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Sleep disordered breathing events conceptually separate into "obstructive" and "central" events. Esophageal manometry is the definitive but invasive means of classifying hypopneas. The purpose of this project was to identify noninvasive markers for discriminating high vs. low resistance hypopneas.
Forty subjects with obstructive or central sleep apnea underwent diagnostic polysomnography with nasal cannula airflow and esophageal manometry; 200% resistance relative to reference breaths was used to define "high" resistance. Noninvasive parameters from 292 randomly selected hypopneas in 20 subjects were analyzed and correlated to resistance. The best parameter and cutoff for predicting high relative resistance was determined and tested prospectively in 2 test sets in the 20 remaining subjects. Test Set A: 15 randomly selected hypopneas in each subject; Test Set B: all hypopneas in 7 subjects.
In the development set, prolongation of inspiratory time during the 2 smallest breaths of a hypopnea (Ti) relative to baseline had the best correlation to high relative resistance. In the Test Set A, relative Ti > 110% classified obstructive events with sensitivity = 72%, specificity = 77%, PPV = 64%, NPV = 83%. Similar numbers were obtained for classification of hypopneas based on presence of flow limitation (FL) alone. When either relative Ti or presence of FL were used to define high resistance, sensitivity = 84%, specificity = 74%, PPV = 65%, NPV = 89%. Similar results were obtained for Test Set B.
Relative prolongation of Ti is a good noninvasive predictor of high/low resistance in a dataset with both FL and NFL hypopneas. Combination of FL and relative Ti improves this classification. The use of Ti to separate obstructive and central hypopneas needs to be further tested for clinical utility (outcomes and treatment effects).
Mooney AM; Abounasr KK; Rapoport DM; Ayappa I. Relative prolongation of inspiratory time predicts high versus low resistance categorization of hypopneas. J Clin Sleep Med 2012;8(2):177-185.
Sleep disordered breathing (SDB) is a term which includes both obstructive sleep apnea/hypopnea (OSAHS) and central sleep apnea (CSAS) syndromes, which are both prevalent conditions.1–6 Although CSAS is most commonly seen in congestive heart failure (CHF), OSAHS is also often seen in these patients.4–6 At the root of defining whether a patient has CSAS or OSAHS is the categorization of the individual events as central or obstructive; there are both diagnostic and therapeutic implications of the distinction. In concept, obstructive events are defined by high upper airway resistance, whereas central events are defined by low "drive." However, high resistance and low drive may not be mutually exclusive. There is increasing recognition that both types of events may exist within the same patient6 and that both etiologies may be invoked in the pathogenesis of some events, leading to difficulty in the overall categorization of a patient's disorder as "obstructive" vs. "central." Despite this, it is currently assumed that the distinction between OSAHS and CSAS has clinical significance, and may have important implications for both diagnosis and treatment. Thus establishing a noninvasive algorithm to characterize individual events which is useful in general polysomnography remains an important target.
For apnea, distinguishing the central vs. obstructive etiology is usually possible noninvasively by the presence/absence of thoraco-abdominal movement (effort). In contrast, for hypopnea (which accounts for the majority of events in SDB), distinguishing the etiology is much more problematic. Esophageal manometry combined with measurement of airflow is the accepted gold standard,7–9 as the ratio of effort to flow defines resistance. However, this technique is invasive, disruptive of sleep, and considered by most clinical laboratories as unrealistic for routine use.
Current Knowledge/Study Rationale: On polysomnography it is difficult to separate central from obstructive hypopneas without invasive monitoring. The purpose of the current project was to separate hypopneas into central (low resistance) and obstructive (high resistance) using non-invasive criteria derived from the flow signal alone.
Study Impact: An algorithm based on the inspiratory time and presence of inspiratory flow limitation on the airflow signal was useful in separating obstructive from central hypopneas. This non-invasive technique has the potential to improve clinical decision making and influence research design.
Pulse transit time has been shown in a small study to be a useful noninvasive tool for recognition of central hypopneas,10,11 but this data is not routinely collected. Noninvasive techniques based on airflow exist to identify collapsible upper airway behavior; this collapsible behavior generally identifies elevated upper airway resistance.12–14 In particular, we and others have shown that the presence of inspiratory flattening on a nasal cannula/pressure transducer tracing15 strongly suggests flow limitation (FL) which corresponds to inappropriate (obstructive) Starling resistor behavior of the airway. Despite this, it is unclear whether absence of FL on a breath implies a central etiology for a given breath.12Figure 1 illustrates flow and esophageal data in events with and without FL and demonstrates both high and low resistance in at least some events where there is an absence of FL.
Each panel shows airflow and esophageal pressure obtained from the PSGs in 3 different subjects
Increasing effort and resistance during a hypopnea with flow limitation indicated by the presence of unequivocal flattening of the flow contour (A). Non-flow limited hypopnea with decreased relative effort and resistance (B). Non-flow limited hypopnea, but with increased relative effort and resistance (C). While the presence of subtle changes in the shape of the inspiratory flow curve may be identified by some observers, it is our experience that this represents cardiogenic oscillations, suggesting low resistance.
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The classification of hypopneas (defined by reduced ventilation), even by invasive means, is not without ambiguity. One conceptual approach is to use changes in "effort" alone during the hypopnea relative to stable breathing during sleep for separation of "central" versus "obstructive" etiologies. Relative increase in effort or maintenance of effort at a time of reduced airflow reflects obstruction of the upper airway. However, events with a relative decrease in effort can be associated with unchanged resistance (proportional decrease in airflow) or increased resistance (disproportionate decrease in airflow); thus decreased effort can be associated with both central or obstructive pathology and effort alone is not sufficient to separate central from obstructive hypopneas. For these reasons, a relative increase in resistance during a hypopnea may be the most appropriate measure for classifying hypopneas as obstructive, but this requires an invasive measurement not usually available in routine polysomnography.
The purpose of the current project was to develop an approach to separating hypopneas into central (low resistance) and obstructive (high resistance) using noninvasive criteria derived from the flow signal alone and validate this in a dataset enriched for central/ambiguous etiology.
The dataset consisted of 40 subjects selected from patients seen in the NYU Sleep Disorders Center. These subjects were chosen with the target of obtaining a wide spectrum of hypopneas with (FL) and without (NFL) inspiratory flow limitation. Twenty-two of these patients had previously undergone an NPSG with esophageal manometry as part of other research protocols for suspected obstructive sleep apnea (19) or suspected central sleep apnea (3). The remaining 18 patients were recruited because they had a clinical presentation suggestive of central sleep apnea and on NPSG had > 25% of hypopneas without flow limitation. No patient was taking sedative or hypnotic medication, but 4 subjects were on narcotic medications at the time of study (3 in development set, 1 in test set). Aggregate patient characteristics are shown in Table 1.
Patient characteristics
[i] Subjects encompassed a wide range of sleep disordered breathing. There were no significant differences be-tween severity of SDB, central or obstructive indices between subjects in the development and test sets.
The study was approved by the Institutional Review Board of New York University School of Medicine, and all subjects signed informed consent prior to being included in this study.
Polysomnography was performed using the standard clinical protocol recommended by the AASM8 with the addition of esophageal manometry. A nasal cannula pressure transducer system transducer (Protech PTAF2) was used to measure airflow along with an oral thermistor to detect mouth breathing.15 An esophageal catheter consisting of a thin catheter ending in a 10-cm latex balloon (Ackrad Labs, NJ) was placed transnasally following lidocaine anesthesia, and positioned in the lower third of the esophagus. Esophageal pressure measurements were made with a 100 cm H2O pressure transducer (Validyne, Northridge, CA). Chest wall and abdominal movement were monitored with uncalibrated respiratory inductance plethysmography. A single technician scored all sleep studies for sleep and respiration. Sleep was scored according to AASM criteria.8 Hypopneas were defined as events ≥ 10 sec where the square root of the airflow signal on the nasal cannula was reduced to < 70% regardless of desaturation or arousal, but not reduced to < 10% (in which case the event was rescored as an apnea). To become proportional to actual flow (which was needed to calculate resistance), the pressure change in the nose obtained with a nasal cannula needs to be linearized with a square root transform.16,17
Each hypopnea used in the development and test set (see below) was characterized as FL or NFL using visual assessment. Specifically we examined the shape of each breath on the airflow/time curve for inspiratory flattening, which we have previously shown to be a reliable surrogate for actual detection of flow limitation on a flow/pressure curve.18–20 While subtle changes in the inspiratory flow curve may be detected by some observers, our experience suggests that when these are inconsistent or ambiguous (e.g., Figure 1B, C), the correlation to the flow/pressure curve deteriorates. Each hypopnea was reviewed visually by 2 experienced researchers and classified as FL only if the 2 researchers agreed. For each hypopnea, the 2 consecutive breaths with the lowest flow were identified. Two consecutive reference breaths with the highest flow were identified from the 30 sec before or after the event. For each breath the following variables were extracted: Flow (peak value of square root of nasal cannula signal for NFL breaths, value of square root of nasal cannula signal during the plateau phase for FL breaths), ΔEsophageal Pressure (from end expiratory baseline [ΔEffort]), Resistance (ΔEffort / Flow), Inspiratory Time (Ti), Duty Cycle (Ti/Ttot), and Inspiratory/Expiratory duration (Ti/Te). For each variable, the values for the 2 breaths within the hypopnea were averaged. Similarly, for each variable the values for the 2 reference breaths were averaged. Data were expressed as the ratio of hypopnea-to-reference values in order to represent relative effort, relative resistance, relative Ti, relative Ti/Ttot and relative Ti/Te.
The 40 sleep studies available for analysis were divided equally into 2 sets—one for development and one for testing of the algorithms. Each set contained 10 patients whose diagnostic PSG suggested primarily obstructive sleep apnea, and 10 patients where the esophageal manometry suggested predominantly central sleep apnea (CSA) or Cheyne Stokes respiration (CSR). In the development set, 5 events with inspiratory flattening of the flow/time signal and 10 without inspiratory flattening (where available) were selected from each study. The development set contained 73 FL and 219 NFL events. Equal numbers of events (where available) were selected from each patient in order to avoid overrepresentation from any given patient while generating rules for categorization of events. Data for the test set subjects were not analyzed until after analysis on the development set (and final definitions of noninvasive criteria) were completed. Test Set A contained 15 randomly selected hypopneas from each patient in parallel fashion as extracted from the development set (5 events with inspiratory flattening of the flow/time signal and 10 without inspiratory flattening [where available]). Test Set A contained 72 FL and 185 NFL events. Test Set B contained all the hypopneas observed in a subgroup of 7 patients. Four of these patients had classical obstructive sleep apnea, and 3 of these patients had atypical sleep disordered breathing with periodic breathing and predominantly NFL hypopneas. Test Set B contained 223 FL and 410 NFL events. Events in the development set and all test sets were chosen randomly without respect to body position during sleep.
As stated in the introduction, relative resistance or relative effort are alternative ways to define obstructive vs central events using the "gold standard" invasive methodology of esophageal manometry. However, events with a relative decrease in effort do not all have a low resistance, and can be associated with either a proportional decrease in airflow (unchanged resistance) or disproportional decrease in airflow (representing increased resistance)21; thus decreased effort can be associated with both central or obstructive pathology. For the present analyses, we chose to define events as obstructive vs. non-obstructive using relative resistance and not relative effort. The relationship between these parameters in our dataset is shown in Figure 2. The high correlation (0.87) suggests similar results would be obtained when either relative resistance or relative effort is chosen as the basis for a reference classification of hypopneas, but importantly, 63% of events with reduced relative effort, i.e., < 100%, (a possible definition of "central") have relative resistances in the 100% to 200% range. Thus, given our choice of relative resistance as the defining variable for separating "low" and "high" resistance events, a decision needed to be made with respect to the cut point separating inappropriately obstructive from central hypopneas. Whereas the breaths chosen within events were clearly during sleep, our reference breaths were chosen from periods surrounding SDB events that were usually but not always associated with subcortical arousal (e.g., heart rate acceleration without clear EEG arousal), cortical arousal, or awakening. A doubling of airway resistance has been described in normal subjects at sleep onset,22 and for this reason, we used > 200% as the cut point to define an inappropriate (above that seen with normal sleep) increase in relative resistance. This definition should identify the level of increased relative resistance having potential clinical significance for inappropriate obstruction of the upper airway. Thus, hypopneas were defined as obstructive if relative resistance of the hypopnea breaths was > 200% compared to the resistance of the reference breaths, and non-obstructive if relative resistance was < 200% compared to the reference breaths.
For each NFL event (n = 219) in the development set, relative resistance is plotted against relative effort of events
Relative resistance is highly correlated to relative effort. Relative resistance and relative effort are calculated as the ratio of the values for the 2 smallest breaths within each respiratory event and the 2 largest breaths within 30 seconds of the event (see methods).
To test the dependence of our conclusions on the cut point chosen to define "high" relative resistance, we repeated our analyses using 150% relative resistance to separate "obstructive" from "non-obstructive" events in defining "truth" in the reference data set against which we compared our noninvasive markers.
Within the development set, correlations between relative resistance, relative effort and each relative noninvasive parameter (Ti, Ti/Ttot, Ti/Te) were first examined only in NFL events. The noninvasive parameter with the highest correlation to relative resistance was submitted to ROC analysis in order to identify the best cutoff for noninvasive classification of resistance or effort. Sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) for high relative resistance (> 200%) were calculated for the NFL events of the development set and Test Set A. An additional analysis was performed after inclusion of FL events in Test Set A and stratified by sleep stage (NREM/REM). Analyses were repeated using presence/absence of FL as the noninvasive parameters, and for the combination of relative Ti and presence of FL. These analyses were repeated for Test Set B. To test the sensitivity of our definition of "obstruction," Test Set A was also analyzed according to alternative definitions (effort > 100% = obstructive, resistance > 150% = obstructive).
As previously shown,23 events with inspiratory flow limitation (FL) showed an overall high (289% ± 142%) relative resistance. Events without flow limitation (NFL) showed a significantly lower relative resistance than FL events (151% ± 100%, p < 0.001), but, as shown in Figure 3, there was a substantial overlap of relative resistance between FL and NFL events. Thus flow contour alone was not sufficient to noninvasively predict low relative resistance.
Distribution of the relative resistance for FL and NFL events
Bars represent events having relative resistance within the bin indicated on the x axis. The height of each bar indicates the percentage of all events of that flow type (FL vs. NFL). There were a total of 73 FL events and 219 NFL events.
Figure 4 shows the relationship of the noninvasive flow parameters (relative Ti, relative Ti/Ttot and relative Ti/Te) to relative resistance in NFL events. All 3 noninvasive parameters were significantly correlated (p < 0.001) with relative resistance; the highest correlation was observed between relative Ti and relative resistance. This was also true when the noninvasive parameters were examined against relative effort (data not shown).
Utility of using noninvasive parameters of flow (x axis) to estimate relative resistance (y axis) of breaths
Data is shown for NFL events in the development set. Relative Ti (A); relative Ti/Te (B); Relative Ti/Ttot (C). Best correlation is with relative Ti (A).
Figure 5 shows an ROC curve for all NFL events in the development set using a cutoff of > 200% relative resistance (solid line) to define obstructive events. Relative Ti > 110% (i.e., prolongation of Ti) was the best cutoff to predict high relative resistance, with an AUC of 0.82. Using an alternative reference definition of obstructive events as relative effort > 100% (dotted line), ROC analysis identifies a similar Ti (> 104%) as the best cutoff to predict high effort, with an AUC of 0.76.
ROC analysis for relative Ti to predict high vs. low relative resistance (solid line) or high vs. low relative effort (dotted line)
Using a cutoff of > 200% relative resistance to define obstructive events, ROC analysis identifies Ti > 110% (relative prolongation of Ti) as the best cutoff to predict high resistance with an AUC of 0.82. With obstructive events defined as effort > 100% of baseline breaths, ROC analysis identifies relative Ti > 104% (prolongation of relative Ti) as the best cutoff to predict increased effort with an AUC of 0.76.
Table 2 shows a classification analysis for NFL events in the development set. Sensitivity, specificity, PPV, and NPV are listed for using relative Ti > 110% to identify obstructive events defined as relative resistance > 200%. The table also lists a classification analysis for using relative Ti > 104% to identify obstructive events when these are defined as relative effort > 100%. By either criterion, relative Ti shows a high negative predictive value: in NFL events, absence of relative lengthening of Ti strongly suggests that an event is not obstructive. However, in NFL events, relative lengthening has little predictive value (PPV = 32% to 36%).
Development Set (219 NFL events)
In NFL events in Test Set A (15 randomly selected hypopneas/patient from 20 patients distinct from patients in the development set), relative prolongation of Ti was again significantly correlated with relative resistance (r = 0.48, p < 0.001), although the correlation was lower than in the development set (where r = 0.65, p < 0.001).
Table 3A shows a classification analysis for NFL events (n = 185) in Test Set A. Sensitivity, specificity, PPV, and NPV for NFL events are shown for the same cutoffs and definitions used for the development set in Table 2. Results are similar to those seen in the development set. Table 3B shows results from a similar classification analysis when both NFL and FL events from Test Set A are included. Of note, the NPV (prediction of central events) remains high, despite the inclusion of the predominantly obstructive events implied by the presence of FL.
Test Set A
Because of the known reduction of effort associated with REM, a separate classification analysis of using Ti to predict resistance by sleep stage is shown in Table 4. The data show that in REM there is an exaggeration of the above findings (in all sleep), with a very high negative predictive value (i.e., a short relative Ti is strongly predictive of a low relative resistance in NFL).
Test Set A, effect of sleep stage (REM/NREM) on test validity
Table 5 shows a classification analysis for events in Test Set A with and without flow limitation (FL and NFL), when the presence or absence of flow limitation alone is used to predict high or low resistance. These results are further analyzed with respect to sleep stage (REM/NREM). The absence of flow limitation in REM has very high negative predictive value.
Test Set A, classification results using presence or absence of flow limitation alone
As a test of the sensitivity of our findings to the definition of "high" relative resistance (> 200%), we repeated the classification analysis of Ti as a predictor of resistance using a cutoff of 150%. Table 6 shows these data and suggests similar trends.
Effect of an alternative definition of resistance as > 150% in Test Set A
To incorporate all of the observations made above for noninvasive prediction, we present a combined classification analysis (Table 7) for predicting relative resistance > 200% for events in Test Set A using either the presence of FL or Ti > 110%. By these criteria, sensitivity rises to 84%, while specificity, PPV and NPV remain similar at 74%, 65%, 89%.
Test Set A, two-tiered classification analysis
Figure 6 compares the validity of each test (1-presence of flow limitation alone, 2-relative prolongation of Ti > 110% alone, 3-either presence of flow limitation or relative prolongation of Ti > 110%) to predict relative resistance > 200%.
Comparison of the sensitivity, specificity, PPV, and NPV for each noninvasive predictor of high resistance, in Test Set A events (FL and NFL)
A two-tiered classification analysis using either the presence of flow limitation or relative prolongation of Ti (> 110%) demonstrates the highest sensitivity while NPV is preserved.
In contrast to Test Set A, which consisted of an equal number of hypopneas randomly selected from all patients, Test Set B evaluated all hypopneas in 7 patients. Four of the patients demonstrated classic loud snoring and flow limitation throughout the majority of the night. The other three patients had predominantly non-flow limited hypopneas occurring in a periodic pattern. There were 633 hypopneas in Test Set B (410 NFL, 223 FL). Table 8 shows that the 3 noninvasive predictors (presence of FL, relative Ti > 110%, and the combination of the two criteria) show good sensitivity, specificity, PPV, and NPV in the data from Test Set B.
Classification results using the 3 noninvasive predictors in Test Set B
The present analysis shows that useful predictions about whether a hypopnea is "obstructive" or "central" (defined by relative resistance) can be made from airflow alone. Our data show that the relative prolongation of Ti can be used to correctly classify the majority of hypopneas without use of invasive monitoring in a dataset enriched for ambiguous (non-flow limited) hypopneas. In this dataset, the combined assessment of relative Ti and inspiratory flow limitation had greater accuracy than either alone. An algorithm categorizing each hypopnea event first according to FL and then according to relative Ti, not only helps classify individual events, but may also help in the clinical classification of patients and thus potentially inform treatment decisions.
The present study was predicated on the assumption that there is a clear dichotomy between "central" and "obstructive" etiologies that can be applied to each individual hypopnea, and that this was represented by the relative resistance obtained using the invasive measurement of esophageal manometry. We acknowledge that there may be considerable overlap in the pathophysiology underlying a given event, and as a result there may not exist an unambiguously correct distinction between an obstructive and a central hypopnea. However, it is currently assumed that this distinction exists and has clinical significance as well as implications for treatment and prognosis24–28; a dichotomous classification scheme is currently standard clinical practice.8
In the absence of consistent definitions of hypopnea,29–31 we chose to use a very inclusive definition of hypopnea based on reduced airflow alone for our analysis,9 rather than one that disregards events without 4% desaturation or EEG arousal.8 In addition, our methodology for classifying hypopneas requires comment. The signals we used for flow are not calibrated. Thus all measurements (such as resistance) were not absolute, and needed to be related to a "baseline." By calculating relative resistance, and relative Ti we build on the logic used to define hypopnea using the accepted change in relative amplitude. We used high vs. low relative resistance as the variable to provide the reference categorization of each SDB event, with > 200% being the cut point between obstructive and non-obstructive (see justification in methods).
Having chosen a definition for "correctly" classifying hypopneas as "obstructive" or "central," the second component of our analysis was to use the now classified events as a test of various noninvasive algorithms to accomplish the same classification. Although relative prolongation of Ti alone provided a highly specific marker for high resistance (similar to flow limitation), it lacks sensitivity. Using the presence of either flow limitation or the prolongation of Ti (relative Ti > 110%) improves sensitivity while maintaining NPV for classifying events as "obstructive." An automated technique utilizing discriminant analysis of flow limitation and other features extracted from the airflow signal was recently reported to demonstrate similar accuracy in predicting relative changes in effort32,33 and supports our conclusions.
The observed low sensitivity for detecting events in Test Set A with high relative resistance is predictable from the choice made in constructing this dataset. We specifically enriched the data set with hypopneas without flow limitation as we felt that these posed the highest ambiguity based on prior work.12 The sensitivity of our algorithm to high resistance events necessarily increases as one includes more patients (and events) that are flow limited and this is confirmed by the higher sensitivity seen in Test Set B that has greater number of FL events.
There are obvious advantages to an algorithm for separating obstructive from central events based on noninvasive measurements. Patient willingness, use of lidocaine, sleep effects, potential extension to home study data and, finally, cost, all favor a noninvasive test over esophageal manometry if comparable classification of events can be achieved. A possible limitation of our data is that quantitative flow was not measured using a pneumotachograph, and thus resistance cannot be quantitatively determined. Our choice of the nasal cannula signal was intentional in this regard, as we were trying to develop a technique was that was generalizable to routine clinical use, and pneumotachographs are generally reserved to specialized research applications. We and others14,18,34,35 have previously shown that the nasal cannula qualitative flow signal can accurately determine presence or absence of flow limitation. Furthermore, breath duration (used to define the respiratory variables we examined relative Ti, relative Ti/Ttot, relative Ti/Te) does not require quantitative airflow measurement. While quantitative resistance cannot be calculated from the nasal cannula signal, relative resistance should not suffer from this limitation.
Other aspects related to our methodology require comment. First, since airflow was collected with a nasal cannula/pressure transducer system where the calibration is only valid across short time periods (3 min) we needed to define "baseline breathing" for each event rather than using one single baseline period per subject We chose periods of breathing within 30 seconds of the hypopnea. Second, in order to maximize reproducibility of breaths chosen for analysis we use the 2 biggest breaths for use as reference and 2 smallest breaths within the hypopnea.
An interesting and striking finding in our study was the behavior of our algorithm specifically in REM. In this state, absence of flow limitation was almost always associated with low resistance. Thus, in REM there was little need to explore additional noninvasive parameters beyond flow limitation to classify hypopneas. One possible explanation is that the upper airway during REM is so susceptible to collapse that any increase in effort brings out flow limitation. In NREM the lesser collapsibility of the airway makes for more overlap between the level of effort and the expression of flow limitation.
A limitation of our dataset is the predominance of male patients. Gender related differences in load response and arousal threshold may affect the appearance of FL and relative prolongation of Ti.36 However, data from Pillar, et al.37 show that despite the greater prevalence of flow limitation and the reduced ventilation seen in men with inspiratory resistive loading, men and women had similar prolongation of inspiratory time. Further testing in a dataset with more women may be desirable before generalizing our conclusions.
In conclusion, we describe a noninvasive algorithm applied to data derived solely from the nasal cannula flow signal which is easily automatable and has good sensitivity and specificity for prediction of relative resistance of hypopneas. The utility of this algorithm lies in its ability to noninvasively classify obstructive and central hypopneas in clinical and research data sets of NPSGs, and thus test the utility and implications of this distinction for diagnostic, therapeutic and long term-outcomes.
This was not an industry supported study. Dr. Rapoport has received support for research from Fisher & Paykel Healthcare, Ventus Medical, speaking and consulting engagements for Fisher & Paykel Healthcare. Dr. Rapoport holds multiple US and foreign patents covering techniques and analysis algorithms for the diagnosis o f OSAHS and techniques for administering CPAP. Several of these have been licensed to Biologics, Fisher & Paykel Healthcare, Advanced Brain Monitoring and Tyco (Health C'Aire). Dr. Indu Ayappa has received support for research from Fisher & Paykel Healthcare, Ventus Medical. Dr. Ayappa holds multiple US and foreign patents covering techniques and analysis algorithms for r the diagnosis of OSAHS and techniques for administering CPAP. Several of these have been licensed to Fisher & Paykel Healthcare and Advanced Brain Monitoring. The other authors have indicated no financial conflicts of interest.
The authors thank Rakhil Kanevskaya for manual scoring of the sleep studies. Supported by grants from: American Sleep Medicine Foundation, NHLBI K25 HL04420, NCRRM01RR0096, Foundation for Research in Sleep Disorders.
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Javaheri S, author. CPAP should not be used for central sleep apnea in congestive heart failure patients. J Clin Sleep Med. 2006;2:399–402. [PubMed]
Teschler H, Dohring J, Wang YM, Berthon-Jones M, authors. Adaptive pressure support servo-ventilation: a novel treatment for Cheyne-Stokes respiration in heart failure. Am J Respir Crit Care Med. 2001;164:614–9. [PubMed]
Philippe C, Stoica-Herman M, Drouot X, et al., authors. Compliance with and effectiveness of adaptive servoventilation versus continuous positive airway pressure in the treatment of Cheyne-Stokes respiration in heart failure over a six-month period. Heart. 2006;92:337–42. [PubMed Central][PubMed]
Kasai T, Usui Y, Yoshioka T, et al., authors. Effect of flow-triggered adaptive servo-ventilation compared with continuous positive airway pressure in patients with chronic heart failure with coexisting obstructive sleep apnea and Cheyne-Stokes respiration. Circ Heart Fail. 2010;3:140–8. [PubMed]
Redline S, Kapur VK, Sanders MH, et al., authors. Effects of varying approaches for identifying respiratory disturbances on sleep apnea assessment. Am J Respir Crit Care Med. 2000;161(2 Pt 1):369–74. [PubMed]
Redline S, Budhiraja R, Kapur V, et al., authors. The scoring of respiratory events in sleep: reliability and validity. J Clin Sleep Med. 2007;3:169–200. [PubMed]
Ruehland WR, Rochford PD, O'Donoghue FJ, Pierce RJ, Singh P, Thornton AT, authors. The new AASM criteria for scoring hypopneas: impact on the apnea hypopnea index. Sleep. 2009;32:150–7. [PubMed Central][PubMed]
Morgenstern C, Schwaibold M, Randerath W, Bolz A, Jane R, authors. Automatic non-invasive differentiation of obstructive and central hypopneas with nasal airflow compared to esophageal pressure. Conf Proc IEEE Eng Med Biol Soc. 2010:6142–5. [PubMed]
Morgenstern C, Schwaibold M, Randerath WJ, Bolz A, Jane R, authors. An invasive and a noninvasive approach for the automatic differentiation of obstructive and central hypopneas. IEEE Trans Biomed Eng. 2010;57:1927–36. [PubMed]
Heitman SJ, Atkar RS, Hajduk EA, Wanner RA, Flemons WW, authors. Validation of nasal pressure for the identification of apneas/hypopneas during sleep. Am J Respir Crit Care Med. 2002;166:386–91. [PubMed]
Hernandez L, Ballester E, Farre R, et al., authors. Performance of nasal prongs in sleep studies: spectrum of flow-related events. Chest. 2001;119:442–50. [PubMed]
Jordan AS, McEvoy RD, Edwards JK, et al., authors. The influence of gender and upper airway resistance on the ventilatory response to arousal in obstructive sleep apnoea in humans. J Physiol. 2004;558(Pt 3):993–1004. [PubMed Central][PubMed]
Pillar G, Malhotra A, Fogel R, Beauregard J, Schnall R, White DP, authors. Airway mechanics and ventilation in response to resistive loading during sleep: influence of gender. Am J Respir Crit Care Med. 2000;162:1627–32. [PubMed]


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Last Monday, I did something spontaneous. I mean, super spontaneous. I haven't done anything that spontaneous in around... uh... a long time.
A group of gals that I run with had arranged a hike to the top of Big Baldy. One sent a text on Saturday with the specifics: meet at Dry Canyon, 8:15. The Yahoos don't have school until 9:15 so I immediately tossed the idea aside. There's no way I'd make it there at 8:15.
No Big Baldy Mounting for me. Frownie face.
If you're a mom, then you know how ridiculous the morning throw-off situation is. Or maybe I'm the only mom with a ridiculous throw-off situation. Morning-time before school-time is hectic. I also have this thing with walking the Yahoos to school. I do it as much as possible because it's currently my favorite part of being a parent. We walk for a little under a mile, and I just watch 'em. I watch them run and walk, and wander, and giggle, and play-fight, and talk. It's terrific. Before I know it, they'll be all grown-up and won't let me walk with them any more. I'm in no hurry for that to happen.
Anyway, on Monday morning, my little Fastinista Friend and I were running (she does that... slows down to run with me and I thank her kindly for it.) She wanted to Mount Big Baldy too, but had a similar morning situation with her kids. She said, "Let's just go later, after you get your kids off to school." And I said, "Nah... it's too much work to rearrange everything." Which is what I say a lot of these days.
As we finished our run on Monday, she was still trying to talk me into it, and I was still poo-pooing it with a blubbery "Too much work!" Then a couple hours later, at about 8:30ish, I decided to blow off my responsibilities – which included helping Yahoo #1's teacher; don't know one turn me in 'cause I'll be there next week – and we did it!
We Mounted Big Baldy. Smilie face.
For the record and for my posterity and whatnot, it's important that I mention this: Big Baldy is not a hike. It's a scramble. Like a grab-on-to-trees-and-branches-to-keep-from-falling-and-maybe-you-slip-and-fall-and-draw-blood scramble. And if you decide to take the Bossette Camera and all her lenses, then you'll do the scramble with a bunch of extra weight, and then you'll be sore the next day. Which is okay. The pictures were worth it.
Cue "It's a Small World After All."
I don't recall if this was before or after I fell on my keaster and tore open my finger.

subset: commoncrawl


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This solicitation will support an organization that will (1) assist the Attorney General's Task Force on American Indian/Alaska Native Children Exposed to Violence (AI/AN Task Force) to conduct public hearings and listening sessions in American Indian/Alaska Native (AI/AN) communities to help the AI/AN Task Force gain a fuller understanding of the issues surrounding AI/AN children's exposure to violence, (2) provide primary technical writing services for the final report from which the AI/AN Task Force may draw specific policy recommendations, and (3) provide all necessary support for the AI/AN Task Force and the public hearings. The Office of Juvenile Justice and Delinquency Prevention (OJJDP) in partnership with the Department of the Interior (DOI), Indian Affairs will administer this project of DOJ's Defending Childhood Initiative. This project will require close coordination between the award recipient and Departments of Justice and Interior staff, in particular the designated federal official (DFO) from the Department of Justice, to ensure that all deadlines and deliverables are met. Note: Exposure to violence includes being a victim of violence or a witness to violence and encompasses sexual abuse, physical abuse, intimate partner violence, school violence, and community violence. This program is authorized by the Department of Justice Appropriations Act, 2013, (Pub. L. No. 113-6). Read full announcement. [1]
[1] http://www.ojjdp.gov/grants/solicitations/FY2013/AGTF%20AIANCEV.pdf


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CLEVELAND (AP) -- The state has been asked to take over a Cleveland-area investigation of road paving contractors.
The Cuyahoga (ky-uh-HOH'-guh) County prosecutor has asked the Ohio auditor to handle the five-year investigation into paving contracts in Solon (SOH'-luhn) and Valley View. Prosecutor Tim McGinty didn't detail the reason for the switch.
Spokeswoman Carrie Bartunek with the state auditor's office says such a request isn't unusual. She tells The Plain Dealer (http://bit.ly/WniW7c ) the auditor's office has expertise in financial cases.
The investigation began in 2007 with a complaint about shoddy road paving work in Solon, and the probe expanded to Valley View.
Two years ago, then-state Auditor Mary Taylor ruled that $2.5 million had been stolen from the suburban communities by contractors. Restitution claims have been stalled by related criminal cases.
Information from: The Plain Dealer, http://www.cleveland.com


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You won't be able to dismiss this by usual means (escape or click button), but you can close it programatically based on user choices or actions.
"Fell in love all over again! Our save the dates came out perfect. Perfect quality, services, & pricing! Would definitely recommend to everyone!"
"Everything about his card exceeded my expectations..the card stock, ink colors, and script. I was soooo happy when I opened the box, not to mention outstanding customer service!!"
"I ordered these Save the Dates and couldn't be more thrilled! The process was super easy, and they arrived a week before anticipated (which was great!). My fiance and I are very, very happy with the way they turned out. I ordered the silver envelopes with them and love the look. We'll definitely be ordering the matching invitations!"
"I personalized this card with my picture as well as size of text and with the help of the designer with wedding paper divas she zoomed out to where my feet were not cut off. I used the pearlized paper and I absolutely love the sparkle and the quality of paper even without getting the thicker paper. The designer also made sure our url was pretty on there and that it fit. I would strongly recommend this product because my wedding guests thought it was the greatest thing ever and they all range from college students to old couples from my church!"
"I love this trifold save the date! It's very unique and gives opportunity to use several engagement photos! Also, the design team worked with me to include the text that I needed (that did not originally fit) and to change the colors to match my wedding colors!"


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Millions of Americans say they wake up tired and will try just about anything to get through the day.
Not getting enough sleep can cause memory problems, heart issues and leave you feeling sluggish the whole day; but, a new, all-natural product is promising to help you wake up and feel refreshed.
It's called Wake Up On Time. The all-natural energy pill created by Rise-N-Shine is made from active ingredients including B vitamins, amino acids to boost mood, guarana seed extract which is a natural form of caffeine and Siberian ginseng.
"The magic behind the pills is the special coating over the tablets that will delay the initial release of the ingredients so you can take it at bedtime," explained single mom Cathy Beggan, who came up with the supplement. "It will never prevent you from falling asleep, but it will kick in when you need it most, when it's time to wake up in the morning."
Sleep Specialist Dr. Puneet Patni says there's not enough research on whether supplements can improve sleep quality or wakefulness.
"There really isn't any great clinical data that's been consistently shown (that) these supplements work in either situation," he said.
The average adult needs between seven to eight hours of sleep.
"I think the most common thing we see is people trying to get a good night's sleep in three hours or four hours," said Patni.
Beggan recommends trying to get six to eight hours of sleep when taking Wake Up On Time.
"I feel alert, energetic. I'm happy in the morning and I feel very well rested even if I didn't necessarily get enough sleep," she said.
So if you have tried everything under the sun and you still don't feel rested, sleep experts say it could be the sign of a much bigger problem.
"One of the biggest things that affects the population that we've realized is sleep apnea, obstructive sleep apnea, but there are less common problems like narcolepsy, periodic limb movement disorders, abnormal behaviors during your sleep that could affect your sleep quality," Patni said.
Sleep specialists say some other ideas that could help you get a better night's sleep include regular exercise and improving your diet by reducing sugars and processed foods.
Wake Up On Time is available online and at select health food stores and pharmacies. It costs about $29.99 for a bottle of 40 pills.
Copyright 2013 by News4Jax.com. All rights reserved. This material may not be published, broadcast, rewritten or redistributed.


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Woman drives into Tampa river, drowns
Published: Thursday, February 14, 2013 at 8:46 a.m.
Last Modified: Thursday, February 14, 2013 at 8:46 a.m.
TAMPA, Fla. — Authorities say a woman got lost while driving to a church outing, accidentally drove down a boat ramp and drowned in the Hillsborough River as rescuers tried to save her.
Tampa police spokeswoman Andrea Davis says 51-year-old Migdalia Mendoza was on the phone with a friend Wednesday night as she drove through Lowry Park. The call ended abruptly with Mendoza saying she was in the water and needed help.
The Tampa Bay Times reports someone across the river saw the car drive into the water and called 911. Two police officers arrived within five minutes and dove in. They found the car but could not get Mendoza out. The police dive team arrived and pulled her from the car.
Rescuers unsuccessfully tried to revive her.
Reader comments posted to this article may be published in our print edition. All rights reserved. This copyrighted material may not be re-published without permission. Links are encouraged.


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Hey there, time traveller!
This article was published 27/4/2013 (1579 days ago), so information in it may no longer be current.
One hundred years ago this November, Winnipeg entrepreneurs Angelo Ferrari and Patrick Grogan opened a hotel on Albert Street, a short distance from the corner of Portage & Main.
The brand-new Royal Albert Hotel had 54 rooms, a buffet restaurant, telephone service and hot water, according to an advertisement in the Free Press at the time. But according to city heritage documents, the Albert's opening was overshadowed by the larger and more luxurious Hotel Fort Garry on Broadway the same year.
One century later, a revitalized Fort Garry Hotel has spent the bulk of 2013 celebrating its 100th year of operation. And yet again, what's now the Royal Albert Arms is still struggling in its shadow, both as a heritage property and an important piece of this city's cultural fabric.
The Fort Garry Hotel, under the proprietorship of Ida Albo, has reclaimed its rightful place as an upscale heritage hotel -- the ideal setting for marriages involving relatively affluent young couples, weekend getaways for Winnipeggers who have no time to get away and trysts for all manner of visitors.
The Royal Albert Arms, up until two years ago, was instead beloved as a living piece of Winnipeg music history. Although down on its luck as a hotel for many decades, the main-floor space has a cherished history as the site of legions of punk, metal and indie-rock shows in the 1980s and onwards.
The Albert nurtured legions of young Winnipeg rock bands, some of them awful but many of them amazing. It also played host to legendary performances by the likes of Minneapolis indie pioneers Hüsker Dü, punk-pop band Green Day before they were an FM radio staple and pretty much every punk or indie band to tour across Canada from the mid-1980s to the last decade.
To suggest the Albert occupies an important place in the heart of Winnipeg's music scene is sort of like saying St. Peter's Basilica is an important building in Rome.
Every facet of the Albert, from the old wooden bar to the raised stage to the infamously awful washrooms back in the day, is effectively hallowed ground in Winnipeg. While the building itself is important from both a heritage and urban streetscape perspective, the venue deserves all the fuzzy nostalgia that goes along with being a legendary venue.
This legacy, however, was interrupted during the Victoria Day weekend of 2011, when a water pipe burst and the hotel was forced to close. Deseo Bistro, the well-regarded restaurant that took up shop in the sunroom at the front of the building, decamped to Fort Rouge. Sam Smith, the well-regarded talent buyer who booked the bands for the Albert, was forced to find work elsewhere.
Hotel owner Daren Jorgenson, who had purchased the Albert in 2007 amid promises of renovations, was left to attempt to raise the money to make the repairs necessary to allow the building to reopen. But the former Internet-pharmacy magnate was struggling with financial troubles of his own.
The Albert did not reopen until March of this year, almost two years after being shuttered. Bands were booked once more for the venue. A restaurant returned to the sunroom.
The future of the Albert looked promising once more -- until this week, when Jorgenson revealed his partner in the building is a convicted criminal once regarded by police as one of the most dangerous people in Winnipeg.
Jorgenson told the Free Press this week his partner in the Albert is Ray Rybachuk, who many Winnipeggers may remember as the figure responsible for erecting a large and illegal electronic sign on the Boyd Building, a Portage Avenue heritage structure.
The City of Winnipeg waged a long and protracted battle to remove the sign, placed without a permit and in defiance of city orders. Rybachuk also ran afoul of the city for transforming a public park alongside the Boyd Building into a surface-parking lot.
Then in 2012, his co-ownership of the Boyd Building proved an immense embarrassment to another one of the structure's investors -- Armik Babakhanians, the president of Caspian Construction, the firm that won a $137-million contract to convert the former Canada Post building on Graham Avenue into Winnipeg's new police headquarters.
This association was embarrassing because Rybachuk is extremely well-known to police and justice officials in Winnipeg. Between 1994 and 2006, Rybachuk was convicted of assault, mischief, narcotic trafficking, money laundering and obstruction of justice, court records show.
As well, criminal background checks on him include warnings he had ties to both the Los Brovos and the Manitoba chapter of the Hells Angels.
In 2012, senior city officials and the Winnipeg Police Service insisted Rybachuk had no involvement in the construction of their new headquarters.
"The city was aware that both Mr. Rybachuk and Mr. Babakhanians, along with others, had investments in the Boyd Building. Security checks, which included speaking with the owner of Caspian Construction, concluded there was no reason not to allow Caspian Construction to bid on the Winnipeg Police Service headquarters project," the city and the police said in a joint statement.
In a story that received prominent play in this newspaper, Babakhanians immediately pledged to end any business association with Rybachuk.
As a result, it is unlikely Daren Jorgenson was not aware of Rybachuk's background before entering into a partnership with the well-known figure. While Jorgenson may not be a big fan of this newspaper -- he has been critical of the coverage of the protracted Albert closure -- a single Google search yields stories by several media outlets about his new partner.
With all due respect to Jorgenson, this is not acceptable. The Royal Albert Arms may not have a crystal ballroom like the Fort Garry Hotel, but it is just as important to this city's cultural life.
Any commercial association with individuals who have a serious criminal past is troubling, especially in a city that has struggled for decades against gang activity. Front-line police officers, who work every day to protect all Winnipeggers from organized crime, are infuriated by the accommodation of known criminals by otherwise legitimate businesspeople.
If Jorgenson needed money to reopen the Albert last year, other businesspeople could have and would have taken the building off his hands. Jorgenson has said he would never sell the property, however.
For the sake of the Royal Albert Arms, Winnipeg's music scene and what remains of our collective sense of pride in this city, here's hoping Daren Jorgenson can find himself a new partner.


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Database: Benefits of the Affordable Care Act by local congressional districts
With most Americans mandated to purchase health insurance by January 1 or risk paying a tax, the debate over the Patient Protection and Affordable Care Act is heating up yet again.
Last week, Republicans in the House of Representatives made their 38th attempt to gut Obamacare, while Democrats released statistics they cite as proof that millions of people are already benefiting from the most significant overhaul and expansion of the nation's health care system since Medicare and Medicaid were passed in 1965.
For 22-year-old UCLA student Daniel Block, however, there is no controversy.
He credits the ACA with preventing his parents' health insurance provider from kicking his sister off their plan when she turned 24.
Emily Block underwent a $23,000 surgery in May to prevent neurological damage and, potentially, paralysis connected to her Ehlers-Danlos Syndrome, a disorder of the body's connective tissues.
"Before the ACA, it was unlikely that a health insurance provider would cover her because there's no known cure for what she has," Daniel Block said.
"And with the ACA removing dollar limits on health benefits, she doesn't have to worry anymore about hitting her lifetime cap way before her lifetime," he added.
Rep. Buck McKeon, R-Santa Clarita, does not dispute the ACA has advantages but believes the cost is too high.
"There are some good reforms within Obamacare, such as protecting patients with pre-existing conditions and offering insurance options for young adults," he wrote in an email this week. "But at a convoluted 2,700 pages, as a whole, Obamacare fatally misses the mark."
Meanwhile, several Republicans in both the House and Senate pressed the White House for additional data on health insurance premiums.
"Based on documents we collected from the nation's largest insurance companies, an average new customer in the individual insurance market could see premiums increase from $1,896 to $3,708 per year, a monthly increase of $151, because of mandates in the health care law," House Energy and Commerce Committee Chairman Fred Upton, R-Michigan, said in a written statement.
But a report by Democratic staffers on that same committee analyzes how ACA has benefited millions of Americans since it was signed by President Barack Obama in 2010, based on breakdowns of every congressional district in the country.
It shows the ACA has already expanded health insurance coverage to 3 million young adults; saved seniors an average of $600 on prescription drugs each year; and made free preventive services available to more than 100 million Americans.
Rep. Henry Waxman, D-Los Angeles, the ranking Democrat on the committee, noted that in his own district, which stretches from Malibu to Rancho Palos Verdes, and parts of the San Fernando Valley and West L.A., 7,500 young adults were able to stay on their parents' health insurance plan after the ACA changed the cutoff age.
It also found 12,000 seniors saved about $550 each in prescription drug discounts this year, while 50,000 consumers received an average of $70 in rebates because the ACA banned insurance companies from spending more than a fifth of their premiums on profits and administrative overhead.
In October, health insurance marketplaces, also known as exchanges, will open throughout the country and serve as a one-stop shop for people to compare health insurance policies and receive financial assistance for coverage that would begin in January.
"Already, people are seeing the benefits of the ACA," Waxman said. "But when the marketplaces open, a lot of people who don't have health insurance now will finally have access to it."
As for McKeon's district, which includes the Santa Clarita and Antelope Valleys, the Democrats' analysis showed almost 70,000 seniors are now eligible for Medicare preventive services without paying any co-pays, coinsurance or deductible.
It also found 250,000 individuals now have insurance that cannot place lifetime dollar limits on their coverage starting in 2014.
McKeon insisted the numbers have been manipulated.
"We are seeing many of the law's supporters selectively picking what data they are sharing regarding the health law and this has left the American people with a very incomplete, misleading picture of reality," he said.
The report also found that about 8,500 seniors in Democratic Rep. Brad Sherman's district in the San Fernando Valley altogether saved $12 million on prescription drugs through the ACA.
In the San Bernardino County district represented by Republican Rep. Gary Miller, it identified up to 50,000 children with pre-existing health conditions who can no longer be denied coverage by health insurance provides.
Republican Rep. Ed Royce's district in the San Gabriel Valley has 88,000 seniors now eligible for Medicare preventive services without paying any co-pays, coinsurance, or deductible, according to the report.
It said 41,000 individuals in Democratic Rep. Alan Lowenthal's district, which includes Long Beach, will be eligible to receive financial assistance for their health insurance coverage through the ACA.
For Daniel Block, the law has made miracles. His sister -- who has suffered several strokes -- is now enrolled at Tufts University in Boston and hopes to become an occupational therapist.
"I got so incredibly frustrated when I saw Republicans trying again to repeal the ACA," he said. "It's political maneuvering -- I understand that -- but this is my family's well-being."
"It's very real to me."


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co·ter·ie (kt-r, kt-r)
A small, often select group of persons who associate with one another frequently.
[French, from Old French, peasant association, from cotier, cottager, from *cote, cottage, possibly of Germanic origin.]
The American Heritage® Dictionary of the English Language, Fourth Edition copyright ©2000 by Houghton Mifflin Company. Updated in 2003. Published by Houghton Mifflin Company. All rights reserved.
Sexton d'City preferred the coterie of Steel Magnolias.
mark lone-wuff Bailey


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A TALENTED teenager has breezed through to the next round of a prestigious singing competition.
Palmer's College student Meg Symons needed only a few seconds in front of a panel of Teen Star judges, performing Laserlight, the hit of Essex-based star Jessie J, to convince them she was good enough to progress to the next round of the competition.
The successful audition, which took place at the Palace Theatre in Southend on Saturday, January 26, edges the 16-year-old songstress a step closer to her dream of stardom.
Dubbed by her friends and family as "the new Beyonce" Meg, who is studying performing arts at Palmer's, but hails from Latchingdon in north Essex, is a fan of "big" voices in pop music.
She draws inspiration from the likes of Beyonce and Jessie J, who regularly blow audiences away with their powerful vocals.
It's the influences of these stars, and Meg's own dynamic voice, that meant Teen Star judges cut her audition short, convinced early on the youngster, though small in height, has big talent.
"It went really well," said Meg, reflecting on the audition. "They took us 16 to 19-year-olds off in groups of six and we each had to sing to the judges without a backing track, which was really nerve-wracking.
"I got cut short by the judges very early on in my song so I was really worried.
"Then you leave the room and within 15 minutes the judges have made their minds up.
"A woman came up to me and two others and told us we were the only ones out of the six to have been picked for the next round.
"It felt amazing. Last year I went in to audition for The Voice and didn't get past the first round, which knocked my confidence. "But I was speechless [after being put through in Teen Star]."
Next up is the regional finals at the Palace Theatre on March 17, where Meg will perform in front of a live audience. Should she make it through, an opportunity to perform at the O2 Arena in London beckons.
The competition has been won previously by Birdy, who went on to have a top 20 hit with Bon Iver's song Skinny Love.
Meg added: "The plan is just to try and get on stage ane show everyone what I can do.
"Singing is my way to show feelings, it's my way of telling people how I feel and what my story is.
"I said to my mum after getting through, when it comes to the next round I'm more than happy if I don't get through because I will have got to perform on stage to a live audience, which is part of my dream coming true."


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Gobel Quality French Bakeware
90mm non-stick round millasson mould
Gobel are one of the leaders in the competitive bakeware market. This superb French patisserie brand has been manufacturing moulds for over 125 years producing high quality products; perfect for the baking enthusiast and chef alike. Their unique expertise in the production of moulds and tins means that Gobel can design entirely new shapes, developing and using new technologies at all stages giving them the ability to adapt to the latest trends in this market whilst catering for traditional tastes.
Their comprehensive range encompasses everything the home baker or professional chef requires, including many items they never knew they needed but absolutely must have
The products come in a variety of ranges: stainless steel, non-stick, tin plated steel and aluminium, all manufactured to the highest standards in France. Numerous sizes offering the consumer complete choice and flexibility.
Gobel holds a unique place in the market offering quality, tradition and expertise with extensive consumer choice and excellent value for money.
Products are shipped by the individual Fruugo retailers, who are located across Europe and the rest of the world. The delivery times and shipping prices vary depending on the retailer's location, the destination country and the selected delivery method.
Fruugo offers two delivery options: Standard or Express. All retailers offer a standard delivery service, and some retailers also offer an express delivery service.
Although Fruugo retailers endeavour to deliver within these timescales, please note that the above timescales are estimated and not guaranteed.
The delivery timescales do not include any customs clearing times beyond Fruugo's control.
Please allow additional shipping time for deliveries to South Africa.
All carriers deliver during normal business working hours and may require a signature on receipt, so please ensure your order is delivered to an address where someone will be available to accept it.
We do our best to ensure that the products that you order are delivered to you in full and according to your specifications. However, should you receive an incomplete order, or items different from the ones you ordered, or there is some other reason why you are not satisfied with the order, you may return the order, or any products included in the order, and receive a full refund for the items.
Certain products purchased at Fruugo cannot be returned. They fall in the following categories:
Please take reasonable care of the goods whilst in your care. Any goods returned must be in a resaleable condition. They must be unworn/unused with original tags attached and in original packaging. It is your responsibility to ensure that the goods are appropriately packaged to ensure they are not damaged in return transit.
Notifying us of a return
If you wish to return an order, or some of the products included in an order, please notify Fruugo customer care within 14 days of receiving the goods, including the following information:
Our customer care will send you specific instructions on how to ship the return package(s) to the retailer(s). Please do not ship the return package before you receive the instructions.
Shipping products back to retailers
Goods must be returned without undue delay and in any event not later than 14 days after notifying us of your cancellation.
If you are returning products to several retailers, you should distribute the products accordingly and send the products to those retailers who shipped them to you initially.
We strongly recommend that you use registered mail (and insure any high-value packages), since neither Fruugo nor the retailer take responsibility for shipments that are lost or damaged during return transportation.
Please ensure you retain a proof of postage receipt so in the unlikely event your parcel goes missing, you will have proof you sent it.
You will be refunded within 14 days of the retailer receiving back the goods. We will notify you by e-mail once the products reach the retailer and are accepted for return. Where a retailer has offered to collect the goods, you will be refunded within 14 days of cancelling your contract.
Unless a product or products you wish to return arrived to you damaged or faulty, you are responsible for the return transportation costs.
Providing you are returning all the products from a specific retailer, we will refund the standard shipping costs you paid for the original delivery. If you chose to pay for a non-standard delivery, we will only refund the cost of our least expensive, standard delivery.
Damaged or faulty goods
If you receive a damaged, broken, or defective product, please notify Fruugo customer care as soon as possible. Include at least the following information:
We will generally instruct you to ship the damaged product back to the retailer. As soon as it reaches the retailer, they will send you a replacement product. If the replacement can't be made, or if you wish to cancel the order, you will be refunded in full. You will also be reimbursed for reasonable returns postage costs for damaged or faulty goods once we have received your postage receipt.
If the outer packaging of your order is clearly damaged on arrival, and you are suspecting that the products are damaged as well, you can either reject the delivery or accept the goods and sign for them as damaged. In both instances, please notify Fruugo customer care as soon as possible.
Refusing delivery
If you refuse to accept delivery of all or part of your order (where the products or packaging do not appear to be damaged or defective) you will be responsible for the postage charges. Any fees and charges incurred by the retailer due to a package being refused will be deducted from your merchandise refund.


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10 Important Moments In The History Of Pubic Hair
Pubic hair has been growing between our legs since … well, since we've existed. Currently en vogue for women, and the subject of much debate, is the hairless, or as-little-hair-down-there-as-possible, look. Whether you choose to go hairless or not, the bald below trend existed way before "Sex and the City."
The ancient Egyptians considered pubic hair uncivilized and removed it with razors made of flint or bronze or by a practice still used today called sugaring. So, we should probably rename "the Brazilian" "the Egyptian."
Click through to see some of the most significant moments in the history of pubic hair. Or lack thereof. [History Undressed]


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Laurier Bookstore
Director, Retail/Printing Services: Debohra Da Costa, email@example.com, ext. 3107
Brantford Bookstore Supervisor: Jennifer Brickman, firstname.lastname@example.com, (519) 756-8228, ext. 5834
Laurier Bookstore is a full service Retail operation offering a wide range of new and used textbooks, general and reference books, school supplies, computer hardware and software, magazines, greeting cards and CDs. The Bookstore also offers a special order service for general books.
There is a clothing and gift department which sells Laurier insignia wear. Academic hood and graduation gown rentals are available through the Laurier Bookstore.
A complete guide to which books are required is available on the textbook section online at www.bookstore.com using your student identification number and your LORIS login. The Book Buyback program is held at the beginning and end of fall and winter term in the Concourse.
There is also an athletic apparel "Hawk Shop" in the Waterloo Campus Athletic Complex specializing in Hawk Wear. Their hours are Monday to Thursday, 10 a.m. to 8 p.m., Friday 10 a.m. to 4 p.m. and Saturday, 9 a.m. to 4 p.m. (except long weekends). Hours extended for special events.
Academic & Related Dates 2009/2010
Other Calendars


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Bust out your lederhosen and beer gut: It's Oktoberfest time! More than 5 million people attend the beer festivities in Munich, Germany, which last from the end of September to the first weekend in October. (September 17 to October 3 to be exact.) Whether you're headed across the globe, or just plan to have a celebration stateside, we've got the recipes and phrases to add some authenticity to your party.
Key Oktoberfest Phrases
(Courtesy Living Language)
- Prost! [prohst] — Cheers!
- Noch ein Bier, bitte. [nokh eyn beer bee-teh] — Another beer, please. (Maybe the most important phrase of all. Practice this one!)
- Die nächste Runde zahlen Sie! [dee nekh-steh roon-deh tsah-lehn see] — Next round is on him/her!
- Halt deine Lederhosen fest! [hahlt dey-neh leh-dehr-hoh sehn fest] — Hold onto your Lederhosen!
Recipes for Oktoberfest
With all that drinking that goes on for Oktoberfest, food is a must. We've rounded up some Oktoberfest favorites, plus some new twists to help you stayed full.
- Pretzels: Give Chuck's Ballpark Pretzels with super cheesy sauce a try, or go big with Emeril's Giant Poppyseed Pretzels.
- Wurst: No German meal is complete without a wurst of some kind. Make Michael Symon's version of Bratwurst Stewed with Sauerkraut. Serve it on a baguette to savor all of the juicy flavor.
- Doughnuts: Fried dough has a way of comforting a beer-full belly. Fill up with Mario's Potato Doughnuts, or go sweeter with Gale Gand's Cinnamon-Spiced Doughnuts.
- Meat-Heavy Dishes: Roast pork, half chickens and other meat-centric mains can all be found at Oktoberfest tents. Recreate the dishes (with a twist) in your own home with Rachael's Slow-Cooked Pork Roast and Roast Chicken Dinner.
Do you join in Oktoberfest festivities?


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FreshDirect Launches Gluten-free Store Online
FreshDirect has gone the extra mile and created a gluten-free store filled with more than 500 items for those who need to follow a gluten-free diet. The store was launched during National Celiac Disease Awareness Month and its goal is to make it easier to find gluten-free foods by putting them under one department. FreshDirect is an online shopping site that delivers groceries ... Read More »


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CyberLink Launches PowerDVD 14 with HEVC Supportby Ganesh T S on 4/8/2014 6:00 AM EST
- Posted in
- Home Theater
- Blu-Ray
- CyberLink
37 Comments
Back to Article
npz - Tuesday, April 08, 2014 - linkInteresting. The ads and somewhat resource intensive software (any piece requires loading a ton of other components) turn me off, but I like their wide ranging support. Their PowerDirector 12 is the only editing and authoring program I'm aware of to support both mkv and subtitle editing. But it still didn't support hi10p AFAIK.
Now with HEVC support, I wonder if h.264 support has improved. h.265 higher end profiles specifiy 10-bit support and I assume Cyberlink also support 10-bit decoding for h.265. But I wonder about h.264. Do they support hi10p? Aside from color depth, what about color/chroma space i.e. YUV 4:2:2 and 4:4:4? I also wonder if subtitle support has also improved, or better yet, if they're using opensource libraries for handling it.
It would also be interesting if you could do LAN streaming, where you'd use a PC to transcode and stream files to devices that can't play them natively or don't have the power. Reply
edzieba - Tuesday, April 08, 2014 - link"Their PowerDirector 12 is the only editing and authoring program I'm aware of to support both mkv and subtitle editing."
Aegisub is kind of the Gold Standard for subtitle editing, particularly in MKV. Reply
npz - Tuesday, April 08, 2014 - linkYes I use Aegisub myself :) But it's subtitle editor, not a video editor Reply
Sivar - Wednesday, April 09, 2014 - linkYes, h.264 supports hi10p (with the x264 encoder). The benefit isn't increased color depth, however, it is increased compression. Reply
Dave12311231 - Tuesday, April 08, 2014 - linkHey everyone. I've just played back a 4k video downloaded from YouTube and it played flawlessly on Windows Media Player (Windows 8.1) and an Ivybridge CPU, better than VLC where the video looked jerky and some frames were dropped. I was amazed and impressed. Video was Costa Rica 4k. Reply
nathanddrews - Tuesday, April 08, 2014 - linkJust remember that 4K videos on YouTube aren't a very high bit rate and typically lower than 1080p Blu-ray. I always opt to stream YouTube at 2160p if given the option. Reply
dylan522p - Tuesday, April 08, 2014 - linkYup, I don't have a 4k screen, but 4k Youtube is about as good as a medium bitrate 1080p video once downs-sampled. Reply
Aberforth - Tuesday, April 08, 2014 - linkYes, when there is no other feature that you can come up with then use cloud as an excuse to sell your product, even winzip has that "cloud" feature. I don't know why you wankers promote these stupid products when there are perfectly free alternatives available. Reply
ganeshts - Tuesday, April 08, 2014 - linkWhat is the 'perfectly free alternative' on a PC for playback of Blu-rays with menus and all associated licenses in-place / support for UltraViolet playback? Reply
nathanddrews - Thursday, April 10, 2014 - linkWhat I don't understand is why anyone would want all that crap. Previews, menus, BDLive, games and all that just interfere with the whole process of trying to enjoy a movie. Extract the videos you want to your container of choice and play through any free player (XBMC, VLC, MPC, etc.). It's like Netflix, but perfect quality. Reply
EdgeOfDetroit - Friday, April 11, 2014 - linkHere's my "cloud". It lets me take my content anywhere I go! And for the number of GB, its half the price of their $1 per gigabyte model, after I've had it for a year: http://www.newegg.com/Product/Product.aspx?Item=N8... Reply
Rafterman - Thursday, February 12, 2015 - linkThe playback quality of VLC compared to Powerdvd is pretty poor. Its easy to test so have a look yourself. While VLC is brilliant in that it plays anything you throw at it the playback quality of video content is not on a par with PowerDVD. Reply
brucek2 - Wednesday, April 09, 2014 - linkI'd settle for knowing just the "playback of Blu-rays with menus" part. Reply
knightracer - Tuesday, April 08, 2014 - linkAt these prices, I'd rather buy a dedicated Blu-Ray player. PowerDVD is still too resource intensive with many processes. Reply
djnforce9 - Thursday, April 10, 2014 - linkIt's a great solution for playing BluRay movies on your PC if you don't want to purchase something separate. Unfortunately there is nothing built into Windows that allows it. Reply
Wolfpup - Tuesday, April 08, 2014 - linkAll I want from the Windows version is a good DVD/Blu Ray player that works 100% reliably and gets out of the way.
From the mobile versions I want something that can (in the case of Windows RT) playback at least DVDs if not also Blu Rays, and MPEG2 from my Tivo...the "cloud" stuff and whatever is utterly meaningless to me. Reply
ssiu - Tuesday, April 08, 2014 - linkWhat is the minimum hardware requirement for smooth software HEVC/H.265 decoding/playback? Reply
ganeshts - Tuesday, April 08, 2014 - linkDepends on what resolution you are looking at. Pretty sure a Sandy Bridge i3 is good enough for 1080p24. Still trying to collect test streams for various resolutions and frame rates to get a good idea. HEVC is still in its infancy, though -- we are not sure yet what the encoding parameters that will be used to create the media files will be. Reply
sajara - Tuesday, April 08, 2014 - linkFrom my own tests since x265 came out in September HEVC still has a long way to go compared to x264 encoder, but in only 7 months months has improved massively in development. The next branch will deal with quality so lets see how long till HEVC stops to be only a nice marketing jargon. Reply
ToTTenTranz - Tuesday, April 08, 2014 - linkSo let me get this straight:
- The "standard version" only plays DVDs but costs almost as much as a standalone BluRay player with all the hardware (optical drive, SoC, motherboard, power supply, case, remote), software licenses, etc.
Besides, isn't DVD playback free with windows nowadays?
- The "Pro version" plays blurays but doesn't support 3D and downmixes all original 7.1 content into 5.1 (probably spending CPU/energy resources into decoding a TrueHD/DTS-HD just to drop 2 channels and send a 5.1 LPCM instead).
It costs almost the same as a full-fledged standalone BluRay player that will play 3D content and won't castrate the sound for people who have a 7.1 setup.
- The "Ultra Version" is more expensive than many standalone BluRay players that offer practically the same functionality.. except that it's just a piece of software.
So what's the pirated/purchased ratio on this? 1 Million to 1?
Do people actually buy this?
HEVC support has been around for ages in free and open-source software. Why would any capable-of-using-google person would want to pay for this? Reply
abrogan - Tuesday, April 08, 2014 - linkI totally agree.
This company has no shame. After forcing me to pay twice to continue having blu-ray support, I won't buy their products ever again. Also forced their customers to pay for windows 8 support eventhough it would work fine if it didn't self check and disable itself. (planned obsolescence, nothing more) Buy a blu-ray player to watch blu-rays. Don't use a computer. And shame on the companies that created the blu-ray format, that they didn't have the foresight to release a free blu-ray application when they released the format. Short-sighted stupidity killed the platform. I didn't experience any of these aggravations with the DVD standard..... Reply
abrogan - Tuesday, April 08, 2014 - link45 dollars a year so that you can continue to watch your blu-rays on your computer... what a joke! Reply
Deelron - Tuesday, April 08, 2014 - linkAgreed, it's sad that it's easier and more cost effective to get a lifetime license for a program that removes copy protection schemes (specifically for Blu-Ray) then it its to try and have a "legitimate" software player. Reply
Flunk - Wednesday, April 09, 2014 - linkMicrosoft charges for Bluray and DVD playback because they need to pay for the licensing. In Windows 7 very few people used the built-in codecs so they decided to try and save money and sell them for $9.99. $9.99 isn't so bad, I think it's pretty close to cost. Reply
HardwareDufus - Thursday, April 10, 2014 - linkYou can't purchase BluRay Playback in Windows 7 for $9.99.
There is no way to enable Windows Media Player in Windows 7 to playback BluRay. Reply
HardwareDufus - Thursday, April 10, 2014 - linkWhat I mean to say is.. .you cannot enable the Stock Windows Media Player that comes with Windows 7 (any addition.. I have Ultimate) to play back BluRay... There is no Codec purchase option available from Microsoft.
You have to go 3rd party...at which point you might as well use a 3rd party player too. Reply
HardwareDufus - Thursday, April 10, 2014 - linkI hope you guys are following what I've typed.... I've presented it as clear as mud... Sorry.
My point was, whereas previously purchasing an Ultimate Edition of Windows gave you near endless play back capability of DVD content.... Microsoft washed its hands of BluRay and other advanced codecs. You have to go elsewhere... 3rd party... can't go stock... can't even go stock with options purchase... you have to go 3rd party.
I use Cyberlink... and I don't like it. Reply
Morawka - Friday, April 11, 2014 - linkAnd the only real affordable option they have is the Media Suite Ultimate for $150, which is 2 year old software missing the cutting edge features. Yes this company is hit with rampant piracy and with good reason, they just arent getting their product out there at a affordable price.
Look at what steam did to slow PC Piracy, They made it easy to buy software and made it very affordable. PC Piracy has droped 500% in the past 5 years. Cyberlink needs to look at what valve did and make thier whole suite affordable. $50 max per program, unless its the Power Director (i agree it's worth more). and maybe $199 for all of the latest and greatest Ultimate Suite.
But nah, they want $100 per, and the suite has 10 programs, so that's $1000 you'd have to spend to get the latest and greatest. Their equivalent to Office 365 subscription is only available on 1-2 products. They need to get real with the pricing is all i'm saying Reply
Morawka - Friday, April 11, 2014 - linkAnd dont forget, everyone else will be rolling out HEVC support in the coming months, and cyberlink will start including the feature in the standard version to remain competitive. Right now they are the first to do it, so they are charging $50 more "because they can". Reply
ericore - Friday, April 11, 2014 - linkMy two cents,
9.99 DVD and Bluray support inc. 3d for Windows Media Player 9,99
Standard version with blu-ray support 19.99
Ultimate version with everything 29.99
Anything else this bloatware is a scam.
VLC does always give the best quality, but it has videos filters :)
WMP Classic home cinema, you will have better luck with. Reply
Morawka - Friday, April 11, 2014 - linkThey Locked H.265 Support to only the ULTRA and LIVE Versions, which is retarded. If you buy the standard version for $50 it should come with H.265, what a greedy company. No wonder its one of the most pirated software in the world.
The $50 version cant even play blu rays WOW Reply
Krysto - Friday, April 11, 2014 - linkWhy adopt a proprietary format when VP9 exists? Reply
EdgeOfDetroit - Friday, April 11, 2014 - linkDoes it still take three months to encode one movie in VP9 format? Reply
DikAlex777 - Tuesday, April 15, 2014 - linkWhenever I try to activate it, the following error appears:
You cannot upgrade to Cyberlink Power DVD 14 because you do not have Administrator privileges on this computer. Sign in to Windows as administrator and try again.
I am the administrator!
What else does it need??
I tried every option from this page
no luck!
How can I activate the product I bought???
Does Cyberlink support ever reply?
I created a ticked 5 days ago, but they keep silent...
Not good at all, I must say. Reply
Flunk - Tuesday, April 22, 2014 - linkI have a copy of Power DVD 10 I bought about 2 years ago, it doesn't play more than half the blurays I've tried to play. For a $99.99 piece of software that's pathetic. Not only that they keep releasing new versions an discontinuing updates for older ones.
All I wanted was a software player than could play all the same movies any hardware player can and what I got was an overpriced, worthless piece of junk. I wouldn't buy anything from this company ever again. Reply
Gadgety - Monday, August 18, 2014 - link$45 a year seems like a rip off but I don't know what kind of fees they have to pay to license the software. Reply
Inkmeal - Thursday, April 16, 2015 - linkIt would be great... if it worked. I subscribed a week ago and they have been unable to activate my subscription. Needed it for a presentation and the tech support takes forever to get back to you with a cut and pasted answer. Four replies later and they still don't seem to understand what I'm saying. Not sure if there's a language barrier, but good luck if you buy this software and need any help. The customer service and tech support are useless. They will give a refund if you give up on making it work, but if you want the software, it's a crap shoot. I would not recommend this software because of the terrible support. Reply


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A FATHER and son have been rescued from the River Foss in the early hours of this morning.
Police were urgently called to reports of screaming coming from the River Foss near the Castle carpark where they found two men, waist deep in water, holding takeaway food above their heads, North Yorkshire Police said.
A 19-year-old man - initially believed to have been older by the fire service - had been drinking and got into difficulties in the river just before 2am, when his 54-year-old father, who had also been drinking, went in to help.
Both men were from York. They were suffering from mild hypothermia when emergency services arrived.
Officers threw life rings to them and worked with firefighters, who wore wet suits and used a ladder, to get the men out.
Paul Richardson, deployment manager in the North Yorkshire Police control room, said: "Yet again the emergency services were tested by the over indulgence of alcohol by drinkers in York, not only putting themselves in danger but risking the lives of the emergency services and people around them.
"The dangers of going near the river are well documented and we would urge the public that when out in York they view the beauty of the city from the river bank and not get into difficulty by entering the water."
The men passed to the care of the paramedics for a precautionary check. Police are continuing to investigate the matter.
Before the weekend warnings were issued to race goers travelling to the John Smith's Cup at the Knavesmire on Friday and Saturday. Police were out in force for the event, which has been dogged by binge drinking problems in the past.
The river incident was not connected to the races and police said few incidents this weekend related to the races or the football.
There were, however, numerous weather and alcohol-related matters with increased incidences of violence in York and across North Yorkshire.
The police control room, which would usually expect to take 180 emergency 999 calls on a Saturday night, was inundated with 310 calls.
The team would usually expect 594 calls to the 101 line, but received 712.


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PLASTICA: Cableyoyo
Omg as a fan of the next best shiney gadget thing, I have many many cords to manage, and this little guy may be the perfect thing to get cords under control. i think i need a dozen of them.
I love any cable managementTags: home, electronics, technology, gadgets, furniture, storage, office, modern, containersAdded 8 Years Ago from Bluelounge


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Tyra Banks casts transgender contestant on America's Next Top Model
Hold on to your androgynous zones; the new season of America's Next Top Model just got a whole lot more penis-ier. Meet Isis (above) a transgender model who "identifies herself as 'a woman born physically male.'" She/He made the cut to be on Tyra Bank's completely scripted modeling competition and looks forward to pretending to have to a chance on this season's cycle, according to Us Weekly:
Will she be a role model?
"I like to help people, but I'm here to follow my dreams," she tells Us.
The inclusion of Isis is being hailed by GLAAD president Neil Giuliano as "an unprecedented opportunity for a community that is underrepresented on television.
"We applaud Tyra Banks and The CW for making this historic visibility of transgender people possible," Giuliano said.
So, if she's a woman born physically male, does that mean she makes herself her own sandwiches? Otherwise, you lost me.