text:
|Publication number
|Publication type
|Application number
|Publication date
|May 23, 2006
|Filing date
|Jul 3, 2002
|Priority date
|Jun 13, 2002
|Fee status
|Also published as
|Publication number
|John C. K. Hui
|Original Assignee
|Vasomedical, Inc.
|Export Citation
|BiBTeX, EndNote, RefMan
|Patent Citations (82), Non-Patent Citations (18), Referenced by (36), Classifications (10), Legal Events (4)
|External Links: USPTO, USPTO Assignment, Espacenet
This application claims the benefit of U.S. Provisional Application No. 60/388,212, filed Jun. 13, 2002.
The present invention relates to an external counterpulsation apparatus and method for controlling the same, and more particularly, to such an external counterpulsation apparatus and method for controlling the same having improved efficiency and utility.
External counterpulsation is a noninvasive, atraumatic means for assisting and increasing circulation in patients. External counterpulsation uses the patient's physiological signals related to their heart cycle (e.g., electrocardiograph (ECG)), blood pressure, blood flow) to modulate the inflation and deflation timing of sets of compressive cuffs wrapped around a patient's calves, lower thighs and/or upper thighs, including the lower buttocks. The cuffs inflate to create a retrograde arterial pressure wave and, at the same time, push venous blood return from the extremities to reach the heart at the onset of diastole. The result is augmented diastolic central aortic pressure and increased venous return. Rapid, simultaneous deflation of the cuffs produces systolic unloading and decreased cardiac workload. The end results are increased perfusion pressure to the coronary artery during diastole, when the heart is in a relaxed state with minimal resistant to blood flow; reduced systolic pressure due to the "sucking effect" during cuff deflation; and increased cardiac output due to increased venous return and reduced systolic pressure.
Under normal operating conditions, when the heart contracts and ejects blood during systole, the aortic and coronary perfusion pressure increases. It should also be noted that the workload of the heart is proportional to the systolic pressure. However, during systole the impedance to coronary flow also increases significantly due to the contracting force of the myocardium, thereby restricting coronary blood flow. Also, during diastole, the myocardium is in a relaxed state, and impedance to coronary flow is significantly reduced. Consequently, although the diastolic perfusion pressure is much lower than systolic pressure, the coronary blood flow during diastole accounts for approximately eighty (80) percent of the total flow.
The traditional objectives of external counterpulsation are to minimize systolic and maximize diastolic pressures. These objectives coalesce to improve the energy demand and supply ratio. For example, in the case of patients with coronary artery disease, energy supply to the heart is limited. External counterpulsation can be effective in improving cardiac functions for these patients by increasing coronary blood flow and therefore energy supply to the heart.
During a treatment session, the patient lies on a table. Electronically controlled inflation and deflation valves are connected to multiple pairs of inflatable devices, typically adjustable cuffs that are wrapped firmly, but comfortably, around the patient's calves, lower thighs, and/or upper thighs, including the buttocks. The design of the cuffs permits significant compression of the arterial and venous vasculature at relative low pneumatic pressures (200–350 millimeters Hg).
An earlobe pulse wave, finger pulse wave or temporal pulse wave is often used as a timing signal to give the appropriate time for application of the external pressure so that the resulting pulse produced by external pressure in the artery can arrive at the root of the aorta just at the closure of the aortic valve. Thus, the arterial pulse wave is divided into a systolic period and a diastolic period. The earlobe pulse wave, finger pulse wave or temporal pulse wave signals, however, may not reflect the true pulse wave from the great arteries such as the aorta.
External counterpulsation treatments and devices are described in the art, including U.S. Pat. No. 3,303,841, Dennis, issued Feb. 14, 1967; U.S. Pat. No. 3,403,673, MacLeod, issued Oct. 1, 1968; U.S. Pat. No. 3,654,919, Birtwell, issued Apr. 11, 1972; U.S. Pat. No. 3,866,604, Curless et al., issued Feb. 18, 1975; U.S. Pat. No. 4,753,226, Zheng et al., issued Jun. 28, 1988; U.S. Pat. No. 5,554,103, Zheng et al., issued Sep. 10, 1996; U.S. Pat. No. 5,997,540, Zheng et al., issued Dec. 7, 1999; PCT Application WO 99/08644, Shabty et al., published Feb. 25, 1999; Zheng et al., "Sequential External Counterpulsation (SECP) in China," Transactions of the American Society of Artificial External Organs, 29:599–603 (1983); Soroff, et al., "Historical Review of the Development of Enhanced External Counterpulsation Therapy and its Physiologic Rationale," Cardiovascular Reviews & Reports (1997); Stroebeck et al., "The Emerging Role of Enhanced External Counterpulsation in Cardiovascular Disease Management," Cardiovascular Reviews & Reports (1997); Chou, "Enhanced External Counterpulsation," ACC Educational Highlights (1998); Arora, et al., "The Multicenter Study of Enhanced External Counterpulsation (MUST-EECP): Effect of EECP on Exercise-Induced Myocardial Ischemia and Anginal Episodes," J. Am. Coll. Cardiology, 33:No. 7 (1999); and Soran et al., "Enhanced External Counterpulsation in the Management of Patients with Cardiovascular Disease," Clin. Cardiol. 22:173–178 (1999).
According to the present invention, there are two factors that should be taken into account to determine the appropriate deflation time of the inflatable devices: (1) release of all external pressure before the next systole to produce maximal systolic unloading, i.e., the maximum reduction of systolic pressure; (2) maintenance of the inflation as long as possible to fully utilize the whole period of diastole so as to produce the longest possible diastolic augmentation, i.e., the increase of diastolic pressure due to externally applied pressure. One measurement of effective counterpulsation is the ability to minimize systolic pressure, and at the same time maximize the ratio of the area under the diastolic waveform to that of the area under the systolic waveform. This consideration can be used to provide a guiding rule for determination of optimal deflation time.
The external counterpulsation system and method for minimizing end diastolic pressure by monitoring and controlling certain hemodynamic effects according to the invention improves a patient's cardiac function. An external counterpulsation apparatus for treating a patient includes inflatable devices received about the lower extremities of the patient and connected to a source of compressed fluid. A fluid distribution assembly distributes compressed fluid from the source to the inflatable devices. A controller controls the fluid distribution assembly to inflate and deflate the inflatable devices to minimize end diastolic pressure and minimize energy spent in ventricular isovolumetric contraction. In this manner, increased cardiac output is achieved.
Moreover, an external counterpulsation apparatus and method for treating a patient by compressing the patient's vascular bed and generating a pulse traveling the patient's arterial tree to the root of the aorta includes controlling the fluid distribution assembly and inflation and deflation of the inflatable devices to inflate the distal inflatable device prior to inflating the proximal inflatable device. For timing purposes, the distal inflatable device is inflated at a time allowing a pulse generated by subsequent application of the proximal inflatable device to compress the vascular bed travels up the arterial tree and reaches the root at the aorta when the aortic valve closes. In one implementation, the proximal inflatable device is inflated beginning at a time delay after the distal inflatable device is inflated. The time delay corresponds to a length of time that a peak of the pulse generated by inflating the distal inflatable device reaches a midpoint of the proximal inflatable device. The distal inflatable device may be such that the distal retrograde pulse arrives at the root of the aorta at approximately twenty-five (25) to fifty (50) percent of a pulse amplitude from end diastole to peak systole in a descending portion of the systolic waveform.
Another implementation includes controlling inflation of the inflatable devices in sequence from the distal inflatable device to the proximal inflatable device. A controller controls inflation of the distal inflatable device ahead of closure of the aortic valve such that a retrograde flow pulse reaches the root of the aorta when the aorta closes. The proximal inflatable device inflates when the pulse generated by the distal inflatable device reaches the midpoint of the proximal inflatable device.
One variation of an external counterpulsation apparatus and method for treating a patient includes a controller in communication with the fluid distribution assembly and controlling inflation and deflation of the inflatable devices. The controller controls at least one of a plurality of inflation functions including: rate of pressure applied by the inflatable devices to the lower extremities of the patient; the magnitude of external pressure applied by the inflatable devices to the lower extremities of the patient; the duration of time that external pressure is applied by the inflatable devices to the lower extremities of the patient; and a duration of time to deflate the inflatable devices. The controller controls at least one of these inflation functions to produce an external pressure waveform minimizing end diastolic pressure.
Another external counterpulsation apparatus and method for treating a patient includes the controller in communication with a fluid distribution assembly and controlling inflation and deflation of the inflatable devices. The controller controls inflation of the inflatable devices by inflating the distal inflatable device to a pressure greater than the proximal inflatable device. The distal inflatable device is inflated to a pressure approximately ten (10) to twenty (20) millimeters Hg greater than the proximal inflatable device.
Further areas of applicability of the present invention will become apparent from the detailed description provided hereinafter. It should be understood that the detailed description and specific examples, while indicating the preferred embodiment of the invention, are intended for purposes of illustration only and are not intended to limit the scope of the invention.
Exemplary embodiments of external counterpulsation apparatus useful in the methods of this invention are depicted in
In particular,
It should be noted that the drawings of devices and counterpulsation pressure waveforms set forth herein are intended to exemplify the general characteristics of external counterpulsation embodiments among those useful in the methods of this invention, for the purpose of describing such embodiments herein. These drawings may not precisely reflect the characteristics of any given embodiment, and are not necessarily intended to define or limit specific embodiments within the scope of this invention.
The present invention relates to an external counterpulsation apparatus and method for controlling an external counterpulsation apparatus. Such methods include the use of an external counterpulsation device, and may optionally use other devices and pharmaceutical treatments. Such devices and treatments useful herein must, accordingly, be therapeutically acceptable. As referred to herein, a "therapeutically acceptable" component is one that is suitable for use with humans and/or animals without undue adverse side effects (such as toxicity, irritation, and allergic response) commensurate with a reasonable benefit/risk ratio.
External Counterpulsation Method:
The methods of the present invention include administering external counterpulsation to a human or other animal subject. As referred to herein, "treatment" includes effecting a long-term physiological improvement in cardiac function, as well as symptomatic improvement, in a subject. Administering external counterpulsation (herein "ECP") to a subject includes applying external pressure to an extremity of the subject so as to create retrograde arterial blood flow and enhanced venous return from the extremity to the heart of the subject during diastole (i.e., the period of relaxation of the left ventricle of the heart). Preferably, the extremity comprises one or more of the legs of the subject, in a human subject preferably including both legs and both arms. In another embodiment, extremity in a human subject comprises both legs, more preferably including the calves, thighs, and upper thighs, and buttocks of the subject. In a preferred embodiment, the external pressure is applied using a plurality of pressure devices applied to the extremities of the subject, and inflated and deflated in synchrony with the cardiac cycle of the subject so as to create a pulse of arterial blood that arrives at the heart essentially at the end of the ejection phase of the left ventricle and closure of the aortic valve. In a preferred embodiment, the administration of optimized ECP is performed using an optimized ECP apparatus, preferably as described herein. (As used herein, the words "preferred" and "preferably" refer to embodiments of the invention that afford certain benefits, under certain circumstances. However, other embodiments may also be preferred, under the same or other circumstances. Furthermore, the recitation of one or more preferred embodiments does not imply that other embodiments are not useful and is not intended to exclude other embodiments from the scope of the invention.)
Preferably, optimized ECP is administered on at least about fifty (50) percent of the days of the treatment period (i.e., on at least about forty (40) days of an eighty (80)-day treatment period), more preferably on at least about seventy (70) percent, more preferably at least about eighty-five (85) percent, of the days of the treatment period. Preferably, optimized ECP is administered at least four (4) days during every seven (7)-day period of the treatment period, such that there are no more than three (3) consecutive days in which optimized ECP is not administered. More preferably, optimized ECP is administered at least five (5) days, even more preferably at least six (6) days, during every seven (7)-day period during the treatment period. Preferably, optimized ECP is administered for from about thirty (30) minutes to about two hundred (200) minutes for each day during which treatment is administered, preferably from about sixty (60) minutes to about eighty (80) minutes per day of treatment. Preferably, the daily administration of optimized ECP is performed in one or more sessions, for from about twenty (20) to about ninety (90) minutes, preferably for from about forty-five (45) minutes to about sixty (60) minutes, more preferably for about sixty (60) minutes per session. As referred to herein, a "session" of optimized ECP comprises the repeated inflation and deflation of pressure devices in synchrony with the cardiac cycle of the subject in a substantially continuous manner. Preferably from one (1) to three (3), more preferably one (1), session is conducted during each day in which optimized ECP therapy is administered. A preferred method comprises from one (1) to three (3) sessions of optimized ECP therapy during each day of at least four (4) days of every seven (7)-day period during a treatment period of from about twenty (20) to about sixty (60) days. Another preferred method comprises the steps of:
Optimized ECP accomplishes many hemodynamic effects including: lowering end diastolic pressure to initiate left ventricle ejection earlier, reducing energy spent in isovolumetric contraction and giving more energy to ejection to increase cardiac output; and increasing velocity of circulating the blood, both antegrade and retrograde, to increase sheer stress on endothelial cells. These hemodynamic effects are characterized as follows:
Two effects of counterpulsation, namely, increased cardiac output and systolic unloading, are in conflict with each other. The more improvement in cardiac output optimized ECP can achieve, the harder it is to reduce systolic pressure. More particularly, due to increased venous return, increased cardiac output increases systolic pressure because of the pressure-volume relationship in the aorta. Under normal conditions, a stroke volume (i.e., the volume of blood that is pumped out during each heartbeat) of fifty (50) milliliters of blood would raise the aortic pressure from a diastolic pressure of eighty (80) millimeters Hg to a systolic pressure of one hundred twenty (120) millimeters Hg. If the stroke volume increased forty percent to seventy (70) milliliters, the systolic pressure should be one hundred thirty-six (136) millimeters Hg, making systolic unloading difficult to achieve.
This conflict can be partially resolved as long as the peripheral vascular space that has been compressed before is large enough to produce the suction effect to receive the increase cardiac output. Thus, optimized ECP compresses as much peripheral vascular tissue as possible. There is a limit, however, to the peripheral artery space, and it is usually smaller than the venous space. Therefore, as ECP performance is optimized, systolic pressure may not be significantly reduced.
But the reduction in systolic pressure during optimized ECP may also be understated as a result of the way in which it is measured. This can be further explained by examining a normal heartbeat wherein the heart pumps out blood during systole causing blood pressure to increase from diastolic pressure (usually eighty (80) millimeters Hg) to peak systolic pressure (usually one hundred twenty (120) millimeters Hg). For this example, a stroke volume of fifty (50) milliliters produces a rise of forty (40) millimeters Hg in the aorta (to about one hundred twenty (120) millimeters Hg from eighty (80) millimeters Hg). Assuming a linear relationship between volume and pressure, the larger the volume of blood being pumped out of the heart, the greater the rise in systolic pressure. For this same normal heartbeat during optimized ECP, because venous return increases, the stroke volume will generally increase about thirty (30) percent to fifty (50) percent. If there is an increase of fifty (50) percent, then a non-optimized ECP stroke volume of fifty (50) millimeters becomes an optimized ECP stroke volume of about seventy-five (75) millimeters. This appears as a rise of sixty (60) millimeters Hg from normal diastolic pressure, giving a systolic pressure of about one hundred forty (140) millimeters Hg.
But during optimized ECP treatment, a slight reduction of systolic pressure to one hundred ten (110) millimeters Hg is typical, at least implying that the systolic pressure is actually reduced from one hundred forty (140) millimeters Hg to one hundred ten (110) millimeters Hg, a significant reduction. However, because the observed systolic pressure without optimized ECP is one hundred twenty (120) millimeters Hg, a systolic pressure of one hundred ten (110) millimeters Hg during optimized ECP—a reduction of only ten (10) millimeters Hg instead of thirty (30) millimeters Hg—might lead to an erroneously conclusion that systolic reduction is not significant during optimized ECP.
Even though it is advantageous to reduce systolic pressure to give the heart a rest, increasing cardiac output, blood flow velocity, circulation and endothelial cells shear stress also improve cardiac function, i.e., by increasing release of nitric oxide (NO2) and reducing vascular resistance. As mentioned above, increasing cardiac output and systolic unloading may be in conflict when using the same inflation/deflation times and applied pressure. In this circumstance, shifting the emphasis from systolic unloading to maximal reduction of end diastolic pressure augments cardiac output by redistributing the increased energy supply from diastolic augmentation so that less energy is spent in left ventricular isovolumetric contraction, and more energy is spent ejecting the larger volume of blood returned to the heart due to increased venous return. In this way optimized ECP differs from other counterpulsation techniques such as intraaortic balloon pumping (IABP) because such other techniques do not increase venous return; therefore, there is no need to reserve the extra energy to pump out the extra volume returned to the heart.
Thus, systolic unloading is not necessarily an objective of optimized ECP, unlike maximizing diastolic augmentation and minimizing end diastolic pressure. Optimized ECP, therefore, seeks to minimize end diastolic pressure (governed by deflation timing, i.e., determining the appropriate time in the cardiac cycle to remove applied pressure), and the maximization of diastolic augmentation (governed by inflation timing, i.e., determining how to cause the retrograde pulse to arrive at the root when aortic valve closes and how long does it hold in relationship to deflation time). The use of sequential application of pressure to the patient's limbs further helps achieve these objectives.
Features employed to increase cardiac output, blood flow velocity, circulation and shear stress on the endothelial cells, and thereby improve cardiac output include: Timing inflation and deflation to minimize end diastolic pressure and maximize diastolic augmentation; controlling the magnitude of externally applied pressure to maximize emptying of vasculature under external pressure; controlling the rate of application of external compression; controlling the rate of deflation of external compression; controlling the volume of peripheral tissue under compression; sequentially timing inflation from distal to proximal portions of body to milk blood back to the heart; controlling the gradient of applied pressure from distal to proximal portions of body to reduce the leakage of blood back to distal portion; and applying pressure uniformly in each section (cuff) along the length of the body.
Optimized ECP Apparatus:
Preferably administration of optimized ECP is performed using an optimized ECP apparatus (herein, "optimized ECP apparatus"), including (a) one or more pressure devices that are applied to an extremity of the subject; (b) a device for inflating and deflating the pressure devices; and (c) a controller that initiates inflation and deflation of the pressure devices in synchrony with the cardiac cycle of the subject. An exemplary optimized ECP apparatus (10) is depicted in
The optimized ECP apparatus preferably comprises pressure devices that are applied to the legs or other limbs of the subject, preferably to the calves, thighs and buttocks of the subject. Such pressure devices apply pressure to the limb using, in a preferred embodiment, a bladder that is inflated with a fluid, preferably air. Preferably the pressure device comprises a bladder and a fastener that holds the bladder against the limb, so that when the bladder is inflated pressure is applied to the limb. In a preferred embodiment, the fastener comprises a cuff body that holds the bladder against the limb, preferably a cuff surrounding a bladder. Preferably, each bladder applies from about one hundred forty (140) to about three hundred twenty (320) millimeters Hg of pressure to the limb. The fastener is made, for example, from materials including vinyl, leather, cloth, canvas, and rigid or semi-rigid materials such as plastic or metal. Different sizes of bladders and fasteners may be provided to meet the requirements of different body shapes. Preferably space between the fastener and the bladder and between the bladder and the limb is minimized. A preferred pressure device comprises a rectangular bladder. Also, preferably, the upper and lower thigh pressure devices are a one-piece design to prevent the lower thigh pressure device from sliding during treatment.
The optimized ECP apparatus also preferably comprises a device for inflating and deflating the pressure devices using a fluid, such as air. In a preferred embodiment, where the pressure devices are inflated with air, the inflating and deflating device comprises a compressor and an air distribution mechanism that operates to distribute the air from the compressor to the pressure devices.
A hose connection assembly (29) is used for quick connecting and disconnecting the above-described components with those mounted on, or otherwise associated with, an assembly including valves that individually control inflation and deflation of the pressure devices. In a preferred embodiment, the valve assembly is part of a treatment table assembly (11). Such a treatment table assembly components include a valve manifold, a number of sequentially operable inflation/deflation valves (30), (31) and (32). Each valve (30), (31), (32) may have an associated pressure transducer/sensor (33), (34), and (35), respectively. A connect/disconnect assembly (36) is provided for quick and easy connection and disconnection of the inflation/deflation valves with associated pressure devices, e.g., the calf pressure devices (37), lower thigh pressure devices (38), and upper thigh pressure devices (39), respectively. In this embodiment, the inflation/deflation valves (30), (31), and (32) are a rotary actuable butterfly-type valve, which can be actuated pneumatically or electrically. In another embodiment, the valve assembly is part of the central console, and the patient may lie on any suitable table or bed.
In one embodiment, the subject may lie on an ordinary bed for treatment. In an another preferred embodiment, the optimized ECP apparatus comprises a bed as part of the treatment table assembly. As depicted in
The optimized ECP apparatus also preferably comprises a controller that initiates inflation and deflation of the pressure devices in synchrony with the cardiac cycle of the subject. In a preferred embodiment, the controller is part of a control console assembly. As depicted in
The user interface (52) is preferably a touch screen monitor for easy monitoring of patient treatment status, treatment parameters, and other relevant data, and provides the capability for adjustment to control operation. In one embodiment, the computer (51) monitors and records information associated with the treatment of the patient. Alternatively, another computer or remote computing system can be used to monitor and record information associated with the treatment of one or more patients. The user interface also provides switches or computer links to switches for adjusting the timing of the inflation/deflation cycle, allowing the operator to adjust the setting of the time for the start of sequential inflation as it is measured relative to the R peak of the treated subject's ECG signal, as further described below.
The apparatus may be configured so as to be self contained, i.e., with all components proximately located. Alternatively, one or more components may not be proximate, but connected to the other components through electrical (wired or wireless) or other appropriate mechanical connections. In some embodiments, the apparatus may have duplicate components (e.g., the user interface), with one component proximate to the device, and another at a remote location. In one embodiment, a user interface may be located remotely from the remainder of the device, such as in another room in the treatment facility. The computer may be located remotely from the remainder of the equipment, such as in the same facility (e.g., through remote cabelling or as part of a local area network), or in another facility (e.g., connected through an appropriate telecommunications device). The apparatus may comprise a computer proximate to the rest of the apparatus, but is connected to another computer for remote acquisition, storage, or maintaining of data. A remote user interface may be used to control two or more devices.
In a preferred embodiment, the user interface (52) displays treatment information, including an electrocardiograph (ECG) signal from the subject being treated. As will be apparent to one skilled in the art, the R wave portion of the ECG signal is typically used to monitor the cardiac cycle of the patient. Preferably, the blood flow and/or blood pressure of the patient is also displayed, e.g., to facilitate monitoring of the cardiac cycle of the subject as well as the effect of the counterpulsation waves being applied to the optimized ECP apparatus. In one embodiment, the signal is a photo-plethysmograph waveform signal as received from a finger plethysmograph probe.
The controller initiates inflation and deflation of the pressure devices in synchrony with the subject's cardiac cycle. Inflation and deflation is effected so as to create a retrograde pulse of arterial blood that arrives at the heart at approximately the end of the ejection phase of the left ventricle at the time of aortic valve closure. The time of aortic valve closure may be determined through direct or indirect measures. In a preferred embodiment, the time of aortic valve closure is determined indirectly using finger plethysmography. The synchronization of inflation and deflation of the pressure devices is exemplified in
The safety and effectiveness of the optimized ECP therapy depends on the precise timing of the inflation/deflation cycle in relation to the cardiac cycle of the patient. For example, a hardened arterial wall (i.e., with significant calcium deposits) will transmit the external pressure pulse up the aorta faster than an elastic artery. Therefore, the inflation valves should be opened later for a calcified artery than for a normally elastic artery. Accordingly, determination of inflation and deflation of the pressure devices is preferably adjusted for every individual subject to be treated.
In a preferred embodiment, there are several factors that are taken into account to determine the appropriate deflation time of the pressure devices. They include release of all external pressure before the next systole to produce maximal systolic unloading (maximum reduction of systolic pressure), and maintenance of inflation as long as possible to fully utilize the whole period of diastole so as to produce the longest possible diastolic augmentation (maximum increase of diastolic pressure due to externally applied pressure). Therefore, one measurement of effective counterpulsation is the ability to minimize systolic pressure, and at the same time maximize the ratio of the area under the diastolic waveform to that of the area under the systolic waveform. Also, preferably, inflation and deflation timing is adjusted to minimize end diastolic pressure. Preferably, timing is adjusted so as to maximize systolic unloading and diastolic augmentation.
Further, there are two basic safety criteria: (1) the inflation valves must not be opened so that the pressure pulse wave reaches the root of the aorta during systole, forcing the aortic valve to close prematurely, thereby creating systolic loading; and (2) the deflation valves are opened to the atmosphere before the next R wave to allow enough time for the air pressure in the pressure devices to decay so there is no significant residual pressure causing a tourniquet effect. Preferably, the air pressure decays to from about zero (0) to about fifty (50) millimeters Hg, more preferably from about zero (0) to about twenty (20) millimeters Hg. Finally, the inflation/deflation valves are preferably not operational when the heart rate is higher than one hundred twenty (120) beats per minute or lower than thirty (30) beats per minute.
In a preferred embodiment, the inflation/deflation timing control logic of the optimized ECP apparatus is divided into two main parts: (1) the initiation stage upon power up of the apparatus, during which the inflation/deflation times are set up automatically; and (2) the operation stage during which the inflation and deflation time can be adjusted manually. In a preferred embodiment, the timing is controlled by a microprocessor.
In a preferred embodiment (as depicted in
During the initiation stage when power is turned on, the computer will start a series of initiation procedures. An exemplary flow chart for these procedures is shown in
The inflation/deflation valve timing logic controls the timing of external pressure applied to the lower legs and thighs of the patient. A diagram of the timing relationship between inflation/deflation valves and ECG R wave is shown in
In calculating the intervals for inflation and deflation, the mechanical properties of the apparatus and the physiologic properties of the subject must be considered. In this regard, in one embodiment, it takes about twenty (20) milliseconds for the valves to fully open, about another thirty (30) milliseconds for the air pressure to arrive at the pressure devices, about another seventy (70) milliseconds to reach full inflation pressure, and about an additional one hundred fifty (150) to three hundred (300) milliseconds for the applied pressure wave to travel from the vasculature of the legs and thighs to the root of the aorta. If inflation was to actually start at the closure of the aortic valve, then these time delays would result in the pulse generated by the external pressure arriving at the root of the aorta long after the end of the systolic period. For example, for a heart rate of sixty (60) beats per minute, the systolic time is approximately four hundred (400) to five hundred (500) milliseconds per heartbeat. Therefore, for the applied pulse wave to arrive at the root of the aorta at the time the aortic valve closes, the inflation signal must start at least about one hundred fifty (150) to two hundred (200) milliseconds after the R wave. As shown in
In initiating therapy, the computer will determine the average interval (TR), after the detection of three to eight complete R-R intervals. The computer will update TR by taking the mean of the last TR and the new R-R interval. Values for the inflation time (T1) and deflation time (T2) are then determined as follows. The initial value assigned to T1 is based on the following formula derived from that of Bazett, Heart 7:353 (1920), which approximates the normal Q-T interval of the ECG as the product of a constant (0.4) times the square root of the R-R interval measured in seconds.
T 1=(12.65*√{square root over (T R )} +C 1−300)ms
In this formula, the constant 12.65 is used instead of 0.4 when converting the unit of TR from seconds to milliseconds, and C1 is a constant that is initially assigned a value equal to two hundred ten (210) milliseconds and may be adjusted as discussed below. The factor three hundred (300) milliseconds is equal to the approximate maximum time it takes for the applied external pressure wave to travel from the lower leg to the aortic valves.
After T1 has been determined, it is compared to a value of one hundred fifty (150) milliseconds. If T1 is less than one hundred fifty (150) milliseconds, it is then set to one hundred fifty (150) milliseconds. If T1 is larger than one hundred fifty (150) milliseconds, then the calculated value will be used. This procedure guarantees that the inflation valves will not open in less than one hundred fifty (150) milliseconds after the R wave. Even when T1 is set at one hundred fifty (150) milliseconds, the leading edge of the pressure wave will not arrive at the aortic root until approximately three hundred fifty (350) milliseconds after the R wave, taking into account the time required for the pulse to travel up from the peripheral vasculature to the root of the aorta.
Once the value of T1 has finally been determined, it is used to calculate T2 using the following formula:
where the constant C2 is initially set at one hundred sixty (160) milliseconds. However, C2 can be increased or decreased manually to achieve an optimal hemodynamic effect.
During the operation stage following the initiation stage, the values of T1 and T2 will be stored in memory in the controller, and used to control the inflation/deflation timing. However, the memory will be updated with every new heartbeat using the updated TR to calculate the new T1 and T2 and stored in memory replacing the old T1 and T2. In addition, the controller will interrogate periodically (e.g., every ten (10) milliseconds) a flag in a register to determine if any manual adjustment has been made.
In the inflation phase of optimized ECP, valve opening is controlled such that (i) the inflation valves furthest from the heart (distal) are opened at a time such that the pulse generated by the application of the external pressure in compressing the vascular bed travels up the arterial tree and reaches the root of the aorta when the aortic valve closes; and (ii) the second inflation valves are opened after the first valves according to a delay corresponding to when the peak of the pulse from the first pressure devices reaches the mid-point of the pressure devices controlled by the second valves (and similarly timed for the third and all other proximal pressure devices). Such a preferred embodiment for opening of the inflation valves in sequence is shown in
In one embodiment, the delay in inflation between sets of pressure devices is approximated, using a fixed time interval (delay) between each set of pressure devices, e.g., ranging from approximately twenty (20) milliseconds to eighty (80) milliseconds and preferably about fifty (50) milliseconds. The delay in each of the successive sets of pressure devices is not fixed in another embodiment. In such an embodiment, timing is varied because the velocity of the pulse generated by the inflation of the distal pressure devices traveling up the peripheral vascular tree to the aorta and the heart (retrograde flow) changes according to the elasticity of the arterial walls of the patients and the rate of application of the external pressure. The delay required for optimized inflation of a distal pressure devices ahead of closure of the aortic valve and delay in opening subsequent inflation valves depends on the distance D of the distal pressure devices to the root of the aorta and elasticity E of the aortic wall. Elasticity E is calculated as dP/(dV/V). In this manner, velocity of the generated pulse traveling up the aorta is controlled. Accordingly, distal inflation valves open at a time such that the generated retrograde pressure or flow pulse will reach the root of the aorta when the aorta closes. The next set of inflation valves opens when the pulse generated by the distal compression reaches the midpoint of its respective pressure devices as determined by a pressure detector. Any subsequent inflation valves open in a similar manner, i.e., when generated distal pulses reach the midpoint of any such pressure devices. In one embodiment, the time delay for sequential inflation of the pressure devices is determined by first calculating the velocity of the retrograde pulse from the lower leg inflation device to the blood pressure detector (e.g., finger plethysmograph). This is calculated as the distance between the lower leg device and the pressure detector, divided by the time between inflation of the device and the detection of the retrograde pulse by the detector. The delay time between inflation of the lower leg device and the upper leg device can then be calculated by dividing the distance between the cuffs by the velocity. The delay between inflation of the upper leg device and the thigh inflation device can be similarly calculated.
In a preferred embodiment, the optimized ECP apparatus comprises manual inflation and deflation timing adjustment inputs, such as touch screen buttons or manual switches, as described above. Each depression of the inflation advance input triggers the controller to compare the value (TR−T1) to 200 milliseconds. If (TR−T1) is larger than two hundred (200) milliseconds, then T1 will be lengthened by ten (10) milliseconds. This is done by adding ten (10) milliseconds to C1 which has been initially set at approximately two hundred ten (210) milliseconds. The same logic is applied to limit the ability of advancing T1 to approximately two hundred (200) milliseconds or less before the next R wave, in order to prevent the inflation valve of the calf pressure devices from opening so late that not enough time remains for the deflation valves to open before the next R wave; keeping in mind the facts that the inflation valve for the lower thigh pressure devices opens approximately fifty (50) milliseconds after T1 and remains open for approximately another one hundred (100) milliseconds, followed by the opening of the upper thigh pressure devices fifty (50) milliseconds thereafter, leaving little, if any, time for the deflation valves to open before the next R wave. Because the logic used in controlling the manual adjustment of the deflation valves sets a limit for the deflation to open no later than approximately thirty (30) milliseconds before the next R wave, in the worst case scenario, the deflation valves will open to the atmosphere within approximately thirty (30) milliseconds after the inflation valve of the upper thigh pressure devices is closed.
The other manual inflation/deflation adjustment inputs work on the same principle; that is, with each depression of one of the manual inputs, the controller will check the conditions limiting the timing of the valves, and if the limits are not reached, then the timing for the inflation/deflation valves can be advanced or retreated by subtracting or adding ten (10) milliseconds to C1 or C2 of the above equation and the equation T2=(TR−C2) milliseconds.
Manual adjustment of the optimized ECP therapy comprises adjustment of the inflation time (varying C1) and deflation time (C2), so as to optimize efficacy. Deflation time is preferably adjusted before inflation time. The objective of adjusting deflation time from the R-wave or other triggering signals is to release all external pressure to achieve maximal decrease in end diastolic (or presystolic) aortic blood pressure. As demonstrated in
When deflation valves open too early, the end diastolic pressure is flat, as shown at A in the middle panel of
As mentioned before, the deflation time T2 is initially set as (TR−C2), and C2 is set as one hundred sixty (160) ms, that is the deflation time is set as one hundred sixty (160) ms before the next R-wave. After this initial set-up, the-operator is to adjust the deflation time manually to minimize the end diastole pressure. The first step is to adjust the deflation time earlier and observe the resulting changes in the patient pressure waveform to determine whether end diastolic pressure is lowered. If end diastolic pressure is lower, the deflation time is further adjusted to be earlier. If no change in end diastolic pressure is detected, then the deflation time is delayed to determine if there is any affect on end diastolic pressure. The procedures are repeated until the lowest end diastolic pressure is achieved with the latest possible deflation time. These steps ensure minimization of left ventricular isovolumetric contraction before ejection begins and maximization of diastolic augmentation by holding the diastolic compression as long as possible.
A diagrammatic representation of optimal inflation time is shown in the left panel of
There are circumstances when the exact time at which aortic valve closes is difficult to detect, such as when noninvasive detection methods are used (e.g., finger plethysmograph) and a dicrotic notch does not appear on the resulting waveform. The dicrotic notch may not be visible because it is composed of a high-frequency wave that is attenuated much faster when transmitting through the vascular bed. In this case, as exemplified in
Concerning the externally applied pressure waveform, optimal operation of the optimized ECP apparatus not only depends on proper inflation and deflation times, it also depends on the manner by which external pressure is applied, which is affected by the specific configuration of components of the apparatus. In particular, the time it takes for the applied pressure to rise to peak pressure (the rise time), the magnitude of the peak pressure, the length of time the pressure is applied (duration), and the speed with which the pressure is released (decay time), are considered.
Compression of the peripheral vascular bed produces a retrograde pulse that represents diastolic augmentation. The magnitude and velocity of propagation of the pressure wave up the aorta represents the potential and kinetic energy transmitted to the vasculature. The kinetic energy depends on the how fast the external pressure is applied, and the potential energy depends on the magnitude of the external pressure. Therefore, as shown in
The rise time R, or rate of applied pressure, depends on the rate of delivery of compressed fluid, which in turn depends on the magnitude of the compressed fluid in the reservoir (as high as possible but limited due to safety factors), the peak external pressure P to be applied to the body (about one hundred sixty (160) to three hundred (300) millimeters Hg for patient safety and comfort), the dimension of the inflation valves and hoses (as large as practical, i.e., one-half (�) to one (1) inch in diameter), the volume of each pressure device to be inflated (dead space should be reduced as much as possible). An acceptable rise time R, for example, is forty (40) to one hundred (100) milliseconds to inflate from zero (0) to three hundred twenty (320) millimeters Hg. The duration L of applied pressure is as long as possible, but is governed by inflation/deflation timing.
The peak external pressure P that can be applied to the body is the most important factor for effectiveness and safety considerations. In principle, one expects to apply a pressure slightly larger than the systolic pressure so as to collapse the conductive large arteries. However, that is typically not enough to compress the tissue surrounding the arteries, the microvessels that actually contain larger volume of blood. In addition, there is a loss of pressure from the skin layer through the muscle to the arteries. For example, some patients with very calcified arteries, or patients with very stiff peripheral muscle, require application of a greater pressure, but not so great as to induce trauma to the skin and muscle (e.g., by exceeding a tank pressure of about three hundred fifty (350) millimeters Hg.)
The decay time D is defined as the time taken for the pressure devices to deflate from peak external pressure P to atmospheric pressure. The faster the decay time D, the more efficient the deflation to lower end diastolic pressure. In addition, when the heart rate of the patient under treatment is high (one hundred (100) to one hundred twenty (120) bpm), the time for inflation and deflation is limited to a very short period, and it becomes necessary to shorten the decay time D to less than one hundred (100) to one hundred twenty (120) milliseconds. The implementation of fast decay is opening the deflation valves as large as possible, employing large diameter hoses, and, if necessary, using a vacuum source to suck the compressed air from the pressure devices, especially during the last portion of deflation when the pressure in the pressure devices is low. An acceptable rate of deflation, for example, is from about forty (40) to about one hundred twenty (120) milliseconds to deflate from about three hundred (300) to approximately atmospheric pressure (or as close thereto as practical).
Also, preferably, the volume of peripheral muscle under compression is maximized by using a pressure device size with length covering all peripheral volume below the iliac crest. Compressing above the iliac crest is not recommended because it is difficult to transmit any externally applied pressure to the vasculature in the abdominal cavity and often results in patient movement rendering the effort useless. Nonetheless, where such pressure can be efficiently transmitted and patient movement retarded, further maximization can be achieved. In addition to producing better diastolic augmentation, the maximal peripheral volume under compression would also produce larger venous return and more emptied vasculature when deflated to receive left ventricle ejected blood volume to achieve a lower systolic pressure as well as end diastolic pressure.
Concerning the pressure gradient between sets of pressure devices, further optimization is achieved by applying peak external pressure in the distal pressure devices that is higher than the proximal pressure devices. Thus, in addition to inflating successive sets of pressure devices sequentially from distal to proximal regions of the body with time delay in an effort to "milk" the peripheral blood back up the vascular tree, the peak applied external pressure in the distal pressure devices is higher than the proximal pressure devices, as shown also in
Optimized ECP apparatus useful in the methods of this invention are disclosed in the following patent documents, all of which are incorporated by reference herein: U.S. Pat. No. 3,303,841, Dennis, issued Feb. 14, 1967; U.S. Pat. No. 3,403,673, MacLeod, issued Oct. 1, 1968; U.S. Pat. No. 3,654, 919, Birtwell, issued Apr. 11, 1972; U.S. Pat. No. 3,866,604, Curless et al., issued Feb. 18, 1975; U.S. Pat. No. 4,753,226, Zheng et al., issued Jun. 28, 1988; U.S. Pat. No. 5,554,103, Zheng et al., issued Sep. 10, 1996; U.S. Pat. No. 5,997,540, Zheng et al., issued Dec. 7, 1999; PCT Application WO 99/08644, Shabty et al., published Feb. 25, 1999; U.S. Patent Application Publication No. 2002/0107461, Hui, published Aug. 8, 2002: and U.S. Patent Application Publication No. 2003/0233118, Hui, published Dec. 18, 2003. Preferred optimized ECP apparatus useful herein include the MC-2 and TS-3 enhanced optimized ECP therapy systems marketed by Vasomedical, Inc., Westbury, N.Y., U.S.A.
In a preferred embodiment, the methods of this invention also comprise monitoring the subject being treated with optimized ECP for one or more indicia of safety or efficacy. Such indicia include those pertaining to blood oxygen level, respiration rate, heart rate, and diagnostic indicators of heart failure including evaluation of symptoms such as dyspnea, orthonea, paroxysmal nocturnal dyspnea, chronic fatigue, peripheral edema, ascites, tachycardia, "galloping" heart rhythm, rales, jugular venous distention, and oliguria; chest x-ray to assess the size of the heart; electrocardiogram, preferably with Doppler interrogation; radionuclide ventriculogram; coronary angiography; and magnetic resonance imaging.
A preferred monitoring step comprises monitoring of the subject's blood oxygen level. Such monitoring may be conducted through oximetry methods among those known in the art. Monitoring may be through devices incorporated into the optimized ECP apparatus, or otherwise. In a preferred embodiment, oximeters function by measuring the oxygen saturation (the amount of oxygenated hemoglobin as a percentage of total hemoglobin) in arterial blood. In general, methods for measuring oxygen saturation utilize the relative difference between the light absorption (or attenuation) coefficient of oxygenated hemoglobin and that of reduced hemoglobin. The light absorption coefficient for oxygenated hemoglobin and reduced hemoglobin is dependent on the wavelength of the light traveling through them. Oxygenated hemoglobin and reduced hemoglobin have different light absorption coefficients with wavelengths in the red and infrared regions. Thus, the two colors typically chosen to shine through the blood sample are red light and infrared light. In oximeters, light intensity is measured at various physiological states created by the pulsing of the vasculature as blood flows. As the heart beats, arterial blood is forced in the arteries and capillaries to produce a blood filled state. The blood then drains leaving a reference which consists of tissue, bone and some amount of venous blood. The collected transmitted light is subjected to photoelectric conversion and then mathematical conversion to eventually calculate the degree of oxygen saturation in the blood.
In a preferred embodiment, non-invasive oximeters are used to measure oxygen saturation. Oximeters function by passing light of various colors or wavelengths through a sample. On the human body, typical measuring points are the tip of a finger or an ear lobe. The oximeter determines SpO2 and pulse rate by passing two wavelengths of low intensity light, one red and one infrared, through body tissue to a photodetector. The sample absorbs the transmitted light to varying degrees relative to the particular constituents through which the light passes. A photosensitive device, such as a photo multiplier tube or photodiode, is used to detect the transmitted light. Alternatively, the photosensitive device can be designed to detect the light reflected from the sample. During measurement, the signal strength resulting from each light source depends on the color and thickness of the body tissue, the sensor placement, the intensity of the light sources, and the absorption of the arterial and venous blood (including the time varying effects of the pulse) in the body tissues. Either system provides a measure of the light the sample absorbs, i.e., the light the sample does not transmit or reflect. Using measurements of the transmitted light intensity, the absorption of light by the sample can be calculated. The oximeter processes these signals, separating the time invariant parameters (tissue thickness, skin color, light intensity, and venous blood) from the time variant parameters (arterial volume and SpO2) to identify the pulse rate and calculate oxygen saturation.
A low oxygen saturation measurement is a warning of dangerous oxygen deprivation, or hypoxemia, a potential cause of injury or death. The specific minimum safe blood oxygen level is determined according to sound medical practice. In one method, the minimum blood oxygen circulating percentage is about eighty-six (86) percent, preferably less than about ninety (90) percent. In another method, the minimum level is a blood oxygen circulation percentage level that is about five (5) percentage points (on an absolute basis) less than the subject's blood oxygen level prior to initiation of an optimized ECP treatment session. In one embodiment, therapy is terminated if the blood oxygen level drops below the minimum level. In another method, the oximeter or optimized ECP apparatus provides the service provider with a visual or audible notification that the minimum level has been reached.
A preferred method includes (1) providing a plurality of inflatable devices adapted to be received about the lower extremities of said subject; (2) interconnecting a source of compressed fluid with said inflatable devices; (3) interconnecting a fluid distribution assembly with said inflatable devices and said source of compressed fluid; (4) distributing compressed fluid from said source of compressed fluid to said inflatable devices; (5) providing a controller in communication with said fluid distribution assembly; (6) inflating and deflating said inflatable devices using said controller so as to minimize end diastolic pressure, whereby an increased cardiac output in said subject is achieved; (7) measuring the oxygen level in the blood of said subject; and (8) providing a warning or (preferably) terminating said inflating and deflating of the inflatable devices if said oxygen level drops below a safe level. In another embodiment, said inflating and deflating step is performed so as to maximize systolic unloading and diastolic augmentation. Preferably, the inflating and deflating step is performed so as to minimize end diastolic pressure and maximize systolic unloading and diastolic augmentation.
In a preferred embodiment, an optimized ECP apparatus comprises a device for measuring blood oxygen level. Preferably in such a device, the optimized ECP apparatus includes a controller that monitors the blood oxygen level and determines if it falls below a safe level determined pursuant to sound medical practice, as discussed above. Such a level may be set by the service provider, or be automatically determined by the optimized ECP apparatus. In one embodiment, the controller terminates therapy if the blood oxygen levels falls below the safe level. In another embodiment, the controller provides a visual or audible signal to the service provider.
The examples and other embodiments described herein are exemplary and not intended to be limiting in describing the full scope of compositions and methods of this invention. Equivalent changes, modifications and variations of specific embodiments, materials, compositions and methods may be made within the scope of the present invention, with substantially similar results.
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|Oct 31, 2017
|Lifecuff Technologies Inc.
|Methods and devices for remote ischemic conditioning via partial limb occlusion
|Dec 28, 2004
|Jul 21, 2005
|Jacob Barak
|Method and apparatus for assisting vascular flow through external compression synchronized with venous phasic flow
|Jul 17, 2007
|Jan 17, 2008
|Arani Bose
|Counter pulsation system and method for stroke recovery treatment
|Nov 7, 2006
|May 8, 2008
|Helgeson Lonnie J
|Combined air pulsator and movable pedestal
|Dec 6, 2006
|Jun 12, 2008
|The Hospital For Sick Children
|System for performing remote ischemic preconditioning
|Mar 8, 2010
|Jun 24, 2010
|The Hospital For Sick Children
|Methods and system for performing remote ischemic preconditioning
|May 13, 2010
|Nov 18, 2010
|The Hospital For Sick Children
|Performance enhancement
|May 28, 2010
|Dec 2, 2010
|The Hospital For Sick Children
|System for performing remote ischemic preconditioning
|Feb 1, 2011
|Aug 4, 2011
|The Hospital For Sick Children
|Remote ischemic conditioning for treatment and prevention of restenosis
|Oct 5, 2010
|Sep 29, 2011
|Fazal Raheman
|Methods and apparatus for optimal remote ischemic preconditioning (ORIP) for preventing ischemia-reperfusion injuries to organs
|Sep 11, 2011
|Dec 29, 2011
|Morteza Naghavi
|Ischemic Conditioning for Improved Athletic Performance
|Jan 31, 2012
|May 24, 2012
|Infarct Reduction Technologies Inc.
|Automatic devices for remote ischemic preconditioning
|Jul 4, 2011
|Aug 15, 2013
|Western Clinical Engineering Ltd.
|Tourniquet Hazard Suppressor
|Mar 12, 2013
|Sep 12, 2013
|Wright Therapy Products, Inc.
|Compression therapy device with multiple simultaneously active chambers
|Jun 16, 2014
|Oct 2, 2014
|Infarct Reduction Technologies Inc.
|Automatic devices for remote ischemic preconditioning
|Mar 18, 2015
|Jul 9, 2015
|Infarct Reduction Technologies Inc.
|Methods and devices for remote ischemic conditioning via partial limb occlusion
|Mar 24, 2014
|Sep 24, 2015
|Neocardium, Limited
|Optimal Remote Ischemic Preconditioning (ORIP) for mitigating DNA damage
|Aug 15, 2012
|Jul 1, 2014
|CellAegis Devices Inc.
|Cuff for remote ischemic conditioning
|Aug 15, 2012
|Jul 15, 2014
|CellAegis Devices Inc.
|Controller for remote ischemic conditioning
|Aug 15, 2012
|Jul 15, 2014
|CellAegis Devices Inc.
|Combined controller and cuff for remote ischemic conditioning
|U.S. Classification
|601/152, 606/201, 601/150
|International Classification
|Cooperative Classification
|European Classification
|Sep 10, 2002
Owner name: VASOMEDICAL, INC., NEW YORK
Free format text: ASSIGNMENT OF ASSIGNORS INTEREST;ASSIGNOR:HUI, JOHN C. K.;REEL/FRAME:013273/0710
Effective date: 20020827
|Nov 23, 2009
|Fee payment
Year of fee payment: 4
|Nov 12, 2013
|Fee payment
Year of fee payment: 8
|Aug 18, 2017
|Fee payment
Year of fee payment: 12


text:
Sold for:
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- Sold Date:
- Source: eBay
This auction is for an Alpine of the Month Angel, April. She measures about 4 1/2" tall. She is holding a rabbit in her arms, and at her feet is a chick in what looks like a bed. She looks like she was made to look like a Hummel. The bottom is marked - Alpine Angel of the Month - F-338. And t is the remants of a sticker, but can't read enough to see who made her. She is in good condition, just a little dirty, but no chips or cracks.Please note that items I have for auction were bought at Estate, rummage, or yard sells, and I do not know the enviroment they were in before I bought them. So if you are offended by tobacco smoke, pets, dirt, dust, ect. be aware that these items may have been in an enviroment w these things were present. Please ask questions if you have any before you bid. Thanks for looking.

subset: commoncrawl


text:
3DOcean Wireless pen drive 8084054
3DOcean Wireless pen drive 8084054
3D Model \ Music \ Instruments \ Electronic
Drive \ Storage \ Windows \ Stick \ Network \ Computer \ Flash \ Memory \ Wireless
3D Model - Wireless pen drive 8084054 by ArtsBlueBall @ 3DOcean
3D Model \ Music \ Instruments \ Electronic
3D File Formats Included: .fbx (multi format), .mb (maya), .obj (multi format); Animated: No; Created In: maya 2013; Geometry: Polygons; Low-poly: Yes; Materials: Yes; Poly Count: 483; Rigged: No; Textured: No; UV Layout: No.
Detailed 3D Model of Netgear Wireless pen drive . Model is based on edge loop topology.
All Materials are Included.
Model is render ready and ready for use.
Off Road; Sport Car.
Keywords: Wireless pen drive, computer, drive, flash, memory, network, pc, pen, stick, storage, wi-fi, windows.
Download Link


text:
Gemma Augustea, ( Latin: "Gem of Augustus") sardonyx cameo depicting the apotheosis of Augustus. He is seated next to the goddess Roma, and both are trampling the armour of defeated enemies. It is one of the most impressive carved cameos of a series of Roman gems representing imperial persons. The Gemma Augustea (now in the Kunsthistorisches Museum, Vienna) was probably carved during the reign of Caligula (ad 37–41). Others in the series include the Grand Camée de France and the Blacas onyx cameo in the British Museum, London.
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text:
Saint Seiya Omega Episode 13 English Subbed
You are watching Saint Seiya Omega Episode 13 English Subbed from the Saint Seiya Omega Anime Show. Watch or Download Saint Seiya Omega Episode 13 MP4 English Sub and other episodes of Saint Seiya Omega Streamed for Free.
"Seiya's Message! To you, I entrust Athena!"
Stream Saint Seiya Omega Episode 13
Episode Summary: Kōga and his friends continue their trek escorting Aria, until they come to a enormous whirlwind blocking their way. Meanwhile, Mars reveals his plans for his Tower that he deems the new Twelve Zodiac Temples, to his daughter and son, Sonia and Eden. A moribund Athena is also revealed by Mars, held hostage inside his tower. The young Saints decide to brave the whirlwind, managing to find a way inside it with the help of Yuna's command over wind. The traitorous Musca Fly tries to steal Kōga and Yuna's Cloths, only to be defeated in a fierce battle. Weary and alone, the young Saints find a new light of hope in the Pegasus constellation, which reveals a message from the legendary Seiya: "To you, I entrust Athena!"


text:
Lesliewrote a review of The North Face Lovers Leap Anorak Jacket - Women's on September 1, 2012
Cute Jacket
Just got this jacket and I love the look of it. The cut of the waist is flattering (less boxy than some other rain jackets I have tried) and the red color is a bright, pretty watermelon sort of shade. The sizing seems to be pretty accurate. I'm 5'8", 150lbs and I got the Large. It fits well and leaves room for a light sweatshirt underneath. Haven't tried it in the rain yet but I have no doubt it will work out just fine.
The jacket isn't lined, it's meant to be a lightweight, easily stowed rain jacket and it seems to work well for that. It scrunches up pretty compactly and I can stick it in my backpack easily.
The jacket has nice bungee pull cords in the hood and hem (and the sleeves have velcro straps) so that you can adjust the fit and be sure to stay dry. The cords in the hood are especially useful for tightening it down so it doesn't blow off in windy conditions.
The only drawback I have found so far with this jacket is that the material is pretty noisy when I move around in it. I'm not sure if it will stay that way or will quiet down after it's worn a few times. Either way it's not that big of a deal for me. Just mildly annoying.
Overall I really like the jacket and would definitely buy it again. It's a little pricey but the construction quality is obvious and (in my opinion) justifies the cost.


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Download Out and About apk 1.2 free for Android smartphone
Posted by Queensland Government - DET in Education | Dec. 21, 2015 | 5 Comments
Apk file size: 12.0 MB
Give your child a flying start in literacy by helping them practice their sight words with this bright and fun app when you are out and about.
'Out & About' has been developed by the Department of Education and Training and is aimed at Prep to Year 2 students to help them master the first 100 sight words to which they are typically introduced.
'Out & About' has been designed for parents to give to young children to fill their time in a fun and educational way.
The words in this kit are grouped into ten word sets. Students select a word set and say the word that appears. If they cannot remember the word, they can touch the word on the screen, listen to it and then swipe to the next word on the list. Once they have mastered all the words, they can move on to the next set.
In no time, your youngster will be ready to zoom through entry-level books.
This app also contains additional games and ideas for parents to help their children recognise sight words.
Whats new
Minor text changes
Queensland Government - DET part of our Education and have average installs from 5000 to 10000. Last Update Dec. 21, 2015. Google play rating is 92.9032. Current verison is 1.2. Actual size 12.0 MB.
Similar applications
5 Comments
Jo Bauer
Excellent. I downloaded this a week ago for my 4year old. He has learned almost 20 sight words in a week. Highly recommend.
Jennifer Mulligan
Perfect!! Found this by accident. Why arent the schools telling us about it??
Tanya Soderholm
The school my son goes to informed me of this wonderful app.
Mereana Dargaville
Awesome app Teachers at my sons pre prep school do this with the kids and they love it..even starting to remember which one is which
chillapuram narendernath
That's stabbed Gucci I will be have a nice day ahead and get send do you know FYI we have a problem is with with you and I will g I I go I I only dkk all ask quo all XL CV bk so zoo XL XL zoo x CL doo


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Rudolph just called in sick, and the rest of the reindeer team refuses to travel without his bright head light leading the way. Santa needs a reliable way to deliver all those toys to the little kids as well as the big electronic toys to the big kids. Santa needs wheels. What should Santa drive?
2011 Chrysler Town & CountryEnlarge Photo
Santa needs lots of cargo space for the gifts. But – let's face it – Santa isn't exactly slim, thanks to all those cookies everybody's been leaving for him by the chimney for decades. So, I suggest the 2011 Chrysler Town & Country. After all, Chrysler invented the minivan, so they know a thing or two about storage space and getting people – or elves – in and out easily.
Since Rudolph with his nose so bright needs to recharge his batteries, Santa needs bright headlights. I recommend the 2011 Mercedes-Benz models with a night vision package and a spotlight function to help him avoid a fender bender with a chimney.
Energy efficiency is critical, because Santa has a long way to go in a short period of time, and we know Santa would rather spend his money on toys than on gas. So, I suggest the 2011 Toyota Prius. There's a reason this is the best-selling hybrid on the planet.
The sleigh must be rugged, because it's a long, tough trip, and millions of good boys and girls are depending on its success. So, I suggest the 2011 Jeep Grand Cherokee. The Jeep name is synonymous with rugged, just as Santa's name defines Christmas.
2011 Lincoln MKZ HybridEnlarge Photo
Santa needs something with a GPS, so he can find the homes of all the good children without wasting time going in the wrong direction. It's good so many models now have nav systems built into the dashboard, since Mrs. Claus will tell you that Santa doesn't like to stop and ask for directions.
It must be safe, because we wouldn't want anything to happen to Santa until (at least) after he's delivered the goods to our house. So, I would suggest any of the cars rated as top safety picks by the Insurance Institute for Highway Safety, including the 2011 Mercedes C Class, Subaru Outback, Volvo S80, Ford Fiesta, Chevrolet Malibu, Buick LaCrosse, VW Jetta and BMW 5-Series.2011 Porsche Panamera, with its combination of elegance, performance and a long list of what I like to call "creature features."
What do you think? What should Santa drive?


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Vulc-Tech Tire & Auto Repair
Review for Vulc-Tech Tire & Auto Repair
Stephen F. on 01/01/2016
"Best customer service ever!"
I had a low tire pressure light, so I stopped in to make sure I just needed air; as always, I was taken care of quickly and professionally. I refer Vulc Tech to anyone that needs tires or auto repair and will continue to do so!
Vehicle: Acura RDX
Service Date: 12/31/2015
Review Created: 01/01/2016 07:40 AM


text:
MORE than 230 cases of influenza have been diagnosed in South Australia this year - four times more than the same time last year.
It is more than three times the 72 cases confirmed in SA for the whole of 2004 and 2 1/2 times more than the 88 cases confirmed in 2006.
Experts are urging all South Australians over six months old to book in for a flu jab to prevent further spread of the potentially deadly disease.
SA Health chief medical officer Professor Paddy Phillips said the 2013 vaccine would become widely available from March 15.
"As we see every year, influenza can be a very serious illness," he said, adding: "We recommend a flu shot each year because the strains change each year."
He said the figures - about 30 cases per week diagnosed for the past eight weeks - were higher than in previous years.
"But they're nothing like the winter peak when we get hundreds of cases per week, not tens," Prof Phillips said.
Of the 233 cases reported so far, 131 were Influenza A, 99 Infleunza B and three were H1N1, or swine flu. This time last year, 55 cases had been reported.
The vaccine covers variants of each of the strains expected to be prevalent this year.
SA GP and founding member of the Influenza Specialist Group, Dr Rodney Pearce, said the number of flu cases fluctuated each year.
"We speculate - rather than know - why there is lots of the flu around," he said.
However, Dr Pearce said South Australians could expect the figures to rise into winter.
"We would expect to start seeing more cases of the flu from about this time of year," he warned.
Some private GP clinics would already have some of the vaccine available.
The cases come as a University of Adelaide study reveals 95 per cent of SA parents believe that vaccines are safe, despite the spread of misinformation about their safety.
The study, by PhD student Adriana Parella, surveyed 469 South Australian parents.
"Until now, little has been known about what Australian parents really think about vaccine safety and how they respond to a perceived adverse event," Ms Parella said.
Originally published as Doctors urge jab as flu spreads


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"For me life is continuously being hungry. The meaning of life is not simply to exist, to survive, but to move ahead, to go up, to achieve, to conquer."
Related quotes
"Life is about a game that makes you a loser, Hope is about restarting it, Living is about fighting it back!"
""To love with all your heart....To forgive with relentless compassion....To be purposefully used up by the great dream that calls you forth....is what there is to do. Anything less would be a travesty to the soul""
"The resistance that you fight physically in the gym and the resistance that you fight in life can only build a strong character."
"Strength does not come from winning. Your struggles develop your strengths. When you go through hardships and decide not to surrender, that is strength."
"What we face may look insurmountable. But I learned something from all those years of training and competing. I learned something from all those sets and reps when I didn't think I could lift another ounce of weight. What I learned is that we are always stronger than we know."


text:
Join us for a non-contact Fitness class that incorporates calisthenics, Kettlebells, Yoga & more! Increase your cardiovascular fitness, increase muscle tone, develop strength and lose fat! Our Fitness class is designed for people of all fitness levels and is open to members & non-members. Take a Trial Class Today!
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text:
Moving to Richmond was a lot like how I clean out my closet. I take everything out and pile it in a big heap on my bed, and then decide what goes back in it.
Our life was frenetic madness in Hampton Roads. Good. But messy. So many great things and great people, filling our days. But there were times when just emptying out the closet and starting over sounded really nice, too.
Coming here, I had to say good-bye to the Sudanese families....left the children's co-ops and my work there...quit my job teaching at the local college...and all of our friends.
So I decided I was going to treat our New Richmond Life as a sabbatical of sorts. I'm not signing up for ANYTHING or making ANY commitments for the first semester. Or so I said.
Maybe this would be the point in motherhood when I'd actually find a routine around the house, and not just throw food at my children in the car as we drove somewhere.
My goal: I was going to decide what I really, truly missed and only add back in those things.
The empty space was really nice. For a few weeks. My floors have never been cleaner. We were sitting down for a home-cooked meal at a regular time every night. Since we weren't driving an hour home from co-op (only FOUR MINUTE commute now), people weren't napping in late afternoon. I could have everyone sleeping by 7, clean up a bit until 8, do my work until Steve gets home at 9 or 10.
It's been very "Betty Draper" (Season 1) around here since we moved in.
But all this empty space in my life has been a bit deafening -- I guess I'm not used to it. So one month into my Don't-Do-Anything Semester, I've already applied for teaching jobs and written to the local Refugee Resettlement organization, and they're going to start their background check on me.
Minimum I can start doing anything with them, though, is several months out (training and background checks). And while I don't understand their full scope yet, they seem more categorized and rigid than my work before. With Julie, I could help put out fires as they came up -- serving whatever current crisis the families needed.
I'm torn about my work with refugees, because my life dynamics have completely changed. My "value" to the Sudanese community was that I was surrounded by incredibly generous persons -- and a lot of them. Starting over, I know almost nobody. My ability to fill needs for brand-new refugees just evaporated.
Pretty much nightly, I ask questions to my husband like: "So what am I supposed to do with the rest of my life? What things in my life make me most 'me'?" And to his credit, he actually listens and answers when I ask completely vague, open-ended questions like that.
Steve suggested grant-writing for refugees, as a way to gather resources that didn't require a social network, and I like that idea. I need to learn a bit (um... like, everything) about grant-writing. But I think I'm going to explore that one.
I've been really struggling with the political side of refugee work in the last few months. I've been so anti-politics and bureaucracy for so long, it's a bit unsettling to realize the work I really *want* to do on a soul-level for these families requires political involvement. A whole 'nother post, that one.
I've been really struggling with the political side of refugee work in the last few months. I've been so anti-politics and bureaucracy for so long, it's a bit unsettling to realize the work I really *want* to do on a soul-level for these families requires political involvement. A whole 'nother post, that one.
BUT... I also really loved how intertwined my children were with my work back in Hampton Roads. It meant a lot to them. It was something WE did, not just my thing. I needed to find a way to keep them involved, keep fostering their awareness of global needs and other people. Grant-writing and political work doesn't really do that.
So today, I opened up another account on www.Kiva.org, just for the kids. On the site, you can give microloans (as little as $25) towards a need -- primarily, entrepreneurs in other countries. I made sure it has all three of their names as the profile, and a picture uploaded of them. It's going to be their thing, I'll just do the typing.
I asked the kids whom they'd most like to help. Andrew and Jack didn't miss a beat before saying, "The Sudanese." Simone said: "I want to help children."
So we went on Kiva, chose "South Sudan" and got 9 profiles back. I explained to Simone that they don't really give loans to children, but we could make sure the person *had* children, so we were helping them too.
I read through all of them out loud to the kids, and figured it was just drone noise for them. I wasn't sure how they'd choose. When I finished though, Jack immediately said "Alice." I was surprised he remembered the name, after all that reading, and asked him why. "Because she had 6 kids, and that was the most. It takes a lot of money to raise that many kids, so she could really use it."
Be still my heart.
She needs $300, but we gave $25. I told them they could do jobs around the house, if they wanted to give her more. I would pay however much they earned for her. The boys loved that idea, and Andrew immediately started naming off all the things he could do to help Alice start her business.
That was a really nice moment, and one I needed to see in my "sabbatical." That there are still ways to matter to the world, even in tiny ways, and to show the children there's something bigger out there.
As sweet and significant as all of that was for me, though, I should add: When I told them about doing jobs around the house if they wanted, Simone shook her head and said, "Nah, I think I'll just keep the money and buy some toys." Ha!
Parenting. It's a process.


text:
Network Slicing in ActionSP360: Service Provider
One particular aspect of mobile network evolution that deserves attention is the idea of reducing round-trip time (RTT) between consumers of a service and the service source itself. So muchRead More
The Internet is Closer to Home Than You ThinkSP360: Service Provider
The Internet is global in spirit. But the traffic associated with it is increasingly local in nature, as we found in our recent VNI study.Read More
Parents in Prison: How Cisco is Helping Families Stay ConnectedGovernment
"When I was growing up in Indianapolis, we didn't have a lot of money. We weren't exactly poor, but then again, we never vacationed at Disneyland. Maybe Rock City .Read More
Supporting the broadcasting of the futureSP360: Service Provider
People are consuming more content online, on a growing number of different devices inside and outside the home. Telco's and Media companies can use a cloud-based video infrastructure to supportRead More
The revenue opportunity of targeted advertisingSP360: Service Provider
Updating their video infrastructure makes it possible for telecoms companies to supply the flexible and personalised services that their customers increasingly expect. And the data from an integrated video platformRead More
Lights, Camera, Action: Sparking Conversations with a Live Demo at NABSP360: Service Provider
NAB 2017 triple threat: enhanced the demo experience, excited customers and pushed the envelope with live demos, showcasing Cisco's engagement with the media industry transformation to IP.Read More
Keeping your edge by delighting customersSP360: Service Provider
Telecom and OTT Video business is changing fast. High video quality and intelligent content discovery are two key elements of a great customer experience.Read More
Next generation video security: laying the foundations for transformationSP360: Service Provider
Intelligent, threat-centric security gives businesses the confidence to create new, flexible video services.Read More
Delivering a New and Improved Online WorldSP360: Service Provider
Service provider networks are at the epicenter of digitization. You need to be faster, more efficient, more focused on strategic partnering and security obsessed. Here are some suggestions for howRead More
How Our Students Will Overcome the MachinesEducation
Any university will tell you that its primary mission is to create opportunities for its students to achieve success. But student success looks quite different today than it has inRead More


text:
Visit Publisher Site
Get phpHostsFinder Hosting
This simple utility allows you to find all hostnames (if any) on a particular domain. You can either put a hostname or an ip address and program will scan the entire subdomain to locate hostnames which resolve. It is very easy to install and to use.Visit publisher site: phpHostsFinder
Listing Details
- Version:
- 1.0
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- Feb 28, 2002
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One of our favourites (probably because it is moreishly addictive). A selection of crunchy nuts gently roasted with a sweet blend of herbs and spices, which when mixed delivers a really satisfying mix of flavours. All laid on rich dark chocolate.
Where to find Kenspeckle this Christmas 2017
Thursday 19th October 2017
Northumbrian Vanilla Fudge
The smooth velvet texture is simply the best you w...


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Whenever Delaware Health and Social Services clients are to be the subjects of a research project, the project must be submitted for HSRB review. The following resources are available to help researchers understand and submit their projects through this process.
For more information about the HSRB, please see the description of the HSRB.


text:
Wigan Athletic (2) vs. Birmingham City (1)
Birmingham City lost to Wigan Athletic 2-1 Saturday in English Premiership action.
Wigan Athletic's goals were scored by T. Cleverley in the 25th minute, and M. Figueroa in the 90th minute.
Birmingham City's goal was scored by L. Ridgewell in the 6th minute.
The combined three goals meant an over play for total bettors who predicted more than 2.5 goals during the match.
Wigan Athletic and Birmingham City were stalemated at 1-1 at the break.
Wigan Athletic's V. Moses in the 52nd minute, A. Alcaraz in the 69th minute, and M. Figueroa in the 86th minute were given cautions by the referee.
Birmingham City's C. Davies in the 73rd minute was given a caution by the referee.


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Results 1 to 1 of 1
11-25-02, 04:14 #1Registered User
- Join Date
- Nov 2002
- Location
- beijing
- Posts
- 3
Unanswered: how can i make all the table integrity
i am a newer of db2
i have a question.
i have a database in aix,about 50 tables
i want to move it to a nt server
but i donot want to move all the data to the nt server,i just want to move some data to the nt server,how can i make the rows integrity in nt
for example.
i have table1,table2,table3,table4
i get a row from t1,and table 2 and table 3 and table 4 are related to table1. how can i get the row from unix server's table2 and insert to table 2 in nt???????????????