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Texarkana RV Rentals By Owner
One of the best ways to experience the beautiful views in Arkansas is by taking a road trip in an RV. Instead of staying put in a hotel, you can experience the natural beauty of the area and see various attractions. Renting an RV or a camper will not only allow you to create fun memories but it's also an affordable way of taking a trip.
Average Prices for Texarkana RVs for Rent by Owner
The average rate for RVs, campers, and motorhomes varies depending on when you plan to book the rental. There is a higher demand for camping vehicles from May to September when tourists spend more time exploring Arkansas. The rates begin to drop once the fall season arrives and continue to stay low until the spring.
You can expect to pay more for an RV if it's larger and you're traveling with more people. The average rate for an RV in Arkansas is $50 each night. The only documents that you need to provide when picking up the rental is a photo ID and your deposit.
One of the top attractions to visit Spring Lake Park where trails are available to hike. A disc golf course is also available for those who want to stay active in a lush outdoor setting. Fishing piers are also offered where you can catch your dinner.
Although you'll need to pay for the rental RV and any campsites that you stay at overnight, the low cost will still allow you to save money compared to staying in hotels. Having a kitchen in the RV will also make it easy to bring your own food along and avoid expensive restaurants and eateries.
Cheap RV Rental by Owner in Texarkana
If you want to save even more money while driving an RV to Texarkana, there are many ways to obtain discounts and deals. A variety of rental companies will include unlimited miles in the packages that are available, which can allow you to drive a long distance without increasing the overall price of the rental.
You can also book the camper or motorhome several months in advance when the prices are lower. Choosing a vehicle that is smaller if you aren't planning on bringing a lot of people along will also allow you to save.
Consider using a camper for your trip instead of a full-size RV if you want to avoid hotels but still have somewhere to lay your head at night. Campervans are similar to RVs but are smaller in size and will allow you to have everything that you need in one place.
Class C RVs are also more affordable and will have the basics without causing you to spend more on extra bells and whistles that may not be needed as you explore Texarkana.
Luxury Motorhome for Rent by Owner in Texarkana
If you have a taste for the finer things and want to enjoy the best RVs that are available to rent, there are several options available. Look for Class A or Class B RVs, which will include plenty of high-end features. You can enjoy driving an RV that has a larger windshield and comfortable leather seats that make for a more leisurely drive.
Ample space is a standard amenity in Class A or B RVs, which offer the chance to travel with more of your family members and friends. You can also drive a rental that is appropriate for parking at sites that include the Discovery Place Children's Museum or the Ace of Clubs House museum. It'll be easy to explore the arts and culture that is present in Texarkana in a regal RV that is appropriate for urban locations.
When you're ready to explore outdoor locations, you can enjoy "glamping" in the vehicle instead of sacrificing your comfort in the wild. You can enjoy cooking your baked beans and hot dogs over a stovetop in the RV instead of huddled over a fire outside. It's also easier to get better sleep at night in a cozy RV.
Opt for Texarkana Private RV Rentals
Those who have the time to research more of their options and be more selective when finding a camper or motorhome for rent in Texarkana can browse listings that are posted by private owners. RV owners often prefer to rent out their vehicle throughout the year when it's not in use to avoid the high cost of storage and maintenance.
With campers for rent by owner in Texarkana, you can speak directly to the owner to discuss the availability and price of the rental when you want to negotiate. You can have peace of mind selecting a model that has more of what you need and make a customized rental plan that suits your budget and schedule.
Campsites for Texarkana Motorhome Rentals by Owner
There are many places to park overnight in Texarkana, which includes Shady Pines RV Park. The establishment offers both shower and bathroom facilities when you need to clean up. There's also a pond available where you can hike and take your dog on a walk.
Sunrise RV Park features gravel lots and a swimming pool to stay cool in the summer. The lots are spacious, making it ideal for those who are traveling in larger RVs or campervans. The site is also close to the interstate, making it easy to get back on the road when it's time to depart.
Purchasing an RV
Many people who rent an RV or camper for their previous trips often find themselves itching to buy one of their own as a way to travel more. You can save more money throughout the year by skipping hotels and having a comfortable place to stay when it's time for your next vacation.


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Mug and Brush Hair Design Inspirational A Grooming Kit is Not A Bad Idea Looks Good and Ensures He Smells
A grooming kit is not a bad idea Looks good and ensures he smells from mug and brush hair design , source:pinterest.com
How To Start A Business With Only mug and brush hair designEveryone has seen screen printed mugs donning the desks of offices promoting one company or any other. Mugs will always be the most popular business gifts because they serve an objective. People prefer to drink coffee and tea while working or on break and it is always nice to experience a ceramic mug handy which means you don't need to use one of the Styrofoam cups. This article compares the modern of promotional mugs brought on by advances in digital printing. The following three print options is highly recommended if you are organising printed mugs for your upcoming promotion.
If You Read Nothing Else Today, Read This Report on mug and brush hair designThere are many great ideas to use for the creation of your custom coffee mug. For example, you may want to buy a few coffee mugs and have them made to order together with your business info such as your address, company telephone number, company fax number as well as your business' promotional gifts. This is a good way to have more clientele for a business. You may also need to pass out the custom mugs as free gifts after a degree has been spent at the store by the customer. Given out coffee mug brings you more customers because when one person has a good experience and feel as if they've got bought something was worth their money they're going to recommend your store or product and they whoever they recommend will recommend and the like. With so many companies offering promotional items these days it's easy to get overwhelmed. However, using the proper research it is possible to locate exactly what you are interested in. Read reviews from previous customers, check forums, and speak right to nokia's. Ask them if they should locate a product that is faulty or unusable, do they really take it back? Do they give you a guarantee? And what is the common percent that they're met with such difficulties? They may not answer the final questions honestly, so make use of your better judgment.
9 Stylish Ideas For Your mug and brush hair design
Finding The Best mug and brush hair designCustomised mugs could be a good party gift, work anniversary gifts, and a lot, far more. You can even customise a mug yourself using normal art supplies including paint, water marker or crayons, makers, while others art materials that are being sold with your local department, office supply, or supermarket. If you want your mug professionalised you can purchase your personal printing machine that is costly however in the long term will save you money when you do not possess to go to an expert. No matter how they're designed they will always make someone happy for your workplace. Custom mugs comes in handy in several ways while supplying you with the chance to make another person happy and save money.
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Manifesto is one of the most traditional rock bars in São Paulo. Opened in 1994, for more than 20 years it is being a refuggee for rockers and starting point for a lot of bands and a must go place for international rockstars when visiting São Paulo.
AC/DC, Megadeth, Kiss, Motorhead, Scorpions, Deep Purple, Adrenaline Mob, Foo Fighters, Metallica, Iron Maiden, Saxon, Skid Row, Motörhead, Winger, Megadeth, Rainbow, Red Hot Chilli Peppers, Marillion, Manowar, Helloween, Ramones and Black Label Society are among the bands that viisted the place.
But not only that, it is stuffed with rock memorabilia, autographed guitars, drum skins, photos etc.
Located in the rich neighborhood of Itaim Bibi, it is right behind Google's Brazilian office, at Iguatemi Street, 36C.
We went there invited by Gustavo Giglio, he is Kisser Clan's bass player and jams together with legendary guitarrist Andreas Kisser and his son, Yohan Kisser. It was an awesome gig! Great performance, lots of heavy metal, technical competence of the band and great vibe.
Check it out!


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Paul Day, the national officer of the Pharmacists' Defence Association Union (PDAU), has said he would "like other chains to recognise us too" after it secured an overwhelming ballot victory over Boots to determine trade union representation.
The day after the PDAU moved a significant step closer to securing union representation of pharmacists at Boots having won the postal vote by 3,229 votes to 266, Day told ICP he hoped other pharmacy chains will voluntarily recognise the PDAU instead of being compelled to do so through a legal struggle.
"We will respond to what our members want us to do and of course we've always been working as hard for the 90% of our members who don't work at Boots as we are for the 10% who do," he said.
"Certainly we would like the other chains to recognise us too and we'd hope that they would do so voluntarily rather than having to be forced by a legal process as Boots have done.
"Some employers already recognise other independent trade unions though, so we couldn't and wouldn't want to encroach on existing agreements they may have."
The PDAU will seek to reach an agreement with Boots over recognition under the guidance of the central arbitration committee. Some 3,308 pharmacists did not vote in the ballot.
Picture: Phoenix0013 (iStock)
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When it comes to taxes on capital gains, the emperor suddenly has no clothes. He's been stripped bare, in bipartisan fashion, by the co-chairs of President Obama's fiscal commission.
The chairs are Republican Alan K. Simpson and Erskine Bowles, a Democrat. Their initial report included a call for equal taxes on capital gains, dividends and ordinary income such as wages. This upends the current tax code, and it contradicts almost the entire history of capital gains taxes in America.
Implicitly, it also rejects the K Street claim that tax breaks for capital gains grow jobs, grow businesses and grow the economy. If the claim had any truth, Messrs. Simpson and Bowles would never support equal taxes on all income as a way to help cut the national deficit.
Liberals instinctively attacked the right-leaning aspects of the report. House Speaker Nancy Pelosi, in full "no" mode, labeled its recommendations "simply unacceptable." Not quite, Madam Speaker; à propos investment income, Simpson/Bowles is a Democratic dream come true.
Income from wealth and income from work were taxed at the same rate in only two widely-separated times in America—from 1916-21, and after Ronald Reagan's Tax Reform Act of 1986. President Clinton restored the tax break on capital gains in 1997, cutting the rate on long-term gains from Reagan's 28 percent to 20 percent. Six years later, President Bush lowered the levy to 15 percent and did likewise for dividends. The Bush cuts were written to expire in 2010, but it's not certain they will. Even if they did, the capital gains rate would still be less than the rate on middle-class wages.
The Simpson/Bowles recommendations could die a quick death: a unified final report needs the votes of 14 out of the commission's 18 members, comprised of nine from each party. If a super-majority of 14 can agree, their report arrives at the White House on December 1.
But the proposals are now on the table, so the genie is out of the bottle. President Obama and Congress were already facing a showdown on extending the Bush tax cuts. Now, in addition, Congress and the Administration have a rare opportunity to set a new course for the nation's fiscal future.
They could start by revisiting the tax code and creating capital gains tax breaks that really would grow jobs and stimulate the economy. Small companies with big dreams raise seed money through initial public offerings (IPOs) and secondary offerings; larger companies sometimes do the same (e.g., the resurgent GM). In a move that would give a built-in boost to the market for new issues, capital gains on these investments could accrue tax-free. Interest on corporate bonds, now taxed as ordinary income, also deserves a tax break. Corporate bonds raise the money to build corporate infrastructure, much like municipal bonds raise money to build local infrastructure. Interest from municipal bonds gets tax breaks; why not corporate interest?
How to pay for these new tax breaks? Easy: the money would come from ending the unproductive tax break on stock market gains, along with the 2003 tax break on dividends.
In 1986, President Reagan essentially traded tax breaks on capital gains for another round of cuts in the marginal rates. A generation later, the initial draft from Obama's fiscal commission holds the makings of a similar endgame.
One major milestone has already been reached. The notion that investments deserve a lower tax than wages has been vaporized. The emperor has no clothes, and really never did.
©2010 Gerald E. Scorse. The author, who writes from New York City, helped pass a bill that tightens the rules for reporting capital gains. His stories are published in the Baltimore Chronicle with his permission.
Republication or redistribution of Baltimore Chronicle content is expressly prohibited without their prior written consent.
Baltimore News Network, Inc., sponsor of this web site, is a nonprofit organization and does not make political endorsements. The opinions expressed in stories posted on this web site are the authors' own.This story was published on November 22, 2010.


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Blackberry curve 9300 not updating
Read more
Human Interface Device Profile HID [ edit ] Provides support for devices such as mice , joysticks , keyboards , as well as sometimes providing support for simple buttons and indicators on other types of devices. Data and voice calls are not covered by this profile. Information on phones that support SAP can be found below: Remote Camera Allows the initiator to remotely use a digital camera. In PC to peripheral usage models such as dial up networking using a cellular phone , the PC may need to download device drivers or other software for that peripheral from a web site. This makes it more suitable for embedded devices such as mobile phones and digital cameras which cannot easily be updated with drivers dependent upon printer vendors.


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New Video shows Virtual Characters in Action
A new video featuring the Virtual Characters has been added to the DynaLearn website. In contrast to previous videos which focused on a learner's interaction with the characters and the software, this one shows the characters explaining the software in a different way…
The video can be found here.
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Using Model A front units.
This gives an awesome 1,850 watts power - also the 20Hz bass for full cinema.
Model S Floorstanders or Standmounts are used for rears and the special Model S based centre unit for the front centre. (see details below)
With the 20Hz bass of the Model A - a sub-woofer is not needed. This avoids detached sounds - and gives a realistic image
We offer a 15 % price reduction on the individual units.
Live outside UK/Europe - or dealer here out of range? We supply directly around the globe - details Buy direct
Using Model S Floorstander front units:.
Combined with Model S Floorstander or Standmount rear units and Model S centre - gives 1,250 watts.power
The 25Hz Model S - can also be used without sub-woofer - avoiding their problems.
Our minimum system uses Model S Standmounts - as sides and rears - with no centre unit. Additional negotiable price reduction - but still with full reality and image.
The Model S based centre unit:
A 250 watt, 25Hz quality speaker on its own
The same HF unit as our flagship Model A.
19cm high, 22.5cm deep and 44cm wide. Price £495, E595
For usage details click on: Centre info PDF


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Gael Monfils beats Stan Wawrinka in Rotterdam Open finalNishikori broke Fucsovics twice in the opener but faced some adversity in the second set, falling behind 2-0. Stan Wawrinka could not complete his comeback as Gael Monfils clinched the Rotterdam Open title.
Lionel Messi penalty helps Barcelona beat Real ValladolidMessi and his teammates missed chances to put away Valladolid, and when they did arrive Masip was up to the challenge. Barcelona defender Gerard Pique: "The only good news is the win, we have not played well". "We didn't play well".
Ex-Congressman Anthony Weiner Finishes Prison TermHe is being closely monitored by the Federal Residential Reentry Management Agency, according to the New York Post . Clinton has blamed the FBI's decision to re-open the probe for her defeat to Donald Trump.
Meghan Markle is in New York City for a secret baby showerIn the letter, which has since been published and publicly scrutinised, Meghan accused her dad of breaking her heart. The Duchess of Sussex has flown to New York City to spend time with friends, according to reports .
Disgruntled Anthony Davis scores just 3 points, rips team after gameE'Twaun Moore, who has struggled with injuries this season, scored 19 points in his first start since January 22. I'm gonna talk about the guys that played. "I'm done talking about it".
Confirmed case of measles in Barren River DistrictIn a short taped message aired over state-run PTV-4 Friday, Duterte said that a child can die from measles if not vaccinated. The province's top doctor said she's not in favour of mandatory vaccines, but there is one change she would like to see.
Famed Fashion Designer Karl Lagerfeld Dies at 85In January, Lagerfeld skipped his final bow at Chanel's Paris Fashion Week show, E! The cause of his death is not yet known. Cape Town - Chanel fashion designer Karl Lagerfeld has died, according to online reports.
Trump's pick for United Nations ambassador withdraws nominationWhen the family discovered that taxes had not been paid, The Post reported, the Nauerts demanded that the tax bill be paid. The Wilson Center's Aaron David Miller said Nauert had a different profile from past US ambassadors to the United Nations.
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Ex-Russia probe overseer Rod Rosenstein 'to step down by March'McCabe and Rosenstein 'look like they were planning a very illegal act, and got caught.,' Trump said in a series of tweets. Rosenstein will use his remaining time in the position to assist with Barr's transition into the attorney general role.
No. 2 Duke handles NC State for 9th straight winChristen Cunningham scored 16 of his 18 points in the second half to rally Louisville, which hung on in the final seconds. We appreciate Floyd and especially the former players that came back, because they're a part of The Brotherhood.
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Leather Fashion Diagonal Crossbody Phone Bag
New design p.u. leather men's chest pack. For phone and little tablets. Going on a short trip and need a small backpack for your trip essentials like a small camera or game-pad. This fashion style crossbody phone backpack will do the job. Low profile easy to carry and beautiful design. It's a fashion casual brown shoulder diagonal bag. Tide male Messenger Sling Bag.
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A four-day festival devoted to new music, including a series of works inspired by the paintings of artist Craig Rubadoux, takes place at the Lunenburg Academy of Music Performance June 20-23.
Artistic director Burt Wathen says the new Contemporary Chamber Music Festival is a natural extension of LAMP's ongoing commitment to contemporary composers and the music of our time.
"If you attend LAMP concerts you know that we love to challenge our audiences by programming contemporary works amidst pieces of classic repertoire," says Wathen. In fact, the school has played host to a number of world premieres during its relatively short history and every year since 2015, it's held an academy for young composers that concludes with a concert of new works.
Interest in LAMP's Composition Academy has grown exponentially – so much so that this year, the school increased its enrollment limit and still has a full complement of young composers from coast to coast, including Nova Scotians, plus students who, unable to get in this year, are coming to audit classes.
Like its programs in opera, strings and other disciplines, LAMP engages the top Canadian and international artists of our times to teach and mentor young composers. This year, program faculty include Pulitzer Prize winner Roger Reynolds, JUNO winner Dinuk Wijeratne and Nicole Lizee, winner of SOCAN's 2017 Jan. V. Matejcek Award. The program is under the direction of Canadian icon Robert Aitken.
LAMP also provides a cadre of professional musicians including singers, string quartets, pianists and percussionists to workshop and perform the new works created by participants. "Having been to composition workshops in the U.S. and Canada, it is hard to think of any other composition institute that can rival what LAMP offers in terms of performance resources and quality of tuition," says 2016 participant Roydon Tse, who last November premiered a new work for the Shanghai Philharmonic Orchestra.
This year, participating composers are creating new works inspired by select paintings by Rubadoux, an American artist with a summer home and studio on the South Shore. An early supporter of LAMP, Rubadoux's bold, original works have graced the school's concert programs and are featured in many public and private collections, including the Guggenheim Museum. The works will be on display during the June 22 Night of World Premieres concert. Tickets for that event are $25, or you can purchase a festival pass for $60.
Other events include the June 21 concert Music of our Masters, featuring works by each of the Composition Academy faculty members performed by artists including Mr. Aitken, the Iris Ensemble with Walter Delahunt and the Friction Quartet of San Francisco; tickets $35.
A third concert, Modernizing the Chamber Music Experience with the Friction Quartet, will take place Saturday, June 23 at 4 pm; tickets $35.
The festival kicks off with a presentation in LAMP's free public series, A Little Light Music, to be hosted by Roger Reynolds and featuring live examples of his work performed by Walter Delahunt and American baritone Jonathan Nussman on Wednesday, June 20 at 7 p.m. Light Music is sponsored by the Town of Lunenburg.
All events take place at the Lunenburg Academy, 97 Kaulbach St, Lunenburg.
The Lunenburg Academy of Music Performance is a global center for advanced studies of performance and music interpretation located in the landmark Lunenburg Academy, a National Historic Site built in 1895. LAMP is grateful for the support of Canada Heritage, the Nova Scotia Department of Communities, Culture and Heritage, Arts Nova Scotia, the Town of Lunenburg and other corporate and private partners.
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A four-day festival devoted to new music, including a series of works inspired by the paintings of artist Craig Rubadoux, takes place at the Lunenburg Academy of Music Performance June 20-23.


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The first in a series of rants about our in store demo facilites: Part 1- Home Theatre Demo Room
Audio Junction's Theatre room is a constanly evolving canvas that changes as we discover new products that raise the bar in terms of both performance and cost. Latest additions include the Epson TW9200 projector and Cambridge Audio's Aero Speaker system. The Epson is simply a stunning projector for the price. We've had a long running relationship with Mitsubishi and were dissappointed when they announced that they were pulling out of the projector business late last year. The search for a new entry level projector began, it had to be well priced, present a stunning image and have reliability and support we could stand behind. After an exhaustive selection process we decided on the Epson TW9200 with its 3 year warranty on both the projector and the lamp. Drop by the store and take a look for yourself, I'm sure you will agree that this is one special bit of kit. We still have a couple of Mitsubishi HC4000's left, another great projector at the price and with 3 year warranty, come and compare the two for yourself.
The Cambridge Audio Aero Speaker system was a product that caught our eye at the Hifi Show in Melbourne late last year, it impressed us enough to earn a spot in the speaker line-up on our comparator. Upon further investigation we have found that the only chink in it's armour is the subwoofer, which can get a little flustered if driven too hard. Our solution to this is to substitute the Cambridge sub for another British sub, the B&W SW610, at the same price, the B&W being a cracker of a sub with prodigous output down to subterranean levels.This combo will set you back a mere $3500
We love to show off our Theatre Demo room so do drop by for a test drive soon, even better call ahead and we will have a cuppa ready for you. In a future BLOG I will discuss our favourite equipment combos in the Theatre Room, but unitl then Keep Calm and Rock On!
Also Check out out Facebook page for daily updates
Equipment currently playing in the Audio Junction Home Theatre Demo Lounge-
- Mitubishi HC4000,
- Epson TW-9200
- Oppo BDP-103
- Oppo BDP-103 Darbee
- Cambridge Audio Azur 752BD
- Yamaha BDS-1020
Screen– Screen Technics 100″ Electricinema
- Yamaha Aventage RX-A730
- Cambridge Audio 751R
- Cambridge Audio 651R
- Cambridge Audio 351R
- Yamaha Aventage RX-A3030
- Yamaha Aventage RX-A2030
- Yamaha Aventage RX-A1030
- B&W MIni Theatre MT50, MT60
- PSB Alpha Theatre System
- PSB ImageTheatre System
- Cambridge Audio Aero Theatre System
- Richter Wizard Theatre System
- B&W CM8 Theatre System
- Niles In-wall Theatre System
- B&W In-wall Theatre System


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Former Auburn Plainsman editor, Rheta Grimsley Johnson, retires
From Trussville Tribune staff reports Rheta Grimsley Johnson, who has led a long career in newspapers spanning 42 years, is retiring from the business. Johnson wrote for King Features Syndicate in New York. [caption id="attachment_41497" align="alignleft" width="150"] Photo from the Montgomery Advertiser.[/caption] In a column for the Daily Journal, Johnson said that she would continue to write but would be ...Read more ›


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Release Date: January 15, 2008
The lung can be injured by positive pressure ventilation (PPV) through several mechanisms. This injury is known as ventilator-induced lung injury (VILI). One such mechanism is overdistention injury when lung units are physically stretched beyond their normal maximums. This occurs when end-inspiratory transpulmonary pressures (and resulting end-inspiratory volumes) exceed the normal maximum of 30 to 35 cmH2O. Another injury occurs when collapsed lung units are subjected to shear stress when repetitively opened and closed during PPV. There may also be a tidal stretch injury that occurs with repetitive use of tidal volumes above the normal of 5 to 6 mL/kg, although this mechanism is more controversial. Of importance, these injuries likely occur predominantly in healthier regions of the lung, which receive the bulk of mechanical ventilatory support. Similarly, shear stress injury likely occurs in healthier regions immediately adjacent to sicker regions. The "art" of providing PPV is thus to support adequate gas exchange without causing regional VILI.
Using small (eg, 6 mL/kg) tidal volumes with plateau airway pressures less than 30 to 35 cmH2O is clearly the standard of care in patients with acute lung injury (ALI) and the acute respiratory distress syndrome (ARDS). Increasing, however, clinical data also suggest that this approach should also be applied to patients without ALI or ARDS to prevent their occurrence while the patient is receiving PPV. Indeed, a large observational trial from the Mayo Clinic has shown that a policy of small tidal volume ventilation in virtually everyone has resulted in marked reductions of ALI and ARDS developing in patients receiving PPV for other reasons.[1]
The approaches to setting positive end-expiratory pressure (PEEP) have been studied in several large randomized clinical trials (RCTs) recently. All of these studies have focused on the question of whether, in the setting of small tidal volume ventilation to minimize shear stress open-close injury, aggressive vs conservative PEEP will further reduce VILI and improve outcomes. The argument for aggressive PEEP is that atelectasis will be further reduced. The argument for conservative PEEP is that this additional atelectasis reduction is not worth the accompanying increase in plateau pressure. The ARDS Network trial, which addressed this issue, showed better gas exchange and mechanics with aggressive PEEP this strategy had no effect on ventilator-free days or mortality.[2] Two other recent large trials using small tidal volume strategies, one from Canada and one from Europe, have only been reported in form but also showed improved mechanics and blood gases with aggressive PEEP and no effect on mortality. Thus the decision to use aggressive vs conservative PEEP in the setting of low tidal volume mechanical ventilation rests on the clinician's judgment on the value of physiology improvements (without an associated mortality benefit) at the cost of higher plateau pressures.[3,4]
Two novel PPV strategies that have been proposed as lung protective for patients with severe oxygenation failure are airway pressure release ventilation (APRV) and high-frequency ventilation (HFV). APRV uses a long inflation period with superimposed spontaneous breathing. It is thus an alternative to tidal volume and PEEP to raise mean airway pressure. HFV uses very small tidal volumes and rapid breathing frequencies (up to 900 breaths/minute). Gas transport is thus by nonconvective flow, and substantial mean pressures can be provided with very small tidal distentions. Two RCTs reported several years ago evaluated APRV. One showed benefit (but with a seriously flawed control group strategy), and the other showed comparable outcomes to conventional ventilation.[5] It must also be remembered that the end-inspiratory lung volume in APRV is the sum of both the ventilator-delivered inflation plus the spontaneous inflations. HFV in the adult has been evaluated in a single RCT conducted in the late 1990s, and the results showed only a "trend" in favor of HFV.[6] More clinical trials are clearly needed to establish the role of these 2 modes before firm recommendations can be made.
Our understanding of patient-ventilator interactions has grown tremendously during the last 2 decades. Serious patient-ventilator dysynchrony is now known to frequently exist during all 3 phases of breath delivery: the trigger phase, the flow delivery phase, and the breath cycling off phase. This dysynchrony can create substantial imposed loads on the ventilatory muscles, which can lead to muscle fatigue, discomfort (with resulting sedation use), and unnecessary time on the ventilator.
Trigger dysynchrony is often a consequence of intrinsic PEEP (PEEPi). PEEPi develops in the setting of high minute ventilation, short expiratory times, and long expiratory time constants (ie, as occurs in obstructive airway disease).[7] Under these conditions, the ventilatory muscles must first overcome the PEEPi before the ventilator senses an effort and delivers an assisted breath.[8] This results in delayed triggering and even missed triggering -- both of which impose significant muscle loads. There are several approaches to improving breath triggering dysynchrony caused by PEEPi. Minute ventilation can be reduced, and expiratory time can be extended. This may be particularly important when using flow-cycled pressure support, which may have a prolonged inspiratory time in the presence of airway obstruction. Shortening the flow-cycling criteria or switching to pressure assist with a set inspiratory time may help this. Finally, applying PEEP in the circuit at levels below the PEEPi level can help equilibrate lung and circuit pressures to reduce the triggering load.[8]
Triggering may also be an issue during sleep, when respiratory drive is reduced (or erratic). This may produce sleep disturbances, which can worsen psychological stress and further delay ventilator discontinuation. Sleep-induced triggering problems may require providing a certain backup rate capability during sleep.
Flow delivery dysynchrony occurs when ventilator-delivered flow is less than patient demand. Flow dysynchrony is often reduced when pressure-targeted, variable- flow breaths are used compared with the fixed-flow breaths of flow-volume targeted breaths. Two new developments may further improve flow (and cycle) dysynchrony: proportional assist ventilation (PAV) and neurally adjusted ventilatory assist (NAVA). PAV senses patient flow demand and puts a pressure and flow gain on this effort. This gain is set by the clinician as a proportion of the measured compliance/resistance characteristics of the patient.[9] PAV has considerable conceptual appeal but no outcome studies have been performed to date. NAVA requires an array of electromyelogram sensors placed in the esophagus at the level of the diaphragm.[10] This electromyelogram array detects inspiratory muscle activity and drives the pressure-flow output of the ventilator off of this. NAVA might thus be the ultimate patient-ventilator synchrony approach. Clinical adoption of NAVA, however, is likely to be driven by the logistic difficulties and the costs associated with the sensor array.
The ventilator discontinuation process continues to occupy a significant portion of a patient's need for mechanical ventilatory support. Several evidence-based guidelines have argued convincingly that daily spontaneous breathing trials (SBTs) are the most direct way to assess the ability of the patient recovering from respiratory failure to tolerate ventilator discontinuation.[11] In patients passing an SBT (as judged by an integrated assessment of gas exchange, hemodynamics, ventilatory pattern, and subjective comfort), the likelihood of tolerating ventilator removal is high and, if airway protection is adequate, the likelihood of extubation success is also high.
Protocols run by nonphysician clinicians (eg, skilled respiratory therapists) can facilitate this discontinuation process. These clinicians are usually more readily available at the bedside to assess patients and to modify support strategies as needed. Of importance, these clinicians do not replace physician judgment -- instead they extend physician judgment through the use of physician-designed protocols.
In recent years, the role of excessive sedation hindering the ventilator discontinuation process has been increasingly appreciated. This has led to calls for daily spontaneous awakening trials (SATs) to be done in conjunction with SBTs. This approach has been met with some resistance because of the perception that abrupt sedation withdrawal can precipitate anxiety/delirium that may be difficult to bring under control.
Within this backdrop, the Awake and Breathe Controlled Trial (ABC Trial) was conducted and recently completed.[12] In this trial 335 mechanically ventilated patients were randomized to management with a daily SBT (usual care + SBT group) or a daily SAT followed by an SBT (SAT + SBT group). The SAT strategy involved daily discontinuation of all sedation and following protocol rules to assure prompt responses to anxiety/delirium.
Compared with usual care plus SBTs, the SAT plus SBT strategy resulted in an average of 3.1 additional days breathing without assistance during the 28-day study period (14.7 vs 11.6; P = .02), discharge from the intensive care unit approximately 4 days earlier (median days, 9.1 vs 12.9; P = .01), and hospital discharge approximately 4 days earlier (median days, 14.9 vs 19.2; P = .04). More SAT plus SBT patients self-extubated (9.6% vs 3.6%; P = .03), but the number of patients who required reintubation after self-extubation was similar (3% vs 1.8%, P = .47) as were total reintubation rates (13.8% vs 12.5%, P = .73). During the 28-day study, 47 patients (28.1%) in the SAT plus SBT group died compared with 58 (34.5%) in the usual care plus SBT group (P = .21). There were trends toward less sedation use and brain dysfunction in the SAT plus SBT group.
These results strongly suggest that aggressive (but properly monitored) sedation reduction coupled with SBTs improve outcome in mechanically ventilated patients recovering from acute respiratory failure.
Ventilator-associated pneumonia (VAP) represents a common and serious nosocomial infection. Because of the implications of VAP for both healthcare systems and for patients, VAP is now a focus of attention to improve patient safety and outcomes. Several presentations and discussions at this year's CHEST meeting reviewed multiple recent advances in the area of VAP.
The first issues to address are the epidemiology, microbiology, outcomes, and diagnostics of VAP. Based on data from the National Nosocomial Infection Surveillance System, VAP represents the most common nosocomial infection seen in the intensive care unit (ICU), but the prevalence of VAP varies greatly based on ICU type.[1] Burn ICUs have higher rates of VAP (approximately 12 cases per 1000 days of mechanical ventilation) whereas medical ICUs have a lower rate of VAP (3 cases per 1000 days of mechanical ventilation). This likely reflects differences in the underlying severity of illness of the patients in these ICUs, the antibiotic-prescribing patterns of the physicians practicing in these ICUs, and the use of mechanical ventilation in these different settings. VAP is caused by a diverse range of pathogens. Multiple studies document that the microbiology of VAP varies across ICUs and across hospitals. Despite these differences, several epidemiologic trends are apparent. Pseudomonas aeruginosa and Staphylococcus aureus occur with similar frequency and when pooled account for nearly 30% of all cases of VAP.[2] In addition, this distribution of pathogens has not shifted much over the last decade.[2] Finally, despite little change in the pathogens causing VAP, the antimicrobial susceptibilities of these organisms have evolved. Specifically, increasing rates of resistance are now reported for both Gram-negative and Gram-positive pathogens. For example, in the ICU, approximately 70% of S aureus sp are methicillin-resistant (MRSA). For P aeruginosa fewer than half of isolates show reliable susceptibility to fluoroquinolones and, nationally, 15% to 20% appear resistant to carbepenems.[3] Understanding these changing patterns of resistance is central to efforts to improve outcomes. Clinicians must know about both the microbiology of VAP and the likely susceptibilities of the culprit pathogens to ensure that patients are given an antibiotic that has in vitro activity against the responsible bacteria.
From the perspective of cost, multiple studies document the extensive economic implications of VAP. In a large database analysis, Rello and colleagues[4] observed that the attributable costs of VAP exceeded $40,000 per case. This excess cost was not driven by pharmacy charges. Rather VAP significantly prolonged both the duration of mechanical ventilation and the length of stay in the ICU. In a similar analysis, Warren and coworkers[5] examined outcomes for VAP at a suburban nonacademic hospital. They also concluded after controlling for a number of potential confounders that VAP extensively added to hospital costs. These researchers estimated that the crude costs of VAP neared $50,000 per case.[5] These financial outcomes reinforce why hospitals can potentially reap significant savings by implementing strategies to reduce rates of VAP. The mortality burden of VAP is less clear. It is often difficult to determine whether a patient died of VAP or with VAP. In an effort to elucidate this issue, Valles and colleagues[6] compared predicted to observed mortality rates in critically ill patients with and without VAP. In patients in whom VAP never developed, the predicted and observed rates were equal, suggesting no excess mortality burden. In subjects with VAP, the observed mortality was 45% compared with a predicted mortality of 30%.[6] This all seemed to be the result of more deaths in patients with late-onset VAP (VAP developing after more than 5 days of mechanical ventilation). In these individuals, the mortality rate was double what one would have predicted based on their severity of illness at time of admission to the ICU.
One of the biggest challenges with VAP remains its diagnosis. There is no gold standard for the diagnosis of VAP and controversy remains regarding whether all subjects require a lower airway culture to confirm the presence of infection. Because lower airway culturing may not be readily available and because it may be expensive, researchers have attempted to develop biomarkers to facilitate VAP diagnosis. In a study of soluble trigger receptor on myeloid cells (sTREM), Gibot and colleagues[7] noted that this had an excellent sensitivity and specificity relative to a mini-bronchoalveolar lavage (BAL) . A small recent analysis of 23 patients, however, questioned the value of sTREM. In this study there seemed little difference in BAL levels of sTREM between those with VAP and those without VAP.[8] It is unclear how many patients in this study actually had VAP because a positive lower airway culture was not required for the diagnosis of VAP. Measurement of procalcitonin is also an area of investigation for VAP diagnosis. Lyut and coworkers[9] measured serial procalcitonin values over 7 days in mechanically ventilated subjects. This performed well in this early analysis. Nonetheless, experience with biomarkers is very limited and more studies are necessary before these technologies become commercially available.
The clinical pulmonary infection score (CPIS) represents an alternative approach to VAP diagnosis. In the CPIS, points are given based on x-ray results, white cell count, temperature, oxygenation, and purulence of secretions. Generally a score of less than 6 is thought to reliably exclude the diagnosis of VAP, and a higher score suggests VAP is more likely. Although attractive because it is simple, the CPIS may be prone to interobserver variability. More importantly, a recent meta-analysis concluded that the role for the CPIS is limited.[10] The sensitivity and specificity for the CPIS varied substantially across the studies reviewed in this meta-analysis. The authors concluded that CPIS may provide suggestive evidence but not definitive evidence that VAP is either present or absent and urged clinicians to consider additional tests when faced with a patient who might have VAP.[10]
Invasive lower airway testing remains a final option to facilitate the diagnosis of VAP. With the development of tools other than the traditional BAL to allow lower airway sampling (eg, mini-BAL), more effort has been placed on lower airway evaluation. The Canadian Critical Care Trials Group[11] undertook a large multicenter, randomized trial to compare reliance on lower airway sampling with reliance on tracheal aspirates. The study included more than 740 subjects thought to have VAP. The final diagnosis of VAP was based on a blinded adjudication panel's conclusions. The 2 populations were similar at baseline. There was no difference in mortality based on the VAP diagnostic tool.[11] Lower airway sampling also did not affect the use of antibiotics. The authors concluded that either paradigm is acceptable for the diagnosis of VAP.[11] However, this analysis has several important limitations. The incidence of VAP in this trial was very low. Based on judgment, there was only one case of definitive VAP among all those evaluated. Furthermore, only 25% of those enrolled were judged to have probable VAP. In addition, the authors excluded patients thought to be at risk for multidrug- resistant pathogens such as MRSA and P aeruginosa. Overall approximately 5% of persons had such pathogens.[11] This differs greatly from what is noted in the United States today.[1] This discordance leads to questions about the generalizability of these findings if such concerning pathogens occur in patients who are at risk for VAP. Given that these organisms may account for 30% of what is seen in ICUs, one must interpret the study's findings with caution.
Marin Kollef, MD, of Washington University in St. Louis discussed the topic of prevention of VAP at this year's ACCP meeting. Before reviewing preventive options, Dr. Kollef briefly described the pathophysiologic development of VAP. By elucidating factors that promote the occurrence of VAP, value of various preventive interventions can be better appreciated. VAP requires the invasion of the lower airways by pathogenic organisms. Additionally, these organisms must gain entry to the lower airway first by colonizing the upper airway and digestive tract. In other words, the pathogenesis has 2 central aspects: colonization and aspiration. Unfortunately, the endotracheal tube (ETT) itself can promote both colonization and aspiration. The ETT impairs mucociliary clearance and limits sinus drainage. Additionally, biofilm can arise on the lumen of the ETT. This biofilm can serve as a direct point of entry of organisms into the lower airway. Dr. Kollef said that VAP should more properly be renamed ETT-associated pneumonia. Given this relationship between the ETT and VAP, it is not surprising that programs which foster earlier removal from mechanical ventilation or which avoid the need for ETT placement by using noninvasive ventilation overall show benefit in terms of reducing the risk for VAP.[12]
Beyond preventing the need for ETT placement, other effective strategies for VAP prevention include keeping the head of the bed elevated to minimize silent aspiration and limiting antibiotic abuse.[13] Less antibiotic exposure can help limit colonization with resistant pathogens that might later cause infection. At his own institution Dr. Kollef and colleagues[14] implemented a VAP prevention bundle targeted at nurses and respiratory therapists. This program (entitled WHAP VAP) required education for all ICU caregivers about the pathophysiology and burden of VAP. It also emphasizes hand hygiene and infection control along with protocolized removal from ventilation and limited use of sedation. Oral care was addressed somewhat as was the issue of upper airway colonization by encouraging the use of orogastric tubes rather than nasogastric tubes. With this overall paradigm, Dr. Kollef and coworkers reduced VAP rates by more than 50%. They estimated they saved their institution millions of dollars over several years.[15]
However, nurses and respiratory therapists cannot do it all. Thus simple and easy interventions dealing the ETT itself appear attractive. A modified ETT that facilitates the continuous suctioning of secretions that pool above the cuff of the ETT is available. This ETT is relatively expensive compared with standard tubes and has been shown in several trials to decrease the risk for VAP.[15] Nonetheless, the benefit of this continuous aspiration ETT has only been demonstrated in early-onset VAP with low-virulence pathogens.[15] Continuous aspiration has not been demonstrated to prevent VAP in patients requiring longer durations of mechanical ventilation or to prevent VAP caused by MRSA or P aeruginosa.
After providing this background, Dr. Kollef reviewed the findings of a recently completed large randomized trial that examined whether a silver-coated ETT could reduce VAP rates.[16] Silver is a potent antimicrobial and active against Gram-positive and Gram-negative organisms. Silver has many clinical uses and is also impregnated onto central venous catheters to limit the potential for bloodstream infections. Animal data suggested that a silver-coated ETT could effective prevent VAP, and early human studies indicated this was a safe and viable alternative.[17,18]
In the large randomized trial, which was initially presented at the European Society of Intensive Care meeting in September, nearly 2000 persons were enrolled.[19] Of these, more than 1600 were intubated for more than 48 hours and comprised the modified intent-to-treat population. The mean age of patients enrolled was approximately 61 years and the mean Acute Physiology and Chronic Health Evaluation II score measured 21. Approximately one quarter of the population was immunocompromised in some fashion. The overall rate of VAP was reduced from 7.5% to 4.8%. This 35% risk reduction was statistically significant (P = .0321). Limiting the analysis to persons in whom VAP developed within the first 10 days of ventilation confirmed the tube's efficacy (rate of VAP reduced from 6.7% to 3.5%, P = .0049). Kaplan-Meier analysis examining the time to onset of VAP also showed that the tube delayed VAP (P = .005). Microbiologically, the ETT, unlike other technologies, reduced VAP infections with both Gram-positive and Gram-negative infections including MRSA and Acinetobacter bumannii. Dr. Kollef suggested that for every 37 silver-coated ETT placed, 1 case of VAP is prevented. The silver-coated ETT did not alter mortality rates (30.4% vs 26.6%, P = .1106).
Although not commercially available, the silver-coated ETT represents a novel and potentially effective approach to VAP prevention. The key for clinicians will be to determine whether this ETT is cost-effective and which patients are appropriate candidates for placement of a silver-coated ETT.
Marcos Restrepo, MD, MSc, from the University of Texas Health Sciences Center in San Antonio, reviewed the contentious topic of empiric therapy for VAP. To comprehend the need for empiric therapy, Dr. Restrepo discussed the multiple studies which document that either delayed or inappropriate therapy for VAP increase the risk for death. Generally, inappropriate therapy is defined as the administration of an antibiotic to which the culprit pathogen is resistant in vitro. Inadequate dosing of an antimicrobial drug that might be active in vitro also represents a form of inappropriate therapy. To confirm the importance of appropriate therapy, Dr. Restrepo highlighted one typical study in which inappropriate or delayed therapy increased a patient's risk for death more than 5-fold.[20]
Several factors complicate attempts to ensure appropriate therapy. The definitions for who is at risk for a resistant pathogen are evolving. The concept of healthcare-associated pneumonia (HCAP) was recently described. HCAP is pneumonia that occurs in a patient who, despite being an outpatient, is constantly in interaction with the healthcare system. Examples of such subjects include those from nursing homes and long-term care facilities and persons receiving wound care, immunosuppression therapy, or hemodialysis. In 1 report, the incidence of MRSA and P aeruginosa was significant in patients with HCAP, despite that these patients come to the emergency department.[21] Hence clinicians must acknowledge that risk factors for infection with resistant pathogens have diffused beyond the confines of the hospital walls.
Dr. Restrepo then described the current empiric antibiotic recommendations from the American Thoracic Society and the Infectious Disease Society of America.[22] In patients with HCAP or late-onset VAP (occurring after more than 5 days of ventilation), the guidelines recommend the use of 2 agents to cover resistant Gram-negative organisms and an additional agent for empiric anti-MRSA therapy. Problem pathogens include P aeruginosa, A bumannii, and extended beta-lactamase producing Klebsiella sp. Double coverage for Gram-negative organisms, Dr. Restrepo stressed, is not because 2 agents are necessarily better than 1 but because no single agent has reliable 100% activity against the bacteria of concern. A recent meta-analysis similarly concluded the only potential value for extended double Gram-negative coverage might be in P aeruginosa.[23] This meta-analysis was limited because few studies were included.
With respect to individual agents, choices must be made based on local susceptibility data. For example, at a hospital where quinolones cover fewer than 50% of P aeruginosa isolates, there is little value to adding this drug as a second agent. Among other options, data are emerging to suggest that some agents may be preferred over others because of their pharmacokinetic and pharmacodynamic attributes. To illustrate this, Dr. Restrepo reviewed a recent trial of imipenem vs doripenem in nosocomial pneumonia.[24] Both of these agents are active in vitro against P aeruginosa, but the susceptibilities of doripenem tend to be better than those of imipenem against P aeruginosa. In the clinical trial (n = 531) cure rates were similar between the 2 carbepenems. However in the subgroup of patients with documented P aeruginosa, the cure rate with doripenem was 80% vs 43% for imipenem (P = .03).[24] For MRSA, a secondary analysis of 2 randomized, controlled trials comparing linezolid to vancomycin, both of which are active in vitro against MRSA, showed that randomization to linezolid was associated with both higher cure rates and improved survival.[25] One limitation with this pooled analysis was that in each individual trial vancomycin was not aggressively dosed to trough levels of 15 micrograms/mL as is currently recommended. According to Dr. Restrepo, it is unclear whether more aggressive dosing will prove effective for vancomycin therapy for pneumonia. The central concern is that vancomycin has very poor lung penetration. Supporting his contention, Dr. Restrepo presented the results of a study that correlated vancomycin serum trough levels with survival in MRSA pneumonias. More aggressive dosing did not enhance cure rates or limit mortality.[26]
In summary, presentations and discussions at CHEST reviewed multiple recent advances in the area of VAP. The literature in this field on topics ranging from diagnosis to prevention is rapidly changing. New diagnostic, preventive, and therapeutic options are available or soon will be available. Clinicians must keep abreast of these changes to make the best decisions for their patients.
The critical care management issues of organ transplant recipients is a growing area to which intensivists are increasingly being exposed, not only in the big academic institutions, but also in smaller community hospitals as more of these patients live longer and further from their "mother ships." Therefore it is becoming increasingly important for intensivists and pulmonologists to be familiar with the management nuances of these complicated patients. The management of organ transplant recipients was the topic of several discussions at the ACCP meeting. Debbie Levine, MD, from the University of Texas in San Antonio, addressed the intensive care unit (ICU) management of liver transplant candidates and recipients. Liver transplantation is the treatment of choice for various forms of end-stage liver disease, including viral liver disease, liver malignancies, acute liver failure, and certain metabolic derangements. What is also being seen in recent years is that sicker patients are undergoing transplantation. Sicker patients before transplant translates into sicker, more complicated patients after transplant. Frequently, these patients undergo transplantation when they have comorbidities and organ dysfunction. Dr. Levine alluded to the operating room experience being a "mere moment between 2 ICU stays" and that othotopic liver transplantation (OLTx) frequently involves extensive abdominal surgery on suboptimal surgical candidates.
For the patient with acute liver failure, there are several clinical consequences that extend into the posttransplant period. These include coagulation abnormalities, inadequate factor synthesis, fibrinolysis, and hypocalcemia. One needs to follow the coagulation abnormalities closely and aim for an international normalized ratio (INR) in the 1.5 to 2 range while keeping the platelet level above 50,000 and fibrinogen levels above 100 mg/dL. Sepsis is another major issue, with a high incidence of fungal infections in particular in patients with acute liver failure. After transplant, as with all forms of transplant, liver recipients are at continuous risk for infections. Neurological issues run the spectrum from encephalopathy to cerebral edema, which may require intracranial pressure monitoring.
Pulmonary problems after transplant include the need for prolonged mechanical ventilation. The cause is usually multifactorial with issues such as weakness, malnutrition, extensive upper abdominal surgery, pain, blood loss, marked vascular volume shifts, and sequelae of reperfusion injury all playing a role. In 1 report of OLTx recipients, 11% of 546 patients required ventilatory support beyond 24 hours.[1] Acute respiratory distress syndrome in this setting has been reported in 4% to 25% of cases and carries with it a mortality rate as high as 80%. Pulmonary edema has been reported in 14% to 88% of cases and can be the result of overhydration and/or cardiac dysfunction. Perioperative pleural effusions may also occur and are usually right-sided or bilateral. These may enlarge over the first week after OLTx and about 10% ultimately require drainage.
The diaphragm may also be affected. In one study, 79% of 48 OLTx patients had delayed or absent phrenic nerve conduction on electromyography.[2] This is mostly felt to be the result of crush injury by the subhepatic caval clamp. However in the context of liver transplantation, it is rarely associated with the need for prolonged mechanical ventilation. Drug-induced pulmonary dysfunction is seen mostly these days after the use of rapamycin, which has been reported to cause interstitial pneumonitis, bronchiolitis obliterans organizing pneumonia, and diffuse alveolar hemorrhage. However, the onset of these is usually insidious and is generally not a perioperative problem.
Venous thromboembolism is seen rarely in patients with cirrhosis despite these patients receiving autoanticoagulation drugs. In one series, venous thromboembolism was found in 0.5% of 113 patients with an elevated INR and in another series of patients undergoing autopsy portal vein thrombosis was seen in more than 50%.
Pulmonary vascular disorders of liver disease run the spectrum from hepatopulmonary syndrome (HPS) to portopulmonary hypertension (portoPH). The former is primarily a disease of vasodilatation and might be caused by various mediators not being cleared appropriately by the liver. On the other end of the spectrum, portoPH is felt to be caused by an excess of vasoconstrictors such as thromboxane and endothelin. HPS tends to be a progressive disease with worsening hypoxemia.[3] The 5-year survival of HPS is a dismal 20%. Transjugular intrahepatic portosystemic shunts do not affect the course of this disease, and the gold standard therapy is liver transplantation. The hypoxemia may take months to years to resolve after OLTx, but complete resolution will be seen in about 80% of patients.
PortoPH can occur with or without cirrhosis. Although it is usually associated with a high cardiac output, the prognosis is very poor and is worse than that of idiopathic pulmonary arterial hypertension or HIV-associated pulmonary hypertension. Patients will usually die of this before they succumb to their liver disease. The advent of effective therapies for pulmonary arterial hypertension has enabled patients with portoPH to be treated and to undergo successful transplant, whereas previously they would not have been regarded as appropriate candidates for OLTx. With regard to HPS and portoPH, liver transplantation allows the unique opportunity to reverse organ disease by transplanting another organ.
Dr. Wickii Vigneswaran, MD, Director of the Lung Transplant Program at the University of Chicago, addressed the perioperative care of the patient undergoing thoracic organ transplant. Dr. Vigneswaran underscored a few salient points to begin. Both heart and lungs are life-saving organs so we have "got to get it right." Both have limited ischemic times so no time can be wasted. Finally, the key to success is a multidisciplinary team approach.[4]
Donor preparation and procurement includes avoiding high filling pressures and barotrauma. Ongoing monitoring of the lung through serial arterial blood gas measurement, chest x-rays, and a surveillance bronchoscopy is also essential. Organ preservation includes cold pulmonary flush with a pulmonary vasodilator, retrograde flushing to ensure the removal of all emboli, and cold solution for transportation.
For recipient preparation, it is important not to discontinue any therapy and to correct any anticoagulant therapy. Prospective cross-matching of the allograft is generally recommended for a panel-reactive antibody titer more than 10%. Such a recipient might also be treated with plasmaphoresis and/or intravenous immunoglobulin G.
A double lumen tube is inserted for lung recipients, preferably a left-sided tube to avoid occluding the right upper lobe. Cardiopulmonary bypass is necessary for patients with significant pulmonary hypertension and right ventricular dysfunction. Structures to avoid include the phrenic nerve, and it is also important to guard against venous or arterial anastamotic stenoses. Attention should be paid to hemostasis, preservation of the blood supply to the bronchial stump, and prevention of excess fluid accumulation. At the end of surgery the endotracheal tube should be changed and a bronchoscopic inspection of the anastamosis should be performed, with clearance of secretions and blood.
Postoperative care includes careful monitoring of the allograft. Primary graft dysfunction is the most common cause of early mortality. Filling pressures should be kept in the normal to low range. Among other factors, the lack of lymphatic drainage may predispose the patient to edema. Ventilator support should include low tidal volumes and low positive end-expiratory pressure (PEEP). PEEP should be avoided for patients with chronic obstructive pulmonary disease who receive a single lung to avoid dynamic hyperinflation of the native lung. Early extubation should be the goal where possible, but not in the operating room because patients might still manifest primary graft dysfunction. If the patient is still intubated for more than 48 hours, then a bronchoscopy prior to extubation is prudent. Early tracheostomy for failed extubation is advised because this will help with early mobilization and rehabilitation.
Postoperative care actually begins before the surgery in terms of education, discharge planning, nutrition, pulmonary rehabilitation, and patient/family education. This also allows for expectations to be managed. A multidisciplinary approach is the key, and collaborative team meetings are essential to ensuring that all team members are "on the same page."
Tim Whelan, MD, from the University of Minnesota, spoke about the medical ICU management of lung transplant recipients. He focused on common problems that might affect these patients and might result in them going to and being treated in a community ICU. The first condition addressed was that of bronchiolitis obliterans syndrome because this is responsible for most deaths beyond the first year. This physiologic entity is characterized by progressive airflow obstruction. Other conditions such as infection, acute rejection, disease recurrence, and airway complications need to be excluded.
Chronic renal disease is also a major long-term problem. This usually results from chronic calcineurin therapy. At 10 years posttransplant, about 50% of patients have a creatinine level more than 2.5, and at 5 years 3.2% of patients are on chronic hemodialysis.
For patients with acute respiratory failure, the differential diagnosis includes infection, acute rejection, congestive heart failure, volume overload, thromboembolic disease, and inflammatory lung disease (eg, rapamycin toxicity). Cytomegalovirus infection is seen in 13% to 75% of lung transplant recipients. It is often diagnosed in conjunction with another problem and clinicians need to be aware of ganciclovir-resistant strains (6% to 10% of cases). Other infections that might occur include community respiratory viruses and fungal infections, especially Aspergillus sp and Candida sp.
A high index of suspicion should always be maintained for venous thromboembolism and pulmonary emboli, which have a reported incidence of 6% to 8.6%
In addition, drug-drug interactions should always be considered, especially with the calcineurin inhibitors because these drugs may result in untoward side effects. Dr. Whelan ended with a sobering quotation that "lung transplant recipients can have as many diseases as they damn well please."
Kevin Chan, MD, from the University of Michigan, discussed ICU outcomes after hematopoietic stem cell transplantation (HSCT). There are about 16,000 HSCT procedures in the United States each year. Indications include hematologic malignancies, certain solid tumors, and some immune-mediated diseases. Prior to HSCT, patients receive some combination of ablative chemotherapy with or without radiation therapy. Pulmonary complications are seen in about 50% to 60% of patients. ICU admission is required in 30% to 40% and respiratory failure occurs in 10% to 25% of cases. The pulmonary problems that may be encountered include infections, acute graft host disease, diffuse alveolar hemorrhage, idiopathic pneumonitis, congestive heart failure, and bronchiolitis obliterans. In all, pulmonary complications account for 30% to 45% of deaths after HSCT.
Dr.Chan provided a historic perspective and through a series of temporarily sequential articles demonstrated a slow improvement in outcomes through the years in these patients. In one of the more recent papers, Soubani and associates[5] reported that 11% of patients who underwent HSCT were admitted to the medical ICU, 61% were discharged from the ICU, and 41% were discharged home. Predictors of a poor outcome include high Acute Physiology and Chronic Health Evaluation scores, high lactate levels, positive blood cultures, need for pressors or mechanical ventilation, bilirubin level, and multiple organ system failure. It is important to discuss the patient's prognosis with both the patient and the patient's family to manage expectations, especially if the patient requires ICU admission.[6]
As an organization accredited by the ACCME, Medscape, LLC requires everyone who is in a position to control the content of an education activity to disclose all relevant financial relationships with any commercial interest. The ACCME defines "relevant financial relationships" as financial relationships in any amount, occurring within the past 12 months, including financial relationships of a spouse or life partner, that could create a conflict of interest.
Medscape, LLC encourages Authors to identify investigational products or off-label uses of products regulated by the US Food and Drug Administration, at first mention and where appropriate in the content.
Neil MacIntyre, MD
Professor, Duke University Medical Center, Durham, North Carolina
Disclosure: Neil R. MacIntyre, MD, has disclosed no relevant financial relationships.
Steven D. Nathan, MD
Medical Director, Advanced Lung Disease and Transplant Program, Inova Fairfax Hospital, Falls Church, Virginia
Disclosure: Steven D. Nathan, MD, has disclosed that he has received grants for clinical research from Intermune, Actelion, and United Therapeutics. Dr. Nathan has also disclosed that he has served as an advisor or consultant to Intermune, Actelion, United Therapeutics, and Gilead, and has received grants for educational activities from Intermune and Actelion.
Andrew Shorr, MD, MPH
Associate Professor of Medicine, Department of Pulmonary & Critical Care Medicine, George Washington University, Washington, DC; Associate Chief, Department of Pulmonary & Critical Care Medicine, Washington Hospital Center, Washington, DC
Disclosure: Andrew F. Shorr, MD, MPH, FCCP, has disclosed that he has received grants for clinical research and/or educational activities from Pfizer, Ortho-McNeil, GlaxoSmithKline, Merck, and Sanofi-Aventis. Dr. Shorr has also disclosed that he has served as an advisor or consultant to Pfizer and Ortho-McNeil.
Margaret A. Clark, RN, RRT-NPS
Editorial Director, Medscape Pulmonary Medicine and Allergy & Clinical Immunology
Disclosure: Margaret A. Clark, RN, RRT-NPS, has disclosed no relevant financial relationships.


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Categories: Mom
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More often than not, the Pilipinas I am referring to, have the innocent belief that the whiter their children, the less struggle they may face. There no need to be jealous or mad, or angry in so far as Filipino marrying anybody on this planet earth other than Filipino man, period. I have no problem with the opinions expressed by all of you. Thanks for the in-depth treatment of this topic. If I feel strongly enough about a certain issue, maybe I will write something. I can speak a tiny bit of different Filipino languages. There is a lot of truth to this.


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Unity and FileMaker data API video 3 of 3
In this third video, I walk you through creating the C# scripts needed to interact with the FileMaker API, as well as connecting them to the interface.
In the third video I reference Wim Decorte's blog post for configuring FileMaker and testing it's rest API. If you are new to configuring the FileMaker data API, I highly recommend his blog post as a getting started point. It is called "FileMaker Server 16: FileMaker Data API" at Soliant Consulting


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Se dispone de escasa información acerca de la situación asistencial a escala poblacional de los síndromes coronarios agudos sin elevación del segmento ST . El síndrome coronario agudo es el paradigma de la enfermedad aterosclerótica cardiaca y conlleva un amplio conjunto de fenómenos que circundan la. Abstract. JARA VERON, Carlos José. Acute coronary syndromes. Rev. virtual Soc . Parag. Med. Int. [online]. , vol.1, n.2, pp ISSN
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Coronaroos chest pain with or without pericardial rub sindromes coronarios agudos suggestive ECG changes. Demonstration and objective documentation of myocardial ischemia by echocardiography or nuclear medicine. International longitudinal registry of patients with atrial fibrillation at risk of stroke: Blush persists on next injection.
In randomized controlled clinical trials of Sindromes coronarios agudos, regulatory authorities mandate very close or strict control of inclusion and exclusion criteria and will be conducted by an expert. Elevation of cardiac biomarkers serum levels preferably troponin with sindromes coronarios agudos least one value above the upper reference limit of 99th percentile. Present to your audience.
sindroes The registry began in November with a planned recruitment during 12 months and a 1-year follow-up. At the beginning four groups will be considered based on ST segment electrocardiographic findings: Constrain to simple back and forward steps. International longitudinal registry of patients with atrial fibrillation at risk sindromes coronarios agudos stroke: All patients will xoronarios an informed consent.
Data collection Data will be sent to the registry coordinating center sindromes coronarios agudos a web site addressed at http: Clinical trials and registries in cardiovascular disease: Cookies are used by this site. Chest X-ray with interstitial, alveolar, or mixed pulmonary edema. More presentations by Oscar Pablo Chianelli Trombosis venosa profunda y tromboemboli Differences between continuous variables with normal distribution will be examined by Student's t test.
In developed and less developed countries they could be seen also as an expression of demographic sindromes coronarios agudos epidemiological transition with a deep impact in terms of mortality, quality of life and resource use.
Archivos de Cardiología de México
Regurgitation murmur radiating to the axilla and objective demonstration by echocardiography and ventriculography. Observations in relation to myocardial infarction: Houston, we have a problem! Necrosis demonstration by ECG, echocardiography, nuclear medicine or nuclear magnetic resonance.
Arch Cardiol Sindromes coronarios agudos, 75pp.
Cancel Reply 0 characters used from the allowed. Data will be collected from newly diagnosed patients with ACS irrespective of whether agudod were receiving any reperfusion approach and will offer insights into outcomes of sindromes coronarios agudos patients.
Sin estertores ni tercer ruido. All patients will sign an informed consent form.
Dye mildly persistent at end of washout. Circulation,pp.
Sindromes Coronarios Agudos
In-hospital outcome in patients with ST-elevation myocardial infarction and right bundle right branch block. Differences between snidromes variables with normal distribution will sindromes coronarios agudos examined by Student's t test. See more popular atudos the latest prezis. Chest pain with ischemic profile: This difference will allow us to calculate the smaller sample size for this outcome: Toxi-infectious medical condition characterized by multiple organ failure, incipient or advanced hematological alterations and clinical data of tisular hypoperfusion.
The sindromes coronarios agudos of zindromes registries in evidence-based medicine. Dye strongly persistent at end of washout. The authors declare no conflict of interest. ST elevation myocardial infarction. The role of cardiac registries in evidence-based medicine. Ojo con VD y sindenafil. Ongoing programs to update, maintain, and improve the electronic database have been established.
Tercer Registro Nacional de Síndromes Coronarios Agudos (RENASICA III)
TIMI flow after procedure:. N Engl J Med,pp.
For more information, visit the cookies page. Arch Cardiol Mex, 82pp.
Numerous studies testify to the importance sindromes coronarios agudos administering them at the critical moment and there is increasing evidence that patients should receive them earlier, at the time when the syndrome is diagnosed and even before percutaneous intervention, and should be given a high dose of a potent statin with proven efficacy.
The registry began in November with a planned sindromes coronarios agudos during 12 months and 1-year follow-up Figure 1.
Sindromes Coronarios Agudos at Colegio ABC de Medicina de Emergencia y Reanimacion, Guadalajara
Thus, accurate assessment of reperfusion and antithrombotic approaches is more difficult to reach. Patients with secondary ischemia anemia, pulmonary embolism, myocarditis, and etcetera and type II infarction sindromes coronarios agudos not be included.
Currently, there is, therefore, a need for a national observational registry of patients treated in everyday clinical practice to test the external validity of the trial data and provide complementary information to that from sindromes coronarios agudos trials.
Technical support Ongoing programs to update, maintain, and improve the electronic database have been established. The authors declare no conflict of interest.


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We welcome you to our new Camperpark Den Haag, specially for campers! In this menu youll find your way around our website. To home...
At our reception desk we are happy to help you with information, advice, forgotten supplies, fresh bread, ice-cream etc. Read more...
To the prices:...
A reservation is not required. Booking is possible with this formular
Den Haag has much to offer. Look here to find tips for your visit to the city and its surroundings.
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On the contactpage, besides campsite-related info, weve listed some helpful adresses like: the nearest doctor, hospital etc.
Upon arrival at the gate, you call our mobile (nr is on the gate), after which we open the gate for you. You can report to the reception and register there. After registration you will receive a mobile phone from us so that you can open the gate yourself during your stay.
Arrival at the campsite between 8.30 AM and 9.30 PM. In accordance with the site manager these times can be adjusted.
Unaccompanied groups of youths are not admitted.
The minimum age to book is 21.
Pay attention:
Every visitor is obliged to register at the reception.
Up to 5 people visit, prices are listed at prices.
You pay in advance at the reception.
Visitors may only use the toilets and not other facilities.
Visitors must leave the motorhome before 21:30 hrs.
Any car of the visitor must be parked at the direction of the manager, don't park next to the camper.
Every (extra) vehicle (from customer and / or visitor) pays parking fees,
see prices. Pay in advance at the reception.