text:
Videos are now available!
GIST Information Support & Therapy Summit (GISTS)
at MD Anderson Cancer Center, Houston, on October 10th, 2009!
82 GIST patients and family members attended the GIST Summit, which was a huge success. Videos of all the presentations are available now! Go to the program table below and click the "watch video" icon for the talk of your choice.
The organizers for this exciting event were Barbara Dore', Dr. Jon Trent, and Ginger Sawyer (shown at the right-hand side of this photo). GSI co-managers Marina Symcox and Lee Ann Lamb (at the left-hand side of this photo) also joined in the meeting.
See more photos below the program, further down this page.
The GISTS event, lunch, and refreshments were free of charge, thanks to generous gifts from sponsors. An initial grant from Novartis Oncology, plus a supplement from Infinity Pharmaceuticals to cover the large number of pre-registered attendees, funded the event.
Video-recording of the presentations was accomplished thanks to a grant from Pfizer Oncology, to enable non-attendees to watch the event on our website.
Click links in Program table below to watch videos
or to view slides.
We are very grateful to our sponsors for making this event and its video-recording possible!
8:30 | Registration and coffee |
9:00 | Welcome |
9:15 | Jonathan Trent, MD: New Therapies for GIST To view slides CLICK HERE |
10:00 | Peter Pisters, MD FACS: Adjuvant therapy and surgical management of GIST To view slides CLICK HERE |
10:45 | Coffee |
11:15 | Haesun Choi, MD: Radiologic imaging: Responding or Not Responding -- Lessons from the GIST Model |
12:00 | Ask the Expert Session featuring Haesun Choi, MD and Pat Neal, RN |
12:45 | Lunch and Social Time |
2:00 | Pat Neal, RN with Ginger Sawyer and Carol Gangstead: Side effects of Tyrosine Kinase Inhibitors To view slides CLICK HERE |
2:45 | Suzanne George, MD: The Role of Drug Plasma Level Testing in Metastatic GIST To view slides CLICK HERE |
3:30 | Coffee and Social Time |
4:00 | Ask the Experts session featuring Suzanne George, MD; Laura Nolden, MS; and Tony Conley, MD |
4:45 | Closing Statements |
Everyone had a great time and learned a lot at GISTS!
The medical professionals who made presentations were terrific!
Dr. Jon Trent and Dr. Suzanne George | Pat Neal, RN and Dr. Haesun Choi |
Dr. Peter Pisters | The MDA facility was great! |


text:
General Question
What is the difference between pudding in the refridgerated section and pudding in the non-refridged section?
Asked by troubleinharlem (7973)
September 24th, 2010
My mum asked me to get her chocolate pudding, and I noticed that there was some in the refrigerated aisle, and some that was in the non-refrigerated aisle with things like cake mixes… so what is the difference?
Observing members:
Composing members:
4 Answers
Answer this question
This question is in the General Section. Responses must be helpful and on-topic.
Have a question?
Ask Fluther!

subset: commoncrawl


text:
To embed, copy and paste the code into your website or blog:
The statutory gateway to an insolvency process under U.K. law hinges on the definition of insolvency in the Insolvency Act 1986 (IA 1986). However, a 2013 decision by the Supreme Court of the United Kingdom has created ambiguity over the definition and has cast significant doubt on whether creditors can continue using a long-standing test to determine whether a company is insolvent.
In the U.K., a company may be wound up if one of two statutory provisions are proved to the satisfaction of a court:
In BNY Corporate Trustee Services Ltd v. Eurosail [2013] 1 WLR 1408, the Supreme Court analyzed the balance-sheet test for the first time. Its decision suggests that, except for the clearest cases, this test will be very difficult for a creditor to use to establish an insolvency event of default.
Eurosail is a special purpose vehicle that was formed by Lehman Brothers in 2007. It acquired sterling-denominated mortgage-backed loans using the proceeds of long-term notes denominated in sterling, U.S. dollars and euros. The rights of the various noteholder classes, including their relative priority, were set out in the finance documents. Such provisions sometimes are known as the payment or priority "waterfall": As cash becomes available, it flows down to meet payment obligations, starting with the most senior noteholders and ending with the most junior class.
Lehman's collapse in 2008 caused adverse movements in foreign exchange rates after currency hedging arrangements were terminated between Eurosail and Lehman. This resulted in a slowdown in the rate at which Eurosail was repaying the non-sterling notes. One class of noteholders wanted to trigger a contractual change to the payment waterfall to improve the speed at which they would have been repaid (albeit at the expense of other noteholders). The finance documents provided that either cash-flow or balance-sheet insolvency was an event of default. The dissatisfied noteholder group alleged that Eurosail was insolvent on a balance-sheet basis only as it was patently able to pay its obligations as they fell due. The latest financial statements of Eurosail showed net liabilities of about £75 million and assets exceeding £600 million, and the applicant noteholders relied on this as clear evidence that the balance-sheet test had been triggered.
Last year, the Supreme Court unanimously held that the noteholders had failed to establish that Eurosail was insolvent on a balance-sheet basis. A petitioner has to establish to the satisfaction of the court that, on the balance of probabilities, a company has insufficient assets to be able to meet all its liabilities, including prospective and contingent liabilities. Eurosail was a structured finance vehicle with income and payment obligations stretching out for 30 years. In such a case, a court should be very cautious in finding balance-sheet insolvency when the company was meeting current liabilities as they fell due. The noteholders faced an even greater hurdle in making their case, as there are inherent uncertainties to determining the levels of future interest and foreign exchange rates over an extremely long period of time.
The Court also held that the assessment of whether a company is balance-sheet insolvent may differ from a company's balance sheet prepared in accordance with U.K. companies legislation. In particular, the assessment of future and contingent liabilities may be different from the standard company accounting approach. Significantly and unfortunately, the Court offered no guidance on how this assessment should be conducted.
A hostile creditor rarely has access to anything other than a company's publicly available financial information. On the back of this judgment and absent extreme facts, it will be extremely challenging for a creditor to establish balance-sheet insolvency, and it remains for future cases to cast meaningful light on what valuation approach or approaches are appropriate. In the meantime, a prudent lender may wish to negotiate a balance-sheet event of default measurable by reference to the accounting standards ordinarily applicable to the borrower rather than the test set out in the Insolvency Act 1986. * This article appeared in the firm's sixth annual edition of Insights on January 16, 2014.
See more »
DISCLAIMER: Because of the generality of this update, the information provided herein may not be applicable in all situations and should not be acted upon without specific legal advice based on particular situations.
© Skadden, Arps, Slate, Meagher & Flom LLP | Attorney Advertising
Your first step to building a free, personalized, morning email brief covering pertinent authors and topics on JD Supra:
Sign up to create your digest using LinkedIn*
JD Supra provides users with access to its legal industry publishing services (the "Service") through its website (the "Website") as well as through other sources. Our policies with regard to data collection and use of personal information of users of the Service, regardless of the manner in which users access the Service, and visitors to the Website are set forth in this statement ("Policy"). By using the Service, you signify your acceptance of this Policy.
JD Supra collects users' names, companies, titles, e-mail address and industry. JD Supra also tracks the pages that users visit, logs IP addresses and aggregates non-personally identifiable user data and browser type. This data is gathered using cookies and other technologies.
The information and data collected is used to authenticate users and to send notifications relating to the Service, including email alerts to which users have subscribed; to manage the Service and Website, to improve the Service and to customize the user's experience. This information is also provided to the authors of the content to give them insight into their readership and help them to improve their content, so that it is most useful for our users.
JD Supra does not sell, rent or otherwise provide your details to third parties, other than to the authors of the content on JD Supra.
If you prefer not to enable cookies, you may change your browser settings to disable cookies; however, please note that rejecting cookies while visiting the Website may result in certain parts of the Website not operating correctly or as efficiently as if cookies were allowed.
Users who opt in to receive emails may choose to no longer receive e-mail updates and newsletters by selecting the "opt-out of future email" option in the email they receive from JD Supra or in their JD Supra account management screen.
JD Supra takes reasonable precautions to insure that user information is kept private. We restrict access to user information to those individuals who reasonably need access to perform their job functions, such as our third party email service, customer service personnel and technical staff. However, please note that no method of transmitting or storing data is completely secure and we cannot guarantee the security of user information. Unauthorized entry or use, hardware or software failure, and other factors may compromise the security of user information at any time.
If you have reason to believe that your interaction with us is no longer secure, you must immediately notify us of the problem by contacting us at firstname.lastname@example.com. In the unlikely event that we believe that the security of your user information in our possession or control may have been compromised, we may seek to notify you of that development and, if so, will endeavor to do so as promptly as practicable under the circumstances.
Except as otherwise described in this privacy statement, JD Supra will not disclose personal information to any third party unless we believe that disclosure is necessary to: (1) comply with applicable laws; (2) respond to governmental inquiries or requests; (3) comply with valid legal process; (4) protect the rights, privacy, safety or property of JD Supra, users of the Service, Website visitors or the public; (5) permit us to pursue available remedies or limit the damages that we may sustain; and (6) enforce our Terms & Conditions of Use.
In the event there is a change in the corporate structure of JD Supra such as, but not limited to, merger, consolidation, sale, liquidation or transfer of substantial assets, JD Supra may, in its sole discretion, transfer, sell or assign information collected on and through the Service to one or more affiliated or unaffiliated third parties.
This Website and the Service may contain links to other websites. The operator of such other websites may collect information about you, including through cookies or other technologies. If you are using the Service through the Website and link to another site, you will leave the Website and this Policy will not apply to your use of and activity on those other sites. We encourage you to read the legal notices posted on those sites, including their privacy policies. We shall have no responsibility or liability for your visitation to, and the data collection and use practices of, such other sites. This Policy applies solely to the information collected in connection with your use of this Website and does not apply to any practices conducted offline or in connection with any other websites.
We reserve the right to change this Policy at any time. Please refer to the date at the top of this page to determine when this Policy was last revised. Any changes to our privacy policy will become effective upon posting of the revised policy on the Website. By continuing to use the Service or Website following such changes, you will be deemed to have agreed to such changes. If you do not agree with the terms of this Policy, as it may be amended from time to time, in whole or part, please do not continue using the Service or the Website.
If you have any questions about this privacy statement, the practices of this site, your dealings with this Web site, or if you would like to change any of the information you have provided to us, please contact us at: email@example.com.
Already signed up? Log in here


text:
Publication number | US7244225 B2 |
Publication type | Grant |
Application number | US 10/681,812 |
Publication date | Jul 17, 2007 |
Filing date | Oct 7, 2003 |
Priority date | Oct 7, 2003 |
Fee status | Paid |
Also published as | US20050075531, USRE42958 |
Publication number | 10681812, 681812, US 7244225 B2, US 7244225B2, US-B2-7244225, US7244225 B2, US7244225B2 |
Inventors | Marvin P. Loeb, Ginger Johnson, John P. Burrell, Robert J. Sullivan, Lawrence J. Perkins |
Original Assignee | Cardiomedics, Inc. |
Export Citation | BiBTeX, EndNote, RefMan |
Patent Citations (13), Referenced by (25), Classifications (20), Legal Events (4) | |
External Links: USPTO, USPTO Assignment, Espacenet | |
This application is related to a co-owned, now abandoned, U.S. patent application having Ser. No. 10/263,954 and file date of Oct. 2, 2002, which is incorporated herein by reference.
Applicant(s) hereby incorporate herein by reference, any and all U.S. patents, U.S. patent applications, and other documents and printed matter cited or referred to in this application.
1. Field of the Invention
The present invention relates to devices and methods for non-invasively enabling blood circulation to be improved in a more effective manner than existing non-invasive circulatory assistance devices and those which require surgical intervention.
2. Description of Related Art
Current circulatory assistance procedures consist of surgically creating an opening in an artery feeding an organ or a portion of the body and a vein exiting the organ or portion of the body, inserting cannulas, catheters or large needles into the artery and vein, pumping blood at an accelerated rate from the artery through the organ or body portion and returning it to the vein. The blood may be oxygenated or otherwise treated while being circulated extra-corporeally. Such procedures require strict sterility and anti-coagulants, cause damage (hemolysis) to red cells and other blood components and entail the cost and risk of adverse events of surgery.
Some years ago, external counter pulsation or ECP devices were introduced which non-invasively provide circulatory assistance by moving blood from the extremities (legs and buttocks) up to the heart to treat angina pectoris, acute myocardial infarctions (heart attacks) and cardiogenic shock. Early ECP devices employed a liquid, typically water, to compress the extremities. Later ECP devices employed air to compress the extremities, which avoided the need to heat the water to body temperature and the risk of an electrical shock if a balloon or bladder containing the water were to leak or burst. Such early ECP devices are disclosed in U.S. Pat. Nos. 3,288,132; 3,303,841; 3,403,673; 3,734,087 and 3,835,845; as well as co-owned U.S. Pat. Nos. 3,654,919; 3,866,604 and 4,388,919, which, as stated above, are incorporated herein by reference.
Current ECP devices typically include bladders disposed in pockets within each of two pairs of cuffs, which are fastened about the calves and thighs of a person, and two bladders contained in a single cuff which is fastened about his or her buttocks. The bladders are sequentially inflated with air. First, the bladders in the cuffs about the calves are inflated. About 30 to 50 milliseconds later, the bladders in the cuffs about the thighs are inflated, followed, after about 30 to 50 milliseconds, by inflation of the bladders in the cuff about the buttocks inflation and deflation of the bladders is initiated and terminated, respectively, during diastole, after the heart has finished its compression cycle (systole) and is temporarily at rest between compressions (heartbeats). Inflation to a desired pressure is begun after a selected time delay period from the "r" wave of the person's electrocardiogram (ECG), forcing blood up the arteries (and veins) to the heart, counter to the usual direction of arterial blood flow. Compression of the cuffs continues for a selected time period, with simultaneous deflation of all of the bladders occurring during diastole, before the onset of systole, so as not to create resistance to the pumping of blood out of the left ventricle of the heart. When the bladders deflate, the air is released into the atmosphere. Alternatively, the air may be withdrawn by the application of a vacuum to the bladders.
Inflation of the bladders tightens the cuffs and forces blood from the legs and buttocks up the veins into the right heart chambers (auricle and ventricle). This reduces the work-effort of the heart, since a major portion of the heart's work is devoted to returning blood to the heart from the extremities. Inflation of the bladders also forces blood from the legs and buttocks up the arteries into the aorta. Since the aortic valve, if competent, is closed during diastole, the blood cannot enter the left heart chambers and flows from the aorta into the coronary, carotid and other arteries. An increase in intra-coronary artery pressure of up to 40% was measured during ECP, using tiny pressure transducers positioned in the coronary arteries of humans. Such transducers are manufactured, for instance, by Millar Instruments, Inc. of Houston, Tex.
A number of papers have been published on clinical studies in which ECP devices, made by the owner of the present disclosure, have been shown to be safe and effective in the treatment of Stable (chronic) Angina, Acute Myocardial Infarctions (heart attacks) and Cardiogenic Shock (the most serious complication of a heart attack), and such ECP devices have been cleared for sale by the FDA for the treatment of these conditions, as well as Congestive Heart Failure.
In the treatment of heart attacks, ECP was administered for four hours to force blood around the blockage in one or more of the coronary arteries, relieving the ischemia (oxygen deprivation) caused by the absence of blood flow and reducing the damage to the area of the heart supplied by the blocked artery or arteries. An estimated one million heart attacks occur each year in the United States with a mortality of about 50%.
The repetitive application of ECP, which has been shown to significantly increase intracoronary artery pressure, is thought to cause the release of endogenous (naturally occurring) angiogenic growth factors, resulting in the creation of capillaries and arterioles (angiogenesis) and to restore the elasticity and vitality of the endothelial lining of the arteries of the heart, which usually decline with age. To treat a chronic condition, such as stable angina pectoris (Angina) or Congestive Heart Failure (CHF), ECP is typically administered for a period of one hour, five days a week for seven weeks. It is thought that most or all of the angiogeriic agents stored in the arteries is released within one hour by ECP, and delaying the treatment for a period of time gives the body time to manufacture and restock the depots in the arteries with such growth factors. An estimated 6 million people in the United States suffer from Stable (chronic) Angina, and approximately 2.5 million suffer from CHF.
One present type of ECP device, manufactured by the owner of this application, Cardiomedics, Inc. of Irvine, Calif., consists of a control console, containing a microprocessor, associated electronics and a touch-screen display, a power supply, one or more air compressors, an air reservoir and electrically actuated solenoid valves ("Solenoid Valves"), as known in the art, which are in fluid communication with and, when actuated, release air from the reservoir. Hoses attached to and in fluid communication with the outlets of the Solenoid Valves extend about four to six feet from the Solenoid Valves to bladders disposed in pockets within cuffs, which are fastened about the patient's calves, thighs and buttocks. Such ECP devices weigh about 400 pounds, are portable and can be moved from bed to bed to treat patients, without having to move the patients from their beds.
Other present ECP devices utilize sets of cuffs and bladders about the calves, thighs and buttocks, as described above, but the air reservoir and attached Solenoid Valves are mounted beneath a bed dedicated to the treatment of patients brought to the ECP device. Such other ECP devices are described in U.S. Pat. Nos. 4,753,226; 5,554,103 and 5,997,540. The air compressor and Solenoid Valves associated with such ECP devices may likewise be mounted beneath the bed, or may be housed in a separate enclosure. Locating the air reservoir and attached Solenoid Valves beneath the bed shortens the length of the air hoses to the bladders disposed within the cuffs to about 2 to 3 feet, slightly reducing the inflation time of the bladders and the amount of air lost from the hoses when the cuffs are deflated. However, the weight of such ECP devices is 700 to 1100 pounds, and the lack of portability generally limits their use to ambulatory patients or requires a critically ill patient to be moved on a gurney to the ECP device, moved onto the bed of the ECP device for the ECP treatment, and finally, moved back into his/her bed.
It would be desirable to further reduce the loss of air from the hoses when the bladders are deflated, as well as to not require that patients, particularly critically ill patients, be brought to the ECP device.
In our co-pending application Ser. No. 10/263,954, an advanced ECP device is described, in which lightweight, air pressure actuated valves ("APA Valves") are attached directly to the individual inlets of bladders disposed within pockets in the cuffs, which are fastened about the calves, thighs and buttocks of the patient. An operating air pressure is maintained in a pneumatic trunk line that extends from a low pressure air reservoir (maintained at up to 10 psi, preferably about 6 psi) and branches into smaller branch pneumatic lines connected to the APA Valves attached to the individual inlets of each of the bladders within the cuffs. The APA Valves, when actuated, admit air into the bladders or allow air to escape through an exhaust port. The APA valves may be spool valves or any other type of valve known in the art.
Air pilot lines are attached to, in fluid communication with, and extend from each of the Solenoid Valves, which are in fluid communication with a high pressure air reservoir (pressurized from about 12 to 30 psi, preferably about 15 to 26 psi). The air pilot lines extend to the APA Valves attached to the inlets of the bladders disposed in the cuffs. By positioning the APA Valves at the inlets of each bladder, pressure is maintained at all times in the trunk and branch pneumatic supply lines. This minimizes the time of inflation of the bladders and significantly reduces the amount of air lost during the exhaust cycle when the bladders are deflated, reducing the size and weight of the compressor(s), reservoir, and power supply of the ECP device. Actuating the APA Valves attached directly to the bladders of the cuffs with air pressure through the air pilot lines, instead of electrically, eliminates the risk of an electrical shock to the patient.
The presence of buttock cuffs in the current ECP devices described above, however, makes it difficult or impossible to insert a catheter into the femoral artery in the patient's groin area, which is required in persons undergoing an angiogram, coronary balloon angioplasty, insertion of an intra-aortic balloon or other cardiac catheterization procedure which may be required in the treatment of the patient. Furthermore, the current ECP devices described above inflate their three sets of cuffs in a fixed sequence, first the calves, then the thighs and finally the buttocks, limiting their use to treating conditions in which such three cuff sequence is desirable. Also, both of the above described ECP devices are programmed to permit compression of the cuffs only during diastole, and the current ECP devices compress the cuffs about both legs of a patient and do not provide for individual cuff inflation, which would be beneficial in the treatment, for example, of an amputee or a person with a broken leg.
As a result, it would be desirable to have an ECP device not subject to the above limitations.
In the treatment of Angina, heart attacks or cardiogenic shock, the patient may suffer from premature ventricular contractions or "PVC's", which can produce a wide "qrs" interval in the ECG pattern (the time from the end of the "q" wave to the start of the "s" wave), which the microprocessor recognizes and ceases actuation of the Solenoid Valves. Persons with a very low heart rate or an HIS bundle branch block, which is typically treated by implanting a cardiac pacemaker, often produce wide "qrs" intervals in the patient's ECG patterns that are recognized as PVC's by the microprocessor, which causes immediate cessation of actuation of the inflation valves.
It would be desirable to be able to overcome these limitations and provide for a means to enable the operator to over-ride the customary computer program of present ECP devices o treat such patients.
In the treatment of cardiac arrest outside a hospital, cardiopulmonary resuscitation or "CPR" is often applied. The chest is manually compressed by a bystander, who periodically pinches the patient's nose to close the nasal air passages and breathes into the patient's mouth to fill the lungs with air. However, survival from cardiac arrest outside a hospital is very low. This is because manual CPR does not effectively return the blood, which is forced out of the heart by compressing the chest, back to the heart. Also, air breathed into the patient's mouth contains significantly less oxygen and more carbon dioxide than ambient air. Mechanical chest compression devices suffer from the same lack of return of blood to the heart.
When paramedics arrive, a mechanical ventilator, such as the Ambu� MediBag� manufactured by Ambu, Inc. of Linthicum, Md., may be used. The bag is manually squeezed to force ambient, air into the lungs. The paramedics may also apply an electrical shock to the chest to defibrillate and restore the heart to a normal rhythm. However, the weakened heart must continue to work hard to pump blood to the feet and back, and a subsequent cardiac arrest may occur, which may prove fatal.
It would be desirable to have a non-invasive, circulatory assist device that could improve circulation and assist the heart of a person in cardiac arrest, and which could also be used for hours after the patient is resuscitated to reduce the heart's work effort and, perhaps, prevent a subsequent cardiac arrest. The present invention teaches certain benefits in construction and use, which give rise to the objectives described above.
In the treatment of CHF, the patient frequently has a left ventricle ejection fraction less than 40% (55% is normal), due to the inability of the heart to efficiently pump and eject the blood from the main pumping ventricle of the heart. Since ECP increases the flow of blood into the ventricles, excessive pre-loading of the heart can occur in these patients, which could worsen their condition or be fatal. It would be desirable to have an ECP device and a method of use that would prevent this event from occurring.
The present invention fulfills these needs and provides further related advantages as described in the following summary.
The present invention teaches certain benefits in construction and use, which give rise to the objectives described below.
The present invention consists of an improved ECP device whose microprocessor, upon commands transmitted from a display screen, such as a touch-screen display, is programmed to actuate or not actuate any of the valves which inflate the bladders of any of the cuffs, at a time separate from the actuation of the valves which inflate the bladders in the other cuffs, in any desired sequence, forcing blood either toward the feet or toward the heart, during either diastole or systole. The present invention also enables an ECP device to more safely and effectively treat persons with a cardiac pacemaker, who suffer from CHF, who are in cardiac arrest or suffer from certain other conditions, as described below.
Good health is dependent on the vitality and functionality of all of the body's systems: circulatory, nervous, musculoskeletal, pulmonary, digestive, urinary, endocrine and others. If blood flow is inadequate to support the function of any of the body's main systems, poor health and death can result.
The present invention, properly applied, is able to therapeutically treat cardiovascular related conditions such as: acute myocardial infarctions, chronic and acute CHF, pre and post ptca, pre and post CAGB surgery, unstable angina, ischemic stroke, cardiac arrest, atrial fibrillation, ventricular fibrillation, ventricular tachycardia, mitral valve prolapse, hypertension, aortic incompetence or regurgitation, peripheral artery disease, gangrene, peripheral edema, pulmonary edema, retinal ischemia and erectile dysfunction; and cardiopulmonary related conditions such as: chronic obstructive pulmonary disease and emphysema; endocrine related conditions such as diabetes; clearance (shear force related conditions such as acute renal kidney failure, septic shock, end stage renal disease, acute hepatic (liver) failure and chronic obstructive pulmonary disease; and brain and nervous system related conditions such as sleep apnea, epilepsy, anxiety disorders, depression, diabetic neuropathy, chronic migraine headaches, insomnia, senile dementia, cognitive deficits, Alzheimer's disease and Parkinson's disease and to prevent deep vein thrombosis, as well as similar and related illnesses, conditions and dysfunctions; all of which shall be referred to as "medical conditions" in this specification and the claims.
Reversing the sequence of inflation of the bladders in the cuffs (first compressing the buttocks, next the thighs' and then the calves) forces blood toward the feet. Such reverse sequence ECP may be employed during diastole, for example, to treat edema in the legs, ankle and/or feet, a condition frequently occurring in patients with congestive heart failure, peripheral vascular disease and other conditions.
Multiple organ failure (often referred to as septic shock) affects about 200,000 people each year in the United States and presently has a 50% mortality rate. To improve perfusion of the kidneys, liver, pancreas and other internal organs in the treatment of septic shock, it would be desirable to apply ECP during systole. The hearts of most septic shock patients are often strong enough to withstand the effect of enhanced blood flow into the heart during systole, when the aortic valve is open, against the heart's compression, as septic shock patients often have normal or elevated cardiac output. Warren R. Summers, M. D., employed ECP during systole in four multiple organ failure (septic shock) patients at Louisiana State University Medical Center in New Orleans, using an ECP device programmed to compress the cuffs during systole, which was specially modified by the owner hereof. Each of the patients, who had a Swan Ganz and arterial catheter in place for hemodynamic monitoring, received 15 to 30 minutes of ECP therapy each day for six days. ECP increased their mean arterial pressure, cardiac output, oxygen delivery, regional distribution of blood flow and renal organ (kidney) perfusion.
Many persons suffering a heart attack or other cardiac event must have a catheter inserted into their femoral artery in the groin, for example, to monitor their cardiac functions or to inject a radio-opaque liquid to ascertain by X-ray imaging the location and degree of blockage in a coronary artery. To enable the use of such a catheter, de-activating the valves that inflate the bladders of the buttocks cuff allows the buttocks cuff to not be used. ECP may then be provided, as described above (first the calves, then the thighs) during diastole, to treat a catheterized patient suffering from unstable angina, an acute myocardial infarction or cardiogenic shock. If desired, after the catheter has been inserted, or after the procedure has been completed, the buttocks cuff can be attached to the patient and the valves actuated to inflate the bladders contained therein.
Applying ECP during diastole as described above, without using the buttocks cuff (compressing first the calves, then the thighs), may also be beneficial in performing coronary artery balloon angioplasty, which requires frequent femoral artery access to insert and remove guide wires and balloon catheters. The application of calf/thigh ECP during balloon angioplasty may increase coronary artery blood flow and eliminate the chest pain experienced by many patients during the balloon's inflation, which blocks blood flow in the affected coronary artery and causes ischemia (oxygen deprivation) of the portion of the heart muscle supplied by such artery. The use of such an ECP device may also allow for slower, gentler inflation of the balloon and a longer inflation period, for example, up to about 5 minutes or longer, from the present balloon inflation time limit of about one minute. Slow inflation of the angioplasty balloon may eliminate "cracking the plaque" and reduce damage to the artery wall. Also, the substantially longer inflation time may allow a dissected section of plaque to be held in place long enough for it to reattach itself and reduce the incidence of abrupt or later closure of the vessel.
To treat gangrene in the calf, ankle and/or foot, inflating the bladders in the buttocks cuff and the thigh cuffs may be employed, during diastole or systole, without inflating the bladders of the calf cuffs, which could be painful to the patient. To treat impotency, which may be due to plaque blockage of the pudental artery or some other circulatory-related cause, only the inflation valves inflating the bladders of the calf and thigh cuffs may be actuated; in that order, during diastole, eliminating the use of the buttocks cuff.
In the improved ECP System described above, where individual air pressure actuated valves ("APA Valves") are mounted directly on the inlets of each of the individual bladders in the cuffs, any or all of the air pilot line Solenoid Valves, which allow air to enter the air pilot lines and actuate the APA Valves, may or may not be actuated. Furthermore, the Solenoid Valves, which admit, when actuated, air into the air pilot lines, can be actuated in any desired sequence, forcing blood either toward the heart or toward the feet, during either diastole or systole.
For example, in the case of an amputee, a patient who recently underwent surgery in one leg (such as removal of the sapphenous vein for use in bypass surgery) or who suffered a broken leg, who is also suffering from a medical condition treatable with ECP, only the bladders of the cuffs about the remaining or undamaged leg may be inflated. In treating a medical condition in a patient, for example, who recently underwent kidney, prostate or other abdominal surgery, or one who suffered a broken hip, the inflation valves of the buttocks cuff may not be actuated, while any or all of the inflation valves of the bladders in the calf and/or thigh cuffs may be actuated in any desired sequence, during systole or diastole, as described above.
The microprocessor of the improved embodiment of the present invention can also be programmed to adjust, upon selection by the operator, the amount of air pressure applied to any or all of the bladders of the cuffs. For example, less pressure may be applied to the bladders in the cuffs of one leg of a person with a wound, who suffered a broken bone or had a vein removed from that leg, to avoid causing pain.
An air relief or check valve can be attached to the exhaust port of the APA Valves and manually set or microprocessor controlled to release into the atmosphere all but a selected residual amount of air pressure in the bladders after their deflation. This further reduces the volume of air lost when the bladders deflate and the size, power requirement and weight of the compressors of the ECP device. The residual pressure, for example, about 0.3 to 0.7 psi, preferably about 0.4 to 0.6 psi, may take up any unused space between the cuff and the portion of the body it encloses, without creating resistance against blood flow out of the heart on its next compression.
The survival rate after a cardiac arrest is very low, especially if it occurs outside of a hospital setting. A bystander may apply cardiopulmonary resuscitation or "CPR" by manually compressing the chest and, periodically, breathing into the patient's mouth, or a paramedic may use a mechanical ventilator and apply a shock to produce a normal heart rhythm. However, there are no means to return the blood, which has been squeezed out of the heart by compressing the chest, back to the heart. Even if CPR restarts the heart or an electrical shock is applied to the chest, the restarted heart may fail again due to the work effort of pumping blood to the feet and back to the heart. While a number of automated chest compression devices have been tried, none has proved successful in increasing survival from cardiac arrest, as again, there is no means to return the blood from the extremities to the heart. Also, air breathed into the patient's mouth from the person performing the CPR procedure contains a significant amount of carbon dioxide and less oxygen than ambient air.
A preferred embodiment of the present invention entails the use of an ECP device whose microprocessor has been programmed to perform ECP without an acceptable ECG signal from the patient, inflating the bladders and compressing the calves, thighs and buttocks (in that order) a selected number of times per minute at selected pressures and periods of time. The paramedic or nurse administering CPR can synchronize his or her manual compressions of the chest with the ECP device's compressions, instead of mentally counting "one thousand, two thousand," etc.
A most preferred embodiment of the present invention entails the use of an additional cuff, which is fastened with Velcro� about the patient's chest. Two or more bladders are disposed within pockets in the chest cuff. Individual, APA Valves are attached to the inlets of each of the bladders in the chest cuff, and individual air pilot lines, each leading from at least one, Solenoid Valve in fluid communication with the high pressure air reservoir of the ECP device, are attached to, in fluid communication with, and actuate the aforesaid APA Valves, to each of which a pressurized branch air hose is removeably attached, as described heretofore. While one chest cuff is described above, two or more chest cuffs or a chest cuff and an abdominal cuff may be utilized.
A further modification of the most preferred embodiment described above may include the microprocessor actuating an additional Solenoid Valve in fluid communication with the aforesaid high pressure air reservoir, which, through a separate air pilot line, causes an APA Valve attached to a mouthpiece to be actuated about 13 to 16 times per minute, preferably about 14 to 15 times per minute, to force air into the patient's lungs. An air pressure regulator attached to the APA Valve admits air from a separate, pressurized branch air hose through the mouthpiece into the patient's airway at a desired pressure. The air pressure regulator can be manually set or controlled by the microprocessor, based on data from an air pressure sensor within the air hose in fluid communication with the APA Valve, to deliver the amount of air pressure selected by the operator on the display screen to avoid over-inflation of the lungs. Alternatively, the APA Valve attached to the mouthpiece can be a variable output or proportional valve, whose output is controlled by the microprocessor, with feedback from a pressure sensor mounted within the air tube of the mouthpiece.
The mouthpiece can include a soft rubber or plastic lip cover to assure a good seal, an attached nose pinch to shut off the nasal passages, and a headband or strap, which can be fastened about the patient's head with Velcro� to hold the mouthpiece in the patient's mouth. Alternatively, the APA Valve can be mounted on and in fluid communication with an intubation tube inserted through the patient's mouth into his/her airway or a mask fastened over the patient's mouth and nose.
The advantage of this most preferred embodiment of the present invention is its ability to function as an automated cardiopulmonary resuscitation or "Auto-CPR" device to treat persons suffering a cardiac arrest.
The microprocessors of current ECP devices are programmed to compare the patient's ECG with an ECG pattern within normal limits. Such limits are generally a heart rate of 45 to 120 beats per minute, a recognizable and commonly sized "r" wave of the ECG and a "qrs" interval not exceeding 300 milliseconds, as well as other normal ECG indices. When an ECG pattern outside normal limits is recognized by the microprocessor, actuation of the valves, which inflate the bladders of the cuffs is immediately ceased. When the heart of a person in cardiac arrest is returned to a normal rhythm, the microprocessor can sense the restoration of an ECG signal within its programmed normal limits and, while continuing the compression of the calf, thigh and buttocks cuffs at the pre-selected parameters, cease actuation of the valves which inflate the bladders of the chest cuff and admit air into the mouthpiece or intubation tube. The inactive chest cuff and the mouthpiece or intubation tube, with the outlet open to enable the patient to breathe, may be left in place. Alternatively, the microprocessor may sound an audible alarm or send a signal to the nursing station to alert nursing personnel to remove the chest cuff and mouthpiece or intubation tube. A nurse alerted by the alarm or signal to the nursing station can also adjust the pressure, inception and duration of compression of the cuffs, based upon the patient's restored ECG pattern and blood pressure indicated by a finger or ear plethysmograph.
The ECP device can continue to compress the calves, thighs and buttocks, during diastole, of a resuscitated patient for a number of hours to reduce the work effort of the damaged heart. If the patient goes back into cardiac arrest and the microprocessor recognizes that an acceptable ECG signal has been lost, if the chest cuff and mouthpiece or intubation tube have been left in place, both can be re-activated at the earlier selected parameters. Alternatively, an audible alarm or a signal to a patient monitoring station may be sent, the chest cuff and mouthpiece may be re-applied and actuation of the APA Valves of the chest cuff and mouthpiece or intubation tube can be resumed.
The improved ECP device of the present invention enables the operator to over-ride the programmed limitations of the microprocessor to enable the allowable "qrs" interval of the ECG pattern to be increased or decreased in the treatment of patients known to have a very low or fast heart rate or a pacemaker, for example. The improved ECP device also enables the operator to over-ride the programmed intervals of 30 to 50 microseconds between compressions of the calf, thigh and buttocks cuffs, for example, to treat an obese patient or a person with a very slow or fast heart rate, such as one whose heart rate is less than 45 or greater than 120 beats per minute.
When ECP is used to treat a person suffering from severe, chronic Angina, the highest compression pressure, the longest duration of compression and the shortest delay time consistent with patient comfort are selected to produce the highest possible peak diastolic to peak systolic pressure ratio "D/S Ratio", usually between 1.5:1 and 2:1 or higher. When the calf, thigh and buttocks cuffs are compressed during diastole, forcing blood up the arteries toward the heart, diastolic pressure is increased, and blood flow from the aorta through the coronary arteries to the heart muscle increases. A high D/S Ratio increases intra-coronary artery flow and pressure and stimulates the release of angiogenic growth factors to cause angiogenesis. At the same time, compressing the extremities and buttocks forces blood up the veins into the right auricle of the heart, filling the chamber with blood, which then flows into the right ventricle. This latter effect is called "pre-loading the heart'.
CHF, which affects an estimated 4 million people in the United States, causes approximately 400,000 deaths per year, a number equal to the deaths from all types of cancer combined. Other than dual chamber, heart "resynchronization" pacemakers, which are extremely expensive (implantation of such a device in the U.S. costs $50,000 or more), require surgery and have shown only a reduction in mortality of 30% according to statistics from the American Heart Association for annual mortality from CHF in the United States, there is presently no truly effective therapy for CHF.
However, if ECP is used to treat CHF patients who typically have weak left ventricular function, excessive pre-loading of the heart can occur if the bladders of the cuffs are inflated at too high a pressure, are inflated too soon after the "r" wave of the patient's ECG or are allowed to remain compressed for too long a period of time. When there is excessive pre-loading of the heart, particularly in CHF patients with a low left ventricle ejection fraction, the heart cannot pump out or "eject" a sufficient amount of blood. This causes blood to "pool" in the blood vessels of the lungs, abdomen and extremities and fluid to build up in the lungs, calves, ankles and feet. The heart muscle works harder, causing it to thicken, which further reduces its pumping efficiency. As a result, more fluid builds up in the lungs, making it difficult for the patient to breathe, and a recurrence or worsening of heart failure or death can result.
When the compression pressures, delay times and compression durations common to the treatment of Angina are used to treat CHF patients, particularly those with low ejection fractions, many of them do well for the first 5 to 15 hours of ECP therapy, after which their CHF symptoms return and their condition is often worsened, which can lead to death. We have discovered that this problem can be avoided by limiting the D/S Ratio during the 35 hour daily, one-hour ECP treatments to between 0.7:1 to 0.8:1 during the first five hours of ECP therapy, 0.8:1 to 0.9:1 during the next five to ten hours of ECP therapy and 0.9:1 to 1.3:1 during the remainder of the 35 hour ECP regimen.
In a recent study (unpublished data) on the treatment of CHF, using an ECP system manufactured by the owner hereof, 130 persons who suffered from both New York Heart Association Class II, III or IV CHF and Canadian Cardiovascular Society Functional (CCSF) Class III or IV refractive, stable Angina, received 35 one-hour long ECP treatments using the daily regimen described above. They experienced an average increase of 20% in their ejection fractions (a recognized indicator of CHF severity), from 33% to 41.2%. In addition to significant improvement in their quality of life and other factors, in the year prior to ECP treatment, hospitalization was required an average of 1.8 times per patient, whereas in the year following ECP therapy, hospitalization was needed an average of only 0.5 times per patient, a reduction of 72%.
In the year following ECP therapy 7 deaths occurred in this group of 130 severe CHF patients, for a mortality of only 5.4%, a reduction of 71.1% from the 18.7% annual mortality rate for CHF in the United States, according to the American Heart Association's Heart Failure and Stroke 2003 Update. Using this mortality figure, 24 deaths would be expected over a one year period in a general population of 130 CHF patients receiving conventional therapy, approximately 30% of whom typically suffer from Angina. Mortality in a group of 130 severe CHF patients, all of whom also suffer from severe Angina, would be expected to be significantly higher than 18.7%.
In 54 of the chronic CHF patients in the above described 130 patient study, the D/S Ratios were limited to an average of less than 1 to 1. In these patients, mortality in the year following ECP treatment was reduced to zero, left ventricular ejection fractions increased 23% and hospitalizations were reduced to 0.4 per year, an 86% reduction. These results demonstrate the benefits of the reduced D/S Ratio regimen.
In the improved ECP device of the present invention, in the treatment of CHF, if the D/S Ratio exceeds or falls below the selected ratio, the microprocessor of the improved ECP device senses the change in the D/S Ratio and increases or decreases the compression pressure to maintain the selected D/S Ratio. In a further preferred embodiment, the delay time and duration of compression may also be adjusted by the microprocessor to maintain the selected D/S Ratio.
ECP creates a "training effect" on the heart, causing it to accommodate the repetitive inflows of both venous and arterial blood. As a result, separating the ECP treatments by more than one day may be more physiologically beneficial in the treatment of CHF patients, for example, for one hour every other day, particularly for those with low left ventricular ejection fractions.
The ability of the microprocessor to maintain a desired D/S Ratio would also be useful in the repetitive treatment of Stable Angina and CHF. In addition to maintaining a desired D/S Ratio throughout the one-hour or longer ECP treatment, when the patient returns for a subsequent ECP treatment, the microprocessor can recall the desired D/S Ratio from an inputted patient identification number or recognized from a patient dedicated compact disk or other electronic record, saving nursing time.
In another preferred embodiment of the ECP device of the present invention, in the treatment of CHF, a multi-function sensor can be attached to a mask over the patient's nose and mouth, the air tube of a mouthpiece fastened about the patient's head or an intubation tube inserted into the patient's airway. The multi-function sensor, by wires or telemetry, as known in the art, can transmit data to the microprocessor on the metabolic and cardiopulmonary functions of the patient, such as ventilatory efficiency/volume of C02 (VE/VC02), oxygen volume (V02), end title C02 (ETC02), volume of C02 (VC02), respiration rate and other indices. The microprocessor can use the data, along with the patient's blood pressure, obtained from the plethysmograph, and the heart rate and heart rate trend, obtained from the patient's ECG, to change the amount of pressure applied to the bladders of the cuffs and/or the time period during diastole that pressurization is commenced and the duration of compression, maintaining a desired D/S Ratio.
ECP produces a number of beneficial effects. These include (a) increasing blood flow and pressure in the arteries of the heart, causing the release of angiogenic factors and the growth of new blood vessels, (b) causing the release of nitrous oxide, a natural vasodilator; and (c) improving endothelial compliance (elasticity) of blood vessels. These effects are well known.
Other important beneficial effects of ECP, which have not been elucidated, include ECP's (a) "training effect" on the heart, particularly in persons suffering from congestive heart failure with low left ventricular ejection fractions, causing the chambers of the heart to beat in better synchrony and gradually accept and eject a greater volume of blood; (b) improving myocardial (heart muscle) contractility, enabling the heart to compress more efficiently; (c) increasing blood flow to the brain and nerves, improving synaptic efficiency of the brain's neurons and the vitality and transmission of signals by the nervous system; (d) increasing the flow of blood to the lungs, kidneys, liver and other organs, increasing shear force and improving oxygen transport and waste clearance; and (e) increasing blood flow to the glands of the endocrine system, improving their functionality.
The combination of the above known and, until now, unexplained benefits of ECP enable ECP to be beneficial in the treatment of a variety of conditions, which are described below and elsewhere in this application.
In three patients, a tiny pressure transducer (Millar Instruments, Inc. of Houston, Tex.) was placed in a coronary artery and when ECP was applied, intra-coronary artery pressure was increased up to 40%. This is deemed to be sufficient pressure to cause the release of angiogenic growth factors, such as a fibroblast growth factor (FGF), a vascular endothelial growth factor (VEGF) and others, which cause new vessels, usually capillaries and/or arterioles (small arteries), to form and grow around the blockage.
Only very small amounts of such growth factors are stored in depots in the artery wall. After about one hour of ECP, most or all of the stored growth factors are released. As a result, allowing about 12 to 24 hours between one hour applications of ECP gives the body time to produce these growth factors and re-stock the depots.
Consequently, in treating Chronic Angina, ECP is applied at high D/S Ratios (typically ≧1.5 to 1) to cause the release of these growth factors. One hour of ECP is typically administered each day, five days a week (weekends off, because of the lack of skilled personnel in hospital outpatient departments, and cardiologists' offices typically being closed on weekends), until a total of 35 hours of more of ECP have been administered.
However, in the treatment of Acute Myocardial Infarctions (heart attacks), while ECP is typically applied at the same high D/S Ratios (≧1.5 to 1) as in the treatment of Angina, a different ECP regimen is used. In a published study (Amsterdam, et al, Am. J. Cardiol., 1980), heart attack victims received 4 hours of ECP, with a 10 minute rest period after each hour of ECP, to increase intra-coronary artery pressure and force blood through the collateral (secondary, often dormant) vessels around the blockage. After about four hours of ECP, blood flow to the area of the heart fed by the blocked vessel was able to reverse or reduce the damage to the heart wall caused by the lack of oxygen. In this study, 4 hours of ECP in the treatment of heart attack patients within 24 hours of the onset of symptoms reduced mortality by more than 56% from 14.7% to 6.5%. Four hours of ECP proved better than 2 hours, while 6 and 8 hours of ECP produced no added benefit.
We have discovered that continuing the application of ECP, after the initial 4 hours of ECP, at the rate of one hour of ECP each 12 or 24 hours, until a total of about 40 hours of ECP has been administered, is a preferred regimen for ECP in the treatment of heart attacks. In addition to the initial 4 hours of ECP's reducing the damage to the heart muscle, continued, periodic application of ECP provides the additional benefit of the release of angiogenic growth factors and the production of new vessels. These new vessels increase the supply of blood to the areas of the heart that may be still experiencing reduced blood flow, even if balloon angioplasty or bypass surgery is performed, which are only able to treat blockages in the 3 or 4 major coronary arteries.
We have discovered that applying about 4 hours of ECP before percutaneous transluminal coronary angioplasty ("PTCA") commonly referred to as balloon angioplasty, or coronary artery bypass graft (CABG) surgery and, commencing 12 to 24 hours after the PTCA procedure or 48 to 96 hours after the CABG procedure, continuing to apply ECP at the rate of one hour of ECP about each 12 or 24 hours thereafter, until a total of about 40 hours of ECP have been administered, can both perfuse and strengthen the heart as a result of the initial 4 hour ECP application, and cause the release of angiogenic growth factors and angiogenesis, as a result of the continued, periodic applications of ECP.
In a published study (Appelbaum, et al, American Heart Journal, 1997) Doppler ultrasound imaging was used during the application of ECP, and an increase of about 20% in both intra-carotid artery pressure (which arteries supply the brain) and renal artery pressure (which arteries supply the kidneys) was seen. Perfusing the brain enables it to better withstand the oxygen deprivation that may result during inflation of the balloon during angioplasty, or if the heart is stopped and the patient is put on a heart/lung machine during bypass graft (CABG) surgery.
We have discovered that ECP, applied in the regimen typically used to treat Chronic Angina, as described above, can be used to treat persons who suffered an ischemic stroke a few days or weeks earlier (ECP is contra-indicated in cases of hemorrhagic stroke) or who suffer from peripheral edema, retinal ischemia, erectile dysfunction, peripheral artery disease, chronic kidney failure or end stage renal disease, hepatic (liver) failure, diabetes and hypertension; cardiac nerve conduction conditions such as atrial fibrillation, ventricular fibrillation and ventricular tachycardia; pulmonary conditions such as emphysema, chronic obstructive pulmonary disease and pulmonary edema; and nervous system conditions such as epilepsy, diabetic neuropathy, sleep apnea, insomnia, anxiety disorders, depression, migraine headaches, senile dementia, cognitive deficits, Alzheimer's disease and Parkinson's disease, due to the release of angiogenic growth factors and increased blood flow to the heart, brain, lungs, pancreas, kidneys and other internal organs, nerves, glands and penis, as well as preventing deep vein thrombosis by moving blood in and out of the major veins.
We have also discovered that ECP applied in the regimen typically used to treat heart attacks, as described above, can also be used to treat acute ischemic strokes, acute renal failure and septic shock, which is now called multiple organ failure. The initial 4 hour ECP regimen perfuses the heart, kidneys, brain, nerves and internal organs, and the continued application of ECP causes the release of angiogenic growth factors and the creation of new blood vessels, as described heretofore.
To treat septic shock, if the patient's heart is strong, evidenced by a left ventricular ejection fraction (LVEF) greater than at least about 50%, ECP is best applied during systole, compressing the calves, thighs and buttocks sequentially, toward the heart. If the septic shock patient has an LVEF less than about 50%, ECP is best applied in the regimen for treating a heart attack, in the same sequence as described above, but during diastole, so as not to cause pressure against a weak heart's compression.
Likewise, we have discovered that the ECP regimen described above to treat heart attacks can be used to treat acute congestive heart failure (CHF), and the ECP regimen described above to treat chronic Angina can be used to treat chronic CHF, but with an important difference in both cases. If the CHF patient has a LVEF less than about 40%, ECP is applied in both acute and chronic CHF at D/S Ratios of about 0.7 to 1 for the first 5 hours of ECP (lower for very low LVEFs), increasing to 0.8 to 1 for the next 5 to 10 hours of ECP (lower for very low LVEFs) and increasing to 0.9 to 1 or 1:1 for the balance of the 35 hour ECP regimen, enabling the heart to gradually eject a greater volume of blood. If the ejection fraction is 40% to 50%, the D/S Ratio after the first 10 to 15 hours of ECP should not exceed 1.3 to 1, preferably not more than 1.2 to 1.
ECP also increases blood flow to nerves, improving their vitality and conduction (transmission) of signals, and to the brain, increasing the synaptic efficiency of neurons in the brain, making ECP beneficial in the treatment of the above brain and nerve related conditions, as well as in the treatment of atrial fibrillation, ventricular fibrillation and ventricular tachycardia (excessively fast heart beats), due to nerve conduction deficits or failures. ECP's aggressively moving blood out of the legs makes ECP valuable in the prevention of conditions such as deep vein thrombosis, and in the treatment of peripheral vascular disease, peripheral edema and diabetic neuropathy.
As described above, ECP is also beneficial in the treatment of cardiac arrest by supplementing manual CPR by returning the blood from the extremities to the heart; compressing the chest, alternating with compression of the extremities or, the latter with forcing air into the patient's lungs.
Numerous other variations of the principles of the present invention may be employed to treat other conditions by actuating the valves inflating the bladders of any or all of the cuffs at such times, at such pressures, and in any desired sequence during either diastole or systole. The invention may be described with greater clarity and particularity by reference to the accompanying drawings.
The present invention avoids the need to fully refill the hoses with pressurized air when the valves mounted on the bladders open and exhaust air into the atmosphere.
The present invention enables any or all of the individual bladders to be inflated for any selected time period during the cardiac cycle, for example, during either diastole or systole.
The present invention enables any or all of the individual bladders to be inflated in any desired sequence, toward the heart or toward the feet.
The present invention enables the time interval between the inflation of any of the individual bladders to be varied.
The present invention enables a selected amount of air pressure to be maintained in the bladders of any or all of the cuffs after the valves mounted on the bladders open and exhaust air into the atmosphere, taking up any empty space, thus requiring less air pressure and time to be consumed during the next cycle to produce the desired therapeutic effect.
The present invention enables the operator to command the microprocessor to over-ride the default limits based on the time interval between the "q" and "s" waveforms of the patient's electrocardiogram (ECG), to enable patients, for example, with a pacemaker or very slow or fast heart rate to be treated.
The present invention enables the operator to select a peak diastolic to peak systolic pressure ratio which the microprocessor will maintain by adjusting the inflation pressure of the bladders and/or the duration of inflation and the delay of inception of inflation from the "r" wave of the patient's ECG, enabling CHF or stable angina patients to be more effective effectively treated.
The present invention enables avoiding excessive pre-loading of CHF patient's hearts by limiting the peak diastolic to peak systolic pressure ratio.
The present invention enables ECP therapy for CHF patients to be optimized by separating the ECP treatments by more than one day.
The present invention enables the legs and buttocks of a person in cardiac arrest to be compressed for selected time periods and therapeutic pressures in the absence of an ECG signal.
The present invention enables the bladders of a chest cuff to be inflated, alternating such inflations with inflations of the bladders of the calf, thigh and/or buttocks cuffs; both for selected time periods, to treat a person in cardiac arrest and having no usable ECG signal.
The present invention enables air to be infused through a mouthpiece, intubation tube or mask into the lungs of a person in cardiac arrest for a desired time period at desired time intervals.
The present invention enables the inflation pressure, duration of inflation and/or delay in the time of inflation of the bladders from the "r" wave of a CHF patient's ECG to be automatically adjusted, based upon blood pressure, heart rate and pulmonary data from a sensor in a mouthpiece attached to the patient.
Other features and advantages of the present invention will become apparent from the following more detailed description, taken in conjunction with the accompanying drawings, which illustrate, by way of example, the principles of the invention.
The accompanying drawings illustrate at least one embodiment of the present invention. In such drawings:
The above described drawing figures illustrate the invention in at least one of its preferred embodiments, which is further defined in detail in the following description.
The present invention is a ECP system, such as the prior art CardiAssist™ ECP System manufactured by Cardiomedics, Inc., of Irvine, Calif., and shown in
In the improvement shown in
As shown in
Alternatively, a pressure sensor mounted in each bladder or on each cuff may deliver, by wire or telemetry to microprocessor 11, data on the air pressure within each bladder of each cuff or the compression pressure of each cuff, and microprocessor 111 can cause each bladder 18 to be inflated to achieve a desired residual pressure. While the residual cuff pressure of, for example, 0.5 psi may generally be desired, it may be varied by the operator, as described above, based on the patient's height, weight or condition.
The operator may press the "Toward Heart" icon 61 or the "Toward Feet" icon 62 to select the sequence of inflation of the bladders 18 to compress the cuffs 19 (
Also, the operator may press any or all of the "Calf', "Thigh" or "Buttocks" icons 65, 66 or 67, respectively, to select which pair of bladders 18 of cuffs 19 are to be inflated. For example, if the patient is to receive a femoral catheter, the buttocks cuff 19 may not be compressed and can be removed. If the buttocks cuff 19 is not employed, the insertion and use of a femoral catheter is facilitated, which is often required to monitor cardiac and other functions. If peripheral edema is to be treated, the sequence of the "Toward the Heart" icon 61 or the "Toward the Feet" icon 62 may be selected. For example, if septic shock is to be treated, compression of the cuffs 19 during systole may be selected by pressing the "Systole" icon 64.
Any or all of the individual icons are preferably illuminated when pressed. When the "Enter" icon 68 is pressed, those icons which were pressed and illuminated are no longer illuminated, the data is recorded by microprocessor 11, drop-down menu 60 disappears, and display screen 20, shown in
When the "Arrest" icon 52 of display screen 20 is pressed, drop-down "Cardiac Arrest Menu" 70, as shown in
To prepare for the restoration of a normal heart rhythm, when an acceptable ECG signal is recognized by microprocessor 11, pressing the "Delay From 'r' Wave" icon 80 and up or down arrows 81 or 82, respectively, the delay time is changed and displayed in milliseconds. The duration of compression may be selected by pressing the. "Compression Duration" icon 77 and up or down arrows 78 or 79, respectively, and the duration of compression is shown as the wavy line 83 overlaid on the simulated ECG signal 84. When the operator is satisfied, the "Enter" icon 85 is pressed, and the selections are recorded by microprocessor 11, but display screen 20 of
When a normal heart rhythm returns, microprocessor 11 recognizes the restoration of an acceptable ECG signal, drop-down menu 70 disappears, the display screen 20 of
As seen in
If the patient being treated is suffering from CHF and has a left ventricular ejection fraction less than about 40%, particularly for CHF patients with an ejection fraction less than about 30%, avoiding excessive pre-loading of the heart is desired. Pressing the "Auto CHF" icon 97 and up or down arrows 98 or 99, respectively, a desired peak diastolic pressure to peak systolic pressure ratio (D/S Ratio can be selected and displayed. If the patient's D/S Ratio exceeds or falls below the selected D/S Ratio, microprocessor 11 increases or decreases the inflation pressure of the bladders 18, without necessitating the constant attention of a nurse or technician. Optionally, microprocessor 11 can also be programmed to increase or decrease the delay time from the "r" wave of the patient's ECG and the duration of inflation of the bladders 18 to maintain the selected D/S Ratio.
This feature can also be utilized to maintain the desired D/S Ratio throughout the repetitive, one hour or, longer ECP treatments of a person with, for example, stable Angina, CHF or after a heart attack. Likewise, the patient's identification number can be inputted or recognized from a patient dedicated compact disc or other electronic record by microprocessor 11, which automatically causes the ECP device to produces the desired D/S Ratio during subsequent ECP treatments, saving nursing time.
If the patient has an HIS bundle block and a pacemaker has been implanted, or if the patient's ECG or heart rate is producing a "qrs" interval outside the normal "qrs" interval programmed into microprocessor 11, but is not producing typical premature ventricular contractions or PVC's, the operator may increase the acceptable minimum and/or maximum "qrs" interval. To do this, the operator may press the "QRS Min." icon 100 and up or down arrows 101 or 102, respectively, and the "QRS Max." icon 103 and up or down arrows 104 or 105, respectively, whereupon the selected minimum and/or maximum qrs widths are displayed in milliseconds. When pressed, the icons may be illuminated and the functions of the "Enter" icon 106 and the optional "Restore Default" icon 107 are as described with respect to
As illustrated in
As illustrated in
High pressure air reservoir 15(a) holds a supply of air under elevated pressure of about 12 to 30 psi, preferably about 16 to 26 psi. Low pressure air reservoir 15(b), main air hose 17 and air hose branches 17(a) and 17(b) hold a supply of air under elevated pressure, up to about 10 psi, preferably up to about 6 psi. Each of branch air hoses 17(a) and 17(b) is attached to one of the air-controlled valves 150 attached to the inlet of one of separate bladders 18 disposed in cuffs 19. High pressure reservoir 15(a) is preferably connected to low pressure reservoir 15(b) by a variable pressure or proportional valve (not separately shown) as known in the art, which is controlled by microprocessor 11 and enables high pressure reservoir 15(a) to "feed" air to low pressure reservoir 15(b) in an amount necessary to maintain the pressure commanded by microprocessor 11. Optionally, microprocessor 11 can adjust the pressures in reservoirs 15(a) and 15(b), based on signals from pressure sensors (not separately shown) contained in reservoirs 15(a) and 15(b) or air hose 17 and air pilot lines 151, respectively.
Air pilot lines 151 and branch air pilot lines 151(a) and 151(b) enable air released from high pressure reservoir 15(a) by solenoid valves 14 to actuate the opening and closing of the inflation/deflation mechanisms (not separately shown) of the valves 150. Using air through air pilot lines 151 and branch air pilot lines 151(a) and 151(b) to actuate valves 150, instead of using wires and electric current, avoids subjecting the patient to the possible risk of an electrical shock. In use, air pilot lines 151 and branch air pilot lines 151(a) and 151(b) may be attached to or bound together with main air hose 17 and branch air hoses 17(a) and 17(b), respectively, as known in the art. Exhaust ports 152 of air controlled valves 150 enable air from bladders 18 to be discharged into the atmosphere. Alternatively, a vacuum pump (not separately shown) may be used to draw air out from bladders 18 through vacuum hoses (not separately shown). Exhaust ports 152 may each contain an exhaust or check valve (not separately shown), as known in the art, which automatically closes when air pressure in their attached bladder 18 falls to a preferred level to retain a residual amount of air pressure in bladders 18.
As seen in
A narrow Velcro� strip 164 is attached to the bottom surface of cuff end 165 of each cuff 19, and a wide Velcro� strip 166 is attached to the top surface of cuff end 167 of each cuff 19. Velcro� strips are manufactured by Velcro USA, Inc., of Manchester, N.H., and are attached to each cuff 19 by sewing them in place, by thermal fusing and/or an adhesive. In use, when cuff ends 165 and 167 are wrapped about a limb or the buttocks of a patient and are brought together, narrow Velcro strip 164 is removeably attached to wide Velcro strip 166. Wide Velcro strip 166 enables narrow Velcro strip 164 to be removeably attached to wide Velcro strip 166 at various points along its length, permitting cuffs 19 to be snugly secured to patients of different sizes.
Cuffs 19 may be made, for example, of a 600 dernier nylon material or a polycoated polyester. The tubing of trunk hose 17 and hose branches 17(a) and 17(b) can be made of wire or nylon cord-reinforced polyvinyl chloride. Hoses 17 and hose branches 17(a) and 17(b) can be smooth or corrugated, as desired. Each branch air pilot line 151(a) or 151(b) is attached to one of the air actuated valves 150. Air pilot lines 151(a) or 151(b) can be made, for example, of polypropylene tubing or any other suitable material, as known in the art.
Each air controlled valve 150 is actuated by air pressure through its attached branch air pilot line 151(a) or 151(b), which is actuated at a pressure of from about five to twenty psi, preferably about seven to fifteen psi. When activated by sufficient air pressure through branch air pilot line 151(a) or 151(b), air controlled valve 150 allows pressurized air from branch hoses 17(a) or 17(b) to fill its attached bladder 18. When the air pressure exerted through branch air pilot line 151(a) or 151(b) falls to between about zero to five psi, inflation air controlled valve 150 allows the air in its attached bladder 18 to exit through exhaust port 152. Hose branches 17(a) and 17(b) and branch air pilot lines 151(a) and 151(b) may be removably attached to their respective air controlled valve 150 by commercially available threaded connectors or quick connect devices, as known in the art.
Optionally, an air relief or check valve (not separately shown), as known in the art, can be attached to, or contained within each of exhaust ports 152 or, optionally, may be a component of each of the air controlled valves 150 and mounted on the inlets of bladders 18. The air relief valves close when the air pressure in its associated bladder 18 falls to a selected level to retain a desired amount of residual air pressure in bladder 18.
A preferred embodiment of the present invention is illustrated in
Alternatively, a mask over the patient's nose and mouth an intubation tube, as known in the art, may be used instead of the mouthpiece assembly described with respect to
As shown in
Head straps 176, terminating in short Velcro� pad 177 and wide Velcro pad 178, are attached about the patient's head and enable mouthpiece assembly 170 or a mask over the patient's mouth and nose to be held in place. Nose clip 173 is applied to the patient's nostrils to prevent air from escaping through his/her nose. In this embodiment, while four (4) settings, based on body size (small, medium, large and obese) of air pressure regulator 174 are shown, any individual selections, such as numbered by pressure or volume, can be used. It is understood that the air actuated valve 150 associated with the mouthpiece assembly 170 is a proportional valve controllable by the microprocessor 11, and may, alternatively, be attached to an intubation tube inserted into a patient's airway, to which an air pressure sensor or multi-function sensor may be attached, as aforesaid.
When treating a person suffering from CHF, air pressure sensor 175 can relay to microprocessor 11, by wire or telemetry, data on a variety of cardio-pulmonary and metabolic functions, such as VE/VC02, V02, ETC02 and respiration rate. Microprocessor 11, along with blood pressure, from the plethysmograph, and heart rate and trend from the ECG, can be programmed to adjust the compression pressure, and inception and duration of compression to maintain a desired peak diastolic/systolic augmentation ratio. Optionally, an air pressure sensor (not separately shown) can provide data to enable microprocessor 11 to limit the pressure or volume of air infused into the patient's lungs through mouthpiece 172 to a physiologically acceptable level, so as to not over-inflate the lungs.
The interval between completion of compression of the buttocks cuff and the inception of compression of the chest cuff can be fixed, preferably at about 30 to 50 milliseconds. Alternatively, pressing the "Buttocks/Chest Interval Time" icon 142 and left or right arrows 143 or 144, respectively, the desired interval in milliseconds between the completion of compression of the buttocks cuff and the inception of compression of the chest cuff can be selected by the operator and displayed.
The words used in this specification to describe the invention and its various embodiments are to be understood not only in the sense of their commonly defined meanings, but to include by special definition in this specification: structure, material or acts beyond the scope of the commonly defined meanings. Thus if an element can be understood in the context of this specification as including more than one meaning, then its use must be understood as being generic to all possible meanings supported by the specification and by the word or words describing the element.
The definitions of the words or elements of this described invention and its various embodiments are, therefore, defined in this specification to include not only the combination of elements which are literally set forth, but all equivalent structure, material or acts for performing substantially the same function in substantially the same way to obtain substantially the same result. In this sense it is therefore contemplated that an equivalent substitution of two or more elements may be made for any one of the elements in the invention and its various embodiments below or that a single element may be substituted for two or more elements in a claim.
Changes from the claimed subject matter as viewed by a person with ordinary skill in the art, now known or later devised, are expressly contemplated as being equivalents within the scope of the invention and its various embodiments. Therefore, obvious substitutions now or later known to one with ordinary skill in the art are defined to be within the scope of the defined elements. The invention and its various embodiments are thus to be understood to include what is specifically illustrated and described above, what is conceptually equivalent, what can be obviously substituted, and also what essentially incorporates the essential idea of the invention.
While the invention has been described with reference to at least one preferred embodiment, it is to be clearly understood by those skilled in the art that the invention is not limited thereto. Rather, the scope of the invention is to be interpreted only in conjunction with the appended claims and it is made clear, here, that the inventor(s) believe that the claimed subject matter is the invention.
Cited Patent | Filing date | Publication date | Applicant | Title |
US3288132 | Nov 1, 1963 | Nov 29, 1966 | Anthony Myron L | Bladder structures useful in therapeutic treatment |
US3303841 | Jun 18, 1964 | Feb 14, 1967 | Dennis Clarence | Process and apparatus for pressurizing lower extremities of a patient during ventricular diastole |
US3403673 | Jul 14, 1965 | Oct 1, 1968 | Frank F Reed | Means and method for stimulating arterial and venous blood flow |
US3654919 | Nov 25, 1970 | Apr 11, 1972 | Medical Innovations Inc | Process and apparatus for synchronous assisting of blood circulation |
US3734087 | Nov 11, 1971 | May 22, 1973 | Medical Innovations Inc | External pressure circulatory assist |
US3835845 | Oct 24, 1972 | Sep 17, 1974 | Medical Innovations Inc | Cardiac synchronization system and method |
US3866604 | Sep 28, 1973 | Feb 18, 1975 | Avco Everett Res Lab Inc | External cardiac assistance |
US4388919 | Nov 17, 1980 | Jun 21, 1983 | Intermedics Cardiassist Corporation | Rapid stabilization of external cardiac pulsation |
US4753226 * | Mar 25, 1986 | Jun 28, 1988 | Biomedical Engineering Development Center of Sun Yat-Sen University of Medical Science | Combination device for a computerized and enhanced type of external counterpulsation and extra-thoracic cardiac massage apparatus |
US4865020 * | Aug 9, 1988 | Sep 12, 1989 | Horace Bullard | Apparatus and method for movement of blood by external pressure |
US5806512 * | Oct 24, 1996 | Sep 15, 1998 | Life Support Technologies, Inc. | Cardiac/pulmonary resuscitation method and apparatus |
US6450981 * | Aug 18, 1998 | Sep 17, 2002 | Paul Shabty | Computer-based control for a counterpulsation device using noncompressed air |
US20020107461 * | Nov 9, 2001 | Aug 8, 2002 | Hui John C.K. | High efficiency external counterpulsation apparatus and method for controlling same |
Citing Patent | Filing date | Publication date | Applicant | Title |
US7879069 * | Apr 4, 2008 | Feb 1, 2011 | Global Monitors, Inc. | Anti-pooling vest for patients undergoing hemodialysis and in critical care |
US8057400 | Jun 12, 2009 | Nov 15, 2011 | Angiologix, Inc. | System and method of measuring changes in arterial volume of a limb segment |
US8128550 * | Apr 14, 2009 | Mar 6, 2012 | Cardiomedics, Inc. | External counter pulsation treatment |
US8257289 | Feb 3, 2010 | Sep 4, 2012 | Tyco Healthcare Group Lp | Fitting of compression garment |
US8287495 | Oct 10, 2011 | Oct 16, 2012 | Tandem Diabetes Care, Inc. | Infusion pump system with disposable cartridge having pressure venting and pressure feedback |
US8298184 | Oct 11, 2011 | Oct 30, 2012 | Tandem Diabetes Care, Inc. | Infusion pump system with disposable cartridge having pressure venting and pressure feedback |
US8408421 | Oct 29, 2008 | Apr 2, 2013 | Tandem Diabetes Care, Inc. | Flow regulating stopcocks and related methods |
US8448824 | Feb 26, 2009 | May 28, 2013 | Tandem Diabetes Care, Inc. | Slideable flow metering devices and related methods |
US8650937 | Sep 18, 2009 | Feb 18, 2014 | Tandem Diabetes Care, Inc. | Solute concentration measurement device and related methods |
US8657755 | Oct 4, 2011 | Feb 25, 2014 | Angiologix, Inc. | System and method of measuring changes in arterial volume of a limb segment |
US8758323 | Jul 29, 2010 | Jun 24, 2014 | Tandem Diabetes Care, Inc. | Infusion pump system with disposable cartridge having pressure venting and pressure feedback |
US8926561 | Jul 29, 2010 | Jan 6, 2015 | Tandem Diabetes Care, Inc. | Infusion pump system with disposable cartridge having pressure venting and pressure feedback |
US8986253 | Aug 7, 2009 | Mar 24, 2015 | Tandem Diabetes Care, Inc. | Two chamber pumps and related methods |
US9155541 | Dec 23, 2010 | Oct 13, 2015 | Global Monitors, Inc. | Compression vest for patients undergoing hemodialysis and in critical care |
US9180243 | Mar 15, 2013 | Nov 10, 2015 | Tandem Diabetes Care, Inc. | Detection of infusion pump conditions |
US9211377 | Jul 29, 2010 | Dec 15, 2015 | Tandem Diabetes Care, Inc. | Infusion pump system with disposable cartridge having pressure venting and pressure feedback |
US9408773 | Apr 29, 2014 | Aug 9, 2016 | Global Monitors, Inc. | Compression vest for patients undergoing hemodialysis and in critical care |
US9555186 | Mar 15, 2013 | Jan 31, 2017 | Tandem Diabetes Care, Inc. | Infusion pump system with disposable cartridge having pressure venting and pressure feedback |
US20040219180 * | Jan 29, 2004 | Nov 4, 2004 | C. R. Bard, Inc. | Imbedded intramuscular implants |
US20060167390 * | Mar 27, 2006 | Jul 27, 2006 | Hui John C | External counterpulsation system and method for minimizing end diastolic pressure |
US20090112129 * | Apr 4, 2008 | Apr 30, 2009 | Global Monitors, Inc. | Anti-Pooling Vest For Patients Undergoing Hemodialysis And In Critical Care |
US20090247809 * | Apr 14, 2009 | Oct 1, 2009 | Loeb Marvin P | External counter pulsation treatment |
US20110093003 * | Dec 23, 2010 | Apr 21, 2011 | Global Monitors Inc. | Compression vest for patients undergoing hemodialysis and in critical care |
US20110190675 * | Feb 3, 2010 | Aug 4, 2011 | Tyco Healthcare Group Lp | Fitting of Compression Garment |
USD770522 * | Jul 3, 2013 | Nov 1, 2016 | Fisher & Paykel Healthcare Limited | Display screen or portion thereof with graphical user interface |
U.S. Classification | 600/17, 601/152 |
International Classification | A61N1/362, A61B5/02, A61H23/04, A61H7/00 |
Cooperative Classification | A61H2201/5002, A61H2205/084, A61H2205/10, A61H2205/086, A61H2205/108, A61H2201/1621, A61H2201/1642, A61H31/006, A61H2205/106, A61H2205/083, A61H9/0078, A61H2201/163 |
European Classification | A61H9/00P6, A61H31/00H4 |
Date | Code | Event | Description |
Oct 7, 2003 | AS | Assignment | Owner name: CARDIOMEDICS, INC., CALIFORNIA Free format text: ASSIGNMENT OF ASSIGNORS INTEREST;ASSIGNORS:LOEB, MARVIN P.;JOHNSON, GINGER;BURRELL, JOHN P.;AND OTHERS;REEL/FRAME:014598/0947 Effective date: 20031002 |
Dec 18, 2007 | CC | Certificate of correction | |
Sep 1, 2009 | RF | Reissue application filed | Effective date: 20090717 |
Jul 19, 2010 | FPAY | Fee payment | Year of fee payment: 4 |


text:
Bac interactions between M-drol and seroquel sleeping pills
Bac interactions between M-drol and seroquel sleeping pills
Sup fellas,
I'm at 20 mg of M-drol and 30 mg of Epi.
I'm in the first week of my cycle. The other night I was feeling really awake before bed so I popped some Seroquel before bed. I was given these when I was suffering from withdrawl insomnia after putting down the bong for the first time in years.
So I take 5 pills, (not sure of the exact amount of Seroquel it is). I've taken 7 before and stayed awake through it all no problem. This night on 5, everything goes normal, I sleep like a brick. I wake up around 7 to take a piss. I'm hung over as hell from the seroquel. Thats nothing new.
I go to the bathroom then I start taking a wizz and I'm getting really dizzy, tunnel vision ensues, and then I proceed to pass out and fall over. I wake up 10 minutes later face planted in the corner covered in piss with two big welts on my head. I can't see straight til about 3 pm. so I just kept sleeping til then.
Can sleeping pills in general be more potent or have bad interactions with M-drol and Epi? Could this have been due to my violent change in diet from huge carbs during bulking, into minimal carbs?
I'm not panicking or worried, just curious and wondering if I should stay away from things like Ambien and other sleeping pills while on cycle. - 02-06-2009, 09:54 AM
I think you should stay away from any and all mind or mood altering substances...including steroids!!!
Please review this... http://www.onlinelawyersource.com/seroquel/liver.html
Now, do you think it is wise to take two different steroids that both affect the liver? M-Drol alone is a known liver destroyer.
Please do some research on the subject.
I would help you out more, but it seems as if you aimed the gun for your own foot and fired. The information is out there.
By the way, how old are you? - 02-06-2009, 10:08 AM
Thank you. So I did ask my doc would seroquel have any affect on my liver and he said no. How am I not suprised by this!
If you're interested my cycle is the following:
Week 1 - 20mg M-drol 30mg Epi .25 ml Letro
Week 2 - 30 mg M-drol .25 ml Letro
Week 3 - 30 mg M-drol .25 ml Letro
Week 4 - 30 mg M-drol .25 ml Letro
Week 5 - 30 mg M-drol .25 ml Letro
Week 6 - 20 mg M-drol 20 mg Epi .25 ml Letro
Week 7 - 40 mg Epi .25 ml Letro
Week 8 - 30 mg Epi .25 ml Letro
Week 1 - 2 ml (40mg)Nolva .25 ml Letro 2 caps Reversitol
Week 2 - 2 ml (40mg)Nolva .25 ml Letro 2 caps Reversitol
Week 3 - 1 ml (20mg)Nolva .25 ml Letro 2 caps Reversitol
Week 4 - 1 ml (20mg)Nolva 2 caps Reversitol
I'm taking CEL's Cycle Assist, AI's Cycle Support, and Milk Thistle.
I'm not going to make a habit out of heavy duty, harsh, and long cycles but this is going to yield some epic results.
I'll tip my hat to you and say yes you got me I wanted to get a question answered the easy way. For that I apologize. - 02-06-2009, 10:31 AM
Jesus man, you are killing your liver. Have you looked into the effects of Letro on your liver? Stacking all of these is just ridiculous. I have to be honest and blunt here.
Not smart. Please review each product that you're taking and note the toxicity of each. - 02-06-2009, 10:43 AM
Natural Selection at its finest.
In this case, fire away!
This is the worst set-up that I have ever seen on here; his liver is going to fall out of his ass.
I mean, 2 steroids, one of which is a known culprit in liver damage (please don't ask me to show you studies) amongst this Body Building Community. To top it off, he is dropping 2.5 of Letro daily. And if anyone took the time to actually read the first post I made about the Bipolar Medication he's taking for sleep, it is noted that Seroquel can, and has caused severe liver damage. I can go on, but I will refrain.
Oh, and his excuse...
Originally Posted by Ironpounder33 - 02-07-2009, 12:20 AM
aghh I didn't make it clear enough in the first post. I took seroquel once. I haven't been using it prior to the cycle or during until that one night.
Just jump around to any other forum where it isn't run by smart folks. Plenty of people doing absurd things. I figure I'll ride this one out just this once. Not gonna make a habit of it. Will post pics when its all said and done. - 02-07-2009, 12:37 AM
M-drol for 6 weeks is a serious health hazard, but bridging into epistane for 8 weeks of C-17 methylated steroids is absurd.
Usually when people first encounter side effects they reconsider their plans and I urge you for your own sake to do this.
See your doctor and take a liver enzyme test at week 4 and if your liver enzymes are raised discontinue your cycle. If your enzymes are in normal range continue for another 2 weeks and get another test. Get another test 2 weeks thereafter if you continue to 8 weeks!
This is the only way people should approach long oral cycles. Ideally you would bridge into something non-C-17 methylated like furazabol or 19-nor tren for an 8 week cycle.
Bottom line is you should have more respect for your health! Sometimes it takes a serious health scare until people realise this, but it doesn't have to get that close if you just heed to other peoples warnings. - 02-07-2009, 01:34 AM
seroquel is nuts, if you don't stay at the same dose you lose resistance to it. You can build it pretty fast. I had a few 300mg pills from some guy i knew once, he takes them for their anti psychotic effect. I ground those up and put them into several caps, like 25mg a cap, made a bunch of pills. All i take is 25 mg once in a while and i sleep like a zombie.
This is one hellofa HARDCORE stack! haha............ no comment.
What i placed in bold though, Sounds like my college days, but adding naked. Ha. Im glad your alright bro, but that is a CRAZY stack! im a little crazy on coming up with stacks but I dont even think I would take that!!!!! You better Deff get some blood work done boss. I get my blood work done every 3 months and check my blood pressure every week. Little overkill but you get my point. But its your life homeskillet! But new livers are very hard to come by. - 02-07-2009, 05:51 AM
[QUOTE=Ironpounder33;1793514]The other night I was feeling really awake before bed so I popped some Seroquel before bed. I was given these when I was suffering from withdrawl insomnia after putting down the bong for the first time in years.
sorry bro i dont believe you for a second.. hate to call you out.. but seroquel is given to people who are withdrawing from opiates usually during and after detox!
Similar Forum Threads
By FOCUS in forum OTC DrugReplies: 49Last Post: 08-10-2012, 11:49 PM -
25 year old male, big libido problem after taking sleeping pills.
By shred81 in forum Male Anti-Aging MedicineReplies: 17Last Post: 06-04-2011, 02:07 PM -
CEL S-drol - too many pills!??!
By hmarks3 in forum AnabolicsReplies: 1Last Post: 12-21-2010, 11:09 AM


text:
Get FREE Kerrrygold Irish Cheese with any Earth Fare purchase this week!
Expires 3/23/10.
{ 2 comments… read them below or add one }
wish we had one close- I love that Dubliner cheese :(
I was excited to see this coupon in my e-mail this morning! We love cheese around here!
Leave a Comment
Previous post: Walmart Deals Week of 3/17/10
Next post: Walmart Deals Week of 3/17/10


text:
I recently finished reading this rather old book of architectural criticism, written by Tom Wolfe in 1981. Architecture students will find this to be a revelation. It provides much needed light reading and a new perspective to those students who have been bogged down under the weight of Peter Eisenman and other dense theorists. The central thesis is that the world of architecture has been overtaken by a small group of elitists who enforce their dogma with religious fervor. His brilliant one liners and wry wit make what can sometimes seem to be deadly serious business of theory into a game of relationships and one-up-manship.
Of great interest to architecture students will be the treatment of American architect Frank Lloyd Wright, aka "Daddy Frank," by the intelligentsia after the arrival of Walter "Silver Prince" Gropius from Europe. Later Wolfe discusses Robert Venturi and his supposedly radical ideas and how he was able to remain a part of the elite while seemingly attacking their most sacred tenets.
Wolfe saves particular scorn for Philip Johnson. Johnson is ubiquitous throughout the text and the history of modernism. Instrumental in bringing and securing position for Gropius in the beginnings of the international style, his long and varied career is an easy target for Wolfe.
A secondary thesis throughout the book is Wolfe's assertion that the Client became subordinate to the Architect during the modern movement. He goes into hilarious detail on this subject while also showing how despite the popularity of non-modern architecture by the general public, any architect who advocated a new style, or who did so while not kissing the correct shoes, could achieve commercial success yet critical failure.
Perhaps I have a dirty mind, but I could not help but chuckle to myself every time Wolfe mentions Philip Johnson, a homosexual man, and various sexual phrases such as "taking it like a man."
My advice to any architecture student is to read this during the summer prior to your final semester. After all, it won't help your academic career to have subversive ideas in your head too early on. The read is just over 100 pages and fun, so go get it!


text:
Skip to Main Content
District Home
Select a School...
Select a School
Ewing High School
Fisher Middle School
Antheil Elementary School
Lore Elementary School
Parkway Elementary School
Sign In
The Ewing
Public Schools
Providing a Foundation For Life
Board of Education
Ewing BoardDocs
Board Members
Board Goals
Board Policies and Regulations
Business Office
Financial Information
General Information
Meeting Dates, Agendas and Minutes
Superintendent's Office
Quick Facts
Curriculum & Instruction
District Supervisors
Professional Development
Technology Resources
Intervention & Referral Services
District Information
Building and Grounds
District Administrative Team
District Calendar
Ewing Public Education Channel
Ewing Public Education Foundation
Extended Day Program
Food Service
Guidance Department
Health Tips/Information
Human Resources
Information Technology
Integrated Preschool
NJDOE Information
Special Services
District PSA
Parent Information
General Information
Internet/Technology Safety
School Closing Information
School Parent Organizations
Virtual Backpack
Who to contact when...
Directions to our Schools
Staff Directory
PARCC Information
Superintendent's Office
Ewing Township Board of Education
Board of Education
Superintendent's Office
Michael Nitti, Superintendent of Schools
Michael Nitti has been an educator for over 25 years in New Jersey and has extensive experience and expertise in all aspects of school operations. Mr. Nitti has been the Superintendent of The Ewing Public Schools, a diverse Pre K-12 district of over 3,700 students, five schools and a 70 million dollar budget, since July of 2009. Prior to being promoted to the Superintendent position, Mr. Nitti served as Assistant Superintendent of Schools for Ewing for four years, with direct oversight over human resources, negotiations and curriculum.
Before joining Ewing, Mr. Nitti was the Director of Human Resource for the Jackson Township Public Schools where he was responsible for all personnel functions emanating from a 1,600 employee labor force in a rapidly growing K-12 district of nine schools, almost 10,000 students, and a $120 million dollar budget. Special challenges at Jackson included opening an elementary school, the staffing implications of redistricting, and the planning of a new high school.
Mr. Nitti began his career as a social studies teacher at Freehold Township High School, where he taught for a decade in the Social Studies Department and International Studies Specialized Learning Center, serving students from all levels ranging from remedial and inclusion classes to Honors and Advanced Placement courses. He has also served as an athletic coach, building administrator and a K-12 district-level supervisor of curriculum and instruction during his career in education.
Mr. Nitti has been an Adjunct Professor of School Law for the College of New Jersey's Graduate Program in Educational Administration since 2006. He was the President of the Mercer County Superintendents Association from 2010 to 2013 and also serves on the New Jersey School Administrators Association Executive Committee and NJSIAA Executive Committee. Mr. Nitti was also part of the New Jersey State Task Force on Mentoring New Teachers and was trained at the Program for Negotiations at Harvard Law School. He possesses New Jersey certifications as a School Administrator, School Business Administrator, Principal, Supervisor and Teacher of Social Studies.
Mr. Nitti earned his Bachelor of Arts from Rutgers College and a Master of Arts with Distinction in Educational Administration from Rider University.