text:
|Publication number
|Publication type
|Application number
|Publication date
|13 Dec 2011
|Filing date
|17 Apr 2007
|Priority date
|17 Apr 2006
|Fee status
|Also published as
|Publication number
|Robert W. Daly
|Original Assignee
|Daly Robert W
|Export Citation
|BiBTeX, EndNote, RefMan
|Patent Citations (72), Non-Patent Citations (9), Referenced by (6), Classifications (37), Legal Events (2)
|External Links: USPTO, USPTO Assignment, Espacenet
This application is a continuation-in-part of U.S. patent application Ser. No. 11/405,948, filed Apr. 17, 2006, which is herein incorporated by reference in its entirety.
1. Field of the Invention
The present invention relates generally to treatment of breathing disorders. In particular, the present invention relates to systems and methods for controlling breathing of a patient by maintaining specific levels of carbon dioxide ("CO2") dissolved in the patient's arterial blood.
Sleep-disordered breathing ("SDB") includes all syndromes that pose breathing difficulties during sleep. These include obstructive sleep apnea ("OSA"), mixed sleep apnea ("MSA"), central sleep apnea ("CSA"), Cheyne-Stokes respiration ("CSR"), and others. Some form of SDB occurs in approximately 3-5% of the U.S. population.
While anatomical problems such as obesity or an abnormally narrow upper airway may be a cause of some SDB, neurological difficulties in controlling levels of blood gases, such as CO2 and oxygen ("O2"), are increasingly being recognized as important contributors to the disease. This is especially true of the "central" syndromes, MSA, CSA and CSR, which may account for as much as 20% of all SDB. Changes in the neurological system that controls the blood gases often produce unsteady respiratory patterns that cause arousals from sleep. These changes are accompanied by severe spikes in blood pressure and release of stress hormones that can cause long-term damage to a number of organ systems. Additionally, some SDB syndromes involve abnormal overall levels of blood gases. For example, low levels of dissolved CO2 in arterial blood are frequently encountered, which represents a clinical problem. Thus, there is a need to stabilize respiration and establish appropriate blood gas levels by restoring normal control of blood gases when treating SDB.
The present invention relates to a system for controlling breathing of a patient. The system includes a respiratory conduit. The respiratory conduit is configured to be coupled to a patient interface device. The respiratory conduit is further configured to be coupled to a pressurized air generating device. The respiratory conduit includes at least two air flow control devices, positioned between the patient interface device and the pressurized air generating device. The respiratory conduit includes at least two volumes, wherein one volume is positioned between a first air flow control device and a second air flow control device and another volume is positioned between a second air flow control device and a third air flow control device. The second airflow control device configured to control evacuation of air from an airflow control conduit that is further configured to include multiple openings.
In some embodiments, the present invention relates to a method for controlling flow of carbon dioxide to a patient. The method includes controlling a level of carbon dioxide in blood of the patient using the system discussed above. The controlling includes measuring airflow through at least one of the airflow control devices, detecting a content of carbon dioxide in the measured airflow, adjusting airflow through at least one other one of the airflow control devices based on the detecting of the concentration of carbon dioxide, and adjusting sizes of the volumes based on the detection of the concentration of carbon dioxide and the adjusting of the airflow through at least one of the air flow control devices.
In some embodiments, the present invention includes a respiratory conduit configured to be coupled to a patient interface device of the patient. The respiratory conduit is configured to be coupled to a pressurized air supply device, wherein the pressurized air supply device supplies air to the patient at the other end. The respiratory conduit includes a first valve located adjacent the patient interface device and includes a first opening configured to control escape of the gas during the breathing process, a second valve configured to withdraw air from at least one location within the respiratory conduit during the breathing process, a first volume connector connecting the first valve and the second valve and configured to control supply of gas to the patient during the breathing process, a third valve that includes a third opening configured to control escape of gas during the breathing process, a second volume connector connecting the second valve and the third valve and configured to allow withdrawal of air from at least one location within the second volume, and a third connector connecting the second valve and the air supply device.
In some alternate embodiments, the present invention relates to a method of controlling breathing of a patient, wherein air is supplied to the patient using a patient interface device coupled to an air supply device using a respiratory conduit that includes at least one valve configured to withdraw air from at least one openings disposed within at least one volume connector, wherein the valves and the volume connectors are positioned along the length of the respiratory conduit. The method includes determining a rate of production of gas generated by the patient, measuring a rate of flow and a concentration of gas at each of the controllable openings, adjusting the flow rate through the multiple openings based on the measuring, and adjusting sizes of the multiple volume connectors based on at least one of the determining and the measuring. The air supplied to the patient includes a mixture of air supplied by the air supply device and a gas generated by the patient.
In yet other alternate embodiments, the present invention relates to a method of controlling breathing of a patient, wherein air is supplied to the patient using a patient interface device coupled to an air supply device using a respiratory conduit that includes at least two air flow control devices, positioned between the patient interface device and a pressurized air generating device, and at least two volumes, wherein at least one volume is configured to allow withdrawal of air from at least one location within the volume using at least one of the air flow control devices. The method includes determining an average concentration of gas in the air flowing out of the second air flow control device, comparing the average concentration of gas to a predetermined setpoint value of concentration of gas, computing the difference between the average concentration and the predetermined setpoint value of concentration, and controlling the breathing of the patient by adjusting flow of air through the first air flow control device until the computed difference is substantially eliminated.
In yet other alternate embodiments, the present invention relates to a system for controlling breathing of a patient. The system includes a respiratory conduit. The respiratory conduit is configured to be coupled to a patient interface device. The respiratory conduit is further configured to be coupled to a pressurized air generating device. The respiratory conduit includes at least two volumes, positioned between the patient interface device and the pressurized air generating device. The respiratory conduit includes at least two air flow control devices, wherein the at least one airflow control device is configured to withdraw air from at least one location within the respiratory conduit.
Further features and advantages of the invention, as well as structure and operation of various embodiments of the invention, are disclosed in detail below will reference to the accompanying drawings.
The present invention is described with reference to the accompanying drawings. In the drawings, like reference numbers indicate identical or functionally similar elements. Additionally, the left-most digit(s) of a reference number identifies the drawing in which the reference number first appears.
Of the two blood gases, carbon dioxide ("CO2") and oxygen ("O2"), problems with neurological control of breathing during sleep are related to control of CO2 than O2. CO2 is dissolved in blood, and together with bicarbonate ions determines blood pH. Excessive CO2 causes the blood to become acidic, while a deficit in CO2 will cause the blood to be alkaline. Since proteins need a stable pH environment in which to function, the CO2 levels should be controlled within a narrow range that will yield a blood pH of about 7.4. This is accomplished by close matching of CO2 excretion via the lungs to the endogenous CO2 production that is the product of cellular metabolism.
A sensitive and finely tuned system detects blood CO2 levels via a number of sensors, or chemoreceptors located within the vasculature and the brain of the patient. Nerve signaling from these sensors is processed by respiratory control centers in the brain, which send appropriate breathing pattern commands to the respiratory muscles including those of the diaphragm, chest and breathing airway. The goal of the system is to match the excretion of CO2 with the production of CO2 by varying the rate of respiration (both the depth and frequency of breathing). In healthy individuals, this system is accurate and steady. It is able to respond quickly to changes in CO2 production and maintain blood CO2 levels within a narrow range. Like many homeostatic mechanisms in the body, control of blood gases is accomplished by a closed-loop negative feedback control system.
When the system for controlling blood CO2 becomes disordered, it can lose its ability to maintain steady CO2 levels. It "chases" blood CO2 in an oscillating pattern of "overshoot" and "undershoot", resulting in a characteristic waxing/waning respiratory pattern. CSR is the classic syndrome associated with this disordered respiratory patterning and it is common in the setting of a heart failure.
Since the waxing/waning respiratory drive associated with poor control of blood gases applies also to control of the muscles holding the airway open, cyclic airway collapse during the waning epoch of respiratory drive is often a feature of these syndromes. In fact, pure waxing/waning respiratory patterns not associated with at least intermittent airway collapse are relatively rare and MSA may be the dominant expression of respiratory instability. MSA may present as an extremely regular and predictable pattern of obstructive events associated with reduced respiratory effort but it may also present as a chaotic mixture of events of different kinds (e.g. obstructive apneas, central apneas, hypopneas) with no visually discernable pattern.
For several decades it has been possible to describe the necessary conditions for respiratory stability in mathematical terms. The analytical framework is identical to that used in classical process control theory for predicting the stability of a closed-loop negative feedback control system. While these systems are able stably to control very complex and sensitive processes if correctly tuned, certain categories of problems are known to cause instability and oscillating control that render the process useless or worse. In general, these problems are caused by an excessive sensitivity or "closed-loop gain" in the control loop and timing problems, where an excessive time delay is encountered in measuring the results of the process and taking the appropriate corrective action. These are the same problems that sufferers from unstable sleeping respiration often exhibit.
It is well-established that the underlying cause of instability in the chemical control of respiration is usually excessive gain or sensitivity of one of the blood gas sensors, namely the peripheral chemoreceptor. The peripheral chemoreceptor is located within the carotid artery and directly samples arterial blood for oxygen and CO2 content. The chemoreceptor is sensing the concentration of H+ ions in the blood, which is a proxy for CO2 content in the arterial blood over a short period of time. The sensing becomes disordered and sends signals to the respiratory centers in the brain that tend to overestimate changes in blood gases, specifically, CO2. Even though the cause of the disordered sensing is unknown, it is common in various diseases, e.g., heart failure. It is difficult to correct the above disordered sensing using current medical technology. Further, problems with blood circulation prolong the time delay in reporting changes in blood gases, which adds to the problem of instability in the patient's respiratory control loop.
Given that increased closed-loop gain in the respiratory control feedback loop resulting in unstable respiration is usually due either to excessively sensitive CO2 sensors or impaired blood circulation, a number of therapeutic strategies have been attempted. Most existing therapies have various drawbacks.
Current therapeutic methods for restoring sleeping respiratory instability have the following problems:
1. They are complicated.
2. They are costly.
3. They are inefficient in that they may reduce one aspect of the closed-loop respiratory control gain while increasing its other aspects. Further, they may fail to reliably reinstate conditions for stability.
4. They fail to enable a clinician to specify a target blood CO2 range to be maintained during therapy where patients are currently hypocapnic.
5. They reduce an amount of oxygen available for breathing, necessitating an addition of supplemental oxygen in order to restore normal level of blood oxygen.
6. They fail rapidly to excrete CO2 under extraordinary circumstances, such as, after a prolonged obstructive apnea event.
7. They fail to respond immediately on a breath-by-breath basis to unstable respiratory patterns and rely on multi-breath pattern-recognition algorithms.
8. They relay on a single fixed estimate of respiratory requirements during the course of treatment and are not configured to adapt to variation in respiratory requirements.
9. They rely on expensive electronic equipment.
Current methods are also unable to permit modeling of the relationship between the rate ventilation of the patient and the rate of CO2 excretion in a non-linear fashion, including imposition of multiple distinct steps that permit "clamping" of respiration by maintaining CO2 excretion within a defined range under most conditions.
The system and method capable of controlling breathing of a patient by maintaining certain levels of CO2 in the patient's blood, while maintaining or improving blood oxygenation, described herein provide a solution to these problems.
The present invention also provides a way to substantially eliminate "deadspace gain". This issue is present in some conventional breathing systems.
Unstable breathing patterns consist of alternating hyperventilation and hypoventilation or apnea. During hyperventilation, there is rapid "blow-off" of CO2 that causes a steep drop in arterial CO2 that initiates an epoch of hypoventilation or even apnea when the arterial blood reaches the peripheral chemoreceptor and the brain detects an abnormally low level of blood CO2. During the hypoventilation, CO2 accumulates rapidly and again initiates an epoch of hyperventilation. This pattern can be repeated indefinitely.
Ideally, the lungs should be made to be less efficient during hyperventilation in order to resist the CO2 blow-off. One of the ways to do this, is to make the patient inhale a high percentage of CO2 in inspired air, which will interfere with gas exchange in the lungs and therefore exhibit excessive excretion of CO2. Likewise, the lungs should be maximally efficient during hypoventilation in order to limit the accumulation of CO2. Thus, inhaled CO2 is optimally zero during hypoventilation. Any design can be characterized in terms of its ability to exert a stabilizing influence by feeding the patient high concentrations of inspired CO2 during hyperventilation and none during hypoventilation.
Unfortunately, the conventional deadspace systems tend to do the opposite. As tidal volume increases, the concentration of CO2 in inspired air decreases, thus, actually promoting instability.
Further features and advantages of the invention, as well as the structure and operation of various embodiments of the invention, are described in detail below with reference to the accompanying drawings. The invention is not limited to the specific embodiments described herein. Such embodiments are presented herein for illustrative purposes only. Additional embodiments will be apparent to persons skilled in the relevant art(s) based on the teachings contained herein.
While the present invention is described herein with reference to illustrative embodiments for particular applications, the invention is not limited thereto. Those skilled in the art with access to the teachings provided herein will recognize additional modifications, applications, and embodiments within the scope thereof and additional fields in which the present invention would be of significant utility.
Regulation of Blood Gas Levels
Methods and systems for controlling breathing of a patient are described herein. The methods and systems use a combination of multiple deadspace volumes and valves to control CO2 levels in a patient's blood and, thereby, control breathing of the patient. The device of the therapeutic system controls a relationship between the rate of ventilation (i.e., total minute volume,
The system provides an interaction between multiple discreet deadspace volumes and multiple ventilation orifices of either fixed (precisely-defined) or variable size, where the volumes and orifices can be organized in a specific pattern. Such interaction offers a possibility of defining a wide spectrum of relationships between the rate of ventilation and the rate of CO2 excretion by the patient when used in conjunction with a ventilatory assist device such as a Continuous Positive Airway Pressure ("CPAP") machine, which is set to a predetermined pressure. In an alternate embodiment, a ventilatory assist device is not used and the same effect is achieved using a simple device into which the patient breathes.
A respiratory conduit, which is placed between a patient interface device (e.g., a sealed CPAP mask) and the CPAP machine (or any other air supply device), has a cylindrical shape. Ventilation orifices are placed in line with the conduit to provide outflow of CO2 that is exhaled by the patient. The lengths of conduit lying between each ventilation orifice represent a distinct deadspace or quasi-deadspace volume. As air containing CO2 is expelled from the patient's lungs into the respiratory conduit, a pressure generated by the CPAP machine causes at least some of the air and CO2 contained in such air to flow out of the various orifices in a specific pattern. The pattern depends on the volume of each one of patient's breaths or tidal volume (VT) and the frequency of breathing, or respiration rate. Each breath consists of an expiratory interval and an inspiratory interval. Once the expiratory interval is over, inspiration commences and most or all of the remaining CO2 in the conduit is re-breathed by the patient. Depending on the volume of each deadspace and the size of each ventilatory orifice, the curve describing a relationship between the rate of ventilation and the rate of CO2 excretion has an arbitrary number of inflection points defining line or curve segments (See,
The above system permits extensive modeling of the relationship between a patient's breathing (i.e., ventilation) and excretion of CO2. Using conventional computer simulation techniques, the sizes of orifices, volumes, and/or configuration of the two are specified to establish a relationship that serves to return the respiratory control feedback loop to a stable operation. Since during the interval prior to falling asleep, CO2 production may be high relative to the levels anticipated to prevail during sleep, an auxiliary ventilation valve is fitted that permits the patient to increase airflow through the device until comfortably resting in bed.
The mask 104 is a sealed orofacial non-invasive ventilation mask. For example, the mask 104 can be a Mirage NV Full Face Mask with adjustable VELCRO� strap headgear, as manufactured by ResMed Corp., Poway, Calif. A full-face mask can be used to cover both the nose and the mouth. This design eliminates mouth leak, permitting therapy for patients who breathe through the mouth and/or the nose. As can be understood by one of ordinary skill in the art, other types of masks can be used, such as a nasal mask, an oral mask, an orofacial mask, a nasal prong device, an intra-oral device, an endotracheal tube, or any other device.
The mask 104 includes a mask valve 105. The mask valve 105 can be a female Luer fitting that includes an orifice 136 and that attaches to one of the existing Luer ports on the mask 104. The orifice 136 can be drilled, punctured, or created by any other methods. The mask valve 105, through orifice 136, allows escape of gas (e.g., CO2) exhaled by the patient.
Alternatively, the mask 104 does not include the mask valve 105. Instead, a first valve 108 is placed on the mixing device 120, substantially adjacent to the mask 104. In one example, the orifice 136 has a fixed size. This design allows a certain volume of air to escape from the mask valve 105 per unit of time. In another example, the orifice 136 has a variable size, which can be altered depending on the amount of air intended to be allowed to escape from the mask valve 105. In one example, the orifice 136 permits air flow of 0.5-6 liters per minute, when the mask is pressurized by the CPAP machine 130 at a specific pressure. This pressure can be equal to the patient's CPAP pressure prescription.
Referring back to
As shown in
The fitting 139 further includes fittings 122 and 124 through which it is coupled to the mask 104 and first volume 111, respectively. The fittings 122, 124 can be standard type fittings having 22 mm outside diameter ("o.d."). To allow proper connection to the fitting 139, the first volume 111 can be a standard 22 mm inside diameter ("i.d.") respiratory hose.
Further, the fittings 122, 124 can be of a swivel type to permit rotation of the fitting 139 to accommodate various positions and orientations of the mixing device 120 and provide substantially leak proof connection. Otherwise, fitting 139 can be a straight fitting or a bent fitting, for example a fitting with two 22 mm o.d. ends and a 90-degree bend. The first valve 108 provides an air flow of 0.5 to 6 liters per minute when the system 100 is pressurized by the CPAP machine 130 at a given pressure equal to the patient's CPAP pressure prescription. Fittings 126, 128 (coupling second valve 112 to first volume 111 and second volume 113, respectively) and fittings 132, 134 (coupling third valve 114 to second volume 113 and connector volume 115, respectively) can be similar to fittings 122, 124.
The first volume 111 can be a standard 22 mm i.d. respiratory hose and can have an internal volume of 100-400 ml depending on the desired increase in the patients' arterial CO2. The hose can be a conventional hose with rubber cuffs as used with CPAP machines; it can be a corrugated disposable respiratory hose, or it can be any other hose appropriate for connecting mask 104 to a fitting 126.
As stated above, the second valve 112 includes a straight connector incorporating the orifice 133 that can have a fixed size. Alternatively, the orifice 133 has a variable size. This connector can be plastic and have 22 mm o.d. ends suitable for connection to the first volume 111 and second volume 113. Further, the orifice 133 location in the connector is such that it is not obstructed by lying on a surface (e.g., a bed). A groove in the fitting containing the second valve 112 can be created to prevent any obstructions. The orifice 133 permits an airflow of 3-8 liters per minute when it is pressurized by the CPAP machine 130 at a given pressure equal to the patient's CPAP pressure prescription.
The second volume 113 is substantially identical in type to the first volume 111. The second volume 113 can have a total volume of 100-400 ml.
The third valve 114 incorporates the orifice 135, which can be variable or fixed. The third valve 114 can be a straight connector, as shown in
The connector volume 115 can be substantially identical in type to the first volume 111 and second volume 113. The length of the connector volume 115 can be set to accommodate placement of the CPAP machine 130 in relation to the patient 101.
Each one of the orifices 131 (or alternatively 136), 133, and 135 is configured to allow escape of air at a specific rate when the pressurized air supply device 130 is operated at a specific pressure. Depending on the concentration of gas in the air flowing through each of the orifices, the gas will be escaping through each orifice at a specific rate. The orifices can be fixed, variable, or a combination of fixed and variable sized orifices can be used. As can be understood by one having ordinary skill in the art, varying locations and/or numbers of fixed and variable orifices can be used as desired. This allows a predetermined amount of air and gas (depending on the concentration of the gas in such air) to escape from the orifices in case of fixed orifices' sizes or a variable amount of gas to escape from the orifices in case of variable orifices' sizes. Further, in case of variable orifices, their sizes can be manually or dynamically controlled. When orifice sizes are manually controlled, a patient, a clinician, or someone else can control the size of the orifice and, thus, the amount of gas allowed to escape from the orifice. When orifice sizes are automatically controlled, their sizes can be adjusted automatically based on an amount of gas exhaled by the patient, amount of gas escaping from each specific orifice, amount of gas contained in the volume connectors 111 and 113, patient physical parameters (such as blood pressure, body mass, age, etc.) and/or other factors.
The sizes of orifices 131, 133, 135 and three volumes 111, 113, 115 can be preliminary determined using an algorithm based on patient's estimated high and low
The respiratory conduit 120 is rotatably coupled to the mask 104 and the CPAP device 130. This arrangement allows the conduit 120 to rotate if the patient turns during sleep. As can be understood by one of ordinary skill in the art, the rotatable connection can be sealed to prevent any leaks during operation of system 100.
Referring to
The auxiliary valve 116, when opened, provides a flow of air through the mixing device 120 sufficient to provide substantial washout of the exhaled CO2 from the mixing device 120. In one example, the patient 101 can operate the auxiliary valve 116 in order to provide CO2 washout until patient 101 is resting comfortably. The auxiliary valve 116 can be closed manually by the patient 101 or automatically after a certain period of time elapsed.
The anti-asphyxiation valve 118 opens when the operating pressure of the CPAP machine 130 falls below a predefined value (i.e., CPAP machine 130 fails to provide adequate pressure). When the latter occurs, the anti-asphyxiation valve 118 opens and allows the patient 101 to breathe ambient air through the valve 118. Hence, the valve 118 prevents asphyxiation of the patient in the event of failure of the CPAP machine 130.
Additionally, the mixing device 120 includes a water condensation collection device that collects moisture from the patient's breaths. This prevents undesirable accumulation of moisture within the mixing device 120.
For example, it may be determined that a male patient with a body mass of 100 kg and a CPAP prescription of 15 cm H2O may require the following configuration of orifices and volumes:
Orifice 131
liters per minute
First volume 113
Orifice 133
liters per minute
Second volume 115
Orifice 135
liters per minute
The mask 214 is similar to 104 shown in
Further, the conduit 218 is configured to vary volumes 213 and 215 using movable pistons or cylinders (shown in
Referring back to
Method of Treatment and Titration of a Patient
Initially, a nightly CO2 excretory profile of a patient during sleep is determined. This profile is determined by measuring a total amount of CO2 production by the patient during a diagnostic overnight polysomnographic study. Such profile contains information about high, low and mean levels of CO2 production during sleep. Prior to a trial fitting of the device (See,
At the end of the titration study, a final configuration of CPAP pressure, volumes and airflow through each of orifices is recorded. A custom-built conduit/mixing device (as shown in
The device and therapeutic system is tailored to each individual patient. Initially, the patient is referred to an appropriate sleep diagnostic facility. In the facility, a clinician orders an evaluation of a patient for possible respiratory instability. Certain modifications and enhancements are optionally made to the usual overnight polysomnographic study, described above. These modifications can include additions of end-tidal CO2 monitoring and calibrated nasal pressure measurement. Alternatively, instead of nasal pressure, another highly accurate means of determining airflow through the patient's nose and mouth can be utilized, including wearing a respiratory mask with an attached flow sensor. The capnography (CO2) waveform (See,
The interpreting clinician inspects the evolution of
Prior to the titration study, the polysomnographic technician will obtain certain demographic and physical information about the patient in order to establish a starting configuration. For example, age, sex, body mass, arterial CO2 level, estimated CPAP prescription, and actual and target end-tidal CO2 values are collected. This information is then used to make an estimate of a probable optimal configuration of orifices and volumes. Patient's age, sex and body mass are used to derive a probable low, mean, and high value for sleeping
After the study is completed, the patient can be provided with a home-use device that is similar to the system 100 shown in
(i) measuring an airflow through each ventilatory orifice 131, 133, 135 individually (conventional gauges can be used as variable area flowmeters or electronic flowmeters coupled to an input/output device, e.g., a computer, can be used to measure the airflow);
(ii) detecting CO2 content in airstreams stemming from each orifice 131, 133, 135 and transmitting the collected content data to an input/output device, e.g., a computer;
(iii) adjusting airflow through (or escaping from) each of the orifices 131, 133, 135 using valves (the valves can be operated manually or automatically);
(iv) adjusting sizes of the two deadspace volumes by disconnecting and connecting hoses of various lengths (alternatively, variable volume devices can be incorporated, which permit altering the deadspace volumes without changing hoses; the variable volume devices can be nested cylinders sealed with o-rings that can slide in and out); and
(v) computing and displaying a rate of flow of CO2 through each of the orifices (this function can be performed by any computing device having an appropriate data acquisition peripheral device running on software, such as DASYLab, which permits acquisition of both the CO2 and flow data channels; a suitable display can be used to permit a clinician to observe flow of CO2 through each orifice as the volumes are adjusted).
Referring to
As can be understood by one having ordinary skill in the art, the above methods can be applied in a laboratory setting, a hospital, a clinic, at patient's home, or any other facility.
Referring back to
As shown in
This hypoventilatory traverse describes a relationship between ventilation and CO2 excretion while the patient is hypoventilating. At values of
The first respiratory plateau segment 306 represents an effect of placing a first deadspace volume in the respiratory conduit. Once the first orifice reaches the saturation point, it does not matter how much the patient increases ventilation until such increase overcomes the first deadspace volume by pushing expired CO2 beyond the first deadspace volume and past the second orifice. Hence, increases in ventilation do not result in any additional CO2 excretion until this point is reached. The rate of ventilation at which the first deadspace is overcome and CO2 can flow from the second orifice is defined at the junction of the segment 306 and segment 308.
This respiratory plateau includes a zone where increased respiration above the first inflection point in the curve results in virtually no increase in
The first respiratory plateau segment 306 also permits the clinician to specify a mean arterial level of CO2 for the patient during sleep. Since affected patients are typically at least slightly hypocapnic (i.e., having lower than normal CO2 in arterial blood), it is desirable to reset their sleeping CO2 levels to a value that is closer to normal. The length of the first respiratory plateau segment 306 determines blood CO2 during therapy. Further, since the segment 306 is generated as a result of existence of the first deadspace volume in the mixing device, increasing the size of the first deadspace volume will raise blood CO2 levels. The amount by which any such increase in volume will raise blood CO2 levels can be calculated based on the patient's collected data.
The eucapnic traverse segment 308 represents placement of a second orifice in the respiratory conduit. Until this orifice is saturated (i.e., the point at which the concentration of CO2 in the air flowing from the orifice reaches a maximum), increases in the rate of ventilation (
Further, segment 308 represents the relationship between
The slope of the eucapnic traverse segment 308 is governed by multiple variables, such as the first and second deadspace volumes and sizes of the first and second ventilatory orifices. The slope of segment 308 becomes shallower when larger deadspace volumes are used and where the saturation points of the first and second orifices are closer together. The range of
The second respiratory plateau segment 310 is similar to the first respiratory plateau segment 306, however, segment 310 represents placement of a second deadspace volume in the respiratory conduit. The effects produced are similar to those discussed above with respect to segment 306. The saturation point of the second deadspace volume is defined at the junction of the segment 310 and 312.
The second respiratory plateau segment 310 is disposed above the highest expected sleeping value of
The first and second respiratory plateaus segments 306, 310 provide a powerful "ventilatory clamp." While
The hyperventilatory traverse segment 312 represents placement of an "escape" valve or a third orifice in the respiratory conduit. The third orifice is larger than the other two orifices. This allows escape of CO2 after saturation of the first and second orifices and deadspace volumes. As can be understood by one having ordinary skill in the art, other configurations of orifices and deadspace volumes are possible, thus, resulting in a different graphical representation.
The hyperventilatory traverse segment 312 serves as a safety precaution in the event that it will be necessary to excrete CO2 at a higher than expected rate, e.g., after a lengthy obstructive breathing event. Such excretion generates vigorous breathing at rates that are twice or more the normal rate of ventilation required to achieve such
In an exemplary setting, the present invention allows for 2-2.5% improvement in oxyhemoglobin saturation in a patient as compared to free breathing of ambient air. Since the oxyhemoglobin saturation curve is flat at its high end, this represents an important increase in available oxygen at the perfused tissues. Further, the present invention potentially obviates a need for supplemental oxygen in a number of medical settings. Also, by increasing oxygenation the present invention may reduce the sensitivity of the peripheral chemoreceptor, which causes most periodic breathing syndromes.
The present invention forces an increase in the depth of breathing and, thus, the overall rate of ventilation, since the first orifice is configured to saturate at a level that is insufficient to permit excretion of all CO2 being produced by the patient. The patient breathes deeply enough to push CO2 through the first deadspace volume, so that CO2 exits the device through at least the second orifice. By the time patient's inspiratory interval commences, the exhaled gas in various deadspace volumes has been replaced with air and, thus, the concentration of oxygen in the inspired air is only slightly lower than that in the ambient air. Taking the two things together, the increase in breathing more than offsets the slight decline in oxygen content of inspired air (FIO
The present invention, as described with respect to
1. Recovery from carbon monoxide poisoning. The systems and methods of the present invention speed up the rate of clearance of CO by three to five times relative to the conventionally available methods (e.g., giving oxygen).
2. Prevention of hypocapnia during birth. Hyperventilation by the delivering mother is very common and cuts oxygen supply to the fetus substantially due to a sharp drop in CO2. Low CO2, or hypocapnia, inhibits oxygen transport in many ways. The present invention improves oxygen flow to the fetus during delivery.
3. Recovery from altitude sickness/mountain climbing. The present invention systems and methods without use of the CPAP machine allows quick recovery from this condition.
4. Recovery from ventilator dependency. It is often difficult to wean patients from ventilator dependency, which is a cause of death in a critical care setting. The present invention stimulates breathing and increases oxygenation of the patient allowing the patient to quickly recover.
5. Recovery from anesthesia. This is similar to the recovery from ventilator dependency.
6. Obviating the use of supplemental oxygen in certain chronic lung diseases. Chronic obstructive pulmonary disease is very common and requires expensive oxygen therapy. However, with the present invention there is no need to use such oxygen therapy.
7. As can be understood by one having ordinary skill in the art, other uses of the present invention's systems and methods are possible.
Referring back to
As shown in
The airflow conduit 1601 can be permanently secured within the second volume 113. Alternatively, the airflow conduit 1601 can be slidably placed within second volume 113 to further control airflow. In some embodiments, the orifice tube 1603 can slide and/or move within the second volume 113. As can be understood by one skilled in the art, such airflow conduits can be placed at any orifice and/or within any volume in the system shown in
The multiple openings 1605 are configured to be disposed throughout the orifice tube 1603. As shown in
As can be understood by one skilled in the art, the openings 1605 can be equally spaced out throughout the orifice tube 1603. Alternatively, the openings 1605 can be sporadically placed on the tube 1603. The openings can be configured to be adjustable or controllable. This means that sizes of the openings can be adjusted while the system 100 is in operational state. Alternatively, the sizes of the openings can be fixed. Depending on the desired configuration, the sizes of the openings 1605 can have equal sizes or vary from opening to opening.
The valve 1609 controls evacuation of air from the volume 113. When the valve 1609 is open, the air is being pumped out through the multiple openings 1605 as indicated by the arrows. The air then travels through the orifice tube 1603 into the valve tube 1607 and out through exit port 1616 on the valve tube 1607. When the valve 1609 is closed, no air is being pumped out from the volume 113.
As can be understood by one skilled in the art, the rate of air evacuation from the volume 113 depends on the sizes of the openings 1605. Additionally, the rate can depend on the type of suction device that may be installed in the valve 1609. The valve 1609 can be any conventional valve configured to have an open and a closed position, wherein in the open position, the valve 1609 allows air to be pumped out from the orifice 1603 and/or to travel through the valve tube 1607 to the exit port 1616 and in the closed position, the valve 1609 prevents any air evacuation through the valve tube 1607.
As stated above with regard to embodiments shown in
When a patient breaths normally or healthy, the level of CO2 in his/her lungs is sustained at approximately 5.5% to 6%. When at rest (e.g., sleep), healthy patients breathe less. Such patients can breathe deeper and get as much air in their lungs as needed. Thus, as stated above, a proper level of CO2 is important for healthy breathing, as it serves as one of the regulators of patient's respiratory system, immune system, nervous system and patient's metabolism. As also stated above, a lot of patients suffer from overbreathing, i.e., a form of hidden hyperventilation that "blows off" CO2 from the lungs. Overbreathing reduces the level of CO2 in patient's blood as well. Overbreathing can be treated by reducing a volume of breathing, which normalizes patient's breathing. Normalizing patient's breathing also leads to healthier respiration, strengthened immune system, calmer nervous system and more efficient energy metabolism. On the other hand, having an excess CO2 can also lead to problems. Thus, appropriate levels of CO2 should be maintained in patient's blood.
As previously mentioned, each breath can be represented by plotting a rate of CO2 excretion as s function of patient's tidal volume. (See,
As also stated above, the slope of the traverse segment 1703 determines patient's respiratory stability, i.e., an ability of a patient to breathe normally during the night. Because of patient's unique physical and physiological characteristics and factors, the slope of the traverse segment 1703 may not be monotonic. In fact, the slope of the traverse segment 1703 decreases throughout the traverse segment, as shown in
Referring back to
The embodiment shown in
The operation of this system is such that the slope of the traverse segment created by the sum of the output of each of the openings 1605 is nearly monotonic and can be adjusted by the valve 1603 governing the evacuation of air out of the tube containing the plurality of orifices. Greater airflow through the tube yields a higher traverse slope and vice versa. Titration of the patient can be achieved by lowering the slope until fundamental stability is attained, and once that is established, no further slope reduction is necessary. Thus, by adjusting the valve 1603, a basic respiratory stability that the system provides for the patient is established. Thus, an advantage of the system is that it provides greater precision, efficacy at minimum required dosage, and fewer side-effects.
As patient's CO2 production varies during the night, the concentration of CO2 in patient's blood also varies. In some embodiments, a solenoid valve (not shown) may be used to switch the embedded CO2 monitor from monitoring and sampling the second orifice to monitoring and sampling the first orifice. Such switching can be done after predetermined periods of time. It can also be done automatically or manually. The peak value of CO2 concentration in the first orifice is substantially similar or closely correlates to the end-tidal CO2 value and it represents the concentration of CO2 in the patient's blood. Should this value be measured as lower than a normal value, as determined for a patient, the predetermined setpoint value can be increased. If the value is measured as higher than the normal value, the predetermined setpoint value can be lowered. Thus, patient's absolute level of CO2 blood concentration can be maintained well within the normal physiological range. As can be understood by one skilled in the art, the above adjustments can be done manually, automatically, periodically, or at predetermined periods of time. In some embodiments, during a particular sleep stage (e.g., REM sleep) a higher predetermined setpoint value of CO2 as well as higher flow through the second orifice (or the array of orifices shown in
In some embodiments, the concentration of gas flowing through second airflow control device is periodically monitored. Based on that monitoring a value for the end-tidal concentration of CO2 in the gas flowing through the at first airflow device is computed. This represents an estimate of the partial pressure of said CO2 in the arterial blood of the patient. The end-tidal CO2 value is compared to a predetermined range of acceptable end-tidal CO2 values. Then, the predetermined setpoint for concentration of gas flowing through the second airflow control device is adjusted.
In some embodiments, the system shown in
In the event of failure of the air generating device, the valve 2100 is configured to open and allow air flow of approximately 30 lpm (liters per minute) through the patient interface device (i.e., patient's mask). The valve 2100 can be configured to be open in a no-pressure, non-energized state. When the air generating device is properly connected and the air generating device's pressure is on, the valve is configured to be closed.
Referring to
In an embodiment, internal volume of the chamber 2102 is approximately 60 ml. The top plate 2112 is configured to allow ventilation of patient at a rate of approximately 30 lpm. The combination of the solenoid body 2116 and solenoid plunger 2118 are configured to be energized to allow the valve to open and close. The closing and opening of the valve 2100 is achieved using the spring 2120 that transmits force to the solenoid plunger 2118.
The valve 2100 can be configured to have threshold pressure values (e.g., upper and lower) at which the valve either opens or closes. The solenoid body 2116 and solenoid plunger 2118 can be further configured to activate when air generating device pressure starts below a lower threshold value and then surpasses an upper threshold value. Once the solenoid body 2116 and plunger 2118 are activated, the valve 2100 closes. In some embodiments, once the valve 2100 closes and the pressure drops below the upper threshold value, the solenoid components will not be re-activated, thus, the valve will remain closed. The solenoid components will re-activate if the pressure drops below the lower threshold or exceeds the upper threshold. In some embodiments, the lower threshold is defined as 2 cm H2O and the upper threshold is defined at 6 cm H2O. These thresholds can be adjusted.
Similar to the embodiments of
As shown in
The electronics box 2216 also receives information from a 3-way solenoid valve 2228. The valve 2228 is configured to be coupled to the airflow control conduit 2220 via airway connection 2275 to receive CO2 measurements and feed that information to the CO2 sensor 2224, which in turn sends this information the electronics box 2216. Such information allows adjustment of CO2 concentration as discussed above with regard to
The electronics box also controls a valve located at the first orifice 2212. The valve at the first orifice 2212 is configured to vent to ambient air 2242 (via an airway connection) based on the measurement of CO2 concentration at the airflow control conduit 2220, as discussed above with regard to
In some embodiments, the system 2200 also includes a water-trap attachment 2238 for collection of moisture (and any other unwanted elements) from the mask 2208 (via airway connection 2279) and/or conduits 2246, deadspace volumes 2204, 2206 or any other components in the system. As shown in
In some embodiments of the present invention, the first orifice 2212 is configured to allow a rate of airflow of 0-10 lpm. The airflow conduit 2220 is configured to allow a rate of airflow of 5 lpm at a pressure of 10 cm H2O. The rate of airflow from the airflow conduit is patient dependent, as discussed above with regard to
Example embodiments of the methods, circuits, and components of the present invention have been described herein. As noted elsewhere, these example embodiments have been described for illustrative purposes only, and are not limiting. Other embodiments are possible and are covered by the invention. Such embodiments will be apparent to persons skilled in the relevant art(s) based on the teachings contained herein. Thus, the breadth and scope of the present invention should not be limited by any of the above-described exemplary embodiments, but should be defined only in accordance with the following claims and their equivalents.
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|U.S. Classification
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|International Classification
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|25 May 2012
Owner name: THE PERIODIC BREATHING FOUNDATION, LLC, A DELAWARE
Free format text: ASSIGNMENT OF ASSIGNORS INTEREST;ASSIGNOR:DALY, ROBERT W;REEL/FRAME:028272/0766
Effective date: 20120525
|15 Jun 2015
|Fee payment
Year of fee payment: 4


text:
ADAMS COUNTY, Miss. (WJTV) — The last of three men charged in connection with a February 2014 shooting death in Adams County has been convicted of aggravated assault for his role in the crime.
Attorney General Jim Hood said 35-year-old Alan T. Thomas pleaded guilty Wednesday to aggravated assault in the killing of Terrance Thornburg.
Thomas was sentenced to 15 years in prison with 10 months already served and 14 years, two months suspended. Additionally, Thomas must serve 10 years of post-release supervision, pay $500 to the Mississippi Crime Victim Compensation Fund, and pay all court costs.
Hood said the investigation did not reveal any substantial evidence that Thomas had prior knowledge of any potential criminal activity before arriving at the victim's residence.
Thomas drove his two co-defendants to the victim's home, then joined them in entering the home prior to the commission of the attempted robbery and murder.
Maurice Davis, of Natchez was sentenced last week for manslaughter to 15 years in prison with 10 years suspended, leaving five years to serve and 10 years of post-release supervision.
Jhakeel Hawkins, of Natchez, was sentenced for aggravated assault Tuesday to 15 years in prison with 10 years suspended, leaving five years to serve and 10 years of post-release supervision.

subset: commoncrawl


text: bendix-1 bendix-2a A good candidate for bead blasting. bendix-2b Evapo-Rust works as well. bendix-2c After a few hours in Evapo-Rust. bendix-5 Head sleeve crimped to bendix shaft. Notice the chisel mark. bendix-9 bendix-10 Stop nut secured with Loctite. bendix-11 Drilling out the staking to free up stop nut. bendix-expanded bendix-8 Collar pin and spring.


text: I dual-boot '95/XP on a mix of fat32 and ntfs partitions. I've heard horror stories of people unable to boot because they messed up their boot files and this gives me nightmares that one sad day this might happen to me too. As I'm not sure how the boot process works, how would I repair that? For the time being, I've put ntldr and boot.ini onto a floppy. Would these 2 files solve the problem if I restored them to the root of C: in case I lost my... booting power? Cheers all. Annette


text:
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text:
First Tutors enables you to find a home biology tutor in Hailsham and across the UK. Local biology tuition is an excellent way to boost confidence as well as increasing grades and doesn't have to be boring! Please use our service to search for Hailsham biology tutors and select which best fits your needs.
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text:
In the past couple of years, Family Film has established itself as a reliable, price-efficient, client-centered production house in Bucharest. Now it's time for Family Film Budapest to write history!
Giuliano Doman, the founder of Family Film and his local partner, Anna Sesztakova, established Budapest office of Family Film in March 2016 to help accomodate the needs of their constantly growing international clientele to find a production house to satisfy all their demands and expectations in Hungary.
It is a huge privilege and a challenge to live up to the expectations of the clients who have shot dozens of projects with Family Film in Romania, and provide the same high end quality but we are happy to declare that this year has been very productive and full of fun, successful projects that we are proud of!
We offer top quality services in pre-production (budgeting, location scouting, casting, concept, set construction and design), as well as in shooting and post-production services for various local and international clients.
Family is not just a brand name, it is an attitude to our partners.We cherish a strong relationship and commitment to our clients. That's why Family Film crew guarantees high quality standards and a professional manner of solving problems, aiming to meet all expectations of cost effectiveness and quality. We always care about you and your money. Therefore, we find the best solutions for every budget and adapt our assets to each client's needs. We'll give our best to make your stay and shoot in Hungary a memorable one!
The international showreel of Family Film includes:
Feature films:
– Jai Ho (2014)
– Singh is Bliing (2015)
– Hero (2015)
– Raaz 4 (2015)
Plus more than 150 commercials for local and international markets.


text:
End of term
The end of the school term is when we say cheerio. And for junior school children especially, this is a time for giving a present to the teacher.
It was at the end of the school year, and a nursery teacher was receiving gifts from her pupils.
The florist's son handed her a gift. She shook it, held it overhead, and said, "I bet I know what it is. Some flowers." "That's right" the boy said, "but how did you know?" "Oh, just a wild guess," she said.
The next pupil was the sweet shop owner's daughter. The teacher held her gift overhead, shook it, and said, "I bet I can guess what it is. A box of sweets." "That's right, but how did you know?" asked the girl. "Oh, just a wild guess," said the teacher.
The next gift was from the son of the owner of the off-license (or 'liquor store' for those living on the other side of the pond). The teacher held the package overhead, but it was leaking. She wiped a drop of the leakage with her finger and touched it to her tongue. "Is it wine?" she asked. "No." the boy replied, with some excitement. The teacher repeated the process, taking a larger drop of the leakage to her tongue. "Is it champagne?" she asked. "No," the boy replied, with more excitement. The teacher took one more taste before declaring, "I give up, what is it?"
With great glee, the boy replied, "It's a puppy!"


text:
Sequoia Johnson
September 4th, 2015 · No Comments
Sequoia Johnson Berkeley Community Fund High Hopes Scholar California State University, East Bay Sequoia is graduating from the Academy of Medicine and Public Service (AMPS) at BHS with a clear focus on a career in medicine. She aspires to be an RN in a challenging specialty and to be an instrument of change in her community. Sequoia is proud of starting the school's Medical Emergency Response Club and of interning with the City of Berkeley's Mental Health Services Department. She also participated in BHS' Bridge program and in Berkeley Youth Alternatives. She will be the first in her family to attend college.


text:
|Home | Articles | News | Blog | About | Mailing List | Resources | Prominent Islamists | Middle East Forum | Keep Us Informed | Donate
CAIR-MI representing incarcerated Muslim in halal lawsuit
Arab American News
The Council on American Islamic Relations of Michigan is representing an incarcerated Muslim, who was denied halal food in the St. Clair County Jail. A lawsuit was filed in the United States District Court for the Eastern District of Michigan regarding the incident.
CAIR-MI has received numerous complaints about the lack of religious accommodations for detained Muslims in county jails and state prisons. If you have complaints regarding family members or friends being denied Halal food or access to practice Islam in correctional facilities in Michigan, call CAIR'S office at 248-559-2247.
Read the complete original version of this item...
Related Topics: Halal, Legal, Lobby Groups, Multiculturalism, Prisons receive the latest by email: subscribe to the free islamist watch mailing list
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Creeping Dhimmitude


text:
Reuters Staff
1 Min Read
April 3 (Reuters) - Silicom Ltd
* Silicom Ltd- files for stock shelf offering up to $80 million - SEC filing Source: (bit.ly/2osOguJ) Further company coverage:
All quotes delayed a minimum of 15 minutes. See here for a complete list of exchanges and delays.
© 2018 Reuters. All Rights Reserved.


text:
Kreativ Blogger Award
Yes, a thumb's up for Chubby*Hobby! Su Loves Sew has kindly presented me the Kreativ Blogger Award!! Thanks so much Su, this is so encouraging and I truly appreciate it!!
So, onto the rules:
- Copy the award to my blog (done!)
- Link to the person who has given me this award (done!)
- Tell 7 interesting things about myself
- Choose 7 other blogs that I want to give this award to
- Link to their blogs
- Comment on their blogs that I have given them this award
Hmmm… 7 interesting (or not-so-interesting) things about myself…
- I drop everything on the floor and leave a trail of stuff as I walk into my house – including my jacket, I just take it off and drop it on the ground!
- I like to drink water with a straw even at home.
- I lived in NZ for 3 years before and used to say "yis yis"…:D
- Whenever I work on a sewing project, Ken thinks that there has been a typhoon in the house :p
- I wanted to be a manga/anime artist when I was little.
- I majored in Software Engineering, but I hate computers!!
- I don't like wearing skirts!!!!
That was hard!! And now onto my nominations (not in any particular order and by no means exhaustive^^). My nominees for the Kreativ Blogger Award go to:
- Cotton & Cloud
- dear fii
- Pink Penguin
- viljtig
- Miss Minzy
- How are you all? (EmiShimosato)
- Smitten Kitchen
Congratulations to the nominees!! hehe.. And I do apologise in advance if you have already receive this award before 😀
Here's my Sunday Inspiration! hehe.. I believe a post is incomplete without a picture?! *smile*
Looks like my job here is done! ^0^
I hope you are having a lovely Sunday!
Thanks so much, Jo, for picking me as one of your nominees!! I am so honored! By the way I totally understand what you mean by a typhoon during a sewing project. I worked on some projects this morning so it sure looks like there has been a typhoon around my crafting space!
Thank you very much for picking up my blog!
The sewing machine in the picture looks sooooooooooo nice! I wish I could have such a antique machine…
Hi Jo!
Thank you very much for picking me as one of your nominees too 😀
How wonderful that you wanted to be a manga artist! When I was about 8 I wanted to be one too but I realised that I was no good at drawing…
Hope you had wonderful weekend!


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Gari la Waziri wa Kazi lapata ajalli njia ya Arusha Moshi!
Discussion in 'Habari na Hoja mchanganyiko' started by LiverpoolFC, Oct 11, 2012.
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Cricket is a 2nd most popular game in the world. So, definitely the players who play the game on the ground get higher audience attraction because of their performances, playing-styles, posture and looks, indeed. Fans of every cricketer do wish to know more about them and the most common thing that attracts them is, 'Who Is His Wife And How Does She Looks?'. Handsome guys get handsome partners and in this post we have compiled a list of 10 Hottest Wives Of Cricketers. That's probably you are willing to know. Scroll down and take a look!
10. Sue Erasmus (Wife Of JP Duminy)
South African cricketer JP Duminy got married to Sue Erasmus in 2011. Sue Erasmus really has some hottest and beautiful looks. She holds the 10th spot in the list of !0 Hottest Wives Of Cricketers.
9. Jessica Taylor (Wife Of Kevin Pietersen)
English cricketer Kevin Pietersen got married to Jessica Taylor in December, 2007. Jessica Taylor is best known as a glamour model, singer and dancer. Overall, Jessica has a brilliant career record and also, she was a member of Liberty X, which was a Brit Award-winning pop group. She has appealing personality and so, she holds the 9th spot in the list of 10 Hottest Wives Of Cricketers.
8. Kyly Boldy (Wife Of Michael Clarke)
Australian former cricketer Michael Clarke got married to Kyly Boldy, in May, 2012. Kyly is well known as a model and TV presenter. Kyly have won numerous titles as Miss Indy 1999, Australian Swimwear Model of the Year 2002, Miss Adrenalin Sports Model of the Year 2003 etc. She also have represented Australia in overseas. She holds 8th spot in the list of 10 Hottest Wives Of Cricketers.
7. Sakshi Singh (Wife Of MS Dhoni)
Indian cricketer Mahindra Singh Dhoni got married to Sakshi Singh in July, 2010. Sakshi is Graduated in Hotel Management and at the time when she first met MS Dhoni, she was working as a trainee at Taj Hotel. Dhoni definitely fell for her as she is a charming and beautiful girl. She holds 7th spot in the list of 10 Hottest Wives Of Cricketers.
6. Lee Furlong (Wife Of Shane Watson)
Australian cricketer Shane Watson got married to Lee Furlong in May, 2010. Lee Furlong is known well as a Fox News presenter. There is no more bio to disclose about her as she have kept her profile very low. But in fact, she is really very hot and beautiful, so she holds the 6th spot in the list of 10 Hottest Wives Of Cricketers.
5. Candice Falzon (Wife Of David Warner)
Australian criketer David Warner got married to Candice Falzon in April, 2015. Candice Falzon is quiet an amazing model and also she is known as a ironwoman and surf life saver. As we talk about her looks, she really has appealing personality, and that's why she holds 5th spot in the list of 10 Hottest Wives Of Cricketers.
4. Jessica Bratich (Wife Of Mitchell Johnson)
Australian cricketer Mitchell Johnson got married to Jessica Bratich in May, 2011. Jessica is a former Karate Black Belt and has earned numerous awards on international level. Jessica looks quiet amazing and beautiful in looks. She holds 4th spot in the list of 10 Hottest Wives Of The Cricketers.
3. Sania Mirza (Wife Of Shoaib Malik)
Pakistani cricketer Shoaib Malik got married to Sania Mirza in April, 2010. Sania Mirza is a professional tennis players who even holds the No. 1 Rank in Doubles format of Tennis. She has got too much fame in India, not just because of her playing talent, but also because of her sexy appearance too. She is known as one of the most popular women athletes in the world and she holds 3rd spot in the list of 10 Hottest Wives Of Cricketers.
2. Mayanti Langer (Wife Of Stuart Binny)
Indian cricketer Stuart Binny got married to Mayanti Langer in 2012. Mayanti Langer is a well-known hot-looking Indian TV Sports journalist. She has hosted in many FIFA tournaments, Cricket tournaments etc. She really has sexy, hot and mind blowing appearance and that's why she holds the 2nd spot in the list of 10 Hottest Wives Of Cricketers.
1. Umme Ahmed Shishir (Wife Of Sakib Al Hasan)
Bangladeshi cricketer Sakib Al Hasan got married to Umme Ahmed Shishir in December, 2012. Undoubtedly, Umme Ahmed Shishir takes the 1st spot of the list because of her dazzling hot looks. She met Sakib Al Hasan in England, in 2010. She is entirely an amazing looking women and so, Sakib Al Hasan is quiet lucky. Winner of our list is Umme Ahmed Shishir! 😉
That's all! These are the hottest wives of cricketers. There are probably more, but we just compiled a list of Top 10 ones. Which one is more beautiful wife in your point of view? Share your thoughts!
Don't forget to check out: 10 Hottest WAGs Of Soccer Players
Stay tuned for more! 🙂


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Writestream Radio is pleased to announce the addition of a new program to our line-up. Love true crime? Crime fiction? Are you a writer with murder in your plot? You're going to love Partners in Crime, co-hosted by authors Kimberly McGath and Sue Coletta:
Every third Tuesday of the month from 1 p.m. – 3 p.m. EDT/EST this talented duo will be talking crime!!!! In the first hour, they'll discuss true crime; the second hour will be geared toward crime fiction. Kimberly and Sue will also answer writers' questions just like they do on their Twitter chat, #ACrimeChat. And they'll even throw in a crime puzzle or two. Be the first to call in with the correct answer and win a prize.
About Kimberly McGath:
Retired detective turned cold case consultant and author, Kimberly McGath recently released Zodiac, Settling the Score, in which she outlines a compelling theory regarding the identity of the infamous Zodiac killer. McGath also recently released a guide entitled Let Them See, warning parents about various emerging diseases that are causing blindness in children.
Kimberly McGath received her Bachelor's degree in Psychology from the University of South Florida. Kimberly McGath's law enforcement career spanned more than a decade in which she worked in the Special Victims Unit, Mounted Patrol, and the Criminal Investigations Bureau. McGath was the first and only detective in her agency to discover the whereabouts of a clandestine grave without an informant. McGath exhumed the body of this female victim which led her on a hunt of a serial killer.
McGath worked in various undercover roles and obtained many confessions from murderers and other violent felons. McGath earned the nicknames "Tenacious K" and "Bulldog" due to her relentless pursuit of the truth.
McGath received various academic awards and was recognized by the U.S. Secret Service for her investigation which led to the recovery of a fugitive from Kansas who had been in hiding for over twenty years. McGath has worked high-profile cold cases which have received worldwide media attention. McGath is also a singer/songwriter and a married mother of three.
About Sue Coletta:
Member of Mystery Writers of America, Sisters in Crime, and International Thriller Writers, Sue Coletta is the Top 10 bestselling author of Wings of Mayhem, MARRED, The Rendering, Crime Writer's Research, and 60 Ways to Murder Your Characters. A multi-published author in numerous anthologies, her forensics articles have appeared in InSinC Quarterly. In addition to her popular crime resource blog, Sue's the communications manager for the Serial Killer Project and Forensic Science and founder of #ACrimeChat on Twitter. Every 3rd Tuesday of the month, Sue co-hosts the radio show "Partners In Crime" on Writestream Radio with author Kim McGath, homicide detective (Ret.) and cold case consultant. Learn more about Sue and her books at: http://www.suecoletta.com.
Stay tuned for details on their debut broadcast on Tuesday, October 18 at 1 PM Eastern.


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Christmas Magnets
Create your very own Christmas Magnets with Adhesive Magnetic Sheets. We offer nine template pages with a mix of all of your favorite holiday images. Decorate your refrigerator with joy!
note: Even though there are Printable Magnetic Sheets on the market, our past experience has shown that they often jam in the printer wasting materials, money and time. This is why we recommend the Adhesive Magnetic Sheets. They are currently available at local stores and are fairly inexpensive.


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March 8th, 2018 | 12:30 – 5:30 pm
Produced By:
All information related to your exhibiting experience at Fresh Ideas is now located in one place! Login to your exhibitor console to access the following:
Exhibiting at Fresh Ideas will help your company earn Priority Points that determine the order in which booth and hotel reservations are made for the Natural Products Expos. For complete information, click here.
Not able to participate in the Space Selection during your company's selection time? Download the Proxy Form to authorize either a New Hope Network show management member or another representative from your company to select your company's exhibit space on your behalf.
It's free, takes a few minutes, and there is no obligation. Please have product packaging and marketing ready to submit electronically. A confirmation email is sent upon completion. Click here to apply.
Fresh Ideas 2017 is a part of the U.S. Department of Commerce, Commercial Service International Buyer Program (IBP). This program leverages the power of U.S. Commercial Service Industry Experts working within the commercial sections at U.S. Embassies in countries around the world. These specialists will be attending and/or leading country delegations to Fresh Ideas 2017 and are your U.S. representatives and business advocates for these countries. The specialists are also eager and available to discuss the current market situation, opportunities, export issues, and needs specific to your business in their respective countries.
The New Hope Network Standards Program is designed to maintain consistency with federal and international regulations and is presented in a spirit of cooperation with current industry efforts to ensure quality and integrity of natural products.
Exhibitors are contractually bound to abide by the Standards policy and New Hope Network reserves the right to determine the eligibility of any company or product for inclusion in its events and publications.
For more information about our Standards Program and contracts, click here or call 1.303.939.8440.
With so many people in one building, it is our goal to ensure the safety of and enjoyment for all attendees and exhibitors at the show. We appreciate your cooperation in adhering to the show policies.
Log in today to:
Click here to retrieve your Company password.
Click here to make your reservation
Please be vigilant if approached by any company or service other than onPeak, that implies or claims to be a housing provider for Expo West. onPeak is the only Official Hotel Partner for Expo West. We are aware that other housing companies or travel agencies may contact you or your company to book your guest rooms through them. Neither onPeak, nor Expo West have any affiliation with these organizations and cannot vouch for their services in any way. Entering into financial agreements with non-endorsed companies can potentially cost you thousands of dollars with no guarantee of an actual hotel reservation. Reservations through these agencies or companies are made at your own risk and responsibility.


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Automated accounting software has dumbed down the profession to such an extent that many accountants no longer understand the basic principles of double-entry bookkeeping, AccountingWEB members have claimed.
It began last month in the Sage 50 Accounts discussion group with a tricky bit of reconstruction work to reallocate a couple of invoices in a bank reconciliation completed during the previous financial year, but escalated into a diatribe against falling professional standards and the havoc wrought by over-reliance on computer software.
Some members of the group looked for ways to delete and re-enter the transactions to reallocate payments against particular invoices, and another member suggested a way to do this by going into the Sage Maintenance module and editing the transactions there.
But witch-queen, a bookkeeper and Sage trainer advised that while "VAT Cash Accounting in Sage can be a pain, but if you just stop and think for a second, there is always a way to manually correct things. Bank Payments can be reversed with a Bank Receipt (and vice versa) and the corrected transaction entered," she wrote.
Invoices on both sides can be reversed with a credit note (and vice versa) via the suspense account and the corrected transaction entered.
The episode prompted a rant from AccountingWEB member Lloyd Sherwood. "What really amazes me [is] the lack of understanding of double entry principle which needs to be applied prior to processing of financial data onto a computerised accounting software," he wrote.
Please Login or Register to read the full article
The full article is available to registered AccountingWEB.co.uk members only. To read the rest of this article you'll need to login or register. Registration is FREE and allows you to view all content, ask questions, comment and much more.
About John Stokdyk
John Stokdyk is the global editor of AccountingWEB UK and AccountingWEB.com.


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Elitebook HP laptop Core i5 4gb RAM, 320gb HDD WiFi ready, 1gb O/b VGA Good battery,w/ charger and Bag
Tips for Online Transactions
- Avoid scams by acting locally or paying with PayPal, Bank Deposit, LBC, or Pera Padala without the item.
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- Don't buy or sell outside of your country. Don't accept cheques
- This site is never involved in any transaction, and does not handle payments, shipping, guarantee transactions, provide escrow services, or offer "buyer protection" or "seller certification"


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Mundine: more regulation of Indigenous corporations needed
The ABC's Four Corners program has alleged that former chief executive of the Jawoyn Association Aboriginal Corporation, Preston Lee, spent hundreds of thousands of dollars of the association's money on himself.
Lee denies the allegations and the Office of the Registrar of Indigenous Corporations, or ORIC, has decided it will not pursue legal action in relation to allegations of fraud because it found insufficient evidence.
However Warren Mundine is still calling for changes to the way that Indigenous corporations are regulated, stating that a radical overhaul of ORIC is necessary.
He joined RN Drive to discuss his views as well as recent ALP leadership ballot.
- Warren Mundine
- Chair, Prime Minister's Indigenous Advisory Council; former national president, Australian Labor Party
- Presenter
- Georgia Moodie


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Advocacy Action Network
Join nearly 30,000 people taking action on cancer
This year, the Irish Cancer Society is building a movement of cancer campaigners across every community in Ireland. By taking an action as simple as signing a petition or emailing a TD, you can make a difference.
The action might be as simple as signing a petition online or writing a letter. We will be in regular contact with these campaigners through email and our social media channels, keeping you up to date on our activities.
Our advocacy team will travel across the country this year to listen to the stories from cancer patients, their families and friends.
Our campaigns will run online and at Irish Cancer Society events, like Relay For Life, a series of 24 hour relay events held in communities across Ireland.
Join us in our campaign. Register today and we will keep you informed by occasional emails about upcoming campaigns and how you can get involved.
Join the Advocacy Action Network
Register for our Advocacy Action Network emails to receive alerts about latest news, upcoming events and campaigns and opportunities for you to get involved.
We won't give up until cancer does


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Everyone is invited to join us Sunday, December 20th at 2:30pm in the Taylor Community Center Gym for a special Christmas treat. This is a special visit from Santa, where he will share stories, songs, and Christmas magic. There will…
Read to Achieve Library Challenge
by Library Director • • 0 Comments
Readers in grades 1-8 have a chance to earn a free ticket to the March 16 or April 5 Milwaukee Bucks game through the Read to Achieve challenge. Pick up a packet which contains a reading record, stickers, bookmarks, and poster…
Read to Rover
by Library Director • • 0 Comments
Read to Rover is coming to the Taylor Memorial Library! Read to Rover is a program sponsored by the Coulee Region Humane Society. A volunteer handler will bring their certified therapy dog or cat to the library and children…
You Did It!
by Library Director • • 0 Comments
The Taylor community should be very proud! During the six weeks of Good Reads for a Good Cause, you read 407 books. Give yourself a huge pat on the back!! Because of your participation and dedication, we raised over $800…
We're Almost Halfway There
by Library Director • • 0 Comments
The Taylor Community Wide Summer Reading Program is well under way! We have had several book logs turned in already and we are almost halfway to our goal. We have a little over a week left, so keep on reading…
4th of July
by Library Director • • 0 Comments
The Taylor Memorial Library will be CLOSED on Friday, July 4th. Everyone have a safe and happy holiday!
Summer Reading Program Kick-Off
by Library Director • • 0 Comments
Our Summer Reading Program kicks off next week with a presentation from Incredible Bats! Thursday, June 26th at 11:00 at the Taylor Community Center Gym Daniel and Sharon Peterson of Incredible Bats! have been educating people about bats for over…
Haunted Wisconsin
by Library Director • • 0 Comments
Come and hear Chad Lewis talk about Wisconsin's Most Haunted Locations Thursday, June 12th at 7pm Taylor Community Center Gym This presentation is FREE and appropriate for all ages Haunted Locations in Your Own Backyard This presentation takes the audience…
by Library Director • • 0 Comments
The library will be CLOSED on April 18th in observance of Good Friday.
Welcome to our new Online Catalog
by Library Director • • 0 Comments
The migration to our new system was successful! Thank you to all of our patrons for your patience. You should now be able to access the catalog from the search box to the right or from this link: WRLSWEB…


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Evil cat ignores owner's protests and is evil anyway
This cat really has no time for your protests and he just needs everything off the coffee table NOW.
First to go is the remote control, the owner doesn't mind that too much but next up is a glass and so she begins to tell her cat not to knock it over.
And he doesn't. Until about five seconds later when he does anyway…
We love them anyway, right? In fact, we think this particular owner has things pretty spot on:


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Meet Our Staff
Pastor: Rev. Dr. J. Richard McDuffie, Jr.
J. Richard "Rick" McDuffie, Jr. is a native of Southeastern North Carolina and a descendant of the original Highland Scot Presbyterian settlers of the Cape Fear region. He grew up in Lumberton and holds a B.A. in Religion and Philosophy from Campbell University , plus two graduate seminary degrees. Rick has been a pastor since 1979, and has been a Teaching Elder in the Presbyterian (USA) since 2001. He has also spent time serving in the United Church of Christ as an interim minister. In his free time, Rick enjoys playing guitar and euphonium, working with his horses, gardening and reading American and world history and a wide variety of other subjects. Rick and his wife Debbie have three daughters and (at present) three grandsons and four granddaughters. Rick enjoys many aspects of church life at Westminster, but is especially glad that the Westminster people have a high degree of commitment to their church family and the Kingdom of God. He is also thankful for the church's delightful sense of humor!
Director of Youth and Church Program Ministries
Erin Wehrmeister ---- email@example.com
Erin Wehrmeister grew up in the Dallas, Texas area and attended Presbyterian churches her entire life. She is a Texas State graduate, with degrees in Public Relations and English. She also earned a Certificate in Youth & Theology from Princeton Theological Seminary. Erin has worked with the youth at several Texas churches & served as the chaplain for the Christian sorority, Sigma Phi Lambda. Upon graduation, she worked with the Center for Student Missions in Washington, DC, followed by various jobs ranging from a rental car company to marketing for a hockey team! She moved to North Carolina and joined staff as a secretary & bookkeeper, while volunteering with our youth and working with the Presbytery of Coastal Carolina Youth Council. Erin is especially excited to be the Director of Youth & Program ministries here at WPC. She is the aunt to 5 wonderful kiddos back in Texas and "mom to one un-impressible cat. Erin loves this church family and feels blessed to be a part of a community that loves Jesus, supports ALL generations, joyfully shares the gospel AND owns a disco ball, Gallagher mallet for watermelons (seriously) and a cardboard Jesus cut-out. You know¦ just in case.
Office Manager: April Venegas- firstname.lastname@example.com
Director of Music: Mary Beth Winter
Organist: Karen Troutman