text:
|Número de publicación
|Tipo de publicación
|Número de solicitud
|Fecha de publicación
|4 May 1976
|Fecha de presentación
|19 Jul 1974
|Fecha de prioridad
|19 Jul 1974
|Número de publicación
|Robert E. Buuck
|Cesionario original
|American Medical Systems, Inc.
|Exportar cita
|BiBTeX, EndNote, RefMan
|Citas de patentes (2), Otras citas (1), Citada por (156), Clasificaciones (6), Eventos legales (1)
|Enlaces externos: USPTO, Cesión de USPTO, Espacenet
1. Field of the Invention
This invention relates generally to prosthetic systems, and pertains more particularly to the prosthetic treatment of erectile impotence in the human male.
2. Description of the Prior Art
Present implantable prostheses dealing with treatment of erectile impotence require surgical insertion of a rigid silicone rubber rod into the penis. This approach provides the desired erectile state but is not patient-controllable. In addition, the permanent erectile stage may prove physically uncomfortable or emotionally disconcerting to the patient. Also, the rigid prosthesis has in a number of instances eroded through the skin and falls out of the penis.
Accordingly, an object of the present invention is to provide a readily controllable penile erection system.
Another object is to avoid physical and emotional discomfort that has attended the rigid rod system mentioned above.
A further object of the invention is to provide a system of the foregoing character in which all components are implanted within the user's body and which are thus totally concealed from view.
Another object of the invention is to provide a system which will achieve the desired result without risking infection, such as is likely to occur when tubes are brought through the skin.
Another object is to provide a system of the above-referred to type that will be physiologically compatible with the person's body tissue and organs. It is also within the purview of the invention to provide a system that is filled with a fluid containing a radiopaque dye that is not only compatible with the material of which the system in constructed but which is also compatible with the body tissues and organs should a leak occur.
A further object of the invention is to provide an implantable system that will not in any way interfere with the performance of other body functions. More specifically, an aim of the invention is to avoid any interference with the passage of either spermatozoa or urine.
Yet another object of the invention is to provide a system that will be simple, compact, long-lasting and which will function without medical supervision once it has been implanted in the body.
Still further, another object is to provide such a system that can be quickly implanted and which will necessitate only a brief hospitalization of the patient.
Briefly, the invention involves the implanting of a self-contained system completely within a human male by replacing the erectile function of the corpora cavernosa of the penis with two inflatable and collapsible cylinders. A fluid transfer system is also implanted in an appropriate portion of the body, such as the lower portion of the patient's abdominal cavity. Included in the system is an elastomeric control bulb located innerjacent the skin, such as within the scrotum, so that the bulb can thereafter be manipulated or squeezed through the skin to force inflating fluid into the cylinders to provide an erection of the penis. A manually operable by-pass valve enables the patient to withdraw fluid so that the penis returns to its normal flaccid condition. Selection of silicone rubber as the material of which the system is constructed plus the use of a fluid containing a radiopaque dye therein that is compatible with the silicone rubber (and also the body tissue and organs) assures that the system will in turn be completely compatible with the body tissue and organs, both as to the material from which it is fabricated and also as far as the fluid is concerned in case there should develop a leak. Also, the employment of a radiopaque dye affords a ready means of determining where the leak has occurred and also the magnitude of any such leak, thereby localizing and thus minimizing the extent of surgical repair.
FIG. 1 is a front sectional view depicting the trunk of a male patient having the erectile system implanted therein, the penis appearing in solid outline with the portions of the expandable cylinders implanted therein appearing in phantom outline;
FIG. 2 is a highly diagrammatic side elevational view of the expandable cylinder located toward the left of the penis shown in only phantom outline, the cylinder being only partially filled with fluid resulting in a flaccid condition of the penis;
FIG. 3 is a diagrammatic view corresponding to FIG. 2 but with additional fluid pumped into the particular cylinder that has been depicted to thereby cause the penis to assume an erect state;
FIG. 4 is a pictorial cross sectional view of a penis equipped with prosthetic cylinders that have been implanted in accordance with the teachings of the invention, the view being taken in the direction of line 4--4 of FIG. 2;
FIG. 5 is a cross sectional view corresponding to FIG. 4 but illustrating a penis as it appears prior to implantation of the expandable cylinders used in the practicing of the invention;
FIG. 6 illustrates my system prior to being implanted in a male, the view being as though the parts were laid on a flat table or planar surface for inspection and not in the relation they assume when implanted;
FIG. 7 is a side elevational view of the inflate-deflate unit, the view being taken in the direction of line 7--7 of FIG. 6;
FIG. 8 is a sectional view taken in the direction of line 8--8 of FIG. 6 for the purpose of illustrating one construction the reservoir of my system may assume;
FIG. 9 is a sectional view of one of the expansible cylinders, the view being taken in the direction of line 9--9 of FIG. 6;
FIG. 10 is a sectional view taken in the direction of line 10--10 of FIG. 7 for the purpose of illustrating the internal construction of the inflate-deflate unit;
FIG. 11 is a sectional view of the by-pass valve contained in the inflate-deflate unit, the view being taken in the direction of line 11--11 of FIG. 10, and
FIG. 12 is a sectional view corresponding to FIG. 11, but with the by-pass valve flexed to permit passage of fluid.
Referring first to FIG. 1, the trunk of a human male has been denoted generally by the reference numeral 10. Within the pelvic cavity 12 are the right and left hip bones 14, 16 and, for the sake of completion, upper ends of the thigh bones 18 have also been illustrated. The person's skin has been assigned the reference numeral 20, and in FIGS. 2 and 3 the pubic symphysis 21 appears, being depicted only diagrammatically in phantom outline. The reference numeral 22 represents the male's penis and the numeral 23 the scrotum, which parts have been superimposed on FIGS. 2 and 3 in only phantom outline.
It may be helpful to refer generally to the more pertinent parts of the penis 22 as far as this invention is concerned. For this reason, FIG. 5 has been presented. It will be understood, though, that numerous medical textbooks show the parts depicted in FIG. 5 with greater clarity and can be resorted to if necessary; one such textbook is "Gray's Anatomy". At any rate, the penis appearing in cross section in FIG. 5 has the usual outer layer of skin 24, the tissue and blood vessels confined therewithin being designated generally by the numeral 26, the corpus spongiosum 28 and the corpora cavernosa 30. As will be presently explained, the tissue in the corpora cavernosa is collapsed in order to provide space within the penis for the implanting of certain parts in accordance with the invention.
At this time it will be mentioned that the erectile system has been designated generally by the reference numeral 40. Assuming first that the corpora cavernosa have been collapsed, attention is directed to FIG. 4 which shows as a portion of the system 40 a pair of expansible cylinders 42a, 42b that are to perform the function of the corpora cavernosa. Although these cylinders 42 are of identical construction, they have been distinguished from each other by the suffix a and b.
More specifically, each cylinder 42 includes a cylindrical silicone rubber body or sleeve 44 (FIG. 9) which, owing to its resiliency, is expansible circumferentially and also longitudinally. The invention however, is primarily concerned with the ability of each sleeve to expand in length. The body is closed at one end by a rounded rubber cap 46, preferably comprised of two layers 46a, 46b reinforced with polyester fibers (Dacron). As can be seen in FIG. 6, the outer layer 46b overlaps the end of the sleeve or body 44, being secured thereto by means of an implantable grade of adhesive, such as Type A adhesive manufactured by Dow Corning Corporation of Midland, Michigan. At the other end of the body or sleeve 44 is a tube 48, which is about 2.5 cm long, having an annular slit at 50 in which the end portion of the body or sleeve 44 is fitted in a fluid-tight relationship. The wall thickness of the tube 48 is sufficiently great (on the order of 0.35mm) to permit this. The otherwise open end of the tube 48 is closed by means of a plastic plug 52 preferably comprised of Dow plastic 4210 RTV. A portion 52a of plug 52 axially extends part way into the tube 48 in each instance. While the cylinders 42 can vary in length, the typical range is from approximately 15 centimeters to about 21 centimeters. Consequently, the volume of fluid in each cylinder 42 may vary from about 10 milliliters in the smaller cylinders and to about 50 milliliters in the larger sizes. The internal diameter of the cylindrical body 44 may vary appreciably but for the mentioned volumes, this results in internal diameters on the order of 0.5 to 1.5 cm. The wall thickness of the sleeve or body 44 is not critical, but where surgical quality silicone rubber is employed, a wall thickness on the order of 0.8 mm can be employed. Another elastomeric material besides silicone rubber that can be employed is one of the newer polyurethane materials (Tecna).
It is obvious, it is believed, that the cylinders 42 are implanted lengthwise within the penis 22, actually being to either side of a vertical plane passing through the corpus spongiosum 28. Inasmuch as the embryonically provided corpora cavernosa 30 are at an elevation above the corpus spongiosum 28, the prosthesis cylinders 42 are also located slightly above the corpus spongiosum as well as to either side of the vertical plane that has just been mentioned; this relationship is believed readily apparent from FIG. 4 where the cylinders 42a, 42b have been placed within the corpora cavernosa 30 of FIG. 5. The lengthwise positioning of the cylinders 42 is believed readily apparent from FIGS. 1, 2 and 3.
The system 40 additionally comprises a fluid transfer mechanism indicated generally by the reference numeral 54. The entire fluid transfer mechanism 54 is preferably implanted in the lower portion of the patient's abdominal cavity or the upper portion of the pelvic cavity 12 as illustrated in FIG. 1. From especially FIG. 8 it will be discerned that a reservoir 55 is formed with two flexible panels 56, 58. The marginal edges of the panels form a lap joint 59, being sealed together with a suitable adhesive, such as the Type A adhesive mentioned hereinbefore, so as to prevent leakage from the reservoir. The volumetric capacity of the reservoir 55 is on the order of from 40-50 cubic centimeters. Reservoir 55 can be made from the same material which comprises cylinder bodies 44.
From FIGS. 1 and 6 it can be seen that a tube or conduit 60 extends from the reservoir 55, this tube also being comprised of silicone rubber. An implantable grade of adhesive can be employed to assure a liquid tight connection of the tube 60 with the reservoir 55. Here again the Type A adhesive, manufactured by Dow Corning Corporation of Midland, Michigan is quite satisfactory. As indicated, one end 60a of the tube 60 has communication with the interior of the reservoir 55; the other end 60b of this tube 60 is connected to an inflate-deflate unit denoted generally by the reference numeral 62.
Describing the inflate-deflate unit 62 which is shown in detail in FIG. 10, it includes a casing 64, such as 20 mil silicone rubber, reinforced with polyester fibers. The tube end 60b actually extends through the housing wall 64 into one end of a specially constructed by-pass valve labeled 66. The by-pass valve 66 comprises first and second transverse silicone rubber tubes 68, 70 having their adjacent ends 68a and 70a spaced apart. The tubes 68, 70 are contained within a reinforced wrap around Teflon tube 72, and an outer reinforced tube 74. The ends 68a and 70a, together with the wrap around tube 72, form a chamber 76, in which is confined a solid, preferably Teflon ball 78. More specifically the ends 68a and 70a are beveled or chamfered to form machined valve seats for the ball 78. Close inspection of FIG. 10 will reveal that the size of the ball 78 is related to the beveled ends or seats 68a and 70a (see FIG. 11 also) so that a sealing action normally exists by reason of the annular or circular line contacts at 78a and 78b with the spherical outer surface of the ball 78. A mass 80 of adhesive, such as the earlier-mentioned Type A adhesive, blocks the remote ends 68b, 70b of the tubes 68, 70. The mass generally fills the casing 64, although a void is provided at 81. More will be said hereinafter concerning the by-pass function played by the valve 66 including the void 81 associated therewith.
A relatively short tube 82 has its end 82a in communication with the same end of the valve 66 as does the tube 60, and has its end 82b connected to a first check valve 84. The check valve 84 includes a cylindrical body 86, actually a silicone rubber tube, the end 82b of the tube 82 being sealed within one end of the cylindrical body 86. Another tube 88, even shorter than the tube 82, extends from the check valve 84, having its end 88a cemented within the opposite end of the cylindrical body 86 as can be pictorially understood from FIG. 10. A chamber 90 exists between the end 82b of the tube 82 and the end 88a of the tube 88. Within this chamber 90 is contained a solid, preferably Teflon ball 92 that performs the actual checking function. In furtherance of this checking goal, a close inspection of the end 82b of the tube 82 will reveal that it has a machined valve seat. Here again, this is just a chamfer or beveling of the end to form the seat. The end 88a of the tube 88 is notched or serrated. Owing to the serrated configuration of the end 88a of the tube 88, fluid flow can occur through the check valve 84 only in the direction of the arrow indicated by the numeral 94. More specifically, when fluid forces the ball 92 toward the serrated seat 88a (away from the seat 82b with which the ball 92 is engaged as illustrated in FIG. 10), there will be flow in the direction of the arrow 94 because of the passage permitted by the serrated or notched configuration. On the other hand, the ball 92, when urged against the machined valve seat 82b (this seated condition being illustrated), will block flow in this direction, that is opposite to the arrow 94.
The tube 88 communicates with an elastomeric bulb 96, preferably of silicone rubber and part of the unit 62, thereby constituting an expansible chamber device that functions as a pump or "inflate" bulb. It will be observed that the casing 64 overlaps the bulb 96 in the region of the check valve 74, actually being sealed to the casing 64. Some of the fluid of the system 40 appears in FIG. 10 (and also in FIG. 8), having been assigned the reference numeral 97.
Another tube 98 corresponding in length to the tube 88 conducts fluid 97 from the bulb 96 to a second check valve 100 comprising a cylindrical body 102. A chamber 104 is formed between the end 98b of the tube 98 and the end 106a of a tube 106 corresponding generally in length to the previously mentioned tube 82. As with the check valve 84, the check valve 100 also contains a solid ball 108. In this instance, the end 98b is machined to form a valve seat, whereas the end 106a is serrated or notched so as to permit the flow of fluid 97 into the tube 106. The flow of fluid is indicated by the directional arrow 110.
The other end 106b of the tube 106 is connected with the other end of the by-pass valve 66. There is still another tube 112 that extends from the casing 64, its end 112a having communication with the tube 106. Actually, the tube 112 functions to supply fluid 97 to the cylinders 42. To effect this, the tube 112 has a Y end 112b. Sealed within the end 112b are the ends 112a, 124a of still additional tubes 122 and 124. These tubes 122, 124 serve as input tubes for the cylinders 42, actually entering the rather thick tube 48 in each instance. In other words, their ends 122b, 124b are sealed to the tubes 48 at the ends of the two expansible cylinders 42a, 42b. It is thought that FIG. 6 adequately depicts this arrangement.
As already indicated to some degree, the system 40 is filled, but not completely, with the fluid 97 which contains a radiopaque dye selected to be compatible with the permeability characteristics of silicone rubber and physiologically compatible with the body tissue and organs in the event a leak should develop in the system. Perhaps more importantly, the radiopaque fluid 97 enables "visualization" of the location and orientation of the prosthesis subsequent to implantation. As previously mentioned, some of the fluid 97 appears in FIGS. 8 and 10.
Inasmuch as the system 40 is to be installed completely within the body of the male to be treated, surgical procedures are resorted to. Assuming that the system 40 is to have its fluid transfer mechanism 44 implanted in the trunk 10 as illustrated in FIG. 1, an abdominal incision is made through the skin 20 so as to provide access to the pelvic cavity 12. With the pelvic cavity open, the reservoir 55 and the tube 60 can be placed therein. Depending on where the inflate-deflate unit 62 is to be placed determines the extent of the surgical operation. The optimum location for the unit 62 is in the scrotum 23. The implacement of the unit 62 in the scrotum 23 offers a convenient region as far as the inflating and deflating procedures are concerned, all of which will be better understood when considering a typical operational sequence.
Having made the abdominal incision as mentioned above, a rigid metal rod is inserted into the corpora cavernosa 30 from the base of the penis 22 as exposed by the abdominal incision. The erectile tissue within the corpora cavernosa regions of the penis is displaced by the inserted rod. In this way, space is created for the subsequent insertion of the prosthetic cylinders 42. The prosthetic cylinders, actually individually labeled 42 a, 42b, are intentionally fabricated into a shape simulating that of the corpora cavernosa 30 and effectively replace their biological function. Inasmuch as the expansible cylinders 42 are of elastomeric material, namely silicone rubber, an exact fit in the resulting cavity derived from the rod insertions steps is not necessary. All that is needed is that the cylinders 42 become stiff when inflated. Quite obviously, the proper selection of size for the prosthetic cylinders 42 will reduce the amount of pumping action, at least initially, so care should be exercised to provide, at least generally, the proper size relationship.
For the sake of facile explanation, the overall or total length of the cylinders 42 in FIG. 6 have been indicated as having a length L. Still further, a line labeled 128 has been superimposed upon FIG. 6 so that approximately one-third the length of the cylinders 42 appear to one side of the line 128 and two-thirds to the other side of the line 128. To further facilitate the description, the one-third length appearing in FIG. 6 has been denoted by the reference numeral 142a as far as the cylinder 42a is concerned, and the corresponding tubular portion of the cylinder 42b by the reference character 142b. The two-third portions have been denoted by the numerals 242a and 242b, respectively. The tubular portions 142a, 142b extend from the pubic symphysis 21 (FIGS. 2 and 3) and provide means by which the cylinders 42a, 42b are anchored so that the tubular portions 242a, 242b, which reside in the penis 22, act as rigid cantilever beams when inflated. The surgeon initially selects the appropriate overall length L (from 15 cm to 21 cm) and during the implanting procedure makes certain that the portions 142a, 142b reside within the trunk 10 and the portions 242a, 242b within the penis 22.
Either before or after the emplacement of the two cylinders 42, more specifically the portions 242a and 242b, into the penis 22, the inflate-deflate unit 62 can be inserted downwardly into the scrotum 23, the pouch-like configuration of this region readily accommodating the entire unit 62.
Although not illustrated, the various tubes 60, 112, 122 and 124 may make use of connectors so that they are the proper length for the particular implanting operation. In other words, the tubes can initially be longer than necessary and shortened to whatever extent is necessary by merely removing a given length and then rejoining the various ends through the agency of the alluded to connectors.
Once the system 40 is implanted, as outlined above, there is no need for further medical attention unless a leak should occur. Leakage, however, is not apt to take place. It has already been pointed out that the radiopaque dye contained in the fluid 97 enables "visualization" of the orientation of the parts within the system, the visualization obviously being with appropriate detection equipment for the particular type of radiant energy being used and for which the radiopaque dye blocks the passage of such energy. Also, the presence of the dye enables any leakage to be detected.
Assuming that the system 40 has been implanted within the trunk 10 of the male body in the manner appearing in FIG. 1 and that it has been substantially filled with fluid 97, from FIGS. 2 and 3 it will be perceived that the user himself can squeeze the particular bulb 96 through the scrotum skin inasmuch as the inflate-deflate unit 62 has been implanted in the scrotum 23 in this instance. In other words, the innerjacency of the bulb 96 with respect to the scrotum skin enables the user to apply squeezing pressure through the skin (and any intervening tissue such as the Dartus Tunic). Hence, the patient's fingers simply knead or squeeze the bulb 96 to force that portion of the fluid 97 therein under pressure through the check valve 100, the tube 112, the tubes 122 and 124 into the expansible cylinders 42a, 42b. It will be appreciated that the ball 108 readily moves away from the seat 98b, being carried by the flowing fluid 97 against the notched or serrated end 106a which, owing to its configuration, allows the passage of fluid. However, the ball 92, under these circumstances, is forced against the seat 82 b to prevent flow back to the reservoir 55 via the tube 60. Stated somewhat differently, the flow can only be in the direction of the arrow 110 at this time.
When the pressure being applied through the scrotum skin, which compresses the bulb 96, is relaxed, then the bulb 96 immediately returns to its normal shape and volume, the resiliency of the silicone rubber constituting this bulb being such as to assure such return. In the process of doing this, however, fluid 97 is drawn from the reservoir 55 through the tube 60, the check valve 84 into the bulb 96. In other words, the ball 92 is moved away from the seat 82b toward the notched or serrated end 88a which allows the fluid to pass by reason of the notched configuration. Flow thus occurs in the direction of the arrow 94. During the return of the bulb 96 to its normal size, the ball 108 is drawn against its seat 98b so that fluid 97 that has already been pumped into the cylinders 42 is not withdrawn.
Therefore, it will be recognized that the bulb 96 functions as an expansion chamber device, the repeated compressing and relaxing thereof producing a pumping of fluid into the expansible cylinders 42. The successively repeated squeezing operation or manipulation of the bulb 96 incrementally increases the pressure within the prosthetic cylinders 42. The resulting expansion or inflation of the cylinders 42, more specifically their rubber bodies 44, quickly eliminates any space within the corpora cavernosa 30 and continued pumping simply stiffens the two cylinders 42a, 42b with a concomitant erection of the penis. It will be appreciated that the patient has full control of the erection process, pumping into the cylinders 42 only enough fluid 97 to provide the desired erection state.
During the foregoing inflation or expansion procedure, the by-pass valve 66 remains closed. More specifically, the ball 78 remains engaged with both the seats 68a and 70a so that no fluid 97 flows through the tubes 70, 68 into the tube 60 and hence back to the reservoir 53. In this regard the contractive force exerted by the tubes 68 and 70, supplemented by the overwrapping 72 and 74, produces the line contact sealing engagement denoted by the reference numerals 78a, 78b.
However, when the inflated or expanded cylinders 42 are to be deflated so as to return them to their normal flaccid condition, all that the patient has to do is to squeeze the casing 64 in the region of the check valve 66, doing so through the upper portion of the scrotum skin in contradistinction to the squeezing in the lower portion thereof when performing the pumping or inflation process.
FIG. 12 represents the deformed or open condition of the by-pass valve 66 when being squeezed laterally in the direction of the arrows 120. It will be appreciated that the internal diameter of the Teflon tube or wrapping 72 is such as to permit inward lateral movement, the seats or ends 68a, 70a riding horizontally inwardly over the curved surface of the ball 78. This, however, results in a vertical deformation with the forming of upper and lower openings or passages 122 and 124, as are discernible in FIG. 12. It is the flow through these openings or passages 122, 124 back to the reservoir 55 that causes the cylinders 42 to be deflated. If desired, manual or squeezing pressure can be applied against the penis 22 with the valve 66 held open, thereby hastening the deflation process and the return to a flaccid or limp condition.
Recapitulating, what occurs by reason of the foregoing operational sequence is that the increase of pressure within the prosthetic cylinders 42 causes them to change from the flaccid state or partially filled condition appearing in FIG. 2 to an erect state or condition as appearing in FIG. 3. In other words, the inflated cylinders 42a, 42b become rigid and the tubular portions 242a, 242b act as cantilever beams to carry the weight of the penis 22, the portions 142a, 142b projecting from the penis 22 into the body 10 so as to provide anchorage of the cylinders 42. With respect to the anchorage of the cylinders 42, it has already been mentioned that the portions 142a, 142b constitute approximately one-third the overall length of the cylinders 42a, 42b. It can be further explained at this stage that the portions 142a, 142b are situated within the body 10, the ends thereof abutting the person's pubic symphysis 21 as schematically indicated in FIGS. 2 and 3. Thus, two thirds of the length of the cylinders 42 are within the penis 22. Consequently, the degree of penile erection is in accordance with the amount of fluid 97 that has been pumped into the prosthetic tubes 42, controlled by varying the amount of fluid within these cylinders 42.
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|Implantable penile prosthesis fluid transfer systems and methods
|6 Dic 2002
|30 Ago 2005
|Ams Research Corporation
|Spontaneous inflation inhibitor for inflatable prosthesis
|2 Dic 2003
|31 Ene 2006
|Ams Research Corporation
|Implantable pump
|14 Feb 2001
|14 Mar 2006
|Obtech Medical Ag
|Male impotence prosthesis apparatus with wireless energy supply
|21 Jun 2005
|27 Jun 2006
|Ams Research Corporation
|Method for detecting an unsatisfactory condition in an implantable system
|5 Oct 2004
|30 Ene 2007
|Ams Research Corporation
|Penile prosthesis with improved tubing junction
|10 Mar 2004
|17 Jul 2007
|Ams Research Corporation
|Implantable penile prosthesis pump
|1 Oct 2004
|31 Jul 2007
|Ams Research Corporation
|Implantable penile prosthesis pump
|21 Jul 2005
|1 Abr 2008
|Ams Research Corporation
|Method of preventing inadvertent inflation of an inflatable prosthesis
|1 Oct 2004
|5 Ago 2008
|Ams Research Corporation
|Penile prosthesis devices and methods
|8 Abr 2004
|21 Oct 2008
|Ams Research Corporation
|Pressure based spontaneous inflation inhibitor with penile pump improvements
|14 Feb 2001
|28 Oct 2008
|Obtech Medical Ag
|Penile prosthesis
|16 Dic 2005
|29 Dic 2009
|Ams Research Corporation
|Implantable penile prosthesis pump
|17 Mar 2006
|15 Jun 2010
|Tonaba Healthscience Ii, Llc
|Cosmetic and reconstructive prostheses with a microencapsulated biologically compatible rupture indicator for sustained release and methods of detecting compromise of a prosthesis
|21 Jul 2005
|25 Ene 2011
|Ams Research Corporation
|Implantable pump
|13 Nov 2009
|29 Mar 2011
|Ams Research Corporation
|Implantable penile prosthesis pump
|9 Feb 2001
|26 Abr 2011
|Obtech Medical Ag
|Controlled impotence treatment
|7 Abr 2006
|24 May 2011
|Ams Research Corporation
|Fluid reservoir for penile implant devices
|10 Sep 2010
|13 Sep 2011
|Coloplast A/S
|Inflatable penile implant
|14 Dic 2010
|22 Nov 2011
|Ams Research Corporation
|Implantable pump
|16 Oct 2002
|17 Ene 2012
|Obtech Medical Ag
|Controlled anal incontinence disease treatment
|19 Nov 2009
|17 Ene 2012
|Obtech Medical Ag
|Urinary incontinence treatment with wireless energy supply
|30 Sep 2008
|17 Ene 2012
|William D. Borkon
|Variable rigidity vaginal dilator and use thereof
|12 Nov 2007
|7 Feb 2012
|Ams Research Corporation
|Inflatable penile prosthesis bypass valve noise reduction
|23 Oct 2008
|14 Feb 2012
|Ams Research Corporation
|Corrugated inflatable penile prosthesis cylinder
|12 Nov 2008
|28 Feb 2012
|Ams Research Corporation
|Corrugated expansion-constraining sleeve for an inflatable penile prosthesis cylinder
|22 May 2006
|28 Feb 2012
|Obtech Medical Ag
|Controlled penile prosthesis
|19 Dic 2006
|1 May 2012
|Pump with one-touch release
|11 Feb 2011
|14 Ago 2012
|Fogarty Terence M
|Inflatable penile prosthesis with spool valve
|30 Nov 2011
|4 Sep 2012
|Coloplast A/S
|Penile prosthetic system and pump having inlet valve with high velocity closure mechanism
|14 Oct 2008
|2 Oct 2012
|Ams Research Corporation
|Diaphragm based spontaneous inflation inhibitor in a pump for an inflatable prosthesis
|29 Abr 2008
|16 Oct 2012
|Obtech Medical Ag
|Mechanical impotence treatment apparatus
|19 Ago 2010
|16 Oct 2012
|Obtech Medical Ag
|Impotence treatment apparatus with energy transforming means
|10 May 2007
|20 Nov 2012
|Peter Forsell
|Hydraulic anal incontinence treatment
|22 Sep 2010
|25 Dic 2012
|Coloplast A/S
|Penile prosthetic with anti-autoinflation mechanism
|2 Nov 2010
|12 Feb 2013
|St. Jude Medical Ab
|Implantable medical lead with housing integrity indicator
|12 Oct 2009
|13 Ago 2013
|Milux Holding Sa
|Heart help device, system, and method
|1 Feb 2010
|1 Oct 2013
|Obtech Medical Ag
|Anal incontinence disease treatment with controlled wireless energy supply
|4 Feb 2010
|1 Oct 2013
|Coloplast A/S
|Inflatable penile implant
|15 Ene 2010
|15 Oct 2013
|Obtech Medical Ag
|Controlled urinary incontinence treatment
|9 Oct 2009
|3 Dic 2013
|Milux Holding Sa
|Apparatus, system and operation method for the treatment of female sexual dysfunction
|25 Abr 2008
|10 Dic 2013
|Obtech Medical, AG
|Mechanical impotence treatment apparatus
|29 Ene 2009
|28 Ene 2014
|Milux Holding Sa
|Device for treating obesity
|14 Mar 2006
|25 Mar 2014
|Obtech Medical Ag
|Male impotence prosthesis apparatus with wireless energy supply
|12 Oct 2009
|15 Abr 2014
|Kirk Promotion Ltd.
|Heart help device, system, and method
|23 Dic 2009
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|Ams Research Corporation
|System to transport components of implantable penile prostheses
|28 Jun 2006
|27 May 2014
|Obtech Medical Ag
|Mechanical anal incontinence
|10 Sep 2008
|1 Jul 2014
|Obtech Medical Ag
|Penile prosthesis
|9 Oct 2009
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|Peter Forsell
|System, an apparatus, and a method for treating a sexual dysfunctional female patient
|23 Oct 2008
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|Ams Research Corporation
|Malleable prosthesis with enhanced concealability
|28 Ene 2009
|24 Feb 2015
|Peter Forsell
|Implantable drainage device
|29 Ene 2009
|23 Jun 2015
|Peter Forsell
|Method and instrument for treating obesity
|12 Oct 2009
|7 Jul 2015
|Peter Forsell
|Heart help device, system, and method
|18 Ene 2013
|21 Jul 2015
|Ams Research Corporation
|Automated implantable penile prosthesis pump system
|2 Dic 2003
|15 Jul 2004
|Ams Research Corporation
|Implantable pump
|17 Feb 2004
|16 Sep 2004
|Teitelbaum George P.
|Anti-occlusion catheter
|10 Mar 2004
|4 Nov 2004
|Morningstar Randy L.
|Implantable penile prosthesis pump
|8 Abr 2004
|4 Nov 2004
|Henkel Gregory J
|Pressure based spontaneous inflation inhibitor with penile pump improvements
|5 Oct 2004
|24 Feb 2005
|Ling Jeremy J.
|Penile prosthesis with improved tubing junction
|1 Oct 2004
|7 Abr 2005
|Ams Research Corporation
|Penile prosthesis devices and methods
|1 Oct 2004
|26 May 2005
|Kuyava Charles C.
|Implantable penile prosthesis pump
|21 Jun 2005
|13 Oct 2005
|Westrum John W Jr
|Implantable fluid transfer system
|21 Jul 2005
|10 Nov 2005
|Kuyava Charles C
|Method of preventing inadvertent inflation of an inflatable prosthesis
|21 Jul 2005
|10 Nov 2005
|Kuyava Charles C
|Implantable pump
|19 Jun 2003
|25 May 2006
|Peter Forsell
|Durable implant
|16 Dic 2005
|22 Jun 2006
|Ams Research Corporation
|Implantable penile prosthesis pump
|7 Abr 2006
|19 Oct 2006
|George Stephanie A
|Fluid Reservoir for Penile Implant Devices
|27 Oct 2011
|Anders Lindgren
|Implantable medical lead
|19 Dic 2006
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|Pump with one-touch release
|20 Nov 1979
|29 May 1980
|American Med Syst
|Chirurgisches geraet
|23 Dic 1980
|1 Oct 1981
|American Med Syst
|10 Jul 1987
|28 Ene 1988
|Bristol Myers Co
|27 Oct 1981
|12 May 1982
|Medical Engineering Corporation
|Penile erectile system
|19 Nov 1981
|2 Jun 1982
|ESKA medical & kunststofftechnik gmbh & co., vormals Walter Koss
|Penis prosthesis
|13 May 1982
|1 Dic 1982
|American Medical Systems, Inc.
|Penile prosthesis with improved fluid control
|2 Ago 1982
|16 Feb 1983
|Medical Engineering Corporation
|Implantable penile erectile system
|8 Mar 1984
|19 Sep 1984
|Giuliano Vignoli
|Rigid-inflatable means for artificially erecting the penis in the case of impotence
|7 Jul 1992
|3 Feb 1993
|Mentor Corporation
|Penile implant with lengthening cylinder
|7 Jul 1992
|17 Mar 1993
|Mentor Corporation
|Unitary inflatable penile prosthesis
|2 Ago 1979
|6 Mar 1980
|S Hakky
|Improvements in surgical implants
|16 Oct 1981
|29 Abr 1982
|David Segal
|Fracture fixation
|20 Dic 1982
|12 Abr 1984
|Medical Eng Corp
|Penile erectile system
|15 Abr 1985
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|24 Feb 1993
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|Penile prosthesis
|19 Dic 2006
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|Coloplast As
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|Clasificación de EE.UU.
|Clasificación internacional
|Clasificación cooperativa
|Clasificación europea


text:
1. THE iGESTURE
The Move: Obama presents Queen Elizabeth with an iPod loaded with Her Majesty's favorite Broadway show tunes.
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The Move: When the First Puppy makes a run for it during his introduction to the White House press corps, instead of yanking the newest Obama back, the master in chief jogs humanely after him.
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The Move: After a campaign event at an Iowa ice-cream parlor is over and all the press (save one photographer) has left, Obama takes a moment to wipe down the counter.
The Message: It doesn't matter how many assistants you have or how much of a hurry you're in—good manners are never optional. You're never too big to clean up after yourself.

subset: commoncrawl


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text:
Page 1
This article is published in a peer reviewed section of the International Journal of Integrated Care
International Journal of Integrated Care – Vol. 5, 3 October 2005 – ISSN 1568-4156 – http://www.ijic.org/
Integrated mental health services in England: a policy
Elizabeth England, Dr., Clinical research fellow, Department of Primary Care, University of Birmingham, Edgbaston,
England, UK
Helen Lester, Dr., Reader in Primary Mental Health Care,Department of Primary Care, University of Birmingham,
Edgbaston, England, UK
Correspondence to: Helen Lester, Phone: q 0121 414 2684, Fax: q 0121 414 6571, E-mail: firstname.lastname@example.com
Purpose: The purpose of this paper is to examine the effects of health care policy on the development of integrated mental health
services in England.
Data sources: Drawing largely from a narrative review of the literature on adult mental health services published between January
1997 and February 2003 undertaken by the authors, we discuss three case studies of integrated care within primary care, secondary
care and across the primaryysecondary interface for people with serious mental illness.
Conclusion: We suggest that while the central thrust of a raft of recent Government policies in England has been towards integration
of different parts of the health care system, policy waterfalls and implementation failures, the adoption of ideas before they have been
thoroughly tried and tested, a lack of clarity over roles and responsibilities and poor communication have led to an integration
rhetoricyreality gap in practice. This has particular implications for people with serious mental health problems.
Discussion: We conclude with suggestions for strategies that may facilitate more integrated working.
mental health, integration, health policy
Health care services in England have been subject to
a series of significant policy imperatives in the past
decade. There has been a shift in the theoretical
debate around the ways in which healthcare organi-
sations should deliver services to improve quality of
care through extending patient choice and access to
care and a particular focus on issues of partnership
working and integrated care. The debates around the
value of integrated care have been rehearsed in many
other countries w1,2x as a model for transforming
health caresystems,improving
responding to the multiple needs of patients both
within and beyond the field of mental health w3x.
This paper explores policy developments around serv-
ice integration within and between primary care and
secondary mental health services in England, and
reflects on how far current services have moved
beyond policy rhetoric towards the reality of integrated
services. We focus on integrated care for people with
serious mental illness, a group for whom continuity of
care is particularly important w4x and who have limited
options and choice to seek care elsewhere if dissat-
isfied. A seamless, co-ordinated accessible pathway
to care is, therefore, arguably more important for
mental health service users than many other patients.
The evidence base sources quoted in this paper are
largely drawn from a narrative review of the literature
on adult mental health services published between
January 1997 and February 2003 undertaken by the
authors w5x. This has been supplemented by discus-
sions with clinical leaders in the field of adult mental
health, particularly in Early Intervention Services
where the authors are involved with a national evalu-
ation of services.
The importance of mental health
Serious mental health problems are relatively com-
mon. Recent statistics suggest that an estimated one
in two hundred people have experienced a psychotic
disorder in the past year in the United Kingdom w6x
and that approximately three per cent of the population
Page 2
International Journal of Integrated Care – Vol. 5, 3 October 2005 – ISSN 1568-4156 – http://www.ijic.org/
This article is published in a peer reviewed section of the International Journal of Integrated Care
have some form of serious mental illness such as
bipolar affective disorder, schizophrenia or severe
depression w7x. The financial costs of mental illness in
England have been estimated at over 77 billion
pounds w8x, and this figure doubles once quality of
life is included alongside costs of care and lost
productivity. Indeed, the total cost to the economy of
mental health problems is greater than ischemic heart
disease, breast cancer and diabetes combined. Men-
tal illness also has a significant impact on the families
of those with mental health problems, many of whom
act as unpaid carers. Whilst harder to quantify, it has
also been argued that mental illness impacts on a
nation's social capital through the medium of poverty
and social exclusion w9x.
Conceptualising integrated health
Integrated care is, of itself, a nebulous and often
poorly defined concept, with different authors empha-
sising different aspects. Kodner and Spreeuwenberg
w10x in this journal have usefully proposed that
integration is a coherent set of methods and models
on the funding, administrative, organisational, service
delivery and clinical levels designed to create connec-
tivity, alignment and collaboration within and between
the cure and care sector « to enhance quality of care
and quality of life, consumer satisfaction and system
efficiency for patients with complex, long-term problems
cutting across multiple services, providers and settings.
Rhodes w11x describes integrated working as a meth-
od of overcoming the complexity associated with wel-
fare care, and is characterised by dynamic, flexible
and evolving methods of working that rely on horizon-
tal self-governing networks. Notions of horizontal and
vertical integration are also important in conceptualis-
ing and understanding policy and practice. Horizontal
integration refers to the bringing together of profes-
sions, services and organisations that operate at sim-
ilar levels in the care hierarchy. Vertical integration
refers to the bringing together of different levels in the
one hierarchy.
The conditions required for an integrated approach
to mental health can be conceptualised as ways of
working that acknowledge the importance of creating
a seamless pathway for the patient as they make their
way through different parts of the mental health sys-
tem. From a structural perspective, integrated care
goes one step beyond collaboration to co-ordination
and often co-location of care. To be sustainable, an
integrated approach needs to be underpinned by
opportunities for health professionals from different
backgrounds to train and learn together. It also
depends on good communication across the interface,
particularly around criteria for referral and discharge.
The importance of integrated mental
health services
As the Kodner and Spreeuwenberg w10x definition of
integrated care suggests, the potential benefits of
generic integrated approaches are significant for both
patients and providers. In the specific context of
primary care mental health, Blountw12xsuggests there
is evidence that an integrated approach to care can
improve adherence to medication because it provides
a better fit with the often undifferentiated way patients
present, increase satisfaction with care and, because
of transfer of expertise among team members, can
improve providers' skills base in dealing with psycho-
social aspects of care. A number of commentators
have also suggested that integrated care can be more
cost effective w12,13x.
There is also an increasing evidence base for both
the central importance of continuity of care for people
with serious mental illness w4x and of the misinterpre-
tations and consequences of being lost to follow up
w14x which add weight to the arguments for a more
integrated approach to mental health care.
People with serious mental health problems are also
among the most socially excluded within any society,
subject to the interlocking and mutually compounding
problems of impairment, discrimination, diminished
social roles, unemployment and lack of social net-
works w15x. They have fewer options and resources
than most and many find it problematic to negotiate
the complex bureaucracies and range of different
agencies involved in mental health. They, therefore,
need services that are well integrated at the point of
contact and a health care system that makes sense
from their perspective, that fits their differing needs at
different points in their journey and that adopts a
holistic approach to care w16x.
The consequences of poorly integrated
There are a number of costs of poor integration.
Perhaps the most extreme cost was reinforced by a
series of enquiries into murder cases involving people
with mental health problems. The Ritchie report w17x,
which was the culmination of the inquiry into the killing
of Jonathan Zito by Christopher Clunis, who was
diagnosed as having schizophrenia, at a London
underground station in 1992, highlighted the difficulties
inherent in joint working between services, the dupli-
Page 3
International Journal of Integrated Care – Vol. 5, 3 October 2005 – ISSN 1568-4156 – http://www.ijic.org/
This article is published in a peer reviewed section of the International Journal of Integrated Care
December 1997
December 1998
The New NHS: Modern, Dependable
Modernising Mental Health Services:
Safe, Sound and Supportive
NSF for Mental Health
NHS Plan
Shifting the Balance of Power
The Health and Social Care Act
Shifting the Balance of Power—
the Next Steps
PCTs go live across England
NHS Reform and Health Care
Professionals Act
New GP contract came into force
October 1999
July 2000
July 2001
August 2001
January 2002
April 2002
June 2002
April 2004
Figure 1. Policy time line from 1997.
cation of effort and indeed the potential for no-one
taking ultimate responsibility. The Ritchie Report did
not, on the whole, blame individuals and indeed noted
that Christopher Clunis was in some sense a victim
of the health and social care system since he had
spent over 5 years being sent between different facets
of the health and welfare service, between hospital,
hostels and prison with no overall plan for his care
and inadequate supervision for many aspects of the
health and social services.
From the patients' perspective, although relatively little
has been published on users' views of integrated
services, Preston w14x found that many patients felt
they had been left in limbo, with poor communication
and co-ordination across the interface often to blame.
As one of the people interviewed in his study
Separate clinics don't talk to each other or ring each
other. I find the whole thing incredible, the length of
time it takes: it's just been horrendous, waiting weeks
to see a consultant to be told 'I don't know why you've
been referred to me'«It can make you feel very insig-
nificant (1999, p.19).
Case studies of integrated care
Policy background
When New Labour formed the Government in the
United Kingdom in 1997, one its main policy focuses
was on the 'modernisation' of all sectors of Govern-
ment. This encompassed the promotion of partnership
working between different areas of Government and
with the voluntary and private sectors, and consulta-
tion with patients. Giddens w18x described this new
way of working as a 'third way' in the delivery of
welfare and health care between centralised, bureau-
cratic planning and marketised, consumerist liberal-
ism. The concept of the 'third way' took on particular
meaning at this time as it also became associated
with the politics of the New Democrats led by Bill
Clinton in the United States.
Echoing third way ideals, the Government's first sub-
stantive health service White Paper The New NHS:
Modern and Dependable w19x stated:
The Government is committed to building on what has
worked but discarding what has failed. There will be
no return to the old centralised command and control
of the 1970s « but nor will there be a continuation of
the divisive internal market system of the 1990's «
Instead there will be a third way of running the NHS—
a system based on partnership (Secretary of State for
Health, 1997, p. 10).
However, as the following case studies will demon-
strate, there is evidence to suggest that the speed of
change and number of significant often paradoxical
policy directives are in many ways responsible for the
failure of fully integrated services across health care
(see Figure 1). We will now examine these policy
paradoxes from three different perspectives: integra-
tion of services for people with serious mental illness
within primary care, secondary care and finally, across
the interface between primary and secondary care.
Case study 1: horizontal integration in
primary care for people with serious
mental illness
One of the main changes heralded in The New NHS
w19x was that commissioning would be in the hands
of Primary Care Trusts, that is, a new basic organi-
sational unit of the National Health Service covering
an average of 100,000 patients set up to manage,
commission and also to some extent provide primary
care services, instead of fund holding General Practi-
tioners and Health Authorities. However, the policy
document on Primary Care Trust formation, Shifting
the Balance of Power w20x in 2001 dramatically accel-
erated the timeframe for their formation. Twelve
months later, Shifting the Balance of Power—the next
steps w21x gave Primary Care Trusts additional
responsibility for commissioning all mental health serv-
ices. There are now over 300 Primary Care Trusts in
England, controlling 75% of the health budget. They
have, in effect, become substitute Health Authorities
for their geographical areas, but operate from primary
care rather than acute care platforms. However,
almost as soon as Primary Care Trusts had started to
function as independent bodies, the introduction of the
new General Medical Services Contract, effective from
April 2004 w22x and of practice based commissioning
in 2005 w23x, led to a further series of fundamental
changes in the way in which primary care is delivered
(see Figure 2).
Page 4
International Journal of Integrated Care – Vol. 5, 3 October 2005 – ISSN 1568-4156 – http://www.ijic.org/
This article is published in a peer reviewed section of the International Journal of Integrated Care
(SHAs) and
NHS Trusts:
NHS (Acute)
Mental Health
Care Trusts
services in
more than one
of State for
of Health
28 SHAs
(the link
between the
DOH and
the NHS)
c. 280 NHS
(Acute) Trusts
c. 33
c. 80 MHTs
c. 31
c. 300 PCTs
Figure 2. The NHS structure in England.
The new General Medical Services Contract, which
directly affects the 36,000 General Practitioners in the
United Kingdom and their patients, is a practice-based
contract between the Primary Care Trust and the
practice. There are far more centrally driven targets
which may theoretically encourage a better quality
core service with, for example, points (meaning mon-
ey) related to the delivery of specific services. It may
also help to ensure greater consistency in standards
and services. General Practitioners can now decide
to offer services at one of three levels: essential
services for people with acute and chronic illnesses
and which have to be provided by all practices;
additional services including maternity and contracep-
tive services which are being offered by most practic-
es, and enhanced services (which are optional)
including specialised care for people with depression.
From the perspective of patients with mental health
problems such as severe depression, the new contract
means that they may be able to see their regular
General Practitioner for the sore throat, but have to
go to a different health care setting to discuss their
depression if the Primary Care Trust has set up
specialised enhanced services for people with depres-
sion as part of the enhanced services scheme. Poten-
tial outcomes of this new way of providing services
include poorer continuity of care, an important part of
integrated care, particularly for people with serious
mental illness. This policy imperative also reinforces
the Cartesian notion of seeing people as having either
a physical or a mental health problem.
The advent of primary care practice based commis-
sioning from April 2005 poses an additional potential
threat to integrated mental health care. In 1997, when
New Labour abolished fund holding, the Government
made it clear that that it was keen to see practices
given the opportunity to hold indicative budgets to
commission a full range of services w19x. The NHS
Improvement Plan w24x stated that practices would be
able to hold an indicative budget from April 2005 to
commission services including community health team
assessments, psychological therapies and services
from specialised functionalised teams such as early
intervention and assertive outreach teams. Potential
benefits cited in support of practice based commis-
sioning include an opportunity to offer 'seamless'
health and social care. However, drawbacks highlight-
ed by Craig et al. w25x include the tension that may
be created between the need for strategic planning to
underpin sustainable commissioning and the frag-
mented nature of devolved commissioning to individ-
uals or groups of practice. Unlike many other areas
of the National Health Service, it is additionally difficult
to attach a price tag to mental health services (indeed
mental health services are excluded from the Payment
by Results scheme introduced in April 2005 precisely
because of this reason). Practice based commission-
ing also requires consistent quality of service delivery
and good quality information about services to be able
to offer patients a meaningful choice. Neither of these
is as far advanced in mental health services as in
other parts of the National Health Service. Whilst the
formation of Primary Care Trusts could be seen as a
Page 5
International Journal of Integrated Care – Vol. 5, 3 October 2005 – ISSN 1568-4156 – http://www.ijic.org/
This article is published in a peer reviewed section of the International Journal of Integrated Care
strong driver towards integrated care, the new GP
contract and subsequent devolution of commissioning
back to individual practices and localities threatens to
significantly fragment services particularly for patients
with serious mental illness.
Case study 2: horizontal integration—
the effect of functionalised mental
health teams on integrated secondary
care mental health services
Since the 1980s, multi-disciplinary generic Community
Mental Health Teams have been the main vehicle for
delivering co-ordinated comprehensive community
based mental health servicesw26x. Recently, however,
this notion of a generic community mental health team
responsible for all aspects of care for people with
common mental health problems referred from primary
care and also people with serious mental illness and
more complex needs has been reassessed. Evidence
from evaluations of service models in North America
w27x and Australia w28x and successful remodelling of
the community mental health services in North Bir-
mingham in the United Kingdom have been influential
in the thinking and development of functionalised
mental health teams, that is, specialist teams organi-
sed to provide for the needs of particular patient
groups. This approach has been reinforced by the
NSF for Mental Health w29x, The NHS Plan w30x and
a series of Mental Health Policy Implementation
Guides w31x describing the more detailed team struc-
ture and functions.
The Guidance on community mental health teams
states that 'Community Mental Health Teams will
continue to be the mainstay of the system. Community
mental health teams have an important and indeed
integral role to play in supporting service users and
families in community settings. They should provide
the core around which newer service elements are
developed' (2002, p. 3). Although the guidance is not
prescriptive about the relationships between Commu-
nity Mental Health Teams and the newer functionali-
sed teams, it suggests that 'mutually agreed and
documented responsibilities, liaison procedures and in
particular transfer procedures need to be in place
when crisis resolution, home treatment teams, asser-
tive outreach teams and early intervention teams are
being established' (2002, p. 17). Community Mental
Health Teams in future are, therefore, envisaged as
the central hub of mental health care, liaising with the
more specialised teams as well as with primary care.
These policy pledges, which led to the formation of a
series of functionalised teams, look on the surface to
encourage more appropriate and focussed care with-
out threatening the horizontal integration of mental
health services. However, in practice, they appear to
be having a number of paradoxical effects. Emerging
evidence from national evaluations of some of the
functionalised teams suggest that one unexpected
consequence of their introduction is a disintegration
of services from the patient's perspective. There are,
for example, concerns about the speed with which
Early Intervention Services are being developed w32x
and commissioned and, indeed, the need for a sepa-
rate Early Intervention Services at all w33x. Within
some Early Intervention Services, evidence from the
EDEN study suggests that variable 'buy in' to the
concept at Primary Care Trust commissioning level
has led to problems with releasing funds to develop
new teams and downward financial pressures on
existing ones. This is turn has led to staff shortages
and time constraints and resulted in some teams
deciding to reduce the age criteria for admission to
services. There has also been insufficient time to
develop links with teams who provide out of hours
care (between 6 pm and 9 am) and liaise with teams
who feed into early intervention services and take over
care once the initial period of care by the Early
Intervention Service is complete, all of which pose
significant threats to patient continuity of care (EDEN
early intervention services evaluation project team,
personal communication). Effective integrated care
requires new teams to have clear lines of communi-
cation with existing teams and adequate financial
resources, not redistribution of existing monies from
more established teams.
Case study 3: vertical integration across
the interface
In the United Kingdom, integrated mental health care
is most commonly represented as a system of shared
care between the primary health care team and sec-
ondary care mental health services w34x. In the early
1990s, it was estimated that, at any one time, between
20 and 30 people per 1,000 of the United Kingdom
population were being referred to out-patients or to
Community Mental Health Teams for further care, and
were, therefore, in receipt of shared care w35x. There
is little to suggest that the numbers are much different
From a policy perspective, shared care has been
increasingly mandated since the advent of the New
Labour Government in 1997, reflecting the partnership
approach within the wider modernisation agenda. Pri-
mary care, for example, has specific responsibility for
delivering standards two and three of the National
Service Framework for Mental Health w29x and is also


text:
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Guatemalart Ikat Crossbody Purse
Item # 255978
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What is this?This is the number of points you get in The Zumiez Stash for purchasing this item. Stash points are redeemable for exclusive rewards only available to Zumiez Stash members. To redeem your points check out the rewards catalog on thestash.zumiez.com.
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All materials on Kansas Memory are made available for noncommercial educational and research purposes only. It is the patron's responsibility to request and obtain permission from both the image and copyright owner(s) to use materials.
To obtain permission or to purchase a reproduction, please contact the KSHS Reference Desk at 785-272-8681, ext. 117 or firstname.lastname@example.com. See the Copyright and Permission FAQ for more information.
This is a studio portrait of three unidentified women all wearing clothes made of the same fabric pattern.
Creator: Palenske, Louis F., 1858-1943
Date: 1888
Item Number: 306476
Call Number: 2014-169
KSHS Identifier: DaRT ID: 306476
Collections - Contributing Institutions - Wabaunsee County Historical Society
Collections - Photograph
Date - 1880s - 1888
Objects and Artifacts - Communication Artifacts - Documentary Artifact - Photograph
People - Notable Kansans - Palenske, Louis, 1858-1943
People - Women
Places - Cities and towns - Alma
Places - Counties - Wabaunsee
Type of Material - Photographs


text:
Valentina Vezzali
Former fencing champion and newly elected member of parliament for... News PhotoDemocracy,Election,Event,Former,Government,Italy,Organized Group,Parliament Building,Politics,Rome - Italy,Success,Valentina Vezzali,VerticalPhotographer AFPCollection: AFP 2013 AFPFormer fencing champion and newly elected member of parliament for the centrist coalition Valentina Vezzali reacts during the first session of Italian lower-house on March 15, 2013 in Rome. General election in Italy took place on February 26 but as a majority in both chambers of parliament is required to form a government, Italy is left in a state of limbo with a hung parliament that is unprecedented in its post-war history. AFP PHOTO / ANDREAS SOLARO (Photo credit should read ANDREAS SOLARO,ANDREAS SOLARO/AFP/Getty Images)


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Welcome to the JMU Pre-Law Program webite. This site provides current JMU students and alumni with information about ABA-accredited law schools, LSAT information, law school admission practices, law-related events and activities at JMU, and a range of resources intended to help students identify appropriate schools for application.
Students should view a Pre-Law preparation as a four-year process of exploring and developing their talents and interests. Many pre-law students will choose to attend law school and practice law, while others will not. In the end, all students will benefit from attentive advising, demanding coursework, and quality co-curricular experiences whether or not they choose to attend law school.
If you have additional concerns or questions regarding law school after you have read the information provided on this website, you may schedule an appointment with an advisor—see the list of JMU Pre-Law advisors in the sidebar. Be sure to familarize yourself with the information on this webpage before meeting with your advisor.
For more information, please contact:
Dr. Jessica Adolino, Associate Dean, College of Arts and Letters
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Thursday, October 1, 2015
Festival Student and Conference Center, JMU
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2: I use screw top wine bottles (seem to have an endless natural supply of them!) with saran wrap and the they are fine... not brown but still dark.
3: I started getting better longeivity when I stored the chemicals in the hot press , this applies especially to winter as it's probably the most temperature consistent place in the house and also when I go to develop the base temperature is always around 18C so it doesn't take much time to get everything up to 20C.


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Take action
Reading Recovery Works! (PDF)
What Works Clearinghouse analysis
Reading Recovery and Common Core State Standards
Reading Recovery can play a vital role in ensuring that students are able to meet the goals of the Common Core State Standards. Free resources include a 20-minute webcast, an article from The Journal of Reading Recovery, and a report from RRCNA.
Reading Recovery and RTI
Response to Intervention
Free online resources
RRCNA is the only association advocating exclusively for Reading Recovery and early literacy intervention.
Hot Topics
Update on ESEA Reauthorization
Read more
A total of 178 amendments were proposed and 165 were adopted. The Senate chose to adopt an amendment that would require 60 votes in the affirmative on certain amendments for acceptance. It appears this action was in response to remarks that the President would veto the final bill if it contained language in conflict with the administration's commitment to Title I, which is designed to assist states in meeting the academic needs of disadvantaged students. By the end of that first day, agreement had been reached on nearly 20 amendments.
Sen. Steve Daines (R-MT) introduced an amendment that would allow a state to submit a declaration of intent to the U.S. secretary of education to combine certain funds to improve the academic achievement of students. Because they did not achieve 60 votes in the affirmative, the amendment could not be agreed to.
Another amendment was introduced by Committee Chairman Sen. Lamar Alexander (R-TN), that would allow states to let federal funds for the education of disadvantaged children follow those children to an accredited or state-approved public or private school or supplemental educational services program. The amendment did not pass (45-52).
The amendments that were agreed to cover a broad range of issues with minimal controversy.
Since the House of Representatives passed its ESEA reauthorization bill last week (see below), we expect a House-Senate Joint Conference Committee will be appointed to resolve the differences between the two bills. Where both bills include the same language, those provisions will be accepted. However, where there are differences or where one bill includes a specific provision and the other does not, the joint committee must come to agreement on whether to create compromise language or take the language from one bill over the other. Upon completion of this process, the final bill moves back to each chamber (Senate and House) for a vote, and if passed moves to the President for signature.
Student Success Act, H.R. 5
The House bill to reauthorize the ESEA, the Student Success Act, H.R. 5, was introduced in the House in February and reported out of the House Education and Workforce Committee later that month. Although H.R. 5 was scheduled for the floor vote on February 27, the bill was subsequently stalled until July 8, when it passed by a vote of 218-213.
The bill restricts the role of the federal government by restoring authority to the states and to local educational agencies. In fact, the language in the final House bill specifically restricts the authority of the U.S. secretary of education in matters historically residing with the states and local educational agencies.
While preserving the requirements for data collection by racial and ethnic groups, H.R. 5 leaves to the states the authority to determine academic standards and criteria for measuring student achievement. Amendments from both Democrats and Republicans are being introduced and receiving bi-partisan support. However, the Republican majority has ensured support for such issues as elimination of federal mandates, consolidation of federal education programs to provide greater flexibility, Title I portability, and reductions in reporting requirements.
Bipartisan Senate ESEA Bill a good first step
Senators Lamar Alexander, R-TN and Patty Miller, D-WA the chairman and ranking member of the education committee, respectively, are sponsors of an ESEA reauthorization bill being heralded as a "good first step." Formally titled the "Every Child Achieves Act of 2015," key provisions address Title I, accountability, data collection, academic standards, student assessment, teacher evaluation systems, and more.
Read more
RRCNA and other members of the national Advocates for Literacy coalition are pleased that the LEARN Act, a comprehensive state literacy program proposal, in included in the bill. Link to a summary of the proposed legislation and Advocates for Literacy letter of support.
Reading Recovery expands efforts to secure increased Congressional support for comprehensive literacy programs
RRCNA, along with other literacy advocates drafted and signed on to a letter to Senate Health, Education, Labor and Pensions (HELP) Committee Chairman Lamar Alexander (R-TN) and Ranking Member Patty Murray (D-WA), urging them to provide strong leadership to expand federal support to improve reading achievement among those students most disadvantaged economically.
Read more
In addition, Advocates for Literacy secured Rep. John Yarmuth (D-KY) and six other members of the House of Representatives—Steven Cohen (D-TN), David Loebsack (D-IA), James McGovern (D-MA), Eleanor Holmes Norton (D-DC), Mark Pocan (D-WA), Jared Polis (D-CO) and Charles Rangel (D-NY—to co-sponsor the LEARN Act, H.R. 858. The LEARN Act would establish a comprehensive literacy program funded by the Department of Education. It is expected that a Senate companion bill will be introduced in the coming weeks.
RRCNA and other literacy advocates were successful in securing Rep. Mark Pocan (D-WA) to introduce Amendment # 18 at the House Education and the Workforce Committee's Mark up of its bill to reauthorize the Elementary and Secondary Education Act (ESEA), H.R. 5, Student Success Act. Unfortunately, the amendment was defeated by voice vote. The amendment, if adopted, would have incorporated into the House ESEA bill the key provisions of H.R. 858.
Regarding the FY-2016 President's budget, the U.S. Secretary of Education has requested that the Striving Readers Program continue to be sustained at the FY-2015 level at $160 million, though the department has significantly changed some key provisions of the program. Advocates for Literacy are working to return the program to being "comprehensive" once again.
FY 2015 budget unlikely to result in education increases
The Committee for Education Funding (CEF) has responded to the FY 2015 budget and its effect on education by presenting a briefing on Capitol Hill.
Because of the sequestration ceiling previously agreed to in Congress, there is little hope for Congress to increase funding for Title I, IDEA, literacy and other formula programs in FY 2015.
Read more
Non-defense discretionary (NDD) caps for FY 2015 and FY 2016 are the same as those for 2014. So, unless Congress replaces the sequester caps, there is little room for additional investments in education.
Little movement seen in renewing federal education laws
Skepticism remains high that federal education laws, already outdated, might not get reauthorized by the end of this congressional session (December), or even by the end of President Obama's second term in 2016. Partisanship in Congress seems to have put most education bills in limbo. As a result, the Obama administration has taken action on education policy through a series of waivers easing parts of the No Child Left Behind Act. This has given the U.S. Department of Education more say in what happens in schools, but these solutions are temporary and make for an uncertain future for educators. Of high importance is the reauthorization of the Elementary and Secondary Education Act, last renewed in 2002.
View a complete list of education laws up for renewal.
Carl D. Perkins Career and Technical Education Act - governs vocational education programs and is the largest federal program for high schools
Last renewed in 2006
Child Care and Development Block Grant Act - Governs major child-care grants
Last renewed in 1996
Education Sciences Reform Act – Governs the Institute of Educations Sciences
Last renewed in 2002
Elementary and Secondary Education Act - Governs Title I and other key K-12 education programs; most recent version is the No Child Left Behind Act
Last renewed in 2002
Head Start Act - Governs the program that offers early childhood education services to low-income families
Last renewed in 2007
Higher Education Act - Governs teacher education programs, as well as student financial aid and college access programs
Last renewed in 2008
Individuals with Disabilities Education Act - Governs special education programs
Last renewed in 2004
Workforce Investment Act - Governs job training programs
Last renewed in 1998
Congress finally reaches budget deal
Advocates for Literacy calls for literacy funding in FY2014 budget
Read more
The letter cited that in order for the United States to compete in a global knowledge-based economy, young people must graduate with the advanced reading and writing skills required for career and college success. Two-thirds of all new jobs will require some type of postsecondary training. Currently, the manufacturing sector reports over 600,000 jobs in the U.S. go unfilled because applicants do not possess necessary literacy skills. Other sectors report that they would relocate new jobs in the United States if the U.S. had the requisite highly skilled workforce.
The Striving Readers Comprehensive Literacy Program takes a comprehensive approach. It supports literacy development and instruction from birth through Grade 12—from beginning letter recognition to the ability to infer and comprehend complex text—to ensure that all students can read and write at grade level.
SRCL provides resources to states and local schools to build educators' knowledge and skills in providing literacy instruction and support for each grade level and in each content area. The six states that have current Striving Readers Comprehensive Literacy grants are building integrated systems of effective literacy instruction that include both core and advanced literacy skills which all students will need to succeed in college and the workplace.
Reading Recovery plays vital role in meeting Common Core Standards
As the vast majority of states move forward with adopting Common Core State Standards, RRCNA has published a description of how Reading Recovery plays a vital role to ensure that first graders who struggle with literacy learning can meet grade-level standards and benefit from instruction at every subsequent grade level.
Read more
Many states are moving forward with the implementation of the Common Core State Standards for English Language Arts and Literacy in History/Social Studies, Science, and Technical Subjects. These Standards define knowledge and skills students need during their K-12 school years in order to be college and career ready at the end of high school. Although the Standards do not define specific methods or programs, an effective early intervention is critical for students already struggling with literacy learning.
Literacy grants to be awarded in six states thanks to Striving Readers Comprehensive Literacy Program
Read More
For the past 3 years, the Reading Recovery Council of North America has been part of a coalition of 40 national education organizations that advocated for increased resources to support literacy for children from birth through Grade 12. The coalition has been instrumental in the development of the Literacy Education for All, Results for the Nation (LEARN) Act and the Striving Readers Comprehensive Literacy Program (SRCL).
Funding for the Striving Readers Program was first appropriated in FY 2010 and provided $200 million for a comprehensive literacy development and education program. In 2012, $159 million was appropriated to continue these efforts. In October 2010, formula grants were awarded to State Education Agencies to create State Literacy Teams that would develop a comprehensive plan. The remainder of the FY 10 funds, $180 million, was open to a competition for all states. Georgia, Louisiana, Montana, Nevada, Pennsylvania, and Texas were winners of the competition. These states will use 95% of their award to make subgrants to LEAs. Contact your state education agency to learn more about timelines and possibilities.
900 organizations join to urge highest budget allocations
RRCNA has joined a coalition of 900 organizations urging congressional leadership to provdie the largest possible budget allocations to the Labor, Health, and Human Services, Education and related agenciess for FY2013. The coalition believes that rebuilding the U.S. investment in these domestic programs will boost the economy and reduce the deficit through prevention of costly chronic diseases, increased earnings, and reduced expenditures for unemployment and other social service programs.
We ensure that children who struggle in learning to read and write gain the skills for a literate and productive future.


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Reviews - Brasteds5
Manor Farm Barns, Framingham Pigot,, Norwich, NR14 7PZ
Price FromView Rooms
Customer Reviews
Our reviews are from genuine LateRooms.com customers. We verify that the customer has stayed before leaving a review.
Very Good
100% would recommend it to a friend
Customer service
Food quality
Room quality
Brasteds stay
Stunning place.staff and venue lovely throughout.recommend to anybody
Bratseds nr Norwich
I thoroughly enjoyed my stay.
The staff were extremely welcoming and helped me find a restaurant locally as their facility was fully booked. The room was spacious and well appointed.
Read More Less
Lovely Weekend Break at Brasteds
Good quality accommodation - stayed in Lady Jane room - highly recommended.
Excellent customer service especially from MD and Rachel. Relaxed but professional approach. Enjoyed fantastic dinner in attached restaurant. Brasteds isperfect for that special weekend away.
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This property allows you to book online with a credit card. After submitting a reservation request, the owner or manager has 24 hours to accept, at which time your card will be charged and you will receive an email confirmation
Other areas nearby to Emerald Isle:
Recent Emerald Isle reviews
"My husband and 17 year old son stayed here and there was plenty of room for all of us. We enjoyed the quick walk to the beach. It was nice being able to go back and forth to the beach to get some breaks from the sun. The condo is well decorated and furnished. The ocean view balcony was fantastic for morning coffee, evening cocktails and a card game if not windy out (a little too hot in the day as this gets all the morning sun). The pool area was very nice except the lights don't go on until 30 min before the pool closes which made it very dark down there for a an hour or so. There is a security guard on the grounds which is good and it is gated. It is close to the grocery store, tourist shops and restaurants (El Zarape, 4Js Cafe both right outside the gate and Sharks Den in plaza with Lion Foods were quite good) The biggest con was the cleanliness. I know the condo is surface cleaned before visitors, but it needs a scrubbing. I had to clean the ceiling fans before I could turn them on there was so much dust on them. The outdoor plastic chairs had rust spots so we had to scrub them and the table, still had to be careful with light clothing. The kitchen cabinets only have 1/2 the knobs so when you grab the drawers they feel sticky. Just a few things that seemed to irk us the whole time we were there. Other than that we really enjoyed our stay. The linen service for $75 is well worth it too. I would recommend staying there."Guest: holli a. Date of Stay: July 2015 Review Submitted: July 29, 2015View listing
"A great beachfront facility with easy access to beach. Complimented by a large pool. Large bedrooms that are well accommodated. Game tables make it a great place for children and teens. An excellent large family vacation facility."Guest: Davis C. Date of Stay: July 2015 Review Submitted: July 22, 2015View listing
"Our family of 6 adults and 5 children thoroughly enjoyed our week at the Tranquility! The view from the house is amazing! The ocean view can be enjoyed from all levels. We loved the clear railings on the bottom and middle level giving us an unobstructed view. The kitchen, bar, dining and family room area was perfect for allowing everyone to be together at the same time. We all enjoyed the the gift of chocolate covered pretzels as well :) We are looking forward to returning next year and hopefully getting to meet George and Suzanne."Guest: Beth Date of Stay: September 2015 Review Submitted: September 24, 2015View listing
"Just perfect! I could end my review here but that wouldn't be fair. The weather was perfect, the view from the upstairs bedrooms allowed me to wake up super early and maximize my days. I could hear the ocean all day long, it was just wonderful. The deck was perfectly built for the shade and the sun lovers. We could not have asked for more. The rooms are far apart enough to where you have enough privacy. This was officially the first vacation with the kids, and they enjoyed it. Thank you for sharing your home with us. We are truly grateful."Guest: ranya b. Date of Stay: June 2015 Review Submitted: July 2, 2015View listing
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