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Safe Shorepower
By Don Casey
However you bring shorepower aboard your boat, if you do it without the appropriate safeguards, you place yourself, your crew, and your guests at a terrible — and foolish — risk.
Three-Conductor System
AC circuits use three wires, and it is essential to your safety to understand the function of each. Because the direction of current flow in an AC circuit is reversing 120 times per second (60 positive-to-negative-and-back-to-positive cycles), it is counter-intuitive to refer to one side of an AC circuit as positive and the other as negative. Instead, we call one side hot, the other side neutral. By code the hot wire in an AC circuit is black, red, or blue; the neutral wire is always white. Since the neutral side is connected to ground, it is the hot side of the circuit that is the most dangerous. However, you should always treat both sides with equal respect because a wire reversal to the outlet will make the neutral side hot.
The grounding wire changes all that. A short to the case instantly becomes a short to ground, probably opening the breaker in the circuit. Even if the short is insufficient to kick the breaker, or if it occurs while you are holding the appliance, the grounding wire still protects you by providing a lower-resistance path to ground than your body offers. Anything that degrades or opens the grounding circuit, such as a broken connection, a corroded or missing ground prong, or an improperly wired outlet leaves you dangerously vulnerable. Ashore the grounding wire is often bare, but in boat wiring it should be insulated and green. We will come back to this all-important green wire.
Inlet Fitting and Dock Cord
A safe shorepower system begins with a weather-tight inlet fitting. If the shorepower inlet on your boat isn't weatherproof — with and without the cord attached — you need a different fitting. The 30-amp locking receptacle has become the norm at most U.S. and Caribbean marinas, so equipping your boat with a 30-amp inlet minimizes compatibility problems.
Make sure the fitting is in a location that does not put it at risk for submersion or mechanical damage, and that the backside is well ventilated. The wire distance from the inlet to the main AC circuit breaker should never exceed 10 feet.
An extension cord from a builder's supply, even one labeled "Heavy Duty," is not an appropriate shorepower cord. To shrug off the exposure, submersion, abrasion, and strain of marine use, the cable should carry a hard-service rating — SO, ST, or STO. There must be no possibility of the cable pulling free of the plugs (dock cords sometimes become dock lines) or of the plugs pulling out of the receptacles. For 30-amp service, the conductors must be #10 AWG or larger.
Circuit Breakers
Factory shorepower in older boats too often omitted a circuit breaker. The thinking was that a boat was just another "appliance" plugged into the marina circuit, which was already protected. But faulty marina wiring is too common to entrust your safety to an unknown breaker behind a dock office a quarter of a mile away. A safe AC system requires an onboard dual-pole breaker.
The breaker's rating must not exceed the service; i.e., a 30-amp inlet limits the main breaker to 30-amp. However, if the circuit directly supplies outlets in the cabin, the size of the breaker is limited to the outlet ratings — either 15 or 20 amps.
A single circuit offers the benefit of simplicity, but if you need multiple AC circuits, breaker panels are available with a main breaker and two or more branch breakers. Despite being commonplace, it is not a good practice to combine AC and DC in the same breaker panel.
Reversed polarity leaves your AC circuits unprotected if you have a single-pole main breaker since the breaker is now on the neutral side. Even with double-pole breakers, reversed polarity puts ON-OFF switches on the wrong side of the circuit, leaving OFF appliances fully energized. Be sure your AC panel is equipped with a polarity tester.
Where branch breakers are single pole, be sure they are on the "hot" side of the circuit.
Resist any temptation to use house wire (Romex) for the AC circuits on your boat. Common house wire is solid copper, fine for a quiescent life inside a wall but unsuitable for the marine environment. Boat wiring requires the flexibility of stranded wire, and it should be tinned for corrosion resistance.
Wire size for AC circuits is generally less a factor of voltage drop than of amperage capacity, but starting currents, particularly for compressors, can momentarily increase the current draw up to 5 times nominal. If the wire is too small, this momentary surge can actually cause supply voltage to drop below the level required to start the compressor. As a practical matter, 15 and 20 amp circuits should be wired with 12-gauge wire. The (unprotected) wire between the inlet fitting and the main breaker should be 10-gauge for a 30-amp inlet and 6-gauge if the service is 50-amp.
The green "grounding" wire in AC circuits provides a low resistance path to ground should any of the various metal cases enclosing your AC system become energized. But what if the leak is into the DC wiring, caused, for example, by crossed wires or a short in a battery charger, inverter, or other dual-voltage appliance? AC leaking into the DC system will seek ground, meaning it will automatically travel through the wiring to the ground connection on the engine and down the prop shaft to the water. This is essentially the same as dropping a hot wire into the water. In fresh water, this poses a real risk of electrocution for anyone in the water nearby. Electrocution is less likely in saltwater, but the current field can be enough to paralyze muscles and cause a swimmer to drown.
Connecting the green wire to the ground terminal on the engine offers AC leakage into the DC system a lower-resistance path to ground — through the grounding wire. This eliminates the risk to swimmers as long as the grounding wire connection to ground is sound. However, if corrosion on the ground prong of your dock cord or some other fault breaks the ground connection, all ground-fault current, not just AC to DC leakage, will flow into the water. It is essential to test the ground connection at the dock and to maintain cords and plugs in good condition.
In your breaker box at home the neutral wires and grounding wires all connect to the same terminal strip (or bus bar), but on a boat the AC grounding wire is connected to the DC ground. Also connecting the neutral wire to it makes underwater hardware a current-carrying path to ground, potentially lethal for anyone in the water nearby. On a boat the neutral (white) conductor and the grounding (green) conductor MUST NEVER BE DIRECTLY CONNECTED.
Outlets are all polarized, and the Lone Ranger's white horse, Silver, can provide the association necessary to remember which wire connects to which terminal. White goes to silver. So the black wire connects to the opposite terminal, usually brass, but sometimes dark. The green terminal is for the green grounding wire.
Electricians ashore simply tighten terminal screws onto a loop of wire or insert the stripped end into a spring clamp. Neither method is appropriate on a boat. Use a proper crimp terminal or install commercial-grade outlets with screw-tightened clamps in place of the more typical screw terminals. These may be used with stranded wire.
Ground Fault Interrupt
Regular circuit breakers are essentially fire-protection devices and offer no protection against electrical shock. A ground-fault circuit interrupter (GFCI), on the other hand, provides a high degree of shock protection. If you accidentally touch an energized wire or component and you are grounded, the GFCI disconnects the circuit in about 1/40 of a second, too little time for the current to build to a dangerous level.
In recognition of the increased risk of shock in damp environments, many municipal building codes mandate GFCIs in bathrooms and, increasingly, kitchens. Boats are damp environments, and every outlet on a boat should be protected by a GFCI.
GFCIs are inexpensive and easy to install. Simply replace the first outlet on a circuit (counting from the breaker) with a GFCI fixture, and all the outlets on that circuit will be protected. Make sure the terminals marked LINE are connected to the wires leading back to the breaker and those marked LOAD feed the remainder of the circuit. After you install a GFCI fixture, always test it.
The safest course is to leave AC system repairs to a qualified marine electrician, but if you opt to do the work yourself, never, ever work on an AC circuit hot. Disconnect the cord — and take it off the dock, lest some Good Samaritan send you to the next life. Also disconnect the inverter. Then religiously check all wires with a voltage tester. This is the electrician's version of "measure twice, cut once." Be absolutely certain that there is no voltage between any two wires or any wire and ground.
When it comes to AC power, what you don't know definitely can hurt you.
AC aboard raises a number of additional considerations not covered here. Sailors and powerboaters alike will find a more complete treatment in Sailboat Electrics Simplified by Don Casey.


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text: ACOG Rounds February 2016 The Executive Desk: Innovation is the Name of the Game President's Blog: Reinventing the Wheel. Technology Should Help Us Engage Our Patients…AND Ourselves Medical Education: ABOG Begins Innovative Pilot Program to Enhance the Maintenance of Certification (MOC) Process Events & Meetings: Hail to Old DC—The Place to be for ACOG 2016 Events & Meetings: Is HPV Testing Ready to Replace the Pap? Hot Topics Debated by the Experts at the Annual Meeting Membership & Fellowship: Get Ready for 2nd Annual Career Fair at Annual Meeting Practice Management: The Pregnancy Wheel Reinvented — Tap, Instead of Spin, Your Way to a Date Membership & Fellowship: ACOG Junior Fellows Wrap Up 2015 and Jump into 2016 Practice Management: How Physician Burnout Affects Health Care – And What Physicians Can Do To Avoid It Advocacy & Health Policy: Take a Pledge for Parity this International Women's Day (March 8) ACOG Practice Guidelines and Patient Education Materials Update: What's New for January and February 2016 ACOG in the News: Depression Screening for Pregnant Women and New Moms, Guidelines for Pregnant Women During Zika Outbreak, and Waiting to Try Again After a Miscarriage


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Rebecca Hall Goes Grecian Goddess While Out On 'The Town!' Do You Love Or Loathe Her Look?
Rebecca channeled her inner Aphrodite in a bright turquoise Vionnet Resort gown in Venice. Is this dress an overflowing beauty or an over-fugly bomb?
Rebecca Hall was attending the Venice International Film Festival on Sept. 8th with The Town co-stars Ben Affleck, Jeremy Renner, and John Hamm. The men looked dapper and handsome in their tuxes, but Rebecca might have missed her dress fitting as the voluminous material almost enveloped her statuesque figure. Clearly this frock from the resort's 2011 collection worked better as she was walking vs. standing & posing.
Also, can you check out that flawless makeup look? Celebrity makeup artist Stephen Sollitto worked with the gorgeous actress to create the look, especially that siren red lip, which was a mixture of the new NARS Pure Matte Lipsticks in Vesuvio and Terre de Feu. They're available now at your local NARS counter.
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Thrifted quilted jacket, BKK sando, Topman jeans
I rarely score items from D's thrifting trips but when we do pick up something, it's usually a keeper like this jacket. I like that it's got a relaxed fit so you don't look like a suman when the rest of your look is tighter or tapered. It's got a nice vintage feel too, with the plaid just peeking out from the inside lining and the corduroy collar.
I was super excited when I found this shop in Platinum selling these awesome printed tops. This is my last ditch effort to get on the tribal bandwagon before it completely leaves the station.
I was really drawn to the eye-catching print. I don't have anything like it so it's refreshing for my wardrobe.
Got these jeans for half off at the Topshop sale in exactly my size. I've been looking forever for a pair of skinny blue jeans in a 90's wash. These fit the bill and my legs exactly.
The jacket's reversible too if you want to go on full lumberjack mode.
D: thrifted lace peplum top, Stradivarius black shorts, Pill heels
I posted about this peplum top before but it was the first time I actually got to wear it out. Things sort of get glazed over in my closet if I don't get to use it as soon as I buy it.
I have nothing in this shade of green in my closet so I was definitely keen to see how I could work with it. Love the sharp gray collar against the feminine lace too.It has ruffled cuffs that I tucked into the ends of the sleeves because it was a bit too twee for my liking.
This cross bracelet from the Topman sale (less than P300!) has been seeing a lot of action recently. I kind of like how subdued it is.
Some candy-colored earrings to brighten up my somber outfit.
These Pill platforms are surprisingly stable. The heel isn't as precarious as I thought so it got some air time on this night out.
Recently, we've both taken to going to Barcino's for their tapas and sangria. We're not huge drinkers but their sangrias are irresistibly good. A few weekends ago, we decided to try our hand at making our own sangria without using a store-bought mix.
There's a variety of fruits that you can add to your sangria but we chose to go with strawberries and pineapples. Some recipes also suggest peaches or raspberries. We didn't bother with fresh fruit but I don't think it makes a huge difference.
3 cans of ginger ale (approximately 4 cups worth)
Citrus fruits are a staple but we substituted limes with calamansi since it was readily available. We used only 1 orange, 1 lemon, and 3 pieces of calamansi.
A lot of sangria recipe resources online said that you don't need to use premium wine. In fact, most sites recommended using leftover/value-for money (read: cheap) wine. They did suggest using Cabernet, Merlot, or Shiraz. We got a random bottle from Pioneer Center's liquor section, along with a bottle of Tanduay Rum.
We didn't have a large enough container to hold all that liquid so we had to use a carafe and a pitcher instead. Oh, you also need some sugar for the recipe as well.
Easy does it when you uncork your bottle!
We started off by quartering the lemons and oranges and halving the calamansi. Everything is going to go into your container so make sure you cut the fruit small enough to fit into the lip of your carafe/pitcher.
Pour the entire bottle of wine in.
Squeeze as much juice from your citrus fruits as possible. Don't stress over it though because like we said, the entire wedge is going in anyway.
Add 2 tablespoons of sugar into your container.
Add in a splash of orange juice. You may also use lemon juice if you prefer.
Then we poured in almost the entire small bottle of Tanduay (about 200+ ml). You can adjust the amount you want to put in based on your desired "kick." Some other recipes also suggest putting in 2 shots of gin or triple sec.
Add in one small can of crushed pineapples. Put in a splash of the juice as well.
Then your waiting game begins. Leave your containers in the refrigerator overnight so that the wine can capture all the flavors of the fruit.
After chilling, pour in your ginger ale.
Finally, add your strawberries (or whatever other fruit you prefer). You're all done! Serve and enjoy!
We were really satisfied with how the drink turned out! In no way do we claim to be wine/alcohol mixing experts but this turned out pretty good. It was a refreshing, flavorful and tasty drink all in all. The huge fruit pieces are slightly cumbersome but just strain them out as you drink. Needless to say, it was a mellow night in as we sipped our sangrias and had a movie marathon.


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Artist description:
This was so hard to do..blood sweat and tears..:O)ref used in part:
Canvas Draw Created Jun 04, 2011 640 x 460px Unless noted Copyright 2011 vinny100.
We encourage you to submit a comment and let the artist know what you think of this drawing. Please log in or join to post a comment.
Post a comment
And the bidding starts!!! I'd give you $100,001.00 at action...lol,, if I had that kind of money,,, this is exquisite.. just a fabulous piece of art work,,, you did a wonderful job on it,, fav-coll4me
Vinny, I absolutely love this drawing. It is so detailed and the colors are just gorgeous. In auction, I would pay at least $100,000.00.......if I had money like that..lol. Honestly, it is just beautiful and should get many awards. Good job!!!
sooo many details-sounds like u put A LOT of effort into it, ouch haha- was worth dis masterpiece tho;fave ofc
Hey I'm Kesey! You liked one of my art sooooo.........I thought I might like one of yours ;) This is very impressive. Better than mine! Keeping drawing! :P
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wow this is so incradible Vinny :) i love the details and the whole atmosphere :) amazing drawing i must say 5/5h C: *hugs*
Vinny100 just checked out all your draws,, just awesome, thank u for ur comment, :-}
Blood, sweat, tears...My fingers wouldn't be attached to my hands if I did something like this!! WOOOOOOOOW!! It's amazing and beautiful! :O 5/5 and favessssss.
woooooow this drawing is awesome i never noticed it before it looks totally amazing i can see how hard you must of worked 5h fav
love it!


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Event: Cycleboat Cruise edit
Location: Fort Myers Beach
December 31, 2019 at 7:15pm (2 hours) edit
Friends. Drinks. Music. Ocean. Fun.
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New Zealand Rugby
Jane suffers hand injury
ESPNscrum Staff
July 16, 2011
Jane already faced a difficult task to force his way into the All Blacks' Tri-Nations squad © Getty Images
Cory Jane faces a race against time to be fit for All Blacks selection after he suffered a hand injury in Wellington's ITM Cup win over Taranaki.
Jane has a point to prove to the All Blacks management after he was left out of Graham Henry's original Tri-Nations squad. The 23-cap winger started for Wellington against Taranaki but was forced to leave the field in the 48th minute. Jane originally tried to play through the pain but the true extent of his injury became apparent later on when he revealed on Twitter that he was forced to go to hospital to have it treated.
Jane said on Twitter "Damn it...bone came out of my finger..Off to the hospital now.. did u see me trying to tackle with one arm haha," This was soon followed by "Got to the hospital and they put me in a wheelchair haha...It's only my finger....I still sat in it tho and they pushed me haha."
Jane is sure to be ruled out of Wellington's immediate ITM Cup campaign and will hope coach Graham Henry will give him the benefit of the doubt when it comes to the selection of the final 30-man squad for the World Cup. Wellington's next game in the ITM Cup is against Auckland on July 23 while the All Blacks face Fiji in Dunedin on July 22.
© ESPN Sports Media Ltd.
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WILLIAMSBURG, Va. (AP) Frantz Massenat scored 19 points to lead Drexel to a 59-48 victory over William & Mary Saturday in Colonial Athletic Association action.
The Dragons (6-11, 2-3), who led 32-24 at halftime, ended a three-game losing streak. William & Mary (7-10, 1-5) has lost seven straight.
Drexel, which got 10 points from Damion Lee off the bench and an eight-point, 11-rebound effort from Dartaye Ruffin, led by as many as 16 points after the break.
Tim Rusthoven led William & Mary with 19 points. Marcus Thornton added 14 and Brandon Britt 13. Only one other William & Mary player scored: Kyle Gaillard, who hit two foul shots.
The teams took an identical number of field goal attempts, but Drexel was 21 for 49 (42.9 percent), the Tribe 16 for 49 (32.7). Drexel had a 35-23 rebound advantage and made eight treys to the Tribe's five.
Massenat's 7-for-14 shooting included three 3-pointers.


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Rachel Jeantel was cross-examined today by the defense team for George Zimmerman, who stands accused of murdering 17-year-old Trayvon Martin last year. Jeantel, who is the prosecution's star witness, was on the phone with Martin in the moments leading up to his fatal encounter with Zimmerman. In the video above, you can see her answering a question from the defense about the possibility that Martin had not been honest with her about his whereabouts while they were on the phone.
Her answer also gave us this wonderful chyron, which graced CNN's broadcast of the trial for a few moments:


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"The Hangover," easily the funniest movie of the year, was rightly named Best Comedy or Musical, immediately washing away the bad taste of James Cameron's Best Director win.
Congratulations to director Todd Phillips, who had the good sense to make choices like having a chicken wandering on the fringes of his film, without trying to make a joke, thereby squeezing the maximum amount of laughs out of it.
Walking out of "The Hangover," two thoughts were dominant: 1) can't wait for it to go into heavy rotation on TBS and 2) can we buy tickets for the sequel now?
U.S. & World
But when the history of film is written, the lasting legacy of "The Hangover" may be its breakout performance of Zack Galifianakis. For years he had toiled in the shadows, enjoying brief moments of acclaim. But the spotlight would never shine long enough for people to learn how to pronounce his name, forget learning to spell it.
Now he's got a hit show on HBO, "Bored to Death," and is starring in the most hotly anticipated comedy of 2010, "Due Date," co-starring Robert Downey Jr.
Oh, and "The Hangover 2" is due sometime in 2011.


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A Greenpeace investigation has revealed the presence of a giant coal mine that has been illegally encroaching on a nature reserve at the source of the Yellow River. Greenpeace has documented the sprawling mining operation, in China's Qinghai Province, covering an area 14 times larger than the City of London, at an altitude of over 4,000m, in detail for the first time. With satellite imagery, evidence gathered in the remote region and analysis by legal experts, the environmental organsiation has established that coal development violates a number of water protection laws and local nature reserve regulations.
A fox is seen in front of the Qinghai Coking Coal Group opencast coal mine, with the Chi-lien mountains in the background.
© Wu Haitao / Greenpeace
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Children and adolescents with restless legs syndrome (RLS) are commonly diagnosed with comorbid attention deficit hyperactivity disorder and behavioral disturbances. Uncertainty exists over the significance of other co-occurring psychiatric disorders and their pharmacologic management in children with RLS. The purpose of this study was to determine the prevalence and nature of psychiatric disorders in children with RLS and to describe the use of psychotropic medications in our study cohort.
The electronic medical records of children younger than 18 years of age who had been diagnosed with RLS between January 1, 2003, and December 31, 2009, were reviewed. Only those patients whose findings were consistent with the 2003 NIH workshop diagnostic criteria for probable or definite restless legs syndrome were included in this study. The medical records were cross-referenced for encounters with a child psychiatrist or psychologist. Likewise, only psychiatric diagnoses whose medical records explicitly reflected DSM-IV diagnostic criteria for psychiatric disorder(s) were included. Demographic data, serum ferritin, psychotropic medications, and in some cases, the results of pharmacogenomic testing were included in the data analysis in an ad hoc fashion.
We found 374/922 patients who met diagnostic criteria for childhood onset RLS. The mean age of the subjects was 10.6 years (range 0 to 18) and the male to female ratio was approximately 1:1. Overall, 239/374 (64%) patients with RLS had one or more comorbid psychiatric disorders. Attention deficit hyperactivity disorder was found in 94/374 (25%) patients, mood disturbances were found in 109/374 (29.1%) patients, anxiety disorders in 43/374 (11.5%) patients, and behavioral disturbances in 40/374 (10.9%) patients. Attention deficit hyperactivity disorder and disruptive behavior disorders were more common in males (OR = 1.94 for both), whereas mood disturbances and anxiety disorders were more common in females (OR = 1.6 and 1.26, respectively).
Mean serum ferritin levels derived from all patients without any psychiatric disorder were compared to all patients with one or more psychiatric disorder. No differences were found. The number of new psychotropic medication trials increased significantly with increase in patient age. Stimulants and antidepressant medications were the most commonly prescribed agents. As a part of clinical care, 15 of these patients underwent pharmacogenomic testing. Metabolic abnormalities were predicted by genotyping in 12/15 (80%) patients.
Comorbid psychiatric conditions occurred in two-thirds of children with RLS, underscoring the need for multidisciplinary management of this condition. An important relationship might exist between psychotropic medication, and possibly pharmacogenomic factors, in children and adolescents with symptoms of restless legs syndrome. These findings are consistent and build on those reported in the adult literature.
Pullen SJ; Wall CA; Angstman ER; Munitz GE; Kotagal S. Psychiatric comorbidity in children and adolescents with restless legs syndrome: a retrospective study. J Clin Sleep Med 2011;7(6):587-596.
Restless legs syndrome (RLS) is a sensorimotor disorder characterized by uncomfortable sensations (often subjectively described as "creepy," "crawly," "tingling," "pulling," or "pain") and an irresistible urge to move, most commonly experienced during the evening or nighttime when the individual is immobile for extended periods of time.1 Approximately 40% of adults diagnosed with RLS have onset of their symptoms before the age of 20, and nearly 10% develop symptoms before the age of 10, thus illustrating the importance of advancing our understanding of childhood onset RLS.2
Using diagnostic criteria developed at a 2003 Consensus Conference sponsored by the National Institutes of Health, Picchietti and colleagues conducted a large survey of over 10,000 subjects, and found the prevalence of definite childhood RLS to be approximately 2%.3 Two recent surveys of over 4300 Turkish children and adolescents and 3300 Turkish adolescents that assessed for symptoms of RLS found the prevalence to be between 2.74% and 3.6%, respectively.4,5 The conclusion from all 3 studies is that childhood RLS is a common disorder, and comorbid mental health conditions are being increasingly recognized.3–5 In a case series of 18 children and adolescents who met diagnostic criteria for pediatric RLS, Picchietti and Stevens described other comorbid disorders such as parasomnias in 7 of 18 subjects, attention deficit hyperactivity disorder (ADHD) in 13 of 18 subjects, oppositional defiant disorder in 4 of 18 subjects, anxiety disorders in 6 of 18 subjects, and depression in 5 of 18 subjects.6 Yilmaz and colleagues also found a high co-occurrence of ADHD symptoms in children with definite RLS.4 However, the scope of psychiatric disorders in children and adolescents with RLS has not been as well studied as in adults. Further complicating matters is the fact that childhood RLS may go unrecognized when there are overwhelming daytime manifestations of comorbid conditions such as ADHD, mood and anxiety disorders.2,7,8 As such, symptoms of RLS may be missed by other providers, such as pediatricians or child psychiatrists, who are at the forefront of treating these comorbid conditions.
Current Knowledge/Study Rationale: Restless legs syndrome is a common sensorimotor disorder that frequently occurs in children and adolescents, and can significantly impact quality of life. Comorbid psychiatric disorders are increasingly being recognized among adults with RLS, but little is known about the prevalence of comorbid psychiatric disorders in children and adolescents with RLS. This was the primary rationale of this study.
Study Impact: Nearly two-thirds of children and adolescents diagnosed with RLS also met diagnostic criteria for one or more psychiatric disorder. This highlights the need for the sleep clinician to assess for psychiatric disturbances in this population, and conversely for the physician treating psychiatric disorders in children and adolescents to assess for RLS.
In adults, several studies have established an association between restless legs syndrome and major depressive disorder and anxiety disorders.9–11 In her paper describing the reciprocal relationship between mood disorders and RLS, Hornyak postulated several mechanisms to help explain the high rate of co-occurrence between mood disorders and RLS that have been observed among adults.11 Both mood disorders and RLS share derangement in dopaminergic metabolism which is demonstrated empirically by the fact that dopaminergic agonists improve RLS symptoms, and can augment antidepressive therapy, whereas dopaminergic antagonists (i.e., antipsychotic medications) may exacerbate RLS symptoms.11–13 Persistent disruption in the quality and quantity of sleep also has profound effects on mood, cognition, and daily functioning.11
An increasing number of clinical reports have also described the triggering or exacerbation of symptoms of RLS by psychotropic medications, which may also help to explain the high co-occurrence rate of RLS and psychiatric disorders in adults.11,14,15 Interestingly, the antidepressant bupropion (Wellbutrin), which acts as both a dopaminergic and noradrenergic agonist, is not known to exacerbate RLS symptoms, thus reinforcing the link between RLS and dopaminergic pathways.11 All studies examining these connections between psychiatric disorders and RLS have been carried out in adults. The role that psychotropic medications might play in exacerbating childhood-onset RLS has not been studied. While ADHD and behavioral disturbances have been previously described in children and adolescents who have RLS, little is known about the occurrence of other psychiatric disorders in childhood RLS. A better understanding of the prevalence of psychiatric disorders and RLS in children and adolescents is a key first step to understanding the putative link between these entities: this was the impetus for our research study.
Studies describing RLS and psychiatric comorbidity in adults, as well as the case series reported by Picchietti and Stevens in children were the basis for our first hypothesis: we postulated that there would be a high rate of comorbid mood and anxiety disorders in addition to ADHD and behavioral disturbances among children and adolescents with RLS. Second, since children who have been diagnosed with one or more psychiatric disorder often receive psychotropic medications, we also planned to cross-link patterns of psychotropic medication use to RLS. As already noted studies in adults have demonstrated a link between psychotropic medication use and worsening of RLS symptoms. We hypothesized that our study results would be similar.
Pharmacogenomic testing for hepatic microsomal enzymes such as P450 is presently available at some medical centers including at our Institution. It can help predict how a patient metabolizes certain medications, including many psychotropic medications. This helps determine predicted responses to medications as well as potential susceptibility to side effects.16,17 At our institution, pharmacogenomic testing is often done as part of a comprehensive workup in both child and adult patients with more serious and chronic psychiatric disorders requiring more complicated pharmacologic management. This aids in predicting response to treatment and susceptibility to potential side effects. Therefore, we also wanted to include the results of any clinically relevant pharmacogenomic testing that may have been conducted in patients who coincidentally had both RLS and comorbid psychiatric disorder. This could further our understanding of how psychotropic medications exacerbate RLS symptoms.
The objectives of this study were to: determine what percentage of a cohort of children and adolescents with clearly defined RLS had a comorbid psychiatric disorder and to determine the nature of this disorder and possible relationship to psychotropic medications used.
This retrospective study was approved by our institutional review board, in accordance with institutional and federal regulations. We reviewed the electronic medical records of children and adolescents younger than 18 years who had been evaluated for RLS at our Center for Sleep Medicine between January 1, 2003, and December 31, 2009. Patients had been referred to the Center for Sleep by both primary care providers and subspecialists practicing both within and outside of our medical center.
The diagnosis of RLS was based on the 2003 National Institutes of Health Consensus Conference criteria. We included only patients who were evaluated by a sleep medicine specialist, and whose electronic medical records explicitly supported a final sleep diagnosis of definite or probable RLS (Table 1). Patients were excluded from the study if their final diagnosis was possible RLS, there was insufficient history in their medical records to support a diagnosis of definite or probable RLS, an alternate final sleep diagnosis was made, or if an alternate medical or neurological condition better accounted for the patient's final diagnosis. We did not exclude patients with comorbid medical or mental health conditions as long as there was sufficient evidence to support the diagnosis of RLS as being an independent contributing factor to the patient's overall presentation. We combined probable or definite RLS categories into one group, and henceforth use the term "RLS" to denote either probable or definite RLS. We identified 922 patients who were initially evaluated for childhood RLS. We found 374 patients whose medical charts fully supported diagnostic criteria for RLS. Of note, data from 16 of 374 patients were derived from a previous study of senior author18 on the clinical characteristics of childhood-onset restless legs syndrome. The remaining 548 patients did not meet our inclusion/exclusion criteria stated earlier in this paragraph.
2003 NIH Workshop Diagnostic Criteria for RLS in Childhood and Adolescence
An urge to move the legs, usually accompanied or caused by uncomfortable and unpleasant sensations in the legs. (Sometimes the urge to move is present without the uncomfortable sensations and sometimes the arms or other body parts are involved in addition to the legs).
The urge to move or unpleasant sensations begin or worsen during periods of rest or inactivity such as lying or sitting.
The urge to move or unpleasant sensations are partially or totally relieved by movement, such as walking or stretching, at least as long as the activity continues.
The urge to move or unpleasant sensations are worse in the evening or night than during the day or only occur in the evening or night. (When symptoms are very severe, the worsening at night may not be noticeable but must have been previously present).
The child meets all 4 essential criteria for RLS and
There is a description, in the child's own words, consistent with leg discomfort.
The child meets all four essential criteria for RLS and
2 of 3 criteria supportive of the diagnosis are present (see below).
Terms such as "wiggly," "tickle," "bugs," "spiders," "hurt," "shaky," "boo boos," "want to run," and "lots of energy in my legs" may be used by the child to describe symptoms. Age-appropriate descriptors are encouraged.
The child meets all 4 essential criteria for RLS except #4: "worse in the evening or at night" and
The child has a biologic parent or sibling with definite RLS.
The child is observed to have behavior manifestations of lower-extremity discomfort when sitting or lying, accompanied by motor movement of the affected limbs, the discomfort has characteristics 2, 3, and 4 of the essential criteria and
1) The child has periodic limb movement disorder (PLMD) and
2) The child has a biologic parent or sibling with definite RLS but the child does not meet definite or probable childhood RLS definitions (as above).
* This last category is intended for young children or cognitively-impaired children, who do not have sufficient language to describe the sensory component of RLS.
** Patients who met criteria for possible RLS were excluded from this research study.
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The medical records of the 374 patients were reviewed for comorbid psychiatric disorders. We considered only the subjects who had been evaluated by a licensed child psychiatrist or psychologist and whose psychiatric disorder(s) clearly met DSM-IV diagnostic criteria, as described in the electronic medical record. Psychiatric diagnoses were excluded from consideration if there was insufficient history in the medical records to support the stated psychiatric disorder, if there were conflicting diagnoses in medical records, or if another medical condition better explained the patient's symptoms. When describing psychiatric data collected from the medical record, patients were stratified by gender and age (0-9 and 10-18) to account for the relative likelihood that they would receive a particular psychiatric diagnosis. For example, attention deficit hyperactivity disorder is typically diagnosed in younger children, and is more common in boys than girls, whereas depressive disorders tend to be more prevalent in teenage girls.19,20
Levels of serum ferritin were recorded to determine whether iron deficiency exacerbated the risk of comorbid psychiatric disorders in the patients with RLS. Prior to data collection all of the authors met to establish data collection guidelines, and gathering of all relevant data in an ad hoc fashion. Data were primarily collected by 3 of the authors (SJP, ERA, and GEM); however, all authors met regularly to ensure that data collection adhered to the previously established inclusion/exclusion criteria.
In order to determine how well our study cohort generalizes to a larger population we collected demographic data on patient age, gender, and race; the patient's state/country of origin, and the type of medical insurance coverage (private, government, or no insurance) patients or their families carried. Data describing the clinical characteristics (number of patients diagnosed with definite 1, definite 2, probable 1, or probable 2 RLS; number of patients diagnosed with both RLS and a comorbid psychiatric disorder; serum ferritin stratified by age, gender, and ± psychiatric disorder), details of psychiatric comorbidities, and psychotropic medications including data from any patient who underwent pharmacogenomics testing were also collected.
A descriptive statistical approach was used to analyze the demographic and clinical data. A one-way ANOVA and Tukey post hoc analysis was done to compare the number of psychotropic medication trials among all patients by age and gender. A multivariate regression model was used to analyze serum ferritin levels among patients by age, gender, and whether or not the patient carried a psychiatric diagnosis.
These are described in Table 2. Socioeconomic data are described in Figure 1. Male and female patients shared similar demographic features (Table 2). The overall mean age at the time of the initial sleep evaluation was 10.6 years (range 11 months to 17.5 years; Table 2). The majority of patients were Caucasian (80.5%, 301/374), and identified the state of Minnesota as their home state (61.5%, 230/374), although 27 different states, and 3 additional countries (Canada, Dominican Republic, and Kuwait) were also represented in this population cohort (Table 2). Socioeconomic status was measured by using the patient's listed health insurance. This demonstrated that all socioeconomic strata were well-represented among different age groups, but were likely skewed toward privatized health insurance when compared with the general U.S. population (Figure 1).
Demographic features
a Other States/Countries represented included: AR, AZ, CA, Canada, CO, Dominican Republic, FL, GA, ID, IN, KS, Kuwait, KY, MA, MO, NC, ND, NE, NY, OH, OK, OR, SD, TN, and TX.
Pie chart showing the relative distribution of health insurance coverage listed for all patients in this study cohort
Patients with private health insurance [private] (Blue Cross/Blue Shield, United Health Care, CIGNA, Aetna, Assurant, etc.) represented approximately 53% (198/374) of all patients. Patients with either state or federally-funded health insurance [public/low income] (Medicaid, Minnesota Healthcare Program) represented approximately 26% (98/374) of all patients. Patients with employer-sponsored health insurance [employer] (Mayo Clinic Employee Sponsored Health Plan) represented approximately 15.5% (58/374) of all patients. Approximately 5.6% (21/374) of all patients either did not have health insurance listed or they were listed as receiving charity care [no insurance].
Pie chart showing the relative distribution of health insurance coverage listed for all patients in this study cohortPatients with private health insurance [private] (Blue Cross/Blue Shield, United Health Care, CIGNA, Aetna, Assurant, etc.) represented approximately 53% (198/374) of all patients. Patients with either state or federally-funded health insurance [public/low income]...
When we cross-referenced these patients for encounters with a licensed child psychiatrist or psychologist, we found that 239/374 (64%; 118 males, 121 females) met DSM-IV diagnostic criteria for one or more comorbid psychiatric conditions during the time for which they were being followed for RLS (Table 2).
All patients were subdivided into whether they met diagnostic criteria for the RLS subcategories of definite 1, definite 2, probable 1, or probable 2 (Table 3). Approximately 76.5% (286/374) met criteria for either definite 1 or definite 2 RLS. We did find 49/376 patients who met diagnostic criteria for probable 2 RLS. These patients were either too young or cognitively impaired (diagnosed with either mental retardation or moderate to severe pervasive developmental disorder) to verbally articulate their symptoms, but had all had well-described behavioral manifestations of RLS and had increased periodic limb movements of sleep scored on polysomnography. Additionally, these patients had well-described immediate family history of definitive RLS in their medical records.
Clinical characteristics
a Other specialties included General Psychiatry, Pain Rehabilitation, Psychology, Ear Nose and Throat, Pediatric Rheumatology, Pediatric Infectious Disease, Pediatric Endocrinology, Pediatric Cardiovascular Medicine, Pediatric Critical Care, Pulmonary Medicine, Internal Medicine, Physical Medicine and Rehabilitation, Allergy, Dermatology, Medical Genetics, Orthopedic Surgery, and Self-Referred.
Serum ferritin levels < 50 μg/L have been associated with RLS or periodic limb movements in sleep in children.20,21 Approximately 80% of subjects with RLS show underlying periodic limb movements in sleep. It is not known whether a difference in serum ferritin level exists between those with a psychiatric disorder and those without one. Therefore, we stratified serum ferritin values by age group, gender, and whether patients had a psychiatric diagnosis to assess for any differences between groups. We identified 355 patients who had their serum ferritin levels checked as part of their evaluation for RLS (Table 3).
A multivariate regression model predicting ferritin levels using groupwise comparisons of age, psychiatric diagnosis, and gender as predictors was not statistically significant (F-value = 0.48, overall p-value = 0.700). This also took into account any statistical outliers that were noted. Age group, defined in the model as either 0-9 or 10-18 (p = 0.447), gender (p = 0.336), or psychiatric diagnosis status (p = 0.467) were not statistically significant in predicting serum ferritin levels. We did not have a large enough sample size to assess for differences in serum ferritin levels between specific psychiatric diagnoses (e.g., major depression vs. generalized anxiety disorder vs. ADHD).
Referral sources from different pediatric disciplines were well represented in our population (Table 3). Primary care pediatricians accounted for 32.9% (123/374) of patient referrals to sleep medicine for evaluation of RLS, and were the single largest referral base to our sleep center. Pediatric disciplines most likely to encounter patients with comorbid psychiatric disorders included General Pediatrics, Pediatric Neurology, Developmental Pediatrics, Child and Adolescent Psychiatry, and Family Medicine and comprised 73.8% (276/374) of the population (Table 3). This was consistent with our finding that of the 239 RLS patients with psychiatric comorbidity, a psychiatric disorder had been diagnosed prior to RLS in 75% (27/36) of females aged 0-9 years, 90.5% (76/84) of females aged 10-18 years, 81% (48/61) of males aged 0-9 years, and 89.6% (52/58) of males aged 10-18 years.
Overall, we found that 25% (94/374) of RLS patients met the criteria for ADHD; 29.1% (109/374) had either a transient mood disturbance (i.e. Adjustment Disorder) or a recurrent mood disturbance (i.e. Major Depressive Disorder or Bipolar Disorder); 11.5% (43/374) had an anxiety disorder; and approximately 11% (40/374) met the criteria for a behavioral disturbance (Table 4). Mood disturbances and anxiety disorders were more prevalent in females (OR = 1.6 and 1.26, respectively), whereas ADHD and behavioral disorders were more prevalent in males (OR = 1.94). Additional comorbidities are described in Table 4. Among the 239 patients with a psychiatric disorder, 109 patients had been diagnosed with one psychiatric condition, 88 patients with 2 psychiatric conditions, and 42 patients had been diagnosed with ≥ 3 psychiatric conditions.
Psychiatric comorbidity in RLS patients
a Pervasive Developmental Disorders included: Asperger's Disorder, Autistic Disorder, and Pervasive Developmental Disorder Not Otherwise Specified.
b Substance Use Disorders included: Alcohol, Cannabis, Nicotine, Prescription Drug, Street Stimulant, and Street Opioid misuse, abuse, or dependence disorders.
c Medical Conditions with Psychological Factors included: Pain Disorder with medical and psychological components, Non-epileptogenic spells, Conversion Disorder, and Somatoform Disorder Not Otherwise Specified.
d Learning Disorders included: Learning Disorder of Reading and Written Expression, Learning Disorder of Mathematics, Learning Disorder of Reading and Mathematics, Non-verbal Learning Disorder, and Learning Disorder Not Otherwise Specified.
e Cognitive Deficits included: Borderline Intellectual Functioning, Mild Mental Retardation, Moderate Mental Retardation, Severe Mental Retardation, and Cognitive Disorder Not Otherwise Specified.
f Other included: Developmental Delay, Expressive Language Disorder, Reactive Attachment Disorder, Eating Disorder Not Otherwise Specified, Schizoaffective Disorder, and Gender Identity Disorder.
* Trichotillomania is classified as an Impulse Control Disorder in the DSM-IV diagnostic schema. This disorder commonly occurs in conjunction with other anxiety disorders such as Obsessive Compulsive Disorder, and was thus included under this heading.
The number of different types of psychotropic medications used by each of the 374 patients was assessed. Patients did not necessarily take these medications all at the same time. In addition, not all patients who were prescribed medications classified as "psychotropic medications" had been diagnosed with a psychiatric disorder, but rather had been diagnosed with other medical conditions where treatment with a psychotropic medication was indicated (e.g., headaches or seizure disorders). Approximately 54% (34/63) of female patients 0-9 years, 69% (92/133) of female patients 10-18 years, 55% (52/95) of male patients 0-9 years, and 71% (59/83) of male patients 10-18 years had been prescribed at least one psychotropic medication during their lifetime (Table 5). The mean number of new psychotropic medication trials started in female patients age in the 0-9 year age group was 1.127 (range 0-8 trials) and 1.932 (range 0-12 trials) in the 10-18 year age group 1.932 (range 0-12 trials). The mean number of new psychotropic medication trials started in male patients was 1.235 (range 0-7 trials) in the 0-9 year age group and 2.085 (range 0-9 trials) in the 10-18 year age group. There was no statistical difference between females and males within the same age group. However, the mean number of new psychotropic medication trials did significantly increase with age (p = 0.0016; Table 5).
Psychopharmacologic data
a A statistical difference was found between age groups (0-9 vs 10-18), but not between gender (male vs female) (p ≤ 0.01).
We found that antidepressants (196) and stimulant medications (196) represented over half (61%; 392/642) of the total psychotropic medication classes prescribed to the patients during their lifetime (Figure 2). The absolute number of medications prescribed was highest within the same year that the diagnosis of RLS was made, although the relative percentage of different psychotropic medications classes prescribed to patients remained consistent across time (Figure 2). Given the cross-sectional nature of the study, it was not possible to assess a causal link between prescribing psychotropic medications and the development of RLS.
Pie charts describe the breakdown of absolute number and relative percentage of psychotropic medications prescribed to patients
Medication groups were organized into different psychotropic medication classes (antidepressants, antipsychotics, mood stabilizers, stimulants, and other). Groups were stratified by year the medications were prescribed relative to when the diagnosis of restless legs syndrome (RLS) was made: (A) at least one year before RLS diagnosis made; (B) same year as RLS diagnosis made; (C) at least one year after RLS diagnosis made.
Pie charts describe the breakdown of absolute number and relative percentage of psychotropic medications prescribed to patientsMedication groups were organized into different psychotropic medication classes (antidepressants, antipsychotics, mood stabilizers, stimulants, and other). Groups were stratified by year the medications were prescribed relative to when the diagnosis of restless legs syndrome...
Pharmacogenomic testing is available at our medical center and is routinely carried out within our department of psychiatry and psychology to aid in predicting psychotropic medication response, and susceptibility to medication side effect. At our Institution pharmacogenomic testing is often carried out in children and adolescents with serious and chronic psychiatric disorders such as schizophrenia, bipolar disorder, or recurrent severe major depression where pharmacologic management can be complicated by poor response to treatment, polypharmacy, and prohibitive medication side effects.
Within our study cohort we identified a subset of 15 patients with RLS and comorbid psychiatric disorder(s) who underwent cytochrome P-450 pharmacogenomic testing for gene polymorphisms encoding for clinically relevant hepatic enzymes, CYP2D6, CYP2C19, and CYP2C9, which are responsible for metabolism of many psychotropic drugs. Allelic variation of genes coding for these 3 enzymes results in abnormal metabolism of these psychotropic drugs. At our institution, variation in metabolic activity is defined as follows: Extensive metabolizers are homozygous for normal genotype and normal drug metabolism. Intermediate metabolizers are heterozygous for one normal allele, and one enzyme-inactivating allele.23 This leads to decreased drug metabolism. There is increased susceptibility to toxic accumulation of parent drug, and side effects at normal drug dosages. We identified 11/15 patients who were intermediate metabolizers of psychotropic medications they were prescribed. Poor metabolizers are homozygous for 2 inactivating alleles. This leads to limited or no drug metabolism. The parent drug often accumulates to toxic levels with serious risk for adverse side effects. We identified one patient who was a poor metabolizer of the psychotropic drugs they were prescribed. Ultra-rapid metabolizers have a duplication of a functional gene resulting in rapid drug metabolism. This results in a decrease in parent drug concentration at normal drug doses and increased risk for poor drug response at normal drug dosages.
A total of 10 patients with reduced metabolic capacity (9 "intermediate metabolizers" and one "poor metabolizer") were prescribed psychotropic medication metabolized by the corresponding enzyme concurrent with the time they were diagnosed with RLS.
The design of this study was a retrospective chart review of pediatric patients who were evaluated RLS at our sleep center from the beginning of 2003 until the end 2009. We selected only those patients with clearly described definite or probable RLS in their medical records, and then cross referenced these records for encounters with a child psychiatrist or psychologist to assess for comorbid psychiatric disorders.
This study was conducted at a Midwest tertiary care facility that receives requests for patient evaluations locally, regionally, nationally, and internationally. The majority of patient evaluations were either local or regional; however this study also included a fair number of national RLS patients and three international RLS patients. Geographically, this study cohort is representative of the Midwest region of the United States. The socioeconomic makeup of this study cohort, as indicated by the breakdown of patient-listed health insurance, was skewed towards patients with privatized health insurance when compared with the general U.S. population. Approximately 26% of patients from our cohort were listed as having either state or federally funded health insurance, and approximately 52% with private health insurance. This reflects a wealthier cohort population when compared with the general U.S. population. The majority of our subjects were Caucasian; thus our cohort is not entirely representative of other regions of the United States. Males and females were equally represented.
Patients with RLS were subcategorized as having definite 1, definite 2, probable 1, or probable 2 RLS based on the available clinical data in the medical record. While most patients met criteria for definite 1 or definite 2 RLS we did find 49 patients that met diagnostic criteria for probable 2 RLS. This contributes to some of the first "probable 2" RLS cases reported in the literature. These patients were some of the youngest in our study cohort (the youngest being 11 months old), and were described as having behavioral manifestations of RLS including increased periodic limb movements noted in their overnight polysomnogram studies. However, they lacked the ability to verbally articulate their symptoms. They also had clearly described family histories of RLS. Some older patients were also diagnosed with probable 2 RLS. These patients were cognitively impaired in some way (either having mental retardation or significant features of autism), and were also limited in their ability to describe their symptoms, but otherwise their clinical features were consistent with RLS.
We used strict inclusion/exclusion criteria that likely led to rejection of a number of patients with legitimate RLS and/or psychiatric disorders because their symptoms had not been adequately described in the medical record. As with any retrospective design, we were able to demonstrate only associations rather than cause and effect, specifically with regard to the relationship between childhood RLS and psychotropic medications. Only prospective evaluation can help determine whether RLS was secondary to psychotropic medication and whether there is a shared biologic link between psychiatric disorders and RLS.
The most significant finding of this study was that nearly two-thirds of children who were diagnosed with RLS also had one or more psychiatric diagnoses, which supported our first hypothesis about the co-occurrence of these disorders. Not surprisingly, ADHD was commonly diagnosed in children with RLS, consistent with what has been previously documented.3–5 Our findings independently support those previously reported results. Additionally, we also identified a high prevalence of other psychiatric disorders. Disturbances in mood were diagnosed even more frequently than ADHD, although this group also included patients with transient mood disturbances such as adjustment disorders. Mood disorders were more prevalent in females and ADHD was encountered more often in males. Psychotropic medications had been started in a majority of subjects prior to formal diagnosis of RLS. This brings up the need for child psychiatrists and psychologists to be more aware of RLS as a possible comorbidity in their patients.
Several studies in adults have shown an important association between RLS and major depression/anxiety disorders.9–11 Lee et al.9 and Hornyak11 have suggested hypotheses to account for this association: first, sleep architecture is adversely affected by both RLS and mood/anxiety disorders, which can exacerbate psychiatric symptoms.9,11 The interplay between decreased sleep quality and quantity on one hand and neurocognitive and psychiatric symptoms on the other hand is well documented.24,25 RLS and some psychiatric disorders may share some similarities in neuropathophysiology, as dopamine is a neurotransmitter central to restless legs syndrome, and plays a key role in psychiatric disorders as well.7,9,26
Somatic disturbances, such as diabetes, cardiovascular disease, and cancer were observed in adult patients with RLS and comorbid depression and anxiety in the study of Winkelmann et al. Even after controlling for this possible confounding variable a strong association was shown between RLS and mood/anxiety disturbances.10 In our study developmental disorders and psychosomatic disorders, such as pain disorders and various medical illnesses with psychological factors were observed among children diagnosed with RLS. We did not control for these diagnoses to focus specifically on depression and anxiety as we were interested in describing any co-occurring psychiatric disturbance. In our study approximately 35% (131/374) of children and adolescents with RLS were diagnosed with more than one psychiatric disorder. This is not surprising because psychiatric disorders commonly co-occur with one another. For example, ADHD and behavioral disturbances commonly co-occur; mood and anxiety disorders also commonly co-occur. We were unable to determine the impact that RLS and comorbid psychiatric conditions had on one another, given the limitations of this study. This would be an important area for ongoing study.
Picchietti and Stevens also described comorbid psychiatric disturbances, such as ADHD, mood disorders, and behavioral disturbances, in a small cohort of children with RLS.6 Our study is consistent with their findings, and demonstrates an important association between childhood RLS and comorbid psychiatric disorders. To the best of our knowledge, this is the largest study to date looking at this association in children and adolescents.
Our study points out those children with RLS may present in the early stages to child psychiatrists or psychologists rather than to sleep specialists for evaluation and management of their behavioral disturbance. Over 50% of all children (ages 0-9 years) and nearly 70% of all adolescents (ages 10-18 years) with RLS had received at least one trial of a psychotropic medication at some point during the course of their care, highlighting the importance of identifying RLS that has been induced or exacerbated by such medications. We found that on average, children had received slightly more than one trial of a psychotropic medication before the age of 10; by the age of 18, adolescents had received nearly two trials of different psychotropic medications. The prescription of psychotropic medications varied considerably, ranging from none to as many as eight or more different medication trials. This variability was reflective of whether a patient had one or more comorbid psychiatric disorders and the severity of that disorder. Those patients diagnosed with more severe or multiple psychiatric disorders tended to receive more trials of different psychotropic medications. While this seems intuitive, it is an important discussion point given that many of these medications can precipitate latent RLS or exacerbate symptoms of RLS.11,14,15,27
We also found that the majority of psychotropic medications were prescribed around the same time that the diagnosis of RLS was made. The implications of this finding are unclear, but as discussed above, psychotropic medications can cause RLS symptoms iatrogenically or exacerbate preexisting symptoms of comorbid RLS. Our finding that patients were being prescribed an increasing number of new psychotropic medication trials as they get older (Table 5) underscores the chronicity of their psychiatric disorder(s) and possible risk for RLS. While we would be cautious about drawing a causal relationship, this should bring increased awareness to providers about the burden of additional medication side effects. Furthermore, this finding illustrates the importance of prospectively studying the mechanism by which psychotropic medications can potentiate RLS symptoms as other studies have failed to find a direct causal relationship between psychotropic medication and RLS symptoms.9,28
Pharmacogenomic studies prior to the initiation of treatment with a selective serotonin reuptake inhibitor or neuroleptic medication (such as risperidone) might also be helpful to assess the potential risk for developing iatrogenic RLS. In humans, the cytochrome P450 enzymes are a group of proteins that are responsible for nearly 75% of oxidative phase I drug metabolism. Allelic variants of several key enzymes, specifically 2D6, 2C9, and 2C19, have clinical relevance in how efficiently some psychotropic drugs are metabolized.29 Pharmacogenetic studies have been shown to be safe and effective to assess for allelic variation in children as well.30 This may have important ramifications for how rapidly a drug is metabolized, and for an individual's susceptibility to a drug's side effects, including symptoms of RLS. In this study we found 12/15 patients with reduced psychotropic drug metabolism predicted by their pharmacogenomic profile. Ten of those patients were taking psychotropic medications around the time they were diagnosed with RLS. This provides a possible mechanism whereby individuals with reduced capacity to metabolize psychotropic drugs are more susceptible to drug side effects such as iatrogenic RLS. However, the widespread use of pharmacogenetics in fields such as psychiatry has not been unanimously received, with concerns raised about cost, predictive power, and clinical utility.31 More research is needed in this emerging field to better define a clinical role for the use of genetic testing.
Iron plays a key role in neurotransmission, neuronal function, and dopaminergic signaling.32 Low serum ferritin plays an important role in RLS pathophysiology and may also contribute to the pathophysiology of some psychiatric disorders such as ADHD.22,32 We were interested in determining if there was a difference in serum ferritin levels in RLS patients without psychiatric disorders compared to those with psychiatric disorders. In this study we found low mean serum ferritin levels (< 50 μg/L) among children and adolescents diagnosed with RLS across age, gender, and the presence/absence of a psychiatric disorder. We did not find a statistically significant difference between patients grouped by gender, age, or whether or not they carried a psychiatric diagnosis. Limited sample sizes prevented us from comparing patients within the "psychiatric disorder" group (ADHD vs. major depression vs. anxiety, etc.). We did not see group-wise differences in serum ferritin in those patients with comorbid psychiatric disorders as compared to patients who did not have a comorbid psychiatric diagnosis. However, our study lacked sufficient power to determine if there were differences in serum ferritin in patients with different psychiatric disorders, and this is an area for further research.
In conclusion, we would propose a bidirectional relationship wherein the sleep disturbance exacerbates mood and attention problems, and the use of psychotropic medications potentially exacerbates the sleep disturbance in some susceptible children. Psychiatric comorbidities occur in two-thirds of children with RLS. This necessitates a comprehensive multidisciplinary approach that involves sleep specialists, child psychiatrists, and psychologists. This study underscores the need for the child psychiatrist/psychologist in assessing for a patient and family history of RLS, as well as being mindful of the role of psychotropic medications in precipitating or exacerbating RLS. It is important for the sleep specialist to look for psychiatric comorbidities; conversely, it is equally important for the child psychiatrist or psychologist to inquire about sleep disorders such as restless legs syndrome, due to the complimentary and at times confounding nature of the illnesses and the need for an integrated management approach.
This was not an industry supported study. The authors have indicated no financial conflicts of interest.
The work for this study work was performed at Mayo Clinic, Rochester, MN, USA. The authors are grateful to Ms. Lori Solmonson for invaluable assistance in manuscript preparation. The authors are also grateful to Ms. Jennifer R. Geske, M.S., for her work statistically analyzing our data set.
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December 3, 2019, 5:30 PM - 8:30 PM @ Council Chamber, City Hall
Unless otherwise noticed, City Council meetings are held on the first and third Tuesdays of every month at 5:30 pm in the Council Chamber, 760 Mattie Road, Pismo Beach. Additional Special Meetings and Closed Sessions are convened as needed; agendas are published no fewer than 72 hours prior to the meeting.


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I made a complete mess of my earlier recursive macros post. I hadn't surrounded the two function calls with
progn so only the last one was called. Not only that, but I hadn't fixed up defstruct* to work with the function instead of the macro.
It is all fixed up now. Take a look.
What happened?
Obviously I tested it before I posted (although I admit it was rushed). What went wrong?
I've actually been caught out by the convenience of the REPL.
During testing, one of my iterations managed to create a
struct--params variable and subsequent tests just worked.
Oops, I'll need to take more care in the future.


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Who We Are
Who is ADMEI
As the global voice of the destination management industry, ADMEI is the premier resource for education, standards and practices within the DMC industry. ADMEI has a global presence and a respected reputation for sharing the value of DMCs to both internal and external stakeholders. Members collaborate to define and advance new initiatives and also look to ADMEI for advances impacting the destination management industry. ADMEI is the trusted partner in the certification of destination management professionals and the accreditation of destination management companies.
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Hear why a member joined ADMEI
Who We Are
Owners, CEOs and executives of the most experienced and long-standing destination management companies in existence form the framework of the Association of Destination Management Executives International (ADMEI). These visionaries came together in 1995, after a series of exploratory meetings in which they agreed an organization was needed to represent this segment of the travel and meetings industry. Many concerned companies donated funds to establish the only non-profit association in existence today for global destination management company executives and their staffs. We are not a lead-generating or marketing consortium. We supply information to corporate and association meetings professionals regarding member DMCs in their locale or a locale in which they will be managing meetings, events, incentive programs, etc.


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The garage is now widely recognized as one of the top home spaces in need of organization, as its perpetual clutter barely allows for cars. In fact, in a recent nationwide poll, only 58 percent of respondents claimed to use their garage for their vehicle. It's time to put some drive into your parking space. Rubbermaid can help you get your garage organized—and keep it that way.
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Apart from God's answers in Genesis, cannot come up with a logikos reason for moral values and rules—yet "sheeple" continue to trust worldly authorities with blind, irrational faith.
A recent, lengthy article in U.S. News & World Report is representative of a flood of writings centered on a "secular" search for truth and meaning.
No results found in .
Answers in Genesis is an apologetics ministry, dedicated to helping Christians defend their faith and proclaim the gospel of Jesus Christ.


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Saving for a comfortable retirement is one of the most common financial goals among
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Windows Essentials (Movie Maker, Windows Photo Gallery, and Windows Live Writer) reached end of support on January 10, 2017. They are no longer available for download.
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Visit this personalization page to surround yourself with the things you love. If you use Windows 10, it's easier to use the Microsoft Store below to download desktop themes.
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