text:
During a period of time comprising a plurality of cardiac cycles, a time relationship between ventricular events and atrial detections is established. Based on the relationship, a post-ventricular atrial refractory period is defined. The period includes an absolute atrial refractory period and a segmented relative atrial refractory period, wherein the segmented relative atrial refractory period includes at least one blanking window during which atrial detections of ventricular events have or are likely to occur.
1. A method comprising:
during a period of time comprising a plurality of cardiac cycles, acquiring data related to the timing of ventricular events and atrial detections;
processing the data as follows to determine if there is a time correlation between ventricular events and atrial detections:
for each of the plurality of cardiac cycles, measuring the time between a ventricular event and each atrial detection within the cardiac cycle;
based on the measured time, associating each atrial detection with one of a plurality of time windows;
for each window, incrementing an atrial-detection count when an atrial detection is associated with it and decrementing the atrial-detection count when a ventricular-event count reaches a predetermined number; and
comparing the atrial-detection count of each time window to a threshold and for each that satisfies the threshold, designating it a blanking window; and
defining a post-ventricular atrial refractory period comprising an absolute atrial refractory period and a segmented relative atrial refractory period, wherein the segmented relative atrial refractory period includes at least one blanking window.
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14. A cardiac device comprising:
a ventricular sense channel for sensing ventricular events;
an atrial sense channel for sensing atrial detections; and
a controller connected to the atrial sense channel and the ventricular sense channel and operative to:
during a period of time comprising a plurality of cardiac cycles, acquire data related to the timing of ventricular events and atrial detections;
process the data as follows to determine if there is a time correlation between ventricular events and atrial detections:
for each of the plurality of cardiac cycles, measure the time between a ventricular event and each atrial detection within the cardiac cycle;
based on the measured time, associate each atrial detection with one of a plurality of time windows;
for each window, increment an atrial-detection count when an atrial detection is associated with it and decrement the atrial-detection count when a ventricular-event count reaches a predetermined number; and
compare the atrial-detection count of each time window to a threshold and for each that satisfies the threshold, designating it a blanking window; and
define a post-ventricular atrial refractory period comprising an absolute atrial refractory period and a segmented relative atrial refractory period, wherein the segmented relative atrial refractory period includes at least one blanking window.
This application is related to copending U.S. patent application Ser. No. 12/116,450, filed May 7, 2008, titled "System and Method for Detecting Hidden Atrial Events for Use with Automatic Mode Switching Within an Implantable Medical Device"; and to copending U.S. patent application Ser. No. 12/118,423, filed May 9, 2008, titled "Determining Atrial Time Periods in Conjunction with Real-Time Testing."
The invention relates generally to implantable cardiac devices, and more particular to such devices and related methods that implement a segmented post-ventricular relative atrial refractory period including one or more blanking windows, wherein far-field signals have or are likely to occur.
Implantable cardiac devices ("ICDs") are well known in the art, and may operate to treat a variety of heart conditions. Generally ICDs are designed to monitor and stimulate the heart of a patient who suffers from a cardiac arrhythmia. Using leads connected to a patient's heart, these devices typically stimulate the cardiac muscles by delivering electrical pulses in response to measured cardiac events that are indicative of a cardiac arrhythmia. Properly administered therapeutic electrical pulses often successfully reestablish or maintain the heart's regular rhythm.
ICDs may treat a wide range of cardiac arrhythmias by using a series of adjustable parameters to alter the energy, shape, location, and frequency of the therapeutic pulses. The adjustable parameters are usually defined in a computer program stored in a memory of the ICD. The program, which is responsible for the operation of the ICD, may be defined or altered telemetrically by a medical practitioner using an external implantable device programmer.
Programmable ICDs are generally of two types: single-chamber ICDs, and dual-chamber ICDs. In a single-chamber ICD, stimulation pulses are provided to, and cardiac activity is sensed within, a single-chamber of the heart, either the right ventricle or the right atrium. In a dual-chamber ICD, stimulation pulses are provided to, and cardiac activity is sensed within, two chambers of the heart, namely both the right atrium and the right ventricle. The left atrium and left ventricle may also be sensed and paced, provided that suitable electrical contacts are effected therewith.
In general, both single and dual-chamber ICDs are classified by type according to a three letter code. In this code, the first letter identifies the chamber of the heart that is paced (i.e., the chamber where a stimulation pulse is delivered) with a "V" indicating the ventricle, and "A" indicating the atrium, and a "D" indicating both the atrium and the ventricle. The second letter of the code identifies the chamber where cardiac activity is sensed, using the same letters to identify the atrium, ventricle, or both, and where an "O" indicates that no sensing takes place.
The third letter of the code identifies the action or response taken by the ICD. In general, three types of actions or responses are recognized: (1) an Inhibiting ("I") response, in which a stimulation pulse is delivered to the designated chamber after a set period of time unless cardiac activity is sensed during that time, in which case the stimulation pulse is inhibited; (2) a Trigger ("T") response, in which a stimulation pulse is delivered to the designated chamber of the heart a prescribed period after a sensed event; or (3) a Dual ("D") response, in which both the Inhibiting response and Trigger response are invoked, inhibiting in one chamber of the heart and triggering in the other.
A fourth letter, "R", is sometimes added to the code to signify that a particular mode identified by the three letter code is rate-responsive, in which the pacing rate may be adjusted automatically by the ICD, based on one or more physiological factors, such as blood oxygen level or the patient's activity level. As used herein, "(R)", for example, DDD(R), refers to the occurrence of two modes, such as DDD and/or DDDR.
Thus, for example, a DDI pacemaker is capable of sensing and pacing in both chambers, and operates in a non-atrial tracking mode, i.e., it inhibits ventricular stimulation pulses when a prior ventricular activity is sensed.
A DDDR ICD represents a fully automatic ICD that is capable of sensing and pacing in both the atrium and ventricle, and is also capable of adjusting the pacing rate based on one or more physiological factors, such as the patient's activity level. In general, DDD(R) pacing has four functional states: (1) P-wave sensing, ventricular pacing; (2) atrial pacing, ventricular pacing; (3) P-wave sensing, R-sensing; and (4) atrial pacing, R-wave sensing. Advantageously, for the patient with complete or partial heart block, the DDD(R) ICD tracks the atrial rate which is set by the heart's SA node, and then paces in the ventricle at a rate that follows this atrial rate. Because the rate set by the SA node represents the rate at which the heart should beat in order to meet the physiological demands of the body (at least for a heart having a properly functioning SA node), the rate maintained in the ventricle by such an ICD is truly physiologic.
One problem facing the advent of dual-chamber ICDs is that when an ICD delivers a stimulation pulse to the ventricle during an appropriate portion of a cardiac cycle, this pulse may be sensed by the atrial channel. Therefore, it is common practice in the art to apply a post-ventricular atrial blanking ("PVAB") period upon delivery of a ventricular stimulation pulse in order to prevent the saturation of the sense amplifiers of the atrial channel. During a PVAB period all cardiac activity is ignored by the atrial channel. Because ventricular and atrial pulses are sensed through the same lead electrodes through which the stimulation pulses are delivered, the resulting polarization signal, also referred to as an "after potential," formed at the electrodes, may corrupt the evoked response, which is sensed by the sensing circuits. This undesirable situation occurs frequently because the polarization signal may be three or more orders of magnitude greater than the evoked response.
Furthermore, the lead polarization signal is not easily characterized; it is a complex function of the lead materials, lead geometry, tissue impedance, stimulation energy and other variables, many of which are continually changing over time. By disabling the atrial sense amplifier, that is, applying a refractory or "blanking" period upon the delivery of a ventricular stimulating pulse, the atrial sense amplifier is not effected by the ventricular stimulation pulse. At a specified time interval after the delivery of a ventricular stimulating pulse, the atrial sense amplifiers are enabled again to sense intrinsic or evoked atrial events.
However, the PVAB period poses a problem in that it may occur mid-way or even late in the atrial cycle and may therefore result in an inability of the atrial channel to sense the next intrinsic atrial event. Essentially, the atrial channel is "blinded" to rapid atrial rates precluding proper diagnostic and therapeutic measures by the ICD. For example, a missed atrial event could trigger an atrial stimulation pulse to be inappropriately delivered by the ICD or, in ICDs programmed to operate in one of a plurality of operating modes, cause the ICD to inappropriately switch modes. Such inappropriate pacing or sensing could endanger the patient by inducing a sequence of events that might induce cardiac arrhythmias.
Another problem facing the development of dual-chamber ICDs is that the evoked R-wave (the electrical signal associated with ventricular contraction) subsequent to a ventricular stimulation pulse will typically propagate to the atrium in patients with intact atrioventricular ("AV") conduction. This propagated signal of a ventricular R-wave in the atria is commonly referred to as "far-field R-wave" (FFR). Even a premature ventricular contraction ("PVC"), an arrhythmic event common in many patients who require implantable cardiac devices, may propagate and produce a far-field signal on the atrial channel. Such far-field signals sensed by the atrial channel could be interpreted as atrial events. This erroneous sensing could be misinterpreted by the controlling operations of the ICD as a change in atrial rate or even an atrial arrhythmia and consequently invoke improper therapeutic measures, potentially harming the patient.
In order to overcome this risk, the PVAB period employed upon the delivery of a ventricular pulse is commonly programmed long enough to encompass the far-field signal associated with the propagation of a ventricular R-wave subsequent to a ventricular stimulation pulse. This PVAB period is commonly programmed to be a fixed time interval, typically 150 msec. However, this relatively long, fixed PVAB period may exacerbate the limitations of a dual-chamber device in that the ability of the ICD to detect rapid atrial rates may be further impaired. Devices use a rate branch algorithm for SVT discrimination. If the atrial signal is not sensed appropriately, the device could miss diagnose the arrhythmia as VT in stead of SVT and deliver inappropriate therapy.
The window of time that the atrial channel is enabled for sensing atrial events is directly shortened as the PVAB period is lengthened to eliminate far-field signals from being sensed. Furthermore, conduction time between the ventricle and the atrium will vary from patient to patient. In some patients, far-field signals associated with ventricular events may occur even later than the typically programmed 150 msec blanking period. Using still longer blanking periods could more severely impair the ability of the ICD to detect even normal atrial rates.
Maximizing the window of time that the atrial channel is enabled for sensing atrial events is particularly important for ICDs that are programmed to operate in one of a plurality of possible operating modes.
ICDs capable of operating in a plurality of modes are important because, for example, a given patient may develop fast atrial rhythms that result from a pathologic arrhythmia, such as a pathological atrial tachycardia, atrial fibrillation, or atrial flutter. In these cases, a DDD(R) ICD may pace the ventricle in response to the sensed atrial arrhythmia up to a programmed maximum tracking rate ("MTR").
Occasionally it is possible at the time of implantation of an ICD to determine whether an atrial tachycardia, atrial fibrillation, or atrial flutter condition is going to develop. In such instances, the ICD may be programmed to operate in a different mode of operation, the leads may be repositioned within the heart, or other actions may be taken to minimize the likelihood of such pathologic arrhythmias occurring. However, it is not always possible at the time of implantation to determine whether a patient will develop an atrial arrhythmia after the ICD is implanted.
Therefore, if such pathologic arrhythmias subsequently occur, they must be treated using other techniques, such as through the administration of medication, which generally requires the attendance of a physician. However, a physician is not always present when such pathologic arrhythmias develop, and even when a physician is available, such medication also may suppress undesirably the ability of the SA node to increase the sinus rate during periods of exercise, emotional stress, or other physiologic stress. Thus, the use of such medication may prevent the ICD from functioning as an intrinsic physiological rate-responsive pacemaker.
As a result, attempts have been made in the art to prevent undesirable tracking of pathologic atrial arrhythmias by automatically switching the mode of operation of the ICD from an atrial tracking pacing mode to a non-atrial tracking pacing mode. For example, an atrium-controlled ICD has been described, wherein the ICD temporarily switches from an atrial tracking mode to a non-atrial tracking mode for a fixed number of stimulation pulses if the sensed atrial activity indicates an atrial arrhythmia may be developing.
Additionally, an atrial tracking ICD with automatic mode switching capability has been disclosed. This ICD has the capability of setting a tachycardia rate limit ("TRL") or tachycardia detection rate ("TDR") slightly above an MTR, so that mode switching to a non-atrial tracking mode occurs when the TRL or TDR is exceeded. A third threshold rate is also set at a value below the MTR. The ICD switches back to an atrial tracking mode when the patient's atrial rate drops below this third threshold. To avoid mode switching based on a single short atrial interval between atrial events, the atrial rate is continuously averaged over several cycles. This technique effectively prevents frequent mode switches in patients whose atrial rates "hover" around the MTR.
Also described is an implantable dual-chamber ICD programmed to operate primarily in an atrial tracking mode. This ICD automatically switches its mode of operation from the atrial tracking mode to a non-atrial tracking mode in the event a filtered atrial rate exceeds a prescribed upper rate limit. This mode switching is accompanied by a corresponding switching from a primary set of operational parameter settings for the primary mode, to an alternate set of operational parameters for the alternate mode.
One parameter shared by mode-switching algorithms that cause the ICD to switch from atrial tracking mode to a non-atrial tracking mode is a step that monitors events sensed by the atrial channel to determine whether a pathologic arrhythmia has occurred such that the mode-switching algorithm should be invoked. Thus it would be desirable to provide a system and method for automatically adjusting the post-ventricular atrial blanking period such that the blanking period following a ventricular stimulation pulse is minimized, thereby allowing the longest atrial sensing window possible in a mode-switching ICD. Furthermore, it would be desirable to implement the system and method in a way that allows far-field signals sensed by the atrial channel to be properly interpreted as the ventricular events that they are associated with, thereby excluding them from atrial rate determinations. It would further be desirable to enable the ICD to perform this automatic PVAB period adjustment without requiring dedicated circuitry and/or special sensors.
Briefly, and in general terms, the invention relates to methods and devices involving automatic atrial blanking, whereby blanking periods are associated with post-ventricular relative atrial refractory periods based on the timing occurrences of atrial detections. The number and location of blanking windows may be automatically updated, on a beat-by-beat basis or periodically.
In one aspect, during a period of time comprising a plurality of cardiac cycles, a relationship between ventricular events and atrial detections is established. Based on the relationship, a post-ventricular atrial refractory period is defined. The period includes an absolute atrial refractory period and a segmented relative atrial refractory period, wherein the segmented relative atrial refractory period includes at least one blanking window during which atrial detections of ventricular events have or are likely to occur.
In another aspect of the invention, time data for ventricular events and atrial detections is acquired. The acquired time data is processed to establish time relationships between a first ventricular event and each atrial detection that occurs prior to a subsequent ventricular event. Time relationships are monitored over time to identify atrial detections corresponding to atrial detections of ventricular events, which are then ignored for purposes of atrial rate calculations.
Further features and advantages of the present invention may be more readily understood by reference to the following description taken in conjunction with the accompanying drawings, in which:
The following description is of the best mode presently contemplated for practicing the invention. This description is not to be taken in a limiting sense but is made merely for the purpose of describing the general principles of the invention. The scope of the invention should be ascertained with reference to the issued claims. In the description of the invention that follows, like numerals or reference designators will be used to refer to like parts or elements throughout. For illustration purposes, the ICD will be described in terms of a dual-chamber ICD having a plurality of selectable modes of operation, including a primary mode and an alternate mode and which is programmed and implanted in a patient with intact AV conduction.
As shown in
To sense left atrial and ventricular cardiac signals and to provide left chamber pacing therapy, the stimulation device 10 is coupled to a "coronary sinus" lead 24 designed for placement in the "coronary sinus region" via the coronary sinus so as to place a distal electrode adjacent to the left ventricle and additional electrode(s) adjacent to the left atrium. As used herein, the phrase "coronary sinus region" refers to the vasculature of the left ventricle, including any portion of the coronary sinus, great cardiac vein, left marginal vein, left posterior ventricular vein, middle cardiac vein, and/or small cardiac vein or any other cardiac vein accessible by the coronary sinus.
Accordingly, the coronary sinus lead 24 is designed to retrieve atrial and ventricular cardiac signals and to deliver: left ventricular pacing therapy using at least a left ventricular tip electrode 26, left atrial pacing therapy using at least a left atrial ring electrode 27, and shocking therapy using at least a left atrial coil electrode 28.
The ICD 10 is also shown in electrical communication with the patient's heart 12 by way of an implantable ventricular lead 30 having, in this embodiment, a right ventricular tip electrode 32, a right ventricular ring electrode 34, a right ventricular ("RV") coil electrode 36, and a superior vena cava ("SVC") coil electrode 38. Typically, the right ventricular lead 30 is transvenously inserted into the heart 12 so as to place the right ventricular tip electrode 32 in the right ventricular apex so that the RV coil electrode will be positioned in the right ventricle and the SVC coil electrode 38 will be positioned in the SVC. Accordingly, the right ventricular lead 30 is capable of receiving cardiac signals and delivering stimulation in the form of pacing and shock therapy to the right ventricle.
As illustrated in
The housing 40 for the stimulation device 10, shown schematically in
To achieve left chamber sensing, pacing, and shocking, the connector includes at least a left ventricular tip terminal 44, a left atrial ring terminal 46, and a left atrial shocking terminal 48, which are adapted for connection to the left ventricular tip electrode 26, to the left atrial tip electrode 27, and the left atrial coil electrode 28, respectively.
To support right chamber sensing, pacing, and shocking, the connector further includes a right ventricular tip terminal 52, a right ventricular ring terminal 54, a right ventricular shocking terminal 56, and a SVC shocking terminal 58, which are adapted for connection to the right ventricular tip electrode 32, right ventricular ring electrode 34, a RV coil electrode 36, and the SVC coil electrode 38, respectively.
At the core of the ICD 10 is a programmable microcontroller 60 that controls the various modes of stimulation therapy. As is well known in the art, the microcontroller 60 typically includes a microprocessor, or equivalent control circuitry, designed specifically for controlling the delivery of stimulation therapy and may further include RAM or ROM memory, logic and timing circuitry, state machine circuitry, and I/O circuitry. Typically, the microcontroller 60 includes the ability to process or monitor input signals (data) as controlled by program code stored in a designated block of memory. The details of the design and operation of the microcontroller 60 are not critical to the present invention. Rather, any suitable microcontroller may be used to carry out the functions described herein. The use of the microprocessor-based control circuits for performing timing and data analysis functions are well known in the art.
As shown in
The microcontroller 60 further includes timing circuitry 79, which is used to control the timing of stimulation pulses (e.g., pacing rate atrial-ventricular (AV) delay, atrial interconduction (A-A) delay, pause durations of ventricular interconduction (V-V) delay, etc.) as well as to keep track of timing of refractory periods, blanking periods, noise detection windows, evoked response windows, alert intervals, marker channel timing, etc., which is well known in the art.
The switch bank 74 includes a plurality of switches for connecting the desired electrodes to the appropriate I/O circuits, thereby providing complete electrode programmability. Accordingly, the switch bank 74, in response to a control signal 80 from the microcontroller 60, determines the polarity of the stimulation pulses (e.g., unipolar, bipolar, combipolar, etc.) by selectively closing the appropriate combination of switches (not shown) as is known in the art.
Atrial sensing circuits 82 and ventricular sensing circuits 84 may also be selectively coupled to the right atrial lead 20 through the switch bank 74 for detecting the presence of cardiac activity in each of the four chambers of the heart. Accordingly, the atrial and ventricular sensing circuits, 82 and 84, may include dedicated sense amplifiers, multiplexed amplifiers or shared amplifiers. The switch bank 74 determines the "sensing polarity" of the cardiac signal by selectively closing the appropriate switches, as is known in the art. In this way, the clinician may program the sensing polarity independent of the stimulation polarity.
Each sensing circuit, 82 and 84, preferably employs one or more low power, precision amplifiers with programmable gain and/or automatic gain control, band pass filters, and a threshold detection circuit, as is known in the art, to selectively sense the cardiac signal of interest. The automatic gain control enables the ICD 10 to deal effectively with the difficult problem of sensing the low amplitude signal characteristics of atrial or ventricular fibrillation. The outputs of the atrial and ventricular sensing circuits, 82 and 84, are connected to the microcontroller 60 which, in turn, are able to trigger or inhibit the atrial and ventricular pulse generators, 70 and 72, respectively, in a demand fashion in response to the absence or presence of cardiac activity, respectively, in the appropriate chambers of the heart. The sensing circuits, 82 and 84, in turn, receive control signals over signal lines, 86 and 88, from the microcontroller 60 for purposes of controlling the gain, threshold, polarization charge removal circuitry (not shown), and the timing of any blocking circuitry (not shown) coupled to the inputs of the sensing circuits, 82 and 84, as is known in the art.
For arrhythmia detection, the device 10 utilizes the atrial and ventricular sensing circuits, 82 and 84, to sense cardiac signals to determine whether a rhythm is physiologic or pathologic as processed by an arrhythmia detector 62. As used herein "sensing" is reserved for the noting of an electrical signal, and "detection" is the processing of the sensed signals and noting the presence of an arrhythmia. The timing intervals between sensed events (e.g., P-waves, R-waves, and depolarization signals associated with fibrillation which are sometimes referred to as "F-waves" or "Fib-waves") are then classified by the microcontroller 60 by comparing them to a predefined rate zone limit (i.e., bradycardia, normal, low rate VT, high rate VT, and fibrillation rate zones) and various other characteristics (e.g., sudden onset, stability, physiologic sensors, and morphology, etc.) in order to determine the type of remedial therapy that is needed (e.g., bradycardia pacing, anti-tachycardia pacing, cardioversion shocks or defibrillation shocks, collectively referred to as "tiered therapy").
Additionally, the arrhythmia detector 62 is programmed with an algorithm responsible for automatic mode-switching. Numerous mode-switching algorithms are known to those skilled in the art and will not be described in detail herein. Preferably, the ICD 10 has a plurality of selectable modes of operation, including a primary mode and an alternate mode. When operating in a primary mode, the ICD of the present invention operates according to a primary set of operational parameters, including a primary pacing rate and when operating in an alternate mode, the ICD operates according to an alternate set of operational parameters, including an alternate pacing rate. Programming ICDs to operate in primary and alternate modes of operation is well known to those of skill in the art. More preferably, the mode-switching algorithm is programmed to provide the ICD 10 with the capability of switching from a primary atrial tracking mode to an alternate non-atrial tracking mode if a pathologic atrial arrhythmia is detected, such as atrial tachycardia, atrial fibrillation, and atrial flutter.
The mode-switching algorithm preferably also is programmed to switch back to the primary mode once the pathologic arrhythmia subsides. As further explained below, the microcontroller 60 further includes an atrial channel blanking algorithm 64 which works in concert with the mode-switching algorithm of the arrhythmia detector 62. In one embodiment, the primary mode of operation for the ICD may include DDD, DDDR, VDD, VDDR, DDT, and DDTR modes of operation. Additionally, the alternate mode of operation for the ICD may include DDI, DDIR, VDI, DDT, and DDTR modes. The system and method of the present invention are not to be limited by the type of mode-switching algorithm employed by the ICD, or the particular primary and secondary modes of operation employed by the ICD.
In one embodiment, the ICD 10 uses a filtered atrial rate ("FAR") as a basis for mode-switching in order to reduce mode-switching responses due to, for example, electrical noise or aberrant P-waves. The FAR may be obtained by filtering the intrinsic atrial rate using a rate smoothing filter subroutine. The rate smoothing filter subroutine generates the FAR during each cycle by limiting the amount by which the FAR may change from cycle to cycle. If the FAR exceeds a predetermined upper rate limit, referred to as an atrial tachycardia detection rate ("ATDR"), a pathological atrial arrhythmia is deemed to exist, and the ICD 10 automatically switches from its primary mode of operation to an alternate mode of operation. Mode-switching according to FAR is well known in the art and will not be described further herein.
Cardiac signals are also applied to the inputs of an analog-to-digital (A/D) data acquisition system 90. The data acquisition system 90 (also referred to herein as a "sampler") is configured to acquire intracardiac electrogram signals, convert the raw analog data into a digital signal, and store the digital signals for later processing and/or telemetric transmission to an external device 102. The data acquisition system 90 is coupled to the right atrial lead 20, the coronary sinus lead 24, and the right ventricular lead 30 through the switch bank 74 to sample cardiac signals across any pair of desired electrodes. Additionally, the data acquisition system 90 is coupled to the microcontroller 60 via signal line 92.
Advantageously, the data acquisition system 90 may be coupled to the microcontroller 60, or other detection circuitry, such as the arrhythmia detector 62, for detecting and sensing events that may be classified as either physiologic or pathologic.
As may be noted in
The microcontroller 60 is coupled to the memory 94 by a suitable data/address bus 96. In addition to internal cardiac signals, the memory 94 may store programmable operating parameters used or modified by the microcontroller 60, as required, in order to control the operation of the ICD 10 to suit the needs of a particular patient. Such operating parameters define, for example, pacing pulse amplitude, pulse duration, electrode polarity, rate, sensitivity, automatic features, arrhythmia detection criteria, and the amplitude, wave shape and vector of each shocking pulse to be delivered to the patient's heart 12 within each respective tier of therapy.
Advantageously, initial operating parameters of the implantable device 10 may be non-invasively programmed into the memory 94 through a telemetry circuit 100 in telemetric communication with an external communication device 102, such as a programmer, transtelephonic transceiver, or a diagnostic system analyzer. The telemetry circuit 100 is activated by the microcontroller 60 by a control signal 106. The telemetry circuit 100 advantageously allows intracardiac electrograms and status information relating to the operation of the device 10 (as contained in the microcontroller 60 or memory 94) to be sent to the external device 102 through the established communication link 104. In a preferred embodiment, the stimulation device 10 further includes a physiologic sensor 108, commonly referred to as a "rate-responsive" sensor because it is typically used to adjust pacing stimulation rate according to the exercise state or other physiological stress of the patient. However, the physiological sensor 108 may further be used to detect changes in cardiac output, changes in the physiological condition of the heart, or diurnal changes in activity (e.g., detecting sleep and wake states). Accordingly, the microcontroller 60 responds by adjusting the various pacing parameters (such as rate, AV delay, V-V delay, etc.) at which the atrial and ventricular pulse generators, 70 and 72, generate stimulation pulses.
The stimulation device 10 additionally includes a battery 110, which provides operating power to all of the circuits shown in
As further shown in
If it is the primary function of the device 10 to function as an implantable cardioverter/defibrillator device, it must detect the occurrence of an arrhythmia, and automatically apply an appropriate electrical shock therapy to the heart aimed at terminating the detected arrhythmia. To this end, the microcontroller 60 further controls a shocking circuit 116 by way of a control signal 118. The shocking circuit 116 generates shocking pulses of low (up to 0.5 joules), moderate (0.5-10 joules), or high energy (11 to 40 joules), as controlled by the microcontroller 60. Such shocking pulses are applied to the patient's heart 12 through at least two shocking electrodes, and as shown in this embodiment, selected from the left atrial coil electrode 28, the RV coil electrode 36, and/or the SVC coil electrode 38. As noted above, the housing 40 may act as an active electrode in combination with the RV coil electrode 36, or as part of a split electrical vector using the SVC coil electrode 38 or the left atrial coil electrode 28 (i.e., using the RV coil electrode as common).
Cardioversion shocks are generally considered to be of low to moderate energy level (so as to minimize pain felt by the patient), and/or synchronized with a R-wave and/or pertaining to the treatment of tachycardia. Defibrillation shocks are generally of moderate to high energy level (i.e., corresponding to thresholds in the range of 5-40 joules), delivered asynchronously (since R-waves may be too disorganized), and pertaining exclusively to the treatment of fibrillation. Accordingly, the microcontroller 60 is capable of controlling the synchronous or asynchronous delivery of the shocking pulses.
In accordance with the invention, automatic mode switching in response to pathologic atrial arrhythmias is improved by preventing or significantly minimizing the use of non-atrial events in atrial rate calculations. This improvement is provided by the inclusion of one or more atrial channel blanking periods or windows of time during the relative period of the post-ventricular atrial refractory period (PVARP). Any signals sensed by the atrial channel during these "blanking periods" are ignored by the mode switching algorithm of the arrhythmia detector 62. Various techniques and processes for including blanking windows within the post-ventricular relative atrial refractory periods are described herein. The techniques are premised on the general observation that non-atrial events detected in the atrium, such as far-field R waves, tend to be very repeatable in their timing relationship with respect to their preceding ventricular event, whereas true atrial events, such as P waves, tend not to have a strong time correlation with their preceding ventricular event.
In general terms and with reference to
Continuing with
With reference to
The segmented second period 134 follows the first period 132 and generally corresponds to a relative atrial refractory period. During this period 134, the atrial sense channel is responsive to sensed signals, but the sensed signals are not used for the purposes of resetting pacing timing cycles or tracking of the sensed atrial signals. They are instead used for example, for computing a filtered atrial rate for purposes of automatic mode switching. This period may, however, include one or more atrial channel blanking windows 146, 148. Any atrial detection—whether it is a true atrial event or a non-atrial event—that occurs during a blanking window is ignored for purposes of atrial rate calculation. Thus, in accordance with the invention, the segmented relative atrial refractory period includes segments where atrial detections are used for atrial rate calculations and other segments where atrial detections are ignored for such purposes.
With reference to
The data acquisition process of
With reference to
With reference to
Returning to
Next, the parameter for each time window is compared to a threshold (block 306). Those time windows with parameters that satisfy the threshold are designated blanking windows (block 308) and the signals within those windows are ignored for purposes of atrial rate calculations. For example, with reference to
Continuing with
With reference to
Accordingly, assuming a far-field R wave (FFR) is detected during each of cycles 1 through 10 at approximately the same time, each far-field R wave would be associated with the third time window after a 25 millisecond absolute atrial refractory period. At cycle 1, ventricular event N=1 and count T=1. At cycle 2, N=2 and T=2. At cycle 3, T would be incremented 1, but because N=3, T is also decremented 1 and thus remains 2. At each cycle, T is compared to the count threshold of 5 and if T satisfies the threshold, e.g., is equal to or greater than the threshold, the third window is blanked—meaning the signal sensed during that window is considered an atrial detection of a ventricular event and is not used for atrial rate calculations. If the count does not satisfy the threshold the signal is considered a true atrial event and is used for atrial rate calculations. This counting and comparing process continues for each cycle. At cycle 7, T=5; accordingly the third window is blanked. For each of cycles 8 through 10, T remains greater than the count threshold and the third window remains blanked. Although the algorithm is designed to blank a particular timing window if its associated count T is equal to or exceeds 5, the counter T has a maximum value of 7 so that a subsequent intermittent loss of detection of far-field events, which will result in the T count decrementing, will not cause the T count to immediately decrement below the threshold.
With reference to
With reference to
During the next cycle only one P event (P1) is detected at time TP1. Accordingly, at third histogram state 404, the P-detect count template [1, 1, 3, 1, 1] is applied to time TP1 while the histogram states at time TP2 and TP3 remain the same. Upon occurrence of a subsequent ventricular event V, at histogram state 406, every bin within the corresponding ventricular-event-type histogram is decremented by one. Again, during the next cycle, only one P event (P1) is detected at time TP1. Accordingly, at fifth histogram state 408, the P-detect count template is applied to time TP1 while the histogram state at time TP2 and TP3 remain the same.
Upon incrementing the histogram bins, the algorithm processes the histogram contents to determine which windows, if any, shall be "blanked", such that the corresponding P detections are ignored for purposes of atrial rate calculations. For example, the algorithm may be programmed such that only those P detections that are associated with bins having a zero count are used for atrial rate calculations, while P detections associated with bins having non-zero counts are blanked. With reference to
In another exemplary count-based data processing implementation, two histograms are maintained. One histogram is associated with cardiac cycles initiated by intrinsic ventricular events (R waves) and the other with cycles initiated by a ventricular stimulation pulses (V paces). In this case the algorithm may be programmed such that, if the ventricular event was an R wave, the R wave histogram is processed and only those P detections that are associated with bins having a zero count are used for atrial rate calculations. P detections associated with bins having non-zero counts are blanked. Likewise, if the ventricular event was a V pace, the V pace histogram is processed and only those P detections that are associated with bins having a zero count are used for atrial rate calculations and P detections associated with bins having non-zero counts are blanked. Alternatively, both the R wave and the V pace histograms may be processed regardless of the ventricular event type, such that P detections associated with a bin is blanked if it is non-zero in either one of the histograms.
As mentioned above, the parameter determined for a time window may be derived using statistical processes other then the basic count based ones described with respect to
Regardless of the particular data processing implementation, the algorithm employs time based analyses to identify windows of time wherein atrial detections of ventricular events have occurred and are likely to continue to occur. While existing devices simply implement long post-ventricular atrial blanking periods to avoid non-atrial events, the algorithm described herein implements a relative atrial refractory period with one or more relatively short blanking segments inserted. As such, the algorithm effectively filters out non-atrial events, i.e., events falling within short blanked segments, from atrial rate calculations while leaving the remaining portions of the relative atrial refractory period—and the signals sense therein—available for atrial rate calculation purposes.
While the invention has been described by means of specific embodiments and applications thereof, it is understood that numerous modifications and variations could be made thereto by those skilled in the art without departing from the spirit and scope of the invention. It is therefore to be understood that within the scope of the claims, the invention may be practiced otherwise than as specifically described.
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In porn movies, the office is all about sex. No one does any work and they get to have sex on a desk. Wouldn't it be great if real offices were like that? Believe it or not, the sex based office we know and love from pornography could be coming soon to real life with a new LinkedIn app called "BangWithProfessionals".
New App helps you have sex with co-workers
Olivia from "Pawn Stars" fired for doing porn
If you haven't seen an episode of Pawn Stars, you will not understand this blog post. This would be a great time to get caught up because it's a great show. It's a reality show on the History Channel where people come in to the Gold and Silver Pawn Shop with treasure or crap and try to make some money. It's like Antiques Roadshow but with a rock n' roll edge.
One of the series highlights was when they hired the attractive alt-girlOlivia Black to work the night-shift in season 5. Though she was only a minor part of the show, she brought a real good energy to the shop as positive, petite, tattooed girls tend to do. Olivia was always a welcome change of pace from the fat old men and Chumlee's incompetence that the show usually focuses on.
But that's all over. Olivia Black has been fired. Why? Because people found out about her porn-past.
Sex.com discusses Star Wars Episode VII
It's been an eventful week…
Hurricane Sandy wreaked havoc across the eastern United States. A new Kim Kardashian sex tape emerged and then was written off as a fake. Lady Gaga and Rhianna both dressed up in weed-related costumes for Halloween.
But really, there was no bigger news story than Disney's 4 billion dollar acquisition of Lucasfilm and the announcement that there will be a Star Wars Episode VII Continue Reading
Fill your G-Spot with a G-Shot
Since its discovery in the 1940s, straight men everywhere have been hopelessly trying to find the woman's G-Spot. Most men can barely even find the clitoris, so trying to find a spot that people aren't too sure exists is even more daunting.
I got good news for all the sexually illiterate men and sexually dissatisfied women of the world. Hollywood gynecologist and surgeon Dr. David Matlock has the women of Los Angeles crowding his clinic, the Vaginal Rejuvenation Institute of America (this the real name of his clinic), to receive their "G-Shots", a surgical procedure that injects filler into a woman's G-Spot for an improved sex life.
Totally insane, right? Well, let's find out more about it!
Prime Time TV has more nudity than ever before!
The Parents Television Council has just confirmed our worst fears:
Nudity on prime time TV is rising.
Since only a year ago, the PTC claims that nudity has gone up 407% in 2011 – 2012. What can explain this sudden decent into depravity? Are we so culturally bankrupt that the only way we can comfort ourselves between hollow Hollywood remakes is to see some pixelated tits on basic cable between 5pm and 9pm?
Of course not, that's why we have the internet. We don't have to wait around for that window where nudity may pop onto the screen. You can look at Sex.com from your phone.
Still, the PTC has crunched the numbers to prove the spike in television nudity. Here are the message as they appeared in the press release:

subset: commoncrawl


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26 Ways to Feed Your Body for Results
By: Lou Schuler
- Overview
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- Caffeinate a Workout
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- Blend the Best Shake
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Burn Fat
Some men don't work out to lose body fat. They eat and train with the goal of becoming stronger or faster or better at their sport, and a great physique is just part of the deal. In fact, athletes can screw up their chance for glory by focusing too much on appearance—that is, cutting the calories they need to fuel their workouts. But for most of us, better performance is just a nice perk. What we really want is to drop fat without losing muscle.
Sign up for our FREE Daily Dose newsletter for the best fitness, health, sex, and nutrition tips delivered to your inbox daily.


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Reporting to the Executive Vice President, the Insurance Program Manager has a critical role in ensuring that we have the best performing products on our site, and that we maintain optimum relationships with our insurance partners. This person will regularly analyze the products we offer, recommend changes for improvement and communicate results. They will work with internal departments and external partners to facilitate implementation of new and revised products. Overseeing all insurance products on our site, the primary goal of this position is to foster growth for us and our business partners.
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2784 kr
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A lightweight and aerodynamic helmet for road riders, the Velodrome is a quality product at a fair price. Featuring the classic Carrera compact look, its superior in-mold construction means both longevity and durable protection for the rider, while safety features include a rear light and reflective stickers.
Key Features:
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NatanaelRate Natanael: Do you like this name?
Meaning and name origin
Natanael \n(a)-ta-nael\ as a boy's name is of Hebrew origin, and the meaning of Natanael is "God has given". Natanael is a variant of Nathaniel (Hebrew); biblical: one of the 12 apostles, who was also called Bartholomew.
Natanael has 1 variant form: Nataniel.
Natanael is not a popular first name for males and an equally uncommon surname or last name for all people (2000 U.S. Census).
Displayed below is a comparison of the popularity of the boy name Natanael and its variant forms. The only popular variation form ranked in the Top 1000/100 is Nathaniel (#94). (2014 statistics).
Similar Names
Suggested similar baby names are Nathanael and Nathanyel. These names tend to be more commonly used than Natanael.


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Nick Grimshaw does my head in!
View Single Post
23-02-2013, 09:58
Forum Member
Join Date: May 2008
Posts: 222
Originally Posted by
The photos suggest otherwise.
He appears to be a walking definition of over-sized ego.
Actually the person you're replying to is right - in so far as we know from people who ACTUALLY know Nick Grimshaw, as opposed to tabloid hack jobs and People On The Internet. Matt Fincham (his producer) has commented twice on his lack of ego, the first time they'd just moved studio and Nick jokingly asked if he'd wrangled it by saying Nick was demanding they changed. To paraphrase Matt, that wouldn't work because "everyone knows you're not like that, you're a nice guy". Add that to all the Call or Deletes when Nick tries to get celebrities to say getting the Breakfast Show's 'changed him' and turned him into a diva and so far not a single person has believed them. In fact they usually protest quite strongly that he wouldn't act that way (I particularly liked Caroline Flack's "Grimmy woudn't do that, he's everyone's friend" to Olly Murs). I have yet to hear anything bad about the man from the people who know him and spend time with him (of which there are a lot - perhaps because he's fun and a good friend? Just a crazy thought!)
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Recent Meetups
March 25 · 6:30 PMPainting With Fire And Light?Who Else Wants To Join Me To Paint With Fire And Light? This meetup will be split in to 2 sections. • In the first section we will be having some fun with Fire twirling... Learn more
March 21 · 9:30 AMHow To Use Your Camera In Manual Beginners Master ClassHow To Use Your Camera In Manual And Take Better Photographs This How To Use Your Camera In Manual And Take Better Photographs will move your photography on from just... Learn more
February 28 · 12:30 PMPose Like A Pro – Posing Masterclass.Pose Like A Pro – Posing Masterclass. This Pose Like A Pro – Posing Masterclass. will give you and your photography the confidence to take professional looking portrait ... Learn more
February 11 · 6:30 PMPanning WorkshopPANNING WORKSHOP It's been a while in the planning but have now finally found a location for the Panning Workshop. In photography, panning refers to the rotation in a... Learn more
February 8 · 6:00 PMSunset Photography WorkshopTHE BRISBANE PHOTOGRAPHY SUNSET PHOTOGRAPHY WORKSHOP This Workshop will move your photography on from just taking snaps to making works of art. It will provide you with... Learn more
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would you wear it? 10/10
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Take some *Time Out* for You, Join our Friendly/Supportive group :)
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No. But I have that backpack.
Quoting roxxyt:
Yes everything but the tights
by Brian's Lil Vixen on Oct. 10, 2012 at 10:01 AM
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With its season on the line in Tuesday's Great Plains Athletic Conference semifinal against Concordia, the Hastings College men's soccer team needed a miracle.
With 1:56 left in the game, the Broncos got it.
Shane Davidson found himself open outside the goal box and hit a crosser that was headed in by Marc Tautz to even the score and force overtime.
Then with 1:59 left in the first overtime, Jake Ramsay hit a turnaround, unassisted goal past the fingertips of Concordia goalkeeper Brendan Buchanan to send Hastings College to the GPAC championship with a 2-1 comeback on a frozen night at Lloyd Wilson Field.
"It was incredible. It was incredible. I saw the ball come in from Shane and I was able to get the goal with just over a minute remaining," said Tautz, a freshman from Limburg, Germany. "It was just incredible. It was important for us so we could keep playing this season."
The NAIA No. 11 Broncos (16-2-2, 9-0-1) will face Midland (12-7-1, 7-2-1) for the second consecutive season in the conference final after the Warriors buried Dordt 6-1 in the other semifinal. The game will be hosted by Hastings College Friday at 7 p.m.
To read more area sports, see Wednesday's Hastings Tribune or the Tribune e-edition.>>


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Before I dump all the entries (+ envelope prints) that's been sitting on my drafts page for the past two months, I just want to share to you my recent haul from Sephora. I've moved back to Manila this month, so this was my last haul from the No. 1 Beauty Authority. /cries
Urban Decay's Naked 3 Palette for my sister.
Daily Makeup Brush Cleaner / Soothing Cleansing Milk / Express Cleaning Wipes / (Not in Photo) Retractable Lip Brush for Mom
I love Sephora's Daily Makeup Brush Cleaner, but I wish they were selling a bigger bottle. The Soothing Cleansing Milk is a good make-up remover but stings my eyes. :(
FREE Tarte BB Tinted Moisturizer Sample / FREE Tarte Amazonian Clay 12-Hour Blush in Dollface Sample


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No strips, no trays, no sensitivity, whiten your smile in just one minute a day. Use GLO Solo and flash a whiter smile in 2 weeks! Simply add GLO Solo to your normal oral care routine by applying a thin layer of gel to fronts of teeth 2x a day after brushing and flossing. Each day you GLO, your smile will get brighter and whiter.
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Apply a thin layer of GLO Lip Care to lips (inside and out) before each application. If you are extra sensitive, also apply to the gum area. Open the G-Vial by holding the base firmly while gently twisting and pulling the cap. Apply whitening gel by squeezing formula onto brush tip and applying a thin layer on the top and bottom teeth, fronts only. Apply once in the morning and once in the evening after brushing and flossing. Repeat every day for 14 days. For best results, don't eat, drink, or kiss for 15 minutes after application so the gel has time to evaporate.
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OpenID Login
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Winter!: Prepare for holiday gaming!
Game Night!: This weekend! https://www.facebook.com/events/317792721696252/
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Answer this question....: Eyup or Nope?
So Gamers...: how is it going?
Fercberk...: Ask us a question or two on our Facebook Page! http://www.facebook.com/gamerDNA
Need Help?: Ask us a question or two on our Facebook Page!
Facebook!: Gamers! Check out our Facebook page!
Youtube!!!: Check out our Youtube channel http://www.youtube.com/user/smg1170?feature=mhee
Gamers......: meh
Closing in:
Typical scene from Drakensang: The Dark Eye
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Ooh, it's soft...
The number of games with "battlefield" in the title.
gamerDNA®, Contents are Copyright 2006–2015 PLAYXPERT LLC and Live Gamer Inc. gamerDNA and the gamerDNA Logo are trademark and property of Live Gamer Inc.


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We created Pandora to put the Music Genome Project directly in your hands
It's a new kind of radio –
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O Little Town Of Bethlehem
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What is your business plan? love the music. will pay for. But never notice ad space.


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For best performance, replace the filter in your Bedroom Air Purifier every five years. This Bedroom Air Purifier Replacement Filter uses a five-step filtration process to clean the air and give you better quality sleep. Having a clean filter every five years helps reduce snoring, coughing, sneezing, wheezing, dry mouth, runny nose, asthma and allergy attacks.
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Item # 202281
Remember to change the filter in your Bedroom Air Purifier every five years for optimum performance.
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Length: 13.75
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Begin New Search
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Kyle Littlepage
member for 8 years, 2 months, 22 days
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my side of families: Littlepage and Joy
my wife's side of families: Sykes and Dalrymple
Please submit any additions or corrections to me at my email.
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Don Littlepage
wrong cemetery
Kyle on #32315670 you have Grace[not Gracie]in the wrong cemetery. She is in Willow Cemetery in Haskell county, Haskell Texas. You have her in Willow City in Gillespie. Also the pic of the cemetery shows wrong cemetery. Have a good day. She is buried next to her husband John Littlepage.
Added by
Don Littlepage
on Nov 24, 2014 10:37 PM
Jesse Bocanegra
Info came from Texas Birth Index, 1903-1997
Please link Jesse "Jay" Bocanegra # 19430857 buried at Assumption Cemetery
with his parents
F. Daniel Bocanegra # 84245930
M. Clotilde Bocanegra # 86647026
Thank you
Added by
on Mar 10, 2013 5:16 PM
Donna Lee Watts
Robert Norman Loftis
Can you please link Robert Loftis to his parents
I have also sent message via website previously...
James Loftis 63032971
Elsie Mae Loftis 63032951
I appreciate your help.
Added by
Donna Lee Watts
on Aug 23, 2012 12:27 PM
Gwen Massie Mines
Robert Massie's Mother
Robert Massie was the son of James Albert and his second wife Lucilla Cofer, 1835-1871. She is buried in the Stiff Chapel Cemetery, Collin County, Texas.
Added by
Gwen Massie Mines
on Aug 14, 2009 8:54 PM
A sincere thank you...xoxo
for your addition to my baby brother's memorial page (Find A Grave Memorial# 33200193) I really appreciate your help. If I can do anything for you in the Houston area, please let me know. Peace, Nikki
Added by
on Jul 15, 2009 6:57 PM
carla page
robert massie
yes he was the son of james albert massie&mary ann bridgewater/bridgwater.they used both spellings of the name.don,t quote me on this but i think the massie,s are buried on the strini property in north garden,virginia.the headstones there date back to the very early 1700,s.
Added by
carla page
on Jul 13, 2009 1:15 AM
Star Rhodes
Do I need to move John Allen Littlepage to the other Cemetery as well.
Added by
Star Rhodes
on Feb 09, 2009 9:02 AM
Star Rhodes
Ollie Barnes Littlepage
I accidentally deleted the page for Ollie Littlepage. I have corrected it, but could you please add your photograph again. Also, can you identify the people in the picture.
I sent you an E-Mail on Ollie's father, Bennet Barnes, He has an interesting but sad history.
Take care!
Added by
Star Rhodes
on Feb 03, 2009 3:45 PM
Star Rhodes
Fannie Leora Littlepage-Johnson, granddaughter of James Bourland Littlepage was my daughter's 2nd great grandmother. I have a photograph of her attached to her memorial on findagrave. In my virtual cemeteries, listed as My Children's Ancestors, you can find the lines from James to Fannie's daughter Gertrude Inez Johnson-Nolley. I have been researching for many years and contributed what I can to findagrave.
God Bless You, Kyle!
Talk to you Soon.
Added by
Star Rhodes
on Jan 29, 2009 10:06 AM
Star Rhodes
James Bourland Littlepage
Dear Kyle,
I love the photograph you added to the memorial of James Bourland Littlepage. I was wondering where you got it and if there were any other's where that came from. I would love to have e-mail copies of any Littlepage photographs you might have.
Added by
Star Rhodes
on Jan 28, 2009 8:30 AM
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text: Kodak - the high-volume market leader - delivers brilliant, never-before-possible advantages for your enterprise with Kodak i5000 Series Scanners. Breakthrough digital architecture offers logic and program ability delivering advantages for today and tomorrow - including optimized memory allocation and processing paths, and customization capabilities for your job streams. Load any mix of diverse documents and your i5000 Series Scanner will find the fastest way to scan, perform imaging functions, extract data and neatly stack originals.


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Categories: Erotica/Erotic Romance/Romance
Publisher: Newsite Web Services Publishing | Date published: 03/14/2008
Lucky St. James is the woman from the wrong side of the tracks, and despite her birth name, her luck with men has been anything but fortunate. Her biological father walker out on her and her mother when she was just a baby, her stepfather abused her mother and kept Lucky in a state of fear her entire childhood, and a string of boyfriends all cheated and lied to her. Now she meets Clay Jackson, a wealthy gentleman farmer who wants nothing more than to prove to Lucky that love and trust are worth taking a chance on. Lucky wants to give herself completely to him, even after he explains to her about his interest in domestic discipline in their relationship. But will she really be able to trust him and allow herself to be loved the way she longs to? For adults only.


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Bozeman HotelsLaunch yourself across the snow of high-level ski runs in the Rocky Mountains, meet bears up close and personal in a dedicated visitor attraction nearby, and discover the history of Montana's earliest inhabitants as you explore interesting museums and walk historic trails. Bozeman is a quaint resort town that sets a trend for skiing in winter time, and hiking through warmer months. Its history is explored through several fascinating museums, while idyllic patches of green parkland lie next to university buildings and towering shopping malls.Things to seeAt the Museum of the Rockies, life in the shadows of this historic mountain range is celebrated in a variety of unique collections. Marvel at the monstrous dinosaurs that once walked the earth in one of the world's most impressive and comprehensive display of fossils and bones. The Planetarium is a mesmerizing display of planets and stars projected into the night sky, and at the Martin Children's Discovery Center kids can discover the magic of science through interactive play. The Bridger Bowl Ski area takes you on a journey to the summit of craggy mountains, where the deep, powdery soft snow creates the perfect skiing trails in sublime scenery. Novices can stick to the easy runs, learning the art of balancing on the slopes, while experts can race down the mountainside to the finishing point below. The Little Bear School House Museum offers a unique insight into a century-old school system inside its 1-room school house, complete with wooden desks and original inkwells. There's a display of memorabilia from Bozeman's earliest pioneering days, and a collection of children's furniture that predates the last century.Hotels in BozemanThe picturesque, almost alpine town is an outdoor wonderland, and many of the hotels in Bozeman exist only to cater for the tourist trade that arrives at the first sign of snow. Hotels are modern and comfortable, but far from luxurious, perfectly in keeping with the cozy, homely feel the town prides itself on. Typically, rooms are a good size and modern in style. Hotels in Bozeman usually provide a cooked breakfast daily, or a continental buffet at least, televisions, private bathrooms, and occasionally WiFi. They're ideally located for a short walk to the main street stores, and some provide shuttle transfer for skiers heading to the slippery white slopes.Where to stayAt the foothills of the Rocky Mountains in Montana, Bozeman is a pretty, quiet town with a love of nature and the outdoors. Characterized by the sprawling campus of the Montana State University at its heart, it's also home to a pretty main street with rows of independent shops, a variety of glitzy shopping arcades with name-brand stores, and the green, rolling fairways of idyllic golf courses tucked into the foothills. As well as hotels in Bozeman, booking accommodation in the neighboring town of Livingston on the picturesque Yellowstone River has a lot to offer visitors, from fishing and rafting, to bear encounters and hiking its magnificent trails you'll be close to many must-dos.How to get to BozemanJust a 13 minute drive from the center of town, the Bozeman Yellowstone International Airport is a good sized airfield that caters well for international flights. With such a short journey to make, and an easy run down the straight lanes of Interstate 90, reaching your hotel won't be complicated. Shuttle buses and taxis are a good way to make the journey with minimum fuss, although a hire car of your own gives you space and independence to explore the fabulous setting of this mountainous terrain.
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Holiday Inn Bozeman
Good 3.7 / 5 ( 139 reviews )
46 people looked at this hotel in the last hour
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"Great location. Spacious room, nicely furnished. Friendly staff. Great price. All the amenities. Be sure to get first floor room though, no elevator. This was my second stay there in two weeks and they honored my request for first floor. Definitely my first choice in Bozeman!"
A Traveller, Jun 2015, US
Microtel Inn & Suites by Wyndham Bozeman
Good 3.8 / 5 ( 296 reviews )
31 people looked at this hotel in the last hour
Most recent review
"Our room was clean and comfortable. We were in the lower level and could hear noise above us, but it didn't bother us much. Breakfast was okay and the staff was very friendly."
A Traveller, Jun 2015, US
Super 8 Motel - Bozeman
Good 3.8 / 5 ( 295 reviews )
26 people looked at this hotel in the last hour
Most recent review
"I will remember Katie's honesty for a long time. I can only wish everyone I meet or talk to would be like her."
A Traveller, Jun 2015, US
Ramada Bozeman
Excellent 4.1 / 5 ( 275 reviews )
23 people looked at this hotel in the last hour
Most recent review
"Our room was clean. This hotel had all the normal expectations for a hotel. The kids loved the pool and water slide! There is a door to the exterior and interior of the hotel bottom floor rooms. Overall good stay with kids."
A Traveller, Jun 2015, US
Comfort Inn Bozeman
Excellent 4.1 / 5 ( 147 reviews )
20 people looked at this hotel in the last hour
Most recent review
"The staff was very friendly and helpful. Thanks for great stay!"
A Traveller, Jun 2015, US
Western Heritage Inn of Bozeman
Excellent 4.0 / 5 ( 543 reviews )
19 people looked at this hotel in the last hour
Most recent review
"We came for the weekend, visiting in the area . We were very pleased"
A Traveller, Jun 2015, IL
Country Inn & Suites By Carlson, Bozeman, Mt
Excellent 4.5 / 5 ( 120 reviews )
14 people looked at this hotel in the last hour
Most recent review
"I had a really nice one-night stay here as part of a trip up north to Glacier. The hotel is somewhat near the airport and not too far from downtown Bozeman, but it's definitely not in the town proper. That being said, the rooms are clean, new, and well-appointed. The free breakfast is pretty ..."
A Traveller, Jun 2015, US
Quality Inn
Excellent 4.3 / 5 ( 375 reviews )
14 people looked at this hotel in the last hour
Most recent review
"My one and only complaint is that our single bed room is still not roomy enough for wheelchair or scooter accessibility . My question is do you have handicapped accessible rooms available ,as we plan on coming back again in the future and we need more bathroom and room space or do we need to look..."
A Traveller, Jun 2015, US
Holiday Inn Express Hotel & Suites Bozeman West
Excellent 4.4 / 5 ( 131 reviews )
14 people looked at this hotel in the last hour
Most recent review
"2 nights for business. Like most HI Express, new, clean, comfortable. Front desk staff needs to learn some customer service skills. However both of the porters who drove me to and from the airport were very nice."
A Traveller, May 2015, US
Holiday Inn Express Hotel & Suites Belgrade
Excellent 4.6 / 5 ( 193 reviews )
13 people looked at this hotel in the last hour
Most recent review
"This was a great hotel. Comfy spacious room and great beds. We traveled out early and they even had apples, yogurts, and oatmeal we could take for breakfast."
A Traveller, Jun 2015, US


text:
42 U.S. Code § 18052 - Waiver for State innovation
(a) Application
(1) In general
A State may apply to the Secretary for the waiver of all or any requirements described in paragraph (2) with respect to health insurance coverage within that State for plan years beginning on or after January 1, 2017. Such application shall—
(B) contain such information as the Secretary may require, including—
(i) a comprehensive description of the State legislation and program to implement a plan meeting the requirements for a waiver under this section; and
(2) Requirements
The requirements described in this paragraph with respect to health insurance coverage within the State for plan years beginning on or after January 1, 2014, are as follows:
(C) Section 18071 of this title.
(3) Pass through of funding
With respect to a State waiver under paragraph (1), under which, due to the structure of the State plan, individuals and small employers in the State would not qualify for the premium tax credits, cost-sharing reductions, or small business credits under sections [1] 36B of title 26 or under part I of subtitle E for which they would otherwise be eligible, the Secretary shall provide for an alternative means by which the aggregate amount of such credits or reductions that would have been paid on behalf of participants in the Exchanges established under this title [2] had the State not received such waiver, shall be paid to the State for purposes of implementing the State plan under the waiver. Such amount shall be determined annually by the Secretary, taking into consideration the experience of other States with respect to participation in an Exchange and credits and reductions provided under such provisions to residents of the other States.
(4) Waiver consideration and transparency
(A) In general
An application for a waiver under this section shall be considered by the Secretary in accordance with the regulations described in subparagraph (B).
(B) Regulations
Not later than 180 days after March 23, 2010, the Secretary shall promulgate regulations relating to waivers under this section that provide—
(i) a process for public notice and comment at the State level, including public hearings, sufficient to ensure a meaningful level of public input;
(ii) a process for the submission of an application that ensures the disclosure of—
(iii) a process for providing public notice and comment after the application is received by the Secretary, that is sufficient to ensure a meaningful level of public input and that does not impose requirements that are in addition to, or duplicative of, requirements imposed under the Administrative Procedures Act, [2] or requirements that are unreasonable or unnecessarily burdensome with respect to State compliance;
(iv) a process for the submission to the Secretary of periodic reports by the State concerning the implementation of the program under the waiver; and
(5) Coordinated waiver process
The Secretary shall develop a process for coordinating and consolidating the State waiver processes applicable under the provisions of this section, and the existing waiver processes applicable under titles XVIII, XIX, and XXI of the Social Security Act [42 U.S.C. 1395 et seq., 1396 et seq., 1397aa et seq.], and any other Federal law relating to the provision of health care items or services. Such process shall permit a State to submit a single application for a waiver under any or all of such provisions.
(6) Definition
In this section, the term "Secretary" means—
(A) the Secretary of Health and Human Services with respect to waivers relating to the provisions described in subparagraph (A) through (C) of paragraph (2); and
(b) Granting of waivers
(1) In general
The Secretary may grant a request for a waiver under subsection (a)(1) only if the Secretary determines that the State plan—
(A) will provide coverage that is at least as comprehensive as the coverage defined in section 18022 (b) of this title and offered through Exchanges established under this title [2] as certified by Office [3] of the Actuary of the Centers for Medicare & Medicaid Services based on sufficient data from the State and from comparable States about their experience with programs created by this Act and the provisions of this Act that would be waived;
(B) will provide coverage and cost sharing protections against excessive out-of-pocket spending that are at least as affordable as the provisions of this title [2] would provide;
(C) will provide coverage to at least a comparable number of its residents as the provisions of this title [2] would provide; and
(2) Requirement to enact a law
(A) In general
A law described in this paragraph is a State law that provides for State actions under a waiver under this section, including the implementation of the State plan under subsection (a)(1)(B).
(c) Scope of waiver
(1) In general
The Secretary shall determine the scope of a waiver of a requirement described in subsection (a)(2) granted to a State under subsection (a)(1).
(d) Determinations by Secretary
(1) Time for determination
The Secretary shall make a determination under subsection (a)(1) not later than 180 days after the receipt of an application from a State under such subsection.
(2) Effect of determination
(A) Granting of waivers
If the Secretary determines to grant a waiver under subsection (a)(1), the Secretary shall notify the State involved of such determination and the terms and effectiveness of such waiver.
(B) Denial of waiver
If the Secretary determines a waiver should not be granted under subsection (a)(1), the Secretary shall notify the State involved, and the appropriate committees of Congress of such determination and the reasons therefore. [4]
(e) Term of waiver
No waiver under this section may extend over a period of longer than 5 years unless the State requests continuation of such waiver, and such request shall be deemed granted unless the Secretary, within 90 days after the date of its submission to the Secretary, either denies such request in writing or informs the State in writing with respect to any additional information which is needed in order to make a final determination with respect to the request.
[1] So in original. Probably should be "section".
[2] See References in Text note below.
[3] So in original. Probably should be preceded by "the".
[4] So in original. Probably should be "therefor."
Source(Pub. L. 111–148, title I, § 1332,Mar. 23, 2010, 124 Stat. 203.)
References in Text
Part I of subtitle E, referred to in subsec. (a)(3), is part I (§§ 1401–1415) of subtitle E of title I of Pub. L. 111–148, which enacted subchapter IV of this chapter and section 36B of Title 26, Internal Revenue Code, amended section 405 of this title, sections 280C, 6103, and 7213 of Title 26, and section 1324 of Title 31, Money and Finance, and enacted provisions set out as a note under section 36B of Title 26. For complete classification of part I to the Code, see Tables.
This title, where footnoted in subsecs. (a)(3) and (b)(1)(A) to (C), is title I of Pub. L. 111–148, Mar. 23, 2010, 124 Stat. 130, which enacted this chapter and enacted, amended, and transferred numerous other sections and notes in the Code. For complete classification of title I to the Code, see Tables.
The Administrative Procedures Act, referred to in subsec. (a)(4)(B)(iii), probably means the Administrative Procedure Act, act June 11, 1946, ch. 324, 60 Stat. 237, which was classified to sections 1001 to 1011 of former title 5 and which was repealed and reenacted as subchapter II (§ 551 et seq.) of chapter 5, and chapter 7 (§ 701 et seq.), of Title 5, Government Organization and Employees, by Pub. L. 89–554, Sept. 6, 1966, 80 Stat. 378. See Short Title note preceding section 551 of Title 5.
The Social Security Act, referred to in subsec. (a)(5), is act Aug. 14, 1935, ch. 531, 49 Stat. 620. Titles XVIII, XIX, and XXI of the Act are classified generally to subchapters XVIII (§ 1395 et seq.), XIX (§ 1396 et seq.), and XXI (§ 1397aa et seq.), respectively, of chapter 7 of this title. For complete classification of this Act to the Code, see section 1305 of this title and Tables.
This Act, referred to in subsec. (b)(1)(A), is Pub. L. 111–148, Mar. 23, 2010, 124 Stat. 119, known as the Patient Protection and Affordable Care Act. For complete classification of this Act to the Code, see Short Title note set out under section 18001 of this title and Tables.
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text:
Yup...Cosina. Cosina actually provides that same body for a bunch of manufacturers. Check out the catalogs or web sites of the big retailers...each camera manufacturer has a "bottom-end" manual camera, and they're almost all the same Cosina body with different lens mounts and a few minor cosmetic differences. Cosina even sells the same body under their own name (with, I believe, a Pentax K-mount).Originally Posted by Paul Sorensen
I think it was these bodies and the kit lenses that come with the bodies more than anything else that allowed Cosina to stay in business long enough to bring out the higher quality cameras they're now making (the Voigtlander Bessa series, the Bessamatic, and now the Zeiss-Ikon). Unfortunately, everyone I know who's purchased one of these low-end bodies has had problems with it before the camera was 2 years old...one hopes that Cosina will bring some of their newer engineering expertise to bear on these bodies some day.
For today, though, I'd avoid the FM10 in favor of almost any other Nikon body...even a well used Nikon FG is likely to be a better choice.