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US 7081095 B2 Abstract A system and method for the automatic diagnosis of obstructive sleep apnea in a centralized hospital critical care monitoring system for the monitoring of a plurality of patients in at least one of a critical care, step down, and cardiac ward by telemetry. The system includes a central processor having a display, and a plurality of telemetry units for mounting with patients, each of the telemetry units has a plurality of sensors for connection with each patient, the telemetry unit is capable of the transmission of multiple signals derived from the sensors to the central processor, in one preferred embodiment the method comprising steps of programming the system to analyze the signals and to automatically identify the presence and severity of obstructive sleep apnea and to provide an indication of the identification.
Claims(7) 1. A method for the automatic detection of obstructive sleep apnea in a centralized hospital critical care monitoring system for the monitoring by telemetry of a plurality of patients in at least one of a critical care ward and a hospital ward, the system including a central processor having a display, and a plurality of telemetry units for mounting with said patients, each of said telemetry units having a plurality of sensors for connection with each said patient, each of said telemetry units transmitting a plurality of signals to said central processor, the method comprising the steps of:
a) programming said system to analyze said signals and to-automatically identify at least one of the presence and severity of obstructive sleep apnea,
b) programming said system to output an indication of said identified obstructive sleep apnea; and
c) programming said system to communicate with an intravenous infusion system to prevent the progression of said identified obstructive sleep apnea by limiting infusion of a narcotic.
2. A method for providing automatic detection of upper airway instability in hospitalized patients who are being otherwise routinely monitored with a centralized hospital monitoring system, in at least one of an acute care environment or a surgical hospital environment, so that the routine monitoring provides automatic screening for upper airway instability, the method comprising the steps of:
a) programming said centralized system to automatically identify the presence of upper airway instability;
b) programming said centralized system to output an indication of said identified upper airway instability; and
c) programming said centralized system to communicate with an intravenous infusion system to prevent the progression of said identified upper airway instability by limiting infusion of a narcotic.
3. The method of
a) programming said centralized system to automatically identify the presence of obstructive sleep apnea; and
b) outputting an indication of said identified obstructive sleep apnea.
4. The method of
programming said centralized system to provide a graded indication based on said identified upper airway instability.
5. The method of
programming said centralized system to communicate with a system for intravenously infusing a medication.
6. The method of
programming said centralized system to communicate with an airway pressure delivery system for treatment of airway instability.
7. A method for facilitating case finding of obstructive sleep apnea in hospitalized patients who are being otherwise routinely monitored with a centralized hospital monitoring system in at least one of an acute care environment, a sub acute care environment and a surgical hospital environment, the method comprising:
a) programming said centralized system to provide a printed output that is formatted to optimize the visual detection of patterns indicative of the presence of obstructive sleep apnea disease, so that routine hospital monitoring renders printed outputs that can be readily interpreted to routinely detect the presence of obstructive sleep apnea disease; and
b) programming said centralized system to communicate with an intravenous infusion system to reduce the progression of an identified upper airway instability by limiting the infusion of a narcotic.
Description This application claims priority of provisional applications U.S. Ser. Nos. 60/291,691 and 60/291,687, both filed 17 May 2001 and provisional application U.S. Ser. No. 60/295,484, filed 1 Jun. 2001, the disclosures and contents of each of which is incorporated by reference as if completely disclosed herein. This invention relates to centralized hospital monitoring systems and particular to the organization, analysis, and automatic detection of patterns indicative of upper airway instability during sleep, deep sedation, and analgesia. The high number of unnecessary deaths in the hospital due to errors related to pharmaceutical administration such as sedative and narcotics has been a recent focus of US government studies and much discussion in the literature and press. The present inventors recognized that these adverse events occur not only due to improper dosage of medications or the administration of drug to the wrong patient, as has been recently highlighted in the medical literature and press, but also due to failure to recognize complex patterns along monitored outputs (such as those shown in In hospitals, throughout the United States monitored patients are experiencing profound physiologic instability before and during medication infusion producing patterns as shown in A major factor in the development of respiratory failure (one of the most common causes of death in the hospital) is airway instability, which results in airway collapse during sedation, stroke, narcotic administration, or stupor. As illustrated in This failure of conventional hospital based patient monitors to timely and/or automatically detect cluster patterns indicative of airway instability can be seen as a major health care deficiency indicative of a long unsatisfied need. Because obstructive sleep apnea, a condition derived from airway instability, is so common, the consequence of the failure of conventional hospital monitors to routinely recognize upper airway instability clusters means that many of patients with this disorder will never be diagnosed in their lifetime. For these patients, the diagnostic opportunity was missed and the health implications and risk of complications associated with undiagnosed airway instability and sleep apnea will persist in this group throughout the rest of their life. A second group of patients will have a complication in the hospital due to the failure to timely recognize airway instability. Without recognition of the inherent instability, a patient may be extubated too early after surgery or given too much narcotic (the right drug, the right patient, the ordered dose but unknowingly a �relative drug excess�). Indeed until clusters indicative of airway instability are routinely recognized by hospital monitors, the true incidence of respiratory failure, arrest, and/or death related to the administration of IV sedation and narcotics to patients in the hospital with airway instability will never be known but the number is probably in the tens of thousands each year and airway instability is just one example of the types of physiologic instability which are not automatically characterized by central hospital systems. To understand the criticality of recognizing airway instability in real-time it is important to consider the significance of the combined effect that oxygen therapy and narcotics or sedation may have in the patient care environment in the hospital, for example, in the management of a post-operative obese patient after upper abdominal surgery. Such a patient may be at particular risk for increased airway instability in association with narcotic therapy in the through 3rd post-operative day due to sleep deprivation, airway edema, and sedation. Furthermore, in the second and third postoperative day monitoring the vigilance of hospital personnel may diminish due to perceived stability, and rebound rapid eye movement (REM) sleep which can increase upper airway instability may occur due to antecedent sleep deprivation. Indeed, many of these patients have significant sleep apnea prior to admission to the hospital which is unknown to the surgeon or the anesthesiologist due to the subtly of symptoms. Such patients, even with severe sleep apnea, are relatively safe at home because of an intact arousal response; however, in the hospital, narcotics and sedatives often remove this �safety net. The administration of post-operative narcotics can shift the arousal curve to the right and this can significantly increase the danger of airway instability and, therefore, place the patient at substantial risk. Many of these patients are placed on electrocardiographic monitoring but the alarms are generally set at high and low limits. Hypoxemia, induced by airway instability generally does not generally produce marked levels of tachycardia; therefore, airway instability is poorly identified by simple electrocardiographic monitoring without the identification of specific pattern of clusters of the pulse rate. In addition, simple oximetry evaluation is also a poor method to identify airway instability. Conventional hospital oximeters often have averaging intervals, which attenuate the dynamic desaturations. Even when the clustered desaturations occur they are often thought to represent false alarms because they are brief. When desaturations are recognized as potentially real this often results in the simple and often misguided addition of nasal oxygen. However, nasal oxygen may prolong the apneas and potentially increase functional airway instability. From a monitoring perspective, the addition of oxygen therapy can be seen to potentially hide the presence of significant airway instability by attenuation of the level of desaturation and reduction in the effectiveness of the oximeter as a monitoring tool in the diagnosis of this disorder. Oxygen and sedatives can be seen as a deadly combination in patients with severely unstable airways since the sedatives increase the apneas and the oxygen hides them from the oximeter. For all these reasons, as will be shown, according to the present invention, it is critical to monitor patients with increased risk of airway instability for the specific monomorphic and polymorphic cluster patterns as will be discussed, during the administration of narcotics or sedatives. Having identified, supra, the long and critical need, a discussion of the background physiology of upper airway instability will first be provided. The central drive to breath, which is suppressed by sedatives or narcotics, basically controls two critical muscle groups. The upper airway �dilator muscles� and the diaphragm �pump muscles�. The tone of both these muscle groups must be coordinated. A fall in afferent output from the brain controller to the airway dilators results in upper airway collapse. Alternatively, a fall in afferent output to the pump muscles causes hypoventilation. Two major factors contribute to respiratory arrest in the presence of narcotic administration and sedation. The first and most traditionally considered potential effect of narcotics or sedation is the suppression by the narcotic or sedative of the brains afferent output to pump muscle such as the diaphragm and chest wall, resulting in inadequate tidal volume and associated fall in minute ventilation and a progressive rise in carbon dioxide levels. The rise in carbon dioxide levels causes further suppression of the arousal response, therefore, potentially causing respiratory arrest. This first cause of respiratory arrest associated with sedation or narcotics has been the primary focus of previous efforts to monitor patients postoperatively for the purpose of minimization of respiratory arrests. Both oximetry and tidal CO2 monitoring have been used to attempt to identify and prevent this development. However, in the presence of oxygen administration, oximetry is a poor indicator of ventilation. In addition, patients may have a combined cause of ventilation failure induce by the presence of both upper airway instability and decreased diaphragm output as will be discussed, this complicates the output patterns of CO2 monitors making recognition of evolving respiratory failure due to hypoventilation more difficult for conventional threshold alarm based systems. The second factor causing respiratory arrest due to narcotics or sedatives relates to depression of the brains afferent output to upper airway dilator muscles causing a reduction in upper airway tone. This reduction in airway tone results in dynamic airway instability and precipitates monomorphic cluster cycles of airway collapse and recovery associated with the arousal response as the patient engages in a recurrent and cyclic process of arousal based rescue from each airway collapse. If, despite the development of significant cluster of airway collapse, the narcotic administration or sedation is continued, this can lead to further prolongation of the apneas, progression to dangerous polymorphic desaturation, and eventual respiratory arrest. There is, therefore, a dynamic interaction between suppression of respiratory drive, which results in hypoventilation and suppression of respiratory drive, which results in upper airway instability. At any given time, a patient may have a greater degree of upper airway instability or a greater degree of hypoventilation. The relative combination of these two events will determine the patterns of the output of the monitor. Unfortunately, this has been one of the major limitations of carbon dioxide monitoring. The patients with significant upper airway obstruction are also the same patients who develop significant hypoventilation. The upper airway obstruction may result in drop out of the nasal carbon dioxide signal due to both the upper airway obstruction, on one hand, or due to conversion from nasal to oral breathing during a recovery from the upper airway obstruction, on the other hand. Although breath by breath monitoring may show evidence of apnea, conversion from nasal to oral breathing can reduce the ability of the CO2 monitor to identify even severe hypoventilation in association with upper airway obstruction, especially if the signal is averaged or sampled at a low rate. For this reason, conventional tidal CO2 monitoring when applied with conventional monitors without out cluster pattern recognition may be least effective when applied to patients at greatest risk, that is, those patients with combined upper airway instability and hypoventilation. The present inventors recognized that this unique physiologic process of reentry of airway collapse could be exploited to provide a system and method for the recognition of the waveform patterns of airway instability. Several early embodiments are described in U.S. Pat. No. 6,223,064 (which is assigned to the present inventor, the disclosure and the entire contents of which are incorporated by reference is if completely disclosed herein). These systems and methods exploit the underlying cyclic physiologic process, which drives the perpetuation of a cluster of airway closures, to provide automatic recognition and indication of upper airway instability in real time. As discussed, the underlying cyclic process, which defines the behavior of the unstable upper airway, is associated with precipitous changes in ventilation and attendant precipitous changes in monitored parameters, which reflect and/or are induced by such ventilation changes. For example, cycling episodes of airway collapse and recovery produces sequential precipitous changes in waveform output defining analogous cluster waveforms in the time series of: oximetry derived pulse, airflow amplitude or/or tidal frequency, the oximetry SpO2, the chest wall impedance and/or motion, EKG pulse rate, and/or R to R interval, EEG (due to clustering of arousals), EMG due to clustering of motor response to arousals, systolic time intervals, and other parameters which vary with the brisk clustered cycles of apnea and recovery. EEG is readily available in the hospital as BIS monitors, according to the present invention the detection of clusters of alpha or high amplitude, mixed frequency arousals in clusters is very useful to indicate the potential presence of airway instability. According to the present invention, any one of these parameters singularly or in combination can be used in the hospital to detect either the absolute presence of airway instability or to provide evidence of probable airway instability so that hospital personnel know that additional testing should be applied. Conventionally, in the hospital, the analysis of one or more time series datasets is widely used to characterize the behavior of physiologic systems and to identify the occurrence adverse events. One basic conventional hospital montage commonly connected to a central monitor by telemetry includes electrocardiogram (EKG), pulse oximetry, and chest wall impedance). Using this grouping of monitors, the human physiologic system produces a large array of highly interactive time series outputs, the dynamic relational configurations of which have substantial relevance when monitored over both brief and long time intervals. The present inventors recognized that multiple unique patterns of airway instability were present along the time series and that these different patterns could be identified to provide an interpretive output such a textual output and/or other alarm. In addition, the present inventors recognized that the complexity and time course variability of these patterns commonly overwhelms hospital workers so that timely intervention is often not applied, resulting in unnecessary death or patient injury. The inventors further recognized that the processed based recognition of these patterns could be used to take action in the interest of the health of the patient, such as automatically lock out narcotic or sedation medication or increase the level and/or type of ventilation support. They also recognized that combined central and satellite processing systems such as those used in the hospital based systems discussed supra, could be modified to provide such automatic recognition and to provide such output and/or take such action to improve the health care of patients such as automatically locking out a drug infusion upon the recognition of the interval development of an unstable pattern potentially indicative of an adverse drug reaction or titration of continuous positive pressure devices. The invention also provides a method of doing business to improve the sale of patient monitoring systems, CPAP, and disposable probes for use with the monitors. According one aspect of the present invention, the recognition of sequential precipitous events or pathophysiologic patterns can be achieved by analyzing the spatial and/or temporal relationships between at least a portion of a waveform of a physiology parameter, (such as, for example, those listed supra), induced by at least a first episode of airway collapse and at least a portion of a waveform induced by at least a second episode of airway collapse. This can include the recognition of a pattern indicative of a cluster, which can compromise a high count of apneas with specified identifying features which occur within a short time interval along said waveform (such as 3 or more apneas within about 5�10 minutes) and/or can include the identification of a waveform pattern defined by closely spaced episodes of airway collapse defining waveform clusters. Further, the recognition can include the identification of a spatial and/or temporal relationship defined by waveform clusters, which are generated by closely spaced sequential apneas due to cycling upper airway collapse and recovery. According to another aspect of the invention, the patterns of these complex interactive signals and the data sets defining path physiologic upper airway instability are characterized by organizing the time series into an ascending hierarchy of objects (which in one preferred embodiment are substantially in the time domain), ordering these objects into a relational data matrix and then recognizing the complex reciprocations across time series and across scales and by applying an expert system to that set of highly organized set of objects. For the purpose of organizing and identifying physiologic datasets, according to the present invention a fundamental dynamic time series object is identified and characterized, which possesses a unique symmetry of scale. The inventors call this object a �physiologic reciprocation�. For the purpose of pattern recognition, according to the present invention, a physiologic reciprocation is a fundamental variation time series output generated by an organ, an organ system, and/or an entire organism, which is at least partially reversed within a specified interval. According to the present invention reciprocations, as recognized by the processor, are widely scalable across substantially all fundamental output patterns of organ function and physiologic control. The present inventors recognized that an scaleable system which recognized and analyzed reciprocations along a time series, across different scales of the time series, and between different scales of different contemporaneously derived time series, could be used to readily identify specific dynamic physiologic patterns of interaction defining both different states of disease and health. Further, the present inventors recognized that, for the purpose of processor based pattern recognition, human physiologic function (and dysfunction) can be characterized by defining and recognizing a object hierarchy of physiologic reciprocations ordered into an ascending, inheritance based relational timed data matrix. Using the above discoveries the present inventors recognized that typical standard central hospital monitors including those with wireless capabilities (such as the system described for example U.S. Pat. No. 6,364,834) and outpatient holter type monitors can be improved to provide automatic recognition of airway instability and sleep apnea and to provide an automatic visual or audible indication of the presence of such clusters and further to provide a visual or audible output and severity of this disorder thereby rendering the timely recognition and diagnosis of upper airway instability and obstructive sleep apnea as routine and automatic in the hospital as the diagnosis of other common diseases such as hypertension. According to one aspect of the invention a microprocessor system is provided for the recognition of specific dynamic patterns of interaction between a plurality of corresponding and related time series, the system comprises a processor programmed to; process a first time series to produce a lower-level time series of sequential time series fragments derived from the first time series, process the lower-level time series to produce a higher-level time series comprised of sequential time series fragments from the lower-level time series, process a second time series, the second time series being related to the first time series, produce a second lower-level time series of sequential time series fragments derived from the second time series, and identify a dynamic pattern of interaction between the first time series and the second time series. The system can be further programmed to process the lower-level time series of the second time series to; produce a higher-level time series derived from sequential time series fragments of the second lower-level time series. The system can be programmed to process a third time-series, the third time series being related to at least one of the first and the second time series, to produce a third lower-level time series of sequential time series fragments derived from said third time series. The system can be programmed to process the higher-level time series to produce a complex-level time series derived from sequential time series fragments of said higher-level time series. The time series fragments of the first and second time series can be stored in a relational database, the fragments of the higher-level time series can comprise objects, the objects inheriting the characteristics of the objects of the lower-level time series from which they are derived. The first and second time series can comprise datasets of physiologic data points and the system can comprise a patient monitoring system wherein the dynamic pattern of interaction comprises convergent clusters of pathologic reciprocations. It is the purpose of the present invention to provide a diagnostic system, which can convert conventional hospital-based central telemetry and hard wired monitoring systems and portable home systems to provide processor based recognition of airway instability through the recognition of patterns of closely spaced reciprocations and/or events induced by apneas and/or hypopneas both in real time and in overnight interpretive format and which can automatically lock-out narcotic infusion upon recognition of patterns of instability. It is the purpose of the present invention to provide a system, which identifies, maps, and links waveform clusters of airway instability from simultaneously derived timed signals of multiple parameters including chest wall movement, pulse, airflow, exhaled carbon dioxide, systolic time intervals, oxygen saturation, EKG-ST segment level, EEG, EMG, and other parameters to enhance the real-time and overnight diagnosis of airway instability. It is further the purpose of the present invention to provide a system to provide a graded index and/or indication of patterns of airway instability. It is further the purpose of the present invention to provide a system, which provides characterization of different types of patterns of ventilation and/or upper airway instability. It is further the purpose of the present invention to provide a system, which provides characterization and/or differentiation of different types of patterns such as monomorphic, polymorphic, and combined patterns of instability. It is further the purpose of the present invention to provide a system, which provides characterization to output an indication of the type of pattern identified by the processor so that a decision relevant the probability of success of auto titration with CPAP and/or BIPAP can be made. It is further the purpose of the present invention to provide timely, real-time indication such as a warning or alarm of the presence of airway instability clusters so that nurses can be aware of the presence of a potentially dangerous instability of the upper airway during titration of sedatives and/or narcotics. It is further the purpose of the present invention to provide a system for the recognition of airway instability for combined cluster mapping of a timed dataset of nasal oral pressure with tidal CO2 to identify clusters of conversion from nasal to oral breathing and to optimally recognize clusters indicative of airway instability in association with tidal CO2 measurement indicative of hypoventilation. It is the purpose of the present invention to provide an iterative object oriented waveform processing system, which can characterize, organize, and compare multiple signal levels across a plurality of signals by dividing each waveform level of each signal into objects for discretionary comparison within a relational database, object database or object-relational database It is further the purpose of the present invention to provide a system, which automatically triggers lockout of medication infusion based on the recognition of an adverse pattern of instability along at least one timed dataset output. It is another aspect of the present invention to provide a system that automatically customizes treatment algorithms or diagnostic algorithms based on the analysis of waveforms of the monitored parameters. It is further the purpose of the present invention to provide a system, which provides recognition and characterization of physiologic reciprocations across different time series scales. It is further the purpose of the present invention to provide a system, which automatically triggers testing (and comparison of the output) of a secondary intermittently testing monitor upon the recognition of patterns indicative of physiologic instability. It is further the purpose of the present invention to provide real time protection to patients against adverse drug and to provide a data matrix comprising matched time series of physiologic signals with a time series of drug infusion so that hospital personnel can readily match specific patterns of pathophysiologic perturbations to specific types of medications and ranges of medication dosage for patients hospital wide. One presently preferred system for processing, analyzing and acting on a time series of multi-signal objects is shown in In one example the occurrence of a dynamic clustering of apneas can be identified and the infusion pump (which can be for example a patient controlled analgesia (PCA) device can be automatically locked out to prevent further infusion and an output such as �Caution�pattern suggestive of mild upper airway instability at dose of 1 mg Morphine.� If in this example the nurse increases the dose to 2 miligram and the pattern shows an increase in severity an output such as �Pattern suggestive of moderated upper airway instability at dose of 2 mg/hr. of Morphine-morphine locked out�. To maintain Morphine dose at the 2 mg. level for this patient, the nurse or physician would have to override the lockout and preferably document the reason for override. Upon an override the processor then tracks the severity of the clusters and if the clusters reaches an additional severity threshold an output such as �Severe upper airway instability�Morphine locked out� is provided. According to the present invention the onset of the drug administration is recognized by the central processor and the dose administered becomes a time series, which can then be matched to the patterns of the monitored physiologic time series. In addition to real time protection, the data matrix comprising matched time series of physiologic signals with a time series of drug infusion provides an ability for hospital personnel to readily match specific patterns of pathophysiologic perturbations to specific types of medications and ranges of medication dosage for patients hospital wide. The composite object level is comprised of sequential and overlapping composite objects, and particularly reciprocations, which are composed, of a specific sequence of dipoles as defined by selected criteria. Each of these composite objects has similar primary characteristics of a slope, duration, and polarity to the fundamental objects. However, for the composite objects, the characteristic of slope can comprise a time series characteristic given as a slope dataset. The composite object level also has the characteristic of �intervening interval time-series� defined by a time series of the intervals between the recognized or selected composite objects. At this level a wide range of discretionary index characteristics can be derived from the comparison of basic characteristics of composite objects. Examples of such index characteristics include; a �shape characteristic� as derived from any specified portion of the slope dataset of the object, a �positional characteristic� as derived from, for example, the value of the lowest or highest points of the object, or a �dimensional value characteristic� as derived by calculating the absolute difference between specified data points such as the value of the lowest and the highest values of the object, or a �frequency characteristic� such as may be derived from performing a Fourier transform on the dataset of the object. The next analysis level is called the �complex object level�. In this level, each sequential complex object comprises plurality of composite objects meeting specific criteria. According to the present invention, the patterns of reciprocations at the complex level are representative of a balance between physiologic perturbation and the control. As such they are useful to characterize the integrity of control of the organism as well as the severity and character of the perturbation. According to the present invention, complex physiologic reciprocations are generally derived from composite level reciprocations and inherit their characteristics. Therefore a complex object (such as a recovery object) inherits the composite (tidal breath) reciprocations from which it is derived and this is exploited by the system as will be discussed. Complex objects have the same categories of primary characteristics and derived index characteristics as a composite object. A complex object also has the additional characteristics of �composite object frequency� or �composite object order� which can be used as search criteria as part of an overlaid expert system. These can be defined by a selected frequency or order of composite object types, which are specified as defining a given complex object. A complex object also has additional higher-level characteristics defined by the time-series of the shapes, dimensional values, and positional characteristics of its component composite objects. As described for the composite objects, similar index characteristics of the complex objects can be derived from these characteristics for example; a complex object can be derived as a cluster of composite level reciprocations. In a further example a complex level reciprocation given by a time series of positional characteristic along a clustered grouping of sequential composite objects (such a a reciprocation object derived of sequential nadir points or characteristics of composite level reciprocations of a cluster object at the complex level) can be readily identified and characterized. Characteristics or index characteristics may be combined with others. For example, a shape characteristic (which contains the slope data set in the time domain) may be combined with a frequency characteristic to provide a time series of a mathematical index of the slopes and the frequencies of the composite objects which can be ordered in an object hierarchy of ascending object data sets and correlated with other object level of other object data sets The next level, termed the �global objects level� is then derived from the time series of complex objects. At this level global characteristics are derived from the time series datasets of complex objects (and all of their characteristics). At the global objects level, the processor can identify general specific patterns over many hours of time. An example of one specific pattern which is readily recognizable at this level would be a pattern of regular monotonous occurrence of negative reciprocations alternating with positive reciprocations at the complex level comprised of composite objects, wherein the composite objects are derived of regular reciprocations of negative reciprocations alternating with positive reciprocations (of tidal breathing) at the composite level and wherein the magnitude of both the negative and positive reciprocations at the composite level oscillates in a regular frequency. This pattern is typical of Cheyenne-Stokes Respirations and according to the present invention an expert system examines the pattern of the objects at the composite level, the complex level, and finally at the global level to provide distinction between this process and the patterns of upper airway instability. Additional higher levels can be provided if desired as by a �comprehensive objects level� (not shown), which can, for example, include multiple overnight, or post operative monitoring periods wherein a comprehensive object is comprised of a dataset of �global objects�. While In the presently preferred embodiment, the time series of each of these signals are processed into time domain fragments (as objects) and organized into the object levels as previously discussed. For the purpose of organizing and analyzing complex interactions between these corresponding and/or simultaneously derived signals, the same basic ascending process is applied to each signal. As shown in This type of representation is too complex for presentation to hospital personnel but is preferred for the purpose of general representation of the data organization because, at this level of complexity, a complete representation of multiple time series does not lend itself well to a two-dimensional graphical (and in some cases a three dimensional) representation. To illustrate the complexity ordered by this approach, consider the components of just one of the three simple recovery objects shown in
As is readily apparent, it is not possible for a health care worker to timely evaluate the values or relationships of even a modest fraction of these parameters and an expert system applied generally to these parameters rapidly becomes inordinately complex and cumbersome. For this reason the output based on the analysis of these time series of objects are optimally first ordered into a relational, inheritance based object hierarchy, and then subjected to expert system analysis and/or presented in a succinct and interpretive format to the hospital worker as will be discussed. One of the longstanding problems associated with the comparison of outputs of multiple sensors to derive simultaneous multiple time series outputs for the detection of pathophysiologic change is that the accuracy and/or output of each sensor may be affected by different physiologic mechanisms in different ways. Because of this, the value of matching an absolute value of one measurement to an absolute value of another measurement is degraded. This is particularly true if the measurement technique or either of the values is imprecise. For example, when minute ventilation is measured by a precise method such as a pneumotachometer, then the relationship between the absolute values of the minute ventilation and the oxygen saturation are particularly relevant. However, if minute ventilation is being trended as by nasal thermister or nasal pressure monitoring or by chest wall impedance, then the absolute values become much less useful. However, according to one aspect of the present invention the relationship between pluralities of simultaneously derived signals can be determined independent of the relationships of the absolute values of the signals. In this way, simultaneously derived signals can be identified as having convergence consistent with physiologic subordination or divergent shapes consistent with the development of a pathologic relationship or inaccurate data acquisition. As noted, with physiologically linked signals, a specific occurrence or magnitude of change in one signal in relationship to such a change in another signal may be more important and much more reproducible than the absolute value relationships of the respective signals. Using the teachings of the present invention, two simultaneously acquired and physiologically linked signals are compared by the microprocessor over corresponding intervals by matching the respective objects (which can be applied at multiple levels) between the signals. As discussed, a primary signal such as airflow is ordered into composite and complex objects along with a contemporaneously measured secondary signal such as oxygen saturation as by the method and system discussed previously. For example, the composite level of airflow can be a of reciprocation objects derived from a fundamental level of amplitude and/or frequency of the tidal airflow as by thermister or pressure sensor, or another plot, which is indicative of the general magnitude of the timed tidal airflow. In the presently preferred embodiment, a plot at the fundamental level of a mathematical index (such as the product) of the frequency and amplitude is preferred, because such an index takes into account the important attenuation of both amplitude and frequency during obstructive breathing. Furthermore, both the frequency and amplitude are often markedly increased during the recovery interval between apneas and hypopneas. Although the exact delay between the signals may not be known, the processor can identify this by identifying the best match between the object sets. In the preferred embodiment, this �best match� is constrained by preset limits. For example, with respect to ventilation and oximetry, a preset limit could be provided in the range of 10�40 seconds although other limits could be used depending on the hardware, probe site and averaging intervals chosen. After the best match is identified, the relationships between the signals are compared (for example, the processor can compare the a rise or fall event of oxygen saturation to a rise or fall event of ventilation as shown in It is not necessary that such a fundamental level plot reflect exactly the true value of the minute ventilation but rather, it is important that the plot reflect the degree of change of a given level of minute ventilation. Since these two signals are physiologically linked, an abrupt change in the primary signal (airflow) generally will produce readily identifiable change in the subordinate signal (oxygen saturation). As previously noted, since the events which are associated with airway collapse are precipitous, the onset of these precipitous events represent a brief period of rapid change which allows for optimal detection of the linkage between the primary signal and the subordinate signal. The signals can be time matched by dipole slopes at the fundamental level. In addition, in one preferred embodiment, the point of onset of precipitous change is identified at the composite object level of the primary signal and this is linked to a corresponding point of a precipitous change in the composite object level of the subordinate signal. This is referred to herein as a delta point. As shown in Using one presently preferred method, a first object (such as is shown in Once the signals have been sufficiently matched at the one object level they can be further matched at another object level. When the objects are matched, the baseline dynamic range relationship between the signals can be determined. This baseline range relationship can be a magnitude value relationship or a slope relationship. The signals can then be monitored for variance from this baseline range, which can indicate pathology or signal inaccuracy. The variance from baseline can be, for example, an increase in the relative value of ventilation in relation to the oximetry value or a greater rate of fall in oxygen saturation in relation to the duration and/or slope of fall of ventilation. In another example, the variance can include a change from the baseline delay between delta points along the signals or a change in the direction (polarity) of one signal in relation to the baseline relationship for example two signals which formally moved in the same direction (after adjusting for a delay) may be recognized to exhibit variance by moving in opposite directions and the occurrence of this variance from a previously identified dynamic relationship (or a pre specified dynamic relationship range) Upon such recognition, according to the present inventor, the processor can be programmed to take action such as lock out a medication, adjust the flow of oxygen, change the positive pressure or tidal volume of a ventilator, or provide an indication, such as an alarm. According to the present invention, clusters of signal perturbation induced by even mild hypopneas can generally be reliably recognized by their cluster patterns utilizing with only a single parameter without setting up a priori and arbitrary rules (such as a 50% reduction in the airflow signal). In addition, when significant signal noise or reduced gain is present reducing cluster recognition in one signal, the objects based system can combine matched clusters within a time series of multi-signal objects in the presence of sub optimal signals by providing a scoring system for sequential objects across a wide range of parameters. The reciprocations are counted in sequence for each matched cluster object. For the purpose of illustration, according to the present invention, the occurrence of a score of 3 in any one signal (meaning that a continuous sequence of 3 reciprocations meeting criteria have occurred within a specified interval) provides sufficient evidence to identify a cluster object. When two simultaneous signals are processed, a total score of 4,derived from adding the number of reciprocations meeting criteria in each signal, is sufficient to indicate the presence of a cluster object. In this manner the cluster is continued by a sequential unbroken count greater than 3 with one signal, or greater than 4 with two signals. Once the presence of a cluster object has been established along the time series, at any point along the cluster object the sequential count along one signal can be converted to a continuation of the sequential count along another signal allowing the cluster object to continue unbroken. The failure of the occurrence of a cycle meeting criteria within either signal within a specified interval (for example about 90�120 seconds, although other intervals may be used) breaks the cluster object. A new cluster object is again identified if the count again reaches the thresholds as noted above. It can be seen that this scoring method takes into account the fact that artifact often affects one signal and not another. Therefore if either signal alone provides a sufficient score, the presence of a cluster object is established. In addition, the effect of brief episodes of artifact affecting both signals is reduced by this scoring method. In this way, artifact, unless prolonged, may cause the cluster object to be broken but as soon as the artifact has reduced sufficiently in any one or more signals the process of scoring for a new cluster object will restart. The skilled artisan will recognize that many other such scoring or artifact rejecting methods using two linked signals can be derived within the scope of this teaching. When applied, one preferred digital pattern recognition program for automatically detecting, characterizing and indexing the severity airway instability proceeds in several phases, which need not be in the illustrative sequence, listed below: 1. Various types of decline and rise objects are identified at the composite level. 2. Various types of negative and positive reciprocations are identified at the composite level. 3. Various types of clusters of reciprocations are identified in the complex level. 4. Various types of reciprocations of clustered reciprocation object characteristics (e.g. nadirs) are identified, 6. Reciprocations at the fundamental level are analyzed within specific objects at the composite level. 7. Objects of one channel are compared to objects of another channel (if multiple time series of objects are rendered). 8. An expert system is applied to recognize a pattern of objects indicative of a diagnosis. 9. The relationship between the events, reciprocations, and complex patterns is calculated and outputted. 10. The severity of the pathophysiologic perturbation is determined 11. A textual alarm and/or other signal, which may be graded based on severity is outputted 12. Treatment is automatically modified to adjust or prevent medication infusion or to eliminate the cluster 13. The process is then repeated with each addition to the dataset in real-time or with stored timed datasets. A mathematical representation of a basic iterative process of waveform object segmentation according to the present invention is described in detail in the co-pending application entitled System and Method for Identifying Dynamic Patterns of Interaction, the disclosure of which is incorporated by reference as if completely disclosed herein and an exemplary mathematical reference listing is provided in The present inventors have described clusters comprised of reciprocations of varied morphology as polymorphic (an example of such a cluster is shown in The present inventors have discover that, at least in one population of patients with airway instability, the basic monomorphic pattern dominates and polymorphic patterns occur in less than 10% of the patients. However, this may increase with narcotic administration or with select subgroups of the severe obesity (at risk for obesity hypoventilation syndrome) or those with COPD, or CHF. The present inventors have discovered that the automatic recognition of complex polymorphic clusters can be useful to determine the stability and integrity of ventilation control and the probability of success of automatic CPAP titration. This is an important discovery because primary care physicians have been reluctant to institute automatic CPAP in the home without attendance because the probability of success for a given patient cannot be known a priori. The present inventors recognized that the presence of polymorphic clusters and/or monomorphic clusters superimposed on other reciprocations (an occurrence which develops, for example, when airway instability is superimposed on other cardiovascular and pulmonary co morbidities) have a lower probability of successful automatic CPAP titration and are therefore may best titrated in a sleep laboratory or other attended setting where a trained attendant can adjust treatment. They also recognized that polymorphic reciprocations are often best treated with multilevel ventilation because they often indicate an incomplete, or delayed recovery, which is often best supported by ventilation rather than simple CPAP. According to the present invention, a automatic CPAP titration which can use any of a range of algorithms for CPAP adjustment, as are known in the art, upon recognition by the processor of polymorphic clusters, or the presence of a decline in a time series of the peaks of clusters (as for example in the oximetry signal), and/or the failure to abort clusters, the processor is programmed to automatically converts the CPAP to a bi level ventilator. According to the present invention, this can be achieved by automatically lowering the pressure on exhalation by for example 2�4 cm H2O and maintaining the original pressure on inhalation. Alternatively, the processor can trigger the addition of higher pressure on inspiration, for example 2 cm H2O, above the original continuous pressure level and then titration of the inspiratory pressure and or expiratory pressure until the cluster is aborted. According to the present invention, if pathophysiologic divergence is identified with a fall in oxygen saturation in relation to a rise in ventilation (as discussed in detail in the aforementioned co-pending application) this recognition can be used to automatically warn of the potential need for oxygen or to automatically initiate or increase oxygen instead of increasing the CPAP or Ventilation. Also the development of pathophysiologic divergence in association with upward titration can be used to reduce the pressure to their original levels. Automatic conversion to ventilation or increasing ventilation upon the occurrence of polymorphic clusters and/or when the cluster peaks exhibit a significant decline or automatically aborting the titration and/or providing an output indication that the patterns indicate that attended titration may be preferable provides a more physiologically focused titration of therapy which can substantially improve the efficacy and sale of automatic positive pressure treatment devices. According to the present invention, a wide range of variations of events, reciprocations and clusters are built from simpler objects and this provides the ability to identify a wide range of physiologic phenomena without losing information gained by aggregating specific types of such phenomena. For this reason the presently preferred time domain analysis starts with a basic segmentation process upon which is built a more complex characterization. The more complex physiologic occurrences are better represented programmatically than mathematically and this representation follows. Because the wide range of permutations causes marked complexity, the present inventors recognized that an effective framework and methodology was required to address the complexity of this type of software system. In the presently preferred embodiment object oriented time series segmentation, in the time domain, into an inheritance based relational hierarchy allows recognition and characterization a very broad range of real-world phenomena including complex, interactive physiological datasets. The diagram of The core objects of the presently preferred analysis are shown in Since the creation of hundreds of thousands of dipole objects can hamper the acquisition of the analysis in a real-time environment, in the presently preferred embodiment, the logical concept of the dipole object has been encapsulated within the time series to improve performance in a real time environment. Correlated events provide the basic mechanism for identifying relationship between channels. The aggregation of these objects within a case analysis object provides the ability to interpret broad, intra and inter-channel trends while also providing access to the large amount of simple objects and raw data from which those trends were derived. according to the present invention this presently preferred structure in the context of an object-oriented programming language that provides the power to readily apply a broad range of expert system based comparisons, create indices, alarms, graphical representations and other human facing mechanisms for interpretation and analysis.
As a further example, the following is a list of functions available for a cluster object (this does not include the ability of that object to access any functionality of the reciprocations, events and time series which are related to the cluster object):
As shown, in the above structure a requesting system will create an analysis request and submit it to the case analysis director. The director is a dispatcher object that oversees the analysis process while delegating the actual processing to other objects. The most important of these delegates is the channel analysis builder. This object performs the basic algorithms described above against the respective time series to produce the aforementioned events, reciprocations, clusters and the relationships between them. During this process data structures for providing fast access by point and dipole are created as point and dipole maps respectively. These objects provide single step access to all objects tied to a particular point and/or dipole. This supports a high level of interactivity (e.g. mouse over actions) in a graphic user interface (e.g. a Microsoft Windows application). Analysis requests may not be comprehensive and therefore further analysis can be requested to the case analysis director. This ability to provide partial analysis further enhances performance by allowing a researcher or physician to specify the particular aspects of the analysis he/she finds useful. The channel integrator performs intra-channel analysis to create event correlations. These correlations (and the aggregations thereof) provide an integrated view of all channels within a case. Of course, the transformation itself can be a quite complex process and the transform has a substantial impact on the waveform morphology and relationships. This has been a significant problem with standard hospital monitoring systems (such as pulse oximeters). Despite the importance of the effect a transform has on time series morphology and alarm reliability the monitoring industry has not standardized to any transform and many oximeters do not even provide documentation relevant the transform applied to generate the time series. The present inventors recognized that, in the interest of providing optimal patient care, the transform needs to be understood by the physician and researcher so that the time series outputs and all algorithms performed are clearly identified and/or can be explicitly requested. For this purpose, the present inventors created a nomenclature for explicit representation of all transformations available. According to the present invention, objects at the composite level encapsulate the objects from which they are derived at the fundamental level. For this reason a recovery object recognized at the composite level in one parameter can used to specify a region for comparison of sequential objects (such as reciprocations) at the fundamental object level in the same parameter or in matched recovery objects along another parameter. For example, upon recognition of the presence of a recovery object (where it is anticipated that the ventilation effort will be high) the ratio of the slope of fall (exhalation) objects and rise (inhalation) objects at the fundamental level can be compared within the recovery object and the time series derived from an continuous calculation this ratio can be plotted at it too analyzed by object mapping if desired. During upper airway obstruction, the inspiration is slowed to a greater degree than exhalation. The magnitude change of inspiratory slowing and/or amplitude and/or ratio during the clusters of apneas provides an index of the magnitude of upper airway narrowing (which slows inhalation during the clustered apnea/hypopnea objects). However, during the recovery object or at the �hyperventilation reference point�, the upper airway should be wide open for both inhalation and exhalation and this can be used as a reference because, during this time,. Because the recovery objects encapsulate the fundamental reciprocation objects from which it is derived, the absolute slope, magnitude, frequency and amplitude, of the fundamental objects during recovery can then be compared to provide a reference for the absolute slope magnitude, frequency and amplitude of the fundamental objects during other times along the night to provide an indication of upper or lower airway narrowing. These encapsulations allow ready exploitation that certain regions along a multi-signal object (as within an airway instability cluster) have a very high probability of association with various levels of ventilation. According to the present invention, the objects defining those regions can then be used as a reference or as an opportunity to examine for the effects of a given level of ventilation effort on the flow characteristics of the encapsulated reciprocations. Patients with obstructive sleep apnea are expected to have a fall in the slopes of fundamental inspiration objects during decline objects at the composite level indicative of upper airway narrowing and/or occlusion. Also, as shown in Another example of object processing at the fundamental object level, according to the present invention, includes the processor-based identification of fluttering of the plateau on the pressure signal to recognize partial upper airway obstruction. During the nasal pressure monitoring a fluttering plateau associated with obstructive breathing often occurs intervening a rise event and a fall event of tidal breathing. Since the plateau objects are easily recognizable at the fundamental level and readily separated using the present object recognition system the plateau can be processed for the tiny rise and fall objects associated with fluttering and the frequency of these objects can be determined. Alternatively, a Fourier transform can be applied to the plateau objects between the rise and fall events of the nasal pressure signal to recognize the presence of fluttering or another method can be utilized which provides an index of the degree of fluttering of the plateau objects. Since reduced effort also lowers the slope of exhalation and inspiration, the configuration (as defined by the slope dataset of the dipoles defining the fundamental objects of both inspiration and expiration at the reference objects) can be applied as reference fundamental object configurations defining the presence of hyperventilation or hypopnea. This process is similar to the selection process for identifying search objects described earlier but in this case the input region is pre-selected. In an example, the range of characteristics of the objects at the fundamental level derived from one or more tidal breaths occurring prior to the second airflow delta point can be used to designate a reference hyperventilation objects range. Alternatively the object based characteristics, defined by of the range of characteristics of the objects derived from one or more tidal breaths occurring prior to the first airflow delta point can be used designate a reference hypopnea objects range. The processor can then automatically assess object ranges along other points of the tracing. In this way the processor can apply an artificial intelligence process to the identification of hypopneas by the following process:
In one embodiment, the multi-signal time series output is placed into a format particularly useful for demonstrating events to hospital personal especially for teaching purposes. In this format the output controls an animation of multiple objects which are shaped into an animated schematic of the as the physiologic system being monitored. The animation moves over time and in response to the signals and one preferred embodiment the type of signals (or the reliability of such signals) determines which components of the schematic are �turned on� and visible. One example includes a multi-signal object defined by outputs of airflow, thoracic impedance, oximetry, and blood pressure rendering set of a connected set animation objects for the lungs, upper airway, lower airway, heart, and blood vessels which can be animated as;
This provides �physiologic animation� which can be monitored in real-time and which can also be derived and reviewed from the stored multi-signal objects at variable time scales. This embodiment of the present invention provides a quickly, easily understood and dynamic animated output of a highly complex, interactive time series derived from a patient. The animation can be reviewed at an increased time lapsed to speed through evolution of a given patients outputs or can be slowed or stopped to see the actual global physiologic state at the point of onset or termination of a given pathophysiologic perturbation. Particularly for use in the hospital, a graded indicator or alarm can be provided, indicative of the severity of the clusters and of airway or ventilation instability. Since very mild clustering may simply represent the effect of moderate sedation, and not, therefore, represent a cause for great concern (although it is important to recognize that it is present). Such a clustering could be identified with a single bar or test warning, whereas more severe clustering would generate a larger warning and, if very severe, an auditory alarm. When the clustering becomes more severe and demonstrates greater levels of desaturation and/or shorter recovery intervals the bar can be doubled According to another aspect of the present invention, a change in one or more time series components of the multi-signal object can be used to change the processing algorithm of a time series component of the multi-signal object. In an example, the recognition of airway instability is enhanced by improved fidelity of the timed waveform (as with pulse oximetry). The present invention thereby provides for more optimal continuous fidelity of the waveform through both motion and non-motion states. As illustrated in Those skilled in the art will recognize that, the information provided from the data and analysis generated from the above-described system can form the basis for other hardware and/or software systems and has wide potential utility. Devices and/or software can provide input to or act as a consumer of the physiologic signal processing system of the present invention's data and analysis. The following are examples of presently preferred ways that the present physiologic signal processing system can interact with other hardware or software systems:
It is anticipated that the physiologic signal processing system will be used in these and many other ways. To facilitate this anticipated extension through related hardware and software systems the present system will provide an application program interface (API). This API can be provided through extendable source code objects, programmable components and/or a set of services. Access can be tightly coupled through software language mechanisms (e.g. a set of C++ modules or Java classes) or proprietary operating system protocols (e.g. Microsoft's DCOM, OMG's CORBA or the Sun Java Platform) or can be loosely coupled through industry standard non-proprietary protocols that provide real-time discovery and invocation (e.g. SOAP [Simple Object Access Protocol] or WSDL [Web Service Definition Language]). In the preferred embodiment the physiologic signal processing system with the API as defined becomes a set of programmable objects providing a feature-rich development and operating environment for future software creation and hardware integration. The program is particularly suited for physiologic signals but can be used to track and identify relationships between a broad range of signals to identify specific patterns or to search for patterns. Although the listed program is coded for contiguous points for efficiency, according to the present invention, the time series data points need not be contiguous and indeed as discussed with physiologic data sets, noncontiguous points are converted into a time series when nadirs or peaks of reciprocations are plotted to identify timed patterns of variation in these parameters. The present invention is applicable to detect dynamic patterns and relationships particularly in the time domain in the along and between one or a plurality of financial time series such as stock prices or stock indexes, vibration time series, time series of sound, air movement, temperature, populations, and other dynamic processes where it may be desirable to identify, along complex data sets, known or unknown dynamic patterns of interaction. Although the presently preferred embodiments have been described, which relate to the processing of physiologic signals, it is also critical to recognize the present streaming parallel objects based data organization and processing method can be used to order and analyze a wide range of dynamic patterns of interactions across a wide range of corresponding signals and data sets in many environments. The invention is especially applicable to the monitoring of the variations or changes to a physical system, biologic system, or machine subjected to a specific process or group of processes over a specific time interval. Many other additional parameters may be added and will become evident to those skilled in the art in association with the application of the present invention and these are included within the scope of this invention. Those skilled in the art that various changes and modifications can be made without departing from the invention. While the invention has been described in connection with what is presently considered to be the most practical and preferred embodiments, it is to be understood that the invention is not to be limited to the disclosed embodiments, but on the contrary, is intended to cover various modifications and equivalent arrangements included within the spirit and scope of the appended claims. Patent Citations
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Are you interested in having one-on-one professional care during your birth? Would you like additional physical, emotional and informational support for yourself and your family during labor? The With Women On-call Birth Doula Program offers gentle, non-judgmental support to all birthing families at certain hospitals. Currently we serve Exempla Lutheran Medical Center, Presbyterian/St. Luke's Medical Center (P/SL), University of Colorado Hospital, Saint Joseph Hospital and St. Anthony Central Hospital. If you are planning a natural birth, birth with an epidural, or are birthing by scheduled cesarean section, our doulas are here to support you.
Program Details
Doulas are trained professionals who understand the birthing process, and can offer comfort, guidance, and reassurance to the birthing mother and all who are there to support her. Our doulas are on-call for registered clients 24/7. Clients enjoy as many prenatal visits as they would like with our doulas during Doula Consultation and Client Workshop events, as well as unlimited email and phone support throughout their pregnancy. The doula on-call at the time you are admitted to the hospital will join you and support you throughout your birth experience. She will stay with you for one to two hours after your birth to assist with first feedings, take pictures, and help you get settled. Your doula will do a follow-up visit at the hospital one or two days after your birth. The fee for this program is $450 - significantly less than the average cost of a doula in the Denver area which ranges from $600-$900. With Women will assist you in submitting for insurance reimbursement for doula services.
More Information
If you would like additional information about the With Women On-call Birth Doula Program, please attend an Doula Consultation and Client Workshop. 2:00 - 2:30pm is for those who want to learn about the on-call program; 2:30 - 4:00 is for registered clients who wish to consult with the doulas. Workshops are currently being held in the Lutheran Birth Center Classrooms on the third Saturday of the month from 2 p.m. to 4 p.m. Please call 303-674-1685 or email us to register.
2015 Doula Consultation and Client Workshop Schedule 3rd Saturdays from 10am-12pm Please call 303-674-1685 or email us to register for these free events!

subset: commoncrawl


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OVER-ARMOR Vest
Spec.-Ops. Brand offers the OVER-ARMOR Vest for the Interceptor Body Armor System, the latest innovation in its line of high-performance tactical nylon gear for military, law enforcement and other demanding applications. Spec.-Ops developed OVER-ARMOR in response to direct feedback from U.S. troops serving in Iraq and Afghanistan, who wanted to maximize "on-body cargo" carrying capacity. They also needed to be able to quickly and easily remove the carried load from their body armor. Spec.-Ops. used the feedback to create a load-bearing vest that simply slips on over standard body armor systems and can be removed just as easily.


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Mystery Guild Book Club ranks first for Cheryl Crane Selection.
Why pay more for Cheryl Crane Books? Our reviewed clubs have many of the best sellers to choose from. ( having the largest selection.) Book Club Shop offers reviews of a wide selection of book clubs that offer Cheryl Crane books at a huge saving off of retail prices. To view some of the selection of Cheryl Crane books, see below.


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Pinterest Spa Wisdom™ Africa Ximenia & Salt Scrub Select size 13.5 oz Quantity 1 2 3 4 5 6 7 8 9 10 Item 13.5 oz Price $28.00 Add to bag Email When In Stock Please note that there is a limit on this product. Offers available on this product Fast & Easy Returns $5.95 standard shipping. More information Product description Best if you want to: Take time to cleanse, revive and revitalize your skin using a luxuriously pampering creamy salt scrub for the body with skin softening butters from Africa that will leave skin soft, smooth and subtly scented with our traditional Spa Wisdom™ Africa fragrance. Best for: all skin types, particularly those with dry skin who need to exfoliate regularly How it works: Community Trade organic beeswax moisturizes and conditions skin while acting as a barrier to help seal in moisture. Community Trade shea butter moisturizes and softens skin. Salt grains gently exfoliate skin. Ximenia, an oil extracted from the ximenia tree native to Africa, helps soften the skin. Shipping Close
Beeswax Our Community Fair Trade honey and beeswax suppliers use hives hand made from bark, hung high in the forests, to collect our Community Trade honey. To the bees these are penthouses hung high in the trees. The honey they make is some of the finest in the world, as the bees visit flowers unspoilt by pollution or pesticides. Learn More →
Shea Butter Our Community Fair Trade shea butter is sourced from northern Ghana, where it has been used for centuries to protect skin from harsh Saharan winds. We work with The Tungteiya Women's Shea Butter Association to produce the rich shea butter we use in our products. The Body Shop provides the 528 women of the Association with a fair wage, and also pays a premium for the women to invest in community projects. Anita Roddick placed our first order in 1994 after an earlier visit to Ghana where she discovered the natural moisturizing properties of shea butter and the amazing women who produced it. Learn More →


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Did IBM Overlook Cost, Ease in Unified Communications Plan?
IBM's UC plan appears to focus on the needs of larger businesses.
On March 10, IBM vowed to make a major push into UC, starting with its new Lotus Sametime Advanced software and going far beyond that into a three-year plan that will encompass acquisitions, internal development and new services.Read the full story on eWEEK Midmarket.


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On 21 September 2007, the QE2 visited Liverpool for the last time to mark the official opening of that city's cruise liner terminal. She was launched at 20 September 1967. She is scheduled to be berthed permanently at the Palm Jumeirah development in Dubai in 2008 to be refurbished and become a floating hotel by 2009.
What a beauty! Excellent composition, use of lightning, and skyline. Well done!
thanks again and for favouriting this one as well.
blessings upon you :-)
Wooow…what a splendid boat!
thanks for the comment. It is a magnificent vessel isn't it.
Oddly enough I was just looking through your own portfolio when I noticed your comment!
Gee, all this controversy this morning led to something good. At least I got to see your work…dare I leave you a comment? LOL! What the heck! I love this shot and I'm adding it to my faves!
funny how things work out isn't it. Just looked at your portfolio. You're going on the old watchlist as well! yeah!
Congratulations on the sale
cheers Les
i love boats, great shot
cheers henry


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Hot Air After Party
Friction Quartet
Sun, March 3, 2013
9:30 pm
Hotel Utah$5.00 - $10.00
Tickets Available at the Door
This event is 21 and over
http://www.hotelutah.com/event/197809/Friction Quartet
Praised for their "broad expressive range" (Luciano Chessa) and "energetic gusto" (SF Examiner), Friction Quartet is the San Francisco Bay Area's most explosive contemporary string quartet. Through artistic collaboration in varied mediums, the commissioning of new works, crossing into genres outside of classical music, and incorporating mixed media technology, Friction will create an exhilarating and inviting atmosphere that will attract audiences of all ages and interests.
Described by the eminent Sergio Assad as "the most inventive and exciting young guitar ensemble today", Mobius Trio has made it its mission to fully integrate the classical guitar into the 21st century's nascent musical lexicon. The Trio exclusively performs music that they have commissioned; they seek to expand the guitar ensemble's repertoire to encompass all of the myriad currents passing through contemporary art music. Mobius Trio has commissioned over a dozen composers in their first two years of existence, and that pace isn't slowing. Recent commissions include Adrian Knight, Samuel Carl Adams, and Frank Wallace, with more pieces and collaborations on the way.


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Tweeting as @RalphEHanson
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9/11 advertising apple audio Because I can blogging books C-SPAN copyright Disney ethics first amendment global media humor international news ipad legal issues long tail media magazines media business media history media law mobile media mobile phones movies music Muslim media newspapers opinion writing photography politics pre-class video public relations questions Secret 3 Secret 4 Secret 6 social media Star Wars Super Bowl television Truth 3 Truth 4 Truth 6 twitterOld Blog Features
Monthly Archives: September 2012
Questions Worth Asking – Maybe
Should we long for the good old days of the Alien and Sedition Acts? A look at how our understanding of the First Amendment has changed over the years. (Lawyers, Guns & Money) What does free speech look like globally? … Continue reading
Posted in Chapter 13, Chapter 15, Chapter 4
Tagged diabetes, global media, Harry Potter, media law, questions
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WP's The Fix Lists Top Political Ads of 2012 (so far)
I don't think that this election cycle has given us a lot of brilliant political ads, but here are four that the writers at The Fix political blog at the Washington Post really like, and I have to agree with … Continue reading
Science in the Movies – Right and Wrong
Science fiction movies are science fiction, right? But that doesn't mean movie makers are free to completely ignore reality. The Smithsonian's Collage of Arts and Sciences recently ran a pair of entries looking at SciFi and fantasy movies that did a … Continue reading
Are phone apps ancillary markets for movies?
I would think so. Questions on Twitter today from students using Mass Communication: Living in a Media World:
Talking about media coverage of health care debate
I'm going to be talking to a business class about media coverage of the health care debate tonight. Most of the figures I'll be using come from two Pew Foundation reports: What Americans Learned from the Media about the Health … Continue reading
When politicians' private remarks go public
The news broke today that Republican presidential nominee Mitt Romney said some pretty disparaging things about the 47% of Americans who don't end up having to pay income tax while speaking at a private fund raising event. The leaked video … Continue reading
Working with social media
I've been talking lately with folks about social media. Here are a few thoughts on the subject: What are social media? Online sites that allow users to generate content, comment, tag, and network with friends or other like-minded people. What … Continue reading
Truth 7 – There is no "they" – Does the anti-Muslim film blamed for rioting even exist?
On Tuesday evening, the U.S. consulate in Benghazi, Libya, and the U.S. embassy in Cairo, Egypt were attacked by protestors. The attack in Benghazi led to the death of American ambassador to Libya J. Christopher Stevens and three other … Continue reading
Posted in Chapter 15, Chapter 2
Tagged international news, media effects, Muslim media, Secret 7, Truth 7
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Sept. 12 Anniversary – We Choose to go to the Moon
No, not the anniversary of the day after Sept. 11, but the 50th anniversary of President John F. Kennedy's "We Choose to go to the Moon" speech at Rice University. "We choose to go to the moon. We choose to … Continue reading
A Motorcycle Ride to the United 93 Memorial on a Rainy Summer Day
This has nothing to do with the media. It's a brief story about a ride I took on my motorcycle to the United 93 Memorial on a rainy June day back in 2004. It was written shortly after I had … Continue reading


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243 Followers / 227 Following
Mmmm, this one is really well balanced with the vanilla, creamy smooth delicious :-) I used up my last bit of this one tonight but it was so good.
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I just a guy who respects and loves the tea :)


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Fairfield Northport Village
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Great location in Historic Northport Village! Beautifully updated large apartments with tuscany style wood cabinetry and stainless steel appliances.
Great location in Historic Northport Village! Beautifully updated large apartments with tuscany style wood cabinetry and stainless steel appliances.Welcome to Fairfield Northport Village. We are located in the charming, historic village of Northport at the edge of the picturesque harbor. A beautiful walking town with many trendy shops and great restaurants, take in an off-broadway show at the historic John Engeman theatre or sit seaside at on the village green! Fairfield Northport Village offers newly updated One Bedroom and Two Bedroom apartments with heat and hot water included! Our apartments feature beautiful upgrades including: Tuscany kitchen cabinetry/granite kitchen countertop, stainless steel appliances with a washer/dryer all-in-one appliance, plush carpeting, ceramic tile bath with updated cabinetry. We have air conditioners, newly updated lighting and hi-hat lighting, crown and base molding and raised panel doors. Call today for your personal tour!
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Sodamco-Weber News
Sodamco-Weber unveils 5 new solutions at the BIG 5 show in Dubai
Visitors at the Big 5 in Dubai discovered the Innovative Building Solutions of Saint-Gobain of which 5 of them for Sodamco-Weber.
November 17-20, 2014 Saint-Gobain at the Big 5 - Dubai
World-leading Saint-Gobain companies at the biggest construction exhibition in the Middle East.
Find all answers to practical cases that you encounter on job sites
Together we build a sustainable future
Innovative Solutions, for a sustainable habitat...


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While Ke$ha's blip of a show Thursday night at The Rave delivered little in the way of actual performance, it did offer a discouraging snapshot of a generation weaned on boozy, sex-obsessed reality television.
Ke$ha rose to fame with songs about partying with abandon, and on Thursday, many female fans of the glittery pop starlet were locked in a figurative arms race to see who could be the drunkest, most scandalously dressed in the audience.
Several young women were slumped over and vomiting in the venue's parking lot well before their hero - a Lady Gaga-lite who replaced the "s" in her name with a dollar sign - took the stage of a packed Eagles Ballroom, The Rave's largest hall.
At this early stage in her career, Ke$ha has had minimal live experience, and she offered just enough in the way of performance and inane banter to keep her fans locked into the catchy synth-pop of her debut album, "Animal." It was fitting that when the blond, glitter-doused pop singer took to the stage in black boots, a ripped-up Metallica T-shirt, feathery army helmet, lace tights and holding a prop guitar, her first song was "Blah Blah Blah," a tune about talking a lot without saying much.
Flanked by American-flag draped speakers and dancers wearing glam metal-indebted outfits, Ke$ha buzzed through a set that lasted hardly an hour with encore included.
She paused occasionally between songs to announce what the next tune was about: "This is my new single. It's about taking your clothes off!" (for "Take It Off")," or, "This song is about partying at a rich dude's house!" (for "Party at a Rich Dude's House").
If you had actually woken up and brushed your teeth with a bottle of Jack Daniels, as Ke$ha sings about on her biggest hit and set closer, "TiK ToK," you may have danced yourself silly and had a good time. If not, you probably wondered what all the buzz over Ke$ha is about.


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simple and beautiful .. less but yet more to see .. congrats on the DI
Jul 22nd, 2011 Reply SubscriberGoing through your gallery is definitely a specific kind of treat. The immensely inspiring images all give each other great competition. This one wins, lol!
Jul 22nd, 2011 ReplyThanks for sharing your beautiful work! It's an inspiration to all of us artists and has been featured in the Daily Inspiration #138, congratulations!


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Messe de Minuit pour Noël, 1690 |
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These pieces (in Noteworthy Composer format) are for private use only. You may download them for your own personal use. You may NOT market them for monetary gain. You may NOT use the scores to give a public performance unless you have the permission of the copyright holder/user who submitted the file. You will find the contact details in this file. If you are having difficulties, please contact for further advice. For more information on copyright, please read this.
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File: | charpmdm.zip (January 2007) 43 kB |
Full name of work: | Messe de Minuit pour Noël, 1690 |
Composer: | Charpentier, Marc-Antoine (1643-1704), French |
Arranger: | N/A |
About: | http://www.naxos.com/person/Marc.....entier/25945.htm |
Lyricist: | N/A |
First line: | N/A |
Music category: | Classical Choral Mass |
Instruments: | arranged for SATB (piccolo, clarinet, French horn, bassoon) and piano (converted to strings etc) |
Name of file creator: | John Hooper |
e-mail address: | NWC "at" thehoopers "dot" demon "dot" co "dot" uk |
Website: | http://www.learnchoralmusic.co.uk |
Running time: | 00:23:22 |
Comments: | This ZIP File contains the following NAMED sections- 1-kyrie.nwc Kyrie 2-gloria.nwc Gloria 3-credo.nwc Credo 4-sancts.nwc Sanctus 5-agnus.nwc Agnus Dei There are no text/lyrics; these Files were generated purely for Choral Rehearsing purposes (using a published piano-reduction Score), and so don't look pretty even though they should sound reasonable (though that depends very much on your hardware/software; mine is a Soundblaster AWE64 Gold). Voice-emphasised Midi Files of the whole work can be downloaded for free from my Website (above). The Site also contains Midi Files for several rather more modern Composers, for which NWC versions may be available. |


text: Dreadnaught 5pts I had a Hot Wheels (or was it Matchbox?), yellow Lamborghini Marzal in 1968. That, the Lamborghini Miura, Ford GT, Lotus Europa, Porsche 917 and Iso Grifo were my favorite cars (Hot Wheels/Matchbox) which I wanted to have when I grew up.. Now that I am "grown-up" and can afford to buy their contemporaries in real life, I find that all things are relative and I still cannot afford my childhood fantasy cars in real life! Damn!


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Job Description
We need a publicist to increase my clients exposure in the speaking circuitry.
Renee Sunday is a motivational speaker looking to grow her speaking business locally, nationally and internationally. The right candidate will have extensive experience working with professional speakers. She is looking for the right person to perform the following but not limited duties.
Write bios, press/ media kit, marketing and book her for nationally and internationally venues. Must be familiar with the speaker/motivational world.
Also, Renee is an author, publisher, tv/radio personality, and an anesthesiologist. She released a book titled Sunday Grief, M.D.. The book is about going through the grieving process from a Christian medical professional perspective.


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