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Tesco Hudl 2
The supermarket chain's update to the original Hudl brings a bigger 8.3-inch HD display, a beefed up quad-core Intel processor, 2GB RAM and Dolby optimised sound. It's available in a myriad of colours, from purple to pink plus there's a microSD slot for storage expansion and a miniHDMI connector for outputting media to your TV. All in all, the Hudl 2 is looking like an impressive package, especially for £129.
£129 | Tesco | Buy it now on Tesco
Kindle Fire HD 6
The smallest of Amazon's range of Kindle Fire devices also happens to be the cheapest, yet it still packs a decent spec list. Running Android 4.4, but with the obvious addition of Amazon's heavy UI, the pocketable tab boasts an HD display, quad-core processor and a choice of 8GB or 16GB internal storage. There's also a front and rear snapper, which can record 1080p video and for the first time for a Fire tablet it will come in a variety of colours.
£79.99 (8GB) | Buy it now on Amazon
Nexus 7 (2013)
The update to the 2012 T3 gadget of the year brings in a new, stunningly bright and sharp display, refined design and faster processor, while pushing the version of Android up to 4.3. Google also added a five megapixel rear camera, wireless charging tech and doubled the amount of RAM, to make a rather enticing high-end tablet for a relatively cheap price-tag.
Price: £199 | Buy now from Amazon | T3 review
Acer Iconia B1
Small but mightly, this Acer somehow packs a lot in without affecting its staggeringly low price. The dual-core 1.3GHz processor makes browsing and reading snappy, and the textured back - a feature interestingly dropped by Nexus - gives the small tablet an easy grip, perfect for holding in one hand. Although storage is seriously low at 1GB or 16GB, a micro-SD card slot is included to add up to 32GB of storage. It's a smooth design that's nice to the touch, and would be ideal for an additional tablet for the kids or first-time users.
£107.99 | Buy now from Amazon
Archos 70 Cobalt Tablet
The baby of the tablet game, the Cobalt focuses on packing a lot into a little. The 7-inch screen boasts a 1024x600 resolution and is housed in a body that's only 10.6" thick and tips the scales at 300g. It runs Andriod 4.2 Jelly Bean without any added overlays which, with its 1.2GHz processor, makes it quick and easy. What it lacks in GPS and Bluetooth capabilities, it makes up for by adding mini-HDMI and micro USB connections. It may have a meagre 2MP camera, but it's a perfect grab-and-go for reading on the commute, and it's also incredibly easy on your wallet.
£71.99 | Buy now from Amazon
Lenovo Yoga 8-inch
Weighing in at only 400g, the 8-inch Yoga tablet punches way above its weight - literally. The three-way stand makes it easily adaptable to whatever position you need, and the Andriod 4.2.2 system works smoothly on the 1280 x 800 display. While it's clearly a little brother to heavyweights such as the Asus Transformer Pad and Nexus 10. The alleged 18-hour battery could tip the balance in the Lenovo's favour - along with its very attractive price.
£199 | Buy now from Amazon | T3 hands-on review
Asus Memo Pad HD 7
Asus may the company behind the Google branded Nexus 7, but they don't seem to get a whole lot of credit for that, so they've decided to go it alone. The Memo Pad HD 7 features a sturdy, plastic build that is available in a wide array of hues, along with a nippy quad-core 1.2 GHz processor. Display wise, the 1,280 x 800 IPS LCD display is decent, especially at this price-tag, though it won't harm any of the big-hitters.
Price: £129 | Buy now from Amazon | T3 review
Amazon Kindle Fire HDX
Amazon has really beefed up the specs this year, with a quad-core Snapdragon 800 processor, 2GB RAM and a unique Mayday feature that puts a trained Amazon customer service advisor right onto your screen. You should get 11 hours of battery life, which can be extender further when reading.
Price: £199 (16GB) | Release: November | Buy now from Amazon | Learn more about Mayday
Tesco Hudl
Yep, you read that correct, Tesco has entered the tablet race, going head to head with Amazon for bargain slate dominance. Named Hudl, this fairly well specced tab boasts a 1.5 GHz quad-core processor, dual-band Wi-Fi and 16GB of internal storage expandable up to 48GB thanks to the Micro SD. That's a decent amount of storage, plus the card slot could give it the edge over some of the competition. Screen-wise, the Hudl has a clear 7-inch 243 ppi display, great for watching content from Tesco's Blinkbox service. It may not be quite as svelte and slim as the new Nexus 7, but it does look rugged and fairly durable. It seems a smart move from Tesco to enter this area, especially as they have a load of apps from Clubcard points to online shopping.
Price: £119 | Buy now from Tesco | T3 review
Amazon Kindle Fire (2013)
Amazon are ditching the original Fire model and replacing it completely with the HD model, which has just seen a price drop, spec bump and slight redesign. The new model comes with a 1280x800 resolution 7-inch display, dual-core processor and version 3.0 of the Fire operating system.
Price: £119 (8GB) £139 (16GB) | Release: October 24th | Buy now from Amazon
Nook HD+
After seeing numerous price-drops in the past few months, the Nook HD+ has now become a much more viable choice for the budget tablet of choice crown. With its HD 9-inch display, it's the best option on this list if you want something a bit bigger than 7-inches. Unlike Amazon's tablets, you'll have direct access to Google services and the Play Store, while the dual-core processor should keep things running smoothly. Internally you've got 16GB of storage to play with, but this can be expanded thanks to a Micro SD slot.
Price: £129 | Buy now from Amazon
Asus Fonepad
As the name suggests, this device is far more than just your run of the mill tablet, in-fact, it's also a phone. Thanks to the 3G sim-card, you make calls, send texts and browse the web just as you would on any other smartphone. Aside from this headline feature there is a 7-inch HD display with good viewing angles, a Micro SD slot and a three megapixel rear camera.
Price: £179 | Buy now from Amazon
Samsung Galaxy Tab 3 7.0
Another tablet boasting a 7-inch display, the third iteration of the Galaxy Tab actually keeps the same screen we saw on the original model about three years. The 1.024 x 600 resolution panel doesn't match up to the likes of the Nexus 7 or even the slightly cheaper Asus Memo Pad HD 7, so you'll probably end up with slightly pixelated images. Narrower bezels give a more edge to edge feel, plus the battery life is quite good and there are two cameras, however the main selling is probably the similarity the software has to other high-end Samsung smartphones.
Price: £179 | Buy now from Amazon


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PRLog - Nov. 13, 2012 - COOKEVILLE, Tenn. -- Ruedas ESPN, held in conjunction with the Miami International Auto Show—formerly known as the South Florida International Auto Show—the honors program is presented by the editorial board of Ruedas ESPN, which is the country's top Spanish-language auto-oriented radio show. That makes the Altima (at least) tri-lingual, since it's also fluent in value.
2013 Altima at Nissan of Cookeville
Consider: The completely redesigned Altima offers a "class-above"
■Blind Spot Warning
■Lane Departure Warning
■Moving Object Detection
■Easy Fill Tire Alert
■The automaker's NissanConnect infotaintment/
■NissanConnect Navigation, complemented by real-time point-of-interest lookup from Google
Topping it all off, the Altima also has the top fuel-economy marks in the mid-size sedan segment, with an EPA line of 21 mpg city/38 mpg highway/31 mpg combined.
"Being honored by Ruedas ESPN as Car of the Year validates that the all-new 2013 Nissan Altima truly is the most innovative Altima ever," said Al Castignetti, vice president and general manager—Nissan division, Nissan Americas. "This award further emphasizes Nissan's strong commitment to developing innovative products while keeping a focus on quality and reliability as well as fuel-efficiency, dynamic performance and premium luxury."
About Nissan of Cookeville (http://www.nissanofcookeville.com/
Welcome to Nissan of Cookeville, located at 501 Neal Street in Franklin, TN. Serving Cookeville, Crosville, Lebanon, Livingston, Murfreesboro and Carthage, we're dedicated to exceeding our customer's expectations every day of the year.
Nissan of Cookeville welcomes you to come and shop the area's largest selection of new Nissans and extensive pre-owned selection. We'll buy your vehicle even if you don't buy from us. Our sales staff will patiently work with you to select the best car, truck or SUV at the best price to fit your particular needs.
You can easily schedule a service appointment on our website or feel free to call us and we'll be happy to take care of you. Our parts and service department is ready to help with any maintenance or service needs that you may have. We also have Nissan rental cars available in case you're only here for a short time.
Nissan of Cookeville is proud to share our One to One Rewards Program (http://www.nissanofcookeville.com/
It's our way of rewarding our best customers...YOU!
No Cost!
Earn points for service work!
Preloaded with sales and service points!
Earn even more points with Rewards+Plus online shopping!
One Point=One Dollar!
Spend points for service or sales back here at our dealership!
Personal website to track points and shop Rewards+Plus!
Only 1 account per household necessary!
If you don't see what you are looking for, click on CarFinder (http://www.nissanofcookeville.com/
Contact Information
Nissan of Cookeville
501 Neal Street
Cookeville, TN 38501
Sales: (888) 471-8099
Service: (888) 810-8041
Parts: (888) 810-8041
Sales Hours
Monday - Saturday: 9:00am -8:00pm
Sunday: CLOSED
Service and Parts Hours
Monday – Friday: 7:30am -5:30pm
Saturday: 7:30am -2:00pm
Sunday: Closed

subset: commoncrawl


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A Rare Thrill
WWII Pilot Flies Last Remaining B-24
It's been 65 years since Bob Bluford last took the controls of a bomber plane, but the decades haven't dulled his pilot's instincts.
While on route from Staunton to Chesterfield last month in the only remaining airworthy B-24, Bluford did not hesitate to accept an invitation to sit in the co-pilot's seat.
And when the pilot of the craft handed him the controls, Bluford didn't hold back either. The 91-year-old Presbyterian minister remained at the helm almost the entire flight before relinquishing the stick for a landing at Chesterfield County Airport.
Asked if his flight training came easily to mind after all those years, Bluford answered in the affirmative.
"But I didn't try any funny stuff," he said with a chuckle. "I just flew straight and level."
After volunteering for the U.S. Army Air Force in 1942, Bluford served as a B-24 bomber pilot and squadron leader, flying 18 missions over the European Theater. While he was based in England, his brother Harry was a ground crew chief, working with P-38's in Italy. The day after Bob Bluford's flight, Harry – now 90 and a resident of The Masonic Home – enjoyed his own flight tour of Richmond.
Organized by The Collings Foundation, an educational non-profit that sponsors living history events, the flight provided five local vets in all with an airborne stroll down Memory Lane, just in time for Veteran's Day. The Wings of Freedom Tour, which left Richmond Oct. 22 bound for North Carolina, is designed both to honor veterans and to educate visitors. Every year, an estimated three to four million people see the planes, which include a B-17 and a P-51 in addition to the B-24.
Polegreen Preacher
Since his World War II days, Reverend Robert Bluford, Jr. has leaned more towards shepherding church congregations than piloting planes.
Resuming his interrupted studies at Hampden-Sydney College, he graduated as valedictorian in 1947 and went on to the seminary. He later served as campus minister at Virginia Polytechnic Institute and had pastorates in North Carolina and South Carolina, then was active in the civil rights movement and war protests of the 1960s. In 1979, he co-founded the Fan Free Medical Clinic, and in 1989, he founded the Historic Polegreen Church Foundation in Hanover County.
Samuel Davies, the first non-Anglican minister licensed to preach in Virginia, pastored the Polegreen Church from 1747 to 1759. Among Davies' regular listeners at Polegreen, considered the birthplace of religious freedom in Virginia, was young Patrick Henry – who later credited Davies with "teaching me what an orator should be."
In addition to establishing Polegreen and overseeing its placement on the National Register of Historic Places, Bluford played a significant role in the preservation of Henrico County's Laurel Historic District, which is also on the register. He is an author as well, having chronicled the Samuel Davies story and the history of Polegreen in the book, "Living on the Borders of Eternity."
"He has a profound knowledge of history," says long-time admirer Susan Nochta, who was among the friends celebrating his flight. "If you have any questions on history, Reverend will probably know the answer."
On a historic tour with Bluford, she adds, he can talk about "every single building, how every brick was laid, who was who and who said what." A former runner, Bluford always carries his running shoes in the car and is known for conducting impromptu, hands-on tours that involve anything from a trek through the woods to digging up dirt.
Last One Left
Nochta notes that Bluford is tireless as a guest preacher as well, and never misses an opportunity to speak on the topic of religious freedom and Polegreen.
"There's not a church he hasn't preached at," says Nochta. "Bob is amazing. He reaches out, he never reaches in. He's given us so much insight – as Christians, friends, family members, and loved ones.
"He's definitely my hero," adds Nochta, noting how gratified she was to see Bluford enjoy an opportunity like the B-24 flight.
After his flight, Bluford observed that the feat was even more remarkable considering that almost all of the B-24's built -- except for a handful preserved in museums – were later "chopped up" for scrap.
"[That plane] was the only one of 18,000 made that is left in the world," he said, "and still flies."
What's more, it appears, the rare bird could not have been in more capable hands.
When Bluford asked the pilot, "How much altitude did I gain or lose?" he was pleased to hear that he had kept the aircraft flying level and true.
"It was quite a thrill for me," said Bluford. "I'm very grateful."
'Proof of Heaven' coming to Glen Allen
Dr. Even Alexander, a New York Times best-selling author who has been featured on Oprah and Dr. Oz, was in town last week to promote his June 27 talk, "Proof of Heaven," at Glen Allen High School.
Alexander (pictured, at right, while Unity of Bon Air church member Harry Simmons interviews him) has written about what he considers to be his journey through the afterlife.
Tickets to this month's event are $25 and will support the new Bon Secours Hospice House being built later this year. > Read more.
Innsbrook Rotary celebrates 25 years
The Innsbrook Rotary Club, which is celebrating its 25th year in 2015, has completed a number of volunteer projects this year and raised thousands of dollars for various organizations through three events.
The club's annual rose sale, benefit for youth live auction and Virginia Fire Games competition, combined with individual and corporate donations, have raised nearly $70,000 – money that the club contributes back to the community.
FeedMore is the beneficiary of the club's 25th anniversary project, which provides refrigerated trailers to be used for the distribution of food throughout Central Virginia. > Read more.
Weekend Top 10
For our Top 10 calendar events this weekend, click here! > Read more.
No one injured during fiery morning wreck on I-295
Va. Guard soldiers, airmen eligible for Va. Veterans ID card
Land Lovers, Clean Businesses honored
Henrico Schools holding job fair to recruit bus drivers
Fairfield MS band wins 5 awards
- More News
Print Edition
Jul. 2, 2015Click here to read the print edition.
Weekend Top 10
Voltaggio to host three-course dinners at Family Meal July 21-22
Fan favorite shines in new West End home
Weekend Top 10
Weekend Top 10
- More Entertainment
Obituary – Ruby White
Obituary – Thomas Stewart Gammon
Obituaries – Frances Inthavong
- More Obituaries
'Proof of Heaven' coming to Glen Allen
Innsbrook Rotary celebrates 25 years
Holman student named Miss Va. Coed Junior Teen
- More Community
My daughters' other dads
All hail to mothers and the hardest job of all
Cabin fever cures - and blessings
- More Opinions
Athlete of the Week – July 3: Kayla Sell
Athlete of the Week – June 19: Sydney Whitaker
Steward School's Enright drafted by NY Mets
- More Sports
Reader Survey | Advertising | Email updates
ClassifiedsSAVE on Cable TV-Internet-Digital Phone. Packages start at $89.99/mo (for 12 months.) Options from ALL major service providers. Call Acceller today to learn more! CALL 1-888-686-5081.
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CalendarHenrico County will host the annual Old-Fashioned Fourth of July Celebration from 1 p.m. to 5 p.m. at Meadow Farm, 3400 Mountain Rd. There will be patriotic activities, games, a… Full text


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Thoughtfly Films launches their second Louisville based feature length film production.
Comedy show at Play January 31 brings together comedy veterans and newbies.
This week the Louisville Orchestra will present a program that includes a world premiere from a young composer and a classic symphony of the Romantic era by Johannes Brahms.
Boone is now a three-time winner of the KDF poster design competition, and has a focus on all-natural materials.
Take a break from work and listen to live, inspiring music!
There's always something to do for families around town.
Find out more about Broadway Across America's Once.
Photographers and body painter transform model into ice queen.
Haymarket celebrates their birthday, Great Flood commemorates the great flood, and various other awesome events.
Three cheers for free homemade peanut butter topping!
The Forecastle lineup is one week away and it wouldn't be complete without these Louisville bands.
What's your family's favorite Llama Llama story?
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Tuesday, January 12, 2010
© Copyright 2015 Albany Herald
ALBANY -- A Dawson man wanted on many counts of child molestation could be 21 miles to the west in Randolph County, possibly in Cuthbert, a Dawson Police e-mail stated.
Scheduled to surrender to police, Anthony Bridges, 30, didn't show, police stated. Bridges was described as a black man, 5 feet, 7 inches tall and weighing 165 pounds.
People should consider that Bridges is dangerous, police added.
Further details from the Randolph County Sheriff's Office, the Cuthbert Police Department and Dawson police were not immediately available.
Anyone with information on Bridges' whereabouts is asked to contact Investigator Shattles of the Dawson Police Department at (229) 995-4414 or to contact a local law enforcement office.
More like this story
- Dawson man sought on child molestation charges ( January 12, 2010 )
- Dawson man turns himself in ( January 13, 2010 )
- Ex-cop charged with child molestation ( December 28, 2011 )
- Man arrested for child molestation ( August 24, 2010 )
- Man faces charges for rape of toddler ( December 1, 2009 )


text:
A minimally invasive, implantable monitor and associated method for chronically monitoring a patient's hemodynamic function based on signals sensed by one or more acoustical sensors. The monitor may be implanted subcutaneously or submuscularly in relation to the heart to allow acoustic signals generated by heart or blood motion to be received by a passive or active acoustical sensor. Circuitry for filtering and amplifying and digitizing acoustical data is included, and sampled data may be continuously or intermittently written to a looping memory buffer. ECG electrodes and associated circuitry may be included to simultaneously record ECG data. Upon a manual or automatic trigger event acoustical and ECG data may be stored in long-term memory for future uploading to an external device. The external device may present acoustical data visually and acoustically with associated ECG data to allow interpretation of both electrical and mechanical heart function.
1. An implantable medical device for monitoring heart function of a patient's heart, comprising:
a housing portion housing circuitry of the device;
a plurality of electrodes, electrically coupled to the circuitry, detecting cardiac depolarizations;
a sensor, electrically coupled to the circuitry, detecting pressure waves corresponding to the heart function;
a storage device storing data corresponding to the cardiac depolarizations and the pressure waves; and
a control unit controlling the sensor and storage of the data in the storage device in response to one of the detected cardiac depolarizations and the detected pressure waves.
2. The implantable medical device of
3. The implantable medical device of
a sensor assembly including the sensor; and
a coupling device electrically coupling the sensor assembly to the housing portion, the sensor assembly having a first thickness and the housing portion having a second thickness greater than the first thickness.
4. The implantable medical device of
5. The implantable medical device of 3, wherein the sensor includes a transmitter and a receiver, both the transmitter and the receiver positioned along one of the sensor assembly and the housing portion.
6. The implantable medical device of
7. The implantable medical device of
8. The implantable medical device of
9. The implantable medical device of
10. The implantable medical device of
11. The implantable medical device of
12. The implantable medical device of
13. The implantable medical device of
14. The implantable medical device of
15. The implantable medical device of
16. A method of monitoring heart function of a patient's heart, comprising the steps of:
detecting cardiac depolarizations and storing data corresponding to the detected cardiac depolarizations in a first memory portion;
determining whether a cardiac event is detected in response to the detected depolarizations; and
detecting pressure waves corresponding to the heart function, storing the data stored in the first memory portion and subsequently detected cardiac depolarizations and detected pressure waves in a second memory portion in response to a cardiac event being detected.
17. The method of
18. The method of
19. The method of
20. The method of
21. An implantable medical device system device for monitoring heart function of a patient's heart, comprising:
a housing portion housing circuitry of the device;
a plurality of electrodes, electrically coupled to the circuitry, detecting cardiac depolarizations;
a sensor, electrically coupled to the circuitry, detecting pressure waves corresponding to the heart function;
a storage device storing data corresponding to the cardiac depolarizations and the pressure waves;
a control unit controlling the sensor and storage of the data in the storage device in response to the detected cardiac depolarizations and the detected pressure waves;
an external device receiving and processing the stored data from the storage device; and
a display unit couple to the external device displaying the cardiac depolarizations and the pressure waves.
22. The implantable medical device system of
23. The implantable medical device system of
24. The implantable medical device of
a sensor assembly including the sensor; and
a coupling device electrically coupling the sensor assembly to the housing portion, the sensor assembly having a first thickness and the housing portion having a second thickness greater than the first thickness.
25. The implantable medical device of
26. The implantable medical device of 24, wherein the sensor includes a transmitter and a receiver, both the transmitter and the receiver positioned along one of the sensor assembly and the housing portion.
27. The implantable medical device of
28. The implantable medical device of
29. The implantable medical device of
30. The implantable medical device of
31. The implantable medical device of
32. The implantable medical device of
33. The implantable medical device of
34. The implantable medical device of
35. The implantable medical device system of
35. The implantable medical device of
36. The implantable medical device of
37. An implantable medical device for monitoring heart function of a patient's heart, comprising the steps of:
means for detecting cardiac depolarizations and storing data corresponding to the detected cardiac depolarizations in a first memory portion;
means for determining whether a cardiac event is detected in response to the detected depolarizations; and
means for detecting pressure waves corresponding to the heart function, storing the data stored in the first memory portion and subsequently detected cardiac depolarizations and detected pressure waves in a second memory portion in response to a cardiac event being detected.
[0001] Cross-reference is hereby made to commonly assigned related U.S. Application, filed concurrently herewith, docket number P-9737, entitled "APPARATUS AND METHOD FOR CHRONICALLY MONITORING HEART SOUNDS FOR DERIVING ESTIMATED BLOOD PRESSURE".
[0002] The present invention relates to implantable medical devices and, in particular, the present invention relates to an implantable medical device subcutaneously implanted for monitoring the hemodynamic function of a patient's heart using an acoustical sensor.
[0003] Chronic monitoring of heart function can provide valuable diagnostic information for a variety of cardiovascular conditions, including arrhythmias, heart failure, syncope or other autonomic system abnormalities, etc. For example, chronic monitoring of the ECG subcutaneously, using a device such as the Reveal� Insertable Loop Recorder available from Medtronic, Inc., can be useful in diagnosing infrequent symptomatic episodes such as unexplained syncope and for capturing asymptomatic arrhythmias, which may be of interest to the patient's physician. Adding a monitor of hemodynamic function to ECG information would allow a physician to monitor and diagnose a larger spectrum of cardiac conditions that may or may not include arrhythmic events as seen in the subcutaneous ECG. In addition, a hemodynamic signal may allow the physician to continue to track the heart rate when the subcutaneous ECG becomes difficult to interpret due to electrical interference from artifacts such as loss of electrode contact, muscle noise or electromagnetic interference (EMI).
[0004] Numerous measurements may be made to gain an indication of hemodynamic function such as blood pressure, blood flow, wall motion, ventricular volume, or other measurements. These types of measurements are commonly made during a clinical examination and may involve both invasive and non-invasive procedures. For example, non-invasive ultrasound measurements may be made to investigate heart chamber volumes, heart wall motion, or blood flow velocities using Doppler ultrasound techniques. Principles and techniques for ultrasound instrumentation and measurements in cardiac applications are known and generally described in: Medical Instrumentation: Application and Design, ed. J. G. Webster (Houghton Mifflin Company, Boston) 1992, pp. 422-436 and Transducers for Biomedical Measurements, ed. R.Cobbold (John Wiley and Sons, New York) 1974, pp. 275-318. While clinical examinations are useful for patient assessment, they are limited in that they reflect the patient's condition only at a particular time on a particular day. Repeated examinations may be performed but the same measurement may not be repeated in exactly the same way because of slight differences in the sensor position and angle of the microphone or ultrasonic probe.
[0005] Chronic hemodynamic monitoring may be performed using implantable devices. For example blood pressure can be measured directly by placing a pressure sensor in the cardiovascular system, such as in the right ventricle. A chronically implantable device for monitoring the intracardiac electrogram (EGM) and right ventricular blood pressure has been implanted in chronic heart failure patients and used to continuously monitor their hemodynamic condition. See Magalski A, et al., J. Card. Fail., 2002;8(2):71-3. Apparatus for monitoring syncope including electrodes for recording electrical activity and/or blood pressure data of the patient's heart is generally disclosed in U.S. Pat. No. 6,351,670 issued to Kroll. An ambulatory cardiac diagnostic unit is generally disclosed in PCT Publication No. WO 90/04942, issued to Baker et al., which monitors heart action using intracardiac electrogram and pressure sensed using an intracardiac lead. These systems advantageously provide chronic heart monitoring but involve placement of a lead with pressure sensors in the patient's heart.
[0006] An implantable cardiac monitoring and therapy device which chronically monitors a patient's hemodynamic status as indicated by a cardiac contractility parameter which is derived from the result of performing Doppler ultrasound interrogation of cardiac tissue is generally disclosed in U.S. Pat. No. 5,156,154, issued to Valenta, Jr., et al. A Doppler ultrasound transducer affixed to a catheter is implanted within the right heart for assessing the motion of cardiac myofibril tissue within the heart, contributing to the pumping performance of the left ventricle. Other implantable devices for monitoring the hemodynamic status of a patient that include placing an ultrasound probe in the heart are described in U.S. Pat. No. 5,188,106 issued to Nappholz et al., and U.S. Pat. No. 6,421,565 issued to Hemmingson.
[0007] Placement of a pressure sensor, ultrasonic probe, accelerometer, microphone, or any other type of hemodynamic sensor, in the heart or anywhere within or along the cardiovascular system is a relatively invasive procedure. Indirect methods of measuring blood pressure, or other indices of hemodynamic function allow a sensor to be placed outside of the cardiovascular system with the measured signal being correlated to hemodynamic status. An implantable pulse generator having a pressure wave sensor mounted in the pulse generator in relation to the proximal end of a pacing lead for sensing pressure waves transmitted from the distal end of the pacing lead is generally described in U.S. Pat. No. 5,702,427, issued to Ecker et al. The pressure wave sensor is employed by a capture verification system to detect pressure waves associated with heart contraction. A pressure sensor is not positioned within the heart itself, however, this system still requires a lead to be placed in the heart to transmit pressure waves.
[0008] The use of extravascular sensors for use in determining hemodynamic status in an implantable device has also been proposed, which avoid the invasiveness of placing a hemodynamic sensor in the cardiovascular system. An implantable monitor for monitoring the hemodynamic status of a patient having extravascular sensors including vascular plethysmography, heart and lung sounds, thoracic impedence and ECG is generally disclosed in U.S. Pat. No. 6,409,675, issued to Turcott. A cardiac stimulating apparatus and method is generally described in U.S. Pat. No. 6,366,811, issued to Carlson, that non-intrusively determines an amount indicative of hemodynamic pulse pressure from an accelerometer signal. The accelerometer transmits a signal to the controller associated with fluid and myocardial accelerations of the patient's heart. The amount indicative of pulse pressure is used to optimize cardiac performance.
[0009] Acoustic waves, both within and outside of the human auditory range, can provide significant information relating to heart function. Medical Instrumentation: Application and Design ed. J. G. Webster (Houghton Mifflin Company, Boston) 1992, pp. 378-407. Contraction of the whole heart can produce relatively low frequency sound waves, and blood flow and valve opening and closure produce relatively higher frequency sound waves. These sound waves are advantageously transmitted through the body such that they may be measured at a location relative to the heart but not necessarily in the heart. Recording acoustical data, such as heart sounds, ultrasonic echoes or otherwise, on a chronic basis could provide useful information relating to a patient's hemodynamic function. See Luisada et al., "Assessment of Left Ventricular Function by Nonivasive Methods", AdvCardiol vol. 32, 1985, pp. 111-141. An apparatus for adjusting the timing of pacing pulses delivered by an implanted cardiac pacer based on acoustic intensity of a particular heart sound received from an acoustic sensor, which may be placed against the sternum or in the pectoral region of the chest but outside the thoracic cavity, is described in U.S. Pat. No. 5,554,177, issued to Kieval et al., incorporated herein by reference in its entirety.
[0010] It is desirable, therefore, to provide a minimally invasive, implantable hemodynamic monitor that allows acoustical data related to the hemodynamic status of the patient to be recorded and stored. Such data may be used for diagnostic or therapy evaluation purposes and may be evaluated alone or in conjunction with ECG data to interpret both the electrical and mechanical function of the heart.
[0011] The present invention provides a minimally invasive, implantable hemodynamic monitor equipped with an acoustic sensor for detecting pressure waves that can be correlated to heart function. A range of low frequency sounds generated, for example, by heart wall motion, to high frequency sounds generated, for example, by blood flowing through valves or arteries, may be acquired. The analog signals generated by one or more acoustic sensors are digitized and processed such that a sampled digital signal may be stored in a temporary looping memory buffer. An automatic or manual trigger event may cause the data to be written to a long-term memory buffer and stored until uploaded to an external device. The stored data may be presented acoustically and/or visually by the external device. The data may be further analyzed by an external microprocessor to derive a number of measures of hemodynamic function.
[0012] An implantable hemodynamic monitoring device in accordance with the present invention is equipped with an acoustic sensor, ECG electrodes, a memory for storing acoustic and ECG data, and a microprocessor based controller for processing data and controlling device functions. An acoustic sensor may be provided as a passive sensor that does not require a power supply such as an accelerometer or piezoelectric sensor. An additional or alternative acoustic sensor may be provided as an active sensor requiring a power supply, such as a miniaturized microphone or an ultrasound transmitter and receiver. The acoustic sensor may be mounted within the device housing or header block, on the external surface of the housing or header block, or on a subcutaneous lead extending from the device.
[0013] An implant location for the device is carefully selected to achieve optimal acoustic signal quality. The acoustic sensor is preferably located such that the sensor reception range has a limited directionality and is focused toward the heart, and more preferably focused on the major acoustic signal generating components of the heart or great vessels, such as the valves, ventricular wall, ascending aorta or otherwise.
[0014] The acoustic sensor signal is received by an input circuit including appropriate amplifiers and filters for isolating the acoustical signals of interest and reducing or eliminating sounds associated with other organs, respiration, muscle or skeletal motion, voice, etc. Both low frequency components, in the range of 0.04 Hz to 50 Hz, and higher frequency components, in the auditory range of approximately 50 Hz to 5 KHz may be of interest, although most of the energy in the heart signal is at frequencies less than 250 Hz.
[0015] In one embodiment, acoustical data is received over a wide range of frequencies from a passive sensor with broad-band filtering so as to retain both high and low frequency information that may be related to hemodynamic function. Sampled data are stored when triggered by a manual patient trigger or by an automatic trigger such as an arrhythmia detection or other automatically detected event. The acoustical data may then be uploaded to an external device for signal processing in which custom variable band-pass filtering can be used to select which components of the acoustical data the user is interested in viewing. Acoustical data may be stored concurrently with ECG data such that cyclic acoustical events may be directly associated with the electrical heart rhythm.
[0016] For an alternative heart and blood flow monitoring signal, an active ultrasound sensor (with a frequency between 1 and 10 MHZ) may be provided as a single transmitter/receiver incorporated in the implanted device or carried by a lead extending from the device. The single transmitter/receiver may be operated in a burst send/receive mode such that a burst of sound waves of a desired frequency are transmitted to a targeted heart location and the reflected echoes are received by the same transmitter/receiver. Alternatively, a separate receiver may be incorporated in the device or carried by a lead extending from the device such that the transmitter may continuously send an ultrasonic signal that is continuously received by the receiver. Ultrasonic sensor positioning and anchoring are important in optimizing the received energy and in repeatability of measurements made. Interference from dense bones, such as the ribs or sternum, is preferably avoided. Transmission and reception through the suprasternal notch or any of the intercostal spaces in close proximity to the heart may be effective.
[0017] In order to reduce the power requirements of the device to make it practical for a chronic, subcutaneous implant, the ultrasound system may be duty cycled such that snippets of the Doppler signal are collected at desired intervals rather than continuously. The ultrasonic sensor may alternatively be activated only when triggered by a manual or automatic event trigger, such as an arrhythmia detected from the ECG signal.
[0018] Thus a device and method are provided that allow minimally invasive, chronic hemodynamic monitoring of the heart for diagnostic or therapy evaluation purposes. The device may advantageously be placed subcutaneously or submuscularly without requiring sensors to be placed within the cardiovascular system.
[0019]FIG. 1A is an illustration of a subcutaneously implantable device 10 for storing ECG and acoustical data received from a passive acoustical sensor according to one embodiment of the present invention.
[0020]FIG. 1B is a side view of the device of FIG. 1A.
[0021]FIG. 2A is an illustration of an alternative embodiment of a subcutaneously implantable device for storing ECG and acoustical data according to the present invention.
[0022]FIG. 2B is a side view of a sensor assembly included in the embodiment of FIG. 2A.
[0023]FIG. 3 is an illustration of the device of FIG. 1 implanted subcutaneously in relation to a patient's heart for receiving acoustical signals.
[0024]FIG. 4 is a high-level block diagram of circuitry included in device 10 of FIG. 1 and an external device in communication with the implanted device.
[0025]FIGS. 5A and 5B illustrate possible arrangements for including an ultrasonic sensor in a subcutaneously implantable device for monitoring heart function.
[0026]FIG. 5C is an illustration of an ultrasonic sensor including a transmitter and a separate receiver.
[0027]FIG. 5D, 5E and 5F are illustrations of alternative implant positions of a heart function monitor provided by the present invention.
[0028]FIG. 6 is a flowchart summarizing the operations performed by the device of FIG. 1 during an automatic trigger mode of operation in one embodiment of the invention.
[0029]FIG. 7 is a flow chart summarizing operations performed by the device of FIG. 1 during an automatic triggering mode in another embodiment of the present invention in which acoustical data is used for automatic triggering.
[0030]FIGS. 1A and 1B illustrate a front and side view of a minimally invasive implantable device 10 for chronically monitoring heart function. The size and shape of device 10 may be generally provided as disclosed in U.S. Pat. No. 5,987,352, issued to Klein et al., incorporated herein by reference in its entirety. The device 10 is provided with a hermetically sealed housing or "can" 12 preferably formed from a biocompatible metal such as titanium and closed at one end by a plastic cap member 18. Cap member 18 may be formed of materials similar to those used for pacemaker connector blocks, such as polyurethane or epoxy. Housing 12 is provided with an insulative coating 20, indicated by dashed line, formed from an insulating material, such as a Parylene coating. Device 10 preferably includes at least two electrodes 14 and 16 for sensing a patient's subcutaneous ECG. Electrode 14 is formed from a biocompatible conductive metal such as platinum, iridium, titanium, or alloys thereof. Electrode 14 may be mounted in cap member 18 with an exposed surface for detecting the patient's ECG and is electrically connected to a conductive feed-through to an internal circuit board, described below in reference to FIG. 4. Electrode 16 may be formed as an uninsulated portion of the housing 12 by creating an opening in the insulative coating 20. Electrode 16 is also electrically coupled to an internal circuit board.
[0031] Device 10 is further provided with an acoustic sensor 22 in accordance with the present invention. In one embodiment, acoustic sensor 22 is a passive sensor that does not require an energizing power supply, such as an accelerometer, or a piezoelectric material, which may be a piezoelectric crystal, ceramic or film. In another embodiment, acoustic sensor 22 may be provided as an active sensor that requires a power supply such as a miniaturized, implantable microphone or an ultrasound transmitter/receiver. Device 10 may be provided with two or more acoustic sensors, which may be any combination of passive or active acoustical sensors. An advantage of providing a passive sensor is that the battery size required by device 10 may be minimized, reducing the overall size of device 10 making it easier to implant under the skin and more comfortable for the patient. However, signals received by a passive sensor may be not be isolated to a specific heart region. An advantage of an ultrasonic sensor is that an isolated area of the heart may be monitored but at the expense of increased power consumption and signal processing.
[0032] Sensor 22 may be mounted on the internal surface of the device housing 12, as shown in the side view of FIG. 1 B. Sensor 22 is electrically coupled to an internal circuit board, described below in reference to FIG. 4. In alternative embodiments, sensor 22 may be located in the header 18 or attached to the external surface of housing 12.
[0033]FIG. 2A is an illustration of an alternative embodiment of a minimally invasive heart function monitor. Identically numbered components in FIG. 2A correspond to those shown in FIG. 1, however, in this embodiment acoustical sensor 22A is mounted on a low-profile sensor assembly 28 carried at the distal end of a lead 26. Lead 26 is connected at its proximal end to the header 18A. Header 18A is provided with a connector bore for receiving lead 26. Sensor assembly 28 may optionally carry an additional ECG electrode 17. Electrode 17 may be used in combination with electrodes 14 and 16 for sensing different vectors of the ECG. Multi-electrode ECG sensing in an implantable monitor is described in U.S. Pat. No. 5,313,953 issued to Yomtov, et al., incorporated herein by reference in its entirety.
[0034]FIG. 2B is a side view of the sensor assembly 28 showing assembly 28 having a relatively flat profile such that assembly 28 is easily implanted under the skin. Because device 10 may be relatively thicker than sensor assembly 28, device 10 may not be as comfortably positioned at various subcutaneous implant sites, such as over the ribs or sternum, as sensor assembly 28. Thus, sensor assembly 28 allows acoustic sensor 22A to be implanted at a site for receiving optimal acoustic signals that may not be a practical site for device 10 implantation due to patient discomfort, such as the ribs or sternum.
[0035]FIG. 3 is an illustration of the device 10 implanted subcutaneously in relation to a patient's heart for receiving acoustical signals. In this arrangement, acoustic sensor 22 is placed against bony tissue 6 directed toward the patient's heart 4. In preliminary experiments, the inventor has found that placement of a passive acoustical sensor, such as an accelerometer, against bone such as the rib or the sternum can improve phonocardiographic components of the acoustical signal compared to when the accelerometer is placed against soft tissue. The bone can enhance coupling of components of the sound waves from the heart into the acoustic sensor. The signal amplitude received when an accelerometer was placed against the sternum or ribs was greater than when the sensor was placed against soft tissue. Other types of acoustical sensors, such as an ultrasonic sensor, may be better positioned over a soft tissue site to avoid reflection of the transmitted ultrasonic waves as will be described in greater detail below.
[0036]FIG. 4 is a high-level block diagram of circuitry included in device 10 of FIGS. 1 and 2. Device 10 preferably includes an ECG monitoring channel 30 and an acoustic monitoring channel 32. ECG electrodes 14 and 16 bring a signal from the body to an input circuit 34, which includes amplifiers and filters for reducing noise and passing the ECG signals of interest. The output of input circuit 34 is fed to an A/D converter 36, which samples and digitizes the ECG signal, preferably at a sampling rate on the order of 100 Hz. Input circuit 34 and A/D converter 36 are included in ECG monitoring channel 30 of device 10. These components may be implemented in device 10 as described in the above-cited '352 patent issued to Klein, or as provided by other subcutaneous ECG monitoring systems known in the art.
[0037] Acoustic monitoring channel 32 includes an input circuit 50 for receiving signals from acoustic sensor 22. Input circuit 50 includes filters and amplifiers for improving the signal-to-noise ratio of cardiac-related acoustical signals by filtering noise due to respiration, muscle or skeletal motion, voice, etc., and passing and amplifying the acoustical signals of interest associated with heart wall motion, valve motion or blood flow. A/D converter 52 samples and digitizes the signal received from input circuit 50. A preferred sampling rate is at least twice the highest frequency of interest, in accordance with the well-known Nyquist criterion.
[0038] Output from A/D converters 36 and 50 are received by memory 40. Memory 40 preferably includes temporary memory buffers 38 and 39 which continuously record ECG and acoustical data in a looping fashion. Temporary memory buffers preferably have at least a 128 Kbyte capacity. Because acoustical data may be sampled at a higher rate than ECG data, looping memory 38, designated for storing acoustical data, may be provided with a greater capacity than looping memory buffer 39, designated for storing ECG data.
[0039] Output from A/D converters 36 and 50 may also be received by control unit 42. Control unit 42 may be provided as a microprocessor based control system for controlling the operations of device 10. Control unit 42, and any other circuits or acoustical sensors included in device 10 that require a power supply, are powered by battery 44. Control unit 42 is in communication with memory 40 for controlling the storage of ECG and acoustical data in long-term memory 41. A real time clock or counter 47 provides control unit 42 with time information that can be used for marking stored data such that events may be temporally identified. Long-term storage of data may be triggered by automatic or manual triggers. As such, control unit 42 receives signals from communications unit 46 which may receive a signal from an external patient activator 60 for manually triggering long-term storage of ECG and acoustical data.
[0040] Patient activator 60 may take the form of a handheld device that is battery-powered and uses coded radio-frequency telemetric signals transmitted upon depressing a button, to trigger data storage by the device 10. A patient, or another person nearby, may use the handheld device when the patient feels symptomatic or has become unconscious. A handheld device may alternatively be provided having a magnet that closes a magnetic switch within device 10 when held in the vicinity of device 10 to elicit a data storage trigger signal. Alternative embodiments for a patient activated trigger can include light activation, sonic activation or mechanical activation by finger tapping or slapping. Various modes of patient activated triggering are described in the above-cited '352 patent.
[0041] If a patient trigger is used it is advantageous to provide feedback to the patient regarding whether the attempt to trigger long term storage of the event was successful. To accomplish this the implant should telemeter out a signal that indicates it has recognized a valid trigger. (This of course requires additional circuitry and usage of the limited available power supply.) The external triggering device then notifies the patient via the triggering device or through some known alarm mechanism whether they have or have not properly triggered the implanted device. This notification can be one of any combination of a number of feedback methods including: one or two visual sources such LED's, an auditory source such as a beeping speaker in one or two tones, or a tactile source such as a vibration. See also U.S. Pat. No. 5,518,001, incorporated herein by reference in its entirety, for other potential trigger-indicator ideas for a hand-held patient activated trigger device.
[0042] Control unit 42 may also generate automatic trigger signals for triggering the long-term storage of data. For example, control unit 42 may be equipped with algorithms for identifying ECG events, such as R-waves, T-waves, and/or P-waves from data received from A/D converter 36. Based on these events, control unit 42 may detect the occurrence of arrhythmias, including asystole, bradycardia, tachycardia, and fibrillation. Arrhythmia detection algorithms known in the field of implantable cardioverter defibrillator technologies may be incorporated in control unit 42. A detected arrhythmia may elicit an automatic trigger to initiate the storage of ECG and acoustical data.
[0043] Alternatively, or additionally, control unit 42 may be equipped with algorithms for detecting a change in an acoustical signal, which may be associated with heart wall motion, valve motion, blood flow or otherwise, and generate an automatic trigger for the long-term storage of data based on that change. In a basic embodiment, a flat line acoustical signal may be used to trigger long-term data storage. In more elaborate schemes, control unit 42 may process acoustic data received from A/D converter 52 to correlate aspects of the received signal to an index of heart function. A change in heart function, as indicated by the acoustical signal, beyond a certain threshold or predetermined range of normal values may be used to trigger long-term data storage.
[0044] Alternatives to the overall design shown in FIG. 4 may be considered. For example, certain functions performed by control unit 42 may be performed by integrated circuits. Integrated circuits for detecting a QRS signal from the sensed ECG and for detecting arrhythmias are described in the above-cited Klein patent.
[0045] Communication unit 46 is also able to communicate with an external device 62, which may generally take the form of a programmer, for delivering operational commands to device 10, receiving confirmation signals from device 10 that operational commands were received, and for receiving data uploaded from memory 40. Communications unit 46 should contain an antenna or other transceiver device or circuitry to communicate with an external device such as device 62. A clock or counter circuit 47 reports the time since start or real time to the external device 62 contemporaneously with a data uploading session so that the events recorded in memory 40 may be temporally pinpointed.
[0046] External device 62 may include a microprocessor 63 for processing digitized data received from device 10. In particular, acoustical data may be processed to separate frequencies associated with particular cardiac sounds, such as lower frequency sounds associated with heart wall motion from higher frequency sounds associated with valve motion and/or blood flow. Acoustical data may be displayed on a display unit 64, which may include an LCD screen 66 or other appropriate display, and a display controller 68. Display controller 68 is provided to allow the user to selectively adjust filters to vary the displayed acoustical data components. As illustrated on display screen 66, ECG data may be displayed graphically with corresponding low frequency and higher frequency acoustical data such that cyclic cardiac events generating acoustical signals, such as valve opening and closing, start of ventricular ejection or filling, and electrical events, may be identified as related to electrical heart function and mechanical heart function. Visual analysis of simultaneous baseline shifts in ECG data and acoustic data may allow the physician to identify major body events such as a fall, which may aid the physician in analyzing significant cardiac events.
[0047] In one embodiment, external device 62 may further include a speaker 65 for broadcasting uploaded acoustical data in the auditory range. Such data would include heart sound data that physicians are generally well trained in detecting and interpreting for diagnosing a variety of heart conditions. Acoustical data may thus be presented both visually on display unit 64 and acoustically through speaker 65 in a simultaneous fashion to enhance the physician's ability to interpret the data. Custom variable bandpass filtering of acoustical data using filter adjustments 67 allows a physician to select the frequency components that are displayed and/or broadcast, thus allowing analysis and interpretation of select components of the acoustical data.
[0048] According to the present invention, sensor 22 may be positioned as described in Medical Instrumentation: Application and Design ed. J. G. Webster (Houghton Mifflin Company, Boston) 1992, pp. 378-407, incorporated herein by reference in its entirety.
[0049]FIGS. 5A and 5B illustrate possible arrangements for including an ultrasonic sensor in a subcutaneously implantable device for monitoring heart function. In FIG. 5A, acoustic sensor 22 is provided as a piezoelectric transmitter and receiver of ultrasonic energy with a frequency between 1 and 10 MHz. Sensor 22 operates in an alternating burst send and receive mode under the control of control unit 42. Ultrasonic sound waves are transmitted in a burst by sensor 22 and the echoes produced by the ultrasound waves reflecting off heart or blood constituents are then received. Sensor 22 is preferably located over soft tissue such that bone does not reflect the transmitted ultrasonic energy, preventing it from reaching the heart or great vessels. Device 10 is shown, therefore, in a location over the ribs such that sensor 22 is aligned with an intercostal space 5. An alternative arrangement is shown in FIG. 5b in which sensor 22 is located on low-profile sensor assembly 28 coupled to lead 26 extending from device 10. Sensor assembly 28 may be anchored in a position over the ribs with sensor 22 positioned over an intercostal space 5. The intercostal space at which sensor 22 is positioned may be selected based on the region of the heart from which wall motion of blood flow measurements are desired. In the configuration of FIG. 5B, the device 10 may advantageously be positioned away from the rib cage, in the pectoral region, which, depending on the size of device 10, may be more comfortable for the patient.
[0050] As is well known in the ultrasound field, heart motion and/or blood flow primarily parallel to the ultrasound beam and within the beam will reflect echoes from the blood constituents or heart tissue as movement occurs toward or away from the ultrasound transducer. Echoes are extracted over a short range and at a desired depth through proper time-gating of the received signal and classic pulsed Doppler processing. The final result of this Doppler processing is a low frequency audible signal proportional to the velocity of movement of the primary reflectors within the beam and over the gated range, referred to herein as "gated Doppler volume."
[0051] In order to maintain a reliable Doppler signal during chronic monitoring, it is important to maintain the implanted device in a fixed position through proper anchoring methods such as suturing, so that the gated Doppler volume encompasses the section of heart and blood flow desired to be viewed. A trade-off is made between enlarging this zone to make it robust to changes in heart position with posture and eliminating undesired Doppler signals from other moving structures. Selection of transducer size, transmitting frequency, and range from the implant to the target volume, all influence the cross-sectional area of the gated Doppler volume. The depth of the ultrasound beam is controlled by the frequency of the transmitted energy. Lower frequencies will penetrate more deeply than higher frequencies. Thus, transmitting a set of frequencies over a predetermined range will allow blood or heart motion at selected distances from the sensor 22 to be detected. Motion in an isolated area of the heart may therefore be chronically monitored.
[0052]FIG. 5C is an illustration of an ultrasonic sensor including a transmitter and a separate receiver. An ultrasonic transmitter 23 a is located on a low-profile sensor assembly 28 extending from device 10 on a lead 26. A separate receiver 23 b is located on device 10. The transmitter 23 a may alternatively be located on device 10 and the receiver 23 b on the low-profile assembly 28. In still other embodiments, transmitter 23 a and receiver 23 b may both be located on low-profile sensor assembly 28 or both located on device 10. In yet another alternative embodiment, transmitter 23 a may be located on a sensor assembly on one lead extending from the device 10 and a separate receiver 23 b may be located on a sensor assembly on a second lead extending from the device 10.
[0053] In the embodiment shown in FIG. 5c, the transmitter 23 a may be located over an intercostal space 5 a to transmit ultrasonic energy toward the heart, and the receiver 23 b may be positioned over the same or a different intercostal space 5 b to receive reflected echoes through the intercostal space. When provided separately, transmitter 23 a and receiver 23 b may operate in a continuous mode such that heart or blood motion may be continuously monitored.
[0054] Alternative locations for positioning an ultrasonic sensor for receiving good acoustical signals from the heart or great vessels include positioning a sensor over the suprasternal notch. In FIG. 5D, device 10 is shown in a location over the suprasternal notch and positioned such that ultrasonic waves may be transmitted from sensor 22 downward toward the heart and aortic outflow tract. An alternative arrangement is shown in FIG. 5E in which the sensor 22 may be located on a low-profile lead 26 extending from the device 10. Sensor 22 may be positioned over the suprasternal notch and device 10 may be positioned in the pectoral region or any area that is comfortable for the patient that allows connection to the lead 26. In FIG. 5F, a transmitter 23 b is located over the suprasternal notch to transmit ultrasonic energy down toward the heart as indicated by dashed arrows, and receiver 23 b, located on device 10, is positioned to receive reflected echoes through an intercostal space. While the configurations illustrated in FIGS. 5D through 5F may provide good acoustical signals related to heart wall motion or blood flow, the area over the suprasternal notch is generally sensitive, and chronic implantation of a device at this site may not be well-tolerated by the patient. The configurations of FIGS. 5A through 5C described above, in which an ultrasonic sensor is aligned with an intercostal space, are believed to be more practical for chronic implantation with minimal patient discomfort.
[0055] In order to meet practical power requirements for an implantable system, an ultrasonic sensor preferably operates according to an on/off duty cycle. The on/off duty cycle may include an on time of 1 minute and an off time of 59 minutes so that monitoring occurs 24 times a day with average power of 60� less than the peak measurement power.
[0056] To further reduce power requirements, the ultrasonic sensor may be powered to monitor heart function only upon an automatic or manual triggering event. For example, when an arrhythmia is detected by device 10 resulting in a long-term data storage trigger, the ultrasonic sensor may be powered to receive acoustical signals that may be stored simultaneously with ECG data.
[0057] Device 10 makes chronic hemodynamic monitoring possible by storing acoustical data received from the heart during episodes or events that may be of interest to the physician. The device may continuously or intermittently record acoustical data in a looping memory. A manual or automatic trigger causes the device to save a predetermined interval of acoustical data in long-term memory. Corresponding ECG data is preferably stored simultaneously. A manual trigger may be delivered by the patient subsequent to feeling symptomatic (e.g. dizziness, short of breath, palpitations, etc.).
[0058] In one embodiment, operational modes for data storage triggering are programmable to allow patient triggering only and/or one or more types of automatic triggers for data storage. An interval of data, preferably on the order of 5 or more minutes for manual triggers and 1 or more minutes for automatic triggers, is stored. The data interval may include data stored in the temporary memory buffers prior to the trigger event and data following the trigger event. It should be considered that with automatic triggering, the determination by the device of an event worth recording and the subsequent activation of the trigger by the device itself will be faster than the patient finding his device for activation or otherwise activating the device, so the pre-trigger time record can be smaller.
[0059]FIG. 6 is a flowchart summarizing the operations performed by device 10 during an automatic trigger mode of operation in one embodiment of the invention. Beginning at step 201, the ECG signal sensed by electrodes 14 and 16 is sampled by A/D converter 36 and stored in temporary looping memory buffer 39.
[0060] The sampled ECG signal is simultaneously analyzed by control unit 42 to determine if an arrhythmia, which may be asystole, bradycardia, tachycardia, fibrillation, premature contractions etc., is present. If an arrhythmia is detected at decision step 205, an automatic trigger signal is generated by control unit 42 at step 210. The trigger signal first enables acoustic sensor 22. In this embodiment, acoustic sensor 22 may be an active sensor, such as a miniaturized microphone or ultrasonic sensor that is preferably enabled only following a triggering event in order to conserve device battery power. The trigger signal next causes data stored in temporary memory buffer 39 to be written to long-term memory 41 at step 220 and continues to write sampled acoustic and ECG data received from A/D converters 36 and 52 to a designated area of long-term memory 41 for a predetermined interval of time following the trigger signal.
[0061] Depending on the long-term memory capacity, a limited number of triggered events may be stored between uploading data sessions. Preferably at least three events of five minutes may be stored. Additional triggered events may overwrite the oldest stored event if uploading has not occurred and long-term memory is full. The number of events that may be stored may be increased by storing data in a compressed format. Data compression may be at a compression ratio of 2:1 or some other device supported ratio. When setting the operational mode of the device, the physician or attendant can decide whether to record data in a compressed mode or not. If greater detail of the ECG or acoustical data is required than can be developed from compressed data storage, the physician should select non-compressed recording, thereby limiting the time available to record. In some embodiments the sampling rate may be modified as well, for both ECG sampling and acoustical data sampling. Many types are known compression algorithms could be used. An excellent example is found in the article Arrhythmia Detection Program for an Ambulatory ECG Monitor by Mueller, copyright 1978, ISA, ISBN 876645, incorporated herein by reference in its entirety.
[0062] In an alternative embodiment, both ECG and acoustic data may be written to temporary, looping memory buffers 39 and 38 simultaneously until a manual or automatic trigger occurs. An automatic trigger may optionally be based on a change in the detected acoustical data indicating a change in hemodynamic function or another change or event, such as a fall, which may be detected from the acoustical signal. Acoustic data can be a rich source of information including not only information relating to heart and blood motion, but also information relating to other body changes such as a fall, the presence of seizures, or resuscitation efforts. Such events may be recognizable by a shift in the acoustic signal baseline. Recognition and detection of these events may be of interest to a physician in interpreting a particular symptomatic event or sequence of events.
[0063]FIG. 7 is a flow chart summarizing operations performed by device 10 during an automatic triggering mode in another embodiment of the present invention in which acoustical data is used for automatic triggering. At step 251, ECG and acoustical data are continuously written to temporary, looping memory buffers 39 and 38, respectively. ECG and acoustical data are received by control unit 42 from A/D converters 36 and 52, respectively. Control unit 42 analyzes the data in order to detect arrhythmias or compromised hemodynamic function or other changes that may be indicative of a whole body event such as a fall or seizure. If an arrhythmia is detected at decision step 255, an automatic trigger is generated at step 270. An interval of pre- and post-trigger ECG and acoustical data is stored in long-term memory at step 280.
[0064] If reduced hemodynamic function is detected at decision step 260, with or without a concurrent arrhythmia detection at decision step 255, an automatic trigger may be generated at step 270 based on the hemodynamic change. The hemodynamic change may be detected as a threshold crossing of a parameter derived from processed acoustical data. Under the control of control unit 42, acoustic and ECG data are written to long-term memory 41 at step 280 such that the data is available for future uploading to external device 62 for review by a physician.
[0065] Other events, such as a fall, a seizure, or resuscitative efforts, may also be detected for the purpose of automatic data storage triggering. For example, at step 265, a fall may be detected by a sudden baseline shift of the acoustical signal due to body impact. Detection of a fall may additionally cause an automatic trigger to be generated at step 270 with subsequent long-term data storage at step 280.
[0066] Monitoring for triggering events at steps 255, 260, and 265 are intended to be performed continuously and simultaneously such that if any ECG-related, hemodynamic-related, or fall-related automatic triggering event occurs at any time, ECG and acoustical data are stored in long-term memory at step 280. Furthermore, if a manual trigger is received by device 10 at any time during the monitoring for automatic triggers, as indicated at decision step 275, acoustic and ECG data are stored in long-term memory.
[0067] According to the method 250, long-term data storage is performed in response to manual triggers and multiple types of automatic triggers making device 10 more sensitive to detecting and storing events that may be of interest to a physician. ECG and hemodynamic data collected whenever a suspected arrhythmia, hemodynamic event, syncopal event, or symptomatic event occurs could provide valuable diagnostic information for a number of pathologic conditions.
[0068] Thus, a subcutaneously implantable heart function monitor has been described that allows hemodynamic function of the heart to be continuously or periodically monitored based on acoustical signals associated with heart motion or blood flow. Acoustical data, along with concurrent ECG data, may be stored in a looping memory until an automatic or manual triggering event occurs, causing the data to be stored in long-term memory until it is uploaded to an external device. The external device may perform additional signal processing to correlate the acoustical data to a hemodynamic measure of heart function. The external device may present the acoustical data, along with concurrent ECG data, both visually and acoustically. The device of the present invention, therefore, provides a physician with valuable diagnostic or therapy evaluation data that allows both the electrical activity of the heart and the hemodynamic function of the heart to be monitored chronically. Acoustic data may further provide a physician with information useful in understanding symptomatic events relating to heart movement, sudden body position changes, the presence of seizures, and evidence of resuscitation efforts. Specific embodiments of a minimally invasive heart function monitor based on acoustical and ECG sensing described herein are intended to be exemplary and should not be considered limiting with regard to the following claims.
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1954 Jaguar XK120 SE OTS 3442CC IN-LINE 6 CYLINDER ENGINE PRODUCING 180HP DUAL OVERHEAD CAMS TWIN SU CARBURETORS 4- SPEED MANUAL TRANSMISSION SERVO ASSIST 4 WHEEL DRUM BRAKES TORISON BAR... More
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This is the best ping pong / table tennis shot I have ever seen. Based on the look of the guy who got beaten on the point, he hadn't ever seen anything like this either. In the immediate aftermath of the shot, there is a brief moment where he maybe wants the shot to be called illegal. Then he just accepts that he had something awesome happen against him, so he applauds the shot. If there was ever actual cause for one of those excessive ping pong celebrations, this shot is it.
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Friday, October 31, 2008
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COVINGTON - Don't let Morgan County's 1-7 record fool you. Eastside is going to face a formable opponent when the teams collide at 7:30 p.m today in Madison."They scare me. They're playing for pride and sometimes that's a scary thing to go up against. They have nothing to lose. They're going to pull out everything in the world to beat us," Eastside coach Rick Hurst said. "They also want to have a say in how the region turns out. They're a dangerous football team that make a huge dent in what we're trying to do." What makes the Bulldogs dangerous is that this is the first time in 13 years that they have not made it to the playoffs, so now they'll be in the role of a spoiler. "They run the ball well, but they've had some turnovers and made some mistakes," Hurst said. "They've had some games where they've come out and did some good things. They did some good things against Hart (County), but they made some mistakes and Hart was able to capitalize on them." The Eagles defense has allowed 100 points this season, while the offense has outscored their opponents 99-7 their last two games. One big reason why the Eagle defense has been so successful lately is the play of defensive ends Karl Williams and Jacorey Maddox. "Jacorey has probably been our best linemen against the run. He's really stepped it up the last couple of games," Hurst said. "You put him and Karl in a pass rush situation, I'll take my chances with those two. They're fast, they're physical off the ball and they're relentless in the pursuit of the quarterback." If the Eagles are to win and guarantee a spot in the playoffs for the first time since 2001, the defense is going to have to continue playing well to stop the run. "I feel like if they have to throw the football, then we're doing our job. We want to set the tone and be physical and make them come out doing something they're not used to doing," Hurst said. On offense, the Eagles' offensive line has to do is continue providing its backs with running lanes. "Our offensive line is playing really well right now. They're confident and they're really in sync with one another. Getting Jarrett (Hubbard) back last week was a really big lift for us," Hurst said. "What's important is that our backs in Git (Aiken), Rashad (Hill), BA (Broderick Alexander) and Greg (Griffieth) or whoever is back there, that they find the crease and get into the secondary." Manny Fils can be reached at firstname.lastname@example.com. SideBar: Eastside at Morgan County When: 7:30 p.m. today Where: Bill Corey Stadium in Madison Series: Morgan County leads 2-0 Last meeting: Morgan County beat Eastside 35-14 in 1999
More like this story
- Eagles believe region, state titles in reach ( August 23, 2008 )
- Eagles' secondary faces test against pass-happy Warriors ( October 25, 2008 )
- Eastside can take pride in historic season ( December 17, 2008 )
- Eagles on brink of perfection
Eastside looks to stay undefeated in region ( October 30, 2009 )
- Eastside soars past Oconee Co. 49-7
Eagles 'clicking up front' in blowout victory ( October 28, 2008 )


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Help with install in Mandrake 9.1
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Help with install in Mandrake 9.1
I am running Mandrake Linux 9.1 on a Dell laptop with a built in GeForce 4 video card with 64meg of ram (i think that's all right). I used to run Mandrake 9.0 and I installed the nvidia drivers just fine for that (i believe i used the rpms) and they worked beutifully (especially because they let me run tux racer which i couldn't do with the generic drivers). Anyway, the problem is this... I tried installing the nvidia drivers using the .run file but had major problems. Here's how I went about it... I set the default runlevel to 3, rebooted, ran the .run file, edited the XF86Config-4 file to change the driver from nv to nvidia and set the default runlevel back to 5 (all of that was done as root). Then, I logged in as my normal user and ran startx. I got the nvidia splash screen and everything ran perfectly (even tux racer). I then rebooted and when it tried to start the graphical mode it would just flash the nvidia splash screen a couple times then go back to the console and say something about loading a module and then it would say "shutting down x server" and i'd be back to the console. This kept happening so I tried uninstalling the drivers and resetting the XF86 file and i would just get the login screen flashing in the same way w/o the nvidia logo. I finially just had to reinstall linux alltogether. Sorry for the long post but could somebody please tell me how to install these drivers properly?! Thanks to anyone who actually read all of this!
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Dr. George H. Orvin, a former acting chairman of MUSC's department of psychiatry, died Friday. He was 92.
Orvin frequently was recognized for his civic work in Charleston. In 1987, he established Charleston's New Hope Treatment Centers, serving as chairman and chairman emeritus until his death. The New Hope Treatment Centers specialize in helping adolescents overcome mental disorders and maintain good relationships with their families.
Orvin was born August 6, 1922, in Columbia. He grew up attending public schools in Charleston and received his undergraduate degree from The Citadel in 1943. He continued his education at MUSC, graduating in 1946.
In 1960, Orvin spent a year in London as a clinical assistant at the University of London Institute of Psychiatry, Maudsley Hospital, while doing a post graduate study in child psychiatry. Upon his return to Charleston, Orvin became well known for his lectures on child psychiatry and mental illnesses.
In 1977, Orvin was appointed a professor of psychiatry at MUSC and served as chief of adolescent psychiatry. In 1982, he became acting chairman of the department of psychiatry. He retired in 1989 and was awarded professor emeritus status in 1993.
Orvin was a diplomat of the American Board of Psychiatry and Neurology, a fellow of the American Society of Adolescent Psychiatry, a fellow of the Royal Society of Medicine, a fellow of the American Psychiatric Association and a fellow of the Southern Psychiatric Association.
He is survived by his wife of 70 years, Rosalie S. Orvin, three children, nine grandchildren, thirteen great-grandchildren and three sisters. Arrangements are being handled by Stuhr's Downtown Chapel of Charleston.
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Adobe Illustrator can be used to accomplish many different design tasks, from illustration to app development. This course demonstrates core concepts and techniques that can be applied to any workflow—for print, the web, or building assets that will find their way into other applications. Author Justin Seeley explains the elements that make up vector graphics (paths, strokes, and fills) while showing how to use each of the drawing tools, and demonstrates how to combine and clean up paths and organize them into groups and layers. The course also covers text editing, working with color, effects, and much more.
In this next movie, we'll be exploring something that you've probably seen me do a few different times throughout this course, but you might not have been exactly sure how I did it. So I've thought I'd take some time and actually show you how to resize your artwork here inside of Illustrator. So the first thing you have to do is actually have your artwork selected on the artboard. So I've grabbed the Selection tool and I'll just grab my little bear here, and once I grab the bear, you'll notice that I get a bounding box all the way around the outside. The bounding box is simply an invisible container that holds your artwork together.
This container is where you're able to do all of the resizing directly on screen. You'll notice that in the four corners of this bounding box, you have little squares. These little squares are what we call control points and on those control points, you can move your cursor to them, and you'll see that it turns into two little arrows, in the corner here, here, and here, and down here as well. You'll also notice when I go to the ones in the middle, they go straight up and down or straight across. This indicates that I'm going to resize horizontally, this indicates that I'm resizing diagonally, and this indicates that I'm resizing vertically.
When you are resizing artwork you need to make sure that you're constraining the proportion of your artwork, unless of course you're going for some funky distortion, but in most cases, you want scale equally on all sides up or down. So in order to do that, you are going to have to utilize something called a modifier key, and in this case, the modifier key is the Shift key. So let's say that I needed my bear to be a little bit smaller. I am going to come up here to the top- right corner and wait for my cursor to turn into the two-pointing arrows. Once it turns into the two-pointing arrows, I'm going to hold down my Shift key. I'm not going to let go of my Shift key until I'm done resizing.
I'm then going to take my mouse, click, and drag straight down. As you can see, I'm resizing it way down. Once I have got it where I want it, I'll release my mouse and then release my Shift key. And now it's the same piece of artwork, only scaled down. If I want to bring it back up, I make a selection, go to the corner, hold down Shift and click and drag. What happens if I don't hold down the Shift key? Well if I do this without holding down the Shift key, you can see I can seriously distort my artwork.
I can make him really short and fat or I can make him really tall and skinny, but it doesn't look the same. It's not actually scaling everything to make it look like he grew or shrink. It's just making him look squished or wide. So in this case, I'll select him and I'll undo those changes and get him back to normal. I undid those changes by using Command+Z or Ctrl+Z on my keyboard. You could also go up to the Edit menu and choose Undo. Now that I've got him up, let's take a look at other ways that we can resize.
We can actually use a tool to resize as well. Over here on the left, there is the Scale tool, which you can access via the letter S on your keyboard or by clicking on it here. With the Scale tool selected, you can actually click an anchor point and Scale artwork like this. If you hold down the Shift key, it'll constrain based upon the angle that you're dragging, like so. You see you still get some distortion as well, but it does scale everything equally as you go.
So it's a little bit difficult to utilize a Scale tool in terms of just resizing, but it is a great way to perform basic scales of smaller objects. In any case, resizing artwork is always going to be a necessity. You are going to have to scale things up, you're going to have the scale things down, especially if you're repurposing artwork for multiple projects like print, web, or even going to mobile and tablet devices. You're going to have to able to scale artwork and utilizing these controls that I've just shown you is the easiest and quickest way to do just that.
Find answers to the most frequently asked questions about Illustrator CS6 Essential Training .
Here are the FAQs that matched your search "" :
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Access exercise files from a button right under the course name.
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Learn how to implement and customize an interactive rotating carousel animation with jQuery and Adobe Dreamweaver. Author Chris Converse covers preparing the carousel images and captions, creating the carousel containers with HTML and CSS, and activating the carousel with JavaScript. The course also explains how to add images to the carousel container, set the caption based on the image in focus, and add animated transitions between captions.
When you download and extract the exercise files, there's four items inside of there. First is the Art-Templates folder. This contains the source Photoshop files: one called template.psd, which has the pre-sliced graphics we use for the template art, and teapots.psd, which has all the teapots we saw in the introduction video. Inside of Files-to-add, we have a copy of jQuery and a copy of Roundabout, which is a jQuery plug-in written by Fred LeBlanc, and he has given us permission to include this in our project files. Third is a Snippet.html file. This is going to contain all of the individual data for all of the individual teapots that we're going to be cutting and pasting in. And item number 4 contains a complete copy of the final project.
And now with all of our exercise files downloaded, in the next movie we will start by creating the folders that are going to hold our project.
There are currently no FAQs about Create a Rotating Carousel with jQuery and Dreamweaver.
Access exercise files from a button right under the course name.
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Rowan Finest is a blend of extra fine merino, cashmere and royal alpaca wool. Soft to the touch and comfortable to wear, knitting to a 4ply tension this yarn gives great stitch definition.
Creative Focus Worsted is a lovely wool and alpaca blended aran weight yarn.
The Thick 'n' Thin feature of the yarn gives the knitted fabric a unique textured finish, made from 100% wool this fashion yarn is ideal for winter accessories, but will equally add definition to any knitted sweater.
Tumble is a glorious lightweight, soft and lofty yarn comprising of 90% Alpaca and 10% Cotton and is the ideal yarn for those snugly soft Autumn Winter garments and accessories.
A luxury blend of merino wool, kid mohair, alpaca and mulberry silk and like the other yarns in the Fine Art family is hand painted with a blend of colours to achieve its unique colour effect.
Made with 100% baby alpaca, Rowan Alpaca Colour is a soft and durable DK knitting yarn. The soft, subtle blend of colours in each shade allows the beauty of the yarn to show through and is ideal for textured knitting stitches.
This wonderful soft roving British yarn is a designer's dream.
This light weight yet bulky yarn creates designs which appear felted or matted.
Tetra Cotton is a unique modern construction of four shades, creating an interesting yet delicate colour palette. Interchangeable with truesilk and Cotton Glace this yarn has lots of pattern support available.
Our ever popular Kidsilk Haze is a beautiful and versatile fine yarn made from a blend of super kid mohair and silk.


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You can now invite anyone to meet at your favorite Starbucks.
Limited-time feature
38 year old man | Hillcrest, CA, USA | Seeking men 28-44 within 50 miles of San Diego, CA
So I says to him I says, "Get your own monkey.
I am a friendly guy and a bit of a dork. I can be reserved around people I don't know, but once I know you I can be quite gregarious and affable. I like early dates to be conversation filled, so dinner, coffee, walk through Birch Aquarium. I can't carry a tune to save my life, but that does not stop me from singing when my jam plays on the radio or my ipod. I have been described by friends as silly, daft, and mercurial. I am looking for a guy that wants to take the time to get to know me, is funny and makes me smile, and will share some of my interests while introducing me to new ones that he enjoys. I'm just looking for a connection, once that happens the rest just flows.
Coffee and conversation , Dining out , Movies/Videos , Museums and art , Music and concerts , Wine tasting
Aerobics, Dancing, Running
I exercise 1-2 times per week.
I have Cats
I like Dogs
I have a black and white tuxedo cat who can be rather high strung. He has always been a bit crazy, but that is why I love him. First time I saw him he was clinging to a chain link fence 7 feet off the ground yowling. I think he's part monkey.
Middle of the Road
Locally I like the Civic Center Theater, the La Jolla Playhouse, and often find myself at Huapangos on 5th. I visit NYC about twice a year to see my sister, my niece and of course take in a few musicals.
The University of Arizona, Tucson, AZ
I am addicted to British TV, especially Eastenders and Doctor Who. Big fan of ABBA, Madonna, David Bowie, Niki and The Dove, Janelle Monae, basically all types of music. I can't pick a favorite movie, but have serious soft spot for Beautiful Thing.
I like watching TV, movies, going to museums, and attending the theater (mostly musicals). I love sleeping in on weekends, it is one of my most favorite pleasures. I think Saturday is for doing things & Sunday should be ultimately lazy and relaxing.
Evil Under the Sun...I am currently working through the works of Agatha Christie in chronological order.
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|What he is looking for
|5'10" (177cms)
|5'9" (175cms) to 6'3" (190cms)
|Body type:
|A few extra pounds
|Slender, About average, Athletic and toned, Heavyset, A few extra pounds, Stocky
|Black, Blue, Brown, Grey, Green, Hazel
|Dark brown
|Auburn / Red, Black, Light brown, Dark brown, Blonde, Salt and pepper, Silver, Dark blonde, Grey, Platinum, Bald
|No Way, Occasionally, Daily, Yes, but trying to quit
|Social Drinker, Regularly, Moderately
|Other profession
|No preference
Research Associate at small Biotech/Drug Discovery company. Work in a lab with my ipod plugged into my ears all day...dream job really.
|$35,001 to $50,000
|No preference
|Never Married
|No preference
|Have kids:
|No preference
|Wants kids:
|Probably not
|No preference
|White / Caucasian
|Asian, Black / African descent, Latino / Hispanic, Middle Eastern, White / Caucasian
75% Italian, 12.5% Irish, 12.5% Scottish...but I associate with none of these, just American is how I truly identify myself.
|No preference
Raised Catholic (confirmed and all) have tried many religions and beliefs, nothing fit. Tried spirituality, that didn't really work for me either. Give me physics, biology, and chemistry...can science be a religion?
|Bachelors degree
|No preference
BS with major in Molecular and Cellular Biology, double minor math/physics/chemistry combo and Spanish


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Evernote Adds Twitter Integration
I have a had a busy week working away on a client site with no Internet access so I have been rather cut off, enough to miss this little gem from Evernote.
I love Evernote and Twitter so the ability to integrate these caught my attention.
So, in a nutshell you can add selective Twitter tweets to your Evernote account by including @myEN to your tweet.
I have just enabled this and I am going to think long and hard for some good usability reasons for doing so.
I would love to hear your thoughts on this, good or bad.
If you do not follow me, please follow me on Twitter!
- 1 Comment... What do you think?
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said on April 18th, 2009 at 1:04 pm
Wow, a week or so with no net access, did you go crazy?Reply


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I'm Blacksan...
I'm like Narubleach!!!
btw, DAT AZZ
btw, DET AZZ
btw, DAT NICE AZZ
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How Should Natural Gas Profits be Divided? The Torah View
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Misc. Codes
Effect Code Flight Mode At the main menu press Left, Down, Right, Left, Up, R2, L1, Up, Left, Right Free Shield with Glitch At the main menu press Left, R1, Left, Right, Down, L2, R2, Left, Right, Up Full Glitch Energy At the main menu press Right, L1, Up, Right, Down, L1, R1, Up, Down, Left Play as Dot Matrix Highlight New Game and press Left, R1, Right, Up, Down, R2, L1, Right, Up, Down Play as Enzo Highlight new game and press Up, Left, Down, Left, Down, L1, R1, Right, Down, Right Refill Ammo At the main menu press Up, L1, Down, Up, Left, R1, L2, Down, Left, Right
Contributed By: Mike Truitt, Chegg, ATadeo, and KasketDarkfyre.
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