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With E3 2016 right around the corner, rumors are swirling about surprise games that will be revealed at the show. Evidence has been stacking up that one game in particular, Red Dead Redemption 2, will have its proper unveiling at E3 in June.
While these Red Dead Redemption 2 rumors should be taken with a grain of salt for now, let's just assume that there is some validity behind them for the moment. If true, Red Dead Redemption 2 will be a prequel to the first Red Dead Redemption game, and it will carry with it the subtitle Legends of the West. Considering this, I think there would be no better protagonist for the game than Landon Ricketts.
Landon Ricketts was introduced to players in the first Red Dead Redemption as a legendary outlaw from the Old American West. Ricketts and his gunslinger exploits made him an iconic figure, and protagonist John Marston shows deep respect for him in the game. However, Ricketts only appears in a handful of missions in Red Dead Redemption, and so I think it would be interesting to see his character fleshed out if RDR2 is in fact a prequel as rumored.
Red Dead Redemption 2 could have players live through some of the most famous exploits of Ricketts that are described in the first Red Dead Redemption. For example, players could see what really happened during the famous battle between Ricketts and the Butcher Brothers, and the Blackwater Massacre could also be shown in great detail.
Speaking of the Blackwater Massacre, if the Red Dead Redemption 2 leaked map has any legitimacy, I think there actually is a distinct possibility of Landon Ricketts having his turn in the spotlight. After all, Blackwater is featured on the map, and the massacre that took place there would be a great way to cap off the story of Landon Ricketts – it is the event that convinced him to leave the life of a gunslinger behind in the first place, as some may recall.
Beyond those specific events in his life, little else is known about Landon Ricketts, except that he had a wife who died before the events of Red Dead Redemption. Perhaps Red Dead Redemption 2 could show gamers the developing romance between Ricketts and his wife, and reveal how she met her untimely end. Such a story could provide plenty of material for Red Dead Redemption 2 to reach the same emotional heights as its predecessor.
Anyone aware of Red Dead Redemption's shocking twist knows just how emotional a game in the series can be. I think that if Rockstar did decide to tell the story of Landon Ricketts, the best way to do it would be to allow players to watch him evolve over a long period of time. His character can begin as a novice gunslinger, and then we can explore the height of his glory days in the Old West. From there, we can perhaps see his interactions with John Marston from his perspective, and then learn what ultimately happened to Ricketts after the events of that game – and no, what we saw in the Undead Nightmare expansion doesn't count, as that can hardly be considered canon.
I think I've made it clear at this point that I am very enthusiastic about the idea of Landon being the star of Red Dead Redemption 2, but I am sure that most people would rather the game star a younger John Marston. That seems too obvious, and I don't think that would make for the most interesting story, necessarily. Marston has already had his character explored rather thoroughly, but there's a lot about Ricketts that's still very much a mystery. Having said that, there may be a chance that fans can have their cake and eat it, too, as rumors point to Red Dead Redemption 2 having multiple playable characters.
Grand Theft Auto V's multiple playable characters seems to be the obvious inspiration for this feature, if it does turn out to be in the game. While there is no overlap between John Marston's adventures and those of Landon Ricketts, perhaps a very young John Marston can be controlled at some point in the game. This would allow players to experience multiple ongoing storylines that don't necessarily involve other playable characters, which is an element that helped Grand Theft Auto V earn as much acclaim as it did when it released a few years back.
Whatever direction Rockstar decides to go in, I'm sure it will be the right one. After all, the studio has released one critically acclaimed masterpiece after another for over a decade now, and so there's no reason to doubt the studio at this point. Even so, I can't say I won't be disappointed if Red Dead Redemption 2 doesn't fulfill my wish of seeing the story of legendary outlaw Landon Ricketts.
Red Dead Redemption 2 is rumored to be in development for unspecified consoles.


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Jittery financial markets were bracing for a landmark decision from Germany's top court Wednesday over the legality of EU bailout packages that could slow down Europe's ability to tackle future crises.
The Constitutional Court is poised to rule on a complaint by six eurosceptic professors and politicians that the 2010 bailout of Greece and subsequent setting-up of the EU's bailout fund broke EU and German law.
While most experts do not expect the court to slap down the bailouts, it could insist that Germany's parliament has a greater say in future aid deals, which markets fear will hamper authorities' room for manoeuvre.
"The Constitutional Court is highly unlikely to declare the government's decision in favour of additional euro aid to be unconstitutional," said Eckart Tuchtfeld, an analyst at Commerzbank.
"However, it will likely strengthen parliament's role versus the government," added the economist.
The decision comes weeks before the German parliament is due to vote on extending the mandate and volume of the EU's bailout fund, the EFSF, with Chancellor Angela Merkel facing a rebellion within her ruling coalition.
The bill is sure to pass, as opposition parties have indicated they will vote in favour, but 25 deputies from Merkel's centre-right coalition voted no or abstained in a test vote on Monday.
"We will get the majority," declared a confident Finance Minister Wolfgang Schaeuble in parliament on Tuesday.
The vote takes place on September 29 but the final wording of the bill will not be completed until the Constitutional Court has delivered its ruling, which is expected at 10:00 am (0800 GMT) on Wednesday.

subset: commoncrawl


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I've been told by most guys that I've dated that I would be considered a "good girl" because I'm "smart, attractive, have a good sense of humor, and know how to dress (in their words)." And usually, things start out fine. But eventually, the phone calls stop, and the guys are on to the next thing. Now I will admit, dating in the "real world" is something I'm new at (recent college graduate). Am I putting out my spark unintentionally? Are these lines that guys say to get what they want? Do guys really want a good girl? Thanks for the feedback!
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Timing is everything!
Of course everyone wants to "end up" with a (good girl) or (good guy) in the end. Everyone has their definition of what is "good" though. Just as a lot of women go through their "Bad Boy" phase where they won't give a "good guy" the time of day because he's "too nice" staying true to their famous quote: "We adore those who ignore us and ignore those who adore us" If only the "good guys" and the "good girls" were attracted to one another!
Many men also go through a phase where they just want to party and get laid by the hottest girls available. This phase often lasts throughout their 20s and sometimes into their early 30s. If they cross paths with a "good girl" they'll usually end up hurting her or they will spare her serious heartache by backing away because they know they aren't ready to cash in their (single life) cards yet. The typical 20 something year old guy just got out of a dorm or broke out of his parent's basement. The last thing on his mind is to settle down and become his parents!
Most women in their 20s who are looking to have a "serious relationship" with marriage potential would probably do better by dating men who are in their early to mid- thirties which have never been married. One man's opinion! :-)
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Hey there ssmith1534. My personal opinion is that most men do want a good woman. Unfortunately, in most guys eyes, they feel like a good woman is a woman who basically adheres to all of their blessings. The second that a woman doesn't, most guys move onto the next. A lot of it boils down to sex as well. Most men feel that if a woman doesn't "give it up" in a certain length of time, that she is a waste of time, and they move on. Regardless as to how we break it down, good guys and good woman often get it harder in the dating world. I've often asked the questions, "Do women want good guys anymore?" But to answer your other questions, it very well may not be you doing anything unintentionally. It just may be the guys that the guys you've been involved with aren't right for you.
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Thanks for your feedback prospectboy! I guess I'm tired of hearing guys say, "I want a good girl," and then when I'm categorized as one, things don't work out. And then there are all these comments about women wanting "thugs." Not into that either.
You're welcome. Just hang in there. The kind of guy you are looking for will most likely come when you least expect it. I don't believe all women want "thugs". I just think a lot of women prefer guys to have a certain image.
Its the same with women who chase bad boys: in the end good guys and gals finish last.
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men want sex. with women but they do respect good women and in most cases not put any moves on a good women, I know for when I do date good woman and I see what they looking for I may stay friend but I know I,m just looking for sex and really don't want to hurt anyone. fast tail women always looking for something and way easier to get so we do. but men want the same for there woman that a women want. a women that there for him like he there for her and you will know when you find him, and if a man can't find that them there no real love in the women he see. just sex
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I think guys want a good girl for their wife or steady girlfriend, but some guys want that and a bad girl on the side... I've had that experience. I was the wife, a good girl, and my husband was messing around with a very bad, nasty, girl who wasn't even attractive at all. It is a very low blow to your self esteem.
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Limoges cup and saucer Horse Riding
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Beautiful Golden Horse Riding cup and saucer Limoges. Excellent condition.For 1st class postage or insurance please send a message. if Overseas buyers please pay by paypal only.
Postage prices are for the UK. If paying by cheque Item will be dispatched after payment clears. All items are wrapped to the highest standards using New boxes, bubble wrap and foam chippings. Please see my other items of Fine Bone China and Pottery. I am happy to combine purchases to reduce postage costs.


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This card is about experiencing or feeling triumph, success, pride & acclaim. It shows a man riding into town elevated on a horse, with a wreath of laurels around his head, the traditional symbol of victory. However, be careful of not getting 'too high on your horse', as that is another meaning of this card. It represents praise, applause, getting the recognition you deserve, and similar things. However, on the low side, it also can contain the archetype of the story, 'The Emperor's New Clothes', where not everything is as it seems, and warns of not becoming condescending or holding yourself in higher esteem than others.
Birthday today? Your Birth Card is Six of Clubs
Learn more about this card here:
Learn Tarot – 6 of Wands
Other Six of Clubs Birthdays:
Frank Sinatra
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Arts & Humanities > Language:
Espanol Es Fantastico! (Ages 4 - 6)
This program will introduce your child to Spanish through games, literature and art activities. Expose your children to this wonderful language and culture!
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If an item you ordered from TextbookRush does not meet your expectations due to an error on our part, simply fill out a return request and then return it by mail within 30 days of ordering it for a full refund of item cost.
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All the information you need in one place! Each Study Brief is a summary of one specific subject; facts, figures, and explanations to help you learn faster.
List price: $12.95Copyright year: 1989Publisher: HeinemannPublication date: 10/23/1989Binding: PaperbackPages: 192Size: 5.00" wide x 7.75" long x 0.75" tall Weight: 0.572Language: English
Ayi Kwei Armah was born in Takoradi, Ghana, in 1939. He was educated at the elite Achimota College, near Accra, and received a degree in sociology from Harvard University in 1963. Upon leaving Harvard he become actively involved in the struggle for African liberation of Algeria, which had just emerged from its armed struggle for independence from France. In Algeria, Armah worked as a translator for the magazine Revolution Africaine until his health failed toward the end of 1963. After a five-month hospitalization in Boston, Massachusetts, he returned to Ghana in 1964. Armah's first novel, The Beautiful Ones Are Not Yet Born (1968), deals with political corruption in a newly independent African nation. The capital of this nation resembles Accra, the capital of his native Ghana. The novel is generally felt to be about the last years of Nkrumah's government. In Fragments (1970), his largely autobiographical second novel, Armah illustrates the difficulties of an intellectual in a culture oriented toward material possessions. His third novel, Why Are We So Blest? (1972), is considered largely an attempt to probe the complex relation of colonizer and colonized-between the European and the African. His most ambitious novel published so far is his fourth, Two Thousand Seasons (1973). Armah has lived and traveled in various parts of Africa, beginning in 1970. He has taught at several universities in Africa and the United States. He currently lives in Dakar, Senegal.
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Okay. I've been very vocal about how awful chile rellenos made with potblano chiles taste, but... A friend dropped by and made some for me as a surprise the other day. They'd have been cold if she'd cooked them at home. She brought both poblano and "Anaheim/Hatch" chiles because she'd heard me desparage poblanos. And to my great amazement, the poblanos DID have a much nicer flavor than the Anaheims! Whoda thunk it?
But this was also the very first time I've ever ever ever had them prepared properly! She broiled them until black and blistered, sweated them, peeled them, stuffed them, whipped the batter with a wire whisk because she says it tastes better than using an electric mixer (what an arm!), then fried them in peanut oil.
Now, I have had chiles rellenos in no less than five different Mexican restaurants since moving to Plano three years ago. And this is the FIRST time I've had poblano peppers properly prepped! (Peter Piper's Peppers have nothing on me!) EVERY stuffed poblano I have ever had in a restaurant in this area was closer to a stuffed rib of raw celery, they were that crunch and totally unprepped. I even called one restaurant before going to ask whether they charred and peeled their peppers before stuffing them and I was assured they ALWAYS do...! They lied to me. They lied to me big time.
So I'm making this public admission that I was wrong on this board just in case I have argued with anyone who would miss it on the Texas board. But it sure says a lot about the restaurants I've been going to, doesn't it? And they've been "better' restaurants, as opposed to holes-in-the-wall, that charged from nine to eleven bucks for ONE chile relleno, rice and beans on their LUNCH menu! Great to have friends who will go to such extremes to educate me. I'm a happy camper! Not about the area restaurants. About finally having delicious stuffed poblano peppers....! '-)


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Booty Time is the new pirate themed online slots game that can lead you to a pirate's worth of gold treasure. This is a five reel online slot machine with wilds, scatters, and images featuring the pirate parrot who is there to help you in your quest. You can also win when you match up the jack, queen, king, or ace playing cards that are seen on pirate flags in this online slot game. With guitar strumming in the background, the game is fun, exiting, and potentially rewarding.
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Many dietitians, bodybuilders and trainers agree that when you wake up in the morning your muscles need a fast source of amino acids to stop muscle loss after 7-8 hours on fasting and it's a good time to take a water based protein shake.
This is because a insulated whey shake with water, can be digest in less than 1 hour without problems while a blend shake can take 1.5 or 2 hours and a casein one 3 hours or more. Some nutritionists also point out that the difference is that proteins are supergroups of amino acids, so putting regular protein (which is how it appears in any food) in your body takes longer to absorb because it has to "release" amino acids, instead most protein shakes directly containing amino acids their absorption is very fast so that in 20-45 minutes the shake may have been absorbed (which is not the same as digested).
Based on this an excellent breakfast for your muscles is a source of good carbohydrates such as a bowl of cooked oats and a water based whey protein shake. In total, about 260 calories with 30 grams of protein for the growth of your muscles.


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|Publication number
|Publication type
|Application number
|Publication date
|Mar 27, 2007
|Filing date
|Jul 7, 2005
|Priority date
|Dec 12, 2002
|Fee status
|Also published as
|Publication number
|Miriam H. Taimisto, David E. Haines, Steven Yee, Steven Ha
|Original Assignee
|Scimed Life Systems, Inc.
|Export Citation
|BiBTeX, EndNote, RefMan
|Patent Citations (28), Non-Patent Citations (1), Referenced by (10), Classifications (10), Legal Events (3)
|External Links: USPTO, USPTO Assignment, Espacenet
This application is a continuation of U.S. patent application Ser. No. 10/318,655, filed Dec. 12, 2002, now U.S. Pat. No. 6,922,579.
The present invention is directed to medical probes, and more particularly, to medical probes for ablation of body tissue.
Physicians make use of catheters today in medical procedures to gain access into interior regions of the body to ablate targeted tissue areas. It is important for the physician to be able to precisely locate the catheter and control its emission of energy within the body during tissue ablation procedures.
For example, in electrophysiological therapy, ablation is used to treat cardiac rhythm disturbances. During these procedures, a physician steers a catheter with a distally mounted ablating element through a main vein or artery into the interior region of the heart. The physician locates the ablating element adjacent the cardiac tissue to be treated, and directs energy from the ablating element into the tissue to form a lesion thereon. Typically, the determination of a target site and the ablation of the target site are performed by a single catheter, which consists of an ablation eye electrode mounted at the tip of the catheter, and a mapping ring electrode mounted distal to the ablation electrode. This and similar catheter tip designs are described in U.S. Pat. No. 6,134,463.
It has been found that current catheter tip designs do not always provide a physician with enough resolution to accurately identify ablation site, causing the physician to perform multiple ablations in several areas. In particular, current catheter tips may detect far field electrical activity, which can negatively affect the detection of local electrical activity. This results in extended operation time and, often times, unnecessary tissue ablation. Furthermore, current catheter tips may include a temperature sensor located behind (or proximal) to the eye electrode for measuring the temperature of the tissue being ablated. Because the eye electrode is in between the temperature sensor and the tissue, and/or because the temperature sensor is not directly placed against the tissue, the temperature measurement obtained by the sensor may not be accurate.
As such, there is a need for a catheter tip that is capable of precisely measuring electrical signals from a heart in order to accurately determine an ablation site. Such catheter tip should also be able to accurately ablate a target tissue at the ablation site, and allow a sensor (in one is used) to accurately measure a characteristic of the tissue being ablated.
According to a first aspect of the present invention, a catheter tip having a first mapping ring electrode and a second mapping ring electrode is provided. The second ring electrode is concentrically located outside the first ring electrode, and is electrically insulated from the first ring electrode. In the preferred embodiment, each of the first and second ring electrodes is electrically coupled to at least one wire for transmitting signals sensed by the respective first and second ring electrodes. Although the present inventions should not be so limited, with respect to the mapping functions, the concentric electrode arrangement can increase mapping resolution. The catheter tip can be a part of, or connected to, the distal end of an elongated member of an catheter or other medical devices. The distal end of the elongated member can have any shape, such as straight, curvilinear, or three-dimensional.
In a preferred embodiment, the distal ends of the first and second ring electrodes form a planar surface that is substantially perpendicular to an axis of the elongated member. Alternatively, the planar surface can be at an angle relative to the axis of the elongated member. The distal ends of the first and second ring electrodes can also form a non-planar surface, such as a surface with a parabolic or an angular profile.
The catheter tip may optionally include a sensor located within the bore of the ring electrode. In a preferred embodiment, the sensor is a thermal sensor that senses the temperature of a body tissue during an ablation process. However, the sensor can also be of the type that senses a current, an impedance, a pressure, or other characteristics of a body tissue. One or more of the sensor can also be secured along a body of the catheter.
Other and further aspects and features of the invention will be evident from reading the following detailed description of the drawings, which is intended to illustrate, not limit, the invention.
The drawings illustrate the design and utility of preferred embodiments of the present invention, in which similar elements are referred to by common reference numerals. In order to better appreciate how the above-recited and other advantages and objects of the present inventions are obtained, a more particular description of the present inventions briefly described above will be rendered by reference to specific embodiments thereof, which are illustrated in the accompanying drawings. Understanding that these drawings depict only typical embodiments of the invention and are not therefore to be considered limiting of its scope, the invention will be described and explained with additional specificity and detail through the use of the accompanying drawings in which:
Turning to the drawings,
As shown in
The catheter body 12 preferably has a cross-sectional geometry that is circular. However, other cross-sectional shapes, such as elliptical, rectangular, triangular, and various customized shapes, may be used as well. The catheter body 12 is preferably preformed of an inert, resilient plastic material that retains its shape and does not soften significantly at body temperature, like Pebax�, polyethylene, or Hytrel� (polyester). Alternatively, the catheter body 12 may be made of a variety of materials, including, but not limited to, metals and polymers. The catheter body 12 is preferably flexible so that it is capable of winding through a tortuous path that leads to a target site, i.e., an area within the heart. Alternatively, the catheter body 12 may be semi-rigid, i.e., by being made of a stiff material, or by being reinforced with a coating or coil, to limit the amount of flexing. The stiffness or flexibility of the catheter body 12 is a matter of design choice, and will depend on the particular application. The outer diameter of the catheter body 12 is preferably less than 0.118 inch (9F). However, other dimensions for the outer diameter of the catheter body 12 may also be appropriate, depending on the particular application or clinical procedure.
The catheter 10 may optionally be used with a sheath 40 as shown in
When the distal end 18 of the catheter body 12 is retracted into the lumen 46 of the sheath 40, as shown in
Referring to
In the illustrated embodiment, the ring electrodes 22 and 24 have outer diameters of 0.052 inch and 0.092 inch, respectively. In particular, the outer diameter of the second ring electrode 24 should be about the same as that of the catheter body 12 so that the catheter body 12 exhibits a uniform diameter along its length. The ring electrodes 22 and 24 may have outer diameters with other dimensions as well. As shown in
The advantage of having concentric ring electrodes 22 and 24 over the ring-eye electrode configuration is that the concentric ring configuration is capable of detecting electrical activity with more precise resolution when used during the mapping function. In particular, the thin profile of the ring electrode 22 contacts less tissue surface area, and therefore, allows measurement of electrical activity at a more focused tissue area. The profile of the ring electrode 22 also reduces the averaging of electrical signal measurements, which commonly happens for eye electrodes. As such, the concentric ring electrode configuration allows a physician to accurately determine a target site to be ablated, which in turn reduces operation time and unnecessary tissue ablation. The concentric ring configuration is believed to also reduce the detection of far field electrical activity which can negatively affect the detection of local electrical activity.
Referring to
As shown in
In the illustrated embodiment, each of the ring electrodes 22 and 24 is electrically coupled to one wire 32. Alternatively, each of the ring electrodes 22 and 24 can be electrically coupled to two spaced apart wires 32 for delivering power in parallel to each of the ring electrodes 22 and 24. This decreases the effect of voltage gradients within each of the ring electrodes 22 and 24, which in turn improves the uniformity of current density delivered by the ring electrodes 22 and 24. The wires 32 for conducting ablation energy to the ring electrodes 22 and 24 are also used to transmit signals sensed by the respective ring electrodes 22 and 24 when the catheter 10 is being used to map heart tissue. Alternatively, a separate wire coupled to each of the respective ring electrodes 22 and 24 may be used to transmit sensed signals.
The additional electrode 30 shown in
The previous embodiments show that an additional electrode 30 may optionally be secured to the catheter body 12. Alternatively, in the case where the distal tip is separate from the elongate member 12, the electrode 30 may be secured to the catheter tip 14.
As shown previously, the single insulative material 26 provides the insulation function among all the electrodes at the catheter tip 14. Alternatively, more than one insulative material may be used to provide insulation among the electrodes.
For all the distal tips 14 described previously, the distal ends of the ring electrodes 22 and 24 form a plane that is substantially perpendicular to an axis 21 of the catheter tip 14. However, for any of the distal tips 14 described previously, the plane formed by the distal ends of the ring electrodes 22 and 24 can be of any angle with respect to the axis 21 of the catheter tip 14. For example, as illustrated in
Any of the previously described distal tips 14 can optionally include a sensor 34, such as that shown in
Turning to
As illustrated in
It should be noted that the steering mechanism is not limited to the illustrative examples described previously, and that other steering mechanisms known in the art may also be used. Steering mechanisms are described in U.S. Pat. Nos. 6,033,378, 5,891,088, 5,531,686, 5,456,664,and 5,395,327. The entirety of these patents is incorporated by reference herein.
Having described the detailed structure of the catheter 10, the details of its operation will now be described. When using the catheter 10 to diagnose or treat a heart, the physician first establishes an access to a selected vein or artery. A conventional introducer may be used to penetrate a patient's skin and establish the access. If the catheter 10 includes a sheath 40, such as that shown in
The physician can use angioscopic, fluoroscopic, or ultrasound imaging, or the like, to observe the distal end 18 of the catheter body 12 while maneuvering it into good contact with an endocardial tissue. If fluoroscopic imaging is used, either or both of the sheath 40 and the catheter body 12 can include a radio-opaque compound, such as barium sulfate, to assist in the positioning of the sheath 40 and the catheter body 12 during a fluoroscopic procedure. Alternatively, a radio-opaque marker can be placed at either or both of the distal ends of the sheath 40 and the catheter body 12 for this purpose. A marker may also be placed at the proximal end 16 of the catheter body 12 or at the handle 20 for indicating the orientation of the distal end 18 of the catheter body 12. Alternatively, any of the ring electrodes 22 and 24 and the additional electrode 30 can assist the navigation of the distal end 18 of the catheter body 12 by emitting and/or sensing a radio frequency signal. Navigation systems that use signal emitting and signal sensing electrodes are described in U.S. patent application Ser. No. 09/624,358,filed on Jul. 24, 2000, the entirety of which is incorporated by reference herein. Furthermore, the catheter body 12 can also carry an ultrasound or magnetic transmitter/sensor for navigating the distal end 18, as is known in the art.
Turning to
If it is difficult to place the ring electrodes 22 and 24 in contact with the heart tissue 60 using the straight distal end 18 of
In certain situations, using a distal end 18 of the catheter body 12 that has a relaxed curvilinear configuration or is steerable may not be sufficient for the catheter tip 14 to make substantial contact with a target tissue.
Referring to
Once proper contact between the ring electrodes 22 and 24 and the heart tissue 60 has been achieved, the mapping process is commenced. During the mapping process, electrical signals sensed by the ring electrodes 22 and 24 are transmitted by the wires 32 to a processor (not shown), such as a computer, a circuit, or a microprocessor. The processor analyzes the signals and converts them to data and/or graphical images on a display, such as a monitor.
At the end of the mapping process, a target site for ablation is then determined. The catheter device 10 can then be used for ablation of a heart tissue 60 at the target site. In the ablation mode, any of the ring electrodes 22 and 24 can be used for ablation. Furthermore, if the catheter 10 includes an additional electrode 30, it can also be used for the mapping and/or ablation. When using the catheter 10 to ablate a target site, the distal end 18 of the catheter body 12 is positioned such that the electrodes (the ring electrodes 22 and 24 and/or the body electrode 30) is in contact with the target site. The distal end 18 of the catheter body 12 can be positioned during the ablation process in the same manner as that used to position the distal end 18 during the mapping process.
While either or both of the ring electrodes 22 and 24 are being used to ablate the heart tissue, the sensor 34 located within the bore of the first ring electrode 22, such as that shown in
It should be appreciated that the catheter tip 14 is not necessarily limited to being a part of the catheters described herein, and that the catheter tip 14 can be attached to other catheters or medical devices for ablation and/or sensing a signal.
Thus, although different embodiments have been shown and described, it would be apparent to those skilled in the art that many changes and modifications may be made thereunto without the departing from the scope of the invention, which is defined by the following claims and their equivalents.
|Cited Patent
|Filing date
|Publication date
|May 15, 1974
|Nov 18, 1975
|Siegfried Hiltebrandt
|Coagulating devices
|Nov 17, 1982
|Oct 22, 1985
|Mentor O & O, Inc.
|Disposable coagulator
|Jan 10, 1985
|Jun 23, 1987
|Pao David S C
|Coaxial bipolar probe
|Nov 24, 1986
|Nov 15, 1988
|Telectronics, N.V.
|Porous pacemaker electrode tip using a porous substrate
|Jul 7, 1988
|Jul 18, 1989
|Telectronics, N.V.
|Method for cardiac pacing and sensing using combination of electrodes
|Nov 18, 1988
|Oct 2, 1990
|Webster Wilton W Jr
|Steerable catheter
|Feb 19, 1991
|Jun 30, 1992
|Everest Medical Corporation
|Ablation catheter with selectively deployable electrodes
|Oct 13, 1992
|Jan 11, 1994
|Delma Elektro- Und Medizinische Apparatebau Gesellschaft Mbh
|Medical high frequency coagulation instrument
|Nov 8, 1991
|Nov 15, 1994
|Ep Technologies, Inc.
|Electrode tip assembly with variable resistance to bending
|Jul 30, 1993
|Mar 7, 1995
|Ep Technologies, Inc.
|Catheter steering mechanism
|Jul 16, 1993
|Mar 21, 1995
|Ep Technologies, Inc.
|Combination monophasic action potential/ablation catheter and high-performance filter system
|Nov 14, 1994
|Oct 10, 1995
|Ep Technologies, Inc.
|Catheter steering mechanism
|Dec 23, 1994
|Jul 2, 1996
|Ep Technologies, Inc.
|Catheter steering mechanism
|Aug 8, 1994
|Dec 10, 1996
|Ep Technologies, Inc.
|Systems and methods for forming large lesions in body tissue using curvilinear electrode elements
|Mar 18, 1996
|Feb 17, 1998
|Electro-Catheter Corporation
|Ablation electrode
|May 23, 1995
|Jul 21, 1998
|Cardima, Inc.
|Over-the-wire EP catheter
|Jan 24, 1997
|Sep 22, 1998
|E.P. Technologies, Inc.
|Systems and methods for controlling tissue ablation using multiple temperature sensing elements
|Oct 4, 1996
|Nov 17, 1998
|Cordis Webster, Inc.
|Split tip electrode catheter
|Mar 6, 1997
|Apr 6, 1999
|Ep Technologies, Inc.
|Catheter steering assembly providing asymmetric left and right curve configurations
|Nov 8, 1996
|Oct 19, 1999
|Novoste Corporation
|Apparatus and methods for procedures related to the electrophysiology of the heart
|Apr 24, 1998
|Dec 14, 1999
|Irvine Biomedical, Inc.
|Catheter system having closely spaced distal bipolar electrodes
|Mar 27, 1997
|Mar 7, 2000
|Ep Technologies, Inc.
|Catheter steering mechanism
|Jun 18, 1998
|May 16, 2000
|Cordis Webster, Inc.
|Multi-element tip electrode mapping catheter
|Mar 31, 1997
|Oct 17, 2000
|Cordis Webster, Inc.
|Electrophysiology catheter with a bullseye electrode
|Oct 5, 1999
|Apr 30, 2002
|Oratec Interventions, Inc.
|Surgical instrument for ablation and aspiration
|Jul 7, 2000
|Jun 11, 2002
|Biosense Webster, Inc.
|Catheter with tip electrode having a recessed ring electrode mounted thereon
|Jul 7, 2000
|Nov 5, 2002
|Biosense Webster, Inc.
|Mapping and ablation catheter
|Dec 12, 2002
|Jul 26, 2005
|Scimed Life Systems, Inc.
|La placian electrode
|Poole, Wayne F., et al., "Method for Modelling the Potential Sensed by a Concentric Multi-Ring Electrode Set from a Moving Depolarization Wave," IEE Engineering in Medicine & Biology Society 11<SUP>th </SUP>Annual International Conference -1297 CH-2770-6/89/0000-1297 C 1989 IEEE.
|Citing Patent
|Filing date
|Publication date
|Feb 23, 2007
|Apr 14, 2009
|Boston Scientific Scimed, Inc.
|La placian electrode
|Dec 10, 2008
|Dec 7, 2010
|Vivant Medical, Inc.
|Localization element with energized tip
|Nov 25, 2008
|Oct 23, 2012
|Vivant Medical, Inc.
|Targeted cooling of deployable microwave antenna
|Apr 9, 2008
|May 6, 2014
|Elcam Medical Agricultural Cooperative
|System and method for accurate placement of a catheter tip in a patient
|Apr 8, 2011
|Feb 28, 2017
|Covidien Lp
|Microwave ablation instrument with interchangeable antenna probe
|Jun 16, 2004
|Feb 15, 2007
|Bernhard Hug
|Electrosurgical instrument for an endoscopre or a catheter
|Feb 23, 2007
|Jun 14, 2007
|Boston Scientific Scimed, Inc.
|La placian electrode
|Nov 25, 2008
|May 28, 2009
|Vivant Medical, Inc.
|Targeted Cooling of Deployable Microwave Antenna
|Dec 10, 2008
|Jun 11, 2009
|Vivant Medical, Inc.
|Localization Element with Energized Tip
|Apr 9, 2008
|Feb 25, 2010
|Elcam Medical Agricultural Cooperative Association
|System and method for accurate placement of a catheter tip in a patient
|U.S. Classification
|600/374, 606/48, 607/122, 606/41, 606/50
|International Classification
|Cooperative Classification
|European Classification
|Nov 6, 2006
Owner name: BOSTON SCIENTIFIC SCIMED, INC., MINNESOTA
Free format text: CHANGE OF NAME;ASSIGNOR:SCIMED LIFE SYSTEMS, INC.;REEL/FRAME:018505/0868
Effective date: 20050101
Owner name: BOSTON SCIENTIFIC SCIMED, INC.,MINNESOTA
Free format text: CHANGE OF NAME;ASSIGNOR:SCIMED LIFE SYSTEMS, INC.;REEL/FRAME:018505/0868
Effective date: 20050101
|Aug 24, 2010
|Fee payment
Year of fee payment: 4
|Aug 27, 2014
|Fee payment
Year of fee payment: 8


text:
Bell, David S. (David Scott), 1947-
From Library of Congress Name Authority File
Bell, David S. (David Scott), 1947-
Instance Of
Scheme Membership(s)
Collection Membership(s)
- Bell, David Scott, 1947-
- Bell, D. S. (David Scott), 1947-
- Bell, David, 1947 May 7-
Additional Information
Birth Date
- (edtf) 1947-05-07
Associated Locale
- Great Britain
- male
Associated Language
- Writer on politics
Use For
Exact Matching Concepts from Other Schemes
Earlier Established Forms
Bell, David Scott
- found: Divided loyalties, c1978 (a.e.) t.p. (David Scott Bell)
- found: Contemporary French political parties, 1982: CIP t.p. (David S. Bell)
- found: His The French Socialist Party, 1984: CIP t.p. (D.S. Bell)
- found: The Conservative government, 1979-84, c1985: CIP t.p. (David S. Bell) data sheet (b. 5-7-49) front matter (Dr.; lecturer in politics at Leeds Univ.)
- found: Communist and Marxist parties of the world, 1990: t.p. (David Bell)
- found: Conflict and cohesion in the west European ... 1994: CIP t.p. (David S. Bell) data sheet (b. May 7, 1947)
- found: Communication from author, Sept. 5, 2005 (David Scott Bell; born 7 May 1947; editor of Conflict and Cohesion in West European Social Democracy)
Change Notes
- 1978-11-17: new
- 2016-05-19: revised
Alternate Formats


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text:
StarTech Virtual 7.1 USB Stereo Audio Adaptor External Sound Card
£17.29 includes FREE UK Postage (other delivery options available)
Shipping Destinations for this item
UK - Shipping Included
United Kingdom
Europe Zone 1 - £2.19
Austria, Belgium, Denmark, France, Germany, Ireland, Luxembourg, Netherlands, Switzerland
Europe Zone 2 - £2.99
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Europe Zone 3 - £2.99
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Falkland Islands
|This USB to Audio Adaptor lets you connect headphones or speakers, and a microphone to your computer without the need to unplug other devices! Compliant with USB 2.0 and USB audio device specification 1.0, this USB to audio adaptor couldn't be any simpler to install.
|Compatible with Windows 98SE and up, as well as Mac OS 9.x and later, the USB Audio Adaptor integrates into any computer environment, providing superb sound quality and convenience that can't be matched. Included with the USB Audio Adaptor is the Xear 3D software for virtual 7.1 channel sound for use with Windows XP and Windows Vista.
|1 Year Warranty
Connector Type
|1 x USB A (Male) • 2 x Phono 3.5mm (Female)
Case Colour
- Compliant with USB audio device class specification 1.0
- No drivers required for Windows XP/2000/Vista, Linux and Mac OS X
- Offers volume up, down, and mute buttons
- USB 2.0 and USB 1.1 compliant
- Xear 3D Software adds Virtual 7.1 Surround for computers running Windows XP and Windows Vista
For more information and our Delivery Policy see here.
For more information and our Returns Policy see here.
Catalogue No: EL-00010246


text:
10-Day Las Vegas, Grand Canyon, Disneyland (Or San Diego), Universal Studios, Oregon, Crater Lake, San Francisco Tour from LV
Hometown - Las Vegas
Summary of The Day: Las Vegas, it's a city that has something to offer for everyone. The infamous Las Vegas Strip is where tourists can enjoy a walk in the warm desert evening and visit the newest and most lavish casinos from Bellagio, Venetian, MGM Grand, The Mirage, and others. Or perhaps take a stroll downtown and view a dazzling light show that spans an entire street (Optional night tour). The are special shows and performances year round that truly makes Las Vegas as a city that never sleeps. Accommodations will be at the Excalibur Hotel & Casino, named for the mythical sword of King Arthur. Immerse yourself in the castle themed resort right in the middle of the Las Vegas Strip. Choose from one of the many eateries on the property, including the Roundtable Buffet, or head down the Strip and stop by one of the other world famous hotels.
- Hotel:
- Excalibur Hotel and Casino or similar
Visiting Attractions
Las Vegas - Hoover Dam - Grand Canyon (South Rim or West Rim Skywalk) - Las Vegas
Summary of The Day: Grand Canyon (South Rim) National Park:
The Grand Canyon offers one of the most spectacular examples of erosion not found anywhere in the world. Canyon National Park is a designated World Heritage Site and is unmatched in the incomparable vistas that it offers to visitors on the rim. Today, take an excursion to this incomparable National Park.
Grand Canyon West Rim "The Skywalk":
Your journey begins from stopping by the Magnificent Hoover Dam and then on to the Majestic Hualapai Indian Reservation where is located at the West Rim of the Grand Canyon (Admission & lunch are excluded). You can walk along the rim of this great wonder of nature - unblemished by modern civilization. You may walk on the Skywalk (Optional tour). David Jin, the man who conceived and funded Skywalk makes this U-shaped platform, which extends 70ft over the edge and about 4,000 feet over the canyon floor. You may also elect to take a helicopter flight into the Grand Canyon & cruise along the Colorado River aboard a pontoon boat (Optional tour). Overnight stay in Las Vegas. Grand Canyon West is NOT part of the Grand Canyon National Park. Grand Canyon west is on the Hualapai Native American Reservation and is owned and operated by the Hualapai Tribe.
- Tips:
- Please note that during the trip to Grand Canyon South, we won't pass by Hoover Dam. Meanwhile, during the trip to Grand Canyon West, we will stop at the visitor's area of Hoover Dam for about 20 minutes.
If "Buy 2 get 3rd discounted" promotion applicants choose to opt out of these Grand Canyon visits and instead spend a free day in Las Vegas, they need to pay $50/person to tour guide as LV explore fee.
- Hotel:
- Excalibur Hotel and Casino or similar
Visiting Attractions
Las Vegas - Los Angeles
Summary of The Day: Transfer to the largest metropolitan area in California, Los Angeles. Stop by the historical landmarks of Hollywood, as well as Hollywood Blvd., Chinese Theater and the Kodak Theater complex (which is now the permanent home for the Oscars). Transfer to hotel after dinner. Overnight stay in Los Angeles.
- Hotel:
- Holiday Inn Select La Mirada / Knott's Berry Farm Hotel or similar
Visiting Attractions
Disneyland OR San Diego
Summary of The Day: From the mind of Walt Disney, enjoy a full day in Disneyland - a theme park suitable for all ages. OR San DiegoAt 9:00am we will depart from the hotel and drive South along the Pacific Ocean heading to sunny San Diego, the second largest city in California. We will first stop by the U.S. Naval compound in San Diego harbor. Docked at Navy Pier is the USS Midway, the longest - serving aircraft carrier in U.S. Naval history from 1945 to 1997. After lunch, we will go to Coronado Island and visit the Hotel Del Coronado. This world-famous luxury hotel was built in the Wooden Victorian style in the 1800s, and has since become a National Landmark. It has been in numerous films and has hosted presidents, royal families, and leaders from around the world. Next we will move on to another National Landmark, Balboa Park. Enjoy the luscious botanical gardens and Spanish architecture lining the long promenades. After, we will visit Old Town San Diego, where you will feel as if you stepped back in time as you walk among the classic Mexican Pueblos and shops offering many Latin American souvenirs and handicrafts. In the evening we will drive back to Los Angeles along the Golden Coast; if you are lucky you may catch a sunset. We will return to the hotel by 7:30pm.
- Hotel:
- Holiday Inn Select La Mirada or Knott's Berry Farm Hotel or similar
Visiting Attractions
Universal Studios
Summary of The Day: Experience movie magic at it best. The studio theme park ride attractions include Shrek, Jurassic Park, The Mummy Returns, and more. There are also various performances throughout the day. Get an inside look at the movie sets and uncover the secrets of legendary films on the world-famous studio tour.
- Hotel:
- Holiday Inn Select La Mirada or Knott's Berry Farm Hotel or similar
Visiting Attractions
Los Angeles - Pyramid Lake - The Outlets at Tejon Ranch - Bay Area
Summary of The Day: Upon departing Los Angeles, the first destination is the Pyramid Lake (except Thanksgiving, Christmas, New Year). Experience the most important commodity in California; the abundant amount of water, cruising boats, and the mirror like reflection, will give you a refreshing view on the importance of water to the survival of life. Visit the museum to see records of the four great ancient floods and modern conservation of the lake. Then stop by the Outlets at Tejon Ranch to satisfy all your brand name shopping needs. Arrive in the Bay Area in the afternoon.
- Hotel:
- Red Roof Inn SFO or similar
Visiting Attractions
Bay Area - Redwood National Forest - Eureka
Summary of The Day: Head north and drive through California's wine country - Napa Valley on the way to the Redwood National Forest. The forest is home to world's tallest trees: old-growth coast redwoods. The trees can live to be 2000 years old and grow to over 300 feet tall. Spruce, hemlock, douglas-fir, berry bushes, and sword ferns create a multiple canopied understory that towers over all visitors. In the afternoon, enter the Redwood National Forest as highlights include: Chandelier Tree, Tree Shop, Founder's Tree Grove, and the Avenue of Giants. Overnight stay in Eureka.
- Hotel:
- Red Lion Hotel or similar
Visiting Attractions
Eureka - Crater Lake - Klamath Falls
Summary of The Day: Visit Crater Lake National Park. The lake was formed after the collapse of Mount Mazama -an ancient volcano that erupted approximately 7,700 years ago. The lake is 6 miles long, 4 miles wide and 1932 feet deep. Overnight stay in Klamath Falls.
- Hotel:
- Days Inn or similar
Visiting Attractions
Klamath Falls - Mount Shasta View Point - McArthur-Burney Falls - Bay Area
Summary of The Day: Driving through the picturesque Klamath river basin, you will arrive at foothills of Mt Shasta. At the elevation of 14,179 feet, it is the highest peak in Northern California covered by snow all year round. Then continue to visit Burney Falls once described as "Eighth wonder of the world" by President Theodore Roosevelt. It is unique in that much of the falls comes out of the middle of the face of the cliff. Burney Falls is not the highest or largest, but definitely one of the most beautiful waterfalls on our planet. Head back to Bay Area after the tour.
- Hotel:
- Red Roof Inn SFO or similar
Visiting Attractions
San Francisco City Tour - Transfer out
Summary of The Day: Discover America's most picturesque and culturally diverse city - San Francisco. Highlights include: Civic Center, Twin Peaks, Golden Gate Park, Golden Gate Bridge, Palace of Fine Arts, Fisherman's Wharf, Market Street and Chinatown. After the tour, we will transfer you to San Francisco airport.
For Tuesday departures, the itinerary will be:
Day 1: LV (meet at 3:30pm)
Day 2: LV- Crand Canyon (west or south)
Day 3: LV-LA
Day 4: Universal Studios
Day 5: Disneyland/San Diego
Day 6: LA - Outlet - Bay Area
Day 7: San Francisco City Tour
Day 8: Bay Area - Redwood National Forest - Eureka
Day 9: Eureka - Crater Lake - Klamath Falls
Day 10: Klamath Falls - Mount Shasta View Point - McArthur-Burney Falls - Bay Area
** If your departure date is Wednesday and Sunday, please arrange your air-ticket departure from SFO after 8:00pm;
If your departure date is Tuesday, please arrange your air-ticket departure from SFO after 10:30pm.
Standard Price/Person By Occupancy
*Price for Single Occupancy applies when one person stays in one standard hotel room.
*Price for Double/Triple/Quadruple Occupancy applies when two/three/four people stay in one standard hotel room respectively.
*Triple/Quadruple price does not guarantee a third/forth bed in the room since each room is equipped with 2 beds. Please check the availability at the time of check-in.
*Child shares the same price as adult.
*Maximum room capacity: 4 people including adult and child/infant.
***Children under 2 years old have to pay $25 insurance fee per day, per infant. Please be sure to offer child's name and age(accurate to month) when booking.
Complimentary LV pickup and SFO airport dropoff (Please arrange your flight depart from SFO after 7:00pm.)
Roundtrip transportation in air-conditioned tour coach
9-night hotel accommodations
Admission to above mentioned national parks(except Grand Canyon)
Professional tour escort
All personal expenses including hotel room service and meals; however, you have the option to pay for meals that tour guide arranges.
Service fees for tour guide (min. $8.00/day per person)
If you choose to visit Grand Canyon West Rim, there are the optionals: (Admission fees and optional tours(Items and prices may vary during different seasons and are subject to the final confirmation made by tour guide when on tour.)
- Las Vegas Night Tour: $35.00/person,$25.00/child(2-12)(According to the weather)
- Grand Canyon South Rim Helicopter Ride: $220.00/person
- Grand Canyon NP Admission: $50.00/person(Mandatory fee, Bilingual -English and Chinese speaking guide and no lunch)
- Grand Canyon IMAX Film: $13.00/Person
- Grand Canyon West Rim Helicopter Ride(Helicopter sightseeing): $188.00/person
- Grand Canyon West Rim Admission : $90.00/person(Mandatory fee, including lunch)
- Grand Canyon Helicopter Tour & Colorado River Boat Cruise: $220.00/Person
- Skywalk: $30.00/Person
- Disneyland : $95.00-$119.00/Adult; $89.00-$113.00/Child(3-9) (Price is subject to final confirmation)(Mandatory fee. Please purchase the tickets from tour guide.)
- San Diego City Tour : $68.00/Adult; $58.00/Child (2-12)(Mandatory fee)
- Universal Studios: $100.00-$120.00/Adult; $94.00-$114.00/Child(3-9)(Price is subject to final confirmation)(Mandatory fee. Please purchase the tickets from tour guide.)
- San Francisco Bay Cruise: $28.00/Adult(18+); $20.00/Child(5-17)
- Please bring you own car seat, if you are travelling with a child under 8 years old. The penalty will be on your own cost, if you do not bring the car seat.
- Customers are allowed up to two items (ie. 1 standard check-in luggage + 1 carry-on) free of charge. Extra items will be charged at additional $25/per luggage.
- Due to the popularity of tours during the high season, the overnight hotels may be fully booked. We will choose the hotels which offer similar standards of service to replace. Please understand.
- Customers under 21 can't enter any casinos or join any gambling activities in Las Vegas.
- Flight information must be provided in order for the airport transfer services to be arranged. At our discretion, if flight information is not provided or provided last minute, your reservation will be noted as a self transfer and no airport transfer services will be arranged. If you decide to self transfer to the tour's first night's hotel, please inform us at your earliest convenience. If you opt out of a transfer service, you may reinstate the airport transfer service if notification to reinstate the service is given well in advance of the tour's departure. Urgent requests to reinstate airport transfer services will not be guaranteed. If a flight is delayed, Tours4fun/ local provider will attempt to arrange a later airport transfer service, however; this later service is not guaranteed. If an airport transfer service is not available and cannot be provided, all guests are responsible for self transferring to the tour's first night's hotel.
- If you need to book air ticket, we recommend that you please book your air ticket after you receive confirmation email for your reservation within one to two business days from us.
- Tour guides and drivers rely upon the service fees charged on the tour to supplement their income. The wages of tour guides and drivers are determined factoring in that they will receive service fees to augment their earnings. Please pay at least the recommended service fee because the tour guides and drivers work hard to accommodate many people on the tour.
- Please Note:
1. Guests are not allowed to use a CITY PASS and admission ticket purchased by themselves to join the sightseeing attractions included in this tour.
2. Guests who do use a CITY PASS or admission ticket purchased by themselves, will not be offered the transportation service for that day, and will possible need to pay a penalty fee. Please consult your tour guide for details.
- Language: This tour is escorted by a professional bilingual tour guide and/or driver guide (English/Chinese). Tours and/or languages may be combined to operate this tour depending on the number of passengers who have booked a particular departure.
- Bus Arrangement: Passengers on the same reservation will be arranged on the same bus unless stated otherwise. If you wish to be on the same bus as another party /an existing reservation, please note your request with the reservation number in the comment section on the checkout page or notify us at least 24 hours prior to tour departure.
- Please make your reservation 5 business before the departure date. Otherwise, surcharges will be applied.
- This tour/activity is overseen by a select local operator in the region. Upon booking your tour or activity and after receiving confirmation, you will be issued an e-ticket detailing the local operator's name and contact information. If you require assistance finding a specific tour, please contact us for more information.
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Hi not sure about your question but we also going on the Escape on the 10th of June. Might see you there, Regs And.
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How do general practitioners persuade parents to vaccinate their children? A study using standardised scenariosJulie Leask
A National Centre for Immunisation Research and Surveillance of Vaccine Preventable Diseases, The Children's Hospital at Westmead
B Discipline of Paediatrics and Child Health, University of Sydney
C School of Public Health, University of Sydney
D Email: firstname.lastname@example.com
NSW Public Health Bulletin 20(8) 119-124 https://doi.org/10.1071/NB08064
Published: 7 September 2009
Objective: To understand how general practitioners (GPs) address parental concerns about childhood immunisation using standardised scenarios. Methods: A combination of typical case and intensity sampling was used to recruit GPs. Interviews began with role-play vignettes of four different scenarios, exemplifying concerns about immunisation and the parents who have them. They ended with GPs' reflections on these encounters. Transcripts were analysed with the focus on describing and evaluating typical persuasive strategies. Results: Eleven GPs were interviewed from a range of demographic areas. In the role plays, GPs acknowledged the mother's concerns, tailored their discussion to her individual circumstances, and conveyed the notion of choice. Theoretical frameworks guided some in their responses. Less successful strategies were to enter into games of scientific 'ping pong'; to discredit a mother's source of information; or to ask confronting hypothetical questions. Attempts to negotiate with a mother refusing all vaccines for her children proved to be the most challenging role play. Conclusions: GPs tended to adopt the role of persuader rather than informer. Communication frameworks such as shared decision-making may help them to better balance these roles.
The analysis of health care communication has been a growing area of interest for qualitative researchers. It has required methods of data collection that access discussions that occur between patients and health professionals. Video or audio-assisted observations of actual patient encounters have been used.1,2 Another approach uses standardised patients. These are people who act out a set patient scenario with a clinician.3 A widely used assessment tool in medical education, standardised patients have been increasingly used in qualitative research of doctor–patient communication.4–6 This study used this method to attempt to describe how general practitioners (GPs) communicate with parents concerned about immunisation.
Discussions about immunisation occur frequently in face-to-face encounters between a health professional and a parent.7 These discussions are key since health professionals are the single most important influence on a parent's decision to immunise or not immunise their children.8–11 Health professionals have a public health responsibility to maximise childhood immunisation rates. They are also faced with ethical and legal obligations to ensure that parents are adequately informed about the risks and benefits of immunisation and that valid consent is given before a vaccine is administered.
This study investigated the ways GPs communicate about vaccine risk and benefit to parents who have strong concerns about immunisation. GPs were chosen because they represented 85% of immunisation providers in NSW at the time of the study.
The study sought to assess the strategies GPs used when communicating with parents. To achieve the study's aims, direct observation of actual conversations with parents would have been the ideal method but this was costly and impractical. A second option was to talk to GPs about their experiences of communicating with parents, yet this approach was likely to result in a polemic on what GPs think 'should' happen. A middle ground was the choice of standardised patients, which would allow both an assessment of the GP's rhetoric and a way into the GP's own reflection of their experiences.
Ethical approval to conduct this study was gained from the University of Sydney Human Research Ethics Committee.
For the standardised scenarios in this study, characters and scripts were based on what is known of parents who refuse or vacillate about immunisation, and the arguments they employ.9,12–16 Proposed scenarios were discussed with a team of researchers, piloted with two GPs and modified accordingly (Box 1).
The study used a purposive sample drawn from typical case sampling and intensity sampling.17 Initially, GPs who were assumed to be typical cases were sought, using a database of respondents to a previous survey who had agreed to a further interview. GPs were chosen from a mix of inner-urban and suburban locations within the Sydney metropolitan area. Each GP was sent a letter that was followed by a telephone call. Due to a poor response using this method, the sample was supplemented with GPs known to have a particular interest in immunisation (intensity sampling). Some of these were 'outliers' – interesting and divergent cases who broaden the scope of the enquiry and provide richer insights than if the study were limited to only typical cases. Similar mixed recruitment strategies have been used elsewhere.18
Interviews were conducted between November 2000 and February 2001. Participants who agreed to an interview were visited in their own practice. Two interstate GPs were interviewed over the telephone and another asked to email her responses. It was emphasised that the study aimed to describe how GPs communicate with parents about childhood immunisation.
In each interview, the researcher played the role of the parent, first giving the GP a brief character description and then initiating the script. GPs were asked to respond as they would in a normal encounter. The mock encounter was followed by questions aimed at debriefing; ascertaining whether the GP felt the scenarios were similar to situations experienced with parents; and discussing their actual experiences.
All interviews were recorded and transcribed by a professional transcription service. Each transcription was checked for inaccuracies.
To evaluate GP communication, the analysis used previous research on what parents desire from such encounters; guidelines in the area of patient–doctor communication; the views of two mothers who read a representative cross-section of the transcripts; and the researcher's own in-character reflections.15,19,20
Qualitative analysis is interpretive by nature.21 When the researcher is the instrument, he or she must be aware of how his or her beliefs and experiences shape the analysis. The qualitative literature labels this 'reflexivity'.22 A journal was kept that included the author's own experiences and reflections relevant to the study. This enabled the analysis to proceed with an awareness of how these might interact with the interpretation.
Transcripts were coded according to the dual perspective of describing typical rhetorical styles and evaluating interactions. Open coding was used where each interview transcript was read and re-read, and emerging patterns and themes noted freely.23 For each interview, memorandums were recorded that made brief observations about the wider meaning of the text and its connection to the emerging themes. Themes were reviewed, refined and grouped into a hierarchical coding system.24 All interviews were then coded according to this system. Passages preceding the coded text were re-read to ensure they were understood in context. Transcripts were also grouped by scenario in order to map typical discursive patterns peculiar to the scenarios. A sample of transcripts considered to most represent a cross-section of the themes was read by two women who had young children. The author met with each woman to discuss her impressions of the GPs' responses. These were used to refine the emergent thematic framework.
Twenty-eight GPs were approached via a letter and a follow-up telephone call. Of the 21 who returned calls, eight declined, with most citing lack of time and one because she was opposed to immunisation. Eleven interviews were completed.
Participants came from a range of areas, including three from semi-rural areas; three from mid-low income suburban areas; three from mid-high income suburban areas; and two from mid-high income inner-urban areas. Six of the GPs were women.
The analysis was grouped under three major categories: GPs' persuasive strategies; content of what GPs said about risk; and the contexts in which discussions with parents occur. This paper focuses on the GPs' persuasive strategies in responding to two of the four scenarios: one mother who was thinking about delaying scheduled vaccines until her baby was older and one who refused vaccines altogether. Each theme is identified in bold text.
Scenario 1: Considering delaying immunisation
Responses to Susan's concerns could be broadly described as a 'yes, but' strategy. The 'yes' was where the GP acknowledged Susan's concerns, sometimes with personalisation. The 'but' was usually expressed as straightforward negation or reframing. One GP even conceded his own concerns about immunisation:
I'm a parent myself ... I know how awful it is to give these tiny little ones a vaccine, but it is safer for them to have it so that they have some protection at that young age from these quite serious diseases. (GP 2)
Many GPs probed for specifics, revealing that Susan held concerns about preservatives after reading about them on a website. One GP explained the strategic usefulness of this:
It's only once you have agreed with them that ... you become their ally before you can start changing them. (GP 11)
Following the acknowledgment and probing, the conjunction 'but' was often used to establish that Susan was wrong using subtle and unsubtle techniques. In relation to Susan's baby's immunity, one GP said:
... what we are actually doing is stimulating it by giving the shots. We're not harming it. (GP 5)
GPs then directly addressed the preservatives issue, discrediting her source of information – the internet. Many compared disease risk with vaccine reaction risk. Some went on to define the possible vaccine side effects and how these might be minimised. Some reframed the vulnerability issue by focusing on the potentially damaging effects of a young child contracting a vaccine-preventable disease.
Scenario 2: Vaccine refusal
After the fifth GP interview, this scenario was introduced differently so that Janice approached the GP to have her Conscientious Objection form signed. Initial GPs had mentioned this as the most common context for encountering vaccine refusal. The Conscientious Objection form is a declaration signed by the parent and the provider, stating that a discussion about the risks and benefits of immunisation has taken place. It allows non-immunising parents in Australia to access government allowances.
Almost all GPs engaged in concerted attempts to convince Janice to vaccinate. Some offered written information and proposed to extend the consultation over a period of time. In the tetanus scenario, some offered immunoglobulin and penicillin as a compromise. In the form-signing scenario, two said they would not sign the form.
This scenario took the longest to act out and was confronting and uncomfortable to role play. It was often terminated by the interviewer before resolution because of time constraints. Debriefing was therefore important. Underlying the difficulties were diametrically opposed belief systems about health and disease prevention. One GP reflected on these conflicts:
I actually think most doctors have a lot of trouble with these sort of patients. They feel quite combatant towards them and quite stupidly evangelical in the same way that these people can be evangelical. (GP 10)
Most GPs began by attempting to convince Janice that her causal thinking had been wrong:
The fact that it occurred at that time in your child and the child subsequently developed various allergies I think is just a coincidence. It's just a timing effect, not a cause ... it was just something that occurred more or less at the same time. (GP 6)
Some conversations with Janice descended into games of scientific 'ping pong' where she would present her opinion, the GP would reply, and the conversation would get lost in a duel of competing claims.
GPs appealed to Janice's sense of social obligation to other children who were at risk from her unvaccinated child. A repeated technique was the use of hypothetical scenarios to persuade Janice:
How would you feel if your child got something? Say your child got measles and another child caught it from your child and that child died? (GP 9)
GPs portrayed strong discomfort with Janice's position. Although many would later acknowledge they stood little chance of changing her mind, many explained their persistence as concern for the child's safety, particularly in the tetanus scenario:
You probably are not going to get her back. That child is at risk. But you can't actually get a court order easily to make him have a tetanus vaccination. I mean, what do you do? (GP 4)
One GP used a counselling framework to explain his persistence:
If, in a counselling situation, someone makes an invalid statement, and then goes on with something and you don't challenge it, they read that response as you agreeing with their position, or concurring with it. (GP 5)
This strategy was useful to the GP in terms of providing a reference point if Janice changed her mind. Using the transtheoretical model of behaviour change, the GP would establish the mother's position on immunisation with respect to her readiness for change and move from there:25
If you want to get behavioural change out of people, you want to try three positions, like 'don't talk to me, I don't want to know about it', 'give me the information, I'm shopping', or 'don't bother me with details, just do it'. They're the three basic levels of readiness for change. So she is number one, 'don't bother me with the information'. So you don't bother them with the information. But you've still got to let them know that there's information, that there is something out there, if they transition to stage 2. (GP 5)
Another GP, while engaged in concerted persuasive efforts, felt ultimately that keeping the 'door open' was in the interests of the child's health should future medical care be needed (GP 9).
One GP's strategy differed strikingly from most. He first established the firmness of Janice's decision by asking, 'Have you ever had any doubts about your decision?'. He then ascertained her knowledge about the consequences of her refusal and completed the discussion. In the debriefing he said:
This isn't about being successful; this is a mother's choice. I don't consider it a failure if the person doesn't choose to immunise their child. (GP 10)
Even though he shared with the other GPs a support for immunisation, his response to Janice was different in terms of brevity, content and implicit goals.
This study examined the communication of 11 GPs who were likely to be confident communicators and interested in immunisation. The study identified many positive aspects of GP communication, some of which are reported in this paper. Almost all GPs acknowledged the mother's concerns and sought to understand them further. Many also acknowledged the mother's choice in relation to immunisation. They would often tailor their advice to the woman's individual circumstances and the use of frameworks to guide communication appeared helpful. Perhaps less successful aspects of the encounters were when GPs entered into games of scientific 'ping pong'; discredited a mother's source of information; or asked hypothetical questions. While all these points are worthy of discussion, the latter two will be explored.
In the discussions following the role plays, GPs would explain their source discrediting strategy. For many, the internet and news media appeared to comprise an external battlefield. From it, parents brought various opinions, arguments and fashions in thinking. By implication, the GP's surgery represented the centre of calm scientific rationality – the 'war room' where those who entered equipped themselves to counter-attack the outside influences. In the discrediting of sources was the implicit message, 'Don't trust what is out there, trust what is in here'. Indeed, many GPs referred to an existing level of trust with their patients. However, where trust is not yet built – either because of a patient's transience or scepticism towards medicine – this strategy may not be helpful. Pointing women to more reliable websites provides an alternative viewpoint while not rejecting their preferred source of information.
Similarly, there are likely to be more successful strategies than the asking of hypothetical 'how would you feel if' questions, as seen in the vaccine refusal scenario. These force the respondent into a rhetorical corner where they must inhabit the GPs definition of how events would transpire. Such strategies are unlikely to be productive in risk discussions because they either alienate the respondent or manipulate them into action. A better way to convey the message might be in terms of it being a woman's own choice, which also acknowledges vaccine risks but is more value neutral. The following example does not oblige the person to answer an emotive question:
You have to consider the illnesses you are preventing and how comfortable you feel about facing those without immunisation, versus the actual immunisation and the slight risks that are associated with that. That is the balancing act you need to decide ... . (GP 10)
The doctors in this study appeared to readily take on the promotion of immunisation. This mainly generated discussion of the risks of non-immunisation, leaving less time to talk about the side effects from vaccines and their magnitude (a finding not detailed in this paper). This focus on persuasion is understandable: if a parent refuses immunisation, the costs are incurred by their child and society more broadly. In addition, GPs receive financial incentives to maintain high vaccination rates within their practices. However, doctors are also obliged to help parents reach an informed decision. Balancing these obligations is challenging.
Strong persuasion, rather than achieving its goal, may be counter-productive, further polarising a parent and, at worst, eroding trust.26,27 The fields of motivational interviewing and shared decision-making recommend a respectful interchange where health professionals help patients consider their options and the consequences of these.20,26 This less direct approach gives parents a supportive space to make their choice in which immunisation would often be chosen.28 Some, however, will stay committed in their resolve and providers must recognise their autonomy.29 The ethical merits of refusing to care for a family who will not vaccinate their child have been discussed.30 However, as some of the GPs in this study noted, maintaining a relationship with parents who delay or refuse immunisation leaves the door open should they change their mind.
In undertaking this study, I assumed that my findings were shaped by the research context and myself as interviewer. I had two roles in this study: that of actor and researcher. Rather than being a conflict, this approach added strength to the analysis, helping me to experience what a parent might feel in these interactions. Reflecting on my own experiences allowed me to explicitly identify how a background in nursing, my expectations and my preferences influenced my reading and evaluation of the interactions in this study. They particularly informed the categorisation of the themes into helpful and unhelpful communication, aided by the reflections of the two mothers and widely accepted principles of good communication.
The GPs in this study made concerted attempts to encourage immunisation while giving some information about its risks. Balancing the promotion of public health alongside supporting valid consent is possible but remains challenging. Communication frameworks such as shared decision-making may help doctors to negotiate these tensions.
This study was supported by a National Health and Medical Research Council project grant 1999–2000. The author is grateful to Simon Chapman, Penny Hawe and Margaret Burgess who were involved in planning the study, with advice from Phyllis Butow. Kirrily Leask and Louise O'Shea provided feedback on the interviews.
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[27] Meszaros JR, Asch DA, Baron J, Hershey JC, Kunreuther H, Schwartz-Buzaglo J. Cognitive processes and the decisions of some parents to forego pertussis vaccination for their children. J Clin Epidemiol 1996; 49 697–703.
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