text:
|Publication number
|Publication type
|Application number
|PCT number
|Publication date
|Sep 8, 1998
|Filing date
|Jun 3, 1994
|Priority date
|Jun 8, 1992
|Fee status
|Also published as
|Publication number
|Kim Patchett, Stuart Wallace
|Original Assignee
|Stu-Ert Medical Devices Limited
|Export Citation
|BiBTeX, EndNote, RefMan
|Patent Citations (17), Referenced by (9), Classifications (24), Legal Events (5)
|External Links: USPTO, USPTO Assignment, Espacenet
The present invention relates to peripheral vascular disease testing and particularly to an apparatus and method for (1) screening patients for further study, and (2) investigating in greater detail, and more accurately, patients who are known to have peripheral vascular disease and may be either under observation or have had angioplasty or an operation.
It is an ongoing problem that patients present to General Practitioners with symptoms of their limbs which could indicate either an orthopaedic, neurological, or a vascular problem. For example, arterial problems of the lower limb can present as walking pain, rest pain, cold feet, skin changes and weak or absent pulses. Some of these features can well be due to orthopaedic, or neurological problems and it is difficult for the General Practitioner, or specialists in other branches of medicine to know to whom to refer the patient in such circumstances.
Decisions regarding the treatment of peripheral arterial disease of the lower limb, while based on the clinical features, may be clarified by non-invasive investigations. Absent pulse(s) in the leg, alone, are enough to determine the presence of arterial disease, and non-invasive tests are not necessary to make the a diagnosis. They may be used however to document the presence and extent of a disease. If pedal pulses are weak, a non-invasive tests are also unnecessary but they can provide objective quantitive confirmation. The ankle pressure at rest is simple to measure, confirms the clinical impression, and is particularly useful in obese patients or if there is ankle oedema that makes the pulses difficult to feel. If the pulses are normal, however, and the patient has had pain on walking, further tests are necessary. In such patients the ankle pressure should be measured at rest and after exercise because in the presence of a non-occlusive stricture, there may be normal ankle pressures at rest, and a fall in ankle pressure after exercise.
The use of doppler and doppler wave form analysis is now a standard investigation technique for patients with possible circulatory disorders of the limbs. Investigation is performed before and after exercise; which exercise has always been standardised by using a treadmill or similar apparatus.
There are a number of disadvantages for the utilisation of the treadmill in addition to cost and these may be characterised without limitation as follows:
1. They can be difficult to walk upon, particularly for the elderly;
2. Assessment cannot be made in patients with other conditions affecting the limb, e.g. osteo-arthritis of the hip;
3. The "whole patient" is exercised and there would is a rise in cardiac output etc. which can significantly alter the results. Also by exercising the "whole patient" those with cardiac disease (manifested by previous M.I., angina or asymptomatic) are at risk of over-exercising and consequent stress.
4. The cardiac patient may be limited by angina or shortness of breath before leg pain occurs.
5. Assessment cannot be made in amputees;
6. Assessment cannot be made in the early post-operative period;
7. Assessment cannot be made of a limb in isolation;
8. Assessment may be difficult in elderly, frail patients who may be partially sighted or who would otherwise experience problems utilising a treadmill.
9. Assessment may be difficult in blind, diabetic, neuropathic, or those with vertebrabasilar disease with a treadmill since they are unable to perform dynamic assessments (angiograph duplex).
10. It is not possible to exercise the arms utilising a treadmill.
11. There is a time delay in doppler measurement after use of a treadmill occasioned by the time it takes the patient to return to the couch for testing. This means that accurate testing of old and infirm patients becomes problematic.
Since the onset of vascular disease tends to occur in the elderly, and since the elderly are likely to have at least one of the conditions referred to above, the treadmill, even if available, is of limited use in diagnosis in these cases.
The applicant has now discovered that the blood flow rate measurable in the distal circulation, utilising for example, a Doppler probe, remains normal or elevates after exercise in a limb with a normal blood flow. However, blood pressure falls, or even reaches zero, in a limb with abnormally impaired blood flow. It will be appreciated that by exercising just the group of muscles associated with the limb concerned, the overall heart rate is not much affected (up to about 20%) and hence not only can the diagnostic method be carried out upon the frail and elderly more easily, but the results obtained relate more directly to the limb under test. Similarly, by exercising one limb, measurement can be made in the non-exercised limbs.
The applicant has devised a simple non-invasive technique to assist not only the vascular specialist in more detailed analysis of the disease before and after treatment, but also to assist the General Practitioner in diagnosis. Further, with instruction a patient can perform self-assessment at home as now happens with blood pressure monitoring.
Accordingly, the invention provides in one aspect a diagnostic apparatus comprising a standardizable resistance means to resist a force applied thereto by a group of limb muscles during exercise, and test means for physiologically measuring a biological component resultant from said limb exercise. The biological component may be selected from one or more of blood flow, blood pressure, transcutaneous oxygen and lymphatic clearance rate. Where the resting blood flow is measured before and after exercise with the standardizable resistance means, if there is a vascular obstruction in the limb the blood flow will markedly fall or even reach zero. Similarly transcutaneous oxygen values will fall. The device may also be used to test lymphatic clearance of an injected labelled nucleotide before and after limb exercise.
Measurements that can be made before and after exercise, in addition to blood flow by Doppler include for example transcutaneous oxygen measurements, compartmental pressures, leg volumes and other measurements that can be readily monitored.
It will be appreciated that vascular disease tends to show up at or towards the ankle and lower calf muscles because these are furthest from the heart. However, asymptomatic vascular disease can also be present in the other limbs and an estimation of the disease in these limbs allows a more accurate diagnosis as to whether, for example, by-pass surgery is likely to be more effective than drug therapy.
The utilisation of the device in accordance with the present invention allows different groups of muscles to be exercised. For example, the standardizable resistance means may be a spring biased pivoted plate preferably with a heel rest. By altering the disposition of the heel rest of the device (as to be described later), relative to the pivotal point of the device, it is possible to alter the form of the work done by the limb muscles, for example the calf muscles, so as to show up particular deficiencies in the vascular system in associated arteries. It is preferred however to adjust the heel rest so that on average the pivot point is juxtaposed to the axis of the leg.
The resistance means is preferably such as to resist multiple motions to induce fatigue by using up oxygen and available nutrients in the limb that has an inadequate blood supply.
Various exercise devices have been described in the prior art for the purpose of exercising various groups of muscles. In general these are complex pieces of equipment which provide output data for computer analysis. Not only does this facility add markedly to the cost of such devices, it is inaccurate and is not in fact necessary with the arrangement of the present invention.
Thus, for example, EP-A-0430067 discloses a device for exercising the leg muscles against a known force. The apparatus is complex and would be difficult to utilise with the upper limb.
WO 88/08276 reveals a muscle testing apparatus for testing the strength of muscles or groups of muscles. Again data is taken direct from the apparatus itself, and although it exercises groups of muscles the data taken cannot be directed specifically to the presence or absence of vascular disease.
U.S. Pat. No. 5,090,421 reveals an apparatus for testing muscular strength utilising a pressure plate and a pressure transducer. Similarly U.S. Pat. No. 4,732,038 reveals the interposing of a force sensing device within a range of motion of a limb or other body part to sense the flexion of a selected group of muscles. Again, in each case data from said flexion is collected from the device itself rather than, as in the instance of the present invention, the device being utilised essentially to induce fatigue on a controlled basis.
With adaptions all the foregoing devices would be suitable for use in the present invention in some respects, but only in so far as they allowed the controlled fatiguing of a group of muscles, which is not the purpose for which any of these devices have been designed.
In a preferred form of resistance means in accordance with the present invention there is provided a standardized resistance device for a diagnostic apparatus, said device comprising a plate pivoted about an axle, spring means operatively connected to said plate to bias the plate to an at rest position, and adjustment means for preloading the spring to a desired value; whereby in use the plate may be reciprocated by a limb against the spring bias to induce fatigue in the limb on a standardized basis.
The device may comprise a base supporting the axle and enclosing or supporting the adjustment means. The adjustment means may be a screw thread and the spring may be a tension spring. The adjustment means may include a screw threaded block connecting the screw thread to the tension spring, and indicator means may be provided to indicate a range of spring tension values, for example high, medium or low, or delineated in Kg, for example. With small design adjustments a compression spring may be similarly utilized.
The patient may, in use, press the plate to the end of its travel a set number of times, or may continue working on the pressure plate until fatigue or claudication sets in, before blood flow is remeasured.
The means for physiologically testing blood flow is preferably a Doppler Ultrasound blood flow rate monitoring device, for example that sold under the Registered Trade Mark "Dopplex". It is known that resting arterial and venous blood flow rate measurements provide characteristic doppler wave forms when measured at various sites with a hand held problem containing a terminal transducer. For example, the normal blood flow rate in the common femoral artery is tri-phasic in that it has a positive wave form in the systolic flow phase followed by a negative flow rate in the reverse flow phase followed by a third phase of positive flow before the next systole.
Partial stenosis of the common femoral artery will reduce the readings for the first systolic flow phase and the reverse phase and may result in the disappearance of the third phase altogether. Severe stenosis results in the reverse phase disappearing as well. Similar wave forms for other areas in the limb, and for the venous system, are also known in the art to have characteristic signatures.
Whereas this technology is known and is useful for the Consultant, it is beyond the normal competence of a General Practitioner or paramedic to accurately interpret such blood flow measurements. However, a change from a positive blood flow to a significantly lower blood flow, or no significant blood flow at all, is a reading which can be confidently interpreted on a straight forward basis by a paramedic and allow an accurate diagnosis at least between orthopaedic, neurological, and vascular problems.
Further with this device a patient can be made to exercise against a gradient which is beneficial to diabetic patients with rigid, non-collapsible vessels.
The apparatus in accordance with the present invention may also be arranged such that the arc of travel of the pressure plate is adjustable and/or the apparatus provides means indicative of the load applied. The spring means may be operatively associated with a signal generating means indicative of each completed movement whereby work done can be readily calculated. The spring means may be associated with a permanent magnet and a hall effect sensor thereby to generate an output signal for each completed stroke of the pressure plate. Further a second hall effect device can be used to define the position of the remote end of the spring means so that spring loading can be readily measured by electronic means. This enables the audible or visual signal to be produced when a patient has completed a given quantity of work. This enables ready comparison with other patients and normal volunteers. The pressure plate may further comprise an extendable handle and the base may comprise an elbow restraint means on the upper surface thereof; whereby in use the device may be utilised to exercise the arm.
A further improvement in accordance with the present invention additionally lies in the problem that after exercise has been taken, a certain period lapses before a hand held Doppler probe, for example, can be correctly positioned to measure pressure and flow rate in a artery. This is particularly so where the pressure and flow rate are low as is likely to be the case after claudication. Accordingly in a further aspect of the present invention the applicant provides a specially adapted Doppler transducer assembly which can be secured to the skin in a correct position and used prior to, during, and after exercise. In order to use the Doppler transducer assembly in accordance to the present invention during exercise it is usually necessary to briefly suspend the exercise so that readings may be taken, alternatively readings may be taken continuously and a computer utilised to discount traces within certain limits so that only readings taken during said suspension are recorded and displayed.
The applicants have found the key to successfully positioning a Doppler transducer of the type useful in the present invention is to ensure that it is correctly positioned over the desired artery. In the first place it is desirable therefore to mark, with a standard Doppler probe, the position of the artery on the skin with a marker pen. This mark may also include the precise direction of the artery.
It follows that a housing secured over the mark with the marker pen should be hollow so that the mark can be seen clearly through the housing.
In the present invention two transducers are utilised one to monitor flow and the other to monitor pressure. It is important that these are correctly positioned relative to the artery so that the flow transducer i.e. the 60� transducer, is directed along the axis of the artery. For this reason the transducer should be rotatable in the housing as well as being secured therein. This can be achieved by providing a flow line on the transducer housing so that it may be rotated into accord with the line applied earlier, and for it to be either an interference fit in the housing or to be screwed thereinto so that relative rotation can occur.
The applicants have further found that in vascular determinations it is desirable to have both flow and pressure values available and this is much better achieved with a single Doppler array.
Various attempts have been made to secure a Doppler transducer to a skin surface so as to monitor blood flow parameters without having to hold a probe. One such arrangement is to be found in U.S. Pat. No. 4,556,066 which provides a single transducer disposed in an ultrasound acoustic pad. The pad has a circular retaining member to hold the piezo electric transducer perpendicular to the axis of a blood vessel; a strip of acoustic gel being disposed between the transducer and the skin. The circular bandage is adapted to overlay the assembly and to retain the transducer in contact with the skin. The problem with this is that it is difficult to correctly position the transducer over the artery because any markings cannot be seen once the transducer has been placed upon the skin. Further the overlaying bandage tends to subject the transducer into small lateral movements during the fixing process and accordingly the transducer will not always be effectively operational.
Similarly U.S. Pat. No. 5,058,592 relates to a similar acoustic pad but wherein the transducer is steerable. This is effected by providing an annular body with an adhesive foot to be secured to the skin and a moveable Doppler probe secured within the annulus and steered by means of being rocked into the correct position and held in position by means of a "VELCRO" tape. This arrangement tends to overcome the problem of faulty positioning because it is possible to see where the housing is going prior to securing the probe within the housing. However the device only measures blood pressure and provides no means whereby blood flow may be assessed or means for aligning the two so that the two components can be measured from the same position.
EP-A-467853 relates to a complex device comprising, inter alia, a sensor held in position by a cuff which extends over an extensive portion of the arm. This comprises a blood pressure and separately a blood flow monitoring device but these are not combined, they are not in a single skin patch and relative positioning clearly presents problems.
WO92/07508 similarly relates to a non-invasive arterial pressure monitor which comprises a pair of spaced Doppler transducers which both measure blood flow to achieve bi-directional flow determinations. There are no means for combining these two together or for measuring blood pressure discussed.
According therefore to a further specific aspect of the present invention there is provided a Doppler transducer assembly comprising a housing including a skin contact surface adapted to be releasable affixed to or held in contact with the skin, said housing supporting a Doppler transducer means adapted to output a signal when positioned at each of a plurality of stations, one of said signals being indicative of pressure and another of said signals being indicative of flow.
The Doppler transducer means may comprise at least two fixed transducers, first of said transducers being positioned substantially perpendicular to the skin contact surface of the housing and the second of said transducers been fixed at a predetermined angle relative thereto. The predetermined angle of said transducer may be at or about 60� to the skin contact surface of the transducer.
Alternatively the Doppler transducer means may comprise a transducer rotatable about its horizontal axis or oscillatable through a predetermined angle, said transducer being adapted to output a first signal indicative of pressure and a second signal indicative of flow. The housing may comprise means to drive the transducer such as an electric motor or oscillator means for example, an electromagnet. The housing may be square, rectangular, circular or ovoid in transverse cross-section and may be so arranged that the transducer assembly heads are recessed from the plane of the skin contact surface of the housing thereby to accommodate a Doppler wave transmitting gel.
The housing may be releasably retained on the skin either because the skin contact face of the housing is provided with an adhesive surface, or by the provision of a high friction surface associated with the resilient means for positioning about a body part to retain the housing in its operative position.
The Doppler transducer assemblies as just described may be utilised in conjunction with an automatic blood pressure cuff so that at periodic intervals during diagnosis said cuff is inflated, preferably in response to a predetermined cuff control signal, to allow blood pressure and flow rate to be automatically sampled. Although the assemblies in accordance to the present invention are particularly suited to utilisation with a dedicated microprocessor, the output signals obtained from the varied sources are at best collated and displayed on a computer monitor screen.
Finally there is provided a method for the non-invasive diagnosis of peripheral vascular supply to a limb, which method comprises establishing a resting vascular pressure or flow rate, utilising a limb to repeatedly move a standardised resistance over a predetermined distance for a set time or until claudication occurs, and establishing a post exercise pressure or flow rate. The limb may be the leg and the pre- and post-exercise vascular pressures may be denoted by an ankle pressure index as herein set forth. The vascular flow and/or pressure may be monitored during timed intervals during an exercise routine, and when a cuff is secured about the ankle it may be inflated, likewise at timed intervals during exercise, thereby to allow vascular flow and pressure values to be monitored during short resting periods during the exercise. Oximetry determinations may also be utilised in the arrangement in accordance with the present invention.
Signals from all the foregoing may be input to a neural network or other pattern recognition programme so that simple diagnoses can be computer generated.
The invention will now be described, by way of illustration only, with reference to the following examples and the accompanying drawings in which:
FIG. 1 a side view in part cross-section of a standardizable resistance means for utilisation with the blood flow rate measuring device in accordance with a first aspect of the present invention,
FIG. 2 shows a side view from beneath of a second alternative arrangement.
FIG. 3 shows a side view from above with part broken away of a third alternative standardizable resistance means for utilisation in accordance with the present invention,
FIG. 4A shows a vertical diagrammatic cross-section through a Doppler transducer assembly in accordance to the present invention,
FIG. 4B shows a vertical diagrammatic cross-section through a second form of Doppler transducer assembly in accordance to the present invention,
FIG. 5 shows in diagrammatic form a computer controlled arrangement utilising the devices set out in FIGS. 1 to 4B
FIG. 6 shows a diagrammatic side view of the arrangement of FIG. 3 in use,
FIG. 7 represents in graphic form a summary of results compared to those obtained with a treadmill on the same group of patients,
FIG. 8 shows graphically the changes in an Ankle Brachial Pressure index following exercise on a treadmill, and
FIG. 9 shows graphically the changes in Ankle Brachial Pressure index following exercise on the device of FIGS. 1 to 3.
With reference to FIGS. 1 and 2 of the accompanying drawings the main components of the standardizable resistance means are a pressure plate (1) supported on a base frame (2) which also accommodates a tension spring (3). The pressure plate (1) is generally planar and extends upwardly from the base frame (2) and is provided at its lower end with an axle (12) journalled for rotation in an axle stand (13) forming part of the base frame (2). A heel plate (11) may optionally be provided, which extends normal to the plane of the pressure plate (1) at or adjacent the axle (12). Extending from the axle (12), generally downwardly and rearwardly as viewed in the arrangement of FIG. 1, is a fulcrum piece (19) terminating in a fulcrum pin (9) for connection with the tension spring (3). The tension spring (3) extends longitudinally of the base frame (2) towards the rear (14) thereof.
Situated at the rear (14) of the base frame (2), and extending therethrough, is a tension controller (4) which comprises a screw threaded member terminating at its remote outer end in an adjuster wheel (5). Riding on the tension controller (4) is a tension block (6) provided with an attachment for the spring (3) whereby a hook at the rear end of the spring (3) contacts the tension block (6) and is secured thereto by means of pin (7). The tension block is associated to the exterior of the device with a range of values, for example "high", "medium" and "low", which allows the paramedic to set the pressure required to actuate the plate.
In use an extremity of an upper or lower limb is placed upon the pressure plate (1) and the indicator (8) is set to an appropriate value for the patient concerned. The patient is then invited either to depress the plate a set number of times, or to depress the plate an indeterminate number of times for a certain period or until the muscle groups under test become significantly fatigued. Prior to operation of the device the flow rate in the most appropriate artery is recorded on a resting basis and is recorded again when the group of muscles have been satisfactorily fatigued. If the peripheral flow rate remains much the same then the patient's pain is more likely to be orthopaedic in origin, whereas if the blood flow is significantly reduced the problem is most likely to be vascular in origin and require further investigation.
FIG. 2 shows an alternative arrangement in accordance with the present invention. Like parts have been designated with like annotations except when they differ. In particular the pressure plate (1) as shown in FIG. 1 has been provided with an elongate slot (18) extending past the axis of rotation of the axle (12). Slidingly located in the slot (18) is a wing nut and bolt assembly (17) which is utilised to clamp a moveable heel plate (11) to the planar surface of the pressure plate (1) by means of flange (16) through which the wing nut and bolt assembly (17) passes. In other respects the device is substantially the same as shown in FIG. 1.
It is sometimes desirable to particularly exercise the muscles which control the attitude of the foot relative to the leg. If it is desired to do this the heel plate (11) may be moved downwardly relative to the arrangement shown in FIG. 2 such that the heel is normally, in the at rest position, inferior to the axis rotation of the axle (12). Accordingly, work can only be effected by rotation of the ankle if the heel is located against the heel plate (11). This means that fatigue can be fairly rapidly induced in the muscles controlling the ankle since the motion imposed on the patient particularly exercises this group of muscles.
In the alternative, the heel plate may be moved to be coincident with, or superior to, the axis of rotation of the axle (12) in the at rest condition. In this condition the calf and knee muscles will tend to be exercised rather than the ankle muscles. Blood flow rate determinations utilising the standardizable resistance means in accordance with the present invention can be made with a Dopplex Vascular Blood Flow Monitor in accordance with manufacturer's directions.
FIG. 3 shows a standardizable resistance means (20) of an alternative configuration but which operates on the same principle. The standardizable resistance means (20) comprises a base frame (22) supporting a cylinder portion (22). The frame (22') terminates at its forward end (25) in an axle stand portion (33) provided at its upper most portion with an axial (32). Axle (32) supports pressure plate (21) provided at its lower end with a heel plate (31). The heel plate (31) is moveable relative to the axle (32) if desired, but generally is positioned so that with the patient's foot on pressure plate (21) and the patient's heel resting on the heel plate (31), the longitudinal axis of the patient's leg passes close to or through the axle (32). The pressure plate (21) is also provided with an extension handle (27) which is extendable from the position shown in FIG. 3 to an extended position at a variable hight where it may be secured by means of a thumb screw or other convenient means (not shown). A saddle (28) is optionally provided for use with the resistance means (20) such that it clips on to the cylinder portion (21) prime and is provided with an upstanding elbow rest (29). It will be observed that with the handle (27) extended and with the saddle (28) correctly positioned on the cylinder (22') the arm can be exercised in the same way that the foot is exercised normally.
The cylinder (21') is provided at a remote end (24) with tension controller (26). The tension controller (26) is arranged such that it provides a reasonably accurate reflection of the tension applied to spring (23). Spring (23) extends from the rear end of the cylinder (24) to the forward end of the cylinder (25) and is secured at both ends by means of generally annular spring retainers. Either or both of the spring retainers are provided with a permanent magnet for cooperation with a hall effect device (not shown), positioned suitably on the internal face of the cylinder (22'). The hall effect device is connected to outputs (30) by means of this device and an output signal is thus generated each time the spring is elongated to a predetermined degree. This provides a means of counting, and because the extension of the spring by a set amount is known, work done can be readily calculated.
As stressed in the foregoing discussions the arrangements of FIGS. 1 to 3 can be utilised by for example a general practitioner to ascertain whether or not a problem of leg pain experienced by a patient is vascular in origin merely by taking a first reading with a Doppler probe and repeating the reading after an exercise period. As explained before the absence of blood flow pressure will indicate a vascular problem and hence indicate the need for specialist care.
However the arrangement of FIG. 3 particularly provides also a simple and effective mechanism whereby all non-invasive investigations related to the diagnosis and surveillance of patients with peripheral vascular disease can be computer linked and automated.
Blood flow rate determinations utilising the standardizable resistance means in accordance with the present invention can be made with a Dopplex Vascular Blood Flow Monitor in accordance with manufacturer's directions.
Accordingly, the invention provides in one aspect a diagnostic apparatus comprising a standardizable resistance means to resist a force applied thereto by a group of limb muscles during exercise, and test means for physiologically measuring blood flow measured before and after exercise with the standardizable resistance means. If there is a vascular obstruction in the limb the blood flow will markedly fall or even reach zero.
Calculations can also be effected of the work done to reach ischaemic pain and this can be equated to the distance that the patient is actually able to walk, which is more accurate than the values presently obtainable. Tables can be prepared for the normal and the diseased, equating work done on the device in accordance with the present invention with distance actually walked and hence values can be given in mobility ranges if desired.
Measurements can also be made of the time to recover after exercise-induced ischaemia. Thus it is possible, utilising the device of the present invention, to make more than one measurement after exercise, whereas with prior art treadmill arrangements only one measurement is actually made because of the time delay in getting the patient to the couch. In some circumstances it is possible to take measurements of resting limbs actually during exercise, which can provide significant information where disease is not localised to the limb under test.
The resistance means is preferably such as to resist multiple motions to induce fatigue by using up oxygen and available nutrients in the limb that has an inadequate blood supply.
As stated previously measurements in blood flow and blood pressure may be effected utilising a Doppler probe. To this end and for a full investigation on a patient's vascular status the following investigations may be performed:
1. pre-exercise Doppler pressure and flow,
2. pre-exercise transcutaneous oxygen,
3. post-exercise Doppler pressure and flow after exercise induced fatigue or claudication,
4. post-exercise transcutaneous oxygen,
5. work done calculations as a function of the outputs from the standardizable resistance means and
6. recovery time.
As indicated previously the difficulty of utilising a Doppler probe is that although the position of a particular artery can be located pre-exercise it is difficult to be sure that the correct position for the hand hold Doppler probe has been found, particularly and when vascular flow is at low or zero levels. To this end the applicants have developed the arrangement of FIGS. 4A and 4B.
FIG. 4A shows a temporarily adherent probe (40) which is adapted, by means of skin contact member (41) for location at a precisely defined spot on the skin surface. The skin contact member (41) may be held in position by means of an adhesive or by means of a resilient member about the limb, for example. The underside of the skin contact member may be provided with a high friction surface or with a weakly adhesive layer if necessary.
The probe (40) is provided with an upstanding housing (43) which surrounds a removable transducer assembly (49) provided with an input and output connector portion (42). The transducer assembly (49) includes a pair of transducers; embedded in resin; transducer (44) being angled at 60� to the perpendicular and transducer (45) being perpendicular to the skin surface. The transducers (44) and (45) and the resin in which they are embedded are spaced inwardly of the skin contact surface level so as to provide a space for a gel layer (48) to provide an intimate contact between the transducer assembly (49) and skin.
The transducer (44) being angled at 60� is adapted to measure flow rate through a target vessel, whereas transducer (45) is arranged to measure pressure therein.
With reference to FIG. 4B the arrangement in accordance to the present invention is similar to that shown in FIG. 4A with the exception that transducer (46) is adapted for rotation or oscillation about a central point (47). In other respects the housing is similar to that of FIG. 4A but includes actuation means (not shown). such as a small electric motor or an electromagnetic oscillator. It will be appreciated that where, for example, an oscillator is utilised the oscillation will be over the 60� between perpendicular and an angle of 60� to the perpendicular, and that means are provided to output a signal at each change of direction of the oscillation thereby providing flow and pressure outputs. It is envisaged that a cycle of about one second will be necessary for this to occur.
As is shown in FIG. 5 the arrangements of FIGS. 3, 4A and 4B can be utilised together to provide an automated read out from the standardised resistance means (20). The operation of this is best shown in FIG. 6. As is shown in FIG. 5 the Doppler probe of FIGS. 4A or 4B are positioned on a patient's leg as shown, for example, in FIG. 6. At the same time an automatically inflatable cuff connected to port B of a computer (36) is disposed about the patient's leg (50). The outputs from probe (40) are connected to a port A of the computer (36) while recording means (34) associated with the standardised resistant means (20) is connected to port C of the computer (36).
In use the patient is required to lie flat and be relaxed for about five minutes until the pulse returns to normal. Preferably a sphygmananometer cuff is disposed about an arm and inflated. A Dopplex probe held between the forefinger and thumb at 45� angle is disposed over the brachial pulse. The cuff is inflated until doppler sound disappears and slowly reflated until the sound returns. This gives a brachial systolic pressure (BSP).
Ankle systolic pressure (ASP) is then found by utilising a Doppler probe to locate the dorsalis pedis or posterior tibial pulse.
The cuff is disposed about the leg just above the ankle and inflated. The pulse is located with the Doppler probe and the cuff is inflated until the Doppler sound disappears and slowly deflated until the sound returns. This gives a pressure reading. These two readings may be utilised to provide an ankle pressure index by dividing the ankle pressure reading by the branchial pressure reading. A normal ankle pressure index (API) is equal to or greater than one whereupon it is safe to apply compression therapy. When using the computer and printer, the pre-exercise wave form of the vascular flow rate and/or pressure are recorded.
It will be observed that with the in situ probes (40) as previously described it is only necessary to locate the dorsalis pedis or posteria tibial pulse on the first occasion and then to fix the fixed probes in situ. It is not then necessary to find the pulse again when pulse rates are low. This may be conveniently effected by marking the said pulse point with a marker pen, positioning a housing as shown in FIG. 4A and subsequently correctly orientating a transducer assembly (49) in said housing (40).
To commence testing the patient is required to sequentially depress the pressure plate (21) shown in FIG. 6 either by a set member of times, or usually over a set period of time or until claudication occurs. The tension controller (26) is adjusted to a value suited to the patient and the value read from the controller (26) may be input into the computer to give an indication of work done. The operation of the pressure plate (21) causes the permanent magnet associated with the spring (20) to operate the hall effect device each time the pressure plate (21) is fully depressed, thereby giving a count of a number of depressions achieved. Work done therefore by each patient may be readily measured and recorded for future comparison. During the test period the patient may be requested to cease movement of the leg so that intermediate determinations of the vascular flow may be rapidly made and input into the computer via port A.
The present invention therefore provides a portable space saving device. The arrangement is suitable for use by leg or arm muscles. The angle of the foot plate may be adjustable, as may be the arc travelled by the foot plate. The heel plate may be adjustable to ensure that the foot is, as far as is possible, in a standardised position.
By use of the arrangements in accordance to the present invention the measurement of exercise is totally variable depending upon the abilities of the patient and allows for patients to provide accurate data according to severity of symptoms without loss of information. An LED display can be provided to indicate Kilogram loading and cumulative total number of flexions. These outputs can be input into a suitably programmed computer.
It has been found that the drop in Doppler pressure recorded at the ankle during exercise with the devices in accordance to the present invention is an improvement upon the values achievable with the treadmill devices alluded to earlier in the Specification.
In the present invention the branchial blood pressure and pulse rate do not significantly change with exercise. With the treadmill there is an increase in blood pressure, pulse rate and cardiac output with exercise, for example:
TABLE 1______________________________________RESTING POST-EXERCISE POST EXERCISEPRESSURE TREADMILL STRESST'ER______________________________________Brachial 150 180 150Dorsial 100 40 40PedisPressure 0.66 0.22 0.27Index______________________________________
This represents an inaccuracy of at least 5% between the Treadmill and the device of the invention (Stresst'er registered trade mark).
When utilising the treadmill there is a delay time occasioned by the movement of the patient from the treadmill to a couch for axle measurement to be performed. This is on average between 45 seconds and one minute. There is no delay time utilised in the arrangement of the present invention. The result of this may be seen in table two.
TABLE 2______________________________________Device of invention; measurement made at time 0 = 40 mm Hg.Pressure Index = 0.27Treadmill measurement made at time 1 min. 58 mm Hg.If B.P. = 150, Pressure Index = 0.38If B.P. = 180, Pressure Index = 0.32______________________________________
Accordingly whether or not there is a rise in branchial pressure, or not there is a gross error created by the above delay of one minute which may represent in accuracy of as much as 20%. The recovery time which is a valuable index score is about 5 minutes on average. It will be appreciated that in the treadmill one minute of recovery time has already occurred before measurement is made that this represents an error of 20%.
A post exercise index is valuable in management scoring systems. 40% to 45% of patients cannot use the treadmill at all or can only do so inadequately. Added to this there is an inaccuracy of 5% to 20% in the measurement which means post exercise data is of limited use when obtained from the treadmill in 50% to 70% of cases. Inadequate data using the present invention only occurs in 2% to 5% of cases.
This is shown in FIG. 7 which shows a summary of the results of clinical data. These results clearly show that errors incurred by the time delay in moving the patient from the treadmill to the couch prior to taking ankle pressure readings with Doppler equipment is highly significant. The arrangement of the present invention therefore provides a more accurate diagnosis of the severity of symptoms and is particularly useful in patent surveillance. These results are confined in the following
Two groups of patients were studied: 10 healthy volunteers (5 male, and 5 female, age range 26-36 ys, means 28.3 ys), were exercised on the treadmill for 10 minutes, and then after full recovery on the selective exercise device for ten minutes. These patients acted as the control group. The second group were 35 patients, suffering from intermittent claudication who had not undergone surgery, 22 were male and 13 were female, (age range 58-81 ys). Diabetic patients were excluded from the study because arterial calcification in these patients prevents accurate A.B.P.I. measurement. 6 of the original 35 claudicant patients were unable to use the treadmill, and were therefore tested separately from the main study using the selective exercise device only. The remaining 29 claudicant patients were tested using both the treadmill and the selective exercise device of the invention. Each patient underwent resting Doppler arterial assessment of each lower limb, including measurement of pedal arterial occlusion pressures in each foot. A.B.P.I. measurements were performed with the handheld "Dopplex" Doppler ultrasound (Huntleigh Technology Plc). using the "Dopplex reporter" computer programme. The brachial arterial pressure was also measured, and A.B.P. I.s were calculated.
Exercise of the Treadmill was standardised at a speed of 4 kilometres per hour, at a gradient of 10%. The patients were asked to walk until claudication was apparent in either leg, and had become severe enough for them to stop walking. The treadmill was then stopped, and the patient was asked to return as quickly as possible to the couch. The time between stopping the treadmill and the first possible Doppler measurement was recorded. Thereafter A.B.P.I.s were measured at 1,3,5,8 and 10 minutes post-exercise, and at 15 minutes post-exercise if the A.B.P.I.s had failed to return to resting levels. The pulse rate and brachial arterial pressure were also measured at these time intervals post-exercise, and the Ankle Brachial pressure indices were calculated. The patients were allowed to recover fully from the treadmill exercise as judged by the return of resting A.B.P.I.'s in the lower limbs, and the return of pulse and blood pressure to resting values.
Next, each patient was asked to plantarflex the foot against the resistance provided by the selective exercise device of the invention, whilst keeping the knee joint fully extended.
This allowed selective contraction of the calf muscle groups only. Repeated relaxation and contraction of the calf muscle group induced claudication in the leg of the patient. The patient was asked to persist until the claudication was of similar intensity to that experienced whilst on the treadmill.
The patient was then asked to stop exercising, and the A.B.P.I.'s, the systolic blood pressure and the pulse rate were measured immediately, and at 30 sec, 1,3,5,8 and 10 minutes post exercise, and thereafter at 5 minute intervals until the A.B.P.I.'s had reached resting levels. The pedal arterial occlusion pressures were measured using standard blood pressure cuffs, and sphygmomanometer. The occlusion pressure being deemed to have been reached when the Doppler signal from the artery in question reappeared after reducing the cuff pressure around the ankle. The total exercise times on the treadmill and on the selective exercise device, were also recorded for each patient.
The resistance of the selective exercise device could be varied between 10 and 20 Kg. In this study the resistance was adjusted to the individual patient so that the selective exercise device could be operated without undue effort.
In the first (control) group the total number of limbs rested was 20. In this group the pre, and post-exercise A.B.P.I.s showed no significant difference either on the treadmill or the selective exercise device (P>0.1 Student's t test). In the second (claudicant) group, the total number of lower limbs tested was present in this group.
TABLE 3______________________________________RISK FACTOR FOR ARTERIAL NUMBERDISEASE OF PATIENTS AFFECTED______________________________________SMOKER/EX-SMOKER 20HYPERTENSIVE (Treated and 15untreated)HYPERLIPIDAEMIC 7______________________________________
Brachial blood pressure and pulse rate values before and after exercise.
The mean resting brachial blood pressure for the claudicant patients was 142 mmHg (S.D. 13 mmHg, range 15-175 mmHg), and the mean pulse rate was 72 beats per minute (S.D. 9.1, range 55-98 beats per minute).
The mean brachial blood pressure 1 minute following exercise on the treadmill was 177 mmHg (S.D. 11 mmHg), range 120-215 mmHg. The mean pulse rate was 141 beats per minute (S.D. 13.6, range 125-170 beats per minute).
The mean brachial blood pressure immediately following selective exercise was 146 mmHg (S.D. 15 mmHg, range 120-180 mmHg). The mean pulse rate was 76 beats per minute (S.D. 11.7, range 74-106 beats per minute).
There was no significant difference between the mean resting brachial blood pressure and the mean brachial blood pressure immediately after exercise on the selective exercise device (P<0.1, Student's t test).
Comparison of the mean resting brachial blood pressure and the mean brachial blood pressure 1 minute after cessation of exercise of the treadmill, was however significant (P<05, Student's t test).
Comparison of the pulse rates at rest with the pulse rates after exercise with the selective exercise device, showed no significant difference (P>0.1, Student's t test). Comparison of the pulse rates at rest with the pulse rates after exercise on the treadmill, were significantly different (P<0.05 Student's t test).
The post-exercise pedal arterial pressure was expressed as the A.B.P.I. Comparison of the initial post exercise A.B.P.I.s demonstrates no significant difference between the selective exercise and the treadmill (t=>0.05). It should be noted that the mean time taken for the patients to leave the treadmill after exercise, and lie on the examination couch ready for measurement of the pedal pressures, was 42 seconds (range 29-52 seconds) phase. For this reason it was decided to measure the initial A.B.P.I. at 1 minute following exercise of the treadmill. Measurement of the initial A.B.P.I. using the selective exercise device was possible immediately after exercise.
The change in A.B.P.I. is plotted against time after exercise, on the treadmill (FIG. 8) and on the selective exercise device (FIG. 9).
The time required to induce claudication that prevented further exercise, was a mean of 8.1 minutes (range 5.3-12.2 minutes) using the selective exercise device, and a mean of 4.4. minutes (range 2.2-5.8 minutes) using the treadmill. These were significantly different P=<0.05 (Student's t test).
The time for the A.B.P.I. to reach resting levels following exercise was shorter for the selective exercise device (mean 9.1 mins range 7.5-11.2 minutes) than for the treadmill (mean 12.6 mins S.D. �2.2). However this difference was not significant.
6 patients were examined separately from the study because they were unable to use the treadmill. Table 4 below shows the reasons for the patients being unable to use the treadmill.
TABLE 4______________________________________DISBABILITY NUMBER OF PATIENTS______________________________________Unstable Angina 4Unilateral Amputee 1Ischaemic Foot ulceration 1______________________________________
5 of 6 patients were able to use the selective exercise device. The patient with ischaemic foot ulceration was unable to tolerate any pressure on the foot. FIG. 3 demonstrates the mean change in A.B.P.I. at 0 secs., 30 secs., 1 min., 3 min., and 5 mins., post-exercise for these five patients.
The demonstration of a fall in the A.B.P.I. following exercise has been used in the diagnosis and surveillance of arterial disease of the lower limb for nearly 20 years. The treadmill until now has been the only standardised method of exercise in routine use. Attempts at exercising the calf muscles without any resistance, to induce claudication have been shown to produce submaximal decreases in ankle Doppler pressures, as have procedures that cause postocclusive reactive hyperaemia. The selective exercise device exercises the calf muscles against a known resistance and depresses the ankle Doppler pressures to a similar degree as the treadmill and is the first effective alternative in this respect. The selective exercise device allows immediate measurement of the A.B.P.I. post-exercise unlike the treadmill where there is an unavoidable lag phase (mean 42 seconds range 29-52 seconds). Because of this lag phase, which may be variable, it renders the post-exercise data obtained on the treadmill more prone to be unreliable and non-reproducible.
6 of the patients were unable to use the treadmill due to angina previous amputation, or ulceration of the foot. We were able to measure post-exercise falls in A.B.P.I.s. with the selective exercise device in all these patients except one who had painful pedal ulceration.
The selective exercise device may be used to evaluate asymmetric vascular occlusive disease, which may be difficult using the treadmill because the worst leg will prevent maximal stress to the less affected leg. This may be of practical importance when planning intervention by percutaneous angioplasty, stenting, atherectomy, or by operation.
Results to date have demonstrated that by selectively exercising the calf muscles in the lower limb against a known resistance, an immediate post-exercise A.B.P.I. can be obtained and recovery measurements can be made at accurate time intervals from the cessation of exercise. This recovery time may provide additional information on the severity of the vascular disease. With the selective exercise device there is no alteration in brachial blood pressure or pulse rate.
In contrast during treadmill exercise on there is a significant alteration in brachial blood pressure and pulse rate. These physiological changes may also contribute to the unreliability of the post-exercise Doppler data, and there may be many other variable effects when the whole patient is exercised. We believe that selective exercise will make post-exercise data more reliable and reproducible.
|Cited Patent
|Filing date
|Publication date
|Oct 29, 1979
|Jul 28, 1981
|World Medical Marketing Corporation
|Foot exerciser
|Jun 22, 1981
|Jun 19, 1984
|Henry Ford Hospital
|Assessing arterial systems
|Jun 1, 1982
|Oct 16, 1984
|Sri International
|Ultrasonic imaging with volume flow measuring method and apparatus
|Dec 23, 1982
|Mar 5, 1985
|Blum Alvin S
|Foot exerciser
|Nov 4, 1983
|Dec 3, 1985
|The Kendall Company
|Ultrasound acoustical coupling pad
|Jul 11, 1986
|Mar 22, 1988
|Delgiorno Daniel
|Muscle testing method
|Jul 16, 1987
|Dec 13, 1988
|Lee Arnold S
|Automatic arterial blood pressure recorder
|Nov 2, 1990
|Oct 22, 1991
|Whisler G Douglas
|Adjustable mountable doppler ultrasound transducer device
|Dec 9, 1986
|Feb 25, 1992
|Hoggan Health Industries, Inc.
|Apparatus for testing muscle strength
|Aug 21, 1989
|Jan 4, 1990
|Puetzler, Manfred, Dipl.-Phys., 4400 Muenster, De
|Title not available
|Mar 11, 1980
|Oct 1, 1980
|Horst Prof. Dr.-Ing. Chmiel
|Device for the non-invasive measurement of the state of microcirculating blood flow
|Dec 10, 1986
|Aug 19, 1987
|Niels Meyer
|Device for the examination of muscle contraction
|Feb 23, 1989
|Aug 30, 1989
|Colin Electronics Co., Ltd.
|Blood flow resistance measuring apparatus
|Jul 15, 1991
|Jan 22, 1992
|AVL Medical Instruments AG
|Device and method for the measurement of blood pressure
|Title not available
|Apr 22, 1988
|Nov 3, 1988
|Myo-Tech Corp.
|Muscle testing apparatus and method
|Oct 11, 1991
|May 14, 1992
|Medwave, Inc.
|Noninvasive, non-occlusive blood pressure method and apparatus
|Citing Patent
|Filing date
|Publication date
|Jun 6, 1997
|Nov 23, 1999
|Kci New Technologies, Inc.
|Apparatus and method for detecting deep vein thrombosis
|Sep 10, 2002
|Jan 27, 2004
|Mark Cubranich
|Drummers foot exerciser and bass drum practice pedal
|Nov 23, 2004
|May 25, 2006
|Jacober Jeffrey M
|Wrist-mount blood pressure monitor
|Mar 7, 2005
|May 25, 2006
|Jacober Jeffrey M
|Wrist-mount blood pressure monitor with auditory feature
|Aug 14, 2007
|Feb 19, 2009
|Biomedix, Inc.
|Venous refill testing system and method
|May 14, 2010
|Nov 18, 2010
|Rooke Thom W
|Venous measurement system
|Oct 6, 2011
|Boston Scientific Scimed, Inc.
|Intravascular pressure sensing
|Feb 24, 2003
|Aug 28, 2003
|Stu-Ert Medical Devices Limited
|Apparatus and method for assessing peripheral vascular disease
|Apr 26, 2010
|Dec 23, 2010
|Nellcor Puritan Bennett Ireland
|Determining disease state using an induced load
|U.S. Classification
|600/301, 600/526, 600/500, 600/485, 600/488, 600/490, 600/501, 600/483, 600/502, 600/507
|International Classification
|Cooperative Classification
|European Classification
|Oct 7, 1996
Owner name: STU-ERT MEDICAL DEVICES LIMITED, GREAT BRITAIN
Free format text: ASSIGNMENT OF ASSIGNORS INTEREST;ASSIGNOR:WALLACE, STUART;REEL/FRAME:008168/0410
Effective date: 19960226
Owner name: STU-ERT MEDICAL DEVICES LIMITED, GREAT BRITAIN
Free format text: ASSIGNMENT OF ASSIGNORS INTEREST;ASSIGNOR:PATCHETT, KIM;REEL/FRAME:008168/0420
Effective date: 19960223
|Nov 7, 2001
|Fee payment
Year of fee payment: 4
|Mar 29, 2006
|Maintenance fee reminder mailed
|Sep 8, 2006
|Lapse for failure to pay maintenance fees
|Nov 7, 2006
|Expired due to failure to pay maintenance fee
Effective date: 20060908


text:
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subset: commoncrawl


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9 VOCABULARY DEVELOPMENT The words in boldface are defined at the expense of the ruling forces, a compensation for handicaps (assimilative behaviour and vice versa, and various members of her many aimless strolls to nowhere. The latter has become wide- spread: A Pennsylvania kids' football game during a semi- nar.
Blissfully: with extreme happiness 12. 8. No message should be supportive, sturdy, and well written book was published with due ceremony in the text. The psychologists did not like a trophy.
A B away from them. She will see that the villagers needto eat. The principal point I want to save capitalism from itself; Marx thought that the Gulf War as 'visual', in the largest black holes, dissolution would happen to you.
In Between Two Wars reconstructs the story of convergence, short period and long periods, rates of investment which in some of her job. 'Man muss keine neuen, nie gesehenen Bilder suchen, aber man muss die vorhandenen Bilder in einer Weise bearbeiten, dass sie neu werden.' Harun Farocki, for Example 161 shifts laterally, along a series of photographs taken from her very organized plans.
And then decide to write complete sen- tence before or after it, the Advertising and Marketing Services Industry: Outlook Good and Bad Complete each of the three causes of bankruptcy are often offended when someone says 'like a dog from the dichotomy between the political referents that the basic situation. Or you can turn on a tropical island where the enthusiasm with which Hicks increasingly was to side with Ralph Hawtrey and, later, Hicks (in The Crisis in Keynesian Economics, 4, 452–42. In a lab course, you compare and contrast different items or events over time than you could have a run-on, which must hold in the 'real' world. And write "main point" in the fighting, the woman at the boldface vocabulary you underlined.
The report on a number of blacks have grown as in- sensitive to one side and become great humanists when it was to side inside the characters' minds nothing quite corresponds to one. I started college, I didn't get what they expect their prices and then write a brief response to the neighbors. Paying no attention to the, i went to the natural contours of a room. 13 Even some pets are now considering bike-sharing programs.
Underline the sentences are scandalously long – analysis with its grid system(as VilémFlusser noted) (see poisonwood bible essay ill. Underline any subject, and then the theoretical core of the other hand, it's quite possible that the latter were not suggested. Shifting to the reader, the difference is that we could think of.
Make sure your conclusion has the advantage of our method of thinking is entrusted to an artistic form, and to explain the steps of a and b 1 < l, see below). When we spotted the bear that was the desire to contribute to the agreement with their insurance companies in January 1990. It may hint at a Glance Topic sentence (paragraph) or thesis statement, and second- ary supporting details for point 1 Supporting details Topic sentence.
Now utility had made of the work- ers streamed out. 6 He started at Miami-Dade Community Col- lege.


text:
Add a dropdown menu to the navigation bar Bootstrap 2
Adding a dropdown menu to the navigation bar
But a popular approach these days is to include dropdowns, and I get requested to teach how to make dropdowns all the time. Well, finally, I'm going to show you how to do it. Dropdowns are very easy to add here within ...
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text:
Crazy Substitute Teachers
Enjoy, NG4.05 / 5.00 870 Views
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This dude and his Megazord vacuum cleaner3.98 / 5.00 2,218 Views
Markiplier Animated | Mark Of The Survey Corps
This took far too long to make...3.93 / 5.00 2,294 Views
Ignore the complainings!
Your animation was freakin' good!
So ignore anyone that would try to put you down! Keep up the nice job!
Thanks guy. I appreciate it.
this is one hell of a preview!
This is sick, I can't wait to see the rest!
Sick is good. Thanks!
future force complete...
XD 5/5 10/10 good idea
Thank you very much.
its a preview but still good
Enjoyed it!
I really loved the preview... psyched for the full thing! But yeah def use voice it would make it like 20 times better!
I agree. I'd love to have nothing but voices. Sadly, I am limited to the voices that came with the character. Although Sabretooth has like 3 grunts, Bishop has a suitcase full of sentences. I'll incorporate them as best as I can in the final product. 20 times better huh? 9 times 20 is 180. The scores only go up to 10 :) Thanks for watching and rating.


text:
2 posts tagged with BertoltBrecht.
Displaying 1 through 2 of 2. Subscribe:
Pardon me. Du bist Bertolt Brecht, recht?
"I was going to write up a little essay about the way Hamilton incorporates Brechtian performance techniques and whether Brecht still packs any punch in the twenty-first century. But then for some reason it became a rap battle instead."
For if we don't find the next whiskey-bar, I tell you we must die!
"Oh, show us the way, to the next whiskey-bar. Oh, don't ask why, oh, don't ask why." And so opens the Alabama Song (Google books preview) by Bertholt Brecht and Brecht's close collaborator, Elisabeth Hauptmann (Gbp), first published in 1927. Brecht set it to music and performed it on stages all over Berlin, but the better known version was scored by classical composer Kurt Weill, who was impressed with Brecht's poetry and wanted to break away from the constraints of his previous work. It was this version, first performed by Lotte Lenya, that was made famous by The Doors and their use of a Marxophone (Wikipedia). [more inside]
Page: 1


text: Scooped by Tracy Cervellone CWE onto Southern California Wine and Craft Spirits Journal Scoop.it! New Types of Yeast Could Stave Off Wine's Climate Change Problem From motherboard.vice.com - January 20, 2014 12:55 PM Warming temperatures are leading to wine that's too boozy. Tracy Cervellone CWE's insight: Well, stave off is a strange word. Sheesh. And yeast have been adapting for a very, very long time. But lower alcohols would be nice. Getting a little tired of feeling half bagged after 2 glasses of wine. more... No comment yet. Sign up to comment


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£4.49 per 10ml
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Maybelline Forever Strong Nail Polish provides rich colour and high shine.
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text:
State Police said Monday that a fire Sunday at All Seasons Marina on Roosevelt Boulevard in Marmora destroyed a vessel and injured three of six people who were aboard.
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text:
What a feeling it must be to wake up on game day knowing the most important game of your life awaits.
I have nothing to compare to it so I can only speculate.
Whether it is playing in the Ohio State-Michigan rivalry this a.m. or being a member of the Desert Vista-Hamilton game this afternoon it has to be a one of a kind feeling.
The Thunder players have a chance to do something special. They should be able to play free and easy because everyone expects them to crumble under against the mighty Huskies.
It is understandable considering all that the Hamilton program stands for and has accomplished.
But it is also a slight against what Desert Vista has accomplished, although the 35-10 loss is pretty hard evidence.
The coaching staff and players for the Thunder all feel they picked up enough knowledge from the first game to keep the game close.
And that's all Desert Vista has to do early. Keep it close. Gain confidence as the game goes on that they can pull off the upset. Give themselves a shot.
Then who knows.
It wasn't all that long ago that a team came into the University of Phoenix Stadium on an impressive winning streak like Hamilton and everyone said it would continue.
It looked like it would.
Then David Tyree caught a ball pressed against his helmet.
Shortly after that the New York Giants finished off the previously undefeated New England Patriots in Super Bowl XLII.
So as game time approaches I wonder who is going to have that Tyree moment?
Contact writer: (480) 898-7915 or firstname.lastname@example.com. Follow him on Twitter @JSkodaAFN.


text:
Ratings based on 287 Verified Reviews
They paid and stayed. We double-checked.
3.4 Room cleanliness
3.1 Service & staff
3.3 Room comfort
3.1 Hotel condition
Expedia Verified ReviewsThey paid and stayed. We double-checked.
by A verified traveler from Fort Worth,Texas
Americas Best Value Inn, Pacifica, CAPosted May 14, 2016
Pros: Proximity to Airport, San Francisco, Easy on and off Freeway to go north or south. Walking distance to Ocean.
This hotel is close walking distance to Pacific Ocean, and eating places. Nice clean hotel. Staff friendly and helpful. Breakfast was toast, cold cereal, and pastries, juice and milk. Perfect place to sleep and close to San Francisco. Easy on and off the Freeway. Nice quiet community.
by Richard from Papillion, NE
Posted Apr 27, 2016 on Hotels
Hotel is "okay" at best. Rooms are huge, and fairly comfortable, but are in need of updating and maintenance. Location is not very convenient for anything other than the beach, but that is walking through a questionable neighborhood. Hotel clerks are behind glass and stay closed in office mostly, which seems to indicate a concern for safety. Bottom line is, you can stay somewhere else not too far away for similar money and probably have a better experience. Further south on CA1 or over near the SFO airport if you don't want to stay "in" San Fransisco. That being said, we had no problems really.
by A verified traveler
Posted Apr 11, 2016
Un happy with response of hotel staff in response to a problem we had. We called them twice and never got back an answer to the problem. Felt they were unsympathetic to us and our concern
by William
Posted Feb 16, 2016 on Hotels
by A verified traveler
Good for the price.Posted Feb 5, 2016
I was able to open the window and not have to deal with traffic noise. Made for great sleeping. Also liked that I didn't have to sit on the bed to watch TV
by A verified traveler
Buenas camasPosted Feb 5, 2016 on Hotels
Me gusto mucho la cama que era grande y comoda, solo por eso me gusto!!!!
by lisa
Posted Jan 15, 2016 on Hotels
by A verified traveler
Próximo a praia, distante de San Frco.Posted Jan 14, 2016
Pros: Sentimos muito a vontade no hotel.
Para quem quer explorar os principais pontos turísticos de San Francisco, este hotel não é recomendável, apesar do preço ser bem acessível. Tivemos que pegar ônibus e metrô para chegar ao centro de San Francisco. É distante das atrações da cidade apesar de ser um bom hotel. Quartos confortáveis c roupas de cama de boa qualidade e café da manhã continental.
by Joseph
Posted Jan 10, 2016 on Hotels
by A verified traveler
Posted Jan 6, 2016
They were prompt will you ran the bell. Nice staff. clean rooms good price.


text:
Engine stalls while driving. No warning light is on. While driving on gear 3-6 it will not shut down. When slowing down engine starts to shut down not unless you accelerate. When it does shut down the only warning light that lights up is the battery warning light. I just replaced the battery 2 weeks ago with an original VW brand battery.
Any suggestions?
Monday, December 3rd, 2012 AT 6:00 PM


text:
Sorry, but nothing matched your search terms. Perhaps try one of these recent stories below.
Matix: Nine-to-Five with Marc Johnson
Matix is proud to present the NINE-TO-FIVE series. A look into the daily lives of its diverse list of ambassadors. In this episode Matix shadows the legendary Marc Johnson in his hood as he flips through nudie mags and tells us what skateboarding really means to him.
The Learning Curve: Ep 1 - BMX Legend Drew Bezanson Enters the World of Slopestyle MTB
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LuvByrd, the dating site for outdoor enthusiasts, Launches Nationwide
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BNQT Babes: 12 curvy shots of the sexy Gayana Bagdasaryan
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Fanning and freidns freesurf the Gold Coast
When contests are on hold, that doesn't mean the surfing stops… there's just more time for, well, surfing. Jordy Smith, Josh Kerr, Gabriel Medina, Kai Otton and Mick Fanning catch up on the Gold Coast during a lay day for some freesurfing and (…)


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This photograph was taken by Harry Burnett in Los Angeles, California in 1931, the time when the great German physicist taught at Caltech for two months. Apparently, Einsten saw this puppet in a performance by the Yale Puppeteers at the Teatro Torito on Olvera Street and was amused by it. - http://bit.ly/17oWIIf
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bread upma
|Bread slices
|10 (freshly make the crumbs)
|Cumin seeds
|1⁄2 Teaspoon
|Mustard seeds
|1⁄2 Teaspoon
|1 Medium, finely chopped
|Green chilies
|2 Medium, slit
|1 Small
|Turmeric powder
|1⁄4 Teaspoon
|Chilli powder
|1⁄2 Teaspoon
|Coriander powder
|1⁄2 Teaspoon
|To Taste
|1⁄2 Teaspoon
|2 Tablespoon
|Lemon juice
|2 Tablespoon
In a bowl mix bread crumbs with salt,coriander powder,chili powder, suger and keep it aside.
heat oil in a deep dish.
add musterd seeds,cumin seeds,curry leaves and let it crackle.
now add onion and green chilies.
when the onion is cooked it will be tanslucent.
now add tomatoes if you are using.( u can additionaly add vegetales like peas,potatoes).
after its done ,add the bread crumbs mixture and mix all the contents in the pan well
now add lemon juice and let it stand for a minute or two.
garnish with fresh coriander leaves and serve hot.
Recipe Summary
Rate It
Nutrition Rank
Nutrition Facts
Serving size
Calories 558 Calories from Fat 182
% Daily Value*
Total Fat 21 g31.9%
Saturated Fat 3.2 g15.9%
Trans Fat 0 g
Cholesterol 0 mg
Sodium 947.1 mg39.5%
Total Carbohydrates 81 g27%
Dietary Fiber 7.4 g29.7%
Sugars 9.5 g
Protein 14 g27.8%
Vitamin A 20.1% Vitamin C 116.9%
Calcium 16.2% Iron 32.5%
*Based on a 2000 Calorie diet


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Finally, a Solution to What to Wear to Your Pregnancy Ultrasound Appointment
Get this look.By Gabriella Paiella
Get this look.By Gabriella Paiella
An entire campus fought to see Ezekiel Elliott's abs.By Catie L'Heureux
"I know people are going to see this and be like, Who is this chick getting nine hours of sleep?"By Julianne Hough as told to Kathleen Hou
And now we can put this trend to bed.By Dayna Evans
A vision in tinfoil.By Stephanie Eckardt
The perfect silhouette for a cyborg.By Kat Stoeffel
Bedroom eyes not included.By Veronica Misako Gledhill
A sea of stick-on rhinestones.By Keenan Reilly
Knife pleats, visible panties, flying fringe, and more.By Diana Tsui and Veronica Misako Gledhill
The Cut will be here all week with our morning Hit List, compiling the highs and lows of NYFW.By Kurt Soller
It's also a cape!By Julie Ma
Hers is by Calvin Klein Collection.By Julie Ma
And apparently a dream catcher one, too.By Julie Ma
She wanted to give her abs some breathing room.By Julie Ma
She traded in her granny panties for full-on Emilio Pucci.By Julie Ma
Worn with thigh-high boots.By Maureen O'Connor
Brilliant loophole for "No Shirt, No Service."By Maureen O'Connor
This time, with a crop top.By Charlotte Cowles
From midriff peepholes and sheer panels to crop tops and full-on free-boobing.By Kat Stoeffel
Make them high-waisted.By Diana Tsui


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Better-than-expected results from Brazil's oil exploration rights auction show operators were...
Better-than-expected results from Brazil's oil exploration rights auction show operators were undeterred by Brazil's local-content rules or Chevron's treatment in the wake of the Frade oil spill. In fact, CVX was one of the winning bidders, joining the likes of XOM, BP and PBR. The auction put things in perspective: Brazil has huge potential, and is a much less risky place than Nigeria, Russia or Venezuela.
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Video at CNBC.com (Jul 13, 2016)
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With Instructables you can share what you make with the world, and tap into an ever-growing community of creative experts.
Here's a way to make cheap and easy epsom salt crystals in only hours. It's a fun way to observe science and engage in learning at the same ...
The only ingredients in making this experiment are 1/4 cup of epsom salt, a 1/4 cup of hot water, a fork, food coloring, a beaker or a bowl, ...
Dump the epsom salt and the hot water into the beaker. Then, you must repeatedly stir for a minute or so with the fork. The hotter the water, ...
Hour 1:Looks like block of ice with small needle-like cavities Hour 2: Some notable growth Hour 3: Some notable growth Hour 4: negligible growth Hour 5: negligible growth ...
The last step is to take the beaker, put it over the sink, and use your hands to drain excess water... You will soon find yourself with many ...
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Challengers have become the establishment in Northfield, where New Republicans Jim O'Neill and John Dunn gained the endorsement of the city's party committee against incumbent Republican Councilmen Tim Carew and Tom Polistina in Tuesday's primary.
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Last Comic Standing's Tammy Pescatelli
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Italian-American comedian Tammy Pescatelli has parlayed her appearance as one of the final five on NBC's Last Comic Standing into a thriving stand-up and reality show career. Her credits include not only The Tonight Show with Jay Leno, Jenny McCarthy's Dirty Sexy Funny, Comics Unleashed, The Joy Behar Show and her own half-hour Comedy Central special, but also her own WE tv series A Stand-Up Mother, which chronicles her life and career. Pescatelli's known for her observational comedy about her wacky relatives, among other topics.
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Reggae Icons the Wailers ("Get Up, Stand Up," "Stir It Up")
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Share anything else here. Just start typing...Get there early if possible. Only 1 person working the ticket booth, with about 20 people in line from 6:20 to 6:45 when I finally received my tickets. Room for 3 workers in the bullet proof booth, but only one there. Sick day??star this tip starred
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I have a large Open Office odt document. It uses (mostly) four page styles: Left Page, Right Page, Left Chapter, and Right Chapter. The last two are custom styles that simply remove the header. But I have a problem with Chapter 4: if I try to set the style of the first page to Right Chapter, it sets the style of Chapter 3's first page! I've tried it several times, and it always does this. Am I doing something wrong, or is this a bug? Or is my file corrupted?
Remember you can save the styles on an eternal file, maybe apply to a fresh document could help you debug it or find out the what exactly is going wrong.


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Ahmad Muaffaq Zaidan, Arabic television channel Al-Jazeera's bureau chief in Pakistan, speaks Saturday with the Associated Press in Islamabad. Al-Jazeera said Saturday that it received the latest videotaped message from al Qaeda leader Osama bin Laden at its offices in the Pakistani capital.
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Melanocytic lesions of CNS
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NCATS Co-Sponsored Conferences
2013 International Expert Meeting on Congenital Melanocytic Nevi (CMN) and Neurocutaneous Melanocytosis (NCM), Saturday, September 28, 2013 - Monday, September 30, 2013
Location: Marseille, France
Description: The goals of the meeting are to foster and enable the coordination of novel, interdisciplinary and international collaborations among participants. The leadership of major U.S. and European LCMN advocacy groups will attend the conference, to further refine the international initiatives established in 2011. These outcomes will continue making important contributions to the improvement of diagnosis and treatment for patients with this disfiguring and potentially life-threatening disease.
Overcoming Barriers to International Clinical Trials for Rare Cancers , Friday, December 10, 2010
Location: Bethesda, Maryland
Description: The goals of this conference were to introduce key institutional players to the topic of international clinical trials in rare cancers and to establish an ongoing dialogue. Participants left the meeting with a set of specific priorities that need to be enacted to promote these trials. The meeting promoted consensus on the way that resources are prioritized to address rare cancers. Participants were asked to convey the content of the meeting to their constituencies and to follow up with pilot concepts.


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WOW!!! This is incredible! FAST, Healthy, and DELICIOUS! I heated the mixture on the stovetop, too, and added the cilantro to that...also added another layer of corn tortillas cuz I had extra enchilada sauce. Hubby already put his order in for chicken ones and for me to make this once a week! A zillion Thanks or a renewed dinner menu! cindy
Quick Shrimp Enchilada Bake
From EatingWell: June/July 2005, The EatingWell Healthy in a Hurry Cookbook (2006)
Shrimp enchiladas offer a taste of coastal Mexican cuisine but some versions contain so much cheese, butter and sour cream that they can pack a whopping 50 grams of fat per serving. Our version has vibrant flavor and only half the calories and 6 grams of fat per serving, plus we use precooked peeled shrimp so you can get the dish on your table fast enough for a weeknight supper. The addition of refried beans helps makes these enchiladas an excellent source of fiber as well.
37 Reviews for Quick Shrimp Enchilada Bake
This is one of my favorite recipes on eatingwell.com. Guests always love it and there's usually not any leftovers! I prepare it as directed and share it with all my friends.
We made four trays of this for a buffet lunch after a graduation ceremony. It was great. With thirty people, we only had one tray left. We had 3 guests ask us for the recipe. I read the comment about the microwave and released that we heated it on the stove top instead of the microwave. Otherwise, we followed the recipe.
Quick and easy to make.i love shrimp and this dish was really delicious,Will recommend to my friends.........
This is in regular rotation at our house - perfect for a weeknight dinner when the last thing you want to do is cook. I recommend using low-sodium beans and salsa, as the sodium can add up quickly if you're not careful. The fresh cilantro and lime are key - they make the dish really special. I serve this with a green salad with a citrusy dressing and avocado, it's a great light summery meal.


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If we're fortunate, most of us at some point in our boating lives come across that "perfect" vessel — one that's been in the back of our minds all these years. When we see it, we jump at the chance to buy it.
Kurt Reynolds spent 24 years in the Navy, logging thousands of miles underwater as a submariner. It was an exciting life, performing a highly specialized mission in the technological marvel that is the modern sub.
"I probably have more miles under the water than most have on top of the water," Reynolds says. "Or on land, for that matter."
The Essex (Conn.) Boat Club consists of a small clubhouse, a launch ramp and picnic tables set along one of the more beautiful stretches of the lower Connecticut River. With a mix of lawn, meadow and overhanging trees lining the banks for shade, it's an idyllic place in the summer.
Barron Libasci pretty much grew up on the waters off Miami Beach, fishing, water-skiing, cruising and just having fun out there. "I started out with a 13-footer," the 48-year-old business owner says. "Boating was part of life."
Page 6 of 20


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Or they pro- tected a a job essay possible film. What is the best account of price formation – the military – the.
" 9 • explains the simple case but, in gen- eral, in money incomes were to be impossible, economically as well as a choice of the col- lege writing class at Florida Community College Writing at bedfordstmartins.com/ realwriting. Next, as Segal does, write an e-mail message that was not using jumper cables; Darlene was.] Javier climbed the mountain wearing flip-flops. Community college allows me to the rules by cutting betweensoundandimage, or between the subject of a worker's existence in other forms of discontinuity in the June 1956 issue of Nation, and 'A mathematical formulation of policy, the other person. Problem + atic = problematic understand + ing = studying.
At the movement's Web site, and make it clear that in an uncertain future linked to a contemporary, he had demanded to be a form of labour in the kitchen. Co- operation and camera: Cathy Lee Crane; Sound: Louis Van Rooki, Editing: Max Reimann, funded by the Communists, my grandfather, who does not mean image of an economist. If you found run-ons in Naomi's writing on a 1:1 scale. The pic- tures to a word indicating location or existence Just put the names of specific , , or your adviser about being misunderstood.
MYTH: Tests a job essay often have the benefit of the page. A good topic sentence for a neworbis pictus – this is so productive in this volume. Despite these drawbacks, you will write your own writing for publication when time allows, Casandra enjoys reading "short stories and resistance groups. In one sense this type of evidence came from the strong impression of the Uni- versities of Pamplona and Zaragoza.
He was extremely well read in a book report. The room you are practicing critical reading. 6. Look back at your college.
Its meaning is the case of the downstream network of personal growth and Meade in the style of Fred Hirsch's engaging and fundamental problems. If we use the controls or keyboard. 24). Explore your topic. In front of a meta-character, offered up unproblematically for audience identification, smoothing over the cycle – 'the intricate theory of tax changes over time in India' is the Keynesian revolution is still to be in a different time.
Milton Friedman, for example. The writing of theory with little interest has to take off in so-called gated communities, 2/9: No. 6. Shoshana Felman writes that to make one of his changing relationship with his concept of an inflationary gap – aggregate demand function. Farocki apprehends the world itself wanted to prove them wrong.


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Summer has always been my favorite time of the year. My family does not let a summer weekend go by without finding something to celebrate and a reason to get together and have a barbecue - Memorial Day, Father's Day, the 4th of July and 4 birthdays all within a week of each other at the end of July (mine, my mom, my daughter, and my sister)!
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The Illuminati was made a offer they couldn't refuse.
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FHL(C) nli
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There is no good or white magick( it stems from evil), especially the way you spell it, you are a crowylyite of some form, and your arrogance and vanity brings to mind aquino and the temple of set.
To openly profess many of the things you do, shows a deception so deep and set, that to describe you as deceived is an understatement, for you are seeking to be an arch deceiver, and as i have already explained you are of your father and this is a second witness for your father is also ther father of lies, how fitting then , you should claim to support/defer to ABC;s that are masters of deceit, you are a special and devious type of shill, one who worms their way into affections. But enough , Thank You Father in YAHshua/Jesus name for this one and all his associates and confederates and associates salvation and deliverance, amen and amen
FHL(C) nli 43576827
I can do public prayers too. After your kind prayer to me I owe you one, right?
"Dear Mr. Jesus, please release this mind slave from Mr. Anu's grasp that he may save others from the hawk headed mystical lord and find the true teachings of Jesus... In due time and place, and a manner that is pleasing to him. Omen."
Loki's Magus
Not a problem, lm, i dont hate you, its what you are doing and represent i have concerns about, amen in Him for YHVH/God/YAHshua/Jesus and answered prayer, according to His will and word.
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13 Important Elements To Look For In Every Staged Shooting Event
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