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Taste Test: The Best Pepper Jack Cheese
First produced by Mexican Franciscan monks of Monterey, California, Monterey Jack cheese is one of the true original American cheeses. Add to that cheese bits of chopped hot peppers (usually jalapeño), and you've got yourself pepper jack. Perfect in jalapeño poppers, bang-up on burgers, crazy-good on crackers, top-notch at topping nachos, and, uh... inquedible in quesadillas, it's the snackers' cheese par excellence. So who makes the ooziest, tangiest, hottest of the bunch? More


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The Rev. Jeremiah Wright, President Barack Obama's former minister, will be traveling from Chicago to be the revivalist during Aiken's Second Baptist Church's revival being held from Monday to Wednesday.
Second Baptist will be holding the event at 7 p.m. each night at the church, located at 425 Hampton Avenue.
In March 2008, Rev. Wright made national headlines for comments made during sermons at Trinity United Church of Christ in Chicago, which were deemed controversial and inflammatory.
Wright's sermons were long attended by Obama before his election to the presidency, leading the pastor's remarks to be highly publicized in connection to his White House campaign.
Obama currently attends church services in Washington, D.C.
Second Baptist Church, which currently has over 500 members, has served the Aiken community for more than 100 years, according to its website.
For more information about the revival, call the church's administrative office at 803-644-3994.
• Michael Ulmer covers the county government beat for the Aiken Standard and has been with the newspaper since March 2013. He is a native of North Augusta and majored in political science at the University of South Carolina.
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subset: commoncrawl


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Ultima Online: Renaissance
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Release Date: April 13, 2000
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Game Details
Published by: Electronic Arts
Developed by: Origin Systems
Genre: RPG
Release Date:
United States: April 13, 2000
Australia: Released
Japan: Unreleased
T for Teen : Blood and Gore, Violence
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About That So-Called 'Pallywood' Video…
This is in response to a couple of other Pages posted regarding film footage of this week's Israeli air strikes in Gaza, both of which questioned the authenticity of several BBC video clips that at least one Israeli blog & one far-right Israeli news outlet are presenting as "Pallywood" productions.
"Don't give anyone your eyes." —ProverbWhile I don't deny that there have been numerous cases of staged or distorted videos, not to mention photoshopped images, it's a mistake to take the default position that nearly everything coming out of Gaza (or the West Bank) is distorted without having sufficient proof of that being the case. Why? Because it's dehumanizing. To be frank, I don't give a damn if someone has a good reason for being cynical—just because something is understandable doesn't make it okay. There have been many, many cases of women who have lied about being raped; does that make it okay to assume by default that all or even most women who claim to have been raped are lying? Of course not, no decent, rational person would think such a thing.
A wise man by the name of Bob Levin once relayed to me a (Jewish?) proverb that I'm going to paraphrase here: Don't give anyone your eyes. Truer words were never spoken. Never, EVER let others tell you what you're seeing.
So while this may be too long & boring for many of you, I want to make a point by illustrating just how easily our eyes can be deceived, by both our personal biases & preconceived notions and by the speed at which visual information flies by, causing us to miss many subtle details.


text: Unicorn Eyeshadow ($8.25 for 0.07 oz.) is described as an "iridescent lavender filled with multi-color sparkle." It's an icy, cool-toned lavender with an iridescent sheen. I applied it alone (dry), and it had good color payoff, and then applied over Pixie Epoxy, the sheen came out slightly more but the pigmentation was buildable to full opacity. This shade wore well for over eight hours–no creasing or fading–without a base as well as just applied over Pixie Epoxy. Urban Decay Aura #2 is lighter. MAC Amethyst is more sparkly. MAC Ready to the Party is more metallic. OCC Datura is slightly purpler. See comparison swatches.


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Professor Guerrero's Summer Bridge class will visit the library today for a session to help students locate articles about "food and culture". During this session we will also be tackling the annotated bibliography in APA format.
Check out the guide for the class and links to online tutorials created by our Online Instructional Design Librarian, Danielle Skaggs, and Digital Learning Initiatives Librarians, Laurie Borchard and Anna Fidgeon.


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Pictured in Denim Blue. Click here to return to lifestyle photo.
Hanes® Beefy-T® - 100% Cotton T-Shirt. 5180
- 6.1-ounce, 100% ring spun cotton (preshrunk)
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- Ash is 99/1 cotton/poly
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- Oxford Grey and Charcoal Heather are 60/40 cotton/poly
Please note: This product is transitioning from tagged labels to tag-free and orders may contain a combination of both.
Adult Sizes: S-3XL


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I gave birth by emergency c section on January 31st 2011 at 33 weeks. My little boy spent 17 days in scbu. I had pre eclampsia, eclampsia and hello, I am also rhesus negative, allergic to latex and can not take any codine or anti inflammatory medication. My son and I were kept in different hospitals for the first 2 days of his life as I was too sick to move and they needed the baby bed for a smaller baby. It was a very difficult time for my husband running between 2 hospitals seeing his tiny baby and very sick wife. After I had started on the road to recovery we were told some very tough facts about our chances of having another child and resigned ourselves to loving the angel we had been blessed with. Jonathan is turning 2 in January and all of my mummy friends are talking or are already pregnant with number 2 and I find myself longing. I have an appointment to take to my gp about our options, we looked into adoption which seems near impossible and then I stumbled upon some success stories on here and so I am wondering could this be possible for us or would it be selfish of me to try, like playing Russian roulette. I am scared of the pain and all the needles and drugs I had to go through the first time, scared of being parted once again from my baby, scared of bringing into the world a baby too small to survive and having to watch it slip away. How can I know what is right and wrong and whether we should just try? I hope to hear from some of you to help me gain some perspective.
Thanks Jennifer


text: The Vic Sage wiki last edited by Hit_Monkey on 04/17/14 11:03AM View full history OriginCharles "Vic" SzaszThe man who would become known as Vic Sage was born as Charles Victor Szasz, an orphan who was raised in a Hub City orphanage, where he gained a reputation as a troublemaker. Because of his behaviour and defiant nature he was frequently beaten by the nuns who ran the orphanage, and often victimized by the other children. When he was old enough he left the orphanage for college, where he studied journalism. He found work as a reporter, but was dissatisfied with his life and had trouble controlling his violent tendencies. Sometime later he met Aristotle Rodor, who helped him channel his anger and aggression into a new, heroic persona - The Question.CreationVic Sage was created for Charlton Comics by Steve Ditko. He first appeared in the DC Universe in 1985, and the character was revamped for that universe by Dennis O'Neil and Denys Cowan in 1987.Character EvolutionCharlton ComicsThe Question (Charlton Comics)Sage was originally created as a minor Charlton Comics hero. He was heavily influenced by his creator's objectivist views, similar to Ditko's other previous creation, Mr A, and espoused a firmly objective standard of ethics. In his first appearances, Sage had very little backstory, and was often ruthless in his treatment of criminals.DC ComicsModern Age: New EarthThe Question (New Earth)When a number of Charlton Comics' characters were purchased by DC, Sage migrated along with them. He made a few small appearances before 1987, at which point the character was given his own series. His backstory was heavily expanded upon. The character maintained the philosophical bent that had characterized his early incarnations, but drifted away from Objectivism towards a more Zen-based philosophy.New 52The Question (Earth 0)The Vic Sage of the the new 52 has received a completely new makeover. He now appears as a supernatural being who is also part of the Trinity of Sin. His identity is still unknown, as are his powers. All that is known is that he now talks in mangled speech balloons (much like Rorschach) and still deals out vigilante justice, he's also seen leaving his unique calling card at the scene of the crimes he prevents.Major Story ArcsCharlton ComicsThe Question is bornVic Sage is an investigative reporter working for World Wide Broadcasting Co. (WWB) in Hub City. He is approached buy an old friend and ex-professor, Aristotle Rodor, who tells Sage that Rodor's old partner, Dr Arby Twain, is attempting to sell Pseudoderm, which had been tested and found to be dangerous when applied to open wounds, to Third World countries as a form of bandage. Sage wants to expose the scheme; however, he can't investigate without revealing his identity. With the help of Rodor, he creates the identity of the Question, wearing a featureless mask made of Pseudoderm. He gathers the information needed, and uses his position at WWB to broadcast the truth about Pseudoderm. After Twain is defeated, Sage decides to use the Question identity in future investigations, and to protect "his" city.Modern Age: New EarthThe QuestionVic Sage, an investigative reporter recently returned to Hub City, the city of his birth, has been stirring up trouble with some very important people, both in his civilian identity and as the Question. These people formulate a plan to silence him that leaves him nearly dead. He is rescued from certain death by Lady Shiva, who sends him to be trained by Richard Dragon. Under Dragon's tutelage he learns martial arts and develops an interest in eastern philosophies. Upon his return to Hub City, a newly refocused Sage dedicates himself to eliminating the corruption that has been slowly but surely taking control of every aspect of life in Hub City.Cry for BloodSage spends some time in Gotham, and takes a professional and romantic interest in Huntress, in whom he sees a reflection of himself. He brings her to Richard Dragon for training in the hopes of moulding her into a better crime fighter, a hope which is continually frustrated by her casual attitude towards murder as a means to an end.QuestionSage is re-imagined as a semi-mystical visionary who utilizes the binary gas (re-imagined as a hallucinogen) to enter into trances that allow him to "communicate" with cities. He also practices a questionable moral code that allows for murder when he feels it is justified, and he often treats enemies brutally. While using the gas, he detects a plot by Lex Luthor to assassinate Superman, and foils it. Superman expresses gratitude for the rescue, but forces Sage from the city because of his flexible morals when it comes to murder.52 WeeksSage makes contact with Renee Montoya, who he hires to observe a warehouse being used by Intergang to smuggle weapons. Eventually it is revealed that Sage is dying of lung cancer, and wishes to train Montoya as his successor and help her understand who she truly is. He has her train in Nanda Parbat with his mentors, Dragon and Rodor, while also working with her in Gotham to discover the Religion of Crime's plot. Sage's condition begins to deteriorate, and Montoya attempts to return him to Nanda Parbat, under the belief that he will not die so long as he is there. They fail to locate the city in time, and Sage succumbs to his cancer in the snow just outside the city, passing on the identity of the Question to Montoya.Blackest NightSage return's for one final comic during Blackest night in the one-shot Question #37, as a resurrected Black Lantern. During a training session between Lady Shiva and Renee Montoya, Charlie interrupts and begins to fight the two, trying to coax them into feeding him emotion. The fight continues until Renee realizes that he cannot be beaten. She uses a mental calming technique, relieving herself from emotion and disappearing to the black lantern senses. Shiva does the same, and becomes invisible, but Tot is feeling fear. Sage shambles closer to him, attempting to slaughter him, but Tot overcomes his emotions and disappears to Charlie's "emotion sight". The question then wanders off looking for the three of them, and Renee claims shes going to stop him.The New 52Trinity of SinQuestions?The Seven Wizards of The Rock of Eternity summon the Trinity of Sin, who consists of Pandora, the Phantom Stranger and The Question. Pandora being the same woman who opened Pandora's box, and the Phantom Stranger turns out to be Judas Iscariot, while the Question's identity is still unknown. The Question challenges the Wizards to kill him, and asserts that he will rise to power and make the world fear his name if they didn't. The Wizards wipe his name from his memory and from history. His facial features are removed, and he is cursed to forever question his identity and search for answers that he will never find. He is banished along with the others to walk the Earth while cursed with immortality, he may be the DC universe equivalent of the Wandering Jew of medieval christian folklore.Years if not decades later, he is shown having rescued the mayors kidnapped daughter in Hub City, searching for answers he seems to be convinced that Pandora and the Phantom Stranger hold the answers he seeks.The Question then appears to Dr. Thirteen and asks him what it would take for him to betray the Phantom Stranger. Under direction from the Question, Dr. Thirteen calls the Stranger and tells him that he may find information about his family if he goes to a casino in Las Vegas. However, this only causes tension between the Stranger and the Sons of Trigon whom he plays in a game of high stakes poker. This gives the Question time to continue with his secret plans and he tells Dr. Thirteen to call the Stranger again, luring him back to Thirteen's lab. When the Stranger arrives at the lab, the Question distracts the Stranger while Thirteen stabs him in the back with the Spear of Destiny. The Question then tells the Stranger to "just shut up and die". Then, believing the Stranger to be dead, the Question continues to haunt Dr. Thirteen telling him that he must gather up the courage to die himself. But when war breaks about between the Justice League and the Justice League of America, it is the Question who seeks the answers to who is trying to impute Superman.Trinity WarSo, while the rest of the Justice Leagues seek different answers to their questions, the Question goes right to Superman disguised as Steve Trevor and frees him asking if he would like to discover who really killed Dr. Light. Question reveals to Superman that he's discovered that the mind-control villain known as Dr. Psycho had been in Kanhdaq just before the incident. JL members Atom, Element Woman, Cyborg and Firestorm as well as JLA members Martian Manhunter and Green Arrow soon discover them but decide to go against Amanda Waller's orders and help Question and Superman with their investigation.In Pittsburgh the group discovers Dr. Psycho in his lair and begins to interrogate them. He tells them that he had nothing to do with what's happening to Superman and that the Secret Society set him up. Then, after it is revealed that the JLA was created as a response to the Justice League, Amanda Waller begins to look rather suspicious. The group returns to ARGUS to question her. But while they are talking with Waller, Plastique is on a mission from the Secret Society and is doing something to Dr. Light's body. Suddenly there is a massive explosion, destroying the ARGUS headquarters and leaving the fate of the Question and his group uncertain.When the three Leagues track down Pandora's Box in Athens, it begins to corrupt them all and they fight amongst themselves. The Question attacks Pandora and asks her what will happen if he opens the box. He asks her if it will give him the answers he wants, specifically if it will tell him who he actually is. In the end, Alfred of Earth-3 opens the box as a doorway to Earth-3 allowing the Crime Syndicate of America to pass through it.Forever EvilAfter the Crime Syndicate supposedly kills the Justice Leagues the Question somehow escapes the same fate and returns to find the Phantom Stranger still alive. But it isn't long before the Stranger is the one seeking out the Question. Confronting him in Hub City, the Stranger wants to know why the Question tried to kill him. There it is finally revealed how much the Question hates the Stranger, seeing himself as an innocent victim, forced to live out eternity never knowing who he is or what his crime was alongside such evil sinners as the Stranger. The Stranger understands now why the Question hates him so much, never knowing what his own sin is or who he is but the Stranger envies him. He tells him how he wishes he could forget the things he did and not be who he is. The Question then takes them to the Mount of Olives near Jerusalem and almost convinces the Stranger to take his own life with the Spear of Destiny. However, the Stranger has a vision of a new path he must take as a gift from Dr. Light whom he tried to save from the afterlife. The Question tries to finish him off but Zauriel intervenes and the Question disappears promising that it isn't over. But it is revealed that all three members of the Trinity of Sin have been brought against their will back to the Rock of Eternity by Constantine and his new Justice League Dark who asks them to help him kill evil.After all three members of the Trinity of Sin break free of Constantine's sealing spell a short skirmish ensues between the Trinity and the makeshift Justice League Dark. The Phantom Stranger quickly ends the battle and it is revealed that they are actually in the House of Mystery. The Stranger then probes Constantine's mind for why he has brought them there and the Trinity learns of the threat of Blight and the growing strength of evil magic since the Crime Syndicate entered their world. Constantine again asks the Trinity for their help. The Question becomes insulted that Constantine should associate him with the other two corrupt souls of the Trinity of Sin and he disappears from the House of Mystery before Constantine has a chance to explain.Powers and AbilitiesMartial Arts - He is a highly skilled martial artist and hand-to-hand combatant. When Shiva visited Hub city she saw promise in the Question and challenged him. She won of course but was convinced a great warrior layed beneath the surface. She sent him to Richard Dragon to be trained further. After this training he fared much better in a rematch though Shive is still his better. She did comment that he had lost some of his killer edge.Exceptional Detective Skills and Higher IntelligenceIllusion / Misdirection - continued use of the gas to bond his mask has allowed Vic to enter a hallucinogenic state much like that of native medicine men. In this state he has taught himself mild mystical abilities. He can cast illusions that affect the minds perception of things. These illusions affect even the greater senses of Superman. They could not fool the electronic detection equipment of Inter-gang monitoring from afar but could make him invisible to those present. He can make himself appear to be someone else. He can also make subtle suggestions that others can take as their own thoughts.Talking to Spirits / Planet - Also with this mysticism he can talk to the spirits or the city/ area/ planet. he used this to be aware of even the hidden activities of inter-gang that Superman wasn't able to detect. He was able to track them and their activities across the city. He was also made aware of the danger presented to Superman in Metropolis while in Boston. The "city called him"Weapons and EquipmentSage wears a Pseudoderm mask that allows him to see, speak and breathe normally but renders his face featureless. It is attached to his face via binary gas which, when released, binds the mask seamlessly to his face as well as changing the color of his hair and clothing, all of which have been specially treated with a reactive agent. A second dose of the gas unbinds the mask and changes his clothing and hair back to their usual color. He stores the mask and gas in a specialized belt buckle. The gas is also used on a specialized calling card that releases the gas at a certain time, revealing a question mark on the formerly blank card.Alternate VersionsFlashpointIn the Flashpoint alternate universe, Vic Sage is a member of the Resistance.Earth-4 and Earth-9An unnamed character who resembles Sage briefly appears on Earth-4 along with a number of other characters who similarly resemble original Charlton properties. On Earth-9 a global surveillance network is named "The Question". It is possible that other variations of the character exists on other Earths.WatchmenThe character of Rorschach was heavily based on the Question. This has lead to an interesting feedback loop where some interpretations of the Question after Watchmen's release have tended towards displaying Rorschach-like qualities. In The Question #14, Sage reads a watchmen comic, and later tries to be more like Rorschach, but after being beaten up and asked any last words he states: "Rorschach Sucks."Other MediaJustice League UnlimitedJustice League UnlimitedThe Question made a number of appearances in the Justice League Unlimited animated series. He first appears in the episode "Fearful Symmetry," and makes speaking appearances in a subsequent four episodes, as well as cameo appearances in five others. He bears more than a passing resemblance to Rorschach, and is noted in the series as a "crackpot" and paranoiac who is obsessively dedicated to an incredibly complex conspiracy theory that he believes dictates the course of human events. He is shown to have feelings towards Huntress and official become a couple at the end of the episode "Double Date." Despite his eccentricities he is acknowledged as a superb detective, and is instrumental in unraveling a conspiracy and uncovering important secrets in the series. He is voiced by Jeffrey Coombs.Batman: The Brave and the BoldBatman: The Brave and the BoldThe Question appears in the cold opens of the Batman: The Brave and the Bold episodes "Mystery in Space!" and "The Knights of Tomorrow!" He also appears in the episode proper of "Darkseid Descending!" In his appearances he speaks almost entirely in questions. He is voiced by Nicholas Guest.


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Heavy Equipment Job Listings, August 1, 2015
8 Pieces of Heavy Equipment in High Demand
Heavy Equipment Job Listings, July 25, 2015
Heavy Equipment Job Listings, July 18, 2015
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text: Alumni and friends of the Hilbert community join together to celebrate the achievements of the 2012 award recipients. Six individuals will be honored at the event. The evening begins with cocktails at 6, dinner and the awards presentation at 7 and desserts and an open bar from 9-10. Pricing and other information can be found on our webpage at http://www.hilbert.edu/alumni/alumni-awards


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You've seen the public outrage at town hall meetings and "Tea Party" protests...now you and TCC must make sure this popular anger is felt in every corner of Washington DC. With your help, TCC will redouble its efforts and make Congress pay for ignoring the will of the American people.
These programs will add more patriotic Americans to the front lines of the fight against Obama's plans for socialism in America.
Thank you for your support for TCC. Donations will help fund TCC's mission to identify conservatives across the nation, to have the ready at a moments notice to help block Obama's socialist agenda for America.
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Buy Tickets New Directors/New Films 2013
Show From Series
Thursday, November 21
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New Directors/New Films 2013
March 20, 2013 – March 31, 2013
In its 42-year history, New Directors/New Films has introduced or cemented the status of some of the most familiar and critically-acclaimed directors of our time. Who will be your next favorite filmmaker? Presented by Film Society and Museum of Modern Art. Read more »


text: Conservation Events for next 90 days All Special Events Feedings Aquarium After Dark Members-Only Activities Conservation National Aquarium Animal Rescue Fundraiser at Seacrets Thursday, July 11, 2013, 3:30 PM Join the National Aquarium Marine Animal Rescue Program in Ocean City, MD, for a fun afternoon and evening at Seacrets: Jamaica USA! Annual Dolphin Count Friday, July 12, 2013, 8:00 AM Join the National Aquarium's Marine Animal Rescue Program for the Annual Maryland Dolphin Count along the Atlantic coast of Maryland. Register Now


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A closed-loop, variable-frequency, vagal-stimulation apparatus for control of ventricular rate during atrial fibrillation. In one embodiment the apparatus includes a stimulator applied to the left vagus nerve and a controller programmed to automatically and continuously adjust the vagal stimulation frequency as a function of the difference between actual and desired ventricular excitation rates. In a second embodiment the apparatus includes a vagal nerve stimulator and a controller which automatically adjusts the vagal stimulation frequency as a function of the difference between ventricular excitation rate and arterial pulse rate in order to eliminate or minimize pulse deficit.
1. A closed-loop, variable-frequency, vagal-stimulation apparatus for control of ventricular rate during an ongoing atrial arrhythmia, comprising:
means for detecting an atrial arrhythmia;
means for sensing ventricular excitation rate;
means responsive to detection of said atrial arrhythmia for generating pulses for stimulation of the left vagus nerve at a stimulation frequency which is variable automatically as a function of the difference between actual and desired ventricular excitation rates, said adjusting means including means for changing said vagal stimulation frequency by a greater amount for one value of said ventricular rate difference than for a smaller value of said ventricular rate difference; and
means for delivering said pulses to said left vagus nerve.
2. The apparatus of claim 1, further comprising means for enabling generation of stimulating pulses by said generating means only in the presence of atrial fibrillation.
3. The apparatus of claim 2, wherein said means for sensing ventricular excitation rate senses QRS complexes and determines ventricular excitation rate therefrom.
4. The apparatus of claim 3, wherein said adjusting means includes means for changing said vagal stimulation frequency over a predetermined time interval by a greater amount for said one value than for said smaller value.
5. The apparatus of claim 4, wherein said adjusting means includes means for calculating a normalized deviation from said desired ventricular rate based on a predetermined tolerance value.
6. The apparatus of claim 5, wherein said adjusting means includes means for adding a value directly proportional to said normalized deviation to the vagal stimulation frequency to obtain a new vagal stimulation frequency.
7. The apparatus of claim 6, wherein said adjusting means includes means for adjusting said vagal stimulation frequency at intervals of approximately one second.
8. The apparatus of claim 1, wherein said adjusting means includes means for calculating a normalized deviation from said desired ventricular rate based on a predetermined tolerance value.
9. The apparatus of claim 1, wherein said adjusting means includes means for adding a value directly proportional to said ventricular rate difference to the vagal stimulation frequency to obtain a new vagal stimulation frequency.
10. A closed-loop, variable-frequency, vagal-stimulation method for control of ventricular rate during an ongoing atrial arrhythmia, comprising:
detecting an atrial arrhythmia;
sensing ventricular excitation rate;
automatically, upon detection of said atrial arrhythmia, determining a left vagal stimulation frequency and automatically adjusting said vagal stimulation frequency as a function of the difference between actual and desired ventricular excitation rates, said adjusting step including changing said vagal stimulation frequency by a greater amount for one value of said ventricular rate difference than for a smaller value of said ventricular rate difference;
generating pulses at said vagal stimulation frequency; and
delivering said pulses to a left vagus nerve.
11. The method of claim 10, further comprising the step of enabling generation of stimulating pulses only in the presence of atrial fibrillation.
12. The method of claim 11, wherein said sensing step includes sensing QRS complexes.
13. The method of claim 12, wherein said adjusting step includes changing said vagal stimulation frequency over a given time interval by a greater amount for said one value than for said smaller value.
14. The method of claim 13, wherein said adjusting step includes calculating a normalized deviation from said desired ventricular rate based on a predetermined tolerance value.
15. The method of claim 14, wherein said adjusting step includes adding a value directly proportional to said normalized deviation to the vagal stimulation frequency to obtain a new vagal stimulation frequency.
16. The method of claim 15, wherein said adjusting step includes adjusting said vagal stimulation frequency at intervals of approximately one second.
17. The method of claim 10, wherein said adjusting step includes calculating a normalized deviation from said desired ventricular rate based on a predetermined tolerance value.
18. The method of claim 10, wherein said adjusting step includes adding a value directly proportional to said ventricular rate difference to the vagal stimulation frequency to obtain a new vagal stimulation frequency.
19. A closed-loop, variable-frequency, vagal-stimulation method of controlling ventricular rate during atrial fibrillation without electrical stimulation of the heart, comprising:
detecting atrial fibrillation;
allowing said atrial fibrillation to persist;
sensing ventricular rate;
automatically, upon detection of said atrial fibrillation, determining a left vagal stimulation frequency in response to sensed ventricular rate relative to a desired value of ventricular rate, said determining step including increasing said vagal stimulation frequency by an amount directly proportional to a detected difference between sensed and desired ventricular excitation rates;
stimulating a left vagus nerve at said vagal stimulation frequency during said atrial fibrillation; and
terminating said vagal stimulation frequency upon cessation of said atrial fibrillation.
This application is a continuation-in-part of application Ser. No. 08/624,109, filed Mar. 29, 1996, now U.S. Pat. No. 5,690,681, issued Nov. 25, 1997.
This invention relates to devices and methods for controlling ventricular rate during atrial fibrillation, and more particularly to such devices and methods employing nerve stimulation techniques.
Atrial tachycardia, flutter and fibrillation are serious arrhythmias resulting in a low cardiac output and limited exercise tolerance. At present these arrhythmias are treated with drugs, electric shock (cardioversion), or surgical destruction of the atrioventricular (A-V) node and pacemaker implantation. Surgical cutting of atrial tissue to eliminate re-entrant paths is now being investigated. Drug therapy is not always effective and there are undesirable side effects. Although cardioversion abolishes some of these atrial arrhythmias, they usually return because the cause for the arrhythmia is still present. Surgical ablation of the A-V node is successful but leaves the subject with a limited exercise tolerance unless a rate-responsive pacemaker is implanted. These existing approaches are accepted by the medical community and biomedical engineers as the only practical choices, despite the existence of research reported in the literature for years on the subject of electrophysiological techniques involving stimulation of various nerves.
To understand the mechanism of action of an alternative system, proposed herein, for ventricular rate control by means of control of the number of atrial excitations reaching the ventricles, it is useful to review some aspects of the effect of cholinergic drive on the heart. Acetylcholine hyperpolarizes the S-A node and atrial muscle membranes, reduces the refractory period of atrial muscle and weakens the force of atrial contraction. Cholinergic drive also delays or blocks the transmission of excitation across the A-V node.
The cholinergic nerves to the heart are the right and left vagii. The right vagus innervates the S-A node, the atrial muscle and, to a much lesser degree, the A-V node. The left vagus nerve innervates the S-A node and atrial muscle to a lesser degree than it innervates the A-V node. It is well known to physiologists that stimulation of the right vagus nerve predominately slows the S-A node rate and thereby reduces heart rate. Stimulation of the left vagus nerve produces some slowing of the S-A node, prolongation of A-V conduction and partial or total A-V block. We have observed in monophasic atrial electrograms that low-frequency left vagal stimulation causes a dramatic shortening of the duration of the atrial monophasic action potential, indicating shortening of the atrial refractory period. Although the left vagus nerve affects atrial rate to a lesser degree, transmission of excitation across the A-V node is largely regulated by the left vagus nerve.
In atrial fibrillation, the A-V node is bombarded with excitations and responds as rapidly as its refractory period will allow, resulting in rapid, irregular ventricular excitations, i.e., R waves, resulting in varying times for ventricular filling. This results in a rapid, irregular pulse with a pulse deficit. A pulse deficit exists when a ventricular excitation (R wave) does not produce a blood pressure pulse. The mean blood pressure and cardiac output are both reduced as a result of the pulse deficit.
There have been some reports of using electrodes to stimulate the vagus nerve, where such stimulation has an effect on heart rhythm. See, e.g., Bilgutay et al., Vagal Tuning, J. Thoracic Cardiovas. Surg. 56(1):71-82, July, 1968. Bilgutay et al. studied the use of right vagal stimulation for treatment of supraventricular arrhythmias, angina pectoris, and heart failure. Experiments were conducted to determine the effective amplitudes, frequencies, wave shapes and pulse length of the stimulating current to achieve an optimal slowing of the heart rate by stimulating the vagus nerve, the optimal heart rate being defined as the slowest heart rate that could be attained by vagal stimulation without causing A-V dissociation or complete heart block or lowering the ventricular and aortic pressures. The experiments involved the right vagus nerve and resulted in selection of a stimulation amplitude of 6 to 10 volts, a frequency of 10 pulses per second, and 0.2 msec. pulse duration. Voltage increases were noted to decrease heart rate, and a unit triggered by the R waves of the subject's electrocardiogram is described as operating on a servo principle, but apparently in all cases the amplitude and frequency settings are fixed whenever the unit is operating. Bilgutay et al. indicated that the right vagus nerve was stimulated because its distribution is known to be mostly to the sinoatrial node area, but mentioned one experiment in which stimulation of the left vagus slowed the ventricular rate in a dog with complete heart block.
Recognizing the possibility of bradyarrhythmia, one recently proposed approach contemplates the inclusion of cardiac pacing with vagal stimulation. This latter approach to ventricular rate control, which entails a bradyarrhythmia pacemaker, is described in U.S. Pat. No. 5,330,507 to Schwartz. The addition of pacemaker circuitry and related components naturally increases the complexity and cost of the medical device. The patent mentions that stimulation frequency may be varied in a predetermined pattern from an optimum stimulation frequency, amplitude and duration determined during patient workup, if the initial delivered therapy fails to convert the tachyarrhythmia; however, there is no indication of a suitable pattern or any method of implementing it. The device described is designed to generate nerve stimulating pulses having a frequency and amplitude that, while programmable, are fixed once programmed. In essence it is an ON/OFF device that switches state in response to, e.g., the crossing of a heart rate threshold. Such ON/OFF switching, with fixed pulse characteristics, is likely to produce a hunting response, i.e., cycling of the heart rate with episodes of tachycardia. Moreover, although mentioning atrial fibrillation, this patent focuses on prevention or interruption of tachyarrhythmia, and contains no apparent recognition or appreciation that atrial fibrillation can be allowed to persist and that stimulation of the left vagus nerve, as opposed to the right vagus, is necessary and sufficient to effectively control the ventricular rate during atrial fibrillation.
U.S. Pat. No. 5,203,326 to Collins discloses a pacemaker which detects a cardiac abnormality and responds with pacing combined with vagal nerve stimulation. Collins discloses a method of vagal stimulation which includes progressively increasing the stimulation frequency in one-minute intervals and, for the pulse delivery rate selected, slowing the heart rate to a desired, stable level by increasing the pulse current. In the illustrated waveforms (FIGS. 12A-D), there is no correlation between stimulation frequency and ventricular rate. Moreover, the method is open-loop, without regard for the difference between the current rate and a desired rate.
There is also no teaching or suggestion that a simplified device without pacing capability could provide effective control of ventricular rate through vagal stimulation while allowing atrial fibrillation to persist. Furthermore, one of ordinary skill in the art would not read the Collins patent as teaching or suggesting that it is the left vagus nerve that must be stimulated to provide effective control of ventricular rate during atrial fibrillation.
Another device using vagal stimulation for treating tachyarrhythmia is disclosed in a European patent application published in 1995 as Publication No. EP0688577A1. This device is designed to terminate fibrillation by vagal stimulation. There is no disclosure of a method for controlling ventricular rate by vagal stimulation while atrial fibrillation is ongoing and no mention of the use of the left vagus nerve for that purpose.
Thus there remains the need for a system that effectively takes advantage of the phenomenon that transmission across the A-V node is largely, but not entirely, regulated by the left vagus nerve, and, more particularly, provides effective control of electrical stimulation of the vagus nerve to control the number of excitations that reach the ventricles during atrial fibrillation.
The present invention overcomes the foregoing and other disadvantages of the prior art by providing a closed-loop, variable frequency vagal stimulation apparatus for control of ventricular rate during atrial fibrillation. The apparatus includes a stimulating means for stimulating the left vagus nerve at a stimulation frequency which is varied automatically in response to sensed conditions, and a controller having an output connected to said stimulating means and including means for automatically and continuously adjusting said left vagal stimulation frequency as a function of the difference between actual and desired ventricular excitation rates.
According to another aspect of the present invention, there is provided an apparatus for automatically controlling ventricular rate by vagal stimulation to minimize pulse deficit during atrial fibrillation. The apparatus includes a stimulating means for stimulating the left vagus nerve at a stimulation frequency which is varied automatically in response to sensed conditions, a means for detecting a ventricular excitation rate, a means for detecting an arterial pulse rate, and a processing means for comparing said ventricular excitation rate and said arterial pulse rate and automatically adjusting said vagal stimulation frequency as a function of the difference between said ventricular excitation rate and said arterial pulse rate.
A general object of the present invention is to provide an improved method and apparatus for controlling ventricular rate in the presence of atrial fibrillation.
A further object is to provide effective control of ventricular rate via vagal stimulation.
Another object of the invention is to provide an effective method and apparatus for stimulating the left vagus nerve and thereby reducing ventricular rate enough to eliminate or minimize the pulse deficit which typically occurs during atrial fibrillation.
FIG. 1 is an illustration of an implanted control unit according to the present invention in its operating environment showing the heart and left and right vagus nerves.
FIG. 2 is a block diagram of one form of the implanted control unit of FIG. 1.
FIG. 3 is a block diagram of another form of the implanted control unit of FIG. 1.
FIG. 4 is a graphical illustration of the relationship between ventricular rate and left vagal stimulation frequency during atrial fibrillation.
FIG. 5 is a graphical illustration of the ratio of R wave rate to arterial pulse rate versus the frequency of left vagal stimulation during atrial fibrillation.
FIG. 6 is a block diagram of the electrogram detectors in FIGS. 2 and 3 and of the arterial pulse detector of FIG. 3.
FIG. 7A is a block diagram of the atrial fibrillation detector incorporated in each controller of FIGS. 2 and 3 and preferably in a common controller.
FIG. 7B is a block diagram of the targeted ventricular rate algorithm portion of the controller.
FIG. 7C is a block diagram of the pulse deficit algorithm portion of the controller.
For the purposes of promoting an understanding of the principles of the invention, reference will now be made to the embodiment illustrated in the drawings and specific language will be used to describe the same. It will nevertheless be understood that no limitation of the scope of the invention is thereby intended, such alterations and further modifications in the illustrated device, and such further applications of the principles of the invention as illustrated therein being contemplated as would normally occur to one skilled in the art to which the invention relates.
FIG. 1 illustrates an implantable device according to the present invention in its operating environment in a mammalian body, in which it is operatively connected to the heart and the left vagus nerve. Information on the electrical activity of the ventricles and the atria is obtained by a catheter having two pairs of electrodes: electrodes 1 and 2 in the right ventricle (RV) and electrodes 3 and 4 in the right atrium (RA). Electrodes 1 and 2 are designed and positioned to detect a ventricular electrogram, which is supplied to the implanted controller unit 10 which processes the ventricular electrogram and derives therefrom the ventricular excitation rate. Electrodes 3 and 4 are designed and positioned to detect an atrial electrogram, which is supplied via the catheter to the implanted control unit, which processes the atrial electrogram. The implanted control unit includes logic circuitry or other circuit means for comparing the atrial and ventricular signals in terms of synchronization and rate, and on the basis of that comparison determining whether or not the patient is experiencing atrial fibrillation. The implantable device includes a pair of electrodes 5 and 6 attached or adjacent to the left vagus nerve for controlled stimulation thereof. One embodiment of the present invention, described below, also includes a sensor of the arterial blood pressure pulse, in the form of a monopolar impedance-measuring electrode applied to the surface of the subclavian (SC) or other convenient artery. Alternately, a piezoelectric pulse pickup placed alongside an artery could be used. A piezoelectric device would generate a voltage pulse and therefore save battery life in an implanted control unit dependent on a battery for operation.
The two embodiments of the invention to be described below are desirably combined in a single implanted control unit operable in two modes respectively associated with the control algorithms for the first and second embodiments. Both embodiments use an adaptive control system which adjusts to changing cardiac states. It operates only during episodes of atrial fibrillation. It retains, in memory, parameters that were successful in previous episodes of required control and uses this previously learned information to improve controller responses under similar situations. It also uses this information to update controller adjustments in newly encountered situations.
The first embodiment and its associated algorithm will be described in connection with FIG. 2, which depicts in block diagram form a controller 20 as an important aspect of the implanted control unit. The ventricular and atrial signals are supplied from their respective electrodes in the heart to a ventricular electrogram detector 22 and atrial electrogram detector 24, respectively, which digitize the electrograms and supply the digitized signals to controller 20, which responds to the detected ventricular and atrial signals.
Electrogram detectors 22 and 24 are shown in further detail in FIG. 6, from which it will be appreciated by those skilled in the art that the electrical activity from the associated electrodes is preamplified (in block 40), amplified (in block 42), and passed through an antialiasing filter 44 prior to sampling in an A/D converter 46. The sampled electrogram is then stored in a data buffer 48. The data are recalled from memory and bandpass filtered in filter 50 with a passband selected to maximize the signal-to-noise ratio. For example, in the case of the ventricular electrogram detector, the passband is selected to maximize the ratio of QRS complexes to T-waves and other noise sources. The bandpass filtered signal is then sent to a signal preprocessor in the controller, as will be described.
Atrial rate can be determined on the basis of the interval between atrial waves and is compared to a threshold established as an indication of atrial fibrillation. If desired, the time interval itself may be measured and compared to a time interval threshold for the same purpose.
Preferably, sufficient hardware and software are combined in a common controller to detect atrial fibrillation, and also to selectively implement a targeted rate algorithm or a pulse deficit algorithm, or a weighted combination of those algorithms, as will be described. Such a common controller is depicted in block diagram form in FIGS. 7A-C. In the presently preferred form of atrial fibrillation detector, shown in block diagram form in FIG. 7A, the atrial electrogram is examined in the time windows between QRS complexes, that is, between the rectangular pulses in a derived ventricular timing signal. Detection of QRS complexes is performed with a QRS signal preprocessor 51 and an adaptive threshold detector 52. The preprocessor takes the derivative of the ventricular electrogram signal from the output of detector 22, squares it, and then integrates it. This preprocessed signal is sent to detector 52 and to a peak detector therein which both detects peaks and classifies peaks as either signal (QRS complexes) or noise (T-waves or other noise sources). Using this information, obtained during a moving window of programmable width, e.g., four seconds, an adaptive threshold is computed which is above the noise and T-wave peak values. This adaptive threshold for the most recent moving window is compared to the incoming preprocessed signal, and, when the preprocessed signal exceeds the adaptive threshold, a QRS complex is determined to be found. The QRS pulses as detected by detector 52 are supplied to signal windowers 54 and 58 and also, as will be described with reference to FIG. 7B, to a counter 70 for determination of ventricular rate.
In atrial fibrillation, the atria are not electrically silent in the time windows between QRS complexes. An atrial electrical activity threshold is derived in threshold generator 56 by computing a percentage of the average value of all peaks found in the atrial electrogram as supplied by signal windower 54 during these time windows. More specifically, it has been found suitable to initiate a four-second interval and then average the largest atrial values detected during the time windows between QRS complexes which occur in the four-second interval, and to set the threshold as one-third the average value. This threshold is used in comparator 60 to reexamine the atrial electrogram during a fixed-width window of programmable width, defined by windower 58, following the end of a detected QRS complex. A width of 150 msec. has been found suitable. If the atrial electrogram amplitude is below the computed threshold for a specific window, that window is determined to be a "quiet interval." The number of quiet intervals is determined in a preselected period of time, e.g., four seconds. The percentage of quiet intervals is determined in block 62 by dividing the number of quiet intervals by the total number of intervals. If the percentage of quiet intervals is less than a preprogrammed threshold value (in block 64), e.g., forty percent (40%), atrial fibrillation is determined by comparator 66 to be present, whereupon the controller is enabled to implement the selected ventricular rate control algorithm.
Other techniques and algorithms for detection of atrial fibrillation with a lead configuration of multiple catheters including one in the right atrium and another in the coronary sinus are disclosed in an article by Kim et al. entitled "An Atrial Fibrillation Detection Algorithm for an Implantable Atrial Defibrillator", Computers in Cardiology, 1995, IEEE 1995: 169-172, which article is hereby incorporated by reference.
In the presence of atrial fibrillation, the controller is enabled to compare the actual R-wave rate with a target rate 25 entered into the controller via an external programmer 26 (FIG. 1) and, based on the difference between those rates, to control the frequency of the pulses which it generates and supplies to a stimulator 28 connected via electrodes 5 and 6 to the left vagus nerve. The controller includes an internal transmitter/receiver (not shown) adapted to establish a two-way telemetry link with external programmer 26, whereby telemetry information may be supplied to and from the controller's internal memory. The controller may be programmed to apply a low initial frequency, and consequently, to increase the stimulus frequency slowly and incrementally until the ventricular rate matches the operator-selected target rate. Preferably, the controller is programmed to automatically and continuously adjust the vagal stimulation frequency, e.g., at one-second intervals, as a function of the difference between the actual and desired ventricular excitation rates.
More specifically, and with reference to FIG. 7B, the actual ventricular rate is determined by first counting (in block 70) the QRS complexes detected with adaptive threshold detector 52 (FIG. 7A) and then, in block 72, dividing the QRS count by the time interval over which the count was obtained, e.g., four seconds. If the actual ventricular rate exceeds the target rate (block 25) by more than a preprogrammed acceptable error, or in other words is outside a tolerance range as denoted in block 76, frequency calculator 74 establishes a vagal stimulation frequency and generates an appropriate output pulse which, when processed by stimulator 28, becomes a stimulation pulse for the left vagus nerve. The vagal stimulation frequency for ventricular rate control, SFVR, is determined in the following manner. First a normalized deviation (ND(x)) from the programmed targeted ventricular rate is computed by subtracting the target rate from the actual value of the ventricular rate and dividing the result by the programmed tolerance range. The controller then takes a percentage of this deviation (by multiplying by K1) and adds this value to the previous value of vagal stimulation frequency. In terms of an equation,
SFVR (x)=SFVR (x-1)+K1 *ND(x)
where x is the epoch number.
If the actual ventricular rate is greater than the targeted ventricular rate, ND(x) will be positive, and vagal stimulation frequency will be increased. If the actual average ventricular rate is less than the targeted ventricular rate, ND(x) will be negative, and vagal stimulation frequency will be decreased. This is the physiologically appropriate action. The controller may be programmed to provide some nominal low initial stimulation frequency, e.g., 1-2 pulses/second, or may start with no stimulation, i.e., zero pulses/second.
The stimulation frequency and the coefficient K1 are measured in pulses/second (or Hz), and a suitable value of K1 is 0.1. A typical target rate is 80 bpm, and a nominal tolerance range is 10 bpm (a tolerance of ±5 bpm), although either one or both may be set higher or lower depending upon patient age and condition. The value of K1 is preferably set to provide a change in stimulation frequency of approximately 0.5 pulses/second per update at the beginning of vagal stimulation. For example, with a target rate of 80 bpm, a tolerance range of 10 bpm, and K1 equal to 0.1 pulses/second, a patient with a ventricular rate of 130 bpm when atrial fibrillation is detected would experience an initial change in stimulation frequency of 0.5 pulses/second:
ΔSFVR =(0.1)*(130-80/10)=0.5 pulses/second
Vagal stimulation frequency will increase or decrease in larger or smaller steps depending upon the magnitude of the difference between actual ventricular rate and the targeted ventricular rate. Thus a large deviation in ventricular rate is counteracted quickly by increasing the vagal stimulation frequency by a proportionately large amount. Small rate deviations are adjusted by small vagal stimulation frequency changes. When the actual ventricular rate equals the targeted ventricular rate or is otherwise within the tolerance range, the vagal stimulation frequency will be unchanged. Dividing by the tolerance range, which is twice the physician-entered tolerance, has the effect of bringing ventricular rate back into tolerance more quickly for cases when there is a small allowable tolerance in ventricular rate and more slowly for cases when a large tolerance is allowed. When the rate is back in tolerance, the most current stimulation frequency is stored for future use as the initial stimulation frequency in the event that the rate is out of the tolerance range again during atrial fibrillation. Alternatively, the frequency calculator, once enabled, may continue to adjust the stimulation frequency according to the above equation even after the ventricular rate is brought within tolerance, and until the atrial fibrillation ceases.
FIG. 4 illustrates the relationship between ventricular rate and left vagal stimulation frequency during atrial fibrillation. An increase in stimulation frequency caused the ventricular rate to be decreased smoothly, in an almost linear manner, down to a rate of 35 bpm with a stimulation frequency of 10 pulses/second. A stimulating pulse width of 100 microseconds (μsec.) has been found suitable, and pulse widths up to 2 msec. may also be effective in some applications. A pulse amplitude in the range of 1 to 25 volts supplied by stimulator 28 has been found suitable in the anesthetized dog.
Although less desirable than the time-based adjustment of stimulation frequency described above, adjustment based on ventricular rate relative to multiple thresholds may be suitable for some patients, with a predetermined threshold for each of several discrete levels of deviation from the desired rate. In this alternative embodiment, the controller has a programmable table of stimulation frequency differentials corresponding to the respective deviation thresholds, and the desired rate and a corresponding nominal vagal stimulation frequency are set by a physician during a patient workup. The frequency differentials, measured with respect to the nominal frequency, are preferably directly proportional to their respective rate deviation thresholds, but, alternatively, may be more or less than proportionately higher for higher rate thresholds.
It is anticipated that a fixed target ventricular rate will be sufficient to allow patients to conduct normal activities. A higher ventricular rate would be desirable for patients desiring to exercise, and it is contemplated that such a capability may be provided by incorporating an exercise sensor coupled to the controller so as to increase the targeted ventricular rate in response to exercise and thereby provide an automatic exercise capability for such patients. The exercise sensor may suitably respond to right ventricular blood temperature, respiratory rate, body motion, or other parameters, a number of which are described in a paper by Geddes et al. entitled: "The Exercise-Responsive Cardiac Pacemaker," IEEE Transactions on Biomedical Engineering, Vol. BME-31, No. 12, December 1984, which paper is hereby incorporated by reference. Another form of exercise sensor that may be utilized, employing an accelerometer technique, is described in U.S. Pat. No. 4,428,378, which is hereby incorporated by reference.
Referring to FIG. 3, the second embodiment or mode of the present invention operates according to an algorithm designed for elimination of a pulse deficit, i.e., the condition in which an arterial pulse fails to occur in response to an R wave. This algorithm does not require the selection of a target ventricular rate and may therefore be operator-independent. The objective of this closed-loop control method is to identify the lowest stimulus frequency required to be applied to the left vagus nerve to achieve a ventricular rate with no pulse deficit. As will be described, the controller 30 is designed and programmed to monitor the blood pressure signal for an arterial pulse after every ventricular excitation (as indicated by the R wave of the ECG), and, in general terms, to use the pulse deficit to control the frequency of stimuli applied to the left vagus nerve in order to identify the minimum stimulus frequency for which each ventricular excitation produces a blood pressure pulse. The controller may be programmed to implement an algorithm corresponding generally to the graph illustrated in FIG. 5, although it will be understood that the shape and values of such a graph will vary somewhat for individual patients and that the automatic control algorithm will be varied accordingly. The ventricular and atrial electrogram detectors 22 and 24 digitize the electrogram signals and supply them to the controller, which also receives digitized data from an arterial pulse detector 32, which includes circuitry of the type shown in FIG. 6 and which is described in further detail below.
One consideration in achieving closed-loop control to eliminate the pulse deficit in atrial fibrillation is adoption of an amplitude criterion for arterial pulse counting. During atrial fibrillation, the arterial pulses vary widely in amplitude. However, a pulse should occur in a time window just after the R wave of the ECG, and so the R wave is preferably used to open a time window to measure the peak-to-peak amplitude of the arterial pulse in the window, which is sufficiently long to accommodate the isovolumic period of the ventricles and the pulse transit time to the arterial measuring site. In a typical situation the former is on the order of 150 msec. and with a measuring site close to the left ventricle, the latter may amount to 50-100 msec. A running average of the pulse amplitude is made, and each newly measured pulse is compared in amplitude to the mean pulse amplitude. Pulses less than a predetermined percentage (20% is presently preferred) of the mean pulse amplitude are treated as absent.
A pulse measurement window is also preferably derived from the blood pressure signal itself. Arterial pulse detector 32 supplies a bandpass filtered blood pressure pulse (BP) signal to a blood pressure pulse signal preprocessor 90 shown in the portion of the controller illustrated in FIG. 7C. The preprocessor differentiates the signal and truncates all negative components. The resultant signal is then used by waveform generator 92 to derive a blood pressure pulse timing signal containing rectangular pulses which are coincident in time with the ejection of blood into the arterial system from the heart and which have a pulse width equal to the duration of the blood ejection. That timing signal is supplied to windower 94 to establish the measurement window. Pulse pressure is calculated (block 96) by subtracting the minimum value of pulse pressure from the maximum value of pulse pressure during the measurement window. The measurement during a particular measurement window is considered valid only if that measurement window occurs within the time window after a detected QRS complex. Pulse counter 98 includes software or circuitry for determining the presence or absence of a blood pressure pulse by comparing the pulse amplitude from calculator 96 with a threshold value, such as a percentage of the running average of pulse amplitudes (block 100) as described above. The blood pressure pulse count is determined in counter 98 by summing all blood pressure pulses counted as being present. Arterial pulse rate is then determined in calculator 104 by dividing the blood pressure pulse count by the time interval over which the count was obtained, e.g., one minute. The pulse deficit is then calculated in terms of a ratio by dividing ventricular rate by arterial pulse rate in divider 106.
The amount of pulse deficit is identified by the relationship between R waves of the ECG and arterial pulse waves over a predetermined interval of time, for example, one minute. This interval may be a moving window providing for calculation of current pulse deficit once a second, but the one-minute calculation interval is preferred.
The vagal stimulation frequency for pulse deficit reduction, SFPD, is then determined by the following equation:
SFPD (x)=SFPD (x-1)+K2 * PD(x)-PDT !-K3 *Y
First the difference between actual pulse deficit, PD(x), and targeted pulse deficit, PDT, is determined. Then a percentage of this difference (by multiplying by K2) is added to the previous value of vagal stimulation frequency, SFPD (x-1). In addition, the vagal stimulation frequency can be decreased by the value of the term K3 *Y, where Y is an integer and represents the number of epochs of the previous Z epochs for which there was no pulse deficit. The value of K3 is programmable and in the preferred embodiment is less than K2. A value of 0.25 pulses/sec/(R waves/arterial pulse) is suitable for K2, where pulse deficit is measured in units of R waves per arterial pulse. A suitable value of K3 is 0.0625 pulses/sec/epoch. Also in the preferred embodiment, the value for Z is 8.
The controller preferably has a programmable tolerance range, or error signal magnitude (block 108). That is, generation of stimulation pulses by the controller and incremental increase thereof occurs if the difference determined in comparator 110 between the target pulse deficit set in block 112 (preferably 1.0) and the actual pulse deficit is greater than a preprogrammed acceptable error, which may be ±0.05, or a tolerance range of 0.1. As with the ventricular rate control algorithm, the current stimulation frequency is maintained once the difference is within the tolerance range and is stored for future use as the initial stimulation frequency the next time the sensed conditions warrant vagal stimulation. The controller has a low R-wave rate safety limit, at which point the controller maintains the current stimulation frequency, in order to protect the patient from an excessively low ventricular rate; the safety limit is preferably programmable.
An arterial pulse detector 32 suitable for use with the present invention includes a monopolar arterial electrode made from a Teflon-coated stainless steel or other suitable wire, insulated except at its distal end, which is sutured to a small sheet of Dacron-reinforced Silastic. The Dacron sheet carrying the electrode is wrapped around the subclavian artery as shown in FIG. 1, or other convenient artery, and sutured. The monopolar arterial electrode operates in conjunction with a reference electrode which is relatively large and located at any convenient site, for example, the metal case of the implanted control unit. Further details of an arterial pulse detector as described above are described in an article by Konrad et al. entitled "A New Implantable Arterial Pulse Sensor for Detection of Ventricular Fibrillation," Medical Instrumentation 22(6):304-311, December, 1988, which article is hereby incorporated by reference. Alternatively, a cuff electrode could be used. For experimental studies, the arterial pulse may be measured directly, e.g., with a piezoelectric pulse pickup as indicated above.
A suitable electrode presently preferred for attachment to the left vagus nerve is a helical cuff electrode described in detail in U.S. Pat. No. 4,573,481, which is hereby incorporated by reference. Alternatively, for greater ease in mounting the electrode on the patient's nerve during implantation, the electrode may be in the shape of a bird's claw as disclosed in U.S. Pat. No. 5,215,089, which is hereby incorporated by reference.
If desired, stimulator 28 may be configured to receive pulses generated by the controller and to supply pulses to the left vagus nerve with a predetermined intensity and duration which are preferably variable and programmable. Alternatively, the stimulator may be configured essentially as an electrode driver circuit without separate pulse generation capability, i.e., limited to supplying voltage or current at a desired level, or it may be a separate programmable pulse generator having a rate control input coupled to a controller correspondingly designed to determine a stimulation frequency and to supply a corresponding command or signal to the rate control input of the pulse generator. The controller and stimulator may be implemented with a conventional microprocessor and associated output circuitry of the type disclosed in U.S. Pat. No. 5,154,172, which is hereby incorporated by reference.
Preferably, the two algorithms described above are implemented in combination to determine the appropriate vagal stimulation frequency. In particular, the stimulation frequency, SF(x), is determined by a weighted sum of the frequencies calculated by frequent calculations 74 and 110, according to the following equation:
SF(x)=W*SFPD (x)+(1-W)*SFVR (x)
where W is a weighting factor.
The permissible range of the weighting factor, W, is 0 to 1, and the preferred range is 0 to 0.6. The weighting factor and acceptable programmable tolerance ranges can be programmed according to patient needs. A new stimulation frequency is preferably calculated every second or at the same update rate as SVR ; consequently, the value of SFPD remains the same for 60 update cycles (one minute) in this weighted sum embodiment because SFPD is preferably only updated at one-minute intervals.
While the invention has been illustrated and described in detail in the drawings and foregoing description, the same is to be considered as illustrative and not restrictive in character, it being understood that only the preferred embodiment has been shown and described and that all changes and modifications that come within the spirit of the invention are desired to be protected. For example, those skilled in the art will appreciate from the foregoing teachings of the present invention that other embodiments can be used to implement the principle of ventricular rate control during atrial fibrillation using controlled left vagal stimulation. For example, both vagus nerves may be stimulated to obtain more A-V block. Alternately, only the cardiac branch of the left vagus nerves (left and/or right) may be stimulated to minimize any possible gastrointestinal effects. The left cervical vagus nerve is believed to advantageously require a low stimulus frequency, but its use has the potential side effect of increased gastrointestinal motility and secretion.
The embodiments illustrated in FIGS. 1 and 2 employ a catheter electrode in the right atrium and ventricle and another electrode on the left vagus nerve. An alternate embodiment could use a catheter electrode in the right pulmonary artery to stimulate the left vagus nerve, as described by Cooper et al. (Circ. Res. 1980, 46:48-57). In this way, the principle can be applied using catheter electrodes.
Another embodiment avoids blood contact by using electrodes applied to the pericardium to detect the atrial and ventricular electrograms. Also, although less sensitive to those electrograms and more sensitive to noise, local subcutaneous sensing electrodes may be useful in certain situations, and they offer the advantage of enabling electrogram sensing without an A-V sensing lead in the heart.
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The North Carolina Museum of Natural Sciences will commemorate the 101st anniversary of the sinking of the maiden voyage of the Titanic on Monday, April 15 at 12 noon for a one-hour "Lunch & Learn" in the Museum's main auditorium.
Commemorate the 101st anniversary of the sinking of Titanic, Monday, April 15 at noon; state employees receive discount into "Titanic: The Artifact Exhibition"April 1, 2013 - 1:54pm
Never before seen landscape paintings by Anthony Ulinski to debut at the Nature Art Gallery Friday, April 5March 20, 2013 - 4:39pm
The Places in Between, landscape paintings by Anthony Ulinski on display at the Nature Art Gallery, Friday, April 5–28.
March 19, 2013 - 12:13pm
RALEIGH — The bizarre world you met in "Planet of the Apes" was only the beginning. What lies beneath may be the end! Or it might just be the second of five Ape Planet movies.
March 7, 2013 - 3:09pm
FOR IMMEDIATE RELEASE — March 7, 2013
Science, Education, Travel Editors.
Contact: email@example.com; 919.707.9837
March 4, 2013 - 8:56am
The North Carolina Museum of Natural Sciences ranked No. 1 in the annual survey of museums and historic attractions for 2012, according to results released this morning by Carolina Publishing Associates, which compiles the data. It is the first change in the top spot during the nine years of the survey.
March 1, 2013 - 12:12pm
On Saturday, March 16 from 9 a.m. to 5 p.m., the main Museum and the Nature Research Center will be transformed into a herpetological paradise. Free! From boas to pythons, pit vipers to rattlesnakes, visitors can get up close and personal with all manner of serpents as well as live frogs, toads, salamanders, turtles, lizards and crocodilians.
A History of African-American Spirituality on the Land, a talk by Dr. Dianne Glave at the Museum, Wednesday, March 6 at 7 pmFebruary 28, 2013 - 4:13pm
Dr. Dianne Glave will give a talk at the Museum titled, "Appeasing the Spirits of Millions of Things Organic & Inorganic: A History of African- American Spirituality on the Land" on Wednesday, March 6 at 7 p.m. in the Museum's Auditorium.
February 28, 2013 - 12:25pm
New Partnership Makes a Science Out of Having Fun in Raleigh on Thursday Nights. Museum, Time Warner Cable Partner for "Science Thursdays" and "Open Minds" Teen Science Café.
February 21, 2013 - 2:50pm
RALEIGH — Evil, as venomous as a snake, turns the quiet of this town into a writhing Hell on Earth. Where every man fears for his safety and his sanity. Where everyone is suspect. Trapped like animals in a cage.
February 21, 2013 - 2:24pm
FOR IMMEDIATE RELEASE – February 20, 2013
Arts, Entertainment, Travel Editors. Images available.


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Buy Long-Range Weather
(Nov. 2014 - Oct. 2015)
Complete 2015 Long-Range Weather Forecast for the Pacific Southwest Region, November 2014 to October 2015 includes week-by-week details.
Free 2-Month Weather Forecast
JULY 2015: temperature 70° (1° below avg.); precipitation 0" (avg.); Jul 1-13: Sunny, hot inland; A.M. clouds, P.M. sun, cool coast; Jul 14-26: Sunny, nice; Jul 27-31: Sunny inland; A.M. clouds and sprinkles, P.M. sun coast.
AUGUST 2015: temperature 70° (1° below avg.); precipitation 0.1" (avg.); Aug 1-3: Sunny, hot; Aug 4-11: Sunny; cool north, warm south; Aug 12-16: Scattered showers north, sunny south; cool; Aug 17-27: Sunny, cool; Aug 28-31: Sunny; hot north, cool south.
Annual Weather Summary: November 2014 to October 2015
Winter will be warmer than normal, with the coldest periods in late December and early to mid- and late February. Rainfall will be above normal in the north and below in the south. Mountain snows will be below normal, with the snowiest periods in early to mid-January and mid- to late February.
April and May will be drier than normal, with temperatures near normal in the north and below in the south.
Summer will be cooler than normal, with near-normal rainfall. The hottest periods will be in mid- and late June in the central valley; in mid- to late June, early August, and mid-September near the northern coast; and in late June, early August, and mid- to late September near the southern coast.
September and October will bring near-normal temperatures, with rainfall above normal in the north and below in the south.


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Questions & Answers
Do you have questions about this product?
Get answers from real customers and in-house experts with AnswerBox.
Q:How do you store this productAsked on 7/28/2015 by Bee
2 answers
A:In a cool dry place.Answered on 7/29/2015 by Kels from LUSH Direct
A:I just keep this out on the bathroom counter, no special storage required. Only the fresh masks need to be kept cold, as far as I know! It's a great moisturizer.Answered on 7/29/2015 by Lisa from NH
Q:Does this product hAve spf in it for sun protection or not?Asked on 6/18/2015 by macey from ohio
4 answers
A:No, it does not have SPF. It would be great if it did though, but unfortunately here in Lush North America we can't make any sunscreen unless they are tested on animals. And since we are completely against animal testing we can't create anything with sun protection.Answered on 6/19/2015 by Pauline
A:No it does not have any SPF, But it is still be best facial cream I have
ever owned.Answered on 6/18/2015 by Anonymous
A:No, it does not have SPF. But it is a great moisturizer!
Hope this helps!Answered on 6/18/2015 by Anonymous
A:It does not.
Sent from my iPhoneAnswered on 6/18/2015 by Lisa from NH
Q:I just bought this moisturizer, and the sticker on the back says its going to expire in 16 days. But I JUST bought it, can I use it past the date? What are the signs that the product is expired?Asked on 6/3/2015 by rizzygoround
1 answer
A:Our facial moisturizers have a 14 month shelf life from when they are made. It is likely that your use by date is in two weeks, but in the year 2016!Answered on 6/7/2015 by Anonymous
Q:I am using this for my nose which has an oily/sensitive combination. Will this be compatible with my skin type? Would it clog my pores?Asked on 3/18/2015 by Richard
3 answers
A:Celestial is our most gentle moisturizer, so it would be perfect for your sensitive skin. Our lightest blend, however, is our Vanishing Cream, which would be perfect for oilier skin, as it has lavender to balance out the oil on your face and witch hazel to tighten your pores.Answered on 3/20/2015 by Meg from LUSH Direct
A:I've been using this for years, a little bit goes a long way, I have combo/aging skin. I do not find that it clogs my pores. And it smells great.Answered on 3/19/2015 by Anonymous
A:I have not had any issues with clogged pores! This stuff is great! just
remember a little goes a long way.. a dab will do!Answered on 3/19/2015 by Anonymous
Q:I'm currently using Cosmetic Lad, but want to try something new (maybe something a little heavier, but won't make my t-zone oilier). Coalface is helping with my oily T-zone but the rest of my face feels dry. Any recommendations?Asked on 1/29/2015 by Mari from Los Angeles
1 answer
A:For your skin, I would recommend our Imperialis moisturizer because it does an amazing job of balancing out the skin. It has a ton of lavender in it, which is a natural sebum balancer. Sebum is the natural oil your skin produces, so the lavender in Imperialis will help to balance the oil on your skin while encouraging the dryer parts of your face to produce the right amount of oil. Imperialis helps your skin meet in the middle for a soft, balanced complexion.Answered on 2/13/2015 by Meg from LUSH Direct
Q:This product makes my face very greasy, but i just use a finger dab..... why?Asked on 1/24/2015 by dana from hopatcong
4 answers
A:I use a very small amount, a little goes a long way. And I wait for it to absorb before applying makeup. Maybe you are still using too much? I do have aging skin, so my skin may be dryer as well.Answered on 3/19/2015 by Anonymous
A:Our Celestial moisturizer might not be the formula that is best for you - if you're still looking for a more lightweight moisturizer, I would recommend either Vanishing Cream or Imperialis!Answered on 2/13/2015 by Meg from LUSH Direct
A:I would say it is too heavy for you. I would try imperialis (I hope I spelled that right) it sinks right into the skin and does a great job of balancing the skin. So you dry areas stay hydrated and your oily areas stay shine free. Maybe use celestial just as a night cream. :)
Sent from my iPhoneAnswered on 1/26/2015 by Anonymous
A:Make sure face is completely patted dry or air dried, rub in and let it absorb. May take a few minutes but greasy feeling should go awayAnswered on 1/24/2015 by Anonymous
Q:Can you use this product under a liquid foundation??Asked on 1/8/2015 by Dana from Hopatcong, NJ
5 answers
A:Absolutely, you can!Answered on 2/13/2015 by Melissa S from LUSH Direct
A:You most certainly can! I do everyday. It works great!
Sent from my iPhoneAnswered on 1/8/2015 by Anonymous
A:Yes. But be sure to let it absorb into skin completely and use a make up primer before applying foundation. A tiny bit of this goes a long way!Answered on 1/8/2015 by Anonymous
A:You have to allow a couple of minutes for it to fully absorb and then go
for it. It is a wonderful moisturizer.
KAAnswered on 1/8/2015 by Anonymous
A:I use it that way all the time without the foundation creasing around my eyes. I also use Celestial at bedtime.Answered on 1/9/2015 by K on the Island from Vashon Island, Washington State
Q:How long does this last until it expires?Asked on 3/14/2014 by hannah
1 answer
A:The full shelf life of the product is about 14 months, but every pot will have its own "Use By' date sticker with the products individual expiry date.Answered on 3/19/2014 by Kayla from LUSH DIRECT
Q:Do all of you face creams have Methylparaben and Propylparaben in them? I am concerned about parabens. Do you have a moisturizing product without parabens in them?
Looking forward to your replyAsked on 11/22/2013 by mimi from ny
1 answer
A:Full of Grace face serum contains absolutely no preservatives! This solid moisturizer is full of hydrating Cupuacu and Murumuru butters, calming chamomile and antioxidant mushroom extract to keep your skin feeling soft and smooth.Answered on 11/28/2013 by Anonymous
Q:Does this product contain mineral oil?Asked on 7/24/2013 by Chandra from Las Vegas, nv
1 answer
A:No, we do not use mineral oil in Celestial.Answered on 8/21/2013 by Megan from LUSH Direct
Q:I'm 30 (used to be acne prone, but not for years) with very sensitive, dry skin. The SA suggested it and I loved it in the store. It is making my face feel AMAZINGLY soft, but is breaking me out. What moisturizer would be a better option for me. Is there another one that is good with sensitive skin? My skin loves/hates celestial no matter how lightly I apply it.Asked on 7/2/2013 by Mary Sunshine from San Diego, CA
3 answers
A:Gorgeous. It's the moisturizer of confused skin. Many customers come in raving. All have had different skin and ages ranged from 13-62. On your next visit, ask for a sample. Though, It may not be enough... :)Answered on 5/28/2014 by onelovelle from Los Angeles, CA
A:You could also try Imperialis, which could still work with sensitive skin. Imperialis has lavender and tiger lily which help to balance oil production, so could help control breakouts.Answered on 9/25/2013 by Anonymous
A:I am 22 with dry, acne-prone/sensitive skin, so maybe my advice can help you. I recently went into LUSH and purchased Fresh Farmacy (miracle worker) and went back for a moisturizer. Despite the hefty price tag, I bought Gorgeous. Then I went back again for a day moisturizer and bought Celestial. Made me breakout all over, so I'm going to return it. I'd recommend Gorgeous because it hasn't made me breakout. It's worth the price if you look at your skin as an investment. Hope I helped!Answered on 9/4/2013 by Louise from Toronto
Q:What is the significant difference between Celestial and Skin Drink, and which would you suggest for sensitive/red/irritated/dry/sometimes flaky spots. I have a combination of eczema and rosacea on my chin and cheeks.Asked on 4/18/2013 by Nat
2 answers
A:Celestial and Skin Drink would be my top recommendations for the issues you've described, but Skin Drink would probably be the best choice in this case as it contains rose petal infusion and rose petal absolute, which really help to calm the skin and tame the redness that rosacea can cause. It's delightfully soothing!Answered on 9/24/2013 by Brandy from LUSH
A:Skin Drink is meant for very, very, very dry skin. It's list of ingredients is a lot longer than Celestial. This is NOT necessarily a bad thing. Skin Drink is made with all the ingredients intended to fill your skin with moisture. I honestly believe that your best bet would be Celestial. The Fresh Dove Orchid extract in it is soothing and calms redness... It has a very short ingredient list which I like... Skin that is sensitive like yours with the rosacea is important to nourish, but gently so. Celestial does just this! Even though the ingredient list is shorter, you will still get plenty of moisture with its creamy cocoa butter base and its vanilla pod infusion. Vanilla pod is soothing and moisturizing, wonderful for sensitivity and redness.
Ultimately I would say that you will get the best result from Celestial.Answered on 4/25/2013 by Phyto Fox from Kansas City, MO
Q:Does this clog pores?Asked on 2/17/2013 by Curious Miss from The United States
3 answers
A:Results can vary from person to person, depending on your skin type. Celestial is one of our moisturizers that is aimed at drier skin, so if you need something a bit lighter, take a look at Imperials or Vanishing Cream!Answered on 8/14/2013 by Anonymous
A:Not at all! This is the best moisturizer I have EVER tried!Answered on 8/1/2013 by Rosey from USA
A:Not that I've noticed.Answered on 4/6/2013 by Mama Em from Massachusetts
Q:Im a person that who have eczema, part of my face have crack and red also dry it's really hurt feels like burning after shower. Will this product help on eczema ?Asked on 9/12/2012 by Cy
3 answers
A:My eczema is pretty bad on my Hands, I often finds it helps with the cracking and doesn't irritate my hands or face. It's a pretty safe bet that it would be fine for you but I would do a 3 day test on a small area that can be hidden if it does irritate your skin.Answered on 3/19/2015 by christie from wisonsin
A:I would NOT recommend this for eczema. I have eczema myself. If you can afford it, I recommend Gorgeous ($89 a pop). Otherwise, vanishing cream works great.Answered on 10/18/2012 by Firedancer731 from Chicago, IL
A:Celestial is our gentle moisturizer for skin that gets irritated easily, such as those with eczema experience. It has lots of almond oil in it which is very high in vitamin E which is one of the best vitamins for the skin. It also has vanilla pod infusion which again, helps to soothe and calm the skin.Answered on 10/26/2012 by Anonymous
Q:Does this product have any SPF?Asked on 1/18/2012 by Anonymous
7 answers
A:It does notAnswered on 6/6/2012 by Elora <3 from Boulder, CO
A:This moisturizer does not contain any SPF.Answered on 1/20/2012 by Community Answer from None
A:No, it doesn't. If you have super sensitive skin, you might try using Celestial along with a mineral makeup on top.Answered on 2/2/2012 by jjdactyl from Philadelphia, PA
A:No.Answered on 2/11/2012 by StrixAluco from Anchorage, AK
A:the label on the front of the product says nothing of SPF.Answered on 3/18/2012 by leese from New York City
A:Sorry, but nope. None of the moisturizers do :(
Hope they'll add SPF soon though~Answered on 5/29/2012 by Lulu Loves Honey from Natick, MA
A:No, the facial moisturizers do not have any SPF content at this time.Answered on 8/30/2012 by Megan from LUSH Direct
Q:I love this lotion, but recently after using it for about a month I've noticed that I've started to get bumps around my t-zone area. They aren't zits or pimples, just weird little bumps. I'm wondering if this is from the lotion or if it's completely unrelated. Has anyone else had problems with this?
Thanks.Asked on 1/18/2012 by Sarah
2 answers
A:Most lotions over time will use build up if used everyday. They may not be zits but clogged pores because the richness of the product. Use more sparingly and be sure to wash face thoroughly before applying.Answered on 1/23/2012 by Community Answer from None
A:This experience is definitely not typical for this moisturizer. It sounds like the Celestial might be a bit too heavy for your skin type. I would also suggest adding an exfoliator (like Ocean Salt) to your skin care routine.Answered on 8/30/2012 by Elizabeth from LUSH Direct