The role of Volatile Anesthetics in Cardioprotection: a systematic review.

This review evaluates the mechanism of volatile anesthetics as cardioprotective agents in both clinical and laboratory research and furthermore assesses possible cardiac side effects upon usage. Cardiac as well as non-cardiac surgery may evoke perioperative adverse events including: ischemia, diverse arrhythmias and reperfusion injury. As volatile anesthetics have cardiovascular effects that can lead to hypotension, clinicians may choose to administer alternative anesthetics to patients with coronary artery disease, particularly if the patient has severe preoperative ischemia or cardiovascular instability. Increasing preclinical evidence demonstrated that administration of inhaled anesthetics - before and during surgery - reduces the degree of ischemia and reperfusion injury to the heart. Recently, this preclinical data has been implemented clinically, and beneficial effects have been found in some studies of patients undergoing coronary artery bypass graft surgery. Administration of volatile anesthetic gases was protective for patients undergoing cardiac surgery through manipulation of the potassium ATP (KATP) channel, mitochondrial permeability transition pore (mPTP), reactive oxygen species (ROS) production, as well as through cytoprotective Akt and extracellular-signal kinases (ERK) pathways. However, as not all studies have demonstrated improved outcomes, the risks for undesirable hemodynamic effects must be weighed against the possible benefits of using volatile anesthetics as a means to provide cardiac protection in patients with coronary artery disease who are undergoing surgery

Worst Things First: Risk, Information, and Regulatory Structure in Toxic Substances Control

Scientific uncertainty is the characteristic problem of toxic substances control, and regulators lack the resources to resolve or significantly reduce uncertainty across all of the risks they must address. For this reason, the Environmental Protection Agency (EPA) has become intensely interested in setting priorities among its responsibilities. EPA lacks, however, a coherent framework within which to implement its findings. In this Article, Professor Applegate proposes that the current regulatory regime for toxic substances be restructured to emphasize thoughtful priority setting rather than unrealistic risk standards and deadlines. In his view, Congress should provide broad parameters for agency action in particular cases, but should give specific directions to the agency for setting priorities and goals. This recommendation necessarily implicates broader issues of congressional specificity in regulatory statutes, presidential control of administrative agencies, and judicial review in the early phases of the regulatory process. Professor Applegate explores these larger issues as they relate to his proposal and evaluates his proposal\u27s feasibility by comparing it to legislatively mandated planning in forest management

The Temporal Dimension of Land Pollution: Another Perspective on Applying the Breaking the Logjam Principles to Waste Management

Unlike air and water pollution, pollution from dangerous solid and liquid wastes on land remains a relatively concentrated, active hazard for long periods of time. Uncontrolled, land pollution moves through the environment slowly and often without significant diminution of toxicity. Persistence, in fact, is often regarded as the defining quality of dangerous land pollutants. Hazardous and nuclear waste regulation is very much concerned with the problem of maintaining the isolation of solid and liquid materials over decades, centuries, and even millennia, and, the author argues, there is good reason to believe that waste management practices and institutions are not well designed to monitor and safeguard wastes over the time periods during which it remains dangerous. The author discusses how the principles of the Breaking the Logjam project might be applied in crafting solutions to the problems posed by the temporal dimension of hazardous waste management and concludes with the suggestion of an additional principle of institutional learning and the conservation of options: in any long-term effort one must expect that over time we will come to understand a problem better and so develop better ideas for addressing it. But these improvements can only be implemented if the regulatory system is capable of learning and if decisions now leave open options for the future