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Clinical Implications
· REM sleep and SWS may have significant roles in memory consolidation, cognitive function, affect regulation, and diminishing the emotional valence of memories; these roles may have significant implications for several psychiatric disorders. · Sleep is influenced by neurochemistry that is also implicated in the pathophysiology of numerous psychiatric disorders, which may explain why so many psychiatric disorders have sleep complaints as a primary symptom; an understanding of these mechanisms may lead to rational manipulation of these relations and lead to improved clinical care of numerous psychiatric disorders. · Psychiatrists should maintain a high index of suspicion for several sleep disorders, including obstructive sleep apnea, restless legs syndrome, periodic limb movement disorder, REM behaviour disorder, and even narcolepsy, all of which may be comorbid or possibly mimic numerous psychiatric disorders, and can even occur as a consequence of psychiatric care; these disorders may exacerbate underlying psychiatric symptoms if left untreated.
· The precise function of sleep is not known; consequently, efforts to understand and rationally manipulate sleep are limited. · There is a paucity of psychiatrists involved in sleep medicine and sleep research; as a result, an understanding of the role of sleep in psychiatric disorders, and the psychiatric symptoms of sleep disorders remains limited.
0 = no effect; + = mild effect; ++ = moderate effect; +++ = strong effect; Tmax = time to peak plasma concentration; t ½ = half-life; WASO = wake time after sleep onset a Reprinted with permission from Krystal et al30
Antipsychotics and Sleep increase SWS in healthy patients, likely because of lessAntipsychotics are currently the mainstay of schizophrenia 5-HT2 antagonism.30 Paliperidone has not been shown totreatment.27 First-generation (typical) antipsychotics are pri- increase SWS.38 For a summary of these effects, see Table 1.marily dopaminergic antagonists, with antihistaminergic and Interpreting these findings can be challenging because theseanticholinergic effects. Second-generation (atypical) effects are studied in different populations, from control sub-antipsychotics have the added effect of blocking serotonergic jects to patients with different psychiatric conditions, leadingreceptors and are associated with improvement of negative to conflicting findings. Additionally, it is unclear that simplyand cognitive symptoms.28 The central H1 (histaminergic reversing the SWS abnormalities results in clinical improve-one) antihistaminergic effects of antipsychotics have signifi- ment of schizophrenia symptoms. However, there is clinicalcant sedating properties, which may be beneficial for patients utility in understanding sleep architecture changes that occurwith schizophrenia and insomnia. Olanzapine is the most with antipsychotics. For instance, quetiapine is an appropri-sedating of the atypical antipsychotics.29 However, excessive ate choice for sleep-onset insomnia, as it reaches peak blooddaytime sedation can facilitate a reversal of the sleep–wake levels quickly, has a relatively short half-life compared withcycle, as daytime naps may enhance nighttime wakefulness, the other atypical antipsychotics, and significantly shortensp a r a d o x i c a l l y e x a c e r b a t i n g in s o mn i a . 3 0 A n o th e r sleep latency. Other atypical antipsychotics includingantihistaminergic effect is increased appetite and weight gain, olanzapine, risperidone, or clozapine may take up to 1 weekwhich can increase the risk of developing OSA.31 OSA may for blood levels to peak. 30 Conversely, ziprasidone,often go unrecognized in these patients and can contribute to olanzapine, or risperidone may be more suitable for sleepseveral problems including aggressive behaviours. Anecdotal maintenance insomnia, owing to their relatively powerfulreports of severely aggressive patients with schizophrenia and potential to increase SWS; however, daytime sedation can beunrecognized OSA have shown that, once treated with CPAP, a side effect.30aggressive tendencies diminished dramatically.32 Sleep in Anxiety DisordersDopaminergic antagonism also has significant sleep effects.Dopamine antagonism has been linked to exacerbation of Patients with anxiety disorders, including GAD, PTSD, andRLS and PLMs, which can fragment sleep and contribute to panic disorder, often have disturbed sleep. Insomnia is thedaytime sleepiness. This has been demonstrated in case most common sleep complaint in these disorders. A largereports for olanzapine,33 risperidone,34 and quetiapine.35 cross-sectional study by Ohayon and Roth39 showed 61% of panic disorder patients and 44% of patients with GAD hadSerotonergic actions also play a role in sleep architecture insomnia. Insomnia can have several etiologies, includingchanges. 5-HT1A agonist effects suppress REM sleep.30 For RLS, or an underlying common neurochemical abnormality.instance, ziprasidone has strong 5-HT1A agonism effects andsignificantly suppresses REM sleep.30 Increased SWS is cor- RLS and Anxiety Disordersrelated significantly with 5-HT2 antagonism. Olanzapine36 RLS is often described as a creepy-crawly or tingling sensa-and risperidone37 have high 5-HT2 antagonism and are tion in the lower limbs associated with a strong desire toreported to increase SWS the most among antipsychotics. move, usually worsened by rest and worse in the evenings.40Ziprasidone also increases SWS, but quetiapine does not Because symptoms frequently occur in late evening, they
often cause initial insomnia. RLS is strongly related to PLMD, patients with nocturnal panic attacks have reduced heart ratein which the legs move periodically in the night, usually at 20- variability and a "qualitatively different cardio-to 40-second intervals, causing fragmented sleep and middle physiology,"55, p 461 possibly suggesting that these patientsinsomnia. CNS dopamine deficiency is strongly implicated in have a distinct variant of panic disorder. Evaluation shouldRLS and PLMD.41 RLS prevalence estimates indicate 5% to consist of a sleep evaluation to screen for other diagnoses10% of the population may be affected.42 Several recent stud- such as night terrors, sleep paralysis, seizures, PLMD, and, inies highlight a strong preponderance of anxiety disorders in particular, OSA, as apneic events can trigger nocturnal panicRLS patients, especially panic disorder.43 The relation may lie attacks.54in a common dopaminergic abnormality.43 Antidepressant useis also linked to RLS, including the tricyclics and SSRIs,44 PTSD and Sleepvenlafaxine,45 and, particularly, mirtazapine.44 Recent studies Studies evaluating sleep in PTSD have shown frequentsuggest an average 5% to 10% increase in incidence of RLS arousals, fragmented sleep, and increased motor activity.57symptoms with SSRI or SNRI antidepressant use, but up to a Although reports on sleep architecture changes are inconsis-30% increase with mirtazapine and no increase with tent, a large recent meta-analysis showed PTSD patients havereboxetine use.44 Although SSRIs and SNRIs may exacerbate more Stage 1 sleep, less SWS, and higher REM density.58RLS, bupropion has been suggested to be neutral for RLS The losses in SWS may be mediated by increases insymptoms and possibly even helpful for RLS because of its cerebrospinal fluid CRF, which is known to inhibit SWS.59dopaminergic activity.46 As untreated RLS is associated with CRF dysregulation may be a core feature of PTSD; as ainsomnia47 and poor quality of life,48 it behooves psychiatrists result, CRF receptor antagonists are being developed as ther-to recognize this disorder. Many patients with anxiety disor- apeutic targets for treatment of PTSD symptoms.59,60ders may have unrecognized RLS. If RLS symptoms occur REM sleep abnormalities in PTSD have attracted significantmore than 3 times per week, treatment with a dopamine ago- attention. Several studies show higher REM density andnist such as pramipexole or ropinirole 2 hours before bed- increased REM latency61 in these patients. Multiple lines oftime49 can be beneficial. evidence suggest REM sleep continuity is disrupted in chronic PTSD. 62,63 Some studies have demonstratedGAD and Sleep increased muscle tone in REM sleep, further suggesting aGAD is commonly associated with insomnia. Although GAD dysfunction of REM sleep mechanisms, as REM sleep nor-has a high comorbidity with MDD, polysomnography studies mally has skeletal muscle atonia.57,64 PLMs also occur fre-of these patients do not consistently demonstrate the reduction quently in PTSD.57 Dream enactment behaviour has alsoin REM latency seen in MDD.50 These studies also showed been evaluated in patients with PTSD,64,65 though surpris-that GAD patients have less SWS and more awakenings than ingly few studies have evaluated this comorbidity, given howcontrol subjects.51 Daytime vigilance and attention remain often parasomnia behaviours occur, including yelling, shout-stable despite SWS deprivation and fragmented sleep, but fine ing, and kicking.motor control and reaction time are diminished, suggestingsome deficits from sleep disturbances.52 Benca et al8 per- Nightmares and PTSDformed a large review of sleep findings in patients with GAD Nightmares occur in up to 96% of PTSD patients,66 predomi-and concluded that while studies consistently reported an nantly emerging from REM sleep.63 Mellman51 has observedincreased sleep latency and decreased sleep efficiency in these that in patients exposed to trauma, those who develop PTSDpatients, findings in SWS, REM latency, REM density, and describe dream content that is "highly replicative"p 1052 of theREM quantity were variable. trauma; whereas those who do not develop PTSD describe dreams with a significant fear component but that are notPanic Disorder and Sleep replicative of the traumatic events. Mellman theorizes thatSeveral surveys show an association between insomnia and these replicative dreams in PTSD represent a "failure ofpanic disorder, with up to 68% of patients with panic disorder adaptive emotional memory that is a normal functioning ofidentifying problems falling asleep and 77% of patients with REM sleep and dreaming."51, p 1052 This theory is consistentpanic disorder endorsing difficulties maintaining adequate with Walker's "sleep to forget hypothesis"7, p 190 (discussedsleep.50 Panic attacks evolving from sleep (sleep panic attacks earlier), as PTSD is envisioned as a failure of the normalor nocturnal panic attacks) may result in insomnia because function of REM sleep to remove the emotional content of asleep may become regarded as a fearful panicogenic state.53 memory, leading some to speculate that PTSD symptomsBetween 44% and 71% of patients with panic disorder experi- may represent a form of sleep disorder,67 in contrast to the tra-ence sleep panic attacks,54 with 18% to 45% of panic attacks ditional view that sleep disturbances are a symptom of PTSD.arising from sleep.50,55 Sleep evaluations have established that Several nonpharmacologic measures have been shown to benocturnal panic attacks typically occur at the transition beneficial for nightmares, including imagery rehearsal ther-between Stages 2 and 3 of sleep56 and are distinct from night apy and CBT, either alone or in combination.68 Eye move-terrors and other parasomnias, as well as from panic attacks ment desensitization and reprocessing may also help withoccurring after nocturnal awakening. Recent studies show sleep efficiency in PTSD.69 Another nonpharmacologic
intervention for PTSD is CPAP. Some studies have demon- include depression,92 cognitive dysfunction,93 poorer qualitystrated frequencies of OSA in PTSD patients of more than of life, and increased mortality.94 Prevalence estimates of90%,70 while another study of community patients with PTSD sleep complaints in the elderly approach 30% to 50%,95 mak-showed no increase in OSA.62 Treatment of underlying OSA ing sleep important to address in this population.in PTSD patients may significantly improve nightmares andinsomnia symptoms.71 Patients with PTSD and OSA may not Insomnia in the Elderlyreport the typical sleepiness reported by classic OSA patients, Insomnia is the most common sleep difficulty reported inas this may be masked by heightened anxiety; instead, they elderly adults, especially elderly women.96 The prevalence ofmay report fatigue or tiredness. Krakow et al72 demonstrated insomnia increases sharply with the number of medical andthat these patients report nocturia, morning headaches, and psychiatric conditions present, the most common beingdry mouth, which may be better indicators of comorbid OSA depression, chronic pain, cancer, chronic obstructive pulmo-in this population. For excellent reviews of sleep abnormali- nary disease, and cardiovascular disease. In an extensiveties in PTSD, see Spoormaker and Montgomery67 and review of 6800 elderly patients with insomnia, only 7% ofGermain et al.73 those with incident insomnia did not have one of these condi- tions, leading the authors to conclude that medical conditionsThe heightened arousal and disturbing dreams in PTSD likely associated with aging lead to insomnia, rather than agingoriginate from an overactive noradrenergic system, with itself.97 Many medications also have insomnia as a sideinvolvement of the limbic system including the amygdala and effect.medial prefrontal cortex.73 Prazosin, an alpha-1 adrenergicantagonist, has significant nightmare attenuation properties. Circadian Rhythm Disturbances in the ElderlyThis agent diminishes noradrenergic activity of the locus The sleep–wake cycle is controlled by the suprachiasmaticcoeruleus, thereby decreasing nightmare frequency and inten- nucleus, located in the anterior hypothalamus. Together withsity.74,75 Studies used between 1 and 20 mg/day, with a mean external time cues (zeitgebers), particularly exogenous lighteffective dosage of 2 to 13 mg/day.75 The 5-HT2A receptors and endogenous melatonin, the suprachiasmatic nucleusalso play an important role in nightmare experiences and sleep entrains the body's circadian rhythms, including thedisturbances in PTSD. Other medications that have demon- sleep–wake cycle. This system becomes less robust with age,strated efficacy for sleep in PTSD include 5-HT2 antagonists, and more prone to phase advancing. Therefore, the elderlymany with antiadrenergic activity, including trazodone,76 may have a tendency to retire early and arise early. Conse-mirtazapine,77 olanzapine,78 risperidone,79 quetiapine,80 quently, 2 patterns may emerge that exacerbate insomnia.98aripiprazole,81 as well as the anticonvulsants topiramate82 and Some elderly may stay awake longer, to more sociallygabapentin.83 The latter 2 agents may reduce kindling– accepted norms but then wake up early in the morning unablehyperreactivity of the limbic system. Other recently studied to return to sleep because their bodily rhythm is entrained tomedications with demonstrated sleep benefits in PTSD an early morning rising. Alternatively, the elderly can feelinclude nabilone84 and dehydroepiandrosterone-sulphate.85 more fatigued earlier in the day and take daytime naps, caus-For further details regarding use of these medications, and ing initial and middle insomnia because of less nocturnalanecdotal reports of other medications with some demon- sleep debt.strated benefits in sleep parameters for patients with PTSD,see the review by Berger et al.86 Among the SSRIs, only Sleep Disorders in the Elderlyfluvoxamine87 has demonstrated improvement in sleep Obstructive Sleep Apnea–Hypopnea Syndrome. OSA isparameters, although SSRIs are still first-line medications for characterized by repeated pharyngeal obstructions resultingother PTSD symptoms.86 While benzodiazepines are fre- in airflow cessation (apnea) or reduction (hypopnea) duringquently used, there is sparse literature on their efficacy for sleep; these lead to sleep deprivation, fragmentation, andsleep in PTSD, with only temazepam demonstrating improve- hypoxemia. The AHI and Respiratory Disturbance Indexments.88 Although this paucity of literature has led several (commonly referred to by its acronym, RDI) are 2 measuresinvestigators to argue against benzodiazepine use in this pop- used to quantify OSA severity. These indices measure theulation,75,86 one exception may be when a parasomnia is frequencies of sleep-disordered breathing events per hour ofobserved, as clonazepam is highly effective for parasomnias sleep, with higher values indicating more severe distur-such as sleepwalking89 and RBD.89 bances. CPAP is usually the optimal treatment for OSA, but surgery (uvulopalatopharyngoplasty) or an oral applianceSleep and Cognitive Disorders can be considered for milder cases, although these are usedNormal Sleep Changes in the Elderly infrequently in OSA in the elderly.Aging is associated with several changes in sleep architecture. Among adults aged 30 to 60 years, the prevalence of OSA,Large studies indicate that percentages of REM sleep and defined as an AHI of greater than 5, is 9% for women andSWS decrease with age.90 However, there is consensus that 24% for men.99 The prevalence of OSA–HS, defined as anthe need for sleep does not change with aging, but the ability to AHI of greater than 5 and daytime hypersomnolence, is 2%sleep diminishes.91 The consequences of poor-quality sleep for women and 4% for men.99 For people aged 61 years and
older, prevalence rates of OSA may rise sharply. The Sleep These agents may be problematic for patients with psychoticHeart Health Study,100 one of the largest studies evaluating symptoms and (or) impulse control difficulties, includingOSA in the elderly, showed stable prevalence rates across age pathological gambling and hypersexuality.109 Another optiongroups from 60 to 98 years, with 51% to 66% having an AHI is gabapentin.49 Benzodiazepines and opioids are consideredof more than 5. Several medical conditions predispose the third- and fourth-line options. 49elderly to developing OSA, including stroke, diabetes (withautonomic neuropathy possibly altering ventilatory controlmechanisms), renal failure (possibly owing to excess fluid RBD in the Elderlyaccumulation), hypothyroidism, obesity, and heart disease. In RBD, the normal skeletal muscle atonia of REM sleep isHowever, other studies show an increased risk of OSA in geri- intermittently absent, resulting in complex motor behavioursatric patients in the absence of these conditions (reviewed by during REM sleep; dream content is then enacted, oftenNorman and Loredo101). Multiple mechanisms have been sug- involving themes of aggression or self-defence. Almost 90%gested to explain this increased vulnerability to developing of affected patients are male, often presenting in their 60s.110OSA, including decreased pharyngeal dilator activity, and These patients are at high risk for developing alphaexcess pharyngeal fat deposits (reviewed by Norman and synucleinopathies, including Parkinson disease, Lewy BodyLoredo101). Additionally, postmenopausal women not on hor- Dementia, and Multisystem Atrophy.111 Recent research sug-mone replacement therapy may lose the protective effect of gests RBD patients have a 20% risk of developing Parkinsonestrogen on the upper airway.101 Further, patients with disease or dementia within 5 years, and a 40% risk in 10dementias may have progressive deterioration of brain stem years,112,113 suggesting RBD is an early clinical marker ofstructures involved in maintaining airway patency and conse- these disorders. Several case reports have identified medica-quently are at higher risk of developing OSA. 102 tions that exacerbate RBD, including tricyclic antidepres- sants, 64 monoamine oxidase inhibitors, 114 SSRIs, 115Although snoring and daytime sleepiness are common OSA mirtazapine, 116 and venlafaxine. 115 RBD responds tosymptoms in elderly patients, other symptoms include insom- clonazepam (0.5 to 2.0 mg at bedtime) in 80% of patients.117nia, nocturia, irritability, morning headaches, depression, and However, clonazepam can increase fall risk and worsencognitive impairment.101 Clinicians may overlook these clues, OSA; in these patients, melatonin may be beneficial.118ascribing these symptoms to aging or medical issues.103Patients with more severe OSA perform worse on dementiarating scales, suggesting a correlation between dementia and Sleep in DementiaOSA severity.104 Other studies highlight the strong associa-tion between OSA and increased risk of cardiovascular dis- Sleep is frequently disturbed in patients with dementia.ease including heart disease, and hypertension in the elderly Often, they are institutionalized and consequently have littlepopulation.101,105 ambient light exposure. They may also have high exposure to nocturnal noise and medications affecting sleep. 119As there are significant consequences for OSA in the geriatric Suprachiasmatic nucleus neurons may degenerate morepopulation, the psychiatrist should maintain a high index of quickly in patients with progressive dementias.120 Melatonin,suspicion, as OSA is common and often undiagnosed. Refer- a hormone normally produced by the pineal gland to regulateral should be considered if there are symptoms suggestive of sleep cycles, has been shown to be diminished by up to 80%OSA with comorbid nocturia, cardiovascular disease, hyper- in elderly patients with dementia.121 Investigators havetension, or cognitive dysfunction.106 CPAP is the treatment of examined melatonin use for insomnia in dementia patients,choice, and has been shown to improve cognitive with benefit in some,122 but not all studies.123 A syntheticfunctioning.104 Although CPAP compliance may be challeng- melatonin receptor agonist, ramelteon, has been developeding, contrary to what clinicians may believe, patients with and approved for treatment of insomnia in the Uniteddementia can adapt to CPAP use with proper assistance. A States.124 For a review on other medications used for insom-study by Ayalon et al107 showed that neither age, severity of nia in the elderly population, see Bloom et al.124dementia, nor severity of OSA correlated with poor CPAPadherence; only comorbid depression predicted poorer Additionally, the elderly may have insomnia related to pain,compliance. medications, depression, or a primary sleep disorder such as OSA, RLS, PLMD, or RBD. Treatment should begin byRLS and PLMD in the Elderly addressing all the aforementioned disorders. Several studiesThe prevalence of RLS and PLMD rises sharply with age,108 demonstrated that increasing bright light exposure, minimiz-with women twice as likely to be affected as men. RLS exacer- ing ambient noise, and addressing sleep hygiene are effectivebates initial insomnia, as symptoms usually occur before sleep at improving sleep quality and consolidating the sleep–wakeonset. PLMD may exacerbate middle insomnia because noc- cycle.125,126 CBT, which includes a combination of sleepturnal leg movements can fragment sleep. Both respond to hygiene, relaxation techniques, stimulus control, and sleepdopaminergic therapy, including ropinirole or pramipexole, restriction, was more effective at maintaining improvementsconsidered first-line pharmacologic recommendations.49 in insomnia than temazepam at 2-year follow-up.127
Substance Use and Sleep irritability,140 which may be connected to REM and (or) SWS deficits. REM sleep deprivation may be hyperalgesic,142Alcohol and Sleep leading to speculation that opioids paradoxically reduce theAcute alcohol use results in decreased sleep latency, modest pain threshold by reducing REM sleep, possibly resulting in aincreases in SWS, and a reduction of REM sleep in the first 2 vicious cycle of excess opioid requirements.143 However,to 4 hours of the night.128 These properties make alcohol an pain itself also reduces REM and NREM sleep, and disruptsappealing hypnotic; up to 67% of insomniacs report alcohol as sleep continuity, thereby making this a complex relationan effective hypnotic.129 However, during the second half of requiring further study.the night, REM sleep rebounds and is associated with intensedreaming and nightmares, leading to sleep fragmentation and Several sleep complications occur with chronic opioid use,decreased sleep efficiency.128 These disruptive effects can especially methadone. Chronic opioid use is associated witheven be seen 6 hours after happy hour drinking (about 5 PM); the development of central sleep apnea occurring as a conse-that is, when blood alcohol levels are zero.130 quence of chronic suppression of ventilatory drive. ThisHowever, the effects of chronic alcohol use are quite different dose-dependent phenomenon has been seen in 30% offrom acute use. Tolerance to alcohol's sleep-enhancing patients on stable methadone maintenance.144 An increase ineffects develops within 3 to 9 nights of daily alcohol use.130 OSA has also been observed in 39% of patients receivingChronic use leads to increased sleep latency and decreased chronic opioid therapy145; these phenomena may play a rolesleep efficiency, SWS, REM sleep, and TST.128 These distur- in the sleep disturbances and increased mortality seen inbances can persist months after alcohol cessation, even up to 2 these patients.146years, although gradual improvement is generally noted.130,131Sleep disturbances persisting in early recovery from alcohol Cannabinoids and Sleepdependence are associated with higher relapse risk.132,133 Studies on the main active ingredient of marijuana, delta-9Benzodiazepines for the treatment of insomnia are avoided tetrahydrocannabinol, show decreases in sleep latency,147,148because of their abuse potential in abstinent alcoholics. Very making marijuana potentially appealing as a sedative. Bothlittle work has been done on evaluating other related pharma- increases and decreases in SWS have been seen with mari-cologic agents for insomnia in these patients, such as juana use.149 Tolerance to sleep-induction effects of mari-zopiclone, zolpidem, or zaleplon, because of similar con- juana has been demonstrated in studies of chronic marijuanacerns. Medications shown to improve sleep disturbances in users.149 Marijuana's sleep effects can be variable149 becausethis population include trazodone,134 carbamazepine,135 it contains numerous compounds, some with sedative effectsacamprosate,136 and gabapentin.137 and others with wakefulness-promoting properties such as cannabidiol.147,148 Marijuana also decreases REM sleep andAlcohol use may exacerbate several sleep disorders, includ- REM density.149 These findings have led investigators to useing OSA, PLMD, and RLS, as well as parasomnias such as nabilone, a synthetic cannabinoid, for mitigating PTSDsleepwalking and RBD. OSA and snoring are worsened by nightmares with some reported success.84 Cannabis with-alcohol, even after a single drink.130 PLMD and RLS preva- drawal has been associated with sleep disturbances, with dis-lence increases 2- to 3-fold in patients having 2 or more drinks turbing dreams most consistently reported.150 Withdrawalper day. 130 The exacerbation of parasomnias, such as symptoms begin 2 to 3 days after the last cannabis use andsleepwalking, may also have distinct forensic implications,128 generally last up to 2 weeks, although they can persist up toincluding "sexsomnia," 138, p 272 a potentially violent 7 weeks.149 Sleep onset latency increases, with reduced SWSparasomnia where sexual behaviours are enacted in sleep.138 and increased REM sleep,149 consistent with the disturbing dreams reported by patients.150Opiates and SleepMost studies of opioid effects on sleep have examined heroin,morphine, and methadone. Acute opioid administration Summarycauses reductions in TST, REM sleep, and SWS.139 With Sleep and sleep disorders are intimately tied to psychiatric ill-chronic opioid use, these changes are minimized. In opioid ness. This is true at both the clinical–behavioural and thewithdrawal, insomnia frequently occurs, with reduced SWS neurochemical levels. Most psychiatric medications targetand markedly diminished REM sleep.140 Maximal REM and receptors involved in the control of sleep. Additionally, itSWS suppression occurs 2 to 3 days into abstinence for appears that physical sleep disorders are pathoplastic to psy-chronic heroin users, and some suppression persists for 5 to 7 chiatric disorders, and need to be suspected by every practis-days into abstinence.141 With protracted abstinence, TST, ing psychiatrist when evaluating the sleep complaints of theirREM sleep, and SWS subsequently increase (rebound). The parents. Future research may change the way psychiatric dis-time course for changes in sleep architecture have not been orders are viewed, with a growing understanding of thestudied for each opioid; however, for methadone, REM and bidirectional relation between sleep disturbances and psychi-SWS rebound occurs 13 to 22 weeks after methadone with- atric symptoms. There is an opportunity to develop new treat-drawal.139 These sleep changes may explain some behavioural ment strategies for psychiatric disorders based on a broaderchanges seen during this withdrawal phase, including initial understanding of sleep physiology and pathophysiology.
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Activation by selegiline (Eldepryle) Psychopharmacol. 2006;21:185–187. of REM sleep behavior disorder in parkinsonism. W V Med J. 1995;91(3):101.82. Berlant J, van Kammen DP. Open-label topiramate as primary or adjunctive 115. Winkelman JW, James L. Serotonergic antidepressants are associated with therapy in chronic civilian posttraumatic stress disorder: a preliminary report. REM sleep without atonia. Sleep. 2004;27:317–321. J Clin Psychiatry. 2002;63:15–20. 116. Onofrj M, Luciano AL, Thomas A, et al. Mirtazapine induces REM sleep83. Hamner MB, Brodrick PS, Labbate LA. Gabapentin in PTSD: a retrospective, behavior disorder (RBD) in parkinsonism. Neurology. 2003;60:113–115. clinical series of adjunctive therapy. Ann Clin Psychiatry. 2001;13:141–146. 117. Gagnon JF, Postuma RB, Montplaisir J. Update on the pharmacology of REM84. Fraser GA. The use of a synthetic cannabinoid in the management of sleep behavior disorder. Neurology. 2006;67:742–747. treatment-resistant nightmares in posttraumatic stress disorder (PTSD). CNS 118. Boeve BF, Silber MH, Ferman TJ. Melatonin for treatment of REM sleep Neurosci Ther. 2009;15:84–88. behavior disorder in neurologic disorders: results in 14 patients. Sleep Med.85. Sageman S, Brown RP. 3-acetyl-7-oxo-dehydroepiandrosterone for healing 2003;4:281–284. treatment-resistant posttraumatic stress disorder in women: 5 case reports. J Clin 119. Schnelle JF, Cruise PA, Alessi CA, et al. Sleep hygiene in physically dependent Psychiatry. 2006;67:493–496. nursing home residents: behavioral and environmental intervention86. Berger W, Mendlowicz MV, Marques-Portella C, et al. Pharmacologic implications. Sleep. 1998;21:515–523. alternatives to antidepressants in posttraumatic stress disorder: a systematic 120. Yesavage JA, Friedman L, Ancoli-Israel S, et al. Development of diagnostic review. Prog Neuropsychopharmacol Biol Psychiatry. 2009;33:169–180. criteria for defining sleep disturbance in Alzheimer's disease. J Geriatr87. Neylan TC, Metzler TJ, Schoenfeld FB, et al. Fluvoxamine and sleep Psychiatry Neurol. 2003;16:131–139. disturbances in posttraumatic stress disorder. J Trauma Stress. 2001;14:461–467. 121. Mishima K, Tozawa T, Satoh K, et al. Melatonin secretion rhythm disorders in88. Mellman TA, Bustamante V, David D, et al. Hypnotic medication in the patients with senile dementia of Alzheimer's type with disturbed sleep-waking. aftermath of trauma. J Clin Psychiatry. 2002;63:1183–1184. Biol Psychiatry. 1999;45:417–421.89. Wills L, Garcia J. Parasomnias: epidemiology and management. CNS Drugs. 122. Garfinkel D, Laudon M, Nof D, et al. Improvement of sleep quality in elderly 2002;16:803–810. people by controlled-release melatonin. Lancet. 1995;346:541–544.90. Espiritu JR. Aging-related sleep changes. Clin Geriatr Med. 2008;24:1–14, v. 123. Gehrman PR, Connor DJ, Martin JL, et al. Melatonin fails to improve sleep or91. Ancoli-Israel S. Sleep problems in older adults: putting myths to bed. Geriatrics. agitation in double-blind randomized placebo-controlled trial of 1997;52:20–30. institutionalized patients with Alzheimer disease. Am J Geriatr Psychiatry.92. Barbar SI, Enright PL, Boyle P, et al. Sleep disturbances and their correlates in 2009;17:166–169. elderly Japanese American men residing in Hawaii. J Gerontol A Biol Sci Med 124. Bloom HG, Ahmed I, Alessi CA, et al. Evidence-based recommendations for Sci. 2000;55:M406–M411. the assessment and management of sleep disorders in older persons. J Am93. Crenshaw MC, Edinger JD. Slow-wave sleep and waking cognitive performance Geriatr Soc. 2009;57:761–789. among older adults with and without insomnia complaints. Physiol Behav. 125. Alessi CA, Schnelle JF. Approach to sleep disorders in the nursing home 1999;66:485–492. setting. REVIEW ARTICLE. Sleep Med Rev. 2000;4:45–56.
126. Ancoli-Israel S, Gehrman P, Martin JL, et al. Increased light exposure 140. Howe RC, Hegge FW, Phillips JL. Acute heroin abstinence in man: II. consolidates sleep and strengthens circadian rhythms in severe Alzheimer's Alterations in rapid eye movement (REM) sleep. Drug Alcohol Depend. disease patients. Behav Sleep Med. 2003;1:22–36. 1980;6:149–161.127. Morin CM, Colecchi C, Stone J, et al. Behavioral and pharmacological therapies 141. Howe RC, Hegge FW, Phillips JL. Acute heroin abstinence in man: I. Changes for late-life insomnia: a randomized controlled trial. JAMA. 1999;281:991–999. in behavior and sleep. Drug Alcohol Depend. 1980;5:341–356.128. Pressman MR. Factors that predispose, prime and precipitate NREM 142. Roehrs T, Hyde M, Blaisdell B, et al. Sleep loss and REM sleep loss are parasomnias in adults: clinical and forensic implications. Sleep Med Rev. hyperalgesic. Sleep. 2006;29:145–151. 2007;11:5–30; discussion 1–3. 143. Dimsdale JE, Norman D, DeJardin D, et al. The effect of opioids on sleep architecture. J Clin Sleep Med. 2007;3:33–36.129. Costa e Silva JA, Chase M, Sartorius N, et al. Special report from a symposium held by the World Health Organization and the World Federation of Sleep 144. Wang D, Teichtahl H, Drummer O, et al. Central sleep apnea in stable Research Societies: an overview of insomnias and related methadone maintenance treatment patients. Chest. 2005;128:1348–1356. disorders—recognition, epidemiology, and rational management. Sleep. 145. Webster LR, Choi Y, Desai H, et al. Sleep-disordered breathing and chronic 1996;19:412–416. opioid therapy. Pain Med. 2008;9:425–432. 146. Walker JM, Farney RJ, Rhondeau SM, et al. Chronic opioid use is a risk factor130. Stein MD, Friedmann PD. Disturbed sleep and its relationship to alcohol use. for the development of central sleep apnea and ataxic breathing. J Clin Sleep Subst Abus. 2005;26:1–13. Med. 2007;3:455–461.131. Drummond SP, Gillin JC, Smith TL, et al. The sleep of abstinent pure primary 147. Nicholson AN, Turner C, Stone BM, et al. Effect of alcoholic patients: natural course and relationship to relapse. Alcohol Clin Exp Delta-9-tetrahydrocannabinol and cannabidiol on nocturnal sleep and Res. 1998;22:1796–1802. early-morning behavior in young adults. J Clin Psychopharmacol.132. Brower KJ, Aldrich MS, Robinson EA, et al. Insomnia, self-medication, and 2004;24:305–313. relapse to alcoholism. Am J Psychiatry. 2001;158:399–404. 148. Murillo-Rodriguez E. The role of the CB1 receptor in the regulation of sleep.133. Clark CP, Gillin JC, Golshan S, et al. Increased REM sleep density at admission Prog Neuropsychopharmacol Biol Psychiatry. 2008;32:1420–1427. predicts relapse by three months in primary alcoholics with a lifetime diagnosis 149. Schierenbeck T, Riemann D, Berger M, et al. Effect of illicit recreational drugs of secondary depression. Biol Psychiatry. 1998;43:601–607. upon sleep: cocaine, ecstasy and marijuana. Sleep Med Rev. 2008;12:381–389.134. Le Bon O, Murphy JR, Staner L, et al. Double-blind, placebo-controlled study of 150. Budney AJ, Hughes JR, Moore BA, et al. Review of the validity and the efficacy of trazodone in alcohol post-withdrawal syndrome: significance of cannabis withdrawal syndrome. Am J Psychiatry. polysomnographic and clinical evaluations. J Clin Psychopharmacol. 2004;161:1967–1977. 2003;23:377–383.135. Malcolm R, Myrick H, Roberts J, et al. The differential effects of medication on mood, sleep disturbance, and work ability in outpatient alcohol detoxification. Am J Addict. 2002;11:141–150. Manuscript received, revised, and accepted October 2009. 1 Assistant Professor, Faculty of Medicine, University of Ottawa,136. Staner L, Boeijinga P, Danel T, et al. Effects of acamprosate on sleep during alcohol withdrawal: a double-blind placebo-controlled polysomnographic study Department of Psychiatry and Psychology, Ottawa, Ontario. 2 in alcohol-dependent subjects. Alcohol Clin Exp Res. 2006;30:1492–1499. Sleep Specialist, Sleep Disorders Clinic, Royal Ottawa Mental Health137. Malcolm R, Myrick LH, Veatch LM, et al. Self-reported sleep, sleepiness, and Centre, Ottawa, Ontario. 3 repeated alcohol withdrawals: a randomized, double blind, controlled Medical Director, Sleep Disorders Clinic, University of Ottawa Institute comparison of lorazepam vs gabapentin. J Clin Sleep Med. 2007;3:24–32. of Mental Health Research and Royal Ottawa Mental Health Centre,138. Andersen ML, Poyares D, Alves RS, et al. Sexsomnia: abnormal sexual behavior Ottawa, Ontario. during sleep. Brain Res Rev. 2007;56:271–282. Address for correspondence: Dr EK Lee, Sleep Disorders Clinic, Royal139. Wang D, Teichtahl H. Opioids, sleep architecture and sleep-disordered Ottawa Mental Health Centre, 1145 Carling Avenue, Ottawa, ON breathing. Sleep Med Rev. 2007;11:35–46. K1Z 7K4; firstname.lastname@example.com


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It was the only thing I thought of.
My heart was burning, on fire. With every beat, it echoed. I could feel the blood run through my veins. I could feel the thickness, the warmth run through every inch of my body. I could feel my lungs expand, brushing against my ribs. I could feel the air flow through my nose and into my body. I could feel all of it.
But worse of all?
I could feel him.
It was no doubt that my baby was in fact a him. I just knew now. My sparkling was a mech.
Sparkling? Mech...what was I saying?
I could feel my baby move in my stomach. I could feel him pushing on my sides, pushing, stretching the skin to make room for his rapidly growing form. I could feel his metal rake against my skin.
Blood. … only, it wasn't blood. It was to heavy to be blood, it was. …
Why would I have energon in my body? …
The mech that was called immediately turned to attention to face his team. They were all looking at him with fearful eyes, gesturing towards the direction that the noise had came from. He hurried past them, into the med bay.
His medical officer stood, watching his holoform gently run a hand across Bells' skin.
"Optimus," the old mech smiled, looking at him. "It's happening."
"Her vitals?" Wheeljack asked, shoving his way through the crowd of autobots to look at the girl on the table.
"They're perfect," Ratchet said, looking at the vitals that he had already checked a thousand times over. "Her skin's changing."
The autobots all crowded around the human sized berth to watch the human that they have grown so fond of. They watched as her skin moved. It wasn't a disgusting move, it was a beautiful, fulfilling move. One of absolute beauty. A blue line would pierce across her skin, and that skin would stretch, turn, change. Her skin moved similar to that of the autobot's metal when they transformed. It folded in on itself, stretched out and moved. A blue light shined through her chest.
"Her spark…" someone said, Optimus really didn't know who, nor did he care. He, too, was mesmerized by the beauty of her spark.
It was so pure.
The light intensified, burning their optics. Those with sensitive optics had to look away, but some of them chose to continue to watch. They could just barely see the outline of The human grow, and expand. She thickened, then would grow, then would thicken again, and grow.
The light died down after completely covering her body. It started to raise, like a curtain, from her feet up. It outlined thin, slim legs, then a firm midsection with soft, delicate hands. Her arms were likewise thin, but were toned with that of thick wiring, her chest plates curved elegantly, thick enough to protect that of her spark and the spark of the child whom she carried. Then her face…
The autobots stared at the new femme in awe. No one moved, no one spoke a word.
Ratchet snapped out of it first. He scanned the femme, finding absolutely nothing wrong with her or the baby. He moved to inspect the sturdiness of the metal on her.
"Optimus," he called, looking at her arms. "Her scars…"
The Prime moved to look, and was shadowed by everyone of the autobots. Sure enough, lining her arms were deep scratches and dents, outlining the battle she's faced.
"Primus didn't want her battles from her previous life to go unnoticed," Optimus said, optics watching as Ratchet moved to her spark.
Ratchet opened her spark chamber, which easily opened with his touch. He gasped as he looked in.
There were two sparks. One, obviously larger than the other and gentle, resting. The other was smaller and bouncing around it's elder. But that wasn't what caught his attention.
On the larger, was the mark of the Primes.


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To get your New Year started in the best way possible, make plans at Midtown Crossing! Your favorite destinations are hosting events to help ring in the New Year.
Enjoy a 3-course dinner for 2 for $89. Choose from 4 starters, 4 entrees, and 3 desserts for this great date night menu.
Call 402-345-9999 for more information or reservations.
Ugly Duck:
Kick off the New Year at Midtown Crossing's newest spot! Have a New Year's Pre Fixe dinner at the Ugly Duck, complete with a champagne/wine and sake pairing.
Call 402-934-7262 for reservations or more information.
Corky Canvas and Corky Boards:
Get corky this New Year's! Start the festivities early with a Noon Year's Eve class from 12-2pm OR check out the date night classes at 7 or 7:30pm.
Call 402-637-4066 for more information or head to Corky Canvas or Corky Boards to register!
The Grey Plume:
The chefs at The Grey Plume have created a special menu for New Years' Eve, complete with a 4-course meal with options for $75 per person and optional wine pairings.
Upgrade to Elite Seating, available only at the bar, for an extravagant meal that includes 8 French Champagnes for $350 per person. Few seats remain!
Check out their Facebook event for more details or call at 402-763-4447.
Cantina Laredo:
December 30 to January 1.
Enjoy a 3 course meal for just $35 per person. Warm up with a tasty holiday Honeycrisp Reposado 'Rita or Hornitos Black Barrel 'Rita for just $8 extra.
Head to Cantina Laredo on Facebook or call 402-345-6000 for questions. Call for reservations.
Black Oak Grill:
December 30 to January 1.
Enjoy three courses for only $25 per person. Don't forget to add some Black Oak Punch for just $5 when ordering from the Celebrate 2017 menu!
Head to Black Oak Grill on Facebook for more information or call 402-341-0622.
The Element Hotel:
Keep the festivities going and treat yourself to a night at The Element! Conveniently right next to all the fun from above.
AND don't miss the second to last showing of the Holiday Lights Spectacular! The best viewing spot is from the center of the park at 7pm, sharp!
Read on for more information about current Midtown Crossing retailer offerings.
June 24, 2020
With a full menu of Chinese food favorites, you're sure to love Yummy 365! Plus, learn more about current retailer offerings...
June 10, 2020
Read on for your guide to #SupportLocal this week at Midtown Crossing!
May 27, 2020
Read on for your guide to #SupportLocal this week!
May 21, 2020
Due to the global COVID-19 health crisis, Midtown Crossing has cancelled the popular Zydeco Festival scheduled for June 20 in Turner Park...


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Tag Archives: mysticism
Mystical Hope
The Universal Pattern Mystical Hope Thursday, April 16, 2020 Hope is the main impulse of life. —Ilia Delio, OSF [1] Because we are so quickly led to despair, most of us cannot endure suffering for long without some sliver of hope or meaning. However, it is worth asking ourselves about where our hope lies. My… Continue Reading Mystical Hope
Inner Experience
Disciples, Prophets, and Mystics Inner Experience Wednesday, March 18 While most Christians consider themselves disciples of Jesus and try to follow his teachings, a much smaller number move toward practical acts of service or solidarity. But I'm afraid even fewer Christians have the courage to go on the much deeper mystical path. Both Catholics and Protestants have failed our people… Continue Reading Inner Experience
Interspiritual Mystics: Weekly Summary
Interspiritual Mystics Summary: Sunday, August 4—Friday, August 9, 2019 At their most mature levels, religions have a common goal: union with all beings and with God. —Beatrice Bruteau (Sunday) By allowing inward change, while at the same time simplifying our external life, spirituality serves as our greatest single resource for changing our centuries-old trajectory of… Continue Reading Interspiritual Mystics: Weekly Summary
Listening for the Genuine
Interspiritual Mystics Listening for the Genuine Friday, August 9, 2019 Anniversary of the Bombing of Nagasaki I'm encouraged by the rediscovery of the broad and deep contemplative mind, which for the first two thousand years of Christianity had largely been limited to monks, women religious, and mystics. It is not our metaphysics ("what is real")… Continue Reading Listening for the Genuine
Cultivating Mysticism
Interspiritual Mystics Cultivating Mysticism Thursday, August 8, 2019 Deep down, each one of us is a mystic. When we tap into that energy we become alive again and we give birth. From the creativity that we release is born the prophetic vision and work that we all aspire to realize as our gift to the… Continue Reading Cultivating Mysticism
Living Mysticism
Interspiritual Mystics Living Mysticism Wednesday, August 7, 2019 Mysticism is a special consciousness of the presence of God that by definition exceeds description and results in a transformation of the subject who receives it. —Bernard McGinn [1] It's not enough to have wonderful theories about God. Authentic mystical encounter radically changes us and our way… Continue Reading Living Mysticism
Feast of the Transfiguration
Interspiritual Mystics Feast of the Transfiguration Tuesday, August 6, 2019 Anniversary of the Bombing of Hiroshima Dom Bede Griffiths (1906–1993) was born in Britain and lived the latter decades of his life in India. Some of our Living School students have been deeply moved by studying his work which sought to make connections between Christianity… Continue Reading Feast of the Transfiguration
Transformative Spirituality
Interspiritual Mystics Transformative Spirituality Monday, August 5, 2019 Catholic monk and mystic Wayne Teasdale (1945–2004) recognized the wisdom in many religious traditions and helped to cultivate respect and understanding between faiths. Though I did not know him personally, Teasdale had an early, long-standing relationship with a community of Franciscans in Massachusetts. He worked tirelessly until… Continue Reading Transformative Spirituality
Foundation of Respect
Interspiritual Mysticism Foundation of Respect Sunday, August 4, 2019 At their most mature levels, religions have a common goal: union with all beings and with God. Unfortunately, many religions and Christian denominations have over-emphasized differences and claimed that their particular brand is superior to others. Jesus didn't come to start another religion but to reveal… Continue Reading Foundation of Respect
Black Women Mystics: Weekly Summary
Black Women Mystics Summary: Sunday, July 28—Friday, August 2, 2019 God is present in everything. In the universe, in creation, in me and all that happens to me, in my brothers and sisters, in the church, and in the Eucharist—everywhere. —Thea Bowman (Sunday) When the word contemplation comes to my mind I want to think… Continue Reading Black Women Mystics: Weekly Summary


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I rather collect thoughts, feelings, and emotions in my life. I'm not a fan of things. Things leave me empty, but I'm full of life. – Ash
This life is yours. Take the power to choose what you want to do and do it well. Take the power to love what you want in life and love it honestly. Take the power to walk in… Read More
Children make you want to start life over. – Muhammad Ali
If you aren't in the moment, you are either looking forward to uncertainty, or back to pain and regret. – Jim Carrey
This morning I took a walk, a deep breath of fresh salty air, and welcomed the gentle pouring rain. Now, I'm alive again. – Ash
As you walk and eat and travel, be where you are. Otherwise you will miss most of your life. – Buddha
Whenever you are creating beauty around you, you are restoring your own soul. – Alice Walker
To heal a wound you must stop scratching it. – Paulo Coelho
I like this place and could willingly waste my time in it. – William Shakespeare
It's never too late to be what you might have been. – George Eliot


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With the conclusion of the NFL draft in April and the subsequent free agent signings like Andy Dalton and Joe Flacco, most NFL team's rosters for preseason are set. While there are certainly a few more questions left like where Jadaveon Clowney and Cam Newton will sign, most teams are looking to prep their players for the season and get them up to snuff on the playbook. Yet, more than any other offseason, this offseason has seen many teams completely change their rosters for better or worse. Some teams have no doubt drastically improved their offense or defense. Other teams have looked towards free agency or trades to attempt to improve their outlook. Yet, there are also a few teams that still have much uncertainty about their future due to contract talks and trade rumors. Given the crazy amounts of change NFL teams have undergone this offseason, it's important to take a step back and examine what teams made the most changes as well as those who might undergo significant change this summer.
Changes around the League
Denver Broncos: Chasing the Chiefs
While the Broncos have boasted a strong defense for the past few years under the tutelage of Ric Fangio, they have often neglected the offensive side of the ball. Yet, this offseason has been different for them. The Broncos have realized that to win the AFC West, you need to be able to outscore the Chiefs. And in order to do that, you need an abundance of offensive weapons as well as an offensive coordinator that can rival Andy Reid's intricate playcalling.
Before I talk about the moves the Broncos made this offseason, it is important to address the young talent on their roster that will certainly take a step forward in 2020. Their quarterback Drew Lock showed dramatic improvement during his 2019 rookie season and has a cannon of an arm. Alongside him, TE Noah Fant displayed impressive skills in pass catching and blocking, especially considering that rookie tight ends are known for not having a high impact. With both of these players showing that they belong in the league as well as exhibited strong signs of improvement, the Broncos offense was sure to change for the better during the 2020 season.
But this wasn't enough for the Broncos. In January, the Broncos announced that Pat Shurmur would be their offensive coordinator. While many might dismiss him from his unsuccessful tenure as Giants head coach in the 2018 and 2019 season, I advise not to. Being a head coach is much different than being an offensive coordinator. Some people are better suited for the coordinator role than head coach and I think Shurmur is one. The teams that Shurmur has coached have never had poor offenses, rather only poor defenses. Thus, I think Shurmur has the chops to be an elite offensive coordinator for the Broncos.
Alongside this, the Broncos managed to snag two amazing wideouts for Drew Lock in the NFL draft. With the 15th pick, the Broncos drafted Jerry Jeudy (pictured above) out of Alabama. During his three years at Alabama, Jeudy caughts 159 catches for 2,742 yards, putting him fifth and fourth on their all time receptions and yards lists respectively. Jeudy is an elite route-runner and possesses a high football IQ. Alongside Jeudy, the Broncos also drafted KJ Hamler out of Penn State with the 46th pick in the second round. Though he is only 5'9" and 176lbs, Hamler can run a 4.27s 40-yard dash, making him able to stretch defenses out much like Tyreek Hill or Marquise Brown.
With all these weapons to choose from, Drew Lock must be one of the happiest quarterbacks this offseason. WR Courtland Sutton, who has established himself as one of the premier young wideouts in the NFL, will be able to catch jump balls. Jerry Jeudy will use his route-running to carve up the slot alongside Noah Fant's fantastic run-blocking. And KJ Hamler will be able to burn cornerbacks and is able to make big plays when the time comes. With so many weapons as well as a top-tier offensive coordinator, the Broncos offense could put up Kansas City-like numbers in 2020.
Indianapolis Colts: Charging Head First
The Colts made headlines when they signed former Chargers QB Philip Rivers (pictured above) to a 1 year $25 million deal. Yet, the Colts have made some other moves on both the offense and the defense to reshape their team. All these moves suggest that this team has to win now.
On offense, the Colts not only signed Rivers, but also drafted WR Michael Pittman Jr. and RB Jonathan Taylor. Rivers is 38 years old and more likely than not will retire after the 2020 season. And while Rivers will be in the Hall of Fame at some point, his play in 2019 was certainly not Hall of Fame worthy. Rivers lacked the accuracy to perform at an NFL level. It was infuriating watching him miss countless balls to his receivers. And it wasn't like Rivers didn't have talent around him. Rivers had Keenan Allen and Mike Williams as wideouts alongside tight end Hunter Henry. He even had Austin Ekeler and Melvin Gordon, both being elite pass catching running backs.
Yet, I would point out that the Colts offensive line is much superior to that of the Chargers. In fact, the Colts offensive line is probably the best in the NFL, led by the young Quentin Nelson. Rivers was sacked 34 times and often had to throw the ball away in a collapsing pocket, leading to many incompletions and missed passes. With a better offensive line, Rivers might see improvement from a terrible 2019.
And with two new weapons: Pittman Jr. and Taylor, Rivers should be pretty happy. Pittman Jr. is a wide receiver from USC and is known for his elite route-running ability. He and T.Y. Hilton should make a great one two combo with him in the slot and Hilton out wide. And Taylor should fit perfectly into the Colts scheme. He is a great pass catcher and we all know how much Rivers likes to target running backs (24.7% of his passes in 2018 were to RBs). I expect the Colts to do many screen passes and because of this, I expect Taylor to be the most successful rookie running back this season.
The Colts also went big on the defensive side of the ball, trading their 2020 first round pick to the 49ers for DT DeForest Buckner. Buckner is an incredible talent and should be able to improve an already formidable Colts defense. I think both the Colts and the 49ers won this trade as the 49ers got cap space and the Colts got a stud on the defensive line.
With these moves, the one question I have for the Colts is their QB situation. Rivers has had an amazing career, but showed strong signs of regression last year. And unlike some older quarterbacks like Drew Brees or Tom Brady, Rivers had issues with accuracy. Thus, much of the Colts success relies on Philip Rivers figuring out his problems from last year and being able to make accurate throws
Miami Dolphins: Stellar Secondary
It may be a surprise to some that I have the Dolphins as a team with a rising defense, looking at their acquisitions this offseason, it makes a lot of sense. While many point to them drafting Tua Tagovailoa, they also nabbed some pretty awesome talent for their secondary in free agency and the draft.
Brian Flores, the head coach of the Dolphins, had been with the Patriots since 2004. This means much of his ideology for how the team should be built is mirrored by the Patriots. And like the Patriots defense that possesses the likes of Stephon Gilmore and the McCourty twins, Flores wants to build a defense back to front. Thus, this year, he has decided to load up on talent at the safety, cornerback, and linebacker positions.
While Flores already has talents at the safety position with the former Patriot Eric Rowe, it is the cornerback position which received massive upgrades this offseason. In free agency, the Dolphins sign star cornerback Byron Jones (pictured above) from Dallas on a 5 year $82.5 million contract. Jones is an incredible outside cornerback and is super fast. His partner in crime will be Xavien Howard, who has been on the Dolphins all his career. Like Jones, Howard is quick and also pretty physical too. Together, they might be one of the best cornerback duos in the league. But if this wasn't enough, the Dolphins also drafted CB Noah Igbinoghene out of Auburn with the 30th pick of the 2020 draft. Igbinoghene is another physical corner who should be able to fill multiple different roles while Jones and Howard take on the top opposing wideouts.
Lastly, it is important to note that the Dolphins also signed Kyle Van Noy, the former Patriot linebacker. Van Noy was one of New England's stalwarts on their defense and is particularly good at getting to the quarterback. Alongside this, he's also an incredible leader and should be able to create a culture of winning in Miami.
This offseason, the Dolphins have certainly turned their secondary around. I don't expect teams like the 2-14 Bengals to be able to cut through the Dolphins pass defense anymore. Instead, I expect Jones, Howard, Igbinoghene, and Van Noy to be able to thwart even the best receiving corps. In fact, considering that the AFC East has very few elite receivers, Stefon Diggs being basically the only one, the Dolphins secondary should feast.
Tampa Bay Buccaneers: Brady and Gronk Down South
By now, everyone has heard about Tampa Bay's acquisition of both Tom Brady and Rob Gronkowski (pictured above). But it's important to talk about how these moves will affect an already strong Buccaneers offense.
Prior to these acquisitions, Tampa Bay's offense was loaded with top tier receiving talent. The headhuncho for the past few years has been Mike Evans. Evans is an elite threat on the outside and is probably the best receiver at catching jump balls in the league. He's never had a below 1000 yard season during his entire tenure in the NFL so it's likely he'll be extremely productive in 2020. Yet, if Evans wasn't enough, the Bucs also have Chris Godwin, a third round pick in 2017 from Penn State. While Godwin is only 24 years old, he has established himself as one of the best receivers in the league, with 1,333 yards in only 14 games in 2019. This would put him on pace for over 1,500 receiving yards, placing him only behind Michael Thomas. Godwin does most of his damage in the slot, and given this, I expect him to be Brady's top target. Godwin is basically Julian Edelman on steroids, and we all know how much Brady loves throwing to Edelman.
Alongside those two receivers, the Bucs also already have two impressive tight ends: O.J. Howard and Cameron Brate. Both Brate and Howard weren't targeted much by Jameis Winston in 2019, but Brady should utilize them a bit more. Howard is incredibly strong and posted phenomenal receiving numbers at Alabama. Alongside Howard, Brate is also a physical specimen, but excels more in blocking than receiving. But with the acquisition of Rob Gronkowski, it makes no sense to have three elite tight ends. Thus, I expect either Brate or Howard to be out of Tampa before the start of the season, most likely Howard as there have been many trade rumors circulating about him, even before Gronk came to the Bucs.
As for Gronkowski himself, I think he will be fairly successful in Tampa Bay. Gronk has accumulated his fair share of injuries over the years and is also 31 years old. Yet, the NFC South is not a conference that is known for having elite strong safety talent. In fact, the strong safeties in the NFC South are for the most part terrible. Thus, I expect Gronk to do well considering that his matchups will often favor him.
Last but not least, Tom Brady will certainly have a great impact on the offense. While Brady may not score as many touchdowns as Jameis Winston in 2019, he also won't throw nearly as many interceptions. This will not only help the offense as a whole, but also give the defense better field position. With Brady at the helm of the offense, the Bucs should be able to have longer drives that give the team better field position, allowing them to be more in control than last year.
Baltimore Ravens: Return of the Grit
Many might ask how the Ravens defense could improve over last season as it was one of the best in the league. But the Ravens made a few moves this offseason that have somehow strengthened their already strong defense.
Most notably, the Ravens traded a fifth round pick to the Jaguars for DE Calais Campbell (pictured above). Soon afterwards, the Ravens and Campbell finalized a two year contract worth $27 million. This was a steal of a trade as the Jaguars are very much in a rebuild and desperate to sell their assets. Campbell, being 33 years old, was probably too old to wait for the Jaguars to rebuild. Yet, a fifth round pick for a five time pro bowler is too low. And while Campbell's stats have been pretty mediocre for the past two years, he is playing on an anemic Jaguars defense. Playing in a more structured and well-run defense like the Ravens, Campbell should excel.
Alongside committing highway robbery on the Jaguars for Campbell, the Ravens also had a great draft. Most importantly, they drafted LB Patrick Queen from LSU with the 28th overall pick. While back in the day, the Ravens were known for their fierce linebackers like Ray Lewis and Terrell Suggs, those days are long gone. In fact, much to many fans' surprise, linebacker is the weak point on the Ravens offense. See RB Derrick Henry ripping them to shreds in the playoffs last year as an example of this. Drafting Patrick Queen, who somehow fell to them, is a big step in the right direction. This acquisition should solidify the Ravens defense as almost unstoppable.
With Campbell and Queen joining a strong Ravens defense, this defense will now basically have no weak points. Their secondary is absurdly good, with CB Marcus Peters, FS Earl Thomas III, SS Chuck Clark, and CB Marlon Humpries. With Queen bolstering the linebacker corp and Campbell anchoring the trenches, the Ravens defense might be borderline unstoppable.
Houston Texans: Wide Receiver Frenzy
On March 20th, the Houston Texans traded DeAndre Hopkins and a 4th round pick for RB David Johnson, a 2nd round pick, and a 4th round pick. Fans were in shock as Hopkins is considered to be a top three wideout in the league. Many questioned what Texans GM Bill O'Brien was thinking, especially considering they have the super athletic Deshaun Watson as their quarterback, who needs good receivers. And while this is an obvious win for the Cardinals as they will now have one of the best wide receiver corps in the league, for Houston, it is a much more complicated.
Many have failed to acknowledge the new look of the Texans wide receiver corp. Houston actually brought in a bunch of talent at the position in an attempt to replace Hopkins. But before this, it's important to review two receivers who were on the Texans last season: Will Fuller V and Kenny Stills.
Being drafted 21st overall in the 2016 draft, Fuller had high expectations entering the league. But Fuller's career thus far has been hampered by a variety of injuries, missing 20 games in the past three regular seasons. And in the games he plays, he is wildly inconsistent. Oftentimes, he'll post duds, but sometimes he'll play like the best receiver in the league. For instance, against the Falcons in 2019, he had 217 receiving yards and 3 touchdowns. But again, this was against a weak Falcons secondary, which I talk about in my 5 Bold NFL Predictions article. Fuller, while talented, is so volatile and has a high risk of injury, making me question his ability to fill the void Hopkins left.
Alongside Fuller, Kenny Stills also remains on the Texans. Stills, like Fuller, is extremely speedy, posting a 4.38s 40yard dash time. Also like Fuller, Stills is pretty inconsistent, but this is due more to his lack of targets than his ability. But Stills is less skillful than Fuller, and certainly less skillful than Hopkins.
For the Texans, Fuller and Stills weren't enough so they signed Randall Cobb from the Cowboys to a 3 year $27 million contract. Cobb is not a flashy receiver and puts up decent numbers. Though his contract might be a year too long, I think Cobb will be a reliable option for Watson.
Lastly, to add even more wide receiver depth to his squad, Bill O'Brien traded for Brandin Cooks (pictured above) in early April. Many know Cooks from his stint in New England in 2017. Back then, Cooks was a pretty reliable receiver, posting 4 seasons in a row with over 1,000 receiving yards. Yet, in recent years, Cooks has been anything but that, only accumulating 583 yards last season. Though Cooks has only missed 2 games in the past 5 seasons, recently he has been plagued with a variety of injuries. And though he pulls through and plays, he remains inefficient on the field.
Many forget to acknowledge that the Texans have brought a variety of decent receivers in to fill the void that DeAndre Hopkins left. While none of these receivers on their own can compare to Hopkins, together, they are a pretty decent receiving corp. Even RB David Johnson is a good receiving option for Deshaun Watson. While the Texans have many concerns in other areas such as the offensive line and secondary, I think when added together, the Texans receivers are nothing to be ashamed about and not nearly as awful as some angry fans make them out to be.
Changes to Come
While most teams have their rosters finalized, there are a few teams I expect to make some changes before the season starts. And surprising no one as both these teams have had plenty of drama these past few years, I picked the Steelers and Cowboys as having high likelihoods of making moves before the season starts.
Pittsburgh Steelers: Snubbing Smith-Schuster?
While the Steelers have a stellar defense, their offense was nothing pretty last year. Thus, there have been plenty of rumors about which players might be moved. Much to fans' surprise, the players that are likely to move are their star players, not their depth guys.
One player who is likely to be moved is Juju Smith-Schuster (pictured above) as many rumors have been circulating about the Steelers dealing him. This is possible due to the fact that he will demand a big contract soon that the Steelers couldn't afford. Alongside this, the Steelers also have a young wide receiver named Dionte Johnson. Many overlooked Johnson in his rookie year in 2019, but his stats are pretty good at second glance. He caught 59 passes for 680 yards and 5 touchdowns. While that doesn't seem incredible, one must remember that he was catching passes from Mason Rudolph and Duck Hodges, two backup QBs. While Johnson's rookie year was overshadowed by other rookie WRs like A.J. Brown or D.K. Metcalf, Johnson is a star in the making and could be a cheaper option to Smith-Schuster.
Word has also come out that the Steelers are looking to make someone other than RB James Conner their lead back and that they have no confidence in him bouncing back. While the Steelers don't really have any other good running backs as of right now, I wouldn't be surprised if they trade for a running back or maybe sign a free agent such as Devonta Freeman. With rumors about changes at the wide receiver and running back positions, I expect some change to occur to the Steelers offense before the season starts.
Dallas Cowboys: Contract Concern
Another team to watch out for is the Dallas Cowboys. Much of their offseason has been dealing with signing Amari Cooper and Dak Prescott (pictured above). Cooper was signed for a massive 5 year $100 million deal. Later on, Prescott was franchised tagged and will make $31.4 million.
But there have been many talks about a new contract for Dak. reportedly, the Cowboys offered Prescott a 5 year $175 million contract which he refused. This refusal has massive implications because while Prescott is good, there are better quarterbacks in the league. In particular, Patrick Mahomes is due for a raise next year and Prescott's refusal of such an expensive contract will most certainly help Mahomes raise his bargaining price. As for the Cowboys, I expect to see a lot of drama coming from Dallas this summer as contract negotiations become more and more stressed. Prescott might even decide to sit out during the 2020 season.
Alongside the Cowboys handing out massive contracts, there are also rumors that they might trade for strong safety Jamal Adams. Recently, contract negotiations between Adams and the Jets stalled, leading to rumors that the Jets might trade him. Furthermore, Adams went on to like this tweet:
Thus, many speculate that Adams could be a trade target for many teams, including the Cowboys. He would be a great asset as they just lost CB Byron Jones to the Dolphins in free agency. Yet, I would argue that if the Cowboys are handing out such big contracts to Cooper, Prescott, and Ezeikiel Elliot, they probably won't have much to spend on Adams. Nonetheless, something is going to happen in Dallas this summer, be it a trade, Dak signing a massive contract, or even him holding out during the 2020 season.
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The BLUESHAPE Dual V-Mount Battery Power Station allows you to power cameras, lights, and other devices in a portable solution. It's hot-swappable and offers simultaneous 3-pin and 4-pin locking XLR outputs. (It is designed to be used as a power station only and does not function as a charger.)
The outputs operate in parallel and share the combined battery input. With two high drain batteries installed (9A and higher), the 3-pin XLR provides a regulated 28V output at up to 280W, and the 4-pin provides regulated 14V at up to 140W. With two standard discharge batteries installed (less than 9A), the 3-pin XLR provides a regulated 28V output at up to 240W, and the 4-pin provides regulated 14V at up to 140W.
A fan vent on the side allows the system to remain cool even after hours of operation. A 3-LED gauge for each battery is positioned on the side and indicates a 0-10A scale for the battery. The power station can conveniently be carried via a handle on top, and rested on a desktop by means of a rotating foot on the bottom. The foot neatly tucks underneath when not needed.
Key Features
- Supports two hot-swappable batteries and offers two simultaneous XLR outputs
- 3-pin XLR output provides a regulated 28V output at up to 280W
- 4-pin XLR output provides a regulated 14V output at up to 140W
- A fan vent keeps the system cool even after hours of operation
- 3-LED gauge for each battery indicates a 0-10A scale
- A rotating foot allows stable desktop positioning and tucks away when not needed
- A handle on top allows convenient carrying
Additional Features
- Illuminated ON/OFF power switch
- 4-pin data socket for computer testing, debugging, and calibration
- Lower gauge LED blinks when current up to 1.5A is being drawn and becomes steady from 1.5A - 3A
- Middle LED blinks from 3A - 4.5A and is steady from 4.5A - 6A
- Upper LED blinks from 6A - 8A and is steady from 8A - 10A


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Up till now, we've had lots of names and phrases floating round for the eventual elimination of the coordinator node:
- Alphanet, the identify of the primary prototype of our decentralized testnet.
- Goshimmer, the group of applied sciences which can be being developed to take away the coordinator.
- Coordicide, the identify of the occasion for once we take away the coordinator
Over the previous few months, we've simplified our naming conventions of IOTA 1.5 (Chrysalis, the intermediate stage of the mainnet earlier than Coordicide) and IOTA 2.0 (Coordicide, the everlasting elimination of the coordinator node and the launch of a completely decentralized IOTA community) to showcase the seamless transition between these two main protocol upgrades and the way they are going to ultimately result in a coordinator-less, scalable, feeless community. The primary of its variety.
These up to date nomenclatures additionally assist our group and companions higher perceive and quantify upcoming technological progress for IOTA. Our purpose is to make a transparent distinction and connection between the work that may hyperlink these two vital protocol upgrades within the continuing months.
With this in thoughts, at present we're blissful to introduce the three phases of IOTA 2.Zero that may replicate vital milestones and testnet releases main as much as Coordicide. To observe the present Apoidea naming conventions used for Hornet, Bee, and HoneycombOS, the three levels are named after the three main milestones for the creation of honey: Pollen, Nectar, and Honey.
Pollen: The primary official testnet of the IOTA 2.Zero community, Pollen represents a serious change with respect to the earlier GoShimmer v0.1.three launch, setting the groundwork for the primary and purposeful coordinator-less community. Iterative enhancements will remodel Pollen into the ultimate, feature-complete launch candidate for IOTA 2.0. The Pollen community will primarily be a analysis testbed for the Basis, group, and exterior researchers to validate ideas from the Coordicide white papers and simulate sure assault vectors. Throughout this lively analysis section, a lot of the Coordicide specs will likely be totally finalized, giving us the ultimate blueprint of IOTA 2.0.
Nectar: Anticipated within the second half of 2020, Nectar will likely be a full implementation of our Coordicide modules on an incentivized testnet. The purpose of this community is to check for any bugs or points that should be fastened earlier than the ultimate launch of the mainnet. Because the identify already mentions, members on this community will likely be incentivized with progressively rising rewards to search out bugs or assault vectors.
Honey: The ultimate launch candidate for IOTA 2.0, Honey, will embrace the entire modules in response to the total and ultimate specification of Coordicide. At this level, the community can have been battle-tested and secured by way of many lots of of hours of testing with full audits of our node software program. Honey may be thought-about the primary model of IOTA 2.0, our totally decentralized IOTA mainnet.


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Global Perspectives and Local Realities: An Evolving Essay Series Exploring Stories of COVID-19 in Real-Time
The Global Network of Internet & Society Centers (NoC) of which the School of Business
The Global Network of Internet & Society Centers (NoC) of which the School of Business
The education system in Egypt is unquestionably the largest in the Middle East and North Africa. It covers more than 55,000 schools and 1.8 million teachers for roughly 20 million pupils. For many years, the various strategic plans for Egypt have called for decentr
Maha Bali, associate professor of practice at the Center for Learning and Teaching, participated in the Online Learning Consortium (OLC) on June 15 and was the opening keynote speaker for OLC Innovate conference, one of the biggest conferences in educational technology. To watch the full keynote
AUC's Society of Petroleum Engineers received the Student Chapter Excellence Award for "accomplishing an admirable level of success"
AUC's Career Center is inviting you to attend the First Virtual Employment Fair Wednesday, July 15 from 11 am to 4 pm! Apply to LIVE Opportunities | Schedule 1:1 LIVE Video Meetings | Attend Company Webinars
With great pride, the AUC School of Business announces that its Master of Business Administration and Master of Science in Finance have advanced in the QS World Rankings for 2020.
The Office of Operations and Services is glad to announce the availability of Service Request On-line Form to be used by the AUC Community for placing repairs requests inside New Cairo campus, Tahrir Square campus and AUC Faculty Housing apartments.
Effective communication is a two-way process; therefore mutual trust, respect and the ability to work towards common goals together is a direct result of effective communication.
Office of the University Financial Controller Fiscal Year 2020 Closing Circular
The School of Humanities and Social Sciences is celebrating HUSS faculty successes of 2019 - 2020 by highlighting their achievements in June's Newsletter.
" The Scientific and Practical Dimensions of Social Protection," A MOOC presented by Hania Sholkamy via Edraak platform (Partner of edX ) in collaboration with AUC. In this MOOC, we will be discussing social protection as a scientific and a professional field that aims at stopping the suffering of the poor and neediest through formulating policies and programs that provide opportunities, resources and services to those who need them.
On March 4, The AUC School of Business Women on Boards Observatory, The Ministry of Planning and Economic Development, and the National Council for Women launched the Women On Boards Observatory 2019 Egypt Annual Monitoring Report at the Women Economic Forum (WEF).
The eukaryotic cells in most of the life forms, including human, animals, and plants, contain specialized structures, known as mitochondria, responsible for energy production. Mitochondria typically have their own DNA to encode for genes required for their function. Dr.


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I think that instead of killing these poor animals to our own selfish reasons for example, murdering them because no one wants them or because there is not enough room. I bet should say the authorities were to kill people because there was "Not enough room" would think they were wrong, however, it's fine to kill animals for those exact reasons. No! I think that we ought to assemble them their own refuge kind of like a zoo, but no one gets to visit them if they don't need to, and we hire people......Read More
According to a poll from the Harris Poll, 96 percent of Americans support the use of video surveillance in public areas from the authorities and law enforcement agencies to prevent terrorism. Of course we all know that video surveillance is employed for more than simply preventing terrorism, but also to keep an eye in our homes and businesses, on roads, in parks and at other areas. So what are some of the arguments for the use of surveillance systems across the nation? .1. Peace of Mind - A......Read More
Animal cruelty is a major problem in the United States. Using animals to struggle as in the case of Michael Vick or abusing them happens daily. The ASPCA is a model of many non-profit organizations that attempt to safeguard and care for abused, abandoned and abused animals. The American Society for the Prevention of Cruelty to Animals (ASPCA) was founded by Henry Bergh. Henry Bergh, born in 1813 to some prominent shipbuilder, was a man of leisure touring Europe. He observed many cruel acts to......Read More
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