text:
Collins not fretting over Tejada's lackluster spring
By Anthony DiComo / MLB.com
VIERA, Fla. -- Well aware of shortstop Ruben Tejada's big league track record and future potential, manager Terry Collins refuses to fret over the 23-year-old's unproductive spring.
"When the bright lights are on," Collins said, "when there's people sitting in the second deck, what they do in those circumstances is what I look at."
What Tejada has done is hit .287 over the past two seasons, reaching base often enough for the front office to avoid searching for an offseason upgrade. Defensive metrics reveal that Tejada has been a tick above average with the glove over that span, giving Collins all the more reason to commit to him.
But Tejada is batting only .080 in his second spring as a full-time starter, totaling four hits in 58 plate appearances. Since homering off Stephen Strasburg in his first Grapefruit League at-bat on Feb. 23, Tejada has gone 3-for-49 with one extra-base hit.
Tejada has worked recently on his contact hitting, trying to spray pitches to right and center field while avoiding fly balls. Tejada also claims he is comfortable at the plate, even if the results have yet to appear.
"I feel good," Tejada said. "I've felt good the last two weeks. I've just got to keep going the same way, try to make good contact so I'm ready for next week."
Murphy's ribs fine after making spring debut
VIERA, Fla. -- If there was any doubt as to the state of Daniel Murphy's strained right intercostal muscle, the second baseman erased it on a wild play in the first inning Thursday. Moments after singling on the first big league pitch he saw all spring, Murphy tagged from first to second, belly-flopping onto the base to beat the tag.
"I bit the ground, but I felt pretty good on it," Murphy said, joking that he "tackled" the bag. "It was the right play."
Murphy finished 1-for-3 during the Mets' 5-1 loss to the Nationals in his long-awaited Grapefruit League debut, which came approximately six weeks after he strained his intercostal in the early days of camp. Though he punched a broken-bat single into right field in his first at-bat, Murphy called that hit "trash." More encouraging, Murphy said, was the line drive he smashed directly at the second baseman in his second at-bat, and the sharp foul he hit before striking out in his last.
Most heartening, of course, was the fact that Murphy felt no twinge in his side, no pain, no discomfort -- nothing.
"That was the good thing about today," Murphy said. "I didn't feel it at all and I was able to just play the game. Now I'll just use these next two days to get my legs underneath me as much as possible, and I'm looking forward to going north."
As long as Murphy remains healthy, he will appear in each of the Mets' final two Grapefruit League games, against the Cardinals and Orioles. Though facing Nationals left-hander Gio Gonzalez was a good first test for Murphy, he believes seeing as much Major League pitching as possible over the next two days will be crucial.
"He needs to [push it]," manager Terry Collins said. "He needs to a little bit, otherwise he stays here. He's got to show us that he's ready to play. He's got to show that he's not going to have a problem swinging the bat or with his mobility, because he hasn't played much. You've got to go play."
Most significant will be making sure that the ribcage discomfort, which has been a part of his life for a month and a half, does not resurface.
"I can't just show up and play without getting some work done on it just to make sure it's ready, but the training staff's done a great job," Murphy said. "I feel good. I felt good today. We'll see how I feel tomorrow."
Worth noting
• Third baseman David Wright (strained left intercostal) returned to Minor League action on Thursday, playing five innings at third base for the first time since the World Baseball Classic. Wright finished 0-for-3 with two walks and two runs scored, telling reporters in Port St. Lucie that he hopes to return to Grapefruit League play on Friday. That would all but ensure that Wright is ready for Opening Day.
• The Mets announced that "Shameless" star Emmy Rossum, a New York City native, will perform the national anthem on Opening Day at Citi Field. Rossum will sing alongside the Scholars' Academy children's choir from Far Rockaway, Queens, as the Mets honor various servicemen and volunteers for their efforts during Hurricane Sandy.
Anthony DiComo is a reporter for MLB.com. Follow him on Twitter @AnthonyDicomo. This story was not subject to the approval of Major League Baseball or its clubs.


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Thanks for helping us sort this video!
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Помогите нам: эти порнозвезды присутствуют в этом видео?
Pornstar Name:
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loved it,arm aching,but happy!
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I love it makes me horny
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@ wantapussyonmypussy & anyone I was thinking the SAME thing...that totally turns me on and ive been looking for vids like that. love pussy rubbing together.
i want to fuck the girl
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subset: commoncrawl


text:
Vittorio Zunino Celotto/Getty Images
Vittorio Zunino Celotto/Getty Images
Naomi Campbell is used to mugging for the camera—not being mugged!
Reports have surfaced that the British supermodel was accosted and injured by a group of men while trying to hail a cab in Paris last month just before Christmas.
Per the New York Post, the 42-year-old Campbell tore a ligament in her leg after she was "knocked over and robbed" by the thugs, a fact apparently borne out by photos that have popped up showing her in crutches and a wheelchair over the last couple of weeks.
No word exactly what the muggers made off with. In the wake of her alleged run-in with the gang, the catwalker's billionaire boyfriend, Vladimir Doronin, reportedly flew her to Vail, Colo., to be treated by an orthopedic surgeon there and has increased the security around her.
However, oddly enough, while the Post reported that French police were investigating the matter, a source with authorities in Paris tells the U.K.'s Daily Mail that law enforcement has no record of an official report of the crime for that month, either with its criminal brigade or with city hospitals.
"If such a serious crime had taken place then a criminal inquiry would have started by now, especially if the victim ended up in a wheelchair," a police source told the paper.
A rep for Campbell was unavailable for comment, though Naomi herself told the Post when reached by phone that she's "fine."
This isn't the first time Campbell's been involved in an incident of violence, though in the past she hasn't exactly been the victim, such as the time in 2007 when she pleaded guilty to misdemeanor assault for hurling a cell phone at her maid's head.
Campbell is now said to be vacationing in Miami, where she's preparing for the premiere of her new Oxygen design competition show, The Face.


text:
Obix Labs have just announced the official release of XConfig, which is a Java/XML configuration library that also works nicely with Spring. It supports auto-reload, annotations, Spring property placeholders etc. And there is no need to write any new classes or to use property files anymore.
For example, it can be integrated into a Spring application like so:
- Annotations which are handled by the bean factory. For example: @FromConfiguration("/@London")private String greetingInLondon;
- Property placeholders like: <property name="greetingInLondon" value="${/@London}"/>
Also, it does not need any new code. So you do not have to write any new Java classes. All you have to do is to store your XML in a configuration file.
The files are modular, so for once you can seperate out the config you want other people to change and the ones that should be handled by development only. For example database or production sensitive information which is only set by system administrators at deploy time.
It also supports auto-reload. So if you change your config, your application can pick up the changes immediately--although this feature is not enabled for annotations or placeholders.
For more information, go to the site: http://www.obix-labs.com/display/jsp/technology/xconfig.jsp


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Damn. Didn't see that coming....not this early.
Damn. Didn't see that coming....not this early.
Umm... was this weeks episode a repeat. For some reason my DVR recorded last weeks episode.
definitely not a repeat.
i really like this show, i'm surprised at how well done it is.
anyone know if it's been picked up for Season 2??
I had Sunday's episode DVR'd and just watched it last night, excellent episode. I was getting worried there, episodes 2 & 3 weren't that good IMO. The scene where the walkers invaded the camp was great, I like the action scenes and the more shooting the better. And of course the walkers taking bites of flesh out of people
great show. that's awesome news about the second season.
How come nobody ever came up with a zombie series before completely baffles me.
Zombie TV without being "too graphic" for Network is impossible. Cable (HBO) and the like only really recently started doing shows like this, and now the AMC'sa re following in the success wake (thankfully).
In the future, I don't knwo what netowrk is going to do, because the vast majority of good TV is being done on Cable now.
Watched it this morning. This is such an awesome tv show, not because of the zombie killing but the drama.
Good episodes with some question marks at the end.. How did the walkers reach camp?
The series is so good that I questioned how they didn't hear all those zombies shuffling through the woods. Apparently I had no problem with the fact that zombies existed in the first place....
The plots thus far have been the perfect mix of gore, tension and (human) character development.
Just read the graphic novels (which are currently about a year ahead of where the show is) and if you think things are nuts right now just wait this series has serious potential if they stick to the story, and i guarantee no one here will be able to predict the direction this story goes
the best part of the series i think is the additional stories and cast that are not part of the graphic novel


text:
You need to check LockerPro in accessibility settings in order to get notificstions to the lockscreen.
Thanks Kinology!
We are waiting almost one month, after hashcode's TWRP release!
In LockerPro lite, it currently shows "Service Inactive" under "Accessibility Service" and clicking it causes LockerPro to FC. I'll investigate that and see if there's anything I can do.
This looks mighty interesting. Can anybody provide more screenshots?
Storage isn't working under device.
No complaints here but if I could be so bold, would you include the cyanogenmod keyboard for a future release?
XDA Developers was founded by developers, for developers. It is now a valuable resource for people who want to make the most of their mobile devices, from customizing the look and feel to adding new functionality.
Are you a developer? | Terms of Service
Copyright © xda-developers. Hosted by Leaseweb


text:
Customized t-shirts and tank tops from ePromos get your company's name out there in style! Our selection of various cuts and designs work well to demonstrate business affiliation at both professional and recreational functions. Outfit your staff for a volunteer event or hand these tees out as promotional gifts at your next corporate expo. When given as a keepsake, customers and employees can proudly broadcast your brand name from the gym to the grocery store. ePromos is ready to help you find the perfect design to complement your company logo. Partner with us and you'll be 110% satisfied with your promotional t-shirts, guaranteed!
These UltraClub 2-tone custom t-shirts will cool and dry while keeping your brand hot!
This moisture wicking custom t-shirt keeps your whole team fresh and confidently cool.


text:
No Hidden Fees - No Credit Card Surcharges - Low Shipping Rates
Images shown may not be an exact representation of the actual product.You may contact us if you have questions about the exact specifications of this item.
The Caldwell XLA Bipods provide a stable shooting support that conveniently attaches to almost any firearm with a sling swivel stud. The lightweight aluminum design adds minimal weight and deploys quickly, with legs that instantly spring out to the shooting position with the touch of a button.
The legs are notched for easy indexing to a specific height. There is a connection point for sling attachment and multi section legs that collapses forward allowing for convenient carry of the firearm. Soft rubber feet provide enhanced stability, while the padded bipod base protects the firearm's forend.
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text:
Hey guys,
I am using MPI to send data between multiple processors. I have one file that I run on about 12 processors, all of which send data back to a single file running on a main node.
I am trying to have the file which is running on the 12 processors spawn a text file with some information regarding the data and time sent to the main node.
However, in the one file running on 12 processors, the code I am using to open the file and print to it is not working. I have a strong feeling this is because the way the code is written now, it is trying to open 12 of the same file and there is a conflict.
I am trying to think of a way to print this information to a file without doing it the cheesy, obvious way, I.E - replicating the fprintf() statements 12 times and have 12 fopen()s, f close()s, etc.
Does anyone have any ideas?


text:
De Hoop Scheffer invites Switzerland to expand ISAF role
- English
- French
During a visit to Bern on 5 July, NATO Secretary General Jaap de Hoop Scheffer invited NATO partner country Switzerland to contribute to the expansion of the Alliance's presence in Afghanistan.
During a visit to Bern on 5 July, NATO Secretary General Jaap de Hoop Scheffer invited NATO partner country Switzerland to contribute to the expansion of the Alliance's presence in Afghanistan.
The Secretary General discussed the results of NATO's Istanbul Summit in meetings with the President of the Swiss Confederation, Joseph Deiss, Foreign Minister Micheline Calmy-Rey, Defence Minister Samuel Schmid and members of the Swiss Parliament.
Working together for security
At the Summit, NATO and partner countries agreed to further strengthen cooperation. The Alliance also announced a new expansion of its presence in Afghanistan. Switzerland and a number of other partner countries are contributing to the NATO-led International Security Assistance Force (ISAF).
Speaking to reporters, the Secretary General said he encouraged partner countries to boost their engagement in Afghanistan by contributing to the five provincial reconstruction teams NATO will be operating in the north of the country.
Mr. De Hoop Scheffer also mentioned the possibility of Switzerland contributing to NATO's assistance to the government of Iraq with the training of its security forces, which was also agreed at the Summit.
He praised Switzerland for its contribution to NATO's Partnership for Peace, including support for Trust Fund projects to assist other partner countries in destroying weapons and munitions stockpiles.
The Secretary General also welcomed the recently launched reform of the Swiss armed forces, saying that making them more flexible and interoperable would put Switzerland on the right track for contributing to international security through co-operation.


text:
October 2012
Lurasidone (Latuda) in Context
The new antipsychotic lurasidone (Latuda) may cause less weight gain than other second-generation antipsychotics but may not be the most efficacious treatment for patients with schizophrenia.
Antidepressants and Acute Angle-Closure Glaucoma
Recent use of antidepressants appears to increase the risk of acute angle-closure glaucoma in elderly patients.
Clozapine Can Prevent Suicide
An increased use of clozapine (Clozaril and others) to treat schizophrenia would prevent more suicides than the number of deaths that would be caused by its adverse events.
In Brief
Obesity and Metabolic Abnormalities in Midlife Associated with Later Cognitive Decline; EMR Practices Provide Less Depression Treatment for Patients with More Complex Conditions
Doctors Overestimate Patient Adherence to Antipsychotics
In a recent survey, physicians were correct about the level of treatment adherence for only about half of their patients.
Osteoporosis, Fracture Risk, and Schizophrenia
Data suggest that both schizophrenia and the drugs used to treat it increase the risk of fractures by causing osteoporosis.
Osteoporosis, Fracture Risk, and Schizophrenia
October 2012
Osteoporosis is an abnormally low bone mineral density (BMD). It has been reported to occur more often in people with schizophrenia than in the general population. Kishimoto and others conducted a review of studies on BMD, osteoporosis, and fracture risk in people with schizophrenia.1


text:
Indoor and outdoor pool and hot tub, sauna, free hot breakfast buffet, ticket service, gift shop, game room, fitness center, wireless high-speed Internet access, guest laundry, elevator, level parking, 24-hour front desk, indoor and outdoor corridors, Montana Mike's Steak House on premises, picnic area.
In-room coffee, iron and ironing board, hair dryer, remote TV with HBO Family, wireless high-speed Internet access, free local calls, electronic locks, non-smoking rooms, two sink vanities available.
* Some room types are not available for on-line reservations.
The hotel's enclosed breakfast area can be used as a meeting space after breakfast hours (usually available by 11:00AM). Contact the hotel directly for details regarding this arrangement (877. 334.1894). View Event Facilities & Services section for more information.


text:
Hewlett-Packard Comp. (HPQ) is still the number one supplier of
personal computers, but its moves in recent weeks have baffled many. It killed its first
webOS tablet two weeks ago, after only giving the device six weeks
to prove itself on the market. At the same time, it announced that it
would be looking to get rid of its
consumer personal computer business.
HP wrote:
HP also reported that it plans to announce that
its board of directors has authorized the exploration of strategic alternatives
for its Personal Systems Group (PSG). HP will consider a broad range of options
that may include, among others, a full or partial separation of PSG from HP
through a spin-off or other transaction.
The PSG is HP's unit responsible for making consumer PCs. Apparently the
"other transaction" is more or less off the table, according
to PSG head Todd Bradley, who spoke with Reuters in an
interview. HP now seems to have its mind set on a spin-off.
Mr. Bradley states, "A standalone company could and will do what's most
required to drive value for shareholders and partners."
He says that "the numbers don't support" a sale. In other
words, HP might want to sell the PSG to somebody, but no major
manufacturer has the cash to stomach the $10-12B USD cost of the unit.
Taiwan's ASUSTEK Computer, Inc. (TPE:2357)
and Acer Inc. (TPE:2353)
-- two prospective buyers don't have the cash. Nor does Hong
Kong-based Lenovo Group, Ltd. (HKG:
0992), which has $3.8B USD cash on hand and would have to relying on
a heavily stock-based purchase should it make an offer.
For now, Mr. Bradley is soldiering along like business as usual. He
comments, "[R]egardless of what happens, we're the largest PC company in
the world. We need everybody energized, and while this isn't business as usual,
we need people to go out and sell products every day."
He's currently on an Asian trip to strengthen the PSG's Chinese manufacturing
capabilities. The PSG plans to increase investments in China,
consolidating its six local employee sites into a single large campus, located
near Shanghai, which it will make its regional headquarters. It also
plans on expanding its manufacturing in China.
Securing cheap, steady contracts for Chinese parts and labor has been a key to
Apple Inc.'s (AAPL) rise to third place in the U.S. personal
computer market.
Mr. Bradley says a webOS revival could be in the works. Following the
rash of interest during the webOS clearance, he says several
manufacturers (presumably tablet or smart phone manufacturers) have approached
HP about licensing the OS. He also would not
rule out a TouchPad revival, stating, "Tablet computing is a segment of
the market that's relevant, absolutely."
The PSG head, recently named Fortune's "smartest executive", has
big plans -- he says he hopes to be chief executive at the new company, should
a spinoff occur. He states, "Unwinding the integration that's taken
place within HP will be enormous amounts of work and effort, justified by the
return we think we'll be able to provide to our shareholders. My
intention would be to lead [the PSG] through this transaction...and if it's a
standalone public company, to lead that."


text:
Making Your Houseplants Chirp When They're Thirsty
11 comments post a comment
Sometimes I think it might be nice if a few of my houseplants would just tell me when they need a drink.
I have a plethora of plants in my house. They all have different watering schedules, but like many people, I'm a creature of habit.
The plants that need watering daily or every other day are taken care of, but those that need water on a more varied schedule can often get overlooked. Chirp sets out to remedy this with a simple alarm.
The Chirp alarm is a small pcb that is inserted into the soil at its driest desired point. From that moment forward it monitors the soil and begins to sound an alarm when the soil reaches the preset dry point. It begins with a quiet chirp, getting more urgent over time. However, it is nice enough to silence itself at night by detecting light levels. The developers note that the battery, a single button cell, can last roughly a year depending on how often it chirps and the light sensors are used. If you keep your plants watered, the battery lasts longer.
One interesting aspect of the chirp is that it is uses capacitive humidity sensing. A capacitive sensor doesn't require physical contact so it can be coated to help prevent corrosion. If you would like to read details about how exactly the capacitive sensing works, the developer has written a nicely detailed article on it here. The rest of the hardware is pretty simple. The device uses a ATTiny44a with a standard AVR 6 pin ISP programming header, allowing for customizing your modifications. This ISP header is also there so that another device can be used to read the data, should a user want to incorporate the Chirp into a larger project.
This project is entirely open-source and even comes with downloadable code. A gallery of images is posted on the website, showing the various prototypes the designers iterated on before landing on final design. One amusing thing to point out: Chirp actually began as a joke. Some people say there is a grain of truth to the best jokes, so with that in mind, the Chirp was born.


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The Clemson women's tennis team is set to play 10 home matches at the Anderson University Tennis Facility in the spring of 2018, while construction is ongoing for a complete renovation on the Hoke Sloan Tennis Center on Clemson's campus.
After an impressive run at the 2017 Oracle ITA National Fall Championships that ended in the quarterfinals, junior Marie-Alexandre Leduc has been recognized for her level of play with a national singles ranking of 20th in the ITA poll released on Nov. 15.
The junior has fallen in love with the college experience and the Clemson family.
Go in depth with Tiger tennis standout Ally Miller-Krasilnikov.
Marie-Alexandre Leduc went 3-1 in singles play, including a second-round upset over a top-15 ranked opponent, at the 2017 Oracle ITA National Fall Championships in Indian Wells, Calif. this week.
Marie-Alexandre Leduc picked up the biggest win of her Clemson tennis career thus far, upsetting 13th-ranked and No. 15-seeded Mayar Sherif Ahmed of Pepperdine in the second round of the singles draw on Thursday at the Oracle ITA National Fall Championships.
Junior Marie-Alexandre Leduc opened play at the 2017 Oracle ITA National Fall Championships in Indian Wells, Calif. on Wednesday morning with a straight-set win in the first round of singles play.
Junior Marie-Alexandre Leduc defeated three ranked opponents and a No. 5-8 seed in the singles draw to advance all the way to the semifinals of the ITA Carolinas Regional, held Oct. 19-23 in Chapel Hill, N.C.
Clemson's Hoke Sloan Tennis Center $12.5 renovation received final approval Tuesday, and construction begins Wednesday.
Five members of the Clemson women's tennis team were in action at the Georgia Invite on Sept. 15-17 in Athens, Ga.
The Clemson women's tennis program has added Tate Schroeder, a sophomore and transfer from the University of Missouri, to the roster for the 2017 season.


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Meggitt to Provide Free Training at SHOT Show 2013
SUWANEE, Ga. – Meggitt Training Systems, makers of FATS® and Caswell technologies, will be sponsoring and conducting two educational sessions as part of the Law Enforcement Education Program (LEEP; www.shotshow.org/LEEP) at the 2013 SHOT Show in Las Vegas. The training is complimentary with paid SHOT Show attendance.
Wednesday, January 16 10:00 a.m. – 11:30 a.m.
Lead Management Best Practices: Safety, Containment, Maintenance, Responsibility
Instructor: David O'Meara, Law Enforcement Systems
Lead cannot only be a long-term silent killer within a range, but it can also be the quickest way to large fines and locked doors. This session will walk new and experienced range owners through best practices for maintaining a clean - and more importantly - healthy range.
Thursday, January 17 10:45 a.m. – 11:45 a.m.
Design and Configuration for Indoor Range Success
Instructor: David O'Meara, Law Enforcement Systems
From the moment officers step into your range, their training experience begins. This session will start the design process and configuration process for those looking to build a new range or redesign an existing facility. From conference and/or simulation training space to HVAC, planning early can save time and money, and also ensure a positive and effective training experience.
To find out more about the sessions and to register visit www.shotshow.org/LEEP.
Visit Meggitt at Booth 12267 – January 15-18 – Sands Expo Convention Center, Las Vegas, NV
About Meggitt Training Systems
Meggitt Training Systems, makers of FATS® and Caswell technologies, a division of Meggitt PLC, is the leading supplier of integrated live-fire and virtual weapons training systems, unmanned land and sea vehicles, aerial targets and electronic scoring systems. Following the acquisition of FATS virtual training systems and Caswell International's live-fire ranges and services, Meggitt Training Systems has continued to grow its capabilities based on the legacy of these two industry leaders. Over 10,000 Meggitt live-fire ranges and 5,200 virtual systems are fielded internationally, providing judgmental, situational awareness and marksmanship training to the armed forces, law enforcement and security organizations.
Meggitt Training Systems employs more than 400 people at its headquarters in Atlanta and at facilities in Orlando, Canada, the UK, Netherlands, UAE, Australia and Singapore. It can deploy service personnel anywhere in the world for instructor training, system installation and maintenance.
About Meggitt PLC
Headquartered in the United Kingdom, Meggitt PLC is an international group operating in North America, Europe and Asia. Known for its specialized extreme environment engineering, Meggitt is a world leader in aerospace equipment, sensing systems, combat support and defence systems training. Meggitt employs 7400 people over 30 manufacturing facilities worldwide.
Request more product info from Meggitt Training Systems.
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In recent years, polysomnography-based eligibility criteria have been increasingly used to identify candidates for insomnia research, and this has been particularly true of studies evaluating pharmacologic therapy for primary insomnia. However, the sensitivity and specificity of PSG for identifying individuals with insomnia is unknown, and there is no consensus on the criteria sets which should be used for participant selection. In the current study, an archival data set was used to test the sensitivity and specificity of PSG measures for identifying individuals with primary insomnia in both home and lab settings. We then evaluated the sensitivity and specificity of the eligibility criteria employed in a number of recent insomnia trials for identifying primary insomnia sufferers in our sample.
Archival data analysis.
Study participants' homes and a clinical sleep laboratory.
Adults: 76 with primary insomnia and 78 non-complaining normal sleepers.
ROC and cross-tabs analyses were used to evaluate the sensitivity and specificity of PSG-derived total sleep time, latency to persistent sleep, wake after sleep onset, and sleep efficiency for discriminating adults with primary insomnia from normal sleepers. None of the individual criteria accurately discriminated PI from normal sleepers, and none of the criteria sets used in recent trials demonstrated acceptable sensitivity and specificity for identifying primary insomnia.
The use of quantitative PSG-based selection criteria in insomnia research may exclude many who meet current diagnostic criteria for an insomnia disorder.
Edinger JD; Ulmer CS; Means MK. Sensitivity and specificity of polysomnographic criteria for defining insomnia. J Clin Sleep Med 2013;9(5):481-491.
Insomnia is a highly prevalent and often debilitating condition that reduces quality of life, increases risks for various mental and medical disorders and enhances healthcare costs for millions of individuals world-wide. Over the past several decades a burgeoning body of insomnia-focused research has advanced our understanding and ability to manage this condition. However, this body of research has not been without its limitations. As noted by Buysse et al.,1 the insomnia research literature has been plagued by lack of standardization, particularly in regard to the methods and criteria used for assessing and characterizing insomnia symptoms, and perhaps more importantly, the more global insomnia disorder. This lack of standardization, in turn, has resulted in considerable variability in the selection of insomnia samples across studies. Consequently, comparisons of findings across studies are often difficult or impossible to conduct. This state of affairs has slowed our progress toward developing optimal insomnia management strategies and reducing the overall prevalence and public impact of this troublesome sleep disorder.
Fortunately, in recent years, there have been a number of efforts in the sleep research and professional community to remedy this situation. Included among these are the development and publication of research diagnostic criteria for defining insomnia,2 as well as the publication of consensus recommendations for standardizing assessment methods and measures in all insomnia research studies.1 Additionally, some investigators have proposed developing quantitative insomnia criteria based on indices of nocturnal sleep disturbance. Studies devoted to this objective3,4 have shown that a cutoff value > 30 minutes for sleep onset latency or wake time after onset derived from respondents' sleep diaries has good sensitivity and specificity for discriminating insomnia sufferers from normal sleepers. Thus, adding such quantitative cut-offs to study selection criteria may add some precision to the participant screening process for insomnia research studies.
Current Knowledge/Study Rationale: In recent years, polysomnography-based eligibility criteria have been increasingly used to identify candidates for insomnia research. The current study was conducted to evaluate the accuracy of this approach for identifying individuals with insomnia.
Study Impact: We found that none of the PSG-based criteria accurately discriminated those with primary insomnia from normal sleepers, and none of the criteria sets used in recent trials demonstrated acceptable sensitivity and specificity for identifying primary insomnia. Thus, our findings suggest that the use of quantitative PSG-based selection criteria in insomnia research may exclude many who meet current diagnostic criteria for an insomnia disorder.
Yet, use of quantitative insomnia criteria based on such subjective sleep estimates may not represent optimal research practice when alternate objective sleep assessment methodologies are readily available. Since polysomnography (PSG) has long been considered the gold standard objective measure of sleep, there has been considerable interest in using quantitative PSG criteria for identifying insomnia research candidates. This has been particularly true for studies designed to test various pharmacological insomnia therapies. For example, parameters such as sleep onset latency, wake time during sleep, and total sleep time derived from pretreatment nights of PSG monitoring have been commonly used in conjunction with clinical diagnostic assessments to select patients deemed appropriate for medication testing. In such cases, PSG measures most typically have been used to select patients with sufficient levels of sleep disturbance to evaluate the effects of medications with particular pharmacologic characteristics on specific aspects of sleep. This practice seems to fit well with the other mentioned developments focusing on increased precision in insomnia research. Moreover, PSG-based criteria have face validity since they overcome the inaccuracies and reporting biases that can encumber the subjective sleep estimates provided by many insomnia sufferers.
However, the practice of defining and selecting insomnia sufferers for clinical trials on the basis of PSG measures is not devoid of its own shortcomings and potential criticisms. As repeatedly noted in the AASM standards of practice literature5,6 and elsewhere,1 only a subset of those who meet diagnostic criteria for insomnia show objective sleep disturbances during PSG monitoring. Also, as noted in the May 2011 proceedings of a FDA-sponsored workshop concerned with the safety and efficacy of insomnia drugs, "…most of the existing studies are based on one night of polysomnography for sleep…… classification. And we don't really know or haven't systematically examined the reliability of that categorizing criterion".7 Although subject selection for many clinical trials has been based on findings from two or more qualifying nights of PSG, the specific quantitative criteria used in these trials have varied considerably. Indeed, multiple distinctive criteria sets have been proposed, and there is no apparent consensus as to which of these is optimal. Furthermore, it remains difficult to evaluate these various criteria since there have been no studies to test the sensitivity and specificity of any PSG measures or criteria sets for discriminating insomnia sufferers from those without insomnia. Thus, whether PSG-based selection criteria add precision to insomnia research remains an open question.
The purpose of this investigation was to test the sensitivity and specificity of PSG measures for the selection of patients with primary insomnia. Specifically, this study tested the usefulness of common sleep measures such as sleep onset time, total sleep time, wake time after sleep onset, and sleep efficiency, derived from lab-based and home-based sleep monitoring for discriminating primary insomnia sufferers from normal sleepers. The sensitivity and specificity of these PSG measures for sample characterization were evaluated by consensus standards8 for judging their adequacy and were compared to the performances of concurrent measures derived from sleep diaries. Additionally, this study tested the sensitivity and specificity of a number of previously proposed PSG criteria sets for discriminating primary insomnia sufferers from the normal sleepers in our sample.
This study comprised a secondary analysis of archival data using a between-groups cross-sectional research design. The study sample included independent groups of age- and gender-matched non-complaining normal sleepers and persons with primary insomnia. The participants for this report were drawn from a larger parent study9–11 conducted to compare the nighttime sleep and daytime functioning of adult insomnia sufferers and normal sleepers. All study procedures were reviewed and approved by the institutional review boards of the VA Medical Center and Duke University Medical Center in Durham, NC. Each participant was required to provide written informed consent prior to enrolling and received a maximum of $250 for completing all procedures of the parent study.
Both non-complaining normal sleepers and insomnia sufferers were recruited in 3 waves between October 1992 and October 2001 via posted study announcements on bulletin board within the VA and Duke University Medical Centers, letters mailed to persons in the Duke University Center for the Study of Aging and Human Development Subject Pool, and flyers posted in the community. In addition, we recruited a subset of the insomnia sufferers through face-to-face solicitations of clinic patients presenting to our university sleep disorders center. During the first recruitment wave, we enrolled age- and gender-matched insomnia suffers and normal sleepers between 60 and 79 years of age. The second recruitment wave was used to enroll similarly matched middle-aged (i.e., aged 40 to 59 years) insomnia sufferers and normal sleepers, whereas the final recruitment period was used to enroll samples of young adult (aged 20 to 39 years) insomnia sufferers and matched normal sleepers. All study candidates underwent a thorough screening process to ensure that they met study selection criteria. Screening procedures included structured psychiatric (SCID)12 and sleep interviews13,14 and a physician-conducted medical exam with thyroid (TSH level) screening. Candidates who passed these initial screening procedures underwent a minimum of 1 to 2 nights of qualifying polysomnography (PSG) conducted in either the sleep lab or in the candidate's home. To be included in the study, insomnia sufferers had to meet DSM-IV criteria for primary insomnia. These criteria include the following: (a) A predominant complaint of difficulty initiating or maintaining sleep or nonrestorative sleep for ≥ 1 month; (b) The sleep disturbance (or associated fatigue) causes clinically significant distress and impairment in social, occupational, or other important areas of functioning; (c) The sleep disturbance does not occur exclusively during the course of another primary sleep disorder; (d) The sleep disturbance does not occur exclusively during the course of another mental disorder; (e) The sleep disturbance is not due to the direct physiological effects of a substance or a general medical condition. We used these criteria for selection of our insomnia sample since they are widely used in clinical venues to identify insomnia sufferers, and currently no biological/medical assay exists for diagnosing insomnia. The normal sleepers selected for this study had to report general satisfaction with sleep in the absence of any reported sleep onset or maintenance difficulties. Exclusion criteria for all participants were: (a) terminal illness; (b) medical condition associated with compromised sleep (e.g., rheumatoid arthritis, thyroid disease); (c) abnormal TSH levels on a screening thyroid panel; (d) history of any prior psychiatric illness (lifelong perspective); (e) current major psychiatric (Axis I) documented by the SCID; (f) current substance abuse; (g) sedative hypnotic dependence and an unwillingness or inability to abstain from hypnotics while in the study; (h) current use of anxiolytics, antidepressants, or any other psychotropic medication; or (i) an apnea/hypopnea index ≥ 15 or a periodic limb movement-related arousal index ≥ 15 during screening PSG. Also excluded were insomnia sufferers who met structured sleep interview criteria13,14 for a comorbid sleep disorder in addition to primary insomnia, as well as normal sleepers who met structured sleep interview criteria for any sleep disorder.
A total of 208 study participants were enrolled; most (> 95%) of these were recruited from posted announcements or solicitation letters. Of the 208 who entered the study, 9 withdrew from the study before undergoing PSG, and 45 were excluded from this investigation because they either failed to complete all scheduled PSG studies described below or because one or more of their PSG recordings were deemed un-scorable due to technical problems (e.g., loss of key electrodes). As a result, 25 (12.5%) participants had 5 nights of usable data, 11 (5.5%) had 4 nights of data, 5 (2.5%) had 3 nights of data, 3 (1.5%) had 2 nights of data, and 1 had only one 1 night of usable data (0.5%). Of the remaining sample, 76 (38 women) met selection criteria for primary insomnia, and the remaining 78 (38 women) were non-complaining normal sleepers. The insomnia sample reported a 10.6-year (SD 9.3 years) history of sleep difficulties on average and comprised 11 persons with solely sleep onset complaints, 25 individuals with solely sleep maintenance complaints (either middle-of-the-night wakefulness and/or early morning awakenings), 38 with a mixture of sleep onset and sleep maintenance difficulties, and 4 persons with other sleep/wake concerns (e.g., non-restorative sleep). The mean age of the insomnia sample was 51.8 years (SD 16.5 years), whereas the mean age of the normal group was 50.9 years (SD 16.0 years). The insomnia group included 59 Caucasians, 10 African Americans, 5 Asian Americans, 1 Hispanic American, and 1 Native American; the normal sleepers included 67 Caucasians, 9 African Americans, 1 Asian American, and 1 Native American.
As part of their requirements for the parent study, all participants were scheduled for 3 consecutive nights of polysomnography (PSG) conducted in their homes and an additional 3 consecutive nights of PSG in our university medical center's sleep laboratory. PSGs were conducted using 8-channel Oxford Medilog 9000 or 9200 series ambulatory recorders. The monitoring montage included 2 electroencephalogram (EEG) channels (C3-A2, Oz-Cz), bilateral electrooculogram (EOG), submental electromyogram (EMG), 2 channels of anterior tibialis EMG (right and left leg), and a nasal-oral thermistor. All PSGs were scored using traditional scoring criteria for assignment of sleep stages, identification of respiratory events (e.g., apneas, hypopneas), and identification of periodic limb movements and periodic limb movement-related arousals.15–18 Per pre-planned study protocols, the first or initial 2 PSG nights (home or lab) were used to screen out those exceeding the aforementioned apneahypopnea index or periodic limb movement arousal index cutoffs for study inclusion. Although PSG typically includes additional respiratory measures to detect breathing abnormalities (e.g., respiratory effort, oximetry), it was thought that monitoring of nasal/oral airflow along with our thorough interview screening for apnea would be sufficient to identify most cases with an apneahypopnea index above the study's exclusionary cut-off.
Laboratory personnel who were kept blind to the participants' diagnoses (insomnia vs. normal sleeper) scored all PSG recordings. Each taped PSG record was scored directly on the screen of the Medilog playback unit using traditional scoring criteria.16 Results of PSG scoring were subsequently used to derive measures of time in bed (TIB: time between the electronically marked bedtime and final rising time on each recording), total sleep time (TST: the total time in stages 1, 2, slow wave sleep, and REM sleep), latency to persistent sleep (LPS: time between lights out and the first 10 min of sleep containing ≤ 2 min of wake time, stage 1 sleep, or movement time), wake time after sleep onset, (WASO: all time awake after the onset of sleep and before the final morning rising time), and sleep efficiency % (SE %; [TST ÷ TIB] × 100%). It should be noted that the sleep onset measure chosen for use here—LPS—differs from other measures of sleep onset that require a more limited number of epochs or shorter time periods of sleep for connoting the transition from wakefulness to sleep. We chose LPS since it has been used in many clinical trials as a measure of sleep onset and because it connotes not only the ability to achieve sleep but also to sustain it. Hence, it is a particularly relevant parameter for those with sleep onset complaints.
In addition to PSG recording, participants were asked to complete sleep diary forms in the morning after each PSG night and during an additional 2-week period when they were not undergoing PSG monitoring. The diary forms asked participants about bed and rising times as well as their how long it took them to fall asleep, how long they were awake in the middle of the night after first falling asleep, and how long they were awake in bed at the end of the night before getting out of bed. The diary forms additionally included items asking participants to rate the quality of each night's sleep (1 = very poor; 5 = excellent) and how well rested they felt upon arising (1 = not at all; 5 = very well rested). These items were common to both sets of diaries. In addition, the diary forms completed by participants after each PSG night included an item that asked how much the PSG recording equipment disturbed their sleep each night (1 = very much; 5 = not at all). The diaries completed after each PSG served mainly to help PSG scorers corroborate participants' bed and rising times as well as to assess the degree to which the sleep monitoring process was perceived to disturb participants' sleep. In contrast, the 2-week diaries were used to obtain measures of participants' subjective measures of time in bed, sleep onset latency (SOL), middle of the night wake time (MWASO), wake time at the end of the night (TWASO), total sleep time (TST), and sleep efficiency (SE = % of time in bed spent asleep). These measures were calculated for each night of sleep recorded by participants on the 2-week diaries and then used to calculate mean values across the 2 weeks of diary monitoring.
Consenting participants who met selection criteria underwent PSGs in a randomly determined order so that roughly half of the participants in each group (normals and insomnia) underwent lab PSG, first whereas the other half underwent home studies first. All sleep studies were scheduled such that the home and laboratory PSGs were separated by ≥ 4 but ≤ 30 intervening days. During both series of studies, participants were instructed to maintain customary home bed and rising times, and they were instructed to note their actual bed and rising times each night using an event marker contained on the PSG recorders. They also recorded bed and rising times on a sleep diary they completed upon arising each morning after each PSG night. In addition, all home studies were scheduled for nights when participants planned to have no overnight houseguests. Participants were instructed to abstain from alcoholic beverages and to not consume caffeinated substances after 18:00 on study nights.
Before conducting our primary analyses, we computed the means and standard deviations of each of the 4 PSG sleep measures for each sample in each recording site. Table 1 shows these data along with results of a series of one-way ANOVAs computed to compare the normal sleepers and insomnia sufferers on these measures in each setting. These analyses showed the insomnia sufferers had significantly higher mean WASO and a significantly lower mean sleep efficiency in the lab setting than did the normal sleepers. In the home setting, the groups differed only on their sleep onset latencies.
Comparisons of mean PSG values from lab and home monitoring
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We also conducted preliminary analyses to determine if those excluded from the final sample (due to their having < 6 nights of PSG data) differed from those who comprised the final sample used to address study objectives. Specifically, we compared these groups in terms of their gender composition, mean age, and mean values of PSG sleep measures obtained in the home and sleep lab settings. A χ2 analysis showed the group of excluded participants was not significantly different from the sample retained for study analyses in terms of their gender composition (p > 0.05). However, a one-way ANOVA showed the group of excluded participants was significantly younger (34.3 years) than those retained (51.3 years) in the final sample (F = 38.89; p = 0.0001). This latter finding was attributable to the fact that the youngest cohort was recruited last and at a time when the recording equipment had undergone extensive use and was more prone to malfunction and fall into disrepair. Consequently, more nights of data loss occurred with the youngest cohort than with the older groups enrolled.
Linear mixed models (LMM) were conducted using the Proc Mixed procedure included in the Statistical Analysis System software version 9.2 to compare our final sample and excluded participants on each of the 10 sleep measures derived from PSG recordings. LMM were chosen since they allow inclusion of all cases including those with missing nights of data in the planned comparisons. Separate series of analyses were conducted with the sets of measures derived from home and lab PSGs, and the statistical model included subject type (insomnia vs. normal sleeper), group (included vs. excluded participants) and nights as independent factors. Because the excluded group was significantly younger than the sample retained for study analyses, age was included as a covariate in the series of analyses conducted. Since a total of 20 LMM analyses were conducted, a Bonferroni-corrected α = 0.0025 (i.e., .05 ÷ 20) might be considered for assigning statistical significance. Whereas this criterion level of significance is appropriate for main study analyses, it arguably is a high bar to reach in our tests of possible study confounding. Hence, we used a more liberal α = 0.01 level for assigning statistical significance in these 20 LMM analyses. Despite selection of this lenient α level, results of all these analyses showed no significant main or interaction effect for the group factor. Hence, the sleep measures derived from the inclusion sample were representative of the larger participant group enrolled.
In order to ascertain how well our selected PSG measures discriminated insomnia sufferers from normal sleepers, we first compared these groups in regard to their means values of the home and lab PSG measures obtained. Table 1 shows these mean values and results of statistical comparisons. These results show the insomnia sufferers had more WASO, lower sleep efficiencies, and a great number of sleep episodes in the lab than did normal sleepers, whereas in the home setting, the insomnia group showed higher WASO values and more sleep episodes than did the normal group. As a follow-up to these simple mean comparisons we used receiver-operating characteristic (ROC) curve analyses to graphically depict the relation between the sensitivity and specificity of the test over all possible values of each mean PSG measure. In these analyses, sensitivity for a particular mean PSG measure represented the probability of detecting insomnia when it is present, and specificity represented the probability of not detecting insomnia when it was not present. The ROC curve was plotted for all values, and the greater the distance of ROC curve above the diagonal reference line, the more accurate the test.19 The area under the curve (AUC) served as one primary index of accuracy. The AUC is the probability that a test result for a randomly chosen positive case will exceed the result for a negative case. Swets8 has suggested that test accuracy be defined as "low" for AUC values under 0.7, "moderate" for AUC values between 0.7 and 0.9, and "high" for values greater than 0.9. In addition, we calculated the Youden Index for each of the sleep measures tested. The Youden Index is an alternative index of diagnostic accuracy. It ranges from 0 to 1, with higher values representing greater separation between 2 distributions. Thus, distributions having complete overlap would have a Youden Index of 0, while those having complete separation would have a Youden Index of 1.
In conducting the ROC analyses, we focused initially on the 4 variables most reflective of an insomnia diagnosis: difficulty falling asleep (LPS); difficulty staying asleep (WASO); sleep duration (TST); and sleep efficiency (SE). Results of the ROC analyses conducted with these home- and laboratory-based measures are summarized in Figures 1 and 2, respectively. The top portions of Table 2 provide summary statistics for these analyses including AUC values, Youden indices, optimal cutoffs for group discrimination, and the sensitivity and specificity of these cutoffs. Collectively, the figures and table show that none of the home or lab PSG measures performed well in discriminating the insomnia sufferers from the non-complaining normal sleepers. The best discriminators among the home-based measures were SE and LPS, whereas the best discriminators among those measures derived from lab recordings were SE and WASO. Nonetheless, AUC estimates all fell in the "low" range, indicating the poor test accuracy of these measures for use as quantitative insomnia criteria. The inadequacy of these mean values for discriminating the insomnia and normal groups is characterized by the plots of data shown in Figure 3. This figure shows the distribution of mean values of TST and SE obtained from lab recordings. These plots show that there is appreciable overlap between the insomnia and normal groups in regard to the distributions of measures across the ranges of values observed. Similar plots (not shown) for all of the remaining lab and home sleep measures included in Table 1 showed comparable results. As a consequence, it is difficult to discern a single quantitative cutoff for any of these mean values, even for measures showing significant group differences by the ANOVA tests.
ROC plots for home PSG measures
ROC plots for lab PSG measures
Comparison of ROC AUCs, optimal cutoff values and sensitivity/specificity of PSG and diary measures for discriminating those with and without insomnia
Distribution of mean PSG values in the two samples
Since an insomnia diagnosis does not require the presence of both a sleep onset and sleep maintenance complaint, we also explored the possibility that PSG-based sleep measures may better discriminate if the type of insomnia complaint (onset versus maintenance) is used as the comparator. We conducted 2 additional analyses comparing normal sleepers to those with a sleep onset complaint and to those with a sleep maintenance complaint. For the purpose of these analyses, the sleep onset group comprised the insomnia sufferers with sleep onset only or mixed onset/maintenance complaints (total = 49), whereas the maintenance group included those with maintenance complaints with or without accompanying sleep onset concerns (total = 63). Results of these tests (see supplemental material) showed that all AUC values fell in the low range, suggesting poor test accuracy. Thus, considering the type of insomnia complaint did not increase the accuracy of PSG sleep variables for discriminating insomnia sufferers from normal sleepers.
Since measures derived from extended periods of sleep diary monitoring have demonstrated sensitivity/specificity for defining insomnia3,4 we conducted ROC analyses using 2-week sleep diary data collected by participants during a period when they were not undergoing PSG. The bottom portion of Table 2 shows the AUCs and Youden indices derived from ROC analyses of these sleep diary measures. Also shown are the optimal cutoffs for group discrimination as well as the sensitivity and specificity of those cutoffs. The sleep diary measures were found to be consistently more accurate than PSG in discriminating insomnia sufferers from normal sleepers, particularly the measures of SE, SOL, and middle of the night wake time (MWASO).
It is possible that mean values of individual sleep measures provide a somewhat limited view of the detectable PSG differences between insomnia sufferers and those without sleep complaints. Indeed, it may be useful to consider indicators of the persistence of sleep difficulties among those with insomnia relative to normal sleepers, and/or to simultaneously consider multiple PSG measures to enhance group discrimination. In this regard, several recently published studies conducted to test hypnotic agents have described sets of PSG criteria used in conjunction with clinical diagnoses to select primary insomnia patients as study participants. The specific criteria sets suggested in these trials are shown in Table 3.20–28 As noted, most of these criteria sets considered both average values of selected sleep measures across 2 qualifying nights of PSG and the magnitude of these measures on each night separately. As such, these selection criteria not only reflect a specific level of sleep difficulty on average, but also a degree of persistence in that sort of disturbance. The criteria proposed by Mayer27 would seem designed to identify those with sleep onset difficulties, whereas those provided by Roth28 appear suited to select patients with sleep maintenance complaints. The remaining criteria sets shown would appear useful for identifying insomnia patients with a mixture of sleep onset and maintenance difficulties.
Published PSG qualifying criteria used for selection of primary insomnia patients
In selecting these various criteria sets, we recognized that they were not intended to be used in isolation to define insomnia, but rather were employed in conjunction with clinical assessments to identify individuals with a particular form or severity of sleep disturbance. We also recognized that these criteria sets were originally intended for PSGs conducted with participants who were provided prescribed (fixed) amounts of time in bed rather than the participant-determined bed and rising times used in this study. Nonetheless, since these criteria sets by and large considered multiple sleep parameters across nights, we reasoned that they might provide better discrimination of our insomnia and normal sleeper groups than would individual measures tested in our above-described ROC analyses. To test this assumption, we conducted a series of cross tabs analyses to evaluate the accuracy of each of these criteria sets for discriminating our insomnia group from our normal sleeper group. In doing so, we selected relevant measures from the first 2 nights of PSG recording conducted in the laboratory and the initial 2 nights obtained in participants' homes. The classification rules were then applied to the lab- and home-derived data separately so as to ascertain how the sleep setting effects influenced our classification results. We used our cross tabs analyses specifically to ascertain each criteria set's sensitivity (i.e., the probability for detecting insomnia when it is present), and specificity (i.e., the probability of not detecting insomnia when it was not present).
Results of these cross-tabs analyses are presented graphically in Figures 4 and 5. Figure 4 depicts results for the various criteria sets when applied to lab-based PSG parameters, whereas Figure 5 shows results obtained with the home-based PSG measures. These figures demonstrate that none of the criteria sets showed good sensitivity and specificity in discriminating our insomnia and normal sleeper groups. Furthermore, the recording site—lab or home—from which PSG data were derived seemingly had little effect on classification results. The majority of the criteria sets showed satisfactory to good specificity but poor sensitivity for identifying our insomnia sufferers. In fact, less than a third of the insomnia sufferers met most of these selection criteria. The Walsh et al. PSG criteria,25 based on TST and MSLT sleep latency measures, had relatively poor sensitivity and specificity. Hence, none of the criterion sets seem to convey sleep characteristics that are specific to insomnia.
Tests of published criteria sets applied to lab PSG values
Tests of published criteria sets applied to home PSG values
In addition to testing each criterion set as proposed, we considered the possibility that some components of these various criteria sets may be effective for discriminating the insomnia and normal sleeper groups. As the LPS criterion used across trials was standard, we chose to test this criterion in isolation and in combination with WASO and/or TST criteria. For the purpose of these analyses we conducted cross tabulations of each of the WASO and TST criteria shown in Table 3 to ascertain the best for group discrimination. Results of these analyses showed that the WASO criterion used by Krystal et al.26 and the TST criterion proposed by Roth et al.28 produced the best group separation. We then conducted cross tabulations of each of these criteria individually and in various combinations to ascertain their sensitivity and specificity for defining our insomnia group. Results of these analyses are shown in Table 4. These data show that none of the individual criteria or their various combinations had acceptable sensitivity and specificity for identifying our insomnia cohort. Thus, our efforts to optimize these published criteria sets proved unsuccessful.
Additional tests of the sensitivity and specificity of various PSG criterion sets considered individually and in combination
The current study was conducted to test the usefulness of quantitative PSG criteria for the identification/selection of primary insomnia sufferers in research protocols. The availability of such criteria derived from objective sleep monitoring would be extremely useful for standardizing the samples used in insomnia research and thereby facilitate comparisons of results across insomnia research studies. Unfortunately, the analyses conducted herein to identify useful quantitative PSG criteria did not support any of the criteria sets examined. Our ROC analyses, for example, showed that mean values of LPS, WASO, TST, and SE, derived from series of lab or home monitoring, failed to accurately discriminate primary insomnia sufferers from normal sleepers. Our analyses also showed that none of the PSG-based insomnia selection criteria sets used in recent insomnia treatment trials demonstrated acceptable sensitivity and specificity for selecting those meeting diagnostic criteria for primary insomnia. In fact, all of these criterion sets showed a tendency to select 50% or fewer of the insomnia sufferers and, for most such sets, our normal sleepers met these criteria at roughly the same rates as did the insomnia sufferers. Moreover, none of the cutoffs included in these criteria sets considered individually or in various combinations accurately selected the insomnia cases. To ensure that we did not overlook other sleep architecture variables which might have performed better in terms of identifying those with insomnia, we conducted additional ROC analyses on other PSG variables including the total number of sleep episodes recorded as well as the times spent in stage 1, stage 2, REM, and slow wave sleep. We found low test accuracy across all of these PSG variables as well. See the supplemental material for the specific results of these analyses.
These findings contrast markedly from those reported for measures taken from sleep diaries. Lichstein et al.,3 for example, found that sleep diary measures of sleep onset latency or wake time after sleep onset ≥ 31 minutes occurring ≥ 3 times per week have good sensitivity and specificity for discriminating insomnia sufferers from normal sleepers. Likewise, we previously were able to identify specific mean values of sleep onset latency and WASO taken from two weeks of sleep diary monitoring that effectively separate primary insomnia sufferers from normal sleepers in younger and older samples.4 In the current study, we expanded on our previous diary findings by showing that individual mean diary values of SOL, SE, and MWASO taken from two weeks of conventional home diary monitoring far outperformed any of our PSG measures for group discrimination. The more limited period of PSG monitoring may have put the PSG measures at a relative disadvantage and, in part, accounted for their poorer performance herein. In addition, both diary data and a clinical insomnia diagnosis are based on self-report and therefore share method variance not shared by objective PSG monitoring. Both these methodological factors should be recognized when considering our findings.
Perhaps our results are not surprising inasmuch as the overlap between the PSG measures derived from insomnia sufferers and normal sleepers has long been recognized. Indeed, there is no established and commonly recognized "finding" on the polysomnogram that is accepted as proof of an insomnia diagnosis. In the clinical setting, it is common experience, in fact, to find relatively normal sleep among some insomnia patients undergoing PSG recording, although such findings may be attributed to the so-called "reverse night effect" or the possible presence of paradoxical insomnia. It is also recognized that PSG recording can be disruptive to normal sleepers and produce sleep results that overlap with the sleep disruption characterizing insomnia samples. Such factors may account for the minimal differences often found in PSG comparisons of insomnia and normal groups. In line with these observations, current practice parameters indicate that polysomnography is generally not required for the routine diagnosis of insomnia, and there are relatively limited indications for its use among patients with insomnia complaints.5,6 Although the studies referenced herein did not necessarily use PSG for purposes of identifying those with insomnia, it would have been useful to have found that these criteria were helpful for this purpose. However, consistent with the current practice parameters, our study findings suggest that relying mainly on quantitative PSG-based criteria for the selection of study participants in insomnia treatment research is not advisable.
In considering our results it should be noted that the effectiveness found for any test is dependent upon the "gold standard" against which it is judged. Insomnia is defined on the basis of a patient's clinical complaints, and there currently exists no biological assay or medical test that reliably confirms an insomnia disorder. For the purposes of this study, we chose to use DSM-IV-TR criteria for primary insomnia in identifying and selecting our insomnia sample; yet the primary insomnia diagnosis is based solely on self-report and is widely accepted to include a somewhat heterogeneous patient group. Moreover, the reliability of this diagnosis across raters seems marginal at best.30,31 Reliance on the clinical insomnia diagnosis as the gold standard has limitations in its own right and likely contributes to the findings obtained herein. Indeed, it could be argued that the clinical insomnia diagnosis has poor sensitivity and specificity for identifying individuals with large amounts of WASO or prolonged sleep latency on PSG. Nonetheless, at this juncture, the clinical diagnosis remains the defining feature of insomnia. Thus, the use of clinical criteria for establishing the diagnosis seemed reasonable for the purposes of this study.
Of course, the role of PSG selection criteria may go beyond the purpose of mere identification of those who meet diagnostic criteria for a specified disorder. There is also the consideration of selecting study participants who have a sufficient level or severity of disease so as to assure that treatment effects can be clearly discerned and detected by whatever statistical methods are deemed appropriate for the study in question. In the case of insomnia, it is common practice in this regard to select patients with a certain amount of wakefulness as measured by sleep onset latency and/or wake time during the night. This practice has indeed been common in studies of both pharmacological and psychological therapies. As the Food and Drug Administration has required the inclusion of PSG outcome measures in tests of new insomnia agents, it is not surprising that the use of quantitative PSG selection criteria have been commonplace in insomnia medication trials. Yet the findings concerning the PSG selection criteria sets listed in Table 3 showed a sizable proportion of insomnia patients fail to meet these criteria and thus would be excluded from such studies. This was the case even when we attempted to increase test precision by considering sleep onset and sleep maintenance insomnia subtypes separately. Such results, in turn, raise questions about how well findings for such trials generalize to the larger insomnia population. It is clear from the previously cited proceedings of the May 2011 FDA/ PERI sponsored workshop7 that the FDA is now reconsidering the role and use of PSG in insomnia clinical trials, so perhaps the sleep research community should do so as well. Of course, PSG may remain a useful research tool for documenting objective sleep changes in insomnia treatment studies. Indeed, as PSG remains the gold standard for sleep measurement, this procedure is perhaps the best suited one for measuring the impact of a treatment on the overall sleep process.
Admittedly, this investigation had some limitations that need to be considered. Although our sample was moderate in size, it was heterogeneous in terms of insomnia complaint (e.g., onset, maintenance, mixed) and was composed largely of research volunteers. The findings therefore may not generalize to clinical populations since research and clinical samples may differ markedly. Furthermore, the sample included mainly Caucasians, so it is not known how representative the findings would be for other ethnic groups. We also should note that many of the criteria sets used latency to persistent sleep (LPS) as a consideration, and the definition of this parameter is typically considered the onset of a 10-minute period of uninterrupted sleep. The definition used for LPS in constructing our archival data set was slightly less demanding. Although our measure of LPS would be expected to correlate highly with the LPS measure use in pharmacology trials, the two measures are admittedly not identical. As a result, it is possible that our analyses may underestimate the performances of at least some of the criteria sets we tested. Yet most of these sets performed so poorly that it is reasonable to assume that the use of more rigorous LPS measures would likely not result in significant performance improvement. Finally, we should acknowledge that the PSG montage used provided inadequate screening for sleep disordered breathing, given the relationship between subtle respiratory disturbance and insomnia complaints, especially in women. Despite this and the other limitations noted, our findings suggest that the use of quantitative PSG-based selection criteria in insomnia research is a practice that should be questioned. Use of such selection criteria in isolation may set an unreasonable metric for patients to achieve, and thus, may exclude many with genuine insomnia disorders from empirical scrutiny.
This was not an industry supported study. The authors have indicated no financial conflicts of interest.
This study was funded by the Department of Veterans Affairs Merit Review Program, Grant # 0009 awarded to Dr. Edinger. Dr. Ulmer was funded by a Department of Veterans Affairs HSR&D Career Development Award CDA 09-218 while working on this manuscript. The views express herein are exclusively those of the authors and do not necessarily reflect the views of the Department of Veterans Affairs.
Buysse DJ, Ancoli-Israel S, Edinger JD, Lichstein KL, Morin CM, authors. Recommendations for a standard research assessment of insomnia. Sleep. 2006;29:1155–73. [PubMed]
Edinger JD, Bonnet M, Bootzin RR, et al., authors. Derivation of research diagnostic criteria for insomnia: Report on an American Academy of Sleep Medicine work group. Sleep. 2004;27:1567–96. [PubMed]
Lichstein K, Durrence H, Taylor D, Bush A, Riedel B, authors. Quantitative criteria for insomnia. Behav Res Ther. 2003;41:427–45. [PubMed]
Lineberger M, Carney C, Edinger J, Means M, authors. Defining insomnia: quantitative criteria for insomnia severity and frequency. Sleep. 2006;29:479–85. [PubMed]
Chesson A Jr, Hartse K, Anderson WM, et al., authors. Practice parameters for the evaluation of chronic insomnia. An American Academy of Sleep Medicine report. Standards of Practice Committee of the American Academy of Sleep Medicine. Sleep. 2000;23:237–41. [PubMed]
Littner M, Hirshkowitz M, Kramer M, et al., authors. Practice parameters for using polysomnography to evaluate insomnia: an update. Sleep. 2003;26:754–60. [PubMed]
Buysse DJ, author. Defining insomnia: major subtypes, key symptoms. In: Paper presented at: Safety And Efficacy Of Hypnotic Drugs: An FDA-PERI Co-Sponsored Workshop; May 10 & 11, 2011; Bethesda, MD
Swets J, author. Measuring the accuracy of diagnostic systems. Science. 1988;240:1285–93. [PubMed]
Edinger JD, Fins AI, Sullivan RJ, et al., authors. Sleep in the laboratory and sleep at home II: Comparison of older insomniacs and normal sleepers. Sleep. 1997;20:1119–26. [PubMed]
Edinger JD, Glenn DM, Bastian LA, et al., authors. Sleep in the laboratory and sleep at home II: Comparison of middle-aged insomnia sufferers and normal sleepers. Sleep. 2001;24:761–70. [PubMed]
Edinger JD, Means MK, Carney CE, Krystal AD, authors. Psychomotor performance deficits and their relation to prior nights' sleep among individuals with primary insomnia. Sleep. 2008;31:599–607. [PubMed Central][PubMed]
Spitzer RL, Williams JBW, Gibbons M, First MB, authors. Instruction Manual for the Structured Clinical Interview for DSM-IV (SCID-IV). (SCID 1996 Revision). 1996. New York: Biometrics Research Department, New York Psychiatric Institute;
Schramm E, Hohagen P, Grasshoff M, et al., authors. Test-retest reliability and validity of the Structured Interview for Sleep Disorders according to the DSM-III-R. Am J Psychiatry. 1993;150:867–72. [PubMed]
Edinger J, Kirby A, Lineberger M, Loiselle M, Wohlgemuth W, Means M, authors. The Duke Structured Interview for Sleep Disorders. 2004. Durham, NC: Duke University Medical Center;
Coleman R, author; Guilleminault C, editor. Periodic movements in sleep (nocturnal myoclonus) and restless legs syndrome. Sleeping and waking disorders: Indications and techniques. 1982. Menlo Park: Addison-Wesley; p. 265–295
Rechtshaffen A, Kales A, authors. A manual of standardized terminology, techniques, and scoring systems of sleep stages of human subjects. 1968. Los Angeles: UCLA Brain Information Service/ Brain Research Institute;
Phillipson EA, Remmers JE, authors. American Thoracic society Consensus conference on Indications and Standards for Cardiopulmonary Sleep Studies. Am Rev Respir Dis. 1989;139:559–68. [PubMed]
American Sleep Disorders Association. EEG arousals: Scoring rules and examples - A preliminary report from the sleep disroders atlas task force of the American Sleep Disorders Association. Sleep. 1992;15:173–84. [PubMed]
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Zammit GK, McNabb LJ, Caron J, Amato DA, Roth T, authors. Efficacy and safety of eszopiclone across 6-weeks of treatment for primary insomnia. Curr Med Res Opin. 2004;20:1979–91. [PubMed]
Fava M, McCall VW, Krystal AD, et al., authors. Eszopiclone co-administered with fluoxetine in patients with insomnia co-existing with Major Depressive Disorder. Biol Psychiatry. 2006;59:1052–60. [PubMed]
Roth T, Rogowski R, Hull S, et al., authors. Efficacy and safety of doxepin 1 mg, 3 mg, and 6 mg in adults with primary insomnia. Sleep. 2007;30:1555–61. [PubMed Central][PubMed]
Scharf M, Rogowski R, Hull S, et al., authors. Efficacy and safety of doxepin 1 mg, 3 mg, and 6 mg in elderly patients with primary insomnia: a randomized, double-blind, placebo-controlled crossover study. J Clin Psychiatry. 2008;69:1557–64. [PubMed]
Lankford DA, Corser BC, Zheng YP, et al., authors. Effect of gaboxadol on sleep in adult and elderly patients with primary insomnia: results from two randomized, placebo-controlled, 30-night polysomnography studies. Sleep. 2008;31:1359–70. [PubMed Central][PubMed]
Walsh JK, Salkeld L, Knowles LJ, Tasker T, Hunneyball IM, authors. Treatment of elderly primary insomnia patients with EVT 201 improves sleep initiation, sleep maintenance, and daytime sleepiness. Sleep Med. 2010;11:23–30. [PubMed]
Krystal AD, Durrence HH, Scharf M, et al., authors. Efficacy and safety of doxepin 1 mg and 3 mg in a 12-week sleep laboratory and outpatient trial of elderly subjects with chronic primary insomnia. Sleep. 2010;33:1553–61. [PubMed Central][PubMed]
Mayer G, Wang-Weigand S, Roth-Schechter B, Lehmann R, Staner C, Partinen M, authors. Efficacy and safety of 6-month nightly ramelteon administration in adults with chronic primary insomnia. Sleep. 2009;32:351–60. [PubMed Central][PubMed]
Roth T, Soubrane C, Titeux L, Walsh JK, authors; on behalf of the Zoladult Study Group. Efficacy and safety of zolpidem-MR: A double-blind, placebo-controlled study in adults with primary insomnia. Sleep Med. 2006;7:397–406. [PubMed]
Carskadon MA, Dement WC, Mitler MM, Guilleminault C, Zarcone VP, Speigel R, authors. Self-reports verses sleep laboratory findings in 122 drug-free subjects with complaints of chronic insomnia. Am J Psychiatry. 1976;133:1382–8. [PubMed]
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Edinger JD, Wyatt JK, Stepanski EJ, et al., authors. Testing the reliability and validity of DSM-IV-TR and ICSD-2 insomnia diagnoses. Results of a multitrait-multimethod analysis. Arch Gen Psychiatry. 2011;68:992–1002. [PubMed]
Comparing home and lab ROC AUCs, optimal cutoff values, and accuracy of architectural and arousal-related PSG-based sleep variables from lab and home monitoring
Comparing home and lab ROC AUCs, optimal cutoff values, and accuracy of PSG-based sleep onset insomnia variables from lab and home monitoring
Comparing home and lab ROC AUCs, optimal cutoff values, and accuracy of PSG-based sleep maintenance insomnia variables from lab and home monitoring


text:
Assistant brewer at Round Guys Brewing Co. in Lansdale, Pa.
Member Profiles
Brewers Association member profiles. See who contributes to the creation of American craft beer, from bottling line technicians to brewers and CEOs.
Kevin Sandefur
Owner and head brewer at Headwaters Brewing Co. in Waynesville, N.C.
Nick Nunns
Owner and brewer at TRVE Brewing in Denver.
Ian Clark
Ian Clark is the brewer at BRU Handbuilt Ales and the executive chef at Centro Latin Kitchen in Boulder, Colo.
Kyle Williams
Owner and brewmaster at Brevard Brewing Co. in North Carolina.
Alec Mull
Director of brewing operations for Founders Brewing Co. in Grand Rapids, Mich.
Mike Byrne
Brewer at Buckeye Lake Brewery in Buckeye Lake, Ohio.
Barbara Jones
Co-owner of Sweet Mullets Brewing Co. in Oconomowoc, Wis.
Jared Barnes
Brewmaster at Darwin's on 4th Restaurant and Brewery in Sarasota, Fla.
Lon Weatherson
Managing partner, brewmaster, and co-founder of College Street Brewhouse & Pub in Lake Havasu City, Ariz.
Submit Your Member Profile
The Brewers Association would like to recognize all who contribute to the creation of American craft beer, from bottling line technicians to brewers and CEOs. Submit your profile today!


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Submit News
W.T.F., What's Going On? CIA Wikileaks Panel Reveals Findings
Jason Mick
December 23, 2010 9:20 AM
Recipient E-mail
Sender E-mail
The CIA didn't let itself fall victim to Wikileaks espionage attempts.
(Source: Saul Loeb / AFP / Getty)
The CIA refused to share its reports on SIPRNET -- a system accessible by close to 2 million soldiers, intelligence officials, and private contractors.
(Source: U.S. Army photo by Spc. Michelle Waters, 133rd Mobile Public Affairs Detachment)
CIA software also sends warnings if large amounts of information are downloaded on a system -- a common sense precaution that the U.S. Military apparently never though of or got around to implementing.
(Source: Microsoft)
The CIA's unwillingness to share saved its secrets, says the Wikileaks Task Force (W.T.F.)
What was the impact of
on the U.S. Central Intelligence Agency (CIA)? In
an interview
with Greg Miller of the
Washington Post
, spokesman George Little shares an inside look at the task force the agency created to answer that question, following the undesired release of
state department cables
Iraqi/Afghani war memos
. The task's force's acronym nickname -- W.T.F. -- and its conclusions are simultaneously intriguing and amusing.
I. W.T.F.'s Conclusion? Cover Not Blown
For better or worse most Americans badly misunderstand the CIA. First, the CIA does not collect intelligence or police within the U.S. (that's the role of the FBI, NSA, etc.). Second, while the CIA may occasionally participate in a James Bondesque operation, its primary role is not to act, but to watch and listen. The agency is fixated on collecting as much information as it can on foreign entities and their relationship to the U.S. One such entity of high interest is
Mr. Little comments, "The director asked the [Wikileaks] task force to examine whether the latest release of WikiLeaks documents might affect the agency's foreign relationships or operations."
Its finding? For all its efforts to "expose" U.S. foreign policy,
had little success in revealing the secrets of the CIA.
The most the leaked documents (according to
past reports
) could reveal was to expose the "Other Government Agency" ("OGA"), an anti-insurgency group that is believed to be created by the CIA in Iraq. The leaks, however, offered little in the way of unexpected information or evidence of wrongdoing (which perhaps again raises the question of
was truly "whistleblowing"
or just releasing documents in an espionage/"freedom of information" bid).
The OGA attacked insurgents (really?). It was once fired on by U.S. soldiers when one of its vehicles failed to slow down and identify itself -- but no one was hurt. And once, one of its agents was shot in the thigh by an insurgent (shocking!). Overall, the leak offered little insight into any more secretive activities of the CIA.
While the Pentagon and State Department bemoan the irritation to allies and
rallying cry to terrorist insurgents
that the leaks provided, W.T.F.'s conclusions are helping CIA officials sleep more comfortably at night. The agency, which requires the utmost secrecy for its overseas operatives safety, remained virtually uncompromised.
II. Caring, but not Sharing
According to former agency officials interviewed in the
Washington Post
piece, the agency's secrecy escaped unscathed only thanks to careful precautions. First, the agency implements a seemingly common sense precaution that the Defense Agency bafflingly does not -- it sends alerts if large amounts of information are downloaded from its systems.
Second, the agency does not allow USB sticks to be used on most of its computers -- something the Pentagon is only now
getting around to implementing
. States a former "high-ranking" agency official, "It's just a huge vulnerability. Nobody could carry out enough paper to do what WikiLeaks has done."
He jokes that if he had tried to use a USB stick on his computer, "There would probably be a little trap door under my chair."
Joking aside, the CIA also did something even more controversial -- it refused to share much of its information with other government departments. While that approach earned it criticism by some, who blamed it for failing to stop the 2001 terrorist attacks, it also prevented the agency's secrets from slipping into hostile hands.
While new legislation forced the agency to share some additional information, its policy largely held in the post-9/11 government. States an unnamed official, "[The agency] has not capitulated to this business of making everything available to outsiders. They don't even make everything available to insiders. And by and large the system has worked."
When asked to post its reports on SIPRNET -- the computer network that U.S. Army Specialist Bradley Manning
removed documents from
, to illegally share with a foreign entity (
) -- the CIA refused. States another former official, "We simply said we weren't going to do it. The consensus was there were simply too many people potentially who had access."
The agency officials shared this information anonymously, because formally the agency can not share its security procedures.
Ultimately, its decision not to share saved it from the danger and humiliation that the Pentagon and State Department now find themselves in. The agency wasn't about to let itself fall for a rubeish espionage scheme by "bradass87". Collecting secrets is a game that the CIA has played long before Spc. Manning or
founder Julian Assange set foot on this Earth.
"You can bet that Sony built a long-term business plan about being successful in Japan and that business plan is crumbling." -- Peter Moore, 24 hours before his Microsoft resignation
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Somalia: looking back on 20 years of lifesaving care at Keysaney Hospital
07-06-2012 Photo gallery
Keysaney Hospital in north-eastern Mogadishu has played an essential role in providing emergency medical care for people affected by war for over 20 years. Two decades of armed conflict have taken a serious toll on the people and the country, with infighting between different political factions resulting in the destruction of essential infrastructure, including hospitals, all over the country. Despite all of this, Keysaney Hospital has managed to treat over 216,000 people, including 30,000 with weapon-related injuries. This photo narrative looks back on the hospital's successes and challenges, and celebrates this year's inauguration of a new operating facility.


text:
November 2, 2012
Standing on the Williamsburg (Brooklyn) waterfront looking across the bay into lower Manhattan, Madeline Gobbo joined thousands who were affected by Hurricane Sandy. The "black-out zone" is evident in the foreground, where hundreds of thousands were left without power after a power substation exploded.
Stories this photo appears in:
Hurricane Sandy: A first-hand account from Brooklyn
HRVHS grad takes away an unexpected lesson as Manhattan skyline goes dark
Hurricane Sandy left a message about isolation
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On 7/31 I upgraded from ZA Internet Security to Extreme Security. Everything was working fine, but a few days later when shutting down Windows Update installed a patch. The patch install hung and I killed it after waiting 7 hrs. I logged in and eveything seemed ok, ZA was working fine. Upon shutdown, the patch installed and this time finished.
Next time I logged in I got the error message: Validation failed for C:\Windows\system32\VSINIT.dll. You probably are missing a necessary root certificate.
I uninstalled ZA Extreme Security based on recommendations and now when I try to reinstall I get the following error messages and the install fails: Installer failed to initialize. Please try to download and run the installer again. When I click OK on the error, I get the following error message: Could not load the DLL library
C:\DOCUME~1\steve\LOCAL~1\Temp\081020222459\vsutil .dll
(ls64bit).The specified procedure could not be found.
Interestingly, MS Security Center says that Extreme Security reports that the Anti Virus and Firewall are working fine, but it is not installed.
Any ideas how I can get the product installed again?


text:
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Hey everyone,
was wondering if anyone could identify what these circular features on this rock are? the main body of rock seems to be some type of quartz-like rock but the rest is a mystery to me! If this works and people are able to identify then it would be fantastic, I've got so many really interesting rocks I've found and just never thought to put them on a forum like this. Thanks for any help in advance!


text:
I bought this and I cant wait to use it on my LO. Its paper layers on paper so it adds a 3d look to it
Great 3-D sticker. Note that Tinkerbell is a separate sticker, so you can put her where you want to!
I really liked the way this looked on the page I used, but it was very large and was difficult to find a place that it would fit nicely.
I loved this sticker as soon as I saw it. It is the perfect sticker for a Disney World or Princess LO. I used it on a recent LO entitled Disney Dreamin'


text:
Seneca Resources Corp., Williamsville, NY, expects to have 15 wells Marcellus shale wells producing into the Trout Run Gathering System in Lycoming County, Pa., by the end of January, including six wells on which it reported completion Jan. 22, said its parent National Fuel Gas Co.
The six wells, on a single pad, had 24-hr peak production rates averaging 17.8 MMcfd, five of which represent the highest peak production rates of any wells operated by Seneca in the Marcellus. The wells have treatable lateral lengths of 4,292 to 5,101 ft and were completed with 14 to 18 frac stages per well.
Three wells had peak production rates above 20 MMcfd, and all six reached a combined 24-hr peak production rate of 107 MMcfd. The wells represent some of the most productive ever drilled in the Marcellus by any operator, Seneca said.
Seneca is running two drilling rigs Lycoming County and does not have the production infrastructure constraints that face many other Marcellus operators.
Sixteen other wells on the DCNR 100 tract will be completed this fiscal year and 25 more in fiscal 2014, the company said.