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Publication number | US6714819 B1 |
Publication type | Grant |
Application number | US 09/524,462 |
Publication date | Mar 30, 2004 |
Filing date | Mar 13, 2000 |
Priority date | Mar 13, 2000 |
Fee status | Lapsed |
Also published as | DE60110962D1, DE60110962T2, EP1136098A2, EP1136098A3, EP1136098B1, US7181280 |
Publication number | 09524462, 524462, US 6714819 B1, US 6714819B1, US-B1-6714819, US6714819 B1, US6714819B1 |
Inventors | Laurence S. Sloman |
Original Assignee | Pacesetter, Inc. |
Export Citation | BiBTeX, EndNote, RefMan |
Patent Citations (22), Referenced by (18), Classifications (4), Legal Events (7) | |
External Links: USPTO, USPTO Assignment, Espacenet | |
The present invention relates in general to cardiac stimulation devices, such as pacemakers, defibrillators, cardioverters, implantable cardioverter-defibrillators ("ICDs"), and similar cardiac stimulation devices that are capable of monitoring and detecting electrical activities and events within the heart. In particular, this invention pertains to a system and method for automatically adjusting the energy of the stimulation pulse so as to automatically set the threshold safety margin based on a series of threshold tests for optimal energy expenditure.
Implantable pacemakers generate electrical stimulation pulses and deliver such stimulation pulses to atrial and/or ventricular muscle tissue of a patient's heart at a prescribed rate and/or rhythm when, through disease or other causes, the heart is not able to maintain the prescribed heart rate or rhythm on its own. When the delivered electrical stimuli are of sufficient energy, they cause the cardiac muscle tissue to depolarize, and therefore contract, thereby forcing the heart rate or rhythm to track the delivery of the electrical stimuli. When the delivered electrical stimuli are of insufficient energy, depolarization does not occur, and the heart rate or rhythm is not controlled by the pacemaker. Hence, for the pacemaker to perform its intended function, it is critically important that the delivered electrical stimuli be of sufficient energy to depolarize the cardiac tissue, a condition known as "capture".
The energy of the electrical stimuli generated by an implanted pacemaker is derived from the energy stored in the pacemaker power source or battery. The pacemaker battery has a limited amount of energy stored therein, and the generation of electrical stimuli represents by far the greatest drain of such energy. In order to preserve this limited energy and to prolong the life of the battery, it is known in the art to adjust the energy of the delivered electrical stimuli so that it is just sufficient to cause capture, with an appropriate safety margin.
Capture detection may occur on a beat-by-beat basis or on a sampled basis. In one embodiment, a capture threshold search is performed once a day during at least the acute phase (e.g. the first 30 days) and less frequently thereafter. A capture threshold search would begin at a desired starting point (either a high energy level or the level at which capture is currently occurring) and decrease the energy level until capture is lost. The value at which capture is lost is known as the capture threshold. Thereafter, a safety margin is added to the capture threshold. For a more detailed description of capture and the implementation of capture detection circuitry and algorithms refer, for example, to U.S. Pat. No. 4,729,376 (Decote, Jr.); U.S. Pat. No. 4,708,142 (Decote, Jr.); U.S. Pat. No. 4,686,988 (Sholder); U.S. Pat. No. 4,969,467 (Callaghan et. al); and U.S. Pat. No. 5,350,410 (Kleks et. al), all of which patents are hereby incorporated herein by reference.
The amount of energy needed to effectuate capture is known as the capture "threshold", and electrical stimuli of energy less than the capture threshold do not bring about capture, while electrical stimuli of energy greater than the capture threshold do bring about capture. By adjusting the energy of the electrical stimuli so that it is always greater than the capture threshold, but not too much greater, the limited energy of the pacemaker battery may thus be preserved. The battery energy is preserved because: (1) electrical stimuli of insufficient energy to cause capture (electrical stimuli below threshold), which stimuli represent wasted energy, are rarely generated; and (2) electrical stimuli of excessive energy (energy much greater than the capture threshold), which excess energy not only represents wasted energy, but also energy that may disadvantageously cause pectoral stimulation and/or sensation, are also rarely generated.
In general, capture verification has been regarded as a process that must be carried out continually, and conventional methods teach that capture must be verified with each and every stimulus so that a servomechanism within the pacemaker can provide a backup pulse in the event that a first pulse fails to provide capture and so that the energy of the next stimulation pulse can be adjusted upward. Reference is made to U.S. Pat. Nos. 4,969,467; 4,969,462; and 4,955,376.
However, capture verification requires a significant amount of processing time and corresponding battery current to be expended. An important aspect of conventional capture verification is setting the safety margin (also referred to as safety factor) is normally set to a fixed value. The safety margin value is determined largely by limitations in the hardware platforms that allow programmed amplitude steps of, for example, 0.125 Volt.
In ventricular auto capture systems, the safety margin has proven to be adequate since beat-by-beat capture verification is provided by the pacemaker. If a threshold increase occurs, the pacemaker responds by increasing the output amplitude, and re-finding the capture threshold, where the safety margin is applied. This method reduces the energy consumption by adding the lowest possible safety margin the pacemaker allows. Reference is made to U.S. Pat. No. 5,766,229 to Bornzin, which is incorporated herein by reference.
However, beat by beat capture verification may not be provided in atrial automatic threshold determination, resulting in a need for higher safety margins. Also, threshold variability has been demonstrated to be greater sometimes due for example to circadian variations, sinus rate variability and other factors that are present in the atrium but not necessarily in the ventricle. The problem that remains heretofore unresolved is to choose the safety margin that guarantees capture and at the same time provides adequate energy savings in an atrial and ventricular automatic threshold testing device.
In addition, conventional pulse energy is set based on the result of a single threshold test and a certain fixed safety margin. As a result, threshold testing must be repeated often to adjust the safety margin. This conventional approach may result in "under-sampling", which can lead to erroneous conclusions and an unstable pacing system. Under-sampling the threshold in turn requires frequent threshold tests, causing additional inefficiencies of the pacing system.
In view of the above, it is evident that there is still an unsatisfied need for an automatic threshold testing method that automatically adjusts the atrial and ventricular threshold safety margins and that minimizes the expenditure of battery current.
The present invention addresses the above and other needs by providing an implantable pacemaker wherein an automatic threshold testing is performed to generate a statistical model. The statistical analysis of a series of threshold tests is then used to adjust the safety margin based on statistically determined threshold and safety margin such that the possibility of a loss of capture episode is minimized.
The threshold testing in accordance with the present invention occurs when a defined trigger event initiates a testing algorithm. Such testing, because it is performed on a limited sampled basis, advantageously limits the time and power needed by the electronic circuitry (typically a microprocessor) to perform the tests, thereby conserving power and freeing up the circuitry for other processes.
Thus, in accordance with one aspect of the invention, the expenditure of battery current in the pacemaker is minimized because threshold tests are performed only on a limited sampled basis, and not with every capture verification test as is traditionally practiced in the art. Periodic threshold tests can therefore be performed less often.
A further aspect of the invention provides for adjustment of the pulse energy based on the statistical analysis of a minimal sample size of threshold tests. A pulse energy based on such a statistical analysis will provide greater confidence that the stimulation pulse energy is equal to or greater than the threshold, thereby minimizing the possibility of a loss of capture event. It is thus seen that the present invention reduces the required frequency of capture verification since greater confidence of capture exists.
In addition, the present invention addresses the problem of potential risk of non-capture by setting the stimulating pulse energy to a value that improves the confidence that capture will occur with every stimulation pulse, thus justifying the use of less frequent capture verification.
The present invention addresses the problem of under-sampling that results from the determination of the pulse energy based on a single threshold test, that requires frequent or over-sampling of capture verification by determining the pulse energy from a series of threshold tests over time, and by setting the threshold and safety margin to levels that minimize the chance that capture will be lost.
The threshold testing algorithm of the present invention includes: setting a specified number of threshold tests that will occur over a specified period of time; performing the threshold tests at the specified points in time and storing the threshold test result; calculating descriptive statistical data for the stored threshold test result; and adjusting the stimulating pulse energy based on the variability of the threshold test results.
It is still a further feature of the invention to provide an implantable pacemaker wherein once the desired number of threshold tests have been performed the stimulation pulse energy is set to value that is the lowest possible value, based on the statistical analysis of the threshold tests, that predicts, with a desired degree of confidence, that capture will occur with every stimulation pulse.
The above and further features, advantages and benefits of the present invention will be apparent upon consideration of the present description taken in conjunction with the accompanying drawings, in which:
FIG. 1 is a simplified, partly cutaway view illustrating an implantable stimulation device in electrical communication with at least three leads implanted into a patient's heart for delivering multi-chamber stimulation and shock therapy;
FIG. 2 is a functional block diagram of the multi-chamber implantable stimulation device of FIG. 1, illustrating the basic elements that provide cardioversion, defibrillation and/or pacing stimulation in four chambers of the heart;
FIG. 3 is a flow chart illustrating an overview of the operation and features implemented in one embodiment of the stimulation device of FIGS. 1 and 2;
FIG. 4 is a chart that graphically illustrates the operation shown in FIG. 3 over a short period of time;
FIG. 5 is a chart that graphically illustrates the operation shown in FIG. 3 over an extended period of time;
FIG. 6 is an exemplary histogram that illustrates the process of selecting a threshold level according to the present invention;
FIG. 7 is a flow diagram that illustrates another mode of operation of the stimulation device of FIGS. 1 and 2; and
FIG. 8 is an illustration that depicts various modes of triggering the operation of the stimulation device.
The following description is of a best mode presently contemplated for practicing the invention. This description is not to be taken in a limiting sense but is made merely for the purpose of describing the general principles of the invention. The scope of the invention should be ascertained with reference to the issued claims. In the description of the invention that follows, like numerals or reference designators will be used to refer to like parts or elements throughout.
FIG. 1 illustrates a stimulation device 10 in electrical communication with a patient's heart 12 by way of three leads 20, 24 and 30 suitable for delivering multi-chamber stimulation and shock therapy. To sense atrial cardiac signals and to provide right atrial chamber stimulation therapy, the stimulation device 10 is coupled to an implantable right atrial lead 20 having at least an atrial tip electrode 22, which typically is implanted in the patient's right atrial appendage.
To sense left atrial and ventricular cardiac signals and to provide left-chamber pacing therapy, the stimulation device 10 is coupled to a "coronary sinus" lead 24 designed for placement in the "coronary sinus region" via the coronary sinus os so as to place a distal electrode adjacent to the left ventricle and additional electrode(s) adjacent to the left atrium. As used herein, the phrase "coronary sinus region" refers to the vasculature of the left ventricle, including any portion of the coronary sinus, great cardiac vein, left marginal vein, left posterior ventricular vein, middle cardiac vein, and/or small cardiac vein or any other cardiac vein accessible by the coronary sinus.
Accordingly, the coronary sinus lead 24 is designed to receive atrial and ventricular cardiac signals and to deliver: left ventricular pacing therapy using at least a left ventricular tip electrode 26, left atrial pacing therapy using at least a left atrial ring electrode 27, and shocking therapy using at least a left atrial coil electrode 28. For a complete description of a coronary sinus lead, refer to U.S. patent application Ser. No. 09/457,277, filed Dec. 8, 1998, titled "A Self-Anchoring, Steerable Coronary Sinus Lead" (Pianca et. al); and U.S. Pat. No. 5,466,254, titled "Coronary Sinus Lead with Atrial Sensing Capability" (Helland), which patent application and patent are hereby incorporated herein by reference.
The stimulation device 10 is also shown in electrical communication with the patient's heart 12 by way of an implantable right ventricular lead 30 having, in this embodiment, a right ventricular tip electrode 32, a right ventricular ring electrode 34, a right ventricular (RV) coil electrode 36, and an SVC coil electrode 38. Typically, the right ventricular lead 30 is transvenously inserted into the heart 12 so as to place the right ventricular tip electrode 32 in the right ventricular apex so that the RV coil electrode 36 will be positioned in the right ventricle and the SVC coil electrode 38 will be positioned in the superior vena cava. Accordingly, the right ventricular lead 30 is capable of receiving cardiac signals, and delivering stimulation in the form of pacing and shock therapy to the right ventricle.
FIG. 2 illustrates a simplified block diagram of the multi-chamber implantable stimulation device 10, which is capable of treating both fast and slow arrhythmias with stimulation therapy, including cardioversion, defibrillation, and pacing stimulation. While a particular multi-chamber device is shown, this is for illustration purposes only, and one of skill in the art could readily duplicate, eliminate or disable the appropriate circuitry in any desired combination to provide a device capable of treating the appropriate chamber(s) with cardioversion, defibrillation and/or pacing stimulation.
The stimulation device 10 includes a housing 40 which is often referred to as "can", "case" or "case electrode", and which may be programmably selected to act as the return electrode for all "unipolar" modes. The housing 40 may further be used as a return electrode alone or in combination with one or more of the coil electrodes 28, 36, or 38, for shocking purposes. The housing 40 further includes a connector (not shown) having a plurality of terminals, 42, 44, 46, 48, 52, 54, 56 and 58 (shown schematically and, for convenience, the names of the electrodes to which they are connected are shown next to the terminals). As such, to achieve right atrial sensing and pacing, the connector includes at least a right atrial tip terminal 42 adapted for connection to the atrial (AR) tip electrode 22.
To achieve left chamber sensing, pacing and/or shocking, the connector includes at least a left ventricular (VL) tip terminal 44, a left atrial (AL) ring terminal 46, and a left atrial (AL) shocking terminal (coil) 48, which are adapted for connection to the left ventricular tip electrode 26, the left atrial tip electrode 27, and the left atrial coil electrode 28, respectively.
To support right chamber sensing, pacing and/or shocking, the connector further includes a right ventricular (VR) tip terminal 52, a right ventricular (VR) ring terminal 54, a right ventricular (RV) shocking terminal (coil) 56, and an SVC shocking terminal (coil) 58, which are adapted for connection to the right ventricular tip electrode 32, right ventricular ring electrode 34, the RV coil electrode 36, and the SVC coil electrode 38, respectively.
At the core of the stimulation device 10 is a programmable microcontroller 60 that controls the various modes of stimulation therapy. As is well known in the art, the microcontroller 60 typically includes a microprocessor, or equivalent control circuitry, designed specifically for controlling the delivery of stimulation therapy, and may further include RAM or ROM memory, logic and timing circuitry, state machine circuitry, and I/O circuitry. Typically, the microcontroller 60 includes the ability to process or monitor input signals (data) as controlled by a program code stored in a designated block of memory. The details of the design and operation of the microcontroller 60 are not critical to the present invention. Rather, any suitable microcontroller 60 may be used that carries out the functions described herein. The use of microprocessor-based control circuits for performing timing and data analysis functions are well known in the art.
Representative types of control circuitry that may be used with the present invention include the microprocessor-based control system of U.S. Pat. No. 4,940,052 (Mann et. al), and the state-machine of U.S. Pat. No. 4,712,555 (Sholder) and U.S. Pat. No. 4,944,298 (Sholder). For a more detailed description of the various timing intervals used within the stimulation device and their inter-relationship, refer to U.S. Pat. No. 4,788,980 (Mann et. al). The '052, '555; '298; and '980 patents are incorporated herein by reference.
As shown in FIG. 2, an atrial pulse generator 70 and a ventricular pulse generator 72 generate pacing stimulation pulses for delivery by the right atrial lead 20, the right ventricular lead 30, and/or the coronary sinus lead 24 via a switch bank 74. It is understood that in order to provide stimulation therapy in each of the four chambers of the heart, the atrial pulse generator 70 and the ventricular pulse generator 72 may include dedicated, independent pulse generators, multiplexed pulse generators, or shared pulse generators. The atrial pulse generator 70 and the ventricular pulse generator 72 are controlled by the microcontroller 60 via appropriate control signals 76 and 78, respectively, to trigger or inhibit the stimulation pulses.
The microcontroller 60 further includes timing control circuitry 79 which is used to control the timing of such 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, PVARP intervals, noise detection windows, evoked response windows, alert intervals, marker channel timing, etc.
The switch bank 74 includes a plurality of switches for connecting the desired electrodes to the appropriate I/O circuits, thereby providing complete electrode programmability. Accordingly, the switch bank 74, in response to a control signal 80 from the microcontroller 60, determines the polarity of the stimulation pulses (e.g. unipolar, bipolar, combipolar, etc.) by selectively closing the appropriate combination of switches (not shown) as is known in the art.
Atrial sensing circuits 82 and ventricular sensing circuits 84 may also be selectively coupled to the right atrial lead 20, coronary sinus lead 24, and the right ventricular lead 30, through the switch bank 74, for detecting the presence of cardiac activity in each of the four chambers of the heart. Accordingly, the atrial and ventricular sensing circuits 82 and 84 may include dedicated sense amplifiers, multiplexed amplifiers, or shared amplifiers. The switch bank 74 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.
Each of the atrial sensing circuit 82 or the ventricular sensing circuit 84 preferably employs 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 stimulation device 10 to deal effectively with the difficult problem of sensing the low amplitude signal characteristics of atrial or ventricular fibrillation.
For a more complete description of a typical sensing circuit, refer to U.S. Pat. No. 5,573,550, titled "Implantable Stimulation Device having a Low Noise, Low Power, Precision Amplifier for Amplifying Cardiac Signals" (Zadeh et. al). For a more complete description of an automatic gain control system, refer to U.S. Pat. No. 5,685,315, titled "Cardiac Arrhythmia Detection System for an Implantable Stimulation Device" (McClure et. al). The '550 and '315 patents are hereby incorporated herein by reference.
The outputs of the atrial and ventricular sensing circuits 82 and 84 are connected to the microcontroller 60 for triggering or inhibiting the atrial and ventricular pulse generators 70 and 72, respectively, in a demand fashion, in response to the absence or presence of cardiac activity, respectively, in the appropriate chambers of the heart. The atrial and ventricular sensing circuits 82 and 84, in turn, receive control signals over signal lines 86 and 88 from the microcontroller 60, for 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 atrial and ventricular sensing circuits 82 and 84.
For arrhythmia detection, the stimulation device 10 utilizes the atrial and ventricular sensing circuits 82 and 84 to sense cardiac signals, for determining whether a rhythm is physiologic or pathologic. As used herein "sensing" is reserved for the noting of an electrical signal, and "detection" is the processing of these sensed signals and noting the presence of an arrhythmia. The timing intervals between sensed events (e.g. P-waves, R-waves, and depolarization signals associated with fibrillation which are sometimes referred to as "F-waves" or "Fib-waves") are then classified by the microcontroller 60 by comparing them to a predefined rate zone limit (e.g. bradycardia, normal, low rate VT, high rate VT, and fibrillation rate zones) and various other characteristics (e.g. sudden onset, stability, physiologic sensors, and morphology, etc.) in order to determine the type of remedial therapy that is needed (e.g. bradycardia pacing, anti-tachycardia pacing, cardioversion shocks or defibrillation shocks, collectively referred to as "tiered therapy").
Cardiac signals are also applied to the inputs of an analog-to-digital (A/D) data acquisition system 90. The data acquisition system 90 is configured to acquire intracardiac electrogram signals, convert the raw analog data into digital signals, and store the digital signals for later processing and/or telemetric transmission to an external device 102. The data acquisition system 90 is coupled to the right atrial lead 20, the coronary sinus lead 24, and the right ventricular lead 30 through the switch bank 74 to sample cardiac signals across any pair of desired electrodes.
Advantageously, the data acquisition system 90 may be coupled to the microcontroller 60 or another detection circuitry, for detecting an evoked response from the heart 12 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 60 detects a depolarization signal during a window following a stimulation pulse, the presence of which indicates that capture has occurred. The microcontroller 60 enables capture detection by triggering the ventricular pulse generator 72 to generate a stimulation pulse, starting a capture detection window using the timing circuitry within the microcontroller 60, and enabling the data acquisition system 90 via control signal 92 to sample the cardiac signal that falls in the capture detection window and, based on the amplitude of the sampled cardiac signal, determines if capture has occurred.
The microcontroller 60 is further coupled to a memory 94 by a suitable data/address bus 96, wherein the programmable operating parameters used by the microcontroller 60 are stored and modified, as required, in order to customize the operation of the stimulation device 10 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 12 within each respective tier of therapy. A feature of the stimulation device 10 is the ability to sense and store a relatively large amount of data (e.g. from the data acquisition system 90), which data may then be used for subsequent analysis to guide the programming of the stimulation device 10.
Advantageously, the operating parameters of the stimulation device 10 may be non-invasively programmed into the memory 94 through a telemetry circuit 100 in telemetric communication with the external device 102, such as a programmer, transtelephonic transceiver, or a diagnostic system analyzer. The telemetry circuit 100 is activated by the microcontroller 60 by a control signal 106. The telemetry circuit 100 advantageously allows intracardiac electrograms and status information relating to the operation of the stimulation device 10 (as contained in the microcontroller 60 or memory 94) to be sent to the external device 102 through the established communication link 104. For examples of such devices, refer to U.S. Pat. No. 4,809,697, titled "Interactive Programming and Diagnostic System for use with Implantable Pacemaker", (Causey, III et al.); U.S. Pat. No. 4,944,299, titled "High Speed Digital Telemetry System for Implantable Device" (Silvian); and U.S. patent application Ser. No. 09/223,422, filed Dec. 30, 1998, titled "Efficient Generation of Sensing Signals in an Implantable Medical Device such as a Pacemaker or ICD" (McClure et al.), all of which are hereby incorporated herein by reference.
In a preferred embodiment, the stimulation device 10 further includes a physiologic sensor 108, commonly referred to as a "rate-responsive" sensor because it is typically used to adjust pacing stimulation rate according to the exercise state of the patient. However, the physiological sensor 108 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). Accordingly, the microcontroller 60 responds by adjusting the various pacing parameters (such as rate, AV Delay, V-V Delay, etc.) at which the atrial and ventricular pulse generators 70 and 72 generate stimulation pulses.
While the physiologic sensor 108 is shown as being included within the stimulation device 10, it is to be understood that the physiologic sensor 108 may alternatively be external to the stimulation device 10, yet still be implanted within, or carried by the patient. A common type of rate responsive sensor is an activity sensor, such as an accelerometer or a piezoelectric crystal, which is mounted within the housing 40 of the stimulation device 10. Other types of physiologic sensors are also known, for example, sensors which sense the oxygen content of blood, respiration rate and/or minute ventilation, pH of blood, ventricular gradient, etc. However, any sensor may be used which is capable of sensing a physiological parameter which corresponds to the exercise state of the patient.
The stimulation device 10 additionally includes a power source such as a battery 110 that provides operating power to all the circuits shown in FIG. 2. For the stimulation device 10, which employs shocking therapy, the battery 110 must be capable of operating at low current drains for long periods of time, and also be capable of providing high-current pulses (for capacitor charging) when the patient requires a shock pulse. The battery 110 must preferably have a predictable discharge characteristic so that elective replacement time can be detected. Accordingly, the stimulation device 10 can employ lithium/silver vanadium oxide batteries.
The stimulation device 10 further includes a magnet detection circuitry (not shown), coupled to the microcontroller 60. The purpose of the magnet detection circuitry is to detect when a magnet is placed over the stimulation device 10, which magnet may be used by a clinician to perform various test functions of the stimulation device 10 and/or to signal the microcontroller 60 that an external programmer 102 is in place to receive or transmit data to the microcontroller 60 through the telemetry circuit 100.
As further shown in FIG. 2, the stimulation device 10 is shown as having an impedance measuring circuit 112 which is enabled by the microcontroller 60 by a control signal 114. Certain applications for an impedance measuring circuit 112 include, but are not limited to, lead impedance surveillance during the acute and chronic phases for proper lead positioning or dislodgment; detecting operable electrodes and automatically switching to an operable pair if dislodgment 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 the valves, etc. The impedance measuring circuit 112 is advantageously coupled to the switch bank 74 so that any desired electrode may be used.
It is a primary function of the stimulation device 10 to operate as an implantable cardioverter/defibrillator (ICD) device. That is, it must detect the occurrence of an arrhythmia, and automatically apply an appropriate electrical shock therapy to the heart aimed at terminating the detected arrhythmia. To this end, the microcontroller 60 further controls a shocking circuit 116 by way of a control signal 118. The shocking circuit 116 generates shocking pulses of low (up to 0.5 Joules), moderate (0.5-10 Joules), or high (11 to 40 Joules) energy, as controlled by the microcontroller 60. Such shocking pulses are applied to the patient's heart through at least two shocking electrodes, and as shown in this embodiment, selected from the left atrial coil electrode 28, the RV coil electrode 36, and/or the SVC coil electrode 38 (FIG. 1). As noted above, the housing 40 may act as an active electrode in combination with the RV electrode 36, or as part of a split electrical vector using the SVC coil electrode 38 or the left atrial coil electrode 28 (i.e., using the RV electrode as 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 asychronously (since R-waves may be too disorganized), and pertaining exclusively to the treatment of fibrillation. Accordingly, the microcontroller 60 is capable of controlling the synchronous or asynchronous delivery of the shocking pulses.
In FIG. 3, a flow chart is shown describing an overview of the operation and features implemented in one embodiment of the stimulation device 10. In this flow chart, and the other flow charts described herein, the various algorithmic steps are summarized in individual "blocks". Such blocks describe specific actions or decisions that must be made or carried out as the algorithm proceeds. Where the microcontroller 60 (or its equivalent) is employed, the flow charts presented herein provide the basis for a "control program" that may be executed or used by such a microcontroller 60 (or its equivalent) to effectuate the desired control of the stimulation device.
In this embodiment, the control program is comprised of multiple integrated program modules, with each module bearing responsibility for controlling one or more functions of the stimulation device 10. For example, one program module may control the delivery of stimulating pulses to the heart 12, while another may control the verification of ventricular capture and ventricular pacing energy determination. In effect, each program module is a control program dedicated to a specific function or set of functions of the stimulation device 10.
In particular, a program module is implemented by the stimulation device 10 to perform periodic threshold tests for generating a statistical model of the threshold, T, and to thereby minimize the number of threshold tests required over a given time. Based on this statistical model of the threshold T, the stimulation pulse energy, PE, is automatically adjusted to a level that minimizes the risk of loss of capture. Furthermore, the safety margin, SM, is determined by the variability of the threshold data accumulated over time such that a minimum safety margin can be set to ensure that the delivered pulse energy always exceeds the threshold to a specified degree of confidence. While two exemplary program modules 200 and 300 are depicted in the flow charts of FIGS. 3 and 7, respectively, it should be understood that alternative program modules can be used.
With reference to FIG. 3, the program module 200 starts at step 202, and uploads fixed parameters, such as a sampling number K, from the memory 94 at step 205. At step 210, the timing control circuitry 79 (FIG. 2) of the control system 30 generates a periodic trigger signal to initiate the threshold test. The timing of the periodic trigger can be programmed in the memory 94 by the practitioner. The interval between two consecutive trigger events or signals could be expressed either in units of time or cardiac cycles.
As shown in FIG. 8, various modes could be used in determining the periodicity of the trigger events. Based on the incorporation of a real-time clock in the timing control circuitry 79 (FIG. 2), the trigger events can be programmed to occur at a fixed interval of time, as illustrated by the downward pointing arrows on the time line 400. Alternatively, the trigger events can be programmed to occur at a random interval, as illustrated by the downward pointing arrows on the time line 410.
The trigger events could also occur at constant intervals within a specified period of time to be repeated after a defined delay, as illustrated by the downward pointing arrows on the time line 420. For example, a trigger event could be initiated every ten minutes during a thirty-minute period every twelve hours, resulting in six threshold tests per day. Still another variation is a trigger event occurring at random intervals within a specified period of time to be repeated after a defined delay, as illustrated by the downward pointing arrows on the time line 430. Several variations or combinations of such trigger event timing modes are possible, and the modes illustrated in FIG. 8 are meant to be exemplary, not exclusive.
According to a preferred embodiment, the timing of the trigger event is continuously adjusted by the control system 30 to be proportional to the variability of the threshold. If the standard deviation, σ, of N threshold measurements increases, the trigger would occur more often. If, and when the standard deviation decreases, the trigger would be adjusted automatically to occur less often. In this way, when the threshold is less stable, more frequent threshold tests will result in more frequent adjustments to the stimulation pulse energy PE in accordance with the patient's need. When the threshold is stable, less frequent threshold tests are performed and fewer adjustments to the stimulation pulse energy are needed.
Once a trigger event occurs at step 210, a threshold search algorithm is initiated at step 220. Any appropriate algorithm for determining threshold can be employed. One such method is taught in U.S. Pat. No. 5,766,229 to Bornzin, in which, after a specified period of stable cardiac rhythm, a high level stimulation pulse is delivered at a shorter interval than the stable rhythm and progressively decremented until loss of capture is detected. Threshold is then defined as the last stimulation pulse energy at which capture was verified. Other algorithms are possible such as starting with a stimulation pulse energy equal to the most recently determined threshold and verifying capture. If capture is verified, the stimulation pulse energy is reduced until capture is lost. If capture is not verified, then the stimulation pulse energy is increased until capture is detected.
During the threshold search test, capture will be detected as generally taught in the art. An evoked response in the atria following an atrial test pulse is received at the atrial sense amplifier 82 (FIG. 2). Likewise, an evoked response in the ventricles following a ventricular test pulse is received at the ventricular sense amplifier 84 (FIG. 1). An output signal from either the atrial sense amplifier 82 or ventricular sense amplifier 84, is received by the microcontroller 60 where it is interpreted as a capture event. Other physiological signals, such the mechanical contraction of the heart muscle or the pulse pressure waveform can also be used for verifying capture.
After the threshold search is completed, the resulting threshold value, TN, is compared to an acceptable range of values, at step 222, to verify that the result is valid. If the threshold value TN is not acceptable, a threshold search will be performed again. If TN is acceptable, it will be recorded in the memory 94 at step 230.
This will result in incrementing the number stored in one particular bin in a histogram 350 of FIG. 6. For example, the particular threshold value TN is stored in bin 352. The program module generates a collection of data such as that depicted as the histogram 350. Each bin or histogram column, e.g. 352, 353, 354, 355, 356, 357, 358, represents a stimulation pulse energy (PE) setting available to the stimulation device 10. The height, or Y-value, of each histogram column represents the number of threshold tests resulting in a threshold value equal to the stimulation pulse energy assigned to a particular bin.
A memory counter or bin is assigned to each stimulating pulse energy setting available in the stimulation device 10. The counter or bin assigned to the stimulation pulse energy is incremented by one at step 232 for incrementing the threshold test.
Returning to FIG. 3, each time a threshold test result TN is recorded in the memory 94, a sample number counter, N, is incremented by one at step 232, and compared to a desired sample number, K, at step 234. In a preferred embodiment, the desired sample number is a user-programmable variable. If the sample number N is less than the desired sample number K, the program module returns to wait for the next trigger event at 210, and repeats steps 220, 222, 230, 232 and 234, as described above. If, however, at step 234, the program module determines that adequate samples N have been collected, a determination of the descriptive statistics of the threshold data will be performed at step 240. The results will be used to adjust the stimulation pulse energy at step 250, as will be described below.
The program module determines the desired threshold level (TLEVEL) by selecting a particular threshold bin of the histogram 350 (FIG. 6). According to one embodiment, the threshold level is set equal to the threshold value (along the X-axis) assigned to the uppermost bin. In the example of FIG. 6, the selected threshold value is 1.0 Volt, which corresponds to bin 354. According to another embodiment, the threshold level is set equal to 1.75 Volts, which corresponds to bin 357. In this latter embodiment, the threshold value would be safer than those for bins 352-356, and would be desirable even though it ignores a minimal number of events in bin 358 that occur at a higher threshold value (e.g. 2 Volts) because the statistical probability of the threshold falling near this value is greatest.
It can therefore be appreciated that the stimulation energy pulse curve 358 illustrated in FIG. 5 is a function of the variability of the threshold level in that the stimulation pulse energy level is reduced when the threshold values do not change significantly over time. In other terms, the stimulation pulse energy 358 is a function of the slope (i.e., rate of change) of a threshold or stimulation curve 362.
The program module adjusts the stimulation pulse energy (PE) at step 250 of FIG. 3 by setting the stimulation pulse energy equal to the sum of the selected threshold value TLEVEL, and a user programmable safety margin (SM), as expressed by the following equation:
After K threshold searches have been performed and the stimulation pulse energy has been adjusted, the sample number counter N is set to 0 at step 260, and the histogram bins (i.e., 352-358) are cleared from memory at step 265. This will reduce or eliminate anomalous data. The program module loops back and waits for the next trigger event (step 210), and repeats steps 220, 222, 230, 232, 234, 240 and 250, as described above, for new threshold search results to begin to accumulate upon the next series of trigger events.
According to an alternative embodiment, instead of clearing the histogram bins from memory, the memory could be a rolling memory, and the memory capacity would be set such that a fixed number of threshold searches can be recorded. Once this capacity is full, the oldest data point written to memory would be deleted to allow the next new threshold search test to be recorded. In other words, K samples would exist in memory at all times. A rolling memory would prevent a delay in the response time required by the stimulation device to adjust the stimulation pulse energy due to the time required to collect K new samples. Rather than having to acquire K new threshold search results before the stimulation pulse energy can be adjusted can be adjusted after each threshold search. If Tn represents a change in the threshold level, the stimulation pulse energy would be adjusted immediately based on this change Tn, rather than wait for K samples to be collected.
The operation of the program module of the present invention is further portrayed graphically in FIG. 4, where changes in the threshold value are shown over a relatively short period of time, and the resulting stimulation pulse energy 358 is compared to the stimulation curve 360 which would have been obtained using conventional capture techniques. According to this exemplary stimulation curve 360, the safety margin is set and plotted above a threshold curve 362. At each hash mark, a threshold search is performed, at frequent intervals, or on a beat-by-beat basis, and the stimulation pulse energy is adjusted to the sum of threshold curve 362 and a user-programmed fixed safety margin. In the example of FIG. 4, the safety margin is fixed to 0.25 Volt (it being understood that other values can alternatively be selected).
Since the stimulation pulse energy curve 358 obtained using the present autocapture method remains unchanged (i.e., flat) over an extended period of time, threshold searching would be performed less frequently. This would probably result in a higher stimulation pulse energy than the curve 360, but fewer threshold searches are required, thus reducing the overall battery expenditure and the detrimental hemodynamic effects associated with short AV and PV intervals. Another advantage of the present invention is that stimulation pulse energy is reset based on the results of N threshold tests rather than a single event, thereby providing greater confidence of capture over time.
Another mode of operation of the stimulation device 10 is illustrated in the flow chart of FIG. 7. The steps or blocks that are labeled with similar numeral references as in FIG. 3, indicate the use of the same steps, and thus the description of these steps will not be repeated.
In the alternative embodiment of FIG. 7, upon the completion of K threshold tests, statistical calculations which characterize the threshold level (TLEVEL) are performed at step 370. These calculations can include, but are not limited to: the mean threshold (TMEAN), the maximum threshold level (TMAX), the variability of the threshold (σ2), and the standard deviation of the threshold (σ). Selected statistical data is then used to adjust PE. In the process 300 of FIG. 7, a safety margin (SM) is first calculated based on the standard deviation of the threshold, and is expressed by the following equation:
where B is a user programmed factor.
Next, the stimulation pulse energy is adjusted, and is expressed by the following equation:
where TMEAN is calculated by averaging the threshold search results over a predetermined period of time. Assuming a normal distribution of the threshold, the stimulation pulse energy will be adjusted at step 375, to TMEAN plus a user-defined number of standard deviations which will ensure a certain degree of confidence that the stimulation pulse energy is greater than the selected threshold level. The statistical distribution of the threshold determines the minimum safety margin. The confidence interval is determined by the user-programmed factor B.
Other statistical distributions of the threshold may be encountered, and alternative statistical parameters may be used to determine the stimulation pulse energy. The added advantage of this mode of operation is that the stimulation pulse energy is minimized by using the lowest safety margin possible to ensure a desired level of confidence that capture will always occur. This lower stimulation pulse energy will further improve battery longevity.
Since a certain amount of time is required for K threshold search samples to be collected and the statistical model of the threshold generated, it is possible that the response time for the stimulation pulse energy adjustment lags behind a sudden increase in the threshold. One method of overcoming this potential lag is included in the operation of FIG. 7. After the resulting threshold value TN is recorded to memory at step 222, it is compared to the previous threshold search result, TN−1. If TN is greater than TN−1, then a trend of increasing the threshold is indicated. As a safety measure, the stimulation pulse energy PE could be immediately adjusted to a higher temporary value, PE(temp) equal to the higher TN plus the safety margin. The temporary value PE(temp) would remain as the stimulation energy until the completion of K threshold searches, at which time calculation of new statistical parameters will allow determination of the appropriate stimulation pulse energy.
Numerous variations in the foregoing method can be made without departing from the scope of the present invention, namely, performing threshold searches in order to generate a statistical model of the threshold, reducing the total number of threshold searches by requiring only a desired sample number of searches, and using the statistical results to adjust the stimulation pulse energy. For example, the exact number of threshold searches, the time interval between successive searches, and the user-programmed factor B for calculating the safety margin could be variables based on the stability of the threshold rather than fixed values.
Further, when the stimulation device 10 is rate-responsive, the control parameters that set the trigger events, the sample number, and the factors used in calculating the stimulation pulse energy could also be automatically adjusted as a function of the same physiological parameters that set the pacing rate.
As described above, it is thus seen that the present invention provides a method for performing threshold searches on a sampled basis in order to improve battery longevity by reducing the overall number of threshold tests performed, and to improve patient safety and comfort by determining the stimulation pulse energy based on the statistical characteristics of threshold, thereby predicting, with a desired degree of confidence, that the stimulation pulse energy will always be greater than the threshold.
While the invention herein disclosed has been described by means of specific embodiments and applications thereof, numerous modifications and variations could be made therein by those skilled in the art without departing from the scope of the invention.
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US4944299 | Aug 8, 1989 | Jul 31, 1990 | Siemens-Pacesetter, Inc. | High speed digital telemetry system for implantable device |
US4955376 | Aug 7, 1989 | Sep 11, 1990 | Teletronics N.V. | Pacemaker with improved automatic output regulation |
US4969462 | Aug 7, 1989 | Nov 13, 1990 | Telectronics N.V. | Pacemaker with improved automatic output regulation |
US4969467 | Aug 7, 1989 | Nov 13, 1990 | Telectronics N.V. | Pacemaker with improved automatic output regulation |
US5350410 | Nov 23, 1992 | Sep 27, 1994 | Siemens Pacesetter, Inc. | Autocapture system for implantable pulse generator |
US5466254 | Sep 22, 1993 | Nov 14, 1995 | Pacesetter, Inc. | Coronary sinus lead with atrial sensing capability |
US5573550 | Apr 28, 1995 | Nov 12, 1996 | Pacesetter, Inc. | Implantable stimulation device having a low noise, low power, precision amplifier for amplifying cardiac signals |
US5601615 | Aug 16, 1994 | Feb 11, 1997 | Medtronic, Inc. | Atrial and ventricular capture detection and threshold-seeking pacemaker |
US5683431 | Mar 27, 1996 | Nov 4, 1997 | Medtronic, Inc. | Verification of capture by sensing evoked response across cardioversion electrodes |
US5685315 | Mar 29, 1996 | Nov 11, 1997 | Pacesetter, Inc. | Cardiac arrhythmia detection system for an implantable stimulation device |
US5713933 | Nov 30, 1994 | Feb 3, 1998 | Medtronic, Inc. | Method and apparatus for automatic pacing threshold determination |
US5766229 | Apr 14, 1997 | Jun 16, 1998 | Pacesetter, Inc. | Capture verification method and apparatus for implantable pacemaker utilizing heart rhythm stability measurements to minimize the likelihood of fusion |
US5855594 | Aug 8, 1997 | Jan 5, 1999 | Cardiac Pacemakers, Inc. | Self-calibration system for capture verification in pacing devices |
US5861012 | Oct 18, 1996 | Jan 19, 1999 | Medtronic, Inc. | Atrial and ventricular capture detection and threshold-seeking pacemaker |
Citing Patent | Filing date | Publication date | Applicant | Title |
US7349732 | Dec 12, 2003 | Mar 25, 2008 | Pacesetter, Inc. | System and method for emulating a surface EKG using internal cardiac signals sensed by an implantable medical device |
US7383080 | Dec 12, 2003 | Jun 3, 2008 | Pacesetter, Inc. | System and method for emulating a surface EKG using internal cardiac signals sensed by an implantable medical device |
US7471983 | Jul 19, 2005 | Dec 30, 2008 | Cardiac Pacemakers, Inc. | Pacing output determination based on selected capture threshold values |
US7546157 | Dec 12, 2003 | Jun 9, 2009 | Pacesetter, Inc. | System and method for emulating a surface EKG using internal cardiac signals sensed by an implantable medical device |
US7783355 * | Jan 21, 2004 | Aug 24, 2010 | Medtronic, Inc. | Dynamic adjustment of capture management "safety margin" |
US7933643 | Jan 5, 2005 | Apr 26, 2011 | Pacesetter, Inc. | System and method for displaying an emulated surface EKG using an external programming device |
US7945314 | May 10, 2006 | May 17, 2011 | Pacesetter, Inc. | System and method for emulating a surface EKG for use with transtelephonic monitoring of an implantable medical device |
US8233983 | Dec 17, 2004 | Jul 31, 2012 | St. Jude Medical Ab | Implantable heart stimulator and method for operation thereof |
US8271086 | Dec 22, 2008 | Sep 18, 2012 | Cardiac Pacemakers, Inc. | Pacing output determination based on selected capture threshold values |
US8565879 * | Mar 25, 2011 | Oct 22, 2013 | Cardiac Pacemakers, Inc. | Method and apparatus for pacing safety margin |
US8688216 | Nov 26, 2012 | Apr 1, 2014 | Cardiac Pacemakers, Inc. | Autothreshold with sensing from pacing cathode |
US8923966 | Sep 19, 2013 | Dec 30, 2014 | Cardiac Pacemakers, Inc. | Method and apparatus for pacing safety margin |
US9008772 | Nov 26, 2012 | Apr 14, 2015 | Cardiac Pacemakers, Inc. | Hybrid autothreshold |
US20050159785 * | Jan 21, 2004 | Jul 21, 2005 | Medtronic, Inc. | Dynamic adjustment of capture management "safety margin" |
US20070021793 * | Jul 19, 2005 | Jan 25, 2007 | Cardiac Pacemakers, Inc. | Pacing output determination based on selected capture threshold values |
US20080281373 * | Dec 17, 2004 | Nov 13, 2008 | Anders Bjorling | Implantable Heart Stimulator and Method for Operation Thereof |
US20110245890 * | Mar 25, 2011 | Oct 6, 2011 | Amy Jean Brisben | Method and apparatus for pacing safety margin |
WO2006065184A1 * | Dec 17, 2004 | Jun 22, 2006 | St. Jude Medical Ab | Implantable heart stimulator and method at an implantable heart stimulator |
U.S. Classification | 607/28 |
International Classification | A61N1/37 |
Cooperative Classification | A61N1/3712 |
European Classification | A61N1/37D2 |
Date | Code | Event | Description |
Mar 13, 2000 | AS | Assignment | Owner name: PACESETTER, INC., CALIFORNIA Free format text: ASSIGNMENT OF ASSIGNORS INTEREST;ASSIGNOR:SLOMAN, LAURENCE S.;REEL/FRAME:010680/0204 Effective date: 20000310 |
Sep 28, 2007 | FPAY | Fee payment | Year of fee payment: 4 |
Oct 8, 2007 | REMI | Maintenance fee reminder mailed | |
Sep 23, 2011 | FPAY | Fee payment | Year of fee payment: 8 |
Nov 6, 2015 | REMI | Maintenance fee reminder mailed | |
Mar 30, 2016 | LAPS | Lapse for failure to pay maintenance fees | |
May 17, 2016 | FP | Expired due to failure to pay maintenance fee | Effective date: 20160330 |


text:
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Lot 5054: A walnut longcase clock. Thomas Carnarvon, England, 19th century
Art and Antiques, Jewellery, Watches, Silver - Day 3
by Vendu Notarishuis
03 November 2016
Rotterdam, Netherlands
Looking for the realised and estimated price?
Description: A walnut longcase clock. Thomas Carnarvon, England, 19th century. Hoogte 220 cm.

subset: commoncrawl


text:
Rosh Hashanah
Rosh Hashanah | |
A shofar made from a ram's horn
Official name | Hebrew: ראש השנה |
Also called | Jewish New Year |
Observed by | Judaism and Jews; Samaritans |
Type | Jewish; Samaritan |
Significance |
Jewish civil new year according to the Hebrew calendar. Commemorates the creation of the world as narrated in the Bible. Beginning of the ten "Days of Awe" culminating in Yom Kippur. |
Begins | Start of first day of Tishrei |
Ends | End of first or second day of Tishrei |
Observances | Praying in synagogue, hearing the shofar. Festive meals with challah. Auspicious foods such as apples dipped in honey, fish heads and pomegranates are often eaten, as well as new fruits on the second night. Refraining from work. |
Related to | Yom Kippur, the "Day of Atonement." |
Rosh Hashanah (Hebrew: ראש השנה, literally "head of the year," Biblical: IPA: [ˈɾoʃ haʃːɔˈnɔh], Israeli: [ˈʁoʃ haʃaˈna], Yiddish: [ˈroʊʃ hɑˈʃɔnə]) is a Jewish holiday commonly referred to as the "Jewish New Year." It is observed on the first day of Tishrei, the seventh month of the Hebrew calendar. The festival lasts for two days.
Rosh Hashanah is the first of the High Holidays or Yamim Noraim ("Days of Awe"), or Asseret Yemei Teshuva (The Ten Days of Repentance) which are days specifically set aside to focus on repentance that conclude with the holiday of Yom Kippur. The story of Rosh Hashanah is about Abraham and his belief in God when he was told to sacrifice his son.


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How do you do it? How is it possible to interweave a recipe about duck with the horrors of cancer? I've lost loved ones to the disease and nearly everyone has or will at some point. I was recently asked to join several other bloggers this week in an effort to raise awareness about breast cancer. My mind immediately went to two strong women who lost their battles; a coworker and a good friend. In 2006, my friend died from Leukemia, a form of blood cancer. She was 24 years old. Is her story even appropriate this week? There is no such thing actually is a Leukemia Awareness Month but it gets no publicity. I think every story is worth telling, whether it's breast cancer, lung cancer or leukemia.
Someone suggested I share one of her favorite recipes. My response was that she loved beef jerky and frozen pizzas covered in garlic powder (because real garlic made her hands smell). Food wasn't really her thing. I doubt she ate duck. But she did love art and photography.
Yes, those are my legs peeking into some of the shots. But she's clearly the star of these photos; the camera loved her. I preferred working behind the scenes (and just to be clear I didn't take these photos of her.) I should also mention that in addition to being incredibly artistic, she was very funny.
She was an artist and I wanted to be just like her. She inspired me to be more creative. To make art. Only I was kind of a terrible artist. I couldn't draw, I couldn't paint, and her homemade jewelry always looked way better than mine. We took nude model drawing classes together and her sketches looked great while mine looked like drunk attempts at crude cartoons. But no matter what she was always encouraging. Little did either of us know that years later I'd discover cooking and that would become my art. I know she'd dig it. I'd certainly make her a pizza.
The cancer took her life within three years of the initial diagnosis. It was difficult to watch, especially because there was a brief period of remission at the halfway point where it looked like everything was going to be ok after all.
Thanks, Ann, for being a good friend and for inspiring me to create art. I couldn't always be the friend you needed, but I did the best I could and I know you knew that.
The recipe I'm sharing today for duck with red wine mushroom sauce and lentils isn't as random as it sounds. While researching ingredients that help prevent cancer my results included (but were not limited to) shallots, mushrooms, lentils, kale and red wine (please check out the links for more details on health benefits). When I saw those ingredients I immediately wanted to pair them with a nice, juicy steak. But since red meat has been linked to cancer that would be very counter-intuitive. After contemplating my options I settled on duck. It has some of the same meaty qualities as steak and it's less boring than chicken. Plus, I've never shared a duck recipe on the blog. By all means, swap out the duck for pork tenderloin, chicken breasts or even steak when preparing this.
- ½ cup French lentils
- 1 shallot, minced
- 1 garlic clove, whole
- 1 cup chicken stock
- 1 sprig thyme
- 1 tablespoon olive oil
- 1 shallot, minced
- 1 clove garlic, minced
- ½ bunch of kale, inner stem removed and ripped into smaller pieces
- ¼ cup water
- 1 large or 2 small duck breasts
- ¼ cup red wine
- 1 cup chicken stock
- 4 ounces button mushrooms, sliced
- 1 shallot, minced
- ½ tablespoon butter
- Pick through the lentils and wash thoroughly.
- Place in a saucepan with stock, shallot, garlic and thyme. Bring to a simmer over medium-low heat.
- Simmer for approximately 20 minutes, until lentils are soft but still toothsome. Drain excess liquid. Remove garlic and stem from thyme.
- In a large pan, saute the shallots and garlic over medium-low heat until tender. Add the kale and water. Stir periodically until the greens have cooked down. This can be reheated right before serving the meal.
- Score the fat on top of the duck breast diagonally in both directions. Make sure to cut all the way through the fat without cutting into the meat. This will help the fat render properly. Season generously with salt and pepper.
- Heat a saute pan over medium heat for several minutes and then place the duck in the pan, fat-side down.
- Let the fat render over medium heat for several minutes (5-10 depending on the size) until it's dark brown and crispy. Drain off some of the duck fat periodically so the meat isn't swimming in fat (save in the fridge for later use).
- Flip the breast and allow it to cook on the opposite side for a few minutes. You're aiming for a medium rare breast with crispy (not chewy) fat. I like to keep a thermometer on hand. Remove from the heat when the center is around 125 degrees (it will continue to cook). Allow the meat to rest for at least 5 minutes.
- While the duck is resting, prepare the pan sauce. Drain any remaining fat from the pan and then deglaze with red wine. Use a spatula to scrape up any brown bits from the bottom and incorporate them. Once the wine is almost cooked away, add the shallots and a sprinkle of salt. Allow them to cook for 2 minutes, then add the mushrooms. Brown the mushrooms for 2-3 minutes and then add the chicken stock.
- Allow the stock to reduce significantly until it's a thin sauce consistency. Remove the pan from the heat and stir in the butter immediately.
- Slice duck on the bias into thin strips. (If you accidentally undercook the meat you can briefly stick it in a 375 degree F oven. Be very careful not to overcook in this scenario.)
- Fan the duck over the lentils and top with the mushroom sauce. Serve with kale.
If at all possible, use homemade chicken stock in the lentils and pan sauce. It tastes much better and is less processed. If making homemade stock seems daunting, please email me. I will personally guide you through the process!


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Christmas is less than two weeks away, and the waiting room of Bow County Court is teeming with people on the brink of losing their homes.
The court sets aside one day a week to hear cases brought by mortgage providers against residents in the Olympic borough of Newham – an area with the second-highest rate of repossession in the country.
Nearly 29,000 homes were repossessed in England between January and September, and housing charities are warning of worse to come. Figures published yesterday by the Financial Services Authority show the number is up 6 per cent compared with this time last year.
In this small court, less than a mile away from the newly built Westfield Stratford City shopping centre, more than 60 repossession cases will be heard today. Carol Stapleton's is just one of them. She worked as a clerical officer at a London hospital until November last year when she lost her job owing to ill health. Her mortgage provider filed a possession order on her home a few months later as she fell behind with payments, and lawyers for the bank have asked the judge that she is evicted immediately. "I kept explaining to my mortgage provider that I had lost my job and could not afford the payments, but I was still being fined every month," Ms Stapleton says.
Accompanying her to the court is her daughter, in her mid-20s, who also works for the NHS. She has brought with her a letter stating that she will pay £600 per month to prevent her mother from being evicted. The rest will come from other family members.
With the help of lawyer Nick Turner, who works for the housing charity Shelter, Ms Stapleton is able to negotiate a higher rate of repayment and stay in her home – for now. Mr Turner sits at his desk for the day in the middle of the busy court's waiting room, where he provides free legal advice to people facing repossession.
Of the dozens of people in court today, he will only have the time to see three of them. Those he doesn't have the chance to see will most likely appear in front of a judge without representation, against a well-prepared lawyer acting on behalf of their mortgage lender or landlord. Typically, he will have about 20 minutes to learn the details of each case.
"It is coal face work," he says as he scribbles down the income and expenditure of the lady in front of him. "Most of the time clients will have not had legal advice before coming to court."
"It never ceases to astound me that with such important litigation – potentially losing someone's home –people are often not represented," he says.
A lack of advice throughout the eviction process means that many who arrive at the court to face repossession are ill-prepared, and often without the right paper work.
When it is given, Mr Turner says legal advice can have a "dramatic" effect in these cases. But impending cuts to legal aid – a planned £350m by April 2013 – will leave many more people vulnerable to eviction.
"It will affect our work enormously. Some work we currently take on, such as preventing eviction by sorting out welfare benefits problems, is likely to be taken out of our scope entirely," he says.
With unemployment at its highest for 15 years and set to rise further, thousands more could find themselves in the same position as Ms Stapleton. But while a scheme currently exists to help unemployed people with mortgage payments, this may soon be scrapped.
The Support for Mortgage Interest (SMI) scheme was cut by 40 per cent last year, and last week the Welfare Minister Lord Freud raised the possibility that the £400m scheme may go.
While the cuts could mean fewer lawyers acting for tenants in the courts, Mr Turner says the squeeze on incomes will ensure that Bow County Court, and others around the country, will see an increasing number of home repossession cases.
"It's a busy court, and I can only see things getting worse," he admits. "There is a recession on."
Case study
Helen Dalton found out in November that she would be losing her home. As is the norm for most repossession cases, unemployment was the catalyst.
Helen, 35, had moved into the house with her husband and three children - two girls aged 16 and 11, and an 8-year-old boy.
She was working as a teaching assistant at a school near to where she lives in Manchester – the area outside of London where people are most at risk of repossession, according to a report published this week by Shelter. However, her contract was not renewed, and shortly after that she separated from her husband, leaving her unable to keep up with mortgage payments.
"I was finding it really hard to cope," she says. "You have to fill in form after form. It's not the nicest process, and I just shoved it to one side. I was in denial really over what was happening."
Before long, Helen had built up over £6000 in arrears with her mortgage provider. While she was trying to figure out a way to pay the fines incurred for missing payments, her mortgage provider attempted to pursue their claim through the courts.
"All they want is their money. There is no customer care, no sympathy for your situation. You can tell them you can't afford it and you have three kids but they just say "we can't give you any more time."
Helen has been told she must leave her home by early January.
She has arranged for herself and her three children to move in with her mother – where she lives with her uncle, mother and grandmother.
She and her children will sleep in one room of the three bedroom house, where in just a few weeks, three generations will be forced to share.
"I am trying make it as exciting as I can for them, to make it like a holiday. It isn't the best situation."
Helen still remains positive, however. "I am a bubbly bright person but this has knocked me off my feet. I am luckier than so many people. I've got somewhere to go."
- More about:
- Hugo Boss AG
- Mortgages
- Unemployment


text:
Giveaway.Only 2 days remaining to enter book giveaway, first four paperback editions of Belinda Lawrence mysteries. Watch the video :-)http://youtu.be/VEf3uKF1Fzs
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boulderdash n: a road game played by California drivers during the wet season <Penelope called her friend to tell her about the ~ that was already underway along Pacific Coast Highway.> -more-
Michael Jackson to Build Amusement Park Near Prison
Buddha's Gym: Becoming One With Any Body
Bush Declares California "Disaster Area—In General"
Tongue Tattoos: New Fad
Lakers Sign Fetus
Beverly Hills Morgue Offers Herbal Body Wraps
sponsor list here sponsor list here sponsor list here sponsor list here sponsor list here sponsor list here
Hilary Swank's Nose Breaks Records
The bloodied cotton swabs shoved up Hilary Swank's nose to fix her character's broken nose during a boxing match in Million Dollar Baby were sold on eBay for $7,500 each and will be on display at the new Celebrity Junk Museum in the recently remodled Boxing Wing, along with Robert DeNiro's false tooth which fell out on the set of Raging Bull.
Steven Spielberg's Pubic Hair Lifted From Urinal
BEVERLY HILLS -- One of Steven Spielberg's pubic hairs was rescued from a urinal cake at Spago's restaurant, where the famed director was dining last week. After the hair was thoroughly DNA tested and confirmed as an authentic hair, it was purchased from an anonymous third party by the Celebrity Junk Museum. The hair is currently being kept in the museum's vault, where it is being prepared for exhibition at the museum.
Eric Gagne's Jock Strap Donated to Museum
LOS ANGELES -- Los Angeles Dodger ace reliever Eric Gagne has generously donated an old jock strap to the Celebrity Junk Museum. The museum's curator, Claxton Pustule, plans to display the item in its used condition, though museum visitors should know that the smell will be contained within a plexiglass box. "I felt that the true impact of this rare item would not be felt unless we displayed it in all its post-modern nitty gritty athleticism."
See more information on the founding of the Celebrity Junk Museumfind out about the museum....


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Home > Maps > Columbia County |
Click on a thumbnail image to view a full size version of that map.
Columbia County is Florida's 16th county, established on February 4, 1832, from a segment of St. Johns County. It was named in honor of Christopher Columbus, the discoverer of America. Lake City, named after the abundance of lakes in the area, is the county seat. An earlier name of the city was Alligator, after Halpatter Tustenugee, an Indian chief known as the "alligator warrior."
For earlier maps of this area, visit the St. Johns County map gallery.
Home > Maps > Columbia County |
Florida: A Social Studies Resource for Students and Teachers
Produced by the Florida Center for Instructional
College of Education, University of South Florida © 2004.


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In the 1930s, the US government issued a hobby to each citizen to keep them entertained until NASA finished working out the bugs in kissing. Self-determine a new pastime with this Groupon.
$64 for 30 Minutes of WhirlyBall for 4–10 Players ($150 Value)
During 30-minute games, 4–10 players zoom around the court in motorized bumper cars called WhirlyBugs, scoring goals with a wiffle ball tossed with plastic scoops. Teams can each include five people, and players must be 12 years or older and at least 4-foot-6.
Sam Elias knows that being cooped up during long winter days can make people stir-crazy. So in 1993, after moving from Florida, land of palm trees and beaches, to Chicago, land of frigid winds and gray slush, he founded WhirlyBall as a way for people to release pent-up energy even as snow was falling outside. During each competitive WhirlyBall game, which combines aspects of basketball, hockey, and jai alai, players zoom across an indoor 50'x80' court in motorized cars called WhirlyBugs. They wield plastic scoops to toss a wiffle ball back and forth to their teammates before throwing the ball through an elevated goal. Refs keep watch during the games, eliminating score arguments that would otherwise end in sunrise duels. To fuel up for a bout, players nibble chicken wings, pretzel bites, and gourmet pizzas, and swig craft beers, which vary by location.
All three WhirlyBall spots boast off-court diversions as well. The Vernon Hills and Lombard locations host video games, pool tables, foosball, and air hockey, and the Chicago and Vernon Hills locations invite guests into multilevel laser-tag arenas, which fill with fog and flashing lights as combatants duck, aim, and invoke Geneva Convention protocols regarding armed conflict.


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"In the second quarter alone, we banked on at least 700 more patients who we couldn't treat because of the rule. Many patients who relied on these services will find it will be no longer available to them."
Alan Sauber
"Maxim for life: You get treated in life the way you teach people to treat you."
Wayne Dyer
"The good physician treats the disease; the great physician treats the patient who has the disease"
William Osler
"A physician who treats himself has a fool for a patient."
"The way you see people is the way you treat them."
Zig Ziglar
"How people treat you is their karma; how you react is yours."
"Treat a man as he is, and he will remain as he is. Treat a man as he could be, and he will become what he should be."
Ralph Waldo Emerson


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seeking a word...
~~Some years ago Koichi Kashiwaya Sensei of Ki Society told me a word, explaining that it meant something that is more painfully beautiful because of it's very transience. I carelessly misplaced it.
~~Does anyone know what I'm referring to? :D |
Wish I could help you... jbd |
Dang it -- and I was just at a seminar with Kashiwaya sensei over the past weekend. I should have asked him then. Sorry, Paula...
Maybe if someone else from here is going to be seeing him sometime in the near future, they could ask him? -- Jun |
Re: seeking a word...
Actually any of these terms may be what Sensei had in mind or something similar. Regards, |
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The University of Dar es Salaam offers Bachelors, Masters, and Doctoral degrees, as well as Certification Programmes, to students from Tanzania and throughout the world . Our Programmes will enable you to rise to the top of your chosen profession.
Read or download the article here
The Swedish International Development Cooperation Agency (Sida) offers, as a part of its bilateral devel


text:
Balloon Ride Metallic Party Balloons
Case Price: $19.95
Product Code: 315324
Balloon Ride party balloons showcase a trio of brightly colored hot air balloons with a trendy chevron border design. This gender-neutral baby shower collection is printed on both sides and will easily coordinate with our Mimosa Yellow and Coral solid colored part supplies. Create an unforgettable baby shower celebration with our discount themed party supplies and decorations! © All Rights Reserved.
© All Rights Reserved.
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- Size: 18 Inches (45.72 cm)
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- Imported.
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Case Quantity: 10 Metallic Balloons
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Packaging Type: Poly packaged and barcoded for resale opportunities.
Minimum Order: 1 Full Case. Not available in smaller quantities.
Product Reviews
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Welcome to Bear Country
Solo camping in the Sierras' Little Lakes, a 6.5-hour drive north of S.D.
Veronica Remsbottom 8:43 p.m., March 26
On March 25, the Union-Tribune ran a story by George Varga titled "Street Scene is set to go home." The article implied that the next annual music fest will be staged downtown for the first time since 2004.
Gaslamp Quarter Association director Jimmy Parker says the article announcing Street Scene's return to downtown was premature and not true.
"Things may not work out for Hagey because of the Varga article," says Parker. "My phone lit up that morning with concerned businesses as well as excited businesses [about the return of Street Scene]."
The Varga article, says Street Scene founder Ron Hagey, "…caught us off guard" because nothing is "set," as the headline declared. Hagey says he has a specific site in mind but that it has yet to be secured.
Last year, Hagey passed on ownership of the 24-year-old music fest to Live Nation, which moved it to the Coors Amphitheatre parking lot. It drew an estimated 10,000 paid fans (compare that to 105,000 in 2004). This year, Live Nation gave Street Scene back to Hagey.
Hagey says he may partner with another large promoter for this year's event; if he doesn't, it may be hard to secure big-name talent because he'd be getting a late start. Hagey says he has no "tentative holds" with talent agents who represent nationally known musicians. He would not rule out a scaled-down event.
"Everyone wants Street Scene to go back to the way it was before," says Parker. "The problem [with a downtown Street Scene] is space. Redevelopment has put buildings on most of the parking lots. The big acts don't fit down there anymore.…
"There's a whole demo who was in their 30s who saw the Street Scene in the early days who miss the Cajun, blues, and jazz. They would probably come back."
– Ken Leighton


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Twilio's SMS API goes global: Featuring support for new languages and 1,000s of carriers
- 2
Twilio, the reigning king of communication APIs, is today greatly expanding its original SMS messaging offering from dozens of carriers to over 1,000. With this change, developers can now send SMS messages worldwide (from anywhere, to anywhere) and so its API is also now multilingual, featuring support for Arabic, Chinese, Japanese, Greek, Russian and "dozens more [languages]."
Back in May, Twilio grew its voice API to support a total of 10 European countries, and so following suit with the SMS API makes perfect sense. According to Patrick Malatack, product manager for Twilio, this move is all about breaking down the "geopolitical boundaries" of the telecom network, so developers can work with it like they do with the Web.
Ever been to a tech festival?
TNW Conference won best European Event 2016 for our festival vibe. See what's in store for 2017.
From Twilio CEO and Co-founder Jeff Lawson:
By adding support for multiple languages with the inclusion of the unicode character set, we are opening up opportunities for many locales to use Twilio SMS. It's very gratifying to be able to ship this to our developers who have been requesting this functionality — now we can't wait to see what they build.*
SMS hasn't been the most glamorous of services for quite some time, but its usefulness and complete ubiquity makes it very valuable — especially outside the US. From what we heard, this has been the company's most requested feature over the years, so hopefully for them, developers will follow through and keep tapping Twilio to communicate with users.
You can check out Twilio's improved SMS API via the link below. Developers can also explore the Voice API here.


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May is a busy month in the life of a Paso Robles Winemaker. First, and most important, the current vintage wines are starting to really show their stuff and are begging to be tasted and blended. All of the '07 reds should be blended by the end of the month, as Dani and I and a few other FOES -- Friends of Edward Sellers -- have already begun tasting and grading the base wines and barrels. We are really hitting our stride with 2007, and I think this may be our best vintage yet (see the amazing whites in your current wine club shipment).
Secondly, there are two major festivals this month: the matchless and fantastic Hospice du Rhone, on the first weekend of May, and the rambunctious and wildly fun Paso Robles Wine Festival on the third weekend. Hospice gathers Rhone wine producers from all over the world for a weekend of education, tasting, and friendly competition that always leaves me thinking about new winemaking adventures and striving for that old-world balance of power and finesse. We hosted a wine dinner at the Range as a part of this year's HdR festivities, and I can fairly say that it was the most fun wine dinner I've ever attended. Chef Jeff and lovely Lindsay did an amazing job of making the whole event feel like a dinner party in their back yard, but with truly outstanding food, great live music, and plenty of perfectly paired Edward Sellers wines. Big thanks to Jeff, Lindsay, Jade, and all those of you who joined us for that event. I always enjoy mixing with the people (you) who make what I do worthwhile.
Wednesday, May 7, 2008
Blending, Mixing, and Mingling
Posted by Amy Butler, Winemaker at 12:49 PM 0 comments
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Pittsburgh, PA Monday March 27, 2017 |
News Sports Lifestyle Classifieds About Us |
Saturday, February 01, 2003
Football is a funny game.
It's public knowledge that the Detroit Lions definitely want to hire Steve Mariucci as their new coach. But they can't make it official until they appease the NFL by interviewing some minority candidates. Former Minnesota Vikings coach Dennis Green and Steelers defensive coordinator Tim Lewis already have declined the chance to be tokens, so Mariucci's hiring is on hold until a black man comes forward to participate in a white man's charade.
I suggest the Lions interview Martin Lawrence. If the hiring process is a joke, why not bring in a comedian? A video of dull-witted Lions President Matt Millen talking with Lawrence about the latter's coaching credentials would be funnier than Jimmy Kimmel's new late-night disaster, that's for sure.
For big-time gridiron laughs, though, there's nothing to beat the Mike Vanderjagt saga.
Vanderjagt, the Indianapolis Colts' kicker, recently said (in so many words) that Colts quarterback Peyton Manning and Coach Tony Dungy are too soft to win big games, that they lack the ability to manufacture extra intensity in meaningful situations.
Manning never has won a playoff game. Dungy left Tampa Bay, and the Buccaneers immediately won a Super Bowl. You can call Vanderjagt a lousy teammate, but you can't call him a liar.
The backlash has been predictable. Manning is upset. Dungy continues to be boring. Vanderjagt has backpedaled, probably for the sake of continued employment in Indianapolis.
The big yucks regarding Vanderjagt's analysis have been generated by former jocks with microphones, most notably Mark Schlereth of ESPN. Schlereth, a Super Bowl-winning lineman, yelped in the register of a teenage girl when responding thusly to Vanderjagt: "He's just a kicker! He's not even a real football player! He doesn't know what it's like to bang helmets, blah, blah, blah, etc."
In defense of Vanderjagt, I present the following:
Statistically, Vanderjagt is the most accurate field-goal kicker in NFL history.
On Nov. 24, in a driving snowstorm at Denver, Vanderjagt kicked a 54-yard field goal to tie the score on the last play of regulation, then hit a 51-yarder in overtime. The victory wound up getting the Colts a playoff spot. Vanderjagt might not be a "real football player." But did Schlereth ever do anything individually that had as much impact on his team's season? No. Did he ever face similar pressure? No.
When was the last time Schlereth read a book? Hardback comic compilations don't count.
Mark, your career's over. You don't need to be that big anymore. Not that I'm implying anything.
The criticism of Vanderjagt by cementheads such as Schlereth underlines a growing trend in sports and in society. What's said is not nearly as important as who says it. If a Colts lineman had blasted Manning, that would have been OK by Schlereth, because after all, guys like that are fighting like men down in the trenches, i.e., randomly assuming the fetal position every 45 seconds.
When are the sports fans of the world going to call the former jocks with microphones on being the fools that they are?
Give me John Clayton over Schlereth any day. Give me someone who has spent a lifetime learning the game over someone who spent a few fleeting moments filling a specialized role within it. If Vanderjagt isn't qualified to criticize a quarterback or a coach, then Schlereth doesn't have the right to analyze the performance of anyone but linemen. I don't seem to recall him running many reverses.
The fans had better figure out what idiots the former jocks are, because the networks won't. They are run and staffed by the worst kind of jock-sniffers.
When Vanderjagt's comments hit the fan, his playoff miss against the New York Jets was shown over and over on TV. What a crucial kick it was, too. If Vanderjagt makes it, the Colts only lose 41-3. His heroics at Denver, meanwhile, got very short shrift.
Some (very few) former jocks have become credible members of the media. But I'm not going to identify any right now. If Schlereth can make a blanket statement about kickers, I can do the same about the lamebrains that the late, great Howard Cosell called the "jockocracy."
Besides abject stupidity, the biggest sin of the jockocracy is their unwillingness to offend the brotherhood. When one guy blows a game, it's not about his mistake. It's about 53 guys winning or losing as a team. Well, 51, anyway, because you can't count the kicker and the punter. Back when, the jockocracy flinched whenever the media made them absorb blame. Therefore, they won't humiliate today's players.
Add it all up, and it's boring. No former jock with a microphone has ever been as entertaining or as informative as Cosell. And none ever will be.
Meantime, I have a new favorite football player: Mike Vanderjagt. It's a shame he's not black. He would make one heck of a coach.
Mark Madden is the host of a sports talk show from 3-7 p.m. weekdays on WEAE-AM (1250).
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(196 quotes found)
"As a rule we develop a borrowed European idea forward, and. . . Europe develops a borrowed American idea backwards."
Mark Twain
"It looks like (the team's going backwards), but I don't know if that's part of the deal. I don't know that. It's not looking good right now. I can tell you that. We have to get the offense rolling. We have to. Defense is fighting to hold their own. And to keep pulling like that, the other side has to turn the corner. That's the bottom line."
Greg Robinson
"To look backward for a while is to refresh the eye, to restore it, and to render it the more fit for its prime function of looking forward"
Margaret Fairless Barber
"Let's just look forward and not backwards — and see how we can get it done now, versus why we haven't been able to see eye to eye thus far."
Todd France
"I have no rancor. I look forward, not backwards,"
John McCain
"I've actually seen twice during the same round, two different guys hit the ball backwards ... and it didn't hit anything. They topped it so bad that it actually went backwards."
Justin Leonard
"We are looking forward, not backward,"
Kathleen Blanco
"It seems we throw away 10 points and then he gives it back. It goes backwards and forwards."
Kimi Raikkonen
"I don't believe in going backwards. I would never say never but I believe in going forwards. I shed lots of tears after the split. It was hard for all of us. But we also had some very good times together - the best."
Myleene Klass
"Revolutions never go backward."
Wendell Phillips


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Friday, September 28, 2012
I'm a Dog Blogger Fer Reals
Um, I get to post my chicken photos there. Because, y'know, the dogs hang out with the chickens. And I can't be interesting while writing ONLY about dogs. Sheesh.
So pop over to my new blog. Check out the words and the pretty pictures. It's still me writing. In fact, it's me writing five days a week. Mostly coherently.
And there are the chicken and duck pictures.
Until I write again ...
11 comments:
- Mental P Mama said...
- September 28, 2012 at 10:20 AM
- Noe Noe Girl...A Queen of all Trades. said...
I like too!
Guess who's gonna love what came in the mail today? Thanks again! xoxo
<>< - September 28, 2012 at 12:23 PM
- Leenie said...
Hi, Flea! Long time no check in. Saw your comment on an old post and thought I'd come on by. Your hen(s) is/are wonderful. Love the duck and your dog is just so patient and understanding of your need for weirdness.
- October 1, 2012 at 3:06 PM
- tubby3pug said...
Thanks so much for visiting our blog! Some people in the city have started raising chickens, we even saw some in Brooklyn this weekend. Your chickens look prettier though
urban hounds - October 1, 2012 at 5:01 PM
- heyitsjethere said...
Hey it's Jet here. Hi Miss Flea.
Very exciting, we'll go visit now. :) - October 1, 2012 at 5:25 PM
- Pearl said...
Well no wonder you're dog-blogging! They just look so GOOD in hats!
Pearl - October 5, 2012 at 9:28 AM
- Jeanne Pursell said...
Hi there! Just popping over to say hello and to say thanks for stopping by. I am a bit unsure of what you mean when you say it is hard to comment? I haven't had anyone else tell me that?? Thanks!
- November 2, 2012 at 1:39 AM
- The Musings Of A Crazy Cat Lady said...
Hi Flea. What neat accessories. Happy Wednesday to you and all your friends.
- November 7, 2012 at 5:38 PM
- Nichole said...
Thanks for stopping by -- Happy Monday! :)
- December 10, 2012 at 3:47 PM
- Jeanne Pursell said...
This IS exciting!!! You really are dog blogging!! WooHOO! xoxo Chloe and LadyBug
- December 11, 2012 at 3:13 AM
- tubby3pug said...
Flea is super cute
urban hounds - January 22, 2013 at 3:56 PM


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KasumiNoir is a Model, Artist & Designer based outside of Glasgow, Scotland.
Specialising in alternative genres & represented by Spirit Model Management, she has over 6 years modelling experience which has seen her model for various designers,authors & appear in publications.
Alongside this, she also has experience in being an artists' model.
With a passion for Make up & hair styling, she uses her skills to ensure that she is as versatile within her modelling as possible, always adapting and evolving her style.


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Lot 96: New Simplicity Needle Case Model "C" with Product
Pepsi, Coca Cola, and Soda Pop Collection - 500 Lots - Vintage Advertising
by Kraft Auction Service
29 October 2016
Lebanon, IN, USA
Live AuctionSold
Looking for the realised and estimated price?
Description: Metal counter top case with some wooden needle cases included inside. There is a dent and scratches on top, the inside shows usage wear, but has great graphics and color. 11 1/2 x 7 1/2 x 3.


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To educate, entertain, and enthuse those who venture beyond the shore. Over 16,618 articles on solo swims, pro races, relays, charity events, ice swims, eco-swims, stage swims, marathon swims, trends, products, services, personalities, coaches, governing bodies, rules, demographics, books, films, blogs, conferences, camps, clinics and happenings in oceans, seas, lakes, rivers, dams, canals, channels, fjords, estuaries, lochs, coves, firths, straits, bays, and harbors. Sponsored by WOWSA.org.
2016 WOWSA Man of the Year – Nejib Belhedi
2016 WOWSA Woman of the Year – Jaimie Monahan
2016 WOWSA Performance of the Year – Sarah Thomas' Lake Powell Swim
2016 WOWSA Offering of the Year – Samsung Bosphorus Cross Continental Swim
Saturday, February 9, 2013
Darian Townsend Sets The Bar At The aQuellé Midmar Mile
His performance gave Chad Ho and Troy Prinsloo a hint of the strength of competition they will face on Sunday at the elite division at the Midmar Mile. While Ho will be seeking his fourth consecutive victory, Prinsloo will be looking for his third victory – but Townsend stands in the way.
It will be a great race among the top men.
Combined aerial photos courtesy of Andrew Martens of RCHELICAM.co.za.
Copyright © 2013 by Open Water Source
A Thank You Gift from WOWSA
WOWSA is celebrating the 1-Year Anniversary of the monthly Open Water Swimming Magazine by giving you a free copy of the anniversary issue. Open Water Swimming Magazine Anniversary Issue File Size: 13MB FREE DOWNLOAD |
Download the file to your computer, and then right-click to extract the magazine which is inside the zip folder. The magazine is in PDF format.
CLICK HERE to download your free copy now.
Open Water Swimming Magazine
Open Water Swimming Magazine
The Open Water Swimming Magazine is the monthly magazine entirely focused on open water swimming heroes and heroines of every age, ability, and background. Published by the World Open Water Swimming Association, the Open Water Swimming Magazine is a free benefit to WOWSA members.WOWSA Member Benefits include 12 issues of the Open Water Swimming Magazine, the annual 276-page Open Water Swimming Almanac, a free listing in Sponsor My Swim, outstanding product discounts from FINIS, an entry in Openwaterpedia and more...
The Other Shore
The Other Shore follows world record holder and legendary swimmer Diana Nyad as she comes out of a thirty-year retirement to re-attempt an elusive dream: swimming 103 miles non-stop from Cuba to Florida without the use of a shark cage. Her past and present collide in her obsession with a feat that nobody has ever accomplished. At the edge of The Devil's Triangle, tropical storms, sharks, venomous jellyfish, and one of the strongest ocean currents in the world, all prove to be life-threatening realities. Timothy Wheeler's documentary brings Diana Nyad's extraordinary adventure to life as Diana sets out to prove that will and determination are all you need to make the unimaginable possible.
2014 Open Water Swimming Almanac
An Almanac for Open Water Swimming
An almanac is essentially a body of knowledge which is so complete that it enables people in different fields to make predictions about the future of their respective industries.This, for example, was the purpose of the traditional farmers almanacs. It enabled farmers to determine as accurately as possible which crops to plant for the greatest harvests in a given year.
But the farmers almanac was just one example among many.
There are, of course, many different kinds of almanacs.
In fact, there is even one for open water swimming...
Preview the Open Water Swimming Almanac:
The trends are very clear.
The tide is rising for open water swimming.


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The inaugural IT Expo held last Saturday morning at the Lok Jack Graduate Business School was a bit of a curiosity.
You are here
Tamana cops first title in California cricket
Tamana United captured the first major title of the 2013 SIS California Women's Windball Cricket League when they narrowly won the round-robin competition at the launch of the season on Saturday.
Batting first in the final played at Macaulay Park, California, Tamana scored 20 runs in their allotted three overs and held their opponents, Combine Forces, to 19, winning by one run.
It was double celebration on the day for Tamana United who were selected as the Best Uniformed Team. Sporting attractive pink uniforms, a change from their customary green and white colours, the Tamana ladies cut striking figures on the field of play.
Tamana captain Sylvie Bhola said that her team, which is the defending Knock-Out champion, intends to take its opening-day success to the other major competitions this year. "We want to take this momentum into the league and knock-out competitions," she said after the victory.
Wilton 'Flex' Griffith, founder and coordinator of the league, said the 2013 season should be very competitive since most of the teams were already engaged in other leagues and were showing good form. The California league, he added, was a nurturing ground for women cricketers, several of whom will represent Trinidad and Tobago national team which will tour South Africa in April.
Matches in the league competition, which carries a prize of $8,000 for the champions, bowl off at Macaulay Park, on Sunday, April 7.