Terms and Conditions - hei.at | The future of lighting. Today.
1.1. All legal transactions with HEI Technology International GmbH (hereinafter referred to as "the contractor") in the field of solar outdoor lights, AC outdoor lights, photovoltaic elements and related products and services shall take place exclusively according to the following conditions.
1.2. We hereby expressly rule out a counter-confirmation on the part of the client with reference to its terms and conditions and/or purchasing conditions.
1.3. Assurances, subsidiary agreements and amendments to the contract shall require our written confirmation in order to be effective.
2.1. We can accept an order from the client within two weeks by sending an order confirmation or by sending the products ordered within the same period of time. The contents of the order confirmation shall be considered the determining factor for the contract.
2.2. We reserve the right to make technical changes provided that no unreasonable disadvantages for the client arise as a result.
2.3. Our offers are made subject to prior sale and are therefore subject to confirmation and not binding until the conclusion of the contract, unless we explicitly describe them as binding.
2.4. In the case of projects, project certificates and official and other permits shall be obtained by the client and made available to us in good time.
2.6. If no business deal is concluded, the originals of any documents we have made available (framework supply contracts, evidence of ability to supply, technical drawings, calculations, etc.) shall be returned to us immediately. They may not be copied or presented to third parties without our written agreement.
2.7. In the case of feigning the conclusion of a contract, we reserve the right to demand damages.
3.1. The delivery dates stated by us are not fixed dates. The actual delivery date can diverge by up to 20 working days from the delivery date stated by us. In the case of a divergence of up to a maximum of 20 working days, the client shall not be entitled to assert any claims of whatsoever nature against the contractor.
3.2. The delivery deadline shall be extended appropriately in the case of unforeseen events which are beyond our control (e.g. force majeure), as far as these have an influence on the completion of the object to be supplied.
3.3. Partial and pre-deliveries shall be permissible.
3.4. The client may only withdraw from the contract in the case of a delay in delivery which is our responsibility, and provided that the promised service or delivery has not been effected within a reasonable period of grace.
3.5. It is not possible to withdraw from the contract for independent services which have already been rendered. In addition, claims on the part of the client due to non-fulfilment, late fulfilment and any possible consequential damage shall be excluded.
3.6. After delivery, the client shall be obliged to carry out an acceptance test without delay. If the client does not fulfil its obligation with regard to acceptance, we will set a reasonable period of grace.
3.7. If the client delays the acceptance test, we shall be entitled to charge for the damage caused, particularly storage costs and any additional costs.
4.1. Prices shall be deemed to be ex works Vienna (EXW Vienna, Incoterms 2010), unless otherwise indicated in the order confirmation. The prices do not include the applicable rate of statutory VAT.
4.2. If more than three months pass between the conclusion of the contract and the delivery of the goods, we reserve the right to increase the price by a reasonable amount, particularly in the case of changes in the cost of materials, energy and wages.
4.3. The EURO shall be the standard currency for payments. Payment in other currencies shall require our express written agreement. In this case, no disadvantages shall be caused to us due to exchange rates.
4.4. Payments shall be made in accordance with the order confirmation. We reserve the right to deliver for cash in advance only. Discounts will not be granted. If other methods of payment or provision of security are permitted by us, particularly letters of credit or bank guarantees, the additional costs which arise shall be borne by the client.
4.5. In the case of default in payment, we shall be entitled to charge 10 % interest on arrears without setting a further deadline. Moreover, the client shall be obliged to reimburse us for all costs, expenses and cash payments caused as well as for costs which we have incurred as a result of the pursuit of our claims.
4.6. The client shall not be able to reduce or fulfil its payment obligations by offsetting these against claims on the contractor.
5.1. We will invariably charge for services which we render on behalf of the customer within the framework of project development and/or project preparation.
5.2. If no order is placed, the services rendered up to this time shall in each case be invoiced. An hourly rate of EUR 95.00 shall be deemed to be agreed.
6.1. All supplied and/or installed goods shall remain our property until full payment has been made.
6.2. If the client should fall into arrears, we shall be entitled to take back the goods which are subject to our reservation of title. Taking back goods subject to reservation of title shall represent a withdrawal from the contract.
6.3. We shall be entitled to realise goods subject to reservation of title after taking them back. After deduction of a suitable amount for realisation costs, the realisation proceeds shall be offset against the amounts owed by the client.
6.4. The client shall immediately and explicitly inform third parties who assert claims to goods subject to reservation of title about our reservation of title.
6.5. The client shall be entitled to resell the object of sale in the ordinary course of business. To safeguard the legal position of the contractor, in particular to safeguard the outstanding receivables from delivery transactions between the contractor and the customer, the latter shall on the conclusion of the contract assign to the contractor all receivables accruing to the customer from the resale to the customer's purchasers or third parties in the amount corresponding to the outstanding balance from the delivery transactions. The customer shall also remain entitled to collect this receivable after the assignment. The power of the contractor to itself collect the receivable shall remain unaffected thereby. However, the contractor engages not to collect the receivable for as long as the customer fulfils his payment obligations, does not fall into default in payment and, in particular, no application has been made for the opening of bankruptcy or composition proceedings. If this is the case, however, the contractor can demand that the customer disclose the receivables assigned to the contractor and the respective debtors, provide all the information necessary for the collection, release the appurtenant documents and notify the debtors (third parties) of the assignment.
7.1. We guarantee for the period of 24 months from the date of delivery that the goods were – in accordance with the respective state of the art at the time of the order – faultless in design, materials and craftsmanship. We assume no liability or additional guarantees for batteries (accumulators) unless required by mandatory law or agreed by written confirmation.
7.2. Guarantee claims shall be asserted in writing by means of a registered letter detailing the defects. The object of the complaint shall be kept available for inspection by us and/or sent back to us if requested.
7.3. Replacement deliveries will be provided ex works Vienna (EXW Vienna). Other expenses shall be borne by the client.
7.4. For guarantee claims of batteries, we can either provide a replacement delivery ex works Vienna (EXW Vienna) or do a compensation payment. The height of the compensation for VRLA batteries is calculated as follows: capacity of the battery (Ah) times number of remaining days till end of warranty period times 0.07 €cent (per day and Ah).
7.5. Minor colour variations, colour variations which are a result of the use or the composition of different materials, as well as breakage and tears of the solar cells shall not be treated as deficiencies.
7.6. The functionality of solar lights (particularly illumination strength, availability, etc.) depends to a great extent on the conditions at the location. It shall not be considered a defect if, due to the local conditions (light/shade, climate), a solar light provides a lower performance than that indicated by us for typical locations.
Improper storage of goods before installation. Batteries shall not be stored at ambient temperatures below 5°C and above 30°C. Batteries shall not be exposed to direct sunlight for long time.
Defective installation by the client or third parties.
Improper interventions which have not been explicitly instructed or permitted by us as well as unauthorised attempts at repair.
Improper cleaning. The goods are not designed forcleaning with high-pressure equipment.
Normal wear and tear as well as force majeure.
7.8. Replaced parts may diverge from the original parts which have to be replaced in their version and their design due to technical progress and design changes, provided that the functioning of the system as a whole is not impaired. Reconditioned parts or parts of returned goods can also be used as replacement parts, provided that the parts are visually and in their operability in conformity with new goods.
7.9. Continuing liability shall be excluded, regardless of the legal nature of the claim which is being asserted. Insofar as our liability is excluded or limited, this shall also apply to the personal liability of our staff, vicarious agents, managers and executive bodies.
8.1. Goods supplied by us only offer the level of safety which can be expected based on licensing regulations, operating instructions, our regulations on the treatment of the goods and other instructions given.
8.2. Any liability on our part shall be excluded if the storage, installation or use of the goods is not carried out according to the relevant regulations, recognised technological standards and the delivery description provided, as well as in the case of changes to the goods which were not carried out by us.
9.1. The order, its execution and the resulting entitlements shall be governed solely by Austrian law unless otherwise agreed.
9.2. The place of jurisdiction shall be Vienna.
9.3. If individual terms of these general terms and conditions should be wholly or partly ineffective, this shall not affect the validity of the remaining contract.


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What's burdock? - Japan's "Burdock BOOM"
by Fumi Tsukamoto September 2, 2013
Our "Gomoku" onigiri flavour contains burdock. We are often asked by customers: "What is burdock?" Please read on for a brief explanation.
Arctium is a genus of biennial plants commonly known as burdock, family Asteraceae. Native to the Old World, several species have been widely introduced worldwide. (Wikipedia)
Burdock root doesn't look very appealing, but it's super delicious in onigiri.
If you were living in Japan, you would see many TV shows extolling the health benefits of burdock. The "Burdock BOOM" started almost two years ago in Japan and it is now well known as a anti-ageing vegetable. Dr. Yoshinori Nagumo was 55 years old when he wrote the book "Gobocha wo Nomuto 20saiwakakaeru" (Burdock tea makes you 20 years younger), which sold 300,000 copies in just 5 months.
As a result, store shelves in Japan are now laden with products containing burdock such as tea, bread, and cookies.
The Anti-Oxidant King of the Vegetable World
Although the search for the fountain of youth is a futile endeavour, it is possible to age gracefully by maintaining a healthy lifestyle. So, what's so great about burdock and what can it do for you?
According to research by the fresh food processing company, Ajikan, and the National Fisheries University, published at The Japan Society of Cookery Science in 2009, burdock has some of the strongest anti-oxidant properties of all vegetables.
resource; http://goboutea.com/kenkou/; Ajikan, National Fisheries University, 2009
*ORAC:Oxygen radical absorbance capacity (ORAC) is a method of measuring antioxidant capacities in biological samples in vitro. (Wikipedia)
Dr. Yoshinori Nagumo says;
Because burdock lives in the soil where it needs to protect itself from bacteria and other harsh physical conditions, burdock has evolved to contain saponin, a kind of polyphenol, in its skin. The origin of "sapo" in saponin shares its root with the word "soap" which breaks down oil as a surface-activating agent. Saponin breaks down the cholesterol based cell membrane of harmful bacteria in the soil. The saponin in burdock also attacks cholesterol and fats in the digestive system, aiding in weight loss. Asian ginseng, which is well known as an all-purpose medicinal herb, also contains saponin. From it we can expect nutritional fortification which warms the body from the inside, boosting immunity, anti-cancer efficacy, wound healing, and anti-oxidant effect.
Burdock looks ugly but it has a wonderful earthy flavour, and may work wonders for your body. We are eager to make burdock a common ingredient in kitchens and lunch boxes across North America by introducing a variety of burdock based products.
We are looking for local farmers who grow burdock, whether on purpose or involuntarily, to become our regular supplier. If you are a farmer who grows burdock, or if you know any farmers who do, please get in touch with us!
-Abokichi
© 2022, abokichi.ca

redpajama_set_name: RedPajamaCommonCrawl


A large launch of 48 SKU's across various printers, printing processes and substrates. There were 8 printers involved with this launch. In working with our client and their Designer, colour consistency was a mandatory.
iMSGroup was involved at the early stages of creative enabling them time to work with each of the printers to agree upon fingerprinting and proofing profiles. When concept was approved one key master artwork was supplied per size. From here iMSGroup completed Artwork engineering, rollout of all the remaining sizes and variants and proofing. Colour accurate proofing meant they could be matched on press.
From 10 master files supplied, we were able to save the entire Finished artwork cost of 38 SKU's, deliver final files and proofs that needed no amendments prior to printing along with proofs that met colour expectation that were reproducible on press.


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Islam Is A Bad Religion
adminon June 13, 2019 June 13, 2019
The Lies and Deceptions of Islam. Muhammad was a false prophet, but they won't tell you that because they want to snare your soul into hell.
Secularism, or separation of religion and state, is one of the most distorted terminologies in Pakistan today, along with Islam and democracy. The fact is that we cherry picked only the bad aspect.
[1] There is, however, one curious case of a movement that pledges allegiance to Islam, obeys the five pillars of the religion — faith, prayer, fasting, charity, and the pilgrimage to Mecca — while.
Deception, Lying and Taqiyya Does Islam permit Muslims to lie? Muslim scholars teach that Muslims should generally be truthful to each other, unless the purpose of lying is to "smooth over differences" or "gain the upper-hand over an enemy"
May 18, 2011 · Islam is the second-largest religion (Christianity is the largest) in the world and one of the fastest growing. While there have been very good Muslims, some have been very bad. This list, in a sense, is a response to the earlier lists of Top 10 People Who Give Christianity a Bad Name and Top 10 People who give Atheism a Bad Name. It is not meant as a commentary on Islam itself – merely ten of.
Nov 12, 2014 · We can debate whether prosperity and peace lead people to be less religious or vice versa. Indeed evidence supports the view that religion thrives on.
2. Ancient Greece 5. #atheism #christianity #greece #islam. Ancient Greece was polytheistic and polycultural: many different communities worshipped many different gods. Various cults and movements dawned and dwindled over time. In this respect, the Roman Empire was civilized, tolerant 6 and peaceful (as much as was possible, given how many problems with Human governance had not yet been.
Diet plays a very important role in the daily life of a believer. There are many verses in the Noble Qur'ân which draw man's attention towards his self and which invite him to carefully study his body and soul and the nature of their mutual relationship.
islam is evil in the name of god. killing islam book trilogy: killing prophet muhammad, killing allah, killing the quran exposing the evil truth of islam: god of moral perfection(tm): a god of all peace, love, mercy and goodness or an evil allah (the antigod) of extermination, genocide, murder, assassination, hate,terror, torture, brutality, rape, slavery.
I'm very specific that I'm not against the religion, I'm not against Islam. of voices building in America and elsewhere who think that all adherence of Islam is bad and that is a very dangerous.
And any other religion, or creed, or god. in essence for what they believe: that Islam is bad and Muslims are dangerous. They weren't only punished for what they did but also for what they thought.
"While Omar, a Minnesota Democrat, holds herself out as a proud Muslim, she repeatedly projects a distorted and patently Islamist interpretation of Islam – a religion that in reality stands for the.
Main Religion In Russia Mueller III's handling of the investigation, according to a Washington Post-ABC News poll. believe there is clear evidence of Russia's
The work "became a refutation of objections non-Muslims have" against the religion, he told the respected. "It is great when somebody who has been so critical of Islam. realises that it is not so.
Mohammed, "the Praised One", the prophet of Islam and the founder of Mohammedanism, was born at Mecca (20 August?) A.D. 570. Arabia was then torn by warring factions. The tribe of Fihr, or Quarish, to which Mohammed belonged, had established itself in the south of Hijas (Hedjaz), near Mecca, which.
Sep 07, 2009 · Slavery in Islam. Although Islam is much credited for moderating the age-old institution of slavery, which was also accepted and endorsed by the other monotheistic religions, Christianity and.
. this wonderful religion or its adherents', they tell us. This is a really bad response, because it is becoming increasingly clear that one of the major problems we face today is not that our.
Sinead O'Connor has converted to Islam after a long and difficult relationship with religion. The singer announced in October. 'We were told we were there because we were bad people. Some of the.
A name is an important symbol that distinguishes one person from another. It is therefore natural that everyone wants a good and honorable name. It is reported
Islam is a Religion of Love and Peace The definition of Islam. The root of the word Islam, silm, refers to "making peace, being in a mutually peaceful environment, greetings, rescue, safety, being secure, finding peace, reaching salvation and well being or being far from danger, attaining goodness, comfort and favor, keeping away from troubles and disasters, submitting the self and obeying.
She projects a distorted and patently Islamist interpretation of Islam – a religion that in reality stands for the values of justice, peace and ethical conduct.
What Religion Prays To Allah To understand the difference between any two things or people or places, one would have to have a very detailed,
Using words with the intention of stirring up racial hatred is not protected and – no doubt for this reason – the APPG definition claims that criticising Islam is a form of racism. But race and.
Hasan is not the first person to invoke Islam when speaking of extremism within other. Is all expression of religion in the public sphere "bad"? Are we then to also speak of a Mullah Martin Luther.
Something bad happens to them, they expect the government to help. rather than become a cliché of extremist Islam.
Last Judgment: Last Judgment, a general, or sometimes individual, judging of the thoughts, words, and deeds of persons by God, the gods, or by the laws of cause and effect. The Western prophetic religions (i.e., Zoroastrianism, Judaism, Christianity, and Islam) developed concepts of the Last Judgment.
A sampling of violence in the Quran. TheReligionofPeace: TROP is a non-partisan, fact-based site which examines the ideological threat that Islam poses to human dignity and freedom.
How To Improve Ushering In Church According to Reverend Lamberth Kofi Xatse,ushers play a vital role for making sure there is order in the church and
To others, it's just another religion to be respected alongside Judaism and Christianity. Many know the story of the two most dominant streams in Islam, of Sunni and Shia, forever torn in a nasty.
Salvation in Islam. SALVATION IN ISLAM (PART 1 OF 3): WHAT IS SALVATION? By Aisha Stacey. Islam teaches us that salvation is attainable through the worship of God alone.
It's obvious the "appearance of an alien religion at the border of a civilization is a threat," Gyöngyösi said, but the "spread of Islam is only a negative. "is the result and consequence of bad.
Aug 09, 2012 · The Christian church's record on teaching sexual morality is patchy. While Jesus taught the indissolubility and exclusivity of marriage, quite early in Christian history some Church leaders began to show a distaste for sexual intercourse which has had damaging results.
Jan 22, 2015 · Unsubstantiated rumor claims CIA Director John Brennan is a Muslim who converted to Islam while stationed in Saudi Arabia.
have been asked to account for our religion. The occasion may be a question from a curious non-Muslim theist, a fellow Muslim who doesn't quite understand something, or an atheist who challenges you.
Islam is not a religion of war," he said. "It's just a religion. Start there." Howk said a Muslim is no more likely to commit a crime than a Christian. That's what he stresses. There are no good or.
In the 2017 survey, Silents are the only group in which more say the Islamic religion encourages violence (53%) than say it does not (36%). Boomers and Gen Xers are divided in views of Islam and.
Now that we have seen how much importance Islam has accorded to marriage and marital life you would perhaps ask, "How do we select a spouse? What are the guidelines provided by Islam in this regard? Do we look for some particular characteristics or just try to get the best from the worldly point of view?" Are Pre-Marital Contacts Necessary?
Catholic Prayer For Alcoholic Husband Theresa Caputo and the "Long Island Medium" television show -A Christian perspective By: Glenn Dallaire Since I have such a
There's A Wideness In God's Mercy Hymn The Presbyterian Hymnal: Hymns, Psalms and Spiritual Songs (The "Blue Hymnal"). (Louisville:. Into Hope" #332. "There's a Wideness in God's
Fargana Gasimova's memories of Islam during the Soviet period are of a faith that had to be kept hidden. Her grandparents would pray and fast in secret, careful to disguise any hint of their religion.
Armstrong had been sitting in a chair, as she always did because of her bad knees. cultivated belief. that Islam is an inherently violent way of life. We saw a suffering people embodying the.
Islam101 is an educational site on Islam, its civilization and culture. It includes an introductory course on Islam and presents Islamic views on contemporary issues. The section on comparative religious studies has articles on the commonality and differences between Islam and other religions.
Center United Methodist Church Welcome Nc
Midway Pentecostal Holiness Church: 4371 NC Highway 55, Erwin. cancer centers and hospices with a variety of items. New members…
Modern Spiritual Songs
Having never heard the song before, I was not prepared for the emotional punch. both hands available for the furtive…


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Council is an age-old practice that involves bringing people together in a circle to bear witness and share authentically. Participants agree to speak one-at-a-time, sharing their personal stories and experiences, rather than opinions, and listening non-judgmentally while others do the same. Sharing and listening to universal stories about love, loss, fear, triumph, challenge, hope and other experiences enables participants to recognize that, despite our many differences, we have much in common.
By fostering attentive listening and authentic expression, council builds positive relationships between participants and neutralizes hierarchical dynamics formed by the inequality of status, race, or other social factors. It supports a deep sense of community and fosters recognition of a shared humanity and interconnectedness. It enables individuals to give voice to their stories, develop mutual respect, cultivate a compassionate response to anger, defensiveness, and violence, as well as strengthen emotional health and resilience.
Our Transformational Programming
applications of council
The practice of council acknowledges everyone present and helps focus intention and energy on our common stories, values, aspirations and our emergent collective wisdom. Its application is widespread and worldwide.
Council programs have been integrated widely in educational settings, with dozens of public and independent schools throughout Southern California – and around the world – initiating council programs for students of all ages and school communities involving teachers, parents and community members.
START-UP BUSINESSES
One of the hardest aspects of starting a business is managing growth. Rarely discussed and addressed are the complex interpersonal relationships that are an inherent aspect of that growth, as new personalities are constantly being added to the mix. Council provides a welcome platform for new employees and emerging work relationships.
BUSINESSES UNDERGOING CHANGE
Widespread changes within an organization of any size, such as layoffs, leadership transitions, and new ventures, can put stress on employees trying to adjust to their new work environment. Council has proven to be a generative and supportive tool for the interpersonal challenges that emerge as businesses manage change.
Council-based wellness and resiliency programs provide a dynamic and effective format for training in approaches that increase mindfulness and support de-escalation and inter-personal communications.
COMMUNITIES DEALING
WITH TRAUMA
Whether trauma is systemic, such as high crime and poverty, or acute, such as a school shooting or environmental disaster, council can provide a stable resource for coming together, bearing witness and navigating the complex emotions and volatile conditions communities confront.
FAITH-BASED GROUPS
Council has been integrated as a tool for contemplative practice, community-building and charitable works in faith-based communities of all denominations.
FIRST RESPONDERS & OTHER PROFESSIONALS
Council-based wellness programs offer practical skills and sustainable practices for recognizing and managing stress, regulating emotions, improving interpersonal relations, and creating a more compassionate work environment.
Council is a powerful and dynamic tool for celebrating connection, marking transitions, and cultivating respectful communication, heartful connection and greater intimacy.
defining terms: what it is and what it isn't
The Latin word concillium, from which the word council derives, means "a gathering of people." As we use the term, council refers to an intentional, set-aside time and place in which people come together. Some use the word "sacred" to describe this special space, though council does not connote any particular spiritual tradition. As a practice, council helps us define WHERE, WHEN, WHO, WHAT and HOW we gather together. We create a circle, in a particular place, for a given length of time, and invite individuals to come together with the intention to listen and speak from the heart. Council is a practice in which individuals deepen self-awareness, groups find cohesion and communities build bridges.
Council is not therapy; nobody purports to hold more authority or wisdom than anyone else. Council is not religion; there is no dogma or belief system that is elevated or preferenced over any other. Council is not gossip; the focus is on personal stories, not judgment or opinions of others. Council is not casual; the form is intended to create a strong container for sharing vulnerably and inviting the emergence of collective wisdom. Council is not fixed; it is a dynamic and emergent co-creation of participants who bring their good intention to the gathering, in service of themselves and others. Council is not exclusive; by including everything, seen and unseen, shadow and light, nothing is ignored.
Council is best learned through experience. Consider joining us for a Social Connection Council or explore our public trainings. For more on the origins of council practice, click here.
Learn More About Council
Becoming A Council Trainer
Additional Resources (PDF)


Nesterchuk N, Grygus I, Prusik K, Zukow W. The technique of physical rehabilitation in clubfoot. Physiotherapy Quarterly. 2019;27(1):25-34. doi:10.5114/pq.2019.83058.
Nesterchuk, Natalia, Igor Grygus, Krzysztof Prusik, and Walery Zukow. 2019. "The technique of physical rehabilitation in clubfoot". Physiotherapy Quarterly 27 (1): 25-34. doi:10.5114/pq.2019.83058.
Nesterchuk, Natalia et al. "The technique of physical rehabilitation in clubfoot." Physiotherapy Quarterly, vol. 27, no. 1, 2019, pp. 25-34. doi:10.5114/pq.2019.83058.
To develop the technique for physical rehabilitation of children with congenital clubfoot. To prove the positive influence of physical rehabilitation available to correct disorders in children with congenital clubfoot.
The pedagogical experiment involved 68 preschool children aged 4–5 years with congenital clubfoot, who were divided into the control 1 (n = 34) and main (n = 34) groups. At the beginning of the study, the children were treated and were classified in the 'D' register by the children's orthopaedist. Peers without developmental disorders (n = 34) constituted the control group 2.
The physical rehabilitation technique based on the methods of functional status diagnosis, purpose, content, and physical rehabilitation program included 3 stages of implementation. The basic technique components of physical rehabilitation experimentally verified its effect on correcting the basic disease and functional status of children with congenital clubfoot. The emphasis was placed on the active involvement of parents, establishing close and trusting relationships with them. Parents are taught to correctly apply physical rehabilitation. They have mastered the skills required for the organization of physical rehabilitation at home.
The technique was based on physical rehabilitation purpose, objectives, and adequate principles. It also discloses the specific organization and methodology of physical rehabilitation in congenital clubfoot. The guiding direction is to achieve physical rehabilitation of motor activity and functional status of children with congenital clubfoot to the level of their peers without disabilities.


"Yes, and all who desire to live godly in Christ Jesus will suffer persecution" (II Tim. 3:12).
Paul clearly declared that all who desire to live godly in Christ Jesus will suffer persecution. It didn't even say that you have accomplished living godly. All it really says that you desire to live godly. Also, it declares that all that have that heart's desire to live godly will not be exempt from persecution, but should expect it. Jesus called out Paul (then Saul) on the road to Damascus (Acts 9:3-6), and sent him in a blinded condition to await the next instructions. Jesus called and sent Ananias to lay hands on Saul. Jesus word to Ananias about Saul was that he was a chosen vessel to bear His name to many (Acts. 9:15) In Jesus' word for Paul He said, "For I will show him how many things he must suffer for My name's sake" (Acts 9:16). I make no apology. Jesus did not promise Paul a rose garden. Jesus clearly informed Paul through Ananias that he would suffer persecution for His name's sake.
As it turns out, suffering persecution can be an important tool used by the Father to train His sons. However, we need to understand its divine purpose. It is declared of Jesus, "though He was a Son, yet He learned obedience by the things which He suffered" (Hebr. 5:8). This wasn't obedience to the law, but obedience to the Father. When Jesus was tempted by the devil with the lust of the flesh when suffering hunger after his 40 day fast, He remained obedient to the word of the Father (Matt. 4:2-4). Jesus suffered the loss of the pride of life and lust of the eyes and remained obedient to the Father. The words He spoke and the deeds that He did were in love obedience to the Father (John 14:10). Jesus ultimately suffered persecution to trial and His sacrificial death on the cross, to become the author of eternal salvation (Hebr. 5:9).


Radio personalities Dave Rios and Steven Sellers appeared at the school Tuesday morning to recognize Campista, who was nominated by a parent of a student she taught last year.
"Everything she did for my daughter was very helpful, and she did it from the heart," Parent Natalia Maldonado said.
To celebrate, Rios and Sellers were also joined by KONO 101.1's mascot, Top Dog. Together, they all sang and read a book to Gillette's kindergarten students. The station also donated a $101 gift card for the school's library.
In addition, Rios recorded the students reciting the "Pledge of Allegiance" and aired the audio recording several times during his morning radio show the following day.


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Le syndrome d'apnées du sommeil (« SAS ») ou plus précisément syndrome d'apnées-hypopnées du sommeil (« SAHS ») est un trouble du sommeil caractérisé par un arrêt du flux respiratoire (apnée) ou une diminution de ce flux (hypopnée).

Ses causes sont diverses mais peuvent être classées en deux catégories :
 dans  90 % des cas elles sont obstructives et le résultat d'une obésité. On parlera alors plus précisément de « syndrome d'apnées obstructives du sommeil » (« SAOS »). Une apnée du sommeil est dite « obstructive » quand elle résulte d'efforts respiratoires pour lutter contre une obstruction des voies aériennes supérieures : nez, bouche, pharynx, larynx ;
 elles peuvent être aussi neurologiques, par anomalie du contrôle de la respiration et il n'y a donc alors pas d'effort d'inspiration comme dans le cas précédent. On parlera alors de « syndrome d'apnées centrales du sommeil » (« SACS »).

Ce syndrome, souvent très invalidant et pouvant dans certains cas entraîner la mort, affecte la qualité de vie non seulement des personnes qui en sont atteintes, mais aussi celle de leur entourage. En effet, les apnées, en dégradant la qualité du sommeil (diminution du sommeil profond et paradoxal, microéveils), provoquent l'apparition d'une somnolence diurne excessive parfois associée à une irritabilité, à une baisse de la libido ou à un état dépressif. D'autre part, les apnées diminuent la pression partielle en oxygène dans le sang et provoquent une désaturation en oxygène. L'hypoxémie chronique qui en résulte est elle-même responsable d'une hypertension artérielle et de l'apparition d'autres troubles cardiovasculaires.
La prévalence du syndrome d'apnées du sommeil est estimée entre 0,5 et 5 %. Ce syndrome est souvent méconnu, bien que son diagnostic soit maintenant bien codifié et obéisse à des critères précis. Longtemps ignoré, le SAS, dans sa forme la plus fréquente (« SAOS »), a été décrit en 1956 sous le nom de « syndrome de Pickwick ». Les traitements sont nombreux et leurs indications varient selon les cas. Ce n'est que depuis 1981 qu'existe un traitement constamment efficace, la ventilation en pression positive continue (PPC). L'entourage des patients joue un rôle essentiel dans l'accompagnement du traitement. Le SAOS affecte quasiment 2 % des personnes adultes, mais seulement un malade sur six est traité. D'après une étude américaine, c'est chaque année  humaines, atteintes de SAOS, qui meurent dans un accident de la route.

Définition

Le syndrome SAS est défini par la survenue durant le sommeil d'épisodes anormalement fréquents d'obstruction complète ou partielle des voies aériennes supérieures, responsables d'interruptions (apnées) ou de réductions significatives (hypopnées) de la ventilation, et associés à des manifestations cliniques le plus souvent dominées par une somnolence diurne excessive avec parfois des endormissements incoercibles.

Les autres symptômes principaux sont le ronflement, la somnolence et les céphalées matinales, et la constatation d'apnées au cours du sommeil par l'entourage.

Plusieurs symptômes et signes sont communs à ceux d'une aggravation de la déglutition salivaire atypique, reliquat de la déglutition infantile : interruption prématurée de la croissance, du développement et de la maturation des organes buccaux (infraclusion des dents, palais étroit et profond ; voir aussi « auxologie »), laxité musculaire (langue, voile du palais, pharynx), respiration buccale, souffrance respiratoire (hypoxémie), infections fréquentes des voies respiratoires, prédisposition aux allergies, bruxisme, acouphènes (en anglais )

Le diagnostic est posé sur un nombre excessif d'événements (apnées et hypopnées) constaté (un index apnée-hypopnée supérieur ou égal à 5) au cours d'un enregistrement polysomnographique. L'index apnée-hypopnée (terme abrégé en IAH) est défini par le nombre d'événements par heure. Un IAH de 10 peut donc être 10 événements en 1 heure ou 80 événements en 8 heures.

Événements respiratoires
L'apnée est définie par une interruption du débit aérien de plus de . Il n'existe aucun consensus de définition pour l'hypopnée. Cette dernière est souvent associée, en polysomnographie, à des phases de désaturation en oxygène (diminution de 3 à 4 % de la saturation, voire plus pour les cas les plus graves), ces événements s'accompagnant d'un allègement du sommeil responsable de somnolence excessive.

La mesure des efforts respiratoires permet de qualifier les apnées en séparant les apnées obstructives (avec efforts respiratoires), les centrales (sans effort) ou les mixtes. . Les analyses acoustiques ne présentent pas d'intérêt. Les microéveils sont induits par l'augmentation de l'effort respiratoire (et pas par la diminution de la saturation en ). Il n'existe pas de consensus sur la durée les définissant, le seuil le plus courant étant une période supérieure à .

Syndromes

Apnées obstructives du sommeil
Le diagnostic n'est posé qu'après une mesure polysomnographique. Aux États-Unis, ce syndrome est défini par une fréquence supérieure à cinq apnées par heure de sommeil. En France, le seuil est de dix apnées par heure de sommeil. Hormis les effets potentiels de la déglutition salivaire atypique, il n'existe pas d'étude de corrélation entre seuils et pathologie ou souffrance ressentie.

Apnées centrales du sommeil
Le diagnostic est également posé après un examen polysomnographique qui ne retrouve pas d'obstruction comme cause des apnées. Il existe cependant des syndromes mixtes.

Ronflement
Le phénomène est banal (d'après les déclarations de leurs conjoint(e)s, 86 % des hommes ronflent). L'interrogatoire reste très peu fiable. Les différents enregistrements de polysomnographie ont montré que les femmes ronflaient autant que les hommes bien que la puissance en décibels soit plus importante chez l'homme que la femme. L'âge (maximum à ), la surcharge pondérale, l'alcool et la prise de certains médicaments induisant un relâchement musculaire favorisent le ronflement. Il constitue une plainte initiale fréquente dans la découverte des SAOS.

Un index de ronflement (nombre de ronflements/heure de sommeil) peut être calculé. Un ronfleur a un index supérieur à 30. Il s'agit d'un cas sévère s'il est supérieur . Là aussi, les valeurs seuils influent sur la prévalence.

Ronfler a été défini comme un facteur de risque cardiovasculaire indépendant du SAOS. Sans SAOS, il existe une somnolence diurne chez certains ronfleurs.

Hautes résistances des voies aériennes supérieures
C'est une définition clinique et polysomnographique. Il s'agit de l'association d'une somnolence diurne excessive, d'« évènements respiratoires nocturnes hors apnées-hypopnées » (ronflements, microéveils, limitation du débit) et d'un test thérapeutique : amélioration par la ventilation en pression positive continue.

Ce syndrome se différencie du SAOS par l'absence d'apnées ou d'hypopnées telles qu'elles sont définies plus haut (inférieur à  par heure, en France), et par l'absence de retentissement sur la saturation artérielle en oxygène au cours du sommeil, même s'il existe une similitude entre ces deux syndromes sur le plan des symptômes (altération de la vigilance, somnolence diurne) et de leur mécanisme (fragmentation du sommeil en rapport avec une élévation des résistances des voies aériennes supérieures).

Épidémiologie
On évalue la sévérité d'un syndrome d'apnées du sommeil au terme d'un enregistrement polysomnographique nocturne en comptant le total moyen horaire du nombre d'apnées centrales, du nombre d'apnées obstructives et du nombre d'hypopnées. Le résultat de cette mesure se nomme l'Index Apnées-Hypopnées (IAH).

La gravité de la maladie apnéique est évaluée par cet IAH :
 IAH inférieur à 5 : le sujet est dans la moyenne de la population, il n'y a pas d'affection ;
 IAH entre 5 et 15 : syndrome léger ;
 IAH entre 15 et 30 : syndrome modéré ;
 IAH égal ou supérieur à 30 : syndrome sévère.

Prévalence
 24 % des sujets testés en polysomnographie ont un IAH égal ou supérieur à 5.
 15 % des sujets testés en polysomnographie ont un IAH égal ou supérieur à 10.
 5 % des sujets testés en polysomnographie ont un IAH égal ou supérieur à 15.
 Les sujets ayant un IAH supérieur à 20 sont beaucoup plus rares
 Et les sujets ayant un IAH supérieur à 30 sont extrêmement rares

Ces chiffres concernent les sujets ayant entrepris la démarche de diagnostic, donc ayant commencé à consulter le neurologue. La prévalence exacte sur la population entière reste toutefois difficile à évaluer car la plupart des personnes souffrant d'apnées du sommeil ne consultent pas et restent sans diagnostic, et donc également sans prise en charge. Comme pour nombre d'affections médicales chroniques et pour les mêmes raisons (la non-consultation) la prévalence sur la population est donc certainement sous-évaluée.

Par ailleurs 1 à 2 % des enfants âgés de  souffrent d'apnées du sommeil (essentiellement ceux ayant de grosses amygdales et des végétations).

La méthode de référence pour l'évaluation de la prévalence est la polysomnographie (PSG). Cette technique est cependant lourde et coûteuse (un peu moins de  en France en 2008) avec des limites : surestimation selon la position de sommeil, effet première nuit Elle est par conséquent inutilisable en épidémiologie.

L'évaluation de la prévalence sur la population repose donc beaucoup plus sur l'utilisation de questionnaires directs ou téléphoniques, mais avec des résultats individuels estimés de manière très imparfaite par rapport à ceux résultant de la polysomnographie. Les résultats de mesure d'une prévalence sur la population par l'emploi de ces questionnaires très subjectifs sont de 5 % à 9 % chez l'homme et d'environ 2,5 % chez la femme et n'ont donc qu'une valeur indicative, la précision objective suffisante chez chaque individu ne pouvant être obtenue qu'au terme d'un véritable examen polysomnographique avec prise en compte des biais, notamment ceux dû à l'effet "première nuit".

Facteurs favorisants
Longtemps on a cru que le sexe masculin était plus sujet à faire des apnées du sommeil mais les différentes études sur la polysomnographie ont montré qu'il y a pratiquement une égalité entre les hommes et les femmes souffrant d'apnées sévères du sommeil, l'âge (maximum à ), la présence d'une surcharge pondérale de type androïde, la prise d'alcool avant le coucher, la prise de certains médicaments induisant un relâchement musculaire, la présence d'un asthme ou autres symptômes respiratoires, le tabagisme. Même si le tableau concerne typiquement un homme âgé et obèse, il peut se voir chez d'autres personnes, même chez la femme longiligne.

La présence d'une maladie cardiovasculaire augmente de deux à trois fois le risque de développer une apnée du sommeil. De même, ce syndrome est plus fréquent chez le diabétique de , chez l'hypertendu. La raison de ces corrélations n'est pas claire, et s'agissant de maladies chroniques, il est impossible de savoir si l'apnée augmente le risque de ces maladies ou si ces maladies augmentent le risque d'apnée.

Il existe des formes familiales caractérisées par des similitudes anatomiques. Certaines maladies endocrines (hypothyroïdie, acromégalie, Cushing, diabète) favorisent la survenue d'apnées du sommeil ; de même, l'obstruction nasale, saisonnière ou non, responsable d'une respiration anormale par la bouche. Déglutition atypique : les interpositions de la langue entre les dents supérieures et les dents inférieures, au cours des  salivaires (« DS ») quotidiennes (appelé DS infantile chez l'enfant, DS atypique ou DS dysfonctionnelle chez l'adulte) favorise également cette anomalie respiratoire.

L'hypodéveloppement des maxillaires (mâchoires, fosses nasales et sinus étroits), la présence d'un palais effondré ou palais creux en ogive, toujours associé à des fosses nasales étroites (le palais est le plancher des fosses nasales), une mandibule (mâchoire du bas) trop petite (micrognathie) et placée trop en arrière (rétrognathie avec menton fuyant, ne pouvant jouer son rôle protecteur des voies respiratoires pendant le sommeil, l'arc mandibulaire devant normalement empêcher la langue de retomber en arrière en position allongée pendant le sommeil) sont également associés au syndrome d'apnées du sommeil.

Histoire naturelle
L'apnée du sommeil, sans intervention, tend à s'aggraver avec le temps. La concomitance de maladies chroniques (diabète, hypertension artérielle ou maladies cardiovasculaires) ne permet pas d'affirmer si ces dernières sont le terrain ou la conséquence d'une apnée du sommeil. Seule la surveillance des patients porteurs de ce syndrome sur le long terme permet de suspecter une relation causale.

Le risque de survenue d'une HTA semble étroitement corrélé au nombre d'apnées. Le traitement du SAOS par ventilation par pression positive continue permet une régression modeste des chiffres tensionnels. Il existe une augmentation sensible de la mortalité, essentiellement cardiovasculaire, chez les patients porteurs d'une apnée du sommeil. Cela est démontré de manière indirecte par une diminution  des chiffres de mortalité chez le patient traité.

Le ronflement est un facteur de risque de faire un infarctus (risque relatif de 4,4). L'hypopnée, si et seulement si elle s'accompagne d'une hypoxie transitoire, semble également être un facteur de risque cardiovasculaire. L'hypoxie a des conséquences à long terme, mais la somnolence diurne a des conséquences immédiates, en particulier sur les fonctions cognitives, l'humeur et le comportement (irritabilité, agressivité, dépression) et augmente le risque d'accident de la route.

Mécanismes
Les apnées obstructives du sommeil sont dues à la fermeture (« collapsus ») des voies aériennes lors de l'inspiration, qui génère une pression négative endopharyngée (pression de « succion »). Ce collapsus peut survenir en un ou plusieurs sites de l'oropharynx ou de l'hypopharynx. De nombreux facteurs peuvent participer à leur genèse, à des degrés divers selon les sujets :
 facteurs anatomiques : hypertrophie amygdalienne, micro(rétro)gnathie, obstruction nasale, obésité Ces facteurs réduisent le calibre des voies aériennes supérieures et augmentent leur résistance ; cette augmentation de résistance est accrue dans certaines positions, comme la flexion du cou et le décubitus dorsal, et lors de l'hyperventilation réflexe qui fait suite aux apnées ;
 augmentation de la compliance des voies aériennes supérieures (« flaccidité ») ;
 facteurs neuromusculaires (aggravés par la consommation d'alcool ou d'hypnotiques) : réduction trop importante du tonus des muscles dilatateurs du pharynx (muscles affectant la position de la langue, de l'os hyoïde, du palais) au cours du sommeil (d'autant plus que celui-ci est profond ou paradoxal), à l'état de base et en réponse aux stimuli mécaniques (anomalies des réflexes induits par la pression négative inspiratoire stimulant des récepteurs pharyngés, ou par le volume pulmonaire) ou chimiques (diminution de la sensibilité des centres respiratoires à l'hypoxémie et à l'hypercapnie) ;
 désynchronisation entre l'activité des muscles dilatateurs et celle du diaphragme ;
 retard à l'éveil en cas de collapsus des voies aériennes supérieures.

Les intrications sont complexes entre ces différents mécanismes. Cette apnée provoque un défaut d'oxygénation sanguin (hypoxémie) et un défaut d'évacuation du gaz carbonique (hypercapnie). Cette dernière stimule la ventilation, quitte à provoquer un bref réveil. Dans les cas les plus graves, ces apnées peuvent se produire jusqu'à plusieurs centaines de fois par nuit chez un patient.

Aspects cliniques
Le syndrome d'apnées du sommeil est responsable de plusieurs manifestations cliniques. Un  IAH  mesure le nombre d'apnées et d'hypopnées par heure pendant le sommeil

Pendant la veille

Pendant le sommeil

Informations complémentaires
Le ronflement du SAOS est souvent intense, interrompu par des apnées (silence) avec une reprise « explosive » qu'accompagnent des mouvements des jambes. Mais, il existe des syndromes d'apnée du sommeil sans ronflement : grande insuffisance respiratoire, patients opérés.

Les apnées ne sont pas toujours perçues par le patient mais constituent une source d'inquiétude pour le conjoint. Elles sont responsables de réveils en sursaut avec sensation d'étouffement. Les sueurs nocturnes sont décrites dans 66 % des cas. Le somnambulisme est présent dans 10 % des cas. La nycturie correspond au fait de se lever trop fréquemment la nuit pour uriner. Elle est présente dans 28 % des cas (par probable sécrétion de facteur natriurétique auriculaire provoqué par les apnées et la dépression thoracique). Les troubles de la libido sont retrouvés chez 28 % des patients. La somnolence diurne est causée par une déstructuration du sommeil et disparition des phases de sommeil profond. Elle se manifeste essentiellement après les repas ou lors d'absence de stimulation : réunion, conduite, en lisant Elle est évaluée par l'échelle de somnolence d'Epworth. Elle est parfois sous-estimée par le patient car ancienne et banalisée et peut être associée à des comportements automatiques : rasage plus long que nécessaire

Les troubles du comportement sont variés et fréquents : irritabilité et agressivité, dépression, troubles cognitifs, céphalées matinales. Il faut rechercher, par l'interrogatoire, des antécédents de réveils post-opératoires compliqués (extubations difficiles, réanimation post-opératoire), une HTA, une bronchopneumopathie chronique obstructive, des interventions ORL, la prise de médicaments.

Échelle de somnolence d'Epworth
La probabilité de s'endormir est cotée de 0 à 3 selon le risque d'assoupissement :
 0 = jamais d'assoupissement ;
 1 = risque faible d'assoupissement ;
 2 = risque modéré d'assoupissement ;
 3 = risque élevé d'assoupissement.

Elle est évaluée pour huit situations différentes :
 assis en train de lire ;
 en regardant la télévision ;
 assis, inactif, dans un lieu public ;
 comme passager dans une voiture roulant pendant  sans s'arrêter ;
 allongé pour se reposer l'après-midi quand les circonstances le permettent ;
 assis en train de parler à quelqu'un ;
 assis calmement après un repas sans alcool ;
 au volant d'une voiture immobilisée quelques minutes dans un encombrement.

Le total est noté sur 24. Un score supérieur à 12 est témoin d'une somnolence pathologique.

Indication d'un enregistrement polysomnographique
Les éléments cliniques les plus pertinents sont les ronflements, les apnées décrites par le conjoint, la somnolence diurne excessive, la surcharge pondérale (IMC supérieure à ), l'âge, le sexe masculin, les antécédents familiaux et l'hypertension artérielle. Aucun de ces éléments n'est très spécifique : les apnées sont retrouvées chez 65 à 92 % des SAOS mais aussi chez 31 à 64 % des sujets normaux. L'absence de somnolence diurne estimée (Epworth inférieur à 12) n'exclut pas le SAOS (40 % des SAOS ?) et le score d'Epworth n'est pas lié à la sévérité du SAOS. Il existe une meilleure sensibilité en associant ronflement et somnolence diurne.

Des scores se basant sur l'âge, l'IMC, le périmètre du cou, la présence d'apnées et de ronflements, la présence ou non d'une HTA, ont été élaborés. Ils sont plus sensibles (92 %) mais peu spécifiques (51 %). Ces scores sont utiles pour un dépistage des SAOS mais n'ont été validés que dans des populations restreintes. des critères morphométriques ont été utilisés (mesures de la cavité buccale, IMC, tour de cou) augmentant la spécificité sans permettre pour autant l'élimination de la polysomnographie.

Il faut cependant noter qu'une polysomnographie nocturne (examen coûteux et souvent accompagné de longs délais d'attente pour le patient) n'est généralement pas indiquée en première intention. Une polygraphie nocturne avec oxymétrie de pouls associée à un questionnaire d'évaluation du sommeil sont souvent suffisants pour poser le diagnostic et traiter le SAOS. En cas de résultats discordants, on pourra discuter une polysomnographie.

Polysomnographie

La polysomnographie est un enregistrement au cours d'une nuit (voire d'une sieste pour le dépistage) de sommeil, visant à quantifier les évènements respiratoires (apnées, hypopnées) et à les corréler à des variables que sont :
 le stade de sommeil et les microéveils ; par enregistrement de l'électroencéphalogramme (électrodes de scalp), d'un électrooculogramme (électrodes collées à l'angle externe de l'œil) et d'un électromyogramme (électrodes collées sur le menton) ;
 la position du sujet déterminée par des capteurs décelant les réactions aux évènements respiratoires et la position de survenue de ces évènements ;
 les efforts respiratoires par des sangles abdominales et thoracique avec des capteurs sensibles à l'étirement ; des mesures plus fines nécessitent l'utilisation d'une sonde de pression œsophagienne ;
 les répercussions gazométriques par mesure de la saturation en oxymétrie percutanée ;
 les répercussions cardiovasculaires avec la mesure de la fréquence cardiaque (la mesure de la pression artérielle n'est pas faite en routine).
La mesure des flux ventilatoires met en évidence les évènements respiratoires : ils peuvent être analysés par enregistrement de la température à la bouche et aux deux narines.

Ces mesures dépistent les apnées mais plus difficilement les hypopnées : leurs dépistages reposent sur la modification de signal thermique associé le plus souvent à une désaturation ou à un microéveil.
Le pneumotachographe reste la méthode de référence pour la mesure des flux ventilatoires.

Pour alléger ces dispositifs, des polysomnographies « partielles » ont été proposées. Cela va de la seule recherche de désaturation nocturne (publications contradictoires) à un examen sans enregistrement des stades du sommeil (sans EEG, EMG ni électrooculogramme). Ces techniques peuvent être suffisantes si elles sont positives mais ne permettent pas de déceler les microéveils. Enfin, certaines équipes font de la polysomnographie ambulatoire (au domicile du patient) mais seuls certains paramètres peuvent être étudiés.

Traitements
De multiples traitements du SAOS ont été évalués :

Mesures hygiénodiététiques
Les mesures hygiénodiététiques (perte de poids, arrêt de la consommation d'alcool ou de sédatifs) ont une efficacité incomplète et transitoire. La réduction du poids est efficace tant dans les apnées modérées que dans les formes intermédiaires et sévères. La démonstration de l'efficacité d'un amaigrissement reste cependant à faire à long terme. Il existe par ailleurs des patients « résistants » (normalisation du poids avec persistance d'une apnée du sommeil). L'exercice physique peut réduire la sévérité de l'apnée sans changer l'IMC. De plus, l'effet bénéfique de l'exercice aérobie combiné à l'entraînement de force est plus important que l'exercice aérobie seul pour réduire l'apnée. L'exercice améliore également la condition cardiopulmonaire, la qualité du sommeil et la somnolence diurne excessive.

Les traitements positionnels visant à empêcher le décubitus dorsal au cours du sommeil ne sont efficaces que chez une petite fraction des patients seulement ; une trachéotomie est constamment efficace mais comporte de trop importantes conséquences fonctionnelles.

Ventilation en pression positive continue

Le traitement de référence reste la ventilation en pression positive continue (PPC, en , CPAP).
Elle maintient les voies aériennes supérieures ouvertes, ce à tous les stades du cycle respiratoire.
Elle semble aussi en partie efficace sur les apnées centrales.

Elle peut être « simple », l'appareil délivrant le même niveau de pression lors des phases inspiratoires et expiratoires et ce durant toute la nuit. Elle peut être également avec relâchement de pression à l'expiration avec une réduction de pression au début de l'expiration afin de réduire la gêne expiratoire, auto-pilotée par adaptation spontanée aux besoins de pression variables au cours de la nuit (position de sommeil, stade du sommeil, réduction d'adaptation en début de traitement, médicaments ou alcool), à double niveau de pression avec l'appareil délivrant une pression moindre à l'expiration et plus forte à l'inspiration pour favoriser le confort respiratoire, ou à double niveau de pression auto-pilotée les deux pressions étant automatiquement ajustées au cours de la nuit selon les besoins du patient.

Les appareils délivrent des pressions de   à des débits de . L'appareil pèse de , son bruit varie de . Les masques sont très variés, en silicone ou en gel avec dispositif de maintien : sangle, harnais Il faut une « fuite calibrée » pour éliminer le . Le calibrage des pressions de ventilation se fait au cours d'un deuxième enregistrement polysomnographique avec, en début de nuit, des pressions faibles progressivement augmentées par paliers de quelques minutes pour faire disparaître les apnées, les hypopnées, les « événements respiratoires » et les ronflements.

Cette première nuit est importante car elle permet parfois un sommeil de qualité, vécu comme réparateur avec régression de la somnolence diurne. Elle est un bon critère de pronostic de réponse à la PPC. À long terme, l'efficacité dépend de l'observance. Le taux initial d'acceptation est de 70 à 80 %, avec un maintien à 80 % à distance mais avec des durées d'utilisation variables (« mouchards » dans les appareils récents). La durée minimale efficace est de  par nuit. L'observance dépend de la prise en charge et de l'information des patients, et, en particulier, de la gestion des effets secondaires mineurs de la PPC :
 irritation cutanée due à un masque inadapté ;
 rhinite, voire obturation nasale (humidification chauffante) ;
 conjonctivites par fuites du masque (bruit peu souvent évoqué).

La PPC peut avoir des effets secondaires plus importants : épistaxis (saignement de nez), pneumothorax, troubles du rythme cardiaque. Les principaux bénéfices concernent l'amélioration de la vigilance diurne, mais certaines études font état d'une réduction de la mortalité, du nombre d'accidents cardiaques, d'une baisse des accidents de la route. L'amélioration de l'HTA est controversée.

Orthèses buccales
Des orthèses médicales permettent de dégager le larynx pour permettre une ventilation naturelle chez les patients réfractaires à l'utilisation de masques ou à la ventilation (cf. Orthèse d'avancée mandibulaire). Ils sont efficaces dans la moitié des cas. Il n'existe néanmoins pas de comparaison directe avec la CPAP et ces dispositifs sont généralement conseillés en deuxième intention.

Autres
D'autres traitements ont été proposés, de type chirurgical (notamment l'uvulopalatoplastie), médical (antidépresseurs stimulants dont les tricycliques, pyschostimulants comme le modafinil), instrumental (orthèse d'avancée mandibulaire, sondes d'intubation nasotrachéale, dilatateurs narinaires), avec une évaluation souvent incomplète de leur efficacité. Dans des cas sélectionnés (anatomie de la bouche) une chirurgie permet d'améliorer 60 % de apnées du sommeil résistantes aux autres traitements.

Des chercheurs ont fait des essais avec un stimulateur implantable (comme un stimulateur cardiaque) qui envoie pendant le sommeil une légère stimulation du nerf moteur de la langue (nerf hypoglosse) qui peut faire avancer la langue et ainsi élargir les voies aériennes supérieures. Chez des patients qui ne tolèrent pas le traitement à la pression positive continue (PPC) des études suggèrent que cette technologie de stimulation du nerf hypoglosse peut diminuer l'Index d'Apnées-Hypopnées (IAH) évoqué plus haut au chapitre Epidémiologie.

Notes et références

Voir aussi

Trouble du sommeil
Apnees
Maladie de l'arbre trachéobronchique
État médical lié à l'obésité
Apnée

redpajama_set_name: RedPajamaWikipedia


A week ago today, we had a snow day in Louisiana. I'm here to tell ya. That just doesn't happen very often. AT ALL!
I love that I was able to whip out some coats and hats and scarves and dress my baby dolls up in winter wear!
The funny thing about a "snow day" in Louisiana is that, as you may have noticed, there is no snow!
We just have no road crews prepared for such events, so our local everything (school boards, court houses, universities, etc) prepare for the worst and close down. It's ridiculous to tell you the truth!
I made a big deal about icycles so at least my girls would have some kind of idea of what it means to be out of school due to the cold weather.
For me, being an independent business owner, these kinds of days are almost the worst! All my employees are praying that I will cancel work. However, we have clinics full of patients scheduled, and since we don't know all their home numbers, someone is going to have to be there on MOnday morning to see who is or who is not going to show for their appointments!
How do I decide who should show up at each clinic to do that?! And then, if indeed the roads are fine (as they WERE), how do I justify all being off? I don't like being the decision maker who affects so many lives. Oh, and with school being off, there is also the situation where working moms have noone to keep their school aged kids.
My girls ended up staying with me. They went to work with me. I did invite my employees (any who asked) to bring their kids with them too!
It was a special day for us. I LOVE having my girls with me at work!
Actually, I love having girls with me anywhere!
We should have about another month of semi cold weather. Then, around the end of February, we'll have daffodils and tulilps coming up and we'll be back in short sleeved shirts.
For now, we will enjoy our sweet hats and coats.
And a happy, happy mama up front driving them to work.
Look this post. The girls look so cute in their outfits. Glad you guys have cool weather down there so we can be treated to these adorable little girls in their coats, gloves, and scarves.
Still no snow day here, despite tons of snow all winter and freezing rain tonight. Temps are supposed to drop 30 degrees tonight to near zero by morning. Kids have been praying every night for a snow day. Finally got the automated call from our district tonight that we've been hoping for. It said school is delayed two hours tomorrow........for PLUMBING PROBLEMS!
p.s. I want Ellie's coat. Those two girls are on the cutting edge of style I tell ya'!
LOVE blogs about your precious, angelic GIRLS!!! Nothing cuter than baby girls in hats, coats and scarves!
Sure hope you consign their clothes, they're adorable!
i could squeeze their cheeks,they are so darn cute!
Oh my goodness, cute, cute winter gear for both little princesses!!! Miss Ellie looks so tall and so much older when she's wearing jeans . . . she's growing up so darn fast . . . I LOVE her plaid jacket. Just cute as a button!
those girlies would love some sledding snow! like when you took ellie to colorado?! the girlies look cute in their "warm" clothes - i love that gg looks like she doesn't have fingers in her gloves lol!!
Mo, you just had to rub it in that you'll have flowers coming up in February, didn't you???
We'll still have plenty of snow on the ground then!
Heck, Friday our HIGH temp is supposed to be -2.
Oh well, I guess these are the days we endure to be so thankful for the beautiful change of seasons.
Great pictures! as usual. I am in South Arkansas..I know what you mean about NEVER getting snow...but with this storm you are talking about, we got about four inches! Our kiddos got TWO snow days!! They were happy campers!
Ellie and Gabbi are cute little "no" snow bunnies!!! Don't fret, we had no snow here either! Not even a "flurry"! We got snow in while visiting Dallas for Christmas 09! It was a dream come true! How I longed for a WHITE CHRISTMAS! The snow was beautiful, the pics of the kids were gorgeous on Christmas day, they had the fun "sledding" in the snow BUT OH BOY it was treacherous to drive in!!
Mo, you ROCK!! You have got to be the WORLDS BEST BOSS!!! I mean really....how many employers tell ya "sure, bring the kiddos with ya"!!
Gotta also say, "Where did you find Ellie's coat?!! Bree has shoes and a skirt that matches it to a T!!!
As usual those girlies are stylin' to the hilt!! They look like they're about to be in an outdoor fashion show :) Cute, cute, cute! We are usually the same about snow around where I live (near Atlanta), but this time we really did get a winter storm! We had about 5 inches of snow with ice on top of that. Our kids were out of school all of last week. Now they've got to make it up on their "Winter Break" which was supposed to be next month...oh well--they had fun playing in the snow!
Well it's a blizzard here right now in Nebraska...come on up!!
The girls look so cute...love Ellie's coat!


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HOME E-MAIL JOE ARCHIVES SEARCH LOG OUT
Internet Travel With Context
August 8 to August 29, 2019
Read all about it! The quest for America's best pizza yields unique styles from coast to coast. Bats on a plane and snakes in a hotel bed. The half-million things wrong with Berlin's still-unopened new airport. United makes stroopwafels popular nationwide. Why is Marriott holding out on Denver Airport? And much more.
Pizza Quest: In Search of American Pies
We take pizza pretty seriously here at Joe Sent Me. Earlier this year, Ralph Raffio offered up a column on ten great pizza places in major hub cities. And I've written extensively about pizza in Rome, the world capital of what is now the global food phenomenon. But full marks to The Wall Street Journal for a remarkable series it has dubbed Pizza Quest. Over three full pages of the print edition, writer Eleanore Park and other contributors offer a nationwide look at the state of pizza in America. It also has details on ten unique pies around the nation, including the so-called Detroit Zoo pie (above) created by Buddy's on Conant Street in Detroit. Also featured: the remarkable tomato pie at Sarcone's Bakery in Philadelphia; the Greek-inspired New England style offered up at Tilton House of Pizza in Tilton, New Hampshire; and the cracker-crusted Midwest-style pie featured at Maria's Pizza in Milwaukee. Also covered: a half-dozen "vanguard" pizza makers, including Sarah Minnich of Lovely's Fifty Fifty in Portland, Oregon; the legendary Chris Bianco of Phoenix and California; and Josey Baker in San Francisco. By the way, great pizza--and great regional styles--in America is crimping the chain-pizza purveyors. Pizza Hut announced last week that it may close as many as 500 sit-down restaurants and concentrate on takeaway and delivery.
Airport Report: Berlin, Belfast and Denver
After 15 years of Sturm und Drang to plan and build, Berlin Brandenburg Airport was weeks away from opening in June, 2012. Then German authorities found fault with the fire-suppression systems. Then another problem and another and another. Seven years later, the airport opening is still at least a year away and the BBC reports that there were actually 550,000 faults turned up by various regulatory bodies. Deutsche Welle says, however, that the airport, now with a second terminal, too, will open "on schedule" in October, 2020. But, uh, don't count your airports before they hatch. ... The glass-winged 519-room Westin Hotel at Denver International Airport was all the rage when it opened in 2015. It was even pitched as the future of airport lodging. Now, however, the city auditor says Marriott, Westin's parent firm, is holding out on Denver, which owns the airport and the hotel. The auditor insists that the city should demand Marriott "comply with Denver law and the terms of its lease" and turn over information about its profitability. The auditor separately reported that the airport transit center and hotel cost $719 million, about $47 million over budget. ... Things are not quite as dicey at Belfast International Airport in Northern Ireland. But the Belfast Telegraph wants you to know that one of the airport's restaurants, Sip & Stone (above), is awful, expensive and oddly un-Irish. "Why in the name of all that's British or Irish would a Belfast airport, gateway to the world and Ireland, not stock Thompson's Irish Breakfast tea?" the reviewer asked.
Flight Log: Bats and Smoke and Delays, Oh My!
It's been a tough few weeks on the road, what with a potential strike at London/Heathrow, disruptive demonstrations at Hong Kong International and brutal thunderstorms along the East Coast. But it could have been worse. You could have been on one of these flights.
AIR CANADA FLIGHT 758: A 12-year-old was forced to remove her hijab before being allowed to board the flight from San Francisco to Toronto/Pearson. The young woman had cleared security, but an Air Canada employee then demanded she remove her head scarf anyway.
ALASKA AIRLINES FLIGHT 1949: Passengers on the 85-minute LAX-to-SFO nonstop were delayed around 250 minutes. They were delayed on departure more than an hour, then endured more than three hours on the tarmac on arrival. It seemed like the flight crew "gave up" after they could not find a gate at SFO, one passenger said.
AMERICAN AIRLINES FLIGHT 2460: A disruptive passenger was removed from the DFW-LAX flight in handcuffs lashed to a wheelchair.
BRITISH AIRWAYS FLIGHT 422: Smoke filled the cabin of the Airbus A321 as the flight from London/Heathrow approached Valencia, Spain. Passengers panicked. BA later blamed the smoke on a "technical issue." So it wasn't a planned feature then ...
SPIRIT AIRLINES FLIGHT 876: A bat emerged from an overhead bin and flew around the cabin on the flight from Charlotte to Newark. Spirit said passengers were not charged extra for the aerial display.
UNITED AIRLINES FLIGHT 162: Both the captain and first officer were arrested before the departure of the Glasgow-Newark flight. The 61-year-old pilot was later charged with alcohol-related offenses. The first officer was released without charge.
Tight Connections ... Quick Hits on the News
Snakes on a ... hotel bed A woman woke up in an East Memphis Hampton Inn hotel and found a snake slithering in her bed.
Some like it hot(ter) With global temperatures breaking records all summer and scientists warning of global warming, have you wondered how much hotter your hometown is in 2019 than it was when you were born? The New York Times has an interactive warming chart for your community--and offers some dire future predictions, too.
United made you love it. Stroopwafels are a beloved Dutch pastry long unknown to most Americans. But if CNBC is to be believed, United Airlines stocking stroopwafels as an in-flight snack has created a U.S. boomlet. No surprise since it worked for Biscoff speculoos, another Low Country biscuit first brought to U.S. attention by an airline.
Maybe switch to tea ... A photo of a moldy in-room coffee pot went viral on Reddit and has led to awful takes on the cleanliness of hotel coffeemakers.
Column and JoeSentMe.com Copyright © 2019 by Joe Brancatelli. All rights reserved.


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Reid: Save federal funding for the cowboy poets!
$8 billion for high speed rail?
"Euro May Already Be Lost" - Vice-Chairman Of EuroThinkTank Warns "No Way . . .
"Whatever Germany Does, the Euro, as We Know It is Dead"
...89,304,000 Americans 'Not in Labor Force'--296,000 Fewer Employed Since Jan.
1938 Law Restricts A Worker's Family Time.


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February 18-25, 2009 – Mom's singing wins career makeover contest
Contributed by Steven Alloway
Granada Hills, CA
Warm-up Question: Have you ever made any major changes to your appearance, or your lifestyle? What changes did you make? Why did you do it? How did the people around you react?
After losing her job in 2007, Nicole Nagy decided to go back to school and become a nurse. But times are tough and her family was behind on their mortgage, so finding the money to pay for tuition seemed unlikely. But Nicole found the solution in an odd place — a contest called Careereoki. The contest invites people to make a video singing about their intended careers, in order to win a "career makeover" that includes a scholarship, résumé help, and a $100 gas card. Nagi appears in the video with her husband and three children, wearing a nurse's uniform and singing, "A Bad Case of Nursing Blues."
2 Kings 2:1-12
Psalm 50:1-6 (2)
For lectionary humor and insight, check the weekly comic Agnus Day
This was an important event in Jesus ministry. He had been known as a teacher, healer, and prophet, but now he reveals himself as something more. There he is, sitting with two of the greatest prophets in history, his face shining with the glory of heaven. Surely, this is the Son of God.
But why did he do it? Most of Jesus' other signs and miracles were to help others: feeding them, healing them, things like that. But now, he takes just three disciples with him to a secluded place, shows them all of his heavenly glory, and then warns them not to tell anyone. Why would Jesus do that?
First, we must keep in mind that Jesus did not perform signs and miracles for himself or fame. He was twice tempted by the devil to do so, by turning stones into bread and by jumping off the temple roof, and he adamantly refused. And his miracles were not just for the physical benefit of the people he healed. They were for the spiritual benefit of the people who witnessed the miracles, and ultimately, of us, as believers.
So Jesus was transfigured (changed in form and appearance) physically, so that Peter, James, and John could be transfigured spiritually. They saw Jesus in all of his glory so that they themselves could be filled with the Spirit, and ultimately be encouraged and energized as witnesses in the world. But then again, if that's true, then why did he tell them not to say anything yet? Because it wasn't time. The world wasn't yet ready to know of Christ in all of his glory. Even the disciples weren't quite ready.
When Peter saw Jesus, talking with Moses and Elijah, he wanted to set up booths or tents for them, places for them to stay, for a night, for a week, or for as long as they could. Peter wanted to camp out and remain in this one glorious moment. Perhaps he wanted to stay there and learn from these prophets of ages past. Perhaps he wanted to bring the other disciples to see Jesus in all his glory. But whatever he wanted, it wasn't what God had in mind. The purpose of the transfiguration wasn't so they could remain on the mountain, but so that they could go out into the world, filled with the Spirit through what they had seen.
If Peter, one of Jesus' closest companions, had this reaction to Jesus' transfiguration, how would the other disciples and the rest of the world react when they heard about it? They'd all want to see it for themselves, and maybe even keep it to themselves. They'd crowd around and yell for Jesus to bring Moses and Elijah in for a panel discussion. They'd try to make him their ruler, and beg him to set up a kingdom here on Earth, as they often did.
But it wasn't time for Jesus' full glory to be displayed to the world. First he had to be humbled, to suffer and die on a cross for our sins, and then his full glory would be revealed through his resurrection and ascension. Then he charged his disciples with spreading the news of his glory to all the nations of the world. With this new responsibility and job, Peter, James, and John were equipped with an amazing story of their experience with Jesus on the mountain, in all of his heavenly glory for the sake of the world. For what purpose? So that we all might be transfigured and changed by God's love for us through Jesus Christ.
Which of Jesus' signs and miracles would you say you've been most changed by?
Which one speaks to you the most, personally and spiritually? Why?
If someone showed you something incredible, then warned you not to tell anyone about it, do you think you could keep your mouth shut? Or would you spread the news to everyone? Who would you tell, email, call, or text first?
Why do you think Jesus chose three specific disciples — Peter, James, and John — out of all the others to witness his transfiguration? How do you think they were transformed or given a "makeover" by witnessing it?
How is Nicole Nagy's "Career Makeover" for her vocation of nursing like our transformation as children of God for our vocation of spreading the gospel to those around us? How are they different?
Find some of the other places in the gospels wherein Jesus charges people not to tell anyone about the miracle he's just performed. Do they tell? Why does Jesus warn them not to in each instance?
Make your own video or skit about Jesus' Transfiguration, and the reactions of the disciples, both at the time, and after Jesus' resurrection. Include a song or two if you want.
Lord Jesus Christ, transform me. Fill me with your Spirit and guide me, so that I can do the things you ask of me: to serve you and all people, and to spread your word of love, forgiveness, hope, and new life. Amen.
The top five finalists were chosen by a panel of judges who based their decision on originality, creativity, and humor. Then the winner was selected by the listeners of a local radio station, who voted for their favorite video on the station's website.
"It was a way to connect to job seekers," said Kimberly Cornett, Vice President of Workforce Central Florida, who helped sponsor the event. "And also for job seekers to take a little break from the stress of unemployment."
Would you videotape yourself singing and dancing in order to get into the career you wanted or get a promotion? What would you sing?
Do you think the contest is a good idea? How do you think it will help more people find jobs? What are the downsides?
If you had the means, how would you help people who have lost their jobs and are looking for a new career? What would you do for them? What would you ask them to do?
Scripture Texts (NRSV) for Sunday, March 1, 2009.
(Text links are to oremus Bible Browser. Oremus Bible Browser is not affiliated with or supported by the Evangelical Lutheran Church in America. You can find the calendar of readings for Year B at Lectionary Readings.)


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HomeSportsFootballWhy Kai Havertz Feels He Isn't The Same as Eden Hazard at...
Why Kai Havertz Feels He Isn't The Same as Eden Hazard at Chelsea
Germany's Kai Havertz arrived at Stamford Bridge on a five-year contract, joining Chelsea in the summer transfer window ahead of the 2020-21 season. The transfer fee was reported to be worth an initial £62 million, which could rise to £71 million with add-ons, making him Chelsea's second-most expensive signing in the London club's history.
In his first season, Havertz won the UEFA Champions League and followed it up with the UEFA Super Cup at the start of the 2021-22 season. The 22-year-old, in an exclusive interview, looks back on his journey so far, time ahead and bagging the Premier League title.
Tell us about football. Could things be going, any better – you win your first Premier League game of the season three-nil and you've already lifted the super cup. What's the atmosphere like around here?
Yeah, I think in the moment, very good. I think when you when you start the season like this when you win the title in the first game, of course, it's good for us. We won the first premier league game that's also very important. But I mean, yes, just the beginning. I think there will be some tough challenges also, and yeah, we just must keep going. As we said before, I think we are just like the hunters. We want to win games win more I think now we tasted a little bit of titles and stuff like that, and I think when you want this before you want to win more. And I think that's also the goal for this season.
You play with Bernd leno for Germany, of course. I know that during the 90 minutes it doesn't matter how good a friend you have on the other team but, say you score the winner, will you be straight on the phone to him after the game?!
For sure! He's a very good friend of mine and Timo as well. We're in a kind of little group in the international team – also our girlfriends are very close together so I like him but when I score the winning goal then I would celebrate for sure!
It's only been a couple of days but tell us about Romeu Lukaku what sort of impact he has had so far.
Yeah, very big, I mean he's a top striker – one of the best in the world I mean we all know that. We all know his quality. We are very happy that he's here now. And I think we waited very long, but we also saw it in training now that he's a very strong character. He always wants to help people and wants to improve. He helps as young players as well, a lot. I mean, it's the first week so it's now difficult to say on Sunday (that) everything will go right, but I mean that also takes a little bit of time but, of course, we are very happy that he's here and for us, yeah, it's nice to have him because he's a very, very good striker.
A little while ago, he tried to take credit for you being here – he said it was all down to a conversation after a Europa league game between Leverkusen and Inter Milan. Do you remember that conversation?
Yeah, I remember. We talked after the game. I was upset that we lost. He was happy. So, he came to me and just said that he thought Chelsea would be the right club for me. And I think I listened very well, and I'm very happy now that we play together.
Look back at your first season in England. It finished on one of the highest highs possible by winning the Champions League, but the 10 months or so overall – how do you rate it?
Not good for me personally, I mean, in the end, we reached our goals, we qualified for the champions league. But I mean, not all the 10 months were bad, but maybe the first four or five months were not perfect for me. I didn't play my best football, and some people were upset with me, but I knew that maybe this will happen because it was a big step for me. But then I think I grew as a player, as a person and maybe sometimes these downs help you as a person and as a player as well and you can learn from it. And for me, yeah, now I'm feeling good, I think. I'm very happy how the season ended for me, for us. And, you know, I'm just looking to the future and will try my best to play like, yeah, play the same good football like at the end of the last season.
When you arrived here you were just 21 it's a completely new country. You arrived, I think, 10 days before the start of the new season so no real pre-season with your new teammates. You then get covid in the middle of the season and there's a change of manager. It couldn't have been less straightforward. And yet, like you said, there was a lot of criticism. That was harsh, wasn't it? Did it feel unfair?
Unfair? I don't know. I mean you come here with the sign of 80 million pounds on your head. I mean, of course we are all humans. But the people expect from you that you are good when you come here for 80 million pounds – I understand that for sure. But of course, it's sometimes not easy, but I knew that I have a strong family and strong friends behind me that always helped me with that. And I knew that after like rain also comes the sun. And I think I knew that there will be also better times for me. And that just was positive. Of course, it was difficult for me. And but also yeah, the teammates, the staff, they helped me a lot. And, yeah, I think then from January on it as very good again. And I think I still have a lot of room to improve. I'm still very young, and I'm hungry and I want to achieve more. And I hope the next, or this season will be then better for me.
I'm not going to dwell on the negatives, but when you were feeling low which teammates were most helpful to you.
Yeah, obviously we have some Germans here like, Timo, Toni and Mateo Kovacic speak German. Christian Pulisic too – it's sometimes easier to speak to them because they speak German. They helped me a lot, but also, I have to say all the English players – because we've been in one changing room because of the covid rules. And it was always funny you know they help you and sometimes of course you also make jokes when you see, I don't know an Instagram – a GIF from you where everybody makes jokes about you. Sometimes it's funny. So, yeah, they helped me a lot, but I have to say, almost everybody. We have a very strong bond here and everybody helps each other, and I think that's also the reason why we won the two titles.
I mentioned before we started that statistics-wise if you look at your first season and Eden Hazard's first season, they're very similar. So, if you carry on along the same path as him, I imagine you'll be very happy.
I hope so. I mean he's, he's one of the best players Chelsea ever had. I hope that I will do the same as him but it's not easy to compare because he's a different type of player. But I mean you always look, look to the best players and you want to achieve the same things as them. And me, I do the same. I want to achieve as many good things as possible. And I have a lot of years in front of me and I will try to do that.
If you look back to the first couple of weeks of last season and compare it to the first couple of weeks now, do you feel very different? Can you feel a difference now to a year ago?
Yeah, I mean 100%. You know, you come here, you don't know any person, it's another language, another type of football, another style of football, you know? Everything is new. And now I'm used to it – I play with them now one year already, and I know everybody and all the staff and all the players, and of course I'm now settled in very well. It's a very good atmosphere here. And the thing of course is different, but I think it's for every transfer, it's always difficult the first, first few weeks. Even though I was very young, and I didn't know how a change would be. But, of course, now I feel better.
And do you have a nice space in the cupboard for a Premier League winners medal next to the Champions League one?
Yeah, no, I mean that's the next goal. It would be nice, but I think now after the first game it's difficult to say, "we want to win the league" because they are still 37 games to play. And we know that we know that we have a lot of good opponents. So, we just think game by game and then we will see at the end of the season.
Live action of the Chelsea vs Aston Villa match on Star Sports Select on Sept. 11. Commentary in Bangla and Malayalam on Star Sports 3
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