text:
US 8034071 B2 Abstract A cavity creating device having a cavity creating axis is introduced through a percutaneous access path into a cancellous bone volume, e.g., within a vertebral body. The cavity creating device is manipulated to form a cavity in the cancellous bone volume. The manipulation includes deflecting the cavity creating device along the cavity creating axis relative to the axis of the access path. A material, such as bone cement, can be conveyed into the cavity.
Claims(50) 1. A method for treating an interior body region having a bone wall, the method comprising:
accessing the interior body region with a therapeutic device along a first axis, the therapeutic device including
a catheter tube and
an expandable structure, having a collapsed geometry and an expanded geometry, and including an interior lumen extending through the expandable structure and sized to accommodate passage of an elongated member for directing the expandable structure;
directing the interior lumen along the first axis;
expanding the expandable structure from the collapsed geometry to the expanded geometry within the interior body region; and
moving at least a portion of the bone wall with a force applied by the expandable structure in its expanded geometry.
2. The method of
3. The method of
4. The method of
5. The method of
6. The method of
removing the expandable structure from the interior body region; and
introducing a fluid material into the interior body region.
7. The method of
removing the expandable structure from the interior body region; and
introducing a therapeutic substance into the interior body region.
8. The method of
9. The method of
10. The method of
11. The method of
12. The method of
13. The method of
14. The method of
15. The method of
16. The method of
17. The method of
18. The method of
19. The method of
20. The method of
21. The method of
22. A method for treating an interior body region enclosed, at least in part, by a bone wall, the method comprising:
inserting a catheter tube into the interior body region along a first axis;
inserting a bone manipulation device through the catheter tube, the bone manipulation device including an inflatable chamber and an interior lumen extending through the inflatable chamber;
directing the orientation of the inflatable chamber within the interior body region with an elongated member extended within the interior lumen of the inflatable chamber;
inflating the inflatable chamber; and
displacing at least a portion of the cortical bone wall with a force applied by the inflatable chamber.
23. The method of
24. The method of
25. The method of
removing the bone manipulation device from the interior body region; and
introducing a fluid material into the interior body region.
26. The method of
removing the bone manipulation device from the interior body region; and
introducing a therapeutic substance into the interior body region.
27. The method of
28. The method of
29. The method of
30. The method of
31. A method for treating an interior body region having tissue bounded, at least in part, by a bone wall, the method comprising:
inserting an expandable body into the interior body region thereby creating a passage through the tissue, the expandable body comprising an expandable chamber and an internal tube passing through the expandable chamber;
directing the orientation of the internal tube with an elongated member extended within the internal tube;
expanding the expandable body within the interior body region; and
compressing the tissue against the bone wall with a force applied by the expandable body.
32. The method of
33. The method of
34. The method of
35. The method of
36. The method of
37. The method of
38. The method of
removing the expandable body from the passage; and
introducing a fluid material into the interior body region.
39. The method of
removing the expandable body from the passage; and
introducing a therapeutic substance into the interior body region.
40. The method of
41. The method of
42. The method of
43. The method of
44. The method of
45. A method for treating an interior body region enclosed, at least in part, by a bone wall, the method comprising:
accessing the interior body region with a catheter tube;
extending a stiffening member through the catheter tube and into the interior body region;
inserting an expandable body into the interior body region, the expandable body including an interior tube defining an interior lumen sized to receive the stiffening member;
expanding the expandable body within the interior body region;
compressing the tissue against the bone wall with a force applied by the expandable body; and
introducing a therapeutic substance into the interior body region.
46. The method of
47. The method of
48. The method of
49. The method of
50. The method of
Description This application is divisional of U.S. patent application Ser. No. 10/436,551, filed May 13, 2003, now U.S. Pat. No. 7,156,861 which is a divisional of U.S. patent application Ser. No. 09/918,942, filed Jul. 31, 2001 (now U.S. Pat. No. 6,623,505), which is a divisional of U.S. patent application Ser. No. 09/404,662, filed Sep. 23, 1999, now U.S. Pat. No. 6,280,456, which is a divisional of U.S. patent application Ser. No. 08/911,827, filed Aug. 15, 1997, now U.S. Pat. No. 5,972,015, each of which is incorporated herein by reference. The invention relates to expandable structures, which, in use, are deployed in interior body regions of humans and other animals. The deployment of expandable structures into interior body regions is well known. For example, expandable structures, generically called �balloons,� are deployed during angioplasty to open occluded blood vessels. As another example, U.S. Pat. Nos. 4,969,888 and 5,108,404 disclose apparatus and methods the use of expandable structures for the fixation of fractures or other osteoporotic and non-osteoporotic conditions of human and animal bones. Many interior regions of the body, such as the vasculature and interior bone, possess complex, asymmetric geometries. Even if an interior body region is somewhat more symmetric, it may still be difficult to gain access along the natural axis of symmetry. For example, deployment of an expandable structure in the region of branched arteries or veins can place the axis of an expandable structure off-alignment with the axis of the blood vessel which the structure is intended to occupy. As another example, insertion of an expandable structure into bone can require forming an access portal that is not aligned with the natural symmetry of the bone. In these instances, expansion of the structure is not symmetric with respect to the natural axis of the region targeted for treatment. As a result, expansion of the body is not symmetric with respect to the natural axis of the targeted region. It can also be important to maximize the size and surface area of an expandable structure when deployed in an interior body region. Current medical balloons manufactured by molding techniques are designed to be guided into a narrow channel, such as a blood vessel or the fallopian tube, where they are then inflated. In this environment, the diameter of the balloon is critical to its success, but the length is less so. Such balloons only need to be long enough to cross the area of intended use, with few constraints past the effective portion of the inflated balloon. This allows conventional balloons to be constructed in three molded pieces, comprising a cylindrical middle section and two conical ends, bonded to a catheter shaft. As a practical matter, neither the length of the conical end, nor the length of the bond of the balloon to the catheter shaft, affect the function of conventional balloons, and these regions on conventional balloons are often 1 cm in length or more. Indeed, the larger the balloon diameter, the longer the end cone, which creates a tradeoff between maximum effective length and maximum effective diameter. This tradeoff makes optimization of conventional structures problematic in interior structures with defined lengths, such as bone. One aspect of the invention provides a device comprising a shaft having an elongated shaft axis and a proximal end portion and a distal end portion. The elongated shaft is sized and configured for passage through a percutaneous access path into a cancellous bone region. The device also includes a cavity forming structure carried on the distal end of the shaft. The cavity forming device is sized and configured to be manipulated to form a cavity in the cancellous bone region. The cavity forming structure has an elongated cavity forming axis. The device further includes a mechanism for deflecting the cavity forming structure along the elongated cavity forming axis, to shift the elongated cavity forming axis relative to the elongated shaft axis. Another aspect of the invention provides a method that provides a percutaneous access path having an axis into bone having an interior volume occupied, at least in part, by cancellous bone. The method introduces a cavity creating device having a cavity creating axis through the access path into the cancellous bone volume. The method manipulates the cavity creating device to form a cavity in the cancellous bone volume. The manipulation includes deflecting the cavity creating device along the cavity creating axis relative to the axis of the access path. In one embodiment, a material, e.g., bone cement, is introduced into the cavity. In one embodiment, the cavity creating device is also expanded to form the cavity. In one embodiment, bone comprises a vertebral body. Features and advantages of the inventions are set forth in the following Description and Drawings, as well as in the appended Claims. The invention may be embodied in several forms without departing from its spirit or essential characteristics. The scope of the invention is defined in the appended claims, rather than in the specific description preceding them. All embodiments that fall within the meaning and range of equivalency of the claims are therefore intended to be embraced by the claims. The preferred embodiment first describes improved systems and methods that embody features of the invention in the context of treating bones. This is because the new systems and methods are advantageous when used for this purpose. Another preferred embodiment describes the improved systems and methods in the context of relieving constrictions or blockages within branched blood vessels. This is because the vasculature also presents an environment well suited to receive the benefits of the invention. The two environments are described for the purpose of illustration. However, it should be appreciated that the systems and methods as described are not limited to use in the treatment of bones or the vasculature. The systems and methods embodying the invention can be used virtually in any interior body region that presents an asymmetric geometry, or otherwise requires an access path that is not aligned with the natural axis of the region. I. Deployment in Bones The new systems and methods will be first described in the context of the treatment of human vertebra. Of course, other human or animal bone types, e.g., long bones, can be treated in the same or equivalent fashion. As The spinal canal 36 (see U.S. Pat. Nos. 4,969,888 and 5,108,404 disclose apparatus and methods for the fixation of fractures or other conditions of human and other animal bone systems, both osteoporotic and non-osteoporotic. The apparatus and methods employ an expandable structure to compress cancellous bone and provide an interior cavity. The cavity receives a filling material, e.g., bone cement, which hardens and provides renewed interior structural support for cortical bone. The compaction of cancellous bone also exerts interior force upon cortical bone, making it possible to elevate or push broken and compressed bone back to or near its original prefracture, or other desired condition. The distal end 54 carries an expandable structure 56, which Tubular bodies of the type shown in The structure 56 can be inserted into bone in accordance with the teachings of the above described U.S. Pat. Nos. 4,969,888 and 5,108,404. For a vertebral body 26, access into the interior volume 30 can be accomplished, for example, by drilling an access portal 43 through either pedicle 42. This is called a transpedicular approach, which As the conventional structure 56 expands within the interior volume 30 (as Due to these asymmetries, the cavity 68 will not provide optimal support to the middle region MR when filled with bone cement. Since the bone cement volume is not centered about the middle region MR, the capability of the vertebral body 26 to withstand loads is diminished. The asymmetric compaction of cancellous bone 32 in the interior volume 30 may also exert unequal or nonuniform interior forces upon cortical bone 32, making it difficult to elevate or push broken and compressed bone. As As A. Optimal Orientation for Cancellous Bone Compaction In A cavity centered with respect to the middle region MR provides support uniformly across the middle region MR when filled with bone cement. The capability of the vertebral body 26 to withstand loads is thereby enhanced. The symmetric compaction of cancellous bone 32 in the interior volume 30 that a centered cavity provides also exerts more equal and uniform interior forces upon cortical bone 32, to elevate or push broken and compressed bone. As in B. Maximizing Cancellous Bone Compaction Referring back to Due to the geometry shown in The lengths (Lc) of the conical regions 62 and bonded ends 58 relative to the entire length of the structure 56 (L2) are important indications of the overall effectiveness of the structure 56 for compacting cancellous bone. The effective bone compaction length (L1) of any expandable structure having conical end regions, such as structure 56 shown in
where (see
As the foregoing expressions demonstrate, for a given conical angle α, the length Lc of the conical portions 62 will increase with increasing maximum diameter BODYDIA of the middle region 64. Thus, as BODYDIA is increased, to maximize the diameter of the formed cavity, the lengths Lc of the conical portions 62 also increase, thereby reducing the effective length L1 of maximum cancellous bone compaction. The bone compaction effectiveness of an expandable structure of a given maximum diameter increases as L1 and L2 become more equal. The geometry of a conventional tubular structure 56 shown in In the embodiment shown in The structures 70 and 80, shown in Furthermore, as in The catheter tube 98 is dipped or sprayed beforehand with a material 102 that absorbs the selected welding energy, for example, laser energy. The folded-over ends 94 are brought into abutment against the material 102. The welding energy transmitted from an external source through the middle region 92 is absorbed by the material 102. A weld forms, joining the material 102, the folded-over ends 94, and the catheter tube 50. The weld constitutes the bond regions 96. The inverted end regions 94 of the structure 90 achieve an abrupt termination of the structure 90 adjacent the distal end 104 of the catheter tube 98, such that the end regions 94 and the distal catheter tube end 104 are coterminous. The structure 90 possesses a region of maximum structure diameter, for maximum cancellous bone compaction, essentially along its entire length. The structure 90 presents no portion along its length where bone compaction is substantially lessened or no cancellous bone compaction occurs. As Once the bonded regions 116 are formed, the inner catheter tube 120 is moved (see arrow 130 in The double jointed inverted ends 114 of the structure 110 in The outer diameter of the inner catheter tube 304 is likewise smaller than the inner diameter of the outer catheter tube 302. A flow passage 312 is defined by the space between the two catheter tubes 302 and 304. The proximal end 314 of an expandable body 306 is bonded to the distal end 308 of the outer catheter tube 302. The distal end 316 of the expandable body 306 is bonded to the distal end 310 of the inner catheter tube 304. An inflation medium 318 is conveyed into the body 306 through the flow passage 312, causing expansion of the body 306. In Due to the differential selection of materials, the lack of compliance of the outer catheter tube 302 at the proximal body end 314 is counterpoised during expansion of the body 306 against the compliance of the inner catheter tube 304 at the distal body end 316. The different compliance characteristics causes the body 306, during expansion, to increase in length in proportion to its increase in diameter during expansion. By virtue of the more compliant body 306 and inner catheter tube 304, the structure 300 shown in The bond between a given expandable structure and its associated catheter tube can be strengthened by using a CO2 or NdYAG laser to weld the structure and tube materials together. Factors influencing joint strength include energy wave length, energy pulse width, pulse period, head voltage, spot size, rate of rotation, working distance, angle of attack, and material selection. The catheter tube 302 can, at its proximal end, be configured like the tube 50 shown in II. Deployment in the Vasculature The catheter tube 416 is introduced by conventional vascular introducer and, with fluoroscopic monitoring, steered to the targeted region 400 along a guidewire 430 deployed within the first and second vessels 402 and 406. The structure 420 is expanded using a sterile fluid, like saline or a radio-contrast medium. Like the expandable structure 20 shown in As III. Deflection of the Structure In all of the foregoing embodiments, a length of the associated catheter tube extends within the expandable structure. In the embodiments shown in Regardless of the particular construction (see The presence of the stylet 606 serves to keep the structure 604 in the desired distally straightened condition during passage through an associated guide sheath 608 toward the targeted body region 610, as As shown in IV. Material Selection In any of the foregoing embodiments, the material of the expandable structure can be selected according to the therapeutic objectives surrounding its use. For example, materials including vinyl, nylon, polyethylenes, ionomer, polyurethane, and polyethylene tetraphthalate (PET) can be used. The thickness of the structure is typically in the range of 2/1000ths to 25/1000ths of an inch, or other thicknesses that can withstand pressures of up to, for example, 250-500 psi. If desired, the material for the structure can be selected to exhibit generally elastic properties, like latex. Alternatively, the material can be selected to exhibit less elastic properties, like silicone. Using expandable bodies with generally elastic or generally semi-elastic properties, the physician monitors the expansion to assure that over-expansion and wall failure do not occur. Furthermore, expandable bodies with generally elastic or generally semi-elastic properties may require some form of external or internal restraints to assure proper deployment in bone. The use of internal or external restraints in association with expandable bodies used to treat bone is discussed in greater detail in copending U.S. patent application Ser. No. 08/485,394, filed Jun. 7, 1995, which is incorporated herein by reference. Generally speaking, for use in treating bone, providing relatively inelastic properties for the expandable structure, while not always required, is nevertheless preferred, when maintaining a desired shape and size within the bone is important, for example, in a vertebral body, where the spinal cord is nearby. Using relatively inelastic bodies, the shape and size can be better predefined, taking into account the normal dimensions of the outside edge of the cancellous bone. Use of relatively inelastic materials also more readily permits the application of pressures equally in a defined geometry to compress cancellous bone. When treating bone, the choice of the shape and size of an expandable structure takes into account the morphology and geometry of the site to be treated. The shape of the cancellous bone to be compressed, and the local structures that could be harmed if bone were moved inappropriately, are generally understood by medical professionals using textbooks of human skeletal anatomy along with their knowledge of the site and its disease or injury. The physician is also able to select the materials and geometry desired for the structure based upon prior analysis of the morphology of the targeted bone using, for example, plain films, spinous process percussion, or MRI or CRT scanning. The materials and geometry of the structure are selected to optimize the formation of a cavity that, when filled with bone cement, provide support across the middle region of the bone being treated. In some instances, it is desirable, when creating a cavity, to also move or displace the cortical bone to achieve the desired therapeutic result. Such movement is not per se harmful, as that term is used in this Specification, because it is indicated to achieve the desired therapeutic result. By definition, harm results when expansion of the structure results in a worsening of the overall condition of the bone and surrounding anatomic structures, for example, by injury to surrounding tissue or causing a permanent adverse change in bone biomechanics. As one general guideline, the selection of the geometry of the expandable structure should take into account that at least 40% of the cancellous bone volume needs to be compacted in cases where the bone disease causing fracture (or the risk of fracture) is the loss of cancellous bone mass (as in osteoporosis). The preferred range is about 30% to 90% of the cancellous bone volume. Compacting less of the cancellous bone volume can leave too much of the diseased cancellous bone at the treated site. The diseased cancellous bone remains weak and can later collapse, causing fracture, despite treatment. Another general guideline for the selection of the geometry of the expandable structure is the amount that the targeted fractured bone region has been displaced or depressed. The expansion of the structure within the cancellous bone region inside a bone can elevate or push the fractured cortical wall back to or near its anatomic position occupied before fracture occurred. However, there are times when a lesser amount of cancellous bone compaction is indicated. For example, when the bone disease being treated is localized, such as in avascular necrosis, or where local loss of blood supply is killing bone in a limited area, the expandable structure can compact a smaller volume of total bone. This is because the diseased area requiring treatment is smaller. Another exception lies in the use of an expandable structure to improve insertion of solid materials in defined shapes, like hydroxyapatite and components in total joint replacement. In these cases, the structure shape and size is defined by the shape and size of the material being inserted. Yet another exception lays the use of expandable bodies in bones to create cavities to aid in the delivery of therapeutic substances, as disclosed in copending U.S. patent application Ser. No. 08/485,394, previously mentioned. In this case, the cancellous bone may or may not be diseased or adversely affected. Healthy cancellous bone can be sacrificed by significant compaction to improve the delivery of a drug or growth factor which has an important therapeutic purpose. In this application, the size of the expandable structure is chosen by the desired amount of therapeutic substance, sought to be delivered. In this case, the bone with the drug inside is supported while the drug works, and the bone heals through exterior casting or current interior or exterior fixation devices. The materials for the catheter tube are selected to facilitate advancement of the expandable structure into cancellous bone. The catheter tube can be constructed, for example, using standard flexible, medical grade plastic materials, like vinyl, nylon, polyethylenes, ionomer, polyurethane, and polyethylene tetraphthalate (PET). The catheter tube can also include more rigid materials to impart greater stiffness and thereby aid in its manipulation. More rigid materials that can be used for this purpose include stainless steel, nickel-titanium alloys (Nitinol� material), and other metal alloys. V. Single Use Expansion of any one of the expandable structures described herein during first use in a targeted body region generates stress on the material or materials which make up the structure. The material stress created by operational loads during first use in a targeted body region can significantly alter the molded morphology of the structure, making future performance of the structure unpredictable. For example, expansion within bone during a single use creates contact with surrounding cortical and cancellous bone. This contact can damage the structure, creating localized regions of weakness, which may escape detection. The existence of localized regions of weakness can unpredictably cause overall structural failure during a subsequent use. In addition, exposure to blood and tissue during a single use can entrap biological components on or within the structure or the associated catheter tube. Despite cleaning and subsequent sterilization, the presence of entrapped biological components can lead to unacceptable pyrogenic reactions. As a result, following first use, the structure can not be relied upon to reach its desired configuration during subsequent use and may not otherwise meet established performance and sterilization specifications. The effects of material stress and damage caused during a single use, coupled with the possibility of pyrogen reactions even after resterilization, reasonably justify imposing a single use restriction upon devices which carry these expandable structures for deployment in bone. To protect patients from the potential adverse consequences occasioned by multiple use, which include disease transmission, or material stress and instability, or decreased or unpredictable performance, the invention also provides a kit 500 (see In the illustrated embodiment (see The kit 500 includes an inner wrap 512, which is peripherally sealed by heat or the like, to enclose the tray 508 from contact with the outside environment. One end of the inner wrap 512 includes a conventional peal-away seal 514 (see The kit 500 also includes an outer wrap 516, which is also peripherally sealed by heat or the like, to enclosed the inner wrap 512. One end of the outer wrap 516 includes a conventional peal-away seal 518 (see Both inner and outer wraps 512 and 516 (see The sterile kit 500 also carries a label or insert 506, which includes the statement �For Single Patient Use Only� (or comparable language) to affirmatively caution against reuse of the contents of the kit 500. The label 506 also preferably affirmatively instructs against resterilization of the probe 502. The label 506 also preferably instructs the physician or user to dispose of the probe 502 and the entire contents of the kit 500 upon use in accordance with applicable biological waste procedures. The presence of the probe 502 packaged in the kit 500 verifies to the physician or user that probe 502 is sterile and has not be subjected to prior use. The physician or user is thereby assured that the expandable structure 504 meets established performance and sterility specifications, and will have the desired configuration when expanded for use. The features of the invention are set forth in the following claims. Patent Citations
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Whitstable Produce Store
33 Harbour Street Whitstable Kent CT5 1AJ
Runner-up: Observer Food Monthly Awards 2014 and Kent Independent Trader Awards 2014. Finalist: Taste of Kent Awards 2014; Kent Life and Kent on Sunday Food and Drink Awards 2014. Nominated Taste of Kent Awards 2015.
We sell great food and drink from over twenty independent Kent makers and suppliers in our Grade 2 listed Georgian Store. Kentinental breakfast (a Continental breakfast with a twist - it's locally sourced); light lunches, handmade cakes and bakes are all available to eat in or take away plus freshly-pressed juices, pure-fruit smoothies, locally-roasted and blended coffee and Kentish wine and craft beers.
Courtyard garden. Baby-change. Wi-Fi.
We also have a holiday flat (sleeps 2) on the first floor with private off-street parking.
Find us on twitter and facebook @Whitproduce

subset: commoncrawl


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Planning Server Deployments
Updated: March 28, 2003
Applies To: Windows Server 2003, Windows Server 2003 R2, Windows Server 2003 with SP1, Windows Server 2003 with SP2
Welcome to Planning Server Deployments of the Microsoft Windows Server 2003 Deployment Kit.
This book provides comprehensive information about planning server storage and designing and deploying file servers, print servers, and terminal servers in medium and large organizations. You can also use the guidelines in this book to maximize the availability and scalability of your servers by planning for remote server management, designing and deploying server clusters, and designing and deploying Network Load Balancing clusters.
This book contains the following chapters:
Designing and Deploying File Servers
Designing and Deploying Print Servers
Hosting Applications with Terminal Server
Planning for Remote Server Management
Planning for High Availability and Scalability
Designing and Deploying Server Clusters


text:
For more information on KPFA's archiving policy go here: Learn More.
"Guns & Butter" investigates the relationships among capitalism, militarism and politics. Maintaining a radical perspective in the aftermath of the September 11th attacks, "Guns & Butter: The Economics of Politics" reports on who wins and who loses when the economic resources of civil society are diverted toward global corporatization, war, and the furtherance of a national security state.
Produced and hosted by Bonnie Faulkner.
E-mail Bonnie at email@example.com
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Here's a quickie tutorial I put together on how to effectively hide knots and make your closed seams pretty!
Step 1:
Tuck in your seam allowance.
Step 2:
Use a ladder stitch to close the seam. When you tug the thread the stitches disappear!
Step 4:
When you finish closing your seam knot your thread and place the needle into the same place your thread came out.
Step 5:
Push the needle through to the other side and gently tug the thread until you hear the knot pop through. You've successfully hidden your knot!
Step 6:
If you're using minky, take a needle and carefully brush the fur out of the seam. When you're finished you should have a nice pretty seam that's barely visible!


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POPSUGAR Celebrity POPSUGAR Celebrity AFI Lifetime Achievement Awards by Celebrity 6/12/09 0 Shares Like us on Facebook Previous Photo 1 of 71 View on One Page ADVERTISEMENT ( more slides) Next Share This Link Copy 1 AFI Lifetime Achievement Awards Previous Photo 1 of 71 View on One Page ADVERTISEMENT ( more slides) Next Get the scoop with our daily newsletter Enjoy the latest news on the celebs you love. A Listers TV Young Hollywood Movies Sign up with 5 years It is a sure thing that the actors and actresses are as beautiful as picture made from heaven. God Bless and I extend the same admiration to the children. They are just beautiful. Thanks to the stars for sharing with me. Link Love India didn't even like the edited version of Fifty Shades — Us Weekly This Clueless star was almost cast in Titanic — HuffPost Celebrity Find out about Nicholas Hoult's latest project — Lainey Gossip Which star was Cupid for Kristen Bell and Dax Shepard? — Dlisted Demi Lovato talks about a possible Eminem collaboration — ET Rosie Huntington-Whiteley is well aware of her privilege — JustJared Eva Longoria is still in magnificent shape — Hollywood Tuna Guess which celebrity quit Instagram? — Pink Is the New Blog Chelsea Handler did not get a breast lift, OK? — The Superficial Latest Celebrity
Kelly Clarkson Responded To Criticism Of Her Weight In The Best Way Possible BuzzFeed Celebrity 26.4K Shares
Jared Leto Goes Platinum at the Same Event Kim Kardashian Debuted Her Blonde Hair: See the Dramatic Makeover! Us Weekly 4.5K Shares


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Alan Wake's new nightmare isn't all that it seems
It's hard to imagine many games that I would want less gameplay but more story involvement in, but if you've been following Remedy games for a while, you know that their penchant for gritty near-noir type settings and dark, imperfect protagonists is best-in-class. The combat always just feels a bit off, even for the people who made bullet time such a popular concept.
The next chapter in Alan Wake's saga is more combat than maybe fans of the first game might want, but is ultimately worth it to see the excellent story and little details put into the characters. Remedy leans hard into the Night Springs pseudo-TV show setting this go-around, leaving a delightfully bizarre and macabre atmosphere. The writing and voice acting is great and makes you feel like you are really experiencing a Twilight Zone reboot, more than just an homage the first Alan Wake paid tribute to.
This time, Wake is up against Mr. Scratch, a much better foil and sinister villain then the simple Dark Presence of the first game. And it picks up in Arizona two years after Wake's last adventure. Without spoiling much, old characters pop up in some surprising ways in American Nightmare and Wake's new friends in this small adventure, though minor, really feel fleshed out.
Unfortunately, the rest of the game seems kind of half-baked. It is all over too soon, the "Oh Snap!" moment is ruined by recycled environments and scenarios, the weapons lack a lot of punch, the enemies aren't that challenging (largely because there is tons of ammo lying around), and manuscript pages, the one collectible worth collecting from the last game, have became this game's great Thermos hunt - by searching for these tidbits of extra story designed to get you deeper into the story, the game forces you to go too far off the beaten path and sucks you right out of the narrative. At least they have made it easier to track these things by adding question marks to the minimap and making them gleam brightly. If you're not so much into the story elements of these collectibles, they also serve as the keys to getting new weapons scattered in briefcases over the course of the game.
For a downloadable title, the game does look great despite the reusing of some assets. I ran into some framerate stuttering during part 2 of American Nightmare with lots of Taken surrounding me, so be mindful of that.
After the roughly 3-hour campaign, there's Arcade Action - a Horde Mode-type survival mode that feels a little tacked-on. You get 10 minutes to try and survive the night against a bevy of Taken with your flashlight and weapons found nearby, but without the context of the larger story, it just serves to remind you how mundane the combat can be. There's leaderboards and half of the game's achievements are devoted to it, but no online multiplayer/co-op. This isn't a big deal (four dudes with flashlights and guns seems a little ridiculous, given Alan Wake's central conceit), but the inclusion of Arcade Mode has me worried Remedy may try to put multiplayer in Alan Wake 2.
The campaign is substantial enough and absolutely worth seeing for Alan Wake fans, but this is not a good jumping point for newcomers. The Arcade mode isn't as addicting as the plot thread in Alan Wake and even if you're here for the combat, the challenge just isn't there with the ludicrous amount of ammo the developers give you. All told, much like Dead Rising 2: Case Zero, American Nightmare is a nice appetizer for the next part of Wake's saga that leaves you wanting more.


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After searching around for all the ingredients I needed (the honey was the hardest to find -- go figure), I finally got everything I required last week to start brewing my first mead. On Saturday, I had cobbled together a basic recipe, which I hope will work out in the end. My ingredients list: 9L of bottled spring water 3kg of clover honey 5 cinnamon sticks 5 Campden tablets 3 tsp. of yeast nutrient 1 packet of Lalvin 71B-1122 wine yeast (recommended by the guy in one of the local make-your-own-wine stores -- I couldn't find any D47) After cleaning and sterilizing, I poured the water into my brew pot and heated until it was boiling. Then I took it off the heat and poured in the 3kg of clover honey, stirring it into the water. Then I put it back on the stove and brought it back up to a boil. I had just purchased some cinnamon sticks for a winter/Christmas ale I plan to make, so once the mix was boiling, I threw in a few. I thought two or three would be too few, so I tossed in five. Within ten minutes, I was barely smelling the honey anymore. The cinnamon smell was overpowering. I boiled it all for 45 minutes, stirring frequently and occasionally skimming the foam off the top and discarding it. After 30 minutes of boiling, I fished three of the cinnamon sticks out (I was worried it would end up too cinnamony). Then I cooled it all and let it sit until it got to room temperature. I added five Campden tablets, as I was a bit concerned that maybe there would still be some unwanted bacteria. This is the part of the process I'm most worried about, as I only barely understand the purpose of the Campden tablets (having never made wine). I poured everything into a carboy and let it sit over night (I can only hope enough oxygen got back into the mix). The next afternoon (yesterday), I prepared the packet of yeast and 3tsp of yeast nutrient, and then pitched it into the mix. I put the airlock in place and moved the carboy to the storage room in my basement. It doesn't look like the fermentation has kicked in yet, and I'm worried I made a mistake somewhere that will ruin my batch. How long does it usually take before I start seeing fermentation activity? Granted, it hasn't even been 24 hours yet, but I'm a worrying sort. Chris
that's too much boiling. you pretty much destroyed the honey aromas. also, the cinnamon flavor might get killed by the yeast. generally its 'safer' to add spices or fruit in the secondary stage, so the yeast doesn't have a strong interaction. luckily you can easily make a spice 'tea' at secondary to add as much cinnamon flavor as you like, if its lacking. as far as the boiling of honey goes, you can do it the way you did to remove some of the proteins, but at the expense of aroma and flavor. otherwise, get the water just boiling, then kill the heat and dissolve the honey into the hot water, which pasteurizes it and doesn't kill as much aroma. some just add raw honey to the fermenter, and sterile water. my first mead/cyser was done like that, and it was fine. I didn't age it long enough so it had a 'lighter fluid' twang to it.
Too much boiling? Oops. Oh well. I'll know better for next time, at which point I'll try what you suggested. If I want to add cinnamon again in secondary, what would be the best way to do it? By "spice tea," do you mean to boil cinnamon in water and then add the water to the secondary? Thanks for the comments and tips, by the way. Chris
do some searching, you can use campden tabs to 'sanitize' the day before you pitch yeast. oops I see you already did that...so really boiling and campden was double duty. and yes, I do mean simply steeping spices in a small amount of hot water, then putting that into the secondary a little at a time, with gentle stirring and tasting. I've boiled my honey before too, not for that long, but long enough to get the proteins to foam up and get skimmed off. the cinnamon would have masked some of the honey aroma anyways. and you can always feed more honey later if its too dry after primary ends.
Thanks again for the helpful tips, malklore and Moonpile. I'm starting to get a little worried I screwed up the batch, as it doesn't appear to be doing anything. By this point, shouldn't it be bubbling a bit due to fermentation -- or something? (With beer, I use pails, so I'm not really sure what it should look like.) Chris
I don't really know much about Campden tablets, but I'm wondering if they hadn't dissipated or whatever it is they do and they just killed the yeast you put in there? Maybe someone else who has used Campden can comment on that? Whether or not that's the case, pitching more yeast is probably not a bad idea.
Honestly, I'd check out some of the sources on nutrients. Hightest's Page is a good starting point. Look at his "Making a Basic Mead" and "Staggered Nutrient Additions (SNA)" articles, though frankly, I have yet to try SNA since I brew at a friend's house and he probably doesn't want to obsessively check over it. I've used Fermax, adding 5 tsp to a mead and 2.5 tsp to a cyser. Fermax is not one of the one's Hightest discusses however, and frankly I don't know what's in it. I was told by the LHBS where I bought it to use 1 tsp per gallon, and so I did. I used less in the cyser, because I was told that apple juice has some of the nutrients that honey alone lacks, though the cyser fermentation was by far my slowest so far (big cake of Wyeast 3068). The mead with 5tsp in 5 gal fermented to dryness in 3 weeks with Cotes de Rhone yeast. EDIT: oh, and don't worry. As long as you get that fermentation started you'll be fine, boil or no boil, nutrients or no nutrients. I'd ask your LHBS about the Campden tablets issue or hope someone who know's of what they speak with regards to them sees this thread.
A bit of reading suggests that the Campden tablets can slow up the start of yeast fermentation, and since I apparently didn't use them entirely properly (it looks like they're supposed to be crushed before added ), that could very well be the reason it's so slow to start. I'm going to give it another couple of days and see what happens. I'll check out those links and do more reading on mead-making, though. Thanks again. Chris


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With 567,000 miles on it, Rachel Veitch's 1964 Mercury Comet Caliente has been all over the U.S., from California and Michigan to Texas and Pennsylvania.
It isn't headed for a spot in the Guinness World Records — that honor belongs to Irv Gordon and his 3-million-mile 1966 Volvo P1800 — but Veitch's Comet has won car show awards — and it owns the heart of its Orlando, Fla. owner.
Veitch, 93, said she never believed the misty-yellow car nicknamed "Chariot" could bring her so much joy, despite the 18 batteries, eight mufflers and endless oil changes over the years.
"She's survived three husbands," she told ABC News today. "She's never lied to me. She's never cheated on me. I could always depend on her. She's American-made. She's solid steel. … This is my ship."
At 48 years old, the car is still purring along nicely, but Veitch opted to end her driving days in March after becoming legally blind due to macular degeneration.
While Chariot's mileage is extreme, automobile experts say most modern cars should easily go as many as 200,000 miles or more.
David Champion, the director of Automobile Testing for Consumer Reports, says high mileage is a credit to the "engine technology and material technology that goes into cars."
But as you might expect, drivers who want their vehicles to rack up the miles and keep on running have to do their part too.
"Really, what you need to do is make sure you keep up with all the scheduled maintenance," Champion told ABC News. "Go by the owner's manual of the vehicle. It will tell you exactly what needs to be done at particular miles and don't skip."
"Make sure you service the car with good quality parts," he added. And between the scheduled maintenance appointments, keep an eye on your car as well.
"You don't have to be an expert," he said. "If you look under the hood, if you see anything that looks weird from the last time you looked at it, it probably needs attention."
Champion also suggested driving like there's a baby sleeping in the back seat.
"The gentler you drive, the less strain you are putting on the engine, the transmission, the suspension parts, the brakes,' he said. "You will get much better fuel economy and maintenance costs will be less and the car will last longer."
All advice that Jason Kavanagh, the engineering editor for the automotive website Edmunds.com, agrees with.
"The single most important thing is to change your oil and filter frequently," he said.
His final piece of advice: "I think the first thing you want to do is you want to make sure it is a car you like. You are going to be spending a lot of time in that car."
The make of your car can also make the difference. Historically, Consumer Reports has found Honda, Toyota and Subaru vehicles are among the most reliable. But U.S. automakers have greatly improved the reliability of their vehicles too.
With the economy in a slump, Americans have been holding onto their cars longer. The Polk research firm found in 2011 that the average age of vehicles on the road was 10.8 years.
Veitch said today that she doesn't feel sad about not driving her Chariot anymore.
It will head to another Florida car show Saturday, but with one of Veitch's relatives behind the wheel.
ABC News' Enjoli Francis contributed to this story.


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Rule 8012. Oral Argument
Oral argument shall be allowed in all cases unless the district judge or the judges of the bankruptcy appellate panel unanimously determine after examination of the briefs and record, or appendix to the brief, that oral argument is not needed. Any party shall have an opportunity to file a statement setting forth the reason why oral argument should be allowed.
Oral argument will not be allowed if
the facts and legal arguments are adequately presented in the briefs and record and the decisional process would not be significantly aided by oral argument.
LII has no control over and does not endorse any external Internet site that contains links to or references LII.


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Queen: Greatest Video Hits
Posted in Disc Reviews by John Ceballos on November 7th, 2012
Please put down the torches. The mediocre rating you see attached to this review is in no way an indictment of Queen, one of rock history's most iconic bands fronted by, arguably, the best male vocalist of all time. No, this mediocre rating is specific to this two-disc DVD collection of Freddy Mercury and Co's music video oeuvre.
Read the rest of this entry »


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by Brandon Wise | CBSSports.com
Barnes suffered a right hamstring injury in Sunday's win, leaving his status for Monday in doubt. The veteran is averaging 9.7 points and 4.0 rebounds in 57 games this season.
The Clippers are currently 8 1/2-point favorites Monday.
by Brandon Wise | CBSSports.com
He was walked out off the floor with a team doctor and headed straight to the locker room.Covington will not return to the game after suffering a right elbow contusion, the team announced. Covington scored 12 points on 5 of 11 shooting with three rebounds before leaving the game.
by Shawn Krest | CBSSports.com
Thompson had 14 points on five-of-nine shooting. He also grabbed a season-high 19 rebounds, including 11 on the offensive end.
Thompson came up big in the fourth quarter, scoring eight points and gathering 10 boards. He scored the final points of regulation, tying the game at the free throw line with 1:09 left.
The Cavaliers next host the Celtics on Tuesday.
by Shawn Krest | CBSSports.com
Jones hit six of 10 from the field and six of nine from the line. The game came on the heels of a 26-point, 12-rebound outing on Friday.
For the weekend, Jones shot 17-of-26 (.654). He now has five straight double-digit games as he continues rounding into form after missing three months with a nerve problem in his leg.
The Rockets next play at the Hawks on Tuesday.
by Shawn Krest | CBSSports.com
James took a personal season-high 35 shots, hitting 15. However he shot better from the 3-point line (four-of-12) than the free-throw line (three-of-11).
With 4.2 seconds remaining, and the Cavaliers trailing 104-103, James went to the free-throw line. He missed both, however, allowing the Rockets to hold on.
"The guys put us in position to win, and I didn't come through for them," James said.
James also had eight rebounds, four assists, three blocks and three steals, posting better numbers than fellow MVP candidate James Harden. He was also on the receiving end of a Harden kick that was whistled for a flagrant foul late in the third quarter.
The Cavs next host the Celtics on Tuesday.
by Shawn Krest | CBSSports.com
Harden scored 33 points with eight rebounds and five assists. He also had three steals and a pair of blocked shots.
Harden shot eight-of-18 from the field and hit 15-of-18 from the free throw line. He also picked up a flagrant foul late in the third quarter for kicking LeBron James.
"Obviously it was not a basketball play, and obviously, the league will take a look at it," James said. "I don't know what he was thinking."
The Rockets next play at the Hawks on Tuesday.
by Shawn Krest | CBSSports.com
Kanter was questionable after missing Friday's game with a thigh injury, but he was in the team's starting lineup for Sunday's game.
by Shawn Krest | CBSSports.com
Prior to the Sixers' game at the Pacers on Sunday, McGee told Keith Pompey of the Philadelphia Inquirer that he doesn't want a buyout and doesn't know about any ongoing negotiations.
"Not on my part, it's not true," McGee said."They might be talking to somebody. But the people I talked to, I haven't [heard anything]. And I know nothing about it. ... I hope it's false."
by Shawn Krest | CBSSports.com
Miles was replaced in the lineup by Damjan Rudez. Miles remained in the locker room at the start of the game, getting treatment for a sore foot. He may still play in the game.
by Shawn Krest | CBSSports.com
It will be the second-straight game that Arthur has missed with a calf injury.
The Nuggets are 4.5-point underdogs at home.


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Intelligent Design 101
What Is Intelligent Design?
FAQs About Intelligent Design
States are weighing whether their public schools should teach intelligent design alongside Darwin's theories. What is ID all about?
The Controversy: Pros and Cons
Evolution of a Thought
What we can learn from what separates humans from ants, bugs, bears, and snakes. By Rabbi Avi Shafran
The Science Community's Myopia Over Intelligent Design
Far from being incompatible with intelligent design, evolutionary biology makes no sense except in light of ID. By William A. Dembski
What Intelligent Design Is--And Isn't
Every scientific advance offers stronger evidence for intelligent design, says Jay W. Richards
"Overwhelming Evidence" for Design
The physical world is the product of intelligence and not simply the result of mindless material forces. By William A. Dembski
The Case for a Creator
Random, undirected evolution is incompatible with Christianity, says Lee Strobel
Finding God in the Questions


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Bay Area Food Banks Are Seeing The New Face Of Hunger
A record number of Americans can't afford to put enough food on the table to feed their families. And a surprising number of them are suburban, middle class, and employed. It's what's known as the "new hungry," and it's become a disturbing trend in the Bay Area.
Bay Area Nutritionists Support New School Lunch Guidelines
It's being called an aggressive step in fighting the nation's childhood obesity epidemic: new federal guidelines that will cut the "junk" out of our school cafeterias.
Nutrition Bill Designed To Help Bay Area Lunch Programs
A federal child nutrition bill, that's designed to remove greasy foods and sugary drinks from school cafeterias, is expected to help Bay Area school districts in adopting stricter lunch programs.
San Francisco Bans Toys In Fast Food Kids Meals
San Francisco is the first major American city to prohibit fast-food restaurants from including toys with children's meals that don't meet nutritional guidelines.
HealthWatch: Some Condiments May Aid Your Diet
Condiments, the ingredients that give a flavor boost to your foods, may also give your body a boost.
SF Kids Eating Better
SAN FRANCISCO (KCBS) _ Students at San Francisco schools are showing marked improvements when it comes to eating healthy, thanks to the district's nutritional program.


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There are still no data or no evaluable data available on mortality, quality of life and potential harm.
As the screening strategies applied in the studies varied greatly and could therefore not be compared with each other, the results still do not allow a recommendation for a specific screening strategy in the German health care system.
Process of report production
The Federal Joint Committee (G-BA) commissioned IQWiG to prepare the report in an accelerated process, known as a "rapid report". Unlike the normal procedure, no preliminary reports are published in this case. Although a draft version of the report is reviewed by external experts, no hearing at which all interested parties can comment takes place.
IQWiG sent the first benefit assessment to the commissioning agency in November 2011 and published it in January 2012. In October, the G-BA commissioned IQWiG to update its report using the same methodological approach. The present report was sent to the G-BA in mid-May 2014.
Contact: Dr. Anna-Sabine Ernst email@example.com 49-022-135-6850 Institute for Quality and Efficiency in Health Care Source:Eurekalert |