text:
|Publication number
|Publication type
|Application number
|Publication date
|Dec 13, 1983
|Filing date
|Mar 12, 1981
|Priority date
|Mar 12, 1981
|Fee status
|Publication number
|Peter P. Tarjan
|Original Assignee
|Cordis Corporation
|Export Citation
|BiBTeX, EndNote, RefMan
|Patent Citations (6), Non-Patent Citations (1), Referenced by (4), Classifications (5), Legal Events (11)
|External Links: USPTO, USPTO Assignment, Espacenet
The present invention relates to a cardiac pacing system and more particularly to a system useful in treating both bradycardia and tachycardia type arrhythmias.
In certain patients, particularly those suffering from sinus node disease, the basic atrial action of the heart may exhibit arrhythmias of both the bradycardia and tachycardia types. Often, the hearts of such patients beat essentially normally with only occasional lapses in bradycardia, in which the heart beats too slowly to effect adequate blood circulation. Occasionally, however, the hearts of such patients will break into tachycardia where the heart beats at too high a rate. While some such tachycardia attacks may revert spontaneously or in response to pharmacologic treatment, other types may persist for almost indefinite periods which are very debilitating to the patient. Certain other patients suffer from periodic ventricular tachyarrhythmias which do not respond to medical treatment.
Among the several objects of the present invention may be noted the provision of atrial pacing apparatus which is useful in treating both bradycardia type and tachycardia type arrhythmias; the provision of such apparatus in which the initiation of a stimulating sequence appropriate for the treatment of tachycardia may be initiated by the patient; the provision of such a system in which a particular sequence of stimulations for treating tachycardia may be externally predetermined; the provision of such a pacing system which incorporates an implantable pacer which is itself effective in treating bradycardia type arrhythmias; the provision of such apparatus which is easy to use, is highly reliable, and is of relatively simple and inexpensive construction. Other objects and features will be in part apparent and in part pointed out hereinafter.
Briefly, a cardiac pacing system according to the present invention involves both an implantable, battery-powered stimulating unit and an external patient-operable overdriver unit. The implantable unit is operable in a first mode to provide, on its own, inhibit mode pacing suitable for treating bradycardia type arrhythmias. Upon application of the external unit, which in a preferred implementation may be sensed by means of a magnet included in the overdriver, the implanted unit switches to a synchronous mode in which it is responsive to control signals generated by the overdriver unit. The overdriver unit generates these control signals in a pattern preselectable by the treating physician so as to effect a corresponding pattern of stimulating pulses to be applied to the patient's heart for the treatment of tachycardia type arrhythmias.
FIG. 1 is a view illustrating the physicial arrangement of an implantable stimulating unit employed in a system of the present invention with a pervenous lead attached;
FIG. 2 is a view illustrating the physical arrangement of an external overdriver which can be employed in cooperation with the implantable pacer of FIG. 1 in the practice of the present invention;
FIG. 3 is a view, with portions shown in section, illustrating the manner in which the external overdriver of FIG. 2 may be applied by a patient to interact with the implanted stimulating unit;
FIG. 4 is a block diagram of circuitry employed in the implantable stimulating unit of FIG. 1;
FIG. 5 is a logic diagram illustrating in greater detail timing and control circuitry which is part of the circuitry of FIG. 4;
FIG. 6 is a block diagram of one type of circuitry which may be employed in the overdriver of FIG. 2; and
FIG. 7 is a block diagram of another type of overdriver circuitry.
Corresponding reference characters indicate corresponding parts throughout the several views of the drawings.
Referring now to FIG. 1, the stimulation unit illustrated is battery powered and is adapted to be completely implanted. The implanted unit comprises the pacer package itself designated by reference character 11, and a flexible lead 13. The particular unit illustrated is adapted for pervenous installation in which the pacer package 11 is implanted in a subcutaneous pocket formed in the patient's chest near his shoulder, the lead 13 being threaded through a vein to the patient's heart. Lead 13 is provided at a distal end with a conductive tip or electrode 15 suitable for stimulating the heart. The distal end may be shaped to facilitate placement within the atrium and may incorporate projections, as indicated at 17, which engage trabeculae within the heart so as to facilitate retention of the lead in the proper position.
The pacer package 11 comprises a hermetically sealed metal can 21 containing stimulation electronics and pulse generating electronics and batteries for powering the electronic circuitry. An electrical feedthrough (not shown) provides a connection through the can wall to a connector which is formed in an insulating neck 22 extending from one side of the can 21. A plug on the proximal end of lead 13 is received in the socket for establishing electrical connection between the pulse generating circuitry and the stimulating electrode 15. As is conventional, the outer surface of the can 21 forms the reference or ground electrode, the lead 13 being of the unipolar type.
As is explained in greater detail hereinafter, the implantable stimulator of FIG. 1 is responsive to the presence of the field of a permanent magnet for switching from an inhibit mode of operation to a synchronous mode in which externally applied electrical signals can control the generation of stimulating pulses. In the inhibit mode, the implanted pacer is principally responsive to naturally occurring heartbeat signals. Only when the time between such signals exceeds a preselected value does the implanted device generate a stimulating pulse.
In accordance with the present invention, a mode switching magnetic field and suitable control signals are provided by an external, patient-operable unit which is integrated in physical form so as to be readily applied and operated by the patient himself. The physical arrangement may be seen in FIGS. 2 and 3. An insulating plastic housing 25 encloses both a permanent magnet 27 for effecting mode switching and electronics for generating control pulses, together with a suitable battery. The electronics may, as illustrated, be assembled on a circuit board, designated generally by reference character 26 in FIG. 3. Finger-contacting electrodes are provided at each end of the housing 25, as indicated at 28 and 29. Electrodes 28 and 29 are preferably formed of a commercially available Velcro material made with metallic thread. This material has been found to reliably form a low resistance contact when gripped by a patient. A pushbutton 31 for initiating operation of the circuitry is located adjacent the electrode 29 so as to be easily operated by a finger of the same hand which is gripping the electrode 29.
FIG. 3 illustrates the manner in which the patient can apply the external device to effect treatment of tachycardia arrhythmias. Holding the external device with one hand gripping each of the electrodes 28, 29, the patient positions the external device over the implanted stimulator so that the field from the permanent magnet 27 operates the mode switching element in the pacer package. Typically, this element will be a magnetic reed switch as is conventionally used for signalling in the pacer art. By then pressing the pushbutton 31, the patient causes the overdriver circuitry to generate a predetermined sequence of control pulses between the electrodes 28 and 29. Through the finger contacts 28 and 29, a conductive path is established between the electrodes 28 and 29 which links the patient's chest so that the pulses can be sensed by the implanted stimulation unit. In other words, a portion of the control pulse potential will appear between the electrode 15 and the pacer case 21. Typically, it will be useful to observe proper polarity in terms of which hand grasps which electrode so as to assure reliable sensing.
In addition to providing a connection which allows control pulses generated by the overdriver to be coupled to the implanted device, the finger electrodes 28 and 29 can also be employed to allow the overdriver circuitry to sense signals generated from within the patient's body. While it would be difficult to sense the natural EKG signal in this manner, pulse signals generated by the implanted pacer are relatively easily detected, both because of their amplitude and their pulse-like waveform. This sensing capability is utilized in one version of the overdriver as described in greater detail hereinafter.
The general arrangement of the circuitry employed in the implantable stimulating unit of FIG. 1 is illustrated in FIG. 4. Pulses of an amplitude suitable for stimulating cardiac tissue are selectively generated by a conventional output pulse generator 35 upon initiation by timing and control circuitry 37. For application to the heart, these output pulses are coupled to the pervenous lead 13. As is understood by those skilled in the art, naturally occurring cardiac signals can be sensed through this same pervenous lead. For this purpose, the lead 13 is connected also to the input terminal of a sense amplifier 39 through a simple input network comprising a resistor R1 shunted by a capacitor C1.
The timing and control circuitry 37 is preferably of the digital type dischosed in U.S. Pat. No. 3,557,796 and comprises a digital counting chain drive by an oscillator operating at a frequency which is a relatively large multiple of a normal heartbeat rate. The timing and control circuitry 37, while similar in certain respects to that employed in previously known inhibit and synchronous mode pacemakers, is modified in certain respects in accordance with the present invention. These modifications are therefore described in greater detail hereinafter. Preferably also, the oscillator frequency is programmable as described in U.S. Pat. No. 3,805,796. In the particular embodiment illustrated, the oscillator's frequency is adjustable by means of an external resistance comprising a series of resistors R2-R5, selective ones of which may be controllably shorted by semiconductor switches so as to effectively vary the operative resistance in the oscillator circuit.
Programming is effected by repetitively operating a magnetically sensitive reed switch 41 at a rapid rate so as to generate an enable code and a programming sequence, again as described in U.S. Pat. No. 3,805,796. The circuitry for performing this sort of programming function is known in the art and is not described in detail herein but is represented generally by block 43. This circuitry also includes elements for conditioning the signal generated by the reed switch and determining whether the reed switch is in a steady state closed condition or is being pulsed in accordance with the predetermined programming sequence. If the reed switch is pulsed in accordance with the proper predetermined code, selected ones of the semiconductor switches are closed to cause the oscillator to operate at the desired rate. The switches are indicated along the upper portion of the block 43. If the reed switch 41 closes and stays closed, a digital output line 45 is asserted. Hereinafter, this signal is designated MAG. In many prior art pacers, this signal is employed to switch the pacing control circuitry from an inhibit or synchronous mode to an asynchronous mode for checking the basic escape interval of the apparatus. This procedure is conventionally known as determining the "magnet rate" of the pacer. Often this rate is used as means of determining battery condition, the magnet rate being a controlled variable of battery voltage. In accordance with the present invention, however, this signal is employed to change the mode of the pacer from an inhibit mode to a special form of synchronous mode, again as described in greater detail hereinafter.
In addition to changing the mode of the timing and control circuitry 37, the magnet signal can also reduce the sensitivity of the sense amplifier by shunting its input through a resistor R9. Whether this reduction in sensitivity is desired or not depends on the particular therapeutic sequence which is to be implemented by the external overdriver. In the following portions of the specification two different overdriver schemes are described, one of which may utilize the reduction in sensitivity and the other of which does not.
While the timing and control circuitry 37 incorporates digitally timed means which determine a minimum refractory period, the device of FIG. 4 also employs a separate and redundant circuit for establishing an operative refractory period during inhibit mode pacing. This is a one-shot multivibrator, i.e. an analog timing circuit, as indicated at 47 in FIG. 4. The refractory one-shot 47 is triggered by the application of a control pulse from the control circuitry 37 to the output pulse generator 35 and the one-shot in turn generates an output signal which is applied to the control circuitry for defining the end of the refractory period. This separate circuit also, by its nature, establishes a rate limit which is independent of the digital timing circuit.
Referring now to FIG. 5, the circuitry illustrated there is preferably implemented as a C-MOS integrated circuit. In one particular embodiment of the invention, the required digital elements were obtained using portions of an already designed C-MOS pacer chip. Different interconnections between the elements were then implemented by changing the last metalization step. The basic chip was the so-called alpha timing chip employed in Cordis Omnicor pacers.
The oscillator described earlier comprises five inverters 51-55. The oscillator frequency is adjustable by varying the resistance value (R2-R5) connected between terminals T1 and T2. Through a buffer inverter 56, the oscillator drives a ninestage binary counter 57. The output from the last stage of the counter, designated Q9, is applied to a falling edge detector comprising an inverter 59 and a lower gate 61.
The brief pulse generated by the falling edge detector is applied to selectively set a flip flop 62 comprising a pair of NOR gates 63 and 65. At the end of one clock period, flip flop 62 can be reset by the clock signal which is applied as one input to the gate 65. In the inhibit mode of operation, this is the mechanism by which output pulses are timed. That is, an output pulse will be generated when the counter 57 reaches its highest value without being reset. In the inhibit mode, such pulses are passed through NOR gates 67 and 68, assuming that the other input to each of these gates is in the appropriate state, to an output buffer gate 70.
The output signal from the sense amplifier 39 (FIG. 4) is applied, through buffering gates 71-73, to set a flip flop 75 comprising a pair of NOR gates 76 and 77. This setting, however, can occur only when the input to gate 77 on line 78 is in a low state. This signal indicates the presence of a refractory period and is high during such periods. The flip flop 75 can be reset by a signal on line 78 which indicates that a refractory period has been initiated. As noted previously, this refractory signal can be derived from either of two sources, either the one-shot multivibrator 47 (FIG. 4) or a digitally timed refractory period as described in greater detail hereinafter.
The output signal from gate 77 is applied to the data input of a D-type flip flop 79 which is clocked directly from the oscillator. The output signal from the D-type flip flop 79 which is considered to be a "clocked sense" signal, is applied as one input to a NOR gate 80 while the direct output from the sense flip flop 75 is applied as the other input to this gate.
The output signal from gate 80 is a negative going pulse when a sensed signal is sensed by the sense amp during a nonrefractory period, i.e., during an alert state. This signal is applied as one input to a NOR gate 81. The other input to this gate is the mode control (MAG) signal. Thus, the sense pulse will be passed by gate 81, in inverted form, only when the reed switch 41 is open. When the device is in its synchronous mode, the output from gate 81 is always low. The output signal from gate 81 is applied as the third input to gate 65, described previously, and to the last gate 68 in the output signal chain.
The clocked sense pulse, i.e., the output signal from D-type flip flop 79, is also applied as a reset signal to the timing counter 57 and as a reset signal to a flip flop 83 comprising a pair of NOR gates 84 and 85. Flip flop 83 is set by the output from the seventh state of the counter 57, i.e. at a count of 64. The same signal sets a second flip flop 87 which comprises NOR gate 88 and 89. Flip flop 87 can be reset by the output from flip flop 83. Flip flop 83 can be reset by either the "clocked sense" signal from D-type flip flop 79 or by the falling edge detector, the output signal from gate 61.
The output signal from gate 89 is taken as a digitally timed refractory period for the implantable device, a signal which is asserted for counts zero through 64 is then unasserted for the rest of the complete cycle of the counter. After passing through a buffering inverter 90, this signal is applied as one input to the NOR gate 91. The other input to this gate is a signal derived from the one-shot multivibrator 47. It can thus be seen that either of the signals can pull low the output of gate 91, and through inverter 93 assert a logical high on line 78.
The operation of the timing and control circuitry 37 in the two modes, inhibit and synchronous, is as follows:
In the inhibit mode, a sensed, heartbeat occurring after the refractory period will, at the next clock cycle, cause the output from D-type flip flop 79 to go high. This signal resets the counter 57, thereby restarting the escape interval, and resets the flip flops 83 and 87. Though a falling edge may be generated out of the last stage of the counter 57, no output pulse will be generated since the positive going output signal obtained from gate 81 will block any output from the gate 68. The resetting of the counter 57 and the flip flops 83 and 87 also initiates the refractory timing circuitry which inhibits further sensing until the count of 64 is reached and until the one-shot multivibrator 47 times out. After these refractory periods time out and the circuitry is in its "alert" state, sensed naturally occurring heartbeats can again reset the counter Thus, so long as naturally occurring heartbeats are sensed more often than the time required to cycle the counter 57, no stimulating pulses will be generated. The actual time required for this complete cycle will, of course, depend upon the frequency of the oscillator which is preferably programmable, as referenced earlier, so as to establish a suitable range of escape intervals or minimum heartbeat rates. Thus, in this mode, the implanted pacer is suitable for treating arrhythmias of the bradycardia type.
In the synchronous mode, where the output of gate 81 is held low by the MAG signal, the gate 68 does not block possible output signals. Such output signals can be generated in either of two ways. From the count of 256 to 512, the falling edge detector will generate an output pulse as described previously. However, even in the preceding 64 counts, an output signal can be generated in response to a signal sensed by the input amplifier 39 by the "clocked sense" signal, i.e. the output from D-type flip flop 79 which is applied as the second input to the gate 67. The reset signal is, in either case, applied to trigger the one-shot multivibrator 47 and initiate its refractory timing interval. As indicated previously, when the device is in this synchronous mode, it will slave to an external device which generates, through the patient's body, a sufficient electrical signal to be picked up by the sense amp 39.
In the embodiment of the overdriver illustrated in FIG. 6, the psssible reduction in sensitivity in the implanted device is not utilized. Rather, this version of the overdriver utilizes the synchronism of implanted device output with naturally occurring heart signals to establish a desired time relationship or phasing of subsequent stimulation pulses in relation to the last occurring natural heartbeat. The particular embodiment illustrated can cause one, two or three stimulating pulses to be issued following a naturally occurring heartbeat, with the delay to each stimulating pulse being individually controlled.
Referring now to FIG. 6, it can be seen that the finger contact electrodes 28 and 29 are connected, through coupling capacitors C3 and C4, to respective input terminals of a differential input, instrumentation amplifier 101. A nominal d.c. ground potential is maintained at each of these inputs by resistors R11 and R12. The output signal from amplifier 101 is a.c. coupled, through a capacitor C5, to one input of a comparator 103. This input is maintained at a nominal negative potential through resistor R13. A preselected reference voltage is applied to the other input of the comparator.
The output from comparator 103 is applied to trigger a first one-shot multivibrator 106. Through resistor R14, this first one-shot is connected to selectively trigger a second one-shot 107. In turn, this second one-shot is connected, through resistor R15, to selectively trigger a third one-shot 108. Sequential triggering of the second and third multivibrators, however, can be selectively inhibited by shunting the triggering signals, i.e. by closing switches S1 and S2 respectively. Each of the one-shot multivibrators 106, 107, and 108 is provided with an RC timing network comprising capacitors C6-C8 respectively, and variable resistors R16-R18 respectively. Thus, the time interval of each of these one-shot multivibrators may be adjusted independently of the others. The presently preferred range of adjustment is 175 to 425 miliseconds.
Output signals from the three multivibrators 106-108 are combined in a diode array D1-D3. The output signal from the diode array will thus be low during each of the three timing intervals. It will, however, exhibit a brief positive-going pulse at the end of each timing interval. These positive-going pulses are coupled, through a capacitor C9 to selectively trigger. The period determining components of one-shot 115, capacitor C11 and resistor R21 are selected to provide a relatively short output pulse, i.e. in the order of two milliseconds. One shot 115 drives a current controlled switching amplifier 17 which applies, through coupling capacitor C12, a corresponding current pulse to the finger electrode 29. The maximum output current which will be provided by amplifier 117 is adjusted by means of a variable resistor R22. The proper nominal potential is maintained at the output terminal of switching amplifier 117 by resistor R23 when the switch is in its off state. One shot 115 also drives an amplifier 119 connected to energize an LED (light-emitting diode) 120 in synchronism with the generation of output pulse to the finger electrode 29.
Positive and negative supply voltage are provided by a battery B1 with the nominal ground potential being established by a resistive voltage divider R24-R25. The various logic elements and one-shot multivibrators employed in this circuit are preferably constructed of low power C-MOS circuitry so that they may be left energized continuously without appreciable drain on the battery. Likewise the output switching amplifiers 117 and 119 draw appreciable power only during the brief output pulses and thus these elements may also be left energized. The instrumentation amplifier 101 and comparator 103, however, are preferably of bipolar construction and draw appreciable current whenever energized. Accordingly, to limit the energization of these elements to only the necessary time period, a power switching circuit is employed for selectively energizing these elements. This power switching circuit employs two S-R flip flops 125 and 126. These flip flops are preferably also of the C-MOS construction so as to themselves dissipate very little power internally.
Assuming that both flip flops 125 and 126 have been reset for some appreciable time, the capacitor C15 will have been charged through resistor R25. These values are chosen to provide a relatively long time constant. When capacitor C15 is charged, pressing the initiation pushbutton 31 will cause the flip flops 125 and 126 to be set. The Q and Q-bar outputs from flip flop 125 will then provide the positive (VQ) and negative (VQ-bar) supplies to the instrumentation amplifier 101 and the comparator 103. Diodes D3 and D4 prevent back biasing of these supplies. The output of comparator 103 is connected to selectively reset the flip flop 125. Flip flop 126 can be reset by the output of a low pass filter, comprising resistor R30 and capacitor C20, which is connected to the diode array. The filter removes the positive-going pulses described previously. As indicated previously, the output from the diode array will be low during the time interval of any one of the one shots 106-108. However, once all of these one shots have executed their timing interval, the output from the gate 111 will go to a steady logic high and the capacitor C20 will recharge, thus resetting the flip flop 126. Until the flip flop 126 is thus reset, further operations of the pushbutton 31 will have no effect on the circuitry, since the capacitor C15 will be discharged through diode D2.
In order to test the device, a test pushbutton S3 is provided for selectively triggering the comparator 103 and initiating a sequence of timing operation, independently of any sensed heartbeat. This provides to test of the timing circuitry. Thus, if switch 31 is closed and the switch S3 is then operated, the various timing intervals may be checked out.
In practice it is contemplated that only the initiation switch pushbutton 31 and the test switch S3 will be accessible to the patient. The switches S1 and S2, the interval adjusting resistances R16-R18 and the current output adjusting resistor R2 will be adjusted by the physician to affect the desired treatment sequence and then closed up inside the enclosure 25. Depending upon the nature of the patient's ailment and the philosophy of the treating physician, a sequence of one, two or three stimulating pulses may be selected and the pulses will follow a preselected time pattern initiated by a naturally occurring heartbeat. A sequence often found to be effective in treating certain tachycardia type arrhythmias is to issue two stimulation pulses following a sensed heartbeat.
As indicated previously, a naturally occurring heartbeat can be sensed relatively easily once the overdriver is in place, since each naturally occurring heartbeat will be accompanied by a synchronized output pulse from the implanted stimulation device 11. Accordingly, when the patient senses that he is experiencing a tachycardia type arrhythmia he can apply the overdriver as illustrated in FIG. 3 and operate the treatment initiation pushbutton 31. Once the pushbutton 31 is operated, the stimulation pulse accompanying the next naturally occurring heartbeat will be sensed by the amplifier 101 and its output pulse will in turn trigger the comparator 103. After a delay determined by the setting of resistance R16, the output one-shot 15 will be triggered applying a signal pulse to the finger electrode 29. This signal pulse will, in turn, be sensed by the implanted stimulation device 11 which will respond by immediately issuing stimulation pulse to the heart. Essentially simultaneously the second one-shot 107 in the overdriver will be triggered and, after its preselected delay, a second control signal will be applied through the finger electrode. The second control pulse will likewise trigger the generation of a stimulation pulse by the implanted device. If desired, a third stimulation pulse may be likewise indirectly elicited from the implanted unit 11 after a delay selectable by means of the third overdriver one-shot 108. As is understood by those skilled in the cardiology art, the application of stimulating pulses in the fashion can break up certain types of tachycardia type arrhythmias, assuming the intervals are appropriately chosen in relation to the heart's own beating pattern in the arrhythmia. This mode of operation thus effectively involves a signalling in both directions. The implanted device, in its synchronous mode, triggers the overdriver so that timing is started on the basis of a naturally occurring heartbeat and then the overdriver signals the implanted device to issue stimulation pulses in accordance with the predetermined pattern selected by the patient's physician.
The overdriver circuitry illustrated in FIG. 7 can provide a greater variety of different stimulation sequences and pattern than the device of FIG. 6 but it does not initially synchronize with a naturally occurring heartbeat. Thus, the implanted stimulation device used in connection with this overdriver is preferably provided with the gain reduction feature described previously. That is, the attenuating resistor R9 is included within the circuitry and is switched onto the sensing input of the implanted unit when the MAG signal is present. With this reduced sensitivity, the implanted stimulating unit is expected not to trigger on natural heart signals but will still sense and track control signals generated by the external overdriver.
The overdriver of FIG. 7 provides both a fixed rate mode of operation in which a preselected number of pulses are issued at a preselected rate or a scanning mode in which the rate at which pulses are issued is scanned at a preselectable speed between preselectable starting point and end point rates. Scanning can either be in an increasing or decreasing direction. Output pulse rate is controlled in the first instance by a voltage controlled oscillator 201. Oscillator 201 operates at a frequency which is eight times higher than the actual output pulse rate and this frequency is counted down by a divide-by-eight binary counter 203. The square-wave output signal from the divide-by-eight counter 203 is differentiated by a network comprising a capacitor C50 and resistor R50 to generate a short pulse of appropriate duration which is applled to a current controlled output amplifier 205. The output signal for this amplifier is applied to the finger electrode 29, just as in the embodiment of FIG. 6.
As in the previous embodiment, only certain portions of the overdriver circuitry are continuously energized and other portions are energized only during operation. Pressing the initiating pushbutton 31, triggers a one-shot multivibrator 191 which is one of the devices continuously energized. The Q output of this device controls the application of power to the other devices in the circuit. The period of one-shot 191 is selected to be about 20 seconds, a period which is long enough to allow the maximum preselectable number of pulses to be generated at the slowest preselectable rate. Triggering of one-shot 191 also, triggers a second one-shot 193 through a differentiating network comprising capacitor C48 and resistor R48. The one-shot 193 has a relatively short period, i.e. one-half a second, and provides a period during which the circuitry can stabilize and be initialized. Initialization is accomplished by means of an S-R flip-flop 220. When power is first applied, the flip-flop 220 assumes its reset state in which the Q output is logic high. After the delay provided by the multivibrator 193, the flip-flop 220 is set allowing the pulse generating circuit to operate in the manner selected. The generation of pulses continues until the flip-flop 220 is reset. The manner in which this resetting occurs differs between the two modes of operation. The fixed rate mode is described first.
The output signal from the divide-by-eight counter 302 is also applied to a decade counter 207 which is utilized in the fixed rate mode of operation of this apparatus. The carry signal from decade counter 207 is applied to a binary counting stage 209 to double the possible counting range. During the initialization state, the decade counter 207 and the binary counting stage 209 are reset and the voltage controlled oscillator is inhibited by the Q output from flip-flop 220. A pair of potentiometers P1 and P2 provide a pair of preselectable voltages representing corresponding rates of stimulation. These potentials are designated LR (low rate) and HR (high rate) for convenience in description. When this apparatus is operated in its fixed rate mode, the voltage HR is applied directly to the voltage controlled oscillator 201 as its control potential, through the switch SW3/1 (CR position).
At the end of the initialization period, the voltage controlled oscillator is released and will begin oscillating with a period determined by HR, in other words by the setting of potentiometer P2. For each eight cycles of the oscillator, an output pulse will be generated and applied to the finger electrodes.
The number of output pulses which are generated during a single sequence in the fixed rate mode is selected by appropriately setting the switches SW4 and SW5. The output signals obtained from the switches SW4 and SW5 are confined in an AND gate 196. In the fixed rate mode, the output of AND gate 196 is connected, through switch SW3/2, to the reset input of SR flip-flop 220. Thus, when the preselected count is reached, indicated by a logic high at both inputs to an AND gate 196, the flip-flop 220 is reset terminating the pulse generating operation.
In the scanning or variable rate mode, the control voltage for oscillator 201 is taken either directly from an integrator 211 or indirectly through a summing amplifier 213 which inverts the output from the integrator, this selection being made through switch SW2. For sensing the desired end of a scanning sequence, the output signal from the integrator 211 is also applied to comparator 215, where it is compared with the other pre-established potential (LR).
Integration is performed, in conventional manner, by linearly charging a capacitor C51 connected from the output of the integrating amplifier 211 to its inverting input, i.e. through resistance R51. The rate of charging during integration is controlled by an adjustable input resistor R52 which limits the charging current independently of the input voltage to the integrator.
In order to permit the rate scanning circuit to be initialized and then operated as a linear integrator, four switches S11-S14 are incorporated in the circuit. The switches are operated simultaneously by complimentary output signals taken from the control flip flop 220. When flip flop 220 is set, switches S13 and S14 are closed and switches S11 and S12 are open. This is the initializing mode during which the inverting input of the amplifier 211 is grounded and the voltage HR is applied to its non-inverting input. The closing of switch S14 causes the output voltage to follow the non-inverting input and accordingly capacitor C51 is charged to potential HR.
When the flip flop 220 is reset, the comlimentary condition prevails, the non-inverting input is grounded and the amplifier operates as an integrator. In this operation the output voltage on capacitor C51 decreases linearly at a rate determined by the setting of potentiometer R52. Linear integration continues until the voltage on the capacitor C51 reaches a level equal to voltage LR. At this point the comparator 215 will be triggered. With the switch SW3/2 in the variable rate position, the triggering of comparator 215 will cause the control flip flop 220 to be reset, thereby terminating the operation.
During the period of integration, the frequency of operation of the voltage controlled oscillator 201 is controlled by the output voltage of the integrator i.e., the voltage on capacitor C51. Accordingly, it can be seen that the pulse rate will be scanned linearly from a preselected high rate corresponding to the voltage HR to a preselected low rate corresponding to the voltage LR. The speed of scanning is also adjustable by means of variable resistance R52. Scanning in the opposite direction, i.e. from a low rate to a higher rate, may be obtained by operating switch SW2 to connect the input of the voltage controlled oscillator 201 to the output of the summing amplifier 213 rather than directly to the output of the integrator 211. The output signal from the integrator, designated DR, is applied as an input to the summing amplifier as are the two limit voltages HR and LR. Summing amplifier generates a voltage, designated IR (increasing rate) which corresponds to the following formula:
The input voltage to the voltage controlled oscillator will thus behave as the inverse of the integrator output voltage.
Using the overdriver of FIG. 7, initiation of treatment for tachycardia-type arrhythmias is initiated by the patient in essentially the same manner as with the version of FIG. 6, that is, the housing 25 is placed over the implanted stimulating device so that the magnet 27 causes the implanted device to switch from an inhibit mode to a synchronous mode and the initiation pushbutton is operated. However, as the sensitivity of the implanted device is simultaneously reduced, no pulses should be generated by the implanted device synchronously with naturally occurring heartbeats. Rather, the implanted device should slave solely to the external overdriver. Thus, when the initiating pushbutton 31 is pressed, the external overdriver circuitry will generate the preselected regime of control pulses and the implanted device will track or mimic these control pulses with stimulating pulses applied to the heart itself.
While finger contacts on the external overdriver are the usually preferred method of applying signals to be tracked by the implanted device, chest electrodes may be more appropriate where the pacing vector is mostly perpendicular to the line between the shoulders.
In view of the foregoing, it may be seen that several objects of the present invention are achieved and other advantageous results have been attained.
As various changes could be made in the above constructions without departing from the scope of the invention, it should be understood that all matter contained in the above description or shown in the accompanying drawings shall be interpreted as illustrative and not in a limiting sense.
|Cited Patent
|Filing date
|Publication date
|Jan 17, 1969
|Jul 7, 1970
|Sessions Robert W
|Electronic heart stimulator
|Feb 19, 1969
|Nov 24, 1970
|Love Winston A
|Surface contacting electrode assembly having electrically conductive pile forming contact surface
|Mar 10, 1969
|Jan 26, 1971
|Cordis Corp
|Digital counter driven pacer
|Sep 27, 1976
|May 30, 1978
|American Optical Corporation
|P-Wave control, R-wave inhibited ventricular stimulation device
|Jun 19, 1978
|May 20, 1980
|Biotronik Mess- Und Therapiegerate Gmbh & Co.
|Security maintenance for programmable pacer reprogramming
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|Dec 29, 1981
|Watfort Limited
|Apparatus for tachycardia investigation or control
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|Citing Patent
|Filing date
|Publication date
|Jun 6, 2001
|Jan 25, 2005
|Pacesetter, Inc.
|Method and apparatus for electrophysiological testing in an implantable device
|Mar 15, 2002
|Mar 7, 2006
|Medtronic, Inc.
|Method and apparatus for connecting various implantable medical treatment system component devices
|Mar 15, 2002
|Sep 18, 2003
|Medtronic, Inc
|Method and apparatus for connecting various implantable medical treatment system component devices
|May 15, 1998
|Dec 2, 1998
|ELA MEDICAL (Soci�t� anonyme)
|Atrial arrhythmia reducing pacemaker, defibrillator and/or cardioverter
|U.S. Classification
|International Classification
|Cooperative Classification
|European Classification
|Mar 12, 1981
Owner name: CORDIS CORPORATION, 10555 W.FLAGLER ST.MIAMI,FLA.C
Free format text: ASSIGNMENT OF ASSIGNORS INTEREST.;ASSIGNOR:TARJAN PETER P.;REEL/FRAME:003873/0115
Effective date: 19810303
|May 26, 1987
|Fee payment
Year of fee payment: 4
|Jun 8, 1987
Owner name: TELECTRONICS, N.V., DE RUYTERKADE 58A, CURACAO, NE
Free format text: ASSIGNMENT OF ASSIGNORS INTEREST.;ASSIGNOR:TNC MEDICAL DEVICES PTE. LTD.;REEL/FRAME:004748/0373
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Owner name: TELECTRONICS, N.V., NAMIBIA
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Effective date: 19870430
|Jun 15, 1987
Owner name: SOUTHEAST BANK, N.A., MIDLAD BANK PLC (SINGAPORE B
Free format text: SECURITY INTEREST;ASSIGNOR:TELECTRONICS N.V.;REEL/FRAME:004748/0364
Effective date: 19870612
|Jul 1, 1987
Owner name: CREDIT LYONNAIS (CAYMAN ISLANDS BRANCH)
Free format text: SECURITY INTEREST;ASSIGNOR:TELECTRONICS N.V.;REEL/FRAME:004747/0217
Effective date: 19870630
Owner name: SOUTHEAST BANK, N.A.
Free format text: SECURITY INTEREST;ASSIGNOR:TELECTRONICS N.V.;REEL/FRAME:004747/0217
Effective date: 19870630
Owner name: MIDLAND BANK PLC (SINGAPORE BRANCH)
Free format text: SECURITY INTEREST;ASSIGNOR:TELECTRONICS N.V.;REEL/FRAME:004747/0217
Effective date: 19870630
|Dec 5, 1988
Owner name: TELECTRONICS N.V., NETHERLANDS ANTILLES
Free format text: RELEASED BY SECURED PARTY;ASSIGNOR:SOUTHEAST BANKN.A., MIDLAND BANK PLC AND CREDIT LYONNAIS;REEL/FRAME:005002/0786
Effective date: 19880615
|May 23, 1991
|Fee payment
Year of fee payment: 8
|Jun 30, 1992
Owner name: TELECTRONICS PACING SYSTEMS, INC., COLORADO
Free format text: ASSIGNORS HEREBY CONFIRMS THE ENTIRE INTEREST IN SAID INVENTIONS TO ASSIGNEE ELECUTED ON SEPT. 16,1988;ASSIGNORS:TELECTRONICS PTY. LTD.;MEDICAL TELECTRONICS HOLDING & FINANCE CO.;TELECTRONIC NV;AND OTHERS;REEL/FRAME:006172/0028
Effective date: 19920622
|May 17, 1995
|Fee payment
Year of fee payment: 12
|Nov 5, 1996
Owner name: TELECTRONICS PACING SYSTEMS, INC., COLORADO
Free format text: CORRECTIVE ASSIGNMENT TO CORRECT ASSIGNEE S STATE OF INCORPORATION. AN ASSIGNMENT WAS PREVIOUSLY RECORDED AT REEL 6172, FRAME 0028;ASSIGNORS:TELECTRONICS PTY. LTD., AN AUSTRALIAN COMPANY;MEDICAL TELECTRONICS HOLDING & FINANCE CO. (BV), A DUTCH COMPANY;TELECTRONICS NV, A COMPANY OF THE NETHERLANDS ANTILLES;AND OTHERS;REEL/FRAME:008321/0072
Effective date: 19961101
|Mar 21, 1997
Owner name: PACESETTER, INC., CALIFORNIA
Free format text: ASSIGNMENT OF ASSIGNORS INTEREST;ASSIGNOR:TELECTRONICS PACING SYSTEMS;REEL/FRAME:008454/0461
Effective date: 19961129


text:
Check in from 12h / Check out prior to 10h
Locanda delle Corse: Find photos, reviews, information, amenities and compare prices for 3 stars hotels in Rome, Italy.
Within a 20-minute stroll from Capannelle Railway Station, Locanda delle Corse provides guests with an ideal base while visiting Rome. This unique hotel is an ideal choice for discovering local vineyards as it is situated in the Latium Wine Region.
Hotel description
This 3.5-star hotel provides valet parking, a coffee bar and an express check-in and check-out feature. Helpful and professional team members are available 24-hours a day.
The rooms at Locanda Delle Corse Hotel Rome have a mini bar, a private bathroom and a coffee maker. They provide a seating area, a sofa bed and a flat-screen TV.
Those staying at Locanda delle Corse are served breakfast each day. For those with day trips planned, the hotel provides packed lunches if needed.
Locanda Delle Corse Hotel Rome is situated just a short walk from Capannelle Racecourse. Circus Maximus, Archbasilica of St. John Lateran and Colosseum are just an easy car ride from the hotel.
Hotel features
Room Service, Air Conditioned, Mini Bar, Coffee / Tea Maker, Hair Dryer, TV, En suite, Private Bathroom, Bidet
24 Hour Reception, Multilingual Staff, Wake-up Service, Meeting Rooms, Laundry service, Photocopier, Luggage Storage, Express Check-In/Check-Out, Self Laundry
Massage / Beauty Centre, Golf Course, Bath / Hot Tub, Garden, Playground, Massage
Valet Parking
Horse Riding, Private Toilet, Packed Lunches
Availability and Prices
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Users who viewed Locanda delle Corse also viewed these 3 stars Rome hotels:
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Tre R Bed & Breakfast
Viale Carlo Tommaso Odescalchi 8, Rome
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Apartment Roma Elegante Roma
Via Germanico 96, Rome
Via Germanico 96, Rome
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Nearest hotels
- Meeting Hotel Rome
1.3 km
- Reunion Cinecitta
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- Double Room 10 min to Rome Center
1.3 km

subset: commoncrawl


text:
FOG Design + Art 2017
January 12th, 2017
I recently returned from a trip to New York and was reminded once again of why that city rocks. I stayed at The Hudson, a Phillipe Starck special and it did not disappoint. Can we just talk about that lobby? … Continue reading
At this point, Paris feels like a lifetime ago but I am still relishing in the memories. No trip to Paris would feel complete without a stop at "Les Puces." It's a chance to browse, hunt and haggle, and draws … Continue reading
Lately, I have had little time for cooking. I really don't want to eat out all the time nor do the typical takeout options inspire me. Crisp Kitchen + Juice to the rescue. The fabulous creation of Annette Shafer, Crisp … Continue reading
Let's be candid. There is a direct correlation between the gifts you like to give and those you hope to receive. We went around the office and spouted a few of our favorites and maybe if we're good Santa might … Continue reading
I asked the team what design trend they feel most thankful for this Thanksgiving. True to form, their answers were thoughtful, inspiring and definitely reflective of their personalities. ECHE – Brutalism being back in fashion. KATIE – Sculptural mirrors like … Continue reading
As you know, I adore art. I want to be stretched, moved and even provoked by what I see. That's the point. Kenturah Davis' new solo show at Papillion in Los Angeles succeeds at all three. Narratives and Meditations, inspired … Continue reading
It's always fun to reveal projects that have been in the works. Earlier this month we celebrated the launch of some rather fun and fabulous (yes, I am bragging) carpets that are available through California Carpet. I love and collect … Continue reading
Creativity abounds in the lighting industry where sculptural forms dangling from cords have earned their status as veritable art. It's amazing to witness how a light fixture can completely transform an ordinary space into one … Continue reading
We aren't shy about shouting out just how much we love Serena & Lily. They have brought a refined eye to catalog shopping with their fresh and happy perspective on life at home. For you San Francisco locals, please trot … Continue reading
Transparency is the new black. Well, not entirely but I do love a touch of glass or lucite in a room. These invisible gems impart a modern jolt to even the most traditional of spaces. Think sexy and subtle. A … Continue reading


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Volunteers assist with Medicare, Medicaid
ESCANABA – At a time when navigating the health insurance industry's complexities can feel labyrinthine and convoluted on the best of days and downright impossible on others, local volunteers trained in the Medicare/Medicaid Assistance Program can help the Upper Peninsula's seniors and individuals with disabilities discover resources they didn't know were available and make the best possible decisions about their health care benefits.
"We help people – anyone on Medicare – it doesn't matter what age you are," said Sherry Whitman, regional MMAP coordinator at Escanaba's Upper Peninsula Commission for Area Progress, which is also the U.P. Area Agency on Aging. "A lot of folks that are younger have a disability and they get Medicare based on their disability, so we help anybody that has Medicare or is going to get Medicare understand their Medicare benefits. And we help them apply for programs that might be helpful to them, such as Medicaid programs, or Medicare Savings Programs.
With 48 volunteer MMAP counselors throughout the U.P., with one in almost every county and many in Marquette and Delta counties especially, Whitman estimated that the program has, since their fiscal year began in October, "probably helped about 200 people … if not more onto an extra help program of some sort."
Whitman said that while Medicare – federal health insurance paid for by both employers and employees in the U.S. through the Federal Insurance Contributions Act payroll tax – is available for people 65 and older and those with disabilities, those who qualify for Medicare often don't realize all of the extra programs available to them, nor that they potentially meet the criteria for some type of Medicaid benefits, as well.
"I think a lot of people don't know about some of the Medicare Savings Programs and other extra help programs available for people who are specifically on Medicare," she said. "And they are income- and resource-based, but they have qualifications that are much more lenient than some of the traditional Medicaid programs. A lot of people just assume they're not eligible because they're not very low income, or they do have a little bit of money in the bank, but that's not necessarily true. So we're trying to find those people specifically right now."
Some of MMAP's outreach efforts include mailings, advertising, articles to be included in area seniors center newsletters and several upcoming "Welcome to Medicare" workshops that let attendees know about the available extra help programs.
"It's pretty far-reaching, and hopefully people are getting the message," Whitman said. "We're getting quite a few calls, so I think it's working."
Funds for supporting the MMAP program are provided by the federal Centers for Medicare & Medicaid Services and Administration on Aging and in turn distributed through the state of Michigan's Office of Services to the Aging to regional agencies like UPCAP.
Finding out if you're eligible is easy, Whitman said, and can often be done right over the phone, though counselors are also available for those who prefer an in-person interaction. People can call MMAP toll-free at 1-800-803-7174 or dial 2-1-1 from anywhere in the U.P. for more information and assistance.
"The calls come in through our Escanaba office and we put them on a call log and within 24 to 48 hours they will get a call back from a counselor either in their area or from our call center here," she said. "And sometimes things can be answered over the phone – even applications, a lot of times, can be done over the phone – because so many things are going Internet-based now … But if somebody wants to sit down one-on-one with a counselor, we make that happen, too."
Zach Jay can be reached at 906-486-4401.


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Food inflation leaner in new research series
June 28, 1999
Throughout 1978-98, annual growth in food and beverage prices was lower in the new CPI research series than in the official Consumer Price Index. Reductions ranged from 0.1 percentage point in 1997 up to 0.7 percentage point in 1990. On average, about half a percentage point a year was sliced off of food inflation.
[Chart data—TXT]
The food CPI climbed at a double-digit pace between 1978 and 1980—the research series brought the growth in food prices to under 10 percent in two of those three years. Since 1990, the official rate of food inflation was no higher than 2.7 percent in every year except 1996. In the research series in 1991-98, the annual change in food prices was less than or equal to 2.1 percent each year other than 1996.
CPI data are produced by the BLS Consumer Price Index program. BLS has made numerous improvements to the CPI over the years, which have increased the accuracy of the index; however, the official historical price indexes are not adjusted to reflect the improvements. More information on the CPI research series can be found in "CPI research series using current methods, 1978-98," by Kenneth J. Stewart and Stephen B. Reed, Monthly Labor Review preprint, June 1999. It is important to note that the CPI research series has certain limitations and that it is subject to revision. Annual percent changes are December-to-December changes.
Bureau of Labor Statistics, U.S. Department of Labor, The Economics Daily, Food inflation leaner in new research series on the Internet at https://www.bls.gov/opub/ted/1999/jun/wk5/art01.htm (visited January 23, 2017).
Recent editions of Spotlight on Statistics
Workplace injuries and illnesses and employer costs for workers' compensation
Workplace injury and illness data and the costs to employers for workers' compensation in natural resources, construction, and maintenance occupations.
A look at the future of the U.S. labor force to 2060
Projected long-term trends in the growth, size, and composition of the labor force.
Union membership in the United States
Historical trends in union membership among employed wage and salary workers; union membership by a variety of demographic characteristics.
A look at healthcare spending, employment, pay, benefits, and prices
Spending on healthcare, current and projected employment in the industry, employer-provided healthcare benefits, healthcare prices, and pay for workers in healthcare occupations.
Self-employment in the United States
Trends in self-employment by various demographic and socioeconomic characteristics, including both the unincorporated and the incorporated self-employed, as well as data on paid employees who work for the self-employed.


text: A meeting of the minds August 17, 2009 No Comments 2009 has challenged beverage companies, and business in general, like few previous years have. Beverage Industry took a mid-year poll of some of the beverage industry's top leaders in diverse product categories to find out how the industry is faring. Read More


text: AVENIR Emiliano Pennisi TipTop Audio Records / Striclty Groove Recordings / Sleep is Commercial Like many electronic artists, Emiliano Pennisi spent his early years experimenting with IDM, glitch and dance, but one consistent element in his musical journey has been his desire to create a more organic, humanised sound. Through these experimentations he has found a process of producing electronic music that feels close to this urge. You can tell many things about Avenir, born Emiliano Pennisi and raised in Palermo, but his character, his feelings and the music he makes it will explain much better who you have in front. Currently managing one of the hottest party downtown Palermo and finishing his second full lenth album, here you find one of the best thing we've read about him and his debut album. Juno Records: JUNO RECORDS REVIEW OF LAST ALBUM BROKEN ANTENNA --------------------------- There's something pleasingly old-fashioned about this debut full-length from Italian producer Emilliano Pennisi. It's not that it sounds particularly dated - the sounds and production techniques he employs are strictly contemporary - but Broken Antenna's adventurous eclecticism evokes a period when electronic producers were not afraid to pack their albums with a variety of sounds and styles. Taking a deep house sensibility as its starting point, Broken Antenna variously touches on off-kilter electronic disco, cinematic electronica, jazz-flecked beats, glistening synth-pop, curious tech-house, muted electro-swing and even glossy Italian house. While it may be lacking the "wow" factor, it's certainly an accomplished and highly entertaining set. AVENIR's tracks Paradigma 2nd.ACT - D.A.N.C.E Introspective by AVENIR published on 2016/11/26 16:42:38 +0000 Avenir@PYC ~ reduced set ~ (available in tape format) 192 kbps by AVENIR published on 2016/11/05 13:22:54 +0000 ___ The Rest ____ by AVENIR published on 2016/08/08 15:11:17 +0000 Everybody's Trying to Be My Baby (djtools) by AVENIR published on 2016/04/26 18:09:27 +0000 Taxidermy (12" vinyl's EP) pre-order available by AVENIR published on 2016/04/21 10:08:00 +0000 Self Generated's Drone (22 min)Free Download by AVENIR published on 2016/01/31 13:54:42 +0000 Avenir - Tender Points (feat.Dilemma) by AVENIR published on 2016/01/17 16:13:26 +0000 Avenir 2 hours set / Unlocked presents Marco Faraone by AVENIR published on 2015/12/07 09:30:50 +0000 I can not always (podcast - free download) by AVENIR published on 2015/11/18 16:36:55 +0000 Codeine (reprise version | WNB - Sleep is Commercial) by AVENIR published on 2015/11/18 01:37:29 +0000


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Nitro Pro allows you to edit, generate, and convert PDF files. This application can generate industry-standard PDF and PDF/A files compatible with Adobe Acrobat. PDF files can be converted to Word, Excel, PowerPoint, and other formats; it can retain the original fonts, images, and formatting.
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Product Key Finder is a free Windows key finder applications that retrieves license key information (CD Keys) from the Windows registry. Product Key Finder currently supports retrieval of 200+ licenses from applications such Microsoft Windows, Microsoft Office and Adobe Acrobat.
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The MPLAB XC Compiler provides a comprehensive solution for your project's development software needs and replaces all MPLAB C and HI-TECH compilers. The MPLAB XC compiler supports all 8-, 16- and 32- bit PIC MCUs and dsPIC® DSCs, integrates with MPLAB X IDE to provide a full graphical front end, and runs on Windows®, Linux® and Mac OS® X.
This program checks all drivers and applications in one's system for updates - once found, these become available for you to download and install. This is not done automatically; the program lets you choose whether or not to use the update found. Each update is listed with a detailed description in VersionTracker's interface.
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This program is your digital key ring that helps you to organize, administrate as well as sort your passwords and only accessible with the master password. Steganos security check ensures strong passwords and provides a highly secure encryption that guarantees secure data protection.
StrongDisk Pro is the most proven and reliable on-the-fly encryption software exists on the market. It makes a plain hard disk into a data strongbox that can be accessed by its owner only.


text: You are hereHome » Meeting Library » Virtual Meeting » 2013 ASCO Annual Meeting Clinical activity, safety, and biomarkers of MPDL3280A, an engineered PD-L1 antibody in patients with locally advanced or metastatic melanoma (mM). Omid Hamid MD PD1/PDL1: An Effective Target in Melanoma Melanoma/Skin Cancers Track Your browser does not support HTML5 video element. More by Omid Hamid : Presentations Ipilimumab (Ipi) expanded access program (EAP) for patients (pts) with stage III/IV melanoma: 10 mg/kg cohort interim results. Meeting: 2012 ASCO Annual Meeting Abstract No: 8508 Session: Melanoma/Skin Cancers (Oral Abstract Session) Presenter: Omid Hamid More


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Broiled Bananas
- 2 ripe but not overly ripe bananas
- 2 tablespoons brown sugar
- 1 tablespoon or so of fresh lime or lemon juice
- Sour cream, optional
- Chopped nuts, optional
Preheat broiler. Peel bananas and slice them crosswise into 3/4-inch thick slices. Mix the brown sugar and lime juice and toss this with bananas. Spread the sliced bananas in a shallow baking pan and broil, as close to the heat source as possible, until the sugar has melted into a glaze - 2 to 3 minutes. Transfer to a pretty serving bowl and serve immediately - topped with sour cream and nuts if you wish.
Recipe courtesy of Michele Urvater
Cooking Tips
More Recipes and Ideas
Banana-Hazelnut Bruschetta
Recipe courtesy of Food Network Kitchen
Strawberry Banana Bread Pudding
Recipe courtesy of Sandra Lee
Recipe courtesy of Food Network Kitchen


text: A flawless integration of indoor/outdoor living, this wonderful home in an inviting setting with an in-ground pool was recently renovated to impart a fresh, contemporary flavor to an already expansive floor plan. Versatile entertaining areas include the reconfigured great room, sunken living room and formal dining behind French doors. Built-ins and a new gas fireplace add atmosphere to the great room that adjoins a crisp white kitchen with atrium doors to the patio, deck and pool. A new picture window adds loads of natural light. Upstairs, the master shows off polished finishes in its updated en suite bathroom with radiant heated flooring. Three additional bedrooms include one that is a two-room suite, ideal as a play or homework room. A deep hall bath is useful on busy mornings. You'll want to ask for the impressive list of upgrades found in this fantastic home!


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For over 10 years, Coastal Living Realty has provided quality and professional Outer Banks real estate services to the beautiful Barrier Islands of North Carolina, specializing in Residential Real Estate Sales and Long-Term Rentals.
A Family Owned And Operated Company
Coastal Living Realty prides itself on building successful relationships. We believe in providing our clients with expert representation, outstanding customer service and delivering results to build relationships that last a lifetime.
Dedicated Agents
Our agents are dedicated to serving our sellers and buyers by maintaining an open line of communication, providing information on market data and trends while creating that all-important trust between client and agent.
Putting Our Passion To Work For You
Because buying a home is one of the most important decisions families make, our agents are passionate about helping our clients navigate the real estate process to avoid the hazards along the way.
Expert Guidance
Whether you are buying or selling, Coastal Living Realty's agents will provide you with expert guidance to help you navigate the twists and turns of the Outer Banks real estate market.
We would love to work for you, as well as, introduce you to the place we love and call our home.
Member of Outer Banks Association of Realtors and Member of National Association of Realtors.


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Sustainable management for crabs and lobsters
Improving the sustainability of the Outer Hebrides' shellfish fisheries is the aim of a new consultation launched today.
The Outer Hebrides Inshore
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cheap Michael Kors handbags outlet controls.
Landings of brown crab, velvet crab and lobster were worth 2.7 million to the economy of the Outer Hebrides in 2012 and more when processing and other related activities are included.
The IFG's proposals include:
increasing the
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prohibiting the landing
cheap Michael Kors handbags outlet of larger female lobsters in the area
IFGs are non statutory bodies whose purpose is to help improve the management of Scotland's inshore fisheries out to 6 nautical miles. One of their key aims is to put commercial fishermen assisted by Government Agencies and others with an interest in the marine environment at the heart of developing initiatives for sustainable and profitable fisheries."I have always said that Scottish fishermen lead the way in Europe with
Michael Kors handbags outlet their commitment to sustainable practices and the proposals in this consultation are a good example of that. Fishing is very important to the local economy with crab and lobster landings worth 2.7 million in 2012 and much more to the wider economy.
"I am delighted to see local fishing interests come together and develop management proposals to help ensure the long term sustainability of their fisheries.""We welcome Marine Scotland's consultation paper which begins the implementation process in taking forward management measures that will promote stock sustainability by helping to increase yield and spawning stock biomass for brown crab, velvet crab and lobster, which are the 3 most important species by value for the static gear fleet operating within the IFG area.
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1556 S RIDGELINE DR E Heber City, UT 84032
Hi, Blueroof .com.
My name is
and I have a question about 1556 S RIDGELINE DR E Heber City
You can respond by either emailing me at
or call during
My Question Is:
Estimated Monthly Payment$5,051
- Photos
- Location
- Questions
- Share
- Virtual Tour
- Mortgage Calculator
- Status: Active
Listing courtesy of Exit Realty Legacy
Amazing views! Wild life lovers dream! Beautifully remodeled home close to to entrance in Timber Lakes. Easy access to schools and town. Huge open floor plan, high ceilings, brand new kitchen, new flooring throughout, stainless steel appliances, granite, pot filler, gas stove, gorgeous deck to enjoy panoramic views of all four seasons and amazing wildlife! New master suite bathroom, fresh paint, hot water on demand, Walk-out basement. Minutes to boating and water sports, 30 minutes to 5 ski resorts, Blue ribbon fishing, 108 holes of championship golf. Come enjoy the quiet, serenity Heber Valley has to offer.
Interior Features Include:
Bath: Master, Closet: Walk-In, Den/Office, Dishwasher, Built-In, Disposal, Range/Oven: Free Stdng., Instantaneous Hot Water, Granite Countertops
Basement Full
Fireplaces 1
Heating: Propane, Wood Burning
Floor Type: Carpet, Tile, Vinyl
Exterior Features Include:
Balcony, Basement Entrance, Double Pane Windows, Entry (Foyer), Porch: Open, Sliding Glass Doors, Walkout
Acreage: 1.2000 Acres
Lot: Secluded Yard, Terrain: Grad Slope, View: Mountain, View: Valley
Landscape Mature Trees, Scrub Oak
Roof: Asphalt Shingles
Exterior: Aluminum/Vinyl
Patio/Deck: 0 Patio 1 Deck
Garage/Parking: Attached, Opener, Rv Parking
Driveway Gravel
Garage Capacity: 2
Other Features Include:
Subdivision: TIMBER LAKES
Inclusions: Ceiling Fan, Microwave, Range, Refrigerator, Window Coverings, Wood Stove
Amenities: Cable Tv Available, Cable Tv Wired
Water: Culinary
Utilities Sewer: Septic Tank, Water: Connected
Storage Basement
Taxes 1410
School District: Wasatch
Information deemed reliable but not guaranteed accurate. Buyer to verify all information.The multiple listing information is provided by Wasatch Front Regional Multiple Listing Service, Inc. from a copyrighted compilation of listings. The compilation of listings and each individual listing are © 2014 Wasatch Front Regional Multiple Listing Service, Inc., All Rights Reserved. The information provided is for consumers, personal, non-commercial use and may not be used for any purpose other than to identify prospective properties consumers may be interested in purchasing.


text:
Is Snap Mayo incorrect or missing key business information? Update your Hotfrog listing today.
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Hotfrog Ireland provides information regarding Snap Mayo in Castlebar Mayo. Snap Mayo is located at N5 Business Park Moneen, Castlebar Mayo and provides books services. Contact them on 094 9028268 or by visiting them on their website http://www.snapmayo.ie.
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We have more books services in Castlebar Mayo available on Hotfrog Ireland. You can update your search for Castlebar books by location, keyword or service options.
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What is the name of your state (only U.S. law)? Maine
Two days ago, my husband and I discovered his ex wifes live in boyfriend on the sex offender registry in our state/town. My husbands son, 11 years old, also lives with them, and is with us every other weekend. Upon discovering this, my husband promptly went to our local PD to get more information. he was told this man had a history in maine 10 pages long of other offenses, mostly alcohol realted, and that they (the police) had responded on more than one occasion to the apartment for arguments. The ex wife has always been just plain difficult, and goes out of her way to alienate my husband from their son...not allowing him to go on family trips with us, making sure my husband does not know about school events, sports events, band concerts, etc....at one point she even had my step son taking photos around our house with his cell phone and texting them to her. We've had enough, and are horrified that this is what the poor boy has been subjected to. My husband wants to file for full custody and get him out of there so that he can be in a more positive, family environment.....Does anyone think this will be a winning battle?


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January 19, 2017
Holder's Second Grab at Executive Privilege?
Carol Platt Liebau
6/22/2012 8:03:59 PM - Carol Platt Liebau
During his confirmation hearings to become Obama's attorney general, Eric Holder stated that he wasn't authorized to talk about his role in the pardoning of Puerto Rican terrorists in the waning days of Bill Clinton's term -- despite the fact that Clinton had waived executive privilege pertaining to the pardons.
As the Daily Caller's Matthew Boyle points out, this is curious
Given that Clinton had waived all executive privilege claims, either Holder was not being truthful when he refused to discuss his role in the pardons -- or President Obama did, indeed, make a claim of executive privilege to protect Holder . . . contrary to Jay Carney's assertions that this go-round with the privilege is the Obama White House's first.
Look, any time that isn't spent discussing the abysmal state of the American economy is, in a sense, time wasted for Republicans in terms of the election. But Holder's record is so appalling -- and The White House's claims of executive privilege so specious -- that they simply can't go unchallenged.


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A network of treasures
What began as a part-time job for a Webster City man in retirement is now a major antiques network spanning across the state.
Mike Constant created the Iowa Antique Network just over a year ago after returning to Iowa. Constant and his wife decided to come back to Webster City after living in Seattle for 30 years. While he was kept busy in retirement by working on his 133 year-old home, he was looking for something more.
"I needed something to get away from the hammer and the scraper, so I took this software that I had and adapted it to antiques because me and my wife are both into that," Constant said.
The Iowa Antique Network is a hub for people seeking antique, primitive, vintage and upcycled goods.
On the website, users can find dealers across the state of Iowa on an interactive Google map. Constant said Iowa natives and visitors from across the country plan road trips from dealer to dealer using the network that currently boasts 130 member dealers.
For those dealers, the Iowa Antique Network gives them access to a large base of clients. Laurie Hagey is the owner of Lily Grace on Central in Fort Dodge. She loves antiques and upcycling old materials, such as cutting old suitcases in half and hanging them on the wall as a shelf. Her store was among the first listed on the network.
"One day, Mike came walking in and said, 'Have I got a deal for you,'" Hagey said. "It really was. The Iowa Antique Network has opened us up to a customer base we never could have gotten to on our own."
When Constant retired, he did so with 37 years of experience as a salesman. For him, the work of going from place to place and selling the concept of the network was really not that much work at all.
"One of the goals I had was to travel all the blacktop roads in Iowa in retirement. I just like to drive. So, this lent itself to that as I went through each town in Iowa and visit each antique store, junk store, flea market, and did everything all over the state," Constant said. "I don't consider it work. It's a heck of a lot more fun."
Constant said he expects the network will grow to 300 members in the near future as it adds restaurants, wineries and other fun places for people to stop as they road trip for antiques. He also expects the network to continue to grow after he eventually steps away from the project.
"Someday when I get a bit older, I'll find somebody to take it over and put it in other states," Constant said.
Visit iowaantiquenetwork.com for more.


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OCCC Spring 2010 Alternates - page 2
Hey, Just wondering if anyone has heard how many alternates they would be accepting for the Spring 2010 Traditional Program? If not, does anyone know who at the school I could ask? Thanks for your... Read More
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Hotel Pueblo Camino Real
No prices found through our partners. Please contact the business directly or check some of our recommended alternatives.
How has this hotel rated in the past?
- Swimming pool
- Restaurant
- Beach
- Free High-Speed Internet
- Bar/lounge
- Wheelchair accessibility
Photos of Hotel Pueblo Camino Real
Travelers also looked at:
- Swimming pool
- Restaurant
- Beach
- Bar/lounge
- Free High-Speed Internet
- Wheelchair accessibility
- Kitchenette
- Kids activities or Babysitting
TripAdvisor Reviews Hotel Pueblo Camino Real Torremolinos
Travel Blogs from Torremolinos
One night only
... that has one or on to Fuengirola which has one or you're best off in Marbella.
Drove through the 7km of beach that is Fuengirola, very nice and instead of the normal boats on roundabouts one here had a herd of elephants (?!?!?, couldn't get the camera out fast enough!), found the campsite, WOW how expensive????
Stayed anyway, thought we'd stay for the weekend, but ...
... br> After the tour, we sat around waiting for our departure back to the hotel. Turned out, we had to let the company know we were ready which was different to the just wait here at 1300 when you are done before the tour. We were out into a bus, then changed to a different one and finally taken down the hill to the hotel and we quickly jumped in the car and started the trip down towards the coast to Malaga.
We arrive in Torremolinos around 1700 and it's ...
My Waterloo
... bend, he spend ages getting the bike down due to the terrain and I can appreciate how hot and bothered he feels. I'm not prepared to suffer another fail on a hill so I'm determined to get up in one go. Off I go, standing up and determined and fly up with no problem Whoo F*ckin Hooo! Steve and Graham take a few goes each before we all stand at the top. Looking to the south we seem as though we are on top of the world but looking north we haven't even got to ...
Torremolinos, Alhambra and La Mancha
... a fortress where the Plaza de San Nicolás is now located. After the disappearance of the Caliphate of Cordoba (1031), the ephemeral Zirid Emirate of Granada replaced it until 1090: the emirs devoted themselves to the embellishment of their capital, constructed on a site of exceptional beauty. A new defensive enclosure was added and around this a settlement grew up. The town prospered under the Nasrid dynasty and this was reflected by ...
... has a very special place in my heart... :)
The museum had a very good collection, I think. The reviews were saying that it has more of his later works than the earlier ones, but there was a special exhibition now showcasing his earlier works (which was borrowed from the museum in Barcelona!), so I was very content. They also had the temporary exhibition showcasing Dennis Hopper! You know, the actor from "Apocalypse Now", "Easy Rider", etc. They were showing many of ...


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Hillman to hire McElrath as new superintendent
HILLMAN – Jason McElrath will be the new superintendent and grades 7-12 principal as the Hillman Community Schools Board of Education reached a decision on Tuesday to hire him after a long process of applicant review and interviews that began in July.
McElrath comes from Manistee and is currently the dean of students for Kaleva Norman Dickson Schools. He handles all K-12 student discipline, parent concerns, school improvement and other building concerns and has worked there for 18 years in numerous leadership and teaching roles. He accepted the Hillman position, pending successful contract negotiations and final background checks.
"If everything goes as planned, we'll have him in the job on Oct. 21," interim Superintendent Tom Harmon said. "We were lucky, we had three candidates that were a good match, but he stood out a little bit. He's a good fit for the district."
The board was looking for someone who would have the experience to carry Hillman to the next level and be able to work well with the staff and students.
"He met a lot of the requirements we were looking for," board President Brad McLaren said. "He has been doing all the functions we were looking for and comes highly recommended. He also has longevity with the district he was previously in, so we are hopeful he will come to Hillman and stay."
The average stay of a superintendent in one district ranges from two to three years and McLaren said it is hard on the staff members to continuously go through the change.
"He is familiar with the area and likes it here, so we hope he will decide to stay," McLaren said. "The district really deserves to have a professional leading it, and he is a professional."
In a recent press release through the school, McElrath said he is looking forward to expanding and continuing his career in Northeast Michigan, and is excited to serve the students.
The board was impressed with the number of highly qualified candidates who applied for the position, and believed any of the three finalists would be successful, but saw McElrath as the best candidate for the position.
"His interview was really phenomenal," McLaren said. "The decision to offer him the job was an all yes vote, 6-0, with board member Nathan Funk absent. I really want to commend our interim Superintendent Tom Harmon with all his help in guiding the process to get to where we are now."
Harmon has been serving as interim superintendent since July, and previously worked as interim superintendent at Hillman.
"I've been through this process many times, and I'm very familiar with it," Harmon said. "I worked on some of the scheduling, contacting and paperwork and helped create interview questions. I've been very impressed with the generosity of the board members' time and all of their hard work. Now that the board has made a selection, it's a matter of confirming everything and getting a timeline together."
Over the last few weeks, the board has been conducting interviews late into the night and diligently going through references and applicants.
"We've been in the meeting room many hours on this topic," McLaren said. "We were guided the right way and at a very aggressive pace to fill the position."
The next step in the process will be a site visit to McElrath's current district, and working out the parameters of his contract as soon as possible.
Harmon said he has enjoyed working with Hillman Schools, and will be helping McElrath with the transition once he is on board.
"Hopefully he will be a great match and move Hillman schools forward," Harmon said. "It's been a pleasure working here again, and I'm grateful for the opportunity to be in Hillman. The staff and students and community have been great and very supportive."
Nicole Grulke can be reached via email at email@example.com or by phone at 358-5687. Follow Nicole on Twitter @ng_alpenanews.


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Vila Bojana, Bled
- Free buffet breakfast and WiFi
Main amenities
- 11 guestrooms
- Rooftop terrace
- Bar/lounge
- Airport shuttle
- 24-hour front desk
- Daily housekeeping
- Garden
- Car rentals on site
- Library
- Front desk safe
- Laundry service
- Multilingual staff
For families
- Cribs/infant beds (surcharge)
- Rollaway/extra beds available
- Private bathroom
- Garden
- Daily housekeeping
- Hair dryer
What's around
- Festival Hall (0.4 mi / 0.6 km)
- St. Martin's Parish Church (0.6 mi / 1 km)
- Bled Castle (0.9 mi / 1.4 km)
- Pustolovski Park Bled (1 mi / 1.7 km)
- Lake Bled (1.1 mi / 1.7 km)
Vila Bojana, Bledfrom $39
- Double Room Single Use
- Double Room
- Double Room, Balcony
- Double Room Single Use, Balcony
More great choices
At a glance
Key facts
Hotel size
- This hotel has 11 rooms
- This hotel is arranged over 3 floors
- 24-hour check-in
- Check-out time is 11 AM
Required at check in
- Cash deposit required
- Government-issued photo ID required
Travelling with others
- Pets allowed *
Extra people
- Roll-away beds available, charges may apply*
- Free WiFi and wired Internet access in public areas
- Free WiFi in rooms
- Airport shuttle (available on request) *
Nearby Three Star Bled hotels
In the hotel
- Free buffet breakfast daily
- Bar/lounge
- 24-hour room service
- 24-hour front desk
- Tours/ticket assistance
- Dry cleaning/laundry service
- Luggage storage
- Multilingual staff
- Number of buildings/towers - 1
- Safe-deposit box at front desk
- Rooftop terrace
- Garden
- Library
In the room
- Minibar
- Iron/ironing board (on request)
- Egyptian-cotton sheets
- Private bathroom
- Hair dryer
- Cable TV channels
- Desk
- Free WiFi
- Phone
- Daily housekeeping
Top Bled hotels
Recently reviewed hotels in Bled
- Hotel Penzion JagodicFrom
"I had great experience with staff and it was convenient as it was very close to the airport "Dec 2, 2016
- Vila IstraFrom
"The property is located just out of the bustle of the down town area. Every was is very helpful and accommodating. Rooms have recently been updated. Would return to this hotel on…"Nov 17, 2016
- Falkensteiner Schlosshotel VeldenFrom
"Everything about the hotel was first class. We booked the junior suite and it was beautiful. Used the spa and pool and ate in the restaurant. Everything was really nice!"Nov 14, 2016
- Turizem LokaFrom
"We were on our way to another location and need accomadations for the night along the route. Two couples, two rooms. Reception was polite, friendly and helpful in finding a…"Nov 9, 2016
Nearby hotels
Also popular with travelers from the USA
Vila Bojana, Bled's small print
Also known as
- Vila Bojana
- Vila Bojana Bled
- Vila Bojana Hotel
- Vila Bojana Hotel Bled
Mandatory fees
You'll be asked to pay the following charges at check in or check out:
- A tax is imposed by the city: EUR 1.01 per person, per night
Optional extras
Cribs/Infant beds are available for EUR 10 per night
Pets are allowed for an extra charge of EUR 10 per pet, per night
Airport shuttle service is offered for an extra charge
We have included all charges provided to us by this hotel. However, charges can vary, for example, based on length of stay or the room you book.
Recent reviews
Good 3.6 /5 from 91 reviews
The location is great and nice easy walk down to the lake and several restaurants. There is a fair amount of parking in the back. The view was great. The room was comfortable but always had a funny smell in it. Not really sure what it was. The only downside was in the morning on the weekends the bald man that was missing teeth was rather loud and rude. I dont know if he had a bad day or what but in general it made for an unpleasant atmosphere. Everything else was great but it should be noted that they do not take credit card so I had to go to atm and get euros out to pay.
The manager of the hotel takes great pride in his hotel and it shows. The room was comfortable, clean, and bright. Breakfast was a typical European breakfast. Our room was next to an outside balcony where my wife would sit. The hotel is about 2 blocks off the lake. We thoroughly enjoyed our stay here.
Sufficient parking, good size room, but room was tired and in need of a refresh. No shower curtain, door, or partition making for a very wet post-shower bathroom. The price was right and the hotel met our need for a one-night stay in Bled, but if looking for a lovely room for your stay in a lovely town, choose elsewhere.
Charming hotel in Bled, Slovenia. Staff very helpful and friendly. Loved it and would stay here again. Nice breakfast as well. patient to teach me a few words of Slovenian language!
I Love
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- Product Description
DetailsThis lamp is a small version of the award-winning Ribbon sculptural metal table lamp in copper finish.
Inspired by the shapes that are created when a ribbon is in movement, the form of the Ribbon lamp was developed through an exploration of origami and paper crafts.
The small table lamp designed exclusively for Habitat by Claire Norcross is also great for use as a bedside lamp. Available in two sizes and various finishes.
- Details & Dimensions
- Exclusive to Habitat.
- Designed by Claire Norcross.
- Recommended bulb (sold separately): 1 x E14 6W Mini golf ball (sku no: 187695).
- Maximum bulb wattage: 40W.
- Electrical class: 2.
- Mains operated.
- In-line switch.
- Energy efficiency rating: A++ to E.
- W15 x H36 x D16cm.
Product Code: 368318
- Electroplated steel.
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Delivery & Returns
Delivery UK Mainland & Northern Ireland
Accessory orders over £50 = FREE
Standard service within 3 days = £4.95
FREE returns.
Delivery Republic of Ireland:
Standard Service = £12
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Click here to see more on our Delivery & Returns page.
- Care Instructions
Care Instructions
- Wipe with a dry cloth.
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