text:
|Numéro de publication
|Type de publication
|Numéro de demande
|Date de publication
|8 mai 2012
|Date de dépôt
|20 déc. 2006
|Date de priorité
|2 nov. 2001
|État de paiement des frais
|Autre référence de publication
|Numéro de publication
|Timothy J. Cox
|Cessionnaire d'origine
|Pacesetter, Inc.
|Exporter la citation
|BiBTeX, EndNote, RefMan
|Citations de brevets (59), Citations hors brevets (4), Référencé par (9), Classifications (13), Événements juridiques (1)
|Liens externes: USPTO, Cession USPTO, Espacenet
This application is a continuation of U.S. patent application Ser. No. 10/833,596, filed Apr. 27, 2004, now U.S. Pat. No. 7,177,700, issued on Feb. 13, 2007, which is a continuation of U.S. patent application Ser. No. 10/001,225, filed Nov. 2, 2001, and now U.S. Pat. No. 6,763,269, issued Jul. 13, 2004.
The present invention generally relates to implantable medical devices.
There are many kinds of implantable medical devices. Some monitor patient conditions while others disperse some form of therapy. One particular type of implantable medical device is an implantable cardiac therapy device, or ICTD. ICTDs are implanted within the body of a patient to monitor, regulate, and/or correct heart activity. ICTDs include implantable cardiac stimulation devices (e.g., implantable cardiac pacemakers, implantable defibrillators) that apply stimulation therapy to the heart as well as implantable cardiac monitors that monitor heart activity.
ICTDs typically include a control unit positioned within a casing that is implanted into the body and a set of leads that are positioned to impart stimulation and/or monitor cardiac activity. With improved processor and memory technologies, the control units have become increasingly more sophisticated, allowing them to monitor many types of conditions and apply tailored stimulation therapies in response to those conditions.
ICTDs are typically capable of being programmed remotely by an external programming device, often called a "programmer". Today, individual ICTDs are equipped with telemetry circuits that communicate with the programmer. One type of programmer utilizes an electromagnetic wand that is placed near the implanted cardiac device to communicate with the implanted device. The wand contains a coil that forms a transformer coupling with the ICTD telemetry circuitry. The wand transmits low frequency signals by varying the current in a coil.
Early telemetry systems were passive, meaning that the communication was unidirectional from the programmer to the implanted device. Passive telemetry allowed a treating physician to download instructions to the implanted device following implantation. Due to power and size constraints, early commercial versions of the implanted devices were incapable of transmitting information back to the programmer.
As power capabilities improved, active telemetry became feasible, allowing synchronous bi-directional communication between the implanted device and the programmer. Active telemetry utilizes a half-duplex communication mode in which the programmer sends instructions in a predefined frame format and, following termination of this transmission, the implanted device returns data using the frame format. With active telemetry, the treating physician is able to not only program the implanted device, but also retrieve information from the implanted device to evaluate heart activity and device performance. The treating physician may periodically want to review device performance or heart activity data for predefined periods of time to ensure that the device is providing therapy in desired manner. Consequently, current generation implantable cardiac therapy devices incorporate memories, and the processors periodically sample and record various performance parameter measurements in the memories.
Current telemetry systems have a limited communication range between the programmer wand and the ICTD, which is often referred to as "short-range telemetry" or "wand telemetry". For effective communication, the wand is held within two feet of the ICTD, and typically within several inches. One problem is that the ICTD has insufficient power to transmit longer range signals. Another consideration is the inherent EMI-resistant design of the ICTD. The ICTD circuitry is typically housed in a hermetically shielded can to prevent electromagnetic interference (EMI) from disrupting operation. The can prevents penetration of high frequencies, thereby limiting communication to the low frequency range of less than 200 KHz. In one exemplary system, signals sent from the programmer to the implanted device are transmitted on a carrier of approximately 36 KHz, and data is transmitted to and from the implanted device at approximately 8 KBaud.
Conventionally, data about a patient's cardiac condition is gathered and stored by the programmer during programming sessions of the ICTDs. Analysis of the cardiac condition is performed locally by the programming software. Programmers offer comprehensive diagnostic capabilities, high-speed processing, and easy operation, thereby facilitating efficient programming and timely patient follow-up.
In addition to local analysis, TransTelephonic Monitoring (TTM) systems are employed to gather current cardiac data of patients when the patient is remote from the healthcare provider. TTM systems are placed in patients' homes. They typically include a base unit that gathers information from the ICTD much like the programmer would. The base unit is connected to a telephone line so that data may be transmitted to the medical staff responsible for that patient. An example of an ICTD TTM system is a service from St. Jude Medical® and Raytel® Cardiac Services called "Housecall™." This service provides current programmed parameters and episode diagnostic information for a plurality of events including stored electrograms (EGMs). Real-time EGMs with annotated status information can also be transmitted.
Using a telephone and a transmitter, the TTM system provides both the medical staff and the patient the convenience of instant analysis of therapy without having the patient leave the comfort of home. Typically, real-time measurements are transmitted in just minutes. Patients may be closely monitored, and the medical staff has more control of their patient's treatment, thus administering better patient management.
While strides have been made for improving patient monitoring, there remains an ongoing need to improve the communication capabilities between implanted devices and external devices, particularly the need to communicate more effectively over greater transmissions ranges.
A system enables high-frequency communication between an external communication device and one or more implantable medical devices. The system implements a communication protocol in which the external communication device interrogates any implantable medical devices within range to establish one-to-one communication links for purposes of exchanging data and/or programming the medical devices.
In one implementation, the external communication device transmits an interrogation signal on one or more frequencies within a first set of frequencies. The interrogation signal serves as an invitation to communicate with the implantable medical device. The implantable medical device listens for the interrogation signal at a frequency within the first set of frequencies. Upon receipt, the implantable medical device transmits a reply on a second frequency selected from a second set of frequencies. The first and second set of frequencies may overlap or be mutually exclusive. The external communication device monitors the second set of frequencies for the reply. Upon receipt of the reply, the external communication device assigns a communication channel to the implantable medical device for purposes of continuing communication. For that point, the devices can frequency hop among multiple channels more than once during communication of information.
In the description that follows, like numerals or reference designators are used to reference like parts or elements.
The following discussion unfolds in the context of an implantable cardiac therapy device (ICTD) linked to a networked system of computing systems. It is noted that the ICTD is just one exemplary type of implantable medical device. Other types of implantable medical devices may be employed, such as implantable medicine dispensers, implantable nerve stimulators, and so on.
Cardiac Therapy Network
The ICTD 102 may communicate with a standalone or offline programmer 110 via short-range telemetry technology. The offline programmer 110 is equipped with a wand that, when positioned proximal to the ICTD 102, communicates with the ICTD 102 through a magnetic coupling.
The ICTD 102 can alternatively, or additionally, communicate with a local transceiver 112. The local transceiver 112 may be a device that resides on or near the patient, such as an electronic communications device that is worn by the patient or is situated on a structure within the room or residence of the patient. The local transceiver 112 communicates with the ICTD 102 using short-range telemetry or longer-range high-frequency-based telemetry, such as RF (radio frequency) transmissions. Alternatively, the local transceiver 112 may be incorporated into the ICTD 102, as represented by dashed line 111. In this case, the ICTD includes a separate and isolated package area that accommodates high-frequency transmissions without disrupting operation of the monitoring and stimulation circuitry.
Depending upon the implementation and transmission range, the local transceiver 112 can be in communication with various other devices of the network architecture 100. One possible implementation is for the local transceiver 112 to transmit information received from the ICTD 102 to a networked programmer 114, which is connected to network 120. The networked programmer 114 is similar in operation to standalone programmer 110, but differs in that it is connected to the network 120. The networked programmer 114 may be local to, or remote from, the local transceiver 112; or alternatively, the local transceiver 112 may be incorporated into the networked programmer 114, as represented by dashed line 116.
Another possible implementation is for the local transceiver to be connected directly to the network 120 for communication with remote computing devices and/or programmers. Still another possibility is for the local transceiver 112 to communicate with the network 120 via wireless communication, such as via a satellite system 122.
The network 120 may be implemented by one or more different types of networks (e.g., Internet, local area network, wide area network, telephone, cable, satellite, etc.), including wire-based technologies (e.g., telephone line, cable, fiber optics, etc.) and/or wireless technologies (e.g., RF, cellular, microwave, IR, wireless personal area network, etc.). The network 120 can be configured to support any number of different protocols, including HTTP (HyperText Transport Protocol), TCP/IP (Transmission Control Protocol/Internet Protocol), WAP (Wireless Application Protocol), IEEE 802.11, Bluetooth, and so on.
A number of knowledge workers are interested in data gathered from the implantable cardiac therapy device 102. Representative knowledge workers include healthcare providers 130, the device manufacturer 132, clinical groups 134, and regulatory agencies 136. The knowledge workers are interested in different portions of the data. For instance, the healthcare providers 130 are interested in information pertaining to a particular patient's condition. The manufacturer 132 cares about how the device is operating. The clinical groups 134 want certain data for inclusion in patient populations that can be studied and analyzed. The regulatory agencies 136 are concerned whether the devices, and various treatments administered by them, are safe or pose a health risk.
The network architecture 100 facilitates distribution of the device data to the various knowledge workers. Information gathered from the device is integrated, processed, and distributed to the knowledge workers. Computer systems maintain and store the device data, and prepare the data for efficient presentation to the knowledge workers. The computer systems are represented pictorially in
The network architecture 100 supports two-way communication. Not only is data collected from the ICTD 102 and distributed to the various computer systems of the knowledge workers, but also information can be returned from these computer systems to the networked programmer 114 and/or the local transceiver 112 for communication back to the ICTD 102. Information returned to the ICTD 102 may be used to adjust operation of the device, or modify therapies being applied by the device. Such information may be imparted to the ICTD 102 automatically, without the patient's knowledge.
Additionally, information may be sent to a patient notification device 160 to notify the patient of some event or item. The patient notification device 160 can be implemented in a number of ways including, for example, as a telephone, a cellular phone, a pager, a PDA (personal digital assistant), a dedicated patient communication device, a computer, an alarm, and so on. Notifications may be as simple as an instruction to sound an alarm to inform the patient to call into the healthcare providers, or as complex as HTML-based pages with graphics and textual data to educate the patient. Notification messages sent to the patient notification device 160 can contain essentially any type of information related to cardiac medicinal purposes or device operation. Such information might include new studies released by clinical groups pertaining to device operation and patient activity (e.g., habits, diets, exercise, etc.), recall notices or operational data from the manufacturer, patient-specific instructions sent by the healthcare providers, or warnings published by regulatory groups.
Notifications can be sent directly from the knowledge worker to the patient. Additionally, the network architecture 100 may include a notification system 170 that operates computer systems 172 designed to create and deliver notification messages 174 on behalf of the knowledge workers. The notification system 170 delivers the messages in formats supported by the various types of patient notification devices 160. For instance, if the patient carries a pager, a notification message might consist of a simple text statement in a pager protocol. For a more sophisticated wireless-enabled PDA or Internet-oriented cellular phone, messages might contain more than text data and be formatted using WAP formats.
A data integrator 200 accumulates the data and stores it in a repository 202. A processing system 204 processes portions of the data according to various applications 206 that are specifically tailored to place the data into condition for various knowledge workers. For example, healthcare workers might be interested in certain portions of the data, such as the ECG data and the patient information. Clinical scientists might be interested in the heart data, but do not wish to see any patient information. Manufacturers may be interested in the raw data stream itself as a tool to discern how the device is operating. Depending on the needs of the end worker, the processing system 204 takes the raw device data, evaluates its accuracy and completeness, and generates different packages of data for delivery to the various knowledge workers. The processed data packages are also stored in the repository 202.
When the data is ready for delivery, a distribution/presentation system 208 distributes the different packages to the appropriate computer systems 140, 144, 148, 152, and 172. The distribution/presentation system 208 is configured to serve the packages according to the protocols and formats desired by the computer systems. In this manner, the network architecture 100 allows relevant portions of device data, collected from the ICTD, to be disseminated to the appropriate knowledge workers in a form they prefer.
Once the ICTD data is delivered, the computer systems 140, 144, 148, 152, and 172 store the data and/or present the data to the knowledge worker. The computer systems may perform further processing specific to their use of the data. Through these processes, the knowledge workers create additional information that is useful to the patient, or other knowledge workers with interests in ICTDs. For example, from the ICTD data, the knowledge workers might devise improved therapies for a given patient, or create instructions to modify operation of a specific ICTD, or gain a better understanding of how implantable cardiac devices operate in general, or develop better technologies for future generations of ICTDs. Much of this created knowledge can be shared among the various knowledge workers.
If the collective knowledge base produces information that may prove helpful to the patient, that information can be passed to the notification system 172 for delivery to one or more patients. Also, any one of the knowledge workers may wish to employ the notification system 172 to send messages to the patient(s).
The patient feedback system 400 may be implemented in many ways. As one exemplary implementation, the patient feedback system 400 is implemented as a server that serves content back to the networked programmer 114, which then uses the information to program the ICTD 102 through a built in transceiver 116, local transceiver 112, or wand-based telemetry. As another possible implementation, the patient feedback system may be a cellular or RF transmission system that sends information back to the patient feedback device 160.
The network architecture 100 facilitates continuous care around the clock, regardless of where the patient is located. For instance, suppose the patient is driving in the car when a cardiac episode occurs. The ICTD 102 detects the condition and transmits an alert message about the condition to the local transceiver 112. The message is processed and delivered to a physician's computer or PDA via the network 120. The physician can make a diagnosis and send some instructions back to the patient's ICTD. The physician might also have a notification message that guides the patient to a nearest healthcare facility for further treatment sent via the notification system 170 to the patient's notification device 160. Concurrently, the physician can share the patient's records online with an attending physician at the healthcare facility so that the attending physician can review the records prior to the patient's arrival.
Exemplary ICTD
The ICTD 102 is also shown in electrical communication with the patient's heart 106 by way of an implantable right ventricular lead 108(3) having, in this implementation, a right ventricular tip electrode 510, a right ventricular ring electrode 512, a right ventricular (RV) coil electrode 514, and an SVC coil electrode 516. Typically, the right ventricular lead 108(3) is transvenously inserted into the heart 102 to place the right ventricular tip electrode 510 in the right ventricular apex so that the RV coil electrode 514 will be positioned in the right ventricle and the SVC coil electrode 516 will be positioned in the superior vena cava. Accordingly, the right ventricular lead 108(3) is capable of receiving cardiac signals, and delivering stimulation in the form of pacing and shock therapy to the right ventricle.
The circuitry is housed in housing 600, which is often referred to as the "can", "case", "encasing", or "case electrode", and may be programmably selected to act as the return electrode for unipolar modes. Housing 600 may further be used as a return electrode alone or in combination with one or more of the coil electrodes for shocking purposes. Housing 600 further includes a connector (not shown) having a plurality of terminals 602, 604, 606, 608, 612, 614, 616, and 618 (shown schematically and, for convenience, the names of the electrodes to which they are connected are shown next to the terminals).
To achieve right atrial sensing and pacing, the connector includes at least a right atrial tip terminal (AR TIP) 602 adapted for connection to the atrial tip electrode 502. To achieve left chamber sensing, pacing, and shocking, the connector includes at least a left ventricular tip terminal (VL TIP) 604, a left atrial ring terminal (AL RING) 606, and a left atrial shocking terminal (AL COIL) 608, which are adapted for connection to the left ventricular ring electrode 504, the left atrial ring electrode 506, and the left atrial coil electrode 508, respectively. To support right chamber sensing, pacing, and shocking, the connector includes a right ventricular tip terminal (VR TIP) 612, a right ventricular ring terminal (VR RING) 614, a right ventricular shocking terminal (RV COIL) 616, and an SVC shocking terminal (SVC COIL) 618, which are adapted for connection to the right ventricular tip electrode 510, right ventricular ring electrode 512, the RV coil electrode 514, and the SVC coil electrode 516, respectively.
At the core of the ICTD 102 is a programmable microcontroller 620 that controls various operations of the ICTD, including cardiac monitoring and stimulation therapy. Microcontroller 620 includes a microprocessor (or equivalent control circuitry), RAM and/or ROM memory, logic and timing circuitry, state machine circuitry, and I/O circuitry. Microcontroller 620 includes the ability to process or monitor input signals (data) as controlled by a program code stored in a designated block of memory. Any suitable microcontroller 620 may be used. The use of microprocessor-based control circuits for performing timing and data analysis functions are well known in the art.
For discussion purposes, microcontroller 620 is illustrated as including timing control circuitry 632 to control the timing of the stimulation pulses (e.g., pacing rate, atrio-ventricular (AV) delay, atrial interconduction (A-A) delay, or ventricular interconduction (V-V) delay, etc.) as well as to keep track of the timing of refractory periods, blanking intervals, noise detection windows, evoked response windows, alert intervals, marker channel timing, and so on. Microcontroller 220 may further include various types of cardiac condition detectors 634 (e.g., an arrhythmia detector, a morphology detector, etc.) and various types of compensators 636 (e.g., orthostatic compensator, syncope response module, etc.). These components can be utilized by the device 102 for determining desirable times to administer various therapies. The components 632-636 may be implemented in hardware as part of the microcontroller 620, or as software/firmware instructions programmed into the device and executed on the microcontroller 620 during certain modes of operation.
The ICTD 102 further includes an atrial pulse generator 622 and a ventricular pulse generator 624 that generate pacing stimulation pulses for delivery by the right atrial lead 108(1), the coronary sinus lead 108(2), and/or the right ventricular lead 108(3) via an electrode configuration switch 626. It is understood that in order to provide stimulation therapy in each of the four chambers of the heart, the atrial and ventricular pulse generators, 622 and 624, may include dedicated, independent pulse generators, multiplexed pulse generators, or shared pulse generators. The pulse generators 622 and 624 are controlled by the microcontroller 620 via appropriate control signals 628 and 630, respectively, to trigger or inhibit the stimulation pulses.
The electronic configuration switch 626 includes a plurality of switches for connecting the desired electrodes to the appropriate I/O circuits, thereby providing complete electrode programmability. Accordingly, switch 626, in response to a control signal 642 from the microcontroller 620, determines the polarity of the stimulation pulses (e.g., unipolar, bipolar, combipolar, etc.) by selectively closing the appropriate combination of switches (not shown).
Atrial sensing circuits 644 and ventricular sensing circuits 646 may also be selectively coupled to the right atrial lead 108(1), coronary sinus lead 108(2), and the right ventricular lead 108(3), through the switch 626 to detect the presence of cardiac activity in each of the four chambers of the heart. Accordingly, the atrial (ATR. SENSE) and ventricular (VTR. SENSE) sensing circuits, 644 and 646, may include dedicated sense amplifiers, multiplexed amplifiers, or shared amplifiers. Each sensing circuit 644 and 646 may further employ one or more low power, precision amplifiers with programmable gain and/or automatic gain control, bandpass filtering, and a threshold detection circuit to selectively sense the cardiac signal of interest. The automatic gain control enables the ICTD 102 to deal effectively with the difficult problem of sensing the low amplitude signal characteristics of atrial or ventricular fibrillation. Switch 626 determines the "sensing polarity" of the cardiac signal by selectively closing the appropriate switches. In this way, the clinician may program the sensing polarity independent of the stimulation polarity.
The outputs of the atrial and ventricular sensing circuits 644 and 646 are connected to the microcontroller 620 which, in turn, is able to trigger or inhibit the atrial and ventricular pulse generators 622 and 624, respectively, in a demand fashion in response to the absence or presence of cardiac activity in the appropriate chambers of the heart. The sensing circuits 644 and 646 receive control signals over signal lines 648 and 650 from the microcontroller 620 for purposes of controlling the gain, threshold, polarization charge removal circuitry (not shown), and the timing of any blocking circuitry (not shown) coupled to the inputs of the sensing circuits 644 and 646.
Cardiac signals are also applied to inputs of an analog-to-digital (ND) data acquisition system 652. The data acquisition system 652 is configured to acquire intracardiac electrogram signals, convert the raw analog data into a digital signal, and store the digital signals for later processing and/or telemetric transmission to an external device 654. The data acquisition system 652 is coupled to the right atrial lead 108(1), the coronary sinus lead 108(2), and the right ventricular lead 108(3) through the switch 626 to sample cardiac signals across any pair of desired electrodes.
The data acquisition system 652 may be coupled to the microcontroller 620, or other detection circuitry, to detect an evoked response from the heart 106 in response to an applied stimulus, thereby aiding in the detection of "capture". Capture occurs when an electrical stimulus applied to the heart is of sufficient energy to depolarize the cardiac tissue, thereby causing the heart muscle to contract. The microcontroller 620 detects a depolarization signal during a window following a stimulation pulse, the presence of which indicates that capture has occurred. The microcontroller 620 enables capture detection by triggering the ventricular pulse generator 624 to generate a stimulation pulse, starting a capture detection window using the timing control circuitry 632 within the microcontroller 620, and enabling the data acquisition system 652 via control signal 656 to sample the cardiac signal that falls in the capture detection window and, based on the amplitude, determines if capture has occurred.
The microcontroller 620 is further coupled to a memory 660 by a suitable data/address bus 662, wherein the programmable operating parameters used by the microcontroller 620 are stored and modified, as required, in order to customize the operation of the implantable device 102 to suit the needs of a particular patient. Such operating parameters define, for example, pacing pulse amplitude, pulse duration, electrode polarity, rate, sensitivity, automatic features, arrhythmia detection criteria, and the amplitude, waveshape and vector of each shocking pulse to be delivered to the patient's heart 106 within each respective tier of therapy. With memory 660, the ICTD 102 is able to sense and store a relatively large amount of data (e.g., from the data acquisition system 652), which may transmitted to the external network of knowledge workers for subsequent analysis.
Operating parameters of the ICTD 102 may be non-invasively programmed into the memory 660 through a telemetry circuit 664 in telemetric communication with an external device, such as a programmer 110 or local transceiver 112. The telemetry circuit 664 advantageously allows intracardiac electrograms and status information relating to the operation of the device 102 (as contained in the microcontroller 620 or memory 660) to be sent to the external devices.
The ICTD 100 can further include one or more physiologic sensors 670, commonly referred to as "rate-responsive" sensors because they are typically used to adjust pacing stimulation rate according to the exercise state of the patient. However, the physiological sensor 670 may further be used to detect changes in cardiac output, changes in the physiological condition of the heart, or diurnal changes in activity (e.g., detecting sleep and wake states, detecting position or postural changes, etc.). Accordingly, the microcontroller 620 responds by adjusting the various pacing parameters (such as rate, AV Delay, V-V Delay, etc.) at which the atrial and ventricular pulse generators, 622 and 624, generate stimulation pulses. While shown as being included within the device 102, it is to be understood that the physiologic sensor 670 may also be external to the device 102, yet still be implanted within or carried by the patient. Examples of physiologic sensors that may be implemented in device 102 include known sensors that, for example, sense respiration rate and/or minute ventilation, pH of blood, ventricular gradient, and so forth.
The ICTD 102 additionally includes a battery 676 that provides operating power to all of circuits shown in
The ICTD 102 can further include magnet detection circuitry (not shown), coupled to the microcontroller 620, to detect when a magnet is placed over the device 102. A magnet may be used by a clinician to perform various test functions of the device 102 and/or to signal the microcontroller 620 that the external programmer is in place to receive or transmit data to the microcontroller 620 through the telemetry circuits 664.
The ICTD 102 further includes an impedance measuring circuit 678 that is enabled by the microcontroller 620 via a control signal 680. Uses for an impedance measuring circuit 678 include, but are not limited to, lead impedance surveillance during the acute and chronic phases for proper lead positioning or dislodgement; detecting operable electrodes and automatically switching to an operable pair if dislodgement occurs; measuring respiration or minute ventilation; measuring thoracic impedance for determining shock thresholds; detecting when the device has been implanted; measuring stroke volume; and detecting the opening of heart valves, etc. The impedance measuring circuit 678 is advantageously coupled to the switch 626 so that any desired electrode may be used.
In the case where the device 102 is intended to operate as an implantable cardioverter/defibrillator (ICD) device, it detects the occurrence of an arrhythmia, and automatically applies an appropriate electrical shock therapy to the heart aimed at terminating the detected arrhythmia. To this end, the microcontroller 620 further controls a voltage delivery circuit or shock circuit 682 by way of a control signal 684. The shocking circuit 682 generates shocking pulses of low (up to 0.5 Joules), moderate (0.5-10 Joules), or high energy (11 to 40 Joules), as controlled by the microcontroller 620. Such shocking pulses are applied to the patient's heart 106 through at least two shocking electrodes, and as shown in this implementation, selected from the left atrial coil electrode 508, the RV coil electrode 514, and/or the SVC coil electrode 516. As noted above, the housing 600 may act as an active electrode in combination with the RV coil electrode 514, or as part of a split electrical vector using the SVC coil electrode 516 or the left atrial coil electrode 508 (i.e., using the RV electrode as a common electrode).
Cardioversion shocks are generally considered to be of low to moderate energy level (so as to minimize pain felt by the patient), and/or synchronized with an R-wave and/or pertaining to the treatment of tachycardia. Defibrillation shocks are generally of moderate to high energy level (i.e., corresponding to thresholds in the range of 5-40 Joules), delivered asynchronously (since R-waves may be too disorganized), and pertaining exclusively to the treatment of fibrillation. Accordingly, the microcontroller 620 is capable of controlling the synchronous or asynchronous delivery of the shocking pulses.
The ICTD 102 is further designed with the ability to support high-frequency wireless communication, typically in the radio frequency (RF) range. The ICTD 102 is equipped with a high-frequency transceiver 692 and a diplexer 694. High-frequency signals received by a dedicated antenna 696, or via leads 108, are passed to the transceiver 692 directly, or via diplexer 694. The high-frequency transceiver 692 may be configured to operate on one or a few frequencies. Alternatively, the transceiver 692 may include a tuner 696 that tunes to various frequencies when attempting to establish communication links with the external communication device (e.g., programmer, local transceiver, etc.).
In one implementation, the high-frequency circuitry may be contained within a secondary, isolated casing 690 to enable handling of high-frequency signals in isolation from the cardiac therapy circuitry. In this manner, the high-frequency signals can be safely received and transmitted, thereby improving telemetry communication, without adversely disrupting operation of the other device circuitry.
Exemplary Computing Device
The computing device 700 may further be equipped with a network I/O connection 720 to facilitate communication with a network. The network I/O 720 may be a wire-based connection (e.g., network card, modem, etc.) or a wireless connection (e.g., RF transceiver, Bluetooth device, etc.). The computing device 700 may also include a user input device 722 (e.g., keyboard, mouse, stylus, touch pad, touch screen, voice recognition system, etc.) and an output device 724 (e.g., monitor, LCD, speaker, printer, etc.).
Various aspects of the methods and systems described throughout this disclosure may be implemented in computer software or firmware as computer-executable instructions. When executed, these instructions direct the computing device (alone, or in concert with other computing devices of the system) to perform various functions and tasks that enable the cardiac therapy network architecture 100.
Communication Protocol
One feature of the network architecture is an improved transmission range between the ICTD 102 and an external device such as the offline programmer 110, the local transceiver 112, and/or programmer 116. Long range telemetry allows communication with implanted medical devices at distances greater than conventional "wand telemetry" of a few inches. Longer range telemetry is made possible by employing high-frequency signals, such as RF signals. However, longer range telemetry introduces a challenge regarding how to establish communication with one or more ICTDs 102 at distances larger than several inches.
To address this challenge, the network architecture contemplates a technique for interrogating one or more ICTDs that might be within range of an external device for purposes of establishing a communication link. Once established, the devices can use the link to exchange data and download programming parameters. The interrogation and communication links are conducted over more than one allocated frequency band to support communication with multiple implantable devices.
The external device 800 is equipped with an interrogation/listening unit 808. It generates an interrogation signal (designated as "IFF" in
The ICTD-based transceiver 692 listens for the interrogation signal. In one implementation, the ICTD transceiver 692 is designed to listen at one frequency within the possible range of interrogating frequencies, although more sophisticated transceivers may be configured to listen over a range of frequencies. When the ICTD receives the interrogation signal, the ICTD-based transceiver 692 transmits a reply at a response frequency within a set of possible response frequencies. The reply may be in the form of a device identification code (designated as "ID" in
The interrogation/listening unit 808 listens for the reply from the ICTD transceiver 692 over the response frequencies. The unit 808 listens for a predetermined response time interval triggered by transmission of the interrogation signal. If no reply is detected within the time interval, the interrogation/listening unit 808 retransmits the interrogation signal and restarts the interval. On the other hand, when the unit 808 detects a reply, it commands the ICTD to tune to a designated frequency channel to facilitate ongoing communication between the ICTD 102 and the external device 800. The frequency assigned to the ICTD is listed in the assigned frequency record 810 and associated with the ICTD. Upon receiving this command, the ICTD-based tuner 696 tunes the transceiver 692 to the designated channel.
From this point, the ICTD and external device can channel hop to other frequencies. According to one aspect, the ICTD and external device are configured to channel hop among frequencies more than once during communication of information (e.g., one segment or bit of information). The channel hopping confers the advantage of greater tolerance to externally-generated electromagnetic interference. This is based on the assumption that interference is less likely to occur in separated frequency bands than in one continuous band. Each information symbol may be encoded as two separated frequencies to take advantage of the decreased probability of interference.
At block 902, the external device 800 selects frequency ranges for transmitting and receiving signals used in establishment of communication with the ICTD. The selected transmission range encompasses an interrogating frequency to which the ICTD 102 is tuned to receive any interrogation signal from the external device 800. The selected receiving range of frequencies includes a response frequency at which the ICTD 102 is expected to return a reply to the interrogation signal. The transmission and receiving ranges may cover the same frequencies, or overlap so that common frequencies are used in both transmission and reception, or be mutually exclusive bands of frequencies with no common frequency.
At block 904, the interrogation/listening unit 808 directs transceiver 802 to transmit the interrogation code IFF at one or more of the interrogating frequencies. According to one possible implementation, the transceiver 802 transmits the interrogation signal on multiple or all interrogating frequencies, either randomly or in a prescribed order. The external device 800 then begins listening to one or more response frequencies for a reply from the ICTD 102 (block 906). It listens for a predetermined response time interval.
Meanwhile, at block 910, the ICTD 102 is listening at one or more frequencies for the interrogation code. Depending upon power resources, the listening may be continuous or intermittent. Once the interrogation code is detected, the ICTD 102 optionally delays for a random time period within the response time interval (block 912) and then transmits a reply at one of the response frequencies (block 914). The random delay allows the external device to listen for multiple ICTDs. That is, if multiple ICTDs respond to the same interrogation code on the same response frequency, the random delays separate the replies allowing them to be received at the external device 800. The replies may be in the form of device identification codes so that the external device can identify the one or more ICTDs.
The external device 800 listens for any reply over one or more receiving frequencies for a predetermined response time interval (blocks 906, 920, 922). If no reply is received, the external device continues listening until the response interval lapses (i.e., the loop including block 906, the "no" branch from block 920, and the "no" branch from block 922). If no reply is received within the response interval, the external device 902 retransmits the interrogation code (i.e., the "yes" branch from block 922 to block 904).
If a reply is received within the response interval (i.e., the "yes" branch from block 920), the external device 800 assigns a communication channel to the ICTD 102 (block 924). The external device 800 records the channel in the log 810 in association with the specific ICTD, and transmits the designated channel to the ICTD (block 926). The ICTD and external device employ the designated channel for ongoing communication.
Once a particular ICTD and external device are communicating on the assigned channel, that communication channel may be used to download data from the ICTD, query the ICTD, or submit programming instructions to the ICTD. The communicating devices may conduct all continuing communication on the assigned channel, or hop to other frequencies using known frequency hopping techniques. Accordingly, at block 928, the ICTD and external device may optionally channel hop to multiple frequencies multiple times during communication of information.
At this point, the process flow returns to block 902 to select the same or a new set of frequencies with the intention of interrogating and establishing communication with another ICTD.
The ICTDs 102(1)-(M) can be configured to transmit the replies after a random delay period. For instance, ICTD 102(1) might reply at random time t1, which is within the response time interval T0 (i.e., 0<t1<T0). Similarly, ICTDs 102(2), . . . , 102(M) reply at random times t2, tM, which are likely to be different from one another, but still fall within the response time interval To. In this manner, if multiple ICTDs listen to the same frequency and respond to the same interrogation code, there is an increased probability that the ICTDs will reply at different times so that the external device receives all replies.
As the external device 800 receives the replies, it assigns different communication channels to the ICTDs 102(1)-(M). For instance, channel CC1 is assigned for communication between ICTD 102(1) and the external device 800; channel CC2 is assigned for communication between the ICTD 102(2) and the external device 800; and channel CCM is assigned for communication between ICTD 102(M) and the external device 800.
The assigned communication channels are recorded in the log 810 in association with the ICTDs identification codes so that continuing communication between the ICTDs and the external devices are handled in a one-to-one link. This ensures that data read from individual ICTDs are associated with the appropriate patients and any programming instructions are delivered to the appropriate ICTDs, thereby preventing any situation where one ICTD is programmed to deliver therapy intended for another patient.
Exemplary Packaging Design
The ICTD 102 has a header 1102 that holds the connection terminals for leads 108(1)-(3). The header is commonly formed of an epoxy material mounted on can 600, which is commonly formed of a conducting material such as titanium. In this construction, the high-frequency circuitry is contained within a separate frequency-isolated packaging region 1104 adjacent to the header 1102. The region 1104 is defined in part by wall 690, which is constructed, for example, of a conducting material such as titanium. The high-frequency packaging region 1104 can be thought of as a separate can or chamber that isolates the RF components from the main circuitry. The dual-can design enables the ICTD to handle high-frequency signals carrying data and control information in one can of the device without disrupting operation of the main circuitry in the second can or chamber of the device.
The transceiver 692 and diplexer 694 are positioned within the high-frequency packaging region 1104. Signals received from a lead 108 or a dedicated antenna 696 are passed through an unfiltered feed-through 1106 to a diplexer 694. The diplexer 694 allows two signals of different frequencies to be transmitted along the same conductor and separates the signal frequencies onto two different connections. In the illustrated implementation, the diplexer 694 is designed to direct RF signals to the RF transceiver 692 and the electrocardiograph (ECG) signals to the main circuitry in the main chamber.
The diplexer's first connection 1108 leads to a feed-through 1110 into the ICTD circuitry within the main chamber. The diplexer 694 filters this first connection to pass low frequencies of the ECG signal. High frequencies are blocked and therefore do not interfere with the sensing of the ECG.
A second connection 1112 on the diplexer 694 connects to the transceiver 692. The filter on this connection is tuned to pass a band of high frequencies. The transceiver is capable of receiving and transmitting high-frequency signals, such as those found in the radio frequency range. As one example range, the transceiver handles signals within 200 to 900 MHz. Low frequency signals, such as the ECG, on connection 1112 are blocked. The transceiver 692 extracts any codes, data and/or control instructions from the carrier frequency modulation and passes the information to the ICTD circuitry via connections 1114 and a feed-through 1116. The feed-through 1116 can be filtered to prevent any high-frequency components from entering the main circuit chamber. The metal shield encompassing the high-frequency chamber 1104 blocks spurious signals emanating from the RF transceiver 692 from interfering with the sensing and pacing functions of the main circuitry. Power is supplied to the transceiver 692 and diplexer 694 from the battery in the main circuitry chamber via the feed-throughs 1110 and 1116.
The dual-chamber design provides optimal isolation. With the diplexer, dual enclosure regions, and filtered feed-throughs, the design isolates the main monitoring/stimulating circuitry from RF interference emanating from the diplexer or transceiver, while simultaneously allowing long-range RF telemetry communication. Additionally, the design allows the leads to be used as both stimulation/sensing leads and as a radio frequency (RF) antenna, without causing interference to the monitoring and/or stimulation functions.
In the illustrated implementation, the high-frequency region 1104 is shown adjacent to header 1102 and above the main circuit chamber, encapsulated by the outer can wall of the device and the interior wall 690. It is noted that the region 1104 may be located in any number of places. It may be, for example, implemented as an isolated cavity contained entirely within the main circuit chamber. Alternatively, it may be constructed external to the ICTD 102, but employ part of the exterior can 600 to define a portion of the region. Another possible implementation is to construct the high-frequency region as a separate implantable can that is in communication with the ICTD, but implanted apart from the ICTD 102.
The antenna for transmitting and receiving the high-frequency data signals may be implemented in a number of ways. One approach is to use one or more of the leads 108(1)-(3) as the antenna. Another approach is to employ a dedicated antenna positioned within the header region 1102. A third approach is to employ a dedicated antenna that extends beyond the header region 1102. Still another approach is to integrate the antenna into the can 600.
Although the invention has been described in language specific to structural features and/or methodological acts, it is to be understood that the subject matter defined in the appended claims is not necessarily limited to the specific features or acts described. Rather, the specific features and acts are disclosed as exemplary forms of implementing the claimed invention.
|Brevet cité
|Date de dépôt
|Date de publication
|8 mars 1983
|31 déc. 1985
|The Johns Hopkins University
|Coherent inductive communications link for biomedical applications
|5 avr. 1985
|21 juil. 1987
|Siemens-Pacesetter, Inc.
|Analog and digital telemetry system for an implantable device
|20 févr. 1990
|22 oct. 1991
|Siemens-Pacesetter, Inc.
|Telemetry apparatus and method for implantable tissue stimulator
|21 aoűt 1990
|19 mai 1992
|Telectronics Pacing Systems, Inc.
|Implantable ambulatory electrocardiogram monitor
|7 janv. 1993
|30 aoűt 1994
|Incontrol, Inc.
|Telemetry system for an implantable cardiac device
|29 janv. 1993
|11 oct. 1994
|Medtronic, Inc.
|Telemetry system for an implantable medical device
|2 nov. 1993
|17 janv. 1995
|Quinton Instrument Company
|Spread spectrum telemetry of physiological signals
|4 juin 1993
|1 aoűt 1995
|M & Fc Holding Company, Inc.
|Duplex bi-directional multi-mode remote instrument reading and telemetry system
|26 juil. 1993
|3 oct. 1995
|Sorin Biomedica S.P.A.
|Method and a device for monitoring heart function
|5 oct. 1994
|5 mars 1996
|Sorin Biomedica S.P.A.
|Device for determining myocardial function and corresponding procedure
|21 juil. 1994
|5 mars 1996
|Pacesetter, Inc.
|System and method for detecting cardiac arrhythmias using a cardiac wall acceleration sensor signal
|28 oct. 1994
|30 avr. 1996
|Segalowitz; Jacob
|Device-system and method for monitoring multiple physiological parameters (MMPP) continuously and simultaneously
|17 juin 1994
|21 mai 1996
|Pacesetter, Inc.
|Cardiac device with patient-triggered storage of physiological sensor data
|13 janv. 1994
|13 aoűt 1996
|Charles L. Davis
|Real time ambulatory patient monitor
|18 janv. 1995
|8 oct. 1996
|Pacesetter, Inc.
|Bidirectional telemetry apparatus and method for implantable device
|1 déc. 1994
|8 avr. 1997
|Quinton Instrument Company
|Spread spectrum telemetry of physiological signals
|13 oct. 1994
|6 mai 1997
|Ael Industries, Inc.
|Medical telemetry system using an implanted passive transponder
|2 mai 1996
|7 oct. 1997
|Incontrol, Inc.
|Atrial defibrillation system having a portable communication device
|11 janv. 1996
|4 nov. 1997
|Medtronic, Inc.
|Adaptive, performance-optimizing communication system for communicating with an implanted medical device
|7 juin 1995
|16 déc. 1997
|Intermedics, Inc.
|Electromagnetic noise detector for implantable medical devices
|6 oct. 1995
|24 févr. 1998
|Pacesetter, Inc.
|Cardiac stimulation system with enhanced communication and control capability
|9 juil. 1996
|5 mai 1998
|Vitalcom, Inc.
|Two-way TDMA telemetry system with power conservation features
|23 juin 1995
|19 mai 1998
|Medtronic, Inc.
|World wide patient location and data telemetry system for implantable medical devices
|12 mars 1997
|1 déc. 1998
|Medtronic, Inc.
|Adaptive, performance-optimizing communication system for communicating with an implanted medical device
|13 nov. 1996
|5 janv. 1999
|Lai; Joseph
|Method and system for remotely monitoring multiple medical parameters
|25 juil. 1997
|19 janv. 1999
|Medtronic Inc.
|Implantable medical device microstrip telemetry antenna
|19 mars 1998
|18 mai 1999
|Medtronic, Inc.
|System and method for deriving relative physiologic signals
|2 juil. 1996
|31 aoűt 1999
|Vitalcom Inc.
|Architecture for TDMA medical telemetry system
|12 sept. 1997
|7 déc. 1999
|Alfred E. Mann Foundation
|Daisy chainable sensors and stimulators for implantation in living tissue
|3 mars 1997
|21 déc. 1999
|Quinton Instrument Company
|Open architecture cardiology information system
|6 févr. 1998
|28 déc. 1999
|Medtronic, Inc.
|Implant device telemetry antenna
|24 nov. 1998
|4 juil. 2000
|Medtronic, Inc.
|World wide patient location and data telemetry system for implantable medical devices
|22 déc. 1998
|5 sept. 2000
|Medtronic, Inc.
|Telemetry for implantable devices using the body as an antenna
|31 déc. 1998
|5 déc. 2000
|Medtronic, Inc.
|Implantable medical device monitoring method and system regarding same
|28 déc. 1998
|19 déc. 2000
|Medtronic, Inc.
|Non-invasive cardiac monitoring system and method with communications interface
|16 avr. 1999
|13 mars 2001
|Medtronic, Inc.
|Peripheral memory patch and access method for use with an implantable medical device
|20 mai 1999
|10 avr. 2001
|Vitalcom, Inc.
|Telemeter design and data transfer methods for medical telemetry system
|20 juil. 1999
|1 mai 2001
|Cardionet, Inc.
|Reprogrammable remote sensor monitoring system
|13 aoűt 1999
|8 mai 2001
|Neuro Pace, Inc.
|Integrated system for EEG monitoring and electrical stimulation with a multiplicity of electrodes
|18 nov. 1999
|22 mai 2001
|Medtronic, Inc.
|Implantable medical device for sensing absolute blood pressure and barometric pressure
|24 oct. 1997
|29 mai 2001
|Fuji Photo Film Co., Ltd.
|Soft magnetic thin film, method for preparing same and magnetic head
|30 avr. 1999
|29 mai 2001
|Medtronic, Inc.
|Telemetry system for implantable medical devices
|31 aoűt 1999
|24 juil. 2001
|Data Critical Corporation
|System and method for generating and transferring medical data
|31 déc. 1999
|7 aoűt 2001
|Cardiac Intelligence Corp.
|System and method for automated collection and analysis of regularly retrieved patient information for remote patient care
|23 nov. 1999
|28 aoűt 2001
|Brigham & Women's Hospital
|Health monitoring system
|8 oct. 1999
|9 oct. 2001
|Pacesetter, Inc.
|High speed telemetry system using transmission medium as a component of a telemetry link
|3 juin 1999
|6 nov. 2001
|Cardiac Intelligence Corporation
|System and method for automated collection and analysis of patient information retrieved from an implantable medical device for remote patient care
|3 janv. 2001
|13 nov. 2001
|Alfred E. Mann Foundation For Scientific Research
|System of implantable devices for monitoring and/or affecting body parameters
|14 déc. 1999
|9 juil. 2002
|Medtronic, Inc.
|Apparatus and method for remote therapy and diagnosis in medical devices via interface systems
|20 déc. 2000
|27 aoűt 2002
|Medtronic, Inc.
|Instrumentation and software for remote monitoring and programming of implantable medical devices (IMDs)
|18 déc. 2000
|12 nov. 2002
|Medtronic, Inc.
|Information network interrogation of an implanted device
|14 oct. 1998
|11 févr. 2003
|Nokia Mobile Phones Limited
|Mobile telephone for internet-applications
|19 avr. 2001
|3 juin 2003
|Medtronic, Inc.
|Passive data collection system from a fleet of medical instruments and implantable devices
|22 juin 2001
|10 juin 2003
|Medtronic, Inc.
|Network compatible RF wireless link for medical device data management
|30 mars 2001
|16 sept. 2003
|Medtronic, Inc.
|Variable encryption scheme for data transfer between medical devices and related data management systems
|2 nov. 2001
|13 juil. 2004
|Pacesetter, Inc.
|Frequency agile telemetry system for implantable medical device
|27 avr. 2004
|13 févr. 2007
|Pacesetter, Inc.
|Frequency agile telemetry system for implantable medical device
|18 déc. 2000
|28 févr. 2002
|Riff Kenneth M.
|Method and a system for using implanted medical device data for accessing therapies
|26 oct. 2001
|5 sept. 2002
|Christophersom Mark A.
|Externally worn transceiver for use with an implantable medical device
|NonFinal Office Action, mailed Dec. 31, 2003: Related U.S. Appl. No. 10/001,225.
|NonFinal Office Action, mailed Jun. 13, 2006: Related U.S. Appl. No. 10/833,596.
|Notice of Allowance, mailed Apr. 7, 2004: Related U.S. Appl. No. 10/001,225.
|Notice of Allowance, mailed Sep. 28, 2006: Related U.S. Appl. No. 10/833,596.
|Brevet citant
|Date de dépôt
|Date de publication
|12 juil. 2010
|7 janv. 2014
|Qualcomm Incorporated
|Adjustable transmitter for privacy protection of content broadcast from a transmitting device to a receiving device
|26 aoűt 2015
|27 déc. 2016
|Cardiac Pacemakers, Inc.
|Medical device with triggered blanking period
|8 janv. 2015
|14 mars 2017
|Cardiac Pacemakers, Inc.
|Systems and methods for detecting cardiac arrhythmias
|1 févr. 2016
|6 juin 2017
|Cardiac Pacemakers, Inc.
|Systems and methods for treating cardiac arrhythmias
|29 juil. 2015
|4 juil. 2017
|Cardiac Pacemakers, Inc.
|Method and apparatus for communicating between medical devices
|29 juil. 2015
|12 sept. 2017
|Cardiac Pacemakers, Inc.
|Communications in a medical device system
|29 juil. 2015
|7 nov. 2017
|Cardiac Pacemakers, Inc.
|Communication between a plurality of medical devices using time delays between communication pulses to distinguish between symbols
|17 aoűt 2016
|26 déc. 2017
|Cardiac Pacemakers, Inc.
|Systems and methods for communication between medical devices
|12 juil. 2010
|13 janv. 2011
|Qualcomm Incorporated
|Adjustable Transmitter For Privacy Protection Of Content Broadcast From A Transmitting Device To A Receiving Device
|Classification aux États-Unis
|607/60, 607/59, 607/30, 607/32, 607/9
|Classification internationale
|Classification coopérative
|Classification européenne


text:
Solid-State Drive Firmware Updates
WARNING: Please do not update firmware unless absolutely necessary. Firmware updates may result in loss of user data and
The page is temporarily unavailable
The page you are looking for is temporarily unavailable.
Please try again later.
we recommend you back up your data before updating the firmware.The firmware update process is done entirely at your own risk. Before attempting to update the firmware, back up or make copies of all important files. If the Mushkin SSD firmware update process is interrupted, your SSD may not function properly.

subset: commoncrawl


text:
Skateboarding's Masters are aging gracefully and were still blowing minds at the 2013 Vans Pool Party at the Vans Skatepark this past weekend. Check out photos of Chris Miller, Steve Caballero, Christian Hosoi, Jeff Grosso, Eddie Elguera, Nicky Guerrero, Mike McGill, Duane Peters, and more. Hard to believe some of these guys are in their 50s and absolutely ripping. Also check out the Masters video.
Photos by Shigeo
1. Chris Miller (Del Mar, CA) $15,000
2. Steve Caballero (San Jose, CA) $7,500
3. Christian Hosoi (Huntington Beach, CA) $4,000
Check out the gallery of the Pro Division photos.
Those who missed the action live can find complete event coverage including more photos and videos at vans.com/poolparty


text:
No Hidden Fees - No Credit Card Surcharges - Low Shipping Rates
Images shown may not be an exact representation of the actual product.You may contact us if you have questions about the exact specifications of this item.
Steel sight set replaces the factory sights on a standard 10/22® barrel to add a realistic detail to your M1 carbine look-alike conversion. Front sight slips over front barrel band, and rear sight fits the factory rear receiver scope base screw holes. Gives the same sight picture as original M1 carbine sights, but is calibrated for the .22 LR trajectory. Completes the "look" of an M1 carbine using the West One M1 Carbine Stock and Sling, both available separately.
All mounting hardware included.
Impact Guns is the gun shop for all your shooting needs. We offer a wide selection of firearms, including: handguns, shotguns, rifles, ammunition, rifle scopes and optics, as well as collectible machine guns and other NFA/Class 3 guns. Impact also services the needs of law enforcement and military with our wide variety of tactical weapons and accessories. Shop online through our 256-bit Secure Sockets Layer encrypted online gun store 24 hours a day!


text:
But 1on1 he still cant tackle. Bush gave him a nasty stiff arm 2 weeks ago. Steven Jackson ran right over him yesterday.
Wilkerson is turning into an absolute star... Guy is still so young too. Hopefully he stays healthy and keeps getting better. Will be a pro bowler on this trajectory.
Cro is not only playing lights out right now, he's been so much more physical this season then we have ever seen throughout his career. He's still not the toughest CB in the league but certainly not the biggest ***** anymore.
Landry has shown Cro the way to the big hits...
The only corner I would take over Cromartie this year is Tillman, who is probable NFC DPOY.
Cromartie has been outstanding this season.
Watt locked down DPOY, but Cro is far and away the best CB in the AFC so far in my opinion.
Better corner for us: Cromartie or Aaron Glenn?
Also Wilkerson looks fantastic. He's already a better player than Ellis was. Ellis is kinda overrated because of his longevity with the Jets. Ellis had a tendency to become invisible for weeks at a time and rarely would his play stick out on Sundays as one of the Jets best defensive players like Wilkerson's play has been doing this year.
Glenn was great too though. Him and first Otis Smith, then Coleman was a very good duo as well.
Remember the years in-between Glenn and Revis? Guys like Abraham, Barrett etc were OK..
.but man we have been spoiled since
ALSO....can't forget my Main Man Mickens at the nickel....loved that guy!
Sent from my LG-P999


text:
Body composition measurements with InBody technology from GE Healthcare can, with accuracy and precision, look beyond weight and traditional BMI to determine and help monitor distribution of body fat, body water, and lean body mass. Along with tetra-polar 8-point tactile electrodes, InBody technology uses a direct segmental multi-frequency bioelectric impedance method that is not dependent on empirical estimations. Knowing what's working for your patients can help you target and reach wellness, appearance, and longevity goals.
For more information, visit www.gehealthcare.com [1].


text:
6-28-13 Passport Announcement: Streamline Expands Existing Service in Mexico
Announcement Number: IM2013-368
Categories: Domestic Price,Domestic Mexico,Streamline Door to Door
Posted Date: June 28, 2013
Passport Announcement
Streamline Expands Existing Service in Mexico
Introducing Streamline Passport
Streamline is pleased to announce that effective July 15th Union Pacific's Passport program will expand to a comprehensive intermodal product managed by Streamline, called Streamline Passport. The Streamline Passport program will enhance current Passport service by providing a door-to-door intermodal solution for customers throughout Mexico, backed by the industry's largest intermodal container fleet and Streamline's extensive drayage network.
As part of this enhanced program, Streamline will provide transactional rates instantly via the QuoteLine web tool, as well as annualized rate offers and committed capacity for repetitive Mexico freight. Technology features include access to Streamline's Shipment Management tool, which provides full visibility & tracking capabilities throughout the U.S. and Mexico, daily snapshot capacity maps, and a D2D intermodal savings calculator.
Additionally, the Streamline Passport program offers Streamline's 24/7 customer service available today, with the added security of dedicated staff on-site in Laredo to monitor your shipments. We're here to streamline your Mexico transportation, and invite you to try the enhanced Streamline Passport product today.
Please note that all existing Passport quotes will expire on July 15th, 2013. Existing Passport customers will receive new Streamline quotes from their sales representative and will be contacted to review transition plans.
Want to know more? Contact your UP Intermodal or Streamline Sales representative for additional details, or track us down day or night at shipstreamline.com.
For Pricing Requests visit: www.ShipStreamline.com Email: firstname.lastname@example.com Thank you for making Streamline your 1st choice for door to door intermodal service.


text:
Brown's one of the best - Care
Danny Care believes England team-mate Mike Brown has the ideal platform to demonstrate he is the world's finest full-back during the summer tour to New Zealand.
With Harlequins unlikely to reach the Aviva Premiership final on May 31, Brown is set to lock horns with All Blacks star Israel Dagg over three Tests in June.
"Mike's right up there at the moment. On current form he's one of the best, if not the best, full-backs in the world," Care said.
"Israel Dagg is a wonderful player and I'm sure Mike will be looking forward to testing himself against him in his own backyard."
Brown has been included on a six-strong shortlist for the Premiership player of the year award - the winner is named on May 15 - to continue an outstanding season.
Man-of-the-match performances against Scotland, Ireland and Italy saw him crowned player of the 2014 RBS 6 Nations and Care holds his Harlequins team-mate in high esteem.
"Mike's had a phenomenal season. He'll clean up at our Quins awards and I'd be shocked if he isn't right up there to win this," Care said.
"He's had a brilliant season and I don't think he's had a bad game all year. That's what you need - consistency of performance.
"He's not just done it for Quins - he's done it for England too, as we've seen during the Six Nations.
"Mike has never been shy of confidence and he's a very competitive person who doesn't want to give anyone else a shot at the 15 shirt. That's the way you have to be.
"He's very professional, looks after himself a lot and lets his rugby do the talking."
:: Danny Care was speaking during an O2 Touch session at Old Alleynian RFC in London. To find your nearest session, visit rfu.com/O2Touch.


text:
Dutch Spice Cookies Recipe
5 1
My sister gave me the recipe for these cookies, which have become a holiday tradition at our house. My kids tear into the spicy, crisp cookies right out of the oven. I prefer them cooled - but it's risky waiting. I might not get any!
Recommended: 21 Christmas Cookies from Around the World
VERIFIED BY Taste of Home Test Kitchen
- 3/4 cup butter, softened
- 1 cup packed brown sugar
- 2-1/4 cups all-purpose flour
- 2 teaspoons ground cinnamon
- 1/2 teaspoon ground mace
- 1/2 teaspoon crushed aniseed
- 1/4 teaspoon each ground ginger, nutmeg and cloves
- 1/4 teaspoon baking powder
- 1/8 teaspoon salt
- 3 tablespoons 2% milk
- 1 cup finely chopped slivered almonds
- In a large bowl, cream butter and brown sugar until light and fluffy. Combine the flour, spices, baking powder and salt; gradually add to creamed mixture and mix well. Stir in milk and almonds.
- Roll dough into a 16-in. x 10-in. rectangle between two sheets of waxed paper. Cut into 2-in. squares. Cover with waxed paper and refrigerate for 30 minutes.
- Place squares 1 in. apart on ungreased baking sheets. Bake 375° for 8-10 minutes or until firm. Remove to wire racks to cool. Yield: 40 cookies.
Originally published as Dutch Spice Cookies in Country Woman Christmas Annual 2003, p44
Reviews forDutch Spice Cookies
My Review
Click stars to rate
Any changes to your rating or review will appear where you originally posted your review


text:
" Age: 3 Years+ "
* Prices may differ from that shown
I think the Nick Jr channel people are extremely crafty! This is where my daughter watches most of her shows and during the half break I would bet my bottom dollar that this silly doll pops up at some point. My daughter then makes a point of shouting "mummy I want that one!" whenever it comes on, and as a treat, hey ho dad decided to buy it for her one evening after work. Mummy was not impressed!
The doll is pretty much a replica of a baby (as most dolls are!) but this one makes burping noises, sucking sounds when a bottle is inserted in the mouth, laughing and a deep breathing sound when she sleeps. Honestly, it's like re-winding to 3 years ago and starting all over again lol! I must say the simulation noises are pretty good though, my daughter loves it no end, and it keeps her entertained as she loves role play and thrives on switching into mummy mode and looking after her new baby lol.
The baby doll also has voice recognition, which I tried to do with my daughter but she just doesn't respond! If you speak, the doll is meant to turn her head but we find her just turning randomly! My daughter doesn't notice this too much at 3 years old, she is just happy to have someone to play with (being an only child lol). Baby also cries real tears which makes a good realistic baby doll as let's face it, that's what they do most often! Fortunately the doll is not too loud so shoving her under a blanket, her noise can be blocked out, but of course the easy option is just the off button lol.
Visually, the doll is good quality, with bright blue eyes that open and close, and arms and legs that move about easily. The arms are plastic and a bit rigid, but the torso is squishy, making the doll quite warm and soft to snuggle up to. Zapf know how to get some money out of us parents so Annabel can be customised with buying clothes, pram, bag etc to go with new found motherhood, but on the zapf website these aren't cheap so we are sticking with what she came with thanks!
The doll requires four AA batteries, and to insert them the battery compartment is at the back of the doll. It requires a screwdriver to open it, which I think is good making it child safe and no trouble can arise! It's pretty straightforward to do, and the batteries seem to last reasonably well as we have had this doll over a month or so and she has been playing with it everyday!
Ananabell comes in different varieties such as ethnic, and smaller versions so I really think there is a doll for everyone. I think naughty daddy paid around £40 for this which I think is rather a lot for a doll, but a) I didn't pay for it, b) it has some good special effects and c) it makes my daughter really happy so it's totally worth it. Can't really think of any negatives so gotta give this doll 5 out of 5!
Baby Annabel is one of the most human like dolls you are likely to come accross, with its interactive motions which make it cry, burp and laugh.
I bought one for my daughter for christmas two years ago and it was a great doll to have, until my daughter saw an advert for the new and improved baby Annabel which has more functions and it is just like a little baby. So my daughter put it on last years christmas list, as her old one was a bit grubby from being played with so much and being pushed on the swing in the garden I decided that I would update her doll...or should I say santa did;)
The doll I purchased two years ago made noises like burping, laughing and sucking when the bottle was placed in her mouth, and breathing sounds when she is asleep, but the new model now also cries real tears and turns her head to the sound of your voice. It was on offer at woolworths at the time of purchase and only cost me £17.99, it normally costs £34.99 so I got a real bargain.
The doll arrived in a very well packaged box with clear plastic so you could see the doll inside. She now comes dressed in a fluffy white baby grow and hat (the one shown above was the old baby annabel outfit) you also get a clear balloon shaped bottle and a pink dummy and a pack of tissues.
Once you eventually manage to get the doll out of the box after undoing all the plastic straps and tape, the only other setting up is putting the batteries in but you will also need a phillips screwdriver for that job, it takes four 1.5v batteries and I have to say they do last quite a while.
The doll itself looks quite life like with its curled up fingers and toes, she has blue eyes that open and close and her mouth is open so it makes it easy to put the bottle or dummy into it, her arms, legs and head is a soft plastic but her body is foam so when you pick her up again she moves like a real baby insted of a doll and she can be placed in a sitting position with ease.
Basically the only things she does not do is fill a nappy (which is one thing I am pleased she does not do!!) and you cannot bath her as the functions would not then work.
You can buy lots of accessories for your baby Annabel ie: various clothes, cot, pram, wardrobe, changing mat, shoes, socks, musical bag etc etc. All the products on offer have the baby Annabel logo which is a sheep with a pink body and hair.
I myself have purchased some of the clothes and they vary in price from around £8 and the musical sheep bag was priced at £15 but I cannot comment on other prices as I have not bought them.
The doll is recommended for children aged 3 years and over, but I have to say my daughters first baby Annabel was played with when she was 2 and she never had any problems with it as it does not have any small parts to it.
I would highly recommend this doll to anyone it is a very good quality toy, my daughter has had so much enjoyment out of both old and new baby Annabel's and loves taking her out in a dolls pram to the shops. It is great for role play. I just hope they do not make a new and improved model next year!!
This baby is a work of genius. It's just like a real child, which I guess is a little freaky but my 2 year old niece loves it! I got it for £17.50 half price in Woolworths for christmas, which is great because at full-price it's a little expensive for a doll, some would say. The list of accessories that Zapf offers in the Baby Annabell range is nearly endless and contains about anything you could buy for a real baby! Beds, wardrobes, changing tables, prams, bouncer chair, baby gym, baby carrier, car seats, changing bags and plenty more! Baby Annabell babbles, cried, moved her head to noise, wees and burps after it's been fed. How life-like can you can without actually having a child? My sister initially wanted to get my niece one of these because my sister is expecting and she wanted my niece to get used to having a baby around and although yes, it's just a doll, it's so life-like it's unreal. My niece even holds it correctly!
We have had baby Annabel in out family for 4 years now on overall she has been very good. Baby Annabel arrived on Christmas when my little darling was only 2 years old. Went you are only 2 years old baby Annabel is very exciting but she is also very heavy! She eats batteries I do not find her to bad on batteries to be honest.
When our new baby Annabel arrived, my daughter was very excited, we got her out the box, which was the most difficult thing we have even done with her! She was strapped in tight with loads of wires that needed undoing. Once the batteries had been put in, she began to cry. My daughter lovingly stoked her head, which did not work so we gave her a bottle of milk. When to tip the bottle up the milk vanishes. Baby Annabel's mouth moves as she sucks on her bottle, which had my daughter fascinated. This also happens if you give baby Annabel her dummy.
We packed baby Annabel up and headed off to my mums. Baby Annabel sat on my daughters lap in the car and she kept her with her all day. Baby Annabel cries quite regularly but this can be soothed by giving her a dummy or bottle. After her bottle baby, Annabel will let out a rather large burp! Which my daughter found very funny for a long time. Baby Annabel makes loads of different noises including crying, burping, cooing etc.
Going back 4 years to when we bought her, she was new out and hard to get hold of at Christmas time. She was also very expensive at £35.00. The clothes and accessories are also very expensive but we have overcome this by buying in the sale as well and buying cheaper brands and even pre baby clothes off e bay.
Baby Annabel is like I said very heavy for a young child and she has caused and had a few accidents over the years. Firstly, her weight causes her to move suddenly in unexpected directions so baby Annabel split my daughter lip one day when she unexpectly changed direction!
Baby Annabel really dislikes the bath but one day my daughter who did not know this dropped her in the bathtub full of water. I removed the batteries and put her in the airing cupboard for a week and luckily she recovered. Please do not bath her she do not like it!
Baby Annabel has been a popular toy for my daughter for 4 years. She is still as popular now as when we first got her. I would recommend getting baby Annabel for children. There is so much extra stuff you can get and the potential for role-play and imagination is massive!
One of my daughters favourite toys. Baby Annabell what fantastic creations much better than the hard plastic dollys that we had when I was younger. We brought my daughter her first baby Annabell when she was 1.5 and her second when she was 2.5 years old. Now aged 3 she loves them both. The newer addition cries, sucks her dummy and drinks her bottle. Comes complete with an off switch for when the parents want peace and quiet. My daughter loves pretending to be her mummy and talking to her. Hours of fun for many more years to come. Be warned that the accessories can be very expensive and are not really needed, you can buy alternatives such as clothes and baby beds, buggys for a much cheaper price. Every year they seem to bring a new vesion out but buy the older version (normally on sale when new one comes out) and you can save pounds.
My 5 year old daughter kept nagging at me to get her one of the baby annabel dolls that moves its head to your voice.
After much thought of whether it would be worth spending £30 on a doll that she might not play with much I decided to buy it for her for christmas last year.
This doll cries, breathes, drinks and turns it head to your voice, she absoloutly loved it and played with it for hours, all i could hear was crying and my daughter talking to it, pushing it, feeding it, ect ect.
It is well worth the money for what the doll does and you can get so many assesories although some are expensive for it which is endless amount of playing time, the only thing I found is once the batteries have died the doll got put away and never played with, so spare batteries are reccomended.
all in all this is a great doll for any little girl... but as a mum I found it rather creapy when it turns it head to the direction of your voice it reminded me of the child's play film...scarey.
I am 13 years old and have a Baby Annabell of my own despite probably being too old for it. I fell in love with her straight away and called her Megan. I change her every day and she goes everywhere with me. She is very easy to keep clean too. Though I wish I could meet a B/A doll mummy more my age to talk to!
This is another of my daughters Dolls which she plays with a lot along with her baby newborns (See my other review on these).
Baby Annabell is made by Zapf creations which seem to be the best when it comes to making good quality dolls for your children. This doll is more lifelike than many of the dolls on today's market. She will react like a baby does she will babble, laugh, cry, sucks her dummy with sucking sounds. Baby Annabell reacts to movement and sounds, if you make her jump with loud noises she will cry. If your gentle she will go off to sleep, sing quietly to her seems to work. My daughter seems to care more for this doll and acts more gentle around her because of the way the doll will react. GOOD NEWS FOR PARENTS you can turn it off at the back because sometimes it can drive you crazy when left on. This doll requires 4 x AA batteries. She is 46cm long and is very cute.
This doll is one of my favourites because it really does teach children how to be responsible and gentle with things. I love watching my daughter play with this doll as it really does bring out imagination.
This doll is suitable for children aged 3 years plus, my daughter is now 8 and still plays with her dolls.
I brought this doll from Argos, the doll came boxed and included dummy, rattle and bottle and was fully dressed. This doll also came with batteries, this is not always the case so check this out when buying. The doll cost me about £29.99 at the time of buying a year ago.
Baby Annabell has a wide selection of items which you can purchase for her, don't expect them to be cheap, try and hunt out car boots which i have done for some bargains.
products include:
A mountain of Clothes
Bed (Musical)
Changing mat/Bag
Baby station for changing
Sling to carry in.
On the market at the moment is also my first baby Annabel which is suitable from 12 months. Also you can buy the Ethnic version of Baby Annabel.
This is a Quote from one of my other reviews which i feel is very important.
'''''This doll helps you teach a child how to be caring and loving and how to respect and treat babies but always make sure their aware that dolls and babies are totally different. As some children have been known to treat a baby as a doll and hurt it in the process its up to us as parents to install this information in our children. I do this by always referring to a a doll as a doll and a baby as a baby, if you get what i mean. Try not to say are you looking after the baby today? Say doll instead. ( i work in a nursery and we encourage this method, in the learning process). ''''''''
Review also on Ciao
My daughter was seven and she hassled and hassled me to get her one. I tried to put her of as i thought she may be a little to old for it, in the end i gave up to the "all my friends have got one" and bought her one. She opened it up on christmas day and by the end of the day i wanted to take the batteries out but she loved it. It wets in its nappy, makes a sucking noise when your feeding it, it laughs cries and even snores when its asleep. The funniest thing i found was when the doll is asleep if you make to much noise she wakes up and cries till you give give her the dummy. I can't remember a doll like this on the market when i was a child :-).
Two months after buying it the doll was forgot about but i put it down to being seven nearly eight just a little to old for a baby anabell. I would advise people to buy it for maybe a younger child although its annoying to the parents it is great fun for little girls.
From the moment on that our daughter Anna,5, first saw an advert for Zapf's Baby Annabel she kept on begging to have one. As christmas came closer her only worry seemed to be that Santa might not know that "all she ever wanted" was Baby Annabel.
So my husband and me decided to have a word with the man himself and a few days before Christmas we were able to collect the newest addition to our household - from the local Argos store.
Now, we do not have one daughter, but two, and as Melis (3 1/2) always wants the same as her older sister, we didn't go to pick up one baby, but two.
The delivery was swift and easy. We gave our order numbers to the counter, paid £34.99 ( per doll) and a considerably higher sum for some of Annabel's acccesories, waited in the pre-christmas queue for about half an hour - and voila: we were the proud parents off a brand-new set of twins - and packed with carrier bags. Totally painfree !
What the twins look like :
When we unpacked the dolls to get them ready for the big day even my husband had to admit that they are extremely sweet and do look quite real.
Baby Annabel has the sweetest and most natural baby face I have seen on a doll lately. She has beautiful blue baby eyes, surrounded by long dark eyelashes, has a little button nose and a tiny, slightly open mouth, which moves when she drinks her bottle and sucks on her dummy. She is soft bodied and her arms,legs and head are plastic.She is wearing a white and pink baby-gro that bears the Baby Annabel sheep emblem and wears a little head.
The first feed:
After removing all the carton pieces we had to feed the babies in order to get them work.
First with 4 AA batteries per doll, the battery compartement is at the back of the doll hidden under a cover that is made out of the same material as the dolls body. You'll need a small cross-head screwdriver to open it, so that the little ones can't get their hands on the batteries.
Then with water out of the supplied sheep-bottle. Baby Annabell needs to drink about 1/4 of the bottle to make the tear function work. While she drinks her mouth moves as if she is really sucking, she makes little sucking noises and her eyes start to open and shut. If she is totally full water starts to run out of her mouth.
As soon as we took the bottles out of our babies mouths they started to cry. We then had to rub the babies tummies and they let out a loud and clear burb. The babies fell asleep right after this and would have most probably continued snoring ( she really does make a snoring sound when she sleeps) if we wouldn't have laughed to loud.
Especially my husband found that burb so hilarious that he couldn't stop laughing and we now found out that Baby Annabel doesn't like to be disturbed in her beauty sleep.
Both dolls started to cry and it took us quite a while to calm them down. Thankfully they come with a dummy as we felt quite foolish to use the other option the manufacturer suggests to calm Baby Annabell down : to sing a song...
Anyway, if you don't play with the doll for more then 60 seconds it shuts itself.
Babies cost a lot of money:
After we finished wrapping the babies in christmas-paper we started to work on the accessories. Everyone of you who's had a child will surely agree that small babies need a lot of stuff.
And Baby Annabel is a very demanding baby...
The list of accessories that Zapf offers in the Baby Annabel range is nearly endless and contains about anything you could buy for a real baby too.
There are beds, a wardrobe, a changing table, pram, a comfort seat, a baby-gym, a baby-carrier, a car-seat, a changing bag, a sleeping bag, lots of different sets of outfits, shoes, nappies,...
What all of them have in comon is the sheep emblem - if it doesn't have it, it doesn't belong to Annabel - and that they are all very, very expensive.
Each outfit costs between £14.99 and £19.99 . It dresses the doll from head to toe, but I still think that this is quite a rip off. Our kids are too small to care about the logo on the clothes, as long as they come in pink that is. Baby Annabel measures a proud 46 cm so we decided to go for a cheaper option. I went shopping for real baby clothes in the early-baby size and bought some really nice baby-gros, socks, pram shoes and even a dress. They fit perfectly and the twins don't seem to mind either.
I couldn't resist to buy the sleeping bag, though. It is pink, has a big heart in the middle, a long front zip which allows the girls to pack their babies in easily and an absolutely cute attached cap with sheep ears. And the ever present sheep logo, of course...
It cost me £14.99 and I didn't tell my husband, as this would have certainly deminished his feelings for our twins - so please don't tell him, too !
As it always is, when there is a new arrival in the family : The grandparents want to help out. What would we do without them...
Our kids got a pram each for their Annabels from my parents. They cost around £40 (EACH !) and you can find them in about every shop that does the Baby Annabel range.The handle height is 76 cm, so if you buy it for a very small girl it might be a bit high.It is pink - what else- and has a shopping net underneath, so that the little mummy can take all of Annabel's accesories on her trip.
From my husbands family they got the metall canopy beds. They are pink again, come with matresses, curtains, pillow and a duvet with the obligatory sheep on it. The bed costs around £30.
Further accessories weren't on the list, as we wanted to give the girls some non-Annabell-related presents too. And there is always another Christmas...
Zapf delivers you a brochure in the carton which makes sure, that your children are very well informed what is on offer. Not only for Annabel, but also for the other Zapf ranges like Baby Born.
There is also an offer for your kids to join the Baby Annabel Club, which would provide them with regular newsletters and magazines about what is new on the market for Baby Annabel. Mercifully that offer applies only to the German market, where the company comes from. I was quite shoked to read that they ask small children a fee of 12.90 to join this club. As much as I like the doll, I am starting to hate the company who makes it ! And wouldn't mind if the club stayed where it is now and doesn't consider to cross the channel to recruit some new members.
The big day :
Needless to say that our girls were over them moon when they unpacked their presents. Santa was clever enough to put the other presents in front of the dolls and whatever came with them, so they had to work their way through to reach them. Otherwise they might have just forgotten to open them.
The kids played only with them for the rest of the day and ignored whatever else they got. We changed them a hundred times and even our little one manages to change her dolly all alone by now. They love it to feed the dolls and see "real" tears running out of their eyes.
Even my husband joined in, although I am slightly suspicious that he only does it because he wants to hear the burb that follows. He really has a thing going for it. Men can be strange creatures...
So we had lots and lots of tears on christmas and the packet of tissues that came with the dolls didn't even last for half an hour.
So where can you get a Baby Annabel :
I know for sure that you can get them from Argos, Toys'r'Us and Woolworth. As they are very popular I suppose you'll be able to get them from nearly every shop that sells toys
How much do they cost:
I've got ours for £34.99 from Argos, prices may vary from shop to shop and if you are lucky, you might find a cheaper option.
Are there any variations to choose:
Yes. Baby Annabell is also availlable as an ethnic doll. Then there is the First Baby Annabell. This is a smaller version, that costs around £15. First Annabell has the same outfit as its 'big sister' but doesn't have any functions.
What comes with the doll:
One outfit, a dummy with a dummy ribbon and clip (sheep-shaped - what else) a sheep bottle with an integrated heart shaped rattle to feed Annabel and a very small packet of sheep tissues.
Annabells Birth size :
46 cm
How to keep Baby Annabell clean :
Out of the manufacturers handbook:
Romper suit : wash by hand
Little sheep bottle: use damp cloth
Dummy with dummy
ribbon and clip : use damp cloth
Sheep tissues: can't be cleaned ( well, who would
have thought that...???)
Manufacturers web site
Don't forget:
To avoid long faces insert the batteries - 4 AA's - before handing over and to feed the baby it's first dossage of water - otherwise it will not work straight away.
Do make sure that the little mummy understands that she should never put anything else then water in her bottle. No matter how much she likes blackcurrant juice herself - one sip just might be lethal for Baby Annabel.
Educational use:
Kids learn to understand babies behaviour and it might be a great toy to prepare them for a real new arrival.
They also learn how to put clothes on and it does encourage role-play.
Our verdict :
We just love "our twins" and think they are a great toy for little girls between 3 and 8 years. We had our little nephew around who is 4 years old and he liked to play with them, too
Don't leave it around if your partner had a drink too much. Otherwise you might just find that usually ,oh so male, subject of your never-ending love with blurry eyes, cradling a doll and babbling about how nice it might be to have another real little one around....
My daughter wanted a baby Annabel for Christmas, which of course Father Christmas managed to fit it on his sledge and deliver it on Christmas day. It claims on the box to cry, burp, snore, and suck it's bottle. I must admit the first time I held her it was just like a holding a real baby as the sucking noises that she makes is very realistic and the snoring is more like heavy breathing. It does do everything it claims which makes a nice change. The doll is made from a soft fabric which makes it lovely to cuddle. It comes complete with a white babygrow and hat, a feeding bottle with actual fake milk inside and a little lamb rattle. When you shake the rattle above her chest she giggles and if you sing to her softly she will fall asleep, but beware make a noise and she will start crying again and you will have to start all over again. It wears a proper baby's nappy and all in all is very realistic. I would say probably one of the best baby dolls around at this time. Here's the best bit though on the back of Annabel there is an on/off button. She runs on AA batteries (3 of them) and they still haven't run out yet-not bad considering that she has been in constant use since Christmas.
Crying, burping, fully interactive doll.