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Ewa Rajtar, Program Director and Registrar
June 15, 2019 / Conscious Dying Institute/ Tarron Estes
Contact: ewa@consciousdyinginstitute.com
June 15, 2019 / Conscious Dying Institute/ Tarron Estes/ Comment
Claudette Bouchard
May 06, 2019 / Tarron Estes
Contact: claudettedoula@telus.net
May 06, 2019 / Tarron Estes/ Comment
Greg Lathrop
Gregory Lathrop is licensed as a registered nurse. Greg's nursing experience of over 35 years has included acute care, critical care, emergency care, air-medical transport, hospice care and integrative healthcare. Greg and his patient were recently interviewed by BBC News about the experience of engaging the "Best 3 Months - End Of Life Coaching And Care Planning Process" - you can listen to the interview here.
In his private practice as a Holistic Nursing Specialist he honors the principles of conscious dying as Sacred Passage Doula, focusing on care of the dying in the home environment. Reinforcing the plan of care established by Hospice, his goal is to demystify the stages of the dying process, increase beauty, pleasure and contentment, provide emotional and spiritual support and engage in conversations about dying while acknowledging the mysteries and miracles during this sacred time.
Through teaching, coaching and assistance with personal care, his goal is to cultivate easewith client and family during a time which can often feel very uneasy. In his experience, integrating holistic therapies such as Healing Touch, Guided Imagery, Aromatherapy, Music and simple relaxing massage, among others, can greatly enhance a sense of well-being physically, mentally, emotionally and spiritually.
His practice also includes Licensure as HeartMath Coach and Certification as HeartMath Trainerreinforcing the principles of HeartMath related to self-regulation, resilience and optimal function.
In addition to this experience, Greg accepted the opportunity to study Traditional Indigenous Medicine for over 13 years with his late "teacher" Will Rockingbear, because of a profound sense of the power of ceremony in the path of the sacred in being with dying. An embodiment of these teachings; "I would prefer that you don't just take care of me. I would rather that you Love me."
He is an accomplished Musician and Native Flautist.
Jan Booth
Jan has worked as a nurse for over 33 years within the intersection of quality of life and end of life, and she is deeply curious about what creates and sustains wellbeing throughout the human experience.
Her initiation into the world of death and dying came during nursing school as an unexpected calling. She had started school with the intention of becoming a midwife and helping birth babies. But then she heard this clear call to serve instead as a midwife for the dying. Since that time, Jan has never looked back. Her work trajectory has taken her from the bedside of hospice and palliative care patients to supporting the wellbeing of caregivers, and now into the larger community to further open our cultural conversation about end of life.
Jan's current work is as an Integrative Nurse Coach around the practice of wellbeing in aging, illness, and dying -- supporting people in navigating serious illness, helping families to talk more openly about end-of-life priorities, and providing health coaching for both professional and personal/family caregivers.
She also serve as faculty for the International Nurse Coach Association, including the Integrative Nurse Coach certificate programs, an End-of-Life Nurse Coaching program in collaboration with the New York Open Center, and co-created an advanced training program called Coaching Conversations for People Living with Chronic & Advanced Illness.
She loves to work with deepening practices and reflections on aging and dying. It not only serves to better prepare us for a more intentional end of life—it also seems to clarify and transform how we live the time we have. Jan served as co-faculty for a course in the Washington, DC area called Sacred Journey: Being Present with Aging, Illness & Dying, in collaboration with the Insight Meditation Community of Washington, DC, and is a current faculty for the monthly retreat program called Companioning the Dying: Opening Fully to Living. Additionally, she's led workshops and given presentations on the transformational possibilities of end-of-life work at places like the Alcyon Center, the New York Open Center's Art of Dying conference, and the Integrative Healthcare Symposium.
Kamala Snow, Program Advisor
Kamala is happy to be a part of the team at Conscious Dying Institute where she works as a Program Advisor for the Sacred Passage End of Life Doula certification in the US and Canada.
She has had many experiences around death, beginning at age five, which have allowed her to see death through a different perspective than the fear and taboo that is exists in our society. This made her somewhat of a seeker of knowledge and experience of the afterlife and the dying process itself. After serving family and friends as a "go to" person working with death processes, she began death work as a volunteer for a local hospice in the hospice house, hospitals, assisted living facilities, and homes and sat vigil with people in the dying process and their extended families.
Kamala is ordained as an Interfaith/Interspiritual Minister & Counselor with One Faith Interfaith Seminary in New York. Kamala feels that this training allows her to be able to meet people where they are spiritually and "speak their language". She enjoys creating ritual and ceremony, especially celebrations of life and rites of passage. She is also a Licensed Massage therapist utilizing Healing Hospice Touch Therapy in her work. She has studied around the world with various cultures and wisdom traditions regarding dying and the death process, indigenous practices and energetic medicine techniques, and holds a Master's Degree in Transpersonal Psychology and Bachelor's degree in Visual Arts & Design. She feels the CDI Sacred Passage Doula training brought her full circle to the work that she began as a child - easing fear of death, giving space to talk and listen, fully expressing end of life wishes and allowing for the mystery and miracles around death to unfold. She feels that this work allows her to be a ripple in the pond of elevating human consciousness by changing the way we see not only death, but life itself. She is thankful to be a part of the educational and societal change taking place in the way we view death.
Kelly Cummings
Kelly (RN, PhD, NEA-BC) received her nursing education and training in Chestnut Hill, Massachusetts at Boston College. She has been a nurse for almost four decades. Kelly has lived in North Carolina for more than 25 years. As a nursing clinician, her focus has been various in areas of critical care, oncology, geriatrics, palliative care, hospice and nursing leadership. She considers herself a devout follower of Dr. Jean Watson's Caring Science Nursing Theory. She believes that compassion and connection are the strongest healing forces in our practice.
Kelly received her PhD from Twente University in the Netherlands. Her dissertation, "Reconstructing Nurses' Relationships with Older Patients" looked at the impact of I:Thou beliefs on healing and wholeness. She considers herself a caring, healing, presence and has dedicated her nursing studies for the past seven years to tending to the miracles that occur at the end of our lives.
Leann Prottengeier
Since childhood, Leann has been most interested in deep conversations and quiet introspection. She has found great interest in witnessing and understanding the inner workings of systems and individuals. She grew up in a small, rural Minnesota town, completed her first degrees in Family Life/Child Development and Sociology in a bigger, rural Minnesota town, traveled, then completed her Masters in Social Work at the University of Minnesota in Minneapolis, where she currently resides.
While learning about the human experience through these academic, Western lenses, Leann immersed herself in health and wellness modalities from Earth, Energy and community based traditions. She has found great emotional, spiritual, and physical freedom through Reiki, yoga, Traditional Chinese Medicine, Thai yoga bodywork, Mindfullness Meditation, journey work, and time with creatures and the elements outdoors.
As a MSW, Reiki Master Practitioner, RYT200, and Certified Sacred Passage Doula, Leann strives to embody and practice the tools she has acquired so as to be deeply present for those she serves. She loves organizing, spreadsheets, being a resource, and has creative ideas almost everywhere she turns. While this sometimes disturbs her sleep, she has been blessed with many collaborative opportunities and positions. She has served as United Way of Central Minnesota's Multicultural Projects Coordinator (a national service position with AmeriCorps), Event and Student Coordinator at Devanadi School of Yoga and Wellness, as well administrative positions within medical facilities. Leann feels blessed to be guided in this life by the teachings that come through the clients at her private practice, New Moon Rising, LLC. It was reflection on her own grief, made visible through the brave grief of her clients, that brought Leann to the Conscious Dying Insititute's Sacred Passage Doula Certificate program.
A lover of living life through the senses and physical experience, Leann can be found eating good food, listening to and, sometimes, playing music, cracking open geodes with extended family, soaking in the elements at the dog park with her pup, snuggling with her kittens, and dreaming of her next vacation with her sweet husband, Elijah. She has continued interest in personal evolution and believes it is not possible, responsible, or ethical unless access to this evolution is available equitably to all beings.
Mitzy Flores
Mitzy has been in the medical field for a little over 18 years. She received my formal nursing education and training in Florida, but has resided in diverse cities across the country. As a nursing clinician, her practice began as a critical care nurse, then transitioned to oncology, followed by community nursing. Finally, she is practicing nursing education. Nursing passion means many things to many people. For Mitzy, nursing is the deep experiences and connections made with others. She began her career saving lives, then moved on to assisting others with life changes. Finally, she transitioned to embracing the stories about the lives lived.
One of the most important aspects for Mitzy is embracing cultures through the lives of others. Foods, customs, rituals, scents and stories are foundational for her when acknowledging and understanding the death and dying process within families. As a sacred passage doula, she assists in bringing all those elements forward to assist person and family during the transition moments of life and death, with love and compassion.
For her nursing is an experience, a journey in which you will be well versed and you will be humbled. Nursing is not simply the skills to improve health. Nursing is the act of nourishing the soul, the body, the environment, and the transformation. As a doula, it is an honor to hold space for the narratives that will live on in the minds and hearts of all those that are willing to listen.
Trish Rux
Contact: trishrux@gmail.com
Woody Winfree, Enrollment Coordinator
Contact: woody@consciousdyinginstitute.com


Homicides that occur in intimate relationships, commonly referred to as 'spousal homicide', have risen in recent years in Portugal. One of the highest totals recorded was in 2014, with 42 women murdered by a partner or ex-partner (OMA 2015). In the last 12 years, there have been about 400 women victims of such types of homicides and about 500 victims of attempted murder (OMA 2016). These numbers have attracted increasing interest from the media, despite reinforced efforts in the fight against domestic violence carried out through the National Plans to Combat Domestic Violence. These have included more social support measures to victims, an increasing number of awareness programmes and, above all, a strong reliance on criminal law amendments, which have increased penalties and offered more protection measures to victims after they file a complaint.
In the light of such a scenario, this project will examine the legal response - juridical and judicial - to cases of domestic violence that have ended in homicide and homicide attempts, the most extreme scenario of violence that occurs in intimate relationships.
3) Gender - to frame the legal and judicial intervention in this particular type of criminal proceeding, starting from a criminological analysis that perceives this crime as a consequence of unequal gender relations.
These goals will be achieved through the use of quantitative (e.g. statistical analysis) and qualitative research methods (e.g. content analysis of judicial proceedings and interviews).
These methodologies will allow empirical investigation - which will go beyond mere statistical analysis (which has proved to be insufficient to understand the dynamics played by these homicides) or simple analysis of the law - in order to understand the reality of these homicides in the Portuguese context, so as to promote adequate socio-legal prevention and intervention measures.
Project results include one book, five scientific articles, a website, four regional workshops, the creation of a database from the analysis of the judicial proceedings, a training kit aimed at the judiciary, two advanced training courses for different audiences, a booklet with key recommendations and an international conference.


the website 'https://www.arduino.cc/en/Reference/WiFiMACAddress' needs an update.
It states that WiFi.macAddress() requires a parameter to save the address.
Actually this is just optional.
It's not required to loop through the byte array parameter to print the MAC address as String.


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Gaza Strip Human rights International International Politics News Report Refugees/Immigration West Bank
Suffering in Gaza Increases as Health Crisis Escalates
Gaza's Ministry of Health has confirmed that the situation in the Gaza Strip is getting worse with the daily depletion of available medicines, medical consumables and limited quantities of fuel.
Health Ministry representative Ashraf Al-Qedra said, in a brief statement on his Facebook page: "There is no solution on the horizon to these accumulated crises," pointing out that the international institutions, relief, human rights and the national action groups are on the details moment by moment.
He considers, according to Al Ray Palestinian Media Agency, the relief institutions to be essential partners in protecting and supporting the rights and therapeutic requirements of patients who are suffering, from the continuing siege and the systematic policies faced by those trapped in the Gaza Strip.
Al-Qedra called on all concerned parties to intensify their efforts in order to rectify the horrible health and humanitarian crisis.
It is noteworthy that the Ministry of Health in Ramallah stopped the supply of shipments of medicines and medical supplies to hospitals in Gaza Strip by political decision.
Meanwhile, the United Nations Relief and Works Agency for Palestine Refugees in the Near East (UNRWA) said, on Monday, that its financial deficit in 2017 amounted to 115 million dollars, noting that no reduction will occur to the services provided to refugees but it will be forced to implement austerity measures.
Bo Schack, Director of UNRWA operations in the Gaza Strip said, during a joint press conference with his counterpart in the West Bank, Scott Anderson, on Monday evening in Amman, that the UNRWA launched an emergency appeal for 2017 worth 406 million dollars, but then reduced it to 140 million dollars only due to the lack of support.
In the conference that took place during the meeting of the UNRWA advisory committee, Schack added that UNRWA has received donations that are not at the required level and it still needs 20 million dollars.
Schack warned, according to the Jordanian newspaper al-Ghad, that the situation in Gaza is on the verge of explosion due to the ten-year blockade imposed on it, the deterioration of life conditions and the absence of solutions.
For his part, director of UNRWA operations in the occupied West Bank, Scott Anderson, said that UNRWA is suffering from a huge deficit in the budget that covers the services delivered.
Anderson stated that UNRWA's regular budget for 2017 is 700 million dollars, to manage its operations in the five regions (Jordan, Syria, Lebanon, the West Bank and Gaza Strip), but, he added, the agency currently suffers from a major financial deficit of about 115 million dollars.
He explained that UNRWA relies on voluntary donations and that the agency has been forced to pursue an austerity policy to address its difficult financial situation without affecting the basic services, in addition to expanding the donor base.
He pointed out that the UNRWA Commissioner-General urged, in his report published two weeks ago, the donor countries to find effective ways to address the UNRWA financial situation, and presented a proposal to allocate a fixed budget for the agency, by the United Nations.
Anderson affirmed that UNRWA is working to improve the infrastructure of the refugee camps and will rebuild 42 health centers in the West Bank during the next five years.
Israeli Soldiers Abduct Five Palestinians Near Jerusalem
Israeli Army Injures One Palestinian, Cause 3 Medics To Suffer Effects Of Teargas Inhalation, In Qalqilia

redpajama_set_name: RedPajamaCommonCrawl


I'm grateful for another successful year of recurrent training. It doesn't matter how many times I go through, my stress increases when I'm being quizzed and evaluated. Some of the scenarios we train for are emergencies I only see once each year, and others, are something I've never encountered before. This helps me hone my skills and keep me sharp. However, I have to watch the internal critic who's still a master at putting myself down for being human, making mistakes, and not performing at my own personal standards.
I'm grateful for recovery, because I've learned not only how to keep that inner critic at bay, but also how to let things go and to give myself balance during these drills. In the past, I'd do nothing but eat, sleep and study. This year, like last, I continued to work on me by staying connected with friends, exercising, and add some enjoyment to my day. I'm grateful to have seen the Hans Solo movie opening night, Overboard, and Life of the Party while also enjoying a good book this past week. Throw in a baby shower with my coworkers, dinner with good friends, and ending the week watching the final episode of American Idol. This year's recurrent training was pretty much a non-event.


Multi-chamber pacing may result in capture of one chamber, capture of multiple chambers, fusion, or non-capture. Approaches for detecting various capture conditions during multi-chamber pacing are described. Pacing pulses are delivered to left and right heart chambers during a cardiac cycle. A cardiac electrogram signal is sensed following the delivery of the pacing pulses. Left chamber capture only, right chamber capture only, and bi-chamber capture may be distinguished based on characteristics of the cardiac electrogram signal. Multi-chamber capture detection may be implemented using detection windows having dimensions of time and amplitude. The detection windows are associated with expected features, such as expected signal peaks, under a particular capture condition. The cardiac electrogram signal features are compared to detection windows to determine the capture condition.
The present invention relates generally to cardiac devices and methods, and, more particularly, to cardiac devices and methods used in detecting capture in multi-chamber pacing.
A pace pulse must exceed a minimum energy value, or capture threshold, to produce a contraction. It is desirable for a pace pulse to have sufficient energy to stimulate capture of the heart chamber without expending energy significantly in excess of the capture threshold. Thus, accurate determination of the capture threshold is required for efficient pace energy management. If the pace pulse energy is too low, the pace pulses may not reliably produce a contractile response in the heart chamber and may result in ineffective pacing. If the pace pulse energy is too high, the patient may experience discomfort and the battery life of the device will be shorter.
Detecting if a pacing pulse "captures" the heart and produces a contraction allows the pacemaker to adjust the energy level of pace pulses to correspond to the optimum energy expenditure that reliably produces capture. Further, capture detection allows the pacemaker to initiate a back-up pulse at a higher energy level whenever a pace pulse does not produce a contraction.
When a pace pulse produces a contraction in the heart chamber, the electrical cardiac signal preceding the contraction is denoted the captured response. The captured response typically includes an electrical signal, denoted the evoked response signal, associated with the heart contraction, along with a superimposed signal associated with residual post pace polarization at the electrode-tissue interface. The magnitude of the residual post pace polarization signal, or pacing artifact, may be affected by a variety of factors including lead polarization, after-potential from the pace pulse, lead impedance, patient impedance, pace pulse width, and pace pulse amplitude, for example. The evoked response may be affected by interaction with intrinsic heart activity and resulting in a fusion or pseudofusion response.
Multi-chamber pacemakers may include electrodes positioned to contact cardiac tissue within or adjacent to both the left and the right ventricles for pacing both the left and right ventricles. This type of device allows bi-ventricular pacing therapy to be applied, for example, to coordinate ventricular contractions when a patient suffers from congestive heart failure (CHF). Furthermore, multi-chamber pacemakers may include electrodes positioned to contact tissue within or adjacent to both the left and the right atria to enable bi-atrial pacing.
It is desirable to determine if pacing pulses delivered to multiple heart chambers produce a captured response in one, both, or none of the paced chambers. The present invention provides methods and systems used for enhancing the discrimination of the cardiac response to multi-chamber pacing and provides various advantages over the prior art.
The present invention involves approaches for detecting various capture conditions during multi-chamber pacing. One embodiment of the invention involves a method for detection various capture conditions. Pacing pulses are delivered to left and right heart chambers during a cardiac cycle. A cardiac electrogram signal is sensed following the delivery of the pacing pulses. The method includes distinguishing between left chamber capture only, right chamber capture only, and bi-chamber capture based on characteristics of the cardiac electrogram signal.
According to one aspect, the pacing pulses are delivered to left and right ventricles. The method includes distinguishing between left ventricular capture only, right ventricular capture only, and bi-ventricular capture.
The cardiac electrogram signal may be sensed, for example, using an electrode positioned in, on or within a vein of the right heart chamber, using an electrode positioned in, on, or within a vein of the left heart chamber or using both left heart chamber and right heart chamber electrodes.
In one implementation, each of the templates, comprising detection windows having dimensions of time and amplitude, are associated with left chamber capture, right chamber capture, or bi-chamber capture. The cardiac electrogram signal is compared to one or more of the templates to determine the type of capture condition. The detection windows are associated with an expected feature, e.g., peaks, of the cardiac electrogram under a particular capture condition.
Another embodiment of the invention involves a cardiac device. The cardiac device includes a sensing channel configured to sense a cardiac electrogram signal following delivery of pacing pulses delivered to left and right heart chambers, respectively, during a cardiac cycle. A processor coupled to the sensing circuitry, the processor configured to distinguish between left chamber capture only, right chamber capture only, and bi-chamber capture based on characteristics of the cardiac signal.
FIG. 3 is a block diagram of an implantable medical device suitable for implementing multi-chamber capture detection in accordance with embodiments of the invention.
FIGS. 9A and 9B are flowcharts illustrating methods of selecting an electrode for capture sensing in accordance with embodiments of the invention.
A pacemaker or other cardiac rhythm management device may determine whether an applied electrical pacing stimulus captures a heart chamber. The systems and methods described herein involve the use of features of a cardiac electrogram to discriminate between various types of cardiac responses to multi-chamber pacing. The approaches of the present invention provide for enhanced capture threshold testing and/or beat to beat automatic capture verification for multi-chamber pacing, for example.
Several functions of cardiac devices rely on the heart response consistency. For example, automatic capture threshold testing and/or automatic capture verification algorithms may rely on templates of the heart's response as the basis for determining whether a future pacing stimulus produces a particular type of response.
Templates representative of various types of cardiac responses may comprise one or more detection windows. The detection windows are compared to a cardiac signal following delivery of multi-chamber pacing. In multi-chamber pacing, pacing pulses delivered to two opposite, i.e., left and right, heart chambers during a cardiac cycle. In accordance with embodiments of the invention, the cardiac signal following pacing is analyzed to discriminate, for example between left heart chamber capture, right heart chamber capture, multi-chamber capture, fusion and non-capture.
FIG. 1 is a flowchart illustrating a method of multi-chamber capture detection in accordance with embodiments of the invention. Pacing pulses are delivered 110 to left and right heart chambers during a cardiac cycle. For example, a pacing pulse may be delivered to the left ventricle (LV) and to the right ventricle (RV). The pacing pulses may be delivered over separate pacing channels and may be delivered substantially simultaneously or may be separated in time by an interventricular delay (IVD). The cardiac signal following delivery of the pacing pulses is sensed 120. The cardiac signal may be sensed, for example, using an evoked response sensing channel that is configured for detection of the cardiac response to the multi-chamber pacing. The cardiac response to the multi-chamber pacing is determined based on characteristics of the sensed cardiac signal. Capture of the left chamber only, right chamber only, multi-chamber capture, fusion or non-capture may be discriminated 130.
The embodiments of the present system illustrated herein are generally described as being implemented in a patient implantable medical device (PIMD) such as a pacemaker/defibrillator (PD) that may operate in numerous pacing modes known in the art. Various types of multiple chamber implantable cardiac pacemaker/defibrillators are known in the art and may be used in connection with cardiac devices and methods that provide multi-chamber capture detection in accordance with the approaches of the present invention. The methods of the present invention may be implemented in a variety of implantable or patient-external cardiac rhythm management devices, including multi-chamber pacemakers, defibrillators, cardioverters, bi-ventricular pacemakers, cardiac resynchronizers, and cardiac monitoring systems, for example.
A device suitable for implementing the capture detection methods of the present invention may include stimulation circuitry from delivering stimulation pulses to the heart and includes sensing circuitry comprising electrodes electrically coupled to the heart. Leads from the sensing and/or stimulation circuitry are coupled to electrodes positioned within heart chambers, positioned within veins of the heart, and/or positioned on the heart. The electrodes sense the heart's electrical signals, which are denoted cardiac electrogram signals. Each lead may include multiple electrodes, and each electrode may be used to sense a separate electrogram signal for capture detection.
Although the present system is described in conjunction with an implantable cardiac pacemaker/defibrillator having a microprocessor-based architecture, it will be understood that the implantable pacemaker/defibrillator (or other device) may be implemented using any logic-based circuit architecture, if desired.
Referring now to FIG. 2 of the drawings, there is shown a partial view of a cardiac rhythm management device that may be used to implement multi-chamber capture detection in accordance with the present invention. The cardiac rhythm management device in FIG. 2 includes a pacemaker/defibrillator 800 electrically and physically coupled to a lead system 802. The housing and/or header of the pacemaker/defibrillator 800 may incorporate one or more electrodes 908, 909 used to provide electrical stimulation energy to the heart and to sense cardiac electrical activity. The pacemaker/defibrillator 800 may utilize all or a portion of the pacemaker/defibrillator housing as a can electrode 909. The pacemaker/defibrillator 800 may include an indifferent electrode 908 positioned, for example, on the header or the housing of the pacemaker/defibrillator 800. If the pacemaker/defibrillator 800 includes both a can electrode 909 and an indifferent electrode 908, the electrodes 908, 909 typically are electrically isolated from each other.
The lead system 802 is used to detect electric cardiac signals produced by the heart 801 and to provide electrical energy to the heart 801 under certain predetermined conditions to treat cardiac arrhythmias. The lead system 802 may include one or more electrodes used for pacing, sensing, and/or defibrillation. In the embodiment shown in FIG. 2, the lead system 802 includes an intracardiac right ventricular (RV) lead system 804, an intracardiac right atrial (RA) lead system 805, an intracardiac left ventricular (LV) lead system 806, and an extracardiac left atrial (LA) lead system 808. The lead system 802 of FIG. 2 illustrates one embodiment that may be used in connection with the multi-chamber capture detection methodologies described herein. Other leads and/or electrodes may additionally or alternatively be used.
The lead system 802 may include intracardiac leads 804, 805, 806 implanted in a human body with portions of the intracardiac leads 804, 805, 806 inserted into a heart 801. The intracardiac leads 804, 805, 806 include various electrodes positionable within the heart for sensing electrical activity of the heart and for delivering electrical stimulation energy to the heart, for example, pacing pulses and/or defibrillation shocks to treat various arrhythmias of the heart.
As illustrated in FIG. 2, the lead system 802 may include one or more extracardiac leads 808 having electrodes, e.g., epicardial electrodes, positioned at locations outside the heart for sensing and pacing one or more heart chambers.
The right ventricular lead system 804 illustrated in FIG. 2 includes an SVC-coil 816, an RV-coil 814, an RV-ring electrode 811, and an RV-tip electrode 812. The right ventricular lead system 804 extends through the right atrium 820 and into the right ventricle 819. In particular, the RV-tip electrode 812, RV-ring electrode 811, and RV-coil electrode 814 are positioned at appropriate locations within the right ventricle 819 for sensing and delivering electrical stimulation pulses to the heart 801. The SVC-coil 816 is positioned at an appropriate location within the right atrium chamber 820 of the heart 801 or a major vein leading to the right atrial chamber 820 of the heart 801.
In one configuration, the RV-tip electrode 812 referenced to the can electrode 909 may be used to implement unipolar pacing and/or sensing in the right ventricle 819. Bipolar pacing and/or sensing in the right ventricle may be implemented using the RV-tip 812 and RV-ring 811 electrodes. In yet another configuration, the RV-ring 811 electrode may optionally be omitted, and bipolar pacing and/or sensing may be accomplished using the RV-tip electrode 812 and the RV-coil 814, for example. The RV-coil 814 and the SVC-coil 816 are defibrillation electrodes.
The left ventricular lead 806 includes an LV distal electrode 813 and an LV proximal electrode 817 located at appropriate locations in or about the left ventricle 824 for pacing and/or sensing the left ventricle 824. The left ventricular lead 806 may be guided into the right atrium 820 of the heart via the superior vena cava. From the right atrium 820, the left ventricular lead 806 may be deployed into the coronary sinus ostium, the opening of the coronary sinus 850. The lead 806 may be guided through the coronary sinus 850 to a coronary vein of the left ventricle 824. This vein is used as an access pathway for leads to reach the surfaces of the left ventricle 824 which are not directly accessible from the right side of the heart. Lead placement for the left ventricular lead 806 may be achieved via subclavian vein access and a preformed guiding catheter for insertion of the LV electrodes 813, 817 adjacent to the left ventricle.
Unipolar pacing and/or sensing in the left ventricle may be implemented, for example, using the LV distal electrode referenced to the can electrode 909. The LV distal electrode 813 and the LV proximal electrode 817 may be used together as bipolar sense and/or pace electrodes for the left ventricle. The left ventricular lead 806 and the right ventricular lead 804, in conjunction with the pacemaker/defibrillator 800, may be used to provide cardiac resynchronization therapy such that the ventricles of the heart are paced substantially simultaneously, or in phased sequence, to provide enhanced cardiac pumping efficiency for patients suffering from chronic heart failure.
The right atrial lead 805 includes a RA-tip electrode 856 and an RA-ring electrode 854 positioned at appropriate locations in the right atrium 820 for sensing and pacing the right atrium 820. In one configuration, the RA-tip 856 referenced to the can electrode 909, for example, may be used to provide unipolar pacing and/or sensing in the right atrium 820. In another configuration, the RA-tip electrode 856 and the RA-ring electrode 854 may be used to provide bipolar pacing and/or sensing.
FIG. 2 illustrates one embodiment of a left atrial lead system 808. In this example, the left atrial lead 808 is implemented as an extracardiac lead with LA distal 818 and LA proximal 815 electrodes positioned at appropriate locations outside the heart 801 for sensing and pacing the left atrium 822. Unipolar pacing and/or sensing of the left atrium may be accomplished, for example, using the LA distal electrode 818 to the can 909 pacing vector. The LA proximal 815 and LA distal 818 electrodes may be used together to implement bipolar pacing and/or sensing of the left atrium 822. The right atrial lead 805 and the left atrial lead 808 may be used in conjunction with the pacemaker/defibrillator 800 to provide bi-atrial pacing.
Referring now to FIG. 3, there is shown a block diagram of a cardiac pacemaker/defibrillator 900 suitable for implementing multi-chamber capture detection methods of the present invention. FIG. 3 shows a cardiac pacemaker/defibrillator 900 divided into functional blocks. It is understood by those skilled in the art that there exist many possible configurations in which these functional blocks can be arranged. The example depicted in FIG. 3 is one possible functional arrangement. Other arrangements are also possible. For example, more, fewer or different functional blocks may be used to describe a cardiac pacemaker/defibrillator suitable for implementing the methodologies for multi-chamber capture detection in accordance with the present invention. In addition, although the cardiac pacemaker/defibrillator 900 depicted in FIG. 3 contemplates the use of a programmable microprocessor-based logic circuit, other circuit implementations may be utilized.
The cardiac pacemaker/defibrillator 900 depicted in FIG. 3 includes circuitry for receiving cardiac signals from a heart and delivering electrical stimulation energy to the heart in the form of pacing pulses or defibrillation shocks. In one embodiment, the circuitry of the cardiac pacemaker/defibrillator 900 is encased and hermetically sealed in a housing 901 suitable for implanting in a human body. Power to the cardiac pacemaker/defibrillator 900 is supplied by an electrochemical battery 980. A connector block (not shown) is attached to the housing 901 of the cardiac pacemaker/defibrillator 900 to allow for the physical and electrical attachment of the lead system conductors to the circuitry of the cardiac pacemaker/defibrillator 900.
The cardiac pacemaker/defibrillator 900 may be a programmable microprocessor-based system, including a control system 920 and a memory 970. The memory 970 may store parameters for various pacing, defibrillation, and sensing modes, along with other parameters. Further, the memory 970 may store data indicative of cardiac signals received by other components of the cardiac pacemaker/defibrillator 900. The memory 970 may be used, for example, for storing historical cardiac electrogram and therapy data. The historical data storage may include, for example, data obtained from long-term patient monitoring used for trending and/or other diagnostic purposes. Historical data, as well as other information, may be transmitted to an external programmer unit 990 as needed or desired.
The control system 920 and memory 970 may cooperate with other components of the cardiac pacemaker/defibrillator 900 to control the operations of the cardiac pacemaker/defibrillator 900. The control system 920 depicted in FIG. 3 incorporates detection window circuitry 926 configured to provide multi-chamber capture detection as described herein.
The control system 920 further includes a cardiac response classification processor 925 that works in conjunction with the detection window circuitry 926. The cardiac response classification processor 925 performs the function of analyzing the location of cardiac signal features with respect to one or more detection windows to determine the cardiac response to pacing.
The control system 920 may include additional functional components including a pacemaker control circuit 922, an arrhythmia detector 921, along with other components for controlling the operations of the cardiac pacemaker/defibrillator 900.
Telemetry circuitry 960 may be implemented to provide communications between the cardiac pacemaker/defibrillator 900 and an external programmer unit 990. In one embodiment, the telemetry circuitry 960 and the programmer unit 990 communicate using a wire loop antenna and a radio frequency telemetric link, as is known in the art, to receive and transmit signals and data between the programmer unit 990 and the telemetry circuitry 960. In this manner, programming commands and other information may be transferred to the control system 920 of the cardiac pacemaker/defibrillator 900 from the programmer unit 990 during and after implant. In addition, stored cardiac data pertaining to capture threshold, capture detection and/or cardiac response classification, for example, along with other data, may be transferred to the programmer unit 990 from the cardiac pacemaker/defibrillator 900.
The telemetry circuitry 960 may provide for communication between the cardiac pacemaker/defibrillator 900 and an advanced patient management (APM) system. The advanced patient management system allows physicians or other personnel to remotely and automatically monitor cardiac and/or other patient conditions. In one example, a cardiac pacemaker/defibrillator, or other device, may be equipped with various telecommunications and information technologies that enable real-time data collection, diagnosis, and treatment of the patient. Various. embodiments described herein may be used in connection with advanced patient management.
Methods, structures, and/or techniques described herein, which may be adapted to provide for remote patient/device monitoring, diagnosis, therapy, or other APM related methodologies, may incorporate features of one or more of the following references: U.S. Pat. Nos. 6,221,011; 6,270,457; 6,277,072; 6,280,380; 6,312,378; 6,336,903; 6,358,203; 6,368,284; 6,398,728; and 6,440,066, which are hereby incorporated herein by reference.
In the embodiment of the cardiac pacemaker/defibrillator 900 illustrated in FIG. 3, electrodes RA-tip 856, RA-ring 854, RV-tip 812, RV-ring 811, RV-coil 814, SVC-coil 816, LV distal electrode 813, LV proximal electrode 817, LA distal electrode 818, LA proximal electrode 815, indifferent electrode 908, and can electrode 909 are coupled through a switch matrix 910 to sensing circuits 931-937.
A right atrial sensing circuit 931 serves to detect and amplify electrical signals from the right atrium of the heart. Bipolar sensing in the right atrium may be implemented, for example, by sensing voltages developed between the RA-tip 856 and the RA-ring 854. Unipolar sensing may be implemented, for example, by sensing voltages developed between the RA-tip 856 and the can electrode 909. Outputs from the right atrial sensing circuit are coupled to the control system 920.
A right ventricular sensing circuit 932 serves to detect and amplify electrical signals from the right ventricle of the heart. The right ventricular sensing circuit 932 may include, for example, a right ventricular rate channel 933 and a right ventricular shock channel 934. Right ventricular cardiac signals sensed through use of the RV-tip 812 electrode are right ventricular near-field signals and are denoted RV rate channel signals. A bipolar RV rate channel signal may be sensed as a voltage developed between the RV-tip 812 and the RV-ring 811. Alternatively, bipolar sensing in the right ventricle may be implemented using the RV-tip electrode 812 and the RV-coil 814. Unipolar rate channel sensing in the right ventricle may be implemented, for example, by sensing voltages developed between the RV-tip 812 and the can electrode 909.
Right ventricular cardiac signals sensed through use of the defibrillation electrodes are far-field signals, also referred to as RV morphology or RV shock channel signals. More particularly, a right ventricular shock channel signal may be detected as a voltage developed between the RV-coil 814 and the SVC-coil 816. A right ventricular shock channel signal may also be detected as a voltage developed between the RV-coil 814 and the can electrode 909. In another configuration the can electrode 909 and the SVC-coil electrode 816 may be electrically shorted and a RV shock channel signal may be detected as the voltage developed between the RV-coil 814 and the can electrode 909/SVC-coil 816 combination.
Left atrial cardiac signals may be sensed through the use of one or more left atrial electrodes 815, 818, which may be configured as epicardial electrodes. A left atrial sensing circuit 935 serves to detect and amplify electrical signals from the left atrium of the heart. Bipolar sensing and/or pacing in the left atrium may be implemented, for example, using the LA distal electrode 818 and the LA proximal electrode 815. Unipolar sensing and/or pacing of the left atrium may be accomplished, for example, using the LA distal electrode 818 to can vector 909 or the LA proximal electrode 815 to can vector 909.
A left ventricular sensing circuit 936 serves to detect and amplify electrical signals from the left ventricle of the heart. Bipolar sensing in the left ventricle may be implemented, for example, by sensing voltages developed between the LV distal electrode 813 and the LV proximal electrode 817. Unipolar sensing may be implemented, for example, by sensing voltages developed between the LV distal electrode 813 or the LV proximal electrode 817 and the can electrode 909.
Optionally, an LV coil electrode (not shown) may be inserted into the patient's cardiac vasculature, e.g., the coronary sinus, adjacent the left heart. Signals detected using combinations of the LV electrodes, 813, 817, LV coil electrode (not shown), and/or can electrodes 909 may be sensed and amplified by the left ventricular sensing circuitry 936. The output of the left ventricular sensing circuit 936 is coupled to the control system 920.
The outputs of the switching matrix 910 may be operated to couple selected combinations of electrodes 811, 812, 813, 814, 815, 816, 817, 818, 856, 854 to an evoked response sensing circuit 937. The evoked response sensing circuit 937 serves to sense and amplify signals developed using various combinations of electrodes for discrimination of various cardiac responses to pacing in accordance with embodiments of the invention. The cardiac response classification processor 925 may cooperate with detection window circuitry 926 to analyze the output of the evoked response sensing circuit 937 for implementation of multi-chamber cardiac pacing response classification.
Various combinations of pacing and sensing electrodes may be utilized in connection with pacing and sensing the cardiac signal following the pace pulses to determine the cardiac response to the pacing pulse. The pacemaker control circuit 922, in combination with pacing circuitry for the left atrium, right atrium, left ventricle, and right ventricle 941, 942, 943, 944, may be implemented to selectively generate and deliver pacing pulses to the heart using various electrode combinations. The pacing electrode combinations may be used to effect bipolar or unipolar pacing pulses to a heart chamber using one of the pacing vectors as described above.
In some implementations, the cardiac pacemaker/defibrillator 900 may include a sensor 961 that is used to sense the patient's hemodynamic need. In one implementation, the sensor may comprise, for example, an accelerometer configured to sense patient activity. In another implementation, the sensor may comprise an impedance sensor configured to sense patient respiration. The pacing output of the cardiac pacemaker/defibrillator may be adjusted based on the sensor output.
The electrical signal following the delivery of the pacing pulses may be sensed through various sensing vectors coupled through the switch matrix 910 to the evoked response sensing circuit 937 and/or other sensing circuits and used to classify the cardiac response to pacing. The cardiac response may be classified as one of left chamber capture only, right chamber capture only, multi-chamber capture, fusion and non-capture, for example.
Subcutaneous electrodes may provide additional sensing vectors useable for cardiac response classification. In one implementation, cardiac rhythm management system may involve a hybrid system including an intracardiac device configured to pace the heart and an extracardiac device, e.g., a subcutaneous defibrillator, configured to perform functions other than pacing. The extracardiac device may be employed to detect and classify cardiac response to pacing based on signals sensed using subcutaneous electrode arrays. The extracardiac and intracardiac devices may operate cooperatively with communication between the devices occurring over a wireless link, for example. Examples of subcutaneous electrode systems and devices are described in commonly owned U.S. Publication Nos. 2004/0230229 and 2004/0230230, which are hereby incorporated herein by reference in their respective entireties.
FIG. 4 is a flowchart illustrating a multi-chamber capture method in accordance with the present invention as applied to a bi-ventricular pacing embodiment. Detection windows are provided 402, each detection window corresponding to an expected feature of the cardiac signal under conditions of LV capture, RV capture or bi-ventricular capture. The detection windows may be provided based on clinical data taken from a number of patients or may be formed based on data taken from the patient.
In one implementation, detection windows associated with a particular capture condition may be formed by measuring a number of cardiac signals of the patient under the particular capture condition, extracting one or more features from each of the cardiac signals, clustering the features, and determining detection window boundaries based on the clustered features. In one implementation, the features extracted and clustered comprise positive and negative cardiac signal peaks. Forming detection windows based on clustering is described in commonly owned U.S. Publication No. 2006/0247707, which is hereby incorporated herein by reference. The one or more detection windows used for detecting the particular capture condition form a detection template. Detection windows and templates comprising one or more detection windows for each capture condition (LV capture, RV capture, and bi-ventricular capture) may be formed using the clustering approach or other methods.
In some cases, pacing the ventricles based on tracked atrial events is used to more closely mimic the patient's natural rhythm. During a cardiac cycle, an atrial pacing pulse is delivered to the atrium or atrial activity is sensed 404. An atrioventricular (AV) delay is initiated 406 relative to the sensed or paced atrial event. The AV delay may have a predetermined, programmable, or automatically adjustable duration.
Maintaining consistent bi-ventricular pacing enhances cardiac resynchronization. The AV delay may be set to a relatively short duration relative to the patient's AV conduction time to promote bi-ventricular pacing.
The first and second ventricles may be paced substantially simultaneously or in phased sequence. In one implementation, a first ventricle (left or right) is paced 408 relative to the AV delay and the second ventricle (right or left) is paced 410 relative an interventricular (IV) delay. The interventricular delay may be a fixed, programmable, or automatically adjustable duration.
The sensing channel used for capture detection, e.g., evoked response channel, is blanked 412 after the ventricular paces. For example, the evoked response channel may be blanked during the interventricular delay and for about 0 milliseconds to about 40 milliseconds after the last ventricular pace. After blanking, the cardiac signal is sensed 414. The cardiac signal comprises a cardiac electrogram signal that may be sensed using one or more electrodes positioned within one or more heart chambers and/or within one or more veins of the heart. In this implementation, the cardiac electrogram signal may be sensed using an electrode positioned in the right ventricle (RV tip electrode, RV ring electrode or RV coil electrode), an electrode positioned within a vein of the left ventricle (LV distal electrode or LV proximal electrode), and/or electrodes positioned in the right ventricle and the left ventricular vein, for example. The cardiac signal is compared to an activity detection threshold (ADT) which comprises positive and negative thresholds. If the cardiac signal does not exceed 416 the ADT in either the positive or negative direction, then the cardiac response is determined 418 to be a non-captured response. If non-capture is detected, 418 a back up pace may be delivered 420 to one or both ventricles.
If the cardiac signal exceeds 416 the ADT, the cardiac signal morphology is compared to the expected morphology associated with various capture conditions. Cardiac signal features are extracted and compared to detection windows comprising a template associated with a particular type of capture condition. Cardiac signal features may be compared 422 to one or more of a template associated with bi-ventricular capture, a template associated with LV capture and a template associated with RV capture.
In one implementation, the extracted features of the cardiac signal may comprise positive and negative peaks. The amplitude and timing of the cardiac signal peaks may be compared to expected peak amplitudes and peak times associated with capture conditions LV capture, RV capture, and/or bi-ventricular capture.
If the cardiac signal peaks fall within one or more detection windows associated with LV capture, then the capture condition is determined 426 to be LV capture. If the cardiac signal peaks fall within one or more detection windows associated with RV capture, then the capture condition is determined 424 to be RV capture. If the cardiac signal peaks fall within on or more detection windows associated with bi-ventricular capture, then the capture condition is determined 428 to be bi-ventricular capture. If the cardiac signal peaks do not fall within any of the detection windows, or if the cardiac signal peaks fall within multiple detection windows representing different capture conditions, then the capture condition may be determined to be fusion.
If the features of the cardiac signal are consistent with a particular capture template, then the particular capture template may be updated 430 using the features. Methods and systems for updating cardiac pacing response templates are described in commonly owned U.S. Publication No. 2006/0247696, which is hereby incorporated herein by reference.
FIG. 5 provides a composite graph of signals representative of bi-ventricular capture 510 and of signals representative of RV capture only (LV non-capture) 520. These signals follow pacing pulses delivered to the right and left ventricles. A signal similar to the bi-ventricular capture signals 510 is produced when the pacing pulses capture both ventricles. A signal similar to the RV capture signals 520 is produced when the pacing pulse delivered to the right ventricle captures the right ventricle and the pacing pulse delivered to the left ventricle does not capture the left ventricle.
Both the bi-ventricular capture signals 510 and the RV capture signals 520 have an initial peak followed by a peak of opposite polarity. However, the signals 510, 520 differ in morphology. As can be seen from FIG. 5, the morphology of the signals 520 associated with RV only capture have slightly wider peak widths and the peaks are delayed in time when compared to the signals 510 associated with bi-ventricular capture.
The morphological differences between signals associated with bi-ventricular capture 510 and signals associated with RV capture 520 can be utilized to discriminate between bi-ventricular capture and RV capture. FIG. 5 illustrates detection windows 512, 514 522, 524 that may be used to discriminate between bi-ventricular capture and RV capture.
First 512 and second 514 bi-ventricular detection windows are used to detect bi-ventricular capture. If the positive peak of a cardiac signal falls within the first bi-ventricular detection window 512 and the negative peak of the cardiac signal falls within the second bi-ventricular detection window 514, then the system determines that both the left and the right ventricles were captured by the pacing pulses.
If the positive peak of the cardiac signal falls in the first RV capture detection window 522 and the negative peak of the cardiac signal falls in the second RV capture detection window 524, then the system determines that the pacing pulse delivered to the right ventricle captured the right ventricle and the pacing pulse delivered to the left ventricle did not capture the left ventricle. If the positive or negative value of the cardiac signal does not exceed the ADT 505, then neither ventricle was captured. If the cardiac signal peaks do not fall within any of the detection windows, or if the cardiac signal peaks fall within multiple detection windows representing the two capture conditions, then the capture condition may be determined to be fusion.
FIG. 6 provides a composite graph of signals representative of bi-ventricular capture 610 and of signals representative of LV capture only (RV non-capture) 620. These signals follow pacing pulses delivered to the right and left ventricles. A signal similar to the bi-ventricular capture signals 610 is produced when the pacing pulses capture both ventricles. A signal similar to the LV capture signals 620 is produced when the pacing pulse delivered to the left ventricle captures the left ventricle and the pacing pulse delivered to the right ventricle does not capture the right ventricle.
As can be seen from FIG. 6, the signals associated with LV capture 620 have peaks that are inverted and delayed in time when compared to the signals associated with bi-ventricular capture 610. The morphological differences between signals associated with bi-ventricular capture and signals associated with LV capture can be utilized to discriminate between bi-ventricular capture and LV capture. FIG. 6 illustrates detection windows 612, 614, 622 that may be used to discriminate between bi-ventricular capture and LV capture.
First 612 and second 614 bi-ventricular detection windows are used to detect bi-ventricular capture. If the positive peak of a cardiac signal falls within the first bi-ventricular detection window 612 and the negative peak of the cardiac signal falls within the second bi-ventricular detection window 614, then the system determines that both the left and the right ventricles were captured by the pacing pulses.
If the positive peak of the cardiac signal falls in the LV capture detection window 622 then the system determines that the pacing pulse delivered to the left ventricle captured the left ventricle and the pacing pulse delivered to the right ventricle did not capture the right ventricle. If the amplitude of the cardiac signal does not exceed the ADT 605, in either the positive or negative direction, then neither ventricle was captured. If the cardiac signal peaks do not fall within any of the detection windows, or if the cardiac signal peaks fall within multiple detection windows representing the two capture conditions, then the capture condition may be determined to be fusion.
By way of example, the processes of the present invention may be used to enhance capture threshold testing to determine a suitable energy for pacing. Determination of a suitable pacing energy may be implemented, for example, by an automatic capture threshold testing procedure executed by an implantable pacemaker/defibrillator or other cardiac rhythm management device. Additionally, automatic capture verification may be used, for example, to monitor capture on a beat-by-beat basis. Automatic capture verification may be used to control back up pacing when a pace pulse delivered to the heart fails to evoke a captured response. These and other applications may be enhanced by the multi-chamber capture approaches of the present invention.
Those skilled in the art will appreciate that reference to a capture threshold testing procedure indicates a method of determining the capture threshold in one or more of the left atrium, the right atrium, both the left atrium and the right atrium, the left ventricle, the right ventricle, and/or both the left ventricle and the right ventricle. In such a procedure, the pacemaker, automatically or upon command, initiates a search for the capture threshold of the selected heart chamber or chambers. The capture threshold is defined as the lowest pacing energy that consistently produces a contraction of the heart chamber.
In one example of an automatic capture threshold procedure, the pacemaker delivers a sequence of pacing pulses to the heart chamber or chambers and detects the cardiac responses to the pace pulses. The energy of the pacing pulses may be decreased in discrete steps until a predetermined number of loss-of-capture events occur. After the predetermined number of loss-of-capture events occur, the pacemaker may increase the stimulation energy in discrete steps until a predetermined number of capture events occur to confirm the capture threshold. A capture threshold test may be performed using the multi-chamber capture detection approaches of the present invention.
Other procedures for implementing capture threshold testing may be utilized. In one example, the pacing energy may be initially set to zero or a relatively low pacing energy and then increased in discrete steps until capture is detected. In another example, the pacing energy may be adjusted according to a binomial search pattern.
Automatic capture threshold determination is distinguishable from automatic capture verification, a procedure that may occur on a beat-by-beat basis during pacing. Automatic capture verification verifies that a delivered pace pulse results in a captured response. When a captured response is not detected following a pace pulse, the pacemaker may deliver a back up safety pace to ensure consistent pacing. The back up pace may be delivered, for example, about 90-110 ms after the initial pace pulse. If a predetermined number of pace pulses delivered during normal pacing do not produce a captured response, the pacemaker may initiate a capture threshold test to determine the capture threshold. Automatic capture verification and back up pacing may be implemented using the multi-chamber capture detection processes of the present invention.
FIG. 7 illustrates an automatic capture threshold testing procedure for multi-chamber pacing using multi-chamber capture detection in accordance with approaches of the invention. The pacing energy of first and second heart chambers is initialized 710 to a value exceeding the capture threshold, such as a maximum pacing value. Blocks 715-730 illustrate a method of incrementally decreasing 715 the pacing energy of the first chamber until loss of capture (LOC) occurs 730. After each incremental reduction 715 in pacing energy, the first and second chambers are paced 720. The cardiac signal following the pacing energy is sensed 725 and compared to one or more detection windows associated with expected characteristics of multi-chamber capture and/or second chamber only capture and/or first chamber only capture. If the signal characteristics are consistent with second chamber only capture, then loss of capture of the first chamber is detected 730. The first chamber energy value is stored 735 as the first chamber capture threshold.
The pacing energy of the first chamber is reinitialized 740 to a value exceeding the capture threshold. Blocks 745-755 illustrate a method of incrementally decreasing 745 the pacing energy of the second chamber until loss of capture (LOC) occurs 755. After each incremental reduction 745 in pacing energy, the first and second chambers are paced 750. The cardiac signal following the pacing energy is sensed 752 and compared to one or more detection windows associated with expected characteristics of multi-chamber capture and/or second chamber only capture and/or first chamber only capture. If the signal characteristics are consistent with first chamber only capture, then loss of capture of the second chamber is detected 755. The second chamber energy value is stored 760 as the second chamber capture threshold.
In some embodiments, a first electrogram signal may be used to determine the capture condition and one or more additional electrogram signals may be used to confirm or increase a level of confidence in the capture determination. In some implementations, the first electrogram signal may be sensed using an electrode electrically coupled to a first heart chamber and an additional electrogram signal may be sensed using an electrode electrically coupled to a second heart chamber. In some implementations, the first and additional electrogram signals may be sensed using electrodes electrically coupled to the same chamber.
The processor may evaluate the first and additional cardiac electrogram signals to distinguish capture conditions in various combinations. For example, the processor may evaluate the first signal to discriminate between a first two of right chamber capture only, left chamber capture only, and multi-chamber capture to determine the capture condition. The processor may use an additional signal to distinguish between a second two of right chamber capture only, left chamber capture only, and multi-chamber capture to confirm the capture condition. Distinguishing between other combinations of capture conditions including left chamber capture only, right chamber capture only, multi-chamber capture, non-capture, and fusion for capture confirmation is possible.
A process of using an additional electrocardiogram signal for confirming capture determination is illustrated by the flowchart of FIG. 8. Pacing pulses are delivered 1010 to left and right heart chambers during a cardiac cycle. A first electrogram signal is sensed 1020, for example, using an electrode associated with a first heart chamber. A second electrocardiogram is sensed 1030, for example, using an electrode associated with a second heart chamber. The capture condition is determined 1040 using the first signal. The second signal is used to confirm 1050 or increase confidence in the capture condition determination.
In some embodiments, a selected electrode may be used to determine the capture condition. The selection may be based on parameters of the signal produced using the electrode, including, for example, signal integrity (signal to noise ratio), suitability for capture detection, sensitivity to a particular capture condition, e.g., LV capture or bi-ventricular capture, over sense condition, lead impedance outside a predetermined range, capture amplitude voltage outside a predetermined range, intrinsic amplitude outside a predetermined range, detection of unintended non-cardiac stimulation, failure to detect an expected event and/or other parameters of the signal. FIGS. 9A and 9B are flowcharts illustrating electrode selection processes in accordance with embodiments of the invention.
FIGS. 9A and 9B illustrate methods of selecting capture sensing electrodes for use in automatic capture threshold testing and/or beat to beat automatic capture verification. The process illustrated in FIG. 9A may be particularly suited, for example, for use in connection with an automatic capture threshold test. Prior to beginning the test, the signals produced by available electrode combinations are evaluated 1101 with respect to signal to noise ratio and/or other parameters associated with capture detection suitability as described above. An electrode combination is selected 1105 for capture detection during the test. Pacing pulses are delivered 1110 to left and right heart chambers. The cardiac signal is sensed 1115 using the selected electrode combination. The capture condition is determined 1120 based on characteristics of the sensed signal.
The capture determination process illustrated by the flowchart of FIG. 9B may be used, for example, to select between available electrode combinations in beat to beat automatic capture verification, and/or other capture detection processes. The illustrated process allows the pacemaker to switch between capture sensing electrodes if the signal from a particular electrode combination becomes noisy or produces unreliable capture results. An initial electrode combination is selected 1125 for capture sensing. Pacing pulses are delivered 1130 to the left and right heart chambers. A cardiac electrogram signal is sensed 1135 using the selected electrode combination. If the signal is suitable 1140 for capture detection, e.g., not noisy, minimum signal level, etc., then the capture condition is determined 1150 based on the signal characteristics. If the signal is unsuitable 1140 for capture detection, particularly if the signal is persistently unsuitable, then the system may select 1145 a different electrode combination. Methods and systems for selective use of various electrode combinations to improve capture detection and other pacemaker/defibrillator functions, aspects of which may be utilized in connection with the present invention, are described in commonly owned U.S. Pat. No. 6,493,586 which is incorporated herein by reference.
The components, functionality, and structural configurations depicted herein are intended to provide an understanding of various features and combination of features that may be incorporated in an implantable pacemaker/defibrillator. It is understood that a wide variety of cardiac monitoring and/or stimulation device configurations are contemplated, ranging from relatively sophisticated to relatively simple designs. As such, particular cardiac device configurations may include particular features as described herein, while other such device configurations may exclude particular features described herein.
confirming left chamber capture only, right chamber capture only, or bi-chamber capture based on characteristics of the additional cardiac electrogram signal.
2. The method of claim 1, wherein distinguishing between at least two of left chamber capture only, right chamber capture only, and bi-chamber capture comprises distinguishing between left chamber capture only, right chamber capture only, and bi-chamber capture.
distinguishing between the at least two of left chamber capture only, right chamber capture only, and bi-chamber capture comprises distinguishing between at least two of left ventricular capture only, right ventricular capture only, and bi-ventricular capture.
4. The method of claim 1, wherein the first electrode is a right heart chamber electrode.
5. The method of claim 1, wherein the first electrode is a left heart chamber electrode.
6. The method of claim 1, wherein sensing the cardiac electrogram signal comprises sensing the cardiac electrogram signal in a bipolar fashion using the first electrode and another electrode.
confirming left chamber capture only, right chamber capture only, or bi-chamber capture comprises distinguishing between a second two of left chamber capture only, right chamber capture only, or bi-chamber capture based on characteristics of the additional cardiac electrogram signal.
distinguishing between the at least two of left chamber capture only, right chamber capture only, and bi-chamber capture based on the comparison.
9. The method of claim 1, wherein delivering the pacing pulse to the left heart chamber and delivering the pacing pulse to the right heart chamber comprises delivering the pacing pulse to the left heart chamber and delivering the pacing pulse to the right heart chamber through separate channels.
10. The method of claim 1, wherein delivering the pacing pulse to the left heart chamber and delivering the pacing pulse to the right heart chamber comprises delivering the pacing pulses separated in time by an interventricular delay.
11. The method of claim 1, wherein distinguishing between the at least two of left chamber capture only, right chamber capture only, and bi-chamber capture further comprises distinguishing between left chamber capture only, right chamber capture only, bi-chamber capture, fusion, and non-capture of the left and right heart chambers.
wherein the processor is configured to confirm left chamber capture only, right chamber capture only, or bi-chamber capture based on characteristics of the additional cardiac electrogram signal.
13. The device of claim 12, wherein the processor is configured to distinguish between left chamber capture only, right chamber capture only, and bi-chamber capture based on characteristics of the cardiac electrogram signal.
14. The device of claim 12, wherein the processor is configured to distinguish between left chamber capture only, right chamber capture only, bi-chamber capture, fusion and non-capture of either chamber.
15. The device of claim 12, wherein the sensing circuitry comprises an electrode adapted to be positioned in the right heart chambers and the sensing circuitry is configured to sense the cardiac electrogram signal using the electrode.
16. The device of claim 12, wherein the sensing circuitry comprises an electrode adapted to be positioned within a vein of the left heart chamber, and the sensing circuitry is configured to sense the cardiac electrogram signal using the electrode.
17. The device of claim 12, wherein the sensing circuitry comprises a left heart chamber electrode adapted to be positioned within a vein of the left heart chamber and a right heart chamber electrode adapted to be positioned in the right heart chamber, and wherein the sensing circuitry is configured to sense the cardiac electrogram signal using the left heart chamber electrode and the right heart chamber electrode.
18. The device of claim 12, wherein the processor is configured to compare the cardiac electrogram signal to one or more templates, each template associated with at least one of left chamber capture, right chamber capture, and bi-chamber capture.
19. The device of claim 12, further comprising stimulation circuitry configured to deliver the pacing pulses to the left chamber and the right chamber.
20. The device of claim 19, wherein the stimulation circuitry is configured to deliver the pacing pulses to a left ventricle and a right ventricle, the delivered pacing pulses separated in time by an interventricular delay.
means for confirming multi-chamber capture, left chamber capture only, or right chamber capture only, based on characteristics of the additional cardiac electrogram signal.
22. The system of claim 21, wherein the distinguishing means is adapted to distinguish between bi-ventricular capture, left ventricular capture only, right ventricular capture only, non-capture of the left and right heart chambers, and fusion, based on the characteristics of the cardiac electrogram signal.
wherein the distinguishing means distinguishs between at least two of bi-ventricular capture, left ventricular capture only, and right ventricular capture only based on the comparison.
US650571A (en) * 1898-08-05 1900-05-29 Hadwen Swain Gas or oil engine.


Halloween candy is out in stores and at least one house in my neighborhood is TOTALLY super ready for Halloween. So this week, I asked our contributors to talk about their favorite Scary Stories. Here are a whole host of some spooky books to fill up your reading lists!
This topic is a bit easier to pick from because I haven't read too many scary /creepy books. Now there is an author that I consider the Queen of Creepy, that's Gretchen McNeil. I have read Possess and Ten by Gretchen and man oh man, they are super SCARY and even creepier. Gretchen's books are not the kind you read with all the lights off. Another book I give honorable mention to is Still Waters by Emma Carlson Berne, creepy and mysterious. I need to read more scary books!
I'm breaking the rules a little bit, because this is a short story and not a book, but my favorite spooky tale is THE LANDLADY, by Roald Dahl. I read it to my class a decade ago, (I was a teacher in another life), and it left us all with chills. There's nothing gritty or gruesome within the pages--no blood or gore--but at the end of the story, you know it's coming. Since I don't like graphic violence, my favorite kind of horror is when the killings take place off the page...in my own imagination. I'm shivering just thinking about it!
I have a special, dark & twisty corner of my heart tucked away for scary stories. I decided to go old school this week and choose a book of short stories by the master, H.P. Lovecraft, titled The Best of H.P. Lovecraft: Bloodcurdling Tales of Horror and the Macabre. You want some short stories that make you want to hide under your covers and begin to question your own sanity. This is the book. One of my favorite short stories ever is in this book. It's called "The Rats in the Walls" and it is the best example of watching a main character go insane in first person that I've ever seen. It's fascinating, terrifying, and I love it.
Even though Halloween is my favorite holiday and I love doing things like ghost tours, I am a big chicken so my Scary Story may be a little tame for any horror fans. I recently read The Devil's Metal by Karina Halle, which started out a lot like the movie Almost Famous and ended up like Hellraiser. The story follows Dawn as she tours with 70's metal band Hybrid, so the first half of the book is a lot of music and rock star antic, so it's absolutely fine. But as you move into the second half of the book, it is clear that something is not right with the band although it is unclear whether it is the Satan worshipping drummer or a curse or hex of some type. Things get creepier and scarier as you find out more about what haunts Hybrid and, while I couldn't put the book down, I didn't love the way it has me jumping at shadows the night I finished it.
Whether it's a book or film, I don't scare easily. But one of the best scary stories I've read in a long time is Rick Yancey's The Monstrumologist. If you like TV shows like The X-Files and Supernatural, you'll enjoy his series of period mystery/horror/thriller books concerning Dr. Warthrop, a man who studies monsters, and his young but able assistant, Will Henry. In the first of these, The Monstrumologist, they are on the track of a vicious and deadly race of legendary creatures called the Anthropophagi--people eaters. Or perhaps the Anthropophagi are tracking them. Creepy, right? An unsettling but compelling read, this book might remind you of your favorite Lovecraft stories, or your worst nightmares.
Great picks! Well Possession wasn't my favorite scary book, there's no doubt that it had it's creepy moments. If you want creepy, just pick up Edgar Allen Poe and you'll be set!


text:
Q: Algebra subgroup question Let $G$ be a group, and let $H$ be a subgroup of $G$. Define $$C_G(H) := \lbrace g \in G \mid h \in H :gh=hg \rbrace.$$
(The set $C_G(G)$ is called the centralizer of $H$ in $G$.) Show that $C_G(H)$ is a subgroup of $G$.
We have that $gh \in C_G(H)$ so the 1st condition of a subgroup holds. The 2nd condition states that $(gh)^{-1}$ must also be in $C_G(H)$ and indeed it is since $g^{-1} \in H$ and $h^{-1} \in H$ so that $(gh)^{-1}=g^{-1}h^{-1}$. Therefore $C_G(H)$ is indeed a subgroup of $G$ as well.
Is this the  correct way to go about proving this? Did I leave any gaps? I just want to know if there was a better way to prove this or a shorter way of doing it.

A: First you have to show that $C_G(H)$ is closed under the group operation and to show that :
if $g_1$ and $g_2$ belong to $C_G(H)$,where $g_1$ and $g_2$ are in $G$ then $g_1h=hg_1$ and $g_2h=hg_2$ for all $h \in H$.
Now $g_1g_2h=g_1(g_2h)=g_1hg_2=(g_!h)g_2=hg_1g_2$ for all $h \in H$
Hence $g_1g_2 \in C_G(H)$.
Clearly $e \in C_G(H)$ as $eh=he$ forall $h \in H$
For inverse observe that once $g_1 \in C_G(H)$, $g_1h=hg_1$ foral $h \in H$. Hence $g_1^{-1}h=hg_1^{-1}$ forall $h \in H$

redpajama_set_name: RedPajamaStackExchange


If you have a developmental disability or love someone with a developmental disability, then here at The Council, you are family. And you will not be left behind. And you shall not be forgotten. At the heart of our mission is the notion that every life matters, that differences are to be embraced and celebrated. The Council commits itself to every Kentuckian with a developmental or intellectual disability, at every stage of life. From prenatal diagnosis to the end of life, we strive to be your advocate and your friend.
We are a small nonprofit with a great big vision: a society that includes, values and empowers children, youth and adults with developmental disabilities. Our mission is to initiate positive change on behalf of our constituents. The Council is a Louisville-based nonprofit that provides advocacy training, support, crisis intervention, information referral, guidance and outreach activities to families, to their children and to adults with autism-spectrum disorders, Down syndrome, cerebral palsy, spina bifida, seizure disorders, and the spectrum of developmental and intellectual disabilities. We have been affiliated with Metro United Way as a partner agency for 45-plus years, and we are grateful for United Way's commitment to serving our community.
The Council helps families support loved ones -- providing training, information and one-on-one assistance to navigate the complexities surrounding special needs trusts, Medicaid waivers, guardianship and the education system. We are here to serve your family for a lifetime, offering training and empowerment through all the stages of your journey.
The Council was founded more than 60 years ago when newspaper publisher Barry Bingham Sr. printed an open letter inviting families of children with developmental disabilities to organize in mutual support. In 1952, a small band of parents responded to the call, joining together to form a private, non-profit parent association. Through the years, The Council's advocacy initiatives have led to changes in laws, services and expectations that have reshaped the culture and the landscape for all Kentuckians with developmental disabilities.
Education advocate. In the 1950s, The Council founded the legendary Stevens School, one of the earliest schools in the nation to integrate children with developmental disabilities. (Twenty years before kids with developmental disabilities were allowed, by law, to attend the public schools!) For more than six decades now, we have been strong advocates of educating children with disabilities. It is at the heart of our mission and work.
Program creator. The Council developed several innovative enterprises to serve people with disabilities. These programs were later transitioned to public or private organizations for ongoing operation. Successful spinoff ventures of The Council include ZoomGroup, one of Kentucky's largest providers of vocational services for adults with developmental disabilities; enTECH, an assistive technology center at Spalding University; and Custom Quality Services, a non-profit whose mission is to create jobs in an integrated setting for people with disabilities and others who face barriers to employment.
Change maker. In 1999, The Council brought 52 organizations together around a vision for services for people with developmental disabilities with the organizing of the Coalition for Quality and Choice. The Coalition's efforts led to an unprecedented increase in expenditures to serve Kentuckians with disabilities.
Public policy leader. The Council was a leader in the movement to pass the Adult Protection Registry, legislation to help prevent the abuse, neglect and exploitation of older adults and individuals with disabilities. After a six-year push, The Registry was successfully passed into law in Kentucky in spring 2014.
Arts advocate. In 2009, The Council opened Weber Gallery, a venue designed to bring together professional artists and artists with disabilities for joint exhibits, Today, the gallery focuses on outreach through art-making projects that engage individuals with disabilities to express themselves through the creation of art.
Community partner. The Council was recognized with a 2014 Imagine Award for its work on behalf of people with disabilities. The Imagine Awards, presented by the Rauch Foundation, celebrate those committed to making a better community and world for people with disabilities.


Our Leaf cross pendant is an elegant design featuring beautiful Cardinal Amethyst round cut Swarovski crystals. This cross comes from the 'Leaf' TM from the SJC 'Vintage Collection' TM. Beautiful wood carved detail accents the cross along with 8 leaves surrounding the center stanhope viewer. Each leaf holds a brilliant Cardinal Amethyst purple Swarovski round crystal rhinestone, with a total of 8 crystals. The Cardinal Amethyst purple crystals are the February birthstone. Choose from Sterling Silver, Silver Tone, Gold Tone, Gold Plated, or Vermiel. This setting is accented with our ultra-high resolution stanhope picturelens. A peep inside the stanhope center reveals the crystal clear image of your choice or to personalize your Leaf cross, upload your own favorite photo. You can also add your own custom message or title. There are many images to choose from including Jesus, The Holy Family, Ten Commandments, Psalm 23, L'Ascension, The Lord's Prayer in English, Spanish, Hebrew and quite a few others. You may also select to add a chain in various lengths. Nicely packaged in a gift box and arrives with a gift bag with tag. Made completely in our workshop in the USA.
Pendant measures approximately 7/8 inches x 1 3/8 inches.


Last week, Homer Brink Elementary School in the Maine-Endwell School District completed the first step of their Maple Project! Students braved the cold to learn how to identify maple trees and the process of tapping the trees. They even got to taste the sap!
Over the next two months students will be learning how to track the temperature and see its effect on the amount of sap the trees produce. The sap will be taken to a local sugar shack and boiled down by families in the district to make maple syrup. One pint will be submitted to judged with syrups from across New York State. In April, the students will celebrate the end of the project and all of their hard work by enjoying a pancake breakfast with the syrup they all worked together to make.


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Above all, an attempt has been made, wherever this seemed feasible, to translate philosophic ideas, normally expressed only in words, into diagrams that convey the same information by way of geometrical metaphor.
After some years of work, spring tides proved that the project was not feasible and all the money that had been spent was as completely lost as if it had been thrown into deep water.
The third alternative, namely that of living in "open sin", is the one which is least harmful, both to the individual and to the community, where it is feasible, but for economic reasons it is impossible in most cases.
The enormous cost shows [indicates] that the plan is in feasible (=not feasible).
Your plan sounds quite feasible.


text:
Listen 12 min
Honoring the tamalada — the Christmas tradition of making tamales
Hosted by Evan Kleiman Dec. 16, 2022 Food & Drink
"The masa that comes from corn, has been dated to 9,000 years ago," says culinary anthropologist Claudia Serrato. Photo by Graydon Herriott.
Christmas in LA means tamale season. If you drive past Cinco Puntos or Tamales Lilianas on Christmas Eve, you will see a queue of hungry folks waiting for a dozen or more of their favorite flavors. For other families tomato season means a tamalada, where friends and family gather and make their own tamales. For culinary anthropologist Claudia Serrato, the tamalada is a yearly ritual. Serrato studies north and Mesoamerican foodways and food is her way to revitalize ancestral memories.
KCRW: Give us a brief history of the tamale.
Claudia Serrato: Tamales have been around for a very long time, and they're very significant for Mesoamerican peoples. Masa, which comes from corn, has been dated to 9000 years ago. So that means the wild version of what has become the domesticated corn, which eventually becomes the masa that is used for the tamale making. In indigenous terms, it has existed since time immemorial. That means that there is no true memory of its origins. However, archaeologists are doing their best to figure this out. So many indigenous pueblos throughout Mexico came up with their own style of tamales. Some take more of a triangle shape. In Mexico City, they are more of the original style of tamale – which is a word meaning wrapped or wrapped food. These tamales predate the tortilla.
Do they know if they reference any other main material besides corn, or does the word presuppose it will always be corn?
It's really interesting because not all masa comes from corn. Masa has also been made with different amaranths. There is a black, red, and white amaranth. That was another grain that was used in the preparation of masa. We also see the same thing in South America – there was the use of quinoa as the masa that the tamales of those regions.
In the Mesoamerican world, do these amaranth mosses still live on today?
Amarinth is actually remembered and it is utilized and integrated in the making of masa. Now because this particular grain was deemed unusable by the Spanish during the time of conquest, many folks forgot about the combination and how nutritionally dense it would make the masa of corn. I have learned to bring it back into my tamale making. What I have found is that it actually fluffs the masa – it creates little pockets of air. So it allows for there to be a fluff, as you cut right into the masa or as you put the masa up into your mouth. It's quite wonderful.
What do we know about how they were made in Mesoamerican times? In terms of the process, and were people already filling them? Or, was it more like a dough?
In pre-colonial times, tamales were prepared all year long, and they were not made just as pockets of dough. They were actually filled. They were usually seasonal fillings. Say it was the springtime, for those that were brought up the coast, you would see more fish. For folks that were up in the hillside you would see more rabbit, or more deer. And for folks that had no access to large bodies of water, then you would see the tamales filled with different plant relatives. Tequesquite was also used as a riser – it is a mineral that comes from the lakes, and it's very rocky, and very salty.
Tamales of pre-colonial times did not contain any lard as we know them today. The texture was a little more coarse and dense. Aside from fish, deer, rabbit, and other wild plants, tamales were made with turkey, iguana, frogs, birds, shrimp, cricket, larva, avocados, bean, tomato, fruit, and vegetables. My ultimate favorite is cacao. Tamales weren't limited to four or five tamales like we know them today – and not just that, but also to the method of preparing them. Some were actually placed on top of comal – just like you would have tortilla – you just kept flipping them and turning them so those would be considered comal tamales. And some tamales were buried underground. Those weren't deep-steamed as we see barbacoa beans, deep steam today. There were also other technologies that were made so that you could place the tamales inside, over a large burning fire. There was a lot of variety. There was a lot of diversity.
Let's talk about modern day and people eating and making tamales. It seems like tamales have been pushed into this one time of year.
Really interestingly, tamales are accessible and available year round. We see this throughout Mexico, Central America, and South America. But in the United States, it seems to be a food that is most craved during the fall equinox or Christmastime. It's really a time when family is able to come together. In my home, this has been since I was born – so for 45 years now, my family continues to honor the tradition of the tamalada. The tamaladas are usually large. There's usually about 20 of us that are doing this work. So you have your grinders, and the masiendos.
What's a masiendo?
The folks that are actually preparing the masa – they're mixing it. I don't like to use a mixer for my masa – for me, it takes away that cultural connection. I'm really used to digging my hands in there and mixing. It's a lot of arm work and doing that reminds me of my grandmother. This is a little emotional for me – but I remember her arms, and I remember looking at them and watching her really mix the masa. It almost felt like it was like a never-ending story. I was always so impatient, but patiently waiting for her to stop. Because she said it was something you just had to keep on doing until the masa was ready. That way, it goes on to the next stage, which is to be able to begin spreading the masa to the oja. It's labor-intensive, but that's the point to make in the tamales because it creates unity. It brings us together, and not just that, but it asserts who we are as indigenous Mesoamerican peoples still thriving, and still surviving in such a beautiful way as we are today.
You make blue corn and bison tamales. Do you make more than one kind of masa?
There are multiple tamales that I like to make and my family likes to make. We use white corn, red corn, and blue corn. Sometimes, tamales are made using Chile poblano; Those are some of my favorites. But the ones that have actually become my signature tamales have been my bison blue corn. And I specifically use the blue corn because it is one of the corns that has not been genetically modified as many other corns have. I also liked this corn because it really complements the bison.
After all of this work, when do people sit down and actually eat the tamales?
Immediately following a Tamalada there are two sessions where one sits down to eat. The first is the taster. So that is when there is a round of tamales, which is usually the first batch where those that are in the kitchen, get to taste – still covered in masa, still with our dirty aprons – we take our first bite. Now this first bite is a slow bite because the tamale is very hot. The feeling I'm always looking for is that feeling that just makes me just go, "oh my goodness." It's a nod. It's a smile. It's at that point that you freshen up, do what you got to do. Then, the tamales are eaten all throughout the day. We usually save the sweet tamales for last.
Evan Kleiman
Laryl Garcia, Gillian Ferguson, Elina Shatkin
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