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Clint Lanford
Clint Lanford

Among The Sleep Enhanced Edition (2017) PC | RePack CPY ##TOP##

This 'bad ending' was scrapped from the story but was placed in the enhanced edition of the game. The ending can be accessed at the Museum level. David wakes up in a broken-down, cage-like baby crib in an unknown area. Then he sees Teddy turning a wheel, where the crib is being held, revealing a room with lifeless dolls, all memory items, and a giant cooking pot. The crib stops moving and Teddy walks creepily towards David, 'happily' greeting him with red eyes. From that moment, his neck cracks and giant skeleton-like hands come out of his body, revealing his true ghostly form: "The Nightmare". It turns out the Nightmare has been using young children to collect beloved items to create a stew by disguising them as stuffed toys and tricking children to venture far from their homes and to his hideout. He prepares his meal by placing all the items in the pot and stirring them while reciting the quotes from the toddler's book "Five Thirsty Animals." He then congratulates David for doing his bidding, grabs him, and drops him into the boiling water ready to be devoured.

Among The Sleep Enhanced Edition (2017) PC | RePack CPY


Among the Sleep is an award winning first person horror adventure in which you play a small child searching for your mother after ominous sounds wake you up in the middle of a night. The enhanced edition of Among the Sleep contains improved visuals, digital art book and soundtrack integrated in the game, selectable pyjamas, enhanced puzzles and gameplay, new dialogue and a brand new museum level where you get to explore behind the scenes and experience never before seen footage and concepts cut from the released game.

They are giving away the enhanced edition of the original Among the Sleep, which was released way back in 2014. The enhanced edition was released in 2017 with improved visuals and gameplay, a digital artbook, enhanced puzzles, new dialogues, and soundtracks integrated within.

The recently released third edition of the International Classification of Sleep Disorders (ICSD) is a fully revised version of the American Academy of Sleep Medicine's manual of sleep disorders nosology, published in cooperation with international sleep societies. It is the key reference work for the diagnosis of sleep disorders. The ICSD-3 is built on the same basic outline as the ICSD-2, identifying seven major categories that include insomnia disorders, sleep-related breathing disorders, central disorders of hypersomnolence, circadian rhythm sleep-wake disorders, sleep-related movement disorders, parasomnias, and other sleep disorders. Significant modifications have been made to the nosology of insomnia, narcolepsy, and parasomnias. Major features and changes of the manual are reviewed in this article. The rationales for these changes are also discussed.

Adil (2017) discuss uvulopalatopharyngoplasty indications. The authors state that UPPP is most common surgery performed for adults with OSA in the U.S.. They report that UPPP surgery can be considered if a patient is unable to tolerate CPAP therapy. They further note general indications for surgical intervention to include mild obstructive sleep apnea with excessive daytime fatigue, an apnea-hypopnea index of 15 or more, oxyhemoglobin desaturation less than 90%, and/or cardiac arrhythmias associated with obstructions.

Radiofrequency ablation may be used to reduce and tighten excess tissues of the soft palate, uvula and tongue base (Somnoplasty) or nasal passages and soft palate (Coblation or Coblation channeling). These procedures are performed in an outpatient setting under local anesthesia. Current literature does not support their efficacy and applicability for OSA. Most published studies have been nonrandomized and have enrolled highly selected patients. These studies also fail to report long-term outcomes or recurrence rates. Woodson et al (2003) reported on the results of radiofrequency ablation of the turbinates and soft palate in patients with mild to moderate obstructive sleep apnea (AHI of 10 to 30 on screening sleep study). A total of 90 subjects were randomly assigned to radiofrequency ablation, CPAP, or sham-placebo. Subjects assigned to radiofrequency ablation had a moderate decrease in AHI that did not reach statistical significance. The AHI of subjects assigned to radiofrequency ablation decreased by an average of 4.5 events/hour, whereas the AHI of subjects assigned to sham-placebo decreased by an average of 1.8 events/hour, a difference that did not achieve statistical significance. However, compared with sham-placebo, subjects assigned to radiofrequency ablation reported statistically significant improvements in quality of life, airway volume, apnea index and respiratory arousal index. In addition to the modest impact of radiofrequency ablation on AHI, this study has a number of other important limitations. First, it is a relatively small study, and improvements were not consistently seen among each of the measured parameters. Second, a significant number of subjects were lost to follow-up, and data were incomplete on 25 % of study subjects. Third, the study does not report on long-term clinical outcomes or recurrence rates. Fourth, although this study did not involve a direct comparison with UPPP, which is the current surgical standard treatment for OSA, studies of UPPP have reported much more substantial improvements in AHI, AI and other relevant parameters. Finally, this study involved a single investigator group and is the only published randomized clinical study of radiofrequency ablation for OSA; this study needs to be replicated by other investigators and in larger numbers of subjects.

In a continuation of a prospective case series, Walker et al (2007) assessed the long-term safety and outcomes of palatal implants for patients with mild-to-moderate OSA. Polysomnography, daytime sleepiness, and snoring intensity were measured at baseline, 90 days, and extended follow-up. A total of 22 (42 %) patients from the previous study were followed for a median of 435.5 days. Thirteen were classified as responders, based on their 90-day evaluation; 76.9 % of initial responders maintained improvements in AHI, daytime sleepiness, and snoring at extended follow-up. Nine patients were initial non-responders for AHI and daytime sleepiness and remained unchanged at extended follow-up. However, snoring for these 9 patients initially improved, and the improvement continued through extended follow-up. The authors concluded that initial response or non-response to palatal implants remains stable over an extended period. However, they noted that the generalizability of these results is unknown because of significant loss to follow-up (31 of 53 or 58 %). Other drawbacks of this study were small sample size, lack of randomization, as well as selection bias that can occur among patients who chose to participate in a follow-up study.

Koutsourelakis et al (2008) stated that although nasal surgery has limited effectiveness in OSA treatment, some patients experience improvement. These researchers tested the hypothesis that post-surgery improvement is associated with increased nasal breathing epochs. A total of 49 OSA patients (mean AHI 30.1 +/- 16.3 events x h(-1)) with symptomatic fixed nasal obstruction due to deviated septum were randomly assigned to either septoplasty (surgery group; n = 27) or sham surgery (placebo group; n = 22). The breathing route was examined during over-night polysomnography. All patients in the placebo group were non-responders, whereas in the surgery group 4 (14.8 %) patients were responders and exhibited considerable increase in nasal breathing epochs (epochs containing more than 3 consecutive phasic nasal signals), and 23 patients were non-responders, presenting a modest increase in nasal breathing epochs. The change in AHI was inversely related to the change in nasal breathing epochs, with responders exhibiting among the greatest increases in nasal breathing epochs. Baseline nasal breathing epochs were positively related to percent change in AHI. Responders had among the lowest baseline nasal breathing epochs; a cut-off value of 62.4 % of total sleep epochs best separated (100 % sensitivity, 82.6 % specificity) responders/non-responders. The authors concluded that nasal surgery rarely treats OSA effectively; but baseline nasal breathing epochs can predict the surgery outcome.

Heiser and associates (2017) obtained additional safety and effectiveness data on the use of selective UAS during daily clinical routine. This was a multi-center, prospective, single-arm study under a common implant; and follow-up protocol took place in 3 German centers. Every patient who received an implant of selective upper airway stimulation was included in this trial (AHI greater than or equal to 15/hour and less than or equal to 65/hour and BMI less than 35 kg/m2). Before and 6 months after surgery, a 2-night home sleep test was performed. Data regarding the safety and effectiveness were collected. From July 2014 through October 2015, a total of 60 patients were included. Every subject reported improvement in sleep and daytime symptoms. The average usage time of the system was 42.9 11.9 hours/week. The median AHI was significantly reduced at 6 months from 28.6/hour to 8.3/hour. No patient required surgical revision of the implanted system. The authors concluded that selective UAS is a safe and effective therapy for patients with OSA and represents an option for its surgical treatment.

Camacho and associates (2017) performed a systematic review with meta-analysis for sleep study outcomes in children who have undergone RME as treatment for OSA. Three authors independently reviewed the international literature through February 21, 2016. A total of 17 studies reported outcomes for 314 children (7.6 2.0 years old) with high-arched and/or narrow hard palates (transverse maxillary deficiency) and OSA. Data were analyzed based on follow-up duration: less than or equal to 3 years (314 patients) and greater than 3 years (52 patients). For less than or equal to 3-year follow-up, the pre- and post-RME AHI decreased from a mean standard deviation (M SD) of 8.9 7.0/hr to 2.7 3.3/hr (70 % reduction). The cure rate (AHI less than 1/hr) for 90 patients for whom it could be calculated was 25.6 %. Random effects modeling for AHI standardized mean difference (SMD) is -1.54 (large effect). Lowest oxygen saturation (LSAT) improved from 87.0 9.1 % to 96.0 2.7 %. Random effects modeling for LSAT SMD is 1.74 (large effect). AHI improved more in children with previous adenotonsillectomy or small tonsils (73 to 95 % reduction) than in children with large tonsils (61 % reduction). For greater than 3-year follow-up (range of 6.5 to 12 years), the AHI was reduced from an M SD of 7.1 5.7/hr to 1.5 1.8/hr (79 % reduction). The authors concluded that improvement in AHI and lowest oxygen saturation had consistently been seen in children undergoing RME, especially in the short term (less than 3-year follow-up). Moreover, they stated that randomized trials and more studies reporting long-term data (greater than or equal to 3-year follow-up) would help determine the effect of growth and spontaneous resolution of OSA.


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