A Smartphone App for Adolescents With Sleep Disturbance: Development of the Sleep Ninja

BACKGROUND

Sleep disturbances are common in young people and have consequences for academic, social, emotional, and behavioral development. The most effective treatment is cognitive behavioral therapy for insomnia (CBT-I), with evidence suggesting that it is efficacious even when delivered digitally.

OBJECTIVE

There are no commercially available digitally delivered CBT-I programs for use by young people. The aim of this project was to develop a smartphone app that delivers CBT-I to young people to improve sleep.

METHODS

To inform the development of the app, young people (N=21) aged between 12 and 16 years attended one of the 3 focus groups (each with 4-10 participants). These focus groups were conducted at different stages of the development process such that the process could be iterative. Participants were asked the reasons why they might use an app to help them sleep, the kinds of features or functions that they would like to see in such an app, and any concerns they may have in using the app. Data were analyzed using a thematic analysis approach. Of the issues discussed by the participants, the researchers selected themes associated with content, functionality, and accessibility and user experience to examine, as these were most informative for the app design process.

RESULTS

In terms of content, young people were interested in receiving information about recommended sleep guidelines and personalized information for their age group. They reported that keeping a sleep diary was acceptable, but they should be able to complete it flexibly, in their own time. They reported mixed views about the use of the phone's accelerometer. Young people felt that the functionality of the app should include elements of game playing if they were to remain engaged with the app. Flexibility of use and personalized features were also desirable, and there were mixed views about the schedule of notifications and reminders. Participants reported that for the app to be accessible and usable, it should be from a trusted developer, have engaging aesthetics, have a layout that is easy to navigate, not rely on Internet coverage, and preferably be free. Participants felt that being able to conceal the purpose of the app from peers was an advantage and were willing to provide personal information to use the app if the purpose and use of that information was made clear. Overall, participants endorsed the use of the app for sleep problems among their age group and reported motivation to use it.

CONCLUSIONS

The Sleep Ninja is a fully-automated app that delivers CBT-I to young people, incorporating the features and information that young people reported they would expect from this app. A pilot study testing the feasibility, acceptability, and efficacy of the Sleep Ninja is now underway.

Stress and distress in parents of neonates admitted to the neonatal intensive care unit for cardiac surgery

BACKGROUND

Parents of infants admitted to the Neonatal Intensive Care Unit (NICU) are at risk of psychological distress and NICU-related stress. However, parents of infants admitted to NICU for cardiac surgery are an under-researched population.

AIMS

Identify levels of NICU-related stress, and levels of psychological distress, reported by parents of infants admitted to the NICU for cardiac surgery.

STUDY DESIGN

Observational study.

SUBJECTS

69 parents of infants admitted to the NICU for cardiac surgery (cardiac group) and 142 parents of healthy infants (control group).

OUTCOME MEASURES

Questionnaire packs provided to parents prior to discharge (time-point 1), and at six and 12months corrected age included: Hospital Anxiety and Depression Scale, Coping Inventory for Stressful Situations, and Family Support Scale. The Parental Stressor Scale:NICU was administered to the cardiac group at time-point 1.

RESULTS

The cardiac group reported (i) that parental role alteration was the most stressful aspect of the NICU and (ii) higher scores for anxiety and depression than the control group at all three time-points, with the highest levels reported during the NICU stay. Correlation analyses indicated (i) stress associated with the sights and sounds of the NICU, and the appearance and behaviour of the infant in the NICU, had a significant positive association with anxiety and depression, and (ii) a significant negative relationship between anxiety and task-focused coping.

CONCLUSIONS

An individualised parent-targeted intervention aimed at reducing stress associated with the NICU and enhancing task-focused coping style may help to reduce levels of anxiety and depression within this group of parents.

Transdiagnostic versus disorder-specific and clinician-guided versus self-guided internet-delivered treatment for Social Anxiety Disorder and comorbid disorders: A randomized controlled trial

Disorder-specific (DS-CBT) and transdiagnostic (TD-CBT) cognitive behaviour therapy have both been used to treat social anxiety disorder (SAD). This study compared internet-delivered DS-CBT and TD-CBT for SAD across clinician-guided (CG-CBT) and self-guided (SG-CBT) formats. Participants with SAD (n=233) were randomly allocated to receive internet-delivered TD-CBT or DS-CBT and CG-CBT or SG-CBT. Large reductions in symptoms of SAD (Cohen's d≥1.01; avg. reduction≥30%) and moderate-to-large reductions in symptoms of comorbid depression (Cohen's d≥1.25; avg. reduction≥39%), generalised anxiety disorder (Cohen's d≥0.86; avg. reduction≥36%) and panic disorder (Cohen's d≥0.53; avg. reduction≥25%) were found immediately post-treatment and were maintained or further improved to 24-month follow-up. No marked differences were observed between TD-CBT and DS-CBT or CG-CBT and SG-CBT highlighting the potential of each for the treatment of SAD and comorbid disorders.

Neonatal-perinatal medicine fellow procedural experience and competency determination: results of a national survey

OBJECTIVE

Ensuring that neonatal-perinatal medicine (NPM) fellows attain competency in performing neonatal procedures is a requirement of training-competent neonatologists.

STUDY DESIGN

A survey of NPM fellows was performed to determine the procedural experience of current fellows, investigate techniques used to track procedural experience and examine the methods programs use to verify procedural competency.

RESULTS

One hundred and sixty-three fellows in 57 accredited training programs responded to the survey. Reported number of procedures provide contemporary normative data on procedural experience during training. The majority of fellows reported using an online reporting system to track experience. The most common technique to verify procedural competency was supervised practice until an arbitrary number of procedures had been performed.

CONCLUSIONS

NPM fellow procedural experience increases significantly for most, but not all, procedures duration training. We speculate that supplemental simulation training for rare neonatal procedures would help ensure the competency of graduating NPM fellows. Experience alone is insufficient to verify competency. Further work on the accurate tracking of experience and verification of procedural competency is needed.

A prospective examination of Axis I psychiatric disorders in the first 5 years following moderate to severe traumatic brain injury

BACKGROUND

Psychiatric disorders commonly emerge during the first year following traumatic brain injury (TBI). However, it is not clear whether these disorders soon remit or persist for long periods post-injury. This study aimed to examine, prospectively: (1) the frequency, (2) patterns of co-morbidity, (3) trajectory, and (4) risk factors for psychiatric disorders during the first 5 years following TBI.

METHOD

Participants were 161 individuals (78.3% male) with moderate (31.2%) or severe (68.8%) TBI. Psychiatric disorders were diagnosed using the Structured Clinical Interview for DSM-IV, administered soon after injury and 3, 6 and 12 months, and 2, 3, 4 and 5 years post-injury. Disorder frequencies and generalized estimating equations were used to identify temporal relationships and risk factors.

RESULTS

In the first 5 years post-injury, 75.2% received a psychiatric diagnosis, commonly emerging within the first year (77.7%). Anxiety, mood and substance-use disorders were the most common diagnostic classes, often presenting co-morbidly. Many (56.5%) experienced a novel diagnostic class not present prior to injury. Disorder frequency ranged between 61.8 and 35.6% over time, decreasing by 27% [odds ratio (OR) 0.73, 95% confidence interval (CI) 0.65-0.83] with each year post-injury. Anxiety disorders declined significantly over time (OR 0.73, 95% CI 0.63-0.84), whilst mood and substance-use disorder rates remained stable. The strongest predictors of post-injury disorder were pre-injury disorder (OR 2.44, 95% CI 1.41-4.25) and accident-related limb injury (OR 1.78, 95% CI 1.03-3.07).

CONCLUSIONS

Findings suggest the first year post-injury is a critical period for the emergence of psychiatric disorders. Disorder frequency declines thereafter, with anxiety disorders showing greater resolution than mood and substance-use disorders.

Disorder-specific versus transdiagnostic and clinician-guided versus self-guided internet-delivered treatment for panic disorder and comorbid disorders: A randomized controlled trial

Transdiagnostic cognitive behaviour therapy (TD-CBT) aims to target the symptoms of multiple disorders whereas disorder-specific CBT (DS-CBT) targets the symptoms of principal disorders. This study compared the relative benefits of internet-delivered TD-CBT and DS-CBT when provided in clinician-guided (CG-CBT) and self-guided (SG-CBT) formats for people with a principal diagnosis of Panic Disorder (PD). Participants (n=145) were randomly allocated to receive TD-CBT or DS-CBT and CG-CBT or SG-CBT. Large reductions in symptoms of PD (Cohen's d ≥ 0.71; avg. reduction ≥ 36%) and moderate-to-large reductions in symptoms of comorbid depression (Cohen's d ≥ 0.71; avg. reduction ≥ 33%), generalised anxiety disorder (Cohen's d ≥ 0.91; avg. reduction ≥ 34%) and social anxiety disorder (Cohen's d ≥ 0.50; avg. reduction ≥ 15%) were found over the 24-month follow-up period. Highlighting their efficacy and acceptability, no marked and consistent differences were observed between TD-CBT and DS-CBT or CG-CBT and DS-CBT.

Abstract P6-10-12: Volumetric breast density better predicts tumour characteristics associated with poor prognosis compared to visual BI-RADS

Purpose:

Early detection of breast cancer through mammography screening reduces breast cancer mortality. To improve outcomes from screening, more than half of invasive cancers and a third of high grade cancers should be small at detection (<15mm), and more than 70% of all cancers should be node negative at diagnosis. Although breast density is associated with reduced mammographic sensitivity, it is unclear whether certain tumor characteristics associated with poorer prognosis are more prevalent in women with denser breasts. The study investigated associations between visually- or volumetrically-assessed breast density and tumor characteristics related to poor prognosis.

Methods:

Our IRB-approved study included 755 DCIS, invasive ductal or invasive lobular breast cancers diagnosed in women (aged over 40) between January 2009 and December 2012. Information on the patients' tumor characteristics including stage, size, receptor, grade and lymph node status was collected retrospectively. Women were excluded if they had a previous history of breast cancer or breast surgery, or if they were missing tumour size data or raw digital mammograms taken within 24 months of the cancer diagnosis. For women with multiple cancers, only the first diagnosed cancer was included. Breast density was assessed using visual BI-RADS density categories and Volpara Density Grades (VDG; an automated equivalent to 4th Edition BI-RADS, assigned using preset cut-offs of volumetric breast density: 4.5, 7.5, 15.5 and >15.5%). VDG was calculated from both breasts if the prior negative mammogram was available, and the contralateral breast for positive mammograms.

Results:

Overall, 55% of invasive tumors and 33% of grade 3 tumors were smaller than 15 mm and 83% were node negative. Mean tumor size increased significantly with increasing VDG (VDG 1 = 12.8, 2 = 14.7, 3 = 16.1, 4 = 20.4 mm, p<0.001) and increasing BI-RADS (1 = 12.2, 2 = 13.9, 3 = 16.8, 4 = 18.2 mm, p=0.01). The proportion of node positive tumors also increased significantly with increasing VDG (5.1%, 12.8%, 19.3%, 26.1%, p<0.001) and BI-RADS (0%, 10.6%, 19.5%, 26%, p=0.01). There was a significant increase in grade 3 tumors (11%, 16.1%, 21.7%, 21.7%, p =0.02) and HER-2 positive tumors (5.6%, 10.5%, 13.3%, 14.3%, p=0.02) with increasing VDG that was not seen with visual BI-RADS assessment (p=0.4). Increasing VDG was also significantly associated with increased proportions of larger (i.e. >15mm) node positive cancers (1.7%, 6.3%, 10.5%, 16%, p=0.004) that were not seen with BI-RADS (p=0.2).

Conclusion:

We found that tumour size and node status differed significantly with breast density as measured by VDG and visual BI-RADS. However, grade 3, HER-2 positive and large/node-positive cancers were all significantly associated with increasing VDG, but not BI-RADS density grade. Further research is needed to investigate whether automated volumetric breast density can be used to predict which women are more likely to be diagnosed with tumours that have poorer prognostic features.

Citation Format: Johnston L, Chan A, Arieno A, Morgan R, Highnam R, Destounis S. Volumetric breast density better predicts tumour characteristics associated with poor prognosis compared to visual BI-RADS. [abstract]. In: Proceedings of the Thirty-Eighth Annual CTRC-AACR San Antonio Breast Cancer Symposium: 2015 Dec 8-12; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2016;76(4 Suppl):Abstract nr P6-10-12.

Transdiagnostic versus disorder-specific and clinician-guided versus self-guided internet-delivered treatment for generalized anxiety disorder and comorbid disorders: A randomized controlled trial

Generalized anxiety disorder (GAD) can be treated effectively with either disorder-specific cognitive behavior therapy (DS-CBT) or transdiagnostic CBT (TD-CBT). The relative benefits of DS-CBT and TD-CBT for GAD and the relative benefits of delivering treatment in clinician guided (CG-CBT) and self-guided (SG-CBT) formats have not been examined. Participants with GAD (n=338) were randomly allocated to receive an internet-delivered TD-CBT or DS-CBT intervention delivered in either CG-CBT or SG-CBT formats. Large reductions in symptoms of GAD (Cohen's d ≥ 1.48; avg. reduction ≥ 50%) and comorbid major depressive disorder (Cohen's d ≥ 1.64; avg. reduction ≥ 45%), social anxiety disorder (Cohen's d ≥ 0.80; avg. reduction ≥ 29%) and panic disorder (Cohen's d ≥ 0.55; avg. reduction ≥ 33%) were found across the conditions. No substantive differences were observed between DS-CBT and TD-CBT or CG-CBT and SG-CBT, highlighting the public health potential of carefully developed TD-CBT and SG-CBT.

Disorder-specific versus transdiagnostic and clinician-guided versus self-guided treatment for major depressive disorder and comorbid anxiety disorders: A randomized controlled trial

Disorder-specific cognitive behavior therapy (DS-CBT) is effective at treating major depressive disorder (MDD) while transdiagnostic CBT (TD-CBT) addresses both principal and comorbid disorders by targeting underlying and common symptoms. The relative benefits of these two models of therapy have not been determined. Participants with MDD (n=290) were randomly allocated to receive an internet delivered TD-CBT or DS-CBT intervention delivered in either clinician-guided (CG-CBT) or self-guided (SG-CBT) formats. Large reductions in symptoms of MDD (Cohen's d≥1.44; avg. reduction≥45%) and moderate-to-large reductions in symptoms of comorbid generalised anxiety disorder (Cohen's d≥1.08; avg. reduction≥43%), social anxiety disorder (Cohen's d≥0.65; avg. reduction≥29%) and panic disorder (Cohen's d≥0.45; avg. reduction≥31%) were found. No marked or consistent differences were observed across the four conditions, highlighting the efficacy of different forms of CBT at treating MDD and comorbid disorders.

Functional expression of KCNQ (Kv7) channels in guinea pig bladder smooth muscle and their contribution to spontaneous activity

Background and Purpose

The aim of the study was to determine whether KCNQ channels are functionally expressed in bladder smooth muscle cells (SMC) and to investigate their physiological significance in bladder contractility.

Experimental Approach

KCNQ channels were examined at the genetic, protein, cellular and tissue level in guinea pig bladder smooth muscle using RT-PCR, immunofluorescence, patch-clamp electrophysiology, calcium imaging, detrusor strip myography, and a panel of KCNQ activators and inhibitors.

Key Results

KCNQ subtypes 1–5 are expressed in bladder detrusor smooth muscle. Detrusor strips typically displayed TTX-insensitive myogenic spontaneous contractions that were increased in amplitude by the KCNQ channel inhibitors XE991, linopirdine or chromanol 293B. Contractility was inhibited by the KCNQ channel activators flupirtine or meclofenamic acid (MFA). The frequency of Ca²⁺-oscillations in SMC contained within bladder tissue sheets was increased by XE991. Outward currents in dispersed bladder SMC, recorded under conditions where BK and K_ATP currents were minimal, were significantly reduced by XE991, linopirdine, or chromanol, and enhanced by flupirtine or MFA. XE991 depolarized the cell membrane and could evoke transient depolarizations in quiescent cells. Flupirtine (20 μM) hyperpolarized the cell membrane with a simultaneous cessation of any spontaneous electrical activity.

Conclusions and Implications

These novel findings reveal the role of KCNQ currents in the regulation of the resting membrane potential of detrusor SMC and their important physiological function in the control of spontaneous contractility in the guinea pig bladder.

Matching residency numbers to the workforce needs

Matching the number of surgeons to the demands for orthopedic services has been notoriously difficult. Not only does one need to evaluate current trends in the supply and provision of services but anticipate the impact of future reforms on these variables. The British Orthopaedic Association has aspired to provide consultant to population ratio of 1:15,000 by 2020. Currently, the orthopedic community is tasked with providing care for an aging population with soaring levels of obesity; with both of these factors set to grow and also with an overall decline in productivity. Orthopedic surgeons must brace themselves for an explosion in demand. At the same time, a paradigm shift has occurred in the delivery of services with the creation of specialist centers. We are amidst a generational shift in the demographics and psychology of the orthopedic workforce. The orthopedic community must be aware of the effects of these far-reaching changes when tailoring the supply of surgeons for the future needs.

Prevalence of graft versus host disease and cytomegalovirus infection in patients post-haematopoietic cell transplantation presenting with gastrointestinal symptoms

BACKGROUND

There is lack of consensus regarding whether both upper and lower endoscopic examinations are required for diagnosis of gastrointestinal acute graft versus host disease (GI-AGVHD).

AIM

To evaluate the impact of endoscopic procedures on the diagnosis of GI-AGVHD.

METHODS

We performed a retrospective case-control study of recipients of allogeneic haematopoetic cell transplant (HCT) from 2000 to 2011, who presented with GI symptoms between 20 and 125 days post-HCT. GI-AGVHD status was based on the National Institutes of Health (NIH) clinical grading system.

RESULTS

One hundred and twenty-nine clinical GI-AGVHD cases and 184 controls underwent endoscopic examinations. Diarrhoea was present in 73% of cases and 38% of controls (P < 0.0001); 99% of patients with nausea ± vomiting and diarrhoea underwent bidirectional endoscopy. Histology had a sensitivity of 92% and specificity of 91% compared to the clinical criteria. The sensitivity for GI-AGVHD was 80% or greater when upper endoscopy (EGD) was performed with either sigmoidoscopy or colonoscopy, or if lower endoscopic examinations were performed alone. The sensitivity of EGD alone was only 48% (P = 0.003). Sensitivity was highest with biopsy of the terminal ileum (79%), followed by the ascending (74%), transverse/descending (73%) and sigmoid colons (69%). Diagnostic yield for cytomegalovirus (CMV) infection was equivalent for biopsies from both upper and lower GI tracts. Patients found to have concurrent GI-AGVHD and CMV infection (N = 18) had a poorer overall prognosis.

CONCLUSION

In patients post-HCT with GI symptoms, sigmoidoscopy alone had equivalent diagnostic yield for GI-AGVHD and CMV infection, compared with the addition of EGD or performance of full colonoscopy.