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Adaptive servoventilation (ASV) is often used to treat central sleep apnea (CSA) and complex sleep apnea syndrome (CompSAS). Both CompSAS and CSA may occur in the setting of CHF and with the use of chronic opioids. We hypothesized that ASV would be less successful in treatment of CSA and CompSAS secondary to opioid use than in CHF patients.
Consecutive patients were studied between January and December 2009 who underwent ASV titration for CSA or CompSAS due to CHF (defined as EF < 45%, or > 50% with evidence for diastolic dysfunction on echocardiogram) and chronic opioid users (defined by the use of opioids > 6 months).
Study included one hundred and eight patients with 77 males (71.3%) and 31 females (28.7%). Subjects had severe sleep apnea at baseline (AHI 45.6 ± 27.4) and inadequate control of sleep disordered breathing on CPAP (AHI 50.0 ± 32.2, CAI 36.6 ± 32). No significant differences were found between the groups in overall ASV success, defined as AHI < 10/h (p = 0.236). ASV was successful in 28 (59.6%) of those in the opioid group, compared to 43 (70.5%) of those in the CHF group. When ASV success was defined as AHI < 5/h at optimum EEP, there was again no significant difference between the groups (p-value = 0.812). Logistic regression showed unit increases in BMI, unit increases in HCO3, and presence of CSR were each associated with decreased likelihood of ASV success.
We did not find a statistically significant difference in the effectiveness of ASV between CHF patients and chronic opioid users, with the overall success rate approaching 70%, as defined by an AHI < 10/h.
A commentary on this article appears in this issue on page 577.
Ramar K; Ramar P; Morgenthaler TI. Adaptive servoventilation in patients with central or complex sleep apnea related to chronic opioid use and congestive heart failure. J Clin Sleep Med 2012;8(5):569-576.
Sleep physicians are increasingly confronted with patients who suffer with centrally mediated sleep disordered breathing. This is in part due to two trends. Since the consensus statement on liberalization of opioids for chronic pain use by the American Academy of Pain Medicine and the American Pain Society, the total doses of prescribed fentanyl, hydromorphone, morphine, and oxycodone have increased dramatically in the last decade.1 With continued increasing use of chronic opioids, there is greater risk and prevalence of central and obstructive sleep disordered breathing that may result in increased morbidity and mortality.2,3 Similarly, congestive heart failure (CHF) is on the rise, with a reported prevalence of 2% among the general population, increasing to 10% among patients 65 years or older, and it also is associated with increased presence of sleep disordered breathing, including central sleep apnea syndromes.4
Adaptive servoventilation (ASV) is often used to treat central sleep apnea (CSA) due to Cheyne-Stokes respiration (CSR) in the setting of CHF5–7 and complex sleep apnea syndrome (CompSAS).8,9 CompSAS is described as the development of central sleep apnea with the application of continuous positive airway pressure (CPAP) in patients with obstructive sleep apnea (OSA). Both CompSAS and CSA may occur in the setting of CHF and with the use of chronic opioid medications.10–13 The predominant pattern of CSA in CHF patients is CSR, which is a highly periodic breathing pattern. In contrast, both periodic and non-periodic breathing patterns of CSA or CompSAS are described with chronic opioid users.10–13 The periodic CSA breathing pattern in chronic opioid users is called cluster breathing, while the non-periodic or irregular form of CSA is called ataxic or Biot breathing pattern. The periodic cluster breathing pattern in chronic opioid users is considerably shorter in length than CSR. The non-periodic ataxic/Biot breathing pattern seen in opioid users is characterized by irregular frequency and variable respiratory rate and tidal volume. Though previous studies have shown ASV to be an effective treatment for CSA-CSR in CHF patients, studies assessing the effectiveness of ASV in chronic opioid users have shown conflicting results.14,15 One study showed it to be highly effective,15 while another reported it as insufficient to treat the sleep disordered breathing.14 The study samples in these two studies were small (5 and 22 patients, respectively). In addition, there are no studies to date that compare the effectiveness of ASV between the CHF and opioid users. This study compares the efficacy of ASV in the treatment of CSA and CompSAS secondary to opioid use with those secondary to CHF.
Current Knowledge/Study Rationale: Based on its internal proprietary algorithm, we hypothesized that adaptive servoventilation (ASV) might function better in the presence of a highly regular and periodic central sleep disordered breathing (such as Cheyne-Stokes respiration (CSR) in the setting of CHF) compared to the non-periodic (such as irregular or ataxic/Biot breathing patterns in chronic opioid users) central sleep disordered breathing.
Study Impact: ASV was as effective in the treatment of central and complex sleep apnea in chronic opioid users as it is in patients with CHF, with the overall success rate of 70% as defined by an AHI ≤ 10/hour. Lower body mass index, but higher bicarbonate values and absence of CSR, were predictors for ASV success in both groups.
Adaptive servoventilation (ASV) is a pressure preset, volume or flow cycled form of closed-loop mechanical ventilator that monitors the patient's breathing pattern over a certain period of time. It uses an internal algorithm to provide breath-by-breath dynamic adjustment of inspiratory pressure support with a back-up respiratory rate to normalize breathing patterns to a predetermined target of either minute ventilation or peak flow, thereby stabilizing the central sleep disordered breathing pattern. Embedded computer-based algorithms use logic to determine whether a given hypopneic breath is towards the beginning of a hyperpnea or leading towards an apnea so that they may adjust the delivered support accordingly. Since ASV, based on its internal proprietary algorithm might function more optimally in the presence of a regular or periodic form of central sleep disordered breathing such as CSR, we considered, as was suggested by Farney et al., that it may prove less effective for the non-periodic, more irregular breathing pattern such as ataxic/Biot breathing pattern seen in chronic opioid users.14 We therefore hypothesized that ASV would be less successful in treatment of CSA and CompSAS secondary to opioid use than in those secondary to CHF.
The study was approved by the Mayo Clinic Institutional Review Board (IRB Application #:11-007500). Retrospectively, we screened consecutive patients referred to our sleep center who underwent ASV titration between January and December 2009. Patients were selected if their baseline diagnostic polysomnography (PSG) showed an AHI ≥ 5/h and subsequent continuous positive airway pressure (CPAP) titration showed control of obstructive events but a residual AHI > 5/h or the persistence of CSA and/or CSR on CPAP. All of our patients were identified based upon split-night studies. They were allotted in the CHF group if they had a transthoracic echocardiogram that showed an ejection fraction (EF) ≤ 45%, or if they had an EF > 50% but had documentation of heart failure with preserved EF (diastolic dysfunction). The chronic opioid group included those who had been treated with opioid medications > 6 months. Patients were excluded from analysis if they did not meet our definition for CHF or chronic opioid use.
One hundred and eight patients were found eligible based on the above screening criteria. Patient records from 2009 contained data on the titration study to assess the optimum AHI at the prescribed end-expiratory pressure (EEP) on ASV titration. EEP was also titrated to a maximum of 15 cm of water, if needed.
Clinical records of consults and follow-up visits were reviewed, and data were collected including age, gender, body mass index (BMI), EF from echocardiogram, and presence or absence of atrial fibrillation. Polysomnographic data on both the diagnostic and titration studies were also collected as stated below. The main reason for the use of chronic opioids was for chronic pain syndrome.
Polysomnography (PSG) was performed using a digital polygraph (Nicolette, San Diego, CA). We used the electroencephalogram ([EEG] 2 channels), electroculogram ([EOG] 2 channels), and electromyogram ([EMG] 1 channel) montage as described in the recent scoring manual of the American Academy of Sleep Medicine.16 Airflow and respiratory effort were monitored using oronasal thermocouple and nasal pressure transducer, respiratory inductive plethysmography (RIP) during the diagnostic study, and, during titration, using the flow channel from the CPAP and bilevel positive airway pressure (BPAP) plus RIP. Sleep staging and arousals were scored.17
An apnea was defined as cessation of inspiratory flow (> 90% reduction in airflow signal) ≥ 10 sec. An obstructive apnea was defined as the absence of airflow in the presence of rib cage and abdominal excursions. A central apnea was defined as the absence of airflow with absence of rib cage and abdominal excursions. Hypopnea was defined as a 30% reduction in airflow signal lasting ≥ 10 sec associated with ≥ 4% drop in oxygen saturation. We defined CSA to be present if the central apnea index (CAI) was > 5/h and the CAI was ≥ 50% of the AHI. CSA due to CSR was considered to be present based on the interpreting physician's report or consult note; CSR was defined by the presence of ≥ 3 consecutive cycles of cyclical crescendo and decrescendo breathing consisting of apneas, hypopneas, hyperpneas, and hypopneas, with each cycle lasting ≥ 45 sec, and a central apnea index ≥ 5/h. Complex sleep apnea (CompSAS) was considered present if the diagnostic PSG demonstrated findings consistent with obstructive sleep apnea, but CPAP titration sufficient to alleviate obstruction left residual central apneas and/or periodic breathing with hypopneas sufficient to produce an AHI ≥ 5/h.
Standard protocols for our sleep laboratory were used to titrate for CPAP and ASV. Different masks were used based on patient's preference, comfort, and fit. Mask leaks were monitored and corrections made accordingly. CPAP (Respironics Inc., Murrysville, PA) titration was performed using a uniform and standard approach. Titration usually began at CPAP of 5 cm of water and titrated to eliminate obstructive sleep disordered breathing events. If central apneas developed, the pressure was increased to monitor for improvement; if not, the pressure was brought back down to the pressure that eliminated the obstructive events. The development and persistence of central sleep apnea on CPAP as defined above led to ASV titration. ASV titration was performed using a ResMed VPAP Adapt SV (ResMed Ltd., NSW, Australia). The EEP was started at 5 cm of water or at the CPAP that eliminated OSA during the CPAP titration. Titration of EEP was performed by the technician to eliminate OSA, while the pressure support was on default settings (minimum inspiratory pressure support of 3 cm of water, maximum inspiratory pressure support of 10 cm of water above EEP that was controlled by the internal algorithm of the machine to target minute ventilation). The back-up rate was in the auto mode. The EEP could be adjusted to a maximum of 15 cm of water pressure.
We assessed the effectiveness of ASV to treat CSA and CompSAS between the CHF group and chronic opioid group. For the primary analysis, we considered treatment successful if the ASV settings resulted in an AHI < 10/h. As a secondary analysis, we also looked at our data using an AHI threshold for control of < 5/h at the optimally prescribed EEP (that EEP that eliminated obstructive events while minimizing central events and sleep disruption, based upon sleep specialist's review of PSG). Finally, we assessed and compared sleep architecture, arousal index, periodic leg movements, and predictors for ASV success between the 2 groups.
All analyses were done in Statistical Analysis System (SAS; version 9.2; SAS Institute, Cary, NC). The primary outcome was ASV success defined as AHI < 10. The secondary outcome was defined as AHI < 5 at the optimum EEP measured during ASV titration. Logistic regression was used to determine which variables predicted ASV success in the overall group as well as separately within the CHF and opioid groups. All p-values were 2-tailed, and statistical significance was defined with p < 0.05. Univariate analyses were first conducted on factors including BMI, age, and AHI during the diagnostic study, AHI on CPAP titration (CPAP AHI), bicarbonate levels (since most patients did not have arterial blood gas analysis to identify PaCO2 levels, we assessed bicarbonate levels close to the time of their PSGs), presence or absence of CSR, presence or absence of CSA, presence or absence of atrial fibrillation, gender, and EF from echocardiogram to identify factors that were independently associated with ASV success. Models were built with 3 different ASV success criteria, one defined as overall titration period AHI < 10/h, and the others with AHI < 5/h or 10/h at the optimum EEP. Based on the Wald test from logistic regression, predictors with p-value < 0.25 were included as candidates for multivariate analysis. This cutoff was selected rather than the traditional p-value cutpoint of 0.05 so as to include important co-variates in the model. Stepwise selection was performed in which the most nonsignificant (p-value > 0.05) and non-confounding co-variates (change in parameter estimate > 20%) were removed iteratively from the model. Hosmer-Lemeshow Goodness of fit test was used to assess model fit. All models were assessed at p < 0.05.
Of 108 patients meeting our selection criteria, 61 (56.48%) had CSA during the diagnostic portion of the night and belonged to the CHF group. Of the 61 patients with CSA, 19 (31.1%) had CSR. Chronic opioid users comprised the remaining 47 of our 108 subjects; among them, 28 had CompSAS (59.6%), while the remaining 19 had CSA. The sample included 77 males (71.3%) and 31 females (28.7%) who ranged in age from 26 to 89 years. Among the males, 23 (29.9%) were in the opioid group and 54 (70.1%) were in the CHF group. Tables 1, 2, and 3 provide characteristics of all subjects, and comparisons between CHF and opioid groups. Forty-six of 61 patients (75%) had systolic congestive heart failure, as defined by an EF ≤ 45%. All 61 CHF patients were in a stable treatment phase at the time of their PSG.
Demographic characteristics
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Polysomnographic respiratory measures
Polysomnographic sleep characteristics
Overall, the subjects had severe sleep apnea at baseline (AHI 45.6 ± 27.4) and had significantly abnormal breathing on CPAP (AHI 50.0 ± 32.2, with CAI 36.6 ± 32). Compared with the opioid group, the CHF group had a significantly higher proportion of men, were older in age, had lower LVEF, and had higher residual CAI on CPAP (Table 1). The 2 groups were not otherwise significantly different with respect to measures of sleep disordered breathing
There was no significant difference between the groups in overall ASV success defined as AHI < 10/h (p = 0.236). Of those in the opioid group, 28 (59.6%) found success with ASV, compared to 43 (70.5%) of those in the CHF group. When success was defined as AHI < 5/h at the optimum EEP, there was again no significant difference between the groups having ASV success (χ2 p-value = 0.812). Of those in the opioid group, 29 (61.7%) found success with ASV, compared to 39 (63.9%) of those in the CHF group. Similarly, no significant differences were noted in ASV success (as defined by an AHI < 10/h) between overall CSA patients (irrespective of whether they belonged to the CHF or chronic opioid group) and CompSAS patients (64.2% vs 65.7%, p = 0.8826). The average EEP was 8 (± 2) cm of water at the end of titration. The mean baseline oxygen saturation during sleep was 92.5% ± 2.5%, and improved during ASV titration to 93.6% ± 2.1% (p < 0.001). Similarly, the percentage of time spent above 90% during the diagnostic portion of the study improved from 81.7 ± 21.6 to 91.7 ± 15.6 (p < 0.001) (Table 5).
The men made up a significantly greater proportion of the CHF group than the opioid group (88.5% vs. 48.9%), however gender was not associated with treatment success as defined by an AHI < 5/h at the optimum prescribed EEP (p = 0.274), or by an AHI < 10/h on ASV titration (p = 0.781). There was also a significant difference in age between the 2 groups (p < 0.001); the CHF group had a median age of 73 (range 47-89), while the opioid group had a median age of 61 (range 26-84). However, age was also not significantly associated with ASV success using AHI < 10/h (p = 0.647), or ASV success using an AHI < 5/h at optimum prescribed EEP (p = 0.733). The overall mean BMI was 31.6 (range 16.3-53.5); mean BMI did vary significantly between the opioid and CHF groups (32.8, range 16.3-53.5 and 31.6, range 18.8-43.6, respectively, p = 0.038) and was a significant predictor of ASV success in both groups as discussed below. There was also a significant difference in mean EF between the groups (60.3 vs. 40.6, p < 0.001) and in the presence of atrial fibrillation (4% vs. 27%, p < 0.001) in the opioid vs. CHF group, respectively.
Summary distributions of sleep architecture, arousal index, and periodic leg movements in our subjects are found in Table 3. Overall, there was a decrease in stage N1, increase in stages N2 and N3, and decrease in stage R in the opioid group compared to the CHF group. The periodic leg movement index (PLMI) and arousal index was lower in the opioid group than in the CHF group.
Logistic regression showed that BMI and CPAP AHI were inversely predictive of overall ASV success using the AHI < 10/h criterion (OR 0.920; CI 0.861, 0.983 and OR 0.984: CI 0.970, 0.998, respectively; Table 4). When ASV success was defined by AHI < 5/h at the optimum EEP, BMI, CSR, bicarbonate levels were all significant predictors of ASV success (OR 0.851: CI 0.775, 0.934; OR 0.213: CI 0.062, 0.727; OR 1.218: CI 1.008, 1.471, respectively). Unit increases in BMI, unit increases in HCO3, and presence of CSR were each associated with decreased likelihood of ASV success (Figure 1). Of note, in the last model, CSR and HCO3 were not significant in univariate analysis; however, they were forced in to the multivariate model due to biologic relevance and came out as significant predictors of ASV success. Overall, higher measures of BMI, especially in the overweight class, correlated with lower probability of ASV success with AHI < 10/h (p = 0.0005) and AHI < 5/h at optimum EEP (p = 0.0048). Interestingly, the highest proportion of those who had failures at AHI < 10/h (37%) had a BMI in the range of 30-36 (Figure 1).
Univariate and multivariate correlates of ASV success
Oxygen saturation during the diagnostic study vs. ASV titration
Proportions of overall success and failure by body mass index (BMI). Unit increases in BMI were associated with decreased likelihood of ASV success. The greatest difference in proportion of successes compared to failures at AHI < 10/h (19%) occurred among those with a BMI in the range of 24 to < 32. The difference between proportion of success compared to failures in this BMI range was even more pronounced (25%) when success was defined as AHI < 5/h at optimum EEP.
Overall percent success and failure by BMIProportions of overall success and failure by body mass index (BMI). Unit increases in BMI were associated with decreased likelihood of ASV success. The greatest difference in proportion of successes compared to failures at AHI
The findings of this study indicate that ASV is as effective in the treatment of central and complex sleep apnea in chronic opioid users as it is in patients with CHF. Overall success rates using more liberal criteria (AHI < 10 on ASV titration) or more stringent criteria (AHI < 5/h at best EEP), were statistically not different. The predictors for success with ASV in both groups were lower BMI, higher bicarbonate values, and absence of CSR. This is not the result we expected. We had hypothesized that ASV would be more likely to succeed in patients with CHF, especially if they had CSR. Although not specifically part of our initial hypothesis, we had considered it likely that since patients with CHF and CSR often have lower PaCO2 and bicarbonate levels, that bicarbonate levels would inversely correlate with likelihood of success. Again, this proved to not be the case.
Of the 108 patients, ASV was successful in reaching an AHI < 5 in 63% and AHI < 10 in 73.2%. These rates are consistent with findings of most other studies. Success rates for ASV (using an AHI < 10) in patients with CompSAS have been reported in as low as 18%14 and as high as 100%15 associated with chronic opioid use, and in more mixed populations as 70% to 100%.8,18–20 Published success rates for patients with CSR have ranged from 73% to 100%.8,21–25 Although our overall success rates were not dissimilar to prior reports, the reason why ASV succeeds in controlling some, but not all types of central sleep apnea remains elusive. Possible mechanisms for ASV failure might include inadequate stabilization of the upper airway, high interface leak, ineffective pressure support, patient-ventilator dyssynchrony due to poorly timed pressure support, or unstable sleep leading to oscillation between ventilatory control patterns.
CPAP provides a pneumatic splint for the upper airway throughout the breathing cycle and successfully treats obstructive sleep apnea (OSA). The expiratory pressure on ASV is titrated to eliminate OSA, while the variable inspiratory pressure support along with the back-up rate tries to eliminate the central sleep disordered breathing events. CPAP has some success in studies to treat CSA in the setting of heart failure,26–28 though overall effectiveness is inferior to ASV.5–7,29 In contrast, CPAP alone is most often ineffective in controlling sleep disordered breathing in patients with chronic opioid use.12,14 In our own study, though it helped to control OSA, CPAP overall was unsuccessful in controlling central sleep disordered breathing in opioid users, and in fact worsened the CSA, similar to findings in other studies. When using ASV, it appears that we achieved adequate EEP, since on ASV the OMAI was only 3.4 ± 6.7/h. Therefore, we do not think the ASV failures were due to inadequate stabilization of the upper airway. It also seems likely that leak was not a major contributor, since titration was performed manually under direct sleep technologist observation; the technologists promptly adjust interfaces when leaking is detected. However, we did not measure leak, and this could be an opportunity for improvement in our practice and outcomes. The fact that higher BMI was associated with lower likelihood of ASV success may speculatively reflect an expected decreased effectiveness of pressure support in enhancing tidal volumes when the respiratory compliance is reduced by obesity. We did not measure tidal volumes in a calibrated fashion, and thus were not able to compare volumes between ASV success and failures.
Failure via ventilatory-patient dyssynchrony might be expected when ventilatory patterns being generated by the ASV do not match or compensate adequately for the patient's pattern. We had postulated that since different underlying mechanisms result in central sleep apnea patterns in patients with chronic opioid use vs. CHF that the interaction of the central respiratory controller with ASV algorithms would be characteristically different. The central sleep apnea patterns noted with CSR (in association mostly with CHF) are most pronounced during NREM sleep and clearly represent the manifestation of a respiratory system with high loop gain and delayed feedback. The pattern is typically reduced during REM sleep because ventilation is less reliant on feedback mechanisms. The resultant ventilatory pattern is predictable and we thought would result in better synchrony with the ASV algorithm. In contrast, most opioid induced sleep disordered breathing patterns are less periodic, poorly attenuated in REM, and the pathophysiology is complex and less well worked out. Opioids appear to exert differential effects on central and peripheral chemoreceptors.30 In addition, opioids inhibit the inspiratory rhythm generating neurons located in the pre-Bötzinger complex neurons, but do not appear to affect the expiratory motor neurons located in the retrotrapezoid nucleus/parafacial respiratory group.31 Thus opioids interfere with normal ventilatory rhythmogenesis and regulation, resulting in less predictable patterns of ventilation than in CSR. Some of the breathing patterns in chronic opioid users are similar to those in heart failure patients, such as the presence of OSA and the cluster breathing pattern, though the cycle lengths in the periodic breathing pattern are considerably shorter in the cluster breathing than in the CSR pattern seen in heart failure patients. In contrast, ataxic/Biot breathing pattern is a non-periodic irregular breathing pattern seen in chronic opioid users but not in CHF.
There were differences in the proportion of sleep stages between the CHF and opioid group during the diagnostic study (Table 3), with a higher percentage of stage N3 and lower REM in the chronic opioid group than the CHF group. Decrease in REM has been reported in chronic opioid users32; however, results are conflicting for NREM sleep. Most studies show a decrease in stage N1 and an increase in stage N2 compared to controls not on opioids, but the results are conflicting with stage N3.12,32 We found a higher percentage of stage N3 in chronic opioid group than the CHF group. Our reported percentage of stage N3 is higher than the previous reported literature in chronic opioid users.12,32 Whether this has any effect on the efficacy of the PAP therapy is unclear, though we believe it not to be the case.
We postulated that the ASV algorithm would synchronize ventilation more poorly with opioid-related SDB than with CHF-associated patterns. We did not demonstrate this. In fact, when we analyzed the influence of CSR pattern on ASV success by forcing CSR into the regression model, its presence correlated negatively. This may be reflective of imprecise characterization of the breathing patterns. Patients might have experienced CSR for only relatively short percentages of the study (for example, 3-5 min out of an entire night) and yet would be characterized as having demonstrated CSR. Our hypothesis regarding a positive correlation between a regular cyclic breathing pattern and ASV success might be better studied by using a more global measure of periodicity across the entire study, such as percent of time spent in a periodic pattern; we did not design our study to accommodate such measures. CSR associated with CHF is most often accompanied by hypocapnia, which we thought might be reflected in serum bicarbonate levels, thus hypothesizing that lower serum bicarbonate levels would be associated with a greater likelihood of ASV success. Again, our hypothesis was proven incorrect. This may be influenced by the fact that not all of our subjects had bicarbonate levels immediately prior to ASV titration. Some of the levels were obtained shortly afterward as a result of other clinical needs. It is possible the bicarbonate levels do not represent in any way the PaCO2 levels at the time of ASV titration. Therefore, the contribution of this mechanism for ASV failure cannot be reliably inferred from our data.
Although our study identified BMI, CSR, and HCO3 levels as significant predictors of ASV success, there may be other factors that might determine success with ASV in chronic opioid users that we did not discern. The type and duration of opioids used, the predominant breathing pattern, i.e., cluster vs. ataxic/Biot breathing pattern, comorbid conditions, and co-ingestion of other medications such as benzodiazepines may be other factors that should be assessed and possibly controlled for, in future studies.
The main limitation of our study is the retrospective nature of our assessment, with no prospective randomization or blinding performed. Referral bias is also likely, and this may have affected the overall effectiveness of ASV, as patients referred to our center were the ones who likely failed therapies elsewhere. While our sample size was small and could have resulted in a type II error, post hoc power calculation of 77% suggests that a type II error is not unlikely with this sample size. Another limitation of our study was the use of bicarbonate levels to indirectly assess pCO2 as most patients did not have arterial blood gas analysis around the time of their PSG. Though our assumption was that bicarbonate values would inversely correlate with pCO2, it is possible that bicarbonate levels may have been affected by various conditions such as the use of diuretics. Not reporting the exact dose of opioids consumed around the time of the PSG, or whether the patients were concomitantly taking benzodiazepines, is another limitation of our study. Due to the retrospective nature of our study, however, we knew that the patients were on opioids based on the medication list; it was difficult to assess the exact dose at the time of the PSG or the type of chronic pain syndrome, as this information was not available on the consult or progress note. We compared two patient cohorts with different underlying diseases. However, both CHF and chronic opioid use are associated with central sleep apnea, and ASV is currently being used to treat varied types of central sleep apnea.
The main intent of this study was to assess whether ASV would be an effective treatment for central sleep apnea, inclusive of CSR and CompSAS, and irrespective of the underlying cause or disorder that triggers it. CompSAS that occurs in the setting of chronic opioids may be different in pathophysiology (probably a "dulling" of the loop gain mechanism) than that due to CSA/CSR (where the loop gain is high with increased chemosensitivity). Therefore, we hypothesized that ASV as a treatment option would not work well in patients on chronic opioids. Although previous data suggest that both CSA and CompSAS improve over time in some patients undergoing treatment with CPAP,33 the retrospective nature of our study design did not allow us to address this, as all patients in our sample with persistent CSA on CPAP immediately underwent ASV titration. A future prospective and randomized study could be designed to specifically address this question. The main purpose of this study was to assess which patients are most likely to acutely succeed with ASV, rather than determining whether ASV would succeed better than CPAP of chronic use. Also, most studies in our center are performed based on the split-night protocol.34 Though there might have been differences in the proportion of obstructive and central sleep disordered breathing between the first and second half of the night, it would be difficult to speculate whether it would have made a difference, as all our patients in this study were selected based on the split night protocol. Additionally, we used only the VPAP Adapt SV, which is a ResMed device and not the Respironics BiPAP AutoSV device during our ASV titration. There are differences between these two machines in how they address the underlying central sleep disordered breathing events. The AutoSV uses a different target (peak flow) in its servomechanism, while the VPAP Adapt SV targets the minute ventilation. Consequently, our findings may not apply to patients using the Respironics BiPAP autoSV. Despite these limitations, our data are the most comprehensive regarding the use and comparing the effectiveness of ASV between CHF and chronic opioid groups. Also, our sample size is the largest on opioid users using ASV to treat their sleep disordered breathing.
In conclusion, we did not find a statistically significant difference in the effectiveness of ASV between the CHF patients and chronic opioid users, with the overall success rate approaching around 70%, as defined by an AHI of less than 10/h. With the increasing use of chronic opioids and increasing prevalence of congestive heart failure and their associated breathing disorders, further studies are needed to assess predictors for success in this group of patients.
This was not an industry supported study. Dr. Morgenthaler is the principal investigator in a multicenter trial for which his institution as received funding form ResMed. The other authors have indicated no financial conflicts of interest.
Dr. Ramar acknowledges funding via an internal faculty development grant from the Mayo Clinic Department of Internal Medicine to prepare and submit this manuscript. Work for this study was performed at Mayo Clinic, Rochester, MN, USA.
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Teichtahl H, Prodromidis A, Miller B, Cherry G, Kronborg I, authors. Sleep-disordered breathing in stable methadone programme patients: a pilot study. Addiction. 2001;96:395–403. [PubMed]
Walker JM, Farney RJ, Rhondeau SM, et al., authors. Chronic opioid use is a risk factor for the development of central sleep apnea and ataxic breathing. J Clin Sleep Med. 2007;3:455–61. [PubMed Central][PubMed]
Teichtahl H, Wang D, Cunnington D, et al., authors. Ventilatory responses to hypoxia and hypercapnia in stable methadone maintenance treatment patients. Chest. 2005;128:1339–47. [PubMed]
Farney RJ, Walker JM, Boyle KM, Cloward TV, Shilling KC, authors. Adaptive servoventilation (ASV) in patients with sleep disordered breathing associated with chronic opioid medications for non-malignant pain. J Clin Sleep Med. 2008;4:311–9. [PubMed Central][PubMed]
Javaheri S, Malik A, Smith J, Chung E, authors. Adaptive pressure support servoventilation: a novel treatment for sleep apnea associated with use of opioids. J Clin Sleep Med. 2008;4:305–10. [PubMed Central][PubMed]
Iber C, Ancoli-Israel S, Chesson A, Quan S, authors. The AASM Manual for the scoring of sleep and associated events: rules, terminology and technical specification. 2007. Westchester, IL: American Academy of Sleep Medicine;
Rechtschaffen A, Kales A, authors. A manual of standardized terminology techniques and scoring system of sleep stages of human subjects. 1968. Los Angeles, CA: Brain Information Service/Brain Research Institute;
Brown SE, Mosko SS, Davis JA, Pierce RA, Godfrey-Pixton TV, authors. A retrospective case series of adaptive servoventilation for complex sleep apnea. J Clin Sleep Med. 2011;7:187–95. [PubMed Central][PubMed]
Randerath WJ, Galetke W, Kenter M, Richter K, Schafer T, authors. Combined adaptive servo-ventilation and automatic positive airway pressure (anticyclic modulated ventilation) in co-existing obstructive and central sleep apnea syndrome and periodic breathing. Sleep Med. 2009;10:898–903. [PubMed]
Randerath WJ, Galetke W, Stieglitz S, Laumanns C, Schafer T, authors. Adaptive servo-ventilation in patients with coexisting obstructive sleep apnoea/hypopnoea and Cheyne-Stokes respiration. Sleep Med. 2008;9:823–30. [PubMed]
Banno K, Okamura K, Kryger MH, authors. Adaptive servo-ventilation in patients with idiopathic Cheyne-Stokes breathing. J Clin Sleep Med. 2006;2:181–6. [PubMed]
Bitter T, Westerheide N, Faber L, et al., authors. Adaptive servoventilation in diastolic heart failure and Cheyne-Stokes respiration. Eur Respir J. 2010;36:385–92. [PubMed]
Bitter T, Westerheide N, Hossain MS, et al., authors. Complex sleep apnoea in congestive heart failure. Thorax. 2011;66:402–7. [PubMed]
Kasai T, Usui Y, Yoshioka T, et al., authors. Effect of flow-triggered adaptive servo-ventilation compared with continuous positive airway pressure in patients with chronic heart failure with coexisting obstructive sleep apnea and Cheyne-Stokes respiration. Circ Heart Fail. 2010;3:140–8. [PubMed]
Zhang XL, Yin KS, Jiang SS, Li XL, Jia EZ, Su M, authors. [Efficacy of adaptive pressure support servo-ventilation in patients with congestive heart failure and Cheyne-Stokes respiration]. Zhonghua Yi Xue Za Zhi. 2006;86:1620–3. [PubMed]
Arzt M, Floras JS, Logan AG, et al., authors. Suppression of central sleep apnea by continuous positive airway pressure and transplant-free survival in heart failure: a post hoc analysis of the Canadian Continuous Positive Airway Pressure for Patients with Central Sleep Apnea and Heart Failure Trial (CANPAP). Circulation. 2007;115:3173–80. [PubMed]
Javaheri S, author. Effects of continuous positive airway pressure on sleep apnea and ventricular irritability in patients with heart failure. Circulation. 2000;101:392–7. [PubMed]
Naughton MT, Liu PP, Bernard DC, Goldstein RS, Bradley TD, authors. Treatment of congestive heart failure and Cheyne-Stokes respiration during sleep by continuous positive airway pressure. Am J Respir Crit Care Med. 1995;151:92–7. [PubMed]
Szollosi I, O'Driscoll DM, Dayer MJ, Coats AJ, Morrell MJ, Simonds AK, authors. Adaptive servo-ventilation and deadspace: effects on central sleep apnoea. J Sleep Res. 2006;15:199–205. [PubMed]
Sarton E, Teppema L, Dahan A, authors. Sex differences in morphine-induced ventilatory depression reside within the peripheral chemoreflex loop. Anesthesiology. 1999;90:1329–38. [PubMed]
Feldman JL, Del Negro CA, authors. Looking for inspiration: new perspectives on respiratory rhythm. Nat Rev Neurosci. 2006;7:232–42. [PubMed Central][PubMed]
Dimsdale JE, Norman D, DeJardin D, Wallace MS, authors. The effect of opioids on sleep architecture. J Clin Sleep Med. 2007;3:33–6. [PubMed]
Javaheri S, Smith J, Chung E, authors. The prevalence and natural history of complex sleep apnea. J Clin Sleep Med. 2009;5:205–11. [PubMed Central][PubMed]
Khawaja IS, Olson EJ, van der Walt C, et al., authors. Diagnostic accuracy of split-night polysomnograms. J Clin Sleep Med. 2010;6:357–62. [PubMed Central][PubMed]


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Francis is a cool Plush Promotional Polar Bear by Gund with your logo on either a t-shirt, bandanna or necktie.
Even grown-ups will be charmed when they receive the Custom Printed Teddy Bear wearing your logo.
This Promotional Teddy Bear is a darling, yet neutral background for any logo
The Custom Printed Gund Fuzzy Brown Teddy Bear has the most engaging expression, sure to captivate all of your customers.
Benji is a dog-gone good custom stuffed animal with your choice of custom printed accessories.
Today, the company manufactures an extensive collection of unique characters and licensed promotional plush under the GUND, GUNDbaby and GUNDKids brands.
GUND is known worldwide for its top quality, soft and huggable plush designs and gift products.
Award-winning GUND products appeal to all ages, from infants up, and are perfect for both play and collecting.

subset: commoncrawl


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WelcomeIntroduction and site features
Missouri is blessed with an abundance of beautiful wildflowers from early spring to late fall, in a multitude of colors, sizes, and shapes. This site contains photos of a few of Missouri's wildflowers, taken mostly in the mid-Missouri area surrounding Jefferson City. It features primarily non-woody plants, but a few vines, shrubs, and trees that have conspicuous flowers are also included.
I created this site simply to share my love of wildflowers, and also as an identification aid. Your best bet in that regard, though, is to make use of one of the excellent resources listed in the bibliography.
The site's color pages lets you choose a portfolio of images based on flower color. Because the color of some flowers is difficult to classify, and because some are quite variable, several are listed under more than one color. Even so, be sure to check other color categories if you don't find what you're looking for in the category you expected.
Site Features
See a portfolio of Yellow/Orange, Red/Pink, White, or Blue/Purple flowers, and click an image for more information.
List wildflowers by genus and species. To find a plant by its common name, use your browser's "find" feature when the list is displayed.
View a list of links to other wildflower image and gardening sites that may be of interest.
Print note cards or download desktop images for free, featuring some of the beautiful wildflower images on this site.
See the answers to frequently asked questions, and send me a message on the contact page.
See the bibliography for a list of resources that were consulted in creating this site.
All images are protected by copyright. I'll usually grant permission for non-commercial use with attribution. Thank you for asking first!


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A couple of years ago when I started blogging about emacs I asked to be included in planet emacsen. And now I have been removed. What can be the reason for that I wonder.
Well, I have just come back from a blogging break. Between my post on sorting records with emacs in August 2009 and my post on Enablers and Obstructors in March 2010, there were almost 7 months. But the latest post in Amortized Analysis (a blog that hasn't been removed from planet emacsen) was 4th January 2008. That is more than 2 years ago.
Maybe I'm not that relevant anymore. I have posted mainly P.erl posts since my break. But I do still do emacs stuff, e.g. Directory Aliases Revisited and Programming with Types. And Alexandre Vassalotti's most recent Emacs post was September 2007.
Or was it the back and forth with Ian Eure (and to a lesser extent, Aaron Hawley) about my Emacs Database Mode. Did someone ask for me to be removed?
Anyway, whatever the reason, it has been done. What solution do I have? I have created a yahoo pipe called Better Planet Emacs which you can subscribe to. It filters a lot of the non-emacs related posts out so for me at least it is better than stock planet emacs. If you want to copy it and customise it for your own use you should go here.


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Need for Speed: The Run
Need for Speed: The Run
In Need for Speed: The Run you play as Jack. Jack has a price on his head and various unsavoury characters trying to track him down. The only way that Jack can save himself is to enter 'the run', an illicit race that crosses America.
Smash through borders, slip past dense rush hour traffic and blaze around icy mountain ranges all at shock inducing speeds!
Developed using the famous Frostbite 2 engine, Need for Speed: The Run drops the hammer and takes the series to the next level.
Order now and go on 'The Run'!


text: I admire filmmaker John M. Woody for his great videos and his teaching of video production. Before he retired as an Apple Distinguished Educator and professor at the School of Media Arts & Design at James Madison University, he taught hundreds of students about how to best use FotoMagico in film production. Recently, he has been busy demonstating what a great camera the iPhone 5s features. This slideshow is a compilation of the best images of 2013 from his iPhone. Thank you, John, for letting us share it.


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Moderator: Moderators
Myth wrote:I have to say I don't particularly agree with this. Yes, voter turn-out in democratic states is almost always disappointing. However, implementing some sort of tax and pay-back system will bring people to the polls just for the sake of getting their money back. I can see people just marking off boxes for sheer sake of getting the ballot filled out and their government check in their hands. It's not going to encourage or require anyone to actually learn anything about the people or referendum or whatever that they are voting for. Instead of small groups of ignorant people voting, you'll have ignorance en masse. While it's true more people may be voting, I don't see how this improves the state overall. Perhaps RAV might explain?
RageAgainstVoid wrote: I think we can agree that it works truest to its sense when there is as good a voter turnout as possible to legitimate the government.
Half + Seven wrote:But that is not the case, we don't all agree...I think it is far too grand an assumption to say high turnout is a necessarily good thing.
Half + Seven wrote:High turnout lead to the wrong result.
Half + Seven wrote:Therefore it's an overly complex way to solve a "problem" I don't think exists.
Half + Seven wrote:You assume we all agree, we do not. The rest is unnecessary.
Half + Seven wrote:artificially
Half + Seven wrote:(hence the complex comment).
Half + Seven wrote:they're are much easier ways to do it. You could just require people to vote, like in France as previously mentioned.
RageAgainstVoid wrote:I already showed that you disagree on something I haven't said
RageAgainstVoid wrote:I think we can agree that it works truest to its sense when there is as good a voter turnout as possible to legitimate the government.
Half + Seven wrote:I won't bother with my opinions any further.
Half + Seven wrote:If all you want
Half + Seven wrote:one of the worst I could imagine
Kaz wrote:
GraveI wrote:One interesting thing I did come across when I was looking up the info on invalid votes (for hard numbers I referenced the IPU databases found at http://www.ipu.org), is that France, a country with mandatory voting, still only had 60% voter turnout in relation to total able-voter populations, very similar to Canada's. So, if voting is mandatory, why is their turnout just as abysmally low as ours?
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Everyone assumed Chewbacca wore that bandolier because it was full of ammo, but it turns out it might have been due to personal space issues. At least if his bandolier worked like Zac Ong's creation which creates a laser perimeter letting people know when they're too close.
On the wearer's left shoulder is a spinning laser that creates a visible 360 degree personal zone that other people should stay clear of. But if they dare to invade that private space, an infrared sensor located on the chest detects their presence and activates blinking LEDs, and random spinning contraptions, that reflect the wearer's increasing anxiety the closer someone gets.
So while the device doesn't actually do anything to stop someone from invading another's personal space, it does provide ample warning that the wearer has become uncomfortable, which isn't always easy for them to convey. And if the wearer happens to be a Wookiee, it's a good indicator that if you approach too close, you're likely to get your arms torn off. [Zac Creation via PSFK]


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South Sudan: Tens of thousands continue to suffer the effects of violence
GENEVA, Switzerland, April 5, 2013/African Press Organization (APO)/ -- Violence has forced thousands of people to abandon their homes in several remote areas over the past few months. The ICRC has recently provided them with vital aid. In Jonglei state, it has distributed fishing tackle to 12,000 needy residents and displaced people.
In some of South Sudan's remotest areas, such as Jonglei, in the eastern part of the country, Malakal, Manyo and Renk counties in Upper Nile State and Jaac in Northern Bahr El Ghazal State, in the north, violence has forced entire communities to abandon their homes and belongings, and prevented them from carrying out the activities they need to survive.
"The upheaval this causes for the people displaced and for the communities that host them is massive," said Melker Mabeck, head of the ICRC's delegation in South Sudan. "Finding clean water, a meal or shelter becomes extremely difficult in places where basic resources are already very scarce in normal times."
In Jonglei, the ICRC has distributed fishing tackle to help 12,000 needy residents and displaced people in and around Pibor and Gumuruk, the two main towns in Pibor county. A combination of heavy seasonal flooding and armed violence has taken its toll on these communities, for whom river and pond fishing is an important source of food. "Access to land has been severely affected, while food prices have shot up, making it difficult for people to buy what they need to survive," explained Mr Mabeck.
The fishing equipment is lightweight and portable, meaning it can be easily carried if people need to move for their own security, which many have been obliged to do in the recent past.
ICRC water engineers have repaired four broken water hand pumps in Pibor town, where an ICRC surgical team has been stationed for more than 3 weeks to treat those wounded in clashes in the surrounding area.
Food and water shortages in other areas
Poor harvests, food shortages and the lack of security have plagued the lives of many communities in other parts of South Sudan. On the west bank of the Nile north of Malakal, accessible mainly by boat, the ICRC is currently distributing aid to approximately 25,000 people. The support, which varies from family to family, includes food, farming tools, seed, fishing kits and household items. "The support we are providing farmers comes just before the rainy season, which is when crops are sown," said Ana Gerlin Hernandez, the ICRC's relief coordinator.
Sporadic bouts of armed violence over the last 12 months in and around Aweil North county, in Northern Bahr-El-Ghazal, have caused thousands to flee their homes in three successive waves, the latest being in December 2012. Many people have reached Jaac, also in Aweil North, putting strain on the town's drinking water supply and creating a degree of tension between the displaced people and their host community. The ICRC has repaired 23 hand pumps in or near the town since the start of 2013 to boost supplies of clean water.
A new field presence close to the northern border
Last month, the ICRC opened a new sub-delegation in the city of Bentiu, close to South Sudan's northern border, from where it will address the humanitarian needs of communities throughout volatile Unity state. The ICRC is repairing water hand pumps throughout the rural county of Pariang. "In remote areas like Pariang, a broken hand pump can mean adding an extra hour or two onto the daily walk to collect water," said Marc Suchet, the ICRC's water and habitat coordinator.
Since opening the sub-delegation, the ICRC has also visited people detained in Bentiu prison. In South Sudan, the ICRC visits detainees in many places to monitor the conditions in which they are held and the treatment they receive, and to support the authorities in their efforts to adhere to international standards. The ICRC provides the detaining authorities with supplies to help them implement its confidential recommendations.


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Teacher resources and professional development across the curriculum
Teacher professional development and classroom resources across the curriculum
Elizabeth Bishop
Ezra Pound
Although admired for his contribution to poetry — among other things, he founded the imagist movement — Ezra Pound was also considered a controversial figure for his erratic personality and the political views he expressed during World War II. Pound saw the poet as a "guide and lamp of civilization," and into his best-known work, the 800-page Cantos, he poured his knowledge of philosophy, economics, art, and history. However divided his critics, Pound's bold theories and poetic experiments set the standards of modernism.
Hear Pound's own inimitable reading of "Canto I," read other Pound poems, and find a brief Pound biography and a list of other helpful Pound links.
A haunting photograph of Pound in his later years greets you on Michael Eiichi Hishikawa's Pound page. Hishikawa, an associate professor of American Literature, also presents a biography and an extensive bibliography of Pound criticism.
Beinecke Rare Book & Manuscript Library of Yale University
T. S. Eliot called Pound "the inventor of Chinese poetry for our time." Explore how Pound and other American writers were influenced by Far East art and literature at the online version of "Petals on a Wet Black Bough: American Modernist Writers and the Orient," presented by the Beinecke Rare Book & Manuscript Library of Yale University.
SUNY-Buffalo, Electronic Poetry Center
Pound's works and politics are fervently discussed at the State University of New York at Buffalo's Electronic Poetry Center.
Did Pound contribute to the end of the Gutenberg era? Read Edwin J. Barton's revealing article on Pound's nine-year correspondence with Marshall McLuhan in the premiere issue of the University of Toronto's McLuhan Studies.
© Annenberg Foundation 2017. All rights reserved. Legal Policy


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WSJ's Joanna Stern "bumps into" Sebastian Thrun, the CEO and co-founder of flying-car company Kitty Hawk. The two discuss Thrun's ambitions to take flying cars mainstream in the next decade and why it's so important that these machines are quiet and easy to fly. Photo: Andria Chamberlin for The Wall Street Journal
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Clewell was made in limited quantities by Charles Walter Clewell of Canton, Ohio, from 1902 to 1955. Pottery was covered with a thin coating of bronze, then treated to make the bronze turn different colors. Pieces covered with copper, brass, or silver were also made. Mr. Clewell developed a blue-green bronze finish in 1923. Clewell's secret formula for blue patinated bronze was burned when he died in 1965.
Enter your email below to receive Kovels Komments for the latest antiques & collectibles news, answers to readers questions, marks and tips. In your inbox every Wednesday.
Current & Past Issues
Buyer's Price Guide
Words of Wisdom (Letter to Lee)


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Online Member Application (pay by credit card)
Mail in Member Application (pay by check)
Members have free and unlimited e-mail access to hundreds of colleagues for referrals, announcements of workshops and classes, office space inquiries, job openings, and active discussions relevant to our profession.
Potential clients have immediate on line access to your professional listing. You can include a link to your personal website where you can provide expanded information about your practice, your training, your specializations and other information which will attract new clients. All listings can be searched by name, location, specialization, insurance, and group offerings.
Members can visit the SBCAMFT website to review back issues of the chapter newsletter for articles, updates on upcoming events, internship and job listings and articles of professional interest.
Attend monthly luncheons (except July and August) and hear informative presentations which provide CEUs. Attend a low cost Law & Ethics workshop presented by a CAMFT staff attorney. Members have the opportunity themselves to present a luncheon talk to their colleagues on a topic in your area of expertise. Join the SBCAMFT Board of Directors or serve on a working board committee.
The chapter provides several annual informal social mixers to meet and get to know your professional colleagues.
Clinical Membership - $75.00
- Shall hold a license as a marriage and family therapist issued by the Board of Behavioral Sciences for the State of California.
- Shall be a member in good standing of CAMFT.
Intern/Prelicensed - $35.00
- Shall have completed all educational requirements for licensure and shall be engaged in the process of gaining hours of experience either as a registered intern, applicant or in some other lawful capacity.
- Shall be eligible to vote only for the director at large who is elected from and by the pre licensed and student membership.
Student - $25.00
- Shall be enrolled in a master's or doctorate program satisfying the educational requirements for eligibility to sit for the licensed marriage and family therapist examination.
- Shall no longer be eligible for Student/Pre-intern membership upon the expiration of 90 days from graduation.
Associate - $75.00
- Shall be in a profession related to marriage and family therapy, whose practitioners are licensed, certified or registered pursuant to California law, or who are specifically exempt from licensure or certification, who shall not hold a marriage and family therapist license.
- Or a California licensed marriage and family therapist who is a resident and domiciliary of a state other then California.
- Or a resident and domiciliary of a state or jurisdiction other then California who lawfully practices marriage and family therapy.
- Shall not be eligible to vote or hold office, but shall be entitled to all other rights and privileges of membership.
Affiliate - $75.00
- Shall be in a profession not related to marriage and family therapy, whose practitioners or licensed, certified or registered pursuant to California law, or who are specifically exempt from licensure.
- Shall not be eligible to vote or to hold office.
- Shall be entitled to all other rights and privileges of association membership.
- Shall not be required to be a member in good standing of CAMFT.
Chapter Dues
Chapter membership payments are due on or before January 1 of each calendar year.
Click here for the Online Application
Alternative mail-in applicationIf you do not wish to apply online a PDF version of the Membership Application (156KB) can be downloaded here. You will need Adobe Acrobat Reader to view this file. It can be downloaded free. Print out the membership application, fill it out, sign it, and mail it in with your check.
Important Note:The Santa Barbara Chapter of CAMFT and state CAMFT are two related, but separate organizations. Before you can join the Santa Barbara Chapter, you must become a member of state CAMFT, except for certain membership categories noted below. A separate application and fee is required for each organization.
Click HERE for the Statewide CAMFT Website.


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The EAI Gold Medal Premium sprocket is different. Most fixed sprockets are designed with bevelled teeth- slants designed to counteract imperfections in chain tension and/or chainline. However, these often make for a noisy transmission until they bed in.
The Gold Medal Premium with its laser cut graphics and presentation wallet could easily be dismissed as little more than bicycle jewellery particularly that gold colour. Well, "that gold colour" is in fact a layer of titanium nitride which is claimed to reduce friction so it as much for durability as decoration although the latter can't hurt.
Titanium nitride is far harder than steel and that's the point of it the late, great, Sheldon Brown reckoned it worked we given it our best efforts and so far failed to put a mark on it.
Closer inspection of the sprocket reveals a unique curve at the end of every tooth, designed to ensure smooth and silent chain feed over the sprocket without the noisy, running in period. Essentially the teeth have been profiled into a 'worn' shape so you get an instantly run in feel. Because the sprocket is so hard it shouldn't wear anymore.
Threaded on the hub, even teamed with a modest chain the transmission becomes super slick and serenely quiet. Nine months continual exposure to the elements on wet, dung strewn lanes without so much as a cursory wipe-over have failed to make the slightest impression on either finish or tooth profile.
However, for many, this will be a hard price to justify, especially given the less ritzy, (but still fairly ritzy), EAI Superstar finished in mirror polished stainless steel costs around half the price and performs in an almost identical fashion. Inch and an eighth sizing might also deter some, but discerning track riders or high end mile eating road fixers would be hard pressed to find a better looking, smoother or more durable sprocket. If you've got to have the best at any price, this is it.
One last thing to bear in mind, given their price the Superstars are not a standard stock item for Hubjub, the UK importers, they will custom order them. Mind you, if you're prepared to pay £59 for a sprocket you're probably prepared to wait a bit too.
Sizes 14-18 teeth
If you're thinking of buying this product using a cashback deal why not use the road.cc Top Cashback page and get some top cashback while helping to support your favourite independent cycling website


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The United Nations will provide a loan of $1.15 million to the Cambodian side of the beleaguered Khmer Rouge tribunal.
Britain's Andrew Cayley issued a statement Monday that he was stepping down as co-international prosecutor due to personal reasons
Cambodian staff have not been paid on their half of the court since May, prompting a walkout of staff this week.
Cambodian staff, including judges, have not been paid since May, court officials said.
Nearly 200 of the 250 staff members did not show up for work Monday in Phnom Penh to protest several months of unpaid wages.
Around 100 staff members at Cambodia's cash-strapped war crimes court will begin an open-ended strike Sunday because they have not received their salaries since May.
Cambodian staff at the U.N.-backed Khmer Rouge war crimes tribunal are threatening to go on strike over unpaid wages.
Reality program reunites families torn apart by genocide, political strife of regime that collapsed more than three decades ago.
Kem Sokha, who is the vice president of the Cambodia National Rescue Party, says the allegations have been trumped up by the ruling party in order to discredit the opposition ahead of July 28 national elections.
Sou Met, who commanded the Khmer Rouge air force, was accused of major atrocity crimes as a ranking member of the regime.
Court observers say they are skeptical of a court that has seen routine delays and completed just one trial since 2006.
Phnom Penh Municipal Court has opened a hearing against senior opposition official Kem Sokha, who is being sued by a Khmer Rouge survivor for allegedly denying atrocities committed by the regime.
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Earthborn Claypaint
2.5L (approx)
- Interior Paint
- Highly Breathable
- Hard Wearing
- Ultra-Matt Finish
- Virtually VOC Free
- Available in 72 Colours
- Covers approx 8m² per litre
- Drying time 6-12 hours
Product Details
An exciting clay-based emulsion that has a distinctive, ultra matt finish that softens and enhances the light in your room while its contemporary colours tempt the senses.
Deliciously thick and creamy, it goes on like a dream and often requires fewer coats than conventional emulsions. All this and no horrible smells or emissions.
Apply with a brush or roller, but we think a short pile roller gives the best results. Then simply wash your tools in water.
Important! Remove any existing paint before applying Earthborn Claypaint.
Frequently Asked Questions
How long does Claypaint take to dry?
The typical drying time is between 6-12 hours.
How much Claypaint will I need?
Claypaint covers approximately 8m² per litre although actual coverage will depend upon absorbency of the surface and method of application. Remember, this paint often requires one less coat than you expect as it is thick and creamy, covering extremely well.
Can I use Claypaint on lime plaster?
Yes, it is a highly breathable paint and is suitable for lime plaster. If you're painting onto fresh lime plaster you'll get best results diluting the first coat with 20% water.
Can I use Claypaint on exposed brick or masonry?
Yes, Claypaint can be used on most internal surfaces, it can also be applied to relatively damp surfaces.
Can I paint straight over existing paint?
No. Conventional paints are non-breathable and contain ingredients that seal the surface. This will prevent Claypaint forming a natural bond with the surface. It negates the breathabile properties of the paint which is likely to flake and blow off later.
Do I need a primer?
If you're painting onto a very absorbant surface then a priming coat of Claypaint diluted with 20% water is recommended. When the priming coat is dry, the following coat would be applied undiluted.
Delivery £6.95 + VAT
Delivery Price is for Mainland UK Only
Deliver Elsewhere? Get a Price, Get Quoted
Availability: In Stock
CupcakeColours will vary on different devices
Change Mix
Orders over 100kg may take longer


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New York – NY-02
Peter King
Tell Peter King: do your constitutional duty by supporting the House's impeachment inquiry into President Trump and voting in favor of impeachment.
It's important that your representative knows you support the impeachment inquiry into President Trump. Messages from constituents like you can make a huge impact in this moment — can you take a minute to urge them to do their constitutional duty and vote YES on impeachment?
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Game Leaders
Team Stats
Passing Yards
Rushing Yards
Time of Poss.
The Illinois College football team posted the first win over Cornell College in school history on Saturday thanks to big performances from Kevin Wallace, Davis Kinville and Kurt Frischman. The Blueboys beat the Rams 50-28.
Wallace caught nine passes for 183 yards and a touchdown, Kinville ran for three scores and Frischman tallied seven tackles, two sacks, two pass break-ups and a forced fumble in the Blueboys' first-ever win over Cornell. IC entered Saturday's game 0-15 against the Rams, who rejoined the Midwest Conference prior to the 2012 season.
"The kids played a full 60 minutes. Cornell is an excellent team with an explosive offense and our kids stepped up to the challenge today," said Illinois College head football coach Garrett Campbell. "I thought our seniors stepped up and played as seniors should, setting a good example of how to take control of a game."
Cornell kept things close early on and held three separate leads early in the game. The visitors got on the scoreboard first with a 13-yard touchdown pass from Juan Flores to Brit Connor before Cecil Brimmage scored on a 27-yard run for the Blueboys. Flores then found Justin Cox on a 17-yard touchdown pass to put Cornell back ahead, but Michael Bates hit Kevin Fuller on a 29-yard touchdown strike to put the Blueboys back ahead. Flores and Cox hooked up on a 40-yard touchdown pass to give Cornell its final lead just moments later, before IC took a nine-point lead into halftime thanks to a 30-yard touchdown pass from Bates to Wallace and a 12-yard Kinville touchdown run.
Cornell's Preston Ritchie made it a one-point game in the third quarter when he scored on a 1-yard plunge, but back-to-back 2-yard touchdown runs from Kinville gave the Blueboys' a 15-point cushion. Brimmage's second touchdown run of the day, a 2-yard scoring run, provided the Blueboys' final points.
IC outgained Cornell in total yards, 475 to 401, despite running six fewer plays. Bates completed 18-of-29 passes for 334 yards and two touchdowns with one interception. Kevin Fuller caught four passes for 90 yards, while Colin Duling made two catches for 45 yards. Brimmage ran for 76 yards, while Kinville and Dakota Lammy added 24 yards each.
Mike Ranos made a team-high 15 tackles for the Blueboys. Joe Gaines and Tim Denney added eight and nine tackles, respectively. Zack Hanlon, Marvell White and Ross Barker all grabbed interceptions. Frischman and Willie Barefield III forced fumbles. Zack Meyer recovered a fumble.
IC improved to 8-1 overall and 7-1 in Midwest Conference play with the win. The Blueboys host Carroll University next Saturday at 1 p.m. in both teams' regular-season finale.


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ALL IS LOST 4 stars. Robert Redford delivers the performance of his career in J.C. Chandor�s majestic, melancholy film about a solo mariner, stranded on his sailboat in the Indian Ocean. 1 hr. 46 PG-13 (profanity, adult themes) � Steven Rea
AMERICAN HUSTLE 4 stars. David O. Russell�s wild, woolly take on the late-�70s FBI sting operation, Abscam, is also a wild, woolly love story: Christian Bale and Amy Adams as con artists recruited by the feds, and fated for each other. Throw Bradley Cooper and Jennifer Lawrence into the mix and something goes kaboom in just about every scene � brilliantly. 2 hrs. 18 R (sex, nudity, profanity, drugs, violence, adult themes) � Steven Rea
ANCHORMAN 2: THE LEGEND CONTINUES 3 stars. Solid sequel to the 2004 smart dumb comedy starring Will Ferrell as a well-coifed TV news reader with delusions of, well, everything. Paul Rudd, David Koechner, Steve Carell, and Christina Applegate return, with Meagan Good as the oblivious news team�s new boss � working for the first 24-hour cable news network. It�s 1980. Do you know where your hair is? 1 hr. 59 PG-13 (sex, profanity, drugs, comic violence, adult themes) � Steven Rea
THE ARMSTRONG LIE 3 stars. A story of epic betrayal and deception � and self-betrayal, self-deception, as Oscar-winning documentarian Alex Gibney tags along with Lance Armstrong on his 2009 Tour de France comeback. And then chases the cycling superstar down again, once all the doping allegations he had long denied turn out to be true. 2 hrs. 02 R (profanity, drugs, adult themes) � Steven Rea
AUGUST: OSAGE COUNTY 2 1/2 stars. A piled-high platter of histrionics, this heartland saga � adapted from Tracy Letts' Pulitzer- and Tony-winning play � is steeped in a grand American theater tradition: the dysfunctional family drama, full of dark secrets, darker resentments, and the darkest sense of dread. Tennessee Williams, Eugene O'Neill, Edward Albee � you get the drift. With Meryl Streep, Julia Roberts leading the parade. 2 hrs. 01 R (profanity, drugs, sex, adult themes) � Steven Rea
BLUE IS THE WARMEST COLOR 4 stars. Yes, there is a lot of sex. Graphic sex between two young women. But that�s only part of what this extraordinary film is about. This three-hour portrait of a French high school student (an amazing Ad�le Exarchopoulos) is shot with a close-up intensity that brings the character out from the screen and into your heart. It�s emotional 3-D! 2 hrs. 59 NC-17 (graphic sex, nudity, profanity, adult themes) � Steven Rea
BLUE JASMINE 3 stars. Cate Blanchett storms her way through the title role of Woody Allen�s pastiche-y melodrama, about a fallen socialite seeking refuge in her sister�s San Francisco flat. Lifted in chunks from �A Streetcar Named Desire, and offering wincing blue-collar-type caricatures, the film is nonetheless a wonder � thanks to its star. With Alec Baldwin, Sally Hawkins, and Bobby Cannavale, looking on in awe. 1 hr. 38 PG-13 (adult themes) � �S.R.
THE BOOK THIEF 2 1/2 stars. World War II melodrama about a German girl who learns to treasure words through her friendship with a Jewish refugee hiding in the basement. Adapted from the bestselling young adult novel, and compromised by production design that is too beautiful by half � the Holocaust has never looked so good. With Sophie N�lisse in the title role, and Geoffrey Rush and Emily Watson as the foster parents she comes to love. 2 hrs. 11 PG-13 (violence, adult themes) � Steven Rea
THE BROKEN CIRCLE BREAKDOWN 3 1/2 stars. The Belgian entry in the Academy Awards foreign language competition offers a time-hopping portrait of a couple�s romance and relationship. He�s a hipster bluegrass-obsessed musician, she�s a tattoo artist, and together they make music, literally � and then make a child. A child who, at 6, is diagnosed with cancer. A surprisingly moving, and musical, film. 1 hr. 51 R (sex, nudity, profanity, adult themes) � Steven Rea
CAPTAIN PHILLIPS 4 stars. Based on the real-life story of a U.S.-flagged cargo ship hijacked by Somali pirates, with Tom Hanks in the title role as a steady-as-she-goes veteran forced to face his own mortality. Paul Greengrass (the second and third �Bourne� films, �United 93�) masterfully orchestrates the intense, suspenseful drama. 2 hrs. 14 PG-13 (violence, profanity, adult themes) � Steven Rea
DALLAS BUYERS CLUB 3 1/2 stars. The �inspired by true events� tale of a party-hardy Texas cowboy and self-employed electrician who, in 1985, contracted the AIDS virus. Matthew McConaughey gives a literally transformative performance as this homophobic hellraiser, who won�t accept the doctors� diagnosis that he has 30 days to live. He proves them wrong, becoming a cash-rich drug dispenser and patients� rights advocate in the process, in this wild, colorful, compassionate film. 1 hr. 57 R (sex, nudity, drugs, profanity, violence, adult themes) � Steven Rea
47 RONIN 2 stars. Keanu Reeves stars in this affectless samurai epic set in 18th century Japan. Lots of visual glitter, little heart. With Ko Shibasaki, Hiroyuki Sanada, and Tadanobu Asano. 1 hr. 59 PG-13 (violence, adult themes) � David Hiltbrand.
FROZEN 3 stars. A plucky princess (voiced by Kristen Bell) is joined by a slapstick snowman (Josh Gad) in a delightful animated film that is part fairy-tale, part farce. 1 hr. 48 PG (fright) � David Hiltbrand
GRAVITY 4 stars. A transcendent, zero-G tale of survival, with Sandra Bullock and George Clooney as orbiting astronauts caught in a debris storm � quite literally at the end of their tether. A technological marvel, and an emotional, spiritual and physical voyage of stratospheric suspense. 1 hr. 30 PG-13 (violence, profanity, adult themes) � Steven Rea
GRUDGE MATCH 2 stars. Robert DeNiro and Sylvester Stallone play a pair of far-past-their-prime boxers who decide to get in the ring one more time. If they can climb through the ropes. The film, which tries to wrap comedy around a gooey sentimental center also stars Kevin Hart, Kim Basinger and Jon Bernthal. 1 hr. 53 PG-13 (violence, adult themes, profanity) � David Hiltbrand
THE HOBBIT: THE DESOLATION OF SMAUG 2 1/2 stars. Eight minutes shorter than its forebear, and at least eight minutes better � less twee, less chatty, more action, more Elvish. The second installment in Peter Jackson's overblown three-part take on Tolkien's children's fantasy, about Bilbo Baggins and his epic quest in the company of a troop of dwarves. Elves and orcs and giant spiders, oh my! Not to mention the titular fire-breathing dragon, voiced � in echo-chamber-style � by Benedict Cumberbatch. 2 hrs. 41 PG-13 (intense action, violence, adult themes) � Steven Rea
THE HUNGER GAMES: CATCHING FIRE 3 stars. Bigger, better, and broodier, with Jennifer Lawrence back again, causing no end of trouble as the Districts� rabble smell rebellion in the air, and the Panem puppetmasters try to quash it. An Occupiers� parable about class warfare? A metaphor for teen defiance? Or just a kooky story of survival in a controlled environment where, sadly, most of the contestants must die? However you read it, this franchise rocks. 2 hrs. 26 PG-13 (violence, dystopian bleakness, adult themes) � Steven Rea
INSIDE LLEWYN DAVIS 4 stars. Oscar Isaac is a hard-luck troubadour on the folk scene of early �60s Greenwich Village in the Coen brothers� sublime time-capsule odyssey to nowhere and back again. It�s a story of artistic struggle, of dumb luck and bad luck, and of the crushing beauty that can be wrested from a song. With Carey Mulligan, Justin Timberlake and John Goodman � and with many a dark laugh along the way. 1 hr. 45 R (profanity, violence, drugs, adult themes) � Steven Rea
LONE SURVIVOR 3 stars. Mark Wahlberg stars in this full-force combat film, based on the true story of four Navy SEALS on a botched mission in 2005 Afghanistan. Harrowing, visceral. With Ben Foster, Emile Hirsch, and Taylor Kitsch. 2 hrs. 01 R (extreme violence, profanity, adult themes) � Steven Rea
MANDELA: LONG WALK TO FREEDOM 3 stars. A conventional biopic made anything but conventional by the magnitude of its subject�s life and accomplishments, and by Idris Elba�s imposing performance in the title role. 2 hrs. 19 PG-13 (violence, nudity, profanity, adult themes) � Steven Rea
NEBRASKA 4 stars. Bruce Dern in a career-defining performance as an ornery coot who believes he�s won a $1 million prize, and heads from Montana to Nebraska to claim it. His son (Will Forte) reluctantly tags along, in Alexander Payne�s funny, sad, poignant, absurd road movie. In black and white. It�s a gem. 1 hr. 55 R (profanity, violence, adult themes) � Steven Rea
OUT OF THE FURNACE 3 stars. Casey Affleck and Christian Bale are brothers facing hard times, and hard choices, in this gripping Rust Belt noir. A solemn, blood-soaked drama about broken dreams. Cue the Springsteen. 1 hr. 56R (violence, profanity, drugs, adult themes) � Steven Rea
PHILOMENA 3 1/2 stars. A surprisingly tough and tender tale from director Stephen Frears, adapted from the true story of a 70-something Irish woman (Judi Dench) looking to find the son she was forced to give up for adoption when she was an unwed teen, and of the cynical veteran journalist (Steve Coogan) who tags along on her quest. 2 hrs. 02 R (profanity, adult themes) � Steven Rea
SAVING MR. BANKS 3 stars. A sweet and affecting piece of Hollywood history, about a battle of wills between Walt Disney and �Mary Poppins� author P.L. Travers. Disney, played by Tom Hanks, is eager to adapt the book, and Travers, beautifully brought to life by Emma Thompson, resists. And resists some more. 2 hrs. 05 PG-13 (adult themes) � Steven Rea
THE SECRET LIFE OF WALTER MITTY 3 stars. Ben Stiller stars in, and directs, this adaptation of the James Thurber story, about a mild-mannered man whose dreamlife gets the better of him. Almost magical comic fun, with Kristen Wiig as the coworker he admires from afar, and Adam Scott as the glib new boss who�s about to fire them. A story about taking the leap, getting out of your comfort zone. Unfortunately, the movie doesn�t quite do that itself � by the end it�s lost some pop, some surprise. 1 hr. 54 PG-13 (violence, profanity, adult themes) � Steven Rea
THE TRIALS OF MUHAMMAD ALI 4 stars. With splendid detail and focus, this documentary examines the momentous forces that led Ali, then heavyweight champion of the world, to refuse service in the Army during the war in Vietnam. 1 hr. 30 No MPAA rating � David Hiltbrand
12 YEARS A SLAVE 4 stars. The remarkable, essential story of Solomon Northup, a free black man who was abducted and sold into slavery in the pre-Civil War South. The British actor Chiwetel Ejiofor gives body and soul in the lead, and Michael Fassbender, Benedict Cumberbatch, Paul Giamatti, Paul Dano and Brad Pitt are part of a superb supporting cast. 2 hrs. 13 R (violence, nudity, profanity, adult themes) � Steven Rea
TWICE BORN 1 1/2 stars. Penelope Cruz and Emile Hirsch play star-crossed lovers in Saravejo in the years leading up to the Bosnian War. What begins as a bright romance turns into a maudlin, improbable melodrama. Partially subtitled. 2 hrs. 10 R (nudity, violence, adult situations, profanity) � David Hiltbrand
TYLER PERRY�S A MADEA CHRISTMAS 1 1/2 stars. A culture-clash comedy from the prolific Perry. This time Madea finds herself in rural redneck country to celebrate the holidays. 1 hr. 45 PG-13 (adult themes, crude humor, sexual innuendos) � Tirdad Derakhshani
WALKING WITH DINOSAURS 2 1/2 stars. Animated family feature about an underdog dinosaur. 1 hr. 27 PG (some intense creature action, mild rude humor) � Tirdad Derakhshani
THE WOLF OF WALL STREET 2 1/2 stars. As thrilling a filmmaker as Martin Scorsese continues to be, and as wild a performance as Leonardo DiCaprio dishes up as its morally bankrupt antihero, this adaptation of Jordan Belfort�s bestselling memoir � a story of stockbroker rapacity in the anything goes �90s � seems almost entirely unnecessary. Cocaine and hookers? Fast cars and fancy yachts? Trophy wives and pesky Feds? For three hours? Really? 3 hrs. R (sex, nudity, profanity, drugs, violence, adult themes) � Steven Rea


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Legendary actor Tony Curtis, the son of a Bronx tailor who went on to star in such classics as "The Defiant Ones," "Some Like it Hot" and "Spartacus," died late Wednesday after going into cardiac arrest in his Las Vegas home. He was 85.
The father of actress Jamie Lee Curtis, he was a classically handsome actor with a range that allowed him to play comedic or dark roles. He was nominated for an Oscar for playing an escaped convict in the 1958 "The Defiant Ones," and starred opposite Jack Lemmon and Marilyn Monroe in the 1960 film "Some Like it Hot." Later in the decade, he gained weight to take on the role of a killer in "The Boston Strangler."
"My father leaves behind a legacy of great performances in movies and in his paintings and assemblages," Jamie Lee Curtis said in a statement. "He leaves behind children and their families who loved him and respected him and a wife and in laws who were devoted to him. He also leaves behind fans all over the world. He will be greatly missed."
Born Bernard Schwartz to Hungarian Jewish parents, Curtis took up acting after serving in the Navy during World War II. In the late 1940s, he studied acting at the Dramatic Workshop of the New School in New York, where fellow students included Walter Matthau and Rod Steiger. He went to Hollywood at age 23 and promptly changed his name.
Roger Moore, who starred with Curtis as a pair of international playboys in the early 1970s TV show "The Persuaders," recalled Curtis as a jokester and a talented actor.
"He was great fun to work with, a great sense of humor and wonderful ad libs," Moore told the BBC. "We had the best of times."
Film and television work came slowly for Curtis in the 1970s and beyond. After recovering from addiction in the early 1980s, he later became a painter whose canvasses sold for as much as $20,000.
In his 2008 autobiography, "American Prince: A Memoir," Curtis wrote of a brief fling with Marilyn Monroe and their later reunion in the gender-bending comedy "Some Like it Hot." He also set the record straight about a flip and misunderstood answer he gave when someone on the set asked him about kissing the sexy screen siren.
"After the scene on the yacht, some of the crew and I stood around to watch the rushes, and afterwards they wanted to know what it was like to kiss her. I figured a question that stupid deserved a stupid answer, so I flippantly responded by saying, 'Kissing Marilyn is like kissing Hitler,'" Curtis wrote.
"[My] thoughtless comment became public knowledge, and the story still makes the rounds. So let me set the record straight once and for all: I hated Hitler. As a Jewish kid in New York, I threw condom bombs on pro-Nazi parades. I loved Marilyn Monroe. And she was a terrific kisser."
Curtis' final screen role came in 2008 in the independent film "David & Fatima," about a romance between an Israeli Jew and a Palestinian Muslim. Curtis' character was named Mr. Schwartz.
Curtis married six times. His first wife was actress Janet Leigh, who starred in "Psycho," "Touch of Evil," and "The Manchurian Candidate." The couple was married from 1951-62 and had two daughters, Jamie Lee and Kelly Curtis.
He is survived by his wife, Jill Vandenberg Curtis, and six children.
Selected Reading: Entertainment Tonight, IMDb, The New York Times.


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McGaughys Suspension Parts
When it comes to the evolution of the family run business McGaughys Suspension Parts, "right from the start" is an expression that not only describes the early days, but pinpoints a philosophy that has been important to the company surviving long enough to celebrate a quarter century of success in 2009.
Since 1984, when Mike McGaughy first opened his doors, a key principle was to do as much manufacturing in-house as possible to provide a level of quality control that is second to none. Some 25 years later, McGaughys still manufactures their drop spindles completely in-house with the exception of the foundry work, which is done in Los Angeles or locally, in Fresno.
The first step of McGaughys Classic Drop spindle manufacturing process begins when McGaughys loads up molds patterned to McGaughys exclusive design and ships them to the foundry where the molds are poured with special high-grade cast iron. As soon as the rough castings cool they are loaded back onto a truck and returned with the molds to McGaughys' Fresno, California, location. While the rough cast-iron spindles are loaded onto a Makino or Nigata CNC horizontal machining center and numerous drilling and precision surfacing operations take place the spindle spuds are manufactured from 4140 chrome-moly on McGaughys Nakamura or Mori Seiki CNC turning center. Vertical machining operations are handled by a Supermax CNC vertical machining center.
One of the things that can really take the fun out of working on a classic truck is trying to mate up different brand components that don't match, or worse yet, will not bolt directly onto a factory part without modification. The ability for the average guy in his garage to be able to do a spindle and brake swap without having to waste time and effort was another important issue McGaughys addressed by filling their shop up with state-of-the-art machinery. Fitment issues are solved thanks to a Mitsubishi CNC laser cutter. Surgical quality cuts are performed adhering to blueprints developed in McGaughys engineering department. After thorough prototype testing has been completed the product moves into production, and then packaged and warehoused by McGaughys where it will remain until it is ordered by calling (559) 226-8196.


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Visionjohn_9 needed a new web page design and created a contest on 99designs.
A winner was selected from 154 designs submitted by 37 freelance designers.
Thomas Emry Homes
2 Pages... We are a new home builder and renovation company targeting the brand conscious, upper middle-class, growing family (in-law suites). Baby boomers will be moving in with their children as they get older and housing design is changing to satisfy this need.
We are a start up company so we have not developed anything yet. We are working on funding and we will need to submit our branding to the investors. ***USE of a CINEMAGRAPH would be a huge selling point if possible. ***Parallax Scrolling would be awesome if possible.
Key Words: Love/Family/Timeless/Design/Develop/Foundation/Community/ Personal/
Natural colors/greys/browns/whites/slate blues. Clean/Crisp/Open. Not too contemporary. The new craftsman style home with an open floor plan is really popular now. We are targeting upper middle class families. $375k and above home buyers. An example below of a home(not web site) that we like. 24 photos of colors and the style of future projects we hope to develop.
Maybe focus more on interior illustrations because that is where people spend a majority of their time. Ex: Open floor plan visual.
Also, we are focusing on in-law suites with the growing baby boomer generation.
After this constest we will be needing more pages to link up the floor plans, renovations, etc. so the winner will have repeat business.
HOMEPAGE: Our contact info.
MARKETS: Williamsburg/New Kent/Richmond, VA
We want the customer to know we build based on their growing family and that we specialize in In-Law Suites. HOW IT WORKS illustration section. Bring us their floor plan or choose one of ours. Floor plans can then be modified to suite their needs. Materials can be enhanced to give them that one of a kind livable masterpiece. Finally their Dream Home is complete. FLOOR PLAN SECTION- 4 of them. TIPS FOR SUCCESS section which helps to navigate the developmental process. MEET OUR CRAFTSMAN section- with words of encouragement to make it a more personalized experience. Youtube Video section.
2nd page: Place for their contact info to be inputted to be contacted. FAQ section. COLOR RULES FOR COORDINATION section. RENOVATION section. TIME OF BUILD ESTIMATE section.
Please no drop down menus. No Palm Trees, No
Apartment Complexes or Resort settings.
I am currently on godaddy. if that makes a difference with coding?
1. Show the mobility of our company's communication (phone/ipad/laptop) where we are easily accessible.
2. How it works section. Design/Develop/Live
3. Maybe a small photo of a grandmother with her son/daughter and their kids to show the growing family aspect of our product?


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College of Earth, Ocean, & Environment
Marine Operations is located on the harbor in the Adrian S. Hooper Building at the College of Earth, Ocean, and Environment's Hugh R. Sharp campus in Lewes.
The facility is named in honor of Adrian S. Hooper, chief executive officer of a major shipping firm who was an adviser and benefactor of the college. Mr. Hooper served as the first president of the Marine Associates, a non-profit corporation whose chartered purpose is to assist the college in developing one of the nation's leading marine programs.
The R/V Sharp serves marine scientists as a state-of-the-art platform for exploring and sampling the coastal ocean.
The R/V Joanne Daiber provides an outstanding experiential classroom for students engaged in coastal research.
The CEOE fleet includes two outboard-driven boats and the R/V Joanne Daiber.
Portable labs for oceanographic research vessels are shared through UNOLS.
Check the latest weather conditions and tide information near the Hugh R. Sharp Campus.
Take in the sights of UD's Hugh R. Sharp campus in Lewes via our live webcam!
UD's Hugh R. Sharp campus in Lewes offers a Recreational Boat Use program to eligible students and employees.
Guidance on recreational use of the CEOE waterfront including all floating docks, fixed docks, and bulkheads.
Seafloor Carbon
Environmental Justice
Coral Reef Starter Kit
Tracking ocean pollution
Advancing the understanding, stewardship, and conservation of estuarine, coastal, and ocean environments.
Discovering how geological processes have operated over various time scales to create and influence the planet's surface environments.
Providing a unique spatial perspective that seeks to explain patterns of differences and commonality across the human and natural environment.
College of Earth, Ocean, and Environment • 111 Robinson Hall • Newark, DE 19716 • USA • Phone: 302-831-8062
Geography and Spatial Sciences: 302-831-2294 • Earth Sciences: 302-831-2569 • Marine Science and Policy: 302-645-4212 • E-mail: email@example.com
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