MIDWESTERN UNDERWRITING · PDF file · 2016-09-12• Aircraft shock absorbers ... // ... Development and generalized use of “smartphones” having

MIDWESTERN UNDERWRITING CONFERENCEMINNEAPOLIS, MN

September 21, 2016

Robert Lund MD

A Geographic Consideration!

12/09/2016Title of presentation and name of speaker 2

Conclusion: We Need to Build More Taverns to Lower Prevalence of Obesity in The United States!


Obesity, US Adults, 2010

The more intense the red thehigher the incidence of obesity

Conclusion: We Need to Build More Taverns to Lower Death Rates Due to Heart Disease in the United States


We May Not Consider Common Chores To Be Associated with Risk


Maybe This Is Why Most Accidents Occur in The Home !


How Complete Are Out MVR’s ?


WEARABLE DEVICES

WILL THEY BE READY FOR PRIME TIME IN LIFEINSURANCE UNDERWRITING ANYTIME SOON?

Midwestern Underwriting Conference

September 21, 2016

Robert W. Lund MD

Probable Inventor of The First Wearable Device


Leonardo da Vinci in 15th Century

Romans used it to calculate the approximate distance military troops had to travel on foot

Da Vinci used it to measure distance more accurately in map making

A gear-driving device with a pendulum arm that would swing to and fro with leg motion while walking

Independence Hall, 1787


The Pedometer: A Mechanical Instrument to Evaluate Walking Behavior

12/09/2016 11

Thomas Jefferson supposedly introduced pedometers (“TomishMeters”) to North America

Pedometers really didn’t catch on until the 1930’s when they became popular with long distance walkers (“Hike-o-meters”)

One pendulum swing produces a “count”

Number of counts x stride length = distance walked

https://www.google.com/search?q=mechanical+pedometer&biw=1680&bih=878&tbm=isch&tbo=u&source=univ&sa=X&sqi=2&ved=0ahUKEwjYyLqU6YTLAhVBox4KHWPaDRcQsAQIUw&dpr=1 Accessed 2/19/2016

http://www.explainthatstuff.com/how-pedometers-work.html Accessed 2/19/2016

https://www.google.com/search?q=mechanical+pedometer&biw=1680&bih=878&tbm=isch&tbo=u&source=univ&sa=X&sqi=2&ved=0ahUKEwjYyLqU6YTLAhVBox4KHWPaDRcQsAQIUw&dpr=1

http://www.explainthatstuff.com/how-pedometers-work.html

Wearable Ambulatory Monitors Sense Physical Motion

Pedometer or Actometer(Assesses “quantity” of “counts”)

Does not well assess older adults with slow or shuffling gaits

Mechanical(count motion only if certain threshold is

reached)Quantity or Quantity and intensity of movement

Electric processing of digitalized data

Electronic

12/09/2016 12Title of presentation and name of speaker

Development of Obesity Problem in The United States Led to Efforts to Increase Activity in The Population


http://www.cdc.gov/nchs/data/hestat/overweight/overweight_adult.pdfAccessed April 25, 2011

Adapted from:

0.00

0.10

0.20

0.30

0.40

1960 1970 1980 1990 2000 2010

BMI = 40 and above

BMI = 30 - 39

BMI = 25 = 29

Proportionof US

Population

Year

Trends in overweight, obesity & extreme obesity in the US

http://www.cdc.gov/nchs/data/hestat/overweight/overweight_adult.pdf

THE ACCELEROMETER

Accelerometers used since the late 1930’s to monitor mechanical wear and force exposure

• An airplane catapult• Passenger elevators• Aircraft shock absorbers

Accelerometers record accelerations of…

• Vibrations of steam turbines and underground pipes• Forces of explosions

Accelerometers record …


In ranges up to 100 g and high Hertz levels

Accelerometer

• Static forces • Constant force of pull of gravity (g = 9.81 m/s2)

• Dynamic forces• Movement

Electromechanical device that will measure acceleration forces

• Determine the angle a device is tilted at with respect to earth

Static acceleration due to gravity

• Detect direction and magnitude of acceleration (g-force or change in g-force)

Dynamic acceleration (vector)


Piezoelectric Accelerometer


Accelerative forces move microscopic crystal structures or piezoceramics and an electric current is generated

Best in high frequency ranges they are preferred in high shock applications

https://www.google.com/search?q=piezoelectric+accelerometer&biw=1664&bih=824&tbm=isch&tbo=u&source=univ&sa=X&sqi=2&ved=0ahUKEwj5udm-h57LAhUJVh4KHSi6AOUQsAQIQQ#imgrc=ki8ZOdztfJ4qZM%3AAccessed 2/29/2016

In an accelerometer, the stress on the crystals occurs as a result of the seismic mass imposing a force on the crystal.

https://www.google.com/search?q=piezoelectric+accelerometer&biw=1664&bih=824&tbm=isch&tbo=u&source=univ&sa=X&sqi=2&ved=0ahUKEwj5udm-h57LAhUJVh4KHSi6AOUQsAQIQQ%23imgrc=ki8ZOdztfJ4qZM%3AAccessed

Maximum Swing And Sensitivity


Accelerometer masses have a maximum distance that they will move in response to force.

This may be either positive or negative, depending on the direction from which the force is exerted

The “maximum swing” is expressed as the multiples of “g” that produce it (g = 9.81 m/s2)

Sensitive only in the plane of their specific axis

+

Customary “g” ranges for Maximum Swing± 2 g± 4 g± 8 g± 16 g

The lower the maximum swing “g”, the more sensitivethe measurement but the more limited the range of sensing.Band pass filter limits usually 0.1 – 10 g.

Chen, et al, Medicine & Science in Sports & Exercise, 2005;37(11):s490 – s500.

Figure 1.


Capacitive Accelerometers – Also Measures “g” Or Gravitational Force

If an accelerative force moves one of two adjacent microstructures the capacitance between them is changed and this can be expressed as an electric current.

Capacitive accelerometers performance is superior in the low frequency range.

AThe deformation caused by the pressure is measured

using a capacitive element. The pressure P will cause a variation of the distance between the two electrodes

BChange in capacitance due to lateral movement of

plates

A

B

https://www.google.com/search?q=capacitance+accelerometer&biw=1664&bih=824&tbm=isch&tbo=u&source=univ&sa=X&sqi=2&ved=0ahUKEwiZ64Dcg57LAhXDuB4KHbo7C94QsAQIIw#imgrc=BeqPecsovmr-0M%3AAccessed 2/29/2016

https://www.google.com/search?q=capacitance+accelerometer&biw=1664&bih=824&tbm=isch&tbo=u&source=univ&sa=X&sqi=2&ved=0ahUKEwiZ64Dcg57LAhXDuB4KHbo7C94QsAQIIw%23imgrc=BeqPecsovmr-0M%3A

Accelerometer As A Single body-Fixed Sensor

12/09/2016Title of presentation and name of speaker 20Weiss A, et al, Neurorehabilitation and Neural Repair 2013;27(8):742 – 752.

Figure 1.

Used by kinesiologists, sport physiologists, etc.

Electronic Wearable Ambulatory Monitor (WAM)

• can be attached to the body or embedded in a clothing garment

Wearable electronic sensor

• Earliest WAM’s had a single uniaxial accelerometer

Accelerometers record the user’s bodily movements

• Doesn’t account for multidirectional bodily movement• Insensitive to low-intensity activities• Insensitive to changes in grade while walking or running

Uniaxial accelerometry (Caltrac®) tends to underestimate bodily energy expenditure


Development of A Triaxial AccelerometerBouten CV, et al, 1997 Paper

Three orthogonally mounted uniaxial piezoresistive accelerometers

Assessed physical movement via human body accelerations

Respond to both the frequency and intensity of human movement

Demonstrated a significant relationship between energy expenditure as estimated by accelerometry and energy expenditure as determined by indirect calorimetry (r = 0.89)

Shortcomings:

Low sensitivity to sedentary activities

Inabililty to register static exercise


Bouten CV, et al, IEEE Transactions on Biomedical Engineering 1997;44(3):136 – 147.

9/12/2016 23

Micro-electro-mechanical System (MEMS) Technology

SMART PHONES AND MINIATURIZATION

Evolving Cell (Smart) Phone Technology


Enhanced computer capacity

Miniaturization

Internet connectivity

GPS

Miniaturizationiphone 4’s Mother Board

12/09/2016 26


Micro-electro-mechanical System (MEMS) Technology& Smartphones

Advent of micro-electro-mechanical system (MEMS) technology enabled accelerometers and other sensing components to be miniaturized leading to smaller wearable sensors

Development and generalized use of “smartphones” having comparatively advanced computing capabilities, GPS receivers and MEMS sensors make them an ideal platform from which to monitor human movement

Main board, iPhone 4

Gyroscope

Accelerometer

Moore’s Law May Soon Become Outmoded

• “The number of components that could be etched onto the surface of a silicon wafer was doubling at regular intervals and would do so for the foreseeable future”

Gordon Moore (co-founder of Intel) in 1965:

• Chips may soon be made out of other materials (e.g. graphene)

We’ve reached the limit on making silicon chips smaller


The New York Times http://nyti.ms/1q0qd24.Accessed 5/10/2016

http://nyti.ms/1q0qd24

Development of Consumer-Based Physical Activity Monitors (“Wearables”)

Personalized social media “apps”

• Low-cost, miniaturized accelerometers• Bluetooth technology

Refinement of technology

• Web sites• Cell phone applications

Physical activity and energy expenditure data tracking


Wearable Devices: “Wearables”(Smart phones, smart watches, wrist bands)

• Fitbit• Nike +

First wearable fitness devices appeared in 2009

• Two leading platforms• iOS• Android

Over 100,000 health focused “apps” released by Q1 2014

• Quantified-self movement• Distance walked• Calories burned• Heart rate

Development of “wearables” mainly consumer driven


Smartphone Multimodal Sensors to Identify Physical Movement

• Location (GPS)• Audio-visual components

Contextual sensors

• Ambient light• Barometric pressure• Magnetometer

Environmental change sensors

• Accelerometer• Gyroscope

Body movement


Evolution of Smartphone Algorithms Enabling Greater Variety in Body Positioning

del Rosario MB, et al, Sensors, 2015;15:18901 – 18933.

Figure 4.

Motion MEMS Sensors in Smartphones

• Measures combined acceleration due to gravity and bodily movement along three orthogonal axes

• Determines “roll,” “pitch” and “yaw”

Triaxial accelerometer

• Measure angular velocity along three orthogonal axes• Changes in orientation of the device determined

Triaxial gyroscope (plus the accererlmeter)

• Uses environmental magnetic sources to determine a heading relative to the magnetic north pole

• Combined with accelerometer readings enables determination of “yaw”

Triaxial magnetometer

• Determines changes in altitude

Barometric pressure sensor


Climbing Stairs with Smartphone in Back Pocket

12/09/2016Title of presentation and name of speaker 34del Rosario MB, et al, Sensors, 2015;15:18901 – 18933.

Figure 2.

PROCESSING THE DATA

Bandwidth – Sampling Rate (should have a frequency at least twice that of the highest frequency movement)

• Nonimpact PA: < 8 Hz (e.g., running)• Upper limit: As high as 25 Hz (specific movements of arms)

Frequency of physical activity (PA) in humans

• 1 to 64 Hz

Sampling frequency of commercially available PA monitors

• Preset low and high frequency limit (usually ~ 0.25 – 7 Hz)• Narrow bandwidth: incomplete data collection• Too broad bandwidth: corrupting electrical artifact and “noise”

Sensor output is filtered


How Raw Accelerometer Data Is Processed inActigraph GT3X

• 0.05 – 2.5 g Accelerations• Sampling rate of 30 Hertz (Hz)

Detecting bodily motion

• Digitized by A/D converter• Digital filter that band limits accelerometer frequency range

• 0.25 to 2.5 Hz (frequency of most bodily movement)

Acceleration signal

• Epoch

Digitized signal summed over time


Obtaining EE from raw vector magnitude activity countsDetermining the counts (aggregated values indicating frequency and intensity of movement)


Objects on Earth are subject to gravitational acceleration. Data from each axis (X, Yand Z) is filtered by a mathematical formula to isolate gravitational acceleration and to remove the force of gravity to obtain linear acceleration for each axis

Linear acceleration values may be either negative or positive so they are “normalized”to obtain all positive values

Linear X2 + Linear Y2 + Linear Z2

Chen, et al, Medicine & Science in Sports & Exercise, 2005;37(11):s490 – s500.

Figure 2.

Obtaining EE from raw vector magnitude activity countsDetermining the counts


Calculate the area under the curve using an integration process. Thisproduces the total number of counts obtained by the accelerometerfor the physical activity performed over that period of time. Time elapsedIs often divided up into “epochs.” Here the epochs are of 15 sec. duration

Chen, et al, Medicine & Science in Sports & Exercise, 2005;37(11):s490 – s500.Figure 2.

DETERMINING ENERGY EXPENDITURE (EE)

How Accurate Are The Numbers ?


ATP, The Body’s Energy Packet, Is Formed through The Oxidation of Carbon Atoms


http://www.medbio.info/Horn/Body%20Energy/body_energy.htmAccessed 3/23/2015

VO2max—the amount of oxygen the body is able to use

Carbon atoms from ingestion ofsugars, starch, fat and proteins

Oxidation

ATP production requires food and adequate circulation, lung function and physical condition

Oxygen from respiration

http://www.medbio.info/Horn/Body%20Energy/body_energy.htm


Indirect calorimetry measures 02 consumption and CO2 production prospectively and with precision from which the rate of EE can be calculated (kcal / min)

Good way to calculate energy expenditure over limited periods of time whileperforming specific physical activities (Kcal / minute)

3.5 ml O2 / Kg / min = 1 MET (metabolic equivalent)

Doubly Labeled Water Method of Determining Energy Expenditure by Indirect Calorimetry


(2H) leaves the body as water, while 18O leaves as water (H2O) and carbon dioxide (CO2). Therefore, CO2 production can be calculated by subtracting 2H elimination from 18O elimination and the total metabolic rate may be estimated.

Good for determining EE in free living situations over time (usually 7 to 14 days)

Results: Kcal / day

Correlating Energy Expenditure with Accelerometer Output Data (Vector Activity Counts or Vector Magnitude Activity Counts



Calibration of the Computer Science and Applications, Inc. Accelerometer (now “Actigraph”)

Relationship between treadmill speed and oxygen consumption

Relationship between treadmill speed and activity counts

Freedson PS, et al, Medicine & Science in Sports & Exercise, 1998;30(5):777 – 781.

Figure 1. Figure 2.

• 3.5 ml O2 / Kg / Min

1 MET =

• 1.439008 + (0.000795 x counts / minute)

METS =

• r = .88

Correlation coefficient =

12/09/2016 47

Determining Number of METS from Single Vector Activity Counts

Single vector activity counts versus METS

Figure 3.Freedson PS, et al, Medicine & Science in Sports & Exercise, 1998;30(5):777 – 781.

Walk Run Transition

EntrantEnergy

ExpenditureMeasured

(x)Estimated

(y) (x*y) (x2) (y2)

1 .0482 .0564 .00272 .00232 .00318

2 .0438 .0544 .00238 .00192 .00296

3 .0461 .0555 .00256 .00213 .00308

4 .0472 .0559 .00264 .00223 .00312


Correlation Coefficient Formula – Finding “ r “

Correlating EE, Measured versus Estimated(Kcal / kg / min) “ r ” = Correlation Coefficient

http://study.com/academy/lesson/pearson-correlation-coefficient-formula-example-significance.htmlAccessed 3/7/2016

r values concerning quantitative scientificdata: > 0.8 generally indicate “strong” correlation.

Non-quantitative data demonstrating r values~ 0.5 considered “acceptable”

http://study.com/academy/lesson/pearson-correlation-coefficient-formula-example-significance.html

• 0.0000191 x vector activity counts x mass in Kg

Manufacturer provided equation: 1 Kcal / min =

• (0.00094 x counts / min) + (0.1346 x mass in Kg) - 7.37418

1 Kcal / min =

• r = .93

Correlation coefficient =

12/09/2016 49

Determining Predicted Energy Expenditure from Single Vector Activity Counts And Body Mass (kg)

Predicted versus actual energy expenditure (Kcal / min)

Calculating equations often are proprietary and are determined at factory calibration

Figure 4.

Freedson PS, et al, Medicine & Science in Sports & Exercise, 1998;30(5):777 – 781.

King GA, et al, Med. Sci. Sports exerc., 2004;36(7):1244 – 1251.

Computer Science Application, Inc. (CSA, now “Actigraph”) Accelerometer Correlates Relatively Well with Indirect Calorimetry at Usual Walking Speeds

12/09/2016 50

Correlation between CSA total EE estimated by Freedson equation and indirect calorimetry is relatively good at usual walking speeds

r = .73 at 2 mph

Correlation decreases as treadmill speed increases

r = .58 at 8 mph

King GA, et al, Med. Sci. Sports Exerc., 2004;36(7):1244 – 1251.

Being Able to Adjust Accelerometer Sensitivity Level Does Not Insure Good Correlation


BioTrainer-Pro

Biaxial accelerometer

User-specified sensitivity level of measurement

X1, x2, x4, x10, x20 and x 40 G

Sensitivity was set at 4 G

Correlation coefficients

r = .34 at 2 mph

r = .485 at 8 mph


BioTrainer-Pro

IndirectCalorimetry

Both the “g” and the “Hz” Settings Are Crucial toObtaining Good Data


Adapted from Table 1.

Ruiz-Zafra A, et al, Sensors, 2015;15:18270 – 18286.

Unfiltered Hz Is Too High in Zephyr (50 Hz)


METS

Ruiz-Zafra A, et al, Sensors, 2015;15:18270 – 18286.

Figure 6.

Static Activities Not Tightly Associated with Bodily Acceleration

12/09/2016 54

Activities with muscle contractionthat expend energy but are not associated with much physicalmotion

All monitors underestimate energy cost by ~ 50%

METS

Matthews CE, Med. Sci. Sports Exerc., 2005;37(11):S512 – S522. Adapted from Figure 3.

• METS = 2.8323 + 0.00054 x vector magnitude activity counts/min. – 0.059123 x body mass (kg) + 1.4410 x gender(women = 1, men = 2)

Adults

• METS = 2.5878 + 0.00047 x vector magnitude activity counts/min. – 0.06453 x gender (women = 1, men = 2)

Elderly

12/09/2016 55

Proper Calibration of Physical Activity EE Is Most Accurately Done When Biometric Data (Age, Gender, Weight) Are Considered

Actigraph Calibration Study (not using biometric data – age, gender, build)

Actigraph GT3X Correlation Formulas

Figure 4.

Matthews Charles E., Medicine & Science in Sports & Exercise 2005;0195-9131/05/3711:S512 – S522.

Santos-Lozano A, et al, Int J Sports Med 2013;34:975 – 982.

Resting Energy Expenditure (kcal / min)

• (0.00473 x wt (kg)) + (0.00971 x ht (cm)) –(0.00513 x age (yr)) + 0.04687

Men

• (0.00331 x wt (kg)) + (0.00352 x ht (cm)) –(0.00353 x age (yr)) + 0.49854

Women


Nichols JF, et al, Medicine & Science in Sports & Exercise 1999;31(6):908 – 912.

Converting METS to Kcal

Physical Activity EE

• Kcal = METS x wt (kg) x time (hours)

Total EE

• Total EE = Activity EE + Resting EE


We Are Homeothermic, Attempting to Maintain A Constant Body Temperature – A Direct Calorimetry Method


http://www.lifechek.com/technology2.htmlAccessed 2/23/2016

Heat flow sensor measurements in context of an individual’s body surface area, are used to calculate calorie expenditure

Heat loss: conductive, radiant, convective and evaporative

Mostly: radiant and convectiveWith exercise: evaporative

http://www.lifechek.com/technology2.html

SenseWear Armband Overestimated Energy Expenditure at All Treadmill Speeds

12/09/2016 59

SenseWear Armband: biaxial accelerometer, heart rate receiver and thermocouple (measures heat production, e.g. direct calorimetry)

Correlation coefficients were not so good at walking speeds (r = .65 at 2 mph)

Correlation coefficients were good at faster treadmill speeds ( r = .82 at 8 mph)


Some Commercial Examples

Table 6.

Del Rosario MB, et al, Sensors 2015;15:18901 – 18933.

In Der Spiegel May 4, 2016


Comparing Estimated (by Wearable Device) and Actual (by both Metabolic Chamber and Doubly Labeled Water Method) TEE


Murakami H, et al, jamainternalmedicine.com 2016:E1 – E2.

“r” “r”

Estimate the activity limit which would cause the applicant to become uncomfortable or want to stop


1 Eating, standing, getting dressed, playing cards

2 Showering, ironing, cooking, washing dishes, walking down 8 steps

3 Making the bed, grocery shopping, sweeping or vacuuming floors

4 Raking leaves, weeding, mowing lawn (power mower), painting

5 Playing doubles tennis, social dancing, washing the car

6 Mowing lawn (push mower), playing 9 holes of golf carrying own clubs,carpentry

7 Digging or spading of soil, walking uphill, carrying 60 pounds (27 Kg) on level surface

8 Carrying groceries upstairs or climbing a flight of stairs quickly, moving heavy furniture> 9 No limitations from any of above

METS

Physical Activity Questionnaires (PAQ) Demonstrate Poor Reliability in Estimating Activity Energy Expenditure (AEE)

• Average “r” = .42 for series of 14 studies

Low to Moderate Correlation Coefficients

• Inaccurate recall• PAQ did not include key activities relating to AEE

Discrepancies due to …

• Older individuals• When individuals are considered rather than groups

Discrepancies Especially with …


Bonnefoy M, et al, J Am Geriatr Soc 2001;49:28 – 35.Neilson HK, et al, Am J Clin Nutr 2008;87:279 – 91.

HOW DOES TOTAL ENERGY EXPENDITURE CORRELATE WITH MORTALITY RISK ASSESSMENT ?


Both Exercise Capacity And Activity Pattern Better Predictor of Overall Mortality Relative to Usual Risk Factors

59 y.o. men referred for TMT for clinical reasons. Given physical activity questionnaire (Paffenbarger),

“r” = 0.39, from which energy costs were estimated

Survival predictors were exercise capacity followed by energy expenditure from recreational activity. 1000 kcal/wkincrease in PA = 1 MET improvement in fitness and 20% better survival

MR = 172 %

MR = 79 %

MR = 187 %

MR = 60 %

Figure 1. Figure 1.

Myers J, et al, Am J Med 2004;117:912 – 918.Paffenbarger RS, et al, NEJM 1986;314:605 – 613.

WHAT OUTPUTS FROM WEARABLE DEVICES OTHER THAN KCAL MIGHT BE USEFUL?

Males Older Than 70 Years Tested for Gait Speed And Followed for 5 Years for Mortality

• Gait speed < 0.82 m/s (2.69 f/s)

Mortality Began to Rise

• Gait speed > 1.36 m/s (4.46 f/s)

No Deaths Observed


Stanaway FF, et al, How fast does the Grim Reaper walk? Receiver operating characteristics curve analysis in healthy men aged 70 and over, BMJ 2011;343:d7679.

Studenski S, Gait Speed and Survival in Older Adults, JAMA 2011;305(1):50 – 58.


~ 34,500 participants, over 17,500 deaths, Metaanalysis

Gait Speed Is A Good Indicator of Mortality in The Elderly (and easily determined)

• ~ 0.80 M/sec Studenski S, et al, JAMA 2011;305(1):50 – 58.

Mortality begins to Rise for Males in Early 70’s

• Gait Speed < 0.8 M/sec British Geriatrics Society, Dec 2014

Frailty Indicators


Barometric Pressure Sensor in A Smartphone

Climbing one flight of stairs ~ 5 METS Climbing one flight of stairs ~ at least New York Heart Functional Class 2

Figure 1.Figure 2.

Regulation of Physical Activity Apps Not Yet Done

• FDA decided not to regulate so – called “low risk” health apps

• FDA is currently focused on the small subset of mobile medical apps that may be associated with potential patient risk

As of First Quarter 2015


Ideal Physical Activity Monitor for Insurance Applicants

Capacitive Accelerometer (better for detecting more sedentary movement)

• Sampling Rate ~ 30 Hz (could be up to 50 Hz)• Band width filter: 0.25 – 7.0 Hz• Sensitivity to g forces: 0.3 – 4 g• Length of EPOCH’s for averaging must be optimized

Correlation formulas (must be transparent and done on representative participant populations)

• Determined using doubly labeled water• Free living activity over several days

• Consider biometric data (age, gender, weight)• Separate equations developed for adults and for the elderly


POTENTIAL FOR FRAUD !

IS THE DATA ACTUALLY DERIVED FROM THE APPLICANT ?

Fitbit for You, FitBark for Fido


Activity trainer for dogs

For health enthusiasts who own dogs orFor dogs with certain medical conditions

http://www.dallasnews.com/lifestyles/health-and-fitness/health/20160404-fitbit-for-you-fitbark-for-fido-will-this-make-your-pet-healthier.ece Accessed 4/5/2016

http://www.dallasnews.com/lifestyles/health-and-fitness/health/20160404-fitbit-for-you-fitbark-for-fido-will-this-make-your-pet-healthier.ece

Also Monitoring Against Fraud


Had Enough?

Industry underwriter away from desk for more than 60 minutes

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MIDWESTERN UNDERWRITING · PDF file · 2016-09-12• Aircraft shock absorbers ... // ... Development and generalized use of “smartphones” having