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After playing in only six games in 2009, and getting injured just before finishing three quarters of play in game one, Robert Gallery may finally be healthy enough to get back on the field — he hopes for the rest of the season. It would probably help if the Raiders don't turn the ball over too often.
Why is that? It's how he injured the hamstring. "I was going full speed on that interception in the Tennessee game, and when you pop [the hamstring] like that it's hard to come back from," said Gallery on Thursday about how he was injured in week one. That play wasn't a total loss though. Gallery was credited with the tackle when he forced Titans defensive back Chris Hope out of bounds at the three.
Unlike last season, Gallery's return isn't as critical to the play of the offensive line this season, thanks in large part to the play of Daniel Loper in his place. Loper has helped the Raiders with their seventh-ranked rushing attack. Unfortunately, Loper has also been credited with two sacks in little over four games played.
Gallery should be able to help in the passing attack while keeping up with the play of Loper in the rushing game. Even though the running game is doing well, Gallery thinks there is still room for improvement. In front of his locker, Gallery told reporters, "Yeah, we can still be a lot better, especially up front, so you know those backs are running hard and gaining yards and we need need to continue to make that a staple for us."
So what does Gallery have left to prove before getting the start on Sunday? "I would expect if we come through today fine – didn't see anything … I just talked to him, he felt pretty good," said Tom Cable at his meeting with the media on Thursday. "And if he's fine in the morning then I would say he's probably ready to go."
If you believe Gallery, then he'll be on the field Sunday. "It feels good to do what I gotta do so I definitely plan on being out there."
Thursday Notes
Nearly every Raider that has spoken with the press this week agrees — the 49ers are not your typical 0-5 team. In fact, every player has made sure to mention how good their next opponent is. Here are just a few quotes on the Niners from Thursday:
This team is not a bad 0-5 team. This is a good team, everybody knows that, and I think everyone here has the right mindset. They're a good team that could easily be 4-1 the way their games have been going
– Robert Gallery
I've been in their situation, I know that, 0-5, a little desparate situation, you just want to get a win. You've put all that work in it. You want to get a little fruit for your labor and they've been struggling. They're a good team, a good running game, struggling right now. I'm sure they'll try to get it going against us.
– Tommy Kelly
You see a former first round quarterback [Alex Smith], you see a Pro Bowl running back [Frank Gore], and you see receivers that are coming along [Michael Crabtree], and coming into their own. And you see a Pro Bowl tight end [Vernon Davis].
– Stanford Routt
Whether or not all that is just lip service, it probably isn't. Their coaches are saying much of the same type of things.
They're a very good defensive football team. Greg Manusky, who I know, does a fabulous job with their defensive personnel. They're a lot like the Chargers. They play from that same mode. They kind of come after you. They have very good players. Their linebacking crew is, again, somewhat like the Chargers, one of the best in football. Manny Lawson, Takeo Spikes, Patrick Willis, this guy, No. 98. These guys are good. They're not an 0-5 football team. But as I always tell our football players, it's really not about who we're playing, it's more about us, how we prepare, how we go to the game, what are determination and desire to go win a football game, I think regardless of what we face on Sunday that we're going to come out and play well.
– Offensive Coordinator Hue Jackson
Most have wondered if Darren McFadden will be available this Sunday. After speaking with the third-year runner and his head coach, it would be best not to bet on McFadden playing on Sunday.
McFadden was asked if he thought he'd play on Sunday and the Raiders leading rusher said, "It's up in the air right now." That's never a good sign just three days prior to a game. McFadden is still limited in practice, but according to the former first rounder, he did test it on Wednesday. "I went out and did pretty good but like I said I'm just still working and taking my time with it."
The key for McFadden is being able to turn on the jets when he needs to during a game. Right now, he's very tentative about that. "It's very hard," said McFadden of his tightrope between proving he's ready to play and avoiding a setback. "You just try to tell yourself you just want to go out and try to coast, don't hit a burst until you feel like you can all the way."
The person with the final say on whether or not McFadden will play is his head coach. Asked if he'd put McFadden in while he's still tentative with his injury, Cable said, "No, I just think that if they're tentative, they can't cut it loose. And if you can't cut it loose, you're not going to run hard or at the best of your ability. And if you do try to, you're probably [going to] pull it again."
The Raiders have been hit hard by hamstring injuries this season. A few reporters took a count of the hamstring injuries since training camp began, and the total they came up with was 13. That is an average nearing one new hamstring injury ever week.
Why are they getting so many hamstring injuries? "The doctors say its from overwork, so I guess I will go with what the doctors say," said Gallery. Out of 53 players on the team, nearly 25% have had hamstring injuries since training camp began and one took a week off due to fatigue. That's one hardworking team!
Michael Bennett was back on Thursday after being with his wife and newborn baby boy on Wednesday. He's also one of the Raiders struggling with the hamstring issue. He didn't practice, but he was seen working on an empty practice field. While he did say that he was confident about being ready for Sunday, the same rule holds true for Bennett as does McFadden — it depends on if he's still tentative with the injury.
Charlie Frye is out of his cast from the broken wrist, but he's on injured reserve and won't be playing any time this season. As he did while in the cast, he was on the practice field with the other quarterbacks on Thursday. Bruce Gradkowski, again, didn't practice.
Kyle Boller took rep's with the first team offense. No, Boller won't be starting on Sunday and shouldn't be added to any fantasy squads anytime soon. Cable said that they wanted to get him some work just in case. "Being prepared, yeah," said Cable on Thursday about Boller's rep's having any significance to Sunday. "I think, there's some improvement with Bruce, but unless he could work tomorrow that we kind of know where we're headed with it."
Cable made it clear on the status of Gradkowski. "Could he go in as a backup? Maybe, but if he's good enough to go, enough to go in and win the game, then he'd play and start and all that." So if you had Gradkowski on your fantasy team, you might want to try and pick up Jason Campbell for this weekend.
Boller did receive very high praise from Cable on Thursday. Cable was asked if he was confident about Boller being ready if he was called upon and he didn't hold back in his answer.
"Very much so. He's lucky because he's been in this particular system a little bit, and he's played enough football as a starter that he knows what all that is about. Kyle's kind of a rare bird. He studies everything and prepares like he is the starter all the time. I know you hear that, but when you watch him work and you listen to him talk, he's talking like a coach, he's talking to Jason or to Bruce like he's doing it all the time. So I think his mentality is he kind of puts himself in that spot of I'm the guy doing it and I've got to be prepared. I have no issues or worries whether he's ready to go or not."
Chaz Schilens won't be playing in a game any time soon. Cable said that he's still limited to rehabbing his injured knee, but the plan is for Schilens to finally take the practice field either next week or the week after. When asked if the injury was taking longer than anticipated, Cable said, "I think it is."
Cable continued on that thought, "I don't know that it's moved along as quickly as we would have liked, obviously. I know it's improving, but it seems to be rather slow."
Schilens is beginning to fall into a precarious situation. In his third year, he's already missed half of one season and will probably not return until after the Raiders have played half of this season. With Louis Murphy and Darrius Heyward-Bey improving while Schilens has been on the sidelines, he may be relegated to a backup position going forward — that is, when he returns.
Don't be too worried about Raiders receivers not getting many catches, at least according to both Cable and Jackson. While Jackson said he'd really like to see his receivers catch more balls, he reiterated what Cable has been saying about the lack of receptions by receivers.
"I'd like for [Darrius Heyward-Bey] to catch 10 balls a game," said Jackson. "I'd like for he and Louis both to catch 10 balls per game. Again, this is about winning, and sometimes teams don't allow you to do certain things, and sometimes there are things that you can do and you have to take advantage of 'em."
Cable was asked a similar question, but his question was whether or not he thought Heyward-Bey had hit a lull in production the last few weeks. "I got asked that the other day," Cable began. "I don't know if it's really a lull so much or if it's been kind of take what they're giving you. If you look at Zach's production has gone up, the backs' production has gone up. It's like everything in this game it kind of comes around to you. I think those guys are definitely ready when the opportunity comes back to them."
You have to wonder when defenses are going to force the Raiders to utilize their receivers. In the last two weeks, Raiders receivers have accounted for just six receptions, four against Houston and two against San Diego. In comparison, fullback Marcel Reece has three receptions in the same span.
That's not to say that the Raiders' fullback isn't a weapon in his own right. The former college receiver has made the transition to fullback quite well. Cable sees the second-year pro as a full-fledged weapon in his offense.
"Look what he did in the preseason," said Cable of Reece. "He caught a couple of deep balls there and a screen play I think against Chicago. We do think he can do some of those kinds of things. We try to put guys in position where they can make plays for us. He can run.For a fullback, he has exceptional hands. Of course, being a former wide receiver I think that helps him. He understands about running routes and being in space and all that."
Quentin Groves is getting healthier, but expect Trevor Scott to be at linebacker again. That will make room on the line for Matt Shaughnessy, who had a sack, two tackles for loss, and a forced fumble last Sunday. As far as Groves returning? "He's getting healthy. That's the way to look at it," said Cable. "When we get everybody healthy and back again we'll get where we need to be."
Hue Jackson was in the running to be the offensive coordinator of the San Francisco 49ers before coming to the Raiders. Talk about dodging a bullet! Jackson was very respectful when recounting his interview for the position. "Yes it was a position I did seriously consider," said Jackson of the job opening. "It just didn't go right. Obviously they went in a different direction and I was back in Baltimore and wished him well, and I'm here in Oakland."
He went on to explain that he didn't get the opportunity to turn the job down. When asked if it was his call to not take the job, Jackson responded, "No, no. That was their call at that time. And that's OK. I feel like I'm where I'm supposed to be now, here at the Raiders and helping this organization get to where it needs to be."
Injury Report
Full practice:
Jeremy Ware (hamstring)
Limited in practice:
Johnnie Lee Higgins (knee)
Robert Gallery (hamstring) – improved
Daniel Loper (ankle) – improved
Darren McFadden (hamstring)
Quentin Groves (hamstring)
Did not practice:
Chaz Schilens (knee)
Michael Bennett (hamstring) – improved
Bruce Gradkowski (shoulder)
Travis Goethel (back)
Thomas Howard (knee) – making good progress and may be ready to go next week
John Henderson (foot)


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Re: [mythsoc] ROTK movie
Expand Messages
- One of the constant themes in LOTR is the test of the Ring: Boromir failed it
and Faramir passed it. How could the contrast between them not be important
to the story?
Steve Gaddis
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subset: commoncrawl


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Table of Contents
This research service examines the global diesel generator set market. With the rise of investments in infrastructure projects, along with the mismatch in power demand in developing markets, the need for diesel generator sets is increasing. This study discusses the driving and restraining factors that are expected to impact market development market the globe during the forecast period (2014 to 2018). Market trends along with forecasts by revenue, output, end user, and application are provided. Furthermore, the study discusses factors impacting the generator set market at a regional level (North America, Latin America, Europe, Asia-Pacific, and Rest of World) and analyzes the prevailing market competition. The base year is 2013.
Key Questions This Study Will Answer
Is the market growing, how long will it continue to grow, and at what rate?
Are the existing competitors structured correctly to meet customer needs?
Will these companies/products/services continue to exist, or are companies looking to acquire and
widen the market presence?
How will the structure of the market change with time?
Are the generator sets offered today meeting customer needs or is additional development required?
How is the market likely to evolve in the next 5 years?
Get Industry Insights. Simply.
This publication enables readers the critical perspectives to be able to evaluate the world market for electric motors and generators. The publication provides the market size, growth and forecasts at ...
This publication enables readers the critical perspectives to be able to evaluate the world market for DC motors and generators. The publication provides the market size, growth and forecasts at the global ...
Asia Pacific was the largest region in the motor and generator manufacturing market in 2016, accounting for around 45% market share. This can be attributed to high demand for motors and generators from ...
Electric Motor
General Aviatio...
Aircraft Manufa...
United States
Reportlinker.com © Copyright 2017. All rights reserved.


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Great Room
A versatile indoor/outdoor space that can be configured for occasions intimate, celebratory, casual or grand, the Great Room lives up to its name.
The Great Room's demonstration kitchen opens out into the space, offering private or corporate organizers the opportunity to throw superb food-focused events. The space can accommodate groups of 15 to 60 people seated and 80 for cocktail or auditorium-style entertaining. The backdrop is our wine library with its beautifully backlit niches as well as a glass barrel vault wall. Washroom facilities are clean and beautifully appointed.
© 2015 Southbrook Vineyards Inc. All Rights Reserved.


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Words containing drozoline
Found 1 words containing drozoline. Browse our Scrabble Word Finder, Words With Friends cheat dictionary, and WordHub word solver to find words that contain drozoline. Or use our Unscramble word solver to find your best possible play! Related: Words that end in drozoline
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Eamonn Ceannt:1881-1916.
"I shall die, like a man, for Ireland's sake."
-note written by Éamonn Ceannt to his wife, May 7th, 1916 , the day before he was executed by the British .
Éamonn Ceannt was an uileann piper, a member of the IRB Military Council and a signatory of the 1916 Proclamation. He was stationed in the South Dublin Union during the Rising of 1916. As a member of the Provisional Government he was executed by the British Army in Kilmainham Gaol on May 8th 1916.
A Republican Commemoration to honour Éamonn Ceannt will be held in the Crumlin area of Dublin , near to a 42-acre park named after the man, on Sunday August 19th 2007. Those attending are asked to assemble at 'Superquinn' on the Sundrive Road at One PM.
All Welcome!
...an award-nominated Irish blog on Irish history and Irish politics-from today and yesterday:all 32 Counties !
Updated a number of times each week . (Mirror site here)
" A wealth of information..."
"1169 And Counting is a wealth of information on our Republican past and present , and demonstrates how the Irish political landscape , like that of any nation, will never be a black and white issue..."
(From the 'e-Thursday' section of the 'Business Week' supplement of the 'Irish Independent' , 21st August 2008.)
(From the 'e-Thursday' section of the 'Business Week' supplement of the 'Irish Independent' , 21st August 2008.)
Tuesday, August 14, 2007
Posted by 1169.... at 6:36 AM


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Think your Halloween costume is cool? Check out this one! Sandy Kott sent us this picture of her son all ready for Halloween as Guy Wood's Bulldozer. Happy Halloween from AllMonster.com!
Happy Halloween
October 31, 2004 By Leave a Comment
Englishtown Rundown; Joliet Coverage
October 25, 2004 By Leave a Comment
Gary Porter and Grave Digger 12 won the racing, donut, and freestyle competitions at today's monster truck event in Englishtown, New Jersey, while Mike Vaters and Black Stallion took the wheelie contest. Andy Slifko's Eradicator caught on fire after exploding a transmission while performing a donut(see picture above), but both truck and driver were fine. Joliet coverage is also available; enjoy, and thanks for visiting AllMonster.com! (photo courtesy Andrew Palochko)
Anderson On Display!
October 21, 2004 By Leave a Comment
Dennis Anderson will be making a special appearance at Courtesy Ford in North Carolina tomorrow and Saturday. More information is available HERE, and photographer Dustin Hart will have photos and maybe some extras for AllMonster when he returns!
Dungeon Shots
October 18, 2004 By Leave a Comment
Monster Profile: Andy Hoffman
October 16, 2004 By Leave a Comment
Andy Hoffman got started in monster trucks working for Kirk Dabney, eventually starting out with Steve Hess' Nitemare truck on the Thunder Nationals circuit. Hoffman now owns and runs Nitemare through many changes and has a new truck in the works. We thank Andy for his time and support.
Wild Night in Joliet!
October 10, 2004 By Leave a Comment
Route 66 Raceway in Joliet, Illinois played host to some wild action last night. Highlights included Mark Hall winning the racing final against Avenger, John Seasock and Sudden Impact rolling in round one, and Avenger taking a wild ride in freestyle, as illustrated by the photo above! More updates and photos will be available soon!
Road Trip! Oshkosh Available
October 9, 2004 By Leave a Comment
This weekend AllMonster.com is making the trip to Route 66 Raceway in Joliet, Illinois for what matters-the monsters! Trucks scheduled at the raceway include Raminator, Rammunition, Sudden Impact, Eradicator, Equalizer (in place of Airborne Ranger), Avenger, Brutus, and Wild Hair. More information can be found HERE. Look for updates here first! Photos from Oshkosh, Wisconsin are also available in our photo gallery.
Monster Profile: Andy Slifko
October 3, 2004 By 1 Comment
Andy Slifko got started in monster trucks in 1998 with the former Toyzilla chassis, naming his truck "Eradicator." In 1999 Slifko debuted a new Patrick chassis and it runs as the current Eradicator. Slifko was kind enough to do an interview with us recently; we thank him for his generosity and support.
RAMINATOR Wins in Indy, Clinches Points Championship
September 27, 2004 By Leave a Comment
Mark Hall took the Raminator Dodge to victory against Doug Noelke's Big Dawg Sunday afternoon to wrap up the ProMT championship. Unofficial season points standings can be viewed by clicking the link below, and a few teaser photos from the weekend of shows are available in the Photos section. A weekend gallery, coverage, and more will be available soon. Enjoy, and as always, thank you for visiting AllMonster.com!
Opening the Doors…
September 24, 2004 By Leave a Comment
Welcome to AllMonster.com! In the coming weeks, months, and even years, we hope to provide the industry and fans a great place to go online for all things monster trucks. A few sections are up and started for now, but don't be fooled–AllMonster will be moving full force by early next week.
This weekend AllMonster travels to the Indiana State Fairgrounds in Indianapolis, Indiana for some great monster truck action beginning on Friday, September 24. The three-show, three-day event will feature a battle between Bigfoot and Raminator for the Special Events/ProMT points championship. Rammunition, Big Dawg, Sudden Impact, Eradicator, Predator, Summit Truckstyle, Black Stallion, and Nitemare are also scheduled to compete.
When the dust settles in Indy, updates will be here at AllMonster.com-Where Monsters are what Matters!


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Should We Rest on Sundays? Thoughts on a Modern Day Sabbath
For many of us, the concept of resting on Sunday can create an internal struggle. We wonder, "Is it relevant to us today?" We want to obey His word, yet we live in a society that does not value the concept of true rest. We are always accessible whether it be via email, text messaging or cell phones. We can shop at virtually any store any day of the week and in some cases, any hour of the day. Even our vacations are not restful. We never get to be "off duty." Nevertheless, God rested. He didn't need to, but He did. There seems to be no better reason than to set an example for His people. God's ways are always best. Once we align our will with His, we will be blessed because of it. Let's look a little deeper into this concept of resting on Sunday.
You may say, "I just can't rest on Sunday. There are not enough days in the week as it is; I can't give up a whole day." However, if you feel convicted to do so and enter into a "Sabbath rest" with an attitude of appreciation for what God has provided you, you will find that He will provide you with all the time you need to complete all that He would have you do. As in the story of the feeding of the 5,000, God can multiply your time and energy in ways that you couldn't imagine.
If you do adopt this principle of rest, you may find yourself slipping into legalism, creating a list of "off limits" activities on Sunday. Be careful. You do not want to recreate a system that Jesus condemned – a system created by the Pharisees that consisted of following a set of extensive rules but lead to no internal change. Instead of making a list of don'ts, create a list of do's. Make time for family, fellowship and worship. Make time for sitting still and reflecting on your week – think of the ways God revealed Himself to you. Make time to plan for your week ahead. Play a game with your kids. Remember, it doesn't even have to be Sunday. You may have a job that requires that you go to work on Sunday. Simply pick another day to give to God and to give back to yourself. He designed you with this in mind.
Resting doesn't have to be sitting in a chair reading your Bible all day. God has created you to live in communion with others in a beautiful world- so on your day of rest, get out and enjoy both!
Category: Family Time, Featured Articles, Just for Fun
About the AuthorLaura Kuehn, LCSW is a licensed clinical social worker specializing in children and families. CfP is the place she combines some of her very favorite things: writing, parenting and God's word. She loves encouraging parents to build their families upon Jesus, the one true Cornerstone. She is happily married to a wonderfully supportive husband and is the mother of two delightfully inspiring children.
Comments (1)
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Thanks for your perspective. I like to think of the Sabbath as "rest-up"! Get your mind "up" to really celebrate who God is, the greatness of his love and call on our lives to be allowed to serve. Makes Sunday a very "up" day!
Kids can get the big picture of "up". Everyone like a party! Why not celebrate this too?


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Warning: Mailbox Monday can lead to envy, toppling TBR piles, and humongous wish lists!
Mailbox Monday, created by Marcia @ A Girl and Her Books, is on a blog tour!
Abi @
Don't you just LOVE the cover? It looks like secrets are locked away inside this book. :)
I HAD to start reading this book....it is AWESOME!!! I love it already!!


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Get all 19 Dj Magics releases available on Bandcamp and save 35%.
Includes unlimited streaming via the free Bandcamp app, plus high-quality downloads of This is why, Good vibes, Perfect Match, BABY BITCH, Icarus, EDM Fuck you, We are what we are, This is trap shit, and 11 more. , and , .
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text: Les Framboises (The Raspberries) A story of love, pain or just some lost raspberries. One man's search for... more »A story of love, pain or just some lost raspberries. One man's search for those elusive tormenting raspberries Join us at Coastersfilm.com for more Waterford Film Festival Ireland 2007. Giggleshorts Comedy Film Festival Toronto 2007. New Film Maker Series Anthology Film Archives New York 2008 « less CoastersFilm July 16, 2009 31 Views More Info Full Credits CoastersFilm Uploader Additional Credits Written By Gary Warburton.Directed By Sean Grant.Edited By David Costello.Music By Erik Satie.Music Arranged By David Costello. Stats & Data 6Funny0Die 31 Views July 16, 2009 Published Category Sketch Clean Comedy Parody Tags A Story Of Love Join Us Waterford Film Festival Les Framboises Raspberries music forest black and white love funny red drama comedy crazy bowl fruit tree meet coasters Up Next: Les Framboises (The Raspberries) AUTOPLAY Up Next In: 10 Les Framboises (The Raspberries) Black Forest 2 - Broken Heart Love It's Your Drama Dept. join Us! Old People Love Funny Or Die Presents Follow Browse Related Comments Vaguely Related Videos Vaguely Related Pics & Words Advertisement Tags: A Story Of Love Join Us Waterford Film Festival Les Advertisement


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Estimating Position answers the question of "Where am I?," preferable with coordinates that can be communicated or memorized if necessary. All the following methods can be applied in real life (though of course not always giving GPS coordinates since your map may differ).
If the player has a GPS they can open it on the screen using default bindings Ctrl + M, and then read off the coordinates displayed.
If the player has only a Map and is at noticeable location that can be read off of the Map, they can open the Map and zoom in until the three grid coordinates appear on each axis (E.g. 123 by 321). Place the cursor over the player's position and refer to the grid coordinates. If the player does not know their location at all, than they will also need a Compass.
If the player owns a Map and Compass, Triangulation can be used to find out where they are located. Firstly, locate at least two distinguishable landmarks somewhat far apart in the player's field of view (FOV). For example one could use a factory tower, a specific building, a lake or a hill. Look directly at landmark "A" and open the map by pressing M (default key binding). One may notice that the compass displayed on the Map has its needle pointing north and the base pointing in the direction the player was looking at. Now locate landmark A and draw a line parallel to the compass. Do the same for landmark "B". Where the two lines intersect, that is where the player is located.
If no two distinct landmarks are available you're not always out of luck yet. Sometimes for example you can find a road crossing and use that together with Map and Compass. Take note in which direction the roads leave the crossing. Take note of surrounding terrain - are there trees, is there a hill? In which directions? Then look at the map and try finding a crossing that meets all the criteria. More likely than not you're there. Keep this information in mind. Be creative in applying all this!


text: 03:04 Tales of Monkey Island Gameplay Trailer Can be played with mouse only. Please add information if you can. Retrieved from "http://pcgamecontrols.wikia.com/wiki/Tales_of_Monkey_Island?oldid=4698" Ad blocker interference detected! Wikia is a free-to-use site that makes money from advertising. We have a modified experience for viewers using ad blockers Wikia is not accessible if you've made further modifications. Remove the custom ad blocker rule(s) and the page will load as expected. Categories: Mouse only Point & Click List of all games on this Wikia Add category Cancel Save


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- Description
Quick Overview
A dual purpose lotion, it cleanses and moisturizes your face simultaneously. Enriched with the goodness of Aloe Vera & Lemon, this penetrates deep into the skin's pores and effectively cleanses your face; removing dirt & make-up; without stealing its moisture. You are left feeling truly clean and fresh!
Additional Information: Sourcing its products from organic farms in different countries around the globe, Vaadi Herbals is devoted to producing high class products in spa, personal care, massage and aromatherapy range. With carefully selected organic ingredients for high class quality, it is providing quality products at an affordable range.
Explore more from our Herbal Acne Cream collection here
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By Amrita Tripathy
I am using this and I just love this. It smells like lemon. Takes the makeup away. It is a non-oily, non-greasy also.
Posted on 8/16/2017
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Posted on 7/31/2017
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Posted on 7/11/2017
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Posted on 6/8/2017
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Posted on 5/10/2017
By Tanashree Pawar
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Posted on 5/9/2017
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Posted on 4/19/2017
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Posted on 1/16/2017
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Posted on 1/13/2017
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What is JotForm?
JotForm is a free online form builder which helps you create online forms without writing a single line of code. No sign-up required.
At JotForm, we want to make sure that you're getting the online form builder help that you need. Our friendly customer support team is available 24/7.
We believe that if one user has a question, there could be more users who may have the same question. This is why many of our support forum threads are public and available to be searched and viewed. If you'd like help immediately, feel free to search for a similar question, or submit your question or concern.
What is your outgoing mail server?Asked by pauljones9005 on April 25, 2017 at 12:16 PM
Im trying to whitelist jotform and I need to know the outgiong mail server
JotForm Support
Please check this guide:
Whitelisting JotMails IP Addresses
You can also send email from your own SMTP sender:
Let us know if you need further assistance.


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Cisco 870 Series of integrated services routers are fixed-configuration routers that support multiple types of DSL technologies, broadband cable, and Metro Ethernet connections in small offices. They provide the performance needed to run concurrent services, including firewall, intrusion prevention, and encryption for VPNs; optional 802.11b/g for WLAN networking; and quality of service (QoS) features for optimizing voice and video applications. In addition, the Cisco Router and Security Device Manager (SDM) Web-based configuration tool simplifies setup and deployment, and centralized management capabilities give network managers visibility and control of the network configurations at the remote site.
The Cisco 880 Series provides:
- Firewall
- Content filtering
- VPNs, and WLANs, at broadband speeds to small offices
- Easy deployment
- Centralized management features
Available options on the Cisco 881 Integrated Services Router include:
- Survivable Remote Site Telephony for teleworker and small branch voice
- Built-in advanced security, including intrusion prevention, GET VPN, dynamic multipoint VPN (DMVPN) for up to 20 site-to-site VPN tunnels
- Cisco Configuration Professional for simplified management
- WAN connection with multiple access options
- Business continuity with primary and backup connections on the Cisco 880 router, including third-generation wireless and ISDN
Additional Information


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Wellington Quilters' Guild was formed in 1990, and became an Incorporated Society in 1992. It is managed by a Committee of up to 12 members. They are elected annually, and meet monthly to plan the programme of meetings, events, and other activities.
These include a biennial exhibition of members' work, classes with visiting tutors from New Zealand and overseas, and more.
A small archive of Guild publications and photographs is maintained by an off-committee member.
Community Work
Every year our members make quilts to donate to the Women's Refuges in Wellington. Members stitch these quilts at home, and at work days held approximately four times a year.
The completed quilts are given to representatives of the Wellington Women's Refuge and Te Whare Rokiroki Maori Women's Refuge, at our June Guild meeting each year.
Each year, we hand over more than 80 quilts. Around 20 additional smaller quilts are donated to the Wellington City Mission as knee rugs for elderly citizens in need of warmth during the cold winter months.
A group affiliated to the Guild coordinates a programme to teach patchwork and quilting at Arohata Women's Prison, near Wellington. The programme is the longest running one at Arohata, started in October 1993. A team of helpers is drawn from groups in the Wellington area.
The group has received funding from the Alexandra Trust in the past; and receives donations of fabric and supplies from quilters the length and breadth of the country.
For further information about the Community Work we do, please contact us.


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The FAA's Safety Tem has sent out a blast on the 2016 list of airports requiring Cold Weather Compensation. This Safety Tem blast is to be used with the procedure found in the Notices to Airmen, International/Domestic, Part 3, International Section. The new list and a new procedure go into effect 13OCT16.
What Has Not Changed
There is still a list of FAA identified airports that have instrument approaches loosing desired terrain and obstacle clearance in colder than standard temperatures. Pilots without an automatic "Temp Comp" feature in the FMC must use the previously published method of cold weather temperature compensation. This is now called the "Segments Method".
Pilots using the "Segments Method" will need to reference the list of affected airports in the Notices to Airmen, International/Domestic, Part 3, International Section. From this list, pilots identify the critical temp and what specific instrument approach segments require a cold weather correction. Here are some more key point to remember using this method:
1. Only airports with a runway length of 2,500 feet or greater were evaluated
2. A critical temperature is identified that when, "at or below" , temperature compensation MUST be used on the identified approach segments
- 3. A "Snowflake icon" on the approach chart indicates there has been a critical temp and segment for this airport combination.
- 4. A manual calculation using the AIM 7-2-3, ICAO Cold Temperature Error Table is needed to determine the required add-on.
- 5. No extrapolation above the 5000ft column required. Pilots should use the 5000ft "height above airport in feet" column for calculating corrections of greater than 5000ft above reporting station.
- 6. ATC will require the pilot to report what altitude they are flying vice the published altitude.
Temperatures for Cold Temperature Restricted Airports are completely separate from the temperatures published on RNAV approaches. Temp restrictions on RNAV approaches for LP or LNAV/VNAV minima must be followed, even if it is warmer than the temperature associated with the "Snowflake" icon. In other words, "APPROACH NOT AUTHORIZED BELOW XX˚" is a separate calculation when using LNAV/VNAV or LP lines of minima.
Pilots must not correct altitudes published on Standard Instrument Departures, SIDs, Obstacle Departure Procedures, ODPs and Standard Terminal Arrivals, STARs.
ATC will not apply a cold temperature correction to radar vectoring altitudes. Pilots must be cleared by ATC to apply a cold temperature compensation to an ATC assigned altitude or when flying on a radar vector in lieu of a published missed approach procedure.
What Has Changed
FMC's with "Temp Comp" available in your FMC the cold temp compensation procedure is somewhat more simplified. This is described as the "All Segments Method" Here are the items to remember:
- 1. Specifically look for a "Snowflake" icon and a cold weather compensation temperature limit on the approach chart. There is no need to reference the restricted airports list.
- 2. If below the Critical Temperature for Cold Weather Correction, pilots will select "Temp Comp" on the FMC and may correct all altitudes from the IAF altitude to the missed approach final holding altitude
- 3. ATC will require the pilot to report what altitude they are flying vice the published altitude.
When Using Either Cold Temperature Compensation Method
In another twist for this procedure in 2016, when using either the "All Segments" or "Segments" methods, pilots need to calculate the correction at the published MDA or DH/A and then add this to published altitude inside the Final Approach Fix (The FAF is included in the "All Segments" and "Segments" calculation already).
Here's an example:
MDA = 7080ft
TDZE = 6606ft
Difference is (7080 – 6606) = 474ft
Use the table in AIM 7−2−3, find 474ft at −24C and the add-on correction is approximately 80ft. It is permissible to round up. In this case to 100 ft. Now add corrections to the MDA and any stepdown fix altitudes in final segment.
Here's an example:
Published FAF Altitude = Do not Correct
Published Stepdown fix = 8400 + 80 = 8480ft
Published MDA = 7080 + 80 = 7160ft
Pilots still must meet the requirements in 14 CFR Part 91.175 in order to operate below the corrected MDA or DA. Pilots must see and avoid obstacles when descending below the MDA. You are correct if you think this procedure may increase your "Effective" descent minimums.


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|Publication number
|Publication type
|Application number
|Publication date
|Sep 24, 2002
|Filing date
|Oct 6, 2000
|Priority date
|May 15, 2000
|Fee status
|Publication number
|Harold C. Schloss
|Original Assignee
|Pacesetter, Inc.
|Export Citation
|BiBTeX, EndNote, RefMan
|Patent Citations (13), Non-Patent Citations (2), Referenced by (25), Classifications (5), Legal Events (4)
|External Links: USPTO, USPTO Assignment, Espacenet
This application claims the benefit of U.S. Provisional Application No. 60/204,318, filed May 15, 2000.
The present invention is generally directed to an implantable medical device, e.g., a cardiac stimulation device, and is particularly directed to an automatic capture/threshold pacing method for use in such a device.
Implantable cardiac stimulation devices are well known in the art. They include implantable pacemakers which provide stimulation pulses to cause a heart, which would normally beat too slowly or at an irregular rate, to beat at a controlled normal rate. They also include defibrillators, which detect when the atria and/or the ventricles of the heart are in fibrillation or a pathologic rapid organized rhythm and apply cardioverting or defibrillating electrical energy to the heart to restore the heart to a normal rhythm. Implantable cardiac stimulation devices may also include the combined functions of a pacemaker and a defibrillator.
As is well known, implantable cardiac stimulation devices sense cardiac activity for monitoring the cardiac condition of the patient in which the device is implanted. By sensing the cardiac activity of the patient, the device is able to provide cardiac stimulation pulses when they are needed and inhibit the delivery of cardiac stimulation pulses at other times. This inhibition accomplishes two primary functions. Firstly, when the heart is intrinsically stimulated, its hemodynamics are generally improved. Secondly, inhibiting the delivery of a cardiac stimulation pulse reduces the battery current drain on that cycle and extends the life of the battery, which powers and is located within the implantable cardiac stimulation device. Extending the battery life will therefore delay the need to explant and replace the cardiac stimulation device due to an expended battery. Generally, the circuitry used in implantable cardiac stimulation devices have been significantly improved since their introduction such that the major limitation of the battery life is primarily the number and amplitude of the pulses being delivered to a patient's heart. Accordingly, it is preferable to minimize the number of pulses delivered by using this inhibition function and to minimize the amplitude of the pulses where this is clinically appropriate.
It is well known that the amplitude of a pulse that will reliably stimulate a patient's heart i.e., its threshold value will change over time after implantation and will vary with the patient's activity level and other physiological factors. To accommodate for these changes, pacemakers may be programmed manually by a medical practitioner to deliver a pulse at an amplitude well above an observed threshold value. To avoid wasting battery energy, the capability was developed to automatically adjust the pulse amplitude to accommodate for these long and short-term physiological changes. In an existing device, the Affinity® DR, Model 5330 L/R Dual-Chamber Pulse Generator, manufactured by the assignee of the present invention an AutoCapture™ pacing system is provided. The User's Manual, ©1998 St. Jude Medical, which describes this capability is incorporated herein by reference. In this system, the threshold amplitude level is automatically determined for a predetermined duration level in a threshold search routine and capture is maintained by a capture verification routine. Once the threshold search routine has determined a pulse amplitude that will reliably stimulate i.e., capture, the patient's heart, the capture verification routine monitors signals from the patient's heart to identify pulses that do not stimulate the patient's heart (indicating a loss-of-capture). Should a loss-of-capture (LOC) occur the capture verification routine will generate a large amplitude (e.g., 4.5 volt) backup pulse shortly after (typically within 80-100 ms.) the original (primary) stimulation pulse. This capture verification occurs on a pulse-by-pulse basis and thus, the patient's heart will not miss a beat. However while capture verification ensures the patient's safety, the delivery of two stimulation pulses (with the second stimulation pulse typically being much larger in amplitude) is potentially wasteful of a limited resource, the battery capacity. To avoid this condition the existing device, monitors for two consecutive loss-of-capture events and only increases the amplitude of the primary stimulation pulse should two consecutive loss-of-capture (LOC) events occur i.e., according to a loss-of-capture criteria. This procedure is repeated, if necessary, until two consecutive pulses are captured, at which time a threshold search routine will occur. The threshold search routine decreases the primary stimulation pulse amplitude until capture is lost on two consecutive pulses and then, in a similar manner to that previously described, increases the pulse amplitude until two consecutive captures are detected. This is defined as the capture threshold. The primary pulse amplitude is then increased by a safety margin value, e.g., 0.3 volts to ensure a primary stimulation pulse whose amplitude will exceed the threshold value and thus reliably capture the patient's heart without the need for frequent backup pulses. In a copending, commonly-assigned application to Paul A. Levine, entitled "An Implantable Cardiac Stimulation Device Having Autocapture/Autothreshold Capability", improved loss-of-capture criteria are disclosed which are based upon X out of the last Y beats, where Y is greater than 2 and X is less than Y. The Levine application is incorporated herein by reference in its entirety.
In some cases automatically determining the stimulation threshold can be energy inefficient. For example, in the case of micro-dislodgment of a stimulation lead, capture may be lost and may be regained at the same primary stimulation pulse energy level, e.g., at the same amplitude. In such a case, the energy dissipated by the pacing pulses and other processing during the threshold search would have been wasted. In other cases, a highly variable threshold would result in frequent losses of capture, frequent threshold searches, and potentially a higher than necessary primary stimulation pulse level (if the higher than normal threshold was transitory) until the next automatic threshold search.
Therefore what is needed is a flexible system that can determine a threshold energy level for the primary stimulation pulse that accommodates threshold variations while limiting the number of automatic threshold searches and thus conserving battery energy.
The present invention provides an improved system and method for performing automatic capture and threshold detection in an implantable cardiac stimulation device. In existing systems, a threshold stimulation energy level is periodically determined and a working stimulation energy level is then set by increasing the threshold stimulation energy level by a fixed or preprogrammed safety margin, e.g., a fixed voltage level or a percentage safety margin. However, in certain circumstances this safety margin may not be sufficient, resulting in either frequent threshold level determinations or losses-of-capture. To avoid these situations which may be wasteful of battery energy or dangerous for the patient embodiments of the present invention periodically increase and/or decrease the safety margin according to the performance of the stimulation device i.e., based upon the frequency of capture.
A preferred embodiment of an implantable cardiac stimulation device is configured for stimulating a patient's heart through at least one electrode implanted in electrical contact with selected cardiac tissue using a pulse generator configured for electrical coupling to the electrode and configured to generate stimulation pulses at a controlled energy level to thereby stimulate the patient's heart, wherein the controlled energy level is defined by an amplitude component and a duration component. Additionally a detection circuit is configured for electrical coupling to the electrode and configured to receive cardiac signals for determining the presence or absence of an evoked response to each of the stimulation pulses. A preferred device operating under control of a controller, coupled to the pulse generator and the detection circuit, determines the controlled energy level by adding a safety margin value to a threshold controlled energy level at which capture is detected. In embodiments of the present invention, the safety margin value varies according to a safety margin adjustment criteria related to the absence of evoked responses.
In a first aspect of the present invention the safety margin adjustment criteria is specified by the relative number of cardiac cycles that do not have evoked response to those which do have evoked responses. In a first alternative, the number of cardiac cycles without evoked responses can be compared to the total number of cardiac cycles (including cardiac cycles which have intrinsic beats) to determine if the safety margin adjustment criteria has been met. In a next alternative, the number of cardiac cycles without evoked responses can be counted during a specified time period to determine if the safety margin adjustment criteria has been met.
In a next aspect of the present invention, the safety margin value is increased if the safety margin adjustment criteria is met. The increased safety margin value is then incrementally decreased (toward an initial safety margin value) in response to the safety margin adjustment criteria not being met for a specified time period.
The novel features of the invention are set forth with particularity in the appended claims. The invention will be best understood from the following description when read in conjunction with the accompanying drawings.
FIG. 1 shows a simplified functional block diagram of an implantable cardioverter/defibrillator (ICD), which represents one type of implantable cardiac stimulation device with which the present invention may be used.
FIG. 2 shows a functional block diagram of an implantable dual-chamber pacemaker, which represents another type of implantable medical device with which the invention may be used.
FIG. 3 is a simplified top level flow diagram of the automatic capture/threshold method of the present invention.
FIGS. 4A and 4B are flow charts of an exemplary capture verification routine as used in FIG. 3 for dynamically adjusting the safety margin in response to the loss-of-capture performance of the implantable device.
The following description is of the best mode presently contemplated for carrying out the invention. This description is not to be taken in a limiting sense but is made merely for the purpose of describing the general principles of the invention. The scope of the invention should be determined with reference to the claims.
The present invention provides an improved system and method for performing automatic capture and threshold detection in an implantable cardiac stimulation device, e.g., a pacemaker or an implantable cardioverter/defibrillator (ICD).
To better understand the invention, it will first be helpful to have an understanding of the basic functions performed by exemplary implantable stimulation devices with which the invention may be used, e.g., an ICD with dual chamber coils (see FIG. 1) and/or a dual-chamber pacemaker (see FIG. 2). While a dual-chamber device has been chosen for this description this is for teaching purposes only. It is recognized that the present invention could be implemented into a device having one to four chambers, that one of skill in the art could readily adapt the dual-chamber device shown in FIG. 2 to perform single or multiple-chamber functionality, and that a single or multiple chamber device is within the spirit of the invention as is any device capable of delivering stimulating impulses to a tissue or organ of the body.
In FIG. 1 there is shown a simplified functional block diagram of an ICD device 20, and in FIG. 2, there is shown a simplified functional block diagram of a dual-chamber pacemaker 70. It should also be noted that in some instances the functions of an ICD and a pacemaker may be combined within the same cardiac stimulation device. However, for teaching purposes, the devices will be described separately.
It is the primary function of an ICD device to sense the occurrence of a tachyarrhythmia and to automatically apply an appropriate electrical shock therapy to the heart aimed at terminating the tachyarrhythmia. To this end, the ICD device 20, as shown in the functional block diagram of FIG. 1, includes a control and timing circuit (hereinafter referred to as a control/timing circuit) 22, such as a microprocessor, state-machine or other such control circuitry, that controls a high output charge generator 26. The high output charge generator 26 generates electrical stimulation pulses of moderate or high energy (corresponding to cardioversion or defibrillation pulses, respectively), e.g., electrical pulses having energies of from 1 to 10 joules (moderate) or 11 to 40 joules (high), as controlled by the control/timing circuit 22.
Such moderate or high energy pulses are applied to the patient's heart 28 through at least one lead 30 having at least two defibrillation electrodes, such as coil electrodes 38 in the atrium and 40 in the superior vena cava. The lead 30 preferably also includes at least one electrode for pacing and sensing functions, such as electrode 32. Typically, the lead 30 is transvenously inserted into the heart 28 so as to place the coil electrodes 38 and 40 where they are in electrical and preferably physical contact with the patient's heart 28. While only one lead is shown in FIG. 1, it is to be understood that additional defibrillation leads and electrodes may be used to apply the shock treatment generated by the high voltage generator 26 to the patient's heart 28.
The ICD 20 also includes a sense amplifier 42 that is coupled to at least one sensing electrode 32. It is the function of the sense amplifier 42 to sense the electrical activity of the heart 28, as is known in the art, such as R-waves which are the electrical representation of ventricular depolarizations which result in the contraction of ventricular tissue, and P-waves which are the electrical representation of atrial depolarizations which result in the contraction of atrial tissue. Thus, by sensing the ventricular and/or atrial depolarizations through the sense amplifier 42, the control/timing circuit 22 is able to make a determination as to the rate and regularity of the patient's heart beat. Such information, in turn allows the control/timing circuit 22 to determine whether the patient's heart 28 is experiencing an arrhythmia, and to apply appropriate stimulation therapy. Alternatively, a pacing pulse generator 43 can be used to pace the heart in accordance with a preselected pacing strategy. To accomplish this task, the amplitude of pacing pulses generated by the pulse generator 43 is set by the physician to a value above the threshold level for the patient's heart to ensure capture i.e., successful stimulation of the patient's heart. Preferably, the control/timing circuit 22 is configured that in the absence of sensed events detected by the sense amplifier 42, the pacing pulse generator 43 is triggered to deliver pacing pulses at an appropriate rate.
The control/timing circuit 22 further has a memory circuit 44 coupled thereto wherein the operating parameters used by the control/timing circuit 22 are stored. Such operating parameters define, for example, the amplitude of each shocking pulse to be delivered to the patient's heart 28 as well as the duration of these shock pulses. The memory 44 may take many forms, and may be subdivided into as many different memory blocks or sections (addresses) as needed to store desired data and control information. A feature of an exemplary ICD 20 is the ability to sense and store a relatively large amount of data as a data record which data record may then be used to guide the operation of the device i.e., the present operating mode of the device may be dependent, at least in part, on past performance data.
Advantageously the operating parameters of the implantable device 20 may be non-invasively programmed into the memory 44 through a telemetry circuit 46, in telecommunicative contact with an external programmer 48 by way of a suitable coupling coil 50. The coupling coil 50 may serve as an antenna for establishing a radio frequency (RF) communication link 52 with the external programmer 48, or the coil 50 may serve as a means for inductively coupling data between the telemetry circuit 46 and the external programmer 48, as is known in the art. See, e.g., U.S. Pat. Nos. 4,809,697 (Causey, III et al.) and U.S. Pat. No. 4,944,299 (Silvian) incorporated herein by reference. Further, such telemetry circuit 46 advantageously allows status information relating to the operation of the ICD 20, as contained in the control/timing circuit 22 or memory 44, to be sent to the external programmer 48 through the established link 52.
The control/timing circuit 22 includes appropriate processing and logic circuits for analyzing the output of the sense amplifier 42 and determining if such signals indicate the presence of an arrhythmia. Typically the control/timing circuit 22 is based on a microprocessor or similar processing circuit which includes the ability to process or monitor input signals (data) in a prescribed manner, e.g., as controlled by program code stored in a designated area or block of the memory 44. The details of the design and operation of the control/timing circuit 22 are not critical to the present invention. Rather any suitable control/timing circuit 22 may be used that performs the functions described herein. The use design, and operation of microprocessor-based control circuits to perform timing and data analysis functions is known in the art.
The ICD 20 additionally includes a battery 62 which provides operating power to all of the circuits of the ICD 20.
In FIG. 2, a simplified block diagram of the circuitry needed for a dual-chamber pacemaker 70 is illustrated. The pacemaker 70 is coupled to heart 28 by way of leads 74 and 76, the lead 74 having an electrode 75 that is in electrical and preferably physical contact with one of the atria of the heart 28, and the lead 76 having an electrode 77 that is in electrical and preferably physical contact with one of the ventricles of the heart 28. The leads 74 and 76 are electrically and physically connected to the pacemaker 70 through a connector 73 that forms an integral part of the housing wherein the circuits of the pacemaker are housed. Typically, leads 74 and 76 are operated in a bipolar mode where a signal is generated by measuring the voltage difference between the voltage present at a "tip" portion and the "ring" portion on the same lead. Alternatively, leads 74 and 76 can operate in a unipolar mode where the voltage is measured from the "tip" portion of each lead to a conductive case 116 which surrounds the pacemaker 70.
The connector 73 is electrically connected to a protection network 79, which network 79 electrically protects the circuits within the pacemaker 70 from excessive shocks or voltages that could appear on the electrodes 75 and/or 77 in the event such electrodes were to come in contact with a high voltage signal, e.g., from a defibrillation shock.
The leads 74 and 76 carry stimulation pulses to the electrodes 75 and 77 from an atrial pulse generator (A-PG) 78 and a ventricular pulse generator (V-PG) 80, respectively. Further, electrical signals from an atrium are carried from the electrode 75, through the lead 74, to the input terminal of an atrial channel sense amplifier (A-AMP) 82; and electrical signals from a ventricle are carried from the electrode 77 through the lead 76, to the input terminal of a ventricular channel sense amplifier (V-AMP) 84. Similarly, electrical signals from both the atrium and the ventricle are applied to the inputs of an intracardiac electrogram amplifier (IEGM) 85. The amplifier 85 is typically configured to detect an evoked response from the heart 28, i.e., a response to an applied stimulation pulse, thereby aiding in the detection of "capture". Capture occurs when an electrical stimulus applied to the heart is of sufficient energy to depolarize the cardiac tissue, thereby causing the heart muscle to contract, or in other words, causing the heart to beat. Capture does not occur when an electrical stimulus applied to the heart is of insufficient energy to depolarize the cardiac tissue. Following each stimulation pulse which causes capture, the associated cardiac tissue (i.e., the atrium or the ventricle) enters into a physiologic refractory period during which it cannot be re-stimulated.
The dual-chamber pacemaker 70 is controlled by a control and timing circuit (hereinafter referred to as a control/timing circuit) 86 that typically includes a microprocessor programmed to carry out control and timing functions. The control/timing circuit 86 receives the sensed signals from the atrial (A-AMP) amplifier 82 over signal line 88. Similarly, the control/timing circuit 86 receives the output signals from the ventricular (V-AMP) amplifier 84 over signal line 90, and the output signals from the IEGM amplifier 85 over signal line 91. These output signals are used to detect intrinsic events, such as R-waves or P-waves. These output signals may also be used to measure the response following a pacing pulse. The control/timing circuit 86 uses these signals to determine if the pacing pulse was captured. Also, the control/timing circuit may be used to measure the polarization artifact present on the electrodes 75 and/or 77 when calibrating the evoked response detection system by pacing when the heart is known to be in a refractory state. The control/timing circuit 86 also generates trigger signals that are sent to the atrial pulse generator (A-PG) 78 and the ventricular pulse generator (V-PG) 80 over signal lines 92 and 94, respectively, to control the energy level (comprised of amplitude and duration components) of the signals delivered to the electrodes, 75 and 77. These trigger signals are generated each time that a stimulation pulse is to be generated by the respective pulse generator 78 or 80. The atrial trigger signal is referred to simply as the "A-trigger",and the ventricular trigger signal is referred to as the "V-trigger".
During the time that either an A-pulse or V-pulse is being delivered to the heart, the corresponding sense amplifier, A-AMP 82 and/or V-AMP 84, is typically disabled by way of a blanking signal presented to these amplifiers from the control/timing circuit 86 over signal lines 96 and 98 respectively. This blanking action prevents the amplifiers 82 and 84 from becoming saturated from the relatively large stimulation pulses that are present at their input terminals during this time. This blanking action also helps prevent residual electrical signals present in the muscle tissue as a result of the pacemaker stimulation from being interpreted as P-waves or R-waves.
As shown in FIG. 2, the pacemaker 70 further includes a memory circuit 100 that is coupled to the control/timing circuit 86 over a suitable data/address bus 102. This memory circuit 100 allows certain control parameters, used by the control/timing circuit 86 in adjusting or programming the operation of the pacemaker 70, to be stored and modified as required, in order to customize the pacemaker's operation to suit the needs of a particular patient. Further, data regarding the operation of the pacemaker 70 (sensed or paced events and activation of any special algorithms or results of interventions) may be stored in the memory 100 for later retrieval and analysis.
As with the memory 44 of the ICD device 20 shown in FIG. 1, the memory 100 of the pacemaker 70 (FIG. 2) may take many forms and may be subdivided into as many different memory blocks or sections (addresses) as needed in order to allow desired data and control information to be stored. A feature of an exemplary cardiac stimulation device is the ability to store a relatively large amount of sensed data as a data record, which data record may then be used to guide the operation of the device. That is, the operating mode of the pacemaker may be dependent, at least in part, on past performance data. For example an average atrial rate may be determined based on the sensed atrial rate over a prescribed period of time. This average rate may then be stored and updated at regular intervals. Such stored rate may then be compared to a present atrial rate and, depending upon the difference, used to control the operating mode of the pacemaker. Other parameters, of course in addition to (or in lieu on atrial rate, may be similarly sensed, stored averaged (or otherwise processed), and then used for comparison purposes against one or more currently-sensed parameters. Advantageously, modern memory devices allow for the storage of large amounts of data in this manner.
A clock circuit 103 directs an appropriate clock signal(s) to the control/timing circuit 86, as well as to any other needed circuits throughout the pacemaker 70 (e.g., to the memory 100) by way of clock bus 105.
A telemetry/communications circuit 104 is further included in the pacemaker 70. This telemetry circuit 104 is connected to the control/timing circuit 86 by way of a suitable command/data bus 106. In turn, the telemetry circuit 104, which is included within the implantable pacemaker 70, may be selectively coupled to an external programmer 108 by means of an appropriate communication link 110. The communication link 110 may be any suitable electromagnetic link such as an RF (radio frequency) channel, a magnetic link an, inductive link, an optical link, and the like. Advantageously, desired commands may be sent to the control/timing circuit 86 through the external programmer 108 and the communication link 110. Similarly, through this communication link 110 with the programmer 108, data commands (either held within the control/timing circuit 86, as in a data latch, or stored within the memory 100) may be remotely received from the programmer 108. Similarly, data initially sensed through the leads 74 or 76, and processed by the microprocessor control circuits 86, or other data measured within or by the pacemaker 70, may be stored and uploaded to the programmer 108. In this manner, non-invasive communications can be established with the implanted pacemaker 70 from a remote, non-implanted, location.
The pacemaker 70 additionally includes a battery 93 which provides operating power to all of the circuits of the pacemaker 70 via a power signal line 95.
It is noted that the pacemaker 70 in FIG. 2 is referred to as a dual-chamber pacemaker because it interfaces with both an atrium and a ventricle of the heart 28. Those portions of the pacemaker 70 that interface with the atrium, e.g., the lead 74, the P-wave sense amplifier 82 the atrial pulse generator 78, and corresponding portions of the control/timing circuit 86, are commonly referred to as the "atrial channel". Similarly, those portions of the pacemaker 70 that interface with the ventricle, e.g., the lead 76, the R-wave sense amplifier 84, the ventricular pulse generator 80 and corresponding portions of the control/timing circuit 86, are commonly referred to as the "ventricular channel". While a dual chamber pacemaker includes a single atrial channel and a single ventricular channel, multichamber devices may include more than one atrial channel and/or more than one ventricular channel.
As needed for certain applications, the pacemaker 70 may further include at least one sensor 112 that is connected to the control/timing circuit 86 of the pacemaker 70 over a suitable connection line 114. While this sensor 112 is illustrated in FIG. 2 as being included within the pacemaker 70, it is to be understood that the sensor may also be external to the pacemaker 70, yet still be implanted within or carried by the patient. A common type of sensor is an activity sensor, such as a piezoelectric crystal, that is mounted to the case of the pacemaker. Other types of sensors are also known, such as sensors that sense the oxygen content of blood, respiration rate, pH of blood body motion, and the like. The type of sensor used is not critical to the present invention. Any sensor or combination of sensors capable of sensing a physiological or physical parameter relatable to the rate at which the heart should be beating (i.e., relatable to the metabolic need of the patient), and/or relatable to whether a tachyarrhythmia is likely to soon occur, can be used. Such sensors are commonly used with "rate-responsive" or "rate-modulated" pacemakers in order to adjust the rate (pacing cycle) of the pacemaker in a manner that tracks the physiological or metabolic needs of the patient.
The pacemaker 70 further includes magnet detection circuitry 87, coupled to the control/timing circuit 86 over signal line 89. It is the purpose of the magnet detection circuitry 87 to detect when a magnet is placed over the pacemaker 70. The magnet may be used by a physician or other medical personnel to perform various reset functions of the pacemaker 70 and/or to signal the control/timing circuit 86 that an external programmer 108 is in place to receive data from, or send data to, the pacemaker memory 100 or control/timing circuit 86 through the telemetry communications circuit 104.
As with the ICD device 20 of FIG. 1, the telemetry or communications circuit 104 may be of conventional design, such as is described in U.S. Pat. No. 4,944,299, or as is otherwise known in the art. Similarly, the external programmer 108 may be of any suitable design known in the art, such as is described in U.S. Pat. No. 4,809,697. Likewise, the memory circuit 100, and the circuits utilized in the atrial and ventricular channels may all be of common design as is known in the pacing art. The present invention is not concerned with the details of the circuitry utilized for each of these pacing elements. Rather, it is concerned with the manner in which the energy level, e.g., amplitude, of the pacing pulses delivered to the heart is determined in coordination with automatic capture and threshold modes of operation. Such determination is controlled by the control/timing circuit 86.
The control/timing circuit 86 may be realized using a variety of different techniques and/or circuits. The preferred type of control/timing circuit 86 is a microprocessor-based control/timing circuit. It is noted, however, that the control/timing circuit 86 could also be realized using a state machine. Indeed, any type of control/timing circuit or system could be employed for the control/timing circuit 86. The present invention is likewise not concerned with the details of the control/timing circuits 22 and 86. Rather, it is concerned with the end result achieved by the control/timing circuit. That is, so long as the control/timing circuit 86 controls the operation of the pacemaker (or other medical device) so that the desired functions are achieved as set forth herein, it matters little what type of control/timing circuit is used. Those of skill in the implantable medical device art, given the teachings presented herein, should thus be able to fashion numerous different types of control/timing circuits that achieve the desired device control.
Representative of the types of control/timing circuits that may be used with the invention is the microprocessor-based control/timing circuit described in U.S. Pat. No. 4,940,052, entitled "Microprocessor Controlled Rate-Responsive Pacemaker Having Automatic Rate Response Threshold Adjustment." Reference is also made to U.S. Pat. Nos. 4,712,555 and 4,944,298, wherein a state-machine type of operation for a pacemaker is described; and U.S. Pat. No. 4,788,980, wherein the various timing intervals used within the pacemaker and their inter-relationship are more thoroughly described. The '052, '555, '298 and '980 patents are incorporated herein by reference.
FIG. 3 is a simplified top level flow diagram of the automatic capture/threshold method of the present invention. To simplify the discussion this method is described in reference to the dual-chamber pacemaker 70 of FIG. 2. In this case the automatic capture/threshold routines preferably monitor and adjust the amplitude of a ventricular pacing pulse in response to whether an evoked response is sensed. However, one of ordinary skill in the art would recognize the applicability of this method to other such implantable stimulation devices, e.g., the atrial channel of a dual chamber pacemaker, the ICD 20 of FIG. 1, or a muscle stimulation device. Initially all of the pacing parameters required by the pacemaker to operate in a desired program mode are set in block 120 from values in memory 100 or by way of the external programmer 108. In addition to conventional pacing parameters, parameters related to practicing the present invention are preferably preprogrammed and include a definition of: the size of the increase or decrease of the primary stimulation pulse (i.e., the ventricular pacing pulse delivered from the ventricular pulse generator 80) used by the automatic capture/threshold routines; a default amplitude and/or duration for the primary stimulation pulse; how often the periodic automatic threshold search routine is to be invoked (e.g., once a day, every 90 minutes, etc.); and a default working or safety margin. The default safety margin defines how much above the determined capture threshold (i.e., the minimum stimulation energy to cause a ventricular contraction) the ventricular pulse amplitude is to be initially set to provide maintenance of capture during the normal course of events, i.e., the ventricular pulse amplitude is initially set to the determined capture threshold plus a safety margin. In a preferred device these parameters include decreased AV (e.g., 50 ms.) and PV (e.g., 25 ms.) delays to be used during the automatic threshold routine to cause the ventricular stimulation pulse to be issued prior to a potential intrinsic conducted R-wave. This decreased delay allows the heart to respond to stimulation pulses since the stimulation pulses will precede any conducted intrinsic beats after which ventricular tissue would be refractory and additionally, it helps to avoid fusion beats. While these preprogrammed parameters are relevant to the present invention, they are also relevant to the general operation of the pacemaker 70 and thus are set using routine methods, well known to those of skill in the art.
Assuming that all of the pacing parameters were set in block 120, a first determination is made in block 122 as to whether automatic capture/threshold is enabled. If the automatic capture/threshold routine has not been enabled (the NO branch of block 122), the pacemaker 70 resumes cardiac pacing in the desired programmed mode in block 124.
If automatic capture/threshold has been enabled (the YES branch of block 122), the sensitivity of the ventricular 84 amplifier is adjusted in an evoked response calibration routine in block 126 (a similar adjustment can be made of the atrial sense amplifier 82 in the case of automatic capture in the atrium). As is known in the art, the evoked response calibration routine adjusts the evoked response detection sensitivity after measuring the polarization caused by a pacing pulse delivered during the natural refractory period of the heart and the evoked response signal amplitude of a pacing pulse known to capture.
After the automatic capture/threshold routine has been enabled in block 128, a determination is made in block 130 as to whether it is time to initiate a periodic running of the threshold search routine. Typically, the threshold search routine 144 will start automatically at a specified rate which can be preset in the device or a programmable parameter, e.g., once a day every 90 minutes, etc. Also the threshold search routine 144 may be initiated following the completion of the loss-of-capture recovery routine 142.
If it is time to start the threshold search routine 144 (the YES branch of block 130), then a first step is to verify in block 136 that proper conditions exist to accurately perform the threshold search routine (the YES branch of block 136). In general, such conditions require that the pacemaker 70 be engaged in ventricular pacing (generating V-pulses from the ventricular pulse generator 80) at a rate that is below the maximum tracking rate. If the ventricular pulse generator 80 is at the maximum tracking rate, then the proper conditions for executing the threshold search routine 144 do not exist (the NO branch of block 136). As such, the threshold search routine 144 is delayed for a prescribed amount of time in block 137, during which delay the pacemaker 70 continues to operate in its present programmed mode and at its present output level before continuing at block 138. Otherwise the threshold search routine 144 will be processed (following blocks 182 and 196 as discussed below).
If it is not time to commence the threshold search routine 144 (the NO branch of block 130), the pacemaker 70 proceeds to execute the capture verification routine 138 in conjunction with the present pacing mode.
When initiated, the capture verification routine 138 is a continuously running program that performs a loss-of-capture criteria test for each stimulation pulse generated during the programmed pacing sequence. Essentially, the capture verification routine 138 determines for each cardiac cycle whether there was an evoked response corresponding to each stimulation pulse. FIGS. 4A and 4B show a more detailed explanation of an exemplary ventricular capture verification routine 138. Initially, in block 150, the control/timing circuit 86 waits a period of time as determined by the present PV or AV delays. In block 152, the control/timing circuit 86 notes if the ventricular channel sense amplifier 84 has sensed a signal. If a signal was sensed, an intrinsic event (I) is counted in block 154. If a signal was not sensed in block 152 by the end of the PV or AV delay, a ventricular stimulation pulse is issued in block 156 by the ventricular pulse generator 80 at the present stimulation pulse amplitude. Optionally, in block 158 a stimulation pulse count can be incremented. However, since each stimulation pulse will either result in capture (C) or non-capture (i.e., the absence of capture) and a backup pulse. (B), the number of stimulation pulses can be calculated as B+C. In block 160, a capture detection window starts. In an exemplary embodiment, the capture detection window is 60 ms. which is comprised of a 14 ms. absolute refractory period during which time the sense amplifier 84 is blanked from looking for evoked responses, followed by a 46 ms. alert period during which the evoked response is detectable. It is determined in block 162 if, by the end of the capture window, an evoked response was sensed by the ventricular channel sense amplifier 84. If there was an evoked response detected in block 162 during the capture detection window (specifically, anytime during the alert period), a capture count (C) is incremented in block 164. Otherwise, if there was no evoked response detected by the end of the capture detection window, a high amplitude (e.g., 4.5 volt) backup pulse is issued in block 166 and a backup pulse (non-capture) count (B) is increased in block 168. Finally, in block 170, the capture counts are evaluated to determine whether a loss-of-capture criteria has been met. Such criteria may include consecutive losses-of-capture, X losses-of-capture out of the last Y cardiac cycles, etc. If the loss-of-capture criteria is met (block 140 in FIG. 3), a loss-of-capture recovery routine is initiated in block 142 to rapidly increase the stimulation energy level e.g., the pulse amplitude, by increasing the stimulation energy by relatively large (coarse) increments to regain capture at a stimulation energy level that will not require backup pulses. A threshold search routine 144 is then initiated to more precisely (i.e., according to a relatively small (fine) increments) determine the threshold stimulation energy level, e.g., the stimulation pulse amplitude. Once, this threshold stimulation energy level (i.e., the determined capture threshold) is determined, a predetermined safety or working margin value (e.g., an amplitude and/or pulse duration value) is added to the threshold stimulation energy level to determine an initial stimulation energy level. Alternatively, the safety margin value may be a predetermined percentage of the threshold stimulation energy level.
However in embodiments of the present invention the safety margin is variable, adjusting to past performance of the stimulation device. Accordingly, in response to the absence of an evoked response to a stimulation pulse, e.g., see path 172 a loss-of-capture (LOC) performance value, e.g., a percentage is determined in block 174 (see FIG. 4A). Alternatively, this performance value may be evaluated when a loss-of-capture criteria has been met in block 140 (see path 176 in FIG. 3) or in response to each cardiac cycle (see path 177 in FIG. 4A). This performance value may be determined by various methods including comparing: the non-captured cycles (B) to the captured cycles (C), the non-captured cycles (B) to the total paced counts (B+C), the non-captured cycles (B) to the total number of cardiac cycles (B+C+I), etc. Alternatively, a comparison can be made between the number of non-captured cycles (B) and a specified period of time to determine a loss-of-capture rate as a performance value. Subsequently, in block 178, it is determined if the LOC performance value exceeds a specified threshold value i.e., whether a safety margin adjustment criteria has been met. This safety margin adjustment criteria may be preprogrammed or may be programmable from the external programmer 108. For example, a threshold value could be 8 out of the last 100 paced events (i.e., B/(B+C)>0.08) or 8 losses-of-capture in the last 8 minutes. If the LOC performance value exceeds the threshold value (the YES path), the present safety margin value (initially set to a default value) is increased by an increment Δs1 in block 180. Otherwise, the process completes (the NO path). For example, with an amplitude only safety margin value of 0.3 volts, a Δs1 value of 0.05 volts could be used and the present safety margin would thus increase to 0.35 volts. Accordingly, in a first variation, the increased safety margin is immediately applied to the present stimulation pulse energy level and thus may avoid the necessity of performing a threshold search. Preferably, the accumulated capture/non-capture data is also reset to enable additional increases in the safety margin if the safety margin adjustment criteria is again met. In a second variation, the increased safety margin value is added to the capture threshold determined the next time that the threshold search 144 occurs (either scheduled or resulting from the loss-of-capture criteria being met).
Preferably, the increased safety margin value (which may represent a transitory physiological condition) is reset (see block 182 in FIG. 3) as part of a periodic invocation of the threshold search routine 144. In another preferred embodiment, the increased safety margin value is decreased back towards its default value if the safety margin adjustment criteria is not met for a specified period of time. Accordingly in an exemplary implementation, a safety margin clock (see SM clock in FIG.2) 183 is set to a terminal count value Tc in block 184. The safety margin clock 183 is then enabled and permitted to count down. When the safety margin clock 183 reaches a value of 0 (e.g., resulting in an interrupt to the control/timing circuit 86) path 186 (the YES path) from block 188 is processed. Otherwise, the process completes (the NO path). It is then determined in block 190 whether the present safety margin value exceeds its default value. If it does not the process completes (the NO path). If the present safety margin does exceed its default value (the YES path), the safety margin value is decreased in block 192, e.g., by Δs2, toward the default safety margin value. While the decrement value Δs2 may be the same as the increment value Δs1, it may also be different. In such a case, block 192 must not allow the safety margin value to decrease below the safety margin default value. If the decrement value Δs2 would cause the present safety margin value to decrease below its default value, the safety margin value is set to its default value. The safety margin clock 183 is then reset to its terminal count value Tc in block 194 to enable the present safety margin value to decrease again (if necessary) toward its default value at the end of the next time period. Altematively, if the present safety margin value is already at its default value, step 194 may be skipped and the safety margin clock 182 and associated interrupt may be disabled. Accordingly, the safety margin will dynamically adjust upwards and downwards according to the present loss-of-capture performance of the system.
Preferably, embodiments of the present invention may additionally accumulate statistical data during the aforementioned process. For example, block 196 may log the time of a scheduled threshold search, block 198 may log a threshold search initiated in response to meeting the loss-of-capture criteria, block 200 may log an increase in the safety margin value, block 202 may log a decrease in the safety margin value, and block 204 may log the results of a threshold search. The logged data may be stored in memory 100 as separate events that are preferably time-stamped. Such logged data may be downloaded to the external programmer 108 for display and/or analysis. In another preferred embodiment, the data may be stored in bins in memory 100 that correspond to time periods, safety margin values, threshold values, or any other suitable parameter. This bin data is suitable for display at an external device as a histogram. Thus, at the external programmer 108, the logged data may be displayed either as a historical log or may be formatted (e.g., by the external programmer 108 or the pacemaker 70) for display as a histogram.
Accordingly, what has been shown is an improved automatic capture/threshold procedure for use in an implantable cardiac stimulation device where the safety margin value adaptively varies in response to the loss-of-capture performance of the device. While the invention has been described by means of specific embodiments and applications thereo,f it is understood that numerous modifications and variations could be made thereto by those skilled in the art without departing from the spirit and scope of the invention. For example, while the description of the safety margin has primarily described adding a value to the amplitude of a threshold stimulation pulse, safety margins that increase the duration of the stimulation pulse is also considered to be within the scope of the present invention. Additionally, embodiments where the safety margin is achieved by increasing the amplitude and duration of the stimulation pulse are also considered to be within the scope of the present invention. Such a safety margin has been described in a copending, commonly-assigned U.S. Provisional Application No. 60/204,317, entitled "Method and Device For Optimally Altering Stimulation Energy to Maintain Capture of Cardiac Tissue" (to Mandell), the teachings of which are incorporated herein by reference in their entirety. It is therefore to be understood that within the scope of the claims, the invention may be practiced otherwise than as specifically described herein.
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Owner name: PACESETTER, INC., CALIFORNIA
Free format text: ASSIGNMENT OF ASSIGNORS INTEREST;ASSIGNOR:SCHLOSS, HAROLD C.;REEL/FRAME:011291/0977
Effective date: 20000922
|Mar 24, 2006
|Fee payment
Year of fee payment: 4
|Mar 24, 2010
|Fee payment
Year of fee payment: 8
|Mar 24, 2014
|Fee payment
Year of fee payment: 12


text:
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