OBJECTIVE: This review aims to impart information regarding recognition of obstructive sleep apnea (OSA) and associated excessive sleepiness (ES) in the primary care setting in order to provide optimal care to patients with this common but serious condition. This review will also discuss the prevalence and treatment of depression in patients with OSA. DATA SOURCES: A MEDLINE search of articles published between 1990 and 2008 was conducted using the search terms obstructive sleep apnea AND excessive sleepiness, obstructive sleep apnea AND depression, and obstructive sleep apnea AND primary care. Searches were limited to articles in English concerned with adult patients. STUDY SELECTION: In total, 239 articles were identified. Articles concerning other sleep disorders and forms of apnea were excluded. The reference lists of identified articles were searched manually to find additional articles of interest. DATA SYNTHESIS: Primary care physicians can aid in the diagnosis of OSA and associated ES by being vigilant for lifestyle and physical risk factors associated with this condition. In addition, primary care physicians should maintain a high level of clinical suspicion when presented with illnesses that are commonly comorbid with OSA, such as psychiatric disorders and depression, in particular. Conversely, assessment of patients with OSA for common comorbidities may also improve a patient's prognosis and quality of life. CONCLUSIONS: Primary care physicians play a vital role in recognizing OSA and ES. These clinicians are crucial in supporting their patients during treatment by ensuring that they have clear, concise information regarding available therapies and the correct application and maintenance of prescribed devices.

OBJECTIVE: To evaluate the efficacy and safety of eszopiclone 3 mg, a nonbenzodiazepine medication/hypnotic indicated for the treatment of insomnia with comorbid rheumatoid arthritis (RA). METHOD: This multicenter, double-blind, placebo-controlled pilot study was conducted in 153 patients aged 25-64 years with American College of Rheumatology-defined RA who met DSM-IV criteria for insomnia. The data were collected from February to November of 2004. Patients were randomly assigned to either eszopiclone or placebo nightly for 4 weeks, followed by a 2-week placebo run out. Efficacy was evaluated using patient reports of sleep (wake time after sleep onset [WASO], sleep latency [SL], and total sleep time [TST]), daytime function, pain, and RA assessments. Insomnia severity was evaluated using the Insomnia Severity Index. Safety was also evaluated. RESULTS: Eszopiclone significantly improved all patient-reported sleep measures (WASO, SL, and TST), sleep quality, depth of sleep, and daytime function (P <.05 vs placebo). At week 4, 48% of eszopiclone-treated patients had no clinically meaningful insomnia as assessed by ISI score (versus 30% of placebo-treated patients, P =.03). Eszopiclone was significantly better than placebo on some RA-associated pain measures:(1) overall (P =.05), pain (P =.006), and pain and other symptoms (P =.02) scores of the Arthritis Self-Efficacy Scale,(2) tender joint counts (P =.03) and pain severity scores (P =.023),(3) the activities domain of the Health Assessment Questionnaire-Disability Index (P =.04), and (4) the role physical (P =.03) and bodily pain (P =.01) scales of the 36-item Medical Outcomes Study Short-Form General Health Survey. The most commonly reported adverse events with eszopiclone were unpleasant taste and transient increases in RA symptoms. CONCLUSIONS: In this pilot study of patients with insomnia comorbid with RA, eszopiclone 3 mg improved all assessed sleep and daytime function measures over the treatment period, as well as some measures of RA-associated pain, disability, and quality of life. TRIAL REGISTRATION: clinicaltrials.gov Identifier: NCT00367965.

OBJECTIVE: Nocturnal awakenings are one of the most prevalent sleep disturbances in the general population. Little is known, however, about the frequency of these episodes and how difficulty resuming sleep once awakened affects subjective sleep quality and quantity. METHOD: This is a cross-sectional telephone study with a representative sample consisting of 8937 non-institutionalized individuals aged 18 or over living in Texas, New York and California. The interviews included questions on sleeping habits, health, sleep and mental disorders. Nocturnal awakenings were evaluated according to their frequency per week and per night, as well as their duration. RESULTS: A total of 35.5% of the sample reported awakening at least three nights per week. Of this 35.5%, 43%(15.2% of the total sample) reported difficulty resuming sleep once awakened. More than 80% of subjects with insomnia symptoms (difficulty initiating or maintaining sleep or non-restorative sleep) also had nocturnal awakenings. Difficulty resuming sleep was associated with subjective shorter sleep duration, poorer sleep quality, greater daytime impairment, greater consultations for sleep disturbances and greater likelihood of receiving a sleep medication. CONCLUSIONS: Nocturnal awakenings disrupt the sleep of about one-third of the general population. Using difficulty resuming sleep identifies individuals with significant daytime impairment who are most likely to seek medical help for their sleep disturbances. In the absence of other insomnia symptoms, nocturnal awakenings alone are unlikely to be associated with daytime impairments.

Pulsed-laser-induced quenching of ferromagnetic order has intrigued researchers since pioneering works in the 1990s. It was reported that demagnetization in gadolinium proceeds within 100 ps, but three orders of magnitude faster in ferromagnetic transition metals such as nickel. Here we show that a model based on electron-phonon-mediated spin-flip scattering explains both timescales on equal footing. Our interpretation is supported by ab initio estimates of the spin-flip scattering probability, and experimental fluence dependencies are shown to agree perfectly with predictions. A phase diagram is constructed in which two classes of laser-induced magnetization dynamics can be distinguished, where the ratio of the Curie temperature to the atomic magnetic moment turns out to have a crucial role. We conclude that the ultrafast magnetization dynamics can be well described disregarding highly excited electronic states, merely considering the thermalized electron system.

The egg-larval parasitoid Chelonus inanitus injects bracoviruses (BVs) and venom along with the egg into the host egg; both components are essential for successful parasitoid development. All stages of eggs of its natural host, Spodoptera littoralis, can be successfully parasitized, i.e. from mainly a yolk sphere to a fully developed embryo. Here, we show that the venom contains at least 25 proteins with masses from 14kDa to over 300kDa ranging from acidic to basic. The majority is glycosylated and their persistence in the host is short when old eggs are parasitized and much longer when young eggs are parasitized. Physiological experiments indicated three different functions. 1. Venom synergized the effect of BVs in disrupting host development when injected into third instar larvae. 2. Venom had a transient paralytic effect when injected into sixth instar larvae. 3. In vitro experiments with haemocytes of fourth instar larvae suggested that venom alters cell membrane permeability. We propose that venom promotes entry of BVs into host cells and facilitates placement of the egg in the embryo's haemocoel when old eggs are parasitized. The multifunctionality of the venom might thus be essential in enabling parasitization of all stages of host eggs.

BACKGROUND: Excessive sleepiness often goes unrecognized in the primary care setting despite its high prevalence and deleterious effects on both individual and public safety. Patients with neurologic and psychiatric illnesses, as well as those with acute and chronic medical conditions, plus those with sleep disorders, often have symptoms of excessive sleepiness, tiredness, and fatigue. Recognition and prompt treatment of these symptoms are important, even though their etiology may not be immediately understood. This review focuses on the underlying causes, consequences, identification, and treatment of excessive sleepiness. DATA SOURCES: A search of the literature to 2007 was performed using the PubMed search engine. English-language articles were identified using the following search terms: excessive sleepiness, fatigue, circadian rhythm, obstructive sleep apnea, shift work disorder, narcolepsy, drowsy driving, and wakefulness. Additional references were identified through bibliography reviews of relevant articles. DATA SYNTHESIS: Current assessments of the prevalence, consequences, and etiologies of excessive sleepiness, with leading treatment strategies, were extracted, reviewed, and summarized to meet the objectives of this article. CONCLUSIONS: Excessive sleepiness is associated with a wide range of medical, neurologic, and psychiatric disorders frequently seen in primary care practice. Excessive sleepiness is a serious, debilitating, potentially life-threatening condition, yet also treatable, and it is important to initiate appropriate intervention as early as possible. Physicians should place increasing emphasis on the substantial benefits that accompany improvements in wakefulness.

PURPOSE: Sleep disruption is prevalent in patients with cancer and survivors, but the prevalence of insomnia, a distressing sleep disorder, in these populations has yet to be determined in large-scale studies. PATIENTS AND METHODS: A total of 823 patients with cancer receiving chemotherapy (mean age, 58 years; 597 female patients) reported on sleep difficulties in a prospective study. RESULTS: During day 7 of cycle 1 of chemotherapy, 36.6%(n = 301) of the patients with cancer reported insomnia symptoms, and 43%(n = 362) met the diagnostic criteria for insomnia syndrome. Patients with cancer younger than 58 years were significantly more likely to experience either symptoms of insomnia or insomnia syndrome (chi(2)= 13.6; P =.0002). Patients with breast cancer had the highest number of overall insomnia complaints. A significant positive association was found between symptoms of insomnia during cycles 1 and 2 of chemotherapy (phi =.62, P <.0001), showing persistence of insomnia during the first two cycles of chemotherapy. Sixty percent of the patient sample reported that their insomnia symptoms remained unchanged from cycle 1 to cycle 2. Those with insomnia complaints had significantly more depression and fatigue than good sleepers (all P <.0001). CONCLUSION: The proportions of patients with cancer in this sample reporting symptoms of insomnia and meeting diagnostic criteria for insomnia syndrome during chemotherapy are approximately three times higher than the proportions reported in the general population. Insomnia complaints persist throughout the second chemotherapy cycle for the majority of patients with cancer in this study. Insomnia is prevalent, underrecognized, undermanaged, and understudied among patients with cancer receiving chemotherapy.

OBJECTIVE: To assess the effect of armodafinil, 150 mg, on the physiologic propensity for sleep and cognitive performance during usual night shift hours in patients with excessive sleepiness associated with chronic (>/=3 months) shift work disorder (SWD) of moderate or greater severity. PATIENTS AND METHODS: This 12-week, randomized controlled study was conducted at 42 sleep research facilities in North America from April 2 through December 23, 2004, and enrolled 254 permanent or rotating night shift workers with SWD. Entry criteria included excessive sleepiness during usual night shifts for 3 months or longer (corroborated by mean sleep latency of </=6 minutes on a Multiple Sleep Latency Test), insomnia (sleep efficiency </=87.5% during daytime sleep), and SWD that was judged clinically to be of moderate or greater severity. Patients received armodafinil, 150 mg, or placebo 30 to 60 minutes before each night shift. Physiologic sleep propensity during night shift hours, clinical impression of severity, patient-reported sleepiness, and cognitive function were assessed during laboratory night shifts at weeks 4, 8, and 12. RESULTS: Armodafinil significantly improved mean (SD) sleep latency from 2.3 (1.6) minutes at baseline to 5.3 (5.0) minutes at final visit, compared with a change from 2.4 (1.6) minutes to 2.8 (2.9) minutes in the placebo group (P<.001). Clinical condition ratings improved in more patients receiving armodafinil (79%) vs placebo (59%)(P=.001). As reported by patients' diaries, armodafinil significantly reduced sleepiness during laboratory nights (P<.001), night shifts at work (P<.001), and the commute home (P=.003). Armodafinil improved performance on standardized memory (P<.001) and attention (power, P=.001; continuity, P<.001) tests compared with placebo. Armodafinil was well tolerated and did not affect daytime sleep, as measured by polysomnography. CONCLUSION: In patients with excessive sleepiness associated with chronic SWD of moderate or greater severity, armodafinil significantly improved wakefulness during scheduled night work, raising mean nighttime sleep latency above the level considered to indicate severe sleepiness during the daytime. Armodafinil also significantly improved measures of overall clinical condition, long-term memory, and attention. Trial Registration: clinicaltrials.gov Identifier: NCT00080288.

We demonstrate the generation of powerful, bandwidth-limited pulses in a KTP optical parametric oscillator synchronously excited by the pulse train of a f lash-lamp-pumped, mode-locked Nd:YLF laser. Operating the optical parametric oscillator a factor of 4 above threshold and optimizing the cavity length yields pulses of 260 +/- 30 fs. The shortening by a factor of 15 relative to the pump is accompanied by extended pulse wings. Tunability of the device is shown in the wavelength range 1.2 -1.6 microm.