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Opponents of sanctions and more forceful measures don't get this. They argue that diplomacy can still succeed – despite decades of failed outreach to Iran's rulers by both Americans and Europeans. They further argue that sanctions are an impediment to diplomacy. Suzanne Maloney, a Senior Fellow at the Saban Center at the Brookings Institute, wrote recently that "the United States cannot hope to bargain with a country whose economy it is trying to disrupt and destroy." The Iranians, she added, "cannot be nudged into a constructive negotiating process by measures that exacerbate their vulnerability."
She has it exactly backward as anyone who has ever been involved in any negotiation should recognize. If we want Supreme Leader Ali Khamenei and the Islamic Revolutionary Guard Corps to stop doing what they are doing – e.g. building nuclear weapons, supporting terrorists, threatening their neighbors, oppressing their own people – we have to do more than "nudge" them. We have to offer them something of great value.
What would Maloney have us put on the table other than an end to sanctions and no use of force -- or no further use of force? What else does she imagine they would accept in exchange for giving up the chance to possess the weapons they see as key to achieving the goals of Iran's Islamic Revolution, which include dominance of the Middle East in the short run and "a world without America" eventually, with the extermination of Israeli men, women and children somewhere along the way?
When conducted between reasonable, peace-loving people, the "art and practice of conducting negotiations" can lead to compromise and the resolution of conflicts. But when dealing with despots, people who respect only power and see even mercy as weakness, there are no talking cures. Iran's rulers see the U.S. as materialistic, decadent, weak-willed and just plain tired of carrying the burdens of leadership. They are convinced Obama will accept what he has called "unacceptable," that, in the end, he will allow the world's worst dictators – and the leading sponsors of terrorism – to arm themselves with the world's worst weapons.
A new round of diplomacy is scheduled to begin next month in Geneva. For there to be any small chance of success Iran's rulers will need to feel pressured and vulnerable – they will need to take seriously the possibility that Americans and/or Israelis have rocks and are prepared to use them.
Clifford D. May is the President of the Foundation for the Defense of Democracies.
Rush Limbaugh defends Rubio's debate answer: He's absolutely right that Obama knows what he's doing | Allahpundit
Time for Team Hillary to break out the gender card for young liberal women who prefer Sanders | Allahpundit


text: You couldn't ask for a cleaner hotel. This place looks brand new (it's only about 7 months old) and has great style. The photos represent the rooms well. We had reservations for 2 nights but decided to stay another night to enjoy the pool/hot tub, comfortable room and just relax. It was great to have a comfortable sofabed so the... More

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January 28, 2016
BY LAUREN HOENEMEYER | August 16, 2010 |
Homepage Latest The Latest
The summer prescription for getting fit? More core—Core Fusion at Exhale Spa Chicago, that is. The latest addition to the class roster, Core Fusion Cardio amps up the calorie burn with an energy-packed fitness experience unlike any other. By merging cardio with Core Fusion's signature strength moves—courtesy of Core Fusion founders Fred Devito (ABOVE LEFT) and Elisabeth Halfpapp (ABOVE RIGHT)—the hour-long workout utilizes all muscle groups for body-shaping results. And because it alternates between free weights and core balls, ab work and cardio components, you'll remain on your toes and engaged. (Combine the cardio version with other Exhale classics like Core Fusion Sport and Core Fusion Yoga for a well-rounded regimen.) The bonus? Not only will your outer self respond to the challenge, your inner self will feel revamped, too. Classes daily; $24 per session. 945 N. State St., 312-753-6500
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iHerb カスタマーレビュー
2 人が、次のレビューが役に立ったと感じています
4649034027884685369により Apr 10, 2013 に掲載
works as it should
1 人が次のレビューが役に立ったと感じています
Reviewer3119083により Apr 16, 2011 に掲載
While not a big fan of high doses of lecithin, this product meets with my approval. I usually take it with a glass of orange juice and the taste is ok to me. It does help my memory and my focus, but it also gets me slightly constipated.
10g = brain fog
1 人が次のレビューが役に立ったと感じています
Reviewer1596539により Feb 26, 2013 に掲載
Gave me brain fog at the recommended amount. Not sure if lower amounts helped with cognitive function or not. I will try this again sometime in the future.
noticeable improvement
5610018190165393149により Nov 11, 2013 に掲載
I have taken this as part of liver-boosting diet in combination with other Now Foods products for that condition. couldn't believe how fast my liver function blood test results improved. And it might be just a coincidence, but there has been some relief in my arm, I have been having pains in ever since I suffered nerve damage in the neck area. And finally, I have even used it in preparing food, deserts mostly.
4913850011091295324により Aug 06, 2013 に掲載


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July 18, 2014
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JACKSONVILLE, Fla. -- Though he has just one offer, from VT, 2016 RB CJ Freeman is still busy at work, as he showed at the Rivals250 Underclssmen Challenge presented by Under Armour. ...More... To continue reading this article you must be a member. Sign Up Now!
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June 12, 2013
Wheaton (Ill.) North senior wide receiver prospect Matt Biegalski (6-foot-2, 190 pounds) added his sixth offer on Tuesday. Biegalski made a recent Big Ten camp and has plans to hit the road hard this month. Get caught up on the latest recruiting news here. ...More... To continue reading this article you must be a member. Sign Up Now!
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Are you Yong-Ming Gao?Claim your profile
Publications (15)28.99 Total impact
Article: Evaluation of Selective Efficiency of Molecular Markers Linked with a Novel Gene Xa39 Resistant to Bacterial Blight in Rice
- [Show abstract] [Hide abstract]
ABSTRACT: Abnormal heading in hybrid rice production has caused great economic loss in recent years, but the genetic basis of this phenomenon remains elusive. In this study, we developed four testcross populations using 38 introgression lines (ILs) from Shuhui 527 (SH527)/Fuhui 838 (FH838)//SH527 population as male parents and four male sterile lines (MSLs; namely II-32A, Xieqingzao A, Gang 46A and Jin 23A) as female parents. Progeny testing allowed us to identify 55 abnormal heading combinations in Hefei, but had late heading date in Hangzhou and Guangzhou of China. By one- and two-way analysis of variance, a total of 21 QTLs and 31 pairs of epistatic QTLs associated with photosensitivity were identified in the four populations, respectively. Genotypic analysis showed that the IL parent of most abnormal heading combinations showed some introgressions at markers RM331 and RM3395 on chromosome 8 (strongly associated with the known genes OsHAP3H/DTH8/Ghd8/LHD1) of donor FH838 alleles, and these two markers were also identified as affecting photosensitivity. The observation that the recipient parent (SH527), donor parent (FH838), their testcross combinations with four MSLs, and the IL parents of abnormal heading combinations had normal heading date in Hefei suggested that OsHAP3H/DTH8/Ghd8/LHD1 showed no independent regulation on abnormal heading in the abnormal heading combinations. It is noteworthy that complex epistasis among RM331 or RM3395 with other loci, including dominant × additive, additive × dominant, and dominant × dominant epistases, were identified only in the four testcross populations of the current study, but not in the SH527/FH838//SH527 population, suggesting the cause of abnormal heading in abnormal heading combinations in Hefei and delayed heading in Hangzhou and Guangzhou.
Article: The 3,000 Rice Genomes Project[Show abstract] [Hide abstract]
ABSTRACT: The 3,000 rice genomes project The 3,000 rice genomes project 1,2,3* Abstract Background: Rice, Oryza sativa L., is the staple food for half the world's population. By 2030, the production of rice must increase by at least 25% in order to keep up with global population growth and demand. Accelerated genetic gains in rice improvement are needed to mitigate the effects of climate change and loss of arable land, as well as to ensure a stable global food supply. Findings: We resequenced a core collection of 3,000 rice accessions from 89 countries. All 3,000 genomes had an average sequencing depth of 14×, with average genome coverages and mapping rates of 94.0% and 92.5%, respectively. From our sequencing efforts, approximately 18.9 million single nucleotide polymorphisms (SNPs) in rice were discovered when aligned to the reference genome of the temperate japonica variety, Nipponbare. Phylogenetic analyses based on SNP data confirmed differentiation of the O. sativa gene pool into 5 varietal groups – indica, aus/boro, basmati/sadri, tropical japonica and temperate japonica. Conclusions: Here, we report an international resequencing effort of 3,000 rice genomes. This data serves as a foundation for large-scale discovery of novel alleles for important rice phenotypes using various bioinformatics and/or genetic approaches. It also serves to understand the genomic diversity within O. sativa at a higher level of detail. With the release of the sequencing data, the project calls for the global rice community to take advantage of this data as a foundation for establishing a global, public rice genetic/genomic database and information platform for advancing rice breeding technology for future rice improvement.
Article: Zhang F, Ma X, Gao Y, Hao X, Li Z.. Genome-wide response to selection and genetic basis of cold tolerance in rice (Oryza sativa L.). BMC Genet 15: 55[Show abstract] [Hide abstract]
ABSTRACT: Cold stress is an important factor limiting rice yield in many areas of high latitude and altitude. Considerable efforts have been taken to genetically dissect cold tolerance (CT) in rice using DNA markers. Because of possible epistasis and gene × environment interactions associated with identified quantitative trait loci, the results of these genetic studies have unfortunately not been directly applicable to marker-assisted selection for improved rice CT. In this study, we demonstrated the utility of a selective introgression strategy for simultaneous improvement and genetic dissection of rice seedling CT. A set of japonica introgression lines (ILs) with significantly improved seedling CT were developed from four backcross populations based on two rounds of selection. Genetic characterization of these cold-tolerant ILs revealed two important aspects of genome-wide responses to strong phenotypic selection for rice CT: (1) significant over-introgression of donor alleles at 57 loci in 29 functional genetic units (FGUs) across the rice genome and (2) pronounced non-random associations between or among alleles at many unlinked CT loci. Linkage disequilibrium analyses of the detected CT loci allowed us to construct putative genetic networks (multi-locus structures) underlying the seedling CT of rice. Each network consisted of a single FGU, with high introgression as the putative regulator plus two to three groups of highly associated downstream FGUs. A bioinformatics search of rice genomic regions harboring these putative regulators identified a small set of candidate regulatory genes that are known to be involved in plant stress response. Our results suggest that CT in rice is controlled by multiple pathways. Genetic complementarity between parental-derived functional alleles at many loci within a given pathway provides an appropriate explanation for the commonly observed hidden diversity and transgressive segregation of CT and other complex traits in rice.
Article: Improvement of Yield and Its Related Traits for Backbone Hybrid Rice Parent Minghui 86 Using Advanced Backcross Breeding Strategies[Show abstract] [Hide abstract]
ABSTRACT: How to overcome yield stagnation is a big challenge to rice breeders. An effective method for quickly developing new cultivars is to further improve an outstanding cultivar. In this study, three advanced backcross populations under yield selection that consist of 123 BC2F2:4 introgression lines (ILs) were developed by crossing Minghui 86 (recurrent parent, RP) with three high-yielding varieties (donors), namely, ZDZ057, Fuhui 838, and Teqing, respectively. The progeny testing allowed the identification of 12 promising ILs that had significantly higher mean grain yields than Minghui 86 in two environments. A total of 55 QTLs that affect grain yield and its related traits were identified, which included 50 QTLs that were detected using the likelihood ratio test based on stepwise regression (RSTEP-LRT) method, and eight grain yield per plant (GY) QTLs were detected using chi-squared (c2) test. Among these QTLs, five QTLs were simultaneously detected in different populations and 22 QTLs were detected in both environments. The beneficial donor alleles for increased GY and its related traits were identified in 63.6% (35 out of 55) of the QTLs. These promising ILs and QTLs identified will provide the elite breeding materials and genetic information for further improvement of the grain yield for Minghui 86 through pyramiding breeding.
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ABSTRACT: Floral transition, which is referred to as a plant's transition from vegetative stage to reproductive stage, is considered to be a critical developmental switch in higher plants, for a timely flowering is a major factor of reproductive success. Endogenous and environmental cues, such as photoperiod, light quality, plant hormones concentrations and temperature, provide information to the plants whether the environment is favorable for flowering. These cues promote, or prevent, flowering through a complex genetic network, mediated by a careful orchestration of temporal and spatial gene expression. One of such cues is photoperiod. Rice (Oryza sativa L.) serves as a powerful model species for the understanding of flowering in higher plants, including flower development and photoperiodic control of flowering. In this review, we overviewed and discussed the flower development and its model. We also overviewed the photoperiodic pathways in rice flowering control, and summarized the pathways at molecular level.
Article: Three genetic systems controlling growth, development and productivity of rice (Oryza sativa L.): A reevaluation of the 'Green Revolution'[Show abstract] [Hide abstract]
ABSTRACT: The Green Revolution (GR-I) included worldwide adoption of semi-dwarf rice cultivars (SRCs) with mutant alleles at GA20ox2 or SD1 encoding gibberellin 20-oxidase. Two series of experiments were conducted to characterize the pleiotropic effects of SD1 and its relationships with large numbers of QTLs affecting rice growth, development and productivity. The pleiotropic effects of SD1 in the IR64 genetic background for increased height, root length/mass and grain weight, and for reduced spikelet fertility and delayed heading were first demonstrated using large populations derived from near isogenic IR64 lines of SD1. In the second set of experiments, QTLs controlling nine growth and yield traits were characterized using a new molecular quantitative genetics model and the phenotypic data of the well-known IR64/Azucena DH population evaluated across 11 environments, which revealed three genetic systems: the SD1-mediated, SD1-repressed and SD1-independent pathways that control rice growth, development and productivity. The SD1-mediated system comprised 43 functional genetic units (FGUs) controlled by GA. The SD1-repressed system was the alternative one comprising 38 FGUs that were only expressed in the mutant sd1 backgrounds. The SD1-independent one comprised 64 FGUs that were independent of SD1. GR-I resulted from the overall differences between the former two systems in the three aspects: (1) trait/environment-specific contributions; (2) distribution of favorable alleles for increased productivity in the parents; and (3) different responses to (fertilizer) inputs. Our results suggest that at 71.4 % of the detected loci, a QTL resulted from the difference between a functional allele and a loss-of-function mutant, whereas at the remaining 28.6 % of loci, from two functional alleles with differentiated effects. Our results suggest two general strategies to achieve GR-II (1) by further exploiting the genetic potential of the SD1-repressed and SD1-independent pathways and (2) by restoring the SD1-mediated pathways, or 'back to the nature' to fully exploit the genetic diversity of those loci in the SD1-mediated pathways which are virtually inaccessible to most rice-breeding programs worldwide that are exclusively based on sd1.
Article: QRL affecting field resistance to false smut identified in a rice introgression line population
Article: Development of Introgression Lines and Identification of QTLs for Resistance to Sheath Blight
Article: Development and application of a set of breeder-friendly SNP markers for genetic analyses and molecular breeding of rice (Oryza sativa L.). Theor Appl Genet[Show abstract] [Hide abstract]
ABSTRACT: Single nucleotide polymorphisms (SNPs) are the most abundant DNA markers in plant genomes. In this study, based on 54,465 SNPs between the genomes of two Indica varieties, Minghui 63 (MH63) and Zhenshan 97 (ZS97) and additional 20,705 SNPs between the MH63 and Nipponbare genomes, we identified and confirmed 1,633 well-distributed SNPs by PCR and Sanger sequencing. From these, a set of 372 SNPs were further selected to analyze the patterns of genetic diversity in 300 representative rice inbred lines from 22 rice growing countries worldwide. Using this set of SNPs, we were able to uncover the well-known Indica-Japonica subspecific differentiation and geographic differentiations within Indica and Japonica. Furthermore, our SNP results revealed some common and contrasting patterns of the haplotype diversity along different rice chromosomes in the Indica and Japonica accessions, which suggest different evolutionary forces possibly acting in specific regions of the rice genome during domestication and evolution of rice. Our results demonstrated that this set of SNPs can be used as anchor SNPs for large scale genotyping in rice molecular breeding research involving Indica-Japonica and Indica-Indica crosses.
- [Show abstract] [Hide abstract]
ABSTRACT: Great progress has been made in genetic dissection of quantitative trait variation during the past two decades, but many studies still reveal only a small fraction of quantitative trait loci (QTLs), and epistasis remains elusive. We integrate contemporary knowledge of signal transduction pathways with principles of quantitative and population genetics to characterize genetic networks underlying complex traits, using a model founded upon one-way functional dependency of downstream genes on upstream regulators (the principle of hierarchy) and mutual functional dependency among related genes (functional genetic units, FGU). Both simulated and real data suggest that complementary epistasis contributes greatly to quantitative trait variation, and obscures the phenotypic effects of many 'downstream' loci in pathways. The mathematical relationships between the main effects and epistatic effects of genes acting at different levels of signaling pathways were established using the quantitative and population genetic parameters. Both loss of function and "co-adapted" gene complexes formed by multiple alleles with differentiated functions (effects) are predicted to be frequent types of allelic diversity at loci that contribute to the genetic variation of complex traits in populations. Downstream FGUs appear to be more vulnerable to loss of function than their upstream regulators, but this vulnerability is apparently compensated by different FGUs of similar functions. Other predictions from the model may account for puzzling results regarding responses to selection, genotype by environment interaction, and the genetic basis of heterosis.
Article: Pyramiding Xa23 and Rxo1 for resistance to two bacterial diseases into an elite indica rice variety using molecular approaches[Show abstract] [Hide abstract]
ABSTRACT: Rice bacterial leaf blight (BB) caused by Xanthomonas oryzae pv. oryzae and bacterial leaf streak (BLS) caused by X. oryzae pv. oryzicola (Xoc) are two important diseases of rice that often outbreak simultaneously and constrain rice production in much of Asia and parts of Africa. Developing resistant cultivars has been the most effective approach to control BB, however, most single resistance genes have limited value in breeding programs because of their narrow-spectrum of resistance to the races of the pathogen. By contrast, there is little progress in breeding varieties resistant to Xoc since BLS resistance in rice was a quantitative trait and so far only a few quantitative resistance loci have been identified. We reported here the development of a high yield elite line, Lu-You-Zhan highly resistant to both BB and BLS by pyramiding Xa23 with a wide-spectrum resistance to BB derived from wild rice and a non-host maize resistance gene, Rxo1, using both marker assisted selection (MAS) and genetic engineering. Our study has provided strong evidence that non-host R genes could be a valuable source of resistance in combating those plant diseases where no single R gene controlling high level of resistance exists and demonstrated that MAS combined with transgenic technologies are an effective strategy to achieve high level of resistance against multiple plant diseases.
Article: QTLs affecting morph-physiological traits related to drought tolerance detected in overlapping introgression lines of rice (Oryza sativa L.)[Show abstract] [Hide abstract]
ABSTRACT: Plant photosynthetic traits such as net photosynthetic rate (Pn), stomata conductance (gs), transpiration rate (Tr), and intercellular CO2 concentration (Ci), are known to relate to drought tolerance in plants, but the genetic basis of these traits remains largely uncharacterized because of the difficulty in phenotyping physiological traits in a large mapping population. In this study, a set of 55 overlapping introgression lines (ILs) in the Teqing (indica) background were used to genetically dissect several morph-physiological traits and their relationship with grain yield under water stress and non-stress conditions. These traits included specific leaf weight (SLW), chlorophyll content (CC), leaf stomata frequency (SF), Pn, gs, Tr, and Ci. A total of 40 QTLs affecting the measured traits were identified and mapped to 21 genomic regions in the rice genome. Clustered QTLs affecting Pn, gs, Tr, and Ci in the same genomic regions suggest common genetic bases for the physiological traits. Low or no phenotypic correlations between leaf morphological traits and photosynthetic traits and between morph-physiological traits and grain yield (GY) appeared to be due to inconsistence in QTL effect for clustered QTLs, unlinked QTLs affecting different traits, and to possible epistasis that could not be adequately addressed in this study. Our results indicate that improving drought tolerant (DT) of rice by selecting any single secondary traits is not expected to be effective and the identified QTLs for GY and related morph-physiological traits should be carefully confirmed before to be used for improving DT in rice by MAS.
Article: Identification of functional candidate genes for drought tolerance in rice, Mol. Genet. Genom. 278, 599-609[Show abstract] [Hide abstract]
ABSTRACT: Drought tolerance (DT) in rice is known to be controlled by many quantitative trait loci (QTLs) and involved differential expression of large numbers of genes, but linking QTLs with their underlying genes remains the most challenging issue in plant molecular biology. To shed some light on this issue, differential gene expression in response to PEG simulated drought in 3 unique genetic materials (a lowland rice, IR64 and its derived line, PD86 which has 11 introgressed DT QTLs, and a upland rice IRAT109) was investigated using a PCR-based subtractive hybridization strategy. More than 300 unique subtracted cDNA sequences, covering genes of diverse cellular activities and functions, were identified and confirmed by semi-quantitative and quantitative RT-PCR. Detailed bioinformatics analyses of the data revealed two interesting results. First, the levels and mechanisms of DT of the three rice lines were associated with the number and types of differentially expressed genes, suggesting different DT mechanisms in rice are controlled by different sets of genes and different metabolic pathways, and most differentially expressed genes under drought were able to contribute to DT. Second, there appeared a high correspondence in genomic location between DT QTLs and clusters of differentially expressed genes in rice, suggesting some DT QTLs may represent clusters of co-regulated and functionally related genes. Thus, differential gene expression analyses using genetically characterized materials can provide additional insights into the molecular basis of QTLs and convergent evidence to shortlist the candidate genes for target QTLs.
Article: Li ZK, Fu BY, Gao YM, Xu JL, Ali J, Lafitte HR et al.. Genome-wide introgression lines and their use in genetic and molecular dissection of complex phenotypes in rice (Oryza sativa L.). Plant Mol Biol 59: 33-52[Show abstract] [Hide abstract]
ABSTRACT: Tremendous efforts have been taken worldwide to develop genome-wide genetic stocks for rice functional genomic (FG) research since the rice genome was completely sequenced. To facilitate FG research of complex polygenic phenotypes in rice, we report the development of over 20,000 introgression lines (ILs) in three elite rice genetic backgrounds for a wide range of complex traits, including resistances/tolerances to many biotic and abiotic stresses, morpho-agronomic traits, physiological traits, etc., by selective introgression. ILs within each genetic background are phenotypically similar to their recurrent parent but each carries one or a few traits introgressed from a known donor. Together, these ILs contain a significant portion of loci affecting the selected complex phenotypes at which allelic diversity exists in the primary gene pool of rice. A forward genetics strategy was proposed and demonstrated with examples on how to use these ILs for large-scale FG research. Complementary to the genome-wide insertional mutants, these ILs opens a new way for highly efficient discovery, candidate gene identification and cloning of important QTLs for specific phenotypes based on convergent evidence from QTL position, expression profiling, functional and molecular diversity analyses of candidate genes, highlights the importance of genetic networks underlying complex phenotypes in rice that may ultimately lead to more complete understanding of the genetic and molecular bases of quantitative trait variation in rice.
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Chinese Academy of Agricultural Sciences
Peping, Beijing, China
- Institute of Crop Sciences
International Rice Research InstituteЛос-Баньос, Calabarzon, Philippines


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This hotel is not expensive, and I think you get what you pay for. We expected it to be worse than it actually seemed at first glance, so it was a positive start. However, if you are not from the Netherlands, do not expect to get good service. At this hotel, the staff speak a bit if Dutch and therefore... More
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/ Sport
RAFA BENITEZ today declared that Chelsea are still capable of winning this season's Barclays Premier League despite seeing them sleepwalk to another bore draw and slip seven points adrift of top spot.
Benitez's first two matches in charge of the European champions have now ended without a goal as they made it six league games without a victory against Fulham last night.
A team that looked champions-elect under Roberto Di Matteo little over a month ago now appear incapable of scoring, never mind winning, and their title challenge is floundering by the game.
But Benitez insisted Chelsea have the quality to overhaul Manchester United and Manchester City, who both won again last night.
"Why can't we?" Benitez said defiantly.
"It's still a long way to go. We have to keep going. We will have chances.
"Remember last season when City were ahead and it was 'easy'.
"Then they needed to win their last game. It's a long, long competition."
Interim manager Benitez acknowledged Chelsea were lacking confidence after a run of two wins in 10 that threatens to wreck their season.
He added: "The main thing is to win games. If we do, we'll be there and we can win competitions.
"We need to start doing that and the confidence will come back."
No-one exemplifies Chelsea's plight more than Fernando Torres who, barring a fluke goal, has not found the net for almost two months.
"It wasn't easy for him, or (Eden) Hazard or Oscar," said Benitez.
"We were on top of them (Fulham), regaining the game higher up the pitch, and might have won it in the last minute."
For all their pressure, Chelsea barely tested the opposition goalkeeper as they recorded two straight goalless draws for the first time since Roman Abramovich bought the club.
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Rockstar have released a new trailer of Undead Nightmare. With over 3 minutes of new footage the trailer features the first glimpse of the Four Horses of the Apocalypse in action as well as a glimpse of Bigfoot. Check it out below.
(PS3, Red Dead Redemption: Undead Nightmare, Xbox 360)


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Zurn Double Handle Wall Mounted Pot Filler From the Aquaspec Series
Polished chrome-plated cast brass 8" [203mm] pot-filler faucet with quarter turn ceramic disc cartridges, 3/8" [10mm] short swivel inlets with check stops providing adjustable centers from 7-1/4" [184mm] to 8-3/4" [222mm] and 2-1/2" [64mm] vandal resistant color-coded metal lever handles. Unit is furnished with a self-closing hand held pot filler valve, an insulated handle, a stay open clip, a 60" [152cm] stainless steel hose and a hose hook.
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Has anyone used Jigsawbox?(2 Posts)
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When taking a shit the log is so long that it taps your balls while it falls into the bowl.
Man I just took a dump and that shit was a ball tapper!
by Infidelc April 13, 2010
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December 7, 2011
The 2011 Christmas Bureau Committee, also known as Santa's Helpers, includes (bottom row, from left) Rita Boivin, Nancy Porter, Liz Bates, (second row, from left) Carol Ledwith, Janet Therrien, Jeanne Pray, Marge Klimachefsky, Janet Lindsley, Bonnie Kisselstein, (third row, from left) Linda Fernandez, Sue McKee, Jo Pelcher, Sue Downey, Elaine Gagas, Phyllis Straub, (back row, from left) Jean Baumann, Joy Pople, Bob Johnson, Annette Mott, Carol Lewis, Lauri Bernstein and Barb Seiffert. Missing from the photo are Peachy Vavala, Sandy Baker and Marion Higman.
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B'ville Christmas Bureau seeks community's help
The need is very great this year with nearly 180 families here in the Baldwinsville community asking for help from the Christmas Bureau.
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Welcome to WebmasterWorld Guest from 22.214.171.124
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It could be to make the results less intimidating. Sometimes when I query something Google will report "12,533,562" or whatever insane number of results. I don't want to look through that many pages, even if I could and I give up after a page or two. But if the SE truncated the list to, say, 250 now I'm thinking "well, that's a lot, but I can probably find something good there."
Yes, I know I should reform my query if I get too many results, but how many people (really) know how to use a search engine well?


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SACRAMENTO — Slightly more than a year ago, Tommy Thompson was starring for Granite Bay High School, playing against the likes of Davis and Jesuit.
But in Monday night's friendly match, the diminutive attacking midfielder lined up for the largest game of his life as the Sacramento Republic FC fell 1-0 to the English Premier League side West Bromich Albion in front of a crowd of 7,461 at Bonney Field.
After 58 minutes of up-and-down play, the on-loan San Jose Earthquake received a loud ovation from his hometown crowd as he departed the match with the Republic trailing.
"It's a dream come true for me," Thompson said about playing in front of those fans. "I got kids that I went to high school with out here. I got family out here. It's exciting. It's a great reception here in Sacramento and I'm happy to be a part of it."
Perhaps the best chance of the night was Thompson's in the 32nd minute when an Adam Jahn header fell to him near the corner of the 6-yard box.
The former Indiana Hoosier collected the ball, opened up his hips, and tried to place it far post, but hit it agonizingly wide.
Despite the miss, Thompson's play saw him named man of the match and earned him a Twitter shout-out from West Brom player and English international Joleon Lescott.
"It's really exciting. Me and my family grew up watching (the English Premier League)," the 18-year-old said. "It was really cool to get a chance to actually go against them. I thought we did well and got a good result."
Republic FC started the match on its back foot when defender Nermanja Vuković took down Nigerian international Victor Anichebe in the box just 12 minutes into the match, leading to a penalty kick that Scottish international Graham Dorrans converted for the only goal of the game.
Sacramento battled back into the game, controlling more of the play after that, and when West Brom's Craig Gardner was sent off in the 82nd minute, the Republic began throwing numbers forward to try to get a result.
Unfortunately for the home team, none of its 21 shots came to fruition thanks to nine saves from Modesto-born goalkeeper Boaz Myhill, who represents Wales at the international level.
Notes: Thompson will represent the MLS homegrown players in the first-ever MLS Homegrown Game, part of the MLS All-Star weekend festivities on Aug. 4. Thompson is considered a homegrown player because he came through the San Jose Earthquakes youth academy… This match was the first match that Bonney Field didn't sell out its capacity of 8,000… Adam Jahn of El Macero started and played the first 70 minutes for the Republic.
— Reach Evan Ream at [email protected] or follow him on Twitter @EvanReam


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Panel discussion will feature alumni of Lesley University's Ph.D. Program in Educational Studies
Tuesday, March 12, 2013
The panel will explore the role of collaboration in research, featuring alumni of Lesley University's Ph.D. program in Educational Studies Sadie Burton-Goss, Meenakshi Chhabra and Amy Rutstein-Riley; Chhabra and Rutstein-Riley (pictured) are now Lesley faculty members. Paul Naso, faculty member in Lesley's Ph.D. program in Educational Studies, will moderate the discussion.
Those interested in the impact of educational research, as well as its ability to be ethically responsive in its use and potential effect on people's lives, will benefit from this conversation.
The annual lecture is held in honor of Lesley Professor Emeritus George Hein, Founding Director of the Ph.D. Program in Educational Studies, who will provide a response following the panel discussion. Dr. Hein also founded the Program Evaluation and Research Group (PERG) at Lesley in 1976, which evaluates projects that serve learners in both formal and informal settings – from K–12 and higher education, to museums and community centers.
The discussion will be held Thursday, March 28, 4:30-6:30pm, in the 2nd Floor Amphitheater of University Hall on Lesley University's Porter Campus, 1815 Massachusetts Ave., Cambridge.
A reception, free and open to the public, will follow.
The event is sponsored by the Graduate School of Education and the Ph.D. Program in Educational Studies.
Lesley's Ph.D. in Educational Studies is designed for students who wish to pursue advanced study and scholarship, and make an intellectual contribution to their fields of interests.
Alumna Alex Truesdell (BA '79, MEd '98) wins MacArthur genius grant
New York Times hails Professor Caroline Heller's "Reading Claudius"
Lesley collaborates to create Somerville schools' first innovation lab
Dr. Nancy Carlsson-Paige named "Hero in Education"
View all News
Emily Harney's pictures pack a punchLesley alumna Emily Harney, whose images have been used in Hollywood films "The Fighter," "The Avengers" and "Creed," is one of the only women who photographs boxingThe Boston GlobeFebruary 3, 2016
Moving MasterworksLesley's incorporation of a former historic church into our new Lunder Arts Center demonstrates the challenges and opportunities of relocationArchitectural RecordFebruary 2016
Before the votes are cast: The presidential front-runners, as seen through the eyes of childrenProfessor Emerita Dr. Nancy Carlsson-Paige, co-founder of education advocacy group Defending the Early Years, says the 2016 presidential campaigning "is not an expression of what adult thinking can be"The Washington Post | Inspired LifeFebruary 1, 2016
Diana Nyad puts her reading to good useFamed long-distance swimmer Diana Nyad, who will come to the Lesley University Boston Speakers Series, is interviewed by Boston Globe BibliophilesBoston Sunday GlobeJanuary 31, 2016
Ayaan Hirsi Ali says complacency is problem on campusesOur Boston Speakers Series welcomed the controversial author and activistThe Boston GlobeJanuary 31, 2016
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Stayed 4 nights in this hotel which is only 5mins walk away from the Ishizugawa train station, very conveniently located. Take the Nankai Line to Namba and cost only 320Yen one way - very easy and the ride is about half an hour. Many good and cheap places to eat in this area - ramen shops, family restaurants all within... More
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We are a new multi timezoned clan, which means there is no location requirements.We participate in all all game types ( core and hardcore). If you would like to join add myself baj2332.
REQUIREMENTS all applicants must:
Have a K/D ratio of atleast 1.0
Have a microphone and use it for clan wars
Attend atleast one clan even or war per week
Accept clan game invitations when online if not already busy
16 or older
Clan events wll be held weekly to set up squads for clan wars,
SQUAD WARS:we want to have multiple teams who play well as a unit.Face off against other squads and players within the clan to EARN your position on the top squad, we would like to have 5 squads and keep our clan tight knit and not to over excessive
Weapon Specific matches: want to play and all sniper game, or all pistol game we will have events set up to support that
We as a clan are currently you in the platinum division with just 25 guys. As we get bigger and better we will be dominating in clan wars. We use call out tactics to defeat enemies. We are looking for guys that can be on somewhat in the afternoon because most of us work.
Not everything here has been listed but if you would like to know more info or apply to join us you can contact me if you have any questions. Thanks
This is the wrong forum, you need to go to Clan Discussions for recruiting.
Moderator will remove you.
hey would love to join. I am tired of joining a clan and then they dont wanna do clan wars and such so would love to join you guys as it seems you have a real nice thing going and would love to join that. tell me what you need me to do and i will do it to apply


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High flow systems for apnoeic oxygenation
December 23, 2014 by Cliff
Filed under All Updates, EMS, ICU, Resus
Apnoeic oxygenation during laryngoscopy via nasal prongs has really taken off in the last couple of years in emergency department RSI, and is associated with decreased desaturation rates in out-of-hospital RSI.
More effective oxygenation and a small amount of PEEP can be provided by high flow nasal cannulae with humidified oxygen (HFNC)
A logical step in the progression of this topic is to consider HFNC for apnoeic oxygenation, and Reuben Strayer wrote about this nearly three years ago.
In a Twitter conversation today, Dr Pete Sherren highlighted a new article describing its use in anaesthesia for patients with difficult airways. This is labelled Transnasal Humidified Rapid-Insufflation Ventilatory Exchange (THRIVE). A reply from Dr Neil Brain points out that when used in kids, the bulkiness of the apparatus may get in the way of bag-mask ventilation (if that becomes necessary).
But does HFNC apnoeic oxygenation confer any advantages over standard nasal cannulae?
In an apnoeic patient, 15l/min via standard cannulae should fill the pharyngeal space with 100% oxygen, and you can't improve on 100%.
HFNC provide some continuous positive pressure, but this may be cancelled by the necessary mouth opening for laryngoscopy.
One issue with apnoea is of course a rise in carbon dioxide with consequent acidosis. The authors of the THRIVE paper (abstract below) point out that in previous apnoeic oxygenation studies, the rate of rise of carbon dioxide levels was between 0.35 and 0.45 kPa/min (2.7-3.4 mmHg/min), whereas with THRIVE the rise was 0.15 kPa/min (1.1 mmHg/min). They suggest that continuous insufflation with high flow oxygen facilitates oxygenation AND carbon dioxide clearance through gaseous mixing and flushing of the deadspace.
So should we switch from standard nasal cannula to high flow cannulae for apnoeic oxygenation? I think not routinely, but perhaps consider it in patients:
(1) with pressure-dependent oxygenation (eg. ARDS) although I'm not sure any CPAP effect would be sustained during laryngoscopy
(2) in patients with significant acidosis in whom a significant rise in carbon dioxide could be detrimental (eg. diabetic ketoacidosis).
I look forward to reading more studies on this, and to hearing from anyone with experience of this technique in the comments section.
Transnasal Humidified Rapid-Insufflation Ventilatory Exchange (THRIVE): a physiological method of increasing apnoea time in patients with difficult airways.
Anaesthesia. 2014 Nov 10. doi: 10.1111/anae.12923. [Epub ahead of print]
Emergency and difficult tracheal intubations are hazardous undertakings where successive laryngoscopy-hypoxaemia-re-oxygenation cycles can escalate to airway loss and the 'can't intubate, can't ventilate' scenario.
Between 2013 and 2014, we extended the apnoea times of 25 patients with difficult airways who were undergoing general anaesthesia for hypopharyngeal or laryngotracheal surgery. This was achieved through continuous delivery of transnasal high-flow humidified oxygen, initially to provide pre-oxygenation, and continuing as post-oxygenation during intravenous induction of anaesthesia and neuromuscular blockade until a definitive airway was secured. Apnoea time commenced at administration of neuromuscular blockade and ended with commencement of jet ventilation, positive-pressure ventilation or recommencement of spontaneous ventilation. During this time, upper airway patency was maintained with jaw-thrust.
Transnasal Humidified Rapid-Insufflation Ventilatory Exchange (THRIVE) was used in 15 males and 10 females. Mean (SD [range]) age at treatment was 49 (15 [25-81]) years. The median (IQR [range]) Mallampati grade was 3 (2-3 [2-4]) and direct laryngoscopy grade was 3 (3-3 [2-4]). There were 12 obese patients and nine patients were stridulous. The median (IQR [range]) apnoea time was 14 (9-19 [5-65]) min. No patient experienced arterial desaturation < 90%. Mean (SD [range]) post-apnoea end-tidal (and in four patients, arterial) carbon dioxide level was 7.8 (2.4 [4.9-15.3]) kPa. The rate of increase in end-tidal carbon dioxide was 0.15 kPa.min(-1) .
We conclude that THRIVE combines the benefits of 'classical' apnoeic oxygenation with continuous positive airway pressure and gaseous exchange through flow-dependent deadspace flushing. It has the potential to transform the practice of anaesthesia by changing the nature of securing a definitive airway in emergency and difficult intubations from a pressured stop-start process to a smooth and unhurried undertaking.
Breaking with tradition in paediatric RSI
'Traditional' rapid sequence induction of anaesthesia is often described with inclusion of cricoid pressure and the strict omission of any artifical ventilation between paralytic drug administration and insertion of the tracheal tube. These measures are aimed at preventing pulmonary aspiration of gastric contents although there is no convincing evidence base to support that. However it is known that cricoid pressure can worsen laryngoscopic view and can occlude the paediatric airway. We also know that children desaturate quickly after the onset of apnoea, and although apnoeic diffusion oxygenation via nasal cannula can prevent or delay that, in some cases it may be preferable to bag-mask ventilate the patient while awaiting full muscle relaxation for laryngoscopy.
A Swiss study looked at 1001 children undergoing RSI for non-cardiac surgery. They used a 'controlled rapid sequence induction and intubation (cRSII)' approach for children assumed to have full stomachs. This procedure resembled RSI the way it is currently done in many modern critical care settings, including the retrieval service I work for:
- No cricoid pressure
- Ketamine for induction if haemodynamically unstable
- A non-depolarising neuromuscular blocker rather than succinylcholine
- No cricoid pressure
- Gentle facemask ventilation to maintain oxygenation until intubation conditions achieved
- Intubation with a cuffed tracheal tube
- Still no cricoid pressure
The authors comment:
The main finding was that cRSII demonstrated a considerably lower incidence of oxygen desaturation and consecutive hemodynamic adverse events during anesthesia induction than shown by a previous study on classic RSII in children. Furthermore, there was no incidence of pulmonary aspiration during induction, laryngoscopy, and further course of anesthesia.
Looks like more dogma has been lysed, and this study supports the current trajectory away from traditional teaching towards an approach more suitable for critically ill patients.
Controlled rapid sequence induction and intubation – an analysis of 1001 children
Paediatr Anaesth. 2013 Aug;23(8):734-40
BACKGROUND: Classic rapid sequence induction puts pediatric patients at risk of cardiorespiratory deterioration and traumatic intubation due to their reduced apnea tolerance and related shortened intubation time. A 'controlled' rapid sequence induction and intubation technique (cRSII) with gentle facemask ventilation prior to intubation may be a safer and more appropriate approach in pediatric patients. The aim of this study was to analyze the benefits and complications of cRSII in a large cohort.
METHODS: Retrospective cohort analysis of all patients undergoing cRSII according to a standardized institutional protocol between 2007 and 2011 in a tertiary pediatric hospital. By means of an electronic patient data management system, vital sign data were reviewed for cardiorespiratory parameters, intubation conditions, general adverse respiratory events, and general anesthesia parameters.
RESULTS: A total of 1001 patients with cRSII were analyzed. Moderate hypoxemia (SpO2 80-89%) during cRSII occurred in 0.5% (n = 5) and severe hypoxemia (SpO2 <80%) in 0.3% of patients (n = 3). None of these patients developed bradycardia or hypotension. Overall, one single gastric regurgitation was observed (0.1%), but no pulmonary aspiration could be detected. Intubation was documented as 'difficult' in two patients with expected (0.2%) and in three patients with unexpected difficult intubation (0.3%). The further course of anesthesia as well as respiratory conditions after extubation did not reveal evidence of 'silent aspiration' during cRSII.
CONCLUSION: Controlled RSII with gentle facemask ventilation prior to intubation supports stable cardiorespiratory conditions for securing the airway in children with an expected or suspected full stomach. Pulmonary aspiration does not seem to be significantly increased.
Atropine for Paediatric RSI?
Comments Off on Atropine for Paediatric RSI?
In some areas it has been traditional to pre-medicate or co-medicate with atropine when intubating infants and children, despite a lack of any evidence showing benefit. It is apparently still in the American Pediatric Advanced Life Support (PALS) Provider Manual when age is less than 1 year or age is 1–5 years and receiving succinylcholine. However it is not recommended with rapid sequence intubation in the British and Australasian Advanced Paediatric Life Support manual and course.
A French non-randomised observational study compares intubations with and without atropine in the neonatal and paediatric critical care setting. Atropine use was associated with significant acceleration of heart rate, and no atropine use was associated with a higher incidence of new dysrhythmia, the most common being junctional rhythm, but with none appearing to be clinically significant.
The incidence of the most important peri-intubation cause of bradycardia – hypoxia – is not reported. It is also not clear how many intubation attempts were required. The authors admit:
"it is not possible using our methodology to deduce whether bradycardia was due to hypoxia, laryngoscopy, or sedation drugs."
Actual rapid sequence was rarely employed – their use of muscle relaxants was low – making this difficult to extrapolate to modern emergency medicine / critical care practice.
My take home message here is that this study provides no argument whatsoever for the addition of atropine in routine RSI in the critically ill child. Why complicate a procedure with an unnecessary tachycardia-causing drug when the focus should be on no desat / no hypotension / first look laryngoscopy?
The Effect of Atropine on Rhythm and Conduction Disturbances During 322 Critical Care Intubations
Pediatr Crit Care Med. 2013 Jul;14(6):e289-97
OBJECTIVES: Our objectives were to describe the prevalence of arrhythmia and conduction abnormalities before critical care intubation and to test the hypothesis that atropine had no effect on their prevalence during intubation.
DESIGN: Prospective, observational study.
SETTING: PICU and pediatric/neonatal intensive care transport.
SUBJECTS: All children of age less than 8 years intubated September 2007-2009. Subgroups of intubations with and without atropine were analyzed.
INTERVENTION: None.
MEASUREMENT AND MAIN RESULTS: A total of 414 intubations were performed in the study period of which 327 were available for analysis (79%). Five children (1.5%) had arrhythmias prior to intubation and were excluded from the atropine analysis. Atropine was used in 47% (152/322) of intubations and resulted in significant acceleration of heart rate without provoking ventricular arrhythmias. New arrhythmias during intubation were related to bradycardia and were less common with atropine use (odds ratio, 0.14 [95% CI, 0.06-0.35], p < 0.001). The most common new arrhythmia was junctional rhythm. Acute bundle branch block was observed during three intubations; one Mobitz type 2 rhythm and five ventricular escape rhythms occurred in the no-atropine group (n = 170). Only one ventricular escape rhythm occurred in the atropine group (n = 152) in a child with an abnormal heart. One child died during intubation who had not received atropine.
CONCLUSIONS: Atropine significantly reduced the prevalence of new arrhythmias during intubation particularly for children over 1 month of age, did not convert sinus tachycardia to ventricular tachycardia or fibrillation, and may contribute to the safety of intubation.
Etomidate – there is always a downside
January 14, 2014 by Viking One
Filed under All Updates, ICU
By Norwegian intensivist/anaesthetist/HEMS Physician Dr Per Bredmose.
[Warning – Rant level: Viking]
Etomidate has for a long time been known in some countries as the "drug of choice" for RSI in unstable/fragile patients. This is due to the fact that induction with etomidate is fairly cardiovascularly stable. However, there is a down side: a subsequent suppression of adrenal function. This was initially discovered after etomidate was used for sedation infusions on ICU.
It has for a long time been debated whether this is a side effect with clinical implications after a single dose induction… and yes it has.
A recent Japanese study demonstrates this(1). This is a large propensity based study. Now, propensity based statistics are pretty complex to explain. In short, it is an advanced method to strengthen the statistics when comparing groups in non-cross over studies.
In this study 2616 patients receiving etomidate for induction and a volatile agent for maintenance are included.
This showed an increased OR for 30-days mortality with a factor of 2.5 and 1.5 times greater chance for a major cardiovascular event in hospital. Interestingly enough, there were no significant differences in either perioperative vasopressor use or infections complications during hospital stay.
What does this mean?
In my mind and experience, it strengthens the fact that there is no wonder drug. And also that there seems to be a reason for why etomidate is de-registered in many countries.
Also, it tells me that for a safe prehospital RSI we need physicians capable of clinical judgment and "decision making" to tailor an (any) induction agent to the specific individual patient. In my mind, there is no room for an etomidate-only (dose / weight) induction protocol!
1. Komatsu R, You J, Mascha EJ, Sessler DI, Kasuya Y, Turan A.
Anesthetic induction with etomidate, rather than propofol, is associated with increased 30-day mortality and cardiovascular morbidity after noncardiac surgery.
Anesth Analg. 2013 Dec;117(6):1329-37
Hyperchloraemia and mortality
November 10, 2013 by Cliff
Filed under All Updates, EMS, ICU, Resus
Comments Off on Hyperchloraemia and mortality
Here's something to add to the pile of data cautioning us to think before we acidify patients with saline. A study in Anesthesia and Analgesia using propensity matching provides retrospective evidence that patients who developed hyperchloremia after noncardiac surgery had worse outcomes.
For more information on why saline isn't 'normal' see: What's with all the chloride? An assault on salt
Hyperchloremia after noncardiac surgery is independently associated with increased morbidity and mortality: a propensity-matched cohort study
Anesth Analg. 2013 Aug;117(2):412-21
BACKGROUND: The use of normal saline is associated with hyperchloremic metabolic acidosis. In this study, we sought to determine the incidence of acute postoperative hyperchloremia (serum chloride >110 mEq/L) and whether this electrolyte disturbance is associated with an increase in length of hospital stay, morbidity, or 30-day postoperative mortality.
METHODS: Data were retrospectively collected on consecutive adult patients (>18 years of age) who underwent inpatient, noncardiac, nontransplant surgery between January 1, 2003 and December 31, 2008. The impact of postoperative hyperchloremia on patient morbidity and length of hospital stay was examined using propensity-matched and logistic multivariable analysis.
RESULTS: The dataset consisted of 22,851 surgical patients with normal preoperative serum chloride concentration and renal function. Acute postoperative hyperchloremia (serum chloride >110 mmol/L) is quite common, with an incidence of 22%. Patients were propensity-matched based on their likelihood to develop acute postoperative hyperchloremia. Of the 4955 patients with hyperchloremia after surgery, 4266 (85%) patients were matched to patients who had normal serum chloride levels after surgery. These 2 groups were well balanced with respect to all variables collected. The hyperchloremic group was at increased risk of mortality at 30 days postoperatively (3.0% vs 1.9%; odds ratio = 1.58; 95% confidence interval, 1.25-1.98) (relative risk 1.6 or risk increase of 1.1%) and had a longer hospital stay (7.0 days [interquartile range 4.1-12.3] compared with 6.3 [interquartile range 4.0-11.3]) than patients with normal postoperative serum chloride levels. Patients with postoperative hyperchloremia were more likely to have postoperative renal dysfunction. Using all preoperative variables and measured outcome variables in a logistic regression analysis, hyperchloremia remained an independent predictor of 30-day mortality with an odds ratio of 2.05 (95% confidence interval, 1.62-2.59).
CONCLUSION: This retrospective cohort trial demonstrates an association between hyperchloremia and poor postoperative outcome. Additional studies are required to demonstrate a causal relationship between these variables.
Xenon – no bull?
August 31, 2013 by Cliff
Filed under All Updates, ICU
Comments Off on Xenon – no bull?
Xenon, an inert 'noble' gas with proven anaesthetic properties, has possible neuroprotective properties and appears to be also cardioprotective in this small study of post-cardiac arrest patients. Its high viscosity affects airway resistance, resulting in higher peak pressures and the need for a strategy to avoid gas trapping (ie. longer expiratory times as with asthma). Apparently it's expensive, but these results suggest further study is warranted.
Feasibility and Cardiac Safety of Inhaled Xenon in Combination With Therapeutic Hypothermia Following Out-of-Hospital Cardiac Arrest
Crit Care Med. 2013 Sep;41(9):2116-24
OBJECTIVES: Preclinical studies reveal the neuroprotective properties of xenon, especially when combined with hypothermia. The purpose of this study was to investigate the feasibility and cardiac safety of inhaled xenon treatment combined with therapeutic hypothermia in out-of-hospital cardiac arrest patients.
DESIGN: An open controlled and randomized single-centre clinical drug trial (clinicaltrials.gov NCT00879892).
SETTING: A multipurpose ICU in university hospital.
PATIENTS: Thirty-six adult out-of-hospital cardiac arrest patients (18-80 years old) with ventricular fibrillation or pulseless ventricular tachycardia as initial cardiac rhythm.
INTERVENTIONS: Patients were randomly assigned to receive either mild therapeutic hypothermia treatment with target temperature of 33°C (mild therapeutic hypothermia group, n = 18) alone or in combination with xenon by inhalation, to achieve a target concentration of at least 40% (Xenon + mild therapeutic hypothermia group, n = 18) for 24 hours. Thirty-three patients were evaluable (mild therapeutic hypothermia group, n = 17; Xenon + mild therapeutic hypothermia group, n = 16).
MEASUREMENTS AND MAIN RESULTS: Patients were treated and monitored according to the Utstein protocol. The release of troponin-T was determined at arrival to hospital and at 24, 48, and 72 hours after out-of-hospital cardiac arrest. The median end-tidal xenon concentration was 47% and duration of the xenon inhalation was 25.5 hours. The frequency of serious adverse events, including inhospital mortality, status epilepticus, and acute kidney injury, was similar in both groups and there were no unexpected serious adverse reactions to xenon during hospital stay. In addition, xenon did not induce significant conduction, repolarization, or rhythm abnormalities. Median dose of norepinephrine during hypothermia was lower in xenon-treated patients (mild therapeutic hypothermia group = 5.30 mg vs Xenon + mild therapeutic hypothermia group = 2.95 mg, p = 0.06). Heart rate was significantly lower in Xenon + mild therapeutic hypothermia patients during hypothermia (p = 0.04). Postarrival incremental change in troponin-T at 72 hours was significantly less in the Xenon + mild therapeutic hypothermia group (p = 0.04).
CONCLUSIONS: Xenon treatment in combination with hypothermia is feasible and has favorable cardiac features in survivors of out-of-hospital cardiac arrest.
Cricoid can worsen VL View
April 12, 2013 by Cliff
Filed under All Updates, ICU, Resus
It is known that cricoid pressure can hinder laryngoscopic view of the cords during direct laryngoscopy. Using a Pentax-AWS Video laryngoscope, these authors have demonstrated that cricoid pressure can also worsen glottic view during video laryngoscopy.
Videographic Analysis of Glottic View With Increasing Cricoid Pressure Force
Ann Emerg Med. 2013 Apr;61(4):407-13
BACKGROUND:Cricoid pressure may negatively affect laryngeal view and compromise airway patency, according to previous studies of direct laryngoscopy, endoscopy, and radiologic imaging. In this study, we assess the effect of cricoid pressure on laryngeal view with a video laryngoscope, the Pentax-AWS.
METHODS: This cross-sectional survey involved 50 American Society of Anesthesiologists status I and II patients who were scheduled to undergo elective surgery. The force measurement sensor for cricoid pressure and the video recording system using a Pentax-AWS video laryngoscope were newly developed by the authors. After force and video were recorded simultaneously, 11 still images were selected per 5-N (Newton; 1 N = 1 kg·m·s(-2)) increments, from 0 N to 50 N for each patient. The effect of cricoid pressure was assessed by relative percentage compared with the number of pixels on an image at 0 N.
RESULTS: Compared with zero cricoid pressure, the median percentage of glottic view visible was 89.5% (interquartile range [IQR] 64.2% to 117.1%) at 10 N, 83.2% (IQR 44.2% to 113.7%) at 20 N, 76.4% (IQR 34.1% to 109.1%) at 30 N, 51.0% (IQR 21.8% to 104.2%) at 40 N, and 47.6% (IQR 15.2% to 107.4%) at 50 N. The number of subjects who showed unworsened views was 20 (40%) at 10 N, 17 (34%) at 20 and 30 N, and 13 (26%) at 40 and 50 N.
CONCLUSION: Cricoid pressure application with increasing force resulted in a worse glottic view, as examined with the Pentax-AWS Video laryngoscope. There is much individual difference in the degree of change, even with the same force. Clinicians should be aware that cricoid pressure affects laryngeal view with the Pentax-AWS and likely other video laryngoscopes.
Updated Difficult Airway Guidelines
February 14, 2013 by Cliff
Filed under All Updates, Guidelines, ICU, Resus
Comments Off on Updated Difficult Airway Guidelines
The American Society of Anesthesiologists has published an update to its Practice Guidelines for Management of the Difficult Airway. You can get the full PDF for free. I'm linking to it for interest, but do not expect to find anything groundbreaking for the management of critical patients.
Practice Guidelines for Management of the Difficult Airway: An Updated Report by the American Society of Anesthesiologists Task Force on Management of the Difficult Airway
Anesthesiology 2013;118:251-70
Lifting the Fogg on ED Intubaton
January 1, 2013 by Cliff
Filed under All Updates, ICU, Resus
Fellow retrieval specialist and Royal North Shore Hospital emergency physician Dr Toby Fogg and coauthors have published their audit of intubations in an Australian Emergency Department(1). More important than the results themselves is that the process of monitoring ones practice inevitably leads to improvements. For example, at Toby's institution an intubation checklist has been introduced since the audit began. Other Australasian EDs are encouraged to participate using the free resources at airwayregistry.org.au.
Recently we have also seen the publication of Korean registry data on paediatric intubations performed in 13 academic EDs over 5 years(2), in which first pass success rates (overall 67.6%) were higher with emergency physicians compared with paediatricians. Interestingly, a rapid sequence intubation technique was only used in 22.4% of intubations, which was more likely to be used by emergency physicians and was associated with a greater likelihood of first pass success.
This relatively low first pass success rate is reminiscent of the American study published in September(3) which raised some eyebrows with its 52% first pass intubation success rates in a paediatric ED, and which also showed that attending-level providers were 10 times more likely to be successful on the first attempt than all trainees combined. Possible reasons for such a low first pass success rate compared with adult registry data include the rigorous video analysis method used, or perhaps more likely that paediatric emergency subspecialists are exposed to fewer critical procedures, resuscitations, and intubations than their general emergency medicine counterparts(4).
As a specialty we must continue to seek to do better, and I salute all these brave authors who are telling it like it is. Particularly with children, whose airways are relatively easy, we have to develop the training, preparation, supervision, monitoring and feedback to aim for as high a success rate as possible.
1. Prospective observational study of the practice of endotracheal intubation in the emergency department of a tertiary hospital in Sydney, Australia
Emerg Med Australas. 2012 Dec;24(6):617-24
OBJECTIVE: To describe the practice of endotracheal intubation in the ED of a tertiary hospital in Australia, with particular emphasis on the indication, staff seniority, technique, number of attempts required and the rate of complications.
METHODS: A prospective observational study.
RESULTS: Two hundred and ninety-five intubations occurred in 18 months. Trauma was the indication for intubation in 30.5% (95% CI 25.3-36.0) and medical conditions in 69.5% (95% CI 64.0-74.5). Emergency physicians were team leaders in 69.5% (95% CI 64.0-74.5), whereas ED registrars or senior Resident Medical Officers made the first attempt at intubation in 88.1% (95% CI 83.9-91.3). Difficult laryngoscopy occurred in 24.0% (95% CI 19.5-29.3) of first attempts, whereas first pass success occurred in 83.4% (95% CI 78.7-87.2). A difficult intubation occurred in 3.4% (95% CI 1.9-6.1) and all patients were intubated orally in five or less attempts. A bougie was used in 30.9% (95% CI 25.8-36.5) of first attempts, whereas a stylet in 37.5% (95% CI 32.1-43.3). Complications occurred in 29.0% (95% CI 23.5-34.1) of the patients, with desaturation the commonest in 15.7% (95% CI 11.9-20.5). Cardiac arrest occurred in 2.2% (95% CI 0.9-4.4) after intubation. No surgical airways were undertaken.
CONCLUSION: Although the majority of results are comparable with overseas data, the rates of difficult laryngoscopy and desaturation are higher than previously reported. We feel that this data has highlighted the need for practice improvement within our department and we would encourage all those who undertake emergent airway management to audit their own practice of this high-risk procedure.
2. The factors associated with successful paediatric endotracheal intubation on the first attempt in emergency departments: a 13-emergency-department registry study
Resuscitation. 2012 Nov;83(11):1363-8
BACKGROUND: We investigated which factors are associated with successful paediatric endotracheal intubation (ETI) on the first attempt in emergency department (EDs) from multicentre emergency airway registry data.
METHODS: We created a multicentre registry of intubations at 13 EDs and performed surveillance over 5 years. Each intubator filled out a data form after an intubation. We defined "paediatric patients" as patients younger than 10 years of age. We assessed the specialty and level of training of intubator, the method, the equipment, and the associated adverse events. We analysed the intubation success rates on the first attempt (first-pass success, FPS) based on these variables.
RESULTS: A total of 430 ETIs were performed on 281 children seen in the ED. The overall FPS rate was 67.6%, but emergency medicine (EM) physicians showed a significantly greater success rate of 74.4%. In the logistic regression analysis, the intubator's specialty was the only independent predictive factor for paediatric FPS. In the subgroup analysis, the EM physicians used the rapid sequence intubation/intubation (RSI) method and Macintosh laryngoscope more frequently than physicians of other specialties. ETI-related adverse events occurred in 21 (7.2%) out of the 281 cases. The most common adverse event in the FPS group was mainstem bronchus intubation, and vomiting was the most common event in the non-FPS group. The incidence of adverse events was lower in the FPS group than in the non-FPS group, but this difference was not statistically significant.
CONCLUSIONS: The intubator's specialty was the major factor associated with FPS in emergency department paediatric ETI, The overall ETI FPS rate among paediatric patients was 67.6%, but the EM physicians had a FPS rate of 74.4%. A well structured airway skill training program, and more actively using the RSI method are important and this could explain this differences.
3.Rapid sequence intubation for pediatric emergency patients: higher frequency of failed attempts and adverse effects found by video review.
Ann Emerg Med. 2012 Sep;60(3):251-9
STUDY OBJECTIVE: Using video review, we seek to determine the frequencies of first-attempt success and adverse effects during rapid sequence intubation (RSI) in a large, tertiary care, pediatric emergency department (ED).
METHODS: We conducted a retrospective study of children undergoing RSI in the ED of a pediatric institution. Data were collected from preexisting video and written records of care provided. The primary outcome was successful tracheal intubation on the first attempt at laryngoscopy. The secondary outcome was the occurrence of any adverse effect during RSI, including episodes of physiologic deterioration. We collected time data from the RSI process by using video review. We explored the association between physician type and first-attempt success.
RESULTS: We obtained complete records for 114 of 123 (93%) children who underwent RSI in the ED during 12 months. Median age was 2.4 years, and 89 (78%) were medical resuscitations. Of the 114 subjects, 59 (52%) were tracheally intubated on the first attempt. Seventy subjects (61%) had 1 or more adverse effects during RSI; 38 (33%) experienced oxyhemoglobin desaturation and 2 required cardiopulmonary resuscitation after physiologic deterioration. Fewer adverse effects were documented in the written records than were observed on video review. The median time from induction through final endotracheal tube placement was 3 minutes. After adjusting for patient characteristics and illness severity, attending-level providers were 10 times more likely to be successful on the first attempt than all trainees combined.
CONCLUSION: Video review of RSI revealed that first-attempt failure and adverse effects were much more common than previously reported for children in an ED.
4. A is for airway: a pediatric emergency department challenge.
Ann Emerg Med. 2012 Sep;60(3):261-3
Reassurance: difficult laryngoscopy in children remains rare
I was taught a useful principle by a paediatric anaesthetist 10 years ago which has proven true in my experience and has contributed to keeping me calm when intubating sick kids. Unlike adults, in whom difficulty in intubation can often be unexpected, the vast majority of normal looking children are easy to intubate, and the ones who are difficult usually have obvious indicators such as dysmorphism.
This appears to be supported by recent evidence: in a large retrospective series of 11.219 anaesthesia patients, the overall incidence of difficult laryngoscopy [Cormack and Lehane (CML) grade III and IV] was only 1.35%, although was much higher in infants less than one year compared with older children. This low percentage is in the same ball park as two other paediatric studies. Besides younger age, their database suggested underweight, ASA III and IV physical status and, if obtainable, Mallampati III and IV findings as predictors for difficult laryngoscopy. The authors point out:
"…the oromaxillofacial surgery department with a high proportion of cleft palate interventions and pediatric cardiac surgery contributed substantially to the total number of difficult laryngoscopies. In patients undergoing pediatric cardiac surgery, a possible explanation for the higher incidence of CML III/IV findings might be that some congenital heart defects are associated with chromosomal anomalies like microdeletion 22q11.2 syndrome. This syndrome is also associated with extracardiac anomalies like cranio-facial dysmorphism"
Take home message: As a very rough rule of thumb to illustrate the difference between the ease/difficulty of laryngoscopy between adults and kids, I think it's fair to say grade III or IV views occur in about 10% of adults but only about 1% of children.
Incidence and predictors of difficult laryngoscopy in 11.219 pediatric anesthesia procedures
Paediatr Anaesth. 2012 Aug;22(8):729-36
OBJECTIVE: Difficult laryngoscopy in pediatric patients undergoing anesthesia.
AIM: This retrospective analysis was conducted to investigate incidence and predictors of difficult laryngoscopy in a large cohort of pediatric patients receiving general anesthesia with endotracheal intubation.
BACKGROUND: Young age and craniofacial dysmorphy are predictors for the difficult pediatric airway and difficult laryngoscopy. For difficult laryngoscopy, other general predictors are not yet described.
METHODS: Retrospectively, from a 5-year period, data from 11.219 general anesthesia procedures in pediatric patients with endotracheal intubation using age-adapted Macintosh blades in a single center (university hospital) were analyzed statistically.
RESULTS: The overall incidence of difficult laryngoscopy [Cormack and Lehane (CML) grade III and IV] was 1.35%. In patients younger than 1 year, the incidence of CML III or IV was significantly higher than in the older patients (4.7% vs 0.7%). ASA Physical Status III and IV, a higher Mallampati Score (III and IV) and a low BMI were all associated (P < 0.05) with difficult laryngoscopy. Patients undergoing oromaxillofacial surgery and cardiac surgery showed a significantly higher rate of CML III/IV findings.
CONCLUSION: The general incidence of difficult laryngoscopy in pediatric anesthesia is lower than in adults. Our results show that the risk of difficult laryngoscopy is much higher in patients below 1 year of age, in underweight patients and in ASA III and IV patients. The underlying disease might also contribute to the risk. If the Mallampati score could be obtained, prediction of difficult laryngoscopy seems to be reliable. Our data support the existing recommendations for a specialized anesthesiological team to provide safe anesthesia for infants and neonates.


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June 17, 2013 Scientists and parents have long been baffled by the fact that children with autism often don't pay attention to human voices. Researchers say that may be because speech doesn't activate a reward system in the brain for those children the way it does for typical children.
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February 4, 2013 Some people with damage to a specific region of the brain called the amygdala do not feel fear. If you make them handle a snake or show them a scene from a scary movie such as The Shining, they won't be affected. But breathing in air with high levels of carbon dioxide can send them into a panic.
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January 10, 2013 In his new book, Jared Diamond describes how readily people in small-scale societies learn to speak many distinct languages. After reading Diamond's book, commentator Barbara J. King takes time to consider what we in the U.S. may lose in a sea of monolingualism.
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November 15, 2012 Scientists have found rappers and jazz musicians use their brains in similar ways when it comes to improvisation. Brain scans show distinct differences in which parts of the brain are most active during rap performances of memorized pieces compared with those that are done freestyle.
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On the hottest days, nothing sounds more appealing than an icy-cold popsicle. A warm-weather favorite of grown-ups and little ones alike, we've rounded up 43 recipes that are especially kid-friendly. From the supremely simple, like easy strawberry-banana pops, to the unexpected and exotic — coconut bubble tea, anyone?! — there's something for everyone.
Peaches and Cream Pops
Nanette Wong [1] for Sugar & Cloth has a recipe for peaches and cream pops [2] to make one of the season's most delicious offerings even better!
Cantaloupe Popsicles
Ripe cantaloupe, fresh mint, and lime zest combine to make these cantaloupe popsicles [3] the perfect thirst-quenching treat on a hot day.
Watermelon Pops
These Watermelon Popsicles [4] have a sneaky lemon layer to them to add some tang to the watermelon flavor.
Lime Creamsicles
A frozen treat with a bit of zest, Lime Creamsicles [5] are a fruity, tangy addition to a hot afternoon.
Coconut Water Pineapple Popsicles
Coconut water is a refreshing alternative used in these Pineapple Popsicles [6] by Boulder Lovacore.
Carrot, Mango, & Raspberry Popsicles
These Carrot, Mango, & Raspberry Popsicles [7] mix fruit and veggies to create a tasty treat that teething tots will love to bite. Cooked carrots are so sweet that they perfectly complement the fruit flavors.
Roasted Berry Popsicles
These Roasted Berry Popsicles [8] are sweet and tangy with an interesting secret ingredient!
Greek Yogurt Berry Smoothie Pops
Mom on Time Out's Greek yogurt-berry smoothie pops [9] use frozen berries to create a healty and delicious treat.
Cherry-Limeade Popsicles
Recipe Girl's cherry-limeade popsicles [10] turn a popular refreshing beverage it into a frozen sweet treat.
Creamy Nutella Popsicles
Creamy Nutella popsicles [11] combine Cool Whip and Nutella to make a creamy, rich, but light dessert.
Vegan Strawberry Cheesecake Pops
Cheesecake flavor without the weight, and vegan to boot, these Vegan Strawberry Cheesecake Popsicles [12] look like they could be your family's next go-to favorite.
Funfetti Yogurt Popsicles
Nothing says dessert like funfetti, so why not mix a family-favorite cake flavor with the joy of a cool popsicle on a Summer day? These funfetti yogurt popsicles [13] are a great way to celebrate every day.
Mango-Kiwi Limeade Popsicles
These Mango-Kiwi Limeade Popsicles [14] are fruity with a secret twist!
Avocado and Pear Pops
The creaminess of The Spunky Coconut's [15] pureed avocado blended with the sweetness of peeled pears makes these pops the perfect addition to little one's menus.
Chocolate-Covered Strawberry Popsicles
What's better than a strawberry popsicle? A chocolate-covered strawberry popsicle [16], of course. This version is made entirely out of fresh strawberries, dipped in a dark-chocolate magic shell.
Cucumber Chili Pops
Although cucumbers aren't a fruit, kids will still love this refreshing treat [17] by Girl Versus Dough [17] for Tablespoon [18]. If you think the chili gives it too much of a kick, simply cut back or omit it.
Lemon Dream Popsicles
Rather than feed your kid a lemon — which honestly is a hysterical photo-op, if you've never done it before — make some of these Lemon Dream Popsicles [19] for a bit of that tangy flavor.
Firework Popsicles
Whether you make them for the Fourth or just as a patriotic treat for a warm day, these Twizzlers Firework Popsicles [20] are a fun frozen treat with a candy surprise!
Mango Vanilla Honey Push Pops
Add a little bit of delicious honey and vanilla flavoring to pureed mango chunks, put it all in some darling push-up molds, and you have yourself Mango Vanilla Honey Push Pops [21] for the whole gang to cool off with.
Blueberry Breakfast Parfait Pops
Take your morning yogurt to the next level with these Blueberry Breakfast Parfait Pops [22]!
Root Beer Float Popsicles
Boulder Locavore's root beer float popsicles [23] use just two ingredients — vanilla ice cream and root beer — transforming the iconic float into something new.
Mango Chia Popsicles
Pureed mango, chia seeds, and coconut milk are all you need for these beautiful looking Mango Chia Popsicles [24]!
Banana Peanut Butter Yogurt Popsicles
Bananas and peanut butter (or any nut or nut-free butter, to be honest) are a perfect combo. Mix them together with yogurt, freeze 'em, and enjoy cold popsicles [25] on a hot Summer day. Mmmmmm.
Fruity Pebbles Yogurt Popsicles
Cereal is taking on a new and exciting form with these Fruity Pebbles yogurt pops [26]. Basically breakfast with their three-ingredient combo of cereal, milk, and yogurt, these puppies can be enjoyed any time of day. Please, Mom?
Berry Greek Yogurt Popsicles
These charming, little striped berry popsicles [27] combine style and flavor for a sweet afternoon snack.
Berry Greek Cheesecake Pops
We Are Not Martha's berry Greek cheesecake pops [28] use Greek cream cheese, raspberries, blueberries, sugar, and milk.
Red, White, and Blue Quick Pops
Red, white, and blue stars and stripes [29] make these patriotic pops extra special . . . Would you believe that the stars are actually apples?!
Strawberry and Coconut Milk Popsicles
If these beautiful Strawberry and Coconut Milk Popsicles [30] don't give you the urge to jump through your screen, we're not sure what will.
Coconut Berry Popsicles
Real coconut flakes and coconut milk go into these Coconut Berry Popsicles [31] to create the perfect sweet frozen treat!
Watermelon Strawberry Mint Popsicles
These watermelon popsicles [32] are not only delicious but also low in calories, so you don't have to feel bad if you give the kids two.
Chai-Coconut Milk Bubble Tea Pops
These Chai Coconut Boba Popsicles [33] are a frozen twist on a classic cup of bubble tea!
Invisible Cookie Dough Ice Pops
Girlichef's easy- and quick-to-make invisible cookie dough ice pops [34] actually taste like frozen cookie dough. Delicious!
Source: Girlichef [35]
These Cherry Popsicles [36].
Honey-Yogurt Popsicles
Yogurt, milk, fruit, honey, and vanilla join forces to make these delicious-looking popsicles [37] possible. With the red cherries and blue blueberries, these would make for a perfect Fourth of July treat.
Raspberry Cheesecake Popsicles
The Comfort of Cooking's raspberry cheesecake popsicles [38] are tart and sweet, with a buttery graham cracker crust. You can also use strawberries, blueberries, or blackberries if raspberries aren't your favorite.
Caramel Popcorn Quick Pops
Satisfy a serious sweet tooth with these Caramel Popcorn Quick Pops [39] — they'd be great for a circus- or movie-themed Summer party!
Leftover Veggie Pops
Over at Growing a Green Family [40], Jennifer Chait experimented making pops out of leftover vegetables including carrots, zucchini, and yams. The results were approved by her son.
Speculoos Popsicles
These "speculoosicles [41]" contain speculoos spread, as well as cookie crumbles, to create the ultimate sweet and creamy yogurt treat.
Rocky Road Pudding Pops
Woah nelly! These pudding pops [42] are a lighter version of their ice cream counterpart, but seem like the way forward on warm day when an indulgent frozen treat is highly necessary (so . . . every single day).
Layered Raspberry-Yogurt Pops
Get creative with this recipe for Layered Raspberry-Yogurt Pops [43] and incorporate any of your kids' favorite fruits.
Kiwi Orange Popsicles
A tangy combination of flavors, these Kiwi Orange Popsicles [44] are sure to cool the whole family down the tasty way.
Strawberry-Banana Popsicles
Wondering what's with the green layer? These Strawberry-Banana Popsicles [45] include a secret ingredient — spinach!


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After an EPIC first day of competition, we're down to only 7 ScrewAttack crew members left that have a chance to go to Japan. What game will they be playing today? Who will be victorious? Who will suffer ultimate defeat? Find out right now!
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