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In obstructive sleep apnea (OSA), arousals generally occur at apnea termination and help restore airflow. However, timing of arousals in central sleep apnea (CSA) has not been objectively quantified, and since arousals can persist even when CSA is alleviated, may not play the same defensive role as they do in OSA. We hypothesized that arousals following central events would occur longer after event termination than following obstructive events and would be related to circulation time.
We examined polysomnograms from 20 patients with heart failure (HF) (left ventricular ejection fraction ≤ 45%): 10 with OSA and 10 with CSA (apneahypopnea index ≥ 15). Twenty central or obstructive apneas or hypopneas were analyzed in each patient.
Compared to the OSA group in whom arousals generally occurred at obstructive event termination, in the CSA group they occurred longer after central event termination (0.9 ± 1.1 versus 8.0 ± 4.1 s, p < 0.0001), but before peak hyperpnea. Time from arousal to peak hyperpnea did not differ between groups (4.3 ± 1.1 vs 4.8 ± 1.6 s, p = 0.416). Unlike the OSA group, latency from apnea termination to arousal correlated with circulation time in the CSA group (r = 0.793, p = 0.006).
In HF patients with CSA, apnea-to-arousal latency is longer than in those with OSA, and arousals usually follow resumption of airflow. These observations provide evidence that arousals are less likely to act as a protective mechanism to facilitate resumption of airflow following apneas in CSA than in OSA.
Simms T; Brijbassi M; Montemurro LT; Bradley TD. Differential timing of arousals in obstructive and central sleep apnea in patients with heart failure. J Clin Sleep Med 2013;9(8):773-779.
In obstructive sleep apnea (OSA), arousals occur at the end of most obstructive events,1,2 and help restore upper airway patency by activating pharyngeal dilator muscles.3 Thus, arousals generally act as a defense mechanism to reestablish airflow and prevent asphyxia in OSA. The role of arousals in central sleep apnea (CSA), however, is less clear. For example, it has been reported that arousals can occur several breaths after apnea termination in heart failure (HF) patients with CSA.4 In such cases, reinstitution of airflow prior to the occurrence of arousal suggests that such arousals may not have the same protective role as they do in OSA. In fact, arousals have been implicated in the pathogenesis of CSA by contributing to respiratory control system instability. Arousals frequently cause an abrupt increase in ventilation, which, in susceptible subjects, drives the PaCO2 below the apnea threshold, triggering a central apnea.5–7 They may also perpetuate further events by provoking ventilatory overshoot during hyperpnea by abruptly increasing chemical ventilatory responsiveness and activating the neurogenic wakefulness drive to breathe.6,7 However, the precise timing of arousals in relation to CSA has not been quantified or compared to timing of arousals in relation to OSA in patients with HF.
Many studies of patients with OSA, both with and without HF, have shown that alleviation of OSA with continuous positive airway pressure (CPAP) dramatically lowers the frequency of arousals.8–14 This observation provides further evidence that OSA causes arousals that are reversible through treatment of OSA. However, in a large, randomized controlled trial involving 258 patients with HF and CSA, alleviation of CSA with CPAP did not reduce arousal frequency.15 These findings suggest that arousals in HF patients with CSA may not be acting as a defense mechanism to the same extent as they do in OSA, and indeed, in many instances may not be a consequence of central events. These observations have given rise to the concept that arousals may play a causative role5–7 or may be an incidental finding,15 rather than serving as a protective mechanism in CSA.
Current knowledge/Study Rationale: Whereas in obstructive sleep apnea (OSA), arousals generally occur at apnea termination and act as a defense mechanism to reestablish airflow, in central sleep apnea (CSA), timing of arousals postapnea termination has not been objectively assessed, and factors related to arousal timing have not been identified. We therefore tested the hypotheses that arousals would coincide closely with termination of obstructive events, in keeping with their protective role, while they would be delayed following reestablishment of airflow after central events in proportion to circulation time, suggesting a non-protective role.
Study Impact: Among patients with heart failure, whereas in those with OSA, arousals were closely linked to apnea termination and were unrelated to circulation time, in those with CSA arousals occurred at longer and more highly variable latencies following apnea termination that were proportional to circulation time. These findings suggest (1) unlike OSA, arousals in CSA do not serve the same protective role in facilitating airflow reestablishment following apneas, and (2) in contrast to OSA, their timing is influenced by cardiac function and circulation time.
Although suppression of CSA by CPAP may not reduce total arousal frequency, the assumption that arousals are therefore not involved in facilitating resumption of respiration at the end of central apneas remains speculative. While it has been reported anecdotally that arousals usually occur several breaths after termination of central events in HF patients,4 the actual timing of arousals was not quantified. We therefore compared the timing of arousals with respect to apnea and hypopnea termination between HF patients with OSA and those with CSA. We therefore tested two hypotheses: (1) that arousals would coincide more closely with termination of obstructive events (in keeping with their protective role), while they would be more delayed until after reestablishment of airflow following central events; and (2) that owing to the longer delay of transmission of blood gas tensions from the lungs to the chemoreceptors in HF patients with CSA than in those with OSA,16 arousals following central events, but not obstructive events, would be related to circulation time.
Consecutive patients with HF were recruited from Mount Sinai Hospital Heart Failure Clinic in Toronto as part of an ongoing prospective epidemiological study irrespective of signs or symptoms of sleep apnea if they met the following criteria: (1) men and women ≥ 18 years of age; (2) HF with left ventricular systolic dysfunction (left ventricular ejection fraction [LVEF] ≤ 45% by radionuclide angiography or echocardiography) secondary to ischemic or nonischemic dilated cardiomyopathy for ≥ 6 months; (3) New York Heart Association (NYHA) class I to III; (4) stable clinical status on optimal medical therapy for ≥ 1 month before entry; and (5) moderatetosevere sleep apnea, defined as ≥ 15 apneas and hypopneas per hour of sleep (apneahypopnea index [AHI]). Patients were further classified as having predominantly OSA if ≥ 50% of the events were obstructive, or predominantly CSA if > 50% of the events were central. Exclusion criteria were unstable angina, myocardial infarction, cardiac surgery within the previous 3 months, and pregnancy. The protocol was approved by the local research ethics board, and all subjects provided written informed consent before entry.
Diagnostic overnight polysomnography was performed in all subjects using standard techniques and scoring criteria for sleep stages.17,18 Wakefulness and sleep stages were identified by central (C3/A2; C4/A1), occipital (O1/A2; O2/A1), and frontal (F3/A2; F4/A1) electroencephalogram (EEG), bilateral electrooculogram (EOG), and submental electromyogram (EMGsm) recordings from surface electrodes. Arousals were defined by American Academy of Sleep Medicine 2007 criteria,18 and arousal index (ArI) was calculated as the total number of arousals per hour of sleep.
Thoracoabdominal movements were measured by spirometry-calibrated respiratory inductance plethysmography (Respitrace; Ambulatory Monitoring, White Plains, NY) and airflow by nasal pressure cannulae (BiNAPS model 550; Salter Labs, Arvin, CA). Central apneas were defined as > 90% reduction in tidal volume (VT) ≥ 10 sec. Central hypopneas were defined as a 50% to 90% reduction in VT from baseline ≥ 10 sec either without thoracoabdominal motion, or with inphase thoracoabdominal motion and without airflow limitation on the nasal pressure tracing. Apneas and hypopneas were classified as obstructive if outofphase thoracoabdominal motion or airflow limitation was present.15 The amplitude criterion for hypopnea termination was ≥ 50% of the baseline tidal volume. The AHI was calculated. Arterial oxygen saturation (SaO2) was measured continuously with a pulse oximeter (Nellcor N200; Tyco International Healthcare, Pleasanton, CA) placed on the ear. Mean SaO2 was derived as previously described.5
Ten consecutive patients with predominantly OSA and 10 with predominantly CSA from the aforementioned epidemiological study were included in the analysis. Twenty events (apneas and hypopneas) were evaluated in each patient during stage 2 NREM sleep—10 from the beginning of the night, and 10 from the end of the night. Stage 2 sleep was analyzed, as it was the dominant sleep stage in which most events occurred and in which ventilation is predominantly under metabolic control.16 In addition, we confined data analysis to a single sleep stage to control for the potential confounding influences of different sleep stages on arousals and respiratory events. Events from both early and late in the night were analyzed in consideration of influences of possible overnight deterioration of cardiac function.19 Time from the end of an event to the beginning of an arousal (apnea-to-arousal time) and time from the end of an event to the peak of hyperpnea (apneatopeak time) were measured. Time from the beginning of an arousal to the peak of hyperpnea (arousaltopeak time) was calculated by subtracting apnea-to-arousal time from apneatopeak time. Hyperpnea time (HT) was defined as the time between the onset of inspiration of the breath terminating the apnea or hypopnea and the end of inspiration of the breath preceding the next apnea or hypopnea. Lungtoear circulation time (LECT), an estimate of lungtocarotid chemoreceptor circulation time, was measured from the end of an apnea to the subsequent nadir of SpO2 as previously described.5 This technique has been previously validated against echocardiographic Doppler as a measure of circulation time and a reflection of cardiac output.20
Data are expressed as mean ± SD unless stated otherwise. Analyses were performed using SPSS 13.0 (SPSS Inc., Chicago, IL). Data from OSA and CSA patients were compared with 2-tailed unpaired ttests for continuous variables. Nominal and ordinal variables were compared by χ2 or Fisher exact test as appropriate. Correlations among variables were performed by leastsquares linear regression analysis. P-values < 0.05 were considered statistically significant.
Characteristics of the 10 OSA and 10 CSA patients are shown in Table 1. Patients with CSA were older and had lower body mass index (BMI) than those with OSA. There were no significant differences in LVEF or medical therapy between the 2 groups. Sleep data are shown in Table 2. Total sleep time and the proportion of stages 1, 2, and REM sleep were similar between the 2 groups, but patients with CSA had a lower proportion of slow wave sleep (p = 0.021). The frequency of arousals was also similar in the 2 groups. However, compared to the OSA group, the ratio of arousals to apneas and hypopneas was lower in the CSA group (94% vs 62%, p = 0.042). With respect to sleep apnea severity, the AHI was higher in the CSA group, but there was no significant difference in the mean or minimum SpO2 between the 2 groups. The CSA patients had a significantly longer hyperpnea time and LECT than those with OSA.
Characteristics of the subjects
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Polysomnographic data
Representative polysomnographic tracings showing arousal timing with respect to the termination of apneas are shown in Figure 1. Note that in the patient with OSA, the arousal occurred coincident with the end of the event (Figure 1A). In contrast, in the patient with CSA, the arousal occurred much later after the end of the apnea, several breaths after resumption of respiration (Figure 1B). Grouped data in Figure 2 show that apnea-to-arousal time was highly variable and much longer in the CSA group than the OSA group (p < 0.0001), but occurred prior to peak hyperpnea so that arousaltopeak time did not differ between the OSA and CSA groups (p = 0.416; Figure 3). Similar to the group variability, the intraindividual variability in apnea-to-arousal time was higher in the CSA patients than in the OSA patients (mean standard deviation of 4.97 ± 2.54 vs. 1.95 ± 0.68, p = 0.002).
Representative polysomnographic recordings from one patient with OSA (A), and one with CSA (B), during stage 2 sleep. Arrows indicate the onset of arousals. Note outofphase thoracoabdominal motion during obstructive apnea that becomes inphase immediately following the arousal indicating termination of the obstructive event (A). In contrast, the arousal occurred several seconds after the end of the central event (B).
Representative polysomnographic recordingsRepresentative polysomnographic recordings from one patient with OSA (A), and one with CSA (B), during stage 2 sleep. Arrows indicate the onset of arousals. Note outofphase thoracoabdominal motion during obstructive apnea that becomes inphase immediately following the arousal indicating termination of the obstructive event (A). In contrast, the...
Time from the end of an apnea or hypopnea to the beginning of an arousal (apnea-to-arousal time) was significantly longer and more variable in the 10 subjects in the CSA group compared to the 10 subjects in the OSA group (8.0 ± 4.1 vs 0.9 ± 1.1 s, p < 0.0001). Data are expressed as means and standard deviations.
Apnea-to-arousal timeTime from the end of an apnea or hypopnea to the beginning of an arousal (apnea-to-arousal time) was significantly longer and more variable in the 10 subjects in the CSA group compared to the 10 subjects in the OSA group (8.0 ± 4.1 vs 0.9 ± 1.1 s, p
Time from the beginning of an arousal to the peak of hyperpnea (arousaltopeak time) did not differ between the 10 subjects with OSA and the 10 subjects with CSA (4.3 ± 1.1 vs 4.8 ± 1.6 s, p = 0.416).
Arousal-to-peak timeTime from the beginning of an arousal to the peak of hyperpnea (arousaltopeak time) did not differ between the 10 subjects with OSA and the 10 subjects with CSA (4.3 ± 1.1 vs 4.8 ± 1.6 s, p = 0.416).
Apnea-to-arousal time was strongly related to LECT in patients with CSA (p = 0.006, Figure 4A), but not in those with OSA (p = 0.107, Figure 4B). There was no significant relationship between arousaltopeak time and LECT in either the CSA or OSA group (p = 0.887 and p = 0.444, respectively). Length of hyperpnea was related significantly to LECT (r = 0.771, p = 0.009) in the CSA patients, as shown in previous studies,5,20 but not in the OSA patients (p = 0.366).
A significant correlation between apnea-to-arousal time and lungtoear circulation time (LECT) was found in the 10 subjects with CSA (A) but not the 10 subjects with OSA (B).
Apnea-to-arousal time and lung-to-ear circulation timeA significant correlation between apnea-to-arousal time and lungtoear circulation time (LECT) was found in the 10 subjects with CSA (A) but not the 10 subjects with OSA (B).
The results of the present study indicate that in HF patients there are marked differences in the timing of arousals following termination of apneas and hypopneas between those with OSA and those with CSA. Arousals were generally simultaneous with apnea termination in the OSA group, with a mean apnea-to-arousal time of 0.9 seconds. This is consistent with a defensive role in augmenting upper airway dilator muscle activity and reestablishing airway patency and airflow.3,15 In contrast, in the CSA group, apnea-to-arousal time was much longer, with a mean latency of 8.0 seconds. Moreover, the ratio of arousals to apneas and hypopneas was significantly lower in the CSA (62%) than in the OSA group (94%), indicating that in the former group, far fewer respiratory events were terminated by an arousal. These observations are not consistent with a similar defensive function in central than in obstructive events, since arousals were not necessary to reestablish airflow. However, the time from the onset of arousal to the peak of hyperpnea (arousaltopeak time) was similar in the two groups, suggesting that arousals may augment hyperpnea and influence the timing of peak ventilation in both OSA and CSA.
Our data are consistent with previous studies showing that arousals occur in close proximity to termination of the great majority of obstructive events,1,2 and thus play a key role in reestablishing airflow.3 In contrast, reports of the timing of arousals following termination of central events are inconsistent, with some indicating that they occur at the end of central events6,21,22 and others, several breaths later at the peak of hyperventilation.23 This discrepancy may be related to the inherent variability in arousal timing that we describe herein, or may be a result of the heterogeneity of the CSA population. Indeed, in non-HF patients with idiopathic CSA, most arousals were reported to occur at the resumption of ventilation following apneas.6 In contrast, in CSA accompanied by a Cheyne-Stokes respiratory pattern in the HF population, such as those herein, arousals have been reported to occur later during the hyperpneic phase several breaths after apnea termination.4 However, quantification of the actual time from the end of a central event until the onset of arousal has not been previously reported. Our data indicate that in HF patients with CSA, the timing of arousals is highly variable and most often occurs several seconds after termination of central events, but before the peak of hyperpnea.
The highly variable timing of arousals following central apneas and hypopneas, and their predominant occurrence several breaths after resumption of respiration are not in favor of them being an important mechanism in terminating such events or in reestablishing normal airflow. In this regard, arousals in HF patients with CSA appear to have a substantially different pathophysiological significance than in those with OSA. Indeed, our previous work suggests that arousals play a provocative role in triggering and perpetuating central apneas in both HF and non-HF patients with CSA.5–7 By causing an abrupt increase in ventilation, arousals can provoke a fall in PaCO2 below the apnea threshold that can result in central apnea. Previous studies have shown that over 90% of episodes of Cheyne-Stokes respiration in HF patients with CSA, and almost 80% of episodes of periodic breathing in non-HF patients with idiopathic CSA are precipitated by arousals that trigger an increase in VT.5,6 Arousals facilitate ventilatory overshoot and ongoing respiratory cycling by increasing statedependent chemical ventilatory responsiveness and by engaging the neurogenic wakefulness drive to breathe.6,7 Both the magnitude of hyperventilation and length of the subsequent apnea increase progressively with increasing intensity of associated arousals.6 Taken together, these data suggest a largely pathological effect of arousals in CSA.
If arousals were a result of CSA, then attenuating CSA should reduce arousal frequency, and vice versa. In this regard, the evidence is inconsistent. On the one hand, several small studies involving 11 to 16 HF patients with CSA showed a decrease in ArI by 52% to 57% in association with a 40% to 71% reduction in AHI with CPAP therapy.22,24,25 On the other hand, several studies involving 17 to 26 HF patients with CSA in which CPAP lowered the AHI by 62% to 89% showed no effect on the ArI.8,26–28 In the largest multicenter trial to date, in which 258 HF patients with CSA were randomized to CPAP treatment or control, CPAP lowered the AHI by 55% after 3 months but did not lower the ArI or improve sleep structure.15 Furthermore, there was no significant change in arousal frequency in the subgroup of 58 patients in whom CPAP reduced the AHI to < 15, nor in the 38 CPAP patients who underwent sleep studies 2 years after randomization, compared to the control group. In contrast, studies of HF patients with OSA have shown that the ArI decreases consistently and significantly in association with a reduction in the AHI in response to CPAP.8–11 CPAP has also been shown to decrease arousal frequency significantly in the non-HF OSA population.12–14 These studies therefore support the notion that arousals are less likely to be a consequence of (or defense mechanism in) HF patients with CSA than in OSA.
In OSA, arousals are triggered by inspiratory effort against the occluded airway,29 hypoxia,30 and hypercapnia.31 The stimuli for arousals following central apneas are not as well understood. The possibility of chemoreceptor-mediated stimuli is compatible with our finding that apnea-to-arousal time is strongly related to LECT (i.e., lung to chemoreceptor circulation time) in patients with CSA, such that the longer the LECT, the longer the apnea-to-arousal time. This suggests that the latency from blood gas changes in the lung to their perception at the chemoreceptors influences the timing of arousals that may be chemoreceptor mediated. Thus, while such stimuli might cause arousal at apnea termination and contribute to reinstitution of airflow in individuals with normal heart function and circulation time, if there is an increase in circulation time due to lower cardiac output in the setting of HF, arousals are delayed such that they occur after the onset of airflow. Accordingly, while the physiological purpose of arousals after central apneas may be to act as a defense mechanism to prevent asphyxia similar to that in obstructive events, prolonged circulation time related to HF defeats this purpose and delays arousal until after airflow has resumed. Further support for this hypothesis is provided by the discrepancy in arousal timing between CSA patients with HF and idiopathic CSA patients without HF and with normal circulation time. In the latter, arousals are coincident with apnea termination,6 as in OSA, while in the former, arousals are delayed until several breaths after apnea termination. This difference may well be due to lower cardiac output and longer LECT in patients with HF-related CSA than in those with idiopathic CSA and normal heart function.20
If arousals following central events arise mainly due to chemostimulation, but fail to subserve a defensive role in the setting of HF due to prolonged circulation time, alleviation of CSA by CPAP should still lower the ArI. However, as described above, most studies in HF patients with CSA showed no significant reduction in the frequency of arousals in response to CPAP, despite a decrease in AHI.8,26–28 There are two possible reasons for this discrepancy. First, arousals may be classified as spontaneous or respiratory related.32 While the stimuli for arousals related to central apneas are likely chemoreceptor mediated, the stimuli for respiratoryrelated arousals in OSA include, in addition, inspiratory efforts against an occluded airway and generation of negative intrathoracic pressure.29,32 These additional mechanical stimuli likely underlie the shorter apnea-to-arousal time found in the OSA group, as well as the lack of relationship between apnea-to-arousal time and LECT in OSA. Moreover, the stimuli for respiratory-related arousals in CSA are thus less potent than those for OSA, and arousals are not required for apnea termination.4 Accordingly, respiratory-related arousals likely comprise a smaller fraction of total arousals in CSA than in OSA. Therefore, while respiratory-related arousals may be reduced by attenuation of CSA with CPAP, the larger proportion of spontaneous arousals are unaffected, ultimately yielding nonsignificant reductions in total arousal frequency.
Second, although the relationship between apnea-to-arousal time and LECT in the CSA group suggests a chemical stimulus for arousals in CSA, it is possible that these "respiratory-relat-ed" arousals are in fact, spontaneous arousals that are entrained by the Cheyne-Stokes respiratory cycle. This may be analogous to the entrainment of oscillations in heart rate and blood pressure by periodic breathing. Experimental periodic breathing and Cheyne-Stokes respiration in HF patients can amplify oscillations in blood pressure and heart rate and entrain them at the frequency of the periodic breathing, independent of hypoxia or arousals from sleep.33–35 It is possible, therefore, that spontaneously occurring arousals may be similarly entrained at the frequency of the Cheyne-Stokes respiratory cycle, whose duration is influenced by circulation time.5 Attenuation of central apneas by CPAP may uncouple this relationship and unmask the spontaneous nature of the arousals, with little or no effect on the total arousal frequency.15 If indeed HF patients with CSA have a high frequency of spontaneous arousals, the reason is not clear. One possibility is that higher left ventricular filling pressures and greater rostral fluid shift from the legs into the thorax in HF patients with CSA than in those with OSA cause a greater degree of pulmonary congestion.36,37 Discomfort arising from such congestion might provoke arousals.
In our study, arousals following central events usually preceded the peak of postapnea hyperpnea. Arousals abruptly augment ventilation by increasing chemical ventilatory responsiveness and activating the nonchemical wakefulness drive to breathe.6,7 Both of these are neurogenic stimuli, which should not be influenced by circulation time. Indeed, arousaltopeak time did not differ between the CSA and OSA groups and bore no relationship to LECT. It is also interesting that the arousal to peak ventilation latency was approximately 5 seconds, which is very similar to the neurogenic latency between sympathetic vasoconstrictor discharge and the peak blood pressure response.38 These data also suggest that arousals may play a role in determining the timing of peak ventilation during hyperpnea in both CSA and OSA.
There are several potential limitations of this study. The detection of the start of an arousal by visual inspection has a subjective component, especially in patients who do not produce prominent alpha waves.32 However, our use of occipital32 and frontal39 EEG electrodes should have optimized arousal detection by the standard criteria. It is also possible that the standard AASM arousal definition18 we used may lack sensitivity, leading to under-appreciation of the full spectrum of arousals related to respiratory events.40 In addition, our analyses were confined to stage 2 NREM sleep to control for potential confounding effects of sleep stage on arousal and respiratory events. Therefore, the influence of sleep state on arousal timing was not examined. Finally, it may not be possible to extrapolate our results to all patients with sleep apnea, as only subjects with HF were studied.
In summary, in HF patients the latency from central events to arousals is highly variable and significantly longer than those following obstructive events. Nevertheless, arousals following both central and obstructive events occur prior to peak hyperpnea. The latency between apnea termination and arousal onset is strongly related to LECT in CSA. This observation suggests involvement of chemical respiratory arousal stimuli, with a postapneic latency to the detection of such stimuli at the chemoreceptors inversely proportional to cardiac output.20 The similarity in time from arousal to peak of hyperpnea between the OSA and CSA groups probably relates to neurogenic arousalmediated augmentation of ventilation that is not related to circulation time. These observations provide further evidence that arousals are less likely to act as a protective mechanism that facilitates resumption of airflow in HF patients with CSA than in those with OSA.
This was not an industry supported study. The authors have indicated no financial conflicts of interest.
This study was supported by operating grant MOP-82731 from the Canadian Institutes of Health Research. Dr. Montemurro was supported by postdoctoral research fellowships from the University of Brescia, Brescia, Italy, and the University Health Network Toronto Rehabilitation Institute.
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Krachman SL, D'Alonzo GE, Berger TJ, Eisen HJ, authors. Comparison of oxygen therapy with nasal continuous positive airway pressure on Cheyne-Stokes respiration during sleep in congestive heart failure. Chest. 1999;116:1550–7. [PubMed]
Arzt M, Schulz M, Wensel R, et al., authors. Nocturnal continuous positive airway pressure improves ventilatory efficiency during exercise in patients with chronic heart failure. Chest. 2005;127:794–802. [PubMed]
Issa FG, Sullivan CE, authors. Arousal and breathing responses to airway occlusion in healthy sleeping adults. J Appl Physiol. 1983;55:1113–9. [PubMed]
Bowes G, Townsend ER, Kozar LF, Bromley SM, Phillipson EA, authors. Effect of carotid body denervation on arousal response to hypoxia in sleeping dogs. J Appl Physiol. 1981;51:40–5. [PubMed]
Berthon-Jones M, Sullivan CE, authors. Ventilation and arousal responses to hypercapnia in normal sleeping humans. J Appl Physiol. 1984;57:59–67. [PubMed]
Berry RB, Gleeson K, authors. Respiratory arousal from sleep: mechanisms and significance. Sleep. 1997;20:654–75. [PubMed]
Lorenzi-Fihlo G, Dajani HR, Leung R, Floras JS, Bradley TD, authors. Entrainment of blood pressure and heart rate oscillations by periodic breathing. Am J Respir Crit Care Med. 1999;159:1147–54. [PubMed]
Trinder J, Merson R, Rosenberg JI, Fitzgerald F, Kleiman J, Bradley TD, authors. Patho-physiological interactions of ventilation, arousals, and blood pressure oscillations during Cheyne-Stokes respiration in patients with heart failure. Am J Respir Crit Care Med. 2000;162:808–13. [PubMed]
Leung R, Floras JS, Lorenzi-Filho G, Rankin F, Picton P, Bradley TD, authors. Influence of Cheyne-Stokes respiration on cardiovascular oscillations in heart failure. Am J Respir Crit Care Med. 2003;167:1534–9. [PubMed]
Solin P, Bergin P, Richardson M, Kaye DM, Walters EH, Naughton MT, authors. Influence of pulmonary capillary wedge pressure on central apnea in heart failure. Circulation. 1999;99:1574–79. [PubMed]
Yumino D, Redolfi S, Ruttanaumpawan P, et al., authors. Nocturnal rostral fluid shift: a unifying concept for the pathogenesis of obstructive and central sleep apnea in men with heart failure. Circulation. 2010;121:1598–605. [PubMed]
Somers VK, Dyken ME, Clary MP, Abboud FM, authors. Sympathetic neural mechanisms in obstructive sleep apnea. J Clin Invest. 1995;96:1897–904. [PubMed Central][PubMed]
O'Malley EB, Norman RG, Farkas D, Rapoport DM, Walsleben JA, authors. The addition of frontal EEG leads improves detection of cortical arousal following obstructive respiratory events. Sleep. 2003;26:435–9. [PubMed]
Thomas RJ, author. Arousals in sleep-disordered breathing: patterns and implications. Sleep. 2003;26:1042–7. [PubMed]


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Bloomberg site registered to city
The name "Mayors Against Illegal Guns" is well known as Mike Bloomberg's gun-control arm, which he spends his personal fortune through on ads. Yet the group's website is registered to, and handled by, official city government servers and staffers.
Domain names for MAIG were registered in 2006 by the New York City Department of Information and Technology, and have remained on official city web servers ever since.
Story Continued Below
Yet the group's "action fund," through which he has piped at least $14 million of his own money in ads over gun control this year alone, is registered as a 501c4, a nonprofit "social welfare" group with the same tax status as, say, the Karl Rove-linked Crossroads GPS or Organizing for Action, President Obama's grassroots arm. And it raises questions about why a website associated with the group is being managed by City Hall.
( PHOTOS: Politicians speak out on gun control)
In fact, the various pieces of the mayor's efforts appear as a confusing muddle online, with sites that are ostensibly not part of the 501c4 nonetheless being visually dominated by entreaties to click through to the ones that are. There's little indication that these are different entities with different oversight.
At minimum, the use of a city web server and city employees underscore what critics have long derided as a blurring of the lines between government resources and Bloomberg's own multi-billion-dollar fortune, his company, and his pet interests in his three terms as mayor.
Bloomberg aides strenuously pushed back on questions of propriety, insisting that there is a distinction between MAIG – which is the "broad coalition of 950 mayors" — and the MAIG "action fund," which is the 501c4. The mayoral coalition, they argued, fits within the legislative priorities of Bloomberg's administration.
"Mayor Bloomberg is the co-chair of the coalition of Mayors Against Illegal Guns," said John McCarthy, a City Hall-based spokesman for Bloomberg who also handles elements of the group's media output.
"Its activities are in the interest of keeping New York City safe. He is acting in his capacity as mayor of New York City," he added. "Just as when he advocates for a bill in Albany that we want passed he is acting in his capacity as mayor, because he believes the bill is in the city's interests. That is the prerogative of any mayor."
Different mayors involved in the coalition often send out their own press releases on specific issues, Bloomberg aides said, although the MAIG website run by the city is the only such site for the coalition.
Questions about the website server were first raised by Ace of Spades blogger John Ekdahl.


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Aboard the Seabourn Legend -Day 2by Kuki, CruiseMates Cruise Director
|Kuki's Daily Ship's Log -- Installment #1 - Day 1 Installment #2 - Day 2 Installment #3 - Day 3 Installment #4 - Day 4 Installment #5 - Day 5
I always sleep great at sea! Unbelievably, Mrs. Kuki and I slept undisturbed until almost 11 A.M. By the time we were dressed, and ready to go, it was noon, so we decided to have a quick lunch in the Verandah Cafe, before getting off the ship to explore Zihiuatanejo, Mexico, today's port of call. With our late arrival, we hadn't booked any excursions, so we set out to explore a bit on our own. Zihiuatanejo is a fishing village, with a small market area, and a few beach side restaurants and bars. It was a pleasant, and not too vigorous, way to start our cruise vacation. Returning to the ship about 3 P.M., we changed and went to lay in the sun, and enjoy the heat of a gorgeous day along the Mexican Riviera.
It was here that we began to experience some of the pampering Seabourn is known for. I was most impressed when a staff member came by offering ice cold face clothes. With the temperature in the mid 80s, these felt great on the skin. Mrs. Kuki and I were discussing what a nice touch the face clothes were when another staff member came by offering frozen oranges, stuffed with fruit sorbets. I can't begin to say how good these tasted while enjoying the hot sun. A short while later, yet another staff member came by with a large spray bottle, offering some short relief from the heat, with a spray of ice cold water. He also carried a selection of sun blocks and lotions, which were complimentary. About the only thing I had to do for myself this afternoon was lift the straws in my BBCs to my lips. And if I'd asked, I'm sure a staff member would have done that as well!
On the mega-ships many of the cruise lines are now offering butler service in their suite categories. On the Seabourn Legend they operate differently. Here, it seems everyone on the staff is my butler or maid. They're all here to care for my every whim.
Tonight was our first dinner in The Restaurant, the ship's elegant dining room. It was also our first experience with totally open seating at dinner. On the Legend one can sit anywhere you like, and with whom you like. You can arrive for dinner anytime the mood strikes, between 7 P.M. and 9:30 P.M. In the spring of 2000 Mrs. Kuki and I were fortunate to have cruised on the Seabourn Sun, and I felt the Sun had the perfect dining room arrangements. There we were assigned a table for dinner, yet we still had the freedom to arrive for dinner anytime during dining hours. Initially, the arrangement on the Legend hasn't struck me as well suited to Mrs. Kuki and I. Since this was our first full day onboard, we really hadn't got to know anyone well enough yet to suggest getting together for dinner. When we arrived for dinner we were seated at a table for two. I looked around and noticed there were many other couples, at tables for two. We didn't know if they wanted to dine privately, or like us, were just seated that way. Mrs. Kuki and I enjoy the company and conversation of other passengers at dinner. After all, after 20 years of marriage we can practically read each other's minds, so conversation between the two of us is redundant. Yet, I felt I might be intruding if I were to ask other people if they'd mind if we joined them. Dinner was delicious, and the service was superb, but we did miss the excitement of meeting our new tablemates for the first time. As dinner went on, it was interesting because we got into conversations with people seated at tables nearby. I'm not sure I wouldn't prefer for the dining room staff to take a more pro-active approach in seating the passengers. Perhaps, as the passengers enter the dining room they could ask if they're meeting someone, would like to dine alone, or if they'd prefer to be seated at a larger table. I know this would suit Mrs. Kuki and I better. There would be the possibility of meeting new people each night at dinner, and avoid the embarrassment of being told to get lost when we asked people if we could join them. That happens all too frequently at home.
Tonight the showroom (King Olav Lounge) was dark. There was no show. Therefore the choice of nightlife was the Midnight Sun Lounge or The Club, with the Club featuring a Name That Tune contest, with a murder mystery twist to it, or a VERY small casino. Mrs. Kuki and I went to the Club after dinner to get a good seat, but there was no rush. The place was empty. We had a drink, and played some blackjack in the casino at 9PM, when it opened. At 10, when Name That Tune began, there were 20-30 people present in the Club.
Having now spent two evenings onboard, we've realized nightlife is not this ship's forte. It's become obvious, compared to our experiences on larger ships; this is not "your typical cruise experience."
Monday, at Sea- Having recovered from our travel fatigue the night before Mrs. Kuki and I awoke at a more reasonable hour and had breakfast on the outside deck of the Verandah Cafe, located at the Stern of the ship, on Deck 6. This is my easily my favorite spot on the ship. I felt like a king breakfasting while looking back over the ship's wake, with "my butlers" standing ready to tend to any need.
By mid afternoon I was ready for "my nap". I've never been one to nap on a cruise. I generally need a vacation when I get home. But I guess I'm adapting to the Seabourn difference. This is a going to be a relaxing cruise vacation, and my system is adapting by relaxing.
Tonight is our first formal night. We've been invited to dine with Captain Karlo Beur this evening, after the Captain's Welcome Aboard Reception. I'll let you know in my next report if I napped during dinner.


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Main Page
Algorithmist is a resource dedicated to anything algorithms - from the practical realm, to the theoretical realm. There are also links and explanation to problemsets.
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How Far Would You Push Your Kids to Learn a Second Language?
In today's increasingly global society, there's more emphasis than ever to teach kids a second language. But how far would you go to make your kids bilingual?
This weekend's New York Times magazine featured the fascinating and thought-provoking piece, "My Family's Experiment in Extreme Schooling." The author, Clifford J. Levy, a reporter at the paper, was transferred to Moscow for four years. His family accompanied him abroad. But instead of enrolling his kids (then in kindergarten, third and fifth grade) in an English-speaking international school, he and his wife opted to place them in a Russian school. No matter that they didn't speak a word of the language and wouldn't have translators or English-speaking tutors. But Levy and wife hoped they would become fluent by immersion. The kids eventually did, but not without lots of effort, resilience and strife. (Not to mention daily did-we-make-the-right-decision doubt on the part of the parents.)
As someone who only speaks one language, I regret never becoming proficient at another, earlier in life. (Though I'm slowly trying to rectify that by studying Spanish.) But now that I know how important and useful it is to be bilingual, I definitely plan to emphasize language-learning when I have kids--even if it's not as extreme as four years of Russian immersion in Moscow.
How important is raising bilingual kids, to you? Are you pushing your children to become proficient in a second language? If so, which one? If your family ever moved abroad, would you make them learn the language of whatever country you're in? Share your thoughts below.
photo via ChernoVAnton/flickr


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John Lee Hooker (1917-2001) is firmly established as one of the true giants of the blues, along with Muddy Waters, B.B. King, and Howlin' Wolf. Hooker is often called the "King of the Boogie" and his driving, rhythmic approach to guitar playing has become an integral element of the blues sound and style.
When he made his recording debut in 1948, scoring a nationwide hit with "Boogie Chillen," John Lee Hooker was considered something of an anachronism. Except for his thunderous electric guitar, Hooker's one-chord and two-chord modal stylings sounded very much like those of a Delta blues artist from the 1920s. But Hooker's music is altogether more fierce and rhythmic than old Delta blues. Early in his career, he played solo for the most part — his dark, hypnotic voice and relentless foot-stomping his only accompaniment.
John Lee has cut records for seemingly every large and small blues label that's ever existed (and doing so without having to vary his approach). Hooker's music is raw, riveting, and almost doom-struck Mississippi blues that demands much of a listener. His music provides one of the great emotional listening experiences in the blues. John Lee Hooker stands alone as a true creative original, often imitated, but never equaled.
From Clarksdale to the Motor City
Born on August 17, 1920, in Clarksdale, Mississippi, John Lee grew up surrounded by the blues, having been taught the guitar by his stepfather, Will Moore. In childhood, Hooker's main musical influence had been his church spiritual singing, that is, until the blues took over.
When he was 15, John Lee ran away from home and moved to Memphis to make his mark in the blues scene. He was caught and sent back home, but eventually returned to Memphis. To make ends meet, he worked as an usher at the New Daisy Theatre movie house. He later moved to Cincinnati, singing with various gospel groups including the Big Six and the Fairfield Four. Enticed by the prospect of regular work in the automobile industry, Hooker moved to Detroit in 1943.
After becoming a fixture on the Detroit blues club and house party scene, John Lee began recording in 1948, hitting pay dirt on his first try with his recording of "Boogie Chillen." Sounding like absolutely nothing else that was on the radio or the jukeboxes at that time, its pounding rhythm helped carry that record all the way to Number One on the R&B charts in 1949.
The "other" John Lee Hookers
Hooker (see Figure 1) spent the next six years cutting records for just about every label that offered him a deal, recording under a number of fake names, nicknames, or names that were a variation of his own. Starting with Modern (under his real name), he went on to record for Staff (as Johnny Williams), Gotham (as John Lee), Regent (as Delta John), Savoy (as Birmingham Sam and his Magic Guitar), Regal, Gone (as John Lee Booker), Sensation, Danceland (as Little Pork Chops), Fortune (as Sir John Lee Hooker), King (as Texas Slim and John Lee Cooker), Swing Time, Acorn (as The Boogie Man), Deluxe (as Johnny Lee), Chart, JVB, Specialty, Chance (as John L Booker), and Chess, before moving over to Vee-Jay under his real name in 1955. It was at Vee-Jay Records where he had his longest affiliation with a single label, recording for them into the early 1960s and scoring hits with "Dimples" and "Boom Boom."
With his solo acoustic blues sound, Hooker gained an appreciative new audience among followers of the folk scene. He performed and recorded extensively throughout the 1960s, and his first-ever tour of Europe in 1962 had an enormous impact on the emerging British blues scene. By the end of the decade, John Lee was playing his blues in the hippest rock clubs and biggest festivals around the country.
Pulling up stakes to head to California
In 1970, Hooker moved from Detroit to Oakland. Once there, he recorded the Hooker 'n' Heat album with blues-rockers Canned Heat. John Lee Hooker issued new albums by the truckload in the 1970s, with the occasional misguided attempt to update his sound by pairing him with rock musicians who had little sensitivity for his spontaneous changes in timing and his unconventional modal approach to song.
Highlights for Hooker in the 1980s were his being inducted into the Blues Foundation's Hall of Fame and a flurry of reissues of his early recordings on a variety of foreign and domestic labels. He also made a cameo appearance in the movie The Blues Brothers, stomping out his trademark boogie patterns on the tune "Boom Boom."
Bigger than ever
John Lee's career took a major upswing with the 1989 release of The Healer, featuring newly recorded material and guest appearances by Bonnie Raitt, Carlos Santana, Robert Cray, and others. The album was nominated for a Grammy award for best blues recording, and Hooker won a Grammy for "I'm in the Mood," a duet recorded with Raitt.
In 1990, Hooker was inducted into the Rock and Roll Hall of Fame, and in the years following, he was honored at a star-studded tribute concert at Madison Square Garden, played dates with the Rolling Stones, and even appeared in a Pepsi commercial. In 1997, he opened his own blues club in California — John Lee Hooker's Boom Boom Room — and continued to record and perform until his death in 2001.
The Ultimate Collection (Rhino). This two-disc set covers Hooker's best known numbers from 1948 to 1990. Blues doesn't sound any deeper and isn't played with more intensity than when it's done by John Lee.


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Zoo Tycoon
Welcome to Zoo Tycoon for Xbox One and Xbox 360. Find links here to videos and demos, information about the game's server status and differences in game versions, and troubleshooting help. You can also find links to purchase the game for Xbox One and Xbox 360.
On this page
Zoo Tycoon overview
Explore videos and demos and learn about gameplay, add-ons, and how to purchase Zoo Tycoon on Xbox One.
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Visit our game forums to learn more about the game, join the community in conversation, and find support for questions not answered here.
If you're having trouble using Xbox Live to play a game, check for current service issues. If there is a relevant alert, wait until the service is up and running and try again.
Sign in to your Microsoft account to manage your information and purchases, your family's devices, and your security and privacy.
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Learn how to install your game to the Xbox One Hard Drive.
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Troubleshoot crashes, freezes, and poor performance with your Xbox 360 games.
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All industrial surroundings are distinctive, with customised requirements. It's important to have the proper selection about flooring surfaces for your setting, to ensure that it's both practical and visually fitting. It's constantly a good idea to meet with business flooring professionals and suppliers to have information on what sort of floors is best suited for the placing, so you can make a knowledgeable determination. Michigan Polished Concrete Contractors
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- Polished Concrete Architecture.
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I have temporary writer's block for my movella so I...
In Perfect Harmony46631495
- by murk798
- Rating:
- Published: 2 Aug 2013
- Updated: 22 Aug 2014
- Status: In Progress
Grace Masciale is a young waitress trying to get by on her meager salary in busy NYC. Her true passion is music, so she works hard playing open mics and doing whatever possible to "make it" as a musician. When Grace meets Liam Payne, she is thrown into a life in the spotlight. Can she manage a relationship with Liam, while attempting to follow her own dreams?
Join MovellasFind out what all the buzz is about. Join now to start sharing your creativity and passion
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CAIRO — A senior Hamas official said the group has decided not to extend a 72-hour cease-fire with Israel that expires on Friday morning. Before the end of truce, Gaza militants fired two rockets at Israel, the army said.
Israel and Hamas have been holding indirect talks in Cairo on new, border arrangements for the blockaded coastal territory. Israel has said it is willing to consider easing border restrictions, but demands that Hamas disarm. The talks began during a three-day truce that is to end at 0800 (0500 GMT) Friday.
The Hamas official told The Associated Press that the group decided not to extend the cease-fire.
He said Hamas representatives were told by Egyptian mediators that Israel had rejected Hamas' conditions for an extension — an agreement in principle to open Gaza's borders and allow for a rebuilding of the strip. The official spoke on condition of anonymity because he was en route to informing Egyptian officials of the decision.
The Israeli military reported early Friday that two rockets were fired from Gaza at Israel, falling in an open field and causing no casualties. Israeli media said mortar rounds, not rockets had been fired.
No one claimed responsibility for the fire from Gaza. There are a number of militant groups in the crowded territory that operate outside the control of Hamas with rockets of their own.
A collapse of the truce could unleash a new round of violence after a month of fighting that has claimed nearly 1,900 Palestinian lives, with 67 deaths on the Israeli side.
In Cairo, the gaps between Israel and Hamas were wide, and it was likely from the start that an extension of the truce would be needed. Hamas has said it will not even contemplate Israel's demand that it disarm. Israel has said it will not lift the blockade of Gaza without a demilitarization of Gaza.
The blockade has been enforced by Israel and Egypt to varying degrees since Hamas seized Gaza by force in 2007.
The blockade, which Israel says is needed to prevent weapons from reaching Gaza, has led to widespread hardship in the Mediterranean seaside territory. Movement in and out of Gaza is limited, and the economy has ground to a standstill and unemployment is over 50 percent.
The war grew out of the killing of three Israeli teens in the West Bank in June. Israel blamed the killings on Hamas and launched a massive arrest campaign, rounding up hundreds of the group's members in the West Bank, as Hamas and other militants unleashed rocket fire from Gaza.
On July 8, Israel launched an air campaign on the coastal territory, and nine days later, sent in ground troops to target rocket launchers and cross-border tunnels built by Hamas for attacks inside Israel.


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Hitachi America, Ltd. is a leading manufacturer of industrial continuous inkjet printer products used for marking and coding in different packaging applications in the Americas marketplace. Our industrial continuous inkjet printers deliver state-of-the-art technology and advanced features to enable high-speed marking and coding operations.
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Explore the options below for complete information on Hitachi continuous inkjet printers.
Choose from the categories below for product support details on Hitachi continuous inkjet printers.


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A Rustic Lowcountry Wedding at Magnolia Plantation and Gardens in Charleston, South Carolina
Maryland natives Carly Cross (28 and a nurse) and Spencer Disque (28 and an engineer) left the mid-Atlantic for a classic Southern destination wedding at Magnolia Plantation and Gardens in Charleston, South Carolina. "I fell in love with Charleston from going to visit my grandparents there. I love the history and romanticism in the city," Carly says. "My husband and I visit two to three times each year and hope to move there eventually." With its Spanish-moss-covered oak trees, views of the Ashley River and a romantic carriage house, Magnolia was a picture perfect venue for Carly and Spencer to say "I do." A subtle and soothing palette of soft yellow, ivory and green blended beautifully with the plantation's natural surroundings. Carly and Spencer personalized their alfresco ceremony by having a friend officiate and writing their own heartfelt vows. A burlap aisle runner, lanterns and shepherd's hooks that held galvanized buckets filled with hydrangeas and yellow bluporum adorned their ceremony, which was held under a grand old oak tree. The couple decorated their rustic reception with whitewashed farm tables, burlap table runners and wooden chiavari chairs. Chandeliers adorned in greenery and table arrangements of white and yellow flowers in reclaimed-wood flower boxes and galvanized buckets gave the dinner party an organic feel. Details included wood-burned "welcome" bag tags and champagne labels made by Carly's mom. "My husband and I are pretty relaxed, adventurous and fun people, which I think was reflected in our celebration," Carly says. "By early in the evening of our reception, most guests were on the dance floor, having a blast." —Marissa Hermanson


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I'm just generating lemonade, my good friend." So commenced a dialogue with Gary Vaynerchuk. Popular for his on the web development of Wine Local library Television set (which just celebrated its 3rd bday) Gary is now something of any twenty-first century evangelist for validity, inspiration, hustle and most importantly, accomplishing your goals.The best thing of this isn't the Business or the Manufacturer Building or perhaps the option...though great each will FAIL in comparison to the proven fact that WE can meet up with countless darn Individuals! Gary Vaynerchuk (resting on the floor in the Soiux Town Airport)Gary's starting review known as the fact that his airline flight from Soiux City had just been canceled, but alternatively than grumble about it, he just switched the situation on its brain (producing soda and pop when lifestyle given him a bag of lemons) and decided to do his beloved point - get in touch with folks. A charged life
I've been keen on Gary with his fantastic show for a long time due to his sincere method toward wine admiration. Experiencing ingested wines for several years, now judging by two overseas wines contests, it's safe to say that I'm a fan of ingesting wines, yet not way too delighted with all the status methods which in turn appear to principle the industry with the metal fist. I enjoy hearing what somebody considers the red wine, and that's what Gary does like not any other.
Been keen on Gary with his fantastic
- This information is very effective in its capability to encourage us to.
- When he could relaxation on his laurels, Gary continue.
- Gary proceeded to clarify a wines tasting that he conducted with a team of Israelis and Lebanese, sample.
- Awaken the giant within.
Called the Thunder Demonstrate, his type is brash, edgy, comical, unusual, in-your-deal with, but also really significant - he genuinely wishes to instruct people and teach them the assurance to create up their particular brain when it comes to what wines to beverage. This can be interest at its very best. Forget about what's politically correct, and there's never a be aware of condescension in the delivery - simply a significant amount of area on opinion with no delicate sides.For anyone attempting to make a link in between wine and Worldwide Patriot, my love of vino is most important in finding different cultures and our innate link with our planet. From my earlier escapades from the California state red wine nation to many trips in foreign countries going to the vineyards of France and France, the beauty of wines, foods and individuals has ingrained in me the concept we're all hooked up in a manner that transends nationality, ethnicity, faith or ideology.
Sides For anyone attempting
I questioned Gary about his activities pertaining to this concept of wines taking us together. "Wines is able to breakdown obstacles and even though also giving people a admiration for terrior." Freely interpreted as "feelings of spot", terrior in guide to wine speaks of the individuality for each vineyard - the dirt, the vines, the replicate of grape, the climate and vineyard control.In my opinion that philosophy decorative mirrors everything we need to do in our lives - eliminate the barriers that always keep us aside, whilst making a value for your identity for each individual and place. Eban pagan
Us together Wines
Gary continued to clarify a vino flavorful that he conducted with a group of Israelis and Lebanese, sampling wines from every single location. The wine beverages were provided blind, with the containers concealed from see in order that the nation of origin could not effect their viewpoint.
Vino flavorful that he conducted with a
"It was actually this kind of intriguing encounter, as someone's preferred wines was frequently through the other land and I could see this common bond create before my view just from flavored wines collectively."Previously season Gary has transferred over and above indicating his passion for wine and is now a motivational speaker at conferences from shoreline to coast. Whilst the chat may possibly differ from one particular area to another, the primary issues center on residing your way of life with interest and determination, of earning things occur, of hooking up with other people, and not living with preconceived ideas of the can't be done.
Before my view just
This message is extremely highly effective in its capability to inspire us to run after our ambitions and do what ever is necessary to achieve our targets, and it's a significant message which is fundamental on the eyesight of International Patriot, which we all have the capability to perform what we could envision. Gary Vaynerchuk
Power Alchemist habits of highly
As he could sleep on his laurels, Gary nevertheless places in 12 to 15 hrs each day to "make points take place." He's working on a half dozens tasks currently, although not at liberty to disclose particulars yet. Once I questioned about his long lasting objective, the important point he really desired to complete, he replied:He frequently covers the Jets on his present. In shining terms when occasions are perfect, and then in scathing design when occasions are not so great. Similar to wine, he doesn't pull any punches with regards to signing up his viewpoint. Enthusiasm by way of and through, 7/24, hustle right up until your desires becoming reality.
Way of
As the chat wound down (he experienced 50 other folks to contact again by now) we returned to the topic of folks. In just one of his video clips Gary spoke of his desire to fulfill everybody in the world. Not really that this type of target was really possible, they know that, but living with that mindset pushes him to get in touch with as many people as possible - anytime, just about anywhere - due to the fact ultimately, above his travel to acquire, to hustle, to grind it, you will find an overwhelming love for men and women. Gary Vaynerchuk
Effective people Starting with the
- I've been keen on Gary and his.
- I questioned Gary about his own experience with regard to this concept.
- When he could relax on his laurels, Gary still positions in 12 to 15.
- This meaning is extremely highly effective in its capability to motivate us to run after our desires.
- Gary went on to describe a wine flavored which he conducted with a small grouping of Israelis and.


text:
The automation company Pilz has opened a production site in the Chinese city of Jintan. In its first production site outside of Europe, the family business from Baden-Württemberg will produce PNOZ safety relays to its company-wide quality standards. As a result, Pilz will be able to supply the growing Chinese market more quickly and consolidate its position there.
Ostfildern, 17 Jun. 2015
Safe automation for Chinese industry – Pilz opens production site in China
In total the Chinese plant covers more than 9,000 m2 of production, office and storage space. The plant has been built in accordance with the latest knowledge in production technology, environmental protection and energy efficiency. PNOZ safety relays for the Chinese market will be manufactured in Jintan in accordance with the same quality standards, processes and procedures and using the same plant and machinery employed in the European production sites. Safety relays serve to protect operators on plant and machinery by monitoring safety functions such as emergency stop or light beam devices. The PNOZ safety relay from Pilz was the world's first product of this type.
In addition to the site at the company's head office in Ostfildern (Germany), Pilz also manufactures in Betschdorf (France). Jintan is situated between the economic centres of Nanjing and Shanghai, in Jiangsu province. This province is one of the country's most active regions economically.
"The new plant sends a clear signal that the Chinese market is particularly significant, for us and the whole automation sector", says Thomas Pilz, Managing Partner of Pilz GmbH & Co. KG, underlining the company's commitment. The production landscape in China is changing. As a result of the 12th 5-year plan of the People's Republic, the trend in manufacturing industries and engineering is towards automation and safety, with the aim of increasing quality and efficiency. "We want to help China achieve these aims", says Thomas Pilz.
The Pilz family opened the company's first production site outside of Europe with an official ceremony. Together with official representatives of the city and Jiangsu Province, Chinese industrial associations and customers, a symbolic red ribbon was cut as a sign of joy, happiness and prosperity.
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