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Front Range Community College's Student Voice
Wolf Life
Front Range Westminster faculty share their outlooks on the novel Coronavirus pandemic
Written by Rhiana Bilderaya
Virtually no sector, public or private, has been untouched by the novel COVID-19 pandemic. FRCC Westminster and higher education institutions throughout the country are no exception. Many closed in March for the remainder of spring semester when it became clear that the virus was spreading. Faculty at FRCC Westminster are adjusting to real time remote learning, one of the new learning options for students.
"Real-time remote" is the term for classes that can be taught virtually. It means that students have an assigned class time, they log onto Zoom for their meeting time, and they submit their work online via Desire to Learn. Attendance and participation are expected. This option is less expensive than online learning and meant to mimic traditional in person classes.
Tamara Box, who teaches computer science classes at FRCC Westminster, said she normally teaches a mix of in person and online classes each semester.
"D2L is an excellent platform for setting up remote learning and that makes the course content and infrastructure very easy," Box said. "However, despite all of these advantages, I still prefer to have some face time with students every week. It is difficult to cater virtual sessions to meet everyone's schedules."
Because her class is computer-based, she is teaching remotely this semester. The loss of in-person interaction has come with some challenges for her and her students. Despite this, she has some tips for success.
"To be successful as a remote student or teacher, you have to put in the effort to connect," Box said. "Sure, you can get through the whole class barely speaking with anyone, but you'll have such a richer experience if you try to engage with students and the instructor. Go to the virtual office hours, IM the instructor with questions, reach out to your peers in discussions and help each other!"
Another computer science professor, Leslie Hurr, is enjoying teaching remotely, despite being worried about the loss of facetime turning students off of college classes.
"I am nervous I'm going to lose students [who are] intimidated by the remote fashion," Hurr said. "I try to tell my students, online and remote, that I'm available for them. I'll do a Zoom session or stay after class."
Overall, she has a very positive outlook about COVID-19 and its effects on both her personally and at FRCC Westminster. She talked at length about President Andy Dorsey's weekly town halls and the extensive support for faculty.
"FRCC has advanced so much because of COVID," Hurr said. "Andy Dorsey and so many people have joined together as a unified group to do as much as they possibly can to provide training and resources. Andy never used to have town halls, and now he has two a week."
Leslie stated that she may even want to teach virtually long-term. Prior to COVID-19, she had a long commute. Now, she just walks downstairs to her office. Between the increased flexibility and support for staff, her outlook is bright.
"We need to rise above and work as a team, all of us together," Hurr said. "Andy Dorsey sees this as another opportunity for us to offer a different mode [of learning] for those that end up liking it. I do think that COVID has advanced everyone further technologically."
The Effects of COVID-19 On Student Life
Written by Sarah McClure
Photo by Sarah McClure
Fall is a time for change, and a major shift has extended to students learning at FRCC Westminster this semester. As Colorado navigates the COVID-19 pandemic for the sixth month since mandatory quarantine orders were issued across the country in March, many students must adapt the ways in which they learn.
Ali West is a student in the fully-remote Web Development Certificate program at FRCC Westminster. She believes she has made the right choice by taking exclusively online courses.
"I chose to do online even when they were still offering some in-person classes, because this is a far better plan," said West. "I know we're probably going to have shutdowns again when it gets cold."
According to BoulderCounty.org, there was a recent spike of 114 new reported cases of the coronavirus in Boulder County. West attributes this to in-person classes resuming at the Colorado University Boulder campus.
"If I were to get [the] coronavirus, I would probably fail my classes," said West. "It's a huge risk. It makes me so glad I chose to do everything online, because it gives me a lot more control over my circumstances."
Although she is glad to have the opportunity of learning remotely, she admitted it would be nice to have more interaction with the professors. One of her professors hosts a weekly Zoom meeting to help with challenges that may arise for students learning via this type of modality.
West mentioned that some benefits she has experienced with online learning are an enhanced sense of ownership of her education, and founding greater time management skills.
"It takes initiative to do online learning," said West.
Maile Wibbens is a student in the Clinical Emergency Medical Technician program at FRCC Westminster. She has a longer commute due to circumstances surrounding COVID-19.
"The Fort Collins EMT program filled up, so I travel down there now," said Wibbens.
Her program, a hybrid modality, is what many educational institutions are implementing this semester as a resolution to concerns for safety. This means that, while her skills labs and tests are done in person, the majority of learning is done online via the Desire2Learn interface and Zoom lectures.
Wibbens has been on campus for class twice now, having taken the other six classes online. When Wibbens and two other students studied for a test in the common area of the A Floor, each of them took care to sit at their own table. The FRCC Westminster staff ensured tables were a CDC-recommended 6 feet apart.
Wibbens is forthcoming with a few pros and cons regarding the hybrid modality. She counts herself as a visual learner, so she prefers to see material on the screen during lectures. She mentions that kinesthetic learners might find online learning challenging, but [linguistic] learners may feel at ease in this type of environment.
The most notable absence thus far is the social aspect of learning.
"I think a big part of learning is being able to bounce ideas off of each other," said Wibbens. "With our class, we're very silent. I think that's kind of hard, not being able to learn beyond just the lecture from a teacher."
One positive takeaway from this situation is that since she only has to make the long drive a few times throughout the semester, there is more time to walk the dogs, ride her horse, or cook a timely dinner. She adds that it's good to sit down and be in the headspace for productivity when she logs in. She is able to do her homework immediately after her lecture, without having to drive home and become distracted by other things.
"You do get a little bit more of your life back." Wibbens says.
"Try not to procrastinate as much, because you don't know what changes [are coming] in the world and in life," said Wibbens. "Taking the chances that you can, while you can. Sometimes it won't be as easy, or you're in isolation in your house because of a pandemic."
Although an influx of people willing to work on the front lines of the healthcare industry may be great news for denizens, Wibbens can't help but worry about potential employment oversaturation after completing the program. She cites that about 140 people in Northern Colorado will be graduating at the same time.
Students at FRCC Westminster are unsure of what the future holds for education.
Written by Joe Fisk
After a short hiatus from publishing over the summer semester due to COVID-19-related complications, The Front Page student newspaper is returning for the fall semester! The paper will continue its dedication to delivering relevant news to Front Range Community College. The Front Page intends to continue bringing readers campus news, features, interests as well as COVID-19 updates and how they affect FRCC. The Front Page staff looks forward to bringing readers new content and thanks you for your patience!
View @frontpagefrcc's profile on Twitter
View @frontpagefrcc's profile on Instagram
The Front Page on Twitter
Call: (303)-404-5411 (WC), (303)-678-3911 (BCC), (970)-204-8124 (LC)
If no answer, hang up and call 911.


Launching a new site soon, but not sure if it's going to go smooth? Maybe you have a history of getting in way too deep with website design only to reach a wall that stops you from moving forward. Setbacks, miscommunication, and missed deadlines are your biggest nightmare when building a new website.
What's the best approach to launch a new website with success?
Don't make the same mistakes twice. Before you ever dive into a redesign, take a good look at the website you currently have and identify the worst. Are there things that are just plain wrong? These days, you can develop a website design that becomes obsolete in less than a year. It's probably not your fault, but it's time to change all the mistakes left on your website.
Something that my team had to fix before our last website redesign was the blog feed location. The blog feed was running from the homepage instead of the subfolder /blog/, which created a mess before we ever started working on the new website redesign. We did our research and concluded it was best to move blog articles to the /blog/ subfolder with 301 redirects before we began building the new website.
Know what you're getting yourself into long before you begin. Launching websites is not an easy task, and it takes a lot more careful planning, time, and attention than you may think. Create a plan that outlines all work needed to be done, and get the conversation started with your team. Sometimes this is best done by conducting a meeting in which every department (design, programming, content, social, administrative) can communicate the total workload for each part of the website design and development.
Once all changes that need to be made are identified, it will be much easier to get a much clearer picture of what the website will look like when finished and what steps it might take to get there.
Give yourself more direction by constructing a roadmap. After you've come up with a rough plan including each department's workload, a general roadmap of your website design procedure will give everyone on your team a better understanding of timelines. Some aspects of your redesign will naturally begin with a programmer, a designer, and copywriter, but eventually, one person will be waiting on the next to supply content to be uploaded.
A map will outline key aspects of your workflow, and help you identify components that must be finished before the next part of the project can even be initiated. It helps to start with a website design checklist to assure that, when you do set tasks for everyone, nothing is overlooked.
Murphy's law states — if there's anything that can go wrong, it will. Considering this, you might want to allow yourself a few extra days or weeks for specific parts of your website redesign. Rushing through a website redesign is a quick way to pile on the stress and raise your blood pressure. It's best to reach one conclusion before you begin — there will be setbacks. If you don't see them coming, they turn into "blocks" that keep the website from launching on the deadline. To avoid being blindsided by blocks and losing momentum, take the time to consider everything that could possibly go wrong when building out your new website.
Once you've gotten the big picture out of the way, it's time to set tasks, dates, and begin. Your website design should begin just after you've outlined the steps needed to finish the design and tasks needed to accomplish each step. All tasks and steps should have their own set of deadlines that move the project along. Keeping all parts of the project moving forward and finishing each step on time will assure your website is ready on launch day.
If you're confident in your ability to publish a working site, then start promoting your website long before launch day arrives. Once you know launch day is in sight, set up a series of posts to complete a redesign launch campaign, and drive more traffic to your website.
Time to test your website before launch to assure everything works. Our web developer builds out new redesigns by first using a dev server then transferring the final product upon completion. This means that he has much more flexibility when programming the redesign since it's not automatically affecting the live website. The testing phase of development assures that your website is going to work, and there are no broken elements before launch day.
By the time lauch day rolls around, you should be confident your website is finally FIN. Launch day is a time for celebration. If you haven't already, start promoting your website redesign launch as soon as you are certain the website is up and running and most importantly works. Give everyone on your team a high five, and be happy because you launched a new website, and holy crap, it works!
Do you use these rules when launching new websites? Please leave a comment, and share this article with your network.
this is really interesting Rules to Successfully Launch New Websites. thanks for the post.
Thanks for this articles are really awesome topics share to us , which help us to deploy new websites.


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Nov 15, 2013 Issue
Treatment of Stable Chronic Obstructive Pulmonary Disease: the GOLD Guidelines
HOBART LEE, MD; JEFFREY KIM, MD; and KARINE TAGMAZYAN, MD, Loma Linda University School of Medicine, Loma Linda, California
Am Fam Physician. 2013 Nov 15;88(10):655-663.
This version of the article contains supplemental content.
Related editorial: Choosing the Right Inhaled Medication Device for COPD
Patient Information: A handout on this topic is available at https://familydoctor.org/familydoctor/en/diseases-conditions/chronic-obstructive-pulmonary-disease/treatment.html.
This clinical content conforms to AAFP criteria for continuing medical education (CME). See the CME Quiz.
Author disclosure: No relevant financial affiliations.
Chronic obstructive pulmonary disease (COPD) is a common problem in primary care. COPD is diagnosed with spirometry only in clinically stable patients with a postbronchodilator forced expiratory volume in one second/forced vital capacity ratio of less than 0.70. All patients with COPD who smoke should be counseled about smoking cessation. Influenza and pneumococcal vaccinations are recommended for all patients with COPD. The Global Initiative for Chronic Obstructive Lung Disease assigns patients with COPD into four groups based on the degree of airflow restriction, symptom score, and number of exacerbations in one year. Pulmonary rehabilitation is recommended for patients in groups B, C, and D. Those in group A should receive a short-acting anticholinergic or short-acting beta2 agonist for mild intermittent symptoms. For patients in group B, long-acting anticholinergics or long-acting beta2 agonists should be added. Patients in group C or D are at high risk of exacerbations and should receive a long-acting anticholinergic or a combination of an inhaled corticosteroid and a long-acting beta2 agonist. For patients whose symptoms are not controlled with one of these regimens, triple therapy with an inhaled corticosteroid, long-acting beta2 agonist, and anticholinergic should be considered. Prophylactic antibiotics and oral corticosteroids are not recommended for prevention of COPD exacerbations. Continuous oxygen therapy improves mortality rates in patients with severe hypoxemia and COPD. Lung volume reduction surgery can improve survival rates in patients with severe, upper lobe–predominant COPD with heterogeneous emphysema distribution.
Chronic obstructive pulmonary disease (COPD) is a common problem in primary care. The estimated prevalence is 6.3% (15 million persons) in the United States,1 with more than 126,000 deaths each year.2 COPD treatments aim to improve quality of life and control symptoms while reducing exacerbation risk, which can lead to increased morbidity and mortality.
This article summarizes expert consensus guidelines from the Global Initiative for Chronic Obstructive Lung Disease (GOLD) for nonpharmacologic and pharmacologic interventions for patients with stable COPD.3 The GOLD guidelines are widely used in the management of COPD. (Disclosure: the GOLD program is funded by pharmaceutical companies that make medications for COPD, and the board of directors, committee members, and reviewers have ties to the pharmaceutical industry. See http://www.goldcopd.org/disclosure-statements.html.)
Enlarge Print
SORT: KEY RECOMMENDATIONS FOR PRACTICE
Clinical recommendation
Suspected COPD should be confirmed by spirometry in stable patients with a postbronchodilator forced expiratory volume in one second/forced vital capacity ratio of less than 0.70.
Smoking cessation is recommended for all patients with COPD who smoke.
Patients in GOLD group A should be treated with a short-acting anticholinergic or short-acting beta2 agonist on an as-needed basis.
Patients in GOLD group B should be treated with a long-acting anticholinergic or long-acting beta2 agonist.
Patients in GOLD group C or D should be treated with a long-acting anticholinergic or a combination of an inhaled corticosteroid and long-acting beta2 agonist.
Long-term oxygen therapy improves mortality rates in patients with severe hypoxemia and COPD.
COPD = chronic obstructive pulmonary disease; GOLD = Global Initiative for Chronic Obstructive Lung Disease.
A = consistent, good-quality patient-oriented evidence; B = inconsistent or limited-quality patient-oriented evidence; C = consensus, disease-oriented evidence, usual practice, expert opinion, or case series. For information about the SORT evidence rating system, go to https://www.aafp.org/afpsort.
Although some of the GOLD recommendations are derived from outcome-oriented evidence, the guidelines have not been shown to provide better clinical outcomes than other guidelines on COPD management, such as those from the National Institute for Health and Care Excellence4 or the joint guidelines from the American College of Physicians, American College of Chest Physicians, American Thoracic Society, and European Respiratory Society.5 A comparison of treatment guidelines is shown in Table 1.3–5 The joint guideline from the American College of Physicians uses the forced expiratory volume in one second (FEV1) to guide treatment decisions, whereas the National Institute for Health and Care Excellence guideline focuses on symptoms of breathlessness and exacerbations. The GOLD guideline combines the subjective and objective components of COPD to classify severity and guide treatment recommendations.
Comparison of Recommendations for Treatment of Chronic Obstructive Pulmonary Disease
American College of Physicians/American College of Chest Physicians/American Thoracic Society/European Respiratory Society guideline5
FEV1 = 60% to 80% predicted: inhaled bronchodilators may be used
FEV1 < 60% predicted: long-acting anticholinergic or long-acting beta2 agonist recommended; combination therapy may be used (long-acting anticholinergic, long-acting beta2 agonist, or inhaled corticosteroid)
Global Initiative for Chronic Obstructive Lung Disease guideline3
Patient group A*: short-acting anticholinergic or short-acting beta2 agonist as needed
Patient group B*: long-acting anticholinergic or long-acting beta2 agonist
Patient group C or D*: long-acting anticholinergic or combination of long-acting beta2 agonist plus inhaled corticosteroid
National Institute for Health and Care Excellence guideline4
Patients with breathlessness and exercise limitation: short-acting beta2 agonist or short-acting anticholinergic as needed
Patients with persistent breathlessness and exacerbations despite therapy above:
FEV1 ≥ 50% predicted: long-acting anticholinergic or long-acting beta2 agonist
FEV1 < 50% predicted: long-acting anticholinergic or combination of long-acting beta2 agonist and inhaled corticosteroid
Patients with persistent breathlessness or exacerbations despite therapy above:
FEV1 ≥ 50% predicted: long-acting beta2 agonist plus inhaled corticosteroid, or combination of long-acting anticholinergic, long-acting beta2 agonist, and inhaled corticosteroid
FEV1 < 50% predicted: long-acting anticholinergic, long-acting beta2 agonist, and inhaled corticosteroid
FEV1 = forced expiratory volume in one second.
*—See Figure 1 for definition of patient groups.
Information from references 3 through 5.
Jump to section +
A diagnosis of COPD should be considered in patients with progressive dyspnea, chronic cough, or increased sputum production with risk factors (e.g., smoking). COPD can be diagnosed with spirometry only in stable patients (i.e., those not experiencing an acute exacerbation of symptoms) with a postbronchodilator FEV1/forced vital capacity ratio of less than 0.70.3 The diagnosis of COPD and interpretation of spirometry results have been reviewed previously.6,7
GOLD classifies persons with COPD into four groups based on the severity of disease, as assessed by the following criteria: the degree of airflow restriction, a patient symptom score, and the number of exacerbations in one year (Figure 1).8 This grading system uses objective spirometry data and subjective symptoms because the degree of airflow restriction does not always correlate well with symptoms.9 The degree of airflow restriction is graded as mild, moderate, severe, or very severe (Table 2).8 Persons with mild or moderate airflow restriction are assigned to group A or B, whereas those with severe or very severe airflow restriction are assigned to group C or D.
Combined Assessment of COPD
Combined assessment of COPD. (CAT = COPD Assessment Test; COPD = chronic obstructive pulmonary disease; GOLD = Global Initiative for Chronic Obstructive Lung Disease; mMRC = modified Medical Research Council Dyspnea Scale.)
Reprinted with permission from the Global Strategy for the Diagnosis, Management and Prevention of COPD, 2013, © Global Initiative for Chronic Obstructive Lung Disease (GOLD), all rights reserved. http://www.goldcopd.org/other-resources-gold-teaching-slide-set.html. Accessed August 20, 2013.
Classification of Severity of Airflow Limitation in Chronic Obstructive Pulmonary Disease*
In patients with FEV1/FVC < 0.70:
GOLD 1 (mild): FEV1 ≥ 80% predicted
GOLD 2 (moderate): 50% ≤ FEV1 < 80% predicted
GOLD 3 (severe): 30% ≤ FEV1 < 50% predicted
GOLD 4 (very severe): FEV1 < 30% predicted
FEV1= forced expiratory volume in one second; FVC = forced vital capacity; GOLD = Global Initiative for Chronic Obstructive Lung Disease.
*—Based on postbronchodilator FEV1.
COPD symptoms are assessed subjectively using one of two validated patient symptom questionnaires.10 Because FEV1 does not necessarily correlate with patient symptoms, and because improvement of a patient's health status and reduction in symptoms are the goals of treatment, the inclusion of symptom questionnaires allows for the diagnostic assessment to match treatment goals, similar to the guidelines from the National Institute for Health and Care Excellence.3 GOLD recommends the use of the COPD Assessment Test (CAT) or the modified Medical Research Council Dyspnea Scale (mMRC, Table 3).11 The CAT is available at http://www.catestonline.org/ (eFigure A), and the CAT and the mMRC are available in the smartphone app COPD Pocket Consultant Guide (http://bit.ly/1aTrkIs). Patients with a CAT score less than 10 or an mMRC score of 0 or 1 are assigned to group A or C. Those with a CAT score of 10 or more or an mMRC score of 2 or more are assigned to group B or D.
eFigure A.
Reprinted with permission from GlaxoSmithKline. COPD assessment test. http://catestonline.org/english/indexEN.htm. AccessedAugust 20, 2013. Copyright © GlaxoSmithKline group of companies. All rights reserved..
Modified Medical Research Council Dyspnea Scale
Description of breathlessness
I get breathless only with strenuous exercise.
I get short of breath when hurrying on level ground or walking up a slight hill.
On level ground, I walk slower than other people my age because of breathlessness, or I have to stop for breath when walking at my own pace.
I stop for breath after walking about 100 yards or after a few minutes on level ground.
I am too breathless to leave the house, or I am breathless when dressing.
Information from reference 11.
The third component used to determine the GOLD group is the number of COPD exacerbations in one year. GOLD defines an exacerbation as an acute event characterized by worsening of respiratory symptoms beyond normal day-to-day variations that leads to a change in medication.3 Exacerbations are associated with higher mortality.12,13 Patients with no or one exacerbation per year are assigned to group A or B, and those with two or more are assigned to group C or D. If there is a discrepancy when all three components are considered, the patient should be assigned to the higher-risk group.
Patients with COPD should be reassessed every two to three months. Symptom questionnaires (e.g., CAT, mMRC), smoking cessation (if applicable), and exacerbation history should be reviewed. Repeat spirometry is recommended on a yearly basis.3
COPD treatment is guided by the patient group assignment. As disease severity increases, long-acting inhalers and combination therapies are added to provide additional symptom control and reduce the risk of exacerbations.
Patients who smoke should be assisted with smoking cessation through counseling and effective medications.14,15 The American Academy of Family Physicians' Ask and Act Tobacco Cessation Program provides online resources for physicians and patients (http://bit.ly/1fV71eZ).
Influenza vaccination reduces COPD exacerbations and is recommended yearly.16 The Centers for Disease Control and Prevention recommends pneumococcal vaccination for all adults 19 years and older who have chronic lung disease, including COPD. However, a meta-analysis of seven studies did not show a decrease in pneumonia rates, hospital admissions, or emergency department visits in patients with COPD who received the pneumococcal vaccine.17
Pulmonary rehabilitation has been shown to improve exercise tolerance, reduce dyspnea, and improve health-related quality of life in patients similar to those in GOLD groups B through D.18
INHALED MEDICATIONS
For patients in group A, a short-acting anticholinergic (e.g., ipratropium [Atrovent HFA]) or short-acting beta2 agonist (e.g., albuterol, levalbuterol [Xopenex HFA], pirbuterol [Maxair Autohaler]) is recommended on an as-needed basis for mild intermittent symptoms. A meta-analysis of 13 studies found that short-acting beta2 agonists improved lung function, dyspnea, and fatigue, and decreased breathlessness compared with placebo.19 A 2006 Cochrane review that included 3,912 patients showed a small benefit in quality of life and lung function in those receiving ipratropium compared with albuterol.20 Combination therapy with scheduled albuterol and ipratropium has been shown to increase FEV1 but does not affect patient symptom scores.21 It is not known if as-needed dosing is more or less effective than scheduled administration.
For patients in group B, long-acting inhaled medications should be used. Options include long-acting anticholinergics (e.g., tiotropium [Spiriva], aclidinium [Tudorza Pressair]) or long-acting beta2 agonists (e.g., arformoterol [Brovana], formoterol [Foradil], indacaterol [Arcapta], salmeterol [Serevent Diskus]). Tiotropium has been shown to improve quality-of-life scores, with a number needed to treat of 14 to prevent one exacerbation and 30 to prevent one hospitalization over one year.22 If tiotropium is prescribed, patients should be switched from ipratropium or ipratropium/albuterol (Combivent) to albuterol alone as short-acting rescue medication.
Long-acting beta2 agonists reduce exacerbation risk and improve FEV1 and daily symptom scores.23 A randomized, double-blind trial of 6,112 patients with moderate to severe COPD showed that salmeterol improved FEV1 and decreased exacerbation risk, but did not reduce mortality.24 Indacaterol is a once-daily long-acting beta2 agonist that improves FEV1 and reduces rescue use of albuterol.25 In patients with comorbid asthma or an unclear diagnosis, monotherapy with a long-acting beta2 agonist is contraindicated because it may increase cardiovascular mortality.26
Tiotropium reduces exacerbations and COPD-related hospitalizations compared with long-acting beta2 agonists, but does not affect mortality.27 For patients whose symptoms are not controlled with tiotropium or a long-acting beta2 agonist alone, a combination of tiotropium and a long-acting beta2 agonist is recommended based on short-term outcomes of improved symptom scores and higher FEV1.28,29
A 2008 meta-analysis found an association between the use of inhaled anticholinergics (ipratropium and tiotropium) and cardiovascular mortality in patients with COPD.30 However, a subsequent randomized, double-blind trial with 5,993 patients demonstrated decreased cardiovascular and overall mortality with tiotropium after four years of follow-up.31 A large cohort study of U.S. veterans showed an increased risk of cardiovascular events with the use of ipratropium in the previous six months.32 Given this association, ipratropium should be avoided in patients with cardiovascular disease.
Patients in GOLD groups C and D should be prescribed a long-acting anticholinergic or a combination of an inhaled corticosteroid and long-acting beta2 agonist.3 Compared with tiotropium alone, fluticasone/salmeterol (Advair) improved daily symptom scores and decreased mortality (number needed to treat = 40), but increased the incidence of pneumonia (number needed to harm = 25) and did not change the rate of exacerbations.33 Patients with poorly controlled symptoms should start triple therapy with an inhaled corticosteroid, long-acting anticholinergic, and long-acting beta2 agonist. The data for triple therapy are inconsistent, with studies showing improvement in lung function and symptom scores but conflicting results regarding reduction in exacerbation rates compared with tiotropium alone.28,34 A summary of initial treatment options and common medications is presented in Table 48and Table 5,35 and patient instructions for inhaler use are reviewed in eFigure B.
Initial Pharmacologic Management of Chronic Obstructive Pulmonary Disease
Patient group*
Short-acting anticholinergic as needed (e.g., ipratropium [Atrovent HFA])
Short-acting beta2 agonist (e.g., albuterol) as needed
Long-acting anticholinergic (e.g., tiotropium [Spiriva])
Long-acting beta2 agonist (e.g., salmeterol [Serevent Diskus])
Short-acting beta2 agonist and short-acting anticholinergic
Long-acting anticholinergic
Long-acting beta2 agonist
Long-acting anticholinergic and long-acting beta2 agonist
Short-acting anticholinergic as needed and/or short-acting beta2 agonist as needed
Inhaled corticosteroid(e.g., fluticasone [Flovent]) and long-acting beta2 agonist
Phosphodiesterase-4 inhibitor (e.g., roflumilast [Daliresp])
Short-acting anticholinergic as needed agonist as and/or short-acting beta2 needed
Inhaled corticosteroid and long-acting beta2 agonist
Inhaled corticosteroid and long-acting anticholinergic
Inhaled corticosteroid and long-acting beta2 agonist and long-acting anticholinergic
Inhaled corticosteroid and long-acting beta2 agonist and phosphodiesterase-4 inhibitor
Long-acting anticholinergic and phosphodiesterase-4 inhibitor
Information from reference 8.
Medications Commonly Used for Treating Chronic Obstructive Pulmonary Disease
Cost*
Potential adverse effects
Short-acting anticholinergic
Ipratropium (Atrovent HFA)
Two puffs every six hours as needed
$236 per inhaler
Anaphylaxis, angioedema, bronchospasm (paradoxical), glaucoma (narrow-angle), hypersensitivity reaction, laryngospasm
Short-acting beta2 agonists
Two puffs every four to six hours as needed
$33 per inhaler (generic)
Angina, angioedema, arrhythmias, bronchospasm (paradoxical), hypertension, hypokalemia, QT-interval prolongation, seizures
Levalbuterol (Xopenex HFA)
$55 per inhaler
Anaphylaxis, arrhythmias, bronchospasm (paradoxical), hypersensitivity reaction, hypertension, hypokalemia, metabolic acidosis, paresthesia, syncope
Pirbuterol (Maxair Autohaler)
One or two puffs every four to six hours as needed
Arrhythmias, bronchospasm (paradoxical), hypersensitivity reaction, hypertension, hypokalemia, seizures
Long-acting anticholinergics
Aclidinium (Tudorza Pressair)
One dose twice per day
$237 for 60 doses
Atrioventricular block, bronchospasm (paradoxical), cardiopulmonary arrest, heart failure, hypersensitivity reaction
Tiotropium (Spiriva)
One dose per day
Angioedema, bronchospasm (paradoxical), glaucoma, hypersensitivity reaction
Long-acting beta2agonists
Arformoterol (Brovana)
15 mcg twice per day (nebulizer only)
$249 for 30 vials (15 mcg per vial)
Arrhythmias, bronchospasm (paradoxical), hypersensitivity reaction, hypokalemia, lung cancer
Formoterol (Foradil)
One dose every 12 hours
Anaphylaxis, arrhythmias, asthma exacerbation, atrial fibrillation, bronchospasm (paradoxical), hypertension, hypokalemia, metabolic acidosis
Indacaterol (Arcapta)
One capsule per day
$187 for 30 capsules
Arrhythmias, bronchospasm (paradoxical), hypersensitivity reaction, hypokalemia, seizure disorder
Salmeterol (Serevent Diskus)
One puff every 12 hours
Anaphylaxis, angioedema, arrhythmias, bronchospasm (paradoxical), fever, glaucoma, hypersensitivity reaction, hypertension, hypokalemia, paresthesia, pelvic inflammatory disease, vasculitis
Inhaled corticosteroids
Beclomethasone (Qvar, 40 to 80 mcg per puff)
40 to 320 mcg twice per day
Anaphylaxis, angioedema, bronchospasm, hypersensitivity reaction, glaucoma, suicidal ideation
Budesonide (Pulmicort, 90 to 180 mcg per puff)
180 to 360 mcg twice per day
$120 to $135 per inhaler, depending on dosage
Adrenal insufficiency, angioedema, benign intracranial hypertension, bronchospasm, glaucoma, hypersensitivity reaction, hypertension, hypokalemia, leukocytosis
Ciclesonide (Alvesco, 80 to 160 mcg per puff)
Angioedema, bronchospasm (paradoxical), elevated liver enzymes, increased intraocular pressure
Fluticasone (Flovent HFA, 44 to 220 mcg per puff; Flovent Diskus, 100 to 250 mcg per puff)
$130 to $275 per inhaler, depending on dosage and delivery system
Anaphylaxis, angioedema, asthma exacerbation, bronchospasm (paradoxical), Churg-Strauss syndrome, fever, hypersensitivity reaction, muscle injury, vasculitis, wheezing
Mometasone (Asmanex, 220 mcg per puff)
One or two puffs per day
Anaphylaxis, angioedema, bronchospasm, fever, hypersensitivity reaction, increased intraocular pressure, wheezing
Combination medications
Budesonide/formoterol (Symbicort)
Two puffs twice per day
$222 to $253, depending on dosage
Anaphylaxis, angioedema, arrhythmias, bronchospasm, glaucoma, hypersensitivity reaction, hypertension, hypokalemia, hypotension, increased intraocular pressure, tachycardia
Fluticasone/salmeterol (Advair)
One puff twice per day (Diskus); two puffs twice per day (HFA)
Anaphylaxis, angioedema, arrhythmias, asthma exacerbation, bronchospasm, hypertension, hypokalemia, myocardial ischemia, stridor, tachycardia, wheezing
Ipratropium/albuterol (Combivent Respimat)
One or two puffs every six hours as needed
Anaphylaxis, angioedema, arrhythmias, exacerbation of chronic obstructive pulmonary disease, glaucoma, hypersensitivity reaction, hypertension, hypokalemia, increased intraocular pressure, metabolic acidosis, myocardial ischemia, tachycardia
Mometasone/formoterol (Dulera)
Adrenal suppression, angioedema, arrhythmias, asthma exacerbation, bronchospasm, glaucoma, hypersensitivity reaction, hypokalemia, seizures, vasculitis
Roflumilast (Daliresp)
500 mcg per day
$215 for 30 500-mcg tablets
Arrhythmias, elevated liver enzymes, hypersensitivity reaction, lung cancer, paresthesia, prostate cancer, renal failure, suicidal ideation
Theophylline (extended-release)
300 mg per day initially, then titrate by serum levels
$10 (generic) for 30 300-mg tablets
Arrhythmias, hyperthyroidism, intractable vomiting, peptic ulcer disease, seizures, status epilepticus
*—Estimated retail price based on information obtained at http://www.goodrx.com and http://www.drugpriceinfo.com (accessed August 20, 2013).
Asthma Basics Booklet
eFigure B.
Directions for appropriate inhaler use. (MDI = metered-dose inhaler.)
ORAL MEDICATIONS
Theophylline can be added or used as an alternative in patients whose symptoms are not controlled with triple therapy or who cannot afford inhaler therapy. Theophylline requires drug level monitoring and improves lung function parameters, but has uncertain effects on symptoms and exacerbations.36
Roflumilast (Daliresp), an oral phosphodiesterase-4 inhibitor approved for use in patients with COPD and chronic bronchitis symptoms, can also be added to long-acting bronchodilators in patients in group C or D. Studies have demonstrated improvement in FEV1 but inconsistent results regarding reduction of exacerbation rates.37,38
Prophylactic antibiotic therapy is not recommended to prevent COPD exacerbations. Although erythromycin and azithromycin (Zithromax) have shown a reduced risk of exacerbations,39,40 there are insufficient data about the effects on macrolide resistance and long-term adverse effects to recommend their use.
Oral corticosteroids do not improve quality of life or reduce exacerbation rates, and are not recommended for patients with stable COPD.41
Long-term oxygen therapy is recommended for patients with COPD and severe hypoxemia (oxygen saturation less than 88% or partial arterial oxygen pressure less than 55 mg Hg). Supplemental oxygen improves endurance and exercise capacity in patients with moderate to severe COPD.42 A multicenter randomized trial with 203 patients who had hypoxemia and COPD demonstrated that continuous oxygen therapy had benefits on survival rates compared with nocturnal oxygen therapy.43 The goal oxygen saturation should be approximately 90% to avoid respiratory acidosis.44
Lung volume reduction surgery improves five-year survival rates in patients with severe COPD and heterogeneous distribution of emphysema with upper lobe predominance.45 Conversely, patients with severe COPD and FEV1 less than 20%, homogenous emphysema, or low carbon monoxide diffusion capacity have increased 30-day mortality after lung volume reduction surgery.46
Lung transplantation may improve quality of life and functional capacity in selected patients with severe COPD. Criteria for referral include a score greater than 5 on the BODE (body mass index, obstruction, dyspnea, exercise) Index3 (Table 647).
BODE Index for Predicting Mortality in Patients with Chronic Obstructive Pulmonary Disease
Body mass index (kg per m2)
Obstruction: percentage of predicted FEV1
Dyspnea: mMRC score (Table 3)
Exercise: distance walked in six minutes (meters)
≥ 350
NOTE: Scores range from 0 to 10; higher scores indicate a greater risk of death. Patients with scores of 6 or greater meet criteria for referral for lung transplantation.
FEV1 = forced expiratory volume in one second; mMRC = modified Medical Research Council Dyspnea Scale.
Adapted from Celli BR, Cote CG, Marin JM, et al. The body-mass index, airflow obstruction, dyspnea, and exercise capacity index in chronic obstructive pulmonary disease. N Engl J Med. 2004;350(10):1007.
Data Sources: A PubMed search was completed in Clinical Queries using the key terms COPD treatment and COPD therapy. The search included meta-analyses, randomized controlled trials, clinical trials, and reviews. Also searched were EBSCO Host Academic Search Premier, DynaMed, Essential Evidence Plus, and UpToDate. Search Date: October 2012.
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HOBART LEE, MD, is the program director and an assistant professor of family medicine at Loma Linda (Calif.) University School of Medicine....
JEFFREY KIM, MD, is the assistant program director and an assistant professor of family medicine at Loma Linda University School of Medicine.
KARINE TAGMAZYAN, MD, is a fourth-year combined family medicine and preventive medicine resident at Loma Linda Inland Empire Consortium for Healthcare Education.
Address correspondence to Hobart Lee, MD, Loma Linda University School of Medicine, 25455 Barton Rd., Ste. 209B, Loma Linda, CA 92354 (e-mail: holee@llu.edu). Reprints are not available from the authors.
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Holding Autonomy to Account: Legal Standards for Autonomous Weapon Systems
by Lauren Sanders, Damian Copeland | Sep 15, 2021
The March 21 UN Panel of Experts on Libya report, citing the use of an autonomous armed drone by Turkish-backed Government of National Accord Affiliate Forces to attack retreating Hafter-Affiliated Forces in Libya, suggests the prospect of weapons with autonomous functionality (AWS) is a reality. While a pre-emptive ban of AWS remains elusive, there is consensus among States party to the CCW that "IHL continues to apply fully to all weapon systems, including the potential development and use of lethal autonomous weapon systems."
Autonomy in weapons is not unlawful per se, however normative questions concerning the application of existing IHL rules remain: what legal standards apply to the use of AWS and how is legal responsibility and accountability distributed between the State, its agents (for example, the military commander responsible for the AWS use), and the AWS designer or manufacturer? Multiple legal regimes may interact to attribute legal responsibility—based on differing standards—for diverse legal objectives relevant to design and use, including accountability, deterrence, compensation, and punishment.
This post attempts to survey the legal standards relevant to the development, acquisition, and use of an AWS in armed conflict and highlights some of the particular challenges that autonomy in weapon systems can pose to States and to those who set the standards and are responsible for compliance.
Challenges to Article 36 Legal Review of AWS
It is axiomatic that machines are not legal entities subject to IHL rules and responsibilities. For States party to Additional Protocol I, Article 36 requires legal reviews of weapons prior to their use in armed conflict. Weapon reviews are an internal State process. A reviewing State must determine what standards an AWS should first meet to determine legality per se in accordance with IHL and other laws binding the State. Then that State must determine the legality of its use in particular circumstances. Despite this requirement, existing State practice does not appear catered to weapon systems that incorporate autonomous functions. Moreover, reviewing a system designed to undertake functions previously the preserve of humans and that may independently change poses novel testing and evaluation challenges.
When determining if a weapon system is legal per se, States must identify the autonomous functionality that engages IHL obligations and apportion compliance standards relevant to the expected use in the design and development phase of new AWS. While weapon reviews are not intended to create subjective standards, in the absence of internationally recognized standards, States must interpret their IHL and international law obligations to create new compliance standards. For each function the machine conducts that triggers an IHL obligation, design criteria must be pre-programmed into the AWS to meet those legal standards. These criteria must also be tested vigorously and meet a pre-determined standard of predictability and compliance.
Establishing pre-programmed legal standards of compliance is unlikely to be straightforward. There may be multiple standards determined by factors including legal risk, complexity of the operational environment, and the ability to maintain human lines of legal responsibility and accountability. These standards may vary depending on the specific task and the anticipated operating environments of the AWS. For example, the standard of compliance for distinguishing between lawful and unlawful targets is likely to be higher in a complex urban operating environment compared to a remote, uninhabited one.
Then, having determined an AWS is lawful per se, a State must set the standards to which AWS must perform to be lawfully used in a particular operational context. Depending on the autonomous functionality, this may include compliance with the IHL prohibitions against weapons using methods of warfare of a nature to cause unnecessary suffering or superfluous injury (Article 35(2) of AP1), indiscriminate attacks (Articles 48 and 51(4) of AP1), or disproportionate attacks (Article 57(2)(a)(iii) of AP1). Inability to meet State-imposed performance standards for legal compliance will influence the Article 36 weapon review.
A few other questions also flow from these two prongs of the legal review process. First, should States adopt a standard of human equivalency, or behavior-based or performance-based standards? While IHL holds humans to a "reasonable" standard, a State may require AWS performance to be of a higher standard, as a matter of both policy and law. Equally, a determination as to whether the machine can meet the same standard expected of humans in the same situation is challenging, if not impossible, to determine given the inherently complex, diverse, and uncertain nature of conflict environments.
Second, a State must then determine which of the numerous validation frameworks and software evaluation methodologies will prove that under these complex conditions in a real-world armed conflict—arguably the most complex and uncertain of environments—these legal standards can be met. Finally, States must consider what technical standards an AWS must meet in terms of trust, predictability, explainability, and reliability to comply with the law.
Responsibility for AWS in Armed Conflict
The legal review of a weapon only gets a State as far as certifying that an AWS is capable of being fielded, consistently with IHL obligations. Once in a situation of armed conflict, States are primarily responsible for implementing IHL, and therefore ensuring AWS are used in compliance with IHL. IHL imposes specific obligations upon States and includes individual mechanisms to give effect to these responsibilities.
One such mechanism—although rarely considered or utilized—could be establishment of an International Fact-Finding Commission, to inquire into facts of an alleged violation associated with a State's use of an AWS (Article 90 of AP1). A relevant question for a fact-finding commission may be the conduct and results of an internal weapon review. If a State were to forgo their weapon review obligation or adopt legal standards below that necessary for lawful AWS use when fielded, the State bears the risk of deploying unlawful weapons in armed conflict. They would then need to, when applicable, pay compensation for unlawful death and destruction resulting from its use. In fact, the responsible State may be required to pay compensation for any violation of the Convention (Article 91 of AP1; Hague Convention IV, Article 3).
In developing AWS, States must therefore consider their technical ability to inform their enquires into IHL compliance, whether supporting specific fact-finding mechanisms, or more generally. Some autonomous neural systems preclude traceability of actions resulting in a so-called AI "black box." Other neural networks can back-trace and map the link between the inputs to the system and the machine's decision-making at the time. Accordingly, there must be consideration as to assigning responsibility for AWS at a particular point in its design, programming, or use, and ascribing standards to comply with those requirements and create records for such compliance mechanisms. Flowing from this is the requirement for the State to assess the AWS's capacity to create records—and to what technical standard—to enable fulfilment of their obligation to investigate breaches of IHL. Must the records support criminal investigations under domestic regimes, or simply be an ability to trace by whom the autonomous system's resultant behavior was initiated?
States are required to implement measures for the execution of their IHL obligations. This includes making legal advisors available to their military commanders (Article 82 of AP1) and by ensuring the members of their military are trained in IHL (Articles 80 and 83 of AP1). Finally, States are responsible for repressing breaches of IHL (Articles 85 of AP1). These combined obligations mean States must ensure that their operators, commanders, and legal advisors are appropriately trained to understand the capabilities and limitations of the AWS. It is necessary for the users to understand how the AWS can be used in compliance with IHL in a particular circumstance and, where necessary, intervene in the AWS operation to ensure compliance and safeguard protected persons and objects.
Individual Responsibility for AWS Use in Armed Conflict
IHL imposes specific obligations upon individuals. The IHL rule on precautions in attack, for example, requires "those who plan or decide upon an attack" to do "everything feasible" to distinguish between lawful and unlawful targets and "take all feasible precautions" to avoid collateral damage. What is "reasonable" and "feasible" is contextually dependent. For AWS it should mean reasonableness given a person's reliance upon an autonomous function subsuming an action that would have previously been conducted or controlled by themselves.
The obligation to do what is reasonable and feasible is followed by accountability. A fundamental premise of international criminal law is to hold individuals who commit grave breaches of IHL to account for their unlawful actions in armed conflict. This raises challenges in the context of AWS. How can an individual be held criminally responsible for the artificial decisions undertaken by an AWS under the person's meaningful human control?
Part of the answer must lie in how the standard is interpreted. In the case of Galić, the International Criminal Tribunal for the former Yugoslavia applied a "reasonable military commander" standard to determine whether an attack was unlawfully disproportionate. The Tribunal observed that clothing, activity, age, and gender were relevant to determine civilian status, as was movement, shape, color, and speed in identifying a civilian object.
If an AWS was designed to recognize such indicia and determine the civilian status of persons and objects, the State must have determined, as a matter of law, an AWS performing a distinction role must achieve an equal or higher standard than reasonable belief required by a human. The commander using the AWS would then be able to consider its use lawful in the particular operation. Ascribing a higher standard to machines remains fraught, however. What is considered "reasonable" in the context of autonomous decision-making systems requires the fielding State to carefully consider differing conditions applicable in every potential use and make legal and policy decisions accordingly.
A requirement for meaningful human control over the critical functions of the AWS is increasingly espoused as a prerequisite for its lawful deployment in armed conflict. Whether meaningful human control is a legal requirement or an ethical or moral obligation is the subject of ongoing debate. Centered on the basis that the machine is under control and supervision and is conducting tasks only at the behest of its human operator, human accountability and responsibility remains for the use of the system with functionality that engages IHL obligations, regardless of which functions for the use of force have been delegated to the machine. Thus, a State must also consider a standard relevant to make the level of control and intervention necessary for the autonomous functionality to be considered "meaningful."
Article 30 of the Rome Statute holds persons criminally liable if they commit the elements of an offence applying the default mental standard of "intent or knowledge." If a military commander deployed an AWS designed to recognize the Galić indicia described above, knowing that it is incapable of doing so in the environment in which it was deployed, and if that deployment resulted in the killing of civilians, could such action meet the mental element of intent or knowledge to be criminally responsible for the war crime of willful killing under Article 8(2)(a)(i)?
Further obscuring the principle of legal accountability being ascribed to human actors is the distributive nature of autonomous systems themselves. Different people are responsible for designing the algorithm, programming it, testing it, training it, deploying it, and potentially for authorizing specific actions conducted by it. In this regard, the criticisms for the dilution of individual responsibility in aerial bombing campaigns by the use of a "kill chain" and "targeting system" are more pronounced. Autonomous systems are even more dispersed and may include actors who were unaware of how and when their work would be put into practice. The attribution for mistake, negligence, malfeasance, or failure to meet IHL standards may occur cumulatively and will be difficult to trace. How to establish standards for responsibility—held by a person in a system of controls that disperses responsibility across a number of actors—will prove a challenge.
Manufacturers' Liability for AWS Design, Development, and Use
Advanced technologies, particularly in relation to those that incorporate autonomous functions, also challenge notions of responsibility for IHL compliance attributed to a designer or developer for the use of the system in a particular operational environment.
The question of whether negligence even applies—and to whom—in armed conflict remains uncertain. Equally, there is ongoing pressure to consider applying IHL to corporations that play an increasing role in armed conflict, utilizing technological advantages provided by AI systems. What responsibility exists, for instance, for a company that knowingly exports its AWS to a State that relies upon the company's assurances of IHL compliance built into that AWS (noting that IHL obligations differ from State to State)? Likewise, the extent to which product liability law applies during armed conflict remains unsettled. Some people consider that the ability to trace actions to developers and designers in armed conflict is too long a bow to draw to result in criminal responsibility for use of the autonomous system.
While there was near State consensus at the recent UNCCW GGE on LAWS that regulation of LAWS must apply to the whole life cycle of a weapon system, it is unclear how this translates to those responsible for the design and development of an AWS. That input may occur years prior to its use, potentially with no knowledge of how the system or algorithm may be used. The possibility for dual-use autonomous technology to be incorporated into weapon systems further exacerbates these legal responsibility considerations.
Considering the broader system of State controls for the use of force, weapons without autonomous functions are designed and tested to meet specified performance standards, after which they are then introduced into a State's military arsenal. The same staged process cannot be applied to AWS. For systems incorporating autonomy, algorithms and data inputs will directly affect the target, selection, and strike decisions that would have ordinarily been undertaken by human actors in armed conflict. Turning to parallels outside of armed conflict for examples of liability processes does not seem helpful. Recent cases relating to the self-learning functions of autonomous vehicles demonstrate that the presence of a human controller generally defers legal responsibility to that actor rather than to the design or developer. But what if a design flaw causes an IHL breach during use in armed conflict, such as an inherent data bias in the algorithm, an undisclosed component of the autonomous neural network that applies gender or ethnic-specific biases to the identification processes of that neural network?
This post has flagged some of the issues that vex the international community and States in their ability to set legal standards relevant to the design, acquisition, and performance of AWS. Although not insurmountable, it is evident that the integration of legal assessments and considerations throughout the design, development, acquisition, and deployment processes associated with AWS is critical to enabling States—and those that use them—to meet their legal obligations in fielding AWS in situations of armed conflict.
In addition to the many challenges faced in the regulation of autonomous weapons systems prior to their lawful use in armed conflict, significant questions remain about whether the standard adopted should be the same as, or better than, a human decision-maker; and what responsibilities will be passed on to the designers and developers of these systems given they are "closer" to the operational decision-making than their traditional weapons manufacturing peers have been in the past. Such standards will all involve complex considerations that take into account State political, economic, and strategic goals, the will of industry to cooperate, and the ability of lawmakers to influence these outcomes.
Regardless of what standard is applied, absent any binding legal instruments to the contrary, it is evident that there will be a period when State practice interpreting existing rules will shape how IHL will adjust in the future to this new technology—hopefully for the betterment of humankind rather than to its detriment.
Lauren Sanders and Damian Copeland are both Senior Research Fellows at the University of Queensland's Law and the Future of War Project. This article represents the authors' personal views and does not reflect those of the Australian Defence Force or Australian Government.


text:
Melink's Bold Steps Towards Sustainable Innovation
by Wendy Johnson February 19, 2019 October 30, 2019
MILFORD, Ohio — In an open field surrounded by solar panels, founder, CEO, and visionary Steve Melink stands where Melink Corporation's second headquarters will be erected. Just across the street from the first building, the second headquarters will be similar in structure but will improve on its design.
As Melink says, the company is "taking building science to the next level." Even throughout the winding driveway of the company's property, Melink's prioritization of sustainability and energy efficiency is prominently on display. The parking lot allocates spaces to charging electric vehicles, and the field next to the parking lot hosts large solar panels…and that is just the exterior of the building. Upon entering the Melink HQ, natural daylight illuminates the workspace in contrast to the anticipated fluorescent office lighting. The building is not only designed to be energy efficient. It also strives to cultivate a productive work environment for employees. Windows can be opened for fresh air to circulate throughout the building. Employees share that they are much happier and more productive in the space that puts the priority on them compared to the all too common stale workplace environments.
Since the first headquarter building, HQ1, was completed in 2006, it has been regularly upgraded. Today, Melink is proud to have achieved net-zero energy use in their headquarters building. It actually produces more energy than it consumes. The building's innovations have received public recognition including several awards, but Steve Melink is not content. He sees an opportunity in the upcoming building (HQ2), to push the boundary even more and implement new innovations that have been developed in the last 15 years.
An Idea and a Basement
Steve Melink founded Melink Corporation in 1987 after developing its first product, a Heating Ventilation and Air Conditioning (HVAC) test and balance system, in the basement of his home. Thirty years later, the company has expanded to over 100 employees throughout the country with a focus on four business products.
Melink specializes in the installation and design of their Intelli-Hood product, solar PV panels, and their most recent expansion: a geothermal HVAC system. Each of these systems offer energy efficient solutions and save Melink's clients money. The Intelli-Hood is used on commercial kitchen hoods. Melink's website explains that "the patented Intelli-Hood controls visually monitor the level of cooking activity and automatically instructs the exhaust fan to operate only as fast as necessary."
"When we slow those fans down during idle, non-cooking periods, we're not throwing away all that conditioned air," Melink said. The Intelli-Hoods are staples in many nationally-recognized chains, including McDonalds and Walmart. Over the past 10 years, Melink has expanded into solar PV and geothermal systems. One of its most prominent local solar projects is the 1.56 megawatt solar canopy over the Cincinnati Zoo's parking lot producing about 20 percent of the zoo's electricity and providing shade for visitors' cars.
Melink's products are in niche markets, yet as corporations increasingly become cost- and energy-aware, their sales continue to
grow. As a privately-owned company, Melink does not release their revenues publicly, but they aim to grow their profits by 15-30 percent annually. Their geothermal service includes innovative new technology that drastically reduces the heating and cooling costs for residences and commercial buildings. As Melink's website explains, "geothermal heat pumps use the ground as a heat exchanger via a closed-loop water circuit." In the winter months, the geothermal pumps take heat from the ground and transfers it into the building. In the summer, the system does the opposite, bringing warm air from the building and pumping it into the ground. Melink expects that geothermal can experience the same growth as solar and will become a mainstream solution to powering buildings.
Residential and commercial building owners often look for the smallest upfront cost, neglecting to consider the hidden costs that will impact them for the rest of the building's life cycle. Melink's message is that people should not be afraid of the up front investment in a better building design. The more efficient a building is, the lower the long-term hidden costs will be. He thinks of this as an iceberg. "The cost of most homes or buildings is the tip of the iceberg that you see," Melink said. "The rest of the iceberg that you can't see under the water is what you are going to pay for the life of the building."
Taking Sustainable Building to the Next Level
Though their employee base has expanded more slowly, the company is nearing full capacity in its first building, which prompted Melink to look to expand. Melink plans for the new HQ2 building to serve as a showcase of innovation and prove to the public that such an energy efficient design is accessible and feasible for most companies. "Sustainability, renewable energy and energy efficiency are ways of the future, and the world needs more of these," Melink said. "We want to be a leader in this space." In the design, Melink first focuses on reducing the electric load of the building as much as possible, and then covering the significantly reduced electric power needs through solar photovoltaic cells.
Strategies for improving the efficiency of the building's envelope, will include increasing insulation values, and specifying window glazing designed to reduce winter heat losses while reducing summer heat gains. To most people, the window frames might seem like a small area of the building, but as they are often made of aluminum, they have a dramatically higher thermal heat transfer than other building materials.
By minimizing the exposed surface area and providing thermal breaks to reduce heat loss, the window frames will be much more efficient. Through these and other efficient construction-detailing measures, the heating and cooling loads for HQ2 will be dramatically lower than other similar building structures. This will in turn reduce the amount of electricity the building needs. HQ2 will feature a solar PV array sized with the goal of reaching netzero energy. Although the company is already known as an innovative and sustainable company, its employees constantly search for opportunities to improve, whether it be on the design of products or the space in which they work. As Melink said, "this is what leaders do, you take bold steps."
by: Sarah Siegel
Written by Wendy Johnson
Wendy Johnson is a communications specialist with more than 20 years experience working with non-profits and churches.
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A particularly dark and humid area in the middle of the Swamp. Can be found after exploring the Swamp 25 times.
Mother Frog - A pregnant frog-girl who wants to transfer her eggs to you.
A medium damp chest can be found here.


Shop Wayfair's sales section to find daily sales up to 70% off. Shop sales by category including living room furniture, rugs, bedroom furniture, cookware, home accents and more. Limited-time deals start every day at 12 pm ET so don't miss out!
With one of the world's largest online selections of furniture, home furnishings, décor and goods, including more than seven million products from over 7,000 suppliers, Wayfair helps people find the perfect product at the right price. Their extensive selection and superior customer service coupled with the convenience of online shopping, make it easier than ever before to find exactly what you want for your home at a price you can afford.
We're looking at getting a new living room set for our home. We've been in our new home for 4 years and are finally getting around to doing some decorating. It's takes me a while to decide on big things like how to decorate a room. Can you tell? Well, it's not all my fault. We've been also waiting due to a certain kitty in our home that thinks the couch is a scratching post. But, we're growing tired of our uncomfortable couch and loveseat we bought when we moved here. Tip No. 1: Don't buy living room furniture from a local furniture outlet just because it's inexpensive. We learned our lesson. It would have been much better if we'd done more looking first. We could have got a nice set at Wayfair for the same price! Plus not have to pay for local delivery which was $75.
I'm going share some of the sets I've found at Wayfair that are great choices for country decor, primitive decor, or farmhouse decor.
Barryknoll Chesterfield Settee – Available in several colors.
Huntingdon Chesterfield Loveseat – Available in several colors.


This low growing variety is ideal for borders, rock gardens or bedding. Plants are covered with golden blossoms forms early spring into June. Blooms second season after sowing.
Shear plants after blooming to maintain their low growing habit and profuse blooming. Plants do best in full sun. May be planted through mid-summer.
Thinning - when plants are 3 inches tall thin to 4 inches apart.


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StampIt standardizes document marking the way YOU want it. It installs with 58 common words and phrases and allows instant custom stamps ― in any hollow, watermark or solid format as well as graphic images and Bates.


text:
Antiwar Leader Hopes for Calm At Convention
By Christopher ConkeyStaff Reporter of THE WALL STREET JOURNAL
Tom Andrews has spent the last two years trying to get people to pay attention to arguments against the war in Iraq. Now, with the media's eyes fixed on his cause and the antiwar movement poised to make one of its loudest statements since Vietnam at next week's Republican national convention in New York, all he can do is sit back and watch.
And hope it doesn't all fall apart.
Mr. Andrews, a 51-year-old former congressman from Maine, is the national director of Win Without War, a coalition of 42 groups founded in 2002. Like the hordes of protesters who will flood New York City this weekend, Win Without War opposes the war in Iraq and the "militarization" of U.S. foreign policy. Yet Win Without War differs from other antiwar groups in key ways. It doesn't do street protests, but rather focuses on, as Mr. Andrews says, presenting a moderate antiwar view to "mainstream people through the mainstream press."
As a nonpartisan group, Win Without War can't endorse a candidate and has chosen to stay away from the convention next week. But Mr. Andrews worries that other groups' protests might turn violent, besmirching the broader movement.
"Some [protesters] will be as outrageous as they can be, but the vast majority will be there because they sincerely believe the U.S. is heading in the wrong direction," says Mr. Andrews. "As long as there's a fair accounting ... I'm confident it will be a net plus for us."


text:
Pehr Magnus Ferdinand Lundberg, född 15 november 1815 i Stockholm, död 23 juni 1901, var en svensk boktryckare och tidningsman. Han startade Umeås första tryckeri och därefter grundade han Umeås första tidning, Wester- och Norrbottens Läns Tidning. Han var Wasabladets första redaktör, grundade Södermanlands Län Tidning och var under en tid Finlands störste förläggare av religiös litteratur.

Biografi
Under 1820-talet arrenderade fadern M.G. Lundberg det Marquardska tryckeriet i Stockholm och Pehr Lundberg fick vid åtta års ålder börja arbeta vid tryckeriets kast. År 1832 gick han i lära hos Per Adam Wallmark som då innehade Ecksteinska tryckeriet i Stockholm. Han utskrevs som fullärd i yrket 1835 efter elva års lärotid. Därefter fick han arbete hos tryckaren J.P. Lundström i Jönköping, och arbetade från 1837 hos Lars Johan Hierta i Stockholm. I slutet av 1830-talet började han som tryckerifaktor vid Carl Gustaf Wolffs boktryckeri i Vasa.

Hösten 1840 flyttar Pehr Lundberg, tillsammans med den yngre bror, Otto Gabriel Lundberg, till Umeå. Anledningen kan vara att det wolffska tryckeriets produktion av religiös litteratur, både på finska och svenska, ogillades och censurerades av ryska censurmyndigheter samt att från finländskt håll kunde man inte ingripa mot ett tryckeri i Sverige. Samma år är tillstånd klart och tryckeriet igång i Umeå.

I Umeå hade Pehr Lundberg inlett ett samarbete med före detta lantmäteriauskultanten och versifikatören Johan Christian Holst. När Lundberg begärde tillstånd att ge ut en tidning så undvek han att själv stå som ansvarig utgivare och i stället utsågs Holst till tidningens ansvarige utgivare. Tidningen, Wester- och Norrbottens Läns Tidning som var Umeås första och Sveriges nordligaste, startade den 1 maj 1841. Under tiden hade Pehr Lundberg träffat Anna Catharina Sundholm från Vasa och den 19 september 1841 gifte de sig.

Tidningen upphörde med en regelbunden utgivning den 13 november 1841 på grund av motsättningar mellan Lundberg och Holst. En av orsakerna var en notis i tidningen där det antyddes att kyrkoherden Anders Abraham Grafström skulle ha fällt ett olämpligt yttrande angående ett komministerval i Umeå. Grafström förnekade detta och som en konsekvens fick Holst avgå från posten som tidningens ansvarige utgivare. Lundberg fick då tillstånd att ta över som ansvarig utgivare. Den nya tidningen fick namnet Wester- och Norrbottens Läns Nya Tidning. I den nya tidningens redaktion inträdde J.G. Rothoff, sedermera Umeås borgmästare. Rothoff kom att prägla tidningens innehåll fram till dess upphörande 31 december 1842.

Den 1 juli 1843 köpte Lundberg delar av det wolffska tryckeriet och bokhandeln i Vasa för 3 500 rubel silver. Med från Umeå följde även konstförvanterna Erik Gustaf Lindroth och Carl Gustaf Rosén. Lindroth återvände dock senare till Umeå och startade Umeå-Bladet. Som förste boktryckare i Finland investerade Lundberg i en snällpress. Under senare delen av 1840-talet blev Lundberg Finlands störste förläggare för religiös litteratur.

Efter att ha bidragit till grundandet av Vasabladet 1856 återvände Lundberg till Sverige 1858, där han startade ett nytt tryckeri i Norrköping. 1862 köpte han Lybeckers tryckeri i Västervik som senare flyttades till Nyköping, där han samma år började utge Södermanlands Län Tidning. Pehr Lundberg avled 1901.

Referenser

Noter

Tryckta källor

Personer från Stockholm
Födda 1815
Avlidna 1901
Svenska publicister
Finländska publicister
Män
Personer i Umeås historia

redpajama_set_name: RedPajamaWikipedia


Sitting at the table for the past three hours, and a blank page screaming at you to get your life together, to start writing already, was definitely not helping anyone calm down. Every time you put pen to paper, another project or problem would pop into your head, until you had assignments, people, places, dates, floating around, until all you could think about was slamming your face into the table enough times that everything would leave except for whatever you were actually supposed to be writing about.
That's right, what you're dealing with is a very common issue, widely known as stress.
Stress is something that, although horrible, everyone endures throughout their lives. Thankfully, however, there are tons of things we can do to alleviate it until the stressful thing has passed.
First of all, one of the easiest ways to get rid of stress can be to stop whatever is stressing you out, and do something you enjoy. This is basically just to get your mind off of everything and can mean watching a movie for a while or reading a book. Even getting some sleep is a great way to relax and recharge your mind so you can power through anything. Drinking a hot beverage such as tea, and listening to your favorite music can even work too, as long as it's something you'll find calming.
Another important way you can reduce stress is, believe it or not, to organize everything that's causing you to stress out. Putting assignments, dates, and events down in a planner or notebook can help you clear your mind and make everything seem less unattainable. You can also attempt to break down any work you might have, just to make it seem less daunting, and you will probably finish it faster if you know what you plan to do. This can be done by just going over everything and seeing what each homework consists of, and maybe planning each part of what your ideas might be. Getting to the root of the problem and planning it, or going through what you'll have to do can make everything less overwhelming.
If worse comes to worse, and you can't seem to overcome the feeling, talking or ranting to a friend can often help as they might be able to offer more ideas on what to do, and they'll probably prove that you aren't the only one! Remember that teachers are usually quite understanding too; they might be able to give you ideas on a project if you're stumped, and if you're lucky sometimes due dates and presentations can be moved around or extended.
Keep in mind that being stressed is something that everyone has to deal with, and there are always ways to relieve the feeling. Stepping away from the cause of the problem, getting sleep, organizing and talking to someone are all things that can help reduce stress so that you can accomplish whatever has to get done.
Next postThe Get Down- Music, Youth, Hope.


text:
Medindia » Mental Health News
Memory Loss and Amnestic MCI – Precursors of Alzheimer Disease
by Medindia Content Team on June 28, 2006 at 11:43 AM
Researchers at the Duke University Medical Center have found that Alzheimer's damaged communication pathways between frontal and temporal lobes, which are responsible for short-term as well as long-term memory power.
According to a new study published in the Journal of Radiology, early Alzheimer's disease plus recent memory loss may be linked to change brain activities in several areas.
For the first time, researchers at Duke University Medical Center in Durham, N.C., used a special, high-field- strength, functional magnetic resonance imaging (fMRI) scanner to study the brain activity of people with amnestic mild cognitive impairment (MCI), a precursor to AD, and found altered functionality in both the frontal and temporal lobes of the brain. Previous studies looking at structural changes alone have shown evidence that brain atrophy in the earliest stages of AD tends to be restricted to the temporal lobe, a region critical to long-term memory formation.
'Involvement of both the frontal and temporal lobes in the earliest stages of AD suggests the possibility of a breakdown in the communication pathway between these two regions, which house short-term and long-term memory, respectively,' said lead author Jeffrey R. Petrella, M.D., associate professor of radiology and director of Alzheimer's Disease Imaging Research Laboratory at Duke. 'So in many ways the AD brain may be like a computer that is having problems with both its temporary files and its hard-drive files.'
MCI affects an estimated 15 percent of the elderly population in the United States. Ten to 15 percent of people with MCI develop AD every year compared to one percent of the normal elderly population. Amnestic MCI is characterized by mild memory impairment and is often confused with ordinary age-related forgetfulness.
The researchers used 4-Tesla fMRI, which has a very strong magnetic field, to observe the brain activity of 20 elderly patients with amnestic MCI and 20 age-matched controls with no memory impairment during a memory task that tested memory formation and retrieval.
'It's like doing a treadmill test for heart patients, except this test puts your brain on a treadmill,' Dr. Petrella said.
The test required 40 patients to recall names of familiar faces and to learn and recall unfamiliar face-name associations. All patients showed brain activation in several brain regions during the task, but, compared with the controls, the patients with MCI showed a lower level of activation in the prefrontal cortex (during formation and retrieval), left hippocampus (during retrieval) and left cerebellum (during formation) and an increased level of activation in the posterior frontal lobes (during retrieval).
'These findings suggest that we should be paying closer attention to frontal lobe function in detecting people at risk for AD and may also point to new preventive strategies,' said co-principal investigator P. Murali Doraiswamy, M.D., chief of the Division of Biological Psychiatry in the Department of Psychiatry at Duke.
Both researchers caution that their findings are preliminary. They are in the process of completing a larger study to confirm these results and to examine their value as a diagnostic or predictive test. There have also been a number of previous fMRI studies in people with MCI, and researchers are working to put these findings together to develop a synergistic combination of memory testing, genetic and imaging studies that together can best predict early onset and monitor progression of AD.
'If memory problems are beginning to impact the day-to-day life of you and your family, you should undergo comprehensive testing by a physician, as memory loss can be caused by many underlying factors such as depression, thyroid problems and stress, and doesn't necessarily indicate early AD,' Dr. Petrella said.
Source: Eurekalert
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text:
Boris Johnson is no friend to Plymouth
by Charlotte Holloway | Jul 23, 2019 | News and Updates
Boris Johnson, the new Conservative Prime Minister, is no friend to Plymouth.
He is out of touch, breaks promise after promise, and is dangerously incompetent and self-interested. He is unfit to be Prime Minister because of his character, his policies, and his lack of empathy.
One of his first pledges was to give more tax breaks for the rich, a move that could cost the country as much as £20bn a year. He is not a man who is in the interests of the working people of Plymouth.
Mr Johnson's proposed tax cuts would not only disproportionately help the rich who help keep this Conservative Government in power, but it would also make it nigh on impossible to end the Tory austerity that has crippled our country and made life more difficult for the man and woman on the street, despite Mr Johnson promising otherwise.
This is a man whose lies have cost him at least three jobs, from being sacked from his job at The Times newspaper after allegations he made up quotes, to losing government positions after lying about extramarital affairs.
Put simply, Boris Johnson is no friend to Plymouth, he is not in the interests of the working people, and he is not fit to lead our country.
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Address Charlotte Holloway for Plymouth Moor View, Lockyer Hall, Alfred Street, Plymouth, PL1 2RP
Email charlotte@charlotteholloway.org
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Five Little Ducks song words.
But only 3 little ducks came back.
But only 2 little ducks came back.
But only 1 little duck came back.
But no little ducks came wondering back.
And 5 little ducks came wandering back.