Snoring Can Indicate Treatable Sleep Condition

Larry Barsh is a man with a new mission. The retired dentist from New York City wants to help Americans recognize that they may have obstructive sleep apnea, a chronic condition among snorers that disrupts sleep. Dr. Barsh started a Web site, SnoringIsn'tSexy.com, to help educate patients and help dentists play a role in identifying patients with sleep apnea.

Barsh says the vast majority of people with apnea don't know they have the condition. Dentists are in a unique position to help patients who might suffer from sleep apnea, he says. Typically, dentists see patients more often than physicians, at least two times a year for teeth cleaning.


For an estimated 12 million Americans, disruptive snoring signals the condition obstructive sleep apnea. iStockphoto.com
At Risk

The National Institutes of Health estimates that more than 12 million American adults have obstructive sleep apnea. Among older Americans, the rate is especially high: at least one out of 10 over the age of 65 has it.

Doctors don't know exactly why sleep apnea occurs, but it is associated with obesity, aging and anatomy, says Dr. Clete Kushida, a neurologist and director of the Stanford Center for Human Sleep Research and president of the American Academy of Sleep Medicine.

The obstructed breathing can result from a variety of factors, such as a large tongue, a large uvula (that cone-shaped projection of tissue in the back of the throat) or a lot of large, crowded teeth. As muscles relax, which they do when people fall asleep — especially on their backs — the tongue muscles tend to pull back and block the airway.

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Snoring And Apnea

Snoring is a sign of apnea. Only about 5 to 10 percent of snorers actually have sleep apnea, says Barsh, but everyone who has the most common form of apnea — obstructive sleep apnea — snores. (People with central sleep apnea, caused by incorrect signals from the brain, may not snore.)

"Snoring is an indication of the possibility of a serious medical problem," he says, because sleep apnea is linked to heart disease, stroke, depression and diabetes.

Struggling For Air

During obstructive sleep apnea episodes, snoring patients become quiet for 10 seconds or more — and literally stop breathing. The silence is followed by choking or gagging sounds when the sleeper is partially aroused and breathing resumes. Finally, snoring resumes and the cycle starts over. This cycle can happen anywhere from five times an hour to sometimes hundreds of times a night. Because people with sleep apnea partially awaken to resume breathing, their sleep is fragmented and they are sleepy in the daytime. The lack of breathing also causes the oxygen level in the blood stream to fall, contributing to medical problems.

Treatments Differ With Severity

The gold standard of treatment for sleep apnea is called CPAP, which means continuous positive airway pressure. An air pump connected by a tube to a face mask, sort of like a vacuum cleaner in reverse, gently pushes air up through the nostrils and mouth into the upper airway, keeping it from collapsing.

But the CPAP can be loud and cumbersome, and many patients who could benefit from CPAP just don't use it. However, experts say, for those with severe apnea, it's the only effective treatment.

Surgical procedures can also help by removing excess tissue in the back of the airway or actually moving parts of the jaw or tongue forward. They're particularly effective with younger patients.


Oral appliances that reposition the tongue and mouth help some obstructive sleep apnea patients maintain regular nighttime breathing. Courtesy Dr. Mark Friedman
The Mouthguard

The third treatment option is an oral appliance, which looks much like a mouthguard used in sports or a dental retainer typically used after orthodontry.

"Research shows the oral appliance works to treat mild-to-moderate sleep apnea," says Kushida. Studies have been limited, but the appliances appear to not only treat apnea but also conditions associated with apnea, such as high blood pressure, he says.

There are many brands of oral appliances, but all of them work basically the same way, says Dr. Mark Friedman, who specializes in treating snoring and sleep apnea in Encino, Calif. He's also a professor of dentistry at the University of Southern California. He says the appliances work to keep the airway open and allow for comfortable breathing. They move parts in the mouth out of the way. They move the tongue forward by moving the jaw forward. So, the lower jaw juts forward a certain amount.

One Patient's Experience


Rani Stoddard found that an oral appliance drastically reduced her snoring and apnea. Courtesy Rani Stoddard
Rani Stoddard is one of Friedman's patients. She is a nurse who describes her husband as a gem, since he put up with her loud snoring for years.

"He says, on a scale of one to ten, I was like a ten plus on snoring," Stoddard says. Today, she wears an oral appliance, "and now I'm like a two," she says. "You know, a little mild, delicate (snoring) in the beginning and then ... it's quiet!"

Stoddard can't speak highly enough about the oral appliance. "I'm a believer!" she says, adding that now, she "sleeps like a baby." She says the appliance is comfortable and she can even take a drink of water while wearing it.

Although most sleep apnea is initially diagnosed after a study is performed at a sleep center and a physician evaluates the study, apnea can also be measured at home to determine how well treatments are working. To do this, the patient wears a compact device on an armband with two finger-sensors attached. The device measures a number of respiratory functions, including the amount of oxygen getting into the blood. Friedman reports that Stoddard's apnea has been dramatically reduced as a result of the appliance.

Friedman says the oral appliance is at least 60 percent effective for most patients. "For some patients, it's 100 percent effective," he says.

The Role Of The Dentist

Barsh says screening in a dentist's office takes only a few minutes and a few pointed questions, and dental hygienists can also be trained to screen for apnea. It involves asking whether patients suffer from high blood pressure, if their bed partner has ever observed them stopping breathing during the night, if they feel sleepy during the day and if they snore. A patient's neck size, particularly if it's large, can also be an indicator of apnea.

Friedman, a dentist who specializes in treating snoring and sleep apnea, also asks patients whether they are aware of dreaming during the night. Sometimes patients are confused about why a dentist would be asking such a question, he says.

"But people who don't dream often are not getting into REM sleep," says Friedman, If that's the case, he says, they're probably not getting good deep sleep either. And that, he says, can "lead me to have an inkling that the patient might have a sleep issue."

Since he started focusing on sleep disorders about six years ago, Friedman says the majority of patients with sleep problems are longtime patients. "You would be amazed at the number of people that we have diagnosed within our own practice," he says.

Special Training

Because a sleep-apnea appliance must be fitted precisely to the mouth, Friedman says it's important for a dentist trained in sleep medicine to fit the device. Dentists can take training at various academic centers, but the American Academy of Dental Sleep Medicine, a branch of the American Academy of Sleep Medicine, offers courses during its annual meetings.

Although there are many appliances advertised on the Internet and on TV, there are only about 60 FDA-approved devices. Of those, Friedman says, he considers only about six to be effective. And, Friedman says, if potential patients are interested in researching what types of oral appliances are available and most effective, the Academy website is a good place to start.

- excerpt from NPR

'Cash For Clunkers' Lacks Cash For Clunkers

"Cash for clunkers" offered the owners of old cars and trucks up to $4,500 if they traded in their old car for a new more fuel efficient one. The clunker had to get 18 miles per gallon or less. The program only started a week ago, but car dealers across the country saw an immediate rush.

"The atmosphere around the dealers just reminds me of, you know, 10 years ago, when people were just flocking in to buy cars — especially in Silicon Valley," says David Horn, the general manager of Boardwalk Volkswagen in Redwood City, Calif.

However, Horn and many other dealers have put the "cash for clunkers" program on hold. Members of Congress have been told that the $950 million program is out of money.

According to Charles Cyrill of the National Automobile Dealers Association, many dealers are worried that they might not be able to get their reimbursements. They says there is a paperwork backlog in Washington. Still, they would like more money for the program which has been a boon for car sales.

"The timing of the "cash for clunkers" program could not have happened at a better time," Cyrill says.

Several members of Congress say they too are working to find more money for the program, but given the current strains on the budget this might be a difficult task.

-excerpt from NPR

Get The Most Nutrition From Your Veggies

Tomatoes are certainly nutritious — a good source of the antioxidants lycopene and beta-carotene. But consider this: if you eat a tomato without adding a little fat — say a drizzle of olive oil — your body is unlikely to absorb all these nutrients.

Scientists at Iowa State University figured this out a while ago. They recruited graduate students to eat bowls of salad greens with tomatoes and various types of salad dressings — from fat-free to regular Italian. "Basically once a month for several months we'd show up first thing in the morning," recalls participant Gregory Brown, now a professor of exercise science at the University of Nebraska. Researchers put IV lines into the participants' veins and drew blood samples before and after they'd eaten the salads in order to get precise measurements of the absorption of nutrients.

"The salads all tasted the same to me," says Brown. But when researchers went back and analyzed the blood samples they realized that people who had eaten fat-free or low-fat dressings didn't absorb the beneficial carotenoids from the salad. Only when they had eaten the oil-based dressing did they get the nutrients.

Carotenoids are the pigments responsible for red-, yellow- and orange-colored fruits and vegetables. And carotenoids are also found in dark green vegetables such as spinach. The compounds convert to Vitamin A in the body, and studies have found that carotenoids have anti-oxidant activity which may help protect cells from damage caused by free radicals. Human studies have linked high consumption of fruits and vegetables to reduced risk of cancer.

Beta-carotene researchers were not particularly surprised by the findings of the fat-free vs. regular Italian salad dressing study. "We already knew that carotenoids were fat soluble," explains Wendy White, a professor of Human Nutrition at Iowa State University. The results helped reinforce the idea that a little fat is healthy.

Chop And Chew

There are other ways to help maximize the absorption of carotenoid nutrients. Chopping or grating breaks down the plant material. "The finer the particle size ... the better the absorption of beta-carotene," explains White.

The findings of nutrition research often go against the grain of trendy food ideas. For instance, many people have heard that raw vegetables are best. But if you're eating carrots, it may be helpful to cook them gently. The heat can soften the food allowing more nutrients to be released.

A recent study in the Journal of Food Science suggests that some cooking methods may be better than others. Researchers at the University of Murcia in Spain cooked 20 different kinds of vegetables six different ways. Then they analyzed how well the foods retained antioxidants. They found that microwaving helped maintain the antioxidants, whereas boiling and pressure cooking led to the greatest losses.

Green beans, beets and garlic all did well with heat — maintaining beneficial phytonutrients after most kinds of cooking. The antioxidant value in carrots actually increased after cooking.

Experts explain that boiling may allow nutrients to leach into the pan water that people end up tossing out, especially with water-soluble nutrients such as Vitamin A and the B Vitamins.

Eat Plenty Of Colors

As testing methods have become more sensitive, scientists have the ability to peer into our foods and tally up all the phytonutrients that may be beneficial. But experts say the ways in which our bodies may use and absorb these compounds are complicated. Therefore, many experts say it's best not to fixate too much on how food is prepared. Instead, focus on eating more plant foods — of all colors.

Jeffrey Blumberg, an antioxidant expert at Tufts University, says "What's important is that you find a way to cook that's palatable to you so you're getting lots of plant foods."

- excerpt from NPR

'Checkout' Girl Cashes In With Bestselling Memoir

In a kind of supermarket Cinderella story, a cashier in France has become a literary sensation. Anna Sam has turned her ungratifying job into a humorous memoir. Now, her book has been translated into 16 languages and turned the 29-year-old into the author she has always wanted to be.

Tribulations of a Cashier is a sociological study of the grocery store world from the viewpoint of the checkout girl. In her book (whose English title is Checkout: A Life on the Tills), Sam dissects the behavior of the shopper:

It's lunchtime and your first customer of the day is stuffing his mouth with a tuna salad sandwich. Chewing noisily, his mouth wide open, you get a glimpse of every ingredient. When you ask to borrow his sandwich for a moment to scan the price, he takes one more giant bite before handing it over. So what's a little mayonnaise on your fingers and crumbs on your register?
Sam presents other shopper types — like the mothers who regularly warn their children that if they don't shape up they'll grow up to be nothing but a cashier, and the sleazeballs who hit on her while trying to steal CDs hidden inside their boxes of Camembert.

Despite the indignations, Sam says in some ways the job actually made her feel good about herself.

"It's a job where you see every people; it's a job where no one sees you. You see families very happy, families very sad. People are very nice, people are very bad. And at the end of your day, you say, 'Oh my god, I'm happy because I have a normal life; I'm better than I thought,' " she says.

In another chapter, Sam describes how scanning groceries can even help you get rid of those unwanted love handles.

By taking a job as a cashier you have also chosen the best route to a super new shape. The cashiers' perch is the perfect place to tighten those buttocks, build those biceps, and yes ladies, even firm up those breasts. Just compare yourself to a customer or a new checkout girl who doesn't have the firming experience you have behind you.
Sam began working as a cashier during college to support her literature studies. When graduation came and went, no other jobs were available. So she stayed on — and on. Five years passed. The work was ungratifying and mind-numbing — until she decided to write about it.

"I started to see my job different and to see differently people. When you start to explain it with humor, people say, 'Oh, what a funny blog, what a funny diary.' I think everything we live can be funny. We just have to see it with the good eye," she says.

Sam first started writing in a blog where she provided a running account of what went on in the world of a cashier. Her blog, Cassiere No Futur, attracted a large number of readers, then newspaper reporters. Soon, publishing houses took note, and Sam had several book offers.

Since her first book, Sam has become the toast of TV and radio talk shows. With her recently published second book, which is also about the supermarket world, Sam has now left her till behind for good. It wasn't all bad, she says. As evidence, she reads one of her favorite chapters about how the cash register beeping could sometimes transport you into a dreamlike state.

The store is packed, shoppers rush to and fro — their grocery carts squeak and rattle. A voice over the intercom barks out the latest sales promotions over a backdrop of jangling Muzak. The general brouhaha intensifies. The store is approaching its maximum sound threshold. The squalling of a brat tips it over the edge, opening the passageway to this other dimension.
Sam says her success has been a wonderful surprise. She is heartened to hear from cashiers who say they now find hope and humor in their daily grind. But what makes her happiest, she says, is that people tell her they now treat the checkout girl with respect.

-excerpt from NPR

New Treat In San Francisco: Parks Allow Food Carts

Facing an $11 million budget gap, San Francisco park officials last week voted to allow long-banned food carts into the city's 200 parks. A monthly permit costs $1,000 or more, and vendors must prove that their food is "healthful" — a term that is not precisely defined.

-excerpt from NPR

Stress, Anxiety May Keep Women Smoking

Quitting cigarettes is not easy for anyone. But some studies show that women have a harder time keeping their no-smoking vows than men. Researchers don't know exactly why this may be the case, but they speculate that women are more sensitive than men to sudden emotional upset.

University of Pittsburgh psychologist Saul Shiffman says acute emotion — getting upset suddenly — can have a "big role" in getting women to pick up a cigarette.

"Relapse is the whole game," says Shiffman, who notes that among men and women who quit smoking without any treatment like nicotine replacement, about three-fourths return to smoking within just one week. "So, essentially the key to quitting is avoiding relapse," he says.

Shiffman says relapse starts with a single lapse — for example, smoking a cigarette during a period of not smoking, thinking that the return to smoking is temporary. Shiffman says people tend to have lapses when they're emotionally upset. He also says this seems to occur more frequently with women.

While data from federal household surveys show that men and women have approximately equal success in ultimately quitting smoking, mounting evidence indicates that women have a harder time when they actually try to quit.

He says the federal data just counts the "bodies, as it were," adding up how many people nationwide are ex-smokers at any given time. He says the federal data don't include the number of times people tried to quit.

Shiffman recently analyzed 12 clinical trials involving more than 4,400 individuals who were trying to quit smoking. Overall, he says, women had a 25 percent lower success rate on any given attempt to quit than men did.

Shiffman suggests the discrepancy in federal "ex-smoker" statistics and the studies he examined may simply reflect that women try harder to quit and more often than men, which ultimately accounts for an overall success rate that looks about the same for men and women.

Quit A Thousand Times

Chesapeake, Va., resident Tonya Guess says she has "a thousand reasons" to quit smoking. No. 1 is her 3-year-old daughter; Guess doesn't want her daughter to think smoking is "normal." "I want her to go 'yuck' when she smells cigarette smoke, says Guess. No. 2 is her health; Guess says she wants to live a long life and see her daughter grow up and get married. No. 3, she says, is her belief in God; she feels that she betrays God every time she reaches for a cigarette.

At this writing, Guess is on her sixth day without cigarettes, but she worries this attempt will end in failure. "I've tried to quit thousands of times, over and over again," she says, adding that she's tried the nicotine patch, the gum — just about "everything you can think of; it all works for about a week or two." And then, she says, something happens that makes her want a cigarette, no matter what.

"I'm hit with an emotion so intense that I don't think twice about it. Next thing you know, I'm back on cigarettes again," she says. And when that urgent craving hits, says Guess, "you don't think about your health or your child, you just think about that one cigarette; just one and I'll be fine again."

A More Complicated Addiction

Carolyn Mazure, a professor of psychology at Yale School of Medicine, is an expert on depression and addictive behaviors, and is principal investigator for the Sex-Specific Factors Core of the NIH-funded Transdisciplinary Tobacco Use Research Center at Yale, which was created to help people quit smoking.

She says cigarettes fill many roles for women who smoke. "Women often report smoking is helpful in reducing negative mood, even enhancing positive mood, managing the stress of daily life and also managing appetite and weight gain," says Mazure. "Women are looking to cigarettes to help them with those different situations, and as a consequence, it's often more difficult for women [than for men] to give up their cigarettes."

Mazure adds that depression and negative moods are more common among women than men. She says her research has shown that women are more "vulnerable to the negative effects of stress and are more likely to relapse back to smoking in the face of stressors" than men. "Women also believe that smoking will help them control their weight," she says.

Human Laboratory Work

Psychologists Mazure and Sherry McKee, both with Yale University, are involved in various studies looking at whether medications and therapy can help, particularly since women don't do as well as men when it comes to the popular first-line treatment for smoking cessation: nicotine replacement, like patches or gum.

With colleagues at Women's Health Research at Yale, they're now investigating whether certain medications can help women better resist cigarettes.

McKee directs the Yale Behavioral Pharmacology Laboratory and is an expert on behavioral factors related to tobacco addiction. Specifically, McKee is looking at whether medications can help ease anxiety and therefore reduce the urge to smoke. In one study, men and women either receive an active medication to reduce anxiety, or a placebo.

Study participants are asked to relay to researchers details of a stressful situation that provoked them to smoke. Researchers then create a fictionalized account of that situation and present it to participants. Participants have cigarettes available to them but are asked to resist. Researchers record whether those taking medication are better able to resist than those on the placebo.

Other studies are looking at various types of medication, including drugs that suppress appetite, to see what might help women resist smoking.

McKee says researchers are also investigating whether certain talk therapies can help women. The therapies help people figure out how to cope when faced with a stressful situation in ways other than grabbing a cigarette.

Such therapy helps people understand that they can engage in activities other than smoking to improve mood, says McKee, "like exercise, reaching out and getting support from somebody, or engaging in a distracting activity like going for a walk." McKee hopes to have some answers both about medication and behavioral therapy within the next few years.

-excerpt from NPR

Turtles Delay Flights At New York's JFK Airport

A runway at John F. Kennedy International Airport was shut down briefly Wednesday morning after at least 78 turtles emerged from a nearby bay and crawled onto the tarmac.

Grounds crews eventually rounded up the wayward reptiles and deposited them back in the brackish water farther from airport property, but not before the incident disrupted JFK's flight schedule and contributed to delays that reached nearly 1 1/2 hours.

"Apparently, this is something the tower has experienced before," said Federal Aviation Administration spokesman Jim Peters. "I guess it's the season for spawning."

The invasion began unfolding, slowly, at around 8:30 a.m., when an American Eagle flight crew reported seeing three turtles while taxiing out for departure. Before long, a chorus of pilots was radioing the tower to report turtles either on the end of a runway that juts out into the water, or approaching on the grass.

The FAA halted flights for about 12 minutes shortly before 9 a.m. while some of the turtles were cleared away, then quit using the runway entirely after getting new reports of "massive numbers" of turtles on the tarmac, Peters said.

Port Authority of New York and New Jersey spokesman John Kelly said airport crews gathered up the turtles in about 35 minutes.

He identified the turtles as Diamondback terrapins, a species common to Jamaica Bay, which surrounds the airport. The turtles appeared to be about 8 inches long and weighed 2 to 3 pounds each.

Jets hit turtles a few times each year at JFK, usually in the final days of June or beginning of July, according to the FAA's wildlife strike database. There have been no recent reports of the strikes causing any damage to an airplane.

-excerpt from NPR

Getting Lost Is Totally Human. Try It

"Let's get lost" is great when Chet Baker is singing about falling in love, but those three words can produce anxiety in anyone, even if you just make a wrong turn in your own hometown.

And we humans are good at getting lost because we are good at being so many places at once. As your feet wander down the street, your brain could be thinking about outer space or your vacation in Vegas or your backyard at home. So it's easy to zone out about where you actually are. But you can train yourself to be more conscious of your surroundings.

Colin Ellard just wrote a book on the topic: You Are Here: Why We Can Find Our Way to the Moon, but Get Lost in the Mall.

Ellard, a psychology professor at the University of Waterloo, took NPR's David Greene on a walk toward a woodsy area of Washington, D.C., to help Greene learn to appreciate being lost — which doesn't take long.

For example, if you want to remember where you parked the car, Ellard says, you can make up a story about something that's nearby.

"Let's look around here. Just paying attention to this house across the street — there's a nice little balcony. It's almost like a Romeo and Juliet balcony. You can conjure up Juliet," Ellard suggests.

"We've talked about that for 10 seconds," he says, so now it'll be easier to remember.

Ellard takes Greene deeper into the woods, and to test their sense of direction, they purposely veer off the dirt trail and walk several hundred feet into a stand of tall trees.

"When people are walking through dense vegetation, it can be difficult to know they're walking in a straight line," Ellard says. "You can make remarkable turns while thinking you're walking in a straight line."

That may not seem to matter — except, Ellard says, "There is a tendency for people to speed up in their movements, and if you march in the wrong direction, you get farther away faster."

Ellard's advice? "Once you're lost, your best decision is to stop."

But, he says, one of the hardest tricks for humans to learn is that sometimes, and in some places, it's OK to get lost — at least for a little while.

-excerpt from NPR

'Water Cops' Patrol L.A. For Violaters

California is in the midst of one of its worst droughts in decades. Residents of Los Angeles are banned from watering their lawns during the day and can only use sprinklers twice a week. To enforce the laws, the L.A. "Water Conservation Team" has taken to the street in Priuses to find water offending scofflaws.

- excerpt from npr

Madoff Likely Won't Be Serving Time In 'Club Fed'

Anyone who thinks convicted swindler Bernard Madoff will serve easy time in a "Club Fed" minimum-security prison should think again. He is unlikely to land in a cushy cellblock, and he will need to watch his back, consultants and former inmates say.

Madoff, who was sentenced to 150 years in prison for masterminding the largest Ponzi scheme in U.S. history, will likely do no better than medium security and could even be assigned to a maximum-security facility if his safety is deemed to be at risk — and it may well be, experts say.

"I don't believe Bernie Madoff is going to give anybody any trouble in prison," says Ed Bales, managing director for Federal Prison Consultants LLC. "But the fact is: What are those other inmates going to do? Is he going to get killed? That's probably the No. 1 question."

Wherever he goes will be based partly on a point system that will give him positive marks for his age (he's 71), his college education and the fact that he has no history of violence. But the sheer magnitude of his sentence would likely offset most or all of the items in the plus column, experts say.

Another consideration is geography. Inmates are generally placed within 500 miles of home, which leaves some unpleasant options for Madoff, a New Yorker. The Lewisburg facility in Pennsylvania, for example, is an aging high-security prison known for its gang violence.

Madoff's notoriety and the nature of his crime will also work against him. At twice the age of most other federal inmates — most of whom were convicted of drug-related crimes and will serve a fraction of his time — the disgraced financier will find it difficult to make friends.

Marvin Ragland, a former inmate who served nine years for drug possession and trafficking, says white-collar criminals such as Madoff are "the low man on the totem pole."

"Everybody hates those kind of guys," he says. Ragland says the pecking order comes down to an unwritten prison code.

"The greater the crime against society, the worse you are treated," he says.

"This guy … told Grandma that he had a great [place] for her to put her money and that it would be safe and she wouldn't have to worry about it," he says. "Grandma's money is gone [and] now she's got to figure out who's going to take care of her. It burdens her whole family, right down to the grandkids."

But other inmates aren't Madoff's only threat, says Pat Nolan, who was the minority leader of the California state assembly until he pled guilty to racketeering for campaign fraud in the 1990s. He served two years in federal prison.

"I was in with several millionaires, and boy, the [corrections] officers really resented them," he says.

Nolan says Madoff will have to fight off the constant negative drumbeat from fellow inmates: "You are nothing, you come from nothing, you will be nothing, you lost everything."

Ragland says he has seen a lot of white-collar inmates cry in prison. They can't handle having to wait up to three weeks for extra paper to write on, asking permission to have a glass of water, or having to barter with other inmates for an ink pen. And they can't handle the violence or the loneliness.

Ragland, who is now sober and about to graduate from trucking school, says he only survived prison because he knew he'd eventually get out.

For Madoff, who will almost certainly die in prison, "it's going to be hell," Ragland says.

To make it in prison, Ragland says, you have to have something that Madoff doesn't. "You have to have something to dream of and hope for," he says.

-excerpt from NPR