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A method and apparatus for treatment of heart failure by increasing secretion of endogenous naturetic hormones ANP and BNP such as by stimulation of the heart atria. Heart pacing is done at an atrial contraction rate that is increased and can be higher than the ventricular contraction rate. Pacing may include mechanical distension of the right atrial appendage. An implantable device is used to periodically cyclically stretch the walls of the appendage with an implanted balloon.
1. A method for pacing a heart of a patient comprising:
determining the patient is suffering from at least one of hypertension, and excessive retention of fluid and sodium;
during a first pacing period synchronously pacing at least one atria and at least one ventricle of the patient's heart;
during a second pacing period, asynchronously pacing the at least one atria of the patient's heart at an atrial pacing rate and synchronously pacing the at least one ventricle of the patient's heart at a ventricular pacing rate, such that the atrial pacing rate exceeds the ventricular pacing rate;
during the pacing of the second pacing period, stressing, beyond a natural stress condition, a wall of the at least one atria due to the atrial pacing rate, wherein the stressed wall secretes a hormone at an elevated secretion level above a secretion level occurring while a natural atrial rate and a natural ventricular rate are equal;
achieving a beneficial therapeutic effect in the patient by the elevated level of the secreted hormone, wherein the beneficial therapeutic effect includes at least one of: limiting a degree of vasoconstriction, limiting a degree of sodium retention, increasing urine output, inhibiting a renin-angiotensin system, inhibiting endothelin secretion, inhibiting systemic and renal sympathetic activity, and counteracting effects of at least one of norepinephrine, endothelin, and angiotensin II, and
repeatedly alternating the first pacing period and the second pacing period to pace the patient's heart, wherein each alternating second pacing period has a duration of at least ten minutes.
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8. A method for treating heart disease in a patient having a heart, the method comprising:
determining the patient is suffering from at least one of hypertension, and excessive retention of fluid and sodium;
during a first pacing period synchronously pacing at least one atria and at least one ventricle of the patient's heart;
during a second pacing period, pacing the patient's heart to cyclically stress walls of the at least one atria of the patient's heart and restore the walls of the atria to a substantially pre-stressed condition;
causing the stressed walls to secrete a hormone at an elevated level above a natural secretion level occurring naturally when the patient's heart is not paced;
achieving a beneficial therapeutic effect to the patient by the hormone secreted at the elevated level, wherein the beneficial therapeutic effect includes at least one of: limiting a degree of vasoconstriction, limiting a degree of sodium retention, increasing urine output, inhibiting a renin-angiotensin system, inhibiting endothelin secretion, inhibiting systemic and renal sympathetic activity, and counteracting effects of at least one of norepinephrine, endothelin, and angiotensin II, and
repeatedly alternating the first pacing period and the second pacing period to pace the patient's heart, wherein each alternating second pacing period has a duration of at least ten minutes.
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13. A method for treating disease in a patient having a heart, the method comprising:
determining the patient is suffering from at least one of hypertension, or excessive retention of fluid and sodium;
during a first pacing period synchronously pacing at least one atria and at least one ventricle of the patient's heart;
during a second pacing period, pacing the patient's heart to achieve an atrial contraction rate faster than a ventricular contraction rate, and
due to the faster atrial contraction rate, stressing the at least one wall of at least one atria of the patient's heart due to the pacing during the second pacing period;
due to the stressing of the at least one wall, inducing a tissue in the at lest one stressed wall to secrete greater amounts of a hormone as compared to a secretion amount of the hormone occurring when said pacing is not applied to the patient's heart, and
achieving a beneficial therapeutic effect to the patient due to the secretion of the greater amounts of the hormone, wherein the beneficial therapeutic effect includes at least one of: limiting a degree of vasoconstriction, limiting a degree of sodium retention, increasing urine output, inhibiting a renin-angiotensin system, inhibiting endothelin secretion, inhibiting systemic and renal sympathetic activity, and counteracting effects of at least one of: norepinephrine, endothelin, and angiotensin II, and
repeatedly alternating the first pacing period and the second pacing period to pace the patient's heart, wherein each alternating second pacing period has a duration of at least ten minutes.
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This application claims the benefit of U.S. Provisional Application 60/657,389 entitled �Increased Secretion of Endogenous Naturetic Hormones by Atrial Stimulation� filed Mar. 2, 2005 and U.S. Provisional Application 60/678,220 having the same titled and filed on May 6, 2005. Both of these provisional applications are incorporated herein.
The present invention generally relates to implantable devices for cardiac stimulation and pacing therapy, and more particularly, the present invention is concerned with cardiac therapies involving the controlled delivery of electrical or mechanical stimulations to the heart for the treatment of congestive heart failure, and an apparatus for delivering such therapies with the objective of altering secretion of hormones by the heart muscle.
Congestive Heart Failure
Congestive heart failure (CHF) occurs when muscle cells in the heart die or no longer function properly, causing the heart to lose its ability to pump enough blood through the body. Heart failure usually develops gradually, over many years, as the heart becomes less and less efficient. It can be mild, scarcely affecting an individual's life, or severe, making even simple activities difficult.
Congestive heart failure (CHF) accounts for over 1 million hospital admissions yearly in the United States (U.S.) and is associated with a 5-year mortality rate of 40%-50%. In the U.S., CHF is currently the most costly cardiovascular disease, with the total estimated direct and indirect costs approaching $56 billion in 1999.
Recent advances in the treatment of CHF with medications, including angiotensin-converting enzyme (ACE) inhibitors, beta-blockers (Carvedilol, Bisoprolol, Metoprolol), Hydralazine with nitrates, and Spironolactone have resulted in significantly improved survival rates. Although many medications have been clinically beneficial, they fall short of clinician's expectations and as a result consideration has turned to procedures and devices as additional and more potent heart failure therapy.
There has been recent enthusiasm for biventricular pacing (pacing both pumping chambers of the heart) in congestive heart failure patients. It is estimated that 30% to 50% of patients with CHF have inter-ventricular conduction defects. These conduction abnormalities lead to a discoordinated contraction of the left and right ventricles of an already failing and inefficient heart. When the right ventricle alone is paced with a pacemaker, the delayed activation of the left ventricle, can also lead to significant dyssynchrony (delay) in left ventricular contraction and relaxation.
Because ventricular arrhythmias continue to threaten CHF patients and many anti-arrhythmic drugs have unacceptable side effects, a sophisticated implantable cardioverter-defibrillator (ICD) device has shown encouraging results. Biventricular pacing in combination with ICDs demonstrates a trend toward improved survival. Preliminary data in animals and humans using subthreshold (of the type that does not by itself cause heart muscle to contract) stimulation of the heart muscle to modulate cardiac contractility are encouraging and may further enhance the quality of life of CHF patients.
It is also clear that many patients with CHF are not candidates for biventricular pacing or do not respond to this treatment strategy. This also applies to other recent advances and experimental therapies. There is a clear need for new, better therapies that will improve and prolong life of heart failure patients and reduce the burden on the medical system. It is particularly important that these new therapies should not require a major surgery, prolonged stay in the hospital or frequent visits to the doctor's office.
Electric Activity of the Heart
In a given cardiac cycle (corresponding to one �beat� of the heart), the two atria contract, forcing the blood therein into the ventricles. A short time later, the two ventricles contract, forcing the blood therein to the lungs (from the right ventricle) or through the body (from the left ventricle). Meanwhile, blood from the body fills the right atrium and blood from the lungs fills the left atrium, waiting for the next cycle to begin. A healthy adult human heart may beat at a rate of 60-80 beats per minute (bpm) while at rest, and may increase its rate to 140-180 bpm when the adult is engaging in strenuous physical exercise, or undergoing other physiologic stress.
The healthy heart controls its rhythm from its sinoatrial (SA) node, located in the upper portion of the right atrium. The SA node generates an electrical impulse at a rate commonly referred to as the �sinus� or �intrinsic� rate. This impulse is delivered to the atrial tissue when the atria are to contract and, after a suitable delay (on the order of 140-220 milliseconds), propagates to the ventricular tissue when the ventricles are to contract. SA node is the natural pacemaker of the heart. If it is disabled, there are other specialized areas of the heart muscle that can generate an intrinsic heart rate.
The ventricular muscle tissue is much more massive than the atrial muscle tissue. The atrial muscle tissue need only produce a contraction sufficient to move the blood a very short distance from the respective atrium to its corresponding ventricle. The ventricular muscle tissue, on the other hand, must produce a contraction sufficient to push the blood through the complete circulatory system of the entire body. Even though total loss of atrial contraction can lead to a small reduction of cardiac output it is not an immediate risk to life.
Electronic Cardiac Pacemakers
It is the function of a electronic pacemaker (pacemaker) to provide electrical stimulation pulses to the appropriate chamber(s) of the heart (atrium, ventricle, or both) in the event the heart is unable to beat on its own (i.e., in the event either the SA node fails to generate its own natural stimulation pulses at an appropriate sinus rate, or in the event such natural stimulation pulses do not effectively propagate to the appropriate cardiac tissue). Most modern pacemakers accomplish this function by operating in a �demand� mode where stimulation pulses from the pacemaker are provided to the heart only when it is not beating on its own, as sensed by monitoring the appropriate chamber of the heart for the occurrence of a P-wave or an R-wave. If a P-wave or an R-wave is not sensed within a prescribed period of time (which period of time is often referred to as the �escape interval�), then a stimulation pulse is generated at the conclusion of this prescribed period of time and delivered to the appropriate heart chamber via a pacemaker lead. Pacemaker leads are isolated wires equipped with sensing and stimulating electrodes.
Modern programmable pacemakers are generally of two types: (1) single-chamber pacemakers, and (2) dual-chamber pacemakers. In a single-chamber pacemaker, the pacemaker provides stimulation pulses to, and senses cardiac activity within, a single-chamber of the heart (e.g., either the right ventricle or the right atrium). In a dual-chamber pacemaker, the pacemaker provides stimulation pulses to, and senses cardiac activity within, two chambers of the heart (e.g., both the right atrium and the right ventricle). The left atrium and left ventricle can also be paced, provided that suitable electrical contacts are made therewith.
Much has been written and described about the various types of pacemakers and the advantages and disadvantages of each. For example, U.S. Pat. Nos. 4,712,555 of Thornander et al. and 5,601,613 of Florio et al. present background information about pacemakers and the manner in which they interface with a patient's heart. These patents are hereby incorporated by reference in their entirety.
One of the most versatile programmable pacemakers available today is the DDDR pacemaker. This pacemaker represents a fully automatic pacemaker which is capable of sensing and pacing in both the atrium and the ventricle, and is also capable of adjusting the pacing rate based on one or more physiological factors, such as the patient's activity level. It is commonly accepted that the DDDR pacemaker is superior in that it can maintain AV synchrony while providing bradycardia (slow hear beat) support. It is also generally more expensive than other, simpler types of pacemakers. A description of DDDR pacing is included in this discloser as a state of the art.
In general, DDDR pacing has four functional states: (1) P-wave sensing, ventricular pacing (PV); (2) atrial pacing, ventricular pacing (AV); (3) P-wave sensing, R-wave sensing (PR); and (4) atrial pacing, R-wave sensing (AR).
It is accepted as important and advantageous, for the patient with complete or partial heart block, that the PV state of the DDDR pacemaker tracks the atrial rate, which is set by the heart's SA node, and then paces in the ventricle at a rate that follows this atrial rate. It is advertised that because the rate set by the SA node represents the rate at which the heart should beat in order to meet the physiologic demands of the body (at least for a heart having a properly functioning SA node) the rate maintained in the ventricle by such a pacemaker is truly physiologic.
In some instances, a given patient may develop dangerously fast atrial rhythms, which result from a pathologic arrhythmia such as a pathological tachycardia, fibrillation or flutter. In these cases, a DDDR pacemaker may pace the ventricle in response to the sensed atrial arrhythmia up to a programmed maximum tracking rate (MTR). The MTR defines the upper limit for the ventricular rate when the pacemaker is tracking the intrinsic atrial rate. As a result, the MTR sets the limit above which the ventricles cannot be paced, regardless of the intrinsic atrial rate. Thus, the purpose of the MTR is to prevent rapid ventricular stimulation, which could occur if the intrinsic atrial rate becomes very high and the pacemaker attempts to track atrial activity with 1:1 AV synchrony.
When the intrinsic atrial rate exceeds the MTR the pacemaker may initiate one or more upper atrial rate response functions�such as automatically switching the pacemaker's mode of operation from an atrial tracking mode to a non-atrial rate tracking mode.
The heart's natural response to a very high atrial rate involves a natural phenomenon known as �blocking��where the AV node attempts to maintain a form of AV synchrony by �dropping out� occasional ventricular beats when the high atrial rate exceeds a certain natural threshold i.e., the refractory period of the heart tissue. The blocking phenomenon is often expressed as a ratio of the atrial beats to the ventricular beats (e.g. 6:5, 4:3, etc.). Of particular importance is a 2:1 block condition where there are two atrial beats for every one ventricular beat. The 2:1 block condition is a natural response to a very high atrial rate, during which full ventricular rate synchronization (i.e. at a 1:1 ratio) would be dangerous to the patient.
Some known pacemakers emulate this 2:1 condition, by tracking P-waves up to the device's programmed total refractory period (TARP) of the heart. That is, P-waves which fall in the total refractory period are not tracked, and the device is said to have a �2:1 response mode�. During the 2:1 block response mode, the ventricles are paced at a lower rate than the natural atrial rate, because P-waves occurring soon after ventricular events are ignored for the purposes of calculating the ventricular pacing rate. As a result, the 2:1 block response mode prevents the pacemaker from pacing the ventricles at a tachycardia rate.
The 2:1 block response mode is an effective response for dealing with short incidences of high atrial rates and in preventing occurrence of a pacemaker mediated tachycardia resulting from retrograde P-waves. However, the 2:1 block response mode may become uncomfortable for the patient if it is maintained for an extended period of time due to programmed long atrial refractory periods, because the pacing rate will be � of the required physiologic rate.
Many more advanced pacemaker operation modes have been described and sometimes implemented. Some of these modes included sensing abnormally high atrial rates and prevented them from causing rapid ventricular rates. Common to prior pacing no attempt has been made to induce a rapid (faster than normal) atrial rate by pacing or to pace atria at rate higher than ventricles.
Natriuretic Peptides (ANP and BNP)
Atrial natriuretic peptide (ANP) is a hormone that is released from myocardial cells in the atria and in some cases the ventricles in response to volume expansion and increased wall stress. Brain natriuretic peptide (BNP) is a natriuretic hormone that is similar to ANP. It was initially identified in the brain but is also present in the heart, particularly the ventricles.
The release of both ANP and BNP is increased in heart failure (CHF), as ventricular cells are recruited to secrete both ANP and BNP in response to the high ventricular filling pressures. The plasma concentrations of both hormones are increased in patients with asymptomatic and symptomatic left ventricular dysfunction, permitting their use in diagnosis. A Johnson and Johnson Company Scios sells popular intravenous (IV) medication Natrecor (nesiritide), a recombinant form of the endogenous human peptide for the treatment of decompensated CHF. The advent of Natrecor marked an important evolution in the understanding and treatment of acute heart failure.
Both ANP and BNP have diuretic, natriuretic, and hypotensive effects. They also inhibit the renin-angiotensin system, endothelin secretion, and systemic and renal sympathetic activity. Among patients with CHF, increased secretion of ANP and BNP may partially counteract the effects of norepinephrine, endothelin, and angiotensin II, limiting the degree of vasoconstriction and sodium retention. BNP may also protect against collagen accumulation and the pathologic remodeling that contributes to progressive CHF.
Increasing levels of ANP and/or BNP in blood would benefit heart failure patients. Unfortunately ANP and BNP cannot be taken as an oral medication since it is a peptide and will be destroyed in the patient's digestive system. BNP is currently available as an IV injectable medication. This limits its use to hospitals and special therapy centers. Many patients would benefit from the increased blood levels of ANP and BNP if the therapy did not require such professional setting and was a part of their normal life.
There is a desire to cause a therapeutic increase of blood plasma ANP and BNP via an increased endogenous release of ANP and BNP from the atria of the patient's heart. Atrial release is mediated via increase of atrial wall stress. The embodiments disclosed here include among others: the mechanical distension of the atria or atrial appendage, rapid pacing of the atria or subthreshold electric stimulation of atria.
Increased heart rates, seen with supraventricular tachycardia (SVT), are clinically associated with polyuria, or increased urine output. The start of the polyuria is coincident with the start of the tachycardia and finishes with the end of the rapid rate. This observation was confirmed in humans by pacing them at high rates, which caused an increase in ANP secretion within the first 30 minutes of pacing.
Electric Stimulation of the Heart
One embodiment disclosed here uses a modified implanted electronic cardiac pacemaker to increase ANP and BNP secretion by pacing the right atrium of the patient at an appropriately high rate. At the same time it generally is not desired to substantially increase the ventricular contraction rate of HF patients. Ventricular ejection at a rate substantially above normal may result in the insufficient time for the heart to relax and to refill with blood between the contractions.
Current cardiac pacemakers with the capability of pacing both the atrium and the ventricle stimulate the heart chambers in a �1:1� ratio, that is no more than one ventricular stimulus per atrial stimulus and vice versa. Few normal people, and certainly no patient with CHF, can tolerate high ventricular rates without hemodynamic compromise from decreased filling. This is one of the reasons many previous therapies have chosen to try to slow heart rate in CHF and why beta-blockers or other negative chrontropic agents (drugs that slow down the heart rate) are preferred in the clinical treatment of CHF. For the purpose of this invention it would be desirable to have a device where the atrium could be stimulated at a high rate to cause release of ANP/BNP but without causing clinically unacceptably high ventricular rates. For example, atrial rates could range from 120 to 240 bpm with ventricular rates in the range of 50 to 110 per minute during pacing intended to release endogenous ANP/BNP. These rates would return to the normal ranges and atrial:ventricular stimulation ratio (i.e., 1:1) pacing as is in currently clinically available pacemakers when the therapy is interrupted or stopped.
In the described embodiment patients have either a natural atrioventricular block (AV block) or have an AV block induced by heart tissue ablation or some other appropriate procedure. For example in patients with a so-called third-degree AV block (complete AV block, no AV conduction), no atrial impulses reach the ventricles, and ventricular rhythm is maintained by a subsidiary natural pacemaker. Since subsidiary pacemakers must be below the level of block, their location is in part determined by the site of block. In third-degree AV nodal block, the ventricular rhythm is usually maintained by pacemakers in the AV junction with resultant narrow QRS complexes. In third-degree AV block localized to the bundle branches, ventricular rhythm is maintained by a pacemaker in the Purkinje fibers, with resultant wide QRS complexes. The junctional pacemaker rate is usually faster (40-80 beats/min) compared with the peripheral Purkinje network (20-40 beats/min). In such patients a dual chamber pacemaker can be used to pace atria at a rate much higher than the ventricles without the risk of patient developing dangerous ventricular tachycardia (rapid heart beat). An atrioventricular (AV) node ablation is a known medical procedure that destroys a part of the heart's normal electrical system. The combination of pacing and AV node ablation is sometimes used clinically in patients with chronic atrial fibrillation and rapid ventricular response that poorly respond to drug therapy.
This is accomplished by cauterizing the AV node, which is located between the upper heart chamber (atria) and the lower heart chambers (ventricles). Once the AV node is cauterized, none or few impulses from the atria will be able to reach the ventricles. Currently an AV node ablation is performed when the patient's rhythm disturbance (arrhythmia) originates in the atria and cannot be controlled adequately. A permanent pacemaker is installed afterwards, to keep the heart beating at a normal pace. The pacemaker lead is connected directly to a ventricle.
Electronic pacemakers are currently used to replace or supplement the natural pacing nodes of the heart by applying electric excitory signals to the heart muscle to cause contraction and blood pumping cycle. Pacemakers are used in patients with diseased nodes (slow heart beat) and defective (blocked) conduction pathways. Bi-ventricular pacemakers pace both ventricles of the heart to restore synchrony between the ventricles.
Generally, the conventional wisdom of all pacing therapies for the heart disease is as follows. A human heart consists of four chambers�two atria and two ventricles. In order for the heart to efficiently perform its function as a pump, the atrial muscles and ventricular muscles should contract in a proper sequence and in a timed relationship, as they do in a healthy heart. Therefore electronic pacemakers are used to restore the normal heartbeat or to restore synchrony between different chambers of the heart.
The inventors broke away from this tradition and proposed a counterintuitive approach to heart pacing. In the invention a pacemaker is counter intuitively used dissynchronously to generate different atrial and ventricular contraction rates. Specifically a higher rate of atrial contractions than ventricular contractions is generated. It is understood that this may result in suboptimal performance of the heart. Inventors propose that this disadvantage will be offset by the benefit of the increased ANP-BNP secretion by the heart atria in heart failure patients.
Mechanical Stimulation
There is a desire to cause a therapeutic increase of blood plasma ANP and BNP via an increased endogenous release of ANP and BNP from the atria of the patient's heart. Atrial release is mediated via increase of atrial wall stress. The embodiments disclosed herein include among others: the mechanical distension of the atria or atrial appendage, rapid pacing of the atria or subthreshold electric stimulation of atria.
One embodiment uses an implantable expandable device (such as an inflatable balloon) placed in an atrial appendage of the heart to cause a therapeutic increase of blood plasma ANP and BNP via an increased endogenous release of ANP and BNP in response to the artificially induced changes of the atrial wall stress. The wall stress is caused by periodic inflation of the balloon to the size that exceeds normal size of the appendage therefore distending its walls.
It is know in the field of cardiology that stretching or otherwise stressing tissue in the walls of the atria of the heart initiates the release of endogenous ANP-BNP. No practical therapy or medical device resulted from this knowledge for the lack of a safe and simple method and a technology enabling such release repeatedly over clinically relevant duration of time.
The right atrial appendage (RAA) or the right auricle of the heart is the appendicular portion of the right atrium that externally originates from the terminal groove. In man, the RAA has a characteristic triangular �pocket� shape and resides inside the pericardial sac on top of the anterior (frontal) surface of the heart. The right atrial appendage is lined internally by pectinate muscles that originate from the terminal crest. The function of the RAA is unclear and its removal or isolation by surgery is not known or expected to have to have serious adverse effects on the patient.
An implantable or implanted device (commonly termed an �implant�) is an artificial device fully enclosed in the patient's body. It is significant that implants allow the natural skin of the patient to serve as a barrier against infection. Relevant to this invention an implant can include, for example, an inflatable balloon, a complex electromechanical pump, a catheter and/or an infusion port. Implantation can be achieved by open surgery, minimally invasive surgery or a transcatheter intervention, whether extravascular, intravascular or combination of any of the above. During the implantation procedure, a surgical instrument or catheter is used to cross the skin, penetrating into the patient's body. The implant is positioned at the desired site and the pathway used to access the site is closed. The site heals and the device is now fully implanted.
Cyclically stretching or otherwise stressing the atria of a patient can result in benefits other or in addition to simple ANP and BNP release. Such benefits can include activation of neuron-hormonal mechanisms and additional release of other hormones that can benefit patients with high blood pressure and heart failure. Of particular importance for the invention are known physiologic pathways between the heart muscle, the brain and the kidneys that can result in vasodilatation of blood vessels and increased urine output in response to atrial stretch. Full description of these interactions goes beyond the scope of this invention and can be obtained from literature on cardio-renal physiology.
Stretching or otherwise stressing the atria of a patient can be achieved in many different ways, for example, by pulling on the atrial appendage, pulling on the atria or on the junctions between the great vessels and the heart atria.
The choice of an inflatable balloon implanted in the right atrial appendage was justified by its simplicity but other controllably expandable medical devices could potentially serve the same purpose.
The right atrial appendage is not the only part of the heart that, when stressed by stimulation, can release beneficial hormones. The choice of the site was justified by the easy surgical and vascular access and low risk of blood clotting. It is understood that similar manipulation of, for example, left atrial appendage, can achieve similar results.
A preferred embodiment and best mode of the invention is illustrated in the attached drawings that are described as follows:
The sinus rhythm normally controls both atrial and ventricular rhythm. Action potentials generated by the SA 107 node spread throughout the atria, depolarizing this tissue and causing right atrial 102 and left atrial 106 contraction. The impulse then travels into the ventricles via the atrioventricular node (AV node) 108. Specialized conduction pathways that follow the ventricular septum 104 within the ventricles rapidly conduct the wave of depolarization throughout the right 103 and left 105 ventricles to elicit the ventricular contraction. Therefore, normal cardiac rhythm is controlled by the pacemaker activity of the SA node and the delay in the AV node. Abnormal cardiac rhythms may occur when the SA node fails to function normally, when other pacemaker sites (e.g., ectopic pacemakers) trigger depolarization, or when normal conduction pathways are not followed.
Leads 203 and 202 can combine sensing and pacing electrodes as known and common in the field. The atrial lead 203 can therefore sense the natural intrinsic contractions of the atria before they occur and communicate them to the generator 201. The generator is equipped with the programmable logic that enables it to sense signals, process the information, execute algorithms and send out electric signals to the leads.
In this embodiment the natural conduction path between the SA node 107 and the AV node 108 is blocked. The patient may already have a natural complete AV block. In this case no intervention is needed. If the patient has functional electric pathways from atria to ventricles, the patient's AV node can be disabled (blocked) by tissue ablation. It is understood that many irreversible and reversible methods of selectively blocking conduction in the heart are known. These include treatment with chemical agents and blocking with subthreshold electric stimulation (non-excitatory stimulation that does not cause muscle fibers to contract). Ablation of the AV node is used as an example since it is widely accepted and easily performed using RF energy catheters. Other devices that use cold, laser and ultrasound energy to perform ablation are also known.
Trace 301 illustrates the natural or intrinsic rate generated by the SA node of the heart. The SA node generates pulses 304, 305, 306 and 307. These pulses can be sensed by the atrial lead 203.
In response to the sensing of intrinsic atrial pulses, the pulse generator 201 generates a series of pulses represented by the trace 302. Pulses are conducted to the atria by the atrial lead 203. Device generated atrial stimulation pulses 311, 313, 315 and 317 are in synchrony with the SA node pulses 304, 305, 306 and 307. They represent the intrinsic heart rate. The generator 201 (based on an embedded algorithm) also generates extra atrial pulses 312, 314 and 316. Together synchronous pulses 311, 313, 315, 317 and asynchronous pulses 312, 314, 316 determine the atrial rate of the heart.
Trace 303 represents ventricular stimulation pulses 321, 322, 323 and 324 conducted to the ventricle of the heart by the ventricular lead 202. The AV node of the heart in this embodiment is blocked. Therefore the ventricular stimulation is generated by the generator 201 based on an embedded algorithm. To ensure better performance of the heart ventricular pulses 321, 322, 323 and 324 are synchronized to the synchronous atrial pulses 311, 313, 315 and 317 with a short delay 308 determined by the embedded algorithm that simulates the natural delay of the AV node conduction.
The algorithm illustrated by the
a. sensing an intrinsic SA node pulse (P-wave),
b. generating a synchronous atrial pacing pulse,
c. calculating the intrinsic atrial rate based on previous SA node pulse intervals,
d. generating synchronous ventricular pacing signal delayed from the synchronous atrial pacing signal at the ventricular rate equal to the intrinsic SA node excitation rate (sinus rhythm),
d. calculating the desired increased atrial rate, such as for example, a 2:1 (A:V) rate,
e. generating asynchronous atrial pacing signal based on the calculated increased atrial rate, and
f. waiting for the next intrinsic SA node pulse (P-wave).
It is understood that this example of an algorithm is an illustration and many other embodiments of the invention can be proposed. It can be envisioned that more than 2:1 (atrial:ventricular) rate can be tolerated by the patient or that less than 2:1 rate is desired such as accelerating every second atrial beat.
It may be not essential to preserve the natural sinus rhythm (from the SA node) is preserved. In some patients it may be desired for the algorithm to take over the heart rate and force all the atrial contraction. Pacing modalities that do not rely on the SA node to generate the heart rate are known and used to treat bradycardia. The SA node of a patient can be ablated similar to the AV node and the embedded pacemaker algorithm will pace the atria. Alternatively, atria may be paced if the natural SA node pulse is not senses within the expected time from the last ventricular contraction. Various activity sensors such as accelerometers can be used to accelerate the heart rate as needed.
Commonly, in comparison to previous devices, this embodiment of the invention purposefully creates ratios of atrial to ventricular contraction higher than 1:1, such as for example in the range of 1:1 to 4:1. In addition, any previous device that allowed more that a 1:1 ratio of contraction based this relationship on sensing native atrial depolarization and deferring generation of a ventricular pacing stimulus (skipping premature ventricular beats). In contrast, in the illustrated embodiment, the higher than 1:1 rate is intentionally and controllably initiated by the implantable generator. As a result the atrial rate is increased to a rate which causes the release of sufficient endogenous naturetic hormone to result in a therapeutically beneficial increase in blood plasma levels of the hormones or increased levels in any other vascular or non-vascular space in which these hormones a found.
It is desirable to cause a therapeutic increase of blood plasma ANP and BNP via an increased endogenous release of ANP and BNP from the atria of the patient's heart. Atrial release is mediated via increase of atrial wall stress. The best embodiment of the invention known to the inventors at the time of the invention is rapid pacing of the atria that is expected to increase the rate of contractions of the atria and release ANP and BNP. The invention has been described in connection with the best mode now known to the applicant inventors. The invention is not to be limited to the disclosed embodiment. Rather, the invention covers all of various modifications and equivalent arrangements included within the spirit and scope of the appended claims.
An implantable pump 602 is an implantable device that is inserted under the patient's skin and can be refilled using a transdermal needle 602 access. An implantable pump may be attached to a separate catheter 507 that delivers fluid to and from the expandable balloon 505. Depending on the desired treatment modality, a preferred implantable pump can be programmable, patient controlled or physician controlled. The pump can be mechanical (activated by finger pressure) or electro-mechanical using motors or solenoid pistons to generate flow and pressure.
The catheter 504 can be introduced into the RAA space under fluoroscopic, MRI or CT guidance without major surgery. The procedure is performed using an access point in a femoral vein 601 in the groin of the patient 600 using tools and techniques commonly used in interventional cardiology and radiology. One end of the catheter can be left outside of the body for the test period that requires only a short duration. Later, if the atrial stretching therapy is clinically successful, an implanted pump or a simple implanted subcutaneous infusion port such as a commercially available Port-A-Cath� device can be connected to the already implanted catheter for repeat infusions and withdrawals of fluid into and from the balloon 505. Alternatively the balloon can be inserted into the RAA surgically by piercing the wall of the RAA 508 from the outside. The actual method of inserting and securing the balloon in the RAA will not change the substance of the invention. General approach in implantable devices is that less invasive methods of implantation are preferred in most cases but tend to be more demanding.
In the illustrated embodiment the pump 602 in implanted in a pocket under the patient's skin. All the mechanisms of the pump are enclosed in a titanium or polymer case. Fluid is stored in the internal reservoir (not shown). To refill the pump or to add or remove fluid, a needle 602 can be used to puncture the patient's skin and the pump reservoir septum (Not shown). The catheter 504 is in bidirectional fluid communication with the pump 602 and the balloon 505. All the fundamental elements described above are known to the developers of implantable drug pumps. An example of an implantable drug infusion device is the MiniMed 6007� implantable insulin pump system for treatment of diabetes or the SynchroMed� Infusion System used to control chronic pain, both manufactured by Medtronic Inc.
The proposed embodiment is different from the existing implantable drug infusion pumps in the following significant way. In existing drug infusion pumps fluid is infused in one direction always from the implanted pump reservoir into the body. In this invention the fluid is bidirectionally moved (shuttled) inside a closed system in both directions between the implanted pump and the implanted balloon. Historically implantable infusion devices have been used for intravenous, intraarterial, intrathecal, intraperitoneal, intraspinal and epidural drug delivery but not to control inflation and deflation of implanted balloons.
For the purpose of an estimate the balloon 105 can have a diameter of 1 cm when the RAA is not stretched and the diameter of 2 to 3 cm when the RAA is stretched. The balloon is 3 cm long. This implies shuttling of approximately 5 to 20 ml of incompressible fluid between the pump reservoir and the balloon. This requirement is within reasonable range for a fully implanted pump of the described type. The Medtronic SynchroMed pump for example has a miniature peristaltic pump mechanism that can be modified to operate bidirectionally and generate necessary pressures. It also has an internal fluid reservoir of 30 ml. The fluid can be a sterile, biocompatible fluid that will not harm the patient if it leaks out such as saline, glycerin or medical grade oil. The balloon 105 can be made of silicone, nylon or other strong medical plastic suited for multiple cycle inflation and deflation. Methods and materials for manufacturing of durable, implantable balloons exist and have been successfully implemented in many medical device applications.
The therapy may include the following steps:
Identifying a patient that will benefit from elevated levels of ANP and BNP likely from the group with heart failure, fluid retention or hypertension
Implanting an expandable device in an atrial appendage of the patients heart
Periodically expanding and contracting the device to temporarily stretch the walls of the atrium to achieve therapeutically significant increase of blood hormones.
The exact regiment of stretching and contracting the atrial wall is likely to be individual for each patient. For example a regiment can be proposed where the balloon is inflated for several minutes followed by several minutes of rest. These cycles will be repeated for several hours several times each day. In heart failure patients with fluid retention the objective of therapy will be to achieve minimum additional urine output of 250 ml per day and preferably 500 ml per day. The high end of the therapeutic range may be 1,000 additional ml of urine per day. This additional urine output is likely to improve patient's condition, allow more exercise and prevent hospital admissions from fluid overload. It is likely that the device will require a pump component that is remotely programmable so that the therapy parameters can be adjusted using wireless communication.
The adjustable programmable parameters may include:
Volume of balloon expansion
Duty cycle and frequency of inflation cycles in each therapy session
Number and time of therapy sessions hourly, daily or weekly
The methodology of programming an implantable pump is not different from programming a common heart pacemaker.
The invention has been described in connection with the best mode now known to the applicant inventors. The invention is not to be limited to the disclosed embodiment. Rather, the invention covers all of various modifications and equivalent arrangements included within the spirit and scope of the appended claims.
Patent Citations
Non-Patent Citations
Referenced by
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text:
Theater performance: "It's a Wonderful Life"
This 90 minute live radio play follows the iconic story of George Bailey unfolds as he considers ending his life one fateful Christmas Eve. General admission seating. Doors to the event venue will open 30 minutes prior to the event. $10 (free for SUNY Oswego students with ID), including parking in the Culkin Hall lot (E-6) and nearby lot E-18. There will be one performance/reading at SUNY Oswego/Ballroom, Hewitt Union and one performance/reading at the Kallet Theatre in Pulaski, NY. http://www.oswego.edu/arts. 312-2141.
Location: Ballroom, Hewitt Union
Saturday, Dec 6, 2 p.m. - 4 p.m.
Oswego Men's Ice Hockey Classic: Oswego vs. Tufts
$8 (free for SUNY Oswego students) at tickets.oswego.edu. 312-2488.
Location: Arena, Marano Campus Center
Friday, Jan 2, 7 p.m. - 9 p.m.
Women's Ice Hockey vs. Hamilton
$4 for adults, $2 for 5-17years, free for children under the age of 5, free for SUNY Oswego students with ID. Tickets may be purchased at tickets.oswego.edu. 312-2488
Location: Oswego, NY- Campus Center Ice Arena
Tuesday, Nov 25, 2 p.m. - 4 p.m.
Men's Basketball vs. Clarkson
$6 adults, $4 children 5-18, and free for SUNY Oswego students with ID and children under 5. Tickets may be purchased at tickets.oswego.edu. 312-3073.
Location: Oswego, NY- Max Ziel Gymnasium in Laker Hall
Tuesday, Nov 25, 5:30 p.m. - 7:30 p.m.
GOLD Third Thursdays
Visit http://www.facebook.com/events/453070221388940 for the latest locations or suggest your own!
Location: Various Cities
Thursday, Dec 18, 6 p.m. - 8 p.m.
GOLD Third Thursdays
Visit http://www.facebook.com/events/453070221388940 for the latest locations or suggest your own!
Location: Various Cities
Thursday, Jan 15, 6 p.m. - 8 p.m.
President Deborah F. Stanley (PDF)
Division of Student Affairs and Enrollment Management (PDF)
- Student Affairs Learning Program
- Department Listing
Code of Student Rights, Responsibilities and Conduct (PDF)
Student Conduct Policies and Procedures (PDF)
Regulations and Procedures for Maintaining Public Order (PDF)
Bill of Rights and Responsibilities for Faculty, Students, Administrators,
Staff, and College Council at Oswego (PDF)
Minimum Living Condition Standards for University Residence Halls (PDF)
Nuclear Emergency Plan and Evacuation Planfor Individuals with Mobility Impairments (PDF)

subset: commoncrawl


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- Shopping Bag ( 0 items )
Posted February 7, 2008
Book should have Nightmare Warnings!
IM is one of those rare books that scared the bejeezus out of me, to the point that I had to put the book down. A few days later, I was drawn back to the book 'like a moth to a flame.' The story moves quickly, switching seamlessly between several points of view - Ed Comparetto the detective, the victims, the bystanders and the killer. The third person narrative, switching to first person narrative with the murderer was intensely effective. Downright creepy! The mystery unfolds in many layers, shifting in time, twisting and turning to the heart-pounding end. Once everything is revealed, Reed isn't done with us yet the story continuing through one final confrontation between Comparetto and the killer. At first, when I read the 'blurb' on the back of the book I was slightly disappointed that so much was given away, but I soon realized that was only the beginning of something so much more. The blurb was like a plot device in itself. I also felt the ending left something unresolved, but once my heart rate returned to normal, the ending made perfect sense - Comparetto was where he wanted to be. Detective Ed Comparetto is an appealing character, a dedicated cop that still feels compassion and remorse for the victims. He isn't one of those wise-cracking police detectives, spewing out one-liners like some 'has been' stand-up comedian. When Comparetto enters the first murder scene, he's feeling unsettled and apprehensive, oppressed with 'what's behind door number one' type of feeling. He hides his true emotions well, slipping into that professional cop-mode, feeling the need to prove himself to those out there that are just waiting for him to 'slip-up.' His professional life is already threatened after a recent 'public' outing. Ed's a humanly portrayed character, with all his human flaws and human weaknesses. In other words, he's not an arrogantly perfect macho man. And this is not meant to be a negative reflection on Ed's sexual orientation. It is wholeheartedly meant as a compliment. I really got into Ed's character, his motivations and toward the end -- his fear. I loved Ed's lover, Peter. The two meet for the first time in a library where Peter worked, when Ed was researching a lead. Peter's like a breath of fresh air in the story, pursuing Ed with an amusing single-minded determination. He's a lot like Nick's Nora (The Thin Man Series), helping Ed investigate and sort out the conflicting clues. A real partner in and out of bed. I would have loved to see more of Peter. Peter begins to have second doubts about their relationship, when Ed starts to become obsessive about the case. For Ed it's more than just finding the killer, it has become something personal. And that's something Peter needs to figure out. The book should have Nightmare Warnings, because I sure as heck had 'em! I liked Reed's use of descriptive phrases to set the proper mood like, 'the gallery of ghouls,' to described the assembled investigation team at the first murder. I thought the plot became a little 'out there' with certain elements, but I realized that was just the type of book I was reading. I just suspended my mundane imagination a little and enjoyed the nightmare ... I mean the story.Was this review helpful? Yes NoThank you for your feedback. Report this reviewThank you, this review has been flagged.
Posted May 4, 2007
I.M. can also mean 'instant murder'!
Timothy Bright grew up being cared for by an Aunt, and sexually abused by her sadistic boyfriend, leaving him an extremely bitter and troubled man, self-loathing in his own homosexuality. Incapable of a normal relationship with anyone, he contacts other men for anonymous sexual encounters on a website called Men4HookUpNow.Com. Once they meet, Timothy attacks and brutally murders them, leaving a trail of unexplained sadistic killings to be solved by the Chicago Police. Ed Comparetto, a openly-gay rookie police detective who knows he must prove himself, was assigned to one of the earlier murder cases, hoping his sexuality might give him some insight into the case. At the scene, he interviews and comforts the slight young man who said he was a neighbor and friend of the victim, and who called 911 after finding the body. When Ed's superiors check out his report, find that none of the information he got checks out, and the name the man supposed gave him - Timothy Bright - is on record as having died several years earlier, Ed is suspended from the force, allegedly for falsifying the report. So begins a twisting and highly engrossing superb murder mystery, which will be especially frightening to many gay men since the territory (gay 'hook up' websites, gay clubs, inner city 'gayborhoods') is familiar, and the villain has more than a passing physical and M.O. resemblance to real-life sicko Jeffrey Dahmer ... thankfully without the latter's culinary peculiarity. Reed skillfully provides background information on Bright through diary entries from his aunt, and keeps the character simultaneously engaging and absolutely frightening in every way. Ed's suspension from the police force gives Reed the freedom to make this more of a personal battle for the young detective, who not only wants to catch this killer but to put himself back in a favorable light with his commander. The book is decidedly gory in parts, which I consider necessary in order to convey just how psychotic Bright is, making it clear he'll do anything to carry out his imagined vendetta against other gay men. Ultimately, others from Bright's past become the focus of his deranged actions, and Ed has to try to rescue his boyfriend from Bright's clutches. A well-written, thoroughly enjoyable, and absolutely terrifying novel, which I recommend highly. I give it five stars out of five.Was this review helpful? Yes NoThank you for your feedback. Report this reviewThank you, this review has been flagged.
Posted October 3, 2011
No text was provided for this review.
Posted December 5, 2009
No text was provided for this review.
Posted January 24, 2010
No text was provided for this review.
Posted October 28, 2009
No text was provided for this review.


text:
Alexandria, Va. – Bob Martin, longtime secretary of the HAI Electronic News Gathering (ENG) Committee and pilot reporter for KRQE TV News, invites you to a day of helicopter safety on Wednesday, December 3, at the New Mexico Army National Guard at 7001 Huey Road, Santa Fe, N.M.
Read the rest of this article...
New South Wales, Australia (byronnews.com.au) - WESTPAC Life Saver Rescue Helicopter was called out to a cruise ship off the coast of Ballina to rescue a woman suffering abdominal problems.
View Story...
Yuma, Ariz. (yumasun.com) - The Yuma County Sheriff's Office, with the assistance of a search and rescue helicopter aircrew from Marine Corps Air Station Yuma, rescued two men who had been reported missing in the Mittry Lake area.
Garmin is looking for an engineer to provide project and technical leadership for complex aircraft certification projects. As an Aircraft Systems Engineer 3 - Aircraft Certification, you will advise product development teams of aircraft certification considerations for new products...
Keep us flying! HFI is offering unique scholarships to help maintenance students become part of tomorrow's exciting world of vertical aviation. Less than one week left to apply - apply now!
A Special Airworthiness Information Bulletin (SAIB) alerts owners and operators of all versions of Airbus Helicopters AS350 and AS355 helicopters of the possibility of a total loss of electrical power due to water entering into the cabin. At this time, the airworthiness concern is not an unsafe condition that would warrant airworthiness directive (AD) action under Title 14 of the Code of Federal Regulations (14 CFR) part 39.
Lincoln, Neb. (klkntv.com) - Emergency flight crews could be arriving at their destinations even quicker. It's all thanks to Star Care's newest chopper. The new helicopter exceeds all requirements by the FAA. Not to mention, it's faster, more fuel efficient, and even comes with a back up camera.
New Delhi - Bell Helicopter and Textron Systems announce an agreement with Dynamatic Technologies Limited of Bangalore, India, establishing Dynamatic as a single-source supplier of major airframe assemblies for the Bell 407GX and 407GT.
In a letter to the FAA, Ron Wyden, chairman of the U.S. Senate Finance Committee, and four other senators are warning the FAA to speed up its approval of test permits for drone flights.
How often do you think about the sensitive nature of the heading reference systems installed in that aircraft you are working on? Maybe you should. Check out the new Special Airworthiness Information Bulletin (SAIB CE-15-01) issued by the FAA on 11/4/2014.


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Top Linksmain detailsbiographyby votesphoto galleryquotes
Filmographiesby yearby typeby ratingsby votesby TV seriesby genreby keyword
Did You Know?photo galleryquotes
General Burgdorf (Character)
from Downfall (2004)
Alternate Names:
FilmographyEdit Credits
- Rommel (2012) (TV) Played by Peter Kremer
- Rommel and the Plot to Kill Hitler (2006) Played by Paul Gustavson
... aka "Rommel and the Plot Against Hitler" - USA (original title)
- Downfall (2004) Played by Justus von Dohnányi (as General Wilhelm Burgdorf)
... aka "Der Untergang" - Germany (original title)
- Hitler: The Last Ten Days (1973) Played by Joss Ackland (as Gen. Burgdorf)
- "ITV Saturday Night Theatre"
- The Death of Adolf Hitler (1973) TV episode, Played by Hector Ross
- Is Paris Burning? (1966) Played by Peter Jacob (as Gen. Burgdorf) / Peter Jacob (as Génaral Burgdorf)
... aka "Paris brûle-t-il?" - France (original title)
- The Last Ten Days (1955) Played by Erik Frey (as General Wilhelm Burgdorf)
... aka "Der letzte Akt" - West Germany (original title)
... aka "The Last Act" - International (English title) (literal title)
- The Desert Fox: The Story of Rommel (1951) Played by Everett Sloane (as Gen. Wilhelm Burgdorf)
... aka "The Desert Fox" - International (English title) (informal short title), USA (short title)
... aka "The Story of Rommel" - International (English title) (informal short title)
Additional Details
Plot Keywords:
Fun Stuff
Adolf Hitler: General von Greim, I appoint you to Commander in Chief of the Air Force and General Field Marshal. A large responsibility rests on your shoulders. You must shake up the entire air force. Many mistakes have been made, so be ruthless. Life never forgives weakness. This so called humanity... is just priests' drivel. Compassion is a primal sin. Compassion for the weak is a betrayal of nature.
Joseph Goebbels: The strongest can only be victorious by eradicating the weak.
Adolf Hitler: I have always obeyed this law of nature by never permitting myself to feel compassion. I have ruthlessly suppressed domestic opposition and brutally crushed the resistance of alien races. It's the only way to deal with it.
[Linge enters with a folder in hand]
Adolf Hitler: Apes, for example, trample every outsider to death. What goes for apes goes even more for human beings.
[Hitler reads the folder]
Adolf Hitler: Himmler, in Lübeck, has made an offer to surrender to the western powers through Count Bernadotte... according to a report by English radio.
[finishes reading]
Adolf Hitler: Himmler... Of all people, Himmler! The truest of the true... This is the worst betrayal of all! Göring, yeah; he was always corrupt, of course. Speer, yeah: an idealistic, unpredictable artist. All the others, yeah yeah yeah yeah yeah!
[puts folder down]
See more »
You may correct errors and omissions on this page directly. Clicking the 'Update' button will take you through a step-by-step process.


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Youth Services Acquisition List Jan/Feb 2010 GRAPHIC NOVEL/COMICS doc
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Date: 2011-10-31
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Local Blogs
By Chandrama Anderson
E-mail Chandrama Anderson | Follow this Blog
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Nov 18, 2014 12:49 pm
Comments: 12 | Views: 2,540
Yesterday I told my mom she's dying. It was one of the hardest things I have ever done in my life. We cried. She thanked me for telling her and said she'll miss... More
Nov 14, 2014 1:33 pm
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What would happen if we let ourselves be truly loved? Fully loved?
I believe that many would say they would love to be loved fully or are letting themselves... More
Nov 11, 2014 8:27 am
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Do you answer fine, good, or okay when asked how you are?
How are you? "Fine."
How are you? "Good."
How are you? "Okay."
Do you have any idea how your mate... More
Nov 7, 2014 1:55 pm
Comments: 4 | Views: 2,824
I just want to start by saying body image is a huge topic and many articles and tomes have been written on the topic. I will just brush the surface here, with the... More
Nov 3, 2014 1:32 pm
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Fear and excitement are on the same spectrum. Consider, in an evolutionary context, of hunters making the approach: fear and excitement. Think of current times,... More
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By Chandrama Anderson | 12 comments | 2,540 views
Grab a Bowl of Heaven soon in Mountain View
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By Laura Stec | 3 comments | 977 views
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By Steve Levy | 4 comments | 862 views


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If your eyebrows are looking a little depleted, this growth stimulating serum from brow guru Anastasia Soare will encourage them back to their bushy, beautiful best. With brows firmly back in the beauty spotlight (the bigger the better) many of us are regretting teenage years spent cultivating a permanent look of surprise. Applied twice daily to clean skin, the five peptides work to condition existing hair while stimulating growth for lustrous brows that perfectly frame your face.For best results, use Brow Enhancing Serum Advanced on clean brows in the morning and evening. This Brow Enhancing Serum can be applied before you put on your normal make-up and after you remove your make-up before bed. Be sure to carefully replace the cap after each use to ensure the specialized pen and brush does not fray or dry out.


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UFC on Fox 6 Shawn Jordan vs Mike Russow Full Fight Preview & Prediction watch video >>
UFC 161: Pat Barry vs Shawn Jordan Full Fight Preview & Prediction by Paulie G watch video >>
Shawn Jordan talks about being rocked by Mike Russow at UFC on FOX 6, turning the fight around, bouncing back after a loss, and more with MMA Fighting's Ariel Helwani. Subscribe to our channel for more MMA videos! Click here:http://www.youtube.com/ subscription_center?add_user=mmafightingonsbn - Check us out on Facebook (Facebook.com/MMAFighting) and follow us on Twitter (@MMAFighting)! - MMA Fighting http://www.mmafighting.com watch video >>
UFC on Fox 6: Mike Russow vs. Shawn Jordan - Although the flyweight division takes center stage on Saturday's UFC on Fox 6 event, it is the heavyweights who will collide on the preliminary card when Mike Russow and Shawn Jordan go toe-to-toe.Russow had won 11 consecutive fights, including four inside the Octagon, when he was stopped by Fabricio Werdum last June. He looks to rebound against Jordan, who also suffered his first UFC loss over the summer.Jordan came up short against Cheick Kongo at UFC 149 in a bout that he took on short notice. The performance was critically panned due to the clinch-heavy strategy utilized by "The Savage," and some called for his UFC release after the loss.Both men are in need of a win on Saturday night, but unfortunately, only one man can have his arm raised.Here is a head-to-toe breakdown of Mike Russow vs. Shawn Jordan. watch video >>
UFC on Fox 6: John Dodson vs Demetrious Johnson Full Fight Prediction by Paulie G watch video >>
UFC on Fox 6: Donald Cerrone vs. Anthony Pettis Fight Video Prediction by Paulie G. watch video >>
Rashad Evans vs Phil Davis - UFC on Fox 2 Full Fight Video Prediction watch video >>
UFC 171: Jake Shields vs Hector Lombard Full Fight Video Prediction & Breakdown by Paulie G watch video >>
UFC 171: Thiago Silva vs. Ovince St. Preux Full Fight Video Prediction by Paulie G watch video >>
UFC 168: Michael Johnson vs.Gleison Tibau Full Fight Video Prediction watch video >>
UFC 168: Fabrício Camões vs Jim Miller Full Fight Video Prediction by Pauile G watch video >>


text:
Paul Mobley takes on new responsibilities.
Members of Manufacturers Agents' Association for the Foodservice Industry (MAFSI) project 2015...
Many foodservice equipment manufacturers continue to offer extended warranties to help sweeten the sales process during this slower growth period.Read more...
Don't focus so much on the total seat count.Read more...
Third quarter customer traffic was flat, sales up, according to The NPD Group. Technomic looks for the Top 500 Chains to have a healthy increase in units. Sysco is planning on divesting assets to gain government approval for its US Foods acquisition. This and a whole lot more in This Week In Foodservice.Read more...
As the 2014-2015 school year draws to a close, I'd like to share the final outcomes of Nardin Academy's new self-operated foodservice program.Read more...
For many foodservice operators, the holiday season is one of the most profitable times of the year.
SHFM gives pair of awards.
The fast-casual segment seems to be the darling of the foodservice industry — and with good reason, if you look at some of the industry data. According to market research firm Technomic, the fast-casual segment is in the best position to achieve real growth this year and next.
As you hear more about the fast-casual segment, have you ever found yourself wondering what it is all about? What's driving its success? And whether you are an operator or supplier, do you ever wonder how to position your business to ride this impressive wave? I have asked myself these questions on many occasions and over the next few posts, I would like to share with you some of my thoughts and observations about this burgeoning segment.
First, I think it is important to understand that fast-casual is a morphing segment. Nowadays it seems as if concepts that 10 years ago would not have made the cut to be categorized as fast-casual are getting thrown into this mix. It used to be easy to recognize a fast-casual concept but that's no longer the case. There has clearly been a blurring of the lines between fast-casual and QSR in many of the benefits offered to the customers. When Subway started, it would have probably been categorized as QSR, yet now, with the advent of concepts like Firehouse Subs and others, it may be seen as a fast-casual concept.
If you look at what fast-casual originally was and compare it to what it seems to be today (more on that in the next post), you begin to wonder how concepts get labeled as fast-casual.
Perhaps a good portion of how concepts become categorized is based on the customers' perceptions of the operation. OK, you can say that perception is reality, which I buy, and the way an operator positions the concept significantly impacts how customers see the business.
Understanding the importance of perception, though, is critical if you want to be part of the segment either as an operator or as a supplier of industrial engineering or other consulting and design services, foodservice equipment and various other forms of technology.
So what makes a fast-casual concept? In an effort to answer this often-asked question, you can approach it from a variety of angles including:
• Is it the menu offering?
• Is it the ambiance and retail design?
• Is it the menu price?
• Is it the production process?
• Is it the service system?
• Is it the employees?
These are but a few of the questions one could pose but it seems like a reasonable place to begin our exploration of the topic. As a preview of the subsequent blog posts, consider that many fast-casual concepts now play in the drive-through arena, a service attribute that was typically the exclusive domain of the QSR. Perhaps that's still the case?
In my next post, I will expand on each of the points listed above further, providing some thoughts on how these attributes are materializing in the marketplace, which could provide support (or not) as to how a concept gets positioned and categorized as a fast-casual concept.
Stay tuned!
The Editors
In an effort to expand its healthcare foodservice business in the Chicago area, The Boelter Companies has acquired Robert Gill & Company.
The Editors
Seasoned foodservice professional takes on a VP role for the equipment manufacturer.
The Editors
SHFM gives pair of awards.
The Editors
Mote joins the Wisconsin manufacturer as vice president of national accounts.
Former Avery Dennison pro to lead the multi-line foodservice equipment manufacturer.
Whether you call them griddles or flattops, these units are one of the workhorses of the...


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Navigational Radar
Consilium Oil Spill Radar Tested
During three days of extensive testing, the advanced capability of Consilium's oil spill radar to detect oil slicks has been successfully verified. The sea trials were part of an exercise in order to certify satisfactory safety and efficiency in oil spill response operations. The operation was conducted by the Norwegian Clean Seas Association For Operating Companies (NOFO), from June 8 – 10, 2010. With the permission of the Norwegian Coast Guard, the Consilium Selesmar Selux ST 340 radar display and a 12kW 9ft antenna radar sensor were temporally installed on the Vessel KV Bergen. The Selux ST radar display was equipped with an add-on Special Edition software package, providing the advanced hardware video processing function to enable the detection and tracking of oil slicks. Consilium reports that it is the first company in this market segment, able to provide an oil detection feature built into in an IMO/Solas ARPA navigational radar plant. The radar plant is using the same hardware already approved by the Federal Maritime and Hydrographic Agency in Germany and is compliant with the European Maritime Directive (MED). The oil spill detection is also achieved by the performance of the Consilium radar sensor and by its capability to increase the speed of the antenna rotation to up to 44 rpm. The advanced video processing allows for operation under all kinds of visibility conditions
Mesa Verde Completes Trials
The Northrop Grumman-built amphibious transport dock ship Mesa Verde (LPD 19) completed builder's trials last week, in a collaborative effort involving the U.S. Navy and Northrop Grumman. Shipbuilders worked on sea trial preparations weeks before the ship sailed the Gulf of Mexico from Aug. 13 to 16. The ship's compartments were 100 percent complete, and all systems and certifications were completed and tested 100 percent to pre-trial requirements.
Ingram Barge Opts for Pinpoint Systems
Navigating the Mississippi River can be a challenge for even the most experienced operators. Currents, changing water levels and visibility are just a few of the factors that can adversely impact navigation. Ingram Barge Company, one of the Mississippi's premier towboat operators, decided on an aggressive approach to safe navigation more than three years ago and have been reaping the benefits for nearly two years. After a thorough investigation
Transas NavCom Package for Kugelbake
Transas Marine GmbH reported the completed supply of the full navigational and communication systems set to a newbuild RoRo vessel for Wulf Seetransporte GmbH & Co. KG, Cuxhaven. Transas delivered a full set of radio-navigational equipment including dual Navi-Sailor 4000 MFD ECDIS, two Navi-Radar 4000 MFD X-band, all navigation sensors, Gyro and steering system and GMDSS A2 equipments, all supplied and commissioned turn-key ready.
Transas Marine Gets Bridge Workstations Order
Transas Marine to supply four DNV NAUT - OSV (A) Class navigational bridge workstations to newbuilds in China Each bridge consists of 7 x Multifunctional Display (MFD) Workstations with DNV NAUT – OSV (A) Class Notation. The bridge equipment including 12KW X-Band Navi-Chart Radar, 30KW S-Band Navi-Chart Radar, Navi-Sailor Dual ECDIS, Navi-Conning, Slave MFDs will be installed on 4 x UT755 PSVs. The Navi-Conning Module, which can also be supplied "Off-the-Shelf"
C-Vu 3D VTS: New 3D Vessel Tracking System
The new course to follow in controlling port traffic. A step change to enhance safety and improve operational efficiency. Large ships navigating narrow waterways are always vulnerable to accidents – one only has to think of the Sea Empress tanker disaster at Milford Haven, or more recently the wrecking of the Costa Concordia. Managing their progress, usually in and out of ports and in other restricted channels, has understandably assumed a critical role in ensuring their safety
Transas VTS System Launched in Taiwan
The long construction works of the port of Ho-Ping (Taiwan) development have been concluded with the successful launch of Transas VTS system there. The project has been implemented by Transas Marine Pacific in cooperation with their Taiwanese agent, Seven Seas Electronic.The new VTS system in Ho-Ping gives significant advantages to the industrial port as it makes it compliant with the VTS IMO/IALA regulations, improves port management system and essentially increases navigational safety in
CG Cape Wind Radar Study Findings
As a cooperating agency with the Department of the Interior's Minerals Management Service, the U.S. Coast Guard is providing an assessment on the proposed Cape Wind project's impacts to Coast Guard missions and the potential impacts the project may have on navigational safety. In Oct. 2008, Capt. Raymond Perry, the commanding officer of Coast Guard Sector Southeastern New England, determined that for Coast Guard officials to make a recommendation to the Minerals Management Service
ICS Applauds Key Navigational Safety Improvements
ICS Welcomes Progress by Governments to help improve Navigational safety in Malacca/Singapore Straits. The International Chamber of Shipping (ICS), which represents 80% of the world merchant fleet, has welcomed the outcome of an important meeting between governments to advance navigational safety in the strategically vital Malacca and Singapore Straits, where there are about 70,000 transits by ships each year.
Singapore POCC: Off with the Old, On with the New
Singapore's first Port Operations Control Room Centre (POCC) de-commissioned, as new upgraded centre takes over control. The decommissioning of the centre at at Tanjong Pagar Complex (POCC-TPC) marks the retirement of Singapore's first POCC after more than 28 years of faithful service in ensuring navigational safety of vessels in the Singapore Strait and Singapore's port waters. First commissioned on 1 May 1984
Furuno Makes Clean Sweep of NMEA Awards
Over the past 43 years, Furuno has received the honor of being the most recognized company in the marine electronics field by the National Marine Electronics Association (NMEA). This year, Furuno won four more NMEA awards at the prestigious 2014 NMEA Convention in Sanibel, FL
Navico Acquires MARIS; Expands Portfolio
Navico Holding AS, parent company to the Simrad brand of navigational marine electronics, has reached an agreement to acquire MARIS (Maritime Information Systems A/S) from The Grieg Group. MARIS is a supplier of data solutions to the commercial maritime sector related to navigation
Eastern's Columbia on Display in Fort Lauderdale
Eastern Shipbuilding Group's reengineered Columbia, built from the original design plans of the classic 1923 Essex-built schooner, will be on display at the Fort Lauderdale International Boat Show, October 30-November 3, 2014. The original Columbia
L-3 MSI Supplies Navigation for the Oasis Class
L-3 Marine Systems International (L-3 MSI) has been awarded a contract to provide its NACOS Platinum navigation system, including an integrated dynamic positioning system, for the third ship in Royal Caribbean International's (RCI) Oasis class
BCG Releases PCVM Emulation
Buffalo Computer Graphics (BCG) Inc. announced the addition of another emulation product to its family of Radar Simulators. BCG has completed an emulation of the VisionMaster FT radar – our PCVM. PCVM utilizes the same simulation engine as the rest of BCG's products
Danelec Introduces VDRConnect at SMM14
At SMM 2014, Danelec Marine is unveiling VDRConnect, a Web-based remote access service available with the Danelec DM100 Voyage Data Recorder (VDR). VDRConnect is a module that provides selective transmission of data from the Danelec DM100 via satellite to the home office
Raytheon Anschütz Unveils New Navigation Radar
On opening day of SMM, the German navigation system manufacturer Raytheon Anschütz officially launched the newly developed NautoScan NX network radar transceivers, the centerpiece of its next generation Synapsis Radar system. The new NautoScan NX transceivers generate raw radar video
Expanded Kelvin Hughes Product Range on Display
Kelvin Hughes is launching and demonstrating a host of new products and services at SMM 2014, including a port security radar system, specialist mission radome radar and displays, Voyage Data Recorders and the latest version of ChartCo PassageManager software.
New Heater Kits for Northern Sea Route Vessels
Northrop Grumman develops winterization field upgrade kits for vessels using the Northern Sea Route These heater kits will enable Marine Navigation Radar Turning Units to be operated in temperatures down below -55 degrees Celsius, in addition to keeping the S-Band and X-Band sensors in the
Kelvin Hughes Debuts Port Security Products
Kelvin Hughes is displaying its new combined camera and radar Single Mast Solution (SMS) at SMM 2014 in Hamburg from September 9-12. The company is also demonstrating the associated CxEye display software which provides intuitive command and control for the system.
GNS Launches Free E-Navigation Solutions
At SMM in Hamburg, Germany this week, Global Navigation Solutions (GNS), the maritime services group announces the launch of (i) its new free Essentials package, as well as (ii) an upgrade to the Voyager Planning Station dashboard, and (iii) a new bundle purchasing option. Essentials Package
AN/SPY-1 SSSA Completes Critical Design Review
The Critical Design Review (CDR) stage for AN/SPY-1 radar Solid-State Switch Assembly (SSSA)'s high voltage modulator completed Aug. 26, confirming that the design is expected to meet performance requirements. A CDR confirms the system is on track to achieve affordability and cost
Canal Marine, Techsol Marine Enter Partnership
Canal Marine and Techsol Marine announced a partnership agreement that will combine the companies' expertise for providing marine system design and fabrication, including switchboards, motor and generator controllers, AC/DC drive and winch controllers, alarm and monitoring systems
Cummins Auxiliaries for New Offshore Vessel
Reliable auxiliary power is as important to a modern offshore vessel as are the main propulsion engines. Ample and reliable electrical power is essential to the basic support systems from the galley appliances to the wheelhouse navigational devices. The Ms
New Simulation Tool for Collision Reconstruction
BMT ARGOSS and BMT Surveys, subsidiaries of BMT Group Ltd, the international design, engineering and risk management consultancy, announced an innovative new service as part of its marine casualty investigation portfolio. Utilizing REMBRANDT, the simulation tool developed by BMT ARGOSS


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What is included in this set?
116 colorful gears (gears, flowers, butterflies, bees, ladybugs, wiggly stems and more!)
Both girls were pretty excited about this new "toy"! They worked together to build and make a working flower garden.
Even Audrey, my 2nd grader, enjoyed this set!
Sophia (the 5 year old) could not stop playing with her new Gears set!
It was all about problem solving and figuring out how things work. Putting things together and taking them apart. Playing and learning all at the same time!
This photo makes me SUPER happy! Sophia took out the picture directions and got busy constructing what she saw in the pictures. This type of learning toy in invaluable! So much fabulous learning takes place when kids get to "play" like this!
I also appreciate how easy the pieces snap together.
This makes it fun for little hands to construct things without feeling frustrated.
This makes it fun for little hands to construct things without feeling frustrated.
She's thinking. How does this work? How do the pieces work together?
LOVE it!!
Sophia worked SO hard on building her garden and she was so proud to see how it all worked together!
When you turn the little hand crank, the gears work together to make all of the pieces move. A spinning flower garden! However, if the pieces are not connected, everything won't work together. This gives kids the perfect opportunity to problem solve and figure it out.
Learning Resources has graciously offered to give a set away to one of the Moffatt Girl readers! For a chance to WIN this Gears! Gears! Gears! set, use the Rafflecopter below!


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One of the most common expressions is "Money talks", and for many - dumbfounded by the fact that a grand jury saw it fit to let a white officer walk free after fatally shooting a young black man…Continue
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Listen to Kelis' new release 'Live in London'. A recording of the musician's Summer concert at London's Somerset House. Joined by a big band and a horn section, the Kelis performs her classic hits and features - as well…Continue
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Detroit singer/songwriter Daniel Wilson unleashes his greatly anticipated five track EP, 'Boy Who Cried Thunder' this week, much to the elation of his fans. After already dropping the rock infused starting track, "Killed Ya" and…Continue
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A lot of the ignorant commentary surrounding Ferguson has been aimed towards the planned responses following the fatal shooting of Michael Brown. Bombarded with images of looting and buildings set alight, many continue to…Continue
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The parents of Michael Brown were interviewed this morning on CBS with Gayle King and Charlie Rose. An interview that acts as a direct response to officer Darren Wilson's ABC interview - interviewed after the grand jury…Continue
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I woke up as angry as when I'd gone to sleep. I thought about writing an essay about how the lack of indictment merely shows that racism in America is so ingrained that at least 9 citizens of St. Louis County felt like…Continue
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In classical music, an Opus designates a major published work. For Signor Benedick The Moor to call his third album 'Opus 3 – A Man Atop the Tower' could be a pretentious declaration if it weren't so accurate. This is an…Continue
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Address: Km 105, Alex-Matrouh Desert Rd., El-Alamein
Opening Hours: 9 am – 4 pm
Ticket Price(s): 10 EGP (Regular), 5 EGP (Student)
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Nearby Attractions
The Italian War Memorial
The Italian War Memorial honors the memory of Italian soldiers who lost their lives in the Battle…Click to AddClick to Remove
El-Alamein Battlefield
El-Alamein is famed for the decisive victory of the Allies in the WWII North Africa campaign.Click to AddClick to Remove
Shopping at Marina
One of the greatest shopping venues of the Egyptian North Coast is located in the upscale resort…Click to AddClick to Remove
British War Memorial
The British Memorial, also known as the War Cemetery is one of the most impressive sites in El-Alamein.Click to AddClick to Remove
Gliding up in the air, feeling the wind on your face and tingling your finger toes, gazing at amazing…
Day CruisesVirtual Tour
Get up close and personal with the Nile: take a felucca cruise. Feluccas have several perks besides…
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LightSail gets $37.3 million for compressed air energy storage systems
- Details
- Category: Finance
- 08 Nov 2012
- Published on Thursday, 08 November 2012 08:52
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I have yet to establish my connection to this line. My ancestor was a Jacob Feller, found in Greene County, TN. which borders Washington County. in 1798, but he is not the Jacob G. Fellers, son of Adam. I believe he is related farther back, but I can't find the parents names of my Jacob, who was listed as born in Pennsylvania, in the TN. Vital Statistics Record, at his death in 1860. By looking at the maps, my ancestor and yours only lived a few miles apart, so I am leaning to "kinship" at this time. It could be a coincidence, but I'm not convinced of it yet.
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Anna Faris
This Week's Best Red Carpet Looks
The Horrible Bosses 2 star showed some leg at the film's LA premiere on November 20, 2014. MORE
Chris Pratt and Anna Faris Reveal Their Son Was Born at Three Pounds
Just when you thought you knew everything about Guardians of the Galaxy hunk Chris Pratt,... MORE
Pretty Little Liars: Could Aria Be A?! Lucy Hale Spills 'It Would Make Sense'
If you're like us, you're probably anxiously awaiting the Pretty Little Liars...MORE
This Week's Best Red Carpet Looks
Jennifer Aniston dazzled in an elegant black dress at the Academy of Motion Picture Arts and Sciences' 2014 Governors Awards at The Ray Dolby Ballroom at Hollywood & Highland Center on Nov. 8. MORE
Anna Faris Talks Possible Chris Pratt Cameo on 'Mom'
Anna Faris is dishing to ETonline about the new season of Mom, and whether there is a chance...MORE
On Set with Allison Janney and Anna Faris at 'Mom,' TV's Most Improved Comedy
It's been a great year for Mom. The award-winning CBS sitcom, which starts its second season on Oct. 30, picked up ratings steam at the beginning of 2014 thanks to critically acclaimed performances from stars Allison Janney and Anna... MORE
7 Times We Fell in Love With Chris Pratt
Chris Pratt is quickly becoming one of Hollywood''s new leading men... it''s about time! His new film Guardians of the Galaxy opens this weekend and is already set to be a huge box office success. To celebrate the Guardians...MORE
'Pretty Little Liars': The 100 Most Terrifying 'A' Threats in 'PLL' History—Ranked!
Scared yet? You should... MORE
Is Fashion the Fifth 'Pretty Little Liar'?
Over the past four seasons, Ashley Benson, Lucy Hale, Troian Bellisario, and Shay Mitchell have all been the stars of Pretty Little Liars. But, there seems to be another one that has really stood out …...MORE
'Mom' Stars Reflect on the Comedic True-Life Series Being Honored by TV Academy
The CBS sitcom Mom broke new television by using comedy to deal with the serious societal problem of addiction and now the series is being honored by the TV Academy for its blunt portrayal of real-life situations.... MORE


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Dr. Lane C. Reed, MD
Family Medicine, Goshen Family Physicians
- 1811 Charlton Ct
Goshen, IN 46526
- 1 Office Location
- (574) 534-8200
Dr. Lane C. Reed has been practicing medicine for 22 years. Dr. Reed graduated from the Indiana University School of Medicine in 1992. He practices medicine in Goshen, IN and specializes in Family Medicine and Obstetrics & Gynecology. Dr. Reed is affiliated with IU Health Goshen Hospital. He speaks English and Spanish.
Gender: Male
Years in Practice: 22 Years
Languages Spoken: English, Spanish
Medical School: Indiana University School of Medicine
Graduation Date: 1992
Hospital Affiliations: IU Health Goshen Hospital
Specialties: Family Medicine, Obstetrics & Gynecology


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Matthew Shipp – 4D (2010)
by Mark Saleski Over the years I have spent many pen scrawls, pencil swipes, and keystrokes trying to describe what it is about 'out' music that moves me so much. Sometimes it's pretty easy
by Mark Saleski Over the years I have spent many pen scrawls, pencil swipes, and keystrokes trying to describe what it is about 'out' music that moves me so much. Sometimes it's pretty easy
Don't get me wrong, I love jazz guitarists who derive their inspiration from guys like Wes Montgomery, Kenny Burrell and Pat Metheny, but it's so refreshing to hear a new guitarist come along who excels by taking the road less traveled. That's former child prodigy guitarist Julian Lage, who seems to be more in line with the vocabulary of swingRead More
by Mark Saleski Why do people hit a musical wall at a certain point in their life? They stop listening to anything put out after their high school (or college) years. Worst of all: they just stop listening. Music is no longer a part of their life.
Art Blakey is spoken about a lot in our little 'berg on the internet, and like most other admirers of his Jazz Messengers body of work, we tend to focus more on the late 50s-mid 60s era that included so many future jazz icons
Stan Kenton would have been 100 this year and, in many ways, he's as misunderstood now as he was in his own time.
Author Jonathan Franzen (The Corrections, Freedom) was feeling sort of burned out and overexposed after spending several months book touring, with his personal history a constant subject. His solution was to travel to a remote island
It's been a couple of years since we last heard from pre-eminent jazz rhythmist Jeff "Tain" Watts, when his star-studded engagement Watts was introduced.
Clarinetist Mort Weiss, who turns 76 years young tomorrow, is ten years into a remarkable comeback after laying off working as a musician for four — that's right — four decades.
Shane Endsley might not be a familiar name to you, but the Grammy-nominated funk-rock-jazz group he cofounded Kneebody might be. Even if it isn't, this trumpeter who'd gigged with Charlie Hunter, Ben Allison and Chris Speed became more noticeable with the debut of his own Music Band. Then The Other was supposed to be a vehicle for Endsley's simpler melodiesRead More
by Mark Saleski There are two things that can be counted on when cracking open a new Carla Bley Big Band record: 1. many, many interesting and twisty passages of musical architecture and 2. volume. Oh yes, the horn section is enormous