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John Metcalfe
John Metcalfe was CityLab's Bay Area bureau chief, covering climate change and the science of cities.
What appears to be a large meteor (CNN reports it was "at least the of, say, a kitchen table") ripped through the atmosphere today over the Chelyabinsk region in Russia, burning out the sky with the light of a billion exploding flashbulbs and leaving billowing smoke trails like a shuttle reentry gone terribly awry.
Official Russian news agency Itar-Tass reported early Friday morning (EST time) that at least 150 people had been injured by the effects of the sonic boom, which knocked down the roof and walls of a zinc plant in the vicinity of Chelyabinsk. Meanwhile, RT chimed in to say that as many as 500 people had sought medical attention for "minor injuries" after the speeding object crashed through the skies, blowing broken window glass all over and somehow causing "concussions." Here's an excerpt:
At least one piece of the fallen object caused damage on the ground in Chelyabinsk. According to preliminary reports, it crashed into a wall near a zinc factory, disrupting the city's Internet and mobile service.
The Emergency Ministry reported that 20,000 rescue workers are operating in the region. Three aircraft were deployed to survey the area and locate other possible impact locations.
Witnesses said the explosion was so loud that it seemed like an earthquake and thunder had struck at the same time, and that there were huge trails of smoke across the sky. Others reported seeing burning objects fall to earth.
The prolonged space-thunder set off car alarms and nervous dogs and babies across the land. Give this video a couple seconds of build-up to experience the bone-electrifying jolt that Russians must have felt when this thing whizzed by:
NASA said earlier that the asteroid 2012 DA14 projected to pass near earth today has "no chance" of colliding with the planet, so this appears to be a separate, freakishly timed phenomenon. But c'mon you NASA guys: After Presidents Day, I want to see an intense equation diagramming the probability of these two rare events happening at virtually the same moment.
And it was damn incredible – a once-in-a-lifetime event for most people. Here's some more footage that was popping up early Friday morning, beginning with a school that gets its windows cancelled:
Because this is Russia, here's the obligatory dash-cam view (warning: if you speak Russian, there's probably profanity in here):
One more look at that ferocious sonic assault:
Cities that require builders to provide off-street parking trigger more traffic, sprawl, and housing unaffordability. But we can break the vicious cycle.
The German company Siemens is launching an ambitious adaptive reuse project to revitalize its historic corporate campus, with a modern data-collecting twist.
In spring 2018, news of the water crisis in South Africa ricocheted around the world—then the story disappeared. So what happened?
Pittsburgh is the worst place for black women to live in for just about every indicator of livability, says the city's Gender Equity Commission.
Two new studies have revived the long-running debate over how police respond to white criminal suspects versus African Americans.


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Our exclusive lifestyle hotel experience, designed to fulfill the needs of the discerning business executive and leisure traveler.
Our hotels offer a broad range of function rooms - from elegant boardrooms to banquet halls.
Whether on an epic journey or a weekend getaway, we make every child's stay magical.
These exquisite properties are the perfect vacation oasis for you and your loved ones.
Purchase a gift card or browse through our selection of quality bed linens, pillows and bathrobes or sample our premium teas.
After an invigorating day on the slopes, step into consummate luxury.
Our luxurious golf destinations include breathtaking mountains, stark deserts and warm tropical beaches.
Experience our growing collection of breathtakingly beautiful spas around the world.
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Luxury Brand Welcomes First Hotel in the Philippines
Fairmont Hotels & Resorts is pleased to announce the opening of Fairmont Makati on December 3, marking the brand's entry into the Philippines. Ideally situated in one of the 17 cities comprising Metro Manila - one of the major financial, commercial and economic hubs in Asia - Fairmont Makati joins a growing portfolio of Fairmont hotels in the Asia Pacific region, including the recently opened Fairmont Jaipur in India and Shanghai's Fairmont Peace Hotel.
Fairmont Makati offers 280 spacious deluxe rooms and suites, including Fairmont Gold, the hotel's exclusive hotel within a hotel. Conceived by leading architects Arquitectonica and interior designers Bent Severin International, the modern architecture features sophisticated style alongside the rich, cultural characteristics of Filipino design. Making use of abundant local materials such as coco-twig white resin, crushed mahogany seeds (embedded in the walls) and abaca laminated glass, a warm, neutral palette boasts colourful accents and detail finishes like pearl in-lay handles on mahogany wood. A focal point of each guestroom is the floor-to-ceiling glass windows overlooking the bustling city.
The tower housing Fairmont Makati also is home to Raffles Makati, a 32-room, all-suite hotel, and Raffles Residences, featuring 237 one- to four-bedroom residences for both short and long- term stays. Raffles is a sister brand under the parent company Fairmont Raffles Hotels International.
A wide array of flavours is on offer at Fairmont Makati. Spectrum is the hotel's innovative all-day dining restaurant where guests can enjoy international cuisine with five 'Culinary Theatres' surrounding the main dining room, bar and lounge seating areas. Cafe Macaron offers a tantalizing selection of freshly baked bread, desserts, pralines and pastries while the Lounge at Fairmont serves afternoon tea and after dinner snacks. The famous Long Bar at Raffles Hotel Singapore is the inspiration behind Long Bar featuring light snacks as well as the renowned Singapore Sling and, for a quieter escape, the Writers Bar is located at the lobby of the Raffles Makati.
For meetings and special events, the hotel offers 1,700 square meters (18,000 square feet) of function space including a 900 square meter ballroom. Fairmont's signature Willow Stream Spa totals 1,200 square meters (14,000 square feet) of soothing surroundings, featuring five fully equipped treatment rooms, hair salon, full-service nail studio, a mineral pool, an outdoor swimming pool and beautiful terrace offering a luxurious urban retreat.
With its premier location in the heart of the Ayala Centre, Makati's financial and entertainment district, the hotel is within walking distance to the Philippine Stock Exchange, Ayala Museum and the city's most luxurious shopping areas. Guests of Fairmont Makati can enjoy a special introductory offer December 4, 2012 through March 31, 2013 and stay three nights, pay for two with the Seeing is Believing package. Rates start from $239 (PHP9,800) per night, excluding taxes. Reservations can be made by calling 1-800-441-1414 or at fairmont.com/makati.
Fairmont Hotels & Resorts is a celebrated collection of more than 60 luxury properties around the globe, including Shanghai's Fairmont Peace Hotel, The Plaza in New York, and Makkah Clock Royal Tower in the Kingdom of Saudi Arabia. The luxury brand's distinctive hotels offer a sense of heritage and sophistication, warm, engaging service and culturally rich experiences. A community and environmental leader, Fairmont is also recognized internationally for its responsible tourism practices and award-winning Green Partnership program. Fairmont is owned by FRHI Holdings Limited, a leading global hotel company with over 100 hotels under the Fairmont, Raffles, and Swissôtel brands. The company also manages Fairmont, Raffles and Swissôtel branded luxury private residences club, whole-ownership residences and serviced residences properties. For more information or reservations, please call 1-800-441-1414, visit fairmont.com, or contact your local travel professional.
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Follow the steps below to download the necessary drivers and install Windows 7 on your iMac:
Note: If you are upgrading from Windows Vista, you'll need to use the Apple_Win7_Upgrade_Utility before starting an upgrade install. This is not required for a clean installation of Windows 7.
- Go to the bottom of the Software License Agreement for Boot Camp and click "Accept and download" to agree to the license.
- The files are contained in a .zip file. Double-click it to expand it.
- Connect your USB storage device or SD card.
 Note: Your USB storage device must be connected to the back of the iMac directly and not to a keyboard or other non-high-powered HUB.
- If the USB device or SD card has not been formatted as MS-DOS (FAT), or if you're not sure, follow steps A through N immediately below; otherwise go to step 5.
 Important: These steps will erase the contents of the USB storage device or SD card; back up any important files that are on it to a different disk.
- Choose Go > Utilities.
- Open Disk Utility.
- Select the USB drive in the left side of the Disk Utility window.
- Click the Partitions tab.
- Choose the number of partitions from the Volume Scheme menu. If you can't choose the number of partitions, you may be trying to partition your startup disk.
- Click Options.
- Click "Master Boot Record."
- Click OK.
- Click the Format tab.
- Select MS-DOS (FAT).
- Name the disk MBRFAT.
- Click Apply.
- Click Partition.
- When the process is complete, quit Disk Utility.
- Drag "Drivers" and "AutoUnattend.xml" from the iMac_Late_2009_2010_ Win7_Drivers folder, which was expanded in step 2, to the icon of the USB or SD card device to copy the files to it. Do not copy them to any subfolders.
- Start the Boot Camp Assistant.
- Select a partition size and click Partition.
- After partitioning has completed, click "Start the installation" and insert your Windows 7 install DVD. Your computer will restart.
- Follow the onscreen Windows install instructions. If this is a new installation, remember to use the Windows installer to format the BOOTCAMP partition. You'll need to click on Drive Options (Advanced) to see a Format selection.
- Your computer will restart several times during the installation process. The screen may go black for several minutes while the Windows installer locates the drivers on your USB storage device. You should not turn off your computer during this process.
- A screen should eventually appear asking you to establish a user account in Windows 7.
If the screen remains black after several minutes, power it off (hold the power button for several seconds), then go back to step 4. Ensure that your USB device or SD card is formatted as Master Boot Record, FAT, and that AutoUnattend.xml and Drivers are on the root level of the directory.


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Are you interested in practicing veterinary medicine with a preventative care and wellness focus? Pet Paradise is a national company that is expanding rapidly. Come grow with us!
Pet Paradise is an established, national Premier Pet Resort committed to enhancing the quality of pet health by adding Veterinary Wellness Clinics to all our locations. We currently have 35 resorts across 9 states and are growing 8-12 resorts per year. Pet Paradise values the importance of offering the ultimate pet experience for each pet guest and pet parent. We aim to instill pet parents with the added confidence a Veterinarian is present to oversee pet wellness during their pet's stay.
We are looking for the right fit... a Veterinarian who possess a friendly and engaging personality and demonstrates exceptional interpersonal skills with both clients and members of our Pet Paradise team. We are seeking Veterinarians committed to delivering high quality medicine while simultaneously focusing on exceptional customer service and associate engagement. Most patients are drop offs so there are less appointments and more flexibility for your work schedule.
We offer a highly competitive salary with a generous benefits package - medical, dental, PTO, licensure, short and long term disability, student loan repayment, relocation, 401(k), pet boarding and day camp - bring your pet to work every day. Extremely flexible work schedules are possible for the right candidate and there are no after-hours calls. Full and part time positions available.


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WASHINGTON – When Gina McCarthy steps into her new role as administrator of the Environmental Protection Agency she will face an army of lawyers trying to sway the agency as it writes rules on power-plant emissions that will form the centerpiece of the Obama administration's climate-action plan.
At least some of those lawyers are likely to lead legal challenges against the rules once they are issued.
McCarthy, confirmed by the U.S. Senate on Thursday, and the EPA will use a rarely used section of the Clean Air Act to carry out the boldest aspect of the plan President Barack Obama announced in June – slashing carbon pollution from the country's biggest source of greenhouse gas emissions, its thousands of existing power plants.
A source at a utility lobbying group said that while some companies may be inclined to wait and then sue the EPA after it finalizes the rules, the better tactic would be to engage in the rulemaking process but prepare for litigation just in case.
"If you are being prudent you are better off working with the EPA," the source said, noting that the courts have tended to side with the agency in recent high-profile cases.
The U.S. Supreme Court ruled in 2007 that greenhouse gases are a harmful pollutant, which gave the EPA the authority to use the act to regulate the climate-warming emissions.
But there is little precedent for using the Clean Air Act to regulate greenhouse gases from existing sources, creating an opening for lawyers to offer their own interpretations on behalf of electricity sector clients or environmental groups.
Bill Bumpers, a partner and Clean Air Act specialist at Baker Botts' Washington climate-change practice, is gearing up to help clients both inform the EPA's rulemaking process and anticipate lawsuits years down the line.
His clients range from companies that have already adopted early action strategies to curb their emissions – some of which he has designed himself – to those that rely heavily on coal and will be harder hit by future rules.
Lobbying a federal agency is often different from seeking to influence Congress. What works on Capitol Hill, especially emotive arguments about the impact a regulation might have on jobs, does not work well inside the EPA, said Raymond Ludwiszewski, a former EPA general counsel under Bill Clinton and the first administration of George W. Bush who is now a partner at Gibson, Dunn & Crutcher.
"If you are trying to influence the agency, you are stronger with technical arguments," Ludwiszewski said.
As a result, many law firms have technical experts on staff and will sometimes commission studies that can be cited during the rulemaking process.
The threat of litigation already has influenced the EPA to make a technical adjustment to its proposed regulation on carbon emissions from new power plants, sources familiar with the process have said. Instead of one emissions standard that would apply to both coal- and gas-fired plants, it will set a separate less stringent standard for coal plants to enable at least some efficient facilities to be built.
Obama last month set a deadline of Sept. 20 for the agency to complete that rule, which was originally required to be finalized by April 13.
The proposed rule initially required any new power plant to emit no more than 1,000 pounds of carbon dioxide per megawatt hour, effectively ruling out new plants powered by coal without the as-yet uncommercialized carbon capture and storage technology.
A legal coalition of utilities known as the Utility Air Regulatory Group (UARG), represented by the climate-law practice of Hunton and Williams, has already sued the agency, arguing that there should be separate standards for gas and coal-fired plants. Although the case was thrown out by the court because the rule has not been approved, the suit gave the EPA an early view of the utilities' legal strategy, probably prompting the agency to adjust it to thwart future challenges.
At Sidley Austin, another major law firm, clients can call upon agency veterans such as Roger Martella, a former general counsel at EPA under George W. Bush, and star litigators like Peter Keisler, who has argued a number of high-profile environmental and energy cases in recent years.
"The prime message we try to get out to our clients, if a company believes the rule is going to impact them, is to not wait until the rule is final to develop a legal strategy," Martella said.
Sophisticated industry players involved in rulemaking adopt a series of approaches. They can have private meetings with officials, participate in public meetings, file written comments and exert pressure outside of EPA – on Capitol Hill or at the White House, for example.
In fact, to file a legal challenge to a regulation, a party has to have raised the issue in the rulemaking process by filing a formal statement.
After a proposed rule is published in the Federal Register, parties that oppose it will generally warn the EPA that they will sue if the rule is not changed prior to approval. Firms differ on how heavily litigators are involved in the rulemaking process.
Scott Fulton, a partner at Beveridge and Diamond who served as general counsel to the EPA until January, said the agency is well aware of the potential legal challenges to its upcoming emissions plan, and is certain to "make the rule as flexible as possible" by deferring most authority to the states.
He said the agency will set up a public engagement process that is much more open than in the past and will probably schedule public listening sessions and other direct meetings.
Whatever the legal merits of EPA's regulations, the agency will first have to seek approval from the White House, which signs off on proposed rules before they are issued.
That judgment, said Sean Donahue, a lawyer who represents the Environmental Defense Fund, will be based in large part on "what is politically possible."


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Rep. Maureen E. Madden November 30, 2016
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Department of Primatology
Max Planck Institute for Evolutionary Anthropology
Deutscher Platz 6
04103 Leipzig
phone: +49 (341) 3550 - 200
fax: +49 (341) 3550 - 299
Affiliated Research Groups
Junior Research Group of Primate Kin Selection
Understanding the impact of kinship upon the evolution of social behavior is one of the central questions in Behavioral Ecology. Kin selection theory predicts that animals can increase their fitness by allocating more cooperation to kin than to non-kin.
The Infectious Disease Lab (GAHMU)
The Infectious Disease Lab (GAHMU) has two main aims. The first is to identify pathogens causing death in wild great apes, and the second is to create baseline data on the "physiological" or chronic pathogen presence in great apes.


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Sharon Stone has taken aim at actresses who refuse to bare all in sex scenes, insisting it just isn't natural to cover up.
The actress has never been afraid of nude scenes in her films and can't understand her peers, who sign up for a little movie lovemaking only to make sure they're buried in the duvet.
She tells WENN, "I feel that it's so disappointing in films when you see the comforter taped to someone's chest. It takes you out of the scene and doesn't protect you from something within the scene.
"My Lovelace co-star Peter Sarsgaard said, 'When I'm in bed with someone and I get up to go to the bathroom, I don't take the comforter with me'."
Stone admits she had to explain her nudity onscreen to her father when he asked her, "Do you really have to be naked all the time?" after watching his daughter in Basic Instinct.
She recalls, "I'm like, 'Well, yeah! I'm playing a sociopathic sexual serial killer!'
"When it has common sense it doesn't make sense to do something else. It really is the costume of your character. What else are you gonna do? It seems foolish to do something else and if you do something else, that distracts the audience if your inauthentic.
"If you're inauthentically naked then it's distracting to the audience when you are naked."
Sharon Stone has taken aim at actresses who refuse to bare all in sex scenes, insisting it just isn't natural to cover up.


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State of the World 2013: Is Sustainability Still Possible?
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|Is Sustainability Still Possible?
Every day, we are presented with a range of "sustainable" products and activities—from "green" cleaning supplies to carbon offsets—but with so much labeled as "sustainable," the term has become essentially sustainababble, at best indicating a practice or product slightly less damaging than the conventional alternative. Is it time to abandon the concept altogether, or can we find an accurate way to measure sustainability? If so, how can we achieve it? And if not, how can we best prepare for the coming ecological decline?
In the latest edition of Worldwatch Institute's State of the World series, scientists, policy experts, and thought leaders tackle these questions, attempting to restore meaning to sustainability as more than just a marketing tool. In State of the World 2013: Is Sustainability Still Possible?, experts define clear sustainability metrics and examine various policies and perspectives, including geoengineering, corporate transformation, and changes in agricultural policy, that could put us on the path to prosperity without diminishing the well-being of future generations. If these approaches fall short, the final chapters explore ways to prepare for drastic environmental change and resource depletion, such as strengthening democracy and societal resilience, protecting cultural heritage, and dealing with increased conflict and migration flows.
State of the World 2013 cuts through the rhetoric surrounding sustainability, offering a broad and realistic look at how close we are to fulfilling it today and which practices and policies will steer us in the right direction.
About State of the World
Worldwatch's flagship publication, State of the World, has educated a broad audience of students, journalists, policymakers, and concerned citizens about trends in sustainable development for a quarter century. The book has been published in 36 languages, and over the years it has authoritatively assessed issues ranging from population, energy, and agriculture to materials use, health, and trade policy. Topics are covered from a global perspective, with an emphasis on innovation and problem-solving. State of the World is recognized as a classic of environmental literature, having attracted luminaries from Kofi Annan to Mikhail Gorbachev to write forewords for the book. News media, policymakers, and NGOs worldwide cite the book for its cutting-edge analysis, reliability, and careful documentation of its arguments, all marshaled to speed the global transition to a sustainable world.
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Titans hire Mike Mularkey as tight ends coach
NASHVILLE, Tenn. — The Tennessee Titans have hired former Jacksonville Jaguars and Buffalo Bills head coach Mike Mularkey as tight ends coach on Ken Whisenhunt's staff.
Mularkey coached the Jaguars to a 2-14 record in 2012 and was fired at the end of the season. He also went 14-18 as Buffalo's coach in 2004-05. Mularkey and Whisenhunt previously worked together as assistants with the Pittsburgh Steelers.
"I am excited to back in the league," Mularkey said Wednesday in a team release announcing the hire. "I took some time off for family time. I got a chance to do some things with them, which I haven't gotten to do over the last 20 years of coaching. I am definitely excited to get back and excited to get back with Ken. We go way back in our relationship, back to when we were players in the NFL and even to college when he was at Georgia Tech and I was at Florida."
Mularkey worked with the Steelers from 1996-2003 and spent his last three years in Pittsburgh as offensive coordinator. He spent two years with the Miami Dolphins as offensive coordinator in 2006 and tight ends coach in 2007. Mularkey was the Atlanta Falcons' offensive coordinator from 2008-11.
The Falcons went 43-21 during Mularkey's time in Atlanta.
"Mike brings a wealth of experience, both as a coordinator and a head coach," Whisenhunt said in a release. "Selfishly, for me, he brings a lot to the table, having been in this situation before. There are things that I will use him for moving forward that will help us a team. He has had a lot of success in this league and we are lucky to have him."
Mularkey played nine seasons in the NFL as a tight end with the Minnesota Vikings and Steelers. He caught 102 passes for 1,222 yards in 114 career games.
Mularkey began his coaching career as an offensive line coach for Concordia College. He worked with the Tampa Bay Buccaneers as a quality control coach in 1994 and a tight ends coach in 1995.
"As a coach, I am diligent about the details of every little thing," Mularkey said. "I am very big into making sure my guys are prepared and I really like them to know what is going to happen before it happens. With my background and knowledge as a player and coach, I can be a resource. I do love what I do and they will see that from me."


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Alys Martinez is a general assignment multimedia journalist for KEYT NewsChannel 3 and is elated to call Santa Barbara home.
Alys grew up in Long Beach and received a degree in Spanish at UCSB. She put her degree to good use, moved back to Long Beach and taught third-grade in a bilingual classroom and Adult Education.
Although she loved teaching, Alys decided to pursue a career in journalism. She moved back to Santa Barbara in 2005 and was hired as an Assignment Editor at KEYT. Within two years, Alys moved up the ranks and became News Operations Manager and Producer. With this experience, she was hired at KABC-TV in Los Angeles as a writer and editor.
She spent nearly four years at KABC writing about everything from the Super Bowl, to the earthquake in Haiti. She has also worked as a writer and editor at KTLA-5 in Los Angeles.
However, Santa Barbara was always calling her home. After marrying and becoming a mom, Alys decided to raise her son in the most beautiful city in the world. In 2012, she accepted a job at KEYT NewsChannel 3 as the weekend producer and also began reporting.
When Alys isn't working, the single-mother spends time with her son Patrick, who is the love of her life. She is also an avid outdoors-woman. She enjoys hiking and has scaled Mount Whitney. Alys has also competed in several marathons, triathlons and adventure races.
Follow Alys on Twitter: @KEYTNC3Alys


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Chris Brown & Her Mother Speaking On The Rihanna Beating "I Don't Remember It" [Larry King Interview Preview)
Brown doesn't remember assault Chris Brown and his mother discuss Rihanna's assault.
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The Barrow County Board of Commissioners will have a total of five public hearings Tuesday night.
Two will begin before the start of the board's regular meeting. A 6 p.m. hearing will be about proposed amendments to the Animal Control Ordinance regarding dangerous and vicious dogs. A 6:30 p.m. hearing will be about installing streetlights on Mears Street.
Once the regular meeting starts at 7 p.m., the BOC will have public hearings on three land-use applications: a special use permit for the operation of a salvage yard on 4.4 acres at 774 West Winder Industrial Pkwy.; rezoning of 3.56 acres at 301 Bowman Mill Road to divide the site into two residential lots; and rezoning of about half of a 21-acre tract off Highway 211 just north of Winder to allow 29 single-family detached dwellings and a 104-unit apartment complex. The site is near where the future West Winder Bypass is to intersect with Highway 211. The BOC is scheduled to vote on each rezoning application following each public hearing.
Five public hearings at BOC meeting Tuesday night
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The demand for car-free ski resorts is on the increase. Environmental concern, child safety, and the desire for noise-free holidays are behind it.
Growing ecologicial awareness about the consequences of uncontrolled use of cars has put pressure on tourist authorities to come up with car-free ski resorts. The Association of National Mayors of Mountain resorts, the body representing winter sports local authorities in France, has completed an ecological audit of 10 leading resorts. It found that 57 percent of green house gas pollution came from motor vehicles.
Vice President, Guy Vaxelaire told OnTheSnow that steps are already being taken to limit cars and introduce electric powered buses. Pilot schemes are underway in Ax les Thermes in the Pyrenees and La Bresse in the Vosges mountains. He said: "This is a problem that is going to have to be dealt with because people are no longer prepared to just accept the dominance of the motor cars and the accompanying pollution".
The greener steps being taken in France are already in place in Switzerland. Zermatt has electric powered buses, mini cars for hotel guests and even electric taxis.


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As a citizens' committee studies possible changes to the Barrow County government structure, citizens can get more info about the county structure online.
Barrow County was created on July 7, 1914 by an act of the Georgia General Assembly. That original legislation has been amended multiple times over the past century to establish the county's current form of government.
To read the provisions that are the subject of the ongoing review, go online to www.municode.com and search the "Municode Library" for Barrow County's Code of Ordinances.
The applicable provisions are under "Part 1 – Special Acts of the General Assembly."
Of particular importance are those that address the balance of power between the BOC and the chairman.
The powers and duties of the board of commissioners are in Section 2.
The powers and duties of the BOC chairman are in Section 7.
Local residents without Internet access may access the document online at any public library.
Barrow County governing provisions available online
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Obstructive sleep apnea syndrome (OSAS) is a common sleep related breathing disorder. Its prevalence is estimated to be between 2% and 25% in the general population. However, the prevalence of sleep apnea is much higher in patients undergoing elective surgery. Sedation and anesthesia have been shown to increase the upper airway collapsibility and therefore increasing the risk of having postoperative complications in these patients. Furthermore, the majority of patients with sleep apnea are undiagnosed and therefore are at risk during the perioperative period. It is important to identify these patients so that appropriate actions can be taken in a timely fashion. In this review article, we will discuss the epidemiology of sleep apnea in the surgical population. We will also discuss why these patients are at a higher risk of having postoperative complications, with the special emphasis on the role of anesthesia, opioids, sedation, and the phenomenon of REM sleep rebound. We will also review how to identify these patients preoperatively and the steps that can be taken for their perioperative management.
Vasu TS; Grewal R; Doghramji K. Obstructive sleep apnea syndrome and perioperative complications: a systematic review of the literature. J Clin Sleep Med 2012;8(2):199-207.
Obstructive sleep apnea is characterized by intermittent and recurrent episodes of partial or complete obstruction of the upper airway during sleep. These episodes disrupt sleep architecture, causing fragmented sleep and daytime sleepiness. OSAS has been shown to be associated with various health-related consequences, including increased rate of motor vehicle accidents, hypertension, diabetes mellitus, congestive heart failure, stroke, and all-cause mortality.1–9
Recently, numerous studies have demonstrated that surgical patients with sleep apnea are at increased risk of having perioperative complications, including hypoxemia, pneumonia, difficult intubation, myocardial infarction, pulmonary embolism, atelectasis, cardiac arrhythmias, and unanticipated admission to the ICU. The majority of patients with OSA are undiagnosed upon admission and are at risk during the perioperative period, presumably due to their underlying sleep apnea. Therefore, it is very important to identify these patients preoperatively so that one can initiate appropriate perioperative measures.
OSAS is an extremely common sleep related breathing disorder, and its prevalence has been increasing throughout the world because of obesity and increasing age of the general population. Its prevalence is between 2% and 25% in the general population, depending upon how sleep apnea is defined. In an epidemiological study, Young et al. noted that the prevalence of sleep apnea, defined as apnea-hypopnea index (AHI) ≥ 5/h was 9% for women and 24% for men.10 However, the prevalence of OSAS (defined as AHI ≥ 5/h and daytime sleepiness) was 2% in women and 4% in men.10 The National Sleep Foundation (NSF) Sleep in America 2005 Poll found that 1 in 4 Americans are at high risk of having sleep apnea based on the Berlin Questionnaire.11 The prevalence of sleep apnea is much higher in surgical patients and depends on the type of surgery. In the bariatric surgery population, the prevalence of sleep apnea has been found to be > 70%.12,13 It is the standard of care for these patients to get a formal sleep evaluation prior to undergoing the bariatric surgery. However, patients who are coming for general surgery also have a higher prevalence of sleep apnea.14 Chung et al. used the Berlin Questionnaire preoperatively and found that 24% of surgical patients were at high risk for sleep apnea.15 We used the STOP-BANG Questionnaire in our elective surgical population and found that 41% of patients were at high risk for sleep apnea based on the questionnaire.16 In a cross-sectional study, 39 patients underwent nocturnal polysomnography (NPSG) prior to undergoing epilepsy surgery. It was found that 1 in 3 patients undergoing epilepsy surgery had sleep apnea.17 In another study, the prevalence of sleep apnea was found to be 64% in a small population of patients undergoing surgery for intracranial tumor.18 The majority of these patients are unaware of their sleep apnea prior to undergoing elective surgery. In an observational study, Finkel et al. noted that > 80% of surgical patients were unaware that they had sleep apnea prior to undergoing surgery.14
Surgical patients receive sedation, anesthesia, and opioids during the perioperative period. These medicines have been shown to increase pharyngeal collapse, decrease ventilatory response, and impair the arousal response, leading to worsening of sleep apnea in the perioperative period.
Patients with sleep apnea have recurrent episodes of partial or complete obstruction of the upper airway during sleep. These episodes usually occur when the negative pressure of inspiratory muscles exceeds the upper airway dilator muscle activity (critical airway pressure).19,20 General anesthetics have been shown to decrease the upper airway dilator muscle activity in a dose-dependent manner and thereby increase upper airway collapsibility.21–23 In 12 healthy subjects undergoing minor surgery, increasing depth of propofol anesthesia was associated with a progressive increase in critical airway pressure and upper airway collapsibility.23,24 This increased upper airway collapsibility was found to be secondary to progressive decrease in the genioglossus muscle activity. Upper airway collapsibility may cause worsening of the sleep apnea and increase the risk of hypoxemia, cardiac arrhythmias, and postoperative complications.
Anesthetic medicines also impair the arousal response, a protective defense mechanism against sleep apnea that helps in overcoming the airway obstruction. Anesthetics, opioids, hypnotics, and benzodiazepines may also cause respiratory depression and thereby decrease the minute ventilation. Studies have shown that halothane reduces the ventilatory response to hypoxemia and hypercapnia in humans.25,26 This depression is most likely secondary to a selective effect of halothane on the peripheral chemoreflex loop. Similarly, a subanesthetic dose of isoflurane has been shown to reduce the hypoxemic ventilatory response via peripheral chemoreceptors.27,28
Patients undergoing surgery frequently receive opioids for the pain control. Opioids have been shown to impair ventilatory function by affecting both peripheral and central carbon dioxide chemoreflex loops.29,30 Studies have shown that small doses of narcotics administered epidurally may also depress the respiratory function, even in healthy adults.31–33 The ventilatory depression of opiates appears to be affected by sex and ethnicity, as well.34,35 Morphine has been shown to reduce hypoxic and hypercapnic ventilatory response in women, but not in men.34 On the other hand, it raises the apneic threshold in men with no effect in women.34 The combination of opiates and benzodiazepines has been shown to cause more significant episodes of hypoxemia and apnea.36 This is most likely secondary to significant reduction of hypoxic ventilatory response to both opiates and benzodiazepines.37–39
Surgical patients have been shown to have highly fragmented sleep on postoperative nights 1 or 2, with a significant reduction in REM sleep, slow wave sleep, and increased stage 2 NREM sleep.40–46 These sleep disturbances usually occur secondary to surgical stress, pain, and the use of anesthetic and pain medications.40,47,48 The stress of surgical trauma leads to increased level of cortisol, and cortisol has been shown to cause significant reduction in REM sleep.49,50 Surgical trauma has also been shown to induce significant inflammatory response, characterized by the increased level of pro-inflammatory markers like tumor necrosis factor alpha (TNF-α), interleukin 1 (IL-1), and IL-6.51–53 These inflammatory markers, especially IL-1 and TNF-α, have been shown to suppress REM sleep.54–56
There are studies that have shown that REM sleep is usually absent on postoperative nights 1 and 2. This is usually followed by a profound increase in the amount and density of REM sleep (REM sleep rebound) during recovery nights 3 to 5.44,57–59 The episodes of sleep disordered breathing and hypoxemia are usually worse during REM sleep due to hypotonia and unstable breathing. REM sleep is also associated with increased sympathetic discharge leading to tachycardia, hemodynamic instability, and myocardial ischemia.60–64
It is well known that most complications after the surgery occur in the first postoperative week, especially between postoperative days 2 and 5, corresponding to periods of REM rebound. Episodes of hypoxemia after surgery have been reported to occur mostly between postoperative nights 2 to 5.58,59,65 These episodes may increase the risk of wound infection, cerebral dysfunction, and cardiac arrhythmias.66 In an observational study at Mayo Clinic, it was found that the incidence of acute myocardial infarction peaked on day 3 after surgery.67 Similarly, episodes of delirium, nightmares, and psychomotor dysfunction have been reported to occur between postoperative nights 3 to 5.68–70
We systematically searched the literature on PubMed, Embase, and Scopus databases to identify relevant studies on association between obstructive sleep apnea and perioperative outcome. We included studies conducted in adults who underwent elective surgery. We excluded bariatric surgery and sleep apnea surgery population. Two authors (TSV and RG) independently searched for the relevant articles published in the English literature from 1966 to December 2011. We used the combination of terms including surgery, perioperative outcome, perioperative complications, perioperative pulmonary outcome, perioperative risk, postoperative complications, and obstructive sleep apnea. Bibliographies of all selected articles and review articles were also reviewed to find any other relevant article. These 2 authors (TSV and RG) also independently assigned the Oxford level of evidence and the grade of recommendation to each article.71 There was 100% agreement between the 2 authors. We identified 11 articles on obstructive sleep apnea and perioperative outcome. These articles along with their Oxford level of evidence are reported in the Table 1 and Table 2.
Studies reporting association between obstructive sleep apnea and perioperative complications
[i] PSG, polysomnography; ICU, Intensive Care Unit; SACS, Sleep Apnea Clinical Score; PACU, Postanesthesia Care Unit.
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The Oxford level of evidence and grade of recommendation for individual studies
Surgical patients are at higher risk of having complications for a variety of reasons, including ASA (American Society of Anesthesiologists) class,72,73 age,73–76 type of paralytics,77,78 current smoking,79–81 low albumin,81–83 duration of surgery,84–86 type of anesthesia,73,78,87,88 and other comorbidities—especially chronic obstructive pulmonary disease, coronary artery disease, and renal failure.79,80,89 The risk of postoperative complications also depends on the type of surgery. The rate of complication is higher in patients undergoing abdominal surgery90–92 and is also increased with aortic aneurysm repair,93–96 vascular,74,78,79,93 thoracic,83,90,93,96 and neck surgery.83,96,97
Gupta et al. have shown an increased risk of postoperative complications (39% vs 18%), higher rate of transfer to ICU (24% vs 9%), and increased length of hospital stay in patients with obstructive sleep apnea compared with control subjects matched for age, sex, and body mass index (BMI).98 In this study, these investigators also reported that OSA patients who received continuous positive airway pressure (CPAP) therapy prior to surgery had a reduced rate of serious complications and a one-day reduction in the length of hospital stay. In another case-control study, Liao et al. found that patients with OSA had higher rate of postoperative complications (44% vs 28%).99 Interestingly, they also noted that OSA patients who were not compliant with their CPAP had the highest rate of postoperative complications. Kaw et al. also demonstrated that patients with OSA had higher incidence of encephalopathy, postoperative infections (mediastinitis), and increased ICU length of stay.100 Similarly, Memtsoudis et al. in their case-control study found that orthopedic and general surgical patients with sleep apnea were at a higher risk of having perioperative pulmonary complications.101
Hwang et al. demonstrated that the rate of postoperative complications was increased in proportion to episodes of overnight desaturation during home nocturnal oximetry.102 In this study, 172 patients underwent home nocturnal oximetry during preoperative evaluation for elective surgery. The number of episodes per hour of oxygen desaturation (or oxygen desaturation index) ≥ 4% (known as the ODI 4%) was calculated for every patient from the home nocturnal oximetry. Patients with an ODI 4% ≥ 5/h had a significantly higher rate of postoperative complications than those with ODI 4% < 5/h (15.4% vs 2.7%). Interestingly, the rate of postoperative complications increased with increasing ODI severity. Patients with an ODI 4% of 5-15 had a 13.8% incidence of complications, compared to 17.5% of those with an ODI 4% > 15.
In a recent cohort study, 471 patients who underwent noncardiac surgery within 3 years of polysomnography were evaluated for postoperative complications and hospital length of stay. It was found that patients with sleep apnea had higher rate of postoperative complications and hypoxemia.103 We used the STOP-BANG Questionnaire preoperatively to identify patients at high risk for OSAS.16 We found that patients at high risk of OSAS had a higher rate of postoperative pulmonary and cardiac complications than patients at low risk (19.6% vs 1.3%). We also noted that patients at high risk of OSAS had significantly higher length of stay in the hospital compared to patients at low risk. Gali et al. used Flemons criteria and SACS (sleep apnea clinical score) to identify patients at high or low risk for obstructive sleep apnea.104 They also noted that patients with high SACS and PACU (postanesthesia care unit) events had a higher rate of postoperative respiratory events. Similarly, Auckley et al. used the Berlin Questionnaire to identify the high-risk patients.105 They demonstrated that patients at high risk of sleep apnea had more postoperative complications (20% vs 4.5%); however, this difference was not statistically significant.
There are two studies that have been conducted in patients undergoing ambulatory surgery to assess the impact of obstructive sleep apnea.106,107 These studies found that the presence of OSA did not increase the rate of unplanned hospital admissions in patients who underwent outpatient surgical procedures. Stierer et al. used a prediction model in a cohort of ambulatory surgical population to assess the probability of sleep apnea.107 They demonstrated that patients with ≥ 70% propensity for OSA had increased rate of difficult intubation, increased oxygen requirement, and intraoperative tachycardia.
Nocturnal polysomnography (NPSG) is considered to be the gold standard to identify patients with obstructive sleep apnea.108 However, in the perioperative setting, it is difficult to implement due to a variety of factors, including its prolongation of the process of surgery and contribution to the overall cost. In many hospital settings, it may also not be readily available. There are other methods that have been shown to identify patients who are at risk for obstructive sleep apnea including questionnaires, nocturnal pulse oximetry, and home sleep testing.
There are many questionnaires that are available to identify surgical patients who are at high risk of having obstructive sleep apnea. Three of these questionnaires have been validated in the surgical population: the Berlin Questionnaire, ASA checklist, and the STOP-BANG questionnaire. The Berlin questionnaire is the most widely used questionnaire to identify patients at high risk for OSA. It contains 11 questions that are organized in 3 symptom categories and has been validated in the primary care patients.109 It has a sensitivity of 86% and positive predictive value of 89% for identifying patients with respiratory disturbance index (RDI) > 5/h in the primary care clinic. Recently, Chung et al. validated the Berlin questionnaire in surgical population and found that it had a sensitivity of 74.3% to 79.5% and a negative predictive value of 76% to 89.3% in identifying patients with moderate-to-severe OSA.110 However, this questionnaire has complex scoring system and is time consuming.111
The American Society of Anesthesiologists (ASA) checklist also appears to be very useful and promising and has been proposed by ASA Task Force to identify patients with OSA.112 It contains 12 items for adults and 14 items for children. The ASA checklist has been shown to have a sensitivity of 78.6% to 87.2% and a negative predictive value of 72.7% to 90.9% in identifying surgical patients with moderate-to-severe OSA.110
Recently, the STOP-BANG (Snoring, Tiredness during daytime, Observed apnea, high blood Pressure, Body mass index, Age, Neck circumference, Gender) questionnaire was validated as a screening modality for OSAS in the preoperative setting.113 It is a concise, self-administered, and easy-to-use questionnaire that consists of 8 yes/no questions. Patients are considered to be at high risk of OSAS if they answer yes to ≥ 3 items. The sensitivity of the STOP-BANG questionnaire at an AHI > 5, > 15, and > 30 cutoff values was 83.6%, 92.9%, and 100%, respectively; corresponding negative predictive values (NPV) were 60.8%, 90.2%, and 100%. This questionnaire has a moderately high level of sensitivity, specificity, and NPV to detect patients with moderate (AHI > 15) to severe (AHI > 30) sleep apnea in the surgical population. Therefore, if the patient is ranked as a low risk for OSA by the STOP-BANG scoring model, practitioners can exclude the possibility that the patient would have moderate-to-severe sleep apnea with a good degree of accuracy.
Abrishami et al. conducted a systematic review to identify and evaluate the different screening questionnaires for sleep apnea.114 They noted that the Berlin and STOP-BANG questionnaires had high sensitivities and specificities in predicting moderate or severe sleep apnea. However, they found that the STOP and STOP-BANG questionnaires had the highest methodological validity, and these questionnaires are very easy to use.
Nocturnal pulse oximetry has also been used for the screening of OSA. Malbois et al. compared the sensitivity of nocturnal oximetry to ambulatory monitoring in order to identify patients with sleep apnea prior to undergoing bariatric surgery.115 They demonstrated that nocturnal oximetry with a 3% desaturation index as a screening tool for OSA could rule out significant OSA (AHI > 10) and also detect patients with severe OSA. This cheap and widely available technique could accelerate preoperative work-up of these patients.
Ambulatory monitoring is another modality that can be employed in patients at high risk for sleep apnea. However, this is recommended only in patients with a high pre-test probability of sleep apnea and is not recommended in patients with coexisting cardiopulmonary complications.116 It also has its limitations in terms of ease of use by the patients. There is one study that has shown the effectiveness of ambulatory monitoring in confirming the diagnosis of OSA in 82 % of adult surgical patients, identified as high risk prior to undergoing surgery, in a large academic medical center.14 It would be helpful to evaluate this modality of diagnosing OSAS in specific surgical patient population.
The American Society of Anesthesiologists published practice guidelines in 2006 on the perioperative management of patients with obstructive sleep apnea.112 It also proposed OSA scoring system to assess the perioperative risk. Based on these guidelines, perioperative care can be subdivided in 3 parts: preoperative evaluation, intraoperative management, and postoperative management (Table 3).
Perioperative management of patients at high risk of obstructive sleep apnea syndrome
Physical Examination
Screening Questionnaires like Berlin, ASA, or STOP BANG to identify high-risk patients
Consider a formal sleep evaluation in very high-risk group
Minimize the surgical stress
Reduce the duration of surgery
Consider regional or local anesthesia instead of general anesthesia
Anticipate difficult intubation
Consider awake extubation preferably in semi-upright position
Minimize the use of opioids and sedation after the surgery
Consider using acetaminophen, NSAIDs, or regional analgesia for the pain control
Continuously monitor oxygenation in the postoperative period
Patients with a known diagnosis of sleep apnea should use their CPAP after the surgery
High-risk patients for sleep apnea should use Auto CPAP during the postoperative period
Follow-up at the sleep center for the management of sleep apnea upon discharge from the hospital
Patients should undergo thorough history and physical examination preoperatively with the special emphasis on the evaluation of sleep apnea. One should obtain history pertinent to sleep apnea including snoring, excessive daytime sleepiness, witnessed apneas, frequent awakenings at night, and morning headaches. A focused physical examination should be conducted to evaluate neck circumference, body mass index, modified Mallampati score, tongue volume, tonsillar size, and nasopharyngeal characteristics. It is important to administer screening questionnaires like the Berlin, ASA, or STOP-BANG to identify patients at high risk for OSA. These questionnaires are simple and easy to administer preoperatively and have been validated in the surgical population. There should be an action plan for the management of high-risk patients during the perioperative period. In few circumstances, anesthesiologists and surgeons may decide to obtain formal sleep evaluation for the management of sleep apnea prior to performing surgery.
Intraoperative management usually focuses on surgical measures and the type of anesthesia. One should minimize the surgical stress and the duration of surgery as these factors have been shown to increase the perioperative complications. Whenever possible, consider using regional or local anesthesia instead of general anesthesia. These patients should be extubated when they are fully awake, preferably in the semi-upright position.
Patients at increased perioperative risk from OSA should be very closely monitored in the post anesthesia care unit (PACU) for hypoxemia or other complications. They should have continuous monitoring of oxygenation with the help of pulse oximetry. Whenever possible, these patients should be placed in the non-supine position after the surgery to decrease the severity of apnea. These patients are very susceptible to opioids and benzodiazepines and one should minimize the use of these medicines in the perioperative period. Consider using NSAIDs, acetaminophen, tramadol, and regional analgesia for pain control. Dexmedetomidine can be very useful for sedation because of its opioid sparing effect and the lack of respiratory depression. Patients with the known diagnosis of sleep apnea should use their CPAP after surgery. There is no randomized controlled trial that has demonstrated that CPAP is beneficial in the postoperative setting. However, one may consider using auto-CPAP in high-risk patients after surgery, although it might be difficult for the CPAP-naïve patient to get used to it in the perioperative period. Once again, the use of auto-CPAP has not been formally studied in this population, and there may be a need to conduct a randomized controlled trial to assess the efficacy of auto-CPAP. These patients should also get formal sleep evaluation after discharge from the hospital.
CPAP acts as a pneumatic splint and helps in opening the collapsed upper airway at night. The application of CPAP also improves functional residual capacity (FRC) and oxygenation with reduction in work of breathing. CPAP has been shown to improve excessive daytime sleepiness in patients with OSAS. There is some evidence that the perioperative use of CPAP may help in reducing postoperative complications. In a case control study, Gupta et al. noted that OSA patients who were compliant with their CPAP had reduced rate of complications and also decreased hospital length of stay.98 Similarly, Liao et al. noted that OSA patients who were not compliant with their CPAP were at the greatest risk of having postoperative complications.99 Squadron et al. demonstrated that the use of CPAP leads to reduction in the incidence of endotracheal intubation and other severe complications in patients who develop hypoxemia after elective major abdominal surgery.117 In a randomized controlled trial, Kingen-Milles et al. found that the prophylactic use of nasal CPAP was associated with a reduction in pulmonary complications and hospital length of stay in patients undergoing thoracoabdominal aortic aneurysm repair.118 In another study, Zarbock et al. also noted significant reduction in the rate of pulmonary complications with the prophylactic use of nasal CPAP in patients undergoing elective cardiac surgery.119 A recent meta-analysis of nine randomized controlled trials in the abdominal surgical population reported reduction in the rate of atelectasis, postoperative pulmonary complications, and pneumonia with the perioperative use of CPAP. 120
Obstructive sleep apnea syndrome (OSAS) is a common type of sleep disordered breathing, with a high prevalence in the surgical population. The majority of patients with sleep apnea are undiagnosed and are therefore unaware of their OSAS at the time of the surgery. These patients are at increased risk for perioperative complications. Sedation, anesthesia, opioids, and REM sleep rebound have been shown to cause worsening of sleep apnea in the perioperative period that may lead to increase in the rate of perioperative complications. It is important to identify these patients preoperatively so that appropriate actions can be taken during their perioperative care. Screening questionnaires such as the Berlin, STOP-BANG, or ASA checklist are easy to administer preoperatively and have been shown to identify high-risk patients. There should be a standard protocol for the perioperative management of high-risk patients in order to reduce the rate of complications. These high-risk patients should also have a formal sleep evaluation for the long-term management of their sleep apnea after the discharge from the hospital.
This was not an industry supported study. The authors have indicated no financial conflicts of interest.
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At this point, I think most journalists have reached the point that they know that Anders Behring Breivik (a) has self-identified as a "Christian," (b) yet he also made it clear that he is not a Christian believer, in terms of beliefs and practice and (c) that it is bizarre to call him a "fundamentalist," in any historic sense of the word. The early facts indicate that this was a political radical committing an act of political terrorism for political motives, motives that happen to include some idealized vision of resurrecting some kind of old, glorified, "Christian" European culture.
Yes, I know plenty of activist and advocate journalists are sticking with the "Christianist" template. Also, there are academics who are sharpening their swords and taking the usual swings at orthodox forms of religion ("When Christianity becomes lethal") Nevertheless, most mainstream journalists seem to be staying in the middle of things and, perhaps, waiting for facts about this terrorist and whatever ties he did or did not have to real people and institutions outside of history books and cyberspace.
At this stage, I would like to point readers toward the following Dan Gilgoff essay at the CNN.com religion blog: "Is 'Christian fundamentalist' label correct for Norway terror suspect?" It contains tons of interesting voices and thoughts. I'll complete this plug for it with the following slice:
"It is true that he sees himself as a crusader and some sort of Templar knight," said Marcus Buck, a political science professor at Norway's University of Tromso, referring to an online manifesto that Breivik appears to have authored and which draws inspiration from medieval Christian crusaders.
"But he doesn't seem to have any insight into Christian theology or any ideas of how the Christian faith should play any role in Norwegian or European society," Buck wrote in an email message. "His links to Christianity are much more based on being against Islam and what he perceives of as 'cultural Marxism.'"
From what the 1,500-page manifesto says, Breivik appears to have been motivated more by an extreme loathing of European multiculturalism that has accompanied rapid immigration from the developing world, and of the European Union's growing powers, than by Christianity.
"My impression is that Christianity is used more as a vehicle to unjustly assign some religious moral weight," to his political views, said Anders Romarheim, a fellow at the Norwegian Institute for Defence Studies. "It is a signifier of Western culture and values, which is what they pretend to defend."
Toward the end, a major American scholar enters the debate:
Experts on religion in Europe said those faith-infused views are likely peculiar to the suspected gunman and do not appear reflect wider religious movements, even as they echoes grievances of Europe's right-wing political groups.
"He was a flaky extremist who might as well have claimed to be fighting for the honor of Hogwarts as for the cause of Christ," said Philip Jenkins, a Pennsylvania State University professor who studies global religion and politics, describing the suspected Norway attacker. "He did not represent a religious movement. ... People should not follow that Christian fundamentalist red herring."
By all means, give this one a careful reading.
All of this is good, but I can hear copy-desk pros muttering in the background, saying, "Academics, smackademics! Get real. What are we supposed to CALL this guy in a headline?
Over at the Huffington Post, an evangelical thinker from the Greater European Mission has weighed in with another option on that front.
Frankly, I don't think his language works for journalists -- outside of quoted material in news features, when there is a bit of space in which to breathe. It takes too much interpretation. However, his content is crucial. Here is a slice of what Ben Stevens has to say in his piece, "Is Anders Breivik a European Fundamentalist?"
Let's start with a quote from page page 1,307 of Breivik's manifesto, and then the minister's take:
A majority of so called agnostics and atheists in Europe are cultural conservative Christians without even knowing it. So what is the difference between cultural Christians and religious Christians? If you have a personal relationship with Jesus Christ and God then you are a religious Christian. Myself and many more like me do not necessarily have a personal relationship with Jesus Christ and God. We do however believe in Christianity as a cultural, social, identity and moral platform. This makes us Christian.
Breivik asserts that a majority of the atheists in Europe are cultural conservative Christians. This comes as a surprise to us all, I suppose. The key to understanding his manifesto, his mania and the confusion currently dominating news headlines lies in the reality that by "Christian" he almost always means "European." In the massive introduction to his manifesto, for example, there is not a single quotation from Scripture, mention of the creeds, allusion to the Church or reference to Jesus Christ himself. And we learn, through the video he posted, that his heroes are not religious figures like Paul or Martin Luther but political figures like Charles Martel and Nicholas I.
Anders Breivik is a cultural fundamentalist. He is a European fundamentalist. But he disowns orthodox Christianity, and this makes it all the more ironic, and disgusting, that he saw himself as a kind of representative against threats to "Christendom."
These pieces will, I am sure, continue.
Truth is, I still do not know the language that I would put into a one- or two-column bold headline, in this case. I pity copy editors who have to make that call. I honestly do.
Once again, for those who have forgotten GetReligion's take on all of this, from the start of this story, we remain very interested in knowing the basic facts about how religion influenced this man's life, if there are any. Here is how I put that on day one:
In terms of the religion angle of this story, what are journalists looking for? I would say they are seeking the exact kinds of facts and leads that they would be seeking if this person was alleged to be a radical Muslim. We need to know what he has said, what he has read, what sanctuaries he has chosen and the religious leaders who have guided him.
Also, follow the money, since Breivik certainly seems to have some. To what religious causes has he made donations? Is he a contributing member of a specific congregation in a specific denomination? Were the contributions accepted or rejected?
Well, we now know more about what he has said -- the manifesto plugged that hole, for journalists. We know a bit about what he may or may not have been reading. We know nothing whatsoever about his own religious life and the practice of his faith, if he ever did so. There are no signs of institutional links or real, live clergy of any kind. Again I urge journalists to look for financial ties.
The ultimate question, in terms of religion: Was this man truly a loner, a man living out a brand of faith that he created on his own and, in the end, one in which he serves as the prophet who produces the private scriptures that guide his life and work? In other words, if he calls himself a "Christian," where is his church, his pew, his altar and his pastor-priest?
Journalists must keep looking for the facts.


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