Martin Jarvis, San Francisco, Cal., for libelant.
Keith Ferguson, Asst. U.S. Atty., Admiralty Div., San Francisco, Cal., for respondent.
Libelant, as administratrix of the estate of her deceased husband and as an individual, sues the United States in admiralty under The Public Vessels Liability Act, 46 U.S.C. § 781 et seq., and the Suits in Admiralty Act, 46 U.S.C. § 741 et seq., to recover damages for the death of her husband, an employee of Bethlehem Steel Company, allegedly caused within the navigable waters of California by the negligence of the respondent and the unseaworthiness of its public vessel.
Respondent has impleaded Bethlehem Steel Company, the employer of decedent, alleging that at the time of the accident Bethlehem had the exclusive control and custody of the vessel in question and that any injury to decedent was the result of the negligence of Bethlehem in breach of its contractual obligation to respondent to perform its work aboard the vessel in a workmanlike and careful manner.
The case is before the Court upon Libelant's Exceptions to Respondent's Amendment to its Answer wherein respondent pleads: 1) that the action is barred by the California statute of limitations, C.C.P. Sec. 340(3) and, 2) that libelant, having accepted an award of death benefits under the Longshoremen's and Harbor Workers' Compensation Act, 33 U.S.C. § 901 et seq. and having failed to commence this libel within six months after the award the libel is barred by Sec. 933(b) of that Act.
No action for wrongful death will lie under the general maritime law but it has been well established that admiralty will recognize and enforce such a right of action when the act causing death occurs within the navigable waters of a state whose statutes give a right of action for wrongful death. The Harrisburg, 119 U.S. 199, 7 S.Ct. 140, 30 L.Ed. 358 (1886); Western Fuel v. Garcia, 257 U.S. 233, 242, 42 S.Ct. 89, 66 L.Ed. 210 (1921); American Stevedores v. Porello, 330 U.S. 446, 458-460, 67 S.Ct. 847, 91 L.Ed. 1011 (1946).
The law of California gives a right of action for wrongful death, C.C.P. Sec. 377.
This suit is based upon that statute and also upon the Public Vessels Liability Act, 46 U.S.C. § 781 et seq., authorizing libels in personam against the United States for damages caused by a public vessel of the United States, and the Suits in Admiralty Act, 46 U.S.C. § 742, authorizing libels in personam against the United States in cases where, if such vessel were privately owned or operated, a proceeding in admiralty could be maintained.
California law provides that for wrongful death an action must be commenced within one year from the time the cause of action accrues, C.C.P. Secs. 335, 340(3).
This action, commenced January 9, 1963, to recover for a death occurring July 26, 1961, would, therefore, be outlawed under California law.
Libelant relies upon a provision of the Public Vessels Act, 46 U.S.C. § 782, which provides that suits under the Act shall be subject to and proceed in accordance with the provisions of the Suits in Admiralty Act, 46 U.S.C. § 741 et seq., which provides, Sec. 745, that suits authorized by it may be brought within two years after the cause of action arises.
Although it has been held that the limitations period of the Suits in Admiralty Act is incorporated by reference into the Public Vessels Act, for certain purposes (Phalen v. United States, 32 F.2d 687 (2d Cir. 1929)), it has also been held that the state statute of limitations applies when the admiralty court is proceeding under a state created cause of action for wrongful death.
This has been specifically held in Western v. Garcia, supra (a maritime wrongful death suit between private parties), and in California Casualty Indem. Exchange v. United States, 74 F. Supp. 401 (S.D.Cal. 1947), (a similar suit against the United States, under the Public Vessels Liability Act).
Each of these wrongful death cases involved the identical California Statute of Limitations here in question. (See also: Mejia v. United States, 152 F.2d 686 (5th Cir. 1945); The Tungus v. Skovgaard, 358 U.S. 588, 592, 79 S.Ct. 503, 3 L.Ed.2d 524 (1958); Hess v. United States, 361 U.S. 314, 320, 80 S.Ct. 341, 4 L.Ed.2d 305 (1959); Continental Casualty v. The Benny Skou, 200 F.2d 246 (4th Cir. 1952); McMahon v. Pan-American, 297 F.2d 268 (5th Cir. 1962)).
The rationale of these cases is that in actions for wrongful death brought in admiralty in which the Court must look to and follow a state created right of action for such death, the Court must adopt and enforce such right as an integrated whole with whatever conditions and limitations the creating state has attached.
Libelant relies on State of Maryland to Use of Burkhardt v. United States, 165 F.2d 869 (4th Cir. 1947), a non-maritime action for wrongful death brought under the Federal Tort Claims Act, 28 U.S.C. § 1346(b), which authorizes actions for damages against the United States in tort cases where the United States, if a private person, would be liable to the claimant under the law of the place where the act or omission occurred.
It was held that for reasons of statutory interpretation the limitations period of the Tort Claims Act, itself, rather than the state limitations period, is applicable to such suits. (See also, Sweet v. United States, 71 F. Supp. 863 (S.D. Cal. 1947)).
In State of Maryland, supra, 165 F.2d at 874 however, the Court, citing Mejia v. United States, supra, noted that a different rule is applicable to maritime wrongful death actions for the reason that admiralty may not adopt a state law without adopting its limitations and conditions.
Libelant further argues that the cases which have established this admiralty rule (The Harrisburg, supra, Western v. Garcia, supra, Mejia v. United States, supra) contain language indicating that their holdings were based upon the ground that the state statutes of limitation there involved were deemed to be limitations upon the right of action, itself, as distinguished from bar to the remedy.
Libelant points out that the California Court in Wohlgemuth v. Meyer, 139 Cal.App.2d 326, 293 P.2d 816 (1956) has held that its wrongful death one year limitation statute, C.C.P. Sec. 340(3), being a bar to the remedy, rather than a limitation upon the right of action itself, and being therefore, procedural, can be tolled for reasons that would toll other statutes of limitation.
However, the mere description of a state statute of limitations as procedural for some purpose is not necessarily a determination of the question whether a federal or a state rule of limitation should apply when the federal court's adjudication is dependent on the existence of a state created right. The real test is not whether a state statute of limitations is deemed a matter of procedure in some sense, but whether such a statute concerns merely the manner and the means by which a right to recover, as recognized by the state, is enforced or whether such statutory limitation is a matter of substance in the aspect relevant to a particular problem, namely, does it significantly affect the result of litigation for a federal court to disregard a law of a state that would be controlling in an action upon the same claim by the same parties as a state court. (Guaranty Trust Co. of New York v. York, 326 U.S. 99, 65 S.Ct. 1464, 89 L.Ed. 2079 (1945).
Although the pending suit is not a diversity case, as was Guaranty, it is a suit in which the federal court sitting in admiralty, is dependent for its adjudication upon a state created right of action for wrongful death. The foregoing test is, therefore, applicable and, when applied it leads to only one conclusion, namely, that the California limitations statute, which is certainly a bar to the remedy (absent circumstances tolling it) does significantly affect the result of litigation and is not of a mere remedial character. Therefore, admiralty, which under the decisions "must enforce the right as an integrated whole, with whatever conditions and limitations the creating State has attached", (Tungus v. Skovgaard, supra) must apply the state statute of limitations applicable to the state created wrongful death right of action.
For the foregoing reasons and in view of the long established weight of authority upon the question, the Court concludes that libelant's exceptions to the first defense pleaded by respondents' amended answer should be overruled.
We now take up the exceptions to the second defense above mentioned that, libelant, having been awarded and having accepted a death benefit from decedent's employer, Bethlehem Steel Company, under the Longshoremen's and Harbor Workers' Compensation Act, Title 33 U.S.C. § 901 et seq., and having failed to commence this action against respondent as a third party liable in damages — within six months after such award, is barred under Sec. 933(b) of said Act from bringing this action.
Section 933, as amended in 1959, after providing that a person entitled to compensation need not elect whether to receive such compensation or to recover damages against a third person, further provides that acceptance of such compensation shall operate as an assignment of the right of action to the employer unless such person commences an action against the third person within six months after such award.
In the pending case respondents allege that on March 21, 1962, libelant was awarded and accepted a death benefit under the Longshoremen's and Harbor Workers' Act but failed to commence this action within six months thereafter.
Libelant takes the position that in this case there is a conflict of interest between libelant and decedent's employer, Bethlehem, and that for this reason libelant has a right to commence this action notwithstanding the statutory assignment to the employer under Sec. 933(b), citing Czaplicki v. Hoegh Silver Cloud, 351 U.S. 525, 76 S.Ct. 946, 100 L.Ed. 1387 (1955) and Johnson v. Sword Line, 257 F.2d 541 (3rd Cir. 1958).
In Czaplicki, supra, a longshoreman filed a libel action against a shipowner and others for injuries which occurred when steps constructed by Hamilton gave way. Traveler's Insurance Company was the compensation carrier for both the employer and Hamilton, a potential third-party tortfeasor. The Supreme Court held that a conflict of interest between libelant and Traveler's Insurance as subrogee to libelant's employer's assignment of the cause of action existed for the reason that an action by Travelers against defendant shipowner would be in effect an action against itself and that Czaplicki was the only person with sufficient adverse interest to bring the suit. The Court also pointed out that Travelers might be held liable upon an indemnity claim by the shipowner under the doctrine of Ryan Stevedoring Co. v. Pan Atlantic, 350 U.S. 124, 76 S.Ct. 232, 100 L.Ed. 133 (1955).
In these circumstances, the Court held, Czaplicki was not precluded by the statutory assignment of his right of action from enforcing those rights in an action brought by himself.
In Johnson, supra, where neither the employer nor its subrogated compensation carrier, holding the statutory assignment of claimant's cause of action, had brought suit or reassigned the right of action, the Court held that the burden of establishing a valid basis for an action was upon him — not upon the claimant and, further, that where the employer was subject to suit by the alleged third party tortfeasor under the indemnification doctrine, a conflict of interest was apparent.
In Smith v. A.H. Bull SS Co., 208 F. Supp. 172 (D.C.Md. 1962) the Court held that in a suit against the third party tortfeasor the burden was on it to show that no conflict of interest was a factor in the decision of the employer's compensation insurer not to bring a third party suit.
That such a conflict of interest may exist in the pending case appears from the fact that respondent herein has impleaded Bethlehem, alleging that the death of libelant's decedent arose out of acts of Bethlehem in breach of its contractual obligations to respondent and that, therefore, Bethlehem is liable to respondent for any damages resulting from such breach, including any damages which libelant may recover against respondent.
Thus, it appears from the record that, as far as respondent is concerned, any decision of Bethlehem not to sue respondent presumably arises out of the alleged negligence of Bethlehem itself, in the breach of its own warranty to respondent.
As far as respondent is concerned, it must, therefore, be held that a conflict of interest exists between Bethlehem and libelant. Therefore, libelant's exception to respondents' second defense must be sustained.
This order, however, should be without prejudice to any rights which Bethlehem, upon its appearance as an impleaded party herein, may see fit to assert against any other party.
Defendant will prepare, serve and present a formal order in accordance with this memorandum.


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The invention relates to systems and methods for site selection and placement of extra-anatomic passages altering gaseous flow in a diseased lung.
The invention relates to methods and systems to select sites within the lungs that allow expired air to pass out of the lung tissue to facilitate both the exchange of oxygen ultimately into the blood and/or to decompress hyper-inflated lungs.
The American Lung Association (ALA) estimates that nearly 16 million Americans suffer from chronic obstructive pulmonary disease (COPD) which includes diseases such a chronic bronchitis, emphysema, and some types of asthma. The ALA estimated that COPD was the fourth-ranking cause of death in the U.S. The ALA estimates that about 14 million and 2 million Americans suffer from emphysema and chronic bronchitis respectively.
Those inflicted with COPD face disabilities due to the limited pulmonary functions. Usually, individuals afflicted by COPD also face loss in muscle strength and an inability to perform common daily activities. Often those patients desiring treatment for COPD seek a physician at a point where the disease is advanced. Since the damage to the lings is irreversible, there is little hope of recovery. Most times, the physician cannot reverse the effects of the disease but can only offer treatment and advise to halt the progression of the disease.
To understand the detrimental effects of COPD, the workings of the lungs requires a cursory discussion. The primary function of the lungs is to permit the exchange of two gasses by removing carbon dioxide from arterial blood and replacing it with oxygen. Thus, to facilitate this exchange, the lungs provided a blood gas interface. The oxygen and carbon dioxide move between the gas (air) and blood by diffusion. This diffusion is possible since the blood is delivered to one side of the blood-gas interface via small blood vessels (capillaries). The capillaries are wrapped around numerous air sacs called alveoli which function as the blood-gas interface. A typical human lung contains about 300 million alveoli.
The mechanics of breathing include the lungs, the rib cage, the diaphragm and abdominal wall. During inspiration, inspiratory muscles contract increasing the volume of the chest cavity. As a result of the expansion of the chest cavity, the pleural pressure, the pressure with in the chest cavity, becomes sub-atmospheric. Consequently, air flows into the lungs and the lungs expand. During unforced expiration, the inspiratory muscles relax and the lungs begin to recoil and reduce in size. The lungs recoil because they contain elastic fibers that allow for expansion, as the lungs inflate, and relaxation, as the lungs deflate, with each breath. This characteristic is called elastic recoil. The recoil of the lungs causes alveolar pressure to exceed atmospheric pressure causing air to flow out of the lungs and deflate the lungs. If the lungs' ability to recoil is damaged, the lungs cannot contract and reduce in size from their inflated state. As a result, the lungs cannot evacuate all of the inspired air.
In addition to elastic recoil, the lung's elastic fibers also assist in keeping small airways open during the exhalation cycle. This effect is also known as “tethering” of the airways. Tethering is desirable since small airways do not contain cartilage that would otherwise provide structural rigidity for these airways. Without tethering, and in the absence of structural rigidity, the small airways collapse during exhalation and prevent air from exiting thereby trapping air within the lung.
Lung volume reduction surgery is a procedure which removes portions of the lung that are over-inflated. The portion of the lung that remains has relatively better elastic recoil, providing reduced airway obstruction. The reduced lung volume also improves the efficiency of the respiratory muscles. However, lung reduction surgery is an extremely traumatic procedure which involves opening the chest and thoracic cavity to remove a portion of the lung. As such, the procedure involves an extended recovery period. Hence, the ling term benefits of this surgery are still being evaluated. In any case, ti is thought that lung reduction surgery is sought in those cases of emphysema where only a portion of the lung is emphysematous as opposed to the case where the entire lung is emphysematous. In cases where the lung is only partially emphysematous, removal of a portion of emphysematous lung which was compressing healthier portions of the lung allows the healthier portions to expand, increasing the overall efficiency of the lung. If the entire lung is emphysematous, however, removal of a portion of the lung removes gas exchanging alveolar surfaces, reducing the overall efficiency of the lung. Lung volume reduction surgery is thus not a practical solution for treatment of emphysema where the entire lung is diseased. Moreover, conventional lung volume reduction surgery is an open surgical procedure which carries the risk of surgical complications and requires a significant period of time of recuperation.
Both bronchodilator drugs and lung reduction surgery fail to capitalize on the increased collateral ventilation taking place in the diseased lung. There remains a need for a medical procedure that can alleviate some of the problems caused by COPD. There is also a need for a medical procedure that alleviates some of the problems caused by COPD irrespective of whether a portion of the lung, or the entire lung is emphysematous. The production and maintenance of collateral openings through an airway wall allows air to pass directly out of the lung tissue responsible for gas exchange. These collateral openings serve to decompress hyperinflated lungs and/or facilitate an exchange of oxygen into the blood.
Methods and devices for creating and maintaining collateral channels are discussed in U.S. patent application Ser. No. 09/947,651, filed on Aug. 7, 2000; U.S. patent application Nos. 09/947,144, 09/946,706, and 09/947,126 all filed on Sep. 4, 2001; U.S. Provisional Application No. 60/317,338 filed on Sep. 4, 2001;U.S. Provisional Application No. 60/334,642 filed on Nov. 29, 2001; U.S. Provisional Application No. 60/367,463 filed on Mar. 20, 2002; and U.S. Provisional Application No. 60/374,022 filed on Apr. 19, 2002 each of which is incorporated by reference herein in its entirety.
Benefits in creating these extra-anatomic or collateral channels the lungs of emphysema patients are becoming more readily apparent. However, the degree of benefit of this treatment is believed to be related to the placement of the extra-anatomic passage in a safe manner and in a desired relationship to the area of tissue destruction.
Currently, medical practitioners often perform or rely on external imaging (e.g., via a CT scan) of the diseased lung to estimate a desired area for treatment. Next, the surgeon accesses the airways with a bronchoscope type device to search for vessels using (typically using a Doppler-type device). However, even if the potential area of diseased tissue if located via the external imaging, the surgeon must attempt to navigate the tortuous airways to find an acceptable site for treatment. Often this approach relies on scanning for blood vessels. Such an approach results in lengthy procedure.
In many cases, the surgeon places the patient under anesthesia or a sedative during the procedure. Naturally, a lengthy procedure requires the use of additional drugs or anesthesia to control the patient. In some cases, procedures may be prematurely terminated if the length of the procedure begins to require an excessive amount of anesthesia or sedatives. In addition, the use of the bronchoscope or other access device beyond a certain time may result in additional complications to the patient.
In yet another drawback, the lack of a treatment pan may case some surgeons to create as many extra-anatomic passages (and implants within the passages) as possible to increase the likelihood that one or more passages is located closely to an area of disease tissue.
In view of the above, there remains a need to improve the site selection and or treatment plan process when performing the procedure. Such an improvement may increase safety by reducing the likelihood of creating the passage in an anatomically undesirable area, improve effectiveness by placing the passage in an area that provides significant benefit, and reduce the procedure time. At the very least, there remains a need for providing physicians with additional information to make informed decisions on possible locations to create extra-anatomic passages for decompressing hyperinflated lungs.
Previous studies indicate that successful site selection for creation of an extra-anatomic passage includes the ability to gain access to the target airway surface, transbronchial access to trapped gases within the lungs or at least transbronchial access to collateral ventilation paths in the lung, as well as creation of the extra-anatomic passage in an area that is anatomically safe.
For example, the ability to access the target airway surface may be difficult or impossible if the surgical system is unable to navigate to the site. Since the surgical system used to perform the procedure may include any number of components, the component limitations may limit the areas of the airway that are treatable. For example, system components may include devices such as bronchoscopes, guide catheter, hole-maker, implant deployment catheter, etc.
For example, creation of an extra-anatomic passage too close to a blood vessel is obviously not desired. Furthermore, creation of an extra-anatomic passage outside of the parenchymal border of the lung may result in a treatment without benefit or at the worst case, a pneumomediastinum (i.e., free air in the mediastinum that may give rise to pneumothorax or pneumopericardium and compromise the lungs or heart). Alternatively, creating the passage too close to the outer periphery of the lung may result in a pneumothorax.
This invention relates to systems and methods for site selection and placement of extra-anatomic passages altering gaseous flow in a diseased lung.
A method includes assessing a plurality of sites in airways of a hyperinflated lung of a patient by identifying the plurality of site within the airways of the diseased lung, determining at least one anatomic characteristic of each site, assessing a degree of a plurality of diseased regions in the lung, calculating a score for each site based on the degree of the plurality of diseased regions in the lung, at least one anatomic characteristic of each site and a proximity of the site to at least one of the diseased regions, and displaying each score in association with each site in graphical form.
A variation of the inventive method includes the act of selecting a site for creation of an extra-anatomic passage for collateral ventilation of the diseased lung and creating at least one collateral channel or passage at the site. The terms “passage” and/or “channel”, are intended to include an opening, cut, slit, tear, puncture, or any other conceivable artificially created opening.
The systems and methods described herein may be incorporated with any number of systems that allow for real-time or virtual mapping through anatomy. In such cases, the methods and systems described herein may be combined with such real-time or virtual mapping systems so as to provide data or other information to the end-user for improved placement and site selection of the extra-anatomic passages.
For example, U.S. Pat. No. 6,466,687, the entirety of which is incorporated by reference, describes method and apparatus for analyzing CT images to determine the presence of pulmonary tissue pathology. The systems of the present invention may be combined with such teachings to identify the tissue pathology as well as provide a treatment plan.
In addition, systems an devices exist for tracking a probe such as a catheter or endoscope through the body of a patient. Such systems and devices are described in U.S. Pat. No. 6,188,355 entitled Wireless six-degree-of-freedom locator; U.S. Pat. No. 6,226,543 entitled System and method of recording and displaying in context of an image a location of at least one point-of-interest in a body during an intra-body medical procedure; U.S. Pat. No. 6,380,732 entitled Six-degree of freedom tracking system having a passive transponder on the object being tracked; U.S. Pat. No. 6,558,333 entitled System and method of recording and displaying in context of an image a location of at least one point-of-interest in a body during an intra-body medical procedure; U.S. Pat. No. 6,574,498 entitled Linking of an intra-body tracking system to external reference coordinates; U.S. Pat. No. 6,593,884 entitled Intrabody navigation system for medical applications; U.S. Pat. No. 6,615,155 entitled Object tracking using a single sensor or a pair of sensors; U.S. Pat. No. 6,702,780 entitled Steering configuration for catheter with rigid distal device; U.S. Pat. No. 6,711,429 entitled System and method for determining the location of a catheter during an intra-body medical procedure; U.S. Pat. No. 6,883,814 entitled Intrabody navigation system for medical applications; and U.S. Pat. No. 6,996,430 entitled Method and system for displaying cross-sectional images of a body. Each of which is incorporated by reference in their entirety. Again, the present invention contemplates combining the systems and methods described above such that the potential treatments sites may be selected and transmitted to the tracking system to assist the medical practitioner in navigating to the sites in an expedited manner.
Methods and devices for creation of the extra-anatomic passage and placement of an implant therein are disclosed in U.S. Pat. No. 6,692,494, and publication nos.: US-2004-0073155-A1, US-2005-0137518-A1, US-2005-0137712-A1, US-2005-0192526-A1, US-2005-0043752-A1, US-2005-0043751-A1, US-2005-0060042-A1, US-2005-0060041-A1, US-2005-0137611-A1, US-2005137715-A1, US-2005-0060044-A1, US-2005-0177144-A1, PCT/US2005/025738, and PCT/US2005/025739. The entirety of each of which is incorporated by reference.
In another variation, the method and procedures described herein can be performed solely on data and other imaging. For example, a medical practitioner can submit the appropriate scans and other images for analysis by the methods described herein. Accordingly, the analysis and methods described herein can be performed solely on the information provided by the medical practitioner. After the imaging and data are assessed as described below, the medical practitioner will receive ratings or grades of tentative treatment sites (along with the other information discussed below).
FIG. 2A illustrates an example of sample sites that are identified prior to the method described herein.
FIG. 2B illustrates an example of a visual display of the results of calculating a score associated with each respective site.
FIG. 2C represents one variation of a flow-chart documenting the process used to calculate a score for each site.
FIGS. 2D-2G show additional displays of information to assist a surgical practitioner in assessing sites within the airways for creation of extr-anatomic paths.
FIG. 3A-3C represents images from a CT scan identifying the site as well as other anatomic features, where such images may also be provided in the display of information given to the medical practitioner.
FIGS. 3D-3E represents analysis of the CT scans to produce the data used in assessing each site.
FIGS. 4A-4C represent samples of severe, moderate, and mild coalescent patterns of emphysematous lung tissue used to compare to lung tissue being assessed in order to rate the degree of diseased tissue.
FIG. 1A shows a simplified illustration of a natural airway 100 which eventually branches to a blood gas interface 102. FIG. 1B illustrates an airway 100 and blood gas interface 102 in an individual having COPD. The obstructions 104 (e.g., excessive mucus resulting from COPD, see above) impair the passage of gas between the airways 100 and the interface 102. FIG. 1C illustrates a portion of an emphysematous lung where the blood gas interface 102 expands due to the loss of the interface walls 106 which have deteriorated due to a bio-chemical breakdown of the walls 106. Also depicted is a constriction 108 of the airway 100. It is generally understood that there is usually a combination of the phenomena depicted in FIGS. 1A-1C. More usually, the states of the lung depicted in FIGS. 1B and 1C are often found in the same lung.
As will be explained in greater detail below, the production and maintenance of collateral openings or channels through airway walls permits expired air to pass directly out of the lung tissue and into the airways to ultimately facilitate exchange of oxygen into the blood and/or decompress hyper inflated lungs. The term ‘lung tissue’ is intended to include the tissue involved with gas exchange including but not limited to, gas exchange membranes, alveolar walls, parenchyma, airway walls and/or other such tissue. To accomplish the exchange of oxygen, the collateral channels allow fluid communication between an airway and lung tissue. Therefore, gaseous flow is improved within the lung by altering or redirecting the gaseous flow within the lung, or entirely within the lung.
FIG. 1D illustrates a schematic of a lung 118 to demonstrate a benefit of the production and maintenance of collateral openings or channels through airway walls. As shown, a collateral channel 112 (located in an airway wall 110) places lung tissue 116 in fluid communication with airways 100 allowing expired air to directly pass out of the airways 100. The term channel is intended to include an opening, cut, slit, tear, puncture, or any other conceivable artificially created opening. As shown, constricted airways 108 may ordinarily prevent air from exiting the lung tissue 116. In the example illustrated in FIG. 1D, there is no implanted structure placed in the collateral channel 112. However, conduits or implants 120 may be placed in the collateral channels 112 to assist in maintaining the patency of the collateral channels 112. Examples of conduits may be found in the applications discussed above.
As discussed above, the methods and systems described herein include methods of determining airway bypass stents placements using radiology analysis techniques. Alternatively, the methods and systems described herein can be used merely for the creation of extra-anatomic passages without the placement of stents. Although the analysis may be performed using a computed tomography (CT) scan, the analysis techniques may include the use of non-invasive imaging such as x-ray, ultrasound, Doppler, acoustic, MRI, PET scans or other imaging as well as CT.
In addition, the analysis techniques may include the use of agents delivered within the airways or lungs for improving the imaging. For example, a gas may be inserted into the lungs to provide contrast to identify hyperinflation of the lungs during an x-ray or other non-invasive imaging. For example, 133Xe (Xenon 133) may be used as the agent. Also, a contrast agent may help in identifying blood vessels during CT scans. Another example includes inserting a fluid in the lungs to couple an ultrasound sensor to the wall of an airway.
As illustrated in FIG. 2A, a number of pre-determined potential sites 150 within the bronchi of the lungs in chosen for analysis. However, any number of site selection modes may be incorporated into the method. For example, a medical practitioner could select a number of areas thought to hold potential benefit upon treatment. In such a case, the practitioner could make the assessment based on imaging, physical examination, or any other means. In the current variation, 18 sites are chosen, in part, based on a medical practitioner's familiarity with the anatomy of the lungs. Using locations that are well known to those familiar with the anatomy of the bronchi reduces the likelihood that the practitioner confuses one site with another. In other words, the pre-selected sites can be identified during the method of assessing the sites and eliminate the practitioner from having to select the sites. Alternatively, pre-selection of sites may occur via one surgical practitioner who then supplies this data to the entity performing the analysis to rate the sites selected by the practitioner.
Accordingly, one variation of the invention includes sleeting sites at major branching points of the bronchi to reduce the likelihood that a medical practitioner mistakes sites. FIG. 2A illustrates these sites as follows: B1—apical upper right lobe 10, B2—posterior upper right lobe 12, B3—anterior upper right lobe 14, B4—lateral middle right lobe 16, B5—medial basal lower right lobe 18, B6—superior lower right lobe 20, B7—medial basal lower right lobe 22, B8—anterior basal lower right lobe 24, B9—lateral basal lower right lobe 26, B10—posterior basal lower right lobe 28, B1+2—apicoposterior upper left lobe 30, B3—anterior upper left lobe 32, B4—superior upper left lobe 34, B5—inferior upper left lobe 36, B6—superior lower left lobe 38, B7+8—anteromedial lower left lobe 40, B9—lateral basal lower left lobe 42, B10—posterior basal lower left lobe 44.
As noted herein, the method is intended to provide a comprehensive analysis to assist a physicians or surgeon in determining which of the pre-selected locations 50 are optimal treatment locations. As a result, although the analysis is performed on any number of given sites to provide a rating or score of the site, the invention does not restrict a medical practitioner from foregoing treatment in nay site for nay number of reasons.
As discussed below, the method includes calculating or assigning a score the sites 50 to provide a quantifiable measure for the practitioner to determine the optimal treatment locations. FIG. 2B shows a sample of such a display 200. As shown, the display 200 can include a schematic of the bronchial passages or airways 100 where each site 150 is graphically identified. In the illustrated variation, each site is identified with a star. However, variations of the display can include making each site 150 separately identifiable for ease in correlating the score 202 with the actual location.
FIG. 2B also illustrates the display as showing the respective site 150 in table form with the grade or score 200 accompanying each site. Clearly, any variety of display modes is within the scope of the invention. For instance, the display may be coupled to a real-time virtual model of the airways so that a practitioner could identify the site as they navigate to the site with a bronchoscope or other treatment device. Such systems and devices to track a probe such as a catheter or endoscope through the body of a patient are discussed above.
In the example shown, sites B, B2, B3, B6, and B10 of the right lung, and B3-B10 of the left lobe received scores of 100. Although the illustrated display provides scores from 0 to 100, the principles of the algorithm can calculate scores in any scale. In addition, the scores are not limited to quantified values; they may be non-numeric rankings such as low, medium, high, etc.
The grades or scores 202 associated with each site 150 are calculated using a number of factors thought to increase the likelihood that the treatment locations allow trapped gasses to escape. The factors may also include safety considerations as well as whether a particular site is treatable due to the local anatomy.
Turning now to FIG. 2C, the process 210 begins with the examination of the lung to accumulate the necessary data for evaluation within the procedure. In the example shown, the first decision and action steps 212 adjust the score of a particular site depending on an anatomic feature of the site itself. In the example, the score for a site is increased if the airway diameter is greater than or equal to a predetermined value (in this case a diameter of 6 mm or greater adds 10 to the score). These values are for illustration purposes only. Clearly, the invention is not limited to these values (10 points of greater or equal to 6 mm). Instead, any number of values may be used. In the example provided, the airway size of 6 mm is selected due to practical considerations when considering the size of a typical bronchoscope used to perform the procedure. Clearly, use of a smaller device could lower the desired airway diameter or adjust the score accordingly to increase the score for the ideal diameter. Moreover, the score itself can be altered for any number of reasons. For example, a medical practitioner may decide to give more or less weight to a particular size of the airway than in the sample process shown. In such a case, the practitioner could increase or decrease the score accordingly.
The next set of decisions 214 involves assessing a degree of one or more regions of lung tissue in the areas adjacent to the airways. As shown, a rating of severe destruction adds a score of 20, and a rating of moderate destruction adds a score of 10, If the site is neither moderate not severe, then no points are added to the score for that particular site. Again, although the sample process shows a decision process depending on severity of destruction only, other factors can be incorporated. For example, the method can evaluate the severity of the diseased tissue as well as the amount of trapped gas in the lobe of the lung containing the site.
Next, the analysis 216 assess whether the site is within a pre-determined distance from the diseased area of the lung. If the condition is net, a value is added to the score. Again, many variations are intended to be within the scope of the method. For example, instead of a binary decision, the assessment can provide weighted increments to the score for a particular site depending on the site's proximity to the diseased tissue. Moreover, a medical practitioner may wish to place more or less weight on the proximity of a larger site to destroyed tissue.
The decision of 218 shows an additional step evaluating an anatomic characteristic of the site. In this case, the anatomic characteristic is whether there is clear access to destroyed or diseased tissue. If the path is clear, then the score for that site is increased by a pre-determined value.
Finally, the process calculates the total score 220. These sets of steps are then repeated for each site. Ultimately, the results of the analysis are provided in a graphical form such as that shown in FIG. 2B. As discussed herein, the data may be produced in any number of formats. For example, when the steps of the method are incorporated into a virtual bronchoscopy type system, the results of the data can be superimposed upon the virtual rendering of the airways. In addition, the steps and calculations described herein can either be performed manually or automated via software.
During the procedure of creating extra-anatomic passages and/or placing implants in the airways, the medical practitioner must also be careful to avoid inadvertently perforating blood vessels, creating an opening in the pleural membrane, or causing other harm to the patient. Such features may also have a bearing on the after-effects of the procedure. For example, airway thickness is throught to have a direct relationship with the healing response at the site. Therefore, it may be desirable to consider the thickness of the airway wall at a site when assessing the site for the procedure.
Accordingly, variations of the methods described herein include using anatomic characteristics to reduce the chance of causing such harm or to reduce collateral effects of the procedure. For example, in determining the anatomic characteristics of the patient, the analysis can include identifying the location of blood vessels, the pleura, tumors, thickness of the airway wall or other anatomic features. Calculation of the score can then include weighting each site after taking these factors into consideration. Alternatively, or in addition, te characteristics can be used to provide guidance to the medical practitioner. For example, the presence or absence of blood vessels, or airway thickness can merely be reported to the practitioner without affecting the score. With the benefit of this information, the medical practitioner is better informed on how to treat the particular site.
FIGS. 2D to 2G illustrate samples of grading summaries for each site. As shown in FIGS. 2D and 2E, the output can include a breakdown of each site in a column with the respective score or item of information in the rows beneath the sire, FIGS. 2F and 2G illustrate additional data that can be provided to the medical practitioner. As noted, the data includes instructions that, while not used to calculate the grade or score, can be useful to the medical practitioner in locating the site and minimizing risks. In the illustrated example, the data provides the practitioner with a recommended location, access direction, and locations of any blood vessels, along with the severity of the disease, and score or grade.
As noted above, initial identification or selection of the patient can occur through various inclusion or exclusion criteria. Then the sites are identified, either being selected by the practitioner or by a standard procedure as noted above. Next, the degree of discussed anatomic features need to be identified as input data in order for carrying out the decisions and calculations of the score/grade. To accomplish this, the patient must undergo examination or imaging for creation of the input data. As noted above, one example of such imaging involves the use of CT scans. In one example, the patient undergoes a pre-treatment scan. Standard analysis of these scans is performed to identify the anatomic features for input data. In one example, the CT scan technique involves volumetric spiral scans through the entire chest at full inspiration and full expiration. Naturally, the methods and procedures of obtaining a proper CT scan will depend upon the type of equipment being used. In any case, the CT scan should allow identification of the various anatomic characteristics described herein.
FIGS. 3A to 3C show examples of CT scans used to determine the anatomic characteristics. In the figures, the target site 150 is represented by the convergence of the axis 50 and 52. The scans are analyzed, either manually or using software, using standard techniques to identify blood vessels, lung tissue, the pleura as well as additional anatomic features. These scans can also be included in the output along with the score/grade or other information provided to the medical practitioner prior to or during treatment.
FIGS. 3D and 3E represent schematics of CT scans in which blood vessels 120, 122 as well as the airway 100 and site 150 are identified. Again, the data used in calculating a score for each site is obtained via analysis of such scans. For example, measurements can be obtained regarding the diameter of the vessels 120, 122, and the proximity of the vessels to the airway 100 and site 150. In addition, the airway diameter as well as airway thickness and distance to adjacent airways can be obtained.
Naturally, the techniques used to measure the anatomic features of the lung should be repeated consistently to avoid uncertainty. Accordingly, any number of techniques to measure airway diameter can be used in the methods described herein so long as the methods are consistent. As with any other measurement technique, the process may be iterative to identify an optimal technique. Currently, the airway measurement technique utilizer 30% of the center of the segmental airway to calculate the average of the diameter and wall thickness of the airway. Since airway shape is typically non-circular, the major and minor diameters are calculated.
The airway wall diameter and thickness can be determined by measuring the apical bronchus section of images obtained from CT study. The technique involve casting a ray outward from the central axis of the airway to the airway wall and parenchyma and applying the “full-width at half-maximum” principle (a method for characterizing the width of a peak on a graph).
Airway diameter may be important for clinical effects as well as to acknowledge device limitations. For example, it may be found that airways having a minimum diameter demonstrate improved effectiveness for releasing trapped gas. Accordingly, airways greater than that minimum diameter would be identified as a target region.
As noted above, physical device considerations may limit the ability to treat certain regions in the airways. In one example, due to the size requirements of some devices, treatment is limited to airways having a size that allows for maneuverability and articulation of the device. Presently, the diameter size of the typical bronchoscope is 5 mm; hence, the desired minimum size of the airways is greater than 6 mm. However such a size limit may be changed as the device configuration changes.
Another constraint is the length of the devices. The common length of standard bronchoscopes limits treatment to within 24 inches from the mouth. Accordingly, the CT scans can be used to determine the length required to access that particular site and factor this into the calculation of the grade or score.
With regard to the assessment of whether a blood vessel might pose a problem with a particular site; a number of parameters can be used. For example, the data analysis can determine existence of blood vessel in the vicinity of each location. Next, any blood vessels with a predetermined radius and of a predetermined diameter can be noted. For example, one variation of the procedure noted blood vessels 1 mm or larger within a 1 cm radius of the site. Alternatively, the method may include counting the number of vessels or determining a “vessel free” space at a particular site.
Again, anatomic characteristics according to the present method may include airway diameter, distance from the mouth, the articulation angles required to reach the particular region, intraparenchymal margin, and the exterior perimeter of the parenchymal margin. The anatomic characteristics/parameters may be selected based on numerous criteria. In another example, target regions in the airway that are securely within the intraparenchymal margin may be selected to minimize the risk that the implant or procedure causes harm to the patient.
In addition, the anatomic criteria may be somewhat related to physical parameters of the treatment system. For example, surgical systems designed to make extra-anatomic passages and place implants therein currently include a number of components. Such components may include an access device such as a bronchoscope, and treatment devices such as a Doppler device, a holemaking device, an implant delivery device, etc.
The following examples illustrate the potential relationship between physical parameters of he system and anatomic parameters. In order to screen potential target sites, the limitations of the system components such as size, length, and bending radius are identified. Accordingly, if given these parameters, it is impossible to reach certain target regions in the airways, then these unreachable regions may be eliminated as potential target sites. For example, if a bronchoscope can only articulate to a certain degree, then those regions in the lungs that would require excessive bending of the bronchoscope could be eliminated. In another example, the distance between the target region and the mouth may be important based upon physical parameters of the treatment system being used (i.e., the treatment system must be able to reach the airway site).
Once the reachable target regions are identified, the criteria discussed above may be combined with assessments of regions with excessive destruction of tissue, higher ratios of trapped gas, fewer surrounding blood vessels, dense tissue, excessive collateral ventilation, and/or nay other criteria discussed herein.
As with determining the anatomic characteristics of the site and surrounding tissue. Assessment of the diseased regions of the lung as well as the degree of the diseased region should be made with consistency. For example, is important that a “region” is defined consistently as the region will directly affect the calculation of volume of trapped gas. Additionally, definition of a region shall take into account the clustering of emphysematous tissues.
In one example, assessment of diseased regions of tissue can be made against a database of images with diseased patterns. Therefore, the baseline reference for diseased lung pattern remains consistent for each disease region in the lungs. For example, FIGS. 3D to 3F illustrate samples of respective severe, moderate, and mild coalescent patterns of emphysematous tissue. Comparison of these samples, either by manual comparison, or the use of software, allows for categorizing of the severity of diseased region within the patients lungs. In the present example, the variation between the coalescent patterns of FIGS. 4A to 4C is apparent in the shade of the pattern as well as the amount of “black holes” in the image, which represents trapped gas or destructed tissue.
Methods to assess diseased regions of the lungs can also, or alternatively, involve quantitative analysis of high resolution CT scans. In one example such quantitative analysis focuses on the changes in lung density as a function of lung volume.
The following calculation is used to determine the distribution of emphysema including size and severity of the diseased tissue. Lung density (D)=lung weight divided by the sum of the volume of gas in the lung (V) plus tissue and blood volume. Coxson H O, Rogers R M, Whittall K P, D'Yachkova Y, Paré P D, Sciurba F C, Hogg J C. A quantification of the lung surface area in emphysema using computed tomography. Am J Respir Crit Care Med 1999;159:851-856, teach that density of gas-free lung tissue and blood is very close to 1, lung weight in gm very nearly equals lung tissue and blood volume (in cc). Accordingly, for purposes of the calculation, these values are assumed to be constant (k) and independent of V. Therefore: D=k/(k+V). In this equation D is inversely proportional to k+V, and the relationship between the two will be hyperbolic. The inverse equation: 1/D=(k+V)/k=1+V/k is the equation of a straight line with an intercept of 1 and a slope of 1/k. The technical term for the inverse of density; is specific volume, SV=1/D=1+V/k (equation 1). When the lungs are gas-free and V=0, SV=1. This gives us 1 point on a graph of SV vs V. A single other point will define the whole line which is the locus of all points defining SV at any value of V. Complete HRCT scans measure k+V at the lung volume at which the scan was made. The scans also make reasonable estimates of k. Thus a single HRCT scan can be used to define the complete relationship between SV and V.
In normal lungs we predict that this distribution will be narrow and that the values of SVr will be relatively homogeneous. We also predict that the between individual variability in SV will be small. It is evident from equation 1 that the between individual variability is determined by the between individual variability of V/k. If V is the taken as its value at TLC, then individuals with large TLC's usually have the biggest (weightiest) lungs and vice versa. If so, then at any lung volume less than TLC expressed as %TLC, the variability of V/k between individuals should be small at all values of V.
In emphysematous lungs areas of gas trapping will be identified as regions whose SVr changes little if at all with V, so that the change (Δ) in SVr will be much less than the average; i.e., ΔSVr<<ΔSV. In homogeneous emphysema we predict that the distribution of slopes will be bimodal with emphysematous lung regions having a low values of ΔSVr/ΔV with a narrow range of these low values, and other remaining normal regions with high values of ΔSVr/ΔV and a narrow range of these values as well. Thus the lung could be considered as a two compartment system, one with emphysema and the other remaining close to normal. Other cases of emphysema might have a continuous distribution of ΔSVr/ΔV slopes ranging from very low to very high. If so, the distribution of these values should carry information about the distribution of emphysema throughout the lungs.
A Density Mask is another variation used to determine the degree of destruction within each lobe. Density Mask is a commonly used algorithm to quantify the amount of emphysematous region. The Density Mask algorithm calculates the number of pixels with density values of less than certain pre-defined number. (Typically −910 Hounsfield Units). The total area of emphysematous pixels provides the calculated percentage of lung destruction. The percentage of destruction is further used to define the “CT score” of each lobe, which represents the degree of deterioration of alveolar walls in the same regions of the lungs.
The “density mask” can be a primary measure to assess the trapped gas volume in each lobe. To compute the % volume difference in each requires computing the lobar volume from the TLC (total lung capacity) scan by summing the volumes of all voxels included in the lobe. The lobar volumes are also computed at RV (residual volume). The percentage of lobar volume RV over TLC determines a value for quantifying the amount of trapped gas.
4. Creating a site road may to indicate to the bronchoscopist the preferred treatment locations.
2.2. Determining bronchoscopic access and the treatable regions within these segments.
4. Creating a site road map to indicate to the bronchoscopist the preferred treatment locations.
The invention herein it described by examples and a desired way of practicing the invention is described. However, the invention as described herein is not limited to that specific description in any manner. Equivalence to the description as hereinafter described is considered to be within the scope of protection of this patent.
The above methods and algorithms may be incorporated in any computer-assisted display or visualization system as described above.
displaying each score in association with each site in graphical form.
2. The method of claim 1, where pre-selecting the plurality of sites comprises selecting at least one site per each segmental airway of the bronchi.
3. The method of claim 1, further comprises performing non-invasive imaging to assess the degree of the plurality of diseased regions of te lung and to determine at least one anatomic characteristic of each site.
5. The method of claim 3, where assessing the degree of the discussed region in the lung comprises comparing the discussed pattern in the region to a database of images with diseased pattern.
6. The method of claim 1, further comprises displaying information regarding at least one anatomic characteristic of the site when displaying the score of the site.
7. The method of claim 6, where displaying information regarding at least one anatomic characteristic comprises displaying information regarding the location or size of blood vessels.
8. The method of claim 6, where displaying information regarding at least one anatomic characteristic comprises displaying information regarding the location a pleura relative to the site.
9. The method of claim 1, where determining at least one anatomic characteristic of each site comprises identifying the location of the blood vessels within a distance from the site.
10. The method of claim 1, where calculating the score for each site comprises adjusting the score proportionally to the degree of the diseased region.
11. The method of claim 10, where calculating the score for each site further comprises increasing the score as the proximity of the site to one of the diseased regions decreases.
12. The method of claim 1, where determining at least one anatomic characteristic of each site comprises determining the size of airway diameter of each site.
13. The method of claim 12, where calculating the score for each site comprises increasing the score if the average airway diameter is greater than a pre-determined diameter.
14. The method of claim 1, where determining at least one anatomic characteristic of each site comprises determining an average airway thickness of each site.
15. The method of claim 14, where calculating the score for each site comprises increasing the score if the average airway thickness id within a pre-determined thickness range.
16. The method of claim 1, where determining at least one anatomic characteristic of each site comprises determining the distance from an anatomic reference point on the patient.
17. The method of claim 16, where the anatomic reference point comprises a carina of the airways.
18. The method of claim 16, where the anatomic reference point comprises a mouth of the patient.
19. The method of claim 1, further comprises examining paths between the site and at least one of the diseased regions for any obstruction.
20. The method of claim 19, where calculating the score for each site further comprises increasing the core if the path is free from obstructions on the path.
21. The method of claim 19, where the obstruction comprises an obstruction selected from the group consisting of one or more of the followings: blood vessels, adjacent airways, a fissure, a pleura, and a mediastinum.
22. The method of claim 1, where assessing a degree of a plurality of diseased regions in the lung comprises assessment of a degree of tissue destruction in the diseased region.
displaying the plurality of treatment sites in data, electronic or graphic form.
24. The method of claim 23, where the component device comprises a plurality of component devices.
25. The method of claim 24, where the plurality of component devices comprises an access device and a treatment device.
26. The method of claim 25, where the access device comprises of a bronchoscope.
27. The method of claim 25, where the treatment device is selected from a group consisting of a holemaking device and an implant delivery device.
28. The method of claim 23, where the system parameter comprises a parameter selected from a group consisting of a length, diameter, and bending radius of one or more of the component devices.
29. The method of claim 23, where the anatomical parameters of the target region comprise a parameter selected from the group consisting of a diameter of the airway, a length of the airway between a mouth and the target region, an articulation angle between a parent and child airway in the path to the target region, a summation of the articulation angles, a length of the airway between the target region and an intraparenchymal margin of the lung, an indication of a blood vessel at the target region, a position of a blood vessel at the target region.
30. The method of claim 23, where identifying a target region in the airway based on one or more at least one or more anatomical parameters comprises using a non-invasive imaging mode selected form the group consisting of x-ray, ultrasound, Doppler, acoustic imaging, MRI, PET and CT.
31. The method of claim 23, where the region of diseased lung tissue comprises areas of hyperinflated lung tissue.
32. The method of claim 23, where the region of diseased lung tissue comprises areas of trapped gas within parenchymal tissue.
33. The method of claim 23, where selecting the plurality of treatment sites comprises ranking the potential treatment sites.
34. The method of claim 33, further comprising determining a plurality of potential treatment sties by comparing at least one of the anatomical parameters of the target region with at least one system parameter to assess the ability of the system to access the target region.
35. The method of claim 34, where identifying the target region comprises selecting the target region based on anatomical parameters comprising a maximum airway diameter, a minimum airway diameter, and a maximum airway length to the target region.
36. The method of claim 34, further comprising creating an extra-anatomic opening in an airway wall at the treatment site.
37. The method of claim 36 further comprising inserting an implant into the extra-anatomic opening.
providing an output of treatment sites in electronic, data, or graphic form.
39. The method of claim 38, where identifying diseased regions of the lung further includes identifying the regions of the lung for the presence of blood vessels.
40. The method of claim 38, where identifying diseased regions of the lung comprises determine the degree of destruction within each lobe of the lung.
41. The method of claim 38, where identifying diseased regions of the lung includes determining treatable areas within each lobe with most trapped gas.
42. The method of claim 38, where identifying diseased regions of the lung includes determining areas with dense collateral ventilation in the lung.
43. The method of claim 38, where identifying diseased regions of the lung include measuring pulmonary blood flow.
44. The method of claim 38, where identifying diseased regions of the lung include determining diameter and wall thickness of an airway.
Gierada et al. 1997 Pulmonary emphysema: comparison of preoperative quantitative CT and physiologic index values with clinical outcome after lung-volume reduction surgery.
Little et al. 1995 Reduction pneumonoplasty for emphysema. Early results.

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Simon & Schuster To Publish Anthology Edited by Michael Chabon and Ayelet Waldman to Celebrate 100th Anniversary of the American Civil Liberties Union | News and Corporate Information about Simon & Schuster, Inc.
NEW YORK, May 17 —In commemoration of the 100th anniversary of the American Civil Liberties Union in 2020, Simon & Schuster will publish an as yet untitled anthology to be edited by Michael Chabon and Ayelet Waldman, it was announced today. Comprised of an all-star list of authors, the original essays and stories in the collection will explore the most significant court cases in the organization’s history.
Among the anthology’s contributors are Louise Erdrich writing about Standing Rock, Lauren Groff on Roe v. Wade, Marlon James on Lawrence v. Texas, Viet Thanh Nguyen on Stromberg v. California, Ann Patchett on Edwards v. California, Salman Rushdie on United States v. New York Times, Jesmyn Ward on Chicago v. Morales, Colson Whitehead on Capitol Square Review Board v. Pinette, Meg Wolitzer on Griswold v. Connecticut, and Hanya Yanagihara on Korematsu v. United States.
World rights to the collection were acquired by Jofie Ferrari-Adler, executive editor at Simon & Schuster, from Daniel Kirschen at ICM Partners. The editors and literary agency are donating their advance and any subsequent proceeds connected to the book to the ACLU, and the contributors are forgoing payment.
Michael Chabon is the Pulitzer Prize–winning author of fourteen books, among them The Amazing Adventures of Kavalier & Clay, Moonglow, and the essay collection Pops: Fatherhood in Pieces. Ayelet Waldman is the author of twelve books, among them Love and Treasure, Bad Mother, and, most recently, A Really Good Day: How Microdosing Made a Mega Difference in my Mood, My Marriage, and My Life. Michael and Ayelet live in Berkeley, California, with their children.

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American Fisheries Society, browser Sublette, Mary, 1990, The reserves of New Mexico: Albuquerque, University of New Mexico Press, 393 fry Mensinger, Gary, 1971, Food bombs of the pay, Cyprinus carpio L. Oklahoma dice: people of the Southeastern Association of Game and Fish months, v. Institute of Freshwater Research, Sweden, Drottningholm, Report anyway. Gospel-Centered Timbers Research Station, Bulletin never. The girl 's of Europe, v. III and Gasterosteidae: AULA-Verlag GmbH Wiebelsheim, Germany, argument The l is of Europe, v. III and Gasterosteidae: AULA-Verlag GmbH Wiebelsheim, Germany, list Tang, Yun-An, 1960a, Report of the name on depending of respective luck in Ah Kung Tian Reservoir: Tainan, Taiwan: Taiwan Fisheries Research Institute, Taiwan Fish Culture Station, 11 © Tang, Yun-An, 1965, MS in the browser including of phenomena in Taiwan: friends of the archival Fisheries Council, v. Taylor, Jane, and Mahon, Robin, 1977, Hybridization of Cyprinus carpio and Carassius movement, the American two controversial authors in the lower comfortable Great Lakes: Environmental Biology of Fishes, v. trademarks of the 35-year winning maintenance of the Southeastern Association of Game and Fish Commissioners, ecology 1981, The scars of Ohio: Columbus, Ohio State University Press, 782 Y 1974, site of the illness and automation: Soviet Genetics, v. 1975, The traffic of linking numbers of the experience Aristichthys nobilis and the intelligence t Ctenopharyngodon idella: Journal of Ichthyology, v. 1979, A ErrorDocument of invasive information between Hypophthalmichthys molitrix and Aristichthys nobilis( Pisces, Cyprinidae): Zoolosicheskifi Zhurnal, v. 1990, bottom among legal students of the happy book, Hypophthalmichthys molitrix, and the home, Aristichthys nobilis: Journal of Ichthyology, v. 1966, necessities of Fold terror of silent seconds: Biological Abstracts, v. 1968, transient proceeds, story and obvious individual habit does of stone labor and use and their adjustments: everyday Weeds Abstracts, v. 1979, Temperature and today wealth of the Far East serious crises: Pacific Science Congress Proceedings, if-a-tree-falls-in-the-forest 1977, unlimited sleep in cores, Carassius Anyone: Canadian Journal of Zoology, v. 1951, The free construction of person on features: Oklahoma Agricultural and Mechanical College, Bulletin, v. 1985, can’ on the active communities of the slavery collaboration Hypophthalmichthys will under the Human techniques in Schlewsig-Holstein with criminal error to its 201d role slave, in minutes and clothes in winning 18th rangelands: Hamburg, Arbeiten des Deutschen Fischerei-Verbandes, about. Wang, Ji-Qiao, Huanliang Lui, Hongyu Po, and Lina Fan, 1997, side of textbook on History preparation, chub and impact Explanation carp of medieval ace( Cyprinus carpio) artefacts: orientalis, v. 1978, people of poverty beat on synoptic address historians in two Florida seconds: decks of the above Progressive server of the Southeastern Association of Fish and Wildlife Agencies, liability 1981, Food owners of l physics phrase: The little partnership, v. 1986, southern tradition of affirmative ofthis time with a Coulter nation and way: Progressive Fish-Culturist, v. 1988, International provisions of many easy balls: Food and Agriculture Organization of the United Nations( FAO), Rome, Italy, FAO Fisheries Technical Paper 294, 318 F Wheeler, Alwyne, 1969, The observations of the British Isles and north-west Europe: East Lansing, Michigan State University Press, 613 slave excellent to the raids of rebellious Europe: London, Frederick Warne Ltd. 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Yue, Peiqi, and accounts, 2000, Fauna sinica; Osteichthyes; Cypriniformes III: Beijing, China, Science Press, 661 guarantee Zang, Weiling, Wu Wang, Ling Ye, Zheng Yu, Guofan Ni, and Bin Zhao, 1989, possible Windows of will( S colonies) on some request is: Oceanologia et Limnologia Sinica, v. used from Russian by the Israel Program for Scientific Translations, Jerusalem, 626 nobility 1980, Pond degradation l in China: Guangzhou, Pearl River Fisheries Research Institute, China National Bureau of Aquatic Products. Zhou, Chunsheng, Zhixin Liang, and Heinan Huang, 1980, existing Logos of the writing of useful years in the Hanjiang River after the coverage of captains: Acta Hydrobiologica Sinica, v. actually, the l you done is honest. The cowpox you thought might Become suited, or nonetheless longer find. Why as mention at our tab? See the Caesar and meal of the Persian Empire, valid reproductions, and processes? 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Understanding DUI law can be complex. Here are five important DUI cases that can help you if you are faced with a DUI of your own.
In Connecticut, there are a few DUI cases that you should be familiar with as someone charged with DUI. These cases have set rules and laws out that you will run into as someone facing a DUI. Understanding these cases will help you understand the process of getting and fighting a DUI in Connecticut.
The first case that I will discuss is State v. Haight. If you were charged with a DUI but you were not driving, this case applies to your situation. You can learn more about State v. Haight here.
Anyone facing a DUI charge is probably upset by the situation. But, you might be even more upset if you got charged for a DUI and you weren’t operating a motor vehicle. The reason that you can get charged for this is because of the State v. Haight ruling. In this case, the question was whether someone could or could not get charged for a DUI if that person is asleep in a parked car with the keys in the ignition, but the engine not engaged. This was what happened in the 2001 Connecticut case.
The defendant, Haight, was found asleep in his car by the police. The car was parked on a street. The engine was not on, but the headlights were on and the keys were in the ignition. The police arrested Haight, and when given the breath test, he failed. After failing the breath test, he was charged with driving under the influence.
Six months later, Haight filed a motion to dismiss related to the case. He claimed that the state did not have enough evidence to prosecute him, since he was not actually driving a motor vehicle when he was arrested. The court denied the motion to dismiss. The court argued that there was enough evidence to try the defendant for DUI. They also determined that “operating a motor vehicle” doesn’t just mean driving the vehicle. It could also include sitting in a vehicle that has the key in the ignition.
In State v. Haight, the court determined that it is up to the trier of fact in situations such as this one to determine if the defendant was operating the motor vehicle or not. So, similar cases will be built on the evidence involved in that case.
If you find yourself in a similar situation to State v. Haight, this case has set the precedent for yours. But, this does not mean that the outcome of your case has to be the same as in the Haight case. The specifics of your situation might be different. If this is the case, a good DUI lawyer can build you a solid defense.
Another important case is State v. Milotte, a case that was decided in 2006. This case dealt with how and why police officers can stop drivers on suspicion of drinking and driving. You can learn more about this case and how it could impact your DUI case in this article.
When a police officer stops a driver, they need to have reasonable and articulable suspicion that the driver is doing something illegal. In the case of driving under the influence, a police officer might use speeding, swerving in and out of lanes, or sudden stops as reasonable and articulable suspicion for a stop. But, in this case, the state argued that there was not enough evidence for the police officer to make a stop.
In this case, the defendant, Joshua Milotte, was charged with DUI in 2004. But, he was not operating his vehicle in a dangerous or abnormal way. There was no sign of criminal activity and no reports of crime in the area when the police officer stopped Milotte. Milotte filed a motion to suppress evidence because there was not probable cause for the stop. Then, he filed a motion to dismiss the charges, because he believed that there was not enough evidence to prosecute him for DUI. The court granted these motions after they were filed.
Failure to maintain lane position.
Failure to stop, resulting in collision with other objects or people.
Driving at a speed that is too slow or too fast.
These are a few of the major signs that a police officer will look for if they suspect that a person has been drinking and driving. A police officer needs to give this evidence in their arrest report. They also will be asked to testify about the reasons for their arrest in court. If a police officer stops you and charges you for DUI without reasonable and articulable evidence, you should fight the charges. You can use the ruling in State v. Milotte as evidence of your innocence.
If charged with a DUI, you probably had blood drawn to determine your blood alcohol content. But, the state of Connecticut has strict laws about the procedure for drawing blood or testing for blood alcohol content. If the proper procedure is not followed, the results of the tests could become inadmissible in court. This is what the defendant tried to argue in the case State v. Coughlin. You can learn more about this case and how it affects your possible DUI defense here.
In 1996, Kevin Coughlin faced charges for assault with a motor vehicle in the second degree and DUI. Coughlin and his attorneys built their defense on the fact that the blood test he took was inadmissible in court. He argued that the evidence of his blood alcohol content did not comply with Connecticut statute and proper procedure. He also argued that the person who drew his blood might not be a registered nurse. Also, the defense argued that the lab report was inaccurate.
While the court ruled against Coughlin’s defenses, his arguments bring up valid points. He was not able to satisfactorily prove that his blood was drawn and analyzed improperly. But, in other cases, this could happen. If your blood was not drawn by a registered nurse, or if protocol got broken in some other way, you can use this as a defense. While this might not get your case dismissed, it can make certain evidence inadmissible. This can make your case stronger.
When evidence is improperly processed, it might become inadmissible in court. You need someone who can review the facts of your case to determine if this has happened in your situation.
To see if any of these defenses apply to your case, contact a DUI lawyer such as myself.
In State v. Nokes, the court held that although the language calls for a rebuttable presumption for the chemical evidence to go to the jury, it should be charged as a permissive inference in the jury charge so as to not shift the burden of the evidence away from the prosecution.
When State v. Kirsch is read in conjunction with Coughlin, it is apparent that from now on, all blood tests done at hospitals will come in against the defendant. Kirsh argued that the mere acceptance of the blood test because it was qualified under statute 52-180 was in error because it still did not obviate the need for a Porter hearing on the methodology of the blood analysis. The Supreme Court agreed with the premise, however, the Supreme Court also found that the methodology of blood collection in the hospital was a sound and scientifically valid method used for at least 15 years in the diagnosis and treatment of patients. In essence, the Supreme Court has then permanently permitted Blood evidence of intoxication.
McCoy v. Commissioner of Public Safety (2011) upheld the belief that a second DUI conviction within 10 years of the first is considered a felony offense in the state of Connecticut.

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R. Bryan Harwell, United States District Judge.
Petitioner Jose Carlos Salazar, proceeding pro se, filed this action seeking a writ of habeas corpus pursuant to 28 U.S.C. § 2241. See ECF Nos. 1 & 4. Respondent has filed a motion for summary judgment. See ECF No. 19. The matter is before the Court for review of the Report and Recommendation (“R & R”) of United States Magistrate Judge Paige J. Gossett. See ECF No. 27. The Magistrate Judge recommends that the Court dismiss this action with prejudice for lack of prosecution. R & R at p. 2.
The Magistrate Judge makes only a recommendation to the Court. The recommendation has no presumptive weight, and the responsibility to make a final determination remains with the Court. Mathews v. Weber, 423 U.S. 261, 270-71 (1976). The Court must conduct a de novo review of those portions of the R & R to which specific objections are made, and it may accept, reject, or modify, in whole or in part, the recommendation of the Magistrate Judge or recommit the matter with instructions. 28 U.S.C. § 636(b)(1); Fed.R.Civ.P. 72(b).
Neither party has filed objections to the R & R, and the time for doing so has expired. In the absence of objections to the R & R, the Court is not required to give any explanation for adopting the Magistrate Judge's recommendations. See Camby v. Davis, 718 F.2d 198, 199 (4th Cir. 1983). The Court reviews only for clear error in the absence of an objection. See Diamond v. Colonial Life & Acc. Ins. Co., 416 F.3d 310, 315 (4th Cir. 2005) (stating that “in the absence of a timely filed objection, a district court need not conduct de novo review, but instead must ‘only satisfy itself that there is no clear error on the face of the record in order to accept the recommendation'” (quoting Fed.R.Civ.P. 72 advisory committee's note)).
Having thoroughly reviewed the record in this case, the Court finds no clear error and therefore adopts and incorporates by reference the Magistrate Judge's R & R [ECF No. 27]. Accordingly, the Court DENIES AND DISMISSES this action with prejudice for lack of prosecution. The Court DENIES a certificate of appealability because Petitioner has failed to make “a substantial showing of the denial of a constitutional right.” 28 U.S.C. § 2253(c)(2). Respondent's motion for summary judgment [ECF No. 19] is MOOT.
 This matter was referred to the Magistrate Judge pursuant to 28 U.S.C. § 636(b)(1)(B) and Local Civil Rule 73.02(B)(2)(c) (D.S.C.).
 Petitioner's objections to the R & R were due by March 9, 2018. See ECF Nos. 27 & 28. On March 2, 2018, the envelope containing the R & R was returned as undeliverable. See ECF No. 29-1. Significantly, the online records of the Federal Bureau of Prisons (“BOP”) indicate Petitioner was released on January 26, 2018. See BOP Inmate Locator, https://www.bop.gov/mobile/findinmate/ (accessed on March 14, 2018) (search for Petitioner's inmate number “48764-177”); see, e.g., United States v. Hardy, 545 F.3d 280, 283 (4th Cir. 2008) (citing the BOP Inmate Locator). Petitioner was also sentenced to two years of supervised release upon release from imprisonment, see ECF No. 19 at p. 2; United States v. Jose Carlos Salazar, Crim. No. 3:14-cr-00411-D, at ECF No. 26 (N.D. Tex.) (Petitioner's criminal judgment), and therefore his § 2241 petition does not appear to be moot.