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Restless legs syndrome and related disordersEkbom's syndrome
An in-depth report on the causes, diagnosis, treatment, and prevention of RLS.
- Restless leg syndrome (RLS) can be a temporary problem (such as during pregnancy) or a chronic, long-term issue. It can develop from several medical conditions and genetic risk factors.
- The condition involves a feeling of "pulling, searing, drawing, tingling,
bubbling, or crawling" beneath the skin, usually in the calf area. This
causes an irresistible urge to move the legs. These sensations can sometimes
affect the thighs, feet, and sometimes even thearms. Treatment often includes over-the-counter remedies and lifestyle changes. Iron supplements may be recommended in cases where a lack of iron has been identified. Prescription medications can provide good relief of symptoms.
RLS and PLMD:
- Periodic limb movement disorder (PLMD) is a condition where leg muscles contract and jerk every 20 - 40 seconds during sleep. These movements may last less than 1 second, or as long as 10 seconds.
- Unlike RLS, contractions in PLMD usually do not wake patients.
- Four out of five people who have of RLS sufferers also report having PLMD, but only about a third of people with PLMD also have RLS.
New Treatment:
- An antiseizure agent, gabapentin enacarbil (Horizant), was approved by the Food and Drug Administration (FDA) in 2011 for moderate-to-severe RLS. Common side effects included mild sleepiness and dizziness.
- The drug rotigotine (Neupro) was withdrawn from the US in 2008 because of concerns about absorption of the medication from the skin patch. The issue has since been corrected and the drug was approved in April 2012 for treatment of moderate-to-severe RLS.
Restless legs syndrome (RLS) is a poorly understood movement disorder that affects 3 - 15% of the general population. The problem can occur in both children and adults. Although effective treatments are available, RLS often goes undiagnosed.
Symptoms of RLS. The core symptom of RLS is an irresistible urge to move the legs (medically known as akathisia). Some people describe this symptom as a sense of unease and weariness in the lower leg. The sensations areaggravated by rest and relieved by movement. Specific characteristics of RLS include:
- "Pulling, searing, drawing, tingling, bubbling, or crawling" beneath the skin, usually in the calf area, causing an irresistible urge to move the legs. These sensations can occur mostly in the lower legs, but they can sometimes affect the thighs, feet, and even the upper body. RLS-type symptoms may also occur in the arms. These may be the first symptoms of RLS in some people.
- About 4 out of 5 patients with RLS also have semi-rhythmic movements during sleep, a condition called periodic limb movement disorder (PLMD). (See description below.)
- Itching and pain, particularly aching pain, may be present.
- Patients experience symptoms when they feel most relaxed and their legs are at rest. Symptoms usually occur at night when lying down. In more severe cases, symptoms also occur during the day while sitting.
- Episodes of RLS usually develop between 10 p.m. and 4 a.m. Symptoms are often worse shortly after midnight and disappearby morning. If the condition becomes more severe, people may begin to have symptoms during the day, but the problem is always worse at night.
- The unpleasant sensations and uncontrollable urge to move the legs often disturbs nighttime sleep.When the person tries to ignore the urge to move the legs, tension builds up until the legs jerk uncontrollably. Individuals who experience daytime symptoms may find itdifficult to sit during air or car travel, or through classes or meetings.
Late-onset and Early-onset Forms. There appear to be two forms of RL -- early-onset and late-onset. Each form may have different characteristics:
- People with early-onset RLS (occurring in the teenage years or earlier) tend to have a family history of the disorder. They usually have RLS without accompanying pain.
- People with late-onset RLS usually do not have a family history of RLS. The condition is more likely toresult from a problem with the nervous system.Symptoms may also include pain in the lower legs.
Periodic Limb Movement Disorder
Periodic limb movement disorder (PLMD) is also known as nocturnal myoclonus. PLMD symptoms include:
- Nighttime episodes that usually peak near midnight (similar to the pattern in restless legs syndrome).
- Contractions and jerking of the leg muscles every 20 - 40 seconds during sleep. Thesemovements may last less than 1 second, or as long as 10 seconds.
- PLMD usually does not wake patients. This conditionis distinct from the brief and sudden movements that occur just as people are falling asleep; these brief jerking movements may interrupt sleep.
- Four out of five people who have RLS also report having PLMD, but only a third of people with PLMD report having RLS.
While treatments for the two conditions are similar, PLMD is a separate syndrome. PLMD is also very common in narcolepsy, a sleep disorder that causes people to fall asleep suddenly and uncontrollably.
The main cause of RLS is unknown. Scientists are researching nervous system problems that may arise in either the spinal cord or the brain. One theory suggests that low levels of thebrain chemical dopamine causes restless legs syndrome.
RLS may often have a genetic basis, particularly in those who develop it before age 40. Restless legs syndrome in older adults is less likely to be inherited.
Genetic Factors
People with RLS often have a family history of the disorder. Researchers have detected at least six genetic factors that may play a part.Two of the genes are linked to spinal cord development. Although none of the genes has been associated with dopamine or iron-regulating systems, these factors are considered likely causes of the condition.
Neurological Abnormalities
Dopamine and Neurologic Abnormalities in the Brain. Several studies support the theory that an imbalance in neurotransmitters (chemical messengers in the brain), notably dopamine, may play a part in RLS. Dopamine triggers numerous nerve impulses that affect muscle movement. The effect is similar tothatseen in Parkinson's disease. In addition,drugs that increase dopamine levels treat both disorders. However, Parkinson's disease itself does not seem to increase the risk for RLS and RLS early in life does not increase the risk ofParkinson's later on.
Neurologic Abnormalities in the Spine. Other research suggests that restless legs syndrome may be due to nerve impairment in the spinal cord. Researchers had thought that such abnormalities beganin nerve pathways in the lower spine. However, some patients with RLS have symptoms in the arms, which indicates that the upper spine may also be involved.
Neuropathy. Some experts suggest that RLS, particularly if it occurs in older adults, may be a form of neuropathy, which is an abnormality in the nervous system outside the spine and brain. So far, there is no evidence to support a cause and effect relationship between neuropathy and RLS.
Abnormalities of Iron Metabolism
Iron deficiency, even at a level too mild to cause anemia, has been linked to RLS in some people. Some research suggest that RLS in some people may be due to a problem with getting iron into cells that regulate dopamine in the brain. Some studies have reported RLS in a quarter to a third ofpeople with low iron levels.
Deficiencies in Cortisol
Other research suggests that lowlevels of thehormone cortisolin the evening and early night hours may be related to restless leg symptoms. Low-dose cortisol injections have reduced symptoms in some people.
Causes of Periodic Limb Movement Disorder
The causes of PLMD are not clear. Some research suggests that it may be due to abnormalities in the autonomic nervous system, which regulates the involuntary actions of the smooth muscles, heart, and glands.
Risk Factors
RLS may affect 3 - 15% of the general population. It is more common in women than in men, and its frequency increases with age. The disorder affects an estimated 10 - 28% of adults older than age 65, however 4 in 10 patients have their first symptoms of RLS as teenagers.
An international study showed that 2% of children ages 8 - 17 have RLS symptoms. RLS may be more common than epilepsy and diabetes in children and teens.
Family History
As many as two-thirds of people with restless legs syndrome (RLS) have a family history of the disorder. In people with a family history of the condition, RLS is more likely to occur before they turn 40. People who develop the condition at a later age are less likely to have a family history of RLS.RLS is also more common in people from northern and western Europe, adding support for the theory that some cases have a genetic basis.
Attention Deficit Hyperactivity Disorder
RLS and PLMD in children are strongly associated with inattention and hyperactivity. Up to a quarter of children diagnosed with attention-deficit hyperactivity disorder (ADHD) may also have RLS, sleep apnea, and PLMD. These conditionsmay actually contribute to inattentiveness and hyperactivity. The disorders have much in common, including poor sleep habits, twitching, and the need to get up suddenly and walk about frequently. Some evidence suggests that the link between the diseases may be a deficiency in the brain chemical dopamine.
About 1 in 5 pregnant women report having RLS. The condition usually goes away within amonthof delivery. RLS in pregnancy has been linked todeficiencies in iron and the B vitamin folate.
Restless legs syndrome is relatively common in people undergoing kidney dialysis. Up to two-thirds of patients report this problem.Symptoms often disappear after a kidney transplant.
Anxiety Disorders
Anxiety can cause restlessness and agitation at night. These symptoms can causerestless legs syndrome or strongly resemble the condition.
Other Conditions Associated with Restless Legs Syndrome
The following medical conditions are also associated with restless legs syndrome, although the relationships are not clear. In some cases, these conditions may contribute to RLS. Others may have a common cause. In some cases, they may coexist due to other risk factors:
- Osteoarthritis (degenerative joint disease). Aboutthree-quarters of patients with RLS also have osteoarthritis, a common conditionaffecting older adults.
- Varicose veins. Varicose veins occur in about 1 in 7 patients with RLS.
- Obesity
- Diabetes. People with type 2 diabetes may have higher rates of secondary RLS. Nerve pain (neuropathy) related to their diabetes cannot fully explain the higher rate of RLS.
- Hypertension
- Hypothyroidism (a condition in which the thyroid gland does not make enough hormones)
- Fibromyalgia (chronic pain of unknown cause)
- Rheumatoid arthritis
- Emphysema (a lung disease usually caused by smoking)
- Chronic alcoholism
- Sleep apnea (pauses in breathing during sleep) and snoring
- Chronic headaches
- Brain or spinal injuries
- Many muscle and nerve disorders. Of particular interest is hereditary ataxia, a group of genetic diseases that affects the central nervous system and causes loss of motor control.Researchers believe that hereditary ataxia may supply clues to the genetic causes of RLS.
Environmental and Dietary Factors
Several environmental and dietary factors can trigger or worsen restless legs syndrome:
- Iron deficiencies. People who are deficient in iron are at risk for restless legs syndrome, even if they do not have anemia
- Folic acid or magnesium deficiencies
- Smoking
- Alcohol abuse
- Caffeine (coffee drinking is specifically associated with PLMD)
- Stress
- Fatigue
- Prolonged exposure to cold
Drugs that worsen or provoke RLS include:
- Antidepressants
- Antipsychotic drugs
- Anti-nausea drugs
- Calcium channel blockers (mostly used to treat high blood pressure)
- Metoclopramide (used to treat various digestive diseases)
- Antihistamines
- Oral decongestants
- Diuretics
- Asthma drugs
- Spinal anesthesia (anesthesia-induced restless legs syndrome typically disappears on its own within several months)
Risk Factors for Periodic Limb Movement Disorder
About 6% of the general population has PLMD. However, the prevalence in older adults is much higher, reaching almost 60%. Studies suggest that PLMD may be especially common in elderly women. As with RLS, there are manyconditions are associated with PLMD. They include sleep apnea, spinal cord injuries, stroke, narcolepsy, and diseases that destroy nerves or the brain over time. Certain drugs, including some antidepressants and anti-seizure medications, may also contribute to PLMD.
RLS rarely results in any serious consequences. However, recurring severe symptoms may cause considerable mental distress, loss of sleep, and daytime sleepiness. Because the condition is worse while resting, people withsevere RLS may avoidactivities that involve extended periods of sitting, such as attending movies or traveling long distances.
Sleep Deprivation
Inability to sleep during the night due to RLS symptoms and subsequent daytime sleepiness can cause mood changes. Lack of sleep can also contribute toworkplace errors and car crashes.
Effect on Daily Performance and Activities. Studies suggest that sleeplessness has a negative effect on the ability to function while awake.Areas that can be affected include:
- Concentration. Loss of deep sleep appears to impair the brain's ability to process information.
- Task performance. Missing several hours of sleep every night over the course of a week can negatively affect a person's ability to function. It also affects mood. In fact, people deprived of sleep show lowered performance levelson a par with those of people who areintoxicated.
- Learning. The extent to whichsleeplessness impairs learning is unclear. Some studies have reported problems in memorization. Other studies, however, have found no differences in test scores between people with temporary sleep loss and those with regular sleep cycles.
Psychiatric Effects
People with restless legs syndrome are more apt to suffer problems such as social isolation,frequent daytime headaches, and depression. The also complain of lower sex drive and other problemsrelated to insufficient sleep.
RLS can contribute to insomnia. Insomnia itself can increase the activity of hormones and pathways in the brain that produce emotional problems. Even modest changes in waking and sleeping patterns can have significant effects on a person's mood. In some cases, ongoinginsomnia may even predict mood disorders in the future.
It is not clear if RLS is responsible formood problemsor if anxiety or depression contributes to RLS. Anxiety can cause agitation and leg restlessness that resemble RLS. Depression and RLS symptoms also overlap. In addition, certain types of antidepressant drugs,such as serotonin reuptake inhibitors,can increase periodic limb movements during sleep.
A diagnosis of restless legs syndrome often relies mainly on the patient's description of symptoms. The first step in diagnosis is usually to gather information on a person's sleep and personal history. The doctor may ask the following questions:
- How would you describe your sleep problem?
- How long have you had this sleep problem? How long does it take you to fall asleep?
- How many times a week does the problem occur?
- How restful is your sleep?
- What do your leg problems feel like (such as cramps, twitching, and crawling feelings)?
- What is your sleep environment like? Noisy? Not dark enough?
- What medications are you taking (including the use of antidepressants and self-medications -- such as herbs, alcohol, and over-the-counter or prescription drugs)?
- Are you taking or withdrawing from stimulants, such as coffee or tobacco? How much alcohol do you drink per day?
- What stresses or emotional factors may be present in your life? Have you experienced any significant life changes?
- Do you snore or gasp during sleep? (This may be an indication of sleep apnea. Sleep apnea is a condition in which breathing stops for short periods many times during the night. It may worsen symptoms of restless legs syndrome or insomnia.)
- If you have a bed partner, does he or she notice that you have jerking legs, interrupted breathing, or thrashing while you sleep?
- Are you a shift worker?
- Do you have a family history of RLS or periodic movement limb disorder, "growing pains" at night, or night walking?
Keeping a Record of Sleep. To help answer these questions, the patient may need to keep a sleep diary for 2 weeks. The patient should record all sleep-related information, including responses to the questions listed above described on a daily basis. Using an extended-play audio or videotape to record sleep behavior can be very helpful in diagnosing sleep apnea. A bed partner can help provide information based on observations of the patient's sleep behavior.
Sleep Disorders Centers
Some patients may need to consult a sleep specialist or go to a sleep disorders center in order for the problem to be diagnosed. At most centers, patients undergo in-depth testing supervised by a team of consultants from various specialties, who can provide both physical and psychiatric evaluations. Centers should be accredited by the American Academy of Sleep Medicine.
Signs that may indicate the need for a sleep disorders center are:
- Insomnia due to psychological disorders
- Sleeping problems due to substance abuse
- Snoring and sudden awakening with gasping for breath (possible sleep apnea)
- Severe restless legs syndrome
- Persistent daytime sleepiness
- Sudden episodes of falling asleep during the day (possible narcolepsy)
Overnight polysomnography involves a series of tests to measure different functions during sleep. This type of evaluation is typically performed in a sleep center. It can help rule out sleep apnea or evaluate the effectiveness of RLS treatments.
To undergo the test, the patient arrives about 2 hours before bedtime without having made any changes in daily habits. Polysomnography electronically monitors the patient through the various sleep stages. Polysomnography tracks the following:
- Brain waves
- Body movements
- Breathing
- Heart rate
- Eye movements
- Changes in breathing and blood levels of oxygen
Actigraphy uses a small wristwatch-like device (such as Actiwatch) worn on the wrist or ankle. The device monitors or sleep quality in people suspected of having RLS, PLMD, insomnia, sleep apnea, and other sleep-related conditions. It measures and records muscle movements during sleep. For example, with PLMD, actigraphy can provide information on how long movements last and the number of times they occur. It can also track whether PLMD occurs in both legs at the same time, and the effect it has on sleep. Actigraphy is not as accurate as polysomnography because it cannot measure all the biological effects of sleep. It is more accurate than a sleep log, however, and very helpful for recording long periods of sleep.
Sleepiness Scale
The Epworth sleepiness scale uses a simple questionnaire to measure excessive sleepiness during eight situations.
The Epworth Sleepiness Scale
Chance of Dosing
Sitting and reading
(Indicate a score of 0 to 3)
0 = no chance of dozing
1= slight chance of dozing
2 = moderate chance of dozing
3 = high chance of dozing
Watching TV
(Indicate a score of 0 to 3)
0 = no chance of dozing
1= slight chance of dozing
2 = moderate chance of dozing
3 = high chance of dozing
Sitting inactive in a public place
(Indicate a score of 0 to 3)
0 = no chance of dozing
1= slight chance of dozing
2 = moderate chance of dozing
3 = high chance of dozing
Riding as a passenger in a car for an hour without a break
(Indicate a score of 0 to 3)
0 = no chance of dozing
1= slight chance of dozing
2 = moderate chance of dozing
3 = high chance of dozing
Lying down to rest in the afternoon when circumstances permit
(Indicate a score of 0 to 3)
0 = no chance of dozing
1= slight chance of dozing
2 = moderate chance of dozing
3 = high chance of dozing
Sitting and talking to someone
(Indicate a score of 0 to 3)
0 = no chance of dozing
1= slight chance of dozing
2 = moderate chance of dozing
3 = high chance of dozing
Sitting quietly after a lunch without alcohol
(Indicate a score of 0 to 3)
0 = no chance of dozing
1= slight chance of dozing
2 = moderate chance of dozing
3 = high chance of dozing
Sitting in a car while stopped for a few minutes in traffic
(Indicate a score of 0 to 3)
0 = no chance of dozing
1= slight chance of dozing
2 = moderate chance of dozing
3 = high chance of dozing
Score Results
1 - 6: Getting enough sleep.
4 - 8: Tends to be sleepy but is average.
9 and over: Very sleepy and suggestive of sleep-disordered breathing. Patient should seek medical advice.
Diagnosing Iron Deficiency Anemia and Its Causes
Because of the high association between restless legs syndrome and iron deficiency, a test for low iron stores should be part of the diagnostic workup in RLS. There are two steps in making this diagnosis:
- The first step is to determine if a person is actually deficient in iron.
- If iron stores are low, the second step is to diagnose the cause of the iron deficiency, which will help determine treatment.
Determining if Iron Stores are Low: The following findings are important in determining that a person is iron deficient:
- Blood cells viewed under the microscope are pale (hypochromic) and abnormally small (microcytic). These observations suggest iron deficiency, but they can appear in anemia resulting from chronic disease and thalassemia (an inherited blood disorder), as well.
- Hemoglobin and iron levels are low. These findings further suggest iron deficiency, but they can also occur in cases of anemia due to chronic disease. Ferritin levels are low.
- Ferritin is a protein that binds to iron; low levels typically indicate a lack of iron in the body. However, normal levels of ferritin in the blood do not always mean a patient has enough iron. For example, pregnant women in their third trimester or patients with a chronic disease may not have enough iron even with normal or high ferritin levels.
- A test that measures a factor called serum transferrin receptor (sTfR) is proving to be very sensitive in identifying iron deficiency in some patients, including the elderly with chronic diseases and possibly pregnant women. When iron deficiency anemia is diagnosed, the next step is to determine the cause of the iron deficiency itself. Menstrual blood loss is a common cause of iron deficiency in women of reproductive age. Tests to check for an underlying cause of iron deficiency, such as gastrointestinal (digestive tract) bleeding, are particularly important in men, postmenopausal women, and children. [See In-Depth Report #57: Anemia.]
Other Laboratory Tests
The following laboratory tests may be helpful in determining causes of restless legs syndrome (RLS) or identifying conditions that rule it out.
- Blood glucose tests for diabetes
- Tests for kidney problems
- In certain cases, tests for thyroid hormone, magnesium, and folate levels
- Electromyography (recording the electrical activity of muscles) for neuropathy, radiculopathy (problem with the nerve roots), myelopathy (problem with the spinal cord)
- Central nervous system MRI for myelopathy or stroke
Ruling Out Other Leg Disorders
In addition to other sleep-related leg disorders, many other medical conditions may have features that resemble restless legs syndrome (RLS). The doctor will need to consider these disorders in making a diagnosis.
Peripheral Neuropathies. Peripheral neuropathies are nerve disorders in the hands or feet, which can produce pain, burning, tingling, or shooting sensations in the arms and legs. Several conditions can cause these disorders; diabetes is a very common cause of painful peripheral neuropathies. Other causes include alcoholism, rheumatoid arthritis, systemic lupus erythematosus, amyloidosis, HIV infection, kidney failure, and certain vitamin deficiencies. Symptoms of peripheral neuropathies may mimic RLS. However, unlike RLS, these disorders ar not usually associated with restlessness. Also, movement does not relieve the discomfort, and the the problem does not worsen at bedtime.
Akathisia. Akathisia is a state of restlessness or agitation, and feelings of muscle quivering. A condition called hypotensive akathisia is caused by failure in the autonomic nervous system. Unlike RLS, it occurs at any time of the day. Also, it usually happens only when the patient is sitting -- not lying down. Anti-nausea drugs and drugs used to treat schizophrenia and other psychoses can cause akathisia. The condition also occurs when drugs to treat Parkinson's disease are stopped.
Painful Legs and Moving Toes Syndrome. This is a rare disorder that affects one or both legs. Painful legs and moving toes syndrome is marked by a constant, deep, throbbing ache in the limbs and involuntary toe movements. The discomfort may be mild or severe. The problem gets worse with activity and usually stops during sleep. Most of the time, the cause is unknown, although it may arise from spinal injuries or herpes zoster infection. The condition is difficult to treat, but the drug baclofen, combined with either clonazepam or carbamazepine, has shown some success. Other treatments that may help include orthotic shoe inserts and transcutaneous electrical nerve stimulation (TENS).
Meralgia Paresthetica. An uncommon nerve condition, meralgia paresthetica causes numbness, pain, tingling, or burning on the front and side of the thigh. It usually occurs on one side of the body. The condition may be caused by compression of the thigh nerve as it passes through the pelvis. The problem typically occurs in people aged 30to60 years, but it can affect people of all ages. It often goes away on its own.
Nocturnal (Nighttime) Leg Cramps
Cramps that awaken people during sleep are very common, but they are not part of restless legs syndrome or periodic limb movement disorder. Nocturnal leg cramps can be very painful and may cause the person jump out of bed in the middle of the night. They typically affect a specific area of the calf or the sole of the foot.
What Are Nocturnal Leg Cramps?
Benign nocturnal leg cramps ("charley horse") are muscle spasms in the calf. They can occur one or many times during the night. Cramping may also occur in the soles of the feet. Typically, cramps last from a few seconds to a few minutes. Some people experience them regularly, others rarely.
Causes of Nocturnal Leg Cramps. In most cases, the cause of nocturnal leg cramps remains unknown. Among the conditions that might cause leg cramps are:
- Calcium and phosphorus imbalances, particularly during pregnancy
- Low potassium or sodium levels
- Overexertion, standing on hard surfaces for long periods, or prolonged sitting (especially with the legs contorted)
- Having structural disorders in the legs or feet (such as flat feet)
- Medical causes of muscle cramping include hypothyroidism, Addison's disease, uremia, hypoglycemia, anemia, and certain medications. Various diseases that affect nerves and muscles, such as Parkinson's, cause leg cramps. Peripheral neuropathy, a complication of diabetes, can cause cramp-like pain, numbness, or tingling in the legs. Patients with kidney disease undergoing dialysis are also prone to leg cramps.
Individuals at Higher Risk for Nocturnal Leg Cramps. Nocturnal leg cramps occur at all ages but peak at different times. They are particularly common in adolescence, during pregnancy, and in older age, affecting up to 70% of adults over age 50 at some point.
Pregnant women and those taking diuretics are also at risk for leg cramps because of low calcium levels and an imbalance in calcium and phosphorus.
Consequences of Nocturnal Leg Cramps. Nocturnal leg cramps, like restless legs syndrome, rarely have serious consequences. However, they can be extremely painful and long lasting. Severe symptoms that occur often can cause chronic insomnia and considerable mental distress.
Managing Nocturnal Leg Cramps
Ways to relieve a cramp once it has begun include:
- Straightening the leg, flexing the foot upward toward the knee, or grabbing the toes and pulling them toward the knee.
- Walking, or shaking the affected leg then elevating it.
If soreness persists, a warm bath or shower or an ice pack may bring relief.
Lifestyle Tips for Preventing Nocturnal Leg Cramps. Nighttime leg cramps are generally treated with lifestyle changes.
- People with leg cramps should drink plenty of water (at least 6to 8 glasses daily) to maintain adequate fluid levels. Nightly stretching exercises may help prevent leg cramps from occurring. (This are generally recommended for RLS, as well).
- To stretch leg muscles: Stand about 30 inches from a wall. Keeping heels flat on the floor, lean forward and slowly move hands up the wall to achieve a comfortable stretch.
- Alternately, pedal for a few minutes on a stationary bicycle at bedtime.
- While in bed, loose covers should be placed over the toes and feet. This prevents the toes and feet from pointing, which causes calf muscles to contract and cramp. Propping the feet up higher than the torso may also help.
- Regular swimming and water exercises are a good way to keep muscles stretched.
- Wearing supportive footwear may help reduce leg cramps
Quinine. Quinine had been widely used to prevent leg cramping. The U.S. Food and Drug Administration (FDA) banned its sale over the counter because it reportedly caused some serious, although rare, side effects. These side effects include bleeding problems and heart irregularities. Other, less serious side effects include headaches, vision problems, and rashes.
The FDA has since banned the marketing of most quinine drugs, cautioning against the off-label (non-approved) use of the drug to treat nocturnal (nighttime) leg cramps. Only one form of the drug, Qualaquin, is approved for sale. It is used for the treatment of some types of malaria. Pregnant women and people with liver problems should avoid quinine in any form. In July 2010 the FDA issued a warning of serious, potentially life-threatening side effects resulting from the use of Qualaquin for nocturnal leg cramps. These side effects include dangerously low blood platelet counts (platelets help the blood clot) and permanent kidney damage.
Supplements. Some small studies indicate that the mineral magnesium, taken as magnesium citrate or magnesium lactate, may provide some benefit to people with leg cramps, including pregnant women. In one small study, taking vitamin B complex was shown to be helpful. Other supplements tried for leg cramps include vitamin E, calcium, and potassium or sodium chloride, but these do not appear to be very effective.
Treatment for complaints of sleeplessness and restless legs syndrome focus on efforts to improve sleep and eliminate possible causes of RLS. Initially, doctors normally try to achieve these goals without the use of drugs. A non-drug approach is a particularly important first step for elderly patients.
- The doctor should first try to treat any underlying medical conditions that may be causing restless legs.
- If medications may be causing RLS, the doctor should try to prescribe alternatives.
If the cause cannot be determined, measures to improvesleep habits and relaxation techniques are the best first steps. These approaches may help, even if medicines may be needed later on.
Lifestyle Changes
Some people report that making the following changes help control restless legs syndrome:
- Taking hot baths or using cold compresses.
- Stopping smoking.
- Getting enough exercise during the day.
- Doing calf stretching exercises at bedtime.
- Using Ergonomic measures. For example, working at a high stool where legs can dangle helps some people. Also, sitting on a aisle during meetings or airplane travel can allow for more leg movement.
- Changing sleep patterns. Some peoplereport that symptoms do not occur when they sleep in the late morning. Therefore, patients may consider changing their sleep patterns if feasible.
- Avoiding caffeine, alcohol, and nicotine also improves some cases of RLS.
Some patients have tried alternative treatments for RLS, such as acupuncture and massage. To date, however, there is not enough data on the effectiveness of these treatments.
Dietary Iron
Restless legs syndrome is associated with iron deficiency, so people with the condition should get enough iron in their diet. [For more information, see In-Depth Report #57: Anemia.] Iron is found in foods either in the form of heme or non-heme iron:
- Foods containing heme iron are the best for increasing or maintaining healthy iron levels. Such foods include clams, oysters, organ meats, beef, pork, poultry, and fish.
- Non-heme iron is less well absorbed. Over half the iron in meat is non-heme. Eggs, dairy products, and iron-containing vegetables (including dried beans and peas) have only the non-heme form. Other sources of non-heme iron include iron-fortified cereals, bread, and pasta products, dark green leafy vegetables (such as chard, spinach, mustard greens, and kale), dried fruits, nuts, and seeds.
Iron Supplements
Iron supplementsmay reduce symptoms in people with restless legs syndrome who are also iron deficient. Patients should use them only when dietary measures have failed. Iron supplements do not appear to be useful for RLS patients with normal or above normal iron levels.
Supplement Forms. To replace iron, the preferred forms of iron tablets are ferrous salts, usually ferrous sulfate (Feosol, Fer-In-Sol, Mol-Iron). Other forms include ferrous fumarate (Femiron, Ferro-Sequels, Feostat, Fumerin, Hemocyte, Ircon), ferrous gluconate (Fergon, Ferralet, Simron), polysaccharide-iron complex (Niferex, Nu-Iron), and carbonyl iron (Elemental Iron, Feosol Caplet, Ferra-Cap). Specific brands and forms may have certain advantages.
Regimen. A reasonable approach for patients with RLS is to take 65 mg of iron (or 325 mg of ferrous sulfate) along with 100 mg of vitamin C on an empty stomach, 3 times a day.
IMPORTANT: As few as 3 adult iron tablets can poison, and even kill, children. This includes any form of iron pill. No one, not even adults, should take a double dose of iron if they miss one dose.
Tips for taking iron are:
- For best absorption, take iron between meals. (Iron may cause stomach and intestinal disturbances, however. Some experts believe that you can take low doses of ferrous sulfate with food and avoid the side effects.)
- Always drink a full 8 ounces of fluid with an iron pill.
- Keep tablets in a cool place. Bathroom medicine cabinets may be too warm and humid, which may cause the pills to disintegrate.
Side Effects. Common side effects of iron supplements include the following:
- Constipation and diarrhea may occur but these sideeffects are rarely severe. However, iron tablets can aggravate existing digestive problems such as ulcers and ulcerative colitis.
- Nausea and vomiting may occur with high doses. You can control this by taking smaller amounts. Switching to ferrous gluconate may help some people with severe digestive problems.
- Black stools are normal when taking iron tablets. In fact, if stools do not turn black, the tablets may not be working effectively.
- Stools appear tarry orhave red streaks may indicate bleeding in the digestive tract, which may be causing iron deficiency. Other warning signs include cramps, sharp pains, or soreness in the stomach. Intestinal bleeding requires immediate medical attention.
- Acute iron poisoning is rare in adults, but can be fatal in children who take adult-strength tablets.
Interactions With Other Drugs. Certain medicines, including antacids, can reduce iron absorption.
Iron tablets may also reduce the effectiveness of other drugs, including:
- Antibiotics -- tetracycline, penicillamine, and ciprofloxacin
- Anti-Parkinson's disease drugs -- methyldopa, levodopa, and carbidopa
At least 2 hours should elapse between doses of these drugs and doses of iron supplements.
[For additional information about iron supplements see In-Depth Report #57: Anemia.]
Exercise early in the day helps achieve healthy sleep. Vigorous too close to bedtime (1to 2 hours before) mayworsen restless legs syndrome (RLS). A study found that people who walked briskly for 30 minutes, four times a week, improved minor sleep disturbances after 4 months. Regular, moderate exercise may help prevent RLS. However, patients report that either bursts of excessive energy or long sedentary periods can worsen symptoms.
Pneumatic Compression Device
Small studies have shown that the use of a pneumatic compression device improves symptoms on RLS in some patients. Pneumatic compression devices wrap an inflatable cuff around the legs. This cuff is attached to a device which then increases pressure around the legs. It is worn for at least an hour, generally around the time symptoms usually begin.
The American Academy of Sleep Medicine recommends medications for RLS or PLMD only for persons who fit strict diagnostic criteria, and who experience excessive daytime sleepiness as a result of these conditions. (Excessive daytime sleepiness results from nighttime sleeplessness due to RLS or PLMD symptoms).
More research and physician training is needed to better diagnose and treat RLS with medications in children and adolescents. Little is known about the best way to treat RLS in general, but some experts suggest the following for adults:
- If lifestyle changes do not control the problem, over-the-counter pain relievers should be the first form of treatment.
- People with RLS should have a test for iron deficiency. If they are iron deficient, they should start treatment with iron supplements.
- Dopaminergic drugs (drugs that increase levels of dopamine) are the standard medicines for treating severe RLS, PLMD, or both.
- Other drugs may be helpful if dopaminergic drugs fail, or for patients who have frequent -- but not nightly -- symptoms. These include opiates (pain relievers), benzodiazepines (sedative hypnotic drugs), or anticonvulsants. However, benzodiazepines and opiates can become habit forming and addictive.
Tylenol and Non-Steroidal Anti-Inflammatory Drugs
Before taking stronger medications, people should try over-the-counter pain relievers, such as acetaminophen (Tylenol) or non-steroidal anti-inflammatory drugs (NSAIDs), which include ibuprofen (Advil, Motrin, Rufen), naproxen (Anaprox, Naprosyn, Aleve), and ketoprofen (Orudis KT, Actron).
Although NSAIDs work well, long-term use can cause stomach problems, such as ulcers, bleeding, and possible heart problems. In April 2005, the FDA asked drug manufacturers of NSAIDs to include a warning label on their product that alerts users of an increased risk for heart-related problems and digestive tract bleeding.
Levodopa and Other Dopaminergic Drugs
Dopaminergic drugs increase the availability of the chemical messenger dopamine in the brain, and are the first-line treatment for severe RLS and PLMD. These drugs significantly reduce the number of limb movements per hour, and improve the subjective quality of sleep. Patients with either condition who take these drugs have experienced up to 100% reduction in symptoms.
Dopaminergic drugs, however, can have severe side effects (they are ordinarily used for Parkinson's disease). They do not appear to be as helpful for RLS related to dialysis as they do for RLS from other causes.
Dopaminergic drugs include dopamine precursors and dopamine receptor agonists.
Dopamine Receptor Agonists. Dopamine receptor agonists (also called dopamine agonists) mimic the effects of dopamine by acting on dopamine receptors in the brain. They are now generally preferred to L-dopa (see below). Because they have fewer side effects than L-dopa, including rebound effect and augmentation, these drugs may be used on a daily basis. About 30% of patients who take dopamine receptor agonists have reported augmentations symptoms. As the newer drugs are taken for longer periods and at higher doses, however, their augmentation rates may become closer to those of L-dopa.
Dopamine agonists have been shown to relieve symptoms in 70to90% of patients. Dopamine agonists can be ergot-derived (such as cabergoline) or non-ergot derived (such as pramipexole and ropinirole). The newer non-ergotamine derivatives may induce fewer side effects than ergot-derived drugs:
- Ropinirole (Requip) was the first drug approved specifically for treatment of moderate-to-severe RLS (more than 15 RLS episodes a month). Side effects are generally mild but may include nausea, vomiting, drowsiness, and dizziness.
- Pramipexole (Mirapex) is also approved for RLS. However, patients may fall asleep, without warning, while taking this drug, even while performing activities such as driving.
- Rotigotine is a patch preparation. Common side effects include back or joint pain, dizziness, decreased appetite, dry mouth, fatigue, sweating, trouble sleeping or upset stomach.
- Cabergoline is a dopamine agnoist that should be used only when other medications have been tried and failed; it poses a risk of heart valve damage.
Other Dopamine Agonists. Other dopamine agonists that have shown some promise in small studies include alpha-dihydroergocryptine, or DHEC (Almirid), and piribedil (Trivastal).
Dopamine Precursors. The dopamine precursor levodopa (L-dopa) was once a popular drug for severe RLS. Although it can still be useful, most doctors now prefer the newer dopamine agonists (see above). The standard preparations (Sinemet, Atamet) combine levodopa with carbidopa, which improves the action of levodopa and reduces some of its side effects, particularly nausea. Levodopa can also be combined with benserazide (Madopar) with similar results, but Sinemet is almost always used in America. (Levodopa combinations are well tolerated and safe.)
Patients typically start with a very low dose taken 1 hour before bedtime. The dosage is increased until the patient finds relief. Patients sometimes need to take an extended-release form or to take it again during the night.
Levodopa acts fast, and the treatment is usually effective within the first few days of therapy.
Serious common side effects of L-dopa treatment (and, to lesser extent, of dopamine receptor agonists) are augmentation and rebound. Many studies report that augmentation (worsening of symptoms that occur earlier in the day) occurs in up to 70% of patients who take L-dopa. The risk is highest for patients who take daily doses, especially doses at high levels (greater than 200 mg/day). For this reason, patients should use L-dopa only intermittently (fewer than 3 times per week). The drug should be immediately discontinued if augmentation does occur. Following withdrawal from L-dopa, patients can switch to a dopamine receptor agonist.
The rebound effect causes increased leg movements at night or in the morning as the dose wears off, or as tolerance to the drug builds up.
Regimens. The effects of L-dopa are apparent in 15to 30 minutes. Dopamine receptor agonists, meanwhile, take at least 2 hours to start working. Some doctors recommend regular use of dopamine receptor agonists for patients who experience nightly symptoms, and L-dopa for those whose symptoms occur only occasionally.
Side Effects. Common side effects of dopaminergic drugs vary but may include feeling faint or dizzy (especially when standing up), headaches, abnormal muscle movements, rapid heartbeat, insomnia, bloating, chest pain, and dry mouth. Nausea may be especially common. Adding the drug domperidone may help to relieve this side effect. In rare cases, dopaminergic drugs can cause hallucinations or lung disease.
Because these drugs may cause daytime drowsiness, patients should be extremely careful while driving or performing tasks that require concentration.
Long-term use of dopaminergic drugs can lead tolerance, which results in to loss of effectiveness. Adding a drug called entacapone (Comtan) may prolong the duration of action of carbidopa-levodopa therapy, but it can cause nausea.
Rebound effect, augmentation, and tolerance can reduce the value of dopaminergic drugs in the treatment of RLS. Using the lowest dose possible can minimize these effects.
Withdrawal Symptoms. Patients who withdraw from these drugs typically experience severe RLS symptoms for the first 2 days after stopping. RLS eventually returns to pre-treatment levels after about a week. The longer a patient uses these drugs, the worse their withdrawal symptoms.
Benzodiazepines, such as clonazepam (Klonopin), are known as sedative hypnotics. Doctors prescribe them for insomnia and anxiety. They may be helpful for restless legs syndrome (RLS) that disrupts sleep, especially in younger patients. Clonazepam may be particularly helpful for children with both periodic limb movement disorder and symptoms of attention deficit hyperactivity disorder. The medicine also may be helpful for patients with RLS who are undergoing dialysis.
Side Effects. Elderly people are more susceptible to side effects. They should usually start at half the dose prescribed for younger people, and should not take long-acting forms. Side effects may differ depending on whether the benzodiazepine is long-acting or short-acting.
- The drugs may increase depression, a common condition in many people with insomnia.
- Breathing problems may occur with overuse or in people with pre-existing respiratory illness.
- Long-acting drugs have a very high rate of residual daytime drowsiness compared to others. They have been associated with a significantly increased risk for automobile accidents and falls in the elderly, particularly in the first week after taking them. Shorter-acting benzodiazepines do not appear to pose as high a risk.
- There are reports of memory loss (so-called traveler's amnesia), sleepwalking, and odd mood states after taking triazolam (Halcion) and other short-acting benzodiazepines. These effects are rare and probably enhanced by alcohol.
- Because benzodiazepines cross the placenta and enter breast milk, pregnant and nursing women should not use them. There are some reports of an association between the use of benzodiazepines in the first trimester of pregnancy and the development of cleft lip in newborns. Studies are conflicting at this point, but other side effects are known to occur in babies exposed to these drugs in the uterus.
- In rare cases, overdoses have been fatal.
Interactions. Benzodiazepines are potentially dangerous when used in combination with alcohol. Some drugs, such as the ulcer medication cimetidine, can slow the breakdown of benzodiazepine.
Withdrawal Symptoms. Withdrawal symptoms usually occur after prolonged use and indicate dependence. They can last 1to 3 weeks after stopping the drug and may include:
- Gastrointestinal distress
- Sweating
- Disturbed heart rhythm
- In severe cases, patients might hallucinate or experience seizures, even a week or more after they stop taking the drug.
Rebound Insomnia. Rebound insomnia, which often occurs after withdrawal, typically includes 1to 2 nights of sleep disturbance, daytime sleepiness, and anxiety. The chances of rebound are higher with the short-acting benzodiazepines than with the longer-acting ones.
Narcotic Pain Relievers
Narcotics are pain-relieving drugs that act on the central nervous system. They are sometimes prescribed for severe cases of restless legs syndrome (RLS). They may be a good choice if pain is a prominent feature. Some evidence also suggests that narcotics reduce the frequency of periodic leg movements.
There are two types of narcotics, both of which have been used for severe RLS:
- Opiates (such as morphine and codeine) come from natural opium. Some patients report relief with the use of the opiate fentanyl (Duragesic), available in skin patch form. An implanted pump that uses morphine and an anesthetic called bupivacaine is showing promise for patients with severe RLS. The pump delivers the drugs to the fluid surrounding the spinal cord (cerebrospinal fluid).
- Opioids are synthetic drugs. The most common example is oxycodone (Percodan, Percocet, Roxicodone, OxyContin, Methadone, and Hydrocodone).
Although the use of narcotics for severe RLS is controversial, some studies have suggested that even when the treatments are long-term, they are rarely addictive for pain sufferers except among patients with a history of substance abuse.
The use of such drugs may be beneficial when included as part of a comprehensive pain management program. Such a program involves screening prospective patients for possible drug abuse, and regularly monitoring those who are taking narcotics. Doses should be adjusted as necessary to achieve an acceptable balance between pain relief and side effects. Patients on long-term opiate therapy should also be monitored periodically for sleep apnea, a condition that causes breathing to stop for short periods many times during the night. Sleep apnea may worsen symptoms of RLS, insomnia, and other complaints.
Tramadol. Tramadol (Ultram) is a pain reliever that has been used as an alternative to opioids. It has opioid-like properties, but is not as addictive. (However, there are reports of dependence and abuse with this drug as well.) Withdrawal after long-term use (longer than a year) can cause intense symptoms, including diarrhea, insomnia, and even restless legs syndrome itself.
Antiseizure Drugs
Antiseizure drugs -- such as gabapentin (Neurontin), valproic acid (valproate, divalproex, Depakote, Depakene), and carbamazepine (Tegretol) are being tested for restless legs syndrome (RLS). In 2011 the FDA approved gabapentin enacarbil, a form of gabapentin, for the once daily treatment of moderate to severe RLS. Gabapentin enacarbil converts to gabapentin in the intestines, and therefore may reduce some of the side effects experienced by patients taking antiseizure medications. (Common side effects included mild sleepiness and dizziness.) The drug is marketed under the name Horizant Extended Release.
Side Effects. All antiseizure drugs have potentially severe side effects. Therefore, patients should try these medications only after non-drug methods have failed. Side effects of many anti-seizure drugs include nausea, vomiting, heartburn, increased appetite with weight gain, hand tremors, irritability, and temporary hair thinning and hair loss (taking zinc and selenium supplements may help reduce this last effect). Some antiseizure drugs can also cause birth defects and, in rare cases, liver toxicity. Gabapentin may have fewer of these side effects than valproic acid or carbamazepine.
Other Drugs
Antidepressants. Bupropion (Wellbutrin), a newer antidepressant, may be helpful for restless legs syndrome (RLS). Bupropion is a weak dopamine reuptake inhibitor -- it causes a slight increase in the availability of dopamine in the brain. The drug is not addictive and does not have the severe side effects of other RLS drugs, but more research is needed to determine if it is useful.
Clonidine. Clonidine (Catapres), a drug used for high blood pressure, is helpful for some patients and may be an appropriate choice for patients who have RLS accompanied by hypertension. It also may help patients with RLS who are undergoing hemodialysis.
Baclofen. The anti-spasm drug baclofen (Lioresal) appears to reduce intensity of RLS (although not frequency of movements).
Alpha-2 Delta Blockers. Gabapentin and gabapentin enacarbil appear to help RLS sufferers. Pregabalin is currently under study.
- www.aasmnet.org -- American Academy of Sleep Medicine
- www.sleepfoundation.org -- National Sleep Foundation
- www.ninds.nih.gov -- National Institute of Neurological Disorders and Stroke
- www.nhlbi.nih.gov/about/ncsdr/ -- National Center on Sleep Disorders Research
- www.rls.org -- Restless Legs Syndrome Foundation
- www.wemove.org -- Worldwide Education and Awareness for Movement Disorders
Aurora RN, Kristo DA, Bista SR, et al. Update to the AASM clinical practice guideline: The treatment of restless legs syndrome and periodic limb movement disorder in adults--an update for 2012: practice parameters with an evidence-based systematic review and meta-analyses. Sleep. 2012;35(8):1039-1062.
Aurora RN, Kristo DA, Bista SR, et al. Letter to the Editor: Update to the AASM clinical practice guideline: The treatment of restless legs syndrome and periodic limb movement disorder in adults--an update for 2012: practice parameters with an evidence-based systematic review and meta-analyses. Sleep. 2012;35(8):1037..
Bayard M, Avonda T, Wadzinski, J. Restless Legs Syndrome. American Family Physician. 2008;78(2):235-240.
Gringas P. When to use drugs to help sleep. Arch Dis Child. 2008;93(11):976-81.
Hening WA. Current Guidelines and Standards of Practice for Restless Legs Syndrome. AmJ Med. 2007;120(1A):S22-S27.
Hornyak M, Rupp A, Riemann D, et al. Low-dose hydrocortisone in the evening modulates symptom severity in restless leg syndrome. Neurology. 2008;70(18):1620-2.
Kushida CA. Clinical Presentation, Diagnosis, and Quality of Life Issues in Restless Legs Syndrome. AmJ Med. 2007;120(1A):S4-S12.
Kushida CA, Becker PM, Ellenbogen AL, et al. Randomized, double-blind, placebo-controlled study of XP13512/GSK1838262 in patients with RLS. Neurology. 2009;72(5):439-46.
Lettieri CJ, Eliasson AH. Pneumatic compression devices are an effective therapy for restless legs syndrome: a prospective, randomized, double-blind, sham- controlled trial. Chest. 2009;135(1):74-80.
Lohmann-Hedrich K, Neumann A, Kleensang A, et al. Evidence for linkage of restless legs syndrome to chromosome 9p: are there two distinct loci? Neurology. 2008;70(9):686-694.
Ondo WG. Restless Leg Syndrome. Neurol Clin. 2009;27(3):779-799.
Ong KH, Tan HL, Tam LP, et al. Accuracy of serum transferrin receptor levels in the diagnosis of iron deficiency among hospital patients in a population with a high prevalence of thalassaemia trait. Int J Lab Hematol. 2008;30(6):487-493
Picchietti D. Restless legs syndrome: prevalence and impact in children and adolescents--the Peds REST study. Pediatrics. 2007; 120(2): 253-66.
Restless Leg Syndrome Foundation. RLS Name Change: Willis-Ekbom Disease. Available online. Last accessed: October 1, 2011.
Stefansson H, Rye DB, Hicks A, et al. A Genetic Risk Factor for Periodic Limb Movements in Sleep. N Engl J Med. 2007;357:639-47.
Trotti LM, Bhadriraju S, Becker LA. Iron for restless legs syndrome. Cochrane Data Base Syst Rev. 2012;16;5:CD007834.
U.S. Food and Drug Administration. FDA approves Horizant to treat restless legs syndrome. FDA News Release, April 7, 2011. Available online. Last accessed September 17, 2011.
U.S. Food and Drug Administration. FDA's MedWatch Safety Alerts: July 2010. Available online. Last Accessed 21 September, 2010.
Advanced Studyec
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Review Date: 1/10/2013�
Reviewed By: Reviewed by: Harvey Simon, MD, Editor-in-Chief, Associate Professor of Medicine, Harvard Medical School; Physician, Massachusetts General Hospital. Also reviewed by A.D.A.M. Health Solutions, Ebix, Inc., Editorial Team: David Zieve, MD, MHA, David R. Eltz, Stephanie Slon, and Nissi Wang.


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The iPod Touch is basically an iPhone without the phone part.
So can someone explain why putting the phone part into an iPod Touch doesn't just make it identical to an iPhone now?
An since iPod Touches aren't subsidized by Mobile Carriers, an iPod Touch 3G should cost $500/$600 (the same price as an unsubsidized iPhone)
So why would Apple think people are going to pay $500 for an iPod Touch 3G (and a monthly data plan fee) when it would be much better value to just get an iPhone for much much less and probably pay the same amount per month on a mobile plan anywho.
If Apple does release an iPod Touch 3G, I hope the jailbreak community unlocks the device to be able to make and receive calls and basically do all the phone features of an iPhone.
I'd buy one, especially if it's $15/month for 250mb (cancel/restart no contract). I don't want an iPhone because I don't want to pay $500/year to talk. My prepaid cell phone costs $100/year for 1000 minutes, and I always have balance to rollover. But, I would love to have data practically everywhere on my iPod when travelling. It fit's in my pocket much better than an iPad.
The Google Voice app (at least for iOS) is not true VOIP, it still routes via a voice call to one of Google's call centers, very much like how Skype for BlackBerry works. Skype for iOS is a true VOIP app, but if you really ever tried to use it as a phone, streaming voice over 3G, your battery would die in an hour.Exactly. Google voice, skype, etc + an ear piece and you're good to go.
It will probably still be cheaper and won't need to be more expensive without being subsidized because the hardware will be cheaper.
Finally, it might be cheaper to buy an iphone if you already plan on signing up for 2 years of service and buying a voice and data package but for users who only want data (such as myself) it will still be much cheaper over the course of 2 years to buy a pre or postpaid data plan and be contract free.
Won't have an ear piece so won't be anything like an iPhone more like a mini iPad 3G!! Just my 2 pence worth
If the new iPod Touch 3G models require a micro SIM card, will I be able to use the micro SIM card on my iPhone 4 on the new iPod Touch?
This is not gonna happen.
I'd consider this over my phone if I could still get unlimited data with the touch, but being that they don't offer it on iPad either, this is extremely unlikely. Makes more sense for me to stay on a family plan with unlimited texting with the iPhone.
Just imagine a 3G iPod touch! Having a plan at 20 to 30 a month with unlimited text messaging and web! Every kid in school would be able to now connect with their parents! I've always said when they add not only 3G but text messaging it'll blow up just like pagers did back in the day! Mark my word!

subset: commoncrawl


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Billy Graham has appeared in many movies over the years, most of them produced by World Wide Pictures, the movie studio that he founded through his evangelistic ministry in the 1950s. But apart from a handful of parodies, no actor has ever played him before, and certainly no film has tried to show what kind of person he was prior to becoming the internationally recognized preacher that he is today. So there was lots of fertile ground for Billy: The Early Years, the first major Graham biopic, to explore. Too bad, then, that the film does such a poor job of bringing his story to life.
Review: Billy: The Early Years (dir. Robby Benson, 2008)
October 10, 2008 by Leave a Comment


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Justin Timberlake and Jessica Biel's Wedding Rings: All the Deets!
Want a peek at the rings Justin Timberlake and Jessical Biel exchanged during their October 19 wedding? Here you go!
-Lucia Peters
We've gotten a look at the dress; now it's time for a peek at the rings! Thanks to People, we've now got all the deets on the rings that Justin Timberlake and Jessica Biel—sorry, Jessica Timberlake—exchanged during their October 19 nuptials. What do you think, Bettys?
Read Jessica Biel's Perfect Pink Wedding Gown: All the Deets!
According to People, the couple collaborated with Las Vegas-based jeweler Leor Yerushalmi on their wedding bands' design. Justin's band is a simple yellow gold domed band with what's called a hammer finish—that is, a texture applied to the surface of the metal with a hammer to give it a dimpled look. Jessica, on the only hand (see what we did there?), went for four stackable wedding bands: Two are white gold with a black rhodium finish and diamonds set all around, while the other two are yellow gold with a hammer finish just like Justin's band. She only wore one of them when they exchanged their vows, as you can see in the photo above; we're sure that worn together, though, they're positively stunning.
Yerushalmi also designed the engagement ring Justin surprised Jessica with when he proposed last December. A what a sparkler it was: Consisting of a square hearts and arrows diamond set in 18-karat white gold plated with black rhodium, the ring features tiny round diamonds and a pair of aquamarines surrounding the center stone. We're loving the aquamarines in particular; Jessica was born in March, making the blue-green gem her birthstone.
Tell us: What do you think of Justin and Jessica's rings?
Lucia Peters is BettyConfidential's associate editor.


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Separate names with a comma.
Discussion in 'Thumpers' started by crankshaft, Sep 6, 2011.
Heh, Beemer on a tow truck, nothing new there.
Its higher.
Just connected TuneEcu to my 690R and noticed that it has loaded the 2009 stock map., however the bike has akrapovic exhaust, foam aifilter and powerparts airbox cover, does not stall, sputter, backfires, or anything.
Shouldn't it act all fussy with these mods and stock map?
It shakes a bit, nothing excessive, but its a single cylinder...
I'm almost inclined not to touch it rather than loading the akro map. If it gets better, it gets dangerous...
$10 says its lean, especially higher in the revs.
I tend to agree... next weekend i'll give it a try with the akro map then... which one BTW? In the TuneEcu site there is an all years Akro map and a evo1 map..
Can I fit a 690 enduro 12 light and surrounding plastic to my 690 R 2010?
OK need some help again. Backstory, I had the fuel pump replaced in March, then it started smoking so I replaced the piston and rings. I rode it about 60 miles and shut it off and it wouldn't restart, then it bound up. I pulled the valve cover and the wheel pin worked its way out of the intake valve rocker and was interfering with the exhause rocker.
I got it back together today and it started quick enough but is running like crap and sometimes won't start at all. When it does start it runs rough backfires a little, won't idle for long and if I give it throttle it bogs like a carbureted bike when it is still cold.
The only thing I know to check is the cam timing for the 3rd time. The engine light is not on.
I'd try to get some wideband O2 readings so you actually know what the bike is doing under load at various RPMs.
Running rich can create just as much damage as running lean.
I recently replaced the stock can on my 690 with the FMF Q4, and after examining the bike post ride, noticed the FMF was loose, even though the bolts are as tight as they can go. The FMF mounts via only one side of the exhaust mounting bracket. While the rubber grommets in the mounting bracket may introduce some play, they are likely present more so to decouple the pipe from the tank (shock absorption). If memory serves, the stock pipe was rock solid.
Anyone else experience this, and have a working fix ?
Tighten the clamp on the pipe, I have the same exhaust and its solid. Ridden all kinds of nasty with zero issues. You might be doing it wrong
(as the upper mount is riveted/siliconed to the pipe, and hence cant be tightened) How tight should the lower pipe clamp be ? I cant see the lower clamp being primarily responsible for rigidity, as that would put alot of stress on the header...
A loose exhaust is probably worse than a tight clamp, think of the weight of the muffler moving around. Think of it like a slide hammer.
Tight man, can't explain it..
Tighten I have, and she now feels much firmer. I'll slap myself for thinking the upper mount would/should bear the brunt of the weight....
Thanks Crank.
Start off checking the injector. Sounds like it could be fuel related. is the pump cycling when powered up? I know you replaced the pump already, but I'd start with fuel, and spark.
Honestly it is acting like the pump but I don't want to go there. The pump is making noise. I checked the spark before I put it all back together. I guess I'll study up on the injector.
That's where I'm at right now also. I cleaned mine myself, and the 690 fired up all sweet like (previously was not starting at all) but it does stall. Changed the fuel filter, recleaned the injector and and runs poor. Stalls when decelerating/stopping, and misses when accelerating. Holding Rpm, it runs, say doing steady 80 kph, or higher. But crack the throttle and it misses.
I have checked spark, wires, everything I could myself and taking the injector out and putting it back in was the only item that resulted in a positve.
So now today I'm in the process of finding someone to do the "ultrasonic" cleaning? Or at least at more "proffessional" cleaning than I gave it. Funny though, the shops I've called so far seem to do the same, homemade cleaning style that I do, just blow air backwards through it.
Once I can rule out the injector, then I'll look at a different part I suppose...but I think it's got something to do with it...
Agree, although finding such equipment with qualified technicians around here is quite a task.
The power wires going to the coil, the 2 spade connectors, were very corroded on my 2010. The gauge size is too small. I was have similar type of problems, it would run great, than barely idle or not start at all and no pattern to it. Just something else you may want to check
I had the same problem on my 09 690r. Seemed like a fuel problem but it was those blade connectors on the coil being a little loose. They were not corroded on my bike but crimping them for a tighter fit solved the problem.


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For companies needing reliable, secure regular backup, LTO 5 is an Ultrium tape that improves on the incredible speed and performance of previous LTO releases. LTO Ultrium tape has become the data backup media of choice among IT professionals. With archival longevity of fifteen to thirty years, LTO 5 will give you years of access to past data from your servers and workstations.
Linear Tape Open is a half-inch Ultrium backup tape with 256-bit encryption. Debuting in 2010, LTO 5 was an improvement over previous versions, doubling storage to 1.5 TB, which equals 1500 GB. The previous edition only had 800 GB. Additionally, the LTO 5 tape provided a slight increase in speed, going from 120 MB per second to 140 MB per second. With Ultrium tapes, the faster the speed, the more quickly data can be saved during your daily backups, which allows them to finish in plenty of time to avoid interfering with the next business day.
One of the newest functions of LTO 5 Ultrium tapes, however, is the new ability to split the tape into two separate write areas. This is thanks to the addition of a partition. Partitions are normally found on hard drives and servers, allowing separate space to be set aside as if it were a completely separate disk. With the LTO 5, this partition can set aside space for data to be stored in two separate areas. This allows the Ultrium tape to be accessed more quickly, which can speed up your ability to access your data and more easily manage it.
The LTO 5 is also WORM capable, allowing these Ultrium tapes to be set up with "write once, read many" capabilities. This, in conjunction with the 256-bit encryption, helps keep your data protected and secure. The LTO 5 is also a "greener" Ultrium tape, using less server power on average to write data than previous generations.


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You still have a few more days to select which players advance from the first round of the Madden 12 cover tournament.
ESPN.com video game writer Jon Robinson blogged some updates Thursday, and New York Jets quarterback Mark Sanchez is having a tougher time than expected with Miami Dolphins left tackle Jake Long.
Other surprises include Denver Broncos quarterback Tim Tebow getting thumped by Kansas City Chiefs running back Jamaal Charles.
The battle between Buffalo Bills receiver Steve Johnson and New England Patriots running back Danny Woodhead wasn't mentioned.
If you're a gamer who wants a sneak preview, you can watch the Madden 12 highlight videos for each of the 32 entries in the bracket.
I've included the Woodhead video below. Click on the other three AFC East nominees to see theirs:


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Study: Eviction Rates for Black Women on Par With Incarcerations for Black Men
Duke University Renames Aycock Hall, Triumphs Over Racist Past
Duke University President Richard H. Brodhead announced Monday the school is renaming a building that was dubbed in honor of a white supremacist. Aycock Hall had been named for a century in honor of former North Carolina Gov. Charles Brantley Aycock. He was considered an advocate for public education, but was a leader in the white supremacy movement prior to his tenure in the governor's office. That period was marked with violence against Republicans and Populists by Democrats who accused them of favoring "Negro domination." Read more.
Another Major Victory In The Fight Against Stop And Frisk
A New York state judge has upheld a law making it easier for citizens to sue police officers performing unlawful stop and frisks based on race. "This law provides an important opportunity for New Yorkers who are subject to racial profiling or other discriminatory behavior the opportunity to vindicate their rights," State Supreme Court Justice Anil Singh wrote in her decision Wednesday. Read more.
More Than 300 Deaths Now Reported in West Africa Related to the Ebola Virus
Dem Rep. Goes Off on Cheney: He Should 'Keep His Mouth Shut' on Iraq
House Democrat Gregory Meeks complained earlier this week that people should stop listening to John McCain on Iraq, and on MSNBC today he said Dick Cheney, of all people, should "keep his mouth shut" on this issue. Cheney has been making the rounds this week sharing his thoughts on Iraq, which has inspired reactions ranging fromskepticism to outright ridicule. Read more.


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UNIVERSAL CITY — Tickets to Jenni Rivera's memorial service Wednesday sold out today within an hour, according to various media reports.
A limited number of tickets were available on a first-come, first-served basis Tuesday at noon. Organizers of the event did not return phone calls, and did not say how many tickets were available.
The service, billed by the Rivera family as a "Celestial Graduation," will be from 10 a.m. to noon at Gibson Amphitheatre in Universal City. Rivera's brother, the Rev. Pedro Rivera Jr., will lead the ceremony.
The theater holds about 6,000 people.
The Los Angeles County Sheriff's Department will have more deputies on hand for what's expected to be a large crowd, Sgt. Kevin Rasmussen of the Universal City substation said.
He said deputies don't know exactly how many people will be there, but they will prepare for a sold-out crowd.
Sold-out events are a near-daily event at the venue, Rasmussen said, so the Rivera event isn't expected to be anything out of the ordinary.
"We're pretty much used to dealing with this," he said
Rivera, a 43-year-old Long Beach native, died Dec. 9 when her rented Learjet LJ25 crashed in northern Mexico about 15 minutes after departing Monterrey, Mexico. Six other people aboard also died.
The singer was en route to Toluca, outside Mexico City.
The family has requested that in lieu of flowers, fans make donations to the Jenni Rivera Love Foundation, along with a single white rose.
Burial services will be private.
Born in Long Beach, the mother of five who maintained an estate in Encino dominated the "banda" style of regional Mexican music popular in California and northwestern Mexico. She was one of the biggest stars on Mexico television and was popular on "regional Mexican" stations in California.
Rivera lived a tumultuous life, which was the basis for much of her music. She had been married and divorced three times, the last time from former Los Angeles Dodgers pitcher Esteban Loaiza.
The singer, who sold more than 15 million records, sang songs of heartbreak and abuse. She had her own reality show, and ABC was developing a comedy pilot for her, according to the entertainment website Deadline.com.


text:
The Betty Interview: Ziggy Marley– and a Free Listening Party!
The infamous reggae artist contributes his efforts and music to children, freedom and Disney.
-Shari Goldhagen
Reggae legend David "Ziggy" Marley has collaborated with everyone from Bruce Springsteen to Elton John. His newest partner, however, has some slightly larger ears.
"Working with Mickey Mouse is great," he jokes. "He's got a lot of fans and can help spread the message."
Ziggy is one of 13 performers covering famous Disney songs for the new children's album The Disney Reggae Club, which hits the airwaves this month.
"I'm doing Louis Armstrong's It's a Wonderful World, Ziggy tells BettyConfidential. "It's a wonderful song and Disney is loved by kids all over the world so it's a good way to reach out to kids with music and to introduce them to Reggae."
Read The Betty Interview: Common
Reaching out to the kiddies has long been a goal of the politically active crooner whose charity—Unlimited Resources Giving Enlightenment (URGE)—recently adopted the Chepstowe Basic School in his home nation of Jamaica and has been working to improve the quality of facilities. A dollar from every concert ticket goes toward the foundation, as well as a portion of proceeds from his record sales. But despite his status as Reggae royalty, Bob Marley's oldest son doesn't shy away from getting his hands dirty when it comes to things like building new classrooms and working with the students.
"There are a lot of problems in the world right now and one of the biggest ways to make a difference is to reach out to the children," says Ziggy, 41. "These are the people who will grow up and be the next citizens of the world, the ones who can make it a better place, so you want to get them while they're young."


text:
Brett Eldredge Looking Ahead To Next Album
Listen to Brett Eldredge Radio on iHeartRadio
Brett Eldredge says he's looking ahead. The singer tells Taste Of Country he's already working on his next studio project. He explains that he had virtually his "whole life" to pen material for his debut disc and will have significantly less time to prepare his sophomore effort, so he's "writing like crazy" for it.
But Eldredge says he's not ready just yet to move beyond his first album, and he expects to release at least one more single from Bring You Back. That album features Brett's breakthrough hit "Raymond" as well as the chart-toppers "Don't Ya" and "Beat of the Music."
Photo: Getty Images


text:
Suburban Propane's Player of the Week: Nerissa Long
April 20, 2013
Photo for the Union by John Hart
Nerissa Long
Bear River softball
Bear River's Nerissa Long impressed from the slab this week going 2-0 in two Pioneer Valley League starts, beating Colfax and Center. The hard throwing freshmen pitcher struck out a combined 30 batters in the two wins and allowed only one earned run. On the season, Long is 5-0 in PVL play with a 1.20 ERA.


text:
Submit News
Study: Single Gene, Plus Some "Junk" DNA Turned Ape Ancestors Into Modern Man
Jason Mick
November 23, 2012 11:03 AM
Recipient E-mail
Sender E-mail
(Source: Matt Groening/Fox)
Crucial gene controls higher brain growth
To the uninformed observer it may seem baffling how geneticists, biochemists, paleontologists, and other researchers can claim that two creatures that look as different as a man and a monkey could not only be "related" but have been
produced by evolution
the last couple million years
I. It's All in the Genes
But the key to understanding evolution is to understand genetics: our body is driven by protein enzymes, which catalyze critical processes inside the body. Many proteins share common domains. And the blueprints to all the proteins a creature makes are stored in a special highly-ordered storage construct called DNA.
While living organisms go to great lengths to preserve their genetic code without errors like swapped sections or deletions, occassionally during the process of making sperm and eggs such an error is made. Most errors result in infertility or death of the offspring. But occasionally just the right combination of protein domains has accidentally been clumped together, producing something that fundamentally transforms the organism.
Researchers have finally found a gene -- perhaps
gene -- which separates humans from the ancestors they share with apes.
Humans and apes, both members of the order Primates, share
96 percent of their genetic code
. Most of the remaining 4 percent is so-called "junk" DNA; stretches of mostly inactive code.
Humans share 96 percent of their genetic code with primates, like this
Rhesus macaque
[Image Source: Mark Snelson]
Of course, junk DNA is not useless geneticists and biochemists have recently discovered. It has been shown to in many cases play a key role in regulation of other genes' expression and other "epigenetic" effects.
But researchers had yet to discover a truly active gene that humans have that apes lack -- until now.
II. miR-941 May Hold the Key to How Mankind is so Crafty
Researchers at the University of Edinburgh in Scotland have discovered a gene called miR-941, which is only found in humans and is absent in their primate relatives.
The gene was absent not only in the gorilla and
chimpanzee genomes
, but also in the genomes of other non-primates, such as mice and rats. The gene, absent in all the other critters except for man, is mainly active in the brain; particularly in areas of the brain
associated with so-called "higher brain" functions
The gene was actively being transcribed in the regions of the brain responsiible for language learning and decision making. Researchers hypothesize that it may play a key role in abilities that are largely unique to humans, such as formulating, understanding, and preserving multiple complex communications codes (languages) and developing advanced tools (weapons, machinery).
The newly discovered human-unique gene is active in areas of the brain associated with higher thinking processes. [Image Source: Neuroimages Tumblr]
Some other creatures -- gorillas, parrots, dolphins, and whales -- show different levels of sign language or spoken/sung language skills. And chimpanzees, octupi, and other creatures have been shown to use basic implements, like sticks, as tools. However, only humans are known to manifest these helpful survival skills in more complex manners.
Now, modern genetics may have cracked a key mystery of human evolution and explained why.
The research was
in the prestigious peer-review journal
Nature Communications
Nature Communications
"Well, we didn't have anyone in line that got shot waiting for our system." -- Nintendo of America Vice President Perrin Kaplan
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Wild YamSkip to the navigation
Parts Used & Where Grown
Wild yam plants are found across the midwestern and eastern United States, Latin America (especially Mexico), and Asia. Several different species exist. All of which possess similar constituents and properties. The root is used medicinally.
Our proprietary "Star-Rating" system was developed to help you easily understand the amount of scientific support behind each supplement in relation to a specific health condition. While there is no way to predict whether a vitamin, mineral, or herb will successfully treat or prevent associated health conditions, our unique ratings tell you how well these supplements are understood by the medical community, and whether studies have found them to be effective for other people.
For over a decade, our team has combed through thousands of research articles published in reputable journals. To help you make educated decisions, and to better understand controversial or confusing supplements, our medical experts have digested the science into these three easy-to-follow ratings. We hope this provides you with a helpful resource to make informed decisions towards your health and well-being.
3 Stars Reliable and relatively consistent scientific data showing a substantial health benefit.
2 Stars Contradictory, insufficient, or preliminary studies suggesting a health benefit or minimal health benefit.
1 Star For an herb, supported by traditional use but minimal or no scientific evidence. For a supplement, little scientific support.
This supplement has been used in connection with the following health conditions:
|Used for
1 Star
High Cholesterol
Refer to label instructions
Wild yam has been reported to raise HDL ("good") cholesterol in preliminary research.
Wild yam has been reported to raise HDL cholesterol in preliminary research. Doctors sometimes recommend 2 to 3 ml of tincture taken three to four times per day, or 1 to 2 capsules or tablets of dried root taken three times per day. 2
1 Star
Refer to label instructions
Wild yam is an herb with weak estrogen-like actions similar to soy. In one trial, a formula containing licorice, burdock, dong quai, wild yam, and motherwort reduced menopause symptoms.
A variety of herbs with weak estrogen-like actions similar to the effects of soy have traditionally been used for women with menopausal symptoms.3 These herbs include licorice , alfalfa , and red clover . In a double-blind trial, a formula containing tinctures of licorice, burdock , dong quai , wild yam, and motherwort (30 drops three times daily) was found to reduce symptoms of menopause.4 No effects on hormone levels were detected in this study. In a separate double-blind trial, supplementation with dong quai (4.5 grams three times daily in capsules) had no effect on menopausal symptoms or hormone levels.5 A double-blind trial using a standardized extract of subterranean clover (Trifolium subterraneum), a relative of red clover , containing 40 mg isoflavones per tablet did not impact symptoms of menopause, such as hot flashes, though it did improve function of the arteries.6 An extract of red clover, providing 82 mg of isoflavones per day, also was ineffective in a 12-week double-blind study.7 In another double-blind study, however, administration of 80 mg of isoflavones per day from red clover reduced the frequency of hot flashes in postmenopausal women. The benefit was noticeable after 4 weeks of treatment and became more pronounced after a total of 12 weeks.8
Traditional Use (May Not Be Supported by Scientific Studies)
Wild yam has been used by herbalists as an expectorant for people with coughs . It was also used for gastrointestinal upset , nerve pain, and morning sickness .1 Eventually, it was discovered that the saponins from wild yam could be converted industrially into cortisone, estrogens, and progesterone -like compounds. Wild yam and other plants with similar constituents continue to be a source for these drugs.
How It Works
How It Works
The steroidal saponins (such as diosgenin) account for some of the activity of wild yam. Another compound, dioscoretine, has been shown in animal studies to lower blood sugar levels.9 An extract of wild yam was also found in a clinical trial to have antioxidant properties and raised HDL, the "good," cholesterol in elderly adults.10
Contrary to popular claims, wild yam roots do not contain and are not converted into progesterone or dehydroepiandrosterone ( DHEA ) in the body.11 , 12 Pharmaceutical progesterone is made from wild yam using a chemical conversion process. This can lead to confusion—while wild yam can be a source of progesterone, it cannot be used without this pharmaceutical conversion, which cannot be duplicated by the body. Women who require progesterone should consult with their physician and not rely on wild yam supplements.
How to Use It
Up to 2–3 ml of wild yam tincture can be taken three to four times per day. Alternatively, 1 gram of dried, powdered root can be taken three times each day.13
Interactions with Supplements, Foods, & Other Compounds
Interactions with Medicines
Side Effects
Side Effects
Some people may experience nausea or vomiting when taking large amounts of wild yam (several times the recommended amounts). The safety of wild yam during pregnancy and breast feeding has not been established.
Related Information
1. Lust JB. The Herb Book. New York: Bantam Books, 1974, 401.
2. Araghiniknam M, Chung S, Nelson-White T, et al. Antioxidant activity of dioscorea and dehydroepiandrosterone (DHEA) in older humans. Life Sci 1996;11:147-57.
3. Crawford AM. The Herbal Menopause Book. Freedom, CA: Crossing Press, 1996.
4. Hudson TS, Standish L, Breed C, et al. Clinical and endocrinological effects of a menopausal botanical formula. J Naturopathic Med 1997;7(1):73-7.
5. Hirata JD, Swiersz LM, Zell B, et al. Does dong quai have estrogenic effects in postmenopausal women? A double-blind, placebo-controlled trial. Fertil Steril 1997;68:981-6.
6. Nestel PJ, Pomeroy S, Kay S, et al. Isoflavones from red clover improve systemic arterial compliance but not plasma lipids in menopausal women. J Clin Endocrinol Metab 1999;84:895-8.
7. Tice JA, Ettinger B, Ensrud K, et al. Phytoestrogen supplements for the treatment of hot flashes: the Isoflavone Clover Extract (ICE) Study: a randomized controlled trial. JAMA 2003;290:207-14.
8. van de Weijer PHM, Barentsen R. Isoflavones from red clover (Promensil®) significantly reduce menopausal hot flush symptoms compared with placebo. Maturitas 2002;42:187-93.
9. Iwu MM, Okunji CO, Ohiaeri GO, et al. Hypoglycaemic activity of dioscoretine from tubers of Dioscorea dumetorum in normal and alloxan diabetic rabbits. Planta Med 1990;56:264-7.
10. Araghiniknam M, Chung S, Nelson-White T, et al. Antioxidant activity of dioscorea and dehydroepiandrosterone (DHEA) in older humans. Life Sci 1996;11:147-57.
11. Araghiniknam M, Chung S, Nelson-White T, et al. Antioxidant activity of dioscorea and dehydroepiandrosterone (DHEA) in older humans. Life Sci 1996;11:147-57.
12. Dollbaum CM. Lab analyses of salivary DHEA and progesterone following ingestion of yam-containing products. Townsend Letter for Doctors and Patients Oct 1995:104.
13. Bertram T. Encyclopedia of Herbal Medicine. Dorset, England: Grace Publishers, 1995, 454.
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Last Review: 04-14-2015
Copyright © 2015 Aisle7. All rights reserved. Aisle7.com
Learn more about Aisle7, the company.
The information presented in Aisle7 is for informational purposes only. It is based on scientific studies (human, animal, or in vitro), clinical experience, or traditional usage as cited in each article. The results reported may not necessarily occur in all individuals. For many of the conditions discussed, treatment with prescription or over the counter medication is also available. Consult your doctor, practitioner, and/or pharmacist for any health problem and before using any supplements or before making any changes in prescribed medications. Information expires June 2016.


text:
Can I use a nic-handle from another database?
Yes, but you must create a person/role object in the RIPE Database to ensure referential integrity. There is no existing distributed database of person/role objects (i.e. contact information) as proposed in "rps-dist" (RFC-2769).
Please note that updating an object in one database does not mean the object will be updated in any other database.


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Just like the first out-of-towner to exercise his free agency in Utah, Jazz shooting guard Randy Foye on Thursday declared, "This is the place."
In different, less historically familiar words, so did DeMarre Carroll, Jamaal Tinsley and Mo Williams.
They make up a group of Jazz free agents whose summer intentions aren't as highly anticipated as those of Al Jefferson or Paul Millsap, but played a key role in a winning season that ended Wednesday when the Jazz finished two games out of the playoffs.
Players including Foye, Tinsley and Carroll all said they hoped to re-sign with the Jazz in the offseason.
"I want to be here," Foye said. "I just feel as though, no matter what nobody else do, it's all about me. I feel as though this is the place for me."
As many as 10 players will be free to sign elsewhere in the summer when they officially become free agents on July 1. Jefferson and Millsap are the headliners, but the Jazz could opt to let them go and be replaced by young big men Derrick Favors and Enes Kanter.
So, what about the rest of the free agents?
Williams, a key to the Jazz's successes, but also their shortcomings when he missed 32 games due to right thumb surgery, said he would like to return to the Jazz, but that it's not necessarily up to him.
"I think it's the ball is in their court," Williams said. "And I think it's more so what direction they want to go. They know how I feel, I know how they feel, so we'll see what happens."
The 35-year-old Tinsley said he thinks he can play "three or four more years" in the NBA, despite being signed to the Jazz in 2010 out of the D-League.
"Hopefully I come back," he said. "If not, it was a good two years for me. I helped a whole lot of young guys develop."
Williams was drafted by the Jazz with the 47th pick in 2004, but signed with Milwaukee after his rookie season. Later, he left the Bucks for Cleveland. It's a routine the one-time All-Star is plenty familiar with.
"We as basketball players," Williams said, "we just sit by the phone in the summertime and the agent and [Jazz executives] Kevin [O'Connor] and Dennis [Lindsey], they do all the talking. We just say, 'Oh, OK. Oh, OK. Sure. Oh. OK. Really?' That's about all that will come from my mouth. That's why we pay our agents and that's why we put our trust in them and let them have our best interests."
The Jazz are likely to build around Favors, Kanter and Gordon Hayward, but are salary cap-rich after missing the playoffs for the second time in three years. The Jazz hold a team option on rookie Kevin Murphy, and Marvin Williams holds an early termination clause.
In the end, just five players on the roster have guaranteed contracts for next season, which likely means the busiest offseason in team history.
Lindsey, the general manager, said he thinks the Jazz can attract quality free agents, if not retain members of the current team.
"I think we have a great story to tell about the history of the organization," Lindsey said. "I think we have plenty of roster spots and a lot of salary cap to pay good players."
Jazz players' statuses
Al Jefferson • Free agent. Paul Millsap • Free agent. Mo Williams • Free agent. Randy Foye • Free agent. Jamaal Tinsley • Free agent. Earl Watson • Free agent. DeMarre Carroll • Free agent. Marvin Williams • Early termination clause. Kevin Murphy • Team option. Jerel McNeal • Non-guaranteed contract.
Saturday's NBA playoff games
O Boston at New York, 1 p.m., Ch. 4
• Golden State at Denver, 5:30 p.m., ESPN
• Chicago at Brooklyn, 6 p.m., ESPN
• Memphis at L.A. Clippers, 8:30 p.m., ESPN


text:
Every era has its defining default mode when it comes to wit, and the sarcasm of the 1990s has given way to millennial snark. Lawrence Dorfman sees snark everywhere, in everyday conversation, and suggests the listener embrace it as a tool to irritate others and get what they want. The Snark Handbook takes a look at the storied tradition of snark, from Lewis Carroll to Gossip Girl. Bernard Setoro Clark has an appropriate, amusingly smarmy tone as he recites quotations from Snark Hall of Famers like Woody Allen, WC Fields, Mae West, and many more, in this entertaining collection.
Comebacks and flip flops - historical and contemporary - that capture the current era of snarky humor.
It's impossible to go a full day without using snark, so why fight it? Snark is everywhere, from television to movies to everyday life. This lively collection provides hours of entertainment - better than an Etch A Sketch, and more fun than Silly Putty! At the heart of it, being in a state of snark can be one of the most useful tools at one's disposal and hence (yes, I used "hence"), a powerful way to get what you want. With snark, you can catch people completely off-guard, and royally piss them off.
Included here is the Snark Hall of Fame, the Best Snarky Responses to Everyday Dumbassness, and much more. It's a book that will make you laugh. It's a book that will make someone else cry. It's a book every student of the American psyche (that's all of us, Sparky) needs to have. Let loose. Let your inner anger become a positive rather than a negative, but most of all, have fun. (Yeah, like that's something you know how to do.)
©2009 Lawrence Dorfman (P)2012 Audible, Inc.
When the word "Handbook" appears in a title, I expect some kind of training or instruction. "Right", I thought, "here's my chance to sharpen my tongue, be witty, and get even wittier". No, my friends, it didn't happen, and probably ain't gonna. I thought I was going to learn when to sock it right back, and when to put a sock in it. What works in the world of repartee, and what doesn't. You know …. It's a HANDBOOK! (Not!)
It's a collection of snide and snarky remarks we've heard before. Like a book of quotations, mostly by famous people, and most of which we've come across elsewhere. It doesn't even give me a handy list of bumper stickers I could sell to get my money back. If we were to use it, we'd simply be parrots. I was aspiring to be unique!
This attempt at a book is a pathetic rip-off.
"save your money"
this book is nothing but snarks from famous people. Nothing to do with verbal sparing. Save your money.
Tell us about yourself!
"Some books just don't work in audio format"
This would be a great bathroom reader. I'm not sure what I expected, but I am not pleased with what I got. Chapters of anecdotal quips create a schizophrenic listen that had me reaching for the stop button after an effortful half-hour. Save the credit and buy the print version - I am sure I would have enjoyed it much more than my attempt at the listen.
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