text:
At first glance, Eden Dora Goldman looks like any other nine-year-old girl.
But the youngster, daughter of Doncaster Rovers training facilities manager Phil Goldman, struggles every day with the effects of a condition which nearly killed her, making tasks she used to find easy an upsetting challenge.
Eden was hours from death after being struck with encephalitis, an illness which causes inflammation of the brain.
After emergency treatment the schoolgirl pulled through – but the condition left her with a brain injury which has slowed her development.
Mum Petrina said her daughter's future prospects are uncertain and she felt 'lost and isolated' after her child's ordeal.
Now Petrina, a jewellery saleswoman, and Eden's dad Phil, have launched the Eden Dora Trust charity.
It aims to raise awareness of encephalitis, and fund research and training for adults who work with children faced with similar problems.
Its patrons including One Direction's Louis Tomlinson and cricket legend Andrew Flintof. Its first big fundraiser – a family fun day – is on Sunday
"Acquired brain injury is a hidden illness and affects every sufferer differently," said Petrina.
"She looks 'normal', but for Eden the simplest task is a huge challenge. She quickly gets extremely mentally tired. Getting through every single day is a struggle.
"She takes longer to process information, and can't ride a bike, for example. She used to love art, but has started to shy away from that. She's starting to feel more and more like a failure."
Eden developed encephalitis three ago. There are several types of the illness with different causes, but the brain inflammation can be triggered by common viruses.
Petrina said she had kept her daughter off school as she seemed 'a little bit poorly'. Later that day she suffered a seizure while the pair were lying on the settee watching a film.
She said: "It was just awful. I could see in her eyes just how terrified she was. Then she fell completely unconscious."
Eden was rushed to hospital and put on specialist medicatio, which saved her life.
She learned to walk and talk again, and it took weeks until she could return home. She still receives therapy.
Petrina said: "I have still got my child, in physical form, but she is different emotionally, physiologically, behaviourally and intellectually.
"I wasn't prepared for that – I don't suppose you ever could be."
"I knew I wanted to raise awareness to help people encountering the same situation."
The fun day is from midday until 4pm at Far Nova Livery Yard on Shorts Lane, Dore, Sheffield.
Visit www.edendoratrust.org for details.


text:
If you are a subscriber to the JCSM (including members of the AASM), please login to access the journal.
Click here to Subscribe:
$75/volume year for individuals or $140/volume year for institutions to access all current articles and archives published in JCSM.
Click Here to DOWNLOAD the article*:
$20 to access a PDF version of a specific article from the current issue of JCSM.
*Purchase of an electronic download of JCSM provides permission to access and print the issue/article for personal scholarly, research and educational use. Please note: access to the article is from the computer on which the article is purchased ONLY. Purchase of the article does not permit distribution, electronic or otherwise, of the article without the written permission of the AASM. Further, purchase does not permit the posting of article text on an online forum or website.
Subscribers can download and print full articles from current and past issues of the JCSM
Login to JCSM
Join the American Academy of Sleep Medicine and receive a subscription to JCSM with your membership
Studies of continuous positive airway pressure (CPAP) adherence in multi-ethnic samples are lacking. This study explores previously described factors associated with therapeutic CPAP use in South Florida veterans with obstructive sleep apnea-hypopnea syndrome (OSAHS).
We performed a retrospective, cross-sectional analysis of CPAP adherence comparing white, black, and Hispanic veterans returning to the Miami VA sleep clinic over a 4-month period. Participants had CPAP use download and completed questionnaires on demographics, sleepiness, insomnia, and social cognitive measures related to adherence. Linear regression modeling was used to explore the impact of measured variables and potential interactions with race-ethnicity on mean daily CPAP use.
Participants (N = 248) were 94% male with mean age of 59 ± 11 years and included 95 blacks (38%), 91 whites (37%), and 62 Hispanic (25%) veterans. Blacks had less mean daily CPAP use than whites (-1.6 h, p < 0.001) and Hispanics (-1.3 h, p < 0.01). Blacks reported worse sleep onset insomnia symptoms compared to whites. In the final multivariable regression model, black race-ethnicity (p < 0.01), insomnia symptoms (p < 0.001), and self-efficacy (p < 0.001) were significantly associated with mean daily CPAP use. In addition, the black race by age interaction term showed a trend towards significance (p = 0.10).
In agreement with recent studies, we found that mean daily CPAP use in blacks was 1 hour less than whites after adjusting for covariates. No CPAP adherence differences were noted between whites and Hispanics. Further investigations exploring sociocultural barriers to regular CPAP use in minority individuals with OSAHS are needed.
Wallace DM; Shafazand S; Aloia MS; Wohlgemuth WK. The association of age, insomnia, and self-efficacy with continuous positive airway pressure adherence in black, white, and Hispanic US veterans. J Clin Sleep Med 2013;9(9):885-895.
Obstructive sleep apnea-hypopnea syndrome (OSAHS) may affect up to 2% of women and 4% of men in the US population.1 It is associated with lower quality of life, greater healthcare utilization, neurobehavioral deficits, and increased risk of hypertension, cardiovascular events, and all-cause mortality.1–4 Continuous positive airway pressure (CPAP), the first-line treatment for moderate to severe OSAHS, completely or partially reverses many of these deleterious consequences when used consistently.5 However, despite its efficacy, empirical studies suggest that rates for regular CPAP use (≥ 4 h daily) range from 30% to 60%.6
Studies in predominantly white OSAHS populations have identified demographic, polysomnographic, social, and psychological factors affecting CPAP adherence.7 For example, age, body mass index (BMI), daytime sleepiness, OSAHS severity, CPAP pressure, optimal CPAP titration, outcome expectancies associated with CPAP use, and perceived confidence in one's ability to use CPAP (self-efficacy) have all been associated with CPAP adherence.6–9 Although race-ethnicity and cultural influences have been found to be important in other health behaviors, their role in CPAP adherence have been relatively understudied. The most well-characterized race-ethnic CPAP differences have been those between black and white individuals with OSAHS. Five recent American studies (2 prospective and 3 cross-sectional) found that blacks use CPAP at least one hour less than whites. The etiology for this disparity in treatment adherence is unclear.8,10–13 There are fewer data about CPAP use in Hispanic individuals, the largest ethnic minority group in the US.14
Current Knowledge/Study Rationale: Although CPAP adherence differences between blacks and whites have been studied, few studies have examined CPAP adherence of US Hispanics or the influence of race-ethnicity on predictor variables for CPAP use. This study describes the influence of demographics, disease severity, sleepiness, insomnia, social cognitive measures, and the interaction of race-ethnicity with these variables on CPAP adherence in a South Florida veteran sleep clinic sample.
Study Impact: Our study adds to the growing awareness of the importance of insomnia symptoms and self-efficacy in CPAP use regardless of race-ethnicity. We found an interaction of black race with age and CPAP adherence, suggesting that generational effects may be considered when developing programs to enhance CPAP adherence in blacks.
Although there are many potential sources of race-ethnic differences in CPAP adherence, we focused on demographic/ anthropometric characteristics, OSAHS severity, CPAP treatment factors (e.g., pressure, duration of CPAP ownership), and self-reported symptoms and thoughts about OSAHS. All of the above have been shown to impact CPAP adherence.6,7 Some American studies have found that blacks have worse OSAHS severity and greater body mass index (BMI) than whites, factors thought to influence CPAP adherence.11,15 American studies in community and sleep clinic samples have shown that OSAHS symptoms, including daytime sleepiness and coexisting insomnia symptoms may vary by race-ethnicity.14,16–18 In the Home-PAP study, Billings and colleagues found that sleep onset insomnia complaints were significantly more common in blacks than whites/Hispanics.19 This study also reported that participants with prolonged subjective sleep onset latency (> 30 min) at baseline used CPAP 70 minutes less per night at 3 months than participants with shorter sleep onset latency after adjusting for apnea-hypopnea index (AHI) and study arm.19 Similarly, our prospective data in US Hispanic veterans has shown that greater baseline insomnia symptoms predict poorer future CPAP use.14 Although social cognitive factors like self-efficacy and outcome expectancies have been shown to be independent predictors of future CPAP use, to our knowledge, no American study has specifically examined potential race-ethnic differences in these measures.6,7 As black and Hispanic individuals comprise approximately 20% of the veteran population, identifying therapeutic targets for enhancing CPAP use in these groups is an important first step in improving adherence.20 Our study aims were (1) to examine previously established variables (demographics, disease-severity, daytime sleepiness, insomnia symptoms, social cognition) associated with CPAP adherence in a culturally diverse sample, and (2) to explore race-ethnic variation in these established factors associated with regular CPAP use in South Florida veterans with OSAHS.
We performed a retrospective, cross-sectional analysis of adult white, black, and Hispanic veterans with OSAHS who attended the Miami VA Healthcare System (VAHS) Sleep Clinic from July 2011 to October 2011 for a scheduled CPAP adherence visit. Inclusion criteria included: (1) OSAHS diagnosis and CPAP prescription at the Miami VAHS within the last 5 years, (2) completion of study questionnaires, and (3) possession of CPAP ≥ 7 days. Veterans were excluded if they (1) were unable to read or comprehend English, (2) had previous surgery for OSAHS, or (3) were prescribed supplemental oxygen.
As part of their routine adherence visit to the Miami VAHS, veterans with OSAHS treated with CPAP complete questionnaires about demographics, medical history, and residual sleep symptoms. Race-ethnic group was determined by self-report (non-Hispanic white, non-Hispanic black, Hispanic/Latino, or other). By this method of categorizing participants, individuals with mixed race-ethnicity (i.e., black Hispanics, n = 2) were included in the Hispanic group. Participants were asked to complete validated questionnaires to determine subjective daytime sleepiness, insomnia severity, and social cognitive factors associated with OSAHS and CPAP treatment (described in section below). Anthropometric measures (height and weight) were recorded on the day of their clinic visit and used to calculate the BMI. Questionnaires were completed in English as all veterans were fluent English speakers. Objective CPAP adherence was verified as described below. The Miami VA Healthcare System Institutional Review Board approved the protocol.
Demographic questionnaires assessed participant age on the day of clinical visit, gender, medical history, marital status (married or partnered vs single or widowed), and highest educational attainment (high school graduate or lower, some college, or college graduate or higher). Medical history, comorbidities, and medications were obtained from questionnaires and review of medical records. Weighted medical comorbidities were calculated using the Charlson Comorbidity Index (CCI).21
Subjective daytime sleepiness was determined using the Epworth Sleepiness Scale (ESS), with 8 items rated on a scale of 0-3, with higher scores indicating a greater propensity to fall asleep in different situations.22 An ESS score > 10/24 defined excessive daytime sleepiness.22,23
Participants completed the insomnia severity index (ISI), a 7-item instrument measuring the individual's perception of his or her insomnia. The total scores range from 0 to 28, with higher scores indicating greater insomnia severity. Its internal consistency, concurrent validity, and sensitivity to clinical improvements are well established.24 In this study, insomnia was defined as a global ISI score ≥ 15 corresponding to a level of at least "moderate clinical insomnia." We explored insomnia complaint subtype (i.e., onset, maintenance, premature awakenings) by comparing the means of the first 3 items of the ISI among the race-ethnic groups.
Social cognitive factors associated with treatment were assessed with the Self-Efficacy Measure for Sleep Apnea (SEMSA). The SEMSA is a 26-item questionnaire assessing CPAP adherence-related cognitions based on principles of social cognitive theory.25 The instrument is divided into 3 subscales that measure risk perception of OSA (e.g., cardiovascular risk), outcome expectancies of CPAP use (e.g., improved alertness), and treatment perceived self-efficacy (the individual's confidence in using CPAP treatment despite challenges). Items are rated from 1 to 4 on a 4-point Likert scale. Higher scores indicate greater risk perception, higher outcome expectancies with treatment, and greater perceived self-efficacy, respectively. Social cognitive measures after using CPAP treatment have been previously shown to be independent predictors of future CPAP adherence.6,7
All veterans completed diagnostic and titration PSGs performed at the Miami VAHS. Attended in-lab PSGs were performed using EMBLA N7000 hardware and REMLOGIC version 1.1 software. Portable PSGs were performed with Embletta x100 portable recording units (Embla, Thorton, CO). We conducted diagnostic in-lab and portable PSG and manual titration PSGs in accordance with standards established by AASM.26–28 A split-night PSG was performed if ≥ 40 obstructive respiratory events were observed in the first 2 h of recorded sleep. All individuals completed either (1) an in-lab diagnostic PSG followed by a manual titration PSG (n = 84), (2) an unattended diagnostic portable PSG followed by a manual titration PSG (n = 17), or (3) an in-lab split-night PSG (n = 147). Scoring was performed manually by a certified sleep technologist, using 30-sec epochs and standardized scoring techniques.27 Hypopnea scoring followed the recommended definition (≥ 30% reduction in nasal pressure relative to baseline associated with ≥ 4% oxygen desaturation). The AHI was defined as the number of apneas and hypopneas per hour of sleep. OSAHS diagnosis was made per ICSD-2 criteria.29 Polysomnography variables of interest (diagnostic and titration study type, diagnostic AHI) were extracted from the medical record.
All veterans accepting CPAP treatment undergo a standardized 30-min mask-fitting and equipment educational session by our sleep-certified respiratory technologist at the time of CPAP distribution. They were also provided with printed information about OSA, its medical consequences, and CPAP troubleshooting techniques. After split-night or in-lab titration PSG, patients received CPAP units (Remstar M series with C-flex and heated humidifier, Philips-Respironics, Murrysville, PA) fixed at the prescribed pressure obtained from the titration PSG and distributed by our laboratory staff. As a standard procedure, CPAP units were set to a C-flex setting of 3 cm H2O. All devices contained software (Philips-Respironics Encore Pro 2) that measured and recorded CPAP mask-on time onto a microchip within a secure digital memory card.
After CPAP distribution, veterans were scheduled for standard clinical follow up for CPAP adherence. These visits occurred at varying intervals, but usually after 3-6 months of use and then annually. Individuals were encouraged to return to our sleep center earlier if they encountered ongoing difficulties. The sample included recently diagnosed individuals having their first CPAP adherence download as well as those who were long-term CPAP users who may have had prior downloads. Adherence measures included all days since initial CPAP distribution (mean of 512 ± 484 days; range: 7-1,818 days). On the day of the clinical visit, the following variables were collected from CPAP SD memory cards: prescribed CPAP pressure, days since CPAP distribution (duration of ownership), % of days used, % of days used > 4 h, mean daily use, and residual AHI.
Demographic and clinical characteristics, CPAP adherence variables, and questionnaire responses were compared between whites, blacks and Hispanics. Data are reported as means and SDs for continuous variables. Categorical data are presented as frequencies (%). Categorical and continuous data were compared among race-ethnic groups using χ2 or ANOVA, respectively. Post hoc pairwise comparisons employed Tukey test. As the duration of CPAP ownership varied widely among our participants (7-1,818 days), duration subgroup comparisons were performed to examine differences in the predictors and adherence. Mean daily hours of CPAP use was used as the primary outcome adherence measure. The assumptions for use of parametric inferential statistics were met for all variables.
Linear regression modeling was used to explore the association of predictor variables with CPAP adherence (mean daily hours). Hispanic and black race-ethnicity was analyzed referent to white race-ethnicity. Variables selected to predict CPAP adherence were chosen based on previous research (age, BMI, marital status, educational level, AHI, CPAP pressure, ESS, insomnia symptoms, outcome expectancies, and self-efficacy).6–9,23 Separate linear regression models were performed assessing 2 domains: (1) demographic/anthropometric variables (race-ethnicity, age, educational level, marital status, and BMI), (2) disease severity, CPAP treatment factors (AHI, CPAP pressure, duration of CPAP ownership), and sleep-related questionnaires responses (ESS, insomnia symptoms measured by the ISI, and SEMSA outcome expectations and perceived self-efficacy scores). In an attempt to control across domains, a final regression model was also tested, which included variables significantly associated with mean daily CPAP use in Models 1 and 2.
For Models 1 and 2, regression analysis was performed in 2 steps: (1) all variables in each domain were entered simultaneously testing for main effects, (2) the product of race-ethnicity and each variable in the domain was entered separately to test for interaction. These interaction terms were of primary interest to determine if race-ethnicity moderated the relationship of the predictors with CPAP adherence. For example, does insomnia impact CPAP adherence differentially in blacks than whites? Continuous interaction variables were mean centered. Each interaction term was added separately and retained in each regression model only if found to be significantly associated with CPAP adherence.
Additional interaction terms were entered into Model 2 and the final model. Because of the possibility of confounding of self-efficacy and insomnia symptoms with duration of CPAP ownership, interaction terms of CPAP ownerships with these variables were also included in these models.
For all 3 models, multicollinearity among predictors was examined by scrutinizing their Pearson correlations, variance inflation factors, eigenvalues, and condition indexes. For all analyses, p < 0.05 was defined as statistically significant. Statistical analyses were performed with SPSS Statistics 20.0 (SPSS, Chicago, IL).
Two hundred forty-eight veterans (94% male, with a mean age of 59 ± 11 years) fulfilled inclusion criteria (Table 1). Forty-six veterans were excluded (36 for incomplete questionnaires, 3 for prior OSAHS surgery, 7 for using supplemental oxygen). Ninety-five (38%) participants self-reported as black, 91 participants (37%) as white, and 62 participants (25%) as Hispanic/Latino. Five veterans (3 Asian, 2 Pacific Islander) were of "Other" race-ethnicity and were also excluded from analysis. Sixty percent of the participants were married or partnered, and most (71%) had some college education or greater. Seventy-seven percent of the sample had hypertension, 35% had diabetes, 17% had heart disease, 51% reported depression, and 28% posttraumatic stress disorder diagnosis (Table 1).
Demographic and clinical characteristics by race-ethnicity
(more ...)
Hispanics were significantly younger than whites but not different in age when compared to blacks. Hypertension diagnosis and "single or widowed" status was significantly more common among blacks than Hispanics, but not different when compared to whites. Blacks reported lower levels of education compared to both other groups. There were no significant group differences in gender distribution, mean BMI or mean Charlson comorbidity index (Table 1).
Participants had a mean AHI of 40 ± 30 events/h of sleep and were prescribed a mean CPAP pressure of 9.8 ± 2.8 cm H2O (Table 2). There were no significant race-ethnic differences in OSAHS severity, mean AHI, prescribed CPAP pressure, or CPAP residual AHI at clinical follow-up. Averaged across all participants, CPAP had been distributed 512 ± 484 days prior to their adherence visit. The entire cohort used CPAP on 58% ± 34% of the nights, with mean daily use of 3.2 ± 2.8 hours. Overall, about one-third of participants had mean daily use ≥ 4 hours.
Comparisons of polysomnography and CPAP adherence by race-ethnicity
The duration of CPAP ownership was significantly shorter in blacks than whites, but not different when compared to Hispanics (Table 2). Blacks used CPAP on significantly fewer days and used CPAP over 1 hour less daily than whites and Hispanics. Similarly, blacks had a significantly lower proportion of participants with mean CPAP use ≥ 4 h daily than whites and Hispanics. No CPAP adherence differences were noted between whites and Hispanics.
To examine the relationship between treatment duration and variables of interest, subgroups of duration of CPAP ownership (i.e., < 6 months, 6-12 months, > 12 months) were compared (Table 3). Seventy-five, 63, and 110 participants had been distributed CPAP < 6 months, 6-12 months, and > 12 months prior to study visit, respectively. There were no race-ethnic frequency differences among the CPAP ownership duration categories (Table 3). This is in contrast to the significant race-ethnic finding above which used continuous mean CPAP ownership duration (Table 2). This discrepancy may be due categorizing the continuous treatment duration variable as well as using a nonparametric statistic. Also, veterans using CPAP > 2 years were significantly less likely to be black than non-black (18% vs 30%, p = 0.04).
Comparisons of CPAP adherence by duration of CPAP ownership
There were no differences among the CPAP ownership duration subgroups in prescribed CPAP pressure, percentage of days used, or mean daily hours of usage. However, veterans who had owned CPAP for > 12 months had a significantly higher proportion of mean daily CPAP use > 4 h compared to veterans who received CPAP < 6 months and 6-12 months prior to study visit (40% vs 28% vs 22%, p = 0.04). Based on these findings, the interaction of CPAP ownership duration with predictor variables (i.e., insomnia, self-efficacy) were entered into the linear models.
Forty-one percent of all participants met the cutoff for significant subjective daytime sleepiness at the adherence clinic visit (Table 4). There were no significant race-ethnic differences in mean ESS or proportion of participants reporting daytime sleepiness. Forty-five percent of participants reported insomnia symptoms (ISI ≥ 15). There were no race-ethnic differences in mean ISI scores. However, blacks had a significantly higher mean ISI item for sleep onset insomnia symptoms than whites but not significantly different from Hispanics. There were no significant differences in the mean ISI items for sleep maintenance insomnia or premature awakening complaints among the race-ethnic groups. Furthermore, there were no race-ethnic differences in SEMSA risk perception, outcome expectations, or perceived self-efficacy scores.
Comparisons of questionnaire responses by race-ethnicity
Linear regression analyses were performed to identify variables that were significantly related to mean daily CPAP use. The reported models used (1) previously described variables associated with regular CPAP use, and (2) significant race-ethnicity interactions terms.6–8,23 There was no significant evidence of multicollinearity between predictors in any of the models. The first model included demographic and anthropometric variables (race-ethnicity, age, BMI, education level, marital status, and race-ethnicity by age). The overall model for demographic/ anthropometric characteristics explained 14.1% of the observed variance (r2 = 0.141, adj. r2 = 0.112, p < 0.001; Table 5). In this model, black race, increased age, higher BMI, and race-ethnicity by age interaction were associated (p < 0.05) with mean daily CPAP use. Figure 1A shows a negative age-adherence relationship for blacks but positive for whites and Hispanics. No other interactions of race-ethnicity with other variables were found to be significant in Model 1.
Regression analysis of measures associated with mean daily CPAP use
Regression lines for predictors and CPAP adherence among whites (dotted), blacks (black) and Hispanics (gray) in Models 1-2. Each regression line is controlled for the additional variables in each individual model (Table 5). Panel A shows a significant race-ethnicity-age interaction while Panels B-D show no race-ethnicity-predictor interaction. All panels show significantly less CPAP use by blacks. CPAP, continuous positive airway pressure.
Regression lines for predictors and CPAP adherenceRegression lines for predictors and CPAP adherence among whites (dotted), blacks (black) and Hispanics (gray) in Models 1-2. Each regression line is controlled for the additional variables in each individual model (Table 5). Panel A shows a significant race-ethnicity-age interaction while Panels B-D show...
The second model included race-ethnicity, OSAHS severity (PSG AHI), CPAP adherence download variables (CPAP pressure and duration of CPAP ownership), and sleep-related questionnaire responses (ESS, insomnia severity index, and SEMSA outcome expectancies and perceived self-efficacy scores). Because of subgroup differences in adherence (Table 3), interaction terms were also entered to examine if the relationship between insomnia symptoms and self-efficacy and adherence depended on CPAP ownership duration. The overall model for disease severity/CPAP download variables, sleep-related questionnaires, and CPAP ownership interaction terms explained 29.2% of the observed variance (r2 = 0.292, adj. r2 = 0.254, p < 0.001; Table 5). In this model, black race, greater insomnia symptoms, and higher self-efficacy were associated (p < 0.05) with mean daily CPAP use. No other interactions of race-ethnicity with other variables were found to be significant in Model 2. Figure 1B-D shows a similar relationship between CPAP pressure, ISI, and SEMSA perceived self-efficacy score, and predicted mean daily CPAP use for the 3 race-ethnic groups, respectively.
In the final regression model (Table 6), we included race-ethnicity in addition to the statistically significant variables (p < 0.05) from the 2 models (age, BMI, insomnia severity index, SEMSA perceived self-efficacy score, and race-ethnicity by age interaction). Educational level was also included as this showed a trend towards significance in Model 1 (Table 5) and has been associated with CPAP adherence.23 In addition, we included CPAP ownership duration, CPAP ownership by self-efficacy, and CPAP ownership by insomnia symptoms interaction terms to control for potential confounding effects of treatment duration. The final model was significant and explained 31.4% of the adherence variance at clinical follow-up (r2 = 0.314, adj. r2 = 0.274, p < 0.001; Table 6). In the final model, the black race by age interaction term showed a trend towards significance (p = 0.10).
Final regression analysis of measures associated with mean daily CPAP use
Black race alone accounted for 5.8% of the variance in the final model. In all 3 models, blacks used CPAP about 1 h less than whites after adjusting for the listed variables (Tables 5, 6). We repeated the linear regression models employing 2 other alternative CPAP adherence outcomes (% of days used and % of days using > 4 h) with similar findings.
As stated previously, our goals were two-fold: (1) to examine previously described variables associated with CPAP adherence in a culturally diverse OSAHS sample of American veterans in a sleep clinic sample, and (2) to determine if race-ethnicity moderated predictors of CPAP adherence in South Florida veterans with OSAHS. Limited data exist for direct comparisons among these three race-ethnic groups.12 Our study findings replicate those of other investigations which have noted about a 1-h adjusted difference in mean daily CPAP use between blacks and whites.8,10–12 Similar to a recent multi-city prospective study in the US, no difference in CPAP adherence was noted between whites and Hispanics.12 Overall, our sample of South Florida veterans returning for objective CPAP adherence follow-up had suboptimal CPAP adherence with mean daily use of only 3.2 ± 2.8 hours. These CPAP adherence rates are disappoint-ingly low but within the range of reported American OSAHS cohorts.7,8,10,14 In contrast with most OSAHS populations reported in the literature, the majority of our OSAHS cohort was non-white.7 Two American studies (one prospective, one retrospective) with predominantly black samples had overall CPAP adherence rates similar to ours (3.4 ± 2.7 h, 3.9 ± 2.6 h).8,13 In addition, our CPAP adherence was collected after longer treatment duration (mean of 512 ± 484 days of CPAP use) than most studies. Thus, our findings consist of predictors of long-term (> 3 months) CPAP use in a diverse veteran sample.
Similar to other investigations, we found three main effects for black race-ethnicity, insomnia severity index, and self-efficacy and CPAP adherence in South Florida veterans.8,11,12,14 First, black race was associated with worse CPAP adherence. Second, a higher insomnia severity index score was associated with worse daily CPAP use; and third, greater self-efficacy was associated with greater daily CPAP adherence. Additionally, we found a significant interaction between black race, age, and CPAP adherence in one of our models. However, we did not find interactions between race-ethnicity and insomnia symptoms or race-ethnicity and self-efficacy and CPAP adherence. This indicates that the relationship between insomnia and CPAP adherence and self-efficacy and CPAP adherence was similar across race-ethnic groups. In the final model with covariates, the CPAP adherence difference between blacks and whites was attenuated (1.6 h to 1.0 h). This smaller difference indicates that insomnia symptoms and self-efficacy partially explained the difference in adherence between blacks and whites. In our final model, the combination of race-ethnicity, age, BMI, duration of CPAP ownership, ISI score, SEMSA self-efficacy, and race-ethnicity-age interaction explained 31% of the variance in mean daily CPAP use at clinical follow-up. Given the wide range of CPAP ownership duration, our models were adjusted to account for potential confounding of treatment duration with insomnia symptoms and self-efficacy.
As we have shown previously, the South Florida Hispanic veteran population is highly acculturated, given the requirements necessary to enlist for military service (i.e., minimum high school education or equivalent, English proficiency).14,30 Thus, from a cultural standpoint, it may not be surprising that their CPAP adherence is similar to that of white veterans. Whether unacculturated US Hispanic immigrants have different CPAP adherence rates remains an unanswered question. Our South Florida veteran population was predominantly male, had a high prevalence of psychiatric comorbidities, and had low-cost access to medical care. Therefore, our veteran sample is not representative of the US population with OSAHS, and these characteristics limit the generalization of our findings.
In all of our regression models, black race was independently associated with 1 hour less mean daily CPAP use than whites despite adjusting for a number of factors (Tables 5, 6). In addition, blacks attempted to use CPAP on fewer days than whites and Hispanics (Table 2). Our findings are consistent with those of previous retrospective and recent prospective studies. In a retrospective analysis at the Durham VA (n = 501), Means and colleagues found that black veterans had a significantly lower mean daily use (3.90 ± 1.94 vs 4.91 ± 2.07 h) and used CPAP on significantly fewer nights (54% vs 68%) after 3 months of treatment compared to white veterans.11 In another retrospective analysis of 100 consecutive participants (39% black) presenting to a Detroit sleep center, blacks were found to have a significantly lower CPAP daily use after 1 month than whites (4.4 ± 1.5 vs 5.5 ± 2.2 h), despite similarities in other demographic and polysomnographic variables.10 In the Home PAP study, a randomized controlled trial in five US cities comparing home diagnosis of OSAHS and treatment to attended in-lab care, Billings and colleagues prospectively examined the predictive value of race, education, and SES on CPAP adherence in participants with moderate to severe OSAHS and excessive daytime sleepiness.12 After 1 month, blacks had a significantly lower mean daily CPAP use (about 1.5 h less) than whites after adjusting for SES, AHI, and study arm. Black race accounted for 6% to 12% of the observed CPAP use variance at 1 and 3 months. In another prospective study with 91 participants (57% black), Ye and colleagues reported that black race was the strongest predictor of 7-day CPAP adherence, independently explaining 12.9% of the variability in the mean daily use.8 In our study, black race alone accounted for 5.8% of the variance of mean daily CPAP use.
We found a negative relationship between insomnia symptoms and CPAP adherence regardless of race-ethnicity. We did not observe any interactions between race-ethnicity, ISI scores, or insomnia complaints and CPAP use. The negative relationship of insomnia symptoms on CPAP use was not influenced by race-ethnicity. That is, the influence of insomnia symptoms was equivalent across all race-ethnic groups. In our study, the rate of coexisting insomnia symptoms in the race-ethnic groups are similar to reported estimates (39% to 58%) in sleep clinic cohorts with untreated OSAHS.16,31 In agreement with the Home PAP study, we found that sleep onset insomnia complaints were greater in blacks than whites.19 In our final linear regression model, a 10-point increase in the ISI at follow-up was associated with approximately 1 hour less of CPAP use (Table 6). In our study, insomnia symptoms were assessed after CPAP initiation. This is important in that it reflects the level of insomnia that may directly affect adherence. Insomnia present prior to CPAP initiation may improve or worsen with CPAP, making assessment of insomnia a potential therapeutic target to enhance CPAP adherence. Our findings provide additional data underscoring the importance of assessing insomnia symptoms in all CPAP users.14,31
Similar to insomnia symptoms, the influence of social cognitive variables on CPAP adherence was equivalent across the race-ethnic groups (Table 4, Figure 1D). Our data were in agreement with previous investigations showing that individuals with higher self-efficacy persevere with regular CPAP treatment.6,7 Participants completed questionnaires after varying lengths of CPAP treatment; therefore, after experiencing CPAP, they were able to accurately report cognitive perceptions of OSAHS and CPAP. Surprisingly, blacks did not have lower SEMSA self-efficacy scores than whites/Hispanics, despite their poorer overall adherence. Even in individuals who have been suboptimally adherent with CPAP, assessment of self-efficacy may identify individuals amenable to motivational enhancement for CPAP therapy, an intervention based on the methods of motivational interviewing.32 Other psychological variables that have been associated with CPAP adherence (locus of control, coping strategy styles, decisional balance) await exploration in these race-ethnic groups.6,7
We found a significant interaction between black race, age, and CPAP adherence in Model 1; however, this finding was attenuated in the final model (Figure 1A; Table 6, p = 0.10). In Model 1, increasing age was associated with greater mean daily CPAP use in white and Hispanics but less CPAP use in blacks. This attenuation was likely due to the addition of insomnia and self-efficacy, suggesting its shared variance between age and these variables. This "generational effect" may be mediated by varying levels of trust in the healthcare system, perceived discrimination, or other factors.33,34 Further research on possible generational issues in blacks with OSAHS could help to clarify its contributing factors.
Adherence to CPAP treatment is a complex behavior impacted by multiple factors.6,7,9 Our model explained about 31% of the variance in mean daily CPAP use. Although insomnia and self-efficacy have a strong association with CPAP adherence and the difference in CPAP use between blacks and whites/Hispanics is attenuated by adjusting for these variables, a 1-hour difference remains to be explained. Thus, other factors contribute to the CPAP adherence differences observed between blacks and whites/Hispanics. For example, in the Home-PAP study, reduced sleep duration has been recently shown to partially mediate the worse CPAP adherence in blacks compared to whites/ Hispanics.19 Also, recent evidence suggests that the home sleeping environments of blacks may be more disruptive than those of whites, which may also contribute to irregular CPAP use.35 Furthermore, inadequate sleep may not be viewed as a serious health issue in the black community, a belief which may also interfere with regular CPAP use.33 In the 2010 National Sleep Foundation Sleep in America Poll, fewer blacks (76%) than whites (83%) recognized that short or poor sleep was related to worse overall health.36 Further research is needed to identify other cultural beliefs or healthcare system factors which may be detrimental to CPAP use among blacks.
Our study has several noteworthy limitations. One limitation is absence of comprehensive assessments of socioeconomic status, which has been associated to CPAP adherence in diverse race-ethnic samples.12,23,37 Low SES individuals have been shown to have worse CPAP adherence.12,23,37 In our sample, blacks were found to have a significantly lower educational level than Hispanics and whites, but educational level was not associated with CPAP adherence in our final model. Another limitation is the cross-sectional design which precludes determining if the race-ethnic differences observed (i.e., sleep onset insomnia complaints) were present prior to CPAP initiation or caused by the treatment. Additionally, we used a convenience sample of patient returning to our CPAP adherence clinic, so we do not have data on patients who abandoned treatment altogether. However, the mean daily CPAP adherence for Hispanic veterans in this study is similar to that we observed in a recent 30-day prospective study (3.5 ± 2.9 vs 3.6 ± 2.0 h).14 Because of the possibility that CPAP non-users did not return for clinical follow-up, the sample may be biased towards better adherence in those with longer CPAP ownership (Table 3). We did not measure other variables that have been associated with CPAP adherence, including neighborhood factors, sleep duration, or detailed measures of social support.7,12,37 Finally, limited power may have hindered our ability to detect interactions of race-ethnicity with variables of interest.
Given the vast health consequences OSAHS, understanding barriers to regular CPAP use in race-ethnic groups is of economic and public health importance.4,38 The strong association between insomnia symptoms, self-efficacy, and adherence suggests that these behavioral factors may represent therapeutic targets. For example, cognitive behavioral therapy for comorbid insomnia and motivational enhancement to improve self-efficacy for CPAP therapy could be used in individuals with insomnia symptoms or low self-efficacy.32,39 Our finding of a significant interaction of black race-ethnicity with age in CPAP adherence merits further investigation. Other explanatory etiologies of the disparity in CPAP adherence between blacks and whites/Hispanics await characterization. Future studies should examine the influence of sociocultural barriers in minority veterans with OSAHS to improve CPAP use and help narrow existing health disparities within the VAHS.
This was not an industry supported study. Dr. Aloia is a paid employee and stock holder of Philips-Respironics, Inc. The other authors have indicated no financial conflicts of interest.
The authors thank Dr. Sandeep Dayanand for database management and the respiratory technologists (Daniel Mora, Rafael Sepulveda, Herblay Alonso, Luis Jinete) at the Miami VA Healthcare System for their contributions to this study. The work was completed at the Bruce W. Carter Department of Veterans Affairs Medical Center, Miami, FL.
Young T, author. Rationale, design, and findings from the Wisconsin Sleep Cohort Study: Toward understanding the total societal burden of sleep disordered breathing. Sleep Med Clin. 2009;4:37–46. [PubMed Central][PubMed]
Wallace DM, Ramos AR, Rundek T, authors. Sleep disorders and stroke. Int J Stroke. 2012;7:231–42. [PubMed Central][PubMed]
Lal C, Strange C, Bachman D, authors. Neurocognitive impairment in obstructive sleep apnea. Chest. 2012;141:1601–10. [PubMed]
Leger D, Bayon V, Laaban JP, Philip P, authors. Impact of sleep apnea on economics. Sleep Med Rev. 2012;16:455–62. [PubMed]
Gay P, Weaver T, Loube D, Iber C, authors. Evaluation of positive airway pressure treatment for sleep related breathing disorders in adults. Sleep. 2006;29:381–401. [PubMed]
Weaver TE, Sawyer AM, authors. Adherence to continuous positive airway pressure treatment for obstructive sleep apnoea: Implications for future interventions. Indian J Med Res. 2010;131:245–58. [PubMed Central][PubMed]
Sawyer AM, Gooneratne NS, Marcus CL, Ofer D, Richards KC, Weaver TE, authors. A systematic review of CPAP adherence across age groups: Clinical and empiric insights for developing CPAP adherence interventions. Sleep Med Rev. 2011;15:343–56. [PubMed Central][PubMed]
Ye L, Pack AI, Maislin G, et al., authors. Predictors of continuous positive airway pressure use during the first week of treatment. J Sleep Res. 2012;21:419–26. [PubMed]
Stepnowsky CJ, DiNicola G, Edward C, Zamora T, authors. Meta-analysis of factors associated with CPAP adherence. Sleep. 2012;35:A173.
Budhiraja R, Parthasarathy S, Drake CL, et al., authors. Early CPAP use identifies subsequent adherence to CPAP therapy. Sleep. 2007;30:320–4. [PubMed]
Means MK, Ulmer CS, Edinger JD, authors. Ethnic differences in continuous positive airway pressure (CPAP) adherence in veterans with and without psychiatric disorders. Behav Sleep Med. 2010;8:260–73. [PubMed]
Billings ME, Auckley D, Benca R, et al., authors. Race and residential socioeconomics as predictors of CPAP adherence. Sleep. 2011;34:1653–8.
Joo MJ, Herdegen JJ, authors. Sleep apnea in an urban public hospital: Assessment of severity and treatment adherence. J Clin Sleep Med. 2007;3:285–8. [PubMed Central][PubMed]
Wallace DM, Vargas SS, Schwartz SJ, Aloia MS, Shafazand S, authors. Determinants of continuous positive airway pressure adherence in a sleep clinic cohort of South Florida Hispanic veterans. Sleep Breath. 2013;17:351–63. [PubMed]
Ruiter ME, DeCoster J, Jacobs L, Lichstein KL, authors. Sleep disorders in African Americans and Caucasian Americans: A meta-analysis. Behav Sleep Med. 2010;8:246–59. [PubMed]
Krakow B, Melendrez D, Ferreira E, et al., authors. Prevalence of insomnia symptoms in patients with sleep-disordered breathing. Chest. 2001;120:1923–9. [PubMed]
Ramos AR, Wohlgemuth WK, Dong C, et al., authors. Race-ethnic differences of sleep symptoms in an elderly multi-ethnic cohort: The Northern Manhattan Study. Neuroepidemiology. 2011;37:210–5. [PubMed Central][PubMed]
O'Connor GT, Lind BK, Lee ET, et al., authors. Variation in symptoms of sleep-disordered breathing with race and ethnicity: The Sleep Heart Health Study. Sleep. 2003;26:74–9. [PubMed]
Billings ME, Rosen CL, Wang R, et al., authors. Is the relationship between race and continuous positive airway pressure adherence mediated by sleep duration? Sleep. 2013;36:221–7. [PubMed Central][PubMed]
United States Department of Veterans Affairs. National Center for Veteran Analysis and Statistics. [cited 2012 October 8]; Available from: http://www.va.gov/vetdata/Veteran_Population.asp.
D'Hoore W, Bouckaert A, Tilquin C, authors. Practical considerations on the use of the Charlson comorbidity index with administrative data bases. J Clin Epidemiol. 1996;49:1429–33. [PubMed]
Johns MW, author. A new method for measuring daytime sleepiness: The Epworth Sleepiness Scale. Sleep. 1991;14:540–5. [PubMed]
Bakker JP, O'Keeffe KM, Neill AM, Campbell AJ, authors. Ethnic disparities in CPAP adherence in new zealand: Effects of socioeconomic status, health literacy and self-efficacy. Sleep. 2011;34:1595–603. [PubMed Central][PubMed]
Bastien CH, Vallieres A, Morin CM, authors. Validation of the insomnia severity index as an outcome measure for insomnia research. Sleep Med. 2001;2:297–307. [PubMed]
Weaver TE, Maislin G, Dinges DF, et al., authors. Self-efficacy in sleep apnea: Instrument development and patient perceptions of obstructive sleep apnea risk, treatment benefit, and volition to use continuous positive airway pressure. Sleep. 2003;26:727–32. [PubMed]
Collop NA, Anderson WM, Boehlecke B, et al., authors. Clinical guidelines for the use of unattended portable monitors in the diagnosis of obstructive sleep apnea in adult patients. Portable monitoring task force of the American Academy of Sleep Medicine. J Clin Sleep Med. 2007;3:737–47. [PubMed Central][PubMed]
Iber C, Ancoli-Israel S, Chesson A, Quan SF, authors; for the American Academy of Sleep Medicine. The AASM manual for the scoring of sleep and associated events: Rules, terminology and technical specifications. 2007. Westchester, IL: American Academy of Sleep Medicine.
Kushida CA, Chediak A, Berry RB, et al., authors. Clinical guidelines for the manual titration of positive airway pressure in patients with obstructive sleep apnea. J Clin Sleep Med. 2008;4:157–71. [PubMed Central][PubMed]
American Academy of Sleep Medicine. The International Classification of Sleep Disorders: Diagnostic and coding manual. 2005. Westchester, IL: American Academy of Sleep Medicine.
Shafazand S, Wallace DM, Vargas SS, et al., authors. Sleep disordered breathing, insomnia symptoms, and sleep quality in a clinical cohort of US Hispanics in South Florida. J Clin Sleep Med. 2012;8:507–14. [PubMed Central][PubMed]
Luyster FS, Buysse DJ, Strollo PJ Jr, authors. Comorbid insomnia and obstructive sleep apnea: Challenges for clinical practice and research. J Clin Sleep Med. 2010;6:196–204. [PubMed Central][PubMed]
Aloia MS, Arnedt JT, Riggs RL, Hecht J, Borelli B, authors. Clinical management of poor adherence to CPAP: motivational enhancement. Behav Sleep Med. 2004;2:205–22. [PubMed]
Shaw RN, Mckenzie S, Taylor T, et al., authors. Beliefs and attitudes towards OSA evaluation and treatment among blacks. Sleep. 2012;35:A152.
Adenekan B, Pandey A, Mckenzie S, Zizi F, Casimir GJ, Jean-Louis G, authors. Sleep in America: role of racial/ethnic differences. Sleep Med Rev. 2013. http://dx.doi.org/10.1016/j.smrv.2012.07.002.
Ruiter ME, Decoster J, Jacobs L, Lichstein KL, authors. Normal sleep in African-Americans and Caucasian-Americans: A meta-analysis. Sleep Med. 2011;12:209–14. [PubMed]
National Sleep Foundation. Summary of findings of 2010 Sleep in America Poll. 2010.
Platt AB, Field SH, Asch DA, et al., authors. Neighborhood of residence is associated with daily adherence to CPAP therapy. Sleep. 2009;32:799–806. [PubMed Central][PubMed]
Saha S, Freeman M, Toure J, Tippens KM, Weeks C, Ibrahim S, authors. Racial and ethnic disparities in the VA health care system: A systematic review. J Gen Intern Med. 2008;23:654–71. [PubMed Central][PubMed]
Garb LR, Bootzin R, Dawson S, et al., authors. Cognitive behavioral treatment for insomnia improves sleep efficiency and ISI in insomnia co-morbid with sleep apnea or periodic limb movements. Sleep. 2012;35:A243.

subset: commoncrawl


text:
A NEW STORY ... Downtown Palo Alto welcomed Story, a new women's and children's boutique, to 444 University Ave. at the beginning of December. Owner Joy Yoo wants shoppers to know that Story isn't your typical overpriced boutique. "Because we are on University Avenue, a lot of people think we are very expensive, but when people come in and check our prices they are usually quite surprised at how reasonable they are," Yoo said. "Even in this economy, you should still be able to buy nice clothes." Story targets the stylish professional woman, with such offerings as dress pants, blazers, sweatpants and funky, colorful tops. Most of the clothing is under $100. The store also sells jewelry from local artists on consignment. Although the only children's items available now are bejeweled denim jackets made by a Hawaiian designer, Yoo said the store will get more kids' clothes in the spring and summer. Go to shareastory.net or call 650-321-4440.
PASTIS BISTRO ON ITS WAY ... The owners/general managers of Joanie's Cafe on California Avenue in Palo Alto are opening a new French restaurant in the Joanie's old location at 447 California Ave. (Joanie's moved down the street to 405 California a few months ago.) Bernard Cartal and Max Roucoule plan to open Pastis Bistro before the new year. The French bistro was scheduled to open at the end of November, but as of Dec. 13 the restaurant's doors are still closed due to technical problems. Roucoule hopes to open for the holidays. Pastis will serve "home-cooked French cuisine," concentrating on food from the southern region of the country. Roucoule says the menu will feature an excellent coq au vin, bouillabaisse and cassoulet. Go to pastispaloalto.com or call 650-324-1355.
INSTANBUL STREET FOOD ON THE AVENUE ... Cafe Taxim, a new Turkish restaurant on University Avenue in Palo Alto, is named after a trendy area in Istanbul and is serving street food in the style of Turkey's capital. The cafe aims to differentiate itself from other area Mediterranean restaurants by offering a casual and relaxed atmosphere where diners can enjoy a gyro without the usual rush of a fast-food restaurant, employee Volkan Guler said. The menu also includes falafel wraps and kebab plates. Chef Coskun Bektas has worked at 11 restaurants since moving to California from Turkey, including San Francisco's Tuba Restaurant. He particularly recommends the Iskender plate (a marinated lamb-and-beef gyro with bread cubes in tomato sauce and yogurt), one of Istanbul's most popular dishes, followed by a cup of Turkish coffee in a handmade cup. The restaurant is decorated with modern tables and chairs, and photographs of Istanbul. Go to cafetaxim.com or call 650-330-1440.
This story contains 535 words.
Stories older than 90 days are available only to subscribing members. Please help sustain quality local journalism by becoming a subscribing member today.
If you are already a subscriber, please log in so you can continue to enjoy unlimited access to stories and archives. Subscriptions start at $5 per month and may be cancelled at any time.


text:
Pumpkin Pancakes
From Petit Appetit: Eat, Drink, and Be Merry [2]
- 1 cup whole-wheat flour
- 2 tablespoons raw turbinado sugar
- 2 teaspoons baking powder
- 1 teaspoon salt
- 1 teaspoon ground cinnamon
- ¼ teaspoon freshly grated nutmeg
- 1 1/3 cup whole organic milk
- 1 cup pumpkin puree
- 4 large cage free organic eggs, separated, at room temperature
- ½ cup organic unsalted butter, melted
- 1 tablespoon pure vanilla extract
- Vegetable oil spray
Preheat oven to 200F.
In a large mixing bowl, stir together flour, sugar, baking powder, salt, cinnamon, and nutmeg until blended.
In a medium mixing bowl, combine, milk, pumpkin, egg yolks, butter, and vanilla and beat until smooth. Pour wet mixture into dry ingredients and stir with a rubber spatula until blended.
In a medium, dry, clean mixing bowl, with clean dry beaters, beat egg whites with a mixer until stiff glossy peaks form when the beaters are lifted, about 2 minutes. Gently fold in egg whites into batter with a rubber spatula until just combined.
Spray a large nonstick griddle or frying pan with oil and heat over medium heat. Pour batter by 1/4 cupfuls into pan and cook until bubbles form on top of pancakes, 2–3 minutes. Flip each pancake and cook until golden, about 1 minute longer. Keep pancakes warm in the oven while cooking remaining batter.
Tip: For convenience refrigerate any leftover, cooked pancakes in an airtight container in the refrigerator for up to three days, or wrap cooked pancakes in waxed paper, seal in freezer bags and freeze for up to one month. These are perfect for quick snacks to take to school or the park, spread with nut butters or sandwich with egg.
*Makes 15–18 (4-inch) pancakes
- Category
- Breakfast/Brunch, Pancakes/Waffles


text:
In its heyday, horse racing had it all. It was the speed and danger sport before NASCAR came along; movie stars and gangsters rubbed glamorous elbows; and a couple sawbucks on a winning long-shot could put you on Easy Street.
As with all nostalgia, the reality could never match the legend. But there was a current of excitement and passion around horse racing back in the days of fedoras and two-toned shoes. Perhaps the popularity of racing was as simple as the fact that Americans used to grow up around horses and knew them as personalities.
(MORE: Twilight at the Track)
And they are personalities. Some are born with loads of talent, but won't do the hard work to become a champion. Some love a challenge, and won't stop working until they win. Some are playful; some are mean. Some are smart; some aren't. Such traits seared the names of great racers into the public consciousness as deeply as the names of some presidents and some billionaires: Gallant Fox, War Admiral, Citation, Seabiscuit.
The glory days endured through a golden age of racing in the 1970s, when Affirmed battled Alydar to join Seattle Slew and the incomparable Secretariat as winners of the Triple Crown. Since then, a long twilight has settled over the Sport of Kings. Attendance, wagers, purses, and new foals all are in decline. Such storied tracks as Hialeah in Florida, Bay Meadows in California, and Garden State in New Jersey have padlocked their stables and turned out the lights for good.
The causes are many. Competition for the gambling and entertainment dollar is more intense than ever. But even more damaging is the widespread culture of doping in the racing business, and the high rate of fatal breakdowns that goes with it. As these photographs make clear, amid the fading memories of glamor and excitement, the beating heart of the sport is, and always will be, the horse. Whoever wants to save racing must first care about that.
Jehad Nga is a photographer who lives in New York. LightBox previously featured Nga's Memories of Libya and his Green Book project.
David Von Drehle is an editor-at-large for TIME, where he has covered politics, breaking news and the Supreme Court since 2007. He is the author of four books, including Abraham Lincoln and America's Most Perilous Year, published in 2012, and Triangle: The Fire That Changed America.


text:
A unique northern city, Madison Heights has plenty to offer visitors, and a Madison Heights hotel room is only a few minutes away from Detroit and the surrounding areas.
There are lots of memorable restaurants in the city; stay up late and sample a slider burger at Madison Heights' famous Telway Hamburger System, open 24 hours a day––or get your pizza fix at the Hungry Howie's Pizza headquarters. There are plenty of shops and restaurants to choose from, from international to classic American to local Michigan cuisine. After lunch, head outdoors and walk the back nine at Red Oaks Golf Course. Or you can peruse the shops and boutiques at the Oakland Mall or the Somerset Collection, convenient to downtown Madison Heights accommodations.
Spend a day in nearby Detroit––stroll among the many wildlife exhibits at the Detroit Zoo, or browse the antique automobiles on display at the Henry Ford Museum. The Detroit Institute of Arts has hundreds of paintings and sculptures to see, in a wide variety of styles, and the Motown Museum is a must-see. Stop by the huge Detroit Antique Mall and search for vintage treasures on the way back to your Madison Heights hotel's room.


text:
don't know where to put this question so excuse me for placing it at the wrong forum.
My problem is that i bought zonealarm extreme security with pc-tune in it. i want to install tune-up but when i push the button in zonealarm to install it nothing happens ??
any ideas how to solve this ?


text:
Read Garden Shredder reviews and compare the price, quality and ratings of all the top models.
Garden Shredders are nowadays available in a variety of sizes, making it easier for the DIY gardener to use them, but also making it important to compare before you buy.
Are big brands necessarily offering you the best product or should you go for a smaller brand? Our honest, consumer garden shredder reviews will help you answer that question. Compare garden shredders and chippers and make an informed choice.
From 5 reviews
From 2 reviews
From 2 reviews
From 1 reviews
From 1 reviews
As rated by our community of reviewers


text:
The best part about keeping small pets is the fun! Why settle for lackluster tan crocks or boring stainless steel bowls? American Pet Crocks add excitement, style and color to your small pets' habitat.
Benefits of our crocks:
Available in four exciting colors and 3 sizes!
There are no reviews for this product.


text:
Fleming Named to Don Hansen NCAA Division II All-America Team
January 24, 2014
The college football season has been over for a couple of months and Cheyney's Isaiah Fleming is still garnering post-season accolades. Fleming was named to the 2013 Don Hansen NCAA Division II All-America Team.
As a third team selection, Fleming is one of 15 student athletes from PSAC institutions to be recognized. Fleming, only a junior, had a standout season from his middle linebacker position. A native of Wilmington, Delaware, Fleming led the Pennsylvania State Athletic Conference in tackles and ranked fourth in the nation at 12.8 tackles per contest. His 8.2 solo tackles per game places him second in the country in solo tackles.
Earlier this season, Fleming was named a Daktronics All American, a Beyond Sports Network All American as well as a PSAC East first team selection and an ECAC All Star.


text:
Video Production
Platinum Members
Testimonial from Tom Wangler, Jr., President, Confident Aire, Inc. - Gold Member
A friend advised me to join the Batavia Chamber around 6 years ago in order to increase exposure for my business. I took the advice and started attending the events. I was welcomed and encouraged by a great group of business owners. I track all of my phone calls, and over 6 months I started to notice an increase in calls and referrals related to the Chamber. By my second year I was so impressed that I got more involved so I could reach and help other businesses succeed. Today the Chamber produces steady, high quality leads and my staff takes advantage of the networking (Net-Working It!) and training opportunities on a regular basis. I have not found a better value for my business!
Contact Us
Content goes here!
Batavia Chamber of Commerce
106 W. Wilson Street
Batavia, IL 60510


text:
Free Horse: Female handler preferred
'Betty' was born with a constricted tendon and was unable to be used for racing. Many hours with a farrier corrected the problem to the extent possible. She prefers being around a woman but I can no longer give her the time and attention she needs. I believe someone with time and knowledge about how to handle horses would be able to continue breaking/training her and might want to breed her. She has lived all her life with Warren T, also available for adoption.
Horse NameYa Betta Bilmac
ColorDark Bay/Brown
Height15.2 hh
Weight650 lbs
SireMark Johnathan
DamFlicka Bilmac
LocationPoland, IN, USA
StatusFound Home


text: Yep. To be honest, the first week I switched over to being Veggie, it wasn't the meat that gave me trouble. On that front, I didn't have a single craving. The problem was the junk food. I like potato chips, pretzels, cheese popcorn, all of these salty foods that have lots of fat and carbohydrates as well, and it was damn near impossible for me to cut back on them. I still allow myself a small serving of potato chips (low salt, low fat) every day until I either completely wean myself off of them, or find a better, truly healthier alternative. The baby carrots thing, though? Totally there. I love baby carrots. They have a nice satisfying crunch while being juicy at the same time. I don't need anything with them, just a handful of baby carrots taste great. Still, it's almost insidious to see what is produced to get us eating. It started out as "give them what they want", and evolved into "give them what we entice them to want", finally becoming "just chemically force their bodies to demand our product, and then sell it to them". It's almost like a drug! Actually, that would be a drug! Remember the episode of DS9 "Rules of Acquisition", where the (female) Ferengi waiter, Pel, convinces Quark to sell sand peas that, when mixed in with food, make people want to reflexively take a drink? The same motive and principle applies here, but it's in more than just one restaurant, or in one type of food. It's spread across every type of food that has any level of processing in it whatsoever.


text:
He was born on Dec. 5, 1947, in Harkey's Valley to the late Bert and Frances Tucker. He was the youngest of eight siblings. He served active duty in the Army National Guard. He later worked as a logger, equipment operator and mechanic. Among his joys in life were hunting, trapping, fishing and mechanical tinkering.
He truly enjoyed his freedom and the fellowship of his close friends and family. He was passionate about Harkey's Valley — he was born there, he enjoyed his life there, and he died there, as so many Tuckers before him had.
He was preceded in death by his parents; one sister, Bertina O'Gwynn; three brothers, James R. Tucker, Joe Tucker and John Tucker; and a grandson, Shawn Wilson Tucker.
Survivors include one brother, Robert Ray Tucker of Amity; sisters, Ora Pearl Scott and Mary Detrick, both of Dardanelle; two sons, David Lee Tucker Jr. and wife, Rachel, of Harkey's Valley, and Charlie Tucker and wife, Ashleigh, of Dover; five grandchildren, Adrean, Caleb, Autumn, Hayden and Brandon. Other survivors include a host of nieces and nephews.
Pallbearers are Shelly Borden, Terry Tucker, David Tucker Jr, Gary Wolfe, Charlie Tucker, Charles Detrick and James O'Gwynn Jr. Honorary pallbearers are Wayne Grey, Robert Spears, Glen Hayes, Ray Wilkinson, Eddie Wilcox, Cody Hayes, James Jackson, Sicabo Christy, Bill Pitts, Don Nealy and Carl Waters.
Funeral services will be conducted at 2 p.m. today at Cornwell Chapel in Dardanelle. Burial will be in Harkey's Valley Cemetery.
In Lieu of Flowers Memorial Donations may be made to Yell County Hospice, 719 N 5th Street, Dardanelle, AR 72834.
Arrangements by Cornwell Funeral Home in Dardanelle. Online guest book and condolences at www.cornwellfuneralhomes.com.
Paid obituary


text:
This course is an advanced, in-depth study of copyright law and policy. The course will explore the boundaries of copyright protection and how copyright law relates to other intellectual property laws. Prerequisite: LAW P501 Intellectual Property Law Core, LAW E567 Survey of Intellectual Property, or LAW A522 Copyrights.
© Copyright 2015, All Rights Reserved University of Washington School of Law
4293 Memorial Way Northeast, Seattle, WA 98195


text:
CARSON, Calif. -- The LA Galaxy became the fourth MLS team to advance to the CONCACAF Champions League Semifinals with a 4-1 aggregate victory over Costa Rican side C.S. Herediano on Wednesday evening.
My Three Points to the match can be found here.
A few notes:
*LA will take on Monterrey with the dates for the two-legged series still to be determined. What we do know is this: the first leg will take place at The Home Depot Center between April 2 and April 4 while the second leg will be at Monterrey's Estadio Tecnológico between April 9 and April 11.
*Attendance for the game was 8,284. The attendance was capped at 12,500 for the match due to the stadium's agreement with CSU-Dominguez Hills. It is worth mentioning that CSUDH will be on Spring Recess during the potential first leg dates, according to their school calendar, so no caps will be necessary.
*Jack McBean now has four goals in the competition and is tied for second among leading goalscorers.
*Elias Aguilar snapped the Galaxy's shutout streak at 264 minutes in all competitions.


text:
Pictures of Cats in Costumes
Cats Join the Meow-loween Costume Fun!
Cats Join the Meow-loween Costume Fun!
Halloween is coming, and everyone's excited about getting dressed up. Well, maybe not your cat. Get ready to be surprised with a collection of kitties that love getting into the Meow-loween spirit. If you have a fluffer at home and are prepared to potentially endure a scratch fest, we've also included a few seriously adorable cat costumes.
0previous images
-17more images


text:
Top Items:
John Boehner / Wall Street Journal:
The President Is Raging Against a Budget Crisis He Created — Obama invented the 'sequester' in the summer of 2011 to avoid facing up to America's spending problem. — A week from now, a dramatic new federal policy is set to go into effect that threatens U.S. national security, thousands of jobs and more.
Kori Schulman / White House.gov Blog: Setting the Record Straight About the Sequester
Hugh Hewitt / Hugh Hewitt's TownHall Blog: Speaker Boehner Spells Out The History of the Obama Sequester
Jim Hoft / The Gateway Pundit: Hilarious!... Hannity Mocks Obama's Melodramatic 'Mayan Sequester Apocalypse' (Video)
Matthew Larotonda / ABCNEWS: White House: Stop-gap Measure Only Way to Avoid Sequestration Deadline
Zachary A. Goldfarb / Washington Post:
Sequester just over a week away, but blame game has already begun
Sequester just over a week away, but blame game has already begun
Discussion: Wall Street Journal, The Fix, The Week, Weekly Standard and Post Politics
Chris Cillizza / The Fix: The sequester is inevitable. So why is President Obama still talking about it?
Geoffrey Norman / Weekly Standard: Sequesterzilla — The president has returned from Florida …
Zachary Goldfarb / Post Politics: White House: GOP will take blame for sequester
Alexander Bolton / The Hill:
Shutdown isn't fight GOP wants
Shutdown isn't fight GOP wants
Michael Tomasky / The Daily Beast:
More Republican Denial — Conservatives keep reminding everyone …
More Republican Denial — Conservatives keep reminding everyone …
Discussion: The Week, The Dish, The Raw Story, Outside the Beltway, Washington Monthly, Right Turn and Washington Post
Andrew Sullivan / The Dish: The GOP's Sequestration Trap
Megan Carpentier / The Raw Story: How Congress became the boy who cried 'Wolf!' or: How I learned to stop worrying and hate the sequester
Doug Mataconis / Outside the Beltway: Obama, GOP Battle Over Sequestration Cuts
Jennifer Rubin / Right Turn: Sequester posturing — Liberals seem to have convinced themselves …
Zachary A. Goldfarb / Washington Post: Obama presses Congress for stopgap sequester fix
Dylan Byers / Politico:
Debate co-chair: 'Mistake' to have Candy Crowley moderate presidential debate — Frank Fahrenkopf, a co-chair of the Commission on Presidential Debates, said tonight that the Commission made a "mistake" by selecting CNN anchor Candy Crowley to moderate one of the 2012 presidential debates.
Discussion: Townhall.com, The Gateway Pundit, Hot Air, CBS Las Vegas, nation.foxnews.com and Weasel Zippers
Katie Pavlich / Townhall.com: Co-Chair of Presidential Debate Commission: Candy Crowley Was a "Mistake"
Jim Hoft / The Gateway Pundit: Duh!... Former RNC Chair Says it Was Mistake to Use Lib Crank Candy Crowley as Debate Moderator
Timothybella / CBS Las Vegas: Presidential Debate Co-Chair: The 'One Mistake' Was Crowley Moderating Debate
ZIP / Weasel Zippers: Presidential Debate Co-Chair Says He's Happy With Debates, Except "We Made One Mistake This Time: Her Name Is Candy"...
Jon.Ralston / Ralston Reports:
Fahrenkopf opines on GOP's "idotic" stances, Christie's "French kiss," the media's bias and more — What better place than the Las Vegas Country Club, where time seems to have stopped in 1974 or so, for a group of conservatives to gather to figure out how to capture the glory days.
Discussion: First Read, Taylor Marsh and The Fix
Taylor Marsh: Candy Crowley Cited as "Mistake" by Republican Co-chair of Presidential Debate Commission
Quinnipiac News + Events:
Release Detail — February 20, 2013 - New Jersey Gov Flies High, Buries Unknown Dem, Quinnipiac University Poll Finds; Christie Close To Clinton, Leads Cuomo In '16 Pres Race — New Jersey voters today continue Gov. Christopher Christie's record-breaking 74 - 22 percent approval rating …
Discussion: Politico, CNN, No More Mister Nice Blog, Taegan Goddard's …, Prairie Weather and Washington Examiner
Kevin Robillard / Politico: New Jersey Poll: Hillary Clinton edges out Chris Christie
Paul Steinhauser / CNN: Poll: Clinton vs. Christie in 2016
Charlie Spiering / Washington Examiner: Poll: Christie has 74 percent approval rating in New Jersey; 56 percent among Democrats
Frank Newport / Gallup:
Congress Approval Holding Steady at 15%
Congress Approval Holding Steady at 15%
Discussion: p m carpenter's commentary, Booman Tribune, Politico and msnbc.com
Katie Glueck / Politico: Poll: 15% approve of Congress
Dan Friedman / NY Daily News:
'Friends of Hamas': My role in the birth of a rumor — A Daily News reporter explains how he inadvertently created the myth that Chuck Hagel spoke to a non-existent group. — Daily News reporter Dan Friedman recounts the origin of a rumor he unwittingly started about Chuck Hagel (pictured) …
Discussion: Washington Monthly, Politico, The National Memo and Daily Kos
Tim Mak / Politico: Reporter says he started Hagel rumor
Jed Lewison / Daily Kos: They're even stupider than you thought
Robert Barnes / Washington Post:
Supreme Court to consider limits on individual political contributions — The Supreme Court reentered the controversial field of campaign finance Tuesday, agreeing to consider a Republican challenge to decades-old limits on the total amount a person can contribute to candidates, political parties and political action committees.
Discussion: PostPartisan, SCOTUSblog and Ballot Box
Hilary Rosen / PostPartisan: The Insiders: Buying elections
Lyle Denniston / SCOTUSblog: Opinion recap: A warning about competition
Richard Wolf / USA Today:
Supreme Court rules in favor of drug-sniffing dog
Supreme Court rules in favor of drug-sniffing dog
Discussion: The Volokh Conspiracy, Washington Post, Hit & Run, SCOTUSblog and Watchdog.org
Orin Kerr / The Volokh Conspiracy: Supreme Court Decides Florida v. Harris: No Bright Line Rules for Probable Cause, But Perhaps A Presumption or Two
Robert Barnes / Washington Post: Supreme Court sides with drug-sniffing dog; supports soldier's child custody case
Jacob Sullum / Hit & Run: SCOTUS Approves Search Warrants Issued by Dogs
Lyle Denniston / SCOTUSblog: Opinion recap: Trust the police dog
Adam Liptak / New York Times:
Supreme Court to Hear Campaign Finance Case
Supreme Court to Hear Campaign Finance Case
Discussion: The Week, Election Law Blog, Prairie Weather, Bloomberg, The Huffington Post, ACS Blog and The Volokh Conspiracy
Rick Hasen / Election Law Blog: The Significance of the Supreme Court's Decision to Hear the McCutcheon Campaign Finance Case
Paul Blumenthal / The Huffington Post: Supreme Court Takes Campaign Finance Case, Will Rule On Contribution Limits
Jeremy Leaming / ACS Blog: High Court to Take up Campaign Finance Regulation, Again
Jonathan H. Adler / The Volokh Conspiracy: Today's Unusual Lineup: Bailey v. U.S.
James Taranto / Wall Street Journal:
The Devil Made Them Do It — Senate Democrats try to dodge responsibility for ObamaCare. — "Powerful Democrats" subjected a top Obama administration health-care official "to withering criticism" last week, notes Walter Russell Mead. When Gary Cohen, head of the Center for Consumer Information …
Discussion: NewsBusters blogs
Spencer Ackerman / Wired:
Senate Minority Leader Fooled by Report in Military Version of The Onion — The best parody contains elements of truth. Which might explain how the military's answer to The Onion suckered the Senate's Republican leader. — Meet The Duffel Blog, if you haven't already.
Discussion: The Maddow Blog
Steven Mufson / Washington Post:
Gas prices are on a mysterious climb — The average price of a gallon of regular gasoline has jumped 45 cents in the past 31 days, according to AAA, the fastest run-up since 2005. — Retail gasoline prices have climbed for 33 days in a row. A month ago, a gallon of regular gasoline cost $3.30 …
Discussion: Hot Air and Informed Comment
Ed Morrissey / Hot Air: WaPo: What's going on with gas prices?
Greg Bishop / New York Times:
A Company That Runs Prisons Will Have Its Name on a Stadium — In recent years, where stadium naming rights could be sold, universities and professional sports teams have sold them — to airlines and banks and companies that sell beer, soda, doughnuts, cars, telecommunications, razors and baseball bats.
Discussion: The Hinterland Gazette and ImmigrationProf Blog
Cristina Silva / Associated Press:
McCain defends immigration plan to angry residents — PHOENIX (AP) — Arizona took center stage in the national immigration debate Tuesday as Homeland Security Secretary Janet Napolitano toured the state's border with Mexico and Sen. John McCain defended his proposed immigration overhaul to an angry crowd in suburban Phoenix.
Discussion: alan.com, Mediaite, The Hill, The Raw Story and nation.foxnews.com
Meenal Vamburkar / Mediaite: 'Where's The Fence?' Sen. McCain Faces Angry Residents While Defending Immigration Plan During Town Hall
Geneva Sands / The Hill: McCain defends immigration reform at heated town hall
Mark Gokavi / Dayton, Ohio, News and Information:
Woman claims she was fired for voting for Obama — DAYTON — A Kettering woman alleges in a lawsuit that she was fired for voting for President Obama, a charge the company denies. — Patricia Kunkle is seeking in excess of $25,000 from Dayton-based defense contractor Q-Mark …
Discussion: Associated Press
Office Depot and OfficeMax Announce Plans to Merge, After Erroneous Release — Updated — Office Depot and OfficeMax announced plans to merge on Wednesday, just hours after an erroneous news release about the deal surfaced briefly. — Under the terms of the deal, Office Depot …
Discussion: Business Insider, NBCNews.com and Mashable!
Corrie MacLaggan / Reuters:
Republican Senator Cruz defends style a Democrat likened to McCarthyism — (Reuters) - First-term Republican Senator Ted Cruz of Texas on Tuesday staunchly defended his aggressive, in-your-face style that already is raising eyebrows in Washington and has led a Senate Democrat to suggest his tactics reminded her of McCarthyism.
Discussion: Washington Monthly, Politico and Washington Examiner
Kevin Cirilli / Politico: Ted Cruz defends his blunt style
Charlie Spiering / Washington Examiner: Ted Cruz: Washington has a tradition of trying to silence people
Adam Liptak / New York Times:
Supreme Court Appears to Defend Patent on Soybean — WASHINGTON — A freewheeling and almost entirely one-sided argument at the Supreme Court on Tuesday indicated that the justices would not allow Monsanto's patents for genetically altered soybeans to be threatened by an Indiana farmer who used them without paying the company a fee.
Discussion: Suburban Guerrilla and Truthdig
Emily Schultheis / Politico:
McAuliffe, Cuccinelli in dead heat in Virginia — A Quinnipiac poll in Virginia finds Democrat Terry McAuliffe and Republican Ken Cuccinelli tied in the race for governor, though it's clear many voters in the state haven't started paying attention to the race yet.
Discussion: CNN
Kevin Liptak / CNN: Dead heat in Virginia governors' race
Niels Lesniewski / Roll Call:
Biden: Buy Shotguns, Not Assault Weapons — Vice President Joseph R. Biden Jr. said Tuesday that parents interested in having firearms for protection should purchase shotguns instead of assault weapons. — "If you want to protect yourself, get a double-barrel shotgun," …
Discussion: Taegan Goddard's …
Jeffrey M. Jones / Gallup:
Americans Say Preventing Terrorism Top Foreign Policy Goal — Nuclear weapons, energy also top foreign policy concerns for Americans — PRINCETON, NJ — Eighty-eight percent of Americans say preventing future acts of international terrorism should be a very important foreign policy goal of the U.S., top among nine issues.
Discussion: The Hill and Weasel Zippers
Jonathan Easley / The Hill: Poll: War on terror tops list of foreign priorities
Judy Kurtz / The Hill:
Conan O'Brien to host White House press dinner for second time — Conan O'Brien will hold court as emcee of the 2013 White House Correspondents' Association (WHCA) dinner. — WHCA President and Fox News Channel senior White House correspondent Ed Henry announced the group's pick of the funnyman …
Meenal Vamburkar / Mediaite: Conan O'Brien To Headline White House Correspondents' Dinner
Ulrike Putz / Spiegel Online:
How the Mossad Works: The Mystery of Israel's 'Prisoner X' — An Israeli agent commits suicide in his prison cell. Was he a traitor? The mysterious case of "Prisoner X," reported to be Australian-born Benjamin Zygier, provides an insight into the workings of the Mossad.
Discussion: The Times of Israel and Israel Matzav
Ilan Ben Zion / The Times of Israel: Enter Bivni, Israel's new high-powered politicouple
David R. Henderson / Wall Street Journal:
An Economist Who Made the Science Less Dismal — Armen Alchian never won a Nobel Prize in economics. But no less than Friedrich Hayek said he 'deserved' one. — In 1975, I attended a week-long conference in Connecticut at which the star attraction was Friedrich Hayek.
Discussion: EconLog and Cafe Hayek
David Henderson / EconLog: Henderson on Alchian — The Wall Street Journal published …
Don Boudreaux / Cafe Hayek: David Henderson (and also Fred McChesney) on Armen Alchian
Kevin Cirilli / Politico:
Rand Paul: Obama 'histrionics' over cuts — Sen. Rand Paul (R-Ky.) is charging that President Barack Obama is full of "histrionics" about what will happen if the sequester kicks in. — "I think the sequester happens and it will be in some ways a yawn because the histrionics that are coming …
Discussion: Reuters and Pirate's Cove
William Teach / Pirate's Cove: Rand Paul Slaps Obama For Sequester "Histrionics"
Manu Raju / Politico:
Joe Miller's return gives GOP establishment heartburn — Republicans who don't want to witness GOP-on-GOP primary warfare in 2014 may want to keep their eyes trained on the Lower 48. — Alaska could be messy. — Joe Miller, the tea party favorite who was backed by Sarah Palin …
Discussion: The Hill
Alexandra Jaffe / The Hill: Johanns's retirement could grow GOP's internal conflict
Katherine Skiba / Chicago Tribune:
Jesse Jackson Jr., Sandi Jackson expected to plead guilty — WASHINGTON — Former Rep. Jesse Jackson Jr., and his wife, former Chicago Ald. Sandi Jackson, are expected to plead guilty to federal charges today, when more details may emerge about an alleged crime spree in which he is accused …


text:
Posts Tagged 'Toronto'
Web Series – Nirvana the Band the Show
click above to visit the site
Starring: Matt Johnson and Jay McCarrol
Series Producer: Jared Raab
Story Editor: Evan Morgan
Camera: Jared Raab, Rich Williamson, Chuck Taylor, Peter Dreimanis
Design: Ritchie Cheung
Animation: Gerrit Van Woudenberg
Nirvana The Band The Show is a Toronto, Canada based web series created by and starring Matt Johnson and Jay McCarrol. The show is a comedic mockumentary that follows Jay and Matt, members of the fictional band "Nirvana The Band," through their futile attempts to book their first show at The Rivoli, a local music club and restauraunt.
No relation to Seattle based rock band of similar name.


text:
I'm looking for a good resource to figure out what is what. I've got about a dozen carb bodies, all in a pile, and I need to figure out which ones go with each other.
Where can I find a resource for identifying the various bodies, and getting some idea of what they're supposed to go to.


text:
you guys added the quality filter in the petscore box, but I wanted to know if the following behaviour is intended or not:
if I click on the rare link, all pets are shown which have a duplicate on rare quality.
for example:
I have 2 alpine chipmunks: one with blue quality, and one with uncommon quality.
If I filter on 'rare', both these pets are shown. (probably because there is at least one with blue quality)
I would expect to not see the green duplicate.


text: My recent project was actually one my mom has assigned to me. She just started some sort of buisness and asked me to make her a website(since I'm the only one in the house that doesn't think a computer is run by a midget). Anyways, I was seeing whether I should use xhtml or html. On an article I read on the web it stated Internet Explorer doesn't support xhtml. Is this true?


text: Home → Five ways Hurricane Sandy could affect the elections Floodwater from Hurricane Sandy creeps up on the Ash Wednesday Storm of 1962's mark at the Oyster House in Bayford, Va., on Sunday, Oct. 28, 2012. Areas on the Chesapeake Bay side of Virginia's Eastern Shore are already experiencing coastal flooding effects of the storm. By Ryan Teague Beckwith Posted: 10/28/12, 12:01 AM PDT | # Comments [View the story "Five ways Hurricane Sandy could affect the election" on Storify]Five ways Hurricane Sandy could affect the electionAs Hurricane Sandy bears down on the East Coast, some political observers have noted that it could have a major effect on the upcoming presidential election. Here are five ways.Storified by Digital First Media · Sun, Oct 28 2012 18:22:36As Hurricane Sandy bears down on the East Coast, some political observers have noted that it could have a major effect on the upcoming presidential election. Here are five ways.Denverpost(AP Photo/Rockford Register Star, Scott Morgan)Polling places could be damaged.Polling places are just as susceptible to wind and water damage as homes and businesses. Poll workers who literally run the election could also find themselves without power or away from home, making the logistics of running the election more difficult.Louisiana Secretary of State Tom Schedler: "After the storm, determine if your locations are still viable and usable and if they're not, make sure you move and consolidate precincts. We did that here in Louisiana with the big mayoral election after Katrina. As long as you have locations, power and equipment or paper ballots -- you can still have the election and go forward."Denverpost(AP Photo)Voters may not see political ads.Both campaigns are spending millions of dollars on advertising on television and radio. They may suspend advertising if the storm causes massive damage. But if power goes out, people won't see ads even if they are on the air.New York magazine: "Politics might well take a back seat to the storm for the next few days, with many television stations expected to bump political ads for more live coverage of Sandy's approach and impact. "Denverpost(AP Photo/Phelan M. Ebenhack)Candidates may have to stop campaigning.During natural disasters, the president often skips campaign events to oversee federal response efforts. That means President Obama won't be holding campaign rallies or even fundraisers during the remaining days of the election. That puts Romney in an awkward position, since he could look bad if he continues.Democratic consultant Bob Shrum: "If this storm is bad enough, and if tens of millions of people are without power, and the seawalls have been breached in New York City, the president's got to get off the campaign trail - he's got to go run the country."Denverpost (AP Photo/Atlanta Journal-Constitution)Unlikely voters may not go to the polls. The storm will affect parts of Virginia and potentially Ohio, crucial swing states. If people have to leave their homes or have their cars damages, it could be harder to get to the polls on Election Day. For so-called "low-propensity voters," that could make a difference.Political reporter John Dickerson: "The number of days you lose because of the weather to turn out those people who don't normally turn out, that's a challenge. It's why it's a little more of a challenge from the weather for Democrats on that score."Denverpost(AP Photo/Stephan Savoia, File)Voters may subconsciously blame the incumbent.Research by Larry Bartels of Vanderbilt University and Christopher Achen of Princeton University found that severe drought and excessive rainfall may have cost Vice President Al Gore the 2000 election by dampening enthusiasm for the incumbent party.Political science professor Gabriel Lenz: "You might imagine there's an ideal world in some peoples' heads where everyone votes on policy and knows what the candidates and parties stand for. I think we're pretty sure we're not in that world." Advertisement


text:
What would it look like if you could track, record, and analyze the gaze tracking patterns of surgeons as they are diagnosing x-rays? What kinds of differences might emerge with experience and which of those are the good habits vs. bad habits?
The first step in answering this question is to just have a look and see what patterns emerge. So that's what we did. Nick Giovinco and Steven Sutton collaborated on this project to create a dataset of gaze tracking information from a group of surgical residents and a group of surgeons with years of medical experience.
We used ITU Gazetracker to capture the gaze information and OGAMA to record and analyze that data. We then put together a setup with a chin rest and webcam at the Dekalb Medical Center.
After a day of setup and calibration, we had consistent results and a reliable testing procedure. We tried to make the test as comfortable as possible, but the need for side supports to keep the head from tilting relative to the screen (as you would imagine people might do while examining something like an x-ray) made the setup a little bit awkward.
We collected data from more than 35 people, but narrowed the data set to 15 residents and 15 surgeons with more than 7 years of experience.


text:
Guide to the Bernard Siegel Papers
Biographical/Historical Sketch
Collection Contents
Anthropology 106/206: Structure and Change in Rural Latin America
Anthropology 108: Peoples of Europe
Anthropology 108: reprints
Anthropology 108: student papers
Anthropology 127: Mediterranean Anthropology: syllabi and exams
Anthropology 127: lecture notes, n.d.
Anthropology 127: lecture notes, n.d.
Anthropology 127: lecture notes, n.d.
Anthropology 127: reprints
Anthropology 127: William A. Douglass, "South Italian Familism" (reprint)
Anthropology 127: student enrollment and exams
Anthropology 127: sourcebook
Anthropology 144: Social and Political Movements: course preparation
Anthropology 144: course syllabi and bibliography
Anthropology 144: James Fernandez, "African Religious Movements"
(unpublished reprint)
Anthropology 144: misc. reprints and fragments
Anthropology 144: student papers
Anthropology 146: Urban Problems and Issues in Anthropological Perspective
Anthropology 147: Peasant Migrations and Social Change: course syllabi and exams
Anthropology 147: lecture notes, n.d.
Anthropology 147: lecture notes, n.d.
Anthropology 147: lecture notes, n.d.
Anthropology 147: reprints: A-J
Anthropology 147: reprints: K-R
Anthropology 147: reprints: S-Z
Anthropology 163: Cultural Dynamics (1965): course materials
Anthropology 163: lecture notes
Anthropology 163: sources and reprints
Anthropology 207: Latin America
Anthropology 235: Cultural Dynamics (1987)
Miscellaneous Stanford Faculty Reports, 1980-1982
Stanford dissertation: Midori Arima, "An Ethnographic Study of the Bonin Islands," outline and correspondence
Stanford dissertation: Janeen Arnold Costa, "Tradition and Change in Peasant Societies," proposal and correspondence
Stanford dissertation: Regina Campos, "Brazilian Psychologists and their Impact on Primary Education," proposal and correspondence
Stanford dissertation: Miguel Diaz-Barriga: "Urban Community Politics in Mexico City," proposal
Stanford dissertation: Merielle Flood: "The Economics of Gender in a Tourist City," proposal and correspondence
Stanford dissertation: Rosemary Henge, "Informal Teaching and Learning in a Greek Community," proposal and correspondence
Stanford dissertation: Allen Willard Johnson, "Economics and Dependence...In Brazil," abstract
Stanford dissertation: Madhuri Mathema, "Improving Women's Lives: A Case Study in Nepal," proposal drafts
Professional: symposia, etc.
European Peasant Society Symposium: papers, 1951-1958
Comparative Civilizations Seminar, Center for Advanced Study in the Behavioral Sciences, Feb.-Mar. 1958
Comparative Civilizations Seminar, Center for Advanced Study in the Behavioral Sciences, Feb.-Mar. 1958
Stanford in Italy: correspondence 1970
Stanford in Italy: minutes 1970
Stanford in Italy: correspondence 1971
Stanford in Italy: minutes 1971
Stanford in Italy: correspondence 1972
Migration in Latin America Seminar, 1976 memorandum and reprint, "Conflict, Parochialism and Social Differentiation in Portuguese Society"
Professional: Siegel articles
"The Contestado Rebellion" reprint, 1977
"Defensive Cultural Adaptation" draft, n.d.
"High Anxiety Levels...A Psycho-Cultural Hypothesis" (from Social Forces, 1955)
"Residence, Households and Kinship...Estates of Northern Brazil," n.d.
"Social Structure...In Rural Brazil and Portugal" (Sociologico, 1958)
"Some Structure Implications...in New Mexico" (reprinted from AES, 1959)
"Urban Research in Milan: Some Technical Considerations," n.d.
Professional: Siegel proposals
"The Role of the School as a Social System...in Northern Italy" draft proposal (1972-3)
Parma Valley Proposal: "Land, Labor and Family" (draft 1, 1975)
Parma Valley Proposal: "Migration and Adaptation in Southern Italy," n.d.
Parma Valley Proposal: (1976)
Parma Valley Proposal: draft 3 (1978)
Parma Valley Proposal: revision (1978)
Parma Valley Proposal: draft 4 (1979)
Parma Valley Proposal: field research
Parma Valley Proposal: Italian sources
Siegel correspondence: 1963
Siegel correspondence: Jan.-May 1964
Siegel correspondence: Jun.-Dec. 1964
Siegel correspondence: 1966
Siegel correspondence: 1967
Siegel correspondence: Jan.-May 1968
Siegel correspondence: Jun.-Dec. 1968
Siegel correspondence: Jan.-May 1969
Siegel correspondence: Jun.-Dec. 1969
Siegel correspondence: 1970
Siegel correspondence: 1971
Siegel correspondence: 1972
Siegel correspondence: 1973
Siegel correspondence: 1974
Siegel correspondence: 1975-1985
Siegel correspondence: 1986-1989
Siegel correspondence: 1990-1992
Japanese educational reform: reports and commentaries by others
Japanese rural society: English summaries of book by Tadashi Fukutake
Japanese social structures: translations of articles
Picuris pueblo photos, San Lorenzo Saints Day (Aug. 10, c. 1957): 1-10
Picuris pueblo photos, San Lorenzo Saints Day (Aug. 10, c. 1957): 11-20
Picuris pueblo photos, San Lorenzo Saints Day (Aug. 10, c. 1957): 21-30
Picuris pueblo photos, San Lorenzo Saints Day (Aug. 10, c. 1957): 31-40
Picuris pueblo photos, San Lorenzo Saints Day (Aug. 10, c. 1957): 41-48
Picuris pueblo photos, miscellaneous
Note on photos
Accession ARCH-2004-094 Additional Papers
Annual Review, 1977-78
Annual Review, 1979-80
Annual Review, 1989
Anthropology 124 Art and Culture, 1968-71
Anthropology 149 Anthropology of Development, class info, 1990
Anthropology 149 Anthropology of Development, course guide and reader, 1991
Anthropology 149 Anthropology of Development, literature, n.d.
Anthropology 210 History and Modern Viewpoints, n.d.
Anthropology 210 History and Modern Viewpoints, handouts and notes, n.d.
Anthropology 251, student project reports, 1951
Aspects of Political Organization at Taos Pueblo [Siegel], n.d.
Beauclerk and Narby, "A Fieldguide to Indigenous Peoples Development," part 1, 1986
Beauclerk and Narby, "A Fieldguide to Indigenous Peoples Development," part 2, 1986
Bibliographies, miscellaneous
Biennial Review: correspondence and notes, 1966-68
Folk Society, notes and paper by Siegel, n.d.
Four: The nature of strain
Italian research, 1972
Johansson, Sheila, "Morality, Welfare and Gender," 1989
Longitudinal study of the physical growth of Tucson, Arizona, school children [possibly by Francis J. Meaney], n.d.
Mountain View project, interview reports, 1952-53
Native American Preservation Act - written testimony, 1987
Nutini, Hugo G. "Structural History: A Programmatic Synthesis of the Nomothetic and Idiographic Elements of Anthropological Studies," n.d.
Orlove, Benjamin S., "Cultural Ecology: A Critical Essay and a Bibliography," Institute of Ecology Publication No. 13, UC Davis, 1977
Parma Project - notes, proposals, bibliographies, etc., 1972-78
Parma Project - notes, proposals, bibliographies, etc., 1978-80
Personal correspondence, 1978-83
Publications, foreign
Polgar, Steven - two papers, 1959
Requests for material, 1977-78
Responses to requests, 1970-72
Review of D. Morris's Intimate Behavior, with correspondence, 1972
Sacred artifacts and skeletal remains - resource information
Saltman, Michael, research plan and paper, ca. 1986
Science articles, 1970-78
Siegel - c.v. and biographical information
Siegel - reprints
Siegel, James, "Conservative Islam in Atjeh," 1962
Sociology 203 - notes, 1941 and n.d.
Stanford Humanities Anthropology Conference, transcript of sessions, 1947
Stanford Humanities Center, year end report, 1990
TA apprenticeship readings, Fall 1997
TA apprenticeship readings, Fall 1997
Taos - interviews and observations, n.d.
Taos - assorted articles, 1949-72
Textor, Robert B., "High Tech Bibliography," Stanford Project on the Human Impacts and Sociocultural Implications of High Technology, May 1989
Wharton, Clifton R., "Risk, Uncerainty and the Subsistence Farmer," 1968