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Your Household Dust Contains Seriously Toxic Chemicals—Here's What To Do About It
By Markham Heid
photographee.eu/shutterstock
Break out the mop and feather duster. The dust in your home is probably coated in unhealthy chemicals, finds a new study appearing in Environmental Science and Technology.
Tests of home dust particles found 90% of samples contained at least one known chemical toxin. Phthalates, phenols, flame retardants, and synthetic fragrance chemicals were among the most common toxins that turned up in the study's samples.
"[These chemicals] are associated with health hazards including toxicity to the reproductive system, hormone disruption, and cancer," says study coauthor Veena Singla, PhD, a staff scientist with the non-profit National Resources Defense Council (NRDC).
Getting specific, thyroid disease, obesity, diabetes, breast and prostate cancers, IBS, and allergies are just a handful of the many health issues that these chemicals may cause or contribute to, according to NRDC resources. Every year, health issues related to these and similar chemicals cost the US more than $340 billion, according to an analysis from New York University, published today in Lancet Diabetes & Endocrinology.
tomas urbelionis/shutterstock
How do these toxins end up in your dust? They "leach, migrate, abrade, or off-gas" from your home's furniture, electronics, wall paint, and personal care or cleaning products, the study authors say.
Once these chemicals latch onto your dust, it's easy for you to inhale or ingest them, Singla says. The average American spends 90% of her time indoors and around dust, and multiple studies have found most of us have these chemicals circulating in our bodies. That's particularly worrisome for young kids and pregnant women—two groups who may be more vulnerable to the hormone-disrupting effects of these toxins.
MORE: 9 Things In Your Home That Cause Thyroid Problems
Health regulators have imposed some bans or restrictions on chemicals that are known to be harmful, including triclosan and some flame retardants.
But the scary reality is that a chemical does not have to be proven safe to end up in the products you buy, Singla says. Just as people are presumed innocent until found guilty of a crime, consumer chemicals are usually considered safe unless public groups can prove otherwise.
Especially for chemicals that may take years or decades to cause harm, the duty of paying for product safety testing (and lobbying for stricter industry regulations) tends to fall on universities and non-profits like the NRDC. (The Silent Spring Institute and public health departments at George Washington University, Harvard, and the University of California, San Francisco all chipped in on this dust study.)
"It's not fair for consumers to have to clean up after the chemical industry," Singla says. Unfortunately, that's currently the only way you can protect yourself and your family from many of these chemicals.
Here's what you can do:
Wash your hands.
When you eat or touch your mouth and nose with dust-covered hands, you're inviting their toxic passengers into your body, Singla says. Washing your hands frequently—especially before you eat—is a good way to remove chemical-carrying particles. Just be sure to use plain, unscented soap, she says. Hand sanitizers kill germs, not dust toxins. And the fragrance or anti-bacterial additives in some soaps may contain some of the same harmful chemicals you're trying to wash away.
Remove household dust.
Dust surfaces with a damp cloth, mop your floors, and vacuum as often as possible. Also, make sure your vacuum uses a high-efficiency particulate air filter. (Most new vacuums do.) Change the vacuums bag per the instructions to ensure it's not pumping toxic dust back into your home as you use it.
Download this app.
For more info on avoiding dust chemicals—as well as other common toxins—the Silent Spring Institute's "Detox Me" app is a free and handy resource.
Markham Heid Markham Heid is an experienced health reporter and writer, has contributed to outlets like TIME, Men's Health, and Everyday Health, and has received reporting awards from the Society of Professional Journalists and the Maryland, Delaware, and D.C.
Your Favorite Mac & Cheese Probably Contains Toxic Chemicals. Here's Everything You Need To Know.
Your Food Packaging Contains 154 Hazardous Chemicals— And It's Completely Legal
The Toxic Truth About Your Cell Phone
Sweating Too Much? Here's What To Do
What Do Boomers Know About Their Health?
Do You Suffer From Chronic Inflammation? Here's How To Tell—And What You Can Do About It

redpajama_set_name: RedPajamaCommonCrawl


Honestly speaking, one feels a sort of embarrassment when there is the need to talk, in such a little space, of a giant like Saint Augustine, a thinker, a saint, a bishop that would need volumes to only grasp the depth of his life. All the Fathers of the Church deserve our attention and respect. Some of them were really influential also for the successive development of theology. Let us think of St Ambrose, St Jerome, St Basil, Origen (this one in a more problematic way). But no one was as influential as Saint Augustine of Hippo (354-430), probably the most important Christian thinker in history together with Saint Thomas Aquinas.
Augustine was influenced in his young age by ideas that were opposed to Christianity and was not in communion with the Church. He was a brilliant man, a rhetorician, but his life was far from the demands of the fellowship in the faith. Likewise, his personal life was troubled. He had a son with a woman and was fond of earthly pleasures. His mother, Monica, was a pious Christian and prayed for his conversation with great strength and many tears. The conversion will arrive and not only that. Augustine will be a bishop and a writer, giving to humanity (because his works are a gift to everyone, even non-Christians) some of the most important works in western literature, as the Confessions, The City of God, On the Trinity among the many others.
I would need so much space to quote wonderful passages only from this work, without mentioning all the others. We have to return to these giants, these great masters, that can give us a solid nourishment for the development of our faith.
Next PostDramatizing the liturgy of the Word?


A number of Web companies are fighting to become the primary service for people to "check in" to real world locations, like coffee shops and stores.
But Meebo believes there's an equally important need for people to check in to Web sites that's been overlooked.
Meebo hopes to fill in what it says is a missing piece of Today's social Web, creating a social network based not just on friends and contacts, but on personal interests.
Meebo's new service, which is being introduced this week, will allow web surfers to "check in" to any Web site, and build a profile that's publicly viewable of other Web sites that they check in to frequently.
The idea, Meebo CEO Seth Sternberg told Reuters, is to provide Web surfers with a quick way to find more information about a topic they're interested in: After all, a person who frequently checks in to a popular biking Web site might also have frequent check ins to other, lesser-known Web sites about biking.
According to Meebo, people who check-in to a particular Web site frequently will become VIPs. Eventually, Meebo plans to offer rewards programs for VIPs with its partner sites.
Meebo's Web check-in service will initially be available as a browser extension, but in December the company will offer the functionality directly within the Meebo bar that sits at the bottom of 8,000 partner Web sites, viewable by 180 million users. A number of companies, including Macy's, Sprint and Fresh Air Fund will also integrate Meebo check-in button directly in their Web sites.


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Q: Sharepoint Online - List Existing "Send To Connections" in C# I need to create a C# method that Lists existing "Send To Conections" inside Shapoint Online Central Administration (https://MYSERVER-admin.sharepoint.com/_layouts/15/TA_OfficialFileAdmin.aspx), returning a List with connection Display Names.
That's possible?
Example: private List GetSendToConnections(){}

A: We don't have CSOM/REST methid available as yet for this .
Dont have any official documentation for this, but you can check the link below where they have mentioned it.
Technet link - Enable and Set Record Management settings using PowerShell & CSOM and Route records to Record Center Site

redpajama_set_name: RedPajamaStackExchange


I list the four ongoing projects below, all of which are related to my work in Professor Paul Soloway's Nutritional Sciences lab on epigenetics. The first and the third are basically for academic exchanges and international cooperation. The first is supported by Cornell, and the other by the Ministry of Agriculture of China. These two grants will jointly fund Dr. Soloway's visit to China. One or two students/young staff from my group will stay at Cornell this year. The aim of the exchange is to learn epigenetic technologies developed in Dr. Soloway's lab for our studies on domestic animals, i.e. pigs (project 4) and chickens (project 3). 1. 2009-2010. "Where Nature Meets Nurture: Exploring the interplay between genetics and environment in pig—an important agricultural animal and model for human physiology," supported by the Jeffrey Sean Lehman Fund for Scholarly Exchange with China, Cornell University. 2. 2010-2013. "Protein metabolism in Yellow-feather broiler chickens: Molecular mechanisms and nutritional manipulation,"supported by NSFC-Guangdong Joint Fund. 3. 2010. "Improving meat quality via metabolic programming in domestic animals," "948" program supported by the Ministry of Agriculture of China, 2010-S14. 4. 2009-2010. "Identification and characterization of breed- and tissue-specific factors (cis- and trans-) involved in the regulation of GR expression in the pig," supported by Ministry of Agriculture of China, (2009ZX08009-138B).
Currently the projects I am working on are mostly basic research that have no direct impact on the advancement of agriculture in rural China. However, my research relates closely to the protection and exploitation of Chinese animal genetic resource, for instance, local breeds of chicken and pig. Animal husbandry in China faces great challenges and has a lot of problems, including the extinction of indigenous breeds, poor animal health and welfare, poor product quality, and compromised food safety. The western style of highly industrialized animal production does not seem to be applicable in China, especially rural China. Farmers lack the basic knowledge regarding the production of local breeds to meet the requirements of local consumers while maintaining animal health and welfare.


Los Angeles County public health officials say that the Motion Picture Assn. of America has not done enough to cut cigarettes out of the picture.
Officials with the film group said last year that they would consider more restrictive ratings for movies that glamorize smoking or show smoking outside of historic or other mitigating contexts. But that hasn't produced satisfactory results, health officials said.
Dr. Jonathan Fielding, director of the L.A. County Dept. of Public Health, said research shows a correlation between youth smoking and depictions of smokers in movies. The country has produced a 15-second anti-smoking message that it hopes to show in local movie theaters this summer.


A 21-year-old woman is recovering after surviving five days in a North Carolina ravine that hid the wreckage of her pickup truck from searchers. Authorities said Amber Pennell was found Monday night in the wreckage in trees and vines at the bottom of a 100-foot-deep ravine off a highway.
LENOIR, N.C. � A 21-year-old woman is recovering after surviving five days in a North Carolina ravine that hid the wreckage of her pickup truck from searchers.
Authorities said Amber Pennell was found Monday night in the wreckage in trees and vines at the bottom of a 100-foot-deep ravine off a highway.
Her husband Mitchell Pennell said on ABC's "Good Morning America" that Amber told him she clung to life for the sake of their two young children.
He said surgeons put a rod in his wife's broken leg and that she would be fine despite a broken arm, skull fracture and other injuries.
Emergency officials said workers used ropes to lower themselves into the ravine and worked 30 to 45 minutes to cut her free. Pennell had gone without food or water for five days in the wreckage.


Courteney Cox will be joining the cast of Shameless in season nine – and the role promises to show the actress like we've never seen before.
The 54-year-old will guest star as Jen Wagner, a famous actress who also happens to be a recovering alcoholic. Jen will become friends with Lip, played by Jeremy Allen White, when he is hired as her sober companion.
Despite her previous problems with alcohol, Jen will give Lip a raucous night to remember as they go off in search of the best cocktail in town, according to Variety.
Jen couldn't be further from Courteney's character in Friends, Monica Geller, the endearingly uptight clean-freak who couldn't quite handle her drink. Devout fans of the iconic sitcom will remember that Friends episode, the one where Monica turns 30 and gets super drunk to cope with getting older. Bless her.
Something tells us Monica wouldn't have gotten on with Jen.
Also joining season nine of Shameless is Katey Sagal, best known for Sons of Anarchy. The 64-year-old actress will become a recurring character, playing Ingrid Jones, a psych patient who steals the heart of Frank after they meet in the E.R.
Showtime's Shameless will return with season nine on 9 September.


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Sean Mc Manus testifying at a Congressional Hearing in 1995.
NEBRASKA SENATE CHALLENGED ON ANTI-IRISH AND ANTI-CATHOLIC ACTION
Posted By: June 08, 2015
Belated Discovery of Mac Bride Principles Repeal
Capitol Hill. June 7, 2015— Irish-Americans in the State ofstunned to belatedly discover that the Nebraska Senate had sneakily repealed the Mac Bride Principles back in 2011: LB303, sponsored by Omaha Senator Beau McCoy, March 4, 2011.
The Mac Bride Principles — a corporate code of conduct for American companies doing business in Northern Ireland — were launched by the Capitol Hill-based Irish National Caucus on November 5, 1984. The Principles were passed by the Nebraska Senate in 1994 to ensure that Nebraska dollars would not subsidize anti-Catholic discrimination in Northern Ireland.
Fr. Sean Mc Manus, President of the Irish National Caucus, said: " In 1994, the Nebraska Senate took an admirable stand against anti-Catholic discrimination in Northern Ireland.
And in 2011 — sneakily and in an underhand way— the Senate, in effect, became complicit in an anti-Catholic and anti-Irish act of repeal. None of us who led the Mac Bride campaign were consulted; no Irish-American organization, nationally or in the State of Nebraska was consulted. The repeal was sneakily slipped past everyone— a sure sign it could not stand the light of day."
Fr. Mc Manus has written to all 49 Nebraska State Senators: "Surely the then Senate Members [2011] had to be aware that repealing Mac Bride— passed to ensure that Nebraska dollars would not subsidize anti-Catholic discrimination in Northern Ireland— would inevitably be seen as anti-Irish and anti-Catholic? Would the Senate have been similarly complicit in an act that would be seen as anti-Jewish-American or anti-African-American? This betrayal of Catholics and Irish -Americans was done in order, allegedly, to save the sum of $8, 500 — the Nebraska Senate's equivalency of Thirty Pieces of Silver."
Fr. Mc Manus tells the Senators: "By this letter, I am polling you and all the other Nebraska Senators on this matter. Your response— or lack thereof —will be widely shared among the Irish and Catholic population of Nebraska, and with all 213 media outlets in the great State of Nebraska.
Please answer this direct question: "Will you continue being complicit in the Nebraska Senate's anti-Irish and anti-Catholic act of having repealed the Mac Bride Principles legislation?"
Fr. Mc Manus concluded:" I am aware that the Nebraska State Senators may have been duped into being complicit, and we want to give them the benefit of the doubt. This is their chance to make right a great wrong, to reinstate the Mac Bride Principles and to show due respect to Catholics and Irish-Americans."


text:
Man hospitalized after crashing into Hollywood Hills building
By Alexa Mae Asperin
1 hospitalized following Cahuenga crash
The 30-year-old driver was extricated from the car and sent to the hospital in critical condition, LAFD said.
LOS ANGELES - One person was hospitalized following a crash in Hollywood Hills on Sunday.
It happened around 8:30 p.m. in the area near 2260 N. Cahuenga Boulevard, according to the Los Angeles Fire Department.
Officials said the 30-year-old driver crashed into the building and was extricated from the car and transported to a local hospital in critical condition.
The building sustained little damage, authorities added.
Anthony Avalos: Trial begins in murder, torture of 10-year-old Lancaster boy


I have worked with many great people at Cornerstone over the years. Overall, you are a quality organization that has helped so many agents come up with solutions for their customers. Keep up the great work you do to make a difference every day to businesses.


B2B content marketing works by grabbing potential clients' attention and holding it long enough for them to understand who you are and what you offer—after all, you can't expect firms to sign up for your services if they don't know you exist.
More companies are seeing the importance of content marketing than ever before. On average, firms are allocating 32% of total marketing budgets on content (Source: Content Marketing Institute).
Stuck for ideas on what content your professional services firm could be producing?
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Why this type of B2B content marketing works: Producing video advice in the form of tutorials forces you to simplify and condense your message if you want to hold your audience's attention. When you do simplify and explain complex topics, your prospective clients will come back for more. And more. And more.
The more they visit your site, the more opportunities you have to put your messages in front of them.
By speaking their language, you're demonstrating that you know what you're talking about—rather than hiding behind a cloud of jargon.
Why this type of B2B content marketing works: Templates are an effective way to provide your audience with real-world examples of how you, as an expert, recommend approaching their problem, how you can relate to their experience, and how you have had previous successes doing so.
N.B. Don't think about it as giving information away for free—because you're not. Instead, you're giving potential clients a low-value outline and structure to work with, which they can choose to upgrade themselves or get you to do for them.
Why this type of B2B content marketing works: Simplifying and communicating a complex problem takes intelligence, experience, and time—and there's nothing more satisfying than discovering an easier way to do or explain something.
Helping your prospective clients with a problem of theirs starts a positive relationship between you and them. They might not have heard of your firm before coming across its infographic, however, knowing that you are able to address complex issues and solve problems they have puts you in a positive light.
Why this type of B2B content marketing works: Free consultations demonstrate assuredness and that you have the ability to solve any problem that comes your way. It's also a great way to judge the market for your services and enables you to filter the serious enquiries from the 'maybe-laters' and tyre-kickers.
After all, if someone clicks for a consultation, it's likely that they want to buy.
Remember: When the GDPR comes in (May 25th, 2018) you'll need to make sure that you understand which lawful basis you are using to process individual's personal data and are transparent about when and how you are using their data.
If you're ready to start using content marketing to get your firm noticed, but aren't sure where to start or are worried that you don't have the in-house expertise needed to produce content that will be worth the investment, get in touch.
We specialise in creating well-positioned content that produces serious enquiries so that you always get the most from your marketing budget.
Let us do what we do best so that you can get on with doing what you do best.


312.3 Apportionment to counties and cities.
1. Apportion among the counties in the ratio that the needs of the secondary roads of each county bear to the total needs of the secondary roads of the state for each fiscal year based upon the total needs of secondary roads of the state as shown in the latest quadrennial need study report developed by the state department of transportation, and which is on record at the department, seventy percent of the allocation from road use tax funds which is credited to the secondary road fund of the counties, and apportion among the counties in the ratio that the area of each county bears to the total area of the state, thirty percent of the allocation from road use tax funds which is credited to the secondary road fund of the counties.
For the purposes of this subsection, "latest quadrennial need study report" includes the annual recalculation of construction and maintenance needs of roads whose jurisdiction has been transferred from the department to a county or from a county to the department during the previous year as recalculated pursuant to section 307.22, subsection 7.
2. Apportion among the cities of the state, in the ratio which the population of each city, as shown by the latest available federal census, bears to the total population of all such cities in the state, the percentage of the road use tax funds which is credited to the street fund of the cities, and shall remit to the city clerk of each such city the amount so apportioned to such city. A city may have one special federal census taken each decade, and the population figure thus obtained shall be used in apportioning amounts under this subsection beginning the calendar year following the year in which the special census is certified by the secretary of state.
3. In any case where a city has been incorporated since the latest available federal census the mayor and council shall certify to the state treasurer the actual population of such incorporated city as of the date of incorporation and its apportionment of funds under this section shall be based upon such certification until the next federal census enumeration. Any community which has dissolved its corporation shall not receive any apportionment of funds under this certificate for any period after said corporation has been dissolved.
4. In any case where a city has annexed any territory since the last available federal census or special federal census, the mayor and council shall certify to the treasurer of state the actual population of such annexed territory as determined by the last certified federal census of said territory and the apportionment of funds under this section shall be based upon the population of said city as modified by the certification of the population of the annexed territory until the next federal or special federal census enumeration.
5. In any case where two or more cities have consolidated, the apportionment of funds under this section shall be based upon the population of the city resulting from said consolidation and shall be determined by combining the population of all cities involved in the consolidation as determined by the last available federal or special federal census enumeration for said consolidating city.


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FarmRaise equips producers with financial resources to build vital farming communities that are profitable, equitable, and ecologically resilient.
What is FarmRaise? We are a digital platform that connects farmers to funding opportunities (grants, loans, cost-share).
How can I get started? Take the FarmRaise Eligibility Quiz to see the grants you're eligible for, book a FarmRaise consultation to make a funding plan, and join our Launch List!
How much does it cost? It's free to register a FarmRaise account, match with grants, and apply for 3 federal programs currently on the platform. In 2021, we'll offer a $50/mo subscription service to help you identify and unlock big profit-boosting opportunities for your farm. Our team will manage the paperwork, deadlines, and help you meet your farming goals. We'll also offer a streamlined common application for dozens more grant and loan programs, charging a small fee-for-success on any funding successfully unlocked.
Is this secure? We care about your safety and security, and we've taken every step we can to protect your information. You can review our privacy policy for more information. This platform is a secure resource for you to streamline your farm funding needs and save information for future applications.
I still have questions! Check out our FAQ page or shoot us an email at info@farmraise.us. We'd love to get to know you!
Jayce Hafner
Jayce grew up on a livestock farm in Virginia and worked for half a decade in environmental policy, lobbying U.S. Congress and organizing civil society delegations to the United Nations. A Fulbright Fellow, Jayce has experience in organic farmland investing and on Apple's Environment, Policy & Social Initiatives team. She holds an MBA/MS from Stanford.
Albert Abedi
Albert comes to FarmRaise after having spent years gaining experience in software engineering and product management at Microsoft, Amazon, PivotalLabs and Expanse. Albert's vision for products that customers love ensures that FarmRaise commitment to farmer obsession will be upheld.
Sami Tellatin
Sami worked at the USDA Sustainable Agriculture Research & Education program and the University of Missouri-Extension before enrolling in the joint MBA/MS program at Stanford. Her prior work focused on soil health practice adoption across Midwestern row crop acreage. She has experience working on farms in both Missouri and Costa Rica and for a large agribusiness cooperative.


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Online Dispute Resolution? You are talking about resolving disputes online?
That's a thing for the future. Won't work now!
It may be working well in the UK or USA.
But India? Are you out of your mind? We have no ODR websites here. There is a lot of resistance in our judiciary. People won't even have faith in an ODR mechanism. It will take a long time.
Well, surprisingly, the answer is "NO".
The primary reason we started this blog on ODR and a page on Facebook was that we felt that there was an urgent need to promote this concept of dispute resolution in India. WE HAVE THE LARGEST BACKLOG OF DISPUTES IN THE WORLD! We need such alternative platforms and innovative methods of dispute resolution more than the UK and US!
Sunny Deol screaming 'Taareekh par Taareekh' cannot be the image that our judiciary represents anymore.
So, we started with our research and, to our surprise, we found something which was quite a jaw-dropper.
Online Dispute Resolution has been in existence in India for a long time!
Techno Legal Centre of Excellence for Online Dispute Resolution (ODR) in India (TLCEODRI) has been dealing with ODR related issues since 2005. Chittu Nagarajan, co-founder of Modria ( which is the most renown ODR platform of the world) started ODR India in 2004. Perry4law, which is known as the first techno legal law firm of India, is also working on building the ODR India mechanism.
But unfortunately, the impact of this field wasn't effective enough in the initial stages. The reasons can be any ranging from the digital divide in India, lack of technological penetration, mindset of the people or just poor execution.
A venture of Yessettle Legal Services LLP backed by a team of Legal Experts from different fields in society i.e. Lawyers, Retired Judges, Chartered Accountants, Social Workers, Retired Sr. Government Officials and Retired Sr. Bank Officials etc.
They have a history of seeking no adjournments.
They assure of providing best efforts in resolving the complaints within 15-20 days.
They have a special "tracking status" feature which helps consumers to track the status of their complaints through a unique Complaint ID No.
They provide special assistance to senior citizens.
Known as the Consumer Online Resource and Empowerment Center(CORE).
It is managed by Consumer Coordination Council (CCC) and supported by the Department of Consumer Affairs, Ministry of Consumer Affairs and Food and Public Administration.
It has been functional since 15th April, 2005. Their last progress report of November,2014 says that they have received a total of 2,36,538 complaints since the inception.
They also claimed to have a resolution rate of 68 percent in the month of November,2014.
Before publishing my blog, I generally send it to my brother for proofreading. I did the same with this blog. By the way, he is a 27 year old investment banker in Mumbai who is a regular consumer of e-commerce products.
Unfortunately, he was not aware of the existence of any of these ODR websites in India. But, to be honest, this wasn't really surprising.
In this last year, we have discussed this idea of ODR with a lot of people including family, friends and law students, among others. Awareness is clearly lacking. Further, there is a clear resistance towards this new approach of resolving disputes. No matter how much we hate the courts, there is still an inherent respect for the judiciary and people are not willing to change and use any new alternative mechanism.
On the other note, there is no denial that every new idea is met with scepticism and cynicism. The execution is extremely important. People need to be made aware of such mechanisms. There is a need for steady trust building.
So has ODR been a success in India? Have these Online Dispute Resolution mechanisms succeeded in generating the trust of the Indian public? Is there enough awareness about such innovative ODR websites?
It is too early to comment.
All these ODR initiatives are operational with the purpose to improve the accessibility aspect of our justice system by providing such alternative online platforms. Some of these platforms are quite recent. They are working hard towards making ODR a reality in India.
We wish them all the luck in the world.


Why do a post about Adam during Christmas? The first week of Advent was to reflect on the Old Testament shadows and prophecies of Jesus and since Adam was "a pattern of the one to come" (Romans 5:14) my reading went to Genesis, Isaiah, and several other places. Most references to Adam outside of Genesis are family tree notations like 1 Chronicles 1:1, Luke 3:38, or Jude 1:14. 1Corinthians, 1Timothy, and Romans actually do some of the explaining of the "pattern" so I am comparing the first Adam and the second Adam (Jesus).
Other comparisons that are interesting: Adam sewed fig leaves together; Jesus cursed a fig tree before His crucifixion. Eve came from Adam and the Bride is found in Jesus.
Notable things in Adam's life – He was the first to operated on, first to make clothes, first to blame some else for his mistake, named all the animals in the Garden, first gardener, and the first to bury a child.
A word about Eve; evolutionists have come to the conclusion that there must have been an "Eve" who birthed all of mankind. I saw a program where they spent forty minutes stating why there had to be one (Eve) and twenty minutes denying the concept. The problem here is dual evolving of human DNA is unbelievable and I am sure that mathematically it has to be impossible.
In Hebrews, the first chapter, Jesus is clearly shown as "The Son." Several quotes from the Old Testament such as "You are my Son today I have become your Father" from Psalm 2:7, other verses that are mentioned at the beginning of Hebrews are 2 Samuel 7:14, and Psalm 45:6,7. Several other verses that tell of things to come are Psalm 110:1 and Isaiah 8:17 where everything is put under His feet showing Lordship of all things.
Since Jesus was a second Adam, if we are found "in Him" we are a completely new and different race of people.


Centennial, CO – In May alone, some 65,000 Americans will experience a stroke with many unaware that they were even at risk. Less than a third will arrive in the emergency room within three hours, the optimal time period for better outcomes.
May marks National Stroke Awareness Month, and this year the National Stroke Association is turning the spotlight on the 10 modifiable risk factors that account for 90% of strokes globally. Hypertension remains the single most important modifiable risk factor, accounting for nearly 48% of strokes. With eight in 10 people experiencing their first stroke having hypertension, getting your blood pressure checked is an important first step in controlling your stroke risk.
Research has shown that unhealthy behaviors such as physical inactivity, poor diet, and smoking have an adverse effect on health and increase your stroke risk. For example, smokers have an increased risk of stroke, up to two to four times, compared to a nonsmoker or those that have quit for longer than 10 years.
During National Stroke Awareness Month, the National Stroke Association is urging the public to look at their stroke risk factors, and pledge to make at least one change to reduce their stroke risk.
Beyond reducing your risk for stroke, knowing the signs and symptoms of a stroke are equally important. Every 40 seconds someone in the U.S. has a stroke and around 800,000 people will have a stroke in the United States this year alone.
S – Speech: Ask the person to repeat a simple sentence. Is their speech slurred?
A common misconception is that strokes occur only in older adults. Although, your stroke risk increases with age, a stroke can happen to anyone at any time. About 15% of ischemic strokes occur in young adults and adolescents.
The need for public awareness surrounding stroke prevention and awareness has never been greater. Despite being a leading cause of adult long-term disability, and the fifth leading cause of death, less than one in five Americans can correctly classify all five stroke symptoms. The time to take action is now. This May, during National Stroke Awareness month, get to know your stroke risk factors and learn to better identify the signs and symptoms of stroke. The life you save just might be your own.


text:
Q: How to set different keyboard for login screen on iPad This is iPad/iOS - specific.
I want a login keyboard that includes the numbers row by default.  I'm using Swiftkey but it only shows up inside running apps, not the login screen.
Is it physically possible to assign a different keyboard to the login screen?


text:
Sleep problems and fatigue as predictors for the onset of chronic widespread pain over a 5- and 18-year perspective
Katarina Aili ORCID: orcid.org/0000-0003-4260-73991,2,7,
Maria Andersson1,3,
Ann Bremander1,3,4,5,6,
Emma Haglund1,4,
Ingrid Larsson1,7 &
Stefan Bergman1,7,8
Previous research suggests that sleep problems may be an important predictor for chronic widespread pain (CWP). With this study we investigated both sleep problems and fatigue as predictors for the onset of CWP over a 5-year and an 18-year perspective in a population free from CWP at baseline.
To get a more stable classification of CWP, we used a wash-out period, including only individuals who had not reported CWP at baseline (1998) and three years prior baseline (1995). In all, data from 1249 individuals entered the analyses for the 5-year follow-up and 791 entered for the 18-year follow-up. Difficulties initiating sleep, maintaining sleep, early morning awakening, non-restorative sleep and fatigue were investigated as predictors separately and simultaneously in binary logistic regression analyses.
The results showed that problems with initiating sleep, maintaining sleep, early awakening and non-restorative sleep predicted the onset of CWP over a 5-year (OR 1.85 to OR 2.27) and 18-year (OR 1.54 to OR 2.25) perspective irrespective of mental health (assessed by SF-36) at baseline. Also fatigue predicted the onset of CWP over the two-time perspectives (OR 3.70 and OR 2.36 respectively) when adjusting for mental health. Overall the effect of the sleep problems and fatigue on new onset CWP (over a 5-year perspective) was somewhat attenuated when adjusting for pain at baseline but remained significant for problems with early awakening, non-restorative sleep and fatigue. Problems with maintaining sleep predicted CWP 18 years later irrespective of mental health and number of pain regions (OR 1.72). Reporting simultaneous problems with all four aspects of sleep was associated with the onset of CWP over a five-year and 18-yearperspective, irrespective of age, gender, socio economy, mental health and pain at baseline. Sleep problems and fatigue predicted the onset of CWP five years later irrespective of each other.
Sleep problems and fatigue were both important predictors for the onset of CWP over a five-year perspective. Sleep problems was a stronger predictor in a longer time-perspective. The results highlight the importance of the assessment of sleep quality and fatigue in the clinic.
Experiencing musculoskeletal pain is common [1], however, the clinical presentation vary substantially.
One way of classifying musculoskeletal pain is by the number and localization of pain-sites. Localized pain is rather uncommon [2] and probably represent a different type of disorder than multisite or widespread pain. Individuals with localized pain report better general health, less pain severity and less problems with sleep than individuals with widespread pain [3]. The number of pain sites has shown to have an almost linear relationship to reduced functional ability [2] and an inverse linear relationship to general health, sleep quality and mental health [4]. If localized pain represents the one end of a pain spectra with overall better general health, chronic widespread pain (CWP) and fibromyalgia represent the other end of the spectra, having a large impact on health. Primary care patients with CWP have more comorbidities with other somatic diseases and mental illness than patients with localized chronic low back pain [5].
Population-based studies have described a CWP-prevalence of 10–17% among adult men and women [6,7,8,9,10]. Between 34 and 57% of those reporting CWP at baseline still reported CWP 1 to 11 years later [6,7,8, 10]. For early identification of patients at risk for CWP it is important to find predictors so that interventions could be directed more efficiently. Number of painful regions at baseline, age and family history of pain have been found to predict the onset of CWP [7]. Other predictors found in population-based prospective studies are somatization, illness behaviour [11, 12] and sleep disturbances [12].
Sleep problems are common among individuals reporting musculoskeletal pain. The causal sleep-pain relationship is complex and reciprocal [13, 14]. Previous studies indicate that sleep predict pain prognosis, [15,16,17]. The underlying mechanisms for why disturbed sleep would predict pain prognosis is not yet fully established, however there are studies indicating that sleep disturbances influence pain sensitization and pain inhibitory systems [18].
CWP, where pain is present above and below the waist, on the right and left side of the body and the axial skeleton (according to the ACR 1990 criteria for fibromyalgia [19]), is a condition commonly associated to disturbed pain systems. Prospective studies have found that sleep problems predict the onset of CWP [12, 20, 21] and resolution from CWP [17]. Sleep problems are typically assessed by (self-reported) items referring to initiating sleep, maintaining sleep and non-restorative sleep. Not feeling rested when waking up (non-restorative sleep) seems from previous studies to be the perhaps most prominent predictor out of the different types of sleep problems [17, 20]. Although this parameter ought to be closely related to fatigue, none of the studies have tried to separate the effect of fatigue from the sleep problems.
Chronic fatigue and CWP is known to common co-occur, and the disorders have been suggested to at least partly share pathogenetic pathways [22]. Sleep quality and sleep loss is related to fatigue [23, 24], but the concept of fatigue also refers to a state of mental or physical energy deprivation, rather than actual sleepiness. Although the co-occurrence of fatigue and CWP is well established, little is known about the association between fatigue and CWP prospectively.
Prospective studies of sleep and CWP share some methodological issues to handle. Musculoskeletal pain conditions, including CWP, are recurrent and regardless of using an established definition (e.g. ACR 1990 criteria for fibromyalgia), you will end up with some "border-line-cases" who move in and out of fulfilling criteria for CWP. This migration in and out of CWP has previously been reported, where almost half of those with CWP at baseline no longer reported CWP at one- or three-year follow-up [7, 8]. Although these subjects most likely have disturbances in pain regulation systems, intensity and locations of pain fluctuates, and they could falsely be categorized as "no CWP" when studied at a single time point. Studying predictors for the onset of CWP is thus complicated by that pain tend to be recurrent over time and there is a need for studies with more stable baseline classifications of individuals free from CWP at baseline.
The aim of this population-based study was to investigate if sleep problems and fatigue predicted the onset of CWP over a 5-year and up to 18- year perspective in a cohort who had not reported CWP 3 years prior to baseline.
Population and design
This study is based on data from the EPIPAIN study, a prospective population study that was initiated in 1995 in order to investigate the prevalence and risk factors for long term musculoskeletal pain in south of Sweden. The target population for EPIPAIN was all of the 70,704 inhabitants aged 20–74, living in two municipalities and healthcare districts on the southern west coast of Sweden. For inclusion to EPIPAIN, a representative sample of subjects was selected from the official computerised population register. The register is categorised by date of birth, and the selection of subjects was made by choosing every 18th man and women respectively for each of the municipalities. A postal questionnaire was sent out in May 1995 to the 3928 selected individuals. After two postal reminders, 2425 subjects had responded to the postal survey in 1995.
Follow-up questionnaires were sent out to the subjects in 1998, 2003 and 2016. The cohort included in this study was formed out of the 1922 subjects who responded the survey in 1995 and 1998. Baseline was set to 1998 in this study with a three-year wash-out period between 1995 and 1998. Only individuals who had not reported CWP in 1995 and 1998 were included in the study. The chosen times to follow-up were 5 years (year 2003); and 18 years (year 2016).
Chronic widespread pain
Chronic musculoskeletal pain was assessed by an overall key question: Have you experienced pain lasting more than 3 months during the last 12 months? An introduction to the question explained that the pain should be persistent or regularly recurrent in the musculoskeletal system. Pain was considered to be chronic if it had been persistent or recurrent for more than 3 months during the last 12 months.
In addition, if chronic pain was reported, the location and distribution of the pain was reported by a manikin with 18 predefined regions. Head and abdomen were not included amongst the predefined regions [7, 25].
A distinction was made between chronic regional pain (CRP) and chronic widespread pain (CWP) according to the ACR 1990 criteria for fibromyalgia [19]. According to the 1990 ACR criteria, pain was classified as widespread when present in both the left and right side of the body and also above and below the waist. In addition, axial skeletal pain (i.e. in the cervical spine, the anterior chest, the thoracic spine or the lower back) should be present. When chronic pain was present but criteria for a widespread condition were not met, the subject was classified as having CRP.
Subjects who did not report any chronic pain were labelled as "no chronic pain" (NCP).
Sleeping problems
Problems related to sleep were assessed by four items adopted from the Uppsala Sleep Inventory (USI), which has been used in several previous epidemiological studies [26, 27]: How much of a problem do you have with: (1) Falling asleep at night? (2) Waking up during the night? (3) Waking up too early in the morning? (4) Not feeling rested after sleep?
The problems were recorded on a five-point Likert scale: [1]=no problems, [2]=minor problems, [3]=moderate problems, [4]=severe problems, and [5]=very severe problems. Those who had responded "moderate problems", "severe problems" or "very severe problems" were considered to have sleep problems.
The sleep problems were treated as four separate variables of sleep, 1) Difficulties initiating sleep; 2) Difficulties maintaining sleep; 3) Early morning awakening; and 4) Non-restorative sleep.
Fatigue was estimated by the vitality subscale from the SF-36 questionnaire [28, 29]. The items from the subscale assess how great part of the time the last 4 weeks one have felt 1) alert and strong; 2) full of energy; 3) worn out; 4) tired. The response rates range from [1] "All the Time" to [6] "None of the time". The scale was converted according to the SF-36 manual into a scale ranging from 0 to 100, were a higher score indicate less problem with fatigue. Three levels of fatigue (low, intermediate, high) was constructed by dividing the included cohort's scoring into tertiles. "Low fatigue" then represented scorings of 85–100; "intermediate fatigue" represent scorings of 70–84 and "high fatigue" represent scorings between 0 and 69. The vitality subscale from SF-36 has been widely used in studies of populations with musculoskeletal pain, including fibromyalgia, and is a validated measure of fatigue [30].
Potential confounders
Mental health [20, 31] and socio-economy [21] as well as baseline pain [20] has previously been found to be associated to both sleep problems and CWP. The potential confounders considered in this study were age, gender, number of musculoskeletal pain sites, socio economy and mental health at baseline.
Number of (chronic) musculoskeletal pain sites were reported by a manikin, as described above, with eighteen possible regions.
Mental Health was assessed by the subscale MH from SF-36, including five items referring to the last 4 weeks: How much of the time during the last 4 weeks have you… 1) been a very nervous person?; 2) felt so down in the dumps that nothing could cheer you up?; 3) felt calm and peaceful; 4) felt downhearted and blue?; 5) been a happy person? Three levels of mental health (poor, intermediate, good) was constructed by dividing the included cohort's scoring into tertiles. "good mental health" then represent scores between 93 and 100; "intermediate mental health" scores between 84 and 92; and "poor mental health" scores between 0 and 83.
Socio economy as measured by Socio economic groups according to Statistics Sweden was based on self-reported occupation in 1995. Four groups of socio-economic classes were formed; Manual workers, assistant non-manual employees, intermediate/higher non-manual employees and others (including self-employed, farmers, housewives, students).
All study participants signed an informed consent before entering the study. The study was approved by the Regional Ethical Review Board, Faculty of Medicine, University of Lund, Sweden (Dnr LU 389–94; Dnr 2016/132).
The included cohort and the subjects that had been excluded due to reporting CWP in 1995 and/or 1998 were compared with respect to age, gender, the four sleep parameters, fatigue, number of pain regions, mental health and socio economy (based on type of occupation) at baseline. The prevalence of exposed to each sleep problem and fatigue respectively within the different categories of gender, pain regions, mental health and socio economy were compared. Pearson's chi-square test and independent t-test were used in the analyses for difference.
Odds ratios for CWP were calculated using binary logistic regression analysis. The effect of the four different sleep problems and fatigue were tested separately, for each year of follow-up.
Firstly, the four different sleep parameters and fatigue were tested in separate models in order to see if the different sleep problems or fatigue were of different importance. The predictors and the potential confounders were tested in binary logistic regression analysis, adjusting for age and gender. Multivariate analyses were then performed. Due to the complex relationship between pain, sleep and mental ill health [13], the analyses were presented in three models: 1) adjusting for age, gender, socio economy and mental health and 2) adjusting for age, gender socio economy and number of pain sites; and 3) adjusting for age, gender, socio economy, mental health and number of pain sites. The decision to let either number of pain sites or mental health enter models 1 and 2 and to let them act together in model 3 was made based on an attempt to be transparent in how the two affect the results, separately and together.
Secondly, the independent effect of sleep and fatigue on CWP was tested, and the two variables were included in the same model. To get one sleep variable instead of four separate sleep variables, sleep problems were categorized into having 0–4 of the (4) sleep problems. Again, number of pain sites and mental health were included in different models, and simultaneously. The effect of number of sleep problems, mental health and socio-economy were analysed in a "Model A", including also age and gender. In separate analyses Model A was tested when including fatigue, and number of pain sites.
All logistic regression analyses were performed twice, one for CWP at the five-year follow-up, and once for CWP at the 18-year follow-up.
The analyses were performed with the SPSS 21 Statistical Package.
In all, 1922 subjects responded to the survey in 1995 and 1998. Missing data on pain questions were found in 49 cases in 1995, and 22 cases in 1998. In all, 1852 subjects had data from both 1995 and 1998 and could thus enter the analysis. Among these, 340 individuals had reported CWP in either 1995 or 1998 and were excluded from the analysis.
The excluded subjects were significantly older, were more likely to be female, to have problems with sleep and differed in socio economy from the included individuals. Further, the excluded individuals generally rated higher fatigue, poorer mental health and more pain severity. See Table 1.
Table 1 Presenting baseline characteristics of the cohort with baseline stable NCP or CRP and individuals excluded from the study due to reporting CWP in − 95 and/or − 98. Prevalence of baseline exposures and covariates in included and excluded subjects, and history of CWP in excluded individuals. Significance of differences between included and excluded subjects are presented as p-values (tested with t-test and chi2-test respectively)
Out of the 1512 individuals who fulfilled the inclusion criteria, 1249 had responded to the pain items in 2003, and were thus eligible for the analysis referring to the 5-year follow up; and 791 responded to the items in 2016 and were thus eligible for the analysis referring to the 18-year follow-up. See flow-chart in Fig. 1.
Flow-chart showing participation in the study
Out of the included subjects, 89 (7%) had CWP in the 5-year follow-up and 103 (13%) had CWP in the 18-year follow-up. There was no difference in proportion of men and women reporting CWP in the 5-year follow up (8% vs 6%, p = 0.14). However, there were significantly larger proportion of females than men reporting CWP in the 18-year follow-up (16% vs 10%, p = 0.01). There was a significantly larger proportion who reported CWP 5- and 18 years later among those with sleeping problems and fatigue compared to those without sleeping problems and fatigue at baseline. See Table 2. The same was seen for differences in number of pain regions and level of mental health. Data not shown.
Table 2 Presenting prevalence of baseline sleep problems and fatigue. Cross tabulation of baseline sleep problems and CWP at respective follow-up. Differences between no CWP and CWP cases in respective year for follow-up have been tested with chi2-test
One fourth of those who reported all four sleep problems (concurrently) at baseline had CWP 5 years later, and one third had CWP 18 years later. Among those reported none of the sleeping problems at baseline, 4% reported CWP 5 years later and 8% 18 years later.
In all, 769 individuals had data on pain at all three time points. Looking at changes in pain between the 5-year follow-up and the 18-year follow-up, 59% stayed in the same pain group (NCP, CRP or CWP). Out of the 52 who reported CWP in the 5-year follow-up (and who had data also at the 18-year follow-up), 56% (n = 29) reported CWP also in the 18-year follow-up. In all, 100 participants reported CWP in the 18-year follow-up. See Fig. 1.
Exposed at baseline
As presented in Fig. 2, there was a significantly higher proportion of females reporting problems with initiating sleep and problems with maintaining sleep at baseline. No gender differences were seen for problems with early awakening, non-restorative sleep or fatigue.
Presenting baseline data. The figure presents the percentage within each category of 1) Gender; 2) Number of pain regions and 3) Mental health, reporting problems with: Initiating sleep, Maintaining sleep, Early awakening, Non-restorative sleep, and Fatigue respectively. *p for difference < 0.05
Describing migration between the pain groups over time. The figure describe migration between reporting No Chronic Pain (NCP); Chronic Regional Pain (CRP) and Chronic Widespread Pain (CWP) between the 5-year follow-up and 18-year follow-up. Including the (N = 769) with data on pain in both 5-year follow-up and 18-year follow-up
There were a larger proportion among individuals reporting more number of pain regions who reported problems with sleeping (significant for all sleep parameters) and fatigue. The same trend was seen for mental health, where subjects reporting poor mental health were more likely to also report problems with sleep (all sleep parameters) and fatigue.
Predictors for CWP in crude analysis
After adjusting for age and gender, all sleep parameters, fatigue (SF-36 Vitality), number of pain regions and mental health (SF-36) predicted the onset of new CWP in the 5-year- and 18-year follow-up. Being a manual worker in 1995 predicted the onset of new CWP in the 5-year follow-up. See Table 3.
Table 3 Presenting results from univariate model (adjusted for age and gender). Odds ratio (OR), 95% confidence intervals (95% CI) and p-value (p) for reporting CWP in the 5-year and 18-year follow-up respectively. Number of individuals per category of exposure at baseline are presented as N for the 5-year follow-up and 18-year follow-up respectively
The effect of sleep as a predictor for CWP in multivariate models
Over a five-year perspective, all sleep parameters and fatigue predicted the onset of CWP, irrespective of age, gender, mental health and socio-economy (model 1). When adjusting for number of pain sites at baseline instead of mental health (model 2), fatigue and all sleep parameters except maintaining sleep predicted the onset of CWP. Finally, adjusting for age, gender, socio-economy, mental health and number of pain sites (model 3), none of the sleep parameters or fatigue significantly predicted the onset of CWP 5 years later.
Over the 18-year perspective, fatigue and all sleep parameters except early awakening significantly predicted CWP when adjusting for age, gender, socio-economy and mental health. However, when including number of pain sites at baseline in the model separately (model 2) and simultaneously with mental health (model 3), maintaining sleep was the only parameter that remained significant in the 18-year follow-up.
Results are presented in Table 4.
Table 4 Results from multivariate analysis. Presenting the effect of difficulties initiating sleep, difficulties maintaining sleep, early morning awakening, non-restorative sleep and fatigue on the odds ratio (OR) for reporting CWP in the 5-year and 18-year follow-up respectively. The OR, 95% confidence intervals (95% CI) and p-value (p) are presented in model 1–3. N = 1249 entered the 5-year follow-up analyses; N = 791 entered in the 18-year follow-up analyses
In all, 785 individuals did not report any of the sleeping problems at baseline (fatigue not included), 268 reported one of the problems, 167 two, 128 three and 117 subjects reported to have all four sleep problems.
In a multivariate model (Model A) including age, gender, mental health, socio-economy and number of sleep problems, reporting four sleep problems, reporting poor mental health and the socio-economy-parameter manual work were all associated with the onset of CWP 5 years later. Adding fatigue to the model showed that sleep problems, fatigue and manual work predicted CWP independently from each other, however mental health did not remain significant in the model. When, instead, including number of pain sites to Model A, reporting four sleep problems, reporting at least three pain-sites and manual work predicted the onset of CWP. Reporting at least three pain sites at baseline and manual work were the only parameters that remained significant when adding also fatigue to the model. See Table 5.
Table 5 Presenting odds ratios (OR) and 95% confidence intervals (95% CI) for CWP 5 years later. Model A includes age, gender, mental health, socio economy and number of sleep problems
Over an 18-year perspective, sleep problems were stronger independent predictor for CWP. Out of the included parameters, only sleep problems and number of pain regions at baseline significantly and independently, predicted CWP. See Table 6.
Table 6 Presenting odds ratios (OR) and 95% confidence intervals (95% CI) for CWP 18 years later. Model A includes age, gender, mental health, socio economy and number of sleep problems
The aim of this study was to investigate if sleep problems and fatigue predict the onset of CWP five- and 18 years later. The results from this study indicate that in a cohort free from CWP at baseline, difficulties initiating sleep, maintaining sleep, early morning awakening, non-restorative sleep and fatigue respectively predicted the onset of CWP in a 5-year perspective irrespective of age, gender, socio-economy and mental health. This was true also over an 18-year perspective, except for the sleep parameter early morning awakening. When adding number of pain sites in the model none of the sleep parameters or fatigue predicted the onset of CWP in the 5-year follow-up. However, problems with maintaining sleep consistently predicted the onset of CWP 18 years later in all models.
When adding all sleep problems together, receiving a parameter measuring 0–4 sleep problems, sleep problems predicted the onset of CWP 5 years later irrespective of age, gender, mental health and socio-economy. Further, sleep problems and fatigue predicted the onset of CWP 5 years later irrespective of each other. However, in a full model including the parameters mentioned above plus sleep problems, fatigue and number of pain sites, only ≥3 pain sites at baseline and having manual work at baseline significantly predicted the onset of CWP 5 years later. Over an 18-year perspective however, reporting 4 sleep problems at baseline and reporting pain at baseline (at least 1–2 pain sites) were the only predictors that remained significant when included in a full multivariate model.
The over-all results, that sleep is a predictor for CWP, is in line with what previous studies have found [12, 21, 31, 32]. These studies have used follow-ups of 15 months, 6 years and 11 years. Our findings, that sleep seems to be an important predictor also over very long time-spans are supported by prospective studies showing that insomnia predict chronic widespread musculoskeletal pain 11 years later [32]. Although the previous studies have used a study design where following a cohort free from CWP at baseline, this study is the first study being able to exclude also those who had had CWP 3 years prior to baseline.
The mechanistic relationship between sleep problems and chronic pain is not yet clear. One suggested mechanism is that insufficient sleep alters the processes of pain habituation and sensitization, and increase vulnerability to chronic pain [18]. The purpose of using a wash-out period was to distinguish between regional pain (presumably without central sensitization) and CWP (where disturbed pain systems are common). We then found that over a five-year perspective, the sleep-CWP relationship was not explained by pain regions at baseline or mental health. Further, fatigue predicted the onset of CWP independently from mental health and sleep problems, but not independently from number of pain regions at baseline. This implies that the association between fatigue and CWP is explained by number of pain sites rather than mental health and sleep problems. In the longer time-perspective of 18 years however, fatigue did not predict the onset of CWP independently from sleep problems. Possibly, this could be interpreted as fatigue being more associated with disturbances in pain systems, whereas sleep problems not only are associated with disturbed pain systems, but also indicates a vulnerability to chronic pain, preceding disturbances of the system.
Using the wash-out period, allowing only those who had not reported CWP both at baseline and 3 years prior to baseline, we attended to capture new onset CWP. This is however more likely to be true for the results found in the 5-year follow-up than the 18-year follow-up. One of the reasons for why sleep problems predict CWP also over longer time periods may be that sleep problems [6] and fatigue [8] predict persistence of CWP. At the 18-year follow-up it is reasonable to believe that what we see is the combined effect of sleep problems on the onset of CWP, as well as persistence of CWP. As shown in Fig. 3, a large part of the study participants stayed in the same pain group between the 5-year and 18-year follow-up. However, 44% of those reporting CWP in the 5-year follow-up reported "No Chronic Pain" or "Chronic Regional Pain" in the 18-year follow-up and the mere part of those reporting CWP in the 18-year follow-up (70%) did not report CWP in the 5-year follow-up. We have not found any previous prospective studies investigating the effect of predictors for CWP both over a "shorter" time span (5 years) and a very long time-span (18 years) simultaneously.
In this study we found that difficulties maintaining sleep, and possibly difficulties initiating sleep, seems to be stronger independent predictors for CWP in a long-term perspective (18 years) than in a 5-year perspective. The opposite trend was seen for early morning awakening, non-restorative sleep and fatigue. Other studies of sleep and CWP that has specified single component of sleep in their analysis [17, 20] point out non-restorative sleep and trouble initiating sleep as the two important components, when investigating the onset of CWP 3 years later (among older adults) [20] and resolution from CWP 15 months later [17]. A previous study [31] suggest that difficulties initiating or maintaining sleep, could worsen a person's depressive symptoms over time, which may explain some of our findings. A recent review concludes that deterioration in sleep is associated with an increased risk for developing a pain condition [33]. Future studies should investigate the variance of both sleep and CWP over time for better understanding of the clinical meaning of the findings in the present study.
We chose to include mental health and number of pain regions in separate models in the analysis. Pain, sleep problems and mental health are known to commonly co-occur. It was not under the scope of this study to unravel the different pathways through which sleep, pain, fatigue and mental health interact. However, knowing that the relationship is complex, we wanted to be as transparent as possible when exploring the effect of sleep and fatigue on CWP. A recent review [13] investigating the relationship between sleep and pain suggest that sleep, pain and negative mood share variance after presenting studies that suggest sleep to be a mediator between the relationship between pain and depression [34]; pain to mediate the relationship between sleep and depression [35]; and negative mood to mediate the relationship between sleep and pain [36]. Sleep problems have further been found to predict the development of depression among individuals with persistent pain [37]. Another recent study found that insomnia and sleep duration are risk factors for developing chronic multisite pain and that the mediation effect of depressive symptoms, at least partially explained the increased risk [31]. Further, CWP and fatigue commonly co-exist, and it has been shown that many of those reporting both fatigue and CWP also report anxiety or depression [38].
Having had pain previously is an important predictor for reporting more pain sites at follow-up [39]. In this study, individuals who had reported CWP 3 years prior to baseline were excluded from entering the analyses to get a more stable baseline classification of "no CWP". Most other studies do not include a wash-out period when studying the onset of CWP. As shown in Tables 1, 30% of the excluded reported CWP in 1995, but not in 1998, which means that if we had chosen to not use a wash-out period, we would have classified them as "no CWP" at baseline (− 98). The included cohort differed significantly from the excluded group in all parameters of interest in this study; age, gender, the four sleep parameters, fatigue, number of pain regions, pain severity, mental health and socio economy and the excluded group were with respect to these parameters supposedly a more vulnerable group of individuals in general. These differences strengthen our hypothesis that these factors are of importance. When interpreting the result, it is important to bear in mind that they are based on a cohort that due to the wash-out period include a higher proportion of individuals who are supposedly less vulnerable to CWP than a random sample from a general population would be.
Previous population-based studies have established a higher CWP-prevalence among women than men [11, 40]. Unexpectedly, in this study, female gender predicted the onset of CWP in the 18-year follow-up, but not in the 5-year follow-up. One explanation for this may be the use of a wash-out period for CWP, as discussed above. The effect of gender that was seen in the 18-year follow-up may reflect that females have higher risk for persistent CWP than men. A previous study on the cohort [7] found that women had higher risk for developing CWP, and higher risk (however non-significant) than men for persistent CWP. The gender difference in risk for long-term persistence of CWP has been seen also in other cohorts [6]. However, a British study with one-year follow-up did not find any gender difference in persistence of CWP [8].
There are some methodological issues to be considered when interpreting the results from this study. The results rely upon self-reported data from questionnaires. Individuals classified as CWP in this study may have differed if they were diagnosed by a physician. By the criterion used in this study, subjects could have reported up to 11 sites without fulfilling the criteria for CWP. One could fulfil the CWP criteria if reporting pain from only three sites, thus the individuals classified as CWP may be heterogeneous. This approach for classifying CWP [19] is however the most commonly used in population-studies, and our results are therefore comparable to other studies [6, 8,9,10,11,12, 17, 20, 21, 40].
The parameter indicating socio economy may have some problems. The classification was made based on occupation according to a classification system by Statistics Sweden, 1982. In 1998, when data was assessed from which the socio-economy parameter was classified in this study, this classification was considered accurate to use. We chose to use this parameter in this study to get an idea of the impact of socio economy and/or type of work, although we are aware it is not a perfect estimation.
Another issue worth mentioning is the repeated analysis, due to our decision to perform separate analysis in models including mental health and number of pain sites, separately and simultaneously. The multiple analysis increases the risk for false positive associations. In the age-gender adjusted analysis (presented as crude analysis) of the predictors, the p-values were very low (below 0.001). This imply that there is a very small risk for false positive results in the "crude" relationship between the investigated predictors and CWP. However, as moving on and analysing the predictors in several models, with less convincing p-values, the risk for false positive results increase. This is a limitation with the study.
Another issue is the potential nonparticipation bias. In the five-year follow-up, the response rate was 90% and in the 18-year follow-up, the response rate was 63%. Especially the response rate of the latter follow-up could potentially have caused bias. However, in comparison to other studies with this long-term follow-up, the response rate is within a range one would expect.
This prospective populations study showed that all the investigated sleep problems, (initiating sleep, maintaining sleep, early awakening and non-restorative sleep) as well as fatigue are important predictors for the future development of CWP both over a 5-year, and 18-year perspective. Problems with maintaining sleep was a weaker predictor in the five-year follow-up but was the only sleep parameter that predicted the onset of CWP over an 18-year perspective irrespective of both mental health and number of pain sites.
Reporting all four sleep problems simultaneously was a strong predictor for CWP 5 years- and 18-years later. Fatigue predicted the onset of CWP 5 years later irrespective of sleep problems, age, gender, socio-economy and mental health, but not independently from pain sites. The results from this study are in line with what previous prospective studies have shown, and with this study we add knowledge of the importance of fatigue as predictor over a shorter perspective. This highlights the importance of the assessment of sleep quality and fatigue in the clinic. This study suggests that the fatigue-CWP association is explained by number of pain sites (and possibly disturbed pain systems) rather than mental health or sleep problems. This study also suggests that sleep problems may indicate a vulnerability to chronic pain at an earlier stage.
CRP:
Chronic regional pain
CWP:
NCP:
No chronic pain
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The Epipain study was supported from a grant from Swedish AFA insurance.
The datasets used and analysed during the current study is available from the corresponding author on reasonable request.
Spenshult Research and Development Center, FoU Spenshult, Bäckagårdsvägen 47, SE-302 74, Halmstad, Sweden
Katarina Aili, Maria Andersson, Ann Bremander, Emma Haglund, Ingrid Larsson & Stefan Bergman
Unit of occupational medicine, Institute of Environmental Medicine, Karolinska Institutet, Stockholm, Sweden
Katarina Aili
Department of Clinical Sciences, Section of Rheumatology, Lund University, Lund, Sweden
Maria Andersson & Ann Bremander
School of Business, Engineering and Science, Halmstad University, Halmstad, Sweden
Ann Bremander & Emma Haglund
Department of Regional Health Research, University of Southern Denmark, Odense, Denmark
Ann Bremander
Syddansk Universitet Research Unit, King Christian X Hospital for Rheumatic Diseases, Hospital of Southern Jutland, Copenhagen, Graasten, Denmark
School of Health and Welfare, Halmstad University, Halmstad, Sweden
Katarina Aili, Ingrid Larsson & Stefan Bergman
Primary Health Care Unit, Department of Public Health and Community Medicine, Institute of Medicine, The Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
Stefan Bergman
Maria Andersson
Emma Haglund
Ingrid Larsson
KA and SB have taken the lead of the work with the study and has shared the responsibility for the integrity of the study as a whole and for taking the progress forward with analysing data and writing the manuscript. MA, AB, EH and IL has actively contributed to the work of formulating the conception and design, data assessments, analysing and interpretation of data and critical review of the manuscript. All authors have approved the final version of the article.
Correspondence to Katarina Aili.
Competing interest
Aili, K., Andersson, M., Bremander, A. et al. Sleep problems and fatigue as predictors for the onset of chronic widespread pain over a 5- and 18-year perspective. BMC Musculoskelet Disord 19, 390 (2018). https://doi.org/10.1186/s12891-018-2310-5
Population study


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