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To investigate the influence of sleep position and sleep state on obstructive sleep apnea (OSA) severity in in children with Down syndrome (DS).
Retrospective review.
Sleep disorders laboratory of a tertiary medical center.
Children with Down syndrome and typically developing children matched for age, gender, apneahypopnea index (AHI), and year of polysomnogram.
Sleep variables from baseline polysomnography. Sensor-recorded position (supine, prone, lateral) was expressed as the percentage of total sleep time. The AHI was calculated in each sleep state (NREM, REM), position, and position-sleep state combination. Of 76 DS subjects (55% male) the median age and AHI were 4.6 years (range 0.2-17.8 years) and 7.4 events/h (range 0-133). In all subjects, AHI was higher in REM than NREM (p < 0.05); however, the NREM AHI was higher in DS subjects than controls (p < 0.05). Compared to controls, the percentage of prone sleep was greater in DS subjects (p < 0.05), but the percentage of supine or non-supine (prone plus lateral) sleep was no different. For DS subjects alone, NREM AHI was higher in supine than non-supine sleep (p < 0.05).
In DS and non-DS children alike, respiratory events are predominantly REM related. However, when matched for OSA severity, children with DS have a higher NREM AHI, which is worse in the supine position, perhaps indicating a positional effect compounded by underlying hypotonia inherent to DS. These findings illustrate the clinical importance of NREM respiratory events in the DS population and implications for treatment options.
Nisbet LC; Phillips NN; Hoban TF; O'Brien LM. Effect of body position and sleep state on obstructive sleep apnea severity in children with Down syndrome. J Clin Sleep Med 2014;10(1):81-88.
Down syndrome (DS), or Trisomy 21, is the most common chromosomal disorder and is associated with multiple coexisting medical conditions affecting the cardiovascular, respiratory, neurological, gastrointestinal, and hormonal systems. One such disorder is obstructive sleep apnea (OSA), which has a reported prevalence of 45% to 79% in children with DS.1–6 In striking contrast, OSA has a prevalence of 1% to 5% in the general pediatric population.7,8 Several clinical characteristics present in DS heighten the risk of OSA and additional sleep disturbance, including hypotonia, overweight, an underdeveloped midface and narrow nasopharynx, occurring in conjunction with relative macroglossia as a function of a normal sized tongue within a small pharynx.9,10 In addition, the pharynx is frequently crowded by both lymphoid hyperplasia and a more posterior location of the tongue, further compounded by a reduction in pharyngeal muscle tone.9,10
OSA is the more severe form of a spectrum of disorders known as sleep disordered breathing (SDB), the hallmark of which is snoring. OSA in children is characterized by frequent prolonged partial obstruction or intermittent complete collapse of the upper airway.11 The pediatric ramifications of OSA are vast, including adverse cardiovascular outcomes such as elevated blood pressure,12 autonomic dysfunction,13,14 and neurocognitive and behavioral deficits.15–19 The gold-standard method to diagnose OSA is overnight polysomnography (PSG), from which OSA severity is typically defined using the apnea-hypopnea index (AHI)—the total number of respiratory events per hour of sleep.20
Current Knowledge/Study Rationale: It has long been known that body position and sleep state can affect OSA severity in adults although findings conflict in the pediatric literature. Although highly prevalent in children with Down syndrome, the effects of body position and sleep state on OSA severity have received little attention despite that consideration of both may impact interpretation of polysomnography and subsequent treatment modality.
Study Impact: When matched for severity of OSA, children with Down syndrome have worse OSA in NREM sleep compared to typically developing children. While the effect of sleep position on OSA severity was similar in both groups of children, those with Down syndrome had worse NREM OSA severity in the supine position. For the clinician, these findings highlight the importance of NREM sleep contribution to OSA severity in children with Down syndrome.
It has long been known in adults that both body position during sleep and sleep state can affect OSA severity, such that AHI is typically reported to be higher in supine sleep,21–28 and to a lesser extent, during REM sleep.21 In fact, the respiratory disturbance index has been reported to be 40% to 50% lower when adult patients with OSA sleep in the lateral position compared to supine position.23,25,28,29 More recently, a significant effect of body position on OSA severity has emerged in pediatric studies, although findings are conflicting; some studies observed an improvement in OSA severity in the supine position30; others reported a worsening when supine31,32; and some found no positional difference.33–35 Furthermore, the long-held conviction that pediatric OSA is a REM-related disorder11,35,36 has also been challenged; while the majority of children do exhibit a higher AHI in REM sleep37,38 a considerable minority of children (30% in one study),38 were found to have predominantly NREM-related OSA.
Despite the astoundingly high prevalence of OSA in children with DS,1–6 the effects of body position and sleep state on OSA severity in the DS population have received little attention. Knowing the effects of these factors on OSA severity is important, as previously the validity of a diagnosis or classification of OSA severity based on PSG has been questioned in those who had inadequate supine and/or REM sleep, as these factors may result in an underestimation of severity.32 There are multiple reasons why the effects of body position and sleep state on OSA severity may be different in the DS population compared to patterns reported in typically developing children or adults with OSA. Positional effects may differ as a function of the etiology of OSA, considering the physical characteristics of DS (relative macroglossia, posterior tongue position, etc.); sleep state effects may also vary as a result of the generalized hypotonia commonly associated with DS and also due to alterations in sleep architecture, notably decreased amounts of REM sleep.39 We therefore aimed to investigate the effects of body position and sleep state on OSA severity, as measured by AHI, in children with DS in comparison to typically developing children matched for age, gender, OSA severity (total AHI), and year of PSG. We hypothesized that, in general, the influence of position and sleep state on OSA severity would differ between DS and non-DS subjects. Specifically, we hypothesized that compared to controls, changes in position would have less effect on OSA severity in DS subjects, such that AHI in the non-supine position would be higher in DS subjects than controls. We also hypothesized that while overall OSA would still be predominantly REM related in DS subjects, it would be to a lesser extent compared to controls, such that the NREM AHI would be higher in DS subjects than in controls.
Ethics approval for this retrospective case-control chart review was granted by the University of Michigan Health System Institutional Review Board. Subjects were children aged 0 to < 18 years, with or without SDB, who were referred to the University of Michigan Pediatric Sleep Disorders Clinic or Pediatric Multidisciplinary Behavioral Sleep Clinic for suspected SDB. All subjects subsequently underwent baseline polysomnography (PSG) between August 2008 and January 2013. Index cases were identified as children with a diagnosis of "Down Syndrome," "Down's Syndrome," or "Trisomy 21." Children with DS were excluded if their baseline PSG was conducted as a split-night PSG involving a period of continuous positive airway pressure (CPAP) titration. Cases were then matched for age, gender, AHI, and year of PSG with control subjects who did not have DS or other major medical conditions (including craniofacial abnormalities). Subjects with adenotonsillectomy (AT) or other upper airway surgery prior to baseline PSG were not excluded, as this is a common clinical SDB treatment pathway for children both with and without DS.
All subjects (cases and controls) underwent standard clinical overnight PSG using a commercially available PSG system. This included 6-channel electroencephalograms (F3-A2, F4-A1, C3-A2, C4-A1, O1-A2, O2-A1 of the 10-20 international system for electrode placement), electro-oculogram (right and left outer canthi), submental and bilateral anterior tibialis surface electromyograms, 3-lead electrocardiogram, thoracic and abdominal excursion (piezoelectric strain gauges), oronasal airflow (thermocouples and nasal pressure), and finger oximetry. As this was a retrospective study, body position during sleep was entirely up to the individual. Position was identified by a calibrated position sensor, located midline on the anterior aspect of the thoracic belt of each subject. Body posture during sleep was recorded as supine, prone, left lateral, and right lateral positions based on the truncal position as detected by the position sensor. Head and neck positions were not recorded.
Demographic variables were reported alongside standard sleep and respiratory PSG parameters for each subject. Height and weight measured on the night of PSG were used to calculate body mass index (BMI) in subjects ≥ 2 years, which was converted to a BMI z-score according to age and gender.40 Sleep staging was performed in 30-s epochs and followed standard criteria.20 The percentage of total sleep time (TST) spent in each sleep state (NREM and REM) was calculated in each subject, along with the percentage of TST spent in each body position (supine, prone, right lateral, left lateral). Durations of sleep in the prone, right lateral, and left lateral positions were combined and termed non-supine sleep, and similarly expressed as a percentage of TST in each subject. Additionally, the percentages of TST spent in both supine and non-supine positions in NREM and REM sleep were calculated separately.
Respiratory events ≥ 2 respiratory cycles in duration were scored as obstructive apneas, hypopneas, RERAs, or central apneas according to pediatric criteria recommended by the American Academy of Sleep Medicine (AASM) in 2007.20 Obstructive apnea was defined as cessation of thermocouple-derived airflow, or decrement > 90% from previous baseline, with continued chest and abdominal movement. Hypopnea was defined as a decrease in oronasal airflow, thoracic, or abdominal excursion ≥ 50% when followed by a decrease in oxyhemoglobin saturation ≥ 4% or an EEG arousal ≥ 3 seconds. The AASM-2007 apnea-hypopnea index was calculated as the number of apneas and hypopneas per hour of sleep, and the AASM-2007 respiratory disturbance index (RDI) was calculated similarly, with the addition of RERAs.20 The mean oxygen saturation (SpO2) during sleep was reported for each subject alongside the SpO2 nadir. Sleep efficiency was calculated as the percentage of time asleep following lights out. The arousal index was calculated as the number of arousals per hour of TST, the periodic leg movement index (PLMI) as the number of periodic leg movements per hour of TST, and the periodic leg movement with arousal index as the number of periodic leg movements per hour of TST that were associated with an arousal.
In addition to the total AHI, the AHI was calculated separately in NREM sleep, REM sleep, and again in each body position (supine, prone, right lateral, left lateral, collective non-supine). Finally, the AHI in supine and non-supine NREM and REM sleep was calculated. There exists no accepted description of positional sleep apnea in children; therefore, 2 methods were used to describe the effect of body position. Firstly, "positional patients" were defined as those in whom the AHI was at least twice as high in one body position as another. For example, "supine positional" meant that the AHI in the supine position was at least twice that of the non-supine position. This description is similar to that used previously in adults23,41 and children,33 although we used non-supine instead of lateral to incorporate the prone position. Secondly, positional patients were identified simply by the absolute numeric majority of AHI for either supine or non-supine sleep in each child.33
Medical records were reviewed, and the number of subjects who underwent a successful CPAP titration study following the baseline PSG were recorded. The difference in total AHI, NREM AHI, and REM AHI from baseline to titration was expressed as a percentage of the relevant baseline AHI.
Statistical analysis was performed using SPSS (Version 20, IBM SPSS, Armonk, NY, USA). Data were first tested for normality and equal variance. Normality could not be achieved through log transformation; hence, demographic and sleep characteristics were compared between DS and control subjects using the Wilcoxon-signed rank test. The predominance of respiratory events in REM sleep (termed REM predominance index, REM PI) was calculated to reflect the ratio of REM to NREM events, using an adjustment factor (0.5) added to the AHI values to allow inclusion of zero values in analysis.38 The equation used was REM PI = log(REM AHI + 0.5) – log(NREM AHI + 0.5), equivalent to log(REM AHI + 0.5 / NREM AHI + 0.5). The REM PI was subsequently compared with a value of 0 (no difference between REM and NREM AHI) using the Wilcoxon-signed rank test. Within DS subjects as a whole and again within control subjects, the Wilcoxon-signed rank test was used to compare the effects of sleep state (NREM, REM) on AHI, of body position (supine, non-supine) on total AHI, and of body position (supine, non-supine) on NREM AHI as well as REM AHI. As infancy and/or puberty may influence the effects of body position and/ or sleep state on AHI, analyses were repeated in a subsample of subjects aged ≥ 2 years and < 13 years. The proportion of subjects in each of the DS and control groups with a REM PI < 0 was compared using χ2 analysis, as were the proportion of positional patients (supine positional, non-supine positional, non-positional), for both methods of categorization of "positional patients." Statistical significance was taken at p < 0.05, and data were expressed as the median and interquartile range.
A total of 76 children with DS were compared with 76 control subjects matched for age, sex, total AHI, and year of PSG.
Demographic and basic polysomnographic variables for DS and control subjects are shown in Table 1. Forty-two case-control pairs (55%) were male. The median age was subjects was 4.6 years (range 0.2-17.8 years) in DS subjects and 5.1 years (range 0.3-17.7 years) in control subjects. There were no differences between DS and control subjects in age or BMI z-score. Compared to controls, TST was reduced in DS subjects (p < 0.05), but there were no differences in the percentage of TST spent in either NREM or REM sleep. Despite matching for severity of SDB, the total AHI was significantly higher in DS subjects than control counterparts (p < 0.05). Sleep efficiency, mean oxygen saturation, and the oxygen saturation nadir were significantly lower in DS subjects than controls (p < 0.05 for all). There was no difference in arousal index or PLM arousal index between DS and control subjects, although subjects with DS had a lower PLMI than controls (p < 0.05).
Demographic and basic polysomnographic characteristics of DS and control subjects
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The NREM AHI was significantly higher in DS subjects than control counterparts (p < 0.05 for both), although the REM AHI was not different (Table 1). In both DS and control subjects, the REM AHI was significantly higher than the NREM AHI (p < 0.001 for both). The REM PI was significantly greater than 0 in both DS and control groups (p < 0.001 for both), further indicating an overall predominance of events in REM sleep. However, the REM PI was not different between DS and control subjects. A REM PI < 0 was seen in 28% of DS subjects, indicating a predominance of NREM events in these subjects, in comparison to 20% of control subjects, although the proportion of subjects with an REM PI < 0 was not different between groups (p = 0.22).
The percentage of TST spent in each body position (supine, prone, right lateral, left lateral, and total non-supine) in both DS and control subjects is shown in Table 2. Compared to controls, DS subjects spent a significantly larger percentage of sleep in the prone position and a smaller percentage of time in the right lateral position (p < 0.05 for both). However, overall there were no differences between DS and control subjects in the percentage of time spent asleep in the non-supine position, or in the supine position.
Body position as a percentage of TST in DS and control subjects
Figure 1 compares the AHI in DS and control subjects for each position of sleep. There were no significant differences in AHI between DS and control subjects for supine or any non-supine sleep position. In DS subjects overall, and similarly in control subjects as a whole, the AHI was not significantly different in the supine compared to the non-supine position, although numerically the AHI appeared to be higher during supine sleep.
The box represents the 25th percentile, median, and 75th percentile. The whiskers represent the 10th and 90th percentiles, and outliers are represented by circles.
Comparison of the apnea-hypopnea index in Down syndrome (gray) and control subjects (white) in each sleep position. The box represents the 25th percentile, median, and 75th percentile. The whiskers represent the 10th and 90th percentiles, and outliers are represented by circles.
DS and control subjects were categorized as "positional patients" using the "twice as high" rule, as shown in Table 3. Categorization was not possible in 18 DS subjects and 5 control subjects, as they had not slept in either the supine or non-supine position, precluding calculation of an AHI in both positions. Of the DS subjects, 48% were found to be "positional patients"; 33% of subjects had an AHI twice as high in the supine position, and 15% of subjects had an AHI twice as high in the non-supine position. The proportion of positional patients was not significantly different between the DS and control groups.
The proportion of positional patients in DS and control groups, categorized according to the AHI "twice as high" rule
According to absolute numerical majority, there were no differences between the DS and control groups in the proportion of subjects with either a higher supine AHI or a higher non-supine AHI (Table 4). In DS subjects, AHI was higher in the supine position in 53%, in the non-supine position in 42%, and was equal in supine and non-supine positions in 5% of subjects.
The proportion of positional patients in DS and control groups, categorized according to the "absolute majority AHI" rule
The percentage of TST spent in the supine or non-supine position in both NREM and REM sleep is shown in Table 5. There were no differences between DS and control subjects in the percentage of non-supine NREM sleep, supine NREM sleep, non-supine REM sleep, or supine REM sleep. The AHIs in each of the respective body position and sleep state combinations were not different between control and DS subjects. In DS subjects as a whole, the AHI of NREM sleep was significantly higher in the supine than the non-supine position (p < 0.05); however, in control subjects this positional difference was not observed. The AHI of REM sleep was not significantly different in the supine and non-supine position in either the DS or control group separately.
Percentage of TST spent supine and non-supine in NREM and REM sleep and associated AHI in DS and control subjects
As the subject age range was wide, analyses were repeated in a subsample of children aged ≥ 2 and < 13 years to exclude the possible effects of infancy and puberty. A total of 51 subjects with DS with a median age of 6.0 years and AHI of 7.5 events/h (range 0-61.3) were compared with 51 matched controls. Results of the effects of sleep state, body position, and the combination of sleep state and body position on AHI were similar to findings with children of all ages (data not shown).
In order to determine the distribution of respiratory events in NREM and REM sleep, we reviewed charts of a subsample of DS subjects who underwent successful CPAP titration (n = 10). Four subjects had a greater percentage improvement in NREM AHI than in REM AHI. Although not statistically significant, a greater improvement in total AHI was observed in those with a greater improvement in NREM AHI than those who had a greater improvement in REM AHI (median change in total AHI 87% [interquartile range 74% to 96%] compared to 76% [37% to 87%]; data not shown).
The present study is the first to investigate both the effects of sleep state and body position on OSA severity in children with DS. Previous studies have assessed these factors, often as a secondary aim, in only a small number of children with DS and have not always included a comparison group of children.5,42,43 The main findings of this study were that, in comparison to typically developing children with OSA of a similar severity, children with DS similarly exhibited a REM predominance of respiratory events, with a minority of individuals demonstrating a preponderance of NREM-related events; and the DS children had a higher NREM AHI, despite being matched for total AHI and having a similar percentage of sleep time in NREM. Notably, children with DS exhibited a higher NREM AHI in the supine position compared to the non-supine position—a finding not observed in the control children or during REM sleep in either group. While the children with DS spent a greater amount of time sleeping prone, overall the amount of non-supine sleep (prone plus lateral) was not different.
In children with and without DS alike, we found respiratory events to be predominantly, although not exclusively, present in REM sleep. This pattern is not surprising and has been reported previously in typically developing children with OSA.37,38 Verginis and colleagues found that a significant subset of children (30%) exhibit a NREM predominance of obstructive events.38 In our DS population, we similarly found 28% of children to have NREM-predominant OSA, illustrating that consideration of sleep state distribution is just as important in individuals with DS. While numerous studies have investigated the prevalence of OSA in children with DS, few have assessed the effects of either sleep state or body position on OSA severity. Two studies provided in-depth descriptions of respiratory events in children with DS but did not report positional or sleep state-specific AHI.2,44 Another study, of 33 children with DS aged 0-19 years, found the REM AHI to be three times higher than the NREM AHI and to be associated with the lowest oxygen saturation recorded.5 The present study introduced another element by comparing AHI with typically developing children. Interestingly, we found that in children of similar overall OSA severity, the NREM AHI was significantly higher in children with DS. Together, these findings suggest a heightened importance of the NREM sleep contribution to OSA in DS subjects, even in the context of REM-predominant OSA.
We observed an increased proportion of sleep time in the prone position in children with DS compared to controls, although when grouped into supine or non-supine sleep, the two groups of children were similar. A previous study of 17 children with DS, aged 2-18 years, found a tendency for an increased proportion of supine sleep compared to controls of similar age, gender and AHI, but no difference in the amount of prone sleep.42 Aside from differences in sample size, findings may differ from the present study due to a lower OSA severity (median total AHI of 4.3 events/h compared to present study AHI of 7.4 events/h). Other studies in children with DS have reported a higher number of changes in position during sleep42,45 and an increased amount of sleep time in the "leaning forward" position42 in comparison to controls; however, we did not measure either of these variables. Our findings suggest that children with DS and moderately-severe OSA generally exhibit positional preferences during sleep similar to those of typically developing children of similar OSA severity. Interestingly, studies of small cohorts of children with OSA have found that the supine position is highly prevalent throughout the night,32,33,46 such that the sleeping positions of children are altered by the presence of OSA. A larger study determined that when compared to children without OSA, children with OSA spent more time in the supine position and less time in the lateral position, while obese children with OSA were more likely to sleep prone.34 The adoption of the prone position in the presence of obesity suggests that the supine or lateral positions may increase the risk for more severe respiratory disturbance when OSA and obesity coexist. It is likely that a similar pattern exists in DS, which could be further augmented not just by the presence of obesity but by other physical characteristics which may act to increase the risk of respiratory difficulty in certain positions. The contention that OSA affects positional sleeping preferences is further supported by the findings of increased supine time, reduced lateral time, and reduced prone time in a relatively overweight group of children with OSA following adenotonsillectomy.46 The positional preferences of children with DS but without OSA are yet to be elucidated.
We observed no difference between DS and non-DS children in relation to the positional effects of OSA severity over the night as a whole. In each position, the AHI was similar in DS and control children despite possible differences in OSA etiology, including contributions of physical characteristics. The only previous study to measure positional AHI in children with DS similarly reported no difference between DS and control groups in the various positions.42 We did not detect a difference in AHI between the supine and non-supine positions in either DS or control children, although OSA severity appeared to be increased in supine sleep. In typically developing children, OSA severity is reportedly worsened when supine or not affected by position, depending on the study.31–35 In our cohort of DS subjects, 53% had a numerically higher supine AHI than non-supine AHI, and 33% of subjects had an AHI twice as high in the supine position. The proportion of subjects in these "positional" categories was not different from proportions seen in our typically developing control children. Supine positional OSA is more common in adults with OSA, accounting for 50% to 60% of individuals.22,25–27 Our findings suggest a heterogeneous effect of position on overall OSA severity in children with DS.
We subsequently examined the effect of supine and non-supine sleep on OSA severity specific to each sleep state and found that children with DS were different from controls in one aspect alone; during NREM sleep the AHI was significantly higher in the supine position compared to the non-supine position. This difference was not found in the control children or in either group during REM sleep, suggesting that the effects of position are more overt in NREM sleep in those with DS. In view of the hypotonia inherent to DS, we contend that the gravitational effect on airway patency associated with supine sleep is possibly augmented by increased pharyngeal muscle hypotonia, which would not normally be seen during NREM sleep in typically developing children. It fits that during REM sleep, a degree of hypotonia occurs regardless of position in children with and without DS alike, hence reducing the positional difference on OSA severity in this state. Therefore, the combination of sleep state and position merits consideration when both interpreting PSG and guiding treatment choices for children with DS.
In typically developing children, the effect of position on OSA severity can vary not only with obesity but also with age32,35; however, we did not find this to be the case in children with DS. Our findings were similar both when all subjects were included, aged from 2 months to less than 18 years, and when restricted to those aged 2 years to less than 13 years. While we could not characterize the positional and sleep state effects during infancy or puberty due to small numbers of subjects of these ages, for the majority of pre-pubescent children with DS, to the best of our knowledge it appears that the positional effects remain the same in children with DS irrespective of age.
Knowledge of the positional and sleep state effects on OSA severity may be important for optimizing treatment in children with DS as a whole, but also on an individual level. We demonstrated in a small subsample of children that improvement in total AHI was greater in children who had a larger change in NREM AHI than in REM AHI. This occurred in spite of a REM predominance of respiratory events. Thus consideration of the sleep state distribution of respiratory events should be an important factor when interpreting PSGs and formulating management plans in children with DS. As recently reported by Eiseman47 in adults with OSA, it is important to consider "conditional" AHI values when position and/or sleep state dependent OSA is evident on PSG, as there is a clear risk for potential misclassification of disease presence or severity. As suggested in both that study and by our findings, routine PSG interpretation should include the frequency of respiratory events by both sleep state and body position, values that may have particular importance for the DS population.
On an individual level, consideration of therapies which treat OSA preferentially in one sleep state or which make a bigger improvement in a certain position may prove helpful. For example, a study in adults with non-positional OSA found uvulopalatopharyngoplasty to produce a much greater decrease in the lateral RDI than in supine RDI.48 Indeed, knowledge of the positional and sleep state distribution of events would allow clinicians to estimate the range of OSA severity that could occur, for example, from presumably the most severe in cases where a child has the majority of sleep in the supine position, to the least severe where the child is mostly in the lateral/prone positions. One night in the sleep laboratory may not be representative of the child's typical sleep in his/her own environment, particularly in regard to position and sleep state distribution, and so the ability to extrapolate data as described is likely to result in improved individual treatment recommendations. It follows that consideration of the OSA pattern may prove beneficial in OSA patients, DS and non-DS alike.
This study is not without limitations. Despite matching, total AHI was statistically higher in children with DS than controls. However, this statistical difference is unlikely to be clinically significant, as paired values were consistently of the same OSA severity grouping as defined clinically; moreover, median total AHI values of each group differed by only 0.1 events per hour. It is possible that the difference in NREM AHI between groups is a result of the statistical difference in total AHI between groups; however, as the median, 25th and 75th percentile values of NREM AHI were all consistently higher in the DS group, this effect is less likely. As this was a retrospective review of the positional effects of OSA, we did not control sleeping positions, and thus not all subjects slept in all positions. However, in doing so, it permitted us to compare the preference for sleep positions in our subjects, albeit in a clinical laboratory setting. For analysis of AHI according to each sleep state-position combination, prone and lateral sleep durations were grouped together as non-supine sleep in order to maximize the number of subjects contributing to the findings. Furthermore, we do not have record of head or neck flexion or rotation during sleep, or of upper airway examination in our subjects. Children in the prone or lateral position can have flexion of their neck, which may lead to increased upper airway collapsibility.49–51 Using rigid video endoscopy, a study of typically developing children with OSA determined that the positional effects varied as a function of the type of upper airway narrowing; the supine position was preferable to lateral in those with only adenoidal hypertrophy; however, in the case of hypertrophic tonsils and adenoids, breathing was worse in the supine position.33 Their findings support a gravitational component of OSA in children, even if the level of obstruction is typically at the adenoids or soft palate52 rather than the tongue as seen in adults, in whom gravity is a key contributor to OSA. As the etiology of OSA in DS is arguably more multifactorial, the delineation of positional effects according to adenoidal or tonsillar hypertrophy may not be possible, although is a potential area for future research. Despite these limitations, the present study has nonetheless provided important insights into factors which affect OSA severity in DS, highlighting areas for future focus and for clinical consideration.
The present study found that in DS and typically developing children of similar age and OSA severity, respiratory events are predominantly REM related but can be related to NREM sleep or the supine position in significant subset of individuals. When matched for total AHI, children with DS have a higher NREM AHI. The effect of position on total AHI is similar in DS and control children, however in children with DS, NREM AHI worsened in the supine position, perhaps indicating a positional effect compounded by underlying hypotonia inherent to DS. These findings illustrate the importance of the NREM sleep contribution to OSA severity in the DS population. Consideration of both sleep state and position warrant attention when interpreting OSA severity and choosing treatment modalities.
This was not an industry supported study. Dr. O'Brien was partially supported by grants from the National Heart, Lung, and Blood Institute (K23 HL095739, R21 HL089918, and R21 HL087819). She receives equipment support from Philips Respironics Inc., has received sleep-related NIH grant funding, and has received honoraria for speaking on the topic of sleep disordered breathing. The other authors have indicated no financial conflicts of interest.
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For more information see my website : : www.augustastylianougallery.com Augusta Stylianou was born in Cyprus, the island of the goddess Aphrodite, in a beautiful sea-side town called Limassol. From a young age she enjoyed Geography and took interest in the customs and traditions of cultures. She wanted to find out, as was possible, about the entire world as well as the way in which it was created. She studied Political Sciences and Public Administration at the university of Athens, regardless of the fact that these fields of study did not reflect her true interests. During her student life she would make handicrafts, including jewellery, in the spare time that she had. This brought her closer to the arts and from then on her aim...
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This is a guest post from Renaud Anjoran. Renaud runs a product quality inspection business in Shenzhen and he also writes the truly excellent and perennially helpful Quality Inspection Tips. My firm has worked with Renaud on a number of China product matters and we have consistently found him to be highly knowledgeable about China product sourcing. This post arose from a long email "conversation" between co-blogger Steve Dickinson and Renaud, which ended as so many of those do: with me suggesting that it be turned into a blog post.
So here's the blog post, written by Renaud Anjoran.
Most transactions with Chinese suppliers are done through bank transfers. This payment method was described in a previous China Law Blog post, China Manufacturing Payment Terms. Limit Your Risks.
Many importers/foreign manufacturers are not familiar with Letters of Credit (LC) as an alternative to bank transfers. Letters of Credit were designed to protect both product buyers and product supplier in international trade. In practice, they are usually more favorable to the buyer.
How a letter of credit protects the buyer
An importer that pays by LC does not have to wire a deposit before production and it usually has the option to cancel the payment in the following cases:
- If a supplier does not ship at the right time. Typically if this happens, the LC simply expires, but the buyer still has the choice to pay if it wants the goods.
- If a supplier does not honor the product specification or if there are too many defects. One of the conditions of the LC should be that the LC will not be paid on unless and until the product buyer has signed off on product quality or a specified third party QC agency has issued its certificate of inspection.
- If the seller fails to provide any document listed as required in the LC or the documents do not fully conform to the LC's requirements.
Why letters of credit can be cancelled by the buyer in most cases
Even something as small as a typo in the LC, or the fact that a quantity is written in dozens rather than in pieces in the invoice is usually enough to cause a discrepancy in the LC, which in turn allows the buyer to cancel payment.
In practice, a small minority of LCs are "clean," i.e., without any discrepancy. In all other cases, the buyer has the option to refuse payment and cancel the transaction, even if the goods are already on a boat (in which case the buyer will not get the documents to get the products out of custom).
CLB Note: We are aware of a Seattle buyer company that refused goods that had already arrived in Seattle because the street address (which was irrelevant) of one of the parties in the letter of credit was off by a single letter.
Tips for negotiating payment by letter of credit
For the reasons mentioned above, Chinese suppliers typically refuse to accept Letters of Credit. Here is how you can increase your chances of finding a Chinese company that accepts this payment method:
- When sourcing your product, try to identify as many potential suppliers as possible. This will at least increase your chances of finding one that will accept an LC.
- In your first conversation with your potential suppliers, mention that you always pay by LC on your first order. Try to get the supplier to accept this payment method in writing
- Sell your project to your potential suppliers. Good manufacturers are inundated with customer inquiries, so you need to make yourself stand out. Explain why they should work with you. Call the Chinese company's sales manager if necessary
- Send your potential Chinese manufacturer a draft of the LC before opening it. You will usually need the commercial invoice, the packing list, the certificate of origin and/or GSM form A, the bill of lading, and an inspection certificate. Try to avoid putting "soft terms" into your Letter of Credit that will make it even more difficult for suppliers to collect payment.
- If possible, use a major international bank. This will tend to reassure your suppliers.
- Unfortunately, bank fees are much higher for an LC than they are for a bank wire, so an LC only makes sense for transactions of at least USD$30,000.
- Chinese exporters are good at guessing whether a project is likely to become a source of long-term business. When they see what they think will be a a one-shot deal, they generally insist on getting a deposit and will not agree to an LC payment arrangement.
In summary, Letter of Credit are a payment tool that makes it unnecessary to transfer a 30% (or more) deposit to your Chinese manufacturer. They are usually more favorable to the buyer's side, and for that reason, many Chinese companies refuse to accept them. But some Chinese product suppliers have been paid via Letters of Credit from some of their foreign customers for years, and sometimes Chinese manufacturers will accept your Letter of Credit if they really want your orders.
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LONDON -- The fourth staging of the European Gaming & Amusement International Exposition came to a rousing conclusion on Jan. 24, having established a new record for attendance. "Despite enduring the very worst of British weather, everyone rallied to prove beyond all doubt the resilience of the industry and the importance of EAG as a standalone event," the show's organizers reported, noting that its January date continues a 70-year tradition in the UK's amusement industry.
Severe storms had taken Western Europe by surprise, dropping enough snow to force flight cancellations. The weekend before EAG opened, London's Heathrow airport had cancelled about 20% of its usual schedule because of snow and low visibility.
EAG International Expo chairman Martin Burlin observed that the 2013 event drew 5,411 "unique visitors," up slightly from the 5,333 showgoers recorded last year. Including registrants who attended the show for more than one day, he added, total "visits" exceeded 7,000. The latest in products and services from approximately 150 manufacturers, suppliers and related trade associations were showcased during the three-day event.
The 2013 expo again was the occasion for the UK's IOA (originally Independent Operators Association) to hold its annual general meeting. IOA is a group of 14 owner-managed regional operating companies that, collectively, cover the entire country. According to chief executive Peter Weir, EAG International Expo provides the perfect time and location to stage its annual gathering.
"This will be the fourth year for holding our AGM at EAG International," he added. "We support and attend many regional shows, but EAG International is the most important. Since its inception, EAG has been the event where we can see and discuss the very latest products."
Also returning to the 2013 EAG event was the British Association of Leisure Parks, Piers and Attractions. BALPPA is the nonprofit trade association that represents the interests of owners, managers, suppliers and developers in the UK's leisure parks, piers, zoos and static attractions sectors. The 76-year-old association has 300 members, including some of the UK's most iconic attractions.
EAG's Burlin welcomed BALPPA's continued support. "With the blurring of divisions between the various markets in the leisure sector, EAG International Expo is enjoying a broadening appeal," he observed. "We're confident that as the show continues to adapt, it will become increasingly relevant to BALPPA members."
"Having a physical presence at key industry events is important for any trade association," said newly appointed BALPPA chief executive Paul Kelly. He reported that the association also scheduled its 2013 annual general meeting for the day before the show opened. The group also hosted a BALPPA lounge in the exhibit area.
Exhibitors were very pleased by the turnout and the interest displayed by showgoers. "This show was the best event we have enjoyed in our company's 16 years' experience," said Josip Tarres of DC Digital Centre (Barcelona, Spain, and Miami, FL).
The show also is exerting its appeal on new categories of exhibitor. A first-time participant this year was Maple Moose, which has developed a proprietary solution for delivering branded crepes, along with waffles, beverages and scoop and whipped ice cream.
Managing director Hans Parker explained, "With 17 outlets in Ireland and the UK, Maple Moose is already a successful franchise operation, trading as standalone shops, stores within stores and food courts plus even as a mobile operation. We believe our concept is the small-space solution for amusement and attraction operators looking to offer their customers something different from the usual run-of-the-mill fast food."
The company was founded in 2008, and its specialty items are produced using a secret French recipe. Making its debut at the EAG was Maple Moose's Popcakes machine, which quickly turns out stacks of 10 "mini American Pancakes" and is about the size of a conventional microwave oven.
Rounding out the agenda were the popular EAG Master Classes. This year's curriculum included a comprehensive overview of the new "machine games duty," imposed on gaming equipment, which has superseded an amusement machine license fee plus "value added tax." A series of presentations at the EAG Expo addressed the impact that MGD is likely to have on an operation, including changes in VAT recovery; the accounting records that operators must maintain to comply with the law; and the practical considerations in the event of a visit or inquiry from Her Majesty's Revenue and Customs department.
On a happier note, Michael Getlan led presentations on two days on "how to make more money," dealing with the choice of ticket redemption equipment, the art of selecting and displaying prizes, and an overview of merchandise dispensing equipment and staff training and motivation.
Getlan, a third-generation amusement center operator, runs a number of facilities in the U.S.; the largest, Fun Fuzion at New Roc City (New Rochelle, NY), occupies almost125,000 sq.ft. He also owns Amusement Consultants LLC and serves on the board of the International Association of Amusement Parks and Attractions.
Next year's European Gaming & Amusement International Exposition, the fifth, will return to the ExCeL exhibition center at the historic Royal Victoria Dock in London's Docklands, from Jan. 21 through 23, 2014. The organizers, Swan Events Ltd., maintain a website for the show at eagexpo.com.
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It's time to talk about NHL expansion again. The topic which most of us have exhausted ourselves discussing is back and this time it comes from a report seen in The Providence. According to Tony Gallagher, an NHL team in Vegas is going to be a reality in the very near future.
From the article:
"Sources close to the situation have indicated Las Vegas is a done deal, the only thing to be determined being which owner will be entitled to proclaim that he brought the first major league sports franchise to Sin City.
With all the activity going on in the Seattle area in the last little bit it would be quite a stretch to imagine that much time and effort being spent by so many wealthy men being frittered away for nothing."
That sounds like one confident writer regarding the Vegas situation. We'll have to wait and see if other writers and sources come forward to back this report, but it's safe to say that expansion is likely sooner than later. Whether it's Vegas, Seattle or Quebec is up for all of us to debate until the NHL finally settles on a city or two.
Like it or not, expansion is coming. We've preached here at PDL that the NHL needs to address issues in other cities before opening up new teams, but that's not an attractive idea when there's guaranteed money to be made in a new city. Still, expansion does make sense purely on a competitive fairness level as the NHL currently has a 16-team East and a 14-team West. Granted they created that problem themselves with the new alignment, but it's still one that needs fixing.


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New to Bullseye? Subscribe to our podcast in iTunes or with your favorite podcatcher to make sure you automatically get the newest episode every week.
And if you're looking for a particular segment to listen to or share, check us out on Soundcloud.
Melissa McCarthy knows how to throw herself into her comedy. Physically, emotionally, she goes all out. People who saw her onstage at the Groundlings knew it. But you didn't really see it on-screen yet. She was mostly known for playing the lovable cook and best friend, Sookie St. James, on Gilmore Girls. Then she had landed a titular role on the CBS show Mike & Molly, which won her an Emmy. In 2011 she got a part in Bridesmaids. And her horizons have only expanded from there.
McCarthy's become a film star, mostly in roles similar to her character in Bridesmaids. Maybe a little crass, maybe a bit of a hot mess. She starred in, her husband Ben Falcone directed, and they both wrote the new comedy Tammy.
Tammy follows a midwestern woman whose life is a mess. So she goes on a road trip with her alcoholic grandmother, to get out of her home town for good.
McCarthy and Falcone met in comedy improv classes, bonded, and eventually became partners both in business and in life.
They'll talk about their high school days, including Melissa's goth phase, their fateful meeting in the Groundlings, and what it was like getting Kathy Bates to play a role that was literally written for her.
Tammy hits theaters this week.
If you liked this, let someone know! Click here to share this segment.
Linda Holmes and Glen Weldon of NPR's Pop Culture Happy Hour stop by to recommend some of their all-time favorite reads.
Glen recommends the manga series called Oishinbo, translated as 'The Gourmet'. It's about two rival newspapers competing to create the perfect Japanese meal. He suggests starting with the volume about sushi.
Linda recommends The Devil's Candy by Julie Salamon, a book about the film production of Bonfire of the Vanities. Salamon was granted unlimited access to the film set. The takeaway? Sometimes folks don't set out to make a bad movie, it just kind of happens.
You can hear Glen and Linda each week on the Pop Culture Happy Hour podcast, and find Linda's writing on NPR.org's Monkey See blog.
If you liked this, let someone know! Click here to share this segment.
Davy Rothbart, Point Guard of FOUND Magazine, shares some of his favorite "finds." He'll share some of his favorite ephemera: to do lists that include items like "hook up with Jen" and "create a circuit of pirate radio stations in the Traverse City area."
FOUND Magazine issue 9 is available now. And stay tuned this fall for FOUND: The Musical, presented by the Atlantic Theater Company.
If you liked this, let someone know! Click here to share this segment.
Randy Sklar and Jason Sklar are stand up comedians. They're also twins. Their work isn't about their twinness, though. In fact, outside of the two of them looking the same, they barely mention it. But it's integral to what they do. Most double acts are about contrast, the Sklars are the opposite.
They diverge, they come back, and all in the service of releasing a firehose of jokes. The pair have been doing comedy together their entire adult lives. They have their own podcast, Skarlbro Country, they hosted their own TV show on the History Channel, and have racked up lots of movie and TV appearances.
They'll talk about why they didn't want to do bits about being twins, why they wanted to combine comedy and sports on Cheap Seats, and how if they were part of the same person, well, Randy's the head and Jason's the heart.
Their stand up special What Are We Talking About? is available now on Netflix Instant.
If you liked this, let someone know! Click here to share this segment.
Jesse will tell you about why he loves the craziest-looking baseball player in the majors, and why you should, too.
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Miami-Dade lawmakers mum on stadium tax deal for Dolphins
Earlier this week, the Miami Dolphins succeeded in getting a committee of lawmakers from across the state to vote for a taxpayer deal written exclusively for the team's $400 million stadium renovation.
"I've never done a bill that benefits one person, statutorily, so I have real concerns with that," said Sen. Nancy Detert, R-Venice, before laying aside her concerns and joining 10 other senators to cast a unanimous vote for the measure.
The legislative triumph appears to be short-lived for the Dolphins' top brass.
The reason: The Miami-Dade delegation of lawmakers decided not to give the proposal its full endorsement.
The 24-member delegation finalized its list of legislative priorities Thursday, naming goals like fighting insurance price hikes, funding Jackson Memorial Hospital and building a memorial for Bay of Pigs veterans.
Conspicuously absent from the list: any mention of a proposal to provide the Dolphins as much as $200 million for a stadium makeover.
"The delegation didn't take a position," said Rep. Eddy Gonzalez, a Hialeah Republican who chairs the delegation and is sponsoring the Dolphins bill. "We have quite a few members that are on board with it, there's a few that are not."
Localized bills that don't have the full support of a local delegation face a steeper challenge of getting approval from the full Legislature, where some lawmakers may be hesitant to vote for special tax deals in other parts of the state.
The Dolphins brushed aside the development, with SunLife stadium CEO Mike Dee saying he remains "confident that our elected leaders can and will address many other important issues" not listed on the priorities list.
State Rep. Jose Felix Diaz, a Miami Republican and vice chair of the delegation, said the Dolphins measure didn't even come up during the recent goal-setting meeting. Gonzalez said he did not consider the bill a priority for the county, even though he's sponsoring it.
Instead, issues like education, affordable housing, healthcare funding are the goals South Florida lawmakers have agreed to focus on.
"These are the things that our constituents want us to concentrate on right now," said Diaz.
The Miami-Dade County commission fully endorsed the stadium project last month, asking state legislators to approve it. The commission did not convince the local delegation to make the measure a priority.
It's not the first time rifts have emerged in the Miami-Dade delegation over a stadium bill.
Last year, members of the delegation held a public feud on the floor of the House over a bill to help the City of Miami avoid paying property taxes after a botched stadium deal with the Marlins. The bill was sponsored by Diaz.
Rep. Ana Rivas Logan, R-Miami, said in a floor speech that she received a threatening phone call — possibly from another lawmaker — after she opposed the measure.
The property tax relief bill eventually passed, and Logan and Diaz went on to square off in a primary election six months later. Diaz won.
The widely-panned Marlins deal continues to cast a shadow over the Dolphins as the team seeks taxpayer assistance to renovate its 25-year-old stadium.
Sponsors and supporters of the Dolphins' proposal often begin their pitches with the phrase, "This is not another Marlins' stadium." A slew of supporters came to Tallahassee this week to tell lawmakers the bill would create thousands of jobs and bring Super Bowls and other events to Florida.
The Greater Miami Chamber of Commerce, city of Miami Gardens and other local groups have come out in support of the package.
But constituents back in South Florida have been making their voice known on the issue, with some blasting the deal as corporate welfare for billionaire Dolphins owner Stephen Ross.
Ross and the Dolphins are asking for the county's mainland hotel tax to increase from 6 percent to 7 percent, as well as up to $90 million in state sales tax rebates, paid out over 30 years.
The delegation's non-endorsement could harm the Dolphins' chances, but the team has a well-connected team of lobbyists and supporters backing the bill.
Ron Book, an influential lobbyist representing the Dolphins, said he wasn't concerned by the delegation's decision. He said the team's strategy is to work with all 160 legislators and convince them that having a state-of-the-art Dolphins stadium will benefit the entire state.
"The legislative session hasn't even started," he said. "We're barely in the first quarter of a long football game."
Miami Herald reporters Mary Ellen Klas and Doug Hanks contributed to this story. Toluse Olorunnipa can be reached at firstname.lastname@example.com or on Twitter at @ToluseO.


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2014 Compact Sedan Comparison Review - Day 5
Welcome to Day 5 of the Automobile Magazine Compact Sedan Comparison Review.
When you look at the cars that Americans drive, you see an awful lot of compact sedans. There is always talk about large, snappy sedans, but simple, small sedans deliver the real-world utility that real people need. That's why the list of the top-ten bestselling cars in the United States includes the Honda Civic and the Toyota Corolla every year, not the Bentley Flying Spur. Sales of compact sedans are especially strong these days because they are more spacious, more luxuriously trimmed, dramatically safer, and far more fuel-efficient than ever before, even while pricing has hardly increased.
Over the past week, we've compared eight of the best compact sedans plying U.S. highways today. We've driven all of them at the same time on the same roads, we've made our notes and organized our facts, and we've argued about the results. And now we've sorted them out and separated the best from the rest.
These compact sedans are the Chevrolet Cruze, Dodge Dart, Ford Focus, Honda Civic, Kia Forte, Mazda 3, Toyota Corolla, and Volkswagen Jetta.
You can read about the mission we set for ourselves on Day 1, then a driving report for each on either Day 2 or Day 3, in which we selected our semi-finalists. The tournament got tougher on Day 4 as we argued about the merits of the four cars that made it that far. And now at last, on Day 5, we present the final match between the 2014 Mazda 3 and the 2014 Volkswagen Jetta.
Today the process involves less driving and a more arguing. It's not just about which compact sedans excel in this category -- because they all do. Instead, it's about finding the right car with the right combination of features and driving enjoyment -- the car that meets our personal expectations. After all, this is Automobile Magazine.
Mazda 3 vs. Volkswagen Jetta
2014 Mazda 3i Touring
The Mazda 3 presents a lively, sporting personality that sets it apart from its competition, and this all-new version also now offers a more spacious cabin, a calm, supple ride on the highway, and impressive fuel economy. Just as important, it is available with a range of active safety features that you might expect only from more expensive sedans.
The Building Blocks
Completely redesigned for 2014, the Mazda 3 features conventional technology employed in an unconventional way. A package with lots of high-strength steel has been stretched over a wheelbase of 106.3 inches, and the sedan measures 180.3 inches in overall length, is 70.7 inches wide, and stands 57.3 inches high. The car incorporates an independent rear suspension, an important contributor to a calm and comfortable ride on the highway.
There's 96.3 cubic feet of passenger volume within, including 42.2 inches of front seat legroom and 35.8 inches of rear-seat legroom. You can pack 12.4 cubic feet of cargo into the trunk, and all trim levels except for the base model feature a 60/40-split folding rear seat to expand cargo capacity.
This front-wheel-drive Mazda 3i is powered by a 2.0-liter inline-four engine that makes 155 hp and 150 lb-ft of torque. A six-speed automatic transmission helps the 2848-pound Mazda 3i Touring get 30 mpg city/41 mpg highway/34 mpg combined.
What We Said
The 2014 Mazda 3 lives up to the "zoom zoom" corporate brand identity in the way it delivers the opportunity for thrills on the long way to lunch across the back roads of Michigan. We had some reservations about the 2.0-liter engine because it has to work harder to deliver its power than the 2.5-liter engine available in higher trim levels of the car. However, the 2.0-liter four is pretty delightful, perhaps because the quick-shifting automatic transmission helped energize it. Plus, its 41 mpg rating is very impressive. Great steering -- a consequence of clever steering geometry to compensate for the relatively uncommunicative electric-assist steering linkage -- is another of the Mazda 3's positive attributes.
On top of all this, the Mazda 3 delivers a surprisingly comfortable ride. A new, more supple suspension calibration plays a factor here, and the cabin is surprisingly quiet thanks to improved acoustic insulation and a very quiet engine. The Mazda 3 also feels more spacious than its dimensions might suggest. The rear-seat legroom seems unimpressive when you look at it on paper, yet no one complained about it.
When you look the 2014 Mazda 3's list of convenience features, you realize that compact sedans now can be equipped with the same things as mid-size sedans. The small, dash-mounted display screen with a rotary knob on the center console is a nice feature (even though we complained about the software logic), and the system has the ability to adapt to the evolution of apps, much like the connectivity systems in a few the other cars in this test. We were even more impressed by the range of active-safety features with which this car can be equipped, including blind-spot monitoring, forward obstruction warning with city-speed brake intervention, lane-departure warning, radar-operated cruise control, and even automatic high-beam control.
2014 Volkswagen Jetta SE (with connectivity and sunroof)
Although the entry-level model was emphasized when the current-generation Jetta was introduced as a 2011 model, the 2014 Volkswagen Jetta SE reminds us that the refinement of the mid-size VW Passat sedan can be had in a smaller size at a more affordable price. Moreover, the turbocharged four-cylinder engine delivers excellent power without sacrificing much fuel efficiency.
The Building Blocks
The 2014 Jetta might have been designed to be an affordable American-style car, but it seems very European in the company of these other compact sedans. It sits on a wheelbase of 104.4 inches, and it is 182.2 inches in overall length, 70.0 inches wide, and 57.2 inches high. For 2014, every Jetta model now features independent rear suspension, which improves the ride quality on the highway.
Much like all the sedans in this comparison, the Jetta is surprisingly spacious, affording 94.1 cubic feet of passenger volume with 41.2 inches of front legroom and 38.1 inches of rear legroom. The large trunk has 15.5 cubic feet of capacity, and a 60/40-split folding rear seat increases utility.
This front-wheel-drive Jetta SE is powered by a turbocharged 1.8-liter four-cylinder engine that makes 170 hp and 184 lb-ft of torque. With its automatic transmission, the SE achieves 25 mpg city/36 mpg highway/29 mpg combined.
What We Said
We've been driving this generation of the Volkswagen Jetta for some time now, so we were surprised that the slightly revised 2014 car seems so much improved. Along with the Chevrolet Cruze and, to some extent, the Dodge Dart, the Jetta delivers a large-car experience. It's as if this Jetta has captured the spirit of the mid-size Volkswagen Passat in a slightly smaller bottle. It surges along the road effortlessly, whether driving on back roads or the freeway. And the highway ride always proves supple, although the body rolls and pitches slightly because the suspension calibration is soft.
It's possible that we were seduced by the power of VW's E888 turbocharged engine, as it delivers 180 lb-ft of torque -- more than enough to keep this 3071-pound car sailing along pretty effortlessly. It kind of sounds like a diesel as it rasps for a second when you accelerate, and it performs a bit like a diesel as well because the smooth but slow-shifting transmission keeps the rpms low to enhance fuel economy. The EPA mileage doesn't come close to that achieved by other powertrains in this comparison, but we told ourselves that it isn't much worse, either.
The refinement of the 2014 Volkswagen Jetta SE appeals to us. There is something about the action of the switches on the dash, the poise of the car as it responds to steering inputs, and the unique flexibility of the engine's power band that strikes us. We also like sitting a little more upright, and the seats themselves are first rate. We might joke about this car's resemblance to a taxi, but sometimes a mix of comfort and utility is just what you want in a compact sedan.
Winner: 2014 Mazda 3
More car, fewer compromises
Whether we're driving a $200,000 luxury sedan or a $20,000 compact car, we can't help but hope to magically find ourselves behind the wheel of a BMW 3 Series. We're totally in the Goldilocks mode, looking for something that drives sporty but not too much so. It has to be compact but not small. It has to be affordable but not cheap. It's not only a miracle that the 2014 Mazda 3 delivers the BMW-style personality that we prefer but also a revelation that any compact sedan meets this lofty standard at all.
We've always enjoyed the lively personality of the Mazda 3, and apparently a lot of other people do as well, since it is Mazda's best-selling car. The big surprise comes in the grown-up way that the Mazda 3 now goes about its business. The car feels poised on its supple suspension, and while there's still some road noise, the cabin is quiet. More important, the seats are comfortable and the there are lots of entertainment and connectivity options. A cabin surrounded with high-strength steel and a package equipped with the latest developments in active safety made us feel safe. In fact, each of the cars in this comparison seemed far more like a mid-size sedan than the crummy compact sedans of the past that we can't help but remember.
What we've learned
Times are still tough these days, and while more people are in the market for a new car, no one wants to spend more than they have to. As a result, a car that has a price tag in the neighborhood of $20,000 has special appeal. Like most of you, we're accustomed to thinking about the compromises we'll have to make at this price point. You know, breathless little engines, interior designs seemingly meant for being hosed out on the driveway, and the general style and comfort of a Cozy Coupe from Little Tikes.
The big news here is the way in which all of these cars offer spaciousness and sophistication, along with powertrains that make 40-mpg fuel economy a likely experience. We have simple, practical, everyday cars like the Honda Civic, Kia Forte, and Toyota Corolla that deliver friction-free daily utility. We have comfortable cars like the Chevrolet Cruze, Dodge Dart, and Volkswagen Jetta that deliver quiet composure on the freeway like a large car. And we have spirited cars like the Ford Focus and Mazda 3 that help you enjoy the drive wherever you go.
There was a time when "compact sedan" was just a politically correct way to say "cheap sedan." Such cars were thought to be only slightly better than something from the rental car counter. Today, the 2014 Mazda 3 proves that modern compact sedans incorporate nearly all the performance and features of mid-size cars, and it makes you wonder if larger sedans are really necessary for most people, especially as sport-utilities take over their role in everyday life.
It's much harder to build a great car for $20,000 that it is to build a great one for $200,000. The funny thing is, you might actually get a better car for real life when you spend $20,000 instead of $200,000.


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Word from Eric with Courtroom Observers: Real truth from the ground on Oregon;
BREAKING: Harney Co Fire Chief Resigns. FBI Caught Posing As Militia At Local Armory
Wednesday - 1/13/16 - Update (1) from Malheur Wildlife Refuge In Burns, Oregon - #OregonFront Pete Santilli Show


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Hannah Guerin is a Brooklyn based jewelry line designed, handcrafted and operated by Hannah Guerin. Hannah's statement jewelry is inspired by materials found on the beaches of Martha's Vineyard, where she grew up.
The Hannah Guerin brand has become synonymous with the quintessential New England feel. Many of the materials collected inspire, and often become a part of each unique piece. The craftsmanship is meticulous, and one of a kind.
The Hannah Guerin line is available at Citrine, Driftwood Jewelry, Studio Shop, Brooklyn Collective and other high-end retailers. Please direct all press and sales inquiries to email@example.com


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The Pug and the Parrot Luxury Travel Designers
Live Large. Travel Big. Think Small.The Pug and The Parrot curators of enriching experiences+amazing adventures to the coolest destinations in the world. As 100%PureNewZealand Specialists, we've got you covered. Ready for the extraordinary? Let's go!
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If you're ready for New Zealand, get ready for amazing. The Pug and The Parrot delivers to you the New Zealand we love. We have swam with fur seals in Kaikoura, jet boated through Shotover Canyon, trekked through Milford Sound, and slept in a luxury tree house. For us, New Zealand is the epicenter of the natural world. Miles beyond miles of purple-blue lupines charge up to the shore of Lake Tekapo. Primordial palms mix into ancient glacial surrounds with sightings of Alpine Parrot, the Kea. These are our memories of the Kiwi Nation, Aotearoa. But what could be more epic than overnight exploration by clipper of the jaw-dropping grandeur of Doubtful Sound as it crashes to the Tasman Sea? The penguins had us at hello. Contact today to explore.
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The Pug and the Parrot Luxury Travel Designers, Avalon Avenue, Dallas, United States.


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* Takeover values NYSE Euronext at $8.2 bln
* ICE to pay $750 mln fee if deal fails for antitrust
* ICE gains control of Liffe, No.2 in Europe derivatives
* Regulatory change to boost demand for clearing derivatives
* CME and Nasdaq planning futures exchanges in Europe
(New throughout, adds detail of break-up fees, background)
By Luke Jeffs and John McCrank and Jessica Toonkel
LONDON/NEW YORK, Dec 21 (Reuters) - IntercontinentalExchange
Inc agreed as part of its $8.2 billion takeover of NYSE
Euronext to pay the New York Stock Exchange operator a
termination fee of $750 million if it fails to gain antitrust
clearances, suggesting a high level of confidence the deal will
go through.
Big Board parent NYSE could get out of the arrangement for a
fee of $300 million if a sweeter deal were to come along,
according to a regulatory filing on Friday.
ICE failed last year to buy NYSE in a joint bid with Nasdaq
OMX Group. At the time, NYSE was involved in year-long
pursuit to sell itself to Frankfurt's Deutsche Bourse
. In the end, regulators killed both deals, saying
they would be anti-competitive.
On its own, Atlanta-based ICE lacks the massive equities
operations of Nasdaq or Deutsche Bourse, so there is less
overlap between the two exchanges, antitrust lawyers said,
making regulatory approval far more likely.
Some in the industry have suggested that CME Group
could table a competing offer for NYSE, but they said that would
not be likely for several reasons, including the break-up fee.
People familiar with the deal said other issues include
potential antitrust concerns and the fact that under the latest
agreement, NYSE's Liffe business will do all its clearing
through ICE regardless of whether the deal goes through.
"The clearing deal they signed is like a second break-up
fee," one of the people said.
Also, CME has not been known for making large deals. "It
does not seem to be in its DNA," said Adam Sussman, director of
research at Tabb Group.
NYSE CEO Duncan Niederauer acknowledged a higher bid could
come along, but that NYSE would not chase after a deal unless it
was almost certain it would pass regulatory muster.
"If we did that for another year and at the end we are told,
'we are not going to allow you to do this because of the overlap
of your businesses,' we would look beyond foolish," he said in
an interview on Thursday.
The deal, announced Thursday, would give 12-year old
commodities and energy bourse ICE a powerful presence in
Europe's lucrative financial derivatives market through control
of NYSE Liffe, Europe's second-largest futures exchange, and a
major advantage over U.S.-based rivals CME and Nasdaq.
All three want to challenge Deutsche Boerse's European
dominance. A shake-up in banking regulation is expected to
increase demand sharply for clearing financial derivatives
through such exchanges.
"The deal would place a bigger and more aggressive
competitor on Deutsche Boerse's doorstep," said Richard Perrott,
an analyst at Berenberg Bank.
Regulatory changes in the wake of the financial crisis are
forcing banks to channel derivatives business through clearing
houses and regulated exchanges to ensure their risk positions
can be better monitored than they were when bank dealers were
trading complex contracts directly among themselves.
The reforms are expected to be fully operational in Europe
in 2014.
ICE's takeover of NYSE Liffe will give it an advantage of
existing presence in Europe over Chicago-based CME, owner of the
world's largest futures market, and New York's Nasdaq, both of
which plan to open their own London-based exchanges next year.
While the New York Stock Exchange, an enduring symbol of
American capitalism, is NYSE Euronext's prestige business,
London's Liffe is the real jewel in the crown.
With profits from stock trading significantly eroded by new
technology and the rise of other places for investors to trade,
the stock market businesses like NYSE are less valuable to ICE.
The company has said it will try to spin off NYSE's Euronext
European stock market businesses in a public offering. This has
generated speculation, which the company has denied, that it may
also have little interest in the NYSE trading floor on Wall
NYSE made an operating income of $473 million from Liffe in
2011 on revenues of $861 million compared to an income of $533
million on revenues of $1.3 billion from its equities business.
ICE's Jeff Sprecher will be CEO of the combined organisation
and Duncan Niederauer, the NYSE Euronext CEO, will be president
- a post he said he plans to remain in until at least 2014. The
two are longtime friends.
ICE started out as an online marketplace for energy trading
before Sprecher initiated a string of acquisitions, from the
London-based International Petroleum Exchange in 2001, to the
New York Board of Trade and, most recently, a handful of smaller
deals, including a climate products exchange and a stake in a
Brazilian clearing house.
A combined ICE-NYSE Euronext would leapfrog Deutsche Boerse
to become the world's third largest exchange group
with a combined market value of $15.2 billion. CME Group has a
market value of $17.5 billion, Thomson Reuters data shows.
Hong Kong Exchanges and Clearing is the world's
largest exchange group, with a market cap of $19.5 billion.
(Additional reporting by New York bureau; Writing by Aaron
Pressman and Carmel Crimmins; Editing by Philippa Fletcher and
Alastair Macdonald)


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Breast enhancement in Cincinnati is becoming increasingly popular. Many women choose to have breast enlargement, also known as breast augmentation or commonly referred to as a boob job, because it increases breast size and creates a lovely, full shape. It is usually considered by women in Cincinnati who have always wanted a bigger cup size, or after pregnancy, breast feeding or even weight loss. Cincinnati Breast enhancement is the USs most common form of cosmetic surgery with the highest satisfaction rate. If you are a woman with naturally smaller breasts, or have breasts that have reduced in size following childbirth or weight loss, your self-confidence may be affected. Breast enhancement is a variety of simple surgical procedures that can help you to regain more body confidence. Cincinnati breast enhancement is performed by some of the finest plastic surgeons. Breast Enhancement in Cincinnati is also known as Mammoplasty, Mastopexy, Breast Augmentation, Breast Enlargement, Breast Reduction, and Breast Implants are some of the most popular cosmetic surgery procedures that are performed. Breast Enhancement, can increase the size of your breast (Breast Enlargement, Breast Augmentation using Breast Implants), or reduce them (Mammoplasty), or simply rectify an asymmetrical problem or lift them (Mastopexy), or reconstruct the breast area for patients whom have had surgery following cancer. Today more and more men are also having Gynaecomastia, which is Male Breast Reduction in Cincinnati to correct excessive development of the breast gland and give greater definition to their chest. If you are considering a Cincinnati Breast Enhancement, then you may want to consider find out more information on what is involved. All of the plastic surgeons who offer Breast Enhancement in Cincinnati are Board Certified and enjoy an excellent reputation in this popular area of cosmetic surgery. If you would like to find out more about Breast Enhancement in Cincinnati, you can complete one of the Perfect Yourself Surgeon Inquiry forms, and meet a surgeon of your choice, who will discuss the various procedures that can enhance your breasts.
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Georgian jewelry is one of the more difficult-to-find genres of jewelry in the antique realm. The Georgian era is named for the 4 King Georges of England, ranging from the years 1714-1837. The influences to these design elements, as well as the techniques used vary because of the length of the Georgian era. Many Georgian jewelers foil-backed paste (faceted glass or crystal,) as well as gemstones. Like-wise much Georgian jewelry employed enameling and carving techniques, with larger formatted pendants and rings. The late Georgian jewelry is attributed as the beginning of the memento mori genre because of the revolutionary war in America, although memento mori jewelry reaches much farther back in time, whether in jewelry or art alike.
Along with Georgian and Georgian-inspired pieces on this page, please find our selection of Memento Mori jewelry. Consisting of gold, hair, and sculls, memento mori jewelry has been a popular item for collectors and was once a craft to memorialize a loved one, prior to photography, which later became the main form of remembrance via the locket.
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