text:
Effectiveness of Vyvanse Compared to Concerta in Adolescents With Attention-deficit/Hyperactivity Disorder
|The safety and scientific validity of this study is the responsibility of the study sponsor and investigators. Listing a study does not mean it has been evaluated by the U.S. Federal Government. Read our disclaimer for details.
|ClinicalTrials.gov Identifier: NCT01552902
Recruitment Status : Completed
First Posted : March 13, 2012
Results First Posted : March 18, 2015
Last Update Posted : March 18, 2015
- Study Details
- Tabular View
- Study Results
- Disclaimer
- How to Read a Study Record
|Condition or disease
|Attention-deficit/Hyperactivity Disorder
|Drug: Lisdexamfetamine dimesylate Drug: Methylphenidate Hydrochloride Drug: Placebo
|Phase 4
|Study Type :
|Interventional (Clinical Trial)
|Actual Enrollment :
|549 participants
|Intervention Model:
|Parallel Assignment
|Quadruple (Participant, Care Provider, Investigator, Outcomes Assessor)
|Primary Purpose:
|Official Title:
|A Phase 4, Randomized, Double-blind, Multicenter, Parallel-group, Active-controlled, Forced-dose Titration, Safety and Efficacy Study of SPD489 (VYVANSE®) Compared With OROS-MPH (CONCERTA®) With a Placebo Reference Arm, in Adolescents Aged 13-17 Years With Attention-deficit/Hyperactivity Disorder (ADHD)
|Study Start Date :
|April 2012
|Actual Primary Completion Date :
|May 2014
|Actual Study Completion Date :
|May 2014
|Experimental: Lisdexamfetamine dimesylate
Drug: Lisdexamfetamine dimesylate
Daily oral dosing in the AM ranging from 30- 70 mg. 4 week forced dose titration, 2 week dose maintenance
Other Name: SPD489, Vyvanse, LDX
|Active Comparator: Methylphenidate Hydrochloride
Drug: Methylphenidate Hydrochloride
Daily oral dosing in the AM ranging from 18-72 mg. 4 week force dose titration, 2 week dose maintenance
Other Name: Concerta, OROS-MPH
|Placebo Comparator: Placebo
Drug: Placebo
Daily oral dosing in the AM for 6 weeks
- Change From Baseline in Attention-Deficit/Hyperactivity Disorder Rating Scale, Fourth Edition (ADHD-RS-IV) Total Score at Week 6 [ Time Frame: Baseline, Week 6 ]The ADHD-RS-IV was developed to measure the behaviors of children with ADHD and is commonly used in clinical studies of ADHD. The ADHD-RS-IV consisted of 18 items designed to reflect current symptomatology of ADHD based on Diagnostic and Statistical Manual of Mental Disorders, 4th Edition-Text Revision (DSM-IV-TR) criteria. Each item was scored on a 4-point scale ranging from 0 (reflecting no symptoms) to 3 (reflecting severe symptoms) with total scores ranging from 0-54, Higher score = more severe symptoms.
- Percentage of Participants With an Improvement on Clinical Global Impression - Global Improvement (CGI-I) at Week 6 [ Time Frame: Week 6 ]The Clinical Global Impressions Scale permits a global evaluation of the participant's severity of illness and improvement over time. The scale included a severity of illness item and a global improvement item. The investigator performed the CGI-I to rate the improvement of a participant's ADHD symptoms based on a 7-point scale (1=very much improved; 2=much improved; 3=minimally improved; 4=no change; 5=minimally worse; 6=much worse; or 7=very much worse.). Percentage of participants with an improved measurement (response of very much improved and much improved) is reported.
- Number of Participants With Treatment-emergent Adverse Events (TEAEs) and Serious TEAEs [ Time Frame: Baseline up to 3 days after last dose (last dose at Week 6) ]An adverse event (AE) was defined as any untoward medical occurrence in a clinical investigation participant administered as a pharmaceutical product that did not necessarily have a causal relationship with this treatment. A serious adverse event (SAE) was an AE resulting in any of the following outcomes or deemed significant for any other reason: death; initial or prolonged inpatient hospitalization; life threatening experience (immediate risk of dying); persistent or significant disability/incapacity; congenital anomaly. TEAEs were events between first dose of double-blind investigational product and up to 3 days after last dose that were absent before treatment or that worsened relative to pretreatment state.
- Change From Baseline in Blood Pressure at Week 6 [ Time Frame: Baseline, Week 6 ]
- Change From Baseline in Pulse Rate at Week 6 [ Time Frame: Baseline, Week 6 ]
Choosing to participate in a study is an important personal decision. Talk with your doctor and family members or friends about deciding to join a study. To learn more about this study, you or your doctor may contact the study research staff using the contacts provided below. For general information, Learn About Clinical Studies.
|Ages Eligible for Study:
|13 Years to 17 Years (Child)
|Sexes Eligible for Study:
|Accepts Healthy Volunteers:
Inclusion Criteria:
- Subject must be 13-17 years of age, inclusive, at the time of consent.
- Subject must weigh more than 79.5lb.
- The parent/LAR must be available at approximately 7:00AM (±2 hours) to dispense the dose of investigational product for the study duration.
- Subject, who is a female, must have a negative serum beta human chorionic gonadotropin (β-HCG) pregnancy test and a negative urine pregnancy test and agree to comply with any applicable contraceptive requirements of the protocol.
- Subject has an ADHD-RS-IV total score ≥28.
- Subject is able to swallow a capsule.
- Subject does not have hypertension and has a resting sitting blood pressure less than or equal to 135/85mmHg.
Exclusion Criteria
- Subject has a current, controlled (with medications prohibited in this study) or uncontrolled, comorbid psychiatric diagnosis with significant symptoms such as any significant comorbid Axis II disorder or significant Axis I disorder (such as post traumatic stress disorder, psychosis, bipolar illness, pervasive developmental disorder, severe obsessive compulsive disorder, depressive or anxiety disorder.
- Diagnosis of conduct disorder. Oppositional defiant disorder is not exclusionary.
- Subject is considered a suicide risk, has previously made a suicide attempt, or is currently demonstrating active suicidal ideation. Subjects with intermittent passive suicidal ideation are not necessarily excluded.
- Subject is underweight or overweight.
- Subject has a concurrent chronic or acute illness (such as severe allergic rhinitis or an infectious process requiring antibiotics), disability, or other condition. Mild, stable asthma is not exclusionary.
- Subject has a history of seizures (other than infantile febrile seizures), a chronic or current tic disorder, or a current diagnosis and/or a known family history of Tourette's Disorder.
- Subject has a known history of symptomatic cardiovascular disease, advanced arteriosclerosis, structural cardiac abnormality, cardiomyopathy, serious heart rhythm abnormalities, coronary artery disease, or other serious cardiac problems that may place him/her at increased vulnerability to the sympathomimetic effects of a stimulant medication.
- Subject has a known family history of sudden cardiac death or ventricular arrhythmia.
- Subject has any clinically significant ECG or clinically significant laboratory abnormality.
- Subject has current abnormal thyroid function, defined as abnormal thyroid stimulating hormone (TSH) and thyroxine (T4). Treatment with a stable dose of thyroid medication for at least 3 months is permitted.
- Subject has a documented allergy, hypersensitivity, or intolerance to amphetamine or to any excipients in the investigational product.
- Subject has a documented allergy, hypersensitivity, or intolerance to MPH or to any excipients in the reference product.
- Subject has failed to fully respond to an adequate course(s) (dose and duration) of MPH or amphetamine therapy.
- Subject has a history of suspected substance abuse or dependence disorder (excluding nicotine). Subjects with a lifetime history of amphetamine, cocaine, or other stimulant abuse and/or dependence will be excluded.
- Subject has a positive urine drug result.
- Subject has previously participated in this study or another clinical study involving SPD489/NRP104.
- Subject has glaucoma.
- Subject is required to take or anticipates the need to take medications that have CNS effects or affect performance, such as sedating antihistamines and decongestant sympathomimetics, or are monoamine oxidase inhibitors. Stable use of bronchodilator inhalers is not exclusionary.
- Subject is female and is pregnant or lactating.
- Subject is well controlled on his/her current ADHD medication.
- Subject has a pre-existing severe gastrointestinal tract narrowing.
To learn more about this study, you or your doctor may contact the study research staff using the contact information provided by the sponsor.
Please refer to this study by its ClinicalTrials.gov identifier (NCT number): NCT01552902
Show 95 Study Locations
Publications automatically indexed to this study by ClinicalTrials.gov Identifier (NCT Number):
|Responsible Party:
|ClinicalTrials.gov Identifier:
|NCT01552902 History of Changes
|Other Study ID Numbers:
2011-005452-34 ( EudraCT Number )
|First Posted:
|March 13, 2012 Key Record Dates
|Results First Posted:
|March 18, 2015
|Last Update Posted:
|March 18, 2015
|Last Verified:
|June 2014
Lisdexamfetamine Dimesylate
Attention Deficit Disorder with Hyperactivity
Pathologic Processes
Attention Deficit and Disruptive Behavior Disorders
Neurodevelopmental Disorders
Mental Disorders
Neurologic Manifestations
Nervous System Diseases
Signs and Symptoms
Central Nervous System Stimulants
Physiological Effects of Drugs
Dopamine Uptake Inhibitors
Neurotransmitter Uptake Inhibitors
Membrane Transport Modulators
Molecular Mechanisms of Pharmacological Action
Dopamine Agents
Neurotransmitter Agents


text:
This San Francisco modern wall clock combines data and style in impressive detail for a high-quality wall clock design.
Each modern wall clock is carefully hand-crafted by a team of architects and urban planners using industry-standard tools and GIS mapping data. From alleys and airports to oceans and riverways, you'll gain a new appreciation and perspective on familiar cities with accurate city map art that doubles as modern home decor and conversation starters.
We aim to inspire both hometown pride and a sense of wanderlust whether you choose from the hundreds of cities already available or order a custom wall clock design of any location on the planet. Let us help you relive your greatest memories and hang your adventures by decorating the home or office with personalized map art or make a modern wall clock collection of cities around the world for a "time-zone" wall feature in any setting.
This San Francisco Wall Clock clock is 10" in diameter and has a depth of 1.75". We offer three finishes: black semi-gloss, white semi-gloss and a natural wood semi-gloss finish.
Each San Francisco Wall Clock is made to order, just for you! We do this both to help the environment by producing only what we need and to ensure that you receive a brand new, high-quality art print.
We aim to ship orders within 2-3 business days. Please allow an extra day for processing if ordering within two days of a holiday. We ship all orders via standard ground shipping. If you require quicker shipping, please email us and we'll happily arrange that for you.
Shipping is free on all clocks shipping to the United States, Canada and the United Kingdom.
Flat $15 shipping to rest of world.
Delivery times:
US: 2-5 business days / Rest of world: 10-21 business days
All of our wall clocks are insured and guaranteed. This means that any order lost, damaged or incorrectly printed will be replaced no questions asked.
We've been designing art and home decor since 2014. We are the original creators of the City Map Print and have hundreds of cities over the years. We continue to create art inspired by everyday-data that tells the story of your every day.LEARN MORE
We're all about patterns and highlighting the natural beauty of things that surround us everyday. From the natural patterns of a city's street grid to the colourful rings of a geode rock, we're turning these natural wonders into inspirational art for your home.
Phasellus viverra nulla ut metus varius laoreet. Etiam sollicitudin, ipsum eu pulvinar rutrum, tellus ipsum laoreet sapien, quis venenatis ante odio sit amet eros. Etiam imperdiet imperdiet orci.
Show off your state pride with a sueded pillow featuring a state crest inspired by the elements that make each state unique. Zippered closure and insert included.
Add a cozy throw blanket to bring a hint of your story into the decor of any room or office. Featuring stylized monotone flags of each state, these modern blankets are woven from 100% cotton threads and are soft yet highly durable.
Create a time zone wall with clocks of your favourite cities. From Alabama to Zanzibar, our wall clocks feature a wood frame in either a black, white or natural wood finish.
Contact our support team using the form and we'll get back to you shortly.
In the meantime, visit our FAQ Page for more information.

subset: commoncrawl


text: A Jewish K-12 College Preparatory School Serving South Florida POSNACK SCHOOL MENUMENUOUR SCHOOL Welcome! Read our latest campus news. Head of School's Message Thoughts for 2019-2020 from Dr. Richard Cuenca. At a Glance Posnack School Difference History Meet Our Administration Our Campus School Calendars Daily Menu Alumni ADMISSIONS K-10 Open House Our next K-10 Open House will take place on November 6, 2019 starting at 9:00 am. Please call the school office to RSVP. Applying Posnack School accepts applications for grades K-10 throughout the year, space permitting. Admissions Applications Tuition & Fees Financial Assistance East Campus Open Houses ACADEMICS Explore Fischer High School Meet Fischer High School Principal Brooke Rosenkrantz Explore Hochberg Middle School Meet Middle School Principal Tamara Zaslow Lower School Lower School East Hochberg Middle School Fischer High School Judaic Studies Posnack Plus College Counseling Learning Resources JUDAICS Divrei Torah Weekly words of Torah from our Director of Judaics, Rabbi Robert Kaplan Lower School Lower School East Hochberg Middle School Fischer High School Judaic Studies Posnack Plus College Counseling Learning Resources ATHLETICS 24 Sports to Join Athletics are central to a Posnack School education. Students can choose from 24 different sports. Meet the AD Meet Coach Wayne Stofsky, the Director of Athletics at the Posnack School. Athletics Athletic Calendars Meet the AD Athletic News ARTS Find Your Passion Discover our award winning art programs. Arts Music Theatre Visual Arts ALUMNI Got Photos? Use our handy photo uploader to share your Posnack School memories. Keep in Touch Read the latest on our alumni and events on campus. Share Memories Transcript Requests NEWS Save the Date! Here's what's coming up on campus. Divrei Torah Weekly words of Torah from our Director of Judaics, Rabbi Robert Kaplan Campus News Dvar Torah Athletics Events East Campus Alumni Community Friday Letter GIVING Make a Difference Find out how your gift helps secure a Jewish future in South Florida. Give Now Make it Happen with your Annual Campaign gift. Annual Campaign Promise Campaign Planned Giving Performing & Visual Arts Leave Your Mark Corporate Giving FIND US Posnack School 5810 S. Pine Island Road Davie, FL 33328 954.583.6100 email@example.com RAM NEWSFischer High School Students Lobby for Israel in the Nation's Capital Undefeated RAMs Varsity Flag Football League Champions Search Search for: Posnack School gratefully acknowledges the support of the Jewish Federation of Broward County. David Posnack Jewish Day School is accredited by The Florida Council of Independent Schools (FCIS), the Florida Kindergarten Council (FKC), the Southern Association of Colleges and Schools (SACS) and the Association of Independent School of Florida (AISF). All general studies teachers at Posnack School meet the standards of SACS, AISF, and FCIS. All core general studies faculty are required to possess a valid Florida Teachers' Certificate. All Hebrew/Judaic Studies teachers at Posnack School must be licensed by the Central Agency for Jewish Education or possess a duly earned Bachelor of Hebrew Letters. David Posnack Jewish Day School serves Broward, Miami-Dade and Palm Beach Counties, including North Miami Beach, Hollywood, Davie, Weston, Sunrise, Plantation, Coral Springs, Parkland, and Boca Raton. *Based on SAT results.


text:
4-H Awards & Recognition
Recognition is an acknowledgment and affirmation of the personal growth in an individual. It can be public or private. It can be within the individual or provided by others. Recognition in 4-H is the encouragement and support for learning. It comes as a result of participation in educational experiences.
4-H uses recognition as one strategy to help youth become more capable and competent. It does this through recognizing and appreciating each person's effort and providing positive reinforcement to continue participating in learning activities. 4-H'ers experiences must be structured so as to incorporate opportunities to build positive esteem and self-reliance. Recognition is a significant incentive to further learning. Recognition properly used can inspire young people to continue participating and learning. If properly designed and used, it will match the needs of young people. Young people become active in 4-H because they benefit personally, not because it is a good program. They make choices depending on their need for security, new experiences, response or recognition.
Recognition must be continually revised to meet the needs of individual participants. Individual progress must be recognized and individual enthusiasm must be encouraged. There is no one way of encouraging and supporting young people. They come from varied backgrounds and with different experiences. They vary in their interests, values, needs, attitudes and aspirations. For some youth intrinsic, or internal, recognition is far more powerful than any extrinsic, or external, recognition. Motivation is determined by a complex blend of environment, attitude, and self-concept. It is what energizes a person and directs individual activity.
- Meet the Team
- State 4-H Calendar
- Event Registration
- 4-H Volunteers
- 4-H Alumni & Supporters
- Employee Resources
- About South Carolina 4-H
- Project Areas
- Pinckney Leadership
- Giving to 4-H


text:
If you are a subscriber to the JCSM (including members of the AASM), please login to access the journal.
Click here to Subscribe:
$75/volume year for individuals or $140/volume year for institutions to access all current articles and archives published in JCSM.
Click Here to DOWNLOAD the article*:
$20 to access a PDF version of a specific article from the current issue of JCSM.
*Purchase of an electronic download of JCSM provides permission to access and print the issue/article for personal scholarly, research and educational use. Please note: access to the article is from the computer on which the article is purchased ONLY. Purchase of the article does not permit distribution, electronic or otherwise, of the article without the written permission of the AASM. Further, purchase does not permit the posting of article text on an online forum or website.
Subscribers can download and print full articles from current and past issues of the JCSM
Login to JCSM
Join the American Academy of Sleep Medicine and receive a subscription to JCSM with your membership
Adults with obstructive sleep apnea (OSA) have lower sex steroid levels than controls. We sought to determine whether OSA also interferes with reproductive hormones in adolescence by tracking the pace of pubertal development.
One hundred seventy-two children in the Tucson Children's Assessment of Sleep Apnea study (TuCASA) underwent two home polysomnographic studies, spaced 4-5 years apart. Height and weight were measured at both visits, and Tanner staging of breasts/genitals and pubic hair were self-assessed by a pictorial questionnaire at follow-up.
Eighty-seven girls and 85 boys, age 8.9 ± 1.6 years (mean ± SD) at baseline and 13.4 ± 1.6 years at follow-up, participated. Twenty-seven percent of participants were overweight or obese at baseline, and the majority remained so at follow-up. Twenty-six percent of girls and 28% of boys met criteria for OSA, defined as a respiratory disturbance index (RDI) ≥ 1/h associated with a 3% desaturation (RDI 3%), at baseline. There was an inverse relationship between baseline log RDI 3% and Tanner breast stage at follow-up (coefficient -1.3, p = 0.02) in girls after adjusting for age (p < 0.001), body mass index (p < 0.005), and ethnicity. Girls with OSA at baseline were more than 1 Tanner breast stage behind girls without OSA at follow-up. OSA did not affect genital development in boys or pubic hair development in either sex.
OSA in preadolescent girls predicts delayed breast development relative to girls without OSA. Sleep fragmentation and/or hypoxia seen in OSA may interfere with reproductive development in girls.
Shaw ND; Goodwin JL; Silva GE; Hall JE; Quan SF; Malhotra A. Obstructive sleep apnea (OSA) in preadolescent girls is associated with delayed breast development compared to girls without OSA. J Clin Sleep Med 2013;9(8):813-818.
Sleep is an important modulator of reproductive hormone secretion. During the early stages of puberty, there is an increase in hypothalamic gonadotropin-releasing hormone (GnRH) and pituitary luteinizing hormone (LH) secretion in both girls and boys that initially occurs only during sleep.1 The results of sleep -wake reversal studies, during which subjects remain awake at night and sleep during the day, indicate that LH secretion is related to sleep per se rather than to time of day.2 The sleep -related augmentation of GnRH/LH secretion is responsible for the increases in testosterone (T) and estradiol secretion that drive pubertal development in boys and girls, respectively.
The impact of disordered sleep on the reproductive axis during adolescence is unknown. However, in adulthood, sleep fragmentation and/or nocturnal hypoxia secondary to obstructive sleep apnea (OSA) is associated with low sex steroid levels,3–8 which in some cases improve after correction of OSA with continuous positive airway pressure (CPAP) treatment or surgery.3,8,9 These findings raise concern that pediatric OSA, which affects 1% to 5% of children,10 may also diminish reproductive hormone secretion during childhood, potentially interfering with normal pubertal maturation.
Current knowledge/Study Rationale: During early to midpuberty, reproductive hormone secretion increases dramatically during sleep compared with wake, raising concern that children with sleep disordered breathing may be at risk for delayed pubertal development. This study was undertaken to determine the impact of sleep disordered breathing on the pace of pubertal development in a community sample of otherwise healthy boys and girls.
Study Impact: The finding that girls with sleep disordered breathing have delayed breast development relative to healthy peers suggests that girls with sleep disorders deserve close monitoring during adolescence to ensure that pubertal milestones are achieved on time. Future studies will be important to determine the impact of sleep disorders on the age of menarche and menstrual cycle regularity.
The Tucson Children's Assessment of Sleep Apnea study (TuCASA) is a prospective cohort study of 6- to 11-year-old children with and without OSA followed over a 4- to 5-year period to investigate the predictors and neurocognitive and physiological sequelae of OSA. As pubertal stage was one of the measures obtained at followup, this study represents a unique opportunity to examine the effect of OSA on the pace of pubertal development in otherwise healthy children. Based on the close temporal, and likely physiologic, connection between sleep and the reproductive axis during puberty, we hypothesized that children with OSA would have delayed puberty relative to controls.
The TuCASA study protocol has been previously described in detail.11 Briefly, nearly 500 Caucasian or Hispanic children, ages 6-11 years, without a chronic medical condition were recruited from the Tucson Unified School District and underwent unattended home polysomnography (PSG). Approximately 5 years later, 304 of the children completed a second inhome PSG study of acceptable quality. Height and weight were measured at each home study visit, and body mass index (BMI) percentiles and standard deviation scores were calculated using the 2000 U.S. Centers for Disease Control and Prevention childhood growth charts.12 Children with BMI between the 85th and 95th %tile or ≥ 95th %tile for age and gender were considered to be overweight or obese, respectively.13 At each home visit, the presence of habitual snoring (defined as snoring loudly "frequently" or "almost always") was determined by parental report. At the second home study (followup) visit, 172 of the children completed a validated pubertal selfassessment questionnaire14 without parental supervision that consists of simple line drawings based on photographs of the Tanner and Marshall standards for pubic hair and breast or genital development15,16 and a small amount of descriptive text. The 172 children who completed two home PSG studies and a pubertal assessment questionnaire at the followup study are the focus of this report.
Unattended overnight PSGs were obtained with the Compumedics PS-2 system (Abbotsford, Victoria, Australia) using the following signals: C3/A2 and C4/A1 electroencephalogram, right and left electrooculogram, a bipolar submental electromyogram, thoracic and abdominal displacement (inductive plethysmography band), airflow (nasal/oral thermistor), nasal pressure cannula, finger pulse oximetry, electrocardiography (single bipolar lead), snoring microphone, body position (Hg gauge sensor), and ambient light.
Scoring of sleep was performed by a single registered polysomnographic technologist using Rechtschaffen and Kales criteria.17 Arousals were identified using the American Academy of Sleep Medicine criteria.18 Apneas were scored if the amplitude (peak to trough) of the thermistor airflow signal decreased below 25% of the amplitude at baseline breathing (identified during a period of regular breathing with stable oxygen levels) > 6 sec or 2 breath cycles, as previously described.11 Hypopneas were scored if the amplitude any respiratory signal decreased below 70% of the amplitude of baseline and if the thermistor signal did not meet the criterion for apnea. The respiratory disturbance index (RDI) was defined as the number of apneas and hypopneas associated with a 3% desaturation per hour of total sleep time (RDI 3%). OSA was defined as an RDI ≥ 1 event per hour of total sleep time based on our previous studies,19 demonstrating that this degree of respiratory disturbance is clinically meaningful (e.g., associated with excessive daytime sleepiness and learning problems).
The TuCASA study was approved by the University of Arizona Institutional Review Board and the Tucson Unified School District Research Committee. Informed consent and assent was obtained from all parents and children, respectively, prior to participation.
Student's ttest and the χ2 test were used to compare sleep study parameters at baseline and followup (paired ttest) and between boys and girls (unpaired ttest). The effect of OSA at baseline on pubertal stage determined at followup was investigated using multiple linear regression, controlling for known predictors of pubertal development (age, BMI, and ethnicity). RDI was log-transformed prior to analysis to improve normality. Statistical analyses were performed using SigmaStat 11 (Systat Software Inc, San Jose, CA).
The study population consisted of 87 girls and 85 boys who were 8.9 ± 1.6 years old (mean ± SD) at the time of their baseline PSG study and 13.4 ± 1.6 years old at followup (Table 1), with no difference in age between boys and girls. Sixty-eight percent of the cohort was Caucasian; 32% was Hispanic. Twenty-seven percent of children were overweight or obese at baseline with no differences between girls and boys, and the majority (83%) of these children remained obese at followup approximately 4 years later. Twenty-six percent of girls and 28% of boys met criteria for OSA (RDI ≥ 1 event/h with 3% desaturation) at baseline (RDI 3% of 1-6.6 in girls with OSA, 1-7.2 in boys with OSA). Parents reported habitual snoring in only 17% of children found to have OSA. At the followup study, OSA had persisted in 30% of the subjects diagnosed at baseline, and an additional 12 subjects were newly diagnosed with OSA, for a total of 26 subjects (RDI 3% of 1-5.3 in girls with OSA, 1-7.2 in boys with OSA). There was no difference in the percent of girls (26%) and boys (33%) with OSA at both baseline and followup. Only 2 children with OSA at baseline underwent tonsillectomy prior to followup, and no child was treated with CPAP.
Subject characteristics at baseline and follow-up visits
(more ...)
Selfassessment of Tanner staging at the followup visit revealed a median stage of 3 (range 1-5) for pubic hair and breast/ genital development in both boys and girls. RDI 3% at visit 1 had no effect on breast/genital stage ascertained at followup after controlling for age (β coefficient 0.4, p < 0.001), BMI Z-score at visit 2 (coefficient 0.1, p = 0.07), and ethnicity (coefficient -0.2, p = 0.2). However, when limited to girls, the same linear regression model revealed an inverse relationship between baseline RDI 3% and Tanner breast stage at followup, suggesting that OSA delays pubertal development in girls (Table 2). On average, girls with OSA at baseline were approximately one Tanner breast stage behind girls without OSA at the followup evaluation after controlling for age, BMI, and ethnicity. Higher BMI Z-scores at visit 2 were associated with advanced breast development, but there was no interaction between BMI and RDI 3%, indicating that OSA is associated with slowed pubertal progression in both lean and overweight/obese girls. Older age predicted more mature breast development, as expected, but ethnicity had no effect on Tanner breast stage (Table 2). Girls with OSA at baseline were heavier than girls without OSA (p < 0.01), but there were no differences in age, ethnicity, arousal index, total sleep time, sleep efficiency, or sleep macroarchitecture between the 2 groups (Table 3). There was no relationship between RDI 3% at followup and Tanner breast stage; however, this analysis was significantly limited by the small number of girls with OSA at followup (n = 9).
Linear regression model for effect of OSA on breast development in girls and genital development in boys, controlling for age, BMI, and ethnicity
Characteristics of girls with and without OSA at the baseline study visit
Similar analyses indicated that there was no relationship between OSA and genital development in boys although there was a trend of slightly more mature genital development (coefficient 1.2, p = 0.06) in boys with a history of OSA. However, this trend appears to have been driven by 2 boys without OSA with relatively delayed (Tanner I genitalia at age 13.1 years) or frankly delayed puberty (Tanner I genitalia at 15.1 years of age) at follow-up, as it was lost after exclusion of these 2 subjects. There was only one girl with delayed puberty, a 14.2-yearold girl with Tanner I breasts who did not have OSA, and her exclusion from the analysis in girls did not impact the results. There was no association between RDI 3% and pubic hair development when girls and boys were analyzed together or separately.
Following a prolonged period of childhood quiescence, the central driver of the reproductive axis—the hypothalamic GnRH neuron—reactivates, thereby initiating puberty. Intriguingly, the increase in reproductive hormone secretion during puberty initially occurs only during sleep.1 The cause of this sleepspecific rise is unknown, but its conservation across a number of species suggests that it has physiologic significance.20,21 Furthermore, the sleep sensitivity of GnRH neurons is observed not only during their reactivation during puberty, but reappears in adulthood during the recovery phase of anorexia nervosa22 and hypothalamic amenorrhea,23 two disorders associated with a prolonged period of diminished GnRH activity.
Given the sensitivity of GnRH neurons to the sleep/wake state, we hypothesized that disordered sleep secondary to OSA would disrupt normal pubertal maturation. Indeed, the current study demonstrates that otherwise healthy preadolescent girls with OSA have delayed pubertal development relative to girls without OSA. Although the increase in GnRH activity with sleep occurs to the same degree in boys as in girls, the reproductive axis in boys appears to be more resistant to disorganized sleep, as OSA did not have a significant effect on pubertal maturation in boys. A similar gender difference in seen in the sensitivity of the reproductive axis to other stressors, such as exercise. Hypogonadism is common among female athletes (socalled hypothalamic amenorrhea) but is rare among male athletes.24 OSA had no effect on pubarche (the development of pubic hair) in boys or girls. Although pubic hair and genital development occur simultaneously during adolescence, the two are independent processes, with pubic hair development driven primarily by adrenal androgen production and genital development driven solely by maturational changes within the brain.25
An association between OSA and decreased sex steroid and/ or gonadotropin levels, as would be predicted to occur in adolescents with OSA and delayed puberty, has previously been reported in adults. Most,3–6,8 but not all,26,27 studies demonstrate that men with moderatetosevere OSA have significantly lower T levels than healthy controls and lower5,26 or inappropriately normal3,4,8 LH levels. Of note, however, many of these studies have been limited by small sample sizes, differences in BMI and/or age between cases and controls, both of which influence serum T, and assessment of gonadal function based on single measurements of T, which is influenced by time of day,28 or LH, which is secreted in a pulsatile manner.29 Only one study has been conducted in adult women with OSA,7 and like men with OSA, women with OSA were found to have lower sex steroid levels (estradiol and progesterone) than age- and BMI-matched controls after adjusting for menstrual cycle phase and pre- or postmenopausal status.
The cause of reproductive dysfunction among adults with OSA is unclear but has been attributed to the hypoxia and sleep fragmentation that characterize OSA. Several studies have demonstrated an inverse correlation between T level and the RDI4,5 in men; however, studies of total sleep deprivation for 48 hours30 or partial sleep deprivation and sleep fragmentation for 24 hours31 reported no adverse effect on gonadotropin or T levels in healthy men. Sleep disruption studies have not yet been conducted in preadolescents whose reproductive axis would be expected to be more vulnerable to sleep disruption than that of adults, given the tight association between LH secretion and sleep during the early stages of puberty.1 The negative correlation between T and the desaturation index in men with OSA and the finding that mean nocturnal oxygen saturation in men with and without OSA is independently associated with erectile dysfunction32 also suggests that hypoxia may play a role in the lower T levels observed in men with OSA. In a rodent model, intermittent hypoxia without concomitant sleep deprivation activates the inflammatory cascade, increases free radical production, and induces neuronal apoptosis in the hippocampus and cortex33; however, the effect of hypoxia on the hypothalamus, the seat of the central components of the reproductive axis, including kisspeptin and GnRH neurons,34 has not yet been investigated. Studies are also necessary to determine whether hypoxia and/or sleep disruption explain the defects in reproductive hormone secretion in women with OSA, as observed in men.
In contrast to the above studies in adults with moderate to severe OSA, the children in the current study had relatively mild OSA (RDI 3% 1-7.2) based on conventional scoring methods. However, it is well recognized that standard PSG measures in children, including arousals and the percent time spent in each sleep stage (as were measured in the current study) are likely to underestimate the degree of sleep disruption as they do not correlate with measures of neurobehavioral morbidity.35,36 This concept has led to the suggestion that alternative measures, such as the number of subcortical arousals identified by spectral analysis,37 sleep dynamics analyses,38 and autonomic arousal measures,39,40 be incorporated into the interpretation of pediatric PSG studies. The use of these more sensitive measures may also help explain why LH pulses, which occur most frequently during slow -wave sleep and rarely during REM sleep during puberty,41 might be diminished in children with OSA who have the greatest number of obstructive events during REM.42 Thus, although the children in the current study appear to have mild OSA according to standard scoring methods, current methods may miss arousals and/or subtle defects in sleep architecture that can explain the detrimental effect of OSA on the reproductive axis in girls during puberty.
Due to the large scale and home-centered approach of the TuCASA study, pubertal staging was determined by a selfassessment questionnaire rather than by a physician's physical examination. It is therefore possible that the present findings are due to an underestimation of pubertal development among girls with OSA. However, a number of studies have demonstrated that adolescent girls (and boys) can accurately determine their degree of pubertal maturation to within one Tanner stage of a trained examiner's assessment using a selfassessment questionnaire that is based on line drawings of pubertal stages.43–45 While girls with and without OSA were of similar age and ethnic background, girls with OSA were more likely to be overweight or obese. Obesity, however, would be expected to lead to an overestimation rather than underestimation of true breast development, in part due to the difficulty in distinguishing lipomastia from true breast tissue. In a study of 135 girls (mean age 9.3 years), Bonat et al. found that obese girls significantly overestimated their actual breast size (by 0.5 Tanner stages)46; other investigators, however, have found that BMI does not bias pubertal assessment in either direction in girls.45,47,48 Lastly, although we controlled for BMI in our regression model, the increased incidence of obesity among girls with OSA would be expected to have accelerated, rather than delayed, pubertal development, as recent studies have demonstrated that obese girls enter puberty at a slightly younger age than normal weight girls.49 Thus, our estimate of the effect of OSA on female pubertal development is likely to be conservative.
In summary, the current study demonstrates that OSA among preadolescent girls is associated with relatively delayed pubertal maturation. The pathophysiological connection between OSA and the reproductive axis is unknown, but the critical role of the hypothalamus in pubertal development suggests that hypoxia and/or sleep fragmentation may have direct effects on the brain. A central mechanism of action is also suggested by the neuropsychological deficits found in children with OSA50 and more recently, by magnetic resonance spectroscopy studies demonstrating neuronal metabolite alterations in children with OSA.51 While in the current study Tanner breast stage at follow- up remained within the normal range in girls with a history of OSA despite a significant delay relative to girls without OSA, future studies will be necessary to address the important question of whether or not childhood OSA has any longterm effects on the reproductive axis beyond early adolescence.
This was not an industry supported study. Dr. Quan is the Editor-in-Chief of the Journal of Clinical Sleep Medicine. The other authors have indicated no financial conflicts of interest.
This work was supported by grant HL 62373 from the National Heart, Lung, and Blood Institute. Dr Shaw received fellowship support from the NICHD National Institutes of Health (1K23HD073304-01).
Boyar R, Finkelstein J, Roffwarg H, Kapen S, Weitzman E, Hellman L, authors. Synchronization of augmented luteinizing hormone secretion with sleep during puberty. N Engl J Med. 1972;287:582–6. [PubMed]
Kapen S, Boyar RM, Finkelstein JW, Hellman L, Weitzman ED, authors. Effect of sleep-wake cycle reversal on luteinizing hormone secretory pattern in puberty. J Clin Endocrinol Metab. 1974;39:293–9. [PubMed]
Grunstein RR, Handelsman DJ, Lawrence SJ, Blackwell C, Caterson ID, Sullivan CE, authors. Neuroendocrine dysfunction in sleep apnea: reversal by continuous positive airways pressure therapy. J Clin Endocrinol Metab. 1989;68:352–358. [PubMed]
Hammoud AO, Walker JM, Gibson M, et al., authors. Sleep apnea, reproductive hormones and quality of sexual life in severely obese men. Obesity (Silver Spring). 2011;19:1118–23.
Luboshitzky R, Aviv A, Hefetz A, et al., authors. Decreased pituitary-gonadal secretion in men with obstructive sleep apnea. J Clin Endocrinol Metab. 2002;87:3394–8. [PubMed]
Luboshitzky R, Lavie L, Shen-Orr Z, Herer P, authors. Altered luteinizing hormone and testosterone secretion in middle-aged obese men with obstructive sleep apnea. Obes Res. 2005;13:780–6. [PubMed]
Netzer NC, Eliasson AH, Strohl KP, authors. Women with sleep apnea have lower levels of sex hormones. Sleep Breath. 2003;7:25–9. [PubMed]
Santamaria JD, Prior JC, Fleetham JA, authors. Reversible reproductive dysfunction in men with obstructive sleep apnoea. Clin Endocrinol (Oxf). 1988;28:461–70.
Luboshitzky R, Lavie L, Shen-Orr Z, Lavie P, authors. Pituitary-gonadal function in men with obstructive sleep apnea. The effect of continuous positive airways pressure treatment. Neuro Endocrinol Lett. 2003;24:463–7. [PubMed]
Marcus CL, Brooks LJ, Draper KA, et al., authors. Diagnosis and management of child-hood obstructive sleep apnea syndrome. Pediatrics. 2012;130:576–84. [PubMed]
Goodwin JL, Enright PL, Kaemingk KL, et al., authors. Feasibility of using unattended polysomnography in children for research--report of the Tucson Children's Assessment of Sleep Apnea study (TuCASA). Sleep. 2001;24:937–44. [PubMed]
Clinical Growth Charts. Centers for Disease Control and Prevention. 2012. http://www.cdc.gov/growthcharts/clinical_charts.htm.
Barlow SE, author. Expert committee recommendations regarding the prevention, assessment, and treatment of child and adolescent overweight and obesity: summary report. Pediatrics. 2007;120 Suppl 4:S164–92. [PubMed]
Taylor SJ, Whincup PH, Hindmarsh PC, Lampe F, Odoki K, Cook DG, authors. Performance of a new pubertal self-assessment questionnaire: a preliminary study. Paediatr Perinat Epidemiol. 2001;15:88–94. [PubMed]
Marshall WA, Tanner JM, authors. Variations in pattern of pubertal changes in girls. Arch Dis Child. 1969;44:291–303. [PubMed Central][PubMed]
Marshall WA, Tanner JM, authors. Variations in the pattern of pubertal changes in boys. Arch Dis Child. 1970;45:13–23. [PubMed Central][PubMed]
Rechtschaffen A, Kales A, authors. A manual of standardized terminology, techniques, and scoring system for sleep stages of human subjects. 1968. Washington DC: Washington Public Health Service, US Government Printing Office.
EEG arousals: scoring rules and examples: a preliminary report from the Sleep Disorders Atlas Task Force of the American Sleep Disorders Association. Sleep. 1992;15:173–84. [PubMed]
Goodwin JL, Kaemingk KL, Fregosi RF, et al., authors. Clinical outcomes associated with sleep-disordered breathing in Caucasian and Hispanic children--the Tucson Children's Assessment of Sleep Apnea study (TuCASA). Sleep. 2003;26:587–91. [PubMed]
Urbanski HF, Ojeda SR, authors. The juvenile-peripubertal transition period in the female rat: establishment of a diurnal pattern of pulsatile luteinizing hormone secretion. Endocrinology. 1985;117:644–9. [PubMed]
Watanabe G, Terasawa E, authors. In vivo release of luteinizing hormone releasing hormone increases with puberty in the female rhesus monkey. Endocrinology. 1989;125:92–9. [PubMed]
Katz JL, Boyar R, Roffwarg H, Hellman L, Weiner H, authors. Weight and circadian luteinizing hormone secretory pattern in anorexia nervosa. Psychosom Med. 1978;40:549–67. [PubMed]
Perkins RB, Hall JE, Martin KA, authors. Neuroendocrine abnormalities in hypothalamic amenorrhea: spectrum, stability, and response to neurotransmitter modulation. J Clin Endocrinol Metab. 1999;84:1905–11. [PubMed]
Skarda ST, Burge MR, authors. Prospective evaluation of risk factors for exercise-induced hypogonadism in male runners. West J Med. 1998;169:9–12. [PubMed Central][PubMed]
Counts DR, Pescovitz OH, Barnes KM, et al., authors. Dissociation of adrenarche and gonadarche in precocious puberty and in isolated hypogonadotropic hypogonadism. J Clin Endocrinol Metab. 1987;64:1174–8. [PubMed]
Bratel T, Wennlund A, Carlstrom K, authors. Pituitary reactivity, androgens and catecholamines in obstructive sleep apnoea. Effects of continuous positive airway pressure treatment (CPAP). Respir Med. 1999;93:1–7. [PubMed]
Gambineri A, Pelusi C, Pasquali R, authors. Testosterone levels in obese male patients with obstructive sleep apnea syndrome: relation to oxygen desaturation, body weight, fat distribution and the metabolic parameters. J Endocrinol Invest. 2003;26:493–8. [PubMed]
Brambilla DJ, Matsumoto AM, Araujo AB, McKinlay JB, authors. The effect of diurnal variation on clinical measurement of serum testosterone and other sex hormone levels in men. J Clin Endocrinol Metab. 2009;94:907–13. [PubMed Central][PubMed]
Midgley AR Jr.; Jaffe RB, authors. Regulation of human gonadotropins. X. Episodic fluctuation of LH during the menstrual cycle. J Clin Endocrinol Metab. 1971;33:962–9. [PubMed]
Akerstedt T, Palmblad J, de la TB, Marana R, Gillberg M, authors. Adrenocortical and gonadal steroids during sleep deprivation. Sleep. 1980;3:23–30. [PubMed]
Luboshitzky R, Zabari Z, Shen-Orr Z, Herer P, Lavie P, authors. Disruption of the nocturnal testosterone rhythm by sleep fragmentation in normal men. J Clin Endocrinol Metab. 2001;86:1134–9. [PubMed]
Budweiser S, Enderlein S, Jorres RA, et al., authors. Sleep apnea is an independent correlate of erectile and sexual dysfunction. J Sex Med. 2009;6:3147–57. [PubMed]
Gozal D, Daniel JM, Dohanich GP, authors. Behavioral and anatomical correlates of chronic episodic hypoxia during sleep in the rat. J Neurosci. 2001;21:2442–50. [PubMed]
Seminara SB, Crowley WF Jr, authors. Kisspeptin and GPR54: discovery of a novel pathway in reproduction. J Neuroendocrinol. 2008;20:727–31. [PubMed Central][PubMed]
Lopes MC, Marcus CL, authors. The significance of ASDA arousals in children. Sleep Med. 2007;9:3–8. [PubMed]
Paruthi S, Chervin RD, authors. Approaches to the assessment of arousals and sleep disturbance in children. Sleep Med. 2010;11:622–7. [PubMed Central][PubMed]
Chervin RD, Burns JW, Subotic NS, Roussi C, Thelen B, Ruzicka DL, authors. Method for detection of respiratory cycle-related EEG changes in sleep-disordered breathing. Sleep. 2004;27:110–5. [PubMed]
Chervin RD, Fetterolf JL, Ruzicka DL, Thelen BJ, Burns JW, authors. Sleep stage dynamics differ between children with and without obstructive sleep apnea. Sleep. 2009;32:1325–32. [PubMed Central][PubMed]
Aljadeff G, Gozal D, Schechtman VL, Burrell B, Harper RM, Ward SL, authors. Heart rate variability in children with obstructive sleep apnea. Sleep. 1997;20:151–7. [PubMed]
Katz ES, Lutz J, Black C, Marcus CL, authors. Pulse transit time as a measure of arousal and respiratory effort in children with sleep-disordered breathing. Pediatr Res. 2003;53:580–8. [PubMed]
Shaw ND, Butler JP, McKinney SM, Nelson SA, Ellenbogen JM, Hall JE, authors. Insights into puberty: the relationship between sleep stages and pulsatile LH secretion. J Clin Endocrinol Metab. 2012;97:E2055–62. [PubMed]
Goh DY, Galster P, Marcus CL, authors. Sleep architecture and respiratory disturbances in children with obstructive sleep apnea. Am J Respir Crit Care Med. 2000;162:682–6. [PubMed]
Chan NP, Sung RY, Kong AP, Goggins WB, So HK, Nelson EA, authors. Reliability of pubertal self-assessment in Hong Kong Chinese children. J Paediatr Child Health. 2008;44:353–8. [PubMed]
Rollof L, Elfving M, authors. Evaluation of self-assessment of pubertal maturation in boys and girls using drawings and orchidometer. J Pediatr Endocrinol Metab. 2012;25:125–9. [PubMed]
Wu Y, Schreiber GB, Klementowicz V, Biro F, Wright D, authors. Racial differences in accuracy of self-assessment of sexual maturation among young black and white girls. J Adolesc Health. 2001;28:197–203. [PubMed]
Bonat S, Pathomvanich A, Keil MF, Field AE, Yanovski JA, authors. Self-assessment of pubertal stage in overweight children. Pediatrics. 2002;110:743–7. [PubMed]
Stephen MD, Bryant WP, Wilson DP, authors. Self-assessment of sexual maturation in children and adolescents with diabetes mellitus. Endocr Pract. 2008;14:840–5. [PubMed]
Williams RL, Cheyne KL, Houtkooper LK, Lohman TG, authors. Adolescent self-assessment of sexual maturation. Effects of fatness classification and actual sexual maturation stage. J Adolesc Health Care. 1988;9:480–2. [PubMed]
Kaplowitz PB, Slora EJ, Wasserman RC, Pedlow SE, Herman-Giddens ME, authors. Earlier onset of puberty in girls: relation to increased body mass index and race. Pediatrics. 2001;108:347–53. [PubMed]
Beebe DW, author. Neural and neurobehavioral dysfunction in children with obstructive sleep apnea. PLoS Med. 2006;3:e323. [PubMed Central][PubMed]
Halbower AC, Degaonkar M, Barker PB, et al., authors. Childhood obstructive sleep apnea associates with neuropsychological deficits and neuronal brain injury. PLoS Med. 2006;3:e301. [PubMed Central][PubMed]


text:
Homer Simpson will Appear Live on The Simpsons This May
February 18, 2016 | | No Comments |
Something new is in the air. Homer Simpson will be appearing in the context of the town of Springfield. A May episode is in the works on the Fox Channel. According to The Wrap, this episode will show Bart, Marge …


text:
Norway is famous for its vibrant but dark metal scene, and Kvelertak is just about the most famous active band out of that culture right now. The group formed in 2007 and released its second album, Meir, earlier this year. The A.V. Club's Jason Heller called that record, "another anthemic blitzkrieg of classic-rock hooks and blackened frenzy," and said the band takes "the rudiments of vintage '70s metal like Judas Priest and Scorpions, then drag[s] it through a minefield of bombast, harmony, and noise." Sounds pretty good.
Kvelertak is touring with High On Fire beginning this Sunday, Nov. 10, and in anticipation, The A.V. Club is streaming one of the band's stellar live recordings. Below, find all the band's tour dates, as well as its take on "Evig Vandrar" live at London's Electric Ballroom.
Kvelertak tour 2013
Nov. 10—Masquerade—Atlanta, Georgia *
Nov. 11—Orange Peel—Asheville, North Carolina *
Nov. 12—Rock & Roll Hotel—Washington, D.C. *
Nov. 13—Underground Arts—Philadelphia, Pennsylvania *
Nov. 15—Webster Hall—New York, New York *
Nov. 16—Middle East—Cambridge, Massachusetts *
Nov. 17—Corona Theatre—Montreal, Quebec *
Nov. 18—Opera House—Toronto, Ontario *
Nov. 19—The Crofoot Ballroom—Pontiac, Michigan *
Nov. 20—A And R Music Bar—Columbus, Ohio *
Nov. 22—Metro—Chicago, Illinois *
Nov. 23—Pop's—Sauget, Illinois *
Nov. 25—House Of Blues—Houston, Texas
Nov. 27—Mohawk Outside—Austin, Texas +
Nov. 29—Granada Theatre—Lawrence, Kansas ^
Nov. 30—First Avenue—Minneapolis, Minnesota ^
Dec. 2—WECC—Winnipeg, Manitoba ^
Dec. 4—Starlite Room—Edmonton, Alberta ^
Dec. 5—Republik—Calgary, Alberta ^
Dec. 7—Venue Vancouver—Vancouver, British Columbia ^
Dec. 8—El Corazon—Seattle, Washington ^
Dec. 9—Hawthorne Theatre—Portland, Oregon ^
Dec. 11—The Regency Ballroom—San Francisco, California ^
Dec. 12—El Rey—Los Angeles, California ^
* with High On Fire, Doomriders
+ with High On Fire, Pack Of Wolves
^ with High On Fire, Windhand


text:
Jenna Bush Hager is an advocate of education and literacy—and she's really nice, too!
I had the pleasure of hearing Jenna Bush Hager speak at a breakfast this week for Wonderopolis, a website where parents and tweens can discover cool things together. Its mission is to make learning a fun family activity using real-world knowledge and curiosity based on the context of daily life.
The site focuses on a Wonder of the Day ("Why is the Statue of Liberty Green?"), and answers are provided via explanations, videos and activities. And it's not just for little kids—some of the Wonders of the Day stumped me!
Jenna spoke about her experience as a teacher and even got choked up about missing her students in the classroom (love)! But mostly she emphasized the importance of parents sharing in kids' learning. To combat summer learning loss, the National Center for Family Literacy and Wonderopolis are launching Camp What-A-Wonder, a program that takes place online every Thursday until August 11. Wonderopolis becomes a virtual camp where kids can explore topics like crawling critters, crafts and campfire cooking, and parents can discuss topics with a facilitator on Twitter each week at 8pm EST. I'll bring the marshmallows!
Photo: Cindy Ord/Getty Images


text:
Culture Shock
It's Autumnal—Mariposa Gallery (3500 Central SE) rings in the fall season with a new show featuring jewelry by Kristen Diener, sculptures by Lisa Smith and mirror creations by Leroy Archuleta. Upstairs in the adjoining Galerie E, there'll also be a Dia de los Muertos exhibit with work by Ken Saville, Maria Moya, Jeff Sipe, Kevin Burgess and others. Both shows open Friday, Oct. 7, with receptions from 5 to 8 p.m. They run through Oct. 30. 268-6828.
Gallery Review
¡Arte Caliente! at the National Hispanic Cultural Center
Wouldn't it be nice to have the spare cash to really collect art? Wherever you happened to be, if you saw a piece of art that yanked your chain, you could just whip out the plastic and buy it on the spot. Joe A. Diaz has just such a luxury. The San Antonio-based businessman might not be able to buy every piece of art he's ever wanted, but for the last decade and a half he's had the resources to develop an astonishing art collection mainly consisting of masterpieces of Chicano art from the Southwest.
Art Magnified
The Most Fabulous Story Ever Told
Rodey Theatre
With a title like this, Paul Rudnick's play had better be pretty freakin' fabulous. By most accounts, this campy gay Bible story about the adventures of two couples—Adam and Steve, Mabel and Jane—is a hoot. A new production of The Most Fabulous Story Ever Told opens this weekend at UNM's Rodey Theatre. It includes sex, foul language and nudity, so you might want to leave the kids at home. $15 general, $10 seniors, $8 students. Call for dates and times. To order tickets, go to unmtickets.com or call 925-5858.
Art Magnified
James Rourke: Neither Here Nor There
Donkey Gallery
For his new exhibit at the Donkey (1415 Fourth Street SW), Rourke has created a small, mirrored tower-like structure and placed it in the middle of the gallery's parking lot. It's designed to stimulate interaction with visitors to the show. Inside the gallery itself, Rourke will display models and drawings used in the design stage. This odd little exhibit opens Friday, Oct. 7, with a reception from 6 to 9 p.m. that will include music by DJ Lukaduke and heaping, steaming troughs of delicious food. The show runs through Oct. 29. 242-7504.
Author Interview
Coming of Age in Country
An interview with Tracy Kidder
Tracy Kidder's tour of duty in Vietnam may have unfolded to a soundtrack of Creedence Clearwater Revival songs, but that's about all it shares with Hollywood portrayals of that war. In fact, Kidder's experience as a young army lieutenant is notable for what it lacked. There were no blazing firefights, no elaborate crying jags beneath slowly turning ceiling fans. He was even turned down by one prostitute and never once fired his gun.


text:
A rickshaw full of flowers is on it's way to some place... This painting reminds me of my mama who, no matter what the condition, time or country, would always grab an arm full of flowers before heading to visit someone's home. What a beautiful touch that is!
This painting is 30" x 30" & is


text:
Weight Loss Center
The Cedars-Sinai Weight Loss Center offers a multi-disciplinary approach, incorporating a broad range of medical and surgical services for adults who are somewhat overweight to morbidly obese. Center physicians evaluate each patient and provide the individualized care that is crucial to effective and long-lasting treatment success. This unique, comprehensive weight loss program addresses the medical, behavioral, nutritional and, if necessary, surgical issues related to obesity.
Although it is often perceived as a cosmetic problem, obesity is associated with many serious health conditions, including diabetes, heart disease, high blood pressure, several types of cancer, sleep apnea, musculoskeletal diseases and other medical problems.
Our expert team of doctors, dieticians and mental health professionals can help you implement the lifestyle changes necessary to achieve sustainable weight loss, enabling you to improve your health. The Center offers weight loss surgery, meal replacements, individualized dietary plans, assessments, classes and support groups.
Cedars-Sinai physicians have led the way in developing techniques for minimally invasive bariataric surgery. The bariatric surgical team specializes in laparoscopic bariatric surgery which has been performed for more than 20 years and has been Federal Drug Administration (FDA) approved since 2001.
Using a revolutionary technique known as magnetic resonance spectroscopy, doctors can now measure the amount of fat inside an organ. Prior to this noninvasive technology, the only other method was by performing a biopsy. The goal of this treatment is to fight Type 2 diabetes.
Besides lifestyle and diet, research has shown that weight gain can also be contributed through methane producing bacteria, epigenetics and hunger inducing hormones. Doctors are beginning to slowly realize that obesity is not a one-size-fits-all type of problem, but individualized between lifestyle and diet, and is genetic, hormonal, and microbe-based.


text:
Terrelle Pryor didn't put away concerns of his starting capabilities in the last preseason game, but against the Colts, he seemed to have added some evidence as to why he rose to the top of Oakland's QB depth chart of sadness.
Not everything was great; Pryor made some big, dumb mistakes at the end of the game that cost the Raiders a chance at winning. He was sacked for a 16-yard loss on first down during the Raiders' final drive, which severely limited the play options that followed. Pryor also threw an interception on third and long to close out the win for the Colts, but then again, the team was getting desperate with not much time left. Before those two plays, though, Pryor was putting the team's offense on his back.
As of writing this, Pryor is this week's leading rusher with 112 yards on 13 attempts. He was the first player to break 100 rushing yards this week, and Adrian Peterson ran for 78 yards on his first touch. Pryor's running turned broken pass plays into substantial gains on the ground.
Pryor's passing wasn't abysmal, which was a nice surprise considering how he closed out the preseason. Yeah, he had a dumb early end-zone pick, but he was generally accurate, throwing 19 completions on 29 attempts for 217 yards with a touchdown on a quick, precise slant pass to Denarius Moore to give the Raiders a 17-14 lead. The offensive line did its job for the most part, too, only allowing Pryor to get sacked once. To be fair, however, the Colts defense is soft and the current pass rush even softer with the departure of Dwight Freeney.
Pryor's decent day doesn't change much about the Raiders' hopes this season, but it adds a little stability to an offense with no identity. Today, we found out that Pryor's running ability is dangerous enough to require quarterback spies, but he'll throw accurately, too. A healthy Darren McFadden could give that offense another dimension and keep opposing defenses honest. Rod Streater and Denarius Moore aren't top producers, but out of what's available, they'll usually catch what's thrown to them, which is good enough right now. Finally, although crying doesn't score points—as far as we know—we got a look into how much Pryor cares about a team many predict to be the worst in the league this season.


text:
Greetings Electribbers.
I have been using the EMX1 and though I have been advancing on its use, I have two problems:
1.- I don't know how to properly use the motion sequence. As far as I understand, when active, it will reproduce the knob movement while recording a specific part while a pattern is playing. I do that but when I play the pattern it doesn't work, just sounds plain acorrding to the adjusting I did before. Could anyone give me an example of how to use it properly?
2.- When I add effects to a part, as far as I understand I can apply a maximum of 3 effects, but actually only 1 sound (if i have selected the fx1, then will play fx1, and so on if i choose fx2 or fx3). I have chosen the fx chain but when I do that it doesn't apply the 3 fx to the sound of the part. Sometimes, when select the chain, adds one effect to the whole pattern. How do I do it properly to add 3 effects part by part? I have tried choosing a part with the "solo" option, but it doesn't work either.
Any help is welcome.


text:
Rick Ross Sends Out A PSA: "I Apologise To The Gay Community" . "I'm Offering To Do A Song With An Openly Gay Artist Such As Curtis 50 Cent Jackson" + Shows His T3 Watch
Rick Ross's PSA. Shout out to Spiff TV
Please click the "Report" button below if the video on this page is not working properly.
Comments will only be displayed by verified emails. No Spamming or Racism.


text:
UCYCOM(4) NetBSD Kernel Interfaces Manual UCYCOM(4) NAME ucycom -- USB support for Cypress microcontroller based serial adapters SYNOPSIS ucycom at uhidev? reportid ? HARDWARE The ucycom driver supports the following adapters: Various low-cost USB-RS232 adapters Delmore Earthmate GPS receiver DESCRIPTION The ucycom driver provides support for Cypress microcontroller based USB- to-RS-232 adapter. The ucycom driver shows a behaviour like a tty(4). This means that normal programs such as tip(1) or pppd(8) can be used to access the device. FILES /dev/ttyY? SEE ALSO uhidev(4), usb(4) HISTORY The ucycom driver appeared in NetBSD 4.0. NetBSD 8.1 July 16, 2005 NetBSD 8.1
You can also request any man page by name and (optionally) by section:


text:
Coastal NWS Forecast Offices have regionally focused marine
webpages which are overflowing with information such as
coastal forecasts, predicted tides, and buoy observations.
Please also visit the NWS National Centers which
produce Radiofax, High Seas, NAVTEX, Offshore and Hurricane
forecasts and provide forecast guidance to the NWS Coastal
Forecast Offices.
Link to live maps showing....Coastal/Great Lakes....Offshore....High Seas....forecast areas
Alternate Offshore and High Seas in single view
Ocean Prediction Center - OPC
(NE Pacific and NW Atlantic)
National Hurricane Center - NHC
(Tropical NE Pacific, Tropical Atlantic, Gulf of Mexico and the Caribbean)
Central Pacific Hurricane Center - CPHC
(Central Pacific)
Anchorage, AK
Fairbanks, AK
Juneau, AK
Mobile, AL
Eureka, CA
San Francisco,
Los Angeles, CA
Diego, CA
Jacksonville, FL
Key West, FL
Melbourne, FL
Miami, FL
Tallahassee, FL
Tampa Bay Area, FL
Charleston, SC
Brownsville, TX
Corpus Christi, TX
Houston, TX
Sterling, VA
Wakefield, VA
Seattle, WA
Green Bay, WI
Milwaukee, WI
Tiyan, Guam
American Samoa
National Weather Service
Analyze, Forecast, and Support Office
Marine, Tropical, and Tsunami Services Branch (W/AFS26)
Last modified:
May 31, 2019
Questions, Comments?


text:
SE Quadrant Plan SAC Discusses Potential Land Use Patterns for the Southern Triangle
The Southern Triangle of the SE Quadrant is enclosed by the Union Pacific rail line to the north and east, SE Powell Blvd to the south and the Willamette River to the west. During a recent visit by the Urban Land Institute Rose Fellows, the area's unique combination of large blocks, new transit infrastructure and close proximity to downtown and the South Waterfront were highlighted as opportunities for new development in addition to existing cultural attractions, such as OMSI and the Oregon Rail Heritage Center. The Stakeholder Advisory Committee will discuss potential land use patterns for this area and will suggest to staff the types of analysis to include in the land use scenarios.
Project staff will also present an update on market feasibility analyses of selected strategic sites, and there will be an update on the activities of the Transportation Working Group (TWG) at their first two meetings in February and March.
See the meeting packet for a more detailed agenda.
Upcoming Meetings
SAC Meeting #5
Thursday, April 3, 6 - 8:30 p.m.
Eastside Exchange – Cascade Energy Meeting Room
123 NE 3rd Ave (3rd Floor) – Directions
TWG Meeting #3
Thursday, April 24, 6 - 8:00 p.m.
ADX Portland
417 SE 11th Ave
SAC Meeting #6
Thursday, May 8, 6 - 8:30 p.m.
Eastside Exchange – Cascade Energy Meeting Room
123 NE 3rd Ave (3rd Floor) – Directions
All SAC meetings are open to the public and will include public comment periods. Meeting packets are posted approximately one week before meetings in the SAC Documents.


text:
Facebook Redesigns Groups, Adds to News Feeds
Facebook is revamping Groups to make them look more like Profiles and Pages.
First, Groups will now have Walls where members can make comments or publish content. Second, Facebook will now publish Group activities to your news feed. Previously, activity was only documented on a Group's page.
"For example, you now will see a story when your friend uploads photos from a recent party at your high school alumni group or when one of your friends posts a message on the Wall of your pick-up soccer group saying that there is a special game this week," Facebook wrote in a blog post.
The changes are intended to keep users more up-to-date with activity in their Groups, as well as to make it easier to comment on things. Facebook is testing the changes with a small group of people and will roll it out site-wide in the near future.
Despite the similar look and feel, Groups and Pages will still serve different purposes, Facebook said. "Groups are for fostering member-to-member collaboration, while Pages remain the best way to broadcast messages to your fans if you are a business, organization, public figure or other entity," the company said.
To date, there are 45 million Groups on Facebook.Originally posted to AppScout.


text:
Purdue Names Director For Inflammation, Immunology And Infectious Disease InstitutePosted: Updated:
5 Things Consumers Should Know About Marketplace Health Insurance
Open Enrollment is upon consumers again and there are likely questions on what they should do in terms of health care coverage for 2020. Options for coverage can be overwhelming, but consumers can choose a plan that fits them best through education on open enrollment, understanding what's new in terms of health plans and learning of any changes going into 2020.
Most Popular Stories
New Housing Coming to East Chicago
The Indiana Housing & Community Development Authority has selected a Chicago nonprofit to participate in a new workforce housing program in East Chicago, according to our partners at The Times of Northwest Indiana. The nonprofit organization A Safe Haven Foundation was awarded a $700,000 grant from the IHCDA that will support the new construction of single-family homes in the West Calumet neighborhood.
ArcelorMittal to Idle Furnace at Indiana Harbor West
ArcelorMittal plans to idle a blast furnace at its Indiana Harbor West in East Chicago. A spokesperson tells our partners at The Times of Northwest Indiana employees will be reassigned and there will be no layoffs as a result of the move.
A New Way of Thinking for Drug Addiction Recovery
The long war against drug addiction continues to rage, with the opioid crisis representing the latest front of the battle. As with any long fight, our strategy must change as the forces of death and destruction find new ways to attack those most vulnerable. According to the Centers for Disease Control and Prevention, 68% of the 70,200 drug overdose deaths in 2017 involved an opioid – six times higher than in 1999.
Manufacturing Skills Training for Inmates
The Indiana Department of Correction is trying to help fill voids in the state's manufacturing workforce by preparing and training low-risk inmates before they are released. Branchville Correctional Facility in downstate Perry County just graduated its first cohort of the Catapult Training Program, following a four-week course in basic manufacturing skills. The facility is classified as a Level II Low Medium Security Correctional Facility. In an interview with...
Calumet Specialty Sells Texas Refinery
Indianapolis-based Calumet Specialty Products Partners (Nasdaq: CLMT) has closed on the sale of its San Antonio,Texas refinery, crude oil terminal and pipeline to Starlight Relativity Acquisition Co. LLC. Starlight agreed to pay $63 million in cash for the plant, property and equipment.


text:
Genes are the basic units of genetic material, the segments of DNA that usually code for the production of specific proteins, including the proteins known as enzymes. Each person has two copies of most genes: one copy is inherited from their mother and one copy is inherited from their father. Each gene is made up of a specific genetic code, which is a sequence of nucleotides. Each nucleotide can be one of four different nucleotides (A, T, G, or C). For each nucleotide position in the gene, one of the four nucleotides is the predominant nucleotide in the general population. This nucleotide is usually referred to as "wild type." If an individual has a nucleotide that is different from "wild type" in one copy of their genes, that person is said to have a heterozygous variant. If an individual has the same variant nucleotide in both copies of their genes, that person is said to have a homozygous variant.
Nucleotide or genetic variants (also called polymorphisms or mutations) occur throughout the population. Some genetic variants are benign — they do not produce any known negative effect or may be associated with features like height, hair colour, and eye colour. Other genetic variants may be known to cause specific diseases. Other variants may be associated with variable response to specific medications.
Pharmacogenetic tests look for genetic variants that are associated with variable response to specific medications. These variants occur in genes that code for drug-metabolizing enzymes, drug targets, or proteins involved in the immune response. Pharmacogenetic tests can determine if a variant is heterozygous or homozygous, which can affect an individual's response or reaction to a drug.
When are the tests requested?
A doctor may test a patient's genes for specific variations that are known to be involved in variable response to a drug at any time during treatment (for example, prior to treatment, during the initial phase of treatment, or later in the treatment). The results of the testing may be combined with the individual's clinical information, including age, weight, health and other drugs that they are taking, to help tailor therapy to the specific individual. Sometimes, the doctor may use this information to adjust the medication dose or sometimes to choose a different drug. Pharmacogenetic testing is intended to give the doctor additional information but may not replace the need for therapeutic drug monitoring.
Pharmacogenetic testing for a specific gene is only performed once since a person's genetic makeup does not change over time. Depending on the medication, a single gene may be ordered or multiple genes may be ordered. An example of a medication for which multiple genes are usually evaluated is warfarin, which can be affected by genetic variation in genes known as CYP2C9 and VKORC1.
Testing may be ordered prior to starting specific drug therapies or if someone who has started taking a drug is experiencing side effects or having trouble establishing and/or maintaining a stable dose. Sometimes patients may not experience such issues until other medications that affect the metabolism or action of the drug in question are added or discontinued.


text:
Google (GOOG) just told the SEC it's invested $2.6 million in Anne Wojcicki's biotech startup 23andMe.
Wojcicki is Google cofounder Sergey Brin's wife, and he's recused himself from the whole deal.
But it's still a head-scratching investment. Not because of the family ties between the companies, but because why does Google want or need to own a piece of a biotech company?
Why is Google now a VC?
Fred Wilson said it best in March:
- "The best talent in the venture industry doesn't work in large companies and won't work in large companies."
- "Corporate investors don't really share the profit motive with the entrepreneurs."
Get the latest Google stock price here.


text:
Visiting Student Guidelines For Elective Application and Registration
EVMS welcomes visiting students to take fourth-year electives. Up to twelve (12) weeks of electives may be taken; extensions beyond that limit may be provided in special circumstances by the Associate Dean for Education. Third-year clerkships are not open to visiting students. Electives are listed in the Course Catalog (see link above).
Qualifications that must be met by the visiting student:
Enrollment in an LCME-accredited medical school in the U.S.
Satisfactory completion of all basic science courses (including physical diagnosis or similar).
Satisfactory completion by the start of the elective of a minimum of thirty-six (36) weeks of full-time clinical experience during which the student's primary responsibility was to follow patients on a teaching service. This experience must include at least four (4) weeks in each of at least four (4) separate disciplines from the following: Family Medicine, General Internal Medicine, Obstetrics and Gynecology, Pediatrics, Psychiatry, and General Surgery.
Documentation and fees that must be provided at least six (6) weeks prior to the start of the elective:
Visiting Student Application Form for each elective requested. You are to complete Section I, and your school official is to complete Section II.
Visiting Student Health Requirements Letter completed by your health-care provider.
Official school transcript
Proof of HIPAA training
Proof of Blood-borne pathogens training
Criminal background report
Proof of personal health insurance coverage
Non-refundable application fee of $150.00
For assistance, please contact Jill Haught at 757-446-5866 or firstname.lastname@example.com.
Any communication with other departments is not considered an official request for an elective. Confirmation must be received from the Office of Medical Education.
Additional information:
In most cases, confirmation for electives will be given as soon as possible after the May 5th scheduling deadline for EVMS students, who have first priority for electives.
Prior to beginning the elective, each visiting student must register with the EVMS Registrar's Office. A student identification card will then be provided by the Personnel Office.
Each student is responsible for obtaining accommodations during his/her stay here.
No stipend will be paid by EVMS to visiting students taking electives for credit.
EVMS will provide evaluations to the sponsoring institutions. Credit for elective experiences will be given by the institution granting the M.D. degree to the student.


text:
The Impressions
- Arthur Brooks
- Richard A. Brooks
- Jerry Butler
- Fred Cash
- Sam Gooden
- Curtis Mayfield
A bridge in more ways than one.
The Impressions traversed the sounds of the Fifties and Sixties as well as old and new social attitudes. Their music was the sound of the civil rights movement.
The Impressions provided a critical link between Fifties rhythm & blues and Sixties soul.
They pioneered and epitomized the sound of Chicago soul, a marriage of gospel and pop influences with a timely conscience. From the beginning, leader Curtis Mayfield was an innovative songwriter and producer whose work with the Impressions was typified by sophisticated yet celebratory grooves, elaborately detailed vocal arrangements, and lyrics that addressed and advanced the black freedom movement of the Sixties. On the strength of such indelible songs of striving and transcendence as "People Get Ready," "Keep On Pushing" and "We're a Winner," Mayfield has been credited with authoring "the soundtrack to the civil-rights movement."
The Impressions came together as a union between Sam Gooden, brothers Richard and Arthur Brooks (members of a vocal group called the Roosters) and songwriter/producers Jerry Butler and Curtis Mayfield (of the Northern Jubilee Gospel Singers). Their debut single, "For Your Precious Love," was a masterpiece of dramatic, resonant soul testifying that sold 900,000 copies and rose to Number Eleven on the Top 40. Released in 1958, it was credited to "Jerry Butler and The Impressions." The spotlighting of the song's lead vocalist resulted in jealousies leading to Butler's departure that same year. For a few years thereafter, the Impressions floundered, but they regained their footing and discovered their signature sound in the early Sixties with Mayfield in command. First, Mayfield co-wrote and performed on "He Will Break Your Heart," a stately soul gem that became Jerry Butler's first solo hit. In 1961 a re-formed Impressions, which found Butler replaced by Fred Cash, released "Gypsy Woman," a marriage of Brazilian rhythms and sensuous soul distinguished by Mayfield's sweet, supple falsetto.
Reduced to a trio by the departure of the Brooks brothers, the Impressions soared through the Sixties with a string of chart successes that established the group as the social conscience of soul music. Their biggest hit was "It's All Right" (Number One R&B, Number Four Pop), a casual, easygoing soul shuffle that provided much-needed comfort and solace to a nation reeling from the recent assassination of President John F. Kennedy. The Impressions songs that have had the greatest staying power are those, like "People Get Ready" and "Amen," that provided inspiration to those caught up in the social struggles of the Sixties. All the while, Mayfield's work outside the group as a songwriter and producer yielded a bumper crop of Chicago-soul hits for such artists as Major Lance ("The Monkey Time," "Um, Um, Um, Um, Um, Um") and Gene Chandler ("Just Be True," "Nothing Can Stop Me").
After leaving the Impressions in 1970, Mayfield addressed issues of black identity and self-assertiveness with an even greater sense of urgency as a solo artist. He founded his own Curtom label and connected with such topical fare as "(Don't Worry) If There's a Hell Below We're All Going to Go." His solo career found him giving freer reign to his guitar playing, a choppy, rhythm-based funk style that owed much to his Chicago blues heritage. (Among other things, Mayfield had played guitar on a few Jimmy Reed sessions.) Mayfield hit his creative and commercial peak in the Seventies with the soundtrack to Superfly (1972), a blend of smoldering rock-disco grooves and pointed social commentary that yielded the Top 10 hits "Freddie's Dead" and "Superfly."
Throughout his career, Mayfield's willingness to give voice to the truth—and the simultaneously dignified and funky ways in which he musically cast forthright sentiments—have made him one of the great soul icons of the age. Mayfield was paralyzed from the neck down in a 1990 accident when a lighting tower fell on him prior to a show in New York. However, this tragic setback did not diminish his spirit or his career. In 1996 he released his twenty-fifth solo album, New World Order. In his own words: "How many 54-year-old quadriplegics are putting albums out? You just have to deal with what you got, try to sustain yourself as best you can, and look to the things that you can do." He died in 1999.
Inductees: Arthur Brooks (deceased), Richard Brooks (born May 13, 1940), Jerry Butler (born December 8, 1939), Fred Cash (born October 8, 1940), Sam Gooden (born September 2, 1934), Curtis Mayfield (born June 3, 1942, died December 26, 1999)