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Evaluating, benchmarking and classifying embedded systems are challenging tasks. By definition, an embedded system is application specific. Furthermore, an embedded system is designed to fit within certain constraints dictated by their target application areas. Aspects such as power consumption, real time awareness, reliability, accuracy of the computation, cost, device and physical size are all metrics under which an embedded system can be classified and that have a direct influence on the overall system performance. All these contrasting metrics define how well an embedded system can address its target application.
An additional challenge derives from the fact that modern embedded systems are composed of a multitude of heterogeneous processing elements and components. They include general-purpose processors, digital signal processors, graphic processors, application specific accelerators, reconfigurable logic and more. These components can be either off-the-shelf or custom designed. Embedded systems often present disparate types of memory hierarchies. Also the software toolchain, which includes compilers, synthesizers and optimization tools, may have significant impacts on the metrics.
This workshop is related to a new DARPA initiative in this arena called SEAK (Suite of Embedded Applications and Kernels), whose goal is to define a new, open suite of benchmarks, together with a novel methodology to evaluate in terms of performance and power end-to-end embedded systems for DOD's application areas.
The workshop aims to involve, from the very early stages of SEAK, the benchmarking, simulation and modeling community to devise novel systematic approaches to evaluate and classify embedded systems, with a particular focus on the power/performance tradeoffs. Its objective is to provide a forum for discussing methodologies and approaches to evaluate embedded systems, including appropriate metrics, benchmarks applications, microbenchmarks, power/performance instrumentation.
Areas of particular interest for this assembly are research topics that identify and analyze novel ideas rather than providing incremental advances on the following themes:
- Benchmark and micro-benchmark creation, analysis, and evaluation issues
- Characterization of relevant workloads for embedded systems - Modeling of application and system behavior
- Tools for analyzing power and energy with different granularities and scope from hardware (e.g. component, core, system) or software views (e.g. threads, tasks, processes, etc) or both (end-to-end systems)
- Definition, identification of metrics that determine the suitability of an embedded system for its target applications, and their collection methodologies
- Characterization of current state-of-the art embedded systems in terms of power and performance
This full day workshop will involve invited talks, a session with selected posters and a closing panel. Invited talks include a keynote from DARPA, stakeholders of SEAK and teams responsible of other benchmarking initiatives. A session will introduce of a proposed methodology and benchmark suite from the SEAK team at PNNL.
The workshop will host a session of rapid-fire talks from embedded system vendors and design automation companies. Posters will be chosen through a peer-reviewed selection of short position papers from academia and industry on the topics of evaluation, characterization, benchmarking and modeling of embedded systems or their components for power and performance.
The panel will involve key people from the previous sections, ideally closing the day-long discussions.
52nd DAC General Chair, Anne Cirkel, will be the featured editor of the "52 Weeks of DAC" blog. Follow this blog for a behind the scenes view of how this conference gets ready for June 2015!
DAC 2015 will be held in San Francisco, California, at the Moscone Center. Get details about travel, hotels, and area attractions in one convenient spot.
DAC provides many opportunities for in-depth learning.


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Agnes Breeden Loveday
Agnes Breeden Loveday, age 87 of Sevierville, passed away Thursday, February 14, 2013.
She was preceded in death by her husband Robert A. Loveday and son, Ronnie Dale Loveday.
Survivors include her sons, Andy Loveday and wife Betty, Ray Loveday and wife Sue; daughters, Betty Wade, Cathie Loveday; grandchildren, De De Williams, Jeremy Loveday and wife Olga, Nikole Reagan, Megan Zabel and husband Beau, Beth Wade, Tony Wade, Matthew Loveday; Great grandchildren, Morgan and Hunter, Zak and Abby, Serina, Bella, Maggie and Gemma; sisters, Stella Stock and Hazel Birge; brother, Wesley Breeden and wife Juanita; several special nieces and nephews.
In lieu of flowers, donations may be sent to Alzheimer's Tennessee, Inc. 2270 Sutherland Ave., Suite 202, Knoxville, TN 37919.
Graveside service and interment 2 PM Sunday in Walnut Grove Cemetery with Rev. Ben Whitted officiating. Arrangements by Atchley Funeral Home, Sevierville.

subset: commoncrawl


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Bernice Aviza of Albany says she put out bird food Thursday, as she often does. Fifteen minutes later, she heard a commotion and saw this hawk coming in for a landing among some crows. "Initially, the bird appeared to be injured, but it recovered and flew away," Aviza said. Look closely and you'll see the hawk has caught a feathered meal.
| Still can't find it? see Site Index


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UPDATE: After a 6-year battle with cancer, Elizabeth Edwards died in her Chapel Hill, NC home Tuesday morning, WRAL reports. She was 61.
The family of Elizabeth Edwards released a statement to the AP on Monday, notifying the public that her cancer has spread, and she has only weeks to live. According to the statement, doctors say that further treatment would be unproductive, and a source close to the family says that Edwards may have only been given a few months to live.
Edwards, estranged wife of one-time Presidential hopeful John Edwards, is currently with her three children and husband at her home in Chapel Hill, North Carolina. The AP's anonymous source says "her sister, brother, nieces, nephews, former campaign advisers and other friends were also there."
Edwards also posted the following to her Facebook page:
"The days of our lives, for all of us, are numbered," she wrote. "We know that. And yes, there are certainly times when we aren't able to muster as much strength and patience as we would like. It's called being human. But I have found that in the simple act of living with hope, and in the daily effort to have a positive impact in the world, the days I do have are made all the more meaningful and precious. And for that I am grateful."
There aren't many of us that can say that their lives haven't been affected, directly or indirectly, by cancer. Everyone has a loved one, a friend, a family member stricken with the disease. Whomever the diagnosis is given to, and however it comes, it's a terrible thing to hear. My heart goes out to Edwards and her family during this emotional time.
Telling, though, more than the content of Mrs. Edwards strong and beautiful words, is the medium in which they have been cast. The press release issued by the family did the work necessary to distribute the facts of Mrs. Edwards' health situation. The Facebook post shed insight into her person. Far more than any public address could have conveyed, Edwards' words feel earnest; they're the contemplative and highly personal thoughts that can only come from a person when a microphone isn't being thrust in their face to record a statement. When a reporter isn't trying to ask questions about how their last moments will be spent. It's studied thought – meditated. I can imagine Mrs. Edwards posting it from her home computer, like she did her picture below, three months ago:
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Charming little girl reading book with her toy on white sofa
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Report: Canucks, Sedins' agent met Monday
Oct 29, 2013, 1:01 PM EDT
You may recall early in September when the agent for Vancouver's Sedin twins, JP Barry, suggested that term would be a "big topic" in contract negotiations with the Canucks.
At the time, the Sedins were believed to be looking for a longer term than the club was thinking. And almost two months later, with no extension yet signed, not a whole lot appears to have changed.
"They're in great shape and will always be that way," Barry said yesterday of his 33-year-old clients, per The Province.
The insinuation there was obvious.
On top of that, Barry noted the twins "have never relied on speed that much," which could serve as a good counter-argument should the Canucks contend that players really start losing their legs in their late 30s.
The way the Sedins have started the 2013-14 season, with a combined 31 points in 14 games, nothing has lessened Barry's chances of getting a good deal for his clients. Without those two, there's almost no way the Canucks would be 9-4-1 after 14 games.
Of course, these negotiations don't appear to be so much about the present as three or four years down the road.
According to The Province, Barry met with Canucks general manager Mike Gillis "for a couple of hours Monday, trying to hammer out a contract extension for the twins," so it's possible there may be some more definitive news on this soon.
- blomfeld - Oct 29, 2013 at 1:45 PM
The bottom line is that Gillis had better make damn sure he re-signs these two at 'whatever' term they want ! If not, then a certain ABBA song could well become the Canuck's new official anthem … 😦
- imleftcoast - Oct 29, 2013 at 1:53 PM
The Red Wings are in town, and the Sedins agent would love to analogize to Datsyuk (35) and his three-year contract extension. It's nice that Brough is helping him out with that. The Canucks can't contend without the Sedins (who knows when Kesler would have gotten going without them), but can they win a Cup with $20m/per season locked up with the Sedins?
- davebabychreturns - Oct 29, 2013 at 3:37 PM
I think you're being a bit hyperbolic with that $20m remark.
We're seeing high end first liners signing in the $8m+ range and over a short term the Sedins would certainly command that kind of money on the market, probably for as long as 4-5 years.
That being said we've never seen them take every last dollar in a negotiation and we have seen them offer to take less in exchange for a long term (boy if only Mike Gillis had taken them up on the 12 year contracts they wanted last time around with the $5m cap hit, we would be laughing now).
I expect we'll see them sign at about $1m each under what they could have got in the open market, and depending on the term that will probably end up in the $7-8m range.
People questioned their ability to contribute this year and they are putting their doubters to shame as usual – and I think Barry is exactly right that these are two players who don't rely on high end speed (or sheer strength for that matter) in order to be effective which bodes well for the next few years – as long as they can stay healthy of course.
- imleftcoast - Oct 29, 2013 at 4:48 PM
I'm looking at Datsyuk who receives $10m, $7.5m and then $5m.
- davebabychreturns - Oct 29, 2013 at 11:44 PM
Francesco, that you?
I don't know about other Canucks fans but I could care less what numbers actually show up on the Sedins paycheques, as long as the cap hit is reasonable (they will not total $20m there for any single season unless they put up 150 points each this year).
- micasa81 - Oct 29, 2013 at 3:44 PM
Tell me those aren't actually the numbers being tossed about. There's no way they'd be asking for $10m/yr even with a 2 year contract, let alone the one they're allegedly trying to get that takes them close to 40 years old.
- colby7 - Oct 29, 2013 at 10:30 PM
Dang, that's Sundin money.
- elvispocomo - Oct 29, 2013 at 4:20 PM
If you're talking cap dollars, no way it gets to $20M combined. If you're talking Aquilini's money, it's closer maybe for the first year but there's no way they even get that much to start even if it decreases over 4+ years. Maybe $15-17K combined depending on term.
- micasa81 - Oct 29, 2013 at 3:36 PM
It's hard to argue against the likelihood of them remaining at the top of their game for longer than most players do. They keep themselves in amazing shape, are ultra-durable, and have never needed blinding speed to play their game. 4 years should be no problem. 5 or even 6 should be fine as long as the last couple of years have commensurate drop-offs in salary.
Personally, I don't care if the Canucks can't win with them as their top players (I don't believe that anyway). These guys are career Canucks who have arguably done more for the franchise than any other duo in team history. It would be criminal to see them don any other team's jersey. Pay them please.
- kingcobraman - Oct 29, 2013 at 6:43 PM
they are not greedy guys ,they love the city and their families are happy here . they will again give a hometown discount … they will get a 4-5yr deal… but the curve ball is Gillis is a idiot…..
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Obituaries, February 14, 2014
Billy Burt Jr.
DURHAM — Funeral service for Mr. Billy Burt Jr. of Durham, N.C. will be conducted on Friday at 1:00 p.m from the United for Christ Outreach Ministry Church & The Interment will follow at Glennview Memorial Gardens. The Family will meet one hour before the funeral service. Survivors are his wife, Mrs. Roberta Melvin-Burt; 2 daughters, Ms. Shaneka Melvin, Ms. Kekneisha Melvin; 6 sons, Mr. Raushaun Burt, Mr. Deon Burt, Mr. Dominque Burt, Mr. Jauan Burt, Mr. DeCarlos Melvin, Mr. Quintonio Melvin; 3 brothers, Mr. Mack McCray, Mr. James Burt, Mr. Edward Burt; 3 sisters, Mrs. Diana LeGrant, Mrs. Deborah Andrews, Mrs. Viola Shareef; grandmother, Mrs.Margie Burt; & a host of other loving relatives & friends.
Funeral arrangements are entrusted to Hanes Funeral Service.
Peggy Rasberry Hodges
DURHAM — Graveside Services for Mrs. Peggy Rasberry Hodges have been rescheduled and will be conducted Monday at 2:00 p.m. at Woodlawn Memorial Park. The family will receive friends at the graveside from 1:30 p.m to 2:00 p.m.
The family is being assisted by Clements Funeral Service, Inc., in Durham, N.C. Online condolences may be made and a full obituary read at www.clementsfuneralservice.com.
Zelma M. Mans
DURHAM — Mrs. Zelma M. Mans of Durham, North Carolina, 87, passed away on Tuesday, February 11, 2014. Survivors include two brothers, O.C. Johnson and Everett Johnson; a sister, Maryland Harris; a son, Darius Mans; beloved daughter-in-law, Deborah Jordan Mans; grandchildren, Paula, Sam and Alex Mans; and many nieces and nephews. Memorial services will soon be announced.
Gracie Green Watson
DURHAM — Mrs. Gracie Green Watson, age 92, departed this life on February 11, 2014 at Hock Family Pavilion.
She leaves to cherish her memory her children: Floyd Watson, Jr. (Cheyenne, WY), Robert Lee Watson, Sr. (Durham, NC), Mary Louise Blue (Durham, NC), Dr. Virginia W. Adams (Wilmington, NC), Shirley A. Jones (Gary, IN), William-Aeric H. Watson (Denver, CO). Other loved ones include 10 grandchildren, many great-grandchildren, nieces and nephews, cousins, other relatives and friends.
Funeral services are planned for Saturday, February 15, at 1:00 P.M., Morehead Avenue Baptist Church, Durham, NC. Visitation will be Friday, February 14, 2014, 7-8 P.M at Holloway Memorial Funeral Home, Durham, NC.
Johnstone Moore Scott
CHAPEL HILL — Johnstone Moore Scott, 69, of Chapel Hill, NC died peacefully at home on February 8, 2014.
John was born March, 31, 1944 in Washington, DC to Lucius Keene and Elizabeth Moore Scott. He was raised in Coronado, CA and moved to Littleton, NC in 1959. He graduated from Fishburne Military Academy in 1962 and the United States Naval Academy in 1967. He served three tours in Vietnam. He earned his MBA from the University of Virginia's Darden School in 1974 and was in business in the paper and chemical industries until his retirement. He married Heather Harmison on May 26, 1991 and they lived in Chapel Hill for 20 years.
John is survived by his sister, Helen Scott Taliaferro, and her husband, Drake, of Atlanta, two nieces and one nephew, Elizabeth Clauson, Leigh Cooper and Scott Taliaferro, all of Atlanta, and his former wife, Heather Scott, of Chapel Hill.
A Memorial gathering is being planned for Chapel Hill on March 29 or 30, 2014. Details will be available at www.cremationsocietync.com. Interment will be April 1, 2014 at 10 a.m. at the Columbarium at the Naval Academy, Annapolis, MD. Memorial donations may be made to Durham VA Medical Center, Home Health Care, 508 Fulton St, Durham, NC 27705, Attn: Ivey Chavis, LCSW, or www.Durham.va.gov or Paws4Ever, 6311 Nicks Road, Mebane, NC 27302 or www.Paws4Ever.org.
Terry Dean Schluchter
RALEIGH — Terry Dean Schluchter, born in Detroit, Michigan, October 21, 1955, and a 48-year resident of Raleigh, passed away peacefully at Duke Raleigh Hospital February 9, 2014, surrounded by his loving family and friends.
He was a graduate of Sanderson High School and the School of Nursing at UNC-Greensboro. His career included both nursing and clinical drug research.
He is survived by his partner, Tom Anderson of Raleigh; his mother, Betty Schluchter, also of Raleigh; sister, Jill Price (Ron) of Lexington, KY; brothers David of Minneapolis, MN and Bruce (Risa) of Raleigh; aunt, Judy Terry of Nashville, TN; nephew, Carson of Lexington, KY; and niece, Samantha (Matt) of Charleston, SC. He is preceded in death by his loving father, Dean Schluchter of Raleigh.
A memorial service will be held on Saturday, February 15 at 1:30 pm at Hudson Memorial Presbyterian Church in Raleigh. The family will receive friends at the church immediately following the service.
In lieu of flowers, donations may be made to the Duke University Cancer Center (www.dukehealth.org/cancer) or the ASPCA (www.aspca.org).
Condolences may be expressed at www.brownwynne.com. Arrangements by Brown-Wynne Funeral Home, St. Mary's Street.


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Puerta del Sol
Not only is the square a key navigational landmark but it's also home to a number of iconic sights. The 18th century Real Casa de Correos is best known for its monumental clock tower – the city's principal timekeeper and the centerpiece of the city's lively New Year's Eve celebrations – and by its entrance lies the famous Kilometer Zero stone, the official starting point for Spain's 6 National Roads, laid out in 1950. Take a moment by the legendary stone to ponder the square's turbulent history - the 1766 Esquilache Mutiny, the 1808 resistance against Napoleon's troops and the 1812 coronation of Fernando VII all took place on this very spot. A number of prized statues also overlook the square, most notably the 'El Oso y El Madroño' (the Bear and the Strawberry Tree), a bronze work by sculptor Antonio Navarro Santa Fe that is known as the official symbol of the city.
Despite its historic roots, Puerta del Sol and its surrounding streets are one of the most modern and liveliest areas of the city, with bars, restaurants and shops crammed in among the period architecture. With so many of the city's principal attractions within walking distance, it's the perfect location for a mid-sightseeing coffee break.
Tours & Tickets
Madrid City Hop-on Hop-off Tour
Get a unique view of Madrid aboard this open-top double-decker bus. There are two tours covering all of the city's highlights, from historical sites and ... Read more
Madrid, Spain
Duration: Varies
8-Day Spain Tour Including Barcelona, Madrid, Cordoba, Seville, Granada and Toledo
Discover beautiful Barcelona, UNESCO World Heritage-listed Toledo and the highlights of Spain's Andalusia region on this 8-day tour. Spend two days exploring ... Read more
Barcelona, Spain
Duration: 8 days (approx.)
Madrid City Sightseeing and Royal Palace Tour
Marvel at the historic sights of Madrid on this city sightseeing and Royal Palace tour. Learn the story of Madrid through its buildings as you travel from ... Read more
Madrid, Spain
Duration: 3 hours (approx.)
Madrid Super Saver: Toledo Half-Day Trip and Panoramic Madrid Sightseeing Tour
Pay less and get more with this Madrid Super Saver tour! Spend the morning in Toledo, Spain's medieval capital and a treasure trove of El Greco artwork. You'll ... Read more
Madrid, Spain
Duration: 7 hours 30 minutes (approx.)
Madrid Bike Tour
Take this fun Madrid cycle tour and see the city at its best! Visit all the famous sights, from the Royal Palace and Retiro Park to Plaza Mayor and Puerta del ... Read more
Madrid, Spain
Duration: 3 hours (approx.)
Panoramic Madrid Sightseeing Tour
Explore the Madrid's top sights on this 2.5-hour sightseeing tour. Traveling by air-conditioned coach, admire showstopper attractions such as the Royal Palace ... Read more
Madrid, Spain
Duration: 2 hours 30 minutes (approx.)
Madrid GPS-Guided GoCar Tour
See the best of the Spanish capital on an independent GoCar tour of Madrid! Simple, fun and easy to drive, GoCars are fitted with GPS navigation systems for ... Read more
Madrid, Spain
Duration: Varies depending on selected tour grade


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How to Play Blackjack
A blackjack game starts with each player at the table putting up a bet and receiving two cards face up.
The dealer also receives two cards, one card face up and one card face down. Remember, it doesn't matter that other players can see your cards since you're only playing against the dealer.
Each player around the table now acts in turn and decides what he or she wants to do – take an additional card, stand, double down etc. But before we go into that, let's look at what you want to achieve.
The Goal in Blackjack
Your goal is to get closer to 21 than the dealer – without going over 21.
Add the card values to find out your current total.
Aces are counted as 11 or 1
Face cards are counted as 10
Numeric cards are counted as their face value
How to Count Your Total
When you don't have an ace, it's simple to count your total.
Say that you have K-5-4. Your hand's value is 19. It can't be counted as anything else and is therefore called a hard hand.
However, if you have an ace in your hand, the total can be two numbers at the same time, which is called a soft hand.
Say, for instance, that you have A-5. Your total is now both 6 and 16 and you could take another card without going bust (if you get a 10, you will have a hard 16 since the ace only can be counted as 1.)
The Player's Options
If you receive an ace and any card valued 10 on your first two, you have blackjack (also called a natural) and the dealer pays 3 to 2 on your wager right away. If you bet 20 you win 30.
In any other situation, you have to choose between one of the following options.
Stand: If you stand, you're not dealt any additional cards and your hand value remains the same. You now wait for the dealer to complete his hand.
Hit: If you hit, you will be dealt an additional card that will add to your hand value. When you've received a card, you can choose to stand or to take another.
Split. When your first two cards are a pair, you can split your existing hand into two separate hands. Each hand will be accompanied by a bet that's equal to your original wager. You then play these hands individually.
Tip: Don't ever split 10s, 4s or 5s. Split aces and 8s, always
Double Down: Doubling down means that you are doubling your wager. In this situation, you announce the move, double your wager and receive one additional card. After this, you're not allowed to take any more cards and it's the dealer's turn to act.
Surrender: Some casinos allow players to surrender hands. When you think that you've been dealt a bad hand, you can cut your losses, give up half of your initial wager and surrender the hand.
Insurance: This is a side bet that you make when you suspect that the dealer has been dealt blackjack. If the dealers up card is an ace, you'll be offered insurance before any further game action happens.
The side bet is equal to half of your wager and is paid 2 to 1 if the dealer has blackjack. So if he does, you break even.
Tip: It's a good idea to avoid insurance bets, simply for the reason that it's bad business.
How the Dealer Plays
When you're finished, it's the dealers turn to act.
First he turns over his second card, which up until now has been face down on the table. After this, his actions are predetermined.
If the dealer has 16 or below, he must hit
If the dealer has 17 or above, he must stand.
If the dealer has a "soft" 17, meaning A6, where a hit can't bust him because he can use the ace as a one-point card, the rule varies from casino to casino as to whether or not he must hit.
If the dealer busts, everyone who has not already busted wins.
If he doesn't, he pays even money to players who have a higher point total than him.
If the dealer and the player end up with the same total, the bet is tied and the wagered money goes back to the player.
Further Reading
Whilst the precise rules of BlackJack can vary from casino to casino – and you should always check the casino-specific rules when you start playing – understanding the general rules will help you a lot.
But just knowing the rules isn't enough to play well. To do so, you'll have to study the basic blackjack strategy. In this article you'll learn how to reduce the house advantage to a minimum.
There are also other variants of blackjack available online – for instance blackjack switch, blackjack surrender and pontoon. If you're interested in the rules and strategy of these games, go tou our page describing different blackjack variations.


text: Before his years at WAWK Fred taught at the East Noble School Corp. from 1966 until 2001 first as a Math Teacher, then as a Guidance Counselor. He coached both girls and boys basketball, baseball, and softball, and was fortunate to win sectional championships in all and had a number of conference championships. Fred has been broadcasting sports since 1969, and was inducted into the ISSA (Indiana Sportscasters, and Sportswriters Association) Hall Of Fame in 2006. You can hear Fred every Thursday night from 8pm till 9pm on The Hawk Sports Talk, and Broadcasting East Noble Football, and Basketball. It's truly a pleasure to have Fred back at THE HAWK.


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A system and method for stimulating the baroreflex arc based on levels of indicators from the body includes a pacemaker for bradycardia support pacing should the indicators show the need for support pacing. Other indicators and a process take advantage of an assumed relationship between peripheral vascular resistance and pulmonary resistance to determine the level of nerve stimulation required. This level is adjusted or optimized based on its interaction with heart activity and changes in the other indicators. These other indicators are readily available to the implanted device and allow for a process to make an estimate of pulmonary vascular resistance, from which SVR is also estimated. The value determined for SVR is the primary value used to determine the level of nerve stimulation absent indicators for the need to provide bradicardia pacing. The pacemaker can be rate responsive, as can the process for determining the level of nerve stimulation to be delivered. Several different lead configurations are described.
1. A system for coordinating the stimulation of nerves for controlling the level of neurohormonal activation in a living body having a heart subject to potential or actual pathologic stress levels comprising:
an implantable pulse generator with a microprocessor and memory adapted and disposed to run a plurality of processes,
a sensor for sensing SVO2 in the body, and a sensor for determining pressure in a ventricle of the heart of the body, both said sensors adapted and disposed to provide readings to said microprocessor for use by said processes,
a bradycardia pacer control process included within said pulse generator for pacing the heart when a condition of bradycardia is present so as to prevent insufficient heart rate by said heart,
at least one stimulation electrode connected to effectively deliver electrical stimulation to a baroreceptor nerve site,
an adjustment process for monitoring heart rate and estimating PVR from said SVO2 and pressure so as to determine appropriate modifications to the stimulation output to said stimulation electrode, and
means for making said modifications.
2. A system as set forth in claim 1 wherein said pulse generator comprises a pacing lead in an atrium and in a ventricle of the heart.
3. A system as set forth in claim 1 wherein said pulse generator comprises separate pacing leads in the atrium and the ventricle.
4. A system as set forth in claim 1 wherein said pulse generator comprises an activity sensor associated therewith which provides data on cardiac demand to said pacer control process.
5. A system as set forth in claim 1 wherein said pulse generator has an activity sensor associated therewith which provides data on cardiac demand to said pacer adjustment process.
6. A system as set forth in claim 1 wherein said sensor for determining pressure provides an indication of sensed absolute pressure.
7. A system for coordinating the stimulation of nerves for controlling the level of neurohormonal activation in a living body having a heart subject to potential or actual pathologic stress levels comprising:
an implantable pulse generator with a microprocessor and memory adapted and disposed to run a plurality of processes,
a sensor for sensing and measuring the value of an indicator of SVR in said body, adapted and disposed to provide readings to said microprocessor for use by said processes,
a bradycardia pacer control process included within said pulse generator for pacing the heart when a condition of bradycardia is present so as to prevent insufficient heart rate by said heart,
at least one stimulation electrode connected to effectively deliver electrical stimulation output to a baroreceptor nerve site,
a process for monitoring heart rate and estimating SVR from said sensor in order to modify said stimulation output.
8. A system as set forth in claim 7 wherein said indicator for determining SVR is right ventricular pressure.
9. A system as set forth in claim 7 wherein said indicator for determining SVR is SVO2.
10. A system as set forth in claim 7 wherein said indicator for determining SVR is a combination of SVO2 and right ventricular pressure.
11. A system as set forth in claim 10 wherein said process for estimating SVR bases that estimate on the relationship of SVR to PVR and determines PVR based on measured SVO2 and right ventricular pressure.
12. A system as set forth in claim 7 wherein said process for estimating SVR increases said stimulation output at a predetermined level of estimated SVR and decreases said stimulation output at another predetermined level of estimated SVR.
13. A system as set forth in claim 12, further comprising an activity sensor, wherein said process for estimating SVR comprises a check of the activity sensor level made before increasing said stimulation output.
14. A system as set forth in claim 12 further comprising an additional process within said pulse generator wherein if the estimated SVR is not determined to be above a predetermined level nor below another predetermined level, said additional process determines whether pacing is needed, and if so provides for a decreased amount of said stimulation output.
15. A system as set forth in claim 7 wherein if said activity sensor indicates strenuous exercise, said stimulation output is suspended for the duration such indication is present.
16. A system as set forth in claim 7 further comprising an intracardiac electrode and an additional process within said pulse generator, wherein said additional process provides that said stimulation output is gated to electrocardiographic indicators of cardiac activity received by said intracardiac electrode.
17. A system as set forth in claim 16 wherein said additional process provides comprises variable stimulation output settings and delay timing.
18. A method of automatically optimizing the cardiovascular responsiveness of a patient for the patient's condition through controlled application of electrical stimulation of nerves emanating from baroreceptors of said patient comprising:
providing electrical stimulation to said nerves of sufficient intensity and duration so as to reduce neurohormonal activation and induce peripheral blood vessel dilation and a drop in heart rate,
determining the responsiveness of the patient's body to said stimulation by sensing a feedback parameter of patient's responsiveness indicating altered cardiovascular function; and
adjusting said electrical stimulation provided to the nerves based on said feedback and an optimization algorithm until the patient's cardiovascular system is optimized for his/her condition,
sensing activity of said patient using an activity sensor, and
if said activity sensor indicates periods of activity, suspending or lowering intensity of said electrical stimulation until a period of time after the sensed activity has ceased.
19. A method as set forth in claim 18 wherein when the optimization algorithm is informed of overshoot in the drop in heart rate and/or peripheral vascular resistance responding by reducing the stimulation of the nerves arising from the baroreceptors.
20. A method as set forth in claim 19, wherein if overshoot of drop in heart rate passes a predetermined threshold, pacing the heart to maintain a predetermined heart rate.
21. A method of controlled application of electrical stimulation of nerves emanating from baroreceptors of said patient comprising:
providing electrical stimulation to said nerves of sufficient intensity and duration so as to reduce neurohormonal activation and induce peripheral blood vessel dilation and a drop in heart rate,
sensing activity of said patient using an activity sensor, and if said activity sensor indicates periods of activity, suspending or lowering intensity of said electrical stimulation until a period of time after the sensed activity has ceased.
This invention is related to Central Nerve stimulation by implanted devices and has particular application to using closed loop feedback techniques to improve its activity. It is potentially useful for patients with congestive heart failure including cases caused by coronary artery disease, myocardial infraction and chronic hypertension but not limited to these causes.
Congestive heart failure (CHF) represents a major unmet medical need. It is a disease with a high incidence and prevalence, high morbidity and mortality, and except for heart transplantation, no definitive treatment. It is estimated that 2-3 million people in just the United States suffer from congestive heart failure, with over 400,000 new cases diagnosed each year. CHF is the leading cause of hospitalization in the United States in patients over 65. The major causes of CHF are coronary artery disease and hypertension. CHF may also result from valvular disease, conduction system disturbances, congenital heart defects, cardiomyopathies or other problems. Patients suffering from CHF may experience weakness, fatigue, labored breathing, water retention in the extremities, exercise intolerance and dizziness. These patients may require repeated hospitalizations and intensive care admissions for close monitoring and supervision. Mean survival after a diagnosis of CHF is 5 years. The annual mortality rate of patients with advanced heart failure may approach 50%.
Annual health care expenditures for CHF in the United States are estimated to exceed $37 billion. Standard medical intervention incompletely controls patient symptoms or is associated with significant side effects, and morbidity and mortality remain high despite optimal care. For patients refractory to conventional medical therapy, heart transplant is the only available treatment.
CHF is defined as a condition in which the heart does not pump enough blood to meet the body's needs. The patient's response to this disorder is complex and includes activation of the sympathetic nervous system, renin-angiotensin system and other neuroendocrine systems. The increased sympathetic nervous system drive and circulating levels of neurohormonal mediators (e.g., angiotensin II) may help the cardiovascular system compensate by resulting in a stronger and faster heart beat coupled with an increase in the blood pressure (by peripheral vasoconstriction) to improve organ perfusion. In the failing heart, however, this normal neurohormonal activation response is associated with accelerated myocardial damage and poor patient prognosis. Consequently, current pharmacological strategies for CHF focus on reducing neurohormonal activation (for example, with ACE inhibitors) or blocking its effects at the tissue level (for example, with beta-adrenergic receptor blockers, angiotensin II receptor blockers, etc.). These approaches can alleviate patient symptoms, improve survival, and delay or prevent the onset of CHF in asymptomatic patients with left ventricular dysfunction.
Reflex control of the heart and peripheral vasculature is provided in part by baroreceptors. These nerve bundles detect changes in blood pressure and are located in the carotid sinus in the patient's neck region the aortic arch, as well as other areas. The baroreceptors respond to increases or decreases in arterial blood pressure by firing more or less frequently, respectively. The carotid sinus nerves transmit these impulses to the brain which modifies heart rate and vasomotor tone as well as changing the concentration of neurohormones by altering the balance of sympathetic and parasympathetic nervous system activation.
Previously, modulation of baroreflex activity by electrical stimulation of carotid sinus nerves has been advocated as a treatment for hypertension as well as intractable angina pectoris (chest pain associated with myocardial ischemia). CSNS can produce a reduction in heart rate, contractility, arteriolar and venous constriction and blood pressure making it a viable treatment for these ailments. These effects are modulated by increased vagal nerve activity and decreased sympathetic tone to the heart and peripheral vasculature. Reduction of sympathetic tone achieved through Carotid Sinus Nerve Stimulation (CSNS), results in reduction in heart rate (reduced oxygen demand), myocardial contractility (reduced myocardial work), peripheral vasoconstriction (afterload reduction) and renin-angiotensin activity (reduced neurohormonal activation). CSNS may offer a therapeutic advantage in any disorder affecting these blood pressure related systems. Moreover, the sensitivity of the baroreflex receptors is reduced in many patients with CHF, contributing to neuroendocrine dysfunction. CSNS could provide a means for compensating for this deficit.
Pharmacological treatments may have side effects requiring discontinuation of drug therapy in up to 30% of patients in clinical studies. Patient non-compliance to drug regimens also limits the utility of pharmacological agents. By contrast, CSNS therapy would ensure patient compliance, could be closely titrated to each patient's needs and may also give patients the ability to maintain a reduced drug regimen. Ultimately, CSNS may lead to improved functional capacity, quality of life and survival. To date, however, this possibility has been largely unrecognized.
Carotid sinus nerve stimulation is well known through developments at Medtronic, Inc., of Minneapolis, Minn. In the 1960s to early 1970s, Medtronic produced and marketed two carotid sinus nerve stimulators for treatment of hypertension, the "Barostat," and angina, the "Angistat." These devices lowered blood pressure, decreased myocardial work and oxygen consumption, and thereby alleviated hypertension and angina.
The stimulation system consisted of an external pulse generator/transmitter (which could be operated by the patient pushing a button), a receiver implanted in the clavicular region, and implanted nerve electrodes in the neck region. As in many devices of that era, the power source was maintained externally as battery technology was a limiting factor. Moreover, the implanted receiver and electrode were large and relatively unsophisticated by today's standards. Eventually, these therapies were superseded by the advent of effective antihypertension medications and coronary artery revascularization techniques.
While antiarrhythmia pacing has been suggested using nerve stimulation before (see for example U.S. Pat. No. 5,203,326, issued to Collins), as well as blood pressure reduction by this mechanism (see U.S. Pat. No. 3,650,277, issued to Sjostrand) no satisfactory use of CSNS for CHF exists in active treatment today.
The idea of using drug delivery to enhance carotid sinus nerve activity for blood related disorders is shown in U.S. Pat. No. 5,305,745 issued to Zacouto, which also suggests using the ECG as an indicator. Also, ischemia detection has been used to generate CSNS electrical stimulation in an implanted device as described in the PCT publication by Obel, et al. in PCT/US92/02250, October, 1992 under number WO92/16257. Nevertheless, the problem of producing a working device that provides the physician with the ability to use CSNS to control Systemic Vascular Resistance (SVR) and thus patient blood pressure has not been solved, and the numbers of CHF patients who could potentially benefit from such a device remains quite large.
FIG. 1 is a flow chart showing how the stimulation by an implantable pulse generator of carotid sinus or other vagal afferent nerves may affect patients with CHF.
FIG. 2 is a heuristic diagram of the brain and its association to the baroreceptors.
FIG. 3 is heuristic diagram of the adrenal gland and its association with various blood pressure related agents which are found in the blood and in the adrenal gland.
FIG. 4 is a system diagram illustrating the open loop association between an IPG and the patient's blood pressure system.
FIG. 5 shows a closed loop system similar to the system of FIG. 4.
FIG. 6 is a flow diagram illustrating the preferred embodiment configuration of steps associated with the control of the cardiovascular regulatory centers in association with an implanted IPG in accord with the present invention.
FIG. 7 is an illustration of one preferred embodiment form in an anatomical drawing of the relevant body parts.
FIG. 8 is a flow chart illustrating process step 129 of FIG. 6.
The disclosure herein describes a device which stimulates the baroreflex arc in patients with congestive heart failure. This stimulation is a mechanism for modulating the neurohormonal activation of the patient and thereby alleviating the symptoms of CHF and underlying cause of morbidity and mortality. The implantable system stimulates the patient's nervous system activating the baroreflex which in turn decreases sympathetic and increases parasympathetic activity. In addition, the stimulation has peripheral effects on the vascular resistance, and cardiac effects on the rate, and strength of contraction.
The system can be operated in a closed loop system in which patient parameters(both intra and extra cardiac in origin) are fed back into the system logic and the output is optimized for the patient's condition.
In a most preferred embodiment, the closed loop system provides electrical stimulation to the carotid sinus nerves of the patient through leads extending through the patient's body from an implanted device. The device may have additional leads associated with the patient's heart. The implanted device varies the electrical stimulation provided to the Central Nervous System (CNS) in response to feedback signals generated by the patient's heart and cardiovascular system sensed by the implanted device, thus forming a closed loop feedback system.
Such cardiovascular optimization would result in reduction of long-term cardiac stress by decreasing sympathetic efferent nerve activity, blood pressure, heart rate and strength of contraction(i.e. reduced O2 consumption), peripheral vasoconstriction and neurohormonal activation. Thus, not only would the system alleviate the symptoms associated with congestive heart failure, but it would also act to abate the causative mechanisms of heart failure.
The use of an activity sensor would allow CSNS stimulation to be decreased during periods of activity when an increased heart rate and blood pressure are needed. The lead associated with the patient's heart would be able to provide bradycardia pacing in the event CSNS induced bradycardia or asystole. Additionally, an oxygen and pressure sensor could be associated with this lead to provide additional feedback parameters for stimulation control.
A sense of this invention can be captured with reference to FIG. 1 in which an implanted pulse generating device (IPG) 10 is shown controlling or affecting the human system 12 via stimulation 11 of the carotid sinus baroreceptors/vagal afferent nerves 13. In heart failure (22), inappropriate Sympathetic Nervous System (SNS) activation causes vasoconstriction 14, neurohormonal stimulation 15, increased systolic calcium 16. All of these factors contribute to a progression of the heart failure symptoms including cardiac arrhythmias and sudden death 17. Overdriving the Central Nervous System (CNS) nerves with the IPG (10) can alleviate these factors by decreasing SNS activation. If the human sensor 13 indicates stimulation is needed, stimulation commences and alleviates vasoconstriction (14) which in turn decreases afterload (32), decreases myocardial energy expenditure (31b) and prevents myocardial cell death (30a). The stimulation also acts to decrease the prevalence of cardiac arrhythmias (17), decrease cytosolic calcium levels (16) which decreases chronotropy and inotropy (33), decreases cell energy expenditure (31a) and prevents cell death (30b). Stimulation would also act to decrease neurohormonal stimulation (15) which is inappropriately elevated in CHF and is associated with the reduction in cardiac output (21).
A simplified version of this description is seen in FIG. 2 in which the firing of baroreceptors (50a and 50b) cause stimulation via the cranial nerve 9 and or 10 to reach a reflex arc in the brain stem (60). In any event, stimulation of this reflex produces a decrease in (61) sympathetic output to the heart, blood vessels, adrenal medulla and kidney granule cells. If the baroreceptors are firing less often 51 as in heart failure, the reflex activity is decreased and sympathetic drive is elevated 61. The implanted system would act to counter this reduction in baroreceptor firing and thus decrease the sympathetic drive.
Another major player in this complex homeostatic system is the adrenal gland (FIG. 3, 65). Stimulation of the adrenal medulla (75) by sympathetic nerve (66) impulses (67) causes the adrenal medulla to produce epinephrine 73 and norepinephrine 74. Sympathetic stimulation of the kidney granule cells releases renin (71) which combines with free floating angiotensinogen (72) in the blood stream. This produces angiotensin I (70) and angiotensin II (69) which stimulate the adrenal cortex (80). Adrenocorticotropin hormone or ACTH (68) is a hormone released into the blood by the anterior pituitary due to stress. The angiotensin II and ACTH cause the adrenal cortex (80) to release glucocortioids 81 as well as mineralocorticosteroids 82 which all generally increase cardiac stress, fluid retention and, blood pressure. Attenuation of the sympathetic drive by the implanted system providing baroreflex stimulation would down-regulate this system leading to a reduction in epinephrine and norepinephrine production, and the release of glucocorticoids and mineralocorticosteroids.
Related systems which may also be affected by the implanted systems would include prostaglandins, the atrial natriuretic factor, ADH secretion by the posterior pituitary which increases vasoconstriction and fluid retention, calcium CO2, lactic acid, hydrogen, potassium, magnesium ions, adenosine, bradykinin and histomem which affect local arterial vascular resistance and Starling's Law. (Starling's Law describes the relationship between cardiac output and cardiac filling.)
Influencing these systems through the stimulation of carotid and aortic baroreceptors 89 by implantable pulse generating device 100 can be seen in FIG. 4. In general, the baroreceptors or 89 initiate a reflex arc which involves the medullary vasomotor and cardiac centers 86 which in turn stimulate higher nervous centers 85 with unknown feedback loop effects into the centers 86. The resulting neurohormonal signals affect the fluid retention 87A and peripheral resistance 87B as well as stroke volume 88A and heart rate 88B (The reduction in peripheral resistance act to reduce the blood pressure 19 making it easier for the heart to pump blood into the systemic vasculature.)
It is helpful to discuss the physical system in the body, illustrated in FIG. 7. The heart 130 pumps oxygenated blood out through the aortic arch 131, which leads to the right subclavian artery 132, the right common carotid 133, the left common carotid 134, the left subclavian artery 135, and the thoracic aorta 136. The body's system utilizes stretch receptors located in the arterial walls in the aortic arch 131 and at the bifurcation of the carotid arteries 137, 138 in the carotid sinus portion of the neck. The bifurcation of the carotid arteries 137, 138 leads to exterior carotid arteries 139, 141, respectively, and to interior carotid arteries 142, 143, respectively.
Nerve fibers extending from stretch receptors in the aortic arch 131 join the left and right vagus nerves 144, 145, respectively, with these fibers being referred to as cardiac depressor nerves 146, 147. A number of nerves extend from the stretch receptors at the bifurcation of the carotid arteries 137, 138 in the carotid sinus, with the areas immediately above the bifurcations being referred to as the carotid bodies 148, 149. Nerve branches 151, 152 extending from the carotid bodies 148, 149, respectively, join the ganglia of vagus nerves 153,154, respectively. Other nerve fibers comprising the sinus nerve branches 155, 156, (generally referred to as "Hering's nerves") of the glossopharyngeal nerves, 157, 158, respectively, also extend from the carotid bodies 153, 154, respectively, to the medulla (not shown).
The rate of the heart is restrained by the right and left vagus nerves 144, 145, respectively in conjunction with the cardiac depressor nerves, 146, 147, respectively. The cardio-inhibitory center of the nervous system exerts a tonic effect upon the heart, via the vagus nerves, restraining its rate. This effect is also known as vagal tone.
A pulse generator 140 (which may have an indifferent case electrode 140' for bradycardia support pacing with a unipolar electrode in the heart, or which may use bipolar pacing electrodes) and the system containing the sensing, nerve stimulation and brady pacing pulse generators in accord with the preferred embodiment of this invention is shown in FIG. 7 in relation to the heart 130 and the cardiac nerve system. A lead body 150 coupled to pulse generator 60 extends into the right atrium, but if desired could extend to the coronary sinus. Lead body 150 or the ventricular lead 150' should contain any relevant sensors in the preferred embodiments, however it is not outside the scope of this invention to employ other locations for the sensors (SVO2, pH, transventricular or other impedance, heart sounds, etc.) as may be in accord with the preference of the designer of a system based on this invention. The second lead 150' extends from the pulse generator 140 through the right atrium and into the right ventricle of the patient's heart to position the tip deep within the ventricular apex. The positioning of such leads and their use with and without extra sensors in the heart is well known.
A second pair of electrical leads 160a and 160b extend from the connector block CB of the pulse generator to respective nerve electrodes 160c and 160d placed around the right and/or left carotid sinus nerve bodies in a manner such as that described, for example, in U.S. Pat. Nos. 3,421,511 and 3,522,811. Although other attachment means may be used if desired. It is currently understood that in general nerve stimulation requires a bipolar electrode. In this document we just call such nerve stimulation connections merely "electrodes" or "leads".
The specific location of the nerve electrodes may vary, and it is contemplated that in the practice of the present invention it may be possible to place such electrodes at the right and/or left stellate ganglions (153 and 154). Alternatively, it is possible to extend a single lead electrode from the pulse generator to a dorsal column stimulating electrode. Such an electrode (not shown) may be positioned in the epidural space roughly at level T2 and may be of the type sold by Medtronic, Inc. as part of the Resume IIa and Picses-Sigmaa electrode system or described in Medtronic U.S. Pat. No. 4,414,986 and other Medtronic patents referenced therein.
If a pH sensor is used on the lead, one such as that described in U.S. Pat. Nos. 4,009,721, 3,577,315, 3,658,053, 3,710,778 may be used. A membrane pH sensor electrode is typically placed in the right ventricle and senses pH, which is proportional to the blood concentration of carbon dioxide, which in turn is generated in increasing amounts by exercise as explained in U.S. Pat. No. 4,716,887. In the '721 patent, a diminution in the pH level is used to produce a higher paced cardiac rate. However, if used in the context of the present invention, it is contemplated that the pH sensor will be placed on lead 150 just inside the coronary sinus (not shown) to detect the level of lactic acid in venous return blood which is expected to increase with exercise of the cardiac muscle, particularly if the muscle is stressed by a lack of sufficient oxygen due to constriction in the cardiac arteries as a result of coronary artery disease. Myocardial ischemia is virtually invariably associated with an increase in the blood lactic acid level in the coronary sinus. The increase in blood lactic acid level is accompanied by a decrease in pH. Because of the difficulty of insertion of leads into the coronary sinus, however, we prefer to use the pressure and SVO2 sensor configuration with the leads positioned as shown.
A dissolved blood oxygen sensor may be of the type described in Medtronic U.S. Pat. Nos. 4,750,495, 4,467,807 and 4,791,935. There, an optical detector is used to measure the mixed venous oxygen saturation.
A dual chamber pacemaker is preferred but the invention could also be practiced with alternatives to this. For example, if a better measure than estimated PVR is used(see below), such as a direct SVR measurement (say, from in the peripheral vasculature), some of the usefulness of the ventricular sensors is supplanted. However, since it is possible (because of the nerve stimulation and body response to it) to throw the patient into a situation where he responds with AV block, the ventricular pacing lead remains quite important in any configuration.
The cardiac output 21 is thus is reduced by baroreceptor stimulation. It seems contradictory that decreasing the cardiac output would help hemodynamically impaired heart failure patients. However, heart failure patients have a deleteriously high level of sympathetic drive keeping their hearts under stress to pump harder and faster while the effect is to exacerbate the cause of the heart failure. The body will compensate for the temporarily lowered cardiac output, and removing the vicious cycle of increased sympathetic drive will help to alleviate CHF related problems.
An alternate depiction of the system and its interactions with the body is shown in FIG. 5. Again, the nerves arising from the baroreceptors (50) are stimulated (111) by the IPG (110) which activates the reflex in the brain (90) and affects the efferent autonomic nervous system (93) with effects on the heart (20), vasculature (94) and kidneys (95). These systems net effects act on the arterial blood pressure (19a) which affects the level of baroreceptor stimulation which occurs naturally. A preferred embodiment has one or two intracardiac leads which collect signals (92) such as heart rate, pressure, etc. and sensors for extracardiac signals such as the systemic vascular resistance (91) and others may also be monitored. These signals feed back into the IPG (91f and 92f) which can then modulate the stimulation to meet the patient's needs. A preferred embodiment would include an activity sensor such as a piezoelectric crystal for sensing vibration caused by exercise. This sensor would also act as a feedback inhibitory mechanism (91f) to reduce the level of baroreflex stimulation. During periods of exercise, the body acts to increase the rate and strength of myocardial contraction raising the blood pressure to meet the body's increased need. Countering this increase in blood pressure with baroreflex stimulation would not be advantageous during exercise as it would limit the patient's exercise capacity. Therefore, this feedback mechanism would prevent overstimulation during periods of exercise when an increase in blood pressure is physiologically necessary.
FIGS. 6 and 8 are is used to illustrate the inventive method 110 for operation of an implanted device that has the capacity to electrically stimulate the baroreflex arc in a living body. The process 110 begins at step (illustrated by a block, here) 121, with the definition of initial parameters and initiation of an algorithm. The rate, pulse width and amplitude, as well as the frequency of the stimulation to the nerve should be set in this step 121. Initial parameter settings can be set by an attending physician, by the factory, or by a program in the programmer that communicates with the implanted device.
In the preferred embodiment, the implanted device (IPG) will monitor the heart rate, at least(step 122), and may monitor other conditions in the body as well, if desired. This step permits the implanted device to decide based on such monitoring whether to vary the initial or later stimulation settings. If the heart rate measured by the device indicates that brady pacing is required (step 123), the device will provide bradycardia back-up pacing via step 124.
This can be determined in a number of ways, generally referred to as overshooting the target rate or range. A body of patent and other literature identifies situations determinable merely through the use of heart rate monitoring by electrographic or other means wherein bradycardia support pacing would be required. For example, in the situation of Vasovagal Syncope, a rapid drop in heart rate provides a good indicator, or if the heart rate falls below a certain predetermined minimum level other pacers begin support pacing.
If pacing is being provided to the body's heart, the level of stimulation provided by the nerve stimulator is generally kept lower than if pacing is not occurring(step 125) as nerve stimulation to the baroreflex arc causes a reduction in the natural heart rate. Again, this can be done in increments or to levels suggested by tables in memory or programmed by the programmer, a physician, or at the factory. (The idea here is that if pacing is required, the heart may be in a condition that is somewhat inadequate and the body is responding by manifesting heart failure. Continuing to stimulate the heart to beat at adequate rhythm while also stimulating vagal tone should reduce the stress on the heart, giving it a chance to recover without incapacitating the body. However, it should be recognized that increasing baroreflex stimulation reduces natural heart rate, and so if it is possible to continue baroreflex stimulation at some level that allows for intrinsic adequate intrinsic heart rhythm, that is the preferred condition to be sought by this series of algorithmic steps.) A flag or counter (127a) can retrigger the algorithm from step 122 to prevent a continuous loop that never rechecks heart rate.
To simulate the baroreflex nerve traffic, stimulation is synchronized to the R-wave of the electrogram, plus an offset would reproduce nerve activation coincident with the arterial pulse. It is believed this is the most effective manner of stimulation. Thus, reduced energy expenditure may be possible by using the natural rhythm to time the stimulus pulses. This step is represented by block 127, which shows adding a predetermined value to the receipt of the R wave signal of the ECG to time the release of the next stimulation pulse or pulse burst.
Step 128 calculates an estimated value of systemic vascular resistance (SVR) as a control parameter for stimulation. We make the assumption that changes in SVR parallel changes in pulmonary vascular resistance (PVR), or at least that the changes in one have a close and probably linear relationship to the other. Therefore since an estimate of PVR can be calculated from pressure and oxygen saturation readings taken by a sensor or sensors, we can determine a value for SVR from that. It should be recognized that any sensor set providing sufficient data for determining PVR or SVR would be useful in the context of this invention.
In the currently preferred embodiment we can use well known measurement techniques to find and define the PVR:SVR relationship in the hospital and set this into the IPG memory for use in the following computations. In other words, this comparison of SVR and PVR would be doing a one-time calibration. However, the use of direct SVR measurements (which may someday become readily and available to the IPG) can be used to alter this relationship constant over time and is contemplated as a use of this invention.
PVR is equal to the difference between the mean pulmonary artery pressure (PAmean) and mean left atrium pressure (LAmean) divided by the cardiac output (CO) as described in the following formula:
PVR=(PAmean -LAmean)/CO (1)
Padiastolic can be calculated from the right ventricle at the time of pulmonary valve opening as described in U.S. Pat. No. 5,368,040 issued to Carney. The mean pressure can then be calculated by estimating that Pasystolic is approximately equal to the RVsystolic pressure and that PA mean is described as the following functions:
RVsystolic =PAsystolic (2)
PAmean =1/3PAsystolic +2/3PAdiastolic (3)
Using the method described by Carney, we can also estimate the LAmean from pressures taken in the right ventricle. Thus equation #1 only needs an estimate of CO in order to be solved. CO can be estimated from the mixed venous oxygen saturation levels (SVO2) in the RV as measured by an oxygen sensor associated with the heart according to the following relationship:
CO=m(SVO2)+b (4)
where m and b are constants to be determined from physiologic testing. Such testing can be done on an ongoing basis as mentioned above with reference to possible SVR data but at the present time it is preferred that it be done while the patient is in the hospital and m and b values left at such settings as indicated unless a problem develops. Therefore equation 1 can be solved for PVR. It should be noted that the process described in FIG. 6 may use an alternative from PVR if available from the implanted system in use. Also other relationships developed to replace equation 4 may be substituted and appropriate sensor measurements taken as such developments occur in this field without deviating from the scope of this invention.
(Note to readers: The terms SVR and PVR in other contexts is often used differently but for this document SVR always means systemic vascular resistance and PVR always means pulmonary vascular resistance. The most common other usage is of PVR to mean peripheral vascular resistance which it does not mean in this document.)
Optimization can be based on an analysis of heart sounds, MRI data (in hospital, probably), transventricular impedance, or other indicators of cardiac output and still use the formulation described for SVR or PVR as described above for Block 128. As technologies improve, new sensors will become available to make this possible and economically feasible.
While we prefer to use cardiac output measures, other indicators of cardiovascular health/responsiveness may eventually be proven to be more accurate. Accordingly, we contemplate use of a block similar to block 128 that may adjust optimization based on other parameters such as pH of venous return blood, (an indirect measure of oxygen saturation) or ST segment variation, (an indirect of indication of heart tissue ischemia). What we are hoping to determine is whether the heart is pumping sufficient blood to maintain the body, and if not, to allow for reduced stimulation of the baroreflex so as to protect the patient while lowering cardiac stress as much as possible.
In FIG. 8 the process of step 129 is detailed. Input from 128 goes to step 131 which determines whether or not the heart rate value is too high. If it is, this provides an indication that the stimulation should be increased (i.e., through step 137), however additional factors may be considered. In the preferred embodiment of the invention a rate responsive pacer is used and a sensor for determining the amount of patient activity is employed. This takes place in step 135 "activity check." If the patient activity level is above a predetermined threshold level, the same level of stimulation will be maintained (step 136). It is possible to improve on this algorithm as well by accelerating the rate of increase of stimulation or not according to some preprogrammed set of values. However, we do not have sufficient experience with this system at this time to suggest what the best alternative is for adjusting the stimulation level based on the activity level. However, we can recommend that nerve stimulation be lowered when activity sensing shows the need for greater cardiac output, such as during indicated strenuous activity of the body.
If the heart rate value is not too high, the second determining step 132 is made. The PVR value determined in step 128 is first checked to determine whether it is too high. If it is, then again the nerve stimulation value should be increased 137 and again the activity level checked to modify this increase if necessary or preferred 136.
In step 133 the PVR level may be determined to be too low. If so, the level of stimulation to the baroreceptor nerves should be decreased (step 138). If the PVR value is neither too high nor too low, the algorithm should exit process 129 for step 123 to make a determination of whether there is a need to pace. Again, the need to pace would be determined based on whether the heart rate was too low or whether there was some other indication such as vasovagal syncope being detected in the heart. Referring back to FIG. 6, if pacing is required (step 124) the stimulation level again will be lowered (step 125).
As will occur to the reader there are numerous applications for the inventive concepts described herein, however the scope of the invention is only limited by the following appended claims.
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BHS Small Schools: Green Academy
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As you consider the various learning community options at Berkeley High, I would highly recommend the Green Academy (formerly SSJE). I have a BHS Sophomore who's in his second year in the Green Academy and we're both very happy with the program and his teachers. The Green Academy is the third-largest learning community at BHS with 285 students and growing, but is small enough that your student will have a real sense of community.
The Green Academy utilizes a Science and Math based curriculum that prepares students for college and the growing green careers field. The course offerings meet all of the UC/CSU requirements, and include AP offerings in Environmental Science, Physics, Calculus, Statistics, American Literature and Composition in the 11th and 12th grades. The Green Academy also offers electives in all four years, which enables students to choose from the myriad of Arts, Humanities and World Languages courses offered at BHS.
I have found my son's teachers at the Green Academy to be dedicated professionals with a real passion for their subject areas and a commitment to creating a more environmentally sustainable and socially just world. I am also very impressed with their availability and willingness to work with me when my student has struggled at times. Please feel free to contact me if you'd like more information, or to go to the Green Academy website @ http://sites.google.com/site/greenacademybhs/ Matthew
Our daughter, currently an eigth grader at MLK, is trying to decide on her second choice of school at Berkeley High School. Her first choice is definitely Academic Choice. Her second choice was BHIS (International School), but she has now begun thinking seriously about the School of Social Justice and Ecology. Are there any parents and/or teens out there who participated in this school last year and can share their experiences with us? My main concern is that I have heard rumors that some of the small schools, including SSJE, might not be as challenging as either Academic Choice or the International School, and, while I have no problem with any direction she might choose to go in, I definitely know that she won't be happy in a program that doesn't challenge her academically. At the same time, I am aware that rumors can be entirely misleading. Can anyone give us some insight into what life at SSJE might be like for a motivated and intellectual incomng ninth-grader? Many thanks! anon.
Great teachers, a committment to community-building, and a strong social-justice component make this a special addition to BHS. Spending four hours a day with the same group of students can difficult, especially in the first semester, but this also forges important bonds between students, and between students and teachers. There is an active parent group that meets monthly. You can contact me for more info. goldhams
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Eva Jurenikova shows the beautiful terrain in the heart of Dalarna.
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Utility Failure
If you discover a utility failure, contact your campus physical plant or facility services. Be prepared to give:
- Building name
- Floor
- Room number
- Nature of problem
- Person to contact and phone number
Electrical/Light Failure
If hallway lights are out, locate exit stairs or doors and evacuate the building while emergency lights are on. Do not enter the building or use laboratories until power is restored. Emergency lighting should be considered temporary and will not support building operations. If you are in a laboratory equipped with a fume hood and/or biosafety cabinet, close all hoods and biosafety cabinet sashes.
Plumbing/Floor/Water Leak
If you discover leaking water or know the source of a water leak, contact Campus Facilities Services. Do not walk through standing water due to the potential for electrocution.
Natural Gas Leak
If you discover a natural gas leak, leave the area immediately and notify the IU Police Department on your campus at 911 (9-911 also works from on-campus phones).


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Chalk it up to Ambassador Ryan Crocker and General John Allen–our dynamic duo in Kabul. They can get results even in the most unpromising circumstances.
Recently, they completed a deal to transfer custody of the main U.S. detention facility to Afghan control while maintaining American oversight and an American veto on any prisoner releases. Now they appear to be on the verge of concluding an agreement that would allow "night raids"–heavily criticized by President Hamid Karzai for their supposed infringement on Afghan sovereignty–to continue with only mild modifications. Afghan judges will be required to approve the raids but their approval apparently will be obtainable after the fact–which means that the secrecy essential for these operations will not be compromised.
Assuming the deal is sealed, this will be an important victory that will allow coalition forces to continue employing one of their most effective counter-terrorist tools while still giving the appearance of respecting Afghan sovereignty.


text: Conflict ConflictPoliticsAfrica Talia Ralph on Jan 20, 2013 @ 12:05 PMJan 20, 2013 @ 12:05 PM Published5 Algerian hostage kidnappers 'taken alive,' reports sayA picture shows a road sign indicating Tiguentourine near In Amenas on a road leading to a gas complex where Islamist gunmen had taken hostages in the desert in Algeria's deep south on January 19, 2013. Islamist gunmen killed seven foreign hostages in Algeria before being gunned down by special forces in a final assault on a remote desert gas complex, state television said, though five members have reportedly been found alive.Five of the kidnappers who took hostages in a seige at an Algerian gas plant this week have been found alive, according to reports.BBC News and Agence France Presse are both reporting that several of the Islamist militants allegedly responsible for the hostage-taking were "taken alive" at the BP plant at In Amenas. Private Algerian television channel Ennahar reported that three other kidnappers remain at large, station director Anis Rahmani told AFP. The reports come after Algerian authorities initially announced that all 32 kidnappers had been killed in the bloody rescue operation, BBC News reported. Algerian officials acknowledged that the death toll of hostages, currently at 25, is expected to rise further. A Japanese engineering company also reported that 17 of its workers remain unaccounted for after the siege, New York Times reporter Jim Roberts tweeted Sunday.Obama said Saturday that the White House would work closely with Algerian officials to get a full understanding of the attack in the Sahara desert, the Wall Street Journal reported. "The blame for this tragedy rests with the terrorists who carried it out, and the US condemns their actions in the strongest possible terms," said Obama. "We have been in constant contact with Algerian officials and stand ready to provide whatever assistance they need in the aftermath of this attack."More from GlobalPost: Bodies of 25 Algeria hostages found in gas facility after deadly raid


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|The most helpful favorable review
|The most helpful critical review
3 of 3 people found the following review helpful:
By Robert from USA on 2009-08-25 11:15:39Things I liked:This is a remarkable air rifle. A great deal for the money. It is very well engineered from the gold metal trigger to the detachable air chamber. My rifle is very accurate for my shooting ability compared to my Marauder which is also very accurate.The metal rotary magazine is easier to load, easier to insert in the rifle and seems more durable than the plastic spring magazine of my Marauder. Also my Halestorm came with 2 metal rotary magazines as opposed to having to purchase a second magazine seperately for my Marauder. The built in dual scope channels for Weaver and 11mm mounts is a great idea that is simple and should be incorporated into more air rifles. The stock is high quality hardwood and is a beautiful match to the rifle that looks better than even the pictures can show. The adjustable rubber butt on the stock is another great feature for the money. I like the automatic safety set with each cock of the rifle compared to my Marauder which is manual. The fiber optic sights are high quality although I removed mine to mount a scope. I like the charging system which involves inserting a brass coupling nozzle from the side. You can easily attach the nozzle to your pump first and then insert it into the fill chamber as opposed to unscrewing an end cap and attaching the pump hose to a fixed quick connect as in the Marauder. The detachable air chamber with the ability to purchase spare air chambers is an innovative design although I probably wont use it for my shooting.
Things I would have changed:Add a shrouded barrel !!!! The Marauder wins for backyard shooting due to the significant noise reduction from the shrouded barrel. This gun and some other high powered air rifles are too loud to shoot in your backyard without disturbing your neighbors. The design of this rifle would very easily lend itself to adding a shrouded barrel. Also it requires a seperate quick connect fitting to adapt the charging nozzle to a Benjamin type air pump. This would be nice to include but I can't complain due to all the other features for the money.
What others should know:The owners manual I received with my rifle did not cover some details. The rifle comes with a heavy brass fitting that has a threaded core. This is a degasser and protective cover that screws over the pressurized air chamber when you remove it from the rifle. Until I removed the air chamber I couldn't figure out where this heavy fitting went. To remove the air chamber you simply unscrew it from the rifle holding the notched areas at the end where the air gauge is. It can be removed fully or partially charged without any air loss and it or another can be easily reinserted and screwed back tight to continue shooting. The manual that came with my rifle did not cover this so I called tech support before I tried to unscrew a high pressure air chamber !! The tech support at Pyramid Air is excellent.
2 of 3 people found the following review helpful:
By Scott from USA on 2009-12-07 15:07:31Things I liked:Great stock, adjustable butt pad open sights, very, very accurate. Shooting 35FPE with Kodiaks. Shoots most pellets well, not very pellet fussy.
Things I would have changed:Trigger is too heavy even after adjusting. Fit & finish & materials. Use machined metal instead of pot metal. Better magazine molding. One of the 2 magazines won't cycle because the teeth are not all uniform.
What others should know:Very rough out of the box. took about 500 pellets for things to smooth out. A lot of pot metal used. Finishes on metal part don't match & some edges had places were the paint has come off. Bottom line, spend the extra $50 bucks & get the Marauder
|By Jeff W from USA on 2010-09-20
|By Andrew from Canada on 2015-03-13
|By pcp4me from USA on 2014-10-03
|By dave from USA on 2011-09-27
|By Mark from USA on 2010-08-11
CheckoutSubtotal (USD):
does not include shipping and tax


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Three local South Korean securities houses have received licences to trade over-the-counter (OTC) derivatives following regulatory changes that opened up the country's OTC market to securities firms in July.Samsung Securities, Daewoo Securities and LG Investment and Securities all became authorised to trade OTC derivatives in the last few weeks. However, the firms have been preparing to build up their derivatives capabilities for the last several months, with a series of new hires and establishment of dedicated teams.
Daewoo Securities, which hopes to begin trading in two weeks time, established a seven-strong OTC derivatives trading department in May headed up by Jung Min Lee, while LG Investment and Securities set up a dedicated derivatives product sales team a year ago, headed by JY Choung.
Meanwhile, Samsung Securities recently hired Alex Choi, an ex-Goldman Sachs banker, to lead the firm's efforts as head of its new capital markets division, which will primarily structure equity and fixed income derivatives with foreign exchange derivatives to follow in the near future.
With the interest rate markets in South Korea dominated by banks, the local securities firms have largely chosen to focus on equity derivatives in the initial stages, although many plan to branch out to fixed-income and foreign exchange derivatives at a later date.
"Interest rate related products are already dominated by banks," says one official at a local securities house in Seoul. "In consequence, we deem interest rate related products as secondary in terms of our focus."
An official at the Financial Supervisory Commission (FSC), the local regulatory body, said he expects that two to three foreign securities houses and two to three more domestic houses will apply for a licence by the end of the year.
While only three firms have received licences, the official added that three others had applied but later withdrew their applications. Woori Securities and Tongwon Securities withdrew applications after failing to meet internal risk management control requirements, while Daishin Securities faced unspecified problems relating to its majority shareholder.
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The Finance and Investment Group was founded in the Fall Semester of 2009 when the Collegiate Finance Organization and Investment Society merged together. The mission of Finance & Investment Group is to present dedicated finance students with career opportunities in the field of finance and to introduce them to professionals in the business community. FIG also wants to increase their awareness of financial markets by providing students with valuable information, either through workshops or our Stock game competition.
We have stayed true to our mission for the past 6 years and grown into the largest student organization in the College of Business.


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Orca (Killer) Whales
|Description & Characteristics:
Orca or Killer whales are the largest members of the dolphin family. Found in all waters, these splendid, toothed whales are sometimes called the 'wolves of the sea' because of their closely-related pack-like behaviors. Gracing the southern seas in abundance, Orcas tend to travel in small close-knit, family pods but can be found in groups of up to 50 individuals. Orcas have not been caught commercially since the early 1980's as a result of protective measures imposed by the International Whaling Commission (IWC). However, Orcas are still captured in small numbers for display at zoos and marine parks. This is an emotional and controversial issue to be sure, but not one of conservation significance as Orca populations are currently thought to be stable.
Probably the most striking feature of Orca whales is their unique coloration pattern. A dazzling contrast of jet black above and bright white markings beneath help make the Orcas both visually appealing and easily identifiable. Add to that their sleek, streamlined shape and imposing dorsal fins (especially in the adult male) and the result is a truly magnificent animal of the sea.
Orca whales are excellent swimmers and can perform impressive acrobatics in the water. They can often be observed breaching, a behavior in which the whale speeds to the surface and leaps completely out of the water, falling back with a spectacular splash. Or they may be seen 'spyhopping'--poking their heads straight out of the water to get a better look at their surroundings. 'Tail slapping' is another common activity possibly meant as a kind of warning to other members in pod.
Orcas are very efficient and sophisticated predators who often hunt in groups, attacking prey much as wolves attack larger caribou or moose, then sharing the spoils. They eat fish, squid, sharks, birds (including penguins), seals, sea turtles, octopi, and other whales. An Orca will tip up small ice floes to dislodge resting seals while other Orcas wait beneath the surface for the kill. They have even been observed attacking young, but still huge, Blue whales. Aside from human beings, Orcas have no natural enemies. They can dive to depths of up to 100 feet in pursuit of prey but prefer to hunt at or near the surface of the water.
Orcas are very social animals. The bonds between pod members are strong and last for life. Orcas share the responsibility of protecting young, and caring for the sick or injured.
Orca breeding occurs mostly in the winter to early spring. The gestation period is about 16-17 months. Newborn Orca calves instinctively swim to the surface within ten seconds for their first breath, helped along by mother's flippers. Calves are about seven feet long and weigh up to 400 pounds at birth. The mother and calf may stay together for a year or longer. Female orcas reach maturity at 6-10 years old, and males at 12-16 years old.
- Like other toothed whales, Orcas use 'echolocation' to navigate and find prey; they emit high-pitched clicks and sense them as they bounce back off objects.
- The largest population of Orca whales seems to be in Antarctica where it is estimated some 160,000 animals range.
- Orcas don't make long, seasonal migrations, though they may cover an area of hundreds of miles in order to find seasonal prey.
- Orcas can swim up to 30 miles per hour in short bursts.
- Orca pods have their own 'dialect' of discrete calls, which aid in navigation, detecting prey, or sensing danger.
- Typical of most whales, Orca calves are born tail first.


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Pronunciation: /ˈCHärjˌmastər/
(also charge description master)
Definition of chargemaster in English:
A list detailing the official rate charged by a hospital for individual procedures, services, and goods: the chargemaster is used to generate each hospital invoice [as modifier]: most insurance companies do not pay the standard chargemaster price that hospitals bill the uninsured
More example sentences
- Reimbursement for many outpatient services are driven by the charge description master.
- The structure and detail of chargemasters are hospital-specific and vary considerably among hospitals.
- After all, as the hospitals themselves concede in downplaying their chargemasters, these insurance prices are the ones that affect most patients.
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