Increasing access to evidence-based insomnia care in the United States: findings from an American Academy of Sleep Medicine stakeholder summit

Challenges exist in access to high-quality care for insomnia disorder. After the recent publication of a clinical practice guideline on behavioral and psychological treatments for insomnia in adults, the American Academy of Sleep Medicine (AASM) hosted a 1-day virtual Insomnia Summit in September 2022 to discuss improving care for patients with insomnia disorder. Fifty participants representing a variety of organizations (eg, medical, psychological, and nursing associations; patient advocacy groups; and federal institutions) participated in the event. Videos highlighting patient perspectives on insomnia and an overview of current insomnia disorder treatment guidelines were followed by thematic sessions, each with 3 to 4 brief, topical presentations by content experts. Breakout groups were used to brainstorm and prioritize issues in each thematic area. Top barriers to care for insomnia disorder include limited access, limited awareness of treatment options, low perceived value of insomnia treatment, and an insufficient number of trained clinicians. Top facilitators of high-quality care include education and awareness, novel care models to increase access, expanding the insomnia patient care workforce, incorporating research into practice, and increasing reimbursement for psychotherapies. Priorities for the future include increasing awareness among patients and providers, increasing the number of skilled behavioral sleep medicine providers, increasing advocacy efforts to address insurance issues (eg, billing, reimbursement, and performance measures), and working collaboratively with multidisciplinary organizations to achieve common goals. These priorities highlight that goals set to improve accessible, high-quality care for insomnia disorder will require sustained, coordinated efforts to increase awareness, improve reimbursement, and grow the necessary skilled health care workforce.

CITATION

Schotland H, Wickwire E, Aaronson RM, et al. Increasing access to evidence-based insomnia care in the United States: findings from an American Academy of Sleep Medicine stakeholder summit. J Clin Sleep Med. 2024;20(3):455-459.

Dynamic ventral disc contraction is necessary for Giardia attachment and host pathology

Giardia lamblia is a common parasitic protist that infects the small intestine and causes giardiasis, resulting in diarrhea, vomiting, weight loss, and malabsorption. Giardiasis leads to cellular damage, including loss of microvilli, disruption of tight junctions, impaired barrier function, enzyme inhibition, malabsorption, and apoptosis. In the host, motile Giardia trophozoites attach to the duodenal microvilli using a unique microtubule organelle called the ventral disc. Despite early observations of disc-shaped depressions in microvilli after parasite detachment, little is known about disc-mediated attachment mechanisms and there little direct evidence showing that parasite attachment causes cellular damage. However, advancements in in vitro organoid models of infection and genetic tools have opened new possibilities for studying molecular mechanisms of attachment and the impact of attachment on the host. Through high-resolution live imaging and a novel disc mutant, we provide direct evidence for disc contraction during attachment, resolving the long-standing controversy of its existence. Specifically, we identify three types of disc movements that characterize contraction, which in combination result in a decrease in disc diameter and volume. Additionally, we investigate the consequences of attachment and disc contractility using an attachment mutant that has abnormal disc architecture. In a human organoid model, we demonstrate that this mutant has a limited ability to break down the epithelial barrier as compared to wild type. Based on this direct evidence, we propose a model of attachment that incorporates disc contraction to generates the forces required for the observed "grasping" of trophozoites on the host epithelium. Overall, this work highlights the importance of disc contractility in establishing and maintaining parasite attachment, leading to intestinal barrier breakdown.

Sleep Efficiency and Naturalistically-Observed Social Behavior Following Marital Separation: The Critical Role of Contact with an Ex-partner

Marital disruption is associated with increased risk for a range of poor health outcomes, including disturbed sleep. This report examines trajectories of actigraphy-assessed sleep efficiency following marital separation as well as the extent to which daily social behaviors and individual differences in attachment explain variability in these trajectories over time. One hundred twenty-two recently-separated adults (N = 122) were followed longitudinally for three assessment periods over five months. To objectively assess daily social behaviors and sleep efficiency, participants wore the Electronically Activated Recorder (EAR) during the day (for one weekend at each assessment period) and an actiwatch at night (for seven days at each assessment period). Greater time spent with an ex-partner, as assessed by the EAR, was associated with decreased sleep efficiency between participants (p = .003). Higher attachment anxiety was also associated with decreased sleep efficiency (p = .03), as was the EAR-observed measure of "television on." The latter effect operated both between (p = .004) and within participants (p = .005). Finally, study timepoint moderated the association between EAR-observed measure of "television on" and sleep efficiency (p = .007). The current findings deepen our understanding of sleep disturbances following marital separation and point to contact with an ex-partner and time spent with the television on as behavioral markers of risk.

Use of Sleep Aids in Insomnia: The Role of Time Monitoring Behavior

Objective: Over-the-counter (OTC) and prescription sleep medications are frequently used as treatments for chronic insomnia, despite risks and limited long-term efficacy. Investigating mechanisms underlying this predilection for pharmacotherapy may uncover strategies to decrease reliance on sleep aids. The objective of this study was to determine how time monitoring behavior (TMB; clock-watching) and associated frustration may interact with insomnia symptoms to drive the use of sleep aids.

Methods: Patients (N = 4,886) presenting for care at a community-based, private sleep medical center between May 2003 and October 2013 completed the Insomnia Severity Index (ISI) and Time Monitoring Behavior-10 (TMB-10) and reported their frequency of sleep medication use (OTC and prescription, separately). Mediation analyses examined how clock-watching and related frustration could be associated with insomnia symptoms and medication use.

Results: The relationship between TMB and sleep medication use was significantly explained by ISI (P < .05), in that TMB (especially related frustration) appears to aggravate insomnia, which in turn leads to sleep aid use. Similarly, but to a lesser extent, the relationship between ISI and sleep medication use was explained by TMB, in that ISI may lead to increased TMB, which may in turn lead to sleep aid use.

Conclusions: TMB and the associated frustration it engenders may perpetuate a negative cycle of insomnia and sleep aid use. Future longitudinal and interventional research is necessary to examine the developmental course of these clinical symptoms and behaviors and to test whether decreasing frustration by limiting TMB reduces the proclivity for pharmacotherapy.

A Micro-Longitudinal Study of Naps, Sleep Disturbance, and Headache Severity in Women with Chronic Migraine

OBJECTIVE

To examine the relationship between headaches, naps, and nocturnal sleep in women with chronic migraine (CM) using micro-longitudinal data from diaries and actigraphy.

METHODS

20 women with CM and 20 age and sex-matched healthy controls (HC) completed self-report questionnaires, electronic diaries, and wrist actigraphy over a 4-week period. Between-group comparisons were conducted with naps (frequency and duration) as the primary variable of interest. Within-group analyses were conducted on the CM group using hierarchical linear mixed models to examine the temporal relationships between headache severity, sleep behaviors, and sleep parameters. The primary variables of interest were naps (number and duration) and nocturnal sleep efficiency (diary and actigraphy).

RESULTS

The CM group reported significantly more days with naps (25.85%) compared to the HC group (9.03%) during the study period (p = .0025). Within-group analyses in CM revealed that greater headache severity was associated with longer nap duration (p = .0037) and longer nap duration was associated with lower sleep efficiency measured using diaries (p = .0014) and actigraphy (p < .0001).

CONCLUSIONS

Napping is more frequent in CM than HC and nap duration in CM is associated with headache severity and nocturnal sleep disturbance. These findings provide initial support for the hypothesis that daytime napping is a behavioral coping strategy used in CM that could contribute to insomnia.

A randomized controlled trial of cognitive behavioral therapy for insomnia and PAP for obstructive sleep apnea and comorbid insomnia: effects on nocturnal sleep and daytime performance

STUDY OBJECTIVES

This study examines the impact of cognitive behavioral therapy for insomnia (CBT-I) and positive airway pressure (PAP) therapy for comorbid insomnia and sleep apnea on nocturnal sleep and daytime functioning.

METHODS

A partial factorial design was used to examine treatment pathways with CBT-I and PAP and the relative benefits of each treatment. One hundred eighteen individuals with comorbid insomnia and sleep apnea were randomized to receive CBT-I followed by PAP, self-monitoring followed by CBT-I concurrent with PAP, or self-monitoring followed by PAP only. Participants were assessed at baseline, PAP titration, and 30 and 90 days after PAP initiation. Outcome measures included sleep diary- and actigraphy-measured sleep, Flinders Fatigue Scale, Epworth Sleepiness Scale, Functional Outcome of Sleep Questionnaire, and cognitive emotional measures.

RESULTS

A main effect of time was found on diary-measured sleep parameters (decreased sleep onset latency and wake after sleep onset; increased total sleep time and sleep efficiency) and actigraphy-measured sleep parameters (decreased wake after sleep onset; increased sleep efficiency) and daytime functioning (reduced Epworth Sleepiness Scale, Flinders Fatigue Scale; increased Functional Outcome of Sleep Questionnaire) across all arms (all P < .05). Significant interactions and planned contrast comparisons revealed that CBT-I was superior to PAP and self-monitoring on reducing diary-measured sleep onset latency and wake after sleep onset and increasing sleep efficiency, as well as improving Functional Outcome of Sleep Questionnaire and Flinders Fatigue Scale compared to self-monitoring.

CONCLUSIONS

Improvements in sleep and daytime functioning were found with PAP alone or concomitant with CBT-I. However, more rapid effects were observed on self-reported sleep and daytime performance when receiving CBT-I regardless of when it was initiated. Therefore, concomitant treatment appears to be a favorable approach to accelerate treatment outcomes.

CLINICAL TRIAL REGISTRATION

Registry: ClinicalTrials.gov; Name: Multidisciplinary Approach to the Treatment of Insomnia and Comorbid Sleep Apnea (MATRICS); URL: https://clinicaltrials.gov/ct2/show/NCT01785303; Identifier: NCT01785303.

CITATION

Tu AY, Crawford MR, Dawson SC, et al. A randomized controlled trial of cognitive behavioral therapy for insomnia and PAP for obstructive sleep apnea and comorbid insomnia: effects on nocturnal sleep and daytime performance. J Clin Sleep Med. 2022;18(3):789-800.

Developing a cognitive behavioral therapy for hypersomnia using telehealth: a feasibility study

STUDY OBJECTIVES

The purpose of this study was to evaluate the feasibility and acceptability of a novel cognitive behavioral therapy for hypersomnia (CBT-H) in people with central disorders of hypersomnolence and co-occurring depressive symptoms using a telehealth model for delivery and assessment.

METHODS

Thirty-five adults with narcolepsy or idiopathic hypersomnia received a 6-session CBT-H delivered individually or in small groups using videoconferencing. The clinical impact of CBT-H was evaluated using the Patient Health Questionnaire, Patient-Reported Outcomes Measurement Information System measures, Epworth Sleepiness Scale, and other patient-reported outcomes collected online at baseline and posttreatment. Feasibility and acceptability of the intervention and telehealth model was also evaluated using qualitative data collected from exit interviews conducted through videoconferencing.

RESULTS

Forty percent of the sample achieved a clinically significant baseline to posttreatment change in depressive symptoms (decrease in Patient Health Questionnaire ≥ 5), which is below the prespecified efficacy benchmark (50% of the sample). The prespecified benchmark for a minimal clinically important difference (Cohen's d > 0.5) on other psychosocial measures was met only on the Patient-Reported Outcomes Measurement Information System global self-efficacy (d = 0.62) in the total sample. Qualitative data revealed enthusiasm for the accessibility of telehealth delivery and the usefulness of several cognitive and behavioral modules but also revealed opportunities to refine the CBT-H program.

CONCLUSIONS

These findings indicate that this new CBT-H program can potentially reduce depressive symptoms and improve self-efficacy in people with central disorders of hypersomnolence. Furthermore, telehealth is a promising model for remote delivery and data collection to enhance participant accessibility and engagement.

CLINICAL TRIAL REGISTRATION

Registry: ClinicalTrials.gov; Name: Psychosocial Adjunctive Treatment for Hypersomnia (PATH); URL: https://clinicaltrials.gov/ct2/show/NCT03904238; Identifier: NCT03904238.

A randomized controlled trial of CBT-I and PAP for obstructive sleep apnea and comorbid insomnia: main outcomes from the MATRICS study

STUDY OBJECTIVES

To investigate treatment models using cognitive behavioral therapy for insomnia (CBT-I) and positive airway pressure (PAP) for people with obstructive sleep apnea (OSA) and comorbid insomnia.

METHODS

121 adults with OSA and comorbid insomnia were randomized to receive CBT-I followed by PAP, CBT-I concurrent with PAP, or PAP only. PAP was delivered following standard clinical procedures for in-lab titration and home setup and CBT-I was delivered in four individual sessions. The primary outcome measure was PAP adherence across the first 90 days, with regular PAP use (≥4 h on ≥70% of nights during a 30-day period) serving as the clinical endpoint. The secondary outcome measures were the Pittsburgh Sleep Quality Index (PSQI) and Insomnia Severity Index (ISI) with good sleeper (PSQI <5), remission (ISI <8), and response (ISI reduction from baseline >7) serving as the clinical endpoints.

RESULTS

No significant differences were found between the concomitant treatment arms and PAP only on PAP adherence measures, including the percentage of participants who met the clinical endpoint. Compared to PAP alone, the concomitant treatment arms reported a significantly greater reduction from baseline on the ISI (p = .0009) and had a greater percentage of participants who were good sleepers (p = .044) and remitters (p = .008). No significant differences were found between the sequential and concurrent treatment models on any outcome measure.

CONCLUSIONS

The findings from this study indicate that combining CBT-I with PAP is superior to PAP alone on insomnia outcomes but does not significantly improve adherence to PAP.

0754 Cognitive Behavioral Therapy for Hypersomnia (CBT-H): A Feasibility Study for Improving Health-Related Quality of Life

Introduction

The purpose of this study was to conduct a feasibility trial for a novel cognitive behavioral therapy (CBT-H) aimed at improving health-related quality of life (HRQoL) in people with hypersomnia.

Methods

Participants were 35 adults (32 female, mean age=32.0 years, SD=12.9) with an established diagnosis of Narcolepsy Type 1 (n=12), Type 2 (n=11), or Idiopathic Hypersomnia (n=12). Participants were assigned to individual (n=19) or group (n=16, 3-5 per group) format of a 6-session, manualized CBT-H, delivered using live videoconferencing. Key components of CBT-H included structuring daytime behaviors (e.g., planned naps), emotion regulation techniques, and energy management strategies. Outcome measures for HRQoL included PROMIS measures for depression, anxiety, self-efficacy, and social isolation. Other clinical outcome measures included the Patient Health Questionnaire (PHQ) and Epworth Sleepiness Scale (ESS). Exit interviews were used to collect qualitative data to inform acceptability of the intervention.

Results

Intent-to-treat analyses were conducted on the entire sample with the last observation carried forward for 3 participants who did not provide post-treatment data. Paired-samples t-test revealed a significant reduction on PROMIS depression (t[34]=2.05, p=0.0486, d=-0.35), and significant increases on PROMIS general self-efficacy (t[34]=3.64, p=0.0009, d=0.62) and self-efficacy managing social interactions (t[34]=2.14, p=0.0396, d=0.36). Significant reductions were also observed on the ESS (t[34]=2.07, p=0.0458, d=-0.35) and PHQ (t[34]=4.42, p&lt;.0001, d=-0.75). Mixed-design ANOVAs revealed no significant differences on hypersomnia diagnosis or treatment format. Qualitative data supported the acceptability of telehealth delivery with mixed opinions regarding the format and number of sessions.

Conclusion

These findings support the acceptability of a novel CBT-H delivered using a telehealth model and the feasibility of reducing excessive sleepiness and improving HRQoL, particularly in the domains of self-efficacy and depression, in people with narcolepsy and idiopathic hypersomnia.

Support

This study was supported by grant 185-SR-17 from the American Sleep Medicine Foundation.

0655 CBT-I and CPAP in Comorbid Insomnia and Sleep Apnea: Effects on Daytime Functioning

Introduction

This study examines the effects of treatment sequences using cognitive-behavioral therapy for insomnia (CBT-I) and continuous positive airway pressure (CPAP) therapy on daytime functioning in people with comorbid insomnia and sleep apnea (COMISA).

Methods

118 participants with COMISA (Age=49.99±13.12; 53.4% female) were randomized to one of the three study arms: Arm A- CBT-I followed by CPAP, Arm B- CBT-I concurrent with CPAP, and Arm C- CPAP only. Participants were assessed at four time points [baseline/ start of phase 1 (A1), CPAP titration/ start of phase 2 (A2), 30 days (A3) and 90 days (A4) after CPAP initiation]. This study examined secondary outcome measures of daytime functioning, including the Functional Outcomes of Sleep Questionnaire (FOSQ), Epworth Sleepiness Scale, and Flinders Fatigue Scale (FFS).

Results

Linear mixed model analyses showed a main effect of time on improving functional outcomes in all measurements, with all p&lt; 0.001. There were also arm by time interactions on FOSQ [F(6, 105.36)=4.21, p=0.001] and FFS scores [F(6, 106.95)=3.10, p=0.008]. Pairwise comparisons with Bonferroni adjustment showed improved FOSQ scores in Arm A from A1 to A2 (p=0.011) and A2 to A3 (p=0.005), Arm B from A2 to A3 (p&lt; 0.001), and Arm C from A2 to A3 (p=0.006). For FFS scores, improvements were shown in Arm A from A1 to A2 (p=0.003), and Arm B from A2 to A3 (p &lt; 0.001).

Conclusion

The results show daytime functioning improvements in patients with COMISA following CPAP and CBT-I. In addition, CBT-I appears to facilitate improvement in sleepiness-related functional status and daytime fatigue. The findings suggest that the combination of CBT-I and CPAP may have a beneficial effect on daytime functioning in patients with COMISA.

Support

This study was supported by the National Institutes of Health (R01HL114529).

1151 Is Timing Of Light Exposure Different In Women With Chronic Migraine?

Introduction

Light avoidance is a common coping behavior of individuals with migraine headaches. It is not known whether timing of light exposure is different in individuals with chronic migraine (CM) compared to those without migraine and how this may relate to headache frequency and severity. We tested this by examining timing of the brightest and darkest light and headaches in women with chronic migraines and healthy controls.

Methods

Sixteen women with CM (mean age = 33.07) and 18 female healthy controls (HC; mean age = 32.22) completed daily ratings of headache severity (0-10, severity &gt; 2 classified as headache) concurrent with light exposure measured by wrist actigraphy for approximately one month (M=28.00 days, range=21-36). Start time of each day’s 10-hour periods of maximum light (M10) and 5-hour periods of lowest light (L5) were calculated and averaged for each participant. T-tests and Cohen’s d effect sizes were used to compare groups. Pearson correlation coefficients were calculated to examine associations between M10/L5 timing and headache frequency and severity.

Results

M10 was earlier in the CM group compared to the HC group (07:42±00:47 vs. 08:50±00:58, t(32)=3.69, p=0.0008, d=1.08). The CM group exhibited non-significant trend towards earlier L5 compared to the HC group (12:26±00:48 vs. 01:07±01:03, t(32)=1.89, p=0.0723, d=0.62). Among individuals with CM, later M10 timing was associated with more severe average daily headache (r=0.60, p=0.0136) and more frequent headaches (r=0.55, p=0.0257). Later L5 timing was significantly associated with more severe average daily headache (r=0.66, p=0.0052) and showed a non-significant trend toward association with more frequent headaches (r=0.47, p=0.0686).

Conclusion

Timing of the greatest light exposure period was earlier in CM compared to HC. Within the CM group, those who had earlier light and dark periods reported lower headache severity and fewer days with headaches. These findings suggest the possibility of a role for the circadian system in chronic migraine.

Support

This study was supported by grant R21NS081088 from the National Institutes of Health.

Increased high-frequency NREM EEG power associated with mindfulness-based interventions for chronic insomnia: Preliminary findings from spectral analysis

OBJECTIVE

Mindfulness-based interventions (MBI) have been shown to reduce subjective symptoms of insomnia but the effects on objective measures remain unclear. The purpose of this study was to examine sleep EEG microarchitecture patterns from a randomized controlled trial of Mindfulness-Based Stress Reduction (MBSR) and Mindfulness-Based Therapy for Insomnia (MBTI).

METHODS

Sleep EEG spectral analysis was conducted on 36 participants with chronic insomnia (>6 months) randomized to 8-week MBSR, MBTI, or self-monitoring control (SM). Overnight polysomnography with 6-channel EEG was conducted at baseline, post-treatment, and 6-month follow-up. Spectral power averaged from channels C3/C4 across NREM epochs (excluding N1) was examined for within-group changes and relationships with self-report measures.

RESULTS

Increases in absolute NREM beta (16-25 Hz) power were observed from baseline to post-treatment (p = .02, d = 0.53) and maintained at 6-month follow-up (p = .01, d = 0.57) in the combined MBI groups, and additionally in the gamma (25-40 Hz) range at follow-up for the MBTI group only. No significant changes in these frequency bands were observed for SM. Following mindfulness intervention, NREM beta was positively associated with Five-Facet Mindfulness (FFM) score (rho = 0.37, p = .091) and negatively associated with Insomnia Severity Index (rho = -0.43, p = .047).

CONCLUSION

These results in people with insomnia corroborate prior reports of increased high-frequency sleep EEG power associated with mindfulness training. This change in beta EEG pattern merits further evaluation as a potential marker of the effects of mindfulness meditation on sleep, especially given the paradoxical findings in the context of insomnia.

CLINICAL TRIAL REGISTRATION

clinicaltrials.gov, NCT00768781.

Giardia Alters Commensal Microbial Diversity throughout the Murine Gut

Giardia lamblia is the most frequently identified protozoan cause of intestinal infection. Over 200 million people are estimated to have acute or chronic giardiasis, with infection rates approaching 90% in areas where Giardia is endemic. Despite its significance in global health, the mechanisms of pathogenesis associated with giardiasis remain unclear, as the parasite neither produces a known toxin nor induces a robust inflammatory response. Giardia colonization and proliferation in the small intestine of the host may, however, disrupt the ecological homeostasis of gastrointestinal commensal microbes and contribute to diarrheal disease associated with giardiasis. To evaluate the impact of Giardia infection on the host microbiota, we used culture-independent methods to quantify shifts in the diversity of commensal microbes throughout the gastrointestinal tract in mice infected with Giardia We discovered that Giardia's colonization of the small intestine causes a systemic dysbiosis of aerobic and anaerobic commensal bacteria. Specifically, Giardia colonization is typified by both expansions in aerobic Proteobacteria and decreases in anaerobic Firmicutes and Melainabacteria in the murine foregut and hindgut. Based on these shifts, we created a quantitative index of murine Giardia-induced microbial dysbiosis. This index increased at all gut regions during the duration of infection, including both the proximal small intestine and the colon. Giardiasis could be an ecological disease, and the observed dysbiosis may be mediated directly via the parasite's unique anaerobic fermentative metabolism or indirectly via parasite induction of gut inflammation. This systemic alteration of murine gut commensal diversity may be the cause or the consequence of inflammatory and metabolic changes throughout the gut. Shifts in the commensal microbiota may explain observed variations in giardiasis between hosts with respect to host pathology, degree of parasite colonization, infection initiation, and eventual clearance.

Meta-cognitive skills training enhances computerized cognitive remediation outcomes among individuals with first-episode psychosis

AIM

Meta-cognitive skills training (MST) is a frequent component of cognitive remediation programmes for individuals with psychosis. However, no study has investigated whether incorporating such activities produces increased clinical benefits compared with computerized cognitive remediation alone.

METHODS

Individuals with first-episode psychosis who completed computerized cognitive remediation with concurrent meta-cognitive skills training (CCR + MST) were compared with a historical control group who received computerized cognitive remediation alone (CCR) and did not differ from the CCR + MST group with regard to pre-intervention cognition, diagnosis, age, duration of psychotic illness or sex. Participants completed assessments of cognition and real-world functioning before and after 6 months of treatment.

RESULTS

Individual receiving CCR + MST experience greater gains in cognition and real-world functioning than individuals who received CCR.

CONCLUSIONS

MST may be an important component within cognitive remediation programmes for first-episode psychosis.

The Early Psychosis Intervention Center (EPICENTER): development and six-month outcomes of an American first-episode psychosis clinical service

BACKGROUND

There is growing evidence that specialized clinical services targeted toward individuals early in the course of a psychotic illness may be effective in reducing both the clinical and economic burden associated with these illnesses. Unfortunately, the United States has lagged behind other countries in the delivery of specialized, multi-component care to individuals early in the course of a psychotic illness. A key factor contributing to this lag is the limited available data demonstrating the clinical benefits and cost-effectiveness of early intervention for psychosis among individuals served by the American mental health system. Thus, the goal of this study is to present clinical and cost outcome data with regard to a first-episode psychosis treatment center within the American mental health system: the Early Psychosis Intervention Center (EPICENTER).

METHODS

Sixty-eight consecutively enrolled individuals with first-episode psychosis completed assessments of symptomatology, social functioning, educational/vocational functioning, cognitive functioning, substance use, and service utilization upon enrollment in EPICENTER and after 6 months of EPICENTER care. All participants were provided with access to a multi-component treatment package comprised of cognitive behavioral therapy, family psychoeducation, and metacognitive remediation.

RESULTS

Over the first 6 months of EPICENTER care, participants experienced improvements in symptomatology, social functioning, educational/vocational functioning, cognitive functioning, and substance abuse. The average cost of care during the first 6 months of EPICENTER participation was lower than the average cost during the 6-months prior to joining EPICENTER. These savings occurred despite the additional costs associated with the receipt of EPICENTER care and were driven primarily by reductions in the utilization of inpatient psychiatric services and contacts with the legal system.

CONCLUSIONS

The results of our study suggest that multi-component interventions for first-episode psychosis provided in the US mental health system may be both clinically-beneficial and cost-effective. Although additional research is needed, these findings provide preliminary support for the growing delivery of specialized multi-component interventions for first-episode psychosis within the United States.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT01570972; Date of Trial Registration: November 7, 2011.

A randomized controlled trial of cognitive remediation and d-cycloserine for individuals with bipolar disorder

BACKGROUND

Cognitive remediation (CR) has shown significant promise in addressing the cognitive deficits that accompany serious mental illness. However, this intervention does not appear to completely ameliorate the cognitive deficits that accompany these illnesses. D-cycloserine (DCS), an NMDA receptor partial agonist, has been shown to enhance the therapeutic benefits of learning-based psychosocial interventions for psychiatric disorders. Thus, the goal of this study is to examine the utility of combining cognitive remediation and d-cycloserine in the treatment of cognitive deficits among individuals with bipolar disorder.

METHODS/DESIGN

Approximately forty individuals with bipolar disorder will be recruited to participate in this study. Participants will be randomized to one of two study arms: CR + DCS or CR + placebo. The primary outcome for this study is change in cognitive functioning. We will also examine several secondary outcomes, including the rate of change of cognitive functioning, social functioning, and symptomatology.

DISCUSSION

Cognitive deficits are a rate-limiting factor in functional recovery among individuals with bipolar disorder. Unfortunately, treatment options for these deficits are limited. The results of the proposed study may reveal a valuable intervention strategy (i.e., CR with concurrent DCS) to improve cognitive functioning among individuals with bipolar disorder. Ultimately, this treatment strategy may prove useful in addressing the cognitive deficits that are ubiquitous across serious mental illnesses.

TRIAL REGISTRATION

ClinicalTrials.gov NCT01934972.

High-resolution crystal structure and in vivo function of a kinesin-2 homologue in Giardia intestinalis

A critical component of flagellar assembly, the kinesin-2 heterotrimeric complex powers the anterograde movement of proteinaceous rafts along the outer doublet of axonemes in intraflagellar transport (IFT). We present the first high-resolution structures of a kinesin-2 motor domain and an ATP hydrolysis-deficient motor domain mutant from the parasitic protist Giardia intestinalis. The high-resolution crystal structures of G. intestinalis wild-type kinesin-2 (GiKIN2a) motor domain, with its docked neck linker and the hydrolysis-deficient mutant GiKIN2aT104N were solved in a complex with ADP and Mg(2+) at 1.6 and 1.8 A resolutions, respectively. These high-resolution structures provide unique insight into the nucleotide coordination within the active site. G. intestinalis has eight flagella, and we demonstrate that both kinesin-2 homologues and IFT proteins localize to both cytoplasmic and membrane-bound regions of axonemes, with foci at cell body exit points and the distal flagellar tips. We demonstrate that the T104N mutation causes GiKIN2a to act as a rigor mutant in vitro. Overexpression of GiKIN2aT104N results in significant inhibition of flagellar assembly in the caudal, ventral, and posterolateral flagellar pairs. Thus we confirm the conserved evolutionary structure and functional role of kinesin-2 as the anterograde IFT motor in G. intestinalis.

The cenH3 histone variant defines centromeres in Giardia intestinalis

Histone H3 variants play critical roles in the functional specialization of chromatin by epigenetically marking centromeric chromatin and transcriptionally active or silent genes. Specifically, the cenH3 histone variant acts as the primary epigenetic determinant of the site of kinetochore assembly at centromeres. Although the function of histone variants is well studied in plants, animals, and fungi, there is little knowledge of the evolutionary conservation of histone variants and their function in most protists. We find that Giardia intestinalis--a diplomonad parasite with two equivalent nuclei--has two phylogenetically distinct histone H3 variants with N-terminal extensions and nonconserved promoters. To determine their role in chromatin dynamics, conventional H3 and the two H3 variants were GFP-tagged, and their subcellular location was monitored during interphase and mitosis. We demonstrate that one cenH3-like variant has a conserved function in epigenetically marking centromeres. The other H3 variant (H3B) has a punctate distribution on chromosomes, but does not colocalize with active transcriptional regions as indicated by H3K4 methylation. We suggest that H3B could instead mark noncentromeric heterochromatin. Giardia is a member of the Diplomonads and represents an ancient divergence from metazoans and fungi. We confirm the ancient role of histone H3 variants in modulating chromatin architecture, and suggest that monocentric chromosomes represent an ancestral chromosome morphology.

Giardia lamblia attachment force is insensitive to surface treatments

Giardia lamblia cell populations show 90% detachment from glass under normal forces of 2.43+/-0.33 nN applied by centrifugation. Detachment forces were not significantly different for cells attached to positively charged, hydrophobic, or inert surfaces than for cells attached to plain glass. The insensitivity of attachment force to surface treatment is consistent with a suction-based mechanism of attachment.

Identification and characterization of bacteria in a selenium-contaminated hypersaline evaporation pond

Solar evaporation ponds are commonly used to reduce the volume of seleniferous agricultural drainage water in the San Joaquin Valley, Calif. These hypersaline ponds pose an environmental health hazard because they are heavily contaminated with selenium (Se), mainly in the form of selenate. Se in the ponds may be removed by microbial Se volatilization, a bioremediation process whereby toxic, bioavailable selenate is converted to relatively nontoxic dimethylselenide gas. In order to identify microbes that may be used for Se bioremediation, a 16S ribosomal DNA phylogenetic analysis of an aerobic hypersaline pond in the San Joaquin Valley showed that a previously unaffiliated group of uncultured bacteria (belonging to the order Cytophagales) was dominant, followed by a group of cultured gamma-Proteobacteria which was closely related to Halomonas species. Se K-edge X-ray absorption spectroscopy of selenate-treated bacterial isolates showed that they accumulated a mixture of predominantly selenate and a selenomethionine-like species, consistent with the idea that selenate was assimilated via the S assimilation pathway. One of these bacterial isolates (Halomonas-like strain MPD-51) was the best candidate for the bioremediation of hypersaline evaporation ponds contaminated with high Se concentrations because it tolerated 2 M selenate and 32.5% NaCl, grew rapidly in media containing selenate, and accumulated and volatilized Se at high rates (1.65 microg of Se g of protein(-1) x h(-1)), compared to other cultured bacterial isolates.

Cadmium removal by a new strain of Pseudomonas aeruginosa in aerobic culture

A fluorescent pseudomonad (strain CW-96-1) isolated from a deep-sea vent sample grew at 30 degrees C under aerobic conditions in an artificial seawater medium and tolerated cadmium concentrations up to 5 mM. After 140 h, strain CW-96-1 removed > 99% of the cadmium from solution. Energy dispersive microanalysis revealed that the cadmium was removed by precipitation on the cell wall; sulfide production was confirmed by growth on Kligler's agar. Based on 16S ribosomal DNA sequencing and fatty acid analysis, the microorganism is closely related to Pseudomonas aeruginosa.

Phylogenetic perspective on microbial life in hydrothermal ecosystems, past and present

Understanding hydrothermal ecosystems, both past and present, requires basic information on the types of organisms present. Traditional methods, which require cultivation of microorganisms, fail to detect many taxa. We have used phylogenetic analyses of small subunit rRNA sequences obtained from microorganisms of a hot spring in Yellowstone National Park to explore the archael (archaebacterial) diversity present. Analysis of these sequences reveals several novel groups of archaea, greatly expanding our conception of the diversity of high temperature microorganisms, and demonstrating that hydrothermal systems harbour a rich variety of life. Many of these groups diverged from the archael line of descent early during evolution, and an understanding of their common properties may assist in inference of the nature of the last common ancestor of all life. The data also show a specific relationship between low-temperature marine archaea and some hot spring archaea, consistent with a thermophilic origin of life. Future use of rRNA-sequence-based techniques in exploration of hydrothermal systems should greatly facilitate study of modern thermophiles and give us insight into the activities of extinct communities as well.

Persistence of four related human immunodeficiency virus subtypes during the course of zidovudine therapy: relationship between virion RNA and proviral DNA

Human immunodeficiency virus (HIV) virion RNA and proviral DNA sequences have been examined over a 1-year period in an HIV-seropositive patient, commencing with the start of zidovudine treatment. By characterizing the variable V3 and V4 env domains, four related but structurally discrete genotypes could be identified prior to the start of therapy and during the subsequent 60-week period of therapy. Each of the four subtypes showed a unique pattern in the preservation of glycosylation sites. A comparison of the V3 amino acid sequences in peripheral blood mononuclear cell proviral DNA and plasma virion RNA at 0, 24, 36, and 60 weeks demonstrated that proviral DNA did not serve as a predictor of the structure of virion RNA. HIV virion RNA subtype 3 was the most prevalent virion RNA subtype at three of the four periods studied, yet no corresponding proviral DNA was detected. Other virion subtypes have been observed, but only on a transient basis. The present data are consistent with a model of HIV infection in which related but different HIV substrains coexist and evolve independently within an individual. Characterization of virion RNA may be required to identify the unique properties of the virus involved in disease progression; characterization of proviral DNA will not yield this information.

Parental knowledge and attitudes toward discussing the risk of death from anesthesia

There is considerable debate as to the extent of disclosure of risks when obtaining informed consent for anesthesia, especially when discussing with parents the rare risk of death of healthy children about to undergo elective, outpatient surgery. In Part I, we attempted to determine parents' knowledge about the risks of anesthesia as well as their thoughts toward either hearing, or not hearing, about the risk of death. In the first part of our study, 115 parents completed questionnaires before speaking with the anesthesiologist. Ninety-six (87%) wanted to know the chances of death as a result of anesthesia, whereas 14 (13%) did not. Seventy-five (68%) parents knew that this risk was "extremely rare," 21 (19%) believed that it occurs "once in a while," and 14 (13%) thought there was "no chance." Eighty-two (74%) parents wanted to know "all possible risks," 26 (24%) wanted to know only "those that are likely to occur," and 3 (2%) wanted to know only about those that would "result in significant injury." Mothers were more likely to want to hear all possible risks, whereas fathers were more likely to want to know only about those that are likely to occur (P = 0.001). Otherwise, responses were not influenced by the sex of the parents, the age of the child, or whether the child or any siblings had had surgery in the past. In Part II, a separate group of 121 parents were surveyed after participating in the preanesthetic discussion with the anesthesiologist.(ABSTRACT TRUNCATED AT 250 WORDS)