text: Battling the Black DogSHAW, GINANeurology Now: July-August 2007 - Volume 3 - Issue 4 - p 20–25 doi: 10.1097/01.NNN.0000286027.43660.eb Special Report: Depression Abstract In Brief Author Information Article Outline What to do when neurological disease goes hand in hand with depression. Many neurological disorders go hand in hand with depression, which can influence the course of your condition in powerful ways. Here's what to look for and what to do if you are living with—or caring for someone with—epilepsy, MS, Parkinson's, or migraine. Gina Shaw is a health and science writer whose articles have appeared in Redbook, Fitness, Glamour, and WebMD: The Magazine. For more information on depression, see RESOURCE CENTRAL on page 46. Abstract SEIZED BY DEPRESSION MIGRAINE AND MELANCHOLY PARKINSON'S AND THE BLACK DOG DEMYELINATION AND DEPRESSION OUT OF THE BLUE TOO YOUNG TO QUIT SYMPTOMS OF DEPRESSION Susan Randall* had always been skeptical of medication for depression. During periodic battles with low-grade depression and anxiety, which she's had throughout much of her life, "I've always been one to go the psychotherapy route," says the central New Jersey woman, who is a therapist herself. That was before she was diagnosed with Parkinson's disease three years ago, at the age of 48. At first she thought it was simply more anxiety, as she felt nervous driving at night because she thought the glare from oncoming headlights was too bright. Then, the brightness of the sun during the day made it seem like everything was coming at her too quickly. After several ophthalmologists told her that her eyes were fine, Randall finally saw a neurologist. "It took him one minute to tell me I had Parkinson's," she recalls. "I asked, 'How do you know?' and he said, 'Look at your face—you look like a judge!'" Randall began medication for Parkinson's, which improved the lack of facial expression caused by the disease. She also wondered if the disease wasn't somehow tied to her depression. "I was worrying so much, and my husband had noticed how depressed I was," she says. She entered a clinical trial through the Robert Wood Johnson Medical School of the University of Medicine and Dentistry of New Jersey comparing two different antidepressants—nortriptyline (Pamelor) and paroxetine (Paxil)—to placebo for people with Parkinson's disease. "After a couple of weeks, I just noticed that one day I felt great," she says. "I thought, 'Why did I wait so long? Why did I suffer? It was a huge learning experience for me.'" Randall wasn't alone. While about 10 percent of people in the U.S. have a depressive disorder in any given year, the rates are much higher for people with neurological conditions: around 35 percent for Parkinson's, nearly 40 percent for epilepsy, and as high as 50 percent for migraine and multiple sclerosis. You might assume that this is simply a reaction to having a chronic, serious medical condition. After all, if you're diagnosed with cancer or heart disease, you are more likely to experience depression as well, right? Not exactly. Although people with other chronic illnesses are at greater risk of depression than the general population, even cancer and heart disease don't seem to boost depression rates the way many major neurological disorders can. And as scientists learn more about the neurobiology of both these conditions and of depression, they're discovering that it's not as simple as feeling down because you have a disease. Figure Back to Top | Article Outline SEIZED BY DEPRESSION Which came first—the epilepsy or the depression? Neither, says Alan Ettinger, M.D., director of the North Shore-Long Island Jewish Medical Center Comprehensive Epilepsy Centers in New York. Epilepsy and depression are what he calls "bi-directional"—sometimes the patient develops epilepsy first and then depression; and vice versa. Another piece of the puzzle: the many chemical commonalities between epilepsy and depression. "A number of anti-depressants and anti-epileptic therapies seem to have similar effects on some aspects of brain chemistry," says Dr. Ettinger. "One example might be the antidepressants known as SSRIs (selective serotonin reuptake inhibitors) and the anti-epileptics such as lamotrigine (Lamictal). Both enhance the transmission of norepinephrine." Rats that are genetically modified to be prone to epilepsy—they're called GEPRs, for "genetically epilepsy-prone rats"—are very deficient in norepinephrine, a chemical messenger in the brain that is also closely associated with depression. In a study published in the journal Neurology in January, scientists from Columbia University in New York used imaging techniques to demonstrate that abnormalities in the hippocampus of the brain are associated with depression among people with epilepsy. In fact, these abnormalities were even stronger predictors of depression than the number and severity of seizures that patients had. Abnormalities in the hippocampus are also associated with depression, independent of epilepsy, which might explain the frequent co-occurrence of these conditions. "This suggests that some day, we may have some very refined ways of predicting who's most at risk for depression, based on structural or functional changes in the brain," says Dr. Ettinger. That means that people with epilepsy who think they might also have depression must come to their doctor visits very well prepared, says Dr. Ettinger. "They need to organize the information in their medical history and understand the medical interview process," he says. His center's Web site, epilepsylongisland.com, offers downloadable forms to make this process easier. Back to Top | Article Outline MIGRAINE AND MELANCHOLY Like epilepsy and depression, migraine and depression are also bidirectional. "Each disorder predisposes you to the other, and it doesn't matter which one you have first," says Richard Lipton, MD, professor of neurology and epidemiology at the Albert Einstein College of Medicine in the Bronx, NY. And just as with epilepsy, depression and migraine have overlapping treatments. Tricyclic antidepressants, for example, are often used as preventive medications for migraine. "The two disorders might share a common brain substrate, which could account for why a single medicine might make both disorders better," says Dr. Lipton. Again, both migraine and depression involve overlapping sets of brain chemicals—in this case, serotonin and norepinephrine. But the puzzle isn't quite so simple: some medications work for one disorder and not the other. "There may be a point at which biochemical pathways in the brain converge, and if you find a drug that works at that point of convergence, it treats both disorders." In fact, Dr. Lipton calls migraine, epilepsy, and depression fellow travelers. "Migraine travels with epilepsy, and epilepsy and depression also travel together," he says. At least part of what is thought to contribute to depression in diseases like migraine and epilepsy is what Dr. Lipton calls the "interictal burden of illness," the interval between attacks of pain or seizures—the period during which most patients don't know when the disease will strike next. "If you have to live your life not knowing when you'll next be incapacitated by pain or a seizure, that can contribute to depression," he says. "If we can develop better methods for predicting migraines and seizures, this can both give us a treatment window and allow the patient to plan their lives better. For example, if you know you're likely to get a migraine today, maybe you'll skip that meeting in the city and stay home." Patients with migraine are often afraid to report their depression to their doctors. "They've often lived for many years with their pain being dismissed," says Dr. Lipton. "They're afraid of being told to just buck up, get a shrink, get a life. But they're doing themselves a real disservice." Back to Top | Article Outline PARKINSON'S AND THE BLACK DOG Parkinson's disease also involves key chemical messengers in the brain, primarily the serotonin system and the dopamine system. Here, too, scientists are just beginning to understand the effects of these chemical alterations. It's currently thought that people with Parkinson's have a biological predisposition to depression because they have decreased levels of these neurotransmitters. Depression in Parkinson's appears to manifest itself a bit differently than depression in the general population. "There's less guilt and thoughts of suicide among people with Parkinson's disease and depression, and more apathy, anhedonia—the inability to experience pleasure from things you normally enjoy—and disturbances in sleep and fatigue," explains Bernard Ravina, M.D., associate professor of neurology and director of the Movement Disorders Unit at the University of Rochester School of Medicine and Dentistry. Of course, sleep disturbances and fatigue are also common in Parkinson's in general, even when the person does not have depression, so the underlying cause of these symptoms can be difficult to tease out. But if you or a loved one have Parkinson's, it's important to be vigilant about depression. "Look for low mood, lack of energy, and lack of interest in the things that you used to do and enjoy," says Dr. Ravina. "These things should not just be written off as a part of the Parkinson's. Don't focus only on motor symptoms and relegate them to the back burner when you talk to your doctor." Patients who have depression along with Parkinson's also tend to report more disability than those who don't. "They have a more rapid course through both their motor illness and their cognitive decline, as well as their ability to care for themselves," says Matthew Menza, M.D., professor and vice chair of the department of psychiatry at the Robert Wood Johnson Medical School. "We're not absolutely certain at this point that treatment for depression changes that, although we do know that it will improve a person's quality of life. Whether or not it would actually change the course of the disease, we don't yet know." Several studies now underway may begin to answer those questions. Dr. Menza and his colleagues are about to close enrollment on a three-year trial comparing one tricyclic antidepressant, an SSRI, and a placebo in treating depression in Parkinson's. They want to see if these drugs successfully treat Parkinson's-associated depression, as well as affect the cognitive and motor problems in the illness. A similar, slightly larger trial is taking place at the University of Rochester. "This is an illness that's treated with a lot of medications that can affect mood," says Dr. Menza. "It can be strongly influenced by depression and vice versa, so it's very important to have a doctor who understands these connections." The American Parkinson Disease Association (APDA) can help through their local information and referral centers (apdaparkinson.org/user/InfoReferal.asp or 1-800-223-2732.) Back to Top | Article Outline DEMYELINATION AND DEPRESSION The relationship between multiple sclerosis (MS) and depression seems to be different from other neurological disorders. Instead of fluctuating levels of neurotransmitters like serotonin, dopamine, and norepinephrine, MS involves lesions on the brain and spinal cord where they have been stripped of their insulating myelin. Could demyelination play a role in depression? It's possible, says Scott Patten, M.D., professor in the departments of community health sciences and psychiatry at the University of Calgary, Alberta, Canada. "Some brain imaging studies show a correlation between MS lesion burden in locations of the brain thought to be associated with mood and affect, particularly in the white matter regions that are connected to the limbic areas. But it's likely that lesions in a large number of specific places could affect a person's vulnerability to depression, so we're probably not going to narrow it down to one location." Other factors likely play a role, including the medications used to treat MS. Corticosteroids in particular are known to be associated with depression and mood disturbances. Says Dr. Patten: "The level of depression is the driving force in the quality of life of people with MS, probably more so than the overall burden of the disease itself." There is also evidence that depression impairs the management of MS symptoms, by reducing adherence to treatment. As with other neurological conditions, patients with MS—and their doctors—may find that they focus on the physical symptoms of their primary disease and pay less attention to the depression. But that's improving, says Dr. Patten. "In 2005, the Multiple Sclerosis Society put out a consensus statement on screening for depression in MS, and I think it's had an impact.… I think eventually we're going to learn that if we deal better with depression in our patients, they'll do better overall." But managing this multifactorial susceptibility to depression isn't easy, as Susan Randall learned. The time-release carbidopa-levodopa (Sinemet CR) she began taking for her Parkinson's left her with what Dr. Menza described as a "dopamine-derived depression," a crash that occurred when the drug began to wear off. "It would just take me over. It had nothing to do with being sad about anything, but I would be a totally different person, completely depressed and anxious," she says. This isn't uncommon, says Dr. Menza. "We see people who have mild depression that becomes much worse when they go through the 'on/off period'—the point at which dopamine drugs stop working over the course of the day," he explains. "We believe it's partially biochemical changes in the brain that are driving the temporary worsening of the depression. When the patient goes back on the medication, they're fine again." Depression during this "wearing-off period" can also occur in Parkinson's patients who don't otherwise experience depression. With Dr. Menza, Randall is working to find the right balance of medications to treat both conditions. "Right now, in terms of its impact on my daily life, I think the depression is worse than the Parkinson's," she says. "Depression is a very serious thing, and it's so important not to neglect it because you're focused on managing your other disease." Back to Top | Article Outline OUT OF THE BLUE In September 2001, SYLVIA POSEY woke up in New York's Long Beach Hospital. "I had no idea what had happened. They told me I had a grand mal seizure," she says. She'd worked as a bookkeeper for New York's Waldbaum's supermarket chain for many years, but soon she had to give up her job and go on disability as she began suffering five to seven seizures every week. "I've been in Long Beach Hospital 50 times over the past year," says Posey, 42. In January, she had surgery to implant a vagus nerve stimulator (VNS) device, which has been shown to help reduce seizures in some people with epilepsy, and now the only time she has seizures are when her menstrual period is due. "It's definitely helped, but I still don't know exactly when they're going to hit." The isolation imposed by her unpredictable seizures has only worsened a depression that was first diagnosed in 1995. "It had probably been coming on since I was a teenager, but I never faced it." Posey says. "As I got older, all I did was work and come home and stay home alone. And then I started to use drugs. And then I saw that things were going wrong at work, and I wasn't paying my rent or my phone bill, and my mother said, 'Sylvia, this is not how I taught you.' I knew I needed to get help." She sought treatment at a community counseling center and was diagnosed with severe depression and bipolar disorder. But she's hopeful that better management of her epilepsy, with the help of the VNS, will also improve her depression. She's also taking daily topiramate (Topamax), a seizure medication that has also been used in the treatment of depression. "What I really want to do is go back to work. I hate being so isolated, and I think it makes the depression worse." Back to Top | Article Outline TOO YOUNG TO QUIT JOAN MACK was 38, the mother of three daughters, and a secretary-receptionist for a busy mortgage company in upstate New York when her Parkinson's disease was first diagnosed three years ago. "I'd go to get a piece of paper or answer the phone, and my hand would move in slow motion," she says. "I'd grab for something and miss it. I wouldn't eat. I went home and just slept." After a week in Utica Hospital, with MRIs, CT scans, and other tests ruling out multiple sclerosis, lupus, and other similar diseases, Mack was started on a Parkinson's drug called ropinirole hydrochloride (Requip). If it wasn't Parkinson's, they told her, the medication wouldn't touch her symptoms. Within days, her movements went back to normal. "It was such a shock to me. I was only 38 years old! I'd heard stories and seen Michael J. Fox and Muhammad Ali on TV, and I thought, I'm looking in the mirror at what I may be like five or 10 or 15 years down the road," she says. Early on in the course of the disease, Mack shut herself away from everyone else. "Without support, I can see where someone with this disease would get into a depression and just fade away," she says. "I was at that point, and it wasn't any fun. I was pushing myself to make everyone else happy and not taking care of myself. When I met my second husband, a year ago, I almost looked anorexic. If I hadn't found someone that was supportive, I think I would have been suicidal." She also credits her doctors at the University of Rochester for helping her to manage medication for both the Parkinson's and the depression. She's now on Requip, Sinemet (another Parkinson's drug), and Anafranil, a tricyclic antidepressant. "It helps a lot. I've seen a big improvement since I've been on the antidepressant. I sleep better at night and it relaxes me," she says. "They're very good about adding medications a little at a time to see how they affect me." "Some days are bad days," Mack says. "But most of the time, I'm happy. I rest if I need to rest, and try to have a normal life and live it to the fullest." Back to Top | Article Outline SYMPTOMS OF DEPRESSION In 2004, Frank Gilliam, M.D., who directs the Comprehensive Epilepsy Center at Columbia University, surveyed a group of neurologists and found that 80 percent did not routinely screen their epilepsy patients for depression. Many people with Parkinson's who have depression probably aren't getting the treatment they need either, says Bernard Ravina, M.D., associate professor of neurology and director of the Movement Disorders Unit at the University of Rochester School of Medicine and Dentistry. "In our study, to be published soon in Neurology, about 40 percent of the [Parkinson's] patients who screened positive for depression were neither referred for further mental health evaluation nor started on any kind of pharmacological therapy." Figure Depression is generally diagnosed when most of the following symptoms have been present every day for at least two weeks, according to the National Institute of Mental Health: ▸Persistent sad, anxious, or "empty" mood ▸Diminished ability to enjoy activities that were once enjoyable ▸Restlessness or irritability ▸Changes in appetite ▸Insomnia, early morning wakening, or excessive sleepiness ▸Decreased energy level ▸Slowed movements ▸Difficulty concentrating, remembering, or making decisions ▸Recurrent thoughts of death or that life is not worth living If you are experiencing any of these symptoms, talk to your neurologist about getting screened for depression.*Names have been changed.Cited Here...Copyright © 2007, AAN Enterprises, Inc.


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Kindergarten is not mandatory in all states. Some states require kindergarten attendance, but most do not (though it's encouraged in all states, and most states require school districts to offer it).Originally Posted by fg_weasley
Kindergarten is not mandatory in all states. Some states require kindergarten attendance, but most do not (though it's encouraged in all states, and most states require school districts to offer it).Originally Posted by fg_weasley
Hmm... Well, I can't speak for states outside of the south, but being as I've lived in just about all of the states in the southern region (I really need to get out of here soon!) I can say that down here, they do. Alabama, Tennessee, Arkansas, Florida, Texas (etc)--every state I've lived in required Kindergarten.Kindergarten is not mandatory in all states. Some states require kindergarten attendance, but most do not (though it's encouraged in all states, and most states require school districts to offer it).
Though I don't dispute your point; there are some states that don't require it. I can see why, too. I barely remember those years but it seems like we studied the exact same curriculum year after year (and even into middle school). Though, that's most likely due to the schools and their limited curriculum rather than the system in general. In Alabama the amount of knowledge needed for GED (General Education Development/alternative to schooling) is far more difficult than an actual high school diploma, and some colleges are more willing to take on GED diplomas than "normal" diplomas.
It's a weird and corrupted system. If advertising were allowed I'd go off on a tangent about it and start advertising the online program that my mother works for, but I won't, and I'll just leave it at that.
School systems are crazy where I live, kindergarten is a must, but you can go public, private, or even homeschool for it, and the cut off date is usually September 1 but that is even negotiable if the kid is ready sooner. Kindergarten can be full day, half-day, twice a week, it just depends on the place. Most private pre-schools also offer kindergarten. My school district has schools set up like this:
Elementary: K-4
Intermediate: 5-6
Junior High: 7-8
Ninth Grade Center
Senior High: 10-12
and everyone thinks it is totally nuts.
Most places, however, has elementary through fifth, junior high/middle school/intermediate from 6-8, and high school from 9-12. When you say jr. high, or middle school, or intermediate school, most people think of 6-8 (11 through 14 year olds usually).
Most kids graduate around 18, some are 17 and some are even 19.
A '91 baby would most likely be a senior, with a small chance of a junior if born after September 1.
Hope this helps.
And to add another wrinkle, in some rural areas they have one school house with K-12 still to this day. Others may be bussed a few hours away to standard schools as explained above. When you get into private (or UK Public?) schools, they can vary widely, especially if they are boarding schools or military prep schools as an example.
Many of the rules for American schools vary by location, so I'll give you mine, just for a bit of variety. I went to a very small school (~200 kids K-12) in the Midwest.
I started Kindergarten when I was 5, but some start when the are 6; it is up to the parents. There was a kid in the grade below me who has my exact same birthday, for instance.Firstly, what age must you be to start school? Is there a certain date that you have to turn that age by? (I.E. here, you have to turn six before the 31st of July to start grade one)
Kindergarten was required.Do you have a mandatory/volantary prep or preschool year?
Middle school was used to describe the 7th and 8th grade years. Basically it was like this:I also don't really get the whole 'middle school' thing. Explain, please.
In elementary (k-6), all of the kids in a grade were put into one classroom and we had one teacher for all of our subjects. We always had the same desks and we got to do little-kid things like recess (go outside and play a couple times a day).
In high school (9-12), we went to different rooms and had different teachers for each subject. At the end of the year previous, we got to pick our own schedule of classes to take. Some classes were required and all kids had to take them (e.g. English). Other classes (e.g. calculus, physics) were up to the discretion of the student; while there were requirements (e.g. 4 math classes and 3 science classes in the four years), it was up to the student to pick which classes he wanted. Also, there was much more freedom (my senior (12th grade) year, seniors could leave if they didn't have a class that period).
Middle school, therefore, was the time between (7-8). While we had classes in different rooms like H.S., we did not get to choose our own classes. It was pretty much just a time to get us used to the way high school worked.
I was 18 (barely).How old are you when you graduate?
They would probably be going into grade 12 this coming fall.And finally, if someone was born in mid-September, 1991, what year would they be in now?
Also, since we are on the subject of school, you should also note the ridiculously long summer breaks: three solid months!
In my hometown, summer break started on the last day of May and we weren't back in school until the day after American Labor Day, which is about a week into September. By the time school does start up again, kids are actually happy to go, because they are sick of having nothing to do!
In most states, however, you're likely to find that it IS mandatory, or at least that most children attend, especially now. Granted, I have not been to every state, nor have I really researched it, and I know its not a must in every single state ... but I think its a safe bet that most children go to kindergarten. Almost every post here has said that wherever they live kindergarten is a must. I will not be surprised when it is mandatory throughout the country in a few years. So, if writing a fic in which a character is around that age, I think it would be best to have them attend kindergarten.Originally Posted by Inverarity
However, by all means, the author can check up on this in whatever state the fic going to take place; that would be what a well-researched author would do, just to be absolutely certain.
I remember fingerpainting. LOL. Really, though, I think the point of kindergarten as well as preschool is so that children go to first grade and so on having already learned the basics so they make connections faster. I know that I learned to read very quickly because I started in preschool and kindergarten. I imagine that they still teach things slowly because not everyone attends preschool or kindergarten, and thus some children take a little longer to get to the same place simply because they've had less exposure. Another reason I will not be surprised if both kindergarten and preschool are someday mandatory every where.Originally Posted by Ari
This I think depends as well, not only on the state, but on the school district. I wish my summer was three whole months! I get out of school around mid-June, and school starts again at the very end of August. My friends that go to school just one city over in another district get out a whole week later than I do. So ... another area thing that should be double-checked.Originally Posted by Molly
"Through literacy you can begin to see the universe.
Through music you can reach anybody.
Between the two there is you, unstoppable."
--grace slick♥avvie: julia/the_opaleye
However, it should be noted that the other breaks aren't long at all. I had two weeks off for Christmas and four days off for Easter, and perhaps the odd Friday or Monday off besides that. But yeah, summer break was awesome, before I had to start working during it.Originally Posted by OliveOil_Med
I think the break up between elementary, middle, and high school, along with the mandatory Kindergarten/Pre-Kindergarten, and the lengths of the hollidays really all depend on which state you live in, which district you belong to, and what sort of inclimate weather days you've had during the year.
For example, I live in Oklahoma, so all of my answers will be based off of the school system I attend in Oklahoma.
Where I live, schooling starts out with nursery school for all children between the ages of three and four. (This type of schooling is optional, and usually conducted by a private business owner, or a daycare.) Pre-K is also optional, though highly, highly recommended for children between the ages of four and five. Kindergarten is mandatory for children aged five, and required to move on to either transitional first (T1) or first grade. Elementary school is grades Kindergarten through fifth; middle sixth through eighth, and high ninth through twelfth.
As for the age restrictions starting school: my younger sister was born in November of 2000. She started Pre-K in August of 2004, and is one of the oldest in her class, because the age cut-off was September 1st. Had she been born just a few months earlier, she could've started Pre-K in August of 2003, and been one of the youngest.
The only difference between elementary and middle school is, as Halgy said, the moving of classes. In elemetary, at the beginning of each school year, you are assigned a teacher and a class. You stay with that teacher, in the same classroom, until the end of the year. At the beginning of the next year, you are assigned a different teacher and a different class, and so on. In middle school, however, you are assigned to seven different teachers and seven different classes. You have a class schedule that you follow each day. Each class period is between forty-five and fifty-five minutes long, with a break for lunch. (i.e., the schedule that I followed for the entire year was First Hour: Reading; Second Hour: Science; Third Hour: Art; Fourth Hour: English; Fifth Hour: Algebra I; Lunch; Sixth Hour: Office Worker; and Seventh Hour: US History and Government.) You homeroom class can either be first hour or seventh (for me it was seventh, but it most places, it's first). Each year you move up a grade, your schedule and teachers change. This is the same concept as high school, only in middle school, your courses are pre-selected (save for your two electives), and in high school, you can pretty much pick what classes you take which years (though there are requirements: 3 math and science classes, 4 english classes, and so on).
However, this is not set in stone. One of the elementary schools where I live has their fifth grade students only rotate classes, to prepare them for their years in middle and high school. And private schools are pretty much free to function however they want. Our christian schools follow the same format as the public school system, but one of the schools in one of our suburbs is broken up into K-8 being in one building and 9-12 being in another, both on the same campus.
In regards to holiday breaks: Our school year starts on the third Friday of August (why they start on a Friday, I have no idea). We get a week off the third week of October for fall break, and Christmas break runs from the Monday before Christmas until the Monday after New Year's Day. We have the third week of March off for spring break, and have the Friday before Easter and the Monday after Easter set aside as inclimate weather days. (Roughly translated, if we have no snow days or other bad weather days, we get those two days off around Easter; If we do have bad weather, then we don't get those days off because we use them to make up for the days we missed during the winter. If we have a really bad winter and miss more than two days--which has happened before, though it's very rare--we either make them up in Saturday school, which is just as the name implies: a full school day on Saturday, or run later into the summer.) We usually end the school year on the third Friday of May, which leaves...around eight and a half weeks of summer break, give or take a few days.
That said, our school board is free to dictate our school years as they wish. It is left entirely up to the board as to how long our breaks are. The state has a manditory setting of 170 school days per year, but how we break them up is up to the school district and the school board.
Whew! That was a lot! Hope I cleared some things up, and if you have any more questions, feel free to PM me. Also, it might be good to concentrate on the area where your story is set, and to find someone who lives near that area to help you out.
I was just wondering if the phrase "he looks like butter wouldn't melt in his mouth" is something that Americans say. I want a 19 year old New Yorker at uni in Britain in 1999 to say it. Whilst I've asked a few American friends about this they've all been living in Britain for a few years now and are unsure whether they knew what this phrase meant prior to coming here or not.
Basically would it sound odd/ jarring to have an american say "he looks like butter wouldn't melt in his mouth"?
Any help would be great! Thanks, Alex
Banner by Minna.

subset: commoncrawl


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Not sure if this helps, but on the leaves to the left of the outdoors "web" photo, there appear to be two small caterpillars. As this web is similar to the ones spun by some moths (for example, ermine moth, but I'm not suggesting this is what it really is!!) it might be worth looking more closely at these for an ID.
Thankyou , I will go back and try to find any caterpillars.
It looks like it has fallen from a tree above and landed in the rose - is that correct? If so it might be "fluff" from a seeding poplar (I think you call it a catkin in English).
Google "cottonwood fluff".
But also google "tent caterpillar".
With Poplar and cottonwood fluff, you can usually see the plant fibres and seeds. With caterpillar webs there is a smoother surface which adheres to and covers individual twigs of a plant. From the photos it isn't clear which it is and I accept it is late in the season for caterpillar webs, but given the weather, I wouldn't rule it out. I have seen some near where I live.
Where are the larvae and why are they spinning their web on the ground?
The "surface" can be an effect of rain which clogs the fibers together when it dries.
(BTW it is late also for poplar snow, however, no date is given. But I guess the photo was taken in May or so, or at least that the "snow" fell in May and what we see are the remains of it.)
Also note that the images are quite large - you should right-click and then open in a new window (and then enlarge) and you will see much more detail.
I agree with Episcophagus that this fluff is the seeds from a Poplar, not only that but an entire inflorescence from a poplar tree rather than just a mass of poplar seeds. The end of the central woody stem of the inflorescence can be seen in the 2nd pic above the edge of the rose leaf, where the white fluff has caught and is partially covering the leaf, and can be followed down through the mass of seeds.
The central woody stem from the inflorescence can be made out in both your photos, as can the cups which held the seeds - like these seen here - especially in the first pic taken indoors. The short fibres from the seeds are also more evident in the first pic.
One way to tell for sure (assuming you still have some to try) is that on gently teasing the mass of fibres apart the poplar seeds would come away in small bundles of short distinct fibres whereas caterpillar silk would come away in long strands, probably stretch and be fairly elastic.
I tried to write that I thought that an entire inflorescence had fallen down an landed in the rose, I thus called it a catkin. (English isn't my first language, so please excuse) so your reply and my reply(ies) is overlapping (coin...something - I cant find that word). Well, I agree with you as you agree with me .
the curled up leaf-like structures are the seed pods, the actual seeds themselves are tiny and attached to the fibres which act like mini parachutes to allow the seeds to be carried on the lightest of breezes well away from the parent tree, a very clever means of distribution.
This photo shows the pods and seeds just after the pods have split. The greenish leaf-like segments of the pods then go brown and dry as in your specimen. There is an interesting sequence of photos of the maturing pods to seed dispersal here.


text: Ok, so here is the deal. I have a really hard time finding boots that fit me well. I wear a size 13 (depending on the boot) and I have a very skinny foot with fairly long toes... thanks dad... Right now, I have two pairs of boots I hunt in. I have Under Armour Speed Freak boots that I love, but they don't have a great sole for going over rocky terrain and are starting to leak. I like them because they are super light and fit like a tennis shoe and are comfortable for miles in the right terrain, but again, they are starting to leak. My other boots are Danner Pronghorns which are also comfortable, but they don't fit that great. I have to wear a thick pair of socks with another pair of thin socks to suck up the difference even with the D width boots laced as tight as they can go. I tried a new insole, but it pushed my heel up too high and I got blisters. So, basically, I'm looking for a good pair of uninsulated boots that are light weight and will last a long time that will fit my foot. I haven't really ever tried any of the higher end boots because I can't bring myself to pay that much for a pair of boots, but at this point I'm giving up and will be looking for new boots for my hunt in November. Anyone else have skis for feet and have good options for boots?


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Rolex: Safety Precautions in Place for Horses, Riders, and Spectators
- May 1, 2007
- Topics:
This support team consists of paramedics for riders and spectators, as well as a cadre of veterinarians.
Lisa Crump, DVM, an associate veterinarian for Rolex, checks the horses before they even start the competition. She offers advice to the judges, who have the final say on whether the horses are physically ready for the competition.
The horses are again checked at the end of the cross country event and the morning of the stadium jumping event. Horses are also randomly drug tested throughout the competition.
The most challenging day of Rolex features the cross country phase, which is when the support teams have to be on their toes. The morning of cross country is filled with preparation for all team members.
Two people working to ensure the safety of all Rolex competitors and attendees are Steven Morris (left), manager of Mediport, LCC, which provides medical care for horsemen and spectators, and Brian O'Connor, chief of control for the Rolex Event.
There are six or seven pods of veterinarians ready to react in case of an emergency on the course, which is divided into sections assigned to each vet pod. Each vet in the pod is connected to O'Connor and Crump via radio in order to delegate resources based on the circumstances on the course.
Crump continually watches television screens covering all the horses and riders on the course. She makes note of the slightest thing, such as a refused jump or a rail clipped by a hoof. Because of this attention to detail, Crump knows what to file in the horses' medical reports at the end of the event.
On the human care side, Steven Morris, a 20-year veteran firefighter and paramedic, is the manager of Mediport LLC, a medical coverage service for special events. He and his team of paramedics and nurses are on the scene for riders and spectators.
Morris has two fire department ambulances available (one for riders and one for spectators), and there is an emergency helicopter ready to provide immediate transportation to a hospital if required. Morris said in the 18 years he has been working the Rolex Kentucky Three-Day Event, he has only needed the helicopter once.
Morris said he "puts extra people at the 'big bad jumps' " to make sure some medics can stay behind if an accident were to happen and a rider had to be taken off course.
While most of this work goes unnoticed by the thousands in attendance at the Rolex Ketnucky Three-Day Event, those working behind the scenes ensure a safe time is had by all, whether equine athlete, human competitor, or spectator.
Dana Bouknight is a graduating senior at Midway College completing an Independent Study course in Equine Journalism. Her visit at the main tent at Rolex was made possible through the courtesy of announcer Nigel Casserly of the National Steeplechase Association. Her supervising professor is Kimberly Tumlin, PhD.
About the Author
Dana Bouknight
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SWORDS, Ireland--(BUSINESS WIRE)--Ingersoll-Rand plc (NYSE:IR), a world leader in creating and sustaining safe, comfortable and efficient environments, announced today that Michael W. Lamach, chairman and chief executive officer of Ingersoll Rand, will discuss the company's long-term strategy, starting at 12:30 p.m. ET, Thursday, February 21, at the Barclays 2013 Industrial Select Conference in Miami.
The live webcast will be accessible on the Ingersoll Rand website at http://www.ingersollrand.com and on the Barclays Industrial Select Conference website at: http://cc.talkpoint.com/barc002/022013a_lp/?entity=19_4UTC4V8
An archive of the webcast will be available for 30 days following the event on the Ingersoll Rand website.
About Ingersoll Rand
Ingersoll Rand (NYSE:IR) advances the quality of life by creating and sustaining safe, comfortable and efficient environments. Our people and our family of brands — including Club Car®, Ingersoll Rand®, Schlage®, Thermo King® and Trane® — work together to enhance the quality and comfort of air in homes and buildings; transport and protect food and perishables; secure homes and commercial properties; and increase industrial productivity and efficiency. Ingersoll Rand is a $14 billion global business committed to a world of sustainable progress and enduring results. For more information, visit www.ingersollrand.com.


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Home > Eyeglasses > Liu Jo > LJ2651 (049)
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LJ2651/049 Eyewear
With these designer eyeglasses, you are always perfectly dressed. The LJ2651 is available in the Edel-Optics online shop in other styles from Liu Jo collections 2017 and 2018.
This Liu Jo model is an all-rounder, equally suiting men and women. Wearing full rim eyewear, you make it unmistakably clear that you are going the whole hog. Rectangular models are particularly suitable for round and oval faces. The rectangular shape also builds a bridge to corners and edges from an image aspect. The first-class craftsmanship of acetate frames meets the highest quality standards. This extremely lightweight material also guarantees maximum comfort.
With the help of our digital dispensing optician, your prescription lenses can be configured according to your own requirements. Anti-reflective and cleaning coatings, antistatic and lotus effect are included as standard for plastic lenses.
The next shipment is on its way, so we will have your Liu Jo back in stock very soon. We hope the unbelievably low price will be a consolation for the short wait. And because Edel-Optics is a paradise for bargain hunters, you can get this top model at an incredibly low price. What is labelled as "in the sale" at other online shops, is for us "all-day-everyday" prices.
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Discussion in 'Pro Match Results and Discussion' started by sandiegoman, Jan 17, 2013.
Who do you think will win?
Wawrinka in 4.
I haven't seen Querrey play a ton but watching this match he seems to have all the tools to be a top 15 or maybe top 10 player. He is ripping his forehand all over the court. Holding his booming serve well. Had a couple break opportunities but couldn't convert. Comes to the net more than most players nowadays and won points there. Warwinka started to play to his backhand more which is serviceable but not threatening. Yet Warwinka is up 2 sets??? Warwinka's strokes in comparison don't appear to be as heavy. His forehand lands just past the service box a lot. His topspin 1HBH is good and he seems to be able to get some sick angles on it for winners. his first serve is also beastly. So is Querrey's achilles heal mental?
Stan takes it. 7-6, 7-5, 6-4.
It's too bad Baker didn't get a shot against Wawrinka. That would be a match I'd love to see.
Wawrinka was playing so well, I don't think that Baker would have stand a chance against him.
Anyway, beautiful shirt he was wearing.
Querrey has two weapons, serve and fh. For opponents who are terrified by these weapons he usually kicks butt. But for opponents who can defuse these weapons he is totally lost. His game relies too much on these weapons and they can be liability as well as weaponry depending on the opponents. Strangely it's the story for so many young American players. Such game lacks versatility and resiliency.
Wawrinka hit some backhand winners that stunned my eyes. Didn't see his BH so consistent since 2008. And that's quite a lot of time.
Stan has the complete game. He was serving bigger than Querry today which really surprised me. Just too often he folds against the top 4 guys, without playing his best.
I have seen Wawrinka blow away guys like Almagro, Tipsy, Berdych and even Ferrer who are all ranked higher than him. He really needs to get his ranking up to avoid playing the top 4 in the second week.
Why doesn't SamQ have a slice backhand? He's like one of the women out there who only hit two-handed backhands, like Sharapova. With his game and footwork he needs a slice.
Best backhand in history of the game won. Querry forgot this fact.
The Worm stayed close with The Donkey. Let's hope Wawa can take inspiration from this and give a better result than his normal output vs Djok.
Wawa is much more talented/solid than Querrey. No contest there.
Separate names with a comma.


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I dont understand none of this .. what reason did Melo have to go to the Boston departure bus? reason for suspension.
whatever the reason it started on the court, and shouldve ended on the court.
Word on the net/media are "Honey nut Cheerios" .. an accident elbow to KG face wouldve been worth a suspension, plus made me proud of Melo.
It just dont make any sense.
All this foolishness Melo has been doing in New York has made me into Amare-Fan, Billups-fan, LinSanity-Fan, Douglas-fan, Fields-fan.


text: Hello all... There are three of us that are doing the Trans America Trail this summer. We are leaving from Delaware on July 5th to travel to Jellico, TN. Try our best to sleep that night and then get up and hit the trail on July 6th. I am looking for any all advice on this trip / trail. If you have ridden the trail please let us know what to see and to watch out for. You can see our site here: www.crosscountryride.com Thank you so much for your time - Dallas


text: Says a lot. Leading up to the Super Bowl here are first rounders we had: Brad Hopkins Henry Ford Steve McNair Eddie George Kenny Holmes Kevin Dyson Jevon Kearse Quite the difference. Not all were stars but no real busts. eakest in that group was probably Kevin Dyson. Dyson was not Randy Moss but ended up a solid player before blowing his knee out.


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There's been other threads discussing this and I wondered if this issue be eventually sorted?
I had the same problem as the other people (PHP application developped locally) and lost a day's work trying to figure out what the problem was.
Adding localhost and 127.0.0.1 to the privacy site list doesn't work.
Leaving the ad blocking(??) on doesn't work
Disabling privacy for browser in progam control IS NOT AN OPTION
Operating System:Windows XP Pro
Product Name:ZoneAlarm Internet Security Suite
Software Version:6.5


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For the sixth year in a row, Kaiser Permanente is the only health plan in California to earn a four-star rating, the highest possible, for overall quality of care in the annual Healthcare Quality Report Card from California's Office of the Patient Advocate (OPA).
Kaiser Permanente operates a clinic in Pleasanton and has other clinics and medical centers in Northern and Southern California.
The medical group also received four stars in the "Patients Rate their HMO" category, which measures members' satisfaction with their care and service.
The 2014 report card (http://www.opa.ca.gov/report_card/) provides California consumers with side-by-side comparisons of the largest health plans in the state. It ranks the health plans on national standard-of-care measures that involve treatment and prevention of a range of conditions that have significant implications for personal health.
Of the 10 HMOs and six PPOs compared in the report card, Kaiser Permanente alone had the top rating for overall clinical-care measures.
"Kaiser Permanente Northern California is transforming health care with its integrated care model, a system in which each member's team of care providers works in concert to ensure the best possible care and outcomes," said Gregory A. Adams, group and regional president of Kaiser Foundation Hospitals/Health Plan Inc., in Northern California.
"We also understand that good health extends beyond the doctor's office and the hospital," he added. "For more than 60 years, we have been committed to helping people lead healthy lives and improving the health of the communities we serve."
This year, Kaiser Permanente in Northern California earned four stars in eight of the nine report-card categories for clinical care, including asthma and lung care, cancer screening, diabetes care, heart care, maternity care and "getting the right care" for both adults and children.
"Today, Kaiser Permanente is the leader in quality and service and a model for health care in this country," said Dr. Robert Pearl, executive director and CEO of the Permanente Medical Group.
"By attracting the best physicians and providing them with cutting edge technology, our patients receive the best and most convenient care possible," he added. "As health-care reform shifts the emphasis from quantity of care to quality of care, Permanente medicine is the model that physician groups across the nation are increasingly trying to emulate."
Since 2012, the National Committee for Quality Assurance, the premier organization measuring the performance of health-care providers in the U.S., has been a partner with the OPA in developing the annual report card in California.
The 2014 OPA ratings follow several other recent honors received by Kaiser Permanente:
• Kaiser Permanente's Medicare plans in California received a 5-star rating for 2014, the only health plan in the state to get the top rating, and one of only 11 plans in the nation to get a 5-star rating from the Center for Medicare and Medicaid Services. More than 430 plans were rated, and 2013 was the third straight year Kaiser Permanente in California has received 5 stars.
• Kaiser Permanente Northern California was ranked the top commercial health plan in the state, and 7th in the Committee for Quality Assurance's 2013 survey of health plans in the U.S. In the same survey, Kaiser Permanente Northern California's Medicare plan was ranked 2nd-best in the nation of the more than 400 plans surveyed.
• Ten Kaiser Permanente hospitals in Northern California were named Top Hospitals in 2013 by the Leapfrog Group. Only 90 hospitals in the nation, out of more than 1,300 surveyed, received this honor.
• Twenty Kaiser Permanente hospitals in Northern California received "A" grades in the Leapfrog Group's 2013 Safety Scores.
• Fourteen Kaiser Permanente hospitals in Northern California were ranked as Top Performers in 2013 by The Joint Commission.
• Kaiser Permanente members rated the organization's health plan highest in member satisfaction in California for the sixth consecutive year in the 2013 U.S. Member Health Plan study by J.D. Power and Associates.


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This Saturday's MLS Cup against the Houston Dynamo may be David Beckham's final game for the LA Galaxy, but according to MLS commissioner Don Garber, he could return to the organization as an owner.
During his state of the league teleconference on Monday, MLS commissioner Don Garber confirmed that interest exists between Beckham and the league for the 37-year-old midfielder to own an MLS club when he decides to retire. The MLS commissioner admitted that the only place that Beckham could not exercise his option was with a potential club in New York City, leaving an option open for investment in the Galaxy.
"There is a possibility for him to work with the league office to find ways to transfer that option into an opportunity in LA," said Garber. "It is way too premature to even talk about that or to even speculate what that would look like, but that opportunity does exist, if it meets the approval of the league, who in essences holds that value. David holds the option and the LA Galaxy would need to be part of the discussion."
The Los Angeles Times mused on this possibility last week after Beckham announced that he'll play his final game with the Galaxy on Dec. 1 in the 2012 MLS Cup against the Houston Dynamo.
In his press conference last week, Beckham reaffirmed his interest in an ownership stake in an MLS club.
"My commitment to the league since I came six years ago stays the same," said Beckham. "I still want to be part of the league; I still want to be an ambassador for this sport in this country and around this country and that continues."
Garber stated that there was "a lot of work to do to figure out how this option gets exercised," but six years removed from Beckham's signing, the commissioner admitted there are "no regrets" with the decision to offer Beckham the option to become an owner.
"At that time, remember where Major League soccer was. I believe we had 12 teams in the league. We had not yet had the television relationships that we have today. We had probably half the number of soccer stadiums and the league was just more immature," said Garber. "What we were looking for was a long-term partner in building this league, someone who was committed to working with us in creating more value for everyone. That's the role that David played. "
Audio of commissioner Garber's complete state of the league address can be found here


text: |Employment Cost Trends: The Employment Cost Index measures the change over time in the cost of labor. The cost of labor includes wages and salaries and employer costs for employee benefits. The quarterly data covers establishments of all sizes in private industry (excluding farms and households) and the public sector (excluding federal government) for all of the United States.


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The acceptance of portable home-based polysomnography together with auto-titrating CPAP has bypassed the need for a laboratory polysomnography. Since bilevel airway pressure (BPAP) is titrated in the sleep lab, patients diagnosed using portable home-based polysomnography may not have the opportunity to receive BPAP. It is unknown whether the patients who would have ordinarily received a BPAP would benefit from it. We determine correlates of receiving BPAP and of being switched from BPAP to CPAP. We examine whether patients with these correlates have better adherence to BPAP versus CPAP.
Retrospective Cohort Study (Correlates at baseline) of 2,513 VA patients with a sleep study between January 2003 and October 2006 and receiving continuous or bilevel positive airway pressure (CPAP [N = 2,251]) or BPAP [N = 262]) by the end of 2007. PAP adherence up to 30 months was assessed.
Significant correlates of BPAP were older age (p < 0.001), higher BMI and CHF (p < 0.01), COPD (p < 0.001), higher blood CO2 (p < 0.05), higher AHI and OSA severity (p < 0.001), lower nadir SpO2 (p < 0.001), and greater sleepiness (ESS) (p < 0.01). Patients on BPAP were more adherent to PAP therapy (p < 0.01), but the association largely disappeared following adjustment for BPAP correlates. There was preliminary evidence that these correlates predict long-term adherence to PAP therapy regardless of mode.
We identified baseline factors that can help clinicians decide whether to prescribe an auto-BPAP as first-line therapy and that predict good long-term PAP adherence.
A commentary on this article appears in this issue on page 337.
Schwartz SW; Rosas J; Iannacone MR; Foulis PR; Anderson WM. Correlates of a prescription for bilevel positive airway pressure for treatment of obstructive sleep apnea among veterans. J Clin Sleep Med 2013;9(4):327-335.
Obstructive sleep apnea (OSA) afflicts 1 in 5 adults in the US.1,2 Continuous positive airway pressure (CPAP) is a highly effective treatment for OSA, eliminating almost all apneas, improving quality of life,3 and reducing accident rates4–6 and coronary events, including mortality.7–9 However, adherence to CPAP may be as low as 50%,10,11 thus limiting benefit. A probable reason for CPAP discontinuance is pressure intolerance12,13; Lojander reported that 29% of his study patients had difficulty expiring against pressure.12
A remedy for pressure intolerance is bilevel continuous airway pressure (BPAP).14,15 BPAP is more expensive than CPAP16 but allows for a difference between inspiratory and expiratory pressures, resulting in more normal breathing for some patients.15 While two randomized clinical trials showed no difference in compliance (at 1 and 3 months, respectively) between BPAP and CPAP in small groups of OSA patients,16–18 patients non-adherent on CPAP often became adherent when switched to BPAP.19,20 BPAP is helpful to patients with hypoventilation15,21,22: one study showed excellent compliance with BPAP in patients with alveolar hypoventilation, resulting in marked reduction of hypercapnia.15
Sleep laboratories generally have a CPAP titration protocol that includes provisions for recommending BPAP instead. Due to the expense and limited availability of the sleep laboratory, however, many OSA patients are instead diagnosed at home using portable equipment, then prescribed auto-titrating CPAP if there is a positive OSA finding. In the James A. Haley Veterans hospital (JAHVA), one of the largest VA hospitals in the United States, 44% of patients prescribed CPAP are diagnosed outside the sleep lab.26 The opportunity for such patients to initially receive a BPAP is thus severely curtailed. Because long-term adherence to CPAP is highly associated with initial comfort,27 it is possible that inability to prescribe BPAP may be a factor in long-term non-adherence: many patients may simply stop using CPAP rather than request an alternative. Knowledge of patient factors that correlate strongly with BPAP preference would allow clinicians to priority-triage patients for in-laboratory full CPAP titration protocol or to prescribe auto-titrating BPAP.
Current Knowledge/Study Rationale: Sleep laboratories generally have a CPAP titration protocol that includes provisions for recommending BPAP, but many OSA patients are now diagnosed at home using portable equipment. Knowledge of patient factors that correlate strongly with BPAP preference would allow clinicians to priority-triage patients for in-laboratory full CPAP titration protocol or to prescribe auto-titrating BPAP.
Study Impact: Our data indicate that, when laboratory titration is not available, correlates of a BPAP prescription, including severity of OSA and concomitant COPD, among others, may be strong and robust enough to be useful in the decision to use a BPAP as first line therapy. We suggest that evidenced-based recommendations could be developed just based on specific comorbidities for first-line prescription of CPAP alternatives including but not limited to BPAP.
We are aware of only one small study of correlates of a BPAP prescription.13 It found that patients who required BPAP were more obese, had higher apnea-hypopnea index (AHI), lower mean SpO2, lower FEV1 and FVC, and were more likely to have COPD and hypercapnia. More information is needed to guide clinical decisions. Our objectives were to (1) determine correlates of an initial BPAP prescription; (2) determine correlates of later being switched from CPAP to BPAP; and (3) examine whether adherence differs depending on PAP mode and whether these correlates predict better adherence to BPAP versus CPAP.
The data come from a retrospective chart review of JAHVA patients to investigate the consequences of a procedural change from laboratory to home-based diagnosis and treatment of OSA. In mid-2006, 3,415 unique patients were identified from among 4 databases: (1) JAHVA Vista with a CPT code indicating a full lab polysomnogram; (2) pulmonary office prior-appointment schedule for the sleep lab; (3) pulmonary staff's log-out list for portable sleep diagnostic equipment; and (4) pulmonary quality control (QC) PAP adherence database.
Patients who never received a PAP (N = 304), had no Pap adherence data (N = 313), received a sleep study at JAHVA but received therapy and follow-up elsewhere (N = 198), whose PAP records started before January 1, 2002, or after December 31, 2007, or with no visit records in the year prior to their PAP (N = 87) were excluded. The latter exclusions ensured that all patients in the analysis would have a year of preexisting morbidity data and ≥ 3 years of PAP adherence data. Thus, our final dataset included 2,513 patients with sleep studies between January 2003 and October 2006 and who received CPAP or BPAP by December 2007.
The 2,513 patients included 1,220 patients with a sleep study in JAHVA lab, 870 patients with a sleep study from an outside lab, and 423 patients diagnosed in their home with portable equipment.
Although data were obtained retrospectively, an understanding of how a patient receives BPAP is necessary for context. To date, patients at JAHVA do not receive a BPAP without a sleep laboratory titration, occurring either inside or outside the VA. For initial BPAP prescription JAHVA Sleep laboratory technicians follow a PAP titration protocol that includes specific provisions for recommending BPAP rather than CPAP—for example, when CPAP exceeds 15 cm water and/or the patient begins to complain about exhaling against the pressure. A patient initially receiving a CPAP may be switched from CPAP to BPAP as follows: PAP compliance data is downloaded, and patients with problems (non-compliance or unresolved apnea) are sent a form letter requesting they make an appointment at the respiratory PAP clinic. The PAP technician then refers the patient to the sleep laboratory for a titration study if: (1) the patient stills feels sleepy; (2) download data show uncorrected apnea although the patient is using the PAP, and/or (3) the PAP is set on maximum pressure (> 15 cm) with unresolved apnea.
PAP adherence data from April 1, 2003, through October 2011 were obtained. Patients were asked to return their PAP card for download at 1 month, 1 year, and annually thereafter. PAP adherence data included therapy (BPAP or CPAP) and daily adherence records from the first date PAP was turned on. We defined 4 intervals: 2 weeks (days 1-21), 6 months (days 169-198), 18 months (days 534-563), and 30 months (days 899-928). We calculated average daily usage by taking the total number of hours used divided by the number of days in the interval and defined good adherence as average use ≥ 4 h per day. For patients who switched from CPAP to BPAP, adherence was measured separately for time on the respective therapy modes. Four patients who switched to BPAP within the first 30 days of PAP use did not contribute to CPAP adherence data.
Measures from sleep studies (apnea-hypopnea index [AHI], nadir oxygen saturation [SpO2], and total score on the Epworth Sleepiness Scale [ESS]) were obtained from the last baseline lab study if the patient had one; from the last laboratory pretitration period from the split study if the patient only had a split study; and from the last portable sleep study if no lab sleep study was available. For some patients, particularly those with sleep studies outside the JAHVA, a diagnosis including severity of apnea was available, but not actual AHI. When AHI was available, we used it to define OSA severity as none/mild (0-14.9), moderate (15-29.9), and severe (≥ 30). There was a difference in completeness of sleep data available to us for in-house versus external lab polysomnography and for portable diagnosis. For patients bringing in their sleep study results from outside, a severity of apnea measure was available, but an explicit AHI or nadir SpO2 was somewhat less likely to be captured in the pulmonary database. ESS was only rarely captured from outside lab studies. Patients diagnosed using a portable system often did not have an ESS.
The index date for evaluating comorbidities is the date the patient first received a PAP prescription. Demographics, laboratory, vital signs, pharmacy, outpatient and inpatient records from 2002 through March 2010 were reviewed. We determined comorbidities, using ICD-9 codes for any outpatient or inpatient visit from 1 year prior to PAP start through 6 months after PAP start. We also summarized data for hypertension (ICD 401-405), diabetes mellitus (ICD 6), heart failure (ICD 402, 425, 428), COPD (ICD 491-494, 496, 415.0, 416.8, 416.9), thyroid disorders (ICD 242-244), depression (ICD 311), traumatic stress disorder (ICD 309.81), and combined physical neurologic disorders (ICDs 323, 331-337, 340-342, 344, 358). The Charlson Morbidity Index was calculated using the method of Deyo.28 Tobacco abuse was evaluated across all available records pre or post PAP start. BMI was taken as the mean of the value closest to the index date within one year before PAP start and the value closest to the index date within one year after PAP start, if both were available; otherwise, only one measure was used. The closest venous sample CO2 taken within one year prior to PAP initiation was used. Most were plasma samples, but for 30 patients without CO2 measures, we used arterial bicarbonate measure (Table 1).
Number of patients with non-missing values for each covariate or outcome
(more ...)
We did two complete sets of analyses using patients with full laboratory polysomnography to meet this objective: (1) an analysis restricted to patients with a study conducted at JAHVA sleep lab; (2) an analysis that included all patients diagnosed in a sleep lab, whether at JAHVA or from outside. The most obvious difference between JAHVA and outside lab patients was the presence of an ESS measure, but there might also be patient differences between groups; during some of the baseline years, there was a 2-year wait for the JAHVA sleep lab, so patients going outside might have had alternate insurance or be more concerned about their health.
The Wilcoxon rank-sum test (continuous variables) or χ2 test (categorical variables) were used to screen correlates. Associations are presented as odds ratios (BPAP vs CPAP), given levels of categorical variables (or categorized continuous variables) from logistic regression. To find the best predictive models, covariates in Table 2 were entered into stepwise logistic regression procedure, with selection probabilities to 0.2 to enter and 0.1 to stay in the model. For continuous variables, we examined both the raw variable and categorized variable for better fit. Lastly, we re-ran the final stepwise model on the full dataset to minimize loss of observations due to missing values. Because ESS was usually available only for patients diagnosed in the JAHVA lab, it was included in stepwise analyses only when the analysis was restricted to JAHVA lab patients.
Objective 1: Summary* of potential correlates of an initial BPAP vs CPAP prescription
This analysis included all patients in our dataset except those initially prescribed BPAP. Patients who were originally diagnosed using portable equipment were included along with lab-diagnosed patients, as they provide more cases of patients initially prescribed CPAP who were switched later to BPAP. This objective is evaluated by comparing CPAP patients switched to BPAP vs. those remaining on CPAP using the same analysis methods and strategy described for objective 1.
Adherence was compared between CPAP and BPAP recipients within the entire cohort (N = 2,513), separately by time period, using univariate logistic regression. To determine if differences in adherence were due to differences in patient characteristics (e.g., comorbidities) or qualities of BPAP itself, we conducted the comparison controlling for patient differences as described below. These analyses used the 1,765 (of 2,513) with non-missing covariate data (Table 1).
Simultaneous control of all covariates was accomplished using propensity scores (PS).29 The PS is an individual's probability of BPAP receipt based on his/her covariates, as calculated from logistic regression. The PS can be considered a summary of that person's covariates, where high PS reflects a patient whose covariates are associated with receiving BPAP and low PS a patient whose covariates are associated with receiving CPAP, irrespective of actual mode received. Propensity scores for patients diagnosed with portable equipment were calculated using coefficients from the model developed from sleep lab patients, as exp (α + βX) / [1 + exp(α + βX)] where βX denotes the sum of age, BMI, COPD, any neurology diagnosis, AHI, and SpO2, each multiplied by its respective logistic coefficient.
We divided patients into two groups: those with covariates likely to lead to BPAP prescription (PS in top 25%) vs. those less likely (PS in bottom 75%), irrespective of mode prescribed. Then within each of these PS strata, we evaluated the difference in adherence for BPAP recipients vs. CPAP recipients separately by time point. Secondly, we ran bivariate models comparing therapy mode (BPAP versus CPAP), controlling for PS stratum (top quartile vs. lower three).
If the "right" patients are receiving BPAP then we expect superior adherence with BPAP (vs. CPAP) would be greater among patients with a higher propensity score for receiving BPAP. We addressed this by adding a therapy-by-PS-stratum interaction term to the models for this objective.
Patients ranged in age from 21 to 90 years (mean 59.7 ± 11.1). The sample was 95% male and 86% white, and BMI ranged from 15 to 69 (mean 34.6 ± 7.1; data not shown).
Unadjusted results (means or percentages) for Objectives 1 and 2 are given in Tables 2 and 3, respectively. Unadjusted odds ratios are given for important covariates (both objectives) in Table 4. For Objective 1, results for JAHVA-lab and anylab diagnosed patients diagnosed were very similar (Table 2), so we refer here only to the latter. Baseline factors that differed significantly between groups, predicting both the initial BPAP prescription (Tables 2, 4) and a later change to BPAP (Tables 3, 4) were higher BMI (OR 2.69 and 1.67, respectively), heart failure (OR 1.82 and 1.91, respectively), higher blood CO2 (OR 1.74 and 2.11, respectively), severe OSA (OR 4.27 and 2.52, respectively), and a lower nadir SpO2 (OR 2.97 and 1.88, respectively) (Tables 2–4). Additional factors associated with the initial BPAP prescription were COPD (OR 2.37), the overall morbidity index 2+ vs < 2 (OR 1.80, not shown); and ESS (OR 2.17 modeled only with patients with a JAHVA lab sleep study).
Objective 2: Summary* of potential correlates of being switched from CPAP to BPAP vs remaining on CPAP
Odds ratios for BPAP receipt for categories of selected characteristics
The final stepwise models showed BMI, COPD, and AHI as independent joint predictors of both an initial BPAP prescription and a later change from CPAP to BPAP. Additional predictors of an initial BPAP prescription were age and nadir SpO2. Among the JAHVA-lab tested patients, ESS was selected by the stepwise procedure. In the final stepwise models, a neurologic disorder was also a predictor of receiving BPAP, and blood CO2 emerged as a predictor of later change from CPAP to BPAP (Table 5), though this was due to the liberal modeling criteria: p = 0.2 and p = 0.1 for entry and staying, respectively.
Final multivariate models: results of stepwise selection*
Patients prescribed BPAP appeared more compliant than those prescribed CPAP, both immediately and long-term (Table 6, Figure 1). Initial (2-week) adherence was 67% and 55% on BPAP and CPAP, respectively, and at 30 months 85% vs. 74%, respectively (OR 1.98, 95%CI 1.16-3.38). CPAP patients later switched to BPAP were initially much more compliant than those not switched (75% versus 54%), with a trend toward better adherence with BPAP persisting at later time points.
Comparisons between groups on PAP adherence, total unadjusted, stratified by propensity score, and adjusted for propensity score*
(A) Percentage of patients, initially prescribed BPAP versus CPAP, using PAP on average more than 4 h/day (based on entire cohort of 2,513 patients). (B) Percentage of patients switched to BPAP versus remaining on CPAP, using PAP on average more than 4 h/day.
Adjusting for patient differences between BPAP and CPAP reduced the observed improved adherence with BPAP to nonsignificance for all time points except 2 weeks (Table 6). Associations were sometimes lower for each propensity group than overall, which indicates that patient correlates confound and are partially responsible for the association between BPAP and adherence.
Interestingly, propensity score stratum turned out to be a highly significant predictor of adherence for all time points after 2 weeks, even when controlling for therapy mode (Table 6). The interaction between therapy mode and PS was not signifi-cant (p > 0.25), nor was there evidence of interaction between propensity score and being switched to BPAP (data not shown).
We determined that independent correlates of a BPAP prescription include older age, higher BMI, COPD, elevated blood CO2, severe OSA, low nadir SpO2, and sleepiness. We found that these correlates tended to be robust. Further, we found that a summary measure of these indicators predicts long-term adherence to PAP therapy.
Some comorbidities such as CHF were—on their own— highly significant predictors of BPAP, but were not significant when controlling for other factors. This only means that they are redundant with other correlates. CHF may manifest in low nadir nocturnal oxygen and possibly higher AHI.
We did obtain some preliminary evidence of an association of a BPAP prescription with neurologic disorders, which included Parkinson disease, ALS, and MS, after adjustment for other factors. Such patients may not have adequate muscle tone to exhale against higher pressures. There are several reports of the helpfulness of BPAP in patients with ALS and neuromuscular disorders.33,34 We did not find an association with diabetes, hypertension, thyroid disorders, depression, traumatic stress disorder, race, Hispanic origin, or marital status.
At JAHVA, BPAP is recommended during laboratory titration by the attending technician according to protocol. Given the VA laboratory protocol, it is highly likely that the correlates we identified are all associated with either difficult-to-treat apneas or patient difficulty expiring at higher pressure. Our findings emphasize that patients identified by this protocol tend to have specific comorbidities that are prominent indications for BPAP in the literature. For example, a recent clinical trial from Russia on COPD patients indicated that BPAP was much more effective than CPAP in affecting the desaturation index.30 It now appears that many clinicians are accepting BPAP as the standard of care in patients with hypercapnia and hypoventilation syndrome.31,32 Indeed, obesity-hypoventilation syndrome may explain the strength of the association we noted between high BMI and a BPAP prescription.
It has been stated that the benefits of BPAP and other advancements to CPAP remain unproven.37 We saw overall improved adherence among BPAP versus CPAP patients, but the difference largely disappeared after controlling for patient characteristics. In our data, the improved adherence among BPAP recipients appears to be related to patient characteristics. While others have reported that severity of OSA and/or low nadir SpO2 predict adherence,38,39 our propensity score—a summary measure of several patient characteristics—was a stronger predictor of long-term PAP adherence than BPAP itself. It appears that in finding correlates of BPAP prescription, we may have serendipitously created a method to predict long-term PAP adherence.
Previous clinical trials that found no benefit to BPAP16–18 may be misleading if interaction (persons with severe disease do better on BPAP but those with less severe do not) obscures an overall effect. We were unable to demonstrate a comparative benefit of BPAP versus CPAP among sicker patients. This may be due to relatively low statistical power to test interaction. This question should be studied further either by looking at interaction in a still larger study, or (if ethical) by a comparative randomized clinical study restricted to patients with high propensity for receiving BPAP.
The baseline measures for nearly all patients in our study were collected before the Portable Monitoring Taskforce (PMT) published their clinical guidelines on which OCST guidelines are based, in 2007.40 Prior to the PMT publication and our own quality control studies, JAHVA patients were triaged to a portable or laboratory sleep study based on patient preference and/ or the triage nurse's judgment as to whether the patient would successfully complete the unattended sleep study. Most of the correlates that we highlight—older age, COPD, CHF, and indirectly obesity hyperventilation syndrome (higher BMI and blood CO2)—are listed in the PMT guidelines either as contra-indications for portable monitoring or necessitating caution because patients with these conditions have not been adequately studied. Our study provides strong empirical support for following these guidelines: patients undergoing diagnosis with portable equipment simply do not have simultaneous access to a titration study necessary to dispense appropriate treatment to those who require devices beyond CPAP.
Our data indicate that, when laboratory titration is not available, correlates of a BPAP prescription may be strong and robust enough to be useful in the decision to use a BPAP as first line therapy. Given the high prevalence of OSA coupled with comorbidities, especially among Veterans, we pose the question of whether evidenced-based recommendations could be developed just based on specific comorbidities, for first-line prescription of CPAP alternatives including but not limited to BPAP.
Our data were retrospectively collected from patient electronic charts, and correlates, including blood CO2, could have been assessed a full year before PAP was dispensed. Since data from BPAP and CPAP patients are handled the same way, misclassification (if it occurred) would be non-differential and make groups more similar rather than exaggerate associations.35,36
Further limitations of this study include the fact that type of apneas (obstructive versus central) was not captured. Similarly, while the propensity score summarizes key comorbidities, it does not include comorbidities or other patient characteristics for which data were not available. There is a potential limitation in adherence data if the likelihood of patients returning adherence cards was related to adherence itself (i.e., poor adherers less likely to submit data). Unfortunately it is not possible to detect or correct for this analytically; however, it is unlikely that this behavior (if it occurred) would differ between BPAP and CPAP groups and therefore bias our results. There is also an additional bias at later time points created by patients being switched to BPAP. If a patient switches from CPAP to BPAP late in the study because of trouble with CPAP, he is excluded from the CPAP group at the time of the switch. The direction of the bias depends on whether these patients would have remained adherent to CPAP had they not been switched to BPAP. If not, then once again, our results are understated. We see no way to address this particular limitation analytically.
Strengths of the study include the large sample size and the consistency of overall results (e.g., all sleep lab patients with JAHVA sleep lab patients).
In summary, we determined that such morbidity indicators as older age, high BMI, COPD, blood CO2, OSA severity, nadir SpO2, and sleepiness can perhaps be used to decide whether BPAP should be used as first-line therapy when PAP titration is not part of the diagnostic procedure. This would speed up time to appropriate treatment and make more efficient use of sleep labs. Further, we found that a summary measure of these indicators predicts long-term adherence to PAP therapy in general. We recommend future research to develop and confirm an algorithm that can be used to decide whether to prescribe an auto-BPAP and to predict long-term adherence. We also recommend that future research on the comparative efficacy and cost effectiveness of BPAP be restricted to patients who would normally be prescribed a BPAP. Lastly, our retrospective study had no opportunity to measure PAP-related quality of life. While our results highlight that sicker people are more adherent to PAP therapy, regardless of type, it may be that they are more comfortable and enjoy better quality of life using BPAP. More research is needed in this area as well.
This was not an industry supported study. The authors have indicated no financial conflicts of interest.
The authors gratefully acknowledge JAHVH for its support of this research. The views expressed here do not necessarily reflect the views of the Veterans Administration. This material is the result of work supported with resources and the use of facilities at the James A. Haley Veterans Hospital, Tampa Florida, Office of Research and Development Health Services Research and Development Service, and Rehabilitation Research and Development. This study was approved by the Research and Development Committee, James A. Haley Veterans Hospital and Institutional Review Board, University of South Florida. There was no financial support and no author has a conflict of interest. The authors also gratefully acknowledge the editorial assistance provided by Debra Weiner.
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text:
El Presidente' Again Has Our Hearts
He is one of the most beloved player to ever strapped on a Rays uniform. Beloved as much for the deeds and efforts he displays on the field as those done within the Tampa Bay community. Maybe it seems fitting with the 2012 Republican National Convention coming to Tampa this Summer, El Presidente aka Carlos Pena could easily run for President and could easily win everywhere but possibly within the 5 boroughs of New York today.
Can anyone else remember a Rays moment when we ever gave 5 standing ovations, and not just to a single player. You read that right, 5 times Pena heard the 30,000+ wedged into the tilted cap of the Trop call for him, cheer for him, wanting him to hear and acknowledge their spirited roar. Pena not only took a "curtain call" after his memorable grand salami off New York Yankee starter CC Sabathia. But who would of expected his final action on this day would not only returned the favor, but burst out a resounding and almost fantasy storyline to the already volume of stories that is the "Legend of 'Los".
There will be some in the Yankee fan-dom that will say Pena just " bent into a few bad pitches", but those same white spheres came from anointed Yankee legendary figures. Pena's grand slam off Sabathia was the first one ever given up to a left-hander in his long career. Mariano Rivera who might be canonized and made a NYC saint someday was going for save # 604 before Pena deposited the deep shot to Left-Centerfield that sent this stadium into a frenzy akin to Game 162.
Not a single Yankee fan will ever acknowledge this but the insane sound of the ball off Pena's bat yesterday sent New York Yankee hearts sinking while a whole stadium instantly again fell back in love with him, almost like he never took a 180 day vacation to Chi-town.
After the game Pena " did his dance" during the Rays 15-minute celebration phase of their 30-minutes and move on "Rays Way" pattern, but something tells me this showcase, this performance that enlightened showed why the Rays Republic has always. Wilder still this was only the 1st act of an 162 act play. I swear it could not have been scripted any better (even by Disney) or played out with any more emotional tugs and pulls during the contest then without warning, Pena simply reached back into all of our hearts and started it beating akin to his own unique rhythm.
It seemed ironic that the same day we hoisted a banner to the rafters showing our pride for 2011 magic, Pena reminded us of what seemed missing last season. Somehow with 2 mighty swings yesterday Pena choreographed the Rays dugout back into his old Salsa groove. From Home Plate to the far reaches of the TBT Deck, on this Opening Day triumphant moment not lost in the excitement was the re-discovery of why we love El Presidente'. May his reign be supreme and his subjects filled with joy. Welcome back 'Los.
2 Comments
A toast for your team and my team for our start but you are beating on the Yankees so cheers with a shot of El Presidente!