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Arch Pulmonol Respir Care
Archives of Pulmonology and Respiratory Care
Review Article Open Access Peer-Reviewed
Evaluating mechanical ventilation in patients with Acute Respiratory Distress Syndrome
Leonidas Grigorakos1,2*
1Faculty of Nursing, National and Kapodistrian University of Athens, Greece
2Intensive Care, "KAT" Trauma Hospital of Athens, Kifissia. Greece
*Corresponding author: Leonidas Grigorakos, Associate Professor, 2 Nikis St, 14561, Kifissia, Athens, Greece, Tel: +30.210.3709522; Fax: +30.210.3709520; E-mail: grigorakos@parliament.gr
DOI: 10.17352/aprc.000031
Received: 04 December, 2018 | Accepted: 09 January, 2018 | Published: 10 January, 2018
Keywords: Acute respiratory distress syndrome; Ventilator-induced lung injury; Mechanical ventilation guidelines; Prone positioning
Grigorakos L (2018) Evaluating mechanical ventilation in patients with Acute Respiratory Distress Syndrome. Arch Pulmonol Respir Care 4(1): 001-005. DOI: 10.17352/aprc.000031
Even though acute respiratory distress syndrome (ARDS) has been intensively and continuously studied in various settings, its mortality remains high. Mechanical ventilation is an essential component of the care of patients with ARDS. Thus, many randomized controlled clinical trials have been conducted, evaluating the efficacy and safety of various methods of mechanical ventilation in order to adapt ventilatory setting to protect patients from ventilator-induced lung injury (VILI) and to treat them effectively.
There is no well-stated practical guideline for mechanically ventilated patients with or without ARDS. However, as general measures low tidal volume, high positive end-expiratory pressure, and conservative fluid therapy seem to improve outcomes.
In conclusion, improving knowledge and evidence regarding the management of mechanically ventilated ARDS patients is critical. Thus, medical personnel managing patients with ARDS should personalize decisions for their patients.
Abbrevations
ARDS: Acute Respiratory Distress Syndrome; VILI: Ventilator-Induced Lung Injury; Ardsnet: Acute Respiratory Distress Syndrome Network; PEEP: Positive End-Expiratory Pressure; Fio2: Fraction Of Inspired Oxygen; PO2: Partial Pressure Of Arterial Oxygen; Pplat: Plateau Pressure; VT: Tidal Volume
Acute respiratory distress syndrome (ARDS) has been defined as an acute respiratory failure in terms of acute onset, hypoxia, diffuse infiltrates on chest X-ray, and absence of cardiac failure, or pulmonary edema due to cardiac origin [1,2]. The severity of ARDS is dependent on the oxygenation failure, expressed as PaO2/FiO2 ratio of 100, 200, and 300 mmHg as severe, moderate, and mild, respectively. During the last 50 years mortality caused by ARDS decreased but the survival rate is still as low as 70%, while the hospital mortality rate reaches more than 40% amongst patients with moderate or severe ARDS [3].
A recent study showed that ARDS is common in the ICU, occurring in 10% of all patients admitted [4]. Although mechanical ventilation is a cornerstone in the management of patients with ARDS, it can aggravate lung injury, a process referred to as ventilator-induced lung injury (VILI), through several mechanisms including volutrauma, barotrauma and biotrauma [5,6]. Dynamic lung distension and repeated opening and closing of recruitable lung units are considered the two main mechanisms contributing to lung injury. In a large randomised controlled study, the lung protective ventilation strategy using low tidal volume and limiting plateau pressure (Pplat) has been proven to improve survival in patients with ARDS and subsequently it was confirmed in a meta-analysis [7,8]. However, current research still suggests that further reducing VILI is the main avenue to further reduce mortality in this syndrome. Thus, improving knowledge and evidence regarding the management of mechanically ventilated ARDS patients is critical.
Diagnosing ARDS
Diagnosis of ARDS may be challenging as the presenting symptoms are nonspecific. The signs and symptoms of ARDS in the case of patients under mechanical ventilation can vary in intensity, depending on its cause and severity, as well as the presence of underlying heart or lung disease. They include: severe shortness of breath, laboured and unusually rapid breathing, low blood pressure, confusion and extreme tiredness (Table 1). Important changes occur also on the monitor parameters: a) increased airway pressure due to increased resistance or reduced Compliance of the system (tube-lung-chest wall), b) changes to PO2 (a normal change of up to 10% may be observed), c) pressure change (hypertension or hypotension), d) arrhythmias [9,10].
Table 1: Diagnosing ARDS.
Dyspnea Yes
Hypoxia Yes
Tachpynea Yes
Pleuritic chest pain Yes/No
Sputum production Yes/No
Rales Yes
Fever Yes/No
Edema No
Jugular venous distention No
Third heart sound No
Hypoxemia Yes
Bilateral infiltrates Yes
Pulmonary wedge pressure ≤ 18 mm Hg Yes
PaO2/FiO2 ≤ 200 Yes
Localized infiltrate No
Elevated brain natriuretic peptide level No
Cardiac enlargement No
Antibiotics No
Diuretics No
Oxygen No
FiO2 – fraction of inspired oxygen, PaO2 – partial pressure of arterial oxygen.
Thus, physicians, in order to narrow the differential diagnosis and determine the optimal course of treatment, must consider patient history (i.e. comorbidities, exposures, medications) in conjunction with a physical examination of other respiratory, cardiac, infectious, and toxic etiologies.
The role of mechanical ventilation in patients with ARDS
The goals of mechanical ventilation in ARDS are to maintain oxygenation, while avoiding oxygen toxicity and the complications of mechanical ventilation.
In an ARDS Network study, patients with ARDS were randomized to mechanical ventilation and it has been demonstrated that subjects in the low-tidal-volume group had a significantly lower mortality rate (31% versus 39.8%) [7]. While previous studies allowed patients to be hypercapnic and acidotic to achieve the protective ventilation goals of low tidal volume and low inspiratory airway pressure, the ARDS Network study allowed increases in respiratory rate and administration of bicarbonate to correct acidosis. More so, patients with severe ARDS receiving mechanical ventilation responded more favourably to early administration of a neuromuscular blocking agent (ie, cisatracurium) than to placebo, showing an improvement in survival and increased time off the ventilator [11]. Evidence suggests that managing medical personnel should not use paralytics in all cases but only in those where length of ventilation is expected to exceed a few hours. Patients should not remain ventilated for longer than it takes for the paralytics to have their effect [11].
Another study examined diaphragmatic weakness during mechanical ventilation along with the relationship between mechanical ventilation duration and diaphragmatic injury or atrophy [12]. It concluded that weakness, injury, and atrophy can occur rapidly in the diaphragms of patients on mechanical ventilation and are significantly correlated with the duration of ventilator support.
General guidelines for ventilator management
During ARDS the lungs are damaged following an insult that may be of pulmonary (i.e. pneumonia, aspiration pneumonitis) or extrapulmonary (i.e. sepsis, trauma, transfusion) origin. Regardless of the source of injury, ARDS is characterized by an acute onset, bilateral airspace infiltrates on chest X-ray, and hypoxemia (PaO2/FiO2 < 300), assuming no evidence of left atrial hypertension. With damage to the alveolar epithelium, alveolar-capillary membrane and endothelium, lung compliance progressively worsens and hypoxemia becomes refractory. Consequently, mechanical ventilation is necessary.
Unfortunately, while respiratory support is needed in ARDS, mechanical ventilation itself can worsen lung injury. Thus, the goals of mechanical ventilation should include achieving adequate gas exchange while limiting additional injury. This "lung-protective" strategy incorporates low tidal volume (VT) ventilation and low airway plateau pressure (Pplat) with permissive hypercapnia, if needed. Experimental studies demonstrated a 9% absolute mortality reduction in a group of patients randomized to receive 6ml/kg (predicted body weight) VT and Pplat less than 30cmH2O compared with 12ml/kg VT and Pplat less than 50cmH2O [13].
Additionally, CT imaging of patients with ARDS has shown that the lung consolidation is heterogeneous. As such, the preserved, highly compliant, lung may be more prone to be exposed to higher tidal volumes and inflation pressures. It has been suggested to use positive end-expiratory pressure (PEEP) and possibly recruitment manoeuvres to expand collapsed alveoli, which may also help to redistribute lung water while reducing injury related to the repeated expansion and collapse of alveoli. Trials suggest greater ventilator-free days and possibly a mortality benefit with high PEEP.
The current protocols do not specify any particular ventilator mode. However, general guidelines have been elaborated in order to cope with ARDS patients under mechanical ventilation [14, 15] (Table 2).
Table 2: General guidelines for ARDS management.
General measures Ventilator settings Monitoring parameters Adjunctive measures
Nutritional support Choose any mode, such as volume assist Arterial pH of 7.30 to 7.45 Conservative fluid therapy
Prophylaxis (Stress Ulcer, Venous thromboembolism) Inspiratory to expiratory ration of 1:1 to 1:3 Oxygen saturation of 88 to 95 percent Possible corticosteroids
PEEP and FiO2 set in accordance with ARDSNet protocol* PaO2 of 55 to 80 mm Hg Prone positioning
Respiratory rate ≤ 35 breaths per minute Plateau pressure ≤ 30 cm H2O Extracorporeal membrane oxygenation only after applying lung-protective strategies such as PEEP
Tidal volume of 6 mL/kg and up to 8 mL/kg (when double triggering or inspiratory airway pressure falling below PEEP)
ARDSNet – Acute Respiratory Distress Syndrome Network; FiO2 – fraction of inspired oxygen; PaO2 – partial pressure of arterial oxygen; PEEP – positive end-expiratory pressure.
• Sample ARDSNet protocol for FiO2 and PEEP.
FiO2 0.3 0.3 0.3 0.3 0.3 0.4 0.4 0.5 0.5 0.5-0.8 0.8 0.9 1.0 1.0
PEEP 5 8 10 12 14 14 16 16 18 20 22 22 22 24
Technical guidelines for the management of patients with ARDS under mechanical ventilation
An important parameter in the management of patients with ARDS under mechanical ventilation is the good knowledge and effective handling of the ventilator itself. Thus, in the case of ARDS manifestation, evidence shows that some initial actions should be followed by the medical personnel [16] (Table 3). If respiratory distress stops with Ambu, this means that the ventilator does not work well or that the parameters were not correct for the patient or that the blockage was removed through suction.
Table 3: Initial actions that should be followed.
1. Disconnecting the patient from the ventilator
2. Administration of 100% O2 through an Ambu system
3. Lungs and Heart auscultation
4. Checking vital signs
5. Checking the ventilator parameters
6. Aspiration
7. Suspicions of airway obstruction or pneumothorax - Thoracic radiography is required
More so, specific problems related to the function of ventilator may also encounter. These are related either to technical airways or with ventilator malfunction.
Problems related to technical airways
1. Incorporation of the tube into a main bronchus can cause atelectasis of the opposite lung. It is characterized by a reduction in respiratory sounds in the left hemithorax compared to the right one. Pulling the tube 2-3 cm solves the problem.
2. Cuff Problems:
a. Obstruction caused by excessive air introduction to the cuff or by cuff's herniation at the end of the tube. Here we see increased pressure in the airways, difficulty passing the suction catheter, musical sounds during inhalation. If we deflate the cuff we can estimate the situation.
b. Failure to seal the airways because we have an air leak from the cuff or have insufficiently inflated it. This can be appreciated when we deflate the cuff. Failure to suck the same volume of air we used to inflate the cuff confirms a loss of air or rupture of the cuff. This may be solved by replacing the tube with a new one.
3. Anonymous artery rupture: This is recognized by the blood stream from the tube and is more common in tracheostomy tubes. If this is the case, we need to swirl the cuff as a means of stamping the vase. In this case, a thoracic surgeon intervention is needed.
Ventilator malfunction
1. The most common problem with ventilators is the air leakage from the system, the wrong pipe connection and insufficient FiO2.
a. Leakage of the system is indicated by low pressure leading to alarms' start. We can also see the leakage by comparing the set tidal volume with patient' s delivered and expired tidal volume.
b. The new types of ventilators have a special instrument for FiO2 display and therefore, any deviation from the desired FiO2 is immediately visible.
c. Incorrect sensitivity of the ventilator results in asynchrony between the patient and the ventilator.
2. Wrong Alarm. The most common cause of the wrong alarm is the inability to achieve a minimum pressure, which would prevent alarm's activation. This is very common in patients with normal compliance or in patients with increased compliance due to emphysema. This can be corrected by increasing the respiratory rate resulting in an increase of the peek pressure. A very small breathing frequency can also cause a false alarm because it does not meet the minimum time requirements necessary to sensitize the alarm.
If the manifestations of respiratory distress continue while the patient is connected to Ambu-Bag and 100% O2, the most likely cause of distress is a respiratory complication under tension. In this case, a systematic assessment of the patient should be attempted in order to investigate the cause of distress (Table 4).
Table 4: How to investigate causes of distress.
Patient overview. Measurement of its vital signs-thoracic and auscultation for localized reduction of respiratory sounds.
Control of heart rate and pulse width.
Control of airway pressures.
Endotracheal aspiration for secretions or sputum plugs.
Diagnosing ARDS requires confirming the presence of bilateral pulmonary infiltrates, using radiographs, and the absence of left atrial hypertension, using pulmonary artery occlusion pressure. However, evidence shows that both measures may be unreliable [17,18]. More so, various pathophysiologies are represented in ARDS (i.e. diverse groups of patients are grouped into a single syndrome diagnosis). Additional sources of heterogeneity in the literature include diverse leading causes, variation with respect to the phases of ARDS in which specific treatments were given, and variability in the mechanisms of lung injury [19,20]. As a recent systematic review indicated [21], therapy that benefits one sub-group of patients with ARDS may not benefit another sub-group. Recently it has been proposed that a more precise and research-focused approach of ARDS is needed to help better understand these conditions and conduct research focused on this topic [22].
Hypoxemia is one of the main clinical concerns in ARDS but the leading cause of mortality is multi-organ failure [23,24]. The mechanisms leading to multi-organ failure are as diverse as the leading cause and subsequent pathophysiologies. One such mechanism is further lung injury caused by vigorous mechanical ventilation to manage hypoxemia, which can induce the production of pro-inflammatory cytokines, endotoxins, or bacteria, resulting in multi-organ failure [25]. Thus, effective management of ventilators are of high importance for a positive outcome.
More so, prone positioning may improve oxygenation. Yet, it may not contribute significantly to decreasing mortality in ARDS patients [26]. Kinetic therapy or lateral positioning with head of bed >30° and sitting with head of the bed >30° may be used for routine positioning of patients with ventilated ARDS [27].
Step-wise early mobilization of ICU patients is safe and is associated with positive outcomes in terms of both hospital length of stay and functional ability of the patient [28,29]. Early intervention of sufficient frequency and duration and over an adequate period are the key to success for many physiotherapy interventions for ventilated ARDS patients.
Although general guidelines and recommendations may help medical personnel in managing the treatment of ARDS patients, they should not be considered mandatory and can never consider all the features of the individual patient. Therefore, clinicians should always personalize their decisions for each patient by assessing the risks and benefits of an intervention for the specific patient, and the potential for combining it with another treatment for greater effect.
New types of ventilators offer a range of tools and features that not only enable clinicians to apply the interventions recommended in the general guidelines, but to customize ventilation therapy to each individual patient. Thus, good knowledge and effective handling of ventilators is extremely important for ventilated ARDS patients' outcome.
Ashbaugh DG, Bigelow DB, Petty TL, Levine BE (1967) acute respiratory distress in adults. Lancet 290: 319-323. Link: https://goo.gl/PYxU9G
ARDS Definition Task Force, Ranieri VM, Rubenfeld GD, Thompson BT, Ferguson ND, et al. (2012) Acute respiratory distress syndrome: The Berlin definition. JAMA 307: 2526-2533. Link: https://goo.gl/m7dzwz
Villar J, Blanco J, Kacmarek RM (2016) Current incidence and outcome of the acute respiratory distress syndrome. Curr Opin Crit Care 22: 1-6. Link: https://goo.gl/YBNmfC
Bellani G, Laffey JG, Pham T, Fan E, Brochard L, et al. (2016) Epidemiology, Patterns of Care, and Mortality for Patients With Acute Respiratory Distress Syndrome in Intensive Care Units in 50 Countries. JAMA 315: 788-800. Link: https://goo.gl/c4LndW
De Prost N, Dreyfuss D (2012) How to prevent ventilator-induced lung injury? Minerva Anestesiol 78: 1054-1066. Link: https://goo.gl/BuErm3
Rittayamai N, Brochard L (2015) Recent advances in mechanical ventilation in patients with acute respiratory distress syndrome. Eur Resp Rev 24: 132-140. Link: https://goo.gl/zpfQW9
Acute Respiratory Distress Syndrome Network, Brower RG, Matthay MA, Morris A, Schoenfeld D, et al. (2000) Ventilation with lower tidal volumes as compared with traditional tidal volumes for acute lung injury and the acute respiratory distress syndrome. The Acute Respiratory Distress Syndrome Network. N Engl J Med 342: 1301-1308. Link: https://goo.gl/uXip8t
Burns KE, Adhikari NK, Slutsky AS, Guyatt GH, Villar J, et al. (2011) Pressure and volume limited ventilation for the ventilatory management of patients with acute lung injury: a systematic review and meta-analysis. PLoS One 6: e14623. Link: https://goo.gl/6kPbwg
McMurray JJ. Clinical practice (2010) Systolic heart failure. N Engl J Med 362: 228-238. Link: https://goo.gl/S6qYpd
Fan E, Del Sorbo L, Goligher EC, Hodgson CL, Munshi L, et al. (2017) An Official American Thoracic Society/European Society of Intensive Care Medicine/Society of Critical Care Medicine Clinical Practice Guideline: Mechanical Ventilation in Adult Patients with Acute Respiratory Distress Syndrome. Am J Respir Crit Care Med 195: 1253-1263. Link: https://goo.gl/UWEGxz
Papazian L, Forel JM, Gacouin A, Penot-Ragon C, Perrin G, et al. (2010) Neuromuscular blockers in early acute respiratory distress syndrome. N Engl J Med 363: 1107-1116. Link: https://goo.gl/vyp9YM
Jaber S, Petrof BJ, Jung B, Chanques G, Berthet JP, et al. (2011) Rapidly progressive diaphragmatic weakness and injury during mechanical ventilation in humans. Am J Respir Crit Care Med 183: 364-371. Link: https://goo.gl/mjMezX
Cho YJ, Moon JY, Shin ES, Kim JH, Hoon Jung, et al. (2016) Clinical Practice Guideline of Acute Respiratory Distress Syndrome. Tuberc Respir Dis 79: 214-233. Link: https://goo.gl/M7vRYL
Saguil A, Fargo M (2012) Acute Respiratory Distress Syndrome: Diagnnosis and Management. American Academy of Family Physicians 85: 352-358. Link: https://goo.gl/27CwER
Chiumello D, Brochard L, Martini J, Slutsky AS, Mancebo J, et al. (2017) Respiratory support in patients with acute respiratory distress syndrome: An expert opinion. Critical Care 21: 240. Link: https://goo.gl/HbLe71
L. Grigorakos. Intensive Care Unit. Respiratory Insufficiency and Mechanical Ventilation. Before-During-After. 2014, Athens, Myedition.gr publisher. Link:
Meade MO, Cook RJ, Guyatt GH, Groll R, Kachura JR, et al. (2000) Interobserver variation in interpreting chest radiographs for the diagnosis of acute respiratory distress syndrome. Am J Respir Crit Care Med 161: 85-90. Link: https://goo.gl/3TX2nQ
Zarich S, Pust-Marcone J, Amoateng-Adjepong Y, Manthous CA (2000) Failure of a brief educational program to improve interpretation of pulmonary artery occlusion pressure tracings. Intens Care Med 26: 698-703. Link: https://goo.gl/kd77Dt
Phua J, Stewart TE, Ferguson ND (2008) Acute respiratory distress syndrome 40 years later: time to revisit its definition. Crit Care Med 36: 2912-2921. Link: https://goo.gl/VEJUQh
Wood KA, Huang D, Angus DC (2003) Improving clinical trial design in acute lung injury. Crit Care Med 31: S305-311. Link: https://goo.gl/iLcJbX
Bakowitz M, Bruns B, McCunn M (2012) Acute lung injury and the acute respiratory distress syndrome in the injured patient. Scand J Trauma, Resusc Emerg Med 20: 54. Link: https://goo.gl/EQQ9Gm
Rubenfeld GD, Caldwell E, Peabody E, Weaver J, Martin DP, et al. (2005) Incidence and outcomes of acute lung injury. N Engl J Med 353: 1685-1693. Link: https://goo.gl/NfNj4L
Piantadosi CA, Schwartz DA (2004) the acute respiratory distress syndrome. Ann Intern Med 141: 460-470. Link: https://goo.gl/ZUvkPy
Slutsky AS (2001) the acute respiratory distress syndrome, mechanical ventilation, and the prone position. N Engl J Med 345: 610-612. Link: https://goo.gl/DxS5PB
Sud S, Sud M, Friedrich JO, Phil D, Adhikari N (2008) Effect of mechanical ventilation in the prone position on clinical outcomes in patients with acute hypoxemic respiratory failure: a systematic review and meta-analysis. CMAJ 178: 1153-1161. Link: https://goo.gl/FapKto
Mancebo J, Fernandez R, Blanch L, Rialp G, Gordo F, et al. (2006) A multicenter trial of prolonged prone ventilation in severe acute respiratory distress syndrome. Am J Respir Crit Care Med 173: 1233-1239. Link: https://goo.gl/LXRisb
Goldhill DR, Imhoff M, McLean B, Waldmann C (2007) Rotational bed therapy to prevent and treat respiratory complications: a review and meta-analysis. Am J Crit Care 16: 50-62. Link: https://goo.gl/xMY9Ke
Needham D (2008) Mobilizing patients in the intensive care unit: improving neuromuscular weakness and physical function. J Am Med Assoc. 300: 1685-1690. Link: https://goo.gl/Bm3nuX
Taito S, Shime N, Ota K, Yasuda H (2016) Early mobilization of mechanically ventilated patients in the intensive care unit. J Intensive Care 4: 50. Link: https://goo.gl/2EpaXo
© 2018 Grigorakos L, et al. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.


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text:
Kabalevsky – Concert voor viool en orkest in C, op 48
May 16, 2021 May 16, 2021 | Arjan Uittenbroek
https://www.discogs.com/Kabalevsky-Viktor-Pikaisen-Vladimir-Feltsman-Moskou-Staats-Symfonie-Orkest-Fuat-Mansurov-Kabalevski/release/11894019
Really modern classic music, only not. The works on this record were written in the 1950, but if you would have told me they were from 1900, I would believe that. They sound outdated. The violin concerto had those overly romantic dynamics, the piano concerto has nice recognisable melodies. But this is the same time as Stravinsky! It doesn't come close.
There is a series on Hyperion records, that does this. They take the lesser known piano-, cello- or violin concertos and record them. I'm betting they have this work too. Though those recordings sound a lot better both in performance and recording quality, my Kabalevsky record can compare. It holds some surprises for me after all these years.
As this is nineteenth century romanticism clad in 1950s Russian colouring, I wonder what the political establishment thought of this work. There always was a lot of comments about Shostakovich and the way he was bending the knee to Stalin, but how did Kabalevsky fare? The ever helpful wikipedia says he was a proponent of social-realism. After the implosion of Sovjet-Russia has didn't get that much recognition anymore. I would say: he did not fare very well.
Kabalevsky was in the Sovjet times also working on a system of music schools for children. Thousands of schools were offering an almost religious curriculum of music lessons. Most of those are closed now. His third piano concerto, also in this record, is now mostly used as a 'first' piano concerto for little students.
#kabalevski #mansurov #no streaming

redpajama_set_name: RedPajamaCommonCrawl


Every single day I want to spend time nurturing my soul by spending time with God. While I wouldn't hesitate to tell you that this is the most important thing, sadly it is often times the easiest to neglect. I seem to be able to run on my own power for a short time but my soul yearns for more. Lasting over the long haul requires consistent time to reconnect and refuel with my maker.
This can be as simple as reading a chapter of a book, listening to a podcast, skimming a few blogs, or spending time with a caring mentor. Like a good exercise routine it's wise to change-up what you do from day-to-day to stave off boredom. Check out the links page of my blog to help you get started.
This is definitely a place where a little energy should be spent every day. Recently I changed how I meet with my staff so that we can spend more time together, both on work stuff and fun relational time. If you don't have a paid team taking a few minutes to send volunteers a text, post something on their Facebook wall, or grabbing coffee or lunch are great ways to stay connected.
This would have been really hard to pull off ten years ago, but in today's world of texting and social media it's much easier to do. Send out a daily status update to keep parents in the loop, make sure your website is up to date, or send out an encouraging tweet. These are small but powerful ways to show families you care.
Take a break! Watch a sitcom and laugh out loud today. Laugh with your kids – maybe play a game at dinner. Let your hair down; it might be just the thing you need to get over the hurdle and help you relax after dealing with a difficult situation.
Question: What habits are helping you thrive in ministry? You can leave a comment by clicking here.
Great post Jeff. I would agree with all of these and add one more – work! I know this is implied, but I've seen too many leaders, especially young ones, have a difficult time managing everything. We can get so consumed growing, sharing, connecting, etc. that we put our actual work aside. Work takes discipline, more so than ever with all of today's distractions. So I would add that to your terrific list, too!


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Kecek-Kecek
On Trengganuspeak and the Spirit of Trengganu
16. How to...Beratang
When your plate's full and hunger's panging, beratang is the word to avoid especially in a crowd. Beratang is a gregarious act that is often done for mutual benefit but sometimes it is directed towards something or someone in common, with or without benefit – jointly or severally - to the persons involved. Yet in spite of beratang's seemingly charitable pose, its participants can still be accused of neglect, as in the popular phrase, "Orang-orang tu dok beratang tèngök je, keliik-keliik!" In other words, they just watched, without as much as a finger raised - a fist fight, a stealing act, or someone disgracing himself. It is the word beratang here that gives the poignancy to the act for all its claims of togetherness.
Beratang in its passive or active form is the staff of life in the East Coast because we were led to it very young, by the posture of ggedik, a source of division in this world between those who have food on their plates and those who have not a wee bit. In a punny way, ggedik in itself embraces the two aspects of the divide: the ggedik person so rich in life's possessions that all s/he has to do in a working day is to just shake the legs (ggedik kaki), or the imploring boy who keeps cadging for a bite of his friend's belebat (banana pud). There will be an old lady here somewhere, looking down from the top: "Beratanglah denge dia tu Che Awang pong!" Go on, share it with him son!
Now that I've come this far I've just realised that there's no proper word for 'them' in Trengganuspeak, and there's no word for beratang in standard language. You can say that mereka (standardspeak, 'they') is a word that you recognise, but how often have you used it in Trengganuspeak to refer to a crowd? In Kedah they have dèpa, in Kelantanspeak there's dèmö tu, but in Trengganuspeak we ignore the crowd. In the sentence above I have resorted to Orang-orang tu as an artificial construct because orang ('people', 'persons') is a known word and used in Trengganuspeak, but even then that's not how we describe 'others'. To call them mereka in this case, would put in a very strange sense indeed. There are no innocent bystanders (mereka, they) in our crowd, we'd prefer them to be 'you lot', mu, mung), Mung dok beratang tengok je...you just stood there watching, you lot.
But the curioser thing is that whilst beratang is widely known in Eastern life, there's no equivalent for it in Standardspeak. In fact they do not have a word at all for it out West where they use kongsi, a Chinese loan-word. Whilst kongsi gives a sense of 'sharing' and goes further to embrace 'partnerships', it is still not the same as beratang because while we can share all the other things, we can still, in all our goodness, beratang tumbok, i.e. to get together and shower thumps on someone else. Put kongsi in there instead of our 'b' word and the phrase is as good as dead, and the victim-lad will want his punches gift-wrapped to take home in a box.
In less bositerous times there's camaraderie and beratang expresses itself mostly in food. "Mari kita beratang makang!", let's all eat together now; but you can also beratang your griefs, your joys, your prayers, your hopes. And then atishoooo! comes a sneeze on the bread, "Excuse me, my cold!" and that's the end of beratang for reasons of health and finis too, definitely, for your ggedik.
Labels: beratang, ggedik
posted by Awang Goneng @ 12:25 am 6 Comments
A lady called me last Saturday to ask if I have ever urinated in a public place. It was part of a survey, I think, to gauge civic responsibility and compliance with the law.
Have you? I asked her. I think she was in faraway Bombay.
She laughed and asked me more questions in rapid fire. Have you ever smoked in a forbidden place, or spoken on the handphone while driving a car?
I don't smoke, don't have a handphone and don't own a car, I told her. And besides, why would I want to smoke in a forbidden place in Bombay when I am ensconsced here in another corner? Yes, but you'll be forbidden from smoking in public places in your corner of the world from the 1st of July, reminded the belle from the Bombay call centre.
And then I remembered pacör ca.
Pacör ca is when you stand up and wet the floor, and as what you do in the privacy of your own place is your own affair, it will really have to be standing up in a public place and using it as a pissoire. But then it can be cute too if you're Manneken Pis, but we're not all little boys in a big square in Bruxelles.
Now you'll have to have a nose for Trengganuspeak to be able to say pacör ca properly as the 'a' in ca is raised to the nasal. It's like cokelat ra as the feel and sound of ra is one that gets up your nose, like good wasabe. Both ca and ra are onomatopoeia words, as the former is the sound of well, your water hitting cigarette packets, cobblestones and the feet of passing strangers; and in the latter, well, there's a slight problem here: it is Trengganuspeak (and Kelantanspeak) translation of the 'sound' of mint going up the nasal, which makes it really a minty feely word. Is there a word here to replace onomatopoeia for your description of not what you hear but what you feel?
There is something I think, in the Sejarah Melayu (the Malay Annals) about the Emperor of China boasting about the number of his subjects by saying that they could all stand and pacör ca and drown all in the neighbouring state. And there's another, in more recent times, that the lady from Bombay reminded me of, as it involved Kennedy and Nehru which is, without doubt, apocryphal. Kennedy in Delhi saw men doing it - pacör ca that is - in the street and mentioned it to Nehru-Ji. The latter, wanting to get even, promised Ken that he'd find similar offenders in Washington too. Fast forward to Nehru in the White House, on a visit to America. There, he said, looking over the White House balcony, there's the man I promised you. Kennedy looked out and saw a man hosing out his pacör in the far end of Pennsylvania Avenue. When the Secret Service men sent out by Kenendy came back to whisper in the President's ear, Nehru turned blue with glee, and the President turned a pale colour.
In Underground London there used to be a long-running series of posters put up by a man called Benny who owned a strange restaurant in sunny Knightsbridge called Borscht-n-Tears. His pleasure was in loading his Underground advertisements with corny jokes, much in the way of Maoists in the turmoil days of China when they filled the days with Wall Newspapers. I saw a sign saying 'Wet Paint' said Benny in one of his fun-packed poster advertisements and soon as I did, I got arrested. I used to stand on the station paltform perplexed by this image of Benny doing his pacör ca and London Bobbies rushing in, clad in their waterproof regulation Macs to arrest the restaurateur offender.
I don't know what's happened to Benny since, or to the Borscht-n-Tears now, but what was it that the Secret Service man was whispering to Kennedy before his honoured guest Nehru?
Kennedy to Nehru: "Mr Prime Minister, the man doing the pacör ca is your ambassador."
Labels: Kenendy, Manneken Pis, Nehru, Pacor
posted by Awang Goneng @ 2:06 pm 5 Comments
This Trengganu
Looking into my friend Shahril Talib's book, "After Its Own Image", I find that between 1830 and 1941 we had quite a bit of excitement in Trengganu: Tengku Long, a member of the royal family and a man 'noted for his prowess with the kris' was lured to Losong then ambushed and killed in in 1885, and a Hari Raya was cancelled by Tengku Muhammad, heir to the throne, in 1913 because something made him very angry. Now, how did he do that, I wonder? Did he continue fasting for another day, or did he just say to his subjects you people just go ahead, celebrate without me? What did the ulama and the people have to say about that? He was, after all, only the heir, not yet the Person Royal.
During the distinguished reign of Sultan Baginda Omar (1839-1876), a court noble Dato Kaya Biji Diraja snapped under the burden of office and went amok; Hugh Clifford's account of this can be read in 'The Further Side of Silence' (Doubleday, Page & Company, New York, 1927). This must have ranked as the most famous amok in 19th century Trengganu; in the next century we had another, this time a commoner who got miffed by some turns in his domestic life, and he became known as Pök Mat Ngammök, shot and buried by some accounts, not far from the bend in the road in Tanjong Mengabang, aka Tanjong Batu Satu.
We had the great flood in Kuala Trengganu in 1926 [see The East Was Red], and the perang (battle) in the Ulu (upriver), in 1928 [see, A Journey Upstream; and Yesterday, Today]. Then as now, judges were torn between two forces, to be just or to bow to the whims of the powerful. Cases that affected the powerful adversely were delayed for as long as was possible in the hope that the petitioners would just drop out from sheer exhaustion. Many succumbed to temptations for personal gain. One judge became well known for being very wealthy and for being merciless to the poor and weak but uninhibited in his favours to the rich and powerful. The British Agent (W.L.Conlay?) wrote in his monthly journal:
"[A]nd when decisions had to be given against the rich and more powerful parties, decisions were made nugatory by not entering the orders of the court or by making a further order altering the first decision."
As justice sometimes turns full circle, the judge found himself in prison after conviction, and worse. He had to share a cell with former victims of his injustice who proceeded to manhandle him in his incarceration that after a few months he had to make a plea to the Sultan for help. This was Muhammad Shah II, well-known for his bad disposition towards the British, and the man who cancelled Hari Raya when he was an up and coming guy.
Tengku Muhammad wasn't at all like his father, Sultan Zain al 'Abidin III, a wihdrawn man who immersed himself in Arabic tomes and texts, and a sincere man in his religious duties. But even under Zain al 'Abidin the administration of justice had already been usurped by powerful royal elders who much preferred the adat law to the shariah as interpreted by the learned ulama. In 1912 W.D.Scott reported to the office of the High Commissioner that "none dared to bring to his notice misdeeds of his officials and if they did, His Highness had not the courage to put things right."
Shahril who read a report of the State Secretary's Office of the tawarikh dahulu zaman (history of yesteryear) summarises his findings thus:
"There were no fixed places for a hearing. Cases were dealt with in houses, boats, mosques or indeed wherever a complaint was made. In addition there was no machinery for enforcing the decisions except force employed by the favour of some chiefs."
Looking at this broadly, Trengganu was then in a difficult state: the British were applying pressure on Zain al 'Abidin to accept an 'adviser'. "I hope I will not live to see a British 'adviser' in Trengganu," Zain al 'Abidin reputedly said. He died while preparations were on-going in 1918.
The following year, acting under pressure, his son Sultan Muhammad was summoned to Singapore to sign a new agreement accepting an Adviser in Trengganu. [see, Man of Oob] In those circumstances, enemies of enemies became friends and judgments became clouded by ulterior motives. When the British asked Tengku Muhammad to dismiss a corrupt judge, for instance, the Tengku took him into his pay as legal adviser. So, not surprisingly, when the plea came from inside for the Sultan (as he later became) to deal with the manhandling cell-mates, the Sultan ordered the corrupt judge released from gaol and sent on a pilgrimage to Makkah, from where presumably, to work on his repentance and pray for the Sultan to be delivered from perfidy.
It is difficult to judge Sultan Muhammad bin Sultan Zain al 'Abidin from a distance now without also bearing in mind that he was quite anathema to the British in their most power hungry days. He was variously described as 'illiterate', 'haughty' and 'short tempered'; while one official, E.A.Dickson, said he was "presumptuous with a good conceit of himself and full, too full perhaps, of confidence in his own powers." [My italics].
Reading through the Merdeka papers in the National Archive in Kew recently I found much the same comments made about the charismatic Dato Onn Jaafar (arrogant, quick-tempered, etc) by colonial officers in comparison to the Tunku. But this is not to demean the Tunku's contributions in the negotiations. He was a man much underrated, a skilled negotiator in his own way.
As for Sultan Muhammad, he abdicated the throne after just over a year and was exiled to Singapore on 20 May, 1920.
Shahril Talib, 'After Its Own Image: The Trengganu Experience 1881 - 1941', Oxford University Press, 1984. ISBN 0 19 5825683.
Labels: Dato Kaya Biji Diraja, Shahril Talib, Sultan Muhammad ibn Sultan Zain al Abidin III
Awang Goneng
Awang Goneng was born at a very young age, has drifted beyond the shores of Trengganu, and is feeling a crick in the neck from constantly looking back. He claims to have captured the essence of Trengganu, which, he says, was given to him by a very old man living in a cave near the Lake Kenyir. His detractors say it's just a bottle of budu. Undaunted, Awang Goneng is still continuing his search which has taken him to wild places and steaming jungles. Once while swimming in the South China Sea, off Batu Buruk, he was chased by a shoal of kerepok lekor. "Very fast swimmers they are," he says. "I bit into one, it tasted very fishy."
awanggonengATyahoo.co.uk
Döh nök wak guane!
Eid Mubarak - Eid al Adha
The Lord Laughs Last
Drawn From memory
The Good Ship Hari raya
Every Day Rainy Beats
Stamping Around the World
A Book In A Quiet Corner
Green Umbrellas and New Books & Old Wind on the Ne...


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Mr. Kevin Fitzgerald Armstrong
December 15, 1963 - November 2, 2021
ARMSTRONG, Mr. Kevin Fitzgerald - Age 57, passed away Tuesday, November 2, 2021. Family hour 10:30 AM Thursday, November 18, 2021 from the Chapel of Lawrence E. Moon Funeral Home, 906 W. Flint Park Blvd., with funeral service commencing at 11:00 AM. Interment Sunset Hills Cemetery, G-4413 Flushing Rd. Friends and pallbearers will assemble at the funeral home 10:30 AM Thursday. Mr. Armstrong will lie in state in the Chapel of Lawrence E. Moon Funeral Home and may be viewed from 12:00 PM - 6:00 PM Wednesday.Mr. Kevin Fitzgerald Armstrong was born December 15, 1963 in Flint, Michigan, the son of Rudolph and June Armstrong. Kevin attended Northern High School he studied General Studies. He enjoyed cooking, detailing cars and spending time with family and friends. Kevin gave his life to the Lord and became a Member at Christ Fellowship Missionary Baptist Church. He also enjoyed riding his motorcycle, working on his cars and spending time with his grandchildren sledding and riding the snowmobile and making people laugh. Mr. Kevin Fitzgerald Armstrong leaves to cherish his memory: wife, Shalina Armstrong; 5 daughters and 1 son, Kim Armstrong, Kevin Armstrong, Shonte Hopson, Nikki Craighead, Angielic Reed and Diamondra (Carl) Seats of Arknasas; grandchildren, Marcus Adams, Teriyana Armstrong, Diamond Armstrong, Angle Armstrong, London Armstrong, Kevin Armstrong Jr., Kevin Nash Jr., Ameron Nash, Lailah Reed, Aubryelle Wilson, Sage Reed, Andre Armstrong, Jasmine Myles London, Aija Harris, Armani Larry and Jaiyir Larry; father, Rudolph Armstrong; 3 sisters, Rhonda (Willie) Huddleston, Tanya (Demetriuss) Sanders of Tennessee and Lana Houston of Arlington, TX; brother, Rudolph Armstrong; 2 nieces, June Armstrong and Jasmine French; 2 nephews, Deon Sanders and Romel Morgan; a host of cousins, other relatives and friends including special friend, Michael Bowman. Mr. Armstrong was preceded in death by his mother, June Armstrong; Christine Edwards, Lora Lee Jackson and Frank Armstrong. The family would like to express special thanks to Lawrence E. Moon Funeral Home and all family friends.
ARMSTRONG, Mr. Kevin Fitzgerald - Age 57, passed away Tuesday, November 2, 2021. Family hour 10:30 AM Thursday, November 18, 2021 from the Chapel of Lawrence E. Moon Funeral Home, 906 W. Flint Park Blvd., with funeral service commencing at... View Obituary & Service Information
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Plan to produce electric vehicles in Mishawaka stalls
By Larry Avila / July 15, 2019 September 21, 2022
A rendering of Seres Automotive/SF Motors' SF5. (File photo)
A plan by a subsidiary of a Chinese automaker to produce an all-electric SUV and bring up to 467 jobs to Mishawaka by 2020 has stalled.
Several news media outlets in recent days reported Seres Automotive, which originally launched as SF Motors, had laid off 90 people at its California headquarters and put on hold development and production of the SF5 all-electric sport utility vehicle. The SF5 was to be produced at the former AM General production plant in Mishawaka, where Seres planned to invest $160 million.
Seres, according to The South Bend Tribune, on Friday also laid off about 30 of its 81 workers in Mishawaka. The Indiana Department of Workforce Development on July 15 said it had not received any notification of layoffs from Seres but noted it wasn't necessary for the company to send a Worker Adjustment and Retraining Notification Act or WARN notice to the state because the layoffs did not impact at least 50 workers.
Seres/SF Motors representatives could not be reached for comment.
The state was disappointed in Seres' setback regarding its plans in Indiana but is hopeful the company will regroup.
"While it is unfortunate that Seres Automotive (SF Motors) has slowed down the timeline for production of its new electric vehicle model, the SF5, we understand that a company's growth plans and expected timelines may be impacted for a variety of reasons," Erin Sweitzer, a spokesperson for the Indiana Economic Development Corp. wrote in an email to Northwest Indiana Business Magazine July 15. "Despite the news, we believe the company remains committed to Indiana and to forging a robust future here."
Sweitzer said the state, "will remain engaged with Seres leadership as they work through next steps."
She said the state also will provide any resources and support to those affected by Seres' altered plans.
Media reports say the company, which is a subsidiary of Chinese automaker Sokon, was changing its focus because of the soft Chinese auto market and tariffs on Chinese-made products.
The project announced in May 2018 said the company planned to hire back as many displaced AM General workers as possible. AM General, a heavy vehicle and contract automotive manufacturer, is best known for producing the rugged Hummer sport utility vehicle as well as the Humvee.
Some work had been done to renovate and equip the former 675,500-square foot AM General facility at 12900 McKinley Highway, which has a Mishawaka mailing address but is located in an unincorporated area of St. Joseph County.
The Indiana Economic Development Corp. originally pledged $3.847 million in conditional tax credits and up to $500,000 in training grants based on the company's job creation plans. The IEDC also offered up to $653,000 in conditional tax credits from the Industrial Recovery Tax Credit program, which encourages companies to invest in former industrial facilities requiring significant rehabilitation or remodeling.
Larry Avila
Larry is an award-winning journalist with more than 25 years of experience working with daily newspapers and business-to-business publications around the Midwest. Avila is a Michigan native and a graduate of Central Michigan University.


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Q: How to set focus for next tab in angularjs? Example File Link
Hi all,

Here I created sample for tabs. What I exactly need is, in this sample i am doing validation with entering anything click submit the focus will go to invalid text which is working fine but once tab one fully valid that time it need to switch to second and set focus is not working how to achieve this can anyone help me on this...
For Ref:-
Without fill anything working fine

After fill every click submit it need to jump and check validation..

something like this

A: Here is the solution to your problem have a look at this , i have used broadcast method to a call method from controller to directive but it can be varied we can also use different approach to call directives method from controller. so that we can change active tab.
Here is the working plnkr
JS file
angular.module('components', []).
  directive('tabs', function() {
    return {
      restrict: 'E',
      transclude: true,
      scope: {
        paneNum : '='
      },
      controller: [ "$scope", function($scope) {
        var panes = $scope.panes = [];
        $scope.select = function(pane) {
          angular.forEach(panes, function(pane) {
            pane.selected = false;
          });
          pane.selected = true;
        }

        $scope.$on('changeText',function(event, data){
          var j = 0;
          angular.forEach(panes, function(pane) {
            j++
            pane.selected = false;
            if(j==data.id)
            {
               pane.selected = true;
            }
          });
         });

        this.addPane = function(pane) {
          if (panes.length == 0) $scope.select(pane);
          panes.push(pane);
        }
      }],
      template:
        '
' +
          '
' +
            '
'+
              '{{pane.title}}' +
            '
' +
          '
' +
          '

' +
        '
',
      replace: true
    };
  }).
  directive('pane', function() {
    return {
      require: '^tabs',
      restrict: 'E',
      transclude: true,
      scope: { title: '@' },
      link: function(scope, element, attrs, tabsCtrl) {
        tabsCtrl.addPane(scope);
      },
      template:
        '
' +
        '
',
      replace: true
    };
  })
  .controller('sample', function($scope,$rootScope){
     $scope.activeTab = 1;
      $scope.Submit = function(){
        var schema = {
          1:["FirstName","MiddleName","LastName"],
          2:["Contact","Address1","Address2"],
          3:["Phone","Mobile","Mobile1"]

        };
        var valid = true;
        angular.forEach(schema[$scope.activeTab],function(v){
          if(!$scope.myForm[v].$valid)
          {
            valid = false;
          }
        });
        if(valid)
        {
          $scope.activeTab++;
        }
      $rootScope.$broadcast('changeText',{id :$scope.activeTab});

      }

  });

Html file
<!DOCTYPE html>

   <link rel="stylesheet" href="style.css">
   <link href="http://netdna.bootstrapcdn.com/twitter-bootstrap/2.3.1/css/bootstrap-combined.min.css">

BootStrap Tab Component

  <form role="form" ng-controller="sample" name="myForm">
  <tabs>
    <pane id="FirstTab" title="First Tab">

    First Name
    <input type="text" name="FirstName" required ng-model="FirstName" class="form-control" id="FirstName">

    Middle Name
    <input type="text" name="MiddleName" required ng-model="MiddleName" class="form-control" id="MiddleName">

    Last Name
    <input type="text" name="LastName" required ng-model="LastName" class="form-control" id="LastName">

    </pane>
    <pane id="SecondTab" title="Second Tab">

          Contact
          <input type="text" name="Contact" required ng-model="Contact" class="form-control" id="Contact">

          Address1
          <input type="text" required name="Address1"  ng-model="Address1" class="form-control" id="Address1">

          Address2
          <input type="text" required name="Address2" ng-model="Address2" class="form-control" id="Address2">

    </pane>
     <pane id="ThirdTab" title="Third Tab">

          Phone
          <input type="text" required name="Phone" ng-model="Phone" class="form-control" id="Phone">

          Mobile
          <input type="text" required name="Mobile" ng-model="Mobile" class="form-control" id="Mobile">

          Mobile1
          <input type="text" required  name="Mobile1"  ng-model="Mobile1" class="form-control" id="Mobile1">

    </pane>
     <pane id="FourthTab" title="Fourth Tab">

This is the content of the Fourth tab.

    </pane>
  </tabs>
    <button type="submit" ng-click="Submit()" class="btn btn-default">Submit</button>
</form>

redpajama_set_name: RedPajamaStackExchange


This is a 3 minute video that explains why the United States needs the Common Core Standards. It is easy to understand and well put together.
http://www.teacherspayteachers.com/Store/Kasha-Mastrodomenico uses the Common Core Standards to write middle school social studies differentiated instruction lesson plans.
This entry was posted in Common Core Standards in Social Studies, Social Studies Differentiated Instruction and tagged Common Core Standards, Common Core Standards in Social Studies, social studies differentiated instruction, social studies differentiated instruction lesson plans on March 29, 2013 by Kasha Mastrodomenico.


I have a projects in Dot net C# which have been partially completed and the developer who worked is facing some issues in delivering the same.
I have the work about 70% done but yes i need it done perfectly and need someone experienced to handle it full time.
Please dont bid if you are working in a company and think of working on this at night time.
I need a full time resource who can work on this and have it deliver in 20 days.
I can send you the project details links etc in pmb.
Hi, I've read your work requirements which suits my skill set. I will surely satisfy you with my work. Thanks Zee.
hello sir, i m new as a freelancer before that i have experience of 4.5 years in this field but right now i just wanted to started working as a freelancer. so i m ready to work consider my profile.


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Where in health am I? : Home / Health Cloud / StaynHealthy / Women's Health / Abortion / Medical Abortion
menu : Medical Abortion
The "abortion pill" is a bit of a misnomer. Known formally as medical or medication abortion, it is really two separate drugs—mifepristone, which stops the pregnancy from progressing, followed by misoprostol, which triggers uterus contractions—that together mimic what happens in a miscarriage - Sarah Zhang
image by: Women Help Women
Spreading Plan C to End Pregnancy
After lunch on a Saturday in late January at her home in Los Angeles, Francine Coeytaux, 63, an abortion rights activist, retrieved a Priority Mail envelope from her office and announced to her guests, a group of young women she had recruited to her cause, the results of a recent experiment. "A couple weeks ago, we Googled 'abortion pills' and tried ordering from a few of the sites that came up," she said.
The pills, misoprostol and mifepristone, are approved by the Food and Drug Administration for use by a licensed provider to end a pregnancy within the first 10 weeks, or what is known as "medical abortion." Mifepristone works by blocking the effects of progesterone, a hormone without…
Plan C was founded by public health researchers, social justice activists and digital strategists. We started with the belief that abortion pills belong in the hands of people who need them, and that this kind of care is a basic human right.
Medication abortion accounts for more than half of abortions in the US each year, so a decision on preemption could determine the future of a substantial portion of them.
Abortion Pills Stand to Become the Next Battleground in a Post-Roe America
Medication abortion allows patients to terminate early pregnancies at home. Some states are moving to limit it, while others are working to expand access.
Abortion Pills Take the Spotlight as States Impose Abortion Bans
Demand for medication abortion is surging, setting the stage for new legal battles.
How medication abortion works and what the end of Roe v. Wade could mean for it
In the states where abortion is expected to be banned if Roe is overturned, medication abortion will become illegal. But access to abortion pills will still be available for those who are able to travel to states with abortion protections. Some may attempt to acquire the medications from out-of-state providers through the mail. A growing number of states have moved to make this approach illegal, but experts say that in practice, it's difficult to police.
The Abortion Backup Plan No One Is Talking About
Even in states with the strictest abortion laws, pregnant people have a safe, inexpensive option to terminate their pregnancies. But few know about it.
What does the future of abortion look like?
Although many people still turn to surgical methods like vacuum aspiration or dilation and curettage (also known as a D&C), abortion with pills (also known as medical abortion or medication abortion) has become an incredibly popular method around the globe. In some European countries, over 90 percent of abortions are performed with pills; in the United States, over half of all abortions performed in 2020 were medication abortions.
What to Know About Abortion Pills Post-Roe
It may become more difficult to obtain the pills, but there will be workarounds. People may still have access to medical abortions through telehealth services and mail-order pharmacies, which rely on overseas doctors and pharmacies in order to skirt U.S. regulations.
The medical abortion works — so why aren't more women using it?
And why aren't doctors more vocal about it?
I Ordered 20 Abortion Pill Packs from the Internet to Test If They're Real
Numerous online drug-sellers say they sell the abortion pill—but what are women actually getting when they order it? I decided to find out.
Misoprostol Is a Game-Changer for Safe Abortion and Maternal Health Care. Why Isn't it More Widely Available?
If we have a cheap and readily available drug that can prevent and treat the two largest causes of maternal mortality worldwide—postpartum hemorrhage and unsafe abortion—why have we not taken more advantage of it?
Plan C: The Safe Strategy for a Missed Period When You Don't Want To Be Pregnant
What is a woman to do if neither her plan A (birth control) nor her plan B (the morning-after pill) worked? Wouldn't it be great if she had a plan C—a medicine similar to these other pills that would start her period and end her anxieties? Such a thing exists, and it should be available to all women.
With Access Under Threat, Advocates Want to Help Women Take Medication Abortion Into Their Own Hands
Recognizing that even women in a country with legal abortion might need help getting one, Women Help Women is introducing a U.S.-specific online counseling service for women who are trying to terminate their own pregnancies at home.
Abortions by mail are available now in the US. Here's what you need to know
The medication used in self-managed abortions is safe for most women less than 10 weeks pregnant.
Mifepristone and misoprostol: Recommended regimen
Up to 10 weeks gestation (70 days since last menstrual period (LMP)): Mifepristone 200mg orally followed 1-2 days later by misoprostol 800mcg buccally, sublingually or vaginally. 10-13 weeks gestation: Following mifepristone, women typically require two doses of misoprostol for a successful abortion. Mifepristone 200mg orally followed 1-2 days later by either misoprostol 600mcg sublingually or 800mcg vaginally, then 400mcg sublingually or vaginally every three hours until expulsion. Alternatively, mifepristone 200mg orally followed 1-2 days later by misoprostol 800mcg buccally, sublingually or vaginally may be used; the dose of misoprostol may be repeated to achieve abortion success.
The Complicated Life of the Abortion Pill
A French doctor's invention and post-Roe America.
The "Abortion Pill" Is Used for So Much More Than Abortions
Though misoprostol and mifepristone are best known as the two components of medication abortion (referred to by many as the "abortion pill"), what they actually do is help soften the cervix and cause contractions, making them vital for a variety of gynecological uses. Yet because they are involved in medication abortions, Gutman is worried about whether doctors like her will be able to continue offering them.
Advocates struggle with how much they can help with self-managed abortions
Organizations in states with abortion bans have their own risk to assess. They feel confident the First Amendment protects sharing medical information endorsed by the World Health Organization. But abortion rights advocates are torn between raising awareness and becoming a target for anti-abortion lawmakers — who are no longer limited by Roe v. Wade.
Everything You Need To Know About The Abortion Pill
For Nicole, taking the abortion pill was like getting through "an extremely painful poop." It hurt, a lot, and then it was done. She was bartending at the time, lightyears away from thinking about motherhood, and decided on medication abortion.
Medical Abortions: The Science Behind How Abortion Pills Work
Following the Supreme Court decision that overturned Roe v. Wade, attention has turned to abortion pills. WSJ's Daniela Hernandez explains how misoprostol and mifepristone work together to terminate a pregnancy, as well as the potential side effects of a medical abortion.
The Science Behind the "Abortion Pill"
"Overall [a medication abortion] is extremely safe," says Thaxton, who is also a member of Physicians for Reproductive Health. Common symptoms include nausea, cramping and heavy bleeding, similar to what women experience during a miscarriage. Thaxton generally tells her patients that if they soak through four maxi pads in two hours, that's too much bleeding, and they should consult their physician.
What Happens to Your Body in the Hours and Days After an Abortion
But if you're going for a medical abortion, here's a rough idea of what you can expect to happen during the 72 hours afterwards.
Abortion After the Clinic
We still have no idea how many people are ordering pills from other websites — like the one Purvi Patel used in Indiana in 2013. We know about women like Patel only when things go wrong.
Abortion Pills Should Be Everywhere
I bought them online. They're easy to get, and they'll change everything.
America's first generic abortion pill, explained
The introduction of a generic abortion medication could mean lower costs for patients, but barriers to access remain.
Are abortion medications delivered by mail illegal?
It is still legal in most states to receive abortion medication by mail, which has been allowed since December 2021, when the Food and Drug Administration lifted a restriction that required patients to obtain the pills from a certified provider.
Buying Abortion Pills Online Is Overwhelmingly Safe, But Maybe Illegal
There's plenty of evidence that most online retailers are selling the real thing.
Is the future of abortion online?
While the abortion debate continues worldwide, even in countries where it has long been legal, new drugs and online telemedicine services could provide access to safe abortion beyond borders and laws.
Medication Abortion Now Accounts for More Than Half of All US Abortions
Currently, medication abortion is approved for use up to 10 weeks of pregnancy. The FDA approved that limit based on research the agency reviewed at the time. However, additional research shows provision beyond 10 weeks is safe and effective and some providers administer medication abortion "off label" after that point in pregnancy.
In 2014, Ms. Coeytaux, Ms. Wells and Victoria Nichols started the Plan C campaign to raise awareness among women in the United States that early in normal pregnancies women have safely used the pills to miscarry at home (ectopic pregnancy, a rare condition in which the fetus develops outside the uterus, cannot be treated with pills). They also campaigned to make the pills available over the counter.
The Abortion Pill Can Be Used Later Than the FDA Says
The medication is approved until week 10 of pregnancy in the U.S. But the WHO says it can be safely used until 12 weeks, and activists have used it even later.
The FDA Is Restricting Access to the Easiest, Safest Form of Abortion
There's a growing consensus that the FDA's regulations on abortion pills aren't medically necessary.
The World Health Organization recommends misoprostol as a safe alternative when mifepristone isn't available, and Grossman says he would use the misoprostol-only method if he didn't have access to mifepristone as well.
What Are Abortion Pills and How Widely Are They Used?
Medication abortion accounts for more than half of procedures nationwide.
What Happens When an Abortion Doesn't Fully Work
Last year, I had an abortion. My reasons for doing so are deeply personal, painful, and nobody's business but mine. Once I'd decided to terminate the pregnancy, a woman from British Pregnancy Advisory Service (BPAS) asked me over the phone if I wanted a medical abortion—which was still possible at my stage of pregnancy (nine weeks)—or a surgical one. I had no idea.
What is a medication, or medical, abortion? 5 questions answered by 3 doctors
People have been self-managing their abortions for hundreds, if not thousands, of years. The difference now is that people have the option of using these same medications which they may obtain online or from pharmacies in some countries or from a variety of sources. And all of the evidence that we have so far indicates that self-managed abortion using these medications is very safe.
When Brazil Banned Abortion Pills, Women Turned to Drug Traffickers
With Roe v. Wade overturned, states banning abortion are looking to prevent the distribution of abortion medication. Brazil shows the possible consequences.
With Reproductive Rights in Great Jeopardy, 'Plan C' Is More Important Than Ever
Plan C—making "missed period pills" widely available—would give users the power to decide whether or not they wished to test for or confirm pregnancy before taking pills to bring on their period.
The F.D.A. warns against purchasing the drugs from online vendors, but women in the United States are doing it anyway. Increasingly, advocates of access to the drugs say, women are turning to the internet to procure the pills for use in their homes.
11 Questions You Probably Have About the Abortion Pill, Answered by Doctors
Despite this, when most people discuss abortion, they're often talking about surgical abortion, as in going into a doctor's office, hospital, or clinic to terminate a pregnancy. But anyone who needs to end a pregnancy should know that, if they're 10 weeks or less along, they have another option: the abortion pill, aka medication abortion.
9 Questions You Probably Have About the Abortion Pill, Answered by Doctors
Any medical procedure can be scary, but abortion is often shrouded in extra mystery or false information that makes it even more intimidating. Here's everything you should know about the abortion pill to keep you safe and informed.
AidAccess
The purpose of the website and the service is to create social justice and improve the health status and human rights of women who do not have the possibility of accessing local abortion services.
Mifepristone ( Mifeprex)
Mifepristone works by blocking the hormone progesterone. Without progesterone, the lining of the uterus breaks down and the pregnancy cannot continue.
Misoprostol.org
Use of misoprostol in obstetrics and gynaecology. The correct dosage varies greatly according to gestation, indication and route of administration - using the correct dosage is vital for success and to prevent complications.
Women Help Women
Contraception and abortion belong in women's hands! Women Help Women is a collaborative non-profit initiative.
Women on Waves
Women on Waves envisions a world where all people can decide about their bodies and lives and can access sexual health services/information including safe abortion services no matter where they live or what is their social economic status. Abortion is fundamentally about social and gender justice.
Women on Web
Women on Web is a digital community of women who have had abortions, medical doctors, researchers, and individuals and organizations that support abortion rights.
Abortion Pills Risk
The abortionpillrisks.org website is designed for patients, families, researchers, professionals, or the general public that have an interest in learning about the facts and health risks of mifepristone (otherwise known as the Abortion Pill or RU-486) and misoprostol for the termination of early pregnancy.
Aid Access
For many women, girls and trans men it can be impossible to secure a safe abortion. Aid Access supports women who cannot otherwise access an abortion and protects their human rights.
safe2choose
safe2choose is a social enterprise that is a part of an international movement for reproductive health and access to safe abortion. Our team includes multilingual counselors, medical doctors and experts in the field of public health and international development that work together to provide you with accurate information about safe abortion. We support and respect women to make their own decisions regarding their bodies and reproductive health.
Last Updated : Tuesday, July 12, 2022


On paper the Indigenous People of Biafra (IPOB) is dead. The five Governors of the South East states proscribed the body a few days ago. They, instead, advised all aggrieved groups in the region to articulate their positions on all national issues and submit them to the Committee of Governors, Ohaneze Ndigbo and the National Assembly members from the region through the Chairman of the South East Governors' Forum.
The action of the governors is futile because they have no power to ban any association, even a rascally one like the IPOB. The 1999 Constitution confers on groups and individuals the freedom to associate. This order by the governors is an infringement of that freedom under the Constitution.
The Governors' Forum is not a parliament that makes laws so its pronouncement on IPOB is not a law. However, each of the governments in the region can get its House of Assembly to pass a law banning IPOB but that law, if passed, will be in conflict with the 1999 Constitution. The Constitution will prevail.
The truth is that the governors' decision on IPOB is an act in futility. The IPOB members can change the name of their pressure group and still carry on with their activities. There used to be a National Union of Nigerian Students (NUNS) many years ago. The Federal Government placed a ban on its activities and prescribed it.
To compound the woes of IPOB the military authorities have gone overboard and declared IPOB a terrorist organization. The military lacks the powers to declare any organization a terrorist organization. Only a court of competent jurisdiction can make that pronouncement. Even the charges made by the military against IPOB are not weighty enough for any such declaration.
If they think they are right to let them head to the court and make a case for the stigmatization of the pressure group. If the IPOB members decide to challenge these decisions in court they may run away with the victory. But that is only my own piece of speculation. The reality is that soldiers are on the ground in the South East marching people's freedom on their big boots and sending terror into every spine.
This activity is called Operation Python Dance II (Egwe Eke II). There was Operation Python Dance 1 in the South East that took place from November 26, 2016, to December 27, 2016. The mandate of that mission was the same as this one: to nip in the bud criminal activities such as kidnapping, armed robbery, a threat to security and peaceful coexistence.
That emphasizes the need to get the police into the act so that the soldiers do not do more damage to the image of the Nigerian military. If that happens they will confirm the wide-ranging allegations that Amnesty International has been making against them on alleged human rights violations.
Let us admit, first, that Nnamdi Kanu has been a loose canon from day one. My suspicion is that the South East political elite saw him as the battle axe that they needed in persuading the Nigerian state of their marginalized status. That is probably why the South East governors did next to nothing when the guy was ordering the closure of markets, schools, public highways, etc.
That is probably why the South East governors did next to nothing when the guy was ordering the closure of markets, schools, public highways, etc. if they had reined him in earlier on the man would not have grown into the monster that he has now become.
Now he has created a Biafra National Guard and a Biafra Security Service. He is rapidly moving towards becoming a government within a government. He has even announced that the November Governorship election in Anambra State will not hold. Not satisfied with his hold on the South East states he has made some futile attempts to annex some territories in the South South region as well. What impudence!
When he was in detention I wrote an article in which I stated that he should be released based on pronouncements by the courts. Some Igbo professionals including Charles Soludo, Pat Utomi, Ebere Onwudiwe, Sam Amadi, Udenta Udenta, Ferdinand Agu under the aegis of Nzuko Umunna pleaded with the Federal authorities for his release. This eminent Igbo intelligentsia and Orji Uzor Kalu all visited Kanu in detention.
Their intervention was based on the rule of law. Kanu was granted bail with still bail conditions which he accepted. However, on stepping out of prison, he vowed not to obey those conditions which he freely agreed to. But Kanu is not above the law. Neither is he below the law. His violation of his bail terms in a violation of the rule of law and a show of disrespect to the eminent Igbo leaders who fought for his release.
In one of his remarks, Kanu stated that the Constitution approves of freedom of association. This is true. But does the Constitution say he is free to create the Republic of Biafra? It doesn't. He wants a referendum on Biafra, but there is no provision for a referendum in our Constitution.
Has he found out whether the Igbos want a referendum or not? No. he simply assumes that he is speaking for the Igbos but the Igbos have elected people who speak for them: Governors and parliamentarians in the states and at the center. Kanu's metamorphosis is amazing.
He now wears a long dress with a white covering on his shoulders and carries a Biafran fan with red, black and green with a rising sun in yellow on top of the black. In one of the pictures posted in the internet one idiot was kissing his feet. He must see himself as some sort of junior Jesus, a redeemer of the Igbos since these urchins who never experienced the pangs of war virtually worship him.
I believe Nigeria needs to be finetuned or retooled for optimal performance. But I don't think that the country is going to be rebuilt by the mechanism of the incendiary rhetoric of which Kanu is the foremost apostle. He said a few weeks ago that Abuja will be burnt down if his bail was revoked. He also said that any policeman who tried to execute an arrest warrant on him will be slaughtered. If his mandate is to fight for a fairer deal for the Igbos within the Federation of Nigeria, such intemperate and incendiary remarks will not help his cause. The truth is that he is not the only one who is asking for a fair deal. Many people from many parts of Nigeria are singing the same song because Nigeria is not yet fair to the bulk of its citizens.
He said a few weeks ago that Abuja will be burnt down if his bail was revoked. He also said that any policeman who tried to execute an arrest warrant on him will be slaughtered.
If his mandate is to fight for a fairer deal for the Igbos within the Federation of Nigeria, such intemperate and incendiary remarks will not help his cause. The truth is that he is not the only one who is asking for a fair deal. Many people from many parts of Nigeria are singing the same song because Nigeria is not yet fair to the bulk of its citizens.
The agitation in the various regions represents a repudiation of Nigeria as it is. Its fragility and dysfunctionality are too glaring to be ignored. I hope President Muhammadu Buhari does not think that these agitations are a phase that strong-arm tactics can drive into the grave of forgotten issues. These are real-life issues that hamper our unity, cohesion and our progress and prevent us from becoming the type of country that our founding fathers dreamt of. They will not go away until they receive the attention that they deserve.
President Buhari must figure out how to sort them out without the country breaking into smithereens under his watch.


One of the many perks of working at Google is the food: free breakfast, lunch, and dinner.
At the Googleplex headquarters in Mountain View, California, the approximately 30 cafés serve more than 40,000 gourmet meals a day.
From gourmet hot dogs to strawberry roses, here are 18 mouthwatering meals served inside Google's cafeterias, according to Instagrammers.
For breakfast, Googlers can head to Stock Market Café for Eggs Benedict.
… and cheesecake with berry sorbet at the Tetsuwan Atom Café.
Café Baadal — the only Google restaurant that takes reservations — serves authentic Indian food. A member of Google's full-service wait staff brought the vegetarian meal pictured below.
But if Googlers want something more casual, they can try the Steam Café. Here's a chili-topped hot dog paired with garlic steak fries.
… and summer salads for lunch.
The first and largest of the Google cafés, Charlie's Café serves things like the rockfish sushi below. It was named after Charlie Ayers, the original Google chef.
If Googlers are in the mood for a smoothie, they can pick from flavors like blueberry, carrot, and kale at the Google Slice Café.
For lunch, they can find a variety of vegan options, like this veggie-filled Moroccan soup, there too.
Victoria Café serves fancy salads, entrées, and snacks, like this green stripe candied fig and brie with a red wine reduction.
Victoria Café also offers seared yellowtail with crispy shallots, lime juice, and basil.
... and pretty strawberry roses.
Dessert at the Blaze Café, like these strawberry and lemon curd cupcakes, looks pretty delectable too.
Not to mention these fancy lattés — enjoyed in the morning or evening.


text:
import { Control } from "@angular/common";

interface ValidationResult{
  [key:string]:boolean;
}

export class UsernameValidator {

  static startsWithNumber(control: Control): ValidationResult {

    if ( control.value !="" && !isNaN(control.value.charAt(0)) ){
      return {"startsWithNumber": true};
    }

    return null;
  }

  static usernameTaken(control: Control): Promise<ValidationResult> {

    return new Promise((resolve, reject) => {
      setTimeout(() => {
        if (control.value === "David") {
          resolve({"usernameTaken": true})
        } else {
          resolve(null);
        };

      }, 1000);
    });

  }
}

redpajama_set_name: RedPajamaGithub


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Copyright © Jonell 2 Person Rope Cotton Camping Hammock By Beachcrest Home in Patio Conversation Sets All right reserved.


text:
Doctor Mid-Nite or Doctor Midnight is the name of multiple fictional superheroes in DC Comics. The figure has been represented in the comics by three different individuals, Charles McNider, Beth Chapel, and Pieter Anton Cross. Dr. Mid-Nite was originally created by writer Charles Reizenstein and artist Stanley Josephs Aschmeier in 1941. The hero, represented first by Charles McNider, appeared for the first time in All-American Comics #25 (April 1941). He continued in All-American Comics until issue #102 (Oct 1948).

Like many Golden Age heroic characters, the original Doctor Mid-Nite appeared as a member of DC's Justice Society of America. His two successors were also represented as members of the group or an offshoot. Doctor Mid-Nite has never appeared as the solo protagonist of a regular title magazine, but the figure has been the subject of an anthology and a mini-series.

All three versions of Doctor Mid-Nite have exhibited the same basic features: a cowled costume featuring a crescent moon symbol, keen ability to see in the darkness at the cost of near or total blindness in sunlight, the use of special visors and "blackout" smoke bombs to gain tactical advantage in combat, a high degree of skill in martial arts, and jobs as physicians serving both normal human beings and "metahuman" superheroes. Additionally, two of the doctors have been accompanied by sidekick owls.

As a blind character, Doctor Mid-Nite is widely regarded as the first superhero in comics to exhibit a physical impairment, pre-dating the creation of Daredevil of Marvel Comics by more than twenty years.

Charles McNider made his live-action debut in the second season of Legends of Tomorrow played by Kwesi Ameyaw. Charles McNider also appears in Stargirl, portrayed by Henry Thomas in season one and Alex Collins in season two, alongside Beth Chapel, portrayed by Anjelika Washington.

Fictional character biographies

Charles McNider

Charles McNider is the original Doctor Mid-Nite appearing in All American Comics #25 (April 1941) in the Golden Age of Comic Books and is a common member of the Justice Society of America. McNider, a young surgeon, was blinded when a grenade went off in front of him caused by gangster "Killer" Maroni, but he found that he could see in the dark. He made special goggles that allowed him to see in the daylight, and decided to use his special power to fight crime. In his civilian identity, he pretends to be a helpless blind man.

Beth Chapel

As the aging McNider spent less time in action, Beth Chapel, a medical doctor, stepped into the role of Doctor Midnight. She was an occasionally a member of Infinity, Inc.

Pieter Cross

Pieter Cross first appeared in Doctor Mid-Nite #1. He is a doctor who develops the same abilities as Charles McNider after being drugged by enforcers from Praeda Industries and being in a car accident.

Owls of Doctor Mid-Nite
Both Charles McNider and Pieter Anton Cross train owls as sidekicks.

McNider trains the same owl which crashes through his window, an event that leads to the discovery of his powers. This owl named "Hooty" (sometimes "Hootie") shares many adventures during the Golden Age.

Cross keeps company with an owl named "Charlie". The bird is named after the original Doctor Mid-Nite Charles McNider. Charlie keeps a mini-camera around his neck that can feed video directly to a display in Cross's goggles.

Enemies

Each incarnation of Doctor Mid-Nite has fought different enemies:

 "Gallows" Gallagher - A gangster who had his brother take his place in prison with help from a corrupt prison warden.
 "Hands" Hannigan - A gangster who wanted to take advantage of Regis Morgan's telescopic vision and make him a lookout for his gang.
 "Killer" Maroni - A gangster who was responsible for the grenade that blinded Charles McNider and became Doctor Mid-Nite's first opponent.
 Banshee -
 Big Mouth - The leader of a gang who worked with Jasper to set up hallucinations to frighten Japser's aunt Martha Yates and his uncle Ambrose Yates.
 Doctor Light - A villain who uses light technology.
 Dr. Gamwell - A man who used a home for the blind as a front for his criminal activities.
 Fisherman - Kurt Hartmann is a fisherman-themed criminal.
 Hans - A Nazi demolition diver.
 Herman Gherkin - A Nazi general.
 Ice Ingram -
 King Cobra - A hooded gangster.
 Madame Zara - A criminal who operated as a psychic.
 Malcolm Mumm - An inventor who invented a sound-nullifying device and operated as the self-proclaimed Master of Silence. He used his invention to cover up the sounds related to his bank vault robberies.
 Mister Nitro -
 Slim - A mobster that planned to sabotage the games of the Yellow Jackets football team.
 Tarantula - A crime lord whose minion Logger suspected that Charles McNider and Doctor Mid-Nite are the same people.
 Terrible Trio - The members in the aliases of Fisk, Shackley, and Volper run Praeda Industries.

Other versions
In 1965, DC Comics had no plans to revive Doctor Mid-Nite. DC editor Julius Schwartz gave M.I.T. student and comic book letterhack Rick Norwood permission to publish a Dr. Midnite story in his fanzine, Five. The story written by Norwood and illustrated by Steve Sabo features a doctor named Tom Benson who is blinded in battle. He discovers that his other senses are super-sensitive and dons the Doctor Midnite costume to fight crime.

Another version of the character was shown in Dan Jolley and Tony Harris' JSA: The Liberty File as a World War II United States intelligence agent code-named the Owl. This character, though a playboy, resembles other Doctor Mid-Nite representations. Though derided for his dalliances with the ladies, McNider was trusted as a valued field operative.

In the Tangent: Superman's Reign series, a version of Doctor Mid-Nite his body completely covered by a black cloak is briefly seen.

In the new Earth-2 created in the wake of Infinite Crisis and 52, a version of Beth Chapel is shown to be a member of the Justice Society Infinity.

In other media

Television
 An unidentified Doctor Mid-Nite appears in the Smallville two-part episode "Absolute Justice", in a painting depicting the Justice Society of America.
 The Charles McNider incarnation of Doctor Mid-Nite makes brief non-speaking appearances in Justice League Unlimited.
 The Charles McNider incarnation of Doctor Mid-Nite appears in the Batman: The Brave and the Bold, voiced by Corey Burton.
 The Charles McNider incarnation of Doctor Mid-Nite appears in Mad episode 46, voiced by Kevin Shinick.
 Pieter Cross appears in Young Justice voiced by Bruce Greenwood. This version is a surgeon and associate of Ray Palmer and Bumblebee.
 The Charles McNider incarnation of Doctor Mid-Nite appears in the second season of The CW's Arrowverse series Legends of Tomorrow, portrayed by Kwesi Ameyaw. This version was active in the 1940s, is a member of the Justice Society of America, and is legally blind, but possesses the metahuman ability to see perfectly in the dark.
 Both the Charles McNider and Beth Chapel incarnations of Doctor Mid-Nite appear in the DC Universe series Stargirl, portrayed by Henry Thomas (season one) and Alex Collins (season two) and Anjelika Washington respectively. The latter takes up the mantle after the former is killed in battle against the Injustice Society.
 Ahead of the series' premiere, Chapel made a cameo appearance in the Arrowverse crossover event, "Crisis on Infinite Earths".

Film
An unidentified Doctor Mid-Nite makes a cameo appearance in the opening credits of the animated film Justice League: The New Frontier. This version is a member of the Justice Society of America.

Toys
 Doctor Mid-Nite was featured as an action figure in the twelfth wave of the DC Universe Classics line. His accessory was his owl, Hooty, who rested on his arm.
 Mattel released an action figure of the Justice League Unlimited version of Doctor Mid-Nite in its DC Universe: Justice League Unlimited Fan Collection line in November 2011.
 DC Direct released two action figures of the Charles McNider and Peter Cross incarnations of Dr. Mid-Nite. The former was released in 2001 and had exchangeable right wrists, with one coming with his pet owl, Hooty.

References

External links
 JSA Fact File: Doctor Mid-Nite I
 Doctor Mid-Nite at Don Markstein's Toonopedia.

All-American Publications characters
Characters created by Roy Thomas
Characters created by Todd McFarlane
Comics characters introduced in 1941
Comics characters introduced in 1985
Comics characters introduced in 1999
DC Comics female superheroes
DC Comics martial artists
DC Comics metahumans
DC Comics male superheroes
DC Comics titles
Earth-Two
African-American superheroes
Fictional characters from parallel universes
Fictional blind characters
Fictional physicians
Fictional surgeons
Golden Age superheroes

redpajama_set_name: RedPajamaWikipedia