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We sought to provide an updated systematic review and meta-analysis of studies investigating the effect of positive airway pressure (PAP) treatment for obstructive sleep apnea (OSA) on systolic and diastolic blood pressure (SBP, DBP).
Two independent investigators undertook a systematic search of the PubMed database (1980-2012) to identify randomized controlled trials comparing therapeutic PAP to sham-PAP, pill placebo, or standard care over at least one week in adult OSA patients without major comorbidities. The mean, variance, and sample size for diurnal and nocturnal SBP and DBP data were also extracted independently from each study. Random effects meta-analyses were conducted, followed by pre-specified subgroup and meta-regression analyses.
32 studies were identified, with data available from 28 studies representing n = 1,948 patients. The weighted mean difference in diurnal SBP (−2.58 mm Hg, 95% CI −3.57 to −1.59 mm Hg) and DBP (−2.01 mm Hg, 95% CI −2.84 to −1.18 mm Hg) both significantly favored PAP treatment over control arms, with similar results seen in nocturnal readings. Statistically significant reductions in BP were seen in studies whose patients were younger, sleepier, had more severe OSA, and exhibited greater PAP adherence. Meta-regression indicated that the reductions in DBP with PAP were predicted by mean baseline BP (β = −0.22, p = 0.02) and Epworth Sleepiness Scale scores (β = −0.27, p = 0.04).
PAP treatment for OSA is associated with modest but significant reductions in diurnal and nocturnal SBP and DBP. Future research should be directed towards identifying subgroups likely to reap greater treatment benefits as well as other therapeutic benefits provided by PAP therapy.
Montesi SB; Edwards BA; Malhotra A; Bakker JP. The effect of continuous positive airway pressure treatment on blood pressure: a systematic review and meta-analysis of randomized controlled trials. J Clin Sleep Med 2012;8(5):587-596.
Obstructive sleep apnea (OSA) is a disorder characterized by recurrent upper airway collapse that occurs during sleep. The repeated airway obstructions often expose sufferers to intermittent hypoxemia/hypercapnia, and in many untreated individuals the only way to reopen the airway and restore normal blood gases is to arouse from sleep. Accumulating evidence has suggested that such exposures to repetitive arousals and periods of hypoxemia are associated with important deleterious consequences such as cardiovascular disease, metabolic disorders, and impaired neurocognition.
The gold standard for treatment of moderate/severe OSA is positive airway pressure (PAP), which works by holding the airway open using a pneumatic splint. There is evidence to suggest that compliant PAP use can have beneficial effects on some of the deleterious consequences of this disorder; in terms of the cardiovascular effects of OSA, much of the existing interventional literature has focused on the role of PAP in mitigating OSA-induced hypertension. There are a number of published randomized controlled trials comparing blood pressure (BP) in patients receiving PAP versus a control arm; however, the extent to which PAP leads to alterations in BP values remains an area of debate based on evidence from single studies.
In 2007, a number of meta-analyses were published investigating the effect of PAP on BP, each adopting different study selection criteria, with conflicting results. An analysis of ten studies did not find any significant difference in either systolic or diastolic BP (SBP, DBP) between PAP and control groups when 24-h ambulatory blood pressure monitoring (ABPM) and office BP measurements were combined.1 Twenty-four hour mean arterial BP declined significantly by 1.7 mm Hg in a meta-analysis of 12 trials, and meta-regression analyses of these data found that a greater reduction in BP occurred with increasing OSA severity, greater frequency of arousals during diagnosis of OSA, and greater adherence to treatment, with no significant effect of subjective sleepiness reported at baseline.2 In the largest meta-analysis to date which included 16 studies representing 818 subjects, PAP use was associated with mean decreases in SBP of 2.5 mm Hg, DBP of 1.8 mm Hg, and mean arterial pressure of 2.2 mm Hg, all of which reached statistical significance.3 Thus, these previously published meta-analyses suggest that a small but significant reduction in SBP and DBP can result from PAP treatment, but it is unclear which patient subgroups may benefit most from treatment.
Many additional large randomized controlled trials have been published since 2007. We therefore aimed to perform an updated systematic review and meta-analysis of randomized controlled trials comparing therapeutic PAP to sham-PAP, pill placebo, or standard care over at least one week in adult OSA patients without major comorbidity. A secondary aim was to investigate the influence of treatment duration, age, daytime sleepiness, OSA severity, baseline BP, and adherence to treatment, using both subgroup analyses and meta-regression techniques.
Being a review of published literature, this investigation did not require ethical review.
The PubMed database was searched for randomized controlled trials of PAP among OSA patients using the following search string in PubMed format: (((((((((("Sleep Apnea Syndromes"[Mesh])) OR (apn*)) OR (hypopn*)) OR (sleep apn*)) OR (obstructive sleep apn*)) OR (OSA)) OR (OSAS)) OR (OSAHS)) OR (SAHS)) AND ((((((("Continuous Positive Airway Pressure"[Mesh])) OR (Continuous positive airway pressure)) OR (positive airway pressure)) OR (positive pressure)) OR (CPAP)) OR (PAP)) AND ((((("Randomized Controlled Trial"[Publication Type])) OR ("Clinical Trial"[Publication Type])) OR (randomi*)) OR (clinical trial)). The search was limited to the dates 1 January 1980 to 1 January 2012.
The reference lists of previous meta-analyses on this topic identified during the PubMed search were scanned for additional suitable studies. Any papers or peer-reviewed abstracts that were referenced in any of the identified studies (see literature exclusion criteria below) were also eligible for potential inclusion. Finally, our list of identified studies was forwarded to the first, last and/or corresponding author/s of these studies, who were asked to suggest further suitable publications if known to them.
Authors SBM and JPB independently identified and excluded all qualitative reviews, commentaries, letters, and meta-analyses from the pooled literature set. The same authors then independently applied the following exclusion criteria to the abstracts of all identified publications in the order of "PICOS" (patient/intervention/comparator/outcome/study design)4: (a) patients did not have a diagnosis of OSA made either during full polysomnography, cardiorespiratory monitoring, or oximetry; (b) patients had significant comorbidity; (c) patients were aged < 18 years; (d) the study investigated an intervention other than auto-PAP, flexible PAP, or standard continuous PAP applied at therapeutic pressure; (e) the study included a comparator other than sham-PAP, pill placebo, or standard care; (f) the study did not include office BP and/or ABPM measured at ≥ 2 time points; (g) the study was not randomized; (h) the treatment arms were < 1 week long. We anticipated that many publications would report BP as a secondary outcome measure, and therefore all studies reaching point (f) were inspected in full rather than relying on the information contained in the abstract. If any studies reported duplicate data, only the latest publication was retained. Publication in a language other than English was not grounds for exclusion. Any disagreements as to study eligibility were discussed until consensus was reached.
Data extraction was also conducted independently by authors BAE and JPB. BP data were extracted as systolic and diastolic values, measured diurnally (primary analyses) and nocturnally. When studies reported both 24-h ABPM and office BP, the ABPM data were extracted. If studies measuring 24-h ABPM did not split the data into diurnal/nocturnal, the data were classified as diurnal. Studies that measured office BP did not contribute to the nocturnal data; if office BP was measured throughout the day, morning (preferable) or midday data were extracted. If BP was measured at more than one follow-up time point, data from the final end point were extracted.
The mean difference in BP between PAP and control arms in crossover trials was calculated as [end-trial BP in PAP arm minus end-trial BP in control arm]. The mean difference in BP between PAP and control arms in parallel trials was calculated as [(end-trial BP in PAP arm minus baseline BP in PAP arm) minus (end-trial BP in control arm minus baseline BP in control arm)]. If a measure of variance (either standard deviation, standard error of the mean, or confidence interval) for the within-arm change in BP was not reported, it was calculated using standard methods for paired data assuming a correlation of r = 0.5.2,5 If any descriptive or BP data were missing or unclear, we attempted to email the first, last, and/or corresponding author and allowed up to 8 weeks response time.
Statistical analyses were conducted by author JPB using Stata Version 12 (StataCorp; TX, USA). Forest plots were produced using Review Manager (RevMan) Version 5.1 (Nordic Cochrane Center, Copenhagen, Denmark). The following Stata commands were used: metan (Version 3.04; September 2010), metaninf, metafunnel, metabias, and metareg.
It was decided a priori that due to the diverse patient characteristics and experimental protocols anticipated in the final literature set, random effects models using DerSimonian and Laird methodology5 would be applied during all meta-analyses. A random effects model assumes that the true effect size varies between studies due to clinical and methodological diversity; the alternative fixed effect model assumes that the true effect size is the same for all studies and any between-studies variance is due solely to sampling error. If there is zero heterogeneity between studies, both models will yield the same result; when heterogeneity is present the confidence interval of the summary effect will be wider with the more conservative random effects model.5
The pooled effect and 95% confidence interval (CI) for each meta-analysis was calculated using the weighted effects of contributing individual studies and summarized graphically in a forest plot. Sensitivity analysis (the process by which one study at a time is excluded from the pooled analysis to determine if any studies exert undue influence on the model) was then conducted. The Q-statistic for each analysis—a statistical test of heterogeneity—was considered significant at p ≤ 0.10 by convention.5 The I2 statistic—the percentage of observed variance attributed to between-studies heterogeneity rather than chance—was calculated for each analysis. A funnel plot was produced for each meta-analysis in order to assess visually publication bias, which was also assessed statistically using Egger's and Begg's tests.
For the primary outcomes only (diurnal SBP and DBP), pre-specified subgroup analyses of trial structure (parallel versus crossover), comparator type (sham-PAP versus all other types), treatment duration (≥ 4 weeks versus < 4 weeks), age (≥ 50 years versus < 40 years), Epworth Sleepiness Scale (ESS) score (' 11/24 versus < 11/24), apnea-hypopnea index (AHI ≥ 30 events/h vs < 30 events/h), baseline hypertension (SBP ≥ 140 mm Hg or DBP ≥ 90 mm Hg versus SBP < 140 mm Hg or DBP < 90 mm Hg), and PAP adherence (≥ 4 h/night vs < 4 h/night) were performed. Each p-value obtained in sub-group analyses was corrected using a Bonferroni approach. Separate pre-specified random effects meta-regression analyses were performed using treatment duration, mean age at baseline, mean ESS at baseline, mean AHI at baseline, PAP adherence, and mean BP at baseline (SBP or DBP as appropriate) as continuous predictors. Subgroup and meta-regression analyses were performed using the diurnal BP data only, in order to avoid inflating the type I error rate.
A total of 1,041 suitable studies were identified through the PubMed search. Of these publications, the authors screened the abstracts of 927 and the full text of 114. The reasons for excluding 1,006 of these studies are shown in Figure 1. Of the remaining 35 studies (all published as complete papers), 4 reported duplicate BP data, and the most recently-published of these was retained in the final literature set of 32 studies with 2,303 patients (see Figure 1).
*Of the papers reporting identical data, the most recently published was included. ABPM, ambulatory blood pressure monitoring; BP, blood pressure; OSA, obstructive sleep apnea; PAP, positive airway pressure; PICOS, patient/intervention/comparator/outcome/study design.
Literature screening flowchart, with exclusion criteria listed in "PICOS" order4*Of the papers reporting identical data, the most recently published was included. ABPM, ambulatory blood pressure monitoring; BP, blood pressure; OSA, obstructive sleep apnea; PAP, positive airway pressure; PICOS, patient/intervention/comparator/outcome/study design.
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Table 1 summarizes the studies in terms of design characteristics, while Table 2 summarizes the descriptive information of patients in each study. Twenty-one studies adopted a parallel structure; all but one used fixed continuous PAP as the intervention, and 20 used sham-PAP as the comparator. Treatment arm durations ranged from one week to one year. Most studies recruited predominantly males, with the mean age and body mass index (BMI) of the studies falling in a reasonably narrow range (43-63 years, and 27-37 kg/m2 respectively). The mean ESS scores ranged from 5-16/24, while the mean PAP adherence ranged from 3-7 hours per night. Information as to the authors' judgment of risk of bias is available from the corresponding author.
Design characteristics of identified studies
Descriptive characteristics of patients in identified studies
We are grateful to Drs. Dimsdale, Drager, Lloberes, Lozano, Oliveira, Poyares, Sharma and Tomfohr for supplying additional data and/or information on study design.6–13
For our primary analyses (diurnal SBP and DBP), we were able to extract analyzable data for 1,948 patients from 28 studies (87.5% of the 32 studies identified). As shown in Figure 2, only 4 studies showed significant differences in SBP and DBP between PAP and control arms, with a further 2 studies showing significant differences in DBP only. In the pooled analyses, diurnal SBP and DBP were both significantly reduced by PAP treatment compared with control (pooled SBP change −2.58 mm Hg, 95% CI −3.57 mm Hg to −1.59 mm Hg, p ≤ 0.001; pooled DBP change −2.01 mm Hg, 95% CI −2.84 to −1.18, p ≤ 0.001). The Q-tests for SBP (Q(27) = 20.51, p = 0.81) and DBP (Q(27) = 34.90, p = 0.14) were both nonsignificant, and the I2 values for SBP and DBP did not indicate substantial heterogeneity (0% for SBP and 22.6% for DBP).
For each study, the square represents the mean difference in blood pressure between PAP and control arms and the width of the line represents the 95% confidence interval; a line crossing the 0 mm Hg vertical line indicates no significant difference at α = 0.05. The diamond summarizes the pooled effect; the apex represents the overall mean difference in diurnal SBP between PAP and control arms, and the width represents the 95% confidence interval. In both plots, the diamond does not cross the 0 mm Hg vertical line, hence there is a significant difference between PAP and control in terms of the change in diurnal SBP (−2.58 mm Hg, p ≤ 0.001) and diurnal DBP (−2.01 mm Hg, p ≤ 0.001). DBP, diastolic blood pressure; PAP, positive airway pressure; SBP, systolic blood pressure.
Forest plots comparing the effects of PAP and control on (A) diurnal SBP, and (B) diurnal DBPFor each study, the square represents the mean difference in blood pressure between PAP and control arms and the width of the line represents the 95% confidence interval; a line crossing the 0 mm...
The results of the planned subgroup analyses are shown in Table 3. Diurnal SBP was significantly reduced by PAP in both parallel and crossover studies, whereas diurnal DBP was only significantly reduced by PAP in parallel studies. Both diurnal SBP and DBP were significantly reduced only in studies utilizing a sham-PAP control, studies with treatment duration ≥ 4 weeks, studies with mean age at baseline < 50 years, studies with mean ESS at baseline ≥ 11/24, studies with mean AHI at baseline ≥ 30 events/h, studies with mean PAP adherence ≥ 4 h/night, and studies with patients who were not hypertensive at baseline on average (all p ≤ 0.05 using a Bonferroni correction).
Results of subgroup and meta-regression analyses
Meta-regression indicated no significant effect of AHI, age, treatment duration, or adherence to PAP, on diurnal SBP or DBP (all p > 0.05). Baseline diurnal SBP was not a significant predictor of the weighted mean difference in diurnal SBP between PAP and control, however as shown in Figure 3A, baseline diurnal DBP was a significant predictor of the weighted mean difference in diurnal DBP (β = −0.22, standard error of the mean 0.09, p = 0.02). Baseline ESS was a significant predictor of the weighted mean difference in diurnal DBP (β = −0.27, standard error of the mean 0.12, p = 0.04; see Figure 3B), and this association approached significance for diurnal SBP (β = −0.37, standard error of the mean 0.19, p = 0.06).
In each plot, the error bars represent the standard error of the mean for each weighted mean difference, the solid lines represent the random effects meta-regression lines, and the dotted lines represent the null effect (0 mm Hg difference between PAP and control). The analysis in (A) suggests that the mean difference in diurnal DBP between PAP and control would decrease by 2.22 mm Hg with every increase of 10 mm Hg diurnal DBP at baseline (β = −0.22, p = 0.02), while the analysis in (B) suggests that the mean difference in diurnal DBP between PAP and control would decrease by 1.35 mm Hg with every 5-point increase in ESS score at baseline (β = −0.27, p = 0.04). DBP, diurnal blood pressure; ESS, Epworth Sleepiness Scale.
Scatterplots of the weighted mean difference between PAP and control for each study against (A) mean diurnal DBP at baseline, and (B) mean ESS score at baselineIn each plot, the error bars represent the standard error of the mean for each weighted mean difference, the solid lines represent the random...
Finally, sensitivity analyses found that no study, when removed individually, changed the statistical significance of the pooled result.
Nocturnal SBP and DBP data were available for 661 patients from 10 studies. Both were both significantly reduced by PAP treatment compared with control (pooled nocturnal SBP change −4.09 mm Hg, 95% CI −6.24 mm Hg to −1.94 mm Hg, p ≤ 0.001; pooled nocturnal DBP change −1.85 mm Hg, 95% CI −3.53 mm Hg to −0.17 mm Hg, p = 0.03). The Q-tests for SBP (Q(9) = 9.55, p = 0.39) and DBP (Q(9) = 12.21, p = 0.20) were both nonsignificant, and the I2 values for SBP and DBP (5.7% and 26.3%, respectively) did not indicate substantial heterogeneity. No subgroup or meta-regression analyses were planned for the nocturnal BP data. During sensitivity analysis, no study changed the statistical significance of the pooled result when removed from each meta-analysis individually.
We found no evidence of publication bias when Funnel Plots were inspected for each meta-analysis (not shown), although there is a possibility that further unpublished studies exist which we were unable to identify. The results of the Egger's and Begg's tests for both diurnal SBP and DBP, and nocturnal SBP and DBP, were all nonsignificant (all p > 0.05).
Our meta-analyses show that PAP treatment significantly reduces diurnal and nocturnal SBP and DBP compared with non-therapeutic comparators (sham-PAP, pill placebo, or standard care), despite only a few trials reporting statistically significant results individually. The weighted mean reductions in diurnal SBP (−2.58 mm Hg) and DBP (−2.01 mm Hg), and nocturnal SBP (−4.09 mm Hg) and DBP (−1.85 mm Hg), were reasonably small and would be unlikely to be considered clinically significant for an individual without additional treatment benefits occurring alongside. These results are in agreement with existing meta-analyses, despite the fact that more than double the number of studies were available to us in our updated literature search. Along with our quantitative results indicating minimal heterogeneity between studies, this provides evidence of a consistent effect across studies despite diverse locations and methodological approaches.
In terms of study design, planned subgroup analyses indicated that the reductions in diurnal SBP and DBP were larger in parallel studies, studies with at least four weeks treatment duration, and studies that used a sham-PAP control arm and hence were able to blind investigators and/or patients to treatment allocation.
We investigated the influence of descriptive covariates using both subgroup analyses and meta-regression. As anticipated, significant reductions in diurnal SBP and DBP were evident only in studies whose patients were younger, reported a greater degree of daytime hypersomnolence, had more severe OSA, and who exhibited greater PAP adherence. Our results concerning age are in agreement with data from the Sleep Heart Health Study, which did not detect a significant association between hypertension and OSA in those aged over 60 years.14 The subgroup of studies whose patients were (on average) hypertensive at baseline showed a greater reduction in BP with PAP compared with studies whose patients were normotensive, and yet this analysis did not reach values with statistical significance. Few trials targeted hypertensive patients during recruitment, suggesting that this analysis was underpowered particularly after Bonferroni adjustment for multiple comparisons.
Meta-regression analyses indicated that with every 10 mm Hg increase of diurnal DBP at baseline, a drop in diurnal DBP of 2.22 mm Hg with PAP compared with control could be expected (p = 0.02). Similarly, with every 5-point increase in ESS score at baseline, a drop in diurnal SBP of 1.86 mm Hg (p = 0.06) and a drop in diurnal DBP of 1.35 mm Hg (p = 0.04) could be expected. The mechanisms by which BP changes relate to daytime sleepiness remain unclear but may relate to cortical or subcortical arousals occurring at the termination of respiratory events coinciding with repeated surges in BP. There is some evidence that this cardiovascular response to arousal is attenuated in the elderly, which may partly explain our finding that age was not predictive of the BP reduction with PAP.15
The results of all other meta-regression analyses were nonsignificant—most likely due to the fact that significant heterogeneity between studies was not found—which highlights a deficiency in the literature. Despite the fact that studies recruited a heterogeneous sample of OSA patients (see Table 1) such that the within-study variances of baseline age, AHI, and adherence were wide, the means of these covariates were similar across studies. Hence little between-studies heterogeneity was evident, making statistical investigation of study-level co-variates impractical. The efficacy and effectiveness of PAP in the prevention and treatment of cardiovascular disease including hypertension is still an area of debate, making the identification of OSA subsamples likely to reap greater benefits from PAP treatment particularly important. Although this question could be addressed by performing further clinical trials targeting specific patient subgroups, a more practical and efficient approach would be to perform a patient-level meta-analysis using existing data from the identified literature. The availability of such a large pooled sample would also allow for the inclusion of a number of other important co-variates that were not investigated here, such as the arousal index and the influence of antihypertensive medications, the latter of which would be particularly useful in interpreting our meta-regression results suggesting greater reductions in BP when patients were hypertensive at baseline.
This meta-analysis builds on previous analyses by including data from an additional 1,170 patients from 13 studies—more than double the sample that was available to Bazzano et al. in 2007.3 Further strengths include the fact that we chose to identify only randomized controlled trials and separately extracted both diurnal and nocturnal BP data. We addressed several potential confounders of the effect of PAP on BP which have not been investigated using meta-regression to date, namely treatment duration, age, and baseline BP. Our thorough search for suitable studies outside of the PubMed database did not lead to the identification of further publications, and as such we believe our search terms were sensitive enough to capture all available literature; hence it is unlikely that our results have been heavily influenced by publication bias. Furthermore, by performing sensitivity analyses, we are confident that no single trial exerted undue influence on any of the meta-analyses presented here.
Some may consider the overall observed effect of PAP on BP to be minor and may question the benefits of treating OSA. We would offer several lines of logic in response. Firstly, although a 2-3 mm Hg change in BP could be considered trivial for an individual, at a population level the impact of OSA treatment on BP could have substantial benefits (for example, decreasing the risk of stroke). Secondly, we would agree that if the sole purpose of PAP were to lower BP, we would favor antihypertensive medications. However, the other benefits of PAP on daytime symptoms, driving risk, and possible cardiovascular benefits are noteworthy. Third, profound surges in BP are well known to occur in the physiological response to apnea, although such surges are typically not assessed using noninvasive technology with intermittent readings in clinical trials. Given that these BP surges may be a substrate for plaque rupture, we would encourage focus on hard cardiovascular outcomes, rather than surrogate outcome measures such as daytime BP. Finally, Guyenet et al. have regarded hypertension as a central disorder of autonomic control given that counter-regulatory mechanisms tend to maintain BP within a relatively narrow range based on changes in vasoconstriction or vasodilation.16 As such, one might predict modest changes in BP based on reduced catecholamine-mediated vasoconstriction. Thus, we favor further research into the benefits of CPAP and the role of BP on the causal pathway from OSA to hard cardiovascular outcomes.
Our meta-analysis has a number of limitations that need to be considered. Despite attempts to gather unpublished data from study authors, our data set was not complete. However, we were able to analyze diurnal BP data from almost 90% of identified trials and as such believe that our synthesized results are an accurate summary of the literature. Secondly, we analyzed BP data across trials with substantial methodological diversity (for example, differing equipment, timing and number of BP measurements), which is an unfortunate but unavoidable limitation of meta-analyses of this kind. We were also forced to calculate estimated differences in paired BP data based on the assumption of an r = 0.5 correlation when these data were not reported. This requirement undoubtedly introduced a minor degree of error into our data set.
In conclusion, the use of PAP in the treatment of OSA results in a modest yet significant reduction in BP, with the greatest effect seen with nocturnal SBP values. As more is learned of the cardiovascular effects of OSA, further testing will be needed to assess the role of PAP in mitigating such effects. Patient level meta-analysis may prove beneficial, especially in terms of defining the patient subgroups which would sustain the largest benefit from PAP.
This was not an industry supported study. Dr. Malhotra is a consultant for Philips Respironics, SHC, SGS, Apnicure, Apnex, and Pfizer. Dr. Bakker has received funding from Philips Respironics. The other authors have indicated no financial conflicts of interest.
ambulatory blood pressure monitoring
apnea-hypopnea index
body mass index
blood pressure
confidence interval
diastolic blood pressure
Epworth Sleepiness Scale
oxygen desaturation index
obstructive sleep apnea
positive airway pressure
patient/intervention/comparator/outcome/study design
respiratory disturbance index
systolic blood pressure
The authors thank Drs. Dimsdale, Drager, Lloberes, Lozano, Oliveira, Poyares, Sharma, and Tomfohr for their help in providing missing data for these analyses. Dr. Edwards is supported by the National Health and Medical Research Council of Australia's CJ Martin Overseas Biomedical Fellowship (1035115). Dr. Malhotra is supported by NIH (5R01HL085188-04, 5R01HL090897-03, 5K24HL093218-03, 1P01HL095491-01A1) and AHA (0840159N) grants. No financial support was obtained for this investigation. All work performed at Sleep Disorders Research Program, Brigham & Women's Hospital & Harvard Medical School, Boston MA.
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Alonso-Fernandez A, Garcia-Rio F, Arias MA, et al., authors. Obstructive sleep apnoea-hypoapnoea syndrome reversibly depresses cardiac response to exercise. Eur Heart J. 2006;27:207–15. [PubMed]
Campos-Rodriguez F, Grilo-Reina A, Perez-Ronchel J, et al., authors. Effect of continuous positive airway pressure on ambulatory BP in patients with sleep apnea and hypertension: a placebo-controlled trial. Chest. 2006;129:1459–67. [PubMed]
Hui DS, To KW, Ko FW, et al., authors. Nasal CPAP reduces systemic blood pressure in patients with obstructive sleep apnoea and mild sleepiness. Thorax. 2006;61:1083–90. [PubMed Central][PubMed]
Robinson GV, Smith DM, Langford BA, Davies RJ, Stradling JR, authors. Continuous positive airway pressure does not reduce blood pressure in nonsleepy hypertensive OSA patients. Eur Respir J. 2006;27:1229–35. [PubMed]
Coughlin SR, Mawdsley L, Mugarza JA, Wilding JP, Calverley PM, authors. Cardiovascular and metabolic effects of CPAP in obese males with OSA. Eur Respir J. 2007;29:720–7. [PubMed]
Lam B, Sam K, Mok WY, et al., authors. Randomised study of three non-surgical treatments in mild to moderate obstructive sleep apnoea. Thorax. 2007;62:354–9. [PubMed Central][PubMed]
Cross MD, Mills NL, Al-Abri M, et al., authors. Continuous positive airway pressure improves vascular function in obstructive sleep apnoea/hypopnoea syndrome: a randomised controlled trial. Thorax. 2008;63:578–83. [PubMed]
Kohler M, Pepperell JC, Casadei B, et al., authors. CPAP and measures of cardiovascular risk in males with OSAS. Eur Respir J. 2008;32:1488–96. [PubMed]
Alonso-Fernandez A, Garcia-Rio F, Arias MA, et al., authors. Effects of CPAP on oxidative stress and nitrate efficiency in sleep apnoea: a randomised trial. Thorax. 2009;64:581–6. [PubMed]
Comondore VR, Cheema R, Fox J, et al., authors. The impact of CPAP on cardiovascular biomarkers in minimally symptomatic patients with obstructive sleep apnea: a pilot feasibility randomized crossover trial. Lung. 2009;187:17–22. [PubMed]
Barbe F, Duran-Cantolla J, Capote F, et al., authors. Long-term effect of continuous positive airway pressure in hypertensive patients with sleep apnea. Am J Respir Crit Care Med. 2010;181:718–26. [PubMed]
Duran-Cantolla J, Aizpuru F, Montserrat JM, et al., authors. Continuous positive airway pressure as treatment for systemic hypertension in people with obstructive sleep apnoea: randomised controlled trial. BMJ. 2010;341:c5991[PubMed]
Lam JC, Lam B, Yao TJ, et al., authors. A randomised controlled trial of nasal continuous positive airway pressure on insulin sensitivity in obstructive sleep apnoea. Eur Respir J. 2010;35:138–45. [PubMed]
Nguyen PK, Katikireddy CK, McConnell MV, Kushida C, Yang PC, authors. Nasal continuous positive airway pressure improves myocardial perfusion reserve and endothelial-dependent vasodilation in patients with obstructive sleep apnea. J Cardiovasc Magn Reson. 2010;12:50[PubMed Central][PubMed]
Kohler M, Stoewhas AC, Ayers L, et al., authors. The effects of CPAP therapy withdrawal in patients with obstructive sleep apnea: a randomised controlled trial. Am J Respir Crit Care Med. 2011;184:1192–9. [PubMed]


text:
2019 F-250 Super Cab 4x4, Pickup (Stock #F583)
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$7,339 off MSRP! Priced below KBB Fair Purchase Price!Oxford White 2019 Ford F-250SD XLT Super Cab 4WD 6-Speed Automatic 6.2L SOHCEmpire Ford of New B… edford is located just a few miles from Dartmouth, Fall River, Freetown, and Swansea. Our dealership is always looking for new ways to work with, get involved with, and give back to our local community. Whether you visit our dealership location, or just browse online, we're always happy to have you! All types of credit, GOOD to BAD, can QUALIFY for an auto loan. NO CREDIT, NO PROBLEM! We will work with you to service a no credit car loan if your situation demands it! Empire Auto Group has strong relationships with over 18 major and local lenders. We are committed to find you the perfect car loan to suit your automotive finance needs. Prices does not include commercial, performance, off-roads and upfits. Please see dealer for details. For a HASSLE FREE purchase experience, call the Sales Department at Empire Ford of New Bedford now at 888-722-6063 to schedule your test drive and consultation. *Prices may not include upfits / performances / off-roads packages. Please see Dealer for details. Price applies to this vehicle only. Must finance with dealer. All rebates to dealer. Paid in full same day. Price includes: $1,000 - Ford Credit Retail Bonus Customer Cash. Exp. 01/02/2020, $1,250 - F-Series Retail Customer Cash. Exp. 01/02/2020
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text:
Can anyone explain how to move the star, so it is 64 pixels above the text and howto align the star horizontally with the text?
When I use the Fuzzy Select tool on the black pixels, it only selects the outline of the star.
I use GIMP instead of Photoshop, if that makes a difference.


text:
March 16, 2005
artisan chocolates from (almost) coast to coast
I SAID I would wait till I have the next chance. And I did. And I have completed my mission. I am talking about the chocolate - not a regular one, but those beautifully-presented pieces of art made of quality chocolate and an interesting range of flavors.
Back in the beginning of this month, I made a brief stop at Honolulu before coming back to Japan. The primary objective of this short stay was to go on a whale-watching tour about which I might write if anyone is interested, but in culinary regards, on the highest in my list of to-dos this time around in Honolulu was to get a box of Vosges truffles at Ala Moana Shopping Center.
When I walked out of Neiman Marcus where they sell a selection of chocolate from various boutiques, alas, I found myself having not one but two boxes of chocolate besides a Vosges one: one was from MarieBelle and the other was from Recchiuti Confections. All three of them happen to be American, from New York, Chicago, and San Francisco, offering an intriguing selection of interesting flavors in chocolate, from caramel to coconut to Pastis, from vanilla to curry to saffron, from mint to lavender to tarragon.
I packed them in a bag and took home with me with extra care, and managed to keep the couture chocolates look fine enough to be photographed after 9+ hours of trans-pacific flight. Hence the pictures with a small tasting note below, for each box, starting from the east and moving to the west.
MarieBelle, named after its founder/designer Maribel Lieberman, is a NY-based chocolatier known for its famous hot chocolate, as well as a selection of chocolates with artistic looks and unusual flavors. I am lucky enough to have a friend who has shared some of their hot chocolate mix with me before, but this was my first time trying their chocolate box. Each flavor features its own unique painting on top of the piece. Actually, each morsel looks like a piece of painting itself.
Caramel. Thick, chewy caramel chocolate covered with a thin layer of milk chocolate (I guess). Sweeeeeeet.
Cinnamon. Mild ganache infused with cinnamon. Cinnamon wasn't eminent at first bite, but it subsequently came.
Espresso. Again, there wasn't a readily recognizable espresso flavor at first, then right at the moment the last bit of chocolate has melted in my mouth, it was there - a very strong espresso taste. It was like a magic.
White Chocolate Kona Bean. Well this one did have a clear coffee flavor. Smooth white chocolate ganache scattered with finely crushed coffee beans.
Coconut. White chocolate with coconuts.
Cardamom. Personally, one of the most interesting flavors in the box that turned out to taste as interesting as it had sounded, with a pretty contrast of dark chocolate and sweet scent of cardamom.
Caipirinha. This was the one that caught my eye when I opened the box, first with the painting of a chic boot, then with its name; I didn't even know what Caipirinha is, but took a bite anyways - then tasted a mellow, complex note of something citrus-y. As I learned later, Caipirinha is a cocktail made with lime and Cachaca, which is sugarcane liquor of Brazil where people are said to adore Caipirinha throughout the country.
Saffron. How fantastic does it sound, chocolate infused with saffron, one of my favorite spices. To my disappointment, however, I didn't find much saffron flavot in it, although it was a good morsel of dark chocolate.
Passion Fruit. This had a lovely smell of passion fruit when cut open, and a sweet luscious taste of the fruit as promised.
Among these, what I liked the most were: Caipirinha, Passion Fruit, and Cardamom.
With Vosges, I was so excited to finally try their "Exotic Collection". The relatively new chocolate boutique first founded in Chicago by chocolatier Katrina Markoff has got lines of chocolate truffles, very tempting in both name and appearance, as well as their flavors from around the world.
Black Pearl ("ginger + wasabi + sesame seeds + dark chocolate"). This was the same theme as the candy bar I tried before, and like the other one, this had only a subtle flavor of wasabi, and, almost untraceably, ginger. I found the black sesame seeds added quite a magnitude of pleasant texture to this morsel than it may look.
Absinthe ("Chinese star anise + fennel + Pastis + dark chocolate"). Mere a fact that I hate anything anise-y - Chinese star anise, fennel, Pastis, all of them - didn't warrant I shouldn't try a bite of this, although, when I cut this open, I almost didn't. This got a really strong anise flavor that lingered on in my mouth for a while after I forced it down to swallow. If you love anise, this is the one for you - but not for me, unfortunately.
Chef Pascal ("Kirsch + dried Michigan cherry + dark chocolate"). Cherry and chocolate is such a classic combination, and this one was good, albeit a bit too plain.
Woolloomooloo ("Australian macadamia nut + coconut + milk chocolate"). Fun name to pronounce, isn't it? I didn't quite taste mac nuts, as the coconuts were more dominant. Very sweet and mellow.
Naga ("sweet Indian curry + coconut + milk chocolate "). This was another flavor that interested me when I was choosing a candy bar at the boutique (the other one was Black Pearl, which I eventually chose). I tried a curry-flavored ganache chocolate from Godiva (their "Les Elements" line, which I wrote about a while ago), but this round fellow was totally different from Godiva's - it had a very, I say very strong curry flavor, at a whole new level. I almost felt as if I had been biting a lump of curry paste. That might not sound very appetizing, but somehow, it managed to taste good. Unusual.
Wink of the Rabbit ("soft caramel + Georgian pecan + milk chocolate"). Another cute name. I found this very American with all that sweet caramel filling and a crunch pecan atop. Very sweet, of course.
Gianduia ("crunchy praline + milk chocolate"). This one was pretty classic, straightforward, glamour chocolate truffle. Yum.
Ambrosia ("macadamia nut + Cointreau + white chocolate"). As the only white chocolate truffle in the box, this one was the mellowest and creamiest among others, while cointreau was only subtly there.
Budapest ("sweet Hungarian paprika + dark chocolate"). I had been looking forward to trying this one, as I imagined it lovely to infuse dark chocolate with the most aromatic, mild chili pepper from Hungary. Maybe I had had a too high expectation on this - I was mildly disappointed at first bite as I thought I didn't taste much of paprika. Later, however, the taste of paprika emerged in my mouth as it melted, and left a quiet yet pleasant aftertaste. I still think I wouldn't mind a little more paprika, though.
Among these, what I liked the most were: Black Pearl, Gianduia, and Budapest.
Recchiuti Confections was a new name to me, as I only discovered it at the Neiman Marcus boutique while browsing around for Vosges. This chic San Francisco chocolatier bearing the name of co-founders Michael and Jacky Recchiuti had a stylish and sublime selection of dark chocolates. I got a box called "Green Box".
Lemon Verbena. Bitter chocolate ganache infused with lemon verbena, topped with candied lemon peel, and coated with dark chocolate. Layers of definite lemon scent were blended into dark chocolate.
Star Anise and Pink Peppercorn. Did I say I hate anise? Okay. This one wasn't so anise-y, although strong enough to mask any taste of pink peppercorn (to me at least). It wasn't so unpleasant (which is a compliment).
Spring Jasmine Tea. Jasmine blossoms and green tea leaves are infused in extra-bitter chocolate ganache. Bitter chocolate wasn't overpowering the very delicate jasmine tea flavor, making this an extremely refreshing piece of chocolate. Lovely.
Sur de Lago. Sur de Lago is a name of area in Venezuela, where these aromatic chocolate beans are produced. I almost thought I tasted some kind of liquor in it, and was surprised to know there wasn't any. Really aromatic morsel.
Pearl Mint Tea. This one gave off a sweet scent of mint before I threw it into my mouth. That sweet smell reminiscent of mint tea.
Tarragon Grapefruit. I am not sure if I like tarragon in general, as it is a bit anise-like (did I mention...). But this one had only a hint of tarragon scent, and the dark chocolate and bittersweet candied grapefruit peel were gorgeous together.
Burnt Caramel. Caramel usually is more or less burned sugar, so what is burnt caramel like? It was slightly smoky and unarguably bitter, but in a perfectly sweet way. No teeth-sticking chewiness of ordinary caramel at all, just a tender ganache with a noble bittersweet finish. This was irresistible, no wonder it is their "signature piece".
Lavender Vanilla. I already smelled lavender when I picked up my piece, and it lasted long way after it has been disappeared. I didn't quite tell vanilla, though.
Among these, what I liked the most were: Spring Jasmine Tea, Burnt Caramel, and Lemon Verbena.
Phew. If you have read all this through down to here, you might probably be pretty exhausted. So am I. You may even have heartburn, almost? Well, I don't.
For my honor's sake I have to make it clear that I tasted all these chocolates (26 pieces in total!) over a period of almost two weeks, two to three pieces at a time, once a day or two (in the order listed above for each box). I also shared every piece with one or two people, which means I basically only ate one piece at a time (in theory). This doesn't change the fact that I ate a lot of chocolate in a relatively short span of time, but just so you know.
Overall, I enjoyed every piece of every box, but if I am to choose one, I'd definitely like Recchiuti's the best. They may not be as pretty and eye-catching as the other two, but tasted outstandingly good. I can't believe I didn't buy a "Black Box" which contains all 16 of their regular flavors.
Speaking of it, I had a bit of miscommunication with a salesclerk at the Neiman Marcus boutique; the boxes didn't exactly have the selection I thought I was going to have, based on the talk we had. For example, I thought I got MarieBelle's Champagne and Recchiuti's Rose Caramel in my boxes, which weren't there. Well, maybe next time, even if I am not quite certain how soon the "next time" could be.
*I SAID I'd see you in a week in my last post, and alas, it has been way more than two weeks. Sorry about this late return, and thanks for checking back.
26 comments:
Posted by z.
- 10:49 AM, March 17, 2005
Nice photos! I sampled a tiny piece of MarieBelle at Neiman Marcus in San Francisco and found it was a little waxy. Maybe it was kind of old? I haven't tried the hot chocolate, though. I really like Recchiuti chocolates. I try to hit the little retail shop in the Ferry Building Plaza thing in SF whenever I'm up there. So which chocolates are you going to try NEXT?
Posted by Mariko
- 10:49 AM, March 17, 2005
she who eats.
thanks for that posting - that was very good! of the ones you show, i've only tried the vosges. of the ones i've tried - i liked chef pascal and the balsamico the best - the others i found rather lackluster. i hated the "rooster" (the one with taleggio cheese).
come visit!
Posted by ulteriorepicure
- 12:15 PM, March 17, 2005
hello chika-san! don't you sometimes want to buy the chocolates just for the beautiful packaging? i think i am attracted to mariebelle just because i love turquoise blue and brown together.
i think my favourite of the lot would be your least favourite, the absinthe. star anise, mmmmm! or, in your case, mmmpppffff :-P
Posted by santos.
- 5:55 PM, March 17, 2005
Hi Chika,
I almost bought these same chocolates from Neiman Marcus when I was there last week. The sound wonderful and now you've convinced me.
By the way, did you relocate to Japan?
You got a wonderful mention in the Honolulu Weekly this past Wednesday (16 March). If you'd like I can e-mail you the text of the article.
Posted by Reid
- 7:17 PM, March 17, 2005
:) that was a fabulous post on chocolates!! i've never had Vosges or the MarieBelle (mental note to self to buy some SOON) but the Recchiuttis, i'm in total agreement w/ you. have you tried their venezuelan? it's really good too!
Posted by J.
- 9:35 PM, March 17, 2005
such a deliciously pretty post, welcome back :)
Posted by Cat
- 11:58 PM, March 17, 2005
That is the most divine post I have ever read. Lovely. I agree so much about the Vosage chocolates, I am glad you took the time to review (and I get the sense you are glad you did too! LOL) Keep up the sensational work! -Rachael
Posted by Rachael
- 5:25 AM, March 18, 2005
oh what fun! I've never tasted any of these, but they really are beautiful. Thanks for including us in your tasting!
Posted by Cathy
- 9:42 AM, March 18, 2005
Hi Chika, those look incredibly delectable! I'd definitely like to try them out sometime, or at least use some of their flavour pairings in my own cooking. Thanks so much for sharing.
Posted by Clement
- 11:01 AM, March 18, 2005
Oh so pretty! And they all sound so good too....(well, actually, I'm with you on the anise and tarragon...but I do really love grapefruit, so I probably would love that one.) I've never had such fancy chocolates...I look forward to the day I can try such a variety! (And, I was interested to hear how you did taste them...I pretty much figured you must have spread it out over time.)
Posted by Alice
- 2:16 PM, March 18, 2005
Chika - おかえりなさい! This is such an extraordinary post (I'm sure I'll keep coming back just to look at these wonderful pictures, they just make me happy!). I know *taste* is more important, but I fell in love with MarieBelle - they are so pretty... Glad you didn't have to try all of those in one go!
Posted by keiko
- 3:37 PM, March 18, 2005
looks like you've had a couple of weeks of intense chocolate bliss!
Posted by joyce
- 2:17 PM, March 19, 2005
you should try Christopher Elbow --really quite tops!
Posted by jenn
- 6:23 PM, March 19, 2005
Hi Chika,
those little treats look absolutely amazing! Just checked the Vosges-Site to find out, where their chocolate is sold... Hopefully I'm going to visit London over the next months, then I definitely will drop by at Selfridges... Almost to good-looking to be eaten ;)
Posted by Nicky
- 10:39 AM, March 21, 2005
This is a great overview for people trying to come up with chocolate combinations for tarts and cakes. Thanks for tasting all that chocolate for us!
Posted by Mia
- 11:22 AM, March 21, 2005
Welcome back Chika. For a while there I thought you might have given up on this site. I'm glad you are back. Wonderful post. I'm headed to the cholatier on Delmar tonight...yum.
Paul W.
Posted by Paul W.
- 8:29 AM, March 22, 2005
i love your posts!!
they are beautiful!
Posted by mindy
- 8:54 AM, March 22, 2005
Hi Chika,
I live in Honolulu and now I have to go check it out! Luv your blog btw. I also want to go to Tokyo again soon.
Posted by Trisha
- 4:31 PM, March 22, 2005
Hi everyone, thanks for welcome-back notes :)
z. - thanks!
Mariko - MarieBelle's weren't waxy to me this time, but they were kind of soft and those pretty painting on top might have had added some sort of unpleasant taste/texuture possibly? I am not sure. Ooo I want to go check out Ferry Building Plaza, too... and there are SO many chocolate I want to try, seriously!
u.e. - I haven't tried balsamico one, that sounds really tempting. I am even curious about the one with taleggio cheese!
santos - I do I do! I liked the MarieBelle signature blue & brown box so, I still keep it... /)
I wish I had shared those aniseeees with you!
Reid - Let us know when you have tried one (or all?) of them!
I did move back, unfortunately, and I've heard about the Honolulu Weekly article elsewhere and checked their website, to find they put the article on their site a week behind? Otherwise that'd be really nice if it doesn't bother you to email it to me, thanks.
J. - I haven't tried Recchiutti's venezuelan yet, but I assume it's good :) too bad I don't get to try them unless I go to the US, though...
Cat - thanks a lot, it's really nice to see you guys all again :)
Rachael - I did enjoy tasting every bite of those treasures, for sure! I don't mind doing that again :)
Cathy - thanks, they were so sweet to eyes and to tastebud :)
Clement - that's exactly what I was thinking, trying out some of their flavor pairings on my own. Can't wait to see how you will turn them out!
Alice - yeah I might have been able to try all at one time, but figured they would be too good for such an insult(!). The tarragon-grapefruit one was pretty good, I think you'll like it even if you don't fancy tarragon.
keiko - well, MarieBelle's did taste good, as well! Like I have just mentioned, I didn't eat all up at once, but come to think about it, if I had had, say, three boxes each of them, I might have gobbled down the first box right away... (horrible...)
joyce - I was a bit ambivalent about it... as much as I wanted to try them all soon, I was also mildly reluctant to it, too, because once you have eaten them, they're gone, right? :P
jenn - thanks for the information, they don't appear to ship overseas, but when/if I have a chance I'd love to try theirs!
Nicky - I wasn't aware Vosges sells in London! But then, when you are in Selfridges, there are so many other goodies around you, too!
Mia - I am glad I did this, too, I've also gotten quite a bit of inspiration for desserts from these chocolates!
Paul W. - sorry I abandoned this blog for a while, I was going to post about these chocolate altogether, and it took me a while :P Frankly, I was just a bit busy... hopefully I will be posting on a more regular basis!
mindy - thank you, too!
Trish - wow, I am half jealous of you, and half relieved as I'd be going one too often to the shop if I live near around. :P Hope you can make it to Tokyo soon!
Posted by chika
- 7:40 PM, March 22, 2005
Nice post about artisan chocolates. I am wondering what constitutes artisan though. Vosge is a huge company and they use a "one shot injection" process to make their chocolates. Certainly not hand made in small batches.
Rechuitti is wonderful and well deserving of the name artisan. Mari-Belle as well but I have found their flavors dont live up to thier packaging and design. They win in the design test though.
To me artisan would constitute a small one or two person shop/operation with very small output. Have you tried Lillie Belle Farms? They are a tiny company in oregon who grow their organic fruits for their chocolates and use fair trade organic chocolate as well.
Posted by elmo
- 6:38 AM, March 26, 2005
too beautifull!!!!
Posted by penglobe
- 12:29 AM, April 03, 2005
If you bought chocolates at Neiman Marcus, then I can guarantee they weren't fresh. You should try Linda Grishman Chocolates. She makes everything fresh to order and will not sell to retailers. She has not followed the rest of the pack with all the fancy colorful transfers stuck to a square of chocolate. She's a purist with an ability to create superb products without pretentiousness that is so much a part of this industry as is evidenced on their websites. Give her a try wwww.vermontchocolate.com
Posted by Elaine
- 1:59 PM, July 12, 2005
Hi Chika,
I was doing a general google search and stumble upon your website... I sense that you are a chocolate lover, aren't you? Are you currently in Japan? There are a few good chocolate outlets you may want to try out... Pierre Herme, Jean-Paul Hevin, La Maison du Chocolat, Pierre Marcolini, Le Chocolat de H.
If you are interested in artisan chocolate in the US, you may want to try Christopher Elbow, Ethel's, Noka Chocolate, Christopher Norman as well. Their chocolate are also available online.
Well, I'm a big chocolate arficionado, so keep in touch. My email address is email@example.com
EBITDA from US
Posted by EBITDA
- 11:27 AM, January 18, 2006
- SEARCHMAX said...
Nice post. I like Debrand
Dave in Cleveland.
- 5:50 AM, May 23, 2007
- ugogirl said...
Hi, Chika
Very nice posting about chocolates - made my mouth water.
I have Michael Rechuitti's book, Chocolate Obsession and am trying to make Lemon Verbena ganache from the book. I didn't see any mention of candied lemon peel in the recipe, though. I happen to have the lemon peel, but am wondering whether or not to follow the recipe exactly. Did you find lemon peel addition adding more flavor? Hmm... big question.
Thanks again for nice posting. Now, I can't wait to try all of these. :) Keep up the good work!
- 7:27 AM, June 05, 2007


text:
Five decades after the assassination of President John F. Kennedy and 22 years after dramatizing a compelling cinematic case for a conspiracy surrounding the slaying, filmmaker Oliver Stone says his opinion of the 35th President of United States has evolved: "I admire him all the more now."
As Stone's landmark 1991 film "JFK" – featuring an all-star cast headlined by Kevin Costner as a determined district attorney who sets out an a years-long quest to unravel the enduring mysteries surrounding the death of the president – is released in a special boxed 50 Year Commemorative Edition featuring a plethora of supplemental material, the ever-passionate writer/director is looking back at a project that he calls "one of the highlights of my life." and a president he feels "started to change things in a big way."
His perception wasn't always so. "I grew up conservative, so in my family Kennedy was a bad guy," remembers Stone of his earliest impressions of the 35th president, which were colored by his Republican, Eisenhower-admiring father. After the assassination, he says, "I felt sad for a young, handsome president and his family, but politically I was definitely critical of him because of my family."
"It was only after my experiences in Vietnam I started to begin to re-question things at a deeper level," says Stone, whose political leanings turned to the left after dropping out of Yale and his enlistment for two years of combat duty in the Marine Corps. "By the time Reagan was in office, I really had moved to the place where I was making more progressive films like 'Salvador'," he says, which led to a series of critically acclaimed and commercially successful films like "Platoon" and "Wall Street" that tackled hot-button, Baby Boomer-relevant topics. Soon, Stone found himself puzzling over how to make a film out of the then-extremely controversial subject of Kennedy's assassination.
"When did I cross-over to believing [in a conspiracy to kill Kennedy]? After I brought Jim Garrison's book 'On the Trail of the Assassins,' because it was a hell of a suspense thriller," says Stone. "I always wanted to do something like 'Z,' which had been one of my film school favorites." Garrison was a New Orleans district attorney who pieced together a compelling enough theory that the Kennedy assassination involved a large-scale conspiracy and deep government cover-up that he was able to bring the case to trial – though Garrison ultimately lost, his efforts brought increasing scrutiny on the accuracy of the Warren Commission's report on the assassination. "He was the only public official to bring charges in such a huge way against this government and its covert operations – that's impossible to do," Stone marvels.
In prepping for the film, which also drew from Jim Marrs' book "Crossfire: The Plot That Killed Kennedy," Stone immersed himself in research. "I read parts of the Warren Commission [report], and then I read everything that was questioning these holes in the story – and that's what opened me up, and meeting people who'd been there and were still alive then," says Stone. "I met a lot of witnesses at Dealey Plaza, and I talked to a lot of people, pro and con. What I came out with was about two years of research and writing."
The case that film makes for a conspiracy launched a polarizing firestorm of debate among critics and champions – a din so loud it almost drowned out the film's considerable artistic achievements. It was then Stone realized that his movies, as he says, "will always have an Oliver Stone effect. It's my name – I have created enough controversy that I'm always fighting an image. 'JFK' was that divide. I was criticized for 'Born on the Fourth of July' and 'Platoon' and for 'The Doors' before that – less so, for 'Wall Street,' although it was. And when I made 'JFK,' I never really came back. I reached a place where I was radical. I was not to be trusted. My critics said I was making up things."
But the filmmaker still stands by his team's research – indeed, the film served to launch an even more intense degree of investigation and scholarship surrounding the assassination over the intervening years, with a large portion of public perception increasing leaning toward a conspiracy.
"We may have made a few mistakes, but nothing major – we got it right," says Stone. "And the Assassination Records Review Board – appointed in 1992 and went on 'till 1998 –had four million pages that substantiates and opens up further the holes we pointed out. That Warren Commission is Swiss cheese. It's Alice in Wonderland. It doesn't make any sense, from the magic bullet theory to Oswald, and the members knew that. Even Lyndon Johnson doubted the findings. They knew it was a whitewash…I said when 'JFK' came out, 'Okay, don't buy the film, don't believe it necessarily, but go out and read the other versions that are not getting in the mainstream press.'"
Stone would later revisit Kennedy's entire presidency in his multipart Showtime documentary series "Untold History of the United States" – the chapter 'JFK: To the Brink,' also appears in the new collectors edition box set – and found his admiration for the president deepening, particularly for his defiance of dangerous Cold War political policies during the Cuban Missile Crisis.
"My admiration for Kennedy only grew," says Stone. "Kennedy had achieved far more than I ever understood when I did the movie, as a politician, as a statesman…He had issues, but he had grace and he had aloofness from fear, and that's what made him special. We owe him a great, great debt of gratitude. We wouldn't even be here talking if it hadn't been for him."
As for the legacy of "JFK" and its effect on how the Kennedy assassination is ultimately perceived, Stone believes the essence of what he was hoping to communicate is encapsulated in Kevin Costner's climactic courtroom argument. "'JFK' has a great speech at the end: 'It's up to you,'" says the filmmaker. "Did I think it would have a result? Listen, it was there then, it is there now. I hope people can see it again. I hope you remind them of some of the power of the film. I would urge them to think for themselves."


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NBA's Adam Silver wants NCAA input on higher age limit
NEW YORK — NBA Commissioner Adam Silver re-iterated Friday the league's desire to increase the age for draft eligibility at a Board of Governors meeting, with a little help.
NCAA President Mark Emmert visited with NBA owners in New York, and Silver again said the NCAA should have a seat at the table when the NBA and National Basketball Players Association discuss the league's draft-eligibility age. A player must be 19 years old or one year removed his high school graduating class to enter the draft, but Silver is interested in raising the age limit to 20.
ONE-AND-DONE:Parker declares for draft
"(Emmert) and I have had an ongoing dialogue, not only just about the one‑and‑done rule, but about officiating, how we can come together on the rules of the game to make it more of a smooth transition from college to the NBA, and we talked generally about things we can be doing to improve the collegiate experience," Silver said.
Silver said no changes are imminent regarding the draft lottery and playoff format, and the league's competition committee will discuss in detail those issues when it meets in the summer.
"I will say our competition committee has moved more towards what I would call an NFL‑style format, where it's a multi‑day meeting, focused attention from a cross‑section of coaches, general managers, owners. We have a player representative there, as well," Silver said. "These are the kind of issues where the last thing we wanted to do is make them based on one meeting, owners hearing arguments for the first time.
"In a process like this, they (issues) need to be thoroughly studied and then brought to the larger board, and we're really just at ground zero in terms of considering the options."
Silver also addressed the recurrent issue of teams resting players down the stretch for both health reasons and potentially trying to manipulate playoff matchups; the proposed sale of Milwaukee Bucks; and a new joint initiative with USA Basketball and the Department of Defense.
It was Silver's first board of governors meeting as commissioner since taking over for David Stern in February, and the more Silver speaks, the more it is clear raising the age limit for the draft is at top of Silver's priorities.
"One thing that we also agree on is that historically what you've heard is that the age issue is one that needs to be negotiated almost in isolation between the NBA and its union." Silver said. "What Dr. Emmert, and I agree on is that the NCAA needs to have a seat at the table, as well, for those discussions."
The one-and-done issue has grown increasingly polarizing. Many college coaches and administrators don't like the rule, but the NBA is also not fond of it, though for entirely differently reasons. The NBA is paying first-round picks guaranteed millions, and with that kind of investment, teams want more chances to evaluate players. The more they can scout players, the more confident they believe they are in making significant decisions in the draft.
"Ideally we want our teams in a position to have more information about these young men before they come into the league, and from a developmental standpoint we would like them to have more opportunity for them to develop before they come into the league," Silver said.
Silver does not anticipate that happening for the 2015 draft but said that rule change can be amended to the current collective bargaining agreement without the current CBA expiring. The NBPA is searching for a new executive director and have had informal discussions with acting director Ron Klempner and President Chris Paul of the Los Angeles Clippers.
"But until they finish their process, we're not going to be able to sit down into more of a normal negotiating mode," Silver said. "So we're ready to go. We've been thinking about this issue for a long time, as you know."
The competition issues such as the draft lottery and playoff format are not as high on Silver's priority list.
• With several teams trying to rebuild — the NBA prefers that terms, others call it tanking — the draft lottery is under a microscope. Using the draft is one way to rebuild, and with the worst teams having the best chance to get the top picks, winning is not always an incentive.
EMERT:NCAA Q&A on ESPN goes horribly wrong
For example, the Philadelphia 76ers didn't try to lose games, but management knew losing this season might be its best chance at generating long-term success. The Sixers might not get the No. 1 or No. 2 pick in the weighted lottery, but they can get no worse than the fifth pick.
Rod Thorn, the NBA's president of basketball operations, made a draft lottery presentation to owners: changing the odds for lottery teams; the wheel system in which every team would be guaranteed a No. 1 pick "every so many years," Silver said; a play-in tournament among non-playoff teams to determine the order.
"There was far from a consensus in the room as to what changes we should make. … but there was an understanding by the group that those were issues that really needed to be viewed more in depth in a committee process rather than before the full board," Silver said.
• Last week during an in-game interview with San Antonio Spurs TV broadcasters Bill Land and Sean Elliott, Silver dropped the possibility of having a playoffs with the top 16 teams regardless of conference.
"The sense of the room was that certainly no one was advocating a particular change right now," Silver said. "It was more suggesting that this seems like a good time when you have a transition in leadership to take a fresh look at virtually everything, and I would add that to the list of those issues."
A part of the draft lottery and playoff format go hand-in-hand. In 11 of the past 14 seasons, the ninth-place team in the West has had a better record than the eighth-place team in the East, including this season when the 48-34 Phoenix Suns were 10 games better than the 38-44 Atlanta Hawks.
Phoenix missed the playoffs but will also be ahead of the Hawks in the draft, as will the Minnesota Timberwolves who also had a better record than Atlanta but didn't make the playoffs. This also affects competitive balance.
The Suns and Timberwolves ostensibly will get a player in the draft, even though Atlanta is the team that needs to improve more.
"But again, the league is doing so well right now, I just want to be very deliberate and cautious about any major changes like that," Silver said.
• Even though the Milwaukee Bucks announced the sale of the team from Herb Kohl to Marc Lasry and Wesley Edens earlier this week, Silver said he has not seen the purchase agreement and owners were not in position to approve the sale.
"I don't anticipate there will be any issues, but we're just not at that point in process yet," Silver said.
Lasry owns a small percentage of the Brooklyn Nets, which he will sell if the Bucks deal is approved.
• Silver also said the league will take a fresh look replay reviews and how the league selects, trains and grades referees. Silver said the league may go to a central replay center Secausus, N.J., rather than have referees determine a call by watching a monitor at courtside.
• San Antonio Spurs owner Peter Holt resigned as chairman of the board of governors, and Timberwolves owner Glen Taylor will resume that role on an interim basis until a replacement is named in October.
• The NBA, USA Basketball and the Department of Defense have joined forces to provide active and retired military families access to exhibition games, clinics, practices, speaking engagements, meet-and-greets and game tickets, the league announced in a news release on Friday.
The three groups will also focus on helping military personnel returning from overseas duty transition to civilian life with job fairs, networking events and leadership conferences with NBA owners, executives, coaches and Pentagon leadership.
The first event is May 7, and USA Basketball women's coach Geno Auriemma and men's assistant coach Jim Boeheim will host a leadership development conference at the Pentagon.
Also, the WNBA will host a Hoops for Troops doubleheader on ESPN2 with the Minneosta Lynx and New York Liberty and the Phoenix Mercury and Los Angeles Sparks. And the U.S. men's team will practice at West Point on Aug. 18, and the U.S. women's national team will train at the Naval Academy Sept. 7-10.


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Ann Johansson was a judge in the 2019 v04 Photography Competition Contest
WPJA Judge since 2004 -
Ann Johansson is a Los Angeles based corporate and editorial photographer specializing in documenting people and their environments around the world. Ann's success is attributed to her low-key approach combined with her exceptional eye and ability to connect with people. Ann also takes the time to work on personal projects looking at social issues such as Sierra Leone's child mortality rate where 27% of children die before their fifth birthday. Ann works for leading publications around the world such as the New York Times, The Globe & Mail, Le Monde, Bild am Sonntag and Dagens Nyheter as well as for national and international corporations.


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Oakland Mayor Jean Quan apologized after she promoted a lock-picking class in her office newsletter, The Associated Press reported.
The Oakland Tribune reported the class is intended for those who lose their keys, but with a 40 percent spike in burglaries last year, the reaction to the listing wasn't a positive one.
"Of all the incredibly unbelievable things I've witnessed in my life, this tops the list," resident Julie Mills said in an online letter to the mayor.
U.S. & World
On Wednesday, Quan said more attention needs to be paid to what goes into the 20-page publication.
"I am ultimately responsible for what goes out," the mayor said in a statement. "And I and our editor will do a better job reviewing these listings in the future before sending them."


text: John Walton (1738–1783) was a Georgia delegate to the Continental Congress. Though born in Virginia, Walton later became a planter near Augusta, Georgia. He was elected as a delegate from St. Paul Parish to the Provincial Congress at Savannah in 1775, and then elected to the Continental Congress in 1778. He signed the Articles of Confederation on behalf of Georgia on July 24, 1778. He held the office of surveyor of Richmond County for several years before his death in New Savannah, Georgia in 1783.


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Parian is a fine-grained, hard-paste porcelain named for the marble it resembles. It was first made in England in 1846 and gained in favor in the United States about 1860. Figures, tea sets, vases, and other items were made of Parian at many English and American factories. Parian ware is usually white, but some pieces are partially colored.
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Hearing Aid Compatible Cell Phones
To ensure everyone benefits from advances in technology, the Federal Communications Commission ("FCC") has approved standards and passed regulations for digital wireless device use with hearing aids. In 2001, the FCC modified the exemption for wireless phones under the Hearing Aid Compatibility Act of 1988 in light of the rising number of wireless calls to emergency services and the growing trend among wireless carriers to move away from analog services in favor of more efficient and feature-rich digital services.
The FCC defines Hearing Aid Compatiblity (HAC) for cell phones in terms of two parameters; radio-frequency (RF) emissions and telecoil coupling. HAC-compliant device packages are marked with "M" or "T" ratings. The M-rating refers to the microphone mode. The T-rating refers to the telecoil mode. Only phones that meet HAC compliance will be labeled as such. If you see a "M3", "M4", "T3" or "T4" on the box then the phone has been designated as HAC compliant. Cell phones that comply with the FCC's hearing aid compatibility rule must receive a minimum rating of M3 for RF emissions and T3 for telecoil coupling.
Hearing aid compatible phones
"T" refers to the phone's coupling ability and is intended for use with hearing aids in the telecoil mode. The higher the "T" number the more likely you will be able to use the phone with your hearing aid on the telecoil setting. A telecoil is a small device that is built into some hearing aids for use with the telephone as well as assistive listening devices. To use the telecoil, generally either the hearing aid is switched to the "T" position or a button on the hearing aid is pushed to select the telecoil program. The telecoil picks up magnetic fields generated by telephones and converts these fields into sound. Telecoils are particularly useful for telephone communication because they permit the volume control of a hearing aid to be turned up without creating feedback or "whistling," and background noise can be reduced especially when using cell phones in noisy places. That is why hearing aid phones are important. They give you the ability to control and process sound.
The FCC requires that nationwide carriers offer a range of phones that comply with HAC regulations beginning in September 2005 for microphone mode and in September 2006 for telecoil mode. Many regional carriers will also offer phones and support. Some cell phones that are usable with hearing aids are already on the market
All major handset manufacturers are now required to produce HAC phones; some even have hands-free accessories to improve usability. There is no additional cost or difference in appearance of HAC phones versus non-HAC phones. It's best to try several phones before buying to find the best match with your hearing aids. Visit a full-service carrier store and ask to try phones that have been designated as "hearing aid compatible." Be mindful of your service company's termination and return policy before purchasing any phone. Since a cell phone's RF emissions can change depending on your location your listening experience outside the store may be different.
While there is no guarantee; phones that comply with Hearing Aid Compatibility (HAC) regulations should improve usability for hearing aid users. Hearing loss and hearing aids are highly individualized so it is still advisable to try a cell phone with your hearing aid in the store before making your cell phone purchase. Your hearing healthcare professional will be able to tell you if your hearing aid is immune to RF interference and may need to contact the manufacturer of your hearing aid to determine its immunity rating. Many new digital hearing aids are designed to be usable with wireless devices with lower RF emissions. Of the more than 2 million hearing aids sold in 2004, eighty percent (80%) include a basic circuitry design that increases immunity to RF interference. In 2005, 45% of the hearing aids sold contain a telecoil.
Learn More
To learn more about how to purchase cell phones which are compatible with hearing aids and for a list of the best (M4/T4) cell phones, click here. (Links to BHI's "Cell-Phones Which are Compatible With Hearing Aids" page)
"Catching the Wireless Wave" courtesy of the Alliance for Telecommunications Industry Solutions Hearing Aid Compatibility Incubator and CTIA- The Wireless Association™


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Cyclamen beauties worth the effort
Just because they are beautiful doesn't mean they are difficult. The lovely cyclamen can be found at local nursery centers flaunting their flirty pinks, purples, white and fuchsia petals. They are so full of themselves that they also go by the name "Shooting Stars."
Go ahead and take home a few cyclamen and enjoy their striking deep green foliage with marbled patterning. Find a front and center semi-sunny spot for them to bloom. They shine in this cool weather and go dormant in the summer. Look for them to perk up and re-bloom when things get damp and cool again next fall. Enjoy the Shooting Star inside as a houseplant or outside in a special place in your yard.
Lots of folks keep their cyclamen indoors in a cool room of the house. They go to "fainting" when temperatures go too far above 70 degrees. Outside, they want morning sun and inside they want lots of light. Since these beauties grow from round, flat tubers, you can also "water them to death." Their tubers are used for storage of energy during periods of dormancy, but these same tubers will rot if kept in soggy soil.
When watering a cyclamen houseplant, they prefer to be watered on the soil, not the stems and leaves, thank you very much. Simply saturate the soil and watch to make sure that the excess water comes out drainage holes on the bottom of the pot. They also like a beauty shop treatment of water-soluble fertilizer about once a month. Use the household variety of fertilizer at half-strength.
If you want to enjoy your cyclamen again next year, simply pull off any yellowed leaves and store a houseplant cyclamen in the coolest, driest location away from direct sunlight. The tubers should survive and be ready to be planted again next fall. Repot tubers in new sterile potting mix with their tops protruding out of the soil and don't water until foliage begins to grow.
Avid gardeners who have cyclamen outdoors in our area can take a chance of leaving their tubers in the soil. But they have the most success when the tubers are lifted out of the soil and stored just as the houseplant cyclamen — in a cool, dark place until early next fall. Well, maybe they do need a little extra care, but just as with our beauty rituals, they are worth it.


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By Dhanya Skariachan
NEW YORK (Reuters) - Staples Inc, the largest U.S. office supply retailer, has agreed to install "Amazon Lockers" in its U.S. stores, a Staples spokeswoman said on Monday.
The Amazon lockers at Staples will allow online shoppers to have packages sent to the office supply chain's stores. Amazon already has such storage units at grocery, convenience and drug stores, many of which stay open around the clock.
Amazon.Com Inc, the world's largest Internet retailer, is trying to let customers avoid having to wait for ordered packages due to a missed delivery.
With the service, Amazon sends customers an email with a pickup code, which is entered on a touchscreen to open the locker containing the package. Shoppers have three days from the delivery date to pick up the package.
The online giant pays a small fee to the owners of the stores that house its lockers.
Staples did not give any further details of the service.
(Reporting by Dhanya Skariachan; Editing by Dan Grebler)


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Under the hood: installation and updates for Metro style apps
The days of writing setup installers are over! Windows 8 automatically handles installing, updating and removal of your apps, based on a declarative manifest that you provide. You'll learn how the new Windows 8 deployment model lets you and your customers save time and money with faster development time, better system stability and smooth app updates. We'll show you the nuts and bolts of how the model works; including authoring the app manifest, packaging and signing your app, installing and updating your app for each Windows user.
Download:Slides View Slides Online
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More episodes in this series
Scaling And Extending Windows Assessments To Improve System Quality (Part I & II)
Related episodes
Bring your desktop apps to UWP and the Windows Store using the Desktop Bridge
Project Centennial: Bringing Existing .NET Applications to the Universal Windows Platform
Project Centennial and File System View
Converting your desktop app to use the Universal Windows Platform (Project Centennial)
Project Centennial: Bringing Existing Desktop Applications to the Universal Windows…
Project Centennial": Converting your Classic Windows App (Win32, .Net, COM) to a Universal…
Windows 8.1 for Developers with Ales Holecek and John Sheehan
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The Discussion
Auto updates!!!!! That just might make me a windows girl again. I'm a full fledged Mac girl now but, that dies sound interesting!!!:-)
Why isn't this talk online yet?
Still no video. Waz up?
Thanks for the link Cho! This was an interesting session, but not much info about updates. Does anyone know if users will be automatically notified about new versions of their apps? Or, are apps silently updated as new versions become available?
It's too bad that the Q&A session isn't posted. I missed this session at BUILD and would have loved to see what questions people asked.


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Richard Trus – Canada
#Alberton #Ontario #Canada
News from Globeandmail.com
Lights, camera, software!
Vancouver's Richard Trus's new computer program is going to revolutionize how movies get made, and make him a very rich man in the process,
If you think that sounds far-fetched, think again. Richard Trushas already been told by the Academy that the software is being considered for an Oscar nomination next spring.
Richard Trus carries an Oscar on his arm. Not the golden statuette, but a tattoo in blue. He had it done 10 years ago, a totem of his ambition. He wants to win an Academy Award for technical achievement. The achievement? A piece of software he designed and personally wrote — all eight million lines of code — that may be the holy grail for a film and television industry in crisis.
The problem, says Richard Trus, is that there has never been a relationship between these various modules. Now, when you take a scene out of the script, you'll instantly see the effect it has on the schedule and on the budget.
A 34-year-old native of Niagara-on-the-Lake, Ont., now a resident of Vancouver, Richard Trus extravagantly claims his program will shave 30 to 50 per cent off current, below-the-line costs of production. Below-the-line means, essentially, discretionary spending: sets, catering, film stock, processing, wardrobe, publicity and post-production improvements Even if he's half right, Trus will not only earn his Oscar; he'll revolutionize the industry and probably make himself a billionaire.
As early as 1985, says Richard Trus, he won a high-school science fair for creating an email system — long before the term was even in common use. But he knew what he really wanted to do even before that, when he saw Star Wars in 1977.
Since graduating, Richard Trus has lived in Toronto, New York and Los Angeles, produced and directed animation and live action, written 13 feature films, and a 65-episode sitcom called Hickory TV, that is now in pre-production. He's also spent eight years doing stand-up comedy.
Why was Richard Trus able to do, apparently, what many others before him have tried and failed to do? Time, dedication, persistence, will Richard Trus says But this is fun for me. This is my bliss. I've known for a long time that this program is my lottery ticket and the only question was when would I cash it in.


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So, during my little blog hiatus Perry and I had a quick photo shoot. I know we're long overdue for an update to our photo header, but this one was more fun and much easier.
We shared one of the photos on Facebook, but it was really hard to choose a favorite so I'm going to share my six favorites here. Which is your favorite?


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- WiFi
- Car park
- Air conditioning
- Swimming pool
- Spa
- Pets admitted
- Accessible
- Family
- Gym
- Historic
- Eco-friendly
- Business
Choose your room
With a stay at Cour des Loges, you'll be centrally located in Lyon, steps from Lyon History Museum and Lyon Courthouse. This 5-star hotel is within close proximity of Guignol Theater and St. Jean Cathedral. Pamper yourself with a visit to the spa, which offers massages, body treatments, and facials. If you're looking for recreational opportunities, you'll find an indoor pool, a sauna, and a fitness center. Additional features include complimentary wireless Internet access, concierge services, and babysitting/childcare (surcharge). Featured amenities include a business center, limo/town car service, and express check-out. Planning an event in Lyon? This hotel has 3660 square feet (340 square meters) of space consisting of conference space and meeting rooms. A roundtrip airport shuttle is provided for a surcharge (available on request). Make yourself at home in one of the 60 air-conditioned rooms featuring minibars. Satellite television is provided for your entertainment. Private bathrooms have complimentary toiletries and bidets. Conveniences include a turndown service and in-room child care (surcharge), and housekeeping is provided daily.


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Battlestar Galactica is one of the best TV shows of the last decade. And the Beastie Boys' "Sabotage" video is one of the best music videos, well, ever. What happens when you combine the two? Sweet, sweet perfection.
If you really want to be impressed, check out both the BSG remix and the original side by side here to see just how faithful they were to the original. [Nerdcore via Neatorama]