The U.S. government is less than three weeks away from another shutdown over a border wall and it's got me in a ranting mood.
Donald Trump lost the last 35-day battle like the Denver Broncos lose Super Bowls. So before giving him any part of what he wants, Democrats have to stop placating his paranoia while indulging in their own.
It's time to stop being scared of being called "soft on the border."
Then Acting White House Chief of Staff Mick Mulvaney (a.k.a. Ralphie from "Christmas Story" turned mean) said on Face the Nation that he's seen estimates as high as 40 million.
Good lord, this is how we're playing now?
And it's an important point to remember as we move forward.
There are 25,772,342 reasons why nothing — not even a wall — will ever be enough for borderphobes.
The border-wall fight has been interrupted by the Beltway equivalent of a Yule log heating the debate as we fight over whether walls work or if a wall is who we are.
Well, if walls aren't who we are, what's that long, tall construction demarking the not-so-imaginary line on the U.S.-Mexico border? And if walls work, how is it that millions, billions, pick-a-number-of illegal immigrants have made such easy work of it?
There's a very easy solution: Replace 300 miles of old fencing with newfangled Very Tremendous and Powerful™ anti-ram fencing. It's happening anyway. Last year, crews took six months to build 20 miles of new fence in New Mexico so 15 times that would keep the wall crowd happy for another two years.
Unless Trump breaks free from the edicts of talk radio ranters, his time in office will end less than two years from now. And No. 46 will be able to scuttle future expansion. The anti-ram fence would be an upgrade over the cobbled-together monstrosity now dividing California from Baja. In return, extract six years of protections for Dreamers so Trump won't be able to go all Cyd from "Toy Story" on their lives to please his rallies or distract from Robert Mueller's investigation.
Here's why Democrats shouldn't take that deal.
In 2005, Congress approved the bureaucratic monstrosity that is REAL ID and let it stand all through Democratic control of government so Republicans could not call them "soft" on border security. They were angling for a path to citizenship for 12 million illegal immigrants. But that would have to wait.
The fencing exists because in 2006, Congress passed the "Secure Fence Act," which Democrats voted for so no one could call them "soft" on border security. It was a necessary step toward a path to citizenship for the nation's 25,772,342 million illegal immigrants. But that would have to wait.
Then President Barack Obama – so Republicans couldn't call him soft on border security – went on a deportation jag during his eight years in office. The theory went, the Republicans couldn't call him soft on border security and that would pave a path to citizenship for those 987,673,221 illegal immigrants. Yet that would have to wait.
All along the way, Democrats voted to increase the size of Customs and Border Protection and Immigration and Customs Enforcement, so Republicans couldn't call them soft on border security. It was all part of a long-term plan to get a path to citizenship for 266 million illegal immigrants, which would have to wait.
Back in the early 2000s right up until today, there have always been four elements of comprehensive immigration reform: Secure the border through personnel and infrastructure, address the hiring of illegal workers, fix the legal immigration system to recognize reality and grant a path to citizenship to the 8.5 billion illegal immigrants here now, which always has to wait.
Well now the path to citizenship has been reduced to a path to some sort of legal status, but the histrionic Right continues to reset the game as if nothing has been done and the crisis of 2001 remains the crisis of 2019.
The border crisis to certain elements of America is as real as the 12.9 trillion illegals living here now. It is as real as they can imagine it and they will always call the Left "soft."
Those voices dominate the debate by remaining in a constant fit of unreasonableness while Democrats are constantly trying to reason with them.
No crisis exists, but they won't pay attention. Facts don't work. Graphics don't work. Statistics don't work. The only thing that seems to work is House Speaker Nancy Pelosi's high heel on Trump's jugular. So more of that, please.
So what are we trying to stop?
Drugs? Yes, drugs are bad. They are coming through our border. Be clear though: Drug runners aren't smuggling their contraband over and then setting it loose in Ohio, where opiods sprint and attack unsuspecting rural whites. The drug trade is a function of U.S. demand. Fix people wanting a fix, and we'll fix the stream of drugs.
Workers? Just what toxicity are they bringing into the country? None. They are doing work that needs to be done to bring goods to market. Lettuce-cutters and maids have zip to do with the wages in accounts receivable or anywhere else in the middle class. The wealth gap isn't their doing.
Are we trying to stem national population growth? Since when is that a good idea? What growth there is in the economy is aided by population growth. Here in Arizona, we know this because we rely almost exclusively on people moving here to make our state's economy great. Gov. Doug Ducey's budget brags about in-migration. So do conservatives traditionally in the growth/no-growth debate that can animate local government in Arizona.
Also, this state has a lousy social safety net and yet people come here for work. If welfare were the draw to migration, then New York and Massachusetts would be the fastest-growing states in the country. Oh … that's right. Those are Americans. Not … y'know … those people.
What immigration laws are trying to control is the composition – and complexion — of the country. Period. End of story.
The right sells our immigration laws as commercial regulations meant to protect U.S. workers but they have a double standard with other such rules. They don't require absolute compliance with environmental regulations before rolling them back to what they call "reasonable." They don't insist all tax cheats be caught before lowering tax rates. Then again, bad air just turns the sky brown and not our neighbors.
Hey, I don't have the same problem with xenophobia that a lot of people do. Phobias and manias are disorders and not signs that Satan has corrupted the soul. It's just time to stop making room for that particular mental aberration in our sober world.
The only way that the immigration issue will be solved, as far as some are concerned, is if Europe moves to Mexico and then comes north speaking Swedish and smothering herring in chili peppers.
In the meantime, Republicans will always call their opponents "soft on" ... you name it. Don't appease them without a deal that includes a path to something big.
Blake Morlock is an award-winning columnist who worked in daily journalism for nearly 20 years and is a former communications director for the Pima County Democratic Party. Now he's telling you things the Devil won't.
Customs and Border Protection constructed a small-scale mockup of the 'bollard wall' for a photo op in New Mexico in the spring.


The Board's vision, mission and values for Wellington East Girls College can be found in the Charter and Annual Plan. It also details the strategic direction the Board has set for the school. You can also view our Annual report and Analysis of Variance.
The Board generally meets 7x a year in Room 71, on the first Tuesday of the month from 5:30 - 8:30pm. All meetings are open to the public and the minutes and associated reports from the meetings are available through the school office on request.
The community representatives on the WEGC Board of Trustees are elected every three years. The current trustees were elected in June 2016 and the next election will be held in June 2019. Students elect a Student Trustee annually. Our Maori Community Representative is elected by Te Whanau Tutahi and our past pupil representative is elected from the Once Were Easters Community, with our Pasifica Parents Group co-opting a Trustee.


A jewel of a philosophical introduction to formal logic. It is logically sound, philosophically sophisticated, and pedagogically thoughtful.
In this book, one gets two things: an informal approach to logic for those who have been terrified by any formula they encountered, and a mathematical presentation that gives an idea of the rigor and beauty of logic as a structural science.
The purchase of this book is strongly suggested to every reader in search of an introduction, not only for substantive . . . but also for stylistic reasons. [Hoyningen-Huene] writes extremely well and at times even quite wittily, which is all too rare in (German) introductory textbooks.
Deserves to become a standard work.


FIM Your Way to Multiple Colas!
So what exactly is FIMing?
FIMing is an easy way for growers to dramatically increase their yields while also making the plant more manageable for limited spaces.
I know that sounds too good to be true, but it's definitely the case!
The problem with the natural growth pattern of the cannabis plant is that it tends to be shaped like a Christmas tree. This is inefficient, and not very good for indoor growing since the main cola will typically receive much more light than the rest of the plant.
When you FIM your marijuana plant, it grows 4 main colas instead of one (this is where the extra yields come from). Next, the grower would typically tie those 4 colas down a bit to help force the plant into having a flat canopy. This allows you to lower your lights and makes it so most of the plant is receiving a higher overall amount of light.
Whenever you see a picture of a marijuana plant with multiple large buds that are at a similar height, the grower almost certainly used FIMing or another technique called 'Topping' to achieve this.
In tiny stealth microgrows, there isn't always room for an effective FIM.
Your plant will get close to skipping the vegetative stage, and that's the only time to FIM.
I know that sounds like a joke (it was, a bit), but some places have limits to the amount of weed you can possess, and FIMing could actually get you in more trouble in some cases because of all the extra buds you will produce.
Topping is a technique similar to FIMing, wherein you cut a young cannabis plant to create extra colas. However, unlike FIMing, the Topping technique produces 2 colas instead of 4.
If you would like to learn how to Top your plant, check out our Topping tutorial on GrowWeedEasy.com.
This article is about FIMing, and does not go in depth about Topping. FIMing can be a superior choice in many cases. Why FIM instead of Top?
When you FIM your cannabis, you only need to pinch the newest growth, which doesn't really stress your plant much. With Topping, totally removing the newest growth is necessary, which is a stressful event for young marijuana plants.
FIMing barely slows down plant growth; Topping slows down plant growth considerably for a short period.
When you FIM your plant, you will see recovery move at a much higher speed than with Topping. When I FIM one of my plants at the beginning of the day, I can usually already see it adjusting by bedtime.
FIMing creates 4 main colas at once, while Topping only creates 2.
Double the main colas…no explanation needed!
It's easy to FIM a plant more than once!
I wouldn't necessarily advise this tactic for growers who are new to FIMing, but definitely keep this in mind! You can FIM your cannabis plant more than once, and with some Low Stress Training, you get plants with dozens of colas like the one to the right.
Nebula says – In my experience, FIMing causes my plants to grow bushier than topping, even when I do it to the same strain. I will choose to top marijuana plants when I'm trying to achieve a specific shape that requires a complete split of the cola, like main-lining.
Sirius says – Although this last point is anecdotal evidence, I have to say that I've experienced the same thing. FIMing causes plants to dramatically "bush out" more than topping.
Pinch vs. Cut – What method do we use to remove/damage the new growth and force new colas?
Amount – How much do I pinch/cut?
Timing – At what point in the plants development do we FIM?
When you're FIMing your plant, you have the option of either cutting off a piece of the new growth or pinching it. Both have the potential to work equally well at forcing the plant to create new colas. However, I strongly recommend pinching your plant instead of cutting it since pinching leaves more room for error.
In my last grow, I saw a few weird looking leaves that appeared to be chewed-up. Upon further examination, and judging by where I found them, I determined that they were actually pinched leaves! The plant kept those leaves, and used them to make energy all the way til harvest!
When FIMing your plants, the amount you'll want to pinch is actually quite small. You're basically pinching the tips of the leaves of the newest growth on the main cola that hasn't 'stretched-out' yet. See the picture further down for a good example.
The first pinch or cut in a FIM should happen when your plant has 3-5 nodes (or sets of leaves) in total. Once that initial FIM has been completed and the plant has recovered, a grower can use his/her discretion to determine when to FIM again as it's mostly based on plant health and desired shape. Just remember to make sure your plant looks healthy and recovered before FIMing again!
Now that you know the basics of FIMing, take a look at some of these other growing techniques. I use these same techniques (in combination with FIMing) to maximize the amount of weed I get per harvest while keeping the total amount of work low.
There are MANY other techniques you can use in combination with FIMing to increase your yields, but in my opinion, these two in particular (with FIM) offer the highest return on investment.
Low Stress Training – Train your plants to grow as a flat surface; easily double your harvest.
Defoliation – Advanced, but well worth it. More buds exposed to light means more, bigger buds!
FIMing is such a versatile technique, that pretty much any marijuana strain is a perfect candidate for it!
However, some strains are experts at recovering and getting HUGE RETURNS on growth control techniques!
These are a few strains I've grown personally that each gave me at least 6 ounces or dried & cured, super sticky bud per plant.
Sirius: This plant effortlessly bends, breaks, recovers, and flourishes. That plus a naturally high yield, pungent diesel smell, and high potency make this a Aurora a must have. Seriously, try growing it!
Sirius: Funky smell, crazy potency, and super resilience are all attributes of the Pure Power Plant. I've once cut off the top 4 nodes of this strain in a panic(it got too big, too fast). This plant totally healed its stem in 2 days and never stopped growing the whole time.
Sirius: Wonder Woman has recently become one of my favorite strains. You can FIM it in the morning and watch it recover before the day ends. That combined with crazy fast growth patterns, the highest yields on this list, and a nose-wrinkling diesel smell make this strains name remarkably accurate.


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Loddon is a small market town and electoral ward about 12 miles (19 km) southeast of Norwich on the River Chet, a tributary of the River Yare within The Broads in Norfolk, England. The name "Loddon" is thought to mean muddy river in Celtic in reference to the Chet.
The earliest written mention of Loddon (Lodne) is in the will of Ælfric Modercope written in 1042 or 1043. In the will Ælfric split his land holdings in Loddon, Bergh Apton and Barton between the Bishops of Bury, Ely and St Benet of Holme. Ælfric held 450 acres (1.8 km2) of land in Loddon and was by far the biggest landowner. His manor house is believed to have been close by the church overlooking the river and the fields are known as Manor Yards.
The Parish Council adopted Ælfric for Loddon's town sign in 1961 and the bronze statue still stands on Farthing Green.
Although Loddon and Chedgrave have been flooded many times through history, the worst or at least the best documented occasions were in August 1912 and September 1968.
At about midnight on 27 August 1912 a portion of the roadway was washed away and soon afterwards part of the bridge caved in. The footbridge across the river between the two industrial sites disappeared downstream. The mill was in great jeopardy and forty men worked hard to preserve as much of the road as possible. The piling and the banks of the Chet were washed away and some of the wherries broke their moorings.
On 12 September 1968 a great storm followed a very wet summer, so when the heavy rain came that night the ground was too waterlogged to let the rain drain away. According to the Eastern Daily Press it had been Norfolk's wettest ever September day. The torrential rain was accompanied by thunder and lightning and many roads were inches deep in water.
Loddon has many fine buildings; from the 15th-century parish church of Holy Trinity, through the 18th-century "Loddon House" (originally a mental institution), to "Farthing Green House", which is a good example of Georgian architecture.
The town centre of Loddon, a designated conservation area, is dominated by the Holy Trinity Church dates from 1490 by Sir James Hobart who lived at Hales Hall, and was Attorney General to King Henry VII. The outside of the building is faced with flintwork and the interior contains a hammerbeam roof, Jacobean pulpit, early Edwardian pews with carved poppy-head ends, several table-top tombs, an ancient poor-box and a panel on the painted rood screen which shows William of Norwich, a boy martyr who is reputed to have been crucified in the 12th century. There is also a medieval baptismal font set high on three steps, however despite its shaft and bowl were originally carved and painted, they were defaced during periods of iconoclasm.
The church is said to have possibly replaced an earlier Norman church and an even older one built by St Felix, Bishop of East Anglia, about 630.
There was a mill mentioned at Loddon in the Domesday Book and a watermill at Chedgrave in the early 1330s, but there is no evidence for the sites of these mills. The present mill, Loddon watermill near the town centre which is no longer functioning, was built in the 18th century with the river diverted to run underneath it. Loddon watermill was sometimes known as Chedgrave mill and is one of the earliest recorded buildings in the town. It was built of weatherboard with a pantiled roof and was situated quite close to the centre of the town. The mill pool was never very big, but was apparently a widened and deepened Y shaped section of river up stream of the mill. This produced adequate power for the miller to meet the needs of the local farmers and villagers. The mill still retains 19th-century milling equipment.
When the mill was built it was found that the best position for it involved diverting the river Chet to the south of its natural course. This involved considerable effort and expense and in times of severe flood the river attempts to revert to its original channel.
According to the indenture dated 25 January 1870 James Cole Copeman conveyed to The Loddon Town Hall Company (Limited), for the sum for £30, the site on which to build the Town Hall. The actual building of the Town Hall must have been started before the conveyance was drawn up because the Petty Sessions were held in the Town Hall for the first time on Wednesday 10 August 1870.
The red brick building was very ornate, as was the style of many Victorian architects. The oldest photograph available shows much fancy brickwork and ornamentation. A great deal of this has succumbed to time and either fallen or been removed for safety. However, the 'Elizabethan style' windows are virtually intact. The building is on the buildings at risk register.
There are many shops and services in central Loddon. These include; two tearooms, a Co-op food store, two newsagents, butcher, various take-aways such as a fish and chip shop and a Chinese take-away, plus an award-winning Bangladeshi restaurant.
There is also a movie rental store, a beauty salon, estate agency, Boots the Chemist, Doctor and Dental surgeries, a garden shop, a veterinarian, a bank, a post office, a dentist, a library, a charity shop, an optician and a hardware store. There are three public houses in central Loddon: The Angel, The Swan and The King's Head. The Swan has recently received a second AA rosette. Loddon Water mill is now a complementary health practice.
Loddon is home to three popular schools; Loddon Infant and Nursery, Loddon Junior and Hobart High School, one of the few schools in the country to have a 'classroom of the future'. This futuristic classroom lasted approximately 2 months before all the tablets had to be replaced, much to the pupils' dismay. There is also Loddon nursery school education. An independent school Langley School, lies just to the North of Loddon at Langley Park.
The first records about schooling in Loddon mention the school in what is now called he Priest's room in the Holy Trinity Church in 1781. The 19th century saw considerable changes, including a rise in the population and consequently in the number of children. It also saw a rise in the popularity of nonconformist religions and a certain amount of competition in the provision of education for the young.
As well as the established schools there were several private schools in the village at one time or another. The 1851/61/71 census figures show a private school on the east side of Bridge Street.
By 1856 it was decided to build a new school in Loddon for 180 pupils on the site of the old guildhall on Church Plain. Two-thirds of the cost was to come from the Town Estates, which was revenue derived from the renting of Town Farm and other town lands. The rest came from public subscription and an appeal was set up to raise money from the community. The eventual result was a flint faced Gothic Revival building which is still used today as the Loddon Branch Library.
The school term started in 1858 (although the building does not appear to have been finished until 1859), when 99 children from 3–13 years old were entered. Many would not stay at school long, nor attend regularly as the need to supplement the family income when possible could not be ignored. Many children had a long walk to school, which could be impossible in bad weather. This building was used as a school until 1969.
Previous industries included egg packing and corn grinding. Loddon also had a gas and brick works.
Nowadays the north of the town has many boatyards situated on the River Chet. These provide yachtsmen and hire boat crews during the season and together with the boat-building and letting yards, make an important contribution to the economy of the town.
Loddon also has a small industrial area situated at the south of the town. Engineering and other industries sited on this industrial estate provide employment for local people. However, Express Plastics, one of the major employers has recently moved to Beccles. The site is to become a small housing estate. A famous East Anglian company Anglian Bus started in Loddon in 1986 before expansion resulted in moving to Beccles.
The Loddon and District Business Association, which was formed in 2011, represents all businesses in the area both micro and multi million pound industry. They work together to enhance the community life and ensure that growth increases and the facilities needed in a community of this size are met.


While the impact of the storm is still uncertain, the National Weather Service on Friday predicted some parts of Alamance and Orange counties could see up to 12 inches of snow and Durham could see 8 inches. Further east, Raleigh could see 4 to 6 inches of snow.
The precipitation is expected to start as soon as late Saturday and continue into Monday evening.
Snow, sleet and ice could create hazardous driving conditions during that time, according to the weather service.
"Travel is going to be bad," said Ryan Ellis, a meteorologist with the National Weather Service in Raleigh.
The expected storm prompted Amtrak to cancel all of its trains in North Carolina on Sunday. This includes all three Piedmont trains between Raleigh and Charlotte and the Carolinian between Charlotte and New York City.
In addition, the northbound Silver Star between Miami and New York, which stops in Raleigh and Cary, is canceled Saturday and Sunday, while the southbound Silver Star is canceled Sunday and Monday.
"It looks like there will be a wide range of snowfall out there," he said.
In western North Carolina, the storm is expected to drop up to 7 inches of snow and ice on the Charlotte area, according to the National Weather Service.
The Weather Channel's Jim Cantore on Friday was headed to Asheville, which could see more than a foot of snow, the Charlotte Observer reported.
In the Triangle, crews were treating roads Friday in anticipation of snow and ice.
The weather service predicted Friday that Durham and Orange counties could see 0.05 inch of ice accumulation. Raleigh could see 0.01 inch.
Durham sent five trucks out during the morning hours to spread brine, said Marvin Williams, the city's Public Works director.
The city has mounted plows and spreaders on more than 30 trucks, and crews will continue their work before and after the storm, Williams said.
But Williams warned that some roads might not be cleared quickly, despite the preparations. It will depend on the type of precipitation and the temperature.
Temperatures in the Triangle are expected to climb into the low- to mid-40s Saturday, with an overnight low of 32. Sunday should be colder, with a high of 35 and an overnight low of 31.
Overnight lows are expected to drop into the 20s starting Monday.
In Raleigh, crews were on standby Friday to treat roads, said spokesman John Boyette.
There was a sense of urgency in Durham, where many people spent their lunch break Friday stocking up on groceries in hopes of avoiding the rush for bread and milk. Some shoppers at a local Food Lion said they weren't just worried about the roadways and losing power, but also the possibility of falling trees.
"We have a big tree in front of my mom's house," said Ashanta Scarlett, 37, as she unloaded her cart filled with enough supplies to feed her mother, daughter and three nieces and nephews during the storm.
Others said they were ready, especially since they got plenty of storm-preparation practice for hurricanes in September and October.
The last winter storm that produced significant snow in the Triangle started on Christmas Day in 2010 and continued the next day, according to the National Weather Service. About 7.1 inches of snow fell during the storm.


text:
About the Sunshine Portal
Launch the Portal
The New Mexico Sunshine Portal
The Sunshine Portal is the official transparency and accountability portal for New Mexico state government. This is your window into government spending, budgets, revenues, employees, contracts and more.
Explore the Sunshine Portal
To jump-start your search, click on any of the icons below, or use the menu at the top of the page.
The Budget page provides information regarding the Approved Budget, Adjusted Budget, Total Expenditures, and the Budget Balance for the State.
Cash Balances
The Cash Balances page provides agency claim balances as extracted from the New Mexico Statewide Human Resources, Accounting, and Management Reporting System (SHARE), the State financial system.
Annual Fiscal Summary
The Annual Fiscal Summary page is a repository of the State of New Mexico Comprehensive Annual Financial Report (CAFR).
The Investment Accounts page is a repository of the Investment Holdings Report issued by the State Investment Council (SIC).
The Revenue page accounts for all monies collected and reported by the Taxation and Revenue Department (TRD).
The Employees page provides information about state employee's extracted from the New Mexico's financial system SHARE, (Statewide Human Resources, Accounting, and Management Reporting System).
State Land Contracts
The State Land Contracts page is a repository of the public land leases, issued by the Land Commissioner, for grazing, agriculture, commercial use, oil and gas drilling, mining, and other surface and subsurface activities.
The Purchases page provides information about state purchase orders (PO) updated monthly from the Statewide Human Resources, Accounting, and Management Reporting System (SHARE).
The Capital Projects page provides the project name and the amount appropriated to the project for the current year.
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The New Mexico Sunshine Portal was created pursuant to the Sunshine Portal Transparency Act, NMSA 10-16D-1 et. seq, to provide public access to state government budgets, expenditures, revenue and specific public school district information, and to make such information accessible on one central website. The Sunshine Portal Transparency Act was enacted by the Fiftieth Legislature, First Session and signed into law by Governor Susana Martinez on March 30, 2011. The web site will be updated monthly, the currency of the data will be published on each information panel.
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text:
Peggy Hubbard
stated on August 20, 2020 in a Facebook post:
"The DNC omitted 'one nation under God' from the Pledge of Allegiance."
Grandchildren of Democratic presidential candidate Joe Biden lead the Pledge of Allegiance during the first night of the Democratic National Convention on Aug. 17, 2020. (DNC via AP)
By Daniel Funke August 21, 2020
The DNC did not omit 'one nation under God' from the Pledge of Allegiance
Some caucuses omitted "under God" from the Pledge of Allegiance during Democratic National Convention meetings. But the line was not excluded from any of the convention's primetime spots.
A former U.S. senatorial candidate says the virtual Democratic National Convention left the word God out of the nation's most famous and solemn oath.
"The DNC omitted 'one nation under God' from the Pledge of Allegiance," said Peggy Hubbard, who lost Illinois' Republican primary election in March, in an Aug. 20 Facebook post.
Hubbard's post was flagged as part of Facebook's efforts to combat false news and misinformation on its News Feed. (Read more about our partnership with Facebook.) It's similar to other claims we've seen on Facebook, so we wanted to check it out.
Some Democratic caucus members omitted "one nation under God" from the Pledge of Allegiance during DNC meetings. But the line was not excluded from any of the convention's primetime televised spots. On each night of the DNC, "under God" was included in the Pledge of Allegiance.
Conservative news outlets like the Washington Examiner have pointed out that, during the livestreamed Muslim Delegates Assembly on Aug. 18, one participant omitted "under God" from the Pledge. A delegate at an Aug. 18 LGBTQ Caucus meeting also abstained from saying it.
stated on January 11, 2022 in a Facebook post
"The CDC director just said that 75% of 'Covid deaths' occurred in people with at least four comorbidities."
By Samantha Putterman • January 12, 2022
There were 30 caucus and council meetings during the DNC, according to the party's website. They were not the scripted, highly produced sessions that aired on television.
The Pledge of Allegiance has existed in some form since the late 19th century, but in 1954, President Dwight Eisenhower signed a bill that officially added the words "under God." There is a long history of legal challenges and religious objections to the inclusion of the phrase, particularly in public schools, where students are often asked to say the pledge.
We reached out to Hubbard for a comment, but we haven't heard back.
Her Facebook post contains an element of truth but ignores critical facts that would give a different impression. We rate it Mostly False.
Correction, Aug. 24, 2020: A previous version of this article incorrectly stated that, on the first night of the DNC, participants sang the "Star-Spangled Banner" instead of saying the Pledge of Allegiance. In fact, the pledge was included on the first night.
Ballotpedia, Peggy Hubbard
Democratic National Committee, "DNC Announces Caucuses and Councils for the Democratic National Convention," Aug. 16, 2020
Democratic National Convention, 08.18 LGBTQ Caucus
Democratic National Convention, 08.18 Muslim Delegates Assembly
Facebook post, Aug. 18, 2020
The National Constitution Center, "The history of legal challenges to the Pledge of Allegiance," June 14, 2020
The University of Chicago Law School, "'Under God:' The Pledge, Present and Future," Oct. 30, 2008
The Washington Examiner, "Democratic convention caucuses omit 'under God' while reciting Pledge of Allegiance," Aug. 20, 2020
YouTube video from the Democratic National Convention, Aug. 17, 2020
stated on January 16, 2022 in an interview on NBC's "Meet the Press":
"People are 7% poorer now because of Biden inflation."
By Louis Jacobson • January 20, 2022
stated on January 18, 2022 in a post:
"Supreme Court Justice Sonia Sotomayor tests positive for COVID-19 despite triple vaccination, diligent masking and working from home."
stated on January 19, 2022 in a news conference:
"This country's working people actually got a raise."
By Jon Greenberg • January 20, 2022
"There (are) over 800 prison camps in the United States, all fully operational and ready to receive prisoners. They are all staffed and even surrounded by full-time guards, but they are all empty. These camps are to be operated by FEMA."
stated on January 17, 2022 in a Facebook post:
Rabbi taken hostage in Texas synagogue is "anti-Zionist" who may have known gunman.
Photo shows Jeffrey Epstein and Kamala Harris posing together.
stated on January 16, 2022 in a tweet:
Novak Djokovic is the first professional athlete to be banned from a major sporting event for "not taking drugs."
stated on December 12, 2021 in an Instagram post:
"Blue Cross Blue Shield pays your doctor a $40,000 bonus for fully vaccinating at least 100 patients under the age of two."
By Vivian Lam • January 19, 2022
"DirecTV cancels OAN after Joe Biden orders media outlets and tech giants to banish voices that deviate from the regime's official narrative."
"India has nearly 1.4 billion citizens. Nearly 800 million of them live in extreme poverty — less than $1.90 per day. Yet EVERY singly (sic) Indian citizen is required to have a valid form of ID to vote in national elections."


Funding Resources – There are many foundations and groups that fund cultural heritage and Native place names projects.
Alaska Humanities Forum awards grants and mini-grants to non-profits, individuals and ad hoc organizations.
Funding Tips – We've compiled a list of helpful tips to consider as you design your project and look for funding.
Getting Started – Examples of recent Native place names projects in Bristol Bay.
Decolonial Atlas – Includes a section for maps labeled with indigenous place names.


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This can not be true, Isn't it? It does not make any sense? How can anyone be fearful of success? Because everyone loves to have success in their lives.
During times of failure, we crave for that one good opportunity which can erase our bad history until then and put us on to the platform of success. That is the intensity with which we seek success. Fear of success is more common than we think. No person feels recognized until they establish their worth. This may sound like an outdated civilizational rule. Success makes us desirable in life.
On the road to success, we plan, contemplate and wonder how life transforms for good. Before we act, there is something that needs to be dealt with. We do not know it yet. The need for a final trigger to be ready for the battle ahead. The road to success is not smooth, a lot needs to be endured. This not-so-easy path may put us in doubt. Is it necessary to really adopt this plan and commit to it? What if we do it without much effort and succeed? Are we worth this success? This simple self-doubt feels very valid.
This doubt arises from the thoughts of not being able to sustain the success. Are we well prepared for everything that comes with success? We don't like to overlooked by others who have already made it. We feel that we should gain knowledge of every little thing that this position of success entails. Strangely, that doesn't help. These doubts will only prevent us from acting now. The further it is delayed, the tougher it gets for us. We are better than what we think of ourselves.
With a relaxed mind, visualize your goals, take an assertive step and experience true success. Do not let the anxiety take over your mind. Trust your ability to handle all situations. You will succeed in time.


This article offers systematic view of a process of identification of security threats and, subsequently, their use in the making of strategic documents, notably the Security Strategy of the Czech Republic. It is not the aim of the authors to name or define such threats, but to present the process itself. It is paramount to any credible security strategy that it deals with the threat identification in the most precise fashion. The authors take reservations against the "catalogue" approach and claim the processes of prioritization and categorization to be essential for any policies derived from the security strategy, especially in times of economic need. It is also the 2011 final paper of the project "Trends, Risks, and Scenarios of the Security Developments in the World, Europe, and the Czech Republic – Impacts on the Policy and Security System of the Czech Republic" (TRS / VG20102013009).
The beginning of the second decade of 21st century is tied with distinctive dynamics and changes in global security environment. Among those changes belong security re-orientations of the United States from Transatlantic area to that of Pacific, East and Southeast Asia resulting from a new American military strategy proclaimed in January 2012. The US drew down from Iraq and Afghanistan, political and security movement in Arab world, after decades of "status quo" were awaking. The author concludes that the EU should be prepared for negative scenarios in the development of security situation, or to have at its disposal effective police and military forces with proper humanitarian background to counter possible instability, e.g. massive migration influxes, economy disorders.
The study explores the possibilities of building a comprehensive security management system for the Czech Republic. The concept of the comprehensive security management system is based on the premise that to cope with a broad range of security challenges we need a state-controlled, sufficiently centralized yet flexible security system that will, at all its levels, guarantee coordinated action to implement the required measures, while leaving enough scope for solving security problems at the lowest possible level. In drafting the concept of the system, the main emphasis so far has been on building its formal structure and elements (which reflects the realities of the Czech security environment). Less attention has been paid to linking the elements and to the management process itself, i. e. to assessing how the system would behave in operation and how effectively it can fulfill the stated aims. While the concept of the system as well as its actors have been defined only in general terms, a critical analysis has revealed a number of problems even at this level: in the drafting and implementation of security documents, in adopting strategic decisions concerning security and in the operation of key security departments. The article also discusses the present-day development of the Czech security system and the problems of its operation.
International relations are in the midst of tremendous transformation; to the distribution of political, economic and military power. This work traces such changes by looking at a wide series of indicators and seeks to explain - in a predictive manner - how the international environment will settle in the decades to come. Certainly, such predictive work is not meant to provide a stubbornly defended "truth." Instead, this work should be read as a contribution to international relations scholarship which attempts to capture trends so that adequate policies may be advanced.
This strategy has received substantial attention and triggered the discussion about the future of U.S. security policy and America's role in the world. The article argues that American strategy is often misunderstood, particularly in the Czech environment. Obama's defence strategy and its foundations must be explained through the lenses of the balance of threats developed by Stephen Walt. Washington is balancing what it perceives to be the greatest threat to American leadership in the world. Threats are presented by emerging power of People's China, the situation in Middle East. Europe is not less important; it is still an important American ally.


Sue's little helpers - Lets talk Turkey!
From cooking instructions to our most popular frequently asked question. You will find the below.
What should I get if most of my family like breast meat?
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For whole Turkeys you will need approximately 500-600g/1lb per serving.
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2004-09-07 Application filed by Tehrani Fleur T. filed Critical Tehrani Fleur T.
Method and apparatus for controlling a ventilator are described. The invention can be used to control mechanical ventilators as well as respiratory assist devices such as CPAP machines. The apparatus receives input data indicative of patient's oxygen level. A controller determines PEEP, or CPAP, and FIO2, on the basis of data indicative of the patient's oxygen level. In an alternative embodiment, the apparatus further receives input data indicative of patient's carbon dioxide levels, respiratory elastance and airway resistance, and barometric pressure. The controller further utilizes the said input data to determine the optimal values of tidal volume and breathing frequency for a next breath of the patient, and uses the respiratory elastance and airway resistance data to determine any necessary adjustments in the I:E ratio. The controller also applies safety rules, detects and corrects artifacts, and generates warning signals when needed.
This application claims the benefit of U.S. provisional patent application No. 60/481,693, filed Nov. 21, 2003, the entire contents of which are incorporated herein by reference. This application is related to U.S. Pat. No. 4,986,268 entitled "Method and Apparatus for Controlling an Artificial Respirator," the disclosure of which is incorporated by reference.
The present invention relates to a method and apparatus for controlling a ventilator such as a mechanical ventilator (i.e. an artificial respirator) or a respiratory assist device. In particular, the present invention relates to a method and apparatus for controlling a ventilator based on the measured levels of oxygen of the patient on the ventilator, as well as other physical conditions of the patient.
Mechanical ventilators and other respiratory assist devices are extensively used to treat and manage all patient populations. In the past few decades, there have been significant changes in the features offered by the ventilators and they have become increasingly responsive to individual patient needs. However, despite much advancement in these devices, most ventilators used today are still mainly open-loop controlled devices and their added features have to some extent contributed to their complexity. The clinicians are required to make many important selections among the wide range of options available in advanced mechanical ventilators. Optimal adjustment of these machines oftentimes requires in depth knowledge about the ventilator along-with thorough review of the patient's status and his/her underlying illness. These adjustments are particularly cumbersome and frequent in more fragile and less medically stable patients.
Some of the prior art on this subject is focused on controlling the patient's oxygenation, and some is intended to automatically control the breathing frequency and tidal volume. The systems intended for controlling only the oxygen level of the patient on the ventilator, either do not provide the automation of all factors that affect oxygenation and/or they do not provide a reliable and sufficiently robust response against oxygen disturbances.
In one embodiment, the present invention describes a method and apparatus that can reliably and robustly control PEEP (or CPAP), and FIO2. These are novel features which significantly improve the oxygenation of patients during ventilatory therapy provided by mechanical ventilators as well as respiratory devices such as CPAP machines.
Furthermore, in a more elaborate embodiment of the invention, in addition to PEEP (or CPAP) and FIO2, the I:E ratio of the patient can be automatically adjusted and by further inclusion of the features of U.S. Pat. No. 4,986,268, the breathing frequency, and tidal volume can be automatically controlled in mechanical ventilation. Application of these features results in a significantly more effective and optimal treatment to the patient based on his/her conditions and requirements, in total or assist ventilatory therapy.
A method and apparatus for controlling a ventilator includes first means receiving at least input data indicative of the patient's measured oxygen levels, and in a more elaborate embodiment of the invention, the first means also receives respiratory mechanics and/or pressure-volume data, as well as data indicative of measured carbon dioxide levels of the patient. The first means which preferably comprises a programmable microprocessor, is controlled by a software algorithm to operate on the input data, and to provide digital output data to control the ventilator and the gas mixer of the ventilator. The software algorithm is divided into two control programs. One control program which can either be used by itself or along with the other program, is designed to automatically adjust FIO2 and PEEP (or CPAP), based on at least the measured oxygen levels of the patient. The control program also operates on data from a pressure volume (PV) monitor/analyzer to set the initial PEEP value in certain groups of respiratory patients. The processing means detects hazardous conditions based on the input data and/or artifacts, replaces and/or corrects the measurement artifacts, and instructs generation of appropriate warning signals. The other control program, most of which is described in U.S. Pat. No. 4,986,268, is designed to control the frequency and ventilation for a next breath of the patient on the ventilator based on at least data indicative of measured CO2 and O2 levels of the patient, barometric pressure (as a reference pressure), and respiratory elastance and airway resistance (respiratory mechanics) data; and to make necessary adjustments in the I:E ratio based on the patient's respiratory mechanics data. The output data from the 1st means indicative of PEEP (or CPAP), FIO2, the adjustment in the I:E ratio, breathing frequency, and ventilation, and status of alarms are transmitted to a Signal Generator which is equipped with converters and/or other electronic components to generate the control and appropriate warning signals. The control signals for the breathing frequency, ventilation, PEEP (or CPAP), and the adjustment in the I:E ratio are supplied to the ventilator. The control signal for FIO2 is supplied to a mixer regulator unit which adjusts the concentration of oxygen added to the inhalation gas in the gas mixer of the ventilator. Based on the instructions from the 1st means, the alarm circuit generates appropriate warning signals when needed.
FIGS. 1-4 illustrate a preferred embodiment of the present invention. However, it is understood that this invention is not limited to the precise arrangements shown in the figures and can be embodied in other arrangements without deviating from the scope of the invention.
FIG. 1 is a block diagram of a mechanical ventilator and the control apparatus according to an alternative embodiment of the invention.
FIGS. 2 a-2 c show the flow chart of a software algorithm that also incorporates the control technique described in U.S. Pat. No. 4,986,268, to automatically control breathing frequency, tidal volume, and the adjustment in the I:E ratio of the patient on the ventilator, according to a preferred method of the present invention.
FIGS. 3 a-3 i show the flow chart of a software algorithm to automatically control PEEP (or CPAP) and FIO2 according to a preferred method of the present invention.
FIG. 4 shows a preferred detailed schematic diagram of a Signal Generator and an Alarm Circuit, for use in a preferred practice of the present invention.
1—The term "ventilator" refers to a device which is used to provide total or assist ventilatory treatment to patients, and includes mechanical ventilators (i.e. artificial respirators) or CPAP (Continuous Positive Airway Pressure) machines.
2—The term "PEEP" represents "Positive End-Expiratory Pressure" and is interchangeable with the term "CPAP," which represents "Continuous Positive Airway Pressure," for example, when assist ventilation is provided to spontaneously breathing subjects.
FIG. 1 shows a block diagram according to an alternative practice of the present invention. The digital processor 10 includes a programmable controller coupled to receive the outputs of 8 bit A/D converters 12, 14 and 16 as shown. The A/D converters 18 and 20 are each a single 8 bit A/D converter. The A/D converter unit 22 is an A/D board containing three 8 bit A/D converters. The inputs 24, 26, and 28 of the A/Ds are from an oxygen sensor, preferably a pulse oximeter, 30, a CO2 sensor, such as a transcutaneous monitor or preferably a capnograph, 32, and a lung mechanics calculator and PV monitor, 34. The outputs 24, and 26 are each a single analog signal while the output 28 represents 3 analog signals; 1—representing respiratory elastance, 2—representing respiratory airway resistance (air viscosity factor in the lungs), and 3—representing the lower inflection point on the inspiratory or expiratory PV curve of the patient, or alternatively, the measured intrinsic PEEP (PEEPi) of the patient on the ventilator. The inputs to the oxygen sensor and the carbon dioxide sensor are respectively shown at 40 and 42 coming from the patient. The input 40 is preferably the arterial hemoglobin oxygen saturation data and the input to the CO2 sensor shown at 42 is preferably the exhaled gas from the patient from which the end-tidal CO2 concentration or the end-tidal partial pressure of CO2 is determined by the sensor. The lung mechanics calculator and PV monitor, 34, receives data from the mechanical ventilator shown at 56, or from the patient through the ventilator circuit, on the line illustrated at 36 and communicates back to the ventilator as shown at 38. The digital processor's outputs shown at 44 are applied to a Signal Generator Circuit, illustrated at 46. The Signal Generator Circuit sends alarm instruction signals 52 to the alarm circuit 54.
The mechanical ventilator 56 receives the control signals 48 from the Signal Generator Circuit 46. These consist of signals to control PEEP, breathing frequency, tidal volume, and the adjustment in the I:E ratio of the patient. A Mixer Regulator circuit 58, receives control signals to adjust FIO2, 50, from the Signal Generator Circuit 46. An oxygen air mixer 62 receives the adjusted output signal 60 from the Mixer Regulator 58. The concentration of oxygen in the mixer is thereby adjusted by mixing the determined concentration of oxygen 66 coming from the oxygen supply 70 and that of air 64 coming from the air compressor 68. The enriched oxygenated air 72 from the mixer is provided to the ventilator 56 which delivers it to the patient at 74.
Where VC is the ratio of alveolar ventilation as the net effect of CO2 to the resting value of ventilation, C1 is the sensitivity factor of the controller to CO2 (e.g., C1=0.405) and C2 is a constant (e.g., C2=14.88).
Where VO is the ratio of alveolar ventilation as the net effect of oxygen to the resting value of ventilation. It is recognized that the above equations are based on the use of a capnograph and a pulse oximeter to measure the carbon dioxide and oxygen levels of the patient respectively. If other measurement techniques are utilized to provide data indicative of said levels, then other alternative equations may be used to determine the required ventilation for the patient, without deviating from the scope and the essential attributes of the invention.
In these equations, VD is the patient's dead space in liters, VED is the equipment dead space due to the tubes and connections, and VDt is the total dead space. It should be noted that the constant factors in these equations are based on measured experimental values for adults and can therefore be different for individual patients. Also, for other patient populations, they need to be adjusted. For example the constant factor of 0.1587 should change to a much smaller value for infants (e.g., 2.28×10−3). In the next step at 128, data indicative of barometric pressure and the patient's airway resistance (or the air viscosity factor in the lungs) and respiratory elastance are read from the input ports. The barometric pressure data which is affected mostly by the altitude, is used as a reference pressure (for the purpose of calibration) in the invention.
Where VE represents total minute ventilation in liters/minute and VT is tidal volume in liters. In the next step at 134, additional safety rules are applied. If breathing frequency, f, tidal volume, VT, or minute ventilation are not within prescribed safe ranges, their values are limited and adjusted.
Where τ is the respiratory time constant and is equal to K″/K′. If in step 136, the breathing frequency is found to be higher than Fmax, then in the next step at 138, its value is reduced to Fmax (in which case VT is also adjusted according to procedures in steps 132 and 134), and step 140 is followed. Otherwise, if the computed breathing frequency is less than or equal to Fmax, it does not need further adjustment and the program is transferred to step 140. In step 140, the expiration time, TE, is compared to 2.5 times τ. If it is found to be less than 2.5 τ, then step 142 is followed and the I:E ratio (the ratio of the inspiratory time to the expiratory time) is adjusted, so that TE becomes at least equal to 2.5 τ. Otherwise, if TE is found to be greater than or equal to 2.5 τ in step 140, it does not need to be adjusted (i.e. the adjustment value is zero) and the program is transferred to step 144. The reason for the adjustments in the breathing frequency and TE in steps 138 and 142 mentioned above, is to provide sufficient time for exhalation based on the patient's respiratory time constant and to avoid build up of intrinsic positive end-expiratory pressure (PEEPi).
where Pm is the inspiratory pressure in cm H2O. Thereafter, the control data indicative of Pm is also provided to an output port and the routine is held for the duration of the next breathing cycle. After the delay is passed, the program returns to the beginning of the loop at A.
It should be noted that the major portion of the procedure depicted in FIG. 2 to calculate the optimal breathing frequency and tidal volume of the breaths of a patient and controlling them automatically, has been described in U.S. Pat. No. 4,986,268. In the present invention, the necessary adjustments in the I:E ratio are controlled automatically as described above, and the levels of FIO2 and PEEP are automatically controlled by another algorithm which is described next.
Referring to FIGS. 3 a-3 i, there is illustrated a flow chart of a control algorithm which is operated upon by the digital processor. This algorithm is either run by itself, or in an alternative embodiment of the invention, it is run in parallel to the algorithm of FIGS. 2 a-2 c described above. The purpose of this algorithm is to automatically control the levels of FIO2 and PEEP provided to the patient on the ventilator and thereby improve the patient's oxygenation. The method depicted in FIGS. 3 a-3 i can be used for patients on mechanical ventilation or those on respiratory assist devices receiving CPAP treatment. Depending on the type of the ventilatory treatment, the term PEEP in the flow chart is meant to be interchangeable with CPAP.
As is seen, at the start of the flow chart, the desired set point for arterial partial pressure of oxygen of the patient is defined in step 200. This is done on the basis of the patient's conditions and his/her underlying illness. Then in the next step at 202, the initial value of FIO2 is set and transmitted to the output port.
In step 204 that follows next, the initial value of PEEP is set and transmitted to an output port. The initial value of PEEP can be set by using different options. For certain patient groups such as COPD patients, the initial PEEP can be chosen to be 80% to 85% of the intrinsic PEEP (PEEPi) which needs to be measured in advance. For some other patient groups such as ARDS patients, the initial PEEP setting can be chosen to be 3-4 cm H2O above the lower inflection pressure point of the inspiratory (or the expiratory) pressure volume curve of the patient. This value can either be calculated by the lung mechanics calculator and PV monitor unit and provided automatically to the digital processor via an input port, or the calculated value of the pressure can be provided manually by the clinician either through one of the input ports or via software. The third option is that the clinician arbitrarily decides an initial setting for PEEP and provides it to the digital processor, preferably via software. After setting the initial PEEP value in 204, the next step in 206 is followed. At this point, a time parameter (e.g., TP) for PEEP adjustment is defined and initially set to zero. The purpose of defining this parameter is to guarantee that PEEP adjustments are done only after a certain time has elapsed since the latest adjustment, thereby giving enough time to an adjustment in PEEP to make an impact on the patient's oxygenation.
In step 208 which follows next, another parameter, AP, for PEEP adjustment is defined. If this parameter is set to zero, then PEEP is controlled manually and only FIO2 is automatically adjusted. If AP is set to one, then both FIO2 and PEEP are automatically controlled.
In the next step 210, the threshold values for arterial hemoglobin oxygen saturation, SpO2, (or alternatively for arterial partial pressure of oxygen) are defined. In a preferred practice of the invention, four threshold values are defined for SpO2 and they are set at 90%, 93%, 95%, and 97% respectively. However, the threshold values may differ for different patients. They should be defined based on the patient's conditions and the desired levels of oxygenation.
Next, program control passes to step 212 in which a loop indicator (e.g., LI) is defined and is set to 1.5, and the main loop starts at A′.
Where PaO2 is the arterial partial pressure of oxygen, and CP is an added correction factor which is used to shift PaO2 based on the patient's measured blood pH level. If the patient's blood pH is within 7.45-7.55, then CP is set to zero. Otherwise, for every +0.1 deviation in pH from this range, CP is adjusted by −3.5 mm Hg as was also mentioned in the description of FIG. 2 earlier.
In step 218 that follows next, the calculated partial pressure of oxygen, PaO2, is compared with a minimum acceptable value. This is done to detect artifacts in the measurement of SpO2. If the calculated PaO2 is found to be less than the minimum acceptable value, then control passes to step 220 in which an artifact is assumed and an alarm is generated. Then step 222 is performed in which the SpO2 data is discarded and the previous value Of PaO2 in the memory is resumed and step 224 is followed. However, if in 218, the calculated PaO2 is found to be greater than or equal to the minimum acceptable value, its value is accepted and control passes to step 224.
In step 224, SpO2 is compared to a minimum safe value, which is the first threshold value defined previously in step 210 (e.g., 90%). If SpO2 is less than or equal to the minimum safe value, loop B is started in 226 and the loop indicator, LI, is set to 2.5. Then in step 228, FIO2 is increased stepwise (i.e. in a step-like arrangement) to a high value, F1, (e.g., 60%), and an alarm is generated in 230. Control then passes to loop F at which the procedure of PEEP adjustment begins as will be described later. However, if SpO2 is found to be higher than the minimum safe value in step 224, control passes to 232 where SpO2 is compared to a second threshold value (e.g., 93%). If SpO2 is less than the second threshold value, then steps 234 and 236 are followed in which the loop indicator, LI, is examined and compared to 2. If LI is less than 2, control passes to another loop E which will be described later. If LI is greater than or equal to 2, the next step in 238 is performed in which LI is compared to 3. If LI is less than 3, control passes to loop B (where FIO2 was set high at F1, e.g., 60%), otherwise, the program transfers to step 240. In this step, LI is compared to 4. If it is less than 4, control passes to loop C; otherwise, the program transfers to loop D (loops C and D will be described later).
Back to step 232, if SpO2 is found to be higher than or equal to the 2nd threshold value (e.g., 93%), then steps 242 and 244 are followed in which LI is compared to 2. If it is less than 2, control passes to loop E. Otherwise, in the next step at 246, LI is compared to 3. If less than 3, loop C is defined and started at 248, and LI is set to 3.5. Then in step 250, FIO2 is set stepwise at a moderately high value, F2 (e.g., 45%), and control transfers to loop F in which the procedure of PEEP adjustment is followed. However, if in step 246, LI is found to be greater than or equal to 3, control passes to step 252 in which LI is compared to 4. If LI is less than 4, then SpO2 is compared to a third threshold value (e.g., 95%) in step 254. If SpO2 is less than the third threshold value, control passes to loop C in which FIO2 was set at a moderately high level, F2 (e.g., 45%). Otherwise, if SpO2 is found to be higher than or equal to the third threshold value in 254, then the next step in 256 is followed in which loop D is defined and started and LI is set to 4.5. Next in step 258, FIO2 is set stepwise at a slightly high level, F3 (e.g., 30%), and control passes to loop F.
In the above equations, Y1(k), Y2(k), and Y3(k) represent the proportional, differential, and integral components of error in PaO2 respectively, and T is a sampling interval.
Where E(k) is an error function, α, β, and γ are the PID coefficients, and G(k) is the required FIO2. In a preferred practice of the invention, T is set to 0.75 seconds, and α, β, and γ are set to 6.45×10−5, 3.22×10−5, and 7.29×10−6 respectively. These parameters were tuned to minimize steady-state oscillations and to keep the overshoot/undershoot in the FIO2 response of the PID controller below 25% of the total change. It is also recognized that other error correction schemes can be used to determine FIO2. As long as those schemes reduce the error in the oxygen level of the patient in a similar way as described above, they will be within the scope of the present invention.
In the next step in 268, the calculated value of FIO2 is compared with a minimum of 0.21 (i.e. 21%). If the FIO2 value is less than 21%, in step 270 which follows, it is set to a minimum of 21% and control passes to loop F. However, if in 268, FIO2 is found to be greater than or equal to 21%, control passes to step 272 in which FIO2 is compared to a maximum allowed value (e.g., 80%). If FIO2 is less than or equal to the maximum allowed value, the next step in 274 is followed where the calculated value of FIO2 is sent to the output port and control passes to step 276. In this step FIO2 is compared to 60%. If it is less than 60%, control passes to loop F. Otherwise, an alarm is generated in 278 and then control transfers to loop F.
Back to step 272, if the calculated value of FIO2 is found to be higher than the maximum allowed value, it is reduced to the maximum value in step 280, an alarm is generated, and then control transfers to loop F.
Up to the beginning of loop F at step 282, the focus of control is on automatic control of FIO2. As shown, two different mechanisms are incorporated in the control process of FIO2 in a preferred practice of the invention. One, a rapid stepwise control scheme which responds instantly to fast declines in SpO2, and the other, a more finely controlled PID algorithm that provides fine control of FIO2 in the absence of sharp and hazardous declines in SpO2. The stepwise controller in a preferred practice of the invention has three loops, each with its defined minimum and maximum SpO2 threshold levels. These three loops were shown respectively at B, C, and D, and the PID control loop was shown at E in the flow chart of FIG. 3. The controller switches from the PID control to the rapid stepwise algorithm only if rapid declines in SpO2 are detected. Once in the stepwise mode, the controller continuously checks SpO2, and if it rises, the controller reduces FIO2 to minimize the exposure of the patient to high and toxic levels of FIO2. The controller is designed to correct hypoxemia within seconds and to avoid hyperoxemia. As shown, the controller detects artifacts in the measurement of SpO2, discards the artifacts, and generates alarms when appropriate. The algorithm also enables clinicians to define the desired oxygenation levels for different patients. This is done by defining an appropriate PaO2 set point, by setting the threshold values for SpO2, and by adjusting the correction parameter, CP, in accordance with the measured pH levels in the patient's blood as described above.
After the determination of the required FIO2, the procedure of adjusting the PEEP value is started at F in step 282. In this step, the ratio of PEEP/FIO2 is calculated. Then in 284, the control parameter AP, which was defined in step 208, is examined. If it is less than 1, it means that PEEP is not adjusted automatically and it is instead adjusted manually by the operator. In this case, the controller merely watches the PEEP/FIO2 ratio and generates warning signals, if the ratio is either too low or too high. In step 286, the ratio is compared to a minimum allowed value (e.g., 0.12). If it is less than the minimum value, an alarm is generated in 288 and control passes to I (which will be described later). However, if the PEEP/FIO2 ratio is found to be equal to or greater than the minimum value in step 286, then the next step in 290 is performed where the ratio is compared to a maximum allowed value (e.g., 0.22). If the ratio is less than or equal to the maximum value, control passes to I. Otherwise, an alarm is generated in step 292 and then control is transferred to I.
Thereafter, control passes to I.
Thereafter, control passes to I. In step 318 at I, the routine is held for a fixed interval (e.g., 0.75 seconds) and then control returns to the beginning of the main loop at A′.
Back to step 308, if the PEEP/FIO2 ratio is found to be less than the maximum allowed limit (e.g., 0.22), the step 320 is next followed. In this step SpO2 is compared to a predefined minimum allowed value (e.g., 92%). If it is higher than or at least equal to the predefined minimum value, the PEEP level is not changed and control passes to J. However, if in 320, SpO2 is found to be less than the predefined minimum value, then control passes to H, where it is determined whether at least 4 minutes have passed since the last PEEP adjustment, and if so, PEEP is increased by a fixed amount (e.g., 2 cm H2—O) as was shown earlier.
In performing the automatic PEEP adjustments, the PEEP/FIO2 is kept within a clinically acceptable range. As shown above, if the PEEP/FIO2 is too low, PEEP is increased by a fixed increment (e.g., 2 cm H2O). Also, if the PEEP/FIO2 ratio is within the acceptable range and SpO2 is low, then PEEP is increased by a fixed increment (e.g., 2 cm H2O) to improve patient's oxygenation. On the other hand, if the PEEP/FIO2 ratio increases beyond a maximum defined value, the program reduces PEEP in fixed amounts (e.g., 2 cm H2O). In any case, the interval between two successive PEEP adjustments is at least equal to a fixed period (e.g., 240 seconds), to allow for the changes in PEEP to have an observable and measurable impact on the patient's oxygenation.
It should be noted that the above examples for the incremental step size for PEEP adjustment (e.g. 2 cm H2O) and the minimum and maximum values for the ratio of PEEP/FIO2, are indicated for patients receiving ventilatory treatment in a more acute clinical setting such as the intensive care or a constant care unit of a hospital. Smaller incremental adjustments (e.g. 1 cm H2O) and more conservative ranges for the ratio of PEEP (or CPAP)/FIO2 may be adopted if the invention is used to improve the breathing and oxygenation of more stable, spontaneously breathing patients.
There has been described a method and apparatus for controlling a ventilator. The invention utilizes data indicative of measured oxygen levels of the patient to automatically control FIO2, and PEEP (or CPAP). In an alternative embodiment, the invention further uses the respiratory mechanics data (i.e. respiratory elastance and airway resistance) to automatically make the necessary adjustments in the I:E ratio of the patient on the ventilator. It further incorporates the features of U.S. Pat. No. 4,986,268 and uses data indicative of measured levels of oxygen and the respiratory mechanics data of the patient, along with data indicative of barometric pressure (as a reference calibrating pressure), and data indicative of measured carbon dioxide level of the patient to automatically control the breathing frequency and tidal volume of breaths of the patient on the ventilator. The invention also detects and corrects artifacts in the measured oxygen and carbon dioxide data and applies safety rules. In its different embodiments, the invention can improve total and/or assist ventilatory treatments provided to different patient groups.
The present invention may be embodied in other specific forms without departing from the scope and the essential attributes thereof. Therefore, reference should be made to the appended claims rather than to the foregoing specification, with regard to the scope of the invention.
wherein the control signals provided to the ventilator automatically control PEEP, and FIO2, for a next breath of the patient.
2. The apparatus of claim 1, wherein the first means comprises a programmable microcomputer.
wherein tee second means further provides an alarm control signal to the alarm unit to warn of the artifact in the measured oxygen levels.
wherein the second means further provides an alarm control signal to the alarm unit to warn of the measured oxygen level of the patient being outside a prescribed range.
5. The apparatus of claim 2, further comprising an analog to digital (A/D) converter connected to an input of the first means for converting analog signals from an oxygen sensor, indicative of the oxygen level of the patient, to digital data.
6. The apparatus of claim 5, wherein the oxygen sensor is a pulse oximeter measuring arterial hemoglobin oxygen saturation in the patient's blood.
7. The apparatus of claim 2, wherein data indicative of the lower inflection pressure point on an inspiratory or expiratory pressure volume curve of the patient (LIP) is provided to the first means.
8. The apparatus of claim 7, wherein the data indicative of LIP is supplied by a monitor operatively coupled to the first means.
9. The apparatus of claim 2, wherein data indicative of the patient's measured intrinsic positive end-expiratory pressure (PEEPi) is provided to the first means.
10. The apparatus of claim 9, wherein the data indicative of PEEPi is supplied by a monitor operatively coupled to the first means.
for a next breath of the patient.
wherein the program means further replaces and/or corrects the data based on the artifact and generates a warning signal in the event the artifact is determined.
13. The apparatus of claim 2, wherein data corresponding to a set point for arterial partial pressure of oxygen, threshold values for the oxygen level of the patient, and a correction factor for oxygen based on measured blood pH levels of the patient are entered manually and stored in a software program.
wherein the second means further generates additional control signals to the ventilator based on the output data of the first means; wherein the additional control signals to the ventilator control tidal volume and frequency of inhaled gas provided to the patient by the ventilator and effect necessary adjustments in the ratio of I:E for a next breath of the patient.
15. The apparatus of claim 14, wherein the input data indicative of respiratory elastance and airway resistance of the patient are supplied to the first means by one or more monitors coupled to the first means.
16. The apparatus of claim 14, wherein the input data indicative of respiratory elastance and airway resistance of the patient are entered manually and stored in a software program.
17. The apparatus of claim 14, wherein the input data indicative of the measured oxygen level of the patient and the measured carbon dioxide level of the patient are provided to the first means by one or more monitors coupled to the first means.
18. The apparatus of claim 17, wherein the input data indicative of the measured oxygen level of the patient is provided by a pulse oximeter measuring arterial hemoglobin oxygen saturation of the patient, and the input data indicative of the measured carbon dioxide level of the patient is provided by an exhaled gas analyzer detecting end-tidal partial pressure of carbon dioxide or end-tidal concentration of carbon dioxide in exhaled gas of the patient.
19. The apparatus of claim 14, wherein the input data indicative of barometric pressure is supplied to the first means by one or more monitors coupled to the first means.
20. The apparatus of claim 14, wherein the input data indicative of barometric pressure is entered manually and stored in hardware.
21. The apparatus of claim 14, wherein the input data indicative of barometric pressure is entered manually and stored in a software program.
and wherein the second means generates a warning control signal that is supplied to an alarm unit that generates an alarm signal.
and wherein the second means generates a warning control signal.
25. The apparatus of claim 24, wherein data corresponding to a set point for arterial partial pressure of oxygen, an adjustment factor for carbon dioxide level of the patient, threshold levels for oxygen level of the patient, and a correction factor for oxygen based on measured blood pH levels of the patient, are entered manually and stored in a software program.
26. The apparatus of claim 14, wherein the first means also receives and processes data indicative of the patient's metabolic rate ratio.
27. The apparatus of claim 26, wherein the data indicative of the patient's metabolic rate ratio is supplied to the first means by a monitor coupled to the first means.
28. The apparatus of claim 26, wherein the data indicative of the patient's metabolic rate ratio is entered manually and stored in a software program.
(c) providing data signals indicative of the required FIO2 and the required PEEP based upon the determining of step (b), for automatically controlling FIO2 and PEEP for a next breath of the patient.
30. The method of claim 29, wherein step (b) further comprises determining, from the data indicative of the measured oxygen level in (a), whether there has been an artifact in the measured oxygen level, and replacing and/or correcting the data signal in (a) in the event the artifact is determined.
31. The method of claim 29, wherein the data signal indicative of measured oxygen level of the patient is in analog form and is converted to digital form before the determining of step (b), and wherein the providing of step (c) further comprises converting the data signals from digital to analog form.
32. The method of claim 29, wherein data corresponding to the lower inflection pressure point on an inspiratory or expiratory pressure volume curve of the patient (LIP) is also provided in step (a), and an initial value for PEEP is set equal to LIP plus 0 to 8 cm H2O and the initial value for PEEP is provided in step (b).
33. The method of claim 32, wherein the data corresponding to LIP is supplied by a monitor.
34. The method of claim 29, wherein data corresponding to the measured intrinsic PEEP of the patient (PEEPi) is also provided in step (a), and an initial value for PEEP is set between 80% and 100% of PEEPi and the initial value for PEEP is provided in step (b).
35. The method of claim 34, wherein the data corresponding to PEEPi is supplied by a monitor.
36. The method of claim 29, wherein an initial value for PEEP is determined by the operator and is manually provided.
37. The method of claim 31, wherein the measuring of the oxygen level of the patient comprises measuring an arterial hemoglobin oxygen saturation of the patient via pulse oximetry.
38. The method of claim 37, wherein an arterial partial pressure of oxygen of the patient is derived from the arterial hemoglobin oxygen saturation of the patient measured by the pulse oximeter.
where PaO2 is in mm Hg and CP is a correction parameter which is used to shift PaO2 and CP is based on the patient's measured blood pH level.
41. The method of claim 29, wherein the required concentration of oxygen in the inspiratory gas of the patient (FIO2) is calculated by using a stepwise control scheme and/or by using a proportional-integral-derivative (PID) technique.
42. The method of claim 41, wherein using a PID technique comprises comparing SpO2 obtained by pulse oximetry to a defined minimum safe value, and wherein using the PID technique continues while SpO2 is greater than the defined minimum safe value.
returning control to the PID technique upon SpO2 rising to the fourth threshold value.
where Y1(k), Y2(k), and Y3(k) are the proportional, derivative, and integral components of error, respectively, E(k) is an error function, T is a sampling interval, G(k) is the required FIO2, and parameters α, β, and γ are PID coefficients.
if the PEEP/FIO2 ratio is not less than the defined maximum allowed value, comparing the PEEP/FIO2 ratio to a value higher than the defined maximum allowed value, RG, whereby if the PEEP/FIO2 ratio is higher than RG, and the time elapsed since the last adjustment in PEEP is greater than or equal to T1, decreasing PEEP by a fixed incremental amount.
(g) providing to the ventilator, based upon the data signals provided in (d), (e) and (f), final data signals for automatically controlling: (i) the required FIO2, (ii) the required PEEP, (iii) the optimal breathing frequency, (iv) the required ventilation, (v) the required adjustment in I:E ratio, for a next breath of the patient.
47. The method of claim 46, wherein step (a) further comprises detecting an artifact in the data indicative of the measured oxygen level of the patient and correcting and/or replacing the data if an artifact is present.
48. The method of claim 46, wherein the determining of step (f) of the optimal breathing frequency, the required ventilation, and the required adjustment in I:E ratio is based upon minimization of a work rate of breathing for a next breath of the patient.
49. The method of claim 46, wherein the measuring of step (a) comprises measuring an arterial hemoglobin oxygen saturation in the patient's blood by a pulse oximeter.
50. The method of claim 46, wherein the measuring of step (b) comprises obtaining data from an exhaled gas analyzer.
where PaCO2 and PaO2 are arterial partial pressures of carbon dioxide and oxygen of the patient, respectively; PetCO2 is end-tidal carbon dioxide partial pressure of the patient supplied by an exhaled gas analyzer; SpO2 is an arterial hemoglobin oxygen saturation of the patient measured by a pulse oximeter; K1 is a difference between the arterial and end-tidal partial pressures of carbon dioxide and K1 can be adjusted to set a desired PaCO2 level of the patient; CP is a correction parameter to shift and correct PaO2 in relation to SpO2 and is adjusted based on measured pH level in the patient's blood.
52. The method of claim 51, wherein PaO2 is compared to a defined minimum acceptable value for oxygen; and wherein if PaO2 is below the defined minimum acceptable value, PaO2 and SpO2 are discarded and replaced by corresponding previous data values in memory, and a warning signal indicative of detection of an artifact is provided.
53. The method of claim 52, wherein PaCO2 is compared to a defined minimum acceptable value for carbon dioxide; and wherein if PaCO2 is below the defined minimum acceptable value, PaCO2 is discarded and replaced by a corresponding previous data value in memory, and a warning signal indicative of detection of an artifact is provided.
54. The method of claim 53, wherein PaCO2 and PaO2 are further compared to respective predefined minimum threshold values; if both PaCO2 and PaO2 are found to be less than the predefined minimum threshold values, the method further comprises providing to the ventilator a predefined ventilation and breathing frequency, a required adjustment in I:E ratio, and a warning signal indicative of possibility of pulmonary embolism.
55. The method of claim 53, wherein PaCO2 and P aO2 are compared to respective predefined ranges, and if either PaCO2 or PaO2 is outside the corresponding predefined range, a warning signal is provided.
where VC is a ratio of alveolar ventilation as a net effect of carbon dioxide to a resting value of ventilation, and C1 and C2 are constant parameters.
where VO is a ratio of alveolar ventilation as a net effect of oxygen to the resting value of ventilation.
where VM is a ratio of alveolar ventilation as a net effect of increase in MRR to a resting value of ventilation, VA at rest is the patient's resting value of alveolar ventilation, and VA is the required alveolar ventilation of the patient.
59. The method of claim 58, wherein the data indicative of MRR of the patient is provided by a monitor.
60. The method of claim 58, wherein the data indicative of MRR of the patient is entered manually and stored in a software program.
where VD is the physiological dead space of the patient, VED is a dead space due to tubes and connections, and VDt is the total dead space.
VAR is the alveolar ventilation per second.
where VE is minute ventilation and VT is tidal volume.
64. The method of claim 46, wherein an input data corresponding to a lower inflection pressure point on an inspiratory or expiratory pressure volume curve of the patient (LIP) is also provided in step (c), and an initial value for PEEP is set equal to LIP plus 0 to 8 cm H2O.
65. The method of claim 64, wherein the input data corresponding to LIP is supplied by a monitor.
66. The method of claim 46, wherein data corresponding to an intrinsic PEEP (PEEPi) of the patient is also provided in step (c), and an initial value for PEEP is set equal to between 80% to 100% of PEEPi.
67. The method of claim 66, wherein the data corresponding to the PEEPi is supplied by a monitor.
68. The method of claim 46, wherein an initial value for PEEP is determined by an operator and is manually supplied.
69. The method of claim 46, wherein the required FIO2 is calculated by using a stepwise control scheme and/or by using a proportional-integral-derivative (PID) control technique.
70. The method of claim 69, wherein, while using the PID technique, SpO2 obtained by pulse oximetry is compared to a defined minimum safe value, and if SpO2 is greater than the defined minimum safe value, control remains in the PID technique.
(vii) when SpO2 rises to the fourth threshold value, control switches to the PID technique.
where Y1(k), Y2(1 k), and Y3(k) are proportional, derivative, and integral components of error, respectively, E(k) is an error function, T is a sampling interval, G(k) is the required FIO2, and parameters α, β, and γ are PID coefficients.
if the PEEP/FIO2 ratio is not less than the defined maximum allowed value, the PEEP/FIO2 ratio is compared to a value higher than the defined maximum limit, RG; if the PEEP/FIO2 ratio is higher than RG and a time elapsed since a last adjustment in PEEP is greater than or equal to T1, PEEP is decreased by a fixed incremental amount.
74. The method of claim 62, wherein a ratio of K″/K′ is compared to one fifth of a reciprocal of the optimal breathing frequency; whereby if K″/K′ is greater than one fifth of the reciprocal of the optimal breathing frequency, the breathing frequency is decreased to less than or equal to the reciprocal of five times K″/K′.
75. The method of claim 74, wherein an expiratory time, TE, is compared to 2.5 times K″/K′; and wherein the I:E ratio is adjusted so that TE is greater than or equal to 2.5 times K″/K′.
76. The method of claim 46, wherein the data indicative of respiratory elastance and airway resistance of the patient are provided by one or more monitors.
77. The method of claim 46, wherein the data indicative of respiratory elastance and airway resistance of the patient are entered manually and stored in a software program.
78. The method of claim 46, wherein the data indicative of barometric pressure are provided by a monitor.
79. The method of claim 46, wherein the data indicative of barometric pressure is provided manually.