text:
By now, most of our readers have seen the coverage coming out of Monday's announcement of the U.S. Environmental Protection Agency's new carbon emission regulations.
According to the Washington Post, the new rules will require states to cut carbon emissions from the electric sector by as much as 30% by 2030 - something that will be impossible to achieve without preserving and perhaps expanding the nation's fleet of nuclear power plants.
So where can you find the nuclear references in the new rules, known better as 40 CFR Part 62? NEI's own Scott Mantsch went to the trouble earlier this week of doing the hard work for us. Please note that we've added paragraph breaks to aid with readability in this format.
Page 39:
States may also identify technologies or strategies that are not explicitly mentioned in any of the four building blocks and may use those technologies or strategies as part of their overall plans (e.g., market-based trading programs or construction of new natural combined cycle units or nuclear plants). Further, the EPA's approach allows multi-state compliance strategies.
Page 114:
Based on our analysis of that information, the proposed state goals reflect the following stringency of application of the measures in each of the building blocks: […] block 3, including the projected amounts of generation achievable by completing all nuclear units currently under construction, avoiding retirement of about six percent of existing nuclear capacity
Page 151:
More than half the states already have established some form of state-level renewable energy requirements, with targets calling on average for almost 20 percent of 2020 generation to be supplied from renewable sources. The EPA is unaware of analogous state policies to support development of new nuclear units, but 30 states already have nuclear EGUs (with five units under construction) and the generation from these units is currently helping to avoid CO2 emissions from fossil fuel-fired EGUs. Policies that encourage development of renewable energy capacity and discourage premature retirement of nuclear capacity could be useful elements of CO2 reduction strategies and are consistent with current industry behavior. Costs of CO2 reductions achievable through these policies have been estimated in a range from $10 to $40 per metric ton.
Pages 214-219:
Nuclear generating capacity facilitates CO2 emission reductions at fossil fuel-fired EGUs by providing carbon-free generation that can replace generation at those EGUs. Because of their relatively low variable operating costs, nuclear EGUs that are available to operate typically are dispatched before fossil fuel-fired EGUs. Increasing the amount of nuclear capacity relative to the amount that would otherwise be available to operate is therefore a technically viable approach to support reducing CO2 emissions from affected fossil fuel-fired EGUs.
1. Proposed quantification of nuclear generation
One way to increase the amount of available nuclear capacity is to build new nuclear EGUs. However, in addition to having low variable operating costs, nuclear generating capacity is also relatively expensive to build compared to other types of generating capacity, and little new nuclear capacity has been constructed in the U.S. in recent years; instead, most recent generating capacity additions have consisted of NGCC or renewable capacity. Nevertheless, five nuclear EGUs at three plants are currently under construction: Watts Bar 2 in Tennessee, Vogtle 3-4 in Georgia, and Summer 2-3 in South Carolina.
The EPA believes that since the decisions to construct these units were made prior to this proposal, it is reasonable to view the incremental cost associated with the CO2 emission reductions available from completion of these units as zero for purposes of setting states' CO2 reduction goals (although EPA acknowledges that the planning for those units likely included consideration of the possibility of future regulation of CO2 emissions from EGUs). Completion of these units therefore represents an opportunity to reduce CO2 emissions from affected fossil fuel-fired EGUs at a very reasonable cost. For this reason, we are proposing that the emission reductions achievable at affected sources based on the generation provided at the identified nuclear units currently under construction should be factored into the state goals for the respective states where these new units are located.
However, the EPA also realizes that reflecting completion of these units in the goals has a significant impact on the calculated goals for the states in which these units are located. If one or more of the units were not completed as projected, that could have a significant impact on the state's ability to meet the goal. We therefore take comment on whether it is appropriate to reflect completion of these units in the state goals and on alternative ways of considering these units when setting state goals. Another way to increase the amount of available nuclear capacity is to preserve existing nuclear EGUs that might otherwise be retired.
The EPA is aware of six nuclear EGUs at five plants that have retired or whose retirements have been announced since 2012: San Onofre Units 2-3 in California, Crystal River 3 in Florida, Kewaunee in Wisconsin, Vermont Yankee in Vermont, and Oyster Creek in New Jersey. While each retirement decision is based on the unique circumstances of that individual unit, the EPA recognizes that a host of factors – increasing fixed operation and maintenance costs, relatively low wholesale electricity prices, and additional capital investment associated with ensuring plant security and emergency preparedness – have altered the outlook for the U.S. nuclear fleet in recent years. Reflecting similar concern for these challenges, EIA in its most recent Annual Energy Outlook has projected an additional 5.7 GW of capacity reductions to the nuclear fleet. EIA describes the projected capacity reductions – which are not tied to the projected retirement of any specific unit – as necessary to recognize the "continued economic challenges" faced by the higher-cost nuclear units. Likewise, without making any judgment about the likelihood that any individual EGU will retire, we view this 5.7 GW, which comprises an approximately six percent share of nuclear capacity, as a reasonable proxy for the amount of nuclear capacity at risk of retirement.
2. Cost of CO2 emission reductions from nuclear generation
We have determined that, based on available information regarding the cost and performance of the nuclear fleet, preserving the operation of at-risk nuclear capacity would likely be capable of achieving CO2 reductions from affected EGUs at a reasonable cost. For example, retaining the estimated six percent of nuclear capacity that is at risk for retirement could support avoiding 200 to 300 million metric tons of CO2 over an initial compliance phase-in period of ten years. According to a recent report, nuclear units may be experiencing up to a $6/MWh shortfall in covering their operating costs with electricity sales. Assuming that such a revenue shortfall is representative of the incentive to retire at-risk nuclear capacity, one can estimate the value of offsetting the revenue loss at these at-risk nuclear units to be approximately $12 to $17 per metric ton of CO2. EPA views this cost as reasonable. We therefore propose that the emission reductions supported by retaining in operation six percent of each state's historical nuclear capacity should be factored into the state goals for the respective states.
For purposes of goal computation, generation from under-construction and preserved nuclear capacity is based on an estimated 90 percent average utilization rate for U.S. nuclear units, consistent with long-term average annual utilization rates observed across the nuclear fleet. The methodology for taking this generation into account for purposes of setting state emission rate goals is described below in Section VII on state goals and in the Goal Computation TSD.
We invite comment on all aspects of the approach discussed above. In addition, we specifically request comment on whether we should include in the state goals an estimated amount of additional nuclear capacity whose construction is sufficiently likely to merit evaluation for potential inclusion in the goal- setting computation. If so, how should we do so – for example, according to EGU owners' announcements, the issuance of permits, projections of new construction by EPA or another government agency, or commercial projections? What specific data sources should we consider for those permits or projections?
Page 282:
In addition, owners of existing nuclear units and nuclear units currently under construction can take action to complete or preserve that capacity, the generation from which likewise can be dispatched in a coordinated manner to substitute for fossil fuel-fired generation. As discussed above, coordination of these decisions in the integrated electricity system can occur through a variety of mechanisms, some centralized and some not.
Page 283:
The EPA believes that the performance of the nuclear measures in building block 3 against the other BSER measures is also positive on balance. With respect to encouragement of technological innovation, incentives for completion of nuclear capacity currently under construction encourage deployment of nuclear unit designs that reflect advances over earlier designs. The nation's nuclear fleet today routinely operates at high average utilization rates, suggesting no reason to expect adverse reliability consequences from completion or preservation of additional nuclear capacity. The five nuclear units currently under construction are all designed to use closed-cycle cooling systems with lower cooling water usage than some existing fossil fuel-fired EGUs; existing nuclear units may use amounts of cooling water comparable to the amounts used by those fossil fuel-fired steam EGUs. The EPA recognizes that nuclear generation poses unique waste disposal issues (although it avoids the solid waste issues specific to coal-fired generation). However, we do not consider that potential disadvantage of nuclear generation relative to fossil fuel-fired generation as outweighing nuclear generation's other advantages as an element of building block 3. For all these reasons, we consider building block 3 to be a component of the "best system of emission reduction ... adequately demonstrated."
E&E TV: An E&E News Video Program
1 hour ago


text:
A Marine Sergeant wrote this in response to an Army guy who posted a comment on the Marine Corps site that he was sick and tired of "Marine arrogance".
The Sergeant writes:
"I think that's what makes Marines special, if only in our own minds, is that elusive Quality of Esprit D'Corps. It's the fact that we, as individual Marines, don't feel that we are individual Marines. When we wear our uniform, when we hear our Hymn, when we go into battle, we are going with every other Marine who ever wore the uniform.
Standing behind us are the Marines who fought during the birth Of our nation. We're standing with the Marines who fought in WWI and gave birth to the legend of the "Tueful Hunden", or "Devil Dogs". We are standing with the Marines who took Iwo and Tarawa and countless other blood soaked islands throughout the Pacific.
We are standing with the "Frozen Chosin" and our beloved Chesty Puller. We are standing with the Marines who battled at Hue City and Khe Sanh and the muddy rice paddies of South East Asia. We are standing with the Marines who fought in Desert Storm and Iraqi Freedom and now, are fighting in Afghanistan.
Like real brothers, their blood courses through our veins, and when we go into battle, we would rather lay down our lives than be a disappointment to them. We carry on our backs, their legacy, their deaths and their honor. We carry that for the rest of our lives.
The Marines Corps uniform doesn't come off when our active duty is over. We wear it daily in our attitude, and our love of Corps and country. We wear it on our tattoos and our bumper stickers. We wear it in our hearts.
It's why, no matter where we are in the world, on November 10th, every Marine celebrates the Marine Corps birthday. It's why we'll never be an army of 1. It's why we never stop being Marines. It's why, for most of us, being a Marine isn't something we were. It's something we are.
It's the most important part of who and what we are. Some say we're arrogant. We say we're proud. We have a right to be proud. We are the United States Marines The most feared and ferocious group of warriors to walk the face of this earth.
When Americas' enemies formulate their battle plans, they plan on going around Marine units, because they know Damn well that they can't go through them. We are what other branches wish they were.
We are the modern day Spartans. This isn't bragging. It's written in the battle history of our country. When there's a parade and the Marines march by, everyone pays a little more attention. Some say "arrogance". We call it "pride". It's why, in a crowd of service men, you can always spot the Marine."
Why are Marines special? I don't know.
We just are.

subset: commoncrawl


text:
P | Pts | |
Man. United | 6 | 16 |
Roma | 6 | 11 |
Sporting | 6 | 7 |
Dynamo Kyiv | 6 | 0 |
Coach Paulo Bento was left ruing Sporting Clube de Portugal's failure to take more than a point from their meetings with AS Roma as the Portuguese side ended their Group F campaign with an impressive victory against FC Dynamo Kyiv in Lisbon. Bento at least has the consolation of a UEFA Cup campaign in the spring, although his opposite number Oleh Luzhny – who steps down after the game to be replaced by Yuri Semin in January – admitted his side had been outclassed after becoming only the eighth club in the 16-year history of the UEFA Champions League to end a group stage without collecting a single point.
Paulo Bento, Sporting coach
We ended the campaign in the best way. We played well and with caution, with the exception of a short period during the second half. We were worthy winners although the margin of victory was flattering. We're not favourites for the UEFA Cup but the approach will be the same as in the Champions League – to be better then the opposition. The most important objective for this match was achieved; to win. We scored goals, didn't concede and now we must pick up six league points before the end of 2007. We could have been playing for a place in last 16, that would have been the fairest thing based on our performances, but we paid for the bad results in both games against Roma. Things didn't run well in those matches. Away from home we lacked concentration at times and that was fatal. [At home] we were unhappy at drawing 2-2 [with Roma on Matchday 4], which ended our realistic hopes.
Oleh Luzhny, Dynamo coach
We didn't show any character or spirit, so we can't play at this level. Character is in each player's heart. When I pick a player I trust in him. I cannot do any more, I can't play for him. Dynamo's side is not that different to in the past – for example in 1992/93 we also suffered defeats – and the game today is not that different either. Before the match I believed we could win but it didn't happen; mistakes were made, that's football. This is of course a special game for me but things didn't go our way. Sporting were the happier side and enjoyed some luck.
©UEFA.com 1998-2011. All rights reserved.


text:
Millions of people in the world have sickle cell anemia, sometimes called sickle cell disease, and at least 100,000 of them live here in the US. A disorder affecting the body's red blood cells, sickle cell anemia is a genetic disorder in which the body lacks the necessary number of red blood cells to function properly.
0 Comments Click here to read/write comments
Tags: medical alert bracelet, medical alert bracelets, medical alert bracelet tips, anemia, Sickle Cell Anemia, Sickle Cell Disease, Sickle Cell


text:
Publication number | US5578062 A |
Publication type | Grant |
Application number | US 08/425,052 |
Publication date | Nov 26, 1996 |
Filing date | Apr 19, 1995 |
Priority date | Apr 19, 1995 |
Fee status | Paid |
Also published as | CA2192847A1, CA2192847C, EP0772476A1, WO1996032984A1 |
Publication number | 08425052, 425052, US 5578062 A, US 5578062A, US-A-5578062, US5578062 A, US5578062A |
Inventors | Eckhard Alt, Lawrence J. Stotts |
Original Assignee | Intermedics, Inc. |
Export Citation | BiBTeX, EndNote, RefMan |
Patent Citations (11), Referenced by (20), Classifications (6), Legal Events (6) | |
External Links: USPTO, USPTO Assignment, Espacenet | |
The present invention relates generally to implantable medical devices, and more particularly to improved implantable cardioverter/defibrillator devices for providing greater efficiency, safety and energy conservation by delivering a defibrillating shock waveform to the implant patient's fibrillating heart at a time of substantially lowest defibrillation threshold (DFT).
Implantable defibrillators are intended to detect events of fibrillation quickly and accurately, and to respond rapidly with an effective defibrillation therapy. Typically, these types of devices are designed to detect pathologic tachycardia and fibrillation events, and, in response, to initiate delivery of an electrical shock waveform (sometimes referred to herein simply as "shock") of appropriate energy and shape to cardiovert or defibrillate the patient's heart accordingly.
Clearly, it is important in the case of any implantable, battery-operated medical device to provide design and operation for energy conservation within the constraints of its therapeutic function to enable sufficient energy reserve for a reasonable lifetime of the device, and to allow for a reduction in size and weight to the lowest possible level. This is particularly important for automatic defibrillators, which may be required to expend comparatively large amounts of energy each time an episode of actual or imminent fibrillation is detected. The aim is that the designated therapy be delivered at a point in time adequate for successful termination of the dysrhythmia, to return the heart to normal sinus rhythm with the least expenditure of energy. Generally speaking, the optimum time for delivering a defibrillating shock is when the DFT is likely to be lowest within a suitable window of earliest opportunity. There is no value to a quest to save energy which imposes a waiting time that could cost the patient's life.
U.S. Pat. No. 4,384,585 to Zipes describes synchronous cardioversion in which the possibility exists to induce fibrillation by non-synchronous shocking. The synchronous cardioversion is intended to deliver the shock at a time when the bulk of the cardiac tissue is depolarized and in a refractory state. Non-synchronous cardioversion is sought to be avoided to preclude delivery of cardioverting energy during the vulnerable T-wave portion of the cardiac cycle. The patient's electrogram is used to detect depolarizations of the cardiac tissue and to produce a corresponding sense signal. Additional detection criteria are applied to determine whether a tachyrhythmia is present. The detection circuitry determines the time interval between successive cardiac depolarizations, and initiates a discharge of energy stored in an output storage capacitor if either the average detected heart rate is above a preset threshold for a specified period of time or the rate accelerates by a preset amount. Alternatively, the device detects a departure of selected beats from a historic data base of successive R-R intervals stored in the device memory; or performs a waveform analysis of the electrogram information with pattern recognition of time domain or frequency domain characteristics of the tachyrhythmia signal. The shock is delivered synchronously with the occurrence of an R-wave after specified criteria are met.
U.S. Pat. No. 4,996,984 to Sweeney describes a defibrillation technique in which fibrillation cycle length (average time interval between successive depolarizations) is measured and therapy is delivered in the form of multiple bursts of electrical current timed according to that cycle length. When cardiac tissue cells are activated, the normal electrical gradient constituting the voltage difference within and outside the cell collapses, or depolarizes. The depolarization propagates from cell to cell, the collapse of each initiating the collapse of the next in a moving wavefront. As a cell is depolarized it immediately begins repolarization to reestablish a voltage difference sufficient once again for depolarization, during the course of which the tissue is refractory. During the refractory period, the cell is incapable of responding to a stimulus. According to the multiple burst defibrillation technique of the '984 patent, the successive bursts are timed to occur at successive depolarizations at a designated site in the myocardium, so that the time interval between bursts is adjusted to correspond to the fibrillation cycle length. The cycle length is determined using cross-correlation, auto-correlation, fast Fourier transformation, counting R-waves of the electrocardiogram over a fixed time period, and determining the R-R intervals of individual cardiograms.
An improved technique for timing the delivery of defibrillating shocks is disclosed in co-pending patent application Ser. No. 310,281, filed Sep. 14, 1994 ("the '281 application") of the same applicants as in this case, commonly assigned herewith. The implanted device delivers the cardioverting or defibrillating therapy to the implant patient's heart timed for rapid and successful termination of a dysrhythmia in an energy efficient manner. To that end, changes are observed in characteristics of the patient's cardiac activity during fibrillation, such as amplitude and frequency of the ECG signal detected by intracardiac, transthoracic, or surface type techniques. The discrete ECG signal detected during fibrillation from intracardiac electrodes, for example, indicates the status of excitability or nonexcitability of the major parts of the heart. As the cardiac activity undergoes several fibrillatory cycles, a major fibrillation wavefront was found to drive the muscular masses through a regular cellular cycle of depolarization and repolarization, with the result that different masses of the heart have different status of absolute refractoriness, relative refractoriness and full excitability. It was determined that this regular cycle of the cells in a particular mass of tissue of the fibrillating heart (or with activity closely related thereto, such as an accelerating pathologic tachycardia or flutter) can serve to identify a point in the fibrillation cycle at which the heart has the lowest DFT and is therefore most susceptible to defibrillation by application of a relatively low energy shock.
In essence, the amplitude and frequency of the intrinsic ECG signal of a fibrillating heart undergo change according to a regular cycle which is detectable from the ECG wave envelope (e.g., by an intracardiac technique), as the major fibrillation wavefront propagates, so that the defibrillating shock may be timed for synchronous application at or near the point in time of highest amplitude of the ECG signal and lowest frequency of discrete intracardiac potentials, consistent with lowest DFT.
In an embodiment disclosed in the '281 application, detection criteria employed by the implanted device are used to sense imminent or ongoing fibrillation. At that time, the output storage capacitor(s) of the device commence charging, and while the charging is underway the phasic variations in amplitude and frequency of the patient's ECG are detected by pattern recognition, in preparation for timing the delivery of a shock waveform from the capacitor(s) at the optimum point in the regular cellular cycle of the cardiac activity. After a sufficient number of successive intervals of high amplitude, low frequency cardiac activity have been observed to indicate a trend, the capacitor(s) arc discharged to deliver a shock at the very next interval of increasing amplitude of the ECG signal, i.e., in substantial synchronism with a point of increasing amplitude of the intrinsic ECG signal and decreasing frequency of discrete depolarizations. The scanning of cardiac events is conducted over a search period of sufficient length to identify an optimum point in the cycle for delivery of the shock. The optimum point may occur where either or both of the amplitude of the intrinsic ECG signal and the interval between occurrences (i.e., reciprocal of frequency) of intracardiac discrete ECG depolarizations are increasing. Both parameters may be increasing, or only one, but the desire is to trigger the shock at a point where the ECG signal amplitude is likely to be greatest. The device may be implemented to calculate the quotient of amplitude over frequency to ascertain optimum timing.
It is the principal aim of the present invention to provide further improvements in methods and devices for timing the delivery of defibrillating shocks to achieve successful defibrillation rapidly and with relatively low energy.
As noted above, it has been traditional upon observing an event of ventricular fibrillation (VF) to apply the defibrillating shock(s) synchronous with the occurrence of an R-wave or a signal indicating an ongoing action potential at the site of the sensing electrode. With transvenous defibrillation, the shocking coil incorporates both sensing at the tip of the electrode and the coil. True integrated bipolar sensing therefore provides a measurement of local activity of the heart. Despite previous assumption that a chaotic state exists when the heart is in VF, measurements performed by the applicants have evidenced a considerable degree of organization within the ventricle during fibrillation. Applicant's studies have shown that, realistically, as much as 65% of the muscle cells of the myocardium undergo an organized depolarization and repolarization. The occurrence of the R-wave at the site of the electrode indicates that the cells at this local site are undergoing depolarization. By measurement of the R-R or fibrillatory cycle length, i.e., the time interval between successive R-waves (referred to herein simply as cycle length), one can determine the wavelength of this wavelet if the speed of conduction is known. Typically, wavelets occurring during VF have cycle lengths ranging from about 180 to 250 milliseconds (ms) with a mean of about 220 ms.
Synchronizing delivery of the shock with occurrence of an R-wave is less than optimum, because the local portion of the heart constituting the detection site is undergoing depolarization at that time. Thus, a shock delivered to that site within the upstroke or refractory period of this very localized myocardial area will not serve to trigger any event. But it is of critical importance to reset areas of the heart relatively remote to that site with the shock to resynchronize the depolarization and repolarization process. Dispersion of the repolarization or lack of resynchronization is the major cause of the inability to defibrillate the heart.
The applicants have found that a shock applied in the relative refractory period, which lies in an interval from about 75% to about 90% of the cycle length, can considerably prolong the action potential induced following the shock. Other portions of the heart currently undergoing an initial upstroke would also be reset by the shock with such timing.
Additional findings have indicated that it is better to apply an anodal (positive) shock into this period of refractoriness at the local site. It is known that thresholds with an anodal stimulus are about 11/2 to 2 times higher than with a cathodal stimulus applied close to the stimulation site. But since the electric field strength in the vicinity of the shocking coil far exceeds the threshold (it is assumed that voltage gradients in a range from 60 to 70 volts are generated close to the electrode), the anodal voltage strength is sufficient to depolarize the locally adjacent myocardium. The more remote parts of the heart (from that site) require a higher field strength to achieve depolarization, which can be achieved by a cathodal shock. Significantly, these more remote portions of the heart are in closer proximity to the cathode, such as if the cathode is located at or near the left side of the heart. For example, an active case (i.e., the metal housing of the signal or shock generator implemented as an electrode) may be employed with unipolar or bipolar configurations. With these findings in mind, according to the present invention, the shock energy needed for defibrillation can be decreased by 10 to 20% (relative to the prior art techniques) if the shock is timed to be applied within the last half of the fibrillatory cycle, and preferably at a point from about 75% to about 90% of the cycle length, and further, if this shock is anodal (of positive polarity) at the time of application to the tissue at or very near the site where the defibrillation coil is located.
High gradient areas are located close to the defibrillating electrodes, and low gradient areas are at sites distant from the electrodes. It has been shown that most defibrillation shocks--successful or not--appear to halt activation waveforms during VF. Unsuccessful shocks are usually followed by reentry, resulting in refibrillation. Moreover, the earliest activation front following an unsuccessful defibrillation shock tends to occur in areas of low potential gradients. Since the areas more remote from the defibrillation coil are the points where the critical field is more difficult to establish, an anodal polarity for the electrode positioned in the right ventricle (RV) is superior for lower DFT if the shock is applied within the relative refractory period of the myocardium closest to the defibrillation coil. Additionally, this lower field strength following an anodal shock diminishes the risk of refibrillation following spontaneous ectopic, post-shock activation originating from areas of high potential gradients most likely to be very close to the area where the RV electrode is located.
Therefore, another aim of the present invention is to provide an implantable cardioverter/defibrillator in which optimum timing of delivery of the prescribed electrical shock to a patient's heart is achieved, with high reproducibility of performance.
A more specific object of the invention is to provide a method for reducing the level of energy required to be delivered in a successful defibrillating shock from an implanted cardioverter/defibrillator by initiating the shock to be applied starting in the latter part of the fibrillation cycle length, and with positive polarity (at least of the initial phase in the case where a multiphasic, as opposed to a monophasic shock waveform is used).
Another important aspect of the invention is to enable reduction of defibrillation energy requirements so as to allow the design and use of implantable defibrillators of smaller size and lighter weight than was heretofore achievable.
The above and other objects, aspects, features and attendant advantages of the invention will be recognized from the following detailed description of a preferred embodiment and method constituting the presently considered best mode of practicing the invention, in conjunction with the accompanying drawings, in which:
FIG. 1 is a generalized intracardiac waveform illustrating detection of peak energy coincident with the occurrence of the R-wave at the detection site during an episode of VF;
FIG. 2 is a diagram of a defibrillator implanted in a patient, illustrating the location of the sensing electrode and shocking coil in the right ventricle and of the shock generator with active case positioned in the patient's chest; and
FIG. 3 is a simplified diagram of a portion of the circuitry of the implantable defibrillator employing the principles of the present invention.
In general, the device operates to recognize a dysrhythmia, specifically pathologic tachycardia or fibrillation of the ventricle, by use of known, conventionally applied internal detection criteria. When these criteria are fulfilled, the device looks at whether the cardiac signal indicates ongoing tachycardia or fibrillation, and, after applying an appropriate electrical therapy regimen, whether sinus rhythm is restored. If the criteria for fibrillation are satisfied, the device is conditioned to react by immediately initiating charging of its shocking capacitor(s).
As observed in the background section above, in the device and method disclosed in the '281 application, the patient's intracardiac ECG signal is scanned during a ventricular fibrillation (VF) event for the highest amplitude and lowest frequency areas within the fibrillatory cycle as the best time to apply the shock. In the art prior to that disclosure, the shock delivery was triggered for synchronization with occurrence of any R-wave or a depolarization signal when sensed from the ventricle. Earlier versions of implantable defibrillators simply applied a shock at any time that VF was detected, without any attempt to synchronize the delivery with a particular point in the cardiac cycle. The '281 application observed that despite an ongoing event of VF, organized intracardiac signals are present which can be sensed and which contribute to the diagnosis of VF.
Thus, although it had previously been assumed that fibrillation was characterized by a chaotic current throughout the heart, an underlying organized cardiac activity is actually present representing more than the local phenomenon, whose rhythm can be detected with the intracardial electrode. The wavelet of this underlying rhythm repeatedly runs through the heart and returns, with a wavelength constituting the time interval between consecutive R-waves (the cycle length typically running on the order of 180 milliseconds up to about 250 ms).
The R-wave may be detected using an intracardial electrode, and in present-day transvenous lead systems that electrode is located on the same lead or otherwise very near the shocking coil electrode in the right ventricle. Therefore, the R-wave is detected at a myocardial site of the heart at which depolarization is taking place, and if synchronous delivery with the R-wave is employed the greatest concentration of the shock energy will be applied into that same site.
The surface ECG has a very close correspondence in cycle length to the intracardial ECG. Additionally, the intracardiac signals are found to have an average amplitude of about 10 millivolts (mv) during VF, compared to about 15 mv during sinus rhythm. This may be a local phenomenon, but with surface ECG detection the signal amplitude during VF is also in the range of about 50% to about 70% of the amplitude during sinus rhythm. The amplitude of the ECG is affected by two factors: 1) the myocardial mass, according to the number of fibers that depolarize; and 2) the vector of the electric field in the region of the detection. If the vector runs parallel to the bipolar lead, maximum amplitude is detected because first the ring and then the tip of the lead is excited. If the vector runs perpendicular, however, both ring and tip are excited at the same time, resulting in no difference in potential being detected between the two.
Experiments conducted by the applicants indicate that approximately from 50% to 70% of the heart still experiences organized depolarization and repolarization cycle during VF. If a defibrillating shock is applied in synchronism with the detected R-wave, the highest energy density will be delivered to or very the same site at which the R-wave is being detected, and hence, at which the muscle cells are already depolarized. But in that case no reset is necessary at that location, so this is wasteful of precious energy and unlikely to terminate the VF.
The success of depolarization is dependent on the dispersion of refractoriness of repolarization, i.e., a cell depolarizes, maintains that status for a time, and then repolarizes. To break the VF, it is essential that all cells should be synchronized to the same repolarizing cycle. It should not be concluded from the measurements, however, that the dispersion of the refractoriness indicates whether the shock is successful or not. Rather, the phase shift of the occurrence of the depolarizations at different portions of the ventricle is the underlying cause.
In dog tests conducted by the applicants, different shock timing schemes were employed to defibrillate the heart in VF, in which the shock was triggered synchronous with the R-wave (or with signals indicating a local action potential) in one test; with a 50 millisecond (ms) delay following the R-wave in another test; with a 100 ms delay in still another test; and with a 150 ms delay in yet another. Additionally, the delay intervals were selected to coincide with about 25%, 50%, and 75%, respectively, of the R-R cycle length. It was found that initial delivery of a shock of positive polarity (so that the coil electrode was acting as the anode) applied into the relatively refractory period of an R-wave next following the detection of fibrillation resulted in defibrillation at an energy level markedly less than that required for a shock applied synchronous with the R-wave. Indeed, the reduction exceeded 15%; for example, 15.4 joules was required versus 11.8 joules in one set of tests using a carbon electrode, and 14.1 versus 12.6 in another set. While this cannot be characterized as an extremely great difference, the trend is significant with respect to both energy and voltage, with a positive stimulus.
The present invention therefore constitutes a significant improvement over the shock timing techniques regularly employed in prior art implanted defibrillator devices, in both energy reduction and likelihood of earlier success. It also represents an advance over the technique disclosed in the '281 application, in that the latter technique requires at least a limited expenditure of time to conduct a search for the point or span of the cardiac activity having the desired characteristics of amplitude and frequency, at which a shock is to be applied. In contrast, the present invention designates the optimum time for application of a shock within milliseconds of the R-wave, as well as being concerned with the polarity selected for the shock.
It turns out that at from 50% to 100%, and preferably from 75% to 90% of the R-R cycle length (typically, at or near the end of the repolarization cycle), a positive polarity shock applied into the relatively refractory tissue provides considerably better results than cathodal-induced depolarization of the same stimulus strength. Full depolarization occurs at about 85% of the cycle length. Because it is usually more difficult to stimulate a cell with a positive (anodal) stimulus than with a negative (cathodal) stimulus, by tradition it is preferable to apply a cathodal pulse to the tissue for stimulation, as in the case of cardiac pacing. But in view of our findings, at the late stages of the repolarization cycle it is more efficient to utilize positive hyperpolarization, at least at initiation of the delivery. Moreover, the tissue more remote from the shocking electrode site is more responsive to cathodal stimulation (the wavelet circulating so that depolarization is occurring at those locations), which is ideal because the cathode is generally placed closer to these remote sites.
A key aspect of the present invention, then, is that the shock is timed to be delivered a predetermined (i.e., programmed) fixed delay interval after the R-wave occurs at the intracardial electrode site. It is desirable that the programmed delay causes the shock to be applied to the heart at a fixed point in the latter 50% of the R-R cycle length. Another important aspect of the invention is that the polarity of the shock at the time of initial application is selected to be positive for application during that preferred portion of the cycle length (and, indeed, at any point in the cycle having a substantial delay relative to the R-wave), in contrast to application synchronous with or only slightly displaced from the R-wave where a shock of negative polarity would be preferable. For a monophasic shock waveform, at least substantially the entire delivery would be of positive polarity, whereas for a biphasic waveform, the positive portion would be applied in the first phase and the negative portion in the second phase.
Preferably, the RV defibrillation electrode is juxtaposed for delivery of the shocks with the active case or "active can" of the signal generator (sometimes referred to as the therapy generator, pulse generator, shock generator, or stimulus generator) of the defibrillator, which, with the shock waveform having that polarity, acts as the cathode when the former is the anode.
Any of three possible mechanisms may cause a shock to fail. First, the minimum voltage gradient or field gradient required in 90% of the myocardial muscle cells may not be reached everywhere, i.e., some areas have low field gradient and cannot be reset. Second, some areas may need a higher field gradient than others, such as where the patient is on medication or has a disorder that imposes the need for a higher minimum field gradient. Third, and a frequent cause of re-fibrillation, is that the voltage gradient close to the electrode is so high that fibrillation is reinitiated starting from the site where the shock was applied.
To achieve a more equal distribution, the polarity and pulse width of the shock should be adapted to the impedance and capacitance of the device to avoid mismatches. For a biphasic shock, it is preferred not only that the first phase have positive polarity, but that it be of greater duration than the second phase. Also, several optimizing factors may be combined to lower the defibrillation threshold (DFT). For example, optimal shock timing as advanced by the present invention provide a 15% or greater reduction, while the use of carbon electrodes can provide another 5% to 10%, and an optimal waveform shape can give yet another 5% to 10%, so that the total effect yields a quite considerable reduction in DFT. Of equal or perhaps even greater importance, these combined factors can serve to eliminate the large variations in DFT sometimes encountered not only in different patients but in the same patient. For example, in one episode of VF the patient may need a 30 joule shock for successful defibrillation, and yet only a 12 joule shock may be required to terminate fibrillation on the very next VF event in the same patient, or vice versa.
According to the laws of electrophysiology, either an electric field (produced, for example, by a shock waveform applied at a selected site of the heart) is strong enough to depolarize a single myocardial cell or it is not--there is no middle ground. Therefore, any excess over that amount of energy required for depolarization serves no useful purpose in depolarizing the cell, and indeed, may be injurious. There is a critical value, which has no relation to the timing of the shock delivery. The DFT relates to the energy threshold at which the cells representing a critical mass depolarize. As noted, however, DFT can vary considerably at different times within the same patient, which may relate more to underlying changes in the morphology or pattern of the fibrillation, i.e., certain regions of the myocardium may be easier to defibrillate at any given moment than other regions.
In a preferred embodiment of the invention, a peak detector is used to sense R-waves during VF. As illustrated in FIG. 1, the R-waves occur with considerable regularity despite ongoing fibrillation. The cycle length (CL) is shown as the interval between these R-wave peaks. If, for example, a delay in application of the shock relative to occurrence of an R-wave were desired to coincide with a point at about 75% of the CL, the delay would be about 150 ms for the "average" CL of 200 ms.
Referring now to FIG. 2, the signal generator 10 is preferably implanted in the left pectoral region of the cardiac patient 12. The conductive case 15 of the generator is electrically connected to the internal circuitry to render the case "hot", or active. That is, the case is to be utilized as an electrode for purposes of interaction with the defibrillation coil electrode 17 located in the right ventricle 18 of the patient's heart 20 when the transvenous lead 22 is implanted. At the distal tip of the transvenous lead, a sensing electrode 25 is positioned in contact with or immediately adjacent the myocardial tissue at the apex of the ventricle to detect the electrical intracardiac activity occurring at that site.
The distal tip electrode 25 and the shocking coil electrode 17 are so close to one another that, for practical purposes, the greatest electric field strength, when an electrical shock waveform is applied to the transvenous lead, will be present at the same site at which an R-wave is detected by the sense electrode. With an active case for the signal generator, the electric field vector 30 is in the direction from the RV shocking coil to the case, so that the field encompasses a substantial part of the ventricular myocardial mass of the heart, diminishing with distance from the coil electrode. If the shock is applied to make the coil the anode and the case the cathode, as is preferred, the positive polarity exists at the myocardial cells proximate the coil, while cells most remote from that site are closer to the generator case and therefore experience negative polarity of the field. This is highly desirable for reasons pointed out above.
The shock waveform circuit, shown generally in FIG. 3, includes a peak detector 35 for detecting the R-wave, in addition to conventional fibrillation detection means 37 which is typically encompassed by software establishing certain criteria indicative of fibrillation and tested in conjunction with an internal microprocessor 40. When the fibrillation criteria are fulfilled, associated logic 42 indicates that the heart 20 is in fibrillation, which results in a command to an output storage capacitor circuit 45 to commence charging the capacitor(s). Alternatively, the capacitor(s) may be charged at any time that a pathologic tachycardia is detected to be rapidly accelerating and thus likely to induce fibrillation, in the interests of saving time to achieve an appropriate magnitude for a defibrillating shock.
A full charge takes a certain time interval that depends on the energy required and the type and size of the capacitor(s) involved. Typically, the charging interval is five to eight seconds. In a conventional manner, the signal generator circuitry (including software) may be implemented to perform a recheck during the charging cycle to verify the existence of fibrillation. If verification is obtained, the device is then ready to deliver an output shock waveform on receipt of an instruction to do so, its capacitor(s) by that time being at "full" charge. If, however, the recheck fails to verify fibrillation, the charging cycle can be aborted. False shocking is not only painful to the patient, but wasteful of battery energy that should be conserved to the greatest practicable extent.
For purposes of the present invention, the generator circuitry includes a timer 46 that times out after a set interval following detection of the R-wave during fibrillation, to provide the predetermined delay (in ms) which will place the shock in the desired portion of the cycle length. The detected R-wave triggers the timer, which initiates a programmed delta from that point. Preferably, both the delay interval and the polarity of the shock (monophasic, or first phase of a biphasic shock) are programmed into the device by conventional techniques using an external programmer (not shown) at the time of or immediately after the device is implanted. For the sake of convenience, this function is provided by the internal block 50 labeled "programming."
Polarity of the shock may be designated, by programming or in conjunction with an algorithm or by any other conventional means, to be negative if initiated in the first quarter or half of the R-R cycle length, and positive if initiated at any other time in the cycle. By way of example, a simple bridge circuit 52 is illustrated to effect a positive polarity shock when triggered after a delay interval (in ms) that causes the shock waveform to be applied across the coil electrode of the transvenous lead and the active case during any part of the last half of the cycle length, and to effect a negative polarity shock when triggered in the first half of the cycle length (or for the second phase of a biphasic shock waveform). To that end, a + or - instruction is delivered to a switching circuit from logic including an exclusive OR gate 54 so that if the instruction level is high the polarity is of one type and if low an inversion occurs to make the polarity of the other type, and the output shock is delivered (with the programmed delay) accordingly to the heart. For biphasic shocking pulses, the phases may also be programmable to make the second phase shorter, of equal length, or longer than the first phase, although preferably, the first phase is the longer.
The shock timing of the invention is maintained irrespective of the particular lead configuration. It would not matter, for example, if electrodes are positioned in RV and superior vena cava (SVC) configuration, or RV to an active case, or if patches or other configurations are employed. Also, the polarity of the shock, and of the electrodes, as taught herein is not limited to a particular electrode configuration. Polarity may be selected not only with the above factors in mind, but also may take into account the clinical situation, i.e., the underlying disease of the patient. Here again, the circuitry is preferably such that both polarities are available, and programmable for selection according to which is most beneficial to the particular patient after testing, and on the basis of lowest DFT.
Therefore, although certain preferred embodiments and methods have been disclosed herein, it will be appreciated by those skilled in the art to which the invention pertains, that variations and modifications of these embodiments and methods may be readily implemented without departing from the spirit and scope of the invention.
Cited Patent | Filing date | Publication date | Applicant | Title |
US3805795 * | Mar 17, 1972 | Apr 23, 1974 | Medtronic Inc | Automatic cardioverting circuit |
US4108148 * | Nov 3, 1976 | Aug 22, 1978 | Sheldon Thaler | Pacer with automatically variable A-V interval |
US4384585 * | Mar 6, 1981 | May 24, 1983 | Medtronic, Inc. | Synchronous intracardiac cardioverter |
US4996984 * | Sep 26, 1989 | Mar 5, 1991 | Eli Lilly And Company | Defibrillation method |
US5048521 * | Jun 29, 1990 | Sep 17, 1991 | Ventritex, Inc. | Method for combined cardiac pacing and defibrillation |
US5086772 * | Jul 30, 1990 | Feb 11, 1992 | Telectronics Pacing Systems, Inc. | Arrhythmia control system employing arrhythmia recognition algorithm |
US5099838 * | Dec 15, 1988 | Mar 31, 1992 | Medtronic, Inc. | Endocardial defibrillation electrode system |
US5184615 * | Mar 8, 1991 | Feb 9, 1993 | Telectronics Pacing Systems, Inc. | Apparatus and method for detecting abnormal cardiac rhythms using evoked potential measurements in an arrhythmia control system |
US5205283 * | Jul 30, 1991 | Apr 27, 1993 | Medtronic, Inc. | Method and apparatus for tachyarrhythmia detection and treatment |
US5275621 * | Apr 13, 1992 | Jan 4, 1994 | Medtronic, Inc. | Method and apparatus for terminating tachycardia |
US5282836 * | Oct 23, 1992 | Feb 1, 1994 | Incontrol, Inc. | Atrial defibrillator and method for providing pre-cardioversion pacing |
Citing Patent | Filing date | Publication date | Applicant | Title |
US5800464 * | Oct 3, 1996 | Sep 1, 1998 | Medtronic, Inc. | System for providing hyperpolarization of cardiac to enhance cardiac function |
US5814079 * | Oct 4, 1996 | Sep 29, 1998 | Medtronic, Inc. | Cardiac arrhythmia management by application of adnodal stimulation for hyperpolarization of myocardial cells |
US5843130 * | Mar 31, 1997 | Dec 1, 1998 | Masood Akhtar | System for delivering atrial defibrillation shocks |
US6152954 | Jul 22, 1998 | Nov 28, 2000 | Cardiac Pacemakers, Inc. | Single pass lead having retractable, actively attached electrode for pacing and sensing |
US6259954 | Feb 18, 1999 | Jul 10, 2001 | Intermedics Inc. | Endocardial difibrillation lead with strain-relief coil connection |
US6345204 | Sep 14, 2000 | Feb 5, 2002 | Cardiac Pacemakers, Inc. | Single pass lead having retractable, actively attached electrode for pacing and sensing |
US6459566 | May 19, 2000 | Oct 1, 2002 | Medtronic, Inc. | Implantable medical device having flat electrolytic capacitor with laser welded cover |
US6622042 | May 9, 2001 | Sep 16, 2003 | Pacesetter, Inc. | Implantable cardiac stimulation device and method utilizing electrogram spectral analysis for therapy administration |
US7181273 | Apr 18, 2003 | Feb 20, 2007 | Medtronic, Inc. | Tachycardia synchronization delays |
US7308305 * | Jul 27, 2004 | Dec 11, 2007 | Pacesetter, Inc. | Optimally timed early shock defibrillation |
US7660629 | Nov 29, 2006 | Feb 9, 2010 | Pacesetter, Inc. | Device and method for preventing the acceleration of cardiac arrhythmias |
US7774056 * | Apr 28, 2006 | Aug 10, 2010 | Medtronic, Inc. | Device site stimulation for notification |
US7774934 | Dec 8, 2005 | Aug 17, 2010 | Cardiac Pacemakers, Inc. | Method for making a terminal connector |
US8209035 | Jun 23, 2008 | Jun 26, 2012 | Cardiac Pacemakers, Inc. | Extendable and retractable lead having a snap-fit terminal connector |
US8285398 | Jul 7, 2010 | Oct 9, 2012 | Cardiac Pacemakers, Inc. | Lead with terminal connector assembly |
US20040210257 * | Apr 18, 2003 | Oct 21, 2004 | Havel William J. | Tachycardia synchronization delays |
US20070088395 * | Nov 29, 2006 | Apr 19, 2007 | Pacesetter, Inc. | Device and method for preventing the acceleration of cardiac arrhythmias |
US20070255339 * | Apr 28, 2006 | Nov 1, 2007 | Medtronic, Inc. | Device site stimulation for notification |
US20070255347 * | Oct 30, 2006 | Nov 1, 2007 | Medtronic, Inc. | Inhibition of stimulation notification |
WO2000047279A1 * | Feb 8, 2000 | Aug 17, 2000 | Heartsine Technologies, Inc. | Apparatus for determining when a patient is susceptible to defibrillation |
U.S. Classification | 607/5 |
International Classification | A61N1/39 |
Cooperative Classification | A61N1/36592, A61N1/3956 |
European Classification | A61N1/39M, A61N1/39 |
Date | Code | Event | Description |
Jun 23, 1995 | AS | Assignment | Owner name: INTERMEDICS, INC., TEXAS Free format text: ASSIGNMENT OF ASSIGNORS INTEREST;ASSIGNOR:ALT, ECKHARD;REEL/FRAME:007563/0771 Effective date: 19950610 |
Jul 11, 1995 | AS | Assignment | Owner name: INTERMEDICS, INC., TEXAS Free format text: ASSIGNMENT OF ASSIGNORS INTEREST;ASSIGNOR:STOTTS, LAWRENCE J.;REEL/FRAME:007552/0864 Effective date: 19950628 |
May 25, 2000 | FPAY | Fee payment | Year of fee payment: 4 |
May 26, 2004 | FPAY | Fee payment | Year of fee payment: 8 |
May 27, 2008 | FPAY | Fee payment | Year of fee payment: 12 |
Jun 2, 2008 | REMI | Maintenance fee reminder mailed |


text:
Google announced a couple of days ago reaching the mark of 10 billion downloads from the Android Market and the current rate of downloads is 1 billion a month. Google seemed to like announcing milestones as the company proudly let us know that in November more than 200 million Android devices were activated and this number is growing with 550,000 more devices every day.
Now it's time for the developers to dive into company's understandable passion for numbers and charts, as Google recently published an infographic on the most successful apps. According to this chart, the most downloaded apps from Android Market are games (25.6%) followed at a huge distance by entertainment apps (12.2%) and tools (11.17%). In the games category, Arcade games ranked the highest (39.25%).
The infographic also lets us know the "Top 10 Most App-crazed countries" and this list was made by downloads per capita. South Korea is the leader, followed by Hong Kong, Taiwan, the US, Singapore, Sweden, Israel, Denmark, the Netherlands and Norway. If we would like to know when the most popular time to download from Android Market is, Google informs us that the peak of the week is on Sundays, at 9.00 PM, while the least popular time to download is on Mondays at 4.00 AM.
« Previous ZTE Targets the US high-end Smartphone Market | Next » Grand Central Terminal Apple Store Ready for Opening |


text:
This is our website. Would you prefer to shop on our website? This is our website. You previously shopped on our website. Would you like to go to our website now?
Other country sites
My Account
My Bag
You are here:
Update your capsule wardrobe with this Boss Orange Kadrapi Sleeveless Crepe Blouse. Ideal for day to night wear, this contemporary essential features a cowl neckline, stitch detailing and discreet logo detailing on reverse.
Product code: 654095
Exchanges & Returns We will happily offer an exchange or refund within 14 days of delivery. For full details please read our returns policy
Using the standard service, your order should be with you within 3-5 days.
International delivery is available for this product. The cost and delivery time depend on the country.
We use cookies to give you the best customer experience possible. If you continue to use our website, we will assume you are happy to receive cookies from us and our partners. More info


text:
Throughout the year there are some sports I cover only once or twice so instead of leaving them out I have decided to show some of my best sports images from random sports. Some of my best photos of the year came from some of these random sports that I normally dont shoot. So while a lot of these sports are far from random for most of you, they are for me.
.In my ten years covering professional sports in the Phoenix area I had never shot NHL hockey before and was finally ready to give it a shot. As with everyone who has ever watched hockey on TV I went to the game in hopes of seeing big hits and some fights. Continue reading to see if I got what I wanted.


text: Resources Mayo Clinic products and servicesBook: Mayo Clinic Guide to Stress-Free LivingMayo Clinic StoreNewsletter: Mayo Clinic Health LetterMayo Clinic researchMayo Clinic Cancer CenterMayo Clinic supportGive today to find cancer cures for tomorrowWeb sites Newsletter: Mayo Clinic Health Letter — Online EditionThe Leukemia & Lymphoma Society: Support resourcesRequest an Appointment at Mayo Clinic MultimediaNews from Mayo Clinic April 19, 2016 Share on: Facebook Twitter References Lichtman MA, et al. Chronic lymphocytic leukemia and related diseases. In: Williams Hematology. 8th ed. New York, N.Y.: The McGraw-Hill Companies; 2010. http://www.accessmedicine.com/. Accessed Jan. 22, 2016. Niederhuber JE, et al., eds. Chronic lymphocytic leukemia. In: Abeloff's Clinical Oncology. 5th ed. Philadelphia, Pa.: Churchill Livingstone Elsevier; 2014 http://www.clinicalkey.com. Accessed Dec. 22, 2015. Chronic lymphocytic leukemia. The Leukemia & Lymphoma Society. https://www.lls.org/sites/default/files/file_assets/cll.pdf. Accessed Feb. 3, 2016. Chronic lymphocytic leukemia treatment (PDQ). National Cancer Institute. http://www.cancer.gov/types/leukemia/patient/cll-treatment-pdq. Accessed Jan. 3, 2016. When cancer doesn't go away. American Cancer Society. http://www.cancer.org/treatment/survivorshipduringandaftertreatment/when-cancer-doesnt-go-away. Accessed Jan. 3, 2016. Berger AM, et al. Cancer-related fatigue, version 2.2015. Journal of the National Comprehensive Cancer Network. 2015;13:1012. Shanafelt TD, et al. Phase 2 trial of daily, oral polyphenon E in patients with asymptomatic, Rai stage 0 to II chronic lymphocytic leukemia. Cancer. 2013;119:363. Green tea. Natural Medicines Comprehensive Database. http://naturaldatabase.therapeuticresearch.com/home.aspx. Accessed Feb. 3, 2016. D'Arena G, et al. Regulatory T cell modulation by green tea in chronic lymphocytic leukemia. International Journal of Immunopathology and Pharmacology. 2013;26:117. Gazya (prescribing information). South San Francisco, Calif.: Genentech, Inc.: 2013. http://www.gazyva.com. Accessed Dec. 22, 2015. Imbruvica (prescribing information). Sunnyvale, Calif.: Pharmacyclics, Inc.: 2014. http://www.imbruvica.com. Accessed Dec. 22, 2015. Zydelig (prescribing information). Foster City, Calif.: Gilead Sciences, Inc.: 2014. https://www.zydelig.com. Accessed Feb. 4, 2016. Revlimid (prescribing information). Summit, NJ: Celgene Corporation: 2015. http://www.revlimid.com. Accessed Feb. 4, 2016. RelatedStem cell transplantChemotherapyCT scanBone marrow biopsyAbdominal painNight sweatsUnexplained weight lossFatigue Mayo Clinic in Minnesota has been recognized as one of the top Cancer hospitals in the nation for 2016-2017 by U.S. News & World Report Learn more about this top honor Chronic lymphocytic leukemiaOverviewSymptoms & causesDiagnosis & treatmentRequest an appointmentDiagnosisTreatmentDepartments & specialtiesExpertise & rankingsLocations, travel & lodgingClinical trialsResearchCosts & insurancePreparing for your appointmentSelf-managementMore aboutIn-DepthExpert BlogMultimediaResourcesNews from Mayo Clinic Advertisement Mayo Clinic does not endorse companies or products. Advertising revenue supports our not-for-profit mission. Advertising & Sponsorship Policy Opportunities Ad Choices Mayo Clinic Store Check out these best-sellers and special offers on books and newsletters from Mayo Clinic. NEW! – The Mayo Clinic Diet, Second EditionHealthy Heart for Life!Mayo Clinic on Better Hearing and BalanceTreatment Strategies for ArthritisThe Mayo Clinic Diet Online Diagnosis & treatmentRequest an appointmentDiagnosisTreatmentDepartments & specialtiesExpertise & rankingsLocations, travel & lodgingClinical trialsResearchCosts & insurancePreparing for your appointment CON-20167628 Patient Care & Health Information Diseases & Conditions Chronic lymphocytic leukemia


text:
Hexa Gear is a new lineup of items from Kotobukiya featuring transformable battle mecha! They utilize the Modeling Support Goods (M.S.G) hexagonal joint system, with a 3mm support pipe hole--so weapons from Frame Arms and Heavy Weapons units can be used with Hexa Gear mechs! The Hexa Gear can also be ridden by their pilots, known as "Governors," sold separately.
Para-Pawn Sentinel will be about 7.4cm tall and fully posable once assembled; he's molded in color so painting isn't necessary. He's equipped with three sets of interchangeable hands, a rifle, an axe, and a shield, as well as a 3mm hard point in his back, for ease of attachment of armor, weapons, etc.
All contents © 2017 HobbyLink Japan Ltd.
Kurohakama-cho 162-1, Sano, Tochigi 327-0813 JAPAN
Fax: +81-283-27-2352


text:
Weird but Fun
For a first time user of any masturbation toy, the Tenga Egg was a great choice! It can be reused if you take the time and care to clean it after each use. Great toy for a great price!Published:
Easy to use, soft stretchy texture, fun alone or together.
The lube it comes with smells weird. Makes weird sloppy noises when you really get going.
This content is the opinion of the submitting contributor and is not endorsed by EdenFantasys.com
Wondeful first review, welcome to Eden.
Actually, the Eggs are made from silicone. If they were made from a material like Cyberskin, they would surely tear pretty quick. Good news though, I have had one last for about ten uses. -
Thanks for sharing!
what kind of lube did you use?? how did you clean it?? glad to hear it can be reused...it is strange looking!!
thanks for sharing.
thanks for sharing.
Mamastoys - We use Pjur original but for the egg we use sliquid.
Toy Time Tim - It feels like the same and has some of the same properties, like after you wash it it gets sticky but a little corn starch rub on the outter shell and its back to being soft and smooth. I don't know how many times we have used the egg but I have started to see some of the insides breaking off so we must be coming up on replacing it. -
Thanks for the review!
Thanks for the review!
Discussion | Posts | Last Update |
tenga+strap-on? | 18 | |
Are tenga eggs any good? | 6 | |
Tenga Egg Material | 43 | |
Would this work for an FTM? | 2 | |
Anyone have this product? Does it work well? | 16 | |
Anyone use this with another person? | 4 | |
Tenga | 7 | |
Fleshlight | 7 | |
Tenga Eggs and Foreskin? | 24 | |
Anything like the Tenga Egg Masturbator? | 3 |
Thank you for viewing Tenga egg masturbator review page!


text:
City and Borough of Juneau |
AJ Mine Advisory Committee (AJMAC)AGENDAAJ Mine Advisory Committee (AJMAC)Meeting #4Wednesday, March 30, 2011 - 5:30 p.m.Assembly Chambers I. CALL TO ORDER II. AGENDA REVIEW III. APPROVAL OF MINUTES A. March 10, 2011 - 3rd Meeting IV. ITEMS FOR INFORMATION A. Small Mine Concept Schematics B. Economic Sub-Committee Report C. Dave Chambers Presentation - "Responsible Mining" D. Report Outline for Committee Member Comments E. Gold Creek Drain Tunnel NPDES Permit V. FUTURE AGENDA ITEMS - Next Meeting Dates - April 7th - (5:30 PM, Assembly Chambers) & April 21st (Location-TBD) A. Permitting B. DNR - Leasing C. Draft Committee Report VI. COMMITTEE MEMBER COMMENTS VII. PUBLIC TESTIMONY (Not to exceed 20 minutes no more than 5 minutes for any individual) VIII. WRITTEN COMMENTS FROM PUBLIC IX. ADJOURNMENT |


text:
Collections are a JPG+ feature. You must be a JPG+ member to create new collections and to add photos to collections.
Sign up for JPG+ to start using collections now!
Photo license: © All rights reserved
Expired film in $2 garage sale camera. Old film looks dark, which disappointed at first, but looks something like a Vermeer painting.
4 responses
peter bodigor gave props (20 Apr 2010):
Michael Lehrman gave props (8 May 2010):
No mistake here - an intriguing character study.
Carol Holmes gave props (14 Aug 2010):
It does remind me of a Vermeer! Even the angle of her face and the wonderful light coming from the window, love this! I had some expired film and all I got was black, so kudos to you!
ajtiM (Deleted) said (4 Nov 2010):
great work!


text:
Sheppard/Dex thematic fic index >> Earth-side Vacation
(Still) In Hollywood by
Sequel to In Hollywood. When the request comes in it specifically asks for Sheppard or Ronon. It makes sense for Ronon to go.
Better Days by
Vacations aren't really the best when you're staying with family.
Christmas Lights by
John and Ronon's first Christmas on earth isn't quite what they had expected.
Comment fic - winter vacation by
John's trying to show Ronon a good time.
Dandelion Clock by
Things change; sometimes you just need a little faith.
In Hollywood by
So, uh, ladycat777 suggested the idea of a SGA/Jossverse crack fusion in which John is showing Ronon L.A. and they come across vamps being staked. It...didn't work out like that. I mean--yeah, it kinda did. But there's limited crack. Also, not much Jossverse. *hands*
No Road Maps by
Ronon's not sure where they're going, but there's only one way to find out.
The History of the World by
After everything, Ronon takes John back to Sateda.
Untitled (mahoni) by
Written before "Outcast". Tag to Nuclear Family (gen).


text:
Water-saving cleaning method for carpets and couches, such as bubbly foam and microscopic crystals; minimal dry time.
Vetted, five-star house cleaners rid living rooms, kitchens, bedrooms, and bathrooms of dust and germs during cleaning sessions.
From the merchant: Now offering Residential Cleaning Services! .
Six Man-Hours of House Cleaning (Three Sessions-Up to Two Man Hours Each).
Licensed and insured cleaning crew scours kitchens, bathrooms, and living rooms with comprehensive cleaning services.
General clean of your home; dusting, vacuuming, mopping, and cleaning bathrooms, the kitchen, and living areas.
More than 50 fashionable and funny aprons protect women, men, and kids from cooking spills
Certified cleaning crew use eco-friendly products to sanitizes homes top to bottom.
Protect homes from dust, pollen, smoke, and smog with air filters delivered right to your door
Experienced professionals offer residential cleaning service ranging from grout-cleaning to linen change and closet-organizing.
From the merchant: We are a locally-owned residential cleaning services that provides exactly what you need, when you need it.
From the merchant: Cleaners will complete dusting, baseboard wipe down, floor vacuum or mopping, bathroom cleaning and disinfecting.
From the merchant: We offer full cleaning services of your home, 25 years of experience, family owned and operated, insured and bonded.
Local businesses like this one promote thriving, distinctive communities by offering a rich array of goods and services to locals like you.
$199 for up to 1,000 square feet of bacteria cleaning with one-year of followup protection ($400 value) .
From the merchant: Service is to be used for move out/in and office cleaning only.
From the merchant: Aroma Tree natural cleaning uses powerful natural pro cleaning products! Clorox used in bathrooms.
In-home cleaning service who gives your home the clean YOU desire!.
Two Hours of House Cleaning.
A combination of cleaning and a bottle of wine help relax while watching the accumulated untidiness go away.
From the merchant: Allergies? Sleep Apnea? Bronchitis? Our Healthy Home Professionals find the source of your air quality problems!
From the merchant: Three rooms steam cleaned with free Scotchgard and a gift card for $10 off your next cleaning.
Steam-cleaning equipment works with degreaser and deodorizing treatments to keep carpets fresh; dry foam cleanses one 6 ft.
Carpet experts offer qualified services with an individual approach tailored to every customer's needs .
From the merchant: SKV Service is a carpet cleaning company, offering qualified services with an individual approach to each customer.
Experienced cleaners lift dirt from carpets in high-traffic areas, leaving carpet looking like new; upholstery cleaning restores couches.
Exterior Cleaning for up to 15 Windows.
$39 for one air-duct cleaning and one furnace inspection ($250 value).
Although steam can be an effective cleaning tool, when pros talk about steam-cleaning a carpet, they're usually talking about a process technically known as hot-water extraction.
$18 Chimney sweep up to 10' and fireplace inspection or Dryer Vent Duct sweep up to 6' and inspection, regular $179
Discover new restaurants, spas, things to do & more great deals added daily!
*Valid on 1 unit per transaction; max 1 Local or Getaways deal per customer. Max discount $30. New customers only. Exclusive and non-transferable. Ends 3/31/17. Full details: gr.pn/promofaq


text:
I would like to install fog lights in my 2010 Impreza 2.5i because of course the base model does not come with them. Can anyone tell me what the process is to installing/ordering them. Do I need a kit or just the lights themselves and price on this. Also, does a toggle need to manually installed or do the fogs come on automatically when the headlights are on. Any feedback is welcome! Thanks.
Asked by for the 2010 Subaru Impreza


text:
Room 1
Room 2
Room 3
Room 4
Room 5
Shangri-La Bosphorus, Istanbul, offers experienced hosts and state-of-the-art services that cater to the highest level of international business, diplomatic and social gatherings.
Our two ballrooms and nine conference and function rooms are conveniently located on the same floor. Spacious pre-function areas are also provided.
All venues feature state-of-the-art audiovisual equipment, including the following:
Complete a simple form to let us know your event requirements and leave the planning to us.
Find an event space that can cater to your event requirements


text:
Lobby DJ's are so last decade. The latest amenity: live concerts at hotels by Grammy Award–winning musicians.
As part of Renaissance Hotels' new program RLife Live, guests may very well check in while listening to musicians—Thievery Corporation, Solange Knowles, or the Neon Trees—perform live. To know who's playing where, visit rlifelive.com (dates are posted two weeks in advance). One recent showstopper: Bruno Mars's New Year's Eve concert at the R Lounge Times Square, with a certain crystal ball as the backdrop.
Sarah Khan is a copy editor at Travel + Leisure


text:
About Toni Makkai
Toni Makkai is a published author. A published credit of Toni Makkai is Antisocial behaviour among young Australians while under the influence of illicit drugs. : An article from: Australian and New Zealand Journal of Criminology.
To edit or update the above biography on Toni Makkai, please Log In or Register.Link to this page: https://www.jacketflap.com/toni-makkai/193728
Published Works by Toni Makkai
Click a book's title or cover for more details and to read reviewsTitle, Creators, Comments / Reviews | Ages | Date Published | |||
1. Antisocial behaviour among young Australians while under the influence o... Author: Ian McAllister, Toni Makkai Publisher: Academic Press |
? |
08/01/2003 Add | |||
Add Review | |||||
Bestselling order determined by Amazon.com SalesRank(tm) |


text:
Valkyrie Profile 2: Silmeria Question and Answers :
Unregistered |
unreachable tresurechests in audoula temple lakeMy sister and i have been stuck in the room to the left on the row of rooms in the front on the map. There is a ledge with some tresure chests but weve been unable to get up there. We've tried to freeze the two monsters but can't seem to get them placed good enough to get on the ledge. |
Sorry, to fulfil this action you have to be CheatsGuru User
Your answer:
• Moshi Monsters cheats, Android • Plants vs. Zombies cheats, NDS, XBOX 360, PS3, IPHONE, Android • Pokemon Heart Gold Version cheats • Pokemon Soul Silver cheats • The Lord of the Rings: War in the North cheats, XBOX 360, PS3 • Shogun 2: Total War cheats • BioShock Infinite cheats, XBOX 360, PS3 • Darksiders 2 cheats, XBOX 360, PS3 • Call of Duty: Modern Warfare 3 cheats, PC, NDS, WII, PS3 • Elder Scrolls V: Skyrim cheats, XBOX 360, PS3 • Torchlight II cheats • Borderlands 2 cheats, XBOX 360, PS3 • Temple Run cheats • Jagged Alliance: Back in Action cheats • XCom: Enemy Unknown cheats, XBOX 360, PS3


text:
Will ot work on stock xema2?m
Sent from my GT-I9300 using xda premium
EMB2 deodexed:
EMB2 odexed:
Just tried the odexed version on odexed emb2. Messages icon disappeared from my dock and in apps. Checked in /system/app and apk + odex is there.
Just copied my original files back to system and messages popped back in apps.
Did notice a big difference in file sizes.
Sent from my GT-I9300 using xda premium
Tags |
no auto-converting mms, sent time, sms mod |
Thread Tools | Search this Thread |
Display Modes | |


text:
Do you know where your variables are? | |
PerlMonks |
Comment on |
( #3333=superdoc: print w/replies, xml ) | Need Help?? |
I'm not sure how efficient it would be, and it probably depends on what your database is, but you could perhaps find the minimum number by a single database query by joining a sequence generation and returning the lowest value of the sequence which is not a table index.
A Monk aims to give answers to those who have none, and to learn from those who know more.
In reply to Re: For loop suggestions
by space_monk


text:
11:15 a.m./12 p.m.
Bank of America
142 East Olive Ave, Burbank, CA 91502
To thank customers for their business in unexpected ways, Bank of America has invited Los Angeles Dodgers outfielder Matt Kemp to surprise customers at Burbank Bank of America. During his unannounced visit, Kemp will give away tickets to upcoming Dodgers games along with other baseball-themed items. His appearances are part of a larger, national program that uses Bank of America's sponsorship of Major League Baseball to demonstrate its gratitude to customers who also share bank's passion for America's National Pastime.


text:
Lucille Screenings update
The Adelaide Film Festival is starting this weekend, and they've kindly invited my short, Lucille, to screen as part of the Animation Passport program. Curated by Eddie White from the People's Republic of Animation, it looks to be a killer program! I'm pretty humbled to be screening my film in such good company.
If you haven't seen these films yet, here's your chance! There are some real gems in this animated mix-tape
The films screening are: Skhizein, KJFG No.5, A Coffee Vending Machine & His Sword, I Met the Walrus, Lucille, Madame Tutli-Putli, Oktopodi, and Western Spaghetti (which I recently featured right here)
Festival screenings for Lucille have also just been confirmed at:
BUFF International Children and Young People's Film Festival in Malmö, Sweden, and Tricky Women's Film Festival in Vienna
Thanks adelaide, Malmö and Vienna!!
Illustration Friday: Time
Victorian Bushfires
Sad times here in Victoria. It's hard to even imagine the scale of the devastation these fires have caused. Please give to the Australian Red Cross Victorian bushfire appeal if you can.
Read news and eye-witness accounts at ABC News
Read news and eye-witness accounts at ABC News
Subscribe to:
Posts (Atom)


text:
Purchasing for SHARE Craig food orders is scheduled for today.
Orders will be taken from 4:45 to 6:45 p.m. at St. Michael Catholic Church, 638 School St.
For more information, call Karen Gibson at 824-7939.
Help available for gambling problems
National Problem Gambling Awareness Week is March 7 to 14.
The Colorado Lottery would like to remind residents that if you or someone you care about has a gambling problem, free and confidential information is available.
Call 1-800-522-4700 or visit http://problemgamblingcolorado.org.
Meeting at 6 tonight for 'herd quitters'
The Colorado First Conservation District is sponsoring a herd quitter meeting from 6 to 9 p.m. today at the Moffat County Fairgrounds. The meeting is free and open to the public.
Herd quitter is a term coined by Kit Pharo of the Pharo Cattle Co. to describe ranchers who are "willing to think outside the box and embrace unconventional, high-output, sustainable agriculture," according to a news release from the Conservation District.
"Kit believes that ranching should be both profitable and enjoyable," the news release reported. "Kit will be presenting an innovative approach to ranchers on grazing, calving and cow size."
For more information, call DeDe Sorrentino at 824-3476, ext. 101.
Editorial Board members sought
The Craig Daily Press is seeking three or four people to participate on its next Editorial Board.
Editorial Board members meet from noon to 1 p.m. Mondays to discuss the newspaper's opinion pieces for that week's Wednesday and Saturday editions.
Editorial Board terms last three months.
If anyone is interested, call Editor Joshua Roberts at 875-1791 or e-mail him at email@example.com.


text:
I get it but it's not simple or quick. You know how many boxes ive been through. I found out a few things along the way. Peak is always in the mid high 40s no matter where I tune after the deadener. Subs like to be up and toward the rear, port likes to be center. That's all I got right now
---------- Post added at 10:41 PM ---------- Previous post was at 10:41 PM ----------


text:
Materials Research Science and Engineering Center
CONTACTSName | Phone | Room | |
Daniele Finotello | firstname.lastname@example.com | (703) 292-4676 | 1065 N |
Birgit Schwenzer | email@example.com | (703) 292-8810 | 1065 N |
Miriam Deutsch | firstname.lastname@example.com | (703) 292-4917 | 1065 N |
Susan Dexheimer | firstname.lastname@example.com | (703) 292-8562 | 1065 N |
Important Information for Proposers
A revised version of the NSF Proposal & Award Policies & Procedures Guide (PAPPG) (NSF 17-1), is effective for proposals submitted, or due, on or after January 30, 2017. Please be advised that, depending on the specified due date, the guidelines contained in NSF 17-1 may apply to proposals submitted in response to this funding opportunity.
Materials Research Science and Engineering Centers (MRSECs) provide sustained support of interdisciplinary materials research and education of the highest quality while addressing fundamental problems in science and engineering. MRSECs address research of a scope and complexity requiring the scale, synergy, and interdisciplinarity provided by a campus-based research center. They support materials research infrastructure in the United States, promote active collaboration between universities and other sectors, including industry and international institutions, and contribute to the development of a national network of university-based centers in materials research, education, and facilities. A MRSEC may be located at a single institution, or may involve multiple institutions in partnership.
FY2014 Materials Research Science and Engineering Centers (MRSEC) competition results
FY2011 Materials Research Centers and Teams competition results
Materials Research Science and Engineering Centers (MRSEC's)
About MRSEC
Text description of Centers and IRGs
List of IRG Research Topics
Contact Information for the Center Directors and links to Center homepages
Additional Program Information
DMR supported NSECs
FY2005 Competition Results
DMR Supported STCs
FY2008 MRSEC Competition Results


text:
Friday, May 13
Arrivederci Italia...
31 comments:
- ShakehMay 16, 2011 at 12:06 AM
Welcome back Emily! It was great seeing glimpses of your trip over the course of your four month trip. You have an amazing eye for all things beautiful. I always tell Ed that you are going to make it and not just make it... but make it BIG. All the best to you and hopefully I'll see you soon.
ReplyDelete You write so beautifully. I've just finished studying in Edinburgh, Scotland and I have the same bittersweet feelings. Not quite as grand as florence but I was living there for 6 years. So it became my home and it taught me to live and to grow up. A huge chapter in my life also just closed.
Florence is a very beautiful place, and I can totally see what you fell in love with. And that Pizza just looks divine! *DROOLS*
I'm following you xxx
www.therubywoo.comFlorence is such a beautiful place! I can understand why you would be sad to leave it.
SOCIAL EMISSIONSbeautiful post love it
you have very interesting blog
follow back please
♥ SadeeStyle ♥
http://thefashionville.blogspot.com/These pictures are lovely, everything looks amazing; I so want to go on a vacation after seeing these pictures, I bet you had a great time and you look so beautiful! You have a lovely blog and I'm a new follower! Hope you'll like my blog and follow back!
Alice&SaraWow! I was JUST there. Like a few days ago. Isn't it gorgeous?! Amazing place.
found the routegorgeous style, adoring your blog miss!
would love to see you in casper&pearl one day!
lots of love from the c&p girls,
casper&pearl blog


text:
- Full Product description
Sensodyne Toothpaste Gentle Whitening 45ml has been specially formulated for people with sensitive teeth. Exposed areas of porous dentine can be prone to discolouration as well as sensitivity. With fluoride to help prevent tooth decay, this low abrasion toothpaste has been formulated to remove stains gently yet effectively, restoring teeth to their natural whiteness.
- Delivery Options
FREE deliveries are available when you spend over £40 on a single transaction and you select standard delivery service.
Standard Tracked Delivery charges = £2.95.
Express Next Day Tracked Delivery chages = £4.99
UK Delivery Times
Standard Delivery is estimated to take 3 - 5 working days after dispatch from our warehouse. All orders are picked within 1 - 2 working days.
Order cut-off for standard delivery service is 2pm and fror our express delivery service it is 12pm. Orders placed after 2pm and 12pm respectively will be treated, for the purpose of delivery, as having been placed the next working day. Working Days are defined as Monday – Friday (Excluding weekends, bank and public holidays)- therefore any orders placed after 2pm on Friday will not be processed until Monday.Delivery will be made through Yodel. Your order can be delivered anytime between 7am and 9pm and not necessarily delivered with your everyday post and if you are not in at the time of delivery, a card should be left by Yodel telling you where your order is being held. All delivery timescales are approximate and subject to availability, precise timing cannot be specified.


text:
Jim Griffin (C) listens as James Manship reads from the U.S. Constitution during a Tea Party Patriots rally on the west lawn of the U.S. Capitol. (photo: Ron Lamkey/Getty Images North America)
The Real I.R.S. Scandal
15 May 13
ashington's scandal machinery, rusty from recent disuse, is cranking back up to speed due to the alleged targeting of conservative groups by the Internal Revenue Service. Darrell Issa, the chairman of the House Committee on Oversight and Government Reform, said, "It's the kind of thing that scares the American people to their core. When Americans are being targeted for audits based on their political beliefs, that needs to change." Senator Susan Collins, of Maine, called on the President to apologize. George Will said President Obama could be impeached. Obama himself is taking the path of contrition. At a news conference Monday, the President said, "If in fact I.R.S. personnel engaged in the kind of practices that have been reported on and were intentionally targeting conservative groups, then that's outrageous. And there's no place for it." More hearings, with more outrage, are planned.
In light of this, it might be useful to ask: Did the I.R.S. actually do anything wrong?
The stories began to come to light on Friday, when the Associated Press reported
that a draft report by a Treasury Department inspector general had
found that the I.R.S. subjected certain Tea Party-affiliated groups to
undue scrutiny. Lois Lerner, head of the I.R.S. tax-exempt-organizations
division, said the agency was "apologetic" for what she termed
"absolutely inappropriate" actions by lower-level workers.
It's important to review why the Tea Party groups were
petitioning the I.R.S. anyway. They were seeking approval to operate
under section 501(c)(4) of the Internal Revenue Code. This would require
them to be "social welfare," not political, operations. There are
significant advantages to being a 501(c)(4). These groups don't pay
taxes; they don't have to disclose their donors - unlike traditional
political organizations, such as political-action committees. In return
for the tax advantage and the secrecy, the 501(c)(4) organizations must
refrain from traditional partisan political activity, like endorsing
If that definition sounds murky - that is, if it's
unclear what 501(c)(4) organizations are allowed to do - that's because
it is murky. Particularly leading up to the 2012 elections, many
conservative organizations, nominally 501(c)(4)s, were all but
explicitly political in their work. For example, Americans for
Prosperity, which was funded in part by the Koch Brothers, was an instrumental force
in helping the Republicans hold the House of Representatives. In every
meaningful sense, groups like Americans for Prosperity were operating as
units of the Republican Party. Democrats organized similar operations,
but on a much smaller scale. (They undoubtedly would have done more, but
they lacked the Republican base for funding such efforts.)
So the scandal - the real scandal - is that 501(c)(4)
groups have been engaged in political activity in such a sustained and
open way. As Fred Wertheimer, the President of Democracy 21, a
government-ethics watchdog group, put it, "it is clear that a number of
groups have improperly claimed tax-exempt status as section 501(c)(4)
'social welfare' organizations in order to hide the donors who financed
their campaign activities in the 2010 and 2012 federal elections."
Some people in the I.R.S. field office in Cincinnati
took the names of certain groups - names that included the terms "Tea
Party" and "patriot," among others, which tend to signal conservatism -
as signals that they might not be engaged in "social welfare"
operations. Rather, the I.R.S. employees thought that these groups might
be doing explicit politics - which would disqualify them for 501(c)(4)
status, and set them aside for closer examination. This appears to have
been a pretty reasonable assumption on the part of the I.R.S. employees:
having "Tea Party" in your name is at least a slight clue about
partisanship. When the inspector-general report becomes public, we'll
surely learn the identity of these organizations. How many will look
like "social welfare" organizations - and how many will look like
political activists looking for anonymity and tax breaks? My guess is a
lot more of the latter than the former.
It is certainly true that the I.R.S., and every other
part of the government, should be evenhanded in how it applies the law,
regarding liberal and conservative groups alike. If left-leaning
organizations were disguising their true purposes to obtain 501(c)(4)
status, the I.R.S. should have turned them down, too. And there will
also be questions about how the Service, which is an independent agency,
answered questions from Congress.
But let's be clear on the real scandal here. The
columnist Michael Kinsley has often observed that the scandal isn't
what's illegal - it's what's legal.
It's what society chooses not to punish that tells us most about the
prevailing ethical standards of the time. Campaign finance operates by
shaky, or even nonexistent, rules, and powerful players game the system
with impunity. A handful of I.R.S. employees saw this and tried, in a
small way, to impose some small sense of order. For that, they'll likely
be ushered into bureaucratic oblivion.


text:
Triumeq (abacavir / dolutegravir / lamivudine) and Alcohol / Food Interactions
There are 4 alcohol/food/lifestyle interactions with Triumeq (abacavir / dolutegravir / lamivudine) which include:
Alcohol (Ethanol) ↔ abacavir
Minor Drug Interaction
Consumer information for this minor interaction is not currently available. Some minor drug interactions may not be clinically relevant in all patients. Minor drug interactions do not usually cause harm or require a change in therapy. However, your healthcare provider can determine if adjustments to your medications are needed.
For clinical details see professional interaction data.
multivitamins with minerals ↔ dolutegravir
Major Drug Interaction
Dolutegravir and multivitamin with minerals should not be taken orally at the same time. Products that contain aluminum, calcium, iron, magnesium and/or other minerals may interfere with the absorption of dolutegravir and reduce its effectiveness in treating HIV infection. You should take dolutegravir at least two hours before or six hours after the multivitamin with minerals dose. Talk to your doctor if you have any questions or concerns, or if you have trouble separating the dosing times. Your doctor may be able to prescribe alternatives that do not interact. It is important to tell your doctor about all other medications you use, including vitamins and herbs. Do not stop using any medications without first talking to your doctor.
dolutegravir ↔ food
Minor Food Interaction
Consumer information for this minor interaction is not currently available. Some minor drug interactions may not be clinically relevant in all patients. Minor drug interactions do not usually cause harm or require a change in therapy. However, your healthcare provider can determine if adjustments to your medications are needed.
For clinical details see professional interaction data.
High Cholesterol (Hyperlipoproteinemia, Hypertriglyceridemia, Sitosterolemia)
Severe Potential Hazard, Moderate plausibility
NRTIs - pancreatitis
The reverse transcriptase inhibitors, didanosine (ddI), zalcitabine (ddC), stavudine (d4T) and lamivudine (3TC), may cause pancreatitis. The incidence is generally low but is approximately 7% with ddI, and up to 15% in pediatric patients given 3TC. Patients with a history of or known risk factors for pancreatitis, such as alcohol abuse or hypertriglyceridemia, should be monitored closely during therapy with these agents. Therapy should be discontinued at the first signs or symptoms suggestive of pancreatitis (e.g., nausea, vomiting, abdominal pain, hyperamylasemia with dysglycemia, rising triglycerides, decreasing serum calcium), and preferably permanently discontinued if clinical pancreatitis develops.
- van Leeuwen R, Katlama C, Kitchen V, Boucher CA, Tubiana R, McBride M, Ingrand D, Weber J, Hill A, McDade H, et al "Evaluation of safety and efficacy of 3TC (lamivudine) in patients with asymptomatic or mildly symptomatic human immunodeficiency virus infection: a phase I/II study." J Infect Dis 171 (1995): 1166-71
- Dolin R, Lambert JS, Morse GD, et al "2',3'-dideoxyinosine in patients with AIDS or AIDS-related complex." Rev Infect Dis 12 (1990): s540-51
- "Product Information. Zerit (stavudine)." Bristol-Myers Squibb, Princeton, NJ.
Triumeq (abacavir / dolutegravir / lamivudine) drug Interactions
There are 282 drug interactions with Triumeq (abacavir / dolutegravir / lamivudine)
Triumeq (abacavir / dolutegravir / lamivudine) disease Interactions
There are 3 disease interactions with Triumeq (abacavir / dolutegravir / lamivudine) which include:
See also...
Drug Interaction Classification
The classifications below are a general guideline only. It is difficult to determine the relevance of a particular drug interaction to any individual given the large number of variables.
Major | Highly clinically significant. Avoid combinations; the risk of the interaction outweighs the benefit. |
Moderate | Moderately clinically significant. Usually avoid combinations; use it only under special circumstances. |
Minor | Minimally clinically significant. Minimize risk; assess risk and consider an alternative drug, take steps to circumvent the interaction risk and/or institute a monitoring plan. |
Do not stop taking any medications without consulting your healthcare provider.
Disclaimer: Every effort has been made to ensure that the information provided by Multum is accurate, up-to-date and complete, but no guarantee is made to that effect. In addition, the drug information contained herein may be time sensitive and should not be utilized as a reference resource beyond the date hereof. This material does not endorse drugs, diagnose patients, or recommend therapy. Multum's information is a reference resource designed as supplement to, and not a substitute for, the expertise, skill, knowledge, and judgement of healthcare practitioners in patient care. The absence of a warning for a given drug or combination thereof in no way should be construed to indicate that the drug or combination is safe, effective, or appropriate for any given patient. Multum Information Services, Inc. does not assume any responsibility for any aspect of healthcare administered with the aid of information Multum provides. Copyright 2000-2017 Multum Information Services, Inc. The information contained herein is not intended to cover all possible uses, directions, precautions, warnings, drug interactions, allergic reactions, or adverse effects. If you have questions about the drugs you are taking, check with your doctor, nurse, or pharmacist.