministry's best speakers, including Tony Campolo, Les Christie, and Mike Yaconelli. Sure to gain a hearing.
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Your search for lively illustrations to spice up your youth talks is over. Hot Illustrations for Youth Talks is here! Veteran youth worker and nationally known speaker Wayne Rice has carefully selected and crafted 100 of the best stories, parables, and anecdotes available anywhere. Rice has collected these illustrations form his own files and from files of some of youth ministry's best speakers -- Mike Yaconelli -- Tony Campolo -- Dewey Bertolini -- Chap Clark -- Les Christie -- Ray Johnston -- Len Kageler -- Rick Bundschuh --- and many more! These stories (all indexed by topic) cover a lot of youth ministry ground -- some will make you laugh, some will make you cry, and all of them will make you think. And they all work with teenagers. They're just the thing to give your youth talks that extra spark you're looking for. You'll love what Hot Illustrations for Youth Talks will do for your youth talks. And your kids will love you for it!
Wayne Rice is founder and director of Understanding Your Teenager (UYT), an organization serving parents of teens and pre-teens. He is adjunct professor of youth ministry at Bethel Theological Seminary (San Diego) and at North American Baptist Seminary in Sioux Falls. He lives with his wife in Lakeside, CA.
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Gaming Merchandise UK Ltd is now open for business.
The company has been set up by industry veteran Luiz Ferreira, who has closed his previous business – accessories and merchandise firm White Room Games – to concentrate on the new venture.
Gaming Merchandise UK will be dedicated to bringing games-branded apparel, toys and other assorted products to retail.
It has already signed the distribution rights for Gaya Entertainment’s catalogue, and now offers products based on the Half-Life, Dota and Temple Run series.
We see the merchandise category growing over the next few years, particularly given that the next generation of consoles will deliver a higher percentage of digital sales than previous generations,” Ferreira told MCV.
More publishers are considering merchandise earlier in the development of franchises.”


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The Last of Us Part I PC Slightly Delayed to Make Sure It “Lives Up to Standards”
The infection is coming.
Naughty Dog has just revealed that it will be delaying The Last of Us Part I PC port to ensure that it is up to the high standards that it has set and that fans expect from the series. The news came by way of a tweet earlier today, which fully detailed the slight delay and the reasoning.
When Does The Last of Us Part I Come Out on PC
While it was originally set to hit PC on March 3, 2023, The Last of Us Part I PC has been pushed back until March 28, 2023. According to the team, these few weeks will allow them to polish up certain parts of the game to avoid any bugs or errors upon release.
Over the past few years, PC releases have become more prominent for PlayStation-exclusive titles, and it seems that Sony has put a heavy emphasis on releasing the best port possible for these games, as seen with titles like Death Stranding and Uncharted.
In other Last of Us news, the live-action adaptation has been taking over the internet as of late, with the recent episode about Bill and Frank being raved about as one of the best episodes of television ever made by many. Anyone interested in checking out the show can do so every Sunday at 9 PM EST via an HBO subscription.
We’ve also got plenty of great coverage for both the game and the show right down below for you as well, so be sure to check out all of those great features, news, and guides.
- GAMIVO Offers Great Deals on Upcoming Games, Including The Last of Us: Part 1
- Bizarre The Last of Us Subreddit Rule is Relevant For the Grossest Reason
- Joel’s Kill Count in HBO’s The Last of Us Is Peanuts Compared to the Game
- Every Major Difference Between The Last of Us Show & Game
- Was Joel Right to Save Ellie in The Last of Us? Answered

domain: hobby


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Blockshipping, a digital platform to register 27 million containers, and the brainchild of several former Maersk executives, was unable to raise the necessarry funding through an ICO. CEO Peter Ludvigsen talks to ShippingWatch about the next steps for the venture.
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|Minimum Stay||6 nights|
This home is situated on a very private cove that has access to the gulf of Mexico. You can observe a variety of water bird such as Egrets, cormorants, osprey, pelicans, blue herons etc. from the large deck overlooking the water. You can also see dolphin and in winter you can occasionally see Manatee. Fish right of the deck and catch snook, redfish, sea trout, jacks and many other types of fish. Bring your own power boat, sailboat, canoe or kayak or rent them from nearby outfitters. There is a large floating dock for your use.
The home is a single story so you can walk directly out of the family room to the covered patio with in-ground pool with attached Jacuzzi. There is also a sliding door for access from the master bedroom. No stairs to deal with. The Jenn-air barbeque and the jacuzzi are heated by propane and is included in the rental. The front yard of the property is surrounded by a 8' high privacy wall and the back yard is very private.
Inside you'll find everything you need to feel right at home including a 50' Plasma TV. The kitchen has been recently remodeled including granite countertops, stainless steel appliances etc. There is a pool table for your use as well as a computer with internet service. Also included is wireless internet for your laptop computers. The master bath has also been recently remodeled including a Jacuzzi tub.
Keywords: Waterfront , private,
We enjoyed our week here. Quiet and convenient location, nice pool, excellent fishing off the dock. The house had everything we needed. Our teens especially enjoyed the fishing and the pool table! We look forward to returning!
This property was the perfect vacation home for our family! My husband enjoyed fishing from the dock and caught a variety of fish every day we were there. A few mornings he even saw dolphins. Our kids enjoyed the pool which was clean and a good size for them. The overall house was clean and well kept. We also found it to be more spacious than the pictures depicted. We comfortably slept 7 adults and 3 children. Our kiddos slept on air mattresses that we brought and there was ample floor space for them. The location was perfect for us as we have family in the Port Richey area but we also found it convenient to several local beaches and a short drive to Clearwater Beach. We only had one issue with one of the AC units but the owner responded quickly and it was easily fixed. We would definitely recommend this property to others and hope to return for our next family reunion.
Place was very nice to stay the area is great fishing right off the dock. We caught a stingray. Swimming pool was very nice. Very good vacation thanks...
This house was everything we wanted and more. We saw dolphins swimming from the dock. The location was convenient and the owner was very helpful. We recommend this house and look forward to returning in the future.
Great vacation experience. From relaxing by the pool to fishing of the dock. House has everything youay need.
Definitely will be staying again in future.
What a wonderful place for a vacation. The home was clean,quiet and equiped with everything you could possible need. It was so quiet that we lost track of time and even what day it was.Sitting outside beside the pool and watching the fish and the birds was marvelous. It really didn't want to leave. Rob is a very courtious and professional person to rent from. He even gave me back my security deposit the day I left. I f you want a clean quiet,spacious and all around great place to relax in, this is it.
|Refundable damage deposit||$200|
|Cleaning Fee||$100 + Tax|
There is a $100.00 cleaning fee regardless of duration.
Weekly minimum rental during peak season
Standard rate applies to all holiday weeks during summer season

domain: travel


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While the fate of fall championships will be left up to each of the NCAA’s three divisions, the NCAA’s Board of Governors announced Wednesday an array of requirements for schools and conferences if they want to play fall sports, including football, amid the coronavirus pandemic.
“The board expressed serious concerns about the continuing high levels of COVID-19 infection in many parts of the nation. The board has determined that it will only support moving forward with fall championships and other postseason play if strict conditions are applied and adhered to,” the NCAA said in a news release.
Those conditions, which span the preseason, regular season and postseason, include schools and conferences strictly following the NCAA’s return-to-sport guidelines and adhering to federal, state and local COVID-19 guidelines.
The conditions also provide protections for athletes after football players from the Pac-12 and Big Ten expressed concerns about playing in 2020 while calling out the NCAA’s “lack of leadership with respect to player safety.”
NCAA COVID-19 protections for athletes
For instance, the NCAA says it will establish a phone number and email address that allows athletes or their parents to “report alleged failures” in following COVID-19-related protocols by schools. The NCAA will then “notify school and conference administrators, who will be expected to take immediate action.”
Additionally, all athletes “must” be permitted to opt out of their seasons if they are concerned about contracting COVID-19. Schools are required to honor the athletic scholarship of any individual who chooses to opt out.
Other protections for NCAA athletes include prohibiting schools from requiring athletes to waive their legal rights regarding COVID-19 “as a condition of athletics participation” and mandating that schools cover COVID-19 related medical expenses “to prevent out-of-pocket expenses for college athletes and their families.”
“The first and most important consideration is whether sports can be conducted safely for college athletes,” said Michael V. Drake, chair of the NCAA’s board. “Each division must examine whether it has the resources available to take the required precautions given the spread of COVID-19.”
Added NCAA president Mark Emmert:
“Our decisions place emphasis where it belongs — on the health and safety of college athletes. Student-athletes should never feel pressured into playing their sport if they do not believe it is safe to do so. These policies ensure they can make thoughtful, informed decisions about playing this fall.”
The NCAA set an Aug. 14 deadline for each division to determine “eligibility accommodations” for athletes who decide not to participate this fall or for athletes whose seasons are canceled or cut short due to the pandemic.
“College athletes and their families must know what their eligibility status will be before beginning the fall season,” the NCAA said.
What will happen with NCAA fall championships?
The NCAA Board of Governors met on Tuesday and decided that each NCAA division — Division I, II and III — will make its own decision about its fall championships. Those decisions — whether or not fall sports seasons and championships will take place — must be reached by Aug. 21.
Divisions II III did not wait long to make their decisions. Both announced Wednesday that their fall sports championships have officially been canceled. D-III made the announcement first with D-II following suit a few hours later.
— NCAA Division III (@NCAADIII) August 5, 2020
— NCAA Division II (@NCAADII) August 5, 2020
If 50 percent or more of eligible teams in a sport in a division cancel their fall seasons, the NCAA said there will be no fall championships in that sport in that particular division. And if a championship is postponed instead of outright canceled, a decision whether or not to hold the championship at a later date “will be based upon the scientific data available at that time regarding COVID-19, along with other considerations.”
This determination from the NCAA, of course, leaves open the chance for Division I competition to take place while the two lower levels do not play fall sports. And even if Division I fall championships are called off, it would not affect football at the highest level. The Football Bowl Subdivision (FBS) operates separately with its championship governed by the College Football Playoff.
The Division I decision will be left up to the Division I Council, which is scheduled to meet next week.
“We will continue to collaborate with medical experts and engage with the Football Oversight Committee, Competition Oversight Committee and national office championships staff,” said Council chair M. Grace Calhoun, the athletic director at Penn.
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The M20 is the first Windows Mobile device generated by the association of the two companies, and their union brings some interesting features to the table.
Garmin brings its GPS experience, and the result is some interesting location based features. The device will feature a large collection of Points of Interests, and the device will use this data to for example let you know when you are going to be late for your airplane when you enter your flight number.
Other interesting features is the ability to send your location to another phone user by sending a MMS picture of your location on a map. Unlike other software that can send your location this will work with any other phone (except the more poorly featured ones like the iPhone of course). You can also annotate these pictures with a voice note or more pictures taken with the camera.
The M20 will automatically enter car GPS navigation mode when you place it into its cradle, but it also has a unique feature of automatically remembering the location when you remove the phone from the cradle, meaning you can easily return to where you parked your car.
A feature which is probably more Asus than Garmin is the lock screen which comes on when you get a call. When a call comes in you are presented with two puzzle pieces, which you have to drop in the appropriate spot to either take or ignore the call.
The devices will either come with European or US maps. Release date and pricing is not known yet.
Read more at PDA.Pl here.


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Home » Unlabelled » Common cold treatment, dietaris and home remedies
Common cold treatment, dietaris and home remedies
The common cold is a self-limited contagious illness that can be caused by a number of different types of viruses. The common cold is medically referred to as a viral upper respiratory tract infection. Symptoms of the common cold may include cough, sore throat, nasal congestion, runny nose, and sneezing. More than 200 different types of viruses are known to cause the common cold, with rhinovirus causing approximately 30%-35% of all adult colds.
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WARNING! Rice Shortage Is Coming Next Year
Come 2019, Nigerians may have to contend with rice shortage.
This is going by the warning from the federal government that because of the heavy flood in about 14 states, there could be shortage of rice.
It warned that if adequate measures were not taken to replant the rice affected by severe flood in some states, Nigeria might experience shortage of the staple by 2019.
The Minister of Agriculture and Rural Development, Audu Ogbeh, stated these at the inauguration of the National Agricultural Seed Council Molecular Facility and the 2018 Seed Fair and Farmers’ Field Day in Abuja on Thursday.
According to him, the flood affected some major rice-producing states and this might be risky in terms of rice availability in the country if not addressed.
Ogbeh outlined some of the affected states to include: Kebbi, Jigawa, Anambra and Kogi.
He said, “We have to find a way to reach out to farmers who have lost their crops, because in places like Jigawa, Kebbi, Anambra and Kogi, many farmers lost everything they planted.
“New varieties of rice are being produced at the National Agricultural Seed Council, the Faro 66 and 67, which are flood-tolerant; we hope to get them into the field in large quantities for farmers to plant in the near future.
“We are also hoping that as soon as the rain recedes, we encourage farmers to replant so that the residual moisture in the soil plus irrigation can give up another crop, maybe by the end of December or early January. Otherwise, we may be in serious trouble for millet, rice, maize and sorghum.”
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MADISON, Wis. (AP) -- A judge says he'll issue a decision on whether to block laws Republicans passed during a lame-duck legislative session within 24 hours.
Five unions filed a lawsuit in Dane County in February arguing the laws violate the separation of powers. Judge Frank Remington heard hours of oral arguments Monday. At the conclusion of the hearing he said he will issue a written decision on whether to order a preliminary injunction blocking the laws or portions of them by the end of business Tuesday.
Remington wouldn't say how he would rule but did say the order will deny Republican legislators' request to dismiss the lawsuit.
Another Dane County judge has blocked the laws in their entirety in a separate lawsuit last week. The 3rd District Court of Appeals is considering whether to stay that order.
The laws limit Democratic Gov. Tony Evers and Attorney General Josh Kaul's powers. Republicans passed the statutes in December, just weeks before Evers and Kaul took office.
Evers says he is moving ahead "as quickly as possible" to fill vacancies after a judge's ruling last week struck down 82 appointments Republicans made during a lame-duck legislative session.
Evers told reporters Monday that he doesn't know how quickly he can fill the positions, but some of the posts may go to people who previously held them. One opening is on the University of Wisconsin Board of Regents and another is on the Public Service Commission.
Evers' attorneys released a brief in opposition to the legislatures emergency motion to stay the temporary iniunction pending interlocutory appeal.
Republicans have asked a state appeals court to put the ruling striking down the lame-duck laws on hold.


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Celtic: Lennon resigns after traumatic second stint
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Celtic have decided to snub the chance to give Rangers a guard of honour when the two sides meet in Sunday’s Old Firm derby. The two sides clash at Celtic Park on Sunday (12pm) in what will be the first meeting between the two sides since Rangers were crowned champions nearly two weeks ago.
Steven Gerrard’s side were dumped out of the Europa League last night by Slavia Prague following a 2-0 defeat at Ibrox (3-1 aggregate)>
Now his men will bid to finish the Scottish Premiership season unbeaten after securing their first title in 10 years.
Celtic have the perfect chance to wreck Rangers’ ambitions as they look to lay down a marker ahead of next season.
Earlier this week, former Celtic boss Brendan Rodgers urged his old side to “show humility and class”.
He was involved with a Chelsea side who received a guard of honour from Sir Alex Ferguson’s Manchester United in 2005, something that still resonates with him.
But Kennedy has decided to go down a different route and is not prepared to put rivalries aside.
Rodgers said: “My feeling is always that you should show humility and class and be a sporting team.
“I can never forget when I was at Chelsea as a young coach and in that first season with Jose Mourinho they won the title.
“I remember going to Old Trafford to watch the game and I’m sure that the United players didn’t want to do it.
“That must have been really, really difficult but it showed you the class of Sir Alex and showed you the humility of him.
“It was sporting but can also provide you with great motivation going forward.
“It’s something that for me – despite the rivalry and how difficult it is – you should do and then use it as motivation.”
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Lana Lopesi: Moana Cosmopolitan Imaginaries
In the last decade, a digital native generation of Moana artists have positioned themselves away from the narratives of displacement and non-belonging featured in the Moana art of previous generations, imagining their subjectivity in globally routed, yet locally rooted, ways. Premised on the diasporic, interconnected, and cosmopolitan character of Moana life today, this lecture examines the way this generation of Moana artists imagine their subjectivities, their cultures, and their places in the world through contemporary art.
A well-known author, art critic and editor, Dr Lana Lopesi is Assistant Professor of Pacific Islander Studies at the University of Oregon. She will be speaking to us via live-stream.
About the Gordon H. Brown Lecture series:
Gordon H. Brown is an artist and freelance writer on a wide variety of New Zealand art topics. He has a Diploma in Fine Arts from Canterbury School of Art and between 1960 and 1977 he worked in various significant libraries and art galleries. The author of the classic Colin McCahon: Artist and An Introduction to New Zealand Painting 1839–1967, he was awarded the OBE in 1980 for services to art history.
In 2002 Te Herenga Waka-Victoria University established the Gordon H Brown Lecture series to further art historical scholarship in New Zealand. Recent lectures in the series have been delivered by Albert Refiti, Conal McCarthy, Christina Barton, Damian Skinner, Rebecca Rice, Nicholas Thomas, Deidre Brown, Ngarino Ellis and Jonathan Mane-Wheoki.

domain: artistic


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The bank further said that the threats to Canada’s economy were “roughly balanced” and per se there was no need for modifications at present. However, “the global economy has slowed markedly as several downside risks … have been realized.”
It is the tenth consecutive time that the Bank of Canada announced to maintain the rate, since it increased it to 1.0 per cent from 0.75 per cent in September last year. The bank’s heads sit together every other month to talk about the benchmark interest rate.
Moreover, the bank says it saw some “significant risks” related to the inflation outlook. According to Statistics Canada, Canada’s inflation rate increased to 3.2 per cent in September while the core rate was 2.2 per cent.
“As a result, core inflation is expected to be slightly softer than previously expected, declining through 2012 before returning to 2 per cent by the end of 2013,” the bank said in its statement Tuesday.
Article viewed on: Oye! Times at www.oyetimes.com