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PostScript fonts are outline font specifications developed by Adobe Systems for professional digital typesetting, which uses PostScript file format to encode font information.
Type 1 and Type 3 fonts were introduced by Adobe in 1984 as part of the PostScript page description language. They did not see widespread use until March 1985, when the first laser printer to use the PostScript language, the Apple LaserWriter, was introduced.
Although originally part of PostScript, Type 1 fonts used a simplified set of drawing operations compared to ordinary PostScript (programmatic elements such as loops and variables were removed, much like PDF), but Type 1 fonts added "hints" to help low-resolution rendering. Originally, Adobe kept the details of their hinting scheme undisclosed and used a (simple) encryption scheme to protect Type 1 outlines and hints, which still persists today (although the encryption scheme and key has since been published by Adobe). Despite these measures, Adobe's scheme was quickly reverse engineered by other players in the industry. Adobe nevertheless required anyone working with Type 1 fonts to license their technology.
Type 3 fonts allowed for all the sophistication of the PostScript language, but without the standardized approach to hinting (though some companies such as ATF implemented their own proprietary schemes) or an encryption scheme. Other differences further added to the confusion.
The cost of the licensing was considered very high at this time, and Adobe continued to stonewall on more attractive rates. It was this issue that led Apple to design their own system, TrueType, around 1991. Immediately following the announcement of TrueType, Adobe published "Adobe type 1 font format",[1] a detailed specification for the format. Font development tools such as Fontographer added the ability to create Type 1 fonts. The Type 2 format has since been used as one basis for the modern OpenType Format.
By using PostScript (PS) language, the glyphs are described with cubic Bézier curves (as opposed to the quadratic curves of TrueType), and thus a single set of glyphs can be resized through simple mathematical transformations, which can then be sent to a PostScript-ready printer. Because the data of Type 1 is a description of the outline of a glyph and not a raster image (i.e. a bitmap), Type 1 fonts are commonly referred to as "outline fonts," as opposed to bitmap fonts. For users wanting to preview these typefaces on an electronic display, small versions of a font need extra hints and anti-aliasing to look legible and attractive on screen. This often came in the form of an additional bitmap font of the same typeface, optimized for screen display. Otherwise, in order to preview the Type 1 fonts in typesetting applications, the Adobe Type Manager utility was required.
Type 0 is a "composite" font format - as described in the PostScript Language Reference Manual, 2nd Edition. A composite font is composed of a high-level font that references multiple descendent fonts.
Windows & OS/2:
.pfb, .pfm
Mac OS:
.pfm, .afm,
.inf (Optional files).
.pfa, .afm
.pfb, .pfm
.pfm, .afm,
.pfa, .afm
Type 1 (also known as PostScript, PostScript Type 1, PS1, T1 or Adobe Type 1) is the font format for single-byte digital fonts for use with Adobe Type Manager software and with PostScript printers. It can support font hinting.
It was originally a proprietary specification, but Adobe released the specification to third-party font manufacturers provided that all Type 1 fonts adhere to it.
Type 2 is a character string format that offers a compact representation of the character description procedures in an outline font file. The format is designed to be used with the Compact Font Format (CFF). The CFF/Type2 format is the basis for Type 1 OpenType fonts, and is used for embedding fonts in Acrobat 3.0 PDF files (PDF format version 1.2).
Type 3 font (also known as PostScript Type 3 or PS3, T3 or Adobe Type 3) consists of glyphs defined using the full PostScript language, rather than just a subset. Because of this, a Type 3 font can do some things that Type 1 fonts cannot do, such as specify shading, color, and fill patterns. However, it does not support hinting. Adobe Type Manager does not support Type 3 fonts.
Type 4 is a format that was used to make fonts for printer font cartridges and for permanent storage on a printer's hard disk. The character descriptions are expressed in the Type 1 format. Adobe does not document this proprietary format.
Type 5 is similar to the Type 4 format but is used for fonts stored in the ROMs of a PostScript printer. It is also known as CROM font (Compressed ROM font).
Ghostscript referred them as CID font types 0, 1, and 2 respectively, documented in Adobe supplements. Types 9, 10, 11 are CIDkeyed fonts for storing Types 1, 3, 42 respectively.
Type 14, or the Chameleon font format, is used to represent a large number of fonts in a small amount of storage space. The core set of Chameleon fonts consists of one Master Font, and a set of font descriptors that specify how the Master Font is to be adjusted to give the desired set of character shapes for a specific typeface.
Adobe does not document the Type 14 format.
Type 32 is used for downloading bitmap fonts to PostScript interpreters with version number 2016 or greater. The bitmap characters are transferred directly into the interpreter's font cache, thus saving space in the printer's memory.
The Type 42 font format is a PostScript wrapper around a TrueType font, allowing PostScript-capable printers containing a TrueType rasterizer (which was first implemented in PostScript interpreter version 2010 as an optional feature, later standard) to print TrueType fonts. Support for multibyte CJK TrueType fonts was added in PostScript version 2015. The out-of-sequence choice of the number 42 is said to be a jesting reference to The Hitchhiker's Guide to the Galaxy, where 42 is the Answer to Life, the Universe, and Everything.
In addition to font types, PostScript specifications also defined the Core Font Set, which dictates the minimum number of fonts, and character sets to be supported by each font.
In original PostScript, there are 35 base fonts:
In PostScript 3, 136 fonts are specified, which includes the standard 35 fonts; core fonts in Windows 95, Windows NT and Macintosh; selected fonts from Microsoft Office and the HP 110 font set. New fonts include:
In PDF, the following 14 fonts are defined:
However, in recent versions of Adobe Reader, Helvetica and Times were internally replaced by Arial and Times New Roman respectively.[2]
Although PostScript fonts can contain any character set, there are character sets specifically developed by Adobe, which are used by fonts developed by Adobe.
It includes a basic character set containing upper and lowercase letters, figures, accented characters, and punctuation. These fonts also contain currency symbols (cent, dollar, euro, florin, pound sterling, yen), standard ligatures (fi, fl), common fractions (1/4, 1/2, 3/4), common mathematics operators, superscript numerals (1,2,3), common delimiters and conjoiners, and other symbols (including daggers, trademark, registered trademark, copyright, paragraph, litre and estimated symbol). Compared to the ISO-Adobe character set, Western 2 also adds 17 additional symbol characters: euro, litre, estimated, omega, pi, partialdiff, delta, product, summation, radical, infinity, integral, approxequal, notequal, lessequal, greaterequal, and lozenge.
Fonts with an Adobe Western 2 character set support most western languages including Afrikaans, Basque, Breton, Catalan, Danish, Dutch, English, Finnish, French, Gaelic, German, Icelandic, Indonesian, Irish, Italian, Norwegian, Portuguese, Sami, Spanish, Swahili and Swedish.
This standard superseded ISO-Adobe as the new minimum character set standard as implemented in OpenType fonts from Adobe.
Fonts with an Adobe CE character set also include the characters necessary to support the following central European languages: Croatian, Czech, Estonian, Hungarian, Latvian, Lithuanian, Polish, Romanian, Serbian (Latin), Slovak, Slovenian and Turkish.
This Simplified Chinese character collection provides support for the GB 1988-89, GB 2312-80, GB/T 12345-90, GB 13000.1-93, and GB 18030-2005 character set standards. Supported encodings include ISO-2022, EUC-CN, GBK, UCS-2, UTF-8, UTF-16, UTF-32, and the mixed one, two- and four-byte encoding as published in GB 18030-2005.
This Traditional Chinese character collection provides support for the Big-5 and CNS 11643-1992 character set standards. It also includes support for a number of extensions to Big-5, which contain characters used mainly in the Hong Kong locale. Primary supported Big-5 extensions include HKSCS.
Supported encodings include ISO-2022, EUC-TW, Big Five, UCS-2, UTF-8, UTF-16, and UTF-32.
It is a series of character sets developed for Japanese fonts. Adobe's latest, the Adobe-Japan1-6 set covers character sets from JIS X 0208, ISO-2022-JP, Microsoft Windows 3.1 J, JIS X 0213:2004, JIS X 0212-1990, Kyodo News U-PRESS character set.
It was originally as an implementation of JIS X 0212-1990 character set standard and the Macintosh extensions, but with the introduction of Adobe-Japan1 supplement 6 (Adobe-Japan1-6) standard, Adobe-Japan2-0 became obsolete.
This Korean character collection is provides support for the KS X 1001:1992 and KS X 1003:1992 character set standards, and their selected corporate variations. Supported encodings include ISO-2022-KR, EUC-KR, Johab, UHC, UCS-2, UTF-8, UTF-16, and UTF-32.
Fonts with an ISO-Adobe character set support most western languages including: Afrikaans, Basque, Breton, Catalan, Danish, Dutch, English, Finnish, French, Gaelic, German, Icelandic, Indonesian, Irish, Italian, Norwegian, Portuguese, Sami, Spanish, Swahili and Swedish. This is the standard character set in most PostScript Type 1 fonts from Adobe.
The CID-keyed font (also known as CID font, CID-based font, short for Character Identifier font) is a font structure, originally developed for PostScript font formats, designed to address a large number of glyphs. It was developed to support pictographic East Asian character sets, as these comprise many more characters than the Latin, Greek and Cyrillic writing systems.
Adobe developed CID-keyed font formats to solve problems with the OCF/Type 0 format, for addressing complex Asian-language (CJK) encoding and very large character sets. CID-keyed internals can be used with the Type 1 font format for standard CID-keyed fonts, or Type 2 for CID-keyed OpenType fonts.
CID-keyed fonts often reference "character collections," static glyph sets defined for different language coverage purposes. Although in principle any font maker may define character collections, Adobe's are the only ones in wide usage. Each character collection has an encoding which maps Character IDs to glyphs. Each member glyph in a character collection is identified by a unique character identifier (CID). Such CIDs are generally supplemental to other encodings or mappings such as Unicode.
Character collections are uniquely named by registry, ordering and supplement, such as "Adobe-Japan1-6." The registry is the developer (such as Adobe). The so-called "ordering" gives the purpose of the collection (for example, "Japan1"). The supplement number (such as 6) indicates incremental additions: for a given language, there may be multiple character collections of increasing size, each a superset of the last, using a higher supplement number. The Adobe-Japan1-0 collection is 8284 glyphs, while Adobe-Japan1-6 is 23,058 glyphs.
CID-keyed fonts may be made without reference to a character collection by using an "identity" encoding, such as Identity-H (for horizontal writing) or Identity-V (for vertical). Such fonts may each have a unique character set, and in such cases the CID number of a glyph is not informative; generally the Unicode encoding is used instead, potentially with supplemental information.
CID-keyed fonts internally have their character sets divided into "rows," with the advantage that each row may have different global hinting parameters applied.
In theory it would be possible to make CID-keyed OpenType versions of western fonts. This would seem desirable for some such fonts because of the hinting advantages. However, according to Adobe, much of the software infrastructure (applications, drivers, operating systems) makes incorrect assumptions about CID-keyed fonts in ways that makes such fonts behave badly in real-world usage.
Adobe ClearScan technology (as from Acrobat 9) creates custom Type1-CID fonts to match the visual appearance of a scanned document after optical character recognition (OCR). ClearScan (in Acrobat 9) does not replace the fonts with your system fonts or substitute them by Type1-MM (as in Acrobat 8 and earlier versions), but uses these newly created custom fonts. The custom fonts are embedded in the PDF file (this is obviously mandatory).
Compact Font Format (also known as CFF font format, Type 2 font format, or CFF/Type 2 font format) is a lossless compaction of the Type 1 format using Type 2 charstrings. It is designed to use less storage space than Type 1 fonts, by using operators with multiple arguments, various predefined default values, more efficient allotment of encoding values and shared subroutines within a FontSet (family of fonts).
The so-called PostScript or Type 1 flavor of OpenType fonts, also called OpenType CFF, contains glyph outlines and hints in a CFF table.
CFF fonts can be embedded in PDF files, starting with PDF version 1.2. It is the usual approach to representing a Type 1 font within PDF.
CID-keyed fonts can be represented within CFF with Type 2 charstrings for CID-keyed OpenType fonts.
A Type 1 font can be losslessly converted into CFF/Type2 format and back.
Multiple master fonts (or MM fonts) are an extension to Adobe Systems' Type 1 PostScript fonts. Multiple master fonts contain one or more "masters" — that is, original font styles, e.g. a light, a regular and a bold version — and enable a user to interpolate these font styles along a continuous range of "axes." While Multiple Master font are not common in end user fonts anymore, they still play an important role when developing complex font families.
PostScript glyph data can be embedded in OpenType font files, but OpenType fonts are not limited to using PostScript outlines. PostScript outlines in OpenType fonts are encoded in the Type2 Compact Font Format (CFF).
When Adobe converted PostScript Type 1 and Type 1 multiple master fonts to OpenType CFF format, they were made based on the last Type 1/MM versions from the Adobe Type Library fonts. In addition to file format change, there are other changes:
For many Adobe Originals fonts, particularly those designed by Robert Slimbach, Adobe did some degree of redesign along with the conversion to OpenType.
The typeface Helvetica Narrow was not converted to OpenType, because the Type 1 original was a mathematically squished version of Helvetica, rather than an actually designed condensed typeface. This was originally done to conserve ROM space in PostScript printers.[3]
As a result of the above changes, Adobe no longer guarantees metric compatibility between Type 1 and OpenType fonts. However, Adobe claims the change is minimal for Adobe (not Adobe Originals) fonts, if:
Original Composite Font format (which uses a Type 0 file structure) was Adobe's first effort to implement a format for fonts with large character sets, debuted with PostScript level 2.
Adobe then developed the CID-keyed font file format which was designed to offer better performance and a more flexible architecture for addressing the complex Asian-language encoding and character set issues. Adobe does not document or support OCF font format.
OCF font metrics are described in Adobe Composite Font Metrics file.
Adobe Font Metrics (AFM), Adobe Composite Font Metrics (ACFM), Adobe Multiple Font Metrics (AMFM) files contain general font information and font metrics information for the font program. These files are generally used directly only in Unix environments.
An AFM file provides both global metrics for a font program and the metrics of each individual character.
The metrics of a multiple master font are described by one AMFM file, which specifies the control data and global font information, plus one AFM file for each of the master designs in the font.
An ACFM file provides information about the structure of a composite font. Specifically, the global metrics of the composite font program and the global metrics of each of its immediately descendent font programs. ACFM file does not associate with a base font, but act as the top-level structure of a composite font. The character metrics of individual characters in the composite font are described completely by one of more associated AFM files.
The formats are sufficiently similar that a compliant parser can parse AFM, ACFM, and AMFM files.
Printer Font ASCII (PFA) is an ASCII version of PFB, usually carrying ".PFA" file name extension. It contains a font's glyph data. PFA is the form of the font used by PostScript-language interpreters, and is also the preferred format for Type 1 fonts used in UNIX environments.
Printer Font Binary (PFB) is a binary PostScript font format created by Adobe Systems, usually carrying ".PFB" file name extension. It contains a font's glyph data.
Printer Font Metric (PFM) is a binary version of AFM, usually carrying ".PFM" file name extension. It contains font metric information.
The PFM format is documented in the Windows 3.1 "Printers and Fonts Kit" help file (PFK31WH.HLP). Some details are also covered in the Windows 3.1 "Device Drivers Adaptation Guide" help file (DDAG31WH.HLP). Both of those documents are part of the Windows 3.1 Device Development Kit (DDK), which is still available (October 2008) to MSDN subscribers.
.inf (INFormation) files contain application-specific information in plain ASCII text, such as font menu names for Windows and DOS-based applications. When a font is installed in Windows, the ATM Installer software takes the AFM and the INF file as input and generates the required PFM file at installation time. The AFM and INF files are not installed in the user's system.
.MMM files are used for the metric data needed by multiple master fonts for the Windows environment.
.OFM is the extension used by OS/2 for its version of binary font metrics file, starting from version 2.1.
Windows 95, Windows 98, Windows NT and Windows Me do not support Type 1 fonts natively. Adobe Type Manager is needed in order to use these fonts on these operating systems. Windows 2000, Windows XP and Windows Vista support Type 1 fonts natively through GDI calls. The Windows Presentation Foundation introduced in Windows Vista, which is also available for Windows XP however drops support for Type 1 fonts, in favor of Type 2 fonts.
For Windows platforms that natively support PostScript, only binary PostScript and OpenType file formats are supported.
Windows Presentation Foundation (formerly codenamed Avalon) in Windows Vista supports rasterizing OpenType CFF/Type 2 fonts, whereas Type 1 fonts will still be supported in GDI, but not in GDI+.
The t1utils font utility package by I. Lee Hetherington and Eddie Kohler provides tools for decoding Type 1 fonts into a human-readable, and editable format (t1disasm), reassembling them back into fonts (t1asm), for converting between the ASCII and binary formats (t1ascii and t1binary), and for converting from Macintosh PostScript format to Adobe PostScript font format (unpost).
Adobe Systems, Steve Jobs, TeX, Vector graphics, Computer graphics


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End of "early game" had me at all the kingdom buildings except the final level of blacksmith, and the 3rd tier class unlocks. I counted Early Midgame as the perid untill I had all of the 3rd tier classes unlocked.
Early Game Writeup Here: viewtopic.php?f=3&t=2421
The unlock prerequisite wierdness for various questlines gets really messy here for various reasons.
Issue No. 1: The Witch Her quest appears too early for newbies to be able to tackle Creeplight Ruins (it's early game), and then she took quite a bit of Tinker scumming, which I feel should be avoided if possible. It also points people east rather than west, and strongly so. I've thought about it quite a bit, and unless the availability of the Burn Salve related to EM desecration is the problem - her unlock quest and subdungeon should probably move to Southern Swamp. It would add a degree of challenge to a Southern Swamp run and foreshadow Ick, and be much less disruptive alltogather. Since the inital complicated tasks quests take place in the first directional dungeons, this gives the player incentive to play them out some more before moving on (instead of backtracking).
Issue No. 2: There are no quests in Slime Pits or Cursed Oasis. Magma Mines and Berserker Camp, however have 2 quests each. Apart from grabing the +8% charm, unless someone really needs one of the trophies, there is no incentive to go there.
New: Issue No. 2.5: This is further made odd by the fact that there are 2 quests in Magma Mines and Berserker Camp, respectively. Move the "complete with 4 classes quests" north and south or make new ones? Please?
Issue No.3: The Blacksmith unlock can happen significantly late in the game for no apparent reason.
Issue No. 4: GETINDARE abuse (use?) can get players a veto slot really, really early, through Thief, Rogue and Assasin challenges. Paladin silver challenge, and Berserker gold have uncovery of vicious dungeons as a prerequisite, which is at odds with every other class. For the Paladin it's glaring because it's the only silver challenge that requires it, and for the Berserker it's glaring because it requires the northern vicious dungeon to be unlocked. Simply changing tilesets and monster names/art for these challenges could straighten things out, otherwise you might consider restricting other class chalenges by state of game progression in a more standardized way.
Issue No. 5: The "Challenge" subdungeon which exists in the South, and is mandatory for Ick Swamp to unlock, doesn't have it's counterparts in the other directions and gives not clue about what you need to do before it spawns somewhere. It should either be removed, be moved in status to a "VICIOUS invite" subdungeon and/or there should be ones like it for each direction. I'd also recommend a "search the subdungeons in X for Y" rewardless quest for this kind of interlude.
Issue No. 6: The Northern Dessert doesn't have a fixed boss spawn, but the kingdom tooltip acts like it does. You can get either Aequitas or Goo Blob listed as boss, and as often as not the wrong one will spawn. I suppose this should be fixed, prefferably by removing the Goo spawn. It would also give more incentive to venture into the slime pit.
Issue No. 7: Tinker, Transmuter and Crusader need questlines of some sort. It would alleviate any gold problems newbies (will) have if theyre ment to purchase the 3rd tier classes on time, as they would have more class completions per dungeon, and likely more badges.
Issue No. 8: Hero's Helm is in a really weird place for a begginer unlock. By the time someone gets it, it probably won't be used much.
Issue No. 9: Note: "Playthrough ????? I've had a cluster**** of toasts happen after defeating the Havendale Bridge (By coincidence it seems). Magma Mines Minecraft, Transmuter, Bezar lvl 3, and the Taxidermist notes, at least. There seemed to be two identical notes for Bezar lvl 3 but with different tags."
Issue No. 10: Note: Gameflow Issue - It just occured to me that there is a thing about locker slots which might warrant consideration. The way they are distributed now is that you get 3 for unlocking the berserker, and 3 for Warlord, and those two aren't exactly the unlocks you want to rush as far as monsters are concerned, yet unlock the Trisword Challenge, the Unlikely Heroe's questline and the Sensation Stone dungeon. On the flipside, if you don't unlock the berserker right away you have no locker slots. I suppose redistributing the slot unlocks to be 2 + 2 + 2 would allow some item lockering right away (like it used to be), but would let you locker the sensation stone in the midgame. Fewer locker slots - fewer strats people feel really comfortable with, and while asking for more locker slots would be silly, asking for a redistribution probably isn't (to allow more diversity and experimentation in the late early game, and early midgame, especially for the item dependent classes).
Well, I used all of them at various points, but Taurog was my most prepped one due to straightforwardness, gold independent items he provides and a really, really non-existant prep penalty in most situations. Most other ones I didn't prep at all.
Issue No. 1: Unlocking the 2nd tier classes is a prerequisite for unlocking the HARD directional dungeons, but is also a prerequisite for unlocking 2nd tier gods once you pick the 1st tier ones up. This leads to situations where TT spawns in the Suthern Swamp. I thought he was supposed to be behind a skill wall? Was this intentional?
Issue No. 2: Find Odd: i just desecrated Taurog and he didn't take away his gear. Wonder if it was always like that or not? Bug thread material?
Issue No. 1: There really should be a way to cycle between your badges and classes in a particular dungeon, and that info should also be available in the dungeon itself. It's rather important when you: choose your next run, prep for your run, play your run. And right now you have to wait untill the panels cycle, hurry up to mouseover while the badge screen is up (they all look the same), and past that point a notebook is your best bet.
Issue No. 2: I have a note saying: "Minor Itch: Am I blind or is there no way to see your quests once you click on a flag on the map?" Later it sayes: "Maybe I'm just blind. And some of it at least is probably being worked on right now...", probably because the dev's are working on graphical and interface stuff.
Issue No. 1 Note: "Like - Transmuter Subdungeon Keyword: "Quest" The subdungeon art is a mite excessive, however. If you find it in a darker subdungeon, like the Havendale Bridge and your screen suddenly flashes orange the reaction is "Bleh!" not "Wow"." I really mean it, there's what, 1 dungeon where the orange screen doesn't come off as jarring, and that's Magma Mines.
Ok, that's it for the Early-Mid game. Now for:
Everything but the gold challenges, the Paladin Silver challenge (was locked due to needing Dragon Isles unlocked for no obvious reason), and the final directional quests (and 4 final throphies).
Generally I've used everything but the Fire Heart at some point, and I might even use it if I turn to healthmonsters. Truly, besides the weird unlock prerequisites such as the Hero's Helm has (in relation to gold required to unlock the quest), I'm having trouble deciding what to fill my veto slots with. You guys really made a lot of stuff work.
Issue No.1 - the Mas09 ledger is easily acquireable, lockerable, has a very cheap activation and prep cost and is on par if not more powerfull than most VICIOUS rewards. It's probably the most powerful item in the game and needs somethign done to it ASAP.
Issue No. 2 - the other guys, Avatar in particular, have expressed a desire to have all the subdungeon items be lockerable, even if it means adjusting their effects and power level so that it makes sense. Darvin even stated that Draco's heart isn't even too powerful. I don't know what to think exactly, except that having a "locker only" items category might be fun, but it has to be uniform.
Issue No. 3 It's not clear whether you can both locker and veto an item. Some people have expressed desire to have this option.
New: (Friday)
Issue No. 4: I've cmpletely changed my mind about Crystall Ball. The viability of the wizard seems to be directly tied to autoprepping it. I'm not sure what to think - i was devastating the game with spellcasters last time around and never touched it. This time around it's an auto-prep, and i'll see what the game looks like without it once I start testing the Mage Fist. What it does is let spellcasters explore almost the entire map and waste a ton of blackspace and still be able to spike 2 bosses. B2P is at least anti-synergistic with schadenfraude, this isn't.
Unlikely Heroes: turned up out of a random comment about Venture Cave not having proper questlines and became the heart and soul of the midgame. It was awesome, just what hard is supposed to be. However, the race/class choices were a bit weird, and there seemed to be no Paladin or Sorcerer represented, but the monk and the wizard turned up twice. Since the wizard also turns up in the Grimm's Grotto quest, I think that he's being needlessly forced.
Issue No. 1 - some of the boys and I decided we'd really like a "conversion fodder" subdungeon as a "can spawn anywhere" one. We made a thread about it.
Issue No. 2 - The Cha Dylan subdungeon seems to appear noticably more often than any other subdungeon. It's awesome the first time around, but gets tiresome after a while (the size of it, yet the relative lack of content in it opposed to the level from which you descend makes it a bit of a subconcious dissapointment. Psych at work there.)
Issue No. 3 - Saint Solitude Subdungeon Is another subdungeon where you can score a LEMISI glyph. The fact that it and Cha Dylan have overlapping spawn areas is a bit puzzling.
Issue No. 3 - Venus Patrol subdungeon rewards seemed quite a bit too good. I like the fact that piety as a resource is getting used more though
I liked the Assasin nerfs, and I liked the Paladin nerfs. Monk nerfs also did a good job of making him very tricky in unfavourable maps. However:
Issue No. 1 The Berserker is noticably struggling outside of very favourable maps.
Issue No. 2 The Warlord is an engine of destruction. He needs nerfs, no joke. He still has Ye Brokene Olde Cydstepp and practicaly the Rogue bonus on top of it. I suppose nerfung his %buffs to 25% each might do the trick, but the fact is that I noticed a big difference between him and everybody else and I wasn't even using the trisword which he has incredible synergy with. Take also into account all the VICIOUS runs the Darvin's been making, and please do something.
Issue No. 2 The Bloodmage is frankly even more powerfull. He was the star of my last playthrough, and then, at the very end, he got buffed. Whether it's the current B2P or the BM in general I don't know, but I don't think anyone can beat him for the level difference between hero and target monster, by a long shot (in otherwise reasonable circumatances).
Well, I've used all of them at some point or another. Adding APHEELSICK to my repertiore scored me a lot of wins, IMAWAL was just great this time around (underused, more than underpowered, but could still use cost decrese maybe). HALPMEH isn't what it used to be, but it's still good with regen fighters, and WHEYTWUT I don't know what to think of. The 3rd tier GLYPHS unlocks actually cause a difficulty spike on the grounds that GETINDARE stops being an almost guaranteed spawn.
Issue No. 1 The operating principles behing PISSORF are obscure to say the least. It's integral to the midgame, it synergizes with Orcs, Tri-Sword, Mage Plate, but none of this is obvious. It needs a tutorial that appears sooner than you get to complete all the spellcasting gold challenges (which are all one big PISSORFF tutorial, as far as I've seen). It needs a clearer tooltip (standardize the effect to save tooltip space, maybe, and make sure that even the village idiot can understand that -% damage doesn't affect it).
New (Friday):
Issue No. 2 The CYDSTEPP that everyone is using and the CYDSTEPP the Warlord is using aren't the same glyph. It's possible that the general purpose one could cost a bit less. I've been using it, and the effect is powerfull, to be sure, but the nature of the glyph prevents overuse, it can't be prepped, and having it (and IMAWAL also maybe) could let us combine it's use with a utility glyph, or help Berserkers out (they're allready struggling compared to others).
Issue No. 1 If Pactmaker could be made to work in a way where you could choose a pact before you pick consensus, then by all means, please make it so. One missclick there can cause all calculations to break down. Also if Alchemy Pact won't be touched, can we please get a clear clarification on why not?
And that's all for now, I'm tired as hell, and I hope the dev's get a chance to go through this, and if they find stuff they agree on and is easy to get in there before the break to do so. If not, well, it was a fun playthrough and I think many of these are sensible and needed polishing touches. Challenges writeup coming along one of these days.

subset: commoncrawl


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Sea Glass Art - Handmade Yellowfin Tuna Sea Glass Mosaic
All US orders ship for free!
Every sea glass mosaic is an original, one of a kind piece made with real sea glass that I've hand picked along the Pacific coastline. All sea glass is entirely authentic from the beach, and has never been machine tumbled or cut.
I use all repurposed wood for my backgrounds - mostly old fencing reclaimed from yards around my Southern California home.
Once I've prepped the wood, I hand paint the piece, then mosaic over the painting using mainly clear sea glass, and in some cases green sea glass and brown sea glass as well. It's like putting together a jigsaw puzzle - I sift through my vast collection of beach glass to pick out just the right shard to build the final picture.
After the mosaic is complete I coat the front of the piece to seal and protect the sea glass. This gives the sea glass a shiny finish. Each piece of wood soaks up the seal differently, so many pieces will have a uniformly shiny finish in the background, while others have a more rustic, patchy finish. Please see my shop policies for more details about these variations.
This piece is approximately 5x8in
A sawtooth hanger is attached to the back of each piece so it is ready to hang on the wall.


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Matteo Manassero contended with his new Versa Putter. Monty made a move on the Champions Tour. Perez, Gainey and Every all had new clubs in the bag. And the Kings of Distance were in action LIVE on our site! Let's get into the top 5 Tour highlights from last weekend.
1. Manassero Moves Into New Versa Putter
At the Valspar Championship, first year Callaway/Odyssey Staff Pro Matteo Manassero moved into a Versa #1 White/Black/White model putter. According to Odyssey Tour Rep, Johnny Thompson, it was a quick transition. "He saw it on the demo bag, gave it a test on the course and liked it enough to put into play," Thompson said. Easy enough. Matteo went on to finish T8 in his first start with his new putter.
2. What's In Matteo's Bag?
Here's a look at what Matteo had in his bag last weekend:
Big Bertha Driver (8.5°)
Big Bertha Fairway Wood (14°)
X2 Hot Pro Hybrid (18°)
X2 Hot Pro Hybrid (20°)
X Forged 13 Irons (4-PW)
An SR 3 Golf Ball
Odyssey Versa #1 W/B/W Putter
Manassero's Big Bertha Driver is 45 ¼" with a Diamana W 50X shaft. It's set to a Draw directional bias and the Loft Adjustability COG is set to +1. The Adjustable Perimeter Weighting slide is set at a -2 Draw.
He hit 76.92% of fairways for the week and was T3 in the field in driving accuracy.
He's been driving the ball great this year, and last week we released a Callaway Get #BerthaLong video where Matteo offered up a tip on how to hit longer drives.
We also sat down with Matteo to talk about his goals for the year in this episode of Callaway Talks.
3. Montgomerie Rallies With Sunday 62, Almost Wins
Callaway staffer Colin Montomgomerie made a furious Sunday run with a final round 62 at the Toshiba Classic. After doing some testing early last week at the Ely Callaway Perforamnce Center in Carlsbad, Montgomerie was dialed in and our Tour Reps told us he was striping it on the range. So the breakout round should hardly come as a surprise.
Montgomerie went on to finish T2 alongside fellow Callaway Staff Pro Steve Pate at the Champions Tour event, just one shot off the winning score. Here's some of the equipment Monty had in his bag:
Big Bertha Alpha Driver (9.5°)
Big Bertha Fairway Wood (15°)
X2 Hot Hybrid (20°)
An SR 3 Golf Ball
Odyssey Versa #7 White
Montgomerie has now posted top-10 finishes in all three of his Champions Tour starts this year, and he's up to 7th in the Charles Schwab Cup standings. Great playing, Colin!
4. Perez, Gainey and Every Put In New Clubs
Callaway staffers Pat Perez, Tommy Gainey and Matt Every all played new clubs last week at the Valspar Championship. Perez put in an 18° X2 Hot Pro Hybrid and Gainey used two new X2 Hot Pro Hybrids (20° and 23°). To learn more about the X2 Hot and X2 Hot Pro Hybrids, take a look at this new episode of Callaway Talks.
Every put in a new 60° Mack Daddy 2 Wedge, featuring a C-Grind design and 8° of bounce. The first year Callaway staffer went on to finish T8 for his fourth top-10 of the season.
5. Kings of Distance Live Stream Was A Hit!
The Callaway #ZooCrew was in Orlando on Monday for a special one night only #KingsofDistance event. We streamed it all live on CG.com as Patrick Reed, Henrik Stenson, Gary Woodland, Nicolas Colsaerts and Matt Every put on a Skills Challenge and a long drive demonstration.
Based off everything we heard from fans on social media, the event was a hit! And we loved putting it on for everyone!
For more on all our Tour players, please visit our Team Callaway page.


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Keeping Snakes Away from your HomeAugust 13, 2019 1:04 pm
If your home is in an area where snake sightings are common, you have likely at some point walked outside... View Article
If your home is in an area where snake sightings are common, you have likely at some point walked outside... View Article
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Protecting one's home, family and belongings is a primary concern for most homeowners. However, installing a fancy alarm system can... View Article
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By Lisa Capobianco
Staff Writer
The Connecticut AARP honored Republican State Senator Joe Markley with the 2013 Legislative Achievement Award for his commitment to protecting the consumer rights of senior citizens in Southington.
Last week, the Connecticut AARP, along with members of the community, applauded Senator Markley at Jensen's Clubhouse for his work to ensure that seniors continued to have access to landline phones and to stabilize reasonable electric costs. Connecticut AARP recognized Markley in 2011 for making consumers aware of a new tax on utility bills.
"He cares about his people and our town. We are impressed with what he does," said AARP volunteer Janet Ferracci-Carter, of Southington.
"He is a genuine person," added AARP volunteer Laura Schiavone.
Markley said he feels proud of the work he has helped accomplish for senior citizens, and members of the community as a whole. During the 2012 Legislative Session, AARP helped defeat legislation that would have "deregulated telephone service in Connecticut," making it "easier for companies to drop landline service in certain areas of the state," reported the AARP on its website. Markley said opposing this legislation served as an important way for him to help not only senior citizens but people of all ages who may not feel ready to transition out of using landline service in their homes.
"I can share some of the same concerns that people feel," said Markley, adding that he has established a close relationship with the Southington volunteers of the AARP, meeting with its members throughout the year to discuss these issues. "It is nice to know that your work is appreciated…I am happy to work with them."
Jennifer Millea, the Communications Director of Connecticut AARP, said over a dozen state legislators received the same award for 2013, including Representative Al Adinolfi, who also represents Southington. She said Senator Markley played a vital role in legislation that "would have affected telecommunications customers in the state."
"It is really legislators who have really championed issues for AARP," Millea said.
For Southington resident Billye Simmers who lives at Jensen Communities, seeing Senator Markley receive the award serves as a reminder of the support she has received from him for an issue she holds a passion for: traumatic brain injuries. As the chair for the Traumatic Brain Injury (TBI) Advisory Committee, Simmers helps spread more awareness about programs and services for individuals who have suffered from TBI. In 2012 year, Markley showed his support by attending the board's annual meeting.
"It engages me to be a part of his work," said Simmers.
Senator Markley honored with AARP award
By Lisa Capobianco


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Get a Glimpse of "Island Time"
At the edge of the US and Canadian border, the San Juan Islands rest in the Olympic Rain Shadow. Fondly referred to as the "Banana Belt," the islands enjoy an average 250 days of sunshine. The collection of natural harbors, gentle waterways and exquisite scenery has long made it a boaters' paradise. In recent years, fertile lands and access to some of the regions best seafood have attracted chefs from around the globe. Today, the San Juans are recognized as a gourmet archipelago.
Reach the Islands by Plane
With Kenmore Air, the San Juan Islands are just 45 minutes away. Home based out of Seattle, this local airline offers daily flights to the three major islands: Orcas Island, San Juan Island, and Lopez Island. Flights depart from one of Kenmore Air's three Seattle terminals and offer stunning scenic views.
Reach the Islands by Ferry
Two and a half hours north of Seattle, Anacortes has nestled itself into Fidalgo Island. The city is bordered by waterways and bays such as Rosario Strait and Fidalgo Bay. It's the launching point for the Washington State Ferry's Anacortes/San Juan Islands route. Daily departure times change seasonally.


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To study the effect of sleep center accreditation and Sleep Medicine board certification of physicians on patient-centered outcomes in obstructive sleep apnea (OSA).
Prospective, multicenter, comparative effectiveness study.
Four sleep centers
502 patients with OSA.
Patients at two accredited and two non-accredited centers underwent polysomnography at participating locations and completed validated questionnaires, with objective measurement of positive airway pressure (PAP) therapy adherence performed three months after therapy initiation. The proportion of patients (age 53 ± 13[SD] years; 26% women; and body mass index 33.6 ± 7.2 kg/m2) who were adherent to PAP therapy by Medicare guidelines (> 70% of nights with ≥ 4 h use over a 30-day period) was greater in accredited (79%) than non-accredited sites (64%; p = 0.004). After adjustment for confounding variables, patients who received care from accredited centers (odds ratio [OR] 2.2, 95% confidence interval [CI], 1.2-4.2; p = 0.016) and certified physicians (OR 2.3, 95% CI, 1.3-4.0; p = 0.005) were more likely to be adherent to PAP therapy than those who received care from non-accredited centers and non-certified physicians. Patient satisfaction was associated with greater education received from physician (OR 4.6; 95% CI 2.3-9.3); greater risk perception (OR 2.7; 95% CI 1.0-7.4); physician certification (OR 2.1; 95% CI 1.1-4.2); and inversely related to delays in care (OR 0.5; 95% CI 0.3-0.9; p < 0.05). Such delays were inversely related to accreditation-certification status (p < 0.0001).
In patients with OSA, accreditation-certification status of sleep centers and physicians was associated with better PAP adherence, better patient education, better patient satisfaction, and greater timeliness.
A commentary on this article appears in this issue on page 251.
Parthasarathy S; Subramanian S; Quan SF. A multicenter prospective comparative effectiveness study of the effect of physician certification and center accreditation on patient-centered outcomes in obstructive sleep apnea. J Clin Sleep Med 2014;10(3):243-249.
Health care delivery in many disease conditions including obstructive sleep apnea (OSA) will be increasingly driven by quality metrics.1–3 One of the important quality metrics for OSA—adherence to positive airway pressure (PAP) therapy— remains a huge problem, with adherence of greater than four hours of daily use ranging from 46% to 83%.4,5 There is much emphasis on patient-centered care that focuses on outcomes relevant to patients such as improving patient satisfaction and enhancing the patient experience.6 We have previously shown that in a cross-sectional national survey, patients with OSA cared for by American Academy of Sleep Medicine (AASM) accredited sleep centers or Sleep Medicine board-certified physicians had lower positive airway pressure (PAP) discontinuation rates and reported greater patient satisfaction than patients cared for by non-accredited centers and non-certified physicians.7 Subsequently, Pamidi and colleagues performed a single-center retrospective chart review that demonstrated higher objective measures of PAP adherence in patients seen by a sleep specialist prior to undergoing polysomnography (PSG) than those who did not receive such sleep specialist consultation.8 Recently, a randomized controlled non-inferiority trial reported that treatment of OSA by primary care physicians was non-inferior to that of sleep specialists with regard to resolution of sleepiness, patient satisfaction, or PAP adherence.9 So far, to our knowledge, a comparative effectiveness trial, in "real-world" circumstances devoid of the artificial constraints of a randomized controlled trial, comparing the effect of both physician certification and center accreditation on clinical outcomes in patients with OSA has not been performed.
Current Knowledge/Study Rationale: Previously, studies of the effect of physicians' board-certification status and sleep-center accreditation status on outcomes in patients with obstructive sleep apnea (OSA) have shown variable results. A prospective multi-center comparative effectiveness trial, in "real-world" circumstances devoid of the artificial constraints of a randomized controlled trial, comparing the effect of both physician certification and center accreditation on clinical outcomes in patients with OSA has so far not been performed.
Study Impact: In patients with OSA, accreditation-certification status of sleep centers and physicians was associated with better PAP adherence, better patient education, better patient satisfaction, and greater timeliness. These results suggest that health policy decisions should be directed toward care pathways involving accredited facilities and board-certified physicians.
Besides quality metrics aimed at measuring treatment adherence and resolution of symptoms, other metrics that serve as mediators are important in health promotion and chronic disease management.10 Specifically, patient education regarding their chronic disease condition can help improve risk perception and self-efficacy, and consequently serve to promote adherence to therapy and further improve health and well-being.10–13 In our previous national survey, we demonstrated that patient education and risk perception mediated the observed better PAP adherence in patients cared for by accredited centers and certified physicians, but such cross-sectional measurements may be subject to recall bias and needed to be performed in a prospective manner.7 Other important benchmarks in the management of patients with OSA such as timely delivery of care and patient satisfaction with care rendered by their physicians and centers are important patient-centric quality metrics that needed to be assessed.14
In order to address these knowledge gaps, we performed a multicenter, prospective, comparative effectiveness study involving four sleep centers (two accredited and two non-accredited) with the overall purpose of studying the effect of center accreditation and physician certification on patient-centered outcomes of OSA. We hypothesized that patients with OSA who are cared for by sleep-certified physicians or accredited centers are more likely to be adherent to PAP therapy than patients cared for by non-certified physicians and non-accredited centers. We also hypothesized that patient education regarding OSA and associated risks are provided by a greater proportion of sleep-certified physicians and accredited centers than by non-certified physicians and non-accredited centers. Lastly, we hypothesized that sleep-certified physicians and AASM-accredited centers provide more timely care and achieve greater patient satisfaction ratings than non-certified physicians and non-accredited centers.
Consecutive patients at 4 sleep centers (2 AASM accredited and 2 non-accredited) referred with a high suspicion for OSA were approached to participate in a 3-month study that entailed a previously published and validated sleep questionnaire aimed at measuring baseline demographics and patient satisfaction.7 Exclusion criteria were: (a) age < 21 years; (b) patients with known diagnosis of OSA who were returning for a PAP titration or PAP re-titration study; (c) patients who were undergoing PSG primarily for suspicion of conditions other than OSA (such as parasomnias, narcolepsy, restless leg syndrome); and (d) cognitive impairment and inability to provide informed consent. The institutional review board approved the study and written informed consent was obtained from all participants. Of the 2 non-accredited centers, one was an urban hospital-based 4-bed academic center and the other was a suburban free-standing 4-bed non-academic center. Of the accredited centers, there was one urban hospital-based 6-bed academic laboratory and one suburban free-standing 4-bed non-academic laboratory. The centers were chosen as such to balance the effect of academic versus private affiliation, urban versus suburban location, and hospital versus free-standing facilities. All sites provided PAP support through contracted durable medical equipment companies. One of the non-accredited sites supplemented such PAP support with in-house PAP set-up by respiratory therapist.
Details of the questionnaire are available elsewhere.7 Briefly, patients were asked to respond "yes," "no," or "don't know" to the following questions: (a) whether they received adequate education from the healthcare provider about OSA in any form—verbal, audio-visual, or pamphlets; (b) whether they received adequate education about OSA from the sleep center in any form; (c) whether such education improved their understanding of OSA; (d) whether such education helped them realize the risks associated with OSA; (e) whether they received education regarding OSA from other sources; (f) whether they were satisfied with their physician's management of their OSA condition on a 5-point Likert scale that ranged from very satisfied to very dissatisfied7,15; and (g) whether they were satisfied with their sleep center's management of their OSA condition on a 5-point Likert scale. Other medical information obtained from patient self-report included demographics, nasal symptomatology, medications, insurance information, comorbid medical conditions, and Epworth Sleepiness Scale. Patients were also asked to report the time delay between the referring physician visit and PSG.
At 3 months, objective PAP adherence information was downloaded from the device and transmitted to coordinating center. Additionally, patients were queried regarding the subjective improvement in sleepiness on a Likert scale.16 Degree of improvement in subjective sleepiness was measured by a 5-point Likert scale that ranged from -1 (sleepiness is worse), 0 (no change), +1 (slightly improved), +2 (substantially improved), and +3 (completely resolved).7
Potential confounders that may affect acceptance of PAP device were also measured: PAP pressure level, device type (automatic PAP, bilevel PAP, or continuous PAP), presence and severity of nasal congestion score, age, gender, height, weight (for body mass index calculations), and highest education (did not finish high school, finished high school, college, masters, or doctorate).7 Potential confounders for timeliness in healthcare delivery such as type of health insurance (HMO, PPO, POS, Medicare, or lack of any insurance) were also requested.
The primary end-point for analysis was adherence to PAP therapy as defined by Medicare criteria—specifically, the use of PAP device ≥ 4 h per night on > 70% of nights during a consecutive 30-day period anytime during the first 3 months of initial usage.17 Secondary end-points were (a) patients' perception of education they received regarding OSA, (b) patients' perception of health risks of OSA, (c) time delay in receiving PSG therapy, and (d) overall patient satisfaction of the care delivered by physician and center, measured separately.
In order to assess the combined "dose-effect" of sleep certification of physicians and AASM accreditation of the centers on patient outcomes, we assigned patients to 1 of 3 groups: (a) both physician and center were certified-accredited, (2) one of the two was certified-accredited, and (3) neither physician nor the center were certified-accredited. From the list of predictors and potential confounders, simple logistic regression analysis was performed to identify significant factors (independent variables) that influenced discontinuation of PAP therapy. Subsequently, we built multivariate logistic regression models with Medicare definition of PAP device adherence as the dependent variable using significant independent variables identified by univariate logistic regression analysis (p ≤ 0.10).
Multi-collinearity between independent variables was verified, and in the event of collinearity, the strongest predictor variable alone was included. Results are presented as mean and standard deviation unless otherwise specified. P values less than 0.05 were considered significant. All analysis was performed using SPSS v20.0 (IBM SPSS Inc., Armonk, NY). Unadjusted proportions were compared using Pearson χ2 test.
PAP device adherence has been reported to be between 46% to 83% when defined as ≥ 4 h of daily use.4 In a previous study, we have shown a 14% difference in PAP acceptance between patients cared for by accredited and non-accredited centers.7 Based upon such information, we assumed a PAP device adherence proportion of 65% and considered a difference in PAP adherence of 14% as clinically meaningful. Therefore, a required sample size of 458 was needed to have 90% power (2-sided α) to detect a difference. Anticipating an estimated 10% attrition rate over the 3-month follow-up, we needed at least 504 participants.
A flow diagram outlining the recruitment is provided in Figure 1. During the recruitment period, 509 patients agreed to participate and provided informed consent. Seven of the 509 patients who gave informed consent did not have OSA and were excluded from the study (3 participants in accredited sites and 4 participants in non-accredited sites). Follow-up data were available in 487 participants with 15 participants lost to follow-up (7 in accredited and 8 in non-accredited facilities). In this real world-study, there were more certified physicians in the accredited centers (41%) than in non-accredited centers (28%; p = 0.007).
Flow diagram of participant recruitment and retention
(more ...)
Baseline demographics of the 502 participants from the 2 accredited (n = 270) and 2 non-accredited sleep centers are shown in Table 1. Group differences in age, gender, education level, and health insurance status were observed. Differences in the apnea-hypopnea index were noted, probably attributable to one of the accredited sites having a larger proportion of patients whose PSG was scored by the 4% desaturation rule for scoring hypopneas. Notably, the lowest SpO2 was not different between the accredited and non-accredited centers (Table 1). Prescription of bilevel PAP devices was not different between accredited (10%) and non-accredited facilities (10%; p = 1.0).
Baseline demographics
The proportion of patients adherent to PAP therapy was greater in patients cared for by accredited centers than those cared for by non-accredited centers (Table 2). Similarly, hours of PAP device use were greater in patients who received care at accredited centers than non-accredited centers (Table 2). When compared to patients at non-accredited centers, patients at accredited centers had shorter time delays for PSG (Figure 2), greater self-reported education from referring physicians and sleep center staff, better understanding about OSA, greater perception of risk of OSA, and were more likely to seek education regarding OSA from other sources (Table 2). Patient ratings of satisfaction with sleep centers were comparable between accredited and non-accredited centers. Patient ratings of satisfaction with physicians was greater for certified than non-certified physicians (unadjusted odds ratio [OR] 2.4; 95% CI 1.4-4.2). Similarly, patients rated a greater proportion of certified physicians (91%) as delivering satisfactory education regarding OSA than non-certified physicians (84%; p = 0.042). Participants reported experiencing similar improvements in sleepiness over a 3-month period in both accredited and non-accredited sites (Table 2). As expected, the Likert scores for improvement in sleepiness were directly related to daily use of PAP therapy (R2 = 0.39; p < 0.0001).
Patient-related outcomes
Time delay from referral to polysomnography (PSG) in non-accredited facilities was greater than that in accredited facilities (p
Accredited and non-accredited sites were served by both sleep medicine board-certified physicians and physicians without such certification. Therefore, we categorized patients by both center accreditation and physician certification status to yield 3 groups: (a) patients cared for by an accredited center and certified physician, (b) either the center or physician was accredited or certified, or (c) neither the center nor physician was accredited or certified (Table 3). The proportion of patients who were PAP adherent was related to accreditation-certification status in a dose-dependent manner: lack of accreditation and certification (none; 59% adherent) less than either accredited center or certified physician (either; 75%), or both being accredited and certified (both; 78% p = 0.004; Table 3).
Proportion of patients who were adherent to PAP therapy*
Univariate logistic regression analysis revealed the following variables that were associated with PAP adherence: accreditation of center, certification status of physician, combination of both accreditation-certification status of the provider and center, higher education level of participants, greater AHI, and greater education received from physician regarding OSA (Table 2). The presence of kidney disease was associated with lower PAP adherence (Table 4). Interestingly, health insurance status, nasal congestion scores, and medications for nasal symptoms were not associated with PAP adherence. Multivariate logistic regression models built to adjust for confounders revealed that objective PAP adherence was associated with physician certification, center accreditation status, or a combination of both in a dose-dependent manner (Table 5). Center characteristics such as academic versus non-academic, urban versus suburban, and hospital versus free-standing centers did not affect PAP adherence (all OR 0.78; 95% CI 0.38-1.61; p = 0.5).
Unadjusted odds ratios of determinants of PAP adherence
Adjusted odds ratios of determinants of PAP adherence
Patient satisfaction was associated with greater education received from physician (OR 4.6; 95% CI 2.3-9.3; p < 0.0001), greater risk perception of OSA (OR 2.7; 95% CI 1.0-7.4; p = 0.049), and physician certification (OR 2.1; 95% CI 1.1-4.2), and inversely related to > 30-day delay for PSG (OR 0.5; 95% CI 0.3-0.9; p = 0.03). Patient satisfaction ratings of sleep centers were not different between accredited and non-accredited centers (Table 2).
Timeliness of care—time delay between the first sleep study and when the patient received the PAP device—was 24 ± 35 days (median 14 days; interquartile range 7, 30) for the entire cohort. Time delays were shorter in accredited centers than non-accredited centers (Table 2 and Figure 2). Timeliness of care was not related to insurance status (p = 0.3). The direct referrals in accredited centers (44%) were not different than those in non-accredited centers (42%; p = 0.9). Also, the proportion of split-night studies in accredited centers (18%) was not different than that in non-accredited centers (21%; p = 0.43; χ2 test). In a multiple regression model, time delay was inversely related to accreditation-certification status of center and physician (OR 0.58; 95% CI 0.45-0.75; p < 0.0001).
Besides the internal consistency of the components of the questionnaire presented in our previous publication,7 we further checked the data for internal and external validity. In order to assess the internal validity, we correlated daily PAP use versus self-reported improvement in sleepiness. In our study, the Likert scores for improvement in sleepiness were related to daily use of PAP therapy (R2 = 0.39; p < 0.0001). The demographic characteristics of our patient population are very similar to those reported in other large series involving patients with OSA (external validity).7,18,19 Furthermore, the prescription of bilevel PAP devices was similar to that in a previous report.20
Some general observations can be made about our study. First, after adjusting for baseline differences and other confounding variables, AASM accreditation and Sleep Medicine certification status of physicians and sleep centers are associated with greater adherence to PAP therapy than non-certified physicians and non-accredited centers in real-world conditions (Table 5). Patient education regarding OSA was independently associated with better PAP adherence, increased risk perception regarding OSA, and physician certification, which together may have mediated the favorable effect of accreditation-certification on PAP adherence. While time delays were shorter in accredited than non-accredited centers, patient satisfaction with sleep centers was comparable between accredited and non-accredited facilities. However, patient satisfaction with physicians was strongly and directly associated with education received from the physician, better risk perception as it pertains to OSA, and physician certification status, and inversely related to time delays in obtaining PSG.
To our knowledge, this is the first multicenter prospective comparative effectiveness study performed in the real-world setting to show favorable effects of physician certification and center accreditation on objective PAP adherence in patients with OSA. A recent multicenter randomized controlled trial did not find a difference in PAP adherence between care rendered by sleep specialists versus primary care physicians in patients with OSA.9 In this efficacy study, controlled multiple educational interventions were delivered to sufficiently train nurses and primary care physicians who then managed patients in a well-controlled and protocolized manner that resulted in non-inferior results compared to sleep specialists.9 However, in our effectiveness study, we conducted our study in the real-world setting with typical interventions delivered by regular staff members without any special educational intervention administered to health care providers. Such differences between controlled trials and comparative effectiveness studies are important translational elements in health services research that bear much import to outcomes research and public health relevance.21 Specifically, comparative effectiveness studies such as ours need to be done first to better understand the current differences in provider training (or specialization) on patient outcomes in OSA. Subsequently, the educational intervention administered to primary care physicians and nurses found to be promising in the efficacy study by Chai-Coetzer and colleagues can be tested in the real-world setting in a comparative effectiveness trial before such data are used to influence public health policy. This is because successful efficacy studies do not necessarily translate into similar outcomes in effectiveness trials because of issues related to reach, adoption, implementation, and maintenance of such educational interventions directed at providers.22,23 Additionally, we cannot exclude the fact that differences in the US and Australian health care systems may have contributed to the observed differences.9
Accreditation of health service systems is widely considered to be a driver of quality.24 However, the effect of such accreditation on healthcare quality is stated to be uncertain and warranting more study.25 Our study is highly responsive to such a call. Physician certification in a specialty is also felt to be result in better health outcomes. For example, physician certification in cardiology has been associated with better metrics, such as reduced hospital readmission and better health-related quality of life in disease management of heart failure.26 Our current report adds to the body of literature that emphasizes the favorable effect of physician certification and training on patient-centered outcomes in OSA.7,8,27–29
Health promotion research in individuals with chronic disease—such as OSA—requires sufficient education to be imparted to patients to help improve self-efficacy, risk perception, and treatment adherence.12,13,30 Such educational interventions directed at patients may have played a role in previous findings of better PAP adherence in OSA patients managed by specialists.7,8 Specifically, in patients with OSA being treated by PAP therapy, Weaver and colleagues demonstrated that three major cognitive factors play a role in adherence to PAP therapy—the patient's perception of health risk associated with OSA, the patient's expectations of outcomes, and the patient's perceived ability to use the PAP device.13 All three of these factors can be favorably influenced by interventions that can deliver adequate patient education.31,32 In our previous study, patient education leading to better patient perception of risk due to OSA was associated with better PAP adherence.7 In our current study, better education delivered by certified physicians was associated with improved objective measure of PAP adherence. This is in agreement with other investigations showing the beneficial effect of intensive education on adherence to PAP therapy.33
Patient satisfaction was associated with greater education received from physician, greater risk perception of OSA, and physician certification status, and inversely related to delays in undergoing PSG. These findings are consistent with other reports that identify access to care and physician communication as important determinants of patient satisfaction.7,34 In light of this information, the sleep community and health care systems need to be mindful of their wait times (Figure 2). Contrary to our previous report, patient satisfaction ratings of sleep centers were not different between accredited and non-accredited facilities. We are unable to explain the lack of such a difference, although it is possible that patients attribute their satisfaction with health care delivery to physicians rather than systems. Alternatively, our study was probably not powered to detect such a difference in satisfaction ratings. For the same reason, we believe that we did not notice differences in resolution of symptoms. Power analysis for a sample size required to detect resolution of sleepiness may be much larger in studies of OSA that have an active control (PAP therapy) arm.35 Unlike our previous study, nasal congestion and therapy for nasal congestion was not associated with PAP adherence. The reasons for such lack of effect are unclear.
One possible limitation to this study is that lack of blinding among the centers and physicians could have resulted in a change in practice. However, accredited and non-accredited centers were equally aware that this study was being performed. If practice was favorably altered, it would have either non-differentially altered the results (both groups changing equally) or biased the results towards the null (the accredited centers changing less because their practices were already favorable, thus narrowing the difference). Thus, we do not believe that our results were altered by the lack of blinding in the study.
In conclusion, we have demonstrated under real-world conditions that AASM sleep center accreditation and Sleep Medicine board certification are important determinants of patient-centered quality metrics such as adherence to PAP therapy, patient satisfaction, patient education, and timeliness of care delivery. These results suggest that health policy decisions should be directed toward care pathways involving accredited facilities and board-certified physicians.36
This study was funded by the American Sleep Medicine Foundation (ASMF). The funding institution had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript. Peer review of the grant application was through an independent process overseen by the ASMF. Dr. Parthasarathy received funding from HL095748 during the writing of this manuscript. He has also received research support and honorarium from Philips Respironics. Dr. Quan has received consulting fees from Saatchi and Saatchi to develop a sleep screening questionnaire. He is the Editor in Chief of Journal of Clinical Sleep Medicine. Dr. Subramanian has indicated no financial conflicts of interest.
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text:
I'm officially old. Intramural sports at Ohio State have always been my forte, until I realized, I'm old.
The business school students are playing in three different intramural football leagues this year: Competitive, Coed, and Casual. With reading assignments piling up on me, applications due, boot camps, networking events, group meetings, and the search for a summer internship, I decided the Casual League was a better fit for my tight schedule. I thought, "Intramural football- casual league, no problem!" I must have forgotten I am not a 19 year-old college kid with nothing to do but hit the gym.
Thursday was our first game of the season and our competition was just that, 19 year-old college kids who obviously had time to practice, run plays, and probably even watched footage from last year's intramural games. The game started out just like the Ohio State-Wisconsin game. The other team scored quickly on their first drive, got an interception on our next drive, and it was all downhill from there.
We came out strong in the beginning of the second half and scored on our first drive, but our competition was just too young, too fast, and possibly too talented for us to handle. We were down 20-some points as we approached the end of the game, grounds for a mercy. Luckily, we were able to convince the other team to let us walk in the end-zone from 15 yards out so we could keep the game going and they could get the ball one more time. This sounded like a great idea until their last drive resulted a 60-yard touchdown and two of our players getting injured.
We ended the game in good spirits, ready to get out there again next week to show the next set of young guns what we're made of. Hopefully, a few more people will come out though, having two subs is tough when six old men are trying to sub-out every other play.