text:
|Publication number
|Publication type
|Application number
|Publication date
|Aug 23, 2011
|Priority date
|Mar 28, 2001
|Fee status
|Also published as
|Publication number
|Kishore Kumar, Laxmikant Rashinkar
|Original Assignee
|Televital, Inc.
|Export Citation
|BiBTeX, EndNote, RefMan
|Patent Citations (5), Referenced by (10), Classifications (26), Legal Events (5)
|External Links: USPTO, USPTO Assignment, Espacenet
This application is a continuation of U.S. patient application Ser. No. 10/109,958 filed Mar. 28, 2002 now U.S. Pat. No. 7,188,151, and also claims priority from Provisional U.S. patent application entitled System and Method for Secure Internet Device Monitoring, filed Mar. 28, 2001 under Ser. No. 60/279,562, and which are both incorporated herein by reference for all purposes.
The present invention relates to remote monitoring of devices over a wide area network, and more particularly, this invention relates to network-based transmission of data from a physiological collecting device.
Telemedicine, also known as telehealth, is the communication over distance through text, audio or video media for the education, evaluation and treatment of disease and illness. Telehealth is the use of information technology and telecommunication for providing access to health assessments, diagnoses, interventions, supervision, consultations, education, and information across a distance.
One prior art telehealth system includes biofeedback applications provided by Floan, James, Earles and Andrasik, and the U.S. Military which uses two telephone lines combined with other technology to conduct biofeedback sessions over great distances. The military application uses two way audio and video (teleconferencing) to communicate along with PC Anywhere type programs for PC to PC communication; but does not allow for the real-time transfer and observation of the physiological signals.
Disease management companies, so far are not providing real-time transmission of physiological data. The information that they do collect like EKG, and blood pressure are recorded and sent to the doctor hours later.
There is a great need for telemedicine technologies in homecare and ambulatory settings as outpatient disease management handles roughly one hundred million chronic patients in the US alone, which costs millions of dollars each year in ER, hospital, specialty and primary care.
It would therefore be desirable to provide an internet abased software system capable of streaming, in real-time, EMG, ECG, EEG, peripheral temp, respiration, skin conductance/resistance, heart-rate variability, FFT, and DFT that would be capable of supporting most hardware.
It would also be desirable to provide such a system in which the hardware is plug-and-play compatible and thus will not require anyone to install any extra software.
What is also needed is software that can transmit signals in real-time, while simultaneously sorting the data so that as the session is being recorded a user could back-up to see past events.
The present invention provides a system and method for remote monitoring of medical and/or biofeedback devices over a wide area network (WAN) such as the Internet. In a preferred embodiment, a browser-based engine supports real-time streaming of information over the WAN. In an exemplary embodiment, the system allows for the real-time streaming of raw, interpreted, and processed physiological data as well as textual/audio/video data from a patient/client to a health care provider. However, other embodiments may contemplate non-medical/non-biofeedback devices and non-human monitoring.
The system of the exemplary embodiment preferably includes at least one patient-side device for collecting data from a patient/client, a provider-side device, and an engine, each coupled to the WAN. The engine manages transmission of the data from the patient-side device to the provider-side device. This means that the engine may configure the devices to transfer the data directly from one device to the other; may receive the data from the patient-side device and transmit the raw or processed data to the provider-side device; may store the data for later transmission to the provider-side device, etc.
The embodiments presented herein contemplate connection of multiple patient-side devices, provider-side devices, and engines. Because a plurality of devices and engines may be in operation, the system may be capable of networking the numerous devices and/or engines into individual, group, clinic, hospital, or other electronic record systems.
For simplicity, the discussion will proceed with description of a system having a single patient-side and provider-side device. The patient-side device is located with the patient/client and gathers physiological data from the patient/client. The patient-side device can include, for example, a medical and/or biofeedback device that communicates through a serial, parallel, wireless, or customized interface. The patient-side device may then be connected via a computing device, such as a computer, personal digital assistant (PDA), etc., to the WAN. Alternatively, the patient-side device may have a built-in computing device for communication over the WAN. Optionally, the provider-side device can be any type of computing device, such as a computer, PDA, etc.
By receiving data from the patient-side device, a provider is able to monitor the patient/client's physiology for research, keeping track of documentation, performing analysis, managing and maintaining records, diagnosing the patient/client, providing treatment in real-time to the patient/client, etc. Additionally, the patient/client may be remotely "examined" by an expert or other medical personnel when one is not physically available or accessible. Such situations may occur, for example, when a patient/client or provider is in or on an airplane or ship, or when the patient/client or provider is located in a different part of the world. The present invention also allows for daily or periodic monitoring of patients without the need for the patient/client to travel to the provider's location. This is ideal for nursing homes and home care patients.
The devices on the patient/client and/or provider sides may allow for various forms of bidirectional communication including, but not limited to instant messaging, an integrated e-mail system, real-time video, and real time audio. Preferably, the communications are provided via a browser-based interface. Further, the provider may remotely control the client-side device. For example, when the patient is sleeping in his/her home with EKG and blood pressure devices connected, the provider can start these devices remotely to read the data periodically or whenever needed.
Alerts may be sent upon occurrence of an event recognized in the data. For example, based on real-time streaming of vital patient/client information, the present system may be tailored to forward proper responses to the patient/client. One of the communication modes described above may be set up to allow for rapid communications to the patient/client or provider in an emergency situation.
Whether or not the provider is not currently accessing real-time streamed information, the data may be stored in a secured storage device for later access, replay, and/or analysis. The storage device may also be used to store all patient data or information. Thus, the exemplary embodiment may allow for simultaneous storage, retrieval, print, analysis, and play back from anywhere in the world with access to the storage device.
Preferably, the present invention is built on a modular architecture in which the patient-side device and/or the computing device coupled to the patient-side device can send a request to the engine with an identifier of the patient-side device, and the engine will send the appropriate plug-in which allows the computing device to communicate with the patient-side device. Thus, the present invention may support both plug-and-play web device drivers and customized graphical user interfaces (GUIs) for the various devices. Existing devices (which are not web-enabled) may be easily web-enabled by installation of the appropriate plug-and-play driver and GUI. Thus, virtually any device may be easily incorporated into the system.
A fee may be charged for transmitting the data, storing the data, etc.
A method for network-based communication of medical-related data from a patient-side device according to one embodiment includes communicating with a computing device from a central site remote from the computing device using a wide area network, the computing device being coupled to a patient-side device, the patient-side device being for collecting physiological data from a patient; communicating with a second device from a central site remote from the second device using the wide area network, the second device being remote from the patient-side device; managing transmission of data from the computing device to the second device; and allowing a user to remotely control at least some function of the computing device or patient-side device via the second device, the function relating to collection of the physiological data 12.
A method for network-based monitoring of physiological data according to another embodiment includes uploading software from a central site to at least one patient-side device, the software enabling collection of the physiological data from at least one of directly from a patient, the at least one patient-side device, and a second device coupled to the at least one patient-side device; collecting physiological data from the patient utilizing the at least one patient-side device; and managing a transmission of the physiological data from the at least one patient-side device to a provider-side device, wherein the software is only active when the at least one patient-side device is connected to the central site, wherein the central site includes at least one server, at least one data storage device, and at least one wide area network interface.
The present invention may be implemented on a program or code that can be stored in a computer-readable (or electronically-readable) medium.
For a fuller understanding of the nature and advantages of the present invention, as well as the preferred mode of use, reference should be made to the following detailed description read in conjunction with the accompanying drawings.
The following description is the best embodiment presently contemplated for carrying out the present invention. This description is made for the purpose of illustrating the general principles of the present invention and is not meant to limit the inventive concepts claimed herein.
System Architecture
The integration of biomedical and/or biofeedback devices along with the connection between service providers and patients allows for many applications, including but not limited to: telemedicine, remote sleep studies, physical evaluations, remote monitoring, event recordings, holter monitoring, home health care, disease management applications, biofeedback, pharmaceutical research, wireless monitoring, anesthesiology-related monitoring, and stress, health and wellness education.
The embodiments presented herein contemplate connection of multiple patient-side devices, provider-side devices, and engines/central servers. Because a plurality of devices and engines may be in operation, the system may be capable of networking the numerous devices and/or engines into individual, group, clinic, hospital, or other electronic record systems. For simplicity, the discussion will proceed with description of a system having a single patient-side device, provider-side device, and engine/central server; it being understood that one skilled in the art would be able to use the system with multiple devices connected without undue experimentation.
Use of the term "patient" is not intended to limit application of the embodiments presented here to medical patients. Rather, patients can include anyone whose biophysical data is being read, healthy or not. Note also that a "provider" as used herein can be a medical provider such as a doctor, nurse, etc., but also includes any recipient of the data, whether affiliated with health care or not. For example, such a recipient could be researcher gathering statistics, a device manufacturer monitoring operation of the device or debugging the device, etc.
The patient-side device is located with a patient and can be any device that gathers physiological data from the patient. Illustrative patient-side devices include, but are not limited to, telemetry EKG, EMG and EEG monitors; continuous blood pressure and blood glucose watches; cellular transmission holter monitors; wireless plethysmograph rings; automated IBS and depression multimedia protocols; T-shirts wired with sensors that monitor and record physical and emotional indicators derived from heart activity, breathing patterns and blood pressure, bracelets, earrings and necklaces that monitor physiological activity; implanted devices that capture and transmits a person's vital body-function data, such as body temperature or pulse, to an internet-integrated ground station while providing global positioning information.
The patient-side device may then be connected via a computing device 110, such as a computer, handheld devices such as personal digital assistants (PDAs) and pocket PCs such as IPAQ with Windows CE operating System and Palm devices based on Palm OS), wireless telephone, or any other computing device, to the WAN. Optionally, the patient-side device may have a built-in computing device for communication over the WAN. A protocol independent device manager 112 running on the computing device establishes a two-way communication with a vast array of client-side devices, including but not limited to medical and/or biofeedback devices, holter monitors, telemetry units, data acquisition units, etc. Each patient-side device can be wired or wireless, and communicates through a serial (RS232, USB, IEEE 1394, etc.), parallel, fire-wire, wireless, or customized interface/protocol. Similarly, the provider-side device can be any type of computing device, such as a computer, PDA, wireless telephone, etc. In one embodiment, the provider's computing device (such as a PDA or telephone) has a wireless connection to the WAN so that, even though the doctor is not at a hospital or in his office, he may still be consulted remotely without the need to rush to the hospital.
The connection to the WAN (such as the Internet) can include dialup (56K), satellite phones, Iridium phones, ISDN, T1, DSL, cable modem, wireless connection, etc.
Preferably, the present invention is built on a modular architecture in which the patient-side device and/or the computing device coupled to the patient-side device can send a request to the engine with an identifier of the patient-side device, and the engine will send the appropriate plug-in which allows the computing device to communicate with the patient-side device. Thus, the present invention may support both plug-and-play web device drivers and customized graphical user interfaces (GUIs) for the various devices. Existing devices (which are not web-enabled) may be easily web-enabled by installation of the appropriate plug-and-play driver and GUI. Thus, virtually any device may be easily incorporated into the system. These teachings can also apply to the provider-side device.
The data interpretation and analysis module 114 is used to interpret the data stream from the client-side device, perform mathematical analysis on the data using FFT, DFT, etc., and generate statistics. The data may be displayed graphically on the display module 116.
The data may also be simultaneously streamed to multiple remote providers over the WAN so that the remote providers can view the data in real time. The streaming manager 118 is responsible for managing transmission of the data to the remote providers, including, optionally, encrypting and compressing the data.
The real time streaming of ECG, EEG, EMG, blood-gas readings, respiration, and other medical wave-forms can be supported by threshold and alarm controls, real-time and/or post-session analysis, email, teleconference medias, and storage, retrieval and replay of raw or interpreted data from any WAN connection, including a dialup Internet connection.
By receiving data from the patient-side device, a provider is able to monitor the patient's physiology for research, keeping track of documentation, performing analysis, managing and maintaining records, diagnosing the patient, providing treatment in real-time to the patient, etc. Additionally, the patient may be "examined" by an expert or other medical personnel when one is not physically available or accessible. Such situations may occur, for example, when a patient or provider is in or on an airplane or ship, or when the patient or provider is located in a different part of the world. The present invention also allows for daily or periodic monitoring of patients without the need for the patient to travel to the provider's location. This is ideal for nursing homes and home care patients.
Depending on available bandwidth, the system may allow for the real-time streaming of raw, interpreted, and processed physiological data as well as textual/audio/video data from a patient to a health care provider. For example, the devices on the patient and/or provider sides may allow for various forms of communication including, but not limited to instant messaging, an integrated e-mail system, real-time video, and real time audio. The audio and/or video can be synchronized with the biomedical signals to help correlate behavior with physiological activity. Preferably, the communications are provided via a browser-based interface.
Using optional remote control features built in to the system, remote providers can control the software on the patient's end. Thus, patients do not need to know how to operate the software.
Preferably, the engine manages transmission of the data from the patient-side device to the provider-side device. This means that the engine may configure the devices to transfer the data directly from one device to the other; may receive the data from the patient-side device and transmit the raw or processed data to the provider-side device; may store the data for later transmission to the provider-side device, etc.
The network I/O processor running the engine preferably forms the core of the real time streaming portion of the engine. The I/O processor is responsible for streaming device data, audio, video, messages, and remote control information between multiple clients and hosts. The processor may also handle data storage and retrieval of the streamed data.
Whether or not the provider is currently accessing real-time streamed information, the data may be stored in a secured storage device at the central server for later access, replay, and/or analysis. The storage device may also be used to store all patient data or information, and integrate the data, whether as raw data, trended data, or summary data, into any electronic medical records system, for example. Thus, the exemplary embodiment may allow for simultaneous storage, retrieval, print, analysis, and play back from anywhere in the world with access to the storage device. This beneficially allows a provider to seek expert consultation for clinically difficult cases, by sharing the patient history and medical test results online. Further, storage of the data allows for the creation of statistical databases, including development of a database of biomedical test results, for example. For example the results of routine medical tests may be stored from the biomedical device directly into the patient's electronic medical record. Further, personal health information can be stored in smart-cards that can be carried by a patient, and which may also carry other personal information such as credit card and back account data.
The system may also track trends during the recording, and using artificial intelligence, predict future behaviors and physiological responses based on the habits of the particular client hooked up.
A remote client module (not shown) allows remote hosts to view the data being streamed in real time. The remote client module can also control the software being run on the patient's and/or provider's end. Multiple remote client modules can run concurrently, allowing multiple remote providers to view data from one device.
Preferably, the entire system runs in the context of an Internet browser. Integration of the client-side device driver is performed in two steps. First, the appropriate device driver is incorporated into the system, preferably via a web page. A customized or standard GUI is incorporated or developed based on user and/or device manager specifications. Thus, a user does not have to install any software, and updates to the software are done by simply running the latest softward from a website.
The present invention may be implemented on a program or code that can be stored in a computer-readable (or electronically-readable) medium. The system may be implemented using Apache web server, MySql on Linux, Oracle on Linux, Java servlets, Applets, HTML, JavaScript, Java, C#, Microsoft's .NET etc. Note also that the server may be implemented on the Internet, intranet, or an extranet.
Alerts may be sent upon occurrence of an event recognized in the data. For example, based on real-time streaming of vital patient information, the present system may be tailored to forward proper responses to the patient. One of the communication modes described above may be set up to allow for rapid communications to the patient or provider in an emergency situation.
In an example of use during a remote session, a patient is connected to a patient-side biophysical monitoring device, such as by adherence of the appropriate sensors to the patient's body. The sensors are coupled to a medical and/or biofeedback patient-side device that is in wireless or wired communication with a computing device. Such patient-side device may include, but is not limited to, EKG, EMG, EEG, and body temperature monitoring devices.
The provider's patients are listed on a screen 500 such as the screen shown in
By joining the session, the healthcare provider can immediately view their patient's real-physiological data by selecting button 504. The healthcare provider can remotely adjust the gain for optimal display, and both parties have the option to communicate with the built-in instant messaging feature, or an external or integrated audio or visual device. At the end of a session, the healthcare provider can view a statistical summary report 600, shown in
Config.java is a general class used by all the Java servlets, and may include a method similar to:
Database specific parameters like UserName, Password etc. can be changed here. AdminName and AdminPassword can also be fixed here.
As shown in
The Sponsor submodule 1106, shown in
As depicted in
To create a session, a servlet 1704 launches an applet that collects bio-medical data from the client and streams it to Service Provider. Another servlet enables the client to attach a message to session. Yet another servlet 1706 writes to the session database. Servlet 1708 displays the sessions sent by the client with option to delete. Servlet 1710 reads the messages sent with the session. Servlet 1712 launches an applet which displays bio-medical data stored in server. A servlet deletes records from the session database.
To enable mail functions, a servlet 1714 displays mails sent by the Service Provider. Servlet 1710 reads mails sent by Service Provider and updates the read flag in the mail database. Servlet 1716 enables clients to compose mails. Another servlet writes to mail a database. Servlet 1718 displays mails sent by the Client with an option to delete. Another servlet may be provided to delete mails sent by the Client from mail database.
The input for the Stage1 servlets include:
The output for the Stage1 servlets include:
The Stage2 servlets are the DB servlets whose function is to update the changes in the database & return the control to the caller servlet. The input for the Stage2 servlets include are the same as shown, and further include callerID.
The input for servlets that read mail can include:
A servlet may be provided that allows client to modify his profile information. Input for this servlet can include:
The output for this servlet may include all of the form inputs plus the Input of this servlet.
A further servlet updates modifications of the profile database. Inputs to this servlet include all the parameter output by the servlet that allows modification of profile information. This servlet further updates the database for changes and returns control to the respective servlet based on the caller.
The Members submodule 2006 includes a servlet that displays disabled members. Input to this servlet includes:
Another servlet displays enabled members. Input to this servlet includes:
Yet another servlet enables or disables members. Five parameters are passed to this servlet from the previous two servlets:
A further servlet displays profile of members. Input to this servlet includes:
The Service Providers submodule 2008 includes a servlet that displays all service providers with an option to subscribe/unsubscribe. This includes a search facility. Another servlet asks for confirmation before a service provider is subscribed or unsubscribed. Yet another servlet adds or deletes a record from a registration database.
The Services submodule 2010 includes a servlet that displays subscribed services and service providers, a servlet that displays the profile of the service provider/client, and a servlet that displays members coming under a service provider for a particular service.
The Edit Profile submodule 2012 includes a servlet that allows a sponsor to modify his profile information, and a servlet that updates modifications to the profile database.
The Session Live submodule 2106 includes a servlet that enables a service provider to view bio-medical information of his client when the client is online. An animated gift indicates that the client is online. Basically this launches an applet with a filename and registration number as a parameter. The registration number is used to check authentication of each block being received.
The Mails Read submodule 2108 includes a servlet that displays mails sent by Clients, and a servlet that reads mails sent by clients and updates the read flag in the mail database. The Mails Compose submodule 2110 includes a servlet that enables a service provider to compose mails, and a servlet that writes to the mail database. The Mails Delete submodule 2112 includes a servlet that displays mails sent by Service Provider with an option to delete, a servlet that reads mails sent by a service provider, and a servlet that deletes mails sent by a service provider from the mail database.
The EditProfile submodule 2114 includes a servlet that allows a service provider to modify his profile information, a servlet that updates modifications to the profile database, a servlet that allows a service provider to modify his professional information, and a servlet that updates modifications to the therapy database.
The Add Service submodule 2116 includes a servlet that allows a service provider to add more services, and a servlet that updates the therapy database with the added service of the service provider.
The following table contains the user profile information as stored in a database of the system according to an illustrative embodiment. As soon as any user signs up with the system, a record is created. The field GroupId can contain under which sponsor the client has been registered in the case of sponsored client.
Table 2 contains the registration details of each client with the service provider for a particular service.
Table 3 stores the details of sponsor registration with a service provider.
Table 4 stores login detail information of each user.
(Login Details)
Table 5 stores all the services.
Table 6 contains the information on various service providers and their services.
Table 7 stores patient mail information.
Table 8 stores patient session information.
The system described above can be adapted for many types of applications. Following are several exemplary WAN-based solutions, including several for monitoring various medical conditions. None that this list of applications is presented by way of example only, and is by no means exhaustive.
Urinary Incontinence (UI)
According to the U.S. Department of Health and Human Services, urinary incontinence (UI), or the unintentional loss of urine, is a problem for more than 13 million Americans, 85% of which are women. The urine loss can range from slight leakage of urine to severe, frequent wetting. This problem has severe economic and psychosocial consequences, and occurs in people of all ages, but it is especially common in older people. UI is not a natural process of aging, but rather an indication that the pelvic floor and/or the sphincters that control the process of urination may be weakening.
Traditional treatment for UI has consisted of pharmacological therapies to improve incontinence medically, and surgical therapies to treat specific anatomical problems. However, less invasive techniques such as behavioral therapy, and pelvic muscle rehabilitation have been quite successful in improving pelvic muscle tone.
One modern type of treatment is to isolate, train and strengthen the pelvic floor without recruiting any other peripheral muscles. The strength of muscular contractions is monitored using surface electromyography. This form of therapy provides immediate auditory or visual information to the person about the status of the pelvic muscle function, and has proven to be helpful in 8 out of 10 people. By monitoring the electromyography, a provider can determine whether pelvic exercises are being done correctly.
The system can be adapted to compliment any existing incontinence program. The surface electromyography signal processing unit, such as J&J Engineering's 1330 C-2 and mini C2 series; and Thought Technology's Myotrac, Procomp+, and Procomp2, plugs into the computer's serial port. Data collected by the unit is processed by the system to provide real-time medical monitoring, summary reports, statistical calculations, and visual displays, which can further be tailored for the healthcare provider's particular needs, and can each be tailored for a particular protocol. This unique technology allows healthcare providers to remotely manage clients worldwide, while communicating with them, and simultaneously viewing their real-time physiological data.
The system can easily provide customized on-line educational segments, and provide nutritional and voiding diaries made available to clients, which can be stored for review and analysis by a healthcare provider. All sessions can be securely stored with a patient and provider logon ID for retrieval and data analysis at anytime and from anywhere. The healthcare provider is able to review each session, including home practice exercises, which assures compliance and proper muscle recruitment. Real-time, stored physiological data and client's medical history can also be securely shared with colleagues for on-line consultation.
The system can also be adapted to make such specialized treatment available worldwide via the Internet, by allowing the provider to use his existing protocol to treat patients in another state or country, while simultaneously communicating with them, and viewing their real-time physiological data.
During an exemplary remote session, as with an in-office visit, the client inserts her own vaginal sensor. The sensor connects to a device that plugs into the serial or USB port of the computer. The client logs on to the main system website with a secure ID and password. A session is created.
The rest is handled by the healthcare provider who is notified with a flashing "live" button when a client is ready to begin. By clicking this button, a healthcare provider is first prompted with an impedance check to ensure a good connection.
After verifying the signals, the healthcare provider can begin a session. Auditory and visual cues guide the client through the entire protocol, and the gain can be remotely adjusted for optimal display. Both parties can communicate with built-in instant messaging features, or an external audio or visual device.
At the end of a session, the healthcare provider views a graphical and statistical summary report that includes a field for adding clinical notes. This may also be displayed on the client's end, which can even be remotely printed. All sessions are dated and stored for retrieval by either party at a later date.
Vulvodynia literally means pain in the vulva. It is a syndrome of unexplained vulvar pain that is frequently accompanied by physical disabilities, limitation of daily activities (such as sitting and walking), sexual dysfunction and psychological disability. The typical patient is in her 20s or 30s, and is frequently misdiagnosed. In a general gynecologic practice population, the prevalence of this condition may be as high as 15 percent. It is characterized by itching, burning, stinging or stabbing in the area around the opening of the vagina. Pain can be unprovoked, varying from constant to intermittent, or occur only on provocation such as attempted sexual intercourse, a condition also known as vulvar avestibulitis syndrome or vestibulodynia.
Conventional medicine often prescribes tricyclic antidepressants, while other forms of treatment consist of topical vaginal cream, intralesional interferon injection, low-oxalate diet, and physical therapy to train the pelvic floor muscles.
Pelvic floor muscle instability is a critical factor in pain associated with vulvar vestibulitis syndrome. The use of a highly sophisticated muscle measurement technology known as surface electromyography used in conjunction with an exercise program significantly stabilizes the pelvic floor muscles, reducing and, in some cases, eliminating symptoms of vulvar vestibulitis syndrome.
It has recently been discovered that the muscles of the pelvic floor in vulvodynia patients were abnormal. This abnormality can be measured by surface electromyography. Once the patients' exact abnormality is known, it can be corrected by an individual program of muscle rehabilitation and continued monitoring to assure that the correct changes occur in the muscle.
The system can be customized to provide an Internet-based software program for the new treatment protocol used in the assessment and treatment of vulvodynia. This innovative approach greatly improves patient access to the specialized treatment.
Patients experiencing vulvodynia can visit their local physicians for remote assessment and treatment by the remotely located provider. Patients would simply insert a vaginal sensor, which connects to a surface electromyographic signal processing unit that plugs into a computer's serial port. The rest is handled by the system's Internet browser-based software that allows the remote provider, and other healthcare providers, to remotely view their patient's real-time physiology, while communicating with each other using real-time audio, video, and/or text communication.
As shown in
Auditory and visual cues guide the patient through the assessment, while healthcare providers have complete remote control to make necessary screen adjustments. After conducting a real-time session, the remote provider is able to remotely print a statistical report for the local physician that includes clinical notes and treatment recommendations. All sessions are securely stored for retrieval and data analysis at anytime and from anywhere.
Repetitive Strain Injury (RSI)
RSI is a term used to describe a broad class of disabling pain injuries, such as Carpal Tunnel Syndrome and Tendonitis, which affect people's ability to work and perform daily activities. RSI is usually caused by a mixture of poor ergonomics & posture, stress, and repetitive motions. According to the Occupational Safety and Health Administration (OSHA), 1.8 Million workers had musculo-skeletal injuries related to ergonomic factors in 1999 alone. This included all injuries related to repetitive motion, overexertion or awkward posture. Approximately 600,000 employees missed some work because of it. Approximately $15-20 billion is spent annually for workers' compensation claims and an additional $30-40 billion is spent on other expenses such as medical care.
The system can be adapted to provide the following model for RSI specialists, who can perform assessment, treatment, and management of RSI over the Internet.
For example, a specialist, after receiving a referral, takes a medical history using web-based assessment inventories, and decides if treatment will be beneficial. Following this evaluation, a two channel EMG device is sent to the client, and an online appointment is scheduled. The client logs into the specialist's web-site and plugs the EMG device into their serial port. The specialist receives notification that his client is on line and that the device is working properly. Using a telephone, an audio/video conferencing software, the specialist directs the client through the exercises designed to bring about changes in the clients muscle activity, as displayed on the computer monitors. The specialist views the muscle activity, as recorded from the EMG device, in real-time allowing him to direct the treatment session remotely. At the end of the appointment, the patient is given practice exercises, which the patient conducts on his own using the EMG device. The practice sessions may be saved for the specialists to review anytime from anywhere to track the patient's progress.
Management of Pulmonary Disorders
Millions of Americans suffer from pulmonary disease while clinicians are unable to monitor their disease-state progression on a day-to-day basis, or between office visits. Patients do not always have easy access to healthcare or the ability to visit specialists because of their location.
The system may be adapted to include web-enabled spirometers and oximeters, allowing healthcare practitioners to perform remote spirometry and oximetry tests.
Web-enabled spirometry allows for real-time remote testing, retrieval, and analysis of a patient's pulmonary function tests from any Internet-enabled computer. Such remote spirometry greatly improves the management and prevention of pulmonary problems in various healthcare segments, including pharmaceutical research, HMO's, education institutions, and from isolated areas such as on aircrafts and ships.
The system's web-enabled protocols support multiple devices, and offer bi-directional communication, while supporting multimedia features. Further, the system's customizable display screens, summary reports, statistical calculations, history intake forms, and on-line educational segments can be tailored for a specific protocol.
The system's web-enabled devices allow physicians a way to provide better services to their parents, while allowing them to get reimbursed for their time. As a further benefit to the remote provider, fee-for-service pulmonary interpretations, education, and treatment protocols can be offered to other healthcare providers.
Cardiovascular Diseases (CVD)
60,800,000 Americans have one or more types of CVD according to current estimates. One in five males and females has some form of cardiovascular disease. The cost of cardiovascular diseases and stroke in 2000 is estimated at $326.6 billion by the American Heart Association. This figure includes direct costs, which include the cost of physicians and other professionals, hospital and nursing home services, the cost of medications, home health and other medical durables and lost productivity resulting from morbidity and mortality (indirect costs). Congestive Heart Failure (CHF) accounts for more hospital admissions than any other diagnosis in patients over the age of 65, and accrues costs between $10 and $40 billion dollars annually according to the Health Care Financing Administration (HCFA). In 1998, the AMA estimated that over 7 million Americans receive home health care each year at a cost of $25 billion.
The web based real-time streaming of vital signs and audio/video data along with central storage and retrieval features provided by a system according to one embodiment are ideal for remote cardiac rehabilitation and cardiac monitoring for sectors like home-care, nursing homes, assisted living facilities for elders and other applications like remote health monitoring on aircraft and ships.
One system includes wireless blood-pressure devices which can measure systolic pressure continuously without the need of the inflation pumps. Taking blood pressure readings two to three times a week is extremely helpful. Some patients get nervous and their blood pressure shoots up just from coming to the doctor's office. Outside readings give physicians a better sense of blood pressure control. They can also correlate the change in the blood pressure to the activities either at their home or office. The real-time vital monitoring service in the corporate market further helps companies to retain productive personnel, while decreasing general employee absenteeism and increasing overall productivity.
Heart Disease
Coronary heart disease is a disorder that affects the heart muscle and the blood vessels. The most serious danger of coronary heart disease is a heart attack, which occurs when the supply of blood to the heart is greatly reduced or stopped due to a blockage in a coronary artery. Coronary heart disease (including heart attack) is the single largest killer in the United States accounting for one out of every 4.7 deaths. There are more than one million heart attacks each year in the US, and every year more than 400,000 people die from heart attacks.
A system according to one embodiment includes a web-enabled EKG device to provide real-time monitoring, assessment, analysis, retrieval, and storage of EKG signals over the Internet.
The system instantly performs a series of measurements and provides a complete narrative interpretation.
Benefits to manufacturers of EKG devices include allowing the manufacturers to provide remote demonstrations of their products, remote product support, and analysis of device usage. Manufacturers may also be able to provide immediate software upgrades without the software distribution through CDs.
Remote Management of Heart Disease
Hundreds of billions of dollars are lost each year because clinicians are unable to monitor disease-state progression on a day-to-day basis, or between clinic visits. Patients don't always have easy access to healthcare or the ability to visit specialists because of their location. There is a great need for telehealth technologies in homecare and ambulatory settings as outpatient disease management handles roughly one hundred million chronic patients in the US alone.
The system according to one embodiment can include a web-enabled QRS Diagnostic's EKG card, which allows healthcare practitioners the ability to perform remote diagnostic procedures in real-time over the Internet. The web-enabled solution allows for central storage, retrieval, and analysis of EKG signals in remote cardiac rehab and cardiac monitoring sectors such as homecare, nursing homes, assisted living facilities. HMO's, emergency care and from isolated locations such as aircrafts and ships.
Fee-for-service EKG interpretations, education, and treatment protocols can be offered to other healthcare providers.
Stroke and Blood Pressure
Inadequately managed blood pressure may be responsible for one third of strokes in patients who are being treated pharamcologically for hypertension, suggest results of a recently published study on Strokes. The numbers are startling: every 53 seconds someone in the United States suffers a stroke, and someone dies from one every 3.3 minutes. Strokes affect a half million people each year, killing about a third of them and disabling another 200,000, according to the American Stroke Association, a division of the American Heart Association. Taking readings two to three times a week is extremely helpful. For one thing, some patients get nervous and their blood pressure shoots up just from coming to a doctor's office. Outside readings give physicians a better sense of blood pressure control. The system may include a wireless continuous blood pressure monitor that is easy to wear and does not need the pumps.
Attention Deficit Hyperactivity Disorder (ADHD)
ADHD is the most commonly diagnosed behavioral disorder of childhood, estimated to affect 3 to 5 percent of school-age children. As many adults as children also have the disorder as it generally remains into adulthood. There is no cure, only a toxic medication to mask the symptoms. The National Institute of Mental Health says that at least 800,000 school-age children have attention disorders. Its core symptoms include developmentally inappropriate levels of attention, concentration, activity, distractibility, and impulsivity. Children with ADHD usually have functional impairment across multiple settings including home, school, and peer relationships. ADHD has also been shown to have long-term adverse effects on academic performance, vocational success, and social-emotional development. One of the major controversies regarding ADHD concerns the use of psychostimulants to treat the condition because of adverse side effects and potential overuse and abuse of drugs like Ritalin, Dexedrine and Cylert. Medications do not treat the condition, only mask the symptoms.
As an alternative to medication, some neurofeedback specialists and neurologists are using EEG signals for the assessment and treatment of ADHD with the help of real-time monitoring.
The system according to one embodiment provides an Internet based infrastructure for Neurofeedback specialists and neurologists to remotely monitor, manage and treat ADD and ADHD patients with the following model.
Following an in house or online evaluation of an ADD or ADHD child, a treatment regimen is designed, and programmed into the child's electronic file on the Internet. The child is sent home with a fashionable helmet integrated with wireless EEG sensors. The treatment regimen utilizes high definition 3-D video games that respond to the attention of the children, as recorded from the EEG sensors. As the children achieve greater levels of attention, feedback is provided to the children in a way that allows them more functionality over the video game. The 'treatment' sessions are done over an Internet connection, while the brainwaves from the children are streamed, stored and analyzed in real-time by the specialists's office remotely. The specialist has the option at any time to change the training specifications. If the specialist is not available to monitor the training session, he has the ability to view all saved sessions, allowing him the option, when desired to make any changes to the treatment regimen. Remote evaluations are also conducted to document improvements.
The system compliments any existing protocol, not only by providing the infrastructure for real-time, remote physiological monitoring, but summary reports, statistical calculations, intake forms, on-line educational segments, diaries, and visual displays can all be customized for the healthcare provider's particular needs. Each session can be reviewed, including home practice exercises, which assures compliance and proper muscle recruitment. Real-time, stored physiological data and patient history can also be securely shared with colleagues for a remote consultation.
Remote Fetal Monitoring
Most pregnant women worry about the health of their unborn child, and are unsure of when to call their healthcare provider. The system according to one embodiment may include web-enable fetal monitoring devices so that fetal Doppler ultrasound can be monitored, fetal heart rate (FHR) can be recorded, and uterine contractions can be measured. Contractions can be timed from the beginning of one contraction to the beginning of the next contraction, which helps to determine true labor. Most obstetricians believe that fetal monitoring identifies serious fetal problems earlier than other methods, thus improving outcome. Physicians can evaluate this data in real-time over the Internet any time and in any place to ensure the safety of the unborn child. All data is securely stored for future retrieval and playback.
Out Patient Monitoring
Many patients require follow up by Home-Health agencies once they leave the hospital. These agencies monitor vital signs, administer medications, and keep physicians informed about the patient's condition. A system according to one embodiment may include medical devices allowing home health nurses and medical doctors the ability to remotely monitor the health of their patients, thereby reducing or eliminating the need for home visits by medical personnel or office calls by the patients.
This is the most prevalent form of renal replacement therapy for patients with end stage renal disease (ESRD) and is typically performed 3 days per week for 3.5 to 4 hours either at home or in a dialysis center. There are over 350,000 patients with end stage renal disease on dialysis in US, and is projected to increase by 7% per year to over 660,000 by the year 2010 according to a recent USRDS report. The economic cost of this program expected to increase from $12 billion to $28 billion by 2010. The majority of the dialysis market (60-65%) is being serviced by publicly traded health care companies, and the other (35 to 40%) is provided by hospitals and private individuals.
The process involves a dialysis machine with a lowered dialysate flow, the internal jugular catheter with newly designed locking box to prevent accidental disconnection and reverse osmosis system for water purification. This requires a remote monitoring of the dialysis functions displayed on the dialysis machine via a modem or internet connection at a nocturnal hemodialysis office. They need the continuous "live" monitoring of all the patients on a single screen. The system according to one embodiment can provide the required display of data from multiple dialysis machines by integrating the machines into the system.
Nocturnal Hemodialysis
This is a novel form of renal replacement therapy which is performed 6-7 nights per week for 8-10 hours during sleep. This form of therapy shows considerable advantages over the conventional three times a week dialysis. Daily hemodialysis is more physiologic in that it reduces the fluctuations of the level of toxic waste products. It provides hemodynamic stability even in-patients with unstable cardiovascular system. Phosphate control was better and many patients discontinued their phosphate binders. Blood pressure control can be achieved with fewer medications.
Sleep Apnea-Hypopnea Syndrome
Sleep apnea-hypopnea syndrome is characterized by repetitive episodes of upper airway obstruction that occur during sleep usually associated with reduction in blood oxygen concentration. However this definition is somewhat narrow and should include occurrence of partial reduction of airflow. This syndrome is associated with snoring, daytime sleepiness and hypertension. Monitoring approaches include the standard in-laboratory polysomnography that includes EEG, right and left electro occulogram, chin electromyogram. Breathing is monitored with thermocouples or thermistors, thoracic EMG or inductive plehysmography and oximetry. These data are collected in the lab by attended monitoring.
A system allows remote monitoring of such devices by providing in-home monitoring utilizing polysomnography and oximetry with newer portable and/or disposable devices with on line live monitoring.
Health Clubs
An embodiment provides web-enabled fitness equipment, and allows personal fitness data to be monitored, recorded, analyzed, and stored in a personal electronic fitness log. It provides an easy way for clients to keep track of their workout progress when they are at home, traveling, or at another chained health club. Trainers can monitor the activities and progress of their clients remotely. Health club administration may also be able to monitor the usage patterns of fitness equipment, and to provide remote diagnostics.
Computer-Related Discomfort (CRD)
Computer Related Discomfort (CRD) is a term used for a broad class of injuries, such as Carpal Tunnel and Tendonitis, which affect people's ability to work and perform activities of daily living. It has also been referred to as Work-related Musculoskeletal Disorders (WMSD). It is a musculoskeletal injury where soft tissues in the body, primarily muscles and occasionally nerves or tendons, become irritated and inflamed from repeated physical movements. There are a multitude of potential risk factors for RSI, however it is important to understand that not all of these factors need to be present for an injury to occur.
Due to the rise in computer use over the years, the Occupational Safety and Health Administration (OSHA) estimates that every year, between 800,000 and 2.7 million Americans develop some form of computer-related discomfort CRF, which can lead to repetitive strain injuries (RSI). CRD has signs and symptoms that develop gradually, and pain and/or discomfort may not be immediately apparent. Over time, signs and symptoms can include pain, tingling, numbness, and swelling arising from a combination of physical tension, emotional stress, repetitive motion, improper posture and ergonomics. Computer users are exposed to all of these, and are commonly prone to poor typing and mousing habits that target the more delicate muscles of the hand and wrist in particular.
One of the major factors in CRD is that some muscles may be fatiguing while other muscles are compensating or overworking. The muscles that were meant to do the work have not been functioning properly, either as a result of acute injury, or from fatigue due to long-term overuse. Over time, neighboring muscles get recruited to compensate for this injury. They quickly fatigue because they are not designed to do the job. When muscles do an unexpected task very suddenly, or when they fatigue from doing repetitive work in awkward positions without rest breaks, they can develop tight knots or bands called Trigger Points. These trigger points are the spots, which indicate that the muscle is not working properly. Trigger points can refer symptoms to certain parts of the body in very consistent ways. It is possible that most of the symptoms being experienced are the result (directly or indirectly) from trigger points. CRD has the potential to cause crippling disability and pain with gradual increments of damage.
These symptoms affect work and daily activities caused by physical and/o psychological stresses on the body beyond its ability to adapt. When muscles and tendons are overused without sufficient time for healing and repair, microscopic tearing occurs with resultant swelling and pain.
One embodiment provides standardized simple screening questionnaires and inventories that allows for the prediction of employees susceptible of developing repetitive strain injuries (RSI). There are many factors that are believed to be responsible for the development of RSI, or "Computer Related Discomfort" (CRD), and these questionnaires help to assess the factors that may contribute to the development of pain symptoms. The inventories include a quick computer related discomfort inventory which assesses pain symptoms, coping skills, work style, work behavior and ergonomic factors, work demands, stress, and interaction/interpersonal styles. Included with each questionnaire is educational content that explains how each factor may contribute to the development of CRD. Treatment and education protocols can be integrated with biofeedback devices to prevent, manage and treat the factors responsible for the development of stress and pain symptoms.
One illustrative embodiment provides a CRD questionnaire. This questionnaire is a multi-part diagnostic tool for assessing whether or not a patient currently has computer related discomfort (CRD), and can identify specific risk factors for developing CRD in the future. For each area that indicates a moderate or high risk factor, the patient will be prompted with a link to a more detailed questionnaire.
The detailed surveys are Work Behavior, Work Style, Stress, Coping Skills, and Pain Inventory. The Work Behavior survey assesses a patient's work behaviors, computer use habits, posture, and ergonomic factors that may contribute to the development of computer related discomfort.
The Work Style survey assesses a patient's particular way of handling events at work. Research has documented two work style behavior patterns that lead to more injury and disease. These work style patterns are called Type A and Type C work style behaviors. Type A patterns are characterized by time urgency, hostility, and competitiveness. Type C is characterized by passiveness, hopelessness, and suppression of emotions.
The Stress survey assesses the contribution of stress in the development of computer related discomfort. Stress has long been known to be a significant risk factor in the development of disease, injury, and illness. One area related to stress includes work demands, which assesses the influence and dynamics of work on health. High work demands are known to contribute to pain and disability. Another area is stress symptoms, which assesses the contribution of other sources of stress in a patient's life. The occurrence of stress symptoms provides cues to the possibility of experiencing stress in the patient's life.
The Coping Skills survey assesses a patient's particular way of handling events at work. People handle stress in different ways. What may be stressful to one person may not be stressful to another. It is not so much a matter of how much stress is in the patient's life, but how she handles and copes with the stress.
The Pain Inventory survey assesses a patient's pain intensity and tells whether pain affects his ability of perform his job or not. This inventory can be used to teach the patient how to handle and cope with the pain.
Remote Troubleshooting
The system may also be used for remote troubleshooting. For example, a manufacturer of the client-side device can use the remote control capabilities of the system to debug and diagnose any hardware connected to the WAN. Further, device manufacturers can monitor, via the WAN, how the device is being used, and analyze any problems or limitations experienced by the providers. This will allow for the improved development software and hardware based on real time feedback received from providers. Also, support from the device manufacturers can be more readily obtained.
Product Demonstrations/Training
The system further provides for product demonstrations and sales over the WAN, reducing the need for a sales representative to visit a doctor's office. The system may also be used for remote supervision and training of local health care providers by a more experience health care provider located remotely.
One embodiment provides a message board that allows clinicians to share research, results, and protocols. Another message board and/or instant messaging system can be provided for patients to allow for support networks, integrated with a wide range of educational materials. Further, pages having information on treatment applications and clinician biographies may be provided on the website. This information could be posted by participating providers, as well as taken from journals, etc.
Monitoring in Remote Locations
Many patients do not even have access to adequate health care facilities. One embodiment is adapted to remote physiological monitoring of a dispersed rural population. For example, satellite or telephone communications can be used to provide healthcare monitoring in forests, tribal areas, mountainous regions, the arctic during expeditions, at sea, etc.
Others have access only to healthcare providers with limited knowledge. One embodiment allows local surgeons, etc. to be assisted by remote providers including specialists and anesthesiologists. For example, an anesthesiologist in the United States can remotely assist a surgeon performing surgery in Ecuador.
Other Applications
Again, it is stressed that the system and methodology of the present invention contemplates uses in many applications other than those presented herein, such as post surgical monitoring; ICU (Intensive Care Unit) monitoring; remote anesthesia monitoring during a surgical process, vital sign monitoring including EKG in the ambulances and other types of vehicles, ships and airplanes; remote physiological monitoring of population exposed to bioterrorism attack; and remote monitoring at correctional facilities.
Remote fetal monitoring and monitoring of elderly patients can be conducted to remotely monitor for signs of trouble. This would provide peace of mind for parents, spouses, offspring, etc.
A further application includes monitoring patients on a mass scale. For example, such a using a screening protocol can include screening persons in third world countries on a large scale.
Revenue Models
Several revenue models are provided by the embodiments presented herein. For example, a fee may be charged for the creation and or acquisition of dedicated server software which includes an engine and one or more applications such as cardiology or pulmonology.
According to another embodiment, a fee may be charged for transmitting the data, storing the data, accessing the data, etc. For example, medical providers, device manufacturers, and service providers may pay a one-time (or continuing) development cost for web-enabling their devices or treatment protocols and supporting those devices/protocols in the engine. These uses may then resell the server software along with their hardware. In another example, these persons/entities may also be billed on a monthly basis per acutal online and streaming time.
Generally cardiologists cannot charge insurance when their patients call them over the phone complaining about their chest pain. With web-enabled devices, not only they can provide better services to their patients, but they can also charge the insurance for real-time interpretation of the ECG/event monitor signals. The system can be adapted to automate and web enable health provider protocols for ECG/pacemaker/ICD interpretations so that they can offer their protocols to other cardiologists for a fee.
In another revenue model, advertisements may be posted to a website for a fee. When a provider or patient logs in, the advertisement is displayed. Another embodiment includes a subscription-based (ASP) model with a web based central server, where users are billed based on the usage or monthly flat fees. A further embodiment
While various embodiments have been described above, it should be understood that they have been presented by way of example only, and not limitation. Thus, the breadth and scope of a preferred embodiment should not be limited by any of the above-described exemplary embodiments, but should be defined only in accordance with the following claims and their equivalents.
|Cited Patent
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|David; Daniel
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|Georgia Tech Research Corporation
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|Criticare Systems, Inc.
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|Nexsys Electronics, Inc.
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|Dec 20, 2000
|Aug 27, 2002
|Medtronic, Inc.
|Instrumentation and software for remote monitoring and programming of implantable medical devices (IMDs)
|Citing Patent
|Filing date
|Publication date
|May 12, 2011
|Oct 29, 2013
|Rajendra Padma Sadhu
|User wearable portable communication device for collection and transmission of physiological data
|Dec 8, 2011
|Mar 31, 2015
|Healthspot, Inc.
|Medical kiosk and method of use
|Mar 14, 2014
|Apr 28, 2015
|eagleyemed, Inc.
|Multi-site video based computer aided diagnostic and analytical platform
|Feb 6, 2013
|May 26, 2015
|HealthSpot Inc.
|Medical kiosk and method of use
|Mar 28, 2013
|Jul 14, 2015
|Pioneer Advanced Solutions, Inc.
|System and method for generating and using customized athletic workouts
|Oct 2, 2014
|Jul 28, 2015
|eagleyemed, Inc.
|Multi-site data sharing platform
|Nov 18, 2010
|Nels Dahlgren
|Interactive learning software
|Mar 12, 2009
|Feb 24, 2011
|Brc Ip Pty Ltd
|Database driven rule based healthcare
|Nov 3, 2011
|AMD Global Telemedicine, Inc.
|Remote healthcare data-gathering and viewing system and method
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|Rajendra Padma Sadhu
|User wearable portable communication device
|U.S. Classification
|International Classification
|Cooperative Classification
|European Classification
|Apr 5, 2007
Owner name: TELEVITAL, INC., CALIFORNIA
Free format text: ASSIGNMENT OF ASSIGNORS INTEREST;ASSIGNORS:KUMAR, KISHORE;RASHINKAR, LAXMIKANT;REEL/FRAME:019120/0077
Effective date: 20020606
|Sep 9, 2013
Owner name: ABODYNE,INC., CALIFORNIA
Free format text: ASSIGNMENT OF ASSIGNORS INTEREST;ASSIGNOR:TELEVITAL,INC.;REEL/FRAME:031166/0987
Effective date: 20130907
|Apr 3, 2015
|Maintenance fee reminder mailed
|Aug 23, 2015
|Lapse for failure to pay maintenance fees
|Oct 13, 2015
|Expired due to failure to pay maintenance fee
Effective date: 20150823


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About Me
..with one thing I have to start: usually I don't want/can't define myself with some adjectives, I like to be like water, that can cross the borders and refuge itselfs beetween the rocks. I like to change, to learn, to listen (especially to music). Sometimes I need to feel life, breaking the rules or the routine other times I just need an hour of silence.
I love to discover places while discovering people and languages, coffee it's like breathing, I love books, photography and good people.
it changes everyday ..but in the end I'm always looking for a crazy and happy equilibrium
photography, reading, music, cooking,arts, contemporary dance, travelling
Music, Movies, and Books
Books to me are precious objects, I prefer the ones who have a light yellow paper, medium size type and smell like life. Favorites books: the black box - Amos Oz, As a Few Days/The Four Meals - Meir Shalev, the Idiot - Dostoyevsky, the Master and Margarita - Bulgakov, I also like almost all books from Fred Vargas, il Piacere - Gabriele D'Annunzio, some books of H. Murakami, Tender is the night - F. Scott Fitzgerald, l'Isola di Arturo - Elsa Morante.
Nothing better that spend a night with a good movie.
I love series such as How I met you mother, Games of Thrones, Sex and the City, Downton Abbey
One Amazing Thing I've Done
I was at a Sunday evening of Candombe (afro-uruguayan drums) in Montevideo..that was great, all that caracatumcaracatum will never leave my heart-brain.
Ipanema's waves were great
face my ghosts, jaja
cut my guest hair!
Teach, Learn, Share
italian or singing an italian song if you don't have a year at least to spend with me practicing and practicing!
cooking and baking
Countries I've Visited
Argentina, Austria, Brazil, Croatia, Finland, France, Germany, Greece, Ireland, Portugal, Slovenia, Spain, Sweden, United Kingdom, United States, Uruguay
Countries I've Lived In
Argentina, Brazil, England, Italy, United States


text:
DEERFIELD, Ill. -- Derrick Rose knows that every team in the NBA has the same strategy when he steps onto the floor.
"Get the ball out of my hands?" Rose said recently while discussing how teams have set up their defensive schemes this season. "I guess, yeah."
After missing a year and a half while recovering from knee surgery, a lot of aspects of Rose's game have looked rusty over the first two weeks of the regular season. He's turned ball over 25 times in the first five games, but his biggest challenge has been the constant double teams and traps he has seen from each team, especially the Miami Heat and Indiana Pacers.
"It's kind of slowing me down," Rose said. "Because it's forcing my teammates to make plays, but at the same time, it's easy basketball when I pass it to them. I know I'm going to have my opportunity to go at them or score when I want to, but us jelling is the biggest thing right now."
When Miami's LeBron James and Indiana's Paul George, both long and athletic big men, switch onto Rose the former MVP has struggled to find a rhythm. Rose said it's a different look than he's used to seeing.
"At first they're not even really giving me a chance to go at the big," Rose said. "They're bringing up both guys so I won't have a chance to split. If anything, they're really forcing me to pass the ball to another one of my teammates. But as a basketball player, as long as I've been in this league it's something that you just get used to. Earlier in my career when they were double-teaming me they were giving me an opportunity to go at the big. They're taking that away now and I just got to learn it."
That's surely one of the things Bulls coach Tom Thibodeau pointed out to Rose during a film session -- Thibodeau wants Rose to focus on finding the open man. The interesting part is that Thibodeau doesn't believe the looks that Rose is seeing are any different than ones he saw before his knee injury.
"It's not different," Thibodeau said. "Great players in this league face traps -- that's part of being a great player. It should be easy offense because any time you're putting two on the ball you have to move the ball freely and the team has to function well together. I think that's why there's such a premium on shooting. You have to surround your best players with shooting. If there's pressure, any time you commit two to the ball, you're saying, 'What are you willing to live with?' So you have to weigh that and you got to make shots."
The broader issue for Thibodeau and the Bulls is that they don't have a lot of pure shooters on this roster. Mike Dunleavy, Jr. was brought in to be a 3-point specialist but he has really struggled in his first few weeks. Outside of Dunleavy, the Bulls don't have a lot of consistent jump shooters on this team.
After dominating in the preseason, Rose is still convinced that his time, and his team's time, will come soon.
"It's not frustrating," Rose said. "It's easy basketball if anything. Me passing it to Joakim (Noah) or Taj (Gibson) or Carlos (Boozer) or anyone and making them have to make the play to make the double teams stop. I think that's only how the double team is going to stop is with us finding easy ways to beat it."
The question for the Bulls becomes: How can they simulate the double teams in practice?
While Thibodeau and his staff ponder that, Rose knows that few teams have the ability to send the type of athletic defenders at him that will make much of a difference.
"Somebody that's quick on their feet," Rose said. "I think teams now, right when I hit the screen, the big ... when I used to play in these double teams they'd kind of be in a contain (position). And I'd be able to go at the big and the guard would be on my hip or kind of behind me. They're not even doing that no more where they're on me the whole time forcing me to pass the ball, jumping in the air, doing all types of things so they're really trying to take me out the game, really with that double team."
The good news for Rose is that he views the extra pressure as motivation to get even better.
"That's the first time in my career I ever had to deal with this and it kind of makes me feel good," he said. "Because I'm getting a little bit of respect out there but at the same time I got to find a way to beat it."


text:
Pros: lots of good information, mostly accurate, no one else's ads
Cons: enough junk mail to heat your house in winter; pricey
I recently started taking Bottom Line Personal (BLP) again after a several-year hiatus, mainly because I saw that it had gotten thicker. I realized that when I did so I was mainly buying their primary advertising vehicle for more profitable goods and services, and I decided it was worth it in order to get the quality of information--fully consensual economic prostitution. Plus, I needed another tax writeoff for the business.
The sample issue of this semimonthly publication was dated April 1, 2001. (All of you who are reading a lot into that, go play in traffic.:)
Format: a very readable, newspaperly presentation style. It's only sixteen pages, and not much of it consists of ads. All such ads are those of the mag's parent company, which is pitching a 'business miracle' called I-Power (owner Martin Edelston's self-improvement program, which can be yours for only $99), as well as Martin's free e-letter found at www.bottomlinepersonal.com. It may well be that you can get a lot of good information about/from the magazine there while rejecting cookies and avoiding paying Marty $30 per year.
(Sorry, Marty. The bottom line is that it's nothing personal, just as you don't mean anything personal when you shell me with junk mail. It's just a business decision.)
Methodology: BLP retains or consults with a number of people they consider experts in various fields. How they choose them, I'm not sure, but I know this much: anyone billing John Gray, 'Ph.D' (Men Are From Sportsbars, Women Are From 'Lifetime') as one of their experts on relationships needs to broaden his or her horizons a little. Deepak Chopra (ulp...excuse me a moment) is also on their list.
I can't help but wonder if some of their Usual Suspects are chosen more for marquee value than actual knowledge... however, they publish the credentials (to varying degrees of depth) of the people whose advice they incorporate, so you could presumably check up on them to see if they were diploma-mill wonders, for example, or bona fide experts.
BLP's advice leans heavily to legal, tax, investment and medical tips, so what I'll do is skip around the magazine and give you an idea of the aggregate relating to each of these core topics. After that, I'll gaggle up whatever miscellaneous stuff doesn't fit these categories (mostly relating to the home, entertainment and travel). This works best because sometimes the information is fairly hodgepodged, and legal advice is generally part and parcel of a given category, so no need to give it its own section. Sections in 'Apostrophes' denote topics that didn't need to be divided into my arbitrary categories because they fell entirely within one or another.
Tax: the tax deadline, advice for last-minute filers. 'Deductions, Deductions'--some guerilla tax deduction tips relating to home modification for medical reasons, starving artists' self-promotion efforts, teachers' foreign travel, salaries to children, rent paid to self, and personal deduction for donation of shares of a business. How to protect your marriage at tax time when you and your spouse are each plotting spousicide over filing tax returns. How employees are taxed on employer-provided life insurance. The property tax trap relating to mortgage escrow accounts.
Investment: 'Inside Information'--comments on how mad cow scares could affect certain stocks (tickers shown); some economic forecasts concerning US companies with European operations. 'Invest small, earn big'--a lengthy (by BLP standards... about a page) essay on small-cap stock investing. How to determine value, how to pick 'em, current favourites (again, with tickers).
A couple of growth stock analyses. Why value investor Marc Faber is hot and heavy for gold stocks. (I guess if Marc Faber is doing it, it must be a good idea. Everyone knows Marc Faber. Don't you know Marc Faber? If not, please justify yourself.) Getting into conference calls between management and Wall Street investors. 'The Perils of Online Investing'--mistakes and how to avoid or correct them, four full columns.
(For those not directly familiar with the term, a 'ticker' is the 1-4 (occasionally longer) letter shorthand that positively identifies a given stock or mutual fund. Investment wonks will say 'buy 13000 shares of MSFT', and other investment wonks will know that 'MSFT' = 'Microsoft', for example, or they'll look the ticker up in a stock guide.)
Medical: spring safety tips about bicycles and outdoor sports; dealing with kids' spring energy bursts. A new test for breast cancer; details of medical savings accounts for the self-employed and for small business employees. How half of all fertility problems are traced to men, and how a hospital patient can have a family member with him or her 24x7. How to avoid the biohazards that pass for public restrooms.
How indoor pesticides can migrate to toys. '12 Weeks to Physical & Mental Health'--a full four columns of nutritional, psychological and exercise advice. Important minerals diets lack. How unclear thinking lurks behind most anger. (Oh, yeah? Who says?! Are you implying something, bub?) Dangers of penile enlargement surgery. Precautions before sending medicine to school. Risks of bee pollen capsules.
Misc: expected spring and summer weather patterns; vacationing tips; date of daylight savings time change this year. Debunking of myths about college admission. How homeowners have less equity in their houses these days (duh). Golden rule of air travel (book in advance). 'Simplify'--your finances, your schedule, your home. Journaling. Internet searching. Anti-virus advice.
Preserve clothes without carcinogenic mothballs. Gasoline moneysavers. Advice on pet CPR, and on detecting and accommodating pets' deafness and blindness. Some funny movies, divided up by age of appeal. 'What's Hot...What's Not at Flea Markets Now'--four columns of ideas for the eBay- and garage sale-minded. Great games for travel. Freebies you can call (or write) and order; cheapbies, in the same vein; slightly less cheapbies. (I suspect that many of these are paid advertising, but I can't prove it.)
'How to Save Time and Money on Home-Cooked Meals'--ones easily frozen or stored for later troughing. Surprising uses for paper and plastic bags. Economic slowdown self-defense. Safest air bags; diesel cars. How to minimize jetlag; downsides of off-season travel. Best deals on Stafford student loans. Home selling tips.
As you can see, this is a pretty eclectic piece of work. It's a quick read, and you'd pretty much have to live a Neolithic existence in a barter economy not to get some useful information out of every issue. Nothing is lengthy--everything is condensed. The complete sentence is sacrificed upon the altar of 'just give me the bottom line right now'. Gratify me or I will reach for the clicker. One thing that just hit me as I was writing: it reads a hell of a lot like a series of extremely dry but informative Epinions essays.
In this way, at least, BLP is very symbolic of the contemporary American middle class to which it proffers advice. It is about as opposite to Utne Reader, for example, as you can possibly imagine--yet both are offering advice for better living. Utne has time for coffee and a granola and ruminations on the meaning of our existence--while BLP is busy timing the signal lights on the arterial street so as to get there two minutes sooner, because Time is Money. And it's figured out how to talk on its cell phone while still driving safely.
Me, I think if you get one, you should get both, just to stay in balance--for the same reason I force myself to read George Will's and Ellen Goodman's columns, because I can't stand either one. We need disparate viewpoints presented differently.
Le junque-mail: I'm not sure how many outfits Marty's company sells your name to these days, if any (we will soon find out), but I remember from before that I got all sorts of pitches from him for this motivational product, that special publication, or the other life-simplifying business tool. You get the idea. There is a sort of aura of Frankie's-Coven, or whatever their name is (you know... mall store, they sell overpriced briefcases and day-timers, and they pant in ecstasy over the 'Seven Habits of Highly Effective People') about everything that issues forth from Martyville.
Value: at roughly $2 per issue, even granting the density of information and the relative lack of advertising, this is a moderately expensive mag considering that for $4 per month you can have both Time and Newsweek, for example, if you want to accept the 'Professional Courtesy Rate' that they send out to anyone they suspect of having a positive blood pressure reading, or of having had one recently.
Appeal: helps to be a homeowner, a parent, an investor, a do-it-yourselfer, a thrifty type, and a skeptic. The more of these things you are, the more you're going to benefit from it. A single person with no money who lives in an apartment, spends money pretty freely and tends to be very credulous, therefore, might find it only semi-relevant. (You may scoff, but except for 'credulous' (I wasn't even a credulous embryo), that was me at thirty.)
However--and I deeply respect Marty's marketing savvy here--there is enough useful information in every issue of BLP--even if you do some heavy filtering--to make it one of those publications you hate to not get. Therefore, Marty probably charges what he knows he can get because most of his subscribers probably don't much sweat $30-50 per year, and in the process, gets a prequalified list of people to market to.
Not everything you get from Marty costs you extra. I remember periodically getting special booklets called 'How to Do Everything Right', and so forth, now and again--and I never ordered any of his special offers at all, no matter how much junk mail he sent me. When I signed up for my subscription it included a booklet that was basically more BLP. It all has a sort of Consumer Reports-like feel about it.
He probably doesn't have to pay his advisors too much--he can offer them national exposure as a form of marketing. (Hell, I'd jump at the chance. I'd be booked up in anticipation of problems with computers people hadn't even purchased yet.) So let's assume he doesn't have to pay too much for his material; he gets a revenue stream from the products his company sells; his consumers are persuaded to pay for his advertising vehicle. Not too shabby. Marty's whole program may feel a little bit 'Re-engineering The Corporation'-slick to my eye, but it's very intelligent. I therefore will never underestimate him, nor will I ever assume I've got all his angles worked out.
But I'm going to keep getting his magazine. I won't Biblify it, but I'll read it--cover to cover.


text:
looking forward to it, never seen a movie in 3D at the cinema before!
We went to the movies last saturday to watch it. It's weird!
undecided about this one, 3D has indeed come a long way and was brilliant. Would have liked to have seen more in your face things.
Red Queen and the other characters were fantastic,
special effects brilliant
I didn't really like the mad hatter!
it was too short.
I'd give it a 7/10. It will be bought on blu ray when it comes out but i won't be stalking the postman for it to be delivered.
I thought the rabbit was scarey!


text:
Jobs & Recruitment
Holdsworth House Hotel prides itself on not only the quality of the product but in the quality and selecting of the personnel who play such an integral role in the success of the business.
Family owned for over 50 years Holdsworth House bases staff selection on two key criteria: honesty and trust. There are lots of great reasons to join the Holdsworth House team, including:
- Competitive salary
- Free meals on duty
- Free uniform
- Free use of Wi-Fi during break periods
- Inclusion in Holdsworth House Pension Scheme*
- Discounted room rates for friends & family
- 20 days holiday and Bank Holidays
- Quarterly bonus scheme available to selected positions based on company performance
- Up to 50 % discount on food and beverage
- Annual staff Christmas lunch
- Annual development reviews
- Fantastic career prospects as we aim to home grow our managers of the future
*Employees earning over £10,000pa and aged between 22 years and state pension age qualify for the pension scheme
You will need to have good physical health, as you will be on your feet for most of the shift. You also need to be good at working in a team. If you are interested in applying please contact our General Manager on 01422 240024
We're looking for a dedicated and enthusiastic Chef de Partie to join our busy 2 AA rosette team and oversee a section of the kitchen, delivering high end banqueting and restaurant food year round.
Key responsibilities:
- Preparing, cooking and presenting dishes within your speciality
- Helping to manage and training any apprentices
- Helping the head chef to develop new dishes and menus
- Ensuring you and your team have high standards of food hygiene and follow the rules of health and safety
- Monitoring portion and waste control to maintain profit margins
You will need to have good physical health, as you will be on your feet for most of the shift. You also need to be good at working in a team. If you are interested in applying please contact our General Manager on 01422 240024
We are always recruiting for ambitious waiting and bar staff, whether local to the area or on a gap year from abroad, if you are of smart appearance, polite, confident and articulate then please submit an application direct to personnel stating the department or position you are applying for. Please contact the Hotel for an application form or Click here to download it


text:
Destination Maternity relaunching site with a mobile focus
More than half of the maternity apparel retailer's online traffic comes from mobile shoppers.
Destination Maternity relaunching site with a mobile focus
More than half of the maternity apparel retailer's online traffic comes from mobile shoppers.
Twitter pivots away from Buy buttons
While the social network isn't doing away with its direct-sale initiative, it is focusing its attention on ads that drive consumers to retailers' sites.
Sign up for IRNewsLink and get daily reports delivery to your inbox. Sign Up Now
Sponsored by 2013 Social Media 300
Consumers have taken to the web this holiday shopping season but two competing researchers are reporting very different numbers.
Consumers have taken to the web this holiday shopping season--no doubt about it. The only question is: To what extent? Two competing researchers are reporting very different numbers. The eSpending report released today by Goldman, Sachs & Co., Harris Interactive, and Nielsen/NetRatings reports that online shoppers spent $2.95 billion during the second week in December, an increase of 48% from the corresponding week in 2002.
In contrast, ComScore Networks Inc. reports that consumers spent $2 billion that week, the second consecutive week that comScore's online retail spending total exceeded $2 billion. Both research reports exclude online travel sales.
The differences between the numbers are usually attributed to differing methodologies. The eSpending Report is based on a weekly national survey of 800 to 1,700 online shoppers randomly chosen from Harris Interactive`s online panel of survey respondents. ComScore gathers its numbers by monitoring a cross-section of 1.5 million consumers who have agreed to allow comScore to track their Internet behavior.
Whichever online number is correct, it's clear that consumers are moving to the web. Total retail sales grew 3.9% for the same week year-over-year, reports ShopperTrak's National Retail Sales Estimate. In addition, the eSpending Report found that through the week of December 12, shoppers spent 21% of their 2003 holiday budget online, up from 16% in 2002. Brick and mortar storefronts have experienced a commensurate decrease in spending. Shoppers said they had expected to spend 72.9% of their budget at brick and mortars in 2003, down from 76.8% last year.
The latest eSpending weekly report brings the total spent online excluding travel to $13 billion this holiday season, an increase of 46% over last year.
British web retailers could be left out of the e-commerce race as other players in ...
Posted 05/27/16
Lenders will look at the ratio of operating income to debit, or the debt service ...
Posted 05/27/16
Online retail is hard, grocery retail is really hard, so online grocery is, of course, really, really hard."


text:
fiberglass shingles
do they make a 30 MPH rated shingle that anyone knows
A properly installed arch can with stand 130mph when installed to high velocity wind requirements.
Most of the states that require specific installations for high velocity winds are generally on the gulf coast.Typically anywhere the potential for extreme winds associated with hurricanes.
|All times are GMT -5. The time now is 07:43 PM.
User Alert System provided by Advanced User Tagging (Pro) - vBulletin Mods & Addons Copyright © 2016 DragonByte Technologies Ltd.


text:
Hi everyone,
were just got internet access in the lounge at the airport the conection inour room was down.
I will upload some pictures tomorrow of the wedding. we have had a wonderful time but are exhausted trying to cram so much into 7 days is hard going.
Highlights the grand floridian it was amazing nothing will ever live up to it ever.
we pulled through the gate to be greated by a young woman who escorted us to our suite to check in she talked the hole way about what we had to do when she opened the door we were all in shock the suite was massive its in one of the turrets and has 4 balconies all looking over MK there was a sauna a tv in the bathroom a huge dressing area big screen tv's every where you looked amazing is an understatement..................
lows le cellier it was awful really dissapointed more later............
anyway will talk to you all real soon when the dream becomes reality
Im Mrs Green
love to all


text:
Newcastle United are exploring the prospect of luring West Ham United striker Andy Carroll back to Tyneside.
The People says Toon boss Alan Pardew believes he can persuade the Londoners to sell after they snapped up Mauro Zarate and Enner Valencia this summer.
Pardew is ready to offer the Londoners their £15m back to bring the England star home to the north east.
And if Pardew gets Carroll he will drop his interest in Manchester United winger Wilfried Zaha.
A Toon source said: "Like all Geordies, Andy Carroll has never lost his love for Newcastle and we are sure if West Ham agree to sell we would have no difficulty in persuading him to come home."
The lure of the black-and-white shirt is strong and the Toon source added: "Don't forget Alan Shearer turned down Manchester United to come home to Newcastle."
For the big stories and the banter follow us on Twitter: @tribalfootball


text:
Construction and Engineering
Company Overview of Underwater Construction Corporation
Company Overview
Underwater Construction Corporation provides underwater services to commercial and government facilities. It offers underwater inspection, maintenance, infrastructure, and technical support services. The company serves power generation, decommissioning, ship husbandry, power and gas transmission, and homeland security industries; and engineering firms, bridges, and water utilities. Underwater Construction Corporation was founded in 1969 and is based in Essex, Connecticut with offices in California, Japan, Korea, Taiwan, and China. It has regional locations in Connecticut, Michigan, and Tennessee.
110 Plains Road
Essex, CT 06426
United States
Founded in 1969
Key Executives for Underwater Construction Corporation
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Sponsored Financial Commentaries
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Only a company representative may request an update for the company profile. Documentation will be required.
To contact Underwater Construction Corporation, please visit www.uccdive.com. Company data is provided by Capital IQ. Please use this form to report any data issues.
Our data partners will research the update request and update the information on this page if necessary. Research and follow-up could take several weeks. If you have questions, you can contact them at firstname.lastname@example.com.


text:
» All whiskey purchases must be made in person with a valid photo ID. Must be 21 years or older. No exceptions.
» On sale at The Shops at Mount Vernon. Whiskey Purchase Hours: Monday-Saturday, 10 a.m. - 6 p.m., Sunday, 1 - 6 p.m.
» You may access The Shops (in the Mount Vernon Inn Complex) without an admission ticket. Parking is free.
» Virginia ABC law prevents us from shipping whiskey purchases, nor can we accept checks for, or discount whiskey.