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Down syndrome (DS) is a neurodevelopmental disorder characterized by multiple comorbidities. Sleep disorders are common among children with DS and can cause significant distress for families. However, research is limited describing sleep problems and correlates in large population-based samples. Accordingly, we aimed to describe sleep behavior among children with DS and its relationship with medical conditions in this population.
We conducted a population-based, cross-sectional study (2009-2011) of sleep disturbances in children and adolescents with DS 7 to 17 years of age (N = 107). We assessed sleep problems using caregiver report on two validated screening tools: the Childhood Sleep Habits Questionnaire (CSHQ) and the Pediatric Sleep Questionnaire (PSQ). The prevalence of sleep problems was compared in children with and without important comorbidities using modified Poisson regression with robust standard errors.
65% of children screened positive on the CSHQ for significant sleep problems in the past month, but their parents often did not report sleeping difficulties in their children. On the PSQ, 46% screened positive for sleep related breathing problems and 21% screened positive for sleep related movement disorders. Children with asthma, autism, and a history of enlarged adenoids and tonsils had more current sleep problems than children without these comorbidities.
Our findings suggest that sleep problems may be an important but under-recognized problem in children with DS. Sleep problems appear to be correlated with prevalent comorbidities, which may provide guidance to augment current practice guidelines to evaluate sleep problems in this population.
Hoffmire CA; Magyar CI; Connolly HV; Fernandez ID; van Wijngaarden E. High prevalence of sleep disorders and associated comorbidities in a community sample of children with down syndrome. J Clin Sleep Med 2014;10(4):411-419.
Every year, approximately 5,400 infants are born with Down syndrome (DS) in the United States, making it one of the most common birth defects and the leading genetic cause of intellectual disability in the country.1
Multiple comorbidities can compromise quality of life for individuals with DS. Prevalent conditions in children with DS include dysmorphic features of the head and neck, congenital heart defects, gastrointestinal defects, celiac disease, seizures, hematologic disorders, thyroid disease, intellectual disability, emotional and behavioral disorders (EBD), and autism.2–4
Sleep problems are also a considerable concern in children with DS. Sleep patterns, also referred to as sleep architecture, have been shown to differ between children with and without DS beginning in infancy and continue throughout childhood, adolescence, and early adulthood.5
For example, most studies show that individuals with DS experience considerable abnormalities in the REM sleep phase, including a decreased percentage of time spent in REM, a decrease in REM activity, and an increase in time to initiation of REM sleep.6–9
Individuals with DS have also been shown to experience greater sleep fragmentation, night wakings, and undifferentiated sleep, as well as lower sleep efficiency (% of time in bed spent asleep) than typically developing individuals.6–8,10,11
Current Knowledge/Study Rationale: Children with Down syndrome are believed to experience significant sleep problems, especially obstructive sleep apnea syndrome. Further research is needed, however, to examine a broader range of sleep problems in population-based samples of children with DS and to determine if sleep problems vary by the pattern of comorbidities a child with DS experiences.
Study Impact: This study suggests that sleep problems beyond obstructive sleep apnea, such as behavioral and sleep related movement problems greatly impact children with DS. Optimal physician monitoring of individuals with DS could benefit from more comprehensive evaluations of sleep in this population across childhood and adolescence
Less is known regarding how these observed differences in sleep structure translate to notable sleep problems and/or clinically relevant sleep disorders in children with DS. Obstructive sleep apnea syndrome (OSAS) has been shown to be considerably more prevalent among children with DS than in the general pediatric population.12–15
Prevalence estimates for OSAS in children with DS range from 24% to 79% in population-based samples and up to 97% in children referred to a sleep clinic with a history of snoring.16–20
There is a relative paucity of research addressing other problematic sleep behaviors in this population, and non-standardized measures of childhood sleep problems and disorders in previous research hinder the comparison and summary of the limited findings to date. Nevertheless, a small number of studies do suggest that bedtime resistance, restless sleep, nocturnal enuresis, nighttime awakenings, sleep talking, and daytime sleepiness may all be common in children with DS, warranting future research to confirm and expand upon these findings.13–15,21
These findings suggest that current practice guidelines,2
which focus on OSAS, may not fully inform optimal physician monitoring and assessment activities to evaluate sleep problems within the DS population.
The literature on pediatric sleep disturbances in the general population indicates that sleep problems, even when transient, are not benign. There appears to be a complex, bidirectional relationship between pediatric sleep disturbances and health: sleep problems have been associated with obesity and cardiovascular disease, epilepsy, autism spectrum disorders, attention deficit hyperactivity disorder, mood and anxiety disorders, and a wide range of neurocognitive problems.22–30
The relationship between OSAS and cognitive and behavioral problems has been particularly well documented.
Understanding health concerns related to sleep becomes even more pertinent among children and adolescents with certain medical, psychiatric, and developmental disorders, such as DS. These special populations have preexisting medical, cognitive, emotional, and behavioral deficits, and may therefore suffer more profound impacts from sleep disturbances. For example, children with DS exhibit greater cardiovascular compromise than typically developing children following an obstructive respiratory event during sleep, and it has therefore been hypothesized that OSAS in this population may be more strongly related to cardiovascular complications such as pulmonary hypertension.31
Furthermore, prevalent comorbidities among children with DS (seizures, obesity, enlarged adenoids and tonsils, and autism), which are associated with sleep disturbances in otherwise healthy children, may alter the pattern of sleep problems within the DS population and/or result in more severe sleep problems.32
Despite the potential impact of sleep problems on the well-being of children with DS, research describing sleep disturbances in large population-based samples of children with DS is lacking. Furthermore, very few studies have investigated the degree to which the variability of sleep problems in these children is related to specific comorbidities. Such information may help practitioners identify children with DS whose pattern of comorbidities suggest that they have a higher likelihood of experiencing sleep problems and can guide more thorough assessment protocols. Accordingly, this study aimed to address these important research gaps in a large population-based sample of children with DS, 7 to 17 years of age, by describing the prevalence and types of sleep disturbances encountered and examining the relationships between common comorbidities and sleep disturbances.
We conducted a cross-sectional survey from 2009 to 2011, drawing our sample from responders to a previous population-based, cross-sectional study conducted through the University of Rochester between 2006 and 2008 to investigate medical and behavioral characteristics in children with DS. The original study identified children with DS 3 to 13 years of age living in New York State outside of New York City through the New York State Congenital Malformations Registry (NYCMR) to estimate the prevalence of Autism Spectrum Disorders in children with DS. A total of 1,453 children were identified from the NYCMR, and 457 (31.5%) families participated in this study and completed multiple autism screening questionnaires. During a second level of assessment, parents of 217 children completed the Autism Diagnostic Interview-Revised (ADI-R)33
via a telephone interview.
Sleep disorders and potentially relevant covariates were not fully examined in the previous study; therefore, participants were re-contacted for the current study. The sampling frame included the 217 participants who completed the ADI-R to ensure the availability of information on autism comorbidity for the current study. Participants who completed the ADI-R included a subsample of study participants screening both negative and positive on initial autism screening tools; 42% of children screened positive for autism on the ADI-R.
At the time of initiation of this study, participant ages ranged from 7 to 18 years. Between 2 and 4 years had passed since the last known study contact with these participants, and an average of 3.2 years elapsed from the time of ADI-R completion to this study's questionnaire completion. Among the 217 participants, we aimed to recruit parents of all subjects < 18 years of age who agreed to be contacted regarding future studies (N = 146). Two of the children were 18 at the time they were contacted for the current study and were therefore not eligible for inclusion. After contacting the families of 144 eligible children, surveys were returned from 116 (80.6% of eligible and 53% of the original sampling frame). Complete data for all variables of interest were available for 107 subjects. Thus, 49% of participants who completed the ADI-R assessment in the original study were included in this analysis.
Recruitment materials were designed to present a study evaluating a broad array of medical and behavioral comorbidities in children with DS and did not highlight sleep disturbances or autism in particular. This was done to minimize the likelihood that parents of children with DS and sleep difficulties or comorbid autism were more likely to participate than parents of children with DS without these additional problems. This study was approved by the University of Rochester Institutional Research Subjects Review Board.
Two validated and widely used questionnaires, the Childhood Sleep Habits Questionnaire (CSHQ)34
and the Pediatric Sleep Questionnaire (PSQ)35–37
were chosen for this study to enable clear interpretation of findings within the broader context of past and future pediatric sleep research. The CSHQ was developed for use with school-aged children 4 to 10 years of age; it is a parent-report screening survey which addresses sleep problems based on symptoms used to assess sleep disorders according to the second edition of the International Classification of Sleep Disorders (ICSD-2).34
Thirty-three of the questions on the CSHQ are combined to generate a "Total Sleep Disturbance Scale." The total scale is made up of 8 subscales: (1) Bedtime Resistance, (2) Sleep Onset Delay, (3) Sleep Duration, (4) Sleep Anxiety, (5) Night Wakings, (6) Parasomnias, (7) Sleep Disordered Breathing, and (8) Daytime Sleepiness. The CSHQ total score has been shown to have good reliability and validity in general pediatric populations,34
and the CSHQ has been successfully applied, but not specifically validated, in special pediatric populations relevant to the current study.13,15
Although 3 questions on the sleep disordered breathing subscale and one additional CSHQ question regarding restlessness during sleep aim to address more physiological sleep problems, the CSHQ is primarily focused on symptoms relating to behavioral insomnia of childhood; parasomnias such as sleep walking, sleep talking, night terrors, and nightmares; and daytime sleepiness. A CSHQ total score > 41 has been shown to reliably identify children with clinically meaningful sleep problems.34
The PSQ is also a standardized parent-report questionnaire used to assess childhood sleep disorder symptoms. Two PSQ subscales were used: sleep related breathing disorders (SRBD),35,37
and periodic limb movement syndrome/restless legs syndrome (PLMS/RLS).36
These scales have been validated in children 2-18 years of age without severe medical or mental impairments. For both scales, a score > 0.33 has been shown to reliably identify children with these specific sleep problems.
Finally, parents were asked directly if they felt their child had trouble sleeping and if their child had ever been diagnosed with specific sleep disorders. Because there are no validated cutoffs for clinically meaningful sleep problems using the CSHQ subscales, the CSHQ total score was used as an indicator of behavioral sleep problems in this study and the PSQ was used to address the more physiologic sleep problems of PLMS/ RLS and OSAS.
Comorbidities of interest were assessed in a questionnaire which asked parents to report on their child's medical and psychiatric history by answering whether their child had ever been diagnosed and/or received treatment for a given health condition. Health conditions of interest due to their suspected or known relationships with sleep included cardiovascular disease (congenital heart disease, systemic hypertension, pulmonary hypertension), overweight and obesity, seizures, autism, asthma and reactive airway disease, vision problems, thyroid disease, celiac disease, and adenotonsillar hypertrophy.22–26
Obesity and overweight were assessed using the body mass index (BMI) based on parental report of their child's last measured height and weight. BMI was compared to the gender-specific Centers for Disease Control (CDC) BMI-for-age growth charts to obtain a percentile ranking.38
We categorized BMI percentiles based on the CDC-recommended cutoffs. A BMI percentile between the 85th and 95th percentile is considered overweight and ≥ 95th percentile is considered obese.38
Autism comorbidity was determined using the ADI-R assessment conducted in the original NYS study. The ADI-R is a clinical diagnostic measure for autistic disorder that can be used in children and adults with a mental age > 2 years.39
The ADI-R was administered to a parent or caretaker over the telephone by a trained clinical interviewer. The ADI-R can be scored with 2 algorithms, diagnostic and current. The diagnostic algorithm, which is based on developmental history,39
was chosen for 2 reasons. First, it was not feasible to re-administer the ADI-R for the current study, and the current algorithm from 2-4 years ago may not have been an accurate assessment of autistic symptoms the time of this study. Second, current behavior may reflect improvements due to treatment or aging alone and therefore may result in a higher false negative rate and/or may capture fewer children with less severe symptoms.
Age, gender, race, parental education level, parental occupation, and medication usage were considered as covariates because these variables may be associated with pediatric sleep problems.40–44
Parental education and occupation were included as indicators of socioeconomic status. All demographic variables were collected via parental report. The age groups chosen (7-11 years, 12-17 years) correspond to a split between childhood and adolescence, as sleep problems can vary considerably during these time periods.40
Primary medications of interest included antidepressants, antipsychotics, antihypertensive agents, antiepileptic drugs, hypnotics, and melatonin as these have been shown to negatively affect sleep and/or are used to treat sleep disturbances.44
On the medical history questionnaire, parents were asked to list all medications (prescription and over-the-counter) that their child took on a regular basis (≥ 3 days/week) at the time of the survey. An exhaustive list of all current medication from both questionnaires was compiled and reviewed to determine and classify known sleep effects of each medication: (1) a primary sleep effect (sleep aid, etc.) or significant sleep side effect (promoting or disrupting), or (2) no/ minimal sleep effects.
Univariate analyses described the study respondents in terms of the frequency of parental-reported demographic factors, medical conditions, and autism comorbidity. Bivariate analyses were conducted to identify demographic covariates that had the potential to affect (or "confound") the relationship between sleep and our medical comorbidities of interest. Covariates found to be associated with one or more of the sleep problem scales (χ2 p-value ≤ 0.10) were included in multivariable analyses.
To describe sleep behaviors and disturbances in this sample based on CSHQ and PSQ findings, the prevalence of total sleep problems (i.e., CHSQ score > 41), sleep related breathing disorders and PLMS/RLS (i.e., PSQ domain-specific scores > 0.33) was computed for all children with DS and among demographically defined subgroups. To evaluate the relationships between sleep and medical comorbidities, the prevalence of overall and specific sleep problems was compared between children with and without parentally reported medical conditions and autism. Crude and adjusted prevalence ratios and 95% confidence intervals were computed. Prevalence ratios for rare medical or behavioral conditions (n < 10: cancer, systemic hypertension, pulmonary hypertension) could not be accurately estimated and are therefore not reported. Prevalence ratios adjusted for covariates significantly associated with CSHQ and PSQ scores in bivariate analyses were computed using modified Poisson regression with robust standard errors. Modified Poisson regression is less prone to overestimating prevalence or risk ratios than logistic regression when used for analysis of cross-sectional data with binary outcomes, especially when the outcome is common.45
Geographically, the sample was widely distributed throughout New York State (outside of New York City); participants represented 35 of the 55 counties in the sampling region. The sample was equally distributed between the younger (7-11 years) and older (12-17 years) age groups, and children were predominately of white race and had well-educated parents. Nearly 72% of children were regularly taking one or more medications known to affect sleep. Gender, parental occupation, and medication usage were found to be related to all sleep problems of interest (
Table 1
) and were therefore included as covariates in multivariable analyses. The most commonly reported medical comorbidities in this sample included congenital heart defects (66%), vision problems (68%), enlarged adenoids and/ or tonsils (66%), and overweight and obesity (for a combined 54%). More than 85% of the children whose parents reported a history of enlarged adenoids and/or tonsils had undergone removal surgery.
Relationships between demographic characteristics, medication usage, and current sleep problems in children with Down syndrome
(more ...)
Approximately 65% of children 7 to 17 years of age experienced clinically meaningful behavioral sleep problems within the past month, as defined by the CSHQ. Additionally, 46% screened positive for sleep related breathing problems and 21% screened positive for a sleep movement disorder on the PSQ. When asked directly, however, 66% of the parents of children classified by validated questionnaires as having sleep problems did not perceive that their child had trouble sleeping. Fewer parents reported their child had a diagnosed sleep disorder: 30% (n = 32) reported a diagnosis of OSAS, 2% (n = 2) reported a diagnosis of RLS, 2% reported a diagnosis of behavioral insomnia, 2% (n = 2) reported a diagnosis of sleep terrors, and 1% (n = 1) reported a diagnosis of sleepwalking.
Compared to the literature on sleep disturbances among typically developing children,41,46–53
the prevalence of sleep problems in this sample does appear to be elevated (
Table 2
). In particular, while 65% of this sample screened positive on the CSHQ, only 23% of a sample of 469 elementary school children screened positive on the same questionnaire.41
In addition to looking at the CSHQ total problem score, mean CSHQ domain scores for this sample were compared to those from a community sample of school-age children.41
Significantly elevated problem scores were observed in this DS population for bedtime resistance, sleep duration, sleep anxiety, night waking, parasomnias, daytime sleepiness, and sleep disordered breathing. These results should be interpreted with caution, however; although evaluating and comparing mean CSHQ subscale scores does provide some additional information on specific sleep concerns, many of the subscales have very narrow ranges and thus are not truly continuous.
Comparison of sleep problem prevalence reported by parents of children with DS to previous estimates for typically developing school-aged children
Table 3
presents observed prevalence ratios for the relationships between medical comorbidities and clinically meaningful sleep problems. In crude analyses, a history of enlarged adenoids or tonsils, asthma or reactive airway disease, and an ADI-R based autism diagnosis were related to overall behavioral sleep problems identified on the CSHQ. In addition, autism was related to PLMD/RLS, while enlarged adenoids and tonsils and asthma were related to SRBD. Specifically, children with a history of enlarged adenoids or tonsils were 1.4 times more likely to exhibit current CSHQ-defined behavioral sleep problems and twice as likely to screen positive for SRBD on the PSQ. These significant relationships were observed despite the fact that most children had already been treated with surgical adenotonsillectomy. Very similar findings were observed for a diagnosis of asthma or RAD in the crude analysis; children with DS and an ADI-R-based autism diagnosis were 1.5 times more likely to demonstrate overall sleep problems and 2.6 times more likely to screen positive for PLMD/RLS.
Crude and adjusteda sleep problem prevalence ratios for children with DS and multiple comorbidities
Crude and adjusteda sleep problem prevalence ratios for children with DS and multiple comorbidities
After adjusting for medication usage and demographic correlates, a history of enlarged adenoids or tonsils (PR = 2.0; CI = 1.1, 3.4) and asthma or reactive airway disease (PR = 1.7; CI = 1.1, 2.5) were independently related to SRBD, but not total sleep problems or PLMD/RLS. A model including both enlarged adenoids/tonsils and asthma/RAD did not meaningfully alter these findings (data not shown). Although the magnitude of the relationship between autism and sleep remained much higher for PLMD/RLS, after adjusting for demographic covariates and medication usage, autism comorbidity only remained independently and significantly related to CSHQ-defined, primarily behavioral, sleep problems (PR = 1.5; CI = 1.1, 1.9).
Both behavioral and physiologic sleep problems were common in this sample of children with DS. However, 66% of the parents of children classified by validated questionnaires as having sleep problems did not perceive that their child had trouble sleeping when asked directly, and even fewer reported diagnosed sleep disorders. Together these findings suggest that sleep problems may be an important, but under-recognized problem in this population by both parents and treating physicians. Furthermore, common comorbidities among children with DS including a history of enlarged adenoids or tonsils, a diagnosis of asthma or reactive airway disease, and an ADI-R-based autism diagnosis were found to be positively associated with one of more of the sleep domains evaluated.
The authors believe that these findings are of both clinical and public health significance. From a clinical practice standpoint, findings from this study should increase physician awareness regarding the importance of sleep problems among children with DS and encourage physicians to address these issues with their patients in an attempt to provide comprehensive care and improve health and quality of life. Similarly, but from a more public health standpoint, the findings from this study can help to support the supplementation and/or revision of existing health care guidelines for children with DS by providing a more comprehensive picture of the prevalence and nature of sleep problems in this population. Consideration of sleep disturbances other than obstructive sleep apnea may improve the clinical care of children with DS. Broader screening for both respiratory and non-respiratory sleep disturbances could be clinically useful in decreasing the impact of sleep disturbances on this population. However, this study was not designed to validate parental questionnaire responses with objective testing like polysomnography. Thus, because these scales have not been specifically validated in this special pediatric population, further research is warranted to determine their true utility for children with DS. Furthermore, consideration of correlates, such as autism and a history of enlarged adenoids and/or tonsils could help identify children who may benefit from more comprehensive screening, such as an overnight sleep study. Finally, close follow-up for children identified with sleep concerns appears to be an important component of clinical care for children with DS, as some treatments (such as adenotonsillectomy for obstructive sleep apnea) may not be curative.
Although this study is more comprehensive than previous research on sleep in children with DS, it is not the first to evaluate and identify the importance of sleep disturbances in this special pediatric population. The vast majority of previous sleep studies in children with DS focused on obstructive sleep apnea; however, and the findings presented here suggest that sleep problems in this population are not limited to OSAS. Behavioral and sleep related movement problems appear to be significant problems as well. Given the known abnormalities in sleep architecture among children with DS, this is not unexpected. For example, increased sleep fragmentation is often associated with OSAS, but can and has been shown in children with DS to be associated with sleep movements as well.54
Furthermore, regardless of whether sleep fragmentation and night wakings originate from respiratory or movement events, they create the opportunity for behavioral problems related to both sleep initiation and maintenance.
Two previous studies that used the CSHQ to screen children with DS provide a basis of comparison for the findings presented here. Carter et al.13
and Breslin et al.15
reported CSHQ total scores for 40 children 4-18 years old and 35 children 7-18 years old, respectively. Compared to the estimated sleep problem prevalence of 65% presented here, 100% of Carter's sample, and 86% of Breslin's sample scored in the clinical range on the CSHQ. The higher prevalence observed in these two samples could be explained by a lack of statistical precision due to smaller sample sizes. The higher mean CSHQ score in Carter's sample could also be due, in part, to age differences, as Carter's study included children below 7 years of age though the percentage of children in this age range was not reported. Neither the current sample nor Breslin's included children between 4 and 7 years of age. Age differences in the mean CSHQ total score between the young (7-11) and old (12-17) age groups were not observed in this study, but CSHQ scores could be higher in children with DS under 7 years of age, perhaps considerably so because of their lower developmental age. The CSHQ total score is observed to be elevated among children in first and second grade (approximately 5-8 years) compared to those in third and fourth grade (approximately 6-11 years) in the general population,41
and toddlers and preschoolers appear to score even higher.55
Thus, the findings presented here are consistent with previous research on sleep in children with DS.
As discussed, current recommendations for the routine care and health supervision of children with DS only identify OSAS as a specific sleep concern.2 Prior research using polysomnography as the gold standard suggests that OSAS is prevalent in 24% to 79% of children with DS.16,19
Forty-five percent of this sample screened positive for sleep related breathing disorders, a midrange estimate compared to previous findings. Because snoring may not be as good a predictor of OSAS in children with DS as it is in the general pediatric population,16
the PSQ, or any screening tool addressing observed breathing events, may result in lower than optimal sensitivity. Children with DS are affected by many other craniofacial abnormalities including mid-face hypoplasia and glossomegaly as well as adenotonsillar hypertrophy and truncal obesity, all of which increase the propensity for sleep related upper airway obstruction and therefore may affect sleep. Additionally, because of global hypotonia, children with DS may be at increased risk of sleep related airway closure, yet not generate sufficient airflow rates to result in palatal vibration necessary to produce the sound of snoring. Nonetheless, the PSQ was the best standardized instrument to assess OSAS in this sample for three reasons: (1) there is a validated cutoff for the SRBD subscale with good sensitivity (85%) and specificity (87%) to identify children in the general population at high risk for OSAS28
; (2) it includes questions addressing important OSAS symptoms beyond observable breathing difficulties such as daytime sleepiness and daytime behavior; and (3) it is widely used in research to describe pediatric sleep problems and to assess treatments for OSAS facilitating comparisons across studies. In the absence of polysomnography it is not possible to accurately ascertain the true prevalence of SRBD in this population. Such studies are sorely needed in the published literature.
The relationship observed between adenotonsillar hypertrophy and OSAS among children with DS has been previously documented in at least one study.18
Of note, however, is the fact that most (87%) of the children screening positive for SRBD in this sample had their adenoids and/or tonsils removed, yet the observed association was still significant. This suggests that treatment for OSAS in the DS population is not entirely effective. Although important, this is not completely unexpected. Treatment studies have shown that even when improvements are made after surgical treatments in children with DS, many children will continue to suffer from clinically significant sleep disordered breathing.56
The complicated craniofacial anatomy in this population, generalized muscular hypotonia and CNS suppression, higher rates of pharyngeal and lingual collapse compared to typically developing children, and the possibility for adenotonsillar regrowth are all factors which may limit treatment success in this population.2,57–59
It is likely that symptoms improve and the severity of OSAS decreases with surgical treatment even in those who still experience problems, but these children may remain at risk for the cognitive, behavioral, and medical consequences of incompletely treated obstructive sleep apnea. Clearly, continued follow-up with a pediatric sleep specialist is very important for all children and adolescents with DS and OSAS.
Finally, sleep related movement disorders were identified in almost a quarter of this sample, with a two-fold increased prevalence of sleep related movement problems among children with autism comorbidity. Conversely, only 2% of parents reported a diagnosis of restless legs syndrome or periodic limb movement disorder for their children, indicating that such problems may be under-diagnosed in this population. However, although the sensitivity of the PSQ movement scale is quite good (79%), the specificity is not ideal (56%) and could therefore result in an increased false positive rate. This study is not the first to recognize the importance of sleep movement problems in DS. One polysomnographic study found that arousals and awakenings in children with DS were more often associated with sleep movements (45%) than with respiratory events (9%).54
As is true for most epidemiologic studies, this study is vulnerable to limitations, but it is balanced by much strength. It is the largest population-based study to date to investigate sleep in children with DS; it is one of the most comprehensive in terms of the sleep problems addressed; and it is the first to carefully evaluate the interrelationships between common comorbidities and sleep disturbances in children with DS. Furthermore, the population-based sampling frame improves the external validity of study findings considerably compared to DS sleep studies conducted within a clinical setting. Participants were drawn from across New York State and included children living in rural and metropolitan regions.
The authors recognize that all variables in this study are based on subjective parental or caregiver report, not objective measurement, and that the accuracy of parental report is likely to depend on many factors. For example, the types of questions being asked and the way they are asked (i.e., standardization of instruments), who is responding (mother vs. father), the child's age, and the seriousness of the event being recalled have been associated with accuracy of parental report for children's health variables.60
Despite these limitations, parental report was chosen for multiple reasons. With a population of children and adolescents with DS, it would have been far less accurate, and often infeasible to solicit direct self-report. It was also infeasible to use objective sleep measures such as actigraphy or polysomnography due to cost, time, and geographic constraints inherent to the population-based design. Furthermore, although polysomnography is the diagnostic gold standard for sleep disorders, it may not provide the best information regarding usual sleep behaviors, as children are removed from their normal environment and are only observed for one or two nights. Additionally, although we relied on parental report, one of the strengths of this study compared to the existing literature was the use of standardized instruments to assess sleep (CSHQ, PSQ) as well as autism (ADI-R). The measures used have all been validated in their target populations, although much less information on validity is available for their use in children with DS specifically.
Finally, although this is the largest population-based study of sleep in children with DS to date, we were only able to recruit approximately 53% of the subjects in our sampling frame and included 49% in this analysis. This is not an unusually low success rate for mail-based survey studies,61
but does increase the concern for non-response bias. Non-response may result in a non-representative sample, biasing findings and/or limiting external validity, particularly if responders and non-responders differ in regards to characteristics related to the study variables of interest.62
Race, ethnicity, and parental education levels were found to be different in the sampling frame as compared to the New York State population of families of children with DS, with a higher percentage of whites, lower percentage of Hispanics, and a high percentage of parents with at least college education. In the current study, parental education levels appear to be even higher. Children living in families from lower socioeconomic strata have been shown to have later and more irregular bedtimes compared to their more socially advantaged peers.63
Thus, the current study may underestimate the true prevalence of sleep problems among children with DS in New York State.
In summary, findings from this study suggest that sleep problems in children with DS go beyond obstructive sleep apnea, and such problems may be more common in children with certain comorbidities. Sleep problems are an important problem in children with DS; these children are burdened by many comorbidities, which can negatively affect health and quality of life both independently and through their relationships with sleep problems. Additionally, sleep problems are a significant source of distress for families.64
Thus, these findings can help guide clinical practice aiming to improve the health and well-being for children and their families. Although future research is warranted prior to recommending specific screening schedules, increasing physician awareness of the breadth of sleep problems that affect this population and providing insight into which children with DS may be more likely to experience sleep concerns, such as those with enlarged adenoids and tonsils or comorbid autism, is an important first step.
This was not an industry supported study. Financial Support was from the National Heart, Lung and Blood Institute Research Training Fellowship in Preventive Cardiology (grant # 5 T32 HL07937 – 9). The authors have indicated no financial conflicts of interest. All work for this study was conducted at the University of Rochester School of Medicine and Dentistry, Department of Public Health Sciences, Rochester, NY.
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Event: Exhibition (permanent) County: Cheshire The Cabinet of CuriositiesJanuary 25th 2014 saw the long awaited public opening of Warrington Museum's Cabinet of Curiosities Gallery. The Museum began working on the Cabinet of Curiosities project back in 2007 when we celebrated the 150th...Warrington Museum & Art Gallery | 25 January 2014 — 30 December 2019

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An early and extraordinarily flattering review of Hogan's I Like To Keep Myself In Pain by WBEZ's "Sound Opinions" co-host Jim DeRogatis. Click here for the review or just scroll down…
"Though she first made her impact on the music scene in Georgia in the '90s, first as the golden voice of the star-crossed Jody Grind and then as a member of the Rock*A*Teens, Kelly Hogan has been Chicago's sweetheart for more than a decade now, perhaps the brightest star in this city's roots-rock/alt-country firmament. Yet whether she never quite found her ideal vehicle (and no disrespect to her jazzy cabaret experiments with Scott Ligon), or she just was overshadowed as she selflessly subsumed her considerable talents and expansive personality backing the likes of Jakob Dylan, Mavis Staples, the Drive-By Truckers and most of all her pal Neko Case, she never won the widespread attention she so richly deserved.
"I wanted to be loved by the world," Hogan coos at one point on her debut for Anti- Records. With the stellar I Like to Keep Myself in Pain, she gives ample reason why the world needs to reciprocate—and she gives us a masterpiece.
As if her new role as a label mate of Tom Waits, Joe Henry and Kate Bush wasn't impressive enough, or we wouldn't have been sufficiently wowed by a backing band that includes Booker T. Jones, James Gadson (Beck) and Gabe Roth (the Dap-Kings), Anti- enabled Hogan to tap a mind-boggling list of songwriters who stepped forward to give her their tunes, ranging from John Wesley Harding and Stephin Merritt to Andrew Bird and Robyn Hitchcock.
Though I'd heard that some impressive names had contributed to this disc, I trashed the press release that came with my advance and purposely avoided looking up the credits on the Net, the better to listen to the album as an album—Hogan's album, and no one else's. It is, and I don't believe this exercise alone led to that conclusion.
Whether it's pulling off the unlikely feat of channeling a boozy Frank Sinatra as he makes a late-night confession about his boundless ambition and subsequent neglect as Nancy's dad ("Daddy's Little Girl," written by M. Ward), turning what might have been surrealism and sarcasm into probing self-analysis (in the title track, by Hitchcock) or flipping the script on a rollicking kiss-off tune and injecting unexpected soul into a bar-band sing-along (Jon Langford's "Haunted"), Hogan not only shows her vocal power and diversity, swinging from giddy '60s girl-group pop to weepy old-school country and from sultry soul to gritty rock, she proves that her biggest strength is in the lost art of interpretation, finding deeper and sometimes unexpected meanings in the tunes she sings, and making us feel every note."


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Baby Angel Thank You
Baby Thank You Cards
Baby Angel Thank You, Item# TYBW1145
Note: Sparkles are simulated and will not light up.
Baby Angel Thank You, Item# TYBW1145
Note: Sparkles are simulated and will not light up.
Baby Angel Envelope Seals
Baby Angel Return Address Labels
This fold-over note card, "Baby Angel" features a classic black and white image of an angelic baby gazing downward. Faint angel wings appear on the white background behind the baby.
A custom message can be printed with flat printing inside the fold-over card (for an additional $0.50), to acknowledge that special gift.
You will be able to select the typestyle and ink colors to use for your personalized text during the design process. Start by clicking on the green 'Personalize and Continue' button. We recommend using the default typestyle and ink colors.
|Estimated Postage Required:
|$0.55 stamp - if other items are not added into the Envelope. Click here for additional postage information.
|Item Type:
|Foldover Notecard
|Card Dimensions:
|5 1/2" X 4 1/8" (W x H)
|Printing Process:
|Thermography Printing
|Paper Weight:
|80 lb. White Matte Cardstock
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|Lucida Calligraphy
|Matching Ink Color:
|Envelopes included. Printed return address and/or Calligraphy is available for an additional cost.


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Harold G. Hamm has served as Chief Executive Officer and a director since our inception in 1967 and currently serves as Chairman of the board of directors.
Growing up in rural Oklahoma, Harold Hamm was the last of 13 children born to sharecroppers. He went to work in the oil fields as a teenager and established Continental Resources in 1967 at the age of 21. He built a grassroots startup into an NYSE-traded, Top 10 oil producer in the U.S. Lower 48. As a voice for America's oil and natural gas industry, he's on a mission to help make America energy independent within the next decade.
In addition to his role as Founder, Chairman and Chief Executive Officer of Continental Resources, Mr. Hamm co-founded and serves as Chairman of the Domestic Energy Producers Alliance, which aims to preserve the millions of jobs and billions of dollars in economic activity and tax revenues generated by onshore drilling and production activities within the United States. Through his work with DEPA, Mr. Hamm is widely recognized as the man who led the charge to lift America's 40-year-old ban on U.S. crude oil exports, a feat that will lower U.S. gasoline prices by up to 13 cents a gallon, create 400,000 American jobs a year, increase GDP by 1%, and ensure America and our allies are never again held hostage by dictatorial regimes.
Mr. Hamm's industry leadership also includes serving as past Chairman and present board member of the Oklahoma Independent Petroleum Association, as a founding board member of the Oklahoma Energy Resources Board, and as past president of the National Stripper Well Association. In addition, he served as Founder and Chairman of Save Domestic Oil Inc., which successfully brought a trade case against four countries trying to put American oil and gas producers out of business.
A national leader in promoting health, education and energy industry advocacy, Mr. Hamm has devoted much time and resources to championing a healthy and secure future for all Americans. With the goal of finding a cure for diabetes, he has donated more than $30 million to establish the world-renowned Harold Hamm Diabetes Center at the University of Oklahoma Health Sciences Center. The Harold Hamm Diabetes Center is at the forefront of diabetes research – inspiring progress toward a cure, education of health care professionals and families, optimal care for those living with diabetes, and effective prevention strategies. To further spark the minds of the world's brightest scientists, he established the Harold Hamm International Prize for Biomedical Research in Diabetes, a $250,000 biennial award celebrating the scientific achievements of an outstanding researcher, team of researchers, or research institution.
In addition to eradicating diabetes, Mr. Hamm is dedicated to preparing the next generation of energy industry leaders. In 2012, he helped establish the Harold Hamm School of Geology and Geological Engineering at the University of North Dakota. He has also funded numerous education initiatives across the nation, including college scholarships, classroom technology, and school capital campaigns.
In 2011, Mr. Hamm joined Bill and Melinda Gates and Warren Buffet in signing The Giving Pledge, committing to give away the majority of his wealth during his lifetime. Forbes Magazine has consistently ranked Mr. Hamm on "The Forbes 400" list of the richest people in America and its list of "The World's Billionaires."
Mr. Hamm has received numerous awards and recognition for his contributions. In 2016, Platts Global Energy Awards honored him with a "Lifetime Achievement Award" for his legacy of leadership, innovation and commitment to bringing America to energy independence. He was named the recipient of the 2016 "Chief Roughneck Award" by U.S. Steel Tubular Products. He was one of 13 corporate and civic leaders across the U.S. to receive the "Horatio Alger Award" for his outstanding leadership and triumph over adversity to achieve success. He was also honored by Oil and Gas Investor magazine as "Executive of the Year" for Continental's leadership in the Bakken, SCOOP and STACK plays and his tireless efforts to lift the ban on U.S. crude oil exports. In 2015, the Western Energy Alliance named him "Wildcatter of the Year" for his contributions to America's energy security and the betterment of society. In 2013, Platts Global Energy Awards named him "CEO of the Year" and at the same time named Continental Resources "Energy Company of the Year." In 2012, he was named one of TIME Magazine's "100 Most Influential People in the World" for his creation of thousands of jobs in the oil industry and continuous support of education and diabetes research. He was inducted into the Oklahoma Hall of Fame in 2011, named the International Energy Policy Conference "Energy Advocate of the Year" in 2009, and named the Ernst & Young "Entrepreneur of the Year" in 2007.


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Comet ISON's Close Encounter With the Sun
A pristine comet called ISON, which left its home at least a million years ago, will be making its closest approach to the sun on Thanksgiving day. Gautam Naik reports.
This transcript has been automatically generated and may not be 100% accurate.
I ... it's Thanksgiving and a new visitor has arrived ... a common call myself ... the tiny costs me on the left its home at least a million years ago ... today it will cost just one point nine million kilometers from the sun ... which cost me terms is not very far at all ... astronomers um like fingernails ... will this tiny ball of the ancient broken by succumb to the sun's intense heat and add additional tons ... and chapter into campus fragments ... over that somehow survived its dangers close encounter ... if this alliance that like a patch of sky ... observers in the northern hemisphere should be able to spot the comic that the naked eye ... in the first week of December ... it could be visible fifteen minutes before sunrise ... some comments on sun raises which is the people I extremely close to the sun ... others are pristine and first time visitors ... materials from which the form of the birth of the solar system ... a relatively intact ... I saw is the first comic in about two hundred years ... that is both the sun's rays The ... and Christine ... this observation shows the ice on fiscal bright and and and and right to speak it ... does that mean that it's on it's way out ... of the comet ... has frequently surprised astronomers ... three days before Thanksgiving for example ... if you do ... the following


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Va. Gov. McDonnell sorry for 'embarrassment' to state
WASHINGTON -- Virginia Gov. Bob McDonnell said Tuesday he has repaid more than $120,000 to a political donor and apologized for bringing "embarrassment" to the state.
"Being governor of Virginia is the highest honor of my 37 years in public service," McDonnell, a Republican, said in a statement. "I am deeply sorry for the embarrassment certain members of my family and I brought upon my beloved Virginia and her citizens."
For months, McDonnell has been dogged by headlines in The Washington Post and other news outlets about his ties to Star Scientific CEO Jonnie Williams. Among other revelations, Williams picked up the $15,000 catering bill for the 2011 wedding of one of McDonnell's daughters and financed a $15,000 shopping spree for Maureen McDonnell, the governor's wife, at Bergdorf Goodman. Williams is also said to have paid $6,500 for a Rolex watch that Maureen McDonnell gave to her husband.
Federal and state authorities are investigating McDonnell and his ties to Williams, whose company makes dietary supplements. The disclosures have damaged the reputation of McDonnell, a prominent Mitt Romney surrogate in 2012 who was once touted as a potential 2016 presidential candidate.
The repayments include $52,278.17 to cover a loan Williams made to Maureen McDonnell and $71,837 loaned to a real estate business co-owned by the governor and his sister. The repayments cover the principal of the loans and interest. McDonnell said the funds for the repayments came from him, the real estate business or his family.
The statement from McDonnell represents a shift for the governor, who had previously criticized the news accounts of the gifts from Williams. McDonnell, who cannot run for another term in 2014 under state law, has resisted calls from Democrats to resign.
"I want you to know that I broke no laws and that I am committed to regaining your sacred trust and confidence," McDonnell said. "I hope today's action is another step toward that end. Virginia has never been stronger and I plan to focus on creating even more jobs and facilitating greater opportunity during the last five months of my term as your governor."
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1) If your posted item is sold or you found what you are looking for please post that it's sold. That way others will know and I can delete it and you won't be bothered by people contacting you unnecessarily.
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Building Department
One Washington Street
2nd Floor
Hempstead, NY 11550
(516) 538-8500
The Department of Buildings strives to preserve life and property and maintain the suburban quality of life through the administration and enforcement of building, plumbing, electrical and housing codes. The department enforces the ordinances, rules and regulations relating to unsafe buildings, multiple residences, places of public assembly, the use and occupancy of real property, buildings and structures. The Building Department is responsible for performing all inspection and enforcement activities with relation to all laws, codes, ordinances, rules and regulations within the general administration of the department.
- Our Front Counter hours of operation are 8 AM to 4:45 PM.
- Building Inspectors can be reached by phone at (516) 812-3088 from 7:30 AM to 10:30 AM, prior to their field inspections.
- Plumbing Inspectors can be reached by phone at (516) 812-3126 from 7:30 AM to 9:30 AM, prior to their field inspections.
- Housing and Zoning Inspectors can be reached by phone at (516) 812-3052 or (516) 812-3115 or (516) 812-3107 from 9 AM to 10:30 AM, prior to their field inspections.
- Plans Examiners can be reached by phone at (516) 812-3073 from 9 AM to 12 noon. When making an appointment with a Plans Examiner, you must call one day prior to the day you wish to be seen.
Please call the Town of Hempstead Department of Buildings during our regular working hours for any questions or concerns you may have regarding the New York State Building Codes, the Town Code or the Town of Hempstead Building Zone Ordinance. The Department of Buildings can be reached at (516) 538-8500.
Rebuilding After Sandy
Please click here for an update on Post-Hurricane Sandy services offered by the Building Department. A list of "Frequently Asked Questions" for Rebuilding After Sandy may be accessed here.


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Defect engineering in 1D Ti–W oxide nanotube arrays and their correlated photoelectrochemical performance. Physical Chemistry Chemical Physics. 2018 ..
Dual-excitation nanocellulose-plasmonic membranes for molecular and cellular SERS detection. ACS applied materials & interfaces. 2018 ..
Electrochemical Synthesis of Ammonia from N2 and H2O under Ambient Conditions Using Pore-Size-Controlled Hollow Gold Nanocatalysts with Tunable Plasmonic Properties. The journal of physical chemistry letters. 2018 ..
Enhancing the rate of electrochemical nitrogen reduction reaction for ammonia synthesis under ambient conditions using hollow gold nanocages. Nano Energy. 2018 ..
Gold nanoparticles for cancer diagnostics, spectroscopic imaging, drug delivery, and plasmonic photothermal therapy. In: Inorganic Frameworks as Smart Nanomedicines. Inorganic Frameworks as Smart Nanomedicines. ; 2018..
Gold Nanorod-Photothermal Therapy Alters Cell Junctions and Actin Network in Inhibiting Cancer Cell Collective Migration. ACS nano. 2018 ..
Real-Time Tracking of Autophagy Process in Living Cells Using Plasmonically Enhanced Raman Spectroscopy of Fucoidan-Coated Gold Nanoparticles. Journal of Materials Chemistry B. 2018 ..
Single-Crystal Electrospun Plasmonic Perovskite Nanofibers. The Journal of Physical Chemistry C. 2018 ..
UV Resonance Raman Study of Apoptosis, Platinum‐based Drugs, and Human Cell Lines. ChemPhysChem. 2018 ..
Efficacy, long-term toxicity, and mechanistic studies of gold nanorods photothermal therapy of cancer in xenograft mice. Proceedings of the National Academy of Sciences. 2017 .
Electrochromic tuning of transparent gold nanorods with poly [(3, 4-propylenedioxy) pyrrole] shells in the near-infrared region. Journal of Materials Chemistry C. 2017 .
Facile size-controlled synthesis of fucoidan-coated gold nanoparticles and cooperative anticancer effect with doxorubicin. Journal of Materials Chemistry B. 2017 .
A force for Egyptian science. Proceedings of the National Academy of Sciences. 2017 ..
High-sensitivity molecular sensing using plasmonic nanocube chains in classical and quantum coupling regimes. Nano Today. 2017 .
Intracellular assembly of nuclear-targeted gold nanosphere enables selective plasmonic photothermal therapy of cancer by shifting their absorption wavelength toward near-infrared region. Bioconjugate Chemistry . 2017 .
Meniscus-assisted solution printing of large-grained perovskite films for high-efficiency solar cells. Nature Communications. 2017 .
Nuclear Membrane-Targeted Gold Nanoparticles Inhibit Cancer Cell Migration and Invasion. ACS Nano. 2017 .
On-Resonance Chiral Metamaterial for Chiroptical Sensing at the Molecular Level. CLEO: QELS Fundamental Science. 2017 .
Platinum-Coated Gold Nanorods: Efficient Reactive Oxygen Scavengers That Prevent Oxidative Damage toward Healthy, Untreated Cells during Plasmonic Photothermal Therapy. ACS Nano. 2017 .
Shape tunable plasmonic nanoparticles. US Patent . 2017 ;9,588,124..
Targeting cancer cell integrins using gold nanorods in photothermal therapy inhibits migration through affecting cytoskeletal proteins. Proceedings of the National Academy of Sciences. 2017 .
An Ultraviolet Resonance Raman Spectroscopic Study of Cisplatin and Transplatin Interactions with Genomic DNA. Journal of Physical Chemistry B. 2017 .
Unraveling the nature of anomalously fast energy storage in T-Nb2O5. Journal of the American Chemical Society . 2017 .
Advances in Nanomedicine for Head and Neck Cancer. Head and Neck Cancer. 2016 .
Carrier dynamics and the role of surface defects: Designing a photocatalyst for gas-phase CO2 reduction. Proceedings of the National Academy of Sciences. 2016 .


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Fall 2012 Schedule
Please note that all schedules are subject to change at any time without notification.
ALL BUSINESS students - to satisfy the Business Computer Tools Requirement, either (1) enroll in 091L, (2) challenge the course by enrolling in a section of 91L and taking the Challenge Exams, or (3) transfer credit from another institution and obtain waiver for 91L.
MIS students who entered the concentration before Fall 2002 should take 188 to satisfy the Business Information Systems Requirement. MIS students who enter the concentration in Fall 2002 and afterwards should take 110A to satisfy the Business Information Systems Requirement. All other business students should take 188 to satisfy the Business Information Systems Requirement.
BUS 110A, formerly known as 110, is still the same coursework and fulfills the same requirement (Course Catalog Number was changed).
BUS 93 is no longer a Lower Division course. It is now an Upper Division course - 110B.
SPECIAL NOTE for BUS 111-02 in Fall 2012: Experimentally run as a synchronous online course with live online instruction at the scheduled times. Student can stay at work and take class during lunch. Students can participate live using Elluminate, a free (for SJSU students) customized took for live online learning. Student needs a sound-enabled Internet connected computer (May need headphones if in a lab or cubicle at work.) Students required to be present in class on the 1st Day and at midterms and final. Student Guide to using Elluminate: http://slisweb.sjsu.edu/software/elluminate/students/


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Blog Archives
BBWAA Historical Overview Committee To Devise 2014 Expansion Era Ballot
Like us on Facebook hereFollow @mlbreports
Tuesday, February 19, 2013
By Patrick Languzzi (Cooperstown Correspondent): Follow @patricklanguzzi
From January 29th – 31st, the Baseball Writers Association of America (BBWAA) Historical Overview Committee met in Cooperstown to screen potential candidates for the 2014 Expansion Era ballot (Veterans Committee). The 12-member ballot will be released in the fall and is scheduled to be voted on at the baseball winter meetings in December by a 16-member electorate.
The Expansion Era is comprised of players, executives and managers who made their greatest career contributions between 1973 – present. Eligible players must be retired for at least 21 years and have played at least 10 major league seasons. Managers and Umpires are eligible five years after retirement, with 10 years of service, or six months from the date of election after retirement, if they are 65 years or older.
All candidates receiving at least 12 of 16 votes (75 percent of the 16 ballots) will gain election into the National Baseball Hall of Fame for a July 2014 ceremonial induction.
Under the new rules, the Veterans Committee ballots run on a three-year rotation beginning in 2010 with the Expansion Era (1973 – present), Golden Era (1947 – 1972) and Pre-Integration Era (1871 – 1946).
Here's a look at the selected nominees from 2010. Long retired players; Dave Concepcion, Steve Garvey, Vida Blue, Ron Guidry, Tommy John, Al Oliver, Rusty Staub and Ted Simmons. Manager Billy Martin and executives George Steinbrenner, Pat Gillick and Marvin Miller.
Pat Gillick HOF Induction Speech:


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Family physicians and the AAFP played a key role in developing or otherwise contributing to a slew of new clinical recommendations that guided family medicine and primary care practices in 2013. The Academy also distinguished itself by guiding national immunization policy and addressing other public health issues.
Speaking during a Feb. 21 press event in Washington, AAFP Board Chair Glen Stream, M.D., M.B.I., center, describes the Choosing Wisely campaign as being part of a "many-faceted journey to reform our health care system -- to make it higher quality, more cost-effective and more equitable, as well." Stream is flanked by Gail Wilensky, Ph.D., senior fellow with Project HOPE, and Jim Knutson, risk manager and human resources director for Aircraft Gear Corp.
In January, a study in JAMA Internal Medicine found significant improvement in the delivery of underused care from 1999 to 2009, but researchers said there were limited changes in the reduction of inappropriate care during the same time. Given the high cost of health care, researchers said the results were concerning.
Just a few weeks later, the AAFP released its second list of recommendations that aim to help physicians curtail the practice of ordering unnecessary tests and procedures. The Academy's second set of Choosing Wisely recommendations -- which was created by family physician volunteers via the AAFP's Commission on Health of the Public and Science -- offered the following recommendations to improve quality and lower costs:
- Don't screen for carotid artery stenosis in asymptomatic adult patients.
- Don't screen women older than 65 years of age for cervical cancer who have had adequate prior screening and are not otherwise at high risk for cervical cancer.
- Don't screen women younger than 30 years of age for cervical cancer with human papillomavirus (HPV) testing, alone or in combination with cytology.
- Don't schedule elective, nonmedically indicated inductions of labor or Cesarean deliveries before 39 weeks, 0 days gestational age.
- Avoid elective, nonmedically indicated inductions of labor between 39 weeks, 0 days and 41 weeks, 0 days unless the cervix is deemed favorable.
"It has been estimated that nearly one-third of health care delivered in the United States is unnecessary," said (then) AAFP Board Chair Glen Stream, M.D., M.B.I., of Spokane, Wash. "Tests and procedures that lack evidence of their effectiveness put our patients at risk and drive up the cost of care."
The AAFP followed up on the recommendations regarding labor and delivery in May when it joined more than a dozen other organizations in sending a letter to 3,100 hospitals, urging them to help eliminate nonmedically indicated deliveries before 39 weeks' gestation.
In addition, the Academy is in the process of reviewing a number of guidelines issued by other health care organizations.
- In December, panel members appointed to the Eighth Joint National Committee issued guidelines that outline nine specific recommendations for initiating and modifying pharmacotherapy for patients with elevated blood pressure.
- In November, the American College of Cardiology and American Heart Association released treatment guidelines for high blood cholesterol in adults that suggest physicians use a new risk assessment tool and grading system to determine who qualifies for statin treatment. The organizations also released guidance related to screening for and managing cardiovascular risk, as well as for identification, evaluation and treatment of obesity.
In May, the American Urological Association (AUA) recommended against performing all routine prostate-specific antigen (PSA)-based screening for prostate cancer, as well as all such screening in men older than 70, men younger than 40 and in average-risk men ages 40-54.
Doug Campos-Outcalt, M.D., M.P.A., of Phoenix, the AAFP liaison to the U.S. Preventive Services Task Force (USPSTF), said the move brought the AUA in line with AAFP and USPSTF recommendations against performing PSA screening in asymptomatic men regardless of age.
"This is pretty big," Campos-Outcalt said at the time. "The AUA was very much against the official USPSTF/AAFP universal recommendation against PSA screening when it was released. I think their guideline committee deserves a lot of praise. It is not easy to buck common practice within your own specialty."
In addition, the American College of Physicians called for physicians to discuss "the limited potential benefits and substantial harms of screening for prostate cancer" with patients between the ages of 50 and 69. The guidance also encourages physicians to perform screening only if a patient expresses a clear preference to do so.
Throughout the year, family physicians like Campos-Outcalt helped shape important health recommendations through their work with groups like the USPSTF and the CDC's Advisory Committee on Immunization Practices.
The USPSTF, with input from the Academy, issued numerous recommendations to guide primary care practices in 2013. Perhaps most notably, the task force overturned decades' worth of routine practice in February, when it recommended against daily supplementation with 400 IU or less of vitamin D3 and 1,000 mg of calcium carbonate for the primary prevention of fractures in noninstitutionalized postmenopausal women.
"What we're saying is that a practice that we have commonly used for years -- literally, years -- routinely in postmenopausal women just doesn't work," said family physician and USPSTF Co-vice Chair Michael LeFevre, M.D., M.S.P.H., of Columbia, Mo.
The USPSTF also made the following recommendations:
- In January, the AAFP and the USPSTF called for physicians to screen all women of childbearing age for intimate partner violence regardless of whether symptoms are present. For women who screen positive, physicians should provide or refer them to intervention services.
- In April, the AAFP and the USPSTF issued new recommendations calling for routine screening of normal-risk adolescents and adults for HIV infection. However, the two organizations differed regarding the recommended age at which routine screening should begin. The task force called for screening beginning at age 15, while the Academy recommended screening at 18. The CDC, meanwhile, calls for such screening to begin at age 13.
- Also in April, the task force proposed a reaffirmation of its position on screening for oral cancer in asymptomatic adults, issuing a draft recommendation statement that indicates current evidence remains insufficient to assess the balance of benefits and harms of testing.
- The task force also issued a draft recommendation encouraging primary care physicians to screen women with a family history of breast or ovarian cancer using a screening tool specifically designed to pinpoint whether that family history may be associated with an increased risk for potentially harmful mutations in breast cancer susceptibility genes BRCA1 or BRCA2. In addition, the task force recommended that women with a positive screening result should receive genetic counseling and, if indicated after counseling, BRCA testing. However, the task force recommended against routine genetic counseling or testing for the majority of women outside this high-risk group.
- The task force issued final recommendations on screening for hepatitis C virus infection, proposing routine screening of high-risk adults, as well as a one-time screen for all adults born between 1945 and 1965.
- The USPSTF issued a draft recommendation in July proposing that physicians screen high-risk, 55- to 79-year-olds for lung cancer annually using low-dose CT scans. High-risk adults in this age group include those who have accumulated 30 cigarette pack-years and are still smoking or who quit within the past 15 years.
- The task force released a draft recommendation in November recommending against using beta-carotene or vitamin E supplements to prevent cardiovascular disease or cancer.
- The AAFP and USPSTF issued final recommendations that physicians provide interventions, including education or brief counseling, to prevent the initiation of tobacco use by school-aged children and adolescents. LeFevre said evidence shows there are intervention programs, including the AAFP's Tar Wars initiative, that family physicians can implement to reduce the number of adolescents who become regular smokers.
On the subject of tobacco, the AAFP continued its efforts to curtail its use, including sending an Aug. 7 letter urging the FDA to ban the use of menthol in cigarettes and other tobacco products.
Vaccines and Immunizations
The CDC -- with input from the AAFP and other primary care organizations -- made several changes to its immunization recommendations, including a move to combine its previously separate child and adolescent schedules into a single 0- to 18-year schedule. Among other changes to the schedule was a recommendation that infants ages 6 months through 11 months who are traveling anywhere outside the United States should receive measles, mumps and rubella (MMR) vaccine.
Lack of MMR immunization generated news in August when the CDC noted that 159 measles cases had been reported, marking the second-largest number since U.S.-originated cases of the viral infection were eliminated in the United States in 2000. Unvaccinated individuals accounted for 131 cases, and 79 percent of those patients had philosophical objections to the vaccine.
"These diseases are still out there," said Anne Schuchat, M.D., director of the CDC's National Center for Immunization and Respiratory Diseases. "They are literally a plane ride away, and every day, about 11,000 babies are born in the United States completely vulnerable to all of these diseases."
The CDC's adult immunization schedule was updated with two new recommendations for tetanus, diphtheria and acellular pertussis (Tdap) vaccine. Specifically, all adults ages 65 and older should be offered the vaccine, and all pregnant women should receive a dose of Tdap in the late second or early third trimester of each pregnancy, regardless of their Tdap immunization history.
A July report from the CDC showed that HPV vaccination coverage among adolescent girls flattened out in 2012, and rates actually decreased for completion of the three-dose series despite the availability of safe and effective vaccines.
In November, the agency announced it had identified a cluster of late vitamin K deficiency bleeding involving four Tennessee newborns whose parents had declined vitamin K prophylaxis. Three infants had bleeding within the brain, and the fourth presented with gastrointestinal bleeding.
In other vaccine news, Merck & Co. Inc. recalled 743,360 vials of its quadrivalent HPV vaccine Gardasil in December because some of the vials may be contaminated with minute glass particles resulting from breakage during the manufacturing process.
Diseases and Outbreaks
An outbreak of infection caused by Cyclospora cayetanensis affected more than a dozen states. In August, epidemiologic investigations by health departments in Nebraska and Iowa linked the outbreaks to prepackaged salads from Mexico.
A novel tick-borne illness that presents with undifferentiated flu-like symptoms similar to those seen in patients with Lyme disease made news in July when it was detected in the Northeastern United States.
Obesity continued to make news, with the AAFP's delegation to the AMA House of Delegates supporting a measure that declared obesity to be a disease. The declaration dominated headlines and sparked discussion by stakeholders across the country.
Meanwhile, researchers at Boston Medical Center and Boston University School of Medicine found evidence that obesity may be an independent risk factor for Clostridium difficile infection.
A study about the AAFP's Americans in Motion-Healthy Interventions (AIM-HI) program showed clinically significant before and after improvements in outcomes for patients in 21 U.S. family medicine practices using the AIM-HI program, which defines fitness as a combination of physical activity, healthy eating, and emotional well-being. Researchers found that 16.2 percent of patients who completed a 10-month postintervention visit and 10 percent of all patients enrolled lost 5 percent or more of their body weight.
Another study that compared aerobic training and resistance training found that aerobic training led to more weight loss than resistance training.
In November, the CDC issued a health advisory in response to reports of eight cases of serogroup B meningococcal disease in students at Princeton University and three cases in students at the University of California, Santa Barbara.
FDA Actions
Throughout the year, the FDA announced numerous actions that were designed to protect public health, many of which affected family physicians and their patients.
- In January, the FDA issued a drug safety warning regarding a possible risk of "significant" liver injury associated with the use of the selective vasopressin V2-receptor antagonist tolvaptan. The agency is urging clinicians to conduct liver tests promptly in patients who report symptoms that may indicate liver injury.
- In March, the FDA said use of the antibiotic azithromycin (Zithromax or Zmax) can lead to a potentially fatal irregular heart rhythm in people with certain risk factors.
- In May, the agency issued a drug safety communication that said administering magnesium sulfate injection to stop preterm labor in pregnant women -- an off-label use of the drug -- for longer than five to seven days may lead to low calcium levels and bone problems in a developing fetus, including osteopenia and fractures.
- In September, FDA officials proposed mandating class-wide label changes to extended-release and long-acting (ER/LA) opioids, including a new boxed warning for pregnant women, as well as imposing a postmarketing research directive on manufacturers of these drugs. The agency said ER/LA opioids should be prescribed only to manage pain severe enough to require daily, around-the-clock, long-term treatment and are not indicated for as-needed pain relief.
- In November, the FDA lifted restrictions the agency had placed on the diabetes medication rosiglitazone (Avandia) based on research findings that failed to confirm a link between use of the drug and an increased risk for cardiovascular events.
- Finally, in December, the FDA issued a proposed rule that would require manufacturers of OTC antibacterial products to submit research showing they are "generally recognized as safe and effective." Manufacturers that fail to submit such data would be required to reformulate or relabel their products.
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What We're Eating: NYC Food Finds We've Loved of Late
Published: Last Updated:
Try as we might, we don't get to writing about everything we've eaten in this great city. Or maybe we have written about a dish, but it's so good we can't stop thinking about it. You know when you tell your friend that they just have to go to a restaurant and try something? That's this post.
Here's our latest installment of What We're Eating, a look at what the Serious Eats editors have devoured and loved recently. Read through the slideshow or jump to what looks tastiest below, then tell us: what dish can't you get out of your head?
- Gyro from BZ Grill in Astoria
- Pad Ped Moo Krob from Larb Ubol
- Tokyo Tsuke-Men at Minca
- Burger from Joe Junior
- Arepas from The Arepa Lady
- Bassanova Ramen
- Maduros from El Olomega
- Spicy Swingle from Steve's Key Lime Pie
- Scallion Pancake at AA Plaza in Flushing
All products linked here have been independently selected by our editors. We may earn a commission on purchases, as described in our affiliate policy.


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Search our database of handpicked sites
Looking for a great physics site? We've tracked down the very best and checked them for accuracy. Just fill out the fields below and we'll do the rest.
You searched for "television"
We found 3 results on physics.org and 14 results in our database of sites
(of which 13 are Websites, 0 are Videos, and 1 is a Experiments)
Search results on physics.org
How Projection Television Works
A brief description of how Projection Television works. This site is part of Marshall Brain's HowStuffWorks.com.
Logie Baird's Television Apparatus
A well written and interesting piece on the invention of television by John Logie Baird.
How Digital Television Works
A brief description of how Digital Television works. From HowStuffWorks.com.
John Logie Baird (1888-1946)
A BBC biography of the inventor of television.
How HDTV Works
A brief description of how High Definition television works, from HowStuffWorks.com.
Dr Karl
Dr Karl Kruszelnicki used to be a "proper pukka scientist, engineer and doctor", but is currently an author and science commentator on Australian radio and television.
How Television Works
Containing a brief description of how TV works, from pixels and motion to inside a cathode ray tube. Tthis excellent set of pages is interactive and is part of HowStuffWorks.com.
How Racef/x Works
A brief description of how Racef/x works, producing places a glowing halo around cars on NASCAR television broadcasts. From HowStuffWorks.com.
TV strobe light - Marvin and Milo
A Marvin and Milo activity about vibration. All you need is a cathode ray television and a rubber band.
Dennis Gabor
Dennis Gabor (1900 - 1971) work led to the development of a number of devices including: a holographic microscope, an analogue computer, a flat thin colour television tube, and a new type of ...


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>>>MLB.com Bio
>>>L.A. Times Article
LOS ANGELES – Former Georgia College lefthanded pitcher Michael Antonini (2006-07) recently received the best news of his professional career, a call up to the big leagues to become a member of the Los Angeles Dodgers bullpen.
Antonini replaces righty reliever Matt Guerrier who went on the 15-day disabled list.
The former Bobcat All-American will be used as either a long reliever or against lefties, according to Dodger head coach Don Mattingly.
A starter for the Albuquerque Isotopes this season, Los Angeles' Triple-A team, Antonini compiled a 4.26 ERA and 1-0 record as a starter in four games this season.
According to the L.A. Times article, Antonini said he received a call from Albuquerque Manager Lorenzo Bundy at 1 a.m. to tell him he was taking his first trip to the majors.
The Aston, Pa. native was an All-American in for the Bobcats 2006 and in his two seasons after transferring from Glouster County College, went 18-7 with a 3.42 ERA. Antonini also fanned 153 in his 192 innings over that two-year span as the Bobcat ace.
The Georgia College Department of Athletics, two-time winners of the PBC Commissioner's Cup, sponsors 10 varsity athletic programs at the NCAA Division II level. As a Division II program, Bobcat Athletics prides itself on balancing the life of the student-athlete, evidenced by the teams' multiple appearances in post-season competition as well as documented academic success and community-service involvement. Sign up at www.twitter.com/BobcatSports and www.facebook.com/gcbobcats for up-to-the-minute reports, and visit www.GCBobcats.com for more information, and to nominate your favorite former Bobcats and Colonials to the GC Athletics Hall of Fame.


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Taxes and Spending
The American cost of living is driven up not only by housing and healthcare costs, but by even larger increases in tax bills and government spending.
Media and CultureU.S. History
The EntrepreneurLabor and Wages
Capitalists provide a service to workers: access to capital with no risk, and immediate payment for services. Meanwhile, starting your own business brings both risk and a long wait before the profits start rolling in.
Many of the worst costs that will come with "Medicare for All" won't be calculated in dollars. They'll come in the form of doctor shortages, long wait times, and less access to care.
Other Schools of Thought
Does the Atlantic Magazine come down on the side of mainstream or behavioral economics?
The costs of recovering from the war would be paid by those who had had little to do with bringing about the massacres.
The Royal Academy made a clear political statement with this year's Nobel Prize in economics.


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Puzzle Levels
Puzzle Categories
Download a FREE Solution for your puzzles!
Click Image to Enlarge
Half H Puzzle
Product Information
|Make the pieces into an H
|Level 7 - Challenging
|Raleigh Puzzles
|Other Wood Puzzles
|2.8 in x 3.5 in x 0.9 in / 7 cm x 9 cm x 2.3 cm
Product Description
The goal of the Half H puzzle is to use all seven pieces to make the shape of an uppercase letter H. It seems simple, right? However, the solution is anything but. This is one of my favorite puzzles designs. Made under licenst to Vesa, I'm glad to be able to offer it!
Raleigh Puzzles is a new line intended for the beginner collector. Perhaps one who is tired of the low quality import puzzles but not yet ready to make the leap into limited edition, high end puzzles. They are hand made in the USA using the same techniques as our cubicdissection puzzles, but in higher volume and without any lacquer finish.
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That's what he does. Cartooning in comics for 39 years - now he's trying to remember some of it...
Monday, 29 August 2011
Dangerous Dan- That's all for now
Anyway, looks like he wasn't just daydreaming after all!
Labels: The Beano
4 comments:
- Lew Stringer said...
A really good strip Nigel, and classy artwork as always. Let's hope it returns! (Perhaps as a short serial in the Eagle Eye vein?)
- Monday, August 29, 2011 4:43:00 pm
- Harry Rickard said...
Good luck Nigel. If everyone likes the same stories as I do then I'm sure he'll be returning!
- Tuesday, August 30, 2011 12:59:00 pm
- Peter Gray said...
It has grown on me each week...getting better and better..glad Smirk is for real;..I don't want it to stop now..
- Wednesday, August 31, 2011 5:35:00 pm
- Hackers said...
Love this week with the robot teacher - I thought he was an annoying nutter before that... just goes to show!
Having said that, maybe he is SMIRK... so desperate to prove they exist he actually pulls a few stunts in their name! Maybe that's a little too dark. :)
- Friday, September 02, 2011 1:14:00 pm
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From New York Times
That Aug. 20, Commerzbank of Germany borrowed $350 million at the Fed's discount window. Two days later, Citigroup, JPMorgan Chase, Bank of America and the Wachovia Corporation each received $500 million. As collateral for all these loans, the banks put up a total of $213 billion in asset-backed securities, commercial loans and residential mortgages, including second liens.
Thus began the bank run that set off the financial crisis of 2008. But unlike other bank runs, this one was invisible to most Americans.


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Upperclass students have the option to live in Lakeland's on-campus apartments located on the south end of campus.
Hill and Morland Houses are four-person apartments with two double rooms, large living room, kitchen and study lounge. Kurtz House offers six-person apartments with two double rooms, two single rooms, two restrooms, large living room and kitchen. Together, all of the apartments house 112 students.
All three houses are fully furnished, air-conditioned and have carpeted living rooms and bedrooms. The houses also have lockable storage rooms within each four-unit section and feature either a patio or deck that overlooks the campus lagoon. All three houses have adjacent student parking. All three houses are tobacco-free.Click Here To See the Floor Plan


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