text:
College of Professional & Applied Studies
The College of Professional & Applied Studies offers several degree programs through its four diverse academic departments: Business, Criminal Justice, Nursing & Allied Health and Sports Studies.
The college's undergraduate programs are designed to prepare graduates for positions in a variety of career fields as well as to be excellent preparation for graduate study.
Master degree programs in business, criminal justice and nursing are also offered through the College of Professional & Applied Studies.
Bachelor Degree Programs & Majors
- Accounting
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- Criminal Justice
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- Entrepreneurial Management
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- Self-Design
Master Degree Programs
- Business Administration - MBA
- Criminal Justice Administration - MA (online only)
- Healthcare Administration MBA (online only)
- Nursing - MSN (Hybrid/F2F)
Associate Degree Programs
Students pursuing their bachelor's degree at Urbana may also elect to add an academic minor that helps to supplement their educational and career goals. The following minors are currently offered through the College of Professional & Applied Studies:
- Accounting
- Entrepreneurial Management
- Management
- Marketing
Educational Partnership
Urbana University and the Ohio Department of Rehabilitation and Corrections have partnered since 1975 to provide career-oriented, college level programs at the London Correctional Institution. Teaching courses at London is central to Urbana University's mission of offering a liberal arts education emphasizing student learning through individual attention, excellence in instruction, career-oriented programs, and critical reflection on moral and ethical values.
Currently, the University offers a Business undergraduate certificate program at the London Correctional Institution. Please see the University Catalog for additional information about this program.


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subset: commoncrawl


text:
Kyle Lovern
Sports Editor
GOODY, Ky. – Once again the Belfry Pirates rolled to an easy early round playoff victory on Friday night at CAM Stadium. This time they defeated visiting Lawrence County 48-6 on a crisp, cold evening.
Belfry got the opening kickoff and almost like an instant replay of last week, junior tailback Justin Johnson scored the first time he touch the ball. He took the handoff, broke free and raced 62 yards for the score. Keilan Carr booted the extra point and Belfry led 7-0 with 11:41 left in the first quarter.
After the defense got in on some action, Johnson hit pay-dirt again with 2:55 left in the opening quarter. Carr's kick made it 14-0.
Belfry continued to roll in the second quarter. Senior Josh Robinson hit the seam and rushed 40 yards for another Pirate TD. Carr's kick made it 21-0 with 7:55 left in the second quarter.
The Bulldogs threatened to score on their next possession. Blake Prince broke loose on a nice run and got the football down to the Belfry 14-yard line, but he was caught by linebacker Madison Ghormley.
Lawrence County appeared to score a couple of plays later when quarterback A. J. Cyrus threw a touchdown pass to Noah Lambert. However, Cyrus had rolled out and had crossed the line of scrimmage before throwing the ball, so the points were negated on the penalty and Belfry took over on downs.
After quickly moving the pigskin back downfield, Johnson scored his third TD of the night, this time a 12-yard run. Carr's kick made it 28-0 with 3:19 left in the first half.
On the ensuing kickoff, the Bulldogs fumbled the ball and it was recovered by Belfry's Kaleb Edwards on the 32-yard line. However, Belfry failed to get the ball into the end zone.
BHS quarterback Sani Warren completed a couple of nice passes on the drive, but his final attempts in the end zone were just out of reach of the receivers, and Belfry turned the ball over on downs.
However, the Bulldogs were unable to move the ball and Cyrus threw an interception. Belfry's Zack Thacker picked off the pass for the final play of the half and the Pirates took a 28-0 lead into the dressing room at the half.
Warren was 4-of-9 passing for 56 yards in the first half. He also rushed for 50 yards on four carries.
Johnson had 132 yards in the first two quarters on 11 carries with three touchdowns. Robinson had one carry for 37 yards and a TD, while Trinity Carr had seven totes for 37 yards. Austin Hatfield had one try for 14 yards.
Eli Huddle and Tony Messer each caught a pass for eight yards, while Keaton Taylor hauled in a pass for six yards.
Belfry's defense held the Bulldogs to 135 total yards in the first half.
The Pirates kept things going in the third quarter. Trinity Carr hit the end zone from 7-yards out. His brother Keilan missed the extra point kick, but Belfry led 34-0.
Belfry took over on downs once again as the defense came up strong. Robinson then scored his second TD of the night from 11 yards out. Carr's kick made it 41-0.
The next time Lawrence County had the football, they coughed it up. Big James May recovered it and rumbled to the 25-yard line with 1:25 left in the third quarter. By this time the clock continued to run without being stopped and the rest of the half few by quickly.
Belfry got one final score as Keaton Taylor hit pay-dirt on a 4-yard run. Carr's kick was good to make it 48-0.
Lawrence County scored in the closing minutes on the second string defense as Blake Prince got into the end zone to cap a drive. He scored from four yards away. The 2-point conversion pass failed, and the final seconds soon ticked off the game clock.
Belfry had a total of 446 yards tonight, 381 yards by rushing and 65 by passing. Johnson finished with 137 yards to lead Belfry's potent rushing attack.
Ghormley once again led Belfry in tackles with 12.
The victory will put Belfry, 10-2, into the Regional championship game. They will host undefeated Breathitt County next Friday night. Breathitt, now 12-0, beat Pike Central 54-18 on Friday night to advance and take on the Pirates.
Ricky Goble led Lawrence County with 110 yards rushing. The Bulldogs finished the season at 5-7.
Score by quarters:


text:
Drug Compare
Generic: drospirenone
It is used as hormone replacement in menopausal women who still have their uterus
What should I watch for while using this medicine?Visit your health care professional for regular checks on your progress. You should have a complete check- up every 6 months. You will need a regular breast and pelvic exam. You should also discuss the need for regular mammograms with your health care professional, and follow his or her guidelines.
This medicine can make your body retain fluid, making your fingers, hands, or ankles swell. Your blood pressure can go up. Contact your doctor or health care professional if you feel you are retaining fluid.
If you have any reason to think you are pregnant; stop taking this medicine at once and contact your doctor or health care professional.
Tobacco smoking increases the risk of getting a blood clot or having a stroke, especially if you are more than 35 years old. You are strongly advised not to smoke.
If you wear contact lenses and notice visual changes, or if the lenses begin to feel uncomfortable, consult your eye care specialist.
If you are going to have elective surgery, you may need to stop taking this medicine beforehand. Consult your health care professional for advice prior to scheduling the surgery.
What side effects may I notice from receiving this medicine?Side effects that you should report to your doctor or health care professional as soon as possible:
Side effects that usually do not require medical attention (report to your doctor or health care professional if they continue or are bothersome):
Copyright © 2005 - 2015 Healthline Networks, Inc. All rights reserved for Healthline. Healthline is for informational purposes and should not be considered medical advice, diagnosis or treatment recommendations. Terms of Use | Privacy Policy


text:
Hatsugama ("The First Tea of the Year")
Thursday, January 1, 2015: Seatings at 11 am and 1 pm
11 am
1 pm
You are invited to join us in celebrating the arrival of 2015 with a traditional tea gathering. Our eight-tatami-mat tearoom with its winter hearth provides an intimate atmosphere in which to appreciate the formal flow of the preparation of tea, along with conversation and good company. Koicha (matcha— thick green tea) will be served, as well as hanabira mochi, a special New Year's sweet. Instruction in basic tea etiquette will be offered.
Limited to 14 guests per seating. Please plan to wear socks in the tearoom.
Fee: $25
To Register: Please use the Register Online button above for the time you wish to attend, or call the Green Gulch front office at 415.383.3134.
(About Registration, Scholarships and Cancellations)


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|14 posts found
So wait a minute...I just read this article: http://www.mmorpg.com/gamelist.cfm/game/431/feature/6742/Storm-Legion-and-the-Power-of-Choice.html
There's nothing in it about raiding.
Is it possible that Rift has an endgame that is not raiding-centric? I haven't played for a while and I'm interested in Storm Legion. I know there is *a lot to do* at endgame in Rift. I enjoy dungeons, pvp, rifts, etc. I just don't like raiding because I don't like scripted events involving large numbers of people and scheduling hours of my time to a game. I want to play when I feel like it. That's why I don't like raiding, not because I'm averse to grouping.
Can I progress my character and get the best gear without raiding with a max level toon either now or in Storm Legion?
Login or Register to never see this panel
Spotlight Poster
Joined: 9/21/12
Its no more or less raid centric than WoW. Raids are a small amount of the max level content, but thats where your best gear comes from. But if you dont raid that gear is meaningless anyway.
Originally posted by strangiato2112
I understand that you don't need the uberest gear if you don't raid. So that means raiding is the pinnacle of what you can achieve in both Rift and WoW (besides having fun).
So can you get "really good" gear to set you up for raiding by doing things other than raiding? I wouldn't mind raiding sometimes, but like I said, I hate to be in a raiding guild where I need to commit blocks of time like Thursday night from 7 to 11 PM. I just don't want to do that.
Sometimes I do want to do a raid or see what's in there, but I don't want to go the whole organizational lockstep guild thing. Maybe WoW is a better choice (for me) because it offers pug raiding? Does Rift have pug raiding?
EDIT: Nitth, I know you're a TSW guy. Me too. I have a lifetime sub. But TSW instances are the hardest I've been in, so far. I can see the time commitment necessary to work with people to be successful in TSW's pve. I just don't have that kind of time to commt. I play TSW for the story and world (and the *potential* for pvp). I like to run a dungeon once in a while, but looking at LFG now, it looks like it's become very exclusive.
Novice Member
Joined: 3/15/12
Before i quit rift more or less 1-2 months ago now, you could achieve max gear by running dungeon dailies, albeit it's alot slower than raiding, but you still can achieve the gear without ever stepping foot into the raids themselves, I believe it wouldn't have changed and they will probably implement this into SL.
Originally posted by Snooze1989
That's good to know. I'm not in a hurry if I'm having fun with the gameplay.
Apprentice Member
Joined: 9/02/12
I have two level 50s and I've never done raids and I don't do dungeons either, I play mostly on Ember Isle at the moment and run dailies on there as well as defend the source wells etc... and do a few instant adventures to boost my planer attunement. It suits me fine. I don't need to be tied to epic gear grinding to play the way I want to play. Rift is one of the few games, maybe the only game where you can carry on playing usefully in the open game world and aren't stuck in instanced dungeons all the time post-max level.
Hmm maybe LOTRO too.
Apprentice Member
Joined: 9/02/12
Originally posted by 7star
Not all raiding in Rift takes place in dungeons, you can open Raid Rifts with planer lures you can get daily in the two major cities or through crafting. If you shout for a raid group and you have a lure and you aren't part of a guild someone might join you. As for raid PUGs, with the LFG tool which slots you into raids across all servers all groups are PUGs.
Hard Core Member
Joined: 10/02/11
The Critical Hit Pretzel!
Originally posted by Snooze1989
Actually you get a lesser version of the gear, and you don't tend to get weapons or the other trinkets. To be truthful, not really huge on it being set up that way myself (I rather have to work my way through) but it doesn't REALLY give you the best loot. At beast it might be 2nd Best in slot, but typically its below that with better raid drops able to replace it until it gets upgraded.
Rift End game IS raising. I doubt they would ever take it out considering the raiding is its bread and butter of what many people find good about it. Yes, hate me, but the raiding in the game is far better then WoW has been offering lately and I highly doubt they would give up on it.
Hammerknell is my second favorite raid of all times in any MMO ever released, the only thing to ever top that would be Karazhan, not for difficulty but for how sheer amazing the place was and interesting.
Originally posted by Purutzil
I have nothing against raiding, mind you. I just don't have (or want to make) the time commitment raiding in a decent raiding guild requires. I'm glad there is good raiding for people who enjoy (whether in Rift, WoW, or TSW). For me, I just want to play the game because I like the world and the gameplay of whatever class.
To be even better, I would like the option to raid through PUGs, so games that offer that are good for casual gamers like me. I don't need best in slot, but I like nice things ;) I don't mind "working" for them. I like it, in fact. It's just that I want to do it when I have time and the inclination to do it. I don't care how long it takes.
Sounds like Rift and WoW have enough for casual players like me, so it just comes down to which gameplay and world and community I like better. With being in a guild, the general community issues isn't too much of a factor.
Spotlight Poster
Joined: 9/21/12
Originally posted by 7star
Rift's raids are mainly only for the hardcore.
WoW has raids for the hardcore (heroic mode, virtually identical difficulty to Rift's raids), raids for the player willing to put in effort but cant do full dedication (regular modes, Rift's slivers can fall into here perhaps), and raids for the very casual (LFR)
Advanced Member
Joined: 11/10/05
I dont do instanced raids or pvp. I enjoy instant adventures, mentoring dungeons, fending off invaders on ember isle, fishing and cooking, working towards crafting epic gear (which is nuts btw), doing zone events and invasions, or pugging a raid rift.
There is a lot to do in this game once you shake the raid and gear progression mentality. And its only going to get better in the expansion.
Apprentice Member
Joined: 12/19/10
In addition to what prior posters have stated, you can get into raids doing Pugs as they are shouted for quite often. Just do not expect to be at the forefront of progression raiding if you are doing this. Along with the Raid Rifts doing normal rifts and other activities grants you currency that you can use to purchase gear from vendors (think dungon currency but from doing dynamic open world events). From the article you read it seems they are throwing in an additional way of progressing through hunting rifts. There is also the PvP route which most gear can be mix maxed with some PvE gear, but this certainly isn't ideal if you plan on doing organized raiding, though there has been some debate in the community throughout the past year in regards to BiS weapons and raiding.
Hard Core Member
Joined: 4/03/12
You can get raid quality gear without ever setting foot in a raid. and it takes a couple weeks to have entry raid level gear and maybe a couple more weeks to upgrade to the next tier.
People blast Rift for having too many currencies, but it's that difference that allows you to grind the different kinds all at the same time. So it doesn't take that long. But you need to participate in a lot of different activities.
Experts, Zone Events, Instant Adventures, World Event Dailys, PVP, Crafting.
That's how I got my latest toon geared on par with most raiders. and I don't raid.
Originally posted by GeezerGamer
That's good to know.
I just want to be able to access all the content at my pace. I don't need the 1337est gear, so LFR works well for me. I just want to be able to see the raids sometimes. I mostly like just traveling around and doing various things, sometimes grouping, sometimes alone.
I like to have some sense of "making progress" toward something, as long as the journey is fun. I don't have to be first or fastest. I'm even happy getting there after everyone else has already done it. I just like to know content is reachable at various levels of dedication with commensurate rewards.


text:
Herd getting stops, but not scoring
HUNTINGTON -- Marshall University played good enough defense to win Wednesday's game when the Thundering Herd men's basketball team limited Delaware State to 53 points.
But, Marshall only scored 51 and lost.
Marshall slumped to a 7-7 record with a non-conference road game Saturday against the Ohio Bobcats (8-5) before getting into its Conference USA slate Wednesday when Tulsa comes to Cam Henderson Center. Tulsa (8-6) opens its conference schedule Sunday at SMU.
Head coach Tom Herrion was at a loss for words to explain the performance, but came up with a few such as "befuddled" and "inept."
"We're offensively challenged right now," Herrion said before Thursday's practice. "Unfortunately, it's putting so much pressure on our defense. You can't get every (defensive) stop. We're turning the ball over too much. We're not getting any of what we call easy points
"Our defense has gotten progressively better. It doesn't show because our offensive is so inefficient."
Delaware State (6-8) shot only 38.8 percent in its win, but it was better than Marshall at 36.2 percent. The Hornets also made eight of 11 free throws (72.7 percent) while the Herd went 13-for-23 (56.5 percent).
Marshall's season field goal percentage has dipped to 41.9 percent after a stretch of eight games when the team didn't hit 40 percent six times. In the last eight games Marshall has averaged 60.5 points after opening the season at an 82.5 clip for the first six games.
Shooting free throws has been a season-long problem for a Herd team making just 58.7 percent.
The Herd has played without a true point guard all season since freshman Kareem Canty was denied initial eligibility by the NCAA.
All-CUSA junior Dre Kane handled point guard duties for 10 games, but missed the last four because of a right hand injury. Kane is the Herd's leading scorer (15.0), was ranked third in the latest NCAA report with 8.5 assists per game and has one of the best assist-turnover ratios (2.7) in the conference.
Marshall has turned the basketball over nearly 18 times a game in Kane's absence.
"We've got guys trying to make plays they aren't accustomed to making because at times we do not have a true point guard on the floor," Herrion said on his Thursday radio show.
Kane had the cast removed from his shooting hand and was on the court for Thursday's practice. The Herd also welcomed 7-foot-2 Yous Mbao to practice for the first time since Nov. 20 when he suffered a head injury during a drill.
Herrion said during his radio broadcast that both players were able to practice on a limited basis. They haven't been cleared to play and are still listed as day-to-day.
Marshall and Ohio both enter Saturday's matchup at the Convocation Center with three losses in their last four games. Ohio opened the season 6-0.
The teams separated by about 80 miles and the Ohio River are meeting for the 100th time. Ohio won last season in Huntington, 70-68, to take a 53-46 lead in the all-time series.
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text:
Tuesday, July 15, 2014
Berkeley County Council has authorized spending up to $285,000 to settle a federal lawsuit by eight Berkeley County Sheriffs Office deputies claiming unfair compensation for overtime.
The authorization was made during a special meeting of council July 14 after mediations by attorneys led to an agreement.
Blakely v. Berkeley County was filed in May 2013. Deputy James Blakely filed the complaint alleging the county did not reimburse him for overtime work. The complaint allowed other deputies to join. The deputies are K-9 and narcotics officers.
Attorney Marybeth Mullaney represented the plaintiffs.
She said the lawsuit is in regard to the Fair Labor Standards Act (FLSA), which ensures overtime pay and holiday pay is compensated. The complaint alleges Blakely and other Berkeley County law enforcement officers suffered damages as a result of FLSA violations.
The complaint stated that Blakely regularly worked in excess of 171 hours in a 28-day work cycle and was rarely compensated properly for those hours. Blakely has worked for the county since 2001.
My clients are pleased that the county worked with us to resolve this matter and they look forward to continuing to do what they love which is serving the citizens of Berkeley County. It was not an easy thing for them to step forward but they did so with the hope of making positive changes for all similarly situated County employees. I hope that the Sheriffs Office will recognize them as leaders and that they will continue to grow in their careers with the department, Mullaney said in a statement released to the Independent.
During the July 14 meeting, county council agreed to pay up to $285,000 with those funds coming from the fund balance.
The lawsuit will be settled once Judge Patrick Michael Duffy of the S.C. District Court approves the agreement.
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text:
Spectators and players at the Masters could face the challenge of bad weather during the early rounds of the famous golf tournament in Augusta. There is a threat of thunderstorms from late Thursday into Friday morning, according to the National Weather Service in Columbia.
It's possible the storms will be severe with damaging winds and hail.
"A cold front will move through the area, and the latest information we have is that the best chance for thunderstorms will be Thursday night," said Jeff Linton, a National Weather Service meteorologist. "We're looking at models and this is not an exact science, so the front could get in here a little bit earlier."
Thursday's forecast for the Master's first round calls for mostly cloudy skies, a 40 percent chance of rain and winds of 10 to 20 miles an hour from the south. Temperatures will climb into the mid-80s.
The possibility of precipitation will increase to 70 percent Thursday night.
"It is very warm and moist ahead of the cold front, and in the upper part of the atmosphere it's cold; the winds aloft are very strong," Linton said. "When you get thunderstorms in an environment like that, some of those strong winds in the upper part of the atmosphere may mix down to the surface. Tornadoes aren't out of the question, but right now it looks like the main threats are damaging straight-line winds and hail."
Friday's forecast for The Masters' second round is for partly cloudy skies, a 30 percent chance of rain, and winds of 20-25 miles from the southwest to west. Temperatures will reach the lower 80s.
"The cold front may be out of the area by 8 a.m.," Linton said.
An entire round at The Masters hasn't been completely lost to rain since 1983, according to bleacherreport.com.
When there is inclement weather, a weather warning sign that shows clouds and a lightning bolt is displayed on the scoreboards/message boards at Augusta National Golf Club. The club advises spectators to take precautions even before play is suspended. The sounding of an air horn or a similar alert will signal suspension of play.
For The Masters' final two rounds Saturday and Sunday, skies will be partly cloudy. Highs will be in the mid-70s on Saturday and in the low 80s on Sunday. There is a zero chance of precipitation for Saturday and a 20 percent chance on Sunday, according to the Weather Channel.
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text:
In the tradition of DK's best-selling title, I'm Pregnant, comes another must-have DK book on how to raise a contented and confident little one. This book taps into the growing demand for child-centered advice on parenting, offering professional information and age-appropriate strategies to help parents deal with all the big toddler issues, from bedtime routines to temper tantrums to mealtime. Its reassuring and personal tone arms parents with an understanding of how their child develops socially, emotionally, and physically in the first four years without ever being preachy or patronizing.
Dr. Tanya Byron - Author
Book: Paperback | 8.26 x 5.23in | 320 pages | ISBN 9780756633608 | 03 Mar 2008 | Dorling Kindersley | 18 - AND UP


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Netflix app for iPhone updated to include video out
The Netflix app for iPhone received a nice little update last night that includes video out support. Yes, this means you are now able to use your iPhone 4 or iPod touch 4 to send any streaming video content available on Netflix directly to your TV.
While jailbreakers have been able to take advantage of this feature for quite some time now, it's nice to finally have it "officially" supported.
If you've tried it out, let us know how it works for you.
UPDATE: for those asking how to get the video from iPhone to your TV, you need a pair of Apple AV cables or similar for that.
Have something to say about this story? Leave a comment! Need help with something else? Ask in our forums!
Reader comments
Netflix app for iPhone updated to include video out
Has to be iPhone 4 to work properly, not 3GS (I'm assuming)
Tried it and the quality is absolutely 100% GARBAGE! thanks for nothing Netflix.
For those of you confused you need the following: http://store.apple.com/us/product/MB128LL/B?fnode=MTY1NDAzOQ&mco=MTA4NDc...
@Luis I hear ya on that. Those cables work great for other videos just not netflix.
So anyone know a source for reasonably priced 30-pin to AV cables?
eBay has "genuine" apple composite cables for $25 that work great. At least for past year on my jailbroken 3G.
I just got the Apple TV. No need for this. :)
One option for jailbreak users would be to buy a cheap set of cables for 5 bucks or so, and then purchase the Resupported App in Cydia, another buck or two. It works for me. What I couldn't figure out is how to get video out from Netflix on my iphone 3G (jailbroken). I tried the TVOut2 app and the video wasn't full framerate
Why does Apple equip the Apple TV and the mini-Mac with HDMI output but decides to not include in on the iPad or iPhone? Makes no sense to me. The video quality using composite cables will suck and won't support 1080p.
Somebody ask Steve to make it easy for all of us and just include HDMI on ALL devices. The royalty payments for using HDMI is $0.04. I think Steve can afford to pay the $0.04 per device. For the ease of use and convenience, I'll gladly pay an extra $0.04 for my next iPhone and iPad. Get over it Steve.
Why no 3gs love. They can run the same OS. I bet it has something to do with the iPhone 4 having limits on data and 3gs/3g unlimited. AT&T was probably bitching about it to Steve and Steve said I'll take care of it.
By the way, tyrus, I was recently told by apple support that the reason everything seems to be included on apple TV and limited on iPhones/iPods (although they are capable) is to push the apple TV. Probably not what he was trained to say.
Qaulity wad ok over 3G. Will have to Check it out over wifi later.
What I don't understand is why I can get youtube videos from iphone 3 to my TV set by either cable or dock but Netflix videos are restricted to the iphone screen. I get audio but the video doesn't make it past the phone.
I also know that I still have several months to a yr on my iPhone 3 before I can update. My phone does a great job and I don't need to shell out more money for another phone.
My phone is a 3G too by the way


text:
Life Is For Service
You are almost at the end of the wave - things are drying up REAL FAST. The best way to build one "right now" is to get an INCOMPLETE Yugo kit (aka M53 or something like that) which is 8mm. The ones from CFS are NOT COMPLETE. As in INCOMPLETE. As in MISSING RECEIVER SECTIONS. Those run around $350 today.
Once you have the incomplete kit, order the $300 "complete" receiver shell segments from Dan at AA. That runs around $300 today.
Spend some quality time absorbing the MG42 BIY thread and Pirate's tutorial info. Pay special attention to:
- the trigger pack modifications
- the welding jig
- the build order (legal compliance issue - if you weld first you've built a machine gun)
Buy some belts, drums, and consider a belt loader (another $100 alone). Shop around for some 8mm ammo - this gun is supposed to be able to eat anything you feed it.
308 conversion parts are available, and *IF* you can find it, 308 barrels. If. BIG IF right now!
You really should get the barrel(s) ASAP. As in call him tomorrow, and put it on the card! No joke, they are drying up fast. I think $150 per barrel is what they are going for now if they can be found.
I phoned Dan the other day and he said he has tons of receiver shells, so no problems there. The pisser is the fact that barrels are going away VERY VERY quickly. I stocked up on .308 barrels when the barrel ban struck, and now it seems that some 8mm stuff is all that's left.
Me, personally, I think 8mm is a better value because the ammo is so darned cheap! Caliber conversion between 8mm and 308 is a matter of a few parts, and these "special" parts will run around $150 total. SO the cost of a barrel plus $150 puts you into a 2-caliber system!
- Jerry
Last edited by hcpookie; 01-31-2006 at 02:30 PM.
Gunco Member #10
The "original" Boltcutter Rivet Squeezers:
Project Pink - the Pink and Blue AK-74:
gtbehary - that's a NICE looking build, BTW! The weld seams look very smooth. That's my big worry. I know you can be off but I'm really interested in getting it right "the first time".
Gunco Member #10
The "original" Boltcutter Rivet Squeezers:
Project Pink - the Pink and Blue AK-74:
Moonshiner, if you think you want one the time to get a kit is now. If you change your mind you can sell the kit at a profit in the future. The 42 is an awesome gun and you won't be sorry you got it!!
Yes, I think I will purchase one of the Yugoslavian jobbers. Any negative things I need to know about 'em ?
Also, Pirate56, I can't help but go "Yaaaar !" everytime I see your screen-name. It reminds me of the Pirates from Final Fantasy 1, darned if I know why.
Я люблю работать с очень большими молотками
Yuh nah waste out yuh chance fi paint di town red,
Cause when yuh buss it up, a fi mek Babylon fled
And uh respect rasta livety yuh nah dis no dread
I can't get the MG42.net link to work, can't even find it doing a Google?????????
it is mg42.us
moonshiner, you will need a receiver with the yugo kits, you can get a kit with a rebuildable receiver or just a receiver from Dan at angola armory
OOPS. Link corrected.Originally Posted by pirate56
Gunco Member #10
The "original" Boltcutter Rivet Squeezers:
Project Pink - the Pink and Blue AK-74:
I have a M53 on the way. I'm looking for options, I missed the boat on the %80 group buy. I checked the cut receivers at Angola, the only ones I saw were WWII dated for $300. Is there a cheaper option anywhere for a rebuildable receiver? For another $200 wouldn't it be better to just buy one of their .308 kits and have some extra parts and the ability to convert calibers? Any rumors of %80 receivers in the pipe? I'm trying no to spend more than I have to in the near term because I have so very many irons in the fire right now... Any info or advice is appreciated.
Basically your only option is to get a receiver from angola. If you spend the extra $$ and get a kit you will have a set of parts for a 2 caliber gun. It is my understanding that brp will not be making receivers anytime soon and when they do make them again they will be a lot more expensive.Originally Posted by G.man10mm


text:
how to: create paint-bombed wallpaper
DYI self-adhesive wallpaper
wall paint
acrylic faux glaze liquid
bowl of water
containers for paint mixtures
drop cloth
rubber gloves
rubber bands
1. Measure and cut sections of wallpaper that will fit the wall that you want to cover.
hint: be sure to mark which section goes where so the pattern flows accordingly.
2. To avoid paint drippings in the pattern, clear a large area of the floor or set up a long table and cover either with a drop cloth to best contain the liquids—then lay flat a section of wallpaper, DIY side up.
hint: the artwork we created is per panel so if a matching pattern is desired, use painters tape on the backside and join panels to create a mural effect.
3. We chose a look that required round/ball-shaped sponges. If this type isn't readily available, or if another shape is desired, one can be made with a few scissor snips and rubber bands. For our project, we cut off about a third of the end of the sponge and formed the large part of the sponge into a ball by folding corners back and under, securing it with a rubber band so it stayed in a ball shape. Cut the remainder in half to use as secondary tools.
hint: a damp sponge is easier to shape than a dry one—just dip, squeeze, and then form it.
hint hint: if the sponge is large enough, simply use scissors to cut a ball, or other shape out of it.
4. Pour about a 1/2 cup of each paint color into separate containers. Ultimately the consistency of the paint mixture should be similar to milk so add about 1/4 cup of faux glaze liquid and a little water
hint: the glaze is optional but we found it was helpful to thin the color without making it too watery.
hint hint: disposable plates worked well as containers for the paint since they allowed the sponges to easily absorb the paint mixture and clean up took no time.
5. Immerse the sponge ball in water and give it a couple squeezes to make sure it's saturated. Dip the end of the sponge into the paint mixture and with a little force, pounce the sponge against the wallpaper to achieve the paint-bombed/splatter effect.
hint: test the technique on scrap paper to know how much force is needed.
6. Cover the wallpaper with a desired pattern and layering colors as desired, then use a clean sponge to pick up any excess paint mixture.
7. Allow the painted wallpaper to dry for a full 48 hours—initially the paint may be fragile and easy to scratch off, this will allow it to cure fully and be more stable.
hint: set up a fan on low to help air circulate and speed the drying process.
8. Lastly, apply the self-adhesive wallpaper per the enclosed directions.
hint: to avoid cracking the paint, bend the paper as little as possible when peeling/adhering.


text:
EAST BEND - A veteran Forbush squad dispatched of the youthful Lady Rams in six innings, cruising to a dominating 15-0 victory in East Bend.
Surry Community College signee Shey Steelman kept Starmount off balanced in the circle, allowing just three hits, while punching out nine to pick up the win.
Freshman Olivia Greene pitched three solid innings for the Lady Rams, only allowing three runs until Forbush exploded in the fourth. The Falcons crossed the plate 12 times in the frame to mercy rule their cross-county rivals.
Starmount put two runners on in the top of the fourth against Steelman as Rachel Wagoner and Madeline Nixon recorded two of the teams' three hits on the night. But Alli St. John's drive to deep left was caught on the warning track before Steelman got out of the jam with one of her nine Ks.
The Rams return to the field Thursday night looking to bounce back against Alleghany at home.
Reach Matthew Gorry at 835-1513 or email@example.com.


text:
A gastrointestinal implant device is anchored in the duodenum and extends beyond the ligament of Treitz. All food exiting the stomach is funneled through the device. The gastrointestinal device includes an anchor for attaching the device to the duodenum and an unsupported flexible sleeve. The anchor can include a stent and/or a wave anchor and is collapsible for catheter-based delivery and removal.
1. A method of treatment comprising the steps of:
with an anchor in the duodenum, anchoring a proximal portion of an unsupported flexible sleeve, open at both ends, the anchor being covered by a proximal portion of the sleeve; and
extending the unsupported flexible sleeve distally into the duodenum.
2. The method of treatment of
3. The method of treatment of
4. The method of treatment of
5. The method of treatment of
6. The method of treatment of
7. The method of treatment of
8. The method of treatment of
9. The method of treatment of
10. The method of treatment of
11. The method of treatment of
12. The method of treatment of
13. The method of treatment of
14. A method of treatment comprising the steps of:
with an anchor in the duodenum, anchoring a proximal portion of an unsupported flexible sleeve, open at both ends; and
extending the unsupported flexible sleeve distally into the duodenum,
wherein the sleeve is coated with silicone.
15. A method of treatment comprising the steps of:
with an anchor in the duodenum, anchoring a proximal portion of an unsupported flexible sleeve, open at both ends; and
extending the unsupported flexible sleeve distally into the duodenum,
wherein the sleeve is coated with polyurethane.
16. The method of treatment of
17. A method of treatment comprising the steps of:
with an anchor in the duodenum, anchoring a proximal portion of an unsupported flexible sleeve, open at both ends; and
extending the unsupported flexible sleeve distally into the duodenum,
wherein the distal end of the sleeve is directionally textured.
18. The method of treatment of
anchoring the proximal portion of the sleeve to the duodenum with barbs extending from the exterior surface of the anchor.
19. The method of treatment of
20. The method of treatment of
21. The method of treatment of
22. The method of treatment of
23. The method of treatment of
24. A method of treating Type-2 diabetes comprising:
with an anchor in the duodenum of a diabetic patient, anchoring a proximal portion of an unsupported flexible sleeve, open at both ends, the anchor being collapsible and including barbs coupled to the anchor, the barbs extending from the exterior surface of the sleeve for anchoring the proximal portion of the sleeve to the duodenum; and
extending the unsupported flexible sleeve into the duodenum to have a therapeutic effect on diabetes.
25. The method of
26. The method of treatment of
27. The method of treatment of
28. The method of treatment of
29. The method of treatment of
30. The method of treatment of
31. The method of
32. The method of
33. The method of
34. The method of
35. A method of treating Type-2 diabetes comprising:
with an anchor in the duodenum of a diabetic patient, anchoring a proximal portion of an unsupported flexible sleeve, open at both ends; and
extending the unsupported flexible sleeve into the duodenum to have a therapeutic effect on diabetes,
wherein the sleeve is coated with polyurethane.
36. The method of
37. The method of
38. The method of
39. The method of
40. A method of treating Type -2 diabetes comprising:
with an anchor in the duodenum of a diabetic patient, anchoring a proximal portion of an unsupported flexible sleeve, open at both ends;
extending the unsupported flexible sleeve into the duodenum to have a therapeutic effect on diabetes; and
removing the unsupported flexible sleeve with a removal device.
41. The method of
at least a portion of the sleeve being impregnated with an active compound.
42. The method of
43. The method of
44. The method of
45. The method of treatment of
46. The method of treatment of
47. The method of treatment of
48. The method of treatment of
49. The method of treatment of
50. The method of
51. The method of
52. The method of
This application is a divisional of U.S. application Ser. No. 10/858,851, filed Jun. 1, 2004 now U.S. Pat. No. 7,476,256, which claims the benefit of U.S. Provisional Application No. 60/528,084, filed Dec. 9, 2003 and U.S. Provisional Application No. 60/544,527, filed Feb. 13, 2004. The entire teachings of the above application are incorporated herein by reference.
According to the Center for Disease Control (CDC), over sixty percent of the United States population is overweight, and almost twenty percent are obese. This translates into 38.8 million adults in the United States with a Body Mass Index (BMI) of 30 or above. The BMI is defined as a person's weight (in kilograms) divided by height (in meters), squared. To be considered clinically, morbidly obese, one must meet one of three criteria: BMI over 35, 100 lbs. overweight or 100% above ideal body weight. There is also a category for the super-obese for those weighing over 350 lbs.
Obesity is an overwhelming health problem. Because of the enormous strain associated with carrying this excess weight, organs are affected, as are the nervous and circulatory systems. In 2000, the National Institute of Diabetes, Digestive and Kidney Diseases (NIDDK) estimated that there were 280,000 deaths directly related to obesity. The NIDDK further estimated that the direct cost of healthcare in the US associated with obesity is $51 billion. In addition, Americans spend $33 billion per year on weight loss products. In spite of this economic cost and consumer commitment, the prevalence of obesity continues to rise at alarming rates. From 1991 to 2000, obesity in the US grew by 61%. Not exclusively a US problem, worldwide obesity ranges are also increasing dramatically.
One of the principle costs to the healthcare system stems from the co-morbidities associated with obesity. Type-2 diabetes has climbed to 7.3% of the population. Of those persons with Type-2 diabetes, almost half are clinically obese, and two thirds are approaching obese. Other co-morbidities include hypertension, coronary artery disease, hypercholesteremia, sleep apnea and pulmonary hypertension.
Although the physiology and psychology of obesity are complex, the medical consensus is that the cause is quite simple—an over intake of calories combined with a reduction in energy expenditures seen in modem society. While the treatment seems quite intuitive, the institution of a cure is a complex issue that has so far vexed the best efforts of medical science. Dieting is not an adequate long-term solution for most people. Once an individual has slipped past the BMI of 30, significant changes in lifestyle are the only solution.
There have been many attempts in the past to surgically modify patients' anatomies to attack the consumption problem by reducing the desire to eat. Stomach saplings, or gastroplasties, to reduce the volumetric size of the stomach, therein achieving faster satiety, were performed in the 1980's and early 1990's. Although able to achieve early weight loss, sustained reduction was not obtained. The reasons are not all known, but are believed related to several factors. One of which is that the stomach stretches over time increasing volume while psychological drivers motivate patients to find creative approaches to literally eat around the smaller pouch.
There are currently two surgical procedures that successfully produce long-term weight loss; the Roux-en-Y gastric bypass and the biliopancreatic diversion with duodenal switch (BPD). Both procedures reduce the size of the stomach plus shorten the effective-length of intestine available for nutrient absorption. Reduction of the stomach size reduces stomach capacity and the ability of the patient to take in food. Bypassing the duodenum makes it more difficult to digest fats, high sugar and carbohydrate rich foods. One objective of the surgery is to provide feedback to the patient by producing a dumping syndrome if they do eat these food products. Dumping occurs when carbohydrates directly enter the jejunum without being first conditioned in the duodenum. The result is that a large quantity of fluid is discharged into the food from the intestinal lining. The total effect makes the patient feel light-headed and results in severe diarrhea. For reasons that have not been determined the procedure also has an immediate therapeutic effect on diabetes.
Although the physiology seems simple, the exact mechanism of action in these procedures is not understood. Current theory is that negative feedback is provided from both regurgitation into the esophagus and dumping when large volumes of the wrong foods are eaten. Eventually, patients learn that to avoid both these issues they must be compliant with the dietary restrictions imposed by their modified anatomy. In the BPD procedure, large lengths of jejunum are bypassed resulting in malabsorption and therefore, reduced caloric uptake. In fact, the stomach is not reduced in size as much in the BPD procedure so that the patient is able to consume sufficient quantities of food to compensate for the reduced absorption. This procedure is reserved for the most morbidly obese as there are several serious side effects of prolonged malabsorption.
Unfortunately, these procedures carry a heavy toll. The morbidity rate for surgical procedures is alarmingly high with 11% requiring surgical intervention for correction. Early small bowel obstruction occurs at a rate of between 2-6% in these surgeries and mortality rates are reported to be approximately 0.5-1.5%. While surgery seems to be an effective answer, the current invasive procedures are not acceptable with these complication rates. Laparoscopic techniques applied to these surgeries provide fewer surgical complications but continue to expose these very ill patients to high operative risk in addition to requiring an enormous level of skill by the surgeon. Devices to reduce absorption in the small intestines have been proposed (See U.S. Pat. No. 5,820,584 (Crabb), U.S. Pat. No. 5,306,300 (Berry) and U.S. Pat. No. 4,315,509 (Smit)). However, these devices have not been successfully implemented.
The present invention provides a method and apparatus for the application of a barrier sleeve in the digestive tract to limit absorption of food products in specific parts of the digestive tract and to provide negative feedback to patients with morbid obesity enabling them to modify their heating habits. The sleeve may also be used for other treatments such as Type-2 diabetes.
A gastrointestinal implant device includes an unsupported flexible sleeve and an anchor coupled to a proximal portion of the sleeve. The flexible sleeve is open at both ends, and adapted to extend into the duodenum to limit absorption of nutrients in the duodenum. The anchor is adapted to be retained within the duodenum, particularly in the duodenal bulb just distal to the pylorus.
The anchor may be collapsible for ease of insertion and/or removal in a minimally. For example, the anchor may be inserted and/or removed endoluminally using a catheter-based procedure. The collapsible anchor is also well adapted for insertion into the duodenum, being capable of collapsing and/or flexing in response to natural movements of the local anatomy. The anchor can be covered by a proximal portion of the sleeve, and in some embodiments is sandwiched between a first inner layer and a second outer layer of the sleeve. The sleeve is of a length that chyme exiting the stomach funneled through the proximal end of the sleeve exits the sleeve through the distal end. The length of the sleeve can be varied. In some embodiments, the sleeve extends below the ligament of Treitz. In preferred embodiments, the sleeve material has a coefficient of friction of less than about 0.2. The sleeve may be formed of a biocompatible, low-friction material such as a fluoropolymer. In some embodiments, the sleeve is formed from PolyTetraFluoroEthylene (PTFE), expanded PTFE (ePTFE), or polyolefin (e.g., as a low density polyethylene film). Additionally, the sleeve may be coated or impregnated with a second material, such as polyurethane or silicone to reduce permeability. Still further, the distal end of the sleeve may be directionally textured.
The anchor can be attached to the surrounding anatomy using mechanical fasteners, such as sutures, surgical staples. In some embodiments, the mechanical fasteners can be dissolvable, dissolving after a predetermined time and allowing the device to pass naturally. In other embodiments, the anchor is attached to the surrounding anatomy using an interference fit provided by the relative size of the anchor in relation to the surrounding anatomy. Alternatively or in addition, the anchor can be attached to the surrounding anatomy using chemical fasteners, such as surgical adhesives.
Mechanical fasteners include barbs that extend from the exterior surface of the anchor for anchoring the proximal portion of the sleeve to the muscular tissue of the surrounding anatomy. The barbs may be bi-directional for anchoring the proximal portion of the flexible sleeve to the duodenum. Alternative anchors coupled to a proximal portion of the sleeve include a ring, a stent formed by a network of struts, or a wire formed as a wave.
An anti-buckling device may also be coupled to the sleeve and extend from below the anchor to the distal end of the flexible sleeve to reduce twisting and buckling of the sleeve. The sleeve allows enzymes secreted in the duodenum to pass through the duodenum outside the sleeve.
The gastrointestinal implant device can be inserted endoluminally in combination with a delivery catheter and can be similarly removed in combination with a removal device. More generally, the device can be implanted through a natural body lumen, such as per-orally and/or per-anally. Alternatively or in addition, the device can be implanted percutaneously. In one embodiment, the delivery apparatus includes a catheter for passage through the intestines and a spherically-shaped element coupled to the distal end of the catheter. In some embodiments, the spherically-shaped element can be remotely releasable.
In another aspect, a gastrointestinal implant device includes an unsupported flexible sleeve and a wave anchor coupled to a proximal portion of the sleeve. The wave anchor includes a compliant, radial spring shaped into an annular wave pattern about a central axis, providing an outward radial force, while allowing substantial flexure about its perimeter. Such flexure is advantageous as it allows for minimally-invasive delivery and ensures that the device will substantially conform to the surrounding anatomical structure when implanted. The annular wave element can be formed from one or more elongated resilient members and defines a lumen along its central axis formed between two open ends. When implanted, the central axis of the anchor is substantially aligned with the central axis of the duodenum, allowing chyme to pass through the device. Additionally, the compliant wave anchor minimizes trauma to the tissue by providing sufficient flexibility and compliance, while minimizing the likelihood of tissue erosion and providing a solid anchoring point to the tissue.
The anchor can be removably attached within the body using any of the methods described herein for securing an anchor, including the use of barbs attached to, and/or formed on the anchor itself. When implanted, the anchor enables a sleeve, or barrier to be securely implanted within the duodenum, preferably providing a fluid seal at the proximal end. To enhance a fluid seal, the proximal end of the sleeve can be contoured along a leading edge of the wave anchor. In this manner, substantially no unsupported sleeve remains proximal to the wave anchor. Thus, chyme is allowed to flow substantially unimpeded into the sleeve without becoming entrapped at the anchor.
The gastrointestinal implant device can be used in a method for treating intestinal bowel disease. An unsupported flexible sleeve is anchored within the duodenum. The sleeve is open at both ends and may be impregnated with a drug that reduces inflammation.
The gastrointestinal implant device can be used as a method for treating obesity. An unsupported flexible sleeve is anchored within the duodenum. The sleeve is open at both ends and enhanced with anti-hunger hormones.
The gastrointestinal implant device can be used as a method for treating Type-2 diabetes. A proximal portion of an unsupported flexible sleeve, open at both ends, is coupled to a collapsible anchor. The anchor includes barbs for insertion into tissue as the anchor expands to anchor the proximal portion of the sleeve in the duodenum. The flexible sleeve is extended at least into the duodenum to limit the digestion and/or absorption of nutrients.
The foregoing and other objects, features and advantages of the invention will be apparent from the following more particular description of preferred embodiments of the invention, as illustrated in the accompanying drawings in which like reference characters refer to the same parts throughout the different views. The drawings are not necessarily to scale, emphasis instead being placed upon illustrating the principles of the invention.
A description of preferred embodiments of the invention follows.
The duodenum 104 has four sections: superior, descending, transverse and ascending which typically form a U-shape. The superior section is about two inches long and ends at the neck of the gall bladder. The superior section also defines a feature referred to as the duodenal bulb 119 that begins just distal to the pylorus 108 and extends for about 1 to 1.5 inches in an adult human. The duodenal bulb 119 defines a lumen therein that is slightly larger than the distal duodenum 104. Advantageously, the duodenal bulb 119 exhibits less motion than the pylorus 108 and even distal portions of the duodenum 104. Notably, the motion is substantially limited to contractions without having a significant linear component (i.e., no movement along the central axis of the intestine). However, the tissue thins as one moves away from the pylorus 108.
The descending section of the duodenum 104 is about three to four inches long and includes a nipple shaped structure (papilla of Vater) 114 through which pancreatic juice from the pancreas and bile produced by the liver and stored by the gall bladder enter the duodenum from the pancreatic and bile ducts. The pancreatic juice contains enzymes essential to protein digestion and bile dissolves the products of fat digestion. The ascending section is about two inches long and forms the duodenal-jejunal flexure 116 where it joins the jejunum 106, the next section of the small intestine. The duodenal-jejunal flexure 116 is fixed to the ligament of Treitz 118 (musculus supensionus duodeni). The juices secreted in the duodenum break the partially digested food down into particles small enough to be absorbed by the body. The digestive system is described in Gray's Anatomy ("Anatomy of the Human Body," by Henry Gray) and "Human Physiology," Vander, 3rd ed, McGraw Hill, 1980, the contents of which are incorporated herein by reference in their entirety.
Within the implant device 200 at the proximal end including the first proximal opening 204 is a collapsible self-expanding anchor 208. The anchor 208 includes a plurality of opposed barbs 210 for anchoring the implant device 200 to the muscular tissue of the duodenum 104. The diameter of the anchor 208 is dependent on the diameter of the duodenum 104 (
Anchoring in the bulbous duodenum 119 offers several advantages over other areas in of gastrointestinal tract. First, the duodenal bulb 119 is proportionally sized to capture an anchor—that is it provides a cavity having a relatively large diameter bounded by anatomies having smaller diameters in both the proximal and distal directions. Thus, the duodenal bulb 119 is naturally configured to retain a suitably-shaped anchor.
Additionally, the duodenal bulb 119 is relatively less active than the either the pylorus or distal portions of the duodenum. The duodenal bulb 119 at least in part acts as a holding area for chyme received from the stomach. Thus, the duodenal bulb 119 provides a more stable anchoring platform as there is less movement there. Movement of the surrounding tissue can act to dislodge an anchor over time. Still further, as the tissue of at least the proximal portion of the duodenal bulb 119 is thicker than the tissue of the distal duodenum. Thus, the duodenal bulb 119 provides a better anchoring platform as it is adapted to regain longer fasteners (e.g., longer barbs).
The sleeve material is thin and conformable so that it collapses in the intestine to a small volume to minimize bowel irritability. It has a low coefficient of friction (less than about 0.20) so that chyme slides easily through it and the bowel slides easily around it. It is of low permeability to fluids so that the chyme does not touch the bowel wall and the digestive enzymes do not significantly breakdown the chyme. It is biologically inert and non-irritating to the tissues. One class of materials includes fluoropolymers. In some embodiments, the sleeve is formed from expanded PTFE with a wall thickness of about 0.006 inches and an internodal distance of 20 microns. This material is hydrophobic but is slightly porous. However, these very small pores may plug over time. The porosity may be reduced by coating the material on the inside, outside or in the pores with dilute solutions of silicone or polyurethane. Another material is polyethylene with a wall thickness of less than 0.001 inches. Other materials include Cast PolyTetraFluoroEthylene (PTFE, e.g., TEFLON), Cast PTFE with Fluorinated Ethylene Propylene (FEP) or PerFluoroAlkoxy (PFA) coating to minimize pin holes, Extruded FEP and Extruded PFA. These materials are solid and substantially non-porous in contrast to ePTFE which is porous, but these materials are also considered to be fluoropolymers. The wall thickness is preferably less than about 0.001 inches. Rubber-like materials typically have friction coefficients of about 1-4, significantly stickier than these materials. However, in alternate embodiments other materials having similar characteristics can be used.
In some embodiments, the sleeve is formed using a combination of two or more materials. For example, the sleeve can be formed using a combination of ePTFE and FEP. Such a combination can be formed by layering the two materials together and generally provides a low coefficient of friction while being substantially non-permeable.
The sleeve 202 includes two layers of material at least at the proximal end. A first outer layer covers the exterior of the anchor 208. The second inner layer covers the interior surface of the anchor 208. The barbs 210 protrude from the exterior surface of the anchor 208 through the first outer layer of the sleeve 202. The holes in the first outer layer through which the barbs 210 protrude can be filled with an impervious material such as silicone or urethane to limit mixing of digestive juices with the chyme flowing through the passageway. The diameter of the sleeve 202 is selected such that the first outer layer of the sleeve 202 fits over the anchor 208.
The sleeve length 212 is variable and can range from about one foot to about five feet. The typical length of the sleeve 202 is about 2 to 4 feet measured from the anchor (barbs 210) in the bulbous duodenum 119 to below the ligament of Treitz 118 (
The covered anchor 208 can be collapsed into a sheath having a diameter less than about 12 mm or less to enable endoluminal and/or catheter-based delivery. Covering the exterior surface of the anchor 208 with the first outer layer of the sleeve 202 permits catheter-based removal of the implant device 200 by preventing tissue in-growth on the exterior surface of the anchor 208.
Additionally, markings can be added to the exterior surface of the sleeve 202 to detect the position and orientation of the sleeve on a fluoroscopic image and whether the sleeve is twisted. For example, a radiopaque stripe can be painted down the length of the device 200 using tantulum impregnated ink, or tantulum bands can be bonded to a surface of the device, such as the interior surface. If the sleeve 202 is twisted, the sleeve 202 can be untwisted by inserting a balloon into the proximal end of the device thereby sealing it, and then injecting water into the sleeve 202 at low pressure. More generally, a radiopaque marking can also be used to facilitate placement and/or removal of the device.
The sleeve 202 can extend over the ligament of Treitz 118 beyond the proximal jejunum 106. Extending the sleeve 202 below the ligament of Treitz 118 reduces the likelihood that the sleeve 202 will move back through the duodenum 104 toward the stomach 102.
After the gastrointestinal implant device 200 has been placed in the body and anchored in the duodenum 104, chyme leaving the stomach passes through passageway 304 (
The sleeve 202 provides weight loss mechanisms by providing negative feedback, reduced fat digestion and reduced desire for food. The reduced fat digestion occurs because the sleeve 202 delays the mixing of bile and pancreatic juices with chyme from the stomach until after the chyme leaves the sleeve 202. The reduced desire for food may occur because the sleeve 202 blocks hormonal release from the duodenum 104. Additionally, providing poorly digested food to distal portions of the intestine, such as to the ileum, can trigger hormones that reduce appetite.
The sleeve 202 is non-compliant and drapes away from the intestinal walls thereby permitting the pancreatic juice to flow unimpeded into the duodenum 104 through the papilla of Vater 114. The normal peristalsis of the bowel is used to propel the chyme, bile, and pancreatic juices through the intestines.
In the embodiment shown, the anchor has a length L of about 1.5 inches and has a diameter D of about 1.5 inches. The struts 602 are flat, about 0.010 inches wide and about 0.004 to 0.010 inches thick. The anchor can be formed from a tube of material by laser cutting followed by expansion and heat setting, or other methods well known to those skilled in the art.
In an alternate embodiment, the struts 602 can be formed separately and the strut intersections can be welded or attached by other means well known to those skilled in the art. Visually the struts form sections 604 around the circumference of the anchor. Each section has a series of triangles with each triangle defined by one distal strut connection 606 and two proximal strut connections 608, 610. The ratio of the collapsed diameter to the expanded diameter of the anchor is roughly 1:4.
When expanded, the angle α between divergent strut sections is about 45-50 degrees and the diameter of the anchor is about 1.5 inches. When compressed, the angle β between divergent strut sections is about 5-6 degrees to reduce the diameter of the anchor to about 0.5 inches for catheter-based delivery and removal. The elasticity of the struts permits this compression. When the radial compression is released, the elasticity of the struts causes the anchor to expand to diameter D. The anchor assumes its desired diameter as the elastic restoring forces seek their minimum stress.
In some embodiments, the ends of the struts at the proximal end of the anchor 600 can be elongated and shaped to provide barbs 612 to anchor to the muscular tissue of the duodenum 104.
The gastrointestinal implant device 200 is designed for catheter-based placement (e.g., endoluminal).
The catheter system 1200 includes an outer sheath 1202 for storing the anchor 208 in collapsed form, a flange 1216 to pull back the outer sheath 1202 and a sleeve retention wire mechanism 1224 for releasing a sleeve retention wire 1210 from the proximal end of the flexible sleeve 202 after the anchor has been released from the outer sheath 1202.
As described in conjunction with
The sleeve 202 is secured temporarily outside the inner sheath 1226 allowing for proper positioning of the gastrointestinal implant device and then for release. As shown, the sleeve 202 is secured by the sleeve retention wire 1210 using a dead-bolt mechanism 1206. Non-stick coatings such as Teflon on the sleeve retention wire 1210 are preferred to make release easier to accommodate tortuous anatomical pathways. The sleeve retention wire 1210 extends through the second inner lumen from the release mechanism 1224 of the catheter system 1200 to the dead-bolt mechanism 1206. The dead-bolt mechanism 1206 is described later in conjunction with
As described in conjunction with
Once in place, the sleeve retention wire 1210 can be removed. As described previously in conjunction with
In another embodiment, the anchor 208 can be configured with a drawstring. The drawstring can be selectively woven around the perimeter of the anchor 208 through openings of opportunity in the anchor 208. The openings can be defined by adjacent interconnected struts of the anchor 208. Alternatively, or in addition the drawstring can be selectively woven through dedicated openings, such as eyelets provided on the anchor 208. In some embodiments, the drawstring is woven through openings at the proximal end of the anchor 208. In operation, the drawstring can be pulled in a proximal direction by a retrieval device. The drawstring, when pulled, contracts about the perimeter of the anchor 208, thereby reducing the diameter of the anchor 208. Thus, the drawstring can be used to facilitate removal of an implanted anchor 208 by pulling it away from the surrounding anatomy thereby extracting any barbs from the surrounding muscular tissue.
The gastrointestinal implant device offers a new alternative where other means of weight loss and efforts at behavior modification have failed. Because the gastrointestinal implant device is introduced through a small diameter catheter (e.g., endoluminally), there is a reduced risk at insertion compared to surgery. The procedure is also completely reversible, making this approach the ideal solution for patients who are desperate to reverse behavioral patterns that have lead to weight gain.
When inserted in the body, the gastrointestinal implant device mimics the duodenal bypass of the Roux-en-Y procedure. The implanted device reduces caloric absorption by delaying enzyme mixing with food and provides the feedback produced by the Roux-en-Y procedure by producing dumping syndrome when high sugar meals are ingested. The implant device is an improvement on the Roux-en-Y procedure because it is minimally invasive and reversible. In the treatment of the super-obese where aggressive weight loss is not achieved, the length of the implant device below the anchor can be further increased to drive the patient close to the point of malabsorption.
Placement of the gastrointestinal implant device effectively provides that ingested food does not digest in a normal manner and the gut hormones that are normally triggered are modified. These hormones result in several physiology changes that impact hunger and digestion. Gut hormones include peptide YY (PYY), cholecystokinin (CCK) and ghrelin.
As under digested food enters the ileum or distal part of the small intestine 112, a hormone called peptide YY or PYY is released. This hormone has been shown to have a direct effect on appetite, reducing it when released. Undigested food in the ileum indicates that too much food has been ingested. Thus, dependent on the length of the sleeve, the gastrointestinal device can promote deposition of undigested or partially digested food to the distal bowel. Therefore, the placement of a sleeve in the intestine promotes the delivery of undigested food to the ileum, which in turn promotes the release of PYY and reduces appetite in humans.
The hormone cholecystokinin (CCK) is released when food contacts the duodenum 104. CCK triggers the release of bile from the gallbladder. Therefore, placing a sleeve in the duodenum 104 reduces the release of CCK and thus reduces bile output resulting in reduction in the digestion of food.
Some ghrelin is released when food contacts the duodenum 104. Ghrelin has been shown to be a factor in the control of appetite. This device will reduce ghrelin output and thereby reduce appetite due to the bypass of the duodenum 104.
Type-2 diabetes is a disease of obesity that occurs when patients cannot adequately use the insulin they produce. Usually, it is not that the patient cannot make enough insulin, but rather that the patient's body cannot effectively use the insulin produced. A particularly dangerous result of Type-2 diabetes is that blood sugar spikes after a meal. This is called post-prandial hyperglycemia. This spike in blood glucose causes cardiovascular and microvascular damage. One class of drugs used to control post-prandial hyperglycemia is the alpha-glucosidase inhibitors. These work by reducing the breakdown and absorption of carbohydrates to sugars. The sleeve has a similar function because it reduces bile and delays the breakdown and absorption of the carbohydrates, which are normally readily absorbed in the duodenum, but are less likely to be absorbed in the jejunum and ileum. Therefore, type 2 diabetes can be controlled by placing a sleeve in the proximal intestine to delay the digestion of carbohydrates which reduces post-prandial hyperglycemia.
The gastrointestinal implant device can be used to reduce Type-2 diabetes symptoms by bypassing the duodenum 104. Following gastric bypass surgery, patients commonly experience complete reversal of Type-2 diabetes. While the exact mechanism of this remarkable effect is not understood, the clinical result is reported in a high percentage of cases. Reversal of Type-2 diabetes after gastric bypass is described in "Potential of Surgery for Curing Type-2 Diabetes Mellitus" by Rubino et al. incorporated herein by reference in its entirety. Since the gastrointestinal implant device provides equivalent blockage of duodenal processes, a similar effect is elicited but without the trauma of surgery. In patients who are not obese but suffer Type-2 diabetes, a modified gastrointestinal implant device is inserted. This gastrointestinal implant device provides the necessary effect to hinder pancreatic processes and receptors without blocking absorption.
In the embodiment of the gastrointestinal implant device for treating diabetes, placement of the anchor within the stomach and/or duodenum allows the pylorus 108 to operate normally. The length of the sleeve may be reduced to mimic the duodenum bypass. The sleeve extends to just below the ligament of Treitz 118 but may not extend further into the jejunum 106, thus allowing absorption to occur in the jejunum 106.
The gastrointestinal implant device can be placed temporarily in the duodenum 104 to allow tissues to heal. For example, the sleeve can be placed temporarily to promote healing of ulcers in the duodenum 104. Ulcers are lesions that form in tissues of the duodenum 104. If they bleed, they are typically cauterized with electrosurgery. For ulcers to heal, they must be protected from the acidic environment. Placement of a sleeve for a short time period, for example, for one to two weeks, promotes healing of ulcers in the duodenum 104 by eliminating the acidic environment and allows the tissues to heal.
Intestinal anastomoses are performed to remove sections of diseased bowel. The stapled or sewn connection is prone to leakage until it heals. The placement of the gastrointestinal implant device temporarily in the bowel can be used to promote healing of small bowel anastomoses by protecting the area from chyme and minimizing leaks.
The gastrointestinal implant device can be used to deliver drugs, hormones and other active agents directly to the intestine. To deliver the agents, the sleeve and/or anchor is either coated or impregnated with the agents. The agents can include anti-inflammatory agents to reduce irritation due to placement of the anchor within the body. The agents can optionally or in addition include anti-hunger hormones.
The two most common intestinal bowel diseases are Crohn's disease and Ulcerative Colitus. Crohn's disease may occur in any part of the digestive tract. Although the exact cause of the disease is unknown, it appears to be an abnormal immune response in the patient, which leads to chronic inflammation of the intestinal lining.
Crohn's disease is treated with drugs intended to reduce inflammation. These include aminosalicylates, corticosteroids, immune modifiers such as azathioprine and methotrexate and antibiotics including ampicillin and cipro. These drugs have negative effects when given systemically. Since the drug is really only needed locally, smaller amounts of drug can be used if delivered directly to the tissues. Thus, an implanted sleeve treated with such a drug advantageously treats the surrounding tissues.
The intestinal sleeve can be coated with polymers that are impregnated with these drugs. Coatings may include polyurethanes, silicones and hydrophilic polymers such as those available from Hydromer of Somerville, N.J. These coatings may be applied to the sleeve material by dipping or spraying techniques. If a porous sleeve material such as ePTFE is used, the drug-filled polymer may be driven into the pores using pressure applied to the sleeve, such as internal pressure inside the sleeve. This increases the amount of drug that is available.
The sleeve material can also be a polymer that permits the incorporation of the drug directly into the wall. Such polymers include Ethylene Vinyl Acetate (EVA) and polyurethane. A greater amount of the drug may be incorporated in this case compared to a coating since there is more material in the wall than simply in coatings, thereby providing longer release times. The drug is compounded into the polymer and then extruded as is normally done to form the tubing or sheet from which the sleeve is made.
The sleeve is deployed transesophageally into the duodenum 104 and proximal jejunum 106. When the sleeve comes in contact with the tissues, the drugs in the coating are released directly into the tissues. Also, the sleeve may act to block the contact of the food to the mucosa, thereby reducing irritation caused by the chyme. Once the drug has fully eluted from the material, the sleeve is removed and a new one is placed.
The control of appetite in the human is a complex function of hormonal interactions. Several hormones have been implicated in its control including Ghrelin, Peptide YY, Leptin, Glucagon-Like Peptide-1 (GLP-1), Cholecystokinin (CCK), insulin and others. These hormones are either released or suppressed by the presence of food in the duodenum. For example, PYY acts as an anti-hunger hormone as injections of PYY have been shown to decrease food intake in both rats and humans and decreases in leptin have been shown to stimulate hunger.
Sleeves that are located in the duodenum 104 where many of these hormones are released may be impregnated with these hormones. When implanted, the hormones elute from the sleeve into the surrounding tissue where they activate the various satiety mechanisms.
The compliant wave anchor 2810 can be manufactured from a resilient metal such as a heat-treated spring steel, stainless steel, or from an alloy such as NiTi alloy commonly referred to as Nitinol. Other alloys include nickel-cobalt-chromium-molybdenum alloys possessing a unique combination of ultrahigh tensile strength, such as MP35N. Additionally, the wave anchor 2810 can be formed from a polymer and/or a composite having similar properties. The wave anchor 2810 can be manufactured from a single strand, such as a wire, contoured into the desired shape. Alternatively, the wave anchor 2810 can be manufactured from multi-strands of the same or different materials similarly contoured to the desired shape. In some embodiments, the wave anchor 2810 can be cut into the wave shape from tubular stock of the desired material, such as Nitinol.
The anchor 2810 can be removably attached within the body using any of the methods described herein for securing a anchor 208, including the use of barbs attached to, and/or formed on the anchor itself. When implanted, the anchor 2810 enables a sleeve 202, or barrier to be securely implanted within the duodenum 104, preferably providing a fluid seal at the proximal end. To enhance a fluid seal, the proximal end of the sleeve can be contoured to the wave anchor as shown in
The catheter system 4250 includes an outer sheath 4222 for storing the collapsible anchor portion of the gastrointestinal implant device in collapsed form. Collapsible anchoring devices have already been described in conjunction with
A first lumen 4202 is used to pass a guide wire or mandrel 4226 through the catheter shaft to increase the rigidity of the catheter shaft during introduction of the catheter into the intestines. The first lumen 4202 is also used to inject fluid to lift the sleeve material 202 away from the inner shaft 4200 after the gastrointestinal device has been delivered to the intestine. A second lumen 4204 is used to pass a sleeve retention wire 4208 to the distal end of the gastrointestinal implant device. The sleeve retention wire is used to hold the distal end of the sleeve 202 to the outside of the inner shaft 4200. A third lumen 4206 is used to inject fluid at the tip of the catheter to lift the distal end of the sleeve 202 off the inner shaft 4200 prior to removal of the catheter system 4250 from the body.
Returning to
Proximal fitting 4220 is connected to the second lumen and proximal fitting 4212 is connected to the third lumen 4206. During delivery of the gastrointestinal implant device, the first lumen 4202 is filled with a 0.035 inch Teflon coated guide wire 4226 that provides column strength for the appropriate amount of pushability without compromising the flexibility of the catheter inner shaft 4200. A 0.015 inch diameter Teflon-coated steel wire is placed in the second lumen 4204 to serve as the distal sleeve retention wire. The second lumen 4204 has 2 skive holes 4214, 4216 near the distal end of the catheter shaft 4200. The distal sleeve retention wire 4208 exits the second lumen 4204 through a proximal skive hole 4214 feeds through the sleeve material 202, which is wrapped tightly around the distal outer diameter of the catheter shaft, and re-enters the second lumen 4204 through a distal skive hole 4216. This creates a dead bolt style lock holding the sleeve 202 to the shaft 4200 until ready to be released similar to the dead bolt style lock described in conjunction with the two lumen catheter shaft shown in
The distal end of the shaft terminates with a spherical shaped element 4218 that is either solid, or inflatable to form an atraumatic tip. In the embodiment shown, the spherical shaped element is a solid ball, similar to the ball described in conjunction with
The collapsed anchor assembly is located in outer sheath 4222. The ball 4218 at the end of the catheter is released to withdraw the catheter. The release mechanism pulls the sleeve retention wire to release the ball end and release the end of the sleeve. The anchor assembly is then released from the outer sheath as previously described The catheter can be used any time access to the intestinal tract is desired. For example, the catheter can be used to pass an endoscope into the intestine. This catheter device can be used to rapidly run the intestines, place a guide wire and then use the placed guide wire as a track for an endoscope.
The small bowel is accessed endoluminally by passing a semi-rigid tube into the stomach and into the pylorus 108 and proximal duodenum, inflating the bowel with a fluid, preferably water, and then passing a thin, flexible catheter with a large, atraumatic ball tip through the bowel.
A guide tube 4300 is placed over the end of a gastroscope 4302. The guide tube/gastroscope assembly is then placed through the patient's mouth, down the esophagus and into the stomach 102. The assembly is then passed into the pylorus 108 and the duodenum 104.
The guide tube 4300 has an inner diameter of approximately 0.63 inch (16 mm) and an outer diameter of approximately 0.70 inch (18 mm). It is approximately 30 inches (76.2 cm) in length and is made of a flexible polymer such as urethane with a flat wire wrap to provide kink resistance and pushability. The distal end of the guide tube 4300 can have a short, flexible end to minimize trauma to the pylorus 108.
Once in place, fluid is introduced through the channel of the gastroscope 4300 to inflate the intestine distally. Saline or water are preferred but air or carbon dioxide (CO2) can also be used. About 500-1000 cc of fluid is introduced for delivery of a 4 foot length of sleeve. Shorter sleeves require less fluid because the length of intestine to distend is less. Likewise, longer sleeves require more fluid. After the fluid is introduced, the gastroscope is removed from the guide tube.
If desired, the gastroscope 4203 can be removed from the guide tube 4300 and a balloon catheter can be introduced to deliver the fluid. The balloon catheter is delivered to the pylorus and inflated to roughly 0.394-0.591 inches(10-15 mm) to seal the intestine. A balloon catheter has already been described in conjunction with
The guide tube 4300 is then removed and the gastroscope re-introduced into the stomach and through the pylorus 108 to view the duodenum. The proximal anchor is then deployed by pulling back on the delivery tube 4222, which is connected to the proximal end of the catheter. After the anchor is deployed, the catheter system 4250 is withdrawn from the patient. The catheter 4302 has no edges that could catch on the sleeve 202 as it is pulled back through the pylorus 108 and the stomach 102 and the esophagus because the ball is left behind. This zero profile catheter design is important since it is typically very difficult to withdraw devices from the gastro-intestinal tract while leaving catheters or other devices behind.
A method for accessing the small bowel by passing a catheter through the mouth has been described in conjunction with
The ends of a wire, or thread 4600 are attached to the ball 4218 and the thread 4600 is looped through sleeve retention wire 4208 to hold the ball 4218 at the distal end of the inner shaft 4200 of the catheter. The ball 4218 is released by pulling back on sleeve retention wire 4208 with fitting 4200 (
The ball 4218 includes two holes 4800, 4802 extending from the recess 4706 to the exterior surface of the ball 4218. The distal end of the sleeve retention wire 4208 passes through hole 166 and is looped back into hole 167. As the sleeve retention wire 4208 is pulled proximally, the wire 4218 is pulled back through hole 4802 and then through hold 4800 and the ball 4218 is released from the distal end of the catheter.
A low profile balloon can be used instead of the ball 4218 at the distal end of the catheter.
Referring to
The further one tries to pass a device into the intestine, the more difficult it is since friction and tortuosity increase.
The delivery system is not limited to the delivery of a distal section of the sleeve for this embodiment of the gastrointestinal implant device. As described in conjunction with
The gastrointestinal implant device is delivered as previously described into the proximal intestines. Once deployed in the intestines, peristalsis from the natural activity of the intestine pulls the pill 5100 distally through the intestine. As the pill is pulled distally, the distal section of the sleeve 202 pulls out of the pill and deploys straight in the intestine. Peristalsis pulls the pill through the remainder of the intestines and the pill finally exits the body.
A one-foot length of sleeve material can be packed into a pill with length of 1 inch (25.4 mm) and diameter of 0.47 inch (12 mm). Therefore, if one only wishes to pass the catheter 2 feet into the intestine for delivery of the gastrointestinal device, the pill 5100 enables a 3 foot sleeve to be delivered with the additional 1 foot distal section of the 3-foot sleeve delivered in the pill 5100.
The delivery mechanism is shown for delivery of the gastrointestinal implant device described in conjunction with
A number of biodegradable materials may be used for the coatings on the pills including polyethylene glycols (PEG), polylactic acids (PLA) and polycaprolactones (PCL). These materials are made in formable resins or in liquids that can be converted to solids through various types of chemical and photochemical reactions. These materials break down into chemicals that are safe to internal tissues. These resins are made biodegradable by formulating a base molecule with a hydrolytically unstable link within the base chain.
For example, PEG is made biodegradable by incorporating lactic acid into the base chain. One end of the lactide molecule forms a link that will break down rapidly in the presence of water. One means of controlling the rate of degradation is by varying the number of lactide elements within the base chain. The greater the number, the faster the chain will break down. Additionally, the percent solids or density of the resulting solid is varied to alter degradation rates. Denser materials take longer to break down. Also, hydrolytically unstable bonds break down faster in elevated pH environments. Such an environment occurs naturally within the small intestines, on the outside of the sleeve where bile and bicarbonates are deposited.
An advantage of the wave design is the ability to form an anchor having a very flat compliance curve over a very long range of diameters. In general, referring now to
While this invention has been particularly shown and described with references to preferred embodiments thereof, it will be understood by those skilled in the art that various changes in form and details may be made therein without departing from the scope of the invention encompassed by the appended claims.
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