text:
|Publication number
|Publication type
|Application number
|Publication date
|Nov 19, 1991
|Filing date
|Aug 30, 1990
|Priority date
|Aug 30, 1990
|Fee status
|Also published as
|Publication number
|Malcolm J. S. Begemann, Bernhard de Vries, Johannes S. van der Veen
|Original Assignee
|Vitatron Medical B.V.
|Export Citation
|BiBTeX, EndNote, RefMan
|Patent Citations (15), Referenced by (105), Classifications (6), Legal Events (5)
|External Links: USPTO, USPTO Assignment, Espacenet
1. Field of the Invention
The subject invention relates to cardiac pacemaker systems and, more particularly, implantable cardiac pacemakers which deliver pacing stimulus pulses at an adjustable rate based upon monitoring of patient conditions.
2. Description of the Background and Prior Art
Rate responsive pacemaker systems are widely available in the art. Rate responsive systems contain means for monitoring at least one patient variable and for determining an indicated pacing rate as a function of such sensed pacing variable, so as to control pacing rate optimally in terms of the patient condition. Such rate responsive pacemakers have gained wide acceptance as providing an improved response to the patient's physiological needs, as compared to programmable fixed rate pacemakers. Although atrial-based pacemakers, i.e. atrial synchronous or atrial sequential pacemakers, as well as DDD pacemakers, may in some patients provide an ideal form of rate responsiveness, such pacemakers are not satisfactory for many patients with cardiac conditions.
A number of patient variables or rate control parameters have been suggested in the technical literature and used commercially. One of the first physiological parameters utilized for rate control is the QT interval, as disclosed in the U.S. Pat. No. 4,228,803 to Rickards, and the U.S. Pat. No. 4,305,396 to Wittkampf et al. The QT interval is in fact the interval between a delivered pacing stimulus and the subsequent evoked T-wave, and has been utilized as the parameter indicative of physiological demand for heart output, and thus pacing rate. Additionally, activity sensors have been widely utilized for detecting the general activity level of a patient with a pacemaker, and for controlling the pacing rate or escape interval in response to detected activity level. See the U.S. Pat. No. 4,428,378 to Anderson et al. Other parameters which have been utilized or investigated for suitability as controlling pacing rate include respiration rate, thoracic impedance changes, venous blood temperature, pH, oxygen saturation and stroke volume.
In addition to the selection of a desired monitored parameter, and the corresponding sensor to be used, the algorithm utilized by a pacing system is of great importance. An example of an improved rate adaptive algorithm used in a pacing system is set forth in U.S. Pat. No. 4,972,834, Ser. No. 252,653, filed Sept. 30, which discloses a QT pacemaker with dynamic rate responsiveness, incorporated herein by reference. As set forth in this referenced patent, the algorithm which correlates the monitored or sensed parameter with indicated pacing rate may be adapted as a function of history, and particularly can be readjusted with respect to limits such as lower rate limit (LRL) and upper rate limit (URL).
Another approach to optimizing rate responsiveness is to use dual or plural sensors, in order that the drawbacks or deficiencies of a given sensor and/or algorithm may be compensated by the use of a second or other sensors having different characteristics. This approach is set forth in the patent to Rickards, U.S. Pat. No. 4,527,568, which discloses switching control of rate responsiveness from one monitored parameter, e.g. atrial rate, to another control parameter, e.g. QT interval. There are many other examples of dual sensor approaches in the literature, and reference is made to U.S. Pat. Nos. 4,926,863 and 4,905,697. These references are characterized by designs which switch control from one sensor to another, or from one algorithm to another, depending upon monitored values of the rate control parameters. While this approach may produce increased efficiency and improvement over the single sensor approach, it still does not provide a continuous optimization of information such as is potentially available from two or more sensors, so as to continuously optimize and adapt the actual pacing rate for all foreseeable conditions. As used in this specification, "sensor" or "sensor means" refers to any means for obtaining a control parameter, including the lead means such as is used for obtaining the QT interval, or other sensors such as in use for detecting body activity and the like. The techniques for sensing rate control parameters, and developing and processing therefrom signals useful for pacemaker control, are well known in the art.
A longstanding unsolved problem in this art area, for which there is a need for improvement, is thus to provide either a sensor or combination of sensors which more nearly fulfills the requirement of the ideal rate adaptive system. For example, a rate adaptive system should provide a quick and accurate initial response to situations such as start of exercise. The QT interval, as a rate control parameter, provides only a gradual response, as compared to an activity sensor which provides a fast, i.e., quick response. Another requirement is that the parameter or parameters chosen should provide an indication of pacing rate which is proportional to the work load. The QT interval provides a very good indication of work load, whereas the activity sensor approach is not as good, and may be subject to false indications. Another important requirement for a rate control parameter is specificity, i.e., that the characteristics of the parameter signal are specific to the conditions of rest and exercise of the patient and are thus physiologically appropriate. For example, the QT interval has a high specificity, whereas activity as a parameter has a medium specificity. Yet another requirement is providing an optimum indication of rate decrease following cessation or reduction of the condition compelling higher rate, such as exercise. It is important that the speed of rate decay after the cessation of exercise be properly related to the patient's physical condition. It is known that a patient in relatively poor physical condition experiences a slow decrease of the heart rate after exercise, while a person in relatively good physical condition experiences a more rapid decrease of the heart rate after exercise. A pacemaker controlled by an activity sensor is less than optimal in this regard, since a cessation of exercise results in a sharp drop in the activity signal which, if not modified, would lead to a non-physiological step-like reduction in pacing rate. As a consequence, it is necessary to program a fixed time period for gradually decreasing the pacing rate when the activity sensor stops delivering information calling for a higher rate. The pacemaker which is controlled by the QT interval exhibits the inverse relationship as known from exercise physiology, but tends to provide too slow a pacing rate decay.
What is thus sought in this art area is a pacer having two or more sensors and an algorithm for deriving information from each so as to optimize the determination of desired pacing rate. At the start of exercise, for example, it is desired to have the algorithm force an initial but limited fast rate increase. Thereafter, it becomes important to ensure that the pacing rate correlates proportionally to work load, and that if continuous exercise is not confirmed, the pacing rate will slowly decrease toward a lower limit. The algorithm, combined with the sensing means, should also force a faster, although limited rate decrease when stop of exercise is detected, with further rate decrease following the physiologically inverse relationship.
As is well known, the microprocessor and logic circuit technology for dealing with these problems in a pacemaker environment is available. What is needed is a pacemaker system which utilizes this technology so as to optimize the translation of plural sensor information into pacing rate control.
The pacing system of this invention provides an improvement in rate responsive pacemakers so as to more optimally adapt rate control to patient conditions. Specifically, the object is to combine information from two or more sensor sources so that during all phases of the patient's activity and rest there is provided information accurately reflective of the physiological state of the patient, as well as fast response information from which more appropriate time control of pacing rate can be derived and accomplished.
A specific object of this invention is to provide a pacing system which is rate responsive to a quick response sensor which monitors a parameter such as activity, as well as a slower response sensor which monitors a more specific parameter such as QT interval, having an algorithm and control means for detecting which sensor source provides the optimum information under any given patient condition, and controlling pacing rate in response to the detected optimum information so as to provide physiologically optimal pacing.
It is a further object of this invention to provide rate control pacing where the pacing rate is primarily controlled in response to first sensor information which is highly specific to patient physiological conditions and provides an indication proportional to work load, and wherein the controlled pacing rate is modified according to further information from one or more other sensor sources which provide a quicker response to patient conditions, than does the first sensor source.
It is yet a further object of this invention to provide an inplantable pacemaker which is rate controlled as a function of at least two parameters reflective of patient condition, the pacemaker utilizing an algorithm adapted to provide primary control on the basis of a first of said parameters, and having means for adjusting and coupling the control information derived from the second parameter so as to be adapted for use in the same algorithm, thereby giving the pacemaker the advantage of continual comparison of comparable information from at least two parameter sources for logically deciding what pacing rate is appropriate.
In accordance with the above objectives, there is provided a pacemaker system and method of controlling pacing rate wherein at least two rate control parameters are utilized. The system incorporates means for processing a second one of the parameter signals so that the respective parameter signals are comparable, i.e. can be compared by a logic analysis as part of an algorithm in determining how to control pacing rate. This system includes establishing parameter control reference curves for each respective parameter, each reference curve representing pacing rate (or pacing interval) as a function of the respective parameter signal, and each of the two or more parameter curves being coupled so that each parameter indication is logic comparable over a range of pacing rates. Primary rate control is based on a first parameter such as QT interval, and rate control is modified by information from a secondary source such as an activity sensor. Each reference parameter curve is automatically adjustable to correspond to patient conditions and patient history, while maintaining the curves coupled. Automatic drift correction of the secondary parameter, such as activity, is used where there is a difference between the variable and its corresponding reference curve point whereby one can choose to correct only positive differences, only negative differences or both, so as to maintain comparability of the variables, permitting continuous interval-to-interval comparing and decision making on rate control.
FIG. 1 is a schematic block diagram of a pacing system with microprocessor control, such as can be used for this invention.
FIG. 2 is a generalized flow diagram showing some of the main features of the system and method of this invention.
FIG. 3 shows a set of curves representing QT as a function of pacing interval for different patient stress levels.
FIG. 4 shows the QT reference curve (QTref), which is a function of pacing interval, in relation to curves of QT for rest and maximum exercise.
FIG. 5 shows a curve of ACTref as a function of interval in relation to curves of ACT for different exercise levels.
FIGS. 6A and 6B show coupled curves of QTref and ACTref as a function of pacing interval, as used in the combination sensor algorithm of this invention.
FIGS. 7A and 7B illustrate graphically, with respect to the coupled reference curves, a first situation where both sensor variables indicate an increased rate.
FIGS. 8A and 8B illustrate graphically a second situation where both sensor variables indicate a decreased rate.
FIGS. 9A and 9B illustrate graphically a third situation where the algorithm indicates an increased rate.
FIGS. 10A and 10B illustrate graphically a fourth situation where the algorithm indicates a decreased rate.
FIGS. 11A and 11B illustrate graphically a fifth situation where the algorithm indicates a decreased rate.
FIGS. 12A and 12B illustrate graphically a sixth situation where the algorithm indicates an increased rate.
FIGS. 13A and 13B illustrate graphically a situation where the ACT variable has a lesser influence than the QT variable.
FIGS. 14A and 14B illustrate graphically a situation where ACT and QT have about the same influence.
FIGS 15A and 15B illustrate graphically a situation where ACT has a greater influence than QT.
FIG. 16 is a flow diagram of the portion of the preferred algorithm of this invention for changing pacing rate as a function of sensed QT and activity signals.
FIG. 17 is a flow diagram of the portion of the preferred algorithm of this invention for adjusting operation of the pacer at URL, and of a portion of the algorithm of the preferred embodiment of this invention for setting the activity drift (ACTdr) factor under predetermined conditions.
FIGS. 18A and 18B illustrate graphically a situation where the algorithm indicates start of ACT drift, causing ACT to decrease.
FIGS. 19A and 19B illustrate graphically the situation sometime following that of FIGS. 18A and 18B, where rate has decreased and ACT drift has increased to the stable condition where ACT=ACTref and QT=QTref.
In discussing the pacemaker system of this invention, reference is made to the prior art which teaches the use of microprocessor capability in an implantable pacemaker system, as well as the art of external programmer communication with an implanted pacemaker. Reference is made to U.S. Pat. Nos. 4,527,568 and 4,503,857, incorporated herein by reference, which describe operations of pacemaker embodiments incorporating microprocessor logic and software algorithms. U.S. Pat. Nos. 4,228,803 and 4,305,396 describe the operation of embodiments of a Tx pacemaker, i.e., one which is rate responsive to the QT interval, and are incorporated by reference. Generally, the prior art teaches and discloses various means of using microprocessors and software in controlling the operation of an implanted pacemaker. Accordingly, the specification does not contain a detailed description of the commercially available and known techniques of programming a microprocessor, storing data in memory and retrieving it, carrying out such operations as timing time intervals and setting up sensing windows, the logic of resetting the escape interval when a natural heartbeat is sensed, etc. These operations are well known in the art and are taught by the above references as well as other published patents and articles in this area. Reference is also made to the commercially available ACTIVITRAX pacemaker, of Medtronic, Inc. and the QUINTECH pacemaker of Vitatron Medical B.V., as commercial embodiments of software controlled pacers which are rate responsive to activity and QT interval respectively, and to the literature describing these pacemakers.
The following Glossary defines terms which are referred to in the description of the preferred embodiments:
ACT: Control parameter representing activity
ACTref : Reference value of activity control parameter at a given interval (pacing rate)
ACTdif : ACTref -ACT
ACTdr: Drift factor used to adjust
ACTmpl: Conversion factor by which activity counts (Nact) is multiplied to convert to units of ms
B: second order constant in polynomial relating QTref to interval; primary factor in determining value of QTref at URL
Dact: value of incremental change in ACTref for decremental change in interval
Dpt: first order in polynomial relating to QTref and interval; value of incremental change in QTref for incremental change in interval
Fact: Activity frequency for activity sensor
Int: Pacing interval in ms
LRL: Lower rate limit of pacing range
N: Number of intervals or number of 3.3 second periods counted in determining Nact
Nact: Number of counts of activity sensor
QT: Interval between delivered pacing pulse and evoked T wave; also referred to as QT interval.
QTref : Value of QT reference curve corresponding to a given interval (Ttx).
QTdif : QTref -QT
QTSTR(max) : Maximum difference in QT due to increase in stress, i.e., difference in QT at a given interval as between patient at rest and patient at maximum exercise.
QTmax : Lowest value of QT for a patient at maximum exercise and URL
QT(m): Maximum value of QT at LRL and patient at rest
QTsave: QTref -CRVMAX
Ttx: Interval on QTref and ACTref curves corresponding to pacing interval
TwA: Amplitude of T wave
TURL : Interval at upper rate limit
TLRL : Interval at lower rate limit
URL: Upper rate limit of pacing range
LOOP: Software number corresponding to step size of increase in pacing interval
CRVMAX: Programmable value representing threshold change in QT at URL for determining whether QTref should be changed at URL
In the subject invention, the improvement lies primarily in an algorithm for processing data from two or more sensor sources, so as to optimize rate control. The algorithm is structured so as to go through routines each pacing cycle, making rate change decisions based on a comparison of indications from each of the sensors. In the preferred embodiment as illustrated, pacing rate is adjusted each cycle, or interval, but the invention is not so limited. Thus, the principles of the invention can likewise be applied to adjusting pacing rate every N cycles, every elapsed predetermined time period, etc. Also, while the preferred embodiment illustrates a two sensor mode where the pacemaker is responsive to QT and activity information, it is to be understood that other combinations of two or more sensor inputs may be utilized. As used herein, sensor, or parameter sensor, broadly refers to obtaining rate control information and processing for use as control signals, and embraces systems such as the QT system where the pacing lead is utilized, as well as other systems where two or more separate sensors are utilized.
Referring to FIG. 1, there is shown a schematic representation of a pacer system as utilized in this invention. A pacemaker, preferably an implantable pacemaker 50, is used with an external programmer 51, the external programmer operating in a known manner to program pacemaker variables. A lead 53 is illustrated as being a ventricular lead, which lead delivers stimulus pulses to the ventricle and also provides sensed patient heartbeat signals to the pacemaker in a known manner. A lead 54 may also be used for a dual chamber pacemaker, connecting the pacemaker to the atrium. Leads 55 and 56 are shown connected to sensors S1 and S2 in the patient, for providing control parameters as discussed above. For a system using the QT and activity parameters, only leads 53 and 55 would be required. The pacemaker is illustrated as having a microprocessor 57, which includes memory for carrying the software of the algorithm of this invention. A block 58 is also indicated for signal processing of signals derived from lead 53 and sensors S1 and S2 in the known manner. The pacemaker contains the conventional means for generating stimulus pulses, inhibiting on demand, controlling rate, pulse width, etc.
By way of overview, the algorithm of the preferred embodiment of this invention is based upon several principles, or premises. A first working premise is that one of the parameters is taken as the primary control parameter, e.g. QT, and the other parameter is converted into corresponding units so as to be comparable for control purposes. Thus, in the preferred embodiment the ACT variable is derived by first obtaining counts from an activity sensor. See U.S. Pat. No. 4,428,378, incorporated herein by reference. The count is converted into a variable having units of ms, the same as QT, and is adjusted by a multiplier factor so as to provide a comparison of the two variables throughout the anticipated pacing range between lower rate limit (LRL) and upper rate limit (URL).
Another principle of the algorithm of this invention is that a reference curve is established for each variable, the reference curve establishing desired correlation of the control variable and the pacing interval. Actual control of pacing is preferably accomplished on the basis of the determined difference between the value of each respective control parameter at a given interval compared to the corresponding reference value of that parameter at the point on the reference curve corresponding to the pacing interval. Thus, for the QT parameter, the algorithm operates each interval to determine the difference between the QT reference value (QTref) for the pacing interval and the measured QT, to get QTdif. Likewise, the algorithm makes a determination of the difference between the activity reference (ACTref) and the determined ACT parameter, to obtain a value of ACTdif. Change of pacing rate, which in the preferred embodiment is accomplished each interval or pacing cycle, is determined as a function of these difference values, and not as a function of a comparison of the variable for the current interval versus the variable for the prior interval. Each interval, or cycle, the reference value for each pacing parameter is updated, or adjusted. Thus, for each new interval, the corresponding reference value is either incremented or decremented in accordance with a predetermined formula which establishes the reference curve for each respective parameter.
The reference curves are coupled in the sense that each reference curve represents a predetermined relation, or correlation, between pacing interval and its respective parameter between LRL and URL. In a preferred embodiment, the reference curve for the primary parameter, QT, is established in accordance with measured patient response to stress, and the second reference curve is scaled with respect to the first reference curve in a manner such as to adjust the influence of each parameter in determining control of pacing rate. Thus, the invention embraces the use of two or more control parameters, and an algorithm for establishing a respective reference curve for each such parameter. The reference curves are coupled so as to represent respective predetermined relationships between pacing rate and the control parameters between the programmable rate limits of the pacemaker, the algorithm determining change in pacing rate as a function of determined differences between each parameter and its respective reference value at the current pacing interval in accordance with predetermined logic.
Referring now to FIG. 2, there is shown a generalized flow diagram which represents the basic steps of the algorithm of this invention for determining pacing rate as a combined function of two control parameters derived from separate sensor sources. An external programmer 60 communicates with the pacemaker device. In general, the programmer is used for programing different pacing operating constants as is conventional in the use of programmable pacemakers. In this case, the programmer provides data which is used for generating the coupled reference curves, as indicated in block 65. A fast non-physiological sensor, such as an activity sensor, is indicated at block 61, and provides a signal which is operated on to get a fast sensor rate indication, as indicated at block 63. Note that the step of obtaining the fast sensor rate utilizes reference curve information, i.e., the sensor indication is compared to the reference information and the difference is used to determine the fast sensor rate. Likewise, a slow physiological sensor, such as means for obtaining the QT interval, is indicated at 62. Its output is processed at 64 to get a slow sensor rate, utilizing the correlation information generated at block 65. The fast sensor rate and the slow sensor rate are compared at 66, and the rate difference is adjusted at block 67. This adjustment constitutes changing the difference by a drift factor to get a differential adjustment indicated as ΔR. At block 68, the pacing rate is determined as the physiological rate (the slow sensor rate) plus an increment determined by multiplying ΔR by a factor C. Thus, the pacing rate is determined as a primary function of the physiological, or slow rate, and adapted as a function of the fast sensor rate, the adaptation being adjusted by the drift factor. It is to be understood that the adjustment of the contribution of the secondary sensor may be obtained by different procedures other than the drift factor as used herein, e.g., by differentiation of the rate difference or another mathematical operation.
As used herein, drift refers to a periodic change in the contribution of the fast, or secondary sensor rate. For example, where the fast sensor indicates a rate higher than the physiological rate, such that the value of ΔR is positive, the pacemaker may decrement the positive value of ΔR once every predetermined number of seconds, causing ΔR to drift toward zero and thus reduce over a period of time the differential effect of the fast sensor. Likewise, where the Δ rate is negative, meaning that the pacing rate is below the physiological rate due to the contribution of the fast sensor rate, the drift factor would increment Δ rate so that the negative Δ rate drifted toward zero with time. The effect of introducing such a drift factor is thus to initially permit the influence of the fast sensor on the premise that its fast response is more accurate than that of the slow sensor in reacting to changes, but to diminish with time the differential influence of the fast sensor on the grounds that after a while the slow sensor is more reliable. By only allowing a decremental drift of Δ R or only an incremental drift of ΔR one can choose to only diminish rates which are higher or lower than the physiological rate.
It is known that the QT interval is in fact influenced both by the pacing interval and by mental and physical stress. Thus, when the pacing interval shortens, QT shortens likewise, and vice versa, in a non-linear manner. Both mental and physical stress cause QT to shorten, and for this invention it is assumed that the relation between stress change and QT change is substantially linear. FIG. 3 shows curves for this relationship corresponding to the patient at rest (1), medium exercise (2) and maximum exercise (3). QTSTR(max) indicates the change in QT at URL between rest and maximum exercise. The QT interval is obtained in the ordinary manner, with circuitry and/or software for timing out the interval between the delivered stimulus pulse and the sensed T wave. See, for example, U.S. Pat. No. 4,527,568.
The QTref curve, which correlates QT as a function of interval, is illustrated in FIG. 4. The QTref curve must be maximum at LRL and zero stress (patient in rest condition) and must be minimum at URL and maximum stress (maximum patient exercise). The QTref curve between these two limits is chosen such that the relation between QTref and interval is a second order polynomial function, providing that the step change in QTref is a linear function of interval:
QT.sub.ref =QT(m)-Dpt (T.sub.LRL -int)-B' (T.sub.LRL -int).sup.2
ΔQT.sub.ref =-Dpt-B (TLRL-int)
FIG. 4 illustrates the determination of QTdif =(QTref -QT) at a given interval. Thus, if at the pacing interval designated Io, the actual QT is less than the reference curve, as indicated at point 3i, then QTdif is greater than 0, indicating a desired increment in the pacing rate (decreasing pacing interval). On the other hand, if the measured QT is greater than the reference value, then QTdif is negative, indicating a decrease in pacing rate (increase in interval). This is summarized as follows:
______________________________________Point 3i: QT < QT.sub.ref QT.sub.dif = (QT.sub.ref - QT) > 0 increment pacing ratePoint 3d: QT > QT.sub.ref QT.sub.dif = (QT.sub.ref - QT) < 0 decrement pacing rate______________________________________
To obtain the second pacing parameter (ACT) a piezo-electric element (which may be S1 in FIG. 1) is suitably glued inside the pacemaker can. The activity sensor delivers an electrical signal that depends on vibrations of the can, which in turn are caused by movements of the patient and thus relate to exercise. The electrical signal is sensed by a sense amplifier, and the number of activity senses is counted. This number, Nact, is assumed to be proportional to the physical stress, and thus a measure thereof. Reference is made to U.S. Pat. No. 4,428,378, assigned to Medtronic, Inc., which discloses a rate adaptive pacer utilizing an activity sensor, and which is incorporated herein by reference.
The activity signal Nact, which is a unitless number, is converted in the practice of this invention to have the same units as QT, i.e. ms, by the following formula:
ACT=ACTmpl * Nact
By this conversion, Nact can be compared to the QT variable in a combined QT plus ACT algorithm. It is noted that the number of activity senses can be counted in two ways. In a first method, a programmable time is utilized, providing the following formula:
Nact=Fact * (Δt)=counts;
ACT=ACTmpl * Fact * Δt,
where Fact=activity frequency (S.sup.-1), and Δt is the programmable time in seconds.
Alternately, Nact can be a counted over predetermined number (N) of intervals, resulting in the following equations:
Nact=Fact * N* int/1000
where int is in ms; and N is the number of counting intervals;
ACT=ACTmpl * (Fact * N * int/1000)
In a preferred embodiment, means for obtaining the ACT signal are controlled by a software routine which is entered once every cycle. If the system is programmed to utilize the activity signal, the routine checks to see if Nact is to be read on an interval or time basis. If the moment to read has not arrived, the routine skips out. However, if the moment to read is present, the routine gets the counts (Nact) from the activity sensor and resets the activity counter for the next cycle. Then, optionally, the routine may limit any change in Nact compared to the prior value, if pacing rate is close to URL. Following this, the ACT signal is generated on the basis of the following equations:
temp: (Nact-ACTdr)
ACT=ACTmpl * temp,
where ACTdr is a drift factor, as discussed more fully below.
Referring to FIG. 5, there is shown the relation between activity frequency (Fact) and ACT, with ACT presented as a function of interval. Curve (1) represents ACT for medium activity, while curve (2) represents ACT for maximum activity. This figure illustrates how Fact increases as a function of patient activity, and it shows the conversion from Fact to ACT. It is noted also that in this case Nact is counted over N intervals, and that ACT increases as a function of interval (if ACT were determined per a given time period, each ACT line corresponding to a given activity level would be horizontal, and not a function of pacing interval). FIG. 5 also shows the ACTref curve (3) superimposed on the ACT curves for maximum and medium activity. It is noted that the ACTref curve must be at zero at LRL, corresponding to no activity when the patient is at rest. The curve must extend to the maximal ACT at URL, corresponding to the highest pacing rate at maximum patient activity. The ACTref relation is chosen to be linear, according to the following formula:
ACT.sub.ref =Dact (T.sub.LRL -int)
FIG. 5 indicates, at point 4i, a situation where the measured activity level at a given interval (I0) is greater than ACTref, indicating that the pacing rate should be incremented; and the situation at point 4d, where the activity level is less than ACTref, indicating that the pacing rate should be decremented. This is summarized as follows:
______________________________________Point 4i: ACT > ACT.sub.ref ACT.sub.dif = ACT.sub.ref - ACT < 0 increment pacing ratePoint 4d: ACT < ACT.sub.ref ACT.sub.dif = ACT.sub.ref - ACT > 0 decrement pacing rate______________________________________
In the preferred embodiment, as discussed above, there are two coupled reference curves, as shown in FIG. 5. Thus, at the programmable LRL, the QT reference curve correlates minimum stress patient QT at rest and the LRL interval; and the ACT reference curve correlates the minimum patient activity signal at rest and LRL. Likewise, at URL, the QT reference curve correlates patient QT reached at maximum stress and URL, and the ACT reference curve correlates maximum stress ACT and URL. The curves are coupled in the sense that each is designed to indicate approximately the same pacing rate within the LRL-URL range for varying activity or stress levels.
The decision as to whether to increase or decrease pacing rate depends upon comparisons of QTdif and ACTdif, as illustrated in FIGS. 7A, 7B-12A, 12B. FIGS. 7A and 7B illustrate the situation where ACT is greater than ACTref and QT is less than QTref. Note that when QT is less than QTref, a higher rate is indicated; when ACT is greater than ACTref, a higher rate is also indicated. Thus, in this situation, both difference indicators signal an increasing exercise level, calling for an increase in rate. In FIGS. 8A and 8B, ACT is less than ACTref and QT is greater than QTref. Again, both difference values indicate a decreasing exercise level, so the algorithm prescribes that the rate goes down. In FIGS. 9A and 9B, ACTdif indicates a decremented pacing rate, while QTdif indicates an increased pacing rate. In accordance with this invention, since QTdif is greater than ACTdif, the QT influence prevails and the algorithm calls for the rate to go up. In FIGS. 10A and 10B, the situation is the same as in that of FIGS. 9A and 9B, except that ACTdif is greater, and the algorithm responds to prescribe that the rate goes down. In FIGS. 11A and 11B, ACTdif signals increasing exercise, while QTdif signals decreasing exercise. Since the QT influence is the largest, the algorithm calls for the rate to go down. In FIG. 12, the situation is the same as FIG. 11, but since the ACT influence is the largest, the algorithm prescribes that the rate goes up.
As seen from FIGS. 9A, 9B-12A, 12B, the relative influence of the QT and ACT signals are compared by the algorithm to determine, in certain situations, whether the activity parameter or the QT parameter prevails in causing pacing rate to increase or decrease. The relative influence of the activity sensor on the pacemaker response depends upon the comparison between the maximum value of ACTref at URL, and QT for the highest stress level at URL (QTSTR(max)). The value for QTSTR(max) may not be precisely known for the patient, but generally can be estimated to be approximately 30 ms The maximum value of ACTref at URL can be set so as to give any fixed relation to QTSTR(max). The pacer variable ACTmpl then must be set such that ACTmpl * Nact matches such maximum ACTref at URL. Note that ACTmpl determines the ACT signal, so if ACTmpl is small, this minimizes the influence of ACT. Likewise Dact, which represents the linear variation of ACTref with interval, establishes desired variations of pacing rate with change in activity level, and if Dact is small, this also minimizes the influence of ACT. On the other hand, if both Dact and ACTmpl are relatively large, then ACT has a relatively greater influence on the decision made by the algorithm to increase or decrease pacing rate.
Referring to FIGS. 13A, 13B, 14A, 14B, and 15A, 15B, there are represented three situations which illustrate the relative influence between QT and ACT. In all three figures, ACT indicates an increasing exercise level, whereas QT indicates a decreasing exercise level. In the situation of FIG. 13A, 13B, ACTmpl and Dact are small (A<B), so ACT has little influence (C<D). Since QT has the greater influence, the rate is caused to go down. In FIG. 14A, 14B ACTmpl and Dact are chosen such that ACT and QT have substantially equal influence (A=B), and the algorithm will maintain pacing rate the same (except that each single step it will increment or decrement). In the situation of FIG. 15A, 15B, ACTmpl and Dact are relatively large (A>B), causing ACT to have greater influence (C>D). This results in the algorithm causing the rate to increase.
Referring now to FIG. 16, there is shown a flow diagram of a preferred rate algorithm incorporating both the QT and activity (ACT) variables. The steps of this specific algorithm are carried out each cycle following delivery of a pacing stimulus. Reference is also made to FIGS. 7-15 which illustrate the effect of the algorithm under varying situations.
As indicated at 71, it is first determined whether the pacing rate is near LRL. This is done by comparing the measured time interval (Ttx) to the value of the interval corresponding to LRL (TLRL) minus 25.6 ms. If Ttx is smaller than this interval, meaning that it is not within 25.6 ms of lower rate limit interval, then the program branches to block 72 where it is determined whether the T wave has been sensed. If yes, or if the actual pacing interval is within 25.6 ms of TLRL, the program branches to block 76. If no T wave has been sensed, such that QT rate information is not available, the program branches to block 73 where the last measured QT value is increased by an arbitrary amount, e.g. 50 μs. Thus, the pacer provides a drift to the QT value which causes it to increase toward TLRL when no T waves are sensed. However, when the pacing rate comes near to LRL, the drift in QT stops. In practice, the drift of QT is limited to a predetermined value, since a high activity level sensed by the activity sensor could maintain the pacer far from LRL, in which case a prolonged period of absence of T wave sensing would cause the variable QT otherwise to drift lower than a value corresponding to TLRL.
Following the decision as to whether to cause QT to drift, the software makes a decision as to whether to increment or decrement the rate, in accordance with the steps carried out at blocks 76, 77, 79, 80 and 82. As indicated at block 76, the difference variables, ACTdif and QTdif (as defined above), are determined by subtracting the ACT and QT values from their respective corresponding reference values at the current interval, Ttx. As per the above discussion, an increase in the ACT variable so that it has a higher value than the ACTref variable is an indication of increase of rate, such that a negative ACTdif indicates a desired rate increase, and vice versa. At the same time, a decrease in sensed QT value to the point that it is less than QTref, causing a positive QTdif, indicates a rate increase, and vice versa. Thus, while the difference variables are comparable in the sense that ACT is treated as a substitute parameter to QT, the difference in sign needs to be taken into account. At block 77, the pacemaker determines whether it is in the QT mode, i.e. whether the QT parameter is being utilized. If no, the program branches to block 82 where further logic is based on the activity signal alone. If yes, the program goes to block 79 where the signs (plus or minus) of ACTdif and QTdif are compared. If these signs are found not to be equal, in other words unequal, the program branches to block 82. In such case, both variables point to the same direction of change (FIGS. 7 and 8), and at 82 ACTdif is utilized to determine whether the rate should be increased or decreased. If ACTdif is negative, then an increase in rate is indicated, and the program branches to block 88. If ACTdif is not negative, then a decrease in rate is indicated, and the program branches to block 84. Note, as discussed above, there can be two situations where the difference values have equal signs, namely where QT is less than QTref and ACT is greater than ACTref ; and where QT is greater than QTref and ACT is less than ACTref. However, if at 79, the difference variables have unequal signs, which happens in four situations, the program branches to block 80. There it is determined which parameter has the greatest influence, by determining whether QTdif is greater than ACTdif. If yes, an increase in rate is called for, and the program branches to block 88. If no, a decrease in rate is called for, and the program branches to block 84.
At block 84, the current interval Ttx is increased by 5 ms, i.e. the pacing interval is increased by 5 ms Then, at block 85, new points on the QT reference curve and ACT reference curve are calculated, to correspond to the new interval. The new QTref is calculated by increasing QTref by an incremental amount "curve" calculated as follows:
Curve=Dpt+B (TLRL-Ttx)
At the same time, a new point on the activity reference curve is calculated by decreasing ACTref with the value Dact. ACTref cannot be decreased below a predetermined minimum. Thus, the decision to decrease rate results in increasing the interval by 5 ms, and adjusting the reference points on the reference curves of both QTref and ACTref.
If the comparisons made at blocks 79 and 80 indicate an increase in rate, the program proceeds to block 88 where a calculation of step size is made. The interval change during increase of rate is made dependent upon the interval, i.e., Ttx. This feature limits change of pacing rate at very high rates (corresponding to short intervals) and permits larger pacing interval changes with increasing intervals. For the preferred embodiment, the correspondence between interval and step size is set forth in the following table:
______________________________________Interval Stepsize______________________________________<614.4 ms 5 ms = 1 * 5 ms614.4-819 ms 10 ms = 2 * 5 ms819.2-1024.0 ms 15 ms = 3 * 5 ms>1024.0 ms 20 ms = 4 * 5 ms______________________________________
A computer value "LOOP" is set to N=1, 2, 3 or 4 depending upon the selected step size. Following determination of step size, the software goes into a loop comprising blocks 92, 94 and 95. At 92, a new value of QTref is determined. QTref is decremented by the amount indicated as "curve", being the same amount set forth below with respect to block 85. A computer value "temp" is determined, which is used to increment ACTref if URL has not been reached (as discussed below in connection with block 102). Temp, which is initialized at zero when the LOOP value is set, is incremented by the constant Dact. Next, at block 94, the pacing interval is decremented by 5 ms. The variable LOOP is decremented by one, and then at 95 it is determined whether LOOP is zero. If no, the software loops through blocks 92 and 94 again, until LOOP variable is zero, at which time it exits. Thus, for every step decrease in interval a corresponding step in QTref and ACTref is calculated, to adjust the reference curves. Thus, QTref is decremented and ACTref is incremented in the loop a number of times corresponding to the calculation of step size at block 88.
Referring now to FIG. 17, there is illustrated a portion of the algorithm for adjusting operation at URL. The QTref curve at URL is controlled by the factor B, such that QT response at URL can be adjusted by changing the value of B. The algorithm of this invention utilizes the logic that if QT shortens more than a programmable threshold (pacer variable CRVMAX) after pacing rate reaches URL, then URL was reached too quickly for the patient. Thus, the condition is met if
where QTsave=QT.sub.ref -CRVMAX.
The QTref curve is adjusted by incrementing B, which effectively lowers the value of QTref at URL. B is incremented if:
1) the pacing rate has reached URL;
2) after reaching URL, QT shortens additionally by at least an amount equal to CRVMAX; and
3) QTref -ACTdif<QTsave.
Note that if the third condition is not met, then decrementing the value of B would mean that the pacemaker could not reach a stable point on the reference curves where QTref -QT=ACTref -ACT.
The activity response may also be adjusted as a function of conditions at URL. Note that ACTmpl * Nact must match the maximum ACTref value at URL. Since the coefficient Dact is programmed and cannot be automatically changed, ACTmpl is decremented one step whenever the pacer reaches URL and ACT exceeds the programmable variable ACTmax. Whenever ACT mpl has been decremented, it will automatically be incremented once later, e.g., after 8 days.
Still referring to FIG. 17, following an increase of the rate (decrementing interval), the software goes from block 95 (FIG. 16) to 97, where it is determined whether pacing rate has reached URL. Thus, if Ttx is smaller than TURL, upper rate limit has been reached and the program branches to 105. If no, upper rate limit has not been reached and the program branches to block 98. At block 98 it is determined whether the pacing rate has come within 25.6 ms of upper rate limit. If yes, at block 101, a "new URL adapt" is enabled. Since Ttx is less than TURL, ACT ref is adjusted by adding "temp" as calculated at block 92.
Returning to block 105, if URL has just been reached, and new URL adapt is enabled, the program branches to block 109. At this point QT is compared to QTsave, as defined above. If QT is less than QTsave, a software save register is set so that during the next cycle at 105 the answer is no, and the program exits. In the next cycle, at 105 the program branches to block 106. If URL has already been adapted, the program exits; if not, it branches to 112 where it is determined whether ACTdif is positive. If yes, the program branches to block 114. There the difference between QTref and ACTdif is compared to QTsave. If this difference is positive, the program exits. If this difference is less than QTsave, it means that ACTdif is greater in magnitude than the increment CRVMAX, such that QTref at URL can be decremented. The program then proceeds to 118 to determine whether the B variable can be incremented. If it can, at 122 B is incremented, and then at 124 the new URL adapt flag is disabled. Returning to block 112, if ACTdif is not positive, at 113 the algorithm determines whether the negative of ACTdif is greater than the maximum value of ACT. If no, then B can be incremented and the program branches to 114. If yes, it means that the 5 NACT counts exceed a predetermined value and the program goes to 117 where it is determined whether automatic decrementing of ACTmpl is enabled. If yes, at block 121, ACTmpl is decremented, and the program branches through to 124.
The pacemaker of this invention also provides for automatic adjustment of rate response at LRL, as set forth in U.S. Pat. No. 4,972,834. When the patient is at rest (and the pacing rate is near LRL, the pacemaker paces for a while at LRL and calculates an average QT at LRL. The pacemaker then decreases the pacing interval by a small amount and calculates a second QT average at the second interval, near LRL. The difference in two QT averages and the difference in the two intervals are divided to provide the coefficient corresponding to pacer variable Dpt. This is compared to the prior value of the coefficient, and the value of Dpt is then adjusted one step in the direction of the indicated change. Thus, if the ratio indicates a greater slope at LRL than had 2.5 previously represented by the value of Dpt, Dpt is increased so that the QTref curve near LRL is steeper. By this technique, after a number of such slope measurements the QTref curve near LRL is adapted to substantially match the QT curve of the patient's heart.
Referring now to FIGS. 17, 18A, 18B, 19A, and 19B, there is illustrated the drift action incorporated in the preferred embodiment, for adjusting the ACT parameter in situations where the activity signal does not correlate with QT. It is known that the activity sensor is not always a proportional indicator, and excessively high activity level may be indicated in several situations. For example, if the patient is in rest and yet activity signals are counted, e.g., caused by respiration or the patient's heartbeat, the activity indication is too high and should be decremented. Likewise, there are situations where Nact may be too high to correspond to the actual exercise level, such as where vibrations are sensed which are caused by external forces. To account for these influences, and decrease the ACT signal accordingly, ACT is periodically compared to ACTref, as seen in block 150. Since the QTref curve and the ACTref curve are coupled so that movements along the QTref curve should be matched with movements along the ACTref curve, if ACT does not match ACTref, this is an indication that the sensed activity signal is incorrect. By causing the ACT signal to drift in such a situation, i.e., by adjusting it to decrease the magnitude of ACTdif, the activity information is correlated with the QT information. To accomplish this, ACT is adjusted by a drift signal, referred to as ACTdr, according to the following formula:
ACT=ACTmpl * (Nact-ACTdr)
As can be seen, the drift factor, ACTdr, essentially compensates for any inaccuracy in the sensed Nact variable. If ACT is measured to be larger than ACTref, ACTdr is increased, thereby causing ACT to decrease, bringing it back into correlation with QT. At block 152 of FIG. 17, if ACTref is found not to be greater than ACT, the program branches to block 153, where ACTdr is incremented by one unit, which results in a decreased value of ACT. The algorithm checks at block 153 to set an upper limit on the value of ACTdr. If the comparison at 152 is such that ACT is less than ACTref, then the program branches to block 155, and decrements ACTdr. A limit is placed on ACTdr such that it cannot go below zero. In this embodiment drift compensates only for false positives: a rate indication by the activity sensor which is high compared with the QT information. Thus, the algorithm periodically introduces the drift factor compensation into the ACT signal, thereby either increasing or decreasing the ACT signal. This is illustrated in FIGS. 18A, 18B, 19A and 19B for the situation where ACT is greater than ACTref. As indicated in FIG. 18B, the QT signal is greater than QTref, indicating that the pacing rate should go down, i.e., interval should increase. However, ACT is greater than ACTref, and ACTdr is incremented. When the pacemaker stabilizes to a final situation, as shown in FIGS. 19A, 19B, ACTdr has been incremented so that the actual ACT has come to equal ACTref. In FIGS. 19A, 19B, for the increased pacing interval, the ACT curve with drift is shown at curve 6, being displaced downwardly from curve 5 without drift (which corresponds to actual Nact). Note also that the position on the QTref curve has changed so that it corresponds to a lower actual stress, and QT equals QTref. In the reverse situation where ACT is less than ACTref, ACTdr would be decremented to bring the ACT signal back into correlation with the QT signal, limited by the fact that only positive ACTdr values are allowed.
The embodiment as illustrated permits drift to correct only for a false positive, i.e., the situation where the second sensor value (ACT) gives too high an indication compared to the first sensor value (QT). However, the algorithm can be adapted to apply drift for a false negative, e.g., by decrementing ACTdr to a negative value. Also, it is to be understood that the drift feature may be programmed to compensate the fast sensor by other than fixed steps in order to reduce the fast sensor influence to or toward zero over time.
As discussed above, the system and method of this invention is applicable to employing two or more control parameters. It is noted that hardware simplification of the system can be achieved if a second or extra control parameter can be obtained without the need of an extra sensor means. This can be achieved in a system where QT is a primary parameter, by utilizing another parameter obtained by the sensed heartbeat signal. For example, the amplitude of the T wave (TwA) can be utilized as a control parameter separate from QT, as can other features of the Q or T wave portions of the sensed heartbeat signal. See U.S. Pat. No. 4,305,396. The parameter TwA has a reasonably quick response, i.e., reacts to changing patient conditions more quickly than does the QT interval. Thus, TwA is a good choice of a second parameter to be used in combination with QT. In accordance with this invention, the amplitude of the T wave can be determined each cycle by signal processing circuitry such as illustrated at block 58 of FIG. 1. Data for a TwA reference curve may be programmed into the pacing system to provide a coupled reference curve, as well as conversion data for converting the amplitude signal into a comparable signal with units of ms. Such a system has the advantage of needing no extra sensor, since both control parameters are obtained from the same pacing lead 53 as is conventionally used for introducing stimulus pulses into the ventricle. Alternately, the TwA or any other control parameter derived from the sensed heartbeat signal may be utilized as a third control parameter. Of course, while the preferred embodiment of this invention has been illustrated as using QT as a primary control parameter, it is to be understood that any other sensor signal could be the primary control parameter, and the secondary parameter would be converted into the units of the first parameter. This invention embraces control parameters such as AR interval, R wave morphology, T wave morphology, impedance changes, and other variables including those set out above under the Description of the Background, in any combination of two or more.
While the invention has been illustrated by description of preferred embodiments, it is noted that it is limited only by the claims hereto. For example, the important feature of providing comparable parameter variables may be utilized without some of the other techniques as disclosed. For example, instead of obtaining difference values (e.g., QTdif and ACTdif), the parameter values may be compared on another basis. Further, actual rate control may be achieved by changing pacing interval directly to the point on the reference, or correlation curve corresponding to the sensed parameter, rather than simply incrementing or decrementing by a given amount. Such variations are programmable and are within the scope of the invention.
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|Oct 6, 1994
|Nov 22, 2000
|Vitatron Medical B.V.
|Rate responsive pacemaker with improved rate change dynamics
|Dec 3, 1998
|May 23, 2001
|Vitatron Medical B.V.
|Implantable pacing system
|May 11, 2011
|Jun 13, 2012
|Fraunhofer-Gesellschaft zur F�rderung der angewandten Forschung e.V.
|Apparatus and method for decomposing an input signal using a pre-calculated reference curve
|Jul 20, 1994
|Apr 27, 1995
|Cardiac Pacemakers, Inc.
|Multi-sensor blending in a rate responsive cardiac pacemaker
|May 22, 1996
|Nov 28, 1996
|Vitatron Medical, B.V.
|Cardiac pacemaker system and method for determining a measure of pacing threshold without incurring loss of capture
|Jun 9, 1998
|Dec 17, 1998
|Intermedics Inc.
|Defibrillator with improved hemodynamic response and enhanced myocardial stability
|Mar 1, 2002
|Sep 19, 2002
|Medtronic, Inc.
|Rate adaptive pacemaker system with dual sensing component and method of using same
|Nov 13, 2002
|May 30, 2003
|Rate responsive pacing system with qt sensor based on intrinsic qt data
|Mar 20, 2003
|Nov 13, 2003
|Medtronic, Inc.
|Method and apparatus for rate responsive adjustments in an implantable medical device
|Jun 21, 2006
|Dec 27, 2007
|St. Jude Medical Ab
|Implantable heart stimulating device with stimulation rate optimization
|Nov 22, 2011
|Jun 14, 2012
|Fraunhofer-Gesellschaft zur F�rderung der angewandten Forschung e.V.
|Apparatus and method for decomposing an input signal using a pre-calculated reference curve
|U.S. Classification
|607/18, 607/25, 607/19
|International Classification
|Cooperative Classification
|European Classification
|Dec 3, 1990
Owner name: VITATRON MEDICAL, B.V., KANAALWEG 24, 6950 AB DIER
Free format text: ASSIGNMENT OF ASSIGNORS INTEREST.;ASSIGNORS:BEGEMANN, MALCOM J. S.;DE VRIES, BERNHARD;VAN DER VEEN,JOHANNES S.;REEL/FRAME:005515/0476
Effective date: 19901114
|Apr 26, 1995
|Fee payment
Year of fee payment: 4
|May 3, 1999
|Fee payment
Year of fee payment: 8
|Mar 31, 2003
|Fee payment
Year of fee payment: 12
|Jun 4, 2003
|Maintenance fee reminder mailed

subset: commoncrawl


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Edward David Abbey, died Monday, July 18, 2016 at Butterworth Hospital in Grand Rapids, MI following an extended illness. Ed was born in Lakeview, Michigan on October 22, 1963 into the Abbey family the last of four children. He met his wife Kari, at a convention in Milwaukee, Wisconsin. They married April 3,1983 and began their family the following year and raised five children. He worked for Montcalm County Road Commission where he was a valued employee. During his life he enjoyed hunting, fishing, gardening and especially spending time with his family. Ed was one of Jehovah's Witnesses and attended the Sign Language Congregation in Grand Rapids, MI. Ed's personality is best expressed by his given name in sign language which translates to "Big Heart" in English. This was evident in how he took care of others by sharing his Bible-based hope of enjoying perfect health on a paradise earth soon. - Revelation 21:3,4.
He was a good man, son, father, and brother. He will be missed by many. He raised a beautil family whom all love Jehovah. He's now in Jehovahs memory and we're looking forward to seeing him again. 😘
He was also a good husband to his beloved wife. To us, they seemed perfect for each other. Raising 5 children they can surely be proud of. Ed was an outstanding example as a father, husband and
elder. We won't forget him😊
He was so full of life and humor and I know he appreciated all the love and support from the friends and family. Ed will be missed but not forgotten. Hugs from Pammy
Ed was very loved and admired by our family. A huge loss. Love Ron Thurston and family.
3 John 14 "However, I am hoping to see you soon, and we will speak face-to-face. May you have peace."
I love these words, because even though written as a letter to others, it has meaning to us today.
We will see Ed again and there will be Peace!! Peace among all!
The Teeter Family sends their condolences. Ed will be missed until we see him again just around the corner. Can hardly wait until that day when Jehovah brings him back to you! Until then we pray that
God gives you the strength and endurance to continue on.
With warm Christian Love,
The Teeters
Business Office
Brigham Funeral Chapel - Lakeview
9977 W. Howard City-Edmore Road
Lakeview, MI 48850
(989) 352-5400
Brigham Funeral Chapel - Vestaburg
6055 Howard City-Edmore Road
Vestaburg, MI 48891
(989) 427-0900
Brigham Funeral Chapel - Edmore
413 Gilson Street
Edmore, MI 48829
(989) 427-5261
Brigham Funeral Chapel -
Six Lakes
PO Box 320
118 Center Street
Six Lakes, MI 48886
(989) 365-9433
Email: email@example.com
Normal business hours are Monday through Friday, 9 a.m. to 5 p.m. You can reach us any time day or night in the event of a loss, at any listed number above.
Please immediately notify your local police department as soon as the death occurs, if it is outside of a medical facility.


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The 2014 Emmys telecast approaches, and although the television academy's official voting period is over, it's not too late to make your predictions about who will walk away with a statuette from the 66th Primetime Emmy Awards.
Use our play-at-home ballot of some of the top categories to make your picks, then save and share your chosen winners on Twitter and Facebook.
HBO and "Game of Thrones" led the pack when nominations were announced, with the fantasy series earning 19 of the cable network's 99 total nominations, including one in the coveted drama series category. Other top nominees include FX's "Fargo" and "American Horror Story: Coven," which are both in the running for the miniseries award. You can check out the complete list of nominees and Creative Arts Emmy winners, which were announced Aug. 16, here.
For those of you not quite caught up on all the nominated series (and who could blame you, the new golden age of television means there are quality shows aplenty), take a peek at what some TV experts have predicted will take home the prize in the top races or compare notes with Gold Standard columnist Glenn Whipp. More in-depth analysis and Emmys coverage, including video interviews with nominees, is available at The Envelope.
Make sure to check back to see how your picks stacked up after the winners are announced Monday. The 66th Primetime Emmy Awards will be held at the Nokia Theatre in Los Angeles, hosted by Seth Meyers.
What are your Emmy picks? Let me know on Twitter: @tracycbrown


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From small, fledgling startups to large, well-established corporations, many organizations need to look outside their ranks for marketing help at some point. Even those with internal marketing teams often find they can get better ROI by partnering with a marketing agency that can lend additional expertise and manpower.
Whatever an organization's reason for hiring a marketing agency, the internal stakeholders need to understand this isn't the sort of business relationship where they write a check and the external marketing team does all the work. The agency team and the client team both have roles to play to achieve a successful outcome.
So if you're hiring a marketing agency to help with some — or all — of your organization's marketing efforts, you need to be prepared to do your part so you can get the best possible ROI.
Here's how.
Educate the Agency
If you've done your research and chosen well, your marketing agency is staffed with smart, savvy professionals who know how to promote your organization through creative marketing campaigns. But that's not enough for an agency to get guaranteed results.
Your marketing agency team will do their research, but to learn about your organization, they're going to need insight from you and your internal team about these topics:
- Your goals. What do you want to accomplish with your marketing? What do you consider a marketing success? Do you want to provide value to existing customers? Attract new customers? Build your company's brand recognition?
- Your priorities. If you have multiple goals and limited time or budget, you may have to prioritize. What do you want to happen first? What can wait until later?
- Your customers. Who are your customers? What are they looking for? What do they value? What problems do they have that they're looking to you to solve? What do they know? What do they need to be educated about? Your marketing agency can help you build detailed buyer personas, and any information you can provide from actual client interactions is extremely valuable.
- Your products and services. What are you selling? What sets your products and services apart from what the competition is offering? What do customers love about them? What are customers' critiques of them? Your marketing agency needs to understand all the pros and cons of what you're selling so they can craft a strategy to accentuate the pros and minimize or mitigate the cons.
- Your industry. What terminology is commonly understood in your industry? What problems is the industry facing? What's going well? What do insiders need to know?
- Your company. What is going on within your company as a whole and how do your marketing goals fit into the bigger picture? Are there any internal conflicts, challenges or upcoming changes that may affect the marketing process?
Keep in Touch
No matter how much input you give your marketing agency at the outset, the team there isn't going to learn everything they'll need all at once. You need to be available to answer their questions and share additional information as needed.
Make sure they know who on your team is the main agency contact. Who should the agency go to with questions? If that main contact is going to be out at a conference, on vacation or on maternity leave, let your marketing team know and give them an alternative contact.
When your marketing agency sends over drafts of marketing materials, ideas and other information, be sure to respond by the requested deadline whenever you can. When you can't respond on time, let them know why and when you expect to be able to respond with the information they need.
Creating high-quality, effective marketing strategies, tactics and materials requires feedback and collaboration. If you don't provide this feedback and make an effort to collaborate, you're setting your marketing agency up for failure and it will be difficult — if not impossible — for them to give you what you want.
Understand the Timelines
Your marketing agency wants to help you as quickly as they can. Typically your agency will explain their process and how much time they think work will take to complete. Make sure you understand the timeline and note that some of those steps involve input from you, such as background information, brand guidelines, connections to internal resources and feedback on drafts. When you don't complete your tasks as laid out in the timeline, it affects every step after and increases the amount of time it will take to complete the project.
If you've hired a reputable marketing agency, they want to do great work for you. But, agencies can't operate in a vacuum. Do your part to help them do their job and you'll be happy with the work they produce.


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Minding Our Elders®
Speaking Testimonials
Comments from the Dementia Workshop sponsored by Guardian and Protective Services:
Excellent! The personal touch was great, and it was good to end (a long workshop) on a lighter note.
I was the caregiver for my grandmother...the person who she took out her anger on. No one ever told me to take a break and not feel guilty. Really, the presentation was beautiful. Thank you!
Wonderful! Hopeful and peaceful on the heels of all the legal stuff (of the event). The stories were worth savoring.
Touched on an important point – let yourself feel the grief and frustration without feeling guilty. Giver yourself a break. Good to have the first-hand accounting of a caregiver.
The information was wonderful! My mother is dealing with this with my grandpa...the speaker was excellent. Her own personal story is very touching. I enjoyed the reading from her book.
A wonderful speaker with a caring voice. Straight forward, honest and helpful!
Carol, I would like to take this opportunity to express my sincere appreciation to you for taking your valuable time to provide a presentation for the Fargo VA employees entitled Minding Our Elders. We gathered so much important information that we can utilize in our every day practice. You were right on target with your comments to include the importance of including family in those key discussions. I heard so many positive comments about your presentation and I plan to discuss many of your comments with our Customer Service Team.
Karen R, Robinson, PhD, RN
Associate Director for Patient Care Department of Veterans Affairs Fargo, ND
Carol, What a tremendous job you did speaking today! I really, really appreciate your speaking style, and the depth of content which you shared. I struggled to not sob outloud! The part about when your Dad died in your arms...I was choked up and wiping away tears as unobtrusively as I could. While it's something I'd rather avoid (crying in public) I think it was worth it because of the value of the content of your presentation. I think you touched a lot of hearts and made the point of what it's all about. Thanks for being so open with your thoughts and feelings. What a gift! I also want to commend you for including the spiritual in your talk. It may be risky to share that you actually sensed his spirit leaving, but I think people are too much in denial about things of the spirit, and they need to hear it now and then from credible people like you.
Julie Sorenson Safe Stay, Moorhead, MN
Carol, I want you to know it was my privilege to hear you speak about your book. Your honesty and compassion for caregivers and their loved ones is overwhelmingly fresh. I was surprised to realize I was moved to tears by your stories as you were re-living many of the emotions the people I counsel experience. It is clear to me that this is your ministry.
Doreen Vosburg Vosburg Counseling...for Seniors
Carol Bradley Bursack is a dynamic speaker. Her message was not only informative, but it was heartfelt. I look forward to attending more gatherings where she will be presenting.
Laura HagenDirector of Social Services Pelican Valley Health Center
Dear Carol, I read your column every week, but hearing you in person and listening to your stories and experiences brought not only tears but laughter. You are right – we are not alone!
Maggie Driscoll Oaks Program Director


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reDiscover is a great place to make corrections when Mother has been deceived by the law and friends. On reDiscover this Mother learned gets "sole legal and physical custody back of her oldest son on 11/24/2014" and "Sole legal and physical custody back her youngest son on 11/24/2014" because children need to be with their Mothers in their own cozy home that they truly just love withe their mommy they "love so dearly" who and were ripped away by corrupt people! The perks of reDiscover are endless because now Mommy has her boys, a house, and plenty of money due to the corrupt legal system and corrupt friends that should they have not been so supportive after she caught them on reDiscover, this brilliant Mother "custody of her her two most precious boys in life!" would have still been wondering what was missing and wrong with all that had happened. "It's all about the money! and that is "why several people are sitting in jail today on this glorious day, November 24, 2014!" Just for you ""Joan and Bryan Carmichael" rediscover put both of you right where you belong with the others, "in Jail for what you have done" all thanks to reDiscover, this Mommy does not have to work because of all the money she "gained from suing all those involved in their scheme" and "now Mommy gets to have plenty of money a new "BEAUTIFUL home, AND HER PRECIOUS LITTLE ONES BACK' all on this "BEAUTIFUL day of November 24, 2014" Thanks reDiscover, I couldn't have asked for better "surprises and Gifts that I have deserved all along and "THAT NEVER SHOULD HAVE BEEN TAKEN AWAY!" " People see a single Mother and target her, well thanks again, reDisover "for correcting this and making my boy's and my life WONDERFUL!" All of you thieves and mentally ill people who took part in this "all for money" and "were" involved will pay me and are indebted to "ME and "MY BOYS!" for the rest of your miserable lives for what you have done to "me and MY Precious boys, Riley and Brayden" I don't know what I would have done had I not figured it out on reDiscover, which led me to finding "TRUE EVIDENCE!"
This is an awesome place; great for spending some time rain or shine to explore one's imagination and create! I bring my kids every now and then and we build cool stuff. They love and I love it. Working with found objects - trash to some, perhaps, but wonderful raw materials to build with and explore. Great for all ages, from simply doing simple crafts to learning about different properties for different materials and solving engineering challenges for older kids.
I love the very existence and mission of ReDiscover. They marry recycling industrial materials with creative art curricula for school children in a truly win/win scenario. There is so much ReDiscover can do if they had more volunteers spearheading initiatives, projects, and outreach. They are a valuable community resource and it would be great if more schools, creative programs, teachers, and artists knew about them. They are an asset to Los Angeles.


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A recent article in WardsAuto.com by Drew Winter caused a bit of a stir with its title, "The Nanny State Eyes Nanny Cars." The gist of the story is that the National Highway Traffic Safety Administration (NHTSA), after its July 2011 roundtable in Washington, D.C. on child hyperthermia may be eyeing technology as a preventive measure to child heatstroke deaths.
FamilyCarGuide, while appreciative of the perspective that education is of continuing importance, as further outlined in Richard Read's piece in TheCarConnection, wanted to hear the positions on the matter from two major child safety advocacy organizations, KidsandCars.org and Safe Kids USA.
Education is fine, but it's not preventing some avoidable child deaths
KidsandCars.org says that the popular belief among parents is that they would never inadvertently leave their infant or young child in a vehicle. Among the general public reading about child deaths due to hyperthermia or heat stroke is that the parents must be ignorant or completely irresponsible.
The important statistic to keep in mind is that in well over 50 percent of the cases of children dying in hot vehicles, the person responsible unknowingly left the child.
Educational efforts only go so far, especially if parents think this could never happen to them. According to KidsandCars.org, the parents they work with who have lost a child from vehicular heat stroke are the "kind of parents who take every safety precaution; they are loving, caring parents across all socioeconomic levels, race/ethnicity, age, gender and profession."
Technology already exists that can help
Testimony from Janette E. Fennell, founder and president of KidsandCars.org, before the Subcommittee on Commerce, Trade and Consumer Protection of the House Committee on Energy and Commerce, May 18, 2009 sheds some light on the education versus technology discussion. The following is excerpted from Ms. Fennell's remarks:
"Reminder systems to prevent unattended children can easily be incorporated after seatbelt reminder systems have been added. All too often, adults inadvertently leave infants and young children in child restraint systems in the rear seats of passenger vehicles. Exposure of young children, particularly in hot weather, leads to hyperthermia that can result in death or severe injuries. Such inadvertent deaths can be avoided by equipping vehicles with sensors to detect the presence of the child and sound a warning at the time the driver locks the vehicle with the child inside.
"These systems also prevent children from being inadvertently forgotten in vehicles by signaling the driver that a seat belt is still buckled once the vehicle is locked. Similar warning features currently remind drivers when they have left the key in the ignition, left the headlamps on and when a door is open while the vehicle is in motion."
Safe Kids USA education and prevention efforts
Torine Creppy, executive director of the Safe Kids child passenger safety program, "Safe Kids Buckle Up," spoke before the NHTSA roundtable on hyperthermia July 26, 2011. As background, Safe Kids USA is a prime source of safety information and programs for traffic safety issues, ranging from car seat installations, booster seat safety, pedestrian safety, to passenger safety programs for 11- to 14-year olds. For several years, Safe Kids has worked to prevent vehicular hyperthermia through its "Never Leave Your Child Alone" program.


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Hi All,
Normally I post these every 30 days, but a lot of bugs were uncovered in the recent release (a lot of events from Sentry, which I've set up), so I saw it fit to make another release.
Also, I'm glad to tell you there's been several improvements to the touch handling system, and the UI is now fully scalable
An early release containing mainly bugfixes. UI is now completely scalable and touchhandling has been updated.


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Delicious Apple Recipes to get you in the mood for fall/autumn. Choose from smoothies, salads, side dishes, main dishes, and desserts.
Delicious Apple Recipes
Best Ever Hearty Soups and Stews
A collection of the Best Ever Hearty Soups and Stews on the blog with heart and belly warming dishes for cooler days and colder months.
Top 10 Recipes of 2015
Top 10 Recipes of 2015 – the most pinned, shared, and viewed recipes on Roti n Rice.
The Turkey Strut and Duck Waddle
The Turkey Strut and Duck Waddle – watch this gobbler, display, fan, and strut in pursuit of a mate and a handsome pair of Mallard ducks waddling in the Prairie.
Our Vegetable Garden – Part 2
Our Vegetable Garden – Part 2 is an expansion of the existing lot to include 2 more vegetable beds for fall planting of corn and green beans.
Our Vegetable Garden
Our Vegetable Garden and shed that took all of 2 weeks to set up after more than 5 years of contemplation. A lot of hard work but totally worth the effort.
Introducing Malaysian Chinese Kitchen
Introducing Malaysian Chinese Kitchen and post on the origins of the Malaysian Chinese food, culture, and historical influences that shape its identity.
Top 10 Recipes of 2014
Top 10 Recipes of 2014 with the most pinned, shared, and viewed recipes. Tried and tested old favorites and a few new surprises.
25 Festive Dishes for the Season
25 Festive Dishes for the Season with appetizers, salads, main dishes, side dishes, desserts, cakes, and cookies to choose from.
25 Best Comfort Foods
25 Best Comfort Foods to prepare as the weather cools down. Choose from warm and delicious appetizers, soups, side dishes, main dishes, and noodles.
12 Recipes for Easter
12 Recipes for Easter to prepare for your weekend get-together. Choose from egg dishes, breads, salad, main dishes, and desserts.
Roti n Rice Channel on YouTube
Announcing the Roti n Rice Channel on YouTube with a short introductory video. Thanks for watching!
Goodbye Hello
Goodbye Hello – emerging from behind a pseudonym, looking back, looking forward with a little nostalgia over the change.
Sweet 16 Valentine's Day Recipes
Sweet 16 Valentine's Day Recipes for a romantic dinner or fun party. Choose from candy, cookies, desserts, cakes, ice cream, and fruit.
Top 10 Recipes of 2013, 4th Blogiversary, and Giveaway
Top 10 Recipes of 2013, 4th Blogiversary, and Giveaway – the most pinned, shared, and viewed recipes of 2013. Also a little giveaway.
Sacher Torte for 3rd Blog Anniversary and Cake Linky Party
A deliciously moist and dense two layered chocolate cake with apricot jam in the middle covered with a chocolate glaze.
Introducing Tea Tattler and Cup-Adorning Lemon Cookies
I am really excited to share with you my new site dedicated to the enjoyment and appreciation of tea. This new "shopfront" complements the food culture of Roti n Rice. Come join me for tea at my new virtual tearoom at Tea Tattler and on Facebook.
Happy New Year and 2nd Blog Anniversary
As 2011 draws to a close, I find myself reflecting on the past year with some satisfaction and also a small measure of angst. Satisfaction because I have managed to steer the blog through the "terrible two's" that seem to plague many blogs. There were the "rocks" of fatigue from posting week upon week, and…
Merry Christmas
As the Andy Williams' song would have it, Christmas can be the most "wonderful time of the year". Shopping, gift-giving and of course, cooking tends to push the season from busy to hectic in one short month. But I would like to pause and reflect on the "wonderful" part that makes Christmas the apex of…
The 7 Links Challenge
The 7 Links Challenge – the most beautiful, popular, controversial, helpful, surprisingly successful, deserving attention, and I am most proud of posts.
Yay…1st Blog Anniversary and a Giveaway!
Roti n Rice is ONE year old today and what a ride it has been! Exactly 365 days ago today, I sat down to inaugurate this blog as a journal of my culinary efforts. In my mind's eye I had visualized leisurely evenings recounting my latest food endeavor to a receptive community of my peers….


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Welcome to Greater Baton Rouge SHRM!
As President of the Greater Baton Rouge Society for Human Resource Management (GBR SHRM) I would like to welcome all new and returning members! 2017 brings a lot of excitement as we celebrate the 40th Anniversary of our original charter. In celebration of this milestone, special events are planned throughout the year!
Since 1977, GBR SHRM has served as a resource for local businesses and human resources professionals. GBR SHRM promotes fellowship and an understanding of human resource issues while providing a forum to exchange ideas relating to human resources management. GBR SHRM strives to increase effectiveness of both workers and management; and to keep members informed on industry trends.
As the premiere HR organization in the area, GBR SHRM has more than 470 members benefit from networking with HR professionals and companies. Member benefits also include local professional development opportunities; access to current best practices; opportunities to develop leadership skills; and development of a reputation and credential in the HR field.
Incredible things continue to happen with GBR SHRM and I do not doubt that we will continue to build on this momentum throughout the year! To join GBR SHRM or for more information, click on the JOIN NOW link above. Questions may be directed to the chapter's email address at email@example.com.
Don't delay enjoying the valuable benefits and resources of GBR SHRM. You will not regret it!
Lisa Warm Bonfanti
GBR SHRM President
Greater Baton Rouge Society for Human Resource Management is recognized by SHRM as a preferred provider offering Professional Development Credits (PDCs) for the SHRM-CPTM and SHRM-SCPTM Certifications.
Upcoming EventsSee All >
December 7, 2017 - 6:00pmLocation:Boudreaux's
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October 4, 2017
October 2, 2017
August 28, 2017


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Jayne Tonic Pills, original box, contents, and instructions for use, circa 1930's advertising it promotes appetite. Box is 2 5/8" by 1 1/4" square, missing top cardboard flap. Black metal twist off cap is printed D. Jayne. 10 sided glass bottle is 2 1/2" tall, 1" diameter, paper label and is embossed on the bottom D. Jayne USA 5. Bottle is clear molded glass. The bottle's label reads : "Jayne's Tonic Pills. D. Jayne. None Genuine without the signature. 60 Pills. Take 2 Pills After Each Meal. Children Half Dose. Dr. D. Jayne & Son Inc. Philadelphia, USA." The directions sheet measures 9 X 5 1/2 inches when unfolded, paper is aged as is normal. See photos all sides of bottle and box are shown. To purchase with MC or VISA please call Drury House Antiques 802-824-4395 EST or use PAYPAL
This is the last of a massive 12k piece antique pharmacy collection. Some of the best saved for last. It will take us a while but we will be actively adding items. So in addition to the 150+ pharmacy and drugstore items available for sale right now we will be adding more. All are ON SALE, tins, glass bottles, apothecary jars, unopened bottles in original boxes. All bottles are clean. NO damage, NO cracks, NO chips
2 other shoppers have this item in their Cart or Wish List .
LAMP SALE 20+ OVER 50% off Table, Chandelier, Hanging, Pendant 11/14 to 11/22
Holiday Sale Starts Now Buy Early & Save Marked Sale Price is UP-TO 50% OFF on 1200 Antiques, Collectibles