text:
Rate responsive pacing is limited in an atrial based pacing mode by the AV interval in order to avoid or minimize ventricular encroachment of atrial pacing. The AV or VA interval is used to permit rate responsiveness; modulate rate responsiveness or to determine a dynamic upper sensor rate.
1. A method comprising:
measuring an AV interval;
determining an averaged AV interval over a predetermined number of cardiac cycles; and
setting a minimum A-A interval equal to the averaged AV interval plus a predetermined constant; and
delivering cardiac pacing in a rate responsive, atrial based pacing mode; comprising:
sensing a physiologic parameter other than the AV interval;
determining an atrial pacing rate based upon the sensed physiological parameter; and
employing the set minimum A-A interval as an upper limit to the determined atrial pacing rate.
2. The method of
3. The method of
analyzing the measured AV interval;
determining if the measured AV interval is associated with a pattern; and
excluding the measured AV interval from the averaged AV interval unless the measured AV interval is associated with the pattern.
4. The method of
5. The method of
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12. The method of
13. A method comprising:
measuring an AV interval;
determining an averaged AV interval over a predetermined number of cardiac cycles;
setting a minimum A-A interval equal to the averaged AV interval plus a predetermined constant;
delivering cardiac pacing in a rate responsive, atrial based pacing mode employing the set minimum A-A interval as an upper rate limit;
analyzing the measured AV interval;
determining if the measured AV interval is associated with a pattern; and
excluding the measured AV interval from the averaged AV interval unless the measured AV interval is associated with the pattern
wherein the measured AV interval is associated with the pattern if a duration of the measured AV interval varies by less than a predetermined amount from previously measured subset of AV intervals.
14. The method of
15. The method of
16. The method of
17. The method of
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This application is a continuation application of Ser. No. 10/971,686, now issued as U.S. Pat. No. 7,248,924, filed Oct. 25, 2004 entitled, "Self Limited Rate Response," which was invented by Casavant et al.
The present invention relates to implantable medical devices and mores specifically to implantable medical devices having rate response capabilities.
While a variety of pacing modes are available, dual chamber pacing/sensing (DDD) is commonly utilized. With a DDD mode, atrial and ventricular events are both sensed. If an expected intrinsic event is not sensed within a predetermined time window, an appropriate atrial or ventricular pacing stimulus is delivered. This mode provides a great deal of control over the patient's cardiac rhythm and the timing (e.g., the atrial-ventricular or AV delay) may be modified based upon many different factors. One of the many benefits provided by the DDD mode is the ability to maintain AV synchrony. That is, for any given atrial event there will be a specifically timed ventricular event, either intrinsic or paced.
Another beneficial feature is rate response (RR) pacing. With rate responsive pacing, a demand sensor is provided that seeks to approximate activity levels or physiological need from the patient and increase or decrease the pacing rate accordingly. For example, an accelerometer is used to sense the patient's motion. As the patient is more active, the accelerometer senses increased movement. This is recognized by the implantable medical device (IMD), which could be, for example, an implantable pulse generator (IPG) or implantable cardioverter defibrillator (ICD) with pacing capabilities. In any event, the accelerometer's signal causes the IMD to pace at a higher rate. The assumption is that increased patient activity requires higher cardiac output and increasing the patient's heart rate (i.e., pacing rate) will lead to greater cardiac output. The higher the activity levels sensed, the higher the paced rate, up to a predetermined maximum rate. There are a variety of demand sensors the may be employed such as, a minute ventilation sensor, blood oxygen sensor, chemical sensors, motion/movement sensors, or any other device that will approximate one or more demand parameters of the patient.
Typically, rate responsiveness is a positive feature that allows patients to engage in higher activity levels than would be possible with fixed rate pacing. The combination of DDD with rate response is also generally positive in that as the pacing rate is increased, the DDD mode will adjust parameters to assure proper timing throughout the cardiac cycle.
Recently, there has been a recognition that conducted or intrinsic ventricular depolarizations are vastly preferable to ventricular pacing in general and pacing in the right ventricular apex in particular. The difficulty in facilitating this preference is that in a great many patients, the intrinsic AV delay is so long that DDD timing will almost always deliver a ventricular pace. In order to minimize or greatly reduce ventricular pacing, a protocol had been provided that, in one embodiment, utilizes an atrial based timing mode that allows a full cardiac cycle to elapse without ventricular activity; thus providing the greatest opportunity to safely allow intrinsic conduction whenever possible. These protocols are described in U.S. Ser. No. 10/755,454, filed Jan. 12, 2004, entitled "Preferred ADI/R: A Permanent Pacing Mode to Eliminate Ventricular Pacing While Maintaining Backup Support", which is a continuation of U.S. Ser. No. 10/246,816, filed Sep. 17, 2002, entitled "Preferred ADI/R: A Permanent Pacing Mode to Eliminate Ventricular Pacing While Maintaining Backup Support", which is a continuation-in-part of U.S. Ser. No. 09/746,571, filed Dec. 21, 2000, entitled "Preferred ADI/R: A Permanent Pacing Mode to Eliminate Ventricular Pacing While Maintaining Backup Support", recently granted as U.S. Pat. No. 6,772,005 which are herein incorporated by reference in their entireties.
As used herein, an atrial based pacing mode is a mode that is programmed to pace in the atria, but only to sense in the ventricles. True single chamber atrial pacing would imply that only a single lead is present and ventricular activity may not be sensed in the ventricle nor would ventricular pacing be deliverable. In the present context we discuss an IMD operating in an atrial based mode, but at least having ventricular sensing capabilities. Though not required, such a device would generally include ventricular pacing. However, in order to deliver ventricular pacing the device would typically mode switch to a different mode, such as DDD.
Atrial based pacing in general, as well as in the context of minimizing ventricular pacing as discussed above, may also include a rate response function. Once again, as the demand sensor indicates a greater need, the heart rate is elevated by increasing the atrial pacing rate. However, without ventricular pacing, there is no control over the ventricular timing. As such, if the AV delay is not shortened or is actually elongated by the AV node in response to the elevated pacing rate, overall timing may become skewed. That is, the A-A interval is decreasing with respect to the resting rate, but the AV delay is not correspondingly and correctly modified. As a consequence, the VA delay (ventricular to atrial delay) may be shortened. Another consequence may be Wenckebach block. Thus, given ratios of ventricular beats are not conducted with respect to the atrial rate. As such, even though the atrial rate may rise, the effective ventricular rate could actually decrease.
If the VA delay becomes too short over a prolonged period of time, negative consequences may result. The contraction of the ventricles takes a finite amount of time from initiation of a depolarization. If the contraction is not completed, a subsequent atrial contraction will attempt to force blood into a contracted ventricle. Often, this results in blood flow out of the atria and back towards the lungs or venous system, causing symptoms. Similarly, the ventricles even if not fully contracted may not be fully relaxed during the atrial contraction, resulting in diminished filling. The net effect of having inadequate VA delay is that the elevation in heart rate fails to increase cardiac output, may actually reduce cardiac output, may affect hemodynamic compromise, and/or cause patient symptoms.
Referring now to
Atrial lead 15 as illustrated includes an extendable helix electrode 17 and a ring electrode 21, the helix electrode being mounted retractably within an insulative head 19. Electrodes 17 and 21 are used for bipolar atrial pacing and for sensing atrial depolarizations. While electrodes 17 and 21 may be used for bipolar pacing and sensing, electrode 17 may be used in conjunction with the surface of device casing 10, which surface acts as a common or indifferent electrode in what is termed unipolar operation. Note that, in this example, atrial lead 15 is not equipped with coils for use in the sensing and delivery of cardioversion of defibrillation pulses. This is not meant to preclude the inclusion of such applications that may be used advantageously with the present invention.
As indicated, the present invention may be used in an atrial based pacing mode, where ventricular pacing is selectively precluded, though a ventricular lead is present. The ventricular lead will provide sensing capabilities and when appropriate, pacing or other therapies. It should be appreciated that the present invention is also applicable to true atrial based devices that is when no ventricular lead is provided; ventricular sensing is accomplished in such a case through far-field sensing of the R-wave in the atrial channel.
An ICD device 10, is shown in combination with atrial and ventricular leads, with the lead connector assembly 13,14, 18, and 22 being inserted into the connector block 12 of the device 10. A specific example of a defibrillation pulse generator that may be used in conjunction with the present ventricular lead is disclosed in U.S. Pat. No. 4,953,551. Other ICD type units can be used; reference is made to U.S. Pat. Nos. 5,163,427 and 5,188,105 as disclosing illustrative forms of apparatus for delivering cardioversion and defibrillation pulses. As used herein, the term "ICD type" device refers to any device that can apply both pacing therapy and shock therapy for controlling arrhythmias.
The device is provided with a lead system including electrodes, which may be as illustrated in
Electrodes 311, 318 and 320 are coupled to high voltage output circuit 234. Electrodes 324 and 326 are located on or in the ventricle and are coupled to the R-wave amplifier 200, which preferably takes the form of an automatic gain controlled amplifier providing an adjustable sensing threshold as a function of the measured R-wave amplitude. A signal is generated on R-out line 202 whenever the signal sensed between electrodes 324 and 326 exceeds the present sensing threshold.
Electrodes 317 and 321 are located on or in the atrium and are coupled to the P-wave amplifier 204, which preferably also takes the form of an automatic gain controlled amplifier providing an adjustable sensing threshold as a function of the measured P-wave amplitude. A signal is generated on P-out line 206 whenever the signal sensed between electrodes 317 and 321 exceeds the present sensing threshold. The general operation of the R-wave and P-wave amplifiers 200 and 204 may correspond to that disclosed in U.S. Pat. No. 5,117,824, by Keimel et al., issued Jun. 2, 1992, for an Apparatus for Monitoring Electrical Physiologic Signals, incorporated herein by reference in its entirety.
Switch matrix 208 is used to select which of the available electrodes are coupled to wide band (0.5-200 Hz) amplifier 210 for use in signal analysis. Selection of electrodes is controlled by the microprocessor 224 via data/address bus 218, which selections may be varied as desired. Signals from the electrodes selected for coupling to bandpass amplifier 210 are provided to multiplexer 220, and thereafter converted to multi-bit digital signals by A/D converter 222, for storage in random access memory 226 under control of direct memory access circuit 228. Microprocessor 224 may employ digital signal analysis techniques to characterize the digitized signals stored in random access memory 226 to recognize and classify the patient's heart rhythm employing any of the numerous signal-processing methodologies known to the art.
The remainder of the circuitry is dedicated to the provision of cardiac pacing, cardioversion and defibrillation therapies, and, for purposes of the present invention may correspond to circuitry known in the prior art. An exemplary apparatus is disclosed of accomplishing pacing, cardioversion and defibrillation functions follows. The pacer timing/control circuitry 212 includes programmable digital counters which control the basic time intervals associated with DDD, VVI, DVI, VDD, AAI, DDI and other modes of single and dual chamber pacing well known to the art. Circuitry 212 also controls escape intervals associated with anti-tachyarrhythmia pacing in both the atrium and the ventricle, employing any anti-tachyarrhythmia pacing therapies known to the art.
Intervals defined by pacing circuitry 212 include atrial and ventricular pacing escape intervals, the refractory periods during which sensed P-waves and R-waves will not restart the escape pacing interval timing. The durations of these intervals are determined by microprocessor 224, in response to stored data in memory 226 and are communicated to the pacing circuitry 212 via address/data bus 218. Pacer circuitry 212 also determines the amplitudes and pulse widths of the cardiac pacing pulses under control of microprocessor 224. A demand sensor 225 is communicatively coupled with the microprocessor 224 and provides and signal indicative of a physical parameter. For example, the demand sensor 225 may be an accelerometer used to sense motion of the patient's body. Demand sensor 225 may be a minute ventilation sensor, blood oxygen sensor, combination of sensors, or any type of sensor that provides an indication of the patient's cardiac demand. Demand sensor data is passed to the pacing control circuitry 212. Alternatively, the demand sensor 225 is directly coupled with the pacing control circuitry 212.
During pacing, the escape interval timers within pacer timing/control circuitry 212 are reset upon sensing of R-waves and P-waves as indicated by signals on lines 202 and 206, and in accordance with the selected mode of pacing on timeout trigger generation of pacing pulses by pacer output circuitry 214 and 216, which are coupled to electrodes 317, 321, 324 and 326. The escape interval timers are also reset on generation of pacing pulses, and thereby control the basic timing of cardiac pacing functions, including anti-tachyarrhythmia pacing. The durations of the intervals defined by the escape interval timers are determined by microprocessor 224, via data/address bus 218. The value of the count present in the escape interval timers when reset by sensed R-waves and P-waves may be used to measure the durations of R-R intervals, P-P intervals, P-R intervals, and R-P intervals, which measurements are stored in memory 226 and used in conjunction with the present invention to diagnose the occurrence of a variety of tachyarrhythmias, as discussed in more detail below.
Microprocessor 224 operates as an interrupt driven device, and is responsive to interrupts from pacer timing/control circuitry 212 corresponding to the occurrences of sensed P-waves and R-waves and corresponding to the generation of cardiac pacing pulses. These interrupts are provided via data/address bus 218. Any necessary mathematical calculations to be performed by microprocessor 224 and any updating of the values or intervals controlled by pacer timing/control circuitry 212 take place following such interrupts. A portion of the memory 226 may be configured as a plurality of recirculating buffers, capable of holding series of measured intervals, which may be analyzed in response to the occurrence of a pace or sense interrupt to determine whether the patient's heart is presently exhibiting atrial or ventricular tachyarrhythmia.
The arrhythmia detection method of the ICD may include prior art tachyarrhythmia detection algorithms. As described below, the entire ventricular arrhythmia detection methodology of presently available Medtronic pacemaker/cardioverter/defibrillators is employed as part of the arrhythmia detection and classification method according to the disclosed preferred embodiment of the invention. However, any of the various arrhythmia detection methodologies known to the art, might also be usefully employed in alternative embodiments of the ICD.
In the event that an atrial or ventricular tachyarrhythmia is detected, and an anti-tachyarrhythmia pacing regimen is desired, appropriate timing intervals for controlling generation of anti-tachyarrhythmia pacing therapies are loaded from microprocessor 224 into the pacer timing and control circuitry 212, to control the operation of the escape interval timers therein and to define refractory periods during which detection of R-waves and P-waves is ineffective to restart the escape interval timers. Alternatively, circuitry for controlling the timing and generation of anti-tachycardia pacing pulses as described in U.S. Pat. No. 4,577,633, issued to Berkovits et al. on Mar. 25, 1986, U.S. Pat. No. 4,880,005, issued to Pless et al. on Nov. 14, 1989, U.S. Pat. No. 7,726,380, issued to Vollmann et al. on Feb. 23, 1988 and U.S. Pat. No. 4,587,970, issued to Holley et al on May 13, 1986, all of which are incorporated herein by reference in their entireties may also be used.
In the event that generation of a cardioversion or defibrillation pulse is required, microprocessor 224 employs the escape interval timer to control timing of such cardioversion and defibrillation pulses, as well as associated refractory periods. In response to the detection of atrial or ventricular fibrillation or tachyarrhythmia requiring a cardioversion pulse, microprocessor 224 activates cardioversion/defibrillation control circuitry 230, which initiates charging of the high voltage capacitors 246, 248 via charging circuit 236, under control of high voltage charging control line 240 242. The voltage on the high voltage capacitors is monitored via VCAP line 244, which is passed through multiplexer 220 and in response to reaching a predetermined value set by microprocessor 224, results in generation of a logic signal on Cap Full (CF) line 254, terminating charging. Thereafter, timing of the delivery of the defibrillation or cardioversion pulse is controlled by pacer timing/control circuitry 212. Following delivery of the fibrillation or tachycardia therapy the microprocessor then returns the device to cardiac pacing and awaits the next successive interrupt due to pacing or the occurrence of a sensed atrial or ventricular depolarization.
In the illustrated device, delivery of the cardioversion or defibrillation pulses is accomplished by output circuit 234, under control of control circuitry 230 via control bus 238. Output circuit 234 determines whether a monophasic or biphasic pulse is delivered, whether the housing 311 serves as cathode or anode and which electrodes are involved in delivery of the pulse. An example of output circuitry for delivery of biphasic pulse regimens may be found in the above cited patent issued to Mehra and in U.S. Pat. No. 4,727,877, incorporated by reference in its entirety.
Based on the physical parameters, the demand detection device outputs a demand signal 330 that is processed by an amplifier 318. The amplified demand signal 330 is output as a pacing rate signal 335 to the pulse generator 320, under control of the pacing circuitry 212. The pacing rate signal 335 causes the pulse generator to pace the heart 314 at an elevated rate, with the rate correlated to the demand perceived by the detection device 316. The resultant elevated rate of the heart 314 affects the patient 310. When the perceived demand diminishes, the demand signal 330 is correspondingly diminished and the pacing rate is gradually lowered.
Thus, within programmed limits an increase in perceived demand by the detection device 316 leads to an elevated pacing rate. When the perceived demand is present, the ICD 10 attempts to satisfy this demand by increasing the pacing rate. With a higher rate, cardiac output is assumed to increase and thus, satisfy the demand. While operating in a DDD mode, the complete cardiac cycle is managed and the increased pacing rate is accommodated. Thus, a higher pacing rate generally results in increased cardiac output.
In an atrial based pacing mode, where ventricular pacing is generally not provided, an elevated pacing rate might not lead to higher cardiac output. Cardiac output is the measure of blood pumped for a given period of time. The components of cardiac output include heart rate and stroke volume. These two components are not necessarily independent of one another and stroke volume is not as dynamically variable as heart rate. An increase in rate often reduces the stroke volume because of reduced filling times. Wenckebach block may also occur, thereby reducing the effective ventricular rate despite an increase in the atrial rate. In addition, the heart requires more energy at the higher rate, thus increasing its own demand for oxygenated blood. Therefore, in order for an elevated pacing rate to increase cardiac output, the increase gained from the rate component must offset the reduction in stroke volume and higher physiological demands that result.
In response to an elevated heart rate (paced or intrinsic), the AV node should normally adjust the AV delay to ensure proper timing. In some patients, this does not occur and the AV delay becomes excessively long with respect to the rate. This might result from a deficiency in the autonomic response mechanism, the AV node, or along the conduction pathway. Furthermore, since a foreign sensor perceives the demand, the autonomic response, even if functional, might not affect the AV node with sufficient speed.
As the AV delay increases, the VA delay correspondingly decreases, assuming a fixed A-A interval dictated by a pacing rate. When the VA becomes too short (VA encroachment) for a prolonged period of time, negative effects may result. As previously discussed, the ventricles may be fully contracted when the subsequent atrial contraction occurs. Alternatively, the ventricles may be only partially relaxed during that subsequent atrial contraction. The result is that stroke volume is moderately to severely reduced and/or Wenckebach block. When this occurs, the elevated pacing rate does not actually increase cardiac output and may in fact reduce it. At the very least, elevated pacing is not beneficial and potentially may be counterproductive in these instances. For example, retrograde conduction may occur.
The present invention provides for a rate response feedback such that a pacing rate is not simply dictated by a given demand sensor output or rate response logic. Rather, the VA interval is monitored and if the VA interval falls within a predetermined range, the demand signal is either modulated to reduce the pacing rate or is effectively ignored, thus maintaining pacing at a resting rate.
In practice, gates may be used to permit or limit the actual demand signal or logic gates may be utilized to cause the demand signal 330 to be ignored or utilized. For example, gate 350 could be an AND gate. If the demand sensor 316 outputs a demand signal to increase pacing, it may also output a logical high into the gate 350. Similarly, if the VA interval is within acceptable parameters, then the output to the gate 350 is high. Thus, the output of the AND gate is high, and the pacing logic will then utilize the demand signal 330. If the VA interval is too short, then the output of the VA interval logic is low and thus the AND gate output is low. The demand signal 330 is not considered. Of course, any logical arrangement achieving such a result may be employed. This embodiment effectively precludes the demand sensor 316 from increasing the pacing rate if the VA interval is too short.
The parameters for determining whether the VA interval is too short may be selected based upon either generalized or patient specific parameters. In one embodiment, VA intervals less than 350 ms are deemed too short. In another embodiment, a VA interval of less than 200 ms is deemed to short. In another embodiment, a VA interval of less than 100 ms is deemed to short while in another embodiment, VA intervals of less than 50 ms are deemed too short. Furthermore, the determinations may be made on a beat-to-beat analysis or based on averaged value over a predetermined number of cardiac cycles. In addition, the measured intervals for the averaged values may be analyzed to exclude anomalous intervals or cardiac events.
If the measured VA interval is too short, the demand signal is precluded from increasing pacing and/or the pacing rate will actually be reduced, e.g., to a resting rate by a predetermined amount or to another rate. As time progresses, the autonomic response may affect the heart and cause the AV node to decrease the AV delay. If this occurs and the demand sensor 316 still indicates a need, the pacing rate may be elevated at that time. Of course, a more complex algorithm may be established. For example, the VA interval may be required to be below the threshold for a predetermined period of time or predetermined number of cycles prior to excluding the demand signal.
In one embodiment, the VA interval logic 360 will effectively act as a gain adjustment of the output of the demand detector 316.
The VA interval values selected to define the unacceptable, intermediate, and acceptable ranges may be set generally or with patient specific information. For example, patients may be paced in a controlled environment with varying VA intervals and monitored for effect. The results would then be utilized to set the specific range values for that patient. In one embodiment, VA delays of between 0 to approximately 100 ms would be considered unacceptable; 100 ms to 200 ms would be considered intermediate; and greater than approximately 200 ms would be acceptable.
Returning to
The activity of the heart 314 is monitored by the VA interval sense logic 360 and, in particular, the VA intervals are measured or calculated. Assuming the VA interval falls within the acceptable range (e.g.,
If the VA interval of the heart 314 is within the intermediate range, the value of the VA interval sense/logic output is proportionally modulated. That is, the demand sensor output will be permitted to affect the pacing rate, but in a reduced manner. Thus, the VA interval sense/logic output will have an absolute value that is smaller than that of the demand sensor output resulting in a lowered demand output from the amplifier 318.
In order to provide the appropriate values, the demand detector 316 and the VA interval sense/logic log 360 are in communication. In another embodiment, the appropriate values are predetermined and preprogrammed. Alternatively, any other type of logic or control mechanism may be employed to preclude an increase and/or require a reduction in rate responsive pacing if the VA interval is in the unacceptable range. For example, switching may be employed to either permit or inhibit rate responsiveness when the VA interval is within the acceptable or unacceptable range. While in the intermediate range, the proportional adjustment may be made with hardware (e.g., logic), firmware, software or the like.
As illustrated in
Such deficiency may manifest itself in a number of ways. Initially, the ANS 410 may fail to increase the intrinsic pacing rate of the heart 314. This, of course, is one reason why a demand sensor 316 is beneficial to begin with. Additionally, when the heart rate is elevated through pacing, the ANS 410 should respond and affect the AV node. The proper response would be to decrease the AV delay. Thus, physiological problems with the ANS 410 and/or the AV node may preclude modification of the AV delay, delay modification, or extend the period of adjustment.
As such, the VA interval sense/logic 360 may reduce or preclude an elevated pacing rate for a period of time. Then, assuming the demand still exists, the ANS 410 and/or the AV node may eventually shorten the AV delay. When this occurs, the VA interval will become longer and this is sensed. If the VA interval length reaches the acceptable or intermediate range, then an elevated rate or higher elevated rate is permitted.
As previously discussed, sporadic VA encroachment is usually non-problematic and any negative effects that would occur typically result if the pattern is present for a longer period of time. Thus, the present embodiment utilizes averaged values rather than reacting to individual cardiac cycles. The measured AV interval is compared (510) with a predetermined number of previous measurements. A determination is made as to whether the current rhythm is consistent (520) with these previous cycles. If not, the current rhythm is not associated (530) with the averaged rhythm. Conversely, if the current rhythm is consistent with the averaged rhythm it is associated (540).
Generally, this process is provided to define an averaged or patterned AV timing, rather than proceeding based upon individual cardiac cycles. For example, the eight most recent cardiac cycles are evaluated and the AV intervals compared. If six of these AV intervals vary from one another by less than some variable, e.g., 40 ms, or by some predetermined percentage, then an associated rhythm is defined. The number of cycles considered, the variable offset and the number of consistent required to define an associated pattern may be selected as desired. Of course, the AV intervals from some fixed, predetermined number of cycles may simply be averaged together to define a pattern; however, this result may be somewhat skewed during transitional periods such as initiating higher activity levels or by unusual, individual cycles or cardiac events.
In any event, an average AV duration for some relevant time frame is defined (550). A useable average might not be defined until the appropriate number of consistent cardiac cycles occurs; if so, the process returns to (500) to continue to collect data or the average is based on the available data set.
The averaged AV interval is then evaluated to determine if it is acceptable (560). An acceptable averaged AV interval will depend upon the A-A pacing interval. For example, the A-A interval should be longer than the AV interval by at least some predetermined nominal value. In one embodiment, this nominal value is 150 ms. Thus, the VA interval will be at least 150 ms. In other embodiments, the nominal value is selected from a range between 50 ms to 350 ms, and in other embodiments is 50 ms, 100 ms, 200 ms, 250 ms, or 300 ms. If the averaged AV interval is acceptable, then rate response is considered (580) or allowable. An increase in the pacing rate is permitted (590) up to the upper sensor rate limit, which is now defined based in part upon the averaged AV interval. In other words, rate response is only permitted if the desired A-A interval will exceed the VA interval by the predetermined nominal value. Subsequently, the process returns to (500) and continues to monitor AV intervals.
If the averaged AV interval is unacceptable (560), the upper sensor rate limit is modified. Obviously, if there is a concurrent increase requested by the rate response algorithm, it will be declined. In addition, the pacing rate may be reduced to a level where the A-A interval exceeds the AV interval by the predetermined nominal value. This becomes the upper rate limit (570). Subsequently, the process returns to (500) and continues to monitor AV intervals.
Thus, the present embodiment averages AV intervals over a number of cardiac cycles and dynamically adjusts an upper rate limit to preclude VA encroachment. This can be used to initially establish an upper rate limit for a given patient and or to continually modify the upper rate limit. Furthermore, any appropriate rate response is permitted up to the dynamic upper rate limit.
As the averaged AV interval may vary depending upon the current A-A interval, the process continually or routinely monitors the AV delay and adjust the upper rate limit accordingly. If, over time, the intrinsic AV delay changes, the new data will automatically be incorporated into a new dynamic upper rate limit. However, there may be situations where the intrinsic AV delay will not improve or vary until higher rates are achieved. Thus, the upper rate limit may be periodically exceeded by the device, based upon demand, to verify the validity of the dynamic upper rate limit. For example, at a moderately elevated heart rate, the intrinsic AV delay may be inadequate and thus the upper rate limit is set at a lower value; however, if the pacing rate is further elevated, the intrinsic AV delay may self correct or otherwise improve at this higher rate. Thus, with a rate response request for increased demand that is being limited by the dynamic upper rate limit, this limit may be periodically exceeded over a sufficient number of cardiac cycles to determine averaged values. Then, the upper rate limit may be increased to accommodate the demand, if appropriate, or maintained at its previous value.
As used throughout, various timing intervals are measured, monitored, or calculated. It should be appreciated that many of these intervals are related and that the use of one such interval in a given embodiment is not meant to exclude or preclude the others. For example, the A-A interval includes the AV interval and the VA interval. Any two may be used to determine the other.
Although the present invention has been described with reference to preferred embodiments, persons skilled in the art will recognize that changes may be made in form and detail without departing from the spirit and scope of the invention.
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Now That I'm a Mom, I Understand My Mom
Now That I'm a Mom, I Understand My Mom
Beth Weinhouse
Shared by Amanda
Right after my son was born I went through a phase when the world suddenly seemed a more threatening and dangerous place than I'd realized before. I'd be driving down a street and get nervous that a rock would fall off the overpass onto the car. Or I'd worry that someone would snatch my baby out of his stroller. Or that I'd accidentally lock him in a hot car. The anxiety was horrible, but I realized it was just part of the fierce protectiveness I felt for this tiny, helpless new being.
And one day during those months of worry, I had an "aha" moment. I suddenly understood why my mother would send me articles about women getting mugged near my college dorm. Why she worried that my first apartment didn't have adequate locks. Why she would tell me about the interview she heard telling people how to avoid a carjacking. Why, long after I was an adult, she still worried that I wasn't safe enough, comfortable enough, warm enough, happy enough.
It's because she's my mom.
And I now accept that the worry I feel for my son will never go away. Once you develop a mom brain, you've got it forever. And one side effect of this brain transformation is that you understand your own mother so much better than you ever did before.
The mom brain isn't just about fear and worry. Why does my mother still comment on my clothing choices? Hate it when my hair is in my face? Think I might look better in high heels? Because she still cares about me. And even though she can't dress me any more or brush my hair, I think she sort of wishes she could.
In fact, I think if she could have chosen my husband (for the record, she loves him), picked out my house, and arranged a job for me, she would have. Because it still matters desperately to her that I'm happy and my life is going well, and if she can do anything to further that, she would.
The mom brain is really just a product of love, a kind of overwhelming, all-consuming love unique to parenthood. When you realize that you would throw yourself in front of a train to save your baby, you realize that your mother felt the same way about you. And probably still does. And all of a sudden lots of things she says and does make perfect sense.
Beth Weinhouse is an award-winning journalist who specializes in writing about parenting issues and women's health. She's been an editor at
Ladies' Home Journal
magazines, and her work has appeared in dozens of consumer magazines and websites.
Our parenting advice is given as suggestions only. We recommend you also consult your healthcare provider, and urge you to contact them immediately if your question is urgent or about a medical condition.
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By Gerry J. GilmoreAmerican Forces Press Service
WASHINGTON, Oct. 4, 2007 Sharing military experiences with the American public injects a human element into events often conveyed through the cold glare of television's nightly news, a group of well-spoken servicemembers said here Oct. 2.
"The numbers that you hear on TV of soldiers dying, the numbers that you hear that we're going to bring 30,000 (troops) home, … I just put a face to those numbers, and we all do," Air Force Senior Master Sgt. Jeffery Duncan told American Forces Press Service.
Duncan, a 40-year-old senior aircraft maintenance supervisor with 21 years of service, completed a five-month deployment to the Middle East in May. He's one of a group of eight military members who've completed a week-long nationwide speaking tour featuring 20-30 engagements as part of the Defense Department's "Why We Serve" public-outreach program.
Audiences at his speaking engagements love the military, Duncan observed, noting he told listeners how much he enjoys the camaraderie inherent across the armed forces. "We are one team, and that's what we do," Duncan emphasized, adding that his speaking tour was an awesome experience.
Former Chairman of the Joint Chiefs of Staff Marine Gen. Peter Pace started the Why We Serve program in the fall of 2006. Duncan's group constituted the fourth iteration of the program, which is conducted in quarterly segments. Why We Serve duty tours are about 90 days. Participants are selected by their individual services and talk to schools, veterans organizations and business groups.
Why We Serve program director Marine Maj. Chris Devine praised Duncan and his fellow speakers in the fourth group for their professionalism and energy.
"They have the high bar for others to knock off," Devine said. "I think they've done extremely well, not only in their venues, but representing their services, as well."
The previous eight-member groups were comprised of two selectees from each military service, Devine noted. However, the next, fifth group will feature 10 speakers, he said.
The Why We Serve program has matured, and Assistant Secretary of Defense for Public Affairs Dorrance Smith has decided to "take it to the next level," Devine explained.
"What this program is doing is helping us win the 'war on narratives,' especially in the mainstream media," Devine noted. The program, he added, offers a different perspective about the war on terrorism, from the viewpoints of military members who've served in Afghanistan, Iraq or the Horn of Africa.
Another Why We Serve member in Duncan's group, Marine 1st Lt. David Bradt, served two tours in Iraq. The 26-year-old combat engineer said he enjoyed telling people about his Iraq experiences.
Bradt noted his experiences in Iraq were varied, from "full-scale infantry missions to cache sweeps to more of a support role."
The Marine said he was emotionally moved when people thanked him for his military service during his speaking tour. "Almost at every single venue a number of people would come up and thank you," Bradt recalled. "We don't need gifts; we don't need medals. Just come up and say, 'Thank you.'"
Bradt said he is impressed with the Why We Serve program. "They should fund as many of these (speaking tours) as they can possibly afford," he urged.
Meeting one-on-one with the American public helps to combat misperceptions about the U.S. effort in Iraq, he said. "It's a new fight. It's a very, very powerful information war," Bradt explained.
Another Why We Serve speaker, Air Force Master Sgt. Howard Watkins, accompanied supply convoys from Kuwait into Iraq during his overseas tour of duty from March to December 2006.
Many people he met during his speaking tour stops weren't aware of the fact that that the Air Force is doing convoys for the Army and has been for the last three or four years, Watkins observed.
He called the Why We Serve program a worthy endeavor . "The best thing that I have gotten from the program was seeing that there are still people out there that have the same ideals and beliefs that I have," Watkins said. "There's so much negative media."
Navy Lt. Judith Lemley served a seven-month tour in Afghanistan before she embarked on her speaking tour. Lemley said she relished urging veterans groups members to keep supporting servicemembers. "It's so much easier for us to focus on our jobs knowing that so many of these people back home" are working to take care of the nation's military veterans, she said.
Lemley said she also told audiences that the military is truly an equal-opportunity employer. "I've never been held back because I'm a female," she said. "I've been given the same opportunities as everyone else."
Lemley, who traveled across Afghanistan to train the country's soldiers, described the often dangerous, gritty conditions she'd experienced to her audiences.
Despite the arduous conditions in Afghanistan, Lemley told her speaking-tour audiences that she didn't complain. "Because I do what I love," she said.
Army Sgt. Daniel Alvarado recalled telling audiences about his wartime experiences in Afghanistan and Iraq. "I could tell I was having an impact on them," Alvarado, a combat engineer, observed.
Asked if he'd volunteer for another hitch in the Why We Serve program, Alvarado replied: "I'd do it in a heart beat."
Other members of the fourth group of Why We Serve speaking-tour participants are: Marine Gunnery Sgt. Jeremy de Vries, Navy Petty Officer 1st Class Caleb Duke, and; Army Sgt. 1st Class Steven Adams, who had to leave the program due to a family issue.


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I'm not going to sit here and pretend that I'm some High on Fire superfan or whatever. But I have to say: I'm as stoked for their show at the Domino Room Saturday night as I have been for any show 'round here in a long time.
Why? I'm not 100-percent sure. I think, mainly, I'm just looking forward to being sonically pummeled for more than an hour. It's not something we get in Bend all that often, really.
Anyway, be jealous metal nerds … I interviewed Matt Pike!
On Monday, I spoke with Pike about High on Fire's new material (they're playing some), the current metal resurgence (he thinks it's great, obvs) and the burden he feels when making an album. An excerpt:
"We get a little bit nitpicky because of what we've put out already," he said. "It's like … how do I top the last one? And I can't put out a bunch of s–t that doesn't sound quite as good, so … it's a little more of a pain."
For all High on Fire's booming brawn, the trio has its sights set on a lofty long-term goal while also dealing with the same kind of indecision and self-doubt faced by mere mortals like you and me.
"You wanna achieve as much as you can in one lifetime, but at the same time, sometimes it's harder than it seems, even if you're a very intelligent person and you know what you're doing," Pike said.
"There's still these moments where you're like, 'I don't know if that's good enough or not. I can't tell,'" he said. "And you second-guess yourself."
I hope you'll click here and read the whole thing.
Also, be sure to check out the back of today's GO! Magazine for our alternate High on Fire cover! (But only if you like awesome, evil demon-goats playing guitar with their foot perched on Pilot Butte as the Cascades erupt in the background.)
Elsewhere in this week's music section: Sisters singer-songwriter Anastacia celebrates her new CD with a show at the HarmonyHouse, Christian Kane brings country to Maverick's, Hellbound Glory brings a decidedly different kind of country to The Horned Hand, the Homegrown Reunion show gathers a bunch of local talent for a good cause, Tony Smiley returns to town, 2nd Hand Soldiers play Silver Moon, and much more.


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Selected Media Coverage: December 16, 2003
**Lehigh in the News** {online press clippings from other news sources}
Scientific American (Readership: 2,100,000)
Polymer Snail Crawls Like the Real Thing
Scientists at Lehigh University have developed a vibrating gel that creeps, crawls and slithers just as worms, snails and snakes do. Manoj K. Chaudhury, professor of chemical engineering at Lehigh and his colleagues describe their artificial creepy-crawly--a hydrogel rod made out of the polymer acrylamide and water--in a report published online this week by the Proceedings of the National Academy of Sciences.
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Innovations-Report (Germany)
Lehigh Group Reports Best Threshold Values for Near-Infrared Range InGaAsN Lasers
The ink was hardly dry on his new contract as assistant professor of electrical and computer engineering at Lehigh, when Nelson Tansu announced a breakthrough in his research into high-performance lasers. In two recent issues of Applied Physics Letters (APL) - on July 7 and Sept. 29, Tansu and other collaborating researchers reported the best threshold values to date for near-infrared-range (with an emission wavelength of 1300-nm), indium-gallium-arsenide-nitride (InGaAsN) lasers emitting from a quantum well.
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The Morning Call (Circulation: 167,191)
"Forging America: The Story of Bethlehem Steel," a book produced by the Morning Call and inserted in this past Sunday's edition as a 100 page supplement, included numerous references to Lehigh University. The book notes how Lehigh's development was intertwined with that of Bethlehem Steel's. A number of Lehigh professors were quoted in the book, including W. Ross Yates, professor emeritus of political science and former dean of the college of arts and sciences and author of the book that is considered the official of history of Lehigh University; John Kenly Smith, associate professor of history; and David Amidon, associate professor of urban studies. In regards to Bethlehem Steel's booming business at the time of World War I, Smith said, "It was the luck of history. Bethlehem Steel is in the armaments business, and World War I turns out to be this unbelievable bonanza." Concerning hiring practices at the Steel, Amidon said he doesn't believe there was "some conspiracy on the part of Bethlehem Steel not to hire blacks. I think because there were so few black people around, it did not dawn on them." And the fourth chapter of the book, "Marvels of Steel," discussed recently deceased Lynn Beedle's career from a Navy ship to university distinguished professor of civil engineering and an international giant in the field of tall buildings. To order a CD-ROM that captures the history of Bethlehem Steel through photos, archival films, new videos, and interviews:
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The Morning Call (Circulation: 167,191)
A Police Escort Means No Waiting in Line
A photograph of the "Shop with a Lehigh Cop" program was featured in the Morning Call on Sunday. "An excited Yeriam Martinez of Bethlehem unloads her stash after a shopping spree during the Shop with a Lehigh Cop program at the Northampton Crossings Wal-Mart in Lower Nazareth Township," the caption said. "She was accompanied Saturday by her brother Christopher and Lehigh University police officer John Tosado."
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Posted on Tuesday, December 16, 2003
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Welcome to Laser Natural Healing (LNH)
LNH is specialized in laser medicine and photobiomodulation equipment to professional medical, veterinary practitioners and home users in North America and distribute in the rest of the world.
Please specify the product that you're interested in, or tell us about your intended application so we may suggest the best range of products for your consideration, at email@example.com or fill out the form at the CONTACT page of this website.
Laser Therapy works on the principle of inducing a biological response through energy transfer, in that the photonic energy delivered into the tissue by the laser modulates the biological processes within that tissue, and those within the biological system of which that tissue is a part. The Arndt-Schultz Law of Biomodulation infers that low dosages of photonic energy will stimulate those biological processes, and higher dosages will inhibit them.
The wavelength at which the laser emits determines the effective depth of penetration, within the tissue, of the laser energy delivered. Far-red to infra-red wavelengths (longer than 800nm) will penetrate deeper, and so are indicated for deeper acupuncture points and trigger points, and deeper tissue injuries. Visible red wavelengths (shorter than 800nm) do not penetrate as far, and are therefore more applicable to superficial tissue and treatment points. Photons emitted at shorter wavelengths do, however, have greater energy/mass which is measured in electron-volts (eV).
In clinical applications the effects of Visible Red laser are of use in, but not limited to, the treatment of open and post-operative wounds, decubitus & venous ulcers, acne, and other dermatological conditions. Visible Red laser has also been effective in the tonification and sedation of superficial acupuncture points.
The therapeutic effects of Visible Red laser are, however, also elicited by Infra-Red wavelengths. For example, research conducted by Sugrue et al (1990) indicated that Infra-Red lasers cause significant decreases in the size of venous ulcers, and corresponding decreases in pain. Infra-red wavelengths have the added benefit of deeper penetration into the tissue, which enhances the healing effect by stimulating micro-circulation and lymphatic drainage.
Laser Therapy is a form of phototherapy which involves the application of monochromatic light over biological tissue to elicit a biomodulative effect within that tissue.
Low-level Laser Therapy (LLLT) - the most widely-used name given to this form of photobiomodulation - can have both a photobiostimulative effect and a photobioinhibitive effect within the irradiated tissue - each of which can be used in a number of therapeutic applications.
LLLT is gaining increasing acceptance in conventional medical, physiotherapy, acupuncture, dental, and veterinary practice - and refers to the "reaction between laser and the irradiated biological tissue" (Baxter, 1994).
LLLT is a complementary form of treatment and, therefore, is not intended to replace other electrotherapeutic modalities, such as ultrasound, interferential therapy, and magnetic therapy. In a number of therapeutic applications, however, LLLT has been rated more highly in its effectiveness than these other modalities (Baxter et al, 1991).
The following information has been compiled in order to raise practitioners' awareness of LLLT, its uses and potential benefits, and to enable the accurate assessment of laser therapy equipment which may be currently available or in use. Spectra-Medics trusts that this information will assist you to make informed decisions when purchasing and using any LLLT system, and to do so economically.
Laser diodes are generally operated at or below the laser diode manufacturer's recommended maximum optical output power rating of, say, 100mW, to ensure maximum stability and long diode life. It is this rating which is usually used to state the output power of a laser therapy unit. It is necessary, for accurate dosage control, to know the actual optical output power emitted from the laser probe at the aperture. Check with the manufacturer or use an output power meter suitable for the wavelength of the laser in question.
Laser Therapy devices are generally specified in terms of the average output power (milliwatts) of the laser diode, and the wavelength (nanometres) of light they emit. This is necessary information, but not enough with which to accurately define the parameters of the laser system. To do this, one must also know the area of the laser beam (cm2) at the treatment surface (usually the tip of the handpiece when in contact with the skin).
If the output power (mW) and beam area (cm2) are known, it is a reasonably straight-forward exercise to calculate the remaining parameters which allow the precise dosage measurement and delivery.
The output power of a laser, measured in milliwatts, refers to the number of photons emitted at the particular wavelength of the laser diode.
Power Density measures the potential thermal effect of those photons at the treatment area. It is a function of Laser Output Power and Beam area, and is calculated as:
Beam area can be calculated by either:
The total photonic energy delivered into the tissue by a laser diode operating at a particular output power over a certain period is measured in Joules, and is calculated as follows:
It is important to know the distribution of the total energy over the treatment area, in order to accurately measure dosage. This distribution is measured as Energy Density (Joules/cm2). "For a given wavelength of light, energy density is the most important factor in determining the tissue reaction"(Baxter, 1994). Energy Density is a function of Power Density and Time in seconds, and is calculated as:
To calculate the treatment time for a particular dosage, you will need to know either the Energy Density (J/cm2) or Energy (J), as well as the Output Power (mW), and Beam Area (cm2). First, calculate the Output Power Density (mW/cm2) as per Equation 1, then:
"For a given wavelength of light, energy density is the most important factor in determining the tissue reaction" (Baxter, 1994). Research indicates that Energy Densities in the range 0.5 to 4 Joules/cm2 are most effective in triggering a photobiological response in tissue (e.g. Mester & Jaszagi-Nagy, 1973; Mester & Mester, 1989; Mashiko et al, 1983; Haina, 1982), with 4 Joules/cm2 having the greatest effect on wound healing (Mester et al, 1973; Mester et al, 1989).
Australian research suggests that this 'therapeutic window' of biostimulation may be extended to include 5 Joules/cm2 (Laakso et al, 1994), and has applications in other areas of practice, such as Myofascial Trigger Point therapy and pain control. Dosages of 8 - 12 J/cm2 and higher, and the resulting bioinhibition, may also have therapeutic applications, such as in the treatment of keloid scarring and pain management.
Many practitioners have found straight Joules dosages - up to 20 J/point in some cases - to be effective in the treatment of a number of common musculoskeletal disorders. This is possibly due to the combined action of the pain attenuating properties of laser bioinhibition at high dosages, and the biostimulatory effect of the lower-powered 'halo' around the target treatment point. However, the same effect may not be elicited from a different laser unit, due to differences in laser parameters (esp. Power Density) and configuration.
It is the Output Power Density which determines the time required to deliver a particular Energy Density (Joules/cm2) dosage, and the Output Power which determines the corresponding Energy (Joules) delivered during that time.
Results obtained from particular dosages and treatments are likely to vary between individual practitioners and patients, therefore, practitioner discretion is recommended in determining the applicable wavelength and dosage parameters for each patient. It is important to note that the appropriate configuration of a laser unit will depend primarily upon the types of conditions most commonly treated, and so specific requirements will generally differ between practitioners.
Table 1. illustrates the difference in Joules and Joules/cm2 dosages for differing output parameters. The calculation of these parameters is explained above.
Output Power (mW)
Beam Spot Size (cm2)
Treatment Time (Secs)
Energy (Joules)
Energy Density (Joules/cm2)
Table 1. Various Laser Parameters v Dosage/Time
Please note that treatment times for Joules/cm2 dosages are the same for a laser unit with any output power, eg: a 100mW diode or a 50mW diode, if the output is collimated to achieve the same Power Density, however the resultant biological effects may differ.
Baxter (1994) recommends a number of treatment parameters for common musculoskeletal disorders in terms of both Joules and Joules/cm2 dosages, such as 1 - 2 Joules (8 - 16 J/cm2) for ligament strains (pp205-207). The energy and energy density combination in this case can only be achieved with a specific laser beam power to spot size ratio of 1:8. Not all laser devices will incorporate this specific ratio, and so a generalised representation of dosage parameters in this way is limited in its usefulness.
However, it can be seen that knowing and understanding the relationship between the Joules dosage and its corresponding Joules/cm2 dosage (per your lasers specific configuration), and the resultant biomodulative effect, allows more accurate specification and delivery of a particular treatment dosage. It also makes a successful treatment easier to replicate, and to share results with other practitioners and researchers.
Of course, individual results may vary between patients, so practitioner discretion is advised at all times.
The general lack of understanding of laser dosimetry has, in part, led to the current reliance on dosages only being measured in straight Joules (Output [Watts] x Time [Seconds]). 'Joules' on its own is essentially a meaningless dosimetric unit in the delivery and recording of LLLT treatment parameters in research, as it does not take into account the treatment area across which laser beam is dispersed, and leads to recorded treatment results which are ambiguous and difficult to replicate (Stuck, 1993; Baxter, 1994). However, it is still a useful dosimetric unit in clinical practice.
Imprecise or inadequate recording of laser and dosage paramenters can lead to over-stimulation of the treatment point, which potentially generates negative or undesired results through the inhibition of desired photobiological responses, or understimulation with little or no therapeutic effect. At higher Power Densities there is also potential for the laser to generate a thermal effect in the tissue. This is undesirable for Low-Level Laser Therapy, and is potentially unsafe.
One can also see that laser units which allow the user to increase or decrease the output power of the treatment probe (for example, a 100mW probe may be switched between 25, 50, 75, & 100mW settings; or a 40mW probe between 10, 20, 30 & 40mW) will offer no control over the power density, as the beam diameter will remain constant. It is more accurate from a therapeutic perspective to effect dosages changes by maintaining a fixed output power and altering the emission time.
There are a number of potential clinical uses for LLLT, such as those in medical, dental, podiatric, chiropractic, osteopathic, and cosmetic applications. Some of the most popular applications of LLLT currently, however, are in physiotherapy, veterinary, and acupuncture practice.
The portability and diversity of battery and mains-powered diode laser systems allows treatment to be carried out in various clinical, hospital, and field locations. This opens up possibilities for the immediate (and thereby more effective) and on-going treatment of sporting and athletic injuries, such as muscle tears, haematomas and tendinopathies (Baxter, 1994).
It is an attractive modality for the treatment of athletes, especially those involved in professional sports, due to the prospect of shorter recovery and lay-off times. Treatment of chronic and acute musculoskeletal disorders is the most common clinical application of LLLT, due to the effectiveness of laser in treating these types of conditions, and the short treatment times required.
Due to its pain-relieving and wound-healing properties, LLLT has many uses in hospitals and aged-care homes, such as for the treatment of pressure sores in bed-ridden patients, and for enhanced post-operative wound healing and pain relief. The effect of LLLT is such that it can accelerate remodelling of scar tissue, and "give a more cosmetically-acceptable result" (Baxter, 1994) to post-operative scarring.
Trelles et al (1987) reviewed the use of local irradiation with Low-Level Laser in therapy. The stimulus was applied mainly to local lesions to elicit the following types of effect:
According to Laakso et al (1994), the "...analgesic response to phototherapy may be mediated through hormonal/opoid mechanisms...and...responses to LLLT are dose and wavelength dependent."
Research being carried out around the world is constantly adding to the ever-expanding body of knowledge and understanding of the mechanisms and effects of LLLT.
Electrotherapy and low-level laser are used in physiotherapy to assist in the attenuation of pain and to stimulate tissue repair. As such, their application is also bound by the Arndt-Schultz Law of Biomodulation, as described above. Thus, it can be seen that the dosage delivered by the practitioner during a laser treatment is determined by the condition being treated, and the desired therapeutic effect. For example, if the desired effect of an initial treatment is that of pain attenuation, an inhibitory dosage (8.0 to 16.0 Joules/cm2) would be indicated.
Australian research has also shown that dosages of between 0.5 and 5 Joules/cm2 (Laakso et al, 1994) applied to Myofascial Trigger Points will effect an analgesic response through the body's hormonal/opoid mechanisms. If the desired effect is that of tissue repair, then the required dosage per treatment point will generally fall within the optimal therapeutic window between 0.5 and 5 Joules/cm2.
Available laser Output Power may range from 5mW to 500mW per laser emitter, with the higher powers indicated for larger muscle groups and treatment of the back. Near-infrared lasers penetrate further into the tissue. Multi-diode cluster probes may be effective in reducing overall treatment times where large tissue areas are to be treated. However, it must be noted that multi-diode LED and LED+Laser cluster probes often contain multiple wavelengths, which can lead to a degredation of the effectiveness of laser therapy (Karu, 1998).
Treatment will be effected by application of the laser probe to points along tendons and ligaments, and at the origins and insertions of muscles. Larger muscles can be treated by application of the laser in a grid pattern to a series of points across the body of the muscle, or by scanning or painting the laser head across the affected area.
Joint conditions, such as osteoarthritis, can be treated by applying the laser probe to a series of points along the joint line, aiming the probe tip at the articular surface where possible, and to the origins and insertions of muscles around the joint.
Open wound healing can be accelerated through laser therapy, by the application of 1-to-4 Joules/cm2 to a series of points in a 1cm square grid pattern across the surface of the wound, or by scaning or painting the wound surface with the laser.
As a gereral rule, optimal biostimulation is effected by the application of smaller dosages-per-point to more points at the treatment site.
Optimal bioinhibition is achieved through applying higher dosages-per-point, but to fewer treatment points.
To maximise irradiance at the target tissue, the laser probe should be held in contact with, and perpendicular to, the tissue surface.
When treating open wounds, the probe should be held slightly away from the tissue surface, whilst still maintaining a 90o angle. The probe tip may be covered with plastic cling film, in order to reduce the likelihood of cross-contamination.
In treating musculoskeletal conditions, laser therapy should be carried out following cryotherapy as the vasoconstriction caused by cooling the tissue will increase the penetration depth of the laser irradiation. Laser therapy helps to relax muscles, and so manipulations should be carried out following laser irradiation. Heat therapies and various creams and lotions can be applied after laser therapy.
Laser treatments can be carried out by irradiating daily for the first week, then gradually increasing the interval between treatments over successive weeks, according to the progression of the condition being treated. The total dosage should not exceed 100-200 J in any single treatment session. Laser dosage is cumulative, and so overtreatment causing a degredation of LLLT effectiveness can come from overly-high dosages in one treatment session, or too many treatment sessions in close succession. Individual practitioner discretion is to be used to determine the appropriate maximum session dosage, and the frequency of treatment, for each particular patient.
Patients may report a number of sensations, such as localised feelings of warmth, tingling, or an increase or decrease in symptoms, within the period immediately following laser therapy. Other sensations that may be experienced in response to laser therapy are nausea or dizziness. It is good practice to advise patients of this possibility.
Treatment reactions, if they occur, are often reported after initial laser treatments, however, they generally diminish after the second or third treatment. If a severe reaction is experienced during treatment, stop immediately.
To reiterate, optimal biostimulation is effected by the application of smaller dosages-per-point to more points at the treatment site.
Optimal bioinhibition is achieved through applying higher dosages-per-point, but to less treatment points.
When treating acute musculoskeletal injuries, the initial desired outcome of laser therapy is the reduction of pain and inflammation. It is very effective when used in conjunction with cryotherapy, rest and elevation of the injury site. Ideally treatment will begin as soon as possible after the injury occcurs, with relatively high, inhibitory dosages (8-12 Joules per point, up to 10 points) being used to attenuate the pain and reduce the initial inflammatory response. A treatment frequency of 1-2 sessions per day may be used for the first 2-4 days post-injury.
As the time post-injury progresses, dosages and treatment frequency may be reduced. In the period 5-10 days post-injury, dosages of 6-8 Joules per point may be useful in promoting the rate of the inflammatory process and in clearing its products from the injury site, thus allowing healing to begin sooner.
Moving into the healing phase, dosages are lowered and treatment frequency is reduced further. Throughout the healing and rehabilitation phase of an injury, biostimulatory dosages (1-4 Joules per point) are used to promote tissue repair and reduce scarring and adhesions. Higher doses may be used as required to alleviate any pain that results from over-working the injured body part during rehabilitation.
When treating chronic injuries or pain, it is best to start with lower doses and then work up to the most effective dose for that particular patient, as a high initial dose may cause an unpleasant exacerbation of symptomatic pain.
Please note that these are very general guidelines. Many factors affect the selection of the appropriate dosage and treatment frequency for each condition and patient. One must take into account the body mass of the patient, their age and general health, the depth of the injury, the tissue type, skin colour and so on.
Laser Acupuncture relies upon similar dosage principles as needling, and a knowledge of acupuncture theory and practice is required.
According to one school of thought, very low powered lasers can be used with great finesse to effect stimulation of acupuncture points. Within this paradigm, dosage is determined by way of the intended effect, which is generally characterised as to TONIFY or SEDATE Acupuncture Points (APs) and Ah-Shi Points. Basing dosage selection upon the Arndt-Schultz Law, it can be seen that low dosages will TONIFY, whereas higher dosages will SEDATE. Dosages of 0.5 to 2.5 J/cm2 are reported to be effective in the stimulation (tonification) of superficial Acupuncture Points, with 2.5 to 5.0 J/cm2 being effective for deeper APs. Higher dosages (8 - 12 J/cm2) are effective for the sedation of APs.
A second, more common belief is that laser is unable to offer the practitioner the ability to finesse an acupuncture point, in the way that a practised acupuncture clinician may do so with a needle, and that laser simply acts as a force applied to a switch: once the appropriate force (dosage) is applied, the switch is thrown. A dosage lower than that required to throw the switch is insufficient to create any effect, and a dosage greater is simply wasted.
Active acupuncture points are typically painful upon palpation. This appears to concur with the observation by a number of authors that there is a 70-75% correlation between acupuncture points and known myofascial trigger points. Thus, the application of a sufficiently high dosage would 'release' that point. Typically, visible or infrared lasers with output powers exceeding 100mW are used to quickly and effectively release an active acupuncture point, with infrared being especially useful for the deeper Ah-Shi points.
Some devices, sold as lasers, do not emit laser light. These devices are based on light emitting diodes (LEDs), which emit non-coherent light. Whilst most research has been conducted using coherent light sources, it has been shown that it is the wavelength and dosage - not coherence of light - that has the most effect on biomodulation. The primary difference between lasers and LEDs is that the laser's coherent beam produces 'speckles' of relatively high power density which can cause local heating of inhomogeneous tissues (Letokhov, 1991).
Laser does have a number of other benefits. A wider range of wavelengths are generally available, and therefore it is easier to find an available wavelength in close proximity to the peak wavelength in a particular action spectra. There is usually a significant price difference between laser diodes and LEDs. However, lasers with significantly higher output powers are becoming a lot more affordable.
One of the major criticisms of low-level laser therapy to date has been the inability of practitioners and researchers to reliably replicate results obtained by other individuals. This is invariably due to the imprecise and incomplete recording of laser and treatment parameters (Stuck, 1993), and of dosages used to obtain these results. It is very difficult to develop an informed opinion about the efficacy of LLLT in these circumstances.
With laser treatment parameters recorded in terms of Output Power, Beam Spot Size, Treatment Time, and Wavelength (Grosman, 1976; Stuck, 1993; Baxter, 1994), a particular treatment can usually be replicated, in vivo and in vitro, not only with the same laser unit but with any laser configured appropriately. This is essential for further research purposes, and offers the potential to add significantly to the overall body of knowledge in the field of low-level laser therapy (especially that derived from human in vivo studies which, due to the imprecise recording of laser and treatment parameters, have in many cases been less than useful).
Irradiation Of The Eyes Class 3b lasers are potentially harmful to the retina. Although accidental retinal damage is highly unlikely, it is recommended that laser protective eyewear, with the correct filter for the wavelength and power being used, be worn.
Pregnancy Laser is NOT contra-indicated for use over the pregnant uterus, however it should be used with caution. It is ideal as an adjunct to other modalities used for the treatment of back pain or other complaints.
Carcinoma Do not use the laser over any known primary or secondary lesions.
Thyroid Laser should not be used over the thyroid gland.
Haemorrhage It is conceivable that laser-mediated vasodilatation may worsen the haemorrhage.
Steroid Injections Patients may suffer an exacerbation of symptoms after laser therapy in conjunction with a recent steroid injection. For this reason laser should be used with caution following a steroid injection on or near the same site. We recommend one or two treatment points only at the minimum recommended dosage for that probe.
Anti-Coagulants It is possible that probe pressure may cause slight bruising after treatment.
Anti-Inflammatories Patients taking anti-inflammatories for acute soft tissue injuries may not respond as quickly to laser therapy as those who are not. Ideally, we would suggest a combination of ice and laser therapy without the use of an anti-inflammatory.
Pins, Metal Plates and Plastics are Not Contraindicated Laser may be safely used over stitches, as well as pacemakers, metal implants, pins, plates and plastics.
Tattoos and Other Pigmented Tissues Dark pigments, such as tattoos and melanin, may absorb light at the wavelengths used in laser therapy. Where probes with high power densities are in use, the absorption of laser energy by these pigments may cause localised heating, and subsequent discomfort or injury, of the irradiated tissue. We recommend conducting patch-tests on darker-pigmented tissues.
General Hygeine Clinical hygiene standards and protocols should be applied.
Legal and Regulatory Requirements Practitioners should be aware of local regulations governing the use of low-level laser therapy equipment.
Low-Level Laser Therapy, by definition, has no appreciable thermal effect in irradiated tissue; it works by modulating the biological processes within the tissue through application of photonic energy at specific wavelengths;
Laser's coherent beam produces 'speckles' of relatively high power density which can cause local heating of inhomogeneous tissues;
LEDs and LASERs both generate biomodulatory effects within living tissue, however, most published research relates to LASER;
Therapeutic effects of laser are both wavelength and dosage dependent;
Low dosages stimulate, high dosages inhibit (ref: Arndt-Schultz Law of Biomodulation) - both have therapeutic applications;
Optimal therapeutic window for photobiostimulation - 0.5 to 5.0 Joules/cm2;
Optimal Biostimulation: lower dosages per point - more treatment points;
Optimal Bioinhibition: higher dosages per point - less treatment points;
Visible red wavelengths (~620-690 nanometers) - shallow penetration - superficial tissue treatment, eg. wound healing, superficial APs, acne, etc.;
Infra-red wavelengths (~760-1260 nanometers) - deeper penetration - deeper tissue treatment, eg. musculoskeletal injuries, sports therapy, deeper APs and myofascial TPs, also wound healing,etc;
High Output Power + Infrared Wavelength + Safe Power Density = Maximum Effective Penetration
Treatment parameters to be recorded in minimum terms of Output Power (mW), Beam Spot Size (cm2), Treatment Duration (Seconds), and, Wavelength (nm);
Do not irradiate cancerous tissue;
Be aware of optical safety at all times.
Airaksinen,O., Rantanen,P., Kolari,P.J. and Pontinen,P.J. (1988) Effects of IR (904nm) and He-Ne (632.8nm) laser irradiation on pressure algometry at TPs. Paper to Nordic AP Society Annual Congress, Laugarvatn, Iceland, August 26th. Scand. J. of Acupuncture and Electrotherapy, 3,56-61.
Baxter, G. D. (1994) Therapeutic Lasers: Theory and Practice. Churchill Livingstone: Edinburgh
Baxter, G.D., Bell, A.J., Allen, J.M., et al (1991) Low Level Laser Therapy: current clinical practice in Northern Ireland. Physiotherapy 77: 171-178
Dyson,M. and Yang,S. (1986) Effect of laser therapy on wound contraction and cellularity in mice. Lasers in med. science 1/2,125-130.
Grosman. Z. (1976) Effect of laser irradiation on different cell structures. SB Omik Vedeckych Praci Lekarske 19:3-4
Illarionov, V.E, & Priezzhev, A.V Current Status of Low-Energy Laser Therapy in Russia: Search for Mechanisms, Clinical Applications and Equipment Development in Low Energy Laser Effects on Biological Systems, Michal Schwartz, Michael Belkin, (eds), (1993) Proc. SPIE 1883, pp8-13
Karu, T. (1998) The Science of Low-Power Laser Therapy. Gordon & Breach Science Publishers, p.xv
Kolari,P.J., Hietanen,M., v. Nandelstad,P., Airaksinen,O. and Pontinen,P.J. (1988) Lasers in physical therapy-measurement of optical output power. Scand. J. Acupuncture and Electrotherapy.
Laakso, E.L., Cramond, T., Richardson, C., & Galligan, J.P. (1994) Plasma ACTH and b-Endorphin Levels in Response to Low-Level-Laser Therapy (LLLT) for Myofascial Trigger Points. Laser Therapy 6: 133-142
Mester,E., Mester,A.E. and Mester,A. (1985) The biomedical effect of laser application. Lasers in surgery and medicine 5, 31-39.
Mester & Mester, (1989) Wound Healing. Laser Therapy 1: 7-15
Muxeneder,R. (1987). Soft laser in the conservative treatment of chronic skin lesions in the horse. Der Prakt. Tierarzt, 68, No. 1, 12-21.
Pontinen,P.J. (1987) Mid-laser and TNS in back pain. Nordic AP Society Annual Meeting: Seminar on back pain. Oslo, September 26.
Pontinen,P.J. (1995) Low Level Laser Therapy (LLLT) and laser acupuncture: a manual for physicians, dentists, physiotherapists and veterinary surgeons.
Rogers,P.A.M., Janssens,L.A.A. & Jagger,D. (1987) The efficacy of cold laser: A survey of members of the International Veterinary Acupuncture Society. Unpublished.
Rogers P.A.M (1996) Clinical Uses of Low Level Laser Therapy. Medical Acupuncture Web Page.
Stuck, B.E Measuring and reporting physical parameters in laser biomodulation research in Low Energy Laser Effects on Biological Systems, Michal Schwartz, Michael Belkin, (eds), (1993) Proc. SPIE 1883, pp21-26
Sumano,H.L., & Casaulon,T. (1987) Evaluation of electro-AP and TENS effects on wound- and burn-healing. Personal Communication, Veterinary School, Mexico City.
Trelles,M.A., Mayayo,E., Mester,A. & Rigau,J. (1987) Low power laser-therapy: Experimental and clinical data. Scandinavian Journal of Acupuncture & Electrotherapy, 2, 80-100.
Tunér, J & Hode, L (1996) 'Laser Therapy in Dentistry and Medicine'. Prima Books
Tunér, J & Hode, L (1999) 'Low Level Laser Therapy - Clinical Practice and Scientific Background'. Prima Books
Low-Level Laser has been shown to be effective in, but not limited to, treating the following indications:
Infra-Red Wavelengths:
Soft Tissue Injuries such as:
- Capsulitis, Bursitis
- Sprains & Strains
- Haematomas
- Tendonitis, Tenosynovitis
- Myofascial Trigger Points, AhShi Points, & Deep APs
Acute & Chronic Joint problems including:
- Osteoarthritis
- Rheumatoid Arthritis
- Ligament & Tendon injuries
- Chrondomalacial Patella
Chronic Pain such as:
- Post Herpetic Neuralgia
- Chronic Back & Neck Pain
- Metatarsalgia
- Trigeminal Neuralgia
- Brachial Neuralgia
- Plantar Fasciitis
- Frozen Shoulder
- Carpal Tunnel
Fractures such as:
- Non Union
- Small bone
Visible Red Wavelengths:
- Herpes
- Apthous Ulcers
- Leg Ulcers
- Dermatitis
- Wound Healing
- Burns
- Acute Epididymitis
- Otorhinolaryngology
- Gynaecology
- Obstetrics
- Superficial AP Stimulation and Tonification
- Cosmetic
- Acne


text:
In Newport, R.I., Shelton will discuss the direction of the military in the 21st Century at a breakfast event hosted by Rep. Patrick J. Kennedy and attended by area community and business leaders.
While in Newport, the chairman will speak at the U.S. Naval War College.
Shelton will visit New York City for meetings with the U.S. Ambassador to the United Nations Bill Richardson and U.N. Secretary General Koffi Annan.
That evening, Shelton will address members of the Council on Foreign Relations.
On Friday, Jan. 16, 1998, Shelton will travel to Carlisle Barracks, Pa., for an address to the students and faculty at the U.S. Army War College.
Shelton will return to Washington, D.C., in the late afternoon.


text: On Fri, Jul 13, 2007 at 05:15:37PM -0500, Sean C. Farley wrote: > Well technically, for setenv() and unsetenv() (the Open Group): > > If the application modifies environ or the pointers to which it > points, the behavior of unsetenv() is undefined. > > However, I would like to have *env() functions work in this case. It seems that anybody will agree with that. > I chose #3. Try the patch[1] again. It creates a setenv() function > which is a wrapper around __setenv(). __setenv() takes the lengths of > name and value to allow the caller to calculate the length using pointer > arithmetic instead of strlen(). > > Sean > 1. http://www.farley.org/freebsd/tmp/setenv/clearenv/patch The wrapper version finally looks OK for me. -- http://ache.pp.ru/ _______________________________________________ freebsd-current_(_at_)_freebsd_(_dot_)_org mailing list http://lists.freebsd.org/mailman/listinfo/freebsd-current To unsubscribe, send any mail to "freebsd-current-unsubscribe_(_at_)_freebsd_(_dot_)_org"


text:
Archive Page Design
Click here to go to Balletco's new home page and site navigation
|About the Change
A Danish Beauty
Royal Danish Ballet are treating themselves to a new Sleeping Beauty. Jane Simpson talks to the choreographer:
Christopher Wheeldon's constant travels have landed him for a few weeks in Copenhagen, where he's preparing a new production of The Sleeping Beauty for the Royal Danish Ballet. In the relatively quiet hour or so while the company was in class he talked to me about his plans and also gave me a preview of the very beautiful costumes - mostly not quite finished as the first night was still four weeks away.
Wheeldon can more or less pick and choose what he does these days, and he's only worked with RDB once before, making The Wanderers for Silja Schandorff and Kenneth Greve in the spring of 2008. So what attracted him to this particular job, with the months of hard work which would need to go into it?
"Well, I had a wonderful time here with The Wanderers - I found the dancers - the dancers that I worked with, anyway - to be very receptive, and I was excited about the prospect of doing something else. Nikolaj [Hübbe] had already suggested that perhaps I might do something, and then he said "We have a Sleeping Beauty but it's Helgi [Tomasson]'s production - it's an old Beauty. It would be great to have a new production and to have a young choreographer interpret it in a way that might be more appropriate to us, as a new generation with a new directorship". So I thought about it, for quite a long time actually, and I wasn't entirely sure: but then I saw La Sylphide. I'd never seen Sylphide danced by this company - up to that point I'd only seen them do Manon and Onegin, and then the Alonso - the Cuban - Don Quixote - which I wasn't so excited by: not really their cup of tea. But when I saw Sylphide, the lightness and the enchantment they conjured up for me made me think well, actually Sleeping Beauty could be quite a good idea, if it was approached in a way that was particular to them - to the company, and to their style. So I think that was the turning point for me. And the city has a magic about it, also - it's the home of Hans Christian Andersen and though of course he didn't write Sleeping Beauty there's a sort of fairytale dust about this place."
When I asked Hübbe, a year or so ago, why he'd chosen Wheeldon for this very big commission, he said without hesitation "Because of the Royal Ballet - because of him growing up with the Royal Ballet, and Sergeyev and the tradition of their Sleeping Beauty". Had he told Wheeldon the same thing?
"We spoke about it, and I certainly come from a training and a school that has an appreciation for Sleeping Beauty. It's part of the Royal Ballet School upbringing and it was one of the first productions I danced in at Covent Garden. I was a child in it - it was still the de Valois production when I was there - then I was a courtier, and before I left for New York I learnt the Florestan pas de trois - it was the first big role I learnt in the Royal Ballet. So Nikolaj knew that I was entrenched in Beauty, and it made sense for him, I guess."
"But I've seen a lot of productions by now - the French school, the Russian school, obviously the English school, and the American school, in the ABT production and in the NYCB production, which is one of Peter's more successful full-length ballets, I think - so there's a lot of information I've gathered, from both seeing and being in those pieces. But I'm very much more of the English school than I am of the Russian school, so far as Beauty is concerned, and I think trying to put the Russian version on this company would be a big mistake. It doesn't make sense for me to come in and make an Ashton recreation here, or a Petipa recreation. It would make sense if Nikolaj wanted that to bring in Christopher Newton to do a true Ashton-based production, or someone from the Kirov to do a Petipa-based production. He asked me to do it, so what I'm bringing are my influences - which are mixed, so anyone coming to see a reconstruction of a particular Beauty will be disappointed - it's not that. And there's a lot of my own choreography in the production as well."
© David Amzallag
Click image for larger version, or one that fills the browser window
"No, the fairy variations will be there, but in the same way that Ashton took the Petipa variations and made his versions of them, I've done the same thing - but yes, they are the fairy variations - it's all there. After all, what is the authentic Beauty? Since the first Petipa production it's become a hybrid. The 4-hour reconstruction the Kirov did - how traditional, how faithful is that really? The French have their production, which is Nureyev's of course, and has very little of the Petipa choreography in it - but Ashton, through the Sergeyev production, was very true and faithful to the spirit of Petipa, and then added his own, wonderful imprint and - with de Valois, of course, made it the English Beauty. So what I wanted to do was come here and make something that - above everything else - just worked well for these dancers, something that makes them look beautiful, makes them feel comfortable in a very difficult ballet, so they can communicate and give a really strong performance. I don't want just to say 'Here's an imprint that I'm going to stick on you, - you balance there, and if you don't balance there you're going to be in trouble' - because all that does is just make people freeze. The Danes have this wonderful sense of theatre and lightness of being on stage, that communicates so generously with the public, but their Don Quixote didn't come across as generous, it came across more as fear on stage: I think it's so important that they feel comfortable."
The last time Wheeldon made a new version of a Russian classic was in 2004, when he produced Swan Lake for the Pennsylvania Ballet. That was a 'conceptual' makeover, starting in a rehearsal studio, and I wondered if he's planning a similar treatment for Beauty here.
"Yes and no. Swan Lake had an updated setting, but although there are ideas that are similar to those I had then, Beauty is set within a more traditional framework. It's really important to me that the fairytale and the magic aren't lost, but I do think Sleeping Beauty can be taken too seriously. It's a very serious work of course, but I think it can be quite boring unless you've got somebody absolutely unbelievable in the role of Aurora. For a ballerina it's the most challenging of all the full-length ballets, without question: in stamina, in the ability to transcend classical steps and create a portrayal - a sort of light, breezy, youthful portrayal that then shows a slipping towards womanhood - there's a very delicate, quite subtle acting ability involved in making Aurora work as more than just a showcase for classical line. And there are only a few in the world who can really carry off a pure rendition. I think my inspiration for this production is to go a little bit back to the fairytale, and combine the beauty of the lightness of the Danish dancing, with a little bit more of a sense of fun and magic and childlike innocence - so that's been the departure point.
© Rosalie O'Connor
"So what I wanted to do with him was to find a way to portray him as somebody who grows through the experience of finding himself inside this fairy tale. Perhaps he's just a man, not a prince at the beginning, and there's a way that we've staged it to show him entering the fairytale world as a man, and then progressively having to work to become the prince. He meets the Lilac Fairy, he's pulled into the fairytale, he's very much in awe, and amazed at the place that he's in, but he's still just a man. The Lilac Fairy shows him the sleeping princess, and he falls in love with her, but then on his journey from that point to the castle he has to fight the creatures of Carabosse, which gives him more confidence and strength. So it's his journey from a man to a prince, but also a little bit talking about a boy becoming mature as a man. I think it's a way to put the audience in the same place as the man, and to help them to relate to him more as a character - because Beauty can often feel so distant - it's always a beautiful tableau, but are we really in there, do we ever feel some kind of connection? I don't think we ever feel that emotional connection with the Prince and with Aurora that we do say with Siegfried and Odette."
Does that affect how you tell the story? Do we get the hunt scene, for instance? "No - the hunt's not there - sorry! Because the man who becomes the Prince enters the fairytale in a different way." I'm sorry too, as it's one of my favourite scenes in the ballet - but a Danish friend tells me that many people in Copenhagen see it as little more than a rehash of part of Bournonville's A Folk Tale so maybe it won't be too badly missed. What else has been cut?
"There'll be no knitting women. One of the things we've had to do with this production is make it very compact - not just beacuse I want to make it a palatable length for the public (which of course is always a good thing) but more so because it's the Christmas ballet, replacing the Nutcracker, and at weekends they're doing shows twice daily, at 12 and 4 - so to fit in with the orchestra's rules it has to last at most 2 hours and 15 minutes, including an interval. There's not actually an awful lot that's gone, but the curtain scene in Act 1 goes straight into the garland dance, so I've had to find ways to tell the story through other parts of the action."
While we're talking about the garland dance, will this be the same one you made for the Royal Ballet in London?
"No, it's my third - I don't think any of the writers noticed - or they certainly didn't write about it - that I did another garland dance for the Royal - that the second time it came back it was a completely different one from the first one - I redid it. So this is my third - it needed to be a garland dance that fitted this production, that made sense against the dancers here."
And - last question about production details - what solo will you give Aurora in the Vision Scene?
"It's a version of .... [sings and demonstrates]"
"After Ashton."
The sets and costumes for the new Beauty are by Jerome Kaplan. He did the decor for David Nixon's A Sleeping Beauty Tale a couple of years ago, but this is clearly going to show a very different part of the forest. Has Wheeldon collaborated with him before?
"No, this is the first time we've worked together. Jerome has this wonderful French eye for fabric and colour and style. His research is phenomenal - when we first started talking about Beauty he showed up at my apartment in New York and he had pages and pages of materials that he'd pulled from libraries in Paris. We talked about having some influence of the court of Louis XIV, and before he even started drawing we had this map of colour and painting to draw influences from. I was originally introduced to him by Ted [Brandsen], who was starting to work on Don Quixote with him at at the Dutch National Ballet and I said to him 'I want someone who can, without losing the essence of the fairy tale, give this a very modern look - who can make this a Sleeping Beauty of today, and not just a reproduction of something that we've seen before'.
© David Amzallag
Click image for larger version, or one that fills the browser window
At that point Wheeldon decided that the easiest way for me to appreciate Kaplan's work on the costumes was for me to see them for myself. He is in and out of the costume shop 'every ten minutes', having one jacket shortened, another made lighter, checking the exact shade of the roses on a tutu bodice, making sure that Aurora's dress is not too pink. Kaplan has bought the fabrics in Paris and they are beautiful almost beyond belief - wonderfully subtle colours, lustrous gold and silver tissues, amazing patterns and embroidery. They must be so satisfying to work with, and if they carry even half their effect across the footlights, this should be a stunning production visually.
Four weeks isn't long to finalise every detail, bring the different casts (there will be six pairs of principals) together, write the programme notes, and so on and on and on. Walking round the theatre there's a feeling of a huge machine in motion, a dozen different bits of it working on different aspects, but all to the same ultimate target: opening night, November 26th.


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Star Wars: The Old Republic
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Join Date: Jul 2002
Location: Hong Kong
Posts: 6,818
Re: Star Wars: The Old Republic
OK...no one with any comment for Patch 1.2?
Legacy system!
Class nerfs due to PVP QQ?
Change to PVP gear
Change to PVP token system
Change to how PVP tokens are rewarded
No Ranked Warzones!
A lot of players have expressed extreme dissatisfaction with the PVP changes...and have threatened to rage quit.
As an avid PVP'er...my class (jedi consular shadow were untouched)i was disappointed with the changes in WZ commendation rewards structure... makes it more of a grind. Perhaps that is their intention but like any MMO, I am patient that they may fix certain aspects but I guess you have to learn to live with it as devs always think they are right than those who play the game and provide the feedback. Hope one day they will listen....and not after I rage quit lol
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Kibot API
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Pat McMahon
Retro Russia
Does it seem at all coincidental to you that premier puffer Putin, all swollen with Cossack pride after winning the Olympic medal count, now decides to flex and display Russia's military superiority?
Just because "Mr. Peabody and Sherman" is returning doesn't mean that we all have to enter "the way-back machine" to time-travel back to the Cold War days of Khrushchev and Brezhnev.
The world has to keep in mind that this is Russia and not the Soviet Union. Much of life there is similar enough that the confusion is easily understood. But it's clear to virtually every other country that the country is led by someone whose primary consideration is not what's best for the Russian people, but what makes Putin look "fantastic" - with or without a shirt.
It's why he reveled in the credit he got for brokering the Syrian chemical weapons deal. He's not a fool and he doesn't want to look foolish to the rest of the world. So strategically he can't create another Chechnya. So let's take a breath, express our strong objections, and wait for the image of Arnold Schwartzenputin to self-destruct.
I'm Pat McMahon.