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US8538500B2 - System and method for probability based determination of estimated oxygen saturation - Google Patents
System and method for probability based determination of estimated oxygen saturation Download PDF
blood flow
flow characteristic
timestep
Expired - Fee Related, expires 2026-09-27
Steven E. Pav
Covidien LP
2011-10-20 Application filed by Covidien LP filed Critical Covidien LP
2011-12-27 Assigned to NELLCOR PURITAN BENNETT LLC reassignment NELLCOR PURITAN BENNETT LLC CHANGE OF NAME (SEE DOCUMENT FOR DETAILS). Assignors: NELLCOR PURITAN BENNETT INCORPORATED
2012-11-26 Assigned to COVIDIEN LP reassignment COVIDIEN LP ASSIGNMENT OF ASSIGNORS INTEREST (SEE DOCUMENT FOR DETAILS). Assignors: NELLCOR PURITAN BENNETT LLC
2014-03-19 Assigned to NELLCOR PURITAN BENNETT INC reassignment NELLCOR PURITAN BENNETT INC ASSIGNMENT OF ASSIGNORS INTEREST (SEE DOCUMENT FOR DETAILS). Assignors: PAV, STEVEN E.
A61B5/145—Measuring characteristics of blood in vivo, e.g. gas concentration, pH value; Measuring characteristics of body fluids or tissues, e.g. interstitial fluid, cerebral tissue
A61B5/1455—Measuring characteristics of blood in vivo, e.g. gas concentration, pH value; Measuring characteristics of body fluids or tissues, e.g. interstitial fluid, cerebral tissue using optical sensors, e.g. spectral photometrical oximeters
A61B5/14551—Measuring characteristics of blood in vivo, e.g. gas concentration, pH value; Measuring characteristics of body fluids or tissues, e.g. interstitial fluid, cerebral tissue using optical sensors, e.g. spectral photometrical oximeters for measuring blood gases
A61B5/02—Detecting, measuring or recording pulse, heart rate, blood pressure or blood flow; Combined pulse/heart-rate/blood pressure determination; Evaluating a cardiovascular condition not otherwise provided for, e.g. using combinations of techniques provided for in this group with electrocardiography or electroauscultation; Heart catheters for measuring blood pressure
A61B5/026—Measuring blood flow
A61B5/0261—Measuring blood flow using optical means, e.g. infra-red light
Present embodiments include providing an initial estimate of a value representative of a blood flow characteristic at a current timestep, and determining a probability distribution of transition, wherein the probability distribution of transition includes potential values of the blood flow characteristic at the current timestep with associated probabilities of occurrence based solely on the initial estimate. Present embodiments further include obtaining an initial measurement of the blood flow characteristic, and determining a probability distribution of measured values, wherein the probability distribution of measured values includes potential values of the blood flow characteristic at the current timestep with associated probabilities of occurrence based on the initial measurement. Further, present embodiments include combining the probability of distribution of transition with the probability of distribution of measured values to determine a meaningful blood flow characteristic value, and posting the meaningful blood flow characteristic value.
This application is a continuation of patent application Ser. No. 11/524,167, entitled "System and Method for Probability Based Determination of Estimated Oxygen Saturation", filed Sep. 20, 2006, which is herein incorporated by reference in its entirety.
The present invention relates generally to medical devices. More particularly, the present invention relates to estimating blood oxygen saturation in a patient.
This section is intended to introduce the reader to various aspects of art that may be related to various aspects of the present invention, which are described and/or claimed below. This discussion is believed to be helpful in providing the reader with background information to facilitate a better understanding of the various aspects of the present invention. Accordingly, it should be understood that these statements are to be read in this light, and not as admissions of prior art.
Pulse oximetry may be defined as a non-invasive technique that facilitates monitoring of a patient's blood flow characteristics. For example, pulse oximetry may be used to measure blood oxygen saturation of hemoglobin in a patient's arterial blood and/or the patient's heart rate. Specifically, these blood flow characteristic measurements may be acquired using a non-invasive sensor that passes light through a portion of a patient's blood perfused tissue and photo-electrically senses the absorption and scattering of light through the blood perfused tissue. A typical signal resulting from the sensed light may be referred to as a plethysmographic waveform. Once acquired, this measurement of the absorbed and scattered light may be used with various algorithms to estimate an amount of blood constituent in the tissue. It should be noted that the amount of arterial blood in the tissue is time varying during a cardiac cycle, which is reflected in the plethysmographic waveform.
The accuracy of blood flow characteristic estimations obtained via pulse oximetry depends on a number of factors. For example, variations in light absorption characteristics can affect accuracy depending on where (e.g., finger, foot, or ear) the sensor is applied on a patient or depending on the physiology of the patient. Additionally, various types of noise and interference can create inaccuracies. For example, electrical noise, physiological noise, and other interference can contribute to inaccurate blood flow characteristic estimates. Some sources of noise are consistent, predictable, and/or minimal, while some sources of noise are erratic and cause major interruptions in the accuracy of blood flow characteristic measurements. Accordingly, it is desirable to provide a system and method that continues to provide substantially accurate blood flow characteristic measurements during interference and noisy periods as well as during periods with little or no noise.
Advantages of the invention may become apparent upon reading the following detailed description and upon reference to the drawings in which:
FIG. 1 shows a perspective view of a basic embodiment of a pulse oximeter system in accordance with an exemplary embodiment of the present invention;
FIG. 2 is a detailed block diagram of the pulse oximeter system of FIG. 1;
FIG. 3 is a graph of an exemplary plethysmographic waveform which may be generated by the system of FIG. 1;
FIG. 4 is a graph of an exemplary plethysmographic waveform, wherein the waveform includes interference due to noise;
FIG. 5 is a diagram representing predictive paths and potential SpO2 values based on a previous SpO2 reading in accordance with an exemplary embodiment of the present invention;
FIG. 6 is a diagram representing predictive paths and the potential SpO2 values for the related timestep based on an initial SpO2 reading for the current timestep in accordance with an exemplary embodiment of the present invention; and
FIG. 7 is a flow diagram of an algorithm employing probability density functions in accordance with embodiments of the present disclosure;
FIG. 8 is a flow diagram of an algorithm for determining an appropriate value to post for a patient's SpO2 level in accordance with an exemplary embodiment of the present disclosure; and
FIGS. 9, 10, and 11 are representations of data acquired by implementing and testing present embodiments against synthetic data using Viterbi's algorithm in accordance with an exemplary embodiment of the present invention.
DETAILED DESCRIPTION OF SPECIFIC EMBODIMENTS
One or more specific embodiments of the present invention will be described below. In an effort to provide a concise description of these embodiments, not all features of an actual implementation are described in the specification. It should be appreciated that in the development of any such actual implementation, as in any engineering or design project, numerous implementation-specific decisions must be made to achieve the developers' specific goals, such as compliance with system-related and business-related constraints, which may vary from one implementation to another. Moreover, it should be appreciated that such a development effort might be complex and time consuming, but would nevertheless be a routine undertaking of design, fabrication, and manufacture for those of ordinary skill having the benefit of this disclosure.
Embodiments of the present invention relate to providing an estimation of blood oxygen saturation (SpO2) at a particular time or over a designated time period based on a previous SpO2 estimation, related probability estimations, initial SpO2 measurements, and a noise value associated with the readings. Rather than storing or utilizing numerous historical data points to facilitate reducing the effects of noise, in accordance with present embodiments it may be assumed that the blood oxygen saturation value can be predicted based on an immediately prior value of the blood oxygen saturation. Specifically, in accordance with present embodiments, first and second portions of a determination may be combined to establish a probable actual SpO2 value based on a prior SpO2 value and an initial SpO2 measurement. In other words, present embodiments estimate what the actual SpO2 value should be based on a preceding SpO2 value and the value of an initial SpO2 measurement. Once the probable actual SpO2 value is determined, that value may be posted as the calculated value.
FIG. 1 shows a perspective view of an exemplary embodiment of a pulse oximeter system 10. The system 10 includes a pulse oximeter or monitor 12 that communicatively couples to a sensor 14. The sensor 14 may include a sensor cable 16, a connector plug 18, and a body 20 configured to attach to a patient (e.g., patient's finger, ear, forehead, or toe). Pulse oximetry systems such as system 10 may be utilized to observe the oxygenation or oxygen saturation of a patient's arterial blood to estimate the state of oxygen exchange in the patient's body by emitting waves into tissue and detecting the waves after dispersion and/or reflection by the tissue. For example, conventional pulse oximeter systems may emit light from two or more light emitting diodes (LEDs) into pulsatile tissue and then detect the transmitted light with a light detector (e.g., a photodiode or photo-detector) after the light has passed through the pulsatile tissue. The amount of transmitted light that passes through the tissue varies in accordance with the changing amount of blood constituent in the tissue and the related light absorption.
Specifically, as illustrated in FIG. 2, the sensor 14 includes two LEDs 30 and a photo-detector 32. The LEDs 30 receive drive signals from the monitor 12 that activate the LEDs 30 and cause them to emit signals alternatively. The sensor 14 is configured such that light from the activated LEDs 30 can pass into a patient's tissue 38. After being transmitted from (or reflected from) the tissue 38, the dispersed light is received by the photo-detector 32. The photo-detector 32 converts the received light into a photocurrent signal, which is then provided to the monitor 12. The illustrated sensor 14 may also include a memory 34 and an interface 36. The memory 34 and/or the monitor 12 may store software applications in accordance with present embodiments. The interface 36 may facilitate communication between the sensor 14 and the monitor 12.
To measure the oxygen saturation of the patient's arterial blood, two different wavelengths of light are typically emitted from the LEDs 30 and are used to calculate the ratio of oxygenated hemoglobin or oxyhemoglobin (HbO2) and deoxygenated hemoglobin or deoxyhemoglobin (Hb), which are dominant hemoglobin components. The light passed through the tissue (e.g., tissue 38) is typically selected to include two or more wavelengths that are absorbed by the blood in an amount related to the amount of blood constituent present in the blood. Specifically, a first wavelength for one of the LEDs 30 is typically selected at a point in the electromagnetic spectrum where the absorption of HbO2 differs from the absorption of reduced Hb. A second wavelength for one of the LEDs 30 is typically selected at a different point in the spectrum where the absorption of Hb and HbO2 differs from those at the first wavelength. For example, LED wavelength selections for measuring normal blood oxygenation levels typically include a red light emitted at approximately 660 nm and an infrared light emitted at approximately 900 nm.
While various techniques may be utilized to estimate oxygen saturation, in one common technique, the first and second light signals detected by the light detector from red and infrared light sources are conditioned and processed (e.g., via the monitor 12) to determine AC and DC signal components. For example, FIG. 3 illustrates one method of determining AC and DC components from a plethysmographic waveform, wherein maximum (MAX) and minimum (MIN) measurements of each wavelength are measured and correlated as set forth in the following equations:
AC=MAX−MIN (Eq. 1)
DC=(MAX+MIN)/2.
It should be noted that in other embodiments the maximum (MAX) and minimum (MIN) measurements are not necessarily employed to determine the AC and DC components. Indeed, the AC and DC components may be obtained by using essentially any pair of points along both the infrared and red light waveforms.
Once obtained, the AC and DC components may be used to compute a modulation ratio of the red to infrared signals. The modulation ratio is generally referred to as "the ratio of ratios" or Ratrat and may be represented as follows:
Ratrat = A   C RED / D   C RED A   C IR / D   C IR . ( Eq .  2 )
The Ratrat at a particular time K or over a designated timestep K may be represented as follows:
Ratrat = v κ u κ , ( Eq .  3 )
wherein the variable vK is representative of a value for red light optical density over timestep K and the variable uK is representative of a value for infrared light optical density over timestep K. A timestep may include multiple optical observations taken over a designated period of time. For example, a timestep of 1 second may include 53 optical observations, which may be used to determine vK and uK.
The Ratrat has been observed to correlate well to arterial blood oxygen saturation, as represented by the following equation:
Ratrat=f(s), (Eq. 4)
wherein s represents blood oxygen saturation. Pulse oximeters and sensors are typically calibrated empirically by measuring the Ratrat over a range of in vivo measured arterial oxygen saturations (SaO2) on a set of patients (e.g., healthy volunteers). The observed correlation is used in an inverse manner to estimate SpO2 based on the measured value of modulation ratios. A correlation to blood concentrations may be represented by the following equation:
( v u ) = ( c 1 c 12 c 21 c 22 )  ( OXY DEOXY ) , ( Eq .  5 )
wherein the variables c11, c12, c21, and c22 represent coefficients, the OXY variable represents an actual value of oxygenated blood concentration, and the DEOXY variable represents an actual value of deoxygenated blood concentration. It should be noted that the coefficients are a function of wavelength. It should further be noted that calculating SpO2 based on the Ratrat is one of various methods that can be utilized to calculate the level of SpO2 in a patient. Indeed, the Ratrat is used herein by way of example, and present embodiments are not limited to the use of the Ratrat in determining SpO2 levels.
The accuracy of blood flow characteristic estimations determined via pulse oximetry can be impacted by various types of noise and interference (e.g., electrical noise, physiological noise, and other interference). In a pulse oximetry system, noise generally manifests as variations in detected light values. Thus, in a noisy system, a "dirty" plethsymographic signal may be obtained. For example, if noise is introduced, the detected light values that define the plethysmographic waveform in FIG. 3 (a "clean" plethysmographic signal) could be extremely skewed, as illustrated by the plethysmographic waveform in FIG. 4 (a "dirty" plethysmographic signal). Such variations in detected light values generally directly impact the calculated value of SpO2. For example, as is clear from the discussion of Ratrat determination above, the value of the Ratrat is dependent on the detected light values, and the Ratrat directly impacts the calculated values of SpO2. Thus, when the Ratrat is used to calculate an SpO2 value, errors in determining the Ratrat due to noise directly impact the calculation of the SpO2 value. Similarly, in other calculations of SpO2, noise can create error in the calculated value of SpO2.
Because noise causes errors such as those discussed above, it is desirable to remove or filter out the effects of noise when determining an SpO2 value with pulse oximetry. Traditional methods for estimating a patient's SpO2 level may limit the impact of noise by utilizing historical data. Indeed, traditional methods may store historical values of SpO2 observed in the patient, and the historical values may then be utilized in calculations to limit the effects of noise. For example, historical values may be averaged (e.g., using ensemble averaging) or trended to facilitate detection and/or filtering of noise or noisy data. Specifically, a current value of the patient's SpO2 level may be estimated based on averaging numerous historical data points and the estimate may then be compared with a measured value to determine whether noise is present. If noise is present, the measured value may be filtered or modified based on the historical data.
Rather than storing or utilizing numerous historical data points to facilitate reducing the effects of noise, in accordance with present embodiments it may be assumed that the value of the SpO2 can be predicted based on an immediately prior value of the SpO2. This can be discussed in terms of the Ratrat because the Ratrat correlates with the value of SpO2. Accordingly, the assumption may be summarized by stating that, in theory, in predicting a future value of the Ratrat (i.e., RatratK+1) based on knowledge of the most recent Ratrat (i.e., RatratK), no additional predictive power can be gained from learning the historical values of the Ratrat (i.e., Ratrat0, Ratrat1, . . . , RatratK−1). For example, the following system may be considered representative:
Ratrat=t K(RatratK−1) (Eq. 6)
v K =u KRatratK +n K R.
wherein RatratK is a function of saturation at major timestep K, uK is a red optical density at major timestep K, vK is an infrared optical density at major timestep K, and nK R represents observation noise. Observation noise may be defined as noise present in physical observations (e.g., optical or otherwise), and not error in the previous or present estimate of saturation. The function t represents the transition of the Ratrat from one timestep to the next, which includes a random variable. The inclusion of a random variable indicates that given the Ratrat at a previous time interval (i.e., RatratK), the value of the Ratrat at a next time interval (i.e., RatratK+1) can be predicted or estimated, but not necessarily directly calculated.
Embodiments of the present invention assume that SpO2 (and hence Ratrat) follow a Hidden Markov Model of a given distribution. A Hidden Markov Model is a statistical model wherein the system being modeled is assumed to be a Markov process with unknown parameters. A Markov Model or Markov Chain may be characterized by the following property: P{Xk+1=x|Xk, Xk−1, . . . , X0}=P{Xk+1=x|Xk}. Only the most recent value of the random variable is relevant for predicting the next value. In some embodiments, the model may be further restricted such that it only takes values in a certain range, or in a certain finite set of numbers. For example, under further restriction the following is representative: P{Xk+1=x|Xk}=0 when x is not a number in that certain range, or in that certain finite set. It should be noted that in some embodiments, there is no need to restrict the Markov process to a finite range. However, it may be assumed that the range is bounded between 0 and 100%, but may take any value in that range. The objective of Viterbi's algorithm is to determine the hidden parameters from observable parameters. The Hidden Markov Model models the underlying process, which is observed with some level of uncertainty (e.g., via optical measurements).
In accordance with present embodiments, first and second portions of a determination may be combined to establish a probable actual SpO2 value based on a prior SpO2 value and an initial SpO2 measurement. In other words, present embodiments estimate what the actual SpO2 value should be based on a preceding SpO2 value and the value of an initial SpO2 measurement. Once the probable actual SpO2 value is determined, that value may be posted as the calculated value. Specifically, in the first portion of the determination, an immediately prior calculated or measured SpO2 value may be utilized to determine a set of predictive paths and potential SpO2 values. These predictive paths and potential SpO2 values correspond to what will probably be the next actual SpO2 value. For example, there is generally a high probability that the SpO2 value following the immediately preceding value will be equivalent to the immediately preceding value. In the second portion of the determination, a set of predictive paths and potential SpO2 values may be determined based on a current SpO2 measurement value. For example, an initial SpO2 measurement may be utilized to determine probabilities associated with potential SpO2 values for the actual SpO2 value. As suggested above, once probabilities based on the immediately preceding SpO2 value and the initial SpO2 measurement are established, they may be combined to predict the actual current SpO2 value for posting. This procedure is discussed in further detail below.
FIG. 5 is a block diagram representing an example of predictive paths and potential SpO2 values for a current reading that may be determined based on a previously calculated or measured SpO2 value. It should be noted that the predictive paths are not necessarily explicitly constructed in accordance with present embodiments. In other words, the transition illustrated in FIG. 5 may be described as a continuum that does not utilize a discrete list of values. Essentially, the predictive paths and potential SpO2 values represent a probability distribution (e.g., Markov Model transition probability distribution) of what the next SpO2 value is likely to be based solely on the most recently measured and/or determined SpO2 value. This probability distribution may represent what can be referred to as a probability distribution of transition.
Calculating these predictive paths and potential SpO2 values represented in FIG. 5 may be considered the first portion of the procedure for determining the SpO2 value to post as the current value. Accordingly, FIG. 5 may be representative of results from the first portion of the procedure. Specifically, FIG. 5 includes a previous SpO2 measurement or determination (block 40) having an exemplary value of 93%. Block 40 represents the SpO2 value obtained from the Ratrat corresponding to timestep K, wherein K is the most recent previous timestep. Each of the arrows 42 extending from block 40 represents a probability that the value of SpO2 for the current or next timestep (e.g., K+1 or the value of SpO2 for the timestep after that represented by block 40) will correspond to one of the values in the corresponding blocks 44, 46, 48, 50, and 52. In other words, the arrows 42 represent predictive paths for the potential SpO2 values in blocks 44-52. It should be noted that while blocks 44-52 represent a specific range of values, in other embodiments the range and values may be different. Indeed, in some embodiments, the range and values represented by blocks 44-52 may be dependent on a selected model of how saturation can change.
The continuum of probability values is represented by a probability distribution function. As indicated above, blocks 44, 46, 48, 50, and 52 are representative of potential SpO2 values that could be obtained at the next timestep (i.e., K+1) using the corresponding Ratrat for that timestep (i.e., RatratK+1). These potential values (block 44-52) represent a range of potential SpO2 values based on established relationships between the value of the timestep between K and K+1 (e.g., 1 second) and the initial or immediately preceding SpO2 value (e.g., block 40). The following equation is representative of the relationship between block 40 and blocks 44-52:
p(x)=C Pr{RatratK=RatratK−1 +x|RatratK−1}, (Eq. 7)
wherein C represent a constant that can be ignored and the function Pr{a|b} means "the probability that a occurs conditioned on the fact that b was observed to occur." It may be assumed that a probability distribution function of the transition function t can be estimated by a particular equation or model. In the case of a continuum, the function p(x) is a probability density, which is integrated to obtain probabilities.
The most likely value for SpO2 that will be obtained in the imminent timestep (i.e., K+1) based on the known Ratrat (i.e., RatratK) is represented by block 48, which has the same SpO2 value as that of the previous timestep (block 40). Values for the SpO2 at K+1 that have lesser probabilities of occurrence are dispersed outwardly according to a probability distribution function used to determine the probabilities 42 for each potential value (blocks 44-52). For example, in accordance with some embodiments, a piecewise linear spline, a double exponential function, or Gaussian probability density function may be utilized to determine probabilities (e.g., probabilities 42). Such probabilities 42 may indicate that, for example, if the timestep is approximately one second, it is highly unlikely that during the transition from K to K+1 the SpO2 level will drop by a certain amount (e.g., twenty points) and that it is highly likely that the SpO2 value will remain the same. Accordingly, changes within a certain range will be given a higher probability value. Generally, these probability values are lower the further the corresponding SpO2 value (blocks 44-52) is from the initial value (block 40) (e.g., the probability of the SpO2 value for timestep K+1 remaining at 93% is greater than that of it changing to 91%) because changes in SpO2 do not typically include large, sudden swings. It should be noted that it may be slightly more likely to have a large increase in the SpO2 value in certain situations (e.g., an oxygen starved patient receiving oxygen).
In accordance with some embodiments, the mean of the probability distribution function for the saturation transition should be the previous value of SpO2. In other words, the probability distribution function of the saturation transition may be designed such that saturation is a Martingale. This generally prevents present embodiments from predicting large fluctuations in saturation levels when presented with noiseless optical observations. Moreover, for this reason, it may be desirable to adjust or tune the probability distribution function such that its variance is minimized, or otherwise controlled. In some embodiments, the probability density function of the saturation transition is represented by a spline function (i.e., a function composed of portions of polynomials linked together). For example, a spline function utilized in accordance with present embodiments may include a piecewise linear function.
FIG. 6 may be representative of results from the second portion of the procedure for determining the SpO2 value to be posted as current. As set forth above, these results may be combined with the results illustrated in FIG. 5 to provide the current SpO2 reading. Specifically, FIG. 6 is a block diagram representing predictive paths and the potential SpO2 values for the related timestep based on an initial SpO2 reading for the current timestep in accordance with embodiments of the present invention. Essentially, the predictive paths and potential SpO2 values represent a probability distribution of what the next SpO2 value is likely to be based on an initial measurement. This probability distribution may represent what can be referred to as a probability distribution of measured values or the probability of observing a given measured value.
Specifically, FIG. 6 includes block 54, which represents an SpO2 value (e.g., 94%±3%) for the current timestep that takes into account observational information. Additionally, FIG. 6 includes the blocks 44, 46, 48, 50, and 52, which are representative of potential actual SpO2 values that could be obtained for the current time step within a certain likelihood. Arrows 56, which connect the potential SpO2 values (blocks 44-52) with the value accounting for observational information (block 54), are representative of probabilities that given the SpO2 value is actually a certain value, the (optical) measurements indicate the given SpO2 value. For example, the probability along the arrow 56 from block 46 to block 54 represents the probability that, given that the SpO2 is actually 92%, optical observations indicate that the SpO2 is 94%. However, the procedure is more general that this example. Optical measurements include an estimate of noise (e.g., ±3%). This estimate of noise facilitates construction of the arrows 56. When the error is small (e.g., ±0.5%), it is likely that SpO2 really is the value indicated by the optical observations (e.g., the probability that the underlying SpO2 is 94% and was observed to be 94% is high, while the probability that the underlying SpO2 value is 92% and was observed to be 94% is low). When the error is larger (e.g., ±6%), the distribution flattens out. In other words, the probabilities associated with the arrows 56 become nearly equal when the error is large. The probabilities 56 may be represented and determined by designated equations, which will be discussed in further detail below.
As illustrated in FIG. 7, once determined, the probabilities represented by arrows 56 may be combined with the probabilities represented by arrows 42 to determine which potential SpO2 value should be posted as the meaningful SpO2 value. The algorithm represented by FIG. 7 employs probability density functions. It should be noted that a probability density function may be defined as the function, f(x), such that given a random variable X, the following equations applies:
P  ( a ≤ x ≤ b ) = ∫ a b  f  ( x )  ⅆ x . ( Eq .  8 )
Further, it should be noted that, in present embodiments, the probability density function may only need to be known up to a constant.
Determining the meaningful SpO2 value for posting may include the following procedures: let P(x) be a nonzero constant times the probability density function associated with the Hidden Markov Model (i.e. the transition of SpO2 values), let Q(x) be a nonzero constant times the probability density function associated with the observation, and let W(x)=P(x)Q(x) be some constant times the probability density function of the value of SpO2 at the current state, conditional on the (optical) observations. This may be represented as follows:
P  ( a ≤ X k + 1 ≤ b | X k   known , optical   observations ) = D  ∫ a b  W  ( x )  ⅆ x , ( Eq .  9 )
where D is an unknown constant. Viterbi's algorithm, which is a maximum likelihood estimate algorithm, estimates Xk+1 by that value x which maximizes W(x). Because P(x) and Q(x) are represented in the algorithm as functions (e.g., P(x) is a linear spline, or the probability distribution function of a Gaussian or normal, double exponential, and so forth, and Q(x) is the probability density function of a Gaussian), this maximum can be found using calculus, and not by checking every value between values (e.g., between 91% and 95%).
In the exemplary embodiment illustrated in FIG. 7, block 60 represents a best estimate of saturation at timestep K based on the previous optical observations. Probabilities 62 (Pj) may be based on the Hidden Markov Model of human physiology. Accordingly, these probabilities 62 may only depend on the estimate of saturation, and not on current optical observations. The probabilities 64 (Qj) may be based on a model of optical noise and optical observations since timestep K. The probabilities 64 represent the probability that, if the saturation were j at timestep K+1, the observations would correspond to the observations made. Block 66 represents a linear regression of red to infrared optical signals over the major time step. Block 68 represents the red to infrared optical signals over one second.
When the noise in optical observations is assumed to be independent identically distributed normal random variables with zero mean and a given variance, the least squares regression slope is a random variable whose expected value is the underlying Ratrat with a certain variance. In this case, the value of the probabilities 64 may be generated from the probability distribution function of the normal. In a specific example, if the saturation value is assumed to be 90 at timestep K, and optical observations indicate 91.8±0.5 saturation, the probability that saturation is j at timestep K+1 is PjQj, under assumptions of independence. Thus, saturation at K+1 may be estimated by that j and an iterative procedure with future optical observations may be invoked.
FIG. 8 is a block diagram of an algorithm for determining the best value to post for a patient's SpO2 value based on the value of the Ratrat (i.e., RatratK−1) for the previous timestep, the current measurement or measurements for the SpO2 value, the probabilities 42 and 56 relating to the actual occurrence of the SpO2 value, and estimated noise. The algorithm is generally referred to by reference number 90. Specifically, algorithm 90 includes several steps for determining an appropriate estimate of the Ratrat for timestep K+1 that is substantially accurate during periods of noise and/or interference. The determination of algorithm 90 is largely based on observations during timestep K+1 and a provided (e.g., measured) value of the Ratrat for timestep K. It should be noted that it is assumed in accordance with present embodiments that the sampling rate of optical observations is higher than the meaningful posting rate. For example, in one embodiment optical observations are made at 53 Hz and saturation values are posted at 1 Hz. Intervals between posts may be referred to as timesteps and intervals between observations may be referred to as minor timesteps.
In block 92, an initial estimate of the Ratrat at an initial time or for an initial timestep (i.e., Ratrat0) is provided. This initial value may simply include the value of the Ratrat assigned to the timestep prior to the timestep for which the Ratrat (or the SpO2 value for posting) is being determined. The initial estimate of the Ratrat may be obtained using various procedures, such as bootstrapping a value from an initial reading. For example, the first estimate of saturation may be the value of the current physical measurement. In other embodiments, an overall probability distribution of the saturation in humans may be determined and utilized as the transition distribution from an unknown saturation in the previous time step. For example, population studies may provide estimates of saturation in groups of people, which may be utilized with safety factors (e.g., lower saturation levels for certain groups and generally lower saturation level estimates) to provide an initial estimate. This universal distribution approach does not require that the previous saturation estimate be known. In another embodiment, an estimate of saturation level and an estimate of confidence in the saturation level may be maintained. For example, information such as "at time step k saturation is in the range of 94.5%-95.499% (posting 94) with 75% certainty" may be maintained. In order to boot strap, the information may be initialized as "at time step 1, the saturation is in the range 89.5%-90.499% (or values provided in accordance with the physical measurement) with 1% certainty (or a value obtained from the physical measurement."
After establishing the initial estimate, in block 94, the optical observations over the previous timestep are correlated and a noise estimate is obtained. Various procedures may be utilized to provide this noise estimate. For example, block 94 may include performing a linear regression of all the optical observations over the previous timestep to obtain a best fit slope, which may be referred to by the variable {circumflex over (m)}. Additionally, an estimate of noise may be obtained by determining a sample standard deviation of the residuals, which may be referenced by the variable θ. Under the assumption of normal noise, {circumflex over (m)} is distributed as the true slope plus an unbiased normal random variable with variance. This variance may be represented as θ2/σ2 ir, where σ2 ir represents the sample standard deviation of the infrared values over the previous timestep. The following equation is representative:
m ^ = σ k + N  ( o , θ 2 σ x  2 ) ( Eq .  10 )
One component of algorithm 90 is the incorporation of a maximum likelihood estimator. That is, the estimate of RatratK is that which is most likely given the previous estimate and the optical evidence over the previous major timestep K−1. This maximum likelihood estimation is represented by block 96, wherein:
+ξ (Eq. 11)
and wherein ξ maximizes the following function:
p  ( ξ )  e  ( - 0.5  ( m ^ - Ratrat j - 1 - ξ ) 2 θ 2 / σ ir 2 ) ( Eq .  12 )
which is proportional to:
Pr{Ratratj−Ratratj-1=ξ|Ratratj-1=
} Pr{{circumflex over (m)} observed|{circumflex over (m)}˜N(Ratratj-1+ξ,θ2/σir 2)} (Eq. 13)
which represents combining (e.g., essentially multiplying) the probability 42 represented in FIG. 5 with the probability 56 represented in FIG. 6 to determine a posting value based on which of the potential values has the highest probability. Because this is a maximum likelihood calculation, it is unnecessary to compute the cumulative distribution function of the normal, and p(x) can be known only up to a constant. Thus, the value posted as the meaningful SpO2 value is represented by Eq. 13.
FIGS. 9, 10 and 11 are representations of data acquired by implementing and testing present embodiments against synthetic data using Viterbi's algorithm. The synthetic data consist of a time signal of saturation with a constant level of noise added. The results are plotted in several graphs in each of FIGS. 9, 10, and 11. The different graphs correspond to different levels of noise in the observation, different choices of the variance in the underlying Markov Model, and different choices of the transition limits (up and down) of the Markov Model. Each of FIGS. 9, 10, and 11 include a first graph (A) with low noise and low variance, a second graph (B) with low noise and high variance, a third graph (C) with medium noise and low variance, a fourth graph (D) with medium noise and high variance, a fifth graph (E) with high noise and low variance, and a sixth graph (F) with high noise and high variance. Further, each graph shows an actual underlying synthetic saturation signal 72, observed saturation with noise added 74, and a maximum likelihood estimator (i.e., output of the algorithm) 76.
FIGS. 9, 10, and 11 each illustrate slightly different information. The graphs in FIG. 9 show a model wherein the maximal decrease in saturation transition of the Markov Model is one-third the maximal increase in saturation transition. Specifically, the graphs in FIG. 9 illustrate the results of a maximum likelihood estimation using a Markov Model with a saturation increase allowed at triple the rate of saturation decrease. This approximates physiological reality, as saturation decreases are typically slow, while increases occur quickly with inspiration. The graphs in FIG. 10 show a model wherein the maximal decrease and maximal increase in saturation transition are equal. Specifically, the graphs in FIG. 10 show the results of a maximum likelihood estimation using a Markov Model with saturation increase allowed at the same rate of decrease. The graphs in FIG. 11 show a model wherein the maximal decrease is 4.5 times greater than the maximal increase in saturation transition. Specifically, FIG. 11 shows the results of a maximum likelihood estimation using a Markov Model with the aforementioned ratio between saturation increase and decrease.
While the invention may be susceptible to various modifications and alternative forms, specific embodiments have been shown by way of example in the drawings and will be described in detail herein. However, it should be understood that the invention is not intended to be limited to the particular forms disclosed. Rather, the invention is to cover all modifications, equivalents and alternatives falling within the spirit and scope of the invention as defined by the following appended claims.
using a monitor for:
providing an initial estimate of a value representative of a blood flow characteristic at a current timestep;
determining a probability distribution of transition, wherein the probability distribution of transition includes potential values of the blood flow characteristic at the current timestep with associated probabilities of occurrence based solely on the initial estimate;
obtaining an initial measurement of the blood flow characteristic from a sensor in communication with the monitor;
determining a probability distribution of measured values, wherein the probability distribution of measured values includes potential values of the blood flow characteristic at the current timestep with associated probabilities of occurrence based on the initial measurement;
combining the probability of distribution of transition with the probability of distribution of measured values to determine a meaningful blood flow characteristic value; and
posting the meaningful blood flow characteristic value.
2. The method of claim 1, wherein determining the probability distribution of measured values includes accounting for estimated noise in the initial measurement.
3. The method of claim 2, wherein when the estimated noise decreases, the likelihood of the initial measurement being reflective of the blood flow characteristic increases.
4. The method of claim 1, wherein obtaining the initial measurement of the blood flow characteristic comprises emitting first and second wavelengths of light from emitters of the sensor, detecting the first and second wavelengths of light with a photo-detector portion of the sensor, transmitting photocurrent signals indicative of the first and second wavelengths of light detected by the photodetector to the monitor, and calculating the initial measurement based on the photocurrent signals with the monitor.
5. The method of claim 1, wherein a mean of the potential values included in the probability distribution of transition is equal to the initial estimate.
6. The method of claim 1, wherein providing the initial estimate comprises assigning a previous value representative of the blood flow characteristic at a preceding timestep as the value representative of the blood flow characteristic at the current timestep.
7. The method of claim 1, wherein providing the initial estimate comprises assigning a current physical measurement of the value representative of the blood flow characteristic at the current timestep as the initial estimate of the value representative of the blood flow characteristic at the current timestep.
8. The method of claim 1, wherein providing the initial estimate comprises assigning a stored estimate value based on patient type as the initial estimate of the value representative of the blood flow characteristic at the current timestep.
9. The method of claim 1, wherein the blood flow characteristic comprises blood oxygen saturation.
10. A system, comprising:
a monitor configured to determine a probability distribution of transition based solely on an initial estimate of a value representative of a blood flow characteristic at a current timestep, wherein the probability distribution of transition includes potential values of the blood flow characteristic at the current timestep with associated probabilities of occurrence;
a sensor configured obtain an initial measurement of the blood flow characteristic and communicate the initial measurement to the monitor;
the monitor configured to determine a probability distribution of measured values based on the initial measurement, wherein the probability of distribution of measured values includes potential values of the blood flow characteristic at the current timestep with associated probabilities of occurrence; and
the monitor configured to combine the probability of distribution of transition with the probability of distribution of measured values to provide a meaningful blood flow characteristic value.
11. The system of claim 10, wherein the sensor is configured to emit first and second wavelengths of light from emitters, detect the first and second wavelengths of light with a photo-detector portion of the sensor, and transmit photocurrent signals indicative of the first and second wavelengths of light detected by the photodetector to the monitor.
12. The system of claim 11, wherein the monitor is configured to calculate a value of the initial measurement based on the photocurrent signals.
13. The system of claim 10, wherein the initial estimate comprises a previous value representative of the blood flow characteristic at a preceding timestep.
14. The system of claim 10, wherein the initial estimate comprises a current physical measurement of the value representative of the blood flow characteristic at the current timestep.
15. The system of claim 10, wherein the initial estimate comprises a stored estimate value based on patient type.
a monitor configured to:
determine a probability distribution of transition based solely on an initial estimate of a value representative of a blood flow characteristic at a current timestep, wherein the probability distribution of transition includes potential values of the blood flow characteristic at the current timestep with associated probabilities of occurrence;
determine a probability distribution of measured values based on an initial measurement received from a sensor, wherein the probability of distribution of measured values includes potential values of the blood flow characteristic at the current timestep with associated probabilities of occurrence; and
combine the probability of distribution of transition with the probability of distribution of measured values to provide a meaningful blood flow characteristic value.
17. The system of claim 16, comprising a sensor including emitters configured to emit first and second wavelengths of light, a detector configured to detect the first and second wavelengths of light, and a transmitter configured to transmit photocurrent signals indicative of the first and second wavelengths of light to the monitor.
18. The system of claim 16, wherein the blood flow characteristic comprises blood oxygen saturation.
20. The system of claim 16, wherein the initial estimate comprises a current physical measurement of the value representative of the blood flow characteristic at the current timestep or a stored estimate value based on patient type.
US13/278,057 2006-09-20 2011-10-20 System and method for probability based determination of estimated oxygen saturation Expired - Fee Related US8538500B2 (en)
US11/524,167 US8064975B2 (en) 2006-09-20 2006-09-20 System and method for probability based determination of estimated oxygen saturation
US14/029,491 US20140018651A1 (en) 2006-09-20 2013-09-17 System and method for probability based determination of estimated oxygen saturation
US11/524,167 Continuation US8064975B2 (en) 2006-09-20 2006-09-20 System and method for probability based determination of estimated oxygen saturation
US14/029,491 Continuation US20140018651A1 (en) 2006-09-20 2013-09-17 System and method for probability based determination of estimated oxygen saturation
US11/524,167 Active 2030-09-20 US8064975B2 (en) 2006-09-20 2006-09-20 System and method for probability based determination of estimated oxygen saturation
US13/278,057 Expired - Fee Related US8538500B2 (en) 2006-09-20 2011-10-20 System and method for probability based determination of estimated oxygen saturation
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Our multi day packages are designed to ensure your peace of mind, safe in the knowledge that all the little details are taken care of. Our Coastal Classic trip, We Love Nelson trip, Art & Food, and Pigeon Valley Loop trips are priced based on our "All Sorted Package".
Price depends on the level of accommodation you choose. Starting price is based on en-suite cabin accommodation at shoulder season rates.
Our "All Sorted" package price includes accommodation and we have been out and about along the trail to find the best accommodation in each village. It includes motels, B&B's and en-suite cabins. These are all close to the trail, and close to cafes for meals.
"All Sorted" package prices start at twin-share en-suite cabin shoulder season rates. B&B or motel level accommodation is also available.
The Gentle Cycling Good Things Maps are included in our packages. These are waterproof, topographic-style maps. They illustrate our exclusive recommendations for detours off the trail to visit all our favourite places. For the adults, we provide tips for the best local food, wine, craft beer, art, history and landscape. And for the kids, we've thought of fun things along the trail that will add something special every day. So everyone can enjoy the journey.
Our itineraries are designed to make it easy for you to add a Park Day to your trip. Stay a night in Kaiteriteri, then go out into the Abel Tasman National Park the next day. And if your cycling trip finished in Kaiteriteri, we will arrange your transport from Kaiteriteri back to Nelson, or to the airport, after your Park Day. Book your Wilsons Abel Tasman trip with us and you pay the same price as when you book it yourselves, plus, you receive a complimentary picnic lunch for your Park Day.
Due to health and safety concerns, the maximum bag weight for our luggage transfers is 15kg. We can provide secure storage for extra luggage at our base.


text:
Industry Minister, Patricia Hewitt Joins Public Debate on Future of Manufacturing in the UK
Originally Published 5 June 2001
Business leaders will have their first chance to cross examine Patricia Hewit - The new Secretary of State for Trade and Industry as she makes one of her first public appearnces as a Cabinet minister when she joins other key commentators and protagonists in UK manufacturing at the University of Warwick in a special debate to ask if there is a future for manufacturing in the UK?
She will join Today Programme presenter John Humphrys who will host a "Question Time" style debate with the other panellists will be: Professor Kumar Bhattacharyya - Director of the Warwick Manufacturing Group at the University of Warwick, Ed Crooks, Economics Editor of the Financial Times, Roger Lyons, General Secretary of the Manufacturing, Science and Finance Union (MSF) and Alan Wood - Chief Executive of Siemens UK plc.
With the projected down turn in the world economy and a recent survey predicting up to 700,000 job losses from manufacturing over the next ten years, A Future For Manufacturing? is a timely issue for the 2001 Warwick Debate. The 2001 Warwick Debate: A Future For Manufacturing? will take place at the University of Warwick Arts Centre on Wednesday 13 June, 7.00pm before an invited audience of business leaders, politicians and trade unionists. People watching the Debate live on the internet (at www.warwick.ac.uk/warwickdebates) will also be able to put their questions directly to the panel.
Alan Wood - Chief Executive of Siemens UK plc and Chairman of the CBI's Manufacturing Council - and one of the panellists on the evening says "I am delighted to be taking part in this debate. It is very timely following the formation of the new Government and with the appointment of Patricia Hewitt as Secretary of State for Trade and Industry. The evening will give us the opportunity to get the message over that the UK must remain a mixed economy and to dispel the myth that we can survive on services alone. With a concerted effort, from both industry and government, the UK can re-position itself as a world leader in supplying innovative, high value-added products to global markets."
Note for Editors: This year's Warwick Debate has been generously supported by Advantage West Midlands, Birmingham International Airport, the CBI, and Jaguar.On display outside the debate venue will be the new Jaguar X-TYPE sports saloon, which is built at Halewood on Merseyside safeguarding 3,000 jobs and creating 500 new jobs in the new associated supplier park there.
Further information about the above press release and all other media services at the University of Warwick can be obtained from:
Peter Dunn, Press Officer
Senate House
Coventry, CV4 7AL
Tel: 024 76 523708
Email: puapjd@admin.warwick.ac.uk
Last revised: Wed 7 Jul 2004

redpajama_set_name: RedPajamaCommonCrawl


230lbs.@ full lockout. 180lbs. power-pushup, 1 30lb. vest, 1 20lb.vest. I do 10 reps remove 180, 10 reps, then remove the 30, 10 reps then remove the 20, then 10 reps no weight.
Was nice meeting you out there brv!
Post your bar pictures here? haha. Strong tricep picture tho Ironloo, very nice!
For a second I thought you were doing somersaults with dumbbells!
bridge jumping is awesome man how many feet is it?
We didn't jump. The water level in that area is very low. It's like 25 meters or so.
120lbs. weighted gravity boots, my top 3 favorite for core.
Sorry for the huge pictures, couldn't figure out how to shrink them and doing this quickly before heading out. I used photobucket since I already had an account from years back, if there are better sites then please let me know.
I see you guys with your fancy parks and home setups, and raise you my makeshift garden setup.
My "bars". Not too bad to use, good for parallel bar pull ups, and standard pull ups. Could be a pain when I get on to muscle ups in the future though due to not being able to shift my grip as easily. Can be dodgy in the rain too, they get really slippery.
And my dip and push up stations.
I love the fact you can literally use anything. Although I am planning on writing to my local council to see about getting a park in town, I'd appreciate it if you guys could check out my thread in the Park Finder section and help if you can. Cheers.


text:
Preppy girls, often named simply 'preps', love to rock a college-inspired wardrobe. Their hangers are lined side to side with girly blouses with matching collared tees as well as a-line skirts and tights. Her hair is almost always amped up with a cute little headband and she usually wears glasses- whether she really needs to or not! This style may appear geeky and slightly luxurious, but the look itself is really not expensive and extravagant at all.
Top-handled and either cutesy and retro or super-sleek in plain leathers, the most influential bag trend of the season will most definitely be anything that feels extra-ladylike and old-fashioned. Although jumbo totes and teeny-tiny mini bags could also be seen on the autumn runways, neither is particularly practical, unlike these this breed of elegant styles. "I find when something is vintage that piece has a much longer staying power since the style feels inherently classic, like the frame bag," says Lisa Aiken, Fashion Director at Moda Operandi. Roomy enough to fit your essentials into, classic enough to last an eternity and offered in enough variations to girls with multiple style personalities sated indeed.
The trench coat is so a year ago! This winter, beat the cruel winter icy with the all new form patterns for ladies, i.e. the cape. It nearly takes after a poncho, and is sufficiently adaptable to beat the various types of winter dressing. It can be worn with either sides up or down, will even now run well with some other winter piece, from over the-knee boots to the pajama style. These are best when the nonpartisan hues are picked. The poncho itself offers a layered appearance. Try not to miss this winter slant.
According to Edited, a rise in jewelled heels and Mary Janes alike aligned with the overarching trend for more "feminine apparel." The movement has been translated in many ways, from Sies Marjan's crystal-strapped courts to more kitsch jewel-dotted pumps at Moschino. Often spotted with tights and socks, you're definitely looking at this coming season's party shoes du jour.
One of the world's most successful fashion designers, Diane von Fürstenberg impressed the fashion world when she introduced her now-iconic "wrap dress" for the working woman in 1972. Elegance, ease, and accessibility have always been the core of her design philosophy, which has allowed her to turn DVF into a global luxury lifestyle brand. In 2005, she became the recipient of the CFDA's Lifetime Achievement Award.
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Known as the champion of star-spangled glamour, Tommy Hilfieger's favorite trends go from red, white and blue. Since introducing his first collection in 1985, no designer has become more closely associated with Ivy League prep than Tommy Hilfiger. After building his company on the modernization of all-American men's wear, and winning the CFDA Menswear Designer of the Year award in 1995, Hilfiger introduced women's wear in 1996 and sold the company for $1.6 billion ten years later.
Born Gabrielle"Coco" Bonheur Chanel, she is a excellent French fashion designer, founder of the well known Chanel brand, whose modernist thought, practical design, and pursuit of expensive simplicity made her an important and influential figure in 20th-century fashion. She was the only fashion designer to be named on Time 100: The Most Important People of the Century.
Prefer to get a slick working wardrobe in order for autumn? Multiple savvy designers are catering to your needs and stepping up to fill the gigantic fashion hole Phoebe Philo has left in her wake since departing (old) Celiné. Want to be a total show-off for A/W 19? You'll have a great deal to choose from when it comes to loud colours, bold prints and even more statement-making silhouettes. But if you'd like to keep things chic and simple, there are many elegant, quiet pieces to combine together to that effect: You can't go wrong with Burberry's tailoring or (new) Celine's renewed bourgeois vibe.
Famous Italian fashion brands include Gucci, Armani, Prada, Dolce & Gabbana, Valentino, Bottega Veneta, Roberto Cavalli, Costume National, Brunello Cucinelli, Diesel, Etro, Fay, Fendi, Salvatore Ferragamo, Fiorucci, Genny, Iceberg, Kiton, La Perla, Loro Piana, Marni, Missoni, Moncler, Moschino, Richmond, Ermanno Scervino, Tod's, Trussardi, and Versace.
As previously mentioned, punk spirit seized the London shows and definitely filtered into some during Paris. Alexander McQueen and Dior are two major luxury brands turning the rebellious signifiers of this look on their heads (studs! leather! mohair hole-y knits! plaid!), but you'll also find some homegrown talent pushing things into even wilder territory. Even if the more extreme ends of this trend aren't going to translate into the mass market, expect to see many tartan creations hitting shop floors over the coming months…
A vibrant fashion style is reserved for the lady who wants to say "Hey, look at ME, world!" This energetic and intense fashion style typically features garments with wild patterns and exaggerated embroidery as well as asymmetrical designs and tons of colors. Most of her wardrobe will be lined with super light and pastel colors that draw the attention of everyone's eyes, no matter where it's worn.


text:
Q: Deleting an object in a different context I have an issue with subscribing and unsubscribing in my app, where the user when clicking on subscribe will send a server call and download data from the server and store in db. At the same time, if the user clicks on unsubscribe button, I have to delete the same data in db. I am getting an error of trying to access an object from different contexts.
I wanna know whether there is a way to do in concurrency where I can delete the object in a private context[Unsubscribing process] and then save the changes once the subscribing process is finished.
I am unable to delete the object this way, Can someone suggest me where I am going wrong?
    func deleteStreamEntityInPrivateContext(_ id: Int){
    privateContext = NSManagedObjectContext(concurrencyType: .privateQueueConcurrencyType)
    privateContext?.parent = CoreDataService.sharedInstance.managedObjectContext

    privateContext?.perform {
        if let stream = self.getStreamEntity(id){
            let managedObjectContext = CoreDataService.sharedInstance.managedObjectContext
            let streamID = managedObjectContext.object(with: stream.objectID)
            debugPrint(streamID, stream.id)
            self.privateContext?.delete((self.privateContext?.object(with: stream.objectID))!)
        }
    }

}

func saveStreamEntityInPrivateContext(){
    if let privateContext = privateContext{
        if privateContext.hasChanges{
            do{
                try privateContext.save()
                if CoreDataService.sharedInstance.managedObjectContext.hasChanges{
                    CoreDataService.sharedInstance.saveContext()
                }
            }catch{
                let nserror = error as NSError
                NSLog("Unresolved error \(nserror), \(nserror.userInfo)")
            }
        }
    }
}

redpajama_set_name: RedPajamaStackExchange


Under the guidance and leadership of the Lord Jesus Christ, we the members of the Gateway to the High Country Cowboy Church adopt the following constitution in order to declare and preserve the principles of our faith, the freedom of our church, and the rights and responsibilities of our individual members.
The name of this church, located in Columbia, Missouri and incorporated under the Laws of the State of Missouri, is the Gateway to the High Country Cowboy Church.
Worships God: Honors God by worshiping Him corporately, in both large and small gatherings, and by maintaining private devotions.
Lives by God's word: Understands the Bible as the ultimate authority for daily living and is involved in corporate, small group and private Bible studies.
Contributes to God's work: Uses their time, abilities, spiritual gifts, and finances for God's glory.
Connects with God's people: Pursues Christ honoring relationships at home, in the church, at work, and in the community.
Impacts God's world: Reaches out to the lost and un-churched by praying for them, witnessing to them, and inviting them to church worship services and activities.
This church affirms the Holy Bible, the inspired word of God, as the authority in all matters of faith and practice. We further identify ourselves as a distinctive body of faith by affirming the 2000 Baptist Faith and Message.
Jesus Christ is the head of the Church; the true source of all that the church is and does, and His glory is to be the objective of every act, function, and motive of the body, both individually and corporately. It is before Him that all other leadership must bow. He communicates His will for the church through His word, the Bible. He gives additional guidance by means of the specific leading of the Holy Spirit who indwells the heart of each believer. He calls forth leaders for the church to whom He gives responsibility for the oversight of the church body and the shepherding of its members.
The government of this church is vested in the body of believers who compose its membership and leadership. Persons who meet the membership requirements and request membership in the congregation shall constitute the membership.
As an autonomous local church, this church is not subject to the control of any ecclesiastical body. However, it relates to and cooperates with the local Baptist Association, the Missouri Baptist Convention, and The Southern Baptist Convention.
A church is understood to be a fellowship of baptized believers brought together to carry out the work of Jesus Christ. A baptized believer is one who has been scripturally immersed and understands baptism to be a symbol of the salvation, which has already been accepted in their life by the grace of God through faith in Jesus Christ.
The church will observe the Lord's Supper on a regular basis (at least quarterly on the annual calendar) and will be led by a selected leader of the church. The Lord's Supper is a symbolic act whereby the church, through partaking of the bread and the fruit of the vine, memorialize the death of Christ and anticipate His Second Coming.
This Constitution may be amended by a three-fourths (3/4) vote of the members present at a Church conference called for that purpose. Amendments may be proposed by the elected leaders or by written petition signed by fifty percent (50%) of the resident members and duly presented to the elected leaders. Proposed amendments shall be in written form and mailed to the last known address of all resident members eligible to vote at least thirty (30) days prior to the election. Amendments will be numbered, dated and attached to the original instrument.
In the event that this church, a non-profit corporation, ceases to operate, all of its remaining resources, assets, and records shall be surrendered to the Crossroads Baptist Association of Central Missouri to support Baptist ministry in the Central Missouri area. At no time will the assets or resources be disbursed or distributed to any person that may constitute personal gain.


text:
Director of Canceled Film 'The Hunt' Says He Wanted to 'Poke At Both Sides' Equally
It's been less than two weeks since Universal canceled the release of The Hunt, their thriller about a dystopian world where liberal elites hunt "deplorables" for sport. The director of the film, Craig Zobel, finally gave an interview about his movie and his feelings about the fact that its release was scuttled after mounting controversy — and he had some interesting things to say.
Speaking via email to Variety, he claimed that his ambition with the movie "was to poke at both sides of the aisle equally" and that his team sought to "entertain and unify, not enrage and divide." In his words, Zobel insisted that he wanted...
...to make a fun, action thriller that satirized this moment in our culture — where we jump to assume we know someone's beliefs because of which 'team' we think they're on… and then start shouting at them. This rush to judgment is one of the most relevant problems of our time.
His words are mighty ironic, given the fact that film was pulled from release before anyone actually watched it because as details of its story began to leak out, conservatives began to hold it up as an example of the "danger" that Hollywood poses to America. (It is also ironic that, per Variety, The Hunt was co-written by Nick Cuse, a "registered Republican," lending credence to Zobel's argument that the film was not simply a smear against any one particular political ideology.)
It is quite possible conservatives would have been offended by The Hunt. It's also possible liberals would have been offended by The Hunt. (The liberals sure sound like the monsters in this scenario, don't they? Variety says the script for the film they read makes it clear "the original intention was to depict working-class conservatives as the heroes.") But if we don't get to see it and judge for ourselves, we'll never know.
Filed Under: The Hunt


Q. Kids today don't have good penmanship. But so what? They use keyboards. Isn't handwriting obsolete?
Hardly. Penmanship has gotten a bad rap lately. It's hardly ever taught for any length of time in school. You see children in second and third grades still grasping their pencils in their fists, and suffering strain and fatigue after just a few minutes. No wonder! There's a trick to holding the pencil, and if you don't teach a child the right way, you're asking for trouble.
Yes, handwriting is an academic skill that is as basic as reading and writing.
Why? Because it builds important mental skills and eye-hand coordination. Keyboard typing doesn't even come close to the mental benefits that learning to use proper penmanship provides.
n Practice with penmanship builds eye-hand coordination. Typing provides little or none of this. But the skills that come from forming letters precisely will pay off in school, work and life. Think: mechanics, doctors, engineers, artists, pilots. . . .
n Good penmanship also builds self-control, with good posture, the proper positioning of the paper on the desk, and the correct alignment of the pencil in the hand. Good handwriting requires mental and physical discipline.
n Many children today hold a pencil in their fists or other wacky positions because they were never taught the proper position. Consequently, they get tired of writing after just a few lines.
n Handwriting allows a child's personality and individuality to shine through, which is important and valuable. A child may express words and ideas better in his or her own "hand" because it feels unique and creative. Typing, by contrast, looks machine-generated and conformist, because it is.
n Spelling, sentence structure and overall writing quality all improve. When you are taught to take care forming individual letters, that same habit of caring spreads to how letters come together into words, and words into sentences and so forth. Diligence starts in those early grades. It's crucial.
n Taking care with handwriting teaches concentration.
n You can't "hide" misspellings when the handwriting's good, so teachers don't miss them.
Homework: Parents can help all children a lot by going to school officials and asking for more of an emphasis on proper penmanship skills in the early grades. Meanwhile, you might want to "do it yourself" if your school skimps on handwriting instruction. A school supply store should have beginning penmanship paper and a copy of the Palmer Method, the best handwriting curriculum ever, for at-home practice.


text:
Crisis resilience in persons with MS
Dr Yvonne Learmonth
| Better treatments | Social And Applied Research | Project | 2021 | Investigator Led Research |
The recent Australian bushfires of 2019/2020, closely followed by the COVID-19 pandemic, have brought crisis care capabilities for people living with MS to the forefront. Currently there is scarce research exploring the impact of natural disasters and pandemics in the MS population. More generally, research has shown that individuals living with disability may be up to four times more likely to sustain injuries or death in disaster circumstances compared to the general population. This is mainly due to impairments in areas such as mobility, cognition and communication. At present there are no formal recommendations in place to guide management of people living with MS in times of crisis.
Dr Learmonth and her team will explore both the prevalence and the impact of the recent bushfires and pandemic on the healthcare of people living with MS in Australia, by performing interviews and surveys to more deeply understand the experiences and responses of people affected. Analysis of this information will provide the foundations for developing a toolkit to be used for healthcare-based disaster management for people with MS in the future. As well as assisting people with MS, it is anticipated that this toolkit will also be useful for people living with disability from other conditions, and can be refined to their specific needs, thus broadening the impact of this research across the wider community.
Stages of the research process
Fundamental laboratory
Laboratory research that investigates scientific theories behind the possible causes, disease progression, ways to diagnose and better treat MS.
Lab to clinic timeline: 10+ years
Research that builds on fundamental scientific research to develop new therapies, medical procedures or diagnostics and advances it closer to the clinic.
Lab to clinic timeline: 5+ years
and Clinical Trials
Clinical research is the culmination of fundamental and translational research turning those research discoveries into treatments and interventions for people with MS.
Lab to clinic timeline: 1-5 years
Dr Claudia Marck
Dr Brody Heritage
Professor Lisa Gibbs
Associate Professor Ingrid van der Mei
Dr Petra Skeffington
Professor Allan Kermode
Professor Diana Walker
MS WA
Lower limb training to improve walking in people with MS
The role of monocytes in MS relapses


text:
Bone Gnawer: Feast Of Flesh
Horror/Death Metal
Pulverizer Records
www.pulverizer.net
www.myspace.com/bonegnawerband
Review: Craig Hartranft, 06.28.2009
Although strict death metal is not the standard fare within the electronic pages of Dangerdog Music Reviews, we'll make a brief exception for the debut from Bone Gnawer. And this is only because Feast Of Flesh, excusing the generic death vocals and horrid content, is some of the best old school thrash/death metal that I've heard in sometime. Bone Gnawer features the well-known death metal master Kam Lee (Massacre, Denial Fiend, ex-Mantas/Death), Rogga Johansson (Paganizer, Demiurg, Ribspreader), Morgan Lie (Naglfar), and Ronnie Bjornstrom (Ribspreader, Hate Ammo). Feast Of Flesh could be best described as blend between classic Florida death metal and early Swedish melodic death metal.
Musically, Feast Of Flesh is flush with uncompromised and speedy, but not brutally punishing, thrash riffage blending with a galloping rhythm section and lightening fret work to create some better than average nasty, yet melodic, American death metal. Musically, Hatchface, Feast Of Flesh or The Lucky Ones Die First are far above what passes for most death metal today.
Lyrically, the thematic content of Feast Of Flesh is a putrid and vulgar glorification of gore, violence, death, and misogyny; All of which are hallmarks of death metal and unsuited for anybody's mind or ears. Feast Of Flesh is quite different from the B-movie zombie theme of Kam Lee and Denial Fiend's They Rise, a genuinely interesting work. Although, I'm sure Bone Gnawer would be happy with the aforementioned description, this is a perfect example of good music and a bad message resulting in bad art; if it can be called art at all. (This is something Cannibal Corpse claimed early on as justification for their music for which they are, intellectually, severely mistaken.)
Even if Bone Gnawer invokes the inspiration of horror B-movies, it still does not justify the blessing of sadism and torture. But, I suppose we're to accept this because, historically, this has been a subject matter of fair game for death metal. I don't think so. (Which begs the question of what puts the 'death' into death metal? The lyrical content, musical style or simply the growling vocals?) All it truly reveals is the pathologically unstable (and near criminally insane) mind and character of the principals involved, and essentially validates the ancient proverb, 'Out of the abundance of the heart, the mouth speaks.'
Kam Lee's latest venture, Bone Gnawer, and their debut Feast Of Flesh is, musically, a brilliant and sound work of thrash/death metal and, lyrically, a horrid and worthless disc which glorifies the worst of human nature: gore, violence, sadism and death. In other words, Feast Of Flesh is the best and worst of death metal.


Michael C. Greiner joined AngioDynamics as the Executive Vice President and Chief Financial Officer in August 2016. Mr. Greiner most recently served as the Chief Financial Officer at Extreme Reach. Prior to Extreme Reach, Mr. Greiner served as Senior Vice President Corporate Finance and Chief Accounting Officer at Cimpress N.V. (Vistaprint N.V.), Global Controller for GE's Water and Processing Technologies division and in leadership roles at Bausch & Lomb and Wyeth. Mr. Greiner is also an advisor for Mirah, Inc., a measurement-based behavioral health Company, and serves as the President of the Foundation for Faces of Children. Mr. Greiner received a Bachelor and Master of Science in Accounting from Fairleigh Dickinson University and Master of Business Administration from the Columbia Business School. Mr. Greiner is also a Certified Public Accountant (inactive).