A randomized controlled trial of cognitive-behavior therapy plus bright light therapy for adolescent delayed sleep phase disorder

OBJECTIVE

To evaluate cognitive-behavior therapy plus bright light therapy (CBT plus BLT) for adolescents diagnosed with delayed sleep phase disorder (DSPD).

DESIGN

Randomized controlled trial of CBT plus BLT vs. waitlist (WL) control with comparisons at pre- and post-treatment. There was 6-month follow-up for the CBT plus BLT group only.

SETTING

Flinders University Child & Adolescent Sleep Clinic, Adelaide, South Australia.

PATIENTS

49 adolescents (mean age 14.6 ± 1.0 y, 53% males) diagnosed with DSPD; mean chronicity 4 y 8 months; 16% not attending school. Eighteen percent of adolescents dropped out of the study (CBT plus BLT: N = 23 vs. WL: N = 17).

INTERVENTIONS

CBT plus BLT consisted of 6 individual sessions, including morning bright light therapy to advance adolescents' circadian rhythms, and cognitive restructuring and sleep education to target associated insomnia and sleep hygiene.

MEASUREMENTS AND RESULTS

DSPD diagnosis was performed via a clinical interview and 7-day sleep diary. Measurements at each time-point included online sleep diaries and scales measuring sleepiness, fatigue, and depression symptoms. Compared to WL, moderate-to-large improvements (d = 0.65-1.24) were found at post-treatment for CBT plus BLT adolescents, including reduced sleep latency, earlier sleep onset and rise times, total sleep time (school nights), wake after sleep onset, sleepiness, and fatigue. At 6-month follow-up (N = 15), small-to-large improvements (d = 0.24-1.53) continued for CBT plus BLT adolescents, with effects found for all measures. Significantly fewer adolescents receiving CBT plus BLT met DPSD criteria at post-treatment (WL = 82% vs. CBT plus BLT = 13%, P < 0.0001), yet 13% still met DSPD criteria at the 6-month follow-up.

CONCLUSIONS

CBT plus BLT for adolescent DSPD is effective for improving multiple sleep and daytime impairments in the immediate and long-term. Studies evaluating the treatment effectiveness of each treatment component are needed.

CLINICAL TRIAL INFORMATION

Australia-New Zealand Trials Registry Number: ACTRN12610001041044.

Predictors of posttraumatic stress in children following injury: The influence of appraisals, heart rate, and morphine use

Prospective studies of posttraumatic stress disorder (PTSD) in children that investigate simultaneously both cognitive and biological or psychophysiological predictors are rare. The present research reports on the impact of cognitive factors (trauma-related appraisals) and biological indicators (heart rate, morphine use) in predicting PTSD and depression symptoms following single-incident trauma. Children and adolescents (N=48) were assessed within 4 weeks of an injury that led to hospital treatment and followed up 6-months later. While morphine did not predict initial PTSD severity, it was associated with lower levels of PTSD at follow-up. Reductions in PTSD symptoms (change scores) between assessments were similarly associated with morphine dosage. Trauma-related appraisals also contributed to PTSD and depression symptom severity. While slightly different patterns of results were obtained depending on whether static or change scores were examined, as a whole the study adds to a growing literature that morphine has the potential to reduce PTSD symptoms severity. Likewise the relationship between unhelpful trauma appraisals and posttrauma psychopathology was replicated.

Enteral histaminosis: Clinical implications

There is increasing evidence that enteral histaminosis is a major cause of food intolerance resulting from dysfunctional metabolism of endogenous histamine in certain food stuffs. However, this phenomenon has been poorly characterised and, due to the lack of epidemiological data, the existence of this condition has been underestimated, which may lead to incorrect diagnosis. This short commentary highlights a stricter regimen of diagnostic procedure in order to take into account the many causes of food intolerance. The underlying mechanisms ascribed particularly to non-immunologically food reactions require more rigorous research and further work is vital.

[Intrafemoral pressure measurement in different cement removal procedures during hip prosthesis replacement operations--experimental study with cadaver femora]

During primary hip arthroplasty an increase in intramedullary pressure (IMP) of up to 1000 mm Hg can be observed. As a result of this increased intrafemoral pressure, intramedullary constituents can pass into the venous circulation creating a risk of fat embolism syndrome (FES). In the present experimental study on 9 femora obtained from human corpses, we investigated the question as to whether various methods of cement removal during total hip revision arthroplasty are also associated with increased intramedullary pressure and a risk of FES. The IMP was recorded with a standardized experimental set-up during removal of cement from the proximal and distal regions, including removal of the cement "tip" and the intramedullary plug. The methods employed for this purpose included the osteotome and mallet, a compressed air powered chisel, and a modified intracorporal lithotripter. All the methods induced fluctuations in the IMP the highest values being recorded for the conventional method using the osteotome and mallet (45 mm Hg) and the lowest values for the intracorporeal lithotripter (7.5 mm Hg). Working on the distal cement caused higher fluctuations in comparison with the proximal region. The study failed to reveal any increase in mean IMP, and all measured values were in the low pressure range (considerably below 150 mm Hg). While there seems to be no apparent risk of an FES developing during removal of cement, careless manipulation of the distal cement plug may result in higher intrafemoral pressures--above 150 mm Hg--thus increasing the risk of a fat embolism syndrome.

Zinc metabolism in fasted rats

The effects of short-term starvation on serum and tissue levels of zinc, metallothionein (MT), and the activity of alkaline phosphatase (EC 3.1.3.1, ALP) were investigated with 6-month-old rats. The rats were fed a diet with adequate zinc (92mg/kg of Zn, 1.12% phytic acid) before they were starved for 0h (control), 12h, 24h, and 36h and then killed by decapitation. Fasting was accompanied by typical changes in serum parameters such as reduced glucose and protein concentrations, elevated ketogenesis, and a rapid breakdown of liver glycogen. Fasting did not alter serum zinc levels, but it did lead to a significant elevation in the percent of unsaturated serum-zinc binding capacity. Liver concentrations of zinc and MT, based both on fresh and dry weight, were increased throughout starvation. However, total liver zinc was reduced by up to 23% in response to fasting and total liver MT was slightly elevated. The increased concentrations of liver zinc and MT are, therefore, mainly a consequence of reduced liver weight. A part of the liver zinc, however, was bound to newly synthesized MT to prevent greater zinc loss. Starvation evoked no altered mucosa MT levels. Changes in kidney zinc and kidney medulla MT caused by starvation were small and not significant. In contrast to this observation some variation of kidney cortex MT was apparent. Starvation produced a permanent reduction of the serum and intestinal activity of ALP. In the liver and the medulla of the kidneys no significant differences of ALP activity could be observed. However, kidney cortex ALP was induced after 36h of fasting.(ABSTRACT TRUNCATED AT 250 WORDS)

Short-term memory performance with magnetic stimulation of the motor cortex

Whether transcranial magnetic stimulation of the motor cortex has an influence on memory was investigated. In a first experiment with 21 healthy volunteers six pronounceable nonsense words were visually presented, immediately followed by a magnetic stimulus. There were three blocks of stimulation with field intensities of 60, 80 and 100% (referring to a maximal intensity of 2 Tesla), each block comprising six magnetic stimuli and six nonsense words. After each block there was a free recall test and at the end another free recall trial as well as a multiple-choice recognition test for all 18 words. Eighteen subjects served as controls, undergoing the same procedure, except that the field intensity was zero. A significant but small reduction of short-term memory performance was observed only for 100% field intensity. In a second experiment with 16 subjects who had not participated in experiment I, the effect of 100% intensity cortical magnetic stimulation was compared with a control stimulation over the cervical spine. There was no difference in free recall or in the multiple-choice test between the sites of stimulation, suggesting that the difference in the 100% intensity block in experiment I was not due to a specific cortical effect of the magnetic field on memory function. With respect to the effect on memory functions, transcranial magnetic stimulation of the motor cortex is thought to be a safe method.