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An alternative mechanism in an implantable device for meeting the physician's need for a stored electrogram and/or other stored physiologic signal associated with a detected arrhythmic or other physiological event without the undesirable current drain associated with continuous operation of a sense amplifier and a looping memory. The device regularly but intermittently activates a sense amplifier or other sensor and associated memory circuitry, independent of detection of arrhythmias. The device may temporarily store only a single record, replacing it with new records as they are stored, or may store multiple records, replacing the oldest stored record with the newest stored record. On detection of an arrhythmia or other defined physiological event, the device may simply transfer the one or more temporarily stored electrogram strips to permanent storage, for later use by the physician in diagnosing the condition of the patient prior to detection of the event.
1. An implantable medical device, comprising:
means for sensing a physiologic parameter;
means for periodically activating said sensing means for first time intervals, responsive to expirations of second, substantially longer time intervals;
means for temporarily storing values indicative of said sensed physiologic parameter during said first time intervals;
means for detection of a physiologic event as a function of values of said physiologic parameter occurring during said second time intervals; and
means responsive to detection of said physiologic event by said event detection means as a function of values of said physiologic parameter occurring during one of said second time intervals, for permanently storing said values temporarily stored during a preceding one of said first time intervals.
2. A device according to claim 1, further comprising means for transmitting said permanently stored values to a receiver external of the implanted device.
3. A device according to claim 1 or claim 2 wherein said detecting means comprises an arrhythmia detector.
4. A device according to claim 3 wherein said physiological sensor comprises a sense amplifier.
5. A device according to claim 1 or claim 2 further comprising means for triggering permanent storage of values indicative of said physiologic parameter in response to expiration of third time intervals substantially longer than said second time intervals.
6. A device according to claim 5 wherein said means for triggering storage comprises means for triggering permanent storage of said temporarily stored values indicative of said sensed physiologic parameters.
7. A method of monitoring a physiologic parameter in conjunction with a physiological event, comprising:
implanting a monitoring device comprising means for sensing said physiologic parameter and means for detecting said physiologic event in a patient's body;
periodically activating said sensing means for a first time interval, responsive to expirations of second, substantially longer time intervals;
temporarily storing in said monitoring device values indicative of said sensed physiologic parameter during said first time intervals;
monitoring said physiological parameter to detect occurrences of said physiologic event as a function of values of said physiologic parameter occurring during said second time intervals; and
responsive to detection of said physiologic event as a function of values of said physiologic parameter occurring during one of said second time intervals, permanently storing said temporarily stored values, stored during a preceding one of said first time intervals, in said monitoring device.
8. A method according to claim 7, further comprising transmitting said permanently stored values to a receiver external of the patient.
9. A method according to claim 7 or claim 8 wherein said permanently storing step comprises storing said temporarily stored values in response to a detected arrhythmia.
10. A method according to claim 9 wherein said sensing step comprises sensing electrical signals in said patient's body.
11. A method according to claim 7 or claim 8 further comprising permanently storing values indicative of said physiologic parameter in said monitoring device in response to expiration of third time intervals substantially longer than said second time intervals.
12. A device according to claim 7 or claim 8 further comprising permanently storing said temporarily stored values indicative of said physiologic parameter in said monitoring device in response to expiration of third time intervals substantially longer than said second time intervals.
This invention relates generally to an apparatus and method for storing electrograms and more particularly to the implementation of such a device in the context of an implantable cardioverter/defibrillator.
Implantable cardioverter/defibrillators and pacemakers have for some time included the capability of storing digitized cardiac electrograms for diagnostic purposes. Most commonly, such electrograms are stored in conjunction with the detection of cardiac arrhythmias, and include the period of time immediately preceding detection of the arrhythmia. For example, the device disclosed in U.S. Pat. No. 4,223,678 issued to Langer et al and the device disclosed in U.S. Pat. No. 4,295,474 issued to Fischell, both employ looping memories to continually store cardiac electrograms, with the contents of the looping memory being frozen on occurrence of an arrhythmic event and transferred to permanent storage. The devices also store electrograms following either detection of the arrhythmic event or delivery of an anti-arrhythmic therapy. While this approach to electrogram storage does provide the physician with information associated with the detected arrhythmia and its treatment, it has the drawback of requiring continuous operation of the looping memory and the sense amplifier, increasing the current drain on the battery and shortening the potential lifespan of the device.
Prior approaches to reducing the current drain associated with electrogram storage have focused on the storage of markers indicative of heart paced or sensed heart depolarizations and/or intervals between depolarizations and on design of low power sense amplifiers. While these approaches have been somewhat successful, the information stored in the form of markers or interval is not always adequate for diagnostic purposes and continuous activation of even low power sense amplifiers in conjunction with looping memories still results in an undesirably high current drain.
The present invention provides an alternative mechanism for meeting the physician's need for a stored electrogram and/or other stored physiologic signal associated with a detected arrhythmic event without the undesirable current drain associated with continuous operation of a sense amplifier and a looping memory. The present invention accomplishes this goal by regularly but intermittently activating a sense amplifier and associated memory circuitry, independent of detection of arrhythmias. For example, five seconds of an electrogram (EGM) might be temporarily stored every fifteen minutes or once a minute, providing a substantial reduction in current drain as compared to continuous operation of a sense amplifier and a looping memory. The device may temporarily store only a single electrogram record, replacing it with new electrogram records as they are stored, or may store multiple electrogram records, replacing the oldest stored record with the newest stored record. On detection of an arrhythmia, the device may simply transfer the one or more temporarily stored electrogram strips to permanent storage, for later use by the physician in diagnosing the heart rhythm history of the patient prior to detection of the arrhythmia. While a continuous recording of cardiac events leading to detection of an arrhythmia may not be included in the stored electrogram records, it is believed that stored information with regard to intervals between the detected depolarizations and other stored information in conjunction with the previously stored electrogram records can provide adequate diagnostic information to the physician. As an alternative or in addition to storage of electrogram records, the device may also store records of other measured physiologic parameters such as pressure, oxygen saturation, temperature and the like.
In addition, the device may also permanently store electrogram and/or other physiologic records at regular intervals, even in the absence of detected arrhythmias. For example, a temporarily stored electrogram record may be permanently stored once every day, once every week or the like, to provide the physician with an electrogram history.
The above and still further objects, features and advantages of the present invention will become apparent from the following detailed description of a presently preferred embodiment, taken in conjunction with the accompanying drawings, and, in which:
FIG. 1 is a representation of the heart, and an implanted electrode lead system, illustrating the a device embodying the present invention;
FIG. 2 is a schematic block diagram illustrating the structure of one embodiment of an implantable pacemaker/cardioverter/defibrillator in which the present invention may be embodied.
FIG. 3 is a functional flow chart illustrating the operation of a device incorporating the invention.
FIG. 1 illustrates an implantable cardioverter/defibrillator system of the type appropriate for use in conjunction with the present invention. The implantable defibrillator 100 is enclosed in a hermetic housing 102 which carries a battery an circuitry adapted to detect and treat tachyarrhythmias. The circuitry within housing 102 includes the circuitry embodying the present invention. The implantable cardioverter/defibrillator 100 is coupled to the heart by means of three electrode leads 110, 120 and 130 which are exemplary of typical cardioversion/defibrillation electrodes. Lead 110 includes a single elongated electrode 112 which may be located in the coronary sinus/great vein as shown or may alternately be located in the superior vena cava or subclavian vein. Lead 120 includes an elongated defibrillation electrode 122 located in the right ventricle and pacing sensing electrodes 124 and 126. Lead 130 is a subcutaneous lead which carries coil electrodes taking the form of loops, 136, 138 and 140 mounted to an insulative electrode pad 134. In alternative embodiments, the conductive housing 102 of the implantable cardioverter/defibrillator 100 may be substituted as an electrode for lead 130. Any other conventional cardioversion/defibrillation and pacing/sensing electrodes may also be employed in conjunction with a device embodying the present invention, including those employed for atrial defibrillation and dual chamber defibrillation.
FIG. 2 is a functional schematic diagram of an implantable pacemaker/cardioverter/defibrillator in which the present invention may usefully be practiced. This diagram should be taken as exemplary of the type of device in which the invention may be embodied, and not as limiting, as it is believed that the invention may usefully be practiced in a wide variety of device implementations, including devices having functional organization similar to any of the implantable pacemaker/cardioverter/defibrillators presently being implanted for clinical evaluation in the United States. The invention is also believed practicable in conjunction with implantable pacemaker/cardioverter/defibrillators as disclosed in prior U.S. Pat. Nos. 4,548,209, to Wielders et al., 4,693,253, to Adams et al., 4,830,006, to Haluska et al, 4,830,006, to Haluska et al. and 4,949,730, to Pless et al., all of which are incorporated herein by reference in their entireties.
The device is illustrated as being provided with six electrodes, 500, 502, 504, 506, 508 and 510. Electrodes 500 and 502 may be a pair of closely spaced electrodes located in the ventricle, for example, corresponding to electrodes 124 and 126 in FIG. 2. Electrode 504 may correspond to a remote, indifferent electrode located on the housing of the implantable pacemaker/cardioverter/defibrillator. Electrodes 506, 508 and 510 may correspond to the large surface area defibrillation electrodes located on the ventricular, coronary sinus and subcutaneous leads illustrated in FIG. 2 or to the epicardial electrodes 204,206 and 208 of FIG. 3.
Electrodes 500 and 502 are shown as hard-wired to the near field, R-wave detector circuit, comprising bandpass filtered amplifier 514, auto threshold circuit 516 (for providing an adjustable sensing threshold as a function of the measured R-wave amplitude) and comparator 518. A signal is generated on ROUT line 564 whenever the signal sensed between electrodes 500 and 502 exceeds the present sensing threshold defined by auto threshold circuit 516. As illustrated, the gain on the band pass amplifier 514 is also adjustable by means of a signal from the pacer timing and control circuitry 520 on GAIN ADJ line 566.
The threshold adjustment circuit 516 sets a threshold corresponding to a predetermined percentage of the amplitude of a sensed R-wave, which threshold decays to a minimum threshold level over a period of less than three seconds thereafter, as described in U.S. Pat. No. 5,117,824, issued to Keimel and incorporated herein by reference in its entirety. The time constant of the threshold circuit is also preferably sufficiently short so that minimum sensing threshold may be reached within 1-3 seconds following adjustment of the sensing threshold equal to 70-80% of the amplitude of a detected spontaneous R-wave.
In any case, each successive R-wave sense event signal on the ROUT line is routed through the pacer/timer control circuit block 520 on data bus 540 to the microprocessor 524, where it operates as an interrupt commencing a number of operations as described further below. It will be understood that the alternative sense amplifiers described above may be substituted for bandpass filtered amplifier 514, auto threshold circuit 516.
Switch matrix 512 is used to select which of the available electrodes are employed for sensing electrograms for storage according to the present invention. The electrode pair so employed may comprise electrodes 502 and 500 or electrode 500 in conjunction with one of the electrodes 504, 506, 508 or 510, or may comprise other combinations of the illustrated electrodes, including combinations of the large surface defibrillation electrodes 506, 508, 510. Selection of which two electrodes are employed is controlled by the microprocessor 524 via data/address bus 540. EGM signals from the selected electrodes are passed through bandpass amplifier 534 and into multiplexer 532, where they are converted to multi-bit digital signals by A/D converter 530, for temporary storage in random access memory 526 under control of direct memory address circuit 528. Temporary storage of a series of EGM records encompassing several seconds each is preferred, with the most recently stored record being written over the oldest temporarily stored record. In response to detection of an arrhythmia or expiration of a pre-set time period, one or more of the records is permanently stored elsewhere in memory 526 as described below.
Optionally, the device may employ a physiologic sensor 574, which may be a pressure sensor, an oxygen sensor, an activity sensor, a temperature sensor or other physiologic sensor as disclosed in as disclosed in U.S. Pat. No. 4,903,701, issued to Moore, U.S. Pat. No. 5,535,752, issued to Halperin et al., U.S. Pat. No. 4,428,378, issued to Anderson et al. and U.S. Pat. No. 4,688,573, issued to Alt, all incorporated herein by reference in their entireties. The sensor 574 may be employed to regulate pacing rate, as a part of the arrhythmia detection method employed by the devise, or simply for monitoring purposes. The sensor is controlled by microprocessor 524 via sensor processing circuitry 576, and the digitized output of the sensor is provided to data/address bus 540, so that it also can be stored in memory 526.
Communication with the device is accomplished via antenna 570 and associated telemetry circuitry 572, which may correspond to any of the various telemetry systems employed by implantable devices. For example, telemetry systems as disclosed in U.S. Pat. No. 5,350,411, issued to Ryan, U.S. Pat. No. 5,324,315, issued to Grevious, U.S. Pat. No. 5,088,488, issued to Markowitz et al. and U.S. Pat. No. 5,127,404, issued to Wyborny et al., all incorporated herein by reference in their entireties may be employed to receive commands from external programmers and to transmit stored EGM records, sensor records, operational parameters and information regarding the detection of arrhythmia by the device to an external programmer.
At defined time intervals, for example once a minute or once every 15 minutes, the microprocessor activates the band-pass amplifier 534 and temporarily stores an EGM and/or a sensor record extending over a pre-defined time period, e.g. five seconds. As discussed above, one or more such records may be temporarily stored. In response to detection of an arrhythmia, or optionally also in response to expiration of a defined longer time period, e.g. one day or one week, the microprocessor initiates permanent storage of one or more of the temporarily stored digitized EGM and/or sensor records.
In conjunction with the operation of the device, the microprocessor preferably also triggers temporary storage of the time intervals separating sensed depolarizations of the heart in response to the detected depolarizations, in the same manner as present commercially available implantable cardioverter defibrillators. These stored intervals may also be permanently stored in response to detection of an arrhythmia, to be used in conjunction with previously stored EGM records.
As discussed above, switch matrix 512 selects which of the various electrodes are coupled to band pass amplifier 534. Amplifier 534 may be a broad band pass amplifier, having a band pass extending for approximately 0.5 to 200 hertz. The filtered EGM signal from amplifier 534 is passed through multiplexer 532, and digitized in A/D converter circuitry 530. For purposes of the present invention, a sampling rate of 256 to 512 samples per second should be sufficient, although somewhat lower or substantially higher sampling rates may be used, depending on the amount of data storage capacity in RAM 526 and on the processing speed of microprocessor 524. The sampled and digitized data is stored in random access memory 526 under control of direct memory address circuitry 528.
The arrhythmia detection criteria employed by the microprocessor 526 may include sustained high rate, onset and irregularity in the heart beat rate of the patient as described above. Other variations on the arrhythmia detection criteria may be employed in the practice of the present invention and are not repeated here. Such detection algorithms for recognizing tachycardias are also described in the above cited '380 patent, U.S. Pat. No. 4,880,005, issued to Pless et al and the '006 patent, incorporated by reference in their entireties herein. An additional set of tachycardia recognition methodologies is disclosed in the article "Onset and Stability for Ventricular Tachyarrhythmia Detection in an Implantable Pacer-Cardioverter-Defibrillator" by Olson et al., published in Computers in Cardiology, Oct. 7-10, 1986, IEEE Computer Society Press, pages 167-170, also incorporated by reference in its entirety herein. However, other criteria may also be measured and employed in conjunction with the present invention, including those disclosed in U.S. Pat. No. 5,545,186, issued to Olson et al., U.S. Pat. No. 5,342,402, issued to Olson et al., U.S. Pat. No. 5,086,772, issued to Larnard et al. and U.S. Pat. No. 5,730,141, issued to Fain et al., all incorporated herein by reference in their entireties may also be employed.
The remainder of the circuitry of FIG. 7 is dedicated to the provision of cardiac pacing, cardioversion and defibrillation therapies. The pacer timing/control circuitry 520 includes programmable digital counters which control the basic time intervals associated with VVI mode cardiac pacing, including the pacing escape intervals, the refractory periods during which sensed R-waves are ineffective to restart timing of the escape intervals and the pulse width of the pacing pulses. The durations of these intervals are determined by microprocessor 524, and are communicated to the pacing circuitry 520 via address/data bus 540. Pacer timing/control circuitry also determines the amplitude of the cardiac pacing pulses and the gain of bandpass amplifier, under control of microprocessor 524.
During VVI mode pacing, the escape interval counter within pacer timing/control circuitry 520 is reset upon sensing of an R-wave as indicated by a signal on line 564, and on time-out triggers generation of a pacing pulse by pacer output circuitry 522, which is coupled to electrodes 500 and 502. The escape interval counter is also reset on generation of a pacing pulse, and thereby controls the basic timing of cardiac pacing functions, including anti-tachycardia pacing. The duration of the interval defined by the escape interval timer is determined by microprocessor 524, via data/address bus 540. The value of the count present in the escape interval counter when reset by sensed R-waves may be used to measure the duration of R--R intervals, to detect the presence of tachycardia and to determine whether the minimum rate criteria are met for activation of the tachycardia/defibrillation discrimination function.
Microprocessor 524 includes therein a read only memory which contains programming information controlling its operation. Microprocessor 524 operates as an interrupt driven device, and responds to interrupts from pacer timing/control circuitry 520 corresponding to the occurrence of sensed R-waves (as described above) and corresponding to the generation of cardiac pacing pulses. These interrupts are provided via data/address bus 540. Any necessary mathematical calculations to be performed by microprocessor 524 and any updating of the values or intervals controlled by pacer timing/control circuitry 520 take place following such interrupts.
In the event that a tachyarrhythmia is detected, and an anti-tachyarrhythmia pacing therapy regimen is desired, appropriate timing intervals for controlling generation of anti-tachycardia pacing therapies are loaded from microprocessor 524 into the pacer timing and control circuitry 520, to control the operation of the escape interval counter and to define refractory periods during which detection of an R-wave by the R-wave detection circuitry is ineffective to restart the escape interval counter. Similarly, in the event that generation of a cardioversion or defibrillation pulse is required, microprocessor 524 employs the counters to in timing and control circuitry 520 to control timing of such cardioversion and defibrillation pulses, as well as timing of associated refractory periods during which sensed R-waves are ineffective to reset the timing circuitry.
In response to the detection of fibrillation or a tachycardia requiring a cardioversion pulse, microprocessor 524 activates cardioversion/defibrillation control circuitry 554, which initiates charging of the high voltage capacitors 556, 558, 560 and 562 via charging circuit 550, under control of high voltage charging line 552. The voltage on the high voltage capacitors is monitored via VCAP line 538, which is passed through multiplexer 532, and, in response to reaching a predetermined value set by microprocessor 524, results in generation of a logic signal on CAP FULL line 542, terminating charging. Thereafter, delivery of the timing of the defibrillation or cardioversion pulse is controlled by pacer timing/control circuitry 520. One embodiment of an appropriate system for delivery and synchronization of cardioversion and defibrillation pulses, and controlling the timing functions related to them is disclosed in more detail in U.S. Pat. No. 5,188,105, to Keimel, and incorporated herein by reference in its entirety. However, any known cardioversion or defibrillation pulse generation circuitry is believed usable in conjunction with the present invention. For example, circuitry controlling the timing and generation of cardioversion and defibrillation pulses as disclosed in U.S. Pat. No. 4,384,585 to Zipes, in U.S. Pat. No. 4,949,719 to Pless et al., cited above, and in U.S. Pat. No. 4,375,817 to Engle et al., all incorporated herein by reference in their entireties may also be employed.
Similarly, known circuitry for controlling the timing and generation of anti-tachycardia pacing pulses as described in U.S. Pat. Nos. 4,577,633 to Berkovits et al., 4,880,005 to Pless et al., 4,726,380 to Vollmann et al., and 4,587,970 to Holley et al., all of which are incorporated herein by reference in their entireties may also be used.
Selection of the particular electrode configuration for delivery of the cardioversion or defibrillation pulses is controlled via output circuit 548, under control of cardioversion/defibrillation control circuitry 554 via control bus 546. Output circuit 548 determines which of the high voltage electrodes 506, 508 and 510 will be employed in delivering the defibrillation or cardioversion pulse regimen, and may also be used to specify a multi-electrode, simultaneous pulse regimen or a multi-electrode sequential pulse regimen. Monophasic or biphasic pulses may be generated. One example of circuitry which may be used to perform this function is set forth in commonly assigned, co-pending patent application Ser. No. 07/612,758, filed by Keimel, for an Apparatus for Delivering Single and Multiple Cardioversion and Defibrillation Pulses, filed Nov. 14, 1990, and issuing Nov. 17, 1992 as U.S. Pat. No. 5,163,427, incorporated herein by reference in its entirety. However, output control circuitry as disclosed in U.S. Pat. No. 4,953,551 to Mehra et al. or U.S. Pat. No. 4,800,883 to Winstrom, both incorporated herein by reference in their entireties, may also be used in the context of the present invention. Alternatively single monophasic pulse regimens employing only a single electrode pair according to any of the above cited references which disclose implantable cardioverters or defibrillators may also be used.
In modern implantable pacemaker/cardioverter/defibrillators, the particular therapies are programmed into the device ahead of time by the physician, and a menu of therapies is typically provided. For example, on initial detection of tachycardia, an anti-tachycardia pacing therapy may be selected. On re-detection of tachycardia, a more aggressive anti-tachycardia pacing therapy may be scheduled. If repeated attempts at anti-tachycardia pacing therapies fail, a higher level cardioversion pulse therapy may be selected thereafter. Therapies for fast ventricular tachycardia may be of the same general types provided in conjunction with detection of ventricular tachycardia at 616 (FIG. 8), and may include anti-tachycardia pacing and cardioversion pulse therapies. However, the therapy menu for fast ventricular tachycardia will be more aggressive than the therapy set for slower ventricular tachycardias. For example, fewer or no attempts at anti-tachycardia pacing may be undertaken prior to delivery of cardioversion pulses. Higher amplitude cardioversion pulses may be specified.
Prior art patents illustrating such pre-set therapy menus of anti-tachyarrhythmia therapies include the above-cited '006, '380 and '970 patents. The present invention is believed practicable in conjunction with any of the known anti-tachycardia pacing and cardioversion therapies, and it is believed most likely that the invention of the present application will be practiced in conjunction with a device in which the choice and order of delivered therapies is programmable by the physician, as in current implantable pacemaker/cardioverter/defibrillators.
In the event that an aggressive therapy is needed, the typical therapy will be delivery of a high amplitude defibrillation pulse, typically in excess of 10 joules, and in some cases as much as 35 joules or more. As in the case of currently available implantable pacemaker/cardioverter/defibrillators, and as discussed in the above-cited references, it is envisioned that the amplitude of the defibrillation pulse may be incremented in response to failure of an initial pulse or pulses to terminate fibrillation.
After delivery of a tachycardia therapy the arrhythmia detection criteria are again monitored. As discussed in the above-cited patents, in some cases it is desirable to have a different standard for re-detection of a tachyarrhythmia than for initial detection of the tachyarrhythmia. Typically the criteria for re-detection will be less stringent than for initial detection, and, in the present invention, the threshold index value may be reduced. Similarly, the microprocessor updates the therapy schedule, to reflect that the previously scheduled therapy had been delivered. As discussed above, in current implantable pacemaker/cardioverter/defibrillators, this generally results in the delivery of a more aggressive therapy upon re-detection of tachycardia. After updating the tachyarrhythmia related functions, the microprocessor returns the device to VVI mode bradycardia pacing and awaits the next R-wave sense event interrupt.
If a tachyarrhythmia was detected previously, the microprocessor checks to determine whether a series of R--R intervals, including the most recent, indicates a return to sinus rhythm or termination of a previously detected arrhythmia. The criterion of detection of return to sinus rhythm may be a series of a predetermined number of sequential R--R intervals which are greater than the tachycardia detection interval (TDI), for example. Following termination detection, the counters, detection methodologies and therapy schedules are all appropriately updated, and the device returns to VVI mode pacing, as discussed above.
FIG. 3 is a simplified flow chart summarizing the general operation of the tachycardia/fibrillation discrimination functions that may be performed in the device illustrated in FIG. 2. FIG. 3 is intended to functionally represent that portion of the software employed by microprocessor 524 (FIG. 2) which implements the electrogram and/or sensor record storage function.
FIG. 3 is a functional flow chart illustrating the overall operation of the portion of the software associated with microprocessor 524 which controls storage of electrocardiogram and/or sensor output records. After initialization at 200, the device waits until the detection of an arrhythmia at 202, the expiration of a relatively short first time period, for example one minute or fifteen minutes as discussed above at 210 or the expiration of a second and longer time interval T2 at 214 which may be for example one day or one week, as discussed above. If a tachyarrhythmia is detected at 202, the device delivers therapy at 204, transfers one or more temporarily stored electrogram or sensor output records to permanent memory at 206 and may optionally initiate storage of post detection electrocardiogram records at 208. It should be understood that steps 204, 206 and 208 may occur in any order following detection of an arrhythmia.
In the absence of a detected arrhythmia, on expiration of first time interval T1 at 210, the microprocessor 526 (FIG. 2) initiates temporary storage of an electrocardiogram and/or sensor output record at 212. Typically, the stored record will extend over a pre-defined, relatively short time period, for example five seconds. Because the duration of the stored record is short relative to the duration of time period T1, a substantial reduction in current drain is achieved as compared to a more conventional device employing a looping memory and a continuously activated amplifier. As discussed above, the device may store one or more electrocardiogram strips temporarily in random access memory 526 (FIG. 2), with the most recent record being stored over the oldest temporarily stored record.
In response to expiration of the second, longer time interval T2 at 214, the device may optionally permanently store one or more electrocardiogram and/or sensor records at 215. Storage of the electrocardiogram and/or sensor records may be accomplished either by creating a new record for permanent storage on expiration of time interval T2 or by transferring one or more temporarily stored electrocardiogram and/or sensor output records previously acquired to permanent storage.
As discussed above, in devices employing the present invention, it is envisioned that additional information will be stored in conjunction with detected arrhythmias. The stored electrogram and/or sensor output records may be used in conjunction with this additional stored information related to specific detected arrhythmia episodes to assist the physician in monitoring the patient's condition and evaluating the performance of the device. Similarly, the electrogram and/or sensor records stored at longer intervals corresponding to time interval T2 can provide the physician with a longer term record indicative of the patient's underlying condition.
It should be recognized that although the disclosed embodiment deals with electrograms sensed in and arrhythmias detected in the lower chambers or ventricles of the heart, the invention may be usefully practiced in the context of the upper chambers or atria of the heart, which are also prone to tachycardia and fibrillation in some patients.
The present invention is believed to be readily applicable in the context of any of the various types of implantable pacemakers, cardioverter/defibrillators, or monitoring devices presently available. In the context of a cardiac pacemaker or implantable monitor, detection of an arrhythmia may not trigger delivery of therapy. However, the stored electrogram segments in conjunction with information as to the detected arrhythmias are still believed valuable in conjunction with monitoring the patient's condition.
In addition, while the therapies discussed in conjunction with the disclosed embodiment generally relate to delivery of electrical pulses, it should be understood that the invention may be usefully practiced in conjunction with any device adapted to deliver differing therapies for tachycardia and fibrillation, including drug therapies, non-pulsatile electrical therapies, and any other such therapies as may be implemented in such devices as their development progresses, whether applied directly to the heart or systemically.
Similarly, it is believed the invention may also be adaptable to implantable devices employing other forms of physiologic monitoring, not related to the functioning of the heart, such as implantable drug dispensers, implantable nerve stimulators, implantable muscle stimulators, and the like. In all such cases, a reduction of current drain associated with monitoring of physiological parameters according to the present invention may still be beneficial. It should be understood that the present invention, while particularly adapted for use in or in conjunction with an implantable device may also in some cases be usefully practiced in conjunction with a non-implantable device, in a device which, for example only treats fibrillation or only treats tachycardia, or even in a device adapted primarily for diagnostic purposes.
Referenziert von
Juristische Ereignisse


text: I've used more complex interactive SWFs in OpenLaszlo-generated Flash apps. Like Tucker mentioned in another thread, you can access the MovieClip that represents a view at <view>.sprite.__LZmovieClipRef Nothing stops you from twiddling MovieClip bits directly but __LZmovieClipRef is not a supported API and is subject to change. I don't think this works for including SWFs the apps compiled to the DHTML target. -e On Mon, Oct 29, 2007 at 5:00 AM, Anze Cesar wrote: hi, it says in the documentation, only basic swf animations may be included. Is there any way of including a full swf application (made with openlaszlo, or any other)? -- lp, Anže -------------- next part -------------- An HTML attachment was scrubbed... URL: http://www.openlaszlo.org/pipermail/laszlo-user/attachments/20071029/423eb66b/attachment.html

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China Economic Net (10/14/08) Na, Tong
Though the lubricant market is maturing in much of the world, opportunities are available in fast-growing China and India, and brand competition is stepping up marketers adjusts product line and launch new packaging and brand promotion.
China's lubricant market is expected to pass the United States to become the world's largest lubricant market in 2020. The Chinese automobile industry has been developing rapidly after starting from nothing a decade ago, and more and more Chinese households are buying cars and paying close attention to maintenance—which in turn is producing more diversified demand in lubricant products.
Large domestic lubricant enterprises are beginning to remodel their brands, deepen channels integration, and strengthen consumer awareness and acceptance through more experienced sale measures. Kunlun Lubricant, the domestic brand, is becoming more and more mature in brand building and market development, right through its years of continuous involvement in international competition. In 2007, Kunlun Lubricant completed the adjustment of 13 of its sub-brands, making them suitable for different market segments. It not only meets the diversified demands of the Chinese lubricant market, but also strengthens and enhances its marketing network.


text:
And an old favourite
a few weeks back i met an elderly woman in the street as i was waiting for my wife with my dogs outside the shop, I thought i'd show her how well Bryn can sing, and as she said she liked Nat King Cole, that was the song we sang together.
unexpectedly reminded again of Melancholia, but what a great song, and i'd forgotten it's one of Wordsworth's best, A Slumber did my spirit seal. What a fascinating album this is developing into
Just reading about Neil Hannon on Wikipedia, it says he wrote this Charlotte Gainsbourg song
i'm haunted by that music!! ^
Yeah, The Turin Horse is one of the titles on my long list of "Saved Discs* on Netflix. Evocative music for sure.
Changing mood now:
I was a bit slow getting into tUnE-yArDs, but I saw her at a festival last summer and was impressed so she has grown on me a lot since then. Looking forward to seeing her again this spring.
This never bores me, an eternal beauty. Portishead – Humming
^Click on the "share" button below the video on You Tube and then select "Embed". You will get some highlighted code to copy and paste.
^Ah yes, another interesting Scandinavian.
20th century go and sleep. You're plasticine.
DOWNBYLAW — That shit is wild! How have I just learned about the tUnE-yArDs? Amazing stuff…
VIKTOR — I really like that song!
Cool that you like it Josh. If you like this, I would recommend the rest of the album: It`s called The Brothel. I think it´s really great.
Josh, yeah amazing indeed. Kind of weird that I was slow getting into her since I like her so much now. St. Vincent and tUnE-yArDs will both be at Coachella, and then they will be touring together afterwards. That's great, but they will be up in Oakland right away. I'd prefer a few weeks gap, but, hey, a show's a show, isn't it?
Hah, Psychic Ills! My brother asked me a few weeks ago what other music I had with drone sounds like The Black Angels. I gave him a few suggestions and then went off hunting around for more. I found Psychic Ills which isn't drone, but I'd never heard them before, and now I've had them on rotation quite a bit the last few weeks.
And yeah, I'm getting that Susanne Sundfør album soon.
For the life of me, I really can't grasp the appeal of tuneyards (no, I won't spell the name properly). I haven't heard music so aggressively awful since the Dirty Projectors but I guess it fits into the same genre of aggressively atonal vocal yodeling/musical noodling tunelessness meets "now it's cool for white people to appropriate African music as long as it's done earnestly". Makes me feel very old but I can only imagine that this is flash in the pan sort of stuff since it's so aurally unpleasant.
Dead Meadow… trippy… dreamy…
I like this Flylo vid:


text:
5 Key Differences Between a PA and a Doctor
The average person does not give much thought to the differences between a physician's assistant (PA) and a doctor. They may not even realize they are not being treated by a doctor due to the knowledge the PA possesses and the professional manner in which they communicate. There are, however, five key differences between a physician's assistant and a doctor. They are education, difference in job functions, salary, job opportunities, and maintaining a malpractice insurance policy.
A Difference in Education
A doctor must earn a four-year undergraduate degree from medical school and then complete an additional two years to obtain a medical degree. Following school, there is anywhere from two to six years of residency training in order to receive a license to practice medicine.
A PA, on the other hand, requires less schooling. They must earn a four year degree, typically the Bachelor of Science, and continue on and complete an accredited Physician Assistant program, usually lasting another two years. Following school, there is a one-year clinical rotation that must be completed. Additionally, PAs must complete ongoing continuing education classes.
The Day-to-Day Duties are Different
A PA operates directly under the supervision of a doctor. The doctor works autonomously. A PA may assist in a surgery but may not perform surgery. The only other major difference between the functions of a PA and that of a doctor is, depending on location, a PA may not be able to write prescriptions.
All other aspects of patient care are shared; examining patients, suturing wounds, diagnosing illnesses, and carrying out treatment plans. There is much overlap between responsibilities.
A Big Bump in Pay
Doctors, of course, command higher salaries because they are educated for a longer time. However, there are PAs that have years of training and experience and earn salaries comparable to doctors. The average salary range for a doctor is $200,000 to $300,000. The salary for PAs average from $86,410 to $100,000+.
Varying Job Opportunities
The medical field is one that continues to grow and job security is quite strong. Doctors are well-sought after professionals, especially depending on the type of medicine they practice. PAs are highly employable as well and, in fact, may be the optimum choice for a clinic where surgery is not performed. The cost savings to the clinic may enable them to offer better patient care, especially in low-income areas.
Cost of Malpractice Insurance
Finally, the biggest difference between a PA and a doctor is the cost of malpractice insurance they each pay. The typical medical liability insurance policy for a PA can cost anywhere from $2,000 and $6,000 a year. The doctor, on the other hand, is looking at $11,000 to $55,000 per year. Of course, doctors also have more earning capability. Depending on location, the PA may not even need to carry malpractice insurance and may be covered under the supervising doctor's policy but it is still a very good idea to obtain an independent policy for a PA.
Whether being treated by a PA or a doctor, you will surely receive excellent medical care. Both are highly educated and work as a team to provide their patients with the best possible treatment.


text:
I'm as packed for South America as you can be the night before departure. See?
It's all in the Osprey, and it all fits! Okay, the only things NOT in the Osprey are my carry-ons — my black cross-body bag and my laptop.
Wanna see what my packing spreadsheet looks like at the moment? Sure you do!
That's organization, right there! Green is for what's packed. Blue is for what I'm wearing. Yellow is for what I still need to get out / what I might not take, and white is for things that I'll be using up until the last minute, and that's why they're not packed yet. Red text is for what I'm sending home after the course. Blue text is for liquids (no idea why I decided that was an important distinction).
I've been in touch with my classmates for the CELTA, and I think most of us are going to try to get together this weekend. I arrive in Buenos Aires on Friday morning, so I'll probably take the rest of Friday to settle in, get some pesos, get my bearings, and (maybe) nap. Saturday is for exploring :) :D
I'm so excited!


text:
One of the Halifax Mooseheads best players will on the shelf for up to two weeks.
The Mooseheads announced Monday that Nathan MacKinnon will be out of the lineup for the next seven to 14 days because of injury suffered in the second period of the team's 8-5 road loss to the Moncton Wildcats on Friday night.
The team isn't specifically saying what is wrong with MacKinnon, but he could be seen favouring his right leg after trying to get the puck in the neutral zone. He left the game and didn't return.
MacKinnon is second in Mooseheads scoring with 28 goals and 69 points in 41 games.


text:
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The Minka Group, located in Corona, CA, offers a variety of products, including Minka Aire fans, Minka Lavery lighting, and George Kovacs fans and lighting.
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text:
Any idea on an estimated turnaround time for PTC to install new pickups & 3-way w/push-pull kit on CU24 (1997)? I'm curious on what kind of time needs to be planned on to be without my baby... I know that I will need to contact them for information, but I was just looking for anyone's past experience.
Thank you!


text:
Johnson celebrates another win at CMS
The 55th Annual Coca-Cola 600 came down between two dominant cars on Sunday: Jimmie Johnson's No. 48 Lowe's Patriotic Chevrolet and Kevin Harvick's No. 4 Budweiser Folds of Honor Chevrolet.
The difference in winning and losing came down to pit road.
Johnson brought home his first victory of the year, aided by his crew's 10 mistake-free stops, and was never far from the front at any point in the race.
Johnson flexed his dominance by winning the pole on Thursday.
He led the most laps (164) Sunday.
"Through the years there has been a lot of references to this race as one of our majors," Johnson said. "I certainly agree with that. Six hundred miles around here is no easy task. To deal with all the things that are thrown at a race team throughout the evening with the track changing, mechanical obstacles, keeping the engine alive, the tires alive, it's a serious team effort. I'm certainly proud of that. ... To have a patriotic paint scheme on our car to say thank you to the families that have lost loved ones and to the men and women out there serving it means something to them and I'm proud to be a part of that."
When Johnson crossed the finish line first he became the most dominant driver ever in the history of points races at CMS.
It was Johnson's seventh points race victory at the track, breaking a tie at the top with NASCAR legends Bobby Allison and Darrell Waltrip.
"That is amazing," Johnson said of the feat. "That is very cool. This is no easy race track to get around and to beat the greats that were before me I'm very proud of that."
It was also Johnson's fourth Coca-Cola 600 victory, which is one behind Waltrip for the most all-time.
The victory virtually locks Johnson into the Chase for the Sprint Cup field. He's the defending series champion and has won six of the last eight titles, including five straight from 2006-2010.
"They know we're awake again," Johnson said of the field. "In winning, it doesn't matter who you are. The 4 car has had that momentum this year. They've been able to go out and execute and show a lot of speed and win. Hopefully this 48 is heading in that direction. We can get those other people thinking about us."
It had been 13 races since his last win victory and he scoffed at the idea that he was worried.
"I mean what 12 races? Give me a break," he said. "Obviously it's a great to win and we are very happy to win here especially in the backyard of Hendrick Motorsports, Lowe's headquarters is just up the road as well. ... We raced up front all night long."
The series heads to Dover International Speedway this weekend for the Fedex 400 Benefiting Autism Speaks.
Johnson has won at Dover three times, including two seasons ago.
Sunday's Coca-Cola 600
(at Charlotte Motor Speedway)
Top 10 finishers1. Jimmie Johnson (Chevrolet)
2. Kevin Harvick (Chevrolet)
3. Matt Kenseth (Toyota)
4. Carl Edwards (Ford)
5. Jamie McMurray (Chevrolet)
6. Brian Vickers (Toyota)
7. Jeff Gordon (Hendrick)
8. Paul Menard (Chevrolet)
9. Kyle Busch (Toyota)
10. Brad Keselowski (Ford)


text:
FSU Home → Arts → Theatre Home → Theatre Season
For reservations contact FSU's Ticket Office at 910-672-1724.
Ticket Prices:
$10 for adults
$8 Staff, faculty and senior citizens
$3 for children (0-12)
$3 for FSU students with a valid ID ONLY until curtain time. After curtain full adult price will apply.
You can purchase individual theatre tickets ONLINE at Etix. For theatre season tickets, call (910) 672-2574 >> More
Show times for all mainstage productions Thursday through Saturday are at 7:30pm. All Sunday show times are at 3:00pm.
Support the Department of Performing & Fine Arts hrough Friends of the Arts
The Friends of the Arts (FOTA) at Fayetteville State University is an organization devoted to supporting the educational and cultural initiatives of the Department of Performing and fine Arts at FSU. >> More
Many music performances are held either in Seabrook Auditorium or in the Rosenthal Building, which are buildings adjacent to each other at the corner of Murchison Road and W.T. Brown Drive at the main entrance of the campus. The Rosenthal Art Gallery is located in the Rosenthal Building. Parking for both buildings is located behind Seabrook Auditorium.
Most of our theatre performances take place in Butler Theater, which can be accessed on the first floor of the G.L. Butler Building at the heart of campus. Sidewalks lead up from the parking area to the breezeway connecting the two halves of the Butler Building.
Parking for Butler Theater is available in the lot adjacent to the Butler Building and the Chestnutt Library at the junction of W.T. Brown Drive and Administration Drive.
>>>Campus Map
You can purchase individual theatre tickets ONLINE at Etix. For theatre season tickets, call (910) 672-2574 >> More
The department's Fine Arts Series brings nationally recognized speakers and performers to campus; and throughout the year the 1,134 seat Seabrook Auditorium is filled with the passion and drama of opera, symphony and live theater.
The Laramie Project
by Moises Kaufmann and members of the Tectonic Theater Project
directed by Jeremy Fiebig
A celebration and examination of the life, death, and aftermath of the murder of Matthew Shepard, The Laramie Project tells the story of Shepard's murder through the perspectives of the people of Laramie, Wyoming.
Butler Theater
Oct. 9-11 at 7:30pm
Oct. 12 at 3pm
The Dumb Waiter
by Harold Pinter
directed by David Griffie
Harold Pinter's riveting exploration of paranoia. Two hit men consider turning on each other in a claustrophobic, suspenseful modern classic.
Seabrook Auditorium
Nov. 13-15 at 7:30pm
Nov. 16 at 3pm
Rumpelstiltskin - Children's Play
FSU's annual children's play features the classic tale of Rumpelstiltskin, the spinning princess, and loads of mischief and fun for kids of all ages - and kids at heart.
Seabrook Auditorium
Feb. 19 & 20 at 9:30am and 11am
February 21 at 2pm
Hair - Musical
music by Galt MacDermot
lyrics and book by James Rado and Gerome Ragni
The classic counter-culture musical where we let it all hang out. Join us as we bring in the dawn of the Age of Aquarius.
Butler Theater
Apr 16-18 at 7:30pm
April 19 at 3pm
September 5-6. September 6 performance. $2 or $1 plus a canned good. Butler Theater, 7pm.
January 23-24. January 24 performance. $2 or $1 plus a canned good. Butler Theater. 7pm.
Individual show ticket prices:
$10 for adults
$8 Staff, faculty and senior citizens
$3 for children (0-12)
$2 for FSU students with a valid ID ONLY until curtain time. After curtain full adult price will apply.
For ticket information call the FSU Box Office at 910-672-1724.


text:
36 Shouts - 155,698 Scrobbles
1) Squarehead is an alias of Sebastian Komor, under which he makes original electronic music and remixes other artists. As Squarehead, he has released multiple singles and an album, "Voltage Controlled Body Music", under Celldweller's FiXT label.
2) Squarehead are a 3 piece garage pop band from Dublin, Ireland. In 2011, they released their debut album, "Yeah Nothing" on Richter Collective. http://www.myspace.com/squareheadmusic
Read more about Squarehead on Last.fm.
User-contributed text is available under the Creative Commons By-SA License and may also be available under the GNU FDL.
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text:
Sony Ccd-tr83 Ntsc 8mm Video 8 Camcorder Video Camera Player Vcr Handycam
SONY 8mm VIDEO 8 CAMCORDER CCD-TR83 VIDEO CAMERA
This Great Operating condition, battery takes and holds a charge at least for a little while as I was testing this.
your 8mm tapes to DVD with this excellent camcorder. 8mm tapes have a
life of 10 years or so depending on conditions. This unit will
transfer your 8mm tapes to DVD, a Laptop, or a PC computer. It will
also record and play 8mm tapes. These units aren't made anymore so get
a high quality unit here.
Features a 12x optical zoom.
If transferring to a dvd recorder, just
use an AV cable for this. If transferring to your computer, you'll
also need an analog to digital conversion cable such as the EasyCap
cable(cheap on Ebay).
It is perfect for transferring your 8mm videos to DVD or VHS, PC or Laptop, or just viewing them.
AC Adaptor and Power Cord
AV Cord
Hand & Neck strap
Manual & Docs
Carrying Bag - Solidex
Let me say there are probably a number of Camcorders that you can do
this with, Sony just Features a similar model in the initial
illustration page so it better work...
Click this link to go directly to the Sony page that explains this process
Click this link to go to the 8mm camcorder page
the one with the mini AV output (figure 4) should show you the cable...
then of course you could just type in "3-RCA FEMALE AUDIO VIDEO to USB
AUX ADAPTOR" in ebay and pull up the other part of the cable that would
make it a little easier
I personally like to use adobe
premiere to do the editing for imported clips, but that's just an old
(for the times) graphics guy talking.
SquareTrade © AP6.0
SquareTrade © squaretrade warranty v2.0


text:
Hello, We are planning a holiday in Hong Kong with a visit to Disneyland.
We have 2 adults, 2 kids 4 and 2 and a newborn baby.
Do we need 2 rooms at the Disneyland hotels in hong kong?
1 room would really be fine for us as the newborn would sleep with us, 2 rooms would mean we wouldn't stay at disneyland hotel due to the price of 2 rooms.
Any recommendations for family friendly hotels that fit people in 1 room and don't cost a huge amount?
thanks :)


text:
1,000 toys and more
McKenna Schwab, a 9-year-old East Wenatchee girl, hoped people would donate 500 items for her toy drive on Make A Difference Day on Oct. 27. She got double that, reports her mother, Melissa Schwab. McKenna's drive brought in 500 toys for Children's Hospital and Medical Center in Seattle, and 500 toys for the Women's Resource Center in Wenatchee, along with $1,000 in cash and gift cards. Those will be split between the two organizations. Born with joint abnormalities called Larsen Syndrome, McKenna has had 10 surgeries, all at Children's Hospital. A story about her toy drive was featured in The Wenatchee World on Oct. 24.
Questions about commenting? See our Disqus commenting FAQ or our full commenting policy.
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For more information see our Disqus commenting FAQ or our full commenting policy


text:
By Kathleen T. RhemAmerican Forces Press Service
WASHINGTON, Oct. 9, 2003 Defense Secretary Donald H. Rumsfeld downplayed the hoopla surrounding a memo from National Security Advisor Condoleezza Rice that explains the National Security Council will assume a broader role in coordinating operations in Iraq.
Rumsfeld said Oct. 7 that he hadn't seen the memo, leading to media speculation that the Defense Department was being sidelined. The secretary quashed those rumors during an Oct. 8 press conference with NATO Secretary-General George Robertson in Colorado Springs, Colo.
Rumsfeld explained that he simply hadn't seen the memo because the issue was being handled at a lower level, and he implied he has more important issues to worry about.
"I think, with the Chicago Cubs in the playoffs and what's going on in California, one could find something more important than (worrying about that memo)," Rumsfeld, a Chicago native, said as he jokingly alluded to the Cubs' quest for their first World Series baseball championship since 1908 and the California gubernatorial recall election.
"I just am really quite surprised about all of this frufrah about this memo," he said.
Moving beyond the issue of the memo's delivery, Rumsfeld also commented on its message. He noted that the NSC's charter is to coordinate among federal agencies.
"The reality is that the National Security Council's responsibility is to do exactly what this one-page memo says they should do," he said.
As Iraq becomes more secure and the focus migrates toward political and economic improvements, it's reasonable for other departments, such as the State Department, to gain more responsibility, Rumsfeld said, explaining the need for more NSC coordination among departments.
"It is not a problem or an issue," he said.


text:
SLC.edu / Graduate Catalogue / Writing / 2014-2015
Shaping the Novel
This workshop is for those students who hope to undertake writing a novel. It will involve a good deal of reading and discussion of possible structures and strategies for a novel. The reading part of the workshop will focus on reading and breaking down form and character development in the novel. The writing begins at the beginning—time spent exploring possible entry points into a novel, moving around in voice, character, point of view, and image patterning. Students will try multiple opening chapters. In fact, there will be a good deal of trying and retrying, considering and reconsidering character, plot, tone, and sentence making.
MFA Writing Program courses
- Articulations of Intimacy and Unmapped Syllable: Poetry and Prose as a Landscape of Pysche
- Colloquium
- Fiction Workshop
- Fiction Workshop
- Fiction Workshop
- Fiction Workshop
- How Does This American Life Do What They Do?-A Narrative Writing for Radio Course
- Nonfiction Workshop
- Not all white, not all men, all good writers
- Poetry Workshop
- Poetry Workshop
- Poetry Workshop: Find Me A Body From Which My Soul Can Sing
- Shaping the Novel
- Studies in Form
- The Hidden Lives of Poems
- The Nature and Purpose of Drama
- Workshop in Creative Nonfiction
- Writing for Magazines
- Writing for the Screen
- Writing With Wit


text:
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Connecticut Postings
Connecticut Post newsroom blog
Posts by Author
Friendly bunny in need of new home
Meet Oreo. This little gal was found in the parking lot of the Ansonia Nature Center recently. She is far too people-friendly to be left out in the wild. If you would like to adopt this furry ball of cuteness, please contact Donna or Ali at the Nature Center; 203-736-1053. [Read More]
Fatal motorcycle crash in Derby
Police investigate the scene of a fatal motorcycle accident on Derby Avenue near Mansfield Street Tuesday evening around 11:30 pm. more info [Read More]
Bees abound at apple picking
Bees love apples as witnessed today at both Beardsley Cider Mill and Orchard and the cider celebration in New Canaan. [Read More]


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"It's great," Robb said. "All of these people are showing support for freedom of speech because that's what this all boils down to."
These folks are full of it. If they really are supporters of free speech, then they should boycott Chik-fil-A for the company's attempt to squash this guy's freedom of speech.
Does that plan include a service road? Just wondering. That is what they have along Route 17 in Bergen county.
The phones come in handy in a variety of ways. For instance, educators say students can use them to text their teacher when they don't understand a concept.
"What the teacher can say is, 'Does everybody understand where we are?' and without fear of embarrassment from their friends, they can text in 'no' or "can you clarify?'" Smith explains.
Wow, students would rather fail than raise their hand and ask a question?
Are kids that introverted they can't use their voices to communicate?
So your expectations of environmental quality is to have to stay indoors until a danger passes? And the word communist went out in the 80s. Unless you hold on to that dusty old word for the Chinese who are eating our lunch in the world of capitalism. And "this person" did just what you wondered aloud, she posted an editorial for the public to read.
Go ahead and keep making things up. Health care costs have been skyrocketing for the last 15 years. But you can't help but blame the ACA for somehow being the culprit.
Not to mention the lame lighting. It looks like some low-budget college game on television.
The comments bemoaning the law against driving while using a cell phone are lame. You sound like small children looking to point out other wrongs done while driving instead of accepting the idea that you might not be able to blurt out your thoughts while driving. Pull over and have you conversation. Don't put others at risk for your selfish behavior.
The governor forgets that a family moving into a home in a top school district often will face a mountain of property taxes. Roll back the property taxes and he might have a good idea, otherwise, it's just another photo-op.
Christie said earlier this week that surveillance undertaken without probable cause is not inherently wrong and must be considered on a case-by-case basis.
Anyone who was a state Attorney General and says such a thing should be force-fed the Constitution until they understand the ramifications of spying on U.S. citizens.
I would like to know who built this building since it is only 21 years old and has multiple problems. Seems like there was a friends and family plan involved.
It isn't about patients getting contraception. It is about employees of the hospitals and schools getting contraception through their employer-based insurance.
I lived in Pennsylvania for a long time. Volunteer Firemen, had to take bulk waste to county dump miles away from my house. The police officers were not paid any where near what they are paid here in NJ.
O'Toole noted that when former Gov. Christine Todd Whitman, also a Republican, cut income taxes in the 1990s, overall income tax revenue increased as the economy expanded, incomes rose and jobs were created.
Wow, so Whitmans' tax cut grew the economy of New Jersey as well as all the other states was quite a feat. I guess the fact that the economy overall in the U.S. was growing had nothing whatsoever to do with the sunny report by State Sen. Kevin O'Toole
I would have loved having these "targets" as a kid. Especially from a rooftop. Snowballs, rocks, anything to hit a moving target like these idiots.
One word for this town: Bulldozer
The Governor is too lazy to govern. He is afraid if he has to pass or veto this bill, he will lose valuable voters in the future. Guess he can't make the tough decisions while he complains about the President not doing so.
I guess you think America second.
Cost wasn't the reason, it was achievement.
Cops are the worst offenders of driving while talking on the cell phone.
You can include all those contractors calling around to their clients while they drive.


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For Keep the Tail Wagging, I'm always being introduced to new and cool dog products and I've been trying to find a way to introduce these products to you and I decided that a weekly or bi-monthly feature would be awesome. Some of the below dog products were sent to me as a gift and others I purchased to try out and LOVED them. I am using affiliate links, because the money I make from them help me keep my site going.
Sleeping With The Beast, Dale Ryan
I received this book in January and it was a pleasure to read and inspired my idea to write a dog book of my own. What I love about Sleeping With the Beast is that it has the feel of a very nice photo book. We've had this on our coffee table since it arrived and it's a nice addition to our dog home. Dale Ryan created a book that invites us into his home of humans and five dogs (FIVE) and shares what it's like to live in a multi-dog household and reminds us that dogs aren't just cool accessories, but living, feeling, and intelligent creatures who deserve our respect and love.
I'm just happy to finally have a book in our home that celebrates dogs. Too often I receive books that are written by dog lovers, but leave me feeling sad. This one is a book I love to pick up and flip through, because I can relate and I just love it. I'm thankful that I was chosen as a person to receive this cool gift. Sleeping With the Beast is also available for the Kindle: Sleeping With The Beast, Kindle Edition
Troff Dog Hydration Non-Spill Pouch
Another great gift from someone I connected with on LinkedIn. With three herding breed mixes in our home, getting them out and exercised is a priority for us. One issue that we've been addressed with is keeping our dogs hydrated. When we go to the beach, the dogs will drink the salt water if we don't have water handy for them. Going on hikes or walking trails leaves us without access to water, because there aren't handy water fountains stationed at each mile marker. Carrying water bottles is an option, but they're heavy and we waste a lot of water if they drink from the bottle or we have to remember to carry a bowl for them too.
That's where the Troff reusable hydration pouch comes in; this is a fantastic invention. I'll admit that when I first heard about it, I thought that it wasn't that big of a deal, but when we received it we got excited and now we're looking forward to our next hike with the dogs. The pouches are reusable, they can be frozen the night before a hike (or hot day), they're compact and easy to store, and their green for those of us who environmental conscious. What I love about them is that they're no spill. When we use water bottles, half the water ends up on the ground, not with these.
You can learn more on TroffPouch.com.
PlaqClnz Daily Treatment Gel, a 1 Step Oral Cleansing without Brushing
When I saw the plaque on our cats' teeth, I wanted to try something before scheduling them for a teeth cleaning. I purchased PlaqClnz on Amazon. This taste-free gel is going to help me keep our pets' teeth clean. The bottle says that it's taste-free, I don't know how true that it is. The cats weren't so happy with me wiping this on their gums, but I'm happy to give it a shot, because I do know that dental care is important for both dogs and cats.
A few days after using the gel on our cats teeth and feeding them Feline Greenies Dental Treats, I was shocked to see that the plaque (it was crazy heavy) was chipping away from their teeth. Wow! This stuff works!
And an interesting product that we received for review (as a gift) on our blog is the Yaff Bar, a bar that we can share with our dogs. When our dogs heard the crinkling of a package being opened, they came running into the kitchen and obediently sat down for their treat. There was a lot of sniffing. Rodrigo took his piece to another room; he likes to check out new things in private. He did return for another try. Blue tried it, but wasn't sure; but he tried another taste too. Sydney loved it.
Just like some health bars I've tried, it's sticky and Rodrigo and Blue weren't prepared for the texture; Sydney is a little more adventuresome. I'd take them on a hike or long walk along with the Troff pouch – a light weight snack to keep our dogs energized when we're away from home.
What I like most are the ingredients – very natural, no refined sugar, and each bar is under 300 calories, which is perfect because we split the bar between our three dogs.
If you've discovered a cool product for your dog, please tell me about it. I'm always looking for something cool to check out.


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Ohio Means Jobs and Ohio Means Internships: The 2012 STEMM Scholarship Showcase at COSI was a huge success! The Ohio Board of Regents recognized all Choose Ohio First Scholarship recipients.
This program, funded by the Ohio Board of Regents, is a collaboration among the Fenn College of Engineering, the College of Sciences and Health Professions and partner institutions Baldwin Wallace University and Ursuline College.
Engineering Across the Pipeline focuses on increasing the number of engineering professionals in Northeast Ohio by providing a career pathway to students who already have shown an interest and ability in physics, biology, chemistry and mathematics at the undergraduate level.
The program provides qualified students with early and convenient access to Engineering Master's degree programs. It facilitates the transition from Sciences, Mathematics and Undergraduate Engineering programs into Graduate programs in Engineering disciplines by coordinating undergraduate curricula.
Engineering Across the Pipeline an important initiative that links the CSU engineering college and local liberal arts institutions in harmony with the STEMM – Science, Technology, Engineering, Mathematics and Medicine - priorities strongly endorsed by the Ohio Board of Regents.
Who can apply?
- Cleveland State University, Baldwin-Wallace or Ursuline College student enrolled Fall 2012
- U.S. citizen or permanent resident, Ohio resident
- Junior or Senior undergraduate student, graduate student or post baccalaureate student
- STEMM (Science, Technology, Engineering, Mathematics and Medicine) major applying, or intending to apply, to a graduate program in engineering at Cleveland State University.
- GPA of 3.0 or higher
- Graduate students with a GPA lower than 3.0 should submit results from a recent [not older than 2 years] Graduate Records Examination (GRE, www.gre.org ) to be eligible.
- Commitment to Choose Ohio First Scholarship Program requirements
- Current FAFSA on file with Financial Aid
- Students on full scholarships are NOT eligible.
How do I apply?
- Complete an application form
- Include copy of transcripts to date (unofficial is OK!)
- Include a one-page essay describing how your past achievements, present study plans and future goals fit within the Choose Ohio First Program.
- DEADLINE: April 30
- Submit to Dr. Jorge E. Gatica, Fenn College of Engineering, CSU, Stillwell Hall Room 104 or email email@example.com
For more information, contact Dr. Jorge E. Gatica
Phone: 216-523-7274
Email: firstname.lastname@example.com
All students are encouraged to stay in touch with the Ohio Board of Regents by liking us on Facebook and following us on Twitter
Ohio Means Jobs and Ohio Means Internships
Ohio Means Jobs has announced a phone application that will give Ohioans access to tens of thousands of job openings and allow users to search, save and even apply for jobs from their iPhone, iPad or Android.
Ohio Means Internships has also been launched. The Ohio Means Internships website will promote awareness of Ohio higher education internship opportunities and will provide information useful during students' educational planning.


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The Best Exotic Marigold Hotel by Deborah Moggach
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Vote For The Women's Soccer Fan's Choice Player of Year!
Related Links
For the fourth straight season, fans of America East women's soccer can voice their
opinion on who the best player in the conference is with voting taking place on the America East Facebook page for the first time.
The nominees are:
Rebecca Lee, Albany
Connie Gormley, Binghamton
Jessica Luscinski, Boston U.
Caitlin Alves, Hartford
Carolyne Nellis, Maine
Rachel McKee, UMBC
Kelly Mooney, New Hampshire
Sa'sha Kershaw, Stony Brook
Alexandra Dezenzo, Vermont
Voting for the 2011 America East Women's Soccer Fans' Choice Player of the Year will go until 12 p.m. on Tuesday, Oct. 25. The winner will be announced that afternoon via release at AmericaEast.com.


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Brazilian playmaker Philippe Coutinho has been assured by a compatriot that missing out on the World Cup this summer would not be a decisive influence on his international career.
The 21-year-old has proven a sublime performer since joining Liverpool in January 2013, prompting and creating from an advanced midfield position within Brendan Rodgers' team.
A look at his international statistics show just one senior appearance for the South American giants, however, and that occurred in a friendly more than three years ago.
But Lucas Leiva, who has recently re-established himself within Luiz Felipe Scolari's squad, regularly speaks to his younger colleague about retaining a long-term vision.
"It shows just how difficult it is to be in that squad," the No.21 told the Liverpool Echo. "I always speak about it with Philippe.
"Of course he's desperate to be there but he's still very young. He will have three or four World Cups ahead in his career.
"I tell him I am sure he will be a very successful player for Brazil one day. I know he's got all the skills and qualities to be there.
"I want him to be in the squad as well but he just needs to be patient and keep doing what he's done for Liverpool.
"If he's doing well for Liverpool then at some point he will have his chance."
Tagged: Coutinho , Philippe Coutinho , brazil , lucas , lucas leiva
Submit your views in the box below. Alternatively, you can debate these issues with fellow fans on our Message Boards or blog about them on The Kop
The views expressed here are not those of Liverpool Football Club (read more)


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Through innovation and new development, Kiddy Car Seats are getting safer. From the ORIGINAL KIDDY PROTECTION SHIELD, to the KIDDY SHOCK ABSORBER and the use of high-tech materials, Kiddy is a step above the rest. We are continually crowned test winners at the Stiftung Warentest, the German independent testing organization. German's would not buy a car seat without this honor.
Kiddy seats make children and adults happy. Every aspect of each design from the shape, the fabric, the fitting and accessories combine to make traveling by car as enjoyable and safe as possible.
The ease of placing your child in and out of the seat and the quick adjustment and lightweight design, let parents and grandparents relax with their children regardless of whose car they use.


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Sir Joseph Whitworth, Baronet
- Article
- Web sites
British engineer
External Web sites
Britannica Web sites
Articles from Britannica encyclopedias for elementary and high school students.
- Sir Joseph Whitworth - Student Encyclopedia (Ages 11 and up)
(1803-87). English mechanical engineer Joseph Whitworth was born in Stockport, Cheshire, England; began career as mechanic for various Manchester machine manufacturers; 1825 went to London; 1833 opened his own tool shop in Manchester; by 1851 his machine tools had become internationally known for their accuracy and quality; had exhibited his screw cutting lathes, his planing, drilling, slotting, and shaping machines, and his millionth-part measuring machine; did pioneering work in ordnance; helped found chair of engineering and laboratories at Owens College, Manchester; in 1868 established the Whitworth scholarships; in 1869 was created a baronet.


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Appearances for men have become increasingly important in recent years. No longer does a simple foam lather and the burn of an aftershave do the job. MensGroom has put together the optimal line of products to take care of everything for every man. The six product lineup from MensGroom will set you apart from the average male and to help introduce this great line of products Splash Magazines Worldwide and MensGroom are giving three lucky readers a chance to try out MensGroom
Los Angeles is full of hot spots this weekend and Splash Magazines Worldwide has put together a few of the best events that you can't miss
The mojito almost more so than any other cocktail seems to get scrutinized in how it is made, where it is made and the fact that most people always feel that their favorite mojito can't be compared to. With National Mojito Day being celebrated on July 11th, Splash Magazines Worldwide decided to share a couple of mojito recipes that are sure to impress even the finickiest mojito drinker
Duke's Waikiki is one of those restaurants that goes far beyond the food. It lets you feel a little history as well as experiencing what is behind the name Duke's. Being hailed as Hawaii's official "Ambassador of Aloha" is a big billing, but one that was fitting of Duke Kahanamoku. Duke's Waikiki takes on all that Duke was, you not only get a sense of his historical significance in surfing, but also all that he meant as a human being and that all translates into the one restaurant that you must experience while in Waikiki
Summertime is all about parties and if you are going to host one yourself you are going to want to do it right and make it memorable. The one thing that can make your party different than everyone other event this summer is the cocktails that you serve. To make sure your drinks are a hit, Splash Magazines Worldwide has put together some tasty cocktail recipes that will impress any guest
With summer upon us you might be looking for a little something extra in your drink or something new to kick start your workout to get ready for the beach, XYIENCE recently unveiled its new line of non-carbonated Xenergy + beverages. Xenergy + is a drink that will give you energy, but is unlike any other energy drink on the market
For any fitness enthusiast TheFitExpo is always one of the highlights of the year and you can bet the fitness buffs will be lined up early this weekend in Santa Clara. TheFitExpo will be taking place on June 29th and 30th at the Santa Clara Convention Center. TheFitExpo will feature over 150 exhibits, meaning if you are looking for it, it will be here
A weekend that will climax with the BET Awards on Sunday night is filled with plenty of other events to fill your weekend. Splash Magazines Worldwide has put together a list of some of the best events for you to attend this upcoming weekend
What is the sign that usually lets you know that summer is upon us? It is seeing everyone busting out their shorts and sunscreen to combat the heat and sun. No one wants to be seen in the same shorts that everyone has on, creativity and orginality are what sets people apart today and Gap decided to give a helping hand to get people started. Wednesday night Gap paired with fashion blogger Jenni Radosevich of I Spy DIY to kick off the beginning of summer but working with guests to personalize their Gap 1969 Shorts at Eveleigh Restaurant in West Hollywood
Las Vegas has always been known for gambling and a nightlife experience that turns the night into sunrise. In recent years the hottest trend in Las Vegas has become the daytime party, leaving you with a dilemma, the amazing night clubs of Vegas or the wild sun filled pool parties. Thanks to the inaugural On the Rocks Las Vegas, you can enjoy the best of both worlds, as long as you can keep your eyes open
Reinventing your restaurant when you are already hugely successful and well known is a task few would undertake. Leave it to Knight to have the fearlessness to attempt this. Recently knighted Chef-Owner Bruno Seratoto decided that revamping the menu of the Anaheim White House was the path he was called to take. Taking on the challenge of turning his restaurant into an Italian Steakhouse brought out the creative juices in Chef Bruno and what he created was a unique that is unlike any other in Southern California
bai5 already boasts a lineup of some of the most creative, flavorful and healthy drinks on the market and they just recently introduced the latest bai 5 flavor sensation, the newly unveiled Molokai Coconut
If you are not going to make it to Las Vegas this weekend to experience Electric Daisy Carnival, this Saturday, June 22nd, sbe and Insomniac Events will be bringing a little of the EDC experience to Los Angeles with a performance by Armin van Buuren. Following his appearance at the festival in Las Vegas, Armin will make his way to sbe's Create Nightclub
The Baja Shrimp menu was such a hit that El Pollo Loco had to come up with a new ingredient that could possibly top the shrimp. Not an easy task but El Pollo Loco looks to have a winner as they are rolling out their new Pork Carnitas entrees that will be served up in the Taco Trio, Burrito and Stuffed Quesadilla. To help introduce readers to the new Pork Carnitas menu, Splash Magazines Worldwide is awarding one lucky reader a certificate to their choice of one of these items in an El Pollo Loco combo meal
Summer season means being outside more often and with the sun, sweat and everything else in the air that can mean wear and tear on your face. M3K Beauty is the answer to keep your face clean and healthy with products for men and women. Two lucky readers are each going to win a package that includes for her Bare Faced and Fabulous Face Wash/Toner and for him Dirty Boy for Fabulous Men Face Wash
Summer is closing in and that means more time outside taking in the sun, hitting the beach and laying poolside. Who can argue with vacations, long weekends and the fun that amps up as the temperature rises. But with all of those outdoor activities, making sure that your skin is protected should be the first thing on your to-do list. While you likely have sunscreen in your beach bag, you do need to realize that not all sunscreens are created equally
Memorial Day Weekend always signifies the kickoff of summertime and pool season in Las Vegas and with so many choices this weekend, you better have rested up during the week, because this is one weekend that sleep will be last on your list of things to do. Splash Magazines Worldwide has put together a list of some of the best places to spend you Memorial Day weekend in Las Vegas
If you are looking for that unique and creative shirt that will set you apart from the crowd G Wear has jumped into the fashion scene with their eco-friendly fashion brand that uses recycled vintage t's to create one-of-a-kind tops designed for active lifestyles. To help introduce our readers to this amazing line from G Wear, Splash Magazines and G Wear have paired up to give one lucky reader their choice of a shirt from the G Wear website
Father's Day is almost here and instead of getting dad the same old tired gifts, how about giving him something he will really enjoy this year. Almost every dad has a sweet tooth and you will not find anything more likely to satisfy that need than some of the tasty cookies from Cookie Daddy. To help celebrate Father's Day this year Cookie Daddy and Splash Magazines Worldwide are going to give two lucky readers one dozen Oatmeal Fruit and Nut cookies packaged in a beautiful gold box with ribbons
The Sunday that lets you know you know summer is about to kickoff is this weekend as XIV Summer Sessions LA returns to The Colony on May 19th. This party takes you from west coast sunshine to the sunset on Sunset before finally taking the party for the rest of the night to HYDE Lounge on Sunset Boulevard
At some point the vacation has gone from a chance to relax, unwind and recharge your batteries to trying to pack something into every second of everyday to make the most out of your so called vacation. If you are looking to get back that real vacation and want to get back to that relaxed and carefree vacation, a leisurely stay at Hofsas House in Carmel-by-the-Sea is for you. They have created the perfect atmosphere that will let you enjoy your vacation, whatever you want it to be
The dream of any true beer connoisseur is to at some point brew your own beer, creating a flavor that comes from your imagination. Most of these dreams end with a beer kit that gathers dust, but Fireman's Brew turned their dream into a microbrewery sensation, as their three flavors are not only gaining notoriety in California, but they have also expanded into several more states recently. This fast and furious grown has propelled Fireman's Brew to announce that they are moving forward with a private offering of stock
El Pollo Loco is known for their unrivaled fire grilled chicken chain has given shrimp lovers a reason to rejoice as they have rolled out three new Baja Shrimp entrees. To help introduce readers to the new Baja Shrimp menu, Splash Magazines Worldwide is awarding one lucky reader three certificates to try out each menu item
Trying to find that perfect Mother's Day gift is always a challenge, so this year take her to the one place that she can find anything that her heart desires, Las Vegas. Once you have her there, The Shops at Crystals will make her feel like this day is truly about her with all of the amazing gifts that they have to offer
The 18th Annual Taste of Anaheim will bring off of the fun and flavor that has defined it over the years to The Shops at Anaheim Gardenwalk on May 9th. This annual event brings together some of the finest restaurants in Anaheim as well as some great bands who create a party atmosphere all night long. If you live in Orange County and want to visit just one "Taste of" event this year, Taste of Anaheim should be the one
The sunshine is starting to make its way through the clouds and that mean summer is not far behind and with that comes all of the vacations, long weekends and family get togethers and you don't want to miss a single memory. To make sure you can download all those great memories and they will look just as vivid as the moment you experienced that memory, Polaroid has come out with the iF045 14-Megapixel Waterproof Dual Screen Digital Camera. This easy to use camera will not only take those great pictures, but it won't put a dent in that vacation budget
Cinco de Mayo is always one of the biggest party days of the year and this year is no excecption. Los Angeles is home to some of the best Cinco de Mayo events in the country, so Splash Magazines Worldwide has put together a few of our favorites as well as some great cocktail recipes
Cirque du Soleil: Worlds Away DVD Giveaway
Four days of Las Vegas, food and wine calls for the highest of expectations. Vegas Uncork'd by Bon Appétit always delivers and this year appears that they will do the same. The only question for you is will you be there and can you still get tickets. The events are filling up fast so we have put together a list of the still remaining and tasty events you can attend this year
To help raise money for friends and family most affected by the tragic events that occurred in Boston, on Tuesday, April 23rd from 7 p.m. to 10 p.m., Rock & Reilly's Irish Pub on Sunset Strip is throwing a Rally for Boston


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Posted at: 08/15/2013 7:25 AM
By: Nikki Ibarra, KOB Eyewitness News 4
About 1 in 8 preschoolers are obese in the United States, but a new federal report said New Mexico is one of the few states where the epidemic is going down.
New Mexico is one of 19 states where obesity among low-income preschoolers has declined.
New Mexico joins states like California, Idaho and Washington. Some of the states were obesity is increasing include, Pennsylvania, Tennessee and Colorado.
The CDC suggests ways for parents to help promote a healthy lifestyle for your child, like starting out with a healthy breakfast and walking to school and to the park.