text:
|January 25, 17
|Messalina the third wife of the Roman Emperor Claudius. She was also a paternal cousin of the Emperor Nero, second cousin of the Emperor Caligula, and great-grandniece of the Emperor Augustus. A powerful and influential woman with a reputation for promiscuity, it was claimed that she conspired against her husband and was executed when the plot was discovered. Her notorious reputation is arguably the result of political bias. It has been perpetuated by works of art and literature into modern times
|September 25, 71
|Valter hugo mãe the artistic name of the Portuguese writer, Valter Hugo Lemos. He is also an editor, singer, plastic artist. valter hugo mãe received the José Saramago Prize in Literature in 2007 for his novel o remorso de baltazar serapião
|December 25, 317
|Philip III of Macedon a Greek king of Macedon from after June 11, 323 BC until his death. He was a son of King Philip II of Macedonia by Philinna of Larissa and a half-brother of Alexander the Great. Named Arrhidaeus at birth, he assumed the name Philip when he ascended to the throne
|February 25, 586
|Prætextatus (bishop of Rouen) the bishop of Rouen from 549 until his assassination in 586.
|January 25, 750
|Leo IV the Khazar Byzantine Emperor from 775 to 780 AD.
|March 25, 826
|Al-Mubarrad an Arab grammarian. After studying grammar in that city, he was called to the court of the Abbasid caliph al-Mutawakkil at Samarra in 860. When the caliph was killed in 861, he went to Baghdad, remaining there most of his life as a teacher
|June 25, 841
|Ricwin of Nantes the Count of Nantes from 831 to 841. A Rihwinus comes witnessed the will of Charlemagne in 811
|July 25, 885
|Ragenold of Neustria the Count of Herbauges from 852 and Count of Maine and Margrave of Neustria from 878. His family is unidentified, but he may have been a son of Reginald of Herbauges
|June 25, 891
|Sunderolt the Archbishop of Mainz from 889 until his death.
|November 25, 902
|Emperor Taizong of Liao the second emperor of the Khitan Empire.
|December 25, 940
|Makan ibn Kaki a Daylamite military leader active in northern Iran in the early 10th century. He became involved in the succession disputes of the Alids of Tabaristan, and managed to establish himself as the ruler of Tabaristan and Gurgan for short periods of time, in competition to other Daylamite warlords such as Asfar ibn Shiruya or the Ziyarid brothers Mardavij and Vushmgir. He alternately opposed and secured support from the Samanid governors of Khurasan, and eventually fell in battle against a Samanid army
|July 25, 975
|Thietmar of Merseburg a German chronicler who was also bishop of Merseburg.
|December 25, 1003
|Pope John XVIII Pope and ruler of the Papal states from January 1004 to his abdication in June 1009. He was born Fasanius at Rapagnano, near Ascoli Piceno, the son of a Roman priest named Leo
|July 25, 1008
|Anund Jacob King of Sweden from 1022 until around 1050. He is believed to have been born on July 25, in either 1008 or 1010 as Jakob. When the Swedish Thing was to elect him the co-ruler of Sweden, the people objected to his non-Scandinavian name. They then gave him the pronomen Anund. The line of kings appended to the Westrogothic law says that he was called Kolbränna as he had the habit of burning down the houses of his opponents
|July 25, 1016
|Casimir I the Restorer a Duke of Poland of the Piast dynasty and the de jure monarch of the entire country from 1034 until his death.
|May 25, 1048
|Emperor Shenzong of Song the sixth emperor of the Chinese Song dynasty. His personal name was Zhao He reigned from 1067 to 1085
|October 25, 1102
|William Clito the fourteenth Count of Flanders and titular Duke of Normandy. His surname "Clito" was a Latin term equivalent to the Anglo-Saxon "Aetheling", and the Germanic "Adelinus". Both "Clito" and "Atheling" signified "man of royal blood", or the modern equivalent, "prince"
|June 25, 1109
|Afonso I of Portugal the first King of Portugal. He achieved the independence of the southern part of the Kingdom of Galicia, the County of Portugal, from Galicia's overlord, the King of León, in 1139, establishing a new kingdom and doubling its area with the Reconquista, an objective that he pursued until his death, in 1185, after forty-six years of wars against the Moors
|January 25, 1138
|Antipope Anacletus II an Antipope who ruled from 1130 to his death, in a schism against the contested, hasty election of Pope Innocent II.
|July 25, 1165
|Ibn Arabi an Arab Andalusian Sufi mystic and philosopher.
|July 25, 1186
|Hugh de Lacy Lord of Meath an Anglo-Norman magnate. He had substantial land holdings in Herefordshire and Shropshire, England. Following his participation in the Norman Invasion of Ireland, he was granted the lands of the Kingdom of Meath by the Anglo-Norman King Henry II of England in 1172. The Lordship of Meath was the most extensive liberty in Ireland
|April 25, 1194
|Ezzelino III da Romano an Italian feudal lord in the March of Treviso who was a close ally of the emperor Frederick II and ruled Verona, Vicenza and Padua for almost two decades. He became infamous as a cruel tyrant though much of his sinister reputation may be due to the propaganda of his many enemies
|July 25, 1201
|Gruffydd ap Rhys II a prince of Deheubarth in south-west Wales.
|April 25, 1211
|Frederick II Duke of Austria the Duke of Austria and the Duke of Styria from 1230 to his death in 1246. He was the fifth and last Duke of Austria from the House of Babenberg
|April 25, 1214
|Louis IX of France a Capetian King of France who reigned from 1226 until his death. Louis was crowned in Reims at the age of 12, following the death of his father Louis VIII the Lion, although his mother, Blanche of Castile, ruled the kingdom until he reached majority. During Louis's minority, Blanche dealt with the opposition of rebellious vassals and put an end to the Albigensian crusade which had started 20 years earlier
|September 25, 1216
|Robert I Count of Artois the first Count of Artois, the fifth son of Louis VIII of France and Blanche of Castile.
|January 25, 1217
|Isabella Queen of Armenia the queen regnant of Cilician Armenia.
|April 25, 1228
|Conrad IV of Germany Duke of Swabia , King of Jerusalem , King of Germany , and of King of Sicily.
|June 25, 1242
|Beatrice of England a Princess of England as the daughter of King Henry III of England and Eleanor of Provence. Her siblings were Edward I of England, Margaret, Queen of Scotland, Edmund Crouchback, 1st Earl of Lancaster, Richard of England, John of England, Katherine of England, William of England, and Henry of England. She and her family were members of the Royal house of Plantagenet, which first ruled in the 12th century and was founded by Henry II of England
|December 25, 1250
|John IV Laskaris emperor of Nicaea from August 18, 1258 to December 25, 1261. This empire was one of the Greek states formed from the remaining fragments of the Byzantine Empire, after the capture of Constantinople by Roman Catholics during the Fourth Crusade in 1204
|March 25, 1252
|Conradin the Duke of Swabia , King of Jerusalem , and King of Sicily.
|March 25, 1259
|Andronikos II Palaiologos Byzantine emperor from 11 December 1282 to 23/24 May 1328. He was the eldest surviving son of Michael VIII Palaiologos and Theodora Doukaina Vatatzina, grandniece of John III Doukas Vatatzes. On 8 November 1273, Andronikos II married Anne of Hungary , daughter of the king Stephen V of Hungary
|July 25, 1261
|Arthur II Duke of Brittany Duke of Brittany from 1305 to his death. He was the first son of John II and Beatrice, daughter of Henry III of England and Eleanor of Provence
|October 25, 1268
|John I de Balliol a leading figure of Scottish and Anglo-Norman life of his time. Balliol College, in Oxford, is named after him
|November 25, 1274
|Catherine of Courtenay Titular Empress of Constantinople from 1283 to her death in 1307. In 1301, she became the second wife of Charles of Valois, by whom she had one son and three daughters; the eldest of these, Catherine II of Valois, Princess of Achaea succeeded her as titular empress
|April 25, 1284
|Edward II of England King of England from 1307 until he was deposed in January 1327. The fourth son of Edward I, Edward became the heir to the throne following the death of his older brother Alphonso. He grew up to be tall and athletic, and was considered good-looking by his contemporaries. From 1300 onward, Edward accompanied his father on campaigns to pacify Scotland, and in 1307 he was knighted in a grand ceremony at Westminster Abbey. Edward succeeded to the throne later that year, following his father's death. In 1308, he married Isabella of France, the daughter of the powerful King Philip IV, as part of a long-running effort to resolve the tensions between the English and French crowns
|April 25, 1287
|Roger Mortimer 1st Earl of March an English nobleman and powerful Marcher lord who had gained many estates in the Welsh Marches and Ireland following his advantageous marriage to the wealthy heiress Joan de Geneville, 2nd Baroness Geneville. In November 1316, he was appointed Lord Lieutenant of Ireland. He was imprisoned in the Tower of London in 1322 for having led the Marcher lords in a revolt against King Edward II in what became known as the Despenser War. He later escaped to France, where he was joined by Edward's queen consort Isabella, whom he took as his mistress. After he and Isabella led a successful invasion and rebellion, Edward was subsequently deposed; Mortimer allegedly arranged his murder at Berkeley Castle. For three years, Mortimer was de facto ruler of England before being himself overthrown by Edward's eldest son, Edward III. Accused of assuming royal power and other crimes, Mortimer was executed by hanging at Tyburn
|March 25, 1297
|Andronikos III Palaiologos Byzantine emperor from 1328 to 1341. Andronikos III was the son of Michael IX Palaiologos and Rita of Armenia. He was roclaimed co-emperor in his youth, before 1313, and in April 1321 he rebelled in opposition to his grandfather, Andronikos II Palaiologos. He was formally crowned co-emperor on February 1325, before ousting his grandfather outright and becoming sole emperor on 24 May 1328. His reign saw the last failed attempts to stem the Ottoman Turks in Bithynia and the defeat at Rusokastro against the Bulgarians, but also the successful recovery of Chios, Lesbos, Phocaea, Thessaly and Epirus. His early death left a power vacuum that resulted in the disastrous seven-year civil war between his Empress-dowager, Anna of Savoy, and his closest friend and supporter, John VI Kantakouzenos
|March 25, 1297
|Arnošt of Pardubice the first Archbishop of Prague. He was also an advisor and diplomat to Emperor Charles IV
|February 25, 1304
|Ibn Battuta a Moroccan explorer of Berber descent. He is known for his extensive travels, accounts of which were published in the Rihla. Over a period of thirty years, Ibn Battuta visited most of the known Islamic world as well as many non-Muslim lands. His journeys included trips to North Africa, the Horn of Africa, West Africa and Eastern Europe, and to the Middle East, South Asia, Central Asia, Southeast Asia and China. Ibn Battuta is generally considered one of the greatest travellers of all time
|August 25, 1316
|John of Eltham Earl of Cornwall the second son of king Edward II of England and his queen Isabella of France. He was heir to the English throne from the date of the abdication of his father to the birth of his nephew Edward, the Black Prince
|May 25, 1320
|Toghon Temür considered the last Khagan of the Mongol Empire.
|June 25, 1328
|William de Montacute 2nd Earl of Salisbury an English nobleman and commander in the English army during King Edward III's French campaigns in the Hundred Years War.
|November 25, 1328
|Antipope Benedict XIII officially considered by the Catholic Church to be an antipope.
|October 25, 1330
|Louis II Count of Flanders Count of Flanders, Nevers and Rethel from 1346 as well as Count of Artois and Burgundy from 1382 until his death.
|May 25, 1334
|Emperor Sukō the third of Ashikaga Pretenders during the Period of the Northern and Southern Courts in Japan. According to pre-Meiji scholars, his reign spanned the years from 1348 through 1351
|July 25, 1336
|Albert I Duke of Bavaria a feudal ruler of the counties of Holland, Hainaut, and Zeeland in the Low Countries. Additionally, he held a portion of the Bavarian province of Straubing, his Bavarian ducal line's appanage and seat
|February 25, 1337
|Wenceslaus I Duke of Luxembourg the first Duke of Luxembourg from 1354. He was the son of John the Blind, King of Bohemia, and Beatrice of Bourbon
|March 25, 1341
|Humphrey de Bohun 7th Earl of Hereford the son of William de Bohun, 1st Earl of Northampton and Elizabeth de Badlesmere, and grandson of Humphrey de Bohun, 4th Earl of Hereford by Elizabeth of Rhuddlan, daughter of King Edward He became heir to the Earldom of Hereford after the death of his childless uncle Humphrey de Bohun, 6th Earl of Hereford.
|March 25, 1345
|Blanche of Lancaster a member of the English royal House of Plantagenet, daughter of the kingdom's wealthiest and most powerful peer, Henry of Grosmont, 1st Duke of Lancaster. She was the first wife of John of Gaunt, 1st Duke of Lancaster, and the mother of King Henry IV


text:
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5 Days in Bhutan
... off"
It took us 2 hours to get there and it was quite a challenge so feel great to have achieved that goal
We left Bhutan this morning with incredibly fond memories and have now flown to Kolkata where we are about to take a city tour.The drive in from the airport gave us an insight as to what to expect but must say the traffic is quite orderly after Dhaka in Bangladesh
Bye for now.
Barcelona to Madrid
... br>
After checking into our hotel we went for a walk around the block to familiarise ourselves with the area and to check out where we might eat tonight. We rounded a corner just down the street from the hotel and came face to face with a billboard advertising The Lion King at the theatre we were walking past. We enquired about available tickets but the show is sold out the whole time we are here.
Tomorrow we are going on an excursion to Segovia.
At sea
At sea today, which was lovely and relaxing. Travelling from Rome to Corfu, Greece through the Messina Straits and around the bottom of Italy. Went out for a beautiful dinner to celebrate our 29th wedding anniversary and chatted about the triumphs, trials and tribulations of our life together. Where has the time gone, may there be 29 more. ...
At sea
Left Barcelona at midnight and at sea all day today. Woke up at 1100am, it was lovely, laid by the pool, went to the the pictures and laid by the pool again. Formal night tonight, so got dressed up and heading off for dinner at 830. Having a wonderful time together ...
Fountaine de Vaucluse
... the car and parted company. Erika and I were casually looking at antique shops and found a beautiful par of vases (glasses) which we bought as a memorabilia of the trip.
Soon after we met up with the Schmockers and headed to the Supermarket in Cavaillon to buy Luberon melons.
We got home about 4 pm and decided not to go out for dinner, Thomas and I went down to the village and bought some cheese, prosutto and port and, with the melon, it was our ...

subset: commoncrawl


text:
Police searching for an eight-year-old girl who disappeared from a homeless shelter almost a month ago have said they believe she may have been killed by a janitor.
Relisha Rudd had vanished for days from her impoverished neighbourhood in Washington DC before anyone reported her missing. Until recently, the case has gone largely unreported outside of local media.
The FBI has been displaying Relisha's face on billboards along a 700-mile stretch of the east coast, offering a $25,000 reward for helping to establish her whereabouts.
Her mother said the last time she saw her was on 26 February when she left Relisha in the care of Kahlil Malik Tatum, a janitor at a homeless shelter they lived in. The converted DC General Hospital reportedly houses some 300 families in the deprived south-east quarter of the city.
On Thursday, DC police chief Cathy Lanier told a press conference that while there was hope Relisha was still alive, police believed Tatum may have killed her. She added that parts of the search had now entered a "recovery operation".
"We can't ignore the possibility he may have killed her," she said.
Relisha's mother never reported her daughter missing, and authorities were alerted only after her extended absence from school. A referral was made to the city's child welfare agency on 13 March, although a formal missing persons search did not begin until 19 March.
The day after the search began, police discovered Kahlil Tatum's wife, Andrea Tatum, had been shot dead at a motel in nearby Maryland. Police then put out a warrant for the janitor's arrest on suspicion of murder.
Lanier said that on 2 March, Tatum purchased carton of 42-gallon contractor trash bags at a store in Washington and was seen in the area of the Kenilworth Aquatic Gardens.
Police were combing the park area and other scrubland, a few miles from the homeless shelter, on Thursday.
There are mounting questions over why welfare agencies and law enforcement took almost a month to begin searching for a vulnerable girl who apparently left the care of her family more than a month ago.
The FBI released video footage of Relisha leaving a bedroom and walking down a hallway with 51-year-old Kahlil Tatum at a Holiday Inn Express in north-east DC on 26 February – the day she was first left in his care.
She made a couple of appearances at her school in the week that followed but also missed several days, claiming to be sick. She had been missing for 30 days, including a string of absences that preceded her disappearance.
Relisha was last seen at her school, briefly, on 7 March. Tatum, who the FBI describes as armed and dangerous, disappeared on 19 March, the day the investigation into into Relisha's disappearance began, and the day before police found his wife had been killed.


text:
|Publication number
|Publication type
|Application number
|Publication date
|Aug 22, 2006
|Filing date
|Mar 5, 2002
|Priority date
|Oct 26, 1999
|Fee status
|Also published as
|Publication number
|Kurt R. Linberg
|Original Assignee
|Medtronic, Inc.
|Export Citation
|BiBTeX, EndNote, RefMan
|Patent Citations (22), Referenced by (28), Classifications (18), Legal Events (2)
|External Links: USPTO, USPTO Assignment, Espacenet
This application is a divisional of application Ser. No. 09/426,741, filed Oct. 26, 1999 now U.S. Pat. No. 6,442,433.
The present invention relates generally to medical device systems. Specifically, the invention pertains to a remote bi-directional communications with one or more programmable devices, that are associated with implantable medical devices. More specifically, the invention relates to an integrated system and method of bidirectional telecommunications between a web-based expert data center and at least one programmer, utilizing various types of network platforms and architecture to implement, in the programmer, distance-based troubleshooting, maintenance, upgrade, information and administrative services thereby providing an economical and highly interactive system for therapy and clinical care.
A technology-based health care system that fully integrates the technical and social aspects of patient care and therapy should be able to flawlessly connect the client with care providers irrespective of separation distance or location of the participants. While clinicians will continue to treat patients in accordance with accepted modem medical practice, developments in communications technology are making it ever more possible to provide medical services in a time and place independent manner.
Prior art methods of clinical services are generally limited to in-hospital operations. For example, if a physician needs to review the performance parameters of an implantable device in a patient, it is likely that the patient has to go to the clinic. Further, if the medical conditions of a patient with an implantable device warrant a continuous monitoring or adjustment of the device, the patient would have to stay in a hospital indefinitely. Such a continued treatment plan poses both economic and social problems. Under the exemplary scenario, as the segment of the population with implanted medical devices increases many more hospitals/clinics including service personnel will be needed to provide in-hospital service for the patients, thus escalating the cost of healthcare. Additionally the patients will be unduly restricted and inconvenienced by the need to either stay in the hospital or make very frequent visits to a clinic
Yet another condition of the prior art practice requires that a patient visit a clinical center for occasional retrieval of data from the implanted device to assess the operations of the device and gather patient history for both clinical and research purposes. Such data is acquired by having the patient in a hospital/clinic to down load the stored data from the implantable medical device. Depending on the frequency of data collection this procedure may pose a serious difficulty and inconvenience for patients who live in rural areas or have limited mobility. Similarly, in the event a need arises to upgrade the software of an implantable medical device, the patient will be required to come into the clinic or hospital to have the upgrade installed.
A further limitation of the prior art relates to the management of multiple implantable devices in a single patient. Advances in modern patient therapy and treatment have made it possible to implant a number of devices in a patient. For example, implantable devices such as a defibrillator or a pacer, a neural implant, a drug pump, a separate physiologic monitor and various other implantable devices may be implanted in a single patient. To successfully manage the operations and assess the performance of each device in a patient with multi-implants requires a continuous update and monitoring of the devices. Further, it may be preferred to have an operable communication between the various implants to provide a coordinated clinical therapy to the patient. Thus, there is a need to monitor the performance of the implantable devices on a regular, if not a continuous, basis to ensure optimal patient care. In the absence of other alternatives, this imposes a great burden on the patient if a hospital or clinic is the only center where the necessary frequent follow up, evaluation and adjustment of the medical devices could be made. Moreover, even if feasible the situation would require the establishment of multiple service areas or clinic centers to provide adequate service to the burgeoning number of multi-implant patients worldwide. Accordingly, it is vital to have a programmer unit that would connect to a remote expert medical center to provide access to expert systems and import the expertise to a local environment. This approach would enable unencumbered access to the IMD or the patient.
The prior art provides various types of remote sensing and communications with an implanted medical device. One such system is, for example, disclosed in Funke, U.S. Pat. No. 4,987,897 issued Jan. 29, 1991. This patent discloses a system that is at least partially implanted into a living body with a minimum of two implanted devices interconnected by a communication transmission channel. The invention further discloses wireless communications between an external medical device/programmer and the implanted devices.
One of the limitations of the system disclosed in the Funke patent includes the lack of communication between the implanted devices, including the programmer, with a remote clinical station. If, for example, any assessment, monitoring or maintenance is required to be performed on the IMD the patient will have to go to the remote clinic station or the programmer device needs to be brought to the patient's location. More significantly, the operational worthiness and integrity of the programmer cannot be evaluated remotely thus making it unreliable over time as it interacts with the IMD.
Yet another example of sensing and communications system with a plurality of interactive implantable devices is disclosed by Stranberg in U.S. Pat. No. 4,886,064, issued Dec. 12, 1989. In this disclosure, body activity sensors, such as temperature, motion, respiration and/or blood oxygen sensors, are positioned in a patient's body outside a pacer capsule. The sensors wirelessly transmit body activity signals, which are processed by circuitry in the heart pacer. The heart pacing functions are influenced by the processed signals. The signal transmission is a two-way network and allows the sensors to receive control signals for altering the sensor characteristics.
One of the many limitations of Stranberg is the fact that although there is corporeal two-way communications between the implantable medical devices, and the functional response of the heart pacer is processed in the pacer after collecting input from the other sensors, the processor is not remotely programmable. Specifically, the system does not lend itself to web-based communications to enable remote troubleshooting, maintenance and upgrade from outside the patient's body because the processor/programmer is internally located in the patient forming an integral part of the heart pacer.
Yet another prior art reference provides a multi-module medication delivery system as disclosed by Fischell in U.S. Pat. No. 4,494,950 issued Jan. 22, 1985. The disclosure relates to a system consisting a multiplicity of separate modules that collectively perform a useful biomedical purpose. The modules communicate with each other without the use of interconnecting wires. All the modules may be installed intracorporeal or mounted extracorporeal to the patient. In the alternate, some modules may be intracorporeal with others being extracorporeal. Signals are sent from one module to the other by electromagnetic waves. Physiologic sensor measurements sent from a first module cause a second module to perform some function in a closed loop manner. One extracorporeal module can provide electrical power to an intracorporeal module to operate a data transfer unit for transferring data to the external module.
The Fischell disclosure provides modular communication and cooperation between various medication delivery systems. However, the disclosure does not provide an external programmer with remote sensing, remote data management and maintenance of the modules. Further, the system does neither teach nor disclose an external programmer for telemetrically programming the modules.
Yet another example of remote monitoring of implanted cardioverter defibrillators is disclosed by Gessman in U.S. Pat. No. 5,321,618 issued. In this disclosure a remote apparatus is adapted to receive commands from and transmit data to a central monitoring facility over telephone communication channels. The remote apparatus includes equipment for acquiring a patient's ECG waveform and transmitting that waveform to the central facility over the telephone communications channels. The remote apparatus also includes a segment, responsive to a command received from the central monitoring facility, for enabling the emission of audio tone signals from the cardioverter defibrillator. The audio tones are detected and sent to the central monitoring facility via the telephone communication channel. The remote apparatus also includes patient alert devices, which are activated by commands received from the central monitoring facility over the telephone communication channel.
One of the many limitations of the apparatus and method disclosed in the Gessman patent is the fact that the segment, which may be construed to be equivalent to a programmer, is not remotely adjustable from the central monitoring device. The segment merely acts as a switching station between the remote apparatus and the central monitoring station.
An additional example of prior art practice includes a packet-based telemedicine system for communicating information between central monitoring stations and a remote patient monitoring station disclosed in Peifer, WO 99/14882 published 25 Mar. 1999. The disclosure relates to a packet-based telemedicine system for communicating video, voice and medical data between a central monitoring station and a patient that is remotely located with respect to the central monitoring station. The patient monitoring station obtains digital video, voice and medical measurement data from a patient and encapsulates the data in packets and sends the packets over a network to the central monitoring station. Since the information is encapsulated in packets, the information can be sent over multiple types or combination of network architectures, including a community access television (CATV) network, the public switched telephone network (PSTN), the integrated services digital network (ISDN), the Internet, a local area network (LAN), a wide area network (WAN), over a wireless communications network, or over asynchronous transfer mode (ATM) network. A separate transmission code is not required for each different type of transmission media.
One of the advantages of the Pfeifer invention is that it enables data of various forms to be formatted in a single packet irrespective of the origin or medium of transmission. However, the data transfer system lacks the capability to remotely debug the performance parameters of the medical interface device or the programmer. Further, Pfeifer does not disclose a method or structure by which the devices at the patient monitoring station may be remotely updated, maintained and tuned to enhance performance or correct errors and defects.
Another example of a telemetry system for implantable medical devices is disclosed in Duffin et at, U.S. Pat. No. 5,752,976, issued May 19, 1998, incorporated by reference herein in its entirety. Generally, the Duffin et al disclosure relates to a system and method for communicating with a medical device implanted in an ambulatory patient and for locating the patient in order to selectively monitor device function from a remote medical support network. The communications link between the medical support network and the patient communications control device may comprise a world wide satellite network, a cellular telephone network or other personal communications system.
Although the Duffin et at disclosure provides significant advances over the prior art, it does not teach a communications scheme in which a programmer is remotely debugged, maintained, upgraded or modified to ultimately enhance the support it provides to the implantable device with which it is associated. Specifically, the Duffin et at disclosure is limited to notifying remote medical support personnel or an operator about impending problems with an IMD and also enables constant monitoring of the patient's position worldwide using the GPS system. However, Duffin et at does not teach the remote programming scheme contemplated by the present invention.
In a related art, Thompson discloses a patient tracking system in a copending application entitled "World-wide Patient Location and Data Telemetry System For Implantable Medical Devices", Ser. No. 09/045,275 filed on Mar. 20, 1998, now U.S. Pat. No. 6,292,698, which is incorporated by reference herein in its entirety. The disclosure provides additional features for patient tracking in a mobile environment worldwide via the GPS system. However, the remote programming concepts advanced by the present Invention are not within the purview of the Thompson disclosure because there is no teaching of a web-based environment in which a programmer is remotely evaluated and monitored to effect functional and parametric tune up, upgrade and maintenance as needed.
Yet in another related art, Ferek-Petric discloses a system for communication with a medical device in a co-pending application, Ser. No. 09/348,506 which is incorporated by reference herein in its entirety. The disclosure relates to a system that enables remote communications with a medical device, such as a programmer. Particularly, the system enables remote communications to inform device experts about programmer status and problems, The experts will then provide guidance and support to the remotely to service personnel or operators located at the programmer. The system may include a medical device adapted to be implanted into a patient; a server PC communicating with the medical device; the server PC having means for receiving data transmitted across a dispersed data communication pathway, such as the Internet; and a client PC having means for receiving data transmitted across a dispersed communications pathway from the SPC. In certain configurations the server PC may have means for transmitting data across a dispersed data communication pathway (Internet) along a first channel and a second channel; and the client PC may have means for receiving data across a dispersed communication pathway from the server PC along a first channel and a second channel.
One of the significant teachings of Ferek Petric's disclosure, in the context of the present invention, includes the implementation of communication systems, associated with IMDs that are compatible with the Internet. Specifically the disclosure advances the art of remote communications between a medical device, such as a programmer, and experts located at a remote location using the Internet. As indicated hereinabove, the communications scheme is structured to primarily alert remote experts to existing or impending problems with the programming device so that prudent action, such as early maintenance or other remedial steps, may be timely exercised. Further, because of the early warning or advance knowledge of the problem, the remote expert would be well informed to provide remote advice or guidance to service personnel or operators at the programmer.
While Ferek's invention advances the art in communications systems relating to interacting with a programmer via a communication medium such as the Internet, the system does neither propose nor suggest remote programming, debugging and maintenance of a programmer without the intervention of a service person.
Accordingly it would be advantageous to provide a system in which a programmer could uplink to a remote expert data center to import enabling software for self-diagnosis, maintenance and upgrade of the programmer. Yet another desirable advantage would be to provide a system to implement the use of remote expert systems to manage a programmer on a real-time basis. A further desirable advantage would be to provide a communications scheme that is compatible with various communications media, to promote a fast uplink of a programmer to remote expert systems and specialized data resources. Yet another desirable advantage would be to provide a high speed communications scheme to enable the transmission of high fidelity sound, video and data to advance and implement efficient remote data management of a clinical/therapy system via a programmer thereby enhancing patient clinical care. As discussed herein below, the present invention provides these and other desirable advantages.
The present invention generally relates to a communications scheme in which a remote web-based expert data center interacts with a patient having one or more implantable medical devices (IMDs) via an associated external medical device, preferably a programmer, located in close proximity to the IMDs. Some of the most significant advantages of the invention include the use of various communications media between the remote web-based expert data center and the programmer to remotely exchange clinically significant information and ultimately effect real-time parametric and operational changes as needed.
In the context of the present invention, one of the many aspects of the invention includes a real-time access of a programmer to a remote web-based expert data center, via a communication network, which includes the Internet. The operative structure of the invention includes the remote web-based expert data center, in which an expert system is maintained, having a bi-directional real-time data, sound and video communications with the programmer via a broad range of communication link systems. The programmer is in turn in telemetric communications with the IMDs such that the IMDs may uplink to the programmer or the programmer may down link to the IMDs, as needed.
In yet another context of the invention, the critical components and embedded systems of the programmer are remotely maintained, debugged and/or evaluated to ensure proper functionality and performance by down linking expert systems and compatible software from the web-based expert data center.
In a further context of the invention, a programmer is remotely monitored, assessed and upgraded as needed by importing expert systems from a remote expert data center via a wireless or equivalent communications system. The operational and functional software of the embedded systems in the programmer may be remotely adjusted, upgraded or changed as apparent. Some of the software changes may ultimately be implemented in the IMDs as needed by down linking from the programmer to the IMDs.
Yet another context of the invention includes a communications scheme that provides a highly integrated and efficient method and structure of clinical information management in which various networks such as Community access Television, Local area Network (LAN), a wide area network (WAN) Integrated Services Digital Network (ISDN), the Public Switched telephone Network (PSTN), the Internet, a wireless network, an asynchronous transfer mode (ATM) network, a laser wave network, satellite, mobile and other similar networks are implemented to transfer voice, data and video between the remote data center and a programmer. In the preferred embodiment, wireless communications systems, a modem and laser wave systems are illustrated as examples only and should be viewed without limiting the invention to these types of communications alone. Further, in the interest of simplicity, the applicants refer to the various communications system, in relevant parts, as a communications system. However, it should be noted that the communication systems, in the context of this invention, are interchangeable and may relate to various schemes of cable, fiber optics, microwave, radio, laser and similar communications or any practical combinations thereof.
Some of the distinguishing features of the present invention include the use of a robust web-based expert data center to manage and tune the operational and functional parameters of a programmer in real-time. Specifically, the invention enables remote diagnosis, maintenance, upgrade, performance tracking, tuning and adjustment of a programmer from a remote location. Although the present invention focuses on the remote real-time monitoring and management of the programmer, some of the changes and upgrades made to the programmer could advantageously be transferred to the IMDs. This is partly because some of the performance parameters of the programmer are functionally parallel to those in the IMDs. Thus, one additional benefit of the present invention is an enhancement of the programmer may be implemented, on a proactive basis, in the IMDs by down linking from the programmer thereby upgrading the IMDs to promote the patient's well being.
Yet one of the other distinguishing features of the invention includes the use a highly flexible and adaptable communications scheme to promote continuous and real-time communications between a remote expert data center and a programmer associated with a plurality of IMDs. The IMDs are structured to share information intracorporeally and may interact with the programmer, as a unit. Specifically, the IMDs either jointly or severally can be interrogated to implement or extract clinical information as required. In other words, all of the IMDs may be accessed via one IMD or, in the alternate, each one of the IMDs may be accessed individually. The information collected in this manner may be transferred to the programmer by up linking the IMDs as needed.
Further, the present invention provides significant advantages over the prior art by enabling remote troubleshooting, maintenance and software upgrade to the programmer. The communications scheme enables remote debugging and analysis on the programmer. In the event a component or software defect is noted, the system is able to check whether a 'remote-fix' is possible. If not, the system broadcasts an alert to an operator thus attending to the problem on a real-time basis. In the execution of this function the communications scheme of the present invention performs, inter alia, a review of usage logs, error logs, power and battery status, data base integrity and the mean time between failures status of all the significant and relevant components. Further, patient history, performance parameter integrity and software status are mined from the programmer's database and analyzed by an analyzer at the remote expert data center.
The invention provides significant compatibility and scalability to other web-based applications such as telemedicine and emerging web-based technologies such as tele-immersion. For example, the system may be adapted to webtop applications in which a webtop unit may be used to uplink the patient to a remote data center for non-critical information exchange between the IMDs and the remote expert data center. In these and other web-based similar applications the data collected, in the manner and substance of the present invention, may be used as a preliminary screening to identify the need for further intervention using the advanced web technologies.
The present invention will be appreciated as the same becomes better understood by reference to the following detailed description of the preferred embodiment of the invention when considered in connection with the accompanying drawings, in which like numbered reference numbers designate like parts throughout the figures thereof, and wherein:
Programming commands or data are transmitted from programmer 20 to IMDs 10, 10′ and 10″ via external RF telemetry antenna 24. Telemetry antenna 24 may be an RF head or equivalent. Antenna 24 may be located on programmer 20 externally on the case or housing. Telemetry antenna 24 is generally telescoping and may be adjustable on the case of programmer 20. Both programmer 20 and webtop unit 20′ may be placed a few feet away from patient 12 and would still be within range to wirelessly communicate with telemetry antennas 28, 32 and 38.
The uplink to remote web-based expert data center 62, hereinafter referred to as, interchangeably, "data center 62", "expert data center 62" or "web-based data center 62" without limitations, is accomplished through programmer 20 or webtop unit 20′. Accordingly programmer 20 and webtop unit 20′ function as an interface between IMDs 10, 10′ and 10″ and data center 62. One of the many distinguishing elements of the present invention includes the use of various scalable, reliable and high-speed wireless communication systems to bi-directionally transmit high fidelity digital/analog data between programmer 20 and data center 62.
There are a variety of wireless mediums through which data communications could be established between programmer 20 or webtop unit 20′ and data center 62. The communications link between Programmer 20 or webtop unit 20′ and data center 62 could be modem 60, which is connected to programmer 20 on one side at line 63 and data center 62 at line 64 on the other side. In this case, data is transferred from data center 62 to programmer 20 via modem 60. Alternate data transmission systems include, without limitations, stationary microwave and/or RF antennas 48 being wirelessly connected to programmer 20 via tunable frequency wave delineated by line 50. Antenna 48 is in communications with data center 62 via wireless link 65. Similarly, webtop unit 20′, mobile vehicle 52 and satellite 56 are in communications with data center 62 via wireless link 65. Further, mobile system 52 and satellite 56 are in wireless communications with programmer 20 or webtop unit 20′ via tunable frequency waves 54 and 58, respectively.
In the preferred embodiment a Telnet system is used to wirelessly access data center 62. Telnet emulates a client/server model and requires that the client run a dedicated software to access data center 62. A Telnet protocol provides for commands entered on the programmer to be executed as if entered directly on the remote data center. The Telnet scheme envisioned for use with the present invention includes various operating systems including UNIX, Macintosh, and all versions of Windows.
Functionally, an operator at programmer 20 or an operator at data center 62 would initiate remote contact. Programmer 20 is down linkable to IMDs via link antennas 28, 32 and 38 to enable data reception and transmission. For example, an operator or a clinician at data center 62 may downlink to programmer 20 to perform a routine or a scheduled evaluation of programmer 20. In this case the wireless communication is made via wireless link 65. If a downlink is required from programmer 20 to IMD 10 for example, the downlink is effected using telemetry antenna 22. In the alternate, if an uplink is initiated from patient 12 to programmer 20 the uplink is executed via wireless link 26. As discussed herein below, each antenna from the IMDs can be used to uplink all or one of the IMDs to programmer 20. For example, IMD 10″ which relates to neural implant 30 can be implemented to up-link, via wireless antenna 34 or wireless antenna 34′, any one, two or more IMDs to programmer 20. Preferably bluetooth chips, adopted to function within the body to outside the body and also adopted to provide low current drain, are embedded in order to provide wireless and seamless connections 42, 44 and 46 between IMDs 10, 10′ and 10″. The communication scheme is designed to be broadband compatible and capable of simultaneously supporting multiple information sets and architecture, transmitting at relatively high speed, to provide data, sound and video services on demand.
Programming commands or data are transmitted between IMD 10 RF telemetry antenna 28, for example, and an external RF telemetry antenna 24 associated with programmer 20. In this case, it is not necessary that the external RF telemetry antenna 24 be contained in a programmer RF head so that it can be located close to the patient's skin overlying IMD 10. Instead, the external RF telemetry antenna 24 can be located on the case of programmer 20. It should be noted that programmer 20 can be located some distance away from patient 12 and is locally placed proximate to the IMDs such that the communication between IMDs 10, 10′ and 10″ and programmer 20 is telemetric. For example, programmer 20 and external RF telemetry antenna 24 may be on a stand a few meters or so away from patient 12. Moreover, patient 12 may be active and could be exercising on a treadmill or the like during an uplink telemetry interrogation of real time ECG or other physiologic parameters. Programmer 20 may also be designed to universally program existing IMDs that employ RF telemetry antennas of the prior art and therefore also have a conventional programmer RF head and associated software for selective use therewith.
In an uplink communication between IMD 10 and programmer 20, for example, telemetry transmission 22 is activated to operate as a transmitter and external RF telemetry antenna 24 operates as a telemetry receiver. In this manner data and information may be transmitted from IMD 10 to programmer 20. In the alternate, IMD 10 RF telemetry antenna 26 operates as a telemetry receiver antenna to downlink data and information from programmer 20. Both RF telemetry antennas 22 and 26 are coupled to a transceiver comprising a transmitter and a receiver.
Further referring to
In order for the physician or other caregiver or operator to communicate with the programmer 20, a keyboard or input 82 coupled to CPU 80 is optionally provided. However the primary communications mode may be through graphics display screen of the well-known "touch sensitive" type controlled by a graphics circuit. A user of programmer 20 may interact therewith through the use of a stylus, also coupled to a graphics circuit, which is used to point to various locations on screen or display 84 which display menu choices for selection by the user or an alphanumeric keyboard for entering text or numbers and other symbols. Various touch-screen assemblies are known and commercially available. Display 84 and or the keyboard comprise means for entering command signals from the operator to initiate transmissions of downlink or uplink telemetry and to initiate and control telemetry sessions once a telemetry link with data center 62 or an implanted device has been established. Display screen 84 is also used to display patient related data and menu choices and data entry fields used in entering the data in accordance with the present invention as described below. Display screen 84 also displays a variety of screens of telemetered out data or real time data. Display screen 84 may also display plinked event signals as they are received and thereby serve as a means for enabling the operator to timely review link-history and status.
Programmer 20 further comprises an interface module, which includes digital circuit, non-isolated analog circuit, and isolated analog circuit. The digital circuit enables the interface module to communicate with the interface controller module. As indicated hereinabove, the operation of programmer 20, in accordance with the present invention, is controlled by microprocessor 80. Programmer 20 is preferably of the type that is disclosed in U.S. Pat. No. 5,345,362 to Winkler, which is incorporated by reference herein in its entirety.
Screen 84 may also display up-linked event signals when received and thereby serve as a means for enabling the operator of programmer 20 to correlate the receipt of uplink telemetry from an implanted device with the application of a response-provoking action to the patient's body as needed. Programmer 20 is also provided with a strip chart printer or the like coupled to interface controller module so that a hard copy of a patient's ECG, EGM, marker channel of graphics displayed on the display screen can be generated.
As will be appreciated by those of ordinary skill in the art, it is often desirable to provide a means for programmer 20 to adapt its mode of operation depending upon the type or generation of implanted medical device to be programmed and to be compliant with the wireless communications system through which data and information is transmitted between programmer 20 and data center 62.
Programmer 20 is connected to remote data center 62 via bidirectional data communication link 136. Data resource center forms the web-based data resources/expert system 100. Accordingly, data resources system 100 is a sub-component of remote data center 62, which includes information identification module 138, analyzation module 140, data storage module 142 and software update module 146.
Referring to programmer 20 in more detail, when a physician or an operator needs to interact with programmer 20, a keyboard coupled to Processor 80 is optionally employed. However the primary communication mode may be through graphics display screen of the well-known "touch sensitive" type controlled by graphics circuit. A user of programmer 20 may interact therewith through the use of a stylus 122, also coupled to a graphics circuit, which is used to point to various locations on screen/display 114 to display menu choices for selection by the user or an alphanumeric keyboard for entering text or numbers and other symbols as shown in the above-incorporated '362 patent. Various touch-screen assemblies are known and commercially available. The display and or the keyboard of programmer 20, preferably include means for entering command signals from the operator to initiate transmissions of downlink telemetry from IMDs and to initiate and control telemetry sessions once a telemetry link with one or more IMDs has been established. The graphics display/screen 114 is also used to display patient related data and menu choices and data entry fields used in entering the data in accordance with the present invention as described below. Graphics display/screen 114 also displays a variety of screens of telemetered out data or real time data. Programmer 20 is also provided with a strip chart printer 118 or the like coupled to interface controller module so that a hard copy of a patient's ECG, EGM, marker channel or similar graphics display can be generated. Further, Programmer 20's history relating to instrumentation and software status may be printed from printer 118. Similarly, once an uplink is established between programmer 20 and any one of IMDs 10, 10′ and 10″, various patient history data and IMD performance data may be printed out. The IMDs contemplated by the present invention include a cardiac pacemaker, a defibrillator, a pacer-defibrillator, implantable monitor (Reveal), cardiac assist device, and similar implantable devices for cardiac rhythm and therapy. Further the IMD units contemplated by the present invention include electrical stimulators such as, but not limited to, a drug delivery system, a neural stimulator, a neural implant, a nerve or muscle stimulator or any other implant designed to provide physiologic assistance or clinical therapy.
Data resources 100 represents a high speed computer network system which is located in remote expert data center 62 having wireless bi-directional data, voice and video communications with programmer 20 via wireless communications link 136. Generally data resources 100 are preferably located in a central location and are equipped with high-speed web-based computer networks. Preferably, the data resource center is manned 24-hours by operators and clinical personnel who are trained to provide a web-based remote service to programmer 20. Additionally, as discussed hereinabove, data resources 100 provide remote monitoring, maintenance and upgrade of programmer 20. The location of remote data center 62 and, consequently, the location of data resources 100 are dependent upon the sphere of service. In accordance with the present invention, data resource 100 may be located in a corporate headquarters or manufacturing plant of the company that manufactures programmer 20. Wireless data communications link/connection 136 can be one of a variety of links or interfaces, such as a local area network (LAN), an internet connection, a telephone line connection, a satellite connection, a global positioning system (GPS) connection, a cellular connection, a laser wave generator system, any combination thereof, or equivalent data communications links.
As stated hereinabove, bi-directional wireless communications 136 acts as a direct conduit for information exchange between remote data center 62 and programmer 20. Further, bidirectional wireless communications 136 provides an indirect link between remote data center and IMDs 10, 10′ and 10″ via programmer 20. In the context of this disclosure the word "data" when used in conjunction with bi-directional wireless communications also refers to sound, video and information transfer between the various centers.
Accordingly, once data communications is established, data resources 100 may assess, monitor or analyze various data and information relating to programmer 20 or its components. For example, data resource 100 can analyze the performance history of a specific component of programmer 20. More specifically, data resource 100 can analyze usage statistical data, component status information or analyze error information of programmer 20. If an error is discovered in programmer 20, or any of its sub-components, preventative actions can be performed via bidirectional wireless data communications link/connection 124.
During one of the wireless bidirectional communications sessions, contemplated by the invention, information identification module 138 receives identification information and historical data from one or more of the components of programmer 20. These components may include analyzer 126, or any sub-component thereof. Further, operational and instrumentation data relating to programmer 20 is collected and submitted for review by analyzation module 140, at remote data center 62. More particularly, information identification module 138 receives information identifying a particular medical component or sub-component through bar code information, a serial number, and/or a model number. Information identification module 138 also receives historical data such as the number of times the component has been turned on, the length of time of each session, the functions performed by the component during each session, and past errors or malfunctions of the component. This data is transferred from programmer 20 to data center 62 for analysis, documentation, evaluation and monitoring of the functional and operational parameters of programmer 20. In the event a defect or malfunction is indicated by the data, remedial action will be taken as deemed appropriate based on the recommendation of the expert systems or technical support residing in data center 62.
Data storage module 142 contains various information including industry-set or manufacturer's recommendation for mean time to failure standards relating to various components of programmer 20. The software contained in module 142 keeps track of usage and mean time to failure information such that when programmer 20 is interrogated, the information is readily available. This information is used to determine the maintenance, replacement or checkup of critical components in programmer 20.
Analyzation module 140 compares the historical data, such as usage, idle time and near failure or actual failure events and similar other information of a component or sub-component with information in data storage module 142. Analyzation module 140 further evaluates the historical and performance data, using the mean time to failure standards as a model. More specifically, analyzation module 140 compares usage information, instrument status information, and error information against preset performance and operations standards for the same or similar conditions. The preset standards are generally derived from analysis of prior similar components use and failure modes. Analyzation module 140 determines whether a present failure has occurred or a near-future failure is eminent. In either case, data resources 100 would attempt to correct the present and foreseeable failures or would initiate a course of action to rectify the situation.
For example, a software upgrade application from update software module 146 can be transmitted via data communications link/connection 136 and remotely installed in a specific component or sub-component of programmer 20. An upgrade software application may correct a present or near-future failure if, for example, the failure mode of an imbedded system are known. In addition, remote data center 62 can interface with a component or sub-component directly of programmer 20 to suggest modifications or adjustments. Remote data center 62, through its web-based expert and computer systems in data resources 100, can also schedule a parts replacement order for a component in programmer 20. Setting or broadcasting an urgent message to the operator over the web-based LAN or WAN system typically does this.
Further, as discussed hereinabove, programmer 20 has touch-sensitive display 114 capable of displaying communications information from data resources 100. Therefore, urgent information relating to a critical component of programmer 20 may be communicated via display 114 to notify an operator of a component failure, a scheduled replacement activity or similar emergency maintenance issues. Finally, data center 62 can interface directly or indirectly with the components of programmer 20 to alert the operator to change/maintain a component. The replacement activity may occur on-site or may require the component be shipped to a centralized repair facility.
With the invention, the computers and software and other tools at data resources 100 residing in remote data center 62 can remotely analyze a diverse number of components and sub-components of programmer 20. As discussed above, data center 62 is preferably a web-based high-speed computer network and includes other resources to enable remote troubleshooting, preventative maintenance, and upgrade of programmer 20. Specifically, updated software can be provided to programmer 20 by exporting it via one of the communications media disclosed herein. Alternatively, a remote assessment and decision as to whether a component or sub-component of programmer 20 requires service can be made by remotely monitoring the component in question.
Referring now to
It should be noted that patient data and related information which is ultimately the basis upon which remote station 62 interacts with programmer 20 is obtained from IMDs 10, 10′ and 10″. Thus, for example, patient history that is collected from the memory bank of the IMDs by up linking to programmer 20 could be ultimately transferred to remote station 62 for evaluation and analysis.
Referring to
Under logic step 258 the patient data port is opened. This data is initially obtained by up linking any one of IMDs 10,10′ and 10″ to programmer 20 and transferring patient specific data stored in the IMDs. The data is generally uploaded and stored in programmer 20 on a regular or on as needed basis. Although, some of the patient data may be analyzed locally at programmer 20 level, the flow chart assumes that all patient data will be exported to remote data center 62 for analysis by analyzation module 140. Thus, the logic proceeds to decision block 262 where inconsistency in the data is checked. In the event there are no recognizable data inconsistencies, the logic proceeds to step 261 and the session is terminated. However, if there are problems in the structure and/or makeup of the patient history data the logic proceeds to decision block 264 and would determine whether the problem could be solved remotely. If the problem is such that remote implementation of a fix is not possible, the logic proceeds to step 263 where an emergency flag is broadcast to an operator thus alerting the responsible party of the problem. In the alternate, if a solution could be implemented remotely, the logic proceeds to implement the solution under logic step 262. Thereafter, the logic proceeds to step 264 where the operation is recorded, indicating a synopsis of the problem and the remedial measures undertaken. Subsequently, the session is terminated.
Similarly, as outlined in the remainder of the logic chart, usage log is checked under logic step 268, component(s) status is evaluated under logic step 280, error log is checked under logic step 292 and interaction/interface error, which may result from programmer 20 interacting with the IMDs, is checked under logic step 308. In all these cases, in the event a problem with a component or an error with a data set is detected by data center 62, a remote solution such as software upgrade via module 146 may be implemented or a component replacement notice may be posted.
Similarly, if the data management issue relates to performance parameters, the logic proceeds to decision block 422. If it is found that the issue is other than performance parameters, for example, of embedded systems in programmer 20, the logic proceeds to step 423 and the session is terminated. The logic otherwise proceeds to decision block 424 to check if the evaluation session relates to current or near-future failure of imbedded systems or operational parameters thereof. If not the sessions ended at logic step 423. If failure or near-future failure is the issue, however, the logic proceeds to decision step 426 to check if a remote correction is possible under logic step 426. If a remote correction is not viable the logic proceeds to step 427 to issue/broadcast an alert to the operator. In the alternate, if a remote solution is possible, the correction is implemented under logic step 428. Thereafter, the logic proceeds to decision step 430 where the correction is checked for accuracy and related factors. If the correction is found to be successful, the session is terminated under logic step 432. However, if the problem remains unresolved, the logic proceeds to step 427 to issue/broadcast an alert to the operator.
Further, if the data management issue relates patient history, the program logic advances to decision step 434. If the investigation does not relate to patient history, the program advances to stop 423 where the event is recorded and the session ended. If, however, the session relates to patient data, the logic advances to step 436 to check various types of patient history status under decision blocks 438, 440 and 442 where the logic checks to see if the session relates to available patient history, initial startup or missing patent history, respectively. If patient history is available under decision step 438, it is copied under step 44 and subsequently the event is recorded and the session terminated. In the alternate, if patient history is not available, the logic proceeds to decision step 44 to check if this is a condition of initial startup of either programmer 20 or initial installation of IMDs 10, 10′ and 10″. Clearly no prior history will be found in the database if the checkup for patient history is done in the early few hours of the implant. Accordingly under decision block 440 if it is found that the session is being undertaken during initial startup, the logic proceeds to step 446 where the event is recorded and the session terminated. In the alternate if the session is not performed during initial startup, the logic proceeds to decision step 442 where the system checks to see if patient history data is missing. If it is found that patient history data is not missing, the logic reverts back to step 436 to repeat the logic steps stated hereinabove. On the other hand, if patient history data is confirmed to be missing, the logic advances to step 443 to issue/broadcast an alert to the operator.
Accordingly, the present invention provides several advantages over the prior art. Specifically, the prior art does not teach a structure and/or method in which components of a programmer are remotely assessed, monitored or evaluated for failure or other performance defects to implement a remote solution to those problems. In summary, the present invention provides several advances over the prior art some of which include: the utilization of a communication scheme integrated with a remote web-based expert data center 62 in which expert systems are remotely deployed to evaluate component usage, check error logs and frequency of failure, check power or battery status, monitor mean time to failure status of components/subcomponents, update software, evaluate data base integrity and check information management, perform remote or order on site repair and replacement of components and alert operators to any significant problems with programmer 20.
Although specific embodiments of the invention have been set forth herein in some detail, it is understood that this has been done for the purposes of illustration only and is not to be taken as a limitation on the scope of the invention as defined in the appended claims. It is to be understood that various alterations, substitutions, and modifications may be made to the embodiment described herein without departing from the spirit and scope of the appended claims.
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|Thomas Doerr
|System for the remote programming of a personal medical device
|Jun 6, 2008
|Jan 29, 2009
|Joachim Reinke
|System and method for the remote programming of a personal medical device
|Aug 11, 2008
|Jun 18, 2009
|Smiths Medical Md, Inc.
|Software Development Kit for a Medical Device and Web-Based Server
|Sep 3, 2013
|May 22, 2014
|Shenzhen Mindray Bio-Medical Electronics Co., Ltd
|First aid equipment, monitoring server, monitoring system, and monitoring method for first aid equipment
|May 19, 2015
|Nov 26, 2015
|Siemens Healthcare Diagnostics Inc.
|Intelligent service assistant inference engine
|U.S. Classification
|International Classification
|Cooperative Classification
|European Classification
|Jan 22, 2010
|Fee payment
Year of fee payment: 4
|Feb 24, 2014
|Fee payment
Year of fee payment: 8


text:
Idle thoughts.
"I understand. If you can't forgive me, I mean." I looked up at Alex then. "I wouldn't forgive me, either."
And so the journey continued, moving ever on through Canada, further North, and into colder territory.
At some point in the few hours that we travelled in silence, I took my tiny razor out of my case, and sliced my finger open repeatedly. I made sure I was turned away from the humans, but Alex glanced down at me briefly, before rolling his eyes and letting me be.
It was my link to being human.
I remembered the way the fallen angel's blood had made my mouth water. It had smelled so horrible - like spoiled milk - but the colour and the way it ran across her skin was so enticing...
I had to stop the thought there, or I would end up massacring the entire bus. I idly wondered if Alex would help me. Probably not.


text:
Guest reviews
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8.6 Excellent
Based on 1,065 reviews
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Metro 360 Hotel Kuala Lumpur puts you within a 10-minute drive of Petaling Street and Merdeka Square. Guests can splash around at the outdoor pool or grab a bite to eat at the restaurant. Rooms at this upscale hotel offer flat-screen TVs, refrigerators, and minibars.


text:
Free personalized radio that
plays the music you love
Selected Discography
Track List: We Don't Give A F**k (Single)
Track List: Revenge Of The Barracuda
Track List: Guilty By Affilliation (Explicit)
Track List: Guilty By Affiliation
Track List: West Side Heavy Hitter (Explicit)
Track List: Ghetto Heisman (Explicit)
Track List: The Shadiest One (Explicit)
Track List: That's What I'm Talking About
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wc and the connection(i c e cube and mac 10)s**t still bangin
Afteroms died days y JM da s**t out of y'all music I been there in 92 wen riot
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That day you're crush will ask you out
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text:
I slam the door behind me as the press bang against it. I lock the door and realise my breathing is heavy.
I walk over and fall on to the sofa. "I hate being famous" I mutter pushing a hand back through my hair and sigh.
I stand up and grab my phone dialling Dan's number.
"Hello, super star" he sings into the phone.
"Dan, I can't take this" I almost shout down the phone. "Can't you find a replacement to take my place for a while"
"Oh Hun, of coarse maybe I could get this girl my bro Tommy's been on about" Dan says down the phone.
"Great, I just can't deal with the press twenty four seven. I mean they follow me shopping for flips shake and wrote my whole shopping list in the paper" I say walking into my bedroom and falling on to my bed.
"You know Hun. I'll get the girl as soon as I can, she surpposedly just your height"
"Well, lets hope her voice can sing my notes. See ya Dan"
"Bye Sasha Hun" I press end and groan when I hear clicking of camera's still outside.
So much for a peaceful work free day.


text:
Sophal Ear:
Sofal Er (Sophal Ear): Beg od Crvenih Kmera
Član programa TED Fellows, Sofal Er je podelio neverovatnu priču o tome kako je negova porodica pobegla iz Kambodže pod režimom Crvenih Kmera. On se priseća domišljatosti i odlučnosti njegove majke kako bi spasila svoju decu.
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text:
Decision makers
- Angostura Limited (Trinidad & Tobago)Robert Wong, CEO
We did it! Angostura has said they will pull the ad! Thank You ALL!!!
The ad is menacing and suggests and encourages date rape!
- Robert Wong, CEO
Angostura Limited (Trinidad & Tobago)
Sent to Robert Wong, CEO of Angostura Limited (email@example.com),
Executive Director, Vidia Persad-Doodnath
Executive Manager of Sales and Marketing Brenda de la Rosa:
Mr. Wong and Senior Executive of Angostura Limited,
I recently saw your newspaper ad. (see attached)
It shows a large image of a rather menacing looking, young man, and an insert image of him tugging on a young woman.
Your ad text suggests that if he buys her your alcohol, she will submit to his advances and take him out of the "friend zone".
To say that this ad shows a complete lack of judgment would be an understatement. An ad would normally go through several levels of discussion before being released. It appears this ad slipped by everyone with a sense of decorum and went from the sewer to the Approved file.
Is this what passes as advertising in the Caribbean? Is this representative of you, the executive of Angostura Limited? "Drink, entice her, seduce her and date rape?"
Is there no element of responsibility even as an alcohol distillery?
I have asked everyone I know to contact you by any means possible, to let you know this is unacceptable.
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text:
2014 Kicks off with a Bang!!! We are back at the Century Casino with VIP dinners and a great night of fighting.
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text:
Range Rover Classifieds
Viewing 1 - 3 of 3 results
Selected Filters:Make: Range Rover
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Advertiser since 1998
Advertiser since 1998
From May, 2017 print edition


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Titles similar to House of Holes
Baker's books The Mezzanine and A Box of Matches gave him a reputation as a master of minutiae. He is also a writer of erotica, with Vox and The Fermata. It's easy to guess which camp House of Holes falls into. Here, people get sucked through various portals to the House of Holes, a wonderland full of sexual pleasures too obscene to mention here. It's a strange land where you can find a woman who makes love to a severed arm; another one literally lays an egg; and still another excretes souvenir sculptures made of asswood. Men undergo temporary decapitations and "cross-crotchal interplasmic transfers." Baker revels in pornographic imagery, exploiting the lexicon of smut, using the usual array of ridiculous euphemisms for sexual organs as well as a few clever originals (e.g., "rogue jacquard" and "Malcolm Gladwell"). Of course, it all builds up to a climax, but one wonders: to what end?
Baker, well known in library land for his defense of the card catalog, received the National Book Critics Circle Award for Double Fold. Expect controversy over the erotic content of his latest work to prompt demand.
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text: John Paul Pinette was an American actor and stand-up comedian. He toured the comedy club circuit beginning in the 1980s and appeared in cinema and on television. Besides stand-up, Pinette did impressions of The Chipmunks, Elvis Presley, Gollum from The Lord of the Rings, Hervé Villechaize, an Ewok, actor Marlon Brando, as well as various ethnic accents. He occasionally sang, for example "Over the Rainbow" from The Wizard of Oz, in stand-up routines.


text:
HP IQ504 TouchSmart PC - KQ436AA
Enjoy your digital life wherever it happens. Put HP sleek, all-in-one, next-generation TouchSmart IQ504 PC in any room you want. Work, listen to music, edit photos and videos, check e-mail, and watch TV. You'll have simple, touch access to entertainment and social networks, and you'll be able to stay connected with people using the integrated webcam and microphone.
Bring photos, movies, and music to life


text:
Compare Domestic Violence attorneys near you. Read reviews, see Avvo Ratings, and contact them directly.
5.0 stars 24 reviews
Avvo Rating: 9.8
The Ladan Law Firm, P.A. continues to build on years of the community involvement of founding Partner, Amir Ladan. The lawyers and staff of our firm are active in the communities we serve. Not only do our lawyers provide pro bono legal services...
Practice areas & skills: Domestic Violence, DUI & DWI, Violent Crime, Criminal Defense, Juvenile
5.0 stars 22 reviews
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The Law Office of David A. Webster, P.A. was established for the exclusive purpose of representing individuals facing criminal charges. Mr. Webster is a graduate of The Ohio State University and the University of Toledo College of Law where he rec...
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5.0 stars 31 reviews
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William C. Rosenfelt "Bill" explores how people in Florida Family Law cases can obtain successful resolutions of their cases through the employment of various legal strategies tailored to their individual needs. Bill has practiced family law for ...
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Jack is a native Floridian who grew up in South Florida. He graduated from Florida State and received an MBA from Florida International before accepting a position with The Coca-Cola Company in Atlanta. While working full time as a project manager...
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Review: "Edda has always kept it very profssional! She is very awesome. Her knowledge base was extensive in the field. I was very confident in her ability to represent me. Edda Keep up the fight for us ... Thank you"
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The product of CHD4 belongs to the SNF2/RAD54 helicase family. Additionally we are shipping CHD4 Antibodies (80) and CHD4 Proteins (9) and many more products for this protein.
Showing 2 out of 5 products:
CHD4 plays a pivotal role in chemoresistance and the maintenance of stemness in liver cancer stem cells and is therefore a good target for the eradication of hepatocellular carcinoma.
Acetyltransferase p300 (show EP300 ELISA Kits) collaborates with chromodomain helicase DNA-binding protein 4 (CHD4) to facilitate DNA double-strand break repair
Specifically, methyl-CpG-binding domain protein 2 (MBD2 (show MBD2 ELISA Kits)) is revealed to be recruited to DNA damage sites after laser microirradiation, which was mediated through MBD (show DPEP1 ELISA Kits) domain and MBD2 (show DPEP2 ELISA Kits) C-terminus.
these data build on our understanding of how CHD4-NuRD acts to regulate gene expression and participates in the DNA-damage response.
CHD4 depletion modulates expression of acute myeloid leukemia (show BCL11A ELISA Kits) cell genes that regulate tumor formation in vivo and colony formation in vitro.
Also discovered a novel causative role for CHD4, a helicase involved in the histone deacetylase (show HDAC1 ELISA Kits) complex that is associated with poor clinical outcome.
CHD4 modulates therapeutic response in BRCA2 (show BRCA2 ELISA Kits) mutant cancer cells.
Endogenous Mta1 (show MTA1 ELISA Kits)/2 forms a complex with chromodomain helicase (Chd)4, histone deacetylases (Hdac)1 (show HDAC1 ELISA Kits)/2, RbAp46 (show RBBP7 ELISA Kits)/48, and Mbd3 (show MBD3 ELISA Kits) in rat cerebellum
CHD4 and HDAC1 (show HDAC1 ELISA Kits) occupy the promoters of several of these hypermethylated tumor suppressor genes and physically and functionally interact to maintain their silencing.
repressive functions of MBD2 (show DPEP2 ELISA Kits)-containing NuRD complexes are dependent on cooperative interactions between the major domains of CHD4 with histones and DNA and on binding of methylated DNA by MBD2 (show DPEP2 ELISA Kits)
CHD4 allows cells to undertake lineage commitment in vivo by modulating the frequency with which lineage-specification genes are expressed.
Chromatin immunoprecipitation assays showed that CHD4-containing NuRD complexes directly bound the promoters of these genes in endothelial cells
Chd4, interacting with Hdac1 (show HDAC1 ELISA Kits)/2, cooperates with its related proteins Kap1 (show TRIM28 ELISA Kits) and Cbx1 (show CBX1 ELISA Kits) to bind at -207/-148 of the Sox9 (show SOX9 ELISA Kits) promoter.
NuRD negatively regulates TIP5 expression, thereby inhibiting ribosomal DNA (rDNA) methylation and maintaining demethylation state of rDNA promoters.
The chromodomain helicase DNA-binding protein 4 (Chd4) is a critical interaction partner of Ezh2 (show EZH2 ELISA Kits) required specifically for Polycomb (show CBX2 ELISA Kits) group (PcG)-mediated suppression of the key astrogenic marker gene GFAP (show GFAP ELISA Kits).
Gata3 (show GATA3 ELISA Kits)/Chd4 forms functionally distinct complexes, which mediate both positive and negative gene regulation to facilitate Th2 cell differentiation.
In this study, we demonstrate that Mi2beta is required for gamma-globin gene silencing during adult definitive erythropoiesis
Concomitant deletion of Chd4 and Brg1 (show SMARCA4 ELISA Kits) rescued vascular abnormalities seen in Brg1 (show SMARCA4 ELISA Kits) mutant yolk sacs (show SACS ELISA Kits) to the same extent as LiCl treatment.
activity of the Mi-2beta nucleosome-remodeling and histone-deacetylase (show HDAC1 ELISA Kits) (NuRD) complex was controlled by the Ikaros (show IKZF1 ELISA Kits) family of lymphoid lineage-determining proteins.
CHD4 functions as a MAP required for MT stabilization and is involved in generating spindle bipolarity.
The product of this gene belongs to the SNF2/RAD54 helicase family. It represents the main component of the nucleosome remodeling and deacetylase complex and plays an important role in epigenetic transcriptional repression. Patients with dermatomyositis develop antibodies against this protein.
chromodomain helicase DNA binding protein 4
, chromodomain-helicase-DNA-binding protein 4
, ATP-dependent helicase CHD4
, Mi-2 autoantigen 218 kDa protein
, Mi-2 autoantigen
, Mi-2 beta


text: Brecon Photos Brecon Old Photos Old Maps Memories of Brecon Nearby Places Displaying Photos 1 - 80 of 105 in total Sort & display options Sort by Default Sort by Most Popular Sort by Recently Added Sort by Oldest Sort by Newest Sort by Description Sort by Memories Shared Show Landscape Images Show Portrait Images Show All Images 1 2 Next › Brecon, High Street 1955 Ref. B192056 Brecon, The Bridge And The Beacons 1899 Ref. 44707 Brecon, The Barracks 1910 Ref. 62651 Brecon, High Street 1910 Ref. 62649 Brecon, Christ College 1899 Ref. 44721 Brecon, The Bridge And Castle 1899 Ref. 44717 Brecon, On The Canal 1899 Ref. 44733 Brecon, Ship Street 1910 Ref. 62657 Brecon, Lower Ffrwdgrech Waterfalls 1910 Ref. 62668 Brecon, Shire Hall 1899 Ref. 44725 Brecon, St Mary's Church 1899 Ref. 44729 Brecon, High Street 1899 Ref. 44714 Brecon, The Promenade And Newton Pool 1899 Ref. 44716 Brecon, The Brecon Barracks c.1960 Ref. B192089 Brecon, Beech Grove 1899 Ref. 44724 Brecon, Newton Pool 1910 Ref. 62663 Brecon, The Groves c.1955 Ref. B192059 Brecon, General View From Slwch Tump c.1965 Ref. B192102 Brecon, Newton Pool 1899 Ref. 44713 Brecon, Castle And River Usk 1899 Ref. 44718 Brecon, The Promenade 1899 Ref. 44715 Brecon, Brecon Beacons 1899 Ref. 44712 Brecon, The Struet 1910 Ref. 62654 Brecon, The Watton 1910 Ref. 62650 Brecon, Ship Street c.1955 Ref. B192121A Brecon, The Honddu 1910 Ref. 62656 Brecon, Llanfaes Bridge c.1960 Ref. B192248 Brecon, c.1955 Ref. B192053 Brecon, Canal Aqueduct 1899 Ref. 44731 Brecon, Alexandra Road 1910 Ref. 62658 Brecon, Christ College From The Captain's Walk 1910 Ref. 62660 Brecon, Ffrwdgrech Waterfalls Bridge 1910 Ref. 62667 Brecon, The Honddu 1910 Ref. 62655 Brecon, The Hospital c.1965 Ref. B192104 Brecon, The Priory Church 1899 Ref. 44726 Brecon, Memorial College 1899 Ref. 44722 Brecon, Castle 1899 Ref. 44720 Brecon, The Bulwark 1910 Ref. 62648 Brecon, The Priory Church Interior 1899 Ref. 44728 Brecon, From South 1899 Ref. 44711 Brecon, Bridges On The Usk 1899 Ref. 44730 Brecon, Camden Road 1910 Ref. 62659 Brecon, View From Aqueduct 1899 Ref. 44732 Brecon, Llangorse Lake 1899 Ref. 44734 Brecon, The Promenade c.1960 Ref. B192073 Brecon, King Street c.1965 Ref. B192105 Brecon, Cathedral c.1955 Ref. B192107 Brecon, Castle 1899 Ref. 44719 Brecon, c.1955 Ref. B192050 Brecon, From South 1899 Ref. 44709 Brecon, Llangorse Lake 1899 Ref. 44736 Brecon, Usk Bridge And The Beacons c.1940 Ref. B192011 Brecon, The Barracks 1910 Ref. 62652 Brecon, Beacons c.1965 Ref. B192171 Brecon, Memorial College 1899 Ref. 44723 Brecon, The River Usk From The Promenade c.1950 Ref. B192021 Brecon, Town And Beacons c.1940 Ref. B192010 Brecon, Upper Ffrwdgrech Waterfalls 1910 Ref. 62669 Brecon, The Bulwark c.1955 Ref. B192026 Brecon, Upper Chapel 1937 Ref. 87928 Brecon, The Canonry c.1950 Ref. B192020 Brecon, c.1955 Ref. B192052 Brecon, Wellington Square c.1955 Ref. B192121B Brecon, Castle Hotel And River Promenade c.1940 Ref. B192007 Brecon, Llangorse Lake 1899 Ref. 44735 Brecon, Bridge c.1960 Ref. B192094 Brecon, River Usk c.1965 Ref. B192244 Brecon, The Beacons From Hay Road c.1965 Ref. B192099 Brecon, The Groves 1910 Ref. 62662 Brecon, The Barracks 1910 Ref. 62653 Brecon, Castle Hotel c.1965 Ref. B192135 Brecon, Llangorse Lake c.1965 Ref. B192177 Brecon, The Castle c.1960 Ref. B192247 Brecon, Llangorse Lake c.1965 Ref. B192157 Brecon, Newton Pool 1910 Ref. 62664 Brecon, Youth Hostel c.1965 Ref. B192185 Brecon, Fan Fawr c.1965 Ref. B192187 Brecon, The Swansea And Brecon Cathedral 1910 Ref. 62661 Brecon, Composite c.1955 Ref. B192042 Brecon, Pen Milan c.1965 Ref. B192188 Displaying Photos 1 - 80 of 105 in total 1 2 Next ›


text:
glad to see there are a few people into darkroom stuff. ive resently been fully convered back to the darkroom fold after a short spell with digital last year at college, theres nothin more satisfying than watching a print appear or stumbling around in the pitch black of a colour darkroom for 4 hours and producing a print ur very happy with. also my student house next year has a cellar with blocked windows, very dark, i think i can heard a home darkroom calling me.
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text: Home Products Skinny Standard Belt Description When a low-profile look is needed, the Skinny Standard Belt, a narrower version of the Standard Belt, will serve nicely and features a matching leather keeper and a range of hardware choices. Details Constructed from 10-11 oz. vegetable-tanned Meridian English Bridle and features a matching leather keeper and metal hardware. The edges are dyed, burnished, and waxed by hand, and each belt is stamped with our signature makers mark. Skinny Standard Belt dimensions: 1" wide. Shipping Details This item is available and will ship within 48 hours of date of purchase. Please refer to shipping details on other individual products if you are purchasing multiple items -- lead times may vary for each. Tanner Goods Skinny Standard Belt Hickory $95.00 Select Your Waist Size Size Chart Suggested Belt Size = 26 Hickory / Black / 26 Hickory / Black / 28 Hickory / Black / 30 Hickory / Black / 32 Hickory / Black / 34 Hickory / Black / 36 Hickory / Black / 38 Hickory / Black / 40 Hickory / Black / 42 Add To Cart Size Chart Scroll For Product & Shipping Details Add a monogram + $20.00 3 Characters Maximum ADD MONOGRAM + $20.00 Have A Question? Questions about our products? Give us a call 1-503-862-3224 Live Chat With Us Product Details Shipping Details Size Chart Product Gallery A peek at the process: Belts From side to strap to you Related Products You May Like You've Looked At No previously viewed products. Tanner Goods Skinny Standard Belt Hickory $95.00 26 28 30 32 34 36 38 40 42