text:
|Publication number
|Publication type
|Application number
|Publication date
|Apr 15, 2008
|Filing date
|May 11, 2004
|Priority date
|May 11, 2004
|Fee status
|Publication number
|Steve Koh
|Original Assignee
|Pacesetter, Inc.
|Export Citation
|BiBTeX, EndNote, RefMan
|Patent Citations (25), Referenced by (36), Classifications (15), Legal Events (3)
|External Links: USPTO, USPTO Assignment, Espacenet
The invention generally relates to implantable medical devices, such as pacemakers or implantable cardioverter/defibrillators (ICDs), and in particular to techniques for controlling delivery of therapy in response to periodic breathing within a patient in which a medical device is implanted.
Periodic breathing refers to abnormal respiration patterns that alternate between hypopnea (i.e. diminished breathing) and hyperpnea (i.e. fast, deep breathing.) One form of periodic breathing is Cheyne-Stokes Respiration (CSR), which can occur in patients with congestive heart failure (CHF). CSR typically occurs while the patient is sleeping. Briefly, CSR arises principally due to a time lag between blood carbon dioxide (CO2) levels sensed by the central nervous system and the blood CO2 levels. With CHF, poor cardiac function results in poor blood flow to the brain such that the central nervous system responds to blood CO2 levels that are no longer properly representative of the overall blood CO2 levels in the body. Hence, the central nervous system triggers an increase in the depth and frequency of breathing in an attempt to compensate for perceived high blood CO2 levels; whereas the blood CO2 levels have already dropped. By the time the central nervous system detects the drop in blood CO2 levels and slows respiration in response, the blood CO2 levels have already increased. This cycle becomes increasingly unbalanced until respiration periodically alternates between hypopnea and hyperpnea. Typically, the time from one period of hyperpnea until the next is about one minute.
The periods of hypopnea occurring during CSR can be sufficiently pronounced that breathing completely ceases during hypopnea, i.e. the patient suffers from episodes of frank apnea. The episodes of apnea can cause the patient to awaken due to blood O2 depletion (i.e. hypoxia). Arousal from sleep usually lasts only a few seconds, but such brief arousals can occur hundreds of times a night, thus significantly disrupting continuous sleep leading to excessive sleepiness during the day, which diminishes quality of life. Worse, the frequent interruptions from sleep can prevent the patient from achieving rapid eye movement (REM) sleep, which is needed. In this regard, REM sleep does not usually occur until after some period of the sustained Stage 3/Stage 4 sleep. CSR usually arises during Stage 3 sleep. Hence, repeated sleep interruptions occurring during CSR typically prevent the patient from achieving any REM sleep or, at least, an insufficient amount of REM sleep is achieved over the course of the night. Whether a patient is actually awakened due to apnea occurring during CSR depends on various factors. In some cases, CSR is sustained without sleep interruption. Such cases are referred to herein as "sustained CSR". In other cases, herein referred to as "non-sustained CSR", sleep interruptions are frequent and debilitating.
In view of the adverse consequences of sleep interruption during CSR, it is highly desirable to provide techniques for treating CSR so as to prevent possible sleep interruption. One particularly promising solution is to employ an implantable medical system for the detection and treatment of CSR. This may be achieved by, for example, applying diaphragmatic pacing via phrenic nerve stimulators during periods of apnea to improve respiration during apnea so as to equalize the cyclic blood chemistry variations occurring during CSR. Alternatively, overdrive pacing therapy may be applied, also in an attempt to mitigate CSR and reduce cyclic blood chemistry variations to prevent repeated sleep interruptions. The implantable medical system may utilize a pacemaker or ICD for use as a controller to coordinate the detection of CSR and delivery of therapy in response thereto. Pacemakers and ICDs are usually implanted primarily for use in applying cardiac therapy for treating arrhythmias or for delivering cardiac resynchronization therapy in an effort to alleviate CHF. However, many patients who are candidates for pacemakers or ICDs also suffer from CSR and hence could benefit from additional functionality directed to the detection and treatment of CSR.
An example of a technique for performing diaphragmatic pacing during the hypopnea/apnea phase of CSR using an implantable medical system incorporating a pacemaker is set forth in U.S. Pat. No. 6,415,183 to Scheineret al., entitled "Method and Apparatus for Diaphragmatic Pacing." Another technique for delivering therapy in response to CSR is set forth in U.S. Pat. No. 6,641,542 to Cho et al., entitled "Method and Apparatus to Detect and Treat Sleep Respiratory Events". A technique for delivering overdrive pacing therapy in response to sleep apnea, including apnea caused by CSR, is set forth in U.S. Patent Application: 2003/0153954 A1 of Park et al., entitled "Sleep Apnea Therapy Device Using Dynamic Overdrive Pacing", which is incorporated by reference herein.
Techniques for treating CSR in an effort to prevent sleep interruptions during CSR using an implantable medical system are promising. However, considerable room for improvement remains. In this regard, many CSR treatment techniques operate to deliver therapy continuously during CSR, without regard to whether sleep is likely to be interrupted. With some techniques, once an episode of CSR has been detected, overdrive pacing is applied continuously throughout the entire episode of CSR. Other techniques operate to deliver diaphragmatic pacing during all episodes of apnea occurring during CSR. Therapy is thereby provided even circumstances where sleep might not actually be interrupted due to CSR. In some cases, the amount of respiration achieved during each burst of respiration during CSR (i.e. during each hyperpnea phase) is a sufficient to sustain the patient through a period of hypopnea/apnea until the next burst of respiration. Hence, although the alternating CSR pattern of hyperpnea and hypopnea/apnea may be sustained, the patient does not awaken due to hypopnea/apnea, and hence the above-described problems arising because of frequent sleep interruption do not occur.
Thus, in at least some cases, CSR therapy is delivered when it is not required or, at least, therapy is delivered that is more aggressive than is otherwise necessary. Either can have adverse consequences. Providing continuous aggressive overdrive pacing throughout all episodes of CSR can unnecessarily diminish power supplies of the implantable system and can potentially adversely affect the hemodynamic balance of the patient—due to the continuously elevated heart rate. Moreover, continuous aggressive overdrive pacing of the atria can potentially trigger atrial fibrillation. Providing continuous diaphragmatic pacing throughout all episodes of apnea occurring during CSR can likewise diminish power supplies of the implantable system. Moreover, frequent diaphragmatic pacing via the phrenic nerves can potentially damage the nerves.
Accordingly, it would be desirable to provide improved treatment techniques for CSR or other forms of periodic breathing for use with implantable medical systems, which address these various concerns.
In accordance with one illustrative embodiment, techniques are provided for controlling therapy delivered in response to periodic breathing such as CSR within a patient using an implantable medical device, wherein a prediction is made as to whether the patient is likely to awaken due to an upcoming period of reduced respiration occurring during periodic breathing; therapy is controlled based on the prediction. Hence, demand-based periodic breathing therapy is thereby provided. By controlling therapy based upon such a prediction, periodic breathing therapy need not be delivered in circumstances where sleep is not likely to be interrupted, thus eliminating unnecessary therapy while also preserving device resources, such as battery supplies. Alternatively, minimal therapy is applied if sleep is not likely to be interrupted; whereas therapy that is more aggressive is applied if the patient is likely to awaken due to periodic breathing.
In an exemplary embodiment, directed primarily to episodes of CSR entailing frank apnea, a prediction of whether the patient is likely to awaken due to an upcoming episode of frank apnea is made on a burst-by-burst basis. Individual bursts of respiration during CSR (i.e. individual periods of hyperpnea) are detected and the amount of respiration achieved during the burst is evaluated. A determination is then made as to whether the amount of respiration achieved during the burst appears sufficient to sustain the patient through the next period of apnea such that the patient will not awaken due to depletion of oxygen reserves in the blood. If it appears that respiration achieved during the burst will not be sufficient to sustain the patient and that sleep therefore will likely be interrupted, CSR therapy is delivered in an effort to increase respiration to prevent the imminent sleep interruption. For example, aggressive overdrive cardiac pacing may be delivered via pacing leads implanted within the heart or diaphragmatic pacing may be delivered using an implanted phrenic nerve stimulator. In this manner, demand-based CSR therapy is achieved on a burst-by-burst basis to allow the implanted system to respond to the changing needs of the patient.
In a specific example, a prediction threshold is set based upon minimal respiration demands of the patient evaluated during an initial period of sleep prior to the onset of CSR. To this end, the onset of sleep is detected, then respiration amplitude values are accumulated over five individual one-minute intervals, spaced one minute apart. The prediction threshold is then set equal to the average of the five accumulated values. In other words, the prediction threshold is thereby representative of the amount of respiration achieved by the patient during normal sleep over a one minute interval. Thereafter, once CSR is detected, respiration amplitudes are accumulated during each individual respiration burst. The amount of respiration accumulated over a burst is then compared against the prediction threshold and, if it exceeds the threshold, the device thereby concludes that the amount of respiration achieved during the burst should probably be sufficient to sustain the patient until the next burst. (As noted above, CSR bursts are typically spaced about one minute apart.) Otherwise, the device concludes that the amount of respiration achieved during the burst will probably not be sufficient to sustain the patient and so the patient will probably awaken due to hypoxia, if aggressive therapy is not immediately delivered. By setting the prediction threshold based upon patient respiration measured shortly after the onset of sleep, the technique thereby automatically responds to changes in the minimal respiration demands of the patient, which may vary from night to night.
Thus, techniques are provided for use with an implantable medical system for providing demand-based periodic breathing therapy.
The above and further features, advantages and benefits will be apparent upon consideration of the descriptions herein taken in conjunction with the accompanying drawings, in which:
The following description includes the best mode presently contemplated. The description is not to be taken in a limiting sense but is made merely to describe general principles of the illustrative embodiments. The scope of the invention should be ascertained with reference to the issued claims. In the description that follows, like numerals or reference designators will be used to refer to like parts or elements throughout.
Once an episode of CSR is detected, the pacer/ICD detects individual respiration bursts and determines, on a burst-by-burst basis, the appropriate CSR therapy to be provided. Briefly, if it appears that the patient is likely to awaken during the next episode of apnea due to insufficient respiration, aggressive CSR therapy is applied to mitigate CSR and prevent sleep interruption. Otherwise, either no therapy is applied or mild therapy is applied. By delivering aggressive CSR therapy only in circumstances where it appears the patient is likely to awaken due to CSR, device resources (such as power supplies) are preserved and any potentially adverse side effects caused by aggressive CSR therapy are avoided. Nevertheless, aggressive CSR therapy is delivered on a demand-basis when needed so as to prevent sleep interruptions, thus allowing the patient to have a restful and therapeutic night's sleep. In addition, by eliminating potentially frequent sleep interruptions, the patient is likely able to achieve REM sleep, which is needed.
Depending upon the specific implementation, CSR therapy may take the form of a diaphragmatic pacing delivered using one or more phrenic nerve stimulators 14, shown mounted adjacent left and right left phrenic nerves 16 and 18, respectively, in the upper thorax. This is merely illustrative. The phrenic nerves typically can be simulated at any point along their path. Note, however, that portions of the phrenic nerves pass epicardially over the heart and it may be disadvantageous to mount phrenic nerve stimulator adjacent to those portions of the phrenic nerves, as any electrical signals generated by the stimulator near the heart could potentially interfere with proper functioning of the heart. Phrenic nerve stimulation devices are set forth in: U.S. Pat. No. 5,056,519 to Vince, entitled "Unilateral Diaphragmatic Pacer" and in the aforementioned patent to Scheiner, et al., entitled "Method and Apparatus for Diaphragmatic Pacing". Other respiratory nerves may be stimulated as well. U.S. Pat. No. 5,911,218 to DiMarco, entitled "Method and Apparatus for Electrical Stimulation of the Respiratory Muscles to Achieve Artificial Ventilation in a Patient" describes stimulation of nerves leading to intercostal muscles.
Additionally, or in the alternative, the CSR therapy may include overdrive pacing therapy, which increases the heart rate and, in many cases, mitigates CSR. The use overdrive pacing during CSR is discussed in the aforementioned patent application to Park et al., One particularly effective overdrive pacing technique, referred to as dynamic atrial overdrive (DAO) pacing, is described in U.S. Pat. No. 6,519,493 to Florio et al., entitled "Methods And Apparatus For Overdrive Pacing Heart Tissue Using An Implantable Cardiac Stimulation Device". The aggressiveness of overdrive pacing may be modulated by adjusting the overdrive pacing rate and related control parameters. See, for example, U.S. Patent Application 2003/0130703, of Florio et al., entitled "Method And Apparatus For Dynamically Adjusting Overdrive Pacing Parameters", published Jul. 10, 2003.
Appropriate diagnostic information is preferably stored for subsequent review by a physician or other medial professional. The physician may then prescribe any other appropriate therapies to address the CSR. The physician may also adjust the operation of the pacer/ICD to activate, deactivate or otherwise control any therapies that are automatically applied.
Overview of Demand-Based CSR Therapy Technique
An example of sustained CSR is shown in
Non-sustained CSR is shown in
Turning now to
In the second example of
Note that the techniques are most advantageously employed in connection with episodes of CSR having periods of frank apnea since the patient is at the greatest risk of being awoken as a result of frank apnea. Nevertheless, the techniques can also be applied to episodes of CSR (or other forms of periodic breathing) that do not have episodes of frank apnea in an effort to prevent possible sleep interruption that might occur therein as well. If frank apnea is not occurring, the amount of respiration expected to be achieved in the next hypopnea/apnea phase of periodic breathing should be taken into account—along with the amount of respiration achieved during the most recent hyperpnea burst phase—before making a prediction of whether sleep is likely to be interrupted. For example, the respiration achieved during the most recent hyperpnea burst may be combined with the amount of respiration expected to be achieved during the upcoming hypopnea/apnea phase then compared against a prediction threshold to determine whether sleep will likely be interrupted during the upcoming hypopnea/apnea phase. The amount of respiration achieved during each hypopnea/apnea phase that does not entail frank apnea can be determined based on an analysis of thoracic impedance. Blood pH and blood oxygen saturation measurements may also be used to aid in the sleep interruption prediction.
Example of Demand-Based CSR Therapy Technique
One particular example of a demand-based therapy technique that may be performed using the systems described above for use with episodes of CSR entailing frank apnea is set forth in
Once the patient has fallen asleep then, at step 202, the pacer/ICD sets a prediction threshold based upon actual patient respiration occurring during an initial period of sleep. By setting the prediction threshold based on actual patient respiration during the initial period of sleep, the prediction threshold is representative of the minimal respiration demands of the patient. In this regard, once a patient has fallen asleep, the central nervous system soon reduces respiration to a minimal level sufficient to meet the respiration needs of the patient during sleep. Since CSR typically does not occur until Stage 3 sleep, respiration occurring during the initial period of sleep is unaffected by CSR respiration patterns and hence is properly representative of the minimal respiration needs of the patient. Moreover, the prediction threshold can thereby vary from night to night to account for any possible changes in the minimal respiration demands of the patient. In this regard, medications newly taken by the patient may affect minimal respiration demands. In addition, whether the patient is sleeping at sea level or at a high elevation may also affect the minimal respiration demands of the patient. Hence, setting the prediction threshold based upon actual patient respiration occurring during the initial period of sleep provides a convenient technique for automatically tailoring the threshold to the specific needs of the patient. An example of a specific technique for setting the prediction threshold based upon actual respiration achieved during the initial period of sleep is illustrated in
At step 204, pacer/ICD detects the onset of an episode of CSR having periods of frank apnea based upon breathing patterns, preferably detected by way of changes in thoracic impedance sensed via cardiac pacing leads (such as leads 12 of
At step 210, the amount of respiration achieved during the most recent CSR burst is compared against the prediction threshold and, if it exceeds the threshold, the amount of respiration is deemed to be sufficient to sustain the patient until a next CSR respiration burst and so, at step 212, either no therapy is delivered or non-aggressive CSR therapy is delivered. However, if the amount of respiration achieved during the most recent burst does not exceed the prediction threshold, then the amount of respiration is deemed insufficient to sustain the patient until the next CSR burst and an imminent sleep interruption is thereby predicted. Accordingly, at step 214, aggressive CSR therapy is delivered in effort to provide sufficient ventilation to the patient to prevent sleep interruption. In either case, processing then returns to step 206 to detect the next burst of respiration and the process is repeated. In this manner, demand-based CSR therapy is performing on a burst-by burst basis wherein each CSR burst is individually analyzed to predict whether a sleep interruption is imminent.
The comparison of respiration accumulated during an individual respiration burst against the prediction threshold is illustrated in
In the second respiration pattern 217 of
Returning to
Turning now to
The accumulation intervals used in
In the example of
Other specific parameters may be employed in connection with the technique of
Turning now to
Then, at step 306, the filtered impedance signal is differentiated, i.e. the mathematical derivative of the filtered signal is calculated, herein denoted dZ. With the filtered impedance signal represented internally by digital values, standard digital techniques are employed to calculate (dZ). Next, at step 308, zero crossing points are identified within the differentiated signal dZ. The zero crossing points correspond to peaks and valleys within the original filtered impedance signal. At step 310, the differentiated signal dZ is then integrated between consecutive zero crossing points to generate a set of amplitude values, indicative of valley-to-peak amplitude variations. With dZ represented internally by digital values, standard digital techniques are employed to integrate or sum dZ to generate the individual amplitude values. Each individual amplitude value thereby provides a measure of the variation from a negative valley to a next positive peak within the filtered impedance signal. Hence, these values are indicative of the range of physical movement of the thorax from maximum contraction to maximum expansion during a respiration cycle. Hence, the amplitude value is representative of the amount of respiration (or the amount of ventilation) achieved during a single respiration cycle.
At step 312, the amplitude of value for the latest respiration cycle is added to amplitude values of any previous respiration cycles during the same interval, i.e. total respiration is accumulated. Steps 302-312 are repeated until the interval is complete. Once the interval is complete, the resulting accumulated respiration value is thereby representative of the amount of respiration achieved during the selected interval and this value is stored in memory for use as needed.
Preferably, diagnostic information is stored indicative of predictions made and the accuracy of those predictions. Thereafter, a physician or other medical professional can review the accuracy of predictions and adjust the predictive parameters, if needed, to improve prediction accuracy. Alternatively, the device can be programmed to exploit automatic adaptive adjustment techniques for automatically adjusting the predictive parameters so as to improve prediction reliability. For example, if the patient is found to awaken in circumstances where the pacer/ICD predicted that no sleep interruption would occur, the prediction threshold is automatically decreased in an effort to improve the predictions so as to properly deliver aggressive therapy to prevent further sleep interruptions. On the other hand, if aggressive therapy is frequently delivered and the patient almost never awakens in circumstances where the pacer/ICD predicted that no sleep interruption would occur, the prediction threshold is automatically increased in an effort to reduce delivery of unneeded therapy. As can be appreciated, a variety of techniques may be implemented for improving prediction accuracy and no attempt is made herein to describe all such techniques.
For the sake of completeness, a detailed description of the pacer/ICD of
With reference to
To provide atrial chamber pacing stimulation and sensing, pacer/ICD 10 is shown in electrical communication with a heart 412 by way of a left atrial lead 420 having an atrial tip electrode 422 and an atrial ring electrode 423 implanted in the atrial appendage. Pacer/ICD 10 is also in electrical communication with the heart by way of a right ventricular lead 430 having, in this embodiment, a ventricular tip electrode 432, a right ventricular ring electrode 434, a right ventricular (RV) coil electrode 436, and a superior vena cava (SVC) coil electrode 438. Typically, the right ventricular lead 430 is transvenously inserted into the heart so as to place the RV coil electrode 436 in the right ventricular apex, and the SVC coil electrode 438 in the superior vena cava. Accordingly, the right ventricular lead is capable of receiving cardiac signals, and delivering stimulation in the form of pacing and shock therapy to the right ventricle.
To sense left atrial and ventricular cardiac signals and to provide left chamber pacing therapy, pacer/ICD 10 is coupled to a "coronary sinus" lead 424 designed for placement in the "coronary sinus region" via the coronary sinus os for positioning a distal electrode adjacent to the left ventricle and/or additional electrode(s) adjacent to the left atrium. As used herein, the phrase "coronary sinus region" refers to the vasculature of the left ventricle, including any portion of the coronary sinus, great cardiac vein, left marginal vein, left posterior ventricular vein, middle cardiac vein, and/or small cardiac vein or any other cardiac vein accessible by the coronary sinus. Accordingly, an exemplary coronary sinus lead 424 is designed to receive atrial and ventricular cardiac signals and to deliver left ventricular pacing therapy using at least a left ventricular tip electrode 426, left atrial pacing therapy using at least a left atrial ring electrode 427, and shocking therapy using at least a left atrial coil electrode 428. With this configuration, biventricular pacing can be performed. Although only three leads are shown in
A simplified block diagram of internal components of pacer/ICD 10 is shown in
The housing 440 for pacer/ICD 10, shown schematically in
At the core of pacer/ICD 10 is a programmable microcontroller 460, which controls the various modes of stimulation therapy. As is well known in the art, the microcontroller 460 (also referred to herein as a control unit) typically includes a microprocessor, or equivalent control circuitry, designed specifically for controlling the delivery of stimulation therapy and may further include RAM or ROM memory, logic and timing circuitry, state machine circuitry, and I/O circuitry. Typically, the microcontroller 460 includes the ability to process or monitor input signals (data) as controlled by a program code stored in a designated block of memory. The details of the design and operation of the microcontroller 460 are not critical. Rather, any suitable microcontroller 460 may be used that carries out the functions described herein. The use of microprocessor-based control circuits for performing timing and data analysis functions are well known in the art.
As shown in
The microcontroller 460 further includes timing control circuitry (not separately shown) used to control the timing of such stimulation pulses (e.g., pacing rate, atrio-ventricular (AV) delay, atrial interconduction (A-A) delay, or ventricular interconduction (V-V) delay, etc.) as well as to keep track of the timing of refractory periods, blanking intervals, noise detection windows, evoked response windows, alert intervals, marker channel timing, etc., which is well known in the art. Switch 474 includes a plurality of switches for connecting the desired electrodes to the appropriate I/O circuits, thereby providing complete electrode programmability. Accordingly, the switch 474, in response to a control signal 480 from the microcontroller 460, determines the polarity of the stimulation pulses (e.g., unipolar, bipolar, combipolar, etc.) by selectively closing the appropriate combination of switches (not shown) as is known in the art. Moreover, as the explained in greater detail below, the microcontroller transmits signals to controlling the switch to connect a different set of electrodes during a far-field overdrive pacing than during near-field overdrive pacing.
Atrial sensing circuits 482 and ventricular sensing circuits 484 may also be selectively coupled to the right atrial lead 420, coronary sinus lead 424, and the right ventricular lead 430, through the switch 474 for detecting the presence of cardiac activity in each of the four chambers of the heart. Accordingly, the atrial (ATR. SENSE) and ventricular (VTR. SENSE) sensing circuits, 482 and 484, may include dedicated sense amplifiers, multiplexed amplifiers or shared amplifiers. The switch 474 determines the "sensing polarity" of the cardiac signal by selectively closing the appropriate switches, as is also known in the art. In this way, the clinician may program the sensing polarity independent of the stimulation polarity. Each sensing circuit, 482 and 484, preferably employs one or more low power, precision amplifiers with programmable gain and/or automatic gain control, bandpass filtering, and a threshold detection circuit, as known in the art, to selectively sense the cardiac signal of interest. The automatic gain control enables pacer/ICD 10 to deal effectively with the difficult problem of sensing the low amplitude signal characteristics of atrial or ventricular fibrillation. The outputs of the atrial and ventricular sensing circuits, 482 and 484, are connected to the microcontroller 460 which, in turn, are able to trigger or inhibit the atrial and ventricular pulse generators, 470 and 472, respectively, in a demand fashion in response to the absence or presence of cardiac activity in the appropriate chambers of the heart.
For arrhythmia detection, pacer/ICD 10 utilizes the atrial and ventricular sensing circuits, 482 and 484, to sense cardiac signals to determine whether a rhythm is physiologic or pathologic. As used herein "sensing" is reserved for the noting of an electrical signal, and "detection" is the processing of these sensed signals and noting the presence of an arrhythmia. The timing intervals between sensed events (e.g., P-waves, R-waves, and depolarization signals associated with fibrillation which are sometimes referred to as "F-waves" or "Fib-waves") are then classified by the microcontroller 460 by comparing them to a predefined rate zone limit (i.e., bradycardia, normal, atrial tachycardia, atrial fibrillation, low rate VT, high rate VT, and fibrillation rate zones) and various other characteristics (e.g., sudden onset, stability, physiologic sensors, and morphology, etc.) in order to determine the type of remedial therapy that is needed (e.g., bradycardia pacing, antitachycardia pacing, cardioversion shocks or defibrillation shocks).
Cardiac signals are also applied to the inputs of an analog-to-digital (A/D) data acquisition system 490. The data acquisition system 490 is configured to acquire intracardiac electrogram signals, convert the raw analog data into a digital signal, and store the digital signals for later processing and/or telemetric transmission to an external device 502. The data acquisition system 490 is coupled to the right atrial lead 420, the coronary sinus lead 424, and the right ventricular lead 430 through the switch 474 to sample cardiac signals across any pair of desired electrodes. The microcontroller 460 is further coupled to a memory 494 by a suitable data/address bus 496, wherein the programmable operating parameters used by the microcontroller 460 are stored and modified, as required, in order to customize the operation of pacer/ICD 10 to suit the needs of a particular patient. Such operating parameters define, for example, pacing pulse amplitude or magnitude, pulse duration, electrode polarity, rate, sensitivity, automatic features, arrhythmia detection criteria, and the amplitude, waveshape and vector of each shocking pulse to be delivered to the patient's heart within each respective tier of therapy. Other pacing parameters include base rate, rest rate and circadian base rate.
Advantageously, the operating parameters of the implantable pacer/ICD 10 may be non-invasively programmed into the memory 494 through a telemetry circuit 500 in telemetric communication with the external device 502, such as a programmer, transtelephonic transceiver or a diagnostic system analyzer. The telemetry circuit 500 is activated by the microcontroller by a control signal 506. The telemetry circuit 500 advantageously allows intracardiac electrograms and status information relating to the operation of pacer/ICD 10 (as contained in the microcontroller 460 or memory 494) to be sent to the external device 502 through an established communication link 504. Pacer/ICD 10 further includes an accelerometer or other physiologic sensor 508, commonly referred to as a "rate-responsive" sensor because it is typically used to adjust pacing stimulation rate according to the exercise state of the patient. However, the physiological sensor 508 may further be used to detect changes in cardiac output, changes in the physiological condition of the heart, or diurnal changes in activity (e.g., detecting sleep and wake states) and to detect arousal from sleep. Accordingly, the microcontroller 460 responds by adjusting the various pacing parameters (such as rate, AV Delay, V-V Delay, etc.) at which the atrial and ventricular pulse generators, 470 and 472, generate stimulation pulses. While shown as being included within pacer/ICD 10, it is to be understood that the physiologic sensor 508 may also be external to pacer/ICD 10, yet still be implanted within or carried by the patient. A common type of rate responsive sensor is an activity sensor incorporating an accelerometer or a piezoelectric crystal, which is mounted within the housing 440 of pacer/ICD 10. Other types of physiologic sensors are also known, for example, sensors that sense the oxygen content of blood, respiration rate and/or minute ventilation, pH of blood, ventricular gradient, etc.
The pacer/ICD additionally includes a battery 510, which provides operating power to all of the circuits shown in
Accordingly, pacer/ICD 10 is preferably capable of high voltage therapy and appropriate batteries.
As further shown in
In the case where pacer/ICD 10 is intended to operate as an implantable cardioverter/defibrillator (ICD) device, it detects the occurrence of an arrhythmia, and automatically applies an appropriate electrical shock therapy to the heart aimed at terminating the detected arrhythmia. To this end, the microcontroller 460 further controls a shocking circuit 516 by way of a control signal 518. The shocking circuit 516 generates shocking pulses of low (up to 0.5 joules), moderate (0.5-10 joules) or high energy (11 to 40 joules), as controlled by the microcontroller 460. Such shocking pulses are applied to the heart of the patient through at least two shocking electrodes, and as shown in this embodiment, selected from the left atrial coil electrode 428, the RV coil electrode 436, and/or the SVC coil electrode 438. The housing 440 may act as an active electrode in combination with the RV electrode 436, or as part of a split electrical vector using the SVC coil electrode 438 or the left atrial coil electrode 428 (i.e., using the RV electrode as a common electrode). Cardioversion shocks are generally considered to be of low to moderate energy level (so as to minimize pain felt by the patient), and/or synchronized with an R-wave and/or pertaining to the treatment of tachycardia. Defibrillation shocks are generally of moderate to high energy level (i.e., corresponding to thresholds in the range of 5-40 joules), delivered asynchronously (since R-waves may be too disorganized), and pertaining exclusively to the treatment of fibrillation. Accordingly, the microcontroller 460 is capable of controlling the synchronous or asynchronous delivery of the shocking pulses.
Microcontroller 460 also includes various components directed to the detection, evaluation and treatment of CSR. More specifically, the microcontroller includes a respiration-based CSR sleep interruption prediction unit 501 operative to predict whether the patient is likely to awaken due to an upcoming episode of apnea occurring during CSR as well as a demand-based CSR therapy controller 503 operative to selectively delivering therapy in an effort to prevent the patient from awakening during the upcoming episode of apnea. The sleep interruption prediction unit 501 uses a sleep detector 505 to detect the onset of sleep for use in setting the prediction threshold discussed above. Depending upon the implementation, sleep detection may be based upon signals received from the accelerometer or other physiologic sensor 508. Once the prediction threshold has been set, then a CSR detection unit 507 is employed to detect the onset of individual episodes of CSR, so that the sleep interruption prediction unit can then evaluate individual respiration bursts occurring during the CSR episodes to make its predictions. The demand-based CSR therapy controller operates in response to the prediction to control delivery of CSR therapy, as discussed above. As noted, one form of therapy may be overdrive pacing, which is performed under the control of a DAO controller 509. Another form of therapy is diaphragmatic pacing applied via phrenic nerve stimulator 14. Note that, although several of the aforementioned components are shown as being sub-components of the microcontroller, some or all may be implemented separately from the microcontroller. Depending upon the implementation, the various components of the microcontroller may be separate software modules. The modules may be combined to permit a single module to perform multiple functions.
What have been described are various systems and methods for treating CSR or other forms of periodic breathing using an implantable system controlled by a pacer or ICD. Principles of the illustrative embodiments may be exploiting using other implantable systems or in accordance with other techniques. Thus, while exemplary embodiments have been described, modifications can be made thereto without departing from the spirit and scope of the invention.
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|Detection and the treatment of ventilatory disorders during sleep for an active implantable medical device, in particular a pacemaker
|Aug 18, 2003
|Feb 24, 2005
|Hatlestad John D.
|Sleep quality data collection and evaluation
|Aug 31, 2004
|Mar 24, 2005
|Cardiac Pacemakers, Inc.
|Coordinated use of respiratory and cardiac therapies for sleep disordered breathing
|Aug 31, 2004
|Mar 24, 2005
|Cardiac Pacemakers, Inc.
|Therapy control based on cardiopulmonary status
|Sep 17, 2004
|Jun 2, 2005
|Stahmann Jeffrey E.
|Patient monitoring, diagnosis, and/or therapy systems and methods
|Jan 31, 2005
|Sep 1, 2005
|Earlysense Ltd.
|Techniques for prediction and monitoring of respiration-manifested clinical episodes
|Dec 5, 2000
|May 23, 2002
|Medtronic, Inc.
|Method and apparatus for monitoring heart rate and abnormal respiration
|Apr 29, 2002
|Nov 7, 2002
|Medtronic, Inc.
|Method and apparatus to detect and treat sleep respiratory events
|Citing Patent
|Filing date
|Publication date
|May 17, 2007
|Sep 14, 2010
|Widemed Ltd.
|Detection of cardiac arrhythmias using a photoplethysmograph
|May 17, 2007
|Sep 28, 2010
|Widemed Ltd.
|Detection of heart failure using a photoplethysmograph
|May 17, 2007
|Sep 28, 2010
|Widemed Ltd.
|Respiration-based prognosis of heart disease
|Sep 10, 2009
|Jul 31, 2012
|Respicardia, Inc.
|Respiratory rectification
|Nov 17, 2006
|Aug 14, 2012
|Respicardia, Inc.
|System and method to modulate phrenic nerve to prevent sleep apnea
|Jan 25, 2011
|Jan 22, 2013
|Eckhard Alt
|Method of detecting sleep apnea and treatment thereof
|Feb 6, 2009
|Apr 30, 2013
|Respicardia, Inc.
|Muscle and nerve stimulation
|Jul 31, 2012
|Mar 25, 2014
|Pacesetter, Inc.
|Systems and methods for controlling neurostimulation of acupuncture sites using an implantable cardiac rhythm management device
|Nov 11, 2009
|Jul 15, 2014
|Cardiac Pacemakers, Inc.
|Mass attribute detection through phrenic stimulation
|Jan 18, 2008
|Dec 9, 2014
|Respicardia, Inc.
|Device and method for the treatment of breathing disorders and cardiac disorders
|Jan 30, 2009
|Mar 22, 2016
|Medtronic, Inc.
|Interdevice impedance
|Mar 27, 2013
|Mar 29, 2016
|Respicardia, Inc.
|Muscle and nerve stimulation
|Dec 16, 2013
|Nov 22, 2016
|Viscardia, Inc.
|Hemodynamic performance enhancement through asymptomatic diaphragm stimulation
|Aug 26, 2014
|Jan 3, 2017
|Cardiac Pacemakers, Inc.
|Unwanted stimulation detection during cardiac pacing
|Aug 26, 2014
|Mar 28, 2017
|Cardiac Pacemakers, Inc.
|Unwanted stimulation detection during cardiac pacing
|Jul 1, 2015
|Apr 11, 2017
|Time Warner Cable Enterprises Llc
|Apparatus and methods for enabling media options in a content delivery network
|Nov 5, 2010
|Jun 13, 2017
|Inovise Medical, Inc.
|Detection and differentiation of sleep disordered breathing
|Sep 22, 2016
|Jul 4, 2017
|Viscardia, Inc.
|Hemodynamic performance enhancement through asymptomatic diaphragm stimulation
|Oct 27, 2011
|Aug 8, 2017
|Medtronic Cryocath Lp
|Method for monitoring phrenic nerve function
|Nov 17, 2006
|May 24, 2007
|Mark Gelfand
|System and method to modulate phrenic nerve to prevent sleep apnea
|May 17, 2007
|Sep 13, 2007
|Widemed Ltd.
|Detection of heart failure using a photoplethysmograph
|May 17, 2007
|Sep 13, 2007
|Widemed Ltd.
|Respiration-based prognosis of heart disease
|May 17, 2007
|Sep 13, 2007
|Widemed Ltd.
|Detection of cardiac arrhythmias using a photoplethysmograph
|Jan 18, 2008
|Aug 28, 2008
|Mark Gelfand
|Device and method for the treatment of breathing disorders and cardiac disorders
|Feb 7, 2006
|Oct 30, 2008
|Widemed Ltd.
|Detection and Monitoring of Stress Events During Sleep
|May 30, 2007
|Dec 4, 2008
|Widemed Ltd.
|Apnea detection using a capnograph
|Jul 21, 2005
|Nov 26, 2009
|Widemed Ltd
|Sleep quality indicators
|Jan 30, 2009
|May 6, 2010
|Medtronic, Inc.
|Interdevice impedance
|Nov 11, 2009
|May 20, 2010
|Mccabe Aaron R
|Mass attribute detection through phrenic stimulation
|Sep 10, 2009
|Mar 10, 2011
|Mark Gelfand
|Respiratory rectification
|Nov 5, 2010
|May 5, 2011
|Inovise Medical, Inc.
|Detection and differentiation of sleep disordered breathing
|Jan 25, 2011
|Aug 4, 2011
|Eckhard Alt
|Method of detecting sleep apnea and treatment thereof
|Jan 25, 2012
|Oct 31, 2013
|Eckhard Alt
|Verbessertes Verfahren zum Erfassen von Schlafapnoe und Behandlung davon
|Oct 29, 2009
|May 6, 2010
|Medtronic, Inc.
|Interdevice impedance
|Jan 25, 2012
|Aug 2, 2012
|Eckhard Alt
|Improved method of detecting sleep apnea and treatment thereof
|Dec 16, 2013
|Jun 26, 2014
|Inovise Medical, Inc.
|Hemodynamic performance enhancement through asymptomatic diaphragm stimulation
|U.S. Classification
|600/536, 607/17, 600/592
|International Classification
|Cooperative Classification
|European Classification
|May 11, 2004
Owner name: PACESETTER, INC., CALIFORNIA
Free format text: ASSIGNMENT OF ASSIGNORS INTEREST;ASSIGNOR:KOH, STEVE;REEL/FRAME:015327/0958
Effective date: 20040508
|Oct 17, 2011
|Fee payment
Year of fee payment: 4
|Oct 15, 2015
|Fee payment
Year of fee payment: 8


text:
Common Components System (CCS)The Common Components System consists of three different components:
- The Common Interface (CI), a software package which is locally installed within the user's IT environment
- The Central Reference File Database (CRD), which is accessible remotely
- The Certification Authority (CA), which provides X509 certificates for secure communication.
While the CI is a technical tool that supports the interoperable exchange of messages, the CRD is a centralised database that stores Location Codes and Company Codes required under TAF TSI (EC Regulation 62/2006, repealed by 1305/2015) and TAP TSI (EC Regulation 454/2011), and makes these available to users.
The Common Interface (Reference Implementation), the Central Reference File Database and the Certification Authority were built on the basis of requirements in the TAF and TAP Regulations following a European tender, with stakeholder and European Union funding for the development.
The CCS was developed by the TAF TSI Common Components Group (CCG), a special UIC group. The Group consisted of the main European Infrastructure Managers (IMs) as well as the largest freight Railway Undertakings (RUs), along with some smaller ones.
On 1 January 2015, the activities of the CCG were officially transferred from the UIC to RNE. Since then RNE has been responsible for the development, operation and maintenance of the TAF and TAP-TSI Common Components. » more
By clicking sign up you will be redirected to the CCS CRD sign up site..
Become a CCS UserAccess to CCS for TAF and TAP actors is based on a user agreement that needs to be signed beforehand:
FeedbackWe need your help to further improve CCS!
Please send your ideas, feedback, criticism and suggestions for improvements to: email@example.com.

subset: commoncrawl


text:
The Stella K. Abraham Beit Midrash for Women, more commonly known as Migdal Oz (Hebrew: מדרשת מגדל עוז), which is the name of the kibbutz in which it is located, is a Beit Midrash, or Orthodox Jewish institution of higher Torah study for women, located in Gush Etzion, Israel. It is the sister school of Yeshivat Har Etzion, and shares its general philosophy, leadership, and much of its faculty.
Migdal Oz is led by Esti Rosenberg, who assumes the title of Rosh Beit Midrash (literally "Head of the Beit midrash"). Rosenberg's father, Rabbi Aharon Lichtenstein, and Rabbi Yehuda Amital are considered sources of rabbinic guidance for Migdal Oz, and often make decisions on the school's religious policies.
Migdal Oz was established in 1997 by Yeshivat Har Etzion. At the time, the Beit Midrash was located in a trailer, which now serves as the kibbutz's sewing room. The impressive edifice overlooking the Gush Etzion region which now houses the Beit Midrash, classrooms, and a dining hall was completed in 2003. The program was originally intended for Israeli girls who had just graduated from high school and had not yet done Sherut Leumi (National service) or service in the Israel Defense Forces. Since then, it has expanded to include girls who have already completed service, as well as girls from outside of Israel. Many girls continue studying at Migdal Oz for two or three years, often participating at the same time in the Teacher's Training Program in conjunction with Herzog College.
Women Learning Talmud
Many Orthodox groups hold that it is forbidden, or looked down upon for women to learn Talmud. Rosenberg's Grandfather Rav Joseph Soloveitchick held it was allowed.
See also
External links
|This yeshiva or kollel article is a stub. You can help by expanding it.
|This Israel-related article is a stub. You can help by expanding it.


text:
Welcome to Smith Lake Bed & Breakfast
Smith Lake Bed & Breakfast is a private resort offering accommodations on Alabama's pristine Lewis Smith Lake including complimentary use of paddle boards, kayaks, and our large boat dock with sun deck, swim deck, jet ski dock and boat slip for guest use. Smith Lake Bed & Breakfast is 70 miles south of Huntsville and 50 miles north of Birmingham.
About the Area
Note From the Innkeeper:
We took a short ride on the pontoon and the water temperature was 80 degrees! Swimming season is here. Between showers, the weather has been beautiful. Our guests have been paddleboarding, kayaking and swimming from the dock. Water is clear and the lake is full up to the summer pool level. Great time for a visit to our beautiful lake. We have suites available, especially during the week.


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Hard to believe that in just a few days my kids will no longer be third, first, and Kindergartners and will instead be fourth, second, and first graders! UN-believable. Maddy wasn't even in Kindergarten when I started this blog, and now she's in fourth grade. Oh my gosh time is flying. We will not let summer zip by us this year. No way, no how. Instead we will control the speed with which we move by making sure we fit every single fun thing in that we want, from the first ear of … [Read more...]
summer learning eBook: 30+ free, fun learning ideas for summer
We're thrilled to share that our third annual summertime learning eBook has hit the presses today! The fab parents and teachers of the we teach forum have submitted tons of rockstar ideas for keeping summer filled with creative, unique, and crazy-cool fun from start to finish. We're sharing these ideas in an eBook, free to all members of the forum--and anyone can join! The goal of the forum is really to share the tools and resources we all need so that we can learn, share, and grow as … [Read more...]
learn through play eBook bundle: spring & summer fun learning
*Though the Learn Through Play eBook Bundle special is over, you may still purchase these eBooks at any time! Just click through to the ones you are most interested in, and purchase from that book's main site!* I'm thrilled beyond thrilled to have the opportunity to be a part of a rockstar mix of bloggers who have worked out a fabulous deal for their readers: a spring eBook bundle. An it's a crazy-awesome deal, for a short, short time. Brought to you by Melitsa of Raising Playful Tots … [Read more...]
teachmama's holiday gift guide for kids and family 2012
I'm not a big gift-guide gal, and I've only ever created my first holiday gift guide for kids and families back in 2010. And two years seems like forever ago. Though our recommendations in our first gift guide still rank as our faves from then, when Maddy, Owen, and Cora were 6, 5, and 3, I figured it was time to update the list. So here's the official teachmama Holiday (or any day) Kids' Gift Guide for 2012: Maddy is 8, Owen is 7, and Cora is 5 years old. It's full of items we love … [Read more...]
national book festival 2012: why families need to go
My favorite event of the year--the National Book Festival & Gala-was just a few weeks ago, and so many of my pals have asked why I love this event so much. So here it is. Short and sweet. Here's why every family should consider dropping the ball on soccer and football and ballet and raking the leaves and closing the pool and everything else on a fall weekend in September to take their kids down to the festival. Yes, it's passed already, but if you bookmark this post, pin it, digg … [Read more...]
halloween learning ideas — silly and scary literacy, math, and science
Halloween is in the air, and though we've just gotten around to decorating our house, we never do a lot of scary Halloween over here. We always stick to the silly or tricky. But, like any holiday, I truly believe that there are opportunities for sneaking in a little bit o' learning during this candy-filled holiday. A whole lot of fun—don't get me wrong—but also a whole lot of fun learning as well. Here's the skinny on a few Halloween learning ideas—both silly and scary--literacy, … [Read more...]
geocaching: what it is & why we're hooked
Right now, we're 2 for 6. That's right--2/6. 2:6? And today we totally thought we had one, but we didn't. We'll masters by wintertime, after a fall of not worrying about poison ivy or scratched legs or sunburn. We'll move from 'navigating to geocache' to using the map or compass (on the phone, of course), and maybe the kids will even have their own Geomate.jr. We'll know every attribute symbol by heart. Decrypting hints will become second-nature. ROT13, anyone? We'll … [Read more...]
sea shell craft: simple, sea shell salt dough pretties
Every time we go to the beach, we end up coming home with a boatload of shells. And why wouldn't we? It's one of our favorite things to do at the shore--collect sea shells during long walks by the water. But at this point, we've done a whole lot with these little beachy guys--I was looking for something a little new and a lot different. I knew we wanted us to keep the shells, but I also wanted the kids to be able to admire and share them. And at this point, we have more than enough … [Read more...]
beach learning: hermit crabs, horseshoe crabs, ghost crabs, sand crabs & more
The beach can be difficult vacation for families with young children, there's no doubt about it. Beyond even getting there--the packing, the long drive, the daily to-and-from the beach with a million trillion supplies--being there is sometimes hard, too. Even with a ton of hands on deck, by the end of the week, the sand, the over-tired kids, the sun, the sand, the sand--everywhere!--is enough to make even the most relaxed parent a little edgy. However, I have to say that once we passed … [Read more...]
getting kids to stop, observe and write
Our Everyday Journal cards have proven to be a really incredible—and sneaky—way of getting the kids focused and thinking in a way that I'm not sure they'd be willing to do otherwise. There's something exciting about choosing a card, about having the topic be a surprise, and about being willing and open to trying something totally new. And Maddy, Owen, and Cora have each slowly discovered their favorite areas of focus with the cards—photo inspiration, nature inspiration, poem inspiration, … [Read more...]
hot summer day fun: crayon melts!
It's been so incredibly hot here in Maryland, I'm sure you can fry an egg on the sidewalk. At least I'm guessing you can because it's been upwards of 100 degrees but it feels about a million. And muggy. And really sticky. And buggy. But because it's been so hot, we've been taking it pretty easy—reading, doing some writing, and trying out a few (can't wait to share them!) new-for-us things and a handful of throwback crafts. There was one day, however, when we did get a little … [Read more...]
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129 S 13th St, Philadelphia, PA 19107
(215) 922-3095
129 S 13th St, Philadelphia, PA 19107
(215) 922-3095
Regular Hours
Vintage Wine Bar & Bistro
Parking: Street
Wi-Fi: No
Bike Parking: Yes
Attire: Casual
Wheelchair Accessible: Yes
Alcohol: Full Bar
Takes Reservations: Yes
Outdoor Seating: Yes
No coupons available
08/20/2009Provided by Citysearch -
Recent visit to Vintage with a large group. the staff issues seemed to have been addressed, our service was good. Food was excellent and even the wine experts in our party enjoyed the selections. We had a very enjoyable evening and for downtown the bill was reasonable.
12/11/2008Provided by Citysearch -
This place has a nice atmosphere & decor (check out the wine bottle chandelier) and a great selection of wines. Try a flight as a good way to taste more than one without shelling out too much money (I had the Shiraz flight the last time-very nice!). The food is also quite good. I've had the burger both times I've been. It's very tasty, although it was dangerously undercooked he last time I went (I ordered medium rare and it was more like seared). My wife loved the coq au vin and most recently enjoyed the french onion soup and goat cheese salad. Long story short, check it out. But watch out for undercooked burgers.
05/19/2008Provided by Citysearch -
At the end of a LONG day this was a welcom oasis!! Arrived on Wednesday at approximately 6:30 PM to a VERY full bar. The Bartender, Remee, was incredibly accomodating - answering all questions with patience - even though she had plenty of others to tend to. Everyone at the bar seemed to understand this as I believe that everyone there received the same personal attention. Had 2 glasses of wine at the bar (from an EXTENSIVE wine list - but, hey!! It's a wine bar!!) while waiting for friends to arrive. Had some concerns that a table was not in the iminent future as it seemed many may be waiting, but as soon as a table opened up by the open-air storefront, our waitress Heather took over and ensured the table was reset and we were seated quickly. The beef satay was extremely flavorful and was a perfect medium rare. Sauce accompanying was SERIOUSLY spicy, but delicious once you knew what to expect...LOL. Several different bruscettas were delicious as well and the lamb special looked out of this world. (Though we never got past the multiple small plates we enjoyed) Heather ensured our glasses were never empty and we weren't in need of anything at anytime - when a third person arrived, an extra seat and a quick glass of wine were provided. When (not if) you visit, be sure to ask for either Remee or Heather (or both) and your service, like the food and drink, will not disappoint!!
04/17/2008Provided by Citysearch -
Writing this review a little late, as we visited approximately 3 weeks ago, but the experience was GREAT!!
My friend picked this location as she knew how much I enjoy a good glass of wine and they definitely did not disappoint. While the selection by the glass was not very extensive, the selections they did have were wonderful. We enjoyed the chardonnay and a wonderful zinfandel. Bartender was wonderful to let us compare a small taste before deciding between two different vineyards of the same varietal. Prices were slightly expensive, but again - very much worth it. The menu specials were extremely enticing - my only regret it that we had later dinner reservations somewhere else. This is one mistake I will correct during my next visit. Was not very crowded when we arrived, but the happy hour crowd soon arrived - still, you didn't feel crowded nor did it become too noisy to enjoy conversation with the person next to you.
04/11/2008Provided by Citysearch -
We had been looking forward to trying Vintage for some time, but walked away very disappointed. The wines were good - but there is a lot of competition in Center City these days, and I have had better wines at other wine bars in town and small French bistros near by. The gorgonzola and fig appetizer was delicious; the rest of the food was again just good - not amazing, not over the top - just serviceable. The biggest problem was the wait staff: our waitress was slow, surly and unhelpful. And, at the end of the night - for a party of 2 - she automatically added a 20% tip, and failed to mention it when she brought the bill. If we hadn't been paying attention we may have even tipped on top of that amount! When we brought it to her attention, she grumbled out something that may have been an apology - I'm not sure. Overall, it was a VERY disappointing experience, especially since we had been looking forward to trying this place out. Food is o.k., wine list is decent but not what I would expect for a place called ""Vintage"", prices are fair, the decor is attractive, and the atmosphere is nice - but, sadly, we won't be back. Managers: be careful who you hire! They represent your restaurant!
01/08/2008Provided by Citysearch -
we had dinner here last night and really enjoyed it. The food was very good, escargot, nice and garlicy, my goat cheese salsd was perfect, loaded with cheese and I think it was hazelnuts, perfect dressing, also good crispy calamari with a smoky tomato paste. The place is cute but pretty loud, our waiter was just soso, no real food knowledge, also my house pinot was such a small pour I complained and he said 5 onces, not the response I was looking for because all the people around me had a much bigger pour!!
So we orderd a bottle. I would recommend it because the food was so good, sevice just soso and watch your pour!
10/10/2007Provided by Citysearch -
Fantastic! One word. I've been to Vintage a bunch of times and it has always been a pleasure. The wine list, which is focused on resonably priced wines from around the world is by far the best deal in town. I eat out three times a week and am always surprised if I find a wine carried by another bar, and when I do it's always a dollar or two more (a place in NoLib comes to mind where Vintage's house Pinot Noir $6, is served for a whopping $8!) and a new place around the corner is typically a buck more with half the list. Whoever put this list together explores the same varietal from all corners of the globe across many different varietals, really cool to try a Sauvignon blanc from France, New Zealand and the US and check the differences.
Vintage has some of the usual suspects - a few bordeaux wines, Chards, S. Blancs, Merlots etc etc etc but also a bunch of wines and varietals I've never heard of such as the Blue Franc, Vranic (sp?) from Macedonia, some heavy Zins, I had a delicious Petite Sirah from Lodi and many different white blends that I'm not familiar with. I am a huge wine geek so I was very surprised to find wines I hadn't heard of.
Some other reviewer criticized Vintage saying they should copy Panorama. Panorama is great, but you've to dress to the nines and be ready to drop $300 as many of the wines by the glass approach $20.
Vintage is a neighborhood bar that is always so comfortable to drop in and have a glass or two and the food they're doing always surprises me, from their main courses to the little plates they offer. It reminds me a bit of Cheers with wine and great food. There are a lot of wines bars popping upbut no one does it quite as good and comfortably as Vintage.
If you haven't been to this spot you have to check it out.
10/01/2007Provided by Citysearch -
We went to Vintage for one of my friend's birthdays. It was a great night and was able to sit by the window. We had a party of 9 ordered bottles of wine appetizers dinner and desserts. Our bill was over $400. Our waitor Richard was extrememly pushy and rude. We were only 1/2 way done one of the bottles of wine and he was pushing us to get the next bottle. We were asking for recommendations on food and was just not helpful...the place was great (decor)...but if I went back...I would stay clear of Richard
08/11/2007Provided by Citysearch -
Yes, I gave Vintage one star, and I must preface ""my opinions"" by saying that I only had wine, and did not give them a chance to drop the ball with the food as they did with the wine. As someone who was previously in the wine industry, stays up to date and has a nice wine cellar, I was highly dissapointed.
The wines on the list are overpriced and not great examples of the varietals or regions. They seem to be selected to fill ""spaces"" without much meaning. Very little on the list shows great creativity or hard work to get ""great"" specialty wines that are available through the state store system. They need high quality value wines as well as some high quality mid-priced wines. Owner, have someone who knows the marketing of wine and the trends in the industry choose your selections. You invested capital in the fit out of the property. Now, invest in what you are claiming the theme is; a wine bar. In a byob town, you need to do it right as a wine bar to have a chance to make a consistent profit. Go to Panorama and copy what they do RIGHT!
The flight selections are absolutely abysmal and overpriced. I could not believe the 3 sparklers they selected for a sparkler flight! No interelation between style and below average wines! They served sparkling wines in small tasting wine glasses, NOT flutes. I asked the manager about this and she said they did not have flutes are not small enough. Sorry manager or owner of this place, take a trip to napa, go to the sparkling facilities, they do one ounce pours in flutes. No REAL wine bar has such ignorence combined with audacity.
Readers, take a look at the July 5th Philadelphia Weekly review of Vintage. Yes, PW give the food ""decent"" reviews, but the article describes the same surley attitude in ""some"" of the staff. One staff member was simply rude to me! Clearly, ownership does not care as they had a month to correct the problem. Lastly, they do not take American Express! AVOID, AVOID, AVOID!
06/24/2007Provided by Citysearch -
If you're looking for a great place where you can sit and have a conversation over great food and wine, this is the place. Never have I had a bad visit out of dozens -- except when I get there after the kitchen is closed, but that's my fault. I highly recommend the burger and the chocolate creme for dessert -- pretty much my standard order. As far as wine goes, ask your bartender. They've always been incredibly helpful and extremely knowledgeable, even when I'm a complete pain and ask them, ""what DO I want?"" I've never been let down. They have a great variety and a very descriptive list that even the most inexperienced wine drinker can navigate. Definitely worth a visit, or five.


text:
Pad Thai
Be the first to review
READY IN: 30mins
Recipe by Camden Cook
Origin: The New Canadian Basics Cookbook. I use 1 box of pad Thai noodles, 2 chicken breasts, 1 bag of frozen shrimp and I double the sauce.
See Discussion:
Ingredients Nutrition
- 226.79 g dried rice noodles
- 118.29 ml fish sauce
- 118.29 ml ketchup
- 29.58 ml lime juice
- 9.85 ml sugar
- 9.85 ml Thai red curry paste (or to taste)
- 59.14 ml vegetable oil
- 2 large garlic cloves, minced
- 226.79 g chicken breast, boneless and skinless cut into thin strips
- 226.79 g shrimp, peeled and deveined
- 2 eggs, lightly beaten
- 473.18 ml fresh bean sprouts
- 4 green onions, chopped
- 118.29 ml roasted unsalted peanuts
garnish with
- fresh coriander leaves
- lime wedge
Directions See How It's Made
- Prepare noodles according to package directions.
- Mix together fish sauce, ketchup, lime juice, sugar and chile paste; set aside.
- In wok over medium high heat, heat the oil.
- Add garlic, chicken and shrimp; stir fry until chicken looses its pink colour.
- Push chicken and shrimp aside and pour in egg: let set slightly then stir to scramble.
- Add noodles, bean sprouts, green onions and reserved sauce.
- Stir fry until noodles are softened and everything is mixed together and hot.
- Serve immediately, sprinkled with peanuts and garnished with lime and corriander.


text:
Download Vote 4 Detroit apk 5.0.2 free for Android smartphone
Posted by Votem Corp in Tools | April 7, 2016 | 3 Comments
Apk file size: 11.0 MB
Vote 4 Detroit is a voter information platform that provides election information for Detroit voters.
Features of Vote 4 Detroit include:
● Voter Registration
● Absentee Ballot Request
● One click to input the user's current location via mobile GPS and location-based services, or web IP address
● Locate an upcoming election or previous election(s)
● Find polling location and operating hours
● View map and directions from your current location or residence to polling location
● View election calendars with customizable alerts
● Access information on candidate(s) at local, state, and federal levels
● Information on statewide ballot initiatives and measures
● Contact information for local and state election officials
Security is the most significant attribute of this platform. The server structure has gone through the penetration testing from two well-known U.S. testing laboratories, Wyle Laboratories and SLI Global Solutions. ABVote follows the guidelines of the National Institute of Standards and Technology (NIST), builds up internal security policies, and never stores users' private data.
For more information on ABVote or additional election solutions by Votem Corporation, please contact us at [email protected], or give us a call at (216) 930-4300. Check out our election management products at www.votem.com or www.abvote.com.
Whats new
Vote 4 Detroit just got better! We completely redesigned the app to give users an improved experience. Vote 4 Detroit is now compatible with Apple VoiceOver. Users who are blind or visually impaired have full access to all the app's features and functions.
Votem Corp part of our Tools and have average installs from 100 to 500. Last Update April 7, 2016. Google play rating is 60.0. Current verison is 5.0.2. Actual size 11.0 MB.
Similar applications
3 Comments
Andrea Perkins
Worked for me! I was able to submit my absentee ballot request with ease. Which was my main purpose in downloading app. I'm a fan.
Virginia Walker
CSR Facebook. I don't understand why all the information comes up it for Detroit but then when you posted it comes up as vote for DC
Doesn't work buggy won't load. Make my phone flash like a christmas tree. Unistalling and buying a newspapaer.


text:
Record Courier Mobile News
by: DoApp, Inc • 6
All Android applications categories
by: DoApp, Inc • 6
Whether or not you're a local or visitor to Minden, Gardnerville, and Carson Valley the area in Nevada, it's easier than ever before to take this beautiful area with you wherever you go. Get all the local news and more from RecordCourier.com on your mobile device. Check for breaking news, events, weather, sports and more anytime, anywhere.
- Weather forecasts and current conditions that change automatically based on your location.
- Local news
- National news
- Business news
- Consumer news
- Sports stories
- Entertainment stories
- Movie reviews -
and more..
Tags: the record courier , courier mobile , courier service application screenshots , jqxd , free games courier mobile , courier mobile application , gardnerville record courier breaking news , record courier , couriers mobile phones applications
from 6 reviews
Download Record Courier Mobile News
Free - V18.104.22.168 - 6M
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House GOP releases documents on health care dealsHouse GOP releases documents, emails from White House health care negotiations with industry
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Related Keywords:GOP Health Care Probe, Political parties, Health care industry, Industries, Business, Political organizations, Government and politics, Government-funded health insurance, Government programs
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text: 7 photos $200,000 89.5 acres Chambers, NE 68725 - Holt County Great Hunting Property in Holt County, Nebraska! Multi-species tree covered property supporting excellent habitat for deer, turkey, and prairie chicken located in southern Holt County, Nebraska. The present owner has cleared out many shooting lanes on the property to ensure successful hunts year after year. The new owner of this property will enjoy outstanding hunting opportunities, electricity on the property, and a domestic well. The property is located approximately 10 miles southwest of Chambers, Nebraska. For additional information, please contact Grant Litz, Agent, at (402) 336-3500 or (402) 340-0538. Farmers National Company Farmers National Company


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Dog Veterinary
Ask a Dog Vet and Get Answers to Your Dog Health Questions
Probably not. External scar tissue isn't expected to be problematic; internal scar tissue is a different story! Have you seen Millie scratching at her shoulder/neck area? That would be highly suggestive of a spinal cord disorder called syringomyelia in the CKCS although she's a bit older than most CKCS with this disorder. Syringomyelia is often associated with a Chiari-like malformation which causes problems with the spinal cord as it emerges from the skull.


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* TSX up 92.57 points at 11,517.33
* Gold-mining and energy shares rally
* Market shrugs off disappointing Canadian retail sales (Adds details and comments)
TORONTO, Sept 22 (Reuters) - Toronto's main stock index was up nearly 1 percent at midmorning on Tuesday as higher commodity prices helped to trigger gains across much of the resource-heavy index.
The index's materials sector, up 1.87 percent, did the bulk of the heavy lifting in the early going, boosted by gold miners, which tracked gold prices as they rose to within striking distance of a record high. [GOL/]
Shares of miner Barrick Gold Corp (ABX.TO), the biggest contributor to index's gain, were up 2.3 percent at C$40.20, followed by Goldcorp (G.TO), which rose 2.2 percent to C$44.98.
Energy shares, up 1.2 percent, also helped drive the TSX higher as oil prices rose back above $70 a barrel due to a weaker U.S. dollar. [O/R]
Shares of Suncor Energy (SU.TO) rallied 1.8 percent to C$39.34, while Canadian Natural Resources (CNQ.TO) was up 1.8 percent at C$75.28.
"We had some U.S. dollar weakness this morning pushing oil and gold prices higher so it's just a natural recipe to get people buying the gold stocks and energy names," said Gareth Watson, Canadian equity advisor at ScotiaMcLeod.
"Overall the sentiment was pretty positive and I think you've seen that translate obviously into gains for the TSX."
At 10:00 a.m. (1400 GMT), the S&P/TSX composite index .GSPTSE was up 92.57 points, or 0.81 percent, at 11,517.33.
The TSX shrugged off data that showed Canadian retail sales unexpectedly fell 0.6 percent in July from June after two months of robust gains. [ID:nN22339158]
($1=$1.07 Canadian) (Reporting by Frank Pingue; editing by Peter Galloway)


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Giants, also known as Ettens (Westron, from rhovanian "Eotenas"), Norsar (Q.) or Neryth (Sindarin, sgl. Noroth) were one of the most enigmatic races of Arda.
Giants were known to have lived in Hithaeglir and the Ered Nimrais. The Stone Giants of Ered Nimrais were a fierce and wild tribe, enemy to any strangers who dared to travel through their lands, while the Hill-giants of the southern Misty Mountains were a more peaceful tribe that lived as herdspeople and farmers near the borders of Dunland and had friendly ties to some of the neighbouring mannish tribes.


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Visiting southeast Asia and Asean countries for vacation travel places to go nightlife & retirement and beautiful pictures
Southeast Asia Travel in ASEAN
Bus Travel
Orchid Flowers in southeast Asia
Southeast Asian Rivers
Southeast Asian History
About our website privacy contact
Retirement tips - Southeast Asia ASEAN
Amazing Places to Visit
Southeast Asia Beaches
Nightlife in southeast Asia
Southeast Asian Nightlife Girls
Asian Street Food
Andaman Sea & Islands
Pagoda & Temples in Myanmar Burma
Myanmar Travel
Yangon Airport
Bagan Day Tours
Sale Monastery Day Tour at Bagan
Bagan Art
Bagan Buddhist Temples
Bagan History
Ananda Temple Bagan
Shwezigon Pagoda
Mural Painting
Yangon to Bagan
Yangon Rangoon walk through and what to see
Yangon City Walk
Yangon Flower Market
Yangon Nightlife
Visiting the Shwedagon Pagoda in Yangon
19th street Yangon Street Food
Yangon River
Old Rangoon City History
Anawrahta Road Yangon
Shwedagon Pagoda Photos
Shwedagon Pagoda Yangon
Mandalay in Myanmar Burma
Mandalay to Bagan
Mandalay Palace
Bago Yangon Day Tour
Top 10 Myanmar travel destinations
Shan State in Myanmar - southeast Asia ASEAN
Pin Oo Lwin - southeast Asia ASEAN
Inle Lake - southeast Asia ASEAN
Sittwe Myanmar
Myanmar Mountains
Myanmar Dating - southeast Asia ASEAN
Burma History - southeast Asia ASEAN
Bogyoke Market Yangon
South Myanmar Islands Tours
Alaungdaw Kathapa National Park in Myanmar
Myanmar Holiday Destinations adventure and fun
Monywa Myanmar - southeast Asia travel shopping
Irrawaddy River Cruise
Irrawaddy at Mandalay
Myanmar Beaches
Ngapali Beach in Myanmar - southeast Asia Travel
Kawthaung south Myanmar
Myanmar Gems
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Myanmar Ruby Stones
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Myanmar Jewelry
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Myanmar Ethnic Jewelry
Myanmar Taunggyi Fire Balloon Festival
Myeik Archipelago in south Myanmar
Myanmar Train Travel
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Singapore Attractions Day & Night
Clarke Quay Singapore
Jurong Bird Park in Singapore
Singapore Changi Airport
Singapore Orchid Garden
Bali Indonesia
Bali Nightlife
Ubud Bali
Bali day tours
Kuta Bali
Hindu Temples of Bali
Tropical Flowers
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Thailand Travel & Day Tours
Ayutthaya Day Tour - Southeast Asia Travel Shop
Ayutthaya River Cruise
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Visiting North Thailand - Southeast Asia Travel
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South Thailand Train Travel- southeast Asia travel
Visiting West Thailand - Southeast Asia Travel
Ang Thong Marine National Park
Ao Nang
Bangkok City Day & Night
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Bangkok Photos
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Chao Phraya Bangkok River
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Nana Plaza Nightlife Bangkok
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Soi Cowboy
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Travel in Thailand start in Bangkok
Chanthaburi City Gem Market
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Erawan Waterfall
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Kanchanaburi Tours
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Krabi Thailand Islands - Southeast Asia Travel
Krabi Thailand & things to do
Mae Hong Son Trip
Mae Sot Myawaddy
Bangkok Transit to Pattaya - Southeast Asia Travel
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Pattaya Beaches Jomtien Klang Beach Road
Pattaya Nightlife Girls - Southeast Asia Travel
Pattaya Walking Street
Phang Nga Bay
Phuket Day Tour
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Phuket Beaches
Bangtao Beach
Chalong Bay and Beach
Friendship Beach
Karon Beach
Kamala Beach
Kata Beach
Mai Khao Beach
Nai Harn Beach
Nai Ton Beach
Patong Beach
Panwa Cape Beaches
Rawai Beach
Surin Beach
Phuket Nightlife
Phuket Girls
Phuket Bar Girls
Bangla Road at Patong Phuket
Tiger Bar Patong
Phuket Shopping and Eating
Phuket Old Town
Phuket Town Nightlife
Vegetarian Festival Phuket
Phuket Bus Terminal
Wat Chalong
From Phuket to Chiang Mai
Phi Phi Islands
Railay Beach
Ranong and Isthmus of Kra
Exotic Thai food in Phuket can be cheap
River Kwai Bridge
Similan Islands Thailand
Tak Thailand
Sukhothai and the historical park in northThailand
Thailand Gallery
Three Pagodas Pass history travel guide Thailand
Thailand Girls 4you
Thai Orchid Farm in Phuket
Thailand Road Travel
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Trang Islands beaches & Thailand Trang history
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Danok Nightlife
Cambodia Travel
Travel in Cambodia
Bangkok to Siem Reap
Phnom Penh Travel by Bus
Cambodia motorcycle tours
Cambodia Beaches
Bokor National Park
Phnom Penh and things to do
The Royal Palace in Phnom Penh
Sisowath Quay Phnom Penh
Phnom Penh Nightlife
Phnom Penh Bar Girls
Siem Reap & Angkor things to do
Siem Reap Nightlife
Angkor Wat walk through
Angkor Thom & Bayon Temple
Cambodia Nightlife
Koh Kong at night
Sihanoukville at night
Mindanao Travel
Cagayan de Oro Tour
Iligan City Tigano and Maria Christina Waterfalls
Sulu Sea Tour ASEAN Philippines
Davao at night
Mindanao Roundtrip
Mount Apo Tour Mindanao
Philippine Beaches
Samal Island
Malaysian Beaches
Georgetown Penang day and night
Penang Island Tour
Penang History
Penang Nightlife
Adventure Sports & Outdoor in Asia
Kuala Lumpur
Kuala Lumpur Chinatown
Kuala Lumpur Orchid Garden - southeast Asia
Jade Museum Kuala Lumpur
Malaysia Nightlife
Kuala Lumpur Nightlife
South China Sea
Deep Sea Creatures
South Sea Islands
Golden South Sea Pearls
Myanmar Burmese Living
Buddha Statues
Phitsanulok North Thailand
Doi Mae Salong Thailand
Buddhist Stupa and Shrine
Buddhist Temples
Buddha head sculptures
Thai Tattoo in Phuket
Reisen in Thailand
Reisen in Asien ASEAN
Burma and the British
Thai Girlfriend
Bogyoke Market Puppets Marionettes
Hua Hin on the Beach
Mount Popa
Ko Tarutao
James Bond Island Thailand - Southeast Asia Travel
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Chin State Myanmar
Kyaiktiyo Pagoda
Soi Crocodile
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Ko Samui travel tips & day tours
Bagan Hotels
Patong Phuket
Khmer Culture and Art
All travel accesories
South Sea
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Submit an online adoption application for me!
My name is BamBam. I was saved by N.A.B.S. when I was impounded in a high kill local shelter. I am approx. 4 years old and 50lbs. I am waiting to find my forever family and home. Here I share a pen with my friend Clover. I am very friendly and I walk good with the leash. I love attention, fetch the ball and treats :)
PLEASE, WATCH MY VIDEO nd if you have any question please do not hesitate to contact my foster mom.
I am fostered in the Houston, TX area. My local adoption fee is $150 and includes all my vaccinations, microchip, spay/neuter, and I am heartworm negative and have been maintained on monthly heartworm/flea prevention. I can be adopted out of state and sent to you one of two ways both of which include the above adoption fee. There is a 3-day rescue ground transport for $400. or I can be flown to you arriving same day for approx. $600. The additional cost of air fare also includes my new travel porta-kennel which is mine to keep. N.A.B.S. will be happy to share more detailed cost comparison of ground vs. air if you are interested in adopting me.
Please email email@example.com or call and leave a message or text 281-330-5238.
You can submit our online adoption application here and we will get back with you promptly:
Thank you for considering me or another rescued dog as an addition to your family.
I have been fully vaccinated, micro-chipped, spayed/neutered and on monthly heartworm and flea prevention. I am also crate-trained. I am ready to be adopted into my forever home! Please consider me or another rescued dog as an addition to your family. Submit an online adoption application for me!
If you would like to meet me then please contact firstname.lastname@example.com or 281-330-5238 so you can make an appointment to see me at the Sanctuary.
If you can't adopt me, you can still help me! I am still in need of a sponsor or co-sponsor, which is a person who makes a monthly donation to help NABS with the costs of vetting and feeding me, along with giving me any other care I may need. Would you please be that for me? Please see our Become A Pet Sponsor page.
We need YOU to join our cause to find loving homes for homeless, abandoned animals! Submit our Online Volunteer Application. and help us SAVE LIVES!
Thank you for your interest in a rescued pet and saving a life.
While visiting read our Monthly Newsletters of some exciting Forever Homes and new families. You can also sign up for a weekly newsletter online to keep abreast of our events and adoptions.
We are always looking for volunteers to join our NABS Team...Click FORMS to fill out an applicaiton.
We are ALWAYS IN NEED OF FOSTER HOMES AND DRY DOG FOOD FOR OUR FUR CHILDREN.
Thank You!
Your message has been sent to Noah's Ark Bayou Sanctuary.
You'll receive a copy, too, at to help you keep track of which pets you've inquired about, and which shelters and rescues you've emailed.
NOTE: Some shelters have physical locations you can visit; some of these shelters may only have pets for a limited time, so please do not wait for a reply—just go visit the shelter! Other organizations are rescue groups run by busy volunteers who may take a while to reply. You can find information about the shelter or rescue group caring for this pet, and their adoption procedures, on the pet's details page on Adopt-a-Pet.com.


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What this means is this month is about to start up the crazy! This month is all about trying to squeeze all the fun we can. Truth be told we didn't really get to what we had wanted to do as time schedules didn't make it happen. That only means each week we have to make it happen.
We have tickets for two different adventures so that is already two weeks that have some fun in it. Although we still have plenty more to squeeze in. This month also calls orientation as well as the start of college for my oldest. It's a very new step and beginning for us both. It shall be interesting to see it unfold.
I also will have to plan out our school shopping for the Littles who have a month to go before school starts. It also means last bits of finishing up school work we might have not finished. Plus working on getting back on routine as well since the kids have had no real bedtime or wake up time. I must admit the waking up part I personally am NOT looking forward to at all.
As the kids all head back to work I have my own personal goals. I am working to see HOW I can personally bring in any extra income. THAT is a big one. I have lots to plan ahead and sadly go figure they involve being able to afford them. As I've said and been saying I leave it in God's hands he knows best and that's all I can do is trust that his will be done as I work hard in the middle of it all.
With that being said I'd love if you guys would help me out. Would anyone be interested in a Project Life Mini Class. The cost of the class wouldn't be more then $10
It's will include a short video and hand out. You know how passionate I am about being able to document this way. As I have seen many of my friends and family grow their own family all I want to scream is document your moments. Time flies by so super fast I can not even tell you. (OK that seems all I can keep saying as of late as my see my own children zoom by) if this sounds like something you would be interested just leave me a comment below.
Some other goals I want to complete include doing a workout Challenge as well as more water as I must admit my water intake had gone down even with this crazy hot weather which is NOT a good thing.
I also want to share with you some more recipes that are healthy and low calorie AND kids approve. They have been my go this Summer.
I also am planning some other fun that are still in the works but once I get more details I'll be sharing it.
Now I'm off to work on my long to do list and organizing it to make it easier to get done! What are some things on your list this month?


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- What other names is Iodine known by?
- What is Iodine?
- How does Iodine work?
- Are there safety concerns?
- Are there any interactions with medications?
- Dosing considerations for Iodine.
What other names is Iodine known by?Atomic number 53, Cadexomer Iodine, Diatomic Iodine, I2, Iode, Iode de Cadexomer, Iode Diatomique, Iode Moléculaire, Iode Mono-atomique, Iode de Povidone, Iode de Sodium, Iodide, Iodized Salt, Iodure, Iodure de Potassium, Iodure de Potassium en Solution Saturée, Iodure de Sodium, KI, Lugol's Solution, Molecular Iodine, Monoatomic Iodine, Numéro atomique 53, Periodate de Sodium, Potassium Iodide, Povidone Iodine, Saturated Solution Potassium Iodide, Sel Iodé, Sodium Iodide, Sodium Iodine, Sodium Periodate, Solution de Lugol, SSKI, Yodo.
What is Iodine?Iodine is a chemical element. The body needs iodine but cannot make it. The needed iodine must come from the diet. As a rule, there is very little iodine in food, unless it has been added during processing, which is now the case with salt. Most of the world's iodine is found in the ocean, where it is concentrated by sea life, especially seaweed.
The thyroid gland needs iodine to make hormones. If the thyroid doesn't have enough iodine to do its job, feedback systems in the body cause the thyroid to work harder. This can cause an enlarged thyroid gland (goiter), which becomes evident as a swollen neck.
Other consequences of not having enough iodine (iodine deficiency) are also serious. Iodine deficiency and the resulting low levels of thyroid hormone can cause women to stop ovulating, leading to infertility. Iodine deficiency can also lead to an autoimmune disease of the thyroid and may increase the risk of getting thyroid cancer. Some researchers think that iodine deficiency might also increase the risk of other cancers such as prostate, breast, endometrial, and ovarian cancer.
Iodine deficiency during pregnancy is serious for both the mother and the baby. It can lead to high blood pressure during pregnancy for the mother, and mental retardation for the baby. Iodine plays an important role in development of the central nervous system. In extreme cases, iodine deficiency can lead to cretinism, a disorder that involves severely stunted physical and mental growth.
Iodine deficiency is a common world health problem. The most recognized form of deficiency is goiter. Additionally, across the globe iodine deficiency is thought to be the most common preventable cause of mental retardation. Early in the twentieth century, iodine deficiency was common in the US and Canada, but the addition of iodine to salt has improved public health. The addition of iodine to salt is required in Canada. In the US, iodized salt is not required, but it is widely available. Researchers estimate that iodized salt is used regularly by about half the US population.
Iodine is used to prevent iodine deficiency and its consequences, including goiter. It is also used for treating a skin disease caused by a fungus (cutaneous sporotrichosis); treating fibrocystic breast disease; preventing breast cancer, eye disease, diabetes, and heart disease and stroke; and as an expectorant.
Iodine is also used to for radiation emergencies, to protect the thyroid gland against radioactive iodides. Potassium iodide tablets for use in a radiation emergency are available as FDA-approved products (ThyroShield, Iosat) and on the Internet as food supplements. Potassium iodide should only be used in a radiation emergency, not in advance of an emergency to prevent sickness.
Iodine is applied to the skin to kill germs, prevent soreness inside the mouth (mucositis) caused by chemotherapy, and treat diabetic ulcers.
Iodine is also used for water purification.
Likely Effective for...
- Iodine deficiency. Taking iodine supplements, including iodized salt, is effective for preventing and treating iodine deficiencies.
- Radiation exposure. Taking iodine by mouth is effective for protecting against exposure to radioactive iodides in a radiation emergency.
- Thyroid conditions. Taking iodine by mouth can improve thyroid storm and hyperthyroidism. Also, taking iodized salt in addition to thyroxine after surgery for thyroid disease appears to reduce the size of the thyroid.
- Leg ulcers. Research suggests that applying cadexomer iodine to venous leg ulcers along with compression for 4-6 weeks increases the healing rate. Also, applying povidone-iodine in addition to compression seems help heal leg ulcers and reduce the chance of a future infection.
Possibly Effective for...
- Catheter-related infection. Some evidence suggests that applying povidone-iodine reduces the risk of blood stream infections for people with hemodialysis catheters. However, other research suggests that applying povidone-iodine where a catheter is inserted does not reduce the risk of infection associated with using other types of catheters.
- Conjunctivitis (pinkeye). Research suggests that povidone-iodine solutions are more effective than silver nitrate for decreasing the risk of pinkeye in newborns. However, it is not more effective than the medications erythromycin or chloramphenicol.
- Foot ulcers in diabetes. Applying iodine to foot ulcers might be beneficial for people with foot ulcers related to diabetes.
- Inflammation of the uterus (endometritis). Applying povidone-iodine solution to the vaginal area before a Cesarean delivery reduces the risk of the inflammation of the uterus.
- Painful fibrous breast tissue (fibrocystic breast disease). Research shows that taking iodine, especially molecular iodine, reduces painful fibrous breast tissue.
- Breast pain (mastalgia). Taking iodine tablets daily for 5 months reduces pain and tenderness in women with breast pain related to their menstrual cycle.
- Soreness and swelling inside the mouth. Applying iodine to the skin seems to prevent soreness and swelling inside the mouth caused by chemotherapy.
- Gum infection (periodontitis). Research suggests that rinsing with povidone-iodine during non-surgical treatments for gum infections (periodontitis) can help reduce the depth of infected gum pockets.
- Surgery. Some research suggests that applying povidone-iodine during surgery reduces the risk of infections. However, povidone-iodine seems to be less effective than chlorhexidine at preventing infections at the surgical site.
Insufficient Evidence to Rate Effectiveness for...
- Bleeding.Early research suggests that washing the tooth socket with povidone-iodine stops bleeding in more patients after having a tooth pulled compared to saline.
- Chyle in the urine (chyluria). Early research suggests that using povidine-iodine in people with chyle in the urine undergoing a pelvic instillation sclerotherapy may be as effective as standard care.
- Eye infection (corneal ulceration). Early evidence suggests that administering povidone-iodine in addition to standard antibiotic therapy does not improve vision in people with corneal ulcers.
- Fungal skin condition (Cutaneous sporotrichosis). Potassium iodide is commonly used for cutaneous sporotrichosis. There are reports that taking potassium iodide by mouth alone or with another antifungal treatment is effective for most people with cutaneous sporotrichosis.
- Pneumonia. Early research suggests that rinsing the throat with povidone-iodine decreases the risk of pneumonia in people with severe head trauma who are using a ventilator.
- Wound healing. There is some interest in using iodine agents to promote wound healing. While there is some evidence that applying iodine to wounds is more effective than non-antiseptic dressings in reducing wound size, iodine seems to be less effective than antibiotics.
- Other conditions.
Natural Medicines Comprehensive Database rates effectiveness based on scientific evidence according to the following scale: Effective, Likely Effective, Possibly Effective, Possibly Ineffective, Likely Ineffective, and Insufficient Evidence to Rate (detailed description of each of the ratings).
Next: How does Iodine work?
Report Problems to the Food and Drug Administration
You are encouraged to report negative side effects of prescription drugs to the FDA. Visit the FDA MedWatch website or call 1-800-FDA-1088.
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