The Sleepio After Cancer (SAC) study. Digital cognitive behavioural therapy for insomnia (dCBT-I) in women cancer patients - Trial protocol of a randomised controlled trial

AIMS

This study will assess the efficacy of digital CBT for insomnia (dCBT-I) compared to sleep hygiene education (SHE) for the management of insomnia in women with cancer.

BACKGROUND

30% of patients with cancer meet insomnia diagnostic criteria and this can be detrimental to health outcomes. Insomnia disorder comprises a dissatisfaction with sleep quantity or quality characterized by difficulty initiating sleep, frequent awakenings, or early morning wakening without the ability to return to sleep, at least 3 nights per week, for at least 3 months, causing significant impairment or distress in areas of functioning.

METHODS

We will recruit 308 women with a current or prior cancer diagnosis who are currently experiencing insomnia; defined as a score of 16 or less on the Sleep Condition Indicator (SCI). Participants will be randomised to dCBT-I or SHE. dCBT-I will be delivered online via 6 sessions. SHE will be provided in an online format. Assessments of sleep and other related parameters, through validated questionnaires, will be taken at 12 and 24 weeks following intervention. Once 24 week assessments are completed, participants will crossover to the alternate arm (either SHE or dCBT-I) and undergo a final assessment at week 36.

OUTCOMES

The primary outcome will be the mean continuous change in SCI score in the intervention arm compared to the control arm at 24 weeks. Additionally, the proportion of women with an SCI > 16 at 24 weeks will be assessed. Secondary outcomes include fatigue, sleep related quality of life, depression, anxiety, and hot flush interference.

REGISTRATION

This study is registered on ClinicalTrials.gov with number NCT05816460.

Acute renal failure due to lymphomatous infiltration of the kidneys

Acute renal failure (ARF) is an unusual manifestation of lymphomatous infiltration of the kidneys. In this article, a patient whose initial presentation of lymphoma was the sudden onset of painless hematuria and ARF is described. The absence of other causes of ARF, together with massively enlarged unobstructed kidneys on renal ultrasonography, strongly suggested an infiltrative process. Renal biopsy established the diagnosis of non-Hodgkin's lymphoma. Pulse steroid therapy was associated with rapid improvement of renal function and kidney size, but a moderate degree of tumor lysis syndrome ensued. Further recovery followed with chemotherapy. Whereas widespread infiltration of the kidneys is present in almost one third of patients with lymphoma at autopsy, this rarely causes clinical symptoms. Nevertheless, because it often responds to therapy, lymphomatous infiltration should be suspected in any patient presenting with unexplained ARF and enlarged kidneys, especially in the setting of widespread lymphoma.

The use of cyclosporin A in adult nephrotic syndrome: nine cases and literature review

Nine adult patients with resistant nephrotic syndrome were treated with cyclosporin A (CyA). All had failed to respond to high dose corticosteroids with or without cyclophosphamide. Three patients had minimal change disease, 3 had focal sclerosing glomerulosclerosis (FSGS), 2 had mesangiocapillary GN, and one had membranous nephropathy. The mean age of the patients was 26.4 years (range 16 to 39 years). CyA was given orally twice daily at a mean dose of 6.7 mg/kg/24 hours (range 6-10 mg/kg/24 hours). Four patients achieved full remission, two patients went into partial remission and three failed to respond. Two patients developed clinical nephrotoxicity, which reversed on dose reduction or cessation of CyA. All 3 patients with minimal change disease who responded subsequently relapsed after stopping CyA, but remitted rapidly on reintroduction of the drug. We suggest that the mode of action of CyA in nephrotic syndrome may be related to intra-renal vasoconstriction in addition to its direct immunosuppressive effect. In this limited series, we found that CyA can be an effective therapy for otherwise refractory nephrotic syndrome, although relapse on withdrawal of CyA may well be a significant clinical problem.

Familial adult medullary cystic disease with spastic quadriparesis: a new disease association

We present two cases of familial adult medullary cystic disease with spastic quadriparesis, an association not previously described. Previous extrarenal associations of the nephronophthisis-medullary cystic disease complex were reported exclusively in childhood cases. Both patients have undergone successful cadaveric renal transplantation, with no evidence of their renal disease recurring. Further work is needed to elucidate the complex genetics of nephronophthisis.

Systemic vasculitis with renal involvement--a review

Twenty five patients with renal vasculitis presenting over an eight year period were reviewed. Ten had microscopic polyarteritis, 6 classic polyarteritis, 5 overlap syndrome, 2 Churg-Strauss syndrome and 2 Wegener's granulomatosis. Clinical features included hypertension, pulmonary involvement, neurological involvement and arthralgia. Serum creatinine was over 500 umol/l in 13 patients, 10 of whom required dialysis. Visceral angiography was positive in 80% of those studied, Focal and segmental necrotising glomerulonephritis was the commonest renal lesion. Treatment consisted of corticosteroids and cytotoxic agents in most cases. Plasmapheresis was used for rapidly progressive renal failure, severe pulmonary haemorrhage or cerebral vasculitis. Improvement or stabilisation of renal function was seen in 68% of patients treated. There were 4 early deaths and one late death. The diagnosis, histology, treatment and outcome of renal vasculitis is discussed. The importance of early diagnosis and treatment is emphasised in this potentially reversible cause of acute renal failure.

Living related renal transplantation in Ireland: a sixteen year review

Between January 1972 and December 1987, a total of 777 transplants were performed of which 135 (17%) were living related. There were 108 sibling donors, 25 parent to child and 2 child to parent. All sibling transplants were HLA identical. Conventional immunosuppression with Prednisone and Azathioprine was used in all cases. Actuarial patient survival were 95%, 91% and 88% at 1, 5 and 10 years respectively. Corresponding actuarial graft survivals were 90%, 80% and 60%. Graft survival in the sibling compared to the parent to child group was 87% versus 60% at 5 years. There were 13 deaths during the study interval and 32 grafts were lost. Five year patient/graft survivals of 91/80% compare favourably with other reported series. The poorer outcome in parent to child transplants has led us to modify the immunosuppressive protocol to include Cyclosporin A in this group. The increased availability and improved survival of cadaveric grafts in recent years and our one year patient/graft survival of 92/88% has led us to reduce emphasis on living related transplantation in our renal replacement programme.

Recurrent glomerulonephritis in renal transplants: fourteen years' experience

A retrospective study of the clinical records and biopsy specimens of all transplants performed between 1974 and 1987 was carried out. Recurrent glomerulonephritis was diagnosed only in those patients who had precise histological classification of their original disease. Of a total of 737 transplants performed in 633 recipients. 603 were from cadaveric and 134 from living related donors. Of 295 patients who were clinically classed as having chronic glomerulonephritis, histological confirmation was available in 156 (54%) as follows: membranoproliferative glomerulonephritis 34%, diffuse proliferative glomerulonephritis 27%, crescentic glomerulonephritis 13% IgA neuropathy 10%, focal sclerosing glomerulonephritis 10%, and membranous nephropathy 7%. There were 24 cases of recurrence in 23 recipients. Of these, 16 occurred in living-related and 8 in cadaveric grafts. Membranoproliferative glomerulonephritis recurred in 14 (8 type I and 6 type II), focal sclerosing glomerulonephritis in 5, IgA neuropathy in 3, crescentic glomerulonephritis in 1 and membranous nephropathy in 1. Graft failure occurred in 13 patients (54%) and was directly attributable to recurrent disease in 12. Membranoproliferative glomerulonephritis caused 8 graft losses, focal sclerosing glomerulonephritis 2, IgA 1 and crescentic glomerulonephritis 1. Recurrence caused graft loss in 50% of cases in which it occurred. The overall incidence of recurrence was 18%. In contrast to other series, a significantly higher incidence of recurrence was seen in our living-related group.