Anesthetic Considerations for Automated High-Frequency Jet Ventilation During Electromagnetic Navigation Bronchoscopy.

Newly advanced diagnostic bronchoscopic procedures, such as electromagnetic navigation bronchoscopy using navigation system technology (superDimension, Medtronic), provides computed tomography referenced and computerized 3-dimensional imaging. To increase accuracy and higher diagnostic biopsy yield, electromagnetic navigation bronchoscopy necessitates special anesthetic and ventilation techniques providing the interventional pulmonologist minimal respiratory lung motion. This anesthetic meets 2 important goals by limiting almost all interference from diaphragmatic and lung movement while allowing the anesthesia provider to achieve hands-free management. Proposed here is an anesthetic ventilation technique by automated high-frequency jet ventilation (HFJV) via double-lumen micro jet endotracheal tubes. This ventilation technique delivers consistent very low tidal volumes. Automated HFJV provides the pulmonologist the advantage of more accurate navigation and target alignment in this Global Positioning System-guided biopsy procedure. The technique offers essentially no chest motion, without interrupting ventilation. Additionally, HFJV allows the anesthetist better availability to attend to total intravenous anesthesia, adjustments, and interventions. The intention of this article is to detail an anesthetic method that provides a hands-free technique that requires only one anesthesia provider.

Jet Ventilation Decreases Target Motion and Increases Yield of ENB Especially in Lesions With Negative Bronchus Sign.

BACKGROUND: Electromagnetic navigational bronchoscopy (ENB) is used to obtain peripheral lung tissue samples for evaluation and staging of central and peripheral lung lesions. Jet ventilation delivers and maintains a sustained airway pressure at high frequency, chest wall and diaphragmatic movement is drastically reduced compared with traditional ventilation. The current study looks to examine the effectiveness of tissue sampling (diagnostic yield) while using jet ventilation on target-lesion movement when compared with traditional ventilation. METHODS: A total of 36 patients received total intravenous anesthesia with both jet and traditional ventilation during ENB procedure where sensor to lesion displacement was recorded. When planning the ENB procedure, the presence or absence of a viable airway to the lesion was recorded. Sensor to lesion movement was recorded and compared for significance using χ and t tests, utilizing stringent P-values. RESULTS: Overall patients with an airway to the lesion (n=23) had a higher proportion of successful diagnostic biopsies, 83% compared with those patients that lacked an airway to the lesion (n=13) 70% proportion of successful diagnostic biopsies. When using jet ventilation, the chance of nonzero displacement was 8.3% (0.14 mm), regardless of the presence of an airway. Compared with traditional ventilation, the chance of a nonzero displacement between the sensor and target-lesion was 83% (6.4 mm), independent of airway presence to the lesions. CONCLUSION: In patients without an airway, jet ventilation significantly decreased target displacement when compared with traditional ventilation (2 vs. 17 mm). In patients with direct airway to the lesion, jet ventilation did not significantly decrease target displacement when compared with the traditional approach.

Confirmation of and explanations for elevated blood lead and other disorders in children exposed to water disinfection and fluoridation chemicals.

Silicofluorides (SiFs), fluosilicic acid (FSA) and sodium fluosilicate (NaFSA), are used to fluoridate over 90% of US fluoridated municipal water supplies. Living in communities with silicofluoride treated water (SiFW) is associated with two neurotoxic effects: (1) Prevalence of children with elevated blood lead (PbB>10microg/dL) is about double that in non-fluoridated communities (Risk Ratio 2, chi2p<0.01). SiFW is associated with serious corrosion of lead-bearing brass plumbing, producing elevated water lead (PbW) at the faucet. New data refute the long-prevailing belief that PbW contributes little to children's blood lead (PbB), it is likely to contribute 50% or more. (2) SiFW has been shown to interfere with cholinergic function. Unlike the fully ionized state of fluoride (F-) in water treated with sodium fluoride (NaFW), the SiF anion, [SiF6]2- in SiFW releases F- in a complicated dissociation process. Small amounts of incompletely dissociated [SiF6]2- or low molecular weight (LMW) silicic acid (SA) oligomers may remain in SiFW. A German PhD study found that SiFW is a more powerful inhibitor of acetylcholinesterase (AChE) than NaFW. It is proposed here that SiFW induces protein mis-folding via a mechanism that would affect polypeptides in general, and explain dental fluorosis, a tooth enamel defect that is not merely "cosmetic" but a "canary in the mine" foretelling other adverse, albeit subtle, health and behavioral effects. Efforts to refute evidence of such effects are analyzed and rebutted. In 1999 and 2000, senior EPA personnel admitted they knew of no health effects studies of SiFs. In 2002 SiFs were nominated for NTP animal testing. In 2006 an NRC Fluoride Study Committee recommended such studies. It is not known at this writing whether any had begun.

Historical change and evolutionary theory.

Despite advances in fields like genetics, evolutionary psychology, and human behavior and evolution--which generally focus on individual or small group behavior from a biological perspective--evolutionary biology has made little impact on studies of political change and social history. Theories of natural selection often seem inapplicable to human history because our social behavior is embedded in language (which makes possible the concepts of time and social identity on which what we call "history" depends). Peter Corning's Holistic Darwinism reconceptualizes evolutionary biology, making it possible to go beyond the barriers separating the social and natural sciences. Corning focuses on two primary processes: "synergy" (complex multivariate interactions at multiple levels between a species and its environment) and "cybernetics" (the information systems permitting communication between individuals and groups over time). Combining this frame of reference with inclusive fitness theory, it is possible to answer the most important (and puzzling) question in human history: How did a species that lived for millennia in hunter-gatherer bands form centralized states governing large populations of non-kin (including multi-ethnic empires as well as modern nation-states)? The fragility and contemporary ethnic violence in Kenya and the Congo should suffice as evidence that these issues need to be taken seriously. To explain the rise and fall of states as well as changes in human laws and customs--the core of historical research--it is essential to show how the provision of collective goods can overcome the challenge of self-interest and free-riding in some instances, yet fail to do so in others. To this end, it is now possible to consider how a state providing public goods can--under circumstances that often include effective leadership--contribute to enhanced inclusive fitness of virtually all its members. Because social behavior needs to adapt to ecology, but ecological systems are constantly transformed by human technology and social behavior, multilevel evolutionary processes can explain two central features of human history: the rise, transformations, and ultimate fall of centralized governments (the "stuff" of history); and the biological uniqueness of Homo sapiens as the mammalian species that colonized--and became top carnivore--in virtually every habitable environment on the earth's surface. Once scholars admit the necessity of linking processes of natural selection with human transformations of the natural world, it will seem anomalous that it has taken so long to integrate Darwinian biology and the social sciences.