text:
|Publication number
|Publication type
|Application number
|Publication date
|Jan 16, 2003
|Filing date
|Sep 15, 2002
|Priority date
|Aug 7, 1998
|Also published as
|Publication number
|Ananth Natarajan, Nitish Thakor
|Original Assignee
|Ananth Natarajan, Thakor Nitish V.
|Export Citation
|BiBTeX, EndNote, RefMan
|Patent Citations (5), Referenced by (64), Classifications (30), Legal Events (6)
|External Links: USPTO, USPTO Assignment, Espacenet
[0001] This application claims the benefit of U.S. Provisional Application No. 60/095,635, filed Aug. 7, 1998, entitled "Method and Apparatus for In Vivo Detection of Myocardial Ischemia."
[0002] The present invention relates to methods and apparatus for detection and treatment of the disease process known as myocardial ischemia and/or infarction (MI/I).
[0003] Ischemia occurs when the blood supply to the heart muscle is temporarily or permanently reduced, such as may result from the occlusion of a coronary artery. This occlusion may lead to local ischemia or infarction of the heart muscle. Ischemia may also occur over large sections of the heart muscle due to conditions such as cardiac arrest, heart failure, or a variety of arrhythmias. The ischemic event can be of the so called "silent type" described in medical literature (e.g. not manifesting itself in terms of symptoms experience by the patient or obvious external indications). The event can also be chronic with continuously evolving symptoms and severity due to underlying heart disease, or very abrupt and possibly even fatal due to infarction of large enough area of the heart to cause a large myocardial infarction.
[0004] The ischemic event often causes the performance of the heart to be impaired and consequently manifests itself through changes in the electrical (e.g. the electrocardiogram signal), functional (e.g pressure, flow, etc.) or metabolic (e.g. blood or tissue oxygen, pH, etc.) parameters of the cardiac function.
[0005] The conventional approach to detection of MI/I is to analyze the electrocardiogram (ECG). An ischemic event results in changes in the electrophysiological properties of the heart muscle that eventually manifest themselves as changes in the ECG signal. The current state of the art is to record these ECG signals from the body surface using amplifiers and associated instrumentation. A standardized set of electrodes in an arrangement known as a 12-lead ECG has been developed. The conventional approach to the detection of ischemia and infarction relies on analysis and interpretation of characteristic features of the ECG signal such as the ST-segment, the T-wave or the Q-wave. Computer-based technology has been employed to monitor, display, and semi-automatically or automatically analyze the ischemic ECG changes described above. The present technology includes ECG machines used in doctor's office, portable ECG machines known has Holter recorders, bedside monitors with displays, and sophisticated computer-based system for automatic analysis of the ECG signals.
[0006] Technology exists for providing therapy once ischemia is detected. The most common approach involves thrombolytic therapy (by external infusion of drugs such as TPA or streptokinase) or opening of the blocked vessels using a variety of angioplasty catheter devices. In the event that ischemic condition results in malignant arrhythmia or arrest of the heart, an external defibrillator may be used to shock the heart and restore the cardiac rhythm.
[0007] Technology also exists for implanting therapeutic devices for treating electrical conduction disturbances or arrhythmias of the heart. These devices include implantable pacemakers, cardioverters and atrial and ventricular defibrillators, drug infusion pumps as well as cardiac assist devices. The implantable devices typically use intracavitary leads to sense the electrogram (EGM) and then provide electrical therapy (pacing or defibrillation) or mechanical therapy (pumping blood). These devices sense the EGM and then utilize the features, such as improper conduction (in case of a pacemaker) or a fatal rhythm (in case of a defibrillator), or simply timing (to coordinate mechanical pumping). Notably, these devices do not specialize in the task of detecting, alerting the patient or treating ischemic heart disease.
[0008] Ischemia detection and analyses are usually done manually by the expert cardiologist or by computers employing algorithms to detect ischemia-related changes in the ECG signals. The preferred features of the ischemia detecting computer algorithms are the ST-segment and the T-wave. These features show elevation, depression or inversion of these ECG signals associated with ischemia. The computer then carries out a careful measurement of the degree of elevation/depression in a specific lead. By identifying ischemia dependent changes from specific leads, the ischemic event is attributed to a specific region of the heart.
[0009] The current approach to diagnosis is that after an ischemic event is perceived by the patient, they contact medical personnel such as the "911" system or their personal physician. Within the clinical setting, the patient is often monitored using a short recording of the ECG signal which may be interpreted by a physician. Alternately, the high risk patient may be continuously monitored at the bedside in a cardiac intensive care unit. Therapy may include using drugs such as TPA, use of catheters for angioplasty (opening the blocked coronary vessel using a balloon or laser), or providing life support back up such as defibrillation.
[0010] The aforementioned cardiovascular medical monitoring technology and medical practice have several significant drawbacks in regard to the detection and treatment of coronary ischemia which can result in severe consequences to the patient up to and including death. They include the following:
[0011] 1) Not being able to immediately alert the patient and/or the physician of an ischemic event, particularly a life threatening event.
[0012] 2) Not being ambulatory with the patient; and/or an inability to provide continuous monitoring to the patient and indication of the necessary diagnostic information to the physician.
[0013] 3) Requiring input and interpretation of a physician or medical practitioner when one may not be present.
[0014] 4) Requiring monitoring devices external to the body, such as an ECG monitor or external defibrillator, which are usually only available in medical centers and hospitals, and which further need special expertise and attention from medical personnel.
[0015] 5) Reduced sensitivity or otherwise inability to detect ischemic events due to loss of sensitivity from use of external electrodes.
[0016] 6) Loss of specificity as to the site of ischemia due to inadequate placement of electrodes in the vicinity of the ischemia or infarction.
[0017] 7) Needing sophisticated expertise of a cardiologist to interpret the clinical condition or needing monitoring instruments with sophisticated computer-aided ECG signal analysis capabilities.
[0018] 8) Over reliance on use of ECG signals for detection and inability to utilize and integrate other physiological data, (e,g pressure, blood flow, and PO2).
[0019] 9) Inability to immediately alert the patient or the physician of the impending or emerging ischemic condition.
[0020] 10) Inability to provide immediate treatment, particularly for life-threatening events (e.g. myocardial infarction, cardiac arrest).
[0021] Certain embodiments of the present invention relate to methods and devices for detection of myocardial ischemia and/or infarction (MI/I). Preferred embodiments relate to electrodes and sensors, devices and methods for interpreting ischemic conditions, devices and methods for initiating the procedure to alert the patient and/or the care-giver, and devices and methods for connecting with a device that provides therapy. MI/I may be detected using implantable devices and methods according to certain embodiments of the present invention.
[0022] Embodiments may include a stand alone device or a modification of another implantable device such as a pacemaker, cardioverter, defibrillator, drug delivery pump or an assist device. Embodiments may use a variety of in vivo sensors located inside the human torso and/or inside the heart. The sensor device preferably includes electrodes that are indwelling in the heart, on or in the vicinity of the heart, under the skin, under the musculature, implanted in the thoracic or abdominal cavity. Preferably the sensor device also includes strategic placement of the electrodes to capture the EGM signal from various positions and orientations with respect to the heart. The sensor device also preferably includes other hemodynamic or mechanical sensors that are sensitive to the condition of the heart in MI/I. MI/I may be recognized using analysis of the features of the signal, namely the EGM, recorded by the electrodes and sensors. The features of the EGM signal (namely, depolarization and repolarization), morphology, and analytical information such as the spectrum, wavelet transform, time-frequency distribution and others, are utilized in the interpretation and recognition of the MI/I condition. Separately or in conjunction, the hemodynamic (namely, blood pO2, pH, conductance, etc.) and mechanical parameters (blood pressure, blood flow, etc.) are sensed according to the embodiments of this invention. MI/I is then recognized by integrating some or all of the sensor information. Embodiments may detect this MI/I event and alert the patient using a variety of methods, including but not limited to vibration, electrical stimulation, auditory feedback, and telemetry. The device to alert the patient may in certain embodiments be incorporated within the instrument itself. The patient may be alerted by direct communication via electrical, sound, vibration or other means or indirect communication to an external device in an electromagnetic link with the implanted device. Once the MI/I event is identified, the device may also institute therapy, such as infusion of a thrombolytic agent or delivering life saving shock in case of an arrest, semi-automatically or automatically. The therapy giving device may be integrated with the MI/I detection, MI/I analysis, and/or patient alerting device into an integrated or separate stand alone system.
[0023] Embodiments of the invention may be used to detect MI/I from inside the body as compared with the traditional approach of detection by placing electrodes on the outer body surface of the torso. This is made feasible in certain embodiments by using the MI/I detection technology in an implantable device. Embodiments utilize sensors, such as electrodes and leads, that record the EGM signal from inside the chest in the vicinity of the heart and/or from electrodes placed on the heart, and/or using catheters or leads placed inside the cavities (atria and ventricles). Embodiments may include built-in interfaces to electrodes, namely circuits for amplification and filtering of the signals, and the circuit for digitization (analog-to-digital conversion) and processing (microprocessor). Embodiments of the implantable device, using its microprocessor, analyze the features of the EGM signal from these leads to detect an ischemic event.
[0024] Embodiments also relate to the design, construction and placement of electrode sensors. Embodiments may include an electrode lead with multiple sensors capable of recording EGM from multiple, strategic locations in the chest or in and around the heart. This embodiment also includes utilization of the body of the instrument and single or multiple leads.
[0025] Embodiments also relate to detection of the ischemic event including identifying particular features of the EGM signal. These features include depolarization (i.e. initial excitation of the heart when a beat is initiated, coincident with the body surface QRS complex) and repolarization (i.e. the subsequent repolarization of the heart coincident with the body surface ST-segment and T-wave). MI/I results in alteration in depolarization and repolarization waves in selected regions of the heart, for the case of focal ischemia, or the entire heart, for the case of global ischemia. These changes alter the action potential (of heart cells) as well as the conduction pattern (in selected regions or the whole heart). The alterations in action potential shape and conduction change together alter both the depolarization features as well as the repolarization features). Depending on where an electrode is placed, these features may be seen in different recordings. The electrodes pick up the local signal (from the heart muscle in its vicinity) as well as the distal signal (distal muscle areas as well as the whole heart). The characteristics of this signal are identified in the form of shape changes, and these shape changes can be identified in a variety of ways, including temporal, spectral, and combined approaches.
[0026] The MI/I detection technology according to embodiments of the present invention, may also utilize non-electrical measures, including hemodynamic and mechanical parameters. An MI/I event may result in a degree of deprivation of oxygen to the heart muscle. This in turn may result in a decreased ability to perfuse the heart muscle as well as the body. This may result in a cyclical reduction in the mechanical performance in terms of contractility and pumping action of the heart. Sensors placed inside the blood stream pick up the changes in blood oxygen, pH, conductance, etc. resulting from the MI/I event. The MI/I event would lead to small changes in case of mild ischemia or infarct or significant changes in case of global ischemia or cardiac arrest. The sensors are usually placed inside a catheter or a lead, although some times in the body of the instrument, and then measurements may be made via the electronic circuit interfaces inside the implantable device. The mechanical function of the heart may be detected utilizing sensors and leads, including those for pressure, volume, movement, contractility, and flow.
[0027] Embodiments also relate to methods and devices for signaling the host patient or others (such as medical personnel) to the incidence of MI/I. When MI/I is detected, it is imperative to take therapeutic actions rapidly and even immediately. Thus, the patient needs to be informed and the caregiver physician needs to be informed. Embodiments of the invention include devices and methods for communication between the implantable device and the host/physician. One of these approaches is to use radio-frequency or radiotelemetry, while another is to communicate through electrical stimulation. Other approaches, including sound, and magnetic fields are also devised. Embodiments may also utilize long distance, remote and wireless means of communication using telephone, telemetry, Internet and other communication schemes. Embodiments may also include the code of communication by which the information pertinent to MI/I is presented in detail. This code may be either analog or digital, relayed via the communication link, and then decoded by the receiving instrument or individual. The code primarily signals to the host patient, or the external device attached to the patient, or directly to the medical caregiver, the condition of MI/I. The code may include information about EGM, the MI/I condition, and other related diagnostic information. The code may also include recommendation and instructions to provide an immediate therapy to the patient to treat MI/I.
[0028] Another aspect of certain embodiments of the invention includes coupling of the MI/I detection technology to a variety of therapeutic devices. The implantable MI/I detection technology makes it feasible to rapidly initiate therapy through direct access to the body, circulatory system or the heart. In some circumstances it is desirable to infuse drug such as Streptokinase or TPA to treat the patient. Other drugs may also be infused immediately or subsequently on a steady state basis. In other instances it is desirable to carry out procedures such as angioplasty. In case the MI/I event leads to a life-threatening arrhythmia or cardiac arrest, means to treat the arrhythmias to resuscitate the heart are disclosed. These may include use of electrical pacing, cardioversion and/or defibrillation. In case the MI/I event leads to a failure of the heart, means to assist the heart are disclosed. These assistive devices include left or right ventricular assistive device and artificial heart pump. Embodiments may declare interface of the implantable myocardial ischemia detection technology to these therapeutic approaches and the use of these therapies upon discovery of MI/I by the implanted devices.
[0029] Another aspect of certain embodiments of the invention includes the use of the technology in an implantable device. The implantable device may include a hermetically sealed can, electronics, analog and digital logic, microprocessor, power source, leads and sensors, circuits and devices to alert the patient, communication link and interface to the external diagnostic and therapeutic means. Embodiments also include modification of implantable arrhythmia detection devices, pacemakers, defibrillators, infusion pumps, or assist devices to have the novel features described above. The technology used in embodiments of the present invention can be partially or fully integrated into these instruments. Embodiments further include hardware, software or firmware modification of the aforementioned devices to have MI/I detection, alerting and therapy initiating features.
[0030] Certain embodiments of the invention are described with reference to the accompanying drawings which, for illustrative purposes, are not necessarily drawn to scale.
[0031]FIG. 1 illustrates a schematic illustration of the torso and heart which also includes the implantable device, its sensing lead, an alarm means, a therapy device, and a communication means to an external device according to an embodiment of the present invention.
[0032]FIG. 2: (a) illustrates a preferred embodiment including an implanted device such as a pacemaker with a full 12-lead electrocardiographic configuration (L, R, F and V1 through V6, and ground reference) using an implantable intra-cavitary and intrathoracic lead; (b) illustrates a second preferred embodiment using an implanted device and a single suitably positioned intrathoracic lead with multiple sensors in the chest and the ventricular cavity of the heart; and (c) illustrates a third preferred embodiment with a suitably placed device with multiple electrical contact sensors on the implanted device can and a suitably threaded lead through the thoracic, abdominal and the ventricular cavity along with the sensor means.
[0033]FIG. 3 illustrates a preferred embodiment, such as a cardioverter-defibrillator with suitable sensing or shocking lead with sensor means indwelling the heart and ventricular cavity and a series of sensors on the shocking lead on the epicardium or the thoracic, abdominal and ventricular cavity.
[0034]FIG. 4 illustrates three of the many placements and shapes of the implanted device inside the thoracic or abdominal cavity, and the sensor means on each can of the implanted device with each sensor insulated from the can (see the inset), according to embodiments of the present invention.
[0035]FIG. 5 illustrates three preferred embodiments with suitable implanted device in the thoracic cavity, placement of different electrode leads and sensors and their different configurations with respect to the heart. The sensor configuration includes leads with (a) unipolar, (b) bipolar sensing and (c) physiologic sensor means inside the ventricular cavity of the heart.
[0036]FIG. 6 illustrates the (a) electronics and microprocessor system used in the implantable myocardial ischemia detection device, and (b) the circuit diagram for amplification and filtering of the EGM signal, according to embodiments of the present invention.
[0037]FIG. 7 illustrates (a) the depolarization and repolarization signals of the electrocardiogram, the action potential, normal and ischemic EGM, the pressure signals, and time-frequency response characteristics of the EGM, (b) the electrical activation pattern on the heart as visualized by isochronal conduction distribution in normally conducting and ischemic zones.
[0038]FIG. 8(a) illustrates various communication links between the implantable device and the external monitoring devices, including alerting the subject with the aide of a loud speaker, vibrator or electrical stimulation, communication to and external device via RF communication, audio communication, and magnetic field modulation according to embodiments of the present invention.
[0039]FIG. 8(b) illustrates the implantable MI/I detection technology piggy-backed or incorporated as a part of a modified implantable pacemaker or a cardioverter-defibrillator according to embodiments of the present invention.
[0040] Certain embodiments of the invention pertain to methods and devices for detecting ischemia or infarction, diagnosing, alerting the patient and/or treating the ischemic heart disease.
[0041] Implantable myocardial ischemia and/or infarction (MI/I) detection technology according to certain preferred embodiments is illustrated in FIG. 1. Embodiments include methods and devices to detect and treat MI/I. One embodiment of a method includes: i) placement/implantation of the device inside the chest or other body cavity, ii) placement and implantation of electrodes and sensors to selected areas of the myocardium, iii) connection of one or more of the electrodes and sensors to the implanted device, iv) detection of an ischemic event by the analysis of the EGM signal and sensor data, v) the method of analysis of the EGM signal using signal processing means in time and frequency domain, vi) communicating the stored EGM signals to an external device using telecommunication means, vii) alerting the patient of the event, vi) communication with the medical attendant using telecommunication means, and vii) initiating or implementing medical therapy for MI/I. Embodiments may include some or all of the above elements, which are described in more detail below.
[0042] One preferred embodiment is illustrated in FIG. 1. It includes a plurality of devices (101) and sensors (102) that are implanted in the human body (103). Referring to FIG. 1, this implementation may include one or more of the following steps: i) a device that would reside inside the body (103) and alert the patient (106) or the medical attendant of an impending or ongoing ischemic event and undertake therapeutic action, ii) one or more implanted sensors (102) positioned in selected areas of the heart (104), such as a ventricular cavity (105), and connected to the aforementioned device, iii) detecting an ischemic event, iv) alerting the patient of the event as depicted in (106), v) communication, as depicted in (107) with a device external to the body (108) or a medical attendant, vi) administration of medical therapy via an intracavitary pacing electrode (109), infusion of drug through the body of the lead (102) or shocking the heart between leads (102 and 110).
[0043] Another preferred embodiment of the device and its method of use is illustrated by FIG. 2(a). The device (101) is implanted in the thoracic cavity under the skin or muscle in the vicinity of the heart (104). The sensing may be accomplished by a detailed electrocardiographic system that provides a device for biopotential recording from locations around the heart that result in a more complete assessment of the ischemic regions of the heart. The leads are positioned in one or more configurations within the chest to form an internal Einthoven's triangle (an external Einthoven's triangle is a concept known in the art). This configuration provides the advantage of enhanced signal sensitivity for discrete selectable areas of the myocardium and allows for easy determination of particular cardiac vectors. The resultant 12-lead electrocardiographic system is employed by those skilled in the art on (not internal to) the chest to provide projection of the cardiac dipole at various electric field orientations. A cardiologist or a computer program is then employed to determine the site and degree of MI/I by interpretation of the electrocardiogram. In the present invention, an intra-thoracic lead system is designed to record the EGM activity using a plurality of sensors situated to record projections of the cardiac dipole from inside the body in a manner analogous to the Einthoven's triangle and a 12-lead recording system from outside the chest. A lead (201) system comprises a biocompatible insulated carrier device with a plurality of electrically conducting metallic sensors that conduct the EGM signal from in or around the chest to the circuitry within the implanted device. The lead depicted in FIG. 2 carries three sensors (202, 203, 204) corresponding respectively to the left arm (L), the right arm (R) and the foot (F) projections of the 12-lead system. A Wilson's central terminal, a central terminal derived through a resistive network, is provided to derive the leads I, II, III and the three augmented leads (external, but not internal, Wilson's central terminal and leads are concepts known to the art). The lead is attached to the body of the implanted, hermetically sealed device (101) via a connector (205) that provides a feed-through interface to the circuitry within. Another lead (206) carries additional sensors (207 through 212) corresponding respectively to the V1 through V6 projections of the 12-lead electrocardiographic system. The body of the device or a conducting sensor incorporated there in provides the ground or the circuit common reference G (213). The sensor signals are electrically connected via the lead to the circuitry within the implanted device. The EGM signals recorded from this lead system is analyzed for the features of MI/I.
[0044] Another preferred embodiment shown in FIG. 2.2(b) comprises an implanted device (221) in the abdominal or lower thoracic cavity (220) with a preferred lead system (222) with a plurality of sensors. The lead system (222) makes a connection through a feed-through connector (223) to the circuitry of the implanted device (221). The lead (222) is suitably implanted within the thoracic cavity and in and around the heart (105) to place the sensors at locations that allow recordings analogous to the aforementioned 12-lead electrocardiographic system. The design involves the placement of the conducting sensors so that their placement inside the thoracic areas of the body (103) and in and around the heart (104,105) preferably corresponds to the 12-lead electrocardiographic system. Thus, the sensors V1 through V6 and L, R, and F (224) along with the ground reference G on the body of the device (225) represents all the electrodes needed to reconstruct the full electrocardiographic system, comprising leads I, II, III, augmented leads, and chest leads, suitable for implantable technology. The EGM signals from this lead system (222) may then be analyzed for the indications of MI/I.
[0045] Another embodiment is depicted in FIG. 2(c). An implanted device (230) is located in the lower thoracic or abdominal cavity and a lead (231) with sensors therein is threaded through the intra-thoracic areas of the body (103) and in and around the heart (104,105). The lead carries the sensors L, R and F, while the body of the implanted device carries the sensors V1 through V6, wherein the sensor array shown as (232). The body of the device (230) carries the ground or the circuit common G, while the conductive sensor elements shown as the open circles are insulated from the body of the device as shown by the dark rings around the circular sensor body (233). This lead system suitably captures the EGM signals from the various regions of the body which are then electrically conducted by the lead (231) to the implanted device (230).
[0046] Still another embodiment is illustrated in FIG. 3. An implanted device (101) placed inside the body (103), utilizes a plurality of leads (301) and (306) and sensors therein. The lead (301) carries with it the sensors L, R and F for EGM sensing within and around the heart (104, 105). The lead 301 also carries plurality of sensors (302) for mechanical or hemodynamic information from within the ventricular cavity (105). The lead (306) connects sensor element (307) carrying plurality of sensor V1 through V6 (308). The body of the device (101) carries the ground reference G.
[0047] In yet another embodiment of the present invention, an implanted device is placed inside the chest in the proximity to the heart. The device is shaped in a manner so that it can carry on its case one or more leads (electrodes and their combination) suitable for recording multiple EGM signals. There are several locations that are preferred. FIG. 4 shows the thoracic part of the body (103), the heart (104), and three of the suggested locations and shapes of the device (401, 402, 403), each one of these locations and electrode placements is to be used independently and exclusively. These locations allow preferred orientation of the electrodes and leads for detection of EGM signal. For example, location (401) with three electrodes (405, 406, 407) give preferred orientation of the ECG in conventional left arm and lead I between (405, 406) signal from the cardiac dipole. The three sensors also give other projections from the heart when taken in pairs (406, 407) and (405, 407). The body of the can or an additional metal sensor insulated from the can is used as a ground reference. Alternately, the signals from the sensors (405, 406, 407) may be summed using resistive network, known, in external devices but not implanted devices, as Wilson's central terminal, to provide a common or reference signal. The location (403) analogously has 3 electrodes (408, 409, 410) which give the conventional right arm and lead I between (408, 409) signal, and other differential pairs II and III between (409, 410) and (408, 410). The location (403) has sensors V1 through V6 (411) giving 6 chest lead signals. In all these designs and placements the sensors are mounted on the encasement of the device known as the can and hence do not require separate leads or wires going out from the can via the feed-through to the heart or to the body. The can and the associated sensors can be entirely hermetically sealed and contained in a single case. The can may be made of a biocompatible material including, but not limited to stainless steel, titanium or a biocompatible engineered polymer such as polysulfone or polycarbonate and the like. The inset in FIG. 4 shows the electrical sensor element (406) surrounded by insulating ring (407) mounted on the can (403). The conducting sensor element provides electrical connection to the circuitry inside the can of the implanted device. The electrical sensor or the body of the implanted device serves as the ground or the circuit common reference. While three preferred embodiments are illustrated, the exact location of the implanted device and the electrical sensor elements can be varied to provide sensing and the lead oriented to improve the sensitivity to detection of the MI/I from a particular region of the heart. For example, a can at location (401) would pick up left and superior infarcts, a can at location (402) would pick up right and superior infarct, and a can at location (403) would pick up left or right inferior infarcts. In addition, in certain embodiments the container or can may be eliminated or integrated into one of the other components.
[0048] In a preferred embodiment of the device, an intracavitary indwelling lead system, as depicted in FIG. 5, is used to sense the EGM signals. Referring to FIG. 5(a), the implanted device (101) encases in the can the electronics while the body of the can serves as the ground or the reference G or otherwise a sensor on the lead serves as the ground or the reference (501). The intracavitary lead consists of a lead (502) going from the device (101) into the right ventricular cavity via the venous blood vessel by the methods well known in the art. The lead (502) may be preferentially threaded through the right or the left subclavian veins. The lead (502) may also be threaded through inferior vena cava or IVC. The lead (502) is placed in the atrial or the ventricular cavity or both. The lead (502) also may lodge in the SVC and through the septal region in the left ventricular cavity. The lead (502) may be placed in the left ventricle via the arterial vessel. The lead made of biocompatible material including, but not limited to polyurethane or silicon carries within it the metallic coil or wire for proper insertion of the lead (502). The lead (502) carries at its tip the pacing electrode (503) by which electrical stimulation is delivered to the heart muscle. Although depicted in this figure as being in contact with the ventricular muscle, the pacing electrode (503) may also be in contacting with atrial muscle or other suitable pacing regions on the heart surface. The sensing and the pacing electrodes may be designed into a single lead body or separate lead bodies. The atrial and ventricular chambers of the heart may be sensed and paced separately or jointly. The external body of the lead also carries the conducting sensor element such as (504) to contact and capture electrical signal from the cavity of the heart (105). A plurality of electrically conducting contact points (505) on the lead serve as sensor elements. As these sensor elements (504) span the atrium to the ventricle, typically on the right side of the heart, these sensor elements (504) capture the EGM signal associated with that part of the heart. In the preferred embodiment in FIG. 5(a), the sensor elements are arranged in the unipolar configuration wherein the sensor elements are well separated from one another, each capable of capturing electrical signal with respect to the ground reference G on the body of the can or electrode (501). In another preferred embodiment illustrated in FIG. 5(b), the sensor elements are arranged in a bipolar configuration wherein pairs of sensor elements (506, 507) are closely spaced. A plurality of sensor element pairs (508) are arranged in the region spanning the atrium, ventricle or both. In another preferred embodiment, illustrated in FIG. 5(c), the sensor element can be at or close the tip of the catheter (510) and may include one or more of many hemodynamic sensors (e.g. pressure, pO2, pH, temperature, conductivity, etc.) or mechanical sensors (strain gauge, accelerometer, etc.).
[0049] Preferably the implanted device consists of a casing or a can made of biocompatible and hermetically sealed case consistent with long term implantation in the hostile environment of the body (with its warm temperature, humidity, blood, etc.). The can is shaped in a variety of forms illustrated in FIG. 2 and FIG. 3. The circuitry associated with the sensor is housed inside this can and may be driven by battery power, typically one of the many contemporary pacemaker/defibrillator batteries using lithium or lithium ion or polymer battery technology well known in the art. The internal circuitry may utilize ultra-low power analog and digital circuit components built from miniaturized packages and running off the battery power supply. One overall schematic design is illustrated in FIG. 6(a) and consists of the input protection stage (601) which serves to protect the amplifier from possible shock hazards. This front-end should also meet electrical safety and leakage specifications conforming to safety standards as set by AAMI, American Heart Association and other standard setting bodies. This stage is followed by the amplifier (602) and followed by electrical isolation circuitry (603), if necessary. Isolation can be electrical or optical. The isolation circuit is followed by the output stage (604) which feeds all the analog signals from multiple channels into a multiplexer, MUX (605). The multiplexed signal is digitized using an A/D converter (analog to digital converter) (606) and then fed into a microprocessor (607). The principal circuit component is the EGM amplifier, which is designed using operational amplifiers as illustrated in FIG. 6(b). The amplifier circuitry consists of protection (610) and filtering (611) components (including diodes, capacitors and inductive chokes), operational amplifier based instrumentation amplifier (612), and active circuit filters for band-pass filtering (613). In various embodiments, the hardware implementation may use a low power, low voltage microprocessor or a custom-designed ASIC or a fully custom VLSI circuit. In an alternative embodiment, the hardware would be contained, or otherwise piggy-backed onto an implantable pacemaker or cardioverter-defibrillator. In this case the ischemia detection technology would use information derived from the existing leads of the implanted pacemaker or defibrillator. Also, the detection software would be embedded in the RAM or the ROM and executed by the microprocessor of the implanted pacemaker or cardioverter-defibrillator.
[0050] The sensors of the implanted device are preferably configured to capture the EGM signal and other physiologic data. From these signals and data, algorithms implemented by the microprocessor and its software identify the ischemic event. Embodiments utilize the EGM signals from inside the body using a plurality of sensors placed inside the thorax and in and around the heart. The sensors preferably seek to mimic the internal or implanted form of the Einthoven triangle and the 12 lead electrocardiographic system. The complete 12 lead system may not always be used and the MI/I event can be captured from only a limited set of leads and electrodes. The complete or partial set of these sensors, so arranged, provide a projected view of the heart's dipole at various sensor locations. The signals recorded from a sensor then give an indication of the MI/I event in its vicinity and the recorded pattern is indicative of the degree of severity of the MI/I event. Certain embodiments utilize both depolarization and repolarization signal components of the EGM signal to detect ischemia events. As illustrated in FIG. 7, ECG signal (701) is accompanied by the action potential signal (702), the EGM signal (703) and the pressure signal (704). Under MI/I conditions, these respective signals may be modified as shown in (705, 706, 707 and 708). Note the appearance of notches in the QRS complex and depression of the ST-segment (705 and 710). Correspondingly, the action potential (706) shows change in upstroke (713), duration and shape (714). Consequently, the EGM signal shows fractionation and multiple depolarization and changed shape (707). The ventricular pressure signal shows a reduction in magnitude as well as shape change (708). The ischemic conditions are some times localized to parts of the heart (focal ischemia or infarct) and at other times throughout the heart (global). Ischemia results in slowed conduction and possible fractionation of the conduction patterns. FIG. 7(b) illustrates the conduction on the heart (750) in normal conditions (left), with traces (752) showing isochronal lines t1 through t6 (places receiving simultaneous activation). An infarcted is indicated as a region 751 on the heart with no isochronal lines, and consequently it is a region which alters the conduction pattern. Therefore, under ischemic conditions (right), the conduction pattern (752) is altered as indicated by the isochornes t1 through t10. The isochrones show different pathways, indicating dispersion and fractionation of conduction. This dispersion and fractionation of conduction produces the EGM signal depicted for ischemic hearts (707) and its features thereof (716).
[0051] The EGM signal for normal versus ischemic myocardial tissue can be distinguished using a variety of means including waveform analysis done in both the temporal and frequency domain and combination of both, which is called a time-frequency method. FIG. 7(a) graphically illustrates the EGM signal for a healthy heart (703) with a relatively large major peak and related inflection and transition points corresponding to depolarization and repolorization events occurring during the cardiac cycle (702). In contrast, the ischemic signal shown in (707) shows significantly more peaks and has unusual transitional points (716). This phenomenon is known as fragmentation and is readily distinguishable. An alternate approach is to detect ischemia in the frequency domain. FIG. 7 also illustrates the time-frequency analysis of the EGM signal. The EGM signal is analyzed through Fourier analysis which is well known in the art and its frequency components are thus obtained. Since the EGM signal is time-varying, time-frequency analysis is more suitable so as to obtain instantaneous frequencies at different times in the cardiac cycle. Magnitude of signal power, indicated by horizontal lines at various frequencies (717) and plotted versus time (718) is calculated. In this case, the ischemic EGM time-frequency distribution (719) is distinguished from the time-frequency distribution of the healthy EGM waveform (720) by a broader range of frequencies at one or more depolarization, repolarization and fractionation event locations. Further during repolarization, there is shift towards lower frequencies corresponding to the ST-segment elevation or depression and T-wave morphology changes in the ECG. Several different approaches of time-frequency and time-scale analyses are applicable to calculating localized frequency information at various instants of the EGM signals. Normal and ischemic EGM waveforms/signals are thus distinguished and the electrodes or sensors displaying the characteristic changes identify ischemia in their vicinity. This approach is extended to analysis of signals from various sensors. FIG. 7(a) shows the cavitary pressure signal in normal (704) and ischemic (707) hearts. Analogously, a cavitary probe measuring conductance can obtain an estimate of the ventricular volume by methods well known in the art. The magnitude and morphology of the conductance signal is also indicative of MI/I. Analogously, ventricular volume signal assessed by the aforementioned conductance method also identifies local changes in the conductance and proportionately the volume in the region of the ventricular cavity. Therefore, a comparison of such signals placed in different positions in the heart (e.g. 505, 508, 509), allows estimation of ventricular volumes at different points in the cardiac cycle and at different locations in heart. Information from the EGM signals (electrical conduction) and hemodynamic/mechanical signals (conductance, pressure, ventricular volume, blood volume, velocity etc.), may be used separately or combined by one or more algorithms, programmable devices or modified pacemaker, cardioverter, defibrillator systems seeking to detect an ischemic event. Ischemic diagnostic function may be further enhanced by combining analysis of ECG and hemodymanic data with metabolic/chemical data (e.g. PO2, CO2, pH, CK (creatine kinase)) collected using in dwelling sensors which may be chemical FETs, optical fibers or otherwise polarimetric or optical based, and the like, all well known in the art.
[0052] In another embodiment of the ischemia detection sensors, a use is made of the multiple sensors spanning the lead in the ventricular cavity. The sensors (505 or 508 or 509) in FIG. 5 capture the changes in the EGM signals in their vicinity. An analysis of the relative morphologies would help identify the ischemia in the vicinity of the electrode. The electrode sensors record the EGM signals whose morphology or frequency characteristics in normal or MI/I conditions is similarly analyzed by the methods illustrated in FIG. 7(a). The EGM signal recorded and analyzed results from spontaneous heart beats or from paced beats. Spontaneous heart beats are produced by the heart's own natural rhythm. Paced beats are produced by a pacing electrode usually at the tip of the lead placed in the atrial or the ventricular cavity. The morphology and the frequency characteristics of the paced beats are analyzed for MI/I condition.
[0053] Once an incident of MI/I is detected, the patient or the medical care giver needs to be informed so that quick intervention may be taken. Noting that certain aspects of embodiments relate to an implanted device, the device needs to communicate the signal out to the patient and/or the physician. FIG. 1 provided a scheme for the communication between the implanted device (101) and the subject (103) or the external device (108). Now, for further detail, FIG. 8 illustrates an implanted device (801) comprising its amplifier and data-acquisition system (802) and microprocessor (803) communicates data and message to the subject or the external device via a D/A converter (804), a parallel port (805), a serial port (806 or 807). The D/A converter is connected to an amplifier (808) which drives a loud speaker, buzzer or a vibrator (811). The external device may receive this information via a microphone (815). The subject may preferably receive the alert message via audio or vibratory signal (811). Alternately, the subject may receive the indication of an MI/I via an electrical stimulus feedback delivered via a voltage to current converter, V-I (829) delivered to the case of the implanted device or to a stimulating lead. The serial port communicates the electrical signals via a modem (809), and a transmitter (812) to an antenna (815) for radio frequency or audio telemetry to the external device. The external device receives the radio telemetry communication via an antenna (816) and a receiver (817) and subsequently conveys these data to a computer connected to the receiver. Alternately, the implanted device may use a serial port (807), connected to a modem (810) and a transmitting coil capable of generating and receiving magnetic fields (818). By pulsed or alternating magnetic field, a message pertaining to the MI/I event or digitized data from the microprocessor (803) are relayed to the external device. An external coil capable of generating or receiving magnetic field communicates the message to and from the implanted device (819) via magnetic induction. The magnetic field fluctuations are processed and a message or data stream may be communicated to a computer connected to the external device. These are among many alternative means to enable communication between the implanted device and the external device may be operated/worn by the physician or the patient. Other communication technologies well known in the art may also be utilized. The implanted and the external device engage in a unidirectional (sending the MI/I alert or sending actual digital or analog data over the link) or bidirectional (external device sending commands, internal sending the data, for example).
[0054] Certain embodiments also include devices and methods for taking a therapeutic action. The therapeutic action is possible because implanted device provides an early indication of an event of MI/I. Therefore, there may be adequate time for this system to perform therapeutic actions to prevent or minimize the development of an infarction. In various embodiments of the invention, therapeutic actions may comprise: infusion of thrombolytic agents such as TPA and streptokinase or anticoagulant agents such as heparin. Since it is known that there is treatment window of several hours after infarction which can prevent more serious medical complications, a timely bolus or steady release of these medicines may prevent or otherwise ameliorate the conditions that may be precipitating the MI/I. FIG. 8(b) illustrates the schema in which the implanted device (801) equipped with a lead (833) connected to a sensing means (831) initiates the action of transmitting a message via a transmitter (832) in a manner described previously. It also initiates infusion of any of the aforementioned drugs via an infusion line or a catheter (835). For example, the drug may be in the catheter tip itself embedded in a slow release polymeric matrix whose release is actuated by the implanted device. Alternately, the drug may be in the device itself and released via infusion tubing (835). The acute MI/I may precipitate a life-threatening arrhythmia. In case such an event, involving arrhythmias such as ventricular tachycardia or fibrillation, the implanted device may initiate electrical rescue therapy, such as pacing, cardioversion or defibrillation. An electrical shock may be given via two leads, which may be a combination of the can of the implanted device (801) and an intracavitary lead (833) or a combination of subcutaneous or an epicardial or intrathoracic lead (834) and an intracavitary lead. Thus, the implanted device would initiate the therapeutic procedures semi-automatically by first alerting the patient or automatically via infusion of a drug or delivery of electrical rescue shock.
[0055] While aspects of the present invention have been described with reference to the aforementioned applications, this description of various embodiments and methods shall not be construed in a limiting sense. The aforementioned is presented for purposes of illustration and description. It shall be understood that all aspects of the invention are not limited to the specific depictions, configurations or relative proportions set forth herein which may depend upon a variety of conditions and variables. The specification is not intended to be exhaustive or to limit the invention to the precise forms disclosed herein. Various modifications and changes in form and detail of the particular embodiments of the disclosed invention, as well as other variations of the invention, will be apparent to a person skilled in the art upon reference to the present disclosure. For example, the logic to perform various analyses as discussed above and recited in the claims may be implemented using a variety of techniques and devices, including software under microprocessor control or embedded in microcode, or implemented using hard wired logic.
[0056] While the invention described above presents some of the preferred embodiments, it is to be understood that the invention in not limited to the disclosed embodiment but rather covers various modifications and equivalent arrangements included within the spirit and scope of the appended claims.
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|Maintenance fee reminder mailed
|Jun 10, 2011
|Surcharge for late payment
|Jun 10, 2011
|Fee payment
Year of fee payment: 4
|May 15, 2015
|Maintenance fee reminder mailed
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Year of fee payment: 8
|Jul 24, 2015
|Surcharge for late payment
Year of fee payment: 7


text: More from SI Report: Dodgers release pitcher Freddy Garcia Report: Dodgers release pitcher Freddy Garcia Marshawn Lynch sports gold cleats for Super Bowl Marshawn Lynch sports gold cleats for Super Bowl Louisville vs. FIU: Game time, live stream, TV coverage Louisville vs. FIU: Game time, live stream, TV coverage Pittsburgh-area high school football player dies after... Pittsburgh-area high school football player dies after... Close Tweet0 Share0 Comment0 Share0 Share0 Stumble It0 Print0 More SI Wire John Elway: Peyton Manning making all the throws after rehab by Tim Polzer Email Posted: Thu Aug. 16, 2012 John Elway said Peyton Manning is throwing well. (Justin Edmonds/Getty Images)Jim Corbett of USA Today has Denver Broncos Executive VP of football operations John Elway saying Peyton Manning is throwing the ball as well as ever – if not better. Elway thinks the four-time MVP's release has gotten even quicker in his first Broncos training camp after rehabbing from four neck surgeries."He's throwing the post route and everything well,'' Elway said. "I went back and looked at film from 2010 and 2009 to get a comparison of Peyton, and he looks to me to be the same guy throwing now that he was then."The ball is coming out quicker all the time the more and more time he gets with the offense and getting to know all his receivers and tight ends. ... That's always been his style. He's never been the Nolan Ryan of quarterbacks anyway. He's always thrown the ball with great anticipation and touch."Elway said the Broncos will extend Manning's snaps during preseason action Saturday night against the Seattle Seahawks. Manning threw his first game pass in 577 days in Denver's preseason opening win against the Chicago Bears. Promoted Stories Comments

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Breach of Faith: Hurricane Katrina and the Near Death of a Great American Cityby Jed Horne
Synopses & Reviews
Publisher Comments:
Hurricane Katrina shredded one of the great cities of the South, and as levees failed and the federal relief effort proved lethally incompetent, a natural disaster became a man-made catastrophe. As an editor of New Orleans daily newspaper, the Pulitzer Prizewinning Times-Picayune, Jed Horne has had a front-row seat to the unfolding drama of the citys collapse into chaos and its continuing struggle to survive.
As the Big One bore down, New Orleanians rich and poor, black and white, lurched from giddy revelry to mandatory evacuation. The thousands who couldnt or wouldnt leave initially congratulated themselves on once again riding out the storm. But then the unimaginable happened: Within a day 80 percent of the city was under water. The rising tides chased horrified men and women into snake-filled attics and onto the roofs of their houses. Heroes in swamp boats and helicopters braved wind and storm surge to bring survivors to dry ground. Mansions and shacks alike were swept away, and then a tidal wave of lawlessness inundated the Big Easy. Screams and gunshots echoed through the blacked-out Superdome. Police threw away their badges and joined in the looting. Corpses drifted in the streets for days, and buildings marinated for weeks in a witches brew of toxic chemicals that, when the floodwaters finally were pumped out, had turned vast reaches of the city into a ghost town.
Horne takes readers into the private worlds and inner thoughts of storm victims from all walks of life to weave a tapestry as intricate and vivid as the city itself. Politicians, thieves, nurses, urban visionaries, grieving mothers, entrepreneurs with an eye for quick profit at public expense–all of these lives collide in a chronicle that is harrowing, angry, and often slyly ironic.
Even before stranded survivors had been plucked from their roofs, government officials embarked on a vicious blame game that further snarled the relief operation and bedeviled scientists striving to understand the massive levee failures and build New Orleans a foolproof flood defense. As Horne makes clear, this shameless politicization set the tone for the ongoing reconstruction effort, which has been haunted by racial and class tensions from the start.
Katrina was a catastrophe deeply rooted in the politics and culture of the city that care forgot and of a nation that forgot to care. In Breach of Faith, Jed Horne has created a spellbinding epic of one of the worst disasters of our time.
"Horne, metro editor of the New Orleans Times-Picayune, writes with the clipped, raw urgency of a thriller writer in this humanist account of what happened after the levees broke. As already widely reported, residents who ignored the mandatory evacuation order (thinking 'Katrina...had all the makings of a flop') quickly found themselves surrounded by bloated corpses floating in toxic floodwaters and without a consolidated rescue effort. Horne quickly moves past the melodrama of a striking disaster to recount the stories of individuals caught in the storm's hellish aftermath or mired in the government's hamstrung response: a Louisiana State University climatologist goes head-to-head with the Army Corps of Engineers over inadequate flood protection and faulty levees; a former Black Panther provides emergency health care at a local mosque. Horne saves his sharpest barbs for President Bush and the Department of Homeland Security ('if Homeland Security...was what stood between America and the next 9/11, then...America was in deep trouble') for failing to muster an appropriate response. Big disasters spawn big books, and though Horne's isn't the definitive account, it's an honest, angry and wrenching response to a massively bungled catastrophe." Publishers Weekly(Copyright Reed Business Information, Inc.)
"It is hard to imagine that, less than a year after the worst natural disaster in modern U.S. history, there would be much appetite for reliving the horrors of Hurricane Katrina — manmade or otherwise. And it is equally difficult to imagine encountering anything fresh on a subject that's been so thoroughly dissected. Yet in this solid if somewhat detached recounting, New Orleans journalist Jed Horne... Washington Post Book Review (read the entire Washington Post review) has provided new insights into how a ferocious storm, governmental ineptitude and racially tinged inequities conspired to permanently jeopardize one of the nation's cultural gems. 'Breach of Faith' begins and ends at the Lower Ninth Ward home of Patrina Peters, 43, a resilient African-American mother of two who's disabled by epilepsy, a heart condition and Crohn's disease. With Katrina barreling up the Gulf Coast, it is Peters, holed up in the 'camelback'-style house that had been in her family for generations, who eerily sets the stage. Exactly 40 years earlier, she recalls, Hurricane Betsy cut a similar course, killing 75 people and decimating much of the historic black neighborhood. 'I have a funny feeling about this,' Peters tells her daughter. From Peters' pre-storm premonition, Horne catalogues the catastrophe in almost hour-by-hour fashion. From the early, misplaced sighs of relief that New Orleans had 'dodged a bullet' to the mid-storm mayhem to the hideous finger-pointing by impotent officials, Horne paints in vivid detail what amounted not to just one disaster but to disaster piled upon disaster. An accomplished author and a veteran editor at the Times-Picayune, the city's gallant newspaper, Horne blessedly brings order to the chaos. 'Breach of Faith' meticulously traces not only the storm's path but also the warnings blared by his colleagues at the newspaper and such experts as Ivor van Heerden, the outspoken deputy director of the Hurricane Center at Louisiana State University. With a much needed calm, Horne helps clarify the record on what transpired in the now-notorious twin cesspools of the calamity: the Superdome and the Ernest N. Morial Convention Center. He knocks down many of the most outlandish tales that circulated at the time, including an assertion by New Orleans Police Chief Edward Compass of 'little babies getting raped' in the sweltering arenas. At the same time, the author does not back away from the roasting, putrid reality for the evacuees there, who were treated more like hostages than like citizens. Nor does Horne flinch from other, less famous tragedies that befell his beloved city. His chapter on the five-day nightmare inside the public Charity Hospital, 'downtown New Orleans's huge depression-era monument to poor people's medicine,' is among the best portrayals ever penned of that grand institution's struggle for survival. Through the eyes of Kiersta Kurtz-Burke, a doctor working in Charity's rehab department for patients recovering from strokes, head traumas and spinal injuries, we see the hospital's valiant efforts to feed and treat 450 patients — 46 of them in critical condition — without electricity to power the ventilators, X-ray machines and laboratory equipment that have become staples of modern medicine. The medical challenges, it turns out, were the least of the woes; rampant rumors of violence and an amply justified sense of abandonment took a far worse toll. 'Kurtz-Burke would recall sitting up Thursday night with a quadriplegic,' Horne writes, with the doctor and her patient listening to the thwack-thwack of helicopters rescuing patients from the adjacent Tulane Medical Center. 'Everybody knew the score,' Kurtz-Burke said months later. 'We had poor people. We were going to be last (to be evacuated). Nobody had any illusions about that.' Horne even traveled to Kobe, Japan, producing a keen assessment of the similarities and differences between the January 1995 earthquake there, which killed 6,401 people instantly, and the crushing blow that struck his hometown. Yet the chapter on Kobe, informative as it is, highlights the weaknesses of 'Breach of Faith.' Strangely, the chapter begins with two pages on storm-related suicides before shifting to the Kobe tale, never returning to the bitterly important issue of the ongoing mental-health crisis in the author's own community. The pages devoted to Kobe might have been better spent in Horne's backyard, taking readers deep inside the devastated Plaquemines Parish, overcrowded shelters, the Army field hospital or a trailer park. What 'Breach of Faith' often lacks is passion. To steal a cliche, Horne's account is more head than guts. By focusing on government agencies such as FEMA and reports produced months later by congressional investigators, he sometimes fails to convey the true emotional blow that Katrina delivered. Politicians, Army Corps engineers, wealthy lawyers, hotel magnates and French Quarter denizens frequent these pages more often than do the city's richer stew of characters — characters such as Malik Rahim, an erstwhile Black Panther and armed-robbery convict turned civic leader who single-handedly built a health clinic, feeding station and shelter out of the rubble. But we never see the faces of the sick and hungry lined up at Rahim's Common Ground clinic; we never ride along as Rahim's street medics visit illegal immigrants injured on construction sites. Horne deserves credit for producing an important book in such short order. Yet by the time we come back to Patrina Peters and her now-drowned house in the Lower Ninth, I found myself yearning for the soul of the Katrina story, the smelly, quirky, gut-wrenching, deadly truth of a city disintegrating. Ah, for just one peek at the unidentifiable bodies inside the makeshift morgue, one drink at the Snug Harbor music club the night the great jazz patriarch Ellis Marsalis made his return, one terrifying night camped out with refugees on the I-10 overpass, one day with a grieving mother or one walk in an old-time jazz funeral procession, the wailing horns just breaking our hearts. Ceci Connolly, a Washington Post staff writer now on leave and writing in Mexico, spent three months in Louisiana covering Hurricane Katrina." Reviewed by Ceci Connolly, Washington Post Book World (Copyright 2006 Washington Post Book World Service/Washington Post Writers Group)
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"Author Jed Horne takes a correct approach with these subjects and issues....Horne doesn't seem to have any recommendations for regular people like us. It's not that kind of book. It is instead a book that excels when it is chronicling Americans left to rot in sewer tides, dodge snakes and starve in chaos." Chicago Sun-Times
"Horne's ability to flesh out the human dimension of the drama is his very real strength." Boston Globe
"[Horne] offers something different to the dialogue, something even worth reading....Breach of Faith is not a book about politics, or about blame, but is most powerful when Horne's honest, rarely angry writing assesses the bureaucratic incompetence and failure that compounded the hurricane's mess." Balitmore Sun
"A heart-wrenching chronicle of nature's wrath and the human condition." Kirkus Reviews
About the Author
Jed Horne, a metro editor of The Times-Picayune, was awarded a Pulitzer Prize for his part in the papers coverage of Hurricane Katrina. His book Desire Street: A True Story of Death and Deliverance in New Orleans was nominated for the 2006 Edgar Award for nonfiction crime writing. He lives in the French Quarter with his wife.
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great ipad mini cover for (1/4) cost
really good quality, working great so far. magnet seems just as strong. auto unlock and lock working great. slightly different from official apple iPad mini smart cover, however design is identical to regular size iPad smart cover. Read More
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Contact us at 1-800-991-66861.800.991.6686
Take action to help STOP breast cancer. The American Cancer Society Dedication Card makes a nice gift and is a small token of your willingness to support such an important cause. This cardstock pink heart honors loved ones lost to breast cancer. The American Cancer Society will receive 100% of proceeds for each dedication card sold.


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Public libraries invited to apply by March 6 to receive $8,000 grant and 18 months of professional development in community engagement
CHICAGO — The American Library Association (ALA) Public Programs Office is accepting applications for the Libraries Transforming Communities Public Innovators Cohort, an 18-month, team-based professional development opportunity for public libraries, developed by ALA and the Harwood Institute for Public Innovation.
CHICAGO — Lifetime Arts, a national leader in arts education programming for older adults, and the American Library Association will offer a pre-conference workshop about the growing field of creative aging at ALA's 2016 Midwinter Meeting in Boston.
CHICAGO -- Anti-bullying activist Lizzie Velasquez will bring her message of not allowing others to define you, and of turning negativity into a motivating force, to 2016 ALA Midwinter Meeting in Boston as the Arthur Curley lecturer from 4 - 5 p.m. on Saturday, Jan. 9.
CHICAGO — Registration and housing are now open at alamidwinter.org for 2016 ALA Midwinter Meeting and Exhibits in Boston, Jan. 8-12. "The conversation starts here . . . " every year at Midwinter Meeting, offering the usual gold-standard networking, updates, exhibits, future-focused discussions, innovators and thought leaders and high-profile speakers. Highlights include:
CHICAGO — Rising United States Senator Cory Booker — known for being innovative and widely recognized as the accessible and energetic new voice of politics — will join ALA President Sari Feldman as speaker during her President's Program at ALA Midwinter Meeting in Boston. This program, in partnership with the ALA Task Force on Equity, Diversity, and Inclusion, will take place from 3:30 - 5:30 p.m. on Sunday, Jan. 10.
BRYN MAWR, Pennsylvania — Do you have a dysfunctional board of Trustees? Do you fight micromanagement, bullies or just plain lack of engagement? How well do your Trustees advocate on behalf of the library? Are they effective participants in the planning process? And what about your Friends? Are they "unfriendly"? Do they hold onto money the library desperately needs? Are they aging out and failing to raise the kind of money you know they can?
CHICAGO -- 2016 ALA Midwinter Meeting attendees have the chance to inspire and entertain colleagues in the popular five-minute "Ignite" sessions, always standing-room-only and high energy events. Session proposals are accepted now through the end of the day on Friday, Oct. 9, 2015. Find out more and submit proposals now.
CHICAGO — Bundle Registration for 2016 Midwinter Meeting and Annual Conference is now open. Bundling the registration for both conferences saves up to $130, and offers the opportunity to book housing for Midwinter immediately. The conversation starts in Boston, Jan. 8-12, 2016 at ALA Midwinter Meeting & Exhibits, and continues at ALA Annual Conference & Exhibition in Orlando, June 23-28.
CHICAGO -- Chelsea Clinton will close out the 2016 Midwinter Meeting at a special session from 2 p.m. - 3 p.m. on Monday, Jan. 11. Attendees will want to be sure to stay to hear her speak about her new book "It's Your World: Get Informed, Get Inspired & Get Going!" that addresses our biggest challenges, offers ideas for action and inspires readers of all ages to do their part to make the world a better place.
CHICAGO — The Reference and User Services Association (RUSA) is now accepting institute, preconference and program proposals for the 2016 Midwinter Meeting in Boston and the 2016 ALA Annual Conference in Orlando.
Proposals will be accepted online through 11:59 p.m. Central on May 11, 2015. Faxed, e-mailed or mailed proposals will not be accepted.
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Experimental Economics
A Journal of the Economic Science Association
Experimental Economics, the official journal of the Economic Science Association, serves the growing group of economists around the world who use laboratory methods to study phenomena that are difficult to observe directly in naturally occurring economic contexts. The journal publishes high quality papers in any area of experimental research in economics and in related fields such as accounting, finance, political science, and the psychology of decision-making. Readers will also find state-of-the-art theoretical work and econometric work motivated by experimental data. Lastly, the journal publishes articles with a primary focus on methodology or replication of controversial findings.
Experimental Economics provides a forum for interactive discussions of major issues by inviting papers and comments on broad topics. In addition to full-length research articles, the journal features a section devoted to short papers.
Officially cited as: Exp Econ
- 18 Volumes
- 64 Issues
- 486 Articles
- 28 Open Access
- 1998 - 2015 Available
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Original Paper
Not just like starting over - Leadership and revivification of cooperation in groups
Jordi Brandts, Christina Rott, Carles Solà (September 2015)
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Same process, different outcomes: group performance in an acquiring a company experiment
Marco Casari, Jingjing Zhang, Christine Jackson (September 2015)
Original Paper
The effects of endowment size and strategy method on third party punishment
Jillian Jordan, Katherine McAuliffe, David Rand (September 2015)
- Journal Title
- Experimental Economics
- Coverage
- Volume 1 / 1998 - Volume 18 / 2015
- Print ISSN
- 1386-4157
- Online ISSN
- 1573-6938
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- Springer US
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I need to update my ebay store. I sell unique items , so each item has a different sku #.
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Pueblo Warehouse Fire Cleanup
Updated: 11/23/2007 - The deadline to clean up the remains of a warehouse fire from last month has passed. The owner of the Pueblo warehouse is saying he can't afford the cost of the cleanup.
Updated: 11/23/2007 - The deadline to clean up the remains of a warehouse fire from last month has passed. The owner of the Pueblo warehouse is saying he can't afford the cost of the cleanup.
Updated: 11/21/2007 - A happy day on Fort Carson: about 70 soldiers are home safe. Wednesday's homecoming for the 2nd Battalion 227th Aviation Regiment was supposed to happen last week. For dozens of soldiers and their families, the countdown finally came to an end.
Posted: 11/21/2007 - Experts: If you stuff yourself on Thanksgiving, work off those extra calories
Updated: 11/22/2007 - On Sunday morning, November 18, 2007, officers from the Sand Creek Division responded to the 900 block of North Murray Boulevard concerning the report of a man down.
Updated: 11/22/2007 - The snow combined with extremely cold temperatures created icy conditions that caused numerous accidents and spinouts Wednesday morning.
Posted: 11/21/2007 - A man with three previous convictions for drunken driving now has a fourth after he pleaded guilty to multiple charges this week in Colorado Springs.
Updated: 11/21/2007 - A warning to parents from a local school district: drug pushers, they believe, are capitalizing on the sweetness of candy to move more crystal meth.
Posted: 11/20/2007 - 29 year old Oliver Newell, from Colorado Springs, was accused of 2nd degree kidnapping, sexual assault and sexual assault on a child earlier this year. He was found guilty on all charges Tuesday.
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Updated: 11/21/2007 - HIs doctor says he shouldn't go back overseas. His wife is concerned about his safety if he goes to Iraq. The biggest concern this soldier's wife has about his deployment papers.
Updated: 11/21/2007 - Pueblo community college and the Pueblo fire department are working together to make fighting fires easier, and safer for the community. Tuesday morning they announced their new Fire Science Technology program.
Posted: 11/20/2007 - Parents, before you start holiday shopping, read this.
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Posted: 11/20/2007 - California's attorney general has filed a lawsuit against 20 different toy companies and retailers, claiming that they knowingly exposed children to lead and failed to provide warning of the risk.
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Updated: 11/20/2007 - Southern Colorado is experiencing an unusually warm winter. And with bright sun comes bright smiles.
Updated: 11/20/2007 - State leaders unveiled a plan on Monday that would rid of crumbling schools in Colorado.
Updated: 11/20/2007 - Record Warmth to start the holiday week in Southern Colorado.
Updated: 11/19/2007 - El Paso County Sheriff Terry Maketa says he could soon run out of room at the county jail.
Updated: 11/19/2007 - Care and Share Food Bank and K-Lite collected 3400 turkeys Friday for "Take Your Turkey to Work Day". While a big thank you goes out to all who donated, Care and Share is still looking for several hundred more turkeys before Thursday.
Updated: 11/19/2007 - Many El Paso County Offices will be closed this week to help balance the county budget. Here is the full list of closures.
Updated: 11/30/2007 - The mother of a four year old Rocky Ford girl who was found dead last month is still waiting to find out how her little girl died.
Updated: 11/19/2007 - 27 million people are expected to fly this Thanksgiving season. That's up four percent from last year. The planes will be packed, flying nearly full.
Updated: 11/17/2007 - Officials in Fremont County believe a man accidentally drowned while fishing late Friday night.
Updated: 11/17/2007 - Gas prices hovering in the $3 range is not stopping most people from hopping in their cars and hitting the road for Thanksgiving.


text:
Handbook of Economic Growth
Edited by
- Philippe Aghion, Harvard University, Cambridge, MA, USA
- Steven Durlauf, University of Wisconsin at Madison, WI, USA
AudienceGraduate students and professors worldwide working in all subdisciplines of economics.
Book information
- Published: November 2013
- Imprint: NORTH-HOLLAND
Table of Contents
- "What Do We Learn From Schumpeterian Growth Theory?" Philippe Aghion (Harvard University), Ufuk Akcigit (University of Pennsylvania), and Peter Howitt (Brown University)
- "Technology Diffusion: Measurement, Causes, and Consequences." Diego Comin (Harvard University) and Marti Mestieri (Toulouse School of Economics)
- "Health and Growth." David Weil (Brown University)
- "Regional Growth." Jonathan Temple (University of Bristol), Gianmarco Ottaviano (London School of Economics), and Holger Breinlich (University of Essex)
- "The Growth of Cities." Gilles Duranton (University of Pennsylvania) and Diego Puga (Centro de Estudios Monetarios y Financieros)
- "Growth and Structural Transformation." Berthold Herrendorf (Arizona State University), Akos Valentinyi (Cardiff Business School), and Richard Rogerson (Princeton University)
- "The Chinese Growth Miracle." Yang Yao (Beijing University)
- "Growth from Globalization? A View from the Very Long-Run." Christopher Meissner (University of California, Davis)


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Move over ISON, time to share the love with Comet Lovejoy
In the furor of following Comet ISON, we've almost lost track of another fine, fuzzy fellow – Comet Lovejoy. Last we checked in on this comet during the first half of November, it had swelled to almost half a degree in diameter with a 2-degree-long tail. From a dark sky the comet was even bright enough to glimpse with the naked eye in moonlight.
I'm here to tell you it's still all of those things. With the moon out of the sky, I could see Lovejoy without difficulty with the naked eye near the star Gamma in the constellation Bootes below the handle of the Big Dipper early this morning. It looked like a small fuzzy blob of magnitude 4.6.
10×50 binoculars really did the comet justice. With them a beautiful, gossamer tail stretched across half the field of view or about 2.5 degrees. One degree is the amount of sky you can cover with your pinkie finger held at arm's length. The photos closely match my visual impression of the tail through the 10x50s.
Through a 15-inch telescope at low magnification, Lovejoy's monster-sized head (just under half a degree, the diameter of a full moon) glowed pale blue-green highlighted by a bright, fuzzy dot at its center – the false nucleus. The real comet nucleus always remains hidden in its wraps of dust and gas.
Upping the magnification to 287x, a striking, funnel-shaped fan of dust issued from the false nucleus to the south-southeast. This feature has been a regular part of Lovejoy's anatomy for at least the past few weeks. I urge observers with 6-inch and larger telescopes to take a look. This amazing jet of dusty material boiling off the comet's nucleus won't be visible forever. Use high power and bore right into the coma's center.
Comet Lovejoy clears the horizon around 1 a.m. (I know -ouch!) but you'll see it best between 2:30 and the start of dawn when it's better placed. The comet passed closest to Earth on Nov. 20 – that's why it's still bright. As it moves away from Earth it will gradually get dimmer, which makes the coming two moonless weeks the best time to seize the opportunity.
31 Responses
I've seen and photographed Lovejoy in three sessions: mid November at dawn, a few days ago in country with quarter Moon, and yesterday with thin crescent Moon but in city. Not the best conditions, but what weather and free time allowed. Of course all such backgrounds limited the tail's length and contrast. However I too noticed in scope the fan-shaped feature and I confirm it's present since weeks. Thanx for underlining that it will be visible for limited time.
Yesterday I also used a camera with telelens on tracking mount, just like you did. It works great.
hey Phil. curious if it was naked-eye out there. i was at my mom's in Hopedale MA but since Lovejoy was right beside a star that appeared slightly brighter, there was only one thing i could detect there with averted vision so probably not the comet. it is remarkable the difference a dark sky makes tho. where my mom lives i can see the Beehive naked-eye, especially averted. where i live no way, really, and Lovejoy doesn't look as spectacular in 10×50 binos, whereas this AM i could clearly see the tail distinctly from the head, for the first time really. looked in the wrong place for Linear X1, so i wonder if i could have seen that. also saw Neptune for the 1st time in a long time last night, once again thx to dark skies rather than the somewhat washed-out ones i usually frequent.
Astro Bob & Sean: I haven't looked for, or at Lovejoy yet in December, but will soon!. Almost woke in Time this Morn, but a little late Twilight already. My best Sightings have been very early 3 a.m. when the Sky is still very Dark, and yes its Faint but very much Visible as a Naked Eye Object.! You are right Bob very much worth the early hour too.! Hope to see again soon, and will Post if & when…
In the furor of following Comet ISON, we've almost lost track of another fine, fuzzy fellow – Comet Lovejoy. Last we checked in on this comet during the first half of November, it had swelled to almost half a degree in diameter with a 2-degree-long tail. From a dark sky the comet was even bright enough to glimpse with the naked eye in moonlight.
– See more at: http://astrobob.areavoices.com/2013/11/29/move-over-ison-time-to-share-the-love-with-comet-lovejoy/#sthash.RiTSGhhj.dpuf
Hi, AstroBob –
Thank you for your informative, easy to understand diagrams, showing where and when it is possible to observe items of interest in the night sky. I appreciate the ease with which I, a backyard novice, can obtain to get out there with the right equipment (if any) and enjoy the event! I don't feel bogged down with tech-speak and yet, your site is educational nonetheless!


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May 1984 issue: Guitar World readers get introduced to a new blues sensation from Texas.
With your help, Guitar World is out to crown the Best American Rock Band Ever!
Two musical titans team up for this Pink Floyd standard.
At a public ceremony in Surrey, British Columbia, on October 21, Paul Rodgers -- the lead singer of Free, Bad Company and The Firm (not to mention Queen) -- sworn in as a Canadian citizen.
William Shatner has a new music video out, and while it's no "Rocket Man", it is most certainly musical entertainment in a way only the Shat can provide. You can watch his video for Queen's "Bohemian Rhapsody" below.
As much as I try to avoid her music, Lady Gaga always seems to find her way into our news stories. I for one still can't tell if this whole rock/metal side of her is genuine or just a ploy to gain some credibility, but at the very least, it's usually entertaining.
Researchers at Goldsmiths University have been looking into the mathematical and physical properties (i.e. sound waves) of songs, trying to determine exactly what makes a song catchy in the first place.
This year marks the 40th anniversary of Queen, as evidenced by the recent two waves of Queen remasters, the latest of which was rolled out on September 13. But the band are working on a reissue of another kind: Queen drummer Roger Taylor has launched a North American talent search that gives singers, guitarists, bassists, keyboardists and drummers the chance to star in the official 2012 Queen Extravaganza Live Tour.
It seems Lady Gaga refuses to stop poking her head into the world of rock and metal: hanging out with the drummer from Anthrax, being Iron Maiden's roadie for a day -- and now performing with legendary guitarist Brian May last night, August 28, at the MTV Video Music Awards.
Chords: Queen "The Show Must Go On"
The last five studio albums from Queen will be reissued this fall by Island Records.
Foo Fighters' recent performance as part of the month-long iTunes Festival is now streaming online, in its entirety, at this location.
The legendary rock group kicks off the celebrations with reissues of first five studio albums and more.
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