text:
|Numéro de publication
|Type de publication
|Numéro de demande
|Date de publication
|13 déc. 2007
|Date de dépôt
|10 avr. 2007
|Date de priorité
|21 mai 1999
|Autre référence de publication
|Numéro de publication
|Jeffrey Stahmann, Andrew Kramer
|Cessionnaire d'origine
|Cardiac Pacemakers, Inc.
|Exporter la citation
|BiBTeX, EndNote, RefMan
|Référencé par (12), Classifications (16), Événements juridiques (1)
|Liens externes: USPTO, Cession USPTO, Espacenet
This application is a continuation of U.S. patent application Ser. No. 10/713,556, filed on Nov. 13, 2003, which is a continuation-in-part of the following commonly assigned patent applications: U.S. patent application Ser. No. 09/748,796 filed on Dec. 26, 2000, now issued as U.S. Pat. No. 7,142,918, and U.S. patent application Ser. No. 09/316,515 filed on May 21, 1999, now issued as U.S. Pat. No. 7,062,325, the specifications of which are herein incorporated by reference in their entirety. This application also incorporates by reference in its entirety U.S. patent application Ser. No. 09/316,588 which issued as U.S. Pat. No. 6,285,907.
This invention pertains to cardiac pacemakers and methods for operating such devices. In particular, the invention relates to methods for cardiac pacing during an atrial tachyarrhythmia.
Congestive heart failure (CHF) is a clinical syndrome in which an abnormality of cardiac function causes cardiac output to fall below a level adequate to meet the metabolic demand of peripheral tissues. CHF can be due to a variety of etiologies with that due to ischemic heart disease being the most common. Some form of cardiac pacing can often benefit CHF patients. For example, sinus node dysfunction resulting in bradycardia can contribute to heart failure which can be corrected with conventional bradycardia pacing. Also, some CHF patients suffer from some degree of AV block such that their cardiac output is improved by synchronizing atrial and ventricular contractions with dual-chamber pacing using a programmed AV delay time (i.e., atrial triggered ventricular pacing or AV sequential pacing).
A common sequela of CHF is dilation of the heart chambers (especially the left ventricle) as end-diastolic volume is increased in the body's attempt to increase stroke volume. The ventricles can then become stretched and less contractile which actually worsens the heart failure. Stretching of the ventricular wall can also cause slowed conduction of depolarization impulses through the ventricle. If conduction velocity is slowed in the left ventricle more than the right, for example, the contraction of the two ventricles during ventricular systole becomes uncoordinated which lessens pumping efficiency. Some CHF patients also suffer from conduction defects of the specialized conduction system of the heart (a.k.a. bundle branch blocks) so that a depolarization impulse from the AV node reaches one ventricle before the other. In both of these situations, cardiac output can be increased by improving the synchronization of right and left ventricular contractions. Cardiac pacemakers have therefore been developed which provide pacing to both ventricles. (See, e.g., U.S. Pat. No. 4,928,688, issued to Mower and hereby incorporated by reference.)
Due to stretching of the atrial walls caused by the cardiac dilation described above, CHF patients are predisposed to occurrence of atrial tachyarrhythmias. Atrial tachyarrhythmias are cardiac rhythms characterized by atrial contractions occurring at a rapid rate, either due to an ectopic excitatory focus or abnormal excitation by normal pacemaker tissue. Atrial tachyarrhythmias can be classified according to increasing rate into entities that include atrial tachycardia, atrial flutter, and atrial fibrillation. Due to the refractory period of the AV node, some degree of AV block is usually always present so that the ventricular rate is less than the atrial rate if the AV conduction pathway is otherwise intact. In atrial fibrillation, the atria depolarize in a chaotic fashion with no effective pumping action, and the ventricles beat both rapidly and irregularly due to conduction of excitatory impulses from the fibrillating atria through the AV node. In atrial tachyarrhythmias, and especially atrial fibrillation, the atria no longer act as effective primer pumps for the ventricles which decreases stroke volume, referred to as a loss of atrio-ventricular synchrony. Also, when the ventricles contract at irregular intervals, the contraction can occur prematurely before diastolic filling is complete and decrease the stroke volume for that contraction. An episode of atrial tachyarrhythmia can thus depress cardiac output and cause such symptoms as dyspnea, fatigue, vertigo, and angina. This is especially problematic in CHF patients who are already hemodynamically compromised.
The present invention relates to a method and system for altering the pacing mode of a pacemaker in order to maintain hemodynamic stability during an atrial tachyarrhythmia such as atrial fibrillation. The invention may be especially beneficial to pacemaker patients with CHF whose hemodynamics are adversely affected by episodes of atrial fibrillation.
In accordance with the invention, the pacing mode of a pacemaker is switched from a normal pacing mode to an atrial fibrillation pacing mode in response to detection of an atrial tachyarrhythmia. The atrial fibrillation pacing mode is adapted for pacing in the presence of an irregular intrinsic ventricular rhythm. Depending upon the individual patient and the normal pacing mode, the atrial fibrillation mode may include initiation or modification of ventricular resynchronization therapy, initiation of ventricular rate regularization pacing, and/or changes to rate-adaptive parameters.
In one embodiment, the atrial fibrillation mode includes ventricular resynchronization, wherein pacing stimulation is applied to both ventricles or to one ventricle in a manner that improves the coordination of ventricular contractions. Such pacing is beneficial in patients with interventricular or intraventricular conduction defects, and switching to a resynchronization mode during an episode of atrial tachyarrhythmia improves cardiac output in those patients. If the normal pacing mode already includes resynchronization therapy, it may be beneficial to modify the resynchronization in the atrial fibrillation mode by, for example, adjusting a biventricular offset value or initiating biventricular triggered pacing.
In another embodiment, the atrial fibrillation mode includes ventricular rate regularization where a ventricular escape interval is dynamically adjusted in accordance with a measured intrinsic ventricular rate. By adjusting the ventricular escape interval to more nearly match the intrinsic ventricular rate, more paces are delivered and less variability in the overall ventricular rhythm is allowed. With a more regular ventricular rate, cardiac output is improved during an atrial tachyarrhythmia. Ventricular rate regularization may also enhance the effectiveness of ventricular resynchronization pacing in the presence of an atrial tachyarrhythmia by increasing the number of paces delivered.
The most common condition for which pacemakers are used is in the treatment of bradycardia, where the ventricular rate is too slow. Atrio-ventricular conduction defects (i.e., AV block) that are fixed or intermittent and sick sinus syndrome represent the most common causes of bradycardia for which permanent pacing may be indicated. If functioning properly, a pacemaker makes up for the heart's inability to pace itself at an appropriate rhythm in order to meet metabolic demand by enforcing a minimum heart rate. As described below, bradycardia pacing modes define which chambers are paced and the manner in which the paces are delivered. Pacing therapy can also be used in the treatment of congestive heart failure (CHF). Some CHF patients suffer from some degree of AV block or are chronotropically deficient such that their cardiac output can be improved with conventional bradycardia pacing. It has also been shown, however, that some CHF patients suffer from intraventricular and/or interventricular conduction defects such that their cardiac outputs can be increased by improving the synchronization of right and left ventricular contractions with electrical stimulation, referred to herein as ventricular resynchronization therapy.
A pacemaker patient with some degree of CHF who experiences an episode of atrial fibrillation will suffer some diminishing of cardiac output from the resulting irregular ventricular rhythm and/or loss of atrio-ventricular synchrony. Thus, even if a patient were adequately treated during normal circumstances with only a bradycardia pacing mode, the same patient may benefit from resynchronization therapy to restore hemodynamic stability during the atrial fibrillation episode. Furthermore, patients treated with resynchronization therapy in addition to a bradycardia pacing mode may benefit from a modification to the pacing mode including changes to the mode of resynchronization. The present invention relates to a method for operating a pacemaker in which a normal pacing mode is switched to an atrial fibrillation pacing mode upon detection of an atrial tachyarrhythmia such as atrial fibrillation that counteracts the adverse effects of atrial fibrillation.
1. Hardware Platform
Cardiac pacemakers are cardiac rhythm management devices that provide electrical stimulation in the form of pacing pulses to selected chambers of the heart. (As the term is used herein, a pacemaker is any cardiac rhythm management device that performs cardiac pacing, including implantable cardioverter/defibrillators having a pacing functionality.) Cardiac rhythm management devices are typically implanted subcutaneously in a patient's chest and have leads threaded intravenously into the heart to connect the device to electrodes used for sensing and pacing, the electrodes being disposed in proximity to selected chambers of the heart. Pacemakers typically have a programmable electronic controller that causes the pacing pulses to be output in response to lapsed time intervals and sensed electrical activity (i.e., intrinsic heart beats not as a result of a pacing pulse). A depolarization wave associated with an intrinsic contraction of the atria or ventricles that is detected by the pacemaker is referred to as an atrial sense (P wave) or ventricular sense (R wave), respectively. In order to cause such a contraction in the absence of an intrinsic beat, a pacing pulse with energy above a certain pacing threshold is delivered to the chamber.
The controller 10 controls the overall operation of the device in accordance with programmed instructions stored in memory. The controller 10 controls the delivery of paces via the pacing channels in accordance with a pacing mode, interprets sense signals from the sensing channels, and implements timers for defining escape intervals and sensory refractory periods. The controller also detects the presence of arrhythmias such as atrial fibrillation by measuring the time interval between senses and implements the mode switching function as described herein. It should be appreciated that these functions could also be performed by custom logic circuitry either in addition to or instead of a programmed microprocessor.
2. Bradycardia Pacing Modes
Bradycardia pacing modes are generally designated by a letter code of three positions where each letter in the code refers to a specific function of the pacemaker. The first letter refers to which heart chambers are paced and which may be an A (for atrium), a V (for ventricle), D (for both chambers), or O (for none). The second letter refers to which chambers are sensed by the pacemaker's sensing channels and uses the same letter designations as used for pacing. The third letter refers to the pacemaker's response to a sensed P wave from the atrium or an R wave from the ventricle and may be an I (for inhibited), T (for triggered), D (for dual in which both triggering and inhibition are used), and O (for no response). Modem pacemakers are typically programmable so that they can operate in any mode which the physical configuration of the device will allow. Additional sensing of physiological data allows some pacemakers to change the rate at which they pace the heart in accordance with some parameter correlated to metabolic demand. Such pacemakers are called rate-adaptive pacemakers and are designated by a fourth letter added to the three-letter code, R.
Pacemakers can enforce a minimum heart rate either asynchronously or synchronously. In asynchronous pacing, the heart is paced at a fixed rate irrespective of intrinsic cardiac activity. There is thus a risk with asynchronous pacing that a pacing pulse will be delivered coincident with an intrinsic beat. Most pacemakers for treating bradycardia today are therefore programmed to operate synchronously in a so-called demand mode where sensed cardiac events occurring within a defined interval either trigger or inhibit a pacing pulse. Inhibited demand pacing modes utilize escape intervals to control pacing in accordance with sensed intrinsic activity. In an inhibited demand mode, a pacing pulse is delivered to a heart chamber during a cardiac cycle only after expiration of a defined escape interval during which no intrinsic beat by the chamber is detected. If an intrinsic beat occurs during this interval, the heart is thus allowed to "escape" from pacing by the pacemaker. Such an escape interval can be defined for each paced chamber. For example, a ventricular escape interval can be defined between ventricular events so as to be restarted with each ventricular sense or pace. The inverse of this escape interval is the minimum rate at which the pacemaker will allow the ventricles to beat, sometimes referred to as the lower rate limit (LRL).
In atrial tracking pacemakers (i.e., VDD or DDD mode), another ventricular escape interval is defined between atrial and ventricular events, referred to as the atrio-ventricular interval (AVI). The atrio-ventricular interval is triggered by an atrial sense or pace and stopped by a ventricular sense or pace. A ventricular pace is delivered upon expiration of the atrio-ventricular interval if no ventricular sense occurs before. Atrial-triggered ventricular pacing attempts to maintain the atrio-ventricular synchrony occurring with physiological beats whereby atrial contractions augment diastolic filling of the ventricles. If a patient has a physiologically normal atrial rhythm, atrial-triggered pacing also allows the ventricular pacing rate to be responsive to the metabolic needs of the body. Atrial tracking modes are contraindicated when there is chronic refractory atrial tachyarrhythmia such as atrial fibrillation or atrial flutter.
A pacemaker can also be configured to pace the atria on an inhibited demand basis. An atrial escape interval is then defined as the maximum time interval in which an atrial sense must be detected after a ventricular sense or pace before an atrial pace will be delivered. When atrial inhibited demand pacing is combined with atrial-triggered ventricular demand pacing (i.e., DDD mode), the lower rate interval is then the sum of the atrial escape interval and the atrio-ventricular interval.
Rate-adaptive pacemakers modulate the ventricular and/or atrial escape intervals base upon measurements corresponding to physical activity. Such pacemakers are applicable to situations in which atrial tracking modes cannot be use. In a rate-adaptive pacemaker operating in a ventricular pacing mode, the LRL is adjusted in accordance with exertion level measurements such as from an accelerometer or minute ventilation sensor in order for the heart rate to more nearly match metabolic demand. The adjusted LRL is then termed the sensor-indicated rate.
3. Ventricular Resynchronization Therapy
In a ventricular resynchronization pacing mode, pacing stimulation is applied to one or both ventricles in a manner that improves the coordination of ventricular contractions and thereby improves ventricular pumping efficiency. In delivering such therapy, for example, it may be useful to pace only one ventricle on an inhibited demand basis in accordance with sense signals received from the opposite ventricle, pace one ventricle in a triggered mode in which an intrinsic beat in one ventricle triggers a pace in the opposite ventricle, pace both ventricles on an inhibited demand basis in accordance with sense signals received from only one ventricle, or pace both ventricles in a combination of triggered and inhibited demand modes. In the examples of resynchronization therapy that follow, the ventricular pacing modes are based upon intrinsic activity in the right ventricle. It should be appreciated, however, that equivalent embodiments could be applied to pacing modes based upon left ventricular intrinsic activity.
One implementation of resynchronization therapy is biventricular (BV) pacing. In BV pacing, a left ventricular pace is delivered either simultaneously or in a timed relation with a right ventricle pace as specified by a biventricular offset interval. The offset interval may be zero in order to pace both ventricles simultaneously, positive in order to pace the left ventricle after the right, or negative if the left ventricle is paced before the right. In many cases, pumping efficiency of the heart will be increased by simultaneous pacing of the ventricles with an offset of zero. However, it may be desirable in certain patients to pace one ventricle before the other in order to compensate for different conduction velocities in the two ventricles, and this may be accomplished by specifying a particular biventricular offset interval. The ventricles may be paced on an inhibited demand basis where the ventricular escape interval is restarted with either a ventricular pace or a right ventricular sense. The pacing mode may also include atrial tracking. In that case, a pair of ventricular paces are delivered after expiration of the AVI escape interval or expiration of the LRL escape interval, with ventricular pacing inhibited by a right ventricular sense that restarts the LRL escape interval or stops the AVI escape interval. Since the ventricular escape interval in this mode is reset or stopped by senses only from the right ventricle, a left ventricular protection period may be provided that starts with the occurrence of a left ventricular sense and lasts for a specified time. A left ventricular pace is then not permitted upon expiration of the escape interval if it would occur within the protection period.
A variation of biventricular pacing is to pace only the left ventricle (LV-only pacing). LV-only pacing may be advantageous where the conduction velocities within the ventricles are such that pacing only the left ventricle results in a more coordinated contraction by the ventricles than with conventional right ventricular pacing or biventricular pacing. LV-only pacing may be implemented in inhibited demand modes with or without atrial tracking, similar to biventricular pacing. A left ventricular pace is then delivered upon expiration of the AVI escape interval or expiration of the LRL escape interval, with left ventricular pacing inhibited by a right ventricular sense that restarts the LRL escape interval or stops the AVI escape interval. As with BV pacing, a left ventricular pace may be inhibited if a left ventricular sense occurs within a protective period prior to expiration of the ventricular escape interval. Since an inhibited left ventricular pace in this mode could result in a cardiac cycle with no pacing, the mode may be further modified such that a right ventricular safety pace is delivered if the left ventricular pace is inhibited and no right ventricular sense has occurred.
Another ventricular resynchronization mode is a biventricular triggered (BT) mode where one or both ventricles are paced within a latency period following a sense from the right ventricle. In this mode, rather than inhibiting pacing upon receipt of a right ventricular sense, ventricular pacing is triggered to occur in the shortest time possible after a right ventricular sense in order produce a coordinated contraction of the ventricles. This mode of pacing may be desirable when the intraventricular conduction time of the heart is long enough that the pacemaker is able to reliably insert a pace before depolarization from the right ventricle would reach the left ventricle. The time delay between a right ventricular sense and the ensuing pace output is dictated by the response time of the hardware and is designated as the sense-to-pace latency (SPL) interval. Note that the SPL interval is a characteristic of the hardware and not a programmable timer interval. The mode may operate such that following a right ventricular sense, either the left ventricle only is paced, or both ventricles are paced. In the latter case, the right ventricle is paced even though a right ventricular sense has been received to allow for the possibility that the right ventricular sense was actually a far-field left ventricular sense in the right ventricular channel. If the right ventricular sense were actually from the right ventricle, the right ventricular pace would occur during the right ventricle's physiological refractory period and be of no consequence. With either type of BT pacing mode, pacing of the left ventricle can be inhibited by a left ventricular sense that triggers a left ventricular protective period interval. Biventricular triggered pacing can also be combined with biventricular inhibited demand pacing.
4. Ventricular Rate Regularization
Ventricular rate regularization (VRR) is a ventricular pacing mode in which the LRL of the pacemaker is dynamically adjusted in accordance with a detected intrinsic ventricular rate. When a pacemaker is operating in a ventricular pacing mode (e.g., VVI), intrinsic ventricular beats occur when the instantaneous intrinsic rate rises above the LRL of the pacemaker. Otherwise, paces are delivered at a rate equal to the LRL. Thus, paces are interspersed with intrinsic beats, and the overall ventricular rhythm as a result of both paces and intrinsic beats is determined by the LRL and the mean value and variability of the intrinsic ventricular rate. VRR regularizes the overall ventricular rhythm by adjusting the LRL of the pacemaker in accordance with changes in the measured intrinsic rate.
The intrinsic ventricular rate is the rate at which intrinsic ventricular beats occur and can be defined both instantaneously and as being at some mean value with a certain variability about that mean. The instantaneous intrinsic rate can be determined by measuring an R-R interval, where an R-R interval is the time between a present ventricular sense (i.e., an R-wave or intrinsic ventricular depolarization) and the preceding ventricular sense or ventricular pace, with the instantaneous rate being the reciprocal of the measured interval. The LRL of a pacemaker is initially set to a programmed base value and defines the ventricular escape interval, which is the maximum time between ventricular beats allowed by the pacemaker and is the reciprocal of the LRL. At any particular mean intrinsic rate above the LRL, a ventricular pace is delivered only when, due to the variability in the intrinsic rate, an R-R interval would be longer than the ventricular escape interval were it allowed to occur. As the mean intrinsic ventricular rate increases above the LRL, fewer paces are delivered and more variability in the overall ventricular rhythm is allowed. The VRR pacing mode counteracts this by increasing the LRL as the intrinsic ventricular rate increases to thereby increase the frequency of paced beats and lessen the variability in the overall ventricular rate. The VRR mode then decreases the LRL toward its base value as the number of paces delivered increases due to a decrease in either the mean intrinsic ventricular rate or its variability. The LRL adjusted in this manner is also referred to herein as the VRR-indicated rate.
In one embodiment of VRR, the LRL is adjusted by measuring an R-R interval when a ventricular sense occurs and then computing an updated ventricular escape interval based upon the measured R-R interval. When a ventricular pace is delivered, on the other hand, the LRL is made to decay toward the programmed base value.
When a ventricular sense occurs, the measured R-R interval is input to a recursive digital filter 515 whose output is the updated ventricular escape interval. The filter 515 multiplies the measured R-R interval by a filter coefficient A and then adds the result to the previous value of the output (i.e., the present ventricular escape interval) multiplied by a filter coefficient B. The operation of the filter is thus described by VEIn=A(RRn)+B(VEIn-1), where A and B are selected coefficients, RRn is the most recent R-R interval duration, and VEIn-1 is the previous value of the ventricular escape interval. A useful way to conceptualize the filter 515 is to decompose the coefficients A and B into a scaling factor a and a weighting coefficient w such that A=a·w and B=(1-w), where w is between 0 and 1. Viewed this way, the filter is seen as computing a weighted average of the present R-R interval multiplied by the scaling factor a and the present ventricular escape interval. The filter thus causes the value of the ventricular escape interval to move toward the present R-R interval multiplied by the scaling factor at a rate determined by the weighting coefficient. This corresponds to the filter moving the pacemaker's LRL toward a fraction 1/a of the instantaneous intrinsic ventricular rate as determined by the measured R-R interval. If a ventricular sense has occurred, the current LRL is necessarily less than the measured instantaneous intrinsic ventricular rate. If it is also less than 1/a of the intrinsic rate, the LRL is increased by the filter up to a value that is 1/a of the intrinsic rate to result in more pacing and less variability in the overall ventricular rhythm.
When a ventricular pace is delivered due to expiration of the ventricular escape interval without a ventricular sense, filter 516 multiplies the present ventricular escape interval by a filter coefficient C so that VEIn=C(VEIn-1). To provide stable operation, the coefficient C must be set to a value greater than 1. Filter 516 then causes the ventricular escape interval to increase in an exponential manner with each pace as successive values of the escape interval are input to the filter up to a value corresponding to the base LRL.
The updating of the ventricular escape interval may be performed in various ways including on a beat-to-beat basis, at periodic intervals, or with averages of successive R-R intervals. In a presently preferred embodiment, however, the updating is performed on a beat-to-beat basis with each ventricular sense or pace causing adjustment of the LRL by filter 515 or 516, respectively. The two filters operating together thus cause the LRL to move closer to 1/a of the measured intrinsic rate after a ventricular sense and to decay toward the base LRL value after a ventricular pace.
The coefficients a and w (or A and B) and C are selected by the user and may be made programmable so that the behavior of the system can be adjusted to produce the clinically best result in an individual patient. For example, as the scaling factor a is made greater than 1, the filter 515 causes the LRL to move toward a smaller fraction 1/a of the detected intrinsic rate which allows more intrinsic beats to occur and greater variability in the overall rhythm. As a is decreased back toward 1, the filter 515 tends to move the LRL of the pacemaker toward a larger fraction of the detected instantaneous intrinsic rate, thus increasing the amount of pacing and decreasing the amount of variability allowed in the overall ventricular rhythm. If a is made smaller than 1, the LRL is moved toward a rate higher than the intrinsic rate, further increasing the amount of pacing to point where most of the ventricular rhythm is made up of paced beats. The larger the weighting factor w, the faster the LRL is moved to the specified fraction of the intrinsic rate, making the system more responsive to increases in the variability of the intrinsic rhythm. The larger the decay coefficient C, the more rapidly will filter 516 cause the LRL to decrease toward its programmed base value when ventricular paces are delivered due to no ventricular senses being detected within the ventricular escape interval. The controller limits the updated ventricular escape interval as a result of the operations of filters 515 and 516 to minimum and maximum values in accordance with a programmed maximum pacing rate MPR and base lower rate limit LRL, respectively.
As noted, the coefficients of filters 515 and 516 can be made programmable by the user, such as by using a remote programmer. In another embodiment, the user selects a desired performance parameter (e.g., desired degree of rate regularization, desired amount of pacing, desired decay rate, etc.) from a corresponding range of possible values. The appropriate combinations of coefficients for filters 515 and 516 are then automatically selected to provide filter settings that correspond to the selected user-programmed performance parameter. The filter coefficients can also be made functions of other parameters, such as the measured R-R interval and current LRL setting, and dynamically adjusted.
The VRR system in this embodiment uses the programmed base LRL of the pacemaker as the lower limit to which the LRL is permitted to decay when no ventricular senses are detected. The base LRL can be changed periodically by the user with an external programmer, and rate-adaptive pacemakers have the capability of dynamically adjusting the LRL in order to adapt to exercise. If a rate-adaptive pacemaker is operated in a VRR mode, the sensor-indicated rate can simply be regarded by the pacemaker as the base LRL. The lower limit for the VRR-indicated rate is then the sensor-indicated rate rather than the programmed base LRL.
5. Pacing Mode Switching During Atrial Fibrillation
The atrial fibrillation mode may include initiation of ventricular rate regularization as shown at block 302. If AV conduction is intact in a patient, atrial fibrillation results in a very rapid and intrinsic ventricular rhythm, and regularizing the ventricular rate improves cardiac output directly through its effect on diastolic filling. Ventricular rate regularization may be applied in this instance with parameter settings such that the ventricles are driven at a rate near the intrinsic rate. The intrinsic ventricular rhythm that occurs during an episode of atrial fibrillation is a result of the chaotically occurring depolarizations occurring in the atria being passed through the AV node to the ventricles. The intrinsic ventricular rate is thus governed by the cycle length of the atrial fibrillation and the refractory period of the AV node. If a ventricular pacing pulse is delivered before the next intrinsic beat occurs, the ventricular depolarization is conducted retrogradely to the AV node causing late depolarization of the AV node during the ventricular beat. The refractory period of the AV node is also delayed, which delays the time before an atrial depolarization can be conducted through the node to result in an intrinsic beat. The effect of the pace is thus to lengthen the time until the next intrinsic beat. Ventricular rate regularization at a pacing rate near the intrinsic ventricular rate is thus especially effective at regularizing the ventricular rate during atrial fibrillation.
Ventricular resynchronization therapy may also be initiated as part of the atrial fibrillation mode. In pacemaker patients having some degree of interventricular or intraventricular conduction delays, a ventricular resynchronization pacing mode can improve cardiac output by improving the coordination of ventricular contractions. Although cardiac output may be adequate in some of these patients during normal circumstances even without ventricular resynchronization pacing, an episode of atrial fibrillation with loss of atrio-ventricular synchrony and irregular diastolic filling may cause the conduction deficits to become clinically evident. Switching the pacemaker to a ventricular resynchronization pacing mode may then be helpful in maintaining cardiac output when atrial fibrillation is detected.
Resynchronization pacing as incorporated into the atrial fibrillation mode may be delivered in a number of different pacing modes. One such resynchronization pacing mode is biventricular pacing with or without an offset interval. This mode can be combined with the reverted to VVI bradycardia pacing mode to result in biventricular pacing on an inhibited demand basis as depicted at block 304. Other alternatives for the atrial fibrillation mode are biventricular-triggered and LV-only pacing modes as shown by blocks 306 and 303, respectively. Biventricular-triggered resynchronization pacing may be particularly useful when the intrinsic ventricular rate is irregular as it allows reliable delivery of resynchronization pulses based upon the irregular rate. It may also be advantageous to combine resynchronization pacing with ventricular rate regulation as the ventricular rate regulation can be set to increase the amount of pacing and, therefore, the amount of resynchronization. If ventricular resynchronization is part of the normal pacing mode, the atrial fibrillation mode may then include particular modification of resynchronization pacing parameters such as adjustments to the biventricular offset interval designated by block 305, or switching to an alternative resynchronization pacing mode or switching to additional or alternate pacing sites.
The diminished cardiac output that occurs during atrial fibrillation can also be partially counteracted by making the pacing rate responsive to measured exertion levels. Accordingly, the atrial fibrillation mode may also include switching from non-rate adaptive to rate-adaptive pacing as shown at block 308, and/or modification of rate-adaptive parameters as shown at block 307. In the latter case, for example, the rate-response curve that maps a given exertion level to a particular pacing rate may be adjusted to make the pacemaker more responsive, and/or the base lower rate limit corresponding to a resting exertion level could be increased.
Although the invention has been described in conjunction with the foregoing specific embodiment, many alternatives, variations, and modifications will be apparent to those of ordinary skill in the art. Such alternatives, variations, and modifications are intended to fall within the scope of the following appended claims.
|Brevet citant
|Date de dépôt
|Date de publication
|13 oct. 2006
|28 sept. 2010
|Cardiac Pacemakers, Inc.
|Apparatus and method for pacing mode switching during atrial tachyarrhythmias
|27 sept. 2010
|9 aoűt 2011
|Cardiac Pacemarkers, Inc.
|Apparatus and method for pacing mode switching during atrial tachyarrhythmias
|12 juin 2006
|22 nov. 2011
|Cardiac Pacemakers, Inc.
|Method and apparatus for treating irregular ventricular contractions such as during atrial arrhythmia
|1 déc. 2008
|13 mars 2012
|Cardiac Pacemakers, Inc.
|System providing ventricular pacing and biventricular coordination
|9 avr. 2010
|7 aoűt 2012
|Cardiac Pacemakers, Inc.
|Atrial arrhythmia detection and discrimination based on intracardiac impedance
|15 juin 2010
|7 aoűt 2012
|Cardiac Pacemakers, Inc.
|Cardiac pacing system for prevention of ventricular fibrillation and ventricular tachycardia episode
|9 févr. 2007
|21 aoűt 2012
|Cardiac Pacemakers, Inc.
|Apparatus and method for ventricular rate regularization
|20 déc. 2010
|5 mars 2013
|Cardiac Pacemakers, Inc.
|Apparatus and method for pacing mode switching during atrial tachyarrhythmias
|7 juin 2007
|20 aoűt 2013
|Cardiac Pacemakers, Inc.
|Rate smoothing control
|31 oct. 2013
|25 nov. 2014
|Cardiac Pacemakers, Inc.
|Biventricular-triggered pacing in the context of multi-site left ventricular pacing
|28 avr. 2010
|17 mars 2015
|Cardiac Pacemakers, Inc.
|Method and apparatus for safety control during cardiac pacing mode transition
|31 oct. 2013
|27 févr. 2014
|Cardiac Pacemakers, Inc.
|Biventricular-triggered pacing in the context of multi-site left ventricular pacing
|Classification aux États-Unis
|Classification internationale
|Classification coopérative
|Classification européenne


text: Miss Murphy | IBDB: The official source for Broadway Information IBDB: The official source for Broadway Information Official Broadway League sites: - sites - broadway.org broadwayleague.com broadwayfanclub.com kidsnightonbroadway.com stagespecs.org tonyawards.com Quick Search For: In This Category: All Show People/Org. Theatre Season Miss Murphy Performer Female Productions ProductionsDate of ProductionsThe Century Girl[Musical, Revue, Original] Performer: Miss Murphy Nov 06, 1916 - Apr 28, 1917Sari[Musical, Operetta, Original] Performer: Miss Murphy [Chorus]Jan 13, 1914 - May 23, 1914 Find out where Miss Murphy and are credited together © 2001-2015, The Broadway League, All Rights Reserved. (Copyright and Disclaimer)

subset: commoncrawl


text:
Billion-Dollar YouTube Suit Ends With a Whimper
Viacom's would-be blockbuster lawsuit against YouTube has fizzled out, with the companies reaching a settlement and apparently planning to collaborate on future endeavors. Though it ended quietly, the billion-dollar lawsuit's stakes were high. The case will have a profound effect on the Internet's future, said the Center for Democracy and Technology's David Sohn.
Mar 18, 2014 3:49 PM PT
Google and Viacom have settled a long-running copyright suit, after a federal judge twice threw out the case.
"Google and Viacom today jointly announced the resolution of the Viacom vs. YouTube copyright litigation," the companies said Tuesday in a brief joint statement. "This settlement reflects the growing collaborative dialogue between our two companies on important opportunities, and we look forward to working more closely together."
Terms of the settlement were not disclosed. No money changed hands in the settlement, according to Re/code.
Google did not respond to our request for further details.
'South Park' Clips
Viacom had claimed in the US$1 billion suit that Google-owned YouTube was violating its copyrights by allowing users to post clips from Viacom's TV shows.
Viacom -- which owns networks including Comedy Central, MTV and Nickelodeon -- said in its original 2007 suit that users were uploading thousands of videos from TV shows including The Daily Show With Jon Stewart and South Park, as well as films by its Paramount Pictures movie studio.
U.S. District Judge Louis Stanton ruled in Google's favor in 2010. However, the U.S. Court of Appeals in New York overturned his ruling and sent the case back to district court. Stanton again threw out the suit last April.
Safe Harbor Provision
Google and YouTube were protected from copyright liability due to the safe harbor provision of the Copyright Act, said Stanton. YouTube removes infringing videos from its network when it is alerted to them -- for instance, when a user reports the copyright infringement manually or when YouTube's automated Content ID system recognizes copyrighted content provided to the company by copyright holders.
Viacom planned to appeal Stanton's decision following his second ruling.
YouTube pulled in visitors to its website and made itself more intriguing to potential viewers by using copyrighted material without consent, Viacom claimed. It also generated revenue from ads placed alongside such content.
Google maintained that it removes infringing videos when alerted.
Viacom itself had added videos to YouTube to promote its TV shows, and YouTube was unable to determine which videos were authorized and which were not, the company also claimed.
Google purchased YouTube in 2006. Viacom also had been interested in acquiring the video-sharing site, Google noted.
Future Partnerships?
The settlement could pave the way for Google and Viacom to work more closely together. In 2011, YouTube struck a deal with Paramount Pictures to offer movie rentals.
"This suit was settled. These companies can now do business together," telecom analyst Jeff Kagan told the E-Commerce Times, "but that doesn't mean there won't be another suit in the future. This is just the way business operates. In fact, often companies sue each other and do business together at the same time."
The settlement brings the legal proceedings to a formal end, according to David Sohn, general counsel and director of the project on copyright and technology at the Center for Democracy and Technology, but the implications of the case will have a profound effect on the Internet's future.
'Full-Frontal Attack'
"It was important litigation when it was filed because it launched a full-frontal attack on the safe harbor provision," Sohn told the E-Commerce Times.
"Viacom really tried to narrow down the scope of that provision in ways that would open up YouYube and others to copyright liability," he added.
"From the CDT's perspective, the decisions and precedents set in this case are important for the Internet," Sohn continued.
"The outcome of the suit is crucial for continuing experimentation on forms for users' free expression. The reason Internet platforms can experiment with new communications tools that let users provide content is that the DMCA provides a safe harbor for platforms like YouTube," he explained. "All new platforms that are starting small and are hoping to grow rely on that legal provision too."


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A federal judge has overturned Arizona's law defunding Planned Parenthood, ruling that women receiving Medicaid have the right to choose the medical provider they want to use for so-called family planning services. In his 11-page ruling shooting down the measure duly passed by the state's elected lawmakers, federal Judge Neil Wake said that there was no reason to believe the abortion giant was not qualified to provide non-abortion "family planning" services covered under the federal medical assistance program, and that the law appeared to be an attempt by Arizona legislators to disqualify Planned Parenthood from state and federal funding.
The Whole Woman's Health Funding Priority Act (H.B. 2800), signed into law May 4 by pro-life Arizona Governor Jan Brewer, was based on model legislation developed by the pro-life Susan B. Anthony List and Alliance Defending Freedom, and was designed to steer government funding away from abortion businesses such as Planned Parenthood to medical providers that concentrate on comprehensive health care for women. The measure prohibited state or any local governments from using public money to contract with organizations that provide abortions.
During a signing ceremony Gov. Brewer called the measure a "common-sense law that tightens existing state regulations and closes loopholes in order to ensure that taxpayer dollars are not used to fund abortions, whether directly or indirectly. By signing this measure into law, I stand with the majority of Americans who oppose the use of taxpayer funds for abortion."
But as it has in every state that has taken away its funding, Planned Parenthood fought back against the bill, insisting that it would deprive women of choice in their healthcare decisions and would especially impact low-income women. "What we are seeing is an assault on women making their own decisions about health care, whether it's abortion or health care," Arizona Planned Parenthood CEO Bryan Howard complained of the new measure. "It makes it harder for women to access birth control, hard for women to access cancer screening and abortion care." He claimed that the lost revenue for Planned Parenthood would hurt thousands of Arizona women living below the poverty level.
Click here to read the entire article.


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Anyone here dealt with one? My surgeon says I don't have an inguinal hernia (had 2 exams to confirm), but that I might have a sports hernia. I decided not to schedule the MRI for now and I'm exercising again cautiously after 6 weeks of no PT. Sports Hernias are not very common outside the sports world, so information is a little hard to come by.
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By Robert OlsonSpring Glen
First off let me inform everyone reading this that this is not intended to attack those who maintain and care for Spring Glen Park; they do an amazing job.
As I read the letter in a recent Sun Advocate issue about the use of the park by a little league baseball team that had come there to practice, I found it a little bit more than disturbing.
As stated in the letter, they were approached by the "keeper of the park" and were told they needed to pay to use the park to practice there. This caused a spectator to become upset. I would have had, and still have, that same reaction.
This park, a community park, should be used and not sit empty as a showcase of our community but, likewise those who use it should take pride in keeping it looking good by cleaning up after they use it.
I've witnessed the youth there playing basketball, children on park equipment, families having picnics. Are they asked to pay? I think the answer to that question is no, Then why are the little league teams expected to?
I have lived in Spring Glen for over 40 years. I've helped in the construction of the building. I've cut the grass when it was mostly weeds. I've witnessed a big change in "Our Park" over the years. Those who are now over it and take care of it have done a super job. The community should be proud of the park and help to keep it nice. And when called upon to help with the up-keep, physically or financially, we should all step up to the challenge.
Keeping the park up requires money. But requiring everyone who uses it to pay to do so is not the way it should be financed. However, if someone or a group reserves it for their use, they should be expected to pay. But for everyday use of the park by individuals or groups, no.
I have attended many social gathering with the community residents at the park; Spring Glen Days, Frontier Days and dinners and breakfasts that were served mostly with donated food prepared by community members to raise funds for the park.
These types of outings are a place to bring us together as a community; to unite us to work for the good we can do when we support and build up projects that make Spring Glen a better place to live.
These activities are also a place to get the funds needed to support the park. I don't think there would be any who would not support and be willing to pay a little more for those dinners or breakfasts, than have what happened with the little league team to happen again.
We have a group of men who give up their time from their families to help form boys into men and we thank them for their efforts and patience with our children, grandchildren and even great-grandchildren. Let them use the park.
As the old saying goes... PLAY BALL!


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PetSmart Charities
Accredited Charity
Meets Standards
19601 North 27th Avenue
Phoenix, AZ 85027
19601 North 27th Avenue
Phoenix, AZ 85027
Accredited Charity
Meets Standards
Standards Legend
- Meets Standards
- Standards Not Met
- Did Not Disclose
- Review In Progress
- Unable to Verify
Standards For Charity Accountability
Board Oversight
Oversight of Operations and Staff: Standard 1
Organizations shall have a board of directors that provides adequate oversight of the charity's operations and its staff. Indication of adequate oversight includes, but is not limited to, regularly scheduled appraisals of the CEO's performance, evidence of disbursement controls such as board approval of the budget, fund raising practices, establishment of a conflict of interest policy, and establishment of accounting procedures sufficient to safeguard charity finances.
The organization meets this standard.
Board Size
Number of Board Members: Standard 2
Soliciting organizations shall have a board of directors with a minimum of five voting members.
The organization meets this standard.
Board Meetings
Frequency and Attendance of Board Meetings: Standard 3
An organization shall have a minimum of three evenly spaced meetings per year of the full governing body with a majority in attendance, with face-to-face participation. A conference call of the full board can substitute for one of the three meetings of the governing body. For all meetings, alternative modes of participation are acceptable for those with physical disabilities.
The organization meets this standard.
Board Compensation
Compensated Board Members: Standard 4
Not more than one or 10% (whichever is greater) directly or indirectly compensated person(s) serving as voting member(s) of the board. Compensated members shall not serve as the board's chair or treasurer.
The organization meets this standard.
Conflict of Interest
Conflict of Interest: Standard 5
No transaction(s) in which any board or staff members have material conflicting interests with the charity resulting from any relationship or business affiliation. Factors that will be considered when concluding whether or not a related party transaction constitutes a conflict of interest and if such a conflict is material, include, but are not limited to: any arm's length procedures established by the charity; the size of the transaction relative to like expenses of the charity; whether the interested party participated in the board vote on the transaction; if competitive bids were sought and whether the transaction is one-time, recurring or ongoing.
The organization meets this standard.
Measuring Effectiveness
Effectiveness Policy
Board Policy on Effectiveness: Standard 6
Have a board policy of assessing, no less than every two years, the organization's performance and effectiveness and of determining future actions required to achieve its mission.
The organization meets this standard.
Effectiveness Report
Board Approval of Written Report on Effectiveness: Standard 7
Submit to the organization's governing body, for its approval, a written report that outlines the results of the aforementioned performance and effectiveness assessment and recommendations for future actions.
The organization meets this standard.
Program Expenses
Program Service Expense Ratio: Standard 8
Spend at least 65% of its total expenses on program activities.
The organization meets this standard.
Fund Raising Expenses
Fund Raising Expense Ratio: Standard 9
Spending should be no more than 35% of related contributions on fund raising. Related contributions include donations, legacies, and other gifts received as a result of fund raising efforts.
The organization meets this standard.
Accumulating Funds
Ending Net Assets: Standard 10
Avoid accumulating funds that could be used for current program activities. To meet this standard, the charity's unrestricted net assets available for use should not be more than three times the size of the past year's expenses or three times the size of the current year's budget, whichever is higher.
The organization meets this standard.
Audit Report
Financial Statements: Standard 11
Make available to all, on request, complete annual financial statements prepared in accordance with generally accepted accounting principles. When total annual gross income exceeds $500,000, these statements should be audited in accordance with generally accepted auditing standards. For charities whose annual gross income is less than $500,000, a review by a certified public accountant is sufficient to meet this standard. For charities whose annual gross income is less than $250,000, an internally produced, complete financial statement is sufficient to meet this standard.
The organization meets this standard.
Detailed Expense Breakdown
Detailed Functional Breakdown of Expenses: Standard 12
Include in the financial statements a breakdown of expenses (e.g., salaries, travel, postage, etc.) that shows what portion of these expenses was allocated to program, fund raising, and administrative activities. If the charity has more than one major program category, the schedule should provide a breakdown for each category.
The organization meets this standard.
Accurate Expense Reporting
Accuracy of Expenses in Financial Statements: Standard 13
Accurately report the charity's expenses, including any joint cost allocations, in its financial statements. For example, audited or unaudited statements which inaccurately claim zero fund raising expenses or otherwise understate the amount a charity spends on fund raising, and/or overstate the amount it spends on programs will not meet this standard.
The organization meets this standard.
Budget Plan
Budget: Standard 14
Have a board-approved annual budget for its current fiscal year, outlining projected expenses for major program activities, fund raising, and administration.
The organization meets this standard.
Fund Raising & Info
Truthful Materials
Misleading Appeals: Standard 15
Have solicitations and informational materials, distributed by any means, that are accurate, truthful and not misleading, both in whole and in part. Appeals that omit a clear description of program(s) for which contributions are sought will not meet this standard. A charity should also be able to substantiate that the timing and nature of its expenditures are in accordance with what is stated, expressed, or implied in the charity's solicitations.
The organization meets this standard.
Annual Report
Annual Report: Standard 16
Have an annual report available to all, on request, that includes: (a) the organization's mission statement, (b) a summary of the past year's program service accomplishments, (c) a roster of the officers and members of the board of directors, (d) financial information that includes (i) total income in the past fiscal year, (ii) expenses in the same program, fund raising and administrative categories as in the financial statements, and (iii) ending net assets.
The organization meets this standard.
Website Disclosures
Web Site Disclosures: Standard 17
Include on any charity websites that solicit contributions, the same information that is recommended for annual reports, as well as the mailing address of the charity and electronic access to its most recent IRS Form 990.
The organization meets this standard.
Donor Privacy
Privacy for Written Appeals & Internet Privacy: Standard 18
Address privacy concerns of donors by (a) providing in written appeals, at least annually, a means (e.g., such as a check off box) for both new and continuing donors to inform the charity if they do not want their name and address shared outside the organization, (b) providing a clear, prominent and easily accessible privacy policy on any of its websites that tells visitors (i) what information, if any, is being collected about them by the charity and how this information will be used, (ii) how to contact the charity to review personal information collected and request corrections, (iii) how to inform the charity (e.g., a check off box) that the visitor does not wish his/her personal information to be shared outside the organization, and (iv) what security measures the charity has in place to protect personal information.
The organization meets this standard.
Cause Marketing Disclosures
Cause Related Marketing: Standard 19
Clearly disclose how the charity benefits from the sale of products or services (i.e., cause-related marketing) that state or imply that a charity will benefit from a consumer sale or transaction. Such promotions should disclose, at the point of solicitation: (a) the actual or anticipated portion of the purchase price that will benefit the charity (e.g., 5 cents will be contributed to abc charity for every xyz company product sold), (b) the duration of the campaign (e.g., the month of October), (c) any maximum or guaranteed minimum contribution amount (e.g., up to a maximum of $200,000).
The organization meets this standard.
Complaints: Standard 20
Respond promptly to and act on complaints brought to its attention by the BBB Wise Giving Alliance and/or local Better Business Bureaus about fund raising practices, privacy policy violations and/or other issues.
The organization meets this standard.
PetSmart Charities meets the 20 Standards for Charity Accountability.
Year, State Incorporated
1994, Arizona
Stated Purpose
"to improve the quality of life for all pets by creating and supporting programs that save the lives of homeless pets and promote healthy relationships between people and pets."
PetSmart creates and supports programs that save the lives of homeless pets, raise awareness of animal companion issues, and promote healthy relationships between people and pets through: adoption, spay and neuter initiatives, emergency relief, and education and awareness. PetSmart grants funding to local animal-welfare organizations in order to help facilitate in-store pet adoption. As reported by the charity, PetSmart Charities Adoption Centers are located in more than 1,200 PetSmart stores nationwide. The organization also provides funding to increase the availability of low-cost spay and neuter services, delivers disaster-relief grants to animal-welfare agencies, and funds education workshops for animal-welfare organizations via webinars.
|Adoptions and transport
|Spay/ neuter
|Emergency relief
|Education and awareness
|Total Program Expenses:
Governance & Staff
Chief Executive
Susana M. Della Maddalena, Vice President and Executive Director
Chair of the Board
Philip Francis
Chair's Profession / Business Affiliation
Retired Executive Chairman of PetSmart, Inc.
Board Size
Paid Staff Size
*2012 compensation includes annual salary and, if applicable, benefit plans, expense accounts, and other allowances.
Fund Raising
Method(s) Used:
Direct mail, special events, television, radio, Internet appeals, planned, cause-related marketing, and in-store donations.
Fund raising costs were 10% of related contributions. (Related contributions, which totaled $40,919,956, are donations received as a result of fund raising activities.)
Tax Status
This organization is tax-exempt under section 501(c)(3) of the Internal Revenue Code. It is eligible to receive contributions deductible as charitable donations for federal income tax purposes.
The following information is based on PetSmart's audited financial statements for the fiscal year ended January 29, 2012.
|Source of Funds
|Individual contributions
|PetSmart, Inc. contributions
|Corporate, foundation and vendor contributions
|Special events net
|Investment income
|Total Income
- Programs: 87%
- Fundraising: 7%
- Administrative: 6%
|Total Income
|Program expenses
|Fundraising expenses
|Administrative expenses
|Other expenses
|Total expenses:
|Expenses in Excess of Income
|Beginning Net Assets
|Ending Net Assets
|Total Liabilities
|Total Assets
According to PetSmart Charities' audited financial statement for the fiscal year ended January 29, 2012, the organization received in-kind donations of $15,469,345, including donated rent, goods and services amounting to $14,867,824 from Pet Smart Inc. As reported by PetSmart Charities, total in-kind donations are recognized as follows: labor ($5,028,622), supplies ($5,017,907), occupancy ($4,089,465), advertising ($1,323,447), printing ($5,604), and equipment rental ($4,300).
An organization may change its practices at any time without notice. A copy of this report has been shared with the organization prior to publication. It is not intended to recommend or deprecate, and is furnished solely to assist you in exercising your own judgment. If the report is about a charity and states the charity meets or does not meet the Standards for Charity Accountability, it reflects the results of an evaluation of information and materials provided voluntarily by the charity. The name Better Business Bureau is a registered service mark of the Council of Better Business Bureaus, Inc.
This report is not to be used for fund raising or promotional purposes.


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By LES BOWENSun Advocate reporter
More than 200 women gathered on April 20 for the 28th annual College of Eastern Utah Women's Conference. Along with a variety of workshops and a luncheon, attendees heard from keynote speaker Holly Mullen.
Mullen has been a journalist for more than 26 years and recently was named editor of Salt Lake City Weekly last month. She spoke to the theme of the conference, "If the shoe fits."
"I'm not sure the men in the room really understand what shoes mean to women," said Mullen.
She called shoes the best accessory and said they are an inexpensive way to change an entire look.
But more than their role are as a fashion accessory, Mullen said changes in the role of women in society can be seen in what shoes they wear.
"I remember fondly going downtown with my grandmother," recalled Mullen. She explained in her grandmother's generation, women often had house shoes or slippers for home, but would never leave the house without a pair of pumps or heels.
And along with the nicer shoes, Mullen said her mother dressed up to go shopping, complete with a pillbox hat.
But then came war.
And as men were called overseas to fight in the world wars, women donned work boots in large numbers. Along with Rosie the Riveter, women formed the labor force that supported combat abroad.
"No war could have been won without the hard work and commitment of women at home in their work boots," said Mullen.
War showed the efforts of women counted outside the home, added Mullen. And since the world wars, the variety of shoes worn by women has expanded.
In the 1970s, women were afforded more opportunities in society with the passage of Title IX, requiring equal opportunities for women on the athletic field and in education.
Prior to the passage of Title IX, one in 20 young women played high school sports. Today, that number is closer to one in 2.5. And there are now more than 2.5 million female high school athletes across the country.
More than 10,000 scholarships for female athletes attract women to college.
With more women attending college, the number of college degrees attained by women has increased as well.
In the 1960s, women accounted for seven percent of law degrees and nine percent of medical degrees. And as long as 10 years ago, women accounted for 44 percent of law degrees and 41 percent of medical degrees.
And it was around the same time that the two-job economy emerged.
More single mothers, working mothers and a whole host of other family arrangements came about in the same period, and women continued to fill new positions in society.
Mullen told attendees her collection of shoes is comprised of flip-flops, river sandals, running shoes, ski boots and cowboy boots to name a few.
But while women have entered new positions in their communities, the wage gap of women compared to men has been slow to close.
"We can get into endless battles about gender and who is the better gender," said Mullen. "I'm not here to do that."
Rather, she said women should seek adequate and fair compensation in the workforce.
In 1963, women earned 59 cents for every dollar men earned. More than 40 years later, women see 77 cents for each dollar men receive today.
Recent reports about the wage gap have attributed the difference largely to the fact that women enter and exit the workforce more frequently than men.
"Someone needs to stay home, at least temporarily, with children," commented Mullen. She said women should not be punished for doing so, adding that women should receive comparable compensation for comparable work.
Even among jobs traditionally filled by women, such as secretaries, nurses and teachers, men don't make as much as other men. Yet men who enter the traditionally female jobs still make 20 percent more than their women have entered the political arena, too often they are judged on abstract qualities tied to their gender.
"I get tired of hearing about Secretary of State Condoleezza Rice's hair and whether she should be wearing boots," said Mullen.
She added that too often, Democratic presidential candidate Hillary Clinton is defined by her "edge" or some other indefinable quality based on her gender.
In her job covering politics in Salt Lake City, Mullen said mayor candidate Jenny Wilson is critiqued on her hair, attire and physical features. She has even heard critics ask, "Isn't she a mother?"
Mullen said Wilson is a mother who has a very supportive husband. But the question of her role as a mother should not weigh in as it does.
"We still have to fight for equality in a lot of ways in this country - in education, in jobs and even within the family," she said.
Mullen urged women to be careful not to seek extra compensation because of their gender.
She cited cases in the legal system where female offenders are often given a lighter sentence.
With male sexual offenders, Mullen said society uses terms like rape and assault, but when female offenders are accused of similar crimes, society uses terms like "slept together," which may give a perception of less wrongdoing.
"I don't want to feed the bias because a woman is involved," said Mullen.
She encouraged women not to whine about their circumstances or seek special privileges based on their gender.
"If we want to play and want a level playing field, we have to take our hits and keep standing up," she said.
Mullen also cautioned against the urge to degrade or minimalize more successful women with snide, undercutting remarks.
"Stand back for a moment and say 'I'm better than this. We are better than this,'" she counseled.
She encouraged women to find supportive, powerful partners who will not abuse them.
And she commended the attendees for coming together to support each other at women's conferences and urged them to continue doing so.
Mullen said she would like to see the day when the shoes worn by women and the shoes worn by men can be thrown into one pile that is open to everyone.


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Main Page Risk Factors Symptoms Diagnosis Treatment Screening Reducing Your Risk Talking to Your Doctor Living With Schizophrenia Resource Guide
You have a unique medical history. Therefore, it is essential to talk with your doctor about your personal risk factors and/or experience with schizophrenia . By talking openly and regularly with your doctor, you can take an active role in your care.
General Tips for Gathering Information
Here are some tips that will make it easier for you to talk to your doctor:
- Bring someone else with you. It helps to have another person hear what is said and think of questions to ask.
- Write out your questions ahead of time, so you don't forget them.
- Write down the answers you get, and make sure you understand what you are hearing. Ask for clarification, if necessary.
- Don't be afraid to ask your questions or ask where you can find more information about what you are discussing. You have a right to know about your health.
Specific Questions to Ask Your Doctor
About Schizophrenia
- What type of schizophrenia do I have?
- How serious is my condition?
- Can you tell me about the course of this illness? What can I expect?
- Will I be able to marry and have children?
- Will I be able to hold a job?
- Where can I get more information about schizophrenia?
About Your Risk of Developing Complications
Am I at risk for developing any complications such as:
- Depression
- Suicide
- Substance abuse
- Other
About Treatment Options
What treatment options are available for schizophrenia?
- What medicines can help me?
- How long will they take to work?
- What benefits can I expect?
- What side effects can I expect?
- How can I manage these side effects?
- Have you treated other people with schizophrenia? If not, do you know of another doctor who does?
Do you know where I can find:
- A treatment group
- Support groups
- Family interventions for people with schizophrenia
- Vocational training
- Other psychosocial interventions
Interview therapists who treat people with schizophrenia. Ask the following questions:
- How much training and experience do you have treating schizophrenia?
- What is your basic approach to treatment?
- How long do I need treatment?
- How long and how frequent are the treatment sessions?
- What type of health insurance is accepted?
- Do you have special fee schedules and/or sliding scale fees to accommodate various financial circumstances?
About Lifestyle Changes
Do I need to make changes in my:
- Daily routine
- Diet
- Activity
- How can I take the best care of myself?
About Outlook
- What are my chances of recovery?
- What can I do to prevent a relapse?
Revision Information
- Reviewer: Michael Woods, MD
- Review Date: 03/2015 -
- Update Date: 03/15/2015 -


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MARKVILLE CHEVROLET CORVETTE in MARKHAM, ON Is happy to meet the needs of each of our customers. We know that you have high expectations, and as a new and used car dealer we enjoy the challenge of meeting and exceeding those standards each and every time. Allow us to demonstrate our commitment to each and every customer we meet!
Regarding our products, our experienced sales staff is also pleased to share it's knowledge and enthusiasm with you. We encourage you to browse our online inventory, schedule a test drive and investigate financing options. You can also request more information about a vehicle using our online form or by calling 1 (866) 980-3290.
If you'd like a see a vehicle in person, click on Dealership: Directions for step-by-step driving instructions to our site, or give us a call. We look forward to serving you!Please confirm with seller accuracy of information. Mileage recorded at time of listing. Taxes are not included in listing price plus HST). Calculator below only provides estimated monthly payments and interest rates may vary"


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Science Friday® is produced by the Science Friday Initiative, a 501(c)(3) nonprofit organization.
Science Friday® and SciFri® are registered service marks of Science Friday, Inc. Site design by Pentagram; engineering by Mediapolis.
|Oncolytic, or cancer-lysing viruses, are being tested by researchers, to see if they efficiently kill cancer cells with minimal side effects. The American Cancer Society's Chief Medical Officer Dr. Otis Brawley discusses oncolytic viruses and other news in cancer treatments.


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25 June, 2009 | (01 hr)
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Talent management is one of the hottest buzz terms in the Human Resources industry right now, but the practice of succession planning is relatively new to many HR professionals and business leaders. Effective succession planning depends not only on the capability of an organization to identify business continuity risks, but also on its capability to identify talent, as well as the extent to which these capabilities are understood and exercised throughout the organization. This webcast explores how the trend now, driven by global events, economic imperatives and workforce demographics, is to move towards succession planning that addresses the entire organization. The webcast shows participants how to expand their perceptions and approaches to consider the rapidly changing environment, and the significant part that succession planning can play in a company's talent management strategies.
This webcast will discuss:
- The challenges faced by today's organizations, both external and internal
- Questions to consider in existing or proposed succession management initiatives
- Valuable methods for identifying high-potential successors
John Beeson
John Beeson is a Senior Fellow, Human Capital at The Conference Board. In this role, John supports the Human Capital Practice which includes The Conference Board Human Capital Exchange™, research, conferences, webcasts and programs in a broad spectrum of human...Full Bio
Ettie McCormack
Ettie McCormack is Managing Director of STEP Forward Solutions, an independent consulting and implementation specialist in talent management strategies.
With over 25 years experience in a wide variety of operational and staff management positions, Ettie joined Unisys in 1996 and tackled m...Full Bio
Andrew Tank
Andrew Tank is executive director, corporate services, at The Conference Board Europe, which is based in Brussels.
Tank coordinates research projects focused on productivity, organizational effectiveness, and corporate governance in Europe and the Middle East. This includes the production...Full Bio


text: (Photo by Mike Ehrmann/Getty Images) [ Miami Marlins Manager Fires Off Mouth–Again! By John McKay April 9, 2012 If you follow sports or baseball with even a half-interest, you're probably aware of Miami Marlins Manager Ozzie Guillen because of his loose cannon mouth. Read More|Comment Category: Sports Tags: fidel castro, manager says he loves castro, marlins manager shoots off mouth, miami marlins, MLB, ozzie guillen Send to a friend! Share on Facebook Share on Twitter Pin it! Reddit This! Share on Tumblr!


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Exelon Generation owns and operates the nation's largest urban solar power plant, Exelon City Solar in Chicago, and is currently developing a 230-megawatt solar plant in California.
Solar energy is part of Exelon Generation's growing renewable energy portfolio of hydro, wind, and landfill gas power.
Exelon aims to be a good neighbor within our local communities with active involvement through sponsorships, charitable giving and volunteering focusing on the environment, education, the arts and diversity. We encourage our employees to give back to their communities and we recognize their efforts through various programs.
Exelon Power is headquartered in Kennett Square, Pennsylvania. A business unit of Exelon Generation, Exelon Power is responsible for operating the company's fleet of fossil, renewable and hydroelectric generating assets. Exelon owns one solar power plant in Illinois and is developing another solar project in southern California. It also has ownership interest in Solar Energy Generating Systems (SEGS) which is also in California.
This 230-megawatt solar photovoltaic (PV) project under construction in northern Los Angeles County, Calif., was acquired by Exelon in September 2011. Full operation is planned for 2014.
This 10 MW solar photovoltaic facility, completed in 2010, was built on a "brownfield" site in an industrial corridor on the south side of Chicago.
Solar Energy Generating Systems (SEGS) is a thermal solar generating facility, consisting of nine solar power plants in California's Mojave Desert. Exelon has ownership interest in SEGS IV, V and VI equivalent to 8 MW.
Exelon Power Fact Sheet [PDF | 97 KB]Exelon Power is the business unit within Exelon Generation Company, LLC that is responsible for managing, operating, and maintaining the company's fossil (coal, oil, and natural gas), landfill gas, hydro, wind and solar-powered fleet of generating assets.
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There's no better sport than tennis for making friends, staying fit and having fun! Whether you've played before or are just picking up the game, there are many ways you can find yourself in the game.
For experienced players in or entering college, varsity tennis is a great option, with hundreds of teams playing on campuses across the country. But for those looking to get into tennis or play in a more relaxed but still competitive environment, Tennis On Campus may br right for you.
For more on the Tennis On Campus program, visit the TOC website.
Another great way to get out and play is by joining a USTA League team. USTA League is the country's largest recreational tennis league, helping more than 800,000 participants nationwide get on the court, have a good time and step up their game.
USTA League play is not only a great way to stay fit, play competitively and have fun, but it's also a great way to network and meet new people.
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Hello!Please email email@example.com for reserving gear.All prices include shipping unless noted. Paypal gift preferred.I have a few odds and ends laying around, that I would like to see go to a good home to get used.Gossamer Gear Hipbelt Pockets - size largeI took off the metal zippers and reattached the pull cord that was on the zipper pull. Lighter and no noise!Perfect condition, I don't think they were ever used. I have a pair of medium size ones that I use. Each pocket is 4" x 7" x 1.5"$8 for one and $15 for both (BOTH SOLD TO DEAN)Black Diamond Alpine Carbon Cork StrapsMisplaced or tore a strap? Here is a replacement. Taken off when I bought poles recently.$5 (SOLD TO DALE)Hyperlite Mountain Gear Accessory cord. 50 feet.I cannot get on their website at the moment, but I think it is 1.4mm diameter. It is their thinnest cord. Brand new.$10 (SOLD TO DANIEL)Gossamer Gear Murmur Hyperlite Grosgrain HipbeltEach piece is 24", so it could make about a 4' hipbelt, can be trimmed. Brand new.$4Granite Gear Air Pair stuff sack(s) - size mediumTwo stuff sacks sewn together with a shared bottom. Never used. Roughly 7" x 11" total.$5 (SOLD TO JACOB)GoLite stuff sackThis came with my GoLite Bitterroot down jacket. Never used. 10" x 10"$5 (SOLD TO DEAN)Seattle Sports E-MERSE Waterproof iPad caseCould be used for other electronic devices, books, or a great map case. Lightly used, in really good condition. One small dark mark on back, only cosmetic.$14Montbell stuff sackThis came with Versalite rain pants. Roughly 4" x 8"$5 (SOLD TO DEAN)MSR Stuff sackThis came with a size medium Ultralite towel, I think.4" x 5.5"$4 (SOLD TO DEAN)Pole JackBought from someone else who thought it was from GoLite. 18" long$7 (SOLD TO CURT)
Edited by codybartz on 08/23/2013 21:58:48 MDT.
PM sent for cord
Updated to show sold items. Thanks so much to everyone so far!
Sold items shipped today (8/23)Prices lowered
what a head-snappingly quick turnaround on this little piece of gear from Cody...kudos to him (and to our postal service, too) for the quick cross-country delivery.thanks for a good deal, better than advertised.
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Heading to Ireland in 2013/2014?
There may be a few things you need to know about before you head over.
Here are 24 practical things to take into account if you're coming to Ireland.
1. Check the baggage restrictions on flights
They can catch you out, especially if you're flying within Europe with Ryanair and you get charged a gazillion euros for carry-on luggage. Don't forget to Google beforehand and check out the weight and size restrictions.
2. You're going to need an adapter
We've wonky looking plug sockets here in Ireland so if you're making your way over you'd better stock up on the adapters. This is especially true for Americans.
3. It's going to rain
It will. You might as well pack your wellies now if you're planning to head over because in Ireland when it rains – it pours.
4. But it might be sunny
There's also a chance that the sun might actually make an appearance so don't forget the sunglasses!
5. We don't all speak in Irish
Thankfully it's not necessary to be fluent in Irish before you arrive – English is our main language. Not many people regularly speak in Irish in Ireland unless you're wandering around in the Gaeltacht areas.
6. But we phrase things differently
'What's the story?', 'do you want a lift?' and 'get the shift', are phrases used on a regular basis here but may not mean what you think they might mean. Never fear though, we've a guide to Irish sayings and phrases to help you along!
7. We complain a lot
Usually about the weather, the banks or the government but don't be afraid to join in - we love a good moan about the state of Ireland.
8. We drive on the 'wrong' side of the road
And by wrong, I mean the left hand side. Just in case you were planning on renting a car!
9. Look to your right when crossing
Following on from that, don't forget to look to your right when you're crossing a road. Thankfully there are now handy signs on the ground if you need a few pointers.
10. We were born to jaywalk
Listen, we just can't help it. If there's even the smallest gap in traffic we're going to go for it.
11. Blasphemy is illegal
Yep, it's true and written in Irish law – whether people actually abide by it however is another story altogether.
12. Don't order a 'black and tan' or 'Irish car bombs' in the local
Just don't. The barman probably won't have any idea what you're ordering and others may find it a bit offensive – don't bother to risk it, safer to order a pint.
13. Tipping not compulsory
We're not big tippers here in Ireland except in restaurant situations where the 10% to the waiter is almost a given. But no need to tip taxi drivers unless they've shown good service.
14. If you're planning to rent a car, don't forget to book an automatic!


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London and Middlesex family history resources online
Unlock the Past 2013
Published in Australia, but equally useful for people anywhere in the world, this short guide includes information about online resources for London and the former county of Middlesex. The resources include civil registration, the census, parish and non-conformist registers, monumental inscriptions, wills and administrations, armed forces' records, newspapers, criminal records, local histories, directories, family history societies, archives and other London-specific websites.
Buy the book now from Gould Genealogy and History, or as an ebook from genEbooks.
Society of Genealogists (SoG) 2012
A concise and straightforward guide designed to help all those starting to trace their Irish ancestry. The book covers civil registration, census returns, census substitutes, church registers, wills and administrations, the Registry of Deeds, records of the armed forces, maps, newspapers, surnames and migration, background information, monumental inscriptions, online sources, Irish archives and family history societies, and Irish resources in the SoG Library.
Buy the book now from the Society of Genealogists.
Society of Genealogists (SoG) 2012
A comprehensive guide to tracing Scottish ancestry, this book covers civil registration, census returns, valuation rolls, taxation records, militia lists, parish and other church registers, wills and inventories, clans and families, the armed forces, maps, newspapers, the Statistical Accounts of Scotland, services of heirs, land and court records, online sources, Scottish archives and family history societies, and Scottish resources in the SoG Library.
Buy the book now from the Society of Genealogists.
Grow Your Own Family Tree
Penguin 2008
The easy guide to researching your family history in England, Wales, Scotland, Ireland, the Isle of Man and the Channel Islands, this book covers civil registration, census records, church registers, wills and administrations, military records, electoral rolls, immigration, DNA, family history societies, and the major archives and libraries of Britain and Ireland. In addition, the book looks at emigration to the US, Canada, Australia, New Zealand and South Africa, and covers the family history records of those countries.
Buy the book now from:
Gathering the Clans:
Tracing Scottish Ancestry on the Internet
Phillimore 2004
My earlier book on Scottish family history is still available from a few outlets.
Buy it now at:
This page has the following sub pages.


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Science Friday® is produced by the Science Friday Initiative, a 501(c)(3) nonprofit organization.
Science Friday® and SciFri® are registered service marks of Science Friday, Inc. Site design by Pentagram; engineering by Mediapolis.
|What will this year's hurricane season look like? Ira Flatow and the National Oceanic and Atmospheric Administration's lead seasonal hurricane forecaster discuss the climate patterns and ocean temperatures that shape the storms. Also, how to plan before the storm hits.


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And Tyanair is suing Aviation Herald for giving them a bad rap?
What next:-
Will they sue all the travelers who took part in the survey?
Get real Ryanair, if you don't want to look like a second rate Airline,
Couldn't happen to a WORSE airline, because they are already at the bottom.
Maybe it's their time to be worst, now that Kingfisher is gone.
It's gotta be lonely down there at the bottom. Perhaps we should include US carriers so Spirit can keep Ryanair company at the bottom of the heap.
Chris.....Spirit just charged you a $10 internet down talking fee
LOL - Dammit!
(Duplicate Squawk Submitted)
Ryanair Voted 'Worst' Short-Haul Airline
More than 5,500 travellers rated dozens of airlines in the survey, giving each a mark out of five for categories including check-in process, baggage allowance, seating allocation, punctuality, food and drinks and value for money. Only those airlines receiving at least 30 votes were included in the final results.


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May 25 marked the 25th anniversary of National Missing Children's Day.
For 25 years, residents nationwide have been asked to remember 6-year-old Etan Patz who disappeared on his way to school in New York.
For 25 years, the nation has been recognizing and remembering the thousands of families who have lost or are still searching for missing children.
Recently, Utah Attorney General Mark Shurtleff announced the launch of the Take 25 campaign - a national public awareness campaign that urges parents to take 25 minutes with children to talk about ways to keep safe at home, school, out and about as well as on the Internet.
"In less time than it takes to watch 'The Simpsons,' parents and their children can learn how to stay safe and survive attacks from predators," pointed out Shurtleff.
The National Center for Missing and Exploited Children has developed 25 ways to make youth safer for the campaign.
The safety campaign recommends that Carbon County adults:
Make sure children in the household have a trusted adult to call if they're scared or have an emergency.
Make sure to screen names and avoid revealing too much about children.
Set up "what if" situations and ask children how they would respond should the potentially dangerous incidents occur.
The Take 25 campaign was kicked off with sixth graders at Viewmont Elementary School because the students have been getting Internet safety training since the children were in kindergarten, according to the attorney general's office.
"The good news is we're catching more people who are trying to hurt children," indicated Utah Internet Crimes Against Children Task Force director Chris Ahearn. "The bad news is more people are still trying to hurt kids."
The ICAC task force also showed the students a new video called "The Survivor Diaries," a poignant presentation with personal stories about males being targeted and victimized on the Internet.
The video highlights the fact that 65 percent of all male teenagers are solicited on the Internet to meet someone they don't know. And 39 percent of the males in question never tell anyone about the solicitation.
"The person who can make the biggest difference is you. We can all be heroes by telling someone," stressed Max Rogers of the Boys and Girls Clubs of America. The clubs have been working with the ICAC Task Force to provide Internet safety presentations to Utah students.
Additional information regarding the Take 25 campaign may be accessed at www.takesafe.org.


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My Skin Affair caught up with Mischa and had a chat about her skin care routine. Enjoy!
What is your skin care routine?
I live by the Clinique 3-step Skin Care System. In the morning I start off with the Mild Facial Soap bar, then the Clarifying Lotion #2 followed by the amazing Dramatically Different Moisturizing Lotion. The best part about this program is that you can alter it to match your skin's needs. I follow that up with the Neocutis Lumiere Eye Cream, it's super light so you can wear it throughout the day. At night, I love to add in the Bliss Triple Oxygen Instant Energizing Mask as a treat after a long day on set. It has a great citrus scent and foams and leaves your skin so clean and soft! And Estee Lauder's Advanced Night Repair is a miracle worker if I ever have a dry patch or any skin problems, it literally works overnight!
What are your favorite skin care products?
You can't beat Crème de la Mer Moisturizing Cream when you want your skin to be well moisturized, silky, smooth and soft! I fit this into my routine 3-4 times a week just to give my skin that certain je ne sais quoi! I also couldn't live without the Clinique Take The Day Off Makeup Remover, it's so easy, fast and gentle on my skin.
What's in your purse?
I always have the Terry Rose Lip Balm – gives your lips great moisture with just the slightest hint of color. I also carry the small bottles of Bliss High Intensity Hand Cream with me everywhere, I must have one in every bag!
How do you pamper your skin?
I LOVE the L'Occitane Shea Butter Foot Cream. I put it on before bed with socks and it leaves my feet so smooth!
Which product is your current "must have"?
I just discovered the Fresh Brown Sugar Body Polish and love how it leaves my skin incredibly soft, even after the first time!
Do you have a favorite spa?
I really enjoy the Silk Day Spa in Manhattan. It's so serene and provides for the best escape from the busy city.
What's your favorite spa treatment?
I love the Silk Melt Away massage, it completely makes all the stresses in my life disappear, if only for an hour.
Do you have a favorite tip/advice for skin care?
Protect your skin! You absolutely have to protect your skin from the sun, the higher the SPF the better! I like to use Clinique Sun SPF 50 Face Cream when I'm outside, or Stila's Sheer Color Tinted Moisturizer on a day-to-day basis. It gives an incredibly even tone to my skin and has a great 30 SPF to protect my face!
Written by: Joanna Canton
Source: My Skin Affair
I think I'll turn this information into a permanent section for the site, as I'm sure some people might want to reference these products and try them out themselves at a later stage.


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|Women's Tennis » Schedule » Roster » News » Coaches » 2015 Stats
Saturday, March 14, 2009Lipscomb played host to Atlantic Sun foe Jacksonville on Friday, March 13 , at the Whitworth Country Club. The Lady Bisons lost 7-0.
"We had some winnable matches in singles, but the girls were unable to come out on top," said Lady Bisons coach Kristin Lusk.
Top singles players for the Lady Bisons included Kara Jackson, who fell in singles No. 2 to Elvina Yusupova 7-5, 7-6 (7). Danielle Hansen advanced into a tiebreaker against Iva Janesova 7-5, 5-7, 7-6 (4).
"Danielle Hansen and Kara Jackson both played great in singles, and if they keep playing the way they did tonight, they are going to able to win some these matches we have coming up," said Lusk.
The Lady Bisons will host to conference team the University of North Florida today at the Whitworth Country Club.
1. Soldatova/Yusupova (JU) def. Jackson/Hansen (LU) 8-4
2. Umeki/Camero (JU) def. Jann/Landry (LU) 8-2
3. Janesova/Spencer (JU) def. Keevil/Ellis (LU) 8-5
Singles 1. Tatiana Soldatova (JU) def. Raphaela Jann (LU) 6-1, 6-1
2. Elvina Yusupova (JU) def. Kara Jackson (LU) 7-5, 7-6 (7)
3. Juliana Umeki (JU) def. Elizabeth Keevil (LU) 6-0, 6-3
4. Iva Janesova (JU) def. Danielle Hansen (LU) 7-5, 4-6, 7-6 (4)
5. Virginia Tuinski (JU) def. Claire Landry (LU) 8-3 (a pro-set was played since the match was already decided)
6. Fernanda Camero (JU) def. Olivia Ellis (LU) 6-1, 6-1
Women's Tennis Archives
2008-09 Women's Tennis