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Clinical review: Long-term noninvasive ventilation
Critical Care volume 11, Article number: 210 (2007)
Noninvasive positive ventilation has undergone a remarkable evolution over the past decades and is assuming an important role in the management of both acute and chronic respiratory failure. Long-term ventilatory support should be considered a standard of care to treat selected patients following an intensive care unit (ICU) stay. In this setting, appropriate use of noninvasive ventilation can be expected to improve patient outcomes, reduce ICU admission, enhance patient comfort, and increase the efficiency of health care resource utilization. Current literature indicates that noninvasive ventilation improves and stabilizes the clinical course of many patients with chronic ventilatory failure. Noninvasive ventilation also permits long-term mechanical ventilation to be an acceptable option for patients who otherwise would not have been treated if tracheostomy were the only alternative. Nevertheless, these results appear to be better in patients with neuromuscular/-parietal disorders than in chronic obstructive pulmonary disease. This clinical review will address the use of noninvasive ventilation (not including continuous positive airway pressure) mainly in diseases responsible for chronic hypoventilation (that is, restrictive disorders, including neuromuscular disease and lung disease) and incidentally in others such as obstructive sleep apnea or problems of central drive.
After the successful use of tracheostomy and intermittent positive pressure ventilation (IPPV) in the 1950s to treat acute bulbar poliomyelitis [1], some patients were discharged at home with long-term mechanical ventilation via tracheostomy (invasive) or mouth piece (noninvasive) [2, 3]. However, it was only in the 1980s after the introduction of noninvasive positive pressure ventilation (NIPPV) through facial interfaces in the intensive care unit (ICU) that long-term NIPPV was considered as a standard of care to treat selected patients following an ICU stay. NIPPV is now a predominant technique for long-term home ventilation [4]. It is also well recognized that NIPPV allows patients treated for acute failure from chronic respiratory insufficiency to be discharged from hospital and also prevents readmissions [5, 6]. These beneficial effects have been reported for both chronic obstructive pulmonary disease (COPD) and neuromuscular/parietal disorders [6]. Depending on the underlying diseases and the severity, IPPV is either continuously mandatory to avoid death in cases of complete or quasi-complete paralysis or is used nightly, producing enough improvement to allow free time during the daytime for spontaneous breathing. This clinical review will address the use of NIPPV (not including continuous positive airway pressure (CPAP)) in the different diseases for which it is currently proposed.
Methods of NIPPV and their uses
The need to select an appropriate and properly fitted interface cannot be overemphasized due to its impact on the quality of ventilation [7]. The aim is to reach a compromise between different objectives: to minimize leaks, improve comfort and implement the mask easily. A wide variety of different factory-made masks of different designs, shapes, sizes and materials is now available. It is usually possible to find a mask that suits most individuals. Because of this, the initial practice of custom made interfaces for different individuals is now seldom needed, even if it remains probably the best interface [7, 8]. There are currently four different types of interfaces: nasal masks, which are used predominantly [8, 9]; facial masks covering the nose and the mouth; nasal pillows; and mouthpieces [9], which are now essentially indicated in the case of daytime ventilation [10]. Mouthpieces may afford an excellent interface to provide adjunct daytime ventilation in neuromuscular patients who are unable to maintain acceptable diurnal arterial blood gases without frequent intermittent periods of assistance. The mouthpiece is positioned close to the patient's mouth where it is intermittently captured to take a few assisted breaths from the ventilator and subsequently released. An advantage of this is that the face is free from face-attached interfaces. Patients needing assistance night and day may use a combination of interfaces.
Ventilators and modes for NIPPV
Ventilators use one of two basic methods: volume-preset and pressure-preset [9]. With volume-preset, the ventilator always delivers the tidal volume that is set by the clinician, regardless of the patient's pulmonary system mechanics (compliance, resistance and active inspiration). However, leaks at the skin-mask interface, or through the mouth when using a nasal mask, reduce the volume received by the patient. Conversely, with pressure-preset, changes in pulmonary mechanics directly influence the flow and the delivered tidal volume (lower or higher) since the ventilator delivers the set pressure throughout inspiration. In this case, leaks augment the flow and tend to maintain the tidal volume [11]. More recently, a third method has been proposed for both ICU and home ventilation. This is called pressure-preset/volume-targeted and aims to guarantee delivery of a tidal volume with the comfort of the pressure-preset method. At the present time, clinical evaluation of this third method remains poorly documented [12]. It is important to understand that NIPPV is dominated by both rapidly varying non-intentional leaks and the geometry and the resistance of the upper airway [13]. Obviously, leaks and airway resistance partly interact. In the face of these continuous changes the respective advantages and drawbacks of volume- and pressure-preset methods, which are opposite, make it difficult to predict their effects. The way inspiration begins and ends is initiated either by the ventilator or in response to a patient effort to do so, allowing one to define the main modes of ventilation: control, assist-control, and assist or spontaneous (assist or spontaneous possible only with pressure-preset).
Most home ventilators function according to only one of the methods, volume-preset or pressure-preset, but modern ones may deliver inspiration by both methods. Besides the classic circuitry, including two valves (on the inspiratory and expiratory limbs) alternately closing and opening, bilevel positive airway pressure (BPAP) ventilators are simpler and, therefore, lend themselves to home mechanical ventilation [14]. Inspiratory and expiratory pressures are alternatively established in a single circuit incorporating an intentional, calibrated leak located close to the patient or even on the mask. The theoretical disadvantage with such a circuit is the risk of variable CO2 rebreathing. However, concern about the risk of CO2 rebreathing has not been definitively documented [15], although the trend is to consider it as negligible provided positive expiratory pressure is applied in order to eliminate CO2 through the intentional leak (at least 2 to 4 cmH2O) [16]. Depending on the ventilator, all the different modes and refined settings, and even closed-loop modes usually applied in the ICU, are more or less available. Some ventilators may analyze ventilation in an on-going manner and keep the data in internal memory for further assessment. The general objective is to provide many possible capabilities in order to have enough tools to adapt and optimize patient-machine synchronization. While conceptually attractive, sufficient studies have not been performed to document or refute the advantages of such complexity in the context of noninvasive home ventilation.
Choice of the ventilator and mode
Many clinicians currently prefer a pressure-preset ventilator in assist mode as the first choice with a view to offering the best synchronization [4]. In fact, in the studies comparing volume and pressure-preset ventilators, no clear differences in the correction of hypoventilation in short-term studies [17, 18] and long-term outcomes [19, 20] have been shown. This is understandable since leaks and resistance changes during NIPPV alternate very quickly and when the pressure target is well achieved, the volume target is not, and vice versa. However, it is important to remain flexible by trying alternative approaches if problems occur with one or the other type of ventilator.
Additionally, even if new generations of BPAP ventilators tend to contain batteries, it should be noted that these batteries most often provide autonomy of only short duration. This would limit security and mobility of neuromuscular patients with hypoventilation and then shift the preference to the volume ventilator.
Criteria to consider when deciding on the implementation of NIPPV
Signs and symptoms of hypoventilation
The presence of clinical symptoms and/or physiological markers of hypoventilation are useful in identifying clinical severity as it relates to therapeutic decision-making with regard to initiation of nocturnal NIPPV. In the course of a typically progressing disease, two successive steps occur more or less rapidly: nocturnal hypoventilation that is reversible during waking hours associated with none or a few clinical symptoms; and nocturnal and daytime hypoventilation associated with clinical symptoms that show a low respiratory reserve and should be considered an unstable state with increased susceptibility to life-threatening acute ventilatory failure that may be triggered by what may otherwise be trivial additional factors [21, 22]. A sleep study continuously recording CO2 (end-tidal (EtCO2) or transcutaneous (TcCO2)) and/or pulse oximetry (SpO2) is required to document nocturnal hypoventilation, which may occur throughout all sleep stages but in some cases exclusively during rapid eye movement sleep. Daytime hypoventilation is defined by abnormally elevated partial pressure of arterial carbon dioxide (PaCO2), a high serum bicarbonate level and a relatively normal pH with associated reduction of the partial pressure of arterial oxygen (PaO2). Chronic daytime hypo-ventilation is an important indicator invariably associated with sleep-related hypoventilation. Thus, in the presence of diurnal hypoventilation, the reason for overnight recording is only to rule out obstructive or central apnea. Clinical symptoms indicating consequences of hypoventilation (Table 1) must be carefully evaluated since, even when modest, they are important for the appreciation of disease severity and prognosis and in the indication of NIPPV. Pulmonary function tests help define and quantify the ventilatory-respiratory disease but have low predictive values for chronic sleep-related hypoventilation in individual patients except in those with neuromuscular disease. Indeed, in Duchenne muscular dystrophy, hypoventilation appears only during rapid eye movement sleep, all night, or during the daytime when supine inspiratory vital capacity is <40%, <25% and <12%, respectively [21]. Similarly, a peak cough flow <160 l/min, related to expiratory muscle deficit, means an increased risk of accumulation of secretions that may worsen hypo-ventilation and trigger acute failure [23]. It is crucial to note that isolated reduced PaO2 does not require mechanical ventilation but only supplemental oxygen because it does not indicate hypoventilation but only a mismatching of ventilation and perfusion.
Diseases that may potentially be treated with NIPPV
The principal diseases that may be addressed using NIPPV therapy are shown in Table 2. Except for those due to respiratory control or upper airway abnormalities, all may become severe enough to cause alveolar hypoventilation during sleep and daytime and eventually may impair the quality of life and threaten life. In neuromuscular disorders, it is important to consider the progressiveness according to each type of disease and the individual concerned.
Survival with NIPPV in different diseases
NIPPV efficacy in terms of survival compared to control treatment is important information required in order to adequately discuss NIPPV. Besides a few randomized control trials [24–27], this information comes from retrospective series compared to the usual prognosis [20, 28–31]. In order to extend the analysis, it is also possible to take into account results obtained with either negative pressure ventilation [32] or tracheostomy [2]. These are informative enough and generally accepted by the medical community even if conclusions derived from them are refutable in terms of evidence-based medicine. In neuromuscular disease, NIPPV always increases survival. Approximate median increased survival times depend on the age of the patient when starting NIPPV and the comorbidities present (including extended paralysis): very long (> 20 years) in the sequelae of poliomyelitis; long (10 years) in spinal muscular atrophy type 2 and 3, Duchenne muscular dystrophy, and acid maltase deficiency; short (4 years) in myotonic dystrophy; and very short (1 year) in amyotrophic lateral sclerosis (ALS). In cases of chest-wall abnormalities, NIPPV also prolongs life: 15 years in kyphosis and 7 years in the sequelae of tuberculosis. No data support a positive effect on survival in lung diseases: in COPD patients randomized trials are negative [25, 26, 32], and data are too scarce in cystic fibrosis or for bronchiectasis patients. However, we must note that the negative results in the trials in COPD may be related to insufficient ventilation due to a too low driving pressure.
Circumstances and indications for NIPPV
In clinical practice, NIPPV is initiated either electively or in the context of acute ventilatory failure initially treated invasively with translaryngeal intubation or noninvasively with facial interfaces [33]. In the latter circumstances, the long-term necessity for NIPPV should be reevaluated after weeks or months during follow-up since the indications for NIPPV may change as the clinical conditions improve or not. In cases of chronic and stable awake hypoventilation, the main criteria for predicting the need for NIPPV are advanced severity with clinical symptoms of hypoventilation plus a balance of several other issues, including: the main primary process explaining the hypoventilation – mechanical or lung deficit; whether the natural rate of progression has been a few years or dozens of years; the clinical severity at the time of decision making; actual symptoms and history of acute-subacute failure in the previous months; and the patient's willingness, including the family and social environment, to undertake this therapy.
Indications for NIPPV are outlined in Table 3. NIPPV is strongly indicated in patients with chest wall and neuro-muscular disorders in the presence of clinical symptoms attributable to diurnal hypoventilation [34–37]. There are no validated values above which NIPPV is definitely indicated; however, many clinicians consider treatment in scoliosis and sequelae of tuberculosis with awake PaCO2 >50 to 55 mmHg and a PaO2 <60 mmHg, and in neuromuscular disease with a PaCO2 around 45 to 50 mmHg and a PaO2 <70 mmHg. In cases with clear clinical symptoms, less severe values may be considered as an indication to start NIPPV [35]. Conversely, in COPD and probably in other lung diseases, diurnal hypo-ventilation does not support the unequivocal utility of NIPPV [38, 39]. Nevertheless, this question remains open since the clinical trials are underpowered and secondary parameters, such as some components of the quality of life or hospitalization days, may have improved. Some observational series suggest better results [40, 41]. Presently, we may admit NIPPV as an option in COPD patients with symptoms of hypoventilation contributing to recurrence of acute-subacute failure, provided that long-term oxygen and drug therapy have already been optimally adjusted. During early stages with only isolated nocturnal hypoventilation, NIPPV is not mandatory but could be optional in kyphoscoliosis and neuromuscular diseases [42]. In the latter, when worsening is both inevitable and rapid (for example, ALS), NIPPV is valuable at an early stage provided that this is an acceptable therapeutic option for the patient.
NIPPV use in some other diseases may also deserve consideration even if clinical experience remains inconclusive. Obesity hypoventilation syndrome is dominated by morbid obesity impeding ventilation, frequent obstructive apnea and more or less reversible decreased reactivity of the respiratory centers [43]. In acute-subacute as in chronic situations, NIPPV has been shown to reverse hypoventilation [44, 45]. However, considering the high prevalence of obstructive apnea, CPAP is a simpler and efficient treatment. In addition, CPAP reduces the resistance of the pharynx, which leads to a light reduction of the work of breathing. This may be another reason for the reversal of the hypoventilation. Cheyne-Stokes breathing with central and obstructive apnea in the context of severe cardiac insufficiency has been shown to negatively influence the clinical situation and survival [46]. Conventional NIPPV or a new modality, such as adaptive servo-ventilation, has been shown to alleviate apnea and improve cardiac function [47, 48]. Nevertheless, no conclusion about the utility of nocturnal NIPPV in terms of survival and main outcomes is available. In addition, a recent large study comparing oxygen and CPAP, which also alleviates apnea and improves cardiac function, does not prove the clinical superiority of CPAP in terms of survival [49]. Pure obstructive sleep apneas in the context of obstructive sleep apnea could be suppressed with NIPPV. Some authors have proposed NIPPV as a second-line treatment in the case of CPAP failure. However, this is not supported with enough conclusive study to be recommended [50]. Ondine's curse, in children, is characterized by the lack of metabolic response of the respiratory centers during sleep and is responsible for severe nocturnal hypoventilation. The usual treatment is tracheostomy and nocturnal ventilation. Some clinical experience suggests that, after years, tracheostomy might be converted in some cases to nocturnal NIPPV. Obviously, such options must remain in the hands of specialized teams [51].
Management of NIPPV
Initiation and settings for nocturnal ventilation
The main goal of NIPPV, which in the best circumstances is used solely during the night, is to improve arterial blood gases up to nearly normal values without discomfort and sleep disruption. However, day time mechanical ventilation in chronic respiratory insufficiency is as good as night time ventilation. The reduction of hypercapnia depends more on the duration of the ventilation than on whether the patient is asleep or awake [52]. The objective when there is residual muscle ability to breathe is to provide enough improvement to allow comfortable time off the ventilator. Even if there is no absolute recommendation, it is good general practice to proceed in three steps. The first step consists of selecting and adjusting the ventilator settings while the patient is awake, insuring physiological adequacy and patient comfort for at least one or two hours. One study, done on awake cystic fibrosis patients, found that clinical observation is as efficient as the use of physiological measurements, including esophageal pressure, in setting the ventilator parameters [53]. Another in patients with COPD and neuromuscular disease has shown that using physiological measurements does not improve ventilation during the day but improves ventilation and sleep quality during the night [54, 55].
In the second step, the clinician should judge adequacy when the patient is napping and/or during nocturnal use. To complete this step, different options according to the resources available in each center could be used. Arterial blood gas (ABG) measurements would seem ideal; however, one or a few samples during the night do not represent the rapid changes observed during several continuous hours of sleep, and the invasiveness of sampling has led most clinicians to noninvasively monitor different parameters. Ideally, a complete polysomnogram recording SpO2 and TcCO2 or EtCO2, airflow, tidal volume, airway pressure, rib cage and abdomen excursion, and sleep staging permits a complete assessment [56]. When resources are not available to perform these detailed recordings, fewer measurements during overnight recordings remain informative. However, the minimal requirement is to record SpO2 overnight in room air, assessing whether the normalization of SpO2 accompanies a normalization, or at least an improvement, of PaCO2. In addition, data related to patient tolerance, comfort, sleep quality and well-being should be obtained.
The third step is carried out after several nights of NIPPV and consists of looking for a reduction in PaCO2 and augmentation of PaO2, without dyspnea, during the day when free from ventilation to confirm that the settings are adequate. This also gives information about the necessity or not to add daylight hours of NIPPV (at first during napping and more when necessary). If the results are not satisfactory, alterations must be made to the settings and possibly the mask and the ventilator, and the effects of these checked again. In most cases, a few days are necessary to achieve success.
If one uses assist pressure-preset ventilation, 10 cmH2O of inspiratory pressure support is a suggested starting point. If necessary, the pressure level is progressively increased to achieve evidence of improvement. Pressure support higher than 20 cmH2O is rarely necessary. Nevertheless, one observational series reports good results in COPD patients ventilated with higher (28 cmH2O) pressure [41]. In COPD, the addition of an expiratory positive pressure (positive end-expiratory pressure (PEEP) or expiratory positive airway pressure (EPAP)), also necessary to decrease the rebreathing with BPAP ventilators, should conceptually improve patient triggering when intrinsic PEEP exists [57]; however, there is no long-term study proving its clinical usefulness. Depending on the ventilator capabilities and observations made of how the patient and ventilator do together, more subtle settings concerning triggers, initial flow, and inspiratory time limit could be tried. A backup frequency set close to the spontaneous frequency of the patient during sleep is a reasonable substitute to avoid central apnea induced by transitory but repeated hyperventilation exceeding the apnea threshold [58].
When employing a volume-preset ventilator, the initial suggested settings may be established by adjusting the frequency of ventilator-delivered breaths so that it approximates the patient's spontaneous breathing frequency during sleep, an inspiratory time/total breathing cycle time between 0.33 and 0.50 and a relatively high tidal volume of around 10 to 15 ml/kg to insure sufficient tidal volume in case of leaks [59].
Supplemental oxygen should be added into the ventilator circuit in those patients requiring oxygen while awake due to lung parenchyma diseases (for example, COPD, cystic fibrosis, bronchiectasis). In the absence of parenchymal disease it is only after trying to optimize all technical parameters that residual desaturation may justify additional oxygen bled into the ventilator circuit during sleep [60].
Continuous NIPPV
In neuromuscular diseases (and to a lesser degree in end-stage lung diseases), ventilator dependency may be total when starting NIPPV or may progressively increase following the gradual worsening of the disease. In cases of continuous need for ventilation, NIPPV could be used provided that interfaces are alternated night and day and assisted coughing is made available [37, 61]. Only a very well trained team that is completely informed and conscious of the constraints and dangers involved may take such an approach in patients. Such application has been reported by different teams in stable neuromuscular patients, such as those with a sequelae of poliomyelitis, high-level spinal cord injury or Duchenne muscular dystrophy [10, 62]. Alternatively, a tracheostomy may be performed to facilitate ventilatory assistance and secretion removal.
There is no clear answer as to whether, and beyond what duration, a totally ventilator-dependent patient is better or more safely ventilated by tracheostomy or NIPPV [35, 63, 64]. This debate will probably continue and, in the end, the decision to indicate NIPPV or to convert to tracheostomy is highly dependent on the philosophy and capabilities of the clinical team as well as that of the patient and their family environmental preferences. It is essential that discussion of such issues be started as early as possible in the patient's course, well before the imperative arises.
Swallowing dysfunction, which is responsible for frequent and massive aspirations and pneumonia and is observed during the course of ALS (frequent occurrence and is due to bulbar origin) or Duchenne muscular dystrophy (occurs seldomly and is due to muscle weakness), is an imperative indication for tracheostomy to prolong survival, although tracheostomy causes major difficulties for communication and reduces opportunities for personal interactions, leading to a locked-in state [64]. In this context, NIPPV, which may be easily stopped, could be the most reasonable option in cases of rapidly devastating diseases like ALS, and can be considered by both the patient and medical team as a limitation of care or a palliative approach [65]. This was confirmed in a study in which NIPPV in ALS patients with bulbar symptoms do not increase survival longer than controls [27].
Clinical follow-up and daytime ABG measurements (or their surrogates) should be conducted regularly (twice per year, for example). When possible, recordings during sleep when on NIPPV, identical to those taken when initiating NIPPV, are useful. At any time when there are unsatisfactory results, such as recurrence of clinical symptoms or hypoventilation on ABG, inadequate NIPPV must be suspected and objective evaluation during sleep must be undertaken. At the very least, overnight oximetry must be done. When NIPPV is determined to be suboptimal, a change in ventilator modality or setting and a review of the mask fitting may be indicated. Increasing the total duration of NIPPV use per day should also be considered, particularly when the underlying disease has progressed. Masks have to be regularly checked and changed or adapted as needed.
Management of complications
Air leaks during NIPPV
To some degree, leaks are present when using nasal NIPPV during sleep in all patients. The major potential adverse effects of such leaks are reduced efficiency of ventilation and sleep fragmentation [66, 67]. A variety of measures, more or less efficacious, have been suggested to address problematic leaks. These include preventing neck flexion, reclining in a semi-recumbent position, discouraging the mouth from opening by use of a chin strap [67] or a cervical collar, switching to pressure-preset mode [59], decreasing the peak inspiratory pressure, increasing the delivered volume [11], optimizing the interface [7, 8], and possibly switching to nasal pillows or a full face mask [68]. The effectiveness of these measures must be confirmed during sleep recordings.
Nasal dryness, congestion, and rhinitis
With reference to the CPAP literature, the side effects of nasal dryness, congestion, and rhinitis are related to a defect of humidification promoted by air leaks [69]. For patients with nasal and mouth dryness, a cold passover or a heated humidifier (the latter is more effective) can be used [70]. Heat/moisture exchangers are not well adapted in cases of leaks since the 'dry' flow from the ventilator is higher than the 'dampened' flow returning from the patient. In a large series, a minority of patients needed humidifiers [9].
Aerophagia, or swallowing air, is frequently reported by patients but is rarely intolerable [71]. Minor clinical signs are eructation, flatulence and abdominal discomfort. Aerophagia is usually dependent on the level of inspiratory pressure and is more commonly seen when using volume and/or mouthpiece ventilation and in the care of patients with neuro-muscular disease. The incidence decreases if the peak inspiratory pressure is kept below 25 cmH20 pressure.
NIPPV effects (other than survival) and related mechanisms
During ventilatory assistance
As expected, when under NIPPV, ventilation and gas exchange are improved in all types of disease [19, 72, 73], even if significant episodes of transient hypoventilation related to mouth leaks may appear [66, 67]. Duration of sleep is augmented without clear changes in its quality [65, 74]. Respiratory muscles are normally put at rest but there are many exceptions due to air leaks and patient-ventilator asynchrony [75].
After ventilation
When spontaneous ventilation exists, and in the absence of major lung disease, gas exchange remains improved after NIPPV is stopped. This may persist for hours and even days before reappearance of hypoventilation [76]. The improvement reported in many studies is important in chest-wall and neuromuscular diseases but inconsistent in COPD [72, 77]. Certainly, NIPPV can account for improvements in clinical symptoms such as general well-being, appetite, exercise capability, headaches, ankle edema, and resurgence of acute failure, as well as decreasing hospitalization, increasing quality of life [78] and improving survival.
Three main explanations for these improvements after NIPPV have been proposed: improved respiratory muscle strength, resetting of the chemoreceptors, and decrease of the ventilatory load. The first hypothesis suggests that ventilatory assistance rests the respiratory muscles, thereby reversing fatigue. Indeed, inspiratory force has been found to be significantly augmented in a few studies [30, 79]. The second hypothesis suggests that, in response to chronic hypercapnia and hypoxia, the chemoreceptors commanding the respiratory centers change their set point, which perpetuates hypo-ventilation rather than attempting to generate non-sustainable ventilatory muscle efforts [80]. The resumption of better ventilation during NIPPV would reset the centers to more normal values. The third hypothesis suggests that an improvement in respiratory chest-wall and/or lung compliance, under the effects of positive pressure ventilation, would reduce the ventilatory load and increase the efficiency of the muscles. In the studies done on scoliosis, vital capacity significantly increased [30, 79]; however, in other diseases, including neuromuscular patients, the vital capacity remained unchanged. In one study, chest-wall and lung compliance did not change even though there was a nonsignificant trend towards an increase [81]. Furthermore, periodic hyper-insufflation using higher inspiratory pressures for a few minutes in scoliosis [82] and ALS [83] patients revealed an increase in compliance. It seems probable that, even if the mechanisms that explain the efficacy of NIPPV are imperfectly understood, several factors, even if not individually significant, change and interact together to improve alveolar ventilation. The minimum mandatory duration of assistance is not clearly known. However, a relationship between a decrease in PaCO2 and the pressure to ventilate has been found [79]. Finally, one study reports a significant decrease in pulmonary arterial hypertension, which obviously favors clinical improvement [84].
In COPD patients, the absence of clinical results compared to those obtained for scoliosis and neuromuscular disease, even if resetting of the respiratory centers has been shown [85], could be explained by the relatively low impairment of respiratory muscles and the importance of the lesions of the lung itself and its progressiveness.
Chronic ventilatory support using NIPPV improves and stabilizes the clinical course of many patients with chronic ventilatory failure. The results appear to be good in patients with restrictive disorders and poor in COPD. Among the neuromuscular disorders results are better in the slowly progressing ones. The benefit of NIPPV is reflected by improvements in survival, blood gas composition and clinical stability, which help avoid the risk of acute failure and/or ICU admissions. Due to its relative simplicity and its non-invasive nature, NIPPV permits long-term mechanical ventilation to be an acceptable option for patients who otherwise would not have been treated if tracheostomy were the only alternative. In this way, nocturnal NIPPV represents a huge advance.
arterial blood gas
amyotrophic lateral sclerosis
bilevel positive airway pressure
chronic obstructive pulmonary disease
continuous positive airway pressure
- EtCO:
end-tidal CO2
intensive care unit
intermittent positive pressure ventilation
noninvasive positive pressure ventilation
- PaCO:
partial pressure of arterial carbon dioxide
- PaO:
partial pressure of arterial oxygen
positive end-expiratory pressure
- SpO:
pulse oximetry
- TcCO:
transcutaneous CO2.
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Robert, D., Argaud, L. Clinical review: Long-term noninvasive ventilation. Crit Care 11, 210 (2007). https://doi.org/10.1186/cc5714
DOI: https://doi.org/10.1186/cc5714


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MAN WITH A MISSION announce all shows for their release tour and reveal aurora borealis album cover
MAN WITH A MISSION played the tour finale of their five-year anniversary tour, titled <5YEARS 5WOLVES 3SHOWS TOUR>, at Shibuya eggman on January 29.
The wolf pack wanted to make this tour about "playing 'one-man' shows at venues that helped us out when we first started out." This memorial tour finale was held at Shibuya eggman, where the band played their first ever "one-man" show on July 3, 2011.
The show started with "Seven Deadly Sins", which is scheduled for release on February 11. The rest of the set worked backwards four years in time. For their double encore, they played "WELCOME TO THE NEWWORLD", the title track off their very first release in 2010.
The impressive song order was as if it was dedicated to the venue staff and the 350 fans that miraculously got their hands on tickets.
MWAM also announced all shows for their upcoming spring release tour, titled "Seven Deadly Sins Tour 2015". The tour will consist of two shows in each of the seven cities, totaling 14 shows.
It will be a live house tour starting at Zepp Tokyo and is sure to be a grand experience. Flyers for priority ticket reservations will be including in "Seven Deadly Sins", which goes on sale on February 11.
The second half of the documentary for the "Seven Deadly Sins" album cover photo shoot and the cover for the regular edition were revealed on this day as well.
The photo shoot took place in Whitehorse, Canada, and the documentary reveals that the band went there to witness the aurora borealis.
The limited edition "Wolf On A Dog Sled" album cover has already been revealed to the public, but the regular edition cover will feature TOKYO TANAKA (vocals) with the aurora borealis in the background.
The cover is sure to make an impact just as the limited edition "Wolf On A Dog Sled" cover did by seeming to hint at the concept of "The Origin of Species".
Each member of MAN WITH A MISSION has appeared alone on each of the band's past singles. Spear Rib (drums) was on 2011's "Trick or Treat e.p.", DJ Santa Monica (DJ, sampling) was on "distance", Kamikaze Boy (bass, backing vocals) was on "Emotions", and Jean-Ken Johnny (guitar, vocals, raps) was on the October 2013 single "database.
New Single "Seven Deadly Sins"
Released on 2015/2/11
M1:Seven Deadly Sins (TV anime opening theme)
M3:Falling (Shiseido "The collagen" CF song)
Official website (English) : http://mwamofficial.com
Official website (Japanese) : http://mwamjapan.info
Twitter (English) : http://twitter.com/MWAMofficial
Twitter (Japanese) : http://twitter.com/mwamjapan
Facebook (English) : https://www.facebook.com/MWAMofficial
Facebook (Japanese) : https://www.facebook.com/MWAMjapan

subset: commoncrawl


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Graydon (Graydy) Forrer is managing director of Life Sciences Strategies, a company that specializes in 'communications programmes for the bio-science industries' yet curiously appears not to have an online presence. It has also been listed among the clients of the Bivings Group - an Internet PR company that numbers Monsanto among its clients.
Forrer has previously been a director of consumer affairs at the U.S. Department of Agriculture, a fact that is regularly included in his self-description. What is rarely mentioned is the fact that he is also Monsanto's former director of executive communications, where he worked alongside Phillip Angell and Jay Byrne. For instance, in a report launched in September 2000, Organic Industry Groups Spread Fear for Profit (later reissued as Marketing and the Organic Food Industry ), which was co-authored with Alex Avery, a 20-line biography makes no reference to the Monsanto PR connection.
Forrer is known to have been working for Monsanto in early autumn 1999. On 10th Nov 1999 he registered the website foodsecurity.net. However, nothing on the site - the main content of which is pro-GM articles - indicates Forrer's involvement. Foodsecurity.net presents itself rather as 'an independent, non-profit coalition of people throughout the world'.


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After a fabulous past 20 years, World Music Expo celebrates its 21st birthday this October in Budapest. This will mark the first time an Eastern European city will organize the famous festival and host well-known artists and rising stars of the world's ethno music scene. But how was it possible and why this occasion will be different from the previous ones? Do Hungarians still have a gipsy-folk-based reputation, or is the image changing? We've discussed these issues with two of the hosts-organizers from the board of Hangvető, Hungarian partner of the WOMEX.
- Fans of ethno-music will be familiar with it, but the wider public has no idea what WOMEX is. Could you summarise in a few sentences what we are talking about?
Balázs Weyer, Director of Programing: – WOMEX or World Music Expo is a complex event combining a tradefair, a conference, a documentary festival and first of all a showcase festival which features 70-80 artists a year. It's the biggest marketplace, art-and-business platform for the world music industry and the only global tradefair. It's like the festival of Cannes for the film industry, except that it's for world music and it's a traveling festival, visiting another city year by year.
- This is the first time ever that an Eastern European country is organising the event. How did Budapest win this opportunity and which cities were its rivals?
András Lelkes, CEO: – Three years ago, some twenty plus countries were applying to organize this event, but only nine of them were shortlisted. Cities like Barcelona, Warsaw, Vienna, Dublin, Gotebourg, Thessaloniki and Budapest, so there was a strong competition. In the end, they chose us. We think there were several reasons behind it: one of them that Budapest is a capital and an important tourist destination – and when we are expecting more than 3000 participants, it's an important point. The second that Eastern Europe was pretty crucial, because it had been an almost blank area on the map of WOMEX…
Weyer: … and now it opens a door from the WOMEX perspective to the region. Simply because it's more affordable for artists and their managers from the Eastern region to come here than to go for example to Copenhagen which is more expensive. Artists coming from Serbia or Macedonia can just jump in the car and get here in a few hours. A third reason could be that Hungarian traditions play an important role in the western European folk-tradition side.
During the late '60-70s when the second folk revival in Britain started, it was inspired partly by the Hungarian "Táncház" (dance-house) movement and also by Béla Bartók, who is a very important reference in the world's ethnomusicology. He was the first musical artist who really massively researched folk traditions. We know a bunch of artists who travelled to Hungary and Transylvania in the '70-80's to see these dance-houses, because by that time there was a strong focus on folk music. It's still one of the most living traditions in Europe and maybe this produced some romantic feelings.
- In what kind this year's WOMEX will be different from the previous ones? What can you offer that others can't?
Weyer: Every WOMEX is different because everybody wants to show their special "stamp" or special footprint on the event that they're organizing.
**What's in the schedule?**The first day is the opening ceremony which is usually a 60-minute long exclusive concert and basically the only time during WOMEX when everybody is in one single space. Then over the next three days, WOMEX is split between the trade fair, some networking events, conferences, and every evening from 9 pm to 1 am there are showcase concerts on five different stages. When all the concerts finish, the DJ Summit starts to play from 1 to 4. Finally, the last day is the award ceremony, where WOMEX gives its life achievement Artist Award, the Professional Excellence Award to someone from the music industry, and the Label Award (record publisher of the year). The artist who gets the life achievement award gives an exclusive closing-concert to the delegates.
As we are the first location in Eastern Europe to host a WOMEX, for us, this is an opportunity but also a responsibility to represent and open up the region.
Lelkes: We want to focus on Eastern Europe in every sense. To feel the atmosphere, to watch and listen more eastern Europeans – not only on the showcase where more eastern European artists will play than ever – but also in the trade fair. It brings the possibility to Hungarian artists to introduce themselves on the larger market. The number of applications from Hungary and from the region was the highest in WOMEX history – but I can say the same globally. We are expecting some 3000 international visitors plus local Hungarians.
- Hungarians already have a long history with Womex – we've represented ourselves on the very first WOMEX, and in 2008 Hungarian band Muzsikás got the life achievement award. How do foreigners think about us? Do they always see us as a gipsy band – or do they recognise modern Hungarian ethno-music?
Lelkes: It's an interesting question. Many of the Hungarian bands from the '70s had been touring in Western Europe and in the USA. So if you ask a non-Hungarian world-music fan, one would name at least an important singer or band. Like Marta Sebestyén who is an icon of world music. Probably, she is the best known artist of the Hungarian ethno music. It's like if you meet a foreigner and you're starting to discuss about football and you mention Puskás, he will surely know who he was. It's similar with Márta and many others, like Muzsikás,Zsarátnok,Vízöntő,Vasmalom. We had a very good reputation.
Weyer: But what you've mentioned about the gipsy music stereotype: it's a brand, and like any brand in the world it is based on stereotypes. And since in Hungary nobody really looks after this image – as they do in other countries with the so-called Music Export Offices (which does not exist in Hungary ) – so there is a bit of confusion among foreigners. It includes superficial images of gipsy coffee house music, some Balkan stereotypes and images of dance house. In the past years, they've seen some successful concerts – like Söndörgő's for example which is really good, we really love it, but it's a very special part of the musical heritage of Hungary. Also they've seen the year before Felix Lajkó who is also fantastic, but again: not typical to the Hungarian tradition.
Lelkes: But these stereotypes are not only characterizing Hungarian music. This is a common phenomenon of Eastern European music which involves Balkan, Polish and Ukrainian bands also. It's like when we think about Africa, we haven't got a very detailed picture of every respective musical region. If you are not an expert, you don't really see the difference between the music from Ivory Coast and from Senegal. That's the same for our region. People don't really care if it is Hungarian, Romanian, Czech or Serbian. We have to work on making Hungarian music's image a bit beyond this stereotypes.
- How many singers/bands will participate at the event? Could you name some?
Weyer: More than 50 bands and performing acts were selected from more than a thousand. As WOMEX is not an ordinary music festival, bands have to apply to participate. There is a jury, the so-called "seven samurais" whose members change every year so their taste does not become predictable. The jury is still working – as there are a thousand bands which applied and lots of them are still being heard, it's difficult to work on the jury – so we don't know all the names yet, but the first 19 performers are already known: there are some well-known names such as last year's winner of the Best World Music Record performer Aziza Brahim or Avishai Cohen and new ones like Moh! Kouyate from Guinea and Pierre Kwenders from Congo.
WOMEX World Music Expo will be held 21-25 October 2015 in Budapest, more info: www.womex.com
First 19 short-cased artists:
• Alo Wala (Danmark/USA)
• Aziza Brahim (West-Sahara/Mali/Spain)
• Baraji (South-Korea)
• Bella Hardy (USA)
• Chouk Bwa Libète (Haiti)
• Cimbalomduó (Hungary)
• Didier Laloy & Kathy Adam (Belgium)
• Emicida (Brazilia)
• Forabandit (Turkey/France)
• Jaakko Laitinen & Väärä Raha (Finland)
• Iberi (Georgia)
• Moh! Kouyate (Guinea/France)
• Nine Treasures (China)
• Palenke Soultribe (Columbia/USA)
• Pat Thomas & Kwashibu Area Band (Ghana)
• Pierre Kwenders (Congo Democratic Republic/Canada)
• Tarek Abdallah & Adel Shams El-Din (Egypt/France)
• Trumpeter Avishai Cohen's Triveni (Israel)
• Vaudou Game (Togo/France)
Main Photo: Friday Night Ethicolor in 2014, photo of Yannis Psathas, and Moh! Kouyate, photo of Hugues Anhes, property of WOMEX


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Two years have passed since I wrote about the rise of MOOCs (Massive Open Online Courses). A MOOC is an online course that can support unlimited participation and open access via the internet.
Quality educational content has never been more widely available.
Quality educational content has never been more widely available. The world's experts are recording their lectures and courses and making them available at affordable prices, if not for free.
It has become cheap and easy for a content expert (not just professors, but consultants, authors and practitioners) to set up a camera, record lecture-like videos, develop testing material, and make it available to everyone through one of any number of digital educational platforms which serve (and bill) the courses.
Higher Ed is scrambling to keep up.
As technology drives down the variable (and even fixed) cost of creating and distributing video content, it is now possible to widely share educational materials. On some level, it's not that different than what the printing press enabled, in terms of democratizing knowledge. But video and digital content are more engaging and fun than textbooks.
Most schools have been experimenting with MOOCs. For example, Wharton at the University of Pennsylvania, one of the most well-regarded business schools in the world, offers MBA-level introductory courses in Marketing, Accounting, Finance and Operations, featuring their most experienced and engaging faculty, peer collaboration and review, and automated testing and feedback.
But much more rapid experimentation is happening outside the walls of top universities. Khan Academy provides brief snippets of instruction to clarify complex ideas, which are often used to support students learning in traditional classrooms. edX has combined forces with Google to open the technology needed for MOOCs to a broader audience. Vishen Lakhiani, founder of the popular educational technology company MindValley, has publicly talked about the failure of traditional higher ed to meet the needs of the world's learners, both in terms of accessibility and content.
According to Inside Higher Ed, there are literally thousands of MOOCs available.
Universities are still trying to answer questions about the future of MOOCs, what their role should be, and how MOOCs will impact business as usual. The pace of experimentation with remote and pre-recorded learning in Higher Ed has accelerated, even as they try to justify their high tuition fees for online learning (which is available much more cheaply elsewhere.)
Here are some of the questions on their minds:
- Should we offer MOOCS? If so, what, if anything, should we charge for them?
- Which faculty should teach our MOOCs?
- What if faculty want to offer MOOCS on their own. Is that allowed? What kind of oversight should the university offer?
- How should MOOCs affect accreditation?
- What, if anything, can we charge for courses?
But the biggest question is this: If all of our courses are offered online, why would someone pay for a campus experience? Especially now, when many of our tuition-paying, degree-seeking students are having a primarily online experience?
Higher education is changing, with traditional organizations and entrepreneurs alike rethinking how best to deliver on the industry's overarching forever promise (equipping citizens to live a good and productive life). One thing is clear: the "four year" year college model is not enough. For some, it's too expensive. For others, it's too disruptive.
The question isn't "how do we get our content online"–it's "how do we expand and extend the way we deliver on our forever promise in light of changing conditions"?
While many institutions are working on remote and online courses, I think they're missing the bigger questions. The question isn't "how do we get our content online"–it's "how do we expand and extend the way we deliver on our forever promise in light of changing conditions"?
The forever promise for Higher Ed, at least in the US, is not limited to the course material itself. It's a promise to change students for the better–to make them good citizens and ensure that they will be able to find and keep interesting and lucrative professional opportunities throughout their career.
Certainly courses are important, but equally if not more important to that promise is the cohort of fellow students, feedback and interaction from faculty, extracurriculars, career guidance and alumni support. Higher Ed Institutions as well as the entrepreneurs who want to replace them need to incorporate community, coaching and ongoing benefits into their programs if the want to stay relevant.
As learners, our journey is never ending. Our needs and our environment change over time, and we know that to live our best and most productive lives, we need a model that provides continuous growth…forever.


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Opera Comments Bot last edited by
Here you can post comments about RoSearcher extension, created by 9b62fd38-68f8-493e-a516-c8c04c2bb2e6
A Former User last edited by leocg
I have two questions.
- Des the person Have to be friended in order for this to find them?
and 2. Do I have to enter the exact username or will it search all related names as well?
- Des the person Have to be friended in order for this to find them?
A Former User last edited by
I highly recommend this plugin for anyone that likes to stalk and freak people out
All jokes aside though, this works just as said. The person is not even required to be friended. They do however have to have their joins on, this plugin basically just saves you the time of looking someones profile up and joining them from there. If their joins are not on then this plugin does not work. -
gingerandrew last edited by
I recommend this extension but i heard that rosercher is a virus what virus? the virus is that it steal your limited items and robux and your accout so becarefull of what you add thank you.
MicDoesStuff last edited by
To anyone saying this is a virus, your incorrect, the chrome extension that people have found out is malicious is Searchblox and to anyone thinking about using this plugin, its perfectly safe and will not steal your data, also SearchBlox has been deleted so its basically impossible to install now
kzqrss last edited by
idk if i would download this. Its pretty fishy since SearchBlox had this same problem, and this is basically the same type of extension..
rigotherobloxgamer last edited by leocg
This is a virus that steels your account details and limiteds! Do Not Install!
azking2012 last edited by
its not a virus i had this said mid 2022 no virus i got data wipe so i no have at this moment but i get agian


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CT7154 - Network Routing Protocols (2023/24)
Module specification | Module approved to run in 2023/24 | ||||||||||||
Module title | Network Routing Protocols | ||||||||||||
Module level | Masters (07) | ||||||||||||
Credit rating for module | 20 | ||||||||||||
School | School of Computing and Digital Media | ||||||||||||
Total study hours | 200 | ||||||||||||
Assessment components |
Running in 2023/24(Please note that module timeslots are subject to change) |
Module summary
This module tackles all issues important in the design, implementation, and configuration and troubleshooting of routing protocols in computer networks. Students learn basic concepts of routing algorithms and associated protocols. They then develop advanced skills in the deployment of individual protocols as well as advanced topics, such as route redistribution, route filtering, and migration to the latest Internet Protocol, IPv6. It includes aspects such as the Hierarchical Network Model, the SONA Framework, IP v4 and 6, Advanced routing protocols including Interior Gateway Protocols such as EIGRP capabilities and attributes and single and multi-area OSPF as well as the Exterior Gateway Protocol, BGP. It also introduces route filtering and path control to provide optimal and secure path selection in a complex computer network. Upon successfully completion of this module student should be able to sit for CCNP Route industry certification subject to satisfying relevant pre-requisite (CCNA).
• The OSI model and data encapsulation
• Routing Fundamentals and Router components,
• Routing protocols and router configuration
• CDP and basic Networking testing, troubleshooting
• The Hierarchical Network Model, Intelligent Information Network (IIN) and the Service-Oriented Network Architecture (SONA).
• Routing fundamentals, Algorithms, Structure and Framework, static and dynamic routing protocols.
• Link-State Routing Protocols, SPF Algorithm, Dijkstra's algorithm, OSPF Terminology, Metric calculations, Maintaining Link-State Sequence Numbers, Verifying Packet Flow, Tracking OSPF Adjacencies, Authentication Methods and Troubleshooting.
• EIGRP Algorithm, Capabilities and Attributes, DUAL Finite-State Machine
• IPv6 concepts, Architecture, addressing, routing, OSPFv3 and IPv4 to IPv6 translation.
• Route optimization, Route map, Policy Routing, Route Redistribution.
• BGP Concepts and Terminology, BGP attributes, Configuration and Verification.
• Multicast Routing protocols concept and terminology, IP Multicast Addresses, IGMP and layer 2 issues, Multicast Configuration and Verification.
Balance of independent study and scheduled teaching activity
A variety of approaches will be adopted. The recommended textbooks in bibliography, covers the detailed syllabus of this module. In addition to this, students also have access to course material on Weblearn which will enable them to further enhance their learning. Formal lecture classes will further emphasis the key features of each syllabus and provide opportunities for interactive discussion on some of the more important issues of routing protocols. Through series of in-depth lab activities students would gain adequate knowledge to design a basic network which meets a small business network requirement. Students are required to provide evidence (through logbooks) how they have completed each phase and demonstrate that their design and configuration meets the initial user's requirement.
The aim of extensive laboratory programs is to help students to gain knowledge and skill of designing and implementing routing protocols and enhances the understanding of the theoretical concepts in their practical context.
Learning outcomes
On successfully completing the work covered in this module, the student should be able
LO1. Evaluate and appraise the most common internetworking components, networking protocols, network addressing schemes and configuration (routers, IP addresses etc.) and conceptual models integral to network communication.
LO2. Design and implement a complex and scalable routed network architecture using appropriate technologies, the Hierarchical Network Model and to understand the key characteristics of scalable internetworks, traffic patterns in a converged network, and critically assess the suitability and applicability of various routing protocols within a campus network and ISP.
LO3. Develop a thorough understanding of routing protocol algorithms, terminology and concepts, and synthesise design strategies for IP addressing, summarisation and route optimisation.
LO4. Identify, configure and verify various routing protocols and learn and develop a comprehensive knowledge of IPv6 Features, Addressing Architecture.
LO5. Effectively plan, execute and report on individual plus peer-review in group programmes of work.
Assessment strategy
The assessment is designed to cover all the learning outcomes.
The module is assessed by a case study (2500 Words, formative and summative) on a complex network topology using basic and advanced routing protocols. Students will be working in small groups of 3 to 4 and are given a detailed brief and will be required to provide an efficient, scalable and innovative solution. A typical case study would comprise a large campus network comprising multiple cores, distribution and access layer devices using appropriate new technologies. Students would be required to develop an efficient, scalable and secure solution and deploy their solutions in the lab. Students are required to record any activities towards the completion of their case study in a separate logbook (not the laboratory logbook) on weekly basis.
The students are split into groups and meet weekly to discuss the work and agree the path the investigation takes. This process is observed by members of the supervisory team and meetings need to be signed off by both students and supervisor.
The final mark of the case study is based on the presence of the case study logbook and successfully completion and submission of the case study individual report. The final mark will take into consideration the marks achieved through several in class tests that cover the topics in their case study as well as participating in a peer assessment.
Final practical examination (summative, 2 hours) consists of configuring a topology of several routers by using Internet Operating System (IOS) command line. All assessments will take place in the laboratories.


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Is Catherine Lough Haggquist married? Yes, she is. Her husband's name is Neil. The pair has already spent over two decades of conjugal life together. They have worked together on several projects including the opening of BizBooks.net in 1996. Scroll down to explore more interesting personal facts and biography of Haggquist:
Who is Catherine Lough Haggquist?
Born as Catherine Lough Haggquist, she landed the planet on April 3 but her exact year of birth isn't available. By profession, she is a Canadian actress, entrepreneur and producer. She is known for being credited for acting over 125 times. She also produced a short film called Reel Women Seen that was able to amass multiple awards including the 2018 Jury Choice Award.
Early Life and Education
Haggquist was born possibly in the 1970s and there is no valid information regarding her exact age. Her place of birth is in Vancouver, Canada. Talking about her family background, she was born to Canadian parents who raised her in the Canadian Prairies in Western Canada. From her young age, she was drawn to various creative mediums and was inspired by storytelling in school and regional Canadian television.
At the age of 11, she returned to her birthplace. With her brother, she grabbed opportunities to appear in commercials. This inspired her to take acting classes and encouraged her to pursue her career in the entertainment industry.
Career and Professional Life of Haggquist
During her long acting career, Haggquist has already appeared in over 125 projects. She has been starred in seven Christmas TV movies. She was honored by UBCP/ACTRA with a life membership for her long contribution to the theatre, television and film industry.
In 1992, she appeared in a television movie called A Killer Among Friends. The following year, she played the role of nurse in For the Love of My Child. The same year, she was seen in an episode of comedy-drama television series The Commish. The following year, she appeared in television movies like No Child of Mine and Sherlock Holmes Returns.
In 1994, she appeared in medical drama television series Birdland as Admissions Nurse. She was also starred in one episode of science fiction drama television series The X Files as Dr. Richmond and M.A.N.T.I.S. as Patricia in 1994. She was also seen in the role of reporter/ news anchor for three episodes of science fiction drama television series.
Her major television appearances include Continuum as Nora Harris, web television series Project Mc2 as Dr. Allison Crawford, drama television series Chesapeake Shores as Linda Nelson and supernatural drama television series Motherland: Fort Salem as Petra Bellwether. Likewise, she has appeared in television films like Nature of Love, Mystery 101: Dead Talk, Jingle Around the Clock, Falling For You, The Sweetest Heart, A Bundle of Trouble, Angels in the Snow, Welcome Home, Fatal Memories, A Bride for Christmas, Innocent, Four Extraordinary Women, The Linda McCartney Story, Fatal Error, To Walk Again, No Child of Mine, Sherlock Holmes Returns and so on.
Her film credits include romantic comedy-drama film Life or Something Like It, Canadian comedy-drama film Moving Malcolm, action horror film Alone in the Dark, science fiction action film Tron: Legacy, Elysium, Canadian drama film The Confirmation, action film Countdown, drama film Broken Diamonds and so on.
How is Haggquist's Personal Life?
Catherine Lough Haggquist is a married woman. She is having a perfect time with her husband Neil. She often uploads a picture with her husband. They have worked together in several projects including BizBooks.net which they established in 1996. Haggquist hasn't disclosed many of her personal facts including her exact age and date of birth.
Body Measurements
Canadian actress Catherine Lough Haggquist stands at an average height of 5 feet and 6 inches. Some wiki sites have mentioned that she weighs about 52 kilograms which makes her possess a perfect/ healthy BMI calculation. She knows the usefulness and necessity of remaining fit and active in order to stay competent in the entertainment industry. Therefore, Haggquist ensures her maintained diet consumption along with following workout plans.
How Much are Salary and Net worth of Haggquist?
Catherine Lough Haggquist has an estimated net worth of 3 million USD. She is active in the industry since 1992 and has already been credited for more than 125 movies. Her produced short film called Reel Women Seen has received the 2018 Jury Choice Award at the Diversity in Cannes Short Film Showcase. She was also honored with Special Jury Award during the 2008 Women in Film and Television Vancouver. She was awarded the Life Membership by UBCP.
Wiki, Social Media and Facts
The biography of actress Catherine Lough Haggquist is provided by multiple wiki sites like IMDb and Wikipedia. Join her on Instagram @thecatlh where she has amassed more than 1.8k followers. Her Twitter account @TheCatLH where she is being followed by more than 2k followers.
Catherine Lough Haggquist is one of the most respected and multi-talented actresses. She has been awarded prestigious awards and nominations or her long contribution to the film and acting industry. The lesson which we learn from her biography is that we need to become active in our profession which will surely make us reach the height soon or later.
Quick Facts
Birth Name: Catherine Lough Haggquist
Date of Birth: April 3
Place of Birth: Vancouver, Canada
Parents Name: N/A
Profession: Actress
Height: 5 feet and 6 inches
Weight: 52 kilograms
Net Worth: $3 million
Sexual Orientation: Straight
Marital Status: Married
Spouse/ Boyfriend: Neil
Children: N/A


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Prof Brenda Yeoh elected to the Fellowship of the British Academy
Professor Brenda Yeoh from the Department of Geography at the NUS Faculty of Arts and Social Sciences has been elected into the British Academy, the United Kingdom's national academy for the humanities and social sciences. Prof Yeoh is the only scholar from Singapore to join an illustrious list of 84 new Fellows.
The British Academy elects up to 52 outstanding UK-based scholars of the humanities and social sciences each year. In addition to this, it also elects overseas scholars as Corresponding Fellows. This year, 29 such scholars were elected from universities in the United States, Australia, India, Russia, Italy, France, Singapore, Poland, China, Turkey, Germany, Canada, Sweden, the Republic of Ireland and Hungary.


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Phycology, a sub-topic of botany, is the academic discipline involving the study of algae. Phycologists, scientists who study algae, tend to be specialize in either diatoms or soft algae, and they tend to further distinguish their studies as either involving marine algae (those living in salt water) or fresh-water algae.
There are many algal taxa; estimates are that as many as 200,000 distinct species may exist, although only a fraction have yet been identified. In the 1940's, diatoms began to be studied for ecological assessment by Dr. Ruth Patrick of the Academy of Natural Sciences Philadelphia. Since algae live in a wide variety of habitats and have specific ecological requirements, the mix of species found in water samples can be an indicator of water quality. Such studies are complex and involve many factors, such as where and when the sampling occurs, how the counting of species is done, and how the data is afterward analyzed. Algal assessment is practiced in modern times by the U.S. Geological Survey and by many state Environmental Protection Agencies.
The study of algal fossils found in sediment cores from lakes and streams is useful in paleolimnology, a field of study concerned with studying the history of inland waters (lakes and streams; freshwater, brackish, or saline), especially climate change and the impact of human activities upon the overall health of water bodies.
In autumn of 2008, the 20th International Diatom Symposium (IDS) was held in Dubrovnik, Croatia and attended by around 200 people. This symposium, which occurs every two years, is a key opportunity for exchange among the relatively few world experts in Phycology. On off years, when there is no IDS, the North American Diatom Symposium (NADS) is held instead. The 19th NADS was held in the autumn of 2007 at the University of Michigan; attendance at this symposium is typically around 100 people.


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When Staff Is like Family
Finding the right fit for a small staff is no easy feat. Many of the Letters' readers know that I have been involved the last year with the restructuring of this publication and strategic planning for the organization. For the publication, we dissected the operations and processes to make the tasks manageable and efficient. For the organization, we underwent a full year of planning, visioning, community input, cultural examination, and process analysis.
As part of the strategic plan, we underwent a full staff analysis to identify the resources needed to move CAMP Rehoboth from a founder-led to professionally-led nonprofit. Getting the work done in programs, outreach, and advocacy with a full-time paid staff of four, part-time contract staff of seven, and several unpaid "staff" (volunteers who do staff-level work in development, accounting, programing, and outreach) plus large volunteer committees who manage the operations for our largest initiatives (Women's FEST, CAMP Chorus, Sundance, Block Party) is a lot of juggling of resources. Each position was examined, with responsibilities and authorities aligned. I am pretty sure that from the outside the pace looked like slower-lower Delaware lava, but inside it has been a cauldron of energy and ideas and emails that move in a flood.
Resulting from this analysis last fall, the Board approved several new staffing initiatives. The first was to approve a new position of communications manager to be hired immediately. Second was to initiate the search for a new executive director. The third was to approve a staff position in development, to be hired by the new executive director.
There was a great deal of discussion on why we would hire this new communications manager ahead of the other positions. That answer ended up being simple: this job had been primarily filled before 2018 by Murray and Steve and others. As a fulltime volunteer, Murray had managed the graphics and communications, shepherding the organization to new tools in the last decade: a website, the world of social media, and email communications.
In order for Murray to lead the organization as interim executive director, and in order for him to move on and for a new executive director to succeed, these tasks had to move to someone else. Through our strategic planning, communications was identified as one of the fundamental keys to fulfilling our mission of creating a positive community. Over the past year, we consolidated the oversight for the production of print and digital materials, including the website, social media, brochures, and other materials to mostly one person: me.
Lots of people play important roles in keeping this organization humming and bringing this publication to life 15 times each year. While I have preferred a mostly uncredited role, I'm outing myself today to thank the board and staff for allowing me to plug along as my bossy-boss self moving us to this future. Most of the work that I've been doing has been structural: creating consistency in vehicles like the Monday emails; setting schedules and tools to coordinate functions and reduce the deluge of emails; writing, tweaking, creating checklists and policies; acting as managing editor for this publication.
My entire motivation has been love. I love this organization and the people involved too much not to help it fly on its own.
We interviewed many people for this position. Using a screening questionnaire, phone interviews, and in-person meetings, we talked to a lot of people who each would have brought different talents to helping us fulfill CAMP Rehoboth's mission. Our first round straddled the holiday season and we weren't able to find just the right combination of talent and skills that we sought. But in our second round, as these things go, we found just the right person. In the current world of recruitment, we haven't circled around to respond to each applicant, but we want to publicly acknowledge our appreciation for every resume we received.
We are thrilled to welcome Mary Shockley to the CAMP Rehoboth staff. As communications manager, reporting to the executive director, Mary comes into a job that has a pretty full plate and plenty still to develop. About half of her job is directing this publication. In addition to that, she will be focused on promoting programs and events, supporting membership, and increasing engagement. While there are many aspects of communications that still live within committees—CAMP Chorus, CROP, Women's FEST, Sundance—those committees will have better support to meet the CAMP Rehoboth mission.
Mary brings a range of experience that includes marketing, journalism, and promotion. She has worked in both for-profit and non-profit organizations. She is local and loves this area. She understands our mission completely and without question. She has a good attitude and is a quick study. She and I will work side-by-side for many weeks to give her a firm foundation in all of the tasks and responsibilities. We expect her to keep things the same and also to change everything. We count ourselves very lucky to have her as part of the CAMP Rehoboth family.
Starting this issue, you will see two major changes to the masthead: Murray moves to the more-appropriate role of publisher, and Mary begins as managing editor.
Murray's role as publisher continues to make him responsible for the editorial and commercial success of this publication. He will guide the editorial position (how this serves the CAMP Rehoboth mission) and manage business operations so that the publication provides high quality content while maximizing revenue and profit.
As managing editor, Mary takes over what I have been doing this past year to coordinate a lot of moving parts. She develops ideas, handles problems, keeps everyone on schedule, writes and coordinates the "In Brief" department, and determines the layout of the publication. She organizes the graphics and photography, and is the liaison with advertising. She oversees all of the contracted part-time staff that make this publication interesting, relevant, and excellent.
Our part-time contract staff make a lean-mean machine: Fay Jacobs as editor, responsible for content acquisition, editorial development, and writing and editing content; Mary Beth Ramsey as our art director, responsible for design and layout; Marj Shannon, our editorial assistant, who hones our product with copyediting and proofreading; Doug Yetter, our arts editor, who keeps his eye on all of the entertainment around this area; plus our many columnists and writers who remain committed to focusing their lenses on the world around and deadlines that come too soon. Additionally, our only true fulltime staffer, Tricia Massella, advertising sales manager since the start of this publication, continues to be steadfast in adopting new systems and more responsibility without batting an eye.
There is plenty of work for everyone. There is room for all.
My love affair with CAMP Rehoboth is not at an end. It is my family.
You still will see me active and involved, doing things here and there. I still will continue as tireless cheerleader, supporter, donor, and activist. I will continue to be constructive about our future and work to make each day as positive as I am able. But I am going to step back some and watch this seed grow. It will thrive. I'm thrilled to have Mary as a new member of the CAMP Rehoboth family and know that you will be too.▼
Sondra N. Arkin is an artist in Washington, DC, has served on several nonprofit boards, and has been involved with CAMP Rehoboth since she was recruited in the mid-90s to do "one small thing."


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The AI for Good Global summit which was cancelled due to covid19 is now online until the end of the year. You may register and listen to speakers and participate in virtual events and discussions.
The goal this year is to
- identify progress towards UN Sustainable Development Goals
- Accelerate solutions for global impact
- Scale practical applications of AI
Breakthrough Days (21-30 September 2020)
The goal of Breakthrough Tracks is to generate and fuel meaningful projects in each of this year's three AI for Good Global Summit domains – Gender, Food, and Pandemics – that will advance progress on the UN Sustainable Development Goals (SDGs).


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"The Ultimate Guide to Plus-Size Backpacking": One Guide to Help Them All!
In 2 days will be the big launch of "The Ultimate Guide to Plus-Size Backpacking"! Here's the official press release… ►►►
In 2 days will be the big launch of "The Ultimate Guide to Plus-Size Backpacking"! Here's the official press release… ►►►
I recently shared a photo album on The PS Backpacker's Facebook page called "#MyMontreal" that presents bits and pieces of the city that became my home 15 years ago, as I moved here to study journalism. ►►►
I previously mentioned this gadget in a post about 1 year ago, but I thought this could be worth it to write a bit more about it as this is, by far, one of the smallest, yet most useful gizmo I carry when I'm away… You know, the good old Traveler's What If Syndrom… ►►►
Though it goes a bit against my backpacker "instincts" to pack very flashy things to wear, in order to be able to mix and match all (or nearly all!) my items of clothing, this one comes as a complete surprise! (I also hate to be too visible while away to avoid drawing unwanted attention.) ►►►
With every week passing by, I'm getting more and more thrilled about the products I ordered that I'm reviewing for you here… and this one is no exception.
Zip top bags (often called "Ziplocs") are part of our traveler's life, whatever our size, since September 11. ►►►
Since September 11, 2001, these little guys made themselves scarcer in passenger's luggage (especially carry-on as they were fully banned from hand-luggage since). ►►►
Bamboo has found its way in many of our homes in the past few years: furniture, flooring, blinds, even sheets… Have you heard about bamboo as a fabric for clothing? ►►►
(C) 2013-2019 The Plus-Size Backpacker / La Backpackeuse taille plus (Edith Bernier) *** This website is non-transactional and cannot be used to conclude a purchase. / Ce site est non transactionnel et aucun achat ne peut y être effectué.