Cognitive behavioural interventions for sleep problems in adults aged 60+

BACKGROUND

The prevalence of sleep problems in adulthood increases with age. While not all sleep changes are pathological in later life, severe disturbances may lead to depression, cognitive impairments, deterioration of quality of life, significant stresses for carers and increased healthcare costs. The most common treatment for sleep disorders (particularly insomnia) is pharmacological. The efficacy of non-drug interventions has been suggested to be slower than pharmacological methods, but with no risk of drug-related tolerance or dependency. Cognitive and behavioural treatments for sleep problems aim to improve sleep by changing poor sleep habits, promoting better sleep hygiene practices and by challenging negative thoughts, attitudes and beliefs about sleep.

OBJECTIVES

To assess the efficacy of cognitive-behavioural interventions in improving sleep quality, duration and efficiency amongst older adults (aged 60 and above).

SEARCH STRATEGY

The following databases were searched: MEDLINE (1966 - October 2001); EMBASE (1980 - January 2002), CINAHL ( 1982 - January 2002; PsychINFO 1887 to 2002; The Cochrane Library (Issue 1, 2002); National Research Register (NRR [2002]). Bibliographies of existing reviews in the area, as well as of all trial reports obtained, were searched. Experts in the field were consulted.

SELECTION CRITERIA

Randomised controlled trials of cognitive behavioural treatments for primary insomnia where 80% or more of participants were over 60. Participants must have been screened to exclude those with dementia and/or depression.

DATA COLLECTION AND ANALYSIS

Abstracts of studies identified in searches of electronic databases were read and assessed to determine whether they might meet the inclusion criteria. Data were analysed separately depending on whether results had been obtained subjectively or objectively.

MAIN RESULTS

Six trials, including 282 participants with insomnia, examined the effectiveness of cognitive-behavioural treatments (CBT) for sleep problems in this population. The final total of participants included in the meta-analysis was 224. The data suggest a mild effect of CBT for sleep problems in older adults, best demonstrated for sleep maintenance insomnia.

REVIEWER'S CONCLUSIONS

When the possible side-effects of standard treatment (hypnotics) are considered, there is an argument to be made for clinical use of cognitive-behavioural treatments. Research is needed to establish the likely predictors of success with such treatments. As it may well be the case that the treatment efficacy of cognitive-behavioural therapy itself is not durable, the provision of "top-up" sessions of CBT training to improve durability of effect are worthy of investigation.

Expulsions following 1000 GyneFix insertions

CONTEXT

The GyneFix intra-uterine device has been used in our family planning service since 1997. One of the perceived advantages is its low expulsion rate, as reported by clinical trials.

OBJECTIVE

To calculate expulsion rates in routine clinical use and to look at possible reasons for expulsion.

DESIGN

Retrospective casenote analysis and opportunistic client consultation.

SETTING

A city centre family planning clinic.

PARTICIPANTS

The first 1000 GyneFix insertions.

MAIN OUTCOME MEASURES

Parity of client, experience of clinician carrying out insertion, time from device insertion to expulsion.

RESULTS

Overall expulsion rate was 7.6%. There was no significant difference in parity of clients experiencing expulsion. Most (4.7%) expulsions were early, occurring within 3 months of insertion. There was considerable variation in early expulsion rate from one clinician to another. Later expulsions also occurred, up to 28 months after insertion. Increasing experience of the inserting clinician led to lower rates of late expulsion. Unnoticed expulsion led to four unplanned pregnancies.

CONCLUSIONS

The GyneFix expulsion rate in our service is higher than quoted in clinical trials. Early expulsions may be related to insertion technique, representing insufficient implantation of the anchoring knot into the fundal myometrium. Late expulsions also occur, often many months after insertion; the reason for these is unclear. Users should be taught to check for the presence of the thread after each menstrual period and unnoticed expulsion should be confirmed by ultrasound and abdomino-pelvic plain X-ray.

Introduction of the GyneFix intra-uterine device into the UK: client satisfaction survey and casenotes review

OBJECTIVE

To assess the first year's use with the GyneFix intra-uterine device. This has been used in Liverpool since early 1997. It is offered mainly to nulliparous women wishing to use an effective non-hormonal method and parous women who have had pain with, or expulsion of, a framed device previously. It is also used as emergency contraception.

DESIGN

Retrospective study, by means of casenote review and client questionnaire.

PARTICIPANTS

All GyneFix users from February 1997 to January 1998; 215 women in total.

MAIN OUTCOME MEASURES

Data were extracted from casenotes to determine reasons for choice of GyneFix, parity, whether the insertion was planned or as an emergency measure, problems reported at follow-up and reasons for removal. Users were asked by questionnaire to comment on insertion procedure, menstrual or other changes since insertion and to state their overall satisfaction.

RESULTS

Over half of the users (57%) were nulliparous and a quarter of insertions were for emergency contraceptive use. A third reported that insertion was 'very painful'. Half reported that their periods had become heavier since insertion, but only 8% said that they were now unmanageable. Unacceptable bleeding was the most common reason for removal. Some reported intermenstrual bleeding and dysmenorrhoea. Satisfaction with the GyneFix was high; 86% of questionnaire responders said that they would recommend it to a friend.

CONCLUSION

The GyneFix is well accepted in Liverpool inappropriately selected clients, and is an effective non-hormonal method for nulliparous as well as parous women.

The development of an Australian national classification system for social work practice in health care

Australian Social Work, over recent years, has been challenged to develop a standardised and accurate classification system for social work interventions. The need for such a system arose through changes in funding arrangements based on the Diagnosis Related Groups (DRGs) treated within hospitals. In Australian hospitals, the mix of DRGs treated became known as its 'casemix.' These new funding arrangements made it necessary for Social Work to classify and measure activity with each patient to ensure continuing resource allocation to social work services in hospitals. A national Casemix Network was formed under the auspice of the Australian Association of Social Workers to develop a classification system. The Network worked collaboratively with other allied health professions to produce a generic framework for professional activities and also developed a classification of social work interventions. These activity classifications have been incorporated into procedure coding in Australian hospitals. The challenges associated with casemix funding required Social Work to address a number of philosophical and methodological issues related to classification of professional activities to ensure an outcome that recognised the unique contribution of Social Work to health care.

Disrupted mitochondrial electron transport function increases expression of anti-apoptotic bcl-2 and bcl-X(L) proteins in SH-SY5Y neuroblastoma and in Parkinson disease cybrid cells through oxidative stress

Death of dopamine neurons in Parkinson disease (PD) may arise from consequences of the complex I (C-I) defect in the mitochondrial electron transport chain (ETC). Whether cells activate programmed death (apoptosis) pathways derives, in part, from relative activities of proteins such as bcl-2 and bcl-X(L), that have anti-apoptotic actions. We studied the responses of bcl-2 and bcl-X(L) genes in pharmacologic (acute incubation with methylpyridinium (MPP+)) and mitochondrial transgenic ("cybrid") models of Parkinson disease C-I defects. MPP+ incubation increased levels of bcl-2 and bcl-X(L) proteins in native SH-SY5Y cells but not in rho(0) cells devoid of ETC activity. MPP+ increased bcl-2 mRNA levels by 40% at 8 hr. Confocal microscopic imaging showed that the intracellular distribution of immunoreactive bcl-2 was not significantly associated with mitochondrial membranes at baseline but was associated with mitochondria after 12 hr of MPP+. Immunoreactive bcl-X(L) protein was significantly and equally associated with mitochondrial membranes both at baseline and after MPP+. PD cybrids showed increased basal levels of bcl-2 and bcl-X(L) proteins, similar to the maximum levels found after MPP+ treatment of control SY5Y cells. After MPP+ exposure, bcl-2 protein levels increased in control cybrids but did not increase further in PD cybrids. Both pharmacologically generated and transgenically induced C-I inhibition increases levels of anti-apoptotic bcl proteins, possibly from increased gene transcription. Augmentation of bcl-2 and bcl-X(L) expression may delay neurodegeneration in PD.

Sleeping with the enemy? A randomized controlled trial of a collaborative health authority/industry intervention to influence prescribing practice

AIMS

To evaluate the effectiveness of a health authority/pharmaceutical company collaborative intervention to influence the choice of proton pump inhibitors

METHODS

Randomized controlled trial, with general practices forming the unit of allocation and analysis.

RESULTS

Constructive working relationships were achieved with five of six pharmaceutical companies involved. One hundred and two out of 140 practitioners in intervention group practices received at least one visit from an industry representative. There were no reports of representatives operating outside their agreed remit. Prescribing in both the intervention and control group moved towards that recommended by the guidelines but there was no difference between the groups in either the proportion of prescriptions in line with the guidelines or the overall cost.

CONCLUSIONS

Health authorities can achieve professional working relationships with the pharmaceutical industry although no changes in practice attributable to the intervention are achieved. Further work is required to develop effective means to influence prescribing in line with independent guidelines especially in the context of the development of Primary Care Groups.

School-based research: problems of access and consent

Public schools are enticing yet intimidating places to conduct research on children and adolescents. A public school provides a large potential subject pool; however, obtaining access to that subject pool can seem impossible with all the layers of permissions that must be obtained. If the study is federally funded, additional regulations apply. This article presents practical and proven approaches to obtaining access to and approval from schools or school systems, as well as parental consent, to conduct school-based research.

Alexander technique for chronic asthma

BACKGROUND

"The Alexander technique" is a taught form of physical therapy involving a series of movements designed to correct posture and bring the body into natural alignment with the object of helping it to function efficiently, and is reported to aid relaxation. Some practitioners claim benefits for those who desire greater ease and efficiency of breathing, including asthmatics.

OBJECTIVES

The objective of this review was to evaluate the efficacy of the Alexander technique in people with chronic, stable asthma.

SEARCH STRATEGY

The specialised register of the Cochrane Airways Group, the Cochrane Complementary Medicine Field trials register and the bibliographies of relevant articles were searched.

SELECTION CRITERIA

Randomised controlled trials of Alexander technique for the improvement of the symptoms of chronic, stable asthma, comparing the treatment with either another intervention or no intervention.

DATA COLLECTION AND ANALYSIS

No trials were found that met the selection criteria.

REVIEWER'S CONCLUSIONS

Robust, well-designed randomised controlled trials are required in order to test claims by practitioners that AT can have a positive effect on the symptoms of chronic asthma and thereby help people with asthma to reduce medication.

Autogenous regulation of transcription termination factor Rho and the requirement for Nus factors in Bacillus subtilis

The expression and activity of transcription termination factor Rho and the requirement for transcription elongation factors NusA and NusG was investigated in Bacillus subtilis. Rho was present at < 5% of the level found in Escherichia coli, but Rho factors from these two bacteria had similar properties as RNA-activated ATPases and in vitro termination of transcription on the lambda tR1 terminator. The B. subtilis rho gene was autoregulated at the level of transcription; autoregulation required sequences within the rho mRNA leader region and gene. To date, the B. subtilis rho is the only gene from a Gram-positive bacterium found to be regulated by Rho. Rho was not involved in bulk mRNA decay in B. subtilis. The E. coli elongation factors NusA and NusG target Rho, and the importance of these proteins in B. subtilis was examined by gene disruption. The B. subtilis NusG was inessential for both the viability and the autoregulation of Rho, whereas NusA was essential, and the requirement for NusA was independent of Rho. This contrasts with E. coli in which NusG is essential but NusA becomes dispensable if Rho terminates transcription less efficiently.

Biosynthesis of Aedes aegypti lipophorin and gene expression of its apolipoproteins

The biosynthesis of lipophorin of the yellow fever mosquito, Aedes aegypti, was investigated. Fat bodies were incubated in vitro with radiolabeled methionine and cysteine, and radiolabeled proteins secreted into the medium were analyzed by density gradient ultracentrifugation, SDS-PAGE and fluorography. Lipophorin was synthesized in the fat body and secreted into the medium. Its density was 1.114 g/ml, similar to that of lipophorin circulating in hemolymph. Three peptides of a tryptic digest of apolipophorin II were sequenced and degenerate oligonucleotide primers were designed based on the amino acid sequences. With these primers, a cDNA product of 1.2 kb was amplified by RT-PCR using as template RNA extracted from adult female mosquitoes 24 h after ingestion of a blood meal. This cDNA was cloned, sequenced and used as a probe for Northern blot analysis, which revealed that the apoproteins of lipophorin were coded for by a single mRNA of approximately 10 kb. The expression of the apolipophorins was induced by blood feeding. From the data presented we concluded that Aedes aegypti lipophorin is synthesized in the fat body and that the expression of its apolipophorins is induced by blood feeding.

Recent developments of magnetic beads for use in nucleic acid purification

The performance of Magarose, an agarose-based bead containing a paramagnetic component has been evaluated. The anion exchanger DEAE-Magarose is effective at binding DNA from a crude cell lysate. The plasmid pBluescript was isolated from 1.5 ml Escherichia coli JM109 cell culture, following alkaline lysis yielding 8.2 micrograms high-quality DNA. Under similar binding conditions 21 micrograms of salmon sperm DNA bound to the ion exchangers. The affinity medium oligo-dT Magarose was demonstrated to bind 75 mumol of an oligo-dA probe/g of medium by hybridization. Under similar conditions mRNA could be isolated from a preparation of baby hamster cell total RNA. The magnetic susceptibility of Magarose is very high, facilitating the use of this separation technique for rapid batch chromatographic processes.

The critical role of p38 MAP kinase in T cell HIV-1 replication

BACKGROUND

Replication of HIV-1 in human T lymphocytes requires the activation of host cellular proteins. This study identifies p38 mitogen-activated protein kinase (MAPK) as one such kinase necessary for HIV-1 replication in T cells.

MATERIALS AND METHODS

Primary human T lymphocytes were infected with the LAI strain of HIV-1 and Jurkat cells were infected with the RF strain of HIV-1. HIV replication was measured by reverse transcriptase activity. Cellular expression of endogenous p38 MAPK protein was analyzed using immunoprecipitation. Blockade of p38 MAPK expression was achieved using antisense oligonucleotides to p38 MAPK and the guanylhydrazone compound CNI-1493, an inhibitor of p38 MAPK activation.

RESULTS

HIV-1 infection of both primary human T lymphocytes and a T cell line rapidly activated the cellular p38 MAPK pathway, which remained activated for the duration of the culture. Addition of phosphothioated antisense oligonucleotides to p38 MAPK specifically inhibited viral replication. Blockade of p38 MAPK activation by addition of CNI-1493 also inhibited HIV-1 viral replication of primary T lymphocytes in a dose- and time-dependent manner. Stimulation of p38 MAPK activation did not occur with the addition of heat-inactivated virus, suggesting that viral internalization, and not just membrane binding, is necessary for p38 MAPK activation.

CONCLUSIONS

These results indicate that activation of the p38 MAPK cascade is critical for HIV-1 replication in primary T lymphocytes, and that blockade of this signal transduction pathway may be a novel therapeutic approach to the treatment of HIV-1 infection.

An exploration of feeding difficulties in children with Down syndrome

Detailed examination of several aspects of feeding was carried out on a representative sample of a defined geographical population of children with Down syndrome. The examination included standardised assessments both of oral-motor function and of parent-child interaction. The findings suggest that the development of oral-motor function in children with Down syndrome not only lags behind intellectual development, but also follows an aberrant pathway. In particular, specific aspects of tongue and jaw function were impaired together with problems initiating and maintaining a smooth sequence of feeding actions. Also, parent-child interactions, as in studies on play, tended to be more controlling. Parents of children with Down syndrome do not spontaneously report the extent of their child's feeding problems unless specific enquiry is made, preferably accompanied by observation of feeding.

CNI-1493 inhibits monocyte/macrophage tumor necrosis factor by suppression of translation efficiency

Tumor necrosis factor (TNF) mediates a wide variety of disease states including septic shock, acute and chronic inflammation, and cachexia. Recently, a multivalent guanylhydrazone (CNI-1493) developed as an inhibitor of macrophage activation was shown to suppress TNF production and protect against tissue inflammation and endotoxin lethality [Bianchi, M., Ulrich, P., Bloom, O., Meistrell, M., Zimmerman, G. A., Schmidtmayerova, H., Bukrinsky, M., Donnelley, T., Bucala, R., Sherry, B., Manogue, K. R., Tortolani, A. J., Cerami, A. & Tracey, K. J. (1995) Mol. Med. 1, 254-266, and Bianchi, M., Bloom, O., Raabe, T., Cohen, P. S., Chesney, J., Sherry, B., Schmidtmayerova, H., Zhang, X., Bukrinsky, M., Ulrich, P., Cerami, A. & Tracey, J. (1996) J. Exp. Med., in press]. We have now elucidated the mechanism by which CNI-1493 inhibits macrophage TNF synthesis and show here that it acts through suppression of TNF translation efficiency. CNI-1493 blocked neither the lipopolysaccharide (LPS)-induced increases in the expression of TNF mRNA nor the translocation of nuclear factor NF-kappa B to the nucleus in macrophages activated by 15 min of LPS stimulation, indicating that CNI-1493 does not interfere with early NF-kappa B-mediated transcriptional regulation of TNF. However, synthesis of the 26-kDa membrane form of TNF was effectively blocked by CNI-1493. Further evidence for the translational suppression of TNF is given by experiments using chloram-phenicol acetyltransferase (CAT) constructs containing elements of the TNF gene that are involved in TNF translational regulation. Both the 5' and 3' untranslated regions of the TNF gene were required to elicit maximal translational suppression by CNI-1493. Identification of the molecular target through which CNI-1493 inhibits TNF translation should provide insight into the regulation of macrophage activation and mechanisms of inflammation.

Neonatal seizures: long-term outcome and cognitive development among 'normal' survivors

The authors report the long-term outcome and cognitive development in the late-teenage years of 'normal' survivors of neonatal seizures. The outcome of the children was good, and normal in that they had attended normal schools and had normal overall intelligence test scores as adults. However, all of the sample displayed abnormal neuropsychological development in terms of intelligence test profile and subtest scatter, or development of spelling, or development of memory. This was independent of social and behavioural difficulties, which may also be increased. Neonatal seizures may be indicative of a subtle neurodevelopmental vulnerability which may manifest later in life as specific learning difficulties or poor social adjustment.

Impaired oral-motor function in children with Down's syndrome: a study of three twin pairs

Three twin births occurring within 18 months in Oxfordshire, in which a girl with Down's syndrome was twin to an unaffected boy, provided an opportunity for a closely matched comparison of ratings on the Schedule for Oral Motor Assessment, which examines oral-motor function in a systematic and reliable way. A detailed description of the video-recording of one twin pair is included. This illustrates abnormalities of oral-motor function which may occur generally in Down's syndrome, as suggested further by a numerical tabulation of the differences found between the twins.

"Think TB:" new focus for family assessment

The growing incidence of tuberculosis (TB) among childrearing families introduces new challenges to pediatric nurses. The following four clinical stories have been developed from the authors' experiences with Hispanic families from high prevalence regions in order to emphasize the characteristics and conditions that nurses need awareness of when caring for patients with possible TB. These stories highlight common themes in families from other high-risk groups as well that may surface in pediatric nurses' practice. Collaboration between pediatric and TB control nurses becomes essential for vigilant control of the spread of this reemerging old disease.

Prenatal diagnosis of bovine citrullinaemia

Holstein/Friesian embryos, progeny of citrullinaemia heterozygotes, were transferred to recipient cows. The citrullinaemia genotype of the fetus/calf was established, at birth, by estimation of citrulline concentration in plasma or by analyses of argininosuccinate synthetase exon 5 sequences in DNA from blood leucocytes. Between 115 and 125 days of gestation amniotic fluid was collected transabdominally from nine recipient cows. The mean citrulline concentration in amniotic fluid from fetuses unaffected with citrullinaemia was 28 microM, SD 9 and range 15 to 38 microM. Citrulline concentration was 107 and 130 microM in amniotic fluid from two fetuses homozygous for the citrullinaemia mutation. Only the normal bovine citrullinaemia sequence was detected in cells cultured from amniotic fluid taken from two homozygous normal and two heterozygous fetuses. Both normal and mutant sequences were found in cells cultured from amniotic fluid collected from three of five heterozygous fetuses. Only the mutant sequence was found in cells cultured from the two citrullinaemia affected fetuses. MHC class II DRB3 haplotyping revealed that in four instances cultured cells were from the surrogate mother, not the fetus, these included samples from two heterozygotes in which only the normal sequence was detected in amniotic fluid.

An economic appraisal of alternative pre-natal screening programmes for Down's syndrome

The objective of this study was to evaluate economically a screening programme within the Oxford Regional Health Authority for Down's syndrome, based on maternal serum alpha fetoprotein, unconjugated oestriol and human chorionic gonadotrophin as well as maternal age (the triple test) against maternal age alone. The design of the study involved cost-effectiveness analysis of the triple test relative to the maternal age screening programme, and the main outcome measure was the cost per Down's birth avoided. It was found that the triple test is more cost-effective over a wide range of assumptions concerning detection rates and procedure costs. Indirect costs are important in considering the cost-effectiveness of the screening programmes. The most efficient detection rate is around 58 per cent for which the cost per Down's birth avoided is approximately 29,600 pounds if only direct costs are evaluated, 20,100 pounds if all NHS costs are considered and -49,800 pounds if all resource consequences are analysed. It may be concluded that screening for Down's syndrome using the triple test is cost-effective over a wide range of assumptions concerning detection rate and procedure costs. If all resource costs are considered, the programme is highly cost-effective in comparison with other health care interventions.