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The "Diagnosis and Treatment of Sleep Apnea in Cerebrovascular Disease" (GoToSleep) study is evaluating a strategy to improve the diagnosis and treatment of sleep apnea among veterans with stroke or transient ischemic attack (TIA) who also have hypertension. Specifically, the GoToSleep study was designed to overcome some of the barriers that exist within the Veterans Health Administration (VHA) to the timely diagnosis and treatment of sleep apnea by using ambulatory home-based polysomnography and auto-titrating continuous positive airway pressure (CPAP) to reduce the reliance on laboratory-based sleep studies.
The GoToSleep study is a prospective, multi-site, randomized, controlled strategy trial among an expected 318 veterans with cerebrovascular disease and hypertension who are assigned to an intervention group or a control group. Patients in the intervention group receive unattended polysomnography at baseline, and those with sleep apnea receive auto-titrating CPAP therapy for up to one year. Patients in the control group receive usual care and unattended polysomnography at the end of the study to identify the rate of undiagnosed sleep apnea. The primary objectives of the GoToSleep study are to determine whether a diagnostic and therapeutic intervention strategy among veterans with cerebrovascular disease and hypertension improves: (1) detection of sleep apnea; (2) appropriate treatment for sleep apnea; and (3) control of hypertension. Twenty-four-hour blood pressure assessments are made at baseline and at the end of the one-year study period for both groups. Antihypertensive medications and their doses are recorded at the time of the 24-hour blood pressure measurements.
This manuscript provides the rationale for 4 key components of the design of the GoToSleep trial: the inclusion of patients with cerebrovascular disease and hypertension without the use of a measure of daytime sleepiness as an eligibility criterion; the use of portable polysomnography and auto-titrating CPAP in patients' homes rather than using sleep laboratory polysomnography with fixed pressure CPAP; the analytic approach to evaluating change in blood pressure in the context of change in antihypertensive medications; and the use of a usual care control group.
Bravata DM; Ferguson J; Miech EJ; Agarwal R; McClain V; Austin C; Struve F; Foresman B; Li X; Wang Z; Williams LS; Dallas MI; Couch CD; Sico J; Fragoso C; Matthias MS; Chumbler N; Myers J; Burrus N; Dube A; French DD; Schmid AA; Concato J; Yaggi HK. Diagnosis and treatment of sleep apnea in patients' homes: the rationale and methods of the "GoToSleep" randomized-controlled trial. J Clin Sleep Med 2012;8(1):27–35.
Current Knowledge/Study Rationale: This manuscript describes the rationale and methods of the GoToSleep study which seeks to evaluate a strategy of diagnosing and treating sleep apnea among veterans with cerebrovascular disease and hypertension. The intervention strategy was designed to reduce the reliance on laboratory-based sleep studies and to enhance treatment adherence by conducting diagnostic and therapeutic activities within patients' homes.
Study Impact: This manuscript describes four key elements of the GoToSleep study design that are either unique to this study or rarely employed in clinical trials: the inclusion of patients with cerebrovascular disease and hypertension without use of a measure of daytime sleepiness as an eligibility criterion; the use of portable polysomnography and auto-titrating CPAP in patients' homes rather than using sleep laboratory polysomnography with fixed pressure CPAP; the analytic approach to evaluating change in blood pressure in the context of change in antihypertensive medications; and the use of a usual care control group.
Sleep apnea is common, affecting as many as one-fifth of the adult population,1 and found in approximately two-thirds of patients who have had a stroke or transient ischemic attack (TIA).2–10 Sleep apnea has been independently associated with a variety of adverse metabolic and disease states and outcomes including hypertension, diabetes, stroke and TIA, incident coronary events and cardiovascular mortality, and all-cause mortality.1,4,11–13 Unfortunately, estimates suggest that as many as 70% to 80% of patients with sleep apnea are neither diagnosed nor treated.14 Even among patients with stroke and TIA, who are at particularly high risk of recurrent vascular events related to sleep apnea, screening for sleep apnea is uncommon. The barriers to diagnosing and treating sleep apnea consist of a variety of patient, provider, and system issues, including case-identification, provider awareness, and access to laboratory-based testing.14
The "Diagnosis and Treatment of Sleep Apnea in Cerebrovascular Disease" (GoToSleep) study is evaluating a strategy to improve the diagnosis and treatment of sleep apnea among veterans with stroke or TIA who also have hypertension. Specifically, the GoToSleep study was designed to overcome some of the barriers that exist within the Veterans Health Administration (VHA) to the timely diagnosis and treatment of sleep apnea by using home-based ambulatory polysomnography and auto-titrating continuous positive airway pressure (CPAP) to reduce the reliance on laboratory-based sleep studies.
The objectives of this manuscript are to describe the methodological approach being employed in the GoToSleep study. Specifically, this manuscript provides the rationale for 4 key components of the design of the GoToSleep trial: the inclusion of patients with cerebrovascular disease and hypertension without use of a measure of daytime sleepiness as an eligibility criterion; the use of portable polysomnography and auto-titrating CPAP in patients' homes rather than using sleep laboratory polysomnography with fixed pressure CPAP; the analytic approach to evaluating change in blood pressure in the context of change in antihypertensive medications; and the use of a usual care control group.
The GoToSleep study is a prospective, multi-site, randomized, controlled strategy trial (NCT00984308). The primary objectives of the GoToSleep study are to determine whether a diagnostic and therapeutic intervention strategy among veterans with cerebrovascular disease and hypertension improves: (1) the detection of sleep apnea; (2) appropriate treatment for obstructive sleep apnea; and (3) control of hypertension.
The intervention consists of a strategy intended to improve the diagnosis and long-term management of sleep apnea among veterans with cerebrovascular disease and hypertension. The GoToSleep study is randomly assigning 318 veterans with cerebrovascular disease and hypertension to an intervention group or a usual care control group in a 1:1 randomization scheme (Figure 1). The randomization is stratified by medical center (Connecticut versus Indiana), baseline blood pressure (mean systolic blood pressure from the 24-h ambulatory blood pressure monitor < 135 mm Hg versus ≥ 135 mm Hg for patients without diabetes, and < 125 mm Hg versus systolic ≥ 125 mm Hg for patients with diabetes), and risk of sleep apnea from the Berlin Questionnaire15 ("high risk" versus "low risk"). Patients in the intervention group receive unattended polysomnography, usually in their home, at baseline; those with sleep apnea receive auto-titrating CPAP therapy for up to one year. Patients in the usual care control group receive unattended polysomnography at the end of the study to identify undiagnosed sleep apnea. Twenty-four hour blood pressure assessments are made at baseline and at the end of the one-year study period for both groups. Antihypertensive medications are recorded with their doses at the time of the 24-h blood pressure measurements. Primary analyses will be conducted as intention-to-treat analyses.
GoToSleep trial design
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The GoToSleep project is being conducted at 2 VHA medical centers (West Haven, CT and Indianapolis, IN). Progress is evaluated via weekly video-conference research team meetings. Institutional review board (IRB) approvals have been received at both participating centers.
Patients are included if they have a history of ischemic stroke or TIA and either a diagnosis of hypertension or blood pressure ≥ 140/≥ 90 mm Hg.16 This study was designed prior to the 2009 revision of the American Heart Association/American Stroke Association definition of TIA and employs the following criteria: an ischemic stroke is a persistent focal neurological deficit of presumed ischemic origin lasting > 24 h,17 and a TIA is a focal neurological deficit of presumed ischemic origin lasting < 24 h.18 Brain imaging is not required for the diagnosis of stroke or TIA. We include the full spectrum of stroke severity, but given that we require patients to provide their own informed consent, patients with severe language impairments are unlikely to be eligible. Patients are recruited ≥ 30 days after their most recent stroke and at any point after their most recent TIA. No limits on the time from the last cerebrovascular event were imposed; we therefore anticipate that the GoToSleep cohort will include a spectrum of patients including those with a relatively recent event and those who are years after their last cerebrovascular event. The exclusion criteria and their justifications are provided in Table 1.
Exclusion criteria
* CPAP refers to continuous positive airway pressure.
Patient interviews and medical record reviews are conducted at baseline and at the end of study by trained research staff to obtain information about demographics, comorbidities, medication use, and symptoms. At these time points, patients are also examined to measure heart rate, neck circumference, height, and weight (using portable digital scale) for the calculation of body mass index (BMI). Daytime sleepiness is assessed using the Epworth Sleepiness Scale (ESS).19,20 The ESS is sensitive to change with appropriate treatment for sleep apnea.21,22 Functional status is measured with the Modified Rankin Scale which is sensitive to the full range of functional status from mild to severe impairment.23,24 Overall health status is assessed with the 12-item Short Form Health Survey (SF-12).25,26 The Berlin Questionnaire asks about snoring and daytime sleepiness and is used to classify patients according to high versus low risk for sleep apnea.15 All of the questionnaires are completed independent of the study staff and are scored centrally by a blinded member of the team. Neurological functioning is measured with the National Institutes of Health Stroke Scale (NIHSS).27,28
Blood pressure is measured for both control and intervention patients. Blood pressure measurements are taken at baseline and at the end of the study by trained research staff both manually and with a 24-h ambulatory monitor. Sitting blood pressure measurements are taken twice with a sphygmomanometer and stethoscope, using the right arm when possible. Arm and position are noted, and when possible, the same arm and position are used for each measurement for an individual patient. Orthostatic measurements are also recorded. A Doppler ultrasound is used to obtain ankle blood pressure measurements to calculate an ankle-brachial index.
Ambulatory 24-h blood pressure measurements are taken using the Dynapulse 5000A ambulatory blood pressure monitor (Pulsemetric Inc. San Diego, CA). Blood pressure measurements are taken every 30 min for a 24-h period. We use both a sleep diary and actigraphy (Actiwatch, Philips Respironics; placed on a non-paretic arm) to categorize blood pressure data as either sleeping or waking.29 Our primary approach for identifying periods of sleep is based on actigraphy data; we use sleep diary data for patients with incomplete actigraphy data. Nocturnal blood pressure dipping patterns will be assessed by comparing mean systolic blood pressure during sleep with mean systolic pressure during wake.30
Antihypertensive medications are not manipulated as part of the study protocol. All antihypertensive medications are recorded for each patient at baseline and at the end of the study. The Defined Daily Dose (DDD) of all antihypertensive medications is calculated using the World Health Organization (WHO) DDD methodology which allows for comparison across antihypertensive regimens.31 The DDD is defined as "the average maintenance dose per day for a drug used for its main indication in adults."31 For example, the DDD for lisinopril is 10 mg per day and for hydrochlorothiazide is 25 mg per day. Therefore, if a patient is taking lisinopril 5 mg per day and hydrochlorothiazide 25 mg per day, their total DDD is 1.5 (0.5 for the lisinopril plus 1.0 for the hydrochlorothiazide).
A consolidated measure that includes both blood pressure and antihypertensive medication dose is needed to evaluate the potential blood pressure lowering effect of CPAP across the wide variety of antihypertensive medication regimens employed in routine clinical practice. In particular, an approach that includes both blood pressure and antihypertensive medications is needed in a long-term study of patients with hypertension who are receiving primary care, given that such patients are likely to have their antihypertensive medications adjusted over the course of the study period. For example, if CPAP therapy were to maintain "stable" blood pressure among patients in the intervention group, whereas patients in the control group were concurrently having their antihypertensive treatment up-titrated, then a blood pressure lowering impact of CPAP therapy would be masked if medication adjustments were not included in the analysis. The calculation of this consolidated measure that is used in the GoToSleep study is based on a meta-analysis of 354 randomized controlled trials of antihypertensive medications including the 5 most commonly used categories of antihypertensives: thiazides, β-blockers, angiotensin converting enzyme (ACE) inhibitors, angiotensin II receptor antagonists, and calcium channel blockers.32 This report found that all drug categories produced similar reductions in blood pressure, but the greatest reductions were observed among patients with the highest pretreatment blood pressures.32 The blood pressure lowering effect was also found to be additive across the various antihypertensive medication classes. The addition of each new antihypertensive medication at half the standard dose reduced systolic blood pressure by an average of 6.7 mm Hg.32 Given that the average reduction in blood pressure was 20% lower when medications were used at half the standard dose compared with full standard dose regimens,32 the addition of each full dose medication (1 DDD) is expected to reduce systolic blood pressure by 8.0 mm Hg. For each patient in the GoToSleep study, the medication-adjusted mean systolic blood pressure will be calculated from the mean systolic blood pressure measurement from the 24-h ambulatory monitor and the patient's DDD as follows: medication-adjusted SBP = [mean systolic blood pressure in mm Hg] + [patient's DDD × (8.0 mm Hg)].32 The medication-adjusted SBP is reported in mm Hg and provides a method for comparing observed blood pressures across a variety of antihypertensive medication regimens. For example, if a patient has a mean systolic blood pressure of 140 mm Hg and a DDD of 0.5 then the medication-adjusted SBP would be 144 mm Hg (140 mm Hg + [0.5 × 8 mm Hg]).
Intervention patients without sleep apnea and control patients receive an in-person visit at baseline, a telephone call at every other month, and an in-person visit at the end of the study.
Unattended polysomnography has been used with excellent reliability in other large scale trials and cohort studies.1,33–35 For the GoToSleep study, full unattended polysomnography is conducted using the portable Safiro device (Compumedics) providing data on: electroencephalogram (EEG), electrooculogram, chin electromyogram, thoracic and abdominal displacement, airflow, finger pulse oximeter, electrocardiogram, body position, leg movement, and audio recording of participant's snoring. Trained research staff members travel to the patient to apply the sleep monitor in the location that is most convenient for the patient (usually the patient's home). Research staff member travel to the same location the following morning to remove the sleep monitor. The polysomnographic data are read centrally and scored according to standard criteria.36
Polysomnographic data are used to identify respiratory events (apneas and hypopneas) while the patient is asleep. The sensor used to detect absence of airflow (for the identification of an apnea) is an oral nasal thermal sensor. The sensor used for the detection of airflow (for the identification of an hypopnea) is a nasal pressure transducer. An apnea-hypopnea index (AHI) is calculated as the number of respiratory events per hour of sleep.36–38 Patients with an AHI ≥ 5 events/h are diagnosed as having sleep apnea.37 Respiratory events made in the presence of thoracic or abdominal effort are scored as obstructive, whereas respiratory events made in the absence of thoracic and abdominal effort are scored as central events. If ≥ 50% of respiratory events are obstructive, patients are classified as having obstructive sleep apnea. If ≥ 50% of respiratory events are central, patients are classified as having central sleep apnea. Patients are classified has having Cheyne-Stokes respiration if the predominant breathing pattern (> 50%) of respiratory events takes the form of a waxing and waning ventilatory effort, and airflow with arousals typically occurring at the peak of the hyperpnea phase. If such a pattern is detected on the ambulatory sleep study, patients are continued in the study. However, such patients are not initiated on auto-titrating CPAP, but rather are referred through the local clinical sleep programs for initiation on adaptive servo-ventilation (ASV).
Patients in the intervention group with obstructive sleep apnea are offered auto-titrating CPAP (System One, Respironics) consistent with the American College of Chest Physicians (ACCP) treatment guidelines to treat patients with documented cardiovascular disease including hypertension and stroke.37 The auto-titrating device being used in this study is able to distinguish central from obstructive respiratory events and respond accordingly.37,39,40
With the use of data card technology, the auto-titrating CPAP machine records pressure, residual AHI, air leak, and compliance data. We download data from the CPAP machines at least once during the first week, weekly during the first month, at the sixth month, and then at the final (close-out) visit. We assess treatment efficacy in 3 ways: (1) by examining and addressing any existing leak; (2) evaluating the residual AHI (targeted AHI < 5); and (3) evaluating oxygenation among patients with hypoxia on initial polysomnography. Oxygen saturation is measured concomitantly with the auto-titrating CPAP via one night of overnight oximetry performed during the first month of CPAP use for patients with good mask fit who have evidence of oxygen desaturations by polysomnography (< 88% for > 5 min during polysomnography). Patients with persistent desaturations despite auto-titrating CPAP are provided supplemental nocturnal oxygen via the CPAP machine.
Auto-titrating CPAP is administered to sleeping patients via a mask. Patients in the intervention group with sleep apnea are originally fit with their CPAP masks by members of the sleep medicine service in accordance with usual practice at the participating VA sites. Our study staff provides ongoing support to patients to ensure that patients receive the mask that is most comfortable and effective, with a goal unintentional leak of < 10 liters/minute.
Our approach to improving CPAP adherence consists of early intensive education and support, followed by regular and ongoing contact with patients. The education and support program is based on a patient narrative conceptual model.41 Based on this conceptual framework, for patients with sleep apnea, during the in-home visit where the staff members give the patients the results of the baseline polysomnography, staff members provide patients with information to about sleep apnea and CPAP and then ask patients to describe their understanding of sleep apnea, how sleep apnea may be related to their overall health status, and their reasons for trying to use CPAP.
During this session, staff answers questions that the patient or family members may have about CPAP. During the first month after delivery of the CPAP machine, the patient is visited each of the first 2 days and then weekly for the first month; thereafter patients receive monthly telephone calls. An in-home visit is scheduled after 6 months of CPAP use and at the end of the study to download the CPAP adherence data. In-person visits are also scheduled as needed upon patient request (e.g., for mask refitting). During the in-home visits, staff review with patients data from the CPAP machine (e.g., number of nights of use, number of hours of use, leak). Patients are instructed to call staff to answer questions about CPAP or the study at any point during the study period.
Control patients receive usual care as directed by their physicians, including care of their vascular risk factors such as hypertension and referral for usual care sleep apnea testing. Many veterans receive care both from VHA providers and from non-VHA providers. The research staff members inquire about all care that patients receive during the study period (e.g., medications provided by the VHA as well as medications obtained at private pharmacies). Control group patients who did not receive polysomnography as part of their usual care (expected to be the overwhelming majority of control group patients) will receive an unattended polysomnography at the end of the study. Polysomnographic data obtained as part of this study on control group patients are communicated with their primary care providers and the facility's sleep medicine service. We defer to the primary care provider regarding the long-term management of control group patients with sleep apnea, given that this diagnosis is made at the end of the study period.
The proportion of intervention and control patients with a diagnosis of sleep apnea will be calculated from the unattended polysomnography performed in the intervention group and from any polysomnography that was performed as part of usual care among control patients. We will use polysomnography data obtained as part of the study protocol at the end of the study period in the control group to determine the prevalence of undiagnosed sleep apnea among control patients.
The proportion of intervention and control patients with obstructive sleep apnea who are receiving treatment will be calculated. Treatment of sleep apnea is defined as use of CPAP ≥ 4 h/night for ≥ 70% of nights42 or use of alternative (non-CPAP) therapies (e.g., positional therapy, oral appliance therapy, or upper airway surgical intervention). Within the VHA, the use of alternative therapies is rare; it is therefore expected that the treatment rate will be based primarily upon the use of CPAP.
The primary outcome measure for hypertension is change in mean 24-h systolic blood pressure from baseline to the end of the study. Ambulatory blood pressure monitoring has been shown to perform better than the use of single blood pressure assessments with a sphygmomanometer for the purpose of cardiovascular risk stratification, and it can be used to describe sleep versus wake blood pressure patterns.29,43 Our secondary hypertension outcomes include: (a) the change in medication-adjusted SBP from baseline to the end of the study; (b) the change in DDD from baseline to the end of the study; (c) the proportion of patients with a nocturnal decline ("dipping") in systolic blood pressure of ≥ 10%30; and (d) the proportion of patients with either a decrease in mean systolic blood pressure of 5 mm Hg or any increase in blood pressure medication.
A cost analysis is planned as a secondary analysis for the GoToSleep trial. We are prospectively collecting all non-VHA direct healthcare costs (e.g., hospitalizations, outpatient visits, durable medical equipment) and overall and specific intervention costs. The prospective data are supplemented with administrative data from the VHA Decision Support System (DSS) that provides patient-level data for all VHA and fee-basis healthcare costs (e.g., hospitalizations, outpatient care, medications) by medical facility (adjusted for regional variation). Unlike Medicare, Medicaid and other prospective payment systems that are charge- or payment-based, the VHA Decision Support System captures actual costs of healthcare provided. For intervention costs, the research staff members perform micro-costing by recording the time (and mileage) they spend with study patients and record details about the activities and care they are engaged in with the patient. In this way, the overall intervention costs can be compared with potential economic savings or benefits of the intervention (reduced health care utilization and costs) to determine the overall net present value of the program (cost-benefit analysis).
The GoToSleep trial was designed to have ≥ 80% power to detect the following pre-specified differences in the 3 primary aims: 60% of intervention patients compared with 10% of control patients will be diagnosed with sleep apnea; 50% of intervention patients diagnosed with sleep apnea as part of the study protocol, compared with 15% of control patients diagnosed with sleep apnea as part of usual care, will use CPAP therapy; and the baseline mean systolic blood pressure in both the intervention and usual care groups will be 135 mm Hg with a standard deviation of 20 mm Hg, but the 1-year mean systolic blood pressure in the intervention group will be 125 mm Hg with a standard deviation of 20 mm Hg, whereas in the control group it will be 135 mm Hg with a standard deviation of 20 mm Hg. The sample size estimates further assumed an estimated 10% loss to follow-up in both the intervention and usual care arms.
Our purpose was to describe the methodological approach being employed in the GoToSleep study and to provide the rationale for the components of the design that are either unique to this study or rarely employed in clinical trials: the inclusion of patients with cerebrovascular disease and hypertension without use of a measure of daytime sleepiness as an eligibility criterion; the use of portable polysomnography and auto-titrating CPAP in patients' homes rather than using sleep laboratory polysomnography with fixed pressure CPAP; the analytic approach to evaluating change in blood pressure in the context of change in antihypertensive medications; and the use of a usual care control group.
Patients with cerebrovascular disease have a high prevalence of sleep apnea. Most studies in this area have reported that 60% to 70% of patients with stroke or TIA have sleep apnea.23456789–10,13,44 Therefore, in the GoToSleep study, patients with cerebrovascular disease were included on the basis of their high pre-test probability of having sleep apnea. No additional clinical characteristic (e.g., daytime sleepiness) were used as part of the inclusion criteria because we sought to include both patients who are symptomatic and patients who are asymptomatic but who nonetheless experience the physiologic consequences of their sleep related respiratory events.
It is expected that control group patients diagnosed with sleep apnea as part of their usual care are likely to be more symptomatic than intervention patients diagnosed with sleep apnea as part of the study, because patients in the usual care group with excessive daytime sleepiness may be more likely to receive polysomnography than control patients without symptoms. Despite conventional wisdom to the contrary, however, symptoms correlate poorly with sleep apnea severity.45 Yet symptomatic patients may be more likely to adhere to CPAP treatment. Therefore, the control patients with sleep apnea who are diagnosed as part of usual care may be more likely to use CPAP than patients diagnosed with sleep apnea in the intervention group. As part of the secondary analyses, we will examine the treatment rate among asymptomatic patients (ESS < 10) and among mild sleep apnea patients (AHI 5-15 events/h).
Polysomnography performed in a sleep laboratory by a sleep technician is the gold standard for diagnosing sleep apnea, but inadequate sleep laboratory infrastructure to accommodate the US population is a major barrier to its use. The Institute of Medicine in its report "Sleep Disorders and Sleep Deprivation: An Unmet Public Health Problem" articulated the problem as follows: "…the current diagnostic and therapeutic capacity is not sufficient for the present demand, let alone the predicted increase in demand arising from the proposed public education campaign. Thus, additional technology development is required."14 Unattended polysomnography is an alternative to polysomnography in a sleep laboratory. Several studies have reported on the agreement between unattended polysomnography and formal polysomnography with sensitivities of 75% to 100% and specificities of 87% to 100%.46 Alternatives to full polysomnography may be acceptable when patients cannot be assessed with polysomnography in a sleep laboratory.42 We designed the GoToSleep study to use portable technology so that sleep apnea could be diagnosed and treated in the patients' homes. Only in rare circumstances do we anticipate that patients will require additional sleep testing—either repeat portable testing or referral to in-laboratory polysomnography for more complex sleep disordered breathing (e.g., Cheyne-Stokes central sleep apnea).
The traditional approach to the treatment of sleep apnea involves the use of fixed-pressure CPAP. This approach requires a two-step process. First, a sleep study is performed to diagnose sleep apnea. Next, CPAP titration is performed by a sleep therapist who increases the fixed-pressure CPAP until the apneas and hypopneas are eliminated. Hence, the use of fixed-pressure CPAP requires that the patient have a sleep study performed in the presence of a sleep technician. Auto-titrating CPAP machines eliminate respiratory disturbances by varying the pressure delivered depending on the patients' respiratory efforts. We use auto-titrating CPAP in the GoToSleep study because it is as effective as fixed-pressure CPAP39,40 and because it does not require an in-laboratory sleep study for titration.
Although some clinical trials have used a measure of blood pressure as a clinical endpoint without evaluation of antihypertensive medication use, other trials have used a consolidated measure of antihypertensive management that includes both blood pressure and antihypertensive medication use (e.g., achievement of a goal blood pressure or any decrement in antihypertensive medication).47 Given that the patients in the GoToSleep study are all cared for by VA primary care providers, and given the emphasis in VA primary care on the management of blood pressure, we anticipate that patients in the GoToSleep study are likely to have their blood pressure measured and managed (e.g., antihypertensive medications adjusted) intensively over the course of the one-year study period.
Our primary blood pressure outcome is change in 24-hour mean systolic blood pressure, with a power calculation based on this outcome measure. We have pre-specified secondary blood pressure outcomes as described above. The medication-adjusted SBP measure will be used to evaluate the effect of the intervention strategy on hypertension control in the context of antihypertensive medications. The advantage of the medication-adjusted SBP outcome is that it includes both blood pressure and antihypertensive medications in a consolidated continuous measure where the output is in mm Hg, a unit that is readily interpretable by clinicians. Moreover, given the known relationship between impaired nocturnal blood pressure dipping and sleep apnea, we will also examine the change in the proportion of patients with a normal nocturnal decline in systolic blood pressure of at least 10% between the two groups.
There are a number of challenges regarding designing long-term randomized controlled trials using CPAP, including pragmatic issues (such as strategies to increase long-term CPAP adherence) as well as conceptual issues (such as safety/ethical considerations among control patients diagnosed with sleep apnea not receiving treatment). For example, one approach would be to use sham-CPAP as the control comparison.48 Significant safety considerations (e.g., drowsiness related motor vehicle accidents, recurrent vascular events, depression/suicide) arise, however, if sham positive pressure were to be used over a one-year intervention period among patients with known sleep apnea. In addition, the use of a sham-CPAP control group might reduce participant enrollment (if participants are unwilling to be randomized to a sham-CPAP group) or overall CPAP adherence (if participants are uncertain about the benefits of the CPAP that they are using).
Rather than a double-blind sham-CPAP control design, the GoToSleep study is a randomized diagnosis and treatment strategy trial. Such a study design serves to ask an important clinical question in the context of usual care (where patients are not prohibited from seeking care for sleep disordered breathing): What additional benefit is conferred by a universal approach to diagnosing and treating sleep apnea? We assert that "usual care" provides a safe means of evaluating the effectiveness of the intervention without incurring undue risks to patients. Patients who are in the control group may receive polysomnography during the study as part of their usual care, and they receive an unattended polysomnography at the end of the study period. The polysomnographic and other medical information (e.g., blood pressure data) are provided to the patients and to their primary care providers. We do not, however, automatically refer patients in the control group who are diagnosed with sleep apnea for treatment with CPAP as part of the study. Rather, we communicate with the primary care providers and offer to assist with establishing treatment depending on the primary care providers' preference.
As a study designed to address the question of whether a strategy of diagnosing and treating sleep apnea among patients with cerebrovascular disease and hypertension can improve rates of sleep apnea diagnosis, sleep apnea treatment, and blood pressure control, the GoToSleep trial has several strengths. First, the GoToSleep study has a relatively long intervention period of up to one year. Much of the literature has focused on short intervention periods (days or weeks), with very few studies examining long-term CPAP use. Second, the GoToSleep study will provide new information about the use of in-home management for both the diagnosis and treatment of sleep apnea. Several studies have examined the use of in-home or portable polysomnography for use in diagnosing sleep apnea, but few data exist on the use of in-home support to improve CPAP adherence.46 Although sleep medicine clinics may be effective in promoting CPAP adherence in general, our anecdotal experience suggests that the older population with cerebrovascular disease is often unable or unwilling to visit the sleep clinic because of difficulties with transportation or competing medical demands. These data will be especially relevant to hospital administrators who might reallocate some sleep medicine resources to the home setting. Third, the GoToSleep study has been designed to provide sufficient sample size to evaluate the issue of whether CPAP can improve hypertension control among patients with sleep apnea. Several studies have evaluated the relationship between CPAP and blood pressure, but the GoToSleep study has a randomized controlled trial design; a sample size large enough to provide sufficient power; and includes measurement of a variety of blood pressure related outcomes.49–53
The primary limitation of the GoToSleep trial is its focus on the veteran population, which may limit generalizability to women. Also, although the sample size has been designed to provide adequate power for the primary analyses, sample size constraints will not allow for subgroup analyses based either on cerebrovascular event type (stroke or TIA) or time from event (recent or distant).
The GoToSleep trial is expected to complete follow-up in 2011. Current guidelines include sleep apnea as a modifiable risk factor for stroke, but the current standard of care does not include routine assessment for sleep apnea among patients with stroke or TIA.54,55 We believe that the GoToSleep trial will provide needed information to clinicians caring for patients with cerebrovascular disease and hypertension and for policy makers deciding about how to allocate limited sleep medicine resources.
This was not an industry supported study. The authors have indicated no financial conflicts of interest.
This project is supported by the Department of Veterans Affairs Health Services Research and Development Service (VA HSR&D; IIR-06-233-2).
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So it finally happened. The product above is being made, being sold, is real. We're sad because it doesn't look like it's some kind of joke. These are actual gloves that connect to your phone through Bluetooth and that have microphones sewn into the fingertips so that you may talk while, you know, looking like a giant tool. The tips of the fingers are even capacitive to allow smartphone operation whilst your hands remain toasty. Battery operated, the Hi-Call gloves, as they're called, will standby for 24 hours and last for 20 hours while conversing.
€50 buys you the privilege of being the laughing stock of the slopes, and you can pre-order them now from Hi-Fun. If you thought Bluetooth earpieces were bad, this… this just kicked things up a notch.
[ Product Page ] VIA [ UberGizmo ]

subset: commoncrawl


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NASA sniffs out (yet more) lunar ice
North pole craters lined with the stuff
NASA has announced that the Moon's north pole is packing substantial amounts of water ice, lurking in around 40 small craters.
The evidence comes from the agency's Mini-SAR (aka Mini-RF) instrument, a synthetic aperture radar which travelled aboard India's Chandrayaan-1 spacecraft. The device used "the polarization properties of reflected radio waves to characterize surface properties", and determined that deposits in permanently-shadowed craters at the pole have characteristics "similar to ice".
The craters range from 2 to 15 km in diameter, and while the total amount of frozen water depends on the deposit thickness in each, NASA has calculated it as "at least" 600 million metric tons.
Paul Spudis, Mini-SAR principal investigator at the Lunar and Planetary Institute in Houston, said: "The emerging picture from the multiple measurements and resulting data of the instruments on lunar missions indicates that water creation, migration, deposition and retention are occurring on the moon.
"The new discoveries show the moon is an even more interesting and attractive scientific, exploration and operational destination than people had previously thought."
NASA's latest findings - published in the journal Geophysical Research Letters - add to a solid body of evidence for lunar ice. In September last year, other results from the Moon Mineralogy Mapper (M3) on Chandrayaan-1, and NASA's Cassini and Deep Impact missions provided "unambiguous evidence for the presence of hydroxyl* or water" on the Moon.
The Lunar CRater Observation and Sensing Satellite (LCROSS) then showed there was plenty of ice at the Moon's south pole.
While it's evident that future Moon explorers will have no shortage of cold stuff to stick in their gin and tonics, one question remains: where did the Moon's water come from? It's possible that it arrived on water-bearing comets which impacted on the surface or, according to NASA's M3 team, by way of an "endogenic" process.
The M3 scientists have suggested that if the solar wind's positively-charged hydrogen atoms impact against the Moon's surface with sufficient force they can "break apart oxygen bonds in soil materials", and "where free oxygen and hydrogen exist, there is a high chance that trace amounts of water will form".
NASA has more details on the Mini-SAR findings here. ®
*One hydrogen atom and one oxygen atom linked by a single bond.
Sponsored: Your Guide to Becoming Truly Data-Driven with Unrivalled Data Analytics Performance


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by Dennis Friedrichsen
Twins Peder and Steen Mondrup were born in 1980, three months early and weighing just 1,200 grams each. Peder was diagnosed with cerebral palsy at birth and has been in a wheelchair his entire life. In the same vein as inspiring duo Dick and Rick Hoyt, the twin brothers have become unstoppable on the endurance circuit: Peder rides in a specially designed race wheelchair that Steen pushes. They ran a half marathon together this spring and, this weekend, will compete as part of a relay team at KMD IRONMAN Copenhagen to raise awareness and understanding for others in Peder's situation.
Peder has lived a full life, despite being in a wheelchair. When he and his brother ran the half marathon a few months ago, Peder says he felt like a regular participant and not "a guy in a wheelchair."
"Peder is a normal person merely affected by a handicap," Steen says. Moreover, being physically active makes Peder "feel the way he sees himself," something that no doubt brings value to Steen's life as well.
Steen, who has been fascinated with sports his whole life, considers an IRONMAN race to be the "craziest and most awesome experience to share with his brother." He says that after the completion of a half marathon, a full marathon is an exciting challenge.
Training for an IRONMAN is never easy and, for this pair, it has been no different. Peder's wheelchair arrived relatively late and Steen has already noticed how it changes running. "You can't use your arms the way you normally would," he says, although is aware that it is merely one more thing to get used to.
Though Steen has never completed a marathon, failure to finish on Sunday is not an option for the twins. They are excited to participate and to experience the unique support they will likely receive. The brothers have been inspired by the Hoyt's story and Steen even got advice from Dick Hoyt on how to handle different aspects of their situation.
Steen says the two have had some funny and strange questions from curious strangers, for instance, surrounding Peder's diet. "People just don't know any better," Steen says. It's this very ignorance the two hope to fight, as creating awareness might conquer the taboo of talking openly about physical and mental handicaps. Participating in the relay this weekend is simply their way of creating awareness and inspiring others to look at life in a different way.
Read more at teamtvilling.dk and be sure to cheer on Team Tvilling on race day: Swim—Anne Marie Nobel, bike—Tasja Stenum, run—Peder and Steen Mondrup.


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B2B- "Beautiful Necklace Scarf"
B2B- "Beautiful Necklace Scarf"
Celebrated designer Sheila Gray and I have teamed up to create a special line of scarves. Our collaboration comes from my deep respect and admiration for Sheila, as a businesswoman and friend but also as a person who believes in bringing back the love, in a world so desperately in need of it! So that's what we are striving to do- BRING BACK THE LOVE!
Each scarf is a one-of-a-kind, handmade piece of craftsmanship, made with (you guessed it) a whole lot of love. Each scarf can be tailor designed to you- with the empowering words you want to wrap yourself with, with the fabrics that make you feel uniquely you.
This collaboration goes hand in hand with my "Bullied to Beautiful" show. We wanted to continue the conversation around bullying and how it is still such a big issue, especially still in schools and in social media so therefore part of the proceeds from the sale of each scarf will go to Lady Gaga's Born This Way Foundation. We are so excited to start to create more positivity, community, empowerment and continue to raise awareness around this issue.


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The 6-5 Pittsburgh Steelers sit three games behind the 9-2 Baltimore Ravens in the AFC North. Until quarterback Ben Roethlisberger returns, that gap promises to grow.
|Take a look back at the best photos from this classic rivalry.
Roethlisberger has missed two straight games with a rare rib and shoulder injury, but hopes to play in Sunday's second and final regular-season meeting with the Ravens.
"I'm going to try," Roethlisberger told the Pittsburgh Post-Gazette on Sunday. "It's killing me to watch."
ESPN's Chris Mortensen reported Big Ben will start soft-tossing the ball early this week to examine his range of motion and work through the pain, according to team sources. Mortensen stated doctors have determined Roethlisberger's rib has healed to the point where further damage isn't a risk.
The Steelers were a mess in Sunday's loss to the Cleveland Browns. Mistakes, breakdowns and a sense of confusion dominated their ugly outing. Backup Charlie Batch doesn't give the Steelers a chance to win down the stretch.
The intense race for the playoffs is in full gear. Check out the latest situation in the postseason chase. More ...
Roethlisberger is needed to save the season. His return is uncertain and boils down to pain-tolerance and mobility, but Ravens running back Ray Rice harbors no doubts about Big Ben's status for Sunday's grudge match.
"I don't know what kind of medicine the Steelers will put Ben Roethlisberger on this week," Rice told SI's Peter King, "but they're going to give him something."
Follow Marc Sessler on Twitter @MarcSesslerNFL.


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- About us
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- Chapters
- Papers
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- Code of Conduct
- Google SoC
- Recent posts
- Security Workshops
While it seems to be impossible to say whether waledac is the successor of storm or not, what we can do is take a look at the traffic encryption. They guys over at Shadowserver have already blogged some details about this. We at the Giraffe Chapter investigated waledac's communication protocol further. Here are our results.
Waledac uses regular HTTP request to transmit command requests and to retrieve responses. It uses HTTP fast-flux proxies to hide the true origin of the command&control (C&C) server. Due to the fact that the regular Windows HTTP API (
WinINet) is used, the traffic is hard to differentiate from regular HTTP traffic. Furthermore, it even allows Waledac to use proxy servers after the user has generally authenticated. The requests use POST and encrypted + encoded payload data:
Waledac relies on up-to-date encryption technologies, like e.g., RSA. We reverse engineered important parts of the traffic encryption engine inside the executable and extracted the important encoding and decoding parts. This enables us to read Waledac traffic. Thanks to Greg Sinclair, a design fault has been found that allows a fast crypto attack and offline decoding. We have developed a traffic decoder that has been used to gather information about the C&C protocol underneath.
The first request is of type
0xff and is used to exchange encryption keys between the infected node and the botnet master. The traffic is nicely formatted using XML. Each request and response start with "
lm" and a command enclosed in "
t"-tags. The "
v"-tag holds the protocol version, which varies among different generations of waledac binaries. The "
i"-tag uniquely identifies the infected node and stays the same after reboots. Here is the decoding of the message from above:
As we can see, for the handshake, the
getkey command is issued. The payload contains an X.509 certificate that holds a self-signed version of the node's public key. It is always generated on the fly even though containing a validity of one year. Details about the certificate can be found here.
The response looks very similar. Version and command tags are duplicated. Instead of the certificate, a base64 encoded session key is exchanged that is encrypted using the RSA key contained in the request's certificate. This session key is then used for all subsequent C&C traffic.
After a successfull handshake, waledac zombies issue a
notify request containing an entity to contact, like e.g., "
mirabella_site". Information about the host's clock is also included, possibly for time synchronization:
The next reponse contains a lot of information: The node's external ip-address and hostname together with a special DNS IP and SMTP address. Both are not related to the node's IP address, but probably related to the fast-flux and spamming engine. In this case the DNS IP address belongs to an open DNS server in the US, the SMTP IP address points to an SMTP server at Google:
Very interesting are the "
dos"-tags (denial of service?), and the commands attribute. The "
p"-tag, in this case, contains an "
update" command that results in the download of a picture of the Governor of California shown below. Besides the real image data, it carries additional data piggybacked that is to be executed on the node. This additional data is actually a Windows PE file, ecnrypted with a static key. We have observed several such updates, all with varying executables.
We are not done with our investigations, yet. And there are still a lot of open question. We will keep you up to date here. Other interesting commands, like the following, are likely to come:
Stay tuned!


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The sun came out for more than ten minutes on Sunday. It came out on Saturday, too, but both the cat and I slept through it. Dunno why the cat preferred to hang about in bed than snooze in a sunbeam, but I can tell you exactly why I was spending most of the day unconscious:
In my brief moments of wakefulness, I read about Krakatoa blowing up and cursed my useless reproductive organ. Whee. (For the record: Simon Winchester kicks Alwyn Scarth's arse, even with a tendency to get some things wrong and over-emphasize others. At least he puts actual damned geology in his books. Gah.)
But things improved dramatically on Sunday, and the sun stuck around. I left the cat happily basking, and went to go look at some interesting fungi I'd seen on the verge when my area director and I were scoping out the floods last week. They were still there, and I shall have a full report with about twelve billion photos shortly. Fungi lovers will swoon. Seriously. No matter what, I promise. Because if you look at them and go, "Yawn, those are soooo common where I'm from," I can pluck one from the ground, bean you with it, and you will definitely swoon. They're that bloody big.
Of course, that would be assault with a deadly fungi, so this will remain a strictly hypothetical situation.
I also have some awesome aftermath of North Creek flooding. But that, too, will wait. I've got to read up on Pompeii unexpectedly. Outtakes first, then!
The pond was looking particularly lovely today. Also, larger. And I love how the willow trees got the memo it's winter, crumpled it up, and threw it away. They're still decked out in their autumn finery. Which reminds me: I shall need more autumn songs stat. I got you some more autumn images. Some will make you gasp – there were some seriously stunning trees that also crumpled their winter memos, then burned them.
Good day for seeing herons. Wasn't much else (although Trebuchet got us something nice, I'll show you it soon). But the herons looked quite fetching, especially against the subdued colors.
I loved this pattern in the muddy sand. Imagine if I'd sliced in to it, I would have seen some interesting bedding patterns. However, I was wearing my new shoes, and hadn't thought to put on the old ones for tromping round in muddy creeks, and it was also butt-ass freezing cold (by Seattle standards), so the idea of getting my feet soaked didn't enthrall. If I was an actual field geologist, I'd get proper shoes. And then promptly forget to wear them on walks like this because all I'd really meant to do was photograph fungi on a lawn anyway.
I came across a very defiant dandelion, blazing away like the sun, with the real sun striking color from it. It instantly became my favorite flower of this winter. Mind you, there are a few others grimly clinging on, but they're coddled cultivated kinds and for all I know were recently whisked out of a nice, warm nursery. This one's got to go it alone, on the edge of a lawn, with mowers and weedkiller everywhere. And it hasn't seen the sun in well over a week. Yet still it thrives. Reminds me a bit of George's sturdy plant. Perspective, doncha know.
Last thing I expected to see in the path was a wooly bear. But according to Wikipedia, I should not have been in the least surprised:
The banded Woolly Bear larva emerges from the egg in the fall and overwinters in its caterpillar form, when it literally freezes solid. First its heart stops beating, then its gut freezes, then its blood, followed by the rest of the body. It survives being frozen by producing a cryoprotectant in its tissues. In the spring it thaws out and emerges to pupate. Once it emerges from its pupa as a moth it has only days to find a mate before it dies.
These little buggers are hardcore. I shall have to gather my myriad photos of them and do a proper essay someday. Perhaps after I've done with all the volcanoes. Ack.
Love this lovely bit of moss. It's a gorgeous color, and when you have the combo of the weathered wood, freshly exposed wood, and the fall leaves in the background, well, it's a shot you've gotta take. I love moss anyway. Did you know that moss was one of the first things to grow on the remains of Krakatoa? That's according to Iain Stewart, and I believe him because of his Scottish accent. Well, that and because I've seen what moss will do in wet environments. Some that was scraped off our roof landed on my porch and still thrives there, living on nothing but air, sun and water. Well, it used to get a wee bit of cigarette ash, too, but it doesn't anymore.
Then there were these quite nice pine cones with the spider webs on them. I like the way the sunlight silhouettes them, and the gleams of light in the blurred background. But then I started playing with exposures, and I like this one, too, although it washes out the subtle play of color in the little light dots.
One can have entirely too much fun playing with different exposures when one should be reading papers. Cough.
And then there was this fine heron, hanging out by the creek. I wonder if it's the same one that flew over the car when my area manager and I were out looking at the floods? (At this juncture, I'd like to mention that my area manager rocks. We flooded five years ago, and the person in charge then didn't keep an eye on the roads – the police had to come shoo us out, and by then, the roads were rivers of water up to the car doors. I'm from Arizona. I've had it drummed into me all my life not to drive into a flooded road, no matter how shallow or still it looks. People die doing that. So the fact that my area manager pays attention to this stuff and is willing to shut us down before it gets out of hand is a huge relief. I love the fact he actually did recon. It didn't stop me from deciding to flee on the small possibility of it getting worse when the skies opened after lunch, mind, but knowing he wasn't waiting for all routes to be cut off before allowing everyone to flee is awesome. And of course, it stopped raining right after I got home, and the city had cleared the gutters, and there were no horrible floods anyway. I'd show you the floods we did have, but I didn't have my camera. Sigh.)
So there we are: a microadventure in winter. If it snows. we'll have another adventure along North Creek, because I've already told the person I commute with that I'm not bloody driving with Seattle-area drivers in the snow. We will damned well walk. And I'll bet you the scenery will be spectacular. I'm glad most of you are atheists. It means I won't have to bean you with a huge fungi for praying for a blizzard.


text:
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User:Þelma is currently busy with major revisions to this article. Before editing, discuss your intentions on this article's talk page.
|Biographical Information
|Sometime during late YOTT, Tirion
|YOTT 1500 (aged 50+)
|Fëanor + Nerdanel
|Physical Description
|Hair color
|Images of Amras
Amras and his twin brother Amrod were the youngest sons of Fëanor. Through their mother Nerdanel they inherited red hair (probably a dark red), instead of Fëanor's black.
He joined his brothers in the Oath of Fëanor, but his mother Nerdanel begged that either he or Amrod be left behind, believing in her heart that one would not return. Fëanor, however, refused her this kindness, and paid for it. Amras was accidentally killed in the swan ships of the Teleri when his father ordered them to be burnt at Losgar. According to the Shibboleth, he claimed (to Amrod) to have felt uncomfortable sleeping on the ground after the Noldor landed on the Lammoth. It was thought later that he wished to return to his mother in the ship, being shocked by his father's deeds. Fëanor was probably aware of his dissention, and this may have been one of the elements of his decision to burn the ships even before all the food and stores had been got out. Yet he was in great dismay when he learned of his son's death, and doubtless remembered the foreboding words of his wife.
Other versions of the Legendarium
In the published The Silmarillion and in earlier texts he is said to have lived on to Beleriand and ruled with his twin Amrod over lands west of the Blue Mountains.
Amras' father-name in Quenya was Telufinwë, "Last [of] Finwë", for he was the last of the sons of the House of Finwë and its short form was Telvo. His mother-name was originally Ambarussa ("Top-russet", referring to his hair), the same as his twin Amrod, but Fëanor insisted that the twins ought to have different names and Nerdanel prophetically called him Umbarto, "The Fated" (from umbar = "fate"). His father, disturbed by it, changed it to Ambarto, "Upwards-exalted" (from amba = "upwards, top" and arta = "exalted", "lofty"). Nevertheless both twins called each other Ambarussa.
The name Amras is the Sindarin version of Ambarussa.
In later notes found in The Peoples of Middle-earth, Tolkien mentions that he wished to change the name to Amros because of linguistic issues. While this occured late in life, and there are no known manuscripts written later that contradict this, its canonicity is in dispute.
Other Versions of the Legendarium
There is no trace of the death of Amras at Losgar in the published The Silmarillion, as it was a very late idea by Tolkien, omitted by Christopher Tolkien as he did not at the time see how it could be incorporated into the primary text of The Silmarillion. Where both Amrod and Amras are mentioned in the published text after the landing in Losgar, it should according to Tolkien's later wishes be Amrod alone. The information regarding Amras' naming, especially, comes from The Peoples of Middle-earth.
- The Silmarillion, Of Eldamar and the Princes of the Eldalië
- The Silmarillion, Of Fëanor and the Unchaining of Melkor
- The Silmarillion, Of the Silmarils and the Unrest of the Noldor
- The Silmarillion, Of the Flight of the Noldor
- The Silmarillion, Of the Return of the Noldor
- The Silmarillion, Of Beleriand and Its Realms
- The Silmarillion, Of the Noldor in Beleriand
- The Silmarillion, Of the Ruin of Beleriand and the Fall of Fingolfin
- The Silmarillion, Of the Fifth Battle: Nirnaeth Arnoediad
- The Silmarillion, Of the Ruin of Doriath
- The Silmarillion, Of the Voyage of Eärendil and the War of Wrath
- The Book of Lost Tales Part 2, The Nauglafring
- The Shaping of Middle-earth, The Earliest Annals of Valinor
- The Shaping of Middle-earth, The Earliest Annals of Beleriand
- The Lost Road and Other Writings, The later Annals of Beleriand
- The Lost Road and Other Writings, The later Annals of Valinor
- The Lost Road and Other Writings, Quenta Silmarillion
- The Lost Road and Other Writings, The Etymologies
- Morgoth's Ring, The Annals of Aman
- Morgoth's Ring, The Later Quenta Silmarillion
- The War of the Jewels, The Grey Annals
- The War of the Jewels, The Later Quenta Silmarillion
- The Peoples of Middle-earth, The Shibboleth of Feanor


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Monkey See, Monkey Doo-Doo
What is it with monkey cupcake cakes? Bad enough that it's a cupcake cake, but then to try and make a monkey out of it? (Heh: "make a monkey out of it". I guess that's not so hard, eh? Eh?) Asking for a cute monkey CCC seems destined to failure, if you ask me.
Case in point: here's what reader Alexis P. wanted for her son Caden's 1st birthday:
Which is sort of cute, but not really; the swirl cupcakes make it look like Mr. Monkey has see-through arms and legs. That isn't the Wreck, though...
This is:
I can't decide if this is a monkey at a stick-up who just soiled himself (an unfortunate effect of not outlining the "tail"), or if he's another steamroller victim. Or, given that expression, I suppose he could be on some Amazon torture rack - I mean, those arms and legs are rather long...
But wait! There's more!
Aren't you curious what the birthday boy thought of his cake? Because fortunately for us Alexis captured little Caden's reaction for posterity:
Ah, I can almost hear the little shrieks of terror from here. Kinda reminds me of my own family gatherings...
Think of it this way, Alexis: without experiences like this, what will Caden talk about later in therapy? Oh, and Caden, there's always our young Wreckporter's intern program for next year.
NOTE: I've been getting some complaints about the proliferation of CCCs here on Cake Wrecks - which is kind of like complaining about all the sick people in hospitals, if you think about it. Still, I'll do my best to space them out between "real" cakes for y'all. Remember, though: if we let these silent menaces go unmentioned, bakeries might start thinking they're acceptable! We can't have that, now can we?


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Salad Beach Bowl - Slate
Salad Beach Bowl - Slate
Perfect for any party, this handcrafted pottery dish is as functional as it is beautiful. Dimensions are approximately 8.5 in diameter and 2" high. Made in Canada.
Each unique piece of pottery is created from high-fired porcelain clay.
Special Care Instructions:
Pottery Seashell dinnerware is oven, microwave, and dishwasher safe. Functional, decorative, and artistically designed to enhance your home. You can bake and serve 'right in the shell!'
About the Artists:
Mussels and More Pottery produce a large collection of beautiful handmade fine art 'Pottery Seashell Dinnerware'. Each piece crafted is an original collectible art piece, unique and durable for everyday serving and entertaining. Their pottery seashell collection includes bowls, beach plates, ocean mugs, and platters.
Jan was born and raised in the coastal community of Campbell River on Northern Vancouver Island in British Columbia, Canada. Jan has been a self-taught potter for the past 25 years. Mike was raised in Vancouver, British Columbia and moved to Campbell River for his final year of high school. After high school he graduated with a degree in Telecommunications. Mike owned and operated a 45-foot fishing boat for 15 years before retiring and joining forces with Jan to create Mussels and More Pottery. Based in Campbell River, BC.


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SANTA BARBARA, Calif. – UC Santa Barbara received goals from a trio of unexpected sources on Friday night, handly defeating visiting Cal State Fullerton 3-0 in the opening Big West Conference match for both teams.
Defenders Matt Glodack, Peter Schmetz, and holding midfielder Fifi Baiden – a group of seniors who entered the game with a combined career total of three goals – all notched goals for the Gauchos. It was the first tally of the season for both Glodack and Baiden, and Schmetz's second after he found the back of the net against Stanford last Friday.
With a four-save performance, freshman keeper Josh McNeely recorded his second consecutive shutout for the Gauchos. He has now gone exactly 120:00 minutes without allowing a score.
UCSB, winners of two straight, improved to 6-4 with the win, while Cal State Fullerton snapped a two match winning streak while falling to 3-6 overall.
"I thought we played very well tonight," said UCSB head coach Tim Vom Steeg. "That's four games in a row that we've put forth a good effort and all three goals were good goals that we've been working on. We're excited about this win."
For the second consecutive match, UCSB recorded a new season-high figure in team shots. The vast majority of those chances came in a 13-shot first frame for the Gauchos. Glodack was able to open the scoring in just the 26th minute.
After winning a corner kick, UCSB unleashed a flurry of shots towards Titans keeper Robbie Hannon. After a few shots were blocked, the ball found its way to senior striker Achille Campion on the right side of the box, and the skilled forward fired a shot to the near post. Hannon was able to stop the shot, but couldn't control the rebound, which was promptly banged in by Glodack for his first goal as a Gaucho in his 42nd appearance.
Less than 90 seconds later, UCSB got right back to work. Awarded a corner kick yet again, Schmetz got his head on the Drew Murphy cross and sent it to the near post for a 28th minute goal. After accruing just one goal in his first two years as a Gaucho, Schmetz now has two in the span of a week.
UCSB headed into the locker room with a 13-4 shot advantage and a two-goal lead, and thus focused more on maintaining possession in the second half. Still, the Gauchos were able to go ahead 3-0 in the 70th minute when Murphy received a ball from Ismaila Jome down the left touchline before crossing to Baiden, who headed over Hannon.
Jome was once again a standout in the offensive half, registering a team-high four shots and beating a number of defenders on the left flank. Sophomore Marshall Cazares, a defender who has been operating in more of an attacking role as of late, had a strong 80-minute performance as well, taking three shots.
Both of Baiden's career goals at UCSB have come against Cal State Fullerton. His first goal was a game-winner against the Titans on Oct. 29, 2011.
With two assists, Murphy recorded the first multi-point game of his career. Jome extended his team-leading assist total to five.
It was the first time that the Gauchos recorded back-to-back shutout wins since Sep. 23-25, 2011, when they accomplished the feat against San Diego and Sacramento State.
UCSB will wrap up its season-long seven match homestand on Sunday evening when they host UC Riverside at 5:00 p.m. Tickets for that match are available here.


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Three journalists are sitting in a bar. This sounds like the beginning of a joke but it isn't. It's a glimpse into the digital sophistication of President Barack Obama's winning re-election strategy.
At a recent Democratic fundraiser for media types in Chicago, people were encouraged to provide their mobile phone numbers, according to Willard Foxton. When three of them were sitting at the bar, their phones rang simultaneously. The intern was asked to text back to donate US$5 ($6.12); the assistant producer was asked for US$12 and the senior executive was asked for US$120.
"The Obama campaign could divide us up by rank and disposable income within five hours of getting our data," Foxton said.
The campaign's detailed data mining and the long game played on the ground in the swing states were undoubtedly the main factors which contributed to Obama's re-election, in addition to the twists and turns of the campaign trail.
While the Romney campaign had the big guns of the Republican Party's seasoned strategists, raising tens of millions of dollars which were spent on negative ads, the Chicago-based Obama campaign had a head start. They kept offices open in the nine battleground states from 2008, knowing the President would be the unopposed candidate, and didn't have to wait until a nominating convention in the northern summer of 2012.
The week before the election, a Washington Post report said 44 per cent of all likely voters had been contacted by the Obama campaign in the toss-up state of Virginia, whose 13 electoral votes went to Obama on election night. (More than 41 per cent were contacted by the Romney campaign, still an impressive figure.)
There is anecdotal evidence galore of the strength of the ground campaign. During interviews with Obama supporters attending a rally in Bristow, Virginia, at the weekend, African American voter Laurie Franklin said that a Democratic activist knocked on her door "and registered me right there".
The effort to bring out the vote by both parties was intensive using personal interviews, phone banks and robocalls.
Both campaigns used Facebook and the full gamut of social media for the first time, using website tracking to get out the vote and appeal to new voters.
The National Association for the Advancement of Coloured People said "tens of thousands" of additional black voters - part of the President's core constituency which voted for him almost universally in 2008 - had been registered in Virginia. By tending to his coalition of voters, Obama won the election by 93 per cent of African Americans, 70 per cent of Hispanics and 70 per cent of Asians.
Time magazine described Obama campaign manager Jim Messina's strategy of setting up a data analysis team five times the size of the one in the 2008 campaign. But "public details were in short supply as the campaign guarded what it believed to be its biggest institutional advantage over Mitt Romney's campaign: its data".
The data mining helped Obama raise US$1 billion via email appeals to targeted voters based on their profiles. It also remade the process of targeting TV ads and "created detailed models of swing state voters that could be used to increase the effectiveness of everything from phone calls and door knocks to direct mailings and social media".
Resources were allocated where the data pointed. "We had a good organisation in '08," said senior adviser David Plouffe. "This organisation is light years ahead of that."
At every campaign stop, the President told supporters the result "depends on you", as he urged volunteers to get out the vote.


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Hello hello from snowy upstate!
We are back, and we have a lot to say, starting later this evening (now that we're in, we have some post editing and such to do. Also, children.).
But in the meantime, comments are so very open and also we wanted to make sure you had the new URL to bookmark. Although if you are reading this, you must have figured it out. Hmmm.
Anyway, please bookmark blogs.slj.com/printzblog (or just remember it, since it's so nice and tiny!), poke around our shiny new site, comment like mad, and let us know if you come across any quirks or issues — there may be some, and the quicker we hear about them, the quicker they can be corrected.
And yay! It's good to be back.


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The Azure Code Samples are currently available in English
Single-Page Application built using Angular2.4 and MSAL.js with Azure AD B2C
IMPORTANT NOTE: Calling an API is not yet shown
This simple sample demonstrates how to use the Microsoft Authentication Library Preview for JavaScript (msal.js) with Angular 2.4 to sign into Azure AD B2C.
How To Run This Sample
The sample is already configured to use a demo environment and can be run simply by downloading the code and running the app on your machine. Follow the instructions below if you would like to use your own Azure AD B2C configuration.
Optionally, if you want to use your own tenant configuration:
Step 1: Get your own Azure AD B2C tenant
You can also modify the sample to use your own Azure AD B2C tenant. First, you'll need to create an Azure AD B2C tenant by following these instructions.
IMPORTANT: if you choose to perform one of the optional steps, you have to perform ALL of them for the sample to work as expected.
Step 2: Create your own policies
This sample uses three types of policies: a unified sign-up/sign-in policy & a profile editing policy. Create one policy of each type by following the instructions here. You may choose to include as many or as few identity providers as you wish.
If you already have existing policies in your Azure AD B2C tenant, feel free to re-use those. No need to create new ones just for this sample.
Step 3: Create your own application
Now you need to register your single page application in your B2C tenant, so that it has its own Application ID. Don't forget to grant your application API Access to the web API you registered in the previous step.
Your single page application registration should include the following information:
- Enable the Web App/Web API setting for your application.
- Set the Reply URL for your app to
- Copy the Application ID generated for your application, so you can use it in the next step.
Step 4: Configure the sample to use your Azure AD B2C tenant
Now you can replace the app's default configuration with your own.
- Open the
- Find the assignment for
ClientIDand replace the value with the Application ID from Step 3.
- Find the assignment for
authorityand replacing
b2c_1_susiby the name of the policy you created in Step 2, and
fabrikamb2c.onmicrosoft.comby the name of the Azure AD B2C tenant.
tenantConfig = {
tenant: "fabrikamb2c.onmicrosoft.com",
clientID: '90c0fe63-bcf2-44d5-8fb7-b8bbc0b29dc6',
signUpSignInPolicy: "b2c_1_susi",
b2cScopes: ["https://fabrikamb2c.onmicrosoft.com/demoapi/demo.read"]
Step 5: Run the sample
- Make sure you've installed Node.
- Install the node dependencies:
powershell cd active-directory-b2c-javascript-angular2.4-spa npm install npm update
- Run the Web application
powershell npm start
- With your favorite browser, navigate to
- Click the login button at the top of the application screen. The sample works exactly in the same way regardless of the account type you choose, apart from some visual differences in the authentication and consent experience.
- Sign out by clicking the Logout button.
More information
For more information on Azure B2C, see the Azure AD B2C documentation homepage.
Community Help and Support
We use Stack Overflow with the msal and azure-ad-b2c tags to provide support. We highly recommend you ask your questions on Stack Overflow first and browse existing issues to see if someone has asked your question before. Make sure that your questions or comments are tagged with [msal.js].
If you find and bug or have a feature request, please raise the issue on GitHub Issues.
To provide a recommendation, visit our Feedback Forum.
This project has adopted the Microsoft Open Source Code of Conduct. For more information see the Code of Conduct FAQ or contact firstname.lastname@example.com with any additional questions or comments.


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- Font:
- +
- -
Try clicking on some of these links:
• MSNBC Continuing Coverage: Conflict in Iraq
Amb. Zalmay Khalilzad, U.S. Ambassador to Iraq |BIO
- Gen. Wesley Clark (Ret.), Fmr. Supreme Allied Commander, Europe | BIO
- Gen. Wayne Downing (Ret.), Fmr. Commander-in-Chief, U.S. Special Operations Command | BIO
- Gen. Barry McCaffrey (Ret.), Fmr. Commander-in-Chief, U.S. Southern Command | BIO
- Gen. Montgomery Meigs (Ret.), Commanding General, U.S. Army, Europe, Fmr. Commander, Stabilization Force, Bosnia-Herzegovina | BIO
© 2013 NBCNews.com Reprints


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Related Resource
Toward an Integrated Arctic Observing Network (March 2006)Report in Brief
Observable changes with regional and global implications, such as warming temperatures and reduced sea ice, are taking place across the Arctic. However, the record of Arctic observations suffers from incomplete geographic coverage and limited duration, and measurements are not well coordinated. This makes it difficult to comprehensively describe current conditions in the Arctic, let alone understand the changes that are underway or their connections to the rest of the Earth system. The U.S. National Science Foundation, through its Office of Polar Programs, asked for guidance to help design a pan-arctic observing network. This report outlines the potential scope, composition, and implementation strategy for an arctic observing network (AON). Such an integrated, complete, dynamic, and multidisciplinary environmental observing network will improve society's understanding of and ability to respond to ongoing systemic changes in the Arctic and its capability to anticipate, predict, and respond to future change both in the Arctic and around the globe. The network would build on and enhance existing national and international efforts and deliver easily accessible, complete, reliable, timely, long-term, pan-arctic observations. The AON would be a system of observational infrastructure -- including satellites, terrestrial observatories, ocean buoys and moorings, weather stations, hydrologic monitoring stations, ecological sampling networks, arctic residents, and other data sources--that will collect, check, organize, and distribute arctic observations while taking the necessary measures to continuously adapt and improve the network. Because many potential components of the network already exist or are being planned, and because of the surge of activity during the International Polar Year, there is an immediate opportunity for major progress.


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Ryan expected to energize donors
In Paul Ryan, Mitt Romney has picked a running mate who's expected to drive enthusiasm among staunch conservatives to cut checks and potentially draw new donors to the presidential race.
While Romney has outraised President Barack Obama in the past three months, there's little question that adding Ryan will help with conservatives who may not have been giving their all.
Story Continued Below
( PHOTOS: Scenes from Romney's VP announcement)
"He's got real strong ties into the Club for Growth and the National Review-type crowd, but he also has a huge following amongst the low-donor conservative base and I think that is really going to kick in the low dollar donor Internet and mail for Romney," said Matt Keelen of the Keelen Group, who worked as a D.C.-based consultant on Ryan's first congressional race.
Romney's team has already scheduled a 10-stop fundraising tour for August.
The House Budget Chairman status in the Republican party went from House leader to national figure during the health care debate and fight over the future of medicare.
Over the past year, Ryan has gone toe-to-toe with President Barack Obama, trading barbs over Obama's health care law and his budget plan. A growing recognition among GOP lawmakers that Ryan was the intellectual backbone for the future of the party and ability to spar with Obama drew major conservative backers.
"With energy and vision, Paul Ryan has become an intellectual leader of the Republican Party," Romney said Saturday.
Over the past week, while the veep stakes intrigue reached new heights, Ryan's darling status among the intellectual right was on full display.
"If Ryan's budget is going to be a central part of the debate over the next three months, who better to explain and defend it than Paul Ryan?" wrote William Kristol and Stephen Hayes of The Weekly Standard.
In addition to Kristol, Ryan is known for speaking regularly with Wall Street Journal editorial page editor Paul Gigot.


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Melanesia is in a good position to influence national and regional processes for sustainable fisheries and responsible oceans governance says the Offshore Fisheries Working Group of the Pacific Islands Roundtable for Nature Conservation, in a presentation last week to Prime Ministers, Ministers and senior government officials attending the weeklong Melanesian Spearhead Group Summit in Suva, Fiji.
The Working Group, comprised of Greenpeace, WWF, IUCN, Sea Web and the University of the South Pacific, presented the worrying scenario of degrading fisheries management in Melanesia countries and urged for stronger leadership, shared vision and a roadmap for sustainable and equitable offshore fisheries.
Inshore and offshore fisheries are the most important protein source in Melanesia and both are increasingly threatened by overfishing, urbanization, climate change and deep-sea mining.
With the global fishing industry in particular, turning their attention to the Pacific Ocean, there is an urgent need for Melanesia and all Pacific island countries to tighten up on their management of fisheries resources in a way that guarantees more benefits for their domestic economies. And to support local fishing industries for food security and the sustainable livelihoods.
The Working Group requested MSG leaders to consider: increased coordination among government departments, better control of licenses and access to fish stocks, incorporation of more balanced management approaches into national fisheries plans such as eco-system-based fisheries management, voluntary eco-certification schemes and multilateral approaches to access arrangements in order to ensure maximum returns across the board as a negotiating block.
More on this story on Fiji Times Online and Eco Business
For questions please contact [email protected] or [email protected]


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BLOCKIT RFID Protector Sleeves - 6 Pack (Floral) Top Load or Side Load Credit Debit Card Protectors, Slim Cards Holders fit all Mens & Womens Wallets
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Will my sleeves fit all of my credit cards?
Yes, all of our sleeves will fit standard credit card sizes.
It's hard to get my card in and out of the sleeve, what can I do?
Some people find the sleeves to be a little tight and hard to get their card in and out when they first receive them, this is a temporary issue. The sleeves will loosen up over time. But they need to be a bit tight in order to make sure they fit in the wallet card slot. You can bend and flex them to help get a better fit.
How do I know these sleeves work?
Our sleeves provide level one FIPS protection. FIPS is the government's new federal processing standard better known as FIPS 201. Our latest sleeves are 100% compliant to level one standards. The next time you're at the grocery store or gas pump test out the sleeves by waving your card past the "touchless" pay system while inside the sleeve.
Can I fit more than one card into a sleeve?
While we've heard some of our customers doing this, we don't recommend it.
Are my cards protected if I place them between two sleeves?
We've tested putting a card between two RFID sleeves and still have them protect our cards.
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