||May 28, 1996
||October 13, 1994
||Obermayer; Anton (91054 Erlangen, DE)
||Burr; Edgar S.
||Raciti; Eric P.
|Attorney Or Agent:
||Spencer & Frank
||128/203.28; 128/204.21; 128/205.13; 128/205.18
|Field Of Search:
||128/203.12; 128/203.28; 128/204.21; 128/204.22; 128/204.23; 128/204.25; 128/204.26; 128/204.27; 128/204.28; 128/205.12
|U.S Patent Documents:
||4231362; 4453543; 4538605; 4909246; 5072728; 5119810
|Foreign Patent Documents:
||058706; 112979; 1904222; 3712389; 3820043; 2062476
||An anesthetic machine, in particular for use as ventilation part of an anesthetic system which has an inspiratory and an expiratory branch. In order to reuse, e.g. in a half-closed anesthetic system, part of the exhaled gas, the expiratory branch is connected via an additional line to the inspiratory branch. In addition, a controllable inspiration valve is used to control the respiratory gas removed from a gas store.
1. An anesthetic machine, comprising:
(A) a pressure generator for supporting and performing ventilation of a patient, and comprising an alternating pressure gas storage device defining a stroke volume, and controllable actuation means operatively connected to said gas storage devicefor increasing the stroke volume;
(B) anesthetic gas exchange means for performing a gas exchange between the anesthetic machine and a patient, comprising:
(1) an inspiratory branch supplying an inspiratory gas to the patient, and having a first end attached to said pressure generator;
(2) an expiratory branch receiving an expiratory gas from the patient;
(3) a patient-connecting T-piece having a first leg connected to a second end of said inspiratory branch, a second leg connected to an end of said expiratory branch, and a third leg for supplying the inspiratory gas and receiving the expiratorygas to and from the patient;
(4) a controllable inspiration valve located in the inspiratory branch downstream of said pressure generator for removing a gas under pressure during an inspiratory phase from said gas storage device;
(5) an expiration valve located in the expiratory branch;
(6) a connecting line connecting said inspiratory branch to a location on said expiratory branch downstream of said expiration valve, said connecting line receiving the expiratory gas from the patient and supplying the expiratory gas to said gasstorage device; and
(7) a controllable surplus valve in communication with said expiratory branch for controlling an amount of expiratory gas supplied to said gas storage device through said expiratory branch and said connecting line, said anesthetic machine formingone of a half-closed, closed, and half-open anesthetic system in dependence on a position of said surplus valve; and
(C) anesthetic delivery means connected to said inspiratory branch for delivering fresh gas to the patient.
2. The anesthetic machine defined in claim 1, wherein the gas under pressure in said gas storage device is a respiratory gas, the pressure of the respiratory gas being controlled by said controllable inspiration valve and being reduced during anexpiration phase so that the expiration gas is passed through said connecting line and collected in said gas storage device.
3. The anesthetic machine defined in claim 1, further comprising means for partially reusing the expiration gas by recirculating a portion of the expiration gas to said gas storage device, and by diverting excess expiration gas using saidcontrollable surplus valve.
4. The anesthetic machine defined in claim 1, wherein said expiration valve comprises a PEEP valve having means for generating a continuous positive airway pressure.
5. The anesthetic machine defined in claim 1, further comprising a supply line connecting said anesthetic delivery means to a location on said inspiratory branch, said location being one of upstream and downstream of said controllableinspiration valve.
6. The anesthetic machine defined in claim 5, further comprising means for one of intermittently and continuously supplying the fresh gas through said supply line.
7. The anesthetic machine defined in claim 1, wherein said gas storage device includes a fixed plate, a movable plate, and spring means for actuating said movable plate to reduce the stroke volume.
8. The anesthetic machine defined in claim 1, wherein said controllable actuation means comprises a piston and cylinder unit, said piston and cylinder unit being one of pneumatically and electrically actuated.
9. The anesthetic machine defined in claim 1, wherein said connecting line includes a non-return valve located therein, said non-return valve being closed during the inspiratory phase.
10. The anesthetic machine defined in claim 1, wherein said controllable surplus valve and said expiration valve are located in said expiratory branch; said expiration valve being controllable; and said connecting line branching off from saidexpiratory branch at a location between said controllable surplus valve and said expiration valve.
11. The anesthetic machine defined in claim 1, wherein said expiration valve comprises a non-return valve, said non-return valve closing said expiratory branch relative to said inspiratory branch; and wherein said surplus valve comprises acombined surplus, expiration and PEEP valve.
12. The anesthetic machine defined in claim 1, wherein said connecting line returns a respiratory gas to said inspiratory branch and to said gas storage device; and wherein said surplus valve comprises a combined surplus, expiration and PEEPvalve connected to said inspiratory branch.
13. The anesthetic machine defined in claim 12, wherein said connecting line opens into said inspiratory branch at a location between the patient and said controllable inspiration valve; wherein said anesthetic gas exchange means furthercomprises a bypass line having a non-return valve, said bypass line bridging said controllable inspiration valve, said non-return valve being closed during the inspiratory phase.
14. The anesthetic machine defined in claim 1, further comprising a manual ventilation unit having a control valve connected to said inspiratory branch.
15. The anesthetic machine defined in claim 1, further comprising a trigger means for registering a breathing of the patient and controlling said inspiration valve; wherein said gas storage device is operatively connected to said inspirationvalve and said trigger means for supplying the inspiratory gas to a spontaneously breathing patient.
16. The anesthetic machine defined in claim 15, wherein said trigger means provides the spontaneously breathing patient with inspiratory respiratory support.
||BACKGROUND OF THEINVENTION
The invention relates to an anesthetic machine.
A distinction is made in medical technology between anesthetic machines and ventilation systems.
Pure ventilation systems have been disclosed, for example, in the form of respiratory support machines as described, for example, in DE 38 20 043 A1, DE 37 12 389 A1 or EP 0 112 979 B1. Ventilation machines or respiratory support machines areused to ventilate patients before or after an operation in cases where the patient's own ability to breathe is insufficient.
By contrast, an anesthetic machine is used for the specific treatment of the patient during an operation. In the case of major surgical interventions, the anesthesia is, as a rule, carried out as so-called inhalation anesthesia. In this case,the patient is supplied by an anesthetic machine with the anesthetic gas mixture which is composed of oxygen, laughing gas and a vaporized anesthetic. At the same time, a ventilation is carried out. An anesthetic/ventilation machine is described, forexample, in EP 0 058 706 B1.
The prior art relevant to the present invention is explained in detail in FIGS. 6 to 13 to improve understanding hereinafter.
Description of known anesthetic machines with various operating techniques:
As depicted in FIGS. 6 to 8, a known anesthetic machine 1 is essentially composed of three main groups, namely an anesthetic apparatus 2, a ventilation part 3 and an anesthetic system 4. The anesthetic apparatus 2 with a high-pressure gas supplyis used to produce a fresh gas flow 5, i.e. an anesthetic gas mixture composed of oxygen, laughing gas and the anesthetic agent. The fresh gas 5 is passed continuously or intermittently into the anesthetic system 4.
The anesthetic system 4 represents the central functional unit of an anesthetic machine with which the actual gas exchange between the machine and the patient is brought about. Depending on the degree of unconsciousness, i.e. the depth ofanesthesia, the gas exchange is achieved by the patient in the form of spontaneous breathing or, if spontaneous breathing ceases, by a mechanical or manual ventilation. In this case the ventilation takes place by the additional ventilation part 3.
The anesthetic systems 4 in use at present can be differentiated, depending on the reuse of the gas which is exhaled by the patient 6 and returned to the anesthetic system, into three different basic types which are depicted in FIGS. 6 to 8.
In the "half-open anesthetic system" depicted in FIG. 6, the gas which is exhaled and flows from the patient 6 back into the anesthetic system 4 through line 7 is not reused but completely removed from the system through the anesthetic gasextractor 8. The amount of gas (respiratory gas 9) required by the patient must be supplied to the anesthetic system 4 as fresh gas 5 from the anesthetic apparatus 2 via supply line 10. The gas supply line 10 is called the inspiratory branch and thegas removal line 7 is called the expiratory branch.
In the so-called "half-closed anesthetic system" depicted in FIG. 7, part of the exhaled gas is reused, i.e. the amount of gas (=tidal volume) supplied for inspiration by the patient consists partly of previously exhaled expiratory gas and onlypartly of fresh gas. A circulation 11 for this purpose is drawn as dotted line in FIG. 7, i.e. the expiratory gas from the expiration line 7 goes in one part to the anesthetic gas extractor 8 and in the other part (arrow 12) back to the inspiratorybranch 10. This use of the expiratory gas makes it possible to achieve a considerable saving of fresh gas and simultaneously a conditioning of the inspiratory respiratory gas. The conditioning of the respiratory gas 9 in this case takes place by mixingthe fresh gas 5 with the expiratory gas which has 100% humidity and a temperature of 37 degrees Celsius. The conditioning accordingly results in a warming and a moistening of the inspiratory respiratory gas. The smaller requirement for fresh gas 5 alsomakes an impact in terms of costs.
In the so-called "closed anesthetic system" depicted in FIG. 8, the expired respiratory gas 9' in the expiration line 7 is completely collected in the anesthetic system 4 and returned to the patient 6 at the next inspiration. This is depicted bythe closed circulation 11 in FIG. 8, i.e. an anesthetic gas extractor is completely absent. The fresh gas flow 5 which is required is minimal in this system shown in FIG. 8 because it is necessary to supply only the oxygen used by the patient and thestored laughing gas and anesthetic agent. The fresh gas flow 5 is accordingly minimal, which also brings about low environmental pollution by the anesthetic gases due to absence of an anesthetic gas extractor. At the same time, optimal conditioning,i.e. warming and moistening, of the inspiratory respiratory gas 9 is achieved.
With all the anesthetic systems shown in FIGS. 6 to 8, artificial ventilation by the ventilation apparatus 3 is necessary, for example during an operation, because the patient's own respiratory system is switched off because of the anesthesia. In this case, the respiratory gas is supplied to the patient in the inspiratory phase with a slight increase in pressure of the order of 10 to 20 mbar. In the expiratory phase, an expiration valve is opened and the respiratory pressure is reduced to theambient pressure (PEEP=0). In special cases an artificial increase in pressure in the expiratory phase may also be chosen, i.e. the expiration valve is set at a PEEP p>0, e.g. p (PEEP).apprxeq.2 to 5 mbar.
The anesthetic machines on the market are, as a rule, designed either only for the half-open anesthetic system or only for the half-closed anesthetic system or can be switched between the two systems.
For the ventilation part in the so-called "half-open anesthetic system", either so-called "flow choppers" or so-called "respirators with compressed gas store" are used. A "flow chopper" of this type with controlled expiration valve is depictedin FIGS. 9a and 9b. In this connection, FIG. 9a shows the inspiratory phase and FIG. 9b shows the expiratory phase. The reference numbers used in FIGS. 6 to 8 are also used further for the same parts hereinafter.
In the inspiratory phase shown in FIG. 9a, with the expiration valve 13 closed the patient's lung is filled by the fresh gas 5 which comes through the inspiratory branch 10 from the combined anesthetic apparatus 2 with ventilation machine 3 andhigh-pressure gas supply. In the expiratory phase shown in FIG. 9b, the patient is able to exhale through the expiration line 7 with the expiration valve 13 open. In this case, the continuous fresh gas flow 5 is, in the expiratory phase, likewisepassed out through the expiration valve 13 to the outside or into an anesthetic extractor 8 (arrow 19). Recycling of the expired respiratory gas is not provided for. This system is therefore uneconomic and costly and requires an additional unit forconditioning the inspiratory gas.
There is no reuse of the expired gas from the patient's airway in the known half-open anesthetic system with a respirator with compressed gas store as depicted in FIGS. 10a, 10b. As depicted in FIG. 10a for the inspiratory phase, this anestheticsystem has besides the anesthetic apparatus 2 an additional compressed gas store 14 as ventilation part 3 which consists of a fixed plate 15 and a movable plate 16 and of a pressure spring system 17. This half-open anesthetic system additionally has acontrollable inspiration valve 18. In the inspiratory phase shown in FIG. 10a, the inspiration valve 18 is open and the controlled expiration valve 13 is closed. When the inspiration valve 18 is open, because of the pressure gradient between thecompressed gas store 14 and the patient's lung, the fresh gas 5 flows through the inspiratory branch 10 to the patient. The compressed gas store 14 forming the ventilation machine is filled continuously or intermittently by the high-pressure gas supplyof the anesthetic apparatus 2 until the pressure is about 5 bar. Very accurate gas metering is possible with the aid of the controllable inspiration valve 18 and also makes it possible to ventilate neonates. Besides good controllability, this system isdistinguished by high gas tightness. However, the disadvantages are the high gas consumption and the lack of conditioning by the half-open anesthetic system because, in the expiratory phase depicted in FIG. 10b with the expiration valve 13 open, theexpired respiratory gas is completely lost to the environment or in the anesthetic extractor 8 (arrow 19). During the expiratory phase, the inspiration valve 18 remains closed and the fresh gas 5 flows into the compressed gas store 14 and loads thelatter up again against the force of the pressure spring system 17.
Another solution for a "half-open anesthetic system" according to the known system is indicated in FIGS. 11 and 12, with FIGS. 11a, 12a in each case depicting the inspiratory phases and FIGS. 11b, 12b depicting the expiratory phases.
In FIG. 11, a piston pump 20 is used as ventilation part 3 in place of the compressed gas store 14 in FIG. 10. This piston pump 20 is extended in FIG. 12 by the so-called "bag in the bottle" principle whose location is identified by referencenumber 21. In place of the controllable inspiration valve 18 in FIG. 10, a normal non-return valve 22 is provided in the exemplary embodiment shown in FIGS. 11 and 12.
In the exemplary embodiment shown in FIG. 11a, the piston pump 20 is actuated in the inspiratory phase and forces the fresh gas 5, which is present in the relevant cylinder space, through the automatically opening non-return valve 22 in theinspiration branch 10 to the patient. The controllable expiration valve 13 is closed in this phase. During the expiration phase shown in FIG. 11b, the expiration gas 9' exhaled by the patient flows into the expiration branch 7 and reaches theenvironment through the opened expiration valve 13 (arrow 19). The inspiration valve 22 in the inspiration branch 10 is closed during this phase. Because the inspiration valve 22 is designed only as non-return valve, the required ventilation pressurecan in principle be built up only during the actual inspiration process, whose level depends on the elasticity of the patient's lungs and the flow resistance. However, it is also possible, by retracting the piston inside the piston pump 20, to convey,even during the expiration phase shown in FIG. 11b, part of the fresh gas 5 from the anesthetic apparatus 2 with high-pressure gas supply into the piston pump 20. However, the pressure which is built up in this inspiratory branch must be less than theexpiratory pressure in the expiration branch 7 so that the non-return valve 22 remains closed.
The half-open anesthetic system shown in FIGS. 12a, 12b operates in principle in the same manner as described for FIGS. 11a, 11b. In this case, the fresh gas 5 is on each occasion removed or charged from the bellow or bag 23 of the unit 21. Thegas flowing out of the piston pump 20 is moreover called the "primary system" inside the container 24, and the gas flowing out of the bag 23 is called the "secondary system".
However, the known system shown in FIGS. 11, 12 with piston pump 20 has considerable disadvantages in practice. The amounts of inspiratory gas required are between 5 ml and 2500 ml depending on the type of patient (infant or baby with a bodyweight below 2 kg or adult). Moreover, the piston advance of the piston pump 20 is not proportional to the amount of gas conveyed thereby and reaching the patient because, on the one hand, the gas is compressed and, on the other hand, there is furtheradditional supply of fresh gas from the anesthetic apparatus 2. "Loading up" of the system is not possible because of the non-return valve 22 so that the inspiratory branch is subject to virtually no control. Furthermore, there is likewise a highconsumption of fresh gas on the basis of the half-open anesthetic system shown in FIGS. 11, 12, associated with a lack of conditioning similar to the embodiment shown in FIGS. 9 and 10.
The known systems shown in FIGS. 11 and 12 can also be designed as so-called "half-closed anesthetic systems". In this case, the connecting line 25, which is drawn in the form of a broken line in FIGS. 11 and 12, is provided between the lowerinspiratory branch 10 and the upper expiratory branch 7. An additional non-return valve 26 in the connecting line 25 is closed during the inspiratory phase shown in FIGS. 11a, 12a and open during the expiratory phase 11b, 12b. The expiratoryrespiratory gas 9' is accordingly able to reach the inspiratory branch 10 via the line 25 from the expiration branch 7 during the expiration phase. This is indicated with the appropriate arrows in FIGS. 11b, 12b. The abovementioned disadvantages withthe restriction of an excessive consumption of fresh gas remain even in a half-closed anesthetic system of this type.
Finally, FIGS. 13a, 13b depict a known "half-closed anesthetic system" as has been further developed from the example shown in FIGS. 11a, 11b. In this case, FIG. 13a shows the inspiratory phase and FIG. 13b shows the expiratory phase of theanesthetic system. The difference from the exemplary embodiment shown in FIG. 11 is in the exemplary embodiment shown in FIG. 13 the provision in the expiratory branch of a controllable expiration valve 13 and, additionally, a controllable outlet valve27. This valve arrangement makes it possible to determine the extent of the expiratory gas to be reused by means of the controllable outlet valve 27. If the outlet valve 27 is completely closed, the anesthetic system changes its function to a "closedanesthetic system" shown in FIG. 8, i.e. the complete expiratory gas 9' reaches the connecting line 25 to the inspiratory branch 10. The extent of the diversion of the expiratory gas is determined according to the degree of opening of the outlet valve27. Accordingly, in intermediate positions, the anesthetic system is a so-called half-closed one as depicted in principle in FIG. 7. The arrangement depicted in FIGS. 13a, 13b accordingly has control advantages compared with the arrangement shown inFIGS. 11a, 11b. However, the mode of functioning in principle is the same.
The above description of the prior art shows the use in principle of anesthetic systems in the half-open, half-closed or closed modes of operation in each case. In general, this multiplicity of known anesthetic systems generally has thedisadvantage that precise control of the inspiratory gas is impossible because even with a controllable inspiration valve 18 according to the known solution shown in FIG. 10, accurate metering and conditioning of the inspiratory gas is impossible. It istrue that the fresh gas can be as it were "previously tensioned" by the compressed gas store 14 during the expiratory phase. However, circulation of the expiratory respiratory gas is not provided for in this known system.
SUMMARY OF THE INVENTION
The invention is based on the object of improving the known systems in such a way as to produce an anesthetic machine for all the modes of operation depicted in FIGS. 6 to 8, in which the minimum amount of fresh gas is required and optimalconditioning of the inspiratory gas is achieved.
This object is achieved starting from an anesthetic machine having ventilation means for supporting and performing ventilation of the patient. The ventilation means comprises a pressure generator comprising an alternating pressure gas storagedevice, and controllable actuation means for increasing the stroke volume of the gas storage device. The anesthetic machine further includes an anesthetic gas exchange means for performing a gas exchange between the anesthetic machine and a patient. The anesthetic gas exchange means includes an inspiratory branch supplying an inspiratory gas to the patient. The inspiratory branch has a first end attached to the pressure generator. An expiratory branch receives an expiratory gas from the patient. A patient connecting T-piece connects a second end of the inspiratory branch to a first end of the expiratory branch. A controllable inspiration valve is located in the inspiratory branch downstream of the pressure generator. The controllableinspiration valve includes means for removing a gas under pressure during an inspiratory phase from the gas storage device. An expiration valve is located in the expiratory branch. A connecting line connects the inspiratory branch to a location on theexpiratory branch downstream of the expiratory valve to form one of a half-closed, closed, and half-open anesthetic system. The connecting line receives the expiratory gas from the patient and supplies the expiratory gas to the gas storage device. Acontrollable surplus valve is in communication with the expiratory branch. The controllable surplus valve includes means for controlling an amount of expiratory gas supplied to the gas storage device through the expiratory branch and the connectingline. The anesthetic machine further includes an anesthetic delivery means connected to the inspiratory branch for delivering fresh gas to the patient.
Advantageous and expedient further developments of the anesthetic machine as claimed in claim 1 are indicated in the dependent claims.
ADVANTAGES OF THE INVENTION
The invention is based on the central concept of combining the advantages of the known, previously described systems and producing, in particular, a controllable system in which one of the basic principles described in FIGS. 6 to 8 of theanesthetic systems employed is used as required. In this connection, as a general rule, the so-called half-closed anesthetic system shown in FIG. 7 will be used, with FIG. 6 and FIG. 8 in each case representing extreme cases. Accordingly, part of therespiratory gas expired by the patient is always returned to the inspiratory branch in order to use a minimum amount of fresh gas from the anesthetic apparatus, with the required amount of fresh gas being determined by the application and requirement ofthe patient. It is necessary for this purpose according to the invention for the inspiratory gas to be controlled by means of a controlled inspiration valve and likewise in the same way for the extent of the circulating airway gas to be controlled by acorrespondingly controlled outlet valve. The anesthetic machine according to the invention with the components anesthetic apparatus, anesthetic system and ventilation system is therefore assigned a control system which controls the wide variety offunctions of the individual elements and, in particular, the inspiration valve and the surplus valve or outlet valve and thus brings about the optimal conditions. It is moreover essential for the invention to provide an alternating pressure gas storewhich influences with a high pressure level the inspiratory phase. It is possible in this way to carry out the control of the inspiratory gas via the inspiration valve in a very sensitive and accurate manner, it being possible to use fresh gas and/orreusable expiratory gas from the alternating pressure gas store.
It is moreover important for the invention that the expiratory and reused gas is able simply to reach the alternating pressure gas store during the expiration phase. This is determined on the one hand by the setting of the controllable outletvalve and on the other hand by the reduced pressure in the alternating pressure gas store itself.
"Alternating pressure" for the purpose of the invention means that the pressure in the gas store can be reduced to zero or slightly below zero to receive the expired gas and/or the fresh gas and, for carrying out the ventilation, can becompressed to a defined working pressure before the start of the inspiration phase.
Besides the accurate metering of the inspiratory gas flow and, associated therewith, also of the inspiratory gas volume, considerable problems always arise with conventional anesthetic machines in the half-closed anesthetic system when it isnecessary, with newer anesthetic and therapeutic methods, for the patient to breathe spontaneously from the anesthetic machine for a lengthy period. The technical difficulties associated with this type of application are that the anesthetic machine mustsuit the gas flow to the patient to the patient's spontaneous breathing behavior. In particularly difficult situations it is moreover necessary to supply the patient not only with the amount of gas necessary for spontaneous breathing but also toprovide--for very weak patients--additional respiratory support or spontaneous breathing assistance. In the system according to the invention this is achieved by supplying the gas via the controllable inspiration valve by a measurement of the reducedpressure and/or gas flow generated by the patient when breathing spontaneously. The measuring unit for the reduced pressure and/or gas flow generated by the spontaneously breathing patient is called the trigger unit.
BRIEF DESCRIPTION OF THEDRAWINGS
Further details and advantages of the invention are explained in the following description of exemplary embodiments which are described in detail by means of the depictions in the figures.
FIGS. 1a, 1b show a standard system for a half-open, half-closed and closed anesthetic system;
FIGS. 2a, 2b show a simple system for a half-closed anesthetic system;
FIGS. 3a, 3b show an anesthetic breathing system in the case of existent circulation system types with integrated, exchangeable inspiration valve;
FIGS. 4a, 4b show a valve combination for connection of anesthetic breathing systems in the case of existent circulation system types and
FIGS. 5a, 5b show a system after the variation of FIGS. 1 to 4 with connectable manual ventilation, where Figure a in each case shows the inspiratory, and Figure b shows the expiratory, ventilation process.
FIGS. 6-8 are schematics of known anesthetic machines.
FIGS. 9a and 9b illustrate the inspiratory and expiratory phases, respectively, of a known anesthetic machine.
FIGS. 10a-12b illustrate a known half-open anesthetic system.
FIGS. 13a and 13b illustrate a known half-closed anesthetic system.
In FIGS. 1 to 5, identical parts are labeled with identical reference numbers as long as they have already been used for identical parts in the description of the prior art shown in FIGS. 6 to 13.
In general, the problem is solved for all the exemplary embodiments shown in FIGS. 1 to 5 by a connecting line 25 with non-return valve 26 (i.e., check valve) always being present between inspiratory branch 10 and expiratory branch 7 andpermitting return of the expiratory respiratory gas 9' to the inspiratory branch 10. A controllable inspiration valve 18 and a controllable outlet valve 27 are present for the inspiratory phase and are connected to a control unit 28. In addition, apressure generator 29, which is designed as an alternating pressure gas store, is provided as ventilation part 3 and can be moved by a separate or integrated pneumatic or electrical piston cylinder unit 30. It is possible by means of the piston cylinderunit 30 to reduce the pressure in the alternating pressure gas store 29 in order to permit problem-free uptake of the expiratory gas during the expiration phase.
The alternating pressure gas store 29 can be designed as any type of unit for maintaining pressure constant. In the exemplary embodiments shown in FIGS. 1 to 5, this gas store consists of a fixed plate 31 and of a movable plate 32 with a springbellows 33 located between them. A spring system 34 located underneath the movable plate 32 serve for automatic actuation of the gas store. It is also, of course, possible to use a positively driven piston cylinder unit to produce the gas space 35inside the gas store 29.
The piston cylinder unit 30 has a pneumatically or electrically driven piston rod 36 which applies a force to the movable plate 32 during the expiratory phase so that the gas volume 35 is increased. In this case the piston rod 36 is in turncontrolled via corresponding lines leading to the control unit 28.
The inspiration phase depicted in FIG. 1a operates as follows:
Shortly before the start of the actual inspiration phase the piston rod 36, which is shown here by way of example, is moved back into the initial position by the control unit 28, which releases the movable plate 32 of the alternating pressure gasstore 29. The spring forces of the spring system 34 which now become effective compress the gas store and generate the working pressure necessary for inspiration. This working pressure is of the order of two to three times the usual ventilationpressure, i.e. e.g. about 60 mbar. The control system of the control unit 28 closes, via an appropriate control line, the expiration valve 13 for the actual inspiration by the patient 6 and, at the same time, opens the inspiration valve so that thedesired inspiratory gas flow is produced between the gas store 29 and the patient 6. In this case, the patient's lung represents an elastic gas store into which the respiratory gas flows. This respiratory gas flowing into the lung increases thepulmonary pressure as a function of the tissue elasticity and the amount of gas flowing in. To maintain the inspiratory gas flow it is therefore necessary to adjust the inspiration valve 18 appropriately by the control unit 28.
After administration of the tidal volume necessary depending on the patient, the inspiration valve 18 is closed and the patient's lung is left in the inflated state for a short time. This is called the so-called inspiratory pause.
During the inspiration phase it is possible for the fresh gas, which has been taken from the anesthetic apparatus 2 with high-pressure gas supply, to be supplied separately via a separate line 37 to the inspiratory branch 10. It is moreoverpossible for continuous or intermittent supply of fresh gas 5 to take place via line 37.
The supply line 37 for the fresh gas can, as depicted in FIGS. 1a, 1b be located between the inspiration valve 18 and the patient-connecting T piece 38. In this case, the supply of fresh gas is unaffected by the setting of the controllableinspiration valve 18 during the inspiration phase. The same applies to the expiration phase which is depicted in FIG. 1b and in which the supply of fresh gas is expediently operated intermittently. This operation is also controlled by the control unit28.
As depicted in FIGS. 1a, 1b the fresh gas supply 37' for the fresh gas 5 can also be located between the alternating pressure gas store 29 and the inspiration valve 18 as depicted by a dotted line. In this case, the gas flow of the fresh gassupply is picked up by the control system of the inspiration valve 18 so that fresh gas can also reach the gas store 29 and thus the ventilation part 3.
The expiration phase depicted in FIG. 1b operates as follows:
Shortly before or at the same time as the switchover to the expiration phase, i.e. at the time when the expiration valve 13 opens, the piston rod 36 is moved out by the control system of unit 28 and thus the movable plate 32 is pushed downwardsagainst the spring forces of the spring system 34. The increase in volume of the gas space 35 in the gas store 29 means that the pressure in this gas store falls to zero or, in some circumstances, even to a reduced pressure slightly below zero. Afteropening of the expiration valve 13, owing to the positive pressure in the lungs of the patient 6, the expiratory gas flows through the expiratory branch 7 and the connecting line 25 through the non-return valve 26, which is open in this case, into thegas store 29. During this phase there is also control of the outlet valve 27. Depending on the degree of opening of the outlet valve or surplus valve 27, the expiratory gas 9' is passed into the gas store 29 or out of the system (arrow 19). The amountof expiratory gas which is not required can accordingly be passed via the surplus valve into the anesthetic gas extractor 8 (arrow 19). This applies in particular as a function of the increasing pressure in the storage system.
Accordingly, the main advantage of the apparatus system according to the invention is the accurate control of the inspiratory gas flow. Moreover, the half-closed anesthetic system with an alternating pressure gas store 29 is preferably used,with the expiratory gas being supplied to the gas store partly or completely (closed anesthetic system) and only the unrequired amount exhaled being removed in the anesthetic gas extractor. In this case, control takes place via the gas pressure in thegas store 29 and the control of the outlet valve 27 which is downstream of the expiration valve 13. The inflow of expiratory gas to the gas store 29 can be solved without difficulty by the piston cylinder unit 30 according to the invention, it alsobeing possible to use another driven gas cylinder unit 29.
It is, of course, also possible for the expiration valve 13 to be designed as so-called PEEP valve.
A simplified system for the half-closed anesthetic system is used in the exemplary embodiment of the invention shown in FIGS. 2a, 2b. In this case, identical parts are labeled with identical reference numbers as in FIGS. 1a, 1b.
In the simplified exemplary embodiment shown in FIGS. 2a, 2b, the non-return valve 26 in the line 25 is dispensed with because this connecting line 25 between the expiratory branch 7 and the inspiratory branch 10 can also be closed in other waysduring the inspiratory phase shown in FIG. 2a. For this purpose the expiration valve 13 present in FIG. 1a is replaced by a simple one-way valve 39, while the outlet valve 27' is designed as combination valve, i.e. as combined surplus, expiration and/orPEEP valve. This makes it possible for the expiratory branch 7 and the surroundings or the anesthetic waste gas extractor to remain closed during the inspiratory phase shown in FIG. 2a.
During the expiratory phase shown in FIG. 2b, the one-way valve 39 opens so that the expiratory gas 9' can reach, depending on the setting of the combination valve 27', the gas store 29 likewise via the connecting line 25 or the anesthetic gasextractor 8 via the combination valve 27' (arrow 19). The functioning of this gas guidance takes place in the same way as described for FIGS. 1a, 1b.
In the exemplary embodiment which is also present and is shown in FIGS. 3a, 3b, an anesthetic breathing system of the type shown in FIGS. 2a, 2b is provided, in which existent circulation system types with integrated, replaceable inspirationvalve 18 are used. In this embodiment identical reference numbers again designate identical parts.
Compared with the exemplary embodiment shown in FIGS. 2a, 2b, in the case of the exemplary embodiment shown in FIGS. 3a, 3b a first gas return line 25' which forms a circular line as depicted in FIG. 8 for the closed anesthetic system is providedin the existent circulation system. The expiratory gas 9' is accordingly always returned through the one-way valve 39 into the inspiratory branch 10 and reaches, via a T piece 40, the inspiratory line 41 between gas store 29 and the controllableinspiration valve 18, as is also the case in the exemplary embodiment shown in FIGS. 1 and 2. In contrast to the two exemplary embodiments mentioned, however, the combination valve 27' is connected, not in the expiratory branch 7 but in the inspiratorybranch 10, via another T piece 42 to the inspiratory line 41 between gas store 29 and inspiration valve 18, so that an additional gas line 43 for the expiratory branch results.
Accordingly, during the inspiratory phase, both the non-return valve 39 and the combination valve 27' are closed, so that the inspiratory gas reaches the patient 6 via the inspiratory branch 41, 10 from the gas store 29 and from the additionalfresh gas supply 37 or 37'. This corresponds to the gas guidance according to the exemplary embodiment shown in FIG. 2a.
During the expiratory phase as depicted in FIG. 3b, the non-return valve 39 opens and the expiratory respiratory gas reaches the T piece 40 via the connecting line 25' and from there reaches the gas store 29 via the line 41. Depending on theposition of the controllable combination valve 27' the expiratory surplus gas is diverted via the additional gas line 43 into the anesthetic gas extractor 8 (arrow 19). In this expiratory phase it is possible for the inspiration branch to be closed byan additional one-way valve 44. This one-way valve 44 is located between the patient-connecting T piece 38 and the inspiration valve 18. The fresh gas supply 37 of the anesthetic apparatus 2, which is not depicted in detail, is located between theone-way valve 44 and the inspiration valve 18.
FIGS. 4a, 4b depicts another exemplary embodiment of the invention as a modification of the exemplary embodiment shown in FIGS. 3a, 3b. Identical parts are identified by identical reference numbers. This valve combination is used for connectingan anesthetic breathing system in the case of existent circulation system types.
In a further development or modification of the system shown in FIGS. 3a, 3b, the inspiration valve 18 is located outside the circulation system. According to the exemplary embodiment of the invention shown in FIGS. 4a, 4b, the expiratory gas issupplied, in a line 45 which is connected in parallel to line 41 and runs from the T piece 40 in the inspiratory branch 10 via another T piece 46, to the parallel line 45 in order to bypass the inspiration valve 18. Another one-way valve 47 is locatedin this parallel line 45 and is closed during the inspiratory phase shown in FIG. 4a and open during the expiratory phase shown in FIG. 4b. It is thus possible for the inspiratory gas to reach the patient during the inspiratory phase, when the one-wayvalve 47 is closed and the combination valve 27' is closed, only via the controllable inspiration valve 18.
During the expiration phase shown in FIG. 4b, the expiratory gas 9' reaches the inspiratory branch 10, via the one-way valve 39 and the return line 25, and from there reaches the additional gas line 43 via the connecting line 45, the one-wayvalve 47. Depending on the opening of the combination valve 27', the expiratory gas is in turn supplied to the gas store 29 or, via the combination valve 27', to the anesthetic gas extractor 8. It is possible where appropriate for the line 25' to bedirectly connected to the line 45.
The exemplary embodiment of the invention shown in FIGS. 5a, 5b represents a simple further development of the exemplary embodiment shown in FIGS. 4a, 4b. Identical parts are provided with identical reference numbers. In the exemplaryembodiment shown in FIGS. 5a, 5b it is possible for the system shown in FIG. 4, and in principle the system of FIGS. 1 to 3, to be provided with a connectable manual ventilation. For this purpose, another controllable valve 48 is connected to line 45and leads to the inspiratory branch via the upper T piece 46. This makes it possible for manually controlled ventilation of the patient to be carried out additionally by means of a manual bellows 49 during the inspiratory phase as long as thecontrollable valve 48 is open.
The valve 48 can be open during the expiratory phase so that fresh gas and, where appropriate, expiratory gas can reach the manual ventilation bellows 49.
Also indicated in FIG. 1a is a measuring unit 50, which is close to the patient and is intended to pick up the spontaneous breathing activity of the patient, for the reduced pressure generated by the spontaneous breathing and/or the gas flow. This "trigger unit" controls the controllable inspiration valve 18 and generates an additional respiratory support or spontaneous breathing assistance.
The invention is not confined to the exemplary embodiments depicted and described. On the contrary, it also embraces all expert further developments within the scope of the inventive concept. In particular, the alternating pressure gas store 29can also be designed as piston/cylinder unit with its own controllable actuation in both directions.
* * * * *
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Caterham has joined forces with RS Performance to offer the ultimate in bespoke Seven coach-building. The model will be powered by the unique RST-V8 engine. The 2.4-liter 40-valve is capable of developing 400 BHP in normally aspirated mode or over 500 BHP as a supercharged variant. This partnership will be open to customers looking for the ultimate in exclusivity, and carry a price tag to reflect the tailoring, detail and hand-built craftsmanship that will go into every RS-badged Caterham. The RS Performance badge will sit alongside the established, and soon to be expanded, Ford powered Caterham Seven range. The price will be starting at $115.000.
For those wanting an expression of British sportscar exclusivity, Caterham Cars has joined forces with RS Performance to offer the ultimate in bespoke Seven coachbuilding.
Caterham has long been the epitome of personalised motoring with almost every version of the 12,000 Sevens on the road differing from one another. The joint venture takes that famous philosophy to an altogether new level.
RS Performance is an exclusive, niche engineering house. Born out of the passion and pedigree of its founder, Russell Savory, it will offer an "everything is possible" service to Caterham customers wanting cars truly "built to order".
Using the motorsport-honed Caterham chassis and benchmark technology as a cosmetic and engineering base, RS Performance, will "turn imagination into reality," says Savory.
The heartbeat of every RS-monikered Seven will be the unique RST-V8 engine.
With more than 16 years of development behind it by Russell Savory, the 40-valve, 2.4 litre engine reliably delivers an incredible 400bhp in normally aspirated mode, or over 500bhp as a supercharged varient, whilst weighing only 90kg in full running gear.
The unbridled lightness of the RST-V8 matched to the already featherweight Seven chassis delivers a power-to-weight ratio of over 1000bhp per tonne â€" more than double of a Bugatti Veyron.
This unique partnership will be open to customers looking for the ultimate in exclusivity, and carry a price tag to reflect the tailoring, detail and hand-built craftsmanship that will go into every RS-badged Caterham.
Validation of the engineering house`s abilities comes in the form of the supercharged "Levante". This is the first Seven to rollout of RS Performance`s Hertfordshire doors and which only seven more of this type will be available.
With a 12 week waiting time and costing over Â£115,000, this supercharged engineering masterpiece boasts a modern interpretation of the Seven`s classic looks with a sophisticated electronics package with traction and launch control to help get the phenomenal power to the floor. Weight reduction runs throughout the car, from the carbon fibre interior finished with Kevlar seats down to the hosing used on the cooling systems
The RS Performance badge will sit alongside the established, and soon to be expanded, Ford powered Caterham Seven range.
"Caterham and Russell Savory have a long history, and this seemed a natural progression of that relationship and shared engineering philosophy," explained Ansar Ali, Caterham Cars managing director.
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On Air Now
The Capital Late Show with Sonny Jay 10pm - 1am
29 February 2012, 20:23 | Updated: 29 February 2012, 20:34
The New York Knicks basketball player gave an impromptu rendition at a team event this week.
Bruno Mars and Travie McCoy's hit single 'Billionaire' was performed by New York Knicks NBA star Landry Fields last night (28th February).
The basketball star was on stage with his team mates at a season subscriber forum which was attended by their fans.
Landry stood up from his seat to deliver his rendition of Bruno's verse and altered some of the words to include the lyrics "ant a championship so frickin bad" and "be on the cover of Slam magazine.
The 'Marry You' star posted a link to the clip on his Twitter account earlier this evening and simply tweeted: "HELL YEAH!"
Meanwhile, the singer recently hit the UK for the BRIT Awards 2012 where he performed 'Just The Way You Are' and won International Male Solo Artist thanked his UK fans for all their support.
You can view a video of New York Knicks NBA star Landry Fields performing 'Billionaire' below:


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16.24 In Stock
This is Prospero's darkest hour. The few remaining humans trapped within the quarantine zone are all but defenseless against the multiplying forces of the Sliver Queen, Locusta. With Ben missing, Aldo among the enemy ranks, and more steel plates than bones left in her body, Mina's passing the hours drowning in morphine and throwing heavy objects at her guards. Stripped of her weapons, her gadgets, and the Network itself, she has just one card left, hidden somewhere under her oft-sutured skin. It might be powerful enough to complete her life's work once and for all... or to reach the one person who could make her life into more than a means to an end. But playing it will cost everything she has, or everything she believes in. The final chronicle of Prospero waits in these pages.

domain: library


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Since lockdown was imposed on the whole of the UK on 23rd March 2020, the lives of many students have certainly been disrupted as they either moved back home or buckled down in Leeds and teaching moved online. Since then most of you will likely have spent some time baking sourdough or banana bread, going for your one hour of state-mandate exercise or sadly slaving away at your dissertation.
However one group of students haven’t been resting as much as the rest of us. I’m talking about the student volunteers at St John Ambulance Service (SJAS). Having run as a society at both Leeds Beckett University and University of Leeds, the student volunteers usually help out with the national charity in providing medical cover at large scale events like fairs, festivals such as Manchester Pride, and services such as the Booze Bus in Leeds City Centre.
The Booze Bus – contrary to what it sounds like – operates around Leeds city centre providing medical assistance for drunk people who might need medical attention for example. Since all of these events have been postponed or cancelled as social distancing policies were introduced, the NHS then called on the St John Ambulance service to help out and these students certainly stepped up to the plate.
Sitting down virtually with Charlie Cassidy, a committee member of the SJAS and member for four years, I asked her about her experience helping out the NHS as it struggled to deal with the influx of coronavirus cases with severe symptoms into hospitals.
She told me how ‘the past few weeks have been very uncertain and somewhat unsettling for all of us’ though members of the society ‘have been busy completing specialist Covid-19 courses to equip us with the skills needed to care for patients during the pandemic”.
While many of us have cooped up for the time being, SJAS has been busy sending volunteers into hospitals and by providing ambulances to support the NHS ambulance services.
Cassidy added that it ‘has been quite scary knowing that we were going to be joining the NHS on the frontline’ but remained positive saying that it has kept them all busy during lockdown and many people have been friendly (at a 6-metre distance of course) while out volunteering.
The tasks they have had to help out with over the past few weeks have certainly varied. Charlie has been working at the organisation’s headquarters in Wakefield to ensure ambulances are full stocked and ambulance crews are provided with personal protective equipment (PPE) keeping the operation running smoothly.
Many volunteers when I interviewed Cassidy were still waiting to hear what hospitals they were needed in with some waiting to hear whether they’ll be needed at any Nightingale hospitals – luckily these hospitals didn’t end up being as busy as expected. Nathan, a second-year Neuroscience student has been working with training teams to deliver specialist COVID-19 care courses to other volunteers.
Nat, a third year Food Science student, and India, due to start a postgraduate nursing degree in September, have been working in the ambulance service. Nat said that one of her favourite jobs so far was “taking an elderly gentleman with dementia back to his care home after being in hospital for several weeks with coronavirus”.
She went on to say:
“The patient was confused and refused to believe that Nat and Jack were taking him home. However, when the patient’s son greeted him on his arrival home, the patient burst into tears with happiness. This was a huge reminder to all of us as to why we do what we do.”
“This was a huge reminder to all of us as to why we do what we do.” – Nat, a third year student.
Some of the students are also getting stuck in helping out at hospitals. One student volunteer Sian has been deployed to an A&E in Brighton, her hometown, while another Fin has been deployed to the wards at Tameside Hospital in Manchester. Their roles have mainly involved taking patient observations (blood pressure, temperature etc), washing and feeding patients, keeping patients company due to current visitor bans and helping them to make phone calls to their families.
Fin told The Gryphon how the staff have been “very welcoming and appreciative of our help on the wards. He went on to say “the current NHS-St John partnership seems to be working really well to take the pressure off staff and to provide for patients’ needs”.
When I asked Charlie about what she thought of both Leeds Beckett and University of Leeds’ responses to the crisis, she said that the support they’ve recieved as a society has been fantastic.
She goes on to say:
“We think it’s great how University of Leeds have provided resources such as accommodation, free car parking and equipment to the NHS”.
She also praised Leeds Beckett University who have been providing free training spaces for newly employed NHS workers. “These small tokens of kindness go a long way and make people’s lives slightly easier in these difficult times!” she told us.
Helping out on the NHS frontlines haven’t been the only thing the society has done recently. They’ve also hosted a fundraiser that has raised a whopping £1244, just under 250% more than their original target.
When I asked Charlie about why they were holding the fundraiser she told me how like many charities across the country, St John Ambulance Service has seen funding dry up in the wake of the pandemic. “When the pandemic hit”, she tells us, “all events at which we would usually provide medical cover were cancelled, and fundraising events were cancelled too”.
These events were the main sources of income for St John Ambulance with the money going towards training volunteers, maintaining our vehicles, buying new equipment and medications. Charlie asked people to continue donating to the fundraiser, perhaps the price of their usual morning coffee, to help support St John Ambulance so they can continue to operate with the NHS.
They’ve recieved significant support from some societies at Leeds including LUU’s Women’s Hockey Club who singlehandedly raised more than £150.
Donations to the fundraiser can be made here.
So what can we take away from this unusual period in time, I ask Charlie.
She says that “to her this pandemic has emphasised the fact that humanity can be incredible in the sense that they can pull together to make the best of a very bad situation”.
She pointed to Leeds Student Radio’s Virtual Fruity, LUU Help and Support team, and all the societies who are currently fundraising for charities and causes. She praised all the volunteers and final-year medic and nursing students being fast tracked saying they are a “credit to this university”. She pointed out how some students providing childcare too for key workers, community, and council schemes helping the vulnerable, shop workers and security guards keeping our shops safe and running.
About her team in particular, she said
“They have pulled together despite the scary circumstances to care for those who need it most, all whilst looking out for each other and completing their university work and dissertations. It’s confirmed to me that they are a dedicated, compassionate and selfless team who are a pleasure to work with“
As for what people can do now, Charlie said the most important thing is that you try to stay safe – follow Government advice on lockdown and handwashing and look out for the vulnerable who may need your help.
To join the Leeds Universities St John Ambulance Society, head to their social media pages for more information.
The society usually has first aid training sessions every Thursday evening in Leeds University Union. For anyone interested, they still do Zoom training sessions.
In September, their first session back will likely be Thursday 24th September at 8pm but nothing is set in stone yet. Each week they teach different topics (e.g. CPR, choking etc) with the chance to get hands on and practice your skills. If it’s something that you realise you have a passion for then there’s always the opportunity to apply to become a volunteer first aider with St John Ambulance.
To donate to the fundraiser, click here.

domain: news


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Densha Otoko is a japanese drama that aired in japan on 2005 ago. if we see the time it aired, it quite long till i watched this drama. Well its because on 2005, i’m not a fan yet (i want to say “otaku”, but i’m not otaku-like yet, so i used “fan”).
I’m not describing the story here, because you can read it on the Wiki (and everywhere everytime you type Densha Otoko on google) but, what i’m trying to say here was this story was so hypnotizing. I mean, easily you can feel like you were the main subject (or maybe just me, because i kinda had some problems like that)
Anyway, to people who havent watched it yet, watch it.. its a good movie. I rarely find a movie that can make me cry.. :’)
It feels like Hypnotized!!

domain: entertainment


text:
Drag box to select area
Cook's Corner is a cook's delight. It sells specialty foods and flavorful coffees and teas, plus plenty of kitchen accessories, teapots, cookie jars and more. Whether you want tasty treats, kitchen decor or cookware, Cook's Corner is the place to go.
1 N New York Rd, Galloway, NJ 08205
- Hours: Mon - Wed, 10am - 6pm; Thu - Sat, 10am -8pm;
Sun, 11am - 6pm

domain: food


IT’S May 23, 2001 and Alan Shatter is in Opposition – and he’s making very serious allegations about Garda corruption in Donegal…involving allegations of bugging.
The Justice Minister was John O’Donoghue (Fianna Fail) – and he was having none of it.
“Will the Minister confirm that there is an allegation that gardai in Donegal were bugging conversations between solicitors and clients?” asked Alan Shatter.
The Minister refused to budge; refusing to answer any questions despite being badgered by the Fine Gael TD.
In fact Minister O’Donoghue accused Deputy Shatter of making “ill-tempered, outrageous and unfounded” allegations.
But Deputy Shatter insisted: “This is a scandal of enormous proportions about which the Minister had done nothing since taking office.”
The record of the Dail exchange is below…..Tags:


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Wedding rings are more than just beautiful pieces of jewelry. They are symbols of love, commitment, and unity between two people. As you plan your wedding and begin to search for the perfect rings, it’s important to understand the significance of this timeless tradition. Here’s a closer look at the symbolism of wedding rings and why they matter.
The Circular Shape
Wedding rings are typically circular, with no beginning or end. This shape represents the unending nature of love and commitment between two people. The circle also symbolizes eternity and the continuity of life.
The metal that wedding rings are made of is also significant. Traditionally, gold was used to symbolize wealth and status. Silver was often used to symbolize purity, while copper represented strength. Today, there are many different metals to choose from, each with its own meaning and symbolism.
While not all wedding rings feature stones, those that do are often chosen for their symbolism. Diamonds, for example, are the most popular choice for engagement rings because they symbolize eternal love and commitment. Other popular gemstones include sapphires, which represent loyalty and fidelity, and emeralds, which symbolize rebirth and new beginnings.
Many couples choose to engrave their wedding rings with special messages or dates. This adds a personal touch to the rings and makes them even more meaningful. Some popular engravings include the wedding date, the couple’s initials, or a meaningful quote or phrase.
The tradition of exchanging wedding rings dates back to ancient Egypt, where they were worn on the fourth finger of the left hand, believed to be connected directly to the heart by a vein. Today, the tradition remains strong, with wedding rings being an essential part of most wedding ceremonies around the world.
Wedding rings are not just pieces of jewelry; they are symbols of love and commitment that represent the unending nature of a couple’s bond. Understanding the significance of these timeless traditions can add even more meaning to your special day.

domain: artistic


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Star Wars: Battlefront gifting players Death Star DLC, credits and double XP this weekend
There's never been a better time to play.
EA today announced it will make Star Wars: Battlefront‘s “Death Star” DLC free to all players this coming weekend.
Additionally, those that login to the game between 23-25 December will receive 5,000 credits and double score in multiplayer matches.
The game’s “Death Star” DLC was released back in September.


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Sharon: Building Support
In the past, Sharon cared for her mother who lived with mental illness. Now she needs to provide care for an adult child living with mental illness. After Gabrielle’s first hospitalization, she attended the NAMI (National Alliance on Mental Illness) Family to Family class, which helped her deal with the emotions surrounding the realization Gabrielle had a mental illness.
Note: NAMI (National Alliance on Mental Illness) offers an 8-week Family to Family class, specifically for family members who have a relative living with mental illness. Participants learn about: 1) major mental illness, medications, and side effects; 2) skills in coping, problem solving, and communication; and 3) community resources.
I teach about 100 classes a year and have been a social worker for 30 years in this community. I wouldn’t be ashamed if people knew me there. . . I wanted to be able to be transparent about my own distress. The very first thing we had to do was to share in the class in one word, what was the word that you felt when you found out how your loved one was diagnosed. My word was relief. Everybody else’s word was horror or shock or fear. I was just relieved, thank God, now we know. Maybe then the fear came later. But at the beginning, I was, okay, we can deal with this.
Sharon also finds support through friendships and work relationships. Her current new best friends are two mothers who have adult children living with mental illness. When she came back to work following her training and Gabrielle’s hospitalization, Sharon told others that her daughter had been in the hospital and was diagnosed with bipolar disorder, which led to co-workers sharing about people close to them who lived with bipolar disorder.
She establishes boundaries in her life to manage her many responsibilities. She needs a lot of sleep and makes sure she regularly gets the nine hours of sleep she needs each night. In addition, she chooses friends who have good boundaries and is careful to maintain boundaries in her work relationships. When Sharon provides mental health training and NAMI classes for work, she briefly shares that Gabrielle lives with bipolar disorder, inherited a genetic predisposition, has insight, and recognizes symptoms. Sharing her experience can be effective in her classes, “because it really makes them feel safe knowing if I can talk about it, everybody can talk about it.”
More of the Story: Impact on Family Relationships

domain: psychology


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Keep your stitches going and your creativity flowing: quilt the motifs and texture you adore without ever breaking thread.
Learn to quilt continuous line designs such as fillers, all-overs, borders and stand alone motifs without spending your time tying off and burying tedious threads! Follow continuous line patterns along with award-winning quilter Ann Petersen as you quilt a sampler with stipples, hearts, leaves, stars, snowflakes and more! With Ann's guidance, you'll feel comfortable turning non-continuous line designs into continuous ones in no time.
If you're not delighted with your Bluprint experience, we'll make it right or give you a full refund.


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The town of Alta is situated in northern Norway about 500 kilometers south of the Arctic Circle. Whilst it has a population of only around 13,000 people, it’s a major tourist destination in the region being considered both the northernmost city in the world and a good place from where to observe the natural phenomenon of the Northern Lights, the Aurea Borealis. To further build on these twin draws for visitors from abroad, the town held an architecture competition in 2001 to design its new main parish church; a building that would create both a visible, iconic landmark for the area, and a symbolic reference to the phenomenon itself. The competition was won by Danish Schmidt Hammer Lassen Architects in cooperation with Norwegian architects Link. Their design is a giant spiral, clearly drawing its inspiration from natural forms, and pointing upwards into the sky, its belfry at a height of 47 metres – making this the tallest building in Alta. The titanium-clad façade reflects the sky in the day and the Northern Lights during the long periods of Arctic winter darkness and is designed to further intensify the visitor's experience.
Inside, the main hall of the church creates a calm contrast to the dynamic exterior of the building. The materials used – raw concrete for the walls with timber floors, panels and ceilings – underline the Nordic context, referring to the most common materials of the region. Daylight enters the church room through tall, slim, irregularly placed windows, whilst a skylight lights up the wall behind the altar. The cathedral, which can accommodate up to 350 people in its main space, also has administration offices, classrooms, a parochial area and exhibition spaces. We asked the architect John F. Lassen a few questions about this extraordinary building.
What where your main reference points when developing the design of this unusual church?
I suppose the design of the Cathedral of the Northern Lights came from looking both at surrounding nature and local culture. The building is meant to be a landmark, reflecting, both literally and metaphorically, the Northern Lights: their ethereal, transient, poetic and beautiful qualities. This church is designed to appear like a solitary sculpture in interaction with spectacular nature.
To an outsider there seems to be something very special about a church in which both God and a natural phenomenon are celebrated at the same time. Is there any connection traditionally made in Norway between the Northern Lights and God?
Of course. While as such, God and the natural phenomenon have no direct connection, in the local tradition of this region, the Northern Lights have certainly always been considered to be a sign of something supernatural.
The spiraling form evokes associations of both watch tower and observatory. Is there any special place inside the church from where the Northern Lights can be watched?
Well, not in the formal sense of an observatory. But the large windows that penetrate the facade will potentially enable visitors to the church to see the Northern Lights from inside. The architecture of the church is rather meant to complement this natural phenomenon, providing a fitting backdrop for the experience of it. The entire shape and the material that we chose for the facade – the spiral and its titanium cladding - both point to the sky above and also reflect the Northern Lights.
Was it quite a challenge to design a church that’s also meant to be a tourist destination at the same time?
Actually that’s not an unusual combination. As in many other parts of the world, it’s quite common in the Nordic countries for churches to be considered as tourist destinations in themselves. Just think of Notre Dame in Paris or the Saint Peter and Saint Paul in St Petersburg.

domain: travel


text:
'American Pie' Doesn't Belong To Saratoga Springs
NEAL CONAN, HOST:
Forty years and a few days ago, an eight-and-a-half-minute song broke on to the record charts, soon drenched the radio and claimed a permanent place in the lives of millions.
(SOUNDBITE OF SONG, "AMERICAN PIE")
CONAN: Singer-songwriter Don McLean, of course. All these years later, "American Pie" continues to haunt the imagination and to inspire folklore, including the claim that the song was first written and performed in Saratoga Springs, New York. The facts from the horse's mouth in just a moment.
For many, "American Pie" recalls a specific moment in time. Where does the Chevy from the levee take you? Give us a call: 800-989-8255. Email us: firstname.lastname@example.org. You can join the conversation at our website. Go to npr.org, click on TALK OF THE NATION.
Don McLean joins us now from his home in Maine. His latest album is "Addicted to Black." Next year, he'll be on the road in the United Kingdom for his 40th anniversary of "American Pie" tour. Thanks very much for joining us today.
: Thank you. Pleasure to talk to you.
CONAN: Last week, the Glens Falls Star-Post published a story that begins by citing a plaque next to a booth in a Saratoga Springs bar called the Tin & Lint that claims that is the exact spot where you started to write "American Pie" in the summer of 1970. True?
: Well, you know, through the years, people have asked me about that. I guess there's a plaque or something there. And I always would say, well, no, that's not really how it was. And so, finally, somebody up there in one of the newspapers said, I really, really want to know this. And he sent me two questions, and I said, well, first of all, it was written in Cold Spring, New York and in Philadelphia, and it was performed first at Temple University when I was just getting started with Laura Nyro. I was opening to her at Temple University. And so that caused The New York Times in this thing. So I think it's kind of funny, and you called, and I said, OK, I'll talk about it, sure.
CONAN: Well, do you know the bar, the Tin & Lint?
: No. But like I said in the article, in The Times, "American Pie" is a little bit like the Mayflower, you know? Everybody has been on it or their parents were on it or something. People knew me that I didn't know, and people know things about me that, you know, that they imagine, and it's just the way things are. But the funny thing is - and there are other of these kinds of little things, like, for example, for a while, everybody was saying "American Pie" was the name of Buddy Holly's airplane, you know? And that was floated around for a while.
CONAN: A little like Rosebud, I guess.
(SOUNDBITE OF LAUGHTER)
: Yeah. So I said, no, actually I coined that phrase. And Buddy's plane did not have a name and wasn't even Buddy's plane, you know? But what makes me think this is funny is that I've been kind of knocking these down for years and it persists. So it makes you wonder, how can you believe history?
(SOUNDBITE OF LAUGHTER)
: You know? I mean, guys who are dead 100 years and you say, oh, this is how it happened, you know, in 1066. I mean, I don't think so.
CONAN: There is a venue that you did perform at a lot, though, in Saratoga Springs.
: Oh, no. The Caffe Lena was a terrific place for me when I was just, you know, a boy just getting started, and Lena Spencer was - and, you know, a wonderful lady who really kept me fed. I mean, you know, I was starving, pretty much. And she kept many, many other people working and encouraged. Encouraged - that was the thing. And she was a sculptor's model whose husband ran off with somebody else, and she just - up in Skidmore. And she decided that, you know, she - you know, what she wanted to do is not get married again, but to have this nightclub and she named it after herself and she brought people up there, and it was a great place to fail. A lot of these places, you know, by the time you get a job in New York, you know, you'd bounced around on that stage and everything.
Anything could happen. And you had to play three shows a night to the same audience, so you had to have hours and hours of material. And it was a terrific place to lean how t o perform.
CONAN: Is it still there?
: Yes, it is. Yup.
CONAN: And, in a way, do you wish you had debuted "American Pie" there, just to lend her some...
: I don't make wishes like that. I'm just - I just think that all of this is fascinating and interesting. And I have songs of mine that turn up in all different contexts and people ask me about them and they're used in different ways. I'll tell you something really funny, is right now, there's a song by the rapper Drake. And he has taken two of my songs from an album called "Prime Time" - one is "When a Good Thing Goes Bad" and the other is "The Wrong Thing To Do" - and used them on a song that he has in his new album.
And I think it's called "Do It Wrong" or something like that. But you just - I've had other things like this happen. You know, kids out there in every area of music are pouring over the work of all of us as singer-songwriters from the '70s and the '60s and looking for little things that they can use, you know, and run with.
CONAN: We want to get some listeners involved in the conversation. Give us a call. 800-989-8255. Email: email@example.com. And let's start with Tim, and Tim's calling from Cincinnati.
TIM: Yes. Good afternoon.
CONAN: Tim, you're on the air. Go ahead, please.
TIM: Thank you. Thank you for taking my call. I just have a comment. I wanted to share a personal story. I met Don McLean from the back row, back years ago, mid-'70s. He played the Temple University outside music festival. And it was just an amazing evening. He came out and thanked the audience for letting him have a career for so long in something that he loved, which I thought was an awesome thing to say.
But the most amazing thing about the concert is that he played "American Pie," as always, and in the very last verse his string broke. He urged the audience to continue to finish the song, although he didn't need to urge us too much.
(SOUNDBITE OF LAUGHTER)
TIM: And then he proceeded to play the entire song a second time. And it's just something that's stuck with me forever. I wanted to thank Mr. McLean for his service for all these years and it was just something that I like to remember.
: Wow. Well, thank you for reminding me, that I remember that, and I still feel exactly the same way. I mean, I've been given a terrific life by the audiences who stuck with me all over the world. And I don't take it for granted, especially, you know, now when times are difficult and it costs a lot of money to come and see somebody sing with a guitar. And it's really an honor to be able to continue this.
Now I've been doing this for 44 years almost. And you know, we have a wonderful band that we love to play with. And of course I play solo stuff too. I sit down and do, like, a half an hour just with a guitar sometimes. But thank you for reminding me of that. And I still feel exactly the same way.
TIM: Thank you.
CONAN: Tim, thanks for the call. Here's an email from Hardin(ph) in Salt Lake City. I read the article in The New York Times yesterday about "American Pie," and I've been thinking about it since then. My memory, perhaps fogged by 40 years believing what I wanted to believe, is different from Don's. I remember going to a concert in a small church in Greenwich Village in September 1970. Don did a great job, very entertaining. He was called back for a couple of encores in the days before obligatory encores were the norm.
He introduced his last song by telling us he has just written it and wasn't sure he could remember the words correctly. Of course, no one there had any idea if he remembered the words because none of us had ever heard it, "American Pie." Perhaps when he performed it at Temple, it was the first time it was actually in a set list? Question mark. If he'd already done it at Temple, why would he have waited to do it so late at a little church and introduce it the way he did? Or is my memory totally bogus?
: That I don't remember. But I do remember the church in Greenwich Village. And if I can have a minute, I'll tell you. This is probably one of the most important shows I ever did, and that was before I was ever really famous. It was around the time of the first album I came out with called "Tapestry." And there were people in Greenwich Village who were - who would basically - they were the backbone of that whole music scene. And one of them was a guy named Israel G. Young, and he ran a place called the Folklore Center, which was on Bleecker Street.
And it was as different from Larchmont or New Rochelle, where I came from, as anything possibly could be. And, you know, I started to come down there a little bit. Friends would take me because I didn't drive. And when I started to perform, he suddenly liked me. And it was a little bit like, you know, like Lena. You know, I was kind of a, you know, a scrubbed-up white kid from Westchester, and they were used to a lot of hippies and stuff. But something or other in what I was doing struck a chord with Lena and with this guy.
And he said, I want to have the Folklore Center actually put you on in a concert. And it was - people still come back and say that they saw that or - and it really started me going in New York City. And those were the days when, you know, the music business was a secret business. And people knew talent and record companies knew talent. And there were only a few radio stations that if you were number one in 1970 or '71, especially also the '50s, '60s, whatever, you were the biggest thing on the planet, and everybody knew your song. Everybody knew you, and it was a huge thing. Now there's so many outlets, hundreds and hundreds of things, stuff's going on, you're - you just - it's a storm of - it's a sensory assault, you know, that's happening all the time. I can't remember anything.
I watch television. I see these people. I don't remember - none of the songs stick in my head, and that's just me. I'm an old guy, you know? But I knew - in the old days, if a song was a good song, I don't care if it was "Yellow Submarine" or, you know, or "The Times They Are a-Changin'" or "Don't Be Cruel," you knew it, you know? You heard that song, and you were talking about it, and you knew it.
CONAN: It's funny you should mention Izzy Young. One of my first jobs in radio was engineering the Izzy Young folk show on WBAI a million years ago.
(SOUNDBITE OF LAUGHTER)
: That's very funny.
CONAN: Where I - I don't think in connection to that - met an earnest young man who was pressing a record into my hand called "Tapestry."
: Oh my God.
CONAN: Long time ago.
: So funny.
CONAN: Don McLean is with us. You're listening to TALK OF THE NATION from NPR News. We have some emails from people who remember that song distinctly. This is from Ruth in Houston, Texas. I remember driving down the River Road in Baton Rouge, looking at the levee and singing the words to "Bye, Bye, American Pie." Wonderful memories. Thank you for this great song. Melinda in Kansas City: I was in the eighth grade the first time I heard the song, before school. We had a dress code and I remember getting to school that morning and having my skirt measured by a male vice principal, no less, and I remember humming that song, and he told me to be quiet. I'll never forget it, and I did get sent home for wearing such a short skirt.
: I liked to be a skirt measurer. I think that would be a great job.
CONAN: This from David Jackson in - or Dave in Jackson, Wyoming: "American Pie" was my very first LP. I got it when it first came out in the mid-1970s. I love that album and still listen to it on my iPod. Thanks for the great music. Let's go next to Margaret, calling us from Fairbanks in Alaska.
MARGARET: Hi. I'm glad to be here. The memory I have with "American Pie" is growing up in Larchmont, New York.
MARGARET: Yeah. And spending the night at my cousin's house, and about 2:00 or 3:00 in the morning, my aunt and uncle had come home from a party. They were probably a little tipsy, and they had gotten the record player, and they were blasting "American Pie" as they were calling their friends on the telephone. So it obviously was a talk of the party, and anyway, my cousin and I just kind of kept looking at each other, laughing, and couldn't believe that her parents were doing this.
: But isn't it funny how, you know, a song that was around and in the wind, you know, turned everybody on, you know, and this happened a lot, you know. All the time we were having - even through the '50s there were, you know, every Everly Brothers song that came around and, you know, whatever it was, you know, a Fats Domino tune, you were hearing it all the time.
MARGARET: Yeah. Definitely, it's a fun song, fun song to listen to in the radio and sing along.
: It came along really at the end of that era, you know? After that, disco came in, and we've been sort of dancing ever since.
CONAN: Margaret, thanks very much for the call.
CONAN: One more call. Let's get Mora on the line, Mora from Nashville.
MORA: Hi. I'm from Nashville, as you say, and - but I was born and reared in Ireland. In 1970 - I was very young - '71 when the album with "American Pie" came out. And as you mentioned earlier about the radio, given the fact, we were as much - we hadn't(ph) heard as much about "American Pie" as anybody did in America and which was part of our whole generation's view of life and poetry and everything like that. And also, I just want to say that you did a lovely version of "The Mountains of Mourne" when you recorded it. It was kind of my first vision of seeing an Irish song treated as just a song and not just an Irish song, and I really thought that was beautiful.
: Well, one of the things that I started doing in 1972 was to tour the world, and different recordings were released. Of course, "American Pie" was the biggest song, but there was "Crying" and "Vincent" and "Castles in the Air" and "And I Love You So." But in Ireland, for some reason "The Mountains of Mourne" took off from an album that really didn't do very well called "Playin' Favorites" that I put out. And that's still one of the songs that the people like the most when I tour Ireland, which I will be doing next fall.
MORA: Oh, well, good for you. Just one more thing, my husband is a farmer, and he said you can't literally drive to a levee. That's always bothered me.
(SOUNDBITE OF LAUGHTER)
MORA: You can't literally drive to a levee. It's not possible.
: No, you really can't, can you?
CONAN: Mora, thanks very much.
: But to tell you, once after - nobody knew what levees were until after Hurricane Katrina, and then everybody knew what a levee was.
CONAN: Well, Don McLean, I know you're going to be touring the UK next year, as you mentioned. There's also a PBS documentary due out. Good luck with all of that.
: Well, oh, thank you. I really thank you for having me on the program.
CONAN: Singer-songwriter Don McLean joined us from his home in Maine. On Monday, actor John Lithgow will join us to talk about his career and his memoir, one of the books we missed this year. Join us for that. I'm Neal Conan. It's the TALK OF THE NATION from NPR News.
NPR transcripts are created on a rush deadline by an NPR contractor. This text may not be in its final form and may be updated or revised in the future. Accuracy and availability may vary. The authoritative record of NPR’s programming is the audio record.


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Romney demonstrates mastery of fundraising loopholes
Michael Isikoff, NBC national investigative correspondent, talks with Rachel Maddow about a mysterious company that transferred $1 million to a PAC that supports Mitt Romney for president and then closed.


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LA Street Vendors And Advocates Caution City Council Against Criminalization Measures
Street vendors and advocates rallied at L.A. City Hall Tuesday morning asking City Council to abandon what they call recent attempts to criminalize sidewalk vending.
They spoke out against two specific measures:
- An already approved motion to give citations to permitted vendors who block the sidewalk.
- Councilmember Gil Cedillo's proposal to get city workers up to speed on spotting health and fire code violations by street vendors.
Carla De Paz, an organizer with Community Power Collective, says often vendors aren't well-versed in American Disability Act (ADA) regulations, and that it's unfair to penalize them for things that are beyond their control.
In a statement, Cedillo said his intention is not to hand out citations, but to provide vendors with further education on compliance.
Vendors and organizers at the rally encouraged the council to support Councilmember Nithya Raman's resolution calling on the county and state to streamline regulations on food preparation. Raman said current rules were not designed with vendors in mind.
“That's why it's incumbent upon legislators in the city of Los Angeles to advocate for these changes because without us keeping it loud they will forget to make these changes,” Raman said.
Vendors also voiced their opposition to a push from stores and residents near Melrose and Fairfax avenues to ban street vending there. The area is in Councilmember Paul Koretz's district, but spokesperson Alison Simard said Koretz has no plans to take such action and instead called for a more visible police presence in the area.
Southern California's Snow-Capped Mountains Are Beautiful. Here's Where To Maximize The View (And Snap A Great Picture)It's been many, many years since we saw this much snow in our mountains. Going up there right now isn't safe, but here are some places where you can enjoy the view and snap a pic.
April Valentine died at Centinela Hospital. Her daughter was born by emergency C-section. She'd gone into the pregnancy with a plan, knowing Black mothers like herself were at higher risk.
A look at years past when snows creeped into our citified neighborhoods, away from the mountains and foothills.
In the face of a drier future, that iconic piece of Americana is on its way out in Southern California.
Another Missing Hiker Has Been Found Dead In San Gabriels As Search For Actor Julian Sands ContinuesBob Gregory, 62, went missing the same day as Sands. His body was recovered near Mount Islip.


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Iowa State Athletics
RHOADS REUNION? One of the names coming up as a potential defensive coordinator under Tom Herman at Texas? Paul Rhoads.
ANTI-HYPE TRAIN. Jamie Pollard is tempering some of the expectations fans have for the 2017 Cyclone football team.
FOOTBALL GREAT, GONE. Jerry Moses Sr., father of ISU footballers JJ and Milan Moses, passed away at 63.
PRIMER. Get all the info and history on ISU-Cincinnati courtesy of Cyclones.com.
FULL LINEUP SOON? The ISU grapplers have been down a few men in every meet this season. But that will hopefully change soon.
HANCHER VS. HILTON. For those of you interested in Iowa State history, a new book on ISU’s transformation into a public university under James Hilton, with objections from the U of I’s Virgil Hancher, is now on sale.
Around the Country
MOAR FIRINGS. Another college football job is open, now that Oregon has fired its head coach.
BIG 12 DOWN, OUT TOO? There’s little hope for the Big 12 to make the CFP based on the newest rankings.
PANIC TIME. With a loss to Delaware State, St. John's and former ISU assistant Matt Abdelmassih are in deep trouble.
CLASSIC J.R. While J.R. Smith was saying hello to Jason Terry, he gave up a dunk.
#NBAREFS. How could they miss this obvious double-dribble?
TEARS OF JOY. I doubt any of you were this happy when Jimmie Johnson won his 7th NASCAR title.
CREATIVE. TAKE THIS, PACKERS FANS!
THAT’S JUST COLD. Bill Belichick convinced Tim Tebow to turn down a $1 million endorsement deal, then cut him.
PART OF A HEALTHY DIET. This milk, which should still be good according to the expiration date... well... doesn’t look good. (NSFW background language)


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"a skilled writer and performer…"
– USA TODAY NETWORK
Mark Binder spins spellbinding stories. Some for adults. Some for families and children.
He has performed in parking lots and basements, in theaters, at festivals, pubs, churches, synagogues, nightclubs and schools around the world.
Mark has written more than two-dozen books. He's won a Parents' Choice Gold Award for storytelling, and is an Audie Award nominee/finalist for best original work. His genres include original and traditional folktales, outrageous "autobiographical lies" and stories and books from Izzy Abrahmson's Village Life.


ARTISTIC DIRECTOR JOHN GILHOOLY CONFIRMS 100 CONCERTS FOR NEWLY REVISED WIGMORE PROGRAMME FROM 13 SEPTEMBER – 21 DECEMBER
- Over 200 artists confirmed, of which over two-thirds are UK born or UK based, underlining Wigmore Hall’s efforts to get artists earning again.
- Reaffirming Wigmore Hall’s ongoing commitment to diversity of repertoire and artists, performances include Apartment House, Kaleidoscope Chamber Collective, Tai Murray (violin), Elizabeth Llewellyn (soprano), Fatma Said (soprano), Roderick Williams (baritone), Arditti Quartet, Elena Urioste (violin), Kit Armstrong (piano), Mahan Esfahani (harpsichord), Claron McFadden (soprano) and Matthew Wadsworth (lute) and a digital fundraising concert for Chineke!.
- Special focuses on Samuel Coleridge-Taylor in song and chamber music, Polish-Jewish-Russian composer Mieczysław Weinberg, and the pioneering 20th century minimalist Julius Eastman who expressed his black and gay identity through music.
- Special documentary on internationally acclaimed double bassist Leon Bosch and his early anti-apartheid activism which saw him jailed as a teenager in South Africa, and Rabbi Baroness Julia Neuberger on Anti-Semitism. To celebrate the release of their respective new books, Graham Johnson will give a talk on Poulenc, and Natasha Loges and Katy Hamilton will present a discussion on Brahms.
- Concerts will go ahead with or without an audience. All concerts will be live streamed in high definition on Wigmore Hall’s website and will be free to view worldwide.
- 28 lunchtime concerts to be broadcast in association with BBC Radio 3 as well as a New Generation Artists weekend.


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The Jakarta Post
The government says that granting an award is an effective way to promote better toilet facilities in Indonesia’s airports, which in turn would improve the country’s international image.
“Ever since the first time we held the Sapta Pesona Clean Public Toilet Award in 2007, airports across the country have been improving their toilet facilities every year and we have made tourists feel more comfortable,” Ministry of Culture and Tourism director general for tourism development Firmansyah told The Jakarta Post on Friday.
The Sapta Pesona Clean Public Toilet Award is organized by the ministry every two years.
“Sanitation is clearly among the most important concerns for supporting our tourism industry because it is part of the principles of Sapta Pesona,” he said.
The principles of Sapta Pesona, or the seven charms of Indonesian tourism, were developed ...


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Caring for a loved one with Alzheimer’s disease or a related dementia is a complicated existence shared by an estimated 16 million Americans, who..
The competition to attract target patient populations is fierce and hospitals, healthcare systems and universities that house clinical research sites..
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