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To evaluate the impact of sleep disorders on non-motor symptoms in patients with Parkinson disease (PD).
This was a cross-sectional study. Patients with PD were evaluated for obstructive sleep apnea (OSA), restless legs syndrome (RLS), periodic limb movement syndrome (PLMS), and REM sleep behavior disorder (RBD). Cognition was assessed with the Montreal Cognitive Assessment and patients completed self-reported questionnaires assessing non-motor symptoms including depressive symptoms, fatigue, sleep complaints, daytime sleepiness, and quality of life.
Sleep laboratory.
86 patients with PD (mean age = 67.4 ± 8.8 years; range: 47-89; 29 women).
Having sleep disorders was a predictor of overall non-motor symptoms in PD (R2 = 0.33, p < 0.001) while controlling for age, PD severity, and dopaminergic therapy. These analyses revealed that RBD (p = 0.006) and RLS (p = 0.014) were significant predictors of increased non-motor symptoms, but OSA was not. More specifically, having a sleep disorder significantly predicted sleep complaints (ΔR2 = 0.13, p = 0.006), depressive symptoms (ΔR2 = 0.01, p = 0.03), fatigue (ΔR2 = 0.12, p = 0.007), poor quality of life (ΔR2 = 0.13, p = 0.002), and cognitive decline (ΔR2 = 0.09, p = 0.036). Additionally, increasing number of sleep disorders (0, 1, or ≥ 2 sleep disorders) was a significant contributor to non-motor symptom impairment (R2 = 0.28, p < 0.001).
In this study of PD patients, presence of comorbid sleep disorders predicted more non-motor symptoms including increased sleep complaints, more depressive symptoms, lower quality of life, poorer cognition, and more fatigue. RBD and RLS were factors of overall increased non-motor symptoms, but OSA was not.
Neikrug AB; Maglione JE; Liu L; Natarajan L; Avanzino JA; Corey-Bloom J; Palmer BW; Loredo JS; Ancoli-Israel S. Effects of sleep disorders on the non-motor symptoms of Parkinson disease. J Clin Sleep Med 2013;9(11):1119-1129.
Parkinson disease (PD) is a progressive neurodegenerative disorder primarily characterized by motor symptoms and increasing motor-related disability, including bradykinesia, rigidity, and tremor.1 Non-motor symptoms (NMS) such as sleep dysfunction, sleepiness, fatigue, pain, and depressive symptoms, are common in PD. In a large multicenter study, NMS were reported by 99% of 1072 PD patients.2 The presentation of NMS in PD is highly variable, and the understanding of such heterogeneity in PD is limited and incomplete.3,4 Chaudhuri et al.4 suggested that NMS dominate the clinical picture in patients with PD and contribute to the severe disability these patients experience, impair quality of life, and even shorten life expectancy. Studies have suggested that NMS, more than motor symptoms, may impact caregiver distress, quality of life, institutionalization rates, and overall costs related to PD.4–6 A 15-year follow-up study of patients with PD reported that the NMS that did not respond to dopamine therapy (e.g., dementia, sleep disruption) were "more disabling than end-of-dose failure or dyskinesia" and were the major cause of morbidity and mortality.7
Current Knowledge/Study Rationale: Parkinson disease (PD) is a progressive neurodegenerative disorder primarily characterized not only by motor symptoms but also by non-motor symptoms (NMS) such as sleep dysfunction, sleepiness, fatigue, pain, and depressive symptoms. This study evaluated the impact of sleep disorders on non-motor symptoms in patients with PD.
Study Impact: These findings indicate a significant relationship between sleep disorders and increased NMS impairment in patients with PD. More specifically, having sleep disorders predicted increased sleep complaints, lower quality of life, increased depressive symptoms, poorer cognition, and more fatigue. The finding of increased NMS in RBD adds further support to a growing body of literature that suggests that RBD is related to increased frequency and severity of non-motor impairment and subsequent poorer quality of life.
Sixty to 98% of patients with PD complain of sleep-related difficulties.4,8,9 In a community-based study of sleep disorders in PD, 32% complained of difficulty falling asleep, 39% reported frequent awakenings during the night, and 23% reported early morning awakenings.10 A longitudinal study of nocturnal sleeping problems in PD reported that 83% of the patients with PD reported sleep complaints at one or more visits during the 8-year study, and such complaints were related to disease duration and depression.9 Another study reported that sleep complaints significantly predicted poor health-related quality of life in PD.11
Sleep disorders such as obstructive sleep apnea (OSA), restless legs syndrome (RLS), periodic limb movements syndrome (PLMS), and REM sleep behavior disorder (RBD) are commonly reported in patients with PD in rates similar or higher than in the general older adult population.12–25 Sleep disorders result in complaints about disturbed sleep, excessive daytime sleepiness, cognitive decline, and depression, all of which are also recognized as NMS of PD.26–29 Additionally, sleep disorders have been shown to substantially impact health-related quality of life in patients with PD.30
Few studies have assessed possible relationships between any given sleep disorder and different NMS in PD population. Those studies that did question this relationship primarily assessed RBD, which has been demonstrated to be associated with hallucinations,31–33 cognitive impairment,34,35 psychiatric comorbidity,36 increased falls,36,37 poor emotional functioning, and lower quality of life.38 Studies looking at OSA in PD had conflicting results, with only one study reporting that OSA was the most important risk factor associated with EDS in PD,21 while another study reported no relationship with NMS (e.g., sleepiness, depression, and cognitive impairment).16 Finally, previous findings from our laboratory suggested a relationship between increased periodic leg movements during the night (not associated with arousals), sleep complaints, and poorer quality of life.39 However, to our knowledge, there have been no studies that simultaneously assessed multiple sleep disorders in patients with PD and the effect of having these sleep disorders on overall NMS impairment. We hypothesized that sleep disorders would be significant contributors to the overall NMS experienced and reported by patients with PD and that PD patients with more sleep disorders would experience more NMS impairment.
Participants were recruited for this study at talks given at PD support group meetings, by flyers, advertisements, or were referred by neurologists at either the University of California, San Diego (UCSD) or in the San Diego County community. A consort table is provided (Figure 1). Of the 183 patients with PD that were contacted, 106 patients met inclusion/exclusion criteria (Table 1), agreed to participate, and consented for this study. The study was approved by UCSD Human Research Protection Program and San Diego Veterans Administration Healthcare System.
CPAP, continuous positive airway pressure; DBS, deep brain stimulation; PSG, polysomnography; REM, rapid eye movement.
Consort table. CPAP, continuous positive airway pressure; DBS, deep brain stimulation; PSG, polysomnography; REM, rapid eye movement.
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Inclusion/exclusion criteria
All participants were screened by telephone. For those meeting inclusion criteria, a meeting was scheduled and the study was described in detail and signed informed consent was obtained. All enrolled participants were tested for cognitive performance by a research associate, were evaluated by a neurologist, and were assessed by a physician trained in sleep medicine for a detailed sleep history, assessment of possible sleep disorders, overall medical condition, and medication use. Additionally, all participants completed the self-administered questionnaire packet that included questionnaires assessing daytime sleepiness, sleep complaints, mood, quality of life, multiple symptoms of PD, and fatigue. All patients were admitted to the General Clinical Research Center (now Clinical and Translational Research Institute) Gillin Laboratory for Sleep and Chronobiology for an overnight video-enabled polysomnography (PSG).
Participants were evaluated for PD by a neurologist using the Unified Parkinson's Disease Rating Scale (UPDRS)40 to characterize the progression of PD. Additionally the Hoehn and Yahr Scale (H&Y)41 was utilized to assess PD severity. The H&Y grades patients from stage 0 (no signs of disease) to stage 5 (wheelchair bound or bedridden unless assisted).
All participants were evaluated by a physician trained in sleep medicine for RBD, RLS, medication use, and overall health. RBD was evaluated using the REM Behavior Disorder Sleep Questionnaire (RBDSQ).42 The RBDSQ was used to assess clinical history of dream enactment behavior. This screening tool for RBD is based on the clinical criteria of the International Classification of Sleep Disorders, second edition (ICSD-II).43 The RBDSQ was previously validated with a cutoff score of 5, exhibiting 96% sensitivity and 56% specificity.42 RLS was evaluated using a structured questionnaire according to the 4 criteria delineated in the International Restless Legs Syndrome Study Group criteria.44 All 4 criteria had to be satisfied for diagnosis of RLS.
Medication use (i.e., type, dose, frequency, time of administration, reason for use, and duration of use) was assessed for all patients. As dopaminergic therapy regimen highly differs between patients with PD, and in order to allow comparisons among patients on different dopaminergic regimens, drug dosages were converted to levodopa dosage equivalents (LDE) according to the formula provided by Tomlinson et al.45
The Montreal Cognitive Assessment (MoCA)46 was used to assess cognition. The MoCA is a brief screening tool designed to identify mild cognitive impairment. The MoCA was administered by trained study staff during consent. The MoCA has been demonstrated to have good reliability and validity in PD47 and is more sensitive in detecting mild cognitive impairment than the Mini Mental State Exam.48 A cutoff of 26 is suggestive of mild cognitive impairment.
The Non-motor Symptoms Questionnaire (NMSQuest)49 is a 30-item questionnaire that was completed by patients. The NMSQuest allows a brief yet comprehensive assessment of the non-motor features of PD, including neuropsychiatric, sleep, autonomic, gastrointestinal, sensory, and other disturbances. Number of symptoms endorsed is added up for a total score. This scale was shown to have good psychometric properties and to be valid as an instrument for detecting NMS in PD.50
Beck Depression Inventory-2nd edition (BDI-II)51 was used to evaluate symptoms of depression and was completed by the patients. The BDI-II is well validated and is the most frequently used scale for depression.52–54 Visser et al. evaluated the reliability and validity of the BDI-II in PD.55 A study that validated sub-threshold depression in PD concluded that a BDI-II score of 9-15 best differentiates sub-threshold depression in this population.55 The use of the BDI-II in PD was championed by expert panels for monitoring severity of symptoms and for evaluation of therapeutic interventions.56
Parkinson's Disease Questionnaire (PDQ-39)57 was designed and validated specifically for evaluating quality of life in PD. The PDQ-39 has 39 items on mobility, emotional well-being, stigma, social support, cognitions, communication, and bodily discomfort. A higher score on this scale indicates poorer quality of life. In a review of different quality of life scales for patients with PD, Marinus et al. concluded that the PDQ-39 is the single most appropriate quality of life instrument for this population.59
The Epworth Sleepiness Scale (ESS)58 is a self-administered questionnaire assessing daytime sleepiness. The ESS has been shown to reliably distinguish good sleepers from those with excessive daytime sleepiness disorders including obstructive sleep apnea, narcolepsy, and idiopathic hypersomnolence. A cutoff score ≥ 10 suggests clinically significant daytime sleepiness.
The Short Form of the Multidimensional Fatigue Symptom Inventory (MFSI-SF)59 is a short questionnaire (30 questions) that provides a total fatigue score and 5 subscales: General, Physical, Emotional, Mental, and Vigor. A total score is computed based on subscales with higher scores indicating worse fatigue. Assessment of the MFSI-SF showed sound psychometric properties and a stable multidimensional factorial structure.
The Parkinson's Disease Sleep Scale (PDSS)60,61 is a self-administered questionnaire that is designed to assess sleep complaints and nocturnal difficulties that are more pertinent in PD. Items address overall quality of sleep, sleep onset and sleep maintenance insomnia, nocturnal restlessness, nocturnal psychosis, nocturia, nocturnal motor symptoms, sleep refreshment, and daytime dozing. Scores for each of 15 items range from 0 (symptom severe and always present) to 10 (symptom free). The mean of the scales is computed, with lower scores suggesting more severe sleep disruption.
The first 4 patients were evaluated with the Embla (Planegg, Germany) while the remaining participants were evaluated with the video-enabled Compumedics Somté (Charlotte, NC). Electroencephalography (F4, C4, O1 or O2), electrooculography (left and right outer canthus), submental electromyography, respiratory effort (thoracic and abdominal piezoelectric bands), airflow (nasal pressure transducer), electrocardiogram, oximetry, and tibialis electromyography were recorded. In addition, technicians noted any visible arousals (e.g., restroom visits, taking medication), any environmental changes (e.g., noise), any vocalization during sleep (e.g., yelling/talking), and any movements (e.g., kicking/arms flailing), both on the PSG recording and in a journal.
All PSG records were staged according to accepted American Academy of Sleep Medicine criteria.62 Apnea-hypopnea index (AHI; the number of apneas + hypopneas/h of sleep), periodic leg movement index (PLMI; the number of leg kicks in a 5- to 90-sec period of ≥ 4 consecutive leg movements/h of sleep), and periodic leg movement arousal index (PLMArI; periodic leg movements associated with arousals/h of sleep) were computed.
To assess for RBD, submental electromyography was assessed for REM sleep without atonia using criteria nearly identical to the scoring method developed by Lapierre and Montplaisir63 and validated by Consens et al.,64 including computation of tonic and phasic components as defined by the American Academy of Sleep Medicine guidelines.62 An electro-myography score (EMG score) was calculated as the average of the percent of tonic REM sleep epochs and the percent of phasic REM sleep mini-epochs. The EMG score is similar to the RBD measure previously proposed by Consens et al.,64 which established a cutoff score of 10% with a sensitivity of 89% and specificity of 57%.
OSA definition was based on an AHI (yes-OSA [AHI ≥ 10] and no-OSA [AHI < 10]), PLMS definition was based on the PLMArI (yes-PLMS [PLMArI ≥ 5] and no-PLMS [PLMArI < 5]), and RLS diagnosis was based on the RLS criteria (yes-RLS [endorsed all 4 RLS questions] and no-RLS [endorsed < 4 RLS questions]).
Finally, RBD diagnosis was based on the ICSD-II,43 which requires subjective clinical history with objective documentation of either REM sleep without atonia or dream enactment behavior during an overnight PSG. Patients were classified into 3 RBD groups based on subjective (RBDSQ) and objective (EMG-score and/or clear evidence of REM sleep without atonia as recorded during overnight PSG) measures; Group 1, Yes-RBD group (RBDSQ ≥ 5 and EMG score ≥ 10% or clear evidence of REM sleep without atonia as recorded during overnight PSG); Group 2, No-RBD group (RBDSQ < 5 and EMG score < 10); and Group 3, Probable-RBD group (either RBDSQ ≥ 5 or EMG-score ≥ 10%).
Summary statistics (means, SDs, ranges, frequencies) were computed for all variables of interest. Of the 7 outcome measures, only the BDI-II and MoCA violated normality assumption and thus were appropriately transformed for subsequent analyses. Analyses were computed both with the transformed and untransformed data. Pearson correlations were used to assess the relationship between NMS measures.
Given that 7 NMS variables were under consideration (i.e., MoCA, NMSQuest, BDI-II, MFSI-SF, PDQ-39, PDSS, and ESS), and in order to avoid multiple comparisons, principal component analysis (PCA) was used to derive component/ factor scores that best described the NMS of PD by distinguishing sets of variables with stronger relationships among multiple observed variables (e.g., mood, sleepiness, functional impairment, and quality of life).65
A hierarchical linear regression correlation was used to assess the relationship between the NMS score (i.e., first principal component of each principal component analysis) and the presence of sleep disorders while controlling for age, PD severity, and dopaminergic therapy (LDE). Using regression analysis allowed the assessment of the unique effects of each explanatory variable (unique sleep disorders) while statistically controlling (partialing) the effects of the other explanatory variables in a single model, thus minimizing the likelihood of a type I error.66 Age, PD severity (H&Y), and dopaminergic therapy (LDE) were included in block 1 and the sleep disorders were included in block 2 to assess if the inclusion of sleep disorders into the model resulted in significant increases of variance explained in the NMS score (ΔR2 and ΔF statistic). Additionally, a separate model assessed the impact of having 0, 1, or ≥ 2 sleep disorders on NMS score while controlling for age, disease severity, and dopaminergic therapy (LDE). All analyses were executed using SPSS (version 17.0, SPSS, Chicago, IL).
A total of 86 patients with PD (mean age = 67.4 ± 8.8 years; range: 47-89, 29f) were included in this study (Figure 1). The majority of the sample was Caucasian (91%), married (73%), and retired (66.3%). The patients had been diagnosed with PD for an average of 6.3 years. The majority of the patients were at H&Y stage I or II (79%), and no patients had stage IV or V. The specific dopaminergic therapy (i.e., levodopa, carbidopa, dopamine agonist) widely differed between patients, and only 6 participants were not receiving any dopaminergic therapy. Additionally, 28% of the patients reported taking an antidepressant.
Of the total sample, 55% (n = 47) were diagnosed with OSA, 42% (n = 36) with RBD, and 22% (n = 19) with RLS. PLMI for the sample was considerably high (PLMI = 21.0) however, these events were rarely associated with arousals and only 2 patients (2%) were diagnosed with PLMS (had a PLMArI ≥ 5). Due to this small number, PLMS was omitted from further analyses. Finally, 10 (11.6%) of the patients had no sleep disorders, 52 (60.5%) had only 1 sleep disorder, and 24 (27.9%) patients had ≥ 2 sleep disorders.
Complete clinical and sleep characteristics for the entire sample and by sleep disorder is provided in Table 2. Descriptive measures are provided in Table 3 and correlations between the measures in Table 4.
Clinical and sleep characteristics by sleep disorder
Mean (SD) of NMS questionnaires by sleep disorder (p-values from the regression models)
Correlational matrix
Principal component analysis on the 7 NMS outcome measures resulted in a single component extracted (NMS score) that explained 53.5% of the variance (Eigenvalue = 3.75). Each of the remaining components had an Eigenvalue < 1.0 and explained ≤ 14% of the variability in the set of NMS variables. Examining the extracted weights for each variable revealed that most of the variable loaded heavily (> |0.8|) on this component with only subjective sleepiness (ESS = 0.48) and cognition (MoCA = -0.27) not heavily loading on this component.
A hierarchical regression model with the NMS score as the dependent variable and LDE, age, and PD severity as independent variables was significant (R2 = 0.20, F = 6.93, p < 0.001). In this model only age (β = -0.24, p = 0.016) and LDE (β = 0.37, p = 0.004) were significant predictors of the NMS score, while PD severity was not (β = 0.16, p = 0.13). Including sleep disorders (i.e., OSA, RLS, RBD) into this model significantly improved the model (ΔR2 = 0.13, ΔF = 5.01, p = 0.003). The full model with the NMS score as the dependent variable and age, PD severity, LDE, OSA, RBD, and RLS, as independent variables was significant (R2 = 0.33, F = 5.97, p < 0.001) with age (β = -0.23, p = 0.014), LDE (β = 0.28, p = 0.004), RBD (β = 0.26, p = 0.006), and RLS (β = 0.24, p = 0.014) as significant predictors of the NMS score. PD severity (β = 0.15, p = 0.12) and OSA (β = 0.06, p = 0.52) were not significant predictors of the NMS score. In summary, sleep disorders (specifically, RBD and RLS) were significant contributors and predictors of NMS score above and beyond that which is explained by age, LDE, and PD severity. Sleep disorders alone accounted for 13% of the variance in the NMS score. Overall this model was significant and explained 33% of the variance in the NMS score.
Patients with RBD (t = 2.51, p = 0.014) and with RLS (t = -2.57, p = 0.012) had a significantly higher NMS score than those without RBD or RLS; there were no significant differences in patients with or without OSA.
Assessment of the impact of having multiple sleep disorders (0, 1, or ≥ 2 sleep disorders) on the NMS score and including this variable in the model while controlling for age, PD severity, and LDE, revealed that the model significantly improved (ΔR2 = 0.07, ΔF = 8.33, p = 0.005). The full model with the NMS score as the dependent variable and age, PD severity, dopaminergic therapy, and number of sleep disorders per patient as independent variables was significant (R2 = 0.28, F = 7.75, p < 0.001) with age (β = -0.25, p = 0.01), LDE (β = 0.3, p = 0.002), and number of sleep disorders (β = 0.27, p = 0.005) being significant predictors of the NMS score.
There were no differences in NMS score between those with no sleep disorders and those with only 1 sleep disorder. However, compared to those with ≥ 2 sleep disorders, those with no sleep disorders (t = 2.1, p = 0.04) and those with only one sleep disorder (t = 2.32, p = 0.023) had significantly lower NMS scores.
As summarized in Table 5, after controlling for age, PD severity, and dopaminergic therapy, sleep disorders were significant predictors of sleep complaints evaluation (i.e., PDSS) (ΔR2 = 0.13, ΔF = 4.54, p = 0.006), mood evaluation (ΔR2 = 0.01, ΔF = 3.17, p = 0.03), quality of life evaluation (ΔR2 = 0.13, ΔF = 5.63, p = 0.002), fatigue evaluation (ΔR2 = 0.12, ΔF = 4.29, p = 0.007), and cognition evaluation (ΔR2 = 0.09, ΔF = 3.0, p = 0.036).
NMS domain regression analyses modeling results (values are standardized Beta coefficients)
After controlling for age, PD severity, and LDE, only RBD (β = -0.3, p = 0.003) was a significant predator of the subjective sleep evaluation, while OSA (β = 0.08, p = 0.42) and RLS (β = -0.17, p = 0.078) were not. Sleep disorders alone accounted for 14% of the variance in this measure. Overall this model was significant (F = 4.85, p < 0.001) and explained 27% of the variance in the subjective sleep evaluation.
After controlling for age, PD severity, and LDE, only RBD (β = 0.28, p = 0.01) was a significant predator of mood symptoms, while OSA (β = 0.11, p = 0.31) and RLS (β = 0.1, p = 0.34) were not. Sleep disorders alone accounted for 10% of the variance in this measure. Overall this model was significant (F = 3.96, p = 0.002) and explained 25% of the variance in the mood evaluation.
After controlling for age, PD severity, and dopaminergic therapy, RLS (β = 0.26, p = 0.005), and RBD (β = 0.2, p = 0.028) were significant predator of the quality of life while OSA (β = 0.16, p = 0.079) was not. Sleep disorders alone accounted for 13% of the variance in this measure. Overall this model was significant (F = 9.02, p < 0.001) and explained 43% of the variance in the quality of life evaluation.
Of the sleep disorders, RBD (β = 0.26, p = 0.01) and RLS (β = 0.23, p = 0.023) were significant predators of fatigue, while OSA (β = 0.05, p = 0.61) was not. Sleep disorders alone accounted for 12% of the variance in this measure. Overall this model was significant (F = 4.88, p < 0.001) and explained 27% of the variance in the fatigue evaluation.
Only OSA (β = -0.28, p = 0.01) was a significant predator of cognition, while RBD (β = -0.11, p = 0.31) and RLS (β = -0.07, p = 0.51) were not. Sleep disorders alone accounted for 9% of the variance in this measure. Overall this model was significant (F = 4.06, p = 0.001) and explained 25% of the variance in the cognition evaluation.
When assessing the impact of having multiple sleep disorders (0, 1, or ≥ 2 sleep disorders) on the on the individual NMS domains while controlling for age, PD severity, and dopaminergic therapy revealed that number of sleep disorders significantly improved the models of multiple symptoms evaluation (ΔR2 = 0.06, ΔF = 6.01, p = 0.017), quality of life evaluation (ΔR2 = 0.07, ΔF = 7.95, p = 0.006), fatigue evaluation (ΔR2 = 0.05, ΔF = 4.92, p = 0.03), and mood evaluation (ΔR2 = 0.06, ΔF = 5.31, p = 0.024). In summary, increased number of sleep disorders significantly predicted more NMS symptoms, poorer quality of life, increased fatigue, and more severe mood symptoms (Figure 2).
After controlling for age, PD severity, and dopaminergic therapy (LDE), increased number of sleep disorders significantly predicted worse scores on the multiple symptoms evaluation (NMSQuest, p = 0.017), quality of life (PDQ-39, p = 0.006), fatigue (MFSI-SF, p = 0.03), and mood (BDI-II, p = 0.024). Post hoc analyses revealed significant differences between those with 0, 1, or ≥ 2 sleep disorders only on the multiple symptoms evaluation and quality of life evaluation.
Number of sleep disorders impact on NMS measures. After controlling for age, PD severity, and dopaminergic therapy (LDE), increased number of sleep disorders significantly predicted worse scores on the multiple symptoms evaluation (NMSQuest, p = 0.017), quality of life (PDQ-39, p = 0.006), fatigue (MFSI-SF, p = 0.03), and mood (BDI-II,...
This study assessed the relationship between sleep disorders and NMS in PD. Using dimension reduction techniques to derive a single factor score representing overall NMS for each individual, the analyses revealed that sleep disorders were independent and significant contributors to the non-motor impairment experienced in PD. Specifically, the data revealed that having a sleep disorder predicted more NMS impairment (i.e., higher scores on the NMS score) with a moderate effect size (R2 = 0.33) after controlling for age, PD severity, and dopaminergic therapy (LDE). This relationship between sleep disorders and overall NMS score held true when omitting the sleep related measures (i.e., ESS, MFSI-SF, and PDSS) from the derived factor, which indicated that sleep symptoms per se did not bias the finding that having sleep disorders increase overall NMS endorsement by patients with PD (data not shown). The multivariate results revealed that sleep disorders were significant predictors of increased sleep complaints, depressive symptoms, lower quality of life, increased fatigue, and poorer cognition.
Furthermore, these results revealed a relationship between the number of sleep disorders per patient and reports of NMS. More specifically, patients with at least two sleep disorders reported significantly more overall NMS than those having no sleep disorders or only one sleep disorder. Additionally, increased number of sleep disorders predicted higher scores on the individual measures of multiple symptoms, quality of life, fatigue, and mood.
Our results showed that RBD was associated with increased NMS in PD. Such findings align with previous research which has shown that patients with PD with RBD have unique clinical characteristics and experience increased NMS (e.g., more visual hallucinations, falls, more cognitive impairment).31–38,67,68 It is important to point out that many of these studies report conflicting findings which are likely due to the different methodology employed and different RBD definitions used.25 Diagnosis of RBD is challenging and includes subjective and objective assessments which are costly and time consuming.69 Additionally, in many of these studies NMS domains were assessed with a single question, and most studies assessed a single NMS domain post hoc. In this study, RBD was evaluated with both subjective and objective data according to the ICSD-II.43 Additionally, increased NMS was tested across multiple domains and this study utilized established measures to assess a given domain and did not utilize single questions for indication of a specific NMS. The results of this study showed that having RBD was associated with overall increased NMS, specifically increased symptoms of depression, fatigue, sleep complaints, and quality of life.
RLS has been shown to significantly affect health related quality of life in other populations, but little is known about how RLS affects quality of life or other NMS in PD.70 To our knowledge, this is the first study to show that RLS was a significant predictor of increased NMS in PD and that RLS was associated with increased fatigue and poorer quality of life.
Perhaps the most surprising result of our study was the lack of association between OSA and the NMS score, indicating that OSA was not a significant contributor to the overall NMS impairment in our sample. These findings align with a recent study that also did not find a relationship between OSA and NMS such as sleepiness, depression, and cognitive impairment, leading the authors to question the clinical relevance of OSA in PD.16 While OSA was not a significant predictor of overall NMS impairment in our sample, it was a significant predictor of cognitive impairment after controlling for age, disease severity, and dopaminergic therapy. Such findings are not surprising as associations between OSA and some cognitive impairment are well established in multiple studies including sleep disorders clinic patients, older adults, patients with Alzheimer disease, and nursing home patients.71–79 We also found that OSA treatment improves nighttime sleep in PD.80 OSA treatment is therefore clinically indicated, as it may also reduce NMS impairment and improve quality of life.
In our study, only two patients met criteria for PLMS. Periodic leg kicks are thought to be more frequent in diseases with impaired dopaminergic transmission, like PD81 and multi-system atrophy.18 A previous study in our laboratory concurred with these reports and showed high prevalence in periodic kicks during the night in PD and an association with lower quality of life.39 However, these studies assessed periodic leg kicks which were independent of arousals. In general, a diagnosis of PLMS is made when leg kicks result in arousals.
Sleep disruption in PD is likely due to a multitude of factors including the neurodegenerative process of the disease itself. PD is marked by dopamine dysfunction and degeneration of the dopaminergic neurons. Dopamine circuitry is also thought to be implicated in several major sleep disorders common in PD such as insomnia and RLS.82 There are reports suggesting that patients with PD exhibit dopamine dysfunction in the hypothalamus, a key area in the regulation of sleep-wake that may contribute to symptoms of insomnia, circadian rhythm disruption, and daytime sleepiness.83 In addition, brain stem deterioration is reported in PD and is also implicated in the REM sleep processes such as muscle atonia during REM.4 Other factors may also be responsible for disturbed sleep in PD, including the medications used to treat the PD, motor symptoms, pain, nocturia, and other sleep disorders common in this age group.84–87 Nonetheless, our results suggest that even when controlling for disease (dopaminergic treatment and PD severity) and age, sleep disorders had a negative impact on NMS in PD.
These findings that sleep disorders are unique predictors of increased NMS and subsequently poorer quality of life is important for considering disease management approaches. Additional studies are now required to determine whether the treatment of sleep disorders in PD may offer significant benefit in terms of overall NMS and quality of life. A recent pilot study that provided behavioral treatment for sleep in a small sample of patients with PD suggested that improving nighttime sleep in these patients improved quality of life both for the patients and their caregivers.88 While treating sleep disorders will likely not affect PD progression, it has the portential for improving NMS and may potentially reduce overall disability and thereby improve the lives of PD patients and their caregivers.
The major strengths of this study include the systematic and objective assessment of sleep disorders in this sample of patients with PD. The availability of overnight PSG data allowed for reliably diagnosing OSA, RBD, and PLMS in PD. Additionally, this study utilized multiple previously validated measures of NMS and the employed advanced statistics to assess different NMS in a cohesive manner and avoiding multiple comparisons.
Nonetheless, this study also had several limitations. Video recordings during PSG were available for less than half of the sample for diagnosing RBD. However, detailed clinical notes were maintained by the technician and these notes were available for all patients. Additionally, the scorer of EMG activity was not blind to technician's notes as notes were made on the PSG records. In our study, only one-night PSG recording was conducted and while this more closely resembles clinical findings, single-night recordings may miss RBD occurrences due to high night-to-night variability.89 However, while we may have underestimated RBD in our sample, our RBD occurrence rate was similar to other studies using similar methodology.36,90 In our sample, 28% were using antidepressants, which may result in increased muscle tone during REM sleep. However, EMG score was not significantly different between those taking vs. not taking antidepressants in the entire sample or in any of the RBD groups. Our study was also limited to a subjective assessment of self-reported symptoms (excluding cognition which was evaluated with a single objective measure) and future studies should include objective measures and/or clinical interviews to further support such findings. Also, due to inclusion/exclusion criteria, our sample may not be generalizable to the overall PD population or to patients with more severe PD. Although our models revealed that sleep disorders significantly predicted higher NMS scores and contributed to the variance explained above and beyond age, PD severity, and dopaminergic therapy, this study modeled associations among variables and thus no inferences of causality can be made. Future research will have to assess rather treating sleep disorders in this population will result in decreased non-motor symptomology to better understand this observed association.
In summary, this study showed that in patients with PD, the presence of comorbid sleep disorders predicts more NMS symptoms in general. More specifically, having sleep disorders predicted increased sleep complaints, lower quality of life, increased depressive symptoms, poorer cognition, and more fatigue. Of the sleep disorders assessed in this study, RBD and RLS were indicators of overall increased NMS but OSA was not. The findings of increased NMS in RBD adds further support to a growing body of literature that suggests that RBD is related to increased frequency and severity of non-motor impairment and subsequent poorer quality of life. This is the first study to systematically assess the effect of RLS on NMS in PD and further research is needed to corroborate these findings.
This was not an industry supported study. Dr Ancoli-Israel has consulted for or been on the scientific advisory board of Astra Zeneca, Ferring Pharmaceuticals Inc., GlaxoSmithKline, Hypnocore, Johnson & Johnson, Merck, NeuroVigil, Inc., Orphagen Pharmaceuticals, Pfizer, Philips, Purdue Pharma LP, and Sanofi-Aventis. The other authors have indicated no financial conflicts of interest. Support provided by NIA AG08415, NIH UL1RR031980, T32MH01394-18, Stein Institute for Research on Aging and Department of Veterans Affairs San Diego Center of Excellence for Stress and Mental Health (CESAMH).
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text:
MMT: A recipe for inflation, capital consumption, and higher time preference.
War and Foreign Policy
The cause of freedom has always been closely connected with the cause of peace.
Bureaucracy and RegulationCronyism and CorporatismTaxes and Spending
The verdict of sound economics is universal. Tariffs cripple economies, reduce the standard of living, and pit some groups against others.
Big GovernmentPolitical Theory
Money and BanksMoney and Banking
Media and CultureStrategy
The Fed
Money and Banks

subset: commoncrawl


text:
Fendi, an Italian successful brand, is famous for the high quality of its production. This company is also known for setting new rules governing elegance and practicality. The collection of accessories is carefully crafted and presents soft and light line of items. Pendants, earrings and necklaces are made of combinations of precious metals while some bracelets are finished with leather. In several models beads are interestingly used.
Each of the adornments expresses its own mood and spirit, it may be playful and bold, tender and soft, or you may feel the sense of the total freedom. Unique touch of the designers is taken throughout all the collection. All jewelry pieces look extremely elegant which is the main concept of Fendi.
For more detail and prices please visit Fendi site.


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The San Francisco Giants and Rockies replayed "Rocky II" on Wednesday afternoon at Coors Field, complete with all of the barely believable, made-for-movie momentum shifts.
In the end, it was the Giants who played Rocky Balboa, repeatedly getting up off the canvas to win the game 12-10 on Hector Sanchez's grand slam to straightaway center field off reliever Chad Bettis in the 11th inning.
Sanchez, who also hit a homer in the eighth, ended a 10-pitch battle against Bettis by driving a 3-2 pitch out of the park into the teeth of a cold wind.
"Once I got to 3-2, I was just trying to fill up the zone, honestly," said Bettis, who took the loss and saw his ERA jump to 7.15. "I had nowhere to put him. He just kept fouling them off until he got a pitch he could hit."
The Rockies threw one final roundhouse — a two-run homer by Justin Morneau off closer Sergio Romo in the bottom of the 11th — but it wasn't enough. Sanchez's knockout punch prevented the Rockies from sweeping San Francisco. The Rockies finished their homestand 4-2. They have Thursday off before beginning a three-game series at Los Angeles.
"I think we are a team with confidence and I feel like the energy in the dugout is always good, even when we get down," Colorado manager Walt Weiss said. "Even being down four in that last inning with Romo in the game, there was a lot of energy and we tried to put something together to try and win the game."
The Giants appeared to have won the game 8-7 in the eighth when Sanchez smashed a leadoff homer off reeling reliever Matt Belisle. Belisle's ERA has careened to 6.30, and he looks nothing like the dominant reliever of two seasons ago. But Belisle got off the hook in the bottom of the frame when the Rockies scratched out a run to tie the game 8-8. DJ LeMahieu led off with a single, moved to second on Charlie Culberson's sacrifice bunt and moved to third when reliever Santiago Casilla was called for a balk. Charlie Blackmon scored LeMahieu with a groundout to short.
All told, the Giants launched six homers, three of them off starter Tyler Chatwood.
Colorado's bullpen continues to be unpredictable, brilliant at times, but shaky at others, especially when the three B's — Belisle, Bettis and Rex Brothers — come to the hill in the late innings.
Brothers served up a two-run homer to Brandon Belt in the seventh. The no-doubter into the second deck in right field gave San Francisco a short-lived 7-6 lead. The Rockies tied it up in the bottom of the inning, on a walk by Blackmon, who scored on Nolan Arenado's double to right. The double extended Arenado's hitting streak to 14 games.
PHOTOS: Giants-Rockies game Wednesday, April 23
For Chatwood to be effective, he must command his sinker and keep the ball low in the strike zone. It appeared that he was unable to do that Wednesday.
The first hint of trouble came in the second inning when he gave up a mammoth leadoff homer to the Giants' powerful cleanup hitter Michael Morse. Confirmation came in the third when he gave up four more runs, including a leadoff homer to Brandon Hicks and another homer to Morse, this one a three-run shot.
Yet Chatwood insisted that an inability to pitch down in the zone was not a problem.
"I wouldn't say that at all," he said. "I made too many mistakes. Obviously the four walks, and then I hung a slider to Morse and then threw a fastball up that Morse hit out. But I thought I handled the lefties well with my two-seamer down."
Chatwood deserves some credit for toughing out six innings, and leaving with a 6-5 lead.
BOXSCORE: San Francisco 12, Colorado 10 (11)
Chatwood stared down impending disaster in the fifth and didn't blink. The Giants loaded the bases with no outs on a single by starting pitcher Matt Cain and walks by Gregor Blanco and Hunter Pence. But Chatwood struck out Belt on a 95 mph fastball and then was rescued by second baseman LeMahieu. On a screaming line drive by Morse, LeMahieu made a diving glove save that would make Patrick Roy proud.
The Rockies battered Cain early, scoring five runs in the first two frames, the big blow a two-run homer by Troy Tulowitzki in the first.
"We would have loved to have gotten this game, especially since we had Cain on the ropes early," Weiss said. "But he battles and competes and somehow he finds a way to stick around."
Patrick Saunders: firstname.lastname@example.com or twitter.com/psaundersdp
Looking ahead
Thursday: Off
Friday: Rockies' Jordan Lyles (3-0, 3.04 ERA) at Dodgers' Josh Beckett (0-0, 3.27), 8:10 p.m., ROOT
Saturday: Rockies' Juan Nicasio (2-0, 4.30) at Dodgers' Paul Maholm (0-1, 4.97), 7:10 p.m., ROOT
Sunday: Rockies' Jorge De La Rosa (1-3, 6.38) at Dodgers' Hyun-jin Ryu (3-1, 1.93), 2:10 p.m., ROOT
Monday: Rockies' Franklin Morales (2-1, 3.86) at Diamondbacks' Wade Miley (2-2, 4.00), 7:40 p.m., ROOT


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With Yurungai Barnardos Learning Centre.
The tale of a young kid trying to get from Perth to Sydney. We'll look at the classic tale the Odyssey, and then come up with our own local version, with natural disasters, spirits, bunyips, and dangerous mining conglomerates as the obstacles. Everyone writes another chapter in this huge adventure.
This is a closed community group workshop series.


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Studying a foreign language at the University of Kansas is your first step toward a richer life. The human experience is a vivid and complex one, and no one language can contain all the vocabulary, literature, music or art to capture it all. Learning a second language — or third or fourth! — enriches your understanding of the world and even of yourself. You'll open up to new ways of thinking, and new opportunities to define and express your unique experiences, feelings and thoughts.
Between our five core foreign language departments (Germanic, Slavic, East Asian, French, Francophone & Italian Studies, and Spanish & Portuguese) and 13 additional affiliated departments and resource centers, you'll have access to:
- Over 40 languages
- 60 different degrees and concentrations
- 140 study abroad programs
More and more business is conducted in languages other than English in today's global society. Having another language under your belt multiplies your job opportunities and makes you more attractive to employers.
KU's School of Languages, Literatures & Cultures is the first stop on your way around the world. Connect with us today, and we'll get you ready for your journey. #KUSLLC


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Here's my latest internet purchase from Scrapbook Takeout. I love the creativity of the owners, love how they work internationally with one another...they are a testament to true friendship.
I love anything and everything 7Gypsies...plan on using this stuff for my Annual All About me Album (Journaling the daily activities of April 2007).
I got this preserves kit for a friend's farewell album...been on the hunt for felt flowers that will compliment her jacket that's in almost every photograph.
(side note: How do I have time for all these projects? I don't I make time...these two projects are at the top of my to do list at the Sistah Scrapbook weekend retreat sponsored by Scraps of Color.)


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For a monthly turnover sheet, I am trying to work out a way to copy a work sheet in such a way that a date formula relates to the same cell in the previous work sheet.
The challange is to do this REGARDLESS of the name of the work sheet. I.e., using a 'PREVIOUS SHEET" argument.
Does anyone have any clue?
About me..:
Upper average. Can't do any programming (wrote a macros once, though)
Profession: Business executive.


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Screen Shots: Webcams for Every Budget
Freetalk Buddy Cam
Make Buddy the newest addition to your family. This webcam's arms and legs bend, so he can stand on your desk or sit on your computer monitor. And thanks to his USB plug-and-play feature, there's no installation necessary. $20
Freetalk Everyman HD
Amp it up to a new level—an HD level, that is. Plus, this webcam is incredibly lightweight, making it a cinch for those on the go. $60
faceVsion Technology TouchCam N1
This HD webcam has a 78-degree auto focus, wide-angle lens, and built-in dual microphones, so both the image and the sound are stunning. $119
Panasonic Viera Series HD TV plus TV-compatible webcam or Samsung 3D LED 8000 Series and TV-compatible webcam
Both these systems are a huge splurge, but they're pretty fantastic. Take video chatting from the home office to the living room, and then supersize it. Now your parents can tune in to their grandkids opening presents, even from across the country. Panasonic Viera Series HD TV ($1,500 to $2,600), TV-compatible webcam ($170), Samsung 3D LED 8000 Series ($2,108), TV-compatible webcam ($150)
Originally published in the November 2010 issue of Family Circle magazine.
This piece was accurate at publication time, but all prices, offerings and styles are subject to change.


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Stony Brook's miraculous season reached a new high point yesterday against six-time national champion LSU.
Facing elimination after dropping the opener of the best-of-three NCAA Super Regional series, 5-4 in 12 innings, the Seawolves moved to within one game of the College Baseball World Series as ace Tyler Johnson tossed a three-hit shutout in a 3-1 victory over the favored Tigers in Baton Rouge, La. It was the first loss for LSU in 10 NCAA Tournament games at new Alex Box Stadium.
Game 3 is set for today at 1 p.m. It will be televised live on ESPN2.
Johnson outdueled LSU ace Kevin Gausman, the fourth overall pick in last week's MLB First-Year Player Draft. Pounding the strike zone with a devastating sinker, Johnson gave up just one unearned run, struck out one and walked four over nine innings for his third postseason victory.
"When you're on the mound you focus on one thing, throwing strikes and getting people out," said Johnson, a 34th-round pick of the Athletics. "He's the No. 4 pick for a reason. I knew I had to be at my best."
LSU struck for an unearned run in the sixth and had the tying runs aboard, but Johnson got Jordy Snikeris to hit into an inning-ending double play. He retired eight in a row from that point on until Snikeris reached on an error in the ninth.
Johnson got just enough run support. Sal Intagliata and Willie Carmona had RBI singles in the third inning and Kevin Courtney had three hits and a solo home run in the sixth for Stony Brook (51-13), the nation's win leader. The Seawolves are one win away from becoming just the second fourth seed to reach the College Baseball World Series.
"We've been battling back from adversity all year. Omaha has been our goal," Johnson said. "We still have to play our best baseball [today]."


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Gartner has published its latest Magic Quadrant for WAN Optimization. Be among the first to get complimentary access to this new report now!
Silver Peak is leading the way into a new era of software-defined WAN optimization. Now more than ever, organizations like yours depend on the wide area network to connect their data centers, branch offices and the cloud. They see that better network performance means better bottom-line results, and Silver Peak gives them the most comprehensive and flexible options for network acceleration, and the most innovative approach to the next-generation WAN.
* Please enter your email address and click the Download Now button to download the white paper.
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Public Safety
Your safety as a member of the Chatham community is one of the University's primary concerns. We are proud of our safety record, however no campus is totally crime free. Please keep in mind that maintaining a safe and secure campus for everyone is a joint effort between our department and the community. Do not only look out for yourself, but look out for others around you. Please use common sense and good judgment when you make your way around campus. Be watchful and alert; do not hesitate to ask for help if you need it. Community members are encouraged to report all crimes and public safety related incidents to the campus police in a timely manner.
The Chatham University Public Safety Department is in charge of all aspects of campus safety and security. The department consists of a Chief of Police and fourteen (14) sworn law enforcement officers. A public safety officer is on-call 24 hours a day. The department falls under the supervision of the Senior Vice-President of Finance and Administration.
Police officers in the Public Safety Department are certified under Pennsylvania Legislative Act 120: Municipal Police Officers Education and Training Act and/or Legislative Act 235: The Lethal Weapons Training Act, and are armed. The officers are sworn in by Allegheny County and have arrest powers as granted by Pennsylvania Legislative Act 501: The Private Police Act. Their jurisdiction includes all Chatham University property and all roads running through and adjacent to the campus. All officers must attend mandatory in-service training sessions, which address a range of topics relating to police work and are updated on a regular basis. The officers are required to be trained in the use of firearms and must qualify annually. Several officers are certified crime-prevention officers through the Pennsylvania Commission on Crime and Delinquency.
The Public Safety Department cooperates fully with local and state law enforcement agencies in cases that involve both on and off campus jurisdictions or when resources of another agency can better facilitate the resolution of an investigation. Crimes occurring on campus are reported to the City of Pittsburgh Police Department when appropriate and when required by law. The Pittsburgh Police also service the campus community and can be contacted directly through the regular emergency numbers. The Public Safety Department maintains an excellent relationship with the Pittsburgh Police and can communicate with the local police by direct radio link. In addition, the Pittsburgh Police Department assists with criminal investigations and crime prevention awareness programs offered to all community members.
The Chatham University Public Safety Department prepares these web pages, including the Crime Statistics Report, to comply with the Jeanne Cleary Disclosure of Campus Security Policy and Crime Statistics Act. This information is prepared in cooperation with local law enforcement agencies surrounding the campus and the Chatham University Public Safety Department. Campus crime statistics, arrests, and referral statistics include those reported to the Chatham University Public Safety Department, designated campus officials, and local law enforcement agencies. Each year, an email notification is made to all community members that provides web site access to the Public Safety Department web site and Crime Statistics Report. All prospective employees may obtain a copy of the Report by contacting the Director of Human Resources or the Director of Public Safety and the web site address is attached to all Chatham University employment applications.
Contact the Chatham University Public Safety Department at firstname.lastname@example.com. All parking permit questions should be addressed to Lisa Zezza at email@example.com.


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LaCrosse, Wis.-based Michaels Energy is pleased to announce the addition of a new senior team member, Brian F. A'Hearn, P.E.
A'Hearn has over 30 years experience, including designing mechanical and plumbing systems, writing control sequences, estimating, and managing construction projects. In 1980, A'Hearn joined Engineering Associates in Cedar Rapids, Iowa, where he developed his design experience. After becoming a registered Iowa professional engineer in 1984, he joined A'Hearn Plumbing and Heating Inc., a family-owned mechanical construction firm founded by his father in 1968. He became president and owner of A'Hearn Plumbing and Heating in 1988, and served in that capacity for 21 years. When the Waldinger Corp., a $300 million construction/services company, acquired the Mechancal Services Division of A'Hearn in 2009, he became Waldinger's Cedar Rapids branch manager.
A'Hearn's business standards and practices align well with the Michaels Energy mission and corporate culture. He genuinely believes there is vast opportunity for energy efficiency and making buildings work right. His passion and determination to expand his expertise into energy efficiency will be of great value to Michaels Energy as it continues to grow and expand in coming years.
A'Hearn will be located in the company's Cedar Rapids, Iowa, office.


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First Peek
The first lady wears a custom Thom Browne coat and dress, "both made of silk jacquard based on a necktie fabric," reports Eric Wilson of the New York Times.
The full scoop from a White House official via the press pool:
"The First Lady is wearing a navy Thom Browne coat and dress. The fabric was developed based on the style of a men's silk tie. The belt she is wearing is from J.Crew, the cardigan is designed by Reed Krakoff and her necklace is designed by Cathy Waterman. She is also wearing J.Crew shoes. At the end of the inauguration, the outfit and accompanying accessories will go to the National Archives.
Malia Obama is wearing a J.Crew ensemble. Sasha Obama is wearing a Kate Spade coat and dress."
Additional details to note: Marian Robinson wears hand carved, hand painted Lucite allegory flower earrings in black from Alexis Bittar.
This is not the first time that Mrs. O has worn Thom Browne. The first lady wore his lace overlay dress for the Democratic National Convention in September 2012, seen here. The designer is the recipient of the 2012 National Design Award in Fashion Design, celebrated with a White House luncheon ceremony hosted by the first lady.


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On the HOT SEAT: Srishti Publishers &Distributors
Publisher On The HOT SEAT is a ground breaking attempt to discuss the trends in Indian writing and publishing. Per our knowledge, this is the first attempt in India to hear the voice of an often neglected but very important part of the publishing cycle : The Publisher. This group of people are visionaries, the final decision makers and the very people who decide fates. They decide fates of not only the manuscripts but of authors too. They have the power to establish trends and deliver to us what we would like to read.
Our first guest on the HOT SEAT, is none other than "Srishti Publishers & Distributors". One of the most influential trend setters of Indian books market in the current times
Our first guest on the HOT SEAT, is none other than "Srishti Publishers & Distributors". One of the most influential trend setters of Indian books market in the current times
"Srishti" has reach; you go to the smallest town in India and you are likely to find their books. I speak from experience because I could find their books in one of those small towns, in south Gujarat, where I grew up. Widely seen as the promoters of young talent, they have launched the likes of Preeti Shenoy and Ravinder Singh. Srishti is a boon for readers, like me, who save their pocket money for books. They have published many a bestseller each year, concretely proving their belief in the budding writing talent of India. Even in the face of criticism from the media, on the falling standards of Indian literature, they have continued to work with young talent.
Q. What was the main motivation behind starting Srishti Publishers?
A: Srishti stands for creation, and has been referred since time immemorial to the creation of the world by Brahma. Srishti Publishers was set up with the objective of creating a unique set of books that provide unmatched reading pleasure to people across the country. We have not only given a platform to budding, debutant authors, but have also made quality books available at affordable prices across India.
Q. What is your opinion about the current trend of writing in India "where anyone can be a writer"?
A: Writer by definition is someone who uses words to convey idea's, images and stories. So we firmly believe anyone who has a story to tell or an idea to share can be a writer.
But that does not necessarily mean anyone who writes is a writer. A gripping storytelling style, firm grounding in basics of grammar and the power to create images out of their words still remain as the most basic and necessary qualities of a writer.
Q. Srishti has been a pioneer in the 100 INR category written by young authors, why? There has been a lot of critique about this, how do you answer that?
A: The main objective behind the price point of INR 100 was to encourage the youths of India to become readers and increase the readership in India. The pricing is done keeping in mind, affordability of an average Indian reader ensuring that it does not burn a hole in the pocket, making them ideal gifts or regular indulgences for the reader themselves.
Q. How many books have you published so far?
A: We have more than 350 titles published by us till date starting with our Teaching Series, incidentally international rights for which were bought by Random House UK.
Q. How many best sellers so far have been published by you?
A: We have approximately 45 titles which can be categorized as "bestsellers" in terms of traditional definition.
Q. Which books are your personal favorites?
A: All of them are personal favorites. A strong emotional connect, is but natural, owing to the fact that we work so closely and invest so much personally into each title. So it becomes really tough to single out any such favorite.
Q. What are the upcoming books coming from Srishti?
A: 2013 is going to be a very exciting year for Srishti. We will be breaking into the field of multiple new genres with books by debut authors coming out from our stable. Releasing in April we have The Homing Pigeon by Sid Bahri and The Secrets of the Dark by Arka Chakrabarti followed by Ketan Bhagat's Complete/Convenient and K. Hari's When Strangers Meet in May. In the month of June we have Ohh! God's are Online and The Guardians of Karma scheduled for release.
Q. Tell us a little bit about these books?
A: The Homing Pigeon is a tale of love- lost, found and lost again set in the backdrop of 2008 recession. Coloring the tale with even more interesting shades is the moral complexity of the characters, interesting anecdotes and the unique storytelling style. The same title has been endorsed by Dr. Shashi Tharoor as "a remarkable novel by a first-time novelist of immense promise... often exquisitely rendered... An exceptional achievement." Also in my personal humble opinion this is one of the finest piece of fiction I had the fortune of reading as a Publisher.
The Secrets of the Dark on the other hand is a tale set in the mystical land of Gaya- a land of wise kings and evil guardians, brave warriors and devious renegades, fractured by a prophecy foretelling of doom. Involving elements of both Western and Eastern Fantasy and Mythos the author vividly creates a new world of epic proportion and wild fun.
In may we have Ketan Bhagat's Complete/Convenient which explores and contrast's the life of a young professional in India and abroad. Based on personal experiences of the author it provides a complete new outlook towards life abroad.
Q. Srishti has managed a good number of "best sellers" in the last few years, what is the secret of success? Is it the in depth understanding of distribution that helps?
A: Marketing and distribution both play an integral role in the sale of these books. Our reach enables us to ensure that our books reach our readers not only in the metros & big cities but even small towns and cities. The readerships in these parts, long neglected, are quite size-able and are hungry to read.
A special mention of the role of social media is very important. The intended audiences are most active there and are not shy to voice their appreciation or discontent over the same medium. Hence the need to engage them over the same is also important.
Q. In your opinion collectively speaking is Indian writing suited for an international market? Why?
A: Indian popular fiction is primarily aimed at the audience in India. The plot, writing style and language are very India centric. But with increasing globalization and integration of world cultures soon these walls will crumble and lead to introduction to a more global audience.
I thank "Srishti Publishers & Distributors" for encouraging The Readers Cosmos in their newest and first ever attempt to bring a publisher on HOT SEAT and more for their honest answers. I also wish the authors of their upcoming books Arka Chakrabarti, Sid Bahri, Ketan Bhagat and K. Hari all the best. Looking forward to reading wonderful stories from Srishti.


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Remember that movie We Are Marshall? Well, that was this Marshall University they were talking about, and its Thundering Herd football team. Of course, that flick was about the 1970s. This ain't the 1970s, so let's get on with it. Marshall University's seen some pretty cool additions to its campus in recent years, including engineering labs, softball fields, and a spiffy Recreation Center, complete with an indoor pool. Make like a virtual tourist and take a virtual tour of the place. Before you let virtual reality run away with you, let's not forget real academics, which, of course, is why you're here. Without going into some essay-length discussion (which you'll have to do eventually, by the way) of why Marshall U's got the goods, just know that Pulitzer Prizes and Marshall graduates go together like a...well, like a grade and a paper.
Huntington, West Virginia's got a rental sure to suit your academic lifestyle. Did we say academic lifestyle? We mean party lifestyle. But it's up to you to be responsible about it. Monthly rents come in a whole lot cheaper here than they do in those trendy hot spots like D.C. and N.Y.C, so you've got that going for you 'round these parts. Yes, there's campus housing, too, and if you need a tip or two about how to make that all work, we've got your back, but the off-campus situation is pretty solid too. Just browse the available units listed on our site, and see what you think! There are over a thousand more female undergrads at Marshall University than male undergrads. For the (straight) fellas, that's good news. For the ladies? Well, at least the bro element shouldn't be too overwhelming. We know that gets annoying.
When it comes to Marshall University livin', we've marshaled the evidence to come up with this conclusion: getting around in Huntington, West Virginia is a breeze. Though it isn't "rural," it's still a small town, so cars may do you some good once in a while—like when you're hatching a plan to carpool to the Huntington Mall. Biking, walking, and jogging (expect to sweat in the muggy summer) are perfectly acceptable ways to get around, too. And where would go? How about Fat Patty's, Huntington's premier hangout joint for burger lovers and students-who-should-be-home-studying alike. Patty's got a full bar too, so she (or he) knows how to round out a good time. Campus action includes concert bands, film societies, and even a symphony orchestra to keep you both entertained and edified to no end. Enjoy!


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West Kendall
Columbus' Odio receives full scholarship to Boston College
Eddie Odio, a 6-foot-7 senior at Christopher Columbus High School, will be playing basketball for Boston College next year. Odio signed a full scholarship offer on the first day of the signing period.
Odio, a West Kendall resident, is the son of Barry University Coach Cesar Odio, who was a star at Columbus High and Florida Southern, and grandson of the former Miami city manager Cesar Odio.
It was no surprise that Odio was highly recruited. He was named to the All Miami-Dade Basketball Team both his sophomore and junior seasons and a nominee for Miami-Dade Athlete of the Year two years running.
"More than 20 schools had contacted me through phone calls, emails, or sending a letter to my home," Odio said. "Boston College was the first school to offer a scholarship. That's what I wanted. There were other schools recruiting me at the time but I felt it was the best fit."
He likes the BC system and felt it was a good match for his style of play.
Not only was the program a good match for him, Odio said he loves the city of Boston and the Boston Red Sox are his favorite team, as evidenced by his dog, who is named Fenway.
BC Coach Steve Donahue came to watch Odio at an open gym at the end of the past school year. Odio said his dad received the call about the scholarship and they discussed the offer.
"My whole family agreed that it was the best choice," he said.
Dad Cesar said they always wanted Eddie to go to a great academic school and Boston College fits that requirement.
"And we always wanted him to play for a great coach who cares about kids," Coach Odio said.
Eddie Odio expects to play small forward or shooting guard. Although he's 6-feet-7, two of the new recruits are taller, at 6-feet-11 and 7 feet.
While Odio has been playing all his life, including in the basketball league at the Dave and Mary Alper Jewish Community Center, on travel teams and school teams, Odio said his dad made sure he kept a low profile.
"He didn't want me getting spoiled with all the AAU hoopla," Eddie said.
His father said they wanted him to develop and enjoy basketball and let nature take its course because Eddie was going to be a late bloomer. In fact, they didn't think Eddie would be taller than 6-feet-2.
"We never thought he'd grow into the kind of player he is now. We're ecstatic and proud of him," Coach Odio said. "When he was small he was skinny and he was a shooter. Now he's athletic. He's a great kid and he's worked awfully hard since he was 5 years old."
That low profile included going to Miami Christian, a small school where he honed his skills his freshman and sophomore years.
"Dad was a star at Columbus which is why I didn't go to Columbus at first," young Odio said. "But I wanted to move on to bigger school to help me get ready for college."
So for his last two years, Odio transferred to Columbus where his dad had been a star. He handled the transition well, leading Columbus to a 22-4 season, losing to Krop in the regional finals last year. This year Columbus is poised to take another run at going deep into the playoffs.


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NAIA Volleyball Player of the Week ? No. 2
By Chad Waller, Director of Communications and Sports Information
KANSAS CITY, Mo. – Daymari Brito of Freed-Hardeman (Tenn.) has been named the NAIA Volleyball National Player of the Week, the national office announced Tuesday. Brito was selected based on her performances from Sept. 9 - 15 and was chosen out of a pool of conference player of the week selections among 23 conferences and independents.
Brito, a 6-foot sophomore outside hitter from Yaracui, Venezuela, averaged 5.56 kills per set, 1.78 digs per set and 0.78 services aces per set in a 2-0 week for the Lady Lions. In the 3-1 win (25-18, 23-25, 25-17, 25-15) over visiting Stephens (Mo.) on Sept. 13, Brito compiled a match-high 25 kills and hit for a .478 clip. She added 10 digs and four blocks (one solo). Brito was instrumental in Freed-Hardeman's monumental 3-2 victory (26-24, 22-25, 17-25, 25-19, 15-12) over then-No. 3 Columbia (Mo.) on Sept. 14. She finished with a match-best 25 kills and hit .309. Her fifth service ace in the deciding set was the winning point. Brito ranks second in the NAIA in kills per set (4.6).
The win over Columbia snapped the Cougar's 159-match American Midwest Conference regular-season win streak. That feat is an all-time NAIA record, breaking the 116 done by Houston Baptist.
For a complete list of all the national statistical leaders, click here.
Nominees: Carolyn Evans, Bryan (Tenn.); Kelly Sung, Menlo (Calif.); Lindsay Mangan, Concordia (Ore.); Laura Wills, St. Francis (Ill.); Alicia Carlton, Bethel (Ind.); Abby Nicholas, Montana State-Northern; Jessica Israel, Concordia (Calif.); Mackenzie Scheef, Midland (Neb.); Sabrina Scott, Southern-New Orleans (La.); Vladi Kopanarova, MidAmerica Nazarene (Kan.); Taylor DeGraaf, Cal State San Marcos; Morgan Martells, Ashford (Iowa); Ciara Lawson, Friends (Kan.); Nicole Wurstle, Point Park (Pa.); Nadelina Nesheva, Lindsey Wilson (Ky.); Sunny Bell, Bellevue (Neb.); Alicia Olson, Viterbo (Wis.); Katie Wangberg, Mayville State (N.D.); Susan Tsisiche, Wiley (Texas); Grecia Rivera, Wayland Baptist (Texas); Ellen Lemos, Brenau (Ga.); Nicole Mcinnis, St. Thomas (Fla.); Cailie Johnson, Cornerstone (Mich.).
2013 NAIA Volleyball Players of the Week (complete schedule)
Week 1 (Sept. 10) - Kaitlin Floerchinger, Northwestern (Iowa)
Week 2 (Sept. 17) - Daymari Brito, Freed-Hardeman (Tenn.)


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A young woman's reddish-brown hair, in close-up, dissolves into an overhead shot of wild reeds, eased this way and that by the wind. "Stoker" would be nothing without such flourishes. The film swims in them, and cares little for conventional narrative tension.
Photographed in Tennessee but set in an indistinct American location near nowhere in particular, the movie follows characters as they glide through a pristine void, eyeing each other amid faultlessly art-directed surroundings before getting stabbed or shot or doing the shooting or stabbing.
The psychosexual cross-currents flow not so much as they do in life, but the way they do in a Park Chan-Wook movie. This is what we have here. "Stoker" comes from the South Korean director whose "Vengeance Trilogy" ("Sympathy for Mr. Vengeance," "Oldboy" and "Lady Vengeance") won admirers around the world, as did Park's vampire picture, "Thirst," my favorite of his so far.
See it if you haven't: It's pretty great, and it'll help you forget "Twilight" ever happened.
Park's latest stakes out new territory for the director as a gun for hire, filming a script by Wentworth Miller deeply indebted to the 1943 Hitchcock picture "Shadow of a Doubt" (speaking of great). Like Joseph Cotten's blithe Uncle Charlie in that film, "Stoker" casts Matthew Goode as the mysterious visiting uncle of our hostess and narrator, India, played by Mia Wasikowska. With her father, Charlie's brother, recently dead and buried, 18-year-old India can't help but notice that her mother (Nicole Kidman) makes goo-goo eyes and squeals every time Uncle Charlie is near. India has her own feelings for this man.
Something's gotta give! Densely plotted, though not exactly full of surprises, "Stoker" nudges India toward all sorts of forbidden fruit and trials of fire. Wasikowska is a fine, intriguing actress, though I'm not sure anyone could make actual psychological sense of this woman. Nobody on screen — not Kidman, not Goode, not Wasikowska, not Jacki Weaver as Auntie Gin — seems entirely at home in the chosen (or guessed-at) style. And yet, as it becomes more and more delirious in its explanations of Charlie's past, "Stoker" at least gives you a few images to remember, such as the precisely judged long shot of one unlucky character staggering across a lonely road with a pair of garden shears sticking out of his skull.
'Stoker' -- 2 1/2 stars
Running time: 1:40
Opens: Friday


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Following in big brother Bell Mobility footsteps, Virgin Mobile will be launching OS 7.1 tomorrow for the BlackBerry Curve 9360.
This is a major boost for the device, as it brings Wi-Fi hotspot (up to 5 devices), NFC features, FM Radio and other BlackBerry goodness.
Likely we will see this update come to us as 188.8.131.52, the same as Bell launched last week.
Will you be up early to check for this update?


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At A Movie Theater Which Arm Rest Is Yours?
At A Movie Theater Which Arm Rest Is Yours? The selection of an arm rest at a movie theater is always a hard challenge, as choosing a particular side may upset or hassle the person next to you.
If it's like kissing, statistically 80% of people should do it wrong anyway.
The Answer To End All Answers[edit]
Well I'm sorry but there are no correct answers to this question or we could pretend this is The Hitchhiker's Guide to the Galaxy? 42?
Ways To Successfully Acquire Both[edit]
The most popular and lucrative way to have control over both armrests is to put on a fake identity. This is not like a costume or something outrageous, but to act brainlessly, you can drool and mumble about time and other stupid philosophical things, in no time you will have the whole row to yourself, sweet :) Or if acting stupid doesn't work you can arm wrestle for control.
Go with your mates and rather than sitting next to each other, piss everyone off by leaving a seat between you. This also ensures that your cheap buddies won't drink your Irn Bru (buy one get one free).
Sit on the floor at the front. No need for armrests then.
Only see really crappy movies where it's guaranteed that no one will be sitting next to you (i.e. Titanic, anything with Hugh Grant in and that one with the Hobbits).
On the rare occasion where you may wish to see an actual good film (i.e. Pokemon: Ash Dies At Last or the one with the hairdresser that was Borat in another film) you can wear a t-shirt saying something dodgy like, "Bollocks on Toast" or "You're staring at my nipples". Or one with a picture of Hugh Grant on.
Cut off your arms. Problem solved.
Break wind regularly.
What One Must Bear in Mind[edit]
You may think that this is a decision of where to rest your forelimbs, but there is as much gravity to the situation as there is coming out of Oscar Wilde's testicles. Quite a lot.
So, it is essential to choose with care. It would be foolish to plonk your elbow into the groin of a serial-killer, eyes-as-mad-as-dad-after-the-washing-up kinda butch lesbian. No? Do an image search for "butch lesbian kills little guy who elbowed her groin" if you don't believe me. The whole of Western civilisation depends on such etiquette as where one's elbow resides.
So there are certain rules to follow to aid you in this decision:
- Don't be a complete dick.
- If it's someone you could beat up sitting next to you, risk it.
- If you find them mildly attractive (albeit in the dark) risk it and you might get lucky, if you don't you might be able to steal their M&Ms.
- NEVER steal an armrest from an old lady with a walking stick. She is probably really strong.
- If you sit next to someone with a snack, put your arm on their side to piss them off.
- Remember the butch lesbian.
- Try your hardest to look like you're enjoying the movie and then wildly "SSSSSSHHHHHHH!" people if they complain about where your hand is.
Oh yeah, and if you ignored rule 1, run like hell when the movie's finished.


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Point Park University welcomes applications for admission to our master's and doctoral programs. Please click to explore each program's details.
Quick Facts:
- No application deadline for master's level programs.
- Convenient class delivery.
- GMAT/GRE scores are
waived for working adults.
- Financial Aid school code: 003357
Contact Information:
Point Park University
Office of Graduate Admission
201 Wood Street
Pittsburgh, PA 15222
Email: email@example.com
Phone: 412-392-3808
Quick Links:
Doctoral Programs
Master's Programs
- Adult Learning and Training* (offered fully online only)
- Athletic Coaching* (offered fully online only) -
- Clinical-Community Psychology
- Communication Technology* (also offered fully online)
- Criminal Justice Administration
- Curriculum & Instruction with teaching and leadership concentration*
- Curriculum & Instruction with PA supervisor of instruction certificate K-12*
Educational Administration*
- Engineering Management
- Environmental Studies
- Health Care Administration* (offered fully online only)
- Intelligence and Global Security* (also offered fully online)
- Leadership *no longer open to applications
- M.B.A.* with concentrations in Business Analytics; Health Systems Management; International Business; Management; Management Information Systems and Sports, Arts and Entertainment Management
- Media Communication
- Screenwriting and Playwriting
- Secondary Education Leading to PA Certification in Grades 7-12
- Special Education Leading to PA Certification in Pre-K through Grade 8*
Special Education Leading to PA Certification in Grades 7-12*
Tuition discounts are available for graduate education students.
*We understand the needs of today's students and have tailored these graduate programs to offer flexible delivery formats including on campus and fully online.
Concurrent Program
Post-Baccalaureate Certificate
Tuition discount available for above post-baccalaureate certificate education students.


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Grand Theft Auto III - Salvatore's Called A Meeting
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Don't Spank 'ma Bitch Up Drive Misty For Me Pump-Action Pimp The Fuzz Ball
Joey Leone
Mike Lips Last Lunch Farewell 'Chunky' Lee Chong Van Heist Cipriani's Chauffeur Dead Skunk In The Trunk The Getaway
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Taking Out The Laundry The Pick-Up Salvatore's Called A Meeting
Salvatore Leone (1/2)
Toni Cipriani (2/2)
Triads And Tribulations Blow Fish
Salvatore Leone (2/2)
Cutting The Grass Bomb Da Base Last Requests
Asuka Kasen (1/2)
Sayonara Salvatore Under Surveillance Paparazzi Purge Payday For Ray Two-Faced Tanner
Kenji Kasen
Kanbu Bust Out Grand Theft Auto Deal Steal Shima Smack Down
King Courtney
Bling-Bling Scramble Uzi Rider Gangcar Round-Up Kingdom Come
Ray Machowski (1/2)
Silence The Sneak Arms Shortage Evidence Dash Gone Fishing Plaster Blaster
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