text:
|Publication number
|Publication type
|Application number
|Publication date
|Oct 23, 2001
|Filing date
|Dec 19, 1996
|Priority date
|Dec 19, 1996
|Fee status
|Also published as
|Publication number
|Joseph A. Orr, Scott A. Kofoed, Dwayne Westenskow, Michael B. Jaffe
|Original Assignee
|Novametrix Medical Systems Inc.
|Export Citation
|BiBTeX, EndNote, RefMan
|Patent Citations (6), Non-Patent Citations (15), Referenced by (54), Classifications (23), Legal Events (8)
|External Links: USPTO, USPTO Assignment, Espacenet
1. Field of the Invention
This invention relates to non-invasive means of determining cardiac output in patients, and specifically relates to partial re-breathing systems and methods for determining cardiac output in patients.
2. Statement of the Art
It is important in many medical procedures to determine or monitor the cardiac output of a patient. Techniques are known and used in the art which employ the use of catheters inserted at certain arterial points (e.g., femoral artery, jugular vein, etc.) to monitor blood temperature and pressure in order to determine cardiac output of the patient. Although such techniques can produce a reasonably accurate result, the invasive nature of the procedure has high potential for morbidity and mortality consequences.
Adolph Fick's measurement of cardiac output, first proposed in 1870, has served as the standard by which all other means of determining cardiac output have been evaluated since that date. Fick's well-known equation, written for CO2, is:
where Q is cardiac output, VCO
are the arterial and venous CO2 concentrations, respectively. Notably, the Fick Equation presumes an invasive method (i.e., catheterization) of calculating cardiac output because the arterial and mixed venous blood must be sampled in order to determine arterial and venous CO2 concentrations.
It has previously been shown, however, that non-invasive means may be used for determining cardiac output while still using principles embodied in the Fick Equation. That is, expired CO2 ("pCO2") levels can be monitored to estimate arterial CO2 concentrations and a varied form of the Fick Equation can be applied to evaluate observed changes in pCO2 to estimate cardiac output. One use of the Fick Equation to determine cardiac output in non-invasive procedures requires the comparison of a "standard" ventilation event to a sudden change in ventilation which causes a change in expired CO2 values and a change in excreted volume of CO2. The commonly practiced means of providing a sudden change in effective ventilation is to cause the ventilated patient to re-breath a specified amount of previously exhaled air. This technique has commonly been called "re-breathing."
Prior methods of re-breathing have used the partial pressure of end-tidal CO2 to approximate arterial CO2 while the lungs act as a tonometer to measure venous CO2. That method of re-breathing has not proven to be a satisfactory means of measuring cardiac output because the patient is required to breath directly into and from a closed volume in order to produce the necessary effect. However, it is usually impossible for sedated or unconscious patients to actively participate in inhaling and exhaling into a bag. The work of some researchers demonstrated that the Fick Equation could be further modified to eliminate the need to directly calculate venous PCO
Known partial re-breathing methods are advantageous over invasive measuring techniques because they 1) are non-invasive, 2) use the accepted Fick principle of calculation, 3) are easily automated, 4) require no patient cooperation and 5) allow cardiac output to be calculated from commonly monitored clinical signals. However, known partial re-breathing methods have significant disadvantages as well. Specifically, known methods 1) are less accurate with non-intubated or spontaneously breathing patients, 2) only allow intermittent measurements (usually about every four minutes), 3) result in an observed slight, but generally clinically insignificant, increase in arterial CO2 levels and 4) do not permit measurement of shunted blood flow (that is, blood which does not participate in gas exchange). Further, known apparatus used for partial re-breathing techniques are of standard construction and do not compensate for differences in patient size or capacities. In addition, many devices employ expensive elements such as three-way valves, which render the devices too expensive to be used as disposable units.
Thus, it would be advantageous to provide a means of measuring cardiac output using partial re-breathing techniques which 1) overcome the disadvantages of prior systems, 2) provide better and more continuous measurement, and 3) require less expensive equipment, thereby making the device suitable for manufacturing as a single-use, or disposable, product. It would also be advantageous to provide partial re-breathing apparatus which is instantaneously adjustable to compensate for various sizes and capacities of patients. Further, it would be advantageous to provide new methods of estimating cardiac output based on alveolar CO2 output rather than end-tidal CO2 as is currently used in the art.
In accordance with the present invention, apparatus and methods for measuring cardiac output using a modified Fick Equation are provided where the amount of deadspace which is provided in the apparatus can be adjusted to increase or decrease the volume of exhalate to be re-breathed by the patient, thereby decreasing ventilation without changing airway pressure. The apparatus and methods of the present invention also provide an adjustability factor which enables the apparatus to be adjusted to suit any size or capacity of patient. The apparatus of the present invention also employs significantly less expensive elements of constriction thereby rendering the device disposable.
The apparatus and methods of the present invention apply a modified Fick Equation to calculate changes in pCO2 flow and concentration to evaluate cardiac output. The traditional Fick Equation, written for CO2 is:
where Q is cardiac output (when calculated using re-breathing techniques referred to as pulmonary capillary blood flow or "PCBF"), VCO
are the arterial and venous CO2 concentrations, respectively. It has been shown in prior work of others that cardiac output can be estimated from calculating the change in pCO2, as estimated by end-tidal C2 ("etCO2"), as a result of a sudden change in ventilation. That can be done by applying a differential form of the Fick Equation as follows:
where Ca is arterial CO2 concentration, Cv is venous CO2 concentration, and the subscripts 1 and 2 reference measured values before a change in ventilation and measured values during a change in ventilation, respectively. The differential form of the Fick Equation can, therefore, be rewritten as:
where ΔVCO
is the change in arterial CO2 concentration in response to the change in ventilation, ΔetCO2 is the change in end-tidal CO2 concentration and s is the slope of the CO2 dissociation curve. The foregoing differential equation assumes that there is no appreciable change in venous CO2 concentration during the re-breathing episode, as demonstrated by Capek, et al., in their previous work. Also, a dissociation curve, well-known in the art, is used for determining CO2 concentration based on partial pressure measurements.
In previous partial re-breathing methods, a deadspace, usually comprising an additional 50-250 ml capacity of air passage, was provided in the ventilation circuit to decrease the effective alveolar ventilation. In the present invention, a ventilation apparatus is provided with an adjustable deadspace to provide the necessary change in ventilation for determining accurate changes in CO2 production and end-tidal CO2 commensurate with the requirements of differently sized patients. In one embodiment of the ventilation apparatus, selectively adjustable deadspace is provided through which the patient exhales and inhales. Thus, the adjustable deadspace of the apparatus permits easy adjustment of the deadspace to accommodate any size or capacity of patient, from a small to a large adult. As a result, the patient is provided with a volume of re-breathable gas commensurate with the patient's size which decreases effective ventilation without changing the airway pressure. Because airway and intra-thoracic pressure are not affected by the re-breathing method of the present invention, cardiac output is not significantly affected by re-breathing. In an alternative method, the deadspace may be effectively lessened by selectively leaking exhaled gas from the ventilation system to atmosphere or to a closed receptacle means during inspiration.
The ventilation apparatus of the present invention includes a tubular portion which is placed in contact with the patient, and an inhalation conduit and exhalation conduit. In a common configuration, the inhalation conduit and exhalation conduit may be interconnected between a ventilator unit and the patient. Alternatively, however, a ventilator unit (i.e., a source of deliverable gas mechanically operated to assist the patient in breathing) need not be used with the ventilation apparatus and inhaled and exhaled breath is merely taken from or vented to atmosphere. Other conventional equipment commonly used with ventilator units or used in ventilation of a patient may be used with the inventive ventilation apparatus, such as a breathing mask.
An electrical pneurnotachometer for measuring flow of gas and a capnograph for measuring CO2 concentrations are provided in proximity to the tubular portion between the inhalation and exhalation portions of the ventilation apparatus and the patient's lungs. The pneumotachometer and capnograph serve as detection apparatus for detecting changes in gas concentrations and flow and are in electrical communication with a computer having software designed to store and evaluate the measurements taken by the detection apparatus in real time. Other forms of detection apparatus may be used. Adjustable deadspace means are provided in connection with the exhalation portion of the ventilation apparatus, and may interconnect with the inhalation portion of the ventilation apparatus. In one embodiment, the adjustable deadspace means may be manually adjusted. Alternatively, electromechanical means may be interconnected between the computer and the adjustable deadspace means to provide automatic adjustment of the deadspace volume responsive to the size or capacity of the patient and responsive to changes in ventilation.
In an alternative embodiment, a tracheal gas insufflation apparatus is used to provide the change in ventilation necessary to calculate pulmonary CO2 changes using the differential Fick Equation. Tracheal gas insufflation ("TGI") apparatus is commonly used to flush the deadspace of the alveolar spaces of the lungs and to replace the deadspace with fresh gas infused through insufflation means. That is, fresh gas is introduced to the central airway to improve alveolar ventilation and/or to minimize ventilatory pressure requirements. TGI apparatus is interconnected to a ventilator system and includes a means of introducing fresh gas into the breathing tube as it enters the patient's lungs. The TGI apparatus may be used in the methods of the present invention to determine baseline measurements of VCO2 and etCO2 during TGI. When the TGI system is turned off, a deadspace is formed by the patient's trachea and the endo-tracheal tube of the TGI apparatus which allows measurement of a change in CO2 to be evaluated in accordance with the invention. Further, the catheter of the TGI apparatus may be variably positioned within the trachea of the patient to further adjust the deadspace volume.
The deadspace provided in the apparatus of the present invention causes a rapid drop in VCO2 which thereafter increases slightly and slowly as the functional residual lung gas capacity equilibrates with the increase in alveolar CO2 level. The change in etCO2 rises more slowly after the addition of deadspace, depending on alveolar deadspace and cardiac output, but then stabilizes to a new level. A "standard," or baseline, breathing episode is conducted for a selected period of time immediately preceding the introduction of a deadspace (i.e., re-breathing) and VCO2 and etCO2 values are determined based on measurements made during the "standard" breathing event. Those values are substituted as the values
in the differential Fick Equation. VCO2 and etCO2 values are also determined from measurements taken approximately thirty seconds following the introduction of a deadspace during partial rebreathing to provide the second values (subscript 2 values) in the differential Fick Equation. The period of time during which partial re-breathing occurs and during which normal breathing occurs may be determined by the individual size and lung capacity of the patient. Additionally, the period of time between a re-breathing episode and a subsequent normal breathing episode may vary between patients depending on a particular patient's size and breath capacity. Thus, a thirty second time period for a breathing episode is only an average time and may be greater or lesser.
Cardiac output is determined, in the present invention, by estimating alveolar CO2 concentration rather than basing output on end-tidal CO2 concentration, as is practiced in the prior art. Partial pressure values that are obtained from CO2 measurements are converted to a value for gas content in the blood using the dissociation equation known in the art. Thus, a more accurate cardiac output can be determined. In addition, the accuracy of cardiac output is increased by correcting VCO2 values to account for flow of CO2 into the functional residual capacity of the lungs, defined as the volume of gas left in the lungs at the end of an expired breath. The determination of values based on experiential data is processed by the software program to determine cardiac output.
The ventilation apparatus of the present invention employs inexpensive yet accurate monitoring systems as compared to the systems currently used in the art. The methods of the invention allow automatic adjustability of the apparatus for accommodating patients of different sizes and provides consistent monitoring with modest recovery time. Further, the present apparatus and methods can be used equally with non-responsive, intubated patients as well as non-intubated, responsive patients.
In the drawings, which illustrate what is currently considered to be the best mode for carrying out the invention:
FIG. 1 is a schematic representation of conventional ventilation systems used for assisting patient breathing;
FIG. 2 is a schematic representation of prior art re-breathing systems;
FIG. 3 is a schematic first embodiment of the ventilation apparatus of the present invention illustrating an adjustably expandable deadspace;
FIG. 4 is a schematic representation of an alternative embodiment of the present invention where the re-breathing circuit is constructed with a leak valve;
FIGS. 5(A)-(C) are a schematic representation of another alternative embodiment of the present invention where the inhalation portion and exhalation portion of the ventilation circuit are interconnected and have a two-way closeable valve;
FIG. 6 is a schematic representation of an alternative embodiment similar to the embodiment shown in FIG. 5, but where the inhalation and exhalation portions are adjustably expandable;
FIG. 7 is a schematic representation of another embodiment of the invention where a series of valves is provided along the length of the inhalation and exhalation portions to provide a selectable volume of deadspace dependent upon the size and/or capacity of the patient;
FIGS. 8(A) and (B) are schematic representations of another embodiment of the invention where a leak valve is provided, both with a vent to atmosphere and to a parallel compliance chamber;
FIG. 9 is a schematic representation of a tracheal gas insufflation apparatus of the present invention which can be used to provide a necessary change in ventilation with a deadspace;
FIG. 10 is a schematic representation of human lungs illustrating the concepts of parallel deadspace, alveolar deadspace and serial deadspace in the lungs of a patient;
FIG. 11 is a flow diagram briefly describing the calculations made in the software program to calculate cardiac output from the measured values of normal breathing and partial re-breathing; and
FIG. 12 is a schematic representation of an alternative embodiment of the invention shown in FIG. 7 which includes variably expandable inhalation and exhalation portions.
For comparative purposes, FIG. 1 schematically illustrates a conventional ventilation system which is typically used with patients who require assisted breathing during an illness, a surgical procedure or recovery from a surgical procedure. The conventional ventilator system 10 includes a tubular portion 12 which is inserted into the trachea by intubation procedures. The distal end 14 of the tubular portion 12 is fitted with a Y-piece 16 which interconnects an inspiratory hose 18 and an expiratory hose 20. Both the inspiratory hose 18 and expiratory hose 20 are connected to a ventilator machine (not shown) which delivers air to the inspiratory hose 18. A one-way valve 22 is positioned on the inspiratory hose 18 to prevent exhaled gas from entering the inspiratory hose 18 beyond the valve 22. A similar one-way valve 24 on the expiratory hose 20 limits movement of inspiratory gas into the expiratory hose 20. Exhaled air flows passively into the expiratory hose 20.
In known re-breathing ventilation circuits 30, as shown in FIG. 2, the tubular portion 32 is inserted into the trachea of the patient by intubation procedures, and gas is provided to the patient from a ventilator machine (not shown) via an inspiratory hose 34 which is interconnected by a Y-piece 36 to an expiratory hose 38. An additional length of hose 40 is provided between the tubular portion 32 and the Y-piece 36 which acts as a deadspace for receiving exhaled gas. A three-way valve 42 generally positioned between the Y-piece 36 and the opening to the additional length of hose 40 is constructed for intermittent actuation to selectively direct the flow of gas. That is, at one setting, the valve 42 allows inspiratory gas to enter the tubular portion 32 while preventing movement of the gas into the additional length of hose 40. In a second setting, the valve 42 allow exhaled gas to enter into the expiratory hose 38 while preventing movement of gas into the additional length of hose 40. In a third setting, the three-way valve 42 directs exhaled air to enter into the additional length of hose 40 and causes the patient to re-breath the exhaled air on the following breath to thereby cause a change in effective ventilation.
The change in VCO2 and end-tidal CO2 caused by the change in ventilation in the prior art system of FIG. 2 can then be used to calculate cardiac output. Sensing and/or monitoring devices may be attached to the re-breathing ventilation circuit 30 between the additional length of hose 40 and the tubular portion 32, The sensing and/or monitoring devices may include, for example, means 44 for detecting CO2 concentration and means 46 for detecting flow parameters during inhalation and exhalation. Those sensing and/or monitoring devices are typically connected to data recording and display equipment (not shown). One problem encountered in use of the prior art system is that the deadspace provided by the additional length of hose 40 is fixed and may not be adjusted. As a result, the amount of deadspace provided in the circuit for a small adult to effect re-breathing is the same amount of deadspace available for a large adult to effect re-breathing, and the resulting changes in CO2 values for patients of different sizes derived from fixed-deadspace systems, can produce inadequate evaluation of cardiac output. Further, the three-way valve 40 of the system is expensive and significantly increases the cost of the ventilation device.
FIG. 3 illustrates the ventilation apparatus of the present invention which provides an improvement over known ventilation devices used to detect or monitor cardiac output. The present ventilation apparatus 50 comprises a tubular airway 52 which is placed in communication with the patient's lungs. Although the present ventilation apparatus 50 may be placed in communication with the trachea by intubation procedures as is done in the prior art, the present ventilation apparatus 50 need not be inserted directly into the trachea of the patient. Alternatively, a breathing mask may be used for positioning over the patient's nose and mouth. Thus, the present invention may be used with unconscious or uncooperative patients needing ventilation assistance and may be used with equal efficacy with patients who are conscious. The ventilation apparatus 50 also includes an inspiratory hose 54 and an expiratory hose 56 which may be each ventilated to atmosphere or may be connected to a ventilator machine 55 (shown in phantom) which provides gas for delivery to the patient through the inspiratory hose 54. The inspiratory hose 54 and expiratory hose 56 may be joined together by a Y-piece 58.
The Y-piece 58 connects to an additional length of conduit or hose 60 which provides a deadspace for receiving exhaled gas from the patient. However, the additional length of hose 60 is structured to be selectively expandable to readily enable the volume of deadspace to be adjusted commensurate with the size or lung capacity of the patient, or to other ventilation parameters, such as increased or decreased tidal volume or modified respiration rate. As suggested by the schematic drawing of FIG. 3, selective expansion of the deadspace may be accomplished by structuring the additional length of hose 60 with an expandable section 62 made of, for example, a piece of corrugated hose which can be lengthened or shortened by simply pulling or pushing the expandable section 62 along its longitudinal axis 64. The corrugated hose will retain the length at which it is positioned until adjusted again. Other suitable means of providing adjustable expansion of the volume of the deadspace are available, extending the length of the hose 60 being but one approach. A three-way valve 68 may be connected to the additional length of hose 60 to force inspiratory gas to enter the deadspace 70 upon inhalation. The three-way valve 68 is also structured to selectively prevent exhaled gas from entering the deadspace 70 during normal breathing or to direct exhaled gas into deadspace 70 during re-breathing episodes so that the patient is forced to re-breath exhaled gas from the deadspace 70.
A flow meter 72, or pneumotachometer, is attached to the ventilation apparatus 50 at a point between the tubular airway 52 and the additional length of hose 60. The flow meter 72 detects gas flow through the ventilation apparatus 50. A CO2 sensor 74, or capnograph, is also connected to the ventilation apparatus 50 between the tubular airway 52 and the additional length of hose 60. The CO2 sensor 74 detects changes in CO2 resulting from a change in ventilation, the data from which is used to calculate cardiac output. The CO2 sensor 74 may be an "on airway" sensor, a sampling sensor of the type which withdraws a side stream sample of gas for testing, or any other suitable CO2 sensor. Both the flow meter 72 and CO2 sensor 74 are connected to a computer 76 which is programmed to store and analyze data from the flow meter 72 and CO2 sensor 74, and to calculate from the data the estimated cardiac output of the patient
As previously described herein, the differential Fick Equation requires a change in pulmonary gas concentration and output to be induced in the patient in order to estimate cardiac output. Re-breathing gas previously exhaled by the patient increases the amount of CO2 breathed in by the patient and enables the evaluation of increased CO2 levels during a change in effective ventilation as compared to standard CO2 levels during normal ventilation. The ventilation apparatus of the present invention provides the ability to selectively adjust the deadspace required in re-breathing to increase the amount of gas (CO2 ) re-breathed by the patient from the previous exhalation. The ventilation apparatus of the present invention also allows the ventilation circuit to be adjusted automatically in accordance with the size or capacity of a patient, and in response to ventilation parameters. That is, if the detected change in etCO2 is less than 3 mm Hg, or the change in VCO2 is less than 0.2 times the VCO2, then the deadspace volume should be increased by twenty percent.
In an alternative embodiment of the apparatus 50 of the invention, as shown in FIG. 4, the expense of using a three-way valve may be eliminated by structuring the additional length of hose 60 with an inexpensive two-way valve 78 and by positioning a flow restrictor 80 between the inlet 82 and outlet 84 of the deadspace 70. Thus, when the two-way valve 78 is closed, gas to and from the ventilator machine will be directed through the flow restrictor 80 and to the patient. During a re-breathing episode, the two-way valve 78 is open so that the exhaled air, encountering the flow restrictor 80, follows the course of less resistance through the deadspace 70. Thus, the deadspace 70 may be adjusted at the expandable section 62 to provide the necessary deadspace 70 for calculating changes in cardiac output.
In another alternative embodiment of the ventilation apparatus 50 of the present invention, as shown in FIGS. 5(A)-(C), a shunt line 84 is positioned between the inspiratory hose 54 and the expiratory hose 56 to provide selectively sized deadspace 70 in the circuit. The structure of the embodiment shown in FIGS. 5(A)-(C) causes the inspiratory hose 54 and expiratory hose 56 to act as part of the deadspace 70, as well. A two-way shunt valve 86 positioned on the shunt line 84 selectively directs the flow of inspired and expired gas dependent upon whether the shunt valve 86 is open or closed. Thus, when the ventilation apparatus 50 is configured for normal or baseline breathing, as depicted in FIG. 5(A), exhaled air (represented by the shaded area) will enter the expiratory hose 56. During normal breathing, the shunt valve 86 is closed. When the ventilation apparatus 50 is configured for a re-breathing episode, as depicted in FIG. 5(B), the shunt valve 86 is opened and exhaled gas may fill a portion of the inspiratory hose 54, all of the expiratory hose 56 and the shunt line 84, all of which serve as the deadspace 70.
The deadspace 70 in the embodiment shown in FIGS. 5(A)-(C) may be rendered adjustably expandable, as shown in FIG, 6, by structuring the inspiratory hose 54 with an expandable section 90 positioned between the shunt line 84 and the Y-piece 58, and by structuring the expiratory hose 56 with an expandable section 92 positioned between the shunt line 84 and the Y-piece 58. Thus, the deadspace 70 can be selectively adjusted in accordance with the size or capacity of the patient, or responsive to operating conditions, by increasing that portion of the inspiratory hose 54 and expiratory hose 56 extending from the Y-piece 58. Any suitable adjustably expandable means may be used. As suggested by FIG. 6, however, the expandable section 90, 92 may be made from corrugated plastic material, the length of which can be easily expanded or contracted, and the plastic material will maintain its adjusted length until repositioned. The embodiment of FIG. 6 provides a particularly simple and inexpensive construction rendering a particularly preferred embodiment because of its ease of use and disposability.
In yet another embodiment of the ventilation apparatus 50 of the present invention, as shown in FIG. 7, the amount of available deadspace 70 may be selectively adjusted by providing a plurality of shunt lines 84, 94, 96 positioned between the inspiratory hose 54 and the expiratory hose 56, with each shunt line 84, 94, 96 being structured with a two-way shunt valve 86, 98, 100. In operation, the amount of deadspace 70 required, as dictated by the size or capacity of the patient, may be selectively provided by using any suitable number of shunt lines 84, 94, 96 to allow exhaled gas to move through the ventilation apparatus 50. For example, given a patient of average size or lung capacity, it may be appropriate to use the first shunt line 84 and the second shunt line 94 as potential deadspace 70. Thus, as the patient exhales in a re-breathing episode the shunt valves 86, 98 associated with the first shunt line 84 and second shunt line 94 may be opened, allowing exhaled and re-breathable gas to fill the expiratory hose 56, the inspiratory hose 54 between the second shunt line 94 and the Y-piece 58, the first shunt line 84 and the second shunt line 94. With a patient of larger size or greater lung capacity, it may be necessary to use the third shunt line 96 as well in providing sufficient deadspace 70 for re-breathing. Notably, each shunt valve 86, 98, 100 may be in electromechanical communication with the computer 76 (not shown in FIG. 7) so that the computer may determine, from the pneurnotachometer, for example, that additional deadspace 70 is required and cause the opening of one or more of the shunt valves 86, 98, 100 to provide sufficient additional deadspace 70. In an alternative embodiment, the ventilation apparatus 50 shown in FIG, 7 may be modified by the addition of selectively expandable sections 90, 92 as shown in FIG. 12.
In the several alternative embodiments of the invention previously illustrated and described, the amount or volume of the deadspace has been selectively adjustable by providing means for adjusting the volume of the deadspace, such as by providing length expanding means. It may be equally appropriate, however, to provide a change in ventilation, as required by the differential Fick Equation, by leaking some of the exhaled gas out of the system during the inspiration phase of a breath. Thus, as illustrated by FIG. 8(A), the ventilation apparatus 50 of the present invention may be structured with an evacuation line 106 connected to the expiratory hose 56 of the ventilation apparatus 50. The evacuation line 106 may be structured with gas releasing structure, such as a simple valve 108 connected thereto which, when opened, allows exhaled gas to move through the evacuation line 106. An orifice 110 positioned at the end of the evacuation line 106 allows some of the exhaled gas to escape to the atmosphere.
When and how much exhaled gas should be leaked from the ventilation apparatus 50 during a re-breathing event may be determined by the computer (not shown in FIG. 8) in response to flow conditions, CO2 conditions and/or the size or lung capacity of the patient. The valve 108, in electromechanical communication with the computer, may be selectively actuated according to ventilation or patient conditions. Where a patient is anesthetized or is otherwise exhaling gas which is undesirable for venting to the atmosphere, a compliant chamber 112, such as an expandable bag shown in FIG. 8(B), may be attached to the evacuation line 106 to receive the exhaled gas leaked from the ventilation circuit.
FIG. 9 schematically illustrates the use of a tracheal gas insufflation (TGI) apparatus 120 to provide the necessary deadspace in determining cardiac output in patients. TGI apparatus is typically used to ventilate sick patients who require the injection of fresh gas into their central airway for the improvement of alveolar ventilation. TGI apparatus can be configured to provide continuous or phasic (e.g., only during inhalation) injections of gas, The TGI apparatus supplies gas, or an oxygen/gas mixture, to the lungs with every breath. As shown in FIG. 9, the TGI apparatus comprises an endotracheal tube 122 which is inserted into the trachea 124 of the patient by intubation procedures. A catheter 126 extends through the endotracheal tube 122 and into the patient's lungs, typically just above the carina. Gas or an oxygen/gas blend is provided from a gas source 128 and is directed through gas tubing 130 into the catheter 126. A flow meter 132 may assist in determining the optimum amount of gas to be introduced into the lungs.
An adaptor fitting 134 may be used to connect a ventilation circuit 136 of a type previously described to the TGI apparatus 120. That is, a ventilation circuit 136 comprising a Y-piece 58 from which extends an inspiratory hose 54 and an expiratory hose 56 is structured with a flow meter line 72 attachable to a flow meter (not shown) and a CO2 sensor 74 for collecting data derived during a re-breathing event. In the illustrated TGI apparatus 120, the endotracheal tube 122 provides deadspace 70 required for re-breathing in addition to the ventilation circuit 136 as previously described. To act as a deadspace, however, the TGI apparatus (i.e., the gas source 128 and flow meter 132 ) must be turned off, reduced or otherwise disabled. Exhaled air is thereby allowed to fill the endotracheal tube 122 and enter through the Y-piece 58. The endotracheal tube 122 and ventilation circuit 136 serve as deadspace when the TGI apparatus 120 is turned off. The volume of deadspace provided by the TGI apparatus configuration may be further increased or decreased as necessary, by varying the depth to which the catheter 126 is positioned in the patient's trachea.
The computer to which the flow meter 72 and CO2 sensor 74 are connected is programmed to receive data collected by the flow meter 72 and CO2 sensor 74 and to analyze the data to calculate an estimated cardiac output. The parameters which are required by the software program to analyze the data and to estimate cardiac output are described hereafter.
The calculation of cardiac output for a given patient is based on the collection of data from the CO2 sensor and flow meter attached to the ventilation apparatus of the present invention. Raw flow and CO2 signals from the flow meter and CO2 sensor 74 are filtered to remove artifacts and the flow signals, CO2 signals and pressure signals are stored in a buffer in the software program. When the flow signal crosses a prescribed threshold (e.g., 15 liters/minute), the buffer is searched to find the most recent zero-crossing. The zero-crossing is identified as the start of a new breath. All data stored in the buffer since the last zero-crossing and the crossing of the prescribed threshold (i.e., the new zero-crossing) is established as one breathing cycle. For each breathing cycle, the parameters of the breathing phase are calculated as follows:
1) etCO2: The average concentration of CO2 during the final 5% of expiratory tidal volume is taken as end-tidal CO2.
2) VCO2: The integral of flow (in milliliters) multiplied by concentration of CO2 over the entire breath is VCO2.
3) Inspired CO2: This is the concentration of inspired CO2. It is the integral of CO2 concentration times the volume (in milliliters) of air flow during inspiration (i.e., negative flow).
4) Airway deadspace: Determined as the expired volume (in milliliters) at which CO2 concentration crosses a selected threshold set at, for example, 0.5 times etCO2.
The initial values of VCO2 and etCO2 are filtered employing a three-point median filter. The etCO2 and VCO2 signals are straight-line interpolated and re-sampled at 0.5 Hz.
A correction is made in the VCO2 value to account for alveolar deadspace. That is, the correction in VCO2 corrects for the flow of CO2 into lung stores such as the functional residual capacity (FRC) in the lungs, or, in other words, the volume of gas left in the lungs at the end of a breath. Alveolar deadspace is demonstrated more clearly in FIG. 10, which schematically illustrates the lungs 150 of a patient. The lungs 150 generally comprise the trachea 152, bronchi 154 and alveoli 156. The trachea 152 and bronchi 154 generally comprise what is known as the anatomic or serial deadspace, which exists in the region indicated between arrows A and B. In the lungs 150, there are alveoli 156 which are perfused with blood (i.e., in contact with blood flow to provide oxygenation to the blood) and alveoli which are not perfused, though both perfused and un-perfused alveoli 156 may be ventilated.
Perfused alveoli 160 and unperfused alveoli 162 are illustrated in FIG. 10. The perfused alveoli 160 are contacted with blood flowing through minute capillaries 164 surrounding the alveoli 160, the venous blood 166 flowing toward the alveoli 160 and the arterial blood 168 flowing away from the alveoli 160 in the direction of arrow 170. In the alveoli 160, 180, a volume of gas known as the functional residual capacity (FRC) 176 remains in the alveoli following exhalation. A portion 172 of the alveoli 160 which is evacuated upon exhalation (i.e., is ventilated) is representational of alveolar CO2 (PACO
In the present invention, the software program compensates, or accounts, for the functional residual capacity of the patient's lungs and the alveolar deadspace which exists. The correction is equal to the FRC times the change in end-tidal concentration or
where "Pbar" is barometric pressure. FRC is estimated as a function of body weight as estimated by the deadspace volume using the equation
where the FRC-factor is a value experimentally determined or is based on published data known in the art and the off-set value is a fixed constant which is added to compensate for breathing masks or other equipment components which may add deadspace to the circuit and thereby unacceptably skew the relationship between FRC and deadspace. The airway deadspace is the volume at which CO2 crosses a selected threshold [e.g., 0.5etCO2]. Dry gas is assumed in all equations.
Compensation is also made for parallel deadspace (See FIG. 10). Parallel dead space CO2 concentration is calculated as a low pass filtered version of the mixed inspired CO2 plus the airway deadspace times the previous end-tidal CO2 concentration. The average CO2PDS is etCO2 times airway deadspace plus inspired CO2 volume divided by the tidal volume. Breath-by-breath calculation of parallel deadspace, or unperfused space, concentration is therefore:
where Vt is the tidal volume (the volume of the breath), PDS is parallel deadspace (i.e., space in the lung that is ventilated but not perfused by blood flow), etCO2 is the concentration of CO2 at the end of the exhaled breath, or "end-tidal," "deadspace" is the volume in the trachea and bronchi through which air must pass to get to the alveoli but in which no gas exchange occurs (also defined as "serial dead space," See FIG. 10) and (n−1) indicates the previous breath.
Alveolar CO2 partial pressure ("PACO
where r is the perfusion ratio calculated as the ratio of perfused alveolar ventilation divided by total alveolar ventilation, or (VA−VPDS)/VA. The perfusion ratio r is estimated to be about 0.92. Perfusion ratio can also be estimated by direct analysis of arterial blood.
The PACO
where CCO
Baseline values of etCO2 and VCO2 , also referred to herein as "before CO2 and before VCO2 ," are those values which exist during normal breathing and are calculated as the average of all samples between 27 and 0 seconds before the start of re-breathing. Once a re-breathing episode begins, the VCO2 value during re-breathing, also referred to herein as "during VCO2 ," is calculated as the average VCO2 between 25 and 30 seconds of re-breathing. The calculation of CCO
Cardiac output is then calculated as follows:
The operation logic of the software program is briefly illustrated in the flow chart of FIG. 11. The computer is programmed to detect the end of an exhalation 200 at which point the computer collects data from the CO2 sensor and the flow meter and calculates CO2 , VCO2 , Inspired CO2 and airway deadspace values 202. The program then calculates FRC, at 204, according to the equation previously noted. The program also corrects the VCO2 value, at 206, in accordance with the equation previously described. At thirty second intervals (thirty seconds only being an average time, which may be adjusted higher or lower commensurate with the size of the patient), the CO2 and VCO2 values are recalculated, at 210, to provide an average of those values based on time, not on the variable time at which exhalation may end.
The program then calculates the estimated pCO2 in the parallel deadspace 212 and calculates the estimated pCO2 in the alveoli 214 using the equations previously described. At that point, a re-breathing episode is initiated 216 and a deadspace is introduced. Again, the computer collects data from the CO2 sensor and the flow monitor of the apparatus and from that data, the change in VCO2 and alveolar CO2 induced by the introduction of the deadspace is calculated 218. If the calculated change in VCO2 is less than twenty percent (20%) of the baseline VCO2 or if the change in partial pressure of alveolar CO2 is less than 3 mm Hg 220, then the operator is notified to increase the partial re-breathing deadspace 222 by increasing the expandable volumetric dimension of the adjustable deadspace of the apparatus. Baseline values are cancelled 224, then recalculated, as suggested by arrow 226. If, however, the change in VCO2 during re-breathing is greater than 80% of baseline values 228, then the operator is notified to decrease the adjustable deadspace of the apparatus by decreasing the volumetric dimension of the adjustable deadspace 230. The baseline values are cancelled 232 and recalculated, as suggested by arrow 234. Notably, the computer may notify the operator to make the necessary changes in the adjustable deadspace or, in an alternative embodiment, the computer may signal mechanical means connected to the adjustable deadspace to increase or decrease the volumetric dimension of the deadspace automatically.
Upon proper adjustment of the adjustable deadspace and the recalculation of baseline CO2 , VCO2 , inspired CO2 and airway deadspace values, the alveolar partial pressure (etCO2 ) is converted by the software program to CO2 content and the change in CO2 content induced by the introduction of deadspace in the re-breathing episode is calculated 236. From those values, cardiac output is calculated 238 in accordance with the equation previously described.
All references to times of data collection assume a thirty (30) second re-breathing period. However, the actual length of time for periods of re-breathing is dependent upon the patient's size, lung capacity and cardiac output determined from previous breathing cycles. The program also controls the operation of the shunt valve or valves in the re-breathing apparatus. The valve or valves are opened based on a timer value determined by patient size, capacity and/or cardiac output.
The ventilation apparatus of the present invention provides a new and more accurate means of determining cardiac output in patients. The structure and electronic capabilities of the present invention may be modified, however, to meet the demands of the particular application. Hence, reference herein to specific details of the illustrated embodiments is by way of example and not by way of limitation. It will be apparent to those skilled in the art that many additions, deletions and modifications to the illustrated embodiments of the invention may be made without departing from the spirit and scope of the invention as defined by the following claims.
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|Feb 3, 2006
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|Systems and methods for accurately, substantially noninvasively determining pulmonary capillary blood flow or cardiac output
|Mar 30, 2012
|Sep 30, 2014
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|Orr Joseph A
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|Mar 6, 2012
|Nellcor Puritan Bennett Llc
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|Mar 13, 2012
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|Oct 29, 2013
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|Jun 2, 2015
|Covidien Lp
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|Jun 2, 2015
|Covidien Lp
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|Mar 8, 2013
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|U.S. Classification
|128/200.26, 600/483, 600/484, 600/485, 128/207.14
|International Classification
|Cooperative Classification
|European Classification
|Dec 19, 1996
Owner name: NOVAMETRIX MEDICAL SYSTEMS, INC., CONNECTICUT
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text:
Latest News on Whitney Houston's Death Investigation; Burial Service
The world is still mourning the loss of the late, great Whitney Houston. Ever since her death on Saturday, we all have been curious to know the cause of her death. Did she drown in her hotel room's bathtub? Was it the cause of drugs? Alcohol?
And what is going to happen to her body?
[photogallerylink id=72451]
For many of Whitney Houston's friends, family members and fans, it's hard to accept that she has left this world. Sure, she hasn't had a solid radio hit in years, but she didn't technically have to. She's Whitney Houston. She is legend, and will forever live in the minds of every one she has ever touched.
The cause of Houston's death hasn't been confirmed, but Beverly Hills Police Department spokesman Lt. Mark Rosen does not believe foul play is involved. The investigation now rests in the hands of the coroner's office.
The pop star was reportedly found submerged in her Beverly Hills Hilton bathtub, but Dr. Cyril Wecht says drowning is an unlikely cause of death.
"I believe Whitney Houston was probably almost certainly dead when she slipped under the water or she was in a deep stupor, semi-comatose state when she slipped under the water and a normal gag reflex would not have kicked in," say the pathologist.
More on Whitney Houston from Fresh1027.com!
Houston had a long-standing, well-known battle with substance abuse. Prescription drugs were found on the scene, but none more than in the average medicine cabinet. An autopsy has been conducted, but the results from toxicology tests could take six to eight weeks to arrive.
Houston's body was flown from Los Anegles to Teterboro Airport late last night. A private funeral will be held Saturday for the singer at New Hope Baptist Church. Earlier reports state that the Prudential Center in Newark would hold a two-day public memorial, but exact times and dates for those services are yet to be announced.
Check back with CBS New York for the latest updates on Whitney Houston.
Latest from Fresh1027.com >
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- Taylor Swift Reveals Pain in Losing Grammy for 'Red': "I Cried a Little Bit"
- One Direction Reveal the Name of Their Next Single
- Demi Lovato Fights Michelle Rodriguez in 'Confident' Music Video

subset: commoncrawl


text:
Mary Parks
May 21, 2015 Parks, Mary C., 85, of Burton, WV., passed away on Monday, May 11, 2015 at her home. Friends will be received on Thursday from 6-8 p.m. at Palmer Funeral Home, Pine Grove, WV. more »»
Geraldine Wykert
May 21, 2015 Wykert, Geraldine Alberta, age 87 of N. 4th Avenue, Paden City, WV passed away Saturday, May 16, 2015 at Genesis in New Martinsville, WV. more »»
Albert Kerrick
May 21, 2015 Herrick, Albert A. "Abe", 83, of New Martinsville, WV went to be with the Lord Friday, May 15, 2015 while at Wheeling Hospital. Expression of sympathy may be made www.jarvisfuneralhomes.com. more »»
doretta Billeter
May 21, 2015 Billeter, Doretta "Betty" R., 91, of Paden City, WV died Monday, May 4, 2015 at her home. Expression of sympathy may be made www.jarvisfuneralhomes. more »»
William Hohman
May 21, 2015 William Lee "Wilbur" Hohman, 59, of Williamstown, W.Va., passed away on May 12, 2015 at Marietta Memorial Hospital. An online guestbook will be available at www.lamberttatman.com. more »»
Barker, Joetta D. "Jo"
May 13, 2015 Barker, Joetta D. "Jo", 57, of Sistersville, WV formerly of Pine Grove, WV died Saturday, May 9, 2015 after a short illness. Expression of sympathy may be made www.williamsfuneralhomewv. more »»
Clegg, Waneta W.
May 13, 2015 Clegg, Waneta W., 95, of Mobile, AL formerly of New Martinsville and Weirton, WV died Sunday, May 10, 2015 at Providence Hospital in Mobile, AL. Expression of sympathy may be made www. more »»
Billeter, Doretta "Betty" R.
May 13, 2015 Billeter, Doretta "Betty" R., 91, of Paden City, WV died Monday, May 4, 2015 at her home. Expression of sympathy may be made www.jarvisfuneralhomes. more »»
Collins, Junior B. "Smokey"
May 13, 2015 Collins, Junior B. "Smokey", 73, of Wileyville, WV died Wednesday, May 06, 2015 at Ohio Valley Medical Center while surrounded by his family. Expression of sympathy may be made www.jarvisfuneralhomes. more »»
Emch, Deloris Jean "Tump" Bohrer
May 13, 2015 Emch, Deloris Jean "Tump" Bohrer, age 79, of New Martinsville, WV, died Thursday, May 7, 2015 at her home. Sympathy expressions at grisellfuneralhomes. more »»
Persinger, George E.
May 6, 2015 George E. Persinger, 74, of Pittsboro, N.C., formerly of New Martinsville, W.Va., passed from an active life Monday, April 27, at the UNC Cancer Hospital in Chapel Hill, N.. more »»
Lasure, Betty Jane Longwell
May 6, 2015 Lasure, Betty Jane Longwell, age 80, of New Martinsville, W.Va., died Tuesday, April 28, 2015 at Ruby Memorial Hospital, Morgantown, WV. Sympathy expressions at grisellfuneralhomes. more »»
Shaffer, Elaine
May 6, 2015 Mrs. Elaine Shaffer, 86, passed away Wednesday, April 22, 2015. Brackney funeral services of Crestview is entrusted with the arrangements. more »»
Klug, Richard Michael
May 6, 2015 Richard Michael Klug, 72, of Moundsville, W.Va, passed away Sunday, May 3, 2015, in Shadyside Care Center, Shadyside, Ohio. Online condolences may be offered to the family at www.altmeyer. more »»
Vandruff, Virginia May
May 6, 2015 Vandruff, Virginia May, 85, of New Martinsville, W.Va., formerly of the Shortline Community died Friday, May 1, 2015 at Genesis New Martinsville. Expression of sympathy may be made www. more »»
Kinkade, Donald E. "Donnie"
April 29, 2015 Kinkade, Donald E. "Donnie," 67, of Pine Grove, W.Va., passed away on Saturday, April 25, 2015, at his home. Online condolences may be expressed at palmerfuneral. more »»
Scott, James D. "Jimmy"
April 29, 2015 Scott, James D. "Jimmy," 68, of Paden City, W.Va., passed away on Saturday, April 25, 2015 at his home. Online condolences may be expressed at palmerfuneral. more »»
Shepard, Mona M.
April 29, 2015 Shepard, Mona M., 81, of New Martinsville, W.Va., died Friday, April 24, 2015 at Sistersville General Hospital in Sistersville, W.Va. Express of sympathy may be made to www.jarvisfuneralhomes. more »»
Butler, Melvin Keith
April 22, 2015 Butler, Melvin Keith, 84, of 49 Hill, Beech Bottom, W.Va., died peacefully on April 18, 2015, at home surrounded by his loving family. Condolences may be sent to www.mullenbachfh. more »»
Craft, Virginia Rose
April 22, 2015 Craft, Virginia Rose, 85, of Rudolph, Ohio, passed away on April 20, 2015, at Bridge Hospice in Bowling Green, Ohio. more »»


text: Hello, here comes a small patch adding the option of a serial console to the grub boot loader configuration. The user will get a basic configuration of a serial console in grub and can change for example the serial speed later, when the config file is loaded into editor during the installtion process. Additionally a normal VGA console is configured. I'm tired to change this again and again :-) Please review/check/apply. If you think this is too much selection, then at least the example of a serial console should to the comment part inside of the grub.conf file. Regards Frank


text:
Many people would consider the size of your manhood a taboo subject but the feedback we have received is that just like bodybuilding, if there is a proven opportunity to help you "be bigger".
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text:
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text:
September 21, 2011
SecrecyKills.com [website no longer exists]
By SUSANNA KIM
Sept. 15, 2011
After the 10-year anniversary of Sept. 11 and six months after the death of al Qaeda leader Osama bin Laden, questions still remain regarding who funded the attacks that led to thousands of deaths and billions of dollars in damages.
The latest legal pursuit is that of an insurance syndicate of British insurer Lloyd's, which says the Kingdom of Saudi Arabia, its banks and various charities should be financially responsible for the $215 million it paid in insurance settlements to 9/11 victims' families.…
by Sibel Edmonds
CIA's Maneuver: A Case of Bluffing? Buying Time? Or Something More?
Last week we broke the story of the CIA issued legal threats against producers Ray Nowosielski and John Duffy on their discovery of the identities of the two key CIA analysts who executed the Tenet-Black-Blee cover-up in the case of two key 9/11 hijackers. The analysts were referred to only by first names initially, but were going to be fully named in a follow up segment.…Continue reading
September 12, 2011
by Hereward Fenton
On this sad anniversary of the worst terrorist attack in post-war history I am reminded of the prophetic words spoken by President Dwight D. Eisenhower in his farewell address to the nation in 1961: "In the councils of government, we must guard against the acquisition of unwarranted influence, whether sought or unsought, by the military industrial complex. The potential for the disastrous rise of misplaced power exists and will persist."
Eisenhower was the supreme commander in western Europe who had led America to victory against one of the most evil regimes in history, a man who had witnessed the depths of human depravity, and wanted finally to warn us that the war machine which had been created to defend freedom in WWII could equally be used for the opposite purpose, and that it was up to the American people to guard against this possibility.…
By Stephen C. Webster
Newly published audio this week reveals that Vice President Dick Cheney's infamous Sept. 11, 2001 order to shoot down rogue civilian aircraft was ignored by military officials, who instead ordered pilots to only identify suspect aircraft.
That revelation is one of many in newly released audio recordings compiled by investigators for the 9/11 Commission, published this week by The Rutgers Law Review. Featuring voices from employees at the Federal Aviation Administration (FAA), North American Aerospace Defense Command (NORAD) and American Airlines, the newly released multimedia provides a glimpse at the chaos that emerged as the attack progressed.…
Jon Gold
For the last year or so, one of my "pet projects" has been to search the video archives of C-SPAN for statements made about different people, different events, and make short movies out of them. They cover a multitude of topics, including NORAD's response, Ahmed Omar Saeed Sheikh, the Israeli Art Students, Saudi Arabia, and many others. Here is my C-SPAN Movie Collection, in the order they were created.
By Paul Craig Roberts
August 24, 2011 Information Clearing House — — -In a few days it will be the tenth anniversary of September 11, 2001. How well has the US government's official account of the event held up over the decade?
Not very well. The chairman, vice chairman, and senior legal counsel of the 9/11 Commission wrote books partially disassociating themselves from the commission's report. They said that the Bush administration put obstacles in their path, that information was withheld from them, that President Bush agreed to testify only if he was chaperoned by Vice President Cheney and neither were put under oath, that Pentagon and FAA officials lied to the commission and that the commission considered referring the false testimony for investigation for obstruction of justice.…
ConsortiumNews.com Exclusive: With few exceptions — like some salacious rumor about the Kennedy family — the mainstream U.S. news media has little interest in historical stories. Such was the case when an ex-White House terrorism official accused a former CIA director of withholding information that might have prevented a 9/11 attack, Ray McGovern reports. <
August 16, 2011
By Ray McGovern
Bulletin for those of you who get your information only from the New York Times, the Washington Post and other outlets of the Fawning Corporate Media (FCM): Former White House counterterrorism czar Richard Clarke has accused ex-CIA Director George Tenet of denying him and others access to intelligence that could have thwarted the attack on the Pentagon on 9/11.…
By Nancy A. Youssef
August 1, 2011
McClatchy Newspapers
WASHINGTON — The last-minute deal that Congress is considering to raise the federal debt limit probably will mean trillions of dollars in government spending reductions for most agencies. But one department stands to gain: the Pentagon.
Rather than cutting $400 billion in defense spending through 2023, as President Barack Obama had proposed in April, the current debt proposal trims $350 billion through 2024, effectively giving the Pentagon $50 billion more than it had been expecting over the next decade.…
One lawyer's relentless quest for information reveals fresh hints of a coverup.
By James Ridgeway
July 21, 2011
In 2007, Mother Jones was the first national media outlet to tell the full story of Jesse Trentadue and his quest for the truth, which began four months after the attack on Oklahoma City's Alfred P. Murrah Federal Building on April 19, 1995, killed 168 people. It was then that Trentadue, a Salt Lake City lawyer, learned that his brother, a construction worker and one-time bank robber, had died in a federal prison in Oklahoma City.…
by Ray McGovern
Published on Saturday, July 2, 2011 by CommonDreams.org
Yes, that was I standing before the U.S. Embassy in Athens on the eve of the July Fourth weekend holding the American flag in the distress mode — upside
[Photo (right): Ret. US Army Colonel Ann Wright, 64, from Honolulu, chants slogans as she and other activists rally in protest outside the U.S. embassy in Athens, Greece, Friday, July 1, 2011. The activists hope to join an international flotilla and to sail to Gaza.]
Indignities experienced by me and my co-guests on "The Audacity of Hope," the American boat to Gaza, over the past ten days in Athens leave no doubt in my mind that Barack Obama's administration has forfeited the right to claim any lineage to the brave Americans who declared independence from the king of England 235 years ago.…
23 May 2011
by Jeffrey Kaye
A great deal of controversy has arisen about what was known about the movements and location of Osama bin Laden in the wake of his killing by US Special Forces on May 2 in Abbottabad, Pakistan. Questions about what intelligence agencies knew or didn't know about al-Qaeda activities go back some years, most prominently in the controversy over the existence of a joint US Special Forces Command and Defense Intelligence Agency (DIA) data mining effort known as "Able Danger."
What hasn't been discussed is a September 2008 Department of Defense (DoD) inspector general (IG) report, summarizing an investigation made in response to an accusation by a Joint Forces Intelligence Command (JFIC) whistleblower, which indicated that a senior JFIC commander had halted actions tracking Osama bin Laden prior to 9/11.…Continue reading
by Paul Craig Roberts
May 17, 2011
In a sensational and explosive TV report, the Pakistani News Agency has provided a live interview with an eye witness to the US attack on the alleged compound of Osama bin Laden. The eye witness, Mohammad Bashir, describes the event as it unfolded. Of the three helicopters, "there was only one that landed the men and came back to pick them up, but as he [the helicopter] was picking them up, it blew away and caught fire." The witness says that there were no survivors, just dead bodies and pieces of bodies everywhere.…
The Associated Press
First published May 11, 2011
Updated May 12, 2011
Salt Lake Tribune
A federal judge in Utah on Wednesday ordered the FBI to produce more information about its record-keeping in response to an inquiry by a man who contends unreleased video and other records from the 1995 Oklahoma City bombing will show more people were involved in the attack.
U.S. District Judge Clark Waddoups said he believes Salt Lake City attorney Jesse Trentadue has raised valid questions about whether the agency has done enough to find a pair of videotapes sought as part of a Freedom of Information Act request.…
Supporters of accused WikiLeaks source vow to fight on for open trial and freedom
May 5, 2011
By the Bradley Manning Support Network
Published at Couragetoresist.org
Hundreds of thousands of individuals globally celebrate today the confirmation that their efforts to end the torturous pre-trial confinement conditions inflicted upon US Army PFC Bradley Manning have been successful. Manning's lead defense attorney, David E. Coombs of Rhode Island, has personally verified that Manning is indeed being held in Medium Custody confinement at the Joint Regional Corrections Facility (JRCF) at Fort Leavenworth, Kansas, as claimed by the Army last week.…
Obama professor among 250 experts who have signed letter condemning humiliation of alleged WikiLeaks source
by Ed Pilkington in New York
More than 250 of America's most eminent legal scholars have signed a letter protesting against the treatment in military prison of the alleged WikiLeaks source Bradley Manning, contesting that his "degrading and inhumane conditions" are illegal, unconstitutional and could even amount to torture.
The list of signatories includes Laurence Tribe, a Harvard professor who is considered to be America's foremost liberal authority on constitutional law.…
March 24th, 2011
By Eric W. Dolan
An Indiana prosecutor and Republican activist has resigned after emails show he suggested Wisconsin Governor Scott Walker stage a fake attack on himself to discredit unions protesting his budget repair bill.
The Republican governor signed a bill on March 11 that eliminates most union rights for public employees.
In an email from February 19, Indiana deputy prosecutor Carlos F. Lam told Walker the situation presented "a good opportunity for what's called a 'false flag' operation."
The Wisconsin Center for Investigative Journalism discovered the email among tens of thousands released to the public last week following a lawsuit by the Isthmus and the Associated Press.…Continue reading
The two main players in releasing the Pentagon Papers were Daniel Ellsberg and United States Senator Mike Gravel.
Senator Gravel is the person who read the Pentagon Papers into the Congressional Record. This act made the papers public record, so that they could not be censored by the government. He was the only member of Congress courageous enough to do so.
Both Ellsberg and Gravel – like many other high-level former officials in the government and intelligence services (including many well-known whistleblowers) – support a new 9/11 investigation.…


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2008 Ford C Max tinted rear windows required.
Tinted Windows
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if you are looking to tint your rear windows, then google this and search around your local area. Many firms offer it, whereby they can apply a tinted film to the window. or go down the scrappy, find some windows that are tinted, and remove the glass from the car, and take it with you and replcae the glass.
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DCCU Scholarships
DCCU believes in the importance of education and is proud to support area students who are committed to continuing their education. For the 21st year, DCCU is pleased to offer a $1,000 scholarship to the following:
- One graduating senior at each of the 19 high schools in the DCCU service area
- One student who attends private school, is home schooled or is a DCCU member living outside the service area
- One adult student continuing their education.
Applicants will conduct research and write a 750 to 1000 word essay based on the following questions:
How do you think technological innovation has changed the financial industry over the last ten years? In light of these changes, how can DCCU balance innovation with personal service for our members?
Use the links on the left to apply. The deadline to apply is Tuesday, March 1, 2016.
DCCU awards a total of $21,000 in scholarships annually.
For questions or further information, contact Sarah Landram, Community Financial Educator, at firstname.lastname@example.com or 540.946.3200 Ext: 3149.
Click below to apply for 2016 scholarships!Adult Scholarship Application Student Scholarship Application


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Well not a lot to tell. I enjoy just about anything outdoors. Hunting, fishing, camping etc. If you wanna know anything just ask.
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30 • Marysville, OH • Man
I'm looking for
- Women
- Ages 21–36
- Near me
- Who are single
- For new friends, long-term dating, short-term dating
My details
- Last online
- Yesterday – 9:53pm
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- Straight
- Ethnicity
- White
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- 6' 0" (1.83m)
- Body Type
- Athletic
- Smoking
- No
- Drinking
- Socially
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- Never
- Sign
- Cancer
- Education
- Post grad
- Offspring
- Might want kids
- Pets
- Has dogs
- Speaks
- English
My self-summary
Write a little about yourself. Just a paragraph will do.
I'm really good at
Go on, brag a little (or a lot). We won't judge.
Cooking. I make some really amazing food. When cooking I like to experiment with different food and it always turns out awesome
Favorite books, movies, shows, music, and food
Help your potential matches find common interests.
Well I don't know how to read....lol jk. Although I'm not much of a book reader. I get bored with that easily. Movies, I like mainly comedy. Music, anything country really. Lol
I spend a lot of time thinking about
Global warming, lunch, or your next vacation… it's all fair game.
What my next move in life is gonna be
On a typical Friday night I am
Netflix and takeout, or getting your party on — how do you let loose?
Well I usually hang out at home. On my way home from work I will grab a 12 pack and food to grill out. Maybe have some friends over for poker or some cornhole. I do occasionally get out. Maybe go see a band or just hanging out
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Residential Real Estate for rent - Real Estate to rent Barceloneta
Advertise real estate for rent in Barceloneta (PR) including Villas and Studios
The rent rates for real estate in Barceloneta is typically competitively priced but rates will mainly depend on location, and then size and quality. Refine your search by price, number of bedrooms, and type of property.
Aguada - Aguada Rental Home (Aguada)
Garrochales - Garrochales Rental Apartments (Arecibo)
Isabela - Isabela Houses For Rent (Isabela)
Aibonito - Aibonito Homes For Lease (Aibonito)
Naguabo - Naguabo Rental Apartment (Naguabo)
Manati - Manati Homes for Rent (Manati)
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Erowid's Psychoactive Vaults is only a click away, unless you live under Mother Russian's apron strings.
544 posts • joined 19 Apr 2007
Erowid's Psychoactive Vaults is only a click away, unless you live under Mother Russian's apron strings.
Probably taken from The Church Sign Generator
Closest approach will occur on Fri 14 July, 11:49:57 UTC, regardless if the probe is in safe mode or not. It's not asif it has any friction or Δv.
QR codes are just plaintext. By convention it's a URL, but that's not required.
The safer thing to do is have the QR contain heinz.de/promo which is a redirect to the real promo site. That way, when the promo ends, the redirect can be changed to a page that reads 'We are sorry, but the promotion has ended. Please enjoy the exciting Heinz Germany site'. The promo site can then be left to expire.
<quote>If this happened anywhere outside London don't expect any help whatsoever.</quote>
Have you ever heard of Aggreko? They are one of the biggest generator hire companies, and their UK operations based in Glasgow. They provided 200MW of generators when Japan got a bit wet in 2011.
Edlin was in MS-DOS 3.1
Isn't it 198 kHz?
… are best eaten when they are young; they only get stringy as they get larger. They add a bit of nuttiness to salads.
Is Cowell any worse than SAW were?
[Costa are going to] implement a "new format" for users' passwords.
Am I cynical enough to read that as "storing it hashed and salted, rather than plain-text"?
Obviously, his homoeopathy stress-relef pills aren't worth the sugar they're made from.
Hold a tick,
does this need the server admin to open what s/he thinks is foo.jpeg, but is really foo.jpeg.apx ? I'd suspect that most admins turn of extension hiding in File Explorer as soon as Windows is installed. Does it still work in that case?
It was The Scorpions Virgin Killer that triggered the block on Wikipedia. However, both Nirvana's Nevermind, and Led Zepplin's Houses of the Holy were discussed in the subsequent fallout.
You get tags that sound an alert if they are separated by too great a distance from their receiver. Keep the receiver attached to your person (not in your jacket, etc!), and the tag on your lanyard. As long as the first secure door isn't too close (might be a problem in a server room), then you will be alerted before you lock yourself out. These ones are to be paired to your phone, but there are also stand alone ones.
There's an Arduino project that does it. You just wire it to the floppies' head and spindle motors, tell how many it has, and then give it a MIDI fie; it does the rest for you.
just sayin'
Each was ordered to pay court costs of $212, while Walker-Gaines is required to repay Schaefer $9,000 in $175-a-month instalments.
That's over 51⅖ months, or about 4¼ years.
1.4.3? The 1.4 series of WordPress was released around 2004/2005. The current version is 4.1.1, which was released around the start of this year.
https://wordpress.org/about/roadmap/ doesn't list all the releases ,
I'd agree with James. There should be automatic systems at the 911 call centre (the bit that asks which emergency it is), that monitors the geographic rate of calls. If an area hass far lower than would be expected for the time-of-day and day-of-week, then an alert is sent, so that someone can look at it.
Likewise, at the subscriber-most exchanges, test calls should be made every, say 15 mins, to make sure that the call connects to an operator. If the call fails to connect, an alert is raised.
If the alerts aren't acknowledged, then it should be sent to another response centre, so they can prod the correct centre to fix it.
Final Integration of Systems Test
Don't most tablets support USB-on-the-go, allowing it's usb port to work as a master as well as a device?
They seem to have installed a new certificate, which was issued on 8th January 2015, and will expire on 1 April 2016. They are also using mixed https/http, which causes a warning flag (but not a direct message) in firefox.
Would the digital prepayment or dumb meters survive this type of overvoltage?
I'm a total dummy when it comes to this stuff. Can someone succinctly state how 4 and 6 can get along?
The underlying transport protocol (normally Ethernet) has a byte to indicate that it's carrying an ARP, rARP, IPv4, IPv6 packet, etc.
There are already programs that will simulate slow or unreliable connections. See http://stackoverflow.com/questions/1094760/network-tools-that-simulate-slow-network-connection for a discussion.
Netem on a linux bridge can add latency, re-order, duplicate and drop packets. It can do this either at a constant rate or in burst mode, which may be useful to simulate dodgy WiFi or GPRS connections. It can also do it to a different extent depending on which way the traffic is going.
Scary fact - Clippy porn, sorry, "erotica", actually exists
Rule 34: If it exists, there is porn of it — no exceptions.
Rule 36: If you've thought of it, then there's somebody out there with a fetish for it.
It uses the deceleration sensors that trigger the air-bag. If the airbag(s) are triggered, it phones 112 for you. If you are just driving with gusto, it doesn't. Simples.
Can you turn off those LEDs? I can see them getting very annoying, very quickly. I normally put stickers over the power-on LED if they are too bright.
Even better for enterprises with dozens or hundreds of computers all trying to update at the same time every Patch Tuesday.
Enterprises are likely to be running WSUS which caches the patches.
The Long Utopia, co-authored with Stephen Baxter, is due for release in the middle of June.
Over what timescale will the £17 billion level of saving be realised?
There are 26 million households in the UK, according to the 2011 census. If the saving is per household, per year, then that's £654 per household, which is clearly bollocks.
The UK's total annual electricity consumption is 330 billion kWh (in 2010). Electricity generators get paid £0.09 per kWh on average, households pay around £0.13 per kWh. At £0.09 per kWh, the UK's total electricity bill is £29.7 billion. The £17 billion saving is 57% of that. Again the stated amount of money saved is bollocks.
I have ignored gas costs, because (1) I don't have the price or consumption values, and (2) a good chunk of the the gas consumed in the UK is used to generate electricity, which leads to double-counting.
Can Windows Server Update Services run on Win7 Home Premium?
It might be worthwhile using WSUS to cache the updates for your users.
I assume that's studio-edit quality, before being compressed to Blu-Ray quality, at 50 GB for a two layer disk, so around 20-30GB for the film itself.
Downloading 300GB at 10Mb/sec will take the best part of three days.
W2K03 = W2030. You meant W2K003 </pedantic>
EasyGroup (HK) files a counter-suite against EasyGroup (UK) in the WIPO, and is given the rights to all Easy™ marks and domains, as they [EasyGroup (HK)] have prior rights.
If the bosses are fined, then they'll charge it to their company as a business expense.
A few random musings.
* It slightly odd that the I²C buses and Analogue ports are numbered from 0, but the digital ports are numbered from 1.
* I hope the power pin-outs on each port are the same, across the port types, so that if you connect a device to the wrong type of port, it doesn't work, but isn't damaged.
* I²C is a bus system, each device has (from memory) a 8 bit address, which is 5 bit class and 3 bit device. Therefore there can be 4 digital ports, with 8 bit output each. Thus, if the LEDs had HEX dip selectors on them, there could be upto 32 LEDs.
* The I²C ports should allow daisy-chaining, or star-topology, subject to power constraints.
All-in-all an useful interesting module. As for it not teaching people how to access a device, why run before you can walk? Adding a UART directly to the data/address bus is the classic way to do it, but is easy to destroy both the CPU, the UART, and anything else on the buses if things go wrong. Anyway, don't modern peripherals for embedded systems come with a SDK, or at least sample code, rather than just a data sheet?
Surely the publishers are allowed to set what fee they want. If they want to, they can decide to set it a €0.01 per excerpt-view, or €1.00 per annum for unlimited excerpt-views.
And in the name of everything that is sensible, turn off root ssh login — always login via a normal user and use su / sudo to become root.
You can also use fail2ban.
This is a small script that monitors your logs, for N occurrences of regexp X in Y seconds, from the same IP number.. If this is reached, then it carries out an action, and a second action after Z seconds.
By default it monitors /var/log/auth.log, looking for ssh login failures (either wrong password, or non-existent/no-login user). If this occurs 5 times in 10 minutes, then it will invoke iptables to block all incoming traffic from that IP number to your ssh server, and then automatically unban it 10 minutes later. It can also be set to email you an alert.
It is possible to have it monitor itself, so if the same IP address gets banned 5 times in a day, they get a week's ban (tweak to your inner BOFH's content).
The Myrka were also stunned or killed when exposed to UV light…
Who broke the V-hold? One would assume that the mud it landed it cushioned the impact a bit.
Did none of the mobile phones survive enough to check their memory cards?
I assume the manufacture can remove the on-board flash chip from a wrecked phone, and then extract all the data from it.
And will Facebook, the electoral commission and .gov.uk be using terrorist-enabling SSL?
Is this only amongst the different versions of MS-Windows, rather than all possible desktop OSes?
I notice the stats are given as school-employee-pervs per general-population, rather than school-employee-pers per school-employee.
If a state has more school-employees per general population (wherever because it has more pupils, or more school-employees-per-pupil), this will bias the stats towards that state.
There's a reason why UV-blocking glass is used for fluorescent lamps, it is harmful to our retinas.
As for solar charging, the Sun gives, on Earth, approx 1kW/m2 of sunlight across all frequencies, when the surface is perpendicular to the Sun. This is largely independent of latitude. A 5.5" 16:9 display is 13cm by 7 cm or about 1/100 of a square metre. If the solar panel can use about 10% of the sunlight (inc non-visible), then it would collect about 1W, which is less than most smart phones phones use when idle.
Or even litho-breaking
Would our gallant reporter have noticed the heat if he was well-oiled from his local taberna?
Well, not until the next morning…
Aye, capsaicin is only slightly water soluble, but is fat soluble. High-fat milk is the best drink to calm chilli fire.


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Here are a few images from some of our favorite "News Of The Weird" stories! But before scrolling down....remember, MANY of these images are extremely disturbing!! Are you sure you really want to look?? Got a story suggestion or a News Of The Weird Tip?? Drop me an email! email@example.com!!
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The Man Who Has Eaten Nothing But Roadkill For 30 Years
by News of the Weird
posted Oct 13 2011 1:28PM
Jonathan McGowan is 44 and he lives in a small coastal town in Southern England…and Jonathan makes his living as a taxidermist. But in addition to preserving the bodies of deceased animals…Jonathan discovered something decades ago that has truly changed his life. For the last 30 years Jonathan has survived on a diet made up of meat entirely from road kill.
1) Take one 8oz roadkill pigeon breast and wash it in warm water which will partially cook it.
2) Place it in foil with 100ml of red wine and cook it thoroughly for around half an hour on a low heat.
3) Mix in with onion and a white sauce and continue to cook it again for another 20 minutes.
Serve with celery and parsnips. It also goes well with chips and roast potatoes.
Serves: Four
1) Skin one badger
and cut into pieces before browning in a frying pan with butter until pieces are golden and stiff,
2) Flambée with glass of Armagnac and pour over one bottle of dry, sparkling wine, then simmer gently for two hours.
3) Mix cooked, chopped badger liver, a glass of pig's blood, two egg yolks and a pot of crème fraîche and serve immediately
Serve with wild mushrooms or chestnuts
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October 08, 2015
Takoma in the 30s 40s 50s
Sunday Oct 11th
On Sunday we will talk about, and listen to, some Southern roots music. 12:30 to 1:30 approximately.
We will try to end in time for you get up the hill to Historic Takoma for this program at 2 pm:
Historic Takoma, 7328 Carroll Avenue, Takoma Park
Meet the Author of THE LAST TROLLEY STOP
Heber Bouland was born in Washington, D.C. in 1928 and lived there for twenty four years. Hear his eyewitness candid account of the Great Depression. He lived with his family on the DC side of Takoma Park, and just over the city line in Maryland was the last stop for trolleys arriving from downtown.
Takoma Park was a neighborhood of contradictions. Within less than two blocks of his home lived a U.S. senator, plus an alleged communist, and several black families living in one room shanties. Men from the shanties worked in the nearby terra cotta plant and the children limped to their small segregated school on legs crippled with rickets. White neighbors often terrified the children by siccing growling dogs on them.
From summer visits to his uncle's small tobacco farm in western Kentucky, Bouland witnessed rural white poverty where toddlers labored long hours in the fields and often smoked or chewed tobacco. Besides the heartbreaking accounts of poverty and bigotry, he will entertain you with folksy stories about the humorous and the naughty.
October 04, 2015
Celebrating Sally Ride
Wednesday, Oct. 7, 7:30 p.m. – Science author Tam O'Shaunessy will talk about her new biography of America's first woman astronaut (and O'Shaunessy's life partner), Sally Ride: A Photobiography of America's Pioneering Woman in Space.
Dr. O'Shaunessy has donated Dr. Ride's papers and personal possessions to the Air and Space museum. She will join a panel at the museum on October 6th at 1 pm. View the event live.
O'Shaunessy's post on the Sally Ride Doodle
Amazing Slate article
The new book was designed for children 10 and up. Politics and Prose will sell copies, but no purchase is necessary to attend this free program.
What else is happening this week?