text:
|Publication number
|Publication type
|Application number
|Publication date
|Dec 17, 1985
|Filing date
|Aug 12, 1983
|Priority date
|Oct 27, 1980
|Fee status
|Publication number
|Robert L. Stephen, Carl Kablitz, Barry K. Hanover, Stephen C. Jacobsen, Jeffrey J. Harrow
|Original Assignee
|University Of Utah Research Foundation
|Export Citation
|BiBTeX, EndNote, RefMan
|Patent Citations (19), Non-Patent Citations (48), Referenced by (56), Classifications (12), Legal Events (8)
|External Links: USPTO, USPTO Assignment, Espacenet
This application is a continuation-in-part application of our copending application Ser. No. 200,830 filed Oct. 27, 1980 for SUBCUTANEOUS PERITONEAL INJECTION CATHETER, which issued as U.S. Pat. No. 4,400,169 on Aug. 23, 1983. This application is also a continuation-in-part application of our copending application Ser. No. 235,185 filed Feb. 17, 1981 for SUBCUTANEOUS PERITONEAL INJECTION CATHETER, which issued as U.S. Pat. No. 4,405,305 on Sept. 20, 1983 and which is a continuation-in-part application of our copending application Ser. No. 200,830 filed Oct. 27, 1980 for SUBCUTANEOUS PERITONEAL INJECTION CATHETER.
1. The Field of the Invention
This invention relates to implantable peritoneal injection catheters and, more particularly, to novel apparatus and methods for minimizing obstruction of subcutaneous peritoneal injection catheters during the period of implantation.
2. The Prior Art
A large proportion of the various chemical reactions that occur in the body are concerned with making energy in foods available to the various physiological systems in the cells. Metabolism of glucose is particularly important in many of these chemical reactions, and the body has a very sophisticated regulatory system adapted to maintain blood glucose levels at an optimum level so that adequate amounts of glucose will be available as needed.
One of the most important elements in the glucose regulatory system is the hormone "insulin." Insulin is a relatively small protein, having a molecular weight of only 5743 daltons; it is comprised of two amino acid chains connected by a pair of disulfide linkages.
Insulin has the ability to regulate glucose metabolism in two ways. First, insulin has the ability to increase the rate of glucose transport through the cell membrane of many types of cells in the body. In the absence of insulin, the rate of glucose transport into these cells is reduced to less than one-fourth of the normal rate. On the other hand, excessive levels of insulin can increase the rate of glucose transport to nearly five times normal. Adjustments in the level of insulin in the body can thus be seen to have the capability of adjusting the rate of glucose absorption by twentyfold.
In addition to its role in glucose transport, insulin also acts as a regulatory hormone. Normally, when digestion results in rising levels of glucose in the body, certain cells in the pancreas, known as "beta cells" of the "islets of Langerhans," commence secreting insulin into the portal vein. About half of the secreted insulin is immediately absorbed by the liver, with the remaining portion being distributed through most of the rest of the body.
In response to the rising level of insulin, the liver produces large quantities of an enzyme known as glucokinase which causes conversion of glucose into glycogen which is then stored. Importantly, a large portion of the excess glucose entering the blood system as a product of digestion is rapidly removed by the liver in order to maintain relatively normal concentrations of glucose in the bloodstream.
Later, when the blood glucose level begins to drop below normal, the pancreas reduces its secretion of insulin, and the "alpha cells" of the islets of Langerhans commence secretion of a hormone known as "glucagon." Glucagon stimulates the conversion of glycogen in the liver into glucose by activating another enzyme known as liver phosphorylase. This, in turn, results in release of glucose into the bloodstream for transport throughout the body.
From the foregoing, it will be appreciated that the pancreas and the liver play a major role in regulating the level of glucose in the bloodstream. Unfortunately, the delicate balance between the actions of the pancreas and the liver can be easily upset. For example, it is not uncommon for the pancreas to suffer damage so that it no longer secretes adequate levels of insulin. This condition is known as "diabetes mellitus," or more commonly, simply "diabetes." Serious cases of diabetes often exhibit a total cessation of insulin secretion.
As would be expected, insufficient secretion of insulin substantially reduces the transport of glucose into most tissues of the body. (The most notable exception is the brain; glucose transport across the blood-brain barrier is dependent upon diffusion rather than insulin-mediated transport.) Further, the glucose regulatory function is also impaired since, in the absence of insulin, little glucose is stored in the liver during times of excess and, hence, is not available for subsequent release in times of glucose need.
One result of the lack of sufficient quantities of insulin in the body is a rise in the blood glucose concentration. This causes the osmotic pressure in extracellular fluids to rise above normal, which in turn often results in significant cellular dehydration. This problem is exacerbated by the action of the kidneys which act to remove excessive quantities of glucose from the blood; the increase in glucose concentration in the kidneys causes yet additional fluids to be removed from the body. Thus, one of the significant effects of diabetes is the tendency for dehydration to develop.
However, an even more serious effect occurs because of the failure of body tissues to receive adequate levels of glucose. In the absence of adequate levels of glucose, the metabolism of body cells switches from carbohydrate metabolism to fat metabolism. When the body is required to depend heavily upon fat metabolism for its energy, the concentration of acetoacetic acid and other keto acids rises to as much as thirty times normal, thus causing a reduction in the pH of the blood below its normal pH level of 7.4.
Again, this problem is exacerbated by the kidneys. As the kidneys remove the various keto acids from the blood, substantial amounts of sodium are also lost, thereby resulting in even further decreases in blood pH. If the blood pH is reduced to below about 7.0, the diabetic person will enter a state of coma; and this condition is usually fatal.
The generally accepted treatment for diabetes is to administer enough insulin so as to restore carbohydrate metabolism. Traditionally, administration of insulin has been by injections into the peripheral circulation, either from an intramuscular or subcutaneous injection. Although widely used, this form of treatment has several disadvantages.
First, using peripheral insulin administration, only about ten percent of the administered insulin reaches the liver, as compared to approximately fifty percent in normal persons. As a consequence, hepatic glucose production is not reduced first; rather, blood glucose is lowered due to the presence of high levels of insulin in the peripheral circulation by increased utilization of the blood glucose by other tissues (such as muscle and fat). Hence, normal levels of blood sugar are achieved only by carefully matching any increased peripheral utilization of blood sugar to an increased hepatic production. This is inherently much more difficult than simply decreasing hepatic glucose production.
Additionally, these traditional administration methods fail to provide the type of control over the blood glucose concentration that occurs in a normal person. Clearly, once- or twice-daily injections of insulin cannot supply controlled variable amounts of insulin in response to changing metabolic demands during the course of the day. Hence, when using traditional insulin administration methods, the blood glucose content tends to fluctuate between normally high and low concentrations. Significantly, there are some indications that such periodic rise and fall of glucose concentrations between hyperglycemia and hypoglycemia contributes to devastating vascular and neurological complications over a period of time. (It is not uncommon, for example, for a long-term diabetic to experience atherosclerosis, arteriosclerosis, hypertension, severe coronary heat disease, retinopathy, cataracts, chronic renal disease, or loss of circulation in the extremities.)
Another consequence of massive injections of insulin on a periodic basis is that excessive amounts of insulin occasionally enter the bloodstream, thereby causing glucose to be rapidly transported into the cells and decreasing the blood glucose to substantially below normal levels. Unfortunately, diabetic patients already have little glucose reserve, since the liver, in its state of under-insulinization, is already releasing glucose. Consequently, the blood sugar level will plummet despite adequate levels of counterregulatory hormones (such as glucagon, epineephrine, norepinephrine, and growth hormones), which normally would increase liver production of glucose in emergency situations.
Importantly, if the blood glucose level is reduced too much, there will be insufficient glucose to diffuse across the blood-brain barrier, and the brain and central nervous system will begin to suffer from depressed metabolism. This hypoglycemic reaction (having a progression of symptoms from nervousness, sweating, stupor, and unconsciousness to occasionally irreparable brain damage), will occur until sugary substances are taken either by mouth or intravenously.
The resulting ongoing cycle between hyperglycemia and hypoglycemia has created a basic rift in the philosophy of diabetic control. The "tight control" philosophy claims that the long-term devastations of diabetes (that is, blindness, heart attacks, kidney failure, and loss of extremities), are due to abnormally elevated sugar levels. Those ascribing to this "tight control" philosophy strive to keep blood sugar within the normal range even at the risk of frequent (more than once a week) hypoglycemic reactions. The converse "loose control" philosophy is based upon the presumption that the basic premise of the "tight control" philosophy has yet to be proved and that the considerable risks of hypoglycemic reactions are not worth an unproved benefit.
In an effort to avoid the undesirable effects of the traditional insulin administration methods, various closed and open loop control delivery systems have been developed. Closed loop delivery systems are synonymous with prolonged hospitalization. Additionally, they are awkward to wear, they require tubing sets and implanted needles and, in spite of claims made to the contrary, they can malfunction ("surge"), usually at the most inconvenient hours.
Open loop delivery systems, on the other hand, actually produce a more sustained, if somewhat better regulated, hyperinsulinemic state. The therapists involved persist in using both open and closed loop systems to deliver insulin peripherally, thereby giving rise to many of the difficulties already mentioned.
Consequently, due to the problems and difficulties set forth above, those skilled in the art of treating diabetes have sought to find improved methods for administering therapeutic insulin to diabetic individuals. Perhaps one of the most promising insulin administration methods which is currently being investigated comprises the administration of insulin via the peritoneum.
The peritoneum is the largest serous membrane in the body and consists (in the male) of a closed sac, a part of which is applied against the abdominal parietes, while the remainder is reflected over the contained viscera. (In the female, the peritoneum is not a closed sac, since the free ends of the uterine and fallopian tubes open directly into the peritoneal cavity.)
The part of the peritoneum which lines the abdominal wall is named the parietal peritoneum and that which is reflected over the contained viscera constitutes the mesenteric (visceral) peritoneum. The space between the parietal and mesenteric layers of the peritoneum is called the peritoneal cavity. However, under normal conditions, this "cavity" is merely a potential one, since the parietal and mesenteric layers are typically in contact.
Of particular significance, a portion of the blood circulation of the peritoneum leads directly into the portal venous system. Hence, any insulin absorbed by the peritoneum would potentially have nearly direct access to the liver. As a result, such insulin would first be available to reduce hepatic glucose production, and the insulin could, therefore, potentially function more effectively in its glucose regulatory capacity.
For a number of years, it has been well-known that the peritoneal membrane will function fairly effectively as an exchange membrane for various substances. Thus, as early as 1923, peritoneal dialysis was first applied clinically. At the present time, peritoneal dialysis is being used with increasing frequency to treat individuals suffering from end-stage renal disease.
In a typical peritoneal dialysis treatment, approximately two liters of dialysate is infused into the peritoneal cavity. Then, after the dialysate has remained within the peritoneal cavity for a period of time, thereby permitting the necessary diffusion across the peritoneal membrane, the dialysate is removed. This procedure is typically repeated a number of times during each dialysis treatment. Thus, in simple terms, the peritoneal cavity, together with the dialysate, functions as an artificial kidney.
The performance of peritoneal dialysis necessarily requires some type of peritoneal access device. The first peritoneal access device was a piece of rubber tubing temporarily sutured in place. By 1960, peritoneal dialysis was becoming an established form of artificial kidney therapy; and, in order to lessen the discomfort of repeated, temporary punctures into the peritoneal cavity, various access devices permitting the painless insertion of acute or temporary peritoneal catheters were developed.
The most common peritoneal access device is of the Tenckhoff type in which a capped, percutaneous, silastic tube passes through the abdominal wall into the peritoneal cavity. Another peritoneal access device (the "Gottloib" prosthesis) consists of a short, "gold tee" shaped device which is adapted to be placed under the skin with a hollow tubular portion extending just into the peritoneal cavity. This cavity is designed specifically to allow the insertion of an acute peritoneal catheter (or trocar) through the skin and down through this access tubing directly into the peritoneal cavity.
Another device consists of a catheter buried underneath the skin and extending into the peritoneal cavity via a long tubing. Peritoneal dialysis is performed by inserting a large needle into the subcutaneous portion of the catheter.
When using such access devices, a variety of drugs or other fluids have sometimes been added to the large volumes of peritoneal dialysis solutions and thereby instialled into the peritoneal cavity for various therapeutic reasons. Some examples of these drugs are antibiotics, amino acids, and insulin. However, such therapeutic maneuvers are merely fortuitous, in that the clinician is simply taking advantage of a particular situation, that is, a peritoneal access device implanted in a particular group of patients. Importantly, there are cogent reasons for not using existing, permanent peritoneal access devices for simple drug injections in a wide variety of patients not suffering from end-stage renal disease.
First, the majority of prior art peritoneal access devices are long, clumsy, percutaneous, infection-prone silastic tubes. Hence, it is undesirable that any patient would wear such a device on a permanent or semi-permanent basis, unless it is absolutely necessary.
In addition, most of the prior art peritoneal access devices have a relatively large internal volume, that is, relatively large volumes of fluid are required in order to fill the devices. As mentioned above, during a typical dialysis treatment, approximately two liters of dialyzing fluid is injected into the peritoneal cavity at one time. Thus, when existing devices are used for purposes of peritoneal dialysis, the relatively large internal volume of the device is of little consequence. However, when injecting small quantities of fluid or drugs into the peritoneal cavity, this volume is a very real hindrance since the injected fluid may simply remain within the device itself instead of entering the peritoneal cavity.
Further, it has been found that bacteria will sometimes accumulate and grow within the prior art access devices. Also, the prior art peritoneal access devices often become obstructed by body cells and/or bacterial after they are implanted in a patient. In many cases, such obstruction cannot be eliminated without damaging the device, and the access device must, therefore, be removed.
Accordingly, it would be an improvement in the art to provide a peritoneal catheter apparatus which can be used to inject small volumes of fluid into the peritoneal cavity and which would minimize the opportunity for catheter obstruction. It would also be an improvement in the art to provide a peritoneal injection catheter apparatus and method which minimizes the accumulation or growth of body cells on the catheter. In addition, it would be an improvement in the art to provide an apparatus and method for minimizing the occurrence of bacterial growth on or in a peritoneal injection catheter. Further, it would be an improvement in the art to provide an apparatus and method for minimizing the occurrence of peritoneal injection catheter obstruction which would preserve the structural integrity of the catheter. Such devices and methods are disclosed and claimed herein.
The present invention relates to a novel subcutaneous peritoneal injection catheter apparatus and methods which minimize catheter obstruction during use.
The apparatus includes a receiving chamber or reservoir having a relatively small internal volume while employing a penetrable membrane and relatively enlarged target surface area. The reservoir is interconnected with the peritoneal cavity by a hollow stem. The penetrable membrane accommodates a hollow needle being inserted into the receiving reservoir and is configurated with a dome-like profile so that the membrane may also be depressed to expel insulin from the receiving reservoir into the peritoneal cavity in a direction generally toward the mesenteric peritoneal membrane.
The distal end of the hollow stem (which is situated inside the peritoneal cavity), is constructed so as to minimize the likelihood of catheter obstruction during use by a patient. For example, in one presently preferred embodiment of the invention, the distal end of the stem is provided with two, parallel, diametrally enlarged flanges. The two flanges are unequal in size, and they are positioned on the stem such that the larger flange resides against the peritoneal membrane and the smaller flange is located immediately adjacent the distal opening of the stem. In addition, an antibacterial agent may be placed within the device, and the device may also be formed of or coated with a substance which inhibits body cell and bacterial growth.
It is, therefore, a primary object of this invention to provide an improved implantable peritoneal injection catheter which minimizes the possibility of catheter obstruction due to cell ingrowth and/or overgrowth.
It is also an object of the present invention to provide an improved, subcutaneously implantable peritoneal injection catheter which minimizes the likelihood of bacterial growth within the subcutaneous reservoir of the catheter.
It is a further object of this invention to provide a method for minimizing or eliminating peritoneal injection catheter obstruction which will maintain the structural integrity of the peritoneal catheter.
Finally, it is an object of this invention to provide an improved implantable subcutaneous peritoneal injection catheter which may be used by a single patient over a relatively long period of time without interruption or malfunction.
These and other objects and features of the present invention will become more fully apparent from the following description and appended claims taken in conjunction with the accompanying drawings.
FIG. 1 is a schematic illustration of a subcutaneous peritoneal injection catheter shown implanted in the abdominal wall of a torso;
FIG. 2 is a vertical cross-sectional view of one presently preferred embodiment of the present invention;
FIG. 3 is a bottom perspective view of the embodiment depicted in FIG. 2;
FIG. 4 is a vertical cross-sectional view of a second preferred embodiment of the present invention;
FIG. 5 is a vertical cross-sectional view of a third preferred embodiment of the present invention;
FIG. 6 is a horizontal, cross-sectional view taken along lines 6--6 of FIG. 5;
FIG. 7 is a bottom perspective view of the embodiment depicted in FIG. 5; and
FIG. 8 is a cross-sectional, schematic illustration of the embodiment of FIG. 5 implanted in an abdominal wall and which is shown in cooperation with a trocar which is being used to break out a frangible portion of the base of the catheter.
This invention comprises an improvement to the subcutaneous peritoneal injection catheters disclosed in our copending applications: Ser. No. 235,185 filed Feb. 17, 1981, and Ser. No. 200,830 filed Oct. 27, 1980.
As an alternative to both intravenous and intramuscular insulin delivery, portal venous administration of insulin has given highly encouraging results in experimental animals: less insulin is required to achieve normoglycemia and hyperinsulinemia is avoided. Long-term access directly into the portal system, however, carries several severe risks, all of which are lethal. Nevertheless, there is a secondary and much safer route leading directly into the portal venous system--the mesenteric (visceral) peritoneal membrane. Although access to the intraperitoneal site is more difficult, it has the potential advantages of avoiding peripheral hyperinsulinemia, insulinizing the liver via direct portal venous system insulin absorption, and more rapid absorption than subcutaneously delivered insulin.
As alluded to above, when administering insulin via the peritoneum, it is most desirable that the insulin be substantially absorbed by the mesenteric, rather than the parietal, peritoneal membrane. If the insulin is absorbed by the parietal peritoneal membrane, the insulin enters the body's general systemic venous system. The effect is thus the same as if the insulin had been injected intramuscularly; that is, the insulin is gradually absorbed into the peripheral circulatory system and only a portion of the insulin reaches the liver. As a result, control of glycemia is not significantly better than that achieved by conventional intramuscular injections. If the injected insulin is absorbed by the mesenteric peritoneal membrane, on the other hand, the insulin is absorbed into the portal venous system and made readily available to the liver.
Preliminary results of experiments using intraperitoneal delivery of insulin appear favorable. Insulin delivery into the peritoneum is reported to have resulted in a rapid rise in circulating peripheral insulin concentration, which peaked at 30-45 minutes following the initiation of insulin delivery. Furthermore, when the infusion rate of intraperitoneal insulin was reduced to the background rate, a gradual decline in peripheral insulin concentration to normal fasting values resulted. (This free insulin response is a marked contrast to the continuing high levels following intramuscular insulin injection.)
It was, therefore, concluded that normalization of plasma insulin profiles was achievable with intraperitoneal infusion of insulin and, further, that meal-related hyperglycemia (elevated blood glucose) is well-controlled with intraperitoneal insulin, yet hypoglycemic episodes are reduced compared to subcutaneous delivery. See, D. S. Schade, R. P. Eaton, N. M. Friedman, & W. J. Spencer, "Normalization of Plasma Insulin Profiles With Intraperitoneal Insulin Infusion in Diabetic Man," 19 DIABETOLOGIA 35-39 (1980).
Intraperitoneal delivery of insulin has been performed in ketosis-prone diabetic human subjects on a short-term basis (i.e., a matter of hours). Such intraperitoneal delivery achieves comparable glycemic control to that achieved with intramuscular insulin, with only approximately half the integrated blood levels of plasma insulin. Intraperitoneal insulin has also been utilized long term in patients with ketosis-prone diabetes and end-stage renal disease who were being treated by continuous ambulatory peritoneal dialysis. Adequate control was achieved in the three patients reported.
There appears to be no conclusive documentation substantiating the thesis that the intraperitoneal delivery of drugs is primarily absorbed into the portal venous system (mesenteric peritoneum) rather than the general systemic venous system (parietal peritoneum). However, there is a considerable amount of indirect evidence for this hypothesis: (1) in laparatomy one's field of vision is virtually totally obscured by the mesenteric peritoneum; (2) the work of other researchers indicates that control of glycemia by intraperitoneal insulin administration is good, even though there was a 50% "loss" of insulin--presumably picked up by the liver before reaching the peripheral circulation; and (3) intraperitoneal administration of sodium nitroprusside (for the purpose of causing intraperitoneal vaso-dilation) results in no detectable levels of peripheral plasma thiocyanate. (It is assumed that metabolism of nitroprusside by the liver accounted for the lack of peripheral thiocyanate.)
In our copending patent applications Ser. No. 235,185 filed Feb. 17, 1981 and Ser. No. 200,830 filed Oct. 27, 1980 for SUBCUTANEOUS PERITONEAL INJECTION CATHETER, we disclose a peritoneal injection catheter having, inter alia, the following features: (1) the internal volume of the device is minimal; (2) it presents a large surface area (consistent with the first constraint) to allow for injection of various drugs; (3) it is designed purely and simply for one-way flow, i.e., drug injection is inward only; (4) it is designed so that a variety of drugs may be injected into the peritoneal cavity toward the mesenteric peritoneal membrane; (5) it has a resilient, dome-shaped surface above the receiving reservoir so that the dome may be depressed to expel insulin from the receiving reservoir into the peritoneal cavity; and (6) it is not designed for peritoneal dialysis and, in fact, would not function if used for this purpose. This peritoneal injection catheter has been quite successful for use in administering insulin to diabetic patients. However, in spite of this success, some difficulties have been observed.
First, it has been noted that this catheter occasionally becomes obstructed after it is implanted in a patient. At present, the chief causes of such catheter obstruction appear to be the accumulation of body cells in the peritoneal opening, tissue growth over or within the peritoneal opening, and total or partial occlusion by the greater omentum. Such obstruction, of course, interrupts catheter use, and the obstruction may be difficult to remove. Additionally, when attempting to dislodge the obstruction from the peritoneal catheter, the peritoneal catheter may occasionally rupture, thereby necessitating complete removal of the catheter.
Second, it has also been noted that bacterial growth may occur with the catheter. When using the subcutaneous peritoneal injection catheter, the patient injects insulin into the device, and the fluid thereafter disperses into the peritoneal cavity. Until recently it has been assumed, probably correctly, that any bacteria driven through the skin by the needle and then transported into the peritoneal cavity would probably cause very little harm. The basis of this assumption is that the peritoneal cavity has some very effective defense mechanisms against invading microorganisms and the number that could be forced into the cavity with the head of a 25 g needle (0.51 mm in diameter) would not represent an overwhelming invasion.
Unfortunately, however, the small subcutaneous reservoir inherent in the device itself is not so protected. The omentum in the peritoneal cavity cannot reach into this region, and mesenteric lymph glands are remote. Thus, the only possible means of combating microorganisms that may be residing in the reservoir would be with microbiocidal chemicals and the few white cells which free peritoneal fluid contains.
The peritoneal catheter of the present invention is constructed so as to minimize both obstruction of the peritoneal catheter and the growth of bacteria within the peritoneal catheter during use by a patient. The invention is best understood by reference to the drawings wherein like parts are designated with like numerals throughout.
Referring now more particularly to FIG. 1, peritoneal catheter 10 is shown implanted in the abdominal wall 90 of a torso 92 and provides fluid communication with peritoneal catheter 10 with the peritoneal membrane 94 surrounding peritoneal cavity 96. It should be noted that peritoneal cavity 96 is shown somewhat distended as though infused with dialysate, in order to more clearly set forth the environment of peritoneal catheter 10.
After peritoneal catheter 10 is implanted and use has commenced, the distal end 54 of peritoneal catheter 10 occasionally becomes obstructed. Such obstruction may be due to the ingrowth and/or the accumulation of body cells in peritoneal catheter 10.
Similarly, peritoneal catheter 10 may sometimes become obstructed by an overgrowth of a portion of peritoneal membrane 94, called the omentum. Also, the obstruction may arise due to the uninhibited growth of bacterial cells within peritoneal catheter 10. The present invention comprises several alternative configurations of and/or attachments to peritoneal catheter 10 which serve to minimize the probability of such catheter obstruction and bacterial growth.
Referring now more particularly to FIGS. 2 and 3, one presently preferred embodiment of the peritoneal catheter apparatus of this invention, designated generally as 10, includes a body 12, a cap 14, and a stem 16. Body 12 serves as the basal member for peritoneal catheter 10 and is configurated with a funnel-like section 20 having a relatively shallow depth in comparison with the relatively enlarged diameter. The depth of funnel section 20 is selectively predetermined so as to contain a body of insulin which may be suitable retained momentarily or expelled, as desired.
Funnel section 20 is surrounded at its upper edge by an upstanding rim 22 and terminates downwardly toward its center in a throat 24. Body 12 is fabricated from a suitable, puncture resistant plastic material such as, for example, a conventional, biocompatible polyurethane. Body 12 is also provided with sufficient thickness so as to preclude inadvertent puncture by a needle.
The opposite edge of rim 22 is formed as a retainer shelf 26 for the purpose of retaining an edge or lip 44 of cap 14. The lower portion of body 12 includes a neck 28 having a coaxial counterbore 30. The internal diameter of counterbore 30 is selectively predetermined so that column 50 may be telescopically received into abutment with throat 24, as will be set forth more fully below.
Cap 14 is configurated with an outwardly curved dome-like puncture zone shown as dome 40. The outer circumference of cap 14 includes an inwardly directed circumferential lip 44 adapted to be received in snap-fit relationship with shelf 26 for the purpose of mounting cap 14 to body 12. The height of rim 22, as well as the diameter and the depth of funnel section 20 in combination with the hemispherical radius of cap 14, selectively predetermine the volume of the resulting receiving reservoir 18.
Cap 14 is fabricated from a suitable biocompatible material (such as silicone rubber) having the desired characteristics of being: (a) resilient, (b) readily penetrable, and (c) resealable to accommodate being flexed and punctured numerous times without degradation of the structural integrity of cap 14. A reinforcing material 42 is preferably imbedded in the biocompatible material of cap 14. Also, a portion of cap 14 and body 12 may be covered with a suitable, biocompatible velour material 43 to accommodate tissue ingrowth.
Stem 16 is configurated as a hollow tubular column 50 having a hollow lumen 52 extending therethrough. As previously mentioned, stem 16 is telescopically received into abutment with throat 24. The diameter of lumen 52 matches the diameter of throat 24 so as to provide a continuous, smooth flow channel through peritoneal catheter 10.
The distal end 54 of tubular column 50 is provided with two, diametrally enlarged flanges 56 and 58. As shown, flange 58 is somewhat smaller than flange 56 and is located immediately adjacent to distal end 54 of tubular column 50. Advantageously, the outer edges of flange 58 are somewhat rounded, as shown, such that flange 58 has no sharp edges which could injure adajcent tissue.
Tubular column 50, together with flanges 56 and 58, may be formed as a single unit, as shown. Alternatively, tubular column 50 and flange 56 may be formed as a single unit, with flange 58 being attached to a smaller tubular column which is adapted to be snugly received within lumen 52.
In use, peritoneal catheter 10 is fist surgically implanted in a patient. This is accomplished by making an incision in the patient's abdominal wall 90 and peritoneal membrane 94 (see FIG. 1). The peritoneal catheter is then placed in the patient such that distal end 54 of stem 16 extends into peritoneal cavity 96 with flange 56 being against peritoneal membrane 94. Peritoneal catheter 10 is then secured in place by means of sutures.
Once peritoneal catheter 10 is in place, the user injects insulin into receiving reservoir 18 by penetrating dome 40 with a conventional, hollow needle. Advantageously, the insulin in receiving reservoir 18 may be allowed to slowly percolate through lumen 52 into peritoneal cavity 96 or, upon demand, the user may depress dome 40 with a finger to forceably expel insulin from receiving reservoir 18 through lumen 52 into peritoneal cavity 96.
In the event that body tissue or cells should begin to grow or accumulate adjacent flange 56 of peritoneal catheter 10, the cells would grow along the surfac of flange 56 so as to grow into the space between flange 56 and flange 58. Thereafter, the tissue would be forced to double back on itself in order to continue its growth. It is well known that, unless the growth is cancerous, cell growth will cease as soon as the tissue doubles back on itself. In any event, it is highly unlikely that the cells would thereafter grow outward and upward over the top of flange 58, thereby occluding the distal end 54 of tubular column 50.
Experimental catheters having substantially the same configuration as the catheter depicted in FIGS. 2 and 3 have been implanted in six diabetic patients to date. Each of these catheters has remained free from any obstruction during the period of implantation (approximately six months). Significantly, when two of these catheters were subsequently removed (due to unrelated, accidental, traumatic injuries to the patient's abdominal area), it was noted that body tissue had, in fact, grown over flange 56 of the catheters. However, such overgrowth had stopped once the tissue reached column 50, and no tissue growth over flange 58 had occurred.
FIG. 4 depicts a second embodiment of the peritoneal catheter 110 of this invention. As with the previous embodiment, this embodiment also includes a body 112, a cap 114, and a stem 116. The body 112 and cap 14 of this embodiment are in all respects identical to those described in connection with the first embodiment. Similarly, stem 116 is also configurated as a hollow, tubular column 150 having two parallel, diametrally enlarged flanges 156 and 158 adjacent the distal end 154 thereof. However, in this embodiment, flange 156 and flange 158 are substantially the same size.
The second embodiment is implanted in a patient in a similar manner as the first embodiment, with flange 156 being secured in place against peritoneal membrane 94 inside peritoneal cavity 96 (see FIG. 1). Should tissue growth or body cell accumulation commence around flange 156, flange 158 acts as a restraining member to inhibit the cells from growing over and obstructing distal end 154.
It will also be appreciated that, while only one opening in distal ends 54 and 154 is illustrated in FIGS. 2-4, both the first and second embodiments of the present invention could have several such openings. Such a configuration would additionally serve to minimize the possibility of catheter obstruction.
FIGS. 5-8 depict a third embodiment of the peritoneal catheter 210 of this invention. The third embodiment also comprises a body 212, a cap 214, and a stem 216. Like the second embodiment, the third embodiment differs from the first embodiment only in the construction and configuration of stem 216. In the third embodiment, tubular column 250 has a diametrally enlarged flange 256 at the distal end 254 thereof. Attached to flange 256 is a generally circular disc 268 having a plurality of radial spacing members 260. As shown best in FIG. 6, disc 268 has a frangible circular area 262 at its center; and each radial spacing member 260 is a narrow strip which is secured along a radius of disc 268 and extends from frangible area 262 to the outer edge of disc 268.
Importantly, frangible area 262 has a diameter which is approximately equal to that of lumen 252. Thus, radial support members 260, together with flange 256 and disc 268, form a plurality of fluid communicating channels 264, which may communicate fluid into the peritoneal cavity through a plurality of openings 266 (see FIG. 7) around the circumference of flange 256.
The third embodiment of catheter 210 is implanted in a patient in the same manner as the first and second embodiments. Should body cells thereafter begin to accumulate near flange 256 of peritoneal catheter 210, it is unlikely that all openings 266 will become occluded so as to prevent fluid flow. Thus, this embodiment of peritoneal catheter 210 also minimizes the possibility of peritoneal injection catheter obstruction.
Referring now more particularly to FIG. 8, the third embodiment of the peritoneal catheter 210 of this invention is shown implanted in abdominal wall 90. A trocar 98 is shown inserted through cap 214 into peritoneal catheter 210 so as to extend down lumen 252 in order to break out frangible area 262. Thus, in the unlikely event that all openings 266 do become obstructed, frangible circular area 262 provides an emergency "bail-out" which serves two primary functions. First, as shown in FIG. 8, frangible circular area 262 provides a means whereby trocar 98 may be pushed into peritoneal cavity 96 in order to push the obstruction away from openings 266 of peritoneal catheter 210. By using trocar 98 in this manner, it may be possible to dislodge an obstructing body from peritoneal catheter 210 so as to free openings 266 for fluid flow. Second, frangible circular area 262 provides an alternate opening into peritoneal catheter 96 in the event that all openings 266 become permanently obstructed.
It will be appreciated that the above-described configurations for the peritoneal catheter of the present invention will significantly reduce the likelihood that the catheter will become obstructed during use. In addition, however, a portion of the catheter may advantageously be formed of or covered with a suitable cellulicidal material (that is, a material which kills growing cells).
Suitable cellulicidal materials include, for example, silver, platinum-silver, and copper. Each of these materials has a toxic effect on growing cells, while remaining safe for internal use. Silver and platinum-silver, for example, are oligodynamic materials, that is, they are effective as sterilizing agents in small quantities. Copper also acts as a sterilizing agent by leaching a toxic substance into surrounding fluids. However, it has been found that the quantity of the toxin leached by the copper is no greater than the quantity of toxins which are naturally present in mother's milk. Thus, the use of copper within the body is considered to be safe.
In order to further deter tissue or bacteria growth and accumulation, therefore, a portion of the catheter may be formed of or coated with one of these cellulicidal materials. For example, one of these materials could be used to form the distal end of the hollow stem of the catheter. Alternatively, a plurality of concentric rings could be provided on any or all of the diametrally enlarged flanges of the catheter, particularly on those flanges which are immediately adjacent the peritoneal opening of the catheter.
These materials may also be advantageously used within the peritoneal catheter of the present invention in order to inhibit the growth of bacteria within the catheter. Thus, for example, the interior of the peritoneal catheter could be coated with silver by sputtering the device with silver paint prior to assembly. Alternatively, silver could be incorporated into the various plastic materials used in forming the catheter. In such case, the silver could either be in the form of a fine powder or as a silver mesh or screen.
In light of the foregoing, it can be appreciated that the novel peritoneal injection catheter and the embodiments described above significantly minimize the possibility of peritoneal catheter obstruction. Both the geometrical configuration and the use of cellulicidal materials on this improved peritoneal injection catheter minimize the possibility of obstruction due to omentum overgrowth, tissue ingrowth, and/or other body cell accumulation. Further, by providing for a cellulicidal material within the catheter, this invention also minimizes the likelihood that bacteria will grow and accumulate within the subcutaneous reservoir of the peritoneal catheter. Significantly, this invention comprises a method for minimizing catheter obstruction while maintaining the structural integrity of the peritoneal catheter. Thus, it will be appreciated that the peritoneal catheter of this invention is an improved implantable subcutaneous peritoneal injection catheter which may be used by a single patient over a relatively long period of time without interruption or malfunction.
The invention may be embodied in other specific forms without departing from its spirit or essential characteristics. The described embodiments are to be considered in all respects only as illustrative and not restrictive. The scope of the invention is, therefore, indicated by the appended claims rather than by the foregoing description. All changes which come within the meaning and range of equivalency of the claims are to be embraced within their scope.
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|Crossley Kent B
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|Feb 17, 1981
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|University Of Utah Research Foundation
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|Sep 30, 1982
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|Moukheibir Nabil W
|Surgically implantable peritoneal dialysis apparatus
|Title not available
|Title not available
|Ash et al., "The Column Disc Peritoneal Catheter: A Peritoneal Access Device with Improved Drainage", ASAIO Journal, 3:109-115 (Jul./Sep., 1980).
|Ash et al., The Column Disc Peritoneal Catheter: A Peritoneal Access Device with Improved Drainage , ASAIO Journal, 3:109 115 (Jul./Sep., 1980).
|Barry et al., "A New Flexible Cannula and Seal to Provide Prolonged Access to the Peritoneal Cavity for Dialysis", Trans. Amer. Soc. Artif. Inter. Organs, 9:105-107 (1963).
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|Brewer et al., "Indwelling Peritoneal (Tenckhoff) Dialysis Catheter", JAMA, vol. 219, No. 8, pp. 1011-1015 (Feb. 21, 1972).
|Brewer et al., Indwelling Peritoneal (Tenckhoff) Dialysis Catheter , JAMA, vol. 219, No. 8, pp. 1011 1015 (Feb. 21, 1972).
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|Fox, Jr., "Silver Sulfadiazine--A New Topical Therapy for Pseudomonas in Burns", Archives of Surgery, 96:184-188 (Feb. 1968).
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|Henderson et al., "Further Experience with the Inlying Plastic Conduit for Chronic Peritoneal Dialysis", Trans. Amer. Soc. Artif. Inter. Organs, 9:108-116 (1963).
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|Jacob et al., "Repeated Peritoneal Dialysis by the Catheter Replacement Method: Description of Technique and a Replaceable Prosthesis for Chronic Access to the Peritoneal Cavity", Proc. EDTA (1967), pp. 136-140.
|Jacob et al., Repeated Peritoneal Dialysis by the Catheter Replacement Method: Description of Technique and a Replaceable Prosthesis for Chronic Access to the Peritoneal Cavity , Proc. EDTA (1967), pp. 136 140.
|Kablitz et al., "Subcutaneous Peritoneal Access Device Used for Intraperitoneal Insulin Treatment of Non-Uraemic Diabetic Patients", Proceedings of the Second International Symposium on Peritoneal Dialysis (1981), pp. 170-172.
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|Karanicolas et al., "Home Peritoneal Dialysis: 3 Years' Experience in Toronto", CMA Journal, 116:266-269 (Canada, Feb. 5, 1977).
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|Malette et al., "A Clinically Successful Subcutaneous Peritoneal Access Button for Repeated Peritoneal Dialysis", Trans. Amer. Soc. Artif. Organs, 10:396-398 (1964).
|Malette et al., A Clinically Successful Subcutaneous Peritoneal Access Button for Repeated Peritoneal Dialysis , Trans. Amer. Soc. Artif. Organs, 10:396 398 (1964).
|Merrill et al., "The Use of an Inlying Plastic Conduit for Chronic Peritoneal Irrigation", Trans. Amer. Artif. Inter. Organs, 8:252-255 (1962).
|Merrill et al., The Use of an Inlying Plastic Conduit for Chronic Peritoneal Irrigation , Trans. Amer. Artif. Inter. Organs, 8:252 255 (1962).
|Modak et al., "Binding of Silver Sulfadiazine to the Cellular Components of Pseudomonas Aeruginosa", Biochemical Pharmacology, 22:2391-2404 (Great Britain, 1973).
|Modak et al., Binding of Silver Sulfadiazine to the Cellular Components of Pseudomonas Aeruginosa , Biochemical Pharmacology, 22:2391 2404 (Great Britain, 1973).
|Moyer et al., "Treatment of Large Human Burns With 0.5% Silver Nitrate Solution", Archives of Surgery, 90:812-867 (Jun. 1965).
|Moyer et al., Treatment of Large Human Burns With 0.5% Silver Nitrate Solution , Archives of Surgery, 90:812 867 (Jun. 1965).
|Nolph, "Effects of Intraperitoneal Vasodilators on Peritoneal Clearances", Proceedings 11th Ann. Contractors' Conference (1978), pp. 29-33.
|Nolph, Effects of Intraperitoneal Vasodilators on Peritoneal Clearances , Proceedings 11 th Ann. Contractors Conference (1978), pp. 29 33.
|Oreopoulos, "Renewed Interest in Chronic Peritoneal Dialysis", Kidney International, vol. 13, Supp. 8, pp. S-117 to S-119 (1978).
|Oreopoulos, Renewed Interest in Chronic Peritoneal Dialysis , Kidney International, vol. 13, Supp. 8, pp. S 117 to S 119 (1978).
|Palmer et al., "Prolonged Peritoneal Dialysis for Chronic Renal Failure", The Lancet, 1:700-702 (1964).
|Palmer et al., Prolonged Peritoneal Dialysis for Chronic Renal Failure , The Lancet, 1:700 702 (1964).
|Schade et al., "Normalization of Plasma Insulin Profiles with Intraperitoneal Insulin Infusion in Diabetic Man", Diabetologia, 19:35-39 (1980).
|Schade et al., Normalization of Plasma Insulin Profiles with Intraperitoneal Insulin Infusion in Diabetic Man , Diabetologia, 19:35 39 (1980).
|Stephen et al., "Long-Term Intraperitoneal Insulin Treatment: Preliminary Studies in 12 Diabetic Patients", Diabetic Renal-Retinal Syndrome, 2:447-461 (1982).
|Stephen et al., "Stabilization and Improvement of Renal Function in Diabetic Nephropathy", Diabetic Nephropathy, 1:8-13 (1982).
|Stephen et al., Long Term Intraperitoneal Insulin Treatment: Preliminary Studies in 12 Diabetic Patients , Diabetic Renal Retinal Syndrome, 2:447 461 (1982).
|Stephen et al., Stabilization and Improvement of Renal Function in Diabetic Nephropathy , Diabetic Nephropathy, 1:8 13 (1982).
|Tenckhoff et al., "A Bacteriologically Safe Peritoneal Access Device", Trans. Amer. Soc. Artif. Inter. Organs, 14:181-186 (1968).
|Tenckhoff et al., A Bacteriologically Safe Peritoneal Access Device , Trans. Amer. Soc. Artif. Inter. Organs, 14:181 186 (1968).
|Citing Patent
|Filing date
|Publication date
|Mar 2, 1987
|Nov 1, 1988
|Vir Engineering
|Resealable injection site
|Apr 29, 1987
|May 2, 1989
|Pacesetter Infusion, Ltd.
|Omentum diffusion catheter
|Dec 9, 1986
|Dec 12, 1989
|Thermedics, Inc.
|Peritoneal access catheter
|Oct 21, 1988
|Feb 27, 1990
|Medical Engineering Corp.
|Septum with a needle stop at the fluid transfer port
|Aug 26, 1988
|Sep 17, 1991
|Giltech Limited
|Apparatus for antimicrobial use
|May 20, 1991
|Feb 4, 1992
|Pudenz-Schulte Medical Research Corporation
|Sterilizable medication infusion device with dose recharge restriction
|May 17, 1991
|Feb 25, 1992
|Geary Gregory L
|Subcutaneous access device for peritoneal dialysis
|Apr 2, 1991
|Aug 11, 1992
|Pudenz-Schulte Medical Research Corporation
|Injection port
|Apr 12, 1995
|Nov 28, 1995
|Giltech Limited
|Medicinal substance for topical application
|Sep 20, 1999
|Nov 20, 2001
|Scimed Life Systems, Inc.
|Implantable vascular access device
|Apr 4, 2000
|Nov 26, 2002
|Insulet, Inc.
|Disposable infusion device
|Sep 20, 2001
|Apr 1, 2003
|Scimed Life Systems, Inc.
|Implantable vascular access device
|May 8, 2002
|Jun 10, 2003
|Biolink Corporation
|Method and apparatus for overcoming infection in a tissue pocket surrounding an implanted device
|Dec 22, 1999
|Jun 17, 2003
|C. R. Bard, Inc.
|Dual mode antimicrobial compositions
|May 10, 2000
|Jul 22, 2003
|C. R. Bard Inc.
|Silane copolymer compositions containing active agents
|Apr 23, 2002
|Dec 2, 2003
|Insulet Corporation
|Dispenser for patient infusion device
|Apr 23, 2002
|Dec 2, 2003
|Insulet Corporation
|Dispenser for patient infusion device
|Oct 12, 2001
|Dec 30, 2003
|Insulet Corporation
|Laminated patient infusion device
|Mar 1, 2002
|Feb 17, 2004
|Insulet Corporation
|Flow condition sensor assembly for patient infusion device
|Nov 9, 2001
|Mar 2, 2004
|Insulet Corporation
|Transcutaneous delivery means
|Jun 6, 2002
|Apr 20, 2004
|Insulet Corporation
|Plunger assembly for patient infusion device
|Feb 22, 2002
|Jun 15, 2004
|Insulet Corporation
|Modular infusion device and method
|Dec 21, 2001
|Jul 27, 2004
|Insulet Corporation
|Medical apparatus remote control and method
|Mar 1, 2002
|Dec 14, 2004
|Insulet Corporation
|Flow condition sensor assembly for patient infusion device
|Apr 23, 2002
|Nov 1, 2005
|Insulet Corporation
|Transcutaneous fluid delivery system
|Jul 16, 2002
|Mar 28, 2006
|Insulet Corporation
|Flow restriction system and method for patient infusion device
|Nov 15, 2002
|Apr 18, 2006
|Insulet Corporation
|Devices, systems and methods for patient infusion
|Sep 30, 2002
|Oct 31, 2006
|Flaherty J Christopher
|Components and methods for patient infusion device
|Oct 28, 2003
|Nov 21, 2006
|Insulet Corporation
|Devices, systems and methods for patient infusion
|Sep 30, 2002
|Dec 5, 2006
|Insulet Corporation
|Dispenser components and methods for patient infusion device
|Apr 22, 2002
|Dec 26, 2006
|Medtronic Minimed, Inc.
|Anti-inflammatory biosensor for reduced biofouling and enhanced sensor performance
|Jan 15, 2003
|Aug 7, 2007
|Boston Scientific Scimed, Inc.
|Implantable vascular access device
|Mar 21, 2005
|Dec 4, 2007
|Insulet Corporation
|Transcutaneous fluid delivery system
|Oct 8, 2003
|Feb 15, 2011
|Insulet Corporation
|Flow condition sensor assembly for patient infusion device
|Jan 29, 2010
|Dec 25, 2012
|Vital Access Corporation
|Vascular access ports and related methods
|Jan 29, 2010
|Dec 25, 2012
|Vital Access Corporation
|Subcutaneous vascular access ports and related systems, methods, and implantation features
|Jun 8, 2009
|Apr 2, 2013
|Duane D. Blatter
|Tissue management methods, apparatus, and systems
|May 1, 2012
|Sep 30, 2014
|Merit Medical Systems, Inc.
|Catheter with distal diffuser
|Dec 21, 2012
|May 19, 2015
|Vital Access Corporation
|Subcutaneous vascular access ports having attachment features
|Feb 14, 2014
|May 26, 2015
|Vital Access Corporation
|Tissue management apparatus for vascular access
|Jan 29, 2010
|Jul 7, 2015
|Vital Access Corporation
|Subcutaneous vascular access ports and related systems and methods
|Jan 31, 2011
|Nov 10, 2015
|Vital Access Corporation
|Vascular access ports and related methods
|Dec 21, 2012
|Mar 28, 2017
|Vital Access Corporation
|Subcutaneous vascular access ports
|Jul 18, 2002
|Feb 13, 2003
|Xiaodong Wang
|Regulation of apoptosis and in vitro model for studies thereof
|Apr 22, 2002
|Oct 23, 2003
|Medtronic Minimed, Inc.
|Anti-inflammatory biosensor for reduced biofouling and enhanced sensor performance
|May 1, 2003
|Nov 6, 2003
|Schwartz Anthony H.
|Implantable device with free-flowing exit and uses thereof
|Aug 31, 2005
|Jun 8, 2006
|Consumer Innovation Partners, Lp
|Semi-collapsible container
|Jun 8, 2009
|May 13, 2010
|Vital Access Corporation
|Tissue management methods, apparatus, and systems
|Jan 29, 2010
|Jul 29, 2010
|Vital Access Corporation
|Subcutaneous vascular access ports and related systems and methods
|Jan 29, 2010
|Jul 29, 2010
|Vital Access Corporation
|Subcutaneous vascular access ports and related systems, methods, and implantation features
|Feb 7, 2011
|May 26, 2011
|John Nottingham
|Collapsible container with stowed component
|Feb 7, 2011
|May 26, 2011
|John Nottingham
|Collapsible container that expands when water is added
|Feb 7, 2011
|May 26, 2011
|John Nottingham
|Collapsible container handle configuration
|Feb 7, 2011
|Jun 2, 2011
|John Nottingham
|Collapsible container with z-shaped hinge
|Oct 6, 2009
|Aug 18, 2011
|Milux Holding Sa
|Fastening means for implantable medical control assembly
|Jan 29, 2010
|Aug 5, 2010
|Vital Access Corporation
|Vascular access ports and related methods
|U.S. Classification
|604/502, 604/266, 604/93.01, 604/185, 604/506, 604/48, 604/267, 604/265, 604/174
|International Classification
|Cooperative Classification
|European Classification
|Oct 17, 1983
Owner name: UNIVERSITY OF UTAH SALT LAKE CITY UT 8112 A UT COR
Free format text: ASSIGNMENT OF ASSIGNORS INTEREST.;ASSIGNORS:STEPHEN, ROBERT L.;KABLITZ, CARL;HANOVER, BARRY K.;AND OTHERS;REEL/FRAME:004221/0228;SIGNING DATES FROM 19830926 TO 19831011
|Nov 19, 1984
Owner name: UNIVERSITY OF UTAH RESEARCH FOUNDATION THE, SALT L
Free format text: ASSIGNMENT OF ASSIGNORS INTEREST.;ASSIGNOR:UNIVERSITY OF UTAH;REEL/FRAME:004329/0094
Effective date: 19841101
|Mar 11, 1986
|Certificate of correction
|Jun 5, 1989
|Fee payment
Year of fee payment: 4
|Jul 20, 1993
|Maintenance fee reminder mailed
|Dec 19, 1993
|Lapse for failure to pay maintenance fees
|Mar 1, 1994
|Expired due to failure to pay maintenance fee
Effective date: 19931219
|Jan 10, 2000
|Surcharge for late payment


text:
KMRL Graduate Technician Trainee Recruitment 2016 is ready. Notification 79 Vacancies Online Application Form at kochimetro.org. Finally, after a long time waiting, the Kochi Metro Rail Limited has enabling the graduate trainee, trainee, trade trainee and technician trainee posts registration forms from 8th November 2016 on wards. Those who are looking for railway jobs in Kochi, they have to fill up and submit their forms soon are on before 25th of this November 2016. Actually, the KMRL advertised the KMRL Graduate Technician Trainee Recruitment 2016 notification almost a couple of months ago, and now they are inviting the registrations. Those who are awaiting from past months, they have to grab the applications soon. As there are only 79 available posts are there is KMRL. So, aspirants need to speed up their process once the applications activate.
KMRL Graduate Technician Trainee Recruitment 2016
Coming to post wise eligibility details, Those who wish to apply for graduate trainee, they must have graduation in BE/B.tech with minimum 60% aggregate marks are eligible. For trainee posts, applying ones should have MBA (HR) with 60% of marks, technician trainee posts should have diploma and finally those who are applying to trade trainee they must passed ITI trade with at least 60% of marks are only applicable to fill the KMRL Graduate Technician Trainee Recruitment 2016 forms. Age limit must be in between minimum 18 and maximum of 25 years are suitable. The pay scale of both trainee and graduate trainee starts from Rs.10,000 per month. Whereas for technician trainee Rs.7500/- and trade trainee Rs.5000/- per month will be offered by the KMRL board. As per above data, this notification is one of the best opening in this season. So, students have to start applying for above 79 vacancy notification soon from 8th November 2016 to 25th November 2016 through online mode.
KMRL Graduate Technician Trainee Notification 2016 and Download Procedure of application
Recruiting of the candidates for above all posts is basis on their academic qualification fallowed by written tests and personal interview. Those who will filled the KMRL Graduate Technician Trainee Recruitment 2016 form with invalid details or incomplete form their forms will be definitely rejected by the board. Verification of age, caste, qualification and remaining details will be happen during the recruitment time. While applying, candidates have to attach attested certificates and recent passport sized photographs with valid signature too. If you still have any queries about eligibility or pay scale and many other details, please read the original notification from kochimetro.org official page.
kochimetro.org Recruitment 2016
Organisation Name: Kochi Metro Rail Limited (KMRL)
Examination Date: Update Shortly
Recruitment Release date: 8th November 2016
Last date of Application: 25th November 2016
Designation: Graduate Trainee, Trainee, Trade Trainee, Technician Trainee.
No of Vacancies: 79
Organisation URL: kochimetro.org
Steps to fill KMRL Graduate Technician Trainee Online Application Form 2016
Now, after go through the above entire notification details. Those who are ready to apply for KMRL recruitment. They have to simply fallow this method. Firstly go to the official page of KMRL, kochimetro.org. Drop up the career icon on the home page then choose the icon jobs @KMRL. Under the open latest vacancies, navigate and hit on the link related to KMRL Graduate Technician Trainee Recruitment 2016. Read the notification details and match it with yours then click on apply online button. Enter complete details of yours on a form then attach required documents and upload recent photograph with signature then click on submit button.
Click Here To Apply For KMRL Graduate Technician Trainee Recruitment 2016

subset: commoncrawl


text:
Luca: Well, That Was A MessMature
My last one had been tough to kill. The others hadn't been much of a challenge, but this guy spotted the fact that my arm wasn't in the best shape and latched onto it tightly. Agony pumped through my arm as he drove his fingers into my flesh, ripping apart the straining stitches as he went.
I roared, reeling from the pain. I couldn't see straight, bright stars popped underneath my eyelids and for a moment there was nothing but the ripping pain. Using that moment to his advantage, he tore my knife out of my hand. I punched at him, but it didn't seem to make much difference. He was the last one standing, and he was determined to get out of this alive. My stomach twisted as he tried to tug the muscle from the bone. His fingernails were inside of me.
He pulled back the knife. I felt it as he moved slightly away from me. My eyes snapped open. He would've torn right into my belly if I hadn't caught his wrist as he brought it swinging back towards me. We struggled. I broke his arm, forcing him to drop the knife. He ripped the hole in my arm further. Both of us were barely standing, slick with blood and panting from the pain. He let go of me and staggered back, cradling his wrist, biting back tears at the way his bone bent at a sickening angle.
I bent to pick up my knife, closing the distance between us. He dropped to his knees, begging with me for his life. His pleas fell on deaf ears. The knife slid into his windpipe and tore a gaping hole in it. I watched him collapse, spluttering for air as he choked on his own blood and cartilage.
Glancing up, I watched as Sophia turned away from me. I frowned.
There was silence for a moment. I sagged with relief. As much as I enjoyed a good fight, I was exhausted, and beginning to feel kinda dizzy from the blood loss.
"You son of a bitch!" I heard Joe screaming. I looked around to where he was just in time to see Joe stick a knife into the guts of a kid about his age. It was the one he'd been glaring at from the shadows before. He brought home the knife a couple more times and the kid collapsed, his hands desperately fumbling to stop the flow of blood. It wasn't going to be much use. Joe stepped back; the rage wavered and was suddenly replaced with disbelief. The kid gurgled on the floor, trying to spit out one last comment before he went. It wasn't audible from here, and from the look on Joe's face, he hadn't quite caught it either. He looked from the kid to me, not certain what to do.
I gave him a moment to finish it as this kid just flopped about on the floor bleeding out, but he didn't do it. I walked over to where they were and rolled the kid over with my foot so he was facing me.
"I'm guessing you deserve this," I muttered. His eyes darted from Joe to my knife to me and back again, silently shaking his head. I looked at Joe. All he could do was nod. It was over in seconds, but as blood leaked out of his throat, it felt like a life time.


text:
Could Sally Say YesMature
It occurred to me this morning that we have made such a saint of Thomas Jefferson, painted him as such an enlightened man, that we just kind of assume him to be this slave owner who really didn't treat his slaves as slaves... I mean after all he took Sally to Paris! All this stirred up for me because three really sick brothers in Ohio kept three women in captivity for a decade...
Could Sally Say Yes
Could Sally say 'yes'
as Tom tore off her dress
and had his wanton way?
Was she free to say 'no'?
Did Tom love her so?
Was she a slave only in name?
Back from 'Gay Paree'
was she still treated as free?
Were the other slaves treated the same?
Did she sign with an 'X'?
Was it consensual sex?
Did Sally have any say?
Did Tom call it love?
Iron fist, velvet glove...
Did his ardor ever decay?
Was he in denial
as to the cause of her smile?
Was it just a role that she played?
Did he see it as wrong?
Did she just go along?
Because at the end of the day
it didn't matter 'no' or 'yes'
she was never a guest
as long as she wore the word slave.


text:
Charline von Heyl
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Tag Archives: frank
Why Bunnies Are Assholes – A Sequel
So, I've been giving this whole "Bunnies are Assholes" thing a lot of thought ever since my post about how forest creatures are freeloading off of me and stealing all my food. I began to analyze all the famous bunnies, … Continue reading
Posted in Uncategorized Tagged br'er rabbit, bunnies, donnie darko, energize bunny, evil, frank, humor, little bunny foo-foo, peter rabbit, rabbit, trix rabbit, winnie the pooh 28 Comments


text:
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Vivekanand Mahavidyalaya
Uttar Pradesh
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Vivekanand Mahavidyalaya is situated at Darwara, Chandpur, Distt. Bijnor 246725 Uttar Pradesh, India in Bijnor.
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Vivekanand Mahavidyalaya - VM
In confronting the many challenges that the future holds in store, we at 'Vivekanand Mahavidyalaya' sees in education an indispensable asset in its attempt to broaden/widen mental horizons and move above and beyond narrow parochial boundaries.Today, in this world of knowledge and information revolution Vivekanand Mahavidyalaya is a dream come true where the future generations will take over the heritage of the past, interweave it in the fine fabric of the present and progress towards a future that ensures happiness, prosperity and peace through a healthy combination of academics, sports and co-curricular activities.The institute's motto is "Higher, Stronger, Brighter". The main objectives of the institute are to provide education, health and other basic amnesties to all section of the society with special attention to educate the girls and women and there by making them secure, self dependent and confident. The institute also aims for the peace and development in the nation and in the world.Thus all our efforts are directed to help our students to forge ahead providing the right job opportunities and ideal environment. We endeavor to instill in students the sense of responsibility and initiative to become useful members of the society and that can play a very important role in the process of building a better and greater nation.
Why join Vivekanand Mahavidyalaya
The College has excellent infrastructure.
2 Type Courses Available
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The institutional library provides pleasant & comfortable surrounding for study. Our library contain large collection of books and journals related with the course subject and extensive manuscript collection.library has specialist librarian who will help you to find the information, you need. Library is open for hours according to the need of the students.
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|TREGAN Fabien <fabien.tre...@airbus.aeromatra.com>
|RE: [how-to] Contribute with my own tutorial
|Thu, 28 Feb 2002 09:44:56 GMT
>Apologies Fabien for the typo on your name. np >I see what you mean. I'm not sure that anything >exists that is in the public domain so you may have to >write something yourself. let's go :) >Also, I >know from my own experience that if you start >developing a Java/XML/XSLT web app yourself you will >almost inevitably end up with something that mirrors >the functionality of Cocoon. Think about components, >database pooling, object pooling, what you would do >about getting a maintainable mix of >logic/content/style. Main chapters of my tutorial will certainly be : I- Why my own servlets would separate content, logic, style II- Benefit of using a framework instead of stand-alone classes calling each-other (existing code, pooling, ...) III- How to extend C2 to fit our problem (how-easy-it-is to make your own source) IV- Why one should avoid using C2 (few unexisting docs, xsp is boring and having < in java code isn't fun and there is not XSPOpenTool for JBuilder) V- You are the boss, your choose (but you will spend fewer money with cocoon) Does someone have something to add ? fabien. ps : sorry for the 'ko'... I start using ko instead of kb when sega/nintendo start using kb for kilo-bit instead of kilo-byte... but know i'm an engeneer, i earn money and all, I should start considering i18n problems instead of video-game problems :) --------------------------------------------------------------------- To unsubscribe, e-mail: firstname.lastname@example.com For additional commands, email: email@example.com
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SearchAll Refuges
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The above map is for general location information only and does not imply access. For access information please check on the refuge's web page or contact the refuge directly. Many refuges have specific visitor services and other recreation opportunity maps. All lands and boundaries depicted in the above web map are not survey quality and should not be used for survey or legal purposes. For more information go to https://www.fws.gov/gis/data/CadastralDB/index_cadastral.html.
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Refuge wetlands provide habitat for up to 40 pairs of breeding sandhill cranes each year. The unison call of these tall, stately birds is a treat to hear in spring, and by mid-summer, an observant visitor may be treated to the sight of one or two rusty-colored 'colts,' following their parents and learning to forage on insects and other invertebrates.
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I was an Employ of Beto Paredes. He riped me off by not paying me my check that he owes me. The acts like a 12 year old child and will not talk to me. he took taxes out of my checks and did not pay them in to the state or my unemployment.
He is also a sexest a*s whole. He would have favrite employes. And would make all weman that worked for him feel ugly and bad about them selfs because of the way he classified all griles he seen or talked to. he also made wemon that worked there in feair for there jobs if they became pregnent.
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I find it difficult to read a complaint about a company that is "publishing" based. Even though the information is published for the website it still deserves proper grammar, spelling and puncuation, which with today's software is easier than it once weas.
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In my eyes your complaint sounds like a personal issue, a complaint that was not thought through and you lost credibility by poor grammar, spelling, and editing. Doing so makes me question your interpretation of someone elses behavior when your own isn't constructive in any way.
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Date: 1905
Description: Rear exterior of the Frank Brown home, 28 Langdon Street.
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Chapter 7
Waiting was beginning to really grate on me. At school I inevitably saw Harriet. Seeing her made me feel a pang of guilt because a part of me told me I should be taking her somewhere private in the school grounds and ending her proprius state now. It also hurt me that she no longer talked to me. I wondered how she could think that I was a bad person for wanting to rescue her? I sorely resented Arthur for possessing her. It wasn't right.
In a bout of bitterness towards my brother and all the others who thought that making someone your proprius could be justified, I wrote a note to her, saying 'You know, Arthur asked Ryan to hypnotise him to be able to be happy without seeing you daily and to not feel pain when you have to say goodbye to each other after spending time together?' and delivered it to her in the lunch queue. I wasn't doing it to spite her, thought it might just have looked that way. I was doing it to try to show her that Arthur wasn't this great person she thought he was. Of course, the chances were, her being his proprius, this wouldn't work at all. I did, however, notice that she had a certain downcast air about her after for the rest of the afternoon. It made me feel cruel.
This opposing Arthur's behaviour causes me so much inner conflict because of its inextricability from Harriet's emotions. If I could just confront my brother and not harm her, there'd be no problem whatsoever. But, of course, Harriet's his girlfriend and his proprius. So I have to decide for myself whether I want to let her continue to be his love-bound slave or if I want her to release her but cause her pain from bringing her out of the proprius state.
At home, I wanted to go to Ryan and talk to him about the stress. But then I remembered how he'd been shocked by my suggestion the night before and couldn't see him being forgiving until I apologised for it - which I wouldn't do, because Arthur's actions were utterlyunjustifiable. Ifheever apologised, then mine would follow.
I noticed my unattractive stubborn attitude and left the house for a long walk before sitting down to do my homework. I don't think it did any good. It just gave me a chance to think about all the things that were wrong in my life.
Did I really have the strength to last 19 days?
Henry's note confused and upset me. I mean, it struck me that he could be lying to drive me and Arthur apart, but the fear that he was telling the complete truth overwhelmed me. It left me cold inside until I saw Arthur that evening.
When he arrived at my front door, I pulled him into the porch and hugged him tightly, burying my head in his chest.
"Harriet?" he asked, concerned. "Is everything okay?"
"No," I told him, unable to lie to him as his proprius. His proprius. I was bound to him. But he wasn't to me. What if he should ever stop wanting me?
"Let's talk upstairs," he said. He closed the front door behind him and led me to my room. Gently tugging me to my bed where he sat and pulled me onto his lap, he said, "Tell me what's wrong, my darling."
Silently I pulled out the note where it had lain crumpled in my pocket since Henry had given it to me. I gave it to Arthur who opened it out and read it quietly.
"The jerk," he muttered. He turned me so I was sitting sideways on him and leant in to kiss him. Most of me was caught up in the beauty of it - as per usual - but a part of me couldn't shake the fear of the truth in the note. I tensed slightly, wondering if he was trying to distract me.
Arthur noticed the difference and leant up.
"Oh, darling, it's not what you think," he promised me. "Do you remember Thursday?"
I nodded, slightly confused. Thursday was when he had felt distressed.
"Well, I talked to Andrew and Ryan about it. They said that maybe it wasn't so healthy for me to feel so distraught after saying goodbye to you. Ryan helped me out by suggesting that I didn't need to see you every single day to be happy - which is a fair point, my love - and you shouldn't need to see me daily either. He also suggested it wouldn't hurt so much - you said yourself, Harriet: me being distressed distresses you." Arthur stroked my cheek. I relaxed a little but his words troubled me a bit.
"Do ... do you still love me?" I asked hesitantly.
"Oh, Harriet," Arthur said softly. "Of course I still love you. How could I ever stop? I think it would anger Fate if I stopped loving you and I'd be eternally cursed for it."
I smiled, starting to lose the fear that had taken over so dramatically.
"Lie down," he ordered gently. I lay on my bed. He sat beside me and took my hand. He kissed it and massaged my palm with his thumb.
"Harriet, I don't want you to ever doubt my feelings for you again. I may not be your proprius but I love you just as much as you love me and am bound in a different way to your wishes." His eyes became more intense. They held me where I was. "I love you."
I nodded. "I understand, Arthur."
He smiled. "Good. Don't you ever forget," he warned.
"I won't," I promised.
He stroked my cheek.
"Now, we won't be able to see each other every day..."
"What?!" I interrupted, despite being the proprius in this relationship.
Arthur laid a finger on my lips.
"It's going to be okay," he promised. "It'll be good for both of us. I know it doesn't seem that way, but we'll still make the most of the time that we do spend together." He stroked my cheek rhythmically. I breathed at the same rate and focused less on implications and more on Arthur's words. "You're going to be fine. You can daydream about me and you'll be able to think of other things than me when we're not in each other's company. It won't hurt."
I tried to believe him but my great love for him made it difficult. Arthur sensed it and stroked my arm.
"Harriet, listen." His voice became drenched in hypnotic-ness. "Listen to my voice, gaze into my eyes, focus on the rhythm as I stroke your arm. When we are not together, it will not hurt."
"Yes, Arthur," I heard myself whisper.
Arthur's eyes decreased in intensity and his voice became gentler as he said, "You'll be okay, my darling."
"I believe you," I murmured.
He smiled and leant in to kiss me.
Ugh, I could murder Henry! Part of me is stunned that he could be so heartless and make Harriet scared like this, but most of me is furious. What right has he to intervene? Thanks to him, I had to use my hypnotic powers to calm Harriet down. I think her fear even weakened the proprius binding slightly.
I spent the rest of the time at her house kissing her and assuring her I loved her, holding her close to me snuggling into her warmth.
When the time came for me to leave she was reluctant but she also said, "I'll be okay. I'll be okay 'cause you'll return."
"That's right - I will return," I promised her. I kissed her hand, like a peasant might kiss a queen's. "I love you."
"You too."
Back at home, the first thing I did was go to Henry's room and give him a piece of my mind.
"Leave us alone, Henry - your interference isn't welcome!"
Henry, who had been startled while doing his homework, regarded me coolly and said, "D'you believe me now when I say I will stop her being your proprius?"
Furious, I snarled "This has nothing to do with you. Leave us alone and go and find yourself a girlfriend, you pitiful wretch. You'll never have Harriet."
"I will in, oh, let's see, 19 days."
Striding up to him, I punched him in the face. He cried out in pain.
I left him there, his nose bleeding.
But an hour later, he appeared at the door to my room and, fixing me with an angry stare, he said, in a tone that hurt me in forcing me into submission, "Tonight, you'll betorturedby not being with Harriet." His green eyes blazed both with rage and hypnotic power; the aura he emanated was dark and menacing. And as soon as he left the room, I found myself doubling up in pain, as I longed desperately for my dear, beautiful Harriet and contemplated something happening to her between now and the next visit which would mean that I could never see again. I found myself crying as every kiss from tonight haunted me - could these have been our last? I felt this agony until midnight - unable to sleep from distress.
And I felt something I'd never,everimagined I would. Fear. Fear of Henry.
What came over me?... The anger, the stress, the pain of being punched in the nose... But nothing can justify what I did to Arthur. I used my powers against him. My own brother. And I used them to hurt him.
I didn't get ready for school on Tuesday morning. I lay in bed, staring at my ceiling uncomprehendingly. Was I a monster?
And then a scarier thought hit me. Could I ever go back to being me?
I'm really worried...
18 days.


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Red Cross Promotes Safe Swimming Through Anti-Drowning Campaign
The Fourth of July holiday may be behind us, but there's still plenty of summer left.
And with eight of 10 Americans planning water activities through the warm-weather months, the American Red Cross is promoting an anti-drowning campaign to promote safe swimming.
Summer is a time for fun and celebration, and the American Red Cross wants to make sure tragedy doesn't strike YOUR gathering.
"Make sure that you know who's around, and people are aware of rules around the pool," Spokesman Jordan Scott said.
He says that's especially true when it comes to children.
"You want to make sure they are supervised -- parents know where they are, especially if they don't know how to swim or don't swim very well," Scott said.
And never let anyone swim alone, whether it's a backyard party or if you're on a big lake.
More safety tips are available from the Red Cross through free downloadable apps for your smart-phone.


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Pack less. Be more.
@dwambaughLocale: Pacific Northwest
SOLD: a GoLite Poncho Tarp and an REI REI Minimalist Bivy, long size. Add your poles, guy lines and stakes and you have UL rain gear and shelter. Both are in excellent condition showing only very light use and no damage.
The poncho is a later model GoLite weighing 7.4oz. The hood drawstring has been swapped out with a lighter one. It has not been seam sealed.
The REI Minimalist Bivy is the longer version (88"x31") which is handy for shorter users too, as you can roll the top over to get a little more rain protection: the screened area over your face does not close. It weighs 16oz. The bivy has an Elements 2.5 layer waterproof/breathable topside and waterproof bottom. I don't have the stuff sack, but I'll include the mesh one shown in the photo. See http://www.rei.com/product/794291/rei-minimalist-bivy-long for more info.
I'll throw in a fresh 62"x210" panel of Frost King polycryo window film which will make a bunch of super light ground cloths to protect the bivy bottom.
$87.50 for the works including US shipping and PayPal fees .
Bottom side of the bivy– clean!
The interior looks like the inside of your rain shell
thanks for clear communication along the way.
happy with purchase, can't wait to try these out!
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About Us
Don't forget to also check out our Facebook page for more pictures & videos of our adoptable dogs/puppies. Plus we post updates on transports, dogs & events.
Donations are always appreciated, we accept:
dog food, used crates (in working condition), dog treats, food/water dishes, collars/leashes, old towels or blankets, tether/runner lines, pet/flea shampoo, and monetary donations
(for increasing vet bills and supplies)
Thank you for any and all help...
from the volunteers and rescue dogs of Open Arms Rescue of WNY
Where: "Rescued is our favorite breed."
"I can't do everything but I can do something."
Open Arms Rescue of WNY
P.O. Box 133 Akron, NY 14001
www.oarwny.org - download an application & much, much more
'Like' us on Facebook!
OARWNY's policy is to screen applicants for adoption. This includes:
We strive not only to find approved homes, but to match the home with the dog/pup. For example, if an applicant is approved and has a cat, but the dog that is applied for is not good with cats, we would not approve that match even if the home is a great home. We want to do everything possible to make sure each adoption is successful, and for the life of the dog/pup.
Effective October 2015:
The adoption fee is $225. If you choose to use one of our participating vets that would include the spay/neuter. If you decide to use your own vet for the spay/neuter then the cost of the procedure is the owner's responsibility and the adoption fee would remain $225. Once the spay/neuter is complete a copy of the certificate must be sent to Open Arms Rescue of WNY. The adoption fee also includes a 15 pound bag of TLC Premium Dog Food which is the food we feed all of our fosters so you won't have to worry about switching foods. If you continue with TLC you can have the food delivered right to your home and TLC will donate back to OAR with each bag sold. It's a win, win......your dog/puppy will be fed a high quality food, also by using auto ship it's delivered right to your door and you're helping other rescue dogs with your purchase.
Email us at email@example.com for more information.
Open Arms Rescue of WNY is a small, grass roots type of rescue group. We are comprised of all volunteer, non-paid members who have all been involved in rescue for years. These members include a professional dog trainer, business owners, and loving foster families, all who share a common goal which is simply to save dogs and pups from either locally unwanted situations, or from dog pounds, and place them into loving forever homes. We are a non-profit organization funded solely on donations and fund raising, and we have our Federal 501c3 status as a non-profit organization.
OARWNY is a 100% pro spay/neuter rescue.
OARWNY does not have a shelter. All of the animals are fostered in homes with families until a forever home is found. There are fosters from Tonawanda, to Akron, to Rochester, so keep in mind that you may need to travel a bit to meet the dog/pup you are applying for.
Check out our website at www.oarwny.org
Email us at firstname.lastname@example.com, to inquire about adoption, volunteering, fostering, or to make a donation.


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- USA TODAY Sports Images
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McLEAN, Va., Oct. 15, 2013 /PRNewswire/ -- Gannett Co., Inc. (NYSE: GCI) today announced Dave Morgan has been named president of USA TODAY Sports Media Group. Morgan succeeds Tom Beusse, who had been president of USA TODAY Sports Media Group since its formation in 2011. Beusse is leaving to pursue other opportunities. Morgan has served as senior vice president of content and editor-in-chief of USA TODAY Sports Media Group since 2011. USA TODAY Sports Media Group, a top five online sports destination, includes sports initiatives across USA TODAY as well as Gannett's more than 100 U.S. Community Publishing and broadcast television properties. It also includes:


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Richard Hughes first came to public attention in 1917, at the age of 17, when his schoolmaster sent one of his essays to The Spectator. He wrote the world's first radio play, called Danger, broadcast in 1924. He became a journalist, travelled extensively, married the painter Frances Bazley, and spent a decade as a scriptwriter at Ealing Studios – but he only managed to write four adult novels, two of which have ostensibly similar plots.
This is odd, because one of the quartet has such timeless power that it should probably be on every school curriculum. A High Wind in Jamaica was published to great acclaim in 1929, and is unique. It is an adventure about children, but is not aimed at them. The prose sweeps away a century of Victorian sentimentality and replaces it with something darker, more clear-eyed and modern.
What starts as merely masterful storytelling becomes something dreamlike and haunting; it's not a book you easily forget. The first page sets the tone when it casually mentions that twin sisters were starved and fed ground glass until they died. Some British children living in Jamaica survive a hurricane and are sent back to England, but are captured by pirates. The description of the storm is filled with bizarre incident – a pack of wildcats is blown through the windows, and the shutters bulge "as if tired elephants were leaning against them". It's a book about growing up and recognising the cruelties that allow the young to survive. Nothing fazes the children, whose amoral attitude to their parents should be a warning that the pirates are not psychologically matched to defeat them. The plot turns on a casually shocking death that underlines the loss of innocence they suffer. Hughes is brilliant at pinning down the interior lives of children, and it would be interesting to know how today's kids would react to it.
Hughes' other seabound novel, In Hazard (1938), feels like a spin-off, as it follows the crew of a British ship facing death in a hurricane. It's thrilling, but less memorable. Two further books outline a virtual history of the early 20th century, but are patchy. Hughes was given the OBE, and then died 50 pages into the last volume of his sea-faring trilogy. Vintage Classics is to be commended for its current editions of A High Wind in Jamaica and In Hazard, but the others – and his excellent children's stories – are out of print.
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