text:
Riiiight. Or discuss the non-Swedish players of said team. Or watch the actual games of said team. Or live anywhere near the hemisphere of said team. Or ever visit the city of said team. Or ever see a game in the arena of said team...Per wrote:
You can marry and divorce as many times as you like, but you don't switch teams.
I guess if checking out early-morning box scores over a plate of reindeer meatballs after being soundly beaten by your 95 lb wife makes you a fan, you're a helluva fan Pare.
Carry on.


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Three-year-old Elizabeth Cumbee, daughter of Billy and Kassie Cumbee of Leland, competed in the N.C. State Miss United States Agriculture Pageant on April 9 in Fayetteville. She won divisional awards for Most Photogenic and Best Sportswear competition themed Red, White and Beautiful. She was also awarded runner-up for the state title but will continue to re-install as Tiny Miss Brunswick County Miss United States Agriculture.
Descendants of Henry Cannon Smith are invited to a Long family reunion from noon to 3 p.m. Sunday, March 13, at Waccamaw Community Center, 5855 Waccamaw School Road in Ash. For more information, call Beverly Smith at 754-6476.
The Second (Indianhead) Division Association is searching for anyone who served in the Army's 2nd Infantry Division at any time. For information about the association and its 95th annual reunion Sept. 20-24 in Springfield, Mo., contact Bob Haynes, secretary/treasurer, at email@example.com or (224) 225-1202 or go to 2ida.org.
Morris and Hilda Hall of Shallotte celebrate their 60th anniversary Feb. 4, 2016, at Lover's Leap in Virginia. The Halls, both originally from Virginia, have two daughters and four granddaughters, and can be seen every Monday and Wednesday morning at Hardees in Supply "dancing up and down the aisles to country music."
A 2013 West Brunswick High School graduate and Supply native is serving in the Navy as part of a crew working aboard one of the world's most advanced ballistic missile submarines, USS Maryland (SSBN 738).
Fireman Kevin Holden is a fire control technician serving aboard the Kings Bay-based boat, one of 14 Ohio-class ballistic missile submarines. A Navy fire control technician is responsible for controlling outgoing weapons, tracking surface and air contacts, launching defensive weapons and verifying the safely of the boat.
The North Carolina Association of Soil and Water Conservation Districts had its 72nd annual meeting Jan. 3-5 at the Sheraton Imperial at Research Triangle Park in Raleigh. The association's theme for this past year was "Conservation — Contagious Enthusiasm."
Announcement is made of the forthcoming marriage of Rachael Menius and Dan Burgess of Boston.
The bride-elect is the daughter of David and Donna Menius of Ocean Isle Beach. A graduate of the University of North Carolina at Chapel Hill and the University of Pennsylvania, she is a pediatric palliative care nurse practitioner at Dana-Farber Cancer Institute and Boston Children's Hospital.
William and Beverly Werner celebrated their 50th wedding anniversary Saturday, Nov. 21, with family and friends at the beach on Ocean Isle Beach. They renewed their vows and then the bride, escorted by her nephew William Payne from California, trashed her original wedding dress in the ocean. The Werners returned to Carolina Shores in 2012 from New Jersey, where William worked as a paramedic at Hackensack Hospital and Beverly worked for United Parcel Service.
Everald and Orine Rankin of Shallotte celebrated their 50th wedding anniversary Dec. 12. The couple first met in Bridgeport, Conn., at a mutual friend's get-together "and it was love at first sight." They were married two weeks later, Dec. 12, 1965. Today they have four children (twins Georgina and George, Shirley and Rosa), eight grandchildren and six great-grandchildren.
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Losing is weight "twice as hard as previously thought", according to media reports. Government weight-loss guidelines "mislead" overweight people about the effort needed to lose weight and dieting rules "don't take into account changes in metabolism that occur when you lose weight", several newspapers said.
The reports are based on a recent conference presentation in which obesity researchers reportedly said that current weight-loss guidelines fail to take into account the changes in metabolism the researchers identified. They said that this means weight loss takes twice the time predicted by current guidelines.
However, there is as yet no officially sanctioned way to work out a bespoke weight-loss programme for yourself, which is why if you're worried about your weight it's a good idea to have a chat with your GP.
The Independent said that there was a "slim chance" of the weight falling off with a reduction in calories. While this pun may have been hard to resist, it's not particularly accurate; nor is the Financial Times' assertion that "obesity experts [have] change[d] fat-loss guidance".
What is the news based on?
The news reports stem from a presentation by Dr Kevin Hall, a researcher with the National Institutes of Health (NIH) in the US, at the annual meeting of the American Association for the Advancement of Science (AAAS) in Vancouver, Canada. Dr Hall reportedly said that dietary changes spark complex processes that alter the body's metabolism and body composition and that this has made it difficult to assess the relationship between diet and weight changes. In a nutshell, he suggests that weight loss is not a straight line towards one's target weight, but a downward curve that plateaus the closer you come to your goal.
Dr Hall's presentation appears to be based on earlier work from the NIH in which a mathematical model was used to predict what happens when people of varying weights, diets and exercise habits try to change their weight. This model suggests that a reduction in energy intake of 100 kilojoules (about 24 calories) a day for each person would eventually lead to a reduction in body weight of about 1kg. Half the weight loss would be achieved in about a year and 95% in about three years. The NIH says this is only half the weight loss claimed for calorie reduction in current guidelines. This is important because it "leads to unrealistically large weight-loss expectations", Dr Hall is reported to have told the AAAS conference.
The NIH has developed an online tool designed to calculate the level of dieting needed to achieve a weight loss target, taking numerous factors into account including metabolism. It allows users to adjust their calorie intake as well as activity levels and see how much their weight, body fat and other measures are predicted to change over time if they stick to the tool's plan.
Is there evidence for this model?
In a paper published in the Lancet in August 2011, NIH researchers, including Dr Hall, described a mathematical model for what happens when people of varying weights, diets and exercise habits try to change their weight. The NIH also developed an accompanying weight-simulation tool. The paper concluded that:
- Body-weight response to a change of energy intake is generally slow and depends on individual body composition and individual metabolic changes.
- Generally, an average overweight adult who reduced their energy intake by 100 kilojoules a day would eventually lose about 1kg. Half the weight change would be achieved in about a year and 95% of the weight change in about three years.
- Adults who are heavier have a larger expected weight loss for the same change of energy intake, although reaching a stable body weight will still take them longer.
It should be noted that this is not a clinical trial looking at real weight loss in people. It is a mathematical model that has been validated by comparing it to some actual changes in people. An NIH clinical trial comparing the effects of reducing fats and carbohydrates in obese adults is currently recruiting participants in the US.
What do current guidelines say?
In the UK, general guidance on losing weight for overweight or obese adults does not make detailed calculations of the relationship between calories in diet and weight change. Dietitians can help someone calculate the calorie loss needed to achieve a target weight over a certain period, but they would tailor this to the individual.
Overweight and obese adults are usually advised to follow a low-fat diet or one where the food eaten each day provides about 600 fewer calories than the body needs to stay the same weight. This is recommended by the National Institute for Health and Clinical Excellence (NICE) based on thorough appraisal of the evidence available, rather than being a "rule of thumb" as suggested in several newspapers. Very low-calorie diets are sometimes recommended by professionals for short periods of time in specific circumstances.
Getting enough physical activity (150 minutes a week for adults) is also usually crucial for most people who need to lose weight.
Do I need to change the way I diet?
This paper uses a mathematical model to advance the theory that for most people weight loss through dieting takes far longer to achieve than has previously been calculated. It doesn't provide any evidence on the topic of specific diets and weight loss or advise specific changes to how people diet.
However, the news stories serve to remind us to set achievable weight loss goals, be realistic about our chances of reaching them and be determined in our efforts to do so.
Can I try the weight simulator?
The NIH online weight simulator tool allows people to input their age, sex and body weight and then calculate how many calories they'd need to cut from their diet in order to achieve their target weight loss. However, it is primarily a research tool. It includes no advice on diet or exercise and is not a substitute for personal medical advice on diet and weight loss. While the general principles of weight loss apply to all humans, this has been developed in the US, presumably for a US audience where the incidence of obesity is greater than that of the UK. As yet, it is not known whether a UK version will become available.
Where can I get weight loss advice?
If you think you need to lose a bit of weight, there's a lot that you can do to help yourself. The key things you might consider are:
- Commit to changing your behaviour to lose weight.
- Understand calories and how the energy balance in your diet works.
- Follow these eight simple healthy eating tips.
- Find out how to get your recommended 150 minutes of activity every week. For example, you could try the NHS Couch to 5K running plan.
- Try to maintain a safe level of weight loss.
If your weight is becoming a real health problem for you, it's best to see a healthcare professional such as your GP or a nurse at your GP surgery. He or she can measure your BMI and provide information and support about losing weight, the benefits of a healthier diet and doing more physical activity. They can also tell you about local organisations that can help people to lose weight.
For most overweight people, losing just 5% of your body weight can have health benefits such as lowering blood pressure and reducing the risk of diabetes.
Analysis by Bazian
Edited by NHS Website
Links to the headlines
Why the weight is so hard to shift: guidelines have been wrong all along
The Guardian, 21 February 2012
Losing weight 'twice as difficult as diets claim'
The Daily Telegraph, 21 February 2012
Losing weight is twice as hard as you may think... cutting calories slows down your body's metabolism
Daily Mail, 21 February 2012
Obesity experts change fat-loss guidance
Financial Times, 21 February 2012
Links to the science
AAAS Meeting 2012:
The Calculus of Calories: Mathematical Modeling of Body Weight Dynamics
Kevin Hall, February 20 2012


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Florida SouthWestern State College's School of Education hosted a Pop-Up Adventure Play from 1-4 p.m. on Saturday, Nov. 4. The event was free and open to children of all ages. Pop-Up Adventure Play events encourage children to use their imaginations and utilize everyday materials such cardboard boxes, paper towel tubes and art materials.
Thank you to everyone who came out to support and participate in our Pop-Up Adventure Play! It was great to see the families and children enjoying themselves and engaged in all of the outdoor activities.


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Mar 13, 2007 | 784 Pages
"Remarkable. . . . A tale that's as colorful, suspenseful and unlikely as any in American history…Bushman earns a place for his biography on the very short shelf reserved for books on Mormonism with appeal to initiates and outsiders, too."—The New York Times Book Review"A fascinating definitive biography. . . . Stirs deeper questions about American religious convictions and how they shape lives and culture." —The Christian Science Monitor"An exhaustively researched and beautifully written biography of Mormonism's enigmatic founder."—Christianity Today"Fascinating. . . .Bushman captures all the harrowing events of Smith's short life, rife with converts and cabals, while meticulously dissecting the revelations that continue to haunt the Smith story." —The Providence Journal"Well-researched and lucidly written. . . . An excellent source for learning about the Mormon faith." —The St. Louis Post-Dispatch


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|2012-02-29, 13:47
|Link #1
Join Date: Dec 2005
Location: Monterrey N.L. Mexico
Another - Character Discussion - Reiko
The purpose of this thread is to provide a place to discuss all things Reiko related.
To keep the discussion enjoyable for all Another fans, please follow the guidelines below and stay on-topic!
Note: Please don't use this for the specifics (i.e. episode, chapter, game, etc. discussion) there are other threads for that stuff.Thread Guidelines
|2012-02-29, 13:52
|Link #2
cho~ kakkoii
Join Date: Nov 2003
Location: 3rd Planet
Started thread in Manju's absence since I couldn't contain myself any longer. This image also suits her so very well from where I'm sitting. While I'm not much impressed by the attempted mystery surrounding the story, I, however, am intrigued by her character. By episode 2 it appeared that she would play a major role at consolidating the flow of this story from the mystery/supernatural aspect.
And I simply can't have enough of her pants. ...ahem
|2012-02-29, 14:06
|Link #3
Join Date: Feb 2012
Location: Greater Boston
Since TinyRedLeaf's and my posts were deleted from the other thread, I'll ask people here: where in episodes 2 or 3 was it said that Reiko and Mikami-sensei are the same person? I skimmed through the episodes and didn't find anything. I've also steered clear from the MAL profiles and Wikipedia, so I'm clean of spoilers at this point.
|2012-02-29, 14:48
|Link #4
Join Date: Nov 2006
Location: Virginia, USA
Age: 57
|2012-02-29, 15:06
|Link #5
Feeling comfy
Join Date: Apr 2006
Location: Singapore
Age: 44
At this point, I believe it's just a massive misunderstanding on some viewers' part. As Kanon mentioned in one of the deleted posts, if Reiko turns out to be Mikami-sensei then I'll have to concede, after all these years, that Clark Kent's disguise wasn't so retarded after all.
The character designs are sufficiently different that there is no way in my mind they could be the same person. Even if you were to discount the fact that the two are played by different voice actors, there are still the many logical inconsistencies that would crop up if they turned out to be a single individual. How could it be, for example, that none of the students — including Yuuya, no less — recognised Reiko as their teacher during their day trip?
Then there is the matter of the "class rules". It would have been exceedingly odd for Reiko/Mikami to ignore her nephew in school only to acknowledge him at home, for example.
And lastly, even if it turns out that Reiko and Ritsuko's (Kouichi's mother) maiden name is Mikami, unless told otherwise, we ought to at least keep in mind that there are multiple Japanese surnames pronounced the same way but written with different kanji. Reiko's "Mikami" may well not be the same as Mikami-sensei's, 三神.
Of course, it could all be an elaborate conspiracy on Reiko's part, to adopt both a disguise and an alias. If so, there had better be a very good reason for her to do so. Because if this turns out to be the twist, then I'm afraid I'd find it exceedingly lame.
That aside, yes, Reiko's hawt (I have to say, though, that her manga design was much sexier). More importantly, she's a lot closer to me in terms of age. Far less creepy for me to oggle her than jailbait.
|2012-02-29, 15:47
|Link #6
Junior Member
Join Date: Feb 2012
- Character designs are just that; character designs. I see Reiko/Mikami the same way I saw Kallen in Code Geass; they use different personas when in school. In this case, Reiko chose a serious persona with a more sophisticated look ( Aka makeup and getting her hair done )
- Yuuya did notice Reiko in the trip. First at the start of the ep where they meet at the car Yuuya is seen blushing. Second when they get to the beach, Yuuya gives her a watermelon while blushing.
- Class rules are just that; class rules. Besides, I don't think Mikami/Reiko could just ignore Sakakibara since they live in the same house.
- In ep 1 and 2 when Sakakibara is asked to comment on how hot Mikami is, he dodges the question. He didn't want to answer because she's his aunt. That would just be awkward.
- In ep 5 during the art club/class, Yuuya comments on Mikami's absence and whether she was sick. In ep 4, Reiko was complaining of headaches.
I hope this clears things up.
|2012-02-29, 16:49
|Link #7
Join Date: Feb 2012
Location: Greater Boston
Yvese, are we seriously having the same debate on two different forums?
Your circumstantial evidence is interesting, but none of it is direct evidence. And our discussion here is whether or not, given the information we have over eight episodes, Reiko and Mikami are the same person. Maybe it's a plot twist to come; maybe Reiko is the Another and this has something to do with that (in which case there will be a supernatural explanation that renders your evidence meaningless anyway). Who knows. But after eight episodes of the anime -- forget the novel, forget the manga, forget the MAL profile -- there is no direct evidence that Reiko and Mikami are the same person.
|2012-02-29, 17:00
|Link #8
Also a Lolicon
Join Date: Apr 2010
I don't think Mikami sensei == Reiko though. This series really likes to use similar names.
Last edited by Solace; 2012-02-29 at 17:25. Reason: Sigh.
|2012-02-29, 17:46
|Link #9
Junior Member
Join Date: Feb 2012
True, none of it is direct evidence. We see Mikami in the next ep's preview so hopefully more will be revealed.
Till then, I'll agree that Reiko is hot
|2012-03-01, 09:44
|Link #13
Kana Hanazawa ♥
Join Date: Jun 2007
Location: France
Age: 32
I wish posts had been moved to the speculation thread instead of deleted. I left shortly after I posted so I never got to see any of the replies, meaning I'm still as clueless as yesterday. From what I can surmise reading Hakuromatsu and TinyRedLeaf, it looks like the Mikami-sensei = Reiko was indeed a misunderstanding on the other poster's part (unfortunately, I can't remember who I replied to... sorry about that).
Spoiler for potential novel spoilers:
Anyway~ we can definitely all agree that Reiko is hot. If only she wasn't so mentally unstable... which I guess can be a turn-on for some people.
|2012-03-01, 09:52
|Link #14
Wonderland's hitman
If Reiko is indeed Mikami sensei it would make sense if she was the another, 'cause it would make her part of the class. But I will need more clues (better ones) to buy it. Let's wait for the next episode
|2012-03-01, 10:14
|Link #15
Join Date: Mar 2006
It's hard to balance removing spoilers without confirming them, but in this case the problem was users referencing events that confused anime viewers because they came from outside sources, which included links to sites containing spoilers. It was better for us to just remove everything, related or not, to help preserve as much of a spoiler free environment as possible. Besides, half of those "spoilers" were wrong anyway. The downside to being a mod is you tend to get spoiled early and often in stories like this.
Reiko is certainly a beautiful woman though. If only real life was like anime, where all my relatives were young and good looking.
|2012-03-01, 11:41
|Link #16
Feeling comfy
Join Date: Apr 2006
Location: Singapore
Age: 44
The other images are floating about in the relevant thread. It's a toss-up between cuteness and hotness, I think. Noizi Ito's Reiko is cuter, while manga Reiko is hotter (not the most representative picture, I know ).
|2012-03-01, 16:37
|Link #17
Kana Hanazawa ♥
Join Date: Jun 2007
Location: France
Age: 32
I figured you guys had to get spoiled all the time. It must be even worse when it comes to series like this one where half of fun is in trying to figure out the answer to the mystery (at least for me). Once you know the answer, it's just not the same.
Which thread are you referring to? I can't find anything in the manga thread. After all this talk about Mikami, I'd like to see what she looks like in the manga.
|2012-03-01, 16:49
|Link #18
Join Date: Aug 2010
Age: 31
She also never got over her sister's death. The scene this pic is from is actually a scene where she crys at kouichi saying that shes sorry again.
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REAL SALT LAKE'S Álvaro SaborÍO NAMED MLS 2010 NEWCOMER OF THE YEAR
High-scoring Costa Rican Forward Becomes Second RSL Player to be Recognized by Major League Soccer at Season's End
SANDY, Utah / NEW YORK (Wednesday, November 10, 2010) – Major League Soccer today announced that Real Salt Lake FW Álvaro Saborío has been named the League's 2010 Newcomer of the Year, as voted on by his fellow players, coaches, general managers, and media. The 28-year-old Saborío beat out two New York Red Bull players – MF Joel Lindpere and FW Thierry Henry – to become the fourth player to earn the award since the League began bestowing it in 2007.
Saborío answered the question of who would pick up departed striker Yura Movsisyan's scoring slack in 2010 resoundingly, leading Real Salt Lake in scoring in both League play (12 goals – 8th on MLS Golden Boot chart) and during its maiden appearance in the CONCACAF Champions League (6 goals – T-2nd in the 2010 portion of the competition). His introduction to the Claret-and-Cobalt faithful at Rio Tinto Stadium was a dramatic one, as he came off the bench to head home the equalizing goal in the 94th minute against Seattle Sounders FC on April 10, punctuating the squad's Championship celebration evening and keeping alive what would later become the longest home unbeaten run in League history.
While Saborio's scoring total was prolific, his goals were also clutch, as the Costa Rican international tallied five match-winners and ended the regular season with a flourish, his double in stoppage time at Colorado single-handedly allowing RSL to earn a 2-2 draw and continue its team-record 14-match undefeated run in League play. While MLS competition is the focus for all awards, factoring in RSL's 2010/11 CONCACAF success brings Saborío's totals to 18 goals in 32 games – the scoring haul equal to MVP candidate and MLS Golden Boot winner Chris Wondolowski of San Jose during the MLS regular season. The Costa Rican international was thrice recognized by MLS during his first year in the League, earning two Player of the Week awards (Week 8 and Week 14) and the title of MLS Player of the Month for May.
Saborío is the first member of Real Salt Lake to capture the Newcomer of the Year honor from MLS, and the second RSL player to win a League award this season, joining Defender of the Year honoree Jamison Olave. The duo are the newest members of an elite list of players who have donned the Claret-and-Cobalt and garnered end-of-season awards from Major League Soccer, with past winners including Will Johnson (2008 Goal of the Year), Jeff Cunningham (2006 Golden Boot and Best XI Team), Chris Klein (2006 Fair Play Award), and Brian Kamler (2005 Humanitarian of the Year). Head Coach Jason Kreis can add to that growing list of award winners, as the RSL sideline boss is among the trio of candidates for the MLS Coach of the Year honor, which will be named tomorrow, Thursday November 11.
MLS Newcomer of the Year Award Winners
2010: Álvaro Saborío – Real Salt Lake
2009: Fredy Montero – Seattle Sounders FC
2008: Darren Huckerby – San Jose Earthquakes
2007: Luciano Emilio – D.C. United
MLS 2010 Awards Announcements Schedule (Schedule subject to change)
November 3: Rookie of the Year (Andy Najar – D.C. United), Fair Play Individual (Sebastian Le Toux – Philadelphia Union) & Team of the Year (San Jose Earthquakes), and Goalkeeper of the Year (Donovan Ricketts – LA Galaxy)
November 5: Visa Defender of the Year (Jamison Olave – Real Salt Lake) and adidas Referee of the Year (Kevin Stott)/Assistant Referee of the Year (Craig Lowry)
November 8: MLS W.O.R.K.S. Humanitarian of the Year (Seth Stammler—New York Red Bulls)
November 10: Newcomer of the Year (Álvaro Saborío – Real Salt Lake) and Comeback Player of the Year (Bobby Convey – San Jose Earthquakes)
November 11: MLS Coach of the Year
November 15: 2010 MLS Best XI
November 17: AT&T Goal of the Year and NAPA Auto Parts Save of the Year
November 19: Volkswagen MVP & Commissioner's Award
www.RealSaltLake.com / www.RioTintoStadium.com / www.RSLtotheCore.com / www.ESPN700Sports.com


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The present study investigated whether bright light exposure during the first half of the evening/night shift combined with light attenuation in the morning is effective in improving sleep problems in nurses undertaking rotating shift work who suffer from clinical insomnia.
This was a prospective, randomized control study. The Insomnia Severity Index (ISI) and the Hospital Anxiety Depression Scale (HADS) were used to evaluate insomnia and anxiety/depression severity, respectively. Female hospital nurses on rotating shifts during the evening or night shift with an ISI score > 14 were enrolled. Subjects in the treatment group (n = 46) were exposed to bright light at 7,000-10,000 lux for ≥ 30 minutes. Exposure was continued for at least 10 days during 2 weeks, and the subjects avoided daytime outdoor sun exposure after work by wearing dark sunglasses. Subjects in the control group (n = 46) were not exposed to bright light, but also wore sunglasses after work. Statistical analyses were performed to examine group differences and differences across treatments.
After treatment, the treatment group showed significant improvements in the ISI score and the HADS total and subscale scores as compared with pre-treatment. The ISI, HADS, and subscales of the HADS scores were significantly improved across treatments in the treatment group as compared with the control group.
The design of this study is easy to put into practice in the real world. This is the first study to document that a higher intensity and briefer duration of bright light exposure during the first half of the evening/night shift with a daytime darkness procedure performed in rotating shift work female nurses suffering from clinical insomnia could improve their insomnia, anxiety, and depression severity.
A commentary on this article appears in this issue on page 647.
Huang LB; Tsai MC; Chen CY; Hsu SC. The effectiveness of light/dark exposure to treat insomnia in female nurses undertaking shift work during the evening/night shift. J Clin Sleep Med 2013;9(7):641-646.
Insomnia is common in the general population. From the review study of Ohayon,1 about one-third of the general population suffers symptoms of insomnia. The prevalence is between 9% and 15% when daytime consequences of insomnia are taken into account. A strong association between insomnia and anxiety/depression is also found in the community and in hospitals.2,3 Chronic insomnia may aggravate the severity of anxiety and depression.4–6 In addition, while insomnia or excessive sleepiness is a risk factor for depression in all individuals, it is a much greater risk factor in rotating or night shift workers.7
Shift work disorder (SWD) is a circadian rhythm sleep disorder characterized by sleepiness or insomnia that can be attributed to the person's work schedule. According to second edition of the International Classification of Sleep Disorders (ICSD-2),8 the major feature of circadian rhythm sleep disorder is "a misalignment between the patient's sleep pattern and the sleep pattern that is desired or regarded as the societal norm." People who work shifts have great difficulty adjusting their internal clocks and develop SWD due to a mismatch between the sleep/wake schedule required by their jobs and their own circadian sleep/wake cycles. It is estimated that around 20% of the US and 35% of the Taiwan labor force works night, evening, or rotating shifts,9,10 and that 10% of these individuals suffer from SWD.7 Circadian misalignment can be caused by shift work. The resulting circadian misalignment associated with shift work can produce significant morbidity associated with disturbed sleep11,12 and impaired alertness.13,14 The longitudinal study of Bara and Arber15 found that women's mental health and anxiety/depression were more adversely affected by varied shift patterns than by night work. Nurses are the largest working group in a hospital and most are on a rotating shift work schedule. Research has shown that shift work, in particular night work, can have negative effects on the health, safety, and well-being of nurses.16,17 The prevalence of depression is significantly higher in those who work rotating and night shifts than in day workers.7 Lin et al.18 also found that female nurses who have a rotation shift work schedule tend to experience poor sleep quality and mental health in Taiwan.
Current Knowledge/Study Rationale: Bright light exposure during the first half of the night shift and daytime darkness have been shown to improve daytime sleep and nocturnal functioning in nurses working the night shift. We aimed to investigate the effectiveness of bright light exposure during the first half of the evening/night shift combined with light attenuation in the morning in nurses undertaking rotating shift work who suffer from clinical insomnia.
Study Impact: Bright light exposure with morning time darkness is effective to improve insomnia, anxiety, and depression severity in rotating shift work female nurses suffering from clinical insomnia. The design of this study is easy to put into practice in the real world.
Light is the dominant environmental time cue that entrains the human circadian clock to a 24-h day, and the timing of light exposure will determine whether the internal clock is phase delayed or advanced.19 Using this principle, bright light exposure during the first half of the night shift and daytime darkness have been shown to improve daytime sleep and nocturnal functioning in night shift workers.20,21
However, no studies have investigated whether bright light exposure could improve sleep problems in nurses working rotating or night shifts with moderate to severe insomnia (clinical insomnia). The aim of the present study was to investigate whether bright light exposure during the first half of the evening/night shift combined with light attenuation in the morning would be effective in improving sleep problems in nurses working rotating shifts during the evening/night shift who suffer from clinical insomnia in a hospital setting. In addition, we also investigated the changes in the anxiety and depression scores after bright light intervention.
This was a randomized controlled study performed to assess the effectiveness of bright light exposure in treating insomnia, anxiety, and depression in female nurses working a 3-shift rotation during the evening/night shift. The project was approved by the Institutional Review Board of Chang Gung Memorial Hospital. The inclusion criteria were: (1) a score on the Chinese version of the Insomnia Severity Index (ISI)22 > 14; (2) rotating-shift female nurses working the evening/night shift; (3) 3-shift rotation including day, evening, and night shifts in the most recent 6 months; and (4) the same work schedule during treatment. The exclusion criteria were: (1) substance abuse or dependence according to the criteria of the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV),23 including caffeine, alcohol, nicotine, and over-the-counter sleeping pills; and (2) unstable physical conditions. Participants were randomly divided into 2 groups, the treatment group and the control group. Randomization was performed using a random digit table. An even number was allocated to the treatment group and an odd number was allocated to the control group. All subjects completed the Chinese version of the Hospital Anxiety and Depression Scale (HADS)24 and the ISI during work before and after intervention. This study was performed in a real workplace. Subjects in the treatment group were exposed to artificial bright light of 7,000-10,000 lux for ≥ 30 min; evening shift exposure took place between 19:30 and 20:30, while night shift exposure occurred between 23:00 and midnight. During exposure, the subjects undertook charting or reading. Light was delivered by an Apollo briteLITE 6. A light box was placed at a 45 degree angle from the face, just above eye level. Light exposure of 7,000-10,000 lux could be obtained at a distance of around 70 cm from the light box to the nurse. Light intensity was measured using a Lutron Electronic LX-1102 light meter. Ward illumination at night is maintained in the range of 100-400 lux in our hospital. Treatment was continued for ≥ 10 days during 2 weeks, and daytime outdoor sun exposure after work and before sleep was avoided by the subjects by wearing dark sunglasses with UV protection, including on off-days. The subjects in the control group were not exposed to artificial bright light, but also wore sunglasses to avoid outdoor sun exposure after work and before sleep. Other aspects of lifestyle were not changed, including off-days, in either group. Subjects who used sleep medications did not change the pattern of use across the treatment duration. All participants were reminded of the study procedure by a telephone call before and after work to enhance protocol adherence.
This study was conducted at a medical center in northern Taiwan from May 1, 2009, to March 31, 2010. Around 2,500 three-shift rotating nurses in the most recent 6 months received information regarding the study by e-mail and during nursing meetings in the hospital in May 2009. Using t-tests and a one-sided type I error of 5%, we estimated that 50 participants in each group would be necessary to achieve a power of 80% to detect the effect size at 0.5. One hundred two nurses agreed to join this study. Ten participants were excluded because their pre-treatment ISI score was < 15. A total of 92 rotating-shift female hospital nurses working the evening shift (4 pm to midnight) or night shift (midnight to 8 am) with an ISI score > 14 were recruited. Written informed consent was obtained from all participants before study enrollment. Forty-six subjects were in the treatment group, and the remainder were in the control group. All subjects completed the study procedure reported by themselves.
The ISI, developed by Morin, is a 7-item self-rated scale designed to assess subjective perception of the severity of insomnia.22 The scale contains items including difficulty falling asleep, difficulty maintaining sleep, early morning awakening, satisfaction with sleep, concerns about insomnia, and the functional impact of insomnia. The total score, ranging from 0 to 28, can be used to categorize patients into different levels of insomnia severity (0-7, no clinically significant insomnia; 8-14, sub-threshold insomnia; 15-21, clinical insomnia, moderate severity; > 21, clinical insomnia, severe severity).22 A total score > 14 represents moderate to severe insomnia. The scale was found to have an adequate internal consistency (Cronbach α = 0.74).25 The Insomnia Severity Index-Chinese version also has a good internal consistency, with a Cronbach α coefficient of 0.94.26 The Cronbach α of the ISI before treatment in this study was 0.65.
The HADS24 is a 14-item self-rated scale designed to assess clinically relevant anxiety and depression. It is divided into an Anxiety subscale (HADS-A) and a Depression subscale (HADS-D), both containing 7 intermingled items. The original English version has been translated into and validated in many languages, including Chinese.27 In most studies an optimal balance between sensitivity and specificity was achieved when caseness was defined by a score ≥ 8.28 The HADS, HADS-A, and HADS-D before treatment had good internal consistency in this study, with a Cronbach α coefficient ranging from 0.72 to 0.82.
Statistical analyses were performed using the Statistical Package for the Social Sciences (SPSS 17.0) for Windows 7. The demographic data of the treatment group and the control group were compared using Student t-test, the χ2 test, or Fisher test. The independent-samples t-test was used to compare the differences in the scores for insomnia, anxiety, and depression between the 2 groups before and after treatment. We used the paired-samples t test to assess the effectiveness of bright light exposure (change from pre-treatment to post-treatment in each group). All continuous variables were compared across both groups using an analysis of covariance model (ANCOVA) to assess the change from pre-treatment, with pre-treatment as the covariate. We also used ANCOVA to compare the changes in anxiety and depression severity in both groups, with the ISI change from pre-treatment to post-treatment as the covariate. The Pearson correlation was used to assess the correlations between the changes in the ISI, HADS-A, and HADS-D scores. All statistical tests were 2-sided, and a significance level of 0.05 was used for all comparisons.
During the study period, all subjects completed the study and did not use psychotropic medication other than sleep medications. All subjects reported that they did not change their lifestyle, such as mealtimes, exercise periods, sleep/wake schedule, and pattern of alcohol/substance/medication use, including off-days, during the study. Although none of the participants met the diagnosis of substance dependence or abuse, 19 nurses (20.7%) use one cup of caffeinated drink per day habitually. Ten subjects were in the treatment group; the remainder were in the control group. There was no significant difference between the two groups. Most subjects (93.6%) did not use sleep medications; 6 participants used sleep medications (zolpidem or lorazepam) prescribed by physicians. Table 1 shows the demographic data of both groups of participants. All demographic data were comparable between groups, including previous work schedule and sleep medications use.
Demographic data of the treatment and control groups
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There were no significant differences in the ISI, HADS, HADS-A, and HADS-D scores between the groups before treatment. The treatment group had significantly lower scores on the insomnia, anxiety, and depression scales than the control group after treatment (Table 2).
Differences in the severity of insomnia, anxiety, and depression between the two groups pre- and post-treatment
After treatment, the treatment group exhibited significantly improved ISI, HADS, HADS-A, and HADS-D scores as compared with pre-treatment (paired-samples t test, all p < 0.001). Depression became worse after treatment, as measured by the HADS and HADS-D, in the control group (paired-samples t test, p < 0.001). The mean changes in the scores of the ISI, HADS, HADS-A, and HADS-D from pre-treatment in the treatment group were -12.2 ± 5.1, -6.6 ± 5.1, -3.8 ± 2.8, and -2.8 ± 3.4, respectively; while those in the control group were -0.2 ± 1.7, 1.5 ± 2.5, 0.2 ± 1.3, and 1.3 ± 1.8, respectively. For subjects in the glasses-only group, the pre-treatment depression score was categorized as either a HADS-D score < 8 or ≥ 8. The mean changes in the scores of depression across treatment in the HADS-D < 8 group and ≥ 8 group were 1.9 ± 1.8 and 0.3 ± 1.0, respectively. The depression score became worse only in the group with a HADSD < 8 (paired-samples t test, p < 0.001). Relative to the control group, the scores of the ISI, HADS, HADS-A, and HADS-D significantly improved across treatment in the treatment group according to ANCOVA (all p < 0.001; Figure 1). After treatment, in the treatment group 37 nurses (80.4%) met the criterion for no insomnia (ISI < 8). Meanwhile, no nurse met the criterion for no insomnia in the control group.
All p < 0.001 between groups. Note: p-values reflect the results of the change from the pre-treatment analyses using ANCOVA. ISI, Chinese version of the Insomnia Severity Index; HADS, Chinese version of the Hospital Anxiety Depression Scale; HADS-A, anxiety subscale of the HADS; HADS-D, depression subscale of the HADS.
Mean change in the ISI, HADS, HADS-A, and HADS-D scores after treatment in the treatment and control groupsAll p
The scales of the ISI, HADS, HADS-A, and HADS-D were not significantly different between nurses undertaking the evening and night shifts in either group. We analyzed whether the changes in the scores for insomnia and mood might differ between evening and night shift workers in the treatment group. The mean changes in the scores of the ISI, HADS, HADS-A, and HADS-D from pre-treatment in the evening shift workers were -11.3 ± 5.5, -6.4 ± 5.1, -3.8 ± 2.8, and -2.7 ± 3.2, respectively; while those in the night shift workers were -14.1 ± 3.5, -7.1 ± 5.2, -4.0 ± 2.9, and -3.1 ± 3.8, respectively. There were no signifi-cant differences in the insomnia/mood scores across treatment between the evening and night shift workers in either groups.
We analyzed whether the changes in anxiety and depression directed the change in insomnia severity. After treatment, the correlations between the changes in the severity of insomnia, anxiety, and depression were high (Pearson correlation between 0.515 and 0.693, p < 0.001). The treatment group nevertheless had significantly decreased scores on the HADS, HADS-A, and HADS-D after treatment as compared with the control group, even when the factor of ISI change was controlled (all p < 0.001).
To the best of our knowledge, this was the first randomized control study to investigate the effectiveness of bright light exposure at night with attenuation of morning light in female nurses undertaking rotating shift work suffering from clinical insomnia during the evening/night shift. Our study found that bright light therapy of 7,000-10,000 lux for at least 30 minutes at night for at least 10 days during 2 weeks significantly improved the sleep problems of nurses working the evening or night shift. Studies have found that bright light exposure improves daytime sleep and nocturnal alertness21,29 in nurses working the night shift. However, the subjects in these studies did not necessarily have insomnia. The study of Yoon et al.21 also found that these improvements could be maximized by attenuation of morning light on the way home. Light attenuation in the morning only was found to be ineffective in improving insomnia in our study.
There is no consistent design of bright light therapy for evening/night shift workers, including schedule, intensity, and duration. Various light intensities, from 1,200 to 10,000 lux, with durations of exposure ranging from 3 to 6 hours, have been used successfully to realign circadian rhythms and improve performance and sleep during the night shift.20,21 Previous studies30,31 have recommended that either intermittent or continuous light exposure begins early in the shift and terminates approximately 2 hours before the end of shift, with the wearing of sunglasses outdoor in the morning was efficacious for phase delay. Importantly, a delayed circadian phase was found to be positively correlated with improved sleep, even in the control group, in subjects during the night shift.31,32 The design of our treatment procedure is easy to put into practice in the real world. Higher intensity and shorter bright light exposure once before work or in a break during the first half of the evening/night shift and a daytime darkness procedure were implemented in our study.
The study of Drake et al.7 found that insomnia or daytime sleepiness is a risk factor for major depression, but it is a much greater risk factor for rotating or night shift workers. A systematic review by Even et al.33 examined the efficacy of light therapy in nonseasonal depression. They found that bright light monotherapy is efficacious in treating seasonal depression, but its efficacy in treating nonseasonal depression is inconsistent. This is the first study to report that in female nurses working rotating shifts, anxiety and depression scores were significantly improved after bright light therapy, even when the change in insomnia severity was controlled. It must be noted that the mean HADS-D score as a group was not above the cutoff point (≥ 8) according to the criteria for depression either before or after intervention in our study, but the scores were high. Besides, the nurses were not diagnosed with depression, nor was the clinical severity of depression evaluated in this study. Some factors may contribute to these findings, such as (1) according to the general criteria of the International Classification of Sleep Disorders, 2nd ed. (ICSD-2)8 for insomnia, depressive symptoms related to nighttime sleep difficulty are commonly reported by insomniacs; (2) treating insomnia in patients with major depressive episode improves mood problems other than insomnia.34–36 It must be mentioned that light therapy is not the only choice of treatment for insomnia or depression. Subjects undertaking shift work can improve insomnia and mood problems through pharmacotherapy, behavioral therapy, or other therapy.
There were some primary limitations in our study. First, this study was not a double-blind study, and "placebo effects" should be considered. The subjects in both groups might work in the same unit, and the use of a sham light box (a light box of a much lower intensity or red light) in the control group would be able to be detected by the controls, who would discern the difference. Therefore, we considered that the "placebo effect" could not have been solved by the use of a sham light box. Second, as this study was performed in a real workplace, it was diffi-cult to measure the differences in endogenous circadian rhythm change and the real intensity and duration of light exposure in groups. Aoki et al.37 reported melatonin could be suppressed by light intensities of around 300 lux. However, compared to ordinary room light (< 250 lux), Martin and Eastman38 found that medium- and high-intensity light, approximately 1,230 lux and 5,700 lux, respectively, for 3 hours, significantly increased the percentage of subjects who adapted to the night shift, as measured by temperature rhythm phase shifts. Larger phase shifts were correlated with more sleep and less fatigue. Third, we only used questionnaires to measure the severity of insomnia, anxiety, and depression in the nurses working shifts. We were not able to confirm the diagnosis of insomnia, because subjects might suffer from shift work disorder (SWD), primary insomnia, insomnia due to mental disorders, or other insomnia-related disorders. According to data from the Detroit tri-county population, 32.1% of night workers and 26.1% of rotating shift workers suffer from insomnia or excessive sleepiness. Thus, the "true prevalence" of SWD in the night- and rotating-worker samples was 14.1% and 8.1%, respectively.7 In a study performed in Norway,39 it was found that 44.3% of nurses working on a three-shift rotation met the criteria of SWD by asking shift work-related symptom questions. Fourth, although the study was a randomized control study, we did not assess the differences in rotation patterns, lifestyle during days off, and off-work periods in the groups. Circadian misalignment might be aggravated by these factors. Rotation patterns such as the number of shifts separated by less than 11 hours and the number of nights worked were found to be positively associated with SWD in the study of Norwegian nurses.39 Lin et al.18 also reported that rotation shift nurses who had at least two days off after their most recent night shift showed significantly improved sleep quality and mental health. Finally, 67.4% of the subjects in the present study were working the evening shift, and 32.6% were working the night shift. In this study, different timings of bright light exposure were employed in the evening and night shift groups. No significant differences were found in the change of insomnia/mood scales across treatment in treatment and control groups. However, since statistical power is reduced by dividing the subjects into smaller subgroups by shift schedule, further studies would be indicated to assess effectiveness under the two different situations.
In conclusion, the design of this study is easy to put into practice in the real world. Female nurses working the evening/ night shift with insomnia can improve their sleep problems by higher intensity and shorter bright light exposure once before work or in a break during the first half of work combined with a daytime darkness procedure. In addition, anxiety and depression scores can be improved after intervention.
This was not an industry supported study. The authors have indicated no financial conflicts of interest.
This study was supported by grants from the Chang Gung Memorial Hospital (CMRPG-380521).
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This guy loves all the bits and pieces associated with gaming. He actually bought the Nintendo Power Glove and the Virtual Boy. He has Rumble Paks on his Rumble Paks. Maybe he just really likes Nintendo... No wait, there's a stack of every color of PlayStation memory card ever made. He always shows up with his own controller in pristine condition, and you laughed at him when he brought over the Master Chief helmet that came with the Legendary edition of Halo 3, because it's tiny and you can't actually wear it. Then he used it to build a scale model that actually fit, and you were kind of jealous.
Ok, I thought pot made your reaction time slower. I thought being on the phone while doing stuff made you less skillful. I thought having played the game before would give me some kind of advantage. Yet here you are, high as a kite, talking on the phone with your girlfriend, never having played this game before, and beating the crap out of me. I don't know whether to salute you or cut you up into little pieces and hide them in the CD tray.
Doing stuff out of order just freaks this guy out. Don't ever invite him to play multiplayer on a level he hasn't played through himself on single player. He won't put down a game until he has every scenario beaten, every achievement achieved. "I'd love to play MF2 with you, man," he says, "but I'm still working on GTA IV." He still brags about how, at the age of 12, he got every star in Super Mario 64 in perfect order. You wonder seriously whether he puts this on his resume.
He's indifferent about games today, but oh man, were you alive when the first Super Mario came out? That game was tight. The mechanics, the controls, both groundbreaking and breathtaking. Halo can't hold a candle to GoldenEye; A Link to the Past leaves Uncharted in the dust. His reaction to any Call of Duty titles is lukewarm at best, though in a private conversation he'll admit he finds the realism of the guns frightening.


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Fri, 22 April 2011
Judy Hintz with exasperation and inspiration...The Kid Fixer. Then, Del Quentin Wilber...Rawhide Down...the story of the near assassination of President Reagan. Then, CityView publishes the names of all the new carry permits. Some are bugged. DNR has Earth Day guides for toxic waste disposal.
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Head track and field coach Bill Taylor gives a narrative for the time he has spent in Haiti. With the trip wrapping up, he discusses his thoughts on carry over into coming back into the states.
I started this mission trip with a blog, so I decided I would end the trip with one too.
As I write this I am aware that I am completely overwhelmed. It is going to take weeks to digest all we have experienced in just seven days. It is impossible to do any justice to our experience in words.
I tried on day one. Alexander and Lacey have done great with their blog updates.
Yet, this is experience. This is unique to your senses and emotions. All of them.
Describe what a banana tastes like to someone who has never eaten a banana. You can't. It must be tasted to be understood. So it is with this. We have seen, heard, tasted, felt and experienced so much and anything I write pales in comparison.
Haiti has been unique. So rather than go into detail about everything we have done, (I think Alexander and Lacey will wrap some of that up in tomorrow's blog) I want to write about some common themes during this trip.
Two major topics have come up a lot since we've been here.
1)There is a spiritual war going on right now, throughout the earth. It will continue for each of us until we die or Jesus returns. You don't have to be aware of it, or acknowledge it for it to be true.
A Christian is actually a spiritual warrior. A Christian is in God's Army, and like any soldier, is supposed to fight.
Christianity is not a club. It's not something you join for a while and attend meetings to keep your membership active.
Christianity is life. We are at war 24/7, and every Christian must be aware of this.
Here in Haiti we (Americans) can see and feel the spiritual battle. You can sense it in the air, see it on the ground, and you can hear it, be it the voodoo drums playing against us the night of our prayer walk, or the witch doctor chanting to bring the sun up each morning.
Here, Satan has found that fear and an open presence in the form of voodoo works best.
At home in the US, this battle is different. Satan chooses his tactics, like any General, to match the army he is up against. In the US this battle is more hidden, maybe even more sinister. Materialism and busyness is our Voodoo.
We get passive, busy, focused on making more money, buying more stuff, earning more power or prestige. We get lost in work, TV, video games, e-mail, Facebook or the thousand other things that distract and numb us. And as such, we become unaware of the battle and our responsibility in it.
In the US, Satan uses distraction, false intellectualism, arrogance, and pleasures taken too far to trick us into laying down our weapons and letting the battle go to the enemy.
I know a war analogy might be tough right now after being at war in Afghanistan and Iraq the past 11 years. But Political Correctness and psychological fatigue does not change the truth.
YOU ARE AT WAR! Christian or not, the battle rages for souls. Victory is assured for God. The spiritual casualties are not assured. Which is why it is important that you fight, and that you prepare yourself for battle.
For us, it was amazing how many times, in different ways, and from different people, the same verse came up. Over and over, Ephesians 6:13-17:
Therefore, put on the full armor of God, so that when the day of evil comes, you may be able to stand your ground, and after you have done everything, to stand. Stand firm then, with the belt of truth buckled around your waist, with the breastplate of righteousness in place, and with your feet fitted with the readiness that comes from the gospel of peace. In addition to all this, take up the shield of faith, which you can extinguish all the flaming arrows of the evil one. Take the helmet of salvation and the sword of the spirit, which is the word of God.
2)We have changed here. There is no doubt at all. How much each person has changed and in what way is unique to each person.
The question we've asked is, what will happen when we get back?
The spiritual war will be felt in more ways than we've felt here. Anyone who has felt the passion for God, the fire for the Lord, during a big youth retreat or a strong mission trip has felt the attack, the "down", immediately after.
So how do we resist that? How do we maintain the most important experiences and lessons from this trip, and then how do we grow from them?
Resist, retain and grow!
This is a tough question though. It will be tougher for our group, going home to all different parts of the US for Christmas break.
The answers we have come up with so far are:
A)Commitment to the Truth.
This means remembering what is real and what is important and being committed to follow Christ fully. To put Him first. To proclaim His name without shame or fear. To try, to the best of our human abilities, to do His will in all things. And to catch ourselves when we fail, and correct it going forward.
B) Personal Devotional and Quiet Time.
One of the great things on this trip has been doing daily morning personal devotions and quiet time with God. I've heard so many in our group talk about how important this has been. It sets the tone for each day, opens our ears, eyes and hearts to God, is relaxing and therapeutic, and so much more. We read the Bible, we answer questions, we pray and we journal. And we are far better for it.
We are committing to finding the time from this moment on to do this for 30min a day. In reflecting on this, I've had many friends and acquaintances that have done this over the years. I've never heard a single one say "That was a waste of time!" On the contrary, every person I've ever known who did this consistently has changed for the better and has grown massively in their walk with God.
C) Small Group Accountability
We have four small groups of five people from our team of 20 on this trip. We will meet once a week for at least the next couple of months to talk, reflect, encourage, teach and learn from each other, with the foundation of shared experience here.
D) Larger Group Accountability
This is for each person to figure out…finding other accountability groups and partners, be the mentors, church groups, FCA, or whatever else. The more each person surrounds themselves with alive, active and on fire Christians, the better.
E) Change
Humans are strange. We seek homeostasis. We want normalcy. We like routine and predictability.
And we hate them.
We like to know how it works inside and out and know what to expect, but we get bored and stagnant.
Change never happens with routine. And we are also built to desire change. This is because change is essential to growth. You can't grow without being pushed into new, usually unpredictable and challenging areas.
We are this strange mix of the two, routine and change.
Most people error on the side of routine and safety. To grow in Christ, we must continue to stretch and grow and strive for greater things. We need to push our limits, get uncomfortable, and move ever forward.
Growth and change usually require some level of pain or discomfort. Many fear this. Embrace it as a part of the adventure of becoming a better person and a stronger Christian soldier.
We wrap up our Haiti mission trip tomorrow by flying home. Back to the states. Back to "our lives."
I wish everyone could experience what we have. I hope everyone on my team and everyone on all the teams at Lipscomb will go on a mission trip. I think most of this group plans to return to Haiti.
My prayer is that "our lives" back in the US look very different than when we left, and never ever look the same again.