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Motorola Droid on Page Plus
It was time for me to upgrade from the Samsung Saga. It's been nice, but the old Windows Mobile is lacking in features that the modern phones have. I've wanted a Droid ever since they've come out, but the original price was about $500 or $200 with a 2 year contract with Verizon (and then we're back to being locked to a data plan that I have no interest in). Well now, it's been almost 2 years since the Droid was released and people are coming to the end of their contracts. It's about that time they usually want to upgrade their phone, which means you can find these older phones on EBay.
I picked up a used Droid for $60 shipped. It was in decent shape (no damage to the keyboard or LCD, but normal wear on the case). I purchased a 16 GB microSD card on sale from TigerDirect for $20 and a cable pack (since the auction I won didn't come with the USB cable) for $6 on EBay which came with the USB sync cable, another wall charger, and a car charger. I used another ESN transfer service that I found on EBay for $1.99 and started using the Droid. All-in-all, I'm about $90 into the phone with 16 GB of storage, 2 wall chargers, a USB sync cable, and a car charger. For a phone that retailed brand new for about $500 2 years ago, that's not too bad.
I have to preface this next portion with the following statement: This is my first experience owning an Android device. Prior to this point, I've only owned non-Smartphone cell phones, 2 Windows Mobile phones (the 6 series), and an IPod Touch. I've seen what Android powered devices could do, so I knew this would work well for what I needed to use it for. The difference between Windows Mobile 6 to iOS was huge, but the jump to Android is incredible. You can jailbreak an iOS device and you'll get more freedom, but rooting an Android device with it's own keyboard is like having a miniature, mobile computer in your pocket that you customize any way you want.
However, there are few things that make me a little uneasy about the Droid. I've heard random noise about security concerns in Android, but never really read into the issues in depth. One thing that I noticed right away is that Android doesn't encrypt any data on the microSD card by default. That made me very reluctant to store any application data on the SD card at all. In the event your phone was stolen, anything that an android application stores on the microSD card would be accessible simply by removing the card and inserting it into a PC. That alone was reason enough to be certain nothing sensitive was stored on the microSD card. I've had several discussions about this with friends and co-workers ever since I found out about this and I still feel Android should have an option to encrypt SD card data (apparently others feel the same). Windows Mobile 6 even had this feature.
After researching the encryption on the microSD card, I then started to question how the apps share data, and found articles regarding certain apps that had been caught reading data stored by other apps. I had always known there was an issue with malicious apps in the Android Market and the iTunes store, but legitimate apps stealing data from other legitimate apps? That's not cool at all… So, this made me very picky as to what apps I was going to install. There are also ways to exploit Android to extract data. One such attack can be done using an XSS bug on an Android 2.2 device that will allow the attacker access to the SD card (video demonstration using XSSF in Metasploit).
To take the same approach that I have taken for the last few years (which is find the cheapest cell phone service that doesn't require a dataplan) WIFI on the phone was a must and the ability to install quality offline applications (that don't require access to the Internet). After some research, I decided Page Plus is still the best value for the service (1200 Talk n' Text with 100 MB of Data for $29.99 is the best and most affordable plan I've seen). I used Kitty Wireless to do the ESN Change (it was $1.99 on EBay). Some apps that I found that were highly recommended are MapDroyd (which allows offline GPS), WikiDroyd (offline Wikipedia reader), and FBReader (popular free e-book reader), MoboPlayer (free video player), and Opera Web Browser for android.
Overall, my impressions of the phone itself is good. Call quality on the Droid is about the same as the Samsung Saga (slightly better). The accelerometer behavior during a call took a little getting used to, but easy to adapt to. It's very easy to turn on/off the data plan, as well as disable Auto-sync or Background data traffic of the applications. Easy to move apps to different home screens. My only complaint of the hardware is the keyboard. The keyboard doesn't quite feel right and takes a little getting used to. The keys themselves are glued on to a press button keypad and one of the keys has already come off. I've come accustomed to the raised button keyboard of the Samsung Saga, so the flat keypad is a step down in my opinion. CNet did a nice video review for more information on the phone.
The TL;DR version of this post: So far, the Motorola Droid on Page Plus works well and I'm satisfied. I like the Droid more than any other mobile device that I have used in the past. I plan on doing a few posts regarding this phone and/or the Android OS as I'm getting used to all that it can do.
8 Responses to Motorola Droid on Page Plus
Charlotte says:
My service provider is ATT. I have an old Razor Phone that doesn't require data service. I want to stay with ATT, I don't want a data service plan nor do I want to do anything with my phone but talk. Are there any new phones that don't require data service and how do recognize one when I see it?
Nokia phones have the best reception in the rural area where I live. -
Chris says:
Try checking the ATT wireless website or call their customer service. They should be able to point you in the right direction. -
Kalpesh says:
Hi Chris,
Great information.
I also need smart phone but with no data plan.
What kind of phone Do I need to buy to work with pageplus?It must be verizon supported?
any unlocked android phone will do?If you could provide details or point me to right direction that would be great.
Thank You,
Kalpesh -
Chris says:
I put together a page with links that have more information on page plus. Look at this page. -
Andrew says:
Chris, was the droid you bought on ebay unlocked? If so, what service did you use to unlock it? I just bought one on ebay, clean esn, but locked. I'd like to port to Page Plus, just not sure if I even need to unlock it.
Chris says:
You shouldn't have to Unlock it. Use an ESN transfer service (you can find them all over on EBay) and they will take care of it for you. -
Jasmine says:
Hi Chris, I really appreciate your comment on all the information that you have researched. I am also looking for a cell phone with out data plan and must have talking gps plan.
Do you have any idea?
Have a very happy New Year!
Josh says:
Are you continuing this endeavor? Seems like as we get farther along having a WIFI only phone is less and less possible.
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US 20030233132 A1 Abstract A cardiac rhythm management device is configured to detect mechanical oscillations in cardiac rhythm. Upon detection of such oscillations, the device may adjust its operating behavior to compensate for the deleterious effects of the condition.
Claims(25) 1. An implantable cardiac rhythm management device, comprising:
an exciter for generating an excitation current between excitation electrodes; voltage sense electrodes for generating an impedance signal corresponding to cardiac volume when the excitation current is applied; and circuitry for processing the impedance signal to detect oscillations in cardiac volume during successive heart beats and to detect volumetric alternans when the measured oscillations exceed a specified magnitude for a specified number of beats. 2. The device of
3. The device of
a first atrial pacing channel;
a second atrial pacing channel; and,
wherein the controller is programmed to deliver pacing therapy in accordance with a bradycardia mode, and further wherein the controller is programmed to initiate atrial resynchronization pacing by delivering paces through both atrial channels when volumetric alternans is detected.
4. The device of
a sensing/pacing channel; and
wherein the controller is programmed to deliver pacing therapy in accordance with a bradycardia mode, and further wherein the controller is programmed to decrease a programmed pacing rate when volumetric alternans is detected.
5. The device of
a sensing/pacing channel; and
wherein the controller is programmed to deliver anti-tachycardia pacing therapy when a measured heart rate exceeds a specified tachycardia threshold rate, and further wherein the controller is programmed to decrease the tachycardia threshold rate when volumetric alternans is detected.
6. The device of
a first ventricular pacing channel;
a second ventricular pacing channel; and
wherein the controller is programmed to deliver pacing therapy in accordance with a bradycardia mode, and further wherein the controller is programmed to initiate ventricular resynchronization pacing by delivering paces through both ventricular pacing channels when volumetric alternans is detected.
7. The device of
a first ventricular pacing channel;
a second ventricular pacing channel; and
wherein the controller is programmed to deliver ventricular resynchronization pacing by delivering paces through both ventricular channels, and further programmed to adjust a resynchronization operating parameter when volumetric alternans is detected.
8. The device of
9. The device of
10. The device of
a ventricular pacing channel; and
wherein the controller is programmed to initiate ventricular resynchronization pacing by delivering left-ventricular only pacing when volumetric alternans is detected.
11. The device of
a plurality of ventricular pacing channels; and
wherein the controller is programmed to initiate ventricular resynchronization pacing by delivering multi-site pacing to the left ventricle when volumetric alternans is detected.
12. A method for operating an implantable cardiac rhythm management device, comprising:
generating an excitation current between excitation electrodes; generating an impedance signal corresponding to cardiac volume when the excitation current is applied; and processing the impedance signal to detect oscillations in cardiac volume during successive heart beats and to detect volumetric alternans when the measured oscillations exceed a specified magnitude for a specified number of beats. 13. The method of
14. The method of
15. The method of
16. The method of
17. The method of
18. The method of
19. The method of
20. The method of
21. The method of
22. The method of
23. The method of
24. A cardiac rhythm management device, comprising:
means for detecting an oscillation in cardiac rhythm when alternations in a measured cardiac parameter during successive heart beats exceed a specified magnitude for a specified number of beats; and a controller programmed to deliver drug therapy upon detection of a cardiac rhythm oscillation. 25. A cardiac rhythm management device, comprising:
means for detecting an oscillation in cardiac rhythm when alternations in a measured cardiac parameter during successive heart beats exceed a specified magnitude for a specified number of beats; first and second pacing channels; a controller programmed to deliver pacing therapy; and wherein the controller is programmed to initiate pre-excitation pacing therapy when an oscillation in cardiac rhythm is detected. Description [0001] This patent application pertains to methods and apparatus for cardiac rhythm management. In particular, it relates to the detections of oscillations in heart rhythm and its use by a cardiac rhythm management device. [0002] Cardiac rhythm refers to the temporal pattern of electrical or mechanical activity in the heart. Cardiac rhythm management devices are implantable devices that provide electrical stimulation to selected chambers of the heart in order to treat disorders of cardiac rhythm. An implantable pacemaker, for example, is a cardiac rhythm management device that paces the heart with timed pacing pulses. The most common condition for which pacemakers are used is in the treatment of bradycardia, where the ventricular rate is too slow. Atrio-ventricular conduction defects (i.e., AV block) that are permanent or intermittent and sick sinus syndrome represent the most common causes of bradycardia for which permanent pacing may be indicated. If functioning properly, the pacemaker makes up for the heart's inability to pace itself at an appropriate rhythm in order to meet metabolic demand by enforcing a minimum heart rate. Cardiac rhythm management devices may also be used to treat tachyarrhythmias where the heart rhythm is too fast. In a type of pacing therapy called anti-tachycardia pacing, one or more pacing pulses are output during a cardiac cycle in an effort to interrupt the reentrant circuit causing a tachycardia. Other tachyarrhythmias such as fibrillation can be treated by devices that deliver a cardioversion/defibrillation shock when the tachyarrhythmia is detected. [0003] Also included within the concept of cardiac rhythm is the manner and degree to which the heart chambers contract during a cardiac cycle to result in the efficient pumping of blood. For example, the heart pumps more effectively when the chambers contract in a coordinated manner. The heart has specialized conduction pathways in both the atria and the ventricles that enable the rapid conduction of excitation (i.e., depolarization) throughout the myocardium. These pathways conduct excitatory impulses from the sino-atrial node to the atrial myocardium, to the atrio-ventricular node, and thence to the ventricular myocardium to result in a coordinated contraction of both atria and both ventricles. This both synchronizes the contractions of the muscle fibers of each chamber and synchronizes the contraction of each atrium or ventricle with the contralateral atrium or ventricle. Without the synchronization afforded by the normally functioning specialized conduction pathways, the heart's pumping efficiency is greatly diminished. Patients who exhibit pathology of these conduction pathways, such as bundle branch blocks, can thus suffer compromised cardiac output. [0004] Heart failure refers to a clinical syndrome in which an abnormality of cardiac function causes a below normal cardiac output that can fall below a level adequate to meet the metabolic demand of peripheral tissues. It usually presents as congestive heart failure (CHF) due to the accompanying venous and pulmonary congestion. Heart failure can be due to a variety of etiologies with ischemic heart disease being the most common. Some heart failure patients suffer from some degree of AV block or are chronotropically deficient such that their cardiac output can be improved with conventional bradycardia pacing. Such pacing, however, may result in some degree of discoordination in atrial and/or ventricular contractions because pacing excitation from a single pacing site spreads throughout the myocardium via the conducting muscle fibers of either the atria or the ventricles, and not the faster specialized conduction pathways as in a physiological heart beat. Most pacemaker patients can still maintain more than adequate cardiac output with artificial pacing, but the diminishment in cardiac output may be significant in a heart failure patient whose cardiac output is already compromised. Intraventricular and/or interventricular conduction defects are also commonly found in heart failure patients and can contribute to cardiac dysfunction by causing unsynchronized contractions during intrinsic beats. In order to treat these problems, cardiac rhythm management devices have been developed that provide electrical pacing stimulation to one or more heart chambers in an attempt to improve the coordination of atrial and/or ventricular contractions, termed cardiac resynchronization therapy. [0005] The present invention relates to an implantable cardiac rhythm management device that is configured to detect oscillatory behavior in the rhythm of the heart as reflected by alternations in measured cardiac volume during successive heart beats, referred to herein as volumetric alternans. Volumetric alternans is indicative of alternations in the strength of systolic contractions and pulse pressure, a condition known as pulsus alternans. Pulsus alternans is generally taken by clinicians to indicate systolic dysfunction and possible heart failure. A cardiac rhythm management device may therefore also be configured to compensate for the decrease in cardiac output when volumetric alternans is detected by initiating or modifying the delivery of cardiac resychronization therapy. Pulsus alternans is also highly correlated with oscillations in the electrical activity of the heart, called electrical alternans. Since electrical alternans is known to be potentially arrhythmogenic, the device may be further configured to adjust its operation when volumetric alternans is detected to deal with this situation. Such operational adjustments may relate to the manner in which either bradycardia pacing or anti-tachycardia pacing is delivered. [0006] In alternative embodiments, alternations in the amplitudes of heart sounds or alternations in detected electrical activity are used as surrogates for pulsus alternans. Also, an oscillatory heart rhythm may be indicative of cardiac ischemia in certain patients. An implantable device may therefore be configured to deliver drug therapy or pre-excitation pacing when triggered to do so by detection of an oscillatory rhythm. [0007]FIG. 1 is a system diagram of an exemplary cardiac rhythm management device. [0008]FIG. 2 illustrates an exemplary algorithm for detecting volumetric alternans. [0009]FIG. 3 illustrates pulsus alternans with accompanying acoustic alternans. [0010]FIG. 4 illustrates an exemplary implementation of an algorithm for detecting acoustic alternans. [0011]FIGS. 5A and 5B are exemplary electrogram waveforms that exhibit electrical alternans. [0012]FIG. 6 illustrates an exemplary implementation of an algorithm for detecting electrical alternans. [0013] Under certain conditions, some individuals exhibit oscillations in the mechanical function of the heart that result in alternations in pulse pressure, referred to as pulsus alternans. Pulsus alternans is generally taken by clinicians to indicate systolic dysfunction, particularly in the left ventricle. It would be useful for an implanted cardiac rhythm management device to be able to detect this condition when it arises so that the presence of the condition can be communicated to a clinician and, as explained below, so that the operating behavior of the device can be adjusted appropriately. Direct detection of blood pressure by an implantable device, however, is problematic. The present invention provides a method for detecting pulsus alternans by using alternations in certain measured quantities during successive heart beats as surrogates for pulsus alternans. [0014] One way of detecting pulsus alternans is to measure the heart blood volume on a beat-to-beat basis. As described below, such measurement of heart volume may be accomplished by an electrical impedance technique. Pulsus alternans refers to an alternation in mechanical function where one contraction is strong and the next is weak. In heart failure patients especially, this mechanical alternation is related to corresponding alternations in heart volume, referred to herein as volumetric alternans. In a typical heart failure patient, the ventricles are very non-compliant or stiff so that end diastolic volume is nearly constant irrespective of variations in diastolic filling pressure. On a strong beat, cardiac cells undergo a stronger contraction and shorten more. Conversely, on a weaker beat, the cardiac cells shorten less. If the end diastolic volume is constant, the increased shortening on the strong beat leads to a smaller end systolic volume, and the lessened shortening on the weak beat causes a larger end systolic volume. The heart volume, as represented by end diastolic volume or stroke volume, thus alternates in correspondence with alternations in mechanical function. [0015] Detection of pulsus alternans using volumetric alternans as a surrogate allows an implanted cardiac rhythm management device to track the progression of heart failure in the patient (since the frequency and magnitude of pulsus alternans tends to increase with with worsening heart failure) and to adjust its operation when volumetric alternans is detected. As noted above, certain cardiac rhythm management devices are designed to deliver pacing therapy in a manner that improves the coordination of both ventricles (or both atria) during systolic contractions, termed cardiac resynchronization therapy. The presence of pulsus alternans in such patients indicates that systolic function has been further impaired, and it may be beneficial for a device configurable for delivering resynchronization pacing to adjust its operating parameters to compensate for this when volumetric alternans, serving as a surrogate for pulsus alternans, is detected. For example, a device may be configured to deliver bradycardia pacing to one ventricle in a conventional manner or even no pacing under normal conditions. If volumetric alternans is detected, however, the device may be programmed to initiate resynchronization therapy by, for example, pacing both ventricles or one ventricle at multiple sites. In another embodiment, a device configured to deliver resynchronization pacing during normal conditions may adjust one or more operating parameters when volumetric alternans is detected so that the resynchronization pacing is modified. Examples of operating parameters that may be so adjusted are the biventricular delay interval between paces delivered to the right and left ventricles and the atrio-ventricular delay interval between an atrial pace or intrinsic sense and a subsequent ventricular pace. [0016] The pattern of electrical excitation of the human heart may also exhibit oscillations during successive heart beats. This phenomena is referred to as electrical alternans and is usually indicative of a pathological state in which potentially dangerous cardiac arrhythmias are more likely to occur. Since the pumping action of the heart is due to the electromechanical coupling between electrical depolarization of myocardial cells and their mechanical contraction, electrical alternans and pulsus alternans may be different manifestations of the same underlying phenomena in certain cases. In any event, detection of volumetric alternans means that it is highly probable that electrical alternans is also present. Since the presence of electrical alternans in an individual may indicate that an arrhythmogenic condition exists, it may be deleterious for an implantable cardiac rhythm management device to deliver its therapy to the patient in a normal manner under such circumstances. An implantable cardiac rhythm management device that detects volumetric alternans in the manner described above may therefore also be configured to adjust its operating behavior when alternans is detected to deal with the arrhythmogenic condition. Such a device may deliver any kind of cardiac rhythm management therapy to the patient during normal conditions including bradycardia pacing, anti-tachycardia pacing, and/or cardioversion/defibrillation. Since it is known that electrical alternans occurs above a critical threshold heart rate, for example, bradycardia pacing at a rate above that critical threshold when electrical alternans is present may aggravate the situation. In one embodiment, a device configured to deliver bradycardia pacing adjusts its pacing rate to a lower value when volumetric alternans is detected. Rapid heart rates may also more readily trigger arrhythmias when an arrhythmogenic condition is present. In another embodiment, a device configured to deliver anti-tachycardia pacing lowers the threshold heart rate at which such therapy is initiated when volumetric alternans is detected in order to reduce the probability of an arrhythmia occurring. [0017] 1. Exemplary Hardware Platform [0018] Cardiac rhythm management devices are usually implanted subcutaneously or submuscularly on a patient's chest and have leads threaded intravenously into the heart to connect the device to electrodes used for sensing and pacing. Leads may also be positioned on the epicardium by various means. A block diagram of a multi-site pacemaker having three sensing/pacing channels is shown in FIG. 1. (As the term is used herein, a �pacemaker� should be taken to mean any cardiac rhythm management device, such as an implantable cardioverter/defibrillator, with a pacing functionality.) Pacemakers sense intrinsic cardiac electrical activity by means of internal electrodes disposed near the chamber to be sensed. A depolarization wave associated with an intrinsic contraction of the atria or ventricles that is detected by the pacemaker is referred to as an atrial sense or ventricular sense, respectively. In order to cause such a contraction in the absence of an intrinsic beat, a pacing pulse (either an atrial pace or a ventricular pace) with energy above a certain pacing threshold is delivered to the chamber. The controller of the pacemaker is made up of a microprocessor 10 communicating with a memory 12 via a bidirectional data bus, where the memory 12 comprises a ROM (read-only memory) for program storage and a RAM (random-access memory) for data storage. The controller can be implemented by other types of logic circuitry (e.g., discrete components or programmable logic arrays) using a state machine type of design, but a microprocessor-based system is preferable. The controller is capable of operating the pacemaker in a number of programmed modes where a programmed mode defines how pacing pulses are output in response to sensed events and expiration of time intervals. An accelerometer 330 enables the controller to adapt the pacing rate in accordance with detected changes in the patient's physical activity that indicate changes in exertion level and metabolic demand. A telemetry interface 80 is also provided for communicating with an external programmer. [0019] Also interfaced to the controller is an exciter 350 and an impedance measuring circuit 360. The exciter supplies excitation current of a specified amplitude (e.g., as a pulse waveform with constant amplitude) to excitation electrodes 351 that are disposed in the thorax. Voltage sense electrodes are disposed in a selected region of the thorax so that the potential difference between the electrodes while excitation current is supplied is representative of the transthoracic impedance between the voltage sense electrodes. The impedance measuring circuitry 360 processes the voltage sense signal from the voltage sense electrodes 361 to derive the impedance signal. The conductive housing or can may be used as one of the voltage sense electrodes. Further processing of the impedance signal allows the derivation of signal representing respiratory activity and/or cardiac blood volume, depending upon the location the voltage sense electrodes in the thorax. (See, e.g., U.S. Pat. Nos. 5,190,035 and 6,161,042, assigned to the assignee of the present invention and hereby incorporated by reference.) If the impedance signal is filtered to remove the respiratory component, the result is a signal that is representative of blood volume in the heart at any point in time. As explained below, measurement of heart volume during successive beats allows the detection of volumetric oscillations that represent the presence of pulsus alternans in certain patients. [0020] The multiple sensing/pacing channels may be configured to deliver bradycardia pacing, cardiac resynchronization therapy, or anti-tachycardia pacing. Illustrated in FIG. 1 is a configuration with one atrial and two ventricular sensing/pacing channels for delivering biventricular pacing. Other embodiments may include additional sensing/pacing channels for multi-site pacing of an atrium and/or ventricle. The atrial sensing/pacing channel in FIG. 1 comprises ring electrode 43 a, tip electrode 43 b, sense amplifier 41, pulse generator 42, and an atrial channel interface 40 which communicates bidirectionally with the controller 10. The device also has two ventricular sensing/pacing channels that similarly include ring electrodes 23 a and 33 b, tip electrodes 23 b and 33 b, sense amplifiers 21 and 31, pulse generators 22 and 32, and ventricular channel interfaces 20 and 30. Each channel thus includes a pacing channel made up of the pulse generator connected to the electrode and a sensing channel made up of the sense amplifier connected to the electrode. The channel interfaces may include analog-to-digital converters for digitizing sensing signal inputs from the sensing amplifiers, registers that can be written to for adjusting the gain and threshold values of the sensing amplifiers, and, in the case of the ventricular and atrial channel interfaces, registers for controlling the output of pacing pulses and/or changing the pacing pulse amplitude. For each channel, the same electrode pair is used for both sensing and pacing. In this embodiment, bipolar leads that include two electrodes are used for outputting a pacing pulse and/or sensing intrinsic activity. Other embodiments may employ a single electrode for sensing and pacing in each channel, known as a unipolar lead. A MOS switching network 70 controlled by the microprocessor is used to switch the electrodes from the input of a sense amplifier to the output of a pulse generator. [0021] The controller 10 controls the overall operation of the device in accordance with programmed instructions stored in memory, including controlling the delivery of paces via the pacing channels, interpreting sense signals received from the sensing channels, and implementing timers for defining escape intervals and sensory refractory periods. The sensing circuitry of the pacemaker detects a chamber sense, either an atrial sense or ventricular sense, when an electrogram signal (i.e., a voltage sensed by an electrode representing cardiac electrical activity) generated by a particular channel exceeds a specified detection threshold. Pacing algorithms used in particular pacing modes employ such senses to trigger or inhibit pacing. The time intervals between such senses can also be measured in order to detect tachyarrhythmias so that appropriate therapy can be delivered by the device. As described below, the controller may also be programmed to detect oscillations in cardiac rhythm and to adjust the manner in which pacing therapy is delivered by the device upon such detection. [0022] 2. Detection of Oscillatory Cardiac Rhythm in the Form of Volumetric Alternans [0023] Detection of volumetric alternans may be implemented by comparing either end systolic or stroke volume during a specified number of successive heart beats to see if volumetric oscillation is occurring. End systolic or stroke volume is determined using the electrical impedance technique described above. FIG. 2 illustrates an exemplary algorithm for detection of volumetric alternans using end systolic volume as the relevant parameter. The impedance waveform may be analyzed independently from detected cardiac electrical activity to determine points of the waveform that represent successive end systolic volumes. In the embodiment illustrated, however, the impedance waveform is analyzed during a time window defined in relation to detected electrical cardiac activity. Accordingly, at step A1, the device waits for a ventricular sense (i.e., an R wave) indicating that a systolic contraction is beginning. After the ventricular sense and during a defined time window, the device determines the minimum of the volume signal to be the end systolic volume at step A2. The difference between the end systolic volume of the present cardiac cycle and end systolic volume of the previous cardiac cycle is then computed at step A3. If the end systolic volume difference exceeds a specified threshold, as determined at step A4, a counter that keeps track of the number of consecutive end systolic volume differences that exceed the threshold is incremented at step A7. Otherwise, a condition of no volumetric alternans is detected at step A5, the counter is reset at step A6, and the device waits for the next R wave at step A1. If the end systolic volume difference does exceed the threshold, after incrementing the counter at step A7, the counter's value is compared to a threshold count value at step A8. The threshold count value specifies the number of consecutive heart beats that the end systolic volume difference must be above threshold before volumetric alternans is detected. If the count exceeds the count threshold value, volumetric alternans is detected at step A9. The device then returns to step A1 and measures the end systolic volume of the next heart beat. [0024] 3. Detection of Oscillatory Cardiac Rhythm in the Form of Acoustic Alternans [0025] An alternative surrogate for pulsus alternans may be detected in the form of oscillations in the amplitudes of measured heart sounds, referred to herein as acoustic alternans. Pulsus alternans occurs due to a difference in the strength of systolic contractions during successive heart beats so that a strong beats alternate with weak beats. As explained below, the strength of a systolic contraction affects the velocity at which the AV and semilunar valves close, which closures are responsible for producing the first and second heart sounds, S1 and S2, heard during cardiac auscultation. Thus, alternating loud and soft heart sounds, or acoustic alternans, is directly reflective of pulsus alternans. Heart sounds may be detected and measured by an implantable device equipped with an accelerometer that responds to the acoustic vibrations transmitted through body fluids. Accelerometers are commonly used in pacemakers to measure the physical activity of the patient so that the pacing rate can be adjusted accordingly. By detecting and measuring the amplitudes of heart sounds during successive heart beats, acoustic alternans can be detected. [0026] When the heart beats, closure of valves brought about by pressure differentials in the heart are associated with audible heart sounds that can be heard by auscultation with a stethoscope. The first heart sound, designated S1, results when the AV valves (the mitral and tricuspid valves) close at the beginning of systole as the ventricular contraction causes a sudden backflow of blood toward the atria and against the valves. Due to the elastic nature of the valves, the movement of blood toward the atria causes the valves to bulge toward the atria and then recoil blood back toward the ventricle. This causes a period of reverberation that results in vibrations being transmitted through the blood and body tissues. The second heart sound, designated S2, similarly results when the semilunar valves (the aortic and pulmonary valves) close at the end of systole as the ventricular pressure drops. Because right-sided pressures are significantly lower than left-sided pressures, the amplitude of the heart sounds are primarily due to the closure of the mitral and aortic valves. During pulsus alternans, the strength of systolic contractions are alternately strong and weak. During a strong contraction, the mitral valve is stretched farther into the atria which then sets up a larger amplitude period of vibration. A stronger systolic contraction also causes an increased rate of pressure increase in the ventricle or dp/dt which may increase blood flow velocity. Thus the measured amplitude of both S1 and S2 would be expected to exhibit oscillatory behavior during pulsus alternans. [0027]FIG. 3 shows an example of how pulsus alternans is reflected by acoustic alternans based upon data published in the literature (See Smith D., Craige E. Am J Cardiol 1985; 55:205). In the figure, five waveforms are shown with respect to a common time axis: a dp/dt waveform which is the time derivative of the left ventricular pressure and reflects the systolic force of contraction, a phonocardiogram which is the acceleration signal measured at the apex, the aortic pressure, the left ventricular pressure, and an electrocardiogram. Six cardiac cycles are shown, numbered CC1 through CC6. In each cardiac cycle, the beginning of ventricular systole is indicated by an R wave in the EKG. At about the same time as the R wave, there is a spike in the dp/dt waveform indicating ventricular contraction, and the left ventricular pressure begins to rise. When the left ventricular pressure exceeds the pressure in the left atrium, the mitral valve closes as indicated by the occurrence of an S1 heart sound in the phonocardiogram. Blood is ejected from the left ventricle into the aorta upon opening of the aortic valve as indicated by the simultaneous rise of both aortic and left ventricular pressure. As the ventricle relaxes, as marked by the T wave in the EKG indicating ventricular repolarization, the left ventricular pressure falls. When the left ventricular pressure falls below the aortic pressure, the aortic valve closes as indicated by the occurrence of an S2 heart sound in the phonocardiogram. Inspection of the left ventricular and aortic pressure waveforms reveals that the patient from whom this data was taken is exhibiting pulsus alternans, with cycles CC2, CC4, and CC6 being strong beats and cycles CC1, CC3, and CC5 being weak beats. It can also be seen that both S1 and S2 are of greater amplitude during the strong beats than during the weak beats. Although this amplitude difference could not be discerned by a clinician performing auscultation, an implantable device can measure the amplitudes with enough precision to allow acoustic alternans to be detected. [0028] In order to detect acoustic alternans with specificity, specified threshold values may be employed so that the magnitude of the beat-to-beat oscillation must be above a certain value and must persist for a certain number of heart beats or period of time before acoustic alternans is detected. FIG. 4 shows an exemplary algorithm for detecting acoustic alternans based upon measurement of the amplitudes of the first and/or second heart sounds that can be implemented by the controller in conjunction with the phonocardiogram signal produced by an accelerometer or other microphonic device. In one embodiment of the invention, heart sounds may be detected without reference to any concomitant electrical activity in the heart, with the heart sounds themselves used to define cardiac cycles. In order to more reliably detect such heart sounds within each cardiac cycle, however, it may be advantageous to only look for them in a time window defined in relation to detected electrical cardiac activity. Accordingly, at step B1, the device waits for a ventricular sense (i.e., an R wave) indicating that a systolic contraction is beginning. After a ventricular sense and during a defined time window, the S1 sound is detected and its amplitude measured at step B2. During another subsequent defined time window, the S2 sound is detected and its amplitude measured at step B3. The time window defined for detection of S2 may optionally be defined with respect to the detection of ventricular repolarization (i.e., a T wave) indicating mechanical relaxation of the ventricles. A heart sound amplitude measurement is thus produced that can be compared with a heart sound amplitude measurement from the immediately preceding cardiac cycle. In various embodiments, the heart sound amplitude measurement may consist of the amplitude of S1, the amplitude of S2, or a value that is a function of the amplitudes of both S1 and S2. The difference between the heart sound amplitude of the present cardiac cycle and the heart sound amplitude of the previous cardiac cycle is then computed at step B4. If the heart sound amplitude difference exceeds a specified threshold, as determined at step B5, a counter that keeps track of the number of consecutive heart sound amplitude differences that exceed the threshold is incremented at step B8. Otherwise, a condition of no acoustic alternans is detected at step S6, the counter is reset at step B7, and the device waits for the next R wave at step B1. If the heart sound amplitude difference does exceed the threshold, after incrementing the counter at step B8, the counter's value is compared to a threshold count value at step B9. The threshold count value specifies the number of consecutive heart beats that the heart sound amplitude difference must be above threshold before acoustic alternans is detected. If the count exceeds the count threshold value, acoustic alternans is detected at step B10. The device then returns to step B1 and measures the heart sound amplitudes of the next heart beat. [0029] 4. Detection of Oscillatory Cardiac Rhythm in the Form of Electrical Alternans [0030] Another way of detecting an oscillating cardiac rhythm is by direct detection of electrical alternans. Electrical alternans detected in this manner indicates that an arrhythmogenic condition may be present and is strongly correlated with the presence of pulsus alternans. FIGS. 5A and 5B show examples of electrogram waveforms that exhibit electrical alternans. In FIG. 5A, the start of ventricular depolarization and the start of ventricular repolarization are marked by an R wave and T wave, respectively. The interval between the R wave and T wave during a single cardiac cycle then corresponds to the action potential duration in the myocardial fibers at the electrode site. One manifestation of electrical alternans is a beat-to-beat oscillation in the action potential duration as reflected by the successive differences in the R-T interval. FIG. 5B shows another example of an electrogram waveform in which the amplitude of the T wave oscillates from beat to beat. [0031] In order to detect electrical alternans, the controller is programmed to extract some feature from the electrogram waveform during successive cardiac cycles and determine if a beat-to-beat oscillation exists with respect to that feature. Examples of such features include the R-T interval and T wave amplitude as noted above. In order to detect electrical alternans with specificity, specified threshold values may be employed so that the magnitude of the beat-to-beat oscillation must be of a certain magnitude and must persist for a certain number of heart beats or period of time before electrical alternans is detected. [0032]FIG. 6 shows an exemplary algorithm for detecting electrical alternans based upon measurement of the R-T interval that can be implemented by the controller. At step C1, the device waits for an R wave (i.e., a ventricular sense). When an R wave is detected, the device then looks for a T wave in the ventricular sensing channel during an appropriate time window at step C2. When both R and T waves are detected during a cardiac cycle, the time interval between the two is measured at step C3. The difference between the R-T interval of the present cardiac cycle and the R-T interval of the previous cardiac cycle is then computed at step C4. If the R-T interval difference exceeds a specified threshold, as determined at step C5, a counter that keeps track of the number of consecutive R-T interval differences that exceed the threshold is incremented at step C8. Otherwise, a condition of no electrical alternans is detected at step C6, the counter is reset at step C7, and the device waits for the next R wave at step C1. If the R-T interval difference does exceed the threshold, after incrementing the counter at step C8, the counter's value is compared to a threshold count value at step C9. The threshold count value specifies the number of consecutive heart beats that the R-T interval difference must be above threshold before electrical alternans is detected. If the count exceeds the count threshold value, electrical alternans is detected at step C10. The device then returns to step C1 and measures the next R-T interval. [0033] 5. Adjustment of Bradycardia Pacing Rate [0034] Bradycardia pacing modes refer to pacing algorithms used to pace the atria and/or ventricles when the intrinsic atrial and/or ventricular rate is inadequate due to, for example, AV conduction blocks or sinus node dysfunction. Such modes may either be single-chamber pacing, where either an atrium or a ventricle is paced, or dual-chamber pacing in which both an atrium and a ventricle are paced. Modern pacemakers are typically programmable so that they can operate in any mode which the physical configuration of the device will allow. Additional sensing of physiological data allows some pacemakers to change the rate at which they pace the heart in accordance with some parameter correlated to metabolic demand, called rate-adaptive pacing. Measurement of minute ventilation by electrical impedance as described above or measurement of body activity with an accelerometer can be used to estimate metabolic demand for this purpose. [0035] Pacemakers can enforce a minimum heart rate either asynchronously or synchronously. In asynchronous pacing, the heart is paced at a fixed rate irrespective of intrinsic cardiac activity. There is thus a risk with asynchronous pacing that a pacing pulse will be delivered coincident with an intrinsic beat and during the heart's vulnerable period which may cause fibrillation. Most pacemakers for treating bradycardia today are therefore programmed to operate synchronously in a so-called demand mode where sensed cardiac events occurring within a defined interval either trigger or inhibit a pacing pulse. Inhibited demand pacing modes utilize escape intervals to control pacing in accordance with sensed intrinsic activity. In an inhibited demand mode, a pacing pulse is delivered to a heart chamber during a cardiac cycle only after expiration of a defined escape interval during which no intrinsic beat by the chamber is detected. If an intrinsic beat occurs during this interval, the heart is thus allowed to �escape� from pacing by the pacemaker. Such an escape interval can be defined for each paced chamber. For example, a ventricular escape interval can be defined between ventricular events so as to be restarted with each ventricular sense or pace. The inverse of this escape interval is the minimum rate at which the pacemaker will allow the ventricles to beat, sometimes referred to as the lower rate limit (LRL). [0036] In atrial tracking and/or atrio-ventricular sequential pacing, another ventricular escape interval is defined between atrial and ventricular events, referred to as the atrio-ventricular interval (AVI). The atrio-ventricular interval is triggered by an atrial sense or pace and stopped by a ventricular sense or pace. A ventricular pace is delivered upon expiration of the atrio-ventricular interval if no ventricular sense occurs before. Atrial-tracking ventricular pacing and atrio-ventricular sequential pacing attempt to maintain the atrio-ventricular synchrony occurring with physiological beats whereby atrial contractions augment diastolic filling of the ventricles. If a patient has a physiologically normal atrial rhythm, atrial-tracking pacing also allows the ventricular pacing rate to be responsive to the metabolic needs of the body. A pacemaker can also be configured to pace the atria on an inhibited demand basis, where an atrial escape interval is then defined as the maximum time interval in which an atrial sense must be detected after a ventricular sense or pace before an atrial pace will be delivered. The LRL in that case is the sum of the atrial escape interval and the AVI. [0037] Rate-adaptive algorithms may be used in conjunction with bradycardia pacing modes. Rate-adaptive pacemakers modulate the ventricular and/or atrial escape intervals based upon measurements corresponding to physical activity. Such pacemakers are applicable to situations in which intrinsic atrial rates are unreliable or pathological. In a rate-adaptive pacemaker, for example, the LRL is adjusted in accordance with exertion level measurements such as from an accelerometer or minute ventilation sensor in order for the heart rate to more nearly match metabolic demand. The adjusted LRL is then termed the sensor-indicated rate. [0038] Electrical alternans is known to occur only above a certain critical threshold heart rate that varies with the individual patient. A pacemaker operating in an inhibited demand mode, by enforcing a specified minimum heart rate, can be responsible in some cases for maintaining a heart rate that allows electrical alternans to occur. The controller may therefore be programmed to decrease the LRL by a specified amount upon detection of volumetric or acoustic alternans that indicate the presence of electrical alternans with high probability or by direct detection of electrical alternans. In the case of rate-adaptive pacing, the maximum sensor-indicated rate and/or the rate-response curve used to map an exertion level to a sensor-indicated rate may be adjusted to also result in a decreased LRL. Such a decrease in the LRL may be beneficial even if the alternans persists by making the triggering of an arrhythmia less likely. [0039] 6. Adjustment of Anti-Tachycardia Pacing [0040] The cardiac rhythm management device of FIG. 1 may be programmed with a plurality of selectable ATP pacing protocols that define the manner in which anti-tachycardia pacing is delivered. In a microprocessor-based device, the output of pacing pulses is controlled by a pacing routine that implements the selected pacing protocol as defined by various parameters. A data structure stored in memory contains the parameter sets that define each of the available pacing protocols. Pacing protocols for ATP therapy can generally be divided into two classes: those that deliver one or more pulses in timed relation to detected depolarizations and those that deliver a continuous pulse train for a specified time beginning after a detected depolarization. Both types of ATP protocols attempt to block the reentrant depolarization wavefront causing the tachycardia with a second depolarizing wavefront produced by a pacing pulse. Protocols of the first group may vary according to parameters that define the number of pulses delivered and the particular timing employed. Protocols of the second group include so-called burst pacing in which a short train of pulses is delivered for a specified time and may vary according to parameters that define the duration, frequency, and timing of the pulses. [0041] The device delivers ATP therapy or a defibrillation shock under programmed control of the microprocessor in response to sensed activity from the sensing channels. A sensing routine analyzes the electrical activity received from the sensing channels in order to detect a tachyarrhythmia, and the tachyarrhythmia is then classified as a tachycardia (i.e., a terminable tachyarrhythmia) or fibrillation based upon rate and/or other criteria. The device detects a ventricular tachyarrhythmia, for example, by counting ventricular senses received via the ventricular sensing channel in order to measure the heart rate and determine whether the rate exceeds a selected threshold value. Once a tachyarrhythmia is detected, the rhythm is classified into either a tachycardia or a fibrillation zone by comparing the heart rate to a fibrillation rate boundary or by other means such as assessing the stability of the rhythm. If the tachyarrhythmia is classified as terminable, a pacing routine executed by the microprocessor delivers ATP pulses in accordance with the parameters of a selected protocol. [0042] As noted above, the object of anti-tachycardia pacing is to create a pace-induced wavefront that propagates into the re-entrant circuit of the tachycardia and extinguishes it. Different protocols are apt to be more successful than others in terminating particular tachyarrhythmias that may differ as to rate and/or depolarization pattern. For this reason, modern cardiac rhythm management devices are capable of employing a number of different ATP protocols to deliver therapy where pacing parameters affecting the magnitude and timing of the pulses can also be adjusted for each protocol. Ideally, a clinician would program the device to deliver pacing therapy using a protocol and parameters that will perform best for a particular patient's tachyarrhythmia. [0043] Upon detection of an oscillating cardiac rhythm (i.e., volumetric, acoustic, or electrical alternans), the controller may be programmed to adjust the manner in which anti-tachycardia pacing is delivered that takes account of the greater potential for onset of an arrhythmic episode. In one example, the tachyarrhythmia rate threshold at which anti-tachycardia pacing is initiated is decreased so that the anti-tachycardia therapy is delivered sooner than in a normal mode of operation. Clinical testing of an individual patient may also reveal that certain anti-tachycardia pacing protocols are more successful than others in terminating a tachycardia preceded by an oscillating cardiac rhythm but less successful in terminating a tachycardia not preceded by an oscillating cardiac rhythm. In those cases, the controller can be programmed to adjust the particular anti-tachycardia pacing protocol to be used for terminating a tachycardia and/or particular parameters defining that protocol when volumetric, acoustic, or electrical alternans is detected. [0044] 7. Adjustment of Cardiac Resynchronization Therapy [0045] Cardiac resynchronization therapy is pacing stimulation applied to one or more heart chambers in a manner that restores or maintains synchronized contractions of the atria and/or ventricles and thereby improves pumping efficiency. Certain patients with conduction abnormalities may experience improved cardiac synchronization with conventional single-chamber or dual-chamber pacing as described above. For example, a patient with left bundle branch block may have a more coordinated contraction of the ventricles with a pace than as a result of an intrinsic contraction. Resynchronization pacing, however, may also involve delivering paces to multiple sites of a heart chamber or pacing both ventricles and/or both atria in accordance with a resynchronization pacing mode as described below. Ventricular resynchronization pacing is useful in treating heart failure because, although not directly inotropic, resynchronization results in a more coordinated contraction of the ventricles with improved pumping efficiency and increased cardiac output. Resynchronization pacing of the atria may also be beneficial in certain heart failure patients, particularly for preventing the onset of atrial arrhythmias. [0046] One way to deliver resynchronization therapy is to pace a site with a synchronous bradycardia pacing mode and then deliver one or more resynchronization paces to one or more additional pacing sites in a defined time relation to one or more selected sensing and pacing events that either reset escape intervals or trigger paces in the bradycardia pacing mode. One such resynchronization pacing mode may be termed offset resynchronization pacing. In this mode, a first site is paced with a bradycardia mode, and a second site receives a resynchronization pace at an offset interval with respect to the pace delivered to the first site. The offset interval may be zero in order to pace both sites simultaneously, positive in order to pace the first site after the second, or negative to pace the first site before the second. For example, in biventricular resynchronization pacing, one ventricle is paced with a bradycardia mode while the contralateral ventricle receives resynchronization paces at the specified biventricular offset interval. The offset interval would normally be individually specified to optimize cardiac output in a particular patient. Ventricular resynchronization can also be achieved in certain patients by pacing at a single unconventional site, such as the left ventricle instead of the right ventricle. In such a mode, right ventricular senses may be used to trigger left ventricular paces or used to define an escape interval that upon expiration causes delivery of a left ventricular pace. [0047] Cardiac rhythm management devices for delivering resynchronization therapy may be configured in a number of different ways and with a number of different parameter settings. These parameters can be initially programmed after implantation while a physician is monitoring the patient so that the resynchronization therapy is delivered optimally. When the pumping efficiency of the patient's heart deteriorates as may be indicated by detection of an oscillatory rhythm, however, modification of those parameters may be necessary for continued optimal treatment. Accordingly, the controller may be programmed to modify its resynchronization pacing parameters upon detection of volumetric, acoustic, or electrical alternans, with the exact manner in which such parameters are modified depending upon the individual patient's condition. Such parameter modifications may result in, for example, initiation of resynchronization pacing when such pacing is not normally delivered by the device, reconfiguration of pacing sites so that different cardiac sites are paced, adjustment of a biventricular offset interval for biventricular pacing modes, and adjustment of the atrio-ventricular interval for resynchronization pacing modes that employ atrial tracking or atrio-ventricular sequential pacing. [0048] 8. Cardiac Rhythm Oscillation as an Indication of Ischemia [0049] In certain patients, mechanical and/or electrical oscillations of cardiac rhythm (i.e., pulsus alternans, acoustic alternans, volumetric alternans, or electrical alternans) may be a manifestation of cardiac ischemia. An implantable device configured to delivery therapy for cardiac ischemia may thus use detection of a cardiac rhythm oscillation as a trigger for initiating therapy. [0050] In one embodiment an implantable device is configured to deliver drug therapy upon detection of ischemia. Once the controller 10 detects a cardiac rhythm oscillation indicating an ischemic change, a command is issued to the drug delivery interface 500. The drug delivery interface then actuates a drug delivery apparatus incorporated into the device. For example, upon actuation by the drug delivery interface 500, a quantity of drug is pumped from a reservoir into the lumen of a catheter that delivers the drug intravenously. In modifications to this embodiment, the catheter may incorporate lead wires and electrodes for facilitating the drug delivery such as by iontophoresis, electroporation, electrorepulsion, or electro-osmosis. The current to the electrodes in that case is then actuated by the drug delivery interface in coordination with operation of the pump. External drug delivery means may also be used by the device for drug delivery in response to ischemia. Examples of external drug delivery apparatus are disclosed in U.S. Pat. No. 6,361,522, assigned to the assignee of the present application and hereby incorporated by reference. [0051] In another embodiment, an implantable cardiac rhythm management device is configured to deliver pacing therapy in a manner such that one or more regions of the myocardium are pre-excited relative to others. The pre-excited region then experiences less mechanical stress than other regions during systole. For example, the device of FIG. 1 may be implanted such that a first ventricular pacing electrodes is disposed near a myocardial region that has been previously damaged by ischemia while a second ventricular pacing lead is disposed elsewhere. If the controller is then programmed to deliver a pace to the first electrode before the second electrode during a cardiac cycle, the damaged region experiences less mechanical stress and hence is less vulnerable to the effects of ischemia. Because it may not be desirable to deliver such pre-excitation therapy at all times, the device may be programmed to initiate pre-excitation therapy upon detection of a cardiac rhythm oscillation indicating an ischemic episode. [0052] Although the invention has been described in conjunction with the foregoing specific embodiments, many alternatives, variations, and modifications will be apparent to those of ordinary skill in the art. Such alternatives, variations, and modifications are intended to fall within the scope of the following appended claims. Referenced by
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Millions of dollars in federal funds is headed to ILM. Wilmington International airport has received $2.4 million for infrastructure improvements.
Specifically, the funds will be used for storm water upgrades and install a pipe system to accommodate future development of the general aviation area.
Construction of the storm water project will start this fall.


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The hotel was relatively close to everything.
My front desk experience was difficult and somewhat unfriendly. I waited for nearly ten minutes to be waited on while the woman at the front desk made calls. The air conditioning did not work at all. At one point I set the air conditioning to 50 degrees and the room temperature never dropped below 72.
The comfortable bed and awesome pillows. Very clean hotel..nice staff.
Breakfast was ok & adequate but could use an upgrade with better choice of items.
By far, the best and most welcoming characteristic was the lovely, lovely staff/ownership. How lovely, thoughtful and polite they were. We would come again if only to feel as warmly greeted!!
I would like to have had the ability to put the housekeeper's gratuity on a credit card or on a charge so that I didn't have to go one half mile down the street to an ATM.
The front desk staff were both friendly and efficient; the bed was one of the most comfortable I've slept on in years, and the duvet/comforter was a fluffy, warm delight to sleep under.
The sound of other rooms' doors slamming shut in the hallway was a bit loud.
Clean rooms, decent free breakfast and friendly staff ... All in all a pleasant 5 day stay.
Housekeeping missed us one day out of 5 and we needed clean towels & tissues which we didn't get ... When reported to the front desk he apologized but said they were all gone and he could get us towels.
Proximity to downtown Concord. Amenities, eg breakfast, pool, hot tea/coffee 24 hours/day. Tip: Request a room on the backside of the hotel.
Staff is courteous and goes out of their way to make your stay enjoyable. Rooms are clean and quiet.
The hotel is clean, comfortable, and lovely. The staff are amazing.
The towels are old. Some of the furniture is very worn.
Clean, had the amenities we needed, comfortable bed. Quiet guests. *Really* nice public spaces.
Would have liked a fridge (we were traveling for thanksgiving, so had food with us). Easy to hear conversation in the next room the next morning.
The breakfast was great every morning! Pool was fun, along with workout room and arcade/game room. Service was excellent. My room was next door to the breakfast area, and sound was never a problem. Free cookies and coffee all day/night, too! Pets were allowed as well, and it didn't seem like there were breed restrictions. I would recommend this hotel to anyone!
Good value. Nice free breakfast
Outdated hotel.
Hotel was clean and modern. Good location from verizon arena.
House keeping kept beating on door in the morning, we were trying to catch up on sleep and planning on a late checkout.
The room was extremely comfortable.
I arrived very late and wished checking out would have been later to catch up on some sleep.
Close to I-393 and Rte. 106
Bathtub/Shower didn't feel squeaky clean under foot!
Coffee available all day. Centrally located for our needs. Free continental breakfast and internet.
Bathroom could have been a little cleaner. Very strong chlorine small in pool area.
The staff was helpful. The rooms were very clean. The weight room was acceptable. Pool was nice but sauna wasn't very hot. It took 30 minutes to break a sweat. Other than that we enjoyed our stay.
Staff was absolutely 100% accommodating- all requests were met and they went above and beyond to assist with all our needs
Parking - $12 / a night -- if this was Boston or NYC I would have expected this --- but this is Manchester NH --- need a way to get over this surcharge.
All staff interactions were pleasant and more than accommodating I was a little concerned when Hooksett came up as the location we were attending an event at the Verizon Arena but it was so convenient.
The fitness center had a lot of trash in it on machines, floor and window sill. Also the carpets in the hallways needed to be vaccumed.
Great location, good value for your money, clean and comfortable.
Friendly clean comfortable room.
I could hear the people in the next room over. Not very sound proof.
Front desk lady kindly moved me to a non-smoking room after I had originally been put in a smoking room.
Room was outdated with ok quality linens and an old TV. Original smoking room I was in had cigarette burns on the comforter
Had a problem with blow dryer and it was replaced in a matter of a couple of hours. Very nice desk help and staff.
Here's why:
We're not the seller At KAYAK we don't set prices, so it's not possible for us to guarantee what other companies are selling.
We aggregate tons of data for you Our service lets you quickly and easily compare results from hundreds of travel sites at once. In this sense, KAYAK is a search engine and we don't guarantee prices we find.
Why aren't prices accurate 100% of the time? Prices on airline seats, hotel rooms and car rentals can change frequently. Several people may also be trying to buy the same travel option simultaneously. As a result, you may find on occasion that certain prices are no longer available.
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- 22 Resorts
- Consistent Snow
- Diverse destinations
- Resorts open before those of many other states
- Home to Vail, Beaver Creek, Copper Mountain
Related Regions:
Powder pumps up the skiing in central Idaho at Sun Valley, Brundage and Tamarack. Full Article
23rd December 2014
Michigan resorts merge, offering double the skiing with a single pass. Full Article
21st December 2014
Free-heelin' ain't easy, but with the right gear and instruction, telemark skiing is just a ski season's worth of lunges away. Full Article
17th December 2014
West Coast resorts are due to receive an early Christmas present. Full Article
17th December 2014
With it finally feeling like winter across North America, we think it's high time you get out for a powder day. That is, if you don't die from cute puppy overload first. Full Article
17th December 2014
Colorado resorts offer timeless ways to celebrate the holiday season, on and off the slopes. Full Article
16th December 2014
Wondering how long your skis should be? Pro skier, Kim Reichhelm shares her guide to proper ski length. Full Article
15th December 2014
With fresh snow, Sugar Bowl celebrates the launch of its 75th anniversary season. Full Article
15th December 2014
Sierra Resort accumulated 15 inches over the past 24 hours, which brings the total season snowfall to 40 inches. The National Weather Service forecast calls for another cold storm to move through the region early next week. As conditions permit, Sierra Resort will continue to open additional terrain. Sierra-at-Tahoe lift and trail status updates can be viewed here. Full Article
13th December 2014
Our on-snow test of the Eider women's Red Square Pant. Full Article
11th December 2014
Our on-snow test of the Eider men's Red Square Jacket and Manhattan Pant. Full Article
11th December 2014
K2's Kim Reichhelm on why women's skis are better for women and not letting some shop guy talk you into buying shorter skis. Full Article
10th December 2014
This week's ski weather forecast calls for heavy snow from coast to coast. Full Article
10th December 2014
Big snow to continue for western resorts. Full Article
3rd December 2014
Five resorts deliver holiday fun with activities on and off the slopes. Full Article
2nd December 2014
Now that Sun Valley is open for the season, find the local faves for where to fuel up and wind down before/after a day on the slopes. Full Article
27th November 2014
California dreamin': The biggest snowstorm of the season heads to Tahoe. Full Article
26th November 2014
Squaw standouts for coffee, breakfast, après, dinner and drinks. Full Article
26th November 2014
Winter arrives in a major way as ski resorts across North America open to powder conditions. Full Article
24th November 2014
Consistent storm track to sweep west to east this week. Full Article
19th November 2014
The scene from Snowbird during Ski Test 2015/2016.More


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March 1, 2015 LONDON (AP) — Newly published emails suggest the man who became known as "Jihadi John" had suicidal thoughts before leaving Britain for Syria. more »»
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March 1, 2015 ALONG THE SERBIA-HUNGARY BORDER (AP) — Exhausted, hungry and cold, they have been walking for miles. What little they have is carried in plastic bags. more »»
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First Iranian flight arrives in rebel-held capital of Yemen
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Afghan avalanches, flooding death toll rises to near 250
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What does PSV mean in Transportation?
This page is about the meanings of the acronym/abbreviation/shorthand PSV in the Governmental field in general and in the Transportation terminology in particular.
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"PSV." Abbreviations.com. STANDS4 LLC, 2015. Web. 4 Mar. 2015. <http://www.abbreviations.com/term/114117>.
PSV also stands for:
- Partial Sea View
- Partido Socialista Vasco
- Passenger Service Vehicle
- Pennsylvania Schuylkill Valley
- Performance Speed Value
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Obama administration not waging war on coal, EPA chief says
Critics say new Obama administration rules to regulate power plants' greenhouse gas emissions will have 'devastating impacts' on the coal industry. But EPA chief Gina McCarthy disagrees.
Michael Bonfigli/The Christian Science Monitor
EPA Administrator Gina McCarthy says that if Congress fails to pass a stopgap spending measure by the Oct. 1 start of the new budget year, "it will mean that EPA effectively shuts down with only a core group of individuals who are there in the event of a significant emergency."
Given the agency's role enforcing laws that protect the environment, Administrator McCarthy added, "I don't think anyone sees that as optimal for the United States to have EPA not fully up and running," she said at a Monitor-hosted breakfast for reporters.
The EPA chief defended new rules the agency released last week that would set the first national limits on heat-trapping carbon pollution from existing power plants. To meet the new standards, coal-fired plants would have to install expensive new technology to capture a portion of their carbon dioxide emissions and bury them underground. Experts say new gas-fired plans could meet the proposed standards without new technology.
The rules triggered a storm of protest from coal-related companies and their political supporters. In a statement, Sen. Joe Manchin (D) of West Virginia said the regulations "will have devastating impacts to the coal industry and our economy." Speaking on the Senate floor, minority leader Mitch McConnell (R) of Kentucky called the rules, "the latest administration salvo in its never ending war on coal – a war against the very people who provide power and energy for our country," Investor's Business Daily editorialized that the rules were "part of an ideologically driven fight to tear the capitalist heart out of western civilization."
When asked about the criticism, McCarthy said, "This is not an energy policy statement, this is not an ideological statement. This is the application of currently existing law in a way that it was supposed to be applied." She added: "We have very good history of 40 years indicating that technology innovates, that businesses adjust, that we can both reduce pollution and maintain the healthy economy that we are all looking for."


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About Indosoft Inc.
Indosoft Inc. is a global provider of call center software, Q-Suite. It has been providing call center solutions to medium and large contact centers around the world for over ten years. Q-Suite is a multi-tenant, scalable call center solution with a unified ACD with skills based routing for voice, chat, e-mail and social media. It is also made available to Indosoft technology partners as a white or private label call center solution.
Read the full story at http://www.prweb.com/releases/2013/5/prweb10738521.htm.
Source: PRWeb Copyright©2012 Vocus, Inc. All rights reserved |


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Uncertainty holds sway in Queensland
PUBLISHED: 15 Aug 2012 10:51:00 | UPDATED: 17 Aug 2012 00:46:24PUBLISHED: 16 Aug 2012 PRINT EDITION: 16 Aug 2012Updated | Consumer sentiment has fallen sharply, a sign of household disappointment over a lack of further interest rate cuts and mounting concern about federal and state government job shedding.
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Oakland voters approve marijuana tax
It is the first US city to assess such a tax, which could raise almost $300,000 in revenue next year. Opponents of the measure say it opens the door to more crime and heavier drug use.
Los Angeles
Oakland, Calif., on Tuesday became the first city in the US to assess a tax on marijuana.
State and national advocates of the tax say the victory is a significant turning point in the history of cannabis use, paving the way for taxation in other communities and states and establishing more social acceptance of marijuana use.
Opponents say an irreversible threshold has been crossed, opening the door to more crime and heavier drug use.
By a wide margin of 80 percent to 20 percent, Oakland voters said "yes" to Measure F, which asked: "Shall City of Oakland's business tax, which currently imposes a tax rate of $1.20 per $1,000 on 'cannabis business' gross receipts, be amended to establish a new tax rate of $18 per $1,000 of gross receipts?"
"The voters of Oakland have sent a message to the nation that cannabis is better treated as a legitimate, tax-paying business than as a cause of crime and futile law-enforcement expenditures," says Dale Gieringer, California state coordinator for the National Organization for the Reform of Marijuana Laws.
The city estimates that the measure will raise $294,000 in additional tax revenue in 2010 and more in future years. Some say the measure will provide funds to help offset the city's current $83 million deficit as well as allow police to direct their limited resources to more serious crimes and drug offenses.
"The public is more interested in having money to preserve social services and fight more important crimes," says Sam Singer, a Berkeley resident and well-known PR consultant.
Mr. Singer and others say that since the passage of Proposition 218 in 1996 – which made marijuana available by prescription to relieve pain and nausea – marijuana use in California has existed behind a "false front": Users can go to a doctor, complain of symptoms, and for about $100, get the doctor to write them a prescription for the drug. A state-issued card lasts for one year.


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"Good story but too much politics..."
I enjoyed the writing, concepts, and narration of the book. That being said, I know that John Ringo is a guest commentator on Fox News, but the constant political bashing does get a bit old after a while. I get it, you don't like liberals but geez... In any case, I did enjoy the book enough to get the following two books :-)
"Enjoyed it ;-)"
I thoroughly enjoyed this book and the series in general. I was a little skeptical because of the title and the cover, but the author/narrator combination works. I am pretty sure Larry is a complete gun nut because of his detailed descriptions of everything dealing with weapons, but it is interesting to see how exciting some of the characters become when talking about them :-). In any case, give it a try, definitely worth the credits.
"John isn't James but not bad"
I am a huge fan of this series and have listened as Jim and James developed the characters through pen and voice. I was very disappointed to hear that James was not going to be reading this book but I figured I'd give John a chance. I went in with an open mind and glad I did. James is not John but as a stand in, he is pretty good actually. He does different voices for everyone and most match fairly close to James' interpretations of the characters. If you truly give it a chance and listen to the performance that John has put on I don't think you will be disappointed. You just have to try to go in unbiased. I know it is difficult especially if you have followed the series thus far... Just my two cents (for all that is worth). All except for the Peewee Herman voice... Extremely annoying (although I think that is what John was going for). That being said, I am very much hoping that James comes back for Cold Days.
As for the book itself, another solid step in the development of Harry. Thanks Jim! Let's just say that if James read the book I would have given it 5 stars.


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Obama orders Guantánamo tribunals to resume. Is he abandoning his pledge?
Obama ends a two-year ban on military tribunals at the US prison at Guantánamo Bay, which he had vowed to close. In a bid to enhance US 'values,' he orders a new review process for detainees.
Jim Young/Reuters
In the 2008 presidential campaign Barack Obama vowed that if elected he'd shut the US prison for terror suspects at Guantánamo Bay, Cuba. But today President Obama seems as far as ever from being able to fulfill that promise.
That may be a bottom line from the administration's move on Monday to end a two-year ban and resume military-commission trials for detainees at the Guantánamo facility.
"The president does remain committed to closing the prison at Guantánamo Bay," said a senior administration official who briefed reporters on the decision.
Besides resuming the commissions, the White House Monday said it remains committed to trying some terrorist suspects in US federal courts. That is something that has met vehement bipartisan opposition in Congress.
"I strongly believe that the American system of justice is a key part of our arsenal in the war against Al Qaeda and its affiliates, and we will continue to draw on all aspects of our justice system – including Article III courts – to ensure that our security and our values are strengthened," Obama said in a statement. Article III courts are civilian tribunals, as opposed to military commissions.


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Justin claimed to have had the 'worst birthday' after getting barred from Cirque Du Soir in London on March 1. Now, a club spokesman reveals the real reason that Justin and his friends were shooed from the venue.
Apparently, celebrities don't always get special privileges — even if it's your birthday! Justin Bieber learned that lesson the hard way when he had no other choice but to leave his circus-themed birthday party in London on March 1, because he wasn't adhering to Cirque Du Soir's guidelines.
Unfortunately for Justin, 19, his friends, Jaden Smith, 14, and Ellapaige Roberts-Clarke, 17, were refused by Cirque Du Soir because they're underage. Justin allegedly left the venue after five minutes because he didn't want to party without his pals. What a guy!
"We, like all clubs in London, operate a strict age policy," a club spokesman tells E! News. "As a few of the members of the party were under the suitable age of 18, the security team at Cirque Du Soir, London, clearly explained this rule and refused entry to the club for anyone who could not provide us with adequate proof of age. Justin Bieber visits Cirque Du Soir regularly, and he and his friends are always welcome, as long the members of the group are legally old enough to enter the club. This was simply a matter of regulation that we must adhere to."
The club spokesman adds, "We are very sorry, and understand it's his birthday, but our hands are tied with local authorities and rules we need to follow as club to keep our license. We clearly didn't want to give him the 'worst birthday.' He is a friend and previously was always welcomed with open arms."
What do YOU think, HollywoodLifers? Do you feel bad for Justin? Hopefully, HollywoodLife.com's Harlem Shake video cheered him up! Watch it below.
WATCH: Justin Bieber Harlem Shake 19th Birthday Celebration
— Chris Rogers
More Justin Bieber Birthday News:
- Selena Gomez Looks Stunning While Justin Bieber Turns 19
- Justin Bieber Parties On 19th Birthday With Ella-Paige Roberts-Clarke
- Justin Bieber Turns 19 — Happy Birthday
View Comment
Posted at 6:53 PM on March 5, 2013
im tired of hollywoodlife. hop outta his face. yall annoyin and dumb. try sayin somethin positive. i dare yall to say this to somebody big and stop pickin on justin. get in somebody face like lil wayne, drake, yo gotti, gucci, boosie, watch you get your brains beat in. watch. im am through wit this website. SHUT UP.
James King
Posted at 4:45 AM on March 5, 2013
Actually licensing law strictly prohibits anyone under the age of 18 entering a bar between 11 and 5am. So it's all to do with the PREMISES license and the PERSONAL LICENSE HOLDER, otherwise known as the DPS, and places like night clubs are only available to access by people over the age of 18, so it has nothing to do with "letting them in and drinking soda" as some of you ignorant people say, because allowing them ENTRY is AGAINST the law. It's actually in order to protect children, because that's what those two underage people were, CHILDREN.
Bieber, you are 19, you are no longer a child star, Be a adult, took off shirt is a 18-year-old college student action, but not a performance sexy action you can swim when took off ur clothes, but not to the performances took off ur shirt,
Put on your clothes ,you are still a sexy man!
Posted at 6:30 PM on March 4, 2013
Posted at 5:39 AM on March 4, 2013
Posted at 11:04 PM on March 3, 2013
Isn't anyone watching their children! What is the matter with Mr. and Mrs Smith allowing a 14 year old to hang out with a 19 year old? Do all the Hollywood parents become so self absorbed they can't see what is going on with their kids? Haven't there been enough young people in Hollywood who have either died or gotten so into the drug culture their lives are ruined? Why does a 19 year old want to hang out with a 14 year old?? This situation is disturbing on so many levels. Justin is headed down a slippery slope. He has a family history of drug addiction so he had better be careful.
Posted at 5:07 PM on July 19, 2013
Posted at 9:46 PM on March 3, 2013
If Justin wants to be treated like and viewed as an adult, he should act like one. Adults know better than to plan a party at a night club if their guests are underage. He has employees who depend on him for a paycheck. He should understand that the club's employees depend on the club staying open so they can get paid. They can't bend the laws for some pop star and risk losing their liquor license and having to shut down. They did the responsible, ADULT thing.
Were the paps out of line and out of control? Sure.Do Beliebers create the demand for pictures of Justin? Yes. If you want them to stop, make sure there's no money in it for them. Stop boosting traffic to sites that use pics of him taken by paparazzi.
If Justin would like to earn some respect from adults, he can stop blaming everyone else for his birthday fiasco. He should step up and say "My bad. I shouldn't have put Cirque du Soir in that position in the first place." Adults take respobsibility for their mistakes. He can man up or he can be a teen idol forever.
Posted at 8:09 PM on March 3, 2013
None ofyour Business
Posted at 7:47 PM on March 3, 2013
READ OR DIE TONIGHT AT 10:35 … … P.M .9 years ago …a person named jerry got dared to sleep in a house that was believed haunted. The .. Nextday his friends waited for him outside the house…. ….. ….. …. They had to go inside and search for him. They went through every room exept the attic. He wasn't supposed to sleep there. He was supposed to sleep in the living room they went to the attic. Hey saw Jerry's corpse and they just left because they were scared. But that night they all died because of their friend. He killed them all for making him sleep in that house if you don't send this to 11 comments you will die tonight by Jerry. Example 1: A man named Stewart read this and didn't believe it. He shut off his computer and went through his day. That night while he was in bed he heard something outside of his door. He got up to look. And now he's dead. Example 2: A girl named Haley Read this in the morning and she got scared but she didn't send it. She wanted to now if it was true. She went to school (She was only 13 years old) and that night she died. If you don't post this on 11 comments tonight jerry will 'visit' you his isn't fake. Apparently, if you you copy and paste this to ten comments in the next ten minuets you will have the best day of your life tomorrow. You will either get kissed or asked out, if you brake this chain you will see a little dead girl in your room tonight. In the next 53 minuets someone will say I love you
Posted at 6:07 PM on March 3, 2013
So much hate! So much anger! Organized Haters willfully publish hateful Social Media BS comments about innocent individuals. Haters intent is to capture maximum market attention and financial gain at the expense of others.
Hate kills. Are you a hater? You can change. Don't be a hater. Hate kills.
Cooler heads prevail. Get cooler. Take back control of your emotions. Consider the source. No one is perfect. We all have flaws. Choose to be positive. It's a personal choice. It's your choice. A positive approach will serve you well in your personal and family lives.
Posted at 5:39 PM on March 3, 2013
Posted at 5:27 PM on March 3, 2013
Posted at 5:12 PM on March 3, 2013
Bravo to the club, the law is the law! There isn't the 'common people law' and 'spoiled rich brat law'
It's his fault he should have contacted the club Managment and asked about thir policy for underage people. Even if I really don't think it is the place for a 14 years old. And now is crying like one of those 'sweet 16′ girls .
Posted at 4:12 PM on March 3, 2013
Posted at 3:19 PM on March 3, 2013
They were trying to stick to the rules and that way they keep their license. But they can close the place down and tell them that since Jaden and Ella are underage, they should not drink or let a guard keep watch. It was the guys b-day! They should just give them soda or something. Then the paps also ruined it (look for the video of how the paps were acting, its disgusting, they knocked his fans down to the ground just to get a pic of him)
Poor Justin. But he was true to his friends and didn't let them get kicked out. That was very nice of him.
Posted at 5:09 PM on July 19, 2013
Posted at 5:10 PM on July 19, 2013
Nobody Special
Posted at 2:37 PM on March 3, 2013
Nobody Special
Posted at 2:36 PM on March 3, 2013
Ok, I'm not a Beibs fan, but hey ! It was the guy's birthday ,for cryin' out loud !! They shoulda allowed them in,and posted a guard and then closed the club,and only served soda,and NO alcohol,and allowed the PRIVATE party to go on, wnd then opened the venue back up ,after the party closed down.
Jus' my thoughts.
Could understand the clubs policy and their statement was courteous. However, another statement was that his entourage reeked of pot which sounds fishy to me. Nevertheless, the paps and probably not so nice club security were what mainly ruined his birthday-see video when they left.
sian glover
Posted at 5:52 PM on March 4, 2013


text: The New York History Blog posts that the companion volume to Black Baseball Entrepreneurs, 1860–1901: Operating by Any Means Necessary, Michael E. Lomax's new book, Black Baseball Entrepreneurs, 1902-1931: The Negro National and Eastern Colored Leagues (Syracuse Univ. Press, 2014), continues to chronicle the history of black baseball in Harlem and the United States. Continue Reading →