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Effects of empagliflozin on progression of chronic kidney disease: a prespecified secondary analysis from the empa-kidney trial. Lancet Diabetes Endocrinol 2024; 12:39-50. [PMID: 38061371 PMCID: PMC7615591 DOI: 10.1016/s2213-8587(23)00321-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/05/2023] [Revised: 10/24/2023] [Accepted: 10/25/2023] [Indexed: 12/23/2023]
Abstract
BACKGROUND Sodium-glucose co-transporter-2 (SGLT2) inhibitors reduce progression of chronic kidney disease and the risk of cardiovascular morbidity and mortality in a wide range of patients. However, their effects on kidney disease progression in some patients with chronic kidney disease are unclear because few clinical kidney outcomes occurred among such patients in the completed trials. In particular, some guidelines stratify their level of recommendation about who should be treated with SGLT2 inhibitors based on diabetes status and albuminuria. We aimed to assess the effects of empagliflozin on progression of chronic kidney disease both overall and among specific types of participants in the EMPA-KIDNEY trial. METHODS EMPA-KIDNEY, a randomised, controlled, phase 3 trial, was conducted at 241 centres in eight countries (Canada, China, Germany, Italy, Japan, Malaysia, the UK, and the USA), and included individuals aged 18 years or older with an estimated glomerular filtration rate (eGFR) of 20 to less than 45 mL/min per 1·73 m2, or with an eGFR of 45 to less than 90 mL/min per 1·73 m2 with a urinary albumin-to-creatinine ratio (uACR) of 200 mg/g or higher. We explored the effects of 10 mg oral empagliflozin once daily versus placebo on the annualised rate of change in estimated glomerular filtration rate (eGFR slope), a tertiary outcome. We studied the acute slope (from randomisation to 2 months) and chronic slope (from 2 months onwards) separately, using shared parameter models to estimate the latter. Analyses were done in all randomly assigned participants by intention to treat. EMPA-KIDNEY is registered at ClinicalTrials.gov, NCT03594110. FINDINGS Between May 15, 2019, and April 16, 2021, 6609 participants were randomly assigned and then followed up for a median of 2·0 years (IQR 1·5-2·4). Prespecified subgroups of eGFR included 2282 (34·5%) participants with an eGFR of less than 30 mL/min per 1·73 m2, 2928 (44·3%) with an eGFR of 30 to less than 45 mL/min per 1·73 m2, and 1399 (21·2%) with an eGFR 45 mL/min per 1·73 m2 or higher. Prespecified subgroups of uACR included 1328 (20·1%) with a uACR of less than 30 mg/g, 1864 (28·2%) with a uACR of 30 to 300 mg/g, and 3417 (51·7%) with a uACR of more than 300 mg/g. Overall, allocation to empagliflozin caused an acute 2·12 mL/min per 1·73 m2 (95% CI 1·83-2·41) reduction in eGFR, equivalent to a 6% (5-6) dip in the first 2 months. After this, it halved the chronic slope from -2·75 to -1·37 mL/min per 1·73 m2 per year (relative difference 50%, 95% CI 42-58). The absolute and relative benefits of empagliflozin on the magnitude of the chronic slope varied significantly depending on diabetes status and baseline levels of eGFR and uACR. In particular, the absolute difference in chronic slopes was lower in patients with lower baseline uACR, but because this group progressed more slowly than those with higher uACR, this translated to a larger relative difference in chronic slopes in this group (86% [36-136] reduction in the chronic slope among those with baseline uACR <30 mg/g compared with a 29% [19-38] reduction for those with baseline uACR ≥2000 mg/g; ptrend<0·0001). INTERPRETATION Empagliflozin slowed the rate of progression of chronic kidney disease among all types of participant in the EMPA-KIDNEY trial, including those with little albuminuria. Albuminuria alone should not be used to determine whether to treat with an SGLT2 inhibitor. FUNDING Boehringer Ingelheim and Eli Lilly.
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Yamada N, Yamagata K, Yamaguchi M, Yamaji Y, Yamamoto A, Yamamoto S, Yamamoto S, Yamamoto T, Yamanaka A, Yamano T, Yamanouchi Y, Yamasaki N, Yamasaki Y, Yamasaki Y, Yamashita C, Yamauchi T, Yan Q, Yanagisawa E, Yang F, Yang L, Yano S, Yao S, Yao Y, Yarlagadda S, Yasuda Y, Yiu V, Yokoyama T, Yoshida S, Yoshidome E, Yoshikawa H, Young A, Young T, Yousif V, Yu H, Yu Y, Yuasa K, Yusof N, Zalunardo N, Zander B, Zani R, Zappulo F, Zayed M, Zemann B, Zettergren P, Zhang H, Zhang L, Zhang L, Zhang N, Zhang X, Zhao J, Zhao L, Zhao S, Zhao Z, Zhong H, Zhou N, Zhou S, Zhu D, Zhu L, Zhu S, Zietz M, Zippo M, Zirino F, Zulkipli FH. Impact of primary kidney disease on the effects of empagliflozin in patients with chronic kidney disease: secondary analyses of the EMPA-KIDNEY trial. Lancet Diabetes Endocrinol 2024; 12:51-60. [PMID: 38061372 DOI: 10.1016/s2213-8587(23)00322-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/05/2023] [Revised: 10/24/2023] [Accepted: 10/25/2023] [Indexed: 12/23/2023]
Abstract
BACKGROUND The EMPA-KIDNEY trial showed that empagliflozin reduced the risk of the primary composite outcome of kidney disease progression or cardiovascular death in patients with chronic kidney disease mainly through slowing progression. We aimed to assess how effects of empagliflozin might differ by primary kidney disease across its broad population. METHODS EMPA-KIDNEY, a randomised, controlled, phase 3 trial, was conducted at 241 centres in eight countries (Canada, China, Germany, Italy, Japan, Malaysia, the UK, and the USA). Patients were eligible if their estimated glomerular filtration rate (eGFR) was 20 to less than 45 mL/min per 1·73 m2, or 45 to less than 90 mL/min per 1·73 m2 with a urinary albumin-to-creatinine ratio (uACR) of 200 mg/g or higher at screening. They were randomly assigned (1:1) to 10 mg oral empagliflozin once daily or matching placebo. Effects on kidney disease progression (defined as a sustained ≥40% eGFR decline from randomisation, end-stage kidney disease, a sustained eGFR below 10 mL/min per 1·73 m2, or death from kidney failure) were assessed using prespecified Cox models, and eGFR slope analyses used shared parameter models. Subgroup comparisons were performed by including relevant interaction terms in models. EMPA-KIDNEY is registered with ClinicalTrials.gov, NCT03594110. FINDINGS Between May 15, 2019, and April 16, 2021, 6609 participants were randomly assigned and followed up for a median of 2·0 years (IQR 1·5-2·4). Prespecified subgroupings by primary kidney disease included 2057 (31·1%) participants with diabetic kidney disease, 1669 (25·3%) with glomerular disease, 1445 (21·9%) with hypertensive or renovascular disease, and 1438 (21·8%) with other or unknown causes. Kidney disease progression occurred in 384 (11·6%) of 3304 patients in the empagliflozin group and 504 (15·2%) of 3305 patients in the placebo group (hazard ratio 0·71 [95% CI 0·62-0·81]), with no evidence that the relative effect size varied significantly by primary kidney disease (pheterogeneity=0·62). The between-group difference in chronic eGFR slopes (ie, from 2 months to final follow-up) was 1·37 mL/min per 1·73 m2 per year (95% CI 1·16-1·59), representing a 50% (42-58) reduction in the rate of chronic eGFR decline. This relative effect of empagliflozin on chronic eGFR slope was similar in analyses by different primary kidney diseases, including in explorations by type of glomerular disease and diabetes (p values for heterogeneity all >0·1). INTERPRETATION In a broad range of patients with chronic kidney disease at risk of progression, including a wide range of non-diabetic causes of chronic kidney disease, empagliflozin reduced risk of kidney disease progression. Relative effect sizes were broadly similar irrespective of the cause of primary kidney disease, suggesting that SGLT2 inhibitors should be part of a standard of care to minimise risk of kidney failure in chronic kidney disease. FUNDING Boehringer Ingelheim, Eli Lilly, and UK Medical Research Council.
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Abstract
Purpose of Review Veterans who kill in war are at risk of developing negative mental health problems including moral injury, PTSD, spiritual distress, and impairments in functioning. Impact of Killing (IOK) is a novel, cognitive-behaviorally based treatment designed to address the symptoms associated with killing that focuses on self-forgiveness and moral repair through cultivation of self-compassion and perspective-taking exercises, such as letter writing, and active participation in values-driven behavior. Recent Findings In a pilot trial assessing IOK, participants demonstrated a reduction in multiple mental health symptoms and improvement in quality-of-life measures, and they reported IOK was acceptable and feasible. Furthermore, trauma therapists have reported that moral injury is relevant to their clinical work, expressed a desire for additional training on the impact of killing, and identified barriers that make addressing killing in clinical settings challenging. Data are currently being collected in a national multi-site trial to examine the efficacy of IOK, compared to a control condition. Summary IOK fills a critical treatment gap by directly addressing the guilt, shame, self-sabotaging behaviors, functional difficulties, impaired self-forgiveness, and moral/spiritual distress directly associated with killing in war. Typically provided following some initial trauma-processing treatment, IOK can be integrated in existing systems of trauma care, creating a pathway for a stepped model of treatment for moral injury.
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Affiliation(s)
- Kristine Burkman
- San Francisco VA Medical Center, 4150 Clement Street (116-E), San Francisco, CA 94121 USA.,University of California, San Francisco, CA USA
| | - Rebecca Gloria
- San Francisco VA Medical Center, 4150 Clement Street (116-E), San Francisco, CA 94121 USA
| | - Haley Mehlman
- San Francisco VA Medical Center, 4150 Clement Street (116-E), San Francisco, CA 94121 USA
| | - Shira Maguen
- San Francisco VA Medical Center, 4150 Clement Street (116-E), San Francisco, CA 94121 USA.,University of California, San Francisco, CA USA
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Ranney RM, Gloria R, Metzler TJ, Huggins J, Neylan TC, Maguen S. Brief behavioral treatment for insomnia decreases trauma-related nightmare frequency in veterans. J Clin Sleep Med 2022; 18:1831-1839. [PMID: 35393934 DOI: 10.5664/jcsm.10002] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
STUDY OBJECTIVES Trauma-related nightmares are highly prevalent among veterans and are associated with higher severity insomnia and PTSD. Cognitive behavioral therapy for insomnia (CBT-I, typically 6-8 sessions) has been shown to reduce trauma-related nightmares. Brief behavioral treatment for insomnia (BBTI, 4 sessions) has been found to be comparable to CBT-I in decreasing insomnia severity; however, the effects of BBTI on nightmares have not been investigated. The current study tested the effects of BBTI on both trauma-related nightmares and non-trauma-related bad dreams using an active control group, progressive muscle relaxation therapy (PMRT). Additionally, we tested whether baseline trauma-related nightmare frequency and baseline non-trauma-related bad dream frequency moderated changes in insomnia severity. METHODS Participants were 91 military veterans with insomnia disorder randomized to BBTI or PMRT. Participants reported insomnia severity on the Insomnia Severity Index and reported trauma-related nightmare frequency and non-trauma-related bad dream frequency on the Pittsburgh Sleep Quality Index--PTSD Addendum. RESULTS We found that BBTI significantly reduced trauma-related nightmares from baseline to post-treatment while PMRT did not. However, reductions in trauma-related nightmares were not maintained at six month follow up. Neither BBTI nor PMRT reduced non-trauma-related bad dreams from baseline to post-treatment. We also found that neither baseline trauma-related nightmare frequency nor baseline non-trauma-related bad dream frequency moderated changes in insomnia symptom severity. CONCLUSIONS Findings from the current study suggest that BBTI may help to reduce trauma-related nightmares. Further research is needed to better understand potential mechanisms underlying how improved sleep may reduce trauma-related nightmares. CLINICAL TRIAL REGISTRATION Registry: ClinicalTrials.gov; Name: Brief Behavioral Insomnia Treatment Study (BBTI); Identifier: NCT02571452; URL: https://clinicaltrials.gov/ct2/show/NCT02571452.
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Affiliation(s)
- Rachel M Ranney
- Veterans Affairs San Francisco Health Care System, San Francisco, CA.,Department of Psychiatry and Behavioral Sciences, University of California, San Francisco School of Medicine, San Francisco, CA.,Sierra Pacific Mental Illness Research Education, and Clinical Center, San Francisco, CA
| | - Rebecca Gloria
- Veterans Affairs San Francisco Health Care System, San Francisco, CA
| | - Thomas J Metzler
- Veterans Affairs San Francisco Health Care System, San Francisco, CA.,Department of Psychiatry and Behavioral Sciences, University of California, San Francisco School of Medicine, San Francisco, CA.,Sierra Pacific Mental Illness Research Education, and Clinical Center, San Francisco, CA
| | - Joy Huggins
- Veterans Affairs San Francisco Health Care System, San Francisco, CA
| | - Thomas C Neylan
- Veterans Affairs San Francisco Health Care System, San Francisco, CA.,Department of Psychiatry and Behavioral Sciences, University of California, San Francisco School of Medicine, San Francisco, CA.,Sierra Pacific Mental Illness Research Education, and Clinical Center, San Francisco, CA
| | - Shira Maguen
- Veterans Affairs San Francisco Health Care System, San Francisco, CA.,Department of Psychiatry and Behavioral Sciences, University of California, San Francisco School of Medicine, San Francisco, CA.,Sierra Pacific Mental Illness Research Education, and Clinical Center, San Francisco, CA
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Fronk GE, Hefner K, Gloria R, Curtin JJ. Central stress response among deprived and continuing marijuana users and nonusers. Psychol Addict Behav 2022; 36:1023-1035. [PMID: 35201806 DOI: 10.1037/adb0000821] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
OBJECTIVE We examined central nervous system [CNS] stress responses among deprived and continuing heavy marijuana users and nonusers. METHOD Participants (N = 210; 46.7% female; Mage = 21.99; 91.4% White, 94.3% Non-Hispanic) were heavy marijuana users (N = 134) and nonusers (N = 76). Heavy users were randomly assigned to a 3-day marijuana deprivation condition (N = 68) or to continue using regularly (N = 66). Participants completed two threat-of-shock stressor tasks that manipulated stressor predictability by varying shock probability or timing. We measured central stress responses via startle potentiation (stressor conditions minus matched no-stressor condition). We examined two group contrasts (heavy use: all heavy users vs. nonusers; deprivation: deprived vs. continuing heavy users) on startle potentiation overall and moderated by stressor predictability (unpredictable vs. predictable). RESULTS Deprivation did not affect startle potentiation overall (timing task: p = .184; probability task: p = .328) or differently by stressor predictability (timing task: p = .147; probability task: p = .678). Heavy use did not affect startle potentiation overall (timing task: p = .213; probability task: p = .843) or differently by stressor predictability (timing task: p = .655; probability task: p = .273). Posthoc analyses showed mixed evidence of general startle reactivity × deprivation interaction on startle potentiation overall (timing task: p = .019; probability task: p = .056) and differently by stressor predictability (probability task: p = .024; timing task: p = .364). CONCLUSIONS A history of marijuana use or acute deprivation did not alter central stress responses despite prominent theoretical expectations. This study adds to growing research on central stress responses in individuals with a history of drug use and begins to parse moderating roles of individual differences and stressor characteristics. (PsycInfo Database Record (c) 2022 APA, all rights reserved).
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Holder N, Kanady JC, Straus LD, Khan AJ, Purcell N, Huggins J, Gloria R, Neylan TC, Lujan C, Maguen S. Reducing Barriers to Behavioral Treatments for Insomnia: A Qualitative Examination of Veterans' Perspectives of BBTI. Behav Sleep Med 2022; 20:37-49. [PMID: 33502265 DOI: 10.1080/15402002.2021.1878173] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
Objective: Although behavioral treatments are recommended for treating insomnia disorder, these treatments are not the most commonly provided treatments due to numerous barriers (e.g., treatment length, time limitations). Brief Behavioral Treatment for Insomnia (BBTI) was developed, in part, to help overcome these barriers. The purpose of the current study was to qualitatively examine the treatment experiences of veterans with insomnia disorder participating in BBTI.Methods: All veterans (n=46) who were randomized to receive BBTI as part of a randomized clinical trial participated in 10-20 minute semi-structured interviews one week after completing treatment. Rapid analysis procedures were used for qualitative analysis.Results: Thirteen qualitative themes were identified: BBTI provided veterans with the skills they believed they needed to continue improving independently post-treatment; beginning BBTI with in-person sessions was valued; phone sessions helped participation; veterans did not perceive that they could cover the same content during phone and in-person sessionsl; materials could be more portable; BBTI created accountability; BBTI required discipline and willingness; BBTI facilitated buy-in; BBTI was aligned with military culture; loved ones could provide important support; BBTI could be improved with more personalization; BBTI challenged expectations of mental health; and BBTI improved awareness of health behaviors beyond sleep.Conclusions: BBTI was successful in overcoming barriers to behavioral insomnia treatment and interviews identified critical treatment aspects that should be maintained to preserve acceptability (e.g., in-person session first). Areas in which BBTI did not fully meet the needs of veterans and targets for improvement (e.g., ameliorating understanding and expectations of phone sessions) were also identified.
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Affiliation(s)
- Nicholas Holder
- San Francisco Veterans Affairs Health Care System, Mental Health, San Francisco, CA, USA.,Sierra Pacific Mental Illness Research, Education, and Clinical Center; Mental Health, San Francisco, CA, USA.,Department of Psychiatry, University of California San Francisco School of Medicine, San Francisco, CA, USA
| | - Jennifer C Kanady
- San Francisco Veterans Affairs Health Care System, Mental Health, San Francisco, CA, USA.,Sierra Pacific Mental Illness Research, Education, and Clinical Center; Mental Health, San Francisco, CA, USA.,Department of Psychiatry, University of California San Francisco School of Medicine, San Francisco, CA, USA
| | - Laura D Straus
- San Francisco Veterans Affairs Health Care System, Mental Health, San Francisco, CA, USA.,Sierra Pacific Mental Illness Research, Education, and Clinical Center; Mental Health, San Francisco, CA, USA.,Department of Psychiatry, University of California San Francisco School of Medicine, San Francisco, CA, USA
| | - Amanda J Khan
- San Francisco Veterans Affairs Health Care System, Mental Health, San Francisco, CA, USA.,Sierra Pacific Mental Illness Research, Education, and Clinical Center; Mental Health, San Francisco, CA, USA.,Department of Psychiatry, University of California San Francisco School of Medicine, San Francisco, CA, USA
| | - Natalie Purcell
- San Francisco Veterans Affairs Health Care System, Mental Health, San Francisco, CA, USA.,Sierra Pacific Mental Illness Research, Education, and Clinical Center; Mental Health, San Francisco, CA, USA
| | - Joy Huggins
- San Francisco Veterans Affairs Health Care System, Mental Health, San Francisco, CA, USA
| | - Rebecca Gloria
- San Francisco Veterans Affairs Health Care System, Mental Health, San Francisco, CA, USA
| | - Thomas C Neylan
- San Francisco Veterans Affairs Health Care System, Mental Health, San Francisco, CA, USA.,Sierra Pacific Mental Illness Research, Education, and Clinical Center; Mental Health, San Francisco, CA, USA.,Department of Psychiatry, University of California San Francisco School of Medicine, San Francisco, CA, USA.,Department of Neurology, University of California San Francisco School of Medicine, San Francisco, CA, USA
| | - Callan Lujan
- San Francisco Veterans Affairs Health Care System, Mental Health, San Francisco, CA, USA.,Department of Psychology, Washington State University, Pullman, WA, USA
| | - Shira Maguen
- San Francisco Veterans Affairs Health Care System, Mental Health, San Francisco, CA, USA.,Sierra Pacific Mental Illness Research, Education, and Clinical Center; Mental Health, San Francisco, CA, USA.,Department of Psychiatry, University of California San Francisco School of Medicine, San Francisco, CA, USA
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7
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Maguen S, Gloria R, Huggins J, Goldstein LA, Kanady JC, Straus LD, Metzler TJ, Lujan C, Neylan TC. Brief behavioral treatment for insomnia improves psychosocial functioning in veterans: results from a randomized controlled trial. Sleep 2021; 44:5918478. [PMID: 33022048 DOI: 10.1093/sleep/zsaa205] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2020] [Revised: 07/28/2020] [Indexed: 11/13/2022] Open
Abstract
STUDY OBJECTIVES Our goal was to compare brief behavioral treatment for insomnia (BBTI) to a progressive muscle relaxation training (PMRT) control condition among veterans with insomnia, examining psychosocial functioning as a primary outcome and sleep-related outcomes, mood, cognition, and pain as secondary outcomes. METHODS Veterans were randomly assigned to either BBTI or PMRT (N = 91; 24-74 years; M = 49 years). BBTI consisted of two in-person (60-min and 30-min sessions) and two telephone sessions (20-min each), and the PMRT control condition was matched to BBTI for session duration and type. Veterans were assessed through clinical interview at baseline and self-report measures at pre-, mid-, and posttreatment, as well as 6-month follow-up for the BBTI condition to assess sustained response. Measures also included continuous sleep monitoring with sleep diary. RESULTS Intent-to-treat analyses demonstrated that individuals who completed BBTI versus PMRT reported greater improvements in work, home, social and cognitive functioning, insomnia symptom severity, mood, and energy. Improvements in psychosocial functioning, insomnia symptoms, and mood were maintained 6-months following BBTI treatment completion. CONCLUSIONS Veterans who received BBTI improved and maintained gains in psychosocial functioning, insomnia, and mood. BBTI is a treatment that can be implemented in primary care, mental health, or integrated care settings and provide symptom relief and improved functioning among those with insomnia, one of the most commonly reported mental health problems among veterans. CLINICAL TRIAL REGISTRATION NCT02571452.
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Affiliation(s)
- Shira Maguen
- San Francisco Veterans Affairs Health Care System, San Francisco, CA.,Department of Psychiatry and Behavioral Sciences, University of California, San Francisco, CA.,Sierra Pacific Mental Illness Research Education, and Clinical Center, San Francisco, CA
| | - Rebecca Gloria
- San Francisco Veterans Affairs Health Care System, San Francisco, CA
| | - Joy Huggins
- San Francisco Veterans Affairs Health Care System, San Francisco, CA
| | - Lizabeth A Goldstein
- San Francisco Veterans Affairs Health Care System, San Francisco, CA.,Department of Psychiatry and Behavioral Sciences, University of California, San Francisco, CA.,Sierra Pacific Mental Illness Research Education, and Clinical Center, San Francisco, CA
| | - Jennifer C Kanady
- San Francisco Veterans Affairs Health Care System, San Francisco, CA.,Department of Psychiatry and Behavioral Sciences, University of California, San Francisco, CA.,Sierra Pacific Mental Illness Research Education, and Clinical Center, San Francisco, CA
| | - Laura D Straus
- San Francisco Veterans Affairs Health Care System, San Francisco, CA.,Department of Psychiatry and Behavioral Sciences, University of California, San Francisco, CA.,Sierra Pacific Mental Illness Research Education, and Clinical Center, San Francisco, CA
| | - Thomas J Metzler
- San Francisco Veterans Affairs Health Care System, San Francisco, CA.,Department of Psychiatry and Behavioral Sciences, University of California, San Francisco, CA.,Sierra Pacific Mental Illness Research Education, and Clinical Center, San Francisco, CA
| | - Callan Lujan
- San Francisco Veterans Affairs Health Care System, San Francisco, CA.,Department of Psychology, Washington State University, Pullman, WA
| | - Thomas C Neylan
- San Francisco Veterans Affairs Health Care System, San Francisco, CA.,Department of Psychiatry and Behavioral Sciences, University of California, San Francisco, CA.,Sierra Pacific Mental Illness Research Education, and Clinical Center, San Francisco, CA
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Kanady JC, Straus LD, Gloria R, Neylan TC, Maguen S. 0503 Reductions in Sleep and Daily Rhythm Variability Following Brief Behavioral Treatment for Insomnia. Sleep 2020. [DOI: 10.1093/sleep/zsaa056.500] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
Abstract
Introduction
Brief behavioral treatment for insomnia (BBTI) is efficacious for insomnia symptoms. Here we examine whether BBTI reduces sleep and daily rhythm variability and whether reductions in variability result in improved functioning and quality of life.
Methods
Ninety-one Veterans with insomnia (49.3±18.7yrs; 18.7% female) were randomized to one of two treatment conditions: BBTI or progressive muscle relaxation training (PMRT; control condition). Variability was assessed using sleep diaries and actigraphy. The sleep diary outcome variables included bedtime variability, wake time variability, and total sleep time variability; actigraphy variables included interdaily stability, intradaily variability, and total sleep time variability. Functioning was assessed using the Work and Social Adjustment Scale. Quality of life was assessed using the Hotel Dieu-16 Scale.
Results
Compared to PMRT, BBTI resulted in a greater reduction in subjective total sleep time variability (F1,90=6.61, p<0.01, partial η 2=0.13) and a greater increase in interdaily stability (F1,78=12.41, p<0.01, partial η 2=0.25). There was a greater decrease in intradaily variability following PMRT (F1,78=27.96, p<0.01, partial η 2=0.42). Across the entire sample, reductions in subjective wake time variability were associated with improved functioning (F1,88=4.43, p=0.04, η 2=0.05) and reductions in subjective total sleep time variability were associated with improved quality of life (F1,89=4.91, p=0.03, partial η 2=0.05).
Conclusion
There was significant improvement in the stability of sleep-wake rhythms following BBTI, suggesting that BBTI not only treats insomnia, but also may stabilize circadian rhythms. Interestingly, PMRT resulted in greater intradaily variability reductions than BBTI. One explanation is that due to BBTI stimulus control guidelines, individuals were getting out of bed in the middle of the night more frequently and thus, these awakenings were better captured by actigraphy. Reductions in wake time and total sleep time variability were associated with improved functioning and quality of life, further demonstrating the importance of stable sleep-wake rhythms.
Support
VA Rehabilitation Research and Development Grant # RX001539-01A2
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Affiliation(s)
- J C Kanady
- San Francisco VA Medical Center, San Francisco, CA
| | - L D Straus
- San Francisco VA Medical Center, San Francisco, CA
| | - R Gloria
- San Francisco VA Medical Center, San Francisco, CA
| | - T C Neylan
- San Francisco VA Medical Center, San Francisco, CA
| | - S Maguen
- San Francisco VA Medical Center, San Francisco, CA
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Wendy S, Rodrigo V, Atena M, Gloria R, Giovanna A, Olov S, Stina O. Cytotoxic activity of sesquiterpene lactones on breast cancer stem cells. Eur J Cancer 2016. [DOI: 10.1016/s0959-8049(16)32947-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
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10
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Gloria R, Angelos L, Schaefer HS, Davis JM, Majeskie M, Richmond BS, Curtin JJ, Davidson RJ, Baker TB. An fMRI investigation of the impact of withdrawal on regional brain activity during nicotine anticipation. Psychophysiology 2009; 46:681-93. [PMID: 19490513 DOI: 10.1111/j.1469-8986.2009.00823.x] [Citation(s) in RCA: 42] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Previous research indicates that drug motivational systems are instantiated in structures that process information related to incentive, motivational drive, memorial, motor/habit, craving, and cognitive control processing. The present research tests the hypothesis that activity in such systems will be powerfully affected by the combination of drug anticipation and drug withdrawal. Event-related fMRI was used to examine activation in response to a preinfusion warning cue in two experimental sessions that manipulated withdrawal status. Significant cue-induced effects were seen in the caudate, ventral anterior nucleus of the thalamus, the insula, subcallosal gyrus, nucleus accumbens, and anterior cingulate. These results suggest that withdrawal and nicotine anticipation produce (1) different motor preparatory and inhibitory response processing and (2) different craving related processing.
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Affiliation(s)
- Rebecca Gloria
- Department of Psychology, University of Wisconsin, Madison, Wisconsin 53706, USA.
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Abstract
Drug motivation models postulate that attention biasing toward smoking-related cues is a cognitive mechanism supporting continued or renewed drug use, and they predict that drug use history, deprivation, and distress should modulate the extent of this bias. The present study used the modified Stroop paradigm to extend past research regarding attention biasing toward smoking and unpleasant, pleasant, and neutral words among adult nonsmokers and daily smokers. Both nonsmokers and smokers showed differential attention toward unpleasant and pleasant cues, particularly pleasant cues, but did not show a unique bias toward smoking-related stimuli. Results suggested that, among smokers, nicotine deprivation and exogenous stress (threat of electric shock) have a nonadditive effect on attention toward pleasant cues but no effect on attention to smoking cues specifically. Similarly, instructing smokers that they would have an opportunity to smoke did not significantly increase the bias of nicotine-deprived smokers' attention toward smoking-related cues, relative to arousing unpleasant and pleasant cues. Overall, results suggest that smokers' attention may be biased toward both smoking-related and other salient cues when deprived of nicotine and anticipating an opportunity to smoke. (PsycINFO Database Record (c) 2009 APA, all rights reserved).
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Bryan JP, Reyes L, Hakre S, Gloria R, Kishore GM, Tillett W, Engle R, Tsarev S, Cruess D, Purcell RH. Epidemiology of acute hepatitis in the Stann Creek District of Belize, Central America. Am J Trop Med Hyg 2001; 65:318-24. [PMID: 11693876 DOI: 10.4269/ajtmh.2001.65.318] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022] Open
Abstract
Hepatitis is common in the Stann Creek District of southern Belize. To determine the etiologies, incidence, and potential risk factors for acute jaundice, we conducted active surveillance for cases. Cases of jaundice diagnosed by a physician within the previous 6 weeks were enrolled. Evaluation included a questionnaire and laboratory tests for hepatitis A, B, C, D, and E, a blood film for malaria, and a serologic test for syphilis. Etiologies of jaundice among 62 evaluable patients included acute hepatitis A, 6 (9.7%), acute hepatitis B, 49 (79.0%), hepatitis non-A-E, 2 (3.2%), and malaria, 5 (8.1%). There were no cases of acute hepatitis E. One patient each with antibody to hepatitis C and D were detected. The annualized incidence of hepatitis A was 0.26 per 1,000. All cases of hepatitis A were in children 4-16 years of age. The annualized incidence of hepatitis B, 2.17 per 1,000, was highest in adults aged 15-44 years (4.4 per 1,000) and was higher in men (36 cases; 3.09 per 1,000) than women (13 cases; 1.19 per 1,000). Four (31%) of the women with hepatitis B were pregnant. The annualized incidence was significantly higher in Mestizo (6.18 per 1000) and Maya (6.79 per 1,000) than Garifuna (0.38 per 1,000) or Creole (0.36 per 1,000). Persons with hepatitis B were significantly more likely to be born outside of Belize (82%), had been in Belize < 5 years (73%), and lived and worked in rural areas (96%) than was the general population. Of those > or = 14 years of age with hepatitis B, only 36% were married. Few persons admitted to transfusions, tattoos, IV drug use, multiple sexual partners, visiting prostitutes, or sexually transmitted diseases. Only 1 of 49 had a reactive test for syphilis. Six patients were hospitalized (including 3 with acute hepatitis B and one with hepatitis A), and none to our knowledge died. Acute hepatitis B is the most common cause of viral hepatitis in the Stann Creek District, but the modes of transmission remain obscure. Infants, women attending prenatal clinics, and new workers are potential targets for immunization with hepatitis B vaccine.
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Affiliation(s)
- J P Bryan
- Department of Preventive Medicine and Biometrics, Uniformed Services University of the Health Sciences, Bethesda, Maryland 20814-4799, USA
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13
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Polich J, Gloria R. Cognitive effects of a Ginkgo biloba/vinpocetine compound in normal adults: systematic assessment of perception, attention and memory. Hum Psychopharmacol 2001; 16:409-416. [PMID: 12404561 DOI: 10.1002/hup.308] [Citation(s) in RCA: 35] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
A computerized test battery was used in a double-blind design to assess the cognitive effects of a nutrient compound containing Ginkgo biloba in 24 normal adults. Ten tasks (perceptual, attention and short-term memory) were presented in a standardized manner designed to maximize performance, with substantial pre-test practice employed to minimize response variability. Subjects were given either placebo or Ginkgo biloba extract capsules to consume for 14 days, after which they performed all tasks twice. They then received the other condition, and after 14 days completed the final test session. Response time and error rate stabilized after pre-test practice. A 'working memory capacity' paradigm demonstrated a reliable 50 ms response time decrease between the placebo and Ginkgo biloba testing, suggesting that Ginkgo biloba speeds short-term working memory processing in normal adults. Copyright 2001 John Wiley & Sons, Ltd.
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Affiliation(s)
- John Polich
- Department of Neuropharmacology, The Scripps Research Institute, La Jolla, California, USA
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14
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Fransson-Hall C, Gloria R, Kilbom A, Winkel J, Karlqvist L, Wiktorin C. A portable ergonomic observation method (PEO) for computerized on-line recording of postures and manual handling. Appl Ergon 1995; 26:93-100. [PMID: 15677005 DOI: 10.1016/0003-6870(95)00003-u] [Citation(s) in RCA: 36] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/24/2023]
Abstract
A new portable ergonomic observation method (PEO) is presented. It is applicable to most professions and work tasks and requires only moderate human resources for data collection and analysis. Observations are made in real time directly at the workplace using a portable personal or hand-held computer, and data are accessible for immediate analysis and presentation. Duration and number of events are calculated for postures at four body regions (arms, neck, trunk and knee) as well as for manual handling. An evaluation of the PEO method, assessing some important aspects of internal validity as well as intra- and inter-observer reliability, was carried out using video recordings. It showed acceptable validity for some types of physical exposure, and high intra- and inter-observer reliability. Practical experiences from using the PEO method in a field study and further improvements of the method are discussed.
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Affiliation(s)
- C Fransson-Hall
- Swedish National Institute of Occupational Health, Division of Applied Work Psychology, S-17184 Solna, Sweden
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15
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Hägg GM, Gloria R. Surface EMG muscular conduction velocity measurement system implemented on a standard personal computer without A/D convertor. Med Biol Eng Comput 1994; 32:691-4. [PMID: 7723434 DOI: 10.1007/bf02524251] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Affiliation(s)
- G M Hägg
- Division of Applied Work Physiology, National Institute of Occupational Health, Solna, Sweden
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Pisano L, Moronesi F, Falco F, Stipa E, Fabbiani N, Dolfi R, Conoscenti E, Gloria R, Pepe R. The use of sulodexide in the treatment of peripheral vasculopathy accompanying metabolic diseases. Controlled study in hyperlipidemic and diabetic subjects. Thromb Res 1986; 41:23-31. [PMID: 3515614 DOI: 10.1016/0049-3848(86)90276-8] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
Abstract
Thirty vasculopathic subjects with hyperlipoproteinemia (18) and/or diabetes (22) underwent a clinical double-blind study in order to evaluate the effect of sulodexide on lipid and hemorheologic parameters. The experimental design consisted of a first 20-day i.m. therapeutic period with either sulodexide (300 Lipasemic Units twice daily via intramuscular route) or placebo and the following 70 days with the active compound for both groups at the same posology. Results obtained demonstrated that sulodexide yields a hypotriglyceridemic effect on type IV hyperlipoproteinemia and hypofibrinogenic effect, as well. Moreover, this compound exerted a beneficial effect on HDL Cholesterol levels and on the antithrombin III activity by increasing both parameters significantly. Signs and symptoms were alleviated, particularly in the most severe cases of peripheral vascular disease. Insignificant and slight changes were observed at the end of treatments as regards the efficacy of the two administration routes, the i.m. one being more efficacious on lipid parameters and faster acting. No side effects or intolerance were observed during the different periods of the trial.
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