text:
The Secret Beyond Matter
Once Upon a Time There was Darwinism
Once, There was the Myth of "Junk" DNA
The last support for faulty or vestigial structures discussed in the last chapter is the new—but recently discredited—concept of "junk" DNA.
In the second half of the 20th century, as we saw in the last chapter, the myth of vestigial organs began to collapse. Organs formerly thought to be useless turned out to have important functions, and the myth became untenable. But evolutionists, not wanting to do without the propaganda this myth afforded, embraced a new version of it, which claimed that some of the genes containing the organs' genetic code but not the organs themselves—were vestigial. The new concept that replaced "vestigial" organs was "junk" DNA.
This term "junk" referred to some sections of the huge DNA molecule in which is encoded all of a living creature's genetic data. According to evolutionist claims, a large part of DNA is now non-functional. These parts did have a function in the so-called past, but in time, after the alleged evolutionary changes, they became vestigial—in short, "junk." The parallel with Darwinism was quite clear, and in a short time, the concept of junk DNA became one of the most repeated terms in scientific literature. But this new version of the myth did not have a long lifespan. Especially with the announcement of the results of the Human Genome Project in 2001, it was more and more loudly proclaimed in the scientific world that the whole concept was wrong, because the functions of so-called junk DNA were slowly being understood. Evan Eichler, an evolutionist scientist from the University of Washington, admitted that "The term 'junk DNA' is a reflection of our ignorance."81
Now, let's examine how the myth of junk DNA was born and how it was discredited.
The Misconception that Non-Coding DNA is Useless
To better understand this evolutionist error, we must know something about the structure of the DNA molecule.
This giant molecular chain within the cells of living creatures is often referred to as a data bank, because of the genetic information it contains. At the same time, this molecule contains a genetic code that directs how this data is employed in the body's activities. As detailed in the previous chapters, every evolutionist's attempt to explain the origin of the DNA molecule has been unsuccessful, and it's been established that the data it contains could not have come into existence at random. The DNA molecule is clearly an example of a superior Creation.
The special parts of DNA encoding our physical characteristics and physiological activities are called genes, which play a role in the synthesis of various proteins and ensure that we survive. But the totality of our genes makes up only about 10% of our DNA. The remaining 90% is known as "non-coding DNA" because it does not direct the production of any proteins.
Non-coding DNA can be categorized into some sub-groups. Sometimes, it's found squeezed between genes and is called an intron. Another kind, called repetitive DNA, is formed by repeated nucleotide sequences extending the length of the chain. If the nucleotides on non-coding DNA were arranged in a way similar to the complex series in a gene, instead of in a repetitive series, they would be called a pseudogene.
Evolutionists have lumped these non-protein-coding segments of DNA under the general heading of "junk DNA" and asserted that they are unnecessary leftovers in the so-called process of evolution. However, this endeavor has clearly been illogical: Just because these DNA segments do not code for proteins does not imply that they have no function. In order to determine these functions, we have to await the results of scientific experiments to be done on them. But evolutionist prejudice, with its longstanding misleading claims about junk DNA, has kept this logic from becoming disseminated in the public domain. In the past 10 years especially, research has shown that evolutionists are wrong and their claims imaginary. The non-coding part of DNA is not "junk" as the evolutionists claim, but on the contrary, is now accepted as a "genomic treasure." 82
Paul Nelson, who received his Ph.D. from the University of Chicago, is one of the leading exponents of the anti-evolutionist movement. In an article titled "The Junk Dealer Ain't Selling That No More," he describes the collapse of the evolutionists' theory of junk DNA:
Carl Sagan [one of the proponents of atheism] argued that "genetic junk," the "redundancies, stutters, [and] untranscribable nonsense" in DNA, proved that there are "deep imperfections at the heart of life". Such comments are commonplace in the biological literature—although perhaps less common than they were a few years ago. The reason? Geneticists are discovering functions for what used to be apparent genetic debris.83
But how did they discover that "junk DNA" is not junk after all?
1. Coding criteria relative to linguistic ability were discovered in the non-coding nucleotide sequence.
In 1994, the joint experiments on non-coding DNA carried out by molecular biologists of Harvard Medical School and physicists of Boston University revealed some striking results. Researchers studied 37 DNA sequences from various organisms and having at least 50,000 base pairs, to determine if there were any particular patterns in the nucleotide arrangement. This study showed that 90% of human DNA, which was previously supposed to be junk, actually possessed structural similarities to natural languages!84 That is, a common coding criterion found in every spoken language in the world was discovered to exist in the arrangement of nucleotides in DNA. This discovery provided no support for the thesis that the data in the so-called junk DNA was assembled by chance; on the contrary, it supported a superior Creation as the basis of life.
2. Repetitive heterochromatin shows an amazing functionality: Nucleotides that appear meaningless by themselves perform important functions together and play a role in the meiotic division.
Recently, scientists have discovered the functions of heterochromatin, one of the chromosome materials formerly thought to be junk. This code is often repeated in DNA, and since its role in the production of any protein could not be determined, it was long defined as meaningless.
Hubert Renauld and Susan Gasser of the Swiss Institute for Experimental Cancer Research comment that despite heterochromatin's significant representation in the genome (up to 15% in human cells and roughly 30% in flies), it has often been considered as "junk DNA," of no utility to the cell.85
But the latest studies have revealed that heterochromatin has some important functions. Emile Zuckerkandl of the Institute of Molecular Medical Sciences has this to say:
...[I]f one adds together nucleotides [DNA base pairs] that are individually nonfunctional, one may end up with a sum of nucleotides that are collectively functional. Nucleotides belonging to chromatin are an example. Despite all arguments made in the past in favor of considering heterochromatin as junk, many people active in the field no longer doubt that it plays functional roles.... Nucleotides may individually be junk, and collectively, gold. 86
One of these "collective" functions of heterochromatin can be seen in meiotic pairing. At the same time, studies of artificial chromosomes show that these segments of DNA have various functions.87
3. Researchers have shown a relationship between non-coding DNA and the cell nucleus—a development that spells the end of the "junk DNA" concept.
A 1999 study examining the genomes of the single-celled photosynthetic organisms known as Cryptomonads discovered that eukaryotic non-coding DNA (also called secondary DNA) was functional in the nucleus.
Characteristically, these organisms show a wide variation in size. But even if they are of varying dimensions, there always remains a direct proportion between the size of their nucleus and that of the overall cell.
Seeing the proportion between the amount of non-coding DNA and the size of the nucleus, researchers concluded that more non-coding DNA was a structural necessity required in larger nuclei. This new research was a major blow to such concepts as junk DNA and Dawkins' "selfish" DNA that dismiss the fact of Creation.88 The researchers concluded their report by saying:
Furthermore, the present lack of significant amounts of nucleomorph secondary DNA ...refut[es] "selfish" and "junk" theories of secondary DNA.89
4. Non-coding DNA was discovered to be necessary for the chromosome structure.
In the past few years, another important role played by non-coding DNA has been discovered: It is absolutely necessary for the structure and functioning of chromosomes. Studies have shown that non-coding DNA provides the structure that lets DNA perform various functions—which it cannot in the absence of a formed structure. Scientists observed that elimination of a telomere (the DNA-protein complexes at both ends of chromosomes that grow smaller after cell division) from a yeast chromosome caused a cell cycle arrest.90 This indicates that telomeres help the cell distinguish between intact chromosomes and damaged DNA. In those cells which recovered from the arrest without repairing the damaged chromosome, the chromosome was eventually lost. This also demonstrates that telomeres belonging to non-coding DNA are necessary to maintain chromosome stability.
5. The discovery of non-coding DNA's role in the development of an embryo
There is proof that during development, non-coding DNA plays a major role in regulating the gene expression (the process by which a gene's coded information is converted into the structures present and operating in the cell).91 Various studies have shown that non-coding DNA plays a role in the development of photoreceptor cells92, of the reproductive tract93, and the central nervous system.94 All this shows that non-coding DNA plays vital roles in embryogenesis, or embryonic development.
6. Introns (considered as junk DNA segments) have been shown to play a vital role in cell functioning.
For years, evolutionists thought introns, which are squeezed between functional genes and are spliced out in the process of producing proteins, to be junk DNA, but only later discovered their importance.
At first, evolutionists thought that introns had no role in the production of proteins and regarded them as merely junk. However, research has proven that they play a vitally important role and today, introns are recognized as "a complex mix of different DNA, much of which are vital to the life of the cell."95
A short but interesting article in the science column of The New York Times exposed the errors of evolutionists with regard to introns. In "DNA: Junk or Not?," C. Claiborne Ray sums up the results of research on introns:
For years, more and more research has, in fact, suggested that introns are not junk but influence how genes work...introns do have active roles. 96
This article emphasizes that in the light of the latest scientific developments, supposedly "junk DNA" like introns really do play a useful role in the life of organisms.
All these developments not only reveal new information about non-coding DNA, but also clearly point to the very important fact that the evolutionist concept of junk DNA was based on lack of knowledge and "ignorance" as Evan Eichler admitted.97
The Last Support for the Myth of Junk DNA has Fallen: A Pseudogene has been Shown to be Functional
Since the 1990s, important developments have all shown that the concept of junk DNA was an evolutionist error based on lack of knowledge. Non-coding DNA, like introns interrupting the sequence of genes and repetitive DNA found as longer sequences, have been shown to be functional. There was only one kind of non-coding DNA left whose functionality was unknown: pseudogenes.
The prefix pseudo means "false, deceptive." Evolutionists gave the name "pseudogene" to a DNA segment produced by a functional gene that had apparently undergone a mutation and lost its functionality. Pseudogenes have a special significance for evolutionists, who covertly acknowledge that mutations cannot bring about evolution and have resorted to pseudogenes as a means to deceive people.
Countless experiments on living things have shown that mutations always result in a loss of genetic data. Just as a few random blows with a hammer will not lead to improvements in the running of a clock, mutations have never led to the development of new organisms, or cause existing ones to evolve. Although the theory of evolution requires an increase in genetic data, mutations always reduce and destroy them.
Evolutionists, lacking even a single demonstrable mechanism to support their theory, presented pseudogenes as by-products of a phantom mechanism functioning in an imaginary evolutionary process. They claimed that these allegedly useless DNA segments were molecular "fossils" of so-called evolution. Their only support for this claim was the lack of knowledge as to whether these genes had any real function.
That is, up until May 1, 2003
That was when Nature magazine published a study showing the functionality of pseudogenes. In a letter titled "An expressed pseudogene regulates the messenger-RNA stability of its homologous coding gene," researchers told of their observations in mice prepared for an experiment.98 According to the information they gave, fatal mutations occurred in a line of transgenic mice as a result of genetic changes in pseudogenes called Makorin1-p1. They observed in the mice polycystic kidneys and bone deformity.
It became evident why a change in the arrangement of the pseudogene would have such a disastrous effect on the mice's organs: A pseudogene is not just functional, but necessary.
An article in Nature evaluating this research stated that this discovery challenged the popular belief of evolutionists that pseudogenes were simply "molecular fossils."99 And so, one more evolutionist myth collapsed.
Just three weeks after pseudogenes were revealed to have a biological function after all, a study in the May 23, 2003 issue of Science dealt another severe blow to the idea of junk DNA100 revealing yet another function of the non-coding DNA. Evolutionists apprised of all these developments had no other choice but to accept that the time had come to "junk" their concept of junk DNA. The title of an article by Wojciech Makalowski of Pennsylvania State University shows the change: "Not Junk After All." Makalowski sums up the situation in these words:
...[T]he view of junk DNA, especially repetitive elements, began to change in the early 1990s. Now, more and more biologists regard repetitive elements as a genomic treasure...These two papers demonstrate that repetitive elements are not useless junk DNA but rather are important, integral components of eukaryotic genomes...Therefore, repetitive DNA should be called not junk DNA...101
Once upon a time, you may have heard a lot about the idea of junk DNA and the evolutionist speculations connected with it.
But as outlined here, Darwinism's last assertion of "vestigiality"—junk DNA—has passed into history, and this last flutter of Darwinism has also been discredited.
82- Gretchen Vogel, "Objection #2: Why Sequence the Junk?", Science, 16 Şubat 2001
83- Wojciech Makalowski, "Not Junk After All", Science, Volume 300, Number 5623, 23 Mayıs 2003,
85- "Does nonsense DNA speak it's own dialect?", Science News, Vol. 164 , 24 Aralık,1994
86- Hubert Renauld and Susan M. Gasser, "Heterochromatin: a meiotic matchmaker," Trends in Cell Biology 7 (May 1997): ss. 201-205
87- Emile Zuckerkandl, "Neutral and Nonneutral Mutations: The Creative Mix-Evolution of Complexity in Gene Interaction Systems,' Journal of Molecular Evolution 44 (1997): S2-8.
88- Hubert Renauld and Susan M. Gasser, "Heterochromatin: a meiotic matchmaker," Trends in Cell Biology 7 (May 1997): 201-205.
89- Bencil DNA tezi: Evrimcilerin, kodlamayan DNA'nın sözde evrimsel oluşumunu açıklamada başvurduğu bir tez. Bu tez, canlıların işlevini yitirmiş DNA parçaları arasında bir tür rekabet olduğunu savunan hayali iddiadır. Bu yazıda da gösterildiği gibi, Crytomonad'lar üzerinde yapılan bu çalışmayla çürütülmüştür.
90- Beaton, M.J. and T. Cavalier-Smith. 1999. Eukaryotic non-coding DNA is functional: evidence from the differential scaling of cryptomonal genomes. Proc. R. Soc. Lond. B. 266:2053-2059
92- Ting SJ. 1995. A binary model of repetitive DNA sequence in Caenorhabditis elegans. DNA Cell Biol. 14: 83-85.
93- Vandendries ER, Johnson D, Reinke R. 1996. Orthodenticle is required for photoreceptor cell development in the Drosophila eye. Dev Biol 173: 243-255.
94- Keplinger BL, Rabetoy AL, Cavener DR. 1996. A somatic reproductive organ enhancer complex activates expression in both the developing and the mature Drosophila reproductive tract. Dev Biol 180: 311-323.
95- Kohler J, Schafer-Preuss S, Buttgereit D. 1996. Related enhancers in the intron of the beta1 tubulin gene of Drosophila melanogaster are essential for maternal and CNS-specific expression during embryogenesis. Nucleic Acids Res 24: 2543-2550.
96- R. Nowak, "Mining Treasures from 'junk DNA ", Science 263 (1994): 608.
97- "DNA; Junk or Not", The New York Times, 4 Mart 2003
98- Gretchen Vogel, "Objection #2: Why Sequence the Junk?", Science, 16 Şubat 2001
99- Hirotsune, S., Yoshida, N., Chen, A., Garrett, L., Sugiyama, F., Takahashi, S., Yagami, K., Wynshaw-Boris, A., and Yoshiki, A. 2003. An expressed pseudogene regulates the messenger-RNA stability of its homologous coding gene. Nature 423: 91-96.
100- Lee, J. T. 2003. Molecular biology: Complicity of gene and pseudogene [News and Views]/78 Emile Zuckerkandl, "Neutral and Nonneutral Mutations: The Creative Mix-Evolution of Complexity in Gene Interaction Systems,' Journal of Molecular Evolution 44 (1997): S2-S8.ature 423: 26-28.
101- "The Birth of an Alternatively Spliced Exon: 3' Splice-Site Selection in Alu Exons ", Galit Lev-Maor, et al. Science, Volume 300, Number 5623, Issue of 23 May 2003, ss. 1288-1291
102- Science, 23 Mayıs 2003


text:
The Restoration of All Things
The Restoration of All Things
President James E. Faust
Second Counselor in the First Presidency
We believe The Church of Jesus Christ of Latter-day Saints is a restoration of the original Church established by Jesus Christ.
James E. Faust, "The Restoration of All Things," Ensign, May 2006, 61
As members of The Church of Jesus Christ of Latter-day Saints, we care about all of God's children who now live or who have ever lived upon the earth. "Our message," as stated by the First Presidency in 1978, "is one of special love and concern for the eternal welfare of all men and women, regardless of religious belief, race, or nationality, knowing that we are truly brothers and sisters because we are sons and daughters of the same Eternal Father." 1 As Elder Dallin H. Oaks stated a few years ago:
"The Church of Jesus Christ of Latter-day Saints has many beliefs in common with other Christian churches. But we have differences, and those differences explain why we send missionaries to other Christians, why we build temples in addition to churches, and why our beliefs bring us such happiness and strength to deal with the challenges of life and death." 2
I wish to testify today of the fulness of the restored gospel of Jesus Christ, which adds to the religious beliefs of other denominations, both Christian and non-Christian. This fulness was originally established by the Savior in His earthly ministry. But then there was a falling away.
Some of the early Apostles knew that an apostasy would occur before the Second Coming of the Lord Jesus Christ. To the Thessalonians, Paul wrote concerning this event, "Let no man deceive you by any means: for that day shall not come, except there come a falling away first." 3
With this falling away, priesthood keys were lost, and some precious doctrines of the Church organized by the Savior were changed. Among these were baptism by immersion; 4 receiving the Holy Ghost by the laying on of hands; 5 the nature of the Godhead—that They are three distinct personages; 6 all mankind will be resurrected through the Atonement of Christ, "both … the just and the unjust"; 7 continuous revelation—that the heavens are not closed; 8 and temple work for the living and the dead. 9
The period that followed came to be known as the Dark Ages. This falling away was foreseen by the Apostle Peter, who declared that "heaven must receive [Jesus Christ] until the times of restitution of all things, which God hath spoken by the mouth of all his holy prophets since the world began." 10 Restitution would only be necessary if these precious things had been lost.
In the centuries that followed, religious men came to recognize that there had been a gradual falling away from the Church organized by Jesus Christ. Some of them suffered greatly for their beliefs, in what came to be called the Reformation, a sixteenth-century movement that aimed at reforming Western Christianity. This resulted in the separation of the Protestant churches from the main Christian church.
Among these reformers was the Reverend John Lathrop, vicar of the Egerton Church in Kent, England. Incidentally, the Prophet Joseph Smith was descended from John Lathrop. In 1623 the Reverend Lathrop resigned his position because he questioned the authority of the Anglican church to act in the name of God. As he read the Bible, he recognized that apostolic keys were not on the earth. In 1632 he became the minister of an illegal independent church and was put in prison. His wife died while he was in prison, and his orphaned children pleaded with the bishop for his release. The bishop agreed to release Lathrop on condition that he leave the country. This he did, and with 32 members of his congregation he sailed to America. 11
Roger Williams, a seventeenth-century pastor who founded Rhode Island, refused to continue as pastor in Providence on the grounds that there was "no regularly-constituted Church on earth, nor any person authorized to administer any Church ordinance; nor could there be, until new apostles were sent by the great Head of the Church, for whose coming he was seeking." 12
These are but two of the religious scholars who recognized an apostasy from the Church organized by Jesus Christ and the need for a restoration of the priesthood keys that had been lost. The Apostle John saw in vision the time when "another angel [would] fly in the midst of heaven, having the everlasting gospel to preach unto them that dwell on the earth, and to every nation, and kindred, and tongue, and people." 13 This prophecy has been fulfilled. Because we believe the fulness of the gospel of Jesus Christ has been restored in our time by the Prophet Joseph Smith, we wish to give all people an opportunity to know and accept this message.
We now have in the restored Church apostles, prophets, pastors, teachers, and evangelists, as spoken of by Paul to the Ephesians. 14
These priesthood offices were established by the Savior when He organized His Church in the meridian of time. We recognize the two orders of the priesthood and the offices contained within them: the lesser priesthood is the Aaronic Priesthood, named after Aaron; and the greater priesthood is the Melchizedek Priesthood, named after Melchizedek, to whom Abraham paid tithes. The Aaronic Priesthood was restored on May 15, 1829, under the hands of John the Baptist, and the Melchizedek Priesthood within a month under the hands of the ancient Apostles Peter, James, and John to Joseph Smith and Oliver Cowdery. Thus those possessing the priesthood today claim the power to act in the name of God through the priesthood, "which power commands respect both on earth and in heaven." 15
In the Kirtland Temple on April 3, 1836, Moses appeared and gave the Prophet Joseph Smith and Oliver Cowdery the keys of the gathering of Israel. After this, Elias appeared and committed the gospel of Abraham, that in "our seed all generations after us should be blessed." 16 After this, Elijah the prophet appeared and gave to them the keys of this dispensation, including the sealing power, to bind in heaven that which is bound on earth within the temples. 17 Thus, prophets of previous gospel dispensations presented their keys to the Prophet Joseph Smith in this, the "dispensation of the fulness of times" spoken of by the Apostle Paul to the Ephesians. 18
I am grateful the Lord has seen fit to establish again the law of tithes and offerings for this people. When we keep the law of tithing, the windows of heaven open for us. Great are the blessings poured down upon those who have the faith to keep the law of tithing.
Through the earth's long history, temple worship has been a significant part of the Saints' worship, by which they show their desire to come closer to their Creator. The temple was a place of learning for the Savior when He was on the earth; it was very much a part of His life.
Temple blessings are available once again in our day. A unique feature of The Church of Jesus Christ of Latter-day Saints is its teaching concerning temples and the eternal significance of all that occurs within them. Our majestic and beautiful temples now dot much of the earth. In them the most sacred work is done. President Gordon B. Hinckley has stated of these temples, "There are only a few places on earth where man's questions about life receive the answers of eternity." 19 The solemn mysteries of where we came from, why we are here, and where we are going are answered more fully in the temples. We came from God's presence and are here on earth to prepare to return to His presence.
Of transcendent significance is that within the sacred walls of the temple, husbands and wives make eternal covenants. These covenants are sealed by priesthood authority. Children of that union, if they are worthy, may enjoy an eternal relationship as part of a family and as children of God. As the Apostle John wrote: "What are these which are arrayed in white robes? … Therefore are they before the throne of God, and serve him day and night in his temple." 20
The Lord has said that His work is "to bring to pass the immortality and eternal life of man." 21 It follows then that all mankind, living and dead, should have the opportunity of hearing the gospel either in this life or in the spirit world. As Paul said to the Corinthians, "Else what shall they do which are baptized for the dead, if the dead rise not at all? why are they then baptized for the dead?" 22 This is the reason we do ordinance work in temples for our deceased ancestors. No person's choice or agency is taken away. Those for whom the work is done may accept it or not, as they choose.
The Apostle John saw in vision the time when an angel would come to the earth as part of the Restoration of the gospel. That angel was Moroni, who appeared to the Prophet Joseph Smith. He directed Joseph to the place where golden plates containing ancient writings were deposited. Joseph Smith then translated these plates by the gift and power of God, and the Book of Mormon was published. This is a record of two groups of people who lived centuries ago on the American continent. Little was known about them before the coming forth of the Book of Mormon. But more importantly, the Book of Mormon is another testament of Christ. It restored precious truths concerning the Fall, the Atonement, the Resurrection, and life after death.
Prior to the Restoration, the heavens had been closed for centuries. But with prophets and apostles upon the earth once more, the heavens were opened once again with visions and revelations. Many of the revelations that came to the Prophet Joseph Smith were written down in a book that came to be known as the Doctrine and Covenants. This contains further insights about principles and ordinances and is a valuable source concerning the structure of the priesthood. In addition, we have another canon of scripture called the Pearl of Great Price. It contains the book of Moses, which came by revelation to the Prophet Joseph Smith, and the book of Abraham, which he translated from a purchased Egyptian scroll. From these we learn not only a great deal more about Moses, Abraham, Enoch, and other prophets but also many more details about the Creation. We learn that the gospel of Jesus Christ was taught to all of the prophets from the beginning—even from the time of Adam. 23
We believe The Church of Jesus Christ of Latter-day Saints is a restoration of the original Church established by Jesus Christ, which was built "upon the foundation of the apostles and prophets, Jesus Christ himself being the chief corner stone." 24 It is not a breakoff from any other church.
We believe that the fulness of the gospel of Christ has been restored, but this is no reason for anyone to feel superior in any way toward others of God's children. Rather, it requires a greater obligation to invoke the essence of the gospel of Christ in our lives—to love, serve, and bless others. Indeed, as the First Presidency stated in 1978, we believe that "the great religious leaders of the world such as Mohammed, Confucius, and the Reformers, as well as philosophers including Socrates, Plato, and others, received a portion of God's light. Moral truths were given to them by God to enlighten whole nations and to bring a higher level of understanding to individuals." 25 Thus, we have respect for the sincere religious beliefs of others and appreciate others extending the same courtesy and respect for the tenets we hold dear.
I have a personal witness of the truth of the covenants, teachings, and authority restored through the Prophet Joseph Smith. This assurance has been with me all of my life. I am grateful that the Restoration of the fulness of the gospel has taken place in our time. It contains the pathway to eternal life. May the strength, peace, and concern of God the Father and the abiding love and grace of the Lord Jesus Christ be with us all, I pray in the name of Jesus Christ, amen.
Gospel topics: apostasy, covenants, Restoration
1. "Statement of the First Presidency regarding God's Love for All Mankind," Feb. 15, 1978.
2. In Conference Report, Apr. 1995, 112; or Ensign, May 1995, 84.
3. 2 Thes. 2:3; emphasis added.
4. See Mark 1:9–10.
5. See Acts 8:14–17; Acts 19:3–6.
6. See Matt. 3:17; Acts 7:55; D&C 130:22.
7. Acts 24:15.
8. See Dan. 2:28; Amos 3:7; D&C 121:26.
9. See Obad. 1:21; Mal. 4:6; 1 Cor. 15:29; Rev. 7:15.
10. Acts 3:20–21.
11. See Mark E. Petersen, The Great Prologue (1975), 34–35.
12. See William Cullen Bryant, ed., Picturesque America; or, the Land We Live In, 2 vols. (1872–74), 1:502; see also LeGrand Richards, A Marvelous Work and a Wonder, rev. ed. (1966), 29.
13. Rev. 14:6.
14. See Eph. 4:11.
15. James E. Talmage, The Articles of Faith, 12th ed. (1924), 204.
18. Eph. 1:10.
19. "Why These Temples?" Temples of The Church of Jesus Christ of Latter-day Saints (1999), 14.
20. Rev. 7:13, 15.
21. Moses 1:39.
22. 1 Cor. 15:29.
23. See Moses 5:58; Moses 8:19; Abr. 2:10–11.
24. Eph. 2:20.
25. First Presidency statement, Feb. 15, 1978.

subset: commoncrawl


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Well, it is official. I am finally taking injections for the upcoming surrogacy journey as of today. These are the little shots that go in my stomach. The med is Lupron. It is typically used for testicular cancer patients, but it has an off-label use for IVF because it shuts the ovaries down. My ovaries need to be shut down so that they don't release any eggs during our IVF cycle. Since my eggs aren't being used (an egg donor is being used instead), this is a desirable thing. The sides effects suck because this all equates to menopause-hot flashes, headaches, increased appetite, etc. The blue and orange pills are prenatal vitamins and the red pill is birth control. Yes, birth control sounds weird to take when you are trying to get pregnant, but there is a good reason for it. It helps sync my cycle with the egg donor's. We have to be at the same point in our cycles to make this all work. My body would reject her fertilized egg if I was in a different phase. Transfer is set for sometime between 10/30-11/5. It will all depend on how the cycle goes. I am so excited for my new couple!! Hopefully, all will go well and they will get a new baby for 2015. :)
A Week In The Life, Vol 40.
2 hours ago


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Montefalco Three Tier Pond Fountain
Montefalco Three Tier Pond Fountain Specifications:
- Dimensions: 75"H x 66"W (Forklift Required)
Montefalco Three Tier Pond Fountain Features:
- Proudly made in the USA
- Durably constructed of high-quality fiber-reinforced cast stone concrete
- Available in your choice of many different premium finishes
- Soothing waterfall sound
- No plumbing required
- Durably constructed of high-quality cast stone concrete, designed to last a lifetime
- Ships on a pallet to any address in the Continental USA. It normally ships in three to four weeks from the order date.
Montefalco Three Tier Pond Fountain Includes:
- Recirculating electric pump
Disclaimer: This water fountain is considered a Custom Fountain due to the finish stain or paint being hand applied after the fountain is ordered. Cancellation of a custom fountain will result in forfeiture of the initial deposit.
We offer free shipping within the United States. Here are some shipping facts about all of our products:
1.) Currently all small items will be shipped through UPS Ground, with free shipping.
2.) Products over 100lbs. will ship freight with Curbside Service. They will not unpackage and/or relocate your order once off the truck. Please make sure to have any kind of assistance needed at time of delivery if you feel necessary. Note: The delivery company will call to arrange a delivery time. Customers must be available to sign for the shipment at time of delivery.
3.) Our cast stone products are made to order and lead times will vary. Please reach out for the current lead time on the product you are interested in.
4.) On the delivery for fountains with extra large bases, a forklift is required for delivery as the base will be too big for lift-gate service. You must arrange this prior to fountain delivery. NOTE: Although most fountains DO NOT require a forklift because they can fit on a lift gate, we will notify you prior to shipping if your fountain requires a fork lift.
Questions & AnswersAsk a Question
ours will be outside all year long in georgia we would drain it before winter so would this be a problem
As long as you winterize your fountain it can be outside year long with no issue!
Basic Winterizing Steps:
- Drain the fountain
- Clean away any residue
- Remove the pump and all other small parts
- Cover the fountain
WARNING: For California Residents- Prop65
This product may be packaged with a wood fiber material which may contain wood dust.
It is very important for you to protect your cast stone and pottery fountains, birdbaths, planters and statuary from the freeze-thaw cycle during the winter months. Ideally, cast stone and pottery décor that can collect water, should not be left outside when temperatures dip down to freezing. They should be stored indoors or in a dry protected place such as a covered porch or garage that is away from the elements. This is not always possible, so it is recommended that you completely dry out your décor and add a waterproof cover. This is because any cast stone or pottery component that can hold water and freeze has the potential to crack and crumble. Components such as fountain pedestals which remain in a basin/pool can also crack or crumble.
For more information on winterizing your cast stone fountain and birdbath, click here.
For more information on winterizing your cast stone planters and statuary, click here.
For more information on winterizing your glazed and terra cotta pottery, click here.


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The Perspective tools in Illustrator CS5 make it a lot easier to draw in perfect one, two or three-point perspective. Using symbols in conjunction with the Perspective tools will make quick work of this stylized cityscape.
Every few weeks, we revisit some of our reader's favorite posts from throughout the history of the site. This tutorial was first published in April of 2011.
Step 1
Click the Perspective Grid Tool. Two things appear on your artboard: The Perspective Grid and the Active Plane Widget. You can change the placement of the Widget by double-clicking on the Perspective Grid Tool to bring up its options. The Widget can only be placed in one of the four corners — you can't move it freely.
A basic 2-point grid is the default setting. If you don't see something like the grid above, go to View > Perspective Grid > Two Point Perspective and choose the Normal preset.
Using the Perspective Grid tool, move the Horizon line down, close to the ground level. This will give a dramatic perspective with exaggerated vanishing points.
If you want, you can save this grid as a preset to use for future illustrations. Go to View> Perspective Grid > Save Grid as Preset to do so.
Step 2
If you're new to the Perspective tools, get a feel for how they work by drawing a few shapes in perspective. First, make sure the grid is visible and click the left plane (dark blue) on the Widget. Now take the Rectangle Tool (M) and draw on the left plane. Your rectangle will be drawn in perspective, fixed to the grid. Notice that the cursor crosshairs now have a left-facing arrow next to it.
This is a visual cue that lets you know which plane is active as you draw. Now Switch to the Perspective Selection Tool (Shift + M) and move the rectangle. You'll see that the rectangle's corner points are solid, rather than hollow, and look heavier than normal ones, indicating that the shape is in perspective. As you move it, the object will stay in perspective, even if you move it off the visible grid.
Step 3
Select the right plane (Orange) and draw another rectangle. Line it up with the first one, and you have the basic structure of a building in perspective.
You can now add elements, such as windows, by drawing a smaller rectangle and drag-copying it — with the Perspective Selection tool — several times to make a row (or drag out one copy, then press Command + D to make a few more). All subsequent copies will remain in perspective.
Step 4
You could continue drawing more rectangles and lining them up on either plane, but that can get tedious. A faster method is to construct the buildings flat (i.e., not in perspective), then make them into symbols, then place them on the grid.
Choose a lighter and darker variation of one color (I'm partial to orange), and make some simple building shapes. You'll enhance these later with gradients, but for now, keep it basic. Make one set that's lighter, and another version with the darker color. These will be used for the light side of the illustration, and the building facades that are in shadow, respectively.
Step 5
Drag each building into the Symbols panel. You can give each one a name if that helps you keep track of them— it can be hard to tell when you're looking at them in thumbnail view.
Step 6
Drag out a "lighter" symbol to the art board. Make sure the Left Plane is active, and using the Perspective Selection tool (Shift + V), drag the symbol into place. You'll see that it snaps to perspective. Do this a few more times, keeping the lighter buildings on the left plane.
Do the same with the darker building symbols, placing them on the right plane. Choose the plane on the widget, or press "3" to activate it.
Step 7
If you have a light and dark building shape placed where the two planes intersect, you'll notice that each side matches up. But if you try to add a dark side to a light shape that's further to the left of the intersection point, the new shape won't line up. The is because if you drag an object that's in perspective on the right plane, and try to match it up to one the right, the left shape will grow in size as you drag, because it continues to adhere to the perspective grid.
So what you need to do is drag that shape perpendicularly, in perspective.
Select the shape with the Perspective Selection tool, hold down the '5' key and drag it to the left. A line indicates that you are dragging perpendicularly.
Step 8
Continue constructing buildings this way, until each facade has a matching side. You'll probably have to send some shapes behind others, which you can do without affecting the perspective.
Step 9
Once all the buildings are arranged to your liking, zoom in and make sure each side of each building is lined up neatly. They do not have to align to a grid line, but if you nudge an object with the arrow keys, it will snap to the nearest one.
Step 10
To give the illustration some polish, add gradients to each building shape. To do this, you must first release the shapes from the Perspective Grid. Select a shape and go to Object > Perspective > Release with Perspective. This will break the link to the Symbol, so you can now change the appearance of each object.
Step 11
Create a set of gradients that are made up of your two original colors, with a darker and lighter color in each. As you color the shapes, use the gradients to enhance the sense of depth in the cityscape. Visualize the light source and color the buildings accordingly, while maintaining a cohesive look.
Applied carefully, gradients can also add depth and interest to the windows and details of the buildings.
Step 12
Now we'll make the reflection. Create a new layer below the first layer. Select the entire cityscape, and click the little colored square in the Layers panel. Hold down the Alt key, then drag the square down to the new layer. This will create a copy of the objects on the bottom layer. Lock or hide the top layer.
Step 13
With the copy still selected, double-click the Reflect Tool and reflect the objects horizontally. Drag the reflected copy down, so that it's just below the original. This will be the reflection.
Step 14
To simplify the reflection and make it less distracting, delete all the details on each building. This is kind of a chore, but you can make it easier by viewing the reflection in Outline mode and selecting multiple windows and other details with the Direct Selection Tool (A), and/or the Lasso Tool (Q).
Step 15
Since the cityscape is a perspective drawing, making the reflection isn't as easy as simply flipping the shapes and placing them below the original. Select just one half of the reflection. Choose the Free Transform Tool (E), then grab the outer side of the selected objects, and drag it up, while holding down the Command key. Add the Shift key to keep the transformation aligned vertically. It can be a bit tricky to master this finger dance, but after a few tries, you'll get the hang of it. Skew the refection until it meets the main cityscape shape. Do the same with the other half.
Step 16
When you are satisfied with the skewed halves, draw a rectangle that covers the entire reflection. Fill this rectangle with a black to white linear gradient, as in the image below.
Step 17
Select the rectangle and the reflection objects. In the Transparency panel, click the flyout menu and choose Make Opacity Mask. The reflection should now appear to fade out. If not, try clicking Invert Mask in the panel.
Step 18
If necessary, adjust the fade-out by editing the gradient. Click on its thumbnail in the Transparency panel and adjust it with the Gradient tool.
Step 19
Nudge the reflection up or down if necessary. Then sit back and admire your shining city!
Before the Perspective tools were introduced in CS5, it was entirely possible to make an illustration such as this one, but you had to carefully measure and plot your own grid. Creating such a grid could take as long as it did to make the rest of the illustration. The Perspective toolset eliminates the need for all that time-intensive preparation, and allows you to concentrate on the creative part of illustrating.


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architectural digest at 100 book
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SAN FRANCISCO, CA – It was revealed this week that cancer survivor and Apple CEO Steve Jobs was undergoing hormone therapy to counteract his notable weight loss. "My doctors think they have found the cause — a hormone imbalance that has been 'robbing' me of the proteins my body needs to be healthy," Jobs said in an official statement.
Weekly World News sources inside Apple say that Jobs is hiding the real reason for his treatments: He wants undergo radical hormone replacement in order to make a run to become California's first female governor in 2010. This is in contrary to the recent debacle at MacWorld, where hackers announced his supposed death.
"Steve Jobs has been a longtime supporter of women's and transgender rights as CEO of Apple," claims the source. "This move to do a total sex change upgrade speaks to his commitment to quality and strict hardware standards."
Jobs is forgoing the keynote speech at MacWorld in order to continue hormone therapy, and prepare for the gubernatorial race, which would pit Jobs against steroid user Arnold Schwarzenegger and perhaps former eBay CEO Meg Whitman (reportedly also woman) for the top job in the Golden State.


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At a wedding I attended recently, I ended up having a long, open-bar-fueled argument with another guest over our favorite speculative fiction books. She loves Robert Jordan; I love George R.R. Martin. I won't bore you with the details, but I do want to emphasize how vehemently opposed our tastes were, so that when I tell you that we both adored The Left Hand of Darkness, you'll know: wow. that must be a seriously awesome book.
And it really, really is. This is about as pure sci-fi as sci-fi can get: a tale of fiction that speculates on the future of science and how it may alter human culture. And, in this book, even human genetics.
The story takes place on the planet Gethen, mostly known as Winter, where Genly Ai has been assigned as a diplomat. His mission is to bring the people of Winter into the broader galactic civilization. His task is complicated by the alien culture and politics of this world, where the human inhabitants are genderless beings whose sexual characteristics and reproductive abilities only surface during mating seasons, when they can become either male or female (depending on their chosen partner). LeGuin is a master: this novel is excellent. It's not about aliens, or sex, or politics, but it is about the way all of those things affect friendship, culture, and human nature. Like all great science fiction, this isn't a work with a limited scope or audience – it's one that uses speculation about the future to make sharp observations and thoughtful arguments about the way we live now.


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Kurt Nimmo
Greek Prime Minister George Papandreou has told his fellow countrymen it is their patriotic duty to accept the austerity plan cooked up by the IMF and the EU. If not accepted, Greece will not get the fifth installment of an international bailout, he warned.
"I'm not asking you to listen to outside pressures, I ask that you listen to your soul and your internal patriotic conscience," Papandreou said.
Greek opposition parties have rejected demands by EU leaders for national unity on the prospect of unemployment, a lower standard of living, and a massive giveaway of national resources.
"You cannot terrorize your MPs by referring to patriotism because if there is something we should be proud of today it's that Greeks have risen up from their indifference and are defending, as is their duty, patriotism by the presence in the streets," said Alexis Tsipras, leader of the leftist party SYRIZA.
Opinion polls indicate three quarters of Greeks oppose tax rises, spending cuts, globalist privatization, and the selling off of national treasures.
On Tuesday, Greek unions shut down government services, brought public transport to a standstill and grounded flights. Unions began their fourth general strike of the year at midnight.
Greece's biggest union, the General Confederation of Greek Workers, has characterized the austerity measures as a "mafia-style rescue."
"This proposed austerity package will only make things worse. It will mean we are pushed deeper into recession and will never pay back our debts," Zoe Lanara, the union's international relations secretary, told The Independent.
As former Wall Street economist Michael Hudson notes, the so-called bailout will not help the Greek people, it will enrich the banks at the expense of the people.
"The Greek economy will not end up with the proceeds of any ECB 'bailout.' The banks will get the money. They would like to turn around and lend it out afresh to the buyers of the land, monopolies and other properties that Greece is being told to privatize," he writes. "Is this not like military tribute? … The bankers are trying to get a windfall by using the debt hammer to achieve what warfare did in times past."
Papandreou and the political elite expect the Greek people to acquiesce to what amount to a military attack on the country by the financial elite. Instead, unions and thousands of protesters will close down the country and continue to resist eurozone enslavement and the theft of their heritage by international finance.


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Here I used the Plumeria Stickers as a little embellishment next to my photo. I die cut some of the papers with the Love Lives Here die by Papertrey Ink and scattered them down the page. The purple cardstock helps ground the photo a little bit. I wrote the journaling on a die cut Half & Half tag and tucked it under the photo!
Here is the sketch if you'd like to play along this week - leave a link to your layout or card at the Basic Grey blog HERE!


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What the Anesthesiologist Should Know before the Operative Procedure
Surgical site infections are second only to urinary tract infections as a cause of nosocomial infections. Such infections are divided into superficial sternal site infections (SSSIs) and deep sternal site infections (DSSIs). DSSIs are a major source of morbidity, mortality, and cost for patients having undergone cardiac surgery. The incidence may range from 0.5% to 5% after sternotomy with a mortality rate of 5% to as high as 50% depending upon the organism. Such infections may triple the cost of care due to a longer length of hospital stay, longer ICU stay, and increased likelihood of readmission to an ICU. Although DSWIs are associated with early mortality after discharge, long-term mortality is no different than those patients that undergo cardiac surgery but do not develop an infection.
Many risk factors have been cited. Patient-specific factors include female sex, use of steroids, current smoking, hypertension, older age, obesity, poor functional status, diabetes, postoperative hyperglycemia, low cardiac output and ejection fraction, and preoperative addiction to opiates. Surgery-specific risk factors include excessive bleeding after the initial procedure, reoperation, longer duration of surgery, surgery performed on intra-aortic balloon counter pulsation, and retention of drainage catheters in the surgical site for more than 48 hours. Early tracheostomy does not appear to be a risk factor for mediastinitis. The risk associated with bilateral internal mammary artery harvest is controversial. The most common organisms are coagulase-negative Staphylococcus epidermidis and Staphlococcus aureus. Methicillin-resistant Staphlococcus aureus (MRSA) is assuming a more important role and has a higher incidence of death.
An SSSI involves only the skin and subcutaneous tissue of the incision with either purulent drainage, microorganisms, or pain, redness, and swelling. A DSSI involves the fascial and muscle layers or organ spaces and pus in the deep incision, spontaneous dehiscence of the wound, an abscess diagnosed by computed tomography, or a diagnosis of osteomyelitis or mediastinitis.
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The anesthesiologist's role in the management of surgical site infections begins at the time of the initial procedure with adherence to specific practice that has been proved to decrease the incidence of infection. Such practice includes maintenance of normothermia, avoidance of hyperglycemia, avoidance of unnecessary blood product transfusions, and timely, appropriate antibiotic prophylaxis.
Certain aspects of cardiac surgery may predispose patients to infections. Cardiopulmonary bypass compromises the immune system through reduced phagocytosis, activation of white blood cells, and impaired humoral immunity. Induced hypothermia and the duration of the procedures further increase the risk of infection as does postoperative bleeding. Patients commonly have many drains in place after surgery providing a conduit from the surface to deeper structures.
The Society of Thoracic Surgeons (STS) have made recommendations and published guidelines that attempt to standardize practice with a goal of decreasing wound infections and reducing the development of resistant organisms (Table I).
1. What is the urgency of the surgery?
Certain practices to prevent wound infections should be standard regardless of the urgency of the surgery. This includes adherence to sterile technique, timely selection and administration of appropriate antibiotics. Adherence to sterile technique during central line placement includes mask, gown, sterile gloves, and full body draping during line placement. Central line protocols may dictate that lines placed under emergent conditions when violation of sterile technique occurs be changed after the procedure if maintenance of sterile technique is not guaranteed.
What is the risk of delay in order to obtain additional preoperative information?
DSSIs are associated with significant mortality in the first 30 days after cardiac surgery. It does appear that long-term mortality is higher even in patients treated appropriately. Thus urgent surgical management is imperative to reduce long-term mortality. The risk associated with delay in management includes the development of systemic involvement and infection of prosthetic material including grafts, artificial valves, or implanted devices.
The presence of DSSI associated with mediastinitis is a medical emergency requiring immediate surgical drainage. Patients may demonstrate manifestations of sepsis including hypotension, ARDS, renal or hepatic dysfunction, and septic myocardial depression.
2. Preoperative evaluation
The preoperative evaluation will generally start with an effort to determine whether the infection is a superficial sternal site infection (SSSI) or a deep sternal site infection (DSSI). The anesthesiologist should review records related to the initial surgical procedure including airway management, intravenous access, and intraoperative course. Patients that present for cardiac surgery have a higher rate of difficult laryngoscopy than patients presenting for non-cardiac surgery.
3. What are the implications of co-existing disease on perioperative care?
Coexisting diseases may affect the incidence of disease and survival after diagnosis including the risk of death after treatment with muscle flap advancement.
a. Cardiovascular system
Patients with impaired left ventricular function and/or advanced heart failure as defined by class III or IV New York Heart Association heart failure are at higher risk for DSSI. These conditions may be improved after the initial cardiac surgery (CABG, valve repair or replacement) but not necessarily. Some conditions may be worse. The systemic effects of infection may worsen ventricular function. Arrhythmias are also more common in patients with DSSI. Patients with systemic manifestation of infection may have associated endocarditis. Transthoracic echocardiography (TTE) or transesophageal echocardiography (TEE) may allow accurate diagnosis.
b. Pulmonary
Coronary artery bypass grafting (CABG) via a sternotomy induces many changes in pulmonary function that persist for weeks and months. Forced vital capacity (FVC), forced expiratory volume in 1 second (FEV1), and peak expiratory flow rate (PEFR) are compromised for at least 3 months. This is likely due to capillary leak, edema, and atelectasis. Sternal pain or sternal non-union may impair ventilation in the immediate postoperative period. Chronic obstructive pulmonary disease (COPD) has been identified in some studies as a risk factor for DSSI. Baseline oxygen saturation and arterial blood gas analysis may help predict the likelihood of successful extubation. Some sternal infections are so severe as to warrant full sternal removal and flap closure only. Such a procedure may have a significant impact on respiratory mechanics.
c. Renal-GI:
Postoperative renal failure is identified as a risk factor for DSSI. Such patients may demonstrate heart failure and pulmonary edema in addition to difficulty with fluid management. Antibiotics should be dosed appropriately based upon renal function.
d. Neurologic:
Neurologic status has not been identified as a risk factor for DSSI although agitation after surgery can increase the risk of sternal instability and infection. Manifestations of infection in the elderly population are often nonspecific. Confusion and delirium may be the only indication of a deep infection.
f. Endocrine:
Patients with diabetes are at an increased risk for sternal site infections as are patients without diabetes but who exhibit hyperglycemia in the perioperative period. Both morbidity and mortality are reduced when hyperglycemia is controlled. Control of hyperglycemia and maintenance of glucose levels to less than 200 mg/dL have resulted in a reduction in the incidence of such infections. The Society of Thoracic Surgeons has published guidelines for the perioperative management of hyperglycemia. These guidelines target a glucose level less than 180 mg/dL.
4. What are the patient's medications and how should they be managed in the perioperative period?
Patients with DSSI are often treated with antibiotics prior to the surgical procedure. Such antibiotics must be continued into the perioperative period. Anticoagulants such as Coumadin and antiplatelet agents create a baseline coagulopathy, which may translate into increased perioperative bleeding. Also, patients having undergone cardiac surgery will be managed with beta-blockers and cholesterol-lowering agents as these are quality measures by many organizations. Beta-blockers should be continued into the perioperative period unless there is evidence of acute heart failure.
h. Are there medications commonly seen in patients undergoing this procedure and for which should there be greater concern?
Anticoagulants such as Coumadin and antiplatelet agents create a baseline coagulopathy, which may translate into increased bleeding during the perioperative period, especially in patients subject to repeat sternotomy. Plavix (clopidogrel) should generally be discontinued 7 days before elective procedures but may place a patient with a coronary stent at risk for thrombosis. The decision as to when to discontinue antiplatelet agents in a patient with a stent should be made in conjunction with the cardiologist and surgeon. Risk is highest in those patients with drug eluting stents
i. What should be recommended with regard to continuation of medications taken chronically?
Quality indicators for patients having undergone CABG include the prescription of a beta-blocker, aspirin, and cholesterol-lowering agent upon discharge from the hospital. Beta-blockers and cholesterol-lowering agents should be continued into the perioperative period. Angiotensin-converting enzyme inhibitors should be discontinued 24 hours prior to surgery if possible. Patients with coronary stents receiving antiplatelet therapy are at high risk for thrombosis should antiplatelet agents be discontinued in the perioperative period. Surgery for superficial and deep surgical site infections cannot be delayed. A multidisciplinary approach involving the cardiologist and surgeon is necessary for determining a safe plan and to monitor for complications.
Bronchodilators should be continued.
j. How To modify care for patients with known allergies –
A rare but challenging situation arises when a patient with a known IgA deficiency presents for redo cardiac surgery. A small percentage of such patients will exhibit anaphylaxis to blood transfusion. The blood bank must be notified as soon as possible to make arrangements. Blood cells should be washed. Fresh frozen plasma and platelets must come from patients with known IgA deficiency through an established donor network. Surgery for a DSSI may not allow time to obtain platelets and FFP. A discussion with the blood bank and surgeon must occur ahead of time and plans made for treating bleeding and coagulopathy.
k. Latex allergy- If the patient has a sensitivity to latex (eg. rash from gloves, underwear, etc.) versus anaphylactic reaction, prepare the operating room with latex-free products.
Allergic reaction to natural latex rubber can result in life-threatening anaphylaxis with exposure to products in the operating room containing natural-rubber latex. The prevalence of IgE antibodies to latex may be as high as nearly 7% in the general population. Patients with myelodysplastic syndromes and urogenital abnormalities are at higher risk as are patients with a history of fruit allergy including banana, avocado, and kiwi. A complete preoperative anesthesia evaluation should reveal any risk of a history of reaction. The history should include reactions to latex gloves. Reactions range from simple rash to full anaphylaxis. Sources of latex in the operating room include gloves, stoppers in medication vials, rubber tourniquets, surgical drains, and urinary catheters.
All operating room personnel should be aware of a patient with a latex allergy. Latex gloves should be removed from the room or isolated to avoid inadvertent use and a non-latex alternative made available. All medications should be prepared without puncturing latex stoppers although this has not been shown to reduce latex levels. Premedication with histamine blocking agents has been recommended although this does not necessarily prevent a reaction.
Medications and a plan for resuscitation should be made ahead of time. Epinephrine, steroids, and antihistamines should be readily available.
Most central lines and introducers are now latex free. The balloon on a flow-directed pulmonary artery catheter contains natural latex rubber. Latex-free pulmonary artery catheters are available but at higher expense.
l. Does the patient have any antibiotic allergies
Cephalosporins are the drug of choice for the prophylaxis of surgical site infections. Patients with a sensitivity to cephalosporins should receive vancomycin and additional coverage for gram-negative organisms, either gentamicin or levofloxacin.
m. Does the patient have a history of allergy to anesthesia?
Malignant hyperthermia (MH) is an autosomal dominant condition that manifests as a hypermetabolic state when an individual is exposed to a triggering agent. Agents that may trigger the reaction include volatile anesthetics (halothane, isoflurane, enflurane, sevoflurane, and desflurane) and succinylcholine. Even trace amounts of the agents can trigger such a reaction.The syndrome will manifest as overproduction of carbon dioxide, muscle rigidity, metabolic and respiratory acidosis, and hemodynamic collapse.
A complete preoperative evaluation should include questions about a history of MH or abnormal reactions to anesthesia in the patient or family members. The absence of such a history does not rule out the possibility of MH but makes it unlikely.
The operating room should be prepared. All triggering agents should be removed (volatile agents and succinylcholine). All vaporizers should be removed from the anesthesia machine. The CO2 absorber should be replaced. Reservoir bags and tubing should be changed as rubber may absorb volatile agents. The machine should be flushed for 5 minutes at least with 10L flow of oxygen prior to use.
The clinical symptoms of MH include tachycardia, tachypnea, arrhythmias, unstable blood pressure, sweating, rigidity, and dark blood on the surgical field. Surgery should be stopped as soon as possible should MH be suspected. Help should be summoned and 100% oxygen should be administered immediately.
The treatment for suspected MH is dantroline, a lyophilized formulation containing mannitol and sodium hydroxide. Dantroline must be dissolved in sterile water and is administered in a dose of 2.5 mg/kg, repeated up to a total of 10 mg/kg. Additional support includes administration of sodium bicarbonate to treat acidosis and hyperkalemia, maintenance of urine output, and intense monitoring. An arterial line should be placed. Intensive care is indicated after the diagnosis.
5. What laboratory tests should be obtained and has everything been reviewed?
Patients with sternal wound infections often present within the first 30 days after the initial surgery. Common laboratory abnormalities include anemia, elevated prothrombin time if the patient is taking coumadin, leukocytosis with a left shift, and an increase in blood urea nitrogen (BUN) and serum creatinine. Blood antibody sampling is imperative and may demonstrate development of abnormal antibodies.
Hemoglobin levels:
Anemia is associated with the initial surgical procedure and current infection. The administration of blood products may also increase the risk of infection.
Hypokalemia and hypomagnesemia may predispose the vulnerable patient to arrhythmias. Hyponatremia may be seen in patients on thiazide diuretics.
Coagulation panel:
Patients are often anticoagulated with coumadin after surgery due to mechanical prosthesis or atrial fibrillation.
Arrhythmias are common in patients with DSSI.
Computed chest tomography may reveal several indicators of DSSI including sternal non-union and abscess formation. Abscess formation may be especially critical in patients with prosthesis such as valves or aortic grafts. Aortic graft disruption has been reported in the presence of DSSI.
Other tests:
TTE or TEE may reveal the presence of vegetations indicating endocarditis or additional cardiac involvement. Blood cultures may reveal bacteremia.
6. Intraoperative Management: What are the options for anesthetic management and how to determine the best technique?
Some very minor SSSIs may be managed with monitored anesthetic care during the initial exploration and drainage. Often it is difficult to determine the degree of tissue involvement and viability by preoperative studies and exploration is necessary. All DSSIs will require general anesthesia.
a. Regional anesthesia
Neuraxial anesthesia has been employed successfully in the management of patients undergoing CABG. The benefits may include improved cough, better pain control, and less nausea and vomiting but the literature is unclear regarding benefit. Patients undergoing redo sternotomy for DSSI are by definition infected. Bacteremia may induce epidural abscess formation in the presence of neuraxial anesthesia.
b. General Anesthesia
General anesthesia is selected for all DSSIs. General anesthesia allows for deep wound exploration and full debridement including placement of vacuum assisted drainage and omental transfer. Muscle flap advancement often requires muscle relaxation and only general anesthesia will suffice. General anesthesia does require endotracheal intubation. Patients with COPD are at risk for sternal wound infection. Such patients are often difficult to extubate due to the change in pulmonary mechanics associated with sternal debridement and in some cases full sternal removal.
Patients presenting for cardiac surgery have a higher incidence of difficult laryngoscopy than patients presenting for other procedures. This may be due to diabetes and "diabetic stiff joint syndrome" or poor neck mobility often seen in elderly patients. By definition, DSSIs have occurred after a prior sternotomy; thus airway records are available and should be reviewed prior to the procedure.
c. Monitored Anesthesia Care
Monitored anesthesia care (MAC) may be successful for drainage of small superficial skin infections and avoids the morbidity associated with intubation. MAC may also be associated with less morbidity in patients who require multiple dressing changes and minor debridements after the initial deeper surgical exploration. MAC would not be adequate during the initial deep sternal debridement and later muscle flap placement. A single agent or combination of agents that provides both analgesia and sedation should be selected. A benzodiazepine such as midazolam and opioid such as fentanyl are easy to titrate. Ketamine in small doses will provide intense analgesia without respiratory depression. Ketamine should be administered with a benzodiazepine to avoid unpleasant hallucinations. MAC does require the same level of basic monitoring as a general anesthetic for the same duration of time.
7. What is the author's preferred method of anesthesia technique and why?
What prophylactic antibiotics should be administered?
Antibiotics administered in the perioperative period during debridement of a DSSI should be tailored to treat the specific infecting organism if possible. The most common infecting organisms are Staphylococcus epidermidis and Staphylococcus aureus. Broad-spectrum antibiotics are indicated in the case of toxemia. Should an organism not be identified, routine prophylaxis with a cephalosporin is indicated.
What do I need to know about the surgical technique to optimize my anesthetic care?
The preoperative evaluation will include a computed tomography of the chest to determine the depth of tissue involvement and whether an abscess has formed. It is wise to plan for a major debridement. Most DSSIs will present in the first 30 days. This is the period of time where thoracic reoperation is most risky due to the presence of very dense, vascular adhesions below the sternum. Structures such as the right ventricle, right atrium, coronary grafts, pulmonary artery, or cardiac patches may be adherent to the sternum. Redo sternotomy and dissection may risk injury and massive hemorrhage. Patients presenting for deep sternal exploration are managed as is any repeat sternotomy case, with arterial line placement and large IV access. SSSIs are managed with debridement and closure by secondary intention, often with vacuum-assisted closure (VAC) dressings. DSSI are managed with deep debridement. Such procedures may involve debridement of sternal bone until viable tissue is noted. Extensive sternal debridement may be required. Sometimes sternal debridement, mediastinal irrigation, and sternal re-wiring are used alone. Most closures are delayed while the patient is treated with vacuum drainage and antibiotics. Definitive closure occurs days to weeks after the initial debridement. Most patients will undergo sternal closure with sternal rewiring or muscular advancement/rotational flaps with either a unilateral or bilateral pectoralis major. The rectus abdominis may also be used.
What are the most common intraoperative complications and how can they be avoided/treated?
Prioritize them by urgency. The anesthesiologist must be prepared for the most catastrophic complication of redo sternotomy and debridement of mediastinitis: damage to underlying structures and massive hemorrhage. Large peripheral and/or central venous access is indicated. Blood products should be ordered and readily available. Our practice is to place all intravenous access on the right side in the case of damage to the left brachiocephalic vein during chest opening. Arterial pressure monitoring should occur on the right side as well. TEE may be beneficial to evaluate for endocarditis and extension of infection. Hypothermia should be avoided by maintaining a warm room, warming all fluids, and using a warming blanket.
What are risk factors for mortality after muscle flap advancement and why?
Deep sternal wound infections are associated with significant mortality. Factors associated with increased mortality after muscle flap advancement include presternotomy end-stage renal disease, presternotomy COPD, and prolonged poststernotomy mechanical ventilation. Patients with end-stage renal disease are immunosuppressed. End-stage renal disease patients often lack the ability to readily deal with fluid shifts. Patients with COPD who are treated with steroids are at risk for impaired wound and sternal healing. Prolonged mechanical ventilation may result in continual contamination of the sternal wound. Other factors potentially associated with a higher mortality rate include increased body weight and female sex.
a. Neurologic:
b. If the patient is intubated, are there any special criteria for extubation?
Most patients who have undergone debridement for DSSI will be extubated in the operating room. Patients with COPD benefit from early extubation but sternal instability or opening may interfere with effective respiratory mechanics. Adequate pain control is imperative.
c. Postoperative management
What analgesic modalities can I implement?
Excessive pain after sternal debridement is rare. Most patients can be adequately managed with oral opioids such as oxycodone. Others may be more effectively managed with patient controlled analgesia. Neuraxial anesthesia (epidural) is rarely necessary and may be contraindicated due to fears of epidural abscess formation in the setting of infection.
What level bed acuity is appropriate?
Patients having undergone debridement for SSSI are unlikely to be unstable or require prolonged extubation. Routine postanesthesia monitoring followed by floor management is appropriate. Patients having undergone initial debridement for DSSI are best managed in an intensive care unit setting.
Are there any other considerations for patients with VAC dressings after surgery?
VAC dressing placement or negative pressure wound therapy (NPWT) may be associated with major complications. Although rare, right ventricular rupture, bleeding from vein grafts, and bleeding from an aortic homograft have been reported and associated with significant mortality. This may bve due to disruption of the heart during therapy. VAC bleeding of the heart can be reduced by application of a non-adherent layer between the heart and VAC sponge.
Are there any other potential treatments?
Hyperbaric oxygen (HBO) has been utilized successfully to augment management of refractory necrotizing soft tissue infection and sternal osteomyelitis. Utilization of HBO is labor intensive, often requires significant patient transport, time, as well as multiple treatment cycles. There may be benefit in a limited number of patients.
What's the Evidence?
Petzina, R, Malmsjo, M, Stamm, C, Hetzer, R. "Major complications during negative pressure wound therapy in poststernotomy mediastinitis after cardiac surgery". J Thorac Cardiovasc Surg. vol. 140. 2010. pp. 1133-6. (This article discusses major complications of negative pressure wound therapy (NPWT))
Hassan, M, Smith, JM, Engel, AM. "Predictors and outcomes of sternal wound complications in patients after coronary artery bypass graft surgery". American Surgeon. vol. 72. 2006. pp. 515-20. (This article outlines the major risk factors and for the development of sternal wound infections and the outcomes after diagnosis.)
Edwards, FH, Engleman, RM, Houck, P, Shahian, DM, Bridges, CR. "The Society of Thoracic Surgeons practice guideline series: antibiotic prophylaxis in cardiac surgery, part I: duration". Ann Thorac Surg. vol. 81. 2006. pp. 397-404. (This is the practice guideline for antibiotic prophylaxis as developed by the Society of Thoracic Surgeons.)
Mauermann, WJ, Nemergut, EC. "The anesthesiologist's role in the prevention of surgical site infections". Anesthesiology. vol. 105. 2006. pp. 413-21. (This article review 6 perioperative factors over which an anesthesiologist may affect the development of infection in the perioperative period.)
Cayci, C, Russo, M, Cheema, F, Martens, T. "Risk analysis of deep sternal wound infections and their impact on long-term survival: a propensity analysis". Ann Plast Surg. vol. 61. 2008. pp. 294-301. (A review of risk factors for deep sternal wound infections, impact on hospital length of stay, and mortality.)
Lazar, HL, McDonnell, M, Chipkin, SR, Furnary, AP. "The Society of Thoracic Surgeons practice guideline series: blood glucose management during adult cardiac surgery". Ann Thorac Surg. vol. 87. 2009. pp. 663-9. (Hyperglycemia has been identified as a risk factor for surgical wounds. The Society of Thoracic Surgeons has developed guidelines for management.)
Patel, NV, Woznick, AR, Welsh, KS, Bendick, PJ, Boura, JA, Mucci, SJ. "Predictors of mortality after muscle flap advancement for deep sternal wound infections". Plast Reconstr Surg. vol. 123. 2009. pp. 132-8. (Patients with a history of end-stage renal disease or chronic obstructive pulmonary disease and those who experience prolonged postoperative ventilation are at higher risk for mortality after muscle flap advancement for deep sternal wound infections.)
Engleman, R, Shahian, D, Shemin, R, Guy, TS. "The Society of Thoracic Surgeons practice guideline series: antibiotic prophylaxis in cardiac surgery, part ii: antibiotic choice". Ann Thorac Surg. vol. 83. 2007. pp. 1569-76. (The Society of Thoracic Surgeons' recommendations for appropriate perioperative antibiotic selection.)
Luckie, M, Khattar, RS, Fraser, D. "Non-cardiac surgery and antiplatelet therapy following coronary artery stenting". Heart. vol. 95. 2009. pp. 1303-8. (The article addresses management of antiplatelet agents in patients presenting for noncardiac surgery.)
Shenkman, Z, Shir, Y, Weiss, YG, Bleiberg, B, Gross, D. "The effects of cardiac surgery on early and late pulmonary functions". Acta Anaesthesiol Scand. vol. 41. 1997. pp. 1193-9. (Cardiac surgery has several affects on pulmonary function that may persist well beyond the immediate perioperative period.)
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- What the Anesthesiologist Should Know before the Operative Procedure
- 1. What is the urgency of the surgery?
- What is the risk of delay in order to obtain additional preoperative information?
- 2. Preoperative evaluation
- 3. What are the implications of co-existing disease on perioperative care?
- a. Cardiovascular system
- b. Pulmonary
- c. Renal-GI:
- d. Neurologic:
- f. Endocrine:
- 4. What are the patient's medications and how should they be managed in the perioperative period?
- h. Are there medications commonly seen in patients undergoing this procedure and for which should there be greater concern?
- i. What should be recommended with regard to continuation of medications taken chronically?
- j. How To modify care for patients with known allergies -
- k. Latex allergy- If the patient has a sensitivity to latex (eg. rash from gloves, underwear, etc.) versus anaphylactic reaction, prepare the operating room with latex-free products.
- l. Does the patient have any antibiotic allergies
- m. Does the patient have a history of allergy to anesthesia?
- 5. What laboratory tests should be obtained and has everything been reviewed?
- 6. Intraoperative Management: What are the options for anesthetic management and how to determine the best technique?
- 7. What is the author's preferred method of anesthesia technique and why?
- a. Neurologic:
- b. If the patient is intubated, are there any special criteria for extubation?
- c. Postoperative management
- What's the Evidence?