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Spinal cord injury (SCI) is associated with 2-5 times greater prevalence of sleep disordered breathing (SDB) than the general population. The contribution of SCI on sleep and breathing at different levels of injury using two scoring methods has not been assessed. The objectives of this study were to characterize the sleep disturbances in the SCI population and the associated physiological abnormalities using quantitative polysomnography and to determine the contribution of SCI level on the SDB mechanism.
We studied 26 consecutive patients with SCI (8 females; age 42.5 ± 15.5 years; BMI 25.9 ± 4.9 kg/m2; 15 cervical and 11 thoracic levels) by spirometry, a battery of questionnaires and by attended polysomnography with flow and pharyngeal pressure measurements. Inclusion criteria for SCI: chronic SCI (> 6 months post injury), level T6 and above and not on mechanical ventilation. Ventilation, end-tidal CO2 (PETCO2), variability in minute ventilation (VI-CV) and upper airway resistance (RUA) were monitored during wakefulness and NREM sleep in all subjects. Each subject completed brief history and exam, Epworth Sleepiness Scale (ESS), Pittsburgh Sleep Quality Index (PSQI), Berlin questionnaire (BQ) and fatigue severity scale (FSS). Sleep studies were scored twice, first using standard 2007 American Academy of Sleep Medicine (AASM) criteria and second using new 2012 recommended AASM criteria.
Mean PSQI was increased to 10.3 ± 3.7 in SCI patients and 92% had poor sleep quality. Mean ESS was increased 10.4 ± 4.4 in SCI patients and excessive daytime sleepiness (ESS ≥ 10) was present in 59% of the patients. Daytime fatigue (FSS > 20) was reported in 96% of SCI, while only 46% had high-risk score of SDB on BQ. Forced vital capacity (FVC) in SCI was reduced to 70.5% predicted in supine compared to 78.5% predicted in upright positions (p < 0.05). Likewise forced expiratory volume in first second (FEV1) was 64.9% predicted in supine compared to 74.7% predicted in upright positions (p < 0.05). Mean AHI in SCI patients was 29.3 ± 25.0 vs. 20.0 ± 22.8 events/h using the new and conventional AASM scoring criteria, respectively (p < 0.001). SCI patients had SDB (AHI > 5 events/h) in 77% of the cases using the new AASM scoring criteria compared to 65% using standard conventional criteria (p < 0.05). In cervical SCI, VI decreased from 7.2 ± 1.6 to 5.5 ± 1.3 L/min, whereas PETCO2 and VI-CV, increased during sleep compared to thoracic SCI.
The majority of SCI survivors have symptomatic SDB and poor sleep that may be missed if not carefully assessed. Decreased VI and increased PETCO2 during sleep in patients with cervical SCI relative to thoracic SCI suggests that sleep related hypoventilation may contribute to the pathogenesis SDB in patients with chronic cervical SCI.
Sankari A; Bascom A; Oomman S; Badr MS. Sleep disordered breathing in chronic spinal cord injury. J Clin Sleep Med 2014;10(1):65-72.
Spinal cord injury (SCI) affects a large number of adults worldwide, with an estimated incidence rate of 15 to 40 cases per million populations. The prevalence of SCI in the United States is estimated to exceed 250,000 people, with approximately 11,000 new cases of SCI each year.1 Most SCIs occur during the second or third decade of life, leading to a major impact on young individuals in the community.2 Respiratory complications secondary to ineffective cough, poor airway clearance, infections and respiratory failure are major causes of morbidity and mortality in patients with SCI, particularly at cervical levels.3 In a longitudinal study from Norway, respiratory failure and ineffective mucous clearance were the main complications after SCI and respiratory causes of death were increased twofold as expected for their age.4 While advances in acute care have resulted in improved survival for the first year after SCI, there is minimal change in survival when the injury becomes chronic after few years.4
Current Knowledge/Study Rationale: High prevalence of sleep disordered breathing (SDB) has been reported in many previous studies and usually classified under the rubric "obstructive sleep apnea." Most studies utilized unattended, limited recordings lacking the precision to characterize the type of events reliably or the ability in identifying the mechanism.
Study Impact: Cervical SCI patients manifest as central SDB and hypoventilate during sleep more commonly than thoracic injuries, which require special consideration in diagnosis and treatment. Limited sleep study recordings (using type IV devices) may fail to accurately detect and classify SDB in patients with SCI. We propose that all SCI patients should undergo full polysomnography studies and be scored using new AASM criteria to better detect SDB.
Patients with SCI are also at increased risk of sleep disordered breathing (SDB), with a prevalence ranging from 27% to 62%.5–13 A longitudinal study in the first year after cervical SCI found that 60% of patients with cervical SCI developed SDB within 2 weeks of injury, peaked at 13 weeks and returned back to 60% after a one-year follow-up.13 It is of note that both SDB and chronic SCI are associated with increased adverse cardiovascular consequences.14,15 Hence it is plausible that SDB may contribute to increased cardiovascular mortality in SCI patients.16 Unfortunately, SDB in SCI patients remains underdiagnosed and undertreated. Furthermore, there are insufficient data on the type of SDB, mechanism of disease, and predictors for the increased prevalence and the relationship to level of injury.
The purposes of this study were (1) to characterize the sleep disturbances in the SCI population using standardized questionnaires and the associated physiological abnormalities using quantitative polysomnography with pharyngeal pressure catheter; (2) to determine the contribution of SCI level on the SDB mechanism (obstructive vs. central); and (3) to determine the magnitude of the fall in ventilation during sleep in chronic SCI patients. To this end, we measured pressure and ventilatory parameters during wake and sleep in addition to apneahypopnea index (AHI). Results of this study have previously been reported in the form of abstracts.17
The Human Investigation Committee of Wayne State University and the VA Medical Center approved the experimental protocol. An informed written consent was obtained and subjects had a screening polysomnography. We studied adults (> 18 years old) with chronic SCI if they fit the inclusion and exclusion criteria.
Inclusion criteria were as follows: non-ventilator dependent subjects with chronic SCI (> 6 months post-injury), American Spinal Injury Association grade A, B, C, or D, spanning the spectrum from cervical to thoracic levels (T6 and above).
Participants were excluded from the study for any of the following: (1) < 18 years of age; (2) pregnant or lactating females; (3) currently ventilator dependent or with tracheostomy tube in place; (4) history of cardiac disease including heart failure, peripheral vascular disease or stroke; (5) history of head trauma resulting in neurological symptoms or loss of consciousness; (6) advanced lung, liver or chronic kidney disease; (7) extreme obesity, defined for this protocol as BMI > 38 kg/m2 (to avoid the effect of morbid obesity on pulmonary mechanics and ventilatory control); or (8) other illness that would interfere with completion of the study in the investigators' judgment.
The participants were recruited from the local and regional spinal cord injury care centers including the Detroit VA Medical Center and the Rehabilitation Institute of Michigan. Additional mailings were sent local electronic database of patients with International Classification of Disease (ICD-9) codes corresponding to paraplegia or quadriplegia (344.0 or 344.1). Letters were sent to area physicians soliciting referrals of appropriate patients. In addition, SCI patients were contacted through publications on the internet by contacting SCI support groups.
Every subject who agreed to enroll had brief history and exam and completed the following questionnaires: Epworth Sleepiness Scale (ESS), Pittsburgh Sleep Quality Index (PSQI), Berlin questionnaire and fatigue severity scale (FSS). All subjects had baseline spirometry (forced vital capacity (FVC), forced expiratory volume in the first second (FEV1), and FEV1/ FVC ratio) and respiratory muscle forces (maximal inspiratory and expiratory pressure MIP and MEP, respectively) in upright and supine position to assess positional effect on respiratory function. In addition to standard polysomnography including EEG and chin EMG, nasal airflow was measured by a pneumotachometer (Hans Rudolph, inc., Model 3700A, Shawnee, KS) connected to a tight-fitting nasal mask. Tidal volume (VT) was obtained by integrating the pneumotachograph flow signal. End-tidal carbon dioxide (PETCO2) was measured with a gas analyzer (VacuMed, Model 17515, Ventura, CA). Supraglottic pressure was measured with a pressure tipped catheter (Millar Instruments, Houston, TX), positioned in the hypopharynx.
The best effort of the baseline spirometry and respiratory muscle forces were reported in each participant (in both absolute and % of predicted) on the same night of the sleep study, which were then summarized as mean ± SD. Baseline wake and sleep monitoring: sleep, ventilation and noninvasive blood pressure were monitored in each subject to assess the effect of SCI during wakefulness and sleep. Periods of 2 min from wakefulness and stable NREM sleep were measured to assess baseline ventilation (VI, VT, FB, TI, TE, PETCO2, O2Sat), and minute ventilation coefficient of variation (VI-CV), which were then summarized as mean ± SD. VI-CV was calculated for VI by the following formula: CV% = (SD/mean)*100.
Standard polysomnography (PSG) was performed according to AASM standards and respiratory events were scored by the 2007 standard (the only scoring criterion accepted by Medicare) criterion18 and by the 2012 AASM recommended scoring criterion.19 The standard scoring criterion for respiratory hypopnea was ≥ 30% reduction in nasal flow signal for ≥ 10 sec associated with ≥ 4% desaturation from pre-event baseline. In 2012, the recommended scoring criterion for respiratory events as hypopnea was modified to 30% reduction in nasal flow for ≥ 10 sec associated with ≥ 3% desaturation from pre-event baseline or arousal.19
Supraglottic pressure was used to differentiate the central from obstructive apneas by identifying the absence or presence of effort as described previously.20 Sleep disordered breathing was identified if the calculated AHI was ≥ 5 events/h of sleep. Central SDB was defined as AHI ≥ 5 events/h of sleep and central apnea index (CAI) > 5 events/h sleep. Cheyne-Stokes respiration (CSR) was defined as ≥ 3 consecutive cycles of cyclical crescendo and decrescendo change in breathing amplitude and at least one of the following: (1) ≥ 5 central apneas or hypopneas/h of sleep, (2) cyclical crescendo and decrescendo change in breathing lasting ≥ 10 consecutive minutes.19 The cycle duration ≥ 40 sec was not implemented in the definition of CSR, as SCI patients did not have heart failure. Periodic breathing (PB) was defined as cyclical increases in the rate and depth of breathing (hyperpnea) alternating with either a reduction by 50% (hypopnea) or complete cessation (apnea) of nasal airflow and respiratory effort lasting ≥ 10 seconds.21,22 We excluded obstructive patterns when defining periodic breathing. For hypopneas, we identified periodic breathing if there was decreased effort by supraglottic pressure and belts.
All data were assessed for normal distribution. An unpaired t-test was used to compare the mean values of all demographic parameters. A paired t-test or adequate nonparametric test such as Wilcoxon signed rank test (when normal distribution failed) was used to compare the group values of each ventilatory data between wake and sleep (VI, VT, FB, TI, TE, PETCO2, O2Sat, and VI-CV). Paired t-test was used to compare the mean values of PSG data scored using conventional AASM scoring criteria and new recommended criteria. Chi-square analysis was used to compare the proportions of SDB in SCI (defined as AHI > 5) using conventional AASM scoring criteria and new recommended criteria. Analysis of variance (ANOVA) was used for subgroups comparisons of thoracic vs. cervical effect on the ventilatory data between wake and sleep. To assess the relationship between the self-reported questionnaires (ESS, PSQI, and FSS) and objectively measured tests (AHI, sleep efficiency, and arousal index) a Spearman correlation analysis was used. Multiple linear regression models were used to identify if ESS, PSQI, and FSS or NC can be independent predictors of AHI.
We studied 26 chronic SCI patients including 15 with cervical (C4-C7) and 11 with thoracic (T2-T6) levels who had similar demographics. Poor sleep quality and fatigue were noted, as evidenced by a high mean PSQI score 10.3 ± 3.7 in 26 SCI patients; 92% had poor sleep quality (PSQI score > 5 indicates poor nocturnal sleep). The mean score of the sleepiness scale (ESS) was 10.4 ± 4.4 in SCI patients and daytime sleepiness (ESS ≥ 10) was present in 59% of the patients. Daytime fatigue (FSS > 20) was reported in 96% those with SCI, while 46% had high-risk scores for OSA on Berlin questionnaire. Table 1 summarizes the demographics, sleep quality, and daytime symptoms in these participants using the PSQI, ESS, FSS, and Berlin questionnaires.
SCI Patient characteristics and sleep quality
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Baseline spirometry on the day of the assessment revealed that forced vital capacity (FVC) in SCI was 70.5% predicted in supine compared to 78.5% predicted in upright positions (Figure 1; p < 0.05). Likewise, FEV1 was 64.9% predicted in supine compared to 74.7% predicted in upright positions (p < 0.05). Mean maximal inspiratory pressure (MIP) was 83.6% and 85.9% predicted in supine and upright positions, respectively (p = NS). Mean maximal expiratory pressure (MEP) was 42.2% and 47.5% predicted in supine and upright positions, respectively (p < 0.05). Table 2 summarizes the upright and supine pulmonary function and respiratory muscle strengths measures in both cervical and thoracic SCI categories. It is of note that the effect of body position on PFTs was different in thoracic SCI versus cervical SCI. FEV1/FVC and MEP decreased in the supine position in cervical SCI but not in thoracic SCI patients. Despite significant drops in FVC, FEV1, and FEV1/FVC from upright to supine positions (6.4 ± 12.1, 14.3 ± 13.2, and 5.7% ± 9.5%, respectively; p < 0.05), there was no correlation between positional FVC change and measured maximal inspiratory pressure in either position.
*p < 0.05.
Mean values of (% predicted) forced vial capacity (FVC), FEV1, and FEV1/FVC of 26 SCI participants during upright (gray bars) and supine (white bars) positions.*p
Baseline pulmonary function and muscle forces
Table 3 summarizes the characteristics of sleep and polysomnography data. In-laboratory polysomnography studies (PSG) with pharyngeal catheter and pneumotachometer revealed that 77% of SCI patients had sleep disordered breathing (AHI > 5). Mean AHI in SCI patients was 29.3 ± 25.0 vs. 20.0 ± 22.8 events/h using the new and conventional AASM scoring criteria, respectively (p < 0.001). The majority of SCI patients (77%) had SDB (AHI > 5) using the new AASM scoring criteria compared to 65% using standard conventional criteria (p < 0.05). It is of note that 9 of 15 (60%) cervical SCI patients demonstrated evidence of central SDB manifesting as central apnea or periodic breathing. Four of the 9 (44%) had Cheyne-Stokes respiration pattern (CSR) as shown in Figure 2. In sub-analysis conducted after excluding individuals who were using opioids (6 cervical and 3 thoracic), it was found that 89% of cervical and 50% of thoracic SCI cases had SDB, with AHI ≥ 5 events/ hour. One-third of those with cervical SCI vs. 13% of those with thoracic SCI had central sleep apnea with CAI > 5/h (Table 4).
Characteristics of sleep and polysomnography data
Note the occurrence of arousals during hyperpneas (maximum tidal volume, which is a common feature in Cheyne-Stokes respiration). Psg, supraglottic pressure; Pmask, mask pressure.
Polygraph from a cervical SCI patient (C6 ASIA C) during stage N2 sleep with Cheyne-Stokes respiration (crescendo-decrescendo pattern) and breathing instability associated with fluctuations in end tidal CO2 (PETCO2) and O2 saturation. Note the occurrence of arousals during hyperpneas (maximum tidal volume, which is a common feature in Cheyne-Stokes respiration). Psg,...
Characteristics of sleep and polysomnography data after excluding patients using opioids
The sleep state was associated with significant changes in ventilation and gas exchange. Median minute ventilation decreased from 7.2 L/min during wakefulness to 5.5 L/min during stable NREM sleep (p < 0.05) as shown in Figure 3. In addition, patients with cervical SCI demonstrated substantial respiratory variability and hypoventilation after transitioning to sleep as evidenced by increased coefficient of variation of VI, lower SpO2 and higher PETCO2 relative to thoracic SCI patients (Figure 4). Baseline ventilation and oxygen saturation were similar between cervical and thoracic SCI patients during wakefulness (Table 5).
Group values of minute ventilation of 26 SCI participants during wake (gray bars) and sleep (white bars).
Group values of PETCO2 (upper panel) and minute ventilation coefficient of variation (lower panel) of 26 SCI participants (15 cervical and 11 thoracic) during wake (gray bars) and sleep (white bars).
Ventilatory parameters (N + 26)
Both AHI and respiratory related arousal index correlated positively with daytime sleepiness (ESS score) (r = 0.40 and 0.39, respectively; p < 0.05) but not with PSQI or FSS (p = NS). AHI also correlated with neck circumference and age (r = 0.52 and 0.43, respectively; p < 0.05), but not with BMI (p = NS). Using multiple linear regression model to predict AHI from the following correlating variables (ESS, NC, and age), ESS score was the only independent predictor of AHI (p < 0.05).
The major findings of this study were that (1) 77% of SCI survivors have symptomatic SDB and poor sleep quality better detected by new AASM scoring criteria; (2) the level of SCI (cervical versus thoracic) affected the prevalence of SDB and type of respiratory events (more central SDB noted in cervical SCI) and PFT findings; (3) decreased ventilation (VT) in the cervical level (VT dropped 21%) compared to thoracic (11% drop) between wakefulness and sleep indicates the importance of hypoventilation during sleep in the mechanism of SDB in chronic cervical SCI.
This is the first study to assess sleep disordered breathing and ventilation changes comparing two different levels of SCI (cervical vs. thoracic). Ventilation decreased significantly more in those with cervical SCI than those with thoracic SCI, as evidenced by the greater drop in tidal volumes and the rise in end-tidal CO2 seen in cervical versus thoracic SCI cases indicating the occurrence of alveolar hypoventilation during sleep.
We noted that sleep quality was very poor in the majority of SCI patients regardless of their level of injury or severity of sleep disordered breathing. SCI patients screening revealed excessive daytime fatigue and sleepiness. We considered several possibilities to explain poor sleep quality and daytime function in patients with SCI. Medication use may be implicated; however, less than one-third of those with SCI were receiving narcotic medications and there was no correlation between daytime symptoms and medication use. Melatonin deficiency has also been reported in patients with SCI; this may affect sleep quality and daytime function. In a small sample of SCI individuals it was found that melatonin level does not increase at night in cervical SCI (tetraplegia) compared to those with thoracic SCI and controls.23 However, melatonin deficiency does not explain poor sleep in thoracic SCI, as melatonin levels increased similar to the able body group. Accordingly, we attribute poor daytime function to increased indices of SDB rather than non-respiratory factors.
Our study revealed a higher prevalence of SDB (defined by AHI > 5; 93% of cervical and 55% of thoracic SCI) than what has been reported in the literature. However, screening tools were inadequate to identify patients with SDB. For example, the Berlin questionnaire suggested that only 50% of SCI patients (thoracic and cervical equally) were at high risk for sleep apnea. High prevalence of OSA has been reported in many previous studies—up to 60%, particularly in the tetraplegic population.4–13 However, SDB in SCI patients is usually classified under the rubric "obstructive sleep apnea." Most studies utilized unattended, limited recordings lacking the precision to characterize the type of events reliably. In fact, the most significant finding was that more than 90% of cervical SCI patients demonstrated SDB, with the majority demonstrating central SDB not explained by daytime hypoventilation, cardiac dysfunction or use of narcotics. Subsequently, more than half of patients with cervical SCI had oxygen desaturation index above five per hour of sleep. Overall, the pattern of SDB differed in the two groups: SDB in thoracic SCI patients may represent "garden variety" sleep apnea/hypopnea syndrome, whereas SDB in cervical SCI patients appears to be centrally mediated, representing an adverse effect of the withdrawal of the wakefulness stimulus to breathe. In contrast to the thoracic SCI group, the majority of events (apnea and hypopnea) observed in the cervical SCI group were central and one in four had Cheyne-Stokes respiration pattern without evidence of heart failure. This unique observation may have significant implications regarding the diagnosis of SDB in patients with SCI.
The fundamental cause of central SDB is the loss of the wakefulness drive to breathe this could be a direct result of hypoventilation (hypercapnic type) or a consequence of post-hyperventilation hypocapnia (hypocapnic type) below a highly sensitive "apneic threshold."24–27 Central apnea rarely occurs as isolated events but as cycles of apnea or hypopnea alternating with hyperpnea, a reflection of the negative feedback closed-loop cycle that characterize ventilatory control; this is often described using the engineering concept of "loop gain,"28,29 which is the net ventilatory change for a given perturbation, combining the response of the ventilatory system to changing PETCO2, (the controller), and the effectiveness of the lung/respiratory system in lowering PETCO2 in response to hyperventilation (the plant). Changes in either parameter would change the requisite hypocapnia to reach central apnea. In addition, sleep state instability, manifested by recurrent arousals, might trigger or exacerbate breathing instability due to rapid fluctuation in chemoreflex sensitivity or upper airway patency.30,31
Repetitive arousals may also contribute to the breathing instability by augmenting the ventilatory response to a given perturbation and periodic breathing.30 Sleep fragmentation might be very relevant to tetraplegic patients, who are already known to have increased occurrences of spasticity, pain and periodic leg movements.12 As a result of these alterations between sleep onset and arousal, repetitive perturbations in ventilatory control can occur throughout sleep. Subtle autonomic arousals, without EEG changes may also contribute to the genesis of unstable breathing and poor sleep quality.30
Our study corroborated previous studies documenting decreased VC, especially in the supine position, indicative of a restrictive defect in SCI patients. Interestingly, there was no significant difference between the two groups. Patients with cervical SCI only demonstrated reduced FEV1/FVC ratio in the supine relative to the upright position. The etiology of this finding is unclear but may be due to a combination of decreased lung volumes and the interruption of the sympathetic innervation of the lung by cervical spine injury, leaving the parasympathetic innervation unopposed.32 Our findings are consistent with the study by Dicpinigaitis et al.,32 which revealed a muscarinic receptor bronchial hyperresponsiveness in cervical SCI patients, as evidenced by the presence of methacholine hyperresponsiveness that is reversible with inhaled ipratropium bromide. The combination of decreased expiratory flow and decreased MEP may contribute to retained secretions and contribute to the development of episodic hypoxia and sleep fragmentation.
We found that FVC and FEV1 were decreased and became lower in the supine position compared to the upright position, which may play a role in predisposing SCI patients for sleep disordered breathing by more collapsible airway and hypoventilation under smaller lung volumes in supine position. Contrary to our findings, previous studies have reported that FVC and FEV1 in tetraplegia patients tended to be larger in supine than seated positions.33,34 Our study measured forced, not slow, vital capacity in upright and supine positions on the day of the sleep study. The changes in spirometric measurements in SCI patients were found previously to be dependent on injury level in complete injuries.34 Incomplete SCI had less effect on FVC in cervical levels, which may explain the higher FVC values in our study, as most injuries were incomplete and low cervical.
Several considerations may influence the interpretation of the findings. First, our design does not allow us to address the prevalence of SDB in patients with SCI. However, we included all consecutive subjects who qualified for enrolment independent of the presence of sleep symptoms. Second, the use of invasive measurements and the small sample size may have affected sleep continuity and generalizability of the findings. Third, our findings do not allow us to isolate the independent effect of SCI on ventilation given the concomitant use of medications and the presence of comorbid conditions. Fourth, although the cervical and thoracic SCI body mass indexes were not statistically different, thoracic SCI individuals were more overweight, which could play a role in the increased obstructive SDB disorders compared to cervical group.
Our findings have significant implications regarding the diagnosis and treatment of sleep apnea in patients with SCI: (1) Positive screening questionnaires in our study may lack the discriminatory power to inform further diagnostic evaluation and may be superfluous given the high prevalence of SDB in this population; (2) Many studies in chronic SCI patients have used type III or IV devices, which have not been validated beyond the diagnosis of OSA in patients with a high index of suspicion. Conventional "qualitative" polysomnography may also fail to detect hypopneas if oxyhemoglobin desaturation is mild, or if arousal threshold is elevated, a potential consequence of narcotics administration. In fact, the diagnosis of SDB may be missed if type IV devices using ODI are used for the diagnosis. We propose that all SCI patients should undergo full polysomnography either as an in-lab (type I) or home polysomnography (type II) studies. Limited recordings may fail to accurately detect and classify SDB in patients with SCI; (3) Nearly all SCI patients have poor sleep quality (increased PSQI) and daytime fatigue (increased FSS), but these do not predict SDB severity. Excessive daytime sleepiness, measured by ESS score, is the only independent predictor of SDB severity; (4) Cervical SCI patients manifest as central SDB more commonly than thoracic injuries, which require special consideration in diagnosis and treatment; (5) Therapeutic methods that target hypoventilation during sleep in cervical SCI may play important role in the treatment of SDB.
This was not an industry supported study. This work was funded by the United States Department of Veterans Affairs. Dr. Sankari is a recipient of Career Development Award # 1IK2CX000547 from the Biomedical Laboratory Research and Development Service of the VA Office of Research and Development from the (U.S.) Department of Veterans Affairs. The authors have indicated no financial conflicts of interest.
The authors thank Nicole Nickert, Sukanya Pranathiageswaran, Lola Adekanmbi, and Anita D'Souza for technical assistance. Author contributions to the study: conception and design: Abdulghani Sankari and M. Safwan Badr; analysis and interpretation: Abdulghani Sankari, Amy Bascom, Sowmini Oomman, and M. Safwan Badr; drafting the manuscript for important intellectual content: Abdulghani Sankari and M. Safwan Badr.
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Khoo MC, Koh SS, Shin JJ, Westbrook PR, Berry RB, authors. Ventilatory dynamics during transient arousal from NREM sleep: implications for respiratory control stability. J Appl Physiol. 1996;80:1475–84. [PubMed]
Longobardo G, Evangelisti CJ, Cherniack NS, authors. Effects of neural drives on breathing in the awake state in humans. Respir Physiol. 2002;129:317–33. [PubMed]
Dicpinigaitis PC, Spungen AM, Bauman WA, Absgarten A, Almenoff PL, authors. Bronchial hyperresponsiveness after cervical spinal cord injury. Chest. 1994;105:1073–6. [PubMed]
Baydur A, Adkins RH, Milic-Emili J, authors. Lung mechanics in individuals with spinal cord injury: effects of injury level and posture. J Appl Physiol. 2001;90:405–11. [PubMed]
Linn WS, Spungen AM, Gong H Jr, Adkins RH, Bauman WA, Waters RL, authors. Forced vital capacity in two large outpatient populations with chronic spinal cord injury. Spinal Cord. 2001;39:263–8. [PubMed]


text:
Pressure rising on Boehner
Speaker John Boehner, who has wrestled with an unruly pack of conservatives for months, will soon be faced with an uncomfortable choice: Pass an emerging bipartisan Senate deal to lift the debt ceiling and fund the government, or don't — and risk massive political and economic consequences.
As the contours of a bipartisan Senate deal became clear, Boehner's leadership team, allies and rank-and-file lawmakers spent Monday saying that Senate Majority Leader Harry Reid and Minority Leader Mitch McConnell are gearing up to send the House a crummy deal.
Story Continued Below
Reid and McConnell are readying a debt ceiling increase into February, a government-funding bill into January coupled with no serious changes to Obamacare. That would be an incredibly difficult sell to Boehner's House, but GOP skepticism about this plan gives his House a chance to get back in the game after a few days of being relegated to the back seat.
( PHOTOS: House GOP meets on shutdown, debt deal)
Rep. James Lankford (R-Okla.), a member of Republican leadership, didn't seem comfortable with the Senate package. Asked if there was anything he likes, Lankford said "not that I've seen so far." Moments later, Lankford was huddling with Majority Leader Eric Cantor (R-Va.) on the House floor.
"That's a long time, that's a lot of dollars," Lankford said of the debt ceiling hike. "I'm going to have to see, is that a date certain? Is that give them the time to be able to reload all the extraordinary measures, so it's really a debt ceiling increase to May or June?"
The buzz in the Republican cloakroom and on the floor was that the House was being asked to vote for a clean debt limit and continuing resolution — in short, the concessions won by McConnell were not victories at all. One House Republican said they would be lucky to find 20 GOP lawmakers willing to vote for this proposal.
( PHOTOS: 25 great shutdown quotes)
Time is running short: The U.S. government's borrowing authority runs out Thursday.
Boehner, Cantor and Majority Whip Kevin McCarthy (R-Calif.) will test the waters Tuesday morning in a House Republican Conference meeting. Aides say Boehner will spend most of the time gauging the reaction of his lawmakers.
As always, Boehner is playing his cards close to his chest. House Minority Leader Nancy Pelosi (D-Calif) called Boehner on Monday evening , and the speaker would not give a hint of what his plans were, Democratic lawmakers said.
That's the big question: What does Boehner do for the next day or two while the Senate tries to pass this bill. Boehner could pass his own six-week debt ceiling increase — first floated last week — but he would have to find 217 of his own lawmakers to get it through the chamber. Plus, not many Republicans will want to sign onto a bill that is dead on arrival in the Senate. If he puts this Senate proposal on the floor as its being described now, Boehner would need at least half of the 232 House Republicans to back it in order to avoid internal calamity.
( POLITICO's full coverage of the government shutdown)
If the Senate passes the proposal, Boehner could put it on the floor and amend it by adding a delay of the medical device tax, or insist that the Obama administration cancel the penalty for not signing up for Obamacare. Yet time is short, and that would put the U.S. government closer to default on its $16.7 trillion debt. Most House Republicans concede that they can't go far past the Oct. 17 deadline, but they think they can tip-toe close — and perhaps dance an inch or two over. Some senior Republicans see Nov. 1 — when Social Security and veterans' benefit payments are to be sent out to millions of Americans — as a more realistic deadline.
At the end of the day, many acknowledge that Boehner will have to pass the Senate's deal, but it won't be pretty.
McCarthy admitted GOP lawmakers were unhappy with the outlines of the proposal.
"The biggest think you hear from members is 'What is this?,' because they keep hearing it change so drastically every time," McCarthy told reporters after two hours of closed-door leadership meetings.

subset: commoncrawl


text:
091 Brew Masters meeting 8/6/2011
Meeting of 091 Brew Masters
- Present
Ciaran, Alan, Bill, Frantisek
- Experimental incubator project
Prototype design
- electronic core: composed from arduino micro controller connected to heat sensors DS18B20 I2C The prototype was build up by Ciaran for another project and will be slightly adjusted. We will build up a copy as soon as possible. The functional temperature measuring prototype should be ready by Thursday 16/6/2011
- chamber: open plastic container at least of a = 60cm; b = 35cm; c = 25cm (fitting two 19 l fermentation vessels), should be ready for Thursday 16/6/2011
- heating element: 250 w aquarium heater will be used for the start with it's own thermostat, the medium to dissipate the heat will be water
- code and data collection: code will be again used from Ciaran former project and data will be collected and stored first at arduino and later on transfered and posted on line, should be ready for Thursday 16/6/2011
- Elderflower brewing project
elderflower cordial (13/6/2011): we have discussed the recipe and have decided to conduct first experiment on Monday 13/6/2011, starting around 15:00 at Bills Place (for more info please ask or check the tread). We will most probably do 5 l experimental batches, with various forms of sugar source and with some of the recipes including a live cultures but some of them being "chemical only". This set of experiments is focused on non alcoholic local elderflower product.
elderflower wine (16/6/2011) - there will be at least two experiments. One will be wild fermentation of sugar source with elder flowers added, performed by Richard (probably 2x 19 l), temperature has to be determined (and time if it suits him). The second will be champagne yeast based fermentation of rapadura (1 x 19l) and white sugar (1 x 19l) both at the optimal temperature for the strand (probably 21-24 C, has to be specified). We have still to find location and confirm the date and time but it should be Thursday 16/6.
- General Discussion
- there is a possibility of on line ordering of the brewing equipment and ingredients from Barna based on line shop, picking them at store which we may be able to have a look at. This opportunity has to be further investigated. Will has purchased equipment from this store and recommends. http://www.homebrewwest.ie/ is the website and the storage unit is situated in the 12 in Barna. The website has a detailed inventory of what is available in the store including many strains of yeast.
- we went through the prices of sugars and where to get them. The advantages of whole sale prices were mentioned.
- the aims and goals of the group were discussed and the "non business" model of think tank and educational/promotional character was strengthen with the notion of supporting brewing as a green collar job style
- we went through the basic "biology" of some cultured drinks
It was a great meeting, let's hope that the next week experiments will go alright and see you all on Wednesday at Javas at 18:30!


text:
NL champion Cardinals don't blink
ST. LOUIS -- Who would blink first when the Dodgers and Cardinals reconvened at Busch Stadium on Friday night for Game 6 of the National League Championship Series? Apparently not Scott Van Slyke or Joe Kelly.
View Full Game Coverage
ST. LOUIS -- Who would blink first when the Dodgers and Cardinals reconvened at Busch Stadium on Friday night for Game 6 of the National League Championship Series? Apparently not Scott Van Slyke or Joe Kelly.
View Full Game Coverage
The Dodgers reserve and Cards right-hander had their teammates giggling and Twitter in a state of LOL after engaging in a bizarre and lighthearted stunt before things got serious.
It began as business as usual. Players from both teams had lined up outside the dugouts for the national anthem, standing at attention with their hats over their hearts. Most of them then retreated after the final note.
All except Van Slyke and Kelly, who remained standing at attention, hats over hearts, for nearly 15 minutes, long enough for the grounds crew to finish its final preparations and for the Cardinals' starters to take the field. They still stood there, Van Slyke a step off the dugout rail on the third-base side, and Kelly all the way out along the edge of the grass near the first-base line, when St. Louis pitcher Michael Wacha finished his warmup pitches on the mound. Perhaps fearing for Van Slyke's safety, a well-meaning Dodgers teammate placed a helmet on the stoic outfielder's head.
"I'd never done that," Van Slyke said. "I stayed out there after the anthem was over and noticed Kelly was out there, too, and I figured I would stay longer than him. Then I caught his eye and he had this big smile, like he was telling me he could stay longer than I could, and before you know it, it was just the two of us.
"It felt like a really long time. My back was tightening up and my feet hurt. I tried to get him to leave, but he looked away. Guys in the dugout were yelling at me telling me not to leave, so I didn't want to leave. It was fun."
After the Cards' 9-0 win punched their ticket to the World Series, Kelly said he'd been doing it all postseason. Van Slyke was the first opponent to notice.
"After every national anthem, I usually stand there and wait for the other team to leave," Kelly said. "It's something that I like doing, and I guess I feel like I get a little grin out of that. But I guess [Van Slyke] caught onto it, and he just started standing there. And so I just started standing there and didn't want to move my ground until they did, so it was fun."
Both sides claimed victory after Major League Baseball's first postseason staring contest -- Van Slyke because Kelly was the first to smile, and Kelly because Van Slyke was the first to leave his post.
They finally scattered after home-plate umpire Greg Gibson had enough, and with a hint of a smile on his own face, emphatically urged both to get the heck out of the way so the big game could begin.
.@ScottVanSlick and @Joe_Kelly_Jr's epic on-field staring contest is one of the best parts of the #NLCS so far: http://t.co/VRj2MWKnFA- Cut4 (@Cut4) October 19, 2013
"He said, 'Y'all go back at the same time! Just go back!'" Wacha said with a laugh.
The memorable staredown was both players' only appearance on Friday. Van Slyke was on the Dodgers' bench (and appeared just once in the series, as a defensive replacement in Game 1), while Kelly had just pitched Game 5 of the series in Los Angeles two days earlier.
It was a strange start to the biggest game of Wacha's life, but he enjoyed it.
"It honestly, I think, calmed me down a little bit," Wacha said. "It gave me a little chuckle out there on the mound. I think I might have been a little too nervous going out there, but I saw the standoff going on and it kind of loosened me up a little bit."
Adam McCalvy is a reporter for MLB.com. Read his blog, Brew Beat, and follow him on Twitter at @AdamMcCalvy.


text:
Saturday, September 29, 2007
"Will you sign my year book?"
Here's one thing we can definitely say about this season: it's almost over.
Still, we're feeling like we do every year at this time: like its that last week of high school. We should be glad that it's over, but we're getting all sentimental, running around to sign one another's yearbook.
So, join us as we make the rounds, and share the love around the Jays' Blogosphere Cafeteria.
Hey Drunk Jays Fans: Can you believe it's really over? The year is so over! Remember back when you found that picture of Richard Griffin drunk on a park bench? That was awesome! You guys are real characters. Don't ever change. See you around sometime, maybe. Cheers (to lots of beers!), The Tao. P.S. "Keep on rockin' in the free world!"
Hey Neate from Out of Left Field: It was great getting to know you this year, and it was no problem for me to do your homework for you for a few weeks while you were away. Hope there's no hard feelings about you having to do summer school. Anyways, this year was really a trip, and we'll see you around sometime, maybe. Peace, the Tao. P.S. "Rock and roll will never die!"
Dear Joanna from Hum and Chuck: We are so outta here! You're the most awesome chick that we met here this year, and we're not just sayin' that. Those guys from Drunk Jays Fans are hitting on you for a reason! We're sorry that we kinda picked on your friend A.J. this year. No hard feelings?! Hope not, 'cause u r wicked cool and we're glad we got to know you. Anyways, we'll see you around sometime, maybe. (We should really try to go to the beach sometime!) Cheers Big Ears! Love, The Tao XO. P.S. "You are like a hurricane, there's a calm in your eye."
Yo! Richie Rich from Home Run Derby! Hey man! This year is so over! We didn't really get to know you much, but you always seemed like a righteous dude, and it was really cool working with you on that B.J. Birdy thing. Anyways, man, we hope you have an awesome time this off-season, and call us if you ever want to party! Rock on! The Tao. P.S., "It's better to burn out, 'cause rust never sleeps!"
Hey Jays Nest! It was great getting to know all of you guys (Dave, David, Jonathan, and that exchange student from New York). We used to think you guys were nerds, but now that we get to know you, we REALLY think you are BIG NERDS! (Just kidding! You're awesome!) Anyways, we had fun with those round tables. We know that we didn't really do our share of the work, but we got through it thanks to you! Anyways, have fun, and we'll see you around sometime, maybe. Cheers, The Tao. P.S. "Catch the mist, catch the myth. Catch the mystery, catch the drift."...Rush rules!
Yo Maldonado Over Everything! Remember when you gave that nerd John Brattain an atomic wedgie? That was awesome! You're really cool, even if we didn't really get to know you that well. Anyways, maybe we'll get the chance to hang out this off-season? Keep in touch, and maybe we can party some time. Cheers, The Tao. P.S. "Long may you run."
Hey Todd at the 500 Level: Hey man...where did you go this year? You're pretty cool. You know a lot about history...can we have your notes? (Just kidding!) Anyways, maybe we'll see each other around soon. Good luck, The Tao.
Hey Fire Gibbons: What'sup?! We used to hang out so much...It's too bad we don't see each other that much anymore. Anyways, you're still awesome, and a real cool guy. I guess we never really got Old Man Gibbons fired, but we tried! Don't let "The Man" change you: You're a rebel! Anyways, maybe we'll see each other around, and we can party when Gibbons finally gets the boot. Cheers, man. The Tao. P.S. "It's better to burn out than to fade to black."
Hey the Ballclub: So sorry to hear about your year. We really hope things work out for you. Be strong. Peace, and God Bless You. The Tao.
Hey Deadspin: You're the coolest guy in the school. We can't believe we're signing your yearbook! (Actually, you left it in the cafeteria, but we're signing it before we bring it back you. Hope you don't mind.) Anyways, it was really cool when you showed everyone that video that we found of the drunken Red Sox fans. We don't know if anyone at this school knew who we were before then! Thanks! Anyways, you're really awesome...we hear you have a book coming out, and we're totally gonna buy it. Call us anytime if you want to party! Keep on rockin'! The ToS. P.S. "Everybody seems to wonder, What it's like down here. I gotta get away from this day-to-day running around, Everybody knows this is nowhere."
Feel free to sign our yearbook in the comments!
7 comments:
- John Brattain said...
Word to the wise: wedgies in boxer shorts are more painful than a wedgie while wearing briefs.
That's waaaay cooler advice than Jimmy Dugan's "avoid the clap."
It was really rude of you to take the talcum powder out of my locker. That just made the pain worse. I had to spend three hours with the guidance counsellor y'know. I hope you're satisfied.
Now if you'll excuse me, the chess club is having a roundtable discussion about our pet goldfish.
Oh yeah, Ethel turned me down for the prom again (I even told her that her front teeth made her look like that lady bunny in "Space Jam" while wearing my most neato polka dot bow tie). I don't get it, why does every girl I ask on a date turn out to be a lesbian? Honestly, what are the odds? I'm going to ask the captain of the math club about that. We're best buds. I bought him a whole case of Brylcream to congratulate him on his graduating with honours from his "12-Steps To Overcomes Bed Wetting" course.
Admitting you have a problem is the first step to overcoming it as my mom always said.
Anyhoo have a way coolio summer dude. Toodles!
Best Regards
- September 29, 2007 at 6:13 PM
- The Mockingbird said...
I know you don't know me or ever look back over your shoulder while I stare at the back of your head in science class or all the other classes I arranged to take with you this year but I followed you around all year and wrote down everything you said and rescued everything you threw in the trash and even snuck into the gym changeroom while you were in the shower and wrung out the sweat from your socks etc. into this jar and I have your picture in my room and I kiss it softly every night before bed and I hope you don't think I'm strange because I just hope we can just be good friends and maybe get married some day.
- September 29, 2007 at 9:19 PM
- Tao of Stieb said...
Wow...that's just creepy.
- September 29, 2007 at 10:26 PM
- sager said...
I signed it too, huh-huh.
See you in the car!
- September 30, 2007 at 1:35 AM
- John Brattain said...
I know you don't know me or ever look back over your shoulder while I stare at the back of your head in science class or all the other classes I arranged to take with you this year but I followed you around all year and wrote down everything you said and rescued everything you threw in the trash and even snuck into the gym changeroom while you were in the shower and wrung out the sweat from your socks etc. into this jar and I have your picture in my room and I kiss it softly every night before bed and I hope you don't think I'm strange because I just hope we can just be good friends and maybe get married some day.
Here I thought he got that manly right forearm from playing on the tennis team.
So, that metallic knocking sound we kept hearing in health class wasn't the boiler heating up after all. I never thought it sounded like it was coming from right below us.
By the way, how much detention did you get from Miss Getunlayde for bringing the coat hanger for your oral presentation on contraception anyway?
Best Regards
- September 30, 2007 at 8:19 AM
- Drew said...
Congrats on a good year fellas.
"Have a summer"
- September 30, 2007 at 12:15 PM
- THE GREAT LAKES KNUCKLEBALLER said...
Tao, you mean so much to us. We know we haven't been around much, but let's stay friends.
Next year is going to be the best one yet. We've got a feeling. It all starts with sugar in Gibbons' gas tank, a lot of weed, some Zeppelin, and a trade for Chone Figgins.
See ya,
FG 4-eva.
- October 2, 2007 at 12:14 PM


text:
Glenn Beck isn't a politician – at least not officially – but he's doing quite well in the polls.
The right-wing weeper and his bosses at Fox News scored big in unrelated surveys that together reveal divisions along partisan lines not only in politics, but in news and entertainment – all of which are becoming increasingly intertwined.
A survey by Harris Interactive found Beck to be the country's second-most popular TV personality, placing behind only Oprah Winfrey. While Winfrey has been a list mainstay for years, this marked Beck's debut showing.
Meanwhile, a survey by Public Policy Polling found that Beck's employer, Fox News, is the country's most-trusted news network, Politico reports. CBS and ABC, which don't have pundit-driven cable new arms, placed in a virtual tie for least trusted.
Now polls aren't a perfect measure – as E.B. White said, "Although you can take a nation's pulse, you can't be sure that the nation hasn't just run up a flight of stairs." But let's take a stab at the possible meaning of these two surveys, both of which touch on Fox ("House" star Hugh Laurie and Fox News commentator Bill O'Reilly also made the top 10 TV favorites list).
We're seeing an increasing melding of punditry, politics and entertainment – Fox is home to commentators who are presidential candidates in waiting (Sarah Palin, Mike Huckabee – and yes, even Beck whose name has been floated for office and who recently announced his "100 Year Plan" for America).
They're all entertainers: Huckabee is witty. Palin can charm and outrage. Watching Beck is to never know what absurdity will pour from his mouth, while guessing when the tears will flow.
So maybe it's not a shocker that Beck's drawing a crowd. What is surprising, though, is shifts in perceptions of what constitutes "fair and balanced" reporting, on all sides of the spectrum.
Or, as Public Policy Polling President Dean Debnam told Politico: "A generation ago you would have expected to place their trust in the most neutral and unbiased conveyor of news. But the media landscape has changed, and now they're turning more toward the outlets that tell them what they want to hear."
What people want to hear reflects larger divisions in the country.
Nearly three-quarters of registered Republicans said they trusted Fox News as opposed to 30 percent of Democrats. The partisan split extended to the TV personality realm: Winfrey, who used her platform to support President Obama's campaign, was favored by self-described Democrats and moderates.
Beck placed first among Republicans and independents. Political satirist Jon Stewart, who came in sixth overall, was the top pick of liberals. (It's unclear how the brilliant and acerbic Dr. House plays politically, but Laurie was No. 1 in the West).
So we're two countries, not only when it comes to politics, but news and even favorite TV personalities. Glenn Beck is a big star in this skewed universe, where news is opinion that people want to hear and all of it is supposed to pass for entertainment.
Who's crying now?
Hester is founding director of the award-winning, multi-media NYCity News Service at the City University of New York Graduate School of Journalism. He is the former City Editor of the New York Daily News, where he started as a reporter in 1992. Follow him on Twitter.


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Secret Missions
| Annihilation Secret Mission 01
| FOUND IN // Mission 02
The challenge here is pretty straight-forward but requires an unrelenting pace; defeat the enemies within the time limit. The time limit is pretty strict, too, so you'll need to be consistently earning kills in order to fulfill the quest. Move from one enemy to the next with the quickness, utilizing your new Snatch grapple to pull enemies toward you to continue combos. As soon as you kill an enemy, look for another to combo and don't stop 'til the stage ends. Your reward for completing this secret mission is a blue orb fragment.
| Alley-Oop Secret Mission 02
| FOUND IN // Mission 04
This mission is pretty easy, and there's no time limit so there's no real rush. Just jump, perform a Snatch grapple, and then execute a Buster grab (by releasing the lock-on and tapping the Devil Bringer attack button) to throw the enemy to the ground. Immediately after tossing the enemy, hold the lock-on and perform another Snatch to bring the enemy (or a different enemy) up to you so that you can throw again in mid-air. Repeat this process to get five consecutive air throws without touching the ground and you'll earn a blue orb fragment.
| Nonviolent Resistance Secret Mission 03
| FOUND IN // Mission 05
You'll have a tough time completing this mission the first time you reach this stage, but go back with Nero once you've earned the Hold technique. Grab and Hold one of the scarecrows over your head, then retreat to a corner and wait for the frost to follow you. Keep the frost in front of you to absorb its attacks and build your style meter, all the while mashing on the taunt button to build the meter faster. Expect your scarecrow shield to die before reaching the style rank of C, so quickly grab the second scarecrow. A second frost will spawn in the room to replace the first scarecrow that died—keep both of the frosts in front of you and you shouldn't have a problem earning the blue orb fragment.
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text:
Beth Judson watched her daughter play college golf for the first time. Then she said, "I love you." Then she said goodbye.
After cheering their daughter through 36 holes on an autumn Monday in Tennessee, Lauren Judson's parents quietly excused themselves Tuesday in hopes of outpacing a coming storm. Judson's Southern Mississippi teammate, Vicky Correa, battled that morning in a playoff to determine the tournament champion, and Judson texted her parents updates on her friend's progress as they flew home to Georgia in the family's small plane. Eventually, she sent good news: Correa had won. But there was no response, no prompt congratulations, no "I love you too."
When Judson returned to Southern Mississippi that evening, her brother called, searching for the humane way to break his little sister's heart. He let her try to call their parents, again and again, so she could discern for herself what he already knew. Jim and Beth's plane crashed Oct. 26, 2010, in northern Mississippi, killing them both.
"That's probably the longest day I've ever had," Judson said.
Since then, Judson has rebuilt herself, tear by tear, smile by smile, swing by swing. When she talks about her parents, her frequent laughs carry the joy of happy memories and the strain of old heartbreak.
Southern Mississippi golf coach Julie Gallup says Judson hasn't let tragedy impede her growth. She has amassed a 3.73 GPA. She'll graduate in May with a degree in forensic science and a minor in psychology. She has shaved nearly 10 strokes from her average round. And in her hometown of Roswell, Ga., she has squeezed in time to help create and oversee a golf tournament and foundation that honors her parents and has raised more than $60,000 for an Atlanta children's hospital.
"I miss them more than anything," Judson said. "Golf has been a security blanket for me."
Though a broken leg derailed her soccer career, Judson was determined to earn a letter jacket as a high school freshman. After countless hours practicing golf with Jim, she earned one. Four years later, a handful of colleges expressed interest, but she landed at Southern Mississippi because of its forensic science program and a chance to redshirt. A year after enrolling, she had a chance to play; her parents were there to watch.
At the behest of her family, Judson returned to school the day after she buried the mother she always confided in about high school's monumental trivialities and the father who was by her side seemingly every time she played 18. She immersed herself in books and fairways.
But by the next fall the numbness started to fade. Into the void stepped pain, loneliness. When Judson hit a bad shot, she no longer heard Jim offering words of encouragement. She took time off to grieve and returned to the team in the spring. A year later, she notched a team-best score in the Conference USA Championships, including a 72 in the final round. She collected her first hole-in-one only a few days after the second anniversary of her parents' death. She's now a team captain.
Gallup has coached for more than a decade. She is accustomed to seeing her players bicker over minutia. But not this team, she said. After Judson lost her parents, the typical squabbles vanished.
"All the other little stuff kind of falls away," Gallup said. "They have tremendous perspective."
A life spent on golf courses means a life spent amid the buzz of planes humming overhead. But Judson doesn't shudder at those reminders in the sky. She wears a necklace with an airplane trinket, clutching it when she hears the familiar sound above. She refuses to run from her memories.
On one of many trips together to a tournament, father and daughter scrolled through options on her phone for a morning alarm to rouse them before he cheered her through another round. One, a man whistling a strange tune, had made Jim laugh. Go with that one, he said.
It has woken her up every day since.


text:
Now target acquisition and illumination at night can be achieved even in the coldest of temperatures. The new incredibly bright ND-3x50 Subzero™ Long Distance Laser Designator is the most powerful Laser Genetics product yet. Equipped with an innovative unique circuitry system that enables the DPSS 532nm green laser to operate at temperatures down to 0˚ Fahrenheit, without loss of power.
The patented Rotary Optical Collimator uses a system of 9 fully multi-coated lenses that allowing full adjustment and control of the beam diameter and intensity to focus light where you need it most. Rotating the collimator to minimum, it creates a bright intense beam of green laser light visible up to 3 miles. Rotating the collimator to a more open setting it provides plenty of illumination to light a trail at night or "paint a target" at up to 500 yards.
For the most extreme and cold weather conditions, with temperatures of 40 degrees and below, we recommend using this ND-3x50 Subzero™. However if you're spending most of your time in warmer climates of 40 degrees Fahrenheit and above, then we recommend using the ND-5® Laser Illuminator or one of the standard ND-3® Series laser designators.
Research has proven that green light is the most visible to the human eye (See Chart) and requires the least amount of eye adjustment at night. An eye that has adapted to daytime conditions generally has a maximum sensitivity around 555nm. Compared to the color red which optical spectrum is around 630 – 650nm our eye is closer to the Green region of the optical spectrum at 510 - 530nm.
ND•3 x50 Subzero - SPECIFICATIONS


text:
Funny story, well, not that funny. I don't like traditional tea. I think it has something to do with the fact that when I was a little kid the only thing my mom seemed to give me to drink when I was thirsty, hot weather, cold weather, morning, afternoon, night, was tea. It really is the only thing I can remember drinking as a kid. I probably also drank juice (well, I hope I did!) but seriously, I just remember being made to drink hot tea in hot weather to help quench my thirst. It didn't work. So I don't like tea. Makes sense right?
Then why on earth have I made a tea flavoured macaron?
I'm not sure where the inspiration came from to make an Earl Grey flavoured macaron, I mean, tea is the last thing on my list of flavour ideas, but for whatever reason this idea got planted a while ago and I hadn't been able to forget about it.
Actually, this is not the first time I've used Earl Grey, I did a "Blue Rinse" Tiramisu which I flavoured with Earl Grey and lavender, and even though the idea to make that was purely as a joke (I hope I'm not the only one who might make a dish purely for the comedy) it actually surprised me and was delicious.
So with one other forray with Earl Grey tea already successful, I thought I'd give my macaron idea a go. And if I didn't like it, at least hubby would. (After all, I used his Earl Grey tea for this experiment).
As I do with most of my recipes, I did a quick search to see if others have also done something similar, and if so, how they did or didn't like it, etc. I was quite surprised that I didn't find any other Earl Grey and Lemon combination macarons.
Even though I'm not a tea drinker, I know that a slice of lemon in your Earl Grey is a popular way of enjoying it. Instead I found macarons combining Earl Grey and caramel, chocolate or honey (honey makes sense) but no lemon. Maybe I just need to search a little more, it must be out there somewhere.
And if not, well, I'll pretend that this combination is my inspired idea alone.
Just kidding, but it's nice to think that it could be an original macaron flavour ;)
As I've done before, I flavoured the actual macaron with the tea. It's a brilliant way to flavour the shell. I've done it with berry tea, even liquorice tea. It's as simple as grinding the tea to as fine a powder as you can then adding it to the dry ingredients. Although you don't need all the tea to be super fine, so don't get overly enthused about making it into a powder. In fact, I actually used a tea that had whole leaves and cute little flowers in the bags (gotta love Tea Pigs) and just ground them as best as I could with my pestle and mortar.
After sieving the tea with the rest of the ingredients, whatever tea leaves were still a little big, I ground a little more and just threw them in with everything else. I like the little speckles the bigger bits make on the shells.
The lemon was also easy to add, but I did this in the filling.
I'm a very lazy macaron filling maker. If I'm going to a lot of effort, like Christmas gifts, then I'll make a Swiss Meringue to use as a filling, but most of the time I try use a filling that's either already done for me (think Nutella!) or easy to make. Ganache is my favourite, not only is it incredibly easy to make, it's also just so darn good. Silky, smooth, creamy, sweet. And when you use white chocolate ganache, you can flavour it almost any way you like.
I simply added some lemon zest to the chocolate before combining it with the hot cream. It worked beautifully! The lemon in the ganache was so beautifully fragrant, and just from a little bit of lemon rind.
I was worried about the lemon overpowering the Earl Grey so the ganache was only lightly lemony. I also decided to fill the macarons with a little less filling than I normally do, both because white chocolate is quite sweet and can easily make a macaron so sweet it makes your teeth shake in fear, and because of the lemon to tea ratio. In any case, I personally don't think macarons need filling as thick as the macaron shell itself, but that's up to your own preferences.
However, even after being cautious with the lemon, I found with my first batch that the Earl Grey seemed to get weaker the next day, which is unusual because normally the maturing brings out the flavours even more. But it could have been that the lemon developed even more than the tea did. There was an instant hit of the lemon on first bite, then a lingering aftertaste of the fragrant bergamot from the tea. Very pleasant, I must say, but I wanted a little more of the tea so I upped the amount of tea I added.
Unfortunately the strength of flavour isn't an exact science as it's all dependant on the brands one gets wherever they are, so it could be that the Tea Pigs I used was a little more subtle than another brand of tea. You'll have to play around with it, but I'd start with 1 tea bag per 1 egg white, then increase it from there if you find it's too subtle.
As you may have figured by now, I thought this was a very successful flavour combination, even as a non tea drinker :)
Earl Grey Macarons
90g Egg Whites
145g Confectioners/Icing Sugar
70g Granulated Sugar
115g Almond Meal/Ground Almonds
3 Earl Grey Tea Bags
Black, purple or blue paste colouring (Optional) - I used a combination of black and blue
- Grind the contents of the tea bags until mostly fine
- Process the confectioners sugar, almond meal & tea until the almond meal is fine then sift into a medium bowl to remove any large bits of tea or nuts.
- Tip: If grinding your own nuts, combine nuts and a cup of confectioners' sugar in the bowl of a food processor and grind until nuts are very fine and powdery.
- Whisk the egg whites with the granulated sugar in a clean dry bowl until the mixture is glossy and holds stiff peaks.
- If colouring, whisk in small amounts of paste colouring until desired shade is reached
- Tip: If you turn the bowl upside down they should make no move to fall out
- Tip: Don't worry about your meringue being a bit dry or over beaten, against popular belief that macarons are a pain to make, they're actually fairly forgiving
- Fold half of the almond flour mixture into the meringue, starting quite vigorously then folding more carefully.
- Add the remaining almond meal mixture and fold in carefully.
- Tip: The macronage process is probably the only part of making macarons that determines if they'll be a fail or success. A good way to tell if the batter is ready is when you fold it onto itself, it should blend back into itself in about 30seconds. Rather under mix than over mix!
- Spoon the mixture into a pastry bag fitted with a plain half-inch tip. You can also use a Ziploc bag with a corner cut off.
- Tip: It's easiest to fill your bag if you stand it up in a tall glass and fold the top down before spooning in the batter.
- Pipe 1 1/2 inch mounds of batter onto baking sheets lined with parchment paper.
- Tip: I don't recommend using a silicon mat, I had trouble taking the macarons off each time I used it.
- Once piped, bang the sheet down on a counter top a couple times to flatten any mounds and bring up air bubbles, also to settle the almond meal to the bottom giving smooth tops.
- (Optional) Sprinkle the shells with a bit of Earl Grey tea
- Leave the unbaked macarons out to dry, between 30min - 1 1/2 hours.
- Tip: If you have a fan assisted oven you can dry them in less time by just having the fan turned on with the macarons in the oven.
- While the macarons are drying, preheat the oven to 140°C (120°C Fan Assisted)
- Once dry, bake for 15-22mins depending on their size
- Tip: They're ready when you push them and they move very slightly on their feet or if you can easily peel one off the baking tray
- Cool on a rack before removing from the parchment, 15-30mins
- (Optional) If not sprinkled with Earl Grey tea earlier, paint each shell with a brushstroke of edible silver lustre paint
- Tip: You can buy little pots of already made edible silver paint, or simply mix silver lustre dust with a bit of vodka, the alcohol will evaporate leaving the lustre dust behind
- Pipe or spoon with filling and sandwich
Lemon White Chocolate Ganache
200g Good Quality White Chocolate
100ml Double Cream
2tsp Lemon Zest
- Grate or finely chop the white chocolate, place in a heat resistant bowl
- Add the lemon zest to the chocolate
- Pour cream into a saucepan and scald over medium high heat
- Tip: The edges will start to bubble, remove from heat immediately
- Pour the cream over the chocolate and lemon zest
- Slowly stir with a fork until the chocolate is melted and completely mixed with the cream
- Leave at room temperature to cool and thicken
- Tip: You can speed up the thickening process by putting the ganache in the fridge, but make sure you stir it occasionally and remove from the fridge when it's the desired consistency
- Spoon ganache into a piping bag fitted with a plain tip
- Pipe onto half of the macaron shells
- Sandwich with other half of macaron shells
This macaron recipe is adapted from Syrup And Tang
Other Tips:
I found a great post busting the myths of macaron making, I highly recommend you read it. The only step that I still do is to dry the macarons, lets just say it's like lucky socks, I can't make my macarons without that step for whatever reason. But as for the rest of the myths? Compeletely busted. I use fresh eggs and don't care what the weather is. Macaron Myths
Store your macarons in an airtight container at room temperature.
You can also store in an airtight container in the fridge, but leave macarons out at room temp for a while before eating.
Best eaten after a day or two, this lets the flavours develop.


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Jonah Hill's "Mid90s" is an admirable debut film by the actor-turned-writer/director, focusing on a thirteen-year-old named Stevie (Sunny Suljic), a boy who is living in '90s-era Los Angeles. It follows this young boy, sans father figure, who immerses himself in a group of five older male influences who shape his coming of age. When Stevie is accepted into the group and nicknamed "Sunburn," Suljic brings a natural delight to the young character's face. "I made it," we can see Stevie thinking through the half-smile on his face, "I'm cool." But Suljic also brings great nuance to the performance, especially in the moments where we sense an internal struggle between what he believes to be right and wrong.
It's a strikingly accurate portrayal of juvenile masculinity, with coarse language and sexually-explicit wordplay leading these characters' conversations, and also captures the universal curse/ecstasy of youth where one believes they are invincible and incapable of death. It's a slice of life with a minimally complicated story structure: Boy meets friends, boy is influenced by friends, boy learns more about himself through friends.
A worthy debut overall, "Mid90s" showcases a fantastic ensemble cast led by a filmmaker finding his footing. With slight thematic brutalities akin to Larry Clark's "Kids" and subtle nods to the youth-meets-the-big-bad-world story arc of Cameron Crowe's "Almost Famous," this film does a lot of things right, yet leaves much to be desired at the same time. It's worth your time for many reasons, but don't be surprised if certain elements leave you wanting more or questioning the decisions made by Hill.
Now on Blu-ray, "Mid90s" includes very limited bonus material, so this is only a worthy addition to your collection if you're a fan of the film. Bonus features include deleted scenes and an audio commentary with Hill and cinematographer Christopher Blauvelt. It's an interesting enough commentary, but behind the scenes footage would have been welcome for a movie with such interesting ambition and origin.


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|Biosequences .. Software .. Molbio soft .. Network News .. FTP
I am pleased to announce that the proposal to create PLANT-SIGNAL-TRANSDUCTION/bionet.plants.signaltransduc (moderated) passed with 105 YES votes and no opposing votes. We will proceed to create this newsgroup as soon as possible. E-mail users, please wait for an announcement in this forum stating that the group is ready before you try to request an e-mail subscription. Sincerely, Dave Kristofferson BIOSCI/bionet Manager biosci-help at net.bio.net ---------------------------------------------------------------------- Proposal for PLANT-SIGNAL-TRANSDUCTION/bionet.plants.signaltransduc (moderated) USENET newsgroup name: bionet.plants.signaltransduc Status: Moderated One line Description: Research on plant signal transduction Moderation address: bionet-plants-signaltransduc at net.bio.net (plsignal-moderator at net.bio.net is an alias for bionet-plants-signaltransduc at net.bio.net) Moderator: Bratislav Stankovic Mailing list name: PLANT-SIGNAL-TRANSDUCTION E-mail addresses: plsignal at net.bio.net plsignal at daresbury.ac.uk Newsgroup Character: bionet.plants.signaltransduc is a forum for scientific discussions and a source of information for the community of biologists interested in any aspect of signals and signaling in plants and fungi. The name PLANT-SIGNAL-TRANSDUCTION was chosen to reflect the common interest among scientists working with different model systems. Functions of the newsgroup: The newsgroup will facilitate rapid communication among research scientists and educators investigating the mechanisms of plant signal transduction in many biological fields, including but not limited to cellular biology, molecular biology, developmental biology, genetics, (electro)physiology, ecology, taxonomy, evolutionary biology, etc. and will thereby allow more rapid progress in research involving plants. The newsgroup will provide a forum for discussions of problems, old and new ideas, journal publications, and recent developments in plant signal transduction research. The newsgroup will also provide sources of practical advice, methodologies, answers to frequently asked questions concerning understanding of the mechanisms of signal transduction in plants and techniques used in such research, and availability of unique reagents for research with plants (e.g. antibodies, cDNA clones, primers and gene sequences, DNA libraries, mutants, etc.). Finally, the newsgroup will serve as a bulletin board for announcements of meetings, conferences, job opportunities, and funding sources of interest to biologists studying signals and signaling in plants. Subscribers are welcome from universities or any academic institutions, government agencies, medical institutions, and industrial or commercial organizations. Contributions within the functions outlined above are encouraged. Moderation Policy: Mass-posted commercial messages, chain letters, and similar postings not germane to plants or signal transduction will be deleted without comment. Inappropriate messages posted in good faith will be returned to the sender. Messages not strictly within the charter but likely to be of interest to many subscribers (e.g., messages dealing with certain aspects of signal transduction in animal systems) will be accepted. Bratislav Stankovic Plant Biology PHONE: 1-614-688-4305 Ohio State University FAX: 1-614-292-6345 1735 Neil Avenue E-MAIL: stankovic.1 at osu.edu Columbus OH 43210, USA


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The women's shows in Milan last week looked really great and all, but we're just as interested in exploring the rest of Italy—which is exactly what one of our lead web developers, Sonya, did over the summer. Check out her pics and travel tips below.
Rome: "Sunset stroll down the streets of Rome."
Barga: "Having an Aperol Spritz at the Pizza Lab in Barga, moments before the music festival starts."
Giotto's Campanile in Florence: "We braved many, many stone steps for a breathtaking view of the city of Florence."
Alimentari in Lucca: "One-stop shop for fresh cheeses and meats from nearby farms, as well as local wine."
Pistoia: "The two-colored marble exterior of the Baptistery in Pistoia."
Sommocolonia: "Tuscan sunset, overlooking Barga."
Piazza Navona: "Only hours after stepping foot in Rome, we immediately sought out the Fountain of the Four Rivers in the heart of Piazza Navona."
Rome: "Moments inside the Vatican."
Rome: "The beautifully preserved Arch of Septimius Severus."
Open Baladin: "Impressive beer selection, including more than a dozen microbrews, near the Campo de' Fiori."
Rome: "Up the Spanish Steps and around the corner, we lucked upon this building with intense, ornate doorways and windows."
Sommocolonia: "Home sweet home in the lovely Tuscan town of Sommocolonia."
(Your travel guide, Sonya, signing off.)
Check out more travel tips here: Los Angeles | New York


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Researchers at Yale University might have found a way to defeat the fifth most lethal cancer in women.
A team of researchers at the Yale School of Medicine believe they have found a vulnerability in ovarian cancer cells and they hope to use that to kill the deadly tumors.
The team, led by Dr. Yingqun Huang, assistant professor in the Department of Obstetrics, Gynecology and Reproductive Sciences, found that shutting down two genes in ovarian cancer stem cells stops the cell from growing.
Huang and other researchers discovered the link between stem cells and ovarian cancer while studying human embryonic stem cells and finding that certain ovarian cancer cells express two particular stem cell proteins, called Lin28 and Oct4. Stopping these two proteins from expressing their function appeared to inhibit growth of the cells.
They also found that the two proteins appear to act together in ovarian cancer tissue cells to produce more advanced tumors. Inhibiting their combined expression led to a significant decrease in the growth and survival of cancer cells. A larger-scale ovarian cancer study is currently underway to confirm the significance of the findings.
Genetic researchers prevent genes from performing their function, "knocking down" the gene, by inserting small interfering RNA (siRNA) molecules into the cells. The next steps in the team's research will be to examine the effect of siRNA in ovarian cancer samples in the lab, and to test the technique on mice. If successful, human trials would follow. Treatment on cancer patients could come within 10 years, Huang said.
"We hope we will soon be able to apply this new information to improve outcomes, perhaps by developing better diagnostic markers and treatment strategies that may be useful in customizing treatment for ovarian cancer patients," said Huang.
Ovarian cancer is difficult to detect in its early stages. It is also challenging to treat because it tends to recur frequently and develop resistance to treatment. According to the Merck Manual online, ovarian cancer was responsible for about 15,000 deaths in 2008.


text: Venus Williams is known for her style on the court, but her method of visualizing her tennis fashion line is surprising. She tells Departures magazine she uses Hello Kitty pads to sketch clothes for her line, Eleven by Venus. "I have a soft spot for all things Hello Kitty, and the notebooks are my sketch pads." Williams, who took home gold in women's doubles with sister Serena Williams at the Olympics, will celebrate the launch of her line at Rita Schrager's Southampton home tomorrow.


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You are currently browsing the tag archive for the 'internet' tag.
After being away from serious gardening for a decade, I recently joined (or re-joined) some excellent plant societies: the American Iris Society, the Species Iris Group of North America, the Aril Society International, the Median and Dwarf sections of AIS, the British Iris Society, The North American Rock Garden Society, and the Scottish Rock Garden Club.
Most horticultural societies date from the early decades of the 20th century, or spun off from such groups a few decades later. For nearly a century, these organizations have provided remarkable services to the horticultural world. Besides being "clubs" where people can socialize with others who share their interest, they have brought order out of chaos by overseeing the names of cultivars, spreading information on how to correctly identify species, promoting plant breeding and propagation, helping finance botanical expeditions, and serving to promote the best "finds" and "creations" of specialist growers to the general gardening public. For most of the 20th century, the publications of horticultural society were effectively the sole source of detailed information on the plants they promoted. They were also the principle conduit through which specialist nurseries reached their public.
Today, most such organizations are in a state of decline, in some cases perilous decline. Memberships are shrinking, and with shrinking memberships come shrinking resources (financial and human) to carry on the crucial functions of the organizations. One sometimes hears this attributed to some particular society program being poorly run, or some particular decisions of a governing body being poorly conceived. Such comments, I feel, largely miss the point. This is a universal phenomenon, not a particular one. I think its cause is obvious: the internet.
During the 20th century, horticultural societies operated on a single core principle: membership dues in exchange for information. If you wanted to know what the best new irises were, where to obtain them, or how to grow and breed them, you had to join the iris society and receive their publications (or be close friends with someone who was a member). The societies were the gatekeepers. Once involved, members would find other things the society offered: the judging program, conventions, discussion groups, and so on. But the basic equation was "pay your dues to learn about irises".
The internet has completely undone this basic equation. The plant societies are no longer the gatekeepers. I can go on line and learn more about irises than I can from a decade of society publications. Don't misunderstand: the publications are excellent and I enjoy them immensely. It's just that they are no longer a unique source of information. They are a supplement, and a comparatively expensive and inconvenient supplement in comparison with online resources.
I don't know of any group that has not recognized the importance of a vibrant online presence in attracting the attention of potential members today. Projects like the forum of the Scottish Rock Garden Club and the AIS Iris Encyclopedia have become phenomenal resources and hubs for enthusiasts around the world. But although embracing the internet is necessary to keep the horticultural societies relevant, it is not sufficient.
Why do I say that? Because having a vibrant online presence cannot, in itself, reverse the trends of declining membership. If the online resources provided by the society are open to all, then the basic problem remains: there is no need to join and pay dues to get the information. If the resources are made members-only, then the society shuts out the very people it intends to attract: potential members. If there were no alternatives, people could be lured into paying dues for access to a web site. But there are, in fact, plenty of free alternatives. Some are of dubious quality, of course. But the basic point remains. Today, if I have a question about irises or rock gardening or plant breeding or species identification or anything else, I can have my answer in a few minutes without having to "sign up" for something (which many people resist on principle) or pay for anything.
I don't see a clear answer. Maybe we should just recognize that we are approaching the end of an era, and let the dinosaurs die off, their archives surviving as reminders of a very different era, when information was a scarce resource. Alas, these societies do more than provide information. The American Iris Society maintains the cultivar registration database, operates an important judging and awards system (flawed, perhaps, but vital nonetheless for promoting the many different types of irises), and sponsors various scientific and horticultural projects. It would be sad indeed to return to the fragmented condition of the 19th century, where there is nothing beyond individual gardeners and commercial nurseries to foster our love of particular plants.
The frustration is parallel to what we are experiencing with regard to brick-and-mortar bookstores. I love them, don't want to see them go, but don't see how they can successfully face the economic realities of the information age and survive.
The only glimmers of hope I see are in the examples of societies that offer tangible benefits, beyond information: seed and plant exchanges, for example. If the only way to obtain a choice species that is not available commercially is through a plant society, enthusiasts will join. I don't know if this single strategy is something that can, by itself, keep the societies relevant into the future, but it's at least a model of the kind of thinking that will be needed. To survive, horticultural societies must move beyond the dues-for-information paradigm that propelled them onward through the 20th century and find a new paradigm.
If I knew in detail what the new paradigm is, I would shout it far and wide. But I don't. I'll wager, though, that by the middle of this century horticultural societies will be either radically different than we know them today or gone altogether.