text:
Download citation file:
From the American College of Physicians, Philadelphia, Pennsylvania; North Shore Medical Group, Huntington, New York; University of Texas Health Science Center at San Antonio, San Antonio, Texas; Beth Israel Deaconess Medical Center, Boston, Massachusetts; Hines VA Hospital and Northwestern University, Chicago, Illinois; and Palo Alto Health Care System and Stanford University, Stanford, California.
Note: Clinical practice guidelines are "guides" only and may not apply to all patients and all clinical situations. Thus, they are not intended to override clinicians' judgment. All ACP clinical practice guidelines are considered automatically withdrawn or invalid 5 years after publication, or once an update has been issued.
Annals of Internal Medicine encourages readers to copy and distribute this paper, providing such distribution is not for profit. Commercial distribution is not permitted without the express permission of the publisher.
Grant Support: Financial support for the development of this guideline comes exclusively from the ACP operating budget.
Potential Financial Conflicts of Interest: Stock ownership or options (other than mutual funds): G.W. Smetana (SafeMed Harvard Imaging); Other: G.W. Smetana (Novartis Pharma Schweiz).
Requests for Single Reprints: Amir Qaseem, MD, PhD, MHA, American College of Physicians, 190 N. Independence Mall West, Philadelphia, PA 19106; e-mail, email@example.com.
Current Author Addresses: Drs. Qaseem and Snow: American College of Physicians, 190 N. Independence Mall West, Philadelphia, PA 19106.
Dr. Fitterman: 120 New York Avenue, Suite 3W, Huntington, NY 11743.
Dr. Hornbake: 7 Shelter Rock Road, P.O. Box 218, Hadlyme, CT 06439.
Dr. Lawrence: 7703 Floyd Curl Drive, Mail Code 7879, San Antonio, TX 78229.
Dr. Smetana: Shapiro 621D, 330 Brookline Avenue, Boston, MA 02215.
Dr. Weiss: P.O. Box 5000, Hines, IL 60141.
Dr. Owens: 117 Encina Commons, Stanford, CA 94305.
Postoperative pulmonary complications play an important role in the risk for patients undergoing noncardiothoracic surgery. Postoperative pulmonary complications are as prevalent as cardiac complications and contribute similarly to morbidity, mortality, and length of stay. Pulmonary complications may even be more likely than cardiac complications to predict long-term mortality after surgery. The purpose of this guideline is to provide guidance to clinicians on clinical and laboratory predictors of perioperative pulmonary risk before noncardiothoracic surgery. It also evaluates strategies to reduce the perioperative pulmonary risk and focuses on atelectasis, pneumonia, and respiratory failure. The target audience for this guideline is general internists or other clinicians involved in perioperative management of surgical patients. The target patient population is all adult persons undergoing noncardiothoracic surgery.
*This paper, written by Amir Qaseem, MD, PhD, MHA; Vincenza Snow, MD; Nick Fitterman, MD; E. Rodney Hornbake, MD; Valerie A. Lawrence, MD; Gerald W. Smetana, MD; Kevin Weiss, MD, MPH; and Douglas K. Owens, MD, MS, was developed for the Clinical Efficacy Assessment Subcommittee of the American College of Physicians (ACP): Douglas K. Owens, MD, MS (Chair); Mark Aronson, MD; Patricia Barry, MD, MPH; Donald E. Casey Jr., MD, MPH, MBA; J. Thomas Cross Jr., MD, MPH; Nick Fitterman, MD; E. Rodney Hornbake, MD; Katherine D. Sherif, MD; and Kevin B. Weiss, MD, MPH (Immediate Past Chair). Approved by the ACP Board of Regents on 21 January 2006.
Recommendation 1: All patients undergoing noncardiothoracic surgery should be evaluated for the presence of the following significant risk factors for postoperative pulmonary complications in order to receive pre- and postoperative interventions to reduce pulmonary risk: chronic obstructive pulmonary disease, age older than 60 years, American Society of Anesthesiologists (ASA) class of II or greater, functionally dependent, and congestive heart failure.
The following are not significant risk factors for postoperative pulmonary complications: obesity and mild or moderate asthma.
Recommendation 2: Patients undergoing the following procedures are at higher risk for postoperative pulmonary complications and should be evaluated for other concomitant risk factors and receive pre- and postoperative interventions to reduce pulmonary complications: prolonged surgery (>3 hours), abdominal surgery, thoracic surgery, neurosurgery, head and neck surgery, vascular surgery, aortic aneurysm repair, emergency surgery, and general anesthesia.
Recommendation 3: A low serum albumin level (<35 g/L) is a powerful marker of increased risk for postoperative pulmonary complications and should be measured in all patients who are clinically suspected of having hypoalbuminemia; measurement should be considered in patients with 1 or more risk factors for perioperative pulmonary complications.
Recommendation 4: All patients who after preoperative evaluation are found to be at higher risk for postoperative pulmonary complications should receive the following postoperative procedures in order to reduce postoperative pulmonary complications: 1) deep breathing exercises or incentive spirometry and 2) selective use of a nasogastric tube (as needed for postoperative nausea or vomiting, inability to tolerate oral intake, or symptomatic abdominal distention).
Recommendation 5: Preoperative spirometry and chest radiography should not be used routinely for predicting risk for postoperative pulmonary complications.
Preoperative pulmonary function testing or chest radiography may be appropriate in patients with a previous diagnosis of chronic obstructive pulmonary disease or asthma.
Recommendation 6: The following procedures should not be used solely for reducing postoperative pulmonary complication risk: 1) right-heart catheterization and 2) total parenteral nutrition or total enteral nutrition (for patients who are malnourished or have low serum albumin levels).
Postoperative pulmonary complications play a significant role in the risk for surgery and anesthesia. The most important and morbid postoperative pulmonary complications are atelectasis, pneumonia, respiratory failure, and exacerbation of underlying chronic lung disease. While clinicians are very conscious of the importance of, and risk factors for, cardiac complications, clinicians who care for patients in the perioperative period may be surprised to learn that postoperative pulmonary complications are equally prevalent and contribute similarly to morbidity, mortality, and length of stay (1–5). Pulmonary complications may also be more likely than cardiac complications to predict long-term mortality after surgery, particularly among older patients (6).
This guideline is based on a 2-part systematic review prepared by Smetana and colleagues (7) and Lawrence and colleagues (8). The American College of Physicians (ACP) developed these guidelines to 1) guide clinicians on clinical and laboratory predictors of perioperative pulmonary risk before noncardiothoracic surgery and 2) evaluate the efficacy of strategies to reduce the risk for postoperative pulmonary complications. Studies of immunosuppressive states other than HIV infection (for example, organ transplantation) and of risk factors for postoperative venous thromboembolism were excluded from the review. The target audience is general internists or other clinicians involved in perioperative management of surgical patients. This guideline applies to adult patients undergoing noncardiopulmonary surgery. The perioperative period as defined in the studies ranged from 2 to 3 months before surgery and up to 3 months after surgery. A more in-depth discussion of the methods and the inclusion and exclusion criteria is available in the accompanying background papers in this issue (7–8). In this paper, patient- and procedure-related risk factors are discussed separately.
Potential patient-related risk factors fell into the following general categories: age; chronic lung disease; cigarette use; congestive heart failure; functional dependence; American Society of Anesthesiologists (ASA) classification; obesity; asthma; obstructive sleep apnea; impaired sensorium, abnormal findings on chest examination, alcohol use, and weight loss; and exercise capacity, diabetes, and HIV infection.
The evidence review found that advanced age is an important predictor of postoperative pulmonary complications, even after adjustment for comorbid conditions. Ten multivariable studies showed that age was a significant risk predictor and was the second most commonly identified risk factor. The odds ratio was 2.09 (95% CI, 1.70 to 2.58) for patients 60 to 69 years of age and 3.04 (CI, 2.11 to 4.39) for those 70 to 79 years of age compared with younger patients (those <60 years of age).
Among studies reporting multivariable analyses, chronic obstructive pulmonary disease was the most commonly identified risk factor for postoperative pulmonary complications (odds ratio, 1.79 [CI, 1.44 to 2.22]). No eligible study determined the incremental risk for postoperative pulmonary complications in patients with chronic restrictive lung disease or restrictive physiologic characteristics due to neuromuscular disease or chest wall deformity, such as kyphoscoliosis. While clinicians may consider such patients with severe limitations to have an increased risk for postoperative pulmonary complications, the literature did not support an estimate of the magnitude of this risk in this group.
The available data are mixed but suggest a modest increase in risk for postoperative pulmonary complications among current smokers. The odds ratio for cigarette use was 1.26 (CI, 1.01 to 1.56). It is important to assess history of current smoking status and support for smoking cessation intervention very early in the preparation for nonemergency surgery.
Good-quality evidence identified congestive heart failure as a significant risk factor for postoperative pulmonary complications (odds ratio, 2.93 [CI, 1.02 to 8.43]).
The evidence review showed that functional dependence is an important predictor of postoperative pulmonary complications. Total dependence was the inability to perform any activities of daily living, and partial dependence was the need for equipment or devices and assistance from another person for some activities of daily living. The odds ratio was 2.51 (CI, 1.99 to 3.15) for total dependence and 1.65 (CI, 1.36 to 2.01) for partial dependence.
Several integrated measures of comorbidity have been evaluated as potential predictors of postoperative pulmonary complications. The ASA classification (Table) aims to predict perioperative mortality rates but has since been proven to predict both postoperative pulmonary and cardiac complications (9). Higher ASA class was associated with a substantial increase in risk when an ASA class of II or greater was compared with an ASA class of less than II (odds ratio, 4.87 [CI, 3.34 to 7.10]) and when an ASA class of III or greater was compared with an ASA class of less than III (odds ratio, 2.25 [CI, 1.73 to 3.76]).
Studies evaluating clinically meaningful pulmonary complications after surgery have generally found no increased risk attributable to obesity, even for patients with morbid obesity (10–11). Definitions of obesity varied from a body mass index of more than 25 kg/m2 to "morbid obesity." Postoperative pulmonary complication rates were 6.3% and 7.0% for obese and nonobese patients, respectively, in studies that reported only univariate data.
Good evidence suggested that asthma is not a risk factor for postoperative pulmonary complications. Only 1 of 4 studies that examined the rate of postoperative pulmonary complications among patients with asthma included a control group; the rate in this study was 3%.
Obstructive sleep apnea increases the risk for airway management difficulties in the immediate postoperative period, but its influence on postoperative pulmonary complications has not been well studied. The evidence review identified a single univariate study that evaluated the risk due to obstructive sleep apnea among patients undergoing hip or knee replacement (12). In this case–control study, nonsignificant trends were seen toward higher rates of reintubation, hypercapnia, and hypoxemia for patients with obstructive sleep apnea. This finding suggests that postoperative pulmonary complication rates may have been higher among patients with obstructive sleep apnea, but this needs to be confirmed by more studies.
Fair evidence shows that impaired sensorium, abnormal findings on chest examination, alcohol use, and weight loss modestly increase the risk for postoperative pulmonary complications. Impaired sensorium is defined as 1) an acutely confused or delirious patient who is able to respond to verbal stimulation, mild tactile stimulation, or both, or 2) a patient with mental status changes, delirium, or both in the context of current illness. This definition excludes patients with stable chronic mental illness or dementia.
Evidence was insufficient to support whether exercise capacity, diabetes, and HIV infection are independent risk factors for postoperative pulmonary complications.
Procedure-related risk factors are as important as patient-related factors in estimating risk for postoperative pulmonary complications. These include surgical site, duration of surgery, anesthetic technique, and emergency surgery.
Good evidence shows that the following procedures are related to increased risk for postoperative pulmonary complications: aortic aneurysm repair, thoracic surgery, abdominal surgery, upper abdominal surgery, neurosurgery, prolonged surgery, head and neck surgery, emergency surgery, and vascular surgery.
Four studies that used multivariable analyses found prolonged surgery duration, ranging from 3 to 4 hours, to be an independent predictor of postoperative pulmonary complications (pooled odds ratio, 2.14 [CI, 1.33 to 3.46]).
Four studies provided estimates for risks related to general anesthesia; the odds ratio was 1.83 (CI, 1.35 to 2.46).
Among studies reporting multivariable analyses, 6 reported emergency surgery as a significant predictor of postoperative pulmonary complications; the odds ratio was 2.21 (CI, 1.57 to 3.11).
To determine the value of preoperative testing to estimate pulmonary risk, the authors of the evidence review assessed studies of spirometry, chest radiographs, blood urea nitrogen, oropharyngeal culture, and serum albumin measurement.
Although spirometry diagnoses obstructive lung disease, it does not translate into effective risk prediction for individual patients. Furthermore, the few studies that have compared spirometric data with clinical data have not consistently shown spirometry to be superior to history and physical examination in predicting postoperative pulmonary complications. Consensus exists regarding the value of spirometry before lung resection and in determining candidacy for coronary artery bypass; its value before extrathoracic surgery, however, remains unproven. Finally, the data do not suggest a prohibitive spirometric threshold below which the risks of surgery are unacceptable. Therefore, spirometry should be reserved for patients who are thought to have undiagnosed chronic obstructive pulmonary disease.
Clinicians frequently obtain chest radiographs as part of a routine preoperative evaluation. Most studies of the value of preoperative chest radiographs, however, have not studied postoperative pulmonary complications as the primary outcome measure but rather have evaluated the frequency with which an abnormal study changes perioperative management. In a recent review of this literature (13), it was found that 23.1% of preoperative chest radiographs were abnormal but only 3% had findings clinically important enough to influence management. An earlier review (14) found that 10% of preoperative chest radiographs were abnormal but only 1.3% showed unexpected abnormalities and only 0.1% influenced management.
Thus, the evidence suggests that clinicians may predict most abnormal preoperative chest radiographs by history and physical examination and that this test only rarely provides unexpected information that influences preoperative management. There is some evidence that this test is helpful for patients with known cardiopulmonary disease and those older than 50 years of age who are undergoing upper abdominal, thoracic, or abdominal aortic aneurysm surgery.
Fair evidence supports serum blood urea nitrogen levels of 7.5 mmol/L or greater (≥21 mg/dL) as a risk factor. However, the magnitude of the risk seems to be lower than that for low levels of serum albumin.
The evidence review found only a single small study that evaluated the value of preoperative oropharyngeal culture to predict postoperative pulmonary complication risk (15). More studies are needed in this area.
Four studies that reported univariate analyses stratified postoperative pulmonary complication rates by serum albumin level and used a threshold of 36 g/L to define low levels (16–19). Unadjusted rates of postoperative pulmonary complications for patients with low and normal serum albumin levels were 27.6% and 7.0%, respectively. In the review of studies reporting multivariable analyses, a low serum albumin level was shown to be an important predictor of postoperative pulmonary complications (low values were defined variably from 30 to 39 g/L) (20–24). The National VA Surgical Risk Study reported that a low serum albumin level was also the most important predictor of 30-day perioperative morbidity and mortality (17). In this report, the relationship between serum albumin levels and mortality was continuous when levels were below approximately 35 g/L without a clear threshold value. On the basis of the multivariate analysis, a serum albumin level less than 35 g/L is one of the most powerful patient-related risk factors and predictors of risk.
Opportunities to reduce risk for postoperative pulmonary complications occur throughout the perioperative period. Lawrence and colleagues' background review (8) discusses the evidence for lung-specific strategies, anesthetic and analgesic techniques, surgical techniques, and perioperative care. The review is limited to randomized, controlled trials; systematic reviews; or meta-analyses. Studies that used administrative data (for example, International Classification of Diseases, Ninth Revision, codes) to identify postoperative complications were excluded. A more detailed description of the methods is available in the paper by Lawrence and colleagues (8).
Studies evaluating the impact of smoking cessation on rates of postoperative pulmonary complications have generally included patients undergoing pulmonary or cardiac surgery, which were excluded from the review. The authors found only 1 randomized trial of a preoperative smoking cessation intervention that began approximately 6 to 8 weeks before hip or knee surgery and continued 10 days after surgery (25). Postoperative ventilatory support was the only measured pulmonary outcome and occurred in 1 patient in each group. However, several factors limited this study's ability to show decreased risk for pulmonary complications. The risk for postoperative pulmonary complications is low with hip and knee replacement, and only 1 potential postoperative pulmonary complication (ventilatory support) was evaluated. Future trials will need to stratify risk by the duration of preoperative smoking cessation. Another study showed that postoperative pulmonary complication rates did not decrease for smokers who stopped smoking or reduced smoking within 2 months of cardiothoracic surgery (26).
Lung expansion techniques include incentive spirometry; chest physical therapy, including deep breathing exercises; cough; postural drainage; percussion and vibration; suctioning and ambulation; intermittent positive-pressure breathing; and continuous positive-airway pressure.
The available evidence suggests that for patients undergoing abdominal surgery, any type of lung expansion intervention is better than no prophylaxis at all. However, no one modality is clearly superior, and the literature varies substantially regarding how clinicians actually administer the different methods. The available evidence does not suggest that combined methods provide additional risk reduction. Incentive spirometry may be the least labor-intensive and nasal continuous positive-airway pressure may be especially beneficial in patients who are unable to perform incentive spirometry or deep breathing exercises.
The incidence of residual neuromuscular blockade was significantly higher among patients receiving pancuronium, and those patients were approximately 3 times more likely to develop postoperative pulmonary complications than patients without residual blockade. In contrast, among patients receiving an intermediate-acting agent (atracurium or vecuronium), there was no difference in the rates between those with and without prolonged blockade (4% vs. 5%). These data directly indicate that pancuronium use leads to higher rates of prolonged blockade and indirectly suggest an increased risk for postoperative pulmonary complications when compared with shorter-acting agents.
A recent meta-analysis examined 141 randomized, controlled trials of general anesthesia versus neuraxial blockade in patients undergoing varied types of surgery (27). The comparison groups were patients receiving neuraxial blockade (44% with and 56% without concomitant general anesthesia) and those receiving general anesthesia alone. Complication rates with and without neuraxial blockade were, respectively, 3% and 5% for pneumonia (odds ratio, 0.61 [CI, 0.48 to 0.76]) and 0.5% and 0.8% for respiratory failure (odds ratio, 0.41 [CI, 0.23 to 0.73]). In a subgroup analysis of trials of neuraxial blockade alone versus general anesthesia alone, results were similar. This meta-analysis has been widely criticized, however, because of the very heterogeneous surgical populations and the use of older anesthetic techniques and older anesthetic agents. Overall, current evidence suggests that shorter-acting neuromuscular blocking drugs may prevent postoperative pulmonary complications.
Postoperative epidural pain management strategies seem superior to other routes of delivering opioids in preventing postoperative pulmonary complications. However, the risk for epidural hemorrhage in the setting of heparin for venous thromboembolism prophylaxis and postoperative epidural catheters may influence decisions regarding methods of pain control and venous thromboembolism prophylaxis.
Overall, literature on laparoscopic versus open procedures did not systematically assess or report pulmonary complications, and most studies did not have sufficient statistical power to detect differences in rates of postoperative pulmonary complications. The evidence is not clear, and further studies are needed.
Malnutrition and hypoalbuminemia increase the risk for postoperative complications. Several studies have tried to determine if nutritional supplementation improves outcomes. Taken as a whole, the body of evidence, which includes a meta-analysis (28) and a multisite randomized trial (29), indicates no proven advantage to total parenteral nutrition over no supplementation or total enteral nutrition in reducing postoperative pulmonary complications. There is also a need for more research regarding "immunonutrition."
Only 1 randomized, controlled trial of pulmonary artery catheters in high-risk surgical patients has been published (30). Patients 60 years of age or older undergoing major abdominal, thoracic, vascular, or hip fracture surgery were randomly assigned to usual care or treatment guided by the use of a perioperative pulmonary artery catheter. All patients were in ASA class III or IV and were therefore at high risk for postoperative complications. The 2 groups did not differ in the primary outcome of in-hospital all-cause mortality, and postoperative pneumonia rates were also similar (6.7% and 7.3%, respectively; P = 0.70). This report shows no beneficial effect of pulmonary artery catheters as a strategy to reduce postoperative pulmonary complications.
Selective use of nasogastric tubes refers to use only if postoperative nausea or vomiting, inability to tolerate oral intake, or symptomatic abdominal distention occur. Routine use of nasogastric tubes refers to standard use after surgery until gastrointestinal motility returns. A meta-analysis examined evidence from 26 studies (including case–control studies) of selective versus routine nasogastric decompression after elective laparotomy (31). Patients receiving selective nasogastric decompression had a significantly lower rate of pneumonia and atelectasis. There was no difference in aspiration rates. These results were confirmed in a more recent meta-analysis (32–33).
Clinicians should employ strategies to reduce postoperative pulmonary complications in patients who are at high risk after clinical risk stratification. Good evidence shows that patient-related risk factors, such as chronic obstructive pulmonary disease, age older than 60 years, ASA class of II or higher, functional dependence, and congestive heart failure, increase the risk for postoperative pulmonary complications. In addition, patients undergoing such procedures as prolonged surgery, abdominal surgery, thoracic surgery, neurosurgery, head and neck surgery, vascular surgery, aortic aneurysm repair, and emergency surgery are at higher risk for postoperative pulmonary complications. General anesthesia and serum albumin levels below 35 g/L are also a strong marker of increased risk. Good evidence exists to support risk reduction strategies, including incentive spirometry and deep breathing exercises, and fair evidence exists to support selective nasogastric tube decompression after abdominal surgery. Fair evidence also suggests that short-acting neuroaxial blockade reduces postoperative pulmonary complications compared with long-acting neuroaxial blockade.
Please read the other comments before posting. Contributors must reveal any conflict
of interest.
Comments are moderated and will appear on the site at the discretion of The American
College of Physicians editorial staff. Please be sure your email address is
updated in your account, otherwise the American College of Physicians will not be
able to contact you about your comment.
Anyone can submit a comment any time after publication, but only those submitted within 4 weeks of an article's publication will be considered for print publication. One month after publication, editors review all posted comments and select some for publication in the Letters section of the print version of Annals. (Not peer reviewed)
Authors: No more than 5
Text: Word Limit 400 (excludes references), 5 references, no figures or tables
* = Required Field
Disclosure of Any Conflicts of Interest*
(applies to the past 5 years and foreseeable future) Indicate any potential conflicts
of interest of each author below, including specific financial interests and relationships
and affiliations relevant to the subject matter or materials discussed in the manuscript
(eg, employment/affiliation, grants or funding, consultancies, honoraria, speakers
bureau, stock ownership or options, expert testimony, royalties, donation of medical
equipment, or patents filed, received, or pending). If all authors have none, check
"No potential conflicts or relevant financial interests" in the box below. Please
also indicate any funding received in support of this work. The information will
be posted with your response.
The new Clinical Guidelines from the ACP (Annals, April 18, 2006) can be very useful for the practicing internist who does every day preoperatory evaluations and also for surgeons and anesthesiologists. Very practical recommendations, among others, are the use of the clinical judgment (history and physical examination), rather than the routine chest X ray, except for specific cases.
In the past, the inspiratory apnea time (to hold the inspiration after hyperventilation) over 40 seconds, was considered a good sign of respiratory function. Anesthesiologists need a good time in apnea for the intubation and usually ventilate and oxygenate before. Thus, enough time in apnea with a normal oxygen saturation (e.g. SpO2 over 95 % or at least 92 %) is desirable. At the other hand, the resting heart rate (RHR), increases as the SpO2 decreases. The lower the RHR, and/or the increase of RHR during apnea, the better the general cardio-respiratory condition of the patient.
I have been doing for several years a prospective observational study of patients with preoperatory evaluations, in the meantime several hundreds, in which I assess the apnea time in seconds (ideal over 50), multiplied by the average SpO2 (ideal over 92 %), and divided by the RHR (ideal under 90). Form these data I calculate an Index, which should be over 50. The higher, the better.
This Index is then compared with the global functional capacity of the patients, with special attention to symptoms like angina or dyspnea during exercise or physical efforts (and their intensity or duration). It is also compared with the ASA Class. Patients in ASA Class I and good functional capacity according to the current guidelines, usually have an Index over 50 to 80, but not under or near to 50. Patients in ASA Class II, have an Index over 50. The patients with an Index under or very close to 50, usually have an ASA Class III or over, with a poor functional capacity. Of course, the younger and physically active have the best results, but the correlation is also observed in obese or elderly patients. I recommend this Index, which is very simple and can be done by any internist, to be done in every preoperatory evaluation.
None declared
This is in response to your current publication in the Annals of Internal Medicine April 18, 2006.
Risk assessment for and strategies to reduce perioperative pulmonary complications for patients undergoing non cardiothoracic surgery : A guideline from the American College of Physicians.
To the Editor,
Qaseem and colleagues in their clinical guidelines for risk assessment for and strategies to reduce perioperative pulmonary complications for patients undergoing non cardiothoracic surgery have overlooked an important factor in preventing postoperative pneumonia related to acid aspiration. Pulmonary aspiration of gastric contents during the perioperative period may be associated with postoperative mortality or pulmonary morbidity (1). While acid aspiration during induction of anesthesia is rare with an incidence of 3 in 10,000, this complication causes high morbidity and mortality. Aspiration-related complications such as pneumonitis, adult respiratory distress syndrome, and laryngeal complications remain important causes of perioperative morbidity and mortality. In a study reported by Rosenstock and colleagues, 7 patients out of 60 with adverse respiratory events during anesthesia had pulmonary aspiration of gastric contents, six of whom died (2). It has also been reported that patients who attend for day surgery are more likely to have larger gastric residual volumes and a higher risk of aspiration pneumonia compared with inpatients (3) .The effects of aspiration are multiple and are thought to be attributable to the acid, chemical, and microbiological composition, as well as the volume of aspirate. Studies in animals have shown that low gastric pH is the more important determinant of aspiration induced lung injury and mortality as compared to the volume of the aspirate. Prophylaxis against aspiration pneumonia is therefore important in preanaesthetic management. These regimens include H2 antagonists, sucralfate and proton pump inhibitors.
Various prophylactic regimens have been investigated and H2 antagonists being shown to be the effective agents for increasing gastric pH and decreasing gastric fluid volume (4). However, rapid development of tolerance to their antisecretory effects has led to studies with proton inhibitors, which are now considered suitable alternatives for increasing gastric pH and decreasing gastric volume.
As the majority of evidence supports the preoperative administration of H2 antagonists or proton pump inhibitors in most patients and certainly in those who are pre-operatively assessed to be at increased risk for aspiration (5), we recommend that either proton pump inhibitors or H2 blockers should be given as pre-anesthetic medicine to reduce gastric volume and acidity. This combined with selective use of naso-gastric decompression after abdominal surgery, as advocated by Qaseem and colleagues can effectively reduce the risk of gastric content aspiration and postoperative pneumonias.
Tahir Qaseem, MD, FACP Presbyterian Healthcare Services Albuquerque, New Mexico
1. Warner MA, Warner ME, Weber JG. Clinical significance of pulmonary aspiration during the perioperative period. Anesthesiology 1993; 78: 56""62
2. Rosenstock C, Møller J, Hauberg A. Complaints related to respiratory events in anaesthesia and intensive care medicine from 1994 to 1998 in Denmark. Acta Anaesthesiol Scand 2001; 45: 53""8
3. Ong BY, Palahniuk RJ, Cumming M. Gastric volume and pH in out- patients. Can Anaesth Soc J 1978; 25: 36""9
4. Talke PO, Solanki DR. Dose-response study of oral famotidine for reduction of gastric acidity and volume in outpatients and inpatients. Anesth Analg 1993; 77: 1143""8
5. Kalinowski CPH, Kirsch JR. Strategies for prophylaxis and treatment fro aspiration. Best Pract Res Clin Anesth. 2004;18:719-737.
We appreciate the comments of Dr Qaseem and he makes an important point in acid suppression prophylaxis in a subset of patients at increased risk of pulmonary aspiration of gastric contents during surgery. While we agree with Dr Qaseem, the use of acid suppression is widely used for GI prophylaxis. As pointed out by Dr Qaseem that even though the acid aspiration syndrome is a critical perioperative complication, it is limited to a very small subset of patients and the use of acid suppression solely as a preventive strategy for pulmonary complications was excluded from our review. These patients need to be individually evaluated and managed as appropriate.
Under this item (A & A), in the last sentence of the first paragraph, when you state "... shorter-acting neuromuscular blocking agents may prevent postoperative pulmonary complications.", don't you mean "neuroaxial blockade may prevent..."?
Otherwise the sentence doesn't seem to relate to the paragraph or item and there is no conclusion over the general anesthesia versus neuraxial anesthesia debate.
In regards to nasogastric decompression after abdominal surgery, the authors found that "patients receiving selective nasogastric decompression had a significantly lower rate of pneumonia and atelectasis." And concluded that, "All patients who are found to be at higher risk for postoperative pulmonary complications should receive selective use of a nasogastric tube."
However, both of the papers that the authors referenced reported an "insignificant trend toward a decrease in pulmonary complications (p=0.07)" and "significantly fewer pulmonary complications' with selective nasogastric tube decompression."
Can you please clarify?
References 31. Cheatham ML, Chapman WC, Key SP, Sawyers JL. A meta-analysis of selective versus routine nasogastric decompression after elective laparotomy. Ann Surg. 1995;221:469-76.
32. Nelson R, Tse B, Edwards S. Systematic review of prophylactic nasogastric decompression after abdominal operations. Br J Surg. 2005;92:673-80.
Risk for and Reduction of Pulmonary Complications in Patients Undergoing Noncardiothoracic Surgery: An American College of Physicians Guideline
The summary below is from the full reports titled "Risk Assessment for and Strategies To Reduce Perioperative Pulmonary Complications for Patients Undergoing Noncardiothoracic Surgery: A Guideline from the American College of Physicians," "Preoperative Pulmonary Risk Stratification for Noncardiothoracic Surgery: Systematic Review for the American College of Physicians," and "Strategies To Reduce Postoperative Pulmonary Complications after Noncardiothoracic Surgery: Systematic Review for the American College of Physicians." They are in the 18 April 2006 issue of Annals of Internal Medicine (volume 144, pages 575-580, pages 581-595, and pages 596-608, respectively). The first report was written by A. Qaseem, V. Snow, N. Fitterman, E.R. Hornbake, V.A. Lawrence, G.W. Smetana, K. Weiss, and D.K. Owens, for the Clinical Efficacy Assessment Subcommittee of the American College of Physicians; the second report was written by G.W. Smetana, V.A. Lawrence, and J.E. Cornell; and the third report was written by V.A. Lawrence, J.E. Cornell, and G.W. Smetana.
Read More...
Terms of Use
The In the Clinic® slide sets are owned and copyrighted by the American College
of Physicians (ACP). All text, graphics, trademarks, and other intellectual property
incorporated into the slide sets remain the sole and exclusive property of the ACP.
The slide sets may be used only by the person who downloads or purchases them and
only for the purpose of presenting them during not-for-profit educational activities.
Users may incorporate the entire slide set or selected individual slides into their
own teaching presentations but may not alter the content of the slides in any way
or remove the ACP copyright notice. Users may make print copies for use as hand-outs
for the audience the user is personally addressing but may not otherwise reproduce
or distribute the slides by any means or media, including but not limited to sending
them as e-mail attachments, posting them on Internet or Intranet sites, publishing
them in meeting proceedings, or making them available for sale or distribution in
any unauthorized form, without the express written permission of the ACP. Unauthorized
use of the In the Clinic slide sets will constitute copyright infringement.
Learn more about subscription options


text:
Panel stream - Anarchist Studies Network Conference, Loughborough University, UK, 3-5th September 2014.
While anarchism has a rich intellectual history, historians of ideas have tended to overlook this political tradition. The purpose of this conference stream is to address this lacuna, and provide a forum for the discussion of the ideas, debates, and thinkers that have animated anarchism's past, and provided an intellectual foundation for contemporary developments in anarchist theory. Papers that discuss the work of specific anarchist thinkers, key themes and controversies in anarchist intellectual history, and offer contextual analysis of anarchism's development as a political tradition are welcome. Particularly welcome are papers that deal with the contributions of lesser-known thinkers to the historical development of anarchism, papers that reflect on the absence of engagement with anarchism in the history of political thought and intellectual history, and explorations of the relevance of anarchist theory to methodologies in the history of ideas.
Please send abstracts for proposed papers of no longer than 250 words to Matthew Adams (email@example.com) by 7th March 2014. Papers should last 20-minutes.

subset: commoncrawl


text:
Members of the Island and Snohomish MRCs meet and approve the Port Susan MSA plan.
Port Susan Bay straddles Island and Snohomish counties from the Marysville area north to Stanwood and west to Camano Island. Since 2007 we have been partnering with Snohomish County MRC in a community process to develop a science-based marine stewardship area for this body of water. Additional partners include the Tulalip Tribes, Stillaguamish Tribe, The Nature Conservancy, Washington Sea Grant with the support of the Northwest Straits Commission, and the WSU Extension offices of Island and Snohomish counties.
On Dec. 6, 2011 the Island and Snohomish MRCs voted unanimously in a joint meeting to recommend adoption of the plan to elected leaders of Island and Snohomish counties. In 2012, the Port Susan MSA plan entered Phase II of the CAP planning process. During this final planning phase the MSA Team continued to work with partner organizations to develop a Conservation Workplan and Measures Plan. View a PDF of the complete plan.
Port Susan Bay is renowned for salmon, Pacific Sturgeon, Gray Whales, clams, crabs, oysters and thousands of migratory waterfowl. The bay's fish and shellfish are harvested both commercially and recreationally. Surf Smelt lay their eggs on the bay's sandy beaches and Ghost Shrimp burrow in the muddy shallows. Salmon and birds feed on the smelt. Gray Whales enter the bay every spring on their migration from Mexico to Alaska. They scoop mouthfuls of bottom and sift it for Ghost Shrimp. Sturgeon visit the bay from the Columbia and Fraser rivers to forage for worms and shellfish.
The bay and its various estuaries also function as a salmon nursery. Juvenile Chinook, Coho and Chum salmon swim here and are carried by the currents from their birthplaces in the Skagit, Stillaguamish and Snohomish rivers. They probe the shoreline for pocket estuaries and creeks. Such places help them adjust their metabolism from river to saltwater environment, feed on insects that drop from overhanging vegetation, and hide from predators. Steelhead, cutthroat trout and other fish also use the estuarine habitat of this shore and nearby Livingston Bay.
Only recently have we really understood how valuable estuaries and salt marshes are to the entire marine food chain. Decades of logging, farming and home-building altered much of our shoreline. Today, only a few precious pockets of marsh and coastal wetland habitat remain. The Audubon Society has designated Port Susan Bay an Important Bird Area. State, tribes and private organizations are working to protect many sections of this bay's shoreline. With public understanding and support of their efforts, future generations will continue to enjoy the beauty and diversity of birds, fish, marine mammals and other wildlife that make Port Susan Bay such a magical place to live and visit.
Targeted Outreach to Reduce Impacts from Shore Armor in the Port Susan Marine Stewardship AreaProgram Assessment Summary Report
To read more about the Port Susan Bay MSA process, please visit the website of our colleagues at Snohomish County MRC.


text:
Laura White was only 15 years old when she saved five children from drowning while working as a camp counselor in Georgia.
The children, ages 8 through 11, all ran into a lake at once while she was supervising them. It became apparent within a minute or so that none of them knew how to swim. So White, who had been involved with competitive swimming throughout her childhood, ran into the water and pulled them out.
The experience inspired the Atlanta native to found Swim 4 Success, a nonprofit that provides free swimming lessons to children whose families otherwise cannot afford them. When White graduated high school and began attending Tulane University in 2008, she brought the program to New Orleans.
Swim 4 Success provides free, one-hour lessons every Sunday to youths ages 4 to 18 who qualify for the state's free or reduced school lunch program. The program is run entirely by college students, so the schedule adheres to university semesters, and there are no lessons during the summer.
The program is filled to capacity until April, but parents can sign up for the waiting list or for the next session, which begins in September.
Children must have transportation to and from the lessons, held at Tulane's Reily Recreation Center and the Love Swimming center a couple of miles away, and must attend seven of the eight lessons in a session.
About 40 students from Tulane, Loyola University and the University of New Orleans volunteer with the program. Tulane sophomore and Swim 4 Success recruiter Cliff Nelson said he was inspired to join after hearing White's story.
"I really believe in what we're trying to accomplish. ... Swimming has had a positive impact on my life, and I want to share that," said Nelson, who taught swimming for three years before coming to Tulane. "Being involved in sports helps you make friends and teaches you discipline. If it can also save lives, it's definitely worth it."
The city announced last month that the American Red Cross would provide a similar service this year, offering free, year-round swimming lessons in an effort to make sure local kids learn the life-saving skill. At least two metro-area children in the last few years have died after wandering into swimming pools. The Red Cross lessons are not available yet, but a class schedule will be posted as soon as residents can register at www.arcno.org.
"I often looked at recreation as a means of saving lives," Fielkow said. "Team sports are a safe alternative to roaming the streets. However, teaching a child to swim is an even more literal way to save a child's life, especially in a city surrounded by water. I applaud the Swim 4 Success volunteers who dedicate their time to teaching kids how to swim."
Swim lessons with Swim 4 Success are one-on-one with a swim instructor about 90 percent of the time, said the program's spokeswoman Claire McCarthy. Nelson said he's worked with the same boy for the three semesters he's volunteered with the program.
"It's awesome to see him progress," he said.
Many of the children who take lessons return for subsequent sessions, and some who have graduated from the program have joined swim teams in the city, McCarthy said. Nelson said he and other program administrators hope to offer opportunities in the future for students who graduate to become instructors themselves.
"The direction we're going in is we want to have a much more profound impact on the kids," he said.
Katie Urbaszewski can be reached at email@example.com or 504.826.3300.


text:
Houses on No 3 Rte in East Jordan
HomeZilla is building a collection of all homes in Nova Scotia. The goals behind collecting this data are many. Two of the most important are allowing people to be able to easily find addresses, to help people do research when buying a home, and also to track when homes go on sale
HomeZilla has addresses for 1 houses on No 3 Rte, East Jordan.
The list of civic address in Nova Scotia is for sale. If intersted email us at info [at] homezilla [dot] com


text:
Brian Benben
Jump to
Engaging lead of TV who has made the occasional venture into films. Benben started performing in off-off-Broadway productions at the age of 17. He moved to TV in the early 80s, debuting on the crime series, "The Gangster Chronicles." He began to work regularly, appearing in TV-movies and in the Broadway production of "Slab Boys" (1983) opposite Sean Penn, Kevin Bacon and Val Kilmer. After co-starring and providing recurring characters in a number of short-lived series in the 80s ("Kay O'Brien" 1986, "A Year in the Life" 1988) Benben landed the lead role of Martin Tupper in HBO's "adult" sitcom "Dream On." As a baby-boomer book editor who responds to life's daily anxieties and absurdities by conjuring up hilariously apt clips from old TV and films, Benben conveyed a warmth and wit little evident in his previous efforts. The scripts often show Martin in a less than flattering light but he retains audience sympathy perhaps since we see most of his world through his eyes. "Dream On" received numerous accolades and jumpstarted Benben's feature career, beginning with a lead role opposite Dolph Lundgren in the futuristic thriller "I Come in Peace" (1990). More impressively, he starred in a George Lucas production, "The Radioland Murders" (1994). He returned to series TV briefly in the fall of 1998 as star and executive producer of "The Brian Benben Show" (CBS), which had him playing a TV newsman.


text:
Earn miles every time you book a hotel, a car, or a vacation package on delta.com.
Seattle's rainy reputation precedes it, but you'll be hard-pressed to find something that will dampen your spirits once you get here. The Pacific Northwest's best known city, Seattle has a lush landscape that is primed for long drives just out of town, a coast that has a certain je ne sais quoi with its picturesque docks, piers and, on top of it all, a city culture that has made it one of the hippest locales on either coast. Travel on flights to Seattle with Delta and see for yourself why Seattle/Tacoma should be on your bucket list.
Fly to Seattle and Stop at the Spots
To know Seattle is to know the iconic Space Needle, The Crocodile, Pike's Place Market, the flagship Starbucks store and the Olympic Sculpture Garden. Seattle offers so much by way of the sights, but it's never overwhelming with generously interspersed parks like Kerry, Discovery and Waterfall Garden — offering serene settings perfect for an afternoon picnic or a quick pickup game or run.
A day trip to Mount Rainier and Mount St. Helens will slow your pace. Mount Rainier is about an hour drive outside Seattle and Mount St. Helens is not much farther after it. The volcano that blew it's top back in 1980 is about 1,000 feet smaller than it was prior to the explosion, but it still stands as one of the pivotal natural monuments of the state. Either park is a good way to take advantage of the camping, climbing and hiking that surround the Emerald City.
Feast your eyes not only on the sites of the lush city, but also on the fresh seafood that is served up at local restaurants around town. Try Palisade for an American-Polynesian blend, or grab some fish and chips at Sunfish. The city's iconic Pike Place Market sells fresh fish, so if you have access to a kitchen, duck into a market for a Seattle staple. And on the chance (or probability) that it's raining, keep warm with a cup of Joe from Starbucks®, Market Spice or the Crumpet Shop.
Go ahead and bring your ruby slippers to the Emerald City. Here, the green space that expands for miles upon miles also plays host to some iconic sights like the Space Needle and Starbucks.
Earn miles every time you book a hotel, a car, or a vacation package on delta.com.
REACH FOR THE SKYopens in a new windowopens in a new window
No matter your destination, Sky Magazine's engaging stories about travel, lifestyle and business help you make the most of your time in the air and on the ground.


text:
Volume in, volume out - the old VIVO drain.
When you flush a toilet, physics takes over. There is a special trap arrangement in the toilet structure, which has water at the bottom of the bowl, and when a flush happens the water volume (weight) flowing down causes to push upward and then downward again, FLUSHING the contents in the bowl into the drain. The flow of water works with itself, dynamically causing the volume (weight) entered to exit, leaving the same amount of water in the bottom of the bowl.
A sink or bath tub drain works much the same way.
Water always resides in the bottom of the trap.
This water essentially plugs the drain also, so sewer gases do not enter the home.
Volume in, volume out - the old VIVO drain.
Sometimes a trap that is unused for a time will evaporate the water out leaving the way for gases to come into the home.
One of the first things I do when I enter a house for an inspection is turn on the dishwasher. I examine it to see if it's buried behind ceramic tile or hardwood flooring, and if it's attached to the cabinet or counter top, and turn it on.
Such was the case with a recent inspection of a flipped house.
I turned on the dishwasher and let it go.
Returning later to the kitchen I noticed that as the dishwasher drained the left sink filled up with water.
The dishwasher drains into the disposal, which is under the right sink, so this filling of the left sink shouldn't happen.
I had not looked under the sink yet. It was time to look!
What I saw was a very deep trap.
A trap should only be 4" deep or so, like in the diagram above.
When it's deep, and especially when two sinks combine, the arrangement holds a lot of water.
A proper trap might only hold a couple of cups of water.
This trap is holding a lot more, as shown, more or less, by the blue I painted in!
And so, here, as the disposal fills with water trying to drain, unless there is enough volume (weight) of water above to force the lowest water below up and out, things will drain slowly.
I turned on the faucet to demonstrate and take a photo. It filled higher than that.
So, the VIVO principle is alive and well!
Want a natural tip for cleaning clogged drains (in a proper P-trap that is)? Mix together very well 1 cup baking soda, 1 cup salt and 1/4 cup cream of tartar (I know, you don't have any). Pour 1/4 cup of the dry mixture into the clogged drain. Follow that with 2 cups of boiling water. Let it sit for 1 hour. Flush the drain with a lot of water weight. How? Fill the sink or tub with water and remove the drain plug. The formula breaks up the mess and the water volume (weight) will wash it down. If one application doesn't work, try another.
Baking soda and white vinegar works on some lesser clogs. Pour down 1 cup of each. But be sure to cover the drain and over-flow hole with a wash cloth to contain the chemical reaction. Letting it sit a while will break up the fats and such and then do the water volume (weight) flush.
My recommendation: run some water into a drain and watch it drain. Listen too. It should go down easily and there should be no glub-glub when it finishes. Glub-glub is a technical word. Look it up. If things don't go well, look underneath! See what surprises are in store! When Flipper is involved, well, you might just be in for a treat.


text:
Police north of Montreal wonder whether a man who admitted to nine sexual assaults over 15 years may have victimized other women.
36-year old Patrick Desjardins became known as the Railroad Rapist because many of his attacks occurred near the train tracks in St. Jerome. There were also attacks in Blainville and Terrebonne.
However, investigators point to unsolved cases in Blainville as well as Mirabel and Two Mountains and, in addition, suspect there may be other attacks which went unreported.
Desjardins usually wore a mask and jumped his victims from behind near train tracks or on walking trails in wooded areas. The victims ranged in age from 10 to 46.
Desjardins is now undergoing a psycho-sexual evaluation and will be back in court in April. The Crown may seek to have him declared a dangerous offender.
Anyone with information about sexual assaults over the past 15 years is asked to call Sergeant-Detective Stephane Goyette at 450-432-3000, extension 2279.
NOTE: This thread is moderated, comments will not post immediately.
Simply confirm your registered email address below and click "Reset Password." We will immediately email you a link back to the site where you can enter a new password for this account.
We've found your existing E-Club account. Please login below to complete the Facebook login process.
Share this article:


text:
Melamine Dinnerware
Melamine dishes are made from a strong and durable plastic. They are lighter weight than ceramic dishes and less prone to breaking.
There are no products matching the selection.If you are having trouble finding the product(s) you are looking for, try our search or contact support at +1 (888) 482 2742 or email email@example.com.
We apologize for any inconvenience.


text:
When the first West Indians arrived in the 'mother country', they were shocked by the coldness of the weather and the welcome. As Small Island, Andrea Levy's novel about these naive hopefuls, is adapted for the BBC, those involved in the production speak of their own forebears' experiences, and of the opportunities they forged
When the first wave of West Indian immigrants arrived in postwar Britain in 1948, many of them believed they would be delivered to the Promised Land. More English than the English, their Caribbean living rooms bore portraits of Winston Churchill and King George VI. Many had fought with the Allies in the War, but the "mother country" turned out to be an austere and unwelcoming place in which the sun didn't shine, food was still rationed and houses bore signs declaring "No blacks, no dogs, no Irish".
And yet the pioneers remained to carve out new lives for themselves, and


text:
The President is the the United States as the ________________ is to the State. What is he/she?
Governor (Head of the executive branch)
Congress is to the United States as the _______________ is to Virginia. What do they do?
General Assembly (makes laws)
The House of Representatives is to Congress as the Virginia ____________ is to the _________________.
Virginia House of Delegates is to the Virginia General Assembly.
Magistrate Court
police courts generally located in larger towns. May handle traffic violations, civil cases involving small amounts of money.
Reserved Powers
powers that the Constitution does not give to the national government that are kept by the states


text:
Chee-Kee: A Panda in Bearland
Author: Sujean Rim
Publish Date: March 2017
Pages: 40
Publisher: Little Brown & Co Inc
We Know Children's Books
Alison McGhee is a Pulitzer Prize nominee and a #1 New York Times bestselling author. She writes for all ages and in all forms, from poetry and stories to novels and picture books and essays, and her books are popular with critics and readers alike. Her novel Shadow Baby was a Today S...


text:
Teri SharpPublic Relations Manager419-255-8000 ext. email@example.com
Exhibition Opening
Feb. 13–May 11, Canaday Gallery
The Art of the Louvre's Tuileries Garden will present 100 paintings, photographs, drawings and sculptures, many never before exhibited in the United States, on loan from the vast collections of the Musée du Louvre, Musée Carnavalet, Palace of Versailles and other museums and private lenders. This major exhibition explores the art, design and evolution of Paris' famed Tuileries Garden and its impact on such artists as Camille Pissarro, photographer Henri-Cartier Bresson and others. It also celebrates garden designer André Le Nôtre (1613–1700)—best known for his grand garden designs for the Château of Versailles—who transformed the Tuileries Garden into a magnificent French formal garden for King Louis XIV. The Tuileries, which stretches from the Louvre to the Place de la Concorde in central Paris, was created in 1564 and became the city's first public park in 1667. The exhibition is organized by the High Museum of Art, Atlanta, the Portland Art Museum, Oregon and the Toledo Museum of Art, with the special collaboration of the Musée du Louvre. The Toledo showing is presented in part by The Andersons, Brooks Insurance and Taylor Cadillac. Admission is free for members. Ticket prices for nonmembers are $8.50 for adults and $5.50 for students and seniors.
Continuing Exhibitions
Jan. 24–May 4, Gallery 28
Jean-Honoré Fragonard's playfully sensual companion paintings, the Toledo Museum of Art's Blind- Man's Buff and the Thyssen-Bornemisza Museum, Madrid's The See-Saw, are reunited for the first time in 25 years. Painted as companion pieces, the two works remained together from their creation in the early 1750s until they came onto the open market in 1954. They were reunited in temporary exhibitions in London in 1968 and in Paris and New York in 1987 and 1988. Fragonard, considered one of the premier artists of the Rococo era of 18th-century French painting, is known for portraying romantic pastoral themes with fluidity and skill. This focus exhibition also includes engravings and a selection of French decorative arts of the 18th century. Free admission.
Dec. 13, 2013–May 25, Wolfe Gallery Mezzanine
Where some see relics of the past, Varujan Boghosian sees material for his next sculpture or collage. The Armenian-American artist's poetic works use unconventional objects like children's toys, ancient paper and shoes. His work is seen at such noted institutions as the Museum of Modern Art and the Metropolitan Museum of Art. This exhibition features works specially selected for their relationships to the works in the Toledo Museum of Art collection. In Gallery 18, see a representation of Boghosian's New England studio, where visitors can create their own collages using the artist's materials (through April 13). Free admission.
Nov. 22, 2013–March 2, 2014, Hitchcock Gallery
This exhibition explores various printmaking techniques used from the Renaissance to the present. The title refers to how ink is transferred from the block or plate to paper or other materials: the "highs" are relief prints such as woodcut, where ink transfers from the uncut raised surfaces; the "lows" are intaglio processes such as engraving, where ink transfers from the lines incised into the metal plate. Students from the University of Toledo curated this show with works from the Museum's collection. Free admission.
Community Gallery
Jan. 24–April 24, Community Gallery Inspired by the Museum's forthcoming major international exhibition, The Art of the Louvre's Tuileries Garden, the Museum issued a challenge to both two- and three-dimensional artists to help fill the Community Gallery with works of art inspired by the natural beauty of the Toledo region. The Community Gallery is sponsored by Hickory Farms.
Jan. 24–April 24, Community Gallery ArtReach serves people in the community who are facing challenges, providing them an artistic outlet. ArtReach workshop participants created art with a nature theme, including ripped paper landscapes. Their works are featured alongside student creations from Art After School, a program that keeps local children engaged in art after the school day ends. The Community Gallery is sponsored by Hickory Farms.
Special Events and Presentations
Feb. 1: 1 p.m., meet in Herrick Lobby
This month's tour for those with mild memory loss and their companions explores the depiction of music in various works of art. Call the Alzheimer's Association, Northwest Ohio Chapter at 419-537- 1999 or 1-800-272-3900 for reservations. The free monthly program is supported in part by Health Care REIT.
Feb. 6, 7 and 14: 9 p.m., meet in the Little Theater
See the Museum in a whole new light on an after-hours flashlight tour. Tickets ($5 members/$10 nonmembers) must be purchased 24 hours in advance of each tour. Call 419-255-8000 ext. 7448.
Feb. 7: 7 p.m.
Lawrence W. Nichols, William Hutton senior curator of European and American painting and sculpture before 1900, will discuss Jean-Honoré Fragonard's companion paintings The See-Saw of the Thyssen- Bornemisza Museum, Madrid and the Museum's own Blind Man's Buff. Created in the early 1750s by one of the premier artists of the Rococo era of 18th-century French painting, the two works of art are reunited for the first time in 25 years in this focus exhibition.
Feb. 9: 3 p.m.
Great Gallery Musicians present a celebration of the 50th anniversary of the March on Washington, the civil rights rally where Martin Luther King Jr. delivered his famed speech, "I Have a Dream."
Feb. 14: 8 p.m., meet in Libbey Court
Feb. 15 and 16: 2 p.m., meet in Libbey Court
Feb. 21: 7 p.m., meet in Libbey Court
Feb. 22 and 23: 2 p.m., meet in Libbey Court
Feb. 28: 7 p.m., meet in Libbey Court
Docent-led tours of the Museum's newest exhibition, The Art of the Louvre's Tuileries Garden, are free but require a ticket to the exhibition.
6:30–8:30 p.m., Glass Pavilion
Sample four wines and light snacks. Tickets ($20 members/$30 nonmembers, plus tax) are available at the information desks.
Feb. 14: Valentine Bubbles: Wines to Tickle Your Loved One's Nose
Feb. 21: In a French Garden: Wines of France
Feb. 28: Fruit & Flower: Wines with Garden Notes
Feb. 15: 7–10 p.m., Main Museum
Music, dancing, food and mask-making will entertain revelers during a ball fit for Marie Antoinette. Masquerade dress is encouraged but not required. Admission is free for members, $25 for adult nonmembers and $10 for nonmembers ages 6–12. Tickets include admission to the exhibition.
Feb. 21: 7:30 p.m., Little Theater
The Tuileries Garden in central Paris serves as a backdrop for the city's activities, from the mundane (joggers getting their daily exercise) to the fabulous (Fashion Week runway shows). University of Toledo art historian Richard Putney, a frequent Tuileries visitor and co-curator of The Art of the Louvre's Tuileries Garden, will discuss the origins of the public park, which inspired the Museum's major spring exhibition.
Feb. 28: 7:30 p.m., Little Theater
While Europe was entering the so-called Dark Ages 1,500 years ago, the Wari Empire began its expansion across the Andes. On its southern frontier, a citadel built on a mountain pinnacle served as an embassy and provincial capital. What were they doing there? Brewing massive quantities of beer, according to Ryan Williams, who excavated the Andes' oldest imperial brewery on the summit of the mountain-top city. Williams, an associate curator of archaeological science and South American anthropology at the Field Museum of Natural History in Chicago, will discuss the role of feasting and brewing in the politics of the first Andean empire as illustrated through the excavations at Cerro Baul, Peru. The presentation is co-sponsored by AIA-Toledo Society.
Dean Tartaglia
Feb. 7: 6:30–8:30 p.m., GlasSalon
Dean Tartaglia, one half of the local duo Silent Lions, will perform "chill punk and spooky soul." A cash bar will be available. It's Friday is sponsored in part by Fifth Third Bank.
The Toledo Museum of Art is open Thursdays until 9 p.m. with programs geared to young adults. Thursday evening activities take place from 6:30–8:30 p.m. in the Museum Café and Little Theater and include eclectic menus, music, drinks and more. All galleries are open on TMA Thursdays, which is sponsored in part by Huntington Wealth Advisors.
Feb. 20: 7–9 p.m., throughout Museum
TMA Third Thursday is a mid-month evening pick-me-up filled with art, drinks and lively discussion. This month the theme is Love + Lust. Events include a Tag Team Discussion at 7:30 p.m. in the Little Theater on the changing portrayals of lust, from 18th-century painting to 20th-century pop culture. From 6:30–9 p.m., enjoy a cash bar in Libbey Court and then embark on a 20-minute art experience with Art à la Carte at 7 or 7:30 p.m. Visitors can also try their hand sketching a romantic scene during Drawing in the Galleries at 7 or 8 p.m., or go to the Glass Pavilion Hot Shop for live glassblowing demonstrations at 7 and 8 p.m.
All demonstrations are in the Glass Pavilion.
Feb. 1: 1, 2 and 3 p.m.
Feb. 2: 1 and 2 p.m.
Feb. 4 and 5: 2 p.m.
Feb. 6 and 7: 2, 7 and 8 p.m.
Feb. 8: 1, 2 and 3 p.m.
Feb. 9: 1 and 2 p.m.
Feb. 11 and 12: 2 p.m.
Feb. 13 and 14: 2, 7 and 8 p.m.
Feb. 15: 1, 2 and 3 p.m.
Feb. 16: 1 and 2 p.m.
Feb. 18 and 19: 2 p.m.
Feb. 20 and 21: 2, 7 and 8 p.m.
Feb. 22: 1, 2 and 3 p.m.
Feb. 23: 1 and 2 p.m.
Feb. 25 and 26: 2 p.m.
Feb. 27 and 28: 2, 7 and 8 p.m.
FREE Public Tours
Feb. 2: 2 p.m., meet in Libbey Court
Feb. 2: 3 p.m., meet in Libbey Court or Family Center
Feb. 9: 2 p.m., meet in Libbey Court
Feb. 13: 3 p.m., meet in Libbey Court
Feb. 14: 6 p.m., meet in Libbey Court
Feb. 14: 7 p.m., meet in Libbey Court
Feb. 20: 7 and 7:30 p.m., meet in Libbey Court
FREE Family Center Activities
For children 10 years of age and younger accompanied by an adult, art activities in the Family Center are made possible in part with support from The Andersons.
Feb. 2: noon to 5 p.m.
Feb. 4 and 6: 10 a.m.–3 p.m.
Feb. 7: 3:30–8 p.m.
Stereoscopic photography was all the rage in 1850s France and visitors to the Tuileries Gardens used stereoscopic viewers to see their favorite images up close. Create your own version of a stereoscopic viewer to see your favorite Museum image.
Feb. 9: noon to 5 p.m.
Feb. 11 and 13: 10 a.m. – 3 p.m.
Feb. 14: 3:30–8 p.m.
Catch the last days of the exhibition Highs & Lows: Printmaking Processes and create a collagraph using our tabletop printing press.
Feb. 16: noon – 5 p.m.
Feb. 18 and 20: 10 a.m. – 3 p.m.
Feb. 21: 3:30–8 p.m.
Celebrate the opening of The Art of the Louvre's Tuileries Garden by designing your own miniature sculpture garden inspired by the exhibition.
Feb. 23: noon – 5 p.m.
Feb. 25 and 27: 10 a.m. –3 p.m.
Feb. 28: 3:30–8 p.m.
Inspired by the works of Varujan Boghosian on display in the Wolfe Gallery, create your own paper collage using a wide variety of materials.
Feb. 28: 6–7 p.m.
Meet local artist Dani Herrera of paperDENIMart and see how she uses recycled, unconventional materials, such as dryer lint, zippers and fabric, to create eye-catching works of art.
Note: Events are subject to change. Check the Museum's online calendar at www.toledomuseum.org for updates.
Name (required)
Mail (will not be published) (required)


text:
The Pleasant Grove Eagles beat the Sheldon Huskies and improve to 4-2 for the season.
No email address was supplied by
To complete your registration on this site, please supply an address.
Please confirm or modify the email address to which you will have subscription offers sent.
For a more personalized experience, please supply the following optional information.


text:
Although video game addiction is not officially recognized as a disorder by the American Medical Association, there is increasing evidence that people of all ages, especially teens and pre-teens, are using computer and video games compulsively or excessively.
"Video games are designed to appeal to a growing audience of players," explained Pediatrician Laurie Penix, M.D. "With better graphics, more realistic characters, and greater challenges, it's not surprising that some teens would rather play their video games than hang out with friends, play sports, or watch television."
For some teens, gaming has become an uncontrollable compulsion. This is especially true for boys in the pre-teen and teenage years. Studies estimate that 10-15% of gamers exhibit signs that meet the World Health Organization's criteria for addiction. Just like gambling and other compulsive behaviors, teens can become so enthralled in the fantasy world of gaming that they neglect their family, friends, work, and school.
Symptoms of Video Game Addiction
Teens need only exhibit two or three of these symptoms to be considered "addicted" to computer, video or Internet gaming:
- Preoccupation: Being preoccupied with the game or computer when the child is away from it, and seeming distracted, irritable, or disinterested in daily activities.
-Loss of Time: A child may go gaming with the intent to spend 15 or 20 minutes, but will keep extending the time until several hours have passed.
-Negative Impact on Other Areas of Life: Look for warning signs like missing meals, losing sleep, dropping activities, skipping showers, missing homework assignments, and growing distant from family or friends.
- "Hiding in the Game" to avoid or escape negative situations.
-Defensiveness: Denial about time spent gaming is often an indication that something is wrong, especially if the person seems unconcerned that friends and family feel neglected.
-Misuse of Money: Spending a disproportionate amount of money continually upgrading hardware, software packages, and accessories.
-Mixed Feelings: Use of the "substance" - in this case, the video game - initially causes euphoric feelings, but that euphoria is quickly followed by guilt.
"Children and teens spend many unstructured hours in front of their computers or TVs, playing games, social networking, and instant messaging," Dr. Penix continued. "It's normal for your children to want to play games and chat with friends, within limits. But parents need to be aware that these activities all have obsessive qualities built into them which perpetuate immediate gratification and feedback."
Many middle and high school teens are drawn to massively multiplayer online role playing games, such as World of Warcraft, Call of Duty or Halo. Games of this type connect players in cyberspace, who then form "guilds" or "clans." Generally, each player is represented by an avatar-usually a three-dimensional character that either the game or the player creates. Guild members may be from all over the world, and the missions can go on for days. Membership on these teams becomes the players' sense of community.
"These games are designed to quickly immerse your child," Dr. Penix continued. "Players soon begin to feel pressure to get ahead or not to let down their teammates."
Setting Limits
"When other areas of a child's life begin to suffer, parents may have cause to take corrective action," Dr. Penix advised. "There are several common warning signs of pathological behavior. These include fantasizing or talking about game characters or missions when offline; lying about or hiding how much time is spent playing; disobeying parental limits; losing interest in sports and hobbies; choosing the game over time with friends; and continuing to play despite plummeting grades. An addicted gamer's physical appearance may also change as he loses sleep, neglects to shower, and skips meals.
"Many cases of gaming overuse can be curtailed by setting rules and remaining vigilant. But for some young people, using the Internet or playing video games becomes a compulsion that they are unable to resist.
"When a parent thinks that his or her child has a problem, you may be tempted to get rid of the computer, Xbox or Playstation all together," said Dr. Penix. "Instead, start talking directly about your concerns, and set some strict guidelines to help them normalize their behavior. This can help your children learn to game and navigate the online world responsibly. In addition, you can gradually introduce substitute activities into their lives, like sports, hobbies, or academics, so they regain a balance of interests.
"However, if you suspect deeper problems, make an appointment with your physician or a mental health professional to help find the resources that will work for your family."
Other Tips to Curb Use:
- Ensure that online activities take place where you can see what's going on. Don't let your children spend time on the Internet behind closed doors.
-Make sure that kids know that their responsibilities, such as homework and chores, need to be finished before the computer turns on.
-Set daily limits on acceptable amounts of screen time -- and make sure that these limits aren't exceeded.
- Know what games your kids play and the game's content, including if it is particularly addictive or violent.
-Get kids involved in offline activities, such as sports teams, cultural or community service activities.
-Know your children's screen names and passwords. If they are active on social networking sites like MySpace or Facebook, check their accounts.
-Learn how to check the computer's history files to confirm what your children have been doing on the Internet.
"The American Academy of Pediatrics recommends that children spend on average no more than two hours a day with all screen media," Dr. Penix concluded.
"That includes time spent on the TV, video games, computer, and iPhone. Children will always ask for more and parents have to enforce the boundaries. The goal is to strike the right balance for your family-one that also includes school, sports, exercise, and social activities."
Laurie Penix, M.D., is a board certified pediatrician affiliated with Salem Community Hospital's Active medical staff. Her office is located at the Salem Pediatric Care Center, 2020 East State Street in Salem, (330) 332-0084.


text: ZEBRA STRIPED SCRUNCH SCARF | Body Central Bodycentral.com Flag this deal What's the matter? Choose a reason Dead deal Duplicate Bad link Spam Inaccurate No value Alive again Edit deal dropslike Jan 17, 2013 I think this SCARF is beautiful and pleasant to wear. It is a good gift for my wife. Reply Load More Comments


text:
- Text Size:
- ASmall Text
- AMedium Text
- ALarge Text
Authorities with the Canadian County Sheriff's Office said Sgt. Gary Garrison died Saturday while on duty.
Officials said Garrison died of heart failure.
Garrison was a 17-year veteran of the Canadian County Sheriff's Office. He was a U.S. Army veteran and worked at the Federal Correctional Institute in El Reno before joining the Sheriff's Office, officials said.


text:
It's from a legume (the guar bean) so it's not primal. That said, I haven't been able to find a single brand of coconut milk that I'm 100% ok with the ingredients. Either I'm stuck with thickeners like guar gum, or preservatives in some of the cheaper imported brands. So I've just been getting whichever one tastes best to me (Thai Kitchen) and trying to be ok with it.
I've only looked for it at grocery stores and natural food stores... maybe there are some ethnic food stores that would have a better option. Or you could make your own! I'm not that ambitious, lol.


text:
The latest version of Adobe Flash Player is required to watch this video.
Please click on the link below to download the latest version. Thanks!
In new signs of al Qaeda's growing strength in Yemen, the terror group killed 20 Yemeni soldiers and captured 25 others in a surprise attack on an army base Monday in the southern Abyan province.
Yemeni military officials say the attackers surrounded the base from the land and the sea.
The strike came one day after the CIA killed Fahd al-Qasaa, a top al Qaeda leader, in an airstrike in Yemen. He was wanted for the bombing of the USS Cole in 2000.
So far, it's not clear whether Monday's pre-dawn assault was retaliation for al Qasaa's death.
Al Qaeda Claims it Killed American Teacher in Yemen
Yemen Youth Cry Out over Slain American Teacher
American Teacher Executed in Yemen 'Loved His Job'
Log in or create an account to post a comment.
Are you seeking answers in life? Are you hurting? Are you facing a difficult situation?
Find peace with God, discover more about God or send us your prayer request.
Call The 700 Club Prayer Center at 1 (800) 823-6053, 24 hours a day.
A caring friend will be there to pray with you in your time of need.
CBN News is a national/international, nonprofit news organization that provides programming by cable, satellite, and the Internet, 24-hours a day. Follow us on Facebook, Twitter, and Google+.


text:
Orthopaedic Surgeon, Surgical Specialist
3601 4th St
Lubbock, TX 79430 Phone number & directions
Lubbock, TX 79430 Phone number & directions
License & Identifications
A medical license is required for a doctor to practice medicine in a particular state. Requirements vary by state but most require, at a minimum, post-graduate training in the doctor's specific specialty. An NPI number is a national identifier unique to an individual health care provider and is managed by the Center for Medicare & Medicaid Services (CMS).
Learn more about Dr. Stephen Flores:
View the full profile to get information on:
- Qualifications
- What's important to you
View full profile
Patient Reviews
Have you visited Dr. Flores? Share your experience.
Write a Review
Write a Review
Prepare before visiting Dr. Flores
Metastatic Melanoma Patient Education Learn all about metastatic melanoma symptoms and treatments by reading Vitals patient education guide.Before Visiting Dr. Flores Learn More
Specialties & Research
- He has special expertise in 3 areas:
- Hip Osteoarthritis
- Knee Osteoarthritis
- Osteoarthritis (Hand and Wrist)
Home > Find an Orthopedic Surgeon > TX > Lubbock Orthopedic Surgeons > Dr. Stephen Flores, MD
Similar doctors nearby
Dr. Adam Wooldridge
Orthopaedic Surgery
Lubbock, TX
Dr. Kathlyn Drexler
Orthopaedic Surgery
Lubbock, TX
Dr. Samuel Strebel
Orthopaedic Surgery
Lubbock, TX
Dr. John Roaten
Orthopaedic Surgery
Lubbock, TX
Dr. Dustin Moore
Orthopaedic Surgery
Lubbock, TX
Dr. Matthew Ferguson
Orthopaedic Surgery
5 years experience
Lubbock, TX
- Additional Information
- Dr. Stephen A Flores MD is a male Orthopaedic Surgeon and practices in Orthopaedic Surgery.
- Where does Dr. Stephen A. Flores practice?
- Dr. Stephen Flores has 1 office location.
Dr. Stephen Flores practices Orthopaedic Surgery near Lubbock, TX.
See Lubbock Orthopedic Surgeons.


text:
Dress Sheets
Narrow Your Results
The Rambo® Newmarket Dress Sheet is an anti-pill, double-bonded fleece. Offers excellent thermal and wicking properties. Cross surcingles and two-surcingle front closures. Attractive stripe pattern will be sure to turn heads.
Dover's Wool Dress Sheet provides the look of a custom dress sheet at a budget-friendly price. Naturally wicking wool offers just the right amount of warmth and just the right look for special occasions. This horse sheet is detailed with trim, piping, a braided hip ornament, tail cord, leather buckle and hidden surcingle.
The NorthWind® Fleece Sheet is breathable and wicks moisture so your horse stays dry. Perfect for cooler days, trailering or keeping your horse clean for shows. A great option to personalize with a monogram. Stays in place with a front buckle closure, and hidden belly surcingle.
The Rambo Fleece Rug is perfect for multiple uses in cool weather. It's made in an anti-pill, high-tech, double-bonded fleece with excellent thermal and wicking properties.
This Triple Crown Custom Heavyweight Wool Dress Sheet looks as great as it performs. Superior wool blend lies beautifully on your horse for a finished look. Choose the body color, trim color and piping color. Many custom options including monogramming are available.
Create your own look with the Blue Ribbon Custom Polarfleece Dress Cooler. Designed for superior chill protection, this horse cooler is expertly made of 13.5 ounce non-pilling, washable polarfleece. Choose body, trim and piping colors. Allow 4-5 weeks for delivery; add 1-2 weeks for a monogram.
This Blue Ribbon Custom Heavyweight Wool Dress Sheet is beautifully made in melton wool and finished with a leather front buckle and hip ornament. Choose body, trim and piping colors. Allow 4-5 weeks for delivery; increase the time allowance by 1-2 weeks for a monogram.
This Blue Ribbon Custom Lightweight Wool Dress Sheet is well crafted in quality, lightweight wool. It's has a leather front closure, removable belly strap, braided tail cord and hip ornament. Choose the body, trim and piping colors. Allow 4-5 weeks for delivery; increase time by 1-2 weeks if you add an optional monogram.
This Blue Ribbon Custom Day Sheet offers a custom look for shows. It's made of pre-shrunk 8.5 ounce cotton in your choices of body color, piping color and trim color. Supplex lining in the shoulders and faux beaver at the withers adds horse comfort. Allow 4-5 weeks for delivery; add 1-2 weeks for a monogram.


text:
Payback Time by Phil Town
In Payback Time, Phil Town teaches you the tenets of value investing, the same approach that Warren Buffett takes, with today's tools. With all the value investing books out there, what separates Town's Payback Time, and his earlier work Rule #1, from the pack? Two reasons – first, he's not a long time investor who is very far removed from "Main Street," he was a regular Joe just a short time ago and he's able to explain concepts in terms most people can understand. Second, he explains these terms and walks you through the tools, like the screener from Yahoo Finance, you can use today to find good companies.
(Click to continue reading…)


text:
Applying online is as easy as 1-2-3. You can apply now in as little as 20 minutes.
- Apply Now and complete the application.
- When you have completed the application, click submit and your information will be reviewed for instant online approval.
- A Peoples Bank Loan Officer will follow up to answer your questions.
Our goal is to provide the highest level of service at competitive rates. Our Loan Officers are only a phone call away if you need help. Contact us at 262-741-1300.
Still want to have personal assistance?
You can call or email one of our mortgage professionals to answer any of your questions or to ask for advice.
Ready to close on your mortgage quickly?
We can get your mortgage approved in minutes, rather than days or weeks! Or you can call or email one of our mortgage professionals to answer any of your questions or to ask for advice anytime.
Free pre-qualifications!
We offer free pre-qualifications, so you can shop for your home knowing that you can afford the mortgage.
Rate Watch
Keep an eye on rates via email. Sign up for Rate Watch.
Home Equity
Put your home to work for you with a home equity loan or line of credit.


text:
Rent Select Cases and Other Authorities on the Law of Property 1st edition today, or search our site for other textbooks by John Chipman Gray. Every textbook comes with a 21-day "Any Reason" guarantee. Published by Gale, Making of Modern Law.
Need help ASAP? We have you covered with 24/7 instant online tutoring. Connect with one of our tutors now.


text:
Asia Pacific
Chef Matsumoto opened his first restaurant "Bernini" in Azabu Juban, Tokyo after his culinary training in Northern Italy. Bernini is renowned for its authentic Italian cuisine and attracting the likes of the famous from all... Read More »
Pizzeria Italia
A small, unsuspecting pizzeria on Mosque Street in Hong Kong. Take out or... Read More »
Joia (translated as 'joy' in Italian) is a sophisticated, business casual restaurant offering relaxed dining in a rooftop garden setting. With a contemporary modern feel and a menu that gives a fresh twist to authentic... Read More »
208 Duecento Otto
208's pizzas are created by Enzo Carbone, a seasoned chef and Napoletana pizza specialist who comes from a family of trattoria owners in Naples. The pizzas are prepared to the specifications of The Association Verace Pizza... Read More »
Va Bene
Styled by award-winning New York architect Tony Chi, Va Bene (meaning 'going well') is the longest established Italian restaurant in Hong Kong's trendiest nightlife district, Lan Kwai Fong. Warm and welcoming, the authentic... Read More »
The original Sabatini Ristorante Italiano restaurant opened in Rome in 1954. Since then, the Sabatini brothers' flair and excellence have led to 2 other Sabatini Ristorante Italiano restaurants around the world, including this... Read More »
Nicholini's delivers the distinctive tastes of Northern Italy and has been acknowledged with the prestigious Four Forks... Read More »