Instant ebooks textbook Sleep disorders in adolescents a clinical casebook 1st edition sanjeev v. ko
Visit to download the full and correct content document: https://textbookfull.com/product/sleep-disorders-in-adolescents-a-clinical-casebook-1s t-edition-sanjeev-v-kothare/
More products digital (pdf, epub, mobi) instant download maybe you interests ...
Sleep Disorders in Pediatric Dentistry Clinical Guide on Diagnosis and Management Edmund Liem
This work is subject to copyright. All rights are reserved by the Publisher, whether the whole or part of the material is concerned, specifically the rights of translation, reprinting, reuse of illustrations, recitation, broadcasting, reproduction on microfilms or in any other physical way, and transmission or information storage and retrieval, electronic adaptation, computer software, or by similar or dissimilar methodology now known or hereafter developed.
The use of general descriptive names, registered names, trademarks, service marks, etc. in this publication does not imply, even in the absence of a specific statement, that such names are exempt from the relevant protective laws and regulations and therefore free for general use.
The publisher, the authors and the editors are safe to assume that the advice and information in this book are believed to be true and accurate at the date of publication. Neither the publisher nor the authors or the editors give a warranty, express or implied, with respect to the material contained herein or for any errors or omissions that may have been made.
Printed on acid-free paper
This Springer imprint is published by Springer Nature
The registered company is Springer International Publishing AG Switzerland
Preface
We would like to dedicate this book to all the patients and their families who taught us even more than our textbooks. We have penned these experiences in this book to enrich your experience in similar situations, and we hope that this will enable you to treat your patients even more effectively. We would also like to acknowledge all the fellows whom we have trained over the years and who taught us to introspect on how we manage our patients to their best satisfaction. Several of these trainees have contributed to chapters in this book. Finally we would like to acknowledge our families, for their understanding for being away from them as we worked on this book.
New York, NY, USA
Rebecca Quattrucci Scott
Sanjeev V. Kothare
Joseph Kaleyias, Rebecca Quattrucci Scott, and Sanjeev V. Kothare 7
Ujjwal Ramtekkar and Anna Ivanenko 8
Vicky Chiang and Alcibiades J.
Mariya Narizhnaya and Matthew R. Ebben
Sejal V. Jain and Sanjeev V. Kothare
Kanwaljit Singh and Sanjeev V. Kothare
Contributors
Vicky Chiang, B.S. Department of Neurology, New York University Medical School, La Mirada, CA, USA
Valerie McLaughlin Crabtree, Ph.D. Department of Psychology, St. Jude Children’s Research Hospital, Memphis, TN, USA
Matthew R. Ebben, Ph.D. Department of Neurology, Weill Cornell Medical College, New York, NY, USA
Danielle M. Graef, Ph.D. Department of Psychology, St. Jude Children’s Research Hospital, Memphis, TN, USA
Stacey Gunn, M.D. Division of Pulmonary, Critical Care and Sleep, Beth Israel Deaconess Medical Center, Boston, MA, USA
Anna Ivanenko, M.D., Ph.D. Department of Psychiatry and Behavioral Sciences, Feinberg School of Medicine, Northwestern University, Division of Child and Adolescent Psychiatry, Ann and Robert H. Lurie Children’s Hospital of Chicago, Chicago, IL, USA
Sejal V. Jain, M.D. Division of Neurology and Pediatrics, Banner University Medical Center, Tucson, AZ, USA
Sasha D. Jaquez, Ph.D. Pulmonary Medicine and Pediatric Psychiatry/Psychology, Northeast Ohio Medical University and Akron Children’s Hospital, Akron, OH, USA
Joseph Kaleyias, M.D., Ph.D. Department of Paediatrics, Colchester University Hospital NHS Foundation Trust, Colchester, Essex, UK
Umakanth A. Khatwa, M.D. Division of Respiratory Diseases, Department of Medicine, Boston Children’s Hospital, Boston, MA, USA
Sanjeev V. Kothare, M.D. Department of Neurology, NYU Comprehensive Sleep Disorders Center, NYU Langone Medical Center and NYU School of Medicine, New York, NY, USA
Jyoti Krishna, M.D. Pulmonary Medicine, North East Ohio Medical University and Akron Children’s Hospital, Akron, OH, USA
Mandana Mahmoudi, M.D. Pulmonary, Critical Care, and Sleep Medicine, New York University Langone Medical Center, New York, NY, USA
Anne Marie Morse, M.D. Division of Sleep Medicine— Neurology, Montefiore Medical Center, Bronx, NY, USA
Mariya Narizhnaya, M.A. Department of Neurology, Weill Cornell Medical College, New York, NY, USA
Ujjwal Ramtekkar, M.D. Division of Psychiatry, Compass Health Network, St. Louis, Wentzville, MO, USA
Alcibiades J. Rodriguez, M.D. Department of Neurology, New York University Medical School, New York, NY, USA
Rebecca Quattrucci Scott, Ph.D. Department of Neurology, NYU Langone Medical Center, NYU Comprehensive Epilepsy Center-Sleep Center, New York, NY, USA
Kanwaljit Singh, M.D. Department of Pediatrics (Neurology), University of Massachusetts Medical School, Worcester, MA, USA
Tushar P. Thakre, M.D., Ph.D. VCU Center for Sleep Medicine, Virginia Commonwealth University, Richmond, VA, USA
Introduction
Sanjeev V. Kothare and Rebecca Quattrucci Scott
It is a known fact that sleep is vital for physical, cognitive and emotional health and well-being [1]. Over the past decade a myriad of studies have linked insufficient or poor quality sleep to a number of negative outcomes, including obesity [2, 3], diabetes [4, 5], cardiovascular disease [5], Alzheimer’s disease [6], cognitive impairment [6], lapses in memory and attention [7], impaired performance [8, 9], sleepiness [8, 9], tiredness [8, 9], and increased depression and anxiety [10, 11]. The Center for Disease Control recently stated that insufficient sleep is a public health epidemic [12]. And yet millions of people still do not get enough sleep. This is especially true among adolescences.
The National Sleep Foundation recommends that teenagers need 8–10 h of sleep a night for optimal function; however, research suggests that <15–20 % of adolescents get the recommended amount on school nights [13]. Lifestyle/behavioral/ environmental factors, such as homework, part-time jobs, extracurricular and social activities, and excessive screen time, contribute to the growing sleep debt in this age group [13]. Additionally, adolescents have a natural biological shift toward later bedtimes and wake times, adding insult to injury.
S.V. Kothare, M.D. (*) • R. Quattrucci Scott, Ph.D.
Department of Neurology, NYU Langone Medical Center and NYU School of Medicine, 223 East 34th Street, New York, NY 10016, USA e-mail: sanjeev.kothare@nyumc.org; rebecca.scott@nyumc.org
S.V. Kothare, R. Quattrucci Scott (eds.), Sleep Disorders in Adolescents, DOI 10.1007/978-3-319-41742-4_1
S.V. Kothare and R. Quattrucci Scott
As with adults, inadequate sleep in teenagers has significant and widespread ramifications across several domains. For example:
Physiological: Sleep deprived teens are at increased risk for obesity, diabetes, and hypertension; have an increased incidence of headaches, gastrointestinal disturbance, backaches, and muscle tension; report lower energy and greater fatigue; and are less likely to engage in health-related behaviors, such as taking responsibility for their health, adopting a healthy diet, implementing regular exercise, and practicing stress management [14].
Cognitive/academic performance: Sleep deprivation in teens is associated with cognitive impairment; difficulties with focus, memory, and attention; impaired decision-making; decreased reaction time; impaired academic performance; and decreased creativity [14, 15].
Psychological/emotional: Sleep deprivation in teens is associated with increased alcohol and drug use, aggression, irritability, risky behaviors, anxiety, depression, suicidal thoughts and behaviors, poor impulse control and social skills, and low motivation [14–17].
In addition to the above biopsychosocial factors contributing to insufficient sleep in this population, there are a number of treatable sleep disorders that could also be contributing. This casebook on adolescent sleep medicine is designed to present a comprehensive review of common, yet sometimes overlooked, sleep problems in adolescents. Each chapter addresses a unique, though not uncommon, sleep disorder in teenagers through illustrative cases, relevant literature, and pearls of wisdom for the practicing sleep specialist or any other practitioner involved in the care of adolescents.
In Chap. 2, four detailed and distinct cases of Delayed SleepWake Phase Disorder (DSWPD), a circadian rhythm disorder that often gives the appearance of sleep-onset insomnia but that is, more accurately, a delay in the ability to fall asleep at conventional times, are presented. Among disorders of circadian rhythm, DSWPD is common in adolescents and young adults, a population that already has a natural endogenous shift towards later bedtimes. Genetic, environmental, social, and behavioral factors that can contribute to the development and perpetuation of this disorder are discussed at
length. Comprehensive evaluation and treatment plans, including the use of sleep diaries, actigraphy, light therapy, melatonin, and a graphic display of phase shifting principles, are also provided.
Chap. 3 depicts three cases of restless legs syndrome (RLS), an often under-recognized neurologic sensorimotor disorder, affecting approximately 2 % of male and female adolescents. RLS is characterized by an urge to move the legs, usually associated with leg discomfort. The symptoms occur at rest, are relieved by movement, and are most severe in the evening and at night. Common mimics of RLS are described in detail, as are non-pharmacological and pharmacological approaches to management.
In Chap. 4, three cases of adolescent obstructive sleep apnea (OSA) are reviewed. While OSA has historically been considered a disorder most common among overweight adult males, adolescent sleep apnea has become increasingly more common with the rise in obesity rates. Management of these patients is less straightforward than management in younger children or older adults, as there are substantial rates of treatment failure following adenotonsillectomy, which remains the first-line treatment approach. Second-line therapy for residual OSA is continuous positive airway pressure therapy (CPAP), which can be poorly tolerated in this age-group. This chapter provides an in-depth discussion of the physical exam findings, comorbid medical conditions, and nighttime and daytime features associated with this condition, as well as factors associated with a high risk of residual OSA in adolescents. Strategies to troubleshoot commonly encountered problems with CPAP management are also presented as is drug-induced sleep endoscopy (DISE), a tool that can help identify common sites of airway obstruction in this population and guide surgical planning.
Chap. 5 presents four cases of Narcolepsy, a chronic neurologic disorder that causes a dysregulation of the sleep-wake cycle, each with unique features and points of consideration regarding associated symptoms, evaluation, diagnosis, and management. Additionally, this chapter includes tables of common descriptors of cataplexy, a distinct associated symptom of narcolepsy; questions that may be useful in identifying these symptoms; suggestions to help patients maintain a safe sleep environment; and a comprehensive list of medications used to treat this disorder.
S.V. Kothare and R. Quattrucci Scott
Chap. 6 reviews three cases of either non-REM or REM Parasomnias, which are undesirable or unpleasant physical events or experiences that occur during entry into sleep, within sleep, or during arousal from deep sleep. They encompass abnormal complex movements, behaviors, emotions, perceptions, dreams, and autonomic activity emanating from or associated with sleep and that can result in sleep disruption, adverse health effects, untoward psychosocial effects, and/or resulting injuries. Characteristic features of various manifestations of parasomnias, features to consider for the differential diagnosis between parasomnias and nocturnal frontal lobe epilepsy, and a schematic regarding evaluation and treatment are also presented.
In Chap. 7, two clinical cases demonstrate the complex relationship between sleep and emotional regulation in adolescents. These cases provide a detailed review of clinical features of major depression and PTSD along with the differential diagnosis as it pertains to sleep disturbances that are typically seen in youth with early onset depression and PTSD. Numerous studies have reported subjective sleep symptoms in adolescents with depressive disorders and anxiety and there have been several studies to identify the objective markers of depression using sleep measures such as polysomnography and actigraphy. This chapter also provides a review of the literature on the phenomenology of sleep disorders in adolescents with depressive disorder and PTSD and presents research-based and clinically guided recommendations for the evaluation and treatment of sleep disorders.
In Chap. 8, three cases exemplify how sleep disorders can commonly coexist with medical disorders. As the human body is not an isolated entity, sleep disturbances affect control and outcome of different medical disorders and medical disorders play an important role in sleep quality and quantity. This chapter presents three very common medical disorders (asthma, hypothyroidism, and migraine) in children and adolescents that may affect sleep and vice versa.
Chap. 9 consists of comprehensive sleep and cognitive evaluations over a 21-month period of a 12-year-old male who was diagnosed with and treated for a brain tumor (craniopharyngioma) and for related complications that included several endocrinopathies and excessive daytime sleepiness (EDS) with a resulting diagnosis of narcolepsy without cataplexy. The clinical outcomes
following a pharmacological intervention for his narcolepsy are presented. Adolescents who have or have been treated for a brain tumor are vulnerable to sleep concerns, including excessive daytime sleepiness. This case highlights the importance of objectively evaluating sleepiness in adolescents with brain tumors (particularly those involving the hypothalamus), the importance of closely monitoring cognitive and academic performance, and the important role of medication management in impacting daytime functioning in this vulnerable population.
Chap. 10 reviews a case of a 19-year-old female college student who complains of Insomnia, characterized by trouble falling asleep and frequent awakenings throughout the night, daytime tiredness, and trouble concentrating in class. She participated in six weekly cognitive behavioral therapy sessions for insomnia, which included nightly monitoring through a sleep diary, cognitive restructuring, sleep restriction, stimulus control, and relaxation techniques. Each of these approaches is discussed in detail.
Chap. 11 introduces three cases of Epilepsy, a neurological condition not uncommon in adolescents. Given that sleep disorders are common in patients with epilepsy, there is an increased likelihood that a sleep specialist may be involved in overall evaluation, management, and care of patients with these comorbid conditions. The most commonly described sleep disorder in patients with epilepsy is obstructive sleep apnea, though forms of insomnia and hypersomnia tend to be common as well. This chapter presents infrequently described but important associations and coexistence of sleep disorders with common epilepsy syndromes.
Chap. 12 presents three case studies discussing the spectrum of sleep disorders associated with Traumatic Brain Injury (TBI), followed by a general discussion of the spectrum of sleep disorders in TBI, proposed mechanisms, and clinical approach to diagnosis and management of these disorders. Treatment considerations for sleep disorders in patients following traumatic brain injury are also presented in detail. The prevalence, recognition, and awareness of concussion have been on the rise in recent years in teenagers participating in impact sports. What is under-recognized is the extent of sleep problems seen in this population. Issues around forced bed rest have also been addressed in this chapter.
S.V. Kothare and R. Quattrucci Scott
References
1. Brand S, Kirov R. Sleep and its importance in adolescence and in common adolescent somatic and psychiatric conditions. Int J Gen Med. 2011;4: 425–42.
2. Beccuti G, Pannain S. Sleep and obesity. Curr Opin Clin Nutr Metab Care. 2011;14(4):402–12.
3. Gupta N, et al. Is obesity associated with poor quality sleep in adolescents? Am J Hum Biol. 2002;14(6):762–8.
4. Lou P, et al. Relation of sleep quality and sleep duration to type 2 diabetes: a population-based cross-sectional. BMJ Open. 2012;2, e000956.
5. Buxton O, Marcelli E. Short and long sleep are positively associated with obesity, diabetes, hypertension, and cardiovascular disease among adults in the United States. Soc Sci Med. 2010;71(5):1027–36.
6. McEwen B. Sleep deprivation as a neurobiologic and physiologic stressor: allostasis and allostatic load. Metabolism. 2006;55(2):S20–3.
8. Basner M, et al. Sleep deprivation and neurobehavioral dynamics. Curr Opin Neurobiol. 2013;23(5):854–63.
9. Belenky G, et al. Patterns of performance degradation and restoration during sleep restriction and subsequent recovery: a sleep dose-response study. J Sleep Res. 2003;12:1–12.
10. Shochat T, et al. Functional consequences of inadequate sleep in adolescents: a systematic review. Sleep Med Rev. 2014;18(1):75–87.
11. Sarchiapone M, et al. Hours of sleep in adolescents and its association with anxiety, emotional concerns, and suicidal ideation. Sleep Med. 2014;15(2):248–54.
12. National Centers for Disease Control and Prevention. Insufficient sleep is a public health problem. Updated September/2015. http://www.cdc.gov/ features/dssleep/
13. National Sleep Foundation. https://sleepfoundation.org/sleep-topics/teensand-sleep.
14. Keyes K, et al. The great sleep recession: changes in sleep duration among US adolescents, 1991–2012. Pediatrics. 2015;135(3):460–8.
15. Wolfson AR, Carskadon MA. Understanding adolescents’ sleep patterns and school performance: a critical appraisal. Sleep Med Rev. 2003;7(6): 491–506.
16. Smaldone A, et al. Sleepless in America: inadequate sleep and relationships to health and well-being of our nation’s children. Pediatrics. 2007;119 Suppl 1:S29–37.
17. Dahl R, Lewin D. Pathways to adolescent health sleep regulation and behavior. J Adolesc Health. 2002;31(6):S175–84.
Delayed Sleep Phase Syndrome
Sasha D. Jaquez, Tushar P. Thakre, and Jyoti Krishna
Abbreviations
AASM American Academy of Sleep Medicine
ADHD Attention-deficit/hyperactivity disorder
CBTmin Core body temperature minimum
CR Circadian rhythm
CRSWD Circadian rhythm sleep-wake disorders
DLMO Dim light melatonin onset
DLMOff Dim light melatonin offset
DSWPD Delayed sleep-wake phase disorder
S.D. Jaquez, Ph.D.
Pulmonary Medicine and Pediatric Psychiatry/Psychology, Northeast Ohio Medical University and Akron Children’s Hospital, 300 Locust Street, Akron, OH 44302, USA e-mail: sdjaquez@seton.org
T.P. Thakre, M.D., Ph.D.
VCU Center for Sleep Medicine, Virginia Commonwealth University, 2529 Professional Road, Richmond, VA 23235, USA e-mail: tushar.thakre@vcuhealth.org
J. Krishna, M.D. ( )
Pulmonary Medicine, North East Ohio Medical University and Akron Children’s Hospital, 215 W. Bowery Street, Akron, OH 44308, USA e-mail: jkrishna@chmca.org
S.V. Kothare, R. Quattrucci Scott (eds.), Sleep Disorders in Adolescents, DOI 10.1007/978-3-319-41742-4_2
S.D. Jaquez et al.
EDS Excessive daytime sleepiness
H Hour
LD Light-dark
PRC Phase response curve
PSG Polysomnography
Case Presentation 1
Hannah is a 17-year-old female presenting to the sleep clinic with complaints of difficulty initiating sleep and excessive daytime sleepiness (EDS). Hannah and her mother recall that Hannah has always been a “bad sleeper” but that the problem has gradually been worsening, particularly over the past several years. No concerns of frequent leg movements, nightmares, sleep terrors, respiratory pauses, snoring, or nighttime awakenings are reported. She has previous diagnoses of depression and attention-deficit/hyperactivity disorder (ADHD). Her ADHD is managed with medication and her depression is managed with a combination of medication and cognitive-behavioral therapy. Both are well controlled at the time of the appointment.
Hannah is a junior at a local high school and reports a gradual decline in grades. She states she falls asleep multiple times a week at school and often will miss her morning classes due to lack of alertness after waking. Hannah reports an average bedtime of 10:00 pm with an estimated sleep onset between 2:00 and 3:00 am. She sets an alarm to wake around 5:30 am for school, but hits the snooze button repeatedly until around 6:50 am, and reports still being sleepy and having difficulty getting out of bed. She admits to occasionally taking naps after school. On weekends, Hannah states she goes to bed around 2:00–2:30 am, initiates sleep around 3:00 am, and wakes between 11:00 am and 12:00 pm. She reports some improvement in her symptoms of EDS during the weekend. However, during longer breaks from school (e.g., winter, summer) she notes significant improvements in her symptoms of EDS when she is able to consistently delay her sleep schedule. Nothing notable is found on her physical exam. Specifically, there is no tonsillomegaly or obesity. Mood and interactions appear unremarkable.
2 Delayed Sleep Phase Syndrome
Discussion
In the patient above, a thorough sleep history and sleep logs (see Fig. 2.1) would be needed to properly diagnose her sleep concerns. Lack of snoring and leg symptoms as well as a normal physical examination make the diagnosis of sleep-related breathing or movement disorder unlikely to explain her presentation. Nor is she likely to have primary insomnia or hypersomnia disorder given her lack of symptoms on longer breaks from her school when she is able to consistently delay her sleep schedule. Based on her sleep logs, it is evident that the diagnosis that best fits Hannah is DSWPD.
The International Classification of Sleep Disorders, Third Edition (ICSD-3), lists DSWPD (formerly known as Delayed Sleep Phase Syndrome) under the broad category of Circadian Rhythm Sleep-Wake Disorders (CRSWD) [1]. In DSWPD, the problem lies
Fig. 2.1 Sample sleep logs. Sleep logs showing sleep-wake routines for Hannah. Note the feeling of daytime tiredness on school days ceases during winter break when a liberal sleep schedule is allowed
S.D. Jaquez et al.
with an inability to initiate sleep at a socially acceptable time at night. In affected individuals, the habitual sleep-wake timing is usually delayed by more than 2 h as compared to the conventional timing, even when an opportunity to sleep is available. This may present very commonly as insomnia of sleep onset, given the appearance of difficulty initiating sleep. Once asleep, an individual with DSWPD usually does not experience difficulty maintaining sleep. As a second component, the individual will report problems waking up at an acceptable time the following day. Typically, this results in delays getting out of bed and trouble coming to full functional alertness upon awakening. This “sleep inertia” is common if the affected individuals have to curtail their sleep to meet social obligations such as going to school on time. However, a key feature of this disorder, assuming no other medical, psychiatric, or sleep-related comorbidities, is that the sleep duration, quality, and subsequent wakeful behavior and function is usually normal if the person does not have any obligations to wake up at a certain time the next day. Taken together, if left to select their own sleep and rise times, the affected person prefers to go to bed and get up significantly later than would be expected for the age and societal norms and report no other sleep-related problems if allowed to keep their favored schedules. Finally, since it is not uncommon for similar changes in sleep-wake behaviors to occur from time to time in normal individuals due to transient social or medical reasons, a firm diagnosis requires that the problem be present for 3 months or longer and that it be substantiated by sleep logs or actigraphy typically spanning a period of a fortnight or more (Fig. 2.2).
DSWPD affects 7 to 16 % of adolescents and young adults [1]. Genetic factors such as polymorphisms in the circadian clock gene hPer3, arylalkylamine N-acetyltransferase, human leukocyte antigen, and Clock have been reported to be associated with DSWPD [2–5]. Some familial aggregation has also been described [6].
Environmental, social, and behavioral factors also play an important role in the development and perpetuation of this disorder. DSWPD is a chronic disorder which may last into the middle and geriatric ages although the prevalence appears to decrease with increasing age [7, 8].
2
Fig. 2.2 Sample actigraphy chart. An actigraphy is a wrist watch-like device with an embedded accelerometer which can graph rest-activity cycles as a surrogate for sleep-wake. In the graphic, the clock hours are on the top (00:00 denotes midnight) and days of the week are on the vertical axis. Dark vertical lines in each row denote wrist activity implying wakefulness. This data is from another patient seen by the authors who exhibited late bedtime (red line) and rise times (blue line) except on 3 days when the teen did make it to school on time!
Pitfalls
• DSWPD is a relatively common disorder that is frequently missed in the primary care setting.
• DSWPD can be difficult to diagnose during the academic school year given societal obligations to rise early.
Learning Points
• If excessive daytime sleepiness is a chief compliant, sleep logs are a important diagnostic tool (actigraphy is useful if available).
• An adolescent with DSWPD will not experience difficulties initiating sleep or excessive daytime sleepiness if allowed to sleep and wake based on their personal circadian rhythm.
• Once asleep, adolescents with DSWPD generally do not experience difficulties maintaining sleep.
S.D. Jaquez et al.
Case Presentation 2
Andrew is a laconic 15-year-old male who presents with his mother for an initial sleep clinic visit with complaints of decreasing academic performance, increased moodiness, behavioral concerns, and an inability to initiate sleep. He denies symptoms of snoring, restless legs, cataplexy, hypnagogic hallucinations, or sleep paralysis.
Past psychiatric evaluation found a lack of motivation and follow-through on recommended therapy. He was also prescribed trazodone to assist with sleep initiation, but Andrew’s mother states it has not been beneficial. His pediatrician also prescribed methylphenidate on a hunch that he was experiencing EDS. This drug caused him to lose weight and feel restless, and the medication was stopped.
When interviewed without his mother, Andrew admits feeling tired in the morning and experiencing difficulty waking for school. He also voices fear that his parents think he is “crazy” or on drugs. Andrew confesses he felt awkward at the psychiatrist’s office when he heard trazodone can cause his penis “to become painful” and he chose to not take the medication. His mother is unaware of this. He denies being sexually active, consuming alcohol or recreational drugs. Andrew states he does drink some caffeine, usually Mountain Dew, in the morning to help him concentrate at school and clear his foggy brain. He does not doze in class but occasionally naps on the bus.
When asked about his sleep habits during school breaks, Andrew confesses that twice a year his family vacations in Hawaii and that he feels fine. While in Hawaii, he is in bed by 10:00 pm, he initiates sleep quickly, and is up before his family and ready to hit the beach. He often teases his family who appear to be experiencing jetlag for the whole week they are on vacation.
His physical examination is unremarkable and a urine drug screen is negative.
A diagnosis of DSWPD is made. The circadian rhythm is explained to Andrew and his mother. Andrew’s interest in biology and science, and validation that he is not “crazy” evoke a flurry of questions. He is eager to try phase advancement with the help of
low-dose melatonin and morning exposure to sunlight. His mother describes his sister’s bedroom as facing East, and it is agreed to have him switch rooms with his sister to allow morning sunlight exposure and use room-darkening shades at night.
Discussion
While several case reports have documented the effectiveness of phase shifting, there have been no controlled trials in adolescents [ 9 ]. Phase advancement is best used when a targeted sleep onset time and the current sleep onset time are less than 3 h apart. Bedtimes and wake-times are gradually moved earlier (by 15 to 30 min a day) until the targeted sleep and wake-times are reached. The starting bedtime is set at a time that the adolescent is consistently able to initiate sleep quickly. The pace (shifting times earlier every 1 day, 2 days, 3 days) and time increments (shifting by 5 min, 15 min, 30 min) is case specific and dependent on patient response to treatment and how quickly the shift in bedtime and wake-times must be accomplished. The longer the delayed sleep phase has been sustained, the more gradual the process might need to be (Table 2.1).
Use of over-the-counter melatonin is also a treatment option in DSWPD. Melatonin is a hormone secreted by the human pineal
Table 2.1 Sample phase advancement schedule
Bedtime Waketime
Current 12:00 AM 9:00 AM
Night 1 11:45 PM 8:45 AM
Night 2 11:30 PM 8:30 AM
Night 3 11:15 PM 8:15 AM
Night 4 11:00 PM 8:00 AM
*Continue to advance both bed/wake times by 15 min each day to goal Goal sleep period: 10:30 PM to 7:30 AM
S.D. Jaquez et al.
Phase
Fig. 2.3 (a) Melatonin phase response curve. The three pulse phase response curve (PRC) to 3 mg of exogenous melatonin generated from subjects freerunning during an ultradian LD cycle. Phase shifts of the DLMO are plotted against the time of administration of the melatonin pill relative to the baseline DLMO (top x-axis). The average baseline DLMO is represented by the upward arrow, the average DLMOff by the downward arrow, and the average assigned baseline sleep times from before the laboratory sessions are enclosed by the vertical lines. Each dot represents the phase shift of an individual subject, calculated by subtracting the phase shift during the placebo session (free-run) from the phase shift during the melatonin session. The curved line illustrates the dual harmonic curve fit. The average clock time axis (bottom x-axis) corresponds to the average baseline sleep times. This PRC can be applied to people with different sleep schedules by moving the average clock time axis until the vertical lines align with the individual’s sleep schedule. Figure and legend reprinted with permission from [12].
2
Delayed Sleep Phase Syndrome
gland in a well-defined 24-h cycle. During the daytime, levels of melatonin are nearly absent and will rise into the evening as one nears their usual bedtime. During the nighttime, levels of melatonin remain relatively constant and will decline as one nears a typical waketime [10]. The American Academy of Sleep Medicine (AASM) has recently released an updated clinical practice guideline for the treatment of intrinsic CRSWDs, which suggests that there is some evidence to support the use of strategically timed melatonin to treat DSWPD in children and adolescents [11]. Several studies have found physiologic doses of oral melatonin (0.3–0.5 mg) administered in afternoon or early evening hours (i.e., 5–7 h before typical sleep onset) seem to be most effective in advancing the sleep phase [9]. However, inappropriately timed melatonin could worsen a phase delay. Melatonin can also have hypnotic effects when given in larger doses just before bedtime. Unfortunately, at this time there is no consensus on the ideal time to take melatonin to achieve a phase advance [9] but research suggests a predictable physiological response [12] (Fig. 2.3a).
Another treatment modality for phase advancement that should be considered is bright light therapy which shows a similar phase response physiology [13] (Fig. 2.3b). By exposing an adolescent to bright light at an appropriate time, the circadian rhythm may be shifted earlier, allowing an adolescent to initiate sleep earlier. However, much like melatonin dosages, there are no currently established guidelines regarding intensity, duration, and time of
Fig. 2.3 (continued) (b) Light phase response curve The PRC to the bright light stimulus using melatonin midpoints as the circadian phase marker. Phase advances (positive values) and delays (negative values) are plotted against the time of the center of the light exposure relative to the melatonin midpoint on the pre-stimulus CR (defined to be 22 h), with the core body temperature minimum assumed to occur 2 h later at 0 h. Data points from circadian phases 6–18 are double plotted. The filled circles represent data from salivary melatonin in subject 1 8K8 from whom blood samples were not acquired. The solid curve is a dual harmonic function fitted through all of the data points. The horizontal dashed line represents the anticipated 0.54 h average delay drift of the pacemaker between the pre- and post-stimulus phase assessments. Figure and legend reprinted with permission from [13]
S.D. Jaquez et al.
light exposure. It should be noted that light exposure at the wrong time could exacerbate a phase delay. In simple cases and sunny places, light exposure may be as easy as eating breakfast in a sunny area or early morning sun exposure. In more complicated cases or cloudy areas, regimented exposure for 20–30 min to bright light (2500 to 10,000 lux) from specially designed light boxes in the early morning (e.g., 6:00 to 8:00 am) may be beneficial [9]. There are a number of commercially available bright light therapy models that can be purchased online.
As with melatonin, knowledge of phase response to light therapy is essential since wrongly timed light can worsen DSWPD. Thus, bright light should also be avoided in the evening or late in the day through the use of dark glasses or dimming of lights. The concept behind strategic avoidance of light is based on the known melatonin-suppressing effect of light. Exposure to light in the evening and before the core body temperature minimum (CBTmin) leads to phase delays [14]. The greater the intensity and duration of light exposure, the greater the effects on the circadian rhythm [15, 16]. Thus, a combination of melatonin and bright light therapy is frequently used for phase advancement (Fig. 2.4).
An alternative treatment option to phase advancement is phase delay (chronotherapy) which is typically used in more severe cases of DSWPD, when the shift needed is greater than 3 h (Table 2.2). Chronotherapy involves delaying bedtime and waketime by 2–3 h every 1–2 days based on the fact that for most people it is often easier to go to bed and initiate sleep later than it is to initiate sleep earlier, allowing for larger shifts to occur. Because shifts in bedtime are larger during chronotherapy, the circadian rhythm can be reset quickly. As a corollary, this is best done during school breaks [17]. Research has found that chronotherapy is highly effective particularly when used in conjunction with bright light therapy [18, 19].
Pitfalls
• Often an erroneous diagnosis of insomnia or hypersomnia is made and sedatives or stimulants are prescribed.
• Substance use must always be considered in the differential diagnosis.
Fig. 2.4 Phase advancement using melatonin and bright light therapy. Normal sleep time is dependent on the circadian clock. In normal persons, endogenous melatonin rises in the evening a little before natural sleep onset and falls to low levels before natural awakening in phase with external time cues such as sunlight (blue curve). In delayed sleep-wake phase disorder this rhythm is shifted to a later clock time such that the person goes to sleep and rises later relative to acceptable social norms (red curve). Therapy with low-dose exogenous melatonin early in the evening (blue arrow) and/or bright light in the morning (red arrow) has been used to shift the circadian phase towards normal (phase advancement)
Current 4:00 AM 12:00 PM Day 1 7:00 AM 3:00 PM Day 2 10:00 AM 6:00 PM Day 3 1:00 PM 9:00 PM Day 4 4:00 PM 12:00 AM
*Continue to delay both bed/wake times for 3 h nightly to goal Goal sleep period: 10:00 PM to 6:00 AM
S.D. Jaquez et al.
Learning Points
• Westward travel may be transiently favorable for patients with DSWPD, but DSWPD would “catch up” after a few days.
• Melatonin and bright light therapy are often used in conjunction to help with phase advancement.
• High levels of motivation and consistency are necessary for successful phase advancement, and a sleep psychologist may be beneficial in increasing motivation for behavior change.
• Once a circadian rhythm has been shifted, the shift can be maintained by the use of judiciously timed evening melatonin and morning bright light therapy.
Case Presentation 3
Carmen is an 18-year-old female presenting to the sleep clinic with her mother with complaints of difficulties initiating sleep. Being an avid member of her high school marching band and recently being voted drum major, Carmen must be at school by 6:30 am each day. She reports that she goes to bed each night at 10:00 pm, but is unable to fall asleep until around midnight or 1:00 am. Her mother states she has removed all electronics from Carmen’s room and charges Carmen’s cell phone in her room each night to ensure she is not texting friends at night. Carmen reports frustration associated with being unable to sleep at night and feeling tired in the morning. Although Carmen denies actually taking naps, she states she feels like she could fall asleep at any point during the day if she tried. When asked if she drinks caffeine, Carmen laughs and states, “all day long.” She admits to one cup of coffee while getting ready for school in the morning. Between band and her next class, Carmen and her friends often hang out at a local coffee shop where she drinks another cup of coffee. Carmen also has an after school job at a movie theater, where she often drinks an additional two or three cups of caffeine while working. She gets home from work around 9:30 pm. She has a well-defined bedtime routine and works to keep a consistent bedtime on week days and weekends.
Another random document with no related content on Scribd:
QUELQUES BANDITS
Nous sortions de la Renaissance, mon ami Cantarelli et moi. Orso Cantarelli est un Corse d’Ajaccio plus qu’aménagé par dix ans de séjour parisien et aussi répandu dans la politique que dans la littérature ; le succès de l’Adversaire se reflétait dans ses yeux, la solidarité corse atteint à l’intensité et à la force d’une francmaçonnerie, et ce soir-là, tout vibrant encore de la scène finale entre Guitry et Brandes, Orso Cantarelli triomphait dans Emmanuel Arène. J’éprouvai le désir de doucher cet enthousiasme.
— Ah ! ces Corses, lui disais-je en l’installant devant une douzaine de natives, quels admirables conquérants, nés pour l’intrigue et l’aventure, et quels dons de séduction ! Ce sont les derniers conquistadors ou condottieri. Voyez, ce siècle appartient à la Corse : Napoléon a conquis l’Europe et Emmanuel Arène vient de dompter Paris. Et forçant sur l’ironie pour exaspérer le légendaire orgueil de la race : D’abord vous êtes un pays de bandits.
Cantarelli haussa les épaules.
— Vous croyez encore que nous avons gardé le culte des bandits ? Quel littérateur vous faites ! Le succès d’Arène vous gêne, il vous gênerait échu à n’importe qui, mais vraiment vous avez perdu votre temps, les deux mois passés, cet été en Corse, et vous croyez encore à notre enthousiasme pour ces malheureux proscrits. C’est une pitié et un bluff. Écoutez-moi, je suis bon prince :
« Nos bandits ! Vous avez, comme tous les continentaux, donné dans le piège du décor. Les bandits ! C’est le cadre de montagnes et de forêts qui les idéalise, la distance aussi, car ils sont si loin de vous par la race et les habitudes ! La plupart enfin bénéficient à vos yeux du recul du temps. Morts ou retirés dans les petits villages du cœur de la Corse, ils vous apparaissent, dans les récits des paysans, comme des héros de la légende ; ce sont les princes lointains du maquis. Si l’on vous en montre un patriarche comme Antoine Bellacoscia, nimbé de cheveux blancs, de petits-enfants et de souvenirs, et, grangrené de romantisme comme vous l’êtes, vous le prenez pour un personnage de la Bible. » Et Orso Cantarelli m’enveloppait de la raillerie de ses yeux clairs ; puis, tout en tirant une bouffée de fumée d’un gros cigare de son pays :
« Il faut donc en découdre de vos enthousiasmes, cher ami, et surtout ne pas propager cette opinion, que nous avons tous l’admiration de nos bandits. C’est avec ces histoires-là que vous nous faites la réputation de sauvages, et notre île finit par passer pour un repaire. Je sais bien que ce banditisme avéré nous vaut, l’hiver, la clientèle d’Allemandes sentimentales et de vieilles misses anglaises, mais croyez que nous préférerions de beaucoup des hiverneurs français ; mais tous se cantonnent dans la Riviera. Hors Nice, Cannes et Monte-Carlo, pas de salut pour un Parisien ! Mais revenons à nos bandits, quelques-uns sont de véritables sacripants ; je vous en fais juge :
« En 1889, un nommé Rochini gagne le maquis et le tient pendant quinze ans, terrorisant tout le pays, de Propriano à Sartène ; savez-vous ce qu’avait fait Rochini ? Amoureux d’une paysanne de son village et repoussé par elle (la fille avait un fiancé) Rochini déclarait à la malheureuse qu’il les tuerait, elle et l’homme de son choix, si elle ne consentait pas à le suivre et à l’épouser. La fille, en vraie Corse qui n’a qu’une parole, riait au nez de Rochini. Celui-ci allait l’attendre à la fontaine — la fontaine où tout le village corse se rencontre, s’aborde et s’entretient — s’arrangeait pour l’y trouver seule, la mettait encore une fois en demeure de choisir entre lui et son fiancé et, sur son refus, l’étourdissait d’un coup de crosse
de fusil et lui coupait les seins. Deux jours après, le fiancé de la misérable fille recevait deux balles dans la tête. Un Apache de Belleville n’eût pas fait mieux. Là-dessus Rochini prenait le maquis et le tenait pendant quinze ans. Voilà ! Ne trouvez-vous pas un tel personnage bien intéressant ?
« D’ailleurs il ne faut pas croire que le village et la montagne tiennent en grande estime leurs bandits. Ils les subissent, terrorisés par les représailles toujours menaçantes de ces « outlaws ». Le paysan corse déteste le gendarme, mais a encore plus peur du bandit. Une fois qu’il a gagné le maquis, le bandit s’érige de luimême en espèce de persona sacra. En même temps qu’il s’arroge le droit de tirer au jugé et au visé sur tout porteur d’uniforme, il prélève la dîme sur le paysan, il s’installe à son foyer, s’assied à sa table, réclame le souper et le gîte et, quelquefois, la femme de son hôte. Avec cela, horriblement méfiant (car ses méfaits ont mis sa tête à prix et dans ce pays pauvre, la prime toujours assez forte peut tenter les consciences) le bandit, toujours sur l’œil, craint l’embuscade, la surprise et la trahison ; il entre chez le paysan en le mettant en joue et exige, à l’heure des repas, que son hôte goûte avant lui de tous les plats. Cette complicité, supportée comme un joug, amène fatalement de brusques révoltes ; en tuant ou en livrant le bandit, le paysan alors se venge des vexations subies, et c’est la mort de Feretti, le bandit de Propriano.
« Poursuivi par les gendarmes, il s’était réfugié chez un sien parent, lequel habitait une masure assez isolée dans la montagne. Il s’y était installé comme chez lui, y commandait en maître, mettant la main au plat et même aux corsages des filles. Il avait fait de celle de son hôte, sa maîtresse, le père, dompté par la terreur, n’osait rien contre le mécréant. Feretti plein d’une juste méfiance pour l’homme qu’il terrorisait, lui faisait manger, avant et devant lui, de tous les plats qui lui étaient servis. Le paysan eut une idée géniale : il trouva le moyen d’introduire de la strychnine dans des figues fraîches, il en avait délicatement coupé la queue. Les fruits empoisonnés furent mêlés à d’autres, intacts : « Mange », faisait Peretti à son parent. Le paysan s’exécutait. Il reconnaissait les figues. Rassuré, le bandit
puisait à l’assiette. A la quatrième figue il tombait foudroyé ; le paysan s’était délivré de son oppresseur.
« Parfois, c’est l’appât du gain qui décide de la mort du bandit. La prime a tenté le paysan, et dans ce cas-là, c’est presque toujours un parent du bandit ou un de ses guides qui fait le coup, car le bandit ne marche que précédé ou escorté d’un guide et, parfois, de plusieurs, qui font autour de lui un vrai service d’avant-garde. Ils explorent le pays, s’assurent de la sécurité du village où le proscrit doit passer, préparent son gîte et favorisent sa fuite en cas d’alerte. Comme les Chouans de Vendée, ils ont entre eux des signes d’eux seuls connus ; trois pierres posées sur le bord de la route, à l’entrée d’un village, préviennent le bandit de ne pas aller plus loin, le lieu n’est pas sûr pour lui ; telle ou telle entaille dans un tronc de châtaignier veut dire que les gendarmes vont passer par là et qu’il doit bifurquer au plus vite à droite ou à gauche pour ne pas tomber entre leurs mains ; et dans toute la contrée, l’arbre et la roche deviennent complices pour protéger et sauver le bandit… Quand l’homme dont la tête est mise à prix se dérobe, le paysan qu’a tenté la prime s’avise quelquefois d’étranges supercheries ; ce fut le cas d’un des neveux de Jacques Bellacoscia.
« Il rêvait depuis longtemps de gagner la grosse somme. La mort de son terrible oncle pouvait seule la lui fournir ; mais, outre que Jacques Bellacoscia n’était pas facile à surprendre, même par un des siens, ce neveu intéressé redoutait les représailles de la famille. Antoine Bellacoscia n’était pas homme à laisser le meurtre de son frère impuni, et puis, tous les Bonelli auraient pris les armes, c’était du coup tous les Bellacoscia dans le maquis.
« Ce madré neveu se décida pour un bandit moins proche, un bandit qui ne fût pas de la famille.
« Un nommé Capa tenait alors la montagne entre Vivario et Vizzavona, c’était un fin limier qui avait toujours déjoué les marches et les contremarches de la maréchaussée et dont, chargée de méfaits, la tête était chèrement cotée. Le neveu de Bellacoscia se rabattit donc sur Capa, mais Capa n’était pas non plus homme à se laisser approcher et abattre comme un vulgaire gibier. Après trois
mois de poursuites et d’embuscades, le malheureux coureur de prime devait renoncer à tuer le fameux bandit, mais il ne renonçait pas à la somme.
« Dans la légitime appréhension du fusil et des balles de Capa, il se décida à une substitution ; le tout était de se procurer un cadavre et de le fournir à la gendarmerie comme celui d’un bandit. Un malheureux mendiant porteur de saintes images, un vieux pellegrine, comme on les appelle ici, fut guetté et assassiné par le paysan dans un sentier de forêt. La Corse est infestée de ces vieux montreurs de saints, la plupart Italiens de naissance et qui, loqueteux et chenus, s’en vont de village en village faire baiser aux paysans la figure de cuivre ou d’étain repoussé, qu’ils portent religieusement pendue à leur cou. Ceux-là sont sans défense, sans famille aussi, et leur meurtre est facile. Un carrefour de forêt vit le crime. L’homme abattu, l’assassin s’empressait de le défigurer, il lui brûlait avec de la poudre la barbe et le visage. Le cadavre ainsi rendu méconnaissable, le chasseur de prime courait prévenir la gendarmerie, l’amenait sur les lieux, et lui faisait reconnaître le mort.
« — C’est Capa, je l’ai guetté, suivi et puis je l’ai tué ! J’ai bien visé, voyez plutôt, à la tête.
« La maréchaussée mystifiée donnait dans le piège, un procèsverbal constatait la mort du fameux Capa, le meurtrier touchait la prime et vivrait encore heureux de polenta de châtaigne en hiver et de polenta de maïs en été, si Capa, furieux de passer pour mort de son vivant, n’avait réclamé.
« Il écrivit au préfet, au procureur de la République, aux directeurs de journaux même, pour démentir sa mort et bien établir qu’il était en vie ; il remua autour de la supercherie, qui le rayait du nombre des Corses, l’opinion publique et la presse. L’assassin du faux Capa était arrêté, une enquête était ouverte qui prouvait son crime, l’identité du pauvre pellegrine était retrouvée et le Corse amateur de primes passait en Cour d’assises et payait sa substitution de cadavre de sa tête.
« Il fut guillotiné à Bastia,
« L’affaire et la mort du fameux bandit Poli, sa rencontre et ses démêlés avec le préfet d’Ajaccio dans la forêt d’Aïtone, la victoria du préfet arrêtée avec son escorte officielle par Poli et ses guides, et les conditions du bandit imposées à l’officier ministériel couché en joue pendant tout l’entretien, toute cette aventure détachée, on dirait des Brigands d’Offenbach, a défrayé trop récemment l’opinion et la presse pour y revenir. Poli, véritable brigand bien plus que bandit, avait été trouver son oncle Lecca et essayé de le rançonner sous menace de mort.
« Reçu à coups de fusil par Lecca, Poli avait juré de se venger et, à quelque temps de là, en effet, Lecca avait été trouvé tué. Poli avait alors gagné le maquis. Arrêté, puis condamné par la Cour de Bastia, il avait été expédié en Nouvelle-Calédonie. Il était parvenu à s’en échapper, s’était réfugié en Italie et, incarcéré à Rome comme anarchiste, y avait toujours caché son identité et son nom. En Corse, on le croyait mort.
« L’arrestation de ses deux frères, impliqués dans l’assassinat de Lecca et emprisonnés comme complices, le ramenait au pays. En apprenant que ses frères étaient compromis à cause de lui et par lui, Poli, bravant tous les périls, rentrait en Corse. Il y affirmait sa présence par des meurtres, des violences et des rapines, mettait le pays en coupe réglée et de brigandage en brigandage, d’audaces en audaces arrêtait la victoria du préfet et mettait ce dernier en demeure de faire acquitter ses frères, alors sur le banc des Assises de Bastia : « Ils étaient innocents, lui seul était coupable et se faisait gloire de le proclamer. » « Le préfet promettait tout ce qu’exigeait le bandit : les frères de Poli sortirent acquittés des Assises, mais la nouvelle de la rentrée du meurtrier en Corse y avait ramené les fils de Lecca, l’oncle assassiné. Pour venger leur père les trois fils Lecca, l’un employé de chemin de fer sur le continent, l’autre sousofficier en Tunisie et le troisième établi à Bône, en Algérie, obtenaient des congés, se faisaient libres et, rentrés dans l’île, y gagnaient le maquis.
« Ils y organisaient la chasse au bandit. Poursuivi par ses cousins, traqué par les gendarmes, Poli était ramassé un matin en
forêt, mort à son tour. Un de ses guides l’avait empoisonné pour toucher la prime.
« Pour une vendetta corse, en voilà une qui, à mon avis, vaut bien celle de Colomba et pourrait tenter un moderne Mérimée, et Poli a été tué, il y a six mois à peine.
« Les légendaires exploits des deux Bellacoscia deviennent bien pâles dans le recul du temps auprès du sang tiède et fraîchement versé de la querelle Lecca-Poli, et puis Antoine Bellacoscia a bien perdu de son prestige depuis que les autorités de l’île l’ont classé bandit décoratif dans les fêtes officielles ! Au dernier voyage de M. Lockroy en Corse, une administration trop zélée n’a-t-elle pas eu l’idée de camper le vieux Bellacoscia en costume de bandit sur l’affreuse glacière en béton qui déshonore la station de Vizzavona, et de grouper autour de lui une vingtaine de vieux paysans guêtrés de peaux et vêtus de velours noir, toute une figuration de bandits de circonstance qui, à la descente du malheureux Lockroy du train, saluèrent d’une brusque fusillade Son Excellence.
« Fusillade héroïque de la Navarraise presque !!
« M. Carré n’eût pas mieux fait. Couleur locale et cabotinage.
« Le préfet d’alors avait servi des bandits au ministre, les bandits se sont revanchés des préfets dans Poli.
« Un mot de Bellacoscia pour finir, du vieil Antoine Bellacoscia, de celui-là même qu’ont un peu démonétisé les cartolines et les fêtes officielles. Il fleure une odeur sauvage de poudre et de maquis.
« On causait au village du nouvel uniforme des gendarmes, Bellacoscia était présent et, comme on consultait son avis, le vieil homme, clignant de l’œil sur la grenade de cuivre doré, qui met un point brillant au-dessus de la visière du shako d’aujourd’hui : Che bella mira ! se contentait-il de dire ! Quel beau point de mire ! et dans sa voix tremblait comme un regret.
TABLE DES MATIÈRES
*** END OF THE PROJECT GUTENBERG EBOOK HEURES DE CORSE ***
Updated editions will replace the previous one—the old editions will be renamed.
Creating the works from print editions not protected by U.S. copyright law means that no one owns a United States copyright in these works, so the Foundation (and you!) can copy and distribute it in the United States without permission and without paying copyright royalties. Special rules, set forth in the General Terms of Use part of this license, apply to copying and distributing Project Gutenberg™ electronic works to protect the PROJECT GUTENBERG™ concept and trademark. Project Gutenberg is a registered trademark, and may not be used if you charge for an eBook, except by following the terms of the trademark license, including paying royalties for use of the Project Gutenberg trademark. If you do not charge anything for copies of this eBook, complying with the trademark license is very easy. You may use this eBook for nearly any purpose such as creation of derivative works, reports, performances and research. Project Gutenberg eBooks may be modified and printed and given away—you may do practically ANYTHING in the United States with eBooks not protected by U.S. copyright law. Redistribution is subject to the trademark license, especially commercial redistribution.
START: FULL LICENSE
THE FULL PROJECT GUTENBERG LICENSE
PLEASE READ THIS BEFORE YOU DISTRIBUTE OR USE THIS WORK
To protect the Project Gutenberg™ mission of promoting the free distribution of electronic works, by using or distributing this work (or any other work associated in any way with the phrase “Project Gutenberg”), you agree to comply with all the terms of the Full Project Gutenberg™ License available with this file or online at www.gutenberg.org/license.
Section 1. General Terms of Use and Redistributing Project Gutenberg™ electronic works
1.A. By reading or using any part of this Project Gutenberg™ electronic work, you indicate that you have read, understand, agree to and accept all the terms of this license and intellectual property (trademark/copyright) agreement. If you do not agree to abide by all the terms of this agreement, you must cease using and return or destroy all copies of Project Gutenberg™ electronic works in your possession. If you paid a fee for obtaining a copy of or access to a Project Gutenberg™ electronic work and you do not agree to be bound by the terms of this agreement, you may obtain a refund from the person or entity to whom you paid the fee as set forth in paragraph 1.E.8.
1.B. “Project Gutenberg” is a registered trademark. It may only be used on or associated in any way with an electronic work by people who agree to be bound by the terms of this agreement. There are a few things that you can do with most Project Gutenberg™ electronic works even without complying with the full terms of this agreement. See paragraph 1.C below. There are a lot of things you can do with Project Gutenberg™ electronic works if you follow the terms of this agreement and help preserve free future access to Project Gutenberg™ electronic works. See paragraph 1.E below.
1.C. The Project Gutenberg Literary Archive Foundation (“the Foundation” or PGLAF), owns a compilation copyright in the collection of Project Gutenberg™ electronic works. Nearly all the individual works in the collection are in the public domain in the United States. If an individual work is unprotected by copyright law in the United States and you are located in the United States, we do not claim a right to prevent you from copying, distributing, performing, displaying or creating derivative works based on the work as long as all references to Project Gutenberg are removed. Of course, we hope that you will support the Project Gutenberg™ mission of promoting free access to electronic works by freely sharing Project Gutenberg™ works in compliance with the terms of this agreement for keeping the Project Gutenberg™ name associated with the work. You can easily comply with the terms of this agreement by keeping this work in the same format with its attached full Project Gutenberg™ License when you share it without charge with others.
1.D. The copyright laws of the place where you are located also govern what you can do with this work. Copyright laws in most countries are in a constant state of change. If you are outside the United States, check the laws of your country in addition to the terms of this agreement before downloading, copying, displaying, performing, distributing or creating derivative works based on this work or any other Project Gutenberg™ work. The Foundation makes no representations concerning the copyright status of any work in any country other than the United States.
1.E. Unless you have removed all references to Project Gutenberg:
1.E.1. The following sentence, with active links to, or other immediate access to, the full Project Gutenberg™ License must appear prominently whenever any copy of a Project Gutenberg™ work (any work on which the phrase “Project Gutenberg” appears, or with which the phrase “Project Gutenberg” is associated) is accessed, displayed, performed, viewed, copied or distributed:
This eBook is for the use of anyone anywhere in the United States and most other parts of the world at no cost and with almost no restrictions whatsoever. You may copy it, give it away or re-use it under the terms of the Project Gutenberg License included with this eBook or online at www.gutenberg.org. If you are not located in the United States, you will have to check the laws of the country where you are located before using this eBook.
1.E.2. If an individual Project Gutenberg™ electronic work is derived from texts not protected by U.S. copyright law (does not contain a notice indicating that it is posted with permission of the copyright holder), the work can be copied and distributed to anyone in the United States without paying any fees or charges. If you are redistributing or providing access to a work with the phrase “Project Gutenberg” associated with or appearing on the work, you must comply either with the requirements of paragraphs 1.E.1 through 1.E.7 or obtain permission for the use of the work and the Project Gutenberg™ trademark as set forth in paragraphs 1.E.8 or 1.E.9.
1.E.3. If an individual Project Gutenberg™ electronic work is posted with the permission of the copyright holder, your use and distribution must comply with both paragraphs 1.E.1 through 1.E.7 and any additional terms imposed by the copyright holder. Additional terms will be linked to the Project Gutenberg™ License for all works posted with the permission of the copyright holder found at the beginning of this work.
1.E.4. Do not unlink or detach or remove the full Project Gutenberg™ License terms from this work, or any files containing a part of this work or any other work associated with Project Gutenberg™.
1.E.5. Do not copy, display, perform, distribute or redistribute this electronic work, or any part of this electronic work, without prominently displaying the sentence set forth in paragraph 1.E.1 with active links or immediate access to the full terms of the Project Gutenberg™ License.
1.E.6. You may convert to and distribute this work in any binary, compressed, marked up, nonproprietary or proprietary form, including any word processing or hypertext form. However, if you provide access to or distribute copies of a Project Gutenberg™ work in a format other than “Plain Vanilla ASCII” or other format used in the official version posted on the official Project Gutenberg™ website (www.gutenberg.org), you must, at no additional cost, fee or expense to the user, provide a copy, a means of exporting a copy, or a means of obtaining a copy upon request, of the work in its original “Plain Vanilla ASCII” or other form. Any alternate format must include the full Project Gutenberg™ License as specified in paragraph 1.E.1.
1.E.7. Do not charge a fee for access to, viewing, displaying, performing, copying or distributing any Project Gutenberg™ works unless you comply with paragraph 1.E.8 or 1.E.9.
1.E.8. You may charge a reasonable fee for copies of or providing access to or distributing Project Gutenberg™ electronic works provided that:
• You pay a royalty fee of 20% of the gross profits you derive from the use of Project Gutenberg™ works calculated using the method you already use to calculate your applicable taxes. The fee is owed to the owner of the Project Gutenberg™ trademark, but he has agreed to donate royalties under this paragraph to the Project Gutenberg Literary Archive Foundation. Royalty payments must be paid within 60 days following each date on which you prepare (or are legally required to prepare) your periodic tax returns. Royalty payments should be clearly marked as such and sent to the Project Gutenberg Literary Archive Foundation at the address specified in Section 4, “Information about donations to the Project Gutenberg Literary Archive Foundation.”
• You provide a full refund of any money paid by a user who notifies you in writing (or by e-mail) within 30 days of receipt that s/he does not agree to the terms of the full Project Gutenberg™ License. You must require such a user to return or destroy all
copies of the works possessed in a physical medium and discontinue all use of and all access to other copies of Project Gutenberg™ works.
• You provide, in accordance with paragraph 1.F.3, a full refund of any money paid for a work or a replacement copy, if a defect in the electronic work is discovered and reported to you within 90 days of receipt of the work.
• You comply with all other terms of this agreement for free distribution of Project Gutenberg™ works.
1.E.9. If you wish to charge a fee or distribute a Project Gutenberg™ electronic work or group of works on different terms than are set forth in this agreement, you must obtain permission in writing from the Project Gutenberg Literary Archive Foundation, the manager of the Project Gutenberg™ trademark. Contact the Foundation as set forth in Section 3 below.
1.F.
1.F.1. Project Gutenberg volunteers and employees expend considerable effort to identify, do copyright research on, transcribe and proofread works not protected by U.S. copyright law in creating the Project Gutenberg™ collection. Despite these efforts, Project Gutenberg™ electronic works, and the medium on which they may be stored, may contain “Defects,” such as, but not limited to, incomplete, inaccurate or corrupt data, transcription errors, a copyright or other intellectual property infringement, a defective or damaged disk or other medium, a computer virus, or computer codes that damage or cannot be read by your equipment.
1.F.2. LIMITED WARRANTY, DISCLAIMER OF DAMAGES - Except for the “Right of Replacement or Refund” described in paragraph 1.F.3, the Project Gutenberg Literary Archive Foundation, the owner of the Project Gutenberg™ trademark, and any other party distributing a Project Gutenberg™ electronic work under this agreement, disclaim all liability to you for damages, costs and
expenses, including legal fees. YOU AGREE THAT YOU HAVE NO REMEDIES FOR NEGLIGENCE, STRICT LIABILITY, BREACH OF WARRANTY OR BREACH OF CONTRACT EXCEPT THOSE PROVIDED IN PARAGRAPH 1.F.3. YOU AGREE THAT THE FOUNDATION, THE TRADEMARK OWNER, AND ANY DISTRIBUTOR UNDER THIS AGREEMENT WILL NOT BE LIABLE TO YOU FOR ACTUAL, DIRECT, INDIRECT, CONSEQUENTIAL, PUNITIVE OR INCIDENTAL DAMAGES EVEN IF YOU GIVE NOTICE OF THE POSSIBILITY OF SUCH DAMAGE.
1.F.3. LIMITED RIGHT OF REPLACEMENT OR REFUND - If you discover a defect in this electronic work within 90 days of receiving it, you can receive a refund of the money (if any) you paid for it by sending a written explanation to the person you received the work from. If you received the work on a physical medium, you must return the medium with your written explanation. The person or entity that provided you with the defective work may elect to provide a replacement copy in lieu of a refund. If you received the work electronically, the person or entity providing it to you may choose to give you a second opportunity to receive the work electronically in lieu of a refund. If the second copy is also defective, you may demand a refund in writing without further opportunities to fix the problem.
1.F.4. Except for the limited right of replacement or refund set forth in paragraph 1.F.3, this work is provided to you ‘AS-IS’, WITH NO OTHER WARRANTIES OF ANY KIND, EXPRESS OR IMPLIED, INCLUDING BUT NOT LIMITED TO WARRANTIES OF MERCHANTABILITY OR FITNESS FOR ANY PURPOSE.
1.F.5. Some states do not allow disclaimers of certain implied warranties or the exclusion or limitation of certain types of damages. If any disclaimer or limitation set forth in this agreement violates the law of the state applicable to this agreement, the agreement shall be interpreted to make the maximum disclaimer or limitation permitted by the applicable state law. The invalidity or unenforceability of any provision of this agreement shall not void the remaining provisions.
1.F.6. INDEMNITY - You agree to indemnify and hold the Foundation, the trademark owner, any agent or employee of the Foundation, anyone providing copies of Project Gutenberg™ electronic works in accordance with this agreement, and any volunteers associated with the production, promotion and distribution of Project Gutenberg™ electronic works, harmless from all liability, costs and expenses, including legal fees, that arise directly or indirectly from any of the following which you do or cause to occur: (a) distribution of this or any Project Gutenberg™ work, (b) alteration, modification, or additions or deletions to any Project Gutenberg™ work, and (c) any Defect you cause.
Section 2. Information about the Mission of Project Gutenberg™
Project Gutenberg™ is synonymous with the free distribution of electronic works in formats readable by the widest variety of computers including obsolete, old, middle-aged and new computers. It exists because of the efforts of hundreds of volunteers and donations from people in all walks of life.
Volunteers and financial support to provide volunteers with the assistance they need are critical to reaching Project Gutenberg™’s goals and ensuring that the Project Gutenberg™ collection will remain freely available for generations to come. In 2001, the Project Gutenberg Literary Archive Foundation was created to provide a secure and permanent future for Project Gutenberg™ and future generations. To learn more about the Project Gutenberg Literary Archive Foundation and how your efforts and donations can help, see Sections 3 and 4 and the Foundation information page at www.gutenberg.org.
Section 3. Information about the Project Gutenberg Literary Archive Foundation
The Project Gutenberg Literary Archive Foundation is a non-profit 501(c)(3) educational corporation organized under the laws of the state of Mississippi and granted tax exempt status by the Internal Revenue Service. The Foundation’s EIN or federal tax identification number is 64-6221541. Contributions to the Project Gutenberg Literary Archive Foundation are tax deductible to the full extent permitted by U.S. federal laws and your state’s laws.
The Foundation’s business office is located at 809 North 1500 West, Salt Lake City, UT 84116, (801) 596-1887. Email contact links and up to date contact information can be found at the Foundation’s website and official page at www.gutenberg.org/contact
Section 4. Information about Donations to the Project Gutenberg Literary Archive Foundation
Project Gutenberg™ depends upon and cannot survive without widespread public support and donations to carry out its mission of increasing the number of public domain and licensed works that can be freely distributed in machine-readable form accessible by the widest array of equipment including outdated equipment. Many small donations ($1 to $5,000) are particularly important to maintaining tax exempt status with the IRS.
The Foundation is committed to complying with the laws regulating charities and charitable donations in all 50 states of the United States. Compliance requirements are not uniform and it takes a considerable effort, much paperwork and many fees to meet and keep up with these requirements. We do not solicit donations in locations where we have not received written confirmation of compliance. To SEND DONATIONS or determine the status of compliance for any particular state visit www.gutenberg.org/donate.
While we cannot and do not solicit contributions from states where we have not met the solicitation requirements, we know of no
prohibition against accepting unsolicited donations from donors in such states who approach us with offers to donate.
International donations are gratefully accepted, but we cannot make any statements concerning tax treatment of donations received from outside the United States. U.S. laws alone swamp our small staff.
Please check the Project Gutenberg web pages for current donation methods and addresses. Donations are accepted in a number of other ways including checks, online payments and credit card donations. To donate, please visit: www.gutenberg.org/donate.
Section 5. General Information About Project Gutenberg™ electronic works
Professor Michael S. Hart was the originator of the Project Gutenberg™ concept of a library of electronic works that could be freely shared with anyone. For forty years, he produced and distributed Project Gutenberg™ eBooks with only a loose network of volunteer support.
Project Gutenberg™ eBooks are often created from several printed editions, all of which are confirmed as not protected by copyright in the U.S. unless a copyright notice is included. Thus, we do not necessarily keep eBooks in compliance with any particular paper edition.
Most people start at our website which has the main PG search facility: www.gutenberg.org.
This website includes information about Project Gutenberg™, including how to make donations to the Project Gutenberg Literary Archive Foundation, how to help produce our new eBooks, and how to subscribe to our email newsletter to hear about new eBooks.
