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By: Bruce Alan Perler, M.B.A., M.D.

  • Vice Chair for Clinical Operations and Financial Affairs
  • Professor of Surgery

https://www.hopkinsmedicine.org/profiles/results/directory/profile/0002711/bruce-perler

For your new kidney to menstruation quiz buy on line clomiphene work maria pregnancy purchase 25 mg clomiphene visa, you must take medications every day menopause weight buy cheap clomiphene 25 mg, exactly as taught women's health center lynchburg va cheap 100mg clomiphene mastercard, for as long as the kidney is working, and perhaps for your whole life. The new kidney will be placed low in your right or left lower abdomen, in the front. Unless your doctor feels it is necessary, your diseased kidneys will not be removed. This stent is usually removed 2 weeks after the transplant in a simple cystoscopy procedure by our expert urologists. Once you are strong enough and your vital signs are stable you will be transferred to either 8 West or 8 East, the transplant floors. They are knowledgeable about the transplant medications and will help you thoroughly learn them. They will educate you on the signs and symptoms of infection and rejection and provide you with follow-up instructions. These lines allow us to give you medications, vital fluids, and to draw blood for lab tests without have to stick you repeatedly while you are in the hospital. You and your caregiver will work with members of the Transplant Team while you are in the hospital to learn your medication regimen, and the do’s and don’ts of life after transplant. Because infections are contagious and other patients in the hospital are sick, you will need to wear a mask when you are outside of your room and walking around the hospital floor. To further protect you from possible infections, we ask that you adhere to the following recommendations both here in the hospital and once you are home. Unless otherwise indicated, all visits after your transplant will take place in the th Transplant Surgery clinic at the Shapiro Ambulatory Care Center, 725 Albany Street on the 7 floor. Your Wednesday appointments with transplant surgery and all your nephrology appointments will take place here. You will leave the hospital with a Black Transplant Binder which includes a list of your medications and doses on a Medication Card, a vital signs log to record your vital signs at home, and your Discharge Education information, which, includes all the contact information for the members of your Transplant Team. Your Binder, Medication Card, and vital signs log should be with you at all clinic visits to allow us to review your medications and make any necessary changes and to allow us to review your weight and blood pressure results and to look for subtle changes that may need attention. The blood will be drawn in the lab drawing station t the Shapiro Center, Lower Level, 725 Albany Street. The transplant team and your nephrologist will advise you when to reduce your visits to the lab. It is very important for the transplant team to know where you plan to have your lab tests done once you are home. We will provide you with information about several local Quest Lab drawing sites near your home, if you like, as this lab can always process your blood tests and get us the results the same day. We ask that you have your blood drawn as early in the morning as possible so that we can receive the results the same day. The tests may be done on either an inpatient or outpatient basis, depending on your circumstances. This passing delay in function is usually caused by temporary damage to the kidney, like a bruise that will heal. As a temporary measure, dialysis may be performed to do the job of a sluggish kidney. After removal, another ultrasound may be performed so your doctors can look for recurrence of swelling. This is true after transplantation as well – the normal immune response is to recognize the transplanted organ as foreign and try to destroy (reject) it. To combat this immune response against the transplanted organ, you will need to take immunosuppressive (antirejection) medications. However, as time passes, the amount of immunosuppression that your body needs will decrease. In spite of the immunosuppressive medications, it is possible that you will experience at least one episode of rejection. This most often occurs during the first two weeks after transplantation and almost always within the first three months. An episode of rejection is a period of time where the kidney function is abnormal and requires intervention because the immune system is attacking it. Ninety-five percent of all rejections are cured with temporary increases in immunosuppressive medications. Your doctors will detect it via a change in the kidney function on your lab tests. These treatments may require admission to the hospital and may include intravenous steroids and adjustment of immunosuppression. You will be given higher doses of the immunosuppressive medicines to prevent rejections during this time. The more obvious signs and symptoms of infection include fever, headache, shortness of breath, persistent cough, urinary frequency, urgency or burning, vomiting and diarrhea. Certain lab tests may be elevated and your white blood cell count may be decreased. Herpes Herpes simplex (cold sores) and Herpes zoster (shingles) are two other viral infections that transplant patients may experience. You should contact the transplant team if you think you have been exposed to any person with chicken pox or shingles. If you do develop one of these infections, they are usually not too severe and can be treated on an outpatient basis. You will be given an antifungal medication for the first 2 to 3 months after transplant to prevent oral thrush. You and your family/support person must have a good understanding of the medications. Shortly after your surgery, you will be provided with a personalized medication information sheet called a “Med Card”. Your nurse will begin teaching you about the medications as she/he gives them to you and a pharmacist will teach you about your medications before discharge. You should study the medications in addition to the information included in this manual so that you have a good understanding of them and feel comfortable leaving at discharge. We will slowly reduce the doses and/or number of your immune suppressant medications. You will notice as you read through this section that many of the medications have side effects. Some people do not experience any side effects, some experience just a few, and some may experience many side effects. The side effects of the immunosuppressive medications are generally related to the dose. Many other medications, including over the counter, non-prescription, and herbal medications have interactions which can dangerously change the amount or effect of your immunosuppressive medications. Therefore, you will be taking medications to suppress your immune system for the life of your kidney after your transplant. Therefore, you may receive very powerful immunosuppressive medications while you are in the hospital. Depending on how strong the transplant team expects your immune response to be, you will receive induction therapy with high dose steroids and either Thymoglobulin or Simulect. Tacrolimus (Prograf) Tacrolimus (Prograf) is the main immunosuppressive medication that you will take after your transplant. You will need to update your medication card with the correct dosage whenever the transplant team changes your dose. Mycophenolate mofetil (CellCept) is supplied in 500 mg tablets or 250 mg capsules. Whenever a change is made in the dose by the transplant team, you should update your medication card. In most cases, we will instruct you to stop taking this medication six months after transplant. In most cases we will instruct you to discontinue this medication 2 to 3 months after your transplant.

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It was also the slave capital of the hemisphere—40 percent of Africans came through Charleston women's health hands discount generic clomiphene uk, `the Ellis Island of Black Americans breast cancer 8 cm tumor purchase clomiphene on line. He read himself into literature menstrual incontinence discount clomiphene online mastercard, classical and modern womens health kenosha clomiphene 50mg for sale, and used his prodigious memory to good effect. The journalist Ann Royall was dazzled by what she called his `personal beauty’ and `frank and courteous manners—a model of perfection. He argued that the political war against the South, and slavery, was being fought mainly by powerful lobbies rather than by the democratic wish of the people: he detected, very early on, the threat to American democracy represented by the lobby system, already growing. Thanks to the slaves he and his wife owned, he could pursue a public career, first in Charleston, then in Washington, of completely disinterested public service. The incongruities of this defense were revealed in a striking passage written by an Englishman, G. A traveling companion told him: `In the North every young man has to scramble rapaciously to make his fortune but in the South the handing down of slave plantations from father to son breeds gentlemen who put honor before profit and are always jealous of their own, and are the natural friends of public liberty. He had `the dignity which had belonged to Southern gentlemen from Washington down to the present time. Inside Featherstonehaugh was joined by a white man in chains and a deputy sheriff. The sentence had been passed on him not for murder but for breaking the law against gambling with slaves. So `shut up as I was in a vehicle with such a horrid combination of beings,’ he reflected on the cultural paradoxes of the Old South. The traveler was later entertained by Calhoun in his mansion, Fort Hill; it was `like spending an evening in a gracious Tuscan villa with a Roman senator. After serving Monroe as secretary of war, 1817—25, he won election as vice—president and ran the Senate 1825—32. He favored the War of 1812 because he wanted America to annex Florida and Texas and turn them into slave states. We come here to the key mechanism in the political battle over slavery—the need of the South to extend it, state by state, in order to preserve its share in the power—balance of Congress. The South felt it could not sit still and fight a defensive battle to preserve slavery, because the population of the North was rising much faster and non—slave states were being added all the time. Once the non—slave states controlled not just the House but the Senate too, they could change the Constitution. So the South had to be aggressive, and it was that which eventually led to the Civil War. Article I, stating the three—fifths rule, merely speaks of `free persons’ and `other persons’ (slaves). The South was terrified of a constitutional amendment abolishing this clause which would lead to a mass escape of slaves across its unpoliced borders. The constitutional duty to hand over escaped slaves caused more hatred, anger, and venom on both sides of the slave line than any other issue and was a prime cause of the eventual conflict. And it was fear of losing this constitutional guarantee which determined the tactics of the South in creating new states. In February 1819 Congress faced a demand from Missouri to become a state, as its population had passed the 60,000 mark. The line between them was defined by the southern and western boundaries of Pennsylvania. This line had been determined by a survey conducted by the English astronomers Charles Mason and Jeremiah Dixon in 1763—7, to settle disputes between Pennsylvania and Maryland. So it was known, then and ever after, as the Mason—Dixon Line, the boundary between freedom and slavery, North and South. By 1819 slavery, though still existing in some places in the North, was rapidly being extinguished. But no attempt had yet been made to extend the dividing line into the Louisiana Purchase territory, let alone beyond it, though the area was being rapidly settled. A New York congressman now introduced an anti—slavery measure, which prohibited the introduction of more slaves into the Territory, and automatically freed any slaves born after it 213 became a state on their twenty—fifth birthday. In short, this would have turned Missouri from a slave territory into a free state. The measure passed the House, where the free states already had a majority of 105 to 81, but was rejected by the Senate, where the numbers were equal, 22—22. The Senate went further and agreed to statehood being given to Maine, which had long wanted to be separate from Massachusetts, and which of course was free, provided Missouri were admitted as a slave state, thus keeping the balance in the Senate 26—26. But a further crisis arose when the proslavery majority in Missouri’s constitutional convention insisted it contain a clause prohibiting free blacks and mulattos from settling in the new state. Jefferson wrote to a friend: `This momentous question, like a firebell in the night, awakened and filled me with terror. Would the South now secede over the refusal of the North to agree to the extension of slaveryfi John Quincy Adams, now Secretary of State, thought this the logical and even the moral solution. He noted grimly in his diaries in March 1820 a conversation he had had with his Cabinet colleague, Calhoun (then War Secretary). Calhoun told him that in his state, South Carolina, `domestic labor was confined to the blacks and such was the prejudice that if he, who was the most popular man in the district, were to keep a white servant in his house, his character and reputation would be irretrievably ruined. But when probed to the quick on it they show at the bottom their soul’s pride and vainglory in their condition of masterdom. In Pennsylvania, for instance, special measures were taken to guard against black crime, the governor of the state insisting that blacks had a peculiar propensity to commit assaults, robberies, and burglaries. Both Ohio and Indiana had a legal requirement that, on entering the state, a black must post a bond for $500 as a guarantee of good behavior. In 1821 New York State’s constitutional convention virtually adopted manhood suffrage: anyone who possessed a freehold, paid taxes, had served in the state militia, or had even worked on the state highways could vote—but only if he was `white. Adams was well aware that in Europe the North’s color bars already shocked educated people. When he was minister in St Petersburg, nobles who were quite happy to beat one of their serfs to death with the knout looked down on Americans as uncivilized because of their treatment of blacks—a foretaste of 20th— century anti—Americanism. He noted (August 5, 1812): `After dinner I had a visit from Claud Gabriel the black man in the Emperor [Alexander I]’s service, who went to America last summer 214 with his wife and children, and who is now come back [to St Petersburg] with them. He complained of having been very ill—treated in America, and that he was obliged to lay aside his superb dress and saber, which he had been ordered to wear, but which occasioned people to insult and beat him. Adams did not deny the humbug of much Northern opposition to slavery but brushed it aside and concentrated on the main issue: the absolute need to end it as a lawful institution. It was his view that slavery made Southerners, who had a sense of masterdom that Northerners did not feel, look down on their fellow—Americans, thus undermining the Union at its very heart. He noted: `It is among the evils of slavery that it taints the very sources of moral principle. He dismissed the African colonization schemes which Madison and other Southern moderates favored as contemptible attempts to pass the responsibility for their crimes onto the federal government—they were, he snarled, `ravenous as panthers’ to get Congress to fund their guilt— ridden schemes. He noted sardonically that, in another of his heart—to—hearts over slavery with Calhoun, the latter admitted that, if the Union dissolved over the issue, the South would have to form a political, economic, and military alliance with Great Britain. To him, if the Union could be preserved only at the price of retaining slavery, it were better it should end, especially since in the break—up slavery itself would perish: If slavery be the destined sword in the hands of the destroying angel which is to sever the ties of this union, the same sword will cut asunder the bonds of slavery itself. A dissolution of the Union for the cause of slavery would be followed by a servile war in the slave—holding states, combined with a war between the two severed portions of the Union. With high—placed statesmen talking in the exalted and irreconcilable terms that Adams and (to a lesser extent) Calhoun employed, it is a wonder that the United States did not indeed break up in the 1820s. It was then beyond the physical resources of the North to coerce it, as it did in the 1860s. Moreover, Calhoun was probably right in supposing that Britain, for a variety of reasons, would have come to the rescue of the South, preferring to deal with America as two weak entities, rather than one strong one. The course of American history would thus have been totally different, with both North and South racing each other to the Pacific, recruiting new territory, just as Canada and the United States did on either side of the 49th parallel. However, it must be noted that Adams came from Massachusetts and Calhoun from South Carolina, the two extremist states. Many Americans believed—General Grant was one—that, when Civil War finally came, these two states bore the chief responsibility for it; that, without them, it could have been avoided.

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Consequently menstruation twice a month clomiphene 100 mg sale, educational difficulties continue ritmo pregnancy best buy for clomiphene, and problems may appear in the areas of employment women's health clinic flowood ms order genuine clomiphene, driving and sexual relationships womens health hotline purchase clomiphene 100 mg overnight delivery. In addition, employment can turn over rapidly through dismissal or a persistent need for change unless the person is self-employed or in a position that allows autonomy at work (198, 200) (see Chapter 13. It has been suggested that impulsivity may overeating with resultant increased weight however biological factors have not been ruled out (221). Studies that include culturally diverse groups and Aboriginal and Torres Strait Islander peoples are also lacking, and more research is needed across all age groups. This includes medical, developmental and psychosocial assessment, and elicitation of evidence of impairment in multiple settings, via gathering information from multiple informants. Often these children have been identified by parents or teachers as having problems with behavioural, emotional, learning difficulties or social interactions (235). Comorbid problems such as conduct disorder, anxiety disorder and mood disorder may also be the reason for bringing a child to attention (236). This should address diagnostic evaluation and consider differential diagnosis and/or comorbidities. Specific medical conditions that may involve attentional problems or hyperactivity, and conditions such as pervasive developmental disorder, posttraumatic stress disorder, attachment disorder and bipolar disorder should be considered. Assessment must not be too time-consuming (although must be of sufficient detail to consider the complexity of presentation). It should not require specialised training on diagnostic interviews to which many practitioners may not have access, or be restricted to certain professions (as with some of the “broadband” measures of psychological functioning which can only be accessed by certain professional groups). The former can aid in recognition of comorbidities and differential diagnosis assessment; the latter, in assessing pervasiveness and severity of symptomatology. There are particular challenges for diagnosis in preschool-aged children and in adults. Regular assessment of response to intervention, whether medication or behavioural. This position has been endorsed by other published best practice guidelines (241-244). Such criteria do not encompass the group whose symptoms are predominantly inattention, despite the fact that individuals with these symptoms may experience significant impairments as well as comorbidities. It is recognised that alternative viewpoints exist, especially from sociology and anthropology; however, discussion of these is beyond the scope of this clinically oriented document. The application of the criteria in relation to preschool children and adults is discussed below. It is easy to overlook the most common subtype, the inattentive one and it may not present until secondary school when there are many additional demands on organisational skills and less support from teachers. These measures do not provide a formal cut-off score for diagnosis, but are intended to help the clinician to decide if a full assessment is needed. This could be enhanced by training by specialist colleges and supported by local divisions of general practice. Diagnosis requires evidence of moderate to severe impairment across settings, including home and school. A thorough psychosocial assessment of the child/adolescent and family and medical assessment of the child/adolescent are part of a comprehensive assessment. Symptoms must be severe enough to be “maladaptive and inconsistent with developmental level” and must cause impairment across two or more contexts. Consequently, symptom checklists and rating scales need to be accompanied by questions on: • the age at which each symptom began • duration of symptoms • the severity of the symptom, with examples • the pervasiveness across situations • the impairment associated with that symptom at home, school (or work) and in social situations. It is clear that the six-symptom cut-off needs to be more ageand gender-specific (249). There has also been discussion in the literature Guidelines on Attention Deficit Hyperactivity Disorder 35 (27) on what to do when five criteria for each subgroup are met and no formal diagnosis can be made. Overall, suitable discretion that takes into account the issues of pervasiveness and impairment is advised in making a diagnosis. It is import to check for symptoms and signs of: o hearing or vision impairment o epilepsy o thyroid dysfunction o allergic history o sleep disorders such as sleep apnoea o dysmorphic syndromes o general medical problems. Guidelines on Attention Deficit Hyperactivity Disorder 36 • Any co-existing disorders and risk factors need to be identified and their contribution to the behavioural/symptom profile and level of impairment assessed. Further assessment may be necessary for selected children to exclude other diagnoses: • Comprehensive audiological assessment, including auditory acuity, “speech-innoise” discrimination and auditory memory (250) may be useful in some cases, for example, where there are learning difficulties and teachers concerned about auditory processing (see section 5. Behaviour rating scales can provide useful information from the point of view of multiple informants, in a standardised fashion. The patient’s symptoms are compared with ageand sex-matched normative data to provide a profile of behavioural symptoms. While extensive diagnostic interviews such as the Diagnostic Interview Schedule for Children may be useful in research, the length of such interviews makes them unsuitable for routine clinical settings. All these exist in multiple forms by age and by informant (parent, teacher or child). They can, however, be an appropriate first step in identifying comorbidities and are widely used in Australia to assess the mental health of children attending agencies. The Conners’ series is most widely used in Australia, with versions available for parents, teachers and older children (as well as for adults). It is available for experienced paediatricians through the Australian Council for Educational Research. Issues that should be considered include academic performance, self-esteem, personal distress from the symptoms, social interactions and relationships, behavioural problems, and the development of psychiatric syndromes. The question of how best to measure impairment has been the subject of debate and a number of instruments have been evaluated (see section 5. Assessment of children under 6 years of age should be undertaken especially thoroughly by paediatricians or child psychiatrists with expertise in developmental assessment, paying particular attention to identification of comorbidities and understanding of family dynamics and of cultural/religious diversity. Diagnosis requires evidence of moderate to severe impairment across settings, including home and kinder/preschool. Assessment of children under 6 years of age should include, as a minimum, a screening developmental measure, such as the Ages and Stages Questionnaire, and, when developmental delay is suspected, a formal developmental assessment such as the Griffiths Mental Developmental Scales. For many children, the effects continue well into adolescence and should not be dismissed as temporary or minor problems. Assessment should include consideration of other causes of behavioural dysregulation, including family contextual patterns, anxiety processes and medical problems. As early childhood development is particularly sensitive to the quality of the caregiver–child relationship, as well as Guidelines on Attention Deficit Hyperactivity Disorder 39 the family, childcare, community and cultural contexts, assessment should include a review of a child’s relationship patterns and developmental and attachment history, as well as parental and other contextual stressors and supports (258). That decisions about diagnosis and treatment planning are reached only after multiple appointments, reports from multiple informants and, in many cases, access to a multidisciplinary team are particularly important in this age group. Assessment should be informed by a thorough knowledge of normal development: young children typically have a shorter attention span than older children, impulsivity is more common and self-regulation in social settings is often not developed until around 3. Similarly, disturbed patterns of attachment between a young child and his or her caregiver can be associated with difficulties in affective and behavioural regulation; a review of attachment relationships therefore is relevant in the assessment of any abnormal pattern of behaviour (260). Careful assessment of cognitive/developmental status, as well as emotional health and the child’s social circumstances, is imperative and frequently will need the services of several professionals, preferably working collaboratively. The Ages and Stages screening tool may be useful as a minimum to determine if the child needs to be referred to a speech pathologist and/or other allied health professionals. Management should be guided by a multi-axial approach to assessment, and is likely to include behavioural therapy, family therapy and developmental therapy. In such instances, vocational/intellectual assessments may be useful, not for diagnostic purposes, but to clarify the functional consequences of the diagnosis. Case identification is based on systematic assessment of the symptom profile and exclusion of alternative psychiatric or medical causes. They do not include developmentally appropriate symptoms and thresholds for adults and fail to identify some significantly impaired adults who may benefit from treatment. Furthermore, there may have been differential improvement in some symptoms (particularly Guidelines on Attention Deficit Hyperactivity Disorder 42 hyperactivity/impulsivity) with age. Individuals may have difficulty sustaining attention in a number of settings, particularly when performing demanding cognitive tasks. Hyperactivity manifests physically, but may also have a mental component (having accelerated thoughts or many thoughts simultaneously). None of the scales, however, are sufficient for diagnostic purposes when used alone. Although the reliability and sensitivity of the instruments are good, specificity can be low, which can give rise to false positive or false negative diagnosis. For example, individuals with disorders such as anxiety or depression are also likely to score high on measures of inattention using these instruments.

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Our sleep-wake cycle pregnancy x drugs cheapest clomiphene, which is linked to menstrual emotions cheap clomiphene 50 mg overnight delivery our environment’s natural light-dark cycle women's health center bowling green ohio buy 100mg clomiphene with mastercard, is perhaps the most obvious example of a circadian rhythm women's health clinic quad cities order clomiphene, but we also have daily fluctuations in heart rate, blood pressure, blood sugar, and body temperature. In the brain, the hypothalamus, which lies above the pituitary gland, is a main center of homeostasis. Homeostasis is the tendency to maintain a balance, or optimal level, within a biological system. The clock sets itself with light information received through projections from the retina. The pineal gland, an endocrine structure located inside the brain that releases melatonin, is thought to be involved in the regulation of various biological rhythms and of the immune system during sleep (Hardeland, Pandi-Perumal, & Cardinali, 2006). For instance, some people would say they are morning people, while others would consider themselves to be night owls. These individual differences in circadian patterns of activity are known as a person’s chronotype, and research demonstrates that morning larks and night owls differ with regard to sleep regulation (Taillard, Philip, Coste, Sagaspe, & Bioulac, 2003). Sleep regulation refers to the brain’s control of switching between sleep and wakefulness as well as coordinating this cycle with the outside world. Disruptions of Normal Sleep Whether lark, owl, or somewhere in between, there are situations in which a person’s circadian clock gets out of synchrony with the external environment. Jet lag is a collection of symptoms that results from the mismatch between our internal circadian cycles and our environment. Rotating shift work refers to a work schedule that changes from early to late on a daily or weekly basis. In such instances, the individual’s schedule changes so frequently that it becomes difficult for a normal circadian rhythm to be maintained. This often results in sleeping problems, and it can lead to signs of depression and anxiety. These kinds of schedules are common for individuals working in health care professions and service industries, and they are associated with persistent feelings of exhaustion and agitation that can make someone more prone to making mistakes on the job (Gold et al. Rotating shift work has pervasive effects on the lives and experiences of individuals engaged in that kind of work, which is clearly illustrated in stories reported in a qualitative study that researched the experiences of middle-aged nurses who worked rotating shifts (West, Boughton & Byrnes, 2009). Several of the nurses interviewed commented that their work schedules affected their relationships with their family. One of the nurses said, If you’ve had a partner who does work regular job 9 to 5 office hours. Because the biological clock is driven by light, exposure to bright light during working shifts and dark exposure when not working can help combat insomnia and symptoms of anxiety and depression (Huang, Tsai, Chen, & Hsu, 2013). They can be helpful for people working night shifts or for people affected by seasonal variations in light. Insufficient Sleep When people have difficulty getting sleep due to their work or the demands of day-to-day life, they 116 Chapter 4 | States of Consciousness accumulate a sleep debt. The consequences of sleep debt include decreased levels of alertness and mental efficiency. Interestingly, since the advent of electric light, the amount of sleep that people get has declined. While we certainly welcome the convenience of having the darkness lit up, we also suffer the consequences of reduced amounts of sleep because we are more active during the nighttime hours than our ancestors were. As a result, many of us sleep less than 7–8 hours a night and accrue a sleep debt. While there is tremendous variation in any given individual’s sleep needs, the National Sleep Foundation (n. If you lie down to take a nap and fall asleep very easily, chances are you may have sleep debt. Given that college students are notorious for suffering from significant sleep debt (Hicks, Fernandez, & Pelligrini, 2001; Hicks, Johnson, & Pelligrini, 1992; Miller, Shattuck, & Matsangas, 2010), chances are you and your classmates deal with sleep debt-related issues on a regular basis. As mentioned earlier, lack of sleep can result in decreased mental alertness and cognitive function. These effects can occur as a function of accumulated sleep debt or in response to more acute periods of sleep deprivation. It may surprise you to know that sleep deprivation is associated with obesity, increased blood pressure, increased levels of stress hormones, and reduced immune functioning (Banks & Dinges, 2007). A sleep deprived individual generally will fall asleep more quickly than if she were not sleep deprived. Some sleep-deprived individuals have difficulty staying awake when they stop moving (example sitting and watching television or driving a car). That is why individuals suffering from sleep deprivation can also put themselves and others at risk when they put themselves behind the wheel of a car or work with dangerous machinery. Some research suggests that sleep deprivation affects cognitive and motor function as much as, if not more than, alcohol intoxication (Williamson & Feyer, 2000). While cognitive deficits may be the most obvious, many body systems are negatively impacted by lack of sleep. In fact, a meta-analysis, which is a study that combines the results of many related studies, conducted within the last decade indicates that by the time we are 65 years old, we average fewer than 7 hours of sleep per day (Ohayon, Carskadon, Guilleminault, & Vitiello, 2004). As the amount of time we sleep varies over our lifespan, presumably the sleep debt would adjust accordingly. This section will consider these questions and explore various explanations for why we sleep. You have read that sleep is distinguished by low levels of physical activity and reduced sensory awareness. As discussed by Siegel (2008), a definition of sleep must also include mention of the interplay of the circadian and homeostatic mechanisms that regulate sleep. Homeostatic regulation of sleep is evidenced by sleep rebound following sleep deprivation. Sleep rebound refers to the fact that a sleepdeprived individual will tend to take a shorter time to fall asleep during subsequent opportunities for sleep. The x-axis shows passage of time in seconds; this record includes 30 seconds of data. The location of the sets of electrode that produced each signal is labeled on the y-axis. Other curves show other sleep-related data, such as body temperature, muscle activity, and heartbeat. Sleep-wake cycles seem to be controlled by multiple brain areas acting in conjunction with one another. Melatonin is thought to be involved in the regulation of various biological rhythms and the immune system (Hardeland et al. The pituitary gland also secretes growth hormone, during sleep, which plays a role in physical growth and maturation as well as other metabolic processes (Bartke, Sun, & Longo, 2013). Given the central role that sleep plays in our lives and the number of adverse consequences that have been associated with sleep deprivation, one would think that we would have a clear understanding of why it is that we sleep. Unfortunately, this is not the case; however, several hypotheses have been proposed to explain the function of sleep. Adaptive Function of Sleep One popular hypothesis of sleep incorporates the perspective of evolutionary psychology. Evolutionary psychology is a discipline that studies how universal patterns of behavior and cognitive processes have evolved over time as a result of natural selection. Variations and adaptations in cognition and behavior make individuals more or less successful in reproducing and passing their genes to their offspring. One hypothesis from this perspective might argue that sleep is essential to restore resources that are expended during the day. Just as bears hibernate in the winter when resources are scarce, perhaps people sleep at night to reduce their energy expenditures. While this is an intuitive explanation of sleep, there is little research that supports this explanation. In fact, it has been suggested that there is no reason to think that energetic demands could not be addressed with periods of rest and inactivity (Frank, 2006; Rial et al. Another evolutionary hypothesis of sleep holds that our sleep patterns evolved as an adaptive response to predatory risks, which increase in darkness. Perhaps our ancestors spent extended periods of time asleep to reduce attention to themselves from potential predators. Comparative research indicates, however, that the relationship that exists between predatory risk and sleep is very complex and equivocal.

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