A fresh look at paralytics in the critically ill: real promise and real concern.

Neuromuscular blocking agents (NMBAs), or "paralytics," often are deployed in the sickest patients in the intensive care unit (ICU) when usual care fails. Despite the publication of guidelines on the use of NMBAs in the ICU in 2002, clinicians have needed more direction to determine which patients would benefit from NMBAs and which patients would be harmed. Recently, new evidence has shown that paralytics hold more promise when used in carefully selected lung injury patients for brief periods of time. When used in early acute respiratory distress syndrome (ARDS), NMBAs assist to establish a lung protective strategy, which leads to improved oxygenation, decreased pulmonary and systemic inflammation, and potentially improved mortality. It also is increasingly recognized that NMBAs can cause harm, particularly critical illness polyneuromyopathy (CIPM), when used for prolonged periods or in septic shock. In this review, we address several practical considerations for clinicians who use NMBAs in their practice. Ultimately, we conclude that NMBAs should be considered a lung protective adjuvant in early ARDS and that clinicians should consider using an alternative NMBA to the aminosteroids in septic shock with less severe lung injury pending further studies

Can\u27t You Smell That Smell? Clean Air Act Fixes for Factory Farm Air Pollution

Massive facilities that keep large numbers of livestock have overtaken small, independent farms as the primary source of meat, eggs, and dairy in the United States. These concentrated animal feeding operations ( CAFOs) compare more to industrial manufacturing operations than to traditional farms, and emit huge quantities of air pollutants that are harmful to public health, sickening people and damaging the environment. The Environmental Protection Agency ( EPA ) possesses statutorily provided tools under the Clean Air Act that it uses to regular other polluting industries. However, this article - after reviewing the rise of CAFOs, examining the threats they pose, and surveying current regulation - suggests that the EPA\u27s approach to CAFOs is grossly inadequate. The article argues that the agency, under the Clean Air Act, should regulate the emissions of hydrogen sulfide and ammonia, two pollutants for which factory farms are major sources. This approach is incomplete, however. Pollutant-based regulation is both overbroad in that it will regulate other sources of these pollutants and underbroad because CAFO air pollution includes more than just these pollutants. The EPA should therefore additionally or alternatively rely on a more thorough and flexible pollution source-specific tool, the New Source Performance Standards ( NSPS ). NSPS are analogous to the rigorous source-specific approach used to regulate CAFO water pollution under the Clean Water Act, and will provide a comprehensive antidote to the ills of modern, industrial animal agriculture

Intermittent Presumptive Treatment for Malaria

A better understanding of the pharmacodynamics of intermittent presumptive treatment, says White, will guide more rational policymakin

Cultural contacts and ethnic origins in Viking Age Wales and northern Britain: the case of Albanus, Britain's first inhabitant and Scottish ancestor

Albanus, an eponymous ancestor for the kingdom of Alba, provides an example of the extent to which the creation of an ethnic identity was accompanied by new ideas about origins, which replaced previous accounts. Through an analysis of the Historia Brittonum’s textual tradition and Welsh knowledge of early Roman history and medieval ethnic groups, this article establishes that Albanus was added to the Historia Brittonum in the late ninth or early tenth century as an ancestral figure for the new kingdom of Alba in northern Britain. This was potentially a result of shared political situations in Gwynedd, Alba (formerly Pictland) and Strathclyde in relation to Scandinavian power at this time, which encouraged contacts and the spread of Alba-based ideology to Gwynedd. The later development of this idea and its significance in Alba itself, Geoffrey of Monmouth's account and English claims to supremacy over Scotland are also traced