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[PHOTO] Tetraploid median seedling | Sat, 7 Jun 2003 14:07:32" />
Here is a median seedling from my tetraploid crosses.
I crossed the outrageous Zandria with Devotee and got
a median version of Zandria. But to my eye, that
starburst pattern in Zandria is now translating into
heavy haft markings in this seedling. This seedling is
24" tall, has nice branching considering neither
parent has very good branching. It's not growing very
well right now and it only has 7 bud. Flowers are a
little too big to be MTB so I guess it would be BB.
Next step would be to add horns, I guess.
Seattle, WA. USA zone 8
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The New York Times
Jews and Powerby Ruth R. Wisse
Taking in everything from the Kingdom of David to the Oslo Accords, Ruth Wisse offers a radical new way to think about the Jewish relationship to power. Traditional Jews believed that upholding the covenant with God constituted a treaty with the most powerful force in the universe; this later transformed itself into a/b>
Part of the Jewish Encounter series
Taking in everything from the Kingdom of David to the Oslo Accords, Ruth Wisse offers a radical new way to think about the Jewish relationship to power. Traditional Jews believed that upholding the covenant with God constituted a treaty with the most powerful force in the universe; this later transformed itself into a belief that, unburdened by a military, Jews could pursue their religious mission on a purely moral plain. Wisse, an eminent professor of comparative literature at Harvard, demonstrates how Jewish political weakness both increased Jewish vulnerability to scapegoating and violence, and unwittingly goaded power-seeking nations to cast Jews as perpetual targets.
Although she sees hope in the State of Israel, Wisse questions the way the strategies of the Diaspora continue to drive the Jewish state, echoing Abba Eban's observation that Israel was the only nation to win a war and then sue for peace. And then she draws a persuasive parallel to the United States today, as it struggles to figure out how a liberal democracy can face off against enemies who view Western morality as weakness. This deeply provocative book is sure to stir debate both inside and outside the Jewish world. Wisse's narrative offers a compelling argument that is rich with history and bristling with contemporary urgency.
From the Hardcover edition.
Editorial Reviews
The New York Times
The Washington Post
This survey of Jewish history highlights the political aspect of Jewish experience, beginning with the observation that in the Hebrew Bible, Jewish power came through military heroics. By the time of the Roman conquest in A.D. 70, the Talmudic rabbis changed the narrative, blaming defeat on internal dissension, thus elevating the need for political discipline above military power. A Harvard professor of Yiddish and comparative literature, Wisse is keen to study how the politics of Jews occasions the politics of what she terms "anti-Jews." For instance, she asserts that Allied leaders entered WWII not to save Europe's Jews but in order to defeat the Nazis, who were also anti-Jews. Similarly, the author says, President Bush was provoked to fight anti-Jewish terrorists by 9/11. Yet in both cases, isolationists accused the administration of caving in to Jewish demands that damaged American interests. Even the founding of Israel, she implies, has not normalized Jews' political position in the world. Palestinians, she says, have forged a national identity in "obsessive opposition" to Israel, and other nations have exploited Israel for their own political ends. Although her prose is sometimes opaque, Wisse is in fine form with well-reasoned, self-assured arguments bound to provoke heated debate among interested intellectuals. (Aug. 28)Copyright 2007 Reed Business Information
In this important book, Wisse (Yiddish & comparative literature, Harvard; If I Am Not for Myself: The Liberal Betrayal of the Jews) explores the patterns of Jewish political strategy through the centuries. Jews' pragmatic and solipsistic strategies, she argues, have enabled them to survive as a people while making them particularly vulnerable to anti-Jewish political behavior-even to extreme violence and near destruction. As Wisse observed in a 2000 lecture delivered in Jerusalem, the "legacy of Jewish politics in the Diaspora continues to haunt the decision-making of Jewish leaders in their own sovereign state." Further, she writes, Jews' "capacity for accommodation dooms them if they fail to repel their assailants when necessary." A thoughtful, well-reasoned yet hard-hitting and radical approach to an urgent world problem; highly recommended for all collections.
Marcia Welsh
"In an era of deepening political and moral confusion, Ruth Wisse supplies a voice that is both clarion and courageous. Hers is a vital message for anyone who cares about Israel's fate and the future of the Jewish people. Jews and Power is a book for our times and a cogent call for clarity."
–Michael Oren, author of Power, Faith, and Fantasy: America in the Middle East, 1776 to the Present
"Wisse's brilliantly discerning analysis supplies insights so historically striking, and so currently indispensable, that no honest thinker can do without them."
–Cynthia Ozick, author of Heir to the Glimmering World
"A book . . . that celebrates the Jewish return to sovereign power, in all its promise and complexity, is as unusual as it is welcome. Wisse has written such a book . . . [Jews and Power is] a good, fighting book that contains much information in few pages."
—New York Times Book Review
"Challenging, erudite and penetrating. . . Wisse shows no fear in these pages in saying exactly what she thinks, and you can't help but be impressed with her chutzpah, even if you totally disagree with her . . . Jews and Power makes no claim for objectivity, but it is an elucidating book. It will cause liberals to question their self-consciousness about Israel, since Wisse's argument about Jewish apologism challenges liberal ideas of victimhood. For conservatives, the book offers an intellectual understanding of what otherwise might seem to be only tribalistic loyalties.
—Los Angeles Times
Product Details
- 9780307533135
- Publisher:
- Knopf Doubleday Publishing Group
- Publication date:
- 12/24/2008
- Series:
- Jewish Encounters Series
- Sold by:
- Random House
- Format:
- NOOK Book
- Pages:
- 256
- File size:
Read an Excerpt
Part One: The Great Experiment
There was no one left for the soldiers to kill or plunder, not a soul on which to vent their fury; for mercy would never have made them keep their hands off anyone if action was possible. So Caesar now ordered them to raze the whole City and Sanctuary to the ground, leaving the towers that overtopped the others . . . and the stretch of wall enclosing the City on the west—the wall to serve as protection for the garrison that was to be left, the towers to show later generations what a proud and mighty city had been humbled by the gallant sons of Rome. All the rest of the fortifications encircling the City were so completely leveled with the ground that no one visiting the spot would believe it had once been inhabited. This then was the end to which the mad folly of revolutionaries brought Jerusalem, a magnificent city renowned to the ends of the earth.[1]—JOSEPHUS, The Jewish War
The loss of Jewish sovereignty was the defining political event in the life of the Jewish people. Before then, Judea with its capital Jerusalem had been a province of the Roman Empire, paying heavy tribute to Rome yet conducting its affairs with perceived, if not complete, autonomy. Despite intense discord among Judea's religious and political factions, King Herod had restored the splendor of the Temple, which served as the center of legislative and religious activity. But the capriciousness of Roman rule angered many Jews and provoked them to armed revolt. In 70 CE, following a three-year siege, Titus crushed the Jewish uprising and burned the Temple, leveling the city—as Josephus describes, so that "no one visiting the spot would believe it had once been inhabited." Sixty-five years later, Rome put down a second Jewish rebellion with a brutality that deterred all further insurrection. Though some Jews always continued to live in the Land of Israel, the vast majority over the next eighteen centuries tried to follow the Jewish way of life outside its borders.
Memory of the national defeat seemed to divide Jewish history into unequal parts: the relatively shorter span when Jews had inhabited their land and the longer stretch of exile when they were ruled elsewhere by others. Mourning the Great Destruction became so intense that it almost rivals praise of God as the central motif of Jewish worship. "Rebuild Jerusalem the holy city quickly in our time," reads the liturgy incorporated into the grace after meals. Every Jewish ceremony and celebration invoked the Great Destruction and expectation of Return. When a Jew dies, family members are consoled with the words, "May God comfort you among the other mourners of Zion and Jerusalem." For three weeks of every year, culminating in the fast of the ninth day of the Hebrew month of Av, Jews commemorate the fall of Jerusalem. The annual Passover Seder concludes with the pledge, "Next year in Jerusalem."
When modern Jewish thinkers began to study the Jewish past, they, too, divided history into before and after. The great historian Heinrich Graetz (1817–1891) separated the "predominantly political character" of the pre-exilic period from the "overriding religious stamp" of the exile. That Graetz was the first Jewish historian since Josephus to attempt to tell the complete story of the nation seemed to substantiate his argument that Jews had lost their political character at the point of going into exile. According to Graetz, Judaism was originally not a religion at all but "a constitution for a body politic": the idea of God was originally meant to work itself out not theologically but in the living history of the Jewish people. Only after the exile did religious interests gain exclusive control so that "Judaism ceased to be the constitution for a state and became a religion in the usual sense of the word."[2] Taking politics to mean that which concerns the state and its institutions, historians following Graetz assumed that with the dispersion, Jews had ceased to function as a political people.
Not all Jewish scholars and historians shared Graetz's regret for the consequences of the exile. Some modern thinkers became convinced that despite its liabilities, the absence of political power had benefited the Jewish people in the long run. Herman Cohen, the main spokesman for liberal Judaism in Germany in the early years of the twentieth century, held that Jews had been able to develop a universal ideal of messianic redemption because they had been freed of the burdens of a state. In his view, Jewish religion alone was the driving force of modern Jewish life, having become more ethically advanced because it was freed of nationalism and a state apparatus. "Religion ought to become more political by educating citizens in the love of humanity, while politics ought to assume the religious tasks of mediating between the individual and the rest of humanity." Purified of the dross of politics, no longer bound by their own territory, Diaspora Jews could become better citizens of the countries in which they lived.[3] Immanuel Kant's ethical ideals could be realized more fully by Jews than they could by Christians precisely because Jews were unscathed by the corruptions of power.
The Russian Jewish historian Simon Dubnow, Cohen's ideological opposite in all other respects, agreed that as a consequence of exile Jews had become a spiritual nation, purified, reborn for new life.[4] Jews were for him primarily a nationality, not a religious group. Encouraged by the model of a multiethnic Austro-Hungarian empire, he believed that Jews were already ahead of the curve in transcending the grosser demands of statehood. "A nationality which lacks a defensive protection of state or territory develops, instead, forces of inner defense and employs its national energy to strengthen the social and spiritual factors for unity."[5] Locating Jewish strength precisely where materialists would have sought its weakness, Dubnow believed with Cohen that Jews could claim preeminence in the modern world not in spite of but on account of their lack of political power. He expected Jews to remain strong national minorities wherever they lived in sufficient numbers, maintaining their national distinctiveness through language, culture, education, and social institutions. His most radical proposal was that the kahal, the medieval Jewish community council, could be reconstituted as a secular institution of Jewish autonomy as part of a federated European state.
Dubnow's hopes for Jewish minority status in Europe were sorely tested by his own experience; he was forced to flee from St. Petersburg to Berlin after the collapse of the tsarist empire, then from Berlin to Riga after the rise of Nazism, and was driven to his death from the Riga Ghetto on December 8, 1941. It would be unfair to say that he paid the price for his optimism, since the Germans arranged the same ending for all Jews, irrespective of the ideas they had held. But some of his fellow intellectuals had been warier of establishing a politically viable autonomy in Europe, warning that Jews must first be granted their natural rights as Jews, not merely as citizens, as a precondition for their national recovery. In 1873 the Yiddish and Hebrew novelist known by the pen name of Mendele the Book Peddler (Mendele Moykher Sforim) had described a pack of dogs and a gang of boys beating an old mare to the point of death. When the bloodied creature is discovered in the ditch—behold! She speaks, claiming to be of noble birth, transformed centuries ago by the sorcerers of Pharaoh into her present lowlier state. Briefly restored to human (and male) form by the Wonder Worker who led her out of Egypt, she was forced back into servitude by her enemies and kept in that servile condition for "as long as the Jewish exile." The Wandering Mare of this allegory reveals to her modern Jewish interlocutor that she will be able to regain human form only if she is released from her curse by the (Gentile) powers that damned her.
Others reformers went further: in response to Russian pogroms of 1881, Leo Pinsker issued a call for Jewish self-emancipation, arguing that exile had turned Jews into a nation of zombies. Wandering like corpses among the living, they frightened Gentiles, who were afraid of ghosts.[6] The Hebrew poet Haim Nahman Bialik excoriated his fellow Jews for allowing themselves to become the targets of slaughter:
Upon the mound lie two, and both are headless—
A Jew and his dog.
The self-same axe struck both, and both were flung
Unto the self-same heap where swine seek dung.[7]
Wasting no sympathy on the victims, Bialik ignored instances of Jewish self-defense in order to magnify his indictment of Jewish submissiveness. Self-liberation became a watchword for those in the Diaspora who were determined to chart their own future.
[1] Josephus, The Jewish War, trans. G. A. Williamson (Harmondsworth, Middlesex, England: Penguin, 1959), 339.
[2] Heinrich Graetz, title essay in The Structure of Jewish History, trans., ed., and introduced by Ismar Schorsch (New York: Jewish Theological Seminary, 1975), 63-124. Quotations on pp. 70 and 84.
[3] Herman Cohen, "Graetz's Philosophy of Jewish History," in Alan L. Mittleman, The Scepter Shall Not Depart from Judah: Perspectives on the Persistence of the Political in Judaism (Lanham: Lexington Books, 2000), 35.
[4] Simon Dubnow, Nationalism and History: Essays on Old and New Judaism, ed. Koppel S. Pinson (Philadelphia: Jewish Publication Society, 1958), 80.
[5] Ibid., 99.
[6] Leo Pinsker, "Auto-Emancipation: An Appeal to His People by a Russian Jew," trans. David Blondheim, in The Zionist Idea, ed. Arthur Hertzburg (Philadelphia: Jewish Publication Society, 1959), 181-98.
[7] Bialik, "In the City of Slaughter," trans. A. M. Klein, in David G. Roskies, ed., The Literature of Destruction: Jewish Responses to Catastrophe (Philadelphia: The Jewish Publication Society, 1989), 161.
From the Hardcover edition.
Meet the Author
Ruth R. Wisse is Martin Peretz Professor of Yiddish Literature and Professor of Comparative Literature at Harvard University. Born in Czernowitz (now part of Ukraine) and raised in Montreal, she was the first professor to offer courses in Yiddish literature at McGill University, where she helped found the Department of Jewish Studies in the late 1960s. She lives in Cambridge, Massachusetts.
From the Hardcover edition.
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small cheese wrote:charliedon'tsurf wrote:and I never head of Yearlong Divide
Probably because there is no such band. It's Year Long Disaster. I know nothing about them, but a friend of mine was really looking forward to their show in Madison a few months ago. I think it was canceled.
That does make more sense and I had heard of that band, but the factual error was not my doing. I cut and pasted the openers in from correspondence my WORT music director forwarded me that came right from Frank Productions. Hopefully they figure it out before they make flyers.


text:
For This Ambitious Photographer, Politics Is Where You Find It
Tim Davis's "My Life in Politics" is this ambitious photographer's most ambitious show. With nearly 80 color images, both large and small, filling the Bohen Foundation's two floors, it's more than most viewers can comfortably absorb, but comfort is definitely beside the point here. Davis means to get on our nerves, to keep us on edgeand maybe that's where we need to be right now.
Spurred by September 11 and inspired equally by his grandmother's collection of activist buttons and Walker Evans's anti-polemical American Photographs (1938), Davis set out across the U.S. looking for signs, however ephemeral, of political engagement. Signs, quite literally, were often what he found: "Vote for Guerra," "Dick for P.V.," "Peace"; handwritten placards, bumper stickers, buttons, banners. Knitted into the chain-link fence behind a baseball diamond is the slogan "Arab = Jew." A Martin Luther King Jr. mural hangs above the booths at a taco stand. Life-size cutouts of the Clintons and JFK wait alongside Buffy, Dr. Evil, and Xena the Warrior Princess for photo ops. Not surprisingly, many of the demonstrations Davis happened upon were just as lifeless and pathetic. Not far from an equestrian statue covered in scaffolding, three people stand behind the podium at an anti-flag-burning protest, facing seven people with cameras and notepads.
As social documentary, this is quirky, deliberately tangential stuff, circling warily around the presidential race, but always with an eye on that particular prize. Davis calls it, immodestly, "an expansive, complex, multifaceted, poly-partisan body of work," but also notes that its sprawling messiness is entirely "appropriate . . . as a way of describing our democracy." He's right on both counts. Politics is in the eye of the beholder, and Davis's show works because it doesn't attempt to make anything perfectly clear.
Tim Davis
Bohen Foundation
415 West 13th Street
Through November 5
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HTC One - 3G reception problem
Hi, I have a HTC One 32GB Unlocked version. I'm using "Family Mobile" service works on T-Mobile network. It was working good in Washington State with 3G data or H speed (Family Mobile dont support 4G LTE) but after I moved to Arkansas, the 3G or HSPA connection is lost. All I'm getting is "E" signal. Couldn't able to figure out the reason?
I tried factory restore. But of no use. Could you please help on this?
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On Friday, Governor Deval Patrick signed into law a $36.5 billion state budget for FY2015, which is nearly $10 billion larger than the budget he proposed back in January 2014. Before signing off on his eighth and final annual spending plan, the Governor issued $16.1 million in vetoes, amounting to less than one percent of the total budget and illustrating a high level of agreement between the Governor and the Legislature on priority items.
Governor Patrick vetoed five outside sections in their entirety and submitted six alternative pieces of legislation in place of sections that the Legislature had included in the final budget. Notwithstanding the overall support the Governor expressed for the budget the House and Senate conference committee delivered to his desk the final day of June, Governor Patrick did make some notable cuts and requests.
The Governor's FY2015 Vetoes & Amendments
The Governor mainly issued vetoes in the areas of education, public safety, and energy and environmental affairs accounts. Specifically, Governor Patrick:
Budget Outlook
The current budget has many things in common with the draft that came before it. Namely, the current draft:
On Monday, the House referred the Governor's vetoes and recommended amendments to the Committee on Ways and Means, and now House and Senate leadership will decide which of Governor Patrick's budget vetoes to override and which of his budget amendments to bring to the floor for consideration.
There are just over two weeks left on the formal legislating calendar, and some of the budget material to be discussed — such as the expanded budgetary discretion for the Governor — does not lend itself to the informal sessions that will follow. Overrides require a two-thirds majority in each chamber, and must be completed by the conclusion of the formal sessions on July 31.
* * *
ML Strategies has tracked the annual budget debate, providing analysis on the Governor's initial budget proposal, the House of Representatives' FY2015 budget, and the House and Senate conference committee budget. If you have any questions about the FY2015 Massachusetts budget, please contact an ML Strategies government relations professional.
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The Good Guys
60 minutes
Jack is a by-the-book detective whose habit of undermining himself has resulted in a dead-end position with the Police Dept. His partner Dan, a drunken, lecherous veteran hangs onto his job only because of one heroic act years ago.
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s1e19 Cop Killer
December 3, 2010
A merciless internal affairs investigator reopens a case that leads to the release of a vengeful and deadly gang.
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mmmmmmpowmmmmmm added it to To Watch (finished)
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The Briefing 10-04-11
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The vision of sexuality glorified by Playboy is no longer on the cutting edge of moral change. Playboy won the battle and can now leave the battlefield commercially wounded but culturally victorious.
Families across the Christian world are gathering for Christmas even now, with caravans of cars and planeloads of passengers headed to hearth and home. Christmas…
Yesterday's release of a video showing the senior medical director of Planned Parenthood casually discussing the sale of organs from aborted babies is a moral…
We must speak the truth in love and seek to be good neighbors to all, but we cannot abandon the faith just because we are told that we are now on the wrong side of history.


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Illinois Rep.: October 2017 Should Be 'Zombie Awareness Month'State Rep. Emanuel "Chris" Welch hopes the bill will encourage discussions on how to be prepared for the next disaster.
Democrats, Social Service Groups Say Rauner Agenda Creating "Armageddon"Some Illinois Democrats who defeated opponents backed by Gov. Bruce Rauner in the primary election said the governor has created "Armageddon" for home healthcare and childcare agencies owed tens of millions of dollars by the state.
Report Alleges Nepotism By High School Board President, State Rep. CandidateThe president of the Proviso High School District board in the western suburbs is running for Illinois state representative, and a report says he has had 19 close friends and relatives hired for school jobs.


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Hotel de Rozenstruik
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Arrived Amsterdam
... with bacon and wild mushrooms. The mushrooms are a local treat that I have been meaning to have on other trips. They are tiny golden ones but to my mind not a lot of flavour. The meal however was very good in the comfortable dining room with stained glass windows. The hotel was full and the restaurant busy, a local tourist trade in our age group. A very good sleep. Nice and quiet and a good ...
Zwolle & Beerz
... ways to get out of the washing up! When I went back to get the washing some Dutch ladies had finished it and dried it for us which was very nice, maybe this fainting thing was a good tactic after all. Decided to move on after 2 nights as the site was a bit noisy, especially the miserable Scottish folk next to us, they should have their T5 taken away ...
Another week working on the farm!
... some of her land today, she knew all kinds of trees and plants, and it was very fascinating as she pointed them out to us.
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Organic Farming! Working hard and eating healthy!
... left with just four of us. I'm going to be sad to see them go. Our hosts here are great, very patient with us learners, and good at teaching. Their names are Gea and John-William. Gea used to be a teacher, so she is good at explaining things. John-William makes the bread every morning for us, and has a great sense of humor. He keeps us laughing all the time. They are both super intelligent, you can tell they have done a lot of reading in thier lifetimes. ...
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... Enschede town centre; a very busy and pleasant place; even the Navigator managed to buy 2 bikinis! Even managed to persuade her to get into the heated pool on the site. However, it wasn't heated enough for liking so the experience was short lived...hey ho!
An evening cycle and then packed, ready for the off to meet Adam and Josie near Brugge tomorrow.


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Telephone & Addresses
(1 - 4 from 163
Jose A Rosa (Age: 33)
93622 Firebaugh CA
Jose A Rosa (Age: 47)
32828 Orlando FL
Jose A Rosa (Age: 49)
98031 Kent WA
Jose D Rosa, 42, Houston, Mohawk St
View Jose C.'s social profiles and photos on Facebook, MySpace, and +40 Networks.
Yellow Page contacts
Network Profiles
(1 - 4 from 418
LinkedIn: Jose Rosa - Argentina | LinkedIn
Ver el perfil profesional de Jose Rosa (Argentina) en LinkedIn. Jose Rosa -- Ubicación Argentina Únete a LinkedIn y accede al perfil completo de Jose Rosa. ¡Es ...
(1 - 4 from 10
City Planning to Update Honor Roll Park - Medford, MA Patch
Medford, MA - Medford seeking the names of those who entered the military from the city for a possible fall addition.
lastFM: (caspeltheghost)
Age: 18, male, United States
Jose Rosa Register Statistics & History | Baseball-Reference.com
Minor League Batting, Pitching, and Fielding Statistics for Nearly Every Player back to 1900
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Jose Rosa patents Recent bibliographic sampling of Jose Rosa patents listed/published in the public domain by the USPTO (USPTO Patent Application #,Title):
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(1 - 4 from 21
Xing: José Rosa
Gerente de Ventas / JORS PROMARKETING
Xing: Jose Rosa
Senior Research Scientist / Trumbull, Vereinigte Staaten
Xing: Jose Rosa
conductor / Braintree, Vereinigtes Königreich
Researchgate: Jose Rosa
Brasília, Distrito Federal, Brazil
Private Homepages
(1 - 4 from 5
Born and raised in Humacao, Puerto Rico, Jose has had the opportunity to perform with renown artists such as Arturo Sandoval, Tito Puente, Marcos Barrientos,...
Quienes Somos - Materiales de Construcción José Rosa, S.L.
Materiales de Construcción José Rosa, S.L.
Dr. José A. Rosa & Prof. Dr. José Rosa
Dr. José A. Rosa - Implantologia Dentária e Prof. Doutor José Rosa - Cirurgia Plástica, Estética e Reconstrutiva
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Rating and reviews for Professor Jose Rosa from College of Mount Saint Vincent Riverdale, NY United States.
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classmates: Jose Rosa
Brimm Medical Arts High School, Camden, NJ, 2005-2009
classmates: Jose Rosa
Greater Lawrence Voc-Tec High School, Andover, MA, 2000-2004
classmates: Jose Rosa
Health Opportunity High School, Bronx, NY, 2006-2010
classmates: Jose Rosa
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IMDB Filmography: Jose Rosa
Actor, El Pirata
Bad news
(1 - 4 from 47
legacy.com: JOSE DE LA ROSA
DE LA ROSA, JOSE G., 79, Visitation: 5:00 to 9:00 p.m. Tuesday, April 22, 2014 at Sunset Funeral Home-West with Vigil at 7:00 p.m. Funeral Mass: 11:00 a.m. Wednesday, April 23,
legacy.com: JOSE DE LA ROSA
DE LA ROSA, JOSE MARIA "DON CHEMA", 75, Visitation: 5-9 p.m. Rosary: 7 p.m. Tuesday, December 23, 2014 at Mt. Carmel Funeral Home. Funeral Mass: 10 a.m. Wednesday, December 24,
legacy.com: Jose De La Rosa
DE LA ROSA, JOSE, 70, Visitation: 5-9 pm today at Sunset Funeral Homes- West with a rosary at 7 pm. Funeral Mass: 10 am November 20, 2008 at Most Holy Trinity Catholic Church.
findagrave: Rosa, Jose
07/6/1881 - 06/26/1963, Sacramento (Sacramento County, California)
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Jose Rosa Rivera, Rivera (1827 - d.) - Genealogy
Genealogy for Jose Rosa Rivera, Rivera (1827 - d.) on Geni with over 100 million profiles of ancestors and living relatives. Page updated July 2 ...
Jose C Rosa - Kissimmee, Florida
Jose C Rosa - Kissimmee, Florida - Free Public Records. First Name. Middle Name. Last Name. City. State. All States, Alabama, Alaska, Arizona, Arkansas ...
Message Boards
Jose Rosa obituary/Rosa family history & genealogy message board. Hosted by Ancestry. Forum of community contributed messages helping members research the...
Jose C Rosa in the 1940 Census | Ancestry.com
View Jose C Rosa's 1940 US census record to find family members, occupation details & more. Access is free so discover Jose C's story today.
Books & Literature
Alcindo José Rosa - Biblioteca Virtual da FAPESP
Alcindo José Rosa em auxílios à pesquisa e bolsas apoiadas pela FAPESP.
Power Spots: A Unique Guide to Contacting Inner and Outer Energy...
Power Spots: A Unique Guide to Contacting Inner and Outer Energy Points That Will Transform Your Life by Jose Rosa, Nathaniel Altman starting at €0,97....
JoVE | Peer Reviewed Scientific Video Journal - Methods and Protocols
JoVE publishes peer-reviewed scientific video protocols to accelerate biological, medical, chemical and physical research. Watch our scientific video articles.
The Book of Contemporary Conga Techniques - Hector Pocho Neciosup,...
Contemporary Conga Techniques secrets revealed! Learn the secret techniques that has been hidden for years that will help you develop the inner conguero in you.
Jose Rosa - Professional Drummer and Percussionist | ReverbNation
World music, lyrics, and videos from San Jose, CR on ReverbNation
Jose Rosa and Friends on Apple Music
Listen to songs and albums by Jose Rosa and Friends, including
Yahweh Live! by Jose Rosa and Friends on Apple Music
Listen to songs from the album Yahweh Live!, including
Related Documents
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Jose Rosa Sola, Auror at Ministerio de magia | SlideShare
View all of Jose Rosa Sola's Presentations.
CiteSeerX — Article URL
Jose C Rosa (email@example.com). Roger Chammas (email@example.com). Harald G Wiker (firstname.lastname@example.com). Gustavo A ...
United States of America, Appellee, v. Jose Rosa, Jose Vega and...
Justia Free Databases of U.S. Federal Courts of Appeals Cases 562 Federal Reporter, 2nd Series 205
Professor » Marcelo Matos Santoro » Instituto de Ciências Biológicas...
... A. Karen C. L. Torres Elizabeth Ribeiro da Silva RIBEIRO-RIBAS, R.N. Jose C. Rosa Danúbia Telles Braga Rezende, Sebastião T. Meza, Andreia N. Webster ...
Scientific Publications
Jose Cesar Rosa
Gustavo D Pimentel, José C Rosa, Fábio S Lira, Nelo E Zanchi, Eduardo R Ropelle, Lila M Oyama, Cláudia M Oller do Nascimento, Túlio Marco de Mello, Sergio Tufik, ...
José M. de la Rosa
Find all publications of the author here.
Hypothalamic inflammation is reversed by endurance training in...
Hypothalamic inflammation is reversed by endurance training in anorectic-cachectic rats. Fábio S Lira,; Alex S Yamashita,; Jose C Rosa,; Fábio ...
Sedentary subjects have higher PAI-1 and lipoproteins levels than...
Sedentary subjects have higher PAI-1 and lipoproteins levels than highly trained athletes. Fabio S Lira,; Jose C Rosa,; Adriano E Lima-Silva,; Hélio A Souza, ...
Video & Audio
Jose Rosa Percussion Studio - YouTube
Jose proudly endorses Pearl Drums and Percussion, Remo Drumheads, Paiste Cymbals, Pro-mark Drumsticks, CYMPAD, Pintech Electronic Percussion, Beato Bags, Off...
Jose Rosa - Dailymotion
fearlessjokers's Zuhause für Videos und Livestreams auf Dailymotion.
Jose Jose Rosa De Fuego 1979 - YouTube
El ultimo LP de la carrera de jose jose en los años 70 donde el surgio como cantante
Mister Hair by josé Rosa penteados práticos - YouTube
penteados praticos e rapidos em bonecas , torcidos e simples de fazer.
Jose Rosa Stats, Highlights, Bio | MiLB.com Stats | The Official Site...
The latest Jose Rosa Stats, Video Highlights, News and more from MiLB.com.
Chicopee police charge Rivers Avenue residents Jose Rosa, 28, and...
Police said the incident began as a dispute between neighbors.
Jose Rosa
Jose Rosa Quartet:
Medford asking veterans to check names for new Honor Roll plaque -...
Mayor Michael J. McGlynn has announced tentative plans for an addition to Medford's Honor Roll Park, on Winthrop Street in Medford.
Reports & Statements
Jose Rosa @ All About Jazz
Learn about and follow jazz musician Jose Rosa (Percussion) at All About Jazz.
52 Year Old Rev. Jose Rosa Missing Since - Scared Monkeys Missing...
Disappearances like this happen all the time. Today most of them are college students. Some are found suicides. Some are accident or crime ...
José Rosa Rodrigues (Dirigente) - Imortais - SerBenfiquista.com -...
José Rosa Rodrigues (Dirigente) - Imortais - SerBenfiquista.com - Fórum de adeptos do Sport Lisboa e Benfica.
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Jose Rosa | LinkedIn
Jose Rosa. Warehouse Operations Manager at Avery Dennison - GFD Plant Location Indianapolis, Indiana Area Industry
Jose Rosa | LinkedIn
Jose Rosa. Versatile and creative synthetic organic chemist with practical industrial experience in the implementation and execution of drug design strategies and ...
Jose Rosa | LinkedIn
View Jose Rosa's professional profile on LinkedIn. LinkedIn is the world's largest business network, helping professionals like Jose Rosa discover inside ...
Jose Rosa-Olivares | LinkedIn
View Jose Rosa-Olivares's professional profile on LinkedIn. LinkedIn is the world's largest business network, helping professionals like Jose Rosa-Olivares ...
JOSE ROSA-DIAZ | LinkedIn
View JOSE ROSA-DIAZ's professional profile on LinkedIn. LinkedIn is the world's largest business network, helping professionals like JOSE ROSA-DIAZ ...
Maria Jose Rosa | LinkedIn
View Maria Jose Rosa's professional profile on LinkedIn. LinkedIn is the world's largest business network, helping professionals like Maria Jose Rosa discover ...
Jose Rosa | LinkedIn
Jose Rosa. Born and raised in Humacao, Puerto Rico, Through the course of his life, Jose has had the opportunity to perform with renown artists such as Arturo ...
BaseballAmerica.com: Stats: Jose Rosa
The Home For Baseball Insiders
Jose Rosa Vale Castro (R. Vallecano) La Liga Football ...
Jose Rosa Vale Castro | Defender. Goals this season: 0. Clubs: Dep. Coruña, R. Vallecano. Born: 13 Jan 1983; Height: 183 cm. Weight: 76 kg.
Jose D' la Rosa
Colombia, Magdalena
Jose Rosa Vale Castro - Yahoo New Zealand Sport
Jose Rosa Vale Castro | Defender. Goals this season: 0. Clubs: Dep. Coruña, R. Vallecano. Born: 13 January, 1983; Height: 183 cm. Weight: 76 kg.
Jose Dela Rosa
Colombia, Magdalena
Colegio 42005 jose rosa ara | tacna | Colegios en Perú
colegio 42005 jose rosa ara, ubicado en Tacna (Tacna, Tacna) tiene la siguiente información de contacto y comentarios de alumnos, padres de familia, profesores y
Jose Rosa - Confeccões - Avenida Dos Estados ,427 ,Vera Cruz...
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LocoLobo Events is a New York entertainment booking agency offering corporate event planning for fundraisers, corporate parties and charities. Book Jose Rosa -...
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Scared Monkeys Missing Persons Site
52 Year Old Rev. Jose Rosa Missing Since 5/21/09 in Milton, Pennsylvania. A 52 year old pastor in central Pennsylvania, Reverend Jose Rosa, has been reported missing.
The Art Of Latin Drumming by Jose Rosa and Hector "Pocho" Neciosup |...
Hundreds of exercises and illuminating playalong tracks are among the features of this high-quality package.
2011-2012 Baseball Profiles: Jose Rosa - Iowa Lakes Community College
2011-2012 Profiles: Jose Rosa. Baseball header. Jose Rosa. #8 Jose Rosa Class: Freshman Position: OF B/T: R/R Height: 6'2. Weight: 215. Hometown: Rio ...
Jose Rosa | Modern Drummer MagazineModern Drummer Magazine
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text:
Local Arrests 3-31-13
St. Mary Parish Sheriff Mark Hebert reported the following arrests this morning.
Christopher Singleton, 18, of 172 Friendship Alley, Amelia, was arrested Wednesday at 1:03 p.m. on a warrant charging him with aggravated assault with a firearm and aggravated criminal damage to property. He reportedly fired several shots into a vehicle on Friendship Alley on March 1. No bond was set.
Jamachia Bowie, 22, of 102 Long St., Jeanerette, was arrested Wednesday at 10:01 a.m. on a warrant charging Bowie with failure to appear on a charge of simple criminal trespassing. She was released on $1,000 bond.
Joseph Young III, 43, of 771 Deforest Brown Lane, Centerville, was arrested today at 2:32 a.m. on a warrant charging him with unauthorized use of a movable. No bond was set.
Charles Chandler II, 21, of 149 Sun Road, Bayou Vista, was arrested today at 4 a.m. on a warrant charging him with failure to appear on charges of second offense possession of synthetic marijuana, abuse of toxic vapors and contributing to the delinquency of juveniles. No bond was set.
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text:
Clinical review: Post-extubation laryngeal edema and extubation failure in critically ill adult patients
DOI: 10.1186/cc8142
© BioMed Central Ltd 2009
Published: 1 December 2009
Laryngeal edema is a frequent complication of intubation. It often presents shortly after extubation as post-extubation stridor and results from damage to the mucosa of the larynx. Mucosal damage is caused by pressure and ischemia resulting in an inflammatory response. Laryngeal edema may compromise the airway necessitating reintubation. Several studies show that a positive cuff leak test combined with the presence of risk factors can identify patients with increased risk for laryngeal edema. Meta-analyses show that pre-emptive administration of a multiple-dose regimen of glucocorticosteroids can reduce the incidence of laryngeal edema and subsequent reintubation. If post-extubation edema occurs this may necessitate medical intervention. Parenteral administration of corticosteroids, epinephrine nebulization and inhalation of a helium/oxygen mixture are potentially effective, although this has not been confirmed by randomized controlled trials. The use of non-invasive positive pressure ventilation is not indicated since this will delay reintubation. Reintubation should be considered early after onset of laryngeal edema to adequately secure an airway. Reintubation leads to increased cost, morbidity and mortality.
Laryngeal edema is a common cause of airway obstruction after extubation in intensive care patients and is thought to arise from direct mechanical trauma to the larynx by the endotracheal tube [1, 2]. The severity of airway obstruction due to laryngeal edema varies. In more severe cases, the edema can lead to acute respiratory compromise necessitating emergency reintubation [2–8]. Reintubation itself is associated with increased mechanical ventilation days and length of stay in the intensive care unit, higher costs, morbidity and mortality [5, 9–12]. These associations, however, do not all apply to reintubation due to laryngeal edema.
The increased attention for post-extubation laryngeal edema is reflected by several recent studies [3, 4, 6–8, 13–16]. Some of these studies have attempted to identify risk factors, whereas others studied the potential preventive effect of corticosteroids on the development of clinically relevant laryngeal edema [3, 4, 6, 7, 13].
The present review will provide an overview of the etiology, incidence, risk factors, prevention and treatment of post-extubation laryngeal edema and extubation failure in adult critically ill patients admitted to the intensive care unit. Since the incidence, pathophysiological mechanisms, consequences and management of laryngeal edema in children differ considerably from those in adults, discussing laryngeal edema in children is beyond the scope of this article.
Etiology and pathogenesis
Although laryngeal edema occurs in nearly all intubated patients, only some of them develop clinical symptoms. Laryngeal edema is therefore usually transient and self-limiting. Clinical signs associated with laryngeal edema develop rapidly following extubation [25]. About 15% of all reintubations are performed because of post-extubation laryngeal edema [1]. In a study by Francois and colleagues, 87 out of 611 patients (12%) developed laryngeal edema requiring reintubation. From these 87 cases, 70 (80%) patients developed symptoms within 30 minutes after extubation, whilst almost one-half (47%) of the patients developed symptoms within 5 minutes [6].
Post-extubation stridor (PES) is accepted as a clinical marker of laryngeal edema following extubation [1–3, 6–9, 14, 25–30]. Stridor is commonly defined as a high-pitched sound produced by airflow through a narrowed airway. The ease of clinically detecting PES, without the need for further diagnostic techniques, makes PES a widely used outcome measure for post-extubation laryngeal edema.
Incidence of post-extubation stridor and laryngeal edema
Extubations or participants (n)
Cases (n)
Post-extubation stridor
Epstein and colleagues [1]
Stridor with resolution upon reintubation
Maury and colleagues [25]
High-pitched inspiratory wheeze within 24 hours of extubation with respiratory rate >30/minute
Sandhu and colleagues [26]
High-pitched inspiratory wheeze requiring medical intervention
Miller and Cole [27]
High-pitched inspiratory wheeze requiring medical intervention
Kriner and colleagues [8]
Inspiratory grunting, whistling or wheezing requiring medical intervention within 24 hours after extubation
Ding and colleagues [28]
High-pitched inspiratory wheeze associated with respiratory distress
Colice and colleagues [2]
Post-extubation stridor or hoarseness
Ho and colleagues [7]
Crowing sound on inspiration
Jaber and colleagues [30]
High-pitched inspiratory wheeze requiring medical intervention
Cheng and colleagues [3]
High-pitched inspiratory wheeze requiring medical intervention (in control group of intervention arm with positive cuff leak test)
de Bast and colleagues [36]
Inspiratory wheezing
Lee and colleagues [13]
Stridor heard with stethoscope
Laryngeal edema
Francois and colleagues [6]
Stridor with respiratory distress with need for medical intervention (minor) or severe respiratory distress needing reintubation <24 hours after extubation (major)
Darmon and colleagues [4]
Laryngeal dyspnea and/or stridor (minor laryngeal edema) or the need for reintubation due to laryngeal edema as confirmed by endoscopy (major laryngeal edema)
de Bast and colleagues [36]
Stridor with respiratory distress requiring reintubation within 24 hours, confirmed by fiberoptic examination or direct view
Chung and colleagues [55]
Near total occlusion of the airway as seen on video bronchoscopy
The main complication of post-extubation laryngeal edema is reintubation. The incidence of extubation failure, however, varies widely - incidences up to 18% are reported [5, 10, 27]. Extubation failure is often defined as reintubation within a certain time after extubation. The need for reintubation may also result from other causes, however, such as pulmonary failure, heart failure, aspiration or abundant secretions [1]. Several studies found reintubation rates of 1 to 4% specifically due to post-extubation laryngeal edema in general intensive care unit populations [4–8]. Reintubation rates among patients with PES are higher than in the general post-extubation population, varying from 18 to 69% [4, 6, 8, 14, 25, 27, 30].
Risk factors
Early identification of patients with an increased risk of developing laryngeal edema evolving into respiratory failure would be useful. This early identification would facilitate prevention and/or early treatment. Early recognition is crucial, since delay to reintubation is a predictor of hospital mortality [1].
Risk factors for extubation complications
Outcome measure
Risk factors
Laryngeal injury
Colice and colleagues [2]
Persistent laryngeal neuromotor activity, tracheostomy
Kastanos and colleagues [17]
Severe respiratory failure, high cuff pressure, duration of endotracheal intubation, secretion infection
Esteller and colleagues [19]
Longer duration of intubation, tracheostomy, number of days in the intensive care unit
Laryngeal edema
Darmon and colleagues [4]
Duration of intubation (>36 hours), gender (female)
Francois and colleagues [6]
Trauma at admission, gender (female), short duration of intubation (<7 days), smaller height to tube diameter ratio, absence of methylprednisolone pre treatment
Post-extubation stridor
Cheng and colleagues [3]
Gender (female), lower Glasgow coma score, nonsedation treatment
Sandhu and colleagues [26]
Duration of intubation (>3 days)
Daley and colleagues [9]
Tracheostomy, time to reintubation
Ho and colleagues [7]
Gender (female)
Jaber and colleagues [30]
High SAPS II, medical patients, difficult intubation, history of self-extubation, prolonged intubation, high cuff pressure
Kriner and colleagues [8]
Gender (female), duration of intubation (>6 days), ratio tube size to laryngeal size >45%
Wang and colleagues [14]
Gender (female)
Maury and colleagues [25]
Gender (female)
Erginel and colleagues [15]
Duration of ventilation (>5 days), body mass index (>26.5)
Daley and colleagues [9]
Tracheostomy, post-extubation stridor
Jaber and colleagues [30]
Post-extubation stridor
Epstein and colleagues [1]
APACHE II score, age, cardiopulmonary cause for reintubation
Sandhu and colleagues [26]
Duration of previous intubation (>3 days)
Controversy remains in the literature about the duration of intubation and the subsequent risk of developing complications. For example, the duration of intubation is identified as a risk factor for laryngeal injury by Kastanos and colleagues and by Esteller and colleagues [17, 19], while Colice and colleagues and Stauffer and colleagues failed to show this relation [2, 35].
Early recognition of laryngeal edema is essential since these patients have the highest risk of evolving to respiratory distress and extubation failure. Even before extubation, signs indicative of laryngeal edema may be present.
Measurement of the cuff leak volume in mechanically ventilated patients
Before performing the cuff leak test, first suction endotracheal and oral secretions and set the ventilator in the assist control mode.
With the cuff inflated, record displayed inspiratory and expiratory tidal volumes to see whether these are similar.
Deflate the cuff.
Directly record the expiratory tidal volume over the next six breathing cycles as the expiratory tidal volume will reach a plateau value after a few cycles.
Average the three lowest values.
The difference between the inspiratory tidal volume (measured before the cuff was deflated) and the averaged expiratory tidal volume is the cuff leak volume.
Miller and Cole made the first attempts to make the cuff leak test quantitative, by measuring the amount of air leak and correlating the cuff leak volume to the likelihood of developing laryngeal edema and PES. They calculated the cut-off value with the highest sensitivity and specificity [27]. Almost none of the patients with cuff leak volume >110 ml developed PES: the specificity of this cut-off value was 99% and the negative predictive value for absence of PES was 98%. If a leak <110 ml was present, only two-thirds of patients developed PES - making the sensitivity 67% [27].
Predictive value of the cuff leak test
Cuff leak cut off
Volume (ml)
Percentage of tidal volumea
Miller and Cole [27]
Jaber and colleagues[30]
de Bast and colleagues [36]
Sandhu and colleagues [26]
PES or reintubation
Wang and colleagues [14]
Maury and colleagues [25]
Chung and colleagues [55]
Laryngeal edema
Engoren [56]
Kriner and colleagues [8]
Cheng and colleagues [3]
Close observation is necessary after extubation, especially in the first hour after extubation. The diagnosis of significant laryngeal edema relies on symptoms. Direct laryngoscopy cannot be performed before extubation, due to the fact that the endotracheal tube blocks sight of the larynx. In addition, laryngoscopy can cause unnecessary complications in patients with respiratory failure if not performed for the purpose of securing the airway [4, 6, 7]. Naso-endoscopy can be performed to inspect the larynx before and after extubation. Based on the clinical aspect of lesions identified, the severity and expected morbidity can be estimated in experienced hands [38]. The severity of initial laryngeal pathology, however, is not an accurate predictor for the severity of adverse effects. Although every patient with symptoms has some degree of injury, not all injuries present clinically [2, 17]. Laryngeal edema therefore remains largely a clinical diagnosis.
Definition for minor and major laryngeal edema
Minor laryngeal edema:
the presence of stridor (defined as an audible high-pitched inspiratory wheeze) and signs of respiratory distress. Signs of respiratory distress are a prolonged inspiratory phase and recruitment of accessory respiratory muscles as seen by subcostal, suprasternal or intercostal retraction.
Major laryngeal edema:
respiratory distress needing tracheal intubation secondary to upper airway obstruction confirmed by direct or video laryngoscopy.
Prevention of laryngeal edema, and thereby decreasing the incidence of extubation failure, is obviously desirable. The strategies for laryngeal edema prevention will now be discussed.
First, considering tube size as a risk factor, intubation with a 7 or 7.5 mm tube in males and a 6.5 mm tube in females would be desirable. A reduced endotracheal tube diameter, however, may delay weaning, potentially interfere with bronchoscopic procedures and will increase ventilatory resistance, making the use of smaller tube sizes not feasible.
Also, several studies have reported the effect of corticosteroids in preventing post-extubation laryngeal edema. Early animal studies showed that administration of steroids reduces laryngeal edema and can prevent post-extubation laryngeal edema [39, 40]. Corticosteroid administration before extubation is part of the extubation protocol in some centers [4, 7, 41]. Steroid use for 24 hours is considered safe, and no major adverse effects related to its use have been reported in a number of studies [3, 6, 13, 16, 32, 42, 43].
Results of recent randomized controlled trials in humans, however, have been contradictory. These differences may be explained by use of different types of steroids and different administration regimens. Moreover, some protocols only use steroids in patients with a positive cuff leak test, thereby attempting to select patients at high risk for the development of laryngeal edema.
Three studies, including two well-described randomized controlled trials, used a single-dose regimen with steroids being administered within 1 hour before extubation. All of these studies failed to show a significant effect on laryngeal edema, PES and reintubation rates [4, 7, 41]. In contrast, a single dose of 40 mg methylprednisolone 24 hours before extubation was effective in lowering the incidence of PES and the reintubation rate in a randomized controlled trial by Cheng and colleagues [3]. A significant rise in the cuff leak volume was measured 7 hours after the first steroid injection. The authors suggest that steroids may have a time window before initiating an effect on laryngeal edema and should therefore be given at least 7 hours before extubation [3]. Indeed, studies that use regimens with multiple doses of steroids, starting at least 6 to 12 hours before extubation, seem to indicate the best chance of showing a preventive effect [3, 6, 13, 16]. The regimen used by Francois and colleagues is currently the most effective regimen known. The regimen consists of 20 mg methylprednisolone 12 hours before planned extubation, which is repeated every 4 hours until extubation [6].
The effect of a multidose steroid regimen was confirmed in a recent meta-analysis. Fan and colleagues calculated a risk reduction of 0.19 (-0.24 to -0.15; number needed to treat, 5) on the occurrence of laryngeal edema and of 0.04 (-0.07 to -0.02; number needed to treat, 25) on the rate of reintubation [16]. On the contrary, the effect of a single-dose regimen used in older studies was not statistically significant in two meta-analyses [16, 44]. The benefit from steroids will be greater in patients at risk for laryngeal edema, who could be identified with a positive cuff leak test [42]. One should bear in mind, however, that the positive predictive value of the cuff leak test is low. This may lead to an overtreatment of patients with a false positive cuff leak test.
Finally, early tracheostomy might be beneficial in patients at risk for extubation failure due to laryngeal edema, but its exact role so far remains unclear. Early tracheostomy, however, has been shown to lead to less laryngeal damage compared with prolonged translaryngeal intubation [45]. Nevertheless, it is impossible to predict morbidity based on the severity of laryngeal damage [17]. There are no data at hand that support the use of tracheostomy as a preventive procedure in patients at risk of extubation failure due to laryngeal edema, but the procedure could be considered in selected cases.
Maintaining the airway, adequate oxygenation and relieving distress associated with obstruction are primary treatment goals. Several treatment modalities, including reintubation, are available and will be discussed below.
Medical therapeutic strategies include systemic administration of steroids and nebulization of epinephrine. Corticosteroids downregulate the inflammatory response by inhibiting the recruitment and action of inflammatory cells [49]. Together with a decrease in capillary vessel dilatation and permeability, this inhibition reduces edema [39]. The most effective dose has not yet been determined. We suggest a dose of 0.5 mg/kg prednisolone intravenously per day. The effectiveness of glucocorticoids in post-extubation laryngeal edema has not been confirmed in randomized controlled trials. In our experience, however, the potential benefit outweighs the risk of adverse events. Moreover, most adverse events are pharmacological effects of corticosteroids that are likely to disappear after the treatment period [50].
Furthermore, epinephrine nebulization is another potentially effective therapy. Epinephrine acts through local stimulation of α-adrenergic receptors on vascular smooth muscle cells, thereby causing vasoconstriction and decreased blood flow, which diminishes edema formation. Randomized controlled trials that prove efficacy of epinephrine in post-extubation laryngeal edema in adults are again lacking. Likewise, there is no consensus about the potentially effective dosage of epinephrine nebulization. A dose of 1 mg epinephrine in 5 ml normal saline has proved successful in some cases of upper airway obstruction in adults [51]. Rebound edema is known to occur and close observation is essential [52]. Side effects can occur, especially in patients with coronary artery disease [52].
Theoretically, non-invasive positive pressure ventilation can help prevent reintubation due to respiratory insufficiency in general [3, 8]. Evidence for benefit of non-invasive positive pressure ventilation in laryngeal edema, however, is lacking. In a general intensive care population of patients with respiratory failure after extubation, Esteban and colleagues found an increased mortality in the non-invasive positive pressure ventilation group (25% vs. 14%, P < 0.048), which can possibly be explained by the increased time from onset of respiratory failure to reintubation [53]. The use of non-invasive positive pressure ventilation in patients with laryngeal edema might therefore be harmful, as laryngeal edema progresses and further obstructs the remaining airway - making reintubation more difficult, if not impossible.
Helium administration can also be considered. Because a helium/oxygen mixture has a lower density than oxygen-enriched air, airway resistance is decreased. Again, there is little evidence of its usefulness in adults with laryngeal edema and in adults even with airway obstruction due to asthma, largely consisting of case reports and nonrandomized trials [54]. If a helium/oxygen mixture is used, a minimum of 40% of helium is advised in profound hypoxemia, since this amount of helium reduces airflow resistance most effectively while not compromising oxygenation [52].
Emergency tracheostomy is the ultimate step in severe cases of laryngeal edema in which endotracheal intubation fails. In our hospital, elective tracheostomy has successfully been used in a few patients with several, consecutive episodes of extubation failure, not responding to preventive measures or conservative therapeutic strategies.
A practical flow chart on prevention and therapy of post-extubation laryngeal edema and extubation failure is depicted in Figure 3.
Clinically relevant post-extubation laryngeal edema occurs in up to 30% of extubated patients, and 4% of patients need to be reintubated due to laryngeal edema. Laryngeal edema most often presents as inspiratory stridor and may be associated with respiratory failure due to airway obstruction. Subsequent reintubation leads to increased costs, morbidity and mortality. Female gender, a relatively small tracheal diameter or a large tube size and a long duration of intubation have been identified as risk factors in different studies. A positive cuff leak test with leak volume <110 ml increases the risk for development of PES and subsequent reintubation significantly. Multiple-dose regimens of corticosteroids starting at least 12 hours before extubation can prevent the development of laryngeal edema in patients with these risk factors.
The decision whether or not to treat laryngeal edema depends on the severity of symptoms. Every patient with stridor after extubation should be monitored closely. If an increase in severity of symptoms is noted, it is advised to start with nebulized epinephrine or a helium/oxygen mixture. Corticosteroids might also be helpful, but sound evidence is lacking. The use of non-invasive positive pressure ventilation is not recommended since it may be harmful due to a delay in reintubation. Reintubation should be considered early to secure the airway when possible. The exact role of preventive or therapeutic tracheostomy needs to be established.
post-extubation stridor.
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Low Down Dirty Z
Dan Zertuche daily driven 350,possibly the lowest 350 ever! Shot on canon t2i with a kit lens. forgot to bring my quick release for the tripod so we worked with what we had.Especially since we were tight on time, we shot this all while my boi Dan was on his lunch break.
Drift Trike Mafia
Nor cal drift trike session .A few Cali Stunt Riders first bombs down the grade ,trying to hang with the Drift Trike Mafia.