text:
|N�mero de publicaci�n
|Tipo de publicaci�n
|N�mero de solicitud
|Fecha de publicaci�n
|20 Abr 2010
|Fecha de presentaci�n
|10 Feb 2006
|Fecha de prioridad
|12 Sep 2005
|Tambi�n publicado como
|N�mero de publicaci�n
|Debra S. Echt, Richard E. Riley, Mark W. Cowan, Axel F. Brisken
|Cesionario original
|Ebr Systems, Inc.
|Exportar cita
|BiBTeX, EndNote, RefMan
|Citas de patentes (97), Otras citas (54), Citada por (23), Clasificaciones (5), Eventos legales (3)
|Enlaces externos: USPTO, Cesi�n de USPTO, Espacenet
This application claims the benefit of U.S. Provisional Application No. 60/716,202, filed on Sep. 12, 2005, which is herein incorporated by reference.
The present invention relates generally to medical devices and methods for treating cardiac conditions. Several embodiments of the present invention are methods and apparatus for determining an implantation site or stimulation site within a heart chamber based on hemodynamic measurements.
Pacemakers and implantable cardioverters/defibrillators are widely used to treat a number of different cardiac conditions. For example, localized pacing has been used to terminate and/or control bradycardia, bradyarrhythmia, tachycardia, tachyarrhythmia, and other conditions. Over the years, many sophisticated algorithms and complex electromechanical devices have been developed and implemented in pacemaker technology for detecting the onset of abnormal rhythms and treating these conditions.
To better understand the effect of pacing devices, it is useful to understand the electrical-mechanical operation of the heart. The normal electrical activation system of the heart initiates left and right heart conduction using a complex structure/network of cardiac cells that rapidly conduct cellular-level electrical activation through cardiac tissue. For example, in the left and right ventricles of the heart, the Purkinje system, a specialized network of cells, conducts electrical activation endocardially and spreads the activation through the myocardial layers to the epicardium. Via connection to the atrial-ventricular node (A-V node), which is a specialized network of cells between the atria and the ventricles, normal ventricular electrical activation originates in the superior, septal aspect of the left ventricle, and then propagates through the septal wall, left ventricular free wall, and right ventricular free wall. This electrical activation induces the mechanical contractions of the ventricles that eject blood from the heart and into the vascular system. The strength and pattern of the mechanical contractility of the heart significantly affects the hemodynamic function. For example, when the normal electrical conduction pattern is blocked by ischemic regions in the ventricles, the mechanical contraction patterns of the heart are modified. Therefore, changes in the electrical conduction pattern have a direct impact on the hemodynamic function of the heart.
In the presence of cardiac disease, the dynamic and complex changes in regional electrical conduction and in mechanical function can lead to inefficiencies and cardiac hemodynamic output that eventually cause cardiomyopathy, mitral valve regurgitation, and other global physical and functional changes. Such mechanical dysfunction leads to further electrical conduction abnormalities, and thus further mechanical dysfunction. This progressively deleterious cycle of events leads to further inefficiencies and ever-worsening cardiovascular status (e.g., progressive heart failure).
Typical pacing devices artificially initiate electrical conduction in the heart by delivering small amounts of electrical current (e.g., a stimulation pulse) between two electrical contacts (electrodes) located on a lead placed in or on the heart. At least one electrode typically touches cardiac tissue. The site of the electrical contact then becomes the earliest site of activation and a conduction pattern propagates from this site throughout the cardiac tissue. It is desirable for pacing devices to deliver the stimulation pulse to a selected site along the normal electrical conduction paths in order to more appropriately synchronize the activation pattern of the heart. In many applications, for example, it would be desirable to stimulate from an endocardial location in the left ventricle to more closely approximate the normal electrical activation that initiates in the superior, septal aspect of the left ventricle. However, as explained below, many lead-based systems cause an abnormal conduction pattern to propagate through the cardiac tissue because lead-based electrodes are limited to being placed at an abnormal site of origin.
One drawback of lead-based pacing systems is that they are not well suited for endocardial pacing in the left ventricle. For the emerging treatment of heart failure, through what is commonly known as resynchronization therapy, bi-ventricular pacing is utilized. Bi-ventricular pacing requires that an additional lead be placed in contact with the left ventricle. To access the left ventricle, a third lead is typically advanced through the right atrium and the orifice of the coronary sinus, and then the third lead is maneuvered through the coronary veins to a position in the vein that is on the epicardial aspect of the lateral wall of the left ventricle. Less commonly, the third lead is placed directly on the epicardium and then subcutaneously tunneled to the implant location of the pacing device. The left ventricle is accordingly stimulated epicardially from this position. Unlike normal endocardial electrical activation in which the activation initiates in the endocardium and then propagates through the myocardial layers to the epicardium, such epicardial stimulation of lead-based electrodes progresses in the opposite transmural direction. This approach may reduce the efficacy of lead-based left ventricular pacing. Moreover, because the size and course of the coronary sinus varies from patient to patient, it is often difficult to manipulate the lead within the coronary sinus. The available stimulation sites within the coronary sinus are accordingly limited by the individual anatomic features of each patient. Also, because the lead is located on the epicardial side of the left ventricle, the electrical current/energy required to stimulate the left ventricle is generally significantly higher for this treatment compared to standard endocardial locations within the right ventricle. This occurs, in part, because the electrical contacts of the lead may not be in intimate contact with the myocardium (i.e., they may be more preferentially in contact with the vein or situated centrally within the vessel). Thus, higher electrical currents in the stimulation pulse may be required to initiate activation. These higher electrical currents may stimulate other unintended, nearby structures such as the phrenic nerve.
Although implanting pacemaker leads directly within the left ventricle has been proposed, it is not yet practiced because prior art medical devices that reside on the arterial side (left side) of the cardiovascular system increase the risk of stroke, myocardial infarction, and vascular occlusions. For example, left ventricular lead placement is not practical because thrombus formation on the lead body and subsequent systemic embolization would require patients to have long-term anticoagulation drugs. Moreover, it may be necessary to extract the lead from the left ventricle, but this procedure may have considerable risks. Placing the lead retrograde through the aortic valve may cause aortic regurgitation and the proximate end of the lead may cause arterial bleeding because this end of the lead would need to exit through an artery. Alternatively, placing the lead through a transeptal atrial puncture and then across the mitral valve into the left ventricle, may possibly worsen mitral valve regurgitation. Therefore, implanting lead-based electrodes into the left ventricle of the patient is not practical using conventional systems.
Another aspect of implanting pacing systems is to determine the stimulation site to effectuate optimal synchronization timing between pacing sites and the resultant hemodynamic performance. Clinical studies of pacing modalities to treat heart failure have shown that acute hemodynamic measurements are correlated with patient benefit. For example, a separate catheter placed acutely within the left ventricle has been used to evaluate hemodynamic responses for bi-ventricular pacing. Specifically, a pressure-volume catheter system has been used to obtain simultaneous measurement of (a) aortic and left ventricular pressures, (b) an index of contractility (dP/dTmax), and/or (c) left ventricular chamber volumes. Based on these clinical studies, it appears that it would be desirable to optimize the number and location of the stimulation sites to provide the optimal patient benefit.
One drawback of using hemodynamic measurements within the left ventricle for pacing applications is that it is impractical to implant lead-based electrodes in the left ventricle for the reasons explained above. Therefore, even though hemodynamic responses have been evaluated for bi-ventricular pacing using epicaridal lead placements, this concept has not been used for endocardial pacing in the left ventricle because conventional pacing devices are not well suited for left ventricular pacing even if such left ventricular sites are the optimal stimulation sites.
A. Overview
The present invention is directed toward apparatus and methods for determining an implantation site for attaching a stimulation electrode to the heart of a patient. Many embodiments of the invention are directed toward implanting a leadless stimulation electrode that is configured to convert acoustic energy to electrical energy and deliver the electrical energy to the stimulation site. Suitable leadless stimulation electrode devices are disclosed in U.S. patent application Ser. Nos. 11/315,023; 11/315,524; 60/689,606; 60/639,037; 60/639,056; 60/704,620, entitled "Efficiently Delivering Acoustic Energy to Tissue," filed on Aug. 1, 2005; and 60/713,241, entitled "Methods And Systems for Heart Failure Treatments Using Ultrasound And Leadless Implantable Device," filed on Aug. 30, 2005, which are herein incorporated by reference. Because the stimulation electrodes are leadless, they can be placed in the left ventricle in a manner that enables pacing therapies that are not practical using lead-based electrodes.
One aspect of the invention is directed toward methods for determining an endocardial implantation site for implanting an electrode, such as a leadless stimulation electrode. This method includes delivering sufficient electrical energy for initiation of cardiac activation to a plurality of different test locations at the heart of a patient, and determining hemodynamic responses in reaction to the stimulus delivered to the different test locations. This method further includes identifying an implantation site for implanting the electrode by selecting at least one of the test locations corresponding to a favorable hemodynamic response.
Another embodiment of a method in accordance with the invention is directed toward determining an implantation site for implanting an electrode in the left ventricle of a patient. This method includes delivering sufficient electrical energy for initiation of cardiac activation to a plurality of different test locations within the left ventricle of the patient, and determining hemodynamic responses in reaction to the stimulus delivered to the different test locations. This method further includes identifying an implantation site for implanting the electrode by selecting at least one of the test locations within the left ventricle corresponding to a favorable hemodynamic response.
Another method of determining an implantation site for attaching a stimulation electrode in accordance with the invention comprises locating a leadless electrode at a first test location at the heart of the patient. The leadless electrode in this embodiment is configured to convert acoustic energy to electrical energy. This method continues by delivering sufficient electrical energy for initiation of cardiac activation to the first test location via the leadless electrode by wirelessly transmitting acoustic energy to the leadless electrode, and determining a first hemodynamic response in reaction to that stimulus to the first test location. This method further includes delivering sufficient electrical energy for initiation of cardiac activation to a second test location via the leadless electrode by wirelessly transmitting acoustic energy to the leadless electrode, and determining a second hemodynamic response in reaction to that stimulus to the second test location. After determining the first and second hemodynamic responses, this process can continue by delivering sufficient electrical energy for initiation of cardiac activation to the heart and determining the corresponding hemodynamic response at several different locations. This method further includes identifying an implantation site for implanting the leadless electrode by selecting at least one of the test locations corresponding to a favorable hemodynamic response.
Yet another method of automatically determining an implantation site for attaching a leadless stimulation electrode in accordance with an embodiment of the invention is directed toward a leadless electrode that is configured to convert acoustic energy to electrical energy and deliver the electrical energy to the stimulation site. An embodiment of this method comprises delivering sufficient electrical energy for initiation of cardiac activation to a plurality of different test locations at the heart of the patient, and determining hemodynamic responses in reaction to the stimulus delivered to the different test locations. This method further includes identifying an implantation site for implanting the electrode by operating a computer to automatically select at least one of the test locations corresponding to a favorable hemodynamic response.
Another aspect of the present invention is directed toward an apparatus for determining an implantation site for attaching a stimulation electrode to the heart of a patient. One embodiment of such an apparatus includes a catheter comprising an elongated body having a proximal portion and a distal portion configured to be inserted into the heart of the patient. The apparatus can further include a hemodynamic sensor and a stimulation electrode at the distal portion of the body. The stimulation electrode can comprise (a) a transducer configured to convert acoustic energy to electrical energy and (b) an electrical contact electrically coupled to the transducer to deliver sufficient electrical energy for initiation of cardiac activation from the transducer to the stimulation site.
Another aspect of the invention is directed toward systems for determining an implantation site for attaching a stimulation electrode to the heart of a patient. One embodiment of such a system comprises a generator configured to wirelessly transmit acoustic energy, a stimulation electrode configured to be placed in contact with the heart tissue of a patient, and a hemodynamic sensor. The stimulation electrode comprises (a) a case, (b) a transducer at least partially in the case and configured to convert the wirelessly transmitted acoustic energy from the generator to electrical energy, and (c) electrical contact electrically coupled to the transducer and configured to deliver the electrical energy from the transducer to the heart tissue of the patient. The hemodynamic sensor is configured to detect hemodynamic responses corresponding to the electrical energy delivered from the stimulation electrode to the heart of the patient. The stimulation electrode and the hemodynamic sensors can be attached to separate catheters such that they are independently positionable within the heart of the patient. In other embodiments, however, the stimulation electrode and the hemodynamic sensor are both carried by a single catheter or other type of elongated body that is configured to be positioned within the heart of the patient.
Another embodiment of a system in accordance with the invention comprises a generator configured to wirelessly transmit a source energy, a stimulation electrode configured to be placed in contact with the heart tissue of the patient, and a hemodynamic sensor. The stimulation electrode comprises a transducer configured to convert the source energy to electrical energy and an electrical contact configured to deliver the electrical energy to the heart of the patient. The hemodynamic sensor is configured to detect acute intrinsic hemodynamic responses in reaction to electrical energy applied to the heart by the stimulation electrode. This system can further include a computer operatively coupled to the hemodynamic sensor and the stimulation electrode. In one embodiment, the computer includes a computer-operable medium containing instructions that provide an output indicative of stimulation performance of the stimulation electrode at test sites of the heart of the patient. The computer-operable medium can further provide an output in which the stimulation performance of the stimulation electrode is mapped onto an image or other representation of the heart of the patient.
In several embodiments of the present invention, the generator is a controller-transmitter device that transmits ultrasound energy through the patient. The controller-transmitter device can be implanted in the patient, or the controller-transmitter device can be external to the patient. The leadless stimulation electrodes can be receiver-stimulator devices configured to be located at different locations throughout the endocardium of cardiac chambers of the patient. In general, at least one of the receiver-stimulator devices is configured to be in direct contact with the endocardial tissue. Suitable controller-transmitter devices and receiver-stimulator devices are disclosed in the U.S. patent applications incorporated by reference above.
In operation, the site for implanting a receiver-stimulator device is based on an assessment of cardiac performance from pacing at the site (such as, assessing the electrical activation timing, activation pattern, and/or hemodynamic responses). In many applications, the implantation site corresponds to the test location where the cardiac performance response indicates an optimal hemodynamic performance. The cardiac performance response can be assessed by measuring the pressure, volume, blood flow velocity, wall movement timing, and/or other hemodynamic measurements, and/or electrical activation timing or activation pattern mapping. These measurements are used to derive the parameters of cardiac performance such as ejection fraction, stroke volume, systolic blood pressure, arterial blood pressure, pressure change rate (dP/dTmax), valve pressure gradient, electrical activation sequences, electrical conduction times, and/or other cardiac performance parameters. According to this invention, the implantation site at the endocardium is determined by selecting the location corresponding to the desired or optimized cardiac performance parameters.
B. Embodiments of Apparatus for Determining Implantation Sites
The catheter 10 can include a pull-wire (not shown) attached to the distal end and an actuator mechanism (not shown) at the proximal end attached to the pull-wire. The construction of the catheter 10 can be the same as catheters that are used for cardiac mapping, cardiac ablation, electrophysiology, and other types of cardiac procedures. As a result, the distal end of the catheter can be steered through the vasculature and the heart, and the catheter can be held at locations in the heart H such that the distal end of the catheter containing the stimulation element 20 contacts the endocardium.
The stimulation element 20 can be lead-based stimulation electrodes or a leadless electrode. In one embodiment of a leadless electrode, the stimulation element 20 comprises acoustic receiver-stimulator device having a case, a transducer at least partially in the case, and stimulation electrodes. The transducer can be a piezoelectric element or other device configured to convert wirelessly transmitted acoustic energy from a remote acoustic generator to electrical energy. The stimulation electrodes are electrically coupled to the transducer and configured to deliver the electrical energy from the transducer to the heart of the patient. In the embodiment illustrated in
In an alternative embodiment, the apparatus 1 can have more than one stimulation element 20, or the stimulation element 20 can be lead-based stimulation electrodes having electrode wires running the length of the catheter 10. In yet another alternative embodiment, the catheter 10 is a pacemaker lead with pressure sensors adapted to be part of the lead construction.
In the embodiment illustrated in
The hemodynamic sensors 30 may be pressure transducers, flow rate meters, electrical sensors, or other types of sensors that can detect hemodynamic measurements. In one embodiment, the hemodynamic sensors are solid-state pressure transducers/sensors similar to those used on Millar Mikro-Tip catheters, or they may be any type of pressure sensor adapted for monitoring intravascular blood pressure. In the case of using solid-state pressure sensors, the apparatus 1 will further include wires running the length of the catheter 10 to electrically couple the sensors 30 to equipment outside of the patient. For example, the sensors 30 can be connected to external pressure recording and monitoring systems to obtain real time and post-process pressure data. Suitable external recording and monitoring systems include the BIOPAC systems, MP 100.
Referring to
In a particular application, the process of using the apparatus 1 to measure the hemodynamic response at a plurality of test locations begins by determining a baseline for the patient. For example, when the stimulation element 20 is placed at one of the endocardial test locations in the left ventricle LV, the baseline pressure data from the hemodynamic sensors is collected, recorded and analyzed over one or more cardiac cycles without applying electrical energy to the test site. This baseline data is typically obtained during the intrinsic rhythm of the heart H. If the patient has a very slow intrinsic heart rate that requires constant pacing with a pacemaker, the implanted pacing leads of the pacemaker or the temporary leads of the external pacemaker can be used to establish a baseline pacing rate to substitute for the intrinsic rhythm. The baseline value can also be compared with other measurements during the intrinsic or paced rhythm. For example, the baseline value from the sensors 30 can be compared with the heart rate, presence or absence of atrial ventricular synchrony, presence or absence of underlying arrhythmias, or blood pressure taken from an arm pressure cuff.
After determining the baseline value, sufficient electrical energy for initiation of cardiac activation is applied to the test location via the stimulation element 20 to initiate a cardiac-paced rhythm. After the characteristics of the hemodynamic data have been captured during the paced rhythm at one test location, the stimulation element 20 is moved to a new test location in the heart H and sufficient electrical energy for initiation of cardiac activation is applied to the new test location via the stimulation element 20 to initiate another cardiac-paced rhythm from the new test location. The hemodynamic data and the location of the new test site are accordingly collected and recorded during the paced rhythm for the new test location. This process is repeated for any number of selected test locations in the left ventricle LV endocardium or other locations of the heart H.
In some embodiments, the duration of the paced rhythm may be varied to determine the hemodynamic responses to different heart rates. Also, the A-V interval may need to be controlled to maintain A-V synchrony or may need to be varied to determine the A-V interval to optimize the atrial contribution to ventricular filling. These judgments can be implemented by an attending physician analyzing the data gathered during the process.
The hemodynamic data, such as pressure data, can be processed to provide one or more hemodynamic parameters to a practitioner or a computer. Suitable hemodynamic parameters include the rate of pressure change (e.g., positive dP/dTmax, negative dP/dTmax, or dP/dTmin), peak systolic pressure, peak diastolic pressure, end diastolic pressure, end systolic pressure, atrial pulse pressure, left ventricle LV pressure wave forms, aortic pressure wave forms, ejection period, aortic valve pressure gradient, and other parameters. Similar hemodynamic measurements can be obtained non-invasively using an echocardiographic imaging system. Echocardiographic data could be obtained for each test stimulation location during implant testing, or supplemental data could be obtained before the implant procedure. In all cases, the desired implantation site can be selected by comparing the hemodynamic parameters and/or the hemodynamic data corresponding to the individual test sites. In one embodiment, the desired implantation site corresponds to the location where the greatest improvement in hemodynamic status occurs based upon a comparison of the hemodynamic baseline and the hemodynamic parameters corresponding to the various test locations. In a further embodiment, the implantation site can be confirmed by placing the stimulation element 20 back at the selected location and repeating the sequence to determine whether the test location produces the expected result.
The test location and the corresponding hemodynamic response from the sensors can be referenced with diagrams or real images (fluoroscopic, ultrasound, MRI, CT, etc.) of the patient's anatomy to map or otherwise correlate the hemodynamic responses to the patient's anatomy. For example, the correlation may be done using an EP mapping system that contains three-dimensional localization technology. Suitable EP mapping systems can be the ultrasound ranging system provided by Boston Scientific, Inc., the impedance ranging system provided by Endocardial Solutions, and/or the magnetic tracking system provided by Biosense Webster. These and other systems can record catheter positions so that the operator can return the catheter to stored locations. These and other systems can also record electrical activation data such as conduction times between two locations or illustrate conduction patterns, known as maps. Thus by using the stimulation electrodes as electrogram recording electrodes in EP systems, electrical conduction data is also available to correlate a test site with improved cardiac performance. Required elements that enable these mapping technologies may be incorporated into the catheter embodiments discussed within but are not shown.
After selecting an implantation site for implanting a stimulation electrode, a suitable stimulation electrode is implanted at that location. In one embodiment, the stimulation element 20 is an acoustic stimulation electrode such as the receiver-stimulator electrode described above, and the stimulation element 20 is detached from the catheter 1 and fixed to the heart H whereupon the catheter 1 is withdrawn/removed. In another embodiment, the catheter 1 itself is fixed to the tissue and used as a pacemaker lead.
Referring to
Referring to
Referring to
The foregoing apparatus and methods described above with reference to
The foregoing embodiments of apparatus and methods in large part describe aspects of hemodynamic measurements that can be made within the heart. Additionally, other embodiments in accordance with the invention may use non-invasive methods of measuring hemodynamic responses. For example, the use of transthoracic ultrasound imaging can be used to measure and characterize heart wall motion timing, wall motion velocity, wall motion force, chamber volume, ejection fraction, flow velocity, and the like. Further the use of blood pressure cuffs on the arms or other extremities would provide hemodynamic measurement of pressure changes as a response to pacing site selection.
The foregoing embodiments of apparatus and methods provide advantages for implantation of cardiac pacing electrodes by using hemodynamic optimization for both single- or multi-site endocardial pacing. There are many potential locations to implant electrodes, and in particular the leadless receiver-stimulator devices that convert acoustic energy to electrical energy can be implanted in places where it is not practical to implant lead-based electrodes. Several embodiments of the apparatus and methods are expected to determine efficacious stimulation sites by using leadless electrodes to take advantage of stimulation sites that are not practical for lead-based electrodes (e.g., endocardial left ventricle locations). As a result, one advantage of particular embodiments of the invention is that the combination of using hemodynamic parameters for implanting leadless electrodes at endocardial left ventricle sites is expected to improve left ventricle function compared to conventional techniques.
In specific embodiments of the co-pending disclosures incorporated by reference above, the hemodynamic data may be used in situations in which the ideal locations for the controller-transmitter are limited due to anatomic constraints. The ideal location for the controller-transmitter device is where it can deliver the maximum amount of acoustic energy to the leadless stimulation electrodes, but certain physiological constraints by the thoracic region and the lungs may limit the locations for implanting the controller-transmitter. Therefore, optimization of the implant locations for the controller-transmitter and the receiver-stimulator devices may require testing at different sites for both the controller-transmitter and the receiver-stimulator devices to obtain the highest level of hemodynamic improvement.
C. Embodiments of Methods for Determining Implantation Sites
The method 600 further includes a sensing stage 620 comprising determining acute intrinsic hemodynamic responses in reaction to the stimulus to the different test locations. As described above, the sensing stage 620 provides the hemodynamic data corresponding to each test location. The method 600 further includes an identification stage 630 comprising identifying an implantation site for implanting the electrode by selecting at least one of the test locations that corresponds to a favorable hemodynamic response. As described above with reference to
From the foregoing, it will be appreciated that specific embodiments of the invention have been described herein for purposes of illustration, but that various modifications may be made without deviating from the spirit and scope of the invention. Accordingly, the invention is not limited except as by the appended claims.
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|Patente citante
|Fecha de presentaci�n
|Fecha de publicaci�n
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|Clasificaci�n de EE.UU.
|Clasificaci�n internacional
|Clasificaci�n cooperativa
|Clasificaci�n europea
|10 Feb 2006
Owner name: EBR SYSTEMS, INC., CALIFORNIA
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Effective date: 20060209
Owner name: EBR SYSTEMS, INC.,CALIFORNIA
Free format text: ASSIGNMENT OF ASSIGNORS INTEREST;ASSIGNORS:ECHT, DEBRA S.;RILEY, RICHARD E.;COWAN, MARK W.;AND OTHERS;REEL/FRAME:017562/0979
Effective date: 20060209
|31 Ago 2010
|Certificate of correction
|16 Oct 2013
|Fee payment
Year of fee payment: 4


text:
Complemented by recipes and a glossary of exotic food terms, the book is a unique blend of bildungsroman and foodie/truffle primer sure to appeal to a wide audience. An informative and charming food and travel memoir.
The thickly bound format is ideally read in bed. This is just the kind of book to shut out the world with a sense of Scandinavian comfort.
Fresh garlic appears in a handful, including chicken Caesar salad and carnitas, but reliance on the processed form undermines the thesis. Perhaps it's intended to aid the transition to the new way of eating.
"Eight Flavors" is the sort of food book that even non-foodies will find fascinating. A lot of that springs from Lohman's style; while her stories are obviously driven by her quest, her easy prose and obvious passion result in a book that is compelling no matter what your spice rack and pantry might look like.
...it's not clear why Towers would make himself sound unnecessarily snooty with the price tag, but it's one of the several details that makes Table Manners not particularly inclusive.
With mix-and-match flexibility, this meal-planning guide helps hosts "optimize the guests' experience." Silverton shares tips on buffet presentation, division of labor, and the importance of colorful plating...
The playful visuals and Meehan's off-the-cuff text offer near-constant reminders that vegetables are wildly versatile, and cooking them ought to be fun.
The French Chef in America, Alex Prud'homme's biography of Julia Child – post-Mastering the Art of French Cooking – wastes no time in reminding us of Child's charm.
There's nothing half-baked about this impressive omnibus as Bittman delivers the promised "everything" in an epic homage to baking.
...it's really all about the standards, and with one glaring omission—sweet potato pie—McDermott excels, giving readers an informative guide they'll be referring to for years to come.
The book itself looks less like a cookbook than an exhibition catalog. The pages are tastefully spare, the images stark. There are full-page portraits...
Going beyond the glories of grits, Howard's text is storytelling at its best, rich in mouthwatering detail and reminiscences, though at times her lively anecdotes obscure the recipe directions. This tribute to her family roots is destined to become an enduring classic.
A memoirist, actress, fashion model, jewelry designer, philanthropist, and food show host, she now adds encyclopedia author to her credits with this handy and knowledgeable look at the wide world of seasonings.
Hartwig succeeds in making the case that seemingly uncontrollable desires for food truly can be conquered with hard work.
I might never eat at Huertas — or at Spoon and Stable, for that matter. But "Generation Chef" has given me an appreciation for what has gone into these restaurants and others. This book is as much about dreams and passion as it is about food.
Over half of the book is a cookbook with delicious-sounding recipes...Throughout, the writing is accessible and well- documented by footnotes.
With 1,000 photos and the expertise of the America's Test Kitchen editors, this title might be the definitive book on bread baking.
Chico Bon Bon's quick thinking saves the day—leftovers have seldom come in so handy—and Monroe's manic cartooning will have kids laughing from start to finish.
Their efforts influenced the culinary arts for decades to come. A highly readable, illuminating look at the many ramifications of feeding the hungry in hard times.
Lo's illustrations have an appropriately faded look, neatly evoking both the times and the craggy wilderness. A frontier adventure that spotlights one of the many significant roles ethnic Chinese played in American history.

subset: commoncrawl


text:
Thomas Grant, from Churchdown, Gloucestershire, died instantly when he intervened to help a woman involved in an argument with a man on a mid-morning train from Glasgow. He was travelling home from the University of St Andrews, where he was in the first year of a degree course in history and Arabic.
Mr Grant left Oakham public school in Rutland last June and had been a model pupil, said the head, Dr JAF Spence. "All who study and work at Oakham school have been deeply saddened to hear of the tragic and violent death of Tom Grant," Dr Spence said.
"Tom enjoyed a fine career at Oakham school, where he was the leading cadet in the Combined Cadet Force and captain of the soccer 1st XI.
"Tom had many friends and touched the lives of all his teachers and peers. He was a vivid personality and a role model for younger pupils. Always alert to the needs of others, he will live long in the memories of everyone who knew him."
Stephen Magee, the vice-principal of the University of St Andrews, said he was "deeply saddened" by the news of Mr Grant's death.
"Tom was a bright, extremely able student who had made many friends in his first year with us and was a very popular and active member of the university community.
"There is a palpable sense of shock here. To have lost someone so young in such circumstances is utterly tragic. Our deepest sympathies are with Tom's mother and father."
Mr Grant was a member of the university's Officer Training Corps and lived in Andrew Melville Hall.
A university spokesman said chaplains had contacted Mr Grant's family and support was being offered to his friends and fellow students at St Andrews. A memorial service would be held later this year.
Mr Grant's father is a retired RAF training officer and lives with his wife, Patricia, in Gloucestershire. The couple were not at home yesterday.
A neighbour, Alison Williams, 32, who is a training officer at the base, said: "I worked for Tom's dad when we were both in Brüggen in Germany. My heart goes out to him - this must be a terrible shock for him and his wife.
"I didn't really know Tom but Kenny was very proud of him. He was a very bright lad."
Yesterday Thomas Lee Wood, 21, of Skelmersdale, Lancashire, appeared before magistrates in Kendal, Cumbria, charged with Mr Grant's murder. He was remanded in custody after a 10-minute hearing. No plea was entered and no application for bail was made. He will appear at Carlisle crown court on June 7.


text:
Peanut Butter Banana Smoothie with Cacao Nibs
Serving Size: 1
Prep Time:
Total Time:
This peanut butter banana smoothie is great for breakfast or as a healthy dairy-free milkshake. Kefir adds probiotics. Cacao, coconut oil and raw honey are powerful anti-oxidants and full of health benefits.
- Combine all the ingredients in a food processor or blender. Puree until smooth. Transfer to a glass and enjoy.
For the full post, visit Feed Me, Phoebe.


text:
Loonie ends at par with U.S. dollar
By Jennifer Kwan
TORONTO (Reuters) - The Canadian dollar ended slightly weaker on Thursday to trade exactly at par with the greenback as a less hawkish-than-expected policy report by the central bank reduced some demand for the currency.
The Bank of Canada laid the groundwork to raise interest rates from their record lows, and said it was time to start withdrawing some of the unprecedented monetary stimulus that helped pull Canada out of recession.
But the quarterly Monetary Policy Report was seen as less aggressive than language used by the central bank on Tuesday that left most investors convinced it will start hiking rates in June.
"It wasn't quite as stridently as hawkish as the press statement on Tuesday," said David Watt, senior currency strategist at RBC Capital Markets.
"As a result of that, people weren't necessarily today looking for reasons to go long, risky securities," Watt said.
Currencies usually strengthen as interest rates rise because higher rates tend to attract capital flows.
The Canadian dollar finished at exactly C$1 to the U.S. dollar, slightly lower than Wednesday's finish at C$0.9992 to the U.S. dollar, or $1.0008.
The currency touched a high of C$0.9961 to the U.S. dollar, or $1.0039, in the overnight session on the lingering effects of Tuesday's central bank statement. Continued...


text:
United States President Barack Obama presented the 2010 National Medal of Arts to jazz great Quincy Jones in the East Room of the White House in Washington, DC on March 2, 2011. President Obama awarded the 2010 National Medal of Arts and National Humanities Medal to 20 honorees. The National Medal of Arts is the highest award given to artists and arts patrons by the United States Government. Quincy Jones was honored for his extraordinary contributions to American music as a musician, composer, record producer, and arranger. As a master inventor of musical hybrids, he has mixed pop, soul, hip-hop, jazz, classical, African, and Brazilian music into many dazzling fusions, traversing virtually every medium, including records, live performances, movies, and television. (Photo by Jeff Malet)
award ceremonymusicmedallionribbonnational awardgold medalpoetsaxsaxaphonejazzIMG4397


text:
Reviews of Chiawa Camp
They do not necessarily represent the views of Expert Africa.
Lovely camp by the Zambezi
We enjoyed our stat at Chiawa, particularly the water activities. Sundowner on the Zambezi was lovely and the canoeing was really good.
Guides were helpful and gave us a lovely experience of a leopard. We stayed at the honeymoon tent which was really comfortable, if a bit hot and airless.
A rather smart camp did not quite have the "bush" atmosphere of others - maybe we should have stayed at Old Mondoro?
Wonderful camp on the Zambezi
Tents were delightful. Spacious, very clean and very well equipped with a great attention to detail.
Beds very comfortable and facilities excellent. Food was excellent. Camp activities were varied and very well organised. It was easy to choose an activity to suit and the guides were very helpful at tailoring activities, e.g. when one of us wanted to go birdwatching.
Chiawa Camp review
The most luxurious of all the places we stayed further upmarket compared to sister camp Old Mondoro
Run exactly the same
Very nice indeed
See whole trip comments
Chiawa another nice camp
Both managers and staff of Chiawa are friendly and the food was excellent.
Guiding was good though we did not see much on our night drives as we did at Tafika and the red light used does mean that taking photographs was tricky, though we do understand why it was used.
The canoe trip was excellent and I highly recommend taking the longer canoe trip. Having a meal on the boat as it travelled down the river was also a lovely surprise, though I wish we had known a little in advance as we would have taken our binoculars and cameras with us.
Chiawa Camp review
This was the largest of our camps and possibly a bit more luxurious. We did prefer the smaller more intimate camps but still enjoyed our stay here immensely.
Had a great walk which turned into an elephant dodge as there was so many elephants around including one that kept coming into the camp, especially at mealtimes.
Chiawa Camp review
A magical place, loved every second from the muffins at breakfast to the sounds of the hippos at night.Read more about the whole safari
Chiawa 2014
Excellent camp with wide choice of activities. Less intimate than other camps. Management excellent.
Lots of treats! Lunch on river and secluded dinner for two (50th wedding anniversary) on river at night. Everyone very friendly, helpful and flexible with activities. Felt quantity of food a bit too much for us with fairly heavy lunch and 4 courses at night.
Chiawa Camp review
millionaires shortbread!!!
Surprise-Lunch and Surprise-Dinner were stunning.
Very luxury accommodation.
But still a lot of wildlife. Even a huge male elephant in the camp.
Chiawa Camp review
Very welcoming and perfectly kept camp.
Good guiding , good food .... and perfect laundry service !
Surprise boatlunch ON the Zambezi.
Thanks to Anita and Peter
Going west we encountered more vehicles from lodges not within the park.
Chiawa offers luxury in the bush!
Chiawa occupies a great location and overall the standards are very high. It is luxurious and is a great place to stay for two or three nights and the guiding is to a very good standard.
A great aspect of the Lower Zambezi is the opportunity to spend time on the river and adopt a leisurely pace to observing the birds and animals. The canoe trip is a wonderful experience.
Not something to dwell on but the camp sometimes felt "over managed" meaning that it was not always clear what roles the management were trying to fulfil!


text:
by Katie Davies • illustrated by Hannah ShawTHE GREAT HAMSTER MASSACRE
Available now • Simon & Schuster Books for Young Readers • Ages 8 - 12
"A top pick for slow or reluctant readers" (Kirkus) and "the first in a series that will appeal to fans of Roald Dahl and Dick King-Smith." (Booklist)
Story: Anna and her brother, Tom, have always wanted a pet. And after their latest pestering campaign, their mother finally gives in and lets them choose a pair of hamsters from the local pet shop. But their happiness soon turns to horror when the hamsters are found mysteriously dead in their cage. Anna and Tom launch a full-scale investigation to determine who—or what—is behind the hamster homicides. Can they solve the case of the Great Hamster Massacre?
Katie Davies' irresistibly funny mystery and Hanna Shaw's spot-on illustrations combine for a quirky, delightful read that is part detective tale, part diary, and altogether hilarious.
Story behind the story:
Author Katie Davies has experience with hamster disasters. When she was twelve years old, after a relentless begging campaign, she was given two Russian Dwarf hamsters for Christmas. She is yet to recover from what happened to those hamsters. The Great Hamster Massacre is her first novel. Katie lives in North London with her husband, comedian Alan Davies, and their baby daughter. They do not have any hamsters.
Illustrator Hannah Shaw was born into a large family of sprout-munching vegetarians. She spent her formative years trying to be good at everything, from roller-skating to gymnastics, but she soon realized there wasn't much chance of her becoming a gold-medal-winning gymnast, so she resigned herself to writing stories and drawing pictures instead! Hannah currently lives in a little cottage in the Cotswolds with her husband, Ben the blacksmith, and her rescue dog, Ren. She finds her overactive imagination fuels new ideas but unfortunately keeps her awake at night!
Read an excerpt or, better yet, read and see this designed excerpt. Here's just one sample spread below but there's much more to enjoy...
"Inspired use of simple words, straightforward syntax and effective repetition make this a top pick for slow or reluctant readers...Under the plot's frothy surface lie serious depths...An auspicious debut." --Kirkus Reviews
"A flippy, fun and extremely fast-paced journey into the world of a very likable brother and sister--and their amusing family and friends. Intermittent silly pencil sketches fill the pages diary-style, creating a whimsical mood and adding comic relief.... Giggles are frequent among the kids in this book, and they will infect readers as well." --BookPage
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text: That's a pretty ignorant comment but the real reason is because he's too short to play DE and too light for DT and not athletic enough to play LB. Not a great pass rusher, had some of the shortest arms at the combine which explains his weakness for fighting off blocks and he needs a lot of work in the weight room. Sure has a great motor and a big heart and sure he's the type of player you like on your team but I don't see anything but a lifetime special teams ace and spot duty player if you can find him a position.


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Stephan Richter
Publisher and Editor-in-Chief
Stephan Richter is Publisher and Editor-in-Chief of The Globalist, the daily online feature service on the global economy, politics and culture. In operation since January 1, 2000, The Globalist attracts tens of thousands of readers every month from over 120 countries around the world.
Mr. Richter is also founder and president of TransAtlantic Futures, Inc., a Washington-based global strategy, media and education firm, which was established in 1989. He is also a monthly columnist for Les Echos, France's leading financial daily, and writes regularly for the Financial Times Deutschland.
Mr. Richter, who received his J.D. degree from the University of Bonn, Germany in 1984, has advised governments and international organizations as well as foundations, corporations and individuals around the world on global strategy issues. His articles and views have appeared in such publications as the New York Times, Wall Street Journal, International Herald Tribune, Le Monde, Singapore Straits Times, South China Morning Post, Bangkok Post, Al Ahram, Washington Post, Time, Newsweek, Die Welt, Die Zeit and Foreign Affairs.
Focus: Business, Finance, Globalization, Trade, Germany, United States, France, Global, Americas, Europe
Specialization:Globalization trends and issues, Global competitiveness and strategy, Role and responsibility of governments and corporations, Country and regional comparisons, US role in the globalization process, Politics of global trade, economics and finance
Language Fluency:English
Last Updated: Sep 22, 2006


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Police have arrested the mother of a newborn baby girl found dead in a plastic bag in a South Auckland stream.
The body was found in the stream at Burnside Road, Ardmore, on the southern outskirts of metropolitan Auckland on July 2.
An autopsy could not reveal how and when the baby died and police are awaiting the results of tests by a paediatric pathologist.
Counties Manukau Police have arrested and charged the baby's 21-year-old mother with concealing the body of a child.
She appeared in the Manukau District Court today and has been remanded on bail until August 11.
Detective Inspector Mark Gutry said further charges were still possible.
"We are waiting for a final report from a paediatric pathologist before making this decision."
The Herald understands the mother is a staff member of champion harness racer Tony Herlihy and had been staying at a cottage he owns on the front of his Burnside Rd property about 400 metres from the culvert.
It houses up to six people.
Detective Senior Sergeant Darrell Harpur earlier said it was understood that the baby was born at the cottage.


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The Cisco Adaptive Security Virtual Appliance (ASAv) is a completely re-imagined virtual security solution that supports both the fabric based deployment with the Cisco Application Centric Infrastructure (ACI) and a traditional tiered deployment. The ASAv supports consistent, transparent security across physical, virtual, application-centric, and cloud environments.
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History researchers are racing to save Missouri French, the dialect spoken fluently by less than 30 people in old mining towns, before the few remaining native speakers succumb to old age.
Missouri French, an amalgam of Old Norman French, Native American languages and frontier English, is spoken in Old Mines, southwest of St. Louis, and is one of the three major forms of French to originate in the United States, remaining widely in use well into the 20 century.
Missouri French speakers are descendants of early French settlers in the upper Mississippi River County, formally known as Illinois Country, over 300 years ago.
The dialect, also called Missouri-Illinois French or paw-paw French for the region's plentiful paw-paw fruit trees, flourished in isolated communities such as Old Mines and was used by hundreds of families for generations.
In the 1980s the paw-paw French was spoken by hundreds of people, according to GeoCurrents, but most of these speakers were middle aged or elderly residents, who would now be aged at least 75-years-old.
The dialect was widely associated with being ignorant or uneducated, meaning only phrases and songs have been passed down in recent generations, who instead spoke English.
"When they didn't want us to know what they talked about, they talked to us in French," said Lucy Baquette, whose husband traces his regional roots back to the founding families of St. Louis.
Examples of Missouri French
- Cars – Chars
- Cold – fraitte
- Party – bouillons
- It rains - ça fait mouier
The last academic study of the dialect is understood to have been written 75 years ago, creating a huge written gap in knowledge.
Dennis Stroughmatt has been working to help preserve the language, after discovering it as a student at the Southeast Missouri State University 20 years ago.
Having studied French for a term, he befriended families in and around Old Mines in an effort to preserve the region's music and language. The area's unofficial slogan is "On est toujours icitte", or "we are still here."
"They have fought to keep their language and culture alive," Mr Stroughmatt said. "I want to do anything I can to help."
He has since recorded oral histories, uncovered wax cylinder recordings and immersed himself in their traditional language, music and stories.
Mr Stroughmatt plays fiddle in his three-piece band, Dennis Stroughmatt et L'esprit Creole, which aims to "carry the torch of this enduring culture" by performing at different folk festivals across America.
His work was honoured in May by the Missouri Humanities Council for seeking to "revive an epoch of Midwestern history that was on the verge of extinction." He was one of five to win the Missouri Humanities Award for Preserving Traditional French Culture and Music of Old Mines, which was hailed as an "exemplary community achievement".
Carol Diaz-Granados, an anthropology researcher at Washington University in St. Louis who studies the region's Native American archaeology, commended Mr Stroughmatt's historical preservation efforts.
Missouri French "was on the verge of being lost," she said. "People are passing away. It's the end of an era."
The Old Mines Area Historical Society, the volunteer-run group which Ms Diaz-Granados is a board member of, is now working to restore an old log cabin on the outskirts of town that would serve as the centrepiece of a 19th century village and history museum commemorating the region's deep French roots.
The region also stages an annual Old Mines Missouri French festival to celebrate its linguistic origins.
Additional reporting by the Associated PressReuse content


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(1999). 97, 282 nn. (1985). Page 375 376 CELLEXPRESSIONANDANALYSISin Vitro 37 Detection of SH3-Binding Proteins on Blots of Total Protein Extracts Detection of SH3-binding proteins by probing of blotted total cell lysates or total protein fractions is possible, but not always easy.
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Go Over and Ask If the Man Knows You
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In large Old-World style letters, August Weber Haus declares its name on its red sign, followed by the telling addendum "Est. 1865." The restaurant preserves much of its vintage charm while serving a modern menu of fondue treats, more than 100 wines, and more than 30 craft beers. Fondue comprises most of the menu, from appetizers to desserts, but only some of it revolves around cheese. Entrees come with hot sauces or flavored oils, with the uncooked morsels following a certain theme. The Sea entree, for instance, boasts bites of scallops, Canadian lobster tail, ahi tuna, and salmon alongside flavors ranging from garlic butter to wasabi soy.
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