text:
|Publication number
|Publication type
|Application number
|Publication date
|Feb 9, 1988
|Filing date
|Feb 13, 1986
|Priority date
|Feb 25, 1985
|Fee status
|Publication number
|Thomas Esposito
|Original Assignee
|Thomas Esposito
|Export Citation
|BiBTeX, EndNote, RefMan
|Patent Citations (10), Referenced by (40), Classifications (8), Legal Events (6)
|External Links: USPTO, USPTO Assignment, Espacenet
This application is a continuation-in-part of application Ser. No. 705,358, filed Feb. 25, 1985, now abandoned.
The present invention relates to improvements in the management of body wastes by ostomates, i.e., persons who have had a colostomy, urostomy or similar operation whereby waste is diverted for discharge through a surgically created opening, or stoma.
For several decades surgical procedures have been available for the excision of malignant portions of the intestinal tract. This, then entails creation of an an artificial opening to which the remaining, healthy portion of the intestine is attached to permit the discharge of body wastes. Such artificial openings, or stomas, are usually located on the front of a person's torso in the region of the abdomen. These procedures are known as colostomies, colectostomies and ileostomies, reflecting the various degrees to which the intestinal tract has been removed. A similar procedure is employed where the urinary tract is diseased. The ureter, in such case, is then connected to an artifical opening or stoma.
The obvious problem is to collect and contain the body wastes discharged from the stoma. This has involved the use of a container which in then emptied from time to time, or, in the more usual case simply replaced by a fresh container. While there are different problems unique to the several procedures, the basic difficulty is in providing a seal between the stoma and the the container.
It is also to be pointed out that there is no bodily control of discharge of the waste. The intestinal tract, for example, has a peristaltic, involuntary muscular movement, i.e., a wavelike motion of the intestine, which forces the feces in a discharge direction to the stoma. Similarly, flow through the ureter is continual and uninterrupted
An essential requirement for an ostomy device is to accommodate normal activities, including athletic exercise, of the the ostomate, all of which involves bending of the torso and a resulting tendency to cause a folding or creasing of the body area where the stoma has been created. This is one of the factors which make obtaining an effective seal with the container difficult.
While a stoma may be generally characterized as a circular orifice, the stoma of each ostomate is unique. many are irregular to a greater or lesser degree, and may be sunken or protruding and have wrinkles radiating into the peristomal skin. These factors likewise contribute to the difficulties in obtaining an effective seal between the stoma and the container employed to collect waste.
The importance of an effective seal is vital. It is obvious that leakage of body wastes in undesirable, if not intolerable. Beyond this, the seal needs to be effective to prevent body wastes from contacting the peristomal skin. Feces, containing digestive juices, can literally eat the skin. The resulting lesions, in extreme cases could even be life threatening.
Ostomy devices came into being essentially at the inception of the surgical procedures, i.e., they have existed for many years. They have taken many forms and approaches to obtaining the desired seal between a collection container and the stoma, as is reflected both in the patent literature and in the present commercial market.
The effectiveness of these devices is limited. Many are not suited to the needs of an ostomate with a sunken or wrinkled stoma. Others are unduly complicated or expensive, for example one type device employs a sealing member custom-molded to the configuration of the individual's stoma and peristomal skin area.
As a general characterization, earlier forms of ostomy devices were predicated on the use of a rigid member which was intended to form a seal with the ostomate's skin surface peripherally of and spaced outwardly of the stoma. Such devices were pressed inwardly by belt means to provide a sealing pressure for the device. While the seal obtained could be effective in preventing leakage, the peripheral skin surface was constantly exposed to body wastes with result irritation from body wastes.
More recently, with the development of improved adhesives, ostomy devices have been based on an adhesive seal approach. A highly effective form of this approach is based on the use of what is termed a santiary wafer. This wafer comprises an adhesive sheet which adheres to the peristomal skin, with an opening therein permitting discharge of waste through the sheet. A circular flange projects outwardly from the sheet to provide for the detachable mounting of a collection container, or bag, into which body wastes are directed, from the stoma.
Nonetheless, the useful life of the sanitary wafers, as well as other devices using and adhesive seal approach, is quite limited, requiring frequent replacement of the device, usually on a daily basis, or more often.
Accordingly the broad object of the present invention is to alleviate the waste disposal problems experienced by ostomates.
A more specific object of the invention is to extend the usefulness and effectiveness of adhesive seals between a stoma and a collection container.
Another, more specific object of the invention is to eliminate, at least for a significant period of time, the need for a collection container.
A further object of the invention is to attain the above ends in a simple and economical fashion having applicability to virtually all types of stomas.
The objects of the present invention are attained through a device which stabilizes the stoma and peristomal region of the ostomate.
The stabilization obtained isolates the peristomal flesh and underlying body portions, from the surrounding portions of the torso and also gives it a firmness. These characteristics of stabilization enhance the effectiveness of body waste management adjuncts, such as the referenced sanitary wafer, as well as permitting some ostomates to dispense entirely with the need for a collection container.
While a limited number of prior ostomy devices have, in fact, stabilized the peristomal region, there has been no appreciation of the full potential of such stabilization in overcoming the waste disposal problems of the ostomate, as herein taught.
Thus the present invention embodies a simple, rigid frame in combination with a belt. The frame has a central opening which the ostomate registers with his stoma. The belt is then tightened about his torso. In so doing the frame is drawn into the flesh and the stoma and peristomal region is thus stabilized.
The device of the present invention is unobstructed, outwardly of the frame opening to provide manual access to the stabilized peristomal region. The stabilized peristomal region then has sufficient rigidity, or firmness, to permit secure attachment of an adhesive sealing sheet of the type commercially available for attaching a collection container, or a mounting device for a collection container, pursuant to the method aspects of the invention.
A further aspect of the present invention is found in a method employing this frame. For colostomates, an absorbent pad is placed over the peristomal region and the frame then secured to stabilize the peristomal region. While feces will be discharged by peristaltic action, the liquid content will be absorbed by the pad and the feces will solidify. The ostomate's sense of touch will alert him when there is a buildup of feces sufficient to require its disposal and replacement of the pad. Such disposal intervals will be in the order of several hours. Thus the ostomates bodily elimination function more nearly approaches that of the ordinary person, requiring no special collection containers. This method is predicated on the ostomate's ability to minimize liquid content of the feces through dietary control.
In other method aspects, the frame may first be used to stabilize the peristomal region and then an adhesive, protective sheet applied to the stabilized peristomal skin. This sheet has an opening which is registered with the stoma. The frame is then temporarily removed and an absorbent pad inserted to overlie the the protective sheet. The frame is remounted to hold the pad in place as above described. A protective sheet may also be inserted to overlie the absorbent pad to prevent moisture from penetrating to the ostomates clothing.
Structural features of the invention relating to the frame are found in the relationship between the span of its central opening and the nominal diameter of the stoma, preferably two to four times, and the thickness of the frame relative to the span of the opening preferably being 15 to 25% of the span. These features combine to provide manual access to the stoma, while causing a minimum protrusion of the ostomate's clothing. The preferred provision of a blunt edge at the inner end of the frame opening, avoids discomfort when the device is worn.
The inner end of the frame opening is preferably formed as an "rounded square" to resist displace of the device relative to the ostomate's torso.
Further features of the invention are specifically directed to enhancing the effectiveness of the referenced sanitary wafers which comprise a flexible, impervious sheet having a layer of adhesive on its inner surface. The sheet also has a flange projecting from its upper surface, on which a waste collection container may be mounted. An opening approximating the outline of the ostomates stoma is formed within the flange and approaches the inner diameter thereof.
In one version of the invention, an insert is employed to further stabilize the peristomal region and concentrate the stabilization closely adjacent the stoma opening of the protective sheet. The insert has a relatively thin planar portion which spans the insert opening. A central opening in this planar opening has a diameter approximating, but somewhat larger than the outer diameter of the water flange and is telescoped thereover.
This provides a high effective stabilization of the peristomal region immediately adjacent the periphery of the stoma opening in the protective sheet. The effectiveness of the adhesive seal at this critical point is thus greatly enhanced, extending the useful life of the sanitary wafer several fold.
In another version of the invention this thin planar section is integrally formed with the ostomate frame.
One of the structural features of devices for the sanitary wafer is the provision of openings in the planar section, within the outline of the frame opening, outwardly of the flange opening, through which the ostomate's flesh protrudes to further minimize relative movement between the device and the santiary wafer and the ostomate's torso.
The present invention represents a distinctly new approach to body waste management. It is based on a rigid device, the function of which is not to form a seal with the skin surface of an ostomate, as other rigid devices have done, but instead to stabilize the peristomal region and thereby to enhance the effectiveness of adhesive seals of body waste management adjuncts, or to enable the ostomate to dispense with a collection container.
The above and other related objects and features of the invention will be apparent from a reading of the following disclosure, making reference to the accompanying drawing and the novelty thereof pointed out in the appended claims.
In the drawings:
FIG. 1 illustrates the front of the torso of an ostomate, with an ostomy device embodying the present invention, secured in place;
FIG. 2 is horizontal section illustrating a typical stoma;
FIG. 3 is a front view, on an enlarged scale of the ostomy device seen in FIG. 1;
FIG. 4 is a section, on a further enlarged scale, taken on line 4--4 in FIG. 3;
FIG. 5 is a section, on the same further enlarged scale, taken on line 5--5 in FIG. 3, with the stabilized peristomal region shown in broken lines;
FIGS. 6 and 7 are sections, also on said further enlarged scale, taken on line 6--6 in FIG. 3, illustrating method aspects of the invention.
FIG. 8 is a plan view of an adhesive wafer to which a disposal bag is attached;
FIG. 9 is an elevation of the wafer seen in FIG. 8;
FIG. 10 is a plan view of an insert used in combination with the present ostomy device;
FIG. 11 is an elevation, partly in section, of the insert seen in FIG. 10,
FIG. 12 is a plan view of an alternate embodiment of the present ostomy device;
FIG. 13 is an elevation of the ostomy device seen in FIG. 12;
FIG. 14 is a vertical section, on an enlarged scale, of the wafer, insert and ostomy device of FIGS. 8-13 secured in place on the body of an ostomate;
FIG. 15 is a plan view of a further embodiment of the present ostomy device secured on the body of an ostomate, illustrating its relationship to the wafer of FIGS. 8 and 9; and
FIG. 16 is a section taken generally on line 16--16 in FIG. 15.
Before giving a detailed description of the specific embodiments, herein disclosed, a brief discussion of stomas will be had. Many factors have a bearing on the physical configuration of a stoma. As indicated above, medical factors determine what portion of the intestinal tract must be removed. This, plus the stature and age of a person will control the diameter of the portion of the intestine (used generically to include a colon, or bowel), which is to be joined to the abdomen in forming a stoma. Stoma diameters, measured from the outer wall of the intestine, generally range from 1 to 15/8 inches, though stoma diameters outside of this range are not unknown.
The intestine itself comprises a compositely formed tubular structure comprising an outer wall and a fleshlike inner lining. The outer wall of the intestine is sutured to the muscle wall of the abdomen, with the terminal end of the intestine, ideally, flush with the skin surface of the abdomen, sutures also being provided at this juncture. Unfortunately, this ideal condition is often not obtained and the stoma is retracted, or sunken beneath the level of the abdomen, or the intestine may extend outward causing a protruding stoma, projecting above the normal level of the skin.
The outer wall of the intestine is essentially inexpansible and, thus, at the stoma, its diameter, for practical purposes, is a constant. The fleshlike inner lining of the intestine is expansible and compressible, within the outer wall, to accommodate feces which advance therethrough by reason of peristaltic action.
FIGS. 1, 2, 5-7, 14, 15 and 17 variously illustrate stomas as herein described. The inner walls of the stoma, in the absence of feces (as in FIG. 7), expand, or collapse inwardly, so that there is little or no open passageway extending through the intestine.
The skin surface surrounding the stoma can be irritated and even ulcerated as a result of exposure to feces and digestive juices which are exuded from the stoma. Adhesively applied sheets are available to protect the peristomal skin surface from this source of irritation. It is an accepted practice for an ostomate to obtain a punch which is accurately configured to the outline of his stoma. Such a punch is employed to form an opening in the the protective sheet which is then registered with the stoma, so that essentially no peristomal skin surface is exposed to feces. It is to be noted that the stoma is seldom of a truly circular outline and can be both irregular, or jagged, as well as somewhat elliptical, hence reference is made herein to the nominal diameter of the stoma.
The devices of the present invention have as their primary function, the stabilization of the peristomal region, both the skin and underlying flesh, so that the effectiveness of the adhesive for the protective sheet will be enhanced and preserved. The stabilization provided thus prevents, for prolonged periods, leakage of feces, or digestive juices, between the protective sheet and the peristomal skin surface. Such stabilization also enables feces management without the need of a collection container, or even a protective sheet.
Referencing FIG. 1, it will be seen that the illustrated ostomy device of the present invention is extremely simple, comprising only a frame 10 and a belt 12 which holds it in registered relation with the stoma of an ostomate.
The frame 10 in preferably of circular outline with an opening 14 which has a "rounded square" outline, at its inner end, which blends to a circular outline at its outer end. The surface of the frame opening 14 is preferably beveled outwardly its inner end which is defined by a small, vertical flat at a lip defined by the inner end of opening and the inner surface of the frame which is to be pressed against the flesh of the ostomate. Peripherally of the inner end of the opening 14, the inner surface initially extends outwardly, generally normal to the opening 14, and then curves outwardly to form the circular side surface of the frame. The lip thus causes only a minimum pressure and discomfort when the frame is pressed against the flesh of the ostomate, as will later appear.
While dimensions will vary for ostomates of different stature and build, as well as for stoma location, it has been found that a frame diameter of approximately 41/2 inches and an opening of approximately 3 inches, with a thickness of 1/2 inch is preferred for approaching a device universally applicable to more than 90% of colostomates. Further these preferred dimensions provide a minimum restriction to the ostomate's activities, while achieving the waste disposal objectives of the present invention. A further function of these preferred dimensions is the comfort factor, i.e., the base of the frame is sufficiently wide that it does not exert an undue concentration of pressure, and yet the belt can be sufficiently tensioned to obtain the desired stabilization of the peristomal region. Thus further enhances the the comfort factor of the blunt lip at the inner end of the opening 14.
The belt 12 comprises two portions, 12a and 12b, respectively secured to opposite sides of the frame 10. Thus, wire bridges 16 are spaced from the outer surface of the frame 10 by posts 18. The ends of the belt portions 12a and 12b are looped respectively around the bridges 16 and secured to themselves to provide for attachment to the frame 10.
The free ends of the belt portions 12a and 12b are preferably provided with fastener strips strips so that these ends may be releasably secured to accommodate ostomates of varying girths in using the ostomy device. Hook and loop fasteners sold under the trademark Velcro are representative of the fasteners which may be used.
The primary physical characteristic of the frame is that it be rigid. Many materials would suffice, however, any of several resinous materials, often referred to as plastics, are preferred for their light weight and ease of fabrication, as by molding. In the same vein, the bridges may be formed of metal wire, with the posts 18 bent therefrom and then joined to internal reinforcements 20 embedded in the frame (see FIG. 4) as an uninterrupted ring, which reinforces the rigidity of the plastic device into which it is molded. A further preferred dimensional relationship is found in the distance of the top of the bridge from the lower surface of the frame. A distance of approximately 5/8 inch has been found highly effective in obtaining the desired stabilization with a tolerable belt tension and a minimal bulging of the clothing.
FIG. 2 illustrates a typical stoma of the the sunken type. The colon, at its point of attachment to the abdominal wall, forms The stoma. Because of the shortness of the colon, the peristomal region is drawn inwardly and wrinkled.
In use and in accordance with method aspects of the invention, the frame 10 is positioned on the torso of the ostomate, with the opening 14 registered with the user's stoma. The belt 12 is wrapped around the torso of the user and, after tightening, is secured by the Velcro fastenings. Preferably the belt 12 is fabricated of elastic material which permits the user to bend and otherwise indulge in activities which would tend to vary his girth, while maintaining a substantially uniform tension on the belt.
From FIG. 5, it will be seen that, when the frame 10 is thus tightened in place, the peristomal region is bulged outwardly bringing the stoma into the plane of the peristomal skin surface. The peristomal region is thus stabilized, with its surface in a defined position which remains virtually unchanged, regardless of the activities of the user. This stabilization is the result of inward pressure of the frame, which is, in turn, a function of the fact that the belt parts 12a and 12b are attached to the bridges 16, which are spaced outwardly of the inner surface of the frame. Thus it is possible to obtain an inward pressure without requiring an undue and uncomfortable tensioning of the belt when attaching the device. Comfort is also a consideration in the rounding of the outer periphery of the frame at its inner surface.
Stabilization of the peristomal region in this fashion serves two very important functions. First, the stoma is brought outwardly relative to the skin surface, so that it is no longer sunken, and also the wrinkles are stretched to a smooth surface. Secondly, the peristomal region is now firm. These factors enable a highly effective, adhesive seal to be obtained. A sealing sheet can be employed with an opening closely matching the outline of the stoma. Such an adhesive sheet can then be firmly adhered to the peristomal skin, by finger pressure which assures adhesion and prevention of feces, and more importantly the digestive juices in the feces, with the skin. Not only does this stabilization of the peristomal region assure greater initial adhesion and sealing of the skin from the feces, it also prevents a break down of the seal obtained.
To illustrate, one form of waste disposal system employs a sanitary wafer which comprises an adhesive sheet with a mounting flange on its outer surface. The sheet is secured to the peristomal region with an opening registered with the stoma. A disposable, flexible container is then mounted on the ring and replaced from time to time as it is filled with feces. (This type of disposal system is dealt with in greater detail, hereinafter, in connection with further embodiments of the invention.) Normally the adhesive sheet must be replaced after not more than seven days, and frequently at much shorter intervals to prevent leaking and/or skin irritation, as digestive juices seep under the sheet because of a breakdown of the adhesive. When this same device is attached with the peristomal region stabilized by the device of the present invention, replacement has not been required after usage for as long as 18 days.
It will be seen that the outward bevel of the frame opening 14 facilitates application of the adhesive sheet. The same consideration motivates the curvature of the bridges 16 so that they are displaced from the outline of the opening.
The illustrate "rounded square" configuration of the frame opening 14 serves to minimize any tendency of the frame to be displaced laterally relative to the body of the user. It also facilitates use of certain commercially available adhesive sheets used with waste containers, which have such configuration.
Again, an important point to note is that the outline of the frame opening is spaced laterally outwardly from the stoma and that the inward pressure of the inner surface of the frame, causes the peristomal region to bulge outwardly into the frame opening. This region is stablized in the sense that the skin surface configuration is relatively stable and isolated from the body portions outside the confines of the frame to the end that body movement, such as bending and twisting, which would otherwise cause flexing of the peristomal skin and relative movement between this skin portion and the protective sheet. Such relative movement is the cause of a breakdown in the effective of the attaching adhesive and resultant seepage of feces beneath the protective sheet.
Attention is now directed to further method aspects of the invention. Previously it has been an accepted concept that a waste receptacle must, at all times, be employed, due to peristalsis, which involuntary action, continuously tends to discharge feces from the stoma. With the stabilization of the peristomal region obtained by the frame previously described, it is now possible to dispense with the container, assuming that the ostomate, through dietary control, is able to maintain a minimal liquid content in the feces, this being a demonstrated capability.
Employing the frame 10, the peristomal region is first stabilized, as shown in FIG. 6, and a protective sheet 22 is adhesively applied to the peristomal skin within the outline of the frame opening 14. This protective sheet has a central opening 24 which is aligned with the stoma of the user.
The belt 12 is then loosened and an absorbent pad 26 placed over the protective sheet 22. Also an outer moisture barrier sheet 28 overlies the absorbent pad 26. The sheet 28 has an outline greater than that of the frame 10. Thus when the frame is remounted, as shown in FIG. 7, the pad 26 is firmly held against the stoma as the peristomal region is again stabilized.
This system provides adequate waste disposal protection even where there is a relatively high liquid content in the feces. The sheet 22 protects the skin from the harmful affect of the digestive juices, while the barrier sheet 28 protects against moisture from seeping through to the user's clothing. With this system, it would also be possible to engage in water sports, and the like without feces contamination.
Where the liquid content of the feces is lower, even greater advantages can be obtained by using a barrier sheet 28 which is perforated. The rate of feces exudation is, generally, relatively slow. In fact, it will be sufficiently slow that the liquid will evaporate, through the perforations in the barrier sheet. However, the sheet still spaces the pad from the ostomate's clothing so protection is had in the event small amounts of moisture migrate to the outer surface of the absorbent pad.
This leads to the simplest method of all, where the liquid content of the feces is minimal. In such case, the barrier sheet 28 can be eliminated altogether. In fact, unless the ostomates skin is extremely sensitive to digestive juices, the skin protective sheet 22 can also be eliminated, because the rate of absorption and evaporation through the pad 26 is sufficient to prevent any substantial contact of the peristomal skin with digestive juices.
Many materials will suffice for the absorbent pad 26. A most economical expedient is simply to use an ordinary kitchen paper towel, folded into eight layers. Similarly, the barrier sheet 28 can be any common plastic film, such as are commonly found in kitchen use.
With the absorbent pad 22 held in place by the frame 10, the feces will tend to solidify as a solid, yet plastic plug in the terminal end of the colon, at the stoma, see FIG. 7. As the feces builds up, this plug will gradually protrude from the stoma. From experience, through the sense of feel, the ostomate can readily determine when feces buildup has reached a tolerable limit. At such time, the frame can be removed and the absorbent pad taken by the fingers and disposed of in a toilet, all without the fingers contacting the feces.
As was earlier indicated, this method is predicated on a relatively low liquid content in the feces. Dietary habits to obtain this end are well known and will also control feces volume. With proper controls, it is possible to go for 24 hours or more without requiring a change of the absorbent pad.
Again, the stabilization of the peristomal region, provided by the frame 10, is of significance in enabling this method of feces disposal. It enables the solidified feces to be readily removed, in addition to preserving the effectiveness of the adhesive for the protective sheet 22.
Reference is next made to FIGS. 8-14 for a description of the benefits of the present invention is connection with the previously referenced disposal system in which the protective sheet is in the form of a flanged, sanitary wafer to which a disposal bag is attached.
FIGS. 8 and 9 illustrate such a wafer, identified by reference character 32. Such wafers are commercially available. They comprise a generally rectangular, flexible sheet 34 of flexible, polymeric material, the lower, or inner surface of which is formed of a layer 36 (thicknesses are exaggerated in FIG. 9) of adhesive material permitting its attachment to the peristomal region of the the ostomate.
A circular flange 38, formed of relatively rigid polymeric material projects from the upper, or outer, surface of the flexible sheet 34. The sheet extends within the outline of the inner diameter of the flange 38 to an opening 40 through which the feces will pass. As will later appear, a feces disposal bag is then attached to this flange, after the wafer is attached to the peristomal region of the ostomate.
In further description of the wafer 32, it is to be recognized, that the generally circular stomas, vary in diameter from one individual to another. In order to essentially eliminate feces leakage along the inner surface of the sheet 34, it is essential that inner diameter of the flange 38 and the underlying adhesive layer 36 closely approximate the diameter of the individual stoma, or be only minimally larger. Thus the wafers are available with incrementally variable flange diameters. The preferable practice is for an ostomate to have a circle cutter so that he can cut an opening 39 to custom fit the diameter of his stoma. In this fashion, the peristomal skin may be protected from feces irritation by a short lip line extension of the sheet 34 and more particularly by the adhesive layer, which also has a neutralizing effect on the acidic effects of the digestive juices.
Next, reference is made to FIGS. 10 and 11 for a brief description of an insert 40, preferably formed of relatively rigid polymeric material. The insert is formed with a planar central portion 41 and a curved outer flange 42. A central opening 44 has a diameter approximating, but greater than the outer diameter of the wafer flange 38. Additionally arcuate openings 46 are formed concentrically of the opening 44, for purposes which later appear.
Reference is now made to FIGS. 12 and 13 which illustrate an alternate ostomy frame 48, corresponding to the frame 10 described in FIGS. 1-5. The primary difference is that the frame 48 is an integral member, conveniently formed by molding.
Again a central opening 50 is provided within the circular outline of the frame. The surface of the opening 50 is angled outwardly from its inner end at lip 52, (see also FIG. 14). The same dimensions for the frame 48 and its opening 50, as given for the frame 10, would be preferred.
The frame 48 is adapted to be secured to the torso of an ostomate by a belt means in the same fashion as the frame 10. However, these means are attached to bridges 54 which are connected to the main body of the frame 10 by integrally molded legs 56, corresponding to the metal posts 18, previously described. Belt portions 58a and 58b are secured to the bridges 54, in correspondence with the belt portions 12a and 12b.
The frame 48 may be employed in the same fashion as the frame 10 to stabilize the peristomal region to facilitate attachment of various feces disposal systems, or for the management of feces disposal through the described method aspects of the invention.
However, the frame 48, or the frame 10, is also adapted to cooperate with the insert 40 to enhance the advantages of the sanitary wafer 32. In use, the wafer is first applied to the stomach of the ostomate. This can be done, in conventional fashion, by distension of the stomach muscles and pressing the adhesive layer against the surface of the skin, with the opening 39 registered with the stoma. Alternatively, the frame 48 can be used to temporarily stabilize the peristomal region, as previously described, to facilitate the mounting of the santiary wafer 32.
After the wafer is in place, the insert 40 is manually pressed against the outer surface of the wafer 32, with the flange 38 projecting through the insert opening 44.
Next, the frame 48 is manually pressed against the insert 40, being centrally registered relative thereto by the curved flange 42 which mates with the outer curved surface of the frame. The frame is then secured to the ostomate's torso by tensioning the belt portions 58a and 58b and securing them together, as previously described.
The mounted positions of the wafer, insert and frame are illustrated, on an enlarged scale, in FIG. 14. FIG. 14 also illustrate a waste disposal bag B with which the wafer 32 is adapted to cooperate. The bag B may be formed of thin, flexible sheet material secured to an attachment ring 60 which telescopes onto the wafer flange 38. The flange 38 and ring 60 engage to provide a seal to prevent leakage of fecal matter between their mating surfaces on the inner diameter of the flange 38. Various refinements in configuration are available to enhance this sealing action.
Several features are to be noted from the mounted, or operative position of the waste management system as illustrated in FIG. 14, wherein the components are in the relative positions seen in FIGS. 8-13.
Again the peristomal region is stablized, which is a basic principle of the present invention. However, the stabilization achieved is with pressure exerted through the full extent of the planar portion 41 of the insert 40.
The inward pressure obtained as greater effectiveness in maintaining the effectiveness of the adhesive seal, but, because of the large area over which it is spread, unit pressure, or concentration is decreased, to the end of greater comfort for the ostomate.
As with the frame 10, the lining of the intestine is also bulged out, which is again of particular importance in the case of sunken stomas. It is to be noted that the condition of the colon and its lining at the stoma is illustrated in FIG. 14 more graphically than in FIG. 5. This is to note that the colon, while generally circular in outline, is expansible. When feces are not present in the colon, (the condition illustrate in FIG. 14), the colon wall folds inwardly. In the stabilized condition of FIG. 14, the terminal portions of the colon wall bulge outwardly. This "budding" effect facilitates isolation of the irritating digestive juices from the ostomates skin, peripherally of the stoma. The manner of folding of this lining can vary greatly and what is shown in the drawings is merely representative.
It is also to be noted that this stoma "bud" is positively positioned to lie primarily within the flange 38 and ring 60 and well below the outer surface of the frame 48. Thus this "bud", which is highly sensitive, is extremely well protected from painful pressures and blows, even when the ostomate engages in strenuous activities.
When the belt means 58 a and b are tightened to draw the frame inwardly and stabilize the peristomal region, the wafer sheet 34 will be stretched, as permitted by the adhesive layer 36, to minimize, if not eliminate any wrinkles which would permit leakage of fecal material.
More importantly, there is a circular concentration of pressure to enhance the sealing effect of the adhesive layer 36, immediately at the periphery of the stoma. It will be noted that the edge of the insert opening is closely adjacent the flange 38. The flange 38, being relatively rigid, then provides an sealing force on the underling portion of the adhesive layer 36. Finally this inward sealing force is transmitted to the lip of the sheet material which extends to the opening 40 which is, preferably, custom cut to the outline of the stoma.
The openings 46 also contribute to the effectiveness of the seal obtained by the adhesive layer 36. As will be seen in Figure 14, the soft tissue of the stomach bulges into these openings. This creates further lines of pressure concentration which enhance the effectiveness of the seal obtained by the adhesive layer 36. Additionally, the multiple pressure concentration points, which are effective on the stomach tissue, minimze the possibility the frame, insert and wafer from shifting laterally, which, in turn, would degenerate the effectiveness of the seal and accelerate the possibility of leakage.
Another point to be noted is that the nested relationship between the frame 48 and insert 40 provides means for preventing lateral shifting between these elements.
Finally reference is again made to the pressure concentration immediately at the periphery of the stoma. When a disposal bag is attached to the flange 38, the ring 60 exerts an inward pressure which tends to displace the central portion of the wafer inwardly. Similarly, when the bag is removed, there is a tendency to pull the central portion of the wafer outwardly. Such movement causes a shearing action in the adhesive layer 36, outwardly of the opening 40, as the sheet 36 (and ring 38) are shifted outwardly, or actually pulled away from the skin in the case of bag removal. All of this tends to cause a degeneration of the adhesive layer and a breakdown in the effectiveness of the seal obtained. While the stabilization obtained by the present invention does not totally prevent such movement, it very significantly less than in the absence of such stabilization, as where the wafer is simply attached to the skin.
In summary, the broad based region of peristomal stabilization, here described, provides a highly effective sealing action, with a minimum of discomfort to the ostomate. The need to replace sanitary wafers is greatly reduced, a use life of seven days has, typically been extended to 30 days or more. It has the further advantage of a low profile which makes it virtually unnoticeable under normal clothing, as well as giving freedom of movement for essentially all physical activities.
The atlernate embodiment of the invention seen in FIGS. 15 and 16 combines the features of the insert 41 integrally into a frame and is customized for use with a sanitary wafer 32, as shown in FIGS. 8 and 9.
This frame, identified by reference character 66, is identical with the frame 48 in being of circular outline with bridges 68 to which elastic belt portions are attached to permit its being secured to the torso, as previously described. Likewise, a "rounded square" opening 70 is formed centrally of the frame.
An integrally formed, planar portion 72 extends across the bottom of the opening 70. A central opening 74 is provided in the planar portion 70. The planar portion is also provided with openings 76 the outer portions of which follow the outline of the "rounded square" opening 72 and the inner portions of which are generally concentric of the opening 74.
FIGS. 15 and 16 illustrate the frame 66 in its operative or functional relation with respect to a sanitary wafer 32 and the stoma of an ostomate. Stabilization of the peristomal region is essentially the same as described in connection with the frame 48 and insert 41, noting that the belt portions are omitted and the disposal bag has not been illustrated as it would be mounted on the flange 38. It will be seen that the openings 76 have a variable width so that there is a variation in the extent to which the stomch tissue protrudes therein, or therethrough. This feature further assures that the frame will not shift laterally and destroy the effectiveness of the adhesive layer 36.
The disclosure has been directed to devices and methods for colostomates and other intestinal ostomates, however, the present invention in many aspects, is also applicable to urostomates. Additionally variations from the specific teachings herein will occur to those skilled in the art which will provide equivalent benefits. The spirit and scope of the invention is, therefore, to be derived from the appended claims.
|Cited Patent
|Filing date
|Publication date
|Dec 17, 1943
|Jun 24, 1947
|Zaro Henry C
|Colostomy appliance
|Dec 21, 1948
|Jan 2, 1951
|Murvin Cloninger William
|Colostomy apparatus
|Sep 10, 1951
|Jul 27, 1954
|Murle Perry
|Stoma receiver, including sealing means for use with ileostomies
|Apr 1, 1953
|Mar 12, 1957
|Leonard Fenton
|Ileostomy receptacles
|Jun 20, 1955
|Jun 3, 1958
|Pauline M Cowles
|Colostomy units
|Apr 8, 1959
|Jul 10, 1962
|Hale Mervin P
|Body waste receptor appliance
|May 16, 1961
|Jan 22, 1963
|Robinson Herman L
|Drainage receiver
|Nov 14, 1966
|Jun 3, 1969
|Sunbeam Equip
|Aluminum annealing furnace
|Mar 15, 1973
|Dec 24, 1974
|Blanchard B
|Post-surgical drainage pouch retaining assembly
|Sep 28, 1973
|Aug 5, 1975
|Marsan Manufacturing Co Inc
|Ostomy devices
|Citing Patent
|Filing date
|Publication date
|Nov 19, 1987
|May 30, 1989
|Hollister Incorporated
|Ostomy appliance and convex pressure ring assembly therefor
|Oct 17, 1988
|Jul 17, 1990
|Amico Ben A D
|Ostomy plug-pouch
|Nov 9, 1990
|Mar 24, 1992
|Iacone Daniel J
|One-piece ileostomy or colostomy bag connector
|Aug 29, 1991
|Jan 12, 1993
|Mcdowell Charles E
|Protective shield for a stoma pough
|May 26, 1995
|Feb 27, 1996
|Anderberg; Steven L.
|Rectal plug and method of introducing same into a slaughtered animal
|Oct 31, 2000
|Jul 15, 2003
|Edward Nitenson
|Absorbent article
|Nov 16, 1999
|Sep 30, 2003
|Coloplast A/S
|Ostomy appliance with perforated flange
|Mar 27, 2002
|Apr 20, 2004
|Bristol-Myers Squibb Company
|Controlled evacuation ostomy device with external seal
|May 30, 2002
|Jul 19, 2005
|Hollister Incorporated
|Skin barrier strip having triangular cross section
|Jan 3, 2007
|Dec 6, 2011
|Convatec Technologies Inc.
|Seal for controlled evacuation ostomy appliance
|Mar 26, 2004
|Jan 10, 2012
|Convatec Technologies Inc.
|Controlled evacuation ostomy device with external seal
|May 9, 2006
|Jan 17, 2012
|Convatec Technologies Inc.
|Controlled evacuation ostomy device with external seal
|Oct 7, 2009
|Jul 3, 2012
|Hollister Incorporated
|Ostomy faceplate having moldable adhesive wafer with diminishing surface undulations
|Nov 27, 2006
|Jul 10, 2012
|ConvTec Technologies Inc.
|Controlled evacuation ostomy appliance
|Nov 12, 2009
|Apr 1, 2014
|Coloplast A/S
|To control bending in a skin plate for use in an ostomy appliance
|Mar 15, 2013
|Jul 21, 2015
|Donna E. Luce
|Absorbent article for an ostomy guard
|Mar 15, 2013
|Mar 1, 2016
|Donna E. Luce
|Support for an absorbent article
|May 30, 2002
|Jan 2, 2003
|Bark Jeffrey E.
|Skin barrier strip having triangular cross section
|Mar 27, 2002
|Oct 2, 2003
|Cline John B.
|Controlled evacuation ostomy device with external seal
|May 30, 2003
|Dec 4, 2003
|Zedlitz Ricky L.
|Absorbent ostomy pad system
|Mar 26, 2004
|Sep 16, 2004
|Cline John B.
|Controlled evacuation ostomy device with external seal
|May 9, 2006
|Sep 14, 2006
|Cline John B
|Controlled evacuation ostomy device with external seal
|Feb 3, 2004
|Jan 4, 2007
|Michael Hansen
|Ostomy support garment
|Oct 11, 2006
|May 3, 2007
|Bristol-Myers Squibb Company
|Controlled evacuation ostomy appliance
|Nov 27, 2006
|May 31, 2007
|Bristol-Myers Squibb Company
|Controlled evacuation ostomy appliance
|Jan 3, 2007
|Aug 16, 2007
|Bristol-Myers Squibb Company
|Seal for controlled evacuation ostomy appliance
|Apr 8, 2008
|May 6, 2010
|Cramer Kathryn E
|Adhesive body fitment for ostomy appliane
|Oct 7, 2009
|Dec 23, 2010
|Hollister Incorporated
|Ostomy faceplate having moldable adhesive wafer with diminishing surface undulations
|Nov 12, 2009
|Sep 8, 2011
|Coloplast A/S
|To control bending in a skin plate for use in an ostomy appliance
|Mar 12, 2014
|Sep 18, 2014
|James Gordon Scott
|Medical device, method of making and using the same
|Apr 7, 1997
|Dec 19, 2000
|Starchtech, Inc.
|Rectal plug and method of introducing same into a slaughtered animal
|Nov 16, 1999
|Nov 14, 2007
|Coloplast A/S
|An ostomy appliance
|Oct 11, 2006
|Apr 18, 2007
|Bristol-Myers Squibb Company
|Controlled evacuation ostomy appliance
|Oct 11, 2006
|Apr 25, 2007
|Bristol-Myers Squibb Company
|Controlled evacuation ostomy appliance
|Jan 5, 2007
|Jul 11, 2007
|Bristol-Myers Squibb Company
|Seal for controlled evacuation ostomy appliance
|May 20, 1996
|Nov 28, 1996
|Anderberg Steven L
|Rectal plug and method of introducing same into a slaughtered animal
|Sep 4, 1999
|Mar 16, 2000
|Park Soo Hak
|Device for stoma patients
|Sep 4, 1999
|Jun 2, 2000
|Park Soo Hak
|Device for stoma patients
|Nov 25, 2002
|Aug 14, 2003
|Zassi Medical Evolutions Inc.
|Pad for use with continent ostomy port
|Aug 20, 2014
|Nov 12, 2015
|Nu-Hope Laboratories, Inc.
|Ostomy pouch support kit, system and method
|U.S. Classification
|International Classification
|Cooperative Classification
|European Classification
|Sep 10, 1991
|Maintenance fee reminder mailed
|Jan 16, 1992
|Fee payment
Year of fee payment: 4
|Jan 16, 1992
|Surcharge for late payment
|Jan 28, 1992
Owner name: CAMPBELL, ARCHIE, OHIO
Free format text: ASSIGNMENT OF ASSIGNORS INTEREST.;ASSIGNOR:BUNKE NORBERT J., EXECUTER AND ENTRY APPOINTING FIDUCIARY OF THE ESTATE OF THOMAS ESPOSITO.;REEL/FRAME:005990/0549
Effective date: 19920121
Owner name: CAMPBELL, ROSE M., OHIO
Free format text: ASSIGNMENT OF ASSIGNORS INTEREST.;ASSIGNOR:BUNKE NORBERT J., EXECUTER AND ENTRY APPOINTING FIDUCIARY OF THE ESTATE OF THOMAS ESPOSITO.;REEL/FRAME:005990/0549
Effective date: 19920121
|Jul 24, 1995
|Fee payment
Year of fee payment: 8
|Aug 2, 1999
|Fee payment
Year of fee payment: 12


text:
Last Updated : 24/04/2017 - 09:29 PM
Tuesday, 25th April 2017
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Wednesday, 24 December 2014 - 19:19
Update: Arrest warrant issued on Deputy Minister Muthuhettigama. -Video
The Baddegama Magistrate Chandima Edirimanne issued today arrest warrant on deputy minister Nishantha Muthuhettigama and his driver and produce them before the court.
The warrant was issued today when the case in connection with the arson attack on common candidate Maithreepala Sirisena's political stage in Wanduramba was taken for hearing today.
Earlier 2 MSD officers attached to deputy minister Muthuhettigama's security crew were arrested in this connection.
The two suspects were released today on personal bail amounting to 100 thousand rupees per head when they were produced before the magistrate.
Related story published below :
Court issues arrest warrant for Deputy Minister Nishantha Muthuhettigama.
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subset: commoncrawl


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Psychic events
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Dog makes a run for it ... cage included
April 23, 2017, 10:05 a.m. by Noel Kirkpatrick
Nothing will stop this pooch from being free.
Ferrets can't get enough of this game of tag
April 20, 2017, 7:02 a.m. by Noel Kirkpatrick
It's a super-cute game of 'catch me if you can!'
8 of the happiest dogs in the world
April 17, 2017, 12:50 p.m. by Shea Gunther
Want to make a dog smile? A favorite returning soldier, a water slide, or a squeaky toy might do the trick.
How to mess with your cat by drawing a square
April 16, 2017, 4:09 p.m. by Mary Jo DiLonardo
Many cats are quite intrigued with the pretend boxes.
9 bunny breeds that are too cute for words
April 14, 2017, 12:07 p.m. by Jenn Savedge
The Easter Bunny has some competition from these real-life rabbits.
Don't let your dog see this story (or he'll want to move to Miami)
April 13, 2017, 1:43 p.m. by Mary Jo DiLonardo
There's a Zen-like pack mentality at Barkhaus doggy daycare in Miami.
Happy animal parents show off their babies
April 12, 2017, 8:28 a.m. by Mary Jo DiLonardo
Animals feel happiness (and maybe even pride) in their new offspring.
The tallest dog in the world is bigger than the average NBA player
April 11, 2017, 1:45 p.m. by Mary Jo DiLonardo
(He probably eats more, too.)
Man jumps into icy lake to save beloved pup
April 10, 2017, 11:18 a.m. by Noel Kirkpatrick
Cosmo the dog jumps in — and his owner doesn't hesitate to follow suit.
The 'Cat Man of Aleppo' loves dogs, too
April 9, 2017, 11:37 a.m. by Noel Kirkpatrick
Mohammad Alaa Jaleel is doing what he can to keep the cats and dogs of Syria safe.
Soothing massage is too much for tiny bird
April 6, 2017, 7:03 a.m. by Noel Kirkpatrick
Getting a massage on a perch is not a great idea.
Rub a dub dub, 2 dogs have very different experiences in the tub
April 4, 2017, 1:26 p.m. by Noel Kirkpatrick
One dog is just sitting, all cool, ready to relax. The other wants to dig through the water.
Cat loves its new toy: A baby in a bouncy swing
April 3, 2017, 8:31 p.m. by Noel Kirkpatrick
At least they're getting along.
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Stray dog follows adventure race team for 430 miles
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text:
Since the basis of this GT, the normal Ceed hatchback, recently got the makeover treatment it's no surprise that they've done the same for their higher performance version. The front end has been upgraded, the brakes and wheels are bigger, the suspension is firmer and it has to be said it looks a treat inside and out.
However the engine remains the same, with a whisker over 200bhp coming from its turbocharged 1.6-litre four-pot. That allows a decent amount of shove but it's never going to get the pulse really racing, it's just pretty good, as it was in the previous incarnation.
It doesn't sound bad either, but then you begin to realize something doesn't sound quite right. And that's because the car has a 'sound symposer' which is a bit of electronic doo-dah that is meant to make the experience in the cabin sound so much more exciting and sporty. Frankly, if you need an artificial soundtrack then the engine really isn't doing what it ought to do. A bit weird.
While your ears are wondering what's going on, you can actually enjoy some fairly sharp steering and handling. It's all quite direct, as is the six-speed manual box. It's fun to drive and it looks just great.
But it doesn't sound that great and the performance needs more than a bit of extra noise to impress. The Proceed GT certainly looks the part and it's well over £4000 cheaper than a Golf GTi, but it doesn't go like a Golf GTi. But if you're prepared to accept that it doesn't go as well as it looks, then this could be a bit of a bargain. But you may want to turn the stereo up when you're driving.
Kia Proceed GT 1.6 T-GDI manual
On sale October
Price: £23,105; Engine 4 cyls, 1591cc, turbocharged petrol
Power: 201bhp at 6000rpm
Torque: 195lb ft at 1750-4500rpm
Kerb weight: 1356kg
Gearbox: 6-speed manual
0-60mph: 7.3sec
Top speed: 143mph
Economy: 28.2mpg
CO2/tax band: 170g/km / 29%
- More about:
- Kia


text:
All support to fair occupation Belo Monte by indigenous peoples
All support to fair occupation Belo Monte by indigenous peoples
by ocupacaobm
The League is Working to support integral Munduruku people, Xipaya, Arara, Kayapó and Tupinambá occupying the Belo Monte plant work. We express our solidarity with all indigenous peoples of the Xingu River regions, Teles Pires, Tapajós, wood and other areas that are being cruelly affected by the destruction of their land, their water, their forests.
We reject these arbitrary works that are the scene of social, environmental destruction, captivity and workers stage of oppression, humiliation, of any kind of violation of labor law, mutilation and deaths from work-related accidents and police violence. Where waves and waves of workers, acquired in poor regions and far, are dumped to, under the repression of the contractors and the Government, build an unnecessary works the Brazilian people and the native peoples; works that serve only the interests of the large economic groups and contractors that the plan to provide conditions to commit more robberies of the wealth of the country (in the region there are large deposits of gold, diamonds, other minerals, etc.).
We reject this Government at the service of imperialism, the great bourgeoisie and landlordism which is implementing the policy of massacres against indigenous peoples and workers. We reject the Government's policy not to meet the just demands of the indigenous peoples, do not negotiate and send the federal police, the national force, abin, and other repressive apparatuses against the legitimate owners of the land in the region and to suppress the workers ' strikes fair. We reject the cut of water and electricity supply on the premises where the natives are housed and the provocations of the National Force and other repressive government troops.
We call on the workers of the construction of Belo Monte, which so many struggles and outages has made against the wage and working conditions bad, to show solidarity with our brothers, Xipaya Munduruku, Arara, Kayapó and Tupinambá, and earn in compliance with requirement of their claims, the total stoppage of Belo Monte and the execution of works that really meet the interests of the people of Brazil.
We demand the end of repression and punishment of delegate Antônio Carlos Moriel Sanches and other federal police blame for coward assassination of Myron Indian the Munduruku Teles Pires. we require that unlike suppress and murder to enforce the construction of dams, the Government ensure the rights of indigenous peoples to education and health, among other needs.
We demand that President Dilma Rousseff talk with indigenous peoples and to stop immediately the unnecessary work of Belo Monte power plant and power plants of the rivers Tapajós and Teles Pires. The environmental and social destruction generated by the works of the Madeira River plants (Jirau and Santo Antonio) are examples of the degree of destruction caused by these poorly planned projects and how they are harmful and unnecessary. The billionaires resources being spent on the Belo Monte dam and other works of the CAP has to be applied is in the priority areas of health, education, housing, transportation and infrastructure for the people and not to serve the interests of the large economic groups.
São Paulo, May 28, 2013.


text:
Published on March 5, 2014
Author: MedicalBusinessSyste
Source: slideshare.net
By Medical Business Systems Building Your Customized Practice Management Software Iridium Suite
Step 1: Create an implementation and training schedule with your Customer Support Representative. Step 2: Provide practice details like NPI, tax ID, referring physician information and payers list to Customer Support.
Step 3: Customer Support reviews practice information and initiates payer electronic enrollment. Step 4: Extensive remote software training is initiated for all practice staff.
Step 5: Customer Support discusses any unique payer claim filing requirements with the practice. Utilizes built-in Iridium Suite functionality to configure these requirements. Step 6: The integrated Claim Scrubber rules are specially selected for use by the practice. New scrubbers can be created by IT staff to meet additional billing needs.
Configurable Integrated Advanced Tools Facility tracks enables the software to bill specific procedures automatically to the correct place of service without user interaction. The Connectivity Clearinghouse uses HL7 data format to communicate directly with your EMR.
Time to cut the ribbon on your customized Practice Management Software Iridium Suite!
Bringing March Madness to Your Medical Practice; Choosing the best medical billing software; ... Iridium Suite Practice Management Software ...
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text:
thesandman2 Review
Perfect for keeping frost off my van
Purchased this to cover my Minivan when the van would no longer fit in the garage. I did not want to have to scrape the frost off my windows. The cover is huge, I have ample room to get it over the van. I have love getting up and pulling the cover off the van and being able to drive without scraping the frost off. Since it is so large, it is cumbersome to maneuver, but well worth the effort.
- How did the color on site compare with the actual product? same
- Please tell us about the quality of the product. Sturdy, flexible
- How accurate was the on site description of the product? very
Was This Review Helpful?


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|21 Aug 2015, 07:53
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Learn about issues that HAP advocates for on behalf of Pennsylvania hospitals and health systems
Find information on programs that help Pennsylvania hospitals address physician leadership, emergency preparedness, health care reform, and health IT.
Learn how Pennsylvania hospitals are working to improve health care quality and safety through the work of the Pennsylvania Hospital Engagement Network.
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HAPAC and HAPAC-Federal are the political action committees of HAP. Participation in HAPAC helps HAP communicate to lawmakers the vital role that health care facilities and their employees play in their communities every day. Learn more
State funding for Pennsylvania hospitals is critical to ensuring access to care for the commonwealth's residents. State dollars improve hospital technology and infrastructure, educate and train health professionals, and ensure specialty services for communities, including trauma, burn, and obstetrics and neonatal care, and health services in rural areas.
On February 7, Pennsylvania Governor Wolf addressed the Pennsylvania House of Representatives and Senate to outline his budget proposal for the 2017–2018 fiscal year. Beginning the week of February 20, the legislature will begin appropriation committee hearings with state agencies to vet the Governor's budget proposal and to develop their own budget proposals.
Specific to Pennsylvania hospitals, the proposed 2017–2018 budget maintains funding levels for hospital payments, including the Medical Assistance Supplemental payments for critical access hospitals, obstetrics/neonatal units, hospital burn centers, and trauma centers. The budget also includes general fund savings from the consolidation of four agencies into a new Department of Health and Human Services: Department of Human Service, Department of Health, Department of Aging, and the Department of Drug and Alcohol Programs. Finally, the budget includes $25 million of federal funding for the Rural Health Global Budget initiative.
The Governor continues to focus on the opioid crisis and allocates $39.9 million in new state and federal funding.
Generally, Governor Wolf proposed a $32.3 billion budget with $2.1 billion identified cost savings in addition to $1 billion in new taxes.
Policymakers will immediately face major policy decisions. Potential changes in the ACA still create a high level of uncertainty for states and stakeholders around funding and payment structures throughout the continuum of care.
However, operating within the confines of the state budget and looking forward to the 2017–2018 fiscal year budget negotiations, HAP will continue to build on the strong legislative support that hospitals received in 2016–2017 budget. HAP is asking state policy makers to maintain current year funding levels proposed in the Governor's 2017–2018 budget for all hospital payments, including Medical Assistance supplemental funding for obstetric and neonatal services, hospital-based burn centers, and trauma centers and necessary funding for critical access hospitals.
April 26, 2017
News Release: The Pennsylvania Health Care Cost Containment Council (PHC4) today made public its financial analysis report for fiscal year (FY) 2016. The PHC4 report highlights the complexities of Pennsylvania's health care landscape.
April 25, 2017
As noted by the Chair of the Senate Health and Human Services Committee, Senator Lisa Baker (R-Luzerne), May is Stroke Awareness Month, and today's committee vote to update the stroke designation law is aptly timed. The committee unanimously voted House Bill 23 out of the Senate committee.
April 20, 2017
Media outlets have started to report about a possible ACA repeal and replace deal. Pennsylvania hospitals continue to oppose any such efforts without an appropriate replacement to ensure continued coverage for Pennsylvanians who have benefited from the ACA.
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January 14, 2016
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South By Southwest Interactive -- SXSWi if you're geeky, South By if you're hip...View gallery
Even with all of the great restaurants in Austin, eating from street vendors...View gallery
If you couldn't make the trip to Texas, we got you covered.View gallery
One man was dead and at least three people were wounded Saturday in a carjacking and series of shootings in Pico Rivera, Whittier and La Mirada, authorities said.
A dog is getting a second chance thanks to a team of good Samaritans who basically brought her back to life. Now, her former owners are facing jail time after pleading guilty to animal cruelty charges.
The Dodgers hit back-to-back-to-back home runs in the bottom of the ninth and walked off on an RBI single by Adrian Gonzalez to shock the Philadelphia Phillies, 6-5, on the 25th anniversary of the L.A. Riots.
Just days after SeaWorld San Diego debuted an hours-old California sea lion pup, the park announced Saturday that the pup has passed away on Friday.
President Donald Trump is turning from his dramatic debut as an outsider president to focus on advancing his plans to cut taxes and get tough on trade deals. "We are not going to let other countries take...
A winning lottery ticket worth an estimated $61 million was sold at a 7-Eleven at 27001 Moulton Parkway in Laguna Hills. No winner has come forward yet.


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Alphabet is working to squash the Zika virus, too
Verily has a few ideas for stopping the disease in its tracks.
Trapped Florida mosquitoes found to contain Zika virus
It seems the virus is spreading even further.
A newsletter a day keeps the FOMO at bay.
CDC warns against visiting a Zika-hit Miami neighborhood
Pregnant women and their partners are being urged to steer clear of Wynwood.
Four people in Florida likely contracted Zika from US mosquitoes
If confirmed, this marks the first instance of active Zika transmission in the continental United States.
CDC outlines how it'll cope with Zika outbreaks
The five-stage plan includes mosquito tracking and emergency response teams.
Zika virus declared an international health emergency
Medical science now has a big challenge on its hands.
'Gene drive' mosquitoes could end malaria once and for all
Researchers figure out how to guarantee that genetic resistance to the disease is passed between generations.
Gene-modded mosquitoes will fight Dengue Fever in Brazil
The Brazilian city of Piracicaba has a potent new weapon in the ongoing fight against Dengue Fever...
Mosquitoes bred with suicide genes to combat disease
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Argentina | Retiro Bus Station TrickIzzie Stopford | 18 May 2011
Retiro Bus Station in Buenos Aires is reknowned for being dangerous. A group of people tried a trick out on us, similar to the spitting-on-your-shoulder trick we (two 18 year old girls) had sun cream squirted on the back of our backpacks as we walked from the metro to the bus station. One by one different people walked past us trying to alert us very dramatically and exaggeratedly to the mess. The intention was that we look round and they nab what they can from the rest of our fronts/side. The next part involves `a cute little old lady` who just happens to have napkins trying to allure us somewhere private where undoubtedly we would have been mugged by the rest of the `team`. If anything like this happens continue as if you know where you`re going and clean yourselves up when you are somewhere safe. We were told that they followed us all the way in to the bus station and we only lost them when we went through departure doors.
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27 Apr, 2017
Venezuela: further anti govenrment protests planned.
Turkey: President Erdogan wins referendum
Peru: Flooding in Lima, Cuzco & Huancavelica states
Ecuador: Presidential M...
26 Apr, 2017
The best bits of Latin America are the rural areas. The topography and environment is diverse, there are many cultural and historical differences and most gappers have a superb time. Our rural...
01 Mar, 2017
Most travellers have a fun and safe time in SE Asia, the area has huge opportunitites. Parts, especailly in Thailand, are overflowing with travellers so one has to make a bit more of and effort to ...


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A large oil painting on primed hand-stretched gallery wrapped canvas using artist grade oil paints. The sides of the canvas are painted so that the artwork is ready to hang without needing a frame. A coat of retouching varnish has been applied to protect the paint surface. The painting is signed on the front and a numbered certificate of authenticity is attached to the back of the canvas.
Artist grade oil paint on stretched cotton duck canvas
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text: The blscrapeR package makes it easy to produce choropleth maps of various employment and unemployment rates from the Bureau of Labor Statistics (BLS.) Install blscrapeR from CRAN: install.packages("blscrapeR") It's easy enough to pull a metric for a certain county. The code below pulls the unemployment rates for Orange County, FL from the BLS API. library(blscrapeR) Read More


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Whether it's a small errand or a large project, we do it all. Life gets busy and your time is precious. Let us do the things on your to-do list that you need done, efficiently and professionally. Locally owned and operated, our goal at Bow Valley Concierge is to make your life easier and free up some of your valuable time to enjoy life. Feel free to give us a call if you have any questions regarding the services that we offer and pricing.
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The Wall (2013)
Blend Film Database
The Wall Synopsis
Martina Gedeck, star of the Academy Award-winning film
The Lives Of Others
, brings a vivid intensity to her role as an unnamed woman who inexplicably finds herself cut off from all human contact when an invisible, unyielding wall suddenly surrounds the beautiful Austrian mountainside where she is vacationing. Accompanied by her loyal dog Lynx, she becomes immersed in a world untouched by civilization and ruled by the laws of nature. As she grapples with her mysterious circumstances, she begins an inward journey of spiritual growth and transcendence. Based on Marlen Haushofer's eponymous classic novel,
The Wall
is both a riveting tale of survival and a gorgeous meditation that raises profound questions about humanity and our relationship to the natural world.
The Wall Release Date
In Theaters June 7, 2013
The Wall Credits
Martina Gedeck, Ulrike Beimpold, Karlheinz Hackl, Wolfgang M. Bauer, Julia Gschnitzer and Hans-Michael Rehberg
Written By:
Julian Pölsler
Directed By:
Julian Roman Pölser
Produced By:
Wasiliki Bleser, Rainer Kölmel, Antonin Svoboda, and Bruno Wagner
Music Box Films
Running Time:
108 min.
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|Video Games
|Games & Hobbies
All of IGN.com's video game podcasts jammed into one feed. It's like one of those little clown cars, but for your ears.
June 30th, 2015
Episode 468 of 1074 episodes
In the thrilling followupto the previous three hundred and ninety-nine episodes of Podcast Beyond, we had a big, huge live event which a whole bunch of you were kindenough to attend. The regular bunch of goons (Max, Marty, Brian, Jaredand Goldfarb) are joined by Beyond 300 attendee-turned-IGN-editor Miranda Sanchezas well as ayoungup-and-coming video game personality namedGreg Miller. In case it doesn't come across in the audio, none of what we do would be possible without you guys, our listeners and readers, so once again, thank you all so much for sticking around. We had an absolute blast on Saturday, and hopefully we'll wind up doingmore IRL meet-ups before Podcast Beyond 500 rolls around.
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The Art of Charm Podcast is where self-motivated guys and gals, just like you, come to learn from a diverse mix of experienced mentors, including the world's best professional and academic minds, scientists, relationship experts, entrepreneurs, bestselling authors, and other badasses. This show will make you a better networker, better connector, and -- most important -- a better thinker.


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With an Eco Billy Instant Kettle, a handful of twigs and leaves and a match, you' can have a hot cuppa in under 5 minutes.
Made from stainless steel, the Eco Billy has cone shaped funnel to acommodate a small fire underneath that rapidly heats water in an environmentally friendly manner.
Simply turn the billy upside down, place leaves and twigs into the cone, flip it back upright, fill with the desired amount of water, light the leaves through the holes in the base and in just a few minutes you will have hot water.
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Free People Pink Around The World Tank Size Xsmall Dress
Listed by V Flourish
Size: 0 (XS)
Price: $35.94
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If your item was misrepresented in any way, you can file a misrepresentation claim. Tradesy will investigate and you'll be eligible for a Full Refund.
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Sleek Racer Back Tank Dress With Dropped Waist And Light Pleating Below Waist. Bottom Hem Is Raw Edged. *70% Cotton, 30% Rayon Measurements For Size Small: Length: 33 1/2" Bust (All Around): 29 1/2" Armhole Drop: 8 3/4" *Machine Wash Cold *Import
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Lace Womens 0 Xs Lined Detail Full Skirt $250 Spring Summer Dress
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Size: 0 (XS)


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Dance. Urban. UK
Beyoncé's bringing her Mrs Carter World Tour back to the UK this week after adding some extra, and unexpected, UK dates. An entire new album has dropped since she last performed the tour, so what can we expect this time round?
Picture 10 of 13
Beyoncé's known not only for her incredible voice and songs, but for putting on incredible shows, from the lighting to the choreography. If there's one thing you're guaranteed to see, it's some serious dancing.
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text: Printed Pearl Chiffon Fabric - Shaoxing Qiuhao Textile Co.,ltd Toggle navigation TRADE DEALS Products Companies Product Company Search LOGIN E-mail Password Remember me Join Free JOIN FREE HomeAgriculture Agricultural Greenhouses Printed Pearl Chiffon Fabric PRICE: contract price Product Description Shaoxing Qiuhao Textile Co.,Ltd is one of the leading China printed pearl chiffon fabric manufacturers and suppliers, welcome to buy fashion or wholesale high quality printed pearl chiffon fabric from us. Quick Details Material: 100% Polyester Supply Type: Make-to-Order Type: Chiffon Fabric Pattern: Crepe Style: Plain Width: 57/58" Technics: Woven Feature: Tear-Resistant, Heat-Insulation, Shrink-Resistant Use: Lining, Curtain, Dress, Garment, Home Textile Yarn Count: 75D*75D Weight: 98gsm Density: 46.9*39 Model Number: 2014 75D pearl chiffon Colors: a variety of different colors Packaging & Delivery Packaging Details: For pearl chiffon fabric Inner plastic bags, Outer woven bags. or packed as all your requests Delivery Detail: 15-25 days after confirmed the colors/patterns Specifications 1,100%polyester 2, printed chiffon fabric 3,high quality and good service 4,China supplier Product Description 2015 New Popular Women 100% Polyester Printed Pearl Chiffon Fabric Description 2015 New Popular Women 100% Polyester Printed Pearl Chiffon Fabric Material 100%polyester Yarn count 75D*75D Width 57"58" Weight 98gsm Technics woven style Plain dyed color According to customer's requirements Produce Capacity 200000 meters per month Delivery Time 15-25 days after confirmed the colors/patterns Payment Terms L/C T/T Other products 75d moss crepe fabric Price: contract price 30d crepe chiffon fabric Price: contract price Cotton plain fabric Price: contract price 75d pearl chiffon fabric Price: contract price Company Info Shaoxing Qiuhao Textile Co.,ltd Contact Person: TED TED Phone: 86-0575-89965480 Contact now × Contact form Your name: Your E-mail: Your Phone: Subject: Enter a message: Close


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Besides "I love you", there are three other words that children just love to hear: "clean your room!"
Well, they don't exactly love to hear this, but they simply must. Children need a clean, tidy space for rest, relaxation, play and often, for studying. Oak wardrobe armoires are a clever storage solution for their bedroom dilemma!
Dressers are great pieces of furniture, but they often fill up quickly with things stuffed in them and on top of them. Wardrobe closets are a great way to expand children's bedroom furniture space to keep clothing and such neatly tucked away. Oak wardrobe closets are perfect . . . → Read More: Bedroom Storage Is Made Simple With Oak Wardrobes


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Troubled Times: U.S.-Japan Trade Relations in the 1990s
€ 21,99
Lieferbar innert 2 Wochen
Mai 1999
BeschreibungIn this book, Edward J. Lincoln tackles the thorny issue of U.S. trade relations with Japan, the subject of so much tension in the 1990s. While Lincoln offers suggestions on what needs to be done by both sides, the most important lesson drawn from recent experience is that expectations should be lowered. Such realism--not to be confused with defeatism--is the only approach that has any chance of realizing gains over time.
PortraitEdward J. Lincoln is a senior fellow in Asia and Economic Studies at the Council on Foreign Relations. His previous Brookings books include Arthritic Japan (2001), Troubled Times: U.S.-Japan Trade Relations in the 1990s (1999), Japan's New Global Role (1995), and Japan's Unequal Trade (1990). In the mid-1990s, Lincoln served as special economic advisor to Walter Mondale, former U.S. ambassador to Japan.
Untertitel: New. Sprache: Englisch.
Verlag: BROOKINGS INSTITUTION
Erscheinungsdatum: Mai 1999
Seitenanzahl: 321 Seiten
Format: kartoniert


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Not surprisingly, the Ravens' coaches and players are quite pleased with the signing of Joe Flacco, who became the NFL's highest-paid player at $120.6 million over six years.
Here's some reaction from the Ravens and from one rival ...
Ravens running back Ray Rice on Twitter: Dinner and a few nights on Joe Flacco when we get back well deserved
Ravens wide receiver Torrey Smith on Twitter: "You don't need to think he deserved it but our front office does and at the end if the day that is all that matters....I'm done."
Ravens defensive lineman Art Jones on Twitter: "Congratulations to my boy joe flacco on the new deal. Much deserved"
Steelers offensive tackle Marcus Gilbert on Twitter: "Hold up? Highest paid player in NFL history?"
Now it's time to hear your thoughts. After you vote, you can give me your take on Flacco's contract (let's keep it to 200 words) by sending me a note to the AFC North mailbag. Your comments could be used in a post on the AFC North blog this week.


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