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The Science of SleepFrom neuroscientists to engineers, USC researchers delve into what happens during slumber—and how to help us get more of it.In the classic fairy tale, Snow White bites into an apple and slips into a state of suspended animation. For her fellow figment of fiction, man-about-the-Catskills character Rip Van Winkle, a sip of moonshine affords the luxury of sleeping through the American Revolutionary War. Sleep has long featured in our collective storybook as an enigmatic netherworld, a far away place where strange things happen and then are forgotten upon our return to reality.Turns out there’s a reason for the mythology. Left to investigate why humans spend nearly a third of our lives in slumber — and what sleep is — scientists don’t have a simple answer.“Why we sleep is still one of the greatest unsolved mysteries of science,” says Terese Hammond, Keck Medicine of USC pulmonary critical care physician and director of the USC Sleep Disorders Center. “No one yet knows the true purpose and nature of the state of sleep.”We may not know the reasons behind it, but here’s what’s clear: Many of us don’t get enough of it.More than a third of Americans get less than the needed seven hours of snoozing a day, according to the U.S. Centers for Disease Control and Prevention. Over time, lack of sleep takes a toll on our well-being—so much so that the CDC calls it a public health epidemic. That makes the field a formidable frontier for scientists and physicians.“This is a very exciting time for sleep research,” says Steve Kay, dean of the USC Dornsife College of Letters, Arts and Sciences and a biologist who has long studied the sleep-wake cycle. It’s also a growing area for USC physicians and other health care professionals who see the wider effects of poor sleep among the patients in their clinics and exam rooms.UNDERSTANDING SLEEPWhat happens to us in those wee hours as we lie unconscious in our beds? Quite a lot.After drifting off, we go through several cycles of what’s called non-rapid eye movement (non-REM) sleep, followed by cycles of rapid eye movement (REM) sleep. During non-REM sleep, the body repairs and restores itself—building bone and muscle, healing wounds and bolstering immune defenses. In REM sleep, body temperature drops and blood thickens. Blood pressure and pulse become erratic. Muscles turn off.The brain, however, buzzes with activity. Cholinergic neurons, which help store memories, fire during REM, says Julie Dopheide, a professor of clinical pharmacy, psychiatry and the behavioral sciences at the USC School of Pharmacy and Keck School of Medicine. REM is when dreams occur. And it may be during this time that the brain tries to interpret and organize information.USC Dornsife neuroscientists and USC Viterbi engineers are trying to uncover what happens in the brain during sleep. Thanks to leaps in imaging technology and a $9.7 million National Institutes of Health grant, the USC research team is mapping neurons in the brains of live zebrafish to see how their activity patterns change as the animals sleep or form new memories. “Brain circuitry underlies the complexity of human consciousness,” Kay says, so breaking through imaging barriers will be critical to “seeing” sleep.Research by Kay and others has improved our understanding of the natural timing system that regulates when we fall asleep and when we wake. Known as the circadian system, this internal clock maintains 24-hour sleep-wake cycles through signals from the brain’s hypothalamus. Our circadian system responds to environmental cues such as darkness and light, using hormones to spur drowsiness or wake us up. If circadian rhythms fall out of sync with day-night cycles—after an overseas flight or a graveyard shift, for example—the system usually realigns in a few days. Sometimes life gets in the way of biology, though, and systems go awry.TOO BUSY TO SLEEPWith mobile devices that allow 24/7 communication and unlimited movies and shows available digitally at the touch of a button, it’s easy to stay up late binge watching a series or updating a report for the boss. It’s no wonder that so many of us fail to get the recommended seven to nine hours of sleep a night. Among teens, snooze time dropped steadily between 1991 and 2012, with 10 percent of high school students claiming they get only five hours of sleep per night.“We wear our lack of sleep like a badge of honor,” says Keck Medicine sleep specialist Raj Dasgupta.As a nation, we’re not just losing sleep time — we’re missing the health benefits that sleep brings. Inadequate sleep is linked to nearly a fifth of serious car crashes. It also seems to weaken a person’s willpower to eat normal portions and choose healthful food instead of junk, according to research.If scant sleep becomes the norm, consequences can mount. Long-term sleep-wake cycle troubles can disrupt the activity of genes that govern metabolism and immunity, leading to potential trouble by spurring diseases like Type 2 diabetes.Several years ago, Kay and his colleagues found a key biochemical link between circadian rhythms and diabetes. In their studies with mice, they discovered that the same protein that regulates the circadian clock also controls the liver’s production of glucose. Too much glucose in the blood is a serious complication of diabetes. Kay’s team found a way to harness that clock protein to slow glucose production, making diabetic mice healthier.But there’s more to it than diabetes. “Chronic disruption of sleep patterns is strongly linked to cardiovascular disease and to a sharp increase in the incidence of breast cancer,” Kay says, citing findings from large studies in the United States and Japan.Other studies done in the lab suggest that staying awake too long can kill brain cells and impair clearance of toxic proteins — including amyloid beta, which builds up in the brains of people with Alzheimer’s disease.SLEEP, INTERRUPTEDMany people come to the USC Sleep Disorders Center after years, often decades, of struggle, Hammond says. Indeed, about 50 million to 70 million U.S. adults suffer chronic sleep disorders.Typically, it should take less than 15 minutes to fall asleep. “If it takes longer than a half hour and impairs your function the next day, it’s considered insomnia,” Dopheide explains. People with insomnia not only struggle to drift off, but also wake up repeatedly.If tossing and turning is part of your nightly routine, don’t just dismiss it, Dopheide warns. Causes range from simple factors like room temperature to serious issues like sleep apnea or depression. “One of the first things to go wrong when you’re having a psychological or physical problem is your sleep,” she says. “Insomnia is a marker for poor health.”Just ask Jennifer Ailshire, a sociologist at the USC Davis School of Gerontology and Ethel Percy Andrus Gerontology Center. She studies how family relationships affect health, including sleep quality. In a 2012 study, she found that demanding relationships with family members can hurt sleep — and it’s about more than just having a fight with your spouse before bed. Even regular contact with a challenging parent or child living outside the home can cause sleep trouble.There’s another modern-day culprit for sleeplessness: artificial light. Nighttime light suppresses the body’s production of melatonin, a hormone that promotes sleep, and the blue light emanating from computers and other electronic devices is particularly harmful.A recent study conducted at Brigham and Women’s Hospital in Boston bore this out. It showed that young adults who read on a tablet for four hours before bedtime took longer to fall asleep, spent less time in REM cycles and woke the next day feeling groggier than those who read a printed book. Scientists who analyzed the volunteers’ blood samples found that the tablet group had lower levels of melatonin.“This work is really solid,” Kay says. “My kids aren’t allowed to use iPads after 6 p.m. now.”Some 20 million U.S. adults can blame another problem for their sleeplessness: sleep apnea. Every night, they snore, wake up and gasp for air over and over again, notes Eric Kezirian, an otolaryngologist with Keck Medicine and an international expert in treating snoring and obstructive sleep apnea.“Your throat is basically a tube surrounded by muscle,” Kezirian says. “It can collapse during deep sleep and block your breathing.” People with severe sleep apnea may wake 30 or more times per hour, increasing their risk for heart attack and stroke.Man yawning — Image by © Kate&Camilla/CorbisSNOOZE SOLUTIONSFortunately, innovations are helping doctors like Kezirian treat sleep apnea. While many patients breathe better by using what’s called a continuous positive airway pressure device, or CPAP, others can’t sleep comfortably while wearing one. Some have found relief from a new sleep apnea treatment approved by the Food and Drug Administration last year. Called the Inspire® Upper Airway Stimulation™, this surgically implantable device keeps the airway open by electrically stimulating thenerve that controls tongue movement. Keck Medicine was the first group in Los Angeles (and one of the relatively few around the world) to offer the Inspire treatment.Sometimes apnea is mysterious. Kezirian is an international leader in a test called drug-induced sleep endoscopy, which allows him to use a tiny camera to observe nasal cavity positioning during sleep. “If we can figure out what’s causing the blockage of breathing, we can hopefully give more targeted and effective treatment,” he says.That’s also why a trio of USC investigators recently developed a new imaging tool for children with sleep apnea. Patients undergo specialized MRI scans that produce a real-time video of the airway opening and closing during natural sleep, and that can help doctors pinpoint the source of breathing problems, says Krishna Nayak, a professor in USC Viterbi’s Ming Hsieh Department of Electrical Engineering. He worked with Children’s Hospital Los Angeles and Keck Medicine pediatric pulmonologist Sally Ward and USC Viterbi biomedical engineer Michael Khoo to develop and test the new technique. About 50 people have received the procedure so far, Nayak says.Khoo and others are also studying how a tool called electroencephalography (EEG) can illuminate the quality of sleep. Electrodes placed on the head can record brain wave patterns, while other sensors detect eye movements, limb movements, heart rate and breathing patterns while a person sleeps. These measurements reveal sleep patterns and arousals, which can help clinicians diagnose sleep disorders and gain insight into potential causes.The USC Sleep Disorders Center treats rare conditions as well, including narcolepsy, sleep walking, sleep talking and sleep-associated movement disorders such as restless legs syndrome. “A thorough sleep evaluation can be very good for patients, especially those with long standing sleep complaints, because it may well identify targets for therapy that will improve daytime functioning and well-being,” Hammond says.Outside the sleep clinic, there may be a much cheaper, albeit lower-resolution, way to measure sleep: using off-the-shelf wearable monitors and mobile health apps you can download on your smartphone. “We’re going to go through a ‘big data’ era for collecting sleep-wake patterns,” Kay says. He notes, however, that “while this allows us to go ‘wide’ on understanding sleep behaviors, it does not go ‘deep’ in the same way an EEG collects interesting data on much smaller numbers of individuals. So one does not replace the other.”Ultimately, you don’t need the latest wearables or phone apps to prioritize sleep. “Treat it like you treat exercise and diet,” Kezirian says. “It’s important for your health and for getting the most out of life.”Illustrations by Oscar Bolton GreenLearn more about the sleep medicine program within the USC Tina and Rick Caruso Department of Otolaryngology – Head and Neck Surgery and the USC Sleep Disorders Center at Keck Medicine of USC.Reference: Keck Medicine of USC - The Science of Sleep

Q. Can someone do a sub-internship in the USA, being a medical graduate?A. My standard answer would have been sub-internships are reserved for medical students who have not graduated. Until I saw this listing:Postgraduate Sub-Internship ProgramOtherwise, graduated physicians can apply for observerships which may or may not allow much direct patient care. Below are programs for IMG listed with the AMA.Observership Programs for International Medical GraduatesObserverships are designed to help international medical graduates (IMGs) adapt to the practice of medicine in the United States. Review the list of observerships that have registered with the AMA.American International Integrated Observership Program (MedicalObs)New applications are being accepted for 2018 positions at this time. Scholarships now available for highly competitive candidates.At MedicalObs, our focus is on the applicant’s experience. While there are many programs to choose from to help better prepare for entry into U.S. medical residency programs, what distinguishes us is our customized, integrated and individualized program curriculum designed to formulate an action plan to set applicants apart from the competition. Our values and philosophies are centered around the importance of personal growth, innovation, communication, commitment, teamwork and reliability.Length of Program4-12 weeksPreceptorsMedical Director for Hospitalist Program, Internal Medicine Physicians, Emergency Medicine Physicians, Psychiatry, SubspecialistsProgram OverviewObserving with U.S. licensed physicians in a hospital-based settingPerformance and evaluation review with chairman/program director*Letter of recommendation from chairman/program director*Certificate of completion with honors from AIIOP-MedicalObs*Review and edit of personal statement for residency applicationLive mock interview seminarsComplex clinical case reviews and live didactic sessionsAccent reduction and dialect coaching coursesAttending colloquium guest speaker series run by U.S. physician leaders and coachesExclusive alumni membership network with U.S. physicians via MedicalObsIntegrated cultural experiences with local community groups and social events*Based on a successful performance/evaluationEligibility CriteriaForeign medical graduates (FMG) from medical school and ECFMG certifiedU.S. senior graduatesU.S. FMGsNonmatched residency graduatesRecommend completion of USMLE Step 1 and Step 2Applications for Observers/PreceptorsGo to www.MedicalObs.com, click on the “apply now” section to fill out formsFor questions and enrollment, email us at [email protected] us via phone at 1 (833) 876-3627 or 1 (833) USMDOBSApplication DeadlinesWe screen applications year round.We accept and screen applications from all countries.Tuition and fees to be paid in full prior to start.AmeriClerkships Postgraduate Subinternships With Residency ProgramsLength of ProgramMinimum 4 weeks; maximum 48 weeks. Start in as little as 2 weeks.​PreceptorsProgram Directors (PDs), Associate PDs, Residency Program Faculty, Teaching Attending Physicians and ResidentsProgram OverviewAmeriClerkships Medical Society (AMS), in partnerships with Graduate Medical Education (GME) departments offers a rare opportunity for medical graduate members of AMS to enroll in Postgraduate Subinternships (PGSIs) in over 30 specialties.PGSIs are designated as AMS-PGY1CONNECT sites, meaning that AMS members have secured residency interviews and even “matched” into such hospital(s).A typical “matched” AMS member who has matched into a PGSI residency program has:Completed 12-28 weeks of PGSISecured 2-4 letters of reference directly from PGSI supervising attendingsIs a U.S. citizen or permanent residentPassed USMLE Step 3By enrolling as an AMS PGSI, medical graduates may expect to gain first-hand exposure to the inner workings of U.S. GME and medical residencies (even in 100% inpatient settings), and develop into an effective PGY1 by learning how to:Become an integral member of U.S. medical residency teams who manage acute and chronic medical problemsRotate and collaborate with top residency program faculties, teaching attending physicians, chief residents and even program directorsParticipate in teaching rounds, and possibly present in journal clubs and residency conferencesRefine history taking and physical examination skillsFormulate problem lists, prioritize medical problems, select laboratory and ancillary tests, as well as institute drug and supportive therapiesUtilize subspecialty consultative servicesDevelop definitive plans for ongoing care and follow-up of dismissed patientsUpon satisfactory completion of each PGSI clinical block, AMS PGSI will be evaluated based on the 6 ACGME Core Competencies, and may request a performance-based letter of recommendation on official GME/teaching hospital letterhead.For questions and enrollment, please contact AmeriClerkships Medical Society directly at +1 (949) 417-8980, or visit the website.Bridgeport Family Medicine Externship/Preceptorship ProgramBridgeport Family Medicine offers real hands-on experience in family medicine, internal medicine, pediatrics and urgent care medicine. The program is structured as a "mini residency program" to prepare IMGs for the U.S. medical system by using state of the art EMR/HER systems.Length of the Program:4-12 weeks, extern may start any Monday of the weekProgram OverviewThe extern interviews the patient, performs the physical exam along with attending physician and discusses differential diagnoses, management options, labs, imaging and forms a management plan. In addition, the extern will:See and manage patients with their preceptorLearn on a state-of-the-art Electronic Medical RecordImprove physical examination skillsImprove patient note taking skillsImprove history taking skillsLearn to perform EKG, Phlebotomy, PFTs and UADiscuss family medicine topics and the latest guidelines on a daily basisFor more details, visit www.usmedicalextern.com or email: [email protected] Medicine® Physician Refresher/Re-entry PreceptorshipDrexel University College of Medicine has a tuition-based structured preceptorship/observership for IMGs preparing for a U.S. residency. Preceptorships are offered in internal medicine, pediatrics, OB-GYN, surgery and anesthesia. Rotations are all on the main university campus in Philadelphia.Length of Program6-week rotations; repeatable once. The course starts on the 1st Monday of every month and is first come, first serve. The application process takes 4–6 weeks.Program OverviewAttend inpatient and outpatient rounds, core conferences, lecture and learn about medical care in the United StatesAttend didactics: morning reports, noon reports, grand rounds and clinical case discussionsHomework will be assigned to hone in on medical knowledge, clinical reasoning and communication skillsMeet weekly with preceptor to review the exercises and receive feedbackFind more details on the program or call (215) 762-2580.Griffin Medical Clinical Observership ProgramThe application process for 2017-2018 runs through Sept. 30, 2017. New applications are accepted during this time only.The program is no longer accepting applications for October 2017 - January 2018. All positions for time have been filled. Only applications for the months of February 2018 - June 2018 are being accepted.Length of Program4 weeksProgram OverviewTo familiarize yourself with the U.S. medical systemTo become proficient in presentation of history and physical examinations on daily roundsTo become proficient in ascertaining patients' acute symptoms and making a therapeutic planTo learn to write daily progress notesTo learn how to interpret basic lab tests and radiology data such as blood, urine serum, X-rays, etc.Eligibility CriteriaForeign medical student graduates must be:Graduates of a medical schoolMust be ECFMG certifiedApplicationsThe following are required to be submitted to the Committee for consideration of participation in the program:A completed application or ERAS application (for ERAS, months for which the candidate is applying should be indicated in the email. In the event that ERAS application is not available, a common application form can be substituted)A cover letter detailing desired rotationA curriculum vitaeAt least 1 letter of reference from a clinical supervisor or advisor, or an attending physicianUSMLE score reportsMedical school diplomaECFMG certificateTOEFL score report ( if available)Documentation of up-to-date immunization record (including flu shot during flu season (Oct-March)Proof of health insurance coverageA recent photograph for identificationCopy of passport and valid visaApplication DeadlineA completed application must be received no later than Oct. 1Formal start date is usually the first working day of a calendar monthTiming is at the discretion of the program coordinator and teaching service schedulesVisit Griffin Medical’s website for more details and to apply.International Observership ProgramAllegheny General and West Penn hospitals host observers from around the world. This program was designed for physicians, nurses, pharmacists, medical students, physiotherapists, technologists, technicians and health administrators.Length of Program4 weeksThe observership is a specific exchange program in which the observer accompanies the medical staff through their daily hospital routine, sharing experiences with doctors, residents, staff and students. This program is not for academic credit.Program OverviewObservation of the clinical care of patientsParticipation in lectures, grand round and other related eventsNo privileges are granted to participate in the clinical treatment of patients to assist in any medical procedures, test or surgeriesFor inquiries about international educational opportunities available through Allegheny General, call International Services (412) 359-5269 or email [email protected] Memorial HospitalIt is the policy of the Public Health Trust to accept physicians or resident physicians desiring to participate as an observer/rotator at Jackson Health System facilities. All requests for observer/rotators must be reviewed and approved by Risk Management.Length of ProgramObserverships may last up to 4 weeks (1 month), longer if written approval by the department is obtained.Program OverviewThe individual desiring to participate must provide the Office of Physician Services all required documentation as set forth in this policy in order to be considered for a rotation or observership. Jackson Health System will not provide professional liability coverage for any resident for an outside institution. If the home institution will not provide the coverage, then they will be classified as observer status only. An observer is a health care professional or student who will not provide patient care or have direct patient contact. Observers differ from students in an academic program in that the observership is not an educational requirement of any academic program (see administrative policy 389 for students).Observer may be one of the following:Physicians (foreign or domestic)Registered nurses (foreign or domestic)Other health professionals (e.g. radiology, respiratory therapy, psychology, pharmacy technicians, etc.)Students not covered under an existing affiliation agreementObserverships may be in an inpatient or outpatient setting and must be approved by the Jackson Health System facility’s department(s) director(s) of the area being observed. For physicians, approval is needed from the associate/chief medical officer. For residents, approval is needed from the GME office. For nurses, approval is needed from the director of patient care services and/or the chief nursing officer. For all other students, approval is needed from the associate/chief medical officer.For more information, view the Policy & Procedure Manual.Contact InformationGraduate Medical Education OfficeJackson Memorial HospitalInstitute 118B1611 NW 12th Avenue, Miami, Florida 33136Phone: 305-585-4310Fax: 305-585-4309For more information on visiting medical students, please visit the information page.Somerset Family MedicineHands-on externship/observership in outpatient family medicine in Michigan for FMG, international medical graduates, Caribbean medical students and Caribbean graduates. Outpatient family medicine office in Troy and Sterling Heights, Michigan.Length of ProgramMinimum 4 weeks; maximum 12 weeksPreceptorNeil Jaddou, M.D., M.S. board-certified family medicine, clinical assistant professor of family medicine and community health, Wayne State School of Medicine and Oakland Beaumont Medical School. Staff at 4 hospitals and affiliated with St. John Oakland-Macomb medical students teaching program.Program OverviewBecome efficient in electronic medical or health records.Get familiar with the health system in the United States.Practice on presenting a patient and doing history and physical examinations.Learn how to interpret basic lab tests and radiology data such as blood, urine, X-rays, EKG and PFT.Expand your medical knowledge and build on your differential diagnosis.Improve your scores on CK, CS and USMLE Step 3.Tour the hospitals and attend conferences when available.Online lectures given by Dr. Jaddou on common problems in family medicine, taken from future textbook by professor Jaddou.Opportunity to publish patient education article in the community newspaper.Receive a letter of recommendation at the end of the rotation that has a university and hospital logo.Receive a certificate of completion at the end of externship. There is also a possibility of finishing with honors and student of the month award.Opportunity to be chief extern and teach others.Volunteer in the church clinic once a week.Eligibility CriteriaUSMLE not required.Immediate availability. Start any day that is convenient for you.Must be living in U.S. to apply. We do not sponsor visas.All visas are accepted as long as you are physically present in U.S.ApplicationVisit www.americanexternship.com for details on price and submitting an application. For additional information or questions email us at [email protected].

In the US you can get immunizations at the physicians office or the local heal unit. Flu vaccines can be obtained at most pharmacies.When I was a child they set up a line in school and pulse air injected the vaccine. I don't know whether there was a consent form or not.