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An implantable stimulation device and associated method allow for the selection of an inter-ventricular or inter-atrial delay which results in optimal hemodynamic benefit for the patient. The stimulation device monitors and measures the width of the QRS complex, or a P wave in response to different interpulse delays during biventricular or biatrial stimulation. The stimulation device then selects the optimal interpulse delay that results in the minimum QRS or P width. The present method allows for the adaptive adjustment of the interpulse interval over time, caused for example, by changes in disease state, medical therapy, physical activity or other factors may cause changes in the electromechanical response of the heart.
1. An optimization method for use in a multi-chamber cardiac stimulation device, comprising:
setting a baseline interpulse delay between a stimulation of a first cardiac chamber on a right side of a heart and a stimulation of a second corresponding cardiac chamber on left side of the heart;
delivering a first stimulation to the first cardiac chamber;
delivering a second stimulation to the second cardiac chamber according to the baseline interpulse delay;
measuring a baseline width of a depolarization event associated with the baseline interpulse delay, in response to the first and second stimulations; and
iteratively determining an optimal interpulse delay that results in an optimum width of the depolarization event.
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19. A multi-chamber cardiac stimulation device comprising:
a plurality of electrodes;
a sense system coupled to a plurality of electrodes, the sense system to sense a cardiac signal in a first cardiac chamber on a right of a heart and a second cardiac chamber on a left side of the heart;
a pulse generator, connected to at least some of the plurality of electrodes, to generate stimulation energy;
wherein at least some of the plurality of electrodes selectively deliver stimulation energy to any one or more of the first or second cardiac chambers; and
a controller, connected to the pulse generator, that sets a predetermined baseline interpulse delay for stimulation energy delivered between the first cardiac chamber and the second cardiac chamber, that measures a baseline width of a depolarization event associated with the predetermined baseline interpulse delay, in response to the stimulation energy delivered between the first cardiac chamber and the second cardiac chamber, and that iteratively determines an optimal interpulse delay which results in an optimum width of the depolarization event.
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25. A bi-chamber cardiac stimulation device comprising:
a plurality of electrodes;
a sense system coupled to the plurality of electrodes, the sense system to sense a cardiac signal in a cardiac chamber on a right of a heart and a second corresponding cardiac chamber on a left side of the heart;
means for generating stimulation energy;
means for selectively delivering the stimulation energy to any one or more of the first or second cardiac chambers;
a controller coupled to the means for generating stimulation energy, the controller to set a predetermined baseline interpulse delay between a stimulation of the first cardiac chamber and a stimulation of the second cardiac chamber;
means for measuring a baseline width of a depolarization event associated with the predetermined baseline interpulse delay, in response to the stimulation energy delivered between the first cardiac chamber and the second cardiac chamber; and
means for iteratively determining an optimal interpulse delay that results in a minimum width of the depolarization event.
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This invention relates generally to programmable cardiac stimulating devices. More specifically, the present invention is directed to an implantable stimulation device and associated method that allow for the selection of an inter-atrial or inter-ventricular stimulation delay which results in optimal hemodynamic benefit for the patient.
In the normal human heart, the sinus node, generally located near the junction of the superior vena cava and the right atrium, constitutes the primary natural pacemaker initiating rhythmic electrical excitation of the heart chambers. The cardiac impulse arising from the sinus node is transmitted to the two atrial chambers, causing a depolarization known as a P-wave and the resulting atrial chamber contractions. The excitation pulse is further transmitted to and through the ventricles via the atrioventricular (A-V) node and a ventricular conduction system causing a depolarization known as an R-wave, also referred to as the QRS complex, and the resulting ventricular chamber contractions. Disruption of this natural pacemaking and conduction system as a result of aging or disease can be successfully treated by artificial cardiac pacing using implantable cardiac stimulation devices, including pacemakers and implantable defibrillators, which deliver rhythmic electrical pulses or other anti-arrhythmia therapies to the heart at a desired energy and rate. One or more heart chambers may be electrically stimulated depending on the location and severity of the conduction disorder.
Cardiac pacemakers conventionally stimulate a heart chamber by applying current pulses to cardiac tissues via two electrodes, a cathode and an anode. Standard pacing leads are available in either of two configurations, unipolar leads or bipolar leads. A unipolar lead has a single cathodic electrode with the anode being the pacemaker housing. A bipolar lead possesses two electrodes located 1 to 2 cm apart.
A single-chamber pacemaker delivers pacing pulses to one chamber of the heart, either one atrium or one ventricle, via either a unipolar or bipolar lead. Single-chamber pacemakers can operate in either a triggered mode or a demand mode. In a triggered mode, a stimulation pulse is delivered to the desired heart chamber at the end of a defined time-out interval to cause depolarization of the heart tissue (myocardium) and its contraction. The stimulating pulse must be of sufficient energy to cause depolarization of the heart chamber, a condition known as "capture." The lowest pulse energy required to achieve capture is termed "threshold." The pacemaker also delivers a stimulation pulse in response to a sensed event arising from that chamber when operating in a triggered mode.
When operating in a demand mode, sensing and detection circuitry allow for the pacemaker to detect if an intrinsic cardiac depolarization, either an R-wave or a P-wave, has occurred within the defined time-out interval. If an intrinsic depolarization is not detected, a pacing pulse is delivered at the end of the time-out interval. However, if an intrinsic depolarization is detected, the pacing pulse output is inhibited to allow the natural heart rhythm to preside. The difference between a triggered and demand mode of operation is the response of the pacemaker to a detected native event.
Dual chamber pacemakers are now commonly available and can provide either trigger or demand type pacing in both an atrial chamber and a ventricular chamber, typically the right atrium and the right ventricle. Both unipolar or bipolar dual chamber pacemakers exist in which a unipolar or bipolar lead extends from an atrial channel of the dual chamber device to the desired atrium (e.g. the right atrium), and a separate unipolar or bipolar lead extends from a ventricular channel to the corresponding ventricle (e.g. the right ventricle). In dual chamber, demand-type pacemakers, commonly referred to as DDD pacemakers, each atrial and ventricular channel includes a sense amplifier to detect cardiac activity in the respective chamber and an output circuit for delivering stimulation pulses to the respective chamber. If an intrinsic atrial depolarization signal (a P-wave) is not detected by the atrial channel, a stimulating pulse will be delivered to depolarize the atrium and cause contraction. Following either a detected P-wave or an atrial pacing pulse, the ventricular channel attempts to detect a depolarization signal in the ventricle. If no R-wave is detected within a defined atrial-ventricular interval (AV interval or AV delay), a stimulation pulse is delivered to the ventricle to cause ventricular contraction. In this way, rhythmic dual chamber pacing is achieved by coordinating the delivery of ventricular output in response to a sensed or paced atrial event.
Over the years, dual-chamber stimulation has been found to provide clinical benefit to patients suffering from congestive heart failure and other cardiac abnormalities. It has also been found that the optimization of timing intervals during stimulation may be critical in providing hemodynamic benefit. Numerous schemes for optimizing the AV delay in order to improve cardiac function have been proposed. Reference is made, for example, to U.S. Pat. No. 5,540,727 to Tockman et al; U.S. Pat. No. 5,584,868 to Salo et al.; and U.S. Pat. No. 6,044,298 to Salo et al. Such schemes often incorporate sensors designed to assess cardiac function by monitoring blood pressure, pulse pressure, cardiac impedance, cardiac wall motion, heart sounds and other similar parameters.
In patients suffering from congestive heart failure, dilation of the heart can alter normal conduction pathways. Conduction through the heart chambers can become slower or inter-atrial or inter-ventricular conduction delays can develop. Thus, synchronizing the right and left heart chambers during bi-ventricular, bi-atrial, or multi-chamber stimulation may be vital to improving cardiac output. Mounting clinical evidence supports the evolution of more complex cardiac stimulating devices capable of stimulating three or even all four heart chambers to stabilize arrhythmias or to re-synchronize heart chamber contractions (see Cazeau S. et al., "Four chamber pacing in dilated cardiomyopathy," Pacing Clin. Electrophsyiol 1994 17(11 Pt 2):1974-9).
One limitation of some multi-chamber stimulation systems is that stimulation of left and right heart chambers is simultaneous. Simultaneous contraction of both left and right chambers is not physiological and is not always necessary or desirable in a given patient. Proposed systems provide a delay between the stimulation of opposing heart chambers. Reference is made to U.S. Pat. No. 5,720,768 to Verboven-Nelissen; U.S. Pat. No. 5,902,324 to Thompson et al.; and U.S. Pat. No. 6,122,545 to Struble et al. While programmable inter-ventricular or inter-atrial delay intervals have been proposed, the selection of such intervals may be arbitrary.
Ideally, a direct measure of cardiac hemodynamics would be the best way to monitor the benefit of stimulation and provide feedback for making adjustments to stimulation timing intervals. However, direct measures such as left ventricular ejection fraction are impossible to perform chronically at the present time. Methods proposed previously for optimizing AV delay during dual chamber stimulation directed at maximizing hemodynamic performance are limited by the need for additional sensors and more complex software algorithms and may not apply to the optimization of inter-atrial timing or inter-ventricular timing.
Therefore, there remains an unmet need for a multi-chamber cardiac stimulation device that allows for the selection of an inter-atrial or inter-ventricular delay that results in optimal hemodynamic benefit for the patient. It would thus be desirable to provide automatic optimization of the delay between left and right heart chamber stimulation that could be adaptive over time, thereby adjusting the stimulation delay as needed with changes in disease state. It would also be desirable to provide such automatic, adaptive adjustment of this stimulation delay without requiring additional sensors or complex hardware.
The present invention addresses these needs by providing a method for optimizing the ventricular (or atrial) interpulse delay, that is the time between left and right ventricular (or atrial) chamber pulse delivery, during biventricular (or biatrial) stimulation. The present invention advantageously measures the width of the QRS complex. Since a narrow QRS complex, that is a relatively short ventricular depolarization signal, generally implies a more uniform contraction of the right and left ventricles, a more uniform contraction is associated with a more effective hemodynamic performance of the cardiac stimulation device.
Conduction abnormalities that cause inter- or intra-ventricular conduction delays produce less synchronized contractions of the right and left ventricles that can be recognized by a widened QRS complex. Thus, by monitoring the QRS width in response to different interpulse delays during biventricular stimulation, the optimal interpulse delay setting that results in the minimum QRS width and presumably the most optimal hemodynamic benefit can be determined.
Thus, one feature of the present invention is a method for sensing and measuring the QRS width. Sensing the QRS complex may be done using the same electrodes used for stimulating the ventricles (near-field sensing), but preferably is done using electrodes that are not in direct contact with the ventricles (far-field sensing) in order to make a global measurement of the ventricular depolarization.
Another feature of the present invention is an algorithm that allows comparisons of the QRS width measured during biventricular stimulation at different interpulse delays. Preferably a convergent, iterative algorithm is used to identify the interpulse delay producing the minimum QRS width.
Yet another feature of the present invention is the adaptive adjustment of the interpulse interval over time. Since changes in disease state, medical therapy, physical activity or other factors may cause changes in the electromechanical response of the heart, the optimal interpulse interval may change over time. Therefore, the present invention includes periodic, automatic execution of the interpulse delay optimization algorithm so that the interpulse delay is automatically adjusted over time, as needed.
In still another embodiment of the invention, the width of P waves are measured during biatrial pulsing. An optimal interpulse delay is selected by determining the P wave having the minimum width, and selecting the associated interpulse delay that caused such P wave.
The various features of the present invention and the manner of attaining them will be described in greater detail with reference to the following description, claims, and drawings, wherein reference numerals are reused, where appropriate, to indicate a correspondence between the referenced items, and wherein:
FIG. 1 is a simplified, partly cutaway view illustrating an implantable stimulation device in electrical communication with at least three leads implanted into a patient's heart for delivering multi-chamber stimulation and shock therapy;
FIG. 2 is a functional block diagram of the multi-chamber implantable stimulation device of FIG. 1, illustrating the basic elements that provide cardioversion, defibrillation and/or pacing stimulation in four chambers of the heart;
FIG. 3 is a flow chart illustrating a high level overview of the operation of one embodiment of the present invention for automatically setting the optimal ventricular interpulse delay; and
FIG. 4 is a flow chart illustrating a more detailed description of the operation for automatically setting the optimal ventricular interpulse delay of FIG. 3.
The following description is of a best mode presently contemplated for practicing certain preferred embodiments of the present invention. This description is not to be taken in a limiting sense but is made merely for the purpose of describing the general principles of the invention.
As indicated above, the present invention relates to a method for optimizing the interpulse delay between stimulation of the right and left ventricles in order to maximize the hemodynamic benefit provided during biventricular or multi-chamber stimulation. The method of optimizing the interpulse delay is based on minimizing the width of the QRS complex as will be more fully described in conjunction with FIG. 4. The method described herein is intended for use in any cardiac stimulation device that is capable of delivering both right and left ventricular stimulations. One such device will now be described in conjunction with FIGS. 1 and 2.
FIG. 1 illustrates a stimulation device 10 in electrical communication with a patient's heart 12 by way of three leads 20, 24 and 30 suitable for delivering multi-chamber stimulation and shock therapy. To sense atrial cardiac signals and to provide right atrial chamber stimulation therapy, the stimulation device 10 is coupled to an implantable right atrial lead 20 having at least an atrial tip electrode 22, which typically is implanted in the patient's right atrial appendage.
To sense left atrial and ventricular cardiac signals and to provide left chamber pacing therapy, the stimulation device 10 is coupled to a "coronary sinus" lead 24 designed for placement in the "coronary sinus region" via the coronary sinus os for positioning a distal electrode adjacent to the left ventricle and additional electrode(s) adjacent to the left atrium. As used herein, the phrase "coronary sinus region" refers to the vasculature of the left ventricle, including any portion of the coronary sinus, great cardiac vein, left marginal vein, left posterior ventricular vein, middle cardiac vein, and/or small cardiac vein or any other cardiac vein accessible by the coronary sinus.
Accordingly, an exemplary coronary sinus lead 24 is designed to receive atrial and ventricular cardiac signals and to deliver left ventricular pacing therapy using at least a left ventricular tip electrode 26, left atrial pacing therapy using at least a left atrial ring electrode 27, and shocking therapy using at least a left atrial coil electrode 28. For a complete description of a coronary sinus lead, see U.S. patent application Ser. No. 09/457,277, filed Dec. 8, 1999, entitled "A Self-Anchoring, Steerable Coronary Sinus Lead" (Pianca et al.); and U.S. Pat. No. 5,466,254, entitled "Coronary Sinus Lead with Atrial Sensing Capability" (Helland), which patents are hereby incorporated herein by reference.
The stimulation device 10 is also shown in electrical communication with the patient's heart 12 by way of an implantable right ventricular lead 30 having, in this embodiment, a right ventricular tip electrode 32, a right ventricular ring electrode 34, a right ventricular (RV) coil electrode 36, and an SVC (superior vena cava) coil electrode 38. Typically, the right ventricular lead 30 is transvenously inserted into the heart 12 so as to place the right ventricular tip electrode 32 in the right ventricular apex so that the RV coil electrode 36 will be positioned in the right ventricle and the SVC coil electrode 38 will be positioned in the superior vena cava. Accordingly, the right ventricular lead 30 is capable of receiving cardiac signals, and delivering stimulation in the form of pacing and shock therapy to the right ventricle.
FIG. 2 illustrates a simplified block diagram of the multi-chamber implantable stimulation device 10, which is capable of treating both fast and slow arrhythmias with stimulation therapy, including cardioversion, defibrillation, and pacing stimulation. While a particular multi-chamber device is shown, this is for illustration purposes only, and one of skill in the art could readily duplicate, eliminate or disable the appropriate circuitry in any desired combination to provide a device capable of treating the appropriate chamber(s) with cardioversion, defibrillation and pacing stimulation.
The stimulation device 10 includes a housing 40 which is often referred to as "can", "case" or "case electrode", and which may be programmably selected to act as the return electrode for all "unipolar" modes. The housing 40 may further be used as a return electrode alone or in combination with one or more of the coil electrodes, 28, 36 and 38, for shocking purposes. The housing 40 further includes a connector (not shown) having a plurality of terminals, 42, 44, 46, 48, 52, 54, 56, and 58 (shown schematically and, for convenience, the names of the electrodes to which they are connected are shown next to the terminals). As such, to achieve right atrial sensing and pacing, the connector includes at least a right atrial tip terminal (AR TIP) 42 adapted for connection to the atrial tip electrode 22.
To achieve left chamber sensing, pacing and shocking, the connector includes at least a left ventricular tip terminal (VL TIP) 44, a left atrial ring terminal (AL RING) 46, and a left atrial shocking terminal (AL COIL) 48, which are adapted for connection to the left ventricular tip electrode 26, the left atrial tip electrode 27, and the left atrial coil electrode 28, respectively.
To support right chamber sensing, pacing and shocking, the connector further includes a right ventricular tip terminal (VR TIP) 52, a right ventricular ring terminal (VR RING) 54, a right ventricular shocking terminal (RV COIL) 56, and an SVC shocking terminal (SVC COIL) 58, which are adapted for connection to the right ventricular tip electrode 32, right ventricular ring electrode 34, the RV coil electrode 36, and the SVC coil electrode 38, respectively.
At the core of the stimulation device 10 is a programmable microcontroller 60 that controls the various modes of stimulation therapy. As is well known in the art, the microcontroller 60 typically includes a microprocessor, or equivalent control circuitry, designed specifically for controlling the delivery of stimulation therapy, and may further include RAM or ROM memory, logic and timing circuitry, state machine circuitry, and I/O circuitry. Typically, the microcontroller 60 includes the ability to process or monitor input signals (data) as controlled by a program code stored in a designated block of memory. The details of the design and operation of the microcontroller 60 are not critical to the present invention. Rather, any suitable microcontroller 60 may be used that carries out the functions described herein. The use of microprocessor-based control circuits for performing timing and data analysis functions are well known in the art.
As shown in FIG. 2, an atrial pulse generator 70 and a ventricular pulse generator 72 generate pacing stimulation pulses for delivery by the right atrial lead 20, the right ventricular lead 30, and/or the coronary sinus lead 24 via an electrode configuration switch 74. As used herein, the shape of the stimulation pulses is not limited to an exact square or rectangular shape, but may assume any one of a plurality of shapes which is adequate for the delivery of an energy packet or stimulus.
It is understood that in order to provide stimulation therapy in each of the four chambers of the heart, the atrial pulse generator 70 and the ventricular pulse generator 72 may include dedicated, independent pulse generators, multiplexed pulse generators, or shared pulse generators. The atrial pulse generator 70 and the ventricular pulse generator 72 are controlled by the microcontroller 60 via appropriate control signals 76 and 78, respectively, to trigger or inhibit the stimulation pulses.
The microcontroller 60 further includes timing control circuitry 79 which is used to control the timing of such stimulation pulses (e.g., pacing rate, atrio-ventricular (AV) delay, atrial interconduction (A—A) delay, or ventricular interconduction (V—V) delay, etc.) as well as to keep track of the timing of refractory periods, blanking intervals, noise detection windows, evoked response windows, alert intervals, marker channel timing, etc., which is well known in the art.
The switch 74 includes a plurality of switches for connecting the desired electrodes to the appropriate I/O circuits, thereby providing complete electrode programmability. Accordingly, the switch 74, in response to a control signal 80 from the microcontroller 60, determines the polarity of the stimulation pulses (e.g., unipolar, bipolar, combipolar, etc.) by selectively closing the appropriate combination of switches (not shown) as is known in the art.
Atrial sensing circuits 82 and ventricular sensing circuits 84 may also be selectively coupled to the right atrial lead 20, coronary sinus lead 24, and the right ventricular lead 30, through the switch 74 for detecting the presence of cardiac activity in each of the four chambers of the heart. Accordingly, the atrial (ATR. SENSE) and ventricular (VTR. SENSE) sensing circuits, 82 and 84, may include dedicated sense amplifiers, multiplexed amplifiers, or shared amplifiers. The switch 74 determines the "sensing polarity" of the cardiac signal by selectively closing the appropriate switches, as is also known in the art. In this way, the clinician may program the sensing polarity independent of the stimulation polarity.
In accordance with one embodiment of the present invention, far-field sensing of the QRS signal is preferred over near-field sensing. Thus, during the execution of the algorithm to be described below in which the QRS signal is measured, the desired electrode pair for sensing the QRS signal will be connected to the appropriate atrial or ventricular sensing circuit 82 or 84 through switch 74.
Each sensing circuit, 82 and 84, preferably employs one or more low power, precision amplifiers with programmable gain and/or automatic gain control, bandpass filtering, and a threshold detection circuit, as known in the art, to selectively sense the cardiac signal of interest. The automatic gain control enables the device 10 to deal effectively with the difficult problem of sensing the low amplitude signal characteristics of atrial or ventricular fibrillation.
The outputs of the atrial and ventricular sensing circuits, 82 and 84, are connected to the microcontroller 60 which, in turn, are able to trigger or inhibit the atrial and ventricular pulse generators, 70 and 72, respectively, in a demand fashion in response to the absence or presence of cardiac activity in the appropriate chambers of the heart. The sensing circuits, 82 and 84, in turn, receive control signals over signal lines, 86 and 88, from the microcontroller 60 for purposes of controlling the gain, threshold, polarization charge removal circuitry (not shown), and the timing of any blocking circuitry (not shown) coupled to the inputs of the sensing circuits, 82 and 86, as is known in the art.
For arrhythmia detection, the device 10 utilizes the atrial and ventricular sensing circuits, 82 and 84, to sense cardiac signals to determine whether a rhythm is physiologic or pathologic. As used herein "sensing" is reserved for the noting of an electrical signal, and "detection" is the processing of these sensed signals and noting the presence of an arrhythmia. The timing intervals between sensed events (e.g. P-waves, R-waves, and depolarization signals associated with fibrillation which are sometimes referred to as "F-waves" or "Fib-waves") are then classified by the microcontroller 60 by comparing them to a predefined rate zone limit (i.e., bradycardia, normal, low rate VT, high rate VT, and fibrillation rate zones) and various other characteristics (e.g. sudden onset, stability, physiologic sensors, and morphology, etc.) in order to determine the type of remedial therapy that is needed (e.g. bradycardia pacing, antitachycardia pacing, cardioversion shocks or defibrillation shocks, collectively referred to as "tiered therapy").
The stimulation device 10 additionally includes a power source, such as a battery 110 that provides operating power to all the circuits shown in FIG. 2. For the stimulation device 10, which employs shocking therapy, the battery 110 is preferably capable of operating at low current drains for long periods of time, and also be capable of providing high-current pulses (for capacitor charging) when the patient requires a shock pulse. The battery 110 must also preferably have a predictable discharge characteristic so that elective replacement time can be detected.
Cardiac signals are also applied to the inputs of an analog-to-digital (A/D) data acquisition system 90. The data acquisition system 90 is configured to acquire intracardiac electrogram signals, convert the raw analog data into digital signals, and store the digital signals for later processing and/or telemetric transmission to an external device 102. The data acquisition system 90 is coupled to the right atrial lead 20, the coronary sinus lead 24, and the right ventricular lead 30 through the switch bank 74 to sample cardiac signals across any pair of desired electrodes. In the present invention, the data acquisition system 90 will be used to collect and digitize the QRS portion of the intracardiac electrogram signal for the purpose of measuring the QRS duration or QRS width.
The microcontroller 60 is further coupled to a memory 94 by a suitable data/address bus 96, wherein the programmable operating parameters used by the microcontroller 60 are stored and modified, as required, in order to customize the operation of the stimulation device 10 to suit the needs of a particular patient. Such operating parameters define, for example, pacing pulse amplitude, pulse duration, electrode polarity, rate, sensitivity, automatic features, arrhythmia detection criteria, and the amplitude, waveshape and vector of each shocking pulse to be delivered to the patient's heart 12 within each respective tier of therapy. In the present invention, the memory 94 will be used to store QRS width data such that measurements made of the QRS width during biventricular stimulation delivered at different interpulse intervals can be compared. Microcontroller 60 controls the delivery of biventricular stimulation by ventricular pulse generator 72 according to the programmed interpulse interval stored in memory 94. Whenever the optimization algorithm included in the present invention is performed, the interpulse delay resulting in the minimum QRS width is determined and stored in memory 94 to be used thereafter in delivering biventricular stimulation.
Advantageously, the operating parameters of the stimulation device 10 may be non-invasively programmed into the memory 94 through a telemetry circuit 100 in telemetric communication with the external device 102, such as a programmer, transtelephonic transceiver, or a diagnostic system analyzer. The telemetry circuit 100 is activated by the microcontroller 60 by a control signal 106. The telemetry circuit 100 advantageously allows intracardiac electrograms and status information relating to the operation of the stimulation device 10 (as contained in the microcontroller 60 or memory 94) to be sent to the external device 102 through an established communication link 104.
In a preferred embodiment, the stimulation device 10 further includes a physiologic sensor 108, commonly referred to as a "rate-responsive" sensor because it is typically used to adjust pacing stimulation rate according to the exercise state of the patient. However, the physiological sensor 108 may further be used to detect changes in cardiac output, changes in the physiological condition of the heart, or diurnal changes in activity (e.g. detecting sleep and wake states). Accordingly, the microcontroller 60 responds by adjusting the various pacing parameters (such as rate, AV Delay, V—V Delay, etc.) at which the atrial and ventricular pulse generators, 70 and 72, generate stimulation pulses. Changes in activity as detected by physiological sensor 108 may be used by the present invention for triggering an algorithm that redetermines the optimal interpulse delay when both the right and left ventricles are stimulated.
While the physiologic sensor 108 is shown as being included within the stimulation device 10, it is to be understood that the physiologic sensor 108 may also be external to the stimulation device 10, yet still be implanted within or carried by the patient. A common type of rate responsive sensor is an activity sensor, such as an accelerometer or a piezoelectric crystal, which is mounted within the housing 40 of the stimulation device 10. Other types of physiologic sensors are also known, for example, sensors that sense the oxygen content of blood, pressure, cardiac output, ejection fraction, stroke volume, end diastolic volume, end systolic volume, respiration rate and/or minute ventilation, pH of blood, ventricular gradient, etc. However, any sensor may be used which is capable of sensing a physiological parameter that corresponds to the exercise state of the patient.
The stimulation device 10 further includes a magnet detection circuitry (not shown), coupled to the microcontroller 60. It is the purpose of the magnet detection circuitry to detect when a magnet is placed over the stimulation device 10, which magnet may be used by a clinician to perform various test functions of the stimulation device 10 and/or to signal the microcontroller 60 that an external programmer 102 is in place to receive or transmit data to the microcontroller 60 through the telemetry circuit 100.
As further shown in FIG. 2, the stimulation device 10 is shown as having an impedance measuring circuit 112 which is enabled by the microcontroller 60 by a control signal 114. Certain applications for an impedance measuring circuit 112 include, but are not limited to, lead impedance surveillance during the acute and chronic phases for proper lead positioning or dislodgment; detecting operable electrodes and automatically switching to an operable pair if dislodgment occurs; measuring respiration or minute ventilation; measuring thoracic impedance for determining shock thresholds; detecting when the device has been implanted; measuring stroke volume; and detecting the opening of the heart valves, etc. The impedance measuring circuit 112 is advantageously coupled to the switch 74 so that any desired electrode may be used.
In the case where the stimulation device 10 is intended to operate as an implantable cardioverter/defibrillator (ICD) device, it needs to detect the occurrence of an arrhythmia, and automatically apply an appropriate electrical shock therapy to the heart aimed at terminating the detected arrhythmia. To this end, the microcontroller 60 further controls a shocking circuit 116 by way of a control signal 118. The shocking circuit 116 generates shocking pulses of low (up to 0.5 Joules), moderate (0.5-10 Joules), or high energy (11 to 40 Joules), as controlled by the microcontroller 60. Such shocking pulses are applied to the patient's heart 12 through at least two shocking electrodes, and as shown in this embodiment, selected from the left atrial coil electrode 28, the RV coil electrode 36, and/or the SVC coil electrode 38 (FIG. 1). As noted above, the housing 40 may act as an active electrode in combination with the RV electrode 36, or as part of a split electrical vector using the SVC coil electrode 38 or the left atrial coil electrode 28 (i.e., using the RV electrode as a common electrode).
Cardioversion shocks are generally considered to be of low to moderate energy level (so as to minimize pain felt by the patient), and/or synchronized with an R-wave and/or pertaining to the treatment of tachycardia. Defibrillation shocks are generally of moderate to high energy level (i.e., corresponding to thresholds in the range of 5-40 Joules), delivered asynchronously (since R-waves may be too disorganized), and pertaining exclusively to the treatment of fibrillation. Accordingly, the microcontroller 60 is capable of controlling the synchronous or asynchronous delivery of the shocking pulses.
In FIG. 3, a flow chart is shown describing an overview of the operation and novel features implemented in one embodiment of the stimulation device 10. In this flow chart, and the flow chart of FIG. 4, the various algorithmic steps are summarized in individual "blocks". Such blocks describe specific actions or decisions that must be made or carried out as the algorithm proceeds. Where the microcontroller 60 (or its equivalent) is employed, the flow charts presented herein provide the basis for a "control program" that may be executed or used by such a microcontroller 60 (or its equivalent) to effectuate the desired control of the stimulation device 10. Those skilled in the art may readily write such a control program based on the flow charts and other descriptions presented herein.
The optimization methods or algorithms 200 and 300 of FIGS. 3 and 4, respectively are performed periodically, the frequency of which is preferably programmable. Since changes in the optimal interpulse delay are expected to occur over relatively long periods of time, such as hours, days, weeks, or months, the methods 200 and 300 do not need to be performed on a beat-by-beat basis. Therefore, the methods 200 and 300 may be performed once a day, for example when the patient is at rest. The methods 200 and 300 may also be performed on a periodic basis determined by a given number of heart cycles or a change in activity level as indicated by physiological sensor 108. The frequency which method 300 is performed may thus be tailored to individual patient need as determined by a medical practitioner.
Once microprocessor 60 initiates the optimization method 200 of FIG. 3, the next ventricular stimulation pulses are delivered at step 205 at the existing, programmed interpulse delay and according to the standard timing operation of device 10. At step 210, the device 10 monitors and measures a baseline QRS width, and at step 215, the device 10 sets a baseline interpulse delay between a stimulation of a first cardiac chamber on one side of a heart and a stimulation of a second cardiac chamber on another side of the heart.
At step 220, the device 10 delivers a first stimulation to the first cardiac chamber, and, at step 225, it further delivers a second stimulation to the second cardiac chamber after the baseline interpulse delay has transpired. At step 230, the device 10 measures a baseline width of an intrinsic depolarization associated with the baseline interpulse delay, in response to the first and second stimulations. The device 10 then iteratively determines at step 235 an optimal interpulse delay that results in an optimum width of the intrinsic depolarization. At step 240, the device 10 sets the baseline as the minimum QRS width with its corresponding interpulse delay.
Once microprocessor 60 initiates the method 300FIG. 4, the next ventricular stimulation pulses are delivered at step 205 at the existing, programmed interpulse delay and according to the standard timing operation of device 10. At step 310, the QRS width is measured. In order to measure the QRS width, the electrogram signal is sampled preferably from a far-field electrode pair, e.g. preferably an electrode pair in which neither electrode has direct contact with either ventricle. Far-field sensing of the QRS signal is preferred because a more global measurement of total ventricular function can be made rather than a more localized measurement. For example, a global QRS signal may be sensed using the SVC coil electrode 38 and the device housing 40.
In an alternative embodiment, the same electrodes used for stimulating the ventricles may also be used for sensing the QRS signal. In this embodiment, sensing may be performed between the right ventricular tip electrode 32 and the housing 40, the left ventricular tip electrode 26 and the housing 40, or between the right ventricular tip electrode 32 and the left ventricular tip electrode 34. Such sensing may not be the optimal sensing configuration because it provides a more localized measurement of ventricular depolarization. However, by providing a programmable sensing configuration, the medical practitioner may select the most suitable sensing configuration on a patient-by-patient basis.
The sensed signal is received by the appropriate sensing circuit. If a far-field signal is sensed, the signal may be received by atrial sensing circuit 82 (FIG. 2). If a more localized signal is sensed, the signal may be received by ventricular sensing circuit 84 (FIG. 2). In either case the sensed QRS complex is sampled and digitized by A/D converter 90, and this data is used to determine the QRS width according to step 310 of method 300 (FIG. 4).
The QRS width may be determined by generating a template from the digitized signal and measuring the time between two sample points indicating when the QRS signal first exceeds a given sensing threshold and when the QRS signal first goes below the same, or another, sensing threshold. Numerous methods may be used for measuring the QRS width. Any suitable technique that provides consistency in measuring the QRS width, such that reliable comparisons between measurements are possible, may be employed.
In an alternative embodiment, more than one QRS width from more than one stimulation cycle using the same interpulse delay may be measured. In this way, an average QRS width, or some other statistical measure of QRS width, for a given interpulse delay may be determined.
At step 315, the measured QRS width is stored in memory 94 as W(0). This is the QRS width associated with the existing interpulse delay setting D(0). The interpulse delay D(0) and its associated QRS width W(0) thus represent the baseline setting and measurement, respectively, for the optimization method 300.
At step 320, the baseline interpulse delay setting D(0) is incremented to a new, longer interpulse delay setting, D(N), by adding a pre-defined interval, N, to the baseline interpulse delay setting D(0), as expressed by the following equation:
At step 325, the QRS width is measured again to obtain the new QRS width, W(N), associated with the new interpulse delay setting, D(N). This new QRS width, W(N), is compared to the baseline QRS width, W(0), at decision step 330. If the new QRS width, W(N), is less than the baseline QRS width, W(0), the new interpulse delay setting D(N) is presumed to be producing better synchronized ventricular contraction. Thus, the new interpulse delay D(N) is considered more optimal than the baseline interpulse delay D(0), and the interpulse delay setting is kept at the new setting D(N) at step 335, and the method 300 is terminated at step 365.
If, at decision step 330 the new QRS width, W(N), is not less than the baseline QRS width, W(0), then the baseline interpulse delay, D(0), is considered to be more optimal then the new interpulse delay, D(N), and the interpulse interval setting is adjusted again at step 340. At step 340, the interpulse interval is decremented by subtracting the pre-defined interval N from the baseline interpulse interval, D(0), to obtain a new, lower interpulse delay D(N), as expressed by the following equation:
The new QRS width, W(N), associated with the new interpulse delay, D(N), is measured at step 345 and compared to the baseline QRS width, W(0), at decision step 350. Again, if the new QRS width W(N) is less than the baseline QRS width W(0), the new interpulse delay D(N) is considered more optimal than the baseline interpulse delay D(0). Thus at step 355, the interpulse delay setting is maintained at the decremented interpulse delay, D(N), and the method 300 is terminated at step 365.
If, however, at decision step 350, the new QRS width, W(N), is not less than the baseline QRS width, W(0), then the baseline interpulse delay, D(0), is still considered the optimal setting. The interpulse delay is reset to the baseline interpulse delay setting, D(0), at step 360, and the method 300 is terminated at step 365. The interpulse delay setting will remain unchanged until the next time microprocessor 60 reinitiates the method 300.
The method 300 is shown to first increment the interpulse delay and then decrement the interpulse delay in an attempt to determine if the optimal setting has changed from the baseline interpulse delay, D(0). The order in which new interpulse delays are tested is not critical to the successful operation of the present invention.
The method 300 is also shown to test only one interpulse delay longer than the baseline interpulse delay, D(0), and one interpulse delay shorter than the baseline interpulse delay, D(0). However, multiple incremental steps may be made in adjusting the interpulse delay such that two, three, or more interpulse delays greater than the baseline setting and two, three, or more interpulse delays less than the baseline setting may be tested. This testing may be accomplished by starting with an initially longer interval N by which the baseline setting, D(0), is increased or decreased. This interval N could then be progressively decreased so that new interpulse interval settings, which are progressively closer to D(0) in value, are tested. This can be referred to as a convergent, iterative algorithm.
Numerous algorithms could be used successfully within the present invention for performing a series of QRS width measurements associated with varying interpulse delay settings. Preferably, an iterative algorithm is used which allows repeated measurements to be made until the minimum QRS width measurement is found.
In alternative embodiments, other surrogate measures of cardiac performance may be implemented in the method 300 of FIG. 4. Likewise, direct measures of cardiac performance that become chronically feasible may be implemented in the method 300 of FIG. 4.
Thus a method has been described for optimizing the interpulse delay during biventricular stimulation. By selecting the interpulse delay that provides the minimum QRS width, the contraction of the left and right ventricles is expected to be better synchronized, thus improving cardiac output. By repeating this method periodically, the interpulse delay setting is adaptively adjusted over time such that if the optimal setting fluctuates with changes in disease state, medication, activity level or otherwise, the interpulse delay will always be set at the optimal setting.
The method described herein may be implemented in cardiac stimulation devices providing stimulation therapy to both the right and left ventricle without additional sensors or complex software algorithms. Though the present method is described as applicable to biventricular stimulation, it could be altered in order to optimize the interpulse delay during biatrial stimulation as well, in which optimization of the P-wave portion of the cardiac signal is achieved. In the latter situation, the device 10 performs atrial interpulse delay optimization by minimizing the P wave width as compared to the QRS width.
While the present invention has been described according to specific embodiments and applications thereof, numerous modifications and variations could be made thereto by those skilled in the art without departing from the scope of the invention.
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I'm told pictures can now be added and some of you have asked to see it so here goes:
I'm making a sweater out of louet 100% linen and I've learned that Linen knits up with a certain bias, due to the twisting of the yarn. Does anyone have any ideas for correcting this?
Finally I was able to upload a couple of pictures of my pillow sides. Both sides are the same stitch pattern using Cascade 220 yarn. The colors are greens, gray, and blue.
im considering knitting a floor rug / carpet since i live in a completely wooden floor boarded house.
...we had a 900 foot long flag this year. It just keeps getting bigger and more pieces get attached every year.
I spent Thursday, Friday, and part of today knitting with this as my view. Are you jealous?
It's true what they say...the camera really does add 70 pounds.
Hello one and all. For those of you who live in or near Portland, Oregon. I am organizing a new knit night starting tonight from 5 pm to 10 pm at Posies Cafe in the Kenton Neighborhood.
I've moved from Oakland, CA to Austin, TX!
But way to fun to pass up!
I'm heading north in a few weeks, and would love to find some treasures of yarn shops in NE Wisconsin/Door County area. If you can recommend any, please pass on their names and locations.

subset: commoncrawl


text:
Studies in biogas technology. Part IV. A novel biogas plant incorporating a solar water-heater and solar still
- Amulya Kumar N. Reddy,
- C. R. Prasad,
- P. Rajabapaiah,
- S. R. C. Sathyanarayan
- … show all 4 hide
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A reduction in the heat losses from the top of the gas holder of a biogas plant has been achieved by the simple device of a transparent cover. The heat losses thus prevented have been deployed to heat a water pond formed on the roof of the gas holder. This solar-heated water is mixed with the organic input for ' hot-charging ' of the biogas plant.
A thermal analysis of such a solar water-heater ' piggy-backing ' on the gas holder of a biogas plant has been carried out.
To test whether the advantages indicated by the thermal analysis can be realised in practice, a biogas plant of the ASTRA design was modified to incorporate a roof-top solar water-heater. The operation of such a modified plant, even under ' worst case ' onditions, shows a significant improvement in the gas yield compared to the unmodified plant. Hence, the innovation reported here may lead to drastic reductions in the sizes and therefore costs of biogas plants.
By making the transparent cover assume a tent-shape, the roof-top solar heater can serve the additional function of a solar still to yield distilled water.
The biogas plant-cum-solar water-heater-cum-solar still described here is an example of a spatially integrated hybrid device which is extremely cost-effective.
- Title
- Studies in biogas technology. Part IV. A novel biogas plant incorporating a solar water-heater and solar still
- Journal
Proceedings of the Indian Academy of Sciences
Volume 2, Issue 3 , pp 387-393
- Cover Date
- 1979-09
- Print ISSN
- 0250-5983
- Online ISSN
- 0973-7677
- Publisher
- Springer India
- Additional Links
- Topics
- Keywords
- Biogas plant
- solar water-heater
- solar still
- thermal analysis
- hot charging
- design modification
- gas yield
- hybrid device
- Industry Sectors
- Authors
- Amulya Kumar N. Reddy (1)
- C. R. Prasad (2)
- P. Rajabapaiah (3)
- S. R. C. Sathyanarayan (2)
- Author Affiliations
- 1. Department of Inorganic and Physical Chemistry, Indian Institute of Science, 560 012, Bangalore
- 2. Department of Mechanical Engineering, Indian Institute of Science, 560 012, Bangalore
- 3. Biogas Laboratory, ASTRA, India


text:
Thank you for your interest in St. Albans Tennis Club. Unfortunately, we are closed for renovation and hope to reopen during July 2015. Please check back with us.
General • Members must register with the attendant when entering the club; if attendant is not present, please sign in
• Members are urged to wear conventional white or off-white tennis attire. Jeans/jean shorts are not permitted
• Members without proper footwear (smooth-soled tennis shoes) are not permitted to enter the courts
• Smoking on the St. Albans premises is strictly prohibited
• Each member is asked to help keep the club clean by picking up and discarding trash
• No events should be planned on the St. Albans courts without director's approval; 8 weeks advance notice is required
• Do not confront other members or guests if there are rule violations; please alert the attendant or director
• The St. Albans Tennis Club is not responsible for lost, stolen or misplaced articles anywhere on the club premises
• A defibrillator is available inside the club house and is only accessible when an office attendant is present
Court Rules
• Each member is only allowed to sign in once during peak time
• During peak time, the club allows 1 hour for singles and 1.5 hours for doubles. If courts are available past this time frame and no other members are waiting, members are permitted to continue playing past the time limit.
• Court #6 is reserved for private or group lessons.
• If a member has completed an hour of singles play and would then like to play doubles with another member who has not yet played, doubles playing time is reduced from 1.5 hours to 1 hour. This is done to assure that as many different members as possible get a chance to play during this "high demand" period.
• Of course, members are permitted to sign in again in the afternoon (1 p.m. - closing).
• Courts are assigned only when at least two players are present
• There must be at least two signatures before a court is taken
• Court time starts when players go out to the court
• Do not use the courts after rain unless permitted by attendant or director
• Junior members are encouraged to play during the hours of least activity and must release the courts to adults during peak times
• Proper court etiquette and behavior are required of all players at all times Guest Procedures
• Guests (and accompanying members) must register at the front desk when first entering the club
• Members are required to pay a guest fee for all adults and children who are not members of the club and who will be using the tennis courts
• The guest fee (for both adults and juniors) is $10
• Any given guest is only allowed to be invited a total of 10 times during the season (April – December)
• It is the members' responsibility to know whether their guest has been invited in the past
• Only members can pay the guest fee; attendants will not accept fees from guests
• Guests may not request a court, nor can they be on the waiting list
• Members are responsible for their guests' attire; juniors are subject to the same rules
• A club member must be physically present while a guest is using the club
The St. Albans Tennis Club is an outdoor facility comprised of 8 clay courts, 2 hard courts, and a small clubhouse, situated on the magnificent grounds of the Washington National Cathedral. Members of the Tennis Club enjoy such benefits as various types of reasonably priced memberships with no additional court fees; play as early as 6:45 a.m. daily; no reservations; $15 guest fee; and an array of activities including clinics, juniors' summer camps, tournaments, and social events.
All St. Albans tennis members, from 4 year-olds to our more distinguished players, will find our staff of instructors, maintenance workers, and directors to be friendly, hard-working, and dedicated. They consistently provide the very best tennis atmosphere from top to bottom, as befitting an institution representative of St. Albans School.
We hope to welcome you to the St. Albans tennis community. We are sure it will be a fun and rewarding experience for all!
Karim Najdi,
Tennis Club Director 202-537-5765
Thank you for your interest in the St. Albans Tennis Club.
Single membership: TBD (Membership is for one person only)
Family membership: TBD (Membership includes spouse and children under the age of 21)
Current St. Albans School Parent membership: TBD (Membership includes spouse and children under the age of 21) Student(s) must be enrolled at St. Albans School at start of the club season.
Billing: Members of the tennis club will be billed for tennis balls, stringing, lessons, clinics, tournament fees etc. every month during the season.
The club's various programs focus on stroke production, mechanics, footwork, mental toughness, fitness, etc. Our programs are exciting, innovative, and geared towards different skill levels to maximize learning and fun! To ensure that each performance level receives the most appropriate and effective coaching, students in group lessons or clinics will be subdivided based on ability and previous tennis experience.
Please report to the St. Albans Tennis Club at 35th and Garfield Streets, NW. All participants should bring a tennis racket, white tennis shoes (running shoes are not allowed), white tennis clothing and water. Parking on St. Albans grounds is strongly encouraged. No parking permit is required on weekends. Please avoid parking on Garfield Street.
The St. Albans Tennis Club offers private and group lessons starting as young as 4 years old. Tennis lessons are available for both members and non-members; however, during sign-up, priority is given to members.
Court number 6 is reserved for private or group lessons.
Private Lessons:
• Private Lesson: $95 per hour, $50 per ½ hour
• Semi-Private Lesson: $55 per hour/person, $45 per ½ hour/person
• Group Lesson (3-5 people): $40 per hour/person
Note: Lessons must be scheduled or cancelled through the club office, at least 24 hours in advance.
Clinics are available for both juniors and adults during the spring, summer, and fall.
For additional information regarding other clinic options, including interest in creating your own group or clinic, please contact the office.
Season Opening Celebration - TBD
Thursday "Stroke of the Week" – held TBD
End of Year Tennis Club Reception - TBD
The St. Albans Tennis Club operates from TBD.
Normal hours of operation: 6:45 a.m. – 8:45 p.m. (Our facility does not have lighting; therefore, closing times will depend on sunlight)
During the school year (September - November, April - May), all courts will be reserved for St. Albans and National Cathedral School tennis teams, Monday – Friday from 2:00 p.m. – 6:00 p.m. (Please note that interscholastic matches may go beyond 6:00 p.m.)
Members will be informed of any other changes to these hours.
Note: The club may close for repairs or emergencies or may need to limit the hours of use due to special events. Any such changes will be communicated to the membership as soon as possible.
Tennis clothing is encouraged of all players using St. Albans tennis courts. We recommend bringing a hat, sunscreen, and water. Participants must provide both a tennis racket and tennis shoes. Running shoes are not allowed on the courts.
Below is a list of suggested places to purchase tennis-related clothing and gear.
Court Rules
Guest Procedures
We ask that the Tennis club members park on Pilgrim Road (between baseball field and tennis club). Pilgrim Road is one way, with entrances on Massachusetts Ave and Wisconsin Ave (turn onto South Road). Please do not enter from Garfield Street!
Parking passes are given to club members to use from 7:30 a.m. – 3:30 p.m. Monday through Friday. These hang tags are necessary during this time period, however members are free to park along Pilgrim Road without a tag outside of these hours.
In order to cooperate with our neighbors over their concerns, we ask that you please refrain from parking on Garfield or neighboring streets.
If parking spaces are not available on Pilgrim Road, please park in the Cathedral garage via Wisconsin Ave entrance.
St. Albans Tennis Club, Mount St. Alban, 3101 Wisconsin Ave., NW
Washington, DC 20016
St. Albans School, Mount St. Alban, Washington, DC 20016, 202-537-6435


text:
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My Account Customer Buzz Birthday Club Retailer Exclusives
Order by Phone 866-429-5200
The Lifestyle Dream Kitchen by Step2 is one of the most realistic play kitchens your child will ever play with! It's upscale, compact and designed to match today's home décor with "granite-look" counter tops. Toddlers will spend hours of fun make believing that they are cooking in their very own play kitchen. With so many accessories and electronic features, multiple children can play together in this play kitchen set. Made in USA of US and imported parts. Phone, play food, silver doors and faucet made in China.
Play Tip: Add labels to things in the kitchen so that your child can get accustom to connecting real life items with words
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Very Nice Kitchen
I am a daddy and just bought this (from Step2 directly)for my 2 year old little girl for her birthday June 3rd and I really don't know where all the negative comments are...Read complete review
I am a daddy and just bought this (from Step2 directly)for my 2 year old little girl for her birthday June 3rd and I really don't know where all the negative comments are coming from, except to think that there are ALWAYS those few who complain about everything. It took about 2 hours to fully put together and that was mostly doing the stickers and odd-and-ends. The doors came attached already and you just have to assemble the main parts, door knobs and stickers. When she unwrapped it (assembled), her face lit up! She started playing with everything right away. I DO suggest that you get a large food accessories package to go with this as the food things they include are not really quality items and do not include the normal items for sandwiches, the refridge, ect. The oven door DOES NOT fall like others have said. I agree with some others that injection molded products do not look as good or as detailed as roto products (they should not have switched manufacturing processes), but it is what it is. In all, I think this is a great little kitchen for little ones who love to pretend cook and I am looking forward to a lot of fun times with my daughter as she cooks for daddy! I added a picture to show size and look in accordance to my little one.
Most Liked Negative Review
Quality isn't like it use to be!
I purchased a lifestyle kitchen in 2004 and was extremely satisfied with the purchase. However, I just purchased the lifestyle dream kitchen and was surprised to see that the quality of the product was...Read complete review
I purchased a lifestyle kitchen in 2004 and was extremely satisfied with the purchase. However, I just purchased the lifestyle dream kitchen and was surprised to see that the quality of the product was not equal to the one I purchased in 2004. Although it looks similar, the doors (oven, microwave and refrigerator) are nothing like the older model. When I inquired with Step2, I was told that they changed the way they manufacture the product from a roto molded appliance doors to injection molded doors.
At the time that I purchased the product from the Step2 website they were displaying the product with the higher quality roto molded doors and this is not what I received. Of course, a new photo was posted to the website as soon as I brought this to Step2's attention and I was told I could ship if it back (at my expense) for a refund. But, after taking the time to put it together that seemed like more trouble than it was worth.
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Comments about Step2 LifeStyle™ Dream Kitchen:
Bought this for my 3 year old grandson's birthday. Was his best present ever. Couldn't have gotten more kisses and hugs for such a great present. Served everybody meals and let his cousin play chef too! Was easy to assemble - let my daughter do this. Made for many hours of fun and pretending.
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Comments about Step2 LifeStyle™ Dream Kitchen:
Oven door pops open too easy
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Comments about Step2 LifeStyle™ Dream Kitchen:
The appliances work and entertain the boy's for hours.
Best Uses
Comments about Step2 LifeStyle™ Dream Kitchen:
I purchased this kitchen as a Christmas gift, so it hasn't been played with yet, however, it came as described and I think it will be a hit! I am pleased with the product overall and can't wait for my little one to enjoy it.
The product seems very well made. I purchased this kitchen specifically for the electronic features, which all worked when tested. Have batteries on hand, it takes (6) AA and (5) AAA.
Installation instructions were reasonably easy to follow, but because of they way they are printed, I did have to "hunt" around to complete the steps in order, and a couple of the photos lacked resolution to be able to tell which part was being referenced. Part inspection, reading instructions, and installation took about an hour and a half. The screws are self drilling but took some "muscle" to get them in with a hand held screw driver, so I would recommend using an electric screw driver. It also required two size drivers (a smaller size for the battery operated parts).
I thought the included play food was slim, so I purchased additional play food set from another source.
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Comments about Step2 LifeStyle™ Dream Kitchen:
I saw this at the store and got the chance to feel it in person. It is super well made and I imagined my daughter having fun playing with it. Didn't buy it as it won't fit my budget for my daughter's birthday but would definitely buy it in the future. Could not help but leave a review though. It looks really fun!
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Vermont teens find activism at end of paintbrushBy Kevin O'Connor
Staff Writer | July 07,2014
Kevin O'Connor / Staff Photo Dylan McAllister, the newest student representative to the Vermont Board of Education, paints a sign at the Governor's Institute on Current Issues & Youth Activism now taking place in Brattleboro.BRATTLEBORO — Ask 15-year-old Molly Engels what she and her peers are talking about at this month's Governor's Institute on Current Issues & Youth Activism and she points to a full spectrum of societal problems and possible solutions.
"We are the generation of change," she says.
That's why the Rutland High School sophomore and 60 fellow Vermont teenagers have momentarily stopped texting and Twittering to dip into an even more fluid means of communication: Tempera paint.
When institute leaders at Brattleboro's World Learning arrived with Dixie cups full of washable color, some students wondered if they had fallen back into kindergarten. But after instructors offered a crash course on the dynamics and durability of the protest sign, the plugged-in generation proved game to turn pigment into political action.
Randolph Union High School students Kate Conard and Addison Rooney tapped a smartphone to translate and paint the word "peace" in nearly a dozen languages.
Conard, 16, noted her father and grandfathers served in the military. She supports them — but doesn't like to see anyone placed in life-threatening situations.
"I feel very strongly about peace," Conard said. "It doesn't make sense to be angry. It just makes things worse."
"We're all one species," Rooney, 15, added. "Why do we have to fight?"
Montpelier student Leah Sagan-Dworsky voiced similar sentiments as she transformed a sheet of corrugated cardboard into a Jackson Pollock canvas featuring the words "equality for all."
"I'm a feminist and a supporter of everybody having rights," she said, "so I thought, let's make it colorful."
That, and she accidentally splattered paint all over her once-white paper, leading to a larger experiment in abstract expressionism.
Some signs played with slogans. ("Drop bass not bombs.") Others poked at public opinion. ("I love GMOs — please don't hurt me.") And a few thoughts went undeclared, based on calls for discretion.
"You can provoke," co-director John Ungerleider advised, "but not alienate."
"That's not an effective way to start a conversation," colleague Simon Norton added.
Dylan McAllister, 16, of Greensboro, hoped to get people talking with a two-part sign. The first featured a drawing of a fish and a monkey beneath a tall tree. The second bore the word "fair" surrounded by question marks.
Have a few yourself? The Hazen Union High School junior and newest student representative to the Vermont Board of Education explained the signs to be a unique critique of standardized testing that expects all students, regardless of differences, to reach the same heights the same way.
The 25th annual program — one of nine summer institutes that also include arts, Asian cultures, engineering, environmental science, information technology, mathematics and, new this year, entrepreneurship and "Farms, Food and Your Future" — offers 12 days of classes in politics, policy and public service.
Participants are working alongside fellow World Learning visitors from Germany, India, Iraq and Ireland and the states of Florida, Illinois and Massachusetts. Vermonters say they appreciate the diversity.
"There are so many cultures here," said Caitlyn Duff, 16, of Stowe.
And so much camaraderie, added Hawley Snipp, 17, from nearby Morrisville: "I come from a school that is very strong for gun rights. If you have a different opinion, you're ostracized."
At the institute, young people are limited only by the amount of space on which they can share. Florida student Fermin Mendoza recalled the first day when, asked for their state, national and world concerns, teens filled an entire chalkboard. That's why he painted his sign with the words, "Acknowledge our issues — we have many."
"One of the reasons they don't get solved," the 16-year-old concluded, "is people don't know about them."
kevin.oconnor @rutlandherald.comMORE IN This Just InMONTPELIER The 22 water systems in Vermont that draw from Lake Champlain are participating in a... Full StoryJOHANNESBURG When Cecil the lions carcass was finally found after he was lured out of a... Full StoryWASHINGTON It took Ted Cruz three months to raise $10 million for his campaign for president, a... Full Story
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Mooresville, North Carolina Pet Friendly Hotels & Lodging
United States » North Carolina » Mooresville
Looking for a hotel in Mooresville, NC that you can bring your pet to? We made sure that each one of the hotels below are pet friendly, so you can enjoy your trip with your pet by your side! Once you have found a pet friendly hotel, you can book your stay instantly from our website or call 866-212-1803 to speak with a pet travel agent.
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130 Norman Station Blvd - Mooresville, NC (Map)
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Located in Mooresville, TownePlace Suites by Marriott Mooresville is convenient to Lowe's Corporate Headquarters and Mooresville Golf Course. This hotel is within close proximity of North Carolina Aut...
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text:
The BabysitterThe babysitter
When I was ten years old, I had this babysitter who was only two years older than me. She was twelve years old. I was in the foster care program at the time. One night my foster mom Alice said "I have to go to a meeting tonight. I won't be back till two or three in the morning. I got you a babysitter. She will be here at six o'clock. I will leave between seven and seven thirty. I want to make sure you two can get along."
I was allowed to play in the backyard till the babysitter got there. When six o'clock came I headed to the house.
"John, your babysitter is here." said Alice as I entered the house.
Since I had been playing outside I was in a pair of shorts and a t-shirt. I went into the front room and sat down on the couch. Alice came into the front room with a twelve year old girl. She had brown hair with blue eyes. She was wearing a blue dress and a pair of sandal. She took off the sandals before she entered the front room.
Alice turned to me and said "This is Susan. She will be your babysitter tonight. You are to do everything she tells you too. No matter what, understand?"
I nodded at her. Susan smiled at that statement and then said "Okay, so he has to listen to me is that correct and do what I want him to do? Does it start right now? Can I make him do something?"
Alice answered "Yes, he does. Yes it does start right now and of course you can make him do something right now."
Susan thought about it and then said "John, I want you to ***** naked."
I looked at Alice and then moaned. "Alice, do I have to?"
Alice looked at Susan and then at me and said "I told you that you have to do what she asks. If she wants you to ***** naked then you will ***** naked."
I pulled off my top and then my shorts. I stood in front of her nude. I covered myself up with my hands after I dropped my clothes to the floor. Alice and Susan both looked at me in the nude.
Susan then said "Put your hands on top of your head and don't ever cover yourself up again. In fact whenever I am over here to babysit you, I want you naked before I get here. You are not to cover yourself up."
I put my hands on top of my head and let Alice and Susan look at me. My penis was small at least to me. It was at least two inches long when limp and when it got hard it added another inch to it. Susan whistled when she saw my penis. She walked up to me and touched it. It jerked a little at her touch. She moved her hand over it and it started to get a little stiff. Alice stood off to one side watching Susan play with my penis.
Susan was so entranced by my penis she did not notice Alice watching her. Alice started to laugh a little. This broke the trance that Susan was in. Susan's checks turned red in embarrassment. Alice said "It is okay Susan. You can do whatever you want to him. If you want to play with his penis then you can. If you want he can play with you as well."
Susan turned to her and said "You mean it? I get to play with him and if I want he can play with me?"
Alice smiled and said "Yep."
Susan then said "Thank you Alice."
With that she turned back to my penis and started rubbing it again. It felt good for her to play with my penis. I keep my hands above my head. It soon grew to its full length. She then stopped playing with it. She unbuttoned her top couple of buttons of her dress. She looked at me then said "Lie down on the couch."
I turned to the couch and laid down on it. I keep my hands above my head. I watched Alice as she moved to keep an eye on what was going on. Susan pulled the dress up over her head and dropped it to the floor. She had been naked under the dress. She had small nubs for breasts and no ***** hair. Her mound was soft looking.
She walked up to the couch and got on. She then straddled me and positioned her ***** over my erection. She looked at me and then said "Touch me all over. Play with my breasts. I want you to suck on my breasts."
I smiled and started to fondle her breasts as she begins to lower herself on top of me. Soon my penis was touching her *****. She looked at me smiling.
"I have never done this before. I have thought about it, but I have never done it before. I have heard of it. You will be my first and I know I will be yours." She said, and then thrust herself down on top of me.
My penis penetrated her ***** as she cried out. I moved my mouth up to her left breast then started to suck on it. She started moving herself up and down on my penis. The feeling was wonderful. Her ***** was tight against my penis. It felt like nothing I had felt before. There was a good feeling building up in side of me as we started to go faster. I stopped sucking on her breasts and just started to move my hands over her body.
We went faster, her moving up and done on top of me. The feeling got better and better till it felt like I exploded. We both cried out as our ******* hit us at the same time. She collapsed against me as we both panted for air.
Alice came up to us. She looked at both of us as I moved my hands around Susan's waist. I kissed Susan and she returned the kiss. Alice laughed then said "Susan, did you enjoy that?"
Susan turned red again from embarrassment. "I forgot you were there. I was having a good time. It felt so wonderful to be able to do that with someone. I have never done it before."
She snuggled closer to me. Alice looked at me and then said "John, did you enjoy it as well?"
I looked at her and said "I didn't like at first to get naked in front of her. But then she started to play with my penis and it felt good. Then she put her ***** on my penis and let me play with her body and it felt great! Can we do it again?"
Alice looked at the clock. It was only six twenty. She smiled and said "You can do it as much as you want anywhere in the house. You two can even do it outside if you wanted to."
Susan looked at me, and then smiled. She said "Let's go outside and do it. It's still light out. We can do it in the front yard."
"But what about all the people who live in the neighborhood?" I asked her.
"Let's do it in front of them. Let's have fun with it and have sex with everyone in the neighborhood watching us do It." she told me.
That night there was a block party going on and all the neighbors were outside having fun. They were having a cook out. The main focus of the party was our house since it was at the end of the street. Our street was a cul-de-sac. Earlier in the day they had set up a stage in front of our house and enough seats for the entire neighborhood in front of it.
I thought about it and then decided. "Alice if we do it in front of everyone in the neighborhood, can we be naked anytime we want in the neighborhood? Can we also have sex anytime we want?"
Alice was the one in charge of the neighborhood and whatever choices she made everyone else followed. Alice smiled. "Yes, you can. You can be naked whenever you want and you will be able to have sex with each other anytime you want. Plus as a bonus any kids around your age you can get naked as well and have sex with them. I will make sure it happens."
"Okay, then I will do it on the stage with Alice." I said.
"Wait, right here, I have to get everyone to the stage." She said as she turned to leave the house.
She left the house. Susan and I stood up. We headed for the front door. The front door was closed but we could hear the party going on in the front yard. We then heard Alice announce into the microphone that had been set up on stage "Can I get everyone to come to the stage please. I need everyone to come to the stage and take a seat. Please be quick."
It only took a couple of minutes for everyone to take a seat. "I need all the children up front please." She said. "I want them to get a good view of what's about to happen. Can everyone see the stage okay? I want you all to get a good view for this. Oh and can I get Susan's family up to the stage too please? If you have a video camera or a regular camera you want to get them out right now."
Susan's family which consisted of her mother, father, a thirteen year old older sister and a seven year old younger sister, got onto the side of the stage. On the stage was an air mattress. It was being inflated by a small pump. Alice bent over and disconnected the pump when the air mattress was full. Everyone was buzzing about what was going on. We heard it through the window as we watched. People were pulling out video cameras and regular cameras.
"Susan and John have decided to put on a little impromptu show for everyone here. They will be coming out of my house so if you want you should focus your cameras there. Steven and Susan you can come out now." she said.
Susan opened the door and taking me by the hand headed for the stage. We heard people gasp as they saw that we were both naked. We saw people with cameras filming us as we headed across the yard toward the stage. We got onto the stage and stood facing everyone there. Susan's family had gotten off the stage to one side to get a good look. We let everyone have a good look at us.
Alice turned to us and said "Yes they are actually naked. Neither one of them is wearing any clothing. What you are about to see is real. They both wanted to have sex in front of the entire neighborhood. However before they do anything there were a couple of terms I had to agree to. From now on they will be able to be naked whenever and where ever they want to be. All children in the neighborhood will be allowed to be undressed by them. This goes for children from the age of seven to the age of fourteen. They will be able to have sex with these children whenever and where ever they want to. This will last for the next year. I hope I have everyone's agreement to that?"
I stepped up to Alice and tugged at her sleeve. She bent down to me and I said into the microphone "All the children here between seven and fourteen should get naked right now. We want them naked for the rest of the weekend and they are to come over here tomorrow in the nude, so we can play with them and to have sex. We will be having sex with them one at a time on this stage. You are all welcome to come and watch if you want. If you do this you show that you want our show to happen and you agree to our terms."
There were about a dozen kids who were in the age range we mention. Their parents moved forward and soon all the kids were naked, this included Susan's sisters. Alice turned to us and smiled.
"Susan, why don't you lay down on the air mattress? Steven I want you to get on top of her. Make sure everyone can see what you are doing to her." said Alice.
Susan laid down on the mattress so her head was facing the crowd while her body was at a slight angle so everyone could see her *****. I went up between her legs, my penis becoming hard once more. I started to rub it against her *****. As I was rubbing it against her ***** I took a look at the crowd. All eyes were on the two of us; even the children were watching us.
When my penis was fully erect I pushed it into her. She moaned as I did it. I then started to get a rhythm going. Our hips started to thrust against each other. I was so entranced by it I forgot we were being watched. We moved back and forth. The feeling was beginning again in my body. Soon it exploded. Susan and I cried out as we had our ******. We collapsed into each other's arms. We looked up when we heard clapping and cheering. The entire neighborhood it seems enjoyed our sex act.
We stood up and took a bow. We then headed into the house as everyone was starting to get up and leave. Susan went over to her family and spoke to them for a couple of minutes. I was not close enough to hear what they said. Susan came up to me and said "I'm tired. Let's go to your bed and get some sleep."
We headed into the house followed by Alice. Alice said "Good night you two. I will lock the door that way no one can disturb you."
We waived at her as we entered the bed room. We climbed into bed and crawled into each other's arms. We did not have the energy for sex so we just fell asleep. The next day all dozen kids between the age of seven and fourteen were at our house in the nude. Susan and I took turns on the stage having sex with the kids. Everyone in the neighborhood came out and watched us. People were even bringing out food for each other. They also had their cameras so they could record every kid having sex.
I started with Susan's seven year old little sister. She and I were the first ones on the stage that morning. Her ***** was even tighter than Susan's. She even screamed louder than Susan when she had her first ******. I had sex with six kids that day. The youngest was seven and the oldest was thirteen. The thirteen year old had been Susan's older sister. For the rest of the weekend all the kids were naked and by then end of the weekend most of the kids were having sex with each other. Susan had sex with six boys as well. The youngest being eight and the oldest being fourteen. Susan ended the show with her screwing the fourteen year old boy.
That night I slept in Susan's parent's bed with Susan and her two sisters. For the next week Susan and I went around the neighborhood naked and having sex with the kids. It was fun all the kids grew to love the sex. For the next year it was an interesting time. All of the holidays were done in one person or another's house. All the kids were naked during this time as well. Christmas was a fun time as everyone got a picture of their kid naked in front of the Christmas tree, as a bonus they got pictures of us having sex with their kids in front of the tree.
During that year it was rare to see a kid between the age of seven and fourteen wearing clothing. Sex between the kids was common place. We had sex in yards, in pools, in houses, and even in bedrooms. I even had sex with Susan's seven year old sister at the intersection to our neighborhood.
vorecat 18-21, M 13 Responses 14 Sep 20, 2012
Great fantasy! Would never happen but fun.
fake, over the top, but worth reading
obviously it didnt happen, and maybe it was a bit over the top, but the details dont matter... it was all about havin fun n bein playful, and it was a hell of a fine romp...
Does anyone notice the name change from john to steve
i doubt that happened
Did that really happen
i am rock hard when i read this
Could that be considered rape if a 12 year old had sex with 10 year old
i don't think so
like story
this is pure bullshit and not at all funny
ofc it is =.=
This was a fantasy story, right?


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Learn how to select the right foods for you and your family, and the cooking styles and cuisines that balance your digestion and energy levels. Develop a strong digestion.
In Ayurveda, traditional Indian medicine, the three doshas (Vata, Pitta and Kapha) are the elemental forces that determine your constitution.
One dosha can be predominant, or two can be equally dominant: vata-pitta, pitta-kapha, vata-kapha; or all three can be equally dominant: vata-pitta-kapha.
Different Diets for Different Doshas will help you to determine which body type (dosha) you are, and the foods and cooking styles that best suit your individual constitution.
As you begin to select the right foods, prepare and cook them in a way that is both delicious and balancing for your body type. You will know whether you need a vata diet, a pitta diet or a kapha diet. Then you will start to enjoy a sense of power over your own health.
Inside this book you will find:
Title: Different Diets for Different Doshas Author: Dr Swami Shankardev Saraswati Publisher: Big Shakti Content: 24 Pages/Self-Analysis Chart/Foods List Media: eBook (Adobe Acrobat PDF)
Thanks for your great diet for doshas book. I worked out my body type and have been experimenting for 4 weeks. I made a few changes and voila - no more tummy aches. I have wasted my time with many diets over the last years, but this one is smart because it's about me and my body type, not them and their diet program!
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Results 31 to 36 of 36
Registered Member
- Join Date
- Jan 2006
- Location
- Australia
- Posts
- 334
Posted On:
8/14/2006 4:10am
I'd like to leave this world like I came into it: Screaming, naked & covered in someone else's blood
- Join Date
- Dec 2005
- Location
- Essex
- Posts
- 3,794
Posted On:
8/14/2006 7:47am--
At every MA school I've ever been at there's always been someone with what I began calling a 'Sifu complex'. This guy would decide that it was his job to show anyone having problems what to do. Even if he'd just been shown it and couldn't do it to save his life. In fact, now I think about it, the guys with Sifu complexes were always totally ****.
Submitting 1d6 Investigators per round
- Join Date
- Jun 2005
- Location
- new jersey
- Posts
- 2,981
Posted On:
8/14/2006 12:58pm
Style: wagamichi shorei kempo--
How about those ass clowns that got thier first degree because they simply paid enough and have been around long enough. the guys that put on the starched white Juka super heavy cardbord thick gi, stand arounf with the other "Yudansha" congratulate themselvs on how tough they are, and mabey hit the heavy bag five or six times. Whew! Good training!
"Hey you! brown belt kickboxing over there! never mind your bloody nose. You did not bow to me when I walked in the Dojo. i just rememberd. Give me 25 pushups!
Yea...long ago when I was a bullshidoist, My Mcdojo was full of these guys. The women black belts were even worse.
They were not content to stand over on the special side of the mat reserved for the enlightend...They had to come over and **** with the few guys that were realy training. You know here is an example.
"Listen when you hit some one even kickboxing you have to say oss. It makes you hit harder."When You absolutely have to hide a body...try Alaska.
Registered Member
- Join Date
- Sep 2004
- Location
- Nor Cal
- Posts
- 382
Posted On:
8/14/2006 1:49pm
Style: BJJ,MT,Wrestling,Boxing--
More Not-so-well-known observations...
In a Karate dojo or Judo club, the female black belt is almost always a slightly unkempt, less-than-feminine, secretly disgruntled woman who plays the content, happy, and noble girl at class , but most often goes home every night and watches Patrick Swayze movies until the wee hours of the morning leaving an empty pint of Ben & Jerry's to congeal on the table beside her recliner, where she also clips her toenails and uses them as toothpicks while waiting for the movie to get to the good parts. She will almost invariably own at least 6 cats.
Dojos run by husband and wife blackbelts are a distant cousin to husband-and-wife evangelical franchises, and in rare cases, one and the same.
Most TMAists would rather bang an asian chick, because they're orientophiles like that, and american women think they're spazzes.


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Fresh ,\ ! /, Morning _- O -_ , _,.+""-._,.+""-._ Feel the freshness & gentle touch of mng sunrise. Have an excellent day.! Gud morn...Dear beats => MASSSUJI.MS
It is really too good
Its too good priya
Jay shri radha krishna
If u like,plz vote and comment..thankq..


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This re-release seems unnecessary at first glance, but the conclusion of Kratos' journey serves up a level of spectacle that remains impressive in 2015.
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Rocksteady's gorgeous-looking third Arkham game refines its open-world format a bit and lets you drive a whole hell of a lot of Batmobile.
Game »
consists of 16 releases.
Released Nov 17, 2002
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Anniversary is a remake of the original Tomb Raider game, running in the engine from Tomb Raider: Legend. Join Lara Croft as she travels the world on her very first adventure all over again!
A Metal Gear Solid game for the PSP which uses similar stealth gameplay found in the popular Playstation and Playstation 2 titles.
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Subsistence is an updated version of Metal Gear Solid 3: Snake Eater which contains several new features, most notably a third-person camera and an online mode, Metal Gear Online. It is extremely hard to find in Europe, as Subsistence in EU is the US Subsistence Limited Edition by default.
Set in the 1980's during the height of the Cold War, players must escape from a Russian complex where American journalist Matt Carter has been captured.
Ascend from a billionaire playboy to a feared superhero in the third-person adventure game tie-in to the 2005 feature film of the same name. It is the only game to be based on The Dark Knight Trilogy.
A budget title with stealth-action similar to the original Splinter Cell and a cover system similar to kill.switch.
The ninja for hire Ayame, on a quest to find her master, suddenly stumbles upon a ruined village; its only survivor being a young assassin by the name of Rin. Together, the two work to uncover the plot behind the village's destruction, and the annihilation of Rin's clan.
The third installment in the Metal Gear Solid franchise is swathed in the Cold War, and it's up to Naked Snake (the "father" of Solid Snake) to keep the Soviet Union and the United States from all-out nuclear war.
Remake of the acclaimed PlayStation stealth-action action title Metal Gear Solid, developed under supervision of creator Hideo Kojima and legendary Nintendo game designer Shigeru Miyamoto.
It's not mission difficult, it's Mission: Impossible.
Busted out of death row, inmate James Earl Cash wakes up to find himself in a snuff film directed by a man who calls himself Starkweather.
Tenchu: Wrath of Heaven is the third Tenchu game and a sequel to the first installment. It had the same basic gameplay as the first two Tenchu games but modernized the movement controls.
Metal Gear Solid 2: Substance is an updated version of Metal Gear Solid 2: Sons of Liberty containing the original game while adding hundreds of VR missions, a theatre mode and more. It was originally released on the Xbox and later made it onto PS2 and PC.
A stealth-action game where you play as Sam Fisher, an elite operative working for the US government
The sequel to The Operative: No One Lives Forever, A Spy in H.A.R.M.'s Way again pits super spy Cate Archer against the hopeless H.A.R.M. organization.
The Mark of Kri is a mash up of American artwork styles like Disney and Don Bluth, a combination of Polynesian, Asian, and European cultures, and the kind of over the top, brutal violence of the Conan series, all swirled up into one unique, if linear, game.
Rainbow Six: Lone Wolf is an early game in the Rainbow Six series.
Headhunter was released for the Sega Dreamcast November 16th 2001, and the Sony PlayStation 2 May 9th 2002. Headhunter takes place in a near future Los Angeles and tells the story of Jack Wade, a professional bounty hunter.
They are the tip of the spear. They strike... swiftly, silently, and invisibly. They call themselves... "The Ghosts."
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