Gary Sánchez has already cooled off considerably since hitting six home runs in his first 13 games with the Padres, leaving them once again in search of a catcher who can actually get on base every now and then. ![]() Bringing in yet another high-priced, multi-year player only makes it that much more difficult for San Diego to find the money to ink Juan Soto to a long-term deal before he hits free agency after next season.īut, hey, if we can clear those two hurdles, this could be a match made in heaven. Perez is making $20 million this season, $20 million in 2024 and $22 million in 2025 with a $13.5 million club option for 2026.Īnd considering the Padres have the third-highest payroll in the majors, that's the part that makes this an outrageous trade idea. Second things second, San Diego has to be willing to spend quite a bit of long-term money to make this happen. Kansas City Royals Receive: RHP Isaiah Loweįirst things first, Perez has to be on board with a trade, as he has 10-and-5 rights and can veto any deal shipping him out of Kansas City. San Diego Padres Receive: C Salvador Perez Kansas City's Salvador Perez Duane Burleson/Getty Images So while it's an overpay for a two-month rental, it's one the Reds could afford to make if they're serious about going for it this year. 320/.384/.603, but he is merely Cincinnati's fifth-best SS/3B. Encarnacion-Strand is rated as a top 100 prospect by MLB.com and has a career triple-slash in the minors of. But things get ugly in a hurry from there.Īdding Stroman would drastically enhance Cincinnati's viability in a postseason series.Īs far as the return for Chicago is concerned, Cincinnati is overflowing with quality prospects on the left side of the infield. ![]() Andrew Abbott has been a godsend since getting called up in early June, and Hunter Greene was having a solid season prior to landing on the IL with hip discomfort 10 days ago. More on that front in a bit.) But we'll split them up with Stroman staying in the NL Central to lend the Cincinnati Reds a hand.īecause while the Reds have been hotter than hot as of late, their starting rotation still leaves a lot to be desired. (The Yankees sure could use both a centerfielder and a starting pitcher right about now. Maybe they could package that duo for a nice haul of prospects. The two biggest ones are Stroman ($21 million player option) and Bellinger ($12 million mutual option), who are all but guaranteed to opt for free agency this offseason. But if they don't gain any more ground on the Reds and Brewers in the next five weeks, there's still a decent chance they'll pack it in and unload some of their expiring assets. Selling is no longer the certainty it seemed to be early in the month. The Cubs have stormed back into the NL Central hunt in recent weeks, winning 11 of their past 14 games. We're coming in hot with what would be an intra-divisional deadline deal for the ages. Trades are presented in no particular order.Ĭhicago's Marcus Stroman Mary DeCicco/MLB Photos via Getty ImagesĬincinnati Reds Receive: RHP Marcus StromanĬhicago Cubs Receive: 1B/3B Christian Encarnacion-Strand It is far from a perfect model of players' trade value-wait until you see what it thinks Max Scherzer is worth-and not all of the trades are necessarily balanced based on its calculations. ![]() Throughout this discussion of hypothetical trades, we will make use of Baseball Trade Values' trade simulator. Rather, these are "outrageous" trades because they're a bit off the wall and for each one, I truly have no idea which fanbase is going to be more livid in the comments. It'd be a waste of everyone's time to suggest that Ohtani might get traded to Oakland, or that a contender is going to gut its farm system for a two-month rental. Though we are labeling these trade proposals as "outrageous," they aren't preposterously irrational or aggressively unbalanced. Is it time for the Mets to give up the ghost and try to recoup some of their exorbitant payroll?Ĭould the highest-rated prospect in all of baseball be on the move? We entered the 2023 MLB season with visions of a Shohei Ohtani trade deadline deal breaking the internet, but what if instead of trading away the 2021 AL MVP, the Angels added the 2022 NL MVP? Louis' Paul Goldschmidt AP Photo/Jeff Roberson
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![]() It’s quite astonishing to think about how much more useful your Switch could be made with homebrew but unfortunately, Nintendo is into blocking hacked Switch consoles from using its online services so thread with caution.Load Core, Load Content, Run. There’s also Joel16’s PayPal link if you want to buy him some well-deserved coffee/beer! Conclusion If you want the latest and greatest NX-Shell, follow this link to get the NRO file. Moving around images after zooming into them is now possible.Animated GIF support so now, you can view your favourite memes on the go!.Now, you can copy files to your Switch wirelessly without switching applications!.Thankfully, Joel16 is regularly updating and working on NX-Shell and he’s released version 1.1 with some exciting features namely: NX-Shell 1.1 now has FTP support so transferring files to your Switch is much easier Unlike VitaShell, NX-Shell is developed and maintained by Joel16 rather than TheFlow and it has a CyanogenMod-esque theme to it. Similar to the PSVita, the Switch has its own go-to *Shell file manager and it is called NX-Shell. Any issues should be reported in the Issues Tab of the GitHub link provided in-line. To grab this updated version, head over to this link for the NRO file to install on your Switch and the updated PC client application. The Switch’s IP is now shown in the app.You need Screen Capture Recorder for this to work.There are occasional crackling noises but they don’t seem to happen too often so you ears won’t start bleeding □.While it’s experimental, a Reddit user posted a video showing how well it works and it seems to be pretty good!.Now, jakibaki and D-VAmpire have worked hard and released version 0.2 with the following updates: ![]() Without a doubt, it achieved a feat by providing PC screen streaming at good framerates (40-60 FPS) but it had one missing feature and that was audio support. Want to play the Assassin’s Creed series on your Switch with sound? Now, you can stream them with sound from your PC! In-Home-Switching is a PC screen streaming solution, similar to Moonlight, for the Nintendo Switch that works well on all graphics cards provided you have a decent CPU and a good local internet connection. ![]() If you still want to try new features, you can grab the latest nightlies as they contain some cool stuff like 1080p support in docked mode which is not available in stable builds of RetroArch! In-Home-Switching gets audio support Currently, it’s not available for download but m4wx, who’s contributing to the Switch port of RetroArch, has stated that a beta may be available around the time when RetroArch 1.7.6 is released. Now, the N64 port is seeing some good progress and this could be checked out by viewing this Reddit thread which also has a video associated with it. This dynarec, which was so important that a bounty was set up for it, was mostly worked on by Gillou and was recently brought over to Android and *nix RetroArch nightlies. Moving to the Switch-side of things, the dynarec being for the Switch is a port of RetroArch’s N64 dynarec for ARM64 devices. This leads to unplayable framerates on systems that aren’t powerful enough but through the aforementioned dynarec, performance can be greatly improved. On the other hand, Interpreters decode one instruction at a time and don’t make use of code caches thus being much slower. After doing this, this decoded code is stored in a code cache so that the same code doesn’t need to be translated again! This is because Dynarecs are much faster than Interpreters since they look at chunks of code, do bulk analysis and decode whole blocks of instructions which they then translates to code that could be used by the host CPU. ![]() While it’s over 20 years old, the Nintendo 64 is still quite challenging to emulate but with a dynarec, performance in your favourite games like Mario Kart 64 could be greatly improved! To pair with the mention above, one of the secrets of the Great Wolf Lodge is that they have off-themed suites. ![]() Check out the video below to see our suite! And comfortably at that! Plus, each room comes with wristband water park access for each registered guest. Even their most basic of rooms can easily fit 6 occupants.īut they offer suites and themed rooms that can accommodate up to 12. One thing that is so amazing about Great Wolf Lodge is that their rooms are HUGE! They have designed their resorts with families in mind. Those tend to have really good grand opening sales! But if you plan early and book in advance, you can find savings of up to 50% off. Relax, rejuvenate and re-energize at Great Wolf Lodge.Every time I’ve looked into booking at the Great Wolf Lodge, I’ve been able to do a simple google search and locate discounts. The Outpost offers signature cocktails and craft beers.The Watering Hole offers soft drinks, iced tea, blended drinks and beer in the water park.Dunkin' Donuts offers coffee and sweet treats.Buckets Incredible Craveables offers a place to grab a bite without leaving the water park.Hungry As A Wolf offers pizza, salads and more.Campfire Kitchen offers breakfast and dinner.DININGĭelight every member of the family with the many delicious dining options available at Great Wolf Lodge. Activities include: Character Appearances, Wake Up with Wiley and Friends, Lunch Time Lineup, PJ Party with the Great Wolf Kids, Story Time, The Forest Friends Show and Great Wolf Kids Activities. No matter what time of the day, there are awesome resort activities to enjoy. Cub Paw Pool geysers and zero-depth entry for tykes and toddlersįamily fun at Great Wolf Lodge also awaits on dry-land! Come explore the Great Wolf Adventure Park that includes an interactive MagiQuest adventure, Oliver's Mining Co., Ten Paw Alley, Northern Lights Arcade, Howler's Peak Ropers Course, Rustic Ridge Climbing Wall, and Creation Station.Chinook Cove basketball and balancing play.Big Foot Pass floating lily pads and cargo nets.Wolf Rider Wipeout indoor surf simulator.We feature a ton of pools, rides, and water slides for everyone in the family. Spend your next family adventure in the 84-degree 75,000 square foot indoor water park. ![]() WATER PARK, ATTRACTIONS & ACTIVITIES Water Park Limited Day Passes are available.Ĭheck Availability of Water Park Day Passes Spend the day at the Great Wolf Water Park. Additional eateries include Hungry as a Wolf, offering handmade pizza and pasta, Buckets Incredible Craveables for delicious poolside fare, and more. Great Wolf Lodge Minnesota features several dining options, including Loose Moose Family Kitchen, serving buffet-style breakfast and dinner daily and Barnwood, a new dining concept featuring small plates and craft cocktails. No Great Wolf Lodge experience would be complete without a trip to Scooops Kids Spa, the perfect place for ice cream-themed manicures and pedicures. A fan-favorite of kids visiting Great Wolf Lodge is MagiQuest, the brand’s exclusive live-action adventure game where guests scour the resort using magic wands to uncover relics and runes needed to defeat dragons and goblins. ![]() The resort features a variety of entertainment offerings and attractions designed specifically for children and families including Great Wolf Adventure Park, a full service family entertainment center featuring the Howlers Peak Ropes Course, Ten Paw mini bowling, Northern Lights Arcade, and a multi-story rock wall. The signature attraction is the 75,000 square-foot indoor water park, which is heated to a comfortable 84 degrees and includes Fort Mackenzie - a multi-level interactive water fort treehouse with a massive tipping water bucket, Crooked Creek lazy river, Slap Tail Pond wave pool, River Canyon Run family raft ride, along with high thrill water slides, water features for toddlers and more. Great Wolf Lodge Minneapolis/Bloomington is a first-class, year-round family destination with 404 guest suites, and numerous attractions and amenities designed to create memorable vacation experiences for the whole family. ![]() ![]() Her last concert in October 2010 at St Dunstan in-the-West was broadcast by TV Shizuoka in Japan. She has also lead the Cosmos Ensemble that gave a world premiere performance of Dai Fujikura’s “Shadow’s Light”. She has played as sub-principal in the Bournemouth Symphony Orchestra and worked with Sir Colin Davis, Tadaaki Otaka, Mark Wigglesworth, Alfred Brendel, Stephen Kovacevich and Freddy Kempf at venues such as the Barbican Hall and the Queen Elizabeth Hall. Having studied further for four years with Yfrah Neaman at the Guildhall School of Music and Drama where she gained a Diploma of Advanced Instrumental Studies, she has given many concerts in the UK and abroad and made several concerto appearances. She was given the honour of a loan of a prestigious Grancino violin from the RAM. ![]() She has participated in many masterclasses including by Ruggiero Ricci, Ida Haendel and Anne-Sophie Mutter and was also a prizewinner of the Anglo-Czechoslovak Music Trust. ![]() During her time at the RAM she was under the guidance of Howard Davis and Zakher Bron and the Amadeus Quartet for chamber music. She came to England in 1988 to study at the Royal Academy of Music where she graduated with First Class Distinction for the violin performance having won two first prizes of violin competitions at the RAM, Alfred J Waley Violin Prize and Winifred Small Solo Violin Prize. She began her studies with Noriko Miki at the age of five and soon went on to take part in masterclasses by Dr Shin-ichi Suzuki (the founder of the Suzuki Method) and William Primrose who praised her talent and to study with a prominent violinist Toshiya Eto of the Toho Gakuen College of Music. She graduated from Harvard Medical School in 1995 and has 28 years of experience. From there, awareness begins to blossom, as we start feeling more connected to ourselves and others.Kazue Yanagida is a Japanese violinist. is an ophthalmologist in New York, NY specializing in ophthalmology (eye disease). I believe change happens when we develop the ability to listen to what we need in the moment, with compassion. I use evidence-based practices and teach practical skills to empower clients. My vibe is gentle and nurturing, which I believe arises naturally from my respect and care for my clients. Therapy with me is validating, grounding, and insightful. Outside of work, I enjoy bike rides, trying new recipes, and building Legos with my family. I also maintain a personal practice of compassion-based mindfulness. I have advanced training in acceptance and commitment therapy. I continue to expand my knowledge and have received specialized training each year to best support clients. I also provided clinical supervision for University of Texas doctoral students for several years. My experiences include an APA-accredited internship at Momentous Institute in Dallas and a postdoctoral fellowship at Austin Child Guidance Center. I have extensive experience working and training in community agencies, schools, university settings, and juvenile services. I completed my doctoral training at The University of Texas at Austin. I also have a passion for working with women of color/global majority, Asian Americans, and children of immigrants. I enjoy supporting clients through transitions, including emerging adulthood and new parenthood. My specialties include ADHD, anxiety, and perfectionism. Julia Hsu, MD is a health care provider primarily located in New York, NY, with another office in Flushing, NY. I am a licensed psychologist practicing in Austin, Texas. Is the 2.0.3 Daemon compatible with the 1.3.15 client? I'm using Windows so I can't update to 2.0.3 for the client as far as I can tell.Įdit: Reverting back to the version you linked has fixed the issue for me. ![]() Jun 23 12:51:28 CoreELEC systemd: Started Deluge daemon. Installation Download the script: wget OR clone using Git git clone Make the script executable: chmod +x installdeluge-1.3.15.sh Run the script as sudo: sudo. Jun 23 12:51:26 CoreELEC systemd: Stopped Deluge daemon. Jun 23 12:51:26 CoreELEC sh: : Can't stop reactor that isn't running. Bugs: No bugs are targeted to this milestone. Blueprints: No blueprints are targeted to this milestone. Assignees: No users assigned to blueprints and bugs. Download RDF metadata Activities Assigned to you: No blueprints or bugs assigned to you. ![]() Jun 23 12:51:26 CoreELEC sh: Traceback (most recent call last): I just migrated Deluge and 750+ torrents to a new Windows 11 Pro 圆4 machine and am currently running Deluge 2.1.1 with LT 2.0.6.0 (previously on Windows Server 2022 圆4 with Deluge 1.3.15) and am running into very frequent crashes with gtk-3-vs16.dll. Drivers cannot target bugs and blueprints to this milestone. Jun 23 12:51:26 CoreELEC sh: Unhandled Error Jun 23 12:51:26 CoreELEC systemd: Stopping Deluge daemon. ![]() Jun 23 11:17:41 CoreELEC systemd: Started Deluge daemon. Code - Logs begin at Fri 13:11:49 CEST, end at Sun 12:52:20 CEST. ![]() It all depends on what you want to say and what “before” refers to. We use different expressions to say “before” in Spanish. Read more about adverbs, prepositions, and conjunctions: Spanish Grammar for Beginners: The 9 Parts of Speech ‘Before’ in Spanish Common prepositions includeĬonjunctions connect nouns, verbs, phrases, and sentences. Prepositions explain the relationships between nouns and other words. ![]() Rápido is an adverb, as it describes the way Juan runs. ![]() These describe verbs, adjectives, and other adverbs. Let’s quickly remind the definitions of these three parts of speech before we go into details: 1. In this case, you have to use either the indicative or the subjunctive mood after them. They also work as conjunctions that join two events. If they’re followed by an infinitive or noun, they function as prepositions. If “after” in Spanish and “before” in Spanish affect the meaning of the entire sentence or of a verb, they will function as an adverb. According to this you’ll translate them as an adverb, preposition, or conjunction. To correctly use “after” and “before” in Spanish, you’ll need to see which part of the sentence they connect with. I also give you a bunch of useful synonyms to throw into casual conversation.Īt the end, you’ll be able to check yourself by taking a multiple-choice quiz.Īre you ready? Let’s tackle another grammar topic on your way to Spanish fluency! Uses of ‘Before’ and ‘After’ in Spanish I provide you with easy-to-remember formulas and many examples. Read this article to learn all about “after” and “before” in Spanish once and for all. In Spanish however, they translate into various expressions with different grammar structures. The words “after” and “before” are pretty straightforward to use in English. Novemby Olga Put Spanish Grammar 0 comments How to Use ‘Before’ and ‘After’ in Spanish Often a shake of the treat bag is all it takes to get her nudging and chirping for a taste! Her first love language is affection.and her second love language is treats and snacks. Lily is very mellow and prefers to lounge around rather than play with toys. She is always curious to know what is going on by looking out windows or greeting whoever is coming home. Once she gets to know her humans, her social and attention-loving side really comes out. She is also a very sweet and gentle fluffball. Lily is an absolute beauty - just look at that adorable, petite face and her gorgeous eyes! If you can foster or adopt this cool Cat, contact us: Adoptions by appointment only ![]() Thunder Cat needs a Foster home so he can put on the weight he lost at the shelter and start living the good life. He is sometimes Dog-like in his behavior, and will follow you around the house to get belly rubs. Thunder Cat loves to be brushed and enjoys watching TV and birds from the window. He’s a bit shy at first, but warms up quickly once he becomes comfortable in the environment. Thunder Cat is a very loving boy and enjoys lots of human interaction. This does not affect his vision and will resolve now that his stitches are out. Thunder Cat was rescued from the shelter and recently had entropion surgery on his eyes that is why he is squinting in the photos. ![]() He has big ears with tufts of hair on the top, a little white under his nose and on his chin, and lots of long white whiskers. Thunder Cat is a striking five year old Brown Tabby Maine Coon mix with a long, shaggy coat, big ruff around his neck, and a large fluffy tail. Open Minecraft and run with Forge to access the mod.Minecraft New Servers Minecraft 1.20 Servers Minecraft 1.19 Servers Minecraft Survival Servers Minecraft Skyblock Servers Minecraft Prison Servers Minecraft Earth Servers Minecraft Pixelmon Servers Minecraft SMP Servers Minecraft Bedrock Servers Minecraft Factions Servers Minecraft Bedwars Servers Minecraft Parkour Servers Minecraft Lifesteal Servers Minecraft CityBuild Servers Minecraft PvP Servers Minecraft Cobblemon Servers Minecraft Creative Servers Minecraft Skywars Servers Minecraft Anarchy Servers Minecraft Towny Servers Minecraft Vanilla Servers Minecraft OPPrison Servers Minecraft Hardcore Servers Minecraft MCMMO Servers Minecraft Mini Games Servers Minecraft Oneblock Servers Minecraft OP Servers Minecraft Crossplay Servers Minecraft Crypto Servers Minecraft Metaverse Servers Minecraft FTB Servers Minecraft Roleplay Servers Minecraft Cracked Servers Minecraft Economy Servers Minecraft Tekkit Servers Minecraft PvE Servers Minecraft Family Friendly Servers Minecraft P2E Servers Minecraft Gens Servers Minecraft Clicker Servers Minecraft 1. Forge for Minecraft 1.18.1 might not be as popular as Minecraft 1.16.5, but there’s definitely lots of amazing mods being released.Open Run and type %appdata%.minecraft\mods\mods and click on run Wiki File Details diet-forge-1.18.2-1.3.2.1.jar By TheIllusiveC4 R 204.38 KB 1.3K 1.18.2 Forge File Name diet-forge-1.18.2-1.3.2.1.jar Supported Versions 1.18.2 Curse Maven Snippet implementation fg.deobf ('curse.Go to CurseForge and download any mod as per your preference.Once that's done, you will see a new mods section available in the game. You will need to start a game then quite, and then close Minecraft to get everything set.So if you have 8 GB memory change it 4 and so on. Best 1.18.1 Minecraft Mods All Categories Minecraft 1.18.1 All Time Advanced Filters 1 2 3 4 5 1 - 25 of 607 Morph Mod (Fabric) Minecraft 1.18.1 Aesthetic Mod 117 86 62.1k 14. You will see "-Xmx2G -XX." under JVM arguments, and you need to change 2G to a different value. ![]()
![]() ![]() If that is the case, you'd still be able to resolve hostnames, as long as you use the DNS servers offered through DHCP. The ISP may now have installed a firewall rule to block very DNS request send to other DNS providers. I would like to allow only one web browser like firefox, chrome or opera. If that DNS server has crashed, it will appear as if every DNS server is now unreachable.īut there will be a difference in the traceroute output you see depending on whether the ISP is hijacking the requests or not.Īnother possibility is that the ISP has been filtering DNS lookups on their own DNS servers, but found customers bypassing this filtering by using other DNS providers. 24 Is it possible to auto block all applications incoming/outgoing internet connection except for example Firefox with default windows firewall I would like to block everything, even including windows update and other software updates. One possibility is that they have always been hijacking DNS requests, and though you think you have been trying different DNS providers, your ISP has always been directing every one of your requests to their own DNS server. Download NetDefender 1. Solo tenemos que dejarlo funcionando en segundo plano y él, de manera silenciosa, se encargará del resto. I am guessing your ISP is filtering the internet "for your protection". TinyWall es un cortafuegos que nos permitirá mantener nuestro equipo seguro sin necesidad de estar sufriendo el asalto de constantes ventanas emergentes avisándonos de cualquier cosa. Ability to disable global shortcuts, as well as numerous other usability enhancements.Compare the output of traceroute -n -U -p 53 8.8.8.8 to that of traceroute -n -I 8.8.8.8 this will tell you how far your packets to port 53 are getting.MalwareGuard System Firewall is a tool to stop Hackers, Trojans. Better authenticode verification support. TinyWall is a free software to harden and control the advanced firewall built.Support for whitelisting on network drives.Enhanced support for and Metro applications.0 chaininput actionaccept protocolicmp src-address-listLAN logno. 3) Drop all ICMP requests not originating from my LAN (for example entering through the gateway) Firewall rules are as follows. Removed automatic network zone switching. 2) Allow ICMP requests originating from any host on my LAN out to the internet and back. TinyWall is described as free software to harden and control the advanced firewall built into Windows Vista, Windows 7 and Windows 8.TinyWall includes a combination of features that sets it apart from both commercial and freeware firewalls: TinyWall does not annoy you with popups at all and is a popular Firewall in the security & privacy category.To keep your settings, please export them before and import them after the upgrade. ' options in the tray menu to unblock specific applications. If you experience connectivity problems in some programs, use one of the 'Whitelist by. Upgrade note: Your firewall rules will reset when upgrading to this version the first time. What happened Upon installation TinyWall locks down your PC such that no network communication may take place, except for a few known applications. No drivers or kernel-components are installed, which keeps your system stable.įirewall modes and lots of other convenience features make TinyWall extremely easy to use for anybody.ġ00% free, no ads, no artificial limitations, no upgrades. Password lock, firewall tinkering protection and built-in tight firewall rules make TinyWall secure. Using the advanced Windows Firewall built into newer Windows versions, TinyWall's performance impact is neglible. No annoying popups and simple configuration. To resolve the issue I have to turn Windows Defender Firewall off from the control panel and turn it on again. Whilst Tinywall is installed Windows Defender Firewall also blocks internet access. My Tinywall icon sits in the tray icon area all greyed out with Unknown Mode status. DCOM was disabled through DCOM Config, but that didn't prevent my SYN scan to detect port 135 as open (locally, not remotely) and detect OS with decent accuracy. Why does Windows Defender Firewall cause conflict with Tinywall. TinyWall lets you work while protecting you. 101 17 10 1 I've been unable to close it with Windows 10 Firewall. Click on the Always block all traffic button below and click on Ok. TinyWall is a lightweight, user-friendly, and secure firewall for Windows. Select the Application executable file you wish to block the Internet connection. Useful if sleep apnea or periodic limb movement disorder is suspected Polysomnography, multiple sleep latency testing Questions should include daytime symptoms such as somnolence and frequency of napping Take medication history physical examination should include neurologic examination, Mini-Mental State ExaminationĪ two-week sleep diary should record information on bedtime, rising time, daytime naps, sleep-onset latency, number of nighttime awakenings, total sleep time, and the patient's mood on arousal Interview partner or caregiver about patient's sleep habits, daytime functioning, substance use (e.g., alcohol, tobacco, caffeine), snoring, apnea, and unusual limb movement Sleep history must span the entire day and should include an interview with the partner or caregiver Helps detect any coexisting medical or psychiatric illness ![]() Irregular sleep–wake cycle, jet lag, shift workĪlcohol, caffeine, drug withdrawal, stimulants (e.g., amphetamines, methamphetamines) Periodic limb movement disorder, restless legs syndrome, sleep apneaĪnxiety disorders, bipolar disorder or schizophrenia, major depressive or dysthymic disorders, personality disorders, post-traumatic stress disorder Selected causes of chronic insomnia (≥ 30 days)Īrthropathies, cancer, chronic pain, congestive heart failure, COPD, end-stage renal disease, gastroesophageal reflux disease, HIV/AIDS, hyperthyroidism, nocturia caused by prostatic hypertrophy, strokeĪnticholinergic agents antidepressants (SSRIs, bupropion ), MAOIs antiepileptics (lamotrigine, phenytoin ) antineoplastics beta blockers bronchodilators (beta agonists) CNS stimulants (methylphenidate, dextroamphetamine, nicotine ) interferon alfa miscellaneous (diuretics, atorvastatin, levodopa, quinidine) steroids, oral contraceptives, progesterone, thyroid hormone Situational stress (e.g., occupational, interpersonal, financial, academic, medical) Selected causes of acute insomnia (< 30 days) * The better safety profile of the newer-generation non-benzodiazepines (i.e., zolpidem, zaleplon, eszopiclone, and ramelteon) makes them better first-line choices for long-term treatment of chronic insomnia. Benzodiazepines are most useful for short-term treatment however, long-term use may lead to adverse effects and withdrawal phenomena. Opiates are valuable in pain-associated insomnia. Alcohol has the potential for abuse and should not be used as a sleep aid. Routine use of over-the-counter drugs containing antihistamines should be discouraged. ![]() Hypnotics generally should be prescribed for short periods only, with the frequency and duration of use customized to each patient's circumstances. ![]() Exercise improves sleep as effectively as benzodiazepines in some studies and, given its other health benefits, is recommended for patients with insomnia. There is good evidence supporting the effectiveness of cognitive behavior therapy. Treatment should begin with nonpharmacologic therapy, addressing sleep hygiene issues and exercise. However, if insomnia is severe or long-lasting, a thorough evaluation to uncover coexisting medical, neurologic, or psychiatric illness is warranted. Physicians may initiate treatment of insomnia at an initial visit for patients with a clear acute stressor such as grief, no further evaluation may be indicated. The frequency of sleep disruption and the degree to which insomnia significantly affects daytime function determine the need for evaluation and treatment. |