text:
|Publication number
|Publication type
|Application number
|Publication date
|Dec 14, 1999
|Filing date
|Apr 22, 1998
|Priority date
|Jun 24, 1994
|Fee status
|Also published as
|Publication number
|Stuart D. Edwards
|Original Assignee
|Vidacare, Inc.
|Export Citation
|BiBTeX, EndNote, RefMan
|Patent Citations (5), Referenced by (112), Classifications (108), Legal Events (3)
|External Links: USPTO, USPTO Assignment, Espacenet
This application is a continuation-in-part of U.S. patent application Ser. No. 08/731,372, filed Oct. 11, 1996, which is a continuation-in-part of U.S. patent application Ser. No. 08/319,373, filed Oct. 6, 1994, now U.S. Pat. No. 5,575,788, which is a continuation-in-part of U.S. application Ser. No. 08/286,862, filed Aug. 4, 1994, now U.S. Pat. No. 5,558,672 which is a continuation-in-part of U.S. patent application Ser. No. 08/272,162, filed Jul. 7, 1994, now U.S. Pat. No. 5,569,241, which is a continuation-in-part of U.S. patent application Ser. No. 08/265,459, filed Jun. 24, 1994, now U.S. Pat. No. 5,505,780, all of which are incorporated by reference.
1. Field of the Invention
This invention relates generally to a method and apparatus to controllably create controlled necrosis of at least a portion of the uterus, and more particularly to a method and apparatus to create selective cell necrosis of target sites of the uterus.
2. Description of Related Art
There are a number of body organs and lumens, including but not limited to the uterus, gall bladder, large intestine and the like, that have inner layers that develop disease states or otherwise abnormal conditions which can cause discomfort to the patient and are precursors to disease states. Traditional methods of treatment for these conditions have included removal all or a major portion of the body organ (e.g. hysterectomy).
Menorrhagia an abnormality of the uterus, is an example of such a disease state. It is characterized by excessive menstrual bleeding of the endometrium in the absence of organic pathology. While the disease has no known aetiology, it has been postulated that it is due to an inappropriate exposure of the endometrium to hormones. Approximately 10% of all women in the US experience menorrhagia and it is responsible for approximately one in five outpatient referrals to gynecological departments. At a minimum, the disease can cause considerable discomfort, distress and curtailment of lifestyle. Women suffering severe menorrhagia are at risk from chronic anemia and other complications. Moreover, it is the most frequent clinical indication for hysterectomy.
While there are a number of available treatments for the disease, many have limitations and/or potentially adverse complications. For example, currently available pharmacological therapy requires the long term administration of medication, which in some case provides only temporary beneficial effects while presenting potentially long term adverse side effects. Hysterectomy is another common treatment, but the associated morbidity and convalescence period can be prolonged, making this treatment an undesirable choice for some patients.
A number of physical and chemical methods have been tried as alternatives to hysterectomy, including the use of superheated steam, cryotherapy, urea injection and radium packing. The most commonly used methods as an alternative to hysterectomy are, ablation of the endometrium either by using a laser, such as a Nd:YAG laser, or the use of RF energy applied with an electrode.
Laser treatments have provided only limited success. RF is an attractive alternative. In RF heating, a conductive probe is placed within the uterine cavity and an insulated ground-plane electrode or belt is placed around the patient's midriff. RF energy is applied to the thermal probe with the external belt electrode acting as the return arm of the circuit. The electrical load presented by the RF thermal probe, patient, and external belt is matched to the output of the RF generator via a tuning unit, to form a series resonant circuit. Once tuned, the majority of the power applied to the probe is deposited into the endometrium as heat.
Current flows primarily capacitively, and an electric field is set up around the active tip of the probe. Tissue lying within the field becomes heated because of rapid oscillation of charged particles and locally induced currents.
Prior et al. have reported on the use of RF to treat menorrhagia. Power at 27�12 MHz was delivered to a probe that was placed into the uterine cavity and capacitively coupled to a second electrode consisting of a belt placed around the patient (Prior et al., Int. J. Hyperthermia, 1991, Vol. 7, No. 2, pgs. 213 to 220). The active electrode was a 10 mm diameter stainless-steel cylinder with a length of 70 mm. This method, however, did not adequately deliver RF energy to the entire endometrium. Because the endometrium has an irregular surface, it is difficult to deliver sufficient RF energy to the entire structure and effectively treat menorrhagia.
However, it is desirable to have close contact between the RF conductive face and the endometrium. In U.S. Pat. No. 5,277,201 (the "'201 patent") an electroconductive, expandable balloon expands the interior of the uterus and effects electrical contact with the endometrial lining to be destroyed. The device of the '201 patent fails, however, to provide sufficient physical contact with the entire endometrium, and thus the treatment is not complete. Not only is the physical contact with the endometrium unsatisfactory, but the effective delivery of RF energy to the endometrium could be improved as well.
There is a need to provide a method and apparatus to minimally invasively treat the uterus. There is a another need for a method and apparatus to minimally invasively treat selected sites of the uterus. There is a further need for a method and apparatus to selectively treat endometriosis and/or fibroids. There is yet another need for a method and apparatus to deliver sufficient energy to treat a substantial portion of the uterus.
Accordingly, an object of the invention is to provide a method and apparatus to minimally invasively treat the uterus.
Another object of the invention is to provide a method and apparatus to minimally invasively treated selected sites of the uterus.
A further object of the invention is to provide a method and apparatus to selectively treat endometriosis.
Another object of the invention is to provide a method and apparatus to selectively treat fibroids.
Still another object of the invention is to provide a method and apparatus to deliver sufficient energy to treat a substantial portion of the uterus.
Another object of the invention is to provide an easy to use method and apparatus to selectively create cell necrosis in the uterus.
These and other objects of the invention are achieved in an apparatus to treat a uterus comprising a deployable member configured to be positioned in a uterine cavity in at least a partially deployed state to define a microwave chamber in an interior of the deployable member, and removed from the uterine cavity in a non-deployed state. The deployable member is at least partially microwave energy absorbable and formed of a fluid permeable material to house and controllably release a fluidic medium from the microwave chamber when the deployable member is positioned in the uterine cavity in the at least partially deployed state. A microwave emitter is positioned in the microwave chamber, the microwave emitter being configured to be coupled to a microwave energy source and deliver microwave energy to the fluidic medium, wherein the fluidic medium transfers thermal energy from the microwave emitter to a uterine structure.
FIG. 1 is a lateral view of the uterine cavity illustrating positioning of the uterine treatment apparatus of the present invention in the uterus.
FIGS. 2B and 2A are lateral view of the present invention illustrating the introducer, introducer lumens, microwave chamber, fluid circuit and expansion device in an expanded and contracted state, respectively.
FIG. 3 is an enlarged lateral view illustrating the composition of the microwave chamber.
FIG. 4 is an enlarged lateral view of the microwave chamber illustrating the use of the microwave chamber to heat a heat transfer medium.
FIG. 5 is an enlarged lateral view illustrating the use of valves in the microwave chamber to control the flow of heat transfer medium.
FIG. 6 is an lateral view illustrating the use of a sheath to house the expandable member.
FIG. 7 is an lateral view illustrating the use of a second expandable member.
FIGS. 8A, 8B and 8C are lateral views illustrating the placement of pores on the expandable member.
FIG. 9 is a lateral view illustrating the expandable member in a fully deployed state inside the uterus and the use of a raised lip and insulating sections to contain endometrial heating to discrete areas of the uterus.
FIG. 10 is a lateral view illustrating the use of heating elements in the expandable member.
FIG. 11 is a lateral view illustrating the construction of the microwave antenna
FIG. 12 is a cross sectional view illustrating a visualization device coupled to an embodiment of the invention.
FIG. 13 is a flow chart illustrating a uterine treatment method using the apparatus of the present invention.
FIG. 14 depicts a block diagram of the feedback control system that can be used with the uterine treatment apparatus of the present invention.
FIG. 15 depicts a block diagram of an analog amplifier, microprocessor and other electronic components used with the feedback control system of FIG. 14.
FIG. 16 depicts a block diagram of the operations performed in the feedback control system depicted in FIG. 14 including control of heat transfer medium flow and the flow area on the expandable member.
Referring now to FIGS. 1 and 2, one embodiment of uterine treatment apparatus 10 that is used to deliver thermal energy to a treatment site 12 and produce thermal injury zones 14 in endometrium 16, includes a flexible introducer 18, coupled to a microwave chamber 20 and a conforming member 22, also called expandable member 22. Endometrium 16 comprises a surface layer of cells 16' (also called endometrial surface 16') that line the interior of the uterus 23. The apparatus of the present invention provides an improved means for the selected necrosis of these cells and other areas within uterus 23.
As shown in FIG. 2, introducer 18 has proximal and distal ends 18' and 18". In one embodiment of the present invention, a fluid source 19 is fluidicaly coupled to introducer 18 at or near its proximal end 18' while expandable member 22 is coupled at or near introducer distal end 18'. Fluid source 19 may be any one of a number controllable fluid pumps well known to those skilled in the art such as a peristaltic or positive displacement pump, versions of which are manufactured by the Cole Palmer Company. Introducer 18 has sufficient length to position microwave chamber 20 and expandable member 22 in the uterus 23 using a vaginal approach. Typical lengths for introducer 18 include, but are not limited to, a range between 2 to 20 cm. Introducer 18 is also sized to be able to enter the cervix 25 without significant resistance and/or the need to heavily anesthetize the patient. In various embodiments, introducer 18 is flexible, articulated and steerable. Introducer 18 may have one or more lumens 21, that extend the full length of introducer 18, or only a portion thereof. Lumens 21 may be used as paths for the delivery of fluids and gases, as well as providing channels for cables, catheters, guide wires, pull wires, insulated wires, and optical fibers. In one embodiment, introducer 18 can be a multi-lumen catheter, as is well known to those skilled in the art.
Referring now to FIG. 3, microwave chamber 20 includes an interior surface 20' an exterior surface 20", a microwave antenna 24, a proximal aperture 26, a microwave reflector 28 and microwave shielding 30. Microwave reflector 28 serves to focus microwaves within microwave chamber 20 and to reduce microwave energy losses from microwave chamber 20. This results in a more efficient conversion of microwave energy to thermal energy, which is used to heat a heat transfer fluid that will be discussed herein. Microwave reflectors 28 can include aluminum and other dichroic materials known to those skilled in the art. Microwave shielding 30 serves to minimize and/or prevent microwave energy from radiating out of microwave chamber 20 and includes materials such as polyiron, teflon�, polyvinyl chloride, silicon carbide fibers and other microwave energy absorbing materials known to those skilled in art. Microwave shielding can also be applied to all or a portion of introducer 18.
Referring now to FIG. 4, microwave chamber 20 is configured to be coupled to a microwave power source 32. Microwave chamber 20 is further configured to receive a fluidic medium, also called a heat transfer medium 34, from introducer 18, heat said fluid via microwave heating from microwave antenna 24 and subsequently delivery heat transfer fluid to exterior surface 20" of chamber 20 via pores, or channels 36 in microwave chamber wall 20'". In one embodiment of the invention, microwave chamber wall 20'", (including shielding and reflective layers 28 and 30) can be constructed of porous materials 38. Typical materials for porous materials 38 include, but are not limited to, expanded PTFE (teflon); and silicon carbide woven fibers such as Nicalon� and Nextel�. Use of porous materials 38 allows heat transfer fluid 34 to permeate through microwave chamber wall 20' under the influence of capillary action and/or a pressure head provided by fluid source 19.
Microwave energy emitted by antenna 24 causes oscillation and friction of the molecules of heat transfer medium 34. As a result of this intermolecular friction, high-frequency energy absorbed by heat transfer medium 34 is transformed into thermal energy, resulting in a temperature rise of heat transfer medium 34. The heating effect is enhanced in electrolyte and salt solutions. Accordingly, solutions for heat transfer medium 34 include, but are not limited to, water, electrolyte and salt solutions.
Microwave chamber 20 may contain one or more sensors 40 for sensing physical properties of heat transfer medium 34 within, on, or adjacent to microwave chamber 20. Such physical properties include temperature, electrical conductivity, electrical capacitance, thermal conductivity, density, flow rate, strength, elasticity, moisture content, optical reflectance, optical transmittance, optical absorption, acoustical impedance and acoustical absorption. Sensors 40 can be located in one or more of the following locations: i) on antenna 24, ii) on the exterior or interior surfaces 20" and 20' of microwave chamber 20 iii) within microwave chamber wall 20'", or iv) on expandable member 22. Suitable sensors that may be used for sensors 40 include: i) thermocouples, ii) fiber optics, iii) photomultipliers, iv) resistive wires, v) thermocouple IR detectors, vi) thin film sensors, vii) anemometric sensors, and viii) ultrasound sensors; all known to those skilled in the art. Sensors 40 may also be electronically coupled to fluid source 19 and a control system 44 discussed herein order to control the flow rate and/or fluidic pressure of heat transfer medium in microwave chamber 20.
In another embodiment of the invention depicted in FIG. 5, microwave chamber 20 includes a distal aperture 26' and a valve 42. Valve 42 may be electronically coupled to control system 44 and may also be controllable by the physician. Valve 42 may be a self actuating pressure-controlled one-way valve, such as a Bunsen valve, designed to open at a set pressure, or a self actuating thermostatically-controlled valve designed to open at a set temperature, or an electronically-controlled valve coupled to control system 44 discussed herein all of which are well known to those skilled in the art. In one embodiment, valve 42 opens when a given temperature or pressure is reached inside microwave chamber allowing heat transfer medium 34 to flow out of microwave chamber 20 into expandable member 22 or uterus 23. Valve 42 may also be opened under control of the physician. In alternative embodiments, valve 42 is opened by control system 44 using another set of control criteria programmable into control system 44 including, but not limited to, a rate of temperature increase, a rate of pressure increase, residence time in microwave chamber 20, or a combination of one or more of the preceding criteria.
Expandable member 22 is sized to be able to fit through cervix 25 in a non-deployed state without significant resistance. To facilitate passage of expandable member 22 through the cervix in its non-deployed state, expandable member 22 can be wrapped or folded around introducer 18 or another supporting member. Typical external diameters for expandable member 22 in a non deployed state include, but are not limited to, a range from 1 to 4 mms. When in the deployed state, expandable member 22 expands sufficiently such that the external surface 22' of conforming member 22 is engaged with all or a portion of endometrial surface 16'. The typical volume for expanded expandable member 22 is in a range that includes but is not limited to, values between 2 and 8 cubic centimeters.
Referring now to FIG. 6, in one embodiment of the invention, expandable member 22 can be disposed in its non-deployed state in a sheathing member 29, also called sheath 29, that extends over all or part of introducer 18. Once expandable member 22 has been properly positioned in uterus 23, sheath 29 is pulled back proximally, allowing expandable member 22 to be deployed in uterus 23. In various embodiments, sheath 29 is flexible, articulated and steerable and contains a continuous lumen of sufficient diameter to allow the advancement of introducer 18. Typical diameters for sheath 29 include 0.05 to 0.5 inches. Suitable materials for sheath 29 include coil-reinforced plastic tubing as is well known to those skilled in the art.
Expandable member 22 is made of a material that suitably conforms to the organ or tissue surface to be treated. This improves the engagement of expandable member 22 with endometrial surface 16' and in so doing, enhances the delivery of energy to treatment site 12. Typical thicknesses for the material used in expandable member 22 include, but are not limited to, a range from 0.0005 to 0.050". Also, expandable member 22 can have apertures 36 for the flow of beat transfer medium 34 to uterine wall 23'. Alternatively, expandable member 22 can be made of a microporous material that does not include distinct apertures. General material types for expandable member 22 include elastomeric polymers, porous polymers, foam materials or a combination thereof. Specific materials include but are not limited to, knitted polyester, continuous filament polyester, polyester-cellulose, rayon, polyimide, polyurethane, polyethylene, silicone, expanded teflon, and the like. Suitable commercial foams include: (i) Opcell, available from Sentinel Products Corp., Hyannis, Mass. and (ii) UltraSorb, HT 4201 or HT 4644MD from Wilshire Contamination Control, Carlsbad, Calif. Expandable member 22 has characteristics that make it particularly moldable and formable to irregular surfaces. In one embodiment, expandable member 22 is made of an open cell foam, or alternatively it can be a thermoplastic film such as polyurethane, low density polyethylene, or it may be a silicone. Referring now to FIG. 7, a second expandable member 22" can be coupled to first expandable member 22 such that first expandable member 22 is disposed inside of second expandable member 22". In various other embodiments, second expandable member 22" can be positioned proximal or to distal to first expandable member 22 and in fluid communication with first expandable member 22 via lumens 21. Second expandable member 22" receives at least a portion of heat transfer medium 34 from exterior surface 22' of first expandable member 22.
Turning now to a discussion of the placement of pores 36 in expandable member 22, pores 36 may be located on all, or only a portion, of expandable member 22 in areas called porous zones 46'. Upon application of sufficient pressure (supplied by fluid source 19), heat transfer medium permeates 34 out of pores 36 in first and/or second expandable member 22 and 22" and makes contact with uterine wall 23'. Referring now to FIGS. 8A, 8B and 8C, in various embodiments of the invention, pores 36 may be located over discrete areas of expandable member 22 in order to control the immediate area of uterine wall 23' contacted by heat transfer medium 34 and hence the area of thermal injury zone 14. As shown in FIG. 8A, pores 36 are positioned only on the distal half of expandable member 22, so as to minimize the heating of the lower half of uterine wall 23'. In another embodiment shown in FIG. 8B, pores 36 are located over most of the surface of expandable member 22, except for a non-porous zone 46' of sufficient area to prevent heating tissue in uterine wall within several centimeters of the cervix 25. In this case, non-porous zone 46' extends 0.5 to 3 cm past the distal end 18" of introducer 18. In another embodiment shown in 8C, pores 36 may be distributed across the surface of expandable member 22 in a pattern of varying pore diameter and pore density, such that pore density and diameter are greatest at the distal end of expandable member 22 with both decreasing in the proximal direction. The directional gradients of pore density and diameter on expandable member 22 are configured to allow the physician to be able to select the area of expandable member 22 that weeps heat transfer medium 34 by raising or lowering the pressure that is applied to expandable member 22 by fluid source 19. Specifically, lower pressures cause only the distal area of expandable member 22 to weep heat transfer medium 34 with increasing fluid pressure increasing this area in a proximal direction.
Referring now to FIG. 9, in order to facilitate the creation of discrete thermal injury zones 14 in uterine wall 23', expandable member 22 is fully inflated inside the uterus to engage the uterine wall and prevent the flow of heat transfer medium to areas of the uterus not contacted by porous sections of expandable member 22. For the same purpose, expandable member 22 may contain a raised lip 48 that impedes/prevents the flow of heat transfer medium to sections of the uterine wall not contacted by porous sections of expandable member 22. Lip 48 is located adjacent to the boundary between porous zone 46 and nonporous zone 46'. Continuing in this regard, to minimize the conduction of unwanted heat through expandable member 22, expandable member may contain a thermally insulating layer 50 over all, or part, of its surface area. Suitable materials for thermally insulating layer 50 include teflon, Thinsulate� and other thermal insulators known to those skilled in the art.
Referring now to FIG. 10 in another embodiment of the present invention, heating of uterine wall 23' may be done by heating elements 52, also called heating layer 52. Heating elements 52 are made of materials that are heated upon exposure to microwaves. The frequency and power of microwave energy form microwave power source 32 are adjustable to produce heating elements temperatures in the range of 45-90� C. The temperature of heating elements 52 can be controlled using control system 44 as will be discussed herein. This process can be facilitated by the use of sensors 40 be placed on or adjacent to heating elements 52. Suitable materials for heating elements 52 include graphite carbon, aluminum and ceramic fibers. Heating elements 52 can be located in all or a portion of the microwave chamber wall 20'"; or in all or a portion of the exterior or interior surface 20' and 20" of microwave chamber 20, which in this case may be integral to, or the same as conforming member 22. Heating elements 52 can be located inside microwave shielding layer 30. Alternatively heating elements 52 can be made of microwave absorbable materials such as silicon carbide and hence, make up microwave shielding layer 30. In an alternative embodiment, heating elements can be porous silicon carbide fibers which allow for the flow a liquid through heating elements for purpose of cooling heating elements 52. Similar to the distribution of pores 36, heating elements 52 can be located in discrete areas of expandable member 22 to in turn produce discrete thermal injury zones 14.
Referring now to FIG. 11, microwave antenna 24 is typically a linear coaxial microwave antenna with a choke or a standard single junction dipole microwave antenna. The dipole microwave antenna 24 is constructed from a semi-rigid coaxial cable 54 having an inner conductor 54' covered by an insulator 54". Coaxial cable 54 from which the antenna 24, is formed extends from the proximal end of introducer 18 and terminates in the slotted radiating portion 55 of antenna 24. The operation of the dipole microwave antenna 24 as is utilized in the apparatus of the present invention is described more fully in U.S. Pat. No. 4,825,880 to Stauffer et. al. for an Implantable Helical Coil Microwave Antenna, which is incorporated herein by reference. In an alternative embodiment, microwave antenna 24 is movable within microwave chamber 20 by advancement of coaxial cable 54. In this embodiment antenna 24 can be increased or decreased in length by a sliding a sheath of microwave absorbable material (not shown) over antenna 24.
Microwave antenna 24 emits microwave energy at a preferred frequency of 1,300 MHz+-50 MHz, and at power levels adjustable up to 50 W or 100. Accordingly, the microwave power source 32 is capable of generating microwaves at a frequency of 1,300 MHz+-50 MHz. and can be set at a precise frequencies value within this range.
Referring now to FIG. 12, another embodiment of uterine treatment apparatus 10 includes a visualization device 56 coupled to introducer 18. Visualization device 56 can include a combination of one or more of the following: a viewing scope, an expanded eyepiece, fiber optics (both imaging and illuminating fibers), video imaging devices and the like. Also, at least portions of uterine treatment apparatus 10 may be sufficiently radiopaque in order to be visible under fluoroscopy and/or sufficiently echogenic to be visible using ultrasonography.
FIG. 13 is a flow chart illustrating one embodiment of the operation of uterine treatment apparatus 10. In this embodiment, treatment apparatus 10 is first introduced into the uterus under local anaesthesia which may be no more than a pericervical block or other local anesthetic known to those skilled in the art. With expandable member 22 in a non-deployed state, the distal portion of introducer 18 is advanced through the cervix 25 until expandable member 22 is positioned in the uterus 23. Sheath 29 is then withdrawn, and expandable member 22 is expanded with the introduction of a fluid such as heat transfer medium 34, causing expandable member 22 to become distended and be self-retained in the uterus 23.
Heat transfer medium 34 can be introduced into microwave chamber 20 at room temperature or preheated to a temperature which can be adjusted and modified as necessary, for example between 60 to 90� C. By heating heat transfer solution 34 prior to introduction into uterine treatment apparatus and or uterus 23, there is a reduction in the amount of time needed to complete a satisfactory thermal injury to uterine wall 23' and also to the total procedure time.
The diagnostic phase of the procedure then begins and can be performed using a variety of diagnostic methods known to those skilled in the art including the following: (i) visualization of the uterus 23 via an endoscope or other viewing apparatus inserted into the uterus 23, (ii) visualization of the interior morphology of the uterine wall 23' using ultrasonography to establish a baseline for the tissue to be treated, (iii) impedance measurement to determine the electrical conductivity between uterine wall 23' and uterine treatment apparatus 10.
After diagnosis, the treatment phase of the procedure begins. Heat transfer medium 34 is heated in microwave chamber 20 introduced into expandable member 22 through valve 42 or pores 36 and subsequently introduced into contact with uterine wall 23' through pores 36. Alternatively, heating elements 56 in or on expandable member 22 are heated and engaged with endometrium 16. Using either approach, the preferred uterine contact temperature to cause thermal injury is between 45 and 85� C. In this phase of the procedure, the delivery of thermal energy to treatment site 12 can be conducted under feedback control, manually or by a combination of both. Feedback can be included and is achieved by the use of one or more of the following methods: (i) visualization, (ii) impedance measurement, (iii) ultrasonography; (iv) temperature measurement; and, (v) contractile force measurement via manometry. The feedback mechanism permits the selected on-off switching of microwave power source 32 and/or fluid source 19.
The area and placement of thermal injury zones 14 in the uterine wall 23' can vary. However the degree of injury must be sufficient to necrose or irreparably damage all of the endometrial cells in the targeted tissue. It is further desirable that these are damaged sufficiently to be sloughed off or otherwise destroyed, and/or removed by wound healing cells of the body including: macrophage, fibroblasts and myofibroblasts. Regarding placement, thermal injury zone 14 may cover the entire endometrium or, alternatively, selected portions of the endometrium may not be ablated such as those portions close to the cervix and or the fallopian tubes. For both complete and partial ablation of endometrium 16, it is important that the thermal injury zones 14 are uniform with the respect to the degree of thermal injury of the tissue within the boundaries of the zone. It is particularly important that there are no areas of relatively uninjured endometrial tissue within the boundaries of thermal injury zone 14.
A second diagnostic phase may be included after the treatment is completed. This provides an indication of the uniformity of the thermal injury to the uterus, and whether or not a second phase of treatment, to all or only a portion of the uterus, now or at some later time, should be conducted. The second diagnostic phase is accomplished through one or more of the following methods: (i) visualization, (ii) measuring impedance. Once treatment is completed, expandable members 22 and 22" are evacuated of fluid and returned to their predeployed state and uterine treatment apparatus 10 is withdrawn from uterus 23.
This results in the uterus 23 returning to approximately its original shape.
Referring now to FIG. 14, an open or closed loop feedback system 44 couples sensor 40, now described as sensor 346, to an energy source 392. In this embodiment, an energy delivery device 314 is one or more heating elements 314; however, in various other embodiments, energy delivery device 314 may include others described herein. Similarly, in this embodiment, sensor 346 senses temperature, but in various other embodiments, sensor 346 may sense other physical properties described herein. In this embodiment, energy source 392 is a microwave energy source.
The temperature of the tissue, or of heating elements 314, is monitored, and the output power of energy source 392 adjusted accordingly. The physician can, if desired, override the closed or open loop system 44. A microprocessor 394 can be included and incorporated in the closed or open loop system to switch power on and off, as well as modulate the power. The closed loop system 44 utilizes microprocessor 394 to serve as a controller, monitor the temperature, adjust the microwave power, analyze the result, refeed the result, and then modulate the power.
With the use of sensor 346 and feedback control system 44, tissue adjacent to heating elements 314 can be maintained at a desired temperature for a selected period of time without causing a shut down of the power circuit to microwave energy source 392. Each heating element 314 is connected to resources which generate an independent output. The output maintains a selected temperature at heating elements 314 for a selected length of time.
Current delivered through heating elements 314 is measured by current sensor 396. Voltage is measured by voltage sensor 398. Impedance and power are then calculated at power and impedance calculation device 400. These values can then be displayed at user interface and display 402. Signals representative of power and impedance values are received by a controller 404.
A control signal is generated by controller 404 that is proportional to the difference between an actual measured value, and a desired value. The control signal is used by power circuits 406 to adjust the power output an appropriate amount in order to maintain the desired power delivered at respective microwave energy source 392.
In a similar manner, temperatures detected at sensor 346 provide feedback for maintaining a selected power. Temperature at sensor 346 is used as a safety means to interrupt the delivery of power when maximum pre-set temperatures are exceeded. The actual temperatures are measured at temperature measurement device 408, and the temperatures are displayed at user interface and display 402. A control signal is generated by controller 404 that is proportional to the difference between an actual measured temperature and a desired temperature. The control signal is used by power circuits 406 to adjust the power output an appropriate amount in order to maintain the desired temperature delivered at the sensor 346.
Controller 404 can be a digital or analog controller, or a computer with software. When controller 404 is a computer it can include a CPU coupled through a system bus. This system can include a keyboard, a disk drive, or other non-volatile memory systems, a display, and other peripherals, as are known in the art. Also coupled to the bus is a program memory and a data memory.
User interface and display 402 includes operator controls and a display. Controller 404 can be coupled to imaging systems including, but not limited to, ultrasound, CT scanners, X-ray, MRI, mammographic X-ray and the like. Further, direct visualization and tactile imaging can be utilized.
The output of current sensor 396 and voltage sensor 398 are used by controller 404 to maintain a selected power level at microwave energy source 392. The amount of energy delivered controls the amount of power. A profile of the power delivered to heating element 314 can be incorporated in controller 404 and a preset amount of energy to be delivered may also be profiled.
Circuitry, software and feedback to controller 404 result in process control, the maintenance of the selected power setting which is independent of changes in voltage or current, and is used to change the following process variables: (i) the selected power setting, (ii) the duty cycle (e.g., on-off time), (iii) bipolar or monopolar energy delivery; and, (iv) fluid delivery, including flow rate and pressure. These process variables are controlled and varied, while maintaining the desired delivery of power independent of changes in voltage or current, based on temperatures monitored at sensor 346.
Referring now to FIG. 15, current sensor 396 and voltage sensor 398 are connected to the input of an analog amplifier 410. Analog amplifier 410 can be a conventional differential amplifier circuit for use with sensor 346. The output of analog amplifier 410 is sequentially connected by an analog multiplexer 412 to the input of A/D converter 414. The output of analog amplifier 410 is a voltage which represents the respective sensed temperatures. Digitized amplifier output voltages are supplied by A/D converter 414 to microprocessor 394. Microprocessor 394 may be a type 68HCII available from Motorola. However, it will be appreciated that any suitable microprocessor or general purpose digital or analog computer can be used to calculate impedance or temperature.
Microprocessor 394 sequentially receives and stores digital representations of impedance and temperature. Each digital value received by microprocessor 394 corresponds to different temperatures and impedances.
Calculated power and impedance values can be indicated on user interface and display 402. Alternatively, or in addition to the numerical indication of power or impedance, calculated impedance and power values can be compared by microprocessor 394 to power and impedance limits. When the values exceed predetermined power or impedance values, a warning can be given on user interface and display 402, and additionally, the delivery of microwave energy can be reduced, modified or interrupted. A control signal from microprocessor 394 can modify the power level supplied by energy source 392.
Referring now to FIG. 16, the control of the delivery of heat transfer medium 434 to tissue site 416 and the area of expandable member 422 that permeates heat transfer medium 434 is done in the following manner. During the application of energy and heat transfer medium 434, sensors 346 provides input to temperature measurement device 408 (which measures temperature) and flow measurement devices 408' (which measures the flow rate of heat transfer medium to tissue site 416 as well the total flowing area of expandable member 422). A comparator 424 receives a signal representative of the measured temperature, flow rate and flow area and compares these values to pre-set signals representative of the desired temperature, flow rate and flow area. If the measured, flow rate or flow area have not exceeded their desired levels, comparator 424 sends a signal to flow regulator 418 to maintain the flow rate and pressure head from electronically-controlled pump 426 at their existing levels. However, if the flow rate or flow area is too low, comparator 424 sends a signal to a flow regulator 418 connected to pump 426 representing a need for an increased flow rate and pressure head. Likewise, if the flow rate or flow area is too high, comparator 424 sends a signal to a flow regulator 418 connected to pump 426 representing a need for a decreased flow rate and pressure head.
The foregoing description of preferred embodiments of the present invention has been provided for the purposes of illustration and description. It is not intended to be exhaustive or to limit the invention to the precise forms disclosed. Obviously, many modifications and variations will be apparent to practitioners skilled in this art. The embodiments were chosen and described in order to best explain the principles of the invention and its practical application, thereby enabling others skilled in the art to understand the invention for various embodiments and with various modifications as are suited to the particular use contemplated. It is intended that the scope of the invention be defined by the following claims and their equivalents.
|Cited Patent
|Filing date
|Publication date
|Jun 24, 1994
|Apr 9, 1996
|Stuart D. Edwards
|Thin layer ablation apparatus
|Dec 20, 1993
|Jul 2, 1996
|Microwave Medical Systems, Inc.
|Dual mode microwave/ionizing probe
|Jun 17, 1996
|Jul 7, 1998
|Urologix Inc.
|Microwave antenna for arterial for arterial microwave applicator
|Jun 17, 1996
|Sep 1, 1998
|Urologix, Inc.
|Device for transurethral thermal therapy with cooling balloon
|Apr 12, 1996
|Nov 3, 1998
|Ep Technologies, Inc.
|Systems for heating and ablating tissue using multifunctional electrode structures
|Citing Patent
|Filing date
|Publication date
|Aug 23, 1999
|Apr 2, 2002
|Prostalund Operations Ab
|Method and device for combined heat treatment of body tissue
|May 4, 2000
|May 28, 2002
|Inbae Yoon
|Apparatus and method for delivering and deploying an expandable body member in a uterine cavity
|Feb 18, 2000
|Jul 30, 2002
|Edward W. Knowlton
|Stomach treatment apparatus and method
|Dec 8, 2000
|Dec 17, 2002
|Urologix, Inc.
|Thermal therapy catheter
|Jun 29, 2000
|Apr 15, 2003
|Inbae Yoon
|Occlusion apparatus and method for necrotizing anatomical tissue structures
|Aug 30, 2000
|Jun 17, 2003
|Scimed Life Systems, Inc.
|Fluid cooled apparatus for supporting diagnostic and therapeutic elements in contact with tissue
|Jan 23, 2002
|Feb 17, 2004
|Endocare, Inc.
|Cryosurgical monitoring system
|Aug 8, 2001
|Mar 2, 2004
|Northeastern University
|Wide-aperture catheter-based microwave cardiac ablation antenna
|Jun 23, 1998
|Nov 2, 2004
|Method for ablating and/or coagulating tissue using moisture transport
|Dec 13, 2000
|Jan 4, 2005
|Scimed Life Systems, Inc.
|Surgical probe for supporting inflatable therapeutic devices in contact with tissue in or around body orifices and within tumors
|Oct 22, 2001
|Sep 6, 2005
|Boston Scientific Scimed, Inc.
|Apparatus for supporting diagnostic and therapeutic elements in contact with tissue including electrode cooling device
|Jan 17, 2001
|Sep 13, 2005
|Boston Scientific Scimed, Inc.
|Fluid cooled apparatus for supporting diagnostic and therapeutic elements in contact with tissue
|Aug 12, 2002
|Dec 4, 2007
|Boston Scientific Scimed, Inc.
|Fluid cooled apparatus for supporting diagnostic and therapeutic elements in contact with tissue
|Jan 21, 2003
|Dec 25, 2007
|Std Manufacturing, Inc.
|Ablation technology for catheter based delivery systems
|Feb 19, 2004
|May 13, 2008
|Boston Scientific Scimed, Inc.
|Cooled probes and apparatus for maintaining contact between cooled probes and tissue
|Sep 28, 2005
|Dec 16, 2008
|Neuwave Medical, Inc.
|Segmented catheter for tissue ablation
|Aug 3, 2005
|Mar 31, 2009
|Cytyc Corporation
|Moisture transport system for contact electrocoagulation
|Oct 20, 2009
|Cytyc Corporation
|Moisture transport system for contact electrocoagulation
|Dec 2, 2003
|Oct 27, 2009
|Boston Scientific Scimed, Inc.
|Surgical methods and apparatus for maintaining contact between tissue and electrophysiology elements and confirming whether a therapeutic lesion has been formed
|Mar 9, 2010
|Cytyc Corporation
|Emergency hemostasis device utilizing energy
|Mar 16, 2010
|Halt Medical, Inc.
|Gynecological ablation procedure and system
|Feb 7, 2007
|Apr 20, 2010
|Alfiero Balzano
|Thermally conductive surgical probe
|Dec 20, 2004
|Jun 8, 2010
|Cytyc Corporation
|Method and system for transcervical tubal occlusion
|Apr 20, 2006
|Oct 19, 2010
|Gynesonics, Inc.
|Rigid delivery systems having inclined ultrasound and needle
|Dec 7, 2010
|Cytyc Corporation
|Method and apparatus for sterilization
|Jan 25, 2011
|Gynesonics, Inc.
|Methods and devices for visualization and ablation of tissue
|Feb 2, 2006
|Apr 5, 2011
|Gynesonics, Inc.
|Method and device for uterine fibroid treatment
|Sep 13, 2011
|Boston Scientific Scimed, Inc.
|Fluid injecting devices and methods and apparatus for maintaining contact between fluid injecting devices and tissue
|Nov 6, 2007
|Sep 27, 2011
|Hologic, Inc.
|Methods, systems and devices for performing gynecological procedures
|Dec 2, 2003
|Nov 8, 2011
|Boston Scientific Scimed, Inc.
|Surgical methods and apparatus for stimulating tissue
|Dec 20, 2011
|Halt Medical Inc.
|Radio frequency ablation device for the destruction of tissue masses
|Jan 3, 2012
|Gynesonics, Inc.
|Methods and systems for controlled deployment of needles in tissue
|May 15, 2012
|Novasys Medical, Inc.
|Apparatus and methods for treating female urinary incontinence
|Jun 26, 2012
|Gynesonics, Inc.
|Ablation device with articulated imaging transducer
|Nov 14, 2007
|Aug 14, 2012
|Halt Medical Inc.
|RF ablation device with jam-preventing electrical coupling member
|Aug 28, 2012
|Halt Medical Inc.
|Anchored RF ablation device for the destruction of tissue masses
|Feb 25, 2010
|Sep 11, 2012
|Gynesonics, Inc.
|Needle and tine deployment mechanism
|Sep 11, 2012
|Gynesonics, Inc.
|Methods and systems for controlled deployment of needles in tissue
|Apr 5, 2012
|Mar 26, 2013
|William Bruce Shingleton
|Vasectomy devices and methods
|Jun 6, 2006
|May 14, 2013
|David R. Staskin
|Injection guidance system and method
|Jun 18, 2013
|Verathon, Inc.
|Apparatus and methods for treating female urinary incontinence
|Jan 4, 2013
|Jun 25, 2013
|Covidien Lp
|Perfused core dielectrically loaded dipole microwave antenna probe
|Sep 18, 2006
|Jul 16, 2013
|Cytyc Corporation
|Power ramping during RF ablation
|Oct 22, 2012
|Jul 23, 2013
|Covidien Lp
|Targeted cooling of deployable microwave antenna and methods of use
|Dec 20, 2010
|Aug 13, 2013
|Gynesonics, Inc
|Devices and methods for treatment of tissue
|Oct 19, 2009
|Aug 13, 2013
|Cytyc Surgical Products
|Moisture transport system for contact electrocoagulation
|May 8, 2006
|Aug 20, 2013
|Halt Medical Inc.
|Anchored RF ablation device for the destruction of tissue masses
|Apr 4, 2008
|Sep 10, 2013
|Hologic, Inc.
|Systems, methods and devices for performing gynecological procedures
|Sep 29, 2009
|Oct 1, 2013
|Covidien Lp
|Flow rate monitor for fluid cooled microwave ablation probe
|Mar 19, 2012
|Oct 8, 2013
|Cytyc Surgical Products
|Radio-frequency generator for powering an ablation device
|Apr 4, 2008
|Nov 5, 2013
|Hologic, Inc.
|Method, system and device for tissue removal
|Oct 6, 2011
|Feb 4, 2014
|Covidien Lp
|High-strength microwave antenna assemblies
|Sep 7, 2007
|Feb 11, 2014
|Hologic, Inc.
|Systems for performing gynecological procedures with mechanical distension
|Jul 18, 2013
|Feb 18, 2014
|Covidien Lp
|Targeted cooling of deployable microwave antenna with cooling chamber
|Mar 26, 2007
|Mar 18, 2014
|Neuwave Medical, Inc.
|Center fed dipole for use with tissue ablation systems, devices and methods
|Dec 17, 2012
|Jun 3, 2014
|Verathon, Inc.
|Treatment of tissue in sphincters, sinuses, and orifices
|Nov 27, 2003
|Jul 1, 2014
|Medical Device Innovations Limited
|Tissue ablation apparatus and method of ablating tissue
|Jul 17, 2008
|Aug 5, 2014
|Boston Scientific Scimed, Inc.
|Surgical probe for supporting inflatable therapeutic devices in contact with tissue in or around body orifice and within tumors
|May 26, 2005
|Aug 12, 2014
|Medical Device Innovations Limited
|Tissue detection and ablation apparatus and apparatus and method for actuating a tuner
|Jul 23, 2010
|Sep 16, 2014
|Hologic, Inc.
|Systems and methods for preventing intravasation during intrauterine procedures
|Sep 7, 2007
|Sep 23, 2014
|Hologic, Inc.
|Systems for performing gynecological procedures with closed visualization lumen
|Sep 7, 2007
|Sep 23, 2014
|Hologic, Inc.
|Systems for performing gynecological procedures with simultaneous tissue cutting and removal
|Feb 9, 2010
|Feb 3, 2015
|Boston Scientific Scimed, Inc.
|Insulated ablation catheter devices and methods of use
|Apr 29, 2009
|Feb 10, 2015
|Hologic, Inc.
|Methods of high rate, low profile tissue removal
|Feb 7, 2007
|Feb 24, 2015
|Viveve, Inc.
|Vaginal remodeling device and methods
|Jun 14, 2013
|Mar 3, 2015
|Verathon Inc.
|Apparatus and methods for treating female urinary incontinence
|Jun 28, 2012
|Mar 31, 2015
|Arsenal Medical, Inc.
|Foam and delivery system for treatment of postpartum hemorrhage
|May 15, 2014
|Apr 7, 2015
|Cytyc Surgical Products
|Moisture transport system for contact electrocoagulation
|Apr 29, 2009
|May 5, 2015
|Verathon Inc.
|Noninvasive devices, methods, and systems for modifying tissues
|Feb 4, 2014
|May 26, 2015
|Covidien Lp
|High-strength microwave antenna assemblies
|Mar 15, 2013
|Jun 2, 2015
|Arsenal Medical, Inc.
|In-situ forming foams with outer layer
|Aug 8, 2013
|Aug 4, 2015
|Cytyc Surgical Products
|Moisture transport system for contact electrocoagulation
|Apr 29, 2009
|Aug 4, 2015
|Hologic, Inc.
|Tissue cutter with differential hardness
|Jul 28, 2010
|Sep 1, 2015
|Neuwave Medical, Inc.
|Energy delivery systems and uses thereof
|Aug 12, 2011
|Nov 3, 2015
|Arsenal Medical, Inc.
|In situ forming hemostatic foam implants
|Dec 21, 2012
|Nov 24, 2015
|Neuwave Medical, Inc.
|Energy delivery systems and uses thereof
|Mar 27, 2009
|Dec 1, 2015
|Covidien Lp
|Re-hydration antenna for ablation
|Dec 13, 2012
|Dec 8, 2015
|Cook Medical Technologies Llc
|RF energy controller and method for electrosurgical medical devices
|Mar 2, 2015
|Feb 2, 2016
|Cytyc Surgical Products
|Moisture transport system for contact electrocoagulation
|Dec 6, 2007
|Feb 16, 2016
|Hologic, Inc.
|Method and device for distending a gynecological cavity
|Sep 16, 2010
|Mar 1, 2016
|Viveve, Inc.
|Vaginal remodeling device and methods
|Aug 29, 2013
|Apr 5, 2016
|Hologic, Inc.
|Systems, methods and devices for performing gynecological procedures
|Apr 7, 2015
|May 17, 2016
|Hologic, Inc.
|Uterine fibroid tissue removal device
|Jan 23, 2002
|Jul 24, 2003
|Ali Jawahar M.
|Cryosurgical monitoring system
|Jan 21, 2003
|Oct 16, 2003
|Tallarida Steven J.
|Ablation technololgy for catheter based delivery systems
|Dec 30, 2004
|Jun 30, 2005
|Koblish Josef V.
|Surgical probe for supporting inflatable therapeutic devices in contact with tissue in or around body orifices and within tumors
|Jul 8, 2003
|Jul 28, 2005
|Paul Swain
|Microwave hollow organ probe
|Aug 24, 2006
|Mar 1, 2007
|Van Der Weide Daniel W
|Microwave device for vascular ablation
|Aug 11, 2006
|Mar 8, 2007
|Lee Fred T Jr
|Intralumenal microwave device
|Feb 7, 2007
|Jun 14, 2007
|Alfiero Balzano
|Thermally conductive surgical probe
|Dec 6, 2007
|Oct 9, 2008
|Gruber William H
|Method and device for distending a gynecological cavity
|Jul 17, 2008
|Apr 16, 2009
|Koblish Josef V
|Surgical Probe For Supporting Inflatable Therapeutic Devices In Contact With Tissue In Or Around Body Orifice And Within Tumors
|Mar 27, 2009
|Oct 1, 2009
|Paulus Joseph A
|Re-Hydration Antenna for Ablation
|Jun 6, 2006
|Dec 10, 2009
|Staskin David R
|Injection guidance system and method
|Jul 15, 2010
|Rassoll Rashidi
|Ablation for atrial fibrillation
|Feb 9, 2010
|Aug 12, 2010
|Bencini Robert F
|Insulated ablation catheter devices and methods of use
|Sep 2, 2010
|Gynesonics, Inc.
|Needle and tine deployment mechanism
|Sep 18, 2009
|Mar 24, 2011
|Vivant Medical, Inc.
|System and Method for Checking High Power Microwave Ablation System Status on Startup
|Mar 31, 2011
|Vivant Medical, Inc.
|Flow Rate Monitor for Fluid Cooled Microwave Ablation Probe
|Aug 24, 2010
|Aug 18, 2011
|Arsenal Medical, Inc.
|Systems and methods relating to polymer foams
|Sep 29, 2011
|Neuwave Medical, Inc.
|Microwave device for vascular ablation
|Feb 2, 2012
|Vivant Medical, Inc.
|High-Strength Microwave Antenna Assemblies
|Jun 28, 2012
|May 2, 2013
|Arsenal Medical
|Foam and Delivery System for Treatment of Postpartum Hemorrhage
|Oct 17, 2012
|May 9, 2013
|Covidien Lp
|Systems and methods for treatment of premenstrual dysphoric disorders
|Feb 24, 2014
|Jul 3, 2014
|Microcube, Llc
|Delivery system for delivering a medical device to a location within a patient's body
|Mar 4, 2014
|Jul 24, 2014
|Boston Scientific Scimed, Inc.
|Cryogenic balloon ablation instruments and systems
|Apr 1, 2004
|Aug 26, 2008
|Prostalund Operations Ab
|Method and device for combined heat treatment of body tissue
|Nov 27, 2003
|Sep 7, 2005
|Mohammed Sabih Chaudry
|Tissue ablation apparatus and method of ablating tissue
|Mar 25, 2008
|Dec 9, 2009
|National University Corporation Shiga University OF Medical Science
|Microwave surgical device
|Jul 19, 2001
|Jan 31, 2002
|Michael Nordmann
|Device for heat treatment of the vaginal or colonic region
|Sep 28, 2001
|Apr 11, 2002
|Novasys Medical, Inc.
|Apparatus and method for treating female urinary incontinence
|Dec 6, 2001
|Jun 20, 2002
|Boston Scientific Limited
|Surgical probe for supporting inflatable therapeutic devices
|U.S. Classification
|607/101, 607/156, 606/41, 607/105
|International Classification
|Cooperative Classification
|European Classification
|Jun 19, 1998
Owner name: VIDACARE, INC., CALIFORNIA
Free format text: ASSIGNMENT OF ASSIGNORS INTEREST;ASSIGNOR:EDWARDS, STUART D.;REEL/FRAME:009497/0183
Effective date: 19980605
|Dec 15, 2003
|Lapse for failure to pay maintenance fees
|Feb 10, 2004
|Expired due to failure to pay maintenance fee
Effective date: 20031214


text:
Update on KishmishThis beautiful lady with the nice name Kishmish, which in Armenian means the best and the sweetest sort of grape, lives in Ijevan with her big family: husband, father-in-law, daughter (married), son (who is in Russian Federation working), daughter-in-law and grandson. Kishmish for many years has worked at Ijevan hospitals as a nurse and she loves her work very much. Her husband works as a locksmith and both of them are engaged in beekeeping and farming. It brings good income to their family and they managed to buy furniture for the kitchen and solved financial problems connected with the marriage of their daughter. Kishmish has a perfect credit history. This is her sixth loan from Nor Horizon and the second one from Kiva.
They need a loan of 1.100.000 Armenian drams to buy 10 bee families and fodder for their farm animals (10 piglets and 15 chickens). Kiashmish thanks Kiva beforehand and she is sure that this deal, like the first one, will be very profitable for her family.
Previous Loan DetailsKishmish S. is married and has two children. She lives in Ijevan city. She works at Ijevan Polyclinic as a nurse and, at the same time, she and her husband are engaged in beekeeping. Thanks to income from beekeeping they have kept their family, bought necessary furniture for their house and also ... More from Kishmish's previous loan »
Additional Information
About "Nor Horizon"
"Nor Horizon" UCO LLC is committed to promoting poverty alleviation in Armenia by providing high-quality financial and other business development services to enterprising individuals in under-served rural and urban markets who have a strong will to establish and develop their own small-scale businesses. Originally created as the Armenian micro credit program of Oxfam (Great Britain) in late 1995, "Nor Horizon" LLC has been licensed under supervision of the Central Bank of Armenia since early 2006.
For more information about "Nor Horizon," please visit the partner page or website.
To stay updated on loans from Armenia, please join the Armenia lending team at http://www.kiva.org/team/armenia.
Concurrent and Successive Loans
Our Field Partners often work with borrowers over a series of loans as the borrowers build credit, take out bigger loans, and expand their businesses. In order to make it easier for our Field Partners to post loans for borrowers who have been listed on Kiva before, we allow them to post successive and concurrent loans for their Kiva borrowers. This means that our Field Partners are able to post a borrower's second, third, etc., loan on Kiva without having to re-enter all of the borrower's information.
This borrower has been listed on Kiva before, so you'll see an updated loan description, as well as excerpts of the original descriptions from earlier loans. Most borrowers take out loans consecutively, meaning that they receive a second loan after having repaid the first. However, sometimes our Field Partners give out concurrent loans, allowing borrowers to take out one primary loan and a secondary "add-on" loan along with it. These "add-on" loans are typically smaller than the borrower's primary loan and serve a different purpose. Because Field Partners can now post loans as successive and concurrent loans, you will be able to track borrower progress over time and see the various ways a borrower is working with our Field Partners through funds from Kiva's lenders.
About Armenia
166View loans »
Success!! The loan was 100% repaid
- Repayment Term
- 38 months (Additional Information)
- Repayment Schedule
- Monthly
- Pre-Disbursed:
- Apr 23, 2013
- Listed
- May 24, 2013
- Currency Exchange Loss:
- Possible
- Ended:
- Jan 17, 2016

subset: commoncrawl


text:
Hi. I just built a new house in North Carolina and the builder screwed up my bricks on the front of the house. Before I closed they cut out a section and replaced them with new bricks. The new bricks have been cleaned (hopefully correctly) but still do not look like they should. The problem is that the sun hits the house during the day which washes out some of the problem. You can really see the difference when it is cloudy or the sun is not on the brick. You can still see the difference with the sun out, but it does look better and is much harder to tell. I will try to arrange a time in the morning or late afternoon with the builder to show the problem, but what happens if they want to stain and the house is evaluated with the sunlight on the bricks? They might say it is acceptable, etc...
Before closing, the builder owner signed a letter acknowledging the problem with the brick and they would work with me to find a solution. If I disagreed with the builder supervisor on an acceptable standard after the brick was cleaned, a third party acceptable to both of us would be contacted.
I am very concerned the building supervisor will say that it looks good enough or that it is acceptable because it is harder to tell when the sun is out. This to me is rediculous especially with a new house. I didn't pay for a new house that looked almost normal on the front when the sun is out.
Thank you very much for your time - this brick issue is really bothering me since it was the builders fault to begin with. If anyone could offer advice I would greatly appreciate it.
- Forum >
- Miscellaneous >
- New house brick problem - staining?
Questions for New House Construction
bad food odor in new house
Cabinet quality in new house
New house - brick or siding?
- 15 Old House Features We Shouldn't Abandon
- 13 Lazy Cleaning Tricks for a Spotless Home
- Laundry Room Ideas to Knock Your Socks Off
- Insanely Easy 60-Minute Home Improvements
- 12 Sheds You Could Live (or Work) In
- Assembly Required: 15 DIY Kit Homes
- 7 House Sounds You Never Want to Ignore
- 10 Surprisingly Simple Woodworking Projects
- Worth It: 8 Renovations That Pay You Back
- Organize Your Life with 12 Dollar-Store Buys
- 9 Totally Amazing Mobile Home Makeovers
- Don't Make These 7 Mistakes in Small Spaces
- 20 Sneaky Storage Ideas
- 15 Totally Unexpected DIY Flooring Alternatives
- 7 Easy Budget-Friendly Backyard Makeovers
- 10 Closet Cures That Cost Less Than $100
- 11 Easy DIY Projects to Declutter Your Home
- 10 "Zero Dollar" Garden Hacks
- 10 Killproof Plants for a No-Effort Landscape
- 9 Insanely Easy 1-Hour Backyard Projects


text: Posted 13 Jun 2013 Right now I have time Warner under a good deal that expires on the 21st of next month.Was thinking about switching to uverse as time Warner was playing hardball on extending my current deal today. Mainly just wanna see if anyone has u-verse as I don't wanna get in a contract with one of the satellite companies. Share this post Link to post Share on other sites


text:
How the Web is Won
July 5, 2013 by Brian Childers Leave a Comment
Brian Childers is the CEO of Foxxr, a web design and internet marketing company based in Capitola, CA. Childers is a community leader and speaker about marketing strategies for small business. Follow Brian on Twitter
Your email address will not be published. Required fields are marked *
Name *
Email *


text: My OS is Windows XP. Recently all my photos (thousands which were saved as .JPG)have migrated to my Display Properties "Desktop" tab as "Background" photos. I cannot delete them there. If I try to delete any "Background" photos anywhere else, my entire picture file is then also deleted. Their sheer number makes it impossibly slow to change the image on the screen, as I like to do. I searched "Wallpaper" to no avail. Can anyone help?


text:
Look sexy and fun for your next costume party with the Adult Sexy Black 20s Flapper Costume. This costume comes with a velvet short, sleeveless dress. The straps of the dress run up to a choker to hold the dress up. The dress is low cut to show off your assets and has a tassel fringed trim along the bottom of the skirt. The Adult Sexy Black 20s Flapper Costume also includes a charming black sequin headband with a feather attached in the back. This costume comes with everything you need to become a Flapper girl from the roaring 20s! So share in the fun of the times with champagne, live music, and livelier conversation when you wear the Adult Sexy Black 20s Flapper Costume to your next party! This costume will look great with a pair of nylons or fishnets, and a pair of black heels.
Not yet rated. Be the first to Write a Review


text:
Mujeres Al Triunfo 3 Group
Constancia has had her business for almost five years. Using some savings and taking loans from other places. She started selling some grocery products from a small stall in her house. Now she has a colmado, a grocery store located in the neighborhood, where more of the neighbors buy their daily meals. Constancia will invest in her business by purchasing rice, beans, sugar, canned food, flour, and other goods. She will use the profits to save and reinvest in her business.
Her group is located in the urban slums surrounding Santo Domingo and is composed of 5 people.
Additional Information
This is a Group Loan
In a group loan, each member of the group receives an individual loan but is part of a larger group of individuals. The group is there to provide support to the members and to provide a system of peer pressure, but groups may or may not be formally bound by a group guarantee. In cases where there is a group guarantee, members of the group are responsible for paying back the loans of their fellow group members in the case of delinquency or default.
Kiva's Field Partners typically feature one borrower from a group. The loan description, sector, and other attributes for a group loan profile are determined by the featured borrower's loan. The other members of the group are not required to use their loans for the same purpose.
About Dominican Republic
0View loans »
Success!! The loan was 100% repaid
- Repayment Term
- 7 months (Additional Information)
- Repayment Schedule
- Monthly
- Pre-Disbursed:
- Dec 19, 2011
- Listed
- Jan 18, 2012
- Currency Exchange Loss:
- Possible
- Ended:
- Jun 16, 2012


text:
Furfrou Sprite by NosciumWatch
©2013-2016 Noscium
New mega absol evolution!
Or not.
Or not.
May I use this? I'll credit you!
Can I use this?
hi, can I use this to make a kabuki styled furfrou?
If I may ask, may I use your pixel for as a bottom image on my blog on a sight? Of course I will credit you.
Can I use this and re-color it? I'll credit you.
Are you gonna do the 9 different styles too?
If you take requests can I request them?
May I use this to make an avatar on a different site? I will give you credit.
One more question, sorry. xD;
Me and a friend plan do make a DA group for breeding Furfrous, may we use and recolor the sprites for different coat colors? Credit given where credit is due of course.
May I use this for sprite splicing (Mixing different pokemon into a hybrid)? I'd give credit.
looks like the real thing
i can use this? i give you credits
aaaaaaaaaaaa!!! incredible!!!1!!eleven
Furfrou looks great as it is. I'm not going to "poodle" mine.
I adore this Pokemon <3 lovely sprite by the way c:
I shall name him sir solstice. He looks quite spectacular.
Nice! Can't believe that there's a customizable Pokemon! I don't care how bad it's stats might be, I am getting one of those! I shall name mine Rodman and he will be fabulous XD
are you going to do the other pokemon too plus the other form changes?
I try to do all Kalos pokemon + mega evolution.
But I dunno If I'll do the other furfrou forms.
the you cand change it;s hair pokemon
My comments might sound repetitive, but great job again!
just STOP!!!


text:
OLYMPIA, Wash. (AP) — Republican presidential candidate Mitt Romney is staying an extra day in Washington state, holding a public event Friday morning.
Romney is in Bellevue Thursday night for a fundraiser, and then will hold a "meet-and-greet" in the city the next morning at the Highland Community Center. His visit comes in advance of the state's Republican caucuses on Saturday.
The former Massachusetts governor is in a crowded primary race with Rick Santorum, Newt Gingrich and Ron Paul. All have now visited the state, and Santorum and Paul are back for a second visit this week in advance of the caucuses.


text:
Update Notes
Updated on: 01/06/2015
Update Notes
Updated on: 01/06/2015
Since we last visited DirtyTalkingBitches...
I friggin' love it whenever a chick talks dirty, so when I was told I'd be reviewing a site called Dirty Talking Bitches, I got really excited. I mean, a whole site dedicated to nothing but pillow talk? (The mid-coital kind, I mean.) Well, it turns out not so much. But there are plenty of filthy discussions being had here.
DirtyTalkingBitches definitely has a bunch of hot babes who say things that will both shock and arouse you. However, that isn't actually the focus, so much as it's coincidental. A lot of the scenes are POV Femdom that have the model trash-talking the camera (meaning you, her sub), while others are masturbation-encouragement videos.
You'll also find blowjobs movies where the only dirty talk comes in the form of her saying, "I want to suck that big cock of yours," before, well, sucking the big cock on the cameraman. Other good scenes are the POV handjobs because they have the models asking if you like how they're stroking "your" cock and telling you how hot it makes them to have their hands wrapped around "your" dick.
My personal faves are the ones where the model wants to get off to the sight of you masturbating. She'll often be in nothing but panties and a bra and details how she hopes you'll stroke it for her and asks if you'll be cumming on her face, tits or ass when you're ready to blow your load.
Not all the content is exclusive as I noticed some scenes belonging to other sites in the network (some come with your membership and other don't). There are 109 videos (links to cam babes make it look like there are more) and their quality varies, with many being average and others good. This is despite the fact that all the scenes are marked as HD when you go for the largest download file. (The 3GP links didn't work.) You can also stream each in an embedded player and they all come with around a dozen vid caps.
It looks like you can count on getting about a dozen new movies over the course of a month. Between updates, you can check out the rest of the Twisted Females network. There are 13 more sites for you to explore, including Bossy Princesses, Cuckold Bitches and Sissy Discipline. There are bonus DVDs as well.
Whether you're just here for the Dirty Talking Bitches or for a variety of porn, I think you'll like what this site provides. It could stand to offer more impressive movies, but it's decent enough overall.
* Please include a pro and a con about the site. Balance is essential in making a comment worthwhile. Scores without comments will be deleted.
* Watch out for ratings of zero and 100. In our opinion, there is no such thing as a site that is absolutely perfect or completely worthless.


text:
NewsOK Blogs / Alternate Crop
Bedlam Football Overhead
During the celebration after yesterday's Bedlam football game, Bryan Terry took a different angle from the rest of our team and photographed from the roof of Boone Pickens Stadium. He took some shots of the Spirit Walk from up high before the game as well. Here's some of Bryan's pictures from overhead.
Also, check out this gallery with other pictures from The Oklahoman of OSU's 44-10 win over OU.
The green arms holding a camera off to the left in the above photo belong to me, by the way.
And remember to check out more Bedlam football pictures in this gallery.
-Nate Billings
1 Show / Hide Archive Comments


text:
Meet and Communicate with Fun Singles Near You on JDate
Register now to search thousands of members and post your FREE profile!
See who's on JDate:
My name is hanan, i work as a hair designer, i would love to meet a nice girl for a serious relationship
108960297 is a 41yr-old single man in Tarzana, CaliforniaView Profile
I would describe myself as a very passionate, determined, caring, giving, genuine, ambitious, articulate and open-hearted person. I am ...
NemashaOfEmunah is a 35yr-old single woman in Tarzana, CaliforniaView Profile
חמוד אמיתי עם ראש על הכתפיים וברק בעיניים ששואף גבוה (לא נסחפתי נכון ?). עם המון סבלנות, הבנה, לב טוב, כן, אמיתי, החלטי, יציב (ודומיננט...
HIGHFLYER565C is a 38yr-old single man in Tarzana, CaliforniaView Profile
I'm a very honest, easy going person w\ a great personality that just enjoys what life has to offer. I enjoy indoor and outdoor activit...
msb037 is a 47yr-old single man in Tarzana, CaliforniaView Profile


text:
since Mar 2010
6 Curated Comments,
14 Total
Maybe it was someone who knew Barry was going to turn himself in and did it for him unbeknownst to ...
FUCK YES! Go Barry!
It's better when you're on weed.
Yeah, Libs and Conservatives bray about personal responsibility, but the people in our government whom we rely upon to prosecute ...
Of course not, because it wouldn't have even been in Lincoln's character to say such a thing, not to mention ...
Um, Stephen, you're not that clever.
First of all, your idea is lame, and won't work. Most "tea baggers" aren't ...
Glad to see others finally catching on.
Don't legalize: Decriminalize
"...an IMF employee told me..."
Uh, yeah.
Sources, please.
This prank is obviously faked. The "vicitm" is the worst "actress" I've ever seen.
Stephen, I want to like you ...
Not only is it stupid, it's dumb.


text:
Boma is at the animal kingdom hotel I think but we wont be staying there as its expensive
is it worth us making a special trip, some people say its really noisy like a school cafeteria and not much better food
Boma is at the animal kingdom hotel I think but we wont be staying there as its expensive
is it worth us making a special trip, some people say its really noisy like a school cafeteria and not much better food
Well, it does depend upon what you like, of course.
When Boma first opened, it was really lovely. Different, and the chefs and line cooks there were very eager to share their knowledge of the dishes available. Now, it's kind of settled into the "same old, same old."
There are some nice dishes there. We like the bobotie, and the seafood "stew" which is really a soup with clams, mussels, shrimp and scallops. Sometimes we like the roast that is offered, other times not so much. We like their chicken, and salads, ect.
It's worth a visit, and plan some extra time so you can view the animals on the savannah. There are many public viewing places, so you can either sit on a balcony and watch, or walk out to one of the protected walkways and watch and visit with the CMs that will be there.
Oh, just to throw you a curve, we far prefer Jiko over Boma.
Boma is one of those restaurants that we really enjoy. It serves a delicious buffet breakfast as well as a dinner buffet. Each of them has different delicacies from Africa.
For finer dining at Animal Kingdom be sure to visit the aforementioned JIKO or even Sanaa at the recently opened Kidani Village of AKL.
My Facebook Profile: Facebook
To the world you may be one person, but to one person you may be the world. - Heather Cortez
When the power of love overcomes the love of power the world will know peace. - Jimi Hendrix
We didn't like Sanaa at all. Not a fan of Boma breakfast either.
That's the whole thing about WDW. There really are many choices. What one person dislikes another will love.
It really is all down to what the individual's preferences are.
We've tried Boma for dinner and breakfast.
I love the ham and eggs for breakfast followed by fresh strawberries
As for dinner, I have quite a plain taste for food so had to stick with the meat off the bone and chicken strips!
FLORIDA VIDEOS HERE.... https://www.youtube.com/user/isafari...?feature=watch
I liked it, but to be honest with you not as much as I thought I would, although the desserts are really really good
Don't know when you were last there, but when we took Seth this past trip, the desserts had changed quite a bit. The "zebra domes" bore no resemblance in taste (and little in appearance) to the originals.Originally Posted by Dorothy, post: 205549
The majority of the rest were tiny little bite sized selections. Not a bad thing by any means, but not the nice display they once had. They took away my favorites long ago though, so I've been disappointed in their desserts for some time.


text:
Enjoy modern amenities in a beautiful, rustic setting. W oolywagons in Russiaville, Indiana, offers stunning wagons such as Gypsy Wagons, Sheep Wagons, Tiny Houses, and Guest Houses that can easily go wherever you need, giving you a great space for camping, relaxing, and unwinding.
The difference between our wagons and other on the market is all in the materials. We use high-grade aluminum and steel to make beautiful, comfortable, durable wagons that are sure to last for years to come.
With a mix of old-time charm and modern convenience, W oolywagons are the perfect way to escape the hustle and bustle of everyday life. Our custom gypsy wagons, tiny houses, guest houses and sheep wagons have spray foam insulation and are built from sturdy, lightweight aluminum, making them strong and durable. Each wagon and tiny house comes with a 30-year, structural framing warranty, ensuring you enjoy your wagon for years to come.
Established in 2008, W oolywagons excels at creating fully custom wagons. We use our more than 30 years of experience to deliver an exceptional product that meets your needs and exceeds your expectations.
Learn More About W oolywagons
Follow Us On


text:
Upcoming Nursing Information Sessions
Dallas: There will be Nursing Information Sessions on the Dallas campus on the following Fridays: June 24, July 15, and August 12, 2016.
Houston: Summer Information Sessions for the Bachelor of Science in Nursing (BS).
Mari Tietze earns Doswell Endowed Chair in Nursing Informatics
As Texas Womans Universitys new Doswell Endowed Chair in Nursing Informatics, associate nursing professor Mari Tietze, R.N., Ph.D., is a champion at navigating the maze of health care information using informatics, which, simply put, is the science of applying technology and data analysis to solve problems.
Read More >>
IMPORTANT ANNOUNCEMENT for All Students Applying to Upper Division Nursing
All applications for BS upper-division nursing (pre-licensure and RN-BS) are now being submitted through NursingCas. TWU no longer uses the old Pioneer Portal and paper application system. NursingCAS allows students to search and apply to more than one nursing school (if desired), keep track of deadlines, application materials needed, check the status of all applications submitted, and more. Go to NursingCAS for more information on account set up, how to apply, and frequently asked questions.
Post-Baccalaureate Certification in Interprofessional Informatics Program
The online Post-Baccalaureate Certificate in Interprofessional Informatics is intended for those professionals who have a bachelor's degree and who are seeking additional education and training in informatics. Content includes technology-based health promotion, data application, interaction design, and telehealth. The certificate program is designed for students from a variety of disciplines including, but not limited to, Nursing, Occupational Therapy, Physical Therapy, Nutrition Science, and Health Systems Management. For complete information on the Informatics program, please click here.
Accreditation information
The (baccalaureate degree in nursing/master's degree in nursing/Doctor of Nursing Practice program and/or post-graduate APRN certificate program) at Texas Woman's University is accredited by the Commission on Collegiate Nursing Education.


text:
Well met at Audiko, where you can aquire ringtones for free for your iPhone. Today we have a ringtone of "Ella Me Dice" by Zion as well as 471 other ringtones by Zion. "Ella Me Dice" is a hit from the "Www.FlowHoT.NeT" album that was recorded and mixed by Zion at their recording studio together with other 7 tracks. You can listen to all 3 Zion – "Ella Me Dice" ringtone variations available here and download it for free in few seconds. You can also choose from other 68 albums produced by Zion for all time. "Ella Me Dice" is referred to Reggaeton, and we can offer you a huge amount of Reggaeton albums absolutely for free. And finally, we have collected lyrics for this track and you can view it here as well. So feel free to browse, listen, download ringtones at Audiko.net. Make your phone sound cool!
Zion Ella Me Dice Ringtone
Similar Ringtones
Browse Genres
Electronic Hip-Hop Latin Latino PsyTrance Reggaeton Spanish
Ella Me Dice 3:47


text:
Hello Friends,
Please I need some help on my site - http://www.smartfoxsecurity.com. I use the latest SEO plugin on the recent WordPress. Anytime I post my site link on my Google+ profile it will show two titles: The Post Title and the SEO Title.
Please take a look at my last posts here and see how it's duplicated: https://plus.google.com/u/0/101305129691335280812/posts
I'e tried publishing without the SEO title but it's still grabbing the 2 titles. This doesn't occur on Twitter or Facebook.
Please what do I need to disable or enable to get this working correctly.


text:
Home Invaders
Not Yet Rated| 1 hr. 40 min.
Plot Summary
Angel is forced to join a crew of home invaders after they catch him swiping credit cards.
Cast: Yancey Arias, Keith David, Luis Guzmán, Nelson Vasquez, Lawrence Gilliard Jr., Judy Reyes, Anna Carolina Alvim, Francis Leik
Director: Gregory Wilson
Genres: Action


text:
Vancouver USA Marathon a fight to the finish line
Youssef Zirari made the Vancouver USA Marathon look like any old Sunday run.
For some of the other finishers, humid conditions meant getting to the finish line took longer than expected.
Zirari, a 26-year-old Vancouver resident, separated himself from the rest of the field right from the starting gun. He completed the 26.2-mile footrace in 2 hours, 34 minutes and 25 seconds, a time that was more than three minutes faster than Cody Barton's winning time in last year's inaugural race — and more than 14 minutes faster than runner up Jon Heli of Portland.
The sun came out early in the marathon, making for conditions that were more muggy than runners from the Northwest usually experience. The result was fewer fast times than in the first Vancouver USA Marathon last June.
The Northwest climate is why women's champion Angie Fiese chose to race in Vancouver. After struggling through the notorious heat at April's Boston Marathon, the Mableton, Ga., resident chose Vancouver for mild conditions.
"It still felt cooler than Atlanta," she said after finishing in a personal-best 3:07:40 to beat the next woman by nearly 10 minutes.
The half marathon champions were Kevin Ko of Portland, who completed 13.1 miles in 1:17:24, and former Vancouver resident Lauren Breihof in 1:25:28. Breihof, 23, was the women's Vancouver USA Marathon champion last year.
Both of Sunday's marathon winners controlled the race most of the way. Zirari, who told the crowd at the finish line that 1,500 meters is his racing specialty, sprinted to a 30-second lead by the second mile and was the only runner to maintain a sub-6 minutes per mile pace.
Though he didn't push Zirari, runner-up Heli of Portland was pleased to run his personal-best marathon time. He said he overcame some early struggles and got stronger has his race went along.
The 31-year-old Portlander was among those praising the course and the event.
"It's nice and small so you don't feel like your just some random person among many thousands of runners," Heli said.
Like the men's champion, Fiese quickly distanced herself from the rest of the women in the marathon. She took the lead near mile six, but wasn't celebrating her first marathon win until the final 20 miles were complete.
"The marathon is really special," the 34-year-old said after finishing her eighth since taking up running in her late 20s. "It can go really great or you can fall apart. You just never know. I was running and I felt good, so I just kept running."
Another runner who appreciated the weather was Guy Potter of Durham, N.C. The 42-year-old finished seventh overall and was the masters division winner as the first runner older than 40 to finish. Potter's time of 2:57:59 beat 44-year-old Brian Meenaghan of Seattle by 12 seconds and made his goal of finishing in less than three hours. Eighth-place finisher Meenaghan was the last to break three hours.
Like Fiese, Potter figured Vancouver would provide good conditions to put behind him the misery of finishing 30 minutes slower than planned at Boston.
"I decided this would be my chance to redeem myself," he said after completing only his third 26.2-mile race.
After Zirari, the top marathon finishers with Vancouver ties were Matt Urbanski, who finished fifth, and Micah Rice, who was 10th. Rice is the News Editor for The Columbian.
Urbanski and his wife Julie lived in Vancouver for more than three years. They recently spent more than a year traveling to races around the world including their first 100-mile ultra marathon in February in Texas.
Urbanski's time on Sunday was 2:53:55. It was the 10th marathon in 2012 for the 28-year-old, who is training for another 100-mile race in August. He and Julie currently live in Seattle, and she is promoting her self-published book titled "The Trail Life" about hiking the Pacific Crest and Appalachian trails.
A total of 566 runners finished the marathon, and 1,153 completed the half marathon. Those numbers were down from 800 in the marathon and 1,427 who completed the half marathon in 2011.
Among the men half-marathoners, 36-year-old Ryan Miles was the first Vancouver resident to finish. He placed sixth in 1:22:07. David Cummings of Vancouver was eighth in 1:25:09.
Finishing second in the women's half was Vancouver's Katrina Mueller, finishing in 1:28:21, just less than three minutes after Breihof. Also among the top-10 women in the half were Vancouver residents Angela Gula (1:32:30) and Tami Wright (1:32:52).
Top 10 men
1, Youssef Zirari, 26, Vancouver, 2:34:25 (course record).
2, Jon Heli, 31, Portland, 2:48:34.
3, David Kyle, 34, San Francisco, 2:49:29.
4, John Strother, 38, Salem, 2:51:59.
5, Matt Urbanski, 31, Seattle, 2:53:55.
6, Trae Richardson, 28, Eugene, 2:57:17.
7, Guy Potter, 42, Durham, N.C., 2:57:59.
8, Brian Meenaghan, 44, Seattle, 2:58:11.
9, Alex Gay, 23, Portland, 3:01:06.
10, Micah Rice, 35, Vancouver, 3:01:24.
Top 10 women
1, Angie Fiese, 34, Mableton, Ga., 3:07:40.
2, Julie Bertoia, 35, Henderson, Nevada, 3:17:01.
3, Michelle Bird, 29, Portland, 3:22:29.
4, Kate Fischer, 29, Portland 3:23:36.
5, Kristina Cupp, 19, Vancouver, 3:28:26.
6, Karissa Hudspeth, 37, Salem, 3:29:29.
7, Linnea Alejandre, 26, Vancouver, 3:32:14.
8, Heidi Wood, 27, Portland, 3:33:01.
9, Kat Degroat, 36, Wilsonville, Ore., 3:33:27.
10, Andrea Strutin, 29, Portland, 3:35:04.
Click here for complete results of the marathon.
Half marathon
Top 10 men
1, Kevin Ko, 27, Portland, 1:17:24.
2, Andrew Lee, 24, Vancouver, 1:18:40.
3, Kyle Roozen, 32, Milwaukie, Ore., 1:18:58.
4, Will Justice, Portland, 1:20:08.
5, Lawrence Merrifield, Jr., 44, Portland, 1:20:45.
6, Ryan Miles, 36, Vancouver, 1:22:07.
7, Martin Pletcher, 20, Sammamish, 1:22:54.
8, David Cummings, 32, Vancouver, 1:25:09.
9, Jacob Fullen, 21, Kent, 1:25:19.
10, Francisco Maya, 40, Beaverton, 1:26.
Top 10 women
1, Lauren Breihof, 23, Redmond, 1:25:28.
2, Katarina Mueller, 20, Vancouver, 1:28:21.
3, Gretchen Van Dyke, 34, Tacoma, 1:29:41.
4, Laura Matsenko, 29, hometown not available, 1:31:13.
5, Angela Gula, 20, Vancouver, 1:32:30.
6, Tami Wright, 34, Vancouver, 1:32:52.
7, Valerie Cross, Flagstaff, Ariz., 1:37:35.
8, Melissa Mocklin-Dwiggin, 36, Beaverton, 1:38:17.
9, Sierra Zollinger, 19, Burley, Idaho, 1:39:05.
10, Jamie Stenstrom, 36, Wilsonville, 1:40:20.


text:
Key things you need to know aboutDr. Zarama:
Dr. Zarama's Experience
Research training, expertise and qualifications
Dr. Zarama's Specialties
- Nephrology
Procedures Dr. Zarama Performs
- Arteriovenostomy for Renal Dialysis
- Biopsy
- See all 7 procedures
Conditions Dr. Zarama Treats
- Anemia
- Chronic Kidney Diseases
- See all 12 conditions
More About Dr. Zarama's Background
Hospital Quality
The right hospital is as important as the right doctor
- North Memorial Medical Center
- 3300 Oakdale Ave N
- Robbinsdale, MN 55422
- Saint Joseph's Hospital
- 45 10th St W
- Saint Paul, MN 55102
9 Facts About Hospital Quality
Patients' risk of dying during a hospital stay for heart bypass surgery could be 87.4% lower, on average, at a hospital rated 5 stars compared to a hospital rated 1 star for that procedure. Choosing the right hospital is critical to your health. View Slideshow
Patient Satisfaction
Patients' feedback on their experience with Dr. Zarama
Likelihood of recommending Dr. Zarama to family and friends is 5 out of 5 5 1 1
See More Survey Results
8 Facts About Patient Satisfaction Surveys
Patient satisfaction surveys provide a standardized way of reporting about healthcare experiences. But there can be more than meets the eye when reviewing scores. Here's what you should know
Appointments & Offices
Check insurance plans, locations and make an appointment
Accepting new patients?
- Yes
- Kidney Specialists of Minnesota PA
- Roseville Clinic
- 2085 Rice St
- Roseville, MN 55113
- (651) 489-9035
- Directions
- Prepare for Your Appointment
- Kidney Specialists of Minnesota PA
- Richfield Clinic
- 6601 Lyndale Ave S Ste 220
- Richfield, MN 55423
- (888) 437-7591
- Directions
- Prepare for Your Appointment
7 Tips to Prepare for Your Appointment
The key to a successful appointment is communication. To get the most out of your visit, prepare ahead of time so you can lead the conversation with your doctor. These 7 tips will get you ready
Oops, you entered a bad link for Dr. Zarama!
The link you entered contains bad characters or identifiers. Please enter the link exactly as it appears in your email or text message.
Thank You
This confirms that we have received your survey about Dr. Zarama. Please note: Your insights will help other patients make informed decisions. Please note: it may take 1 business day for your survey response to appear.
Thank You
Our records show that you have already confirmed your survey for Dr. Zarama. Please note: it takes 24 hours for your survey results to show up on the doctor's profile.


text:
Parent Peer Pressure
For the first 12 months you cannot:
- Allow passengers younger than 20 to ride in the car.
- Drive between 11 p.m. and 5 a.m.
In order to do either, the state requires you to have a licensed parent/guardian (or another licensed driver age 25 or older) or a licensed/certified driving instructor in the car with you.After 12 months have passed from the issue date on your driver's license, the above no longer applies. If you break those rules before that period is up, you could face a fine and/or community service, not to mention a dangerous driving situation you might not be able to handle as an inexperienced driver. (DMV.org)


text:
Hostal Zabala
Madrid, Spain (MAD)
1 of 15
View on map
Room & Rates
Double Room, Private Bathroom
- One Double Bed
Hide room details
Single Room, Private Bathroom
- One Single Bed
Hide room details
Hostal Zabala
Calle Magdalena 21, 2nd floor left, Madrid, Spain 28012
Make yourself at home in one of the 7 guestrooms. Complimentary wireless Internet access is available to keep you connected. Bathrooms have bathtubs or showers and hair dryers.
Business, Other Amenities
The front desk is staffed during limited hours. Parking (subject to charges) is conveniently located nearby.
Know Before You Go
- No pets and no service animals are allowed at this property.
- Elevator / Lift
(+) = Additional fees may apply for the use of these amenities.
(*) = Free, some restrictions may apply
(*) = Free, some restrictions may apply
Based on 216 reviews 0
Be the first person to review this property!
Similar Hotels


text:
This content has been marked as final. Show 3 replies
Re: Best of both worlds possible?kamas716 Sep 5, 2013 10:35 AM (in response to SuNooksie)With the HD/HD+ you have access to the Google Play Store and the Kindle app. The NT and NC don't have this, so no you can't read Kindle eBooks unless you root or strip DRM.
Re: Best of both worlds possible?SuNooksie Sep 5, 2013 2:31 PM (in response to kamas716)
Re: Best of both worlds possible?BFCoughlin Sep 6, 2013 5:44 AM (in response to SuNooksie)
You can get an N2A card of the equivalent (or make one yourself) which will allow you to boot into Android if you choose. Then you can get the Kindle app and read Kindle books on yyour NC. That's what I've done. Not quite as convenient as having a Kindle app right on the Nook side, but it works.


text:
Position: C ▪ Shoots: Left
Height: 6-0 (183 cm)
Weight: 185 lbs. (84 kg)
Born: January 26, 1961 in Brantford, Ontario
Amateur Teams: Peterborough Petes, Sault Ste. Marie Greyhounds
Relatives: Brent Gretzky (brother)
Hall of Fame: Inducted as Player in 1999 (Full List)
As Coach: 4 Yrs, 143-161-24, 310 Pts (Full Record)
Other SR Links: Olympics at Sports-Reference.com


text:
Subscribe and Get
40% off
Be the first to know
for joining!
You are on the list!
Please check your email for 40% OFF coupon code.
If you have any questions before making a purchase, chat with our online operaters to get more informations.
Please log in to "MY ORDERS" to get your order status or other after-sales issues.Submit a ticket
Special offer for VIP Learn more
( Earn SheIn Points )
Our Guarantee
Return or exchange within 30 days from the delivered date.
1. Items received within 30 days from the delivered date.
2. Items received unused, undamaged and in original package.
3. Return shipping fee is paid by buyer.
You can get 30 Points by writing a review at your "My Orders" after the purchase.
Item Size: S Weight:49Kg/108.0Lbs Height:158cm/62.2in Bust:32A Waist:60cm/23.6in Hips:81cm/31.9in Overall Fit:True to Size
Just amazing and unique. I had been looking for such a top from long time ago to set it with a pink skirt and now I founded here. the material is great, and the color is amazing
Item Size: M
Like photo soft material I liked
Item Size: M
Bella blusa, tal como en la foto
O alta bluza ce emana căldură si finețe,modelul sau îmi da o stare de bine,ma incarca de energie ,perfecta pt primavara
|Your account needs an email binding
|The email you entered is invalid


text:
Sign in now to view, license and download this image or contact us to see this image without a watermark. Want to embed this image on a non-commercial website or blog? Learn more.
Similar imagesView all
- Cloud - Sky,
- Color Image,
- Construction Platform,
- Day,
- Exploration,
- Famous Place,
- History,
- Horizontal,
- International Landmark,
- Large Group Of People,
- Leisure Activity,
- Mountain,
- Mt Rushmore National Monument,
- National Monument,
- On The Move,
- Outdoors,
- People,
- Photography,
- Sculpture,
- Sky,
- South Dakota,
- The Past,
- Tourism,
- Tourist,
- Travel Destinations,
- Tree,
Tourists Gather At View Of Mount Rushmore Stock PhotoCloud - Sky,Color Image,Construction Platform,Day,Exploration,Famous Place,History,Horizontal,International Landmark,Large Group Of People,Leisure Activity,Mountain,Mt Rushmore National Monument,National Monument,On The Move,Outdoors,People,Photography,Sculpture,Sky,South Dakota,The Past,Tourism,Tourist,Travel Destinations,Tree,USAPhotographer Nivek NesloCollection: Photodisc ©2010 Kevin CooleyTourists milling around the platform at Mount Rushmore national memorial with the sculptures in the background.


text:
Quotes & Info
|BEAV > SEC Filings for BEAV > Form 8-K on 23-Oct-2012
|All Recent SEC Filings
Results of Operations and Financial Condition, Financial Statements and Exhibits
On October 23, 2012, B/E Aerospace, Inc. issued a press release announcing financial results for the quarter ended September 30, 2012. A copy of such press release is furnished herewith as Exhibit 99.1, attached hereto and incorporated herein by reference.
The information included in this item, including Exhibit 99.1, is hereby furnished and shall not be deemed "filed" for purposes of Section 18 of the Securities Exchange Act of 1934 (the "Exchange Act"), nor shall it be deemed incorporated by reference in any filing under the Securities Act of 1933 or the Exchange Act, except as shall be expressly set forth by specific reference in such filing.
(d) Exhibits
99.1 Press Release, dated October 23, 2012, issued by B/E Aerospace, Inc. announcing financial results for the quarter ended September 30, 2012.


text:
Appliness digital magazine
by: Michaël Chaize | 86
All Android applications categories
All Android games categories
by: Michaël Chaize | 86
Appliness is a free digital magazine for web developers and web designers. It contains technical tutorials, videos, news, interactive samples and news about the web industry. If you're a developer who wants to discover new technologies such as PhoneGap, HTML5, jQuery Mobile, Backbone, JavaScript, then you should read appliness. Appliness is edited by developers. You can also contribute and publish your own tutorials, or showcase your work. To do so, visit our website appliness.com.
Tags: appliness logs , dynamiclayout , free magazine , adobe appliness
Users review
from 86 reviews
Download Appliness digital magazine
Free - V1 - 0
More actions


text:
On the 17 March, UNIC held an event commemorating the International Day of Remembrance of the Victims of the Transatlantic Slave Trade. The event was marked by poems, music and key messages about how slavery impacted on the African way of life. Nobulekhosi T. Sibanda, a student from Founders Community School, delivered an impassioned poem to guests that delved deep into culture of her African heritage and the ills of slavery that plagued the African continent.
The Trade
When I think about this time- the waves, death, sickness, vomiting, the smell of fresh sea water, rape abuse, the crack of the traders whip, those days, those months, those years, Oh my heart quivers. Continue reading


text:
Subject: [OMPI devel] v1.5: thumbs up or down?
From: Jeff Squyres (jsquyres_at_[hidden])
Date: 2010-06-29 11:38:44
Rainer and I are feeling good about v1.5; it is possible we could release within a week.
Can we get a thumbs up / down from each organization about where you think we are with v1.5? Cisco and HLRS obviously give a thumbs up.
Also please submit NEWS and README updates for v1.5. Thanks.
Jeff Squyres
For corporate legal information go to:


text:
County children's program faces big cut
A county program that seeks to improve families' access to health care, preschool and developmental services for young children stands to lose nearly $90 million, as state lawmakers continue to tap local governments to breach a yawning budget gap.
The budget bill that shifts half of reserve funds — $88.3 million for First 5 San Diego — from local commissions to the state was recently approved by the Legislature and signed by Gov. Jerry Brown. First 5 San Diego was created after state voters adopted a special tobacco tax in 1998 to pay for programs that benefit children up to 5 years old.
County officials and providers worry that some programs and services could be reduced or eliminated. Executive Director Barbara Jiménez said most of the money that will be taken by the state was already designated to programs for young children and their families. The commission had a balance of $177 million as of June 2010.
Once the money is transferred the commission could only fund about 18 months of services based on approved five-year allocation and 10-year spending plans, she said.
That troubles Ellen Yaffa, development director for SAY San Diego, which over the last three years has received about $4.4 million from First 5.
"Over all the years SAY has assisted families with First 5 funding, we have heard time and again that new parents simply do not know how to stimulate early development in their babies and toddlers, or do not know what community resources are available to them, or how to access them in a way that will help their children," Yaffa said.
Without the services, many of the 4,800 people assisted last year would have to bring children to emergency rooms for health care and skip dental examinations, she said. Others would miss early warning signs for asthma, vision or hearing problems.
Supervisor Pam Slater-Price, chairwoman of the First 5 Commission of San Diego County, said preventive efforts such as these save taxpayer dollars. The loss of local funding would eliminate a range of programs that serve 73,000 children and 26,000 parents in the county, according to Slater-Price.
Last year, about 36,500 children received developmental services, of which more than 90 percent showed improvement. Another 9,227 children and 2,389 pregnant women signed up for health insurance and 3,906 children enrolled in Preschool for All.
"When you're dealing with things locally rather than at the state level, we can make corrections on the ground," Slater-Price said. "I just see what happens to money when it goes to Sacramento. It seems to just fall into black holes.
"The public voted for this because they wanted it to happen," she continued. "But right now what the state is doing is coming in and taking money that voters decided should be spent one way and backfilling their general fund."
Assemblyman Marty Block, D-San Diego, said the vote was one in a series of difficult votes meant to help close the state's massive budget deficit, which now stands at more than $15 billion with a projected general fund of $85 billion.
"None of these cuts are easy because they impact services across the board, but we need to do what we can, with the resources available, to address the fiscal challenges in front of us," he said. "Without additional revenues, we will continue to face these draconian cuts and that is not in the best interest of California's future. We have worked hard to eliminate the most severe cuts by pushing to extend certain revenue sources as part of a comprehensive solution, but there has been little support from our colleagues across the aisle."