Digital Therapeutics for Insomnia: Assessing the Effectiveness of a Computerized Home-Based Cognitive Stimulation Program

BACKGROUND

Sleep disturbances represent a major health burden today, affecting up to one-third of the population worldwide. Computerized cognitive stimulation has been proven as an effective approach in diminishing negative symptomatology and improving the quality of life in a range of medical conditions. Given its nature in enhancing neural networks, such as those involved in stimulus monitoring and inhibitory processes, computerized cognitive stimulation is arising as a potential tool to overcome underlying cognitive deficits found among patients suffering from insomnia. In the current study, we report the results of Phase 1 and Phase 2 clinical trials of a home-based computerized cognitive stimulation program.

METHODS

The cognitive stimulation intervention followed a home-based approach with online supervision by a psychologist. The training activities were gamified cognitive tasks that had been designed to improve executive functions, with a focus on inhibition skills. The Insomnia Severity Index and the Pittsburgh Sleep Quality Index scales were used as the main assessment measures. Data from the Behavior Rating Inventory of Executive Function, the Beck Depression Inventory, the State-Trait Anxiety Inventory, and the Penn State Worry Questionnaire were also recorded before and after the intervention. During 15 consecutive days, participants performed on alternate days a total of 7 training sessions (each lasting 45 minutes).

RESULTS

Twelve patients with clinical insomnia were administered the home-based online cognitive stimulation program. After seven training sessions, mean changes in sleep quality, depressive and anxiety symptoms, worry thoughts, and everyday function were found, with significant improvements in these domains in the full absence of safety issues.

CONCLUSIONS

In patients with insomnia, cognitive stimulation demonstrated improvements in sleep quality, mood, and cognitive performance over a 15-day protocol. No relevant side effects were reported. The long-term effectiveness of the intervention is still unknown.

CLINICAL TRIAL REGISTRATION

The study protocol has been reviewed and published in ClinicalTrials.gov, assigning it the code NCT05050292 https://clinicaltrials.gov/ct2/show/NCT05050292?term=NCT05050292&draw=2&rank=1.

Study Protocol for a Randomized Controlled Trial Assessing the Effectiveness of Personalized Computerized Cognitive Training for Individuals With Insomnia

Insomnia is a frequent and heightened pathology in the general population of developed countries, and its condition generally leads to health discomfort and performance drop in daily and work-related tasks. As current pharmacological treatments for insomnia do not always seem sufficient to mitigate impairment, contemporary cognitive approaches might shed light on developing complementary therapies for this population. We propose a cognitive stimulation intervention program based on the importance of cognitive abilities as precipitating and maintenance variables of sleep disturbances. A full phase I-II-III clinical trial is proposed in which the first two studies will serve to assess the safety of the intervention and to identify the maximum tolerated time of the computerized cognitive training (phase I) and the minimum effective number of training sessions (phase II) in the absence of adverse events or side effects. Next, a phase-III double-blind randomized controlled trial design will be set. Sixty individuals with insomnia aged 25 to 55 years will enroll in a home-based personalized computerized cognitive stimulation program for a total time of 8 weeks, training 5 days per week. Sixty insomnia patients matched in a variety of factors will constitute the active control group, where the orthogonal activities will not be cognitively demanding. Sleep, cognitive, emotional, and quality of life variables will be measured before and immediately after training. A linear mixed model and hierarchical regression analysis will be used to investigate intervention effects. The results derived from this study will be precious for future research and treatment in cognitive performance and clinical pathologies.

Clinical Trial Registration: [https://clinicaltrials.gov/], identifier [NCT05050292].

Narcolepsy and adjuvanted pandemic influenza A (H1N1) 2009 vaccines - Multi-country assessment

BACKGROUND

In 2010, a safety signal was detected for narcolepsy following vaccination with Pandemrix, an AS03-adjuvanted monovalent pandemic H1N1 influenza (pH1N1) vaccine. To further assess a possible association and inform policy on future use of adjuvants, we conducted a multi-country study of narcolepsy and adjuvanted pH1N1 vaccines.

METHODS

We used electronic health databases to conduct a dynamic retrospective cohort study to assess narcolepsy incidence rates (IR) before and during pH1N1 virus circulation, and after pH1N1 vaccination campaigns in Canada, Denmark, Spain, Sweden, Taiwan, the Netherlands, and the United Kingdom. Using a case-control study design, we evaluated the risk of narcolepsy following AS03- and MF59-adjuvanted pH1N1 vaccines in Argentina, Canada, Spain, Switzerland, Taiwan, and the Netherlands. In the Netherlands, we also conducted a case-coverage study in children born between 2004 and 2009.

RESULTS

No changes in narcolepsy IRs were observed in any periods in single study sites except Sweden and Taiwan; in Taiwan incidence increased after wild-type pH1N1 virus circulation and in Sweden (a previously identified signaling country), incidence increased after the start of pH1N1 vaccination. No association was observed for Arepanrix-AS03 or Focetria-MF59 adjuvanted pH1N1 vaccines and narcolepsy in children or adults in the case-control study nor for children born between 2004 and 2009 in the Netherlands case-coverage study for Pandemrix-AS03.

CONCLUSIONS

Other than elevated narcolepsy IRs in the period after vaccination campaigns in Sweden, we did not find an association between AS03- or MF59-adjuvanted pH1N1 vaccines and narcolepsy in children or adults in the sites studied, although power to evaluate the AS03-adjuvanted Pandemrix brand vaccine was limited in our study.

[Factors related with the presence of erectile dysfunction in patients with obstructive sleep apnea]

BACKGROUND AND OBJECTIVE

Obstructive sleep apnea (OSA) syndrome can contribute to the development of erectile dysfunction (ED) through multiple mechanisms. The aim was to identify factors influencing the presence of ED in these patients.

PATIENTS AND METHODS

Cross sectional study in men diagnosed with OSA by polysomnography. We obtained information about demographic variables, apnea-hypopnea index (AHI), comorbidity, blood pressure, drugs, Epworth Sleepiness Scale, physical examination, electrocardiogram, ankle-brachial index and blood and urine analysis. The presence of ED was assessed by questionnaire IIEF-5.

RESULTS

We included 142 patients, mean age was 53 (11) years. The prevalence of ED was 69%. We found significant differences in AHI between patients with mild and severe ED (41 [21] vs 63 [18], P=.023). ED was associated with hypertension (odds ratio [OR]=3.56 [1.64-7.72]), hypercholesterolemia (OR=7.19 [2.39-21.68]), diabetes mellitus type 2 (OR=3.07 [1.02-9.48]) and ischemic heart disease (OR=1.51 [1.33-1.70]); and treatment with antihypertensive (OR=4.05 [1.76-9.31)], lipid-lowering drugs (OR=9.71 [2.2-22.72]), anti-diabetic drugs (OR=3.21 [0.69-14.89]), antiplatelet and anticoagulant agents (OR=6.44 [1.45-28.64]). After logistic regression analysis, only age (OR=1.11 [1.05-1.16]) and hypercholesterolemia (OR=4.87 [1.49-15.96]) were associated with ED.

CONCLUSIONS

Patients with OSA have a high prevalence of ED, mainly in severe OSA. Factors influencing the presence of ED in patients with OSA are primarily age and hypercholesterolemia. Other factors that may be related include hypertension, poor metabolic control, ischemic heart disease, and treatment with antihypertensive, lipid-lowering and anti-diabetic drugs.

Consensus on Drug Treatment, Definition and Diagnosis for Insomnia

Thirty-four experts and a literature supervisor got together in order to reach a 'consensus' regarding the definition, diagnosis and pharmacological treatment of insomnia. Insomnia is a subjective perception of dissatisfaction with the amount and/or quality of sleep. It includes difficulty in initiating or maintaining sleep or early awakening with inability to fall asleep again. It is associated with complaints of non-restorative sleep and dysfunction of diurnal alertness, energy, cognitive function, behaviour or emotional state, with a decrease in quality of life. The diagnosis is based on clinical and sleep history, physical examination and additional tests, although polysomnography is not routinely indicated. Therapy should include treatment of the underlying causes, cognitive and behavioural measures and drug treatment. Hypnotic therapy can be prescribed from the onset of insomnia and non-benzodiazepine selective agonists of the GABA-A receptor complex are the drugs of first choice. It is recommended that hypnotic treatment be maintained in cases where withdrawal impairs the patient's quality of life and when all other therapeutic measures have failed. Experience suggests that intermittent treatment is better than continuous therapy. The available data do not confirm safety of hypnotics in pregnancy, lactation and childhood insomnia. Benzodiazepines are not indicated in decompensated chronic pulmonary disease but no significant adverse effects on respiratory function have been reported with zolpidem and zopiclone in stable mild to moderate chronic obstructive pulmonary disease and in treated obstructive sleep apnoea syndrome. Data for zaleplon are inconclusive. If the patient recovers subjective control over the sleep process, gradual discontinuation of hypnotic treatment can be considered.

Efficacy of the antioxidant ebselen in experimental uveitis

Inflammation results in the production of free radicals. In a model of experimental uveitis upon subcutaneous injection of endotoxin to Lewis rats, i.e., endotoxin-induced experimental uveitis (EIU), we have evaluated the status of the antioxidant capacity of ocular tissues. EIU results in a decrease of glutathione (GSH) content and glutathione peroxidase (GPx) activity in whole eye homogenates 24-h after endotoxin administration. Furthermore, an increase in malondialdehyde (MDA) content was observed in these same samples, thus confirming the involvement of oxidative stress in the pathophysiology of the process. In view of the ability of the antioxidant ebselen as GPx enzyme mimic, we tested the effect of the oral treatment with two doses of 100 mg/kg body weight of ebselen (first dose administered at the same time of endotoxin, and the second after 12 h). Ebselen administration normalized the GSH and MDA contents and protected the GPx activity of the EIU rat eyes. The GPx activity in the eye homogenate of the treated rats could be completely acounted for by the ebselen-dependent GPx-like activity, i.e., GPx activity measured in the acidic supernatant of the homogenate after neutralization. Unmodified ebselen was detected in whole eye homogenates, thus it shows for the first time the penetration of ebselen through the blood-aqueous and blood-retina barrier. The results herein may allow the proposal of ebselen as a suitable antiinflammatory agent in ocular tissues.

[Arousal of respiratory origin and upper airway resistance syndrome: pathophysiological and diagnostic aspects]

INTRODUCTION

The description of Upper Airway Resistance Syndrome (UARS) let us to recognize the importance of the pair 'respiratory effort-arousal' on sleep-disordered breathing pathophysiology.

DEVELOPMENT

First part of this paper reviews knowledge about respiratory arousal pathophysiology. Arousal response is normally needed to end obstructive respiratory episodes, but it is also the cause of sleep fragmentation. Among respiratory stimuli able to provoke arousal (respiratory effort, hypoxemia and hypercapnia), respiratory effort is the most constant. Neurophysiological mechanisms involved in arousal, sleep and vegetative consequences, and the possible role of non visible arousals, are also discussed. In UARS, because of the absence of apnea/hypopnea and significative O2 desaturations, arousals are induced by the increased respiratory effort. Diagnosis needs the simultaneous recording of polysomnography and esophageal pressure. Some symptoms and signs of UARS are similar to those of Obstructive Sleep Apnea Syndrome. However, UARS shows any differences: a lower Body Mass Index, less constant snoring, males and females are similarly affected or higher frequency of craniofacial abnormalities. Diagnostic difficulties may be due to confusion between hypopneas and episodes of increased resistance of upper airway, or to the lack of definitive diagnostic criteria. Finally, differential diagnosis needs a broad knowledge of disorders of excessive daytime sleepiness.

Serum vitamin E levels negatively correlate with severity of age-related macular degeneration

Age-related macular degeneration (AMD) pathogenesis has been related to UV radiation and other factors that may promote increased oxidative damage to the retina. Patients with different AMD grading (n = 25) were compared with an age-matched group of AMD-free subjects (n = 15), both groups older than 60 years. A modification of the AMD grading system is proposed that allows patient grading and not single eye grading. AMD patients showed statistically significant lower serum levels of vitamin E and Zn than AMD-free subjects. Moreover, a negative correlation (Spearman's correlation coefficient r = -0.815, P < 0.001) could be established between AMD grading of both the patients' eyes and serum vitamin E levels. Sun exposure index (SEI) was also compared and found to be significantly higher in the AMD group. The results presented establish the importance of antioxidants in AMD, and set the basis for further studies on adjuvant therapies with antioxidants for AMD. Finally, the results also confirm the pathogenic role of UV radiation in AMD.

[Diagnostic difficulties in the narcolepsy-catalepsy syndrome: with reference to our series of cases]

The narcolepsy-cataplexy syndrome is a disorder of unknown aetiology, characterized by excessive daytime sleepiness associated with cataplexy and other REM sleep phenomena. Diagnosis is based on the clinical findings, although this may be difficult especially with respect to confirming the cataplexy. Objective tests, such as typing for HLA, DR2DQ1 (DRw15DQw6, WHO90) and above all TMLS (average latency < 5 mn and two or more onsets of sleep in the phases REM and SOREMP's) is of great help. However, the exact diagnostic significance of some aspects of these tests and their parameters is still under discussion. In this paper we review our series of cases consisting of fourteen patients who fulfil the clinical diagnostic criteria required in the ICSD-1990. TMLS and HLA typing was done for all. Of the HLA types, DQ1 was present in all our patients, unlike DR2 which was not found in two patients. Regarding TMLS, the average latency < 5 mn is a parameter met by all cases, although one did not have SOREMP's. The findings of the objective tests done on our patients are in agreement with those described by other authors. They underline the significance of the support they lend to the diagnosis. However, they are not the definite answer to the problem.

Glutathione system of human retina: enzymatic conjugation of lipid peroxidation products

The major aspects of the glutathione (GSH)-related antioxidant defense of human retina are presented. These include concentration of GSH and activities of some GSH-dependent enzymes: glutathione peroxidase, glutathione disulfide reductase, and glutathione S-transferase toward a broad spectrum substrate 1-chlor-2,4-dinitrobenzene and a toxic product of lipid peroxidation (4-hydroxynonenal). The presence of a relatively high GSH concentration, GSH peroxidase activity, and GSH S-transferase specific activity toward 4-hydroxynonenal in human retina might constitute a central defense mechanism in inflammation-promoted oxidative stress and subsequent lipid peroxidation. The use of different substrates for the determination of the GSH peroxidase activity showed no statistically significant difference, thus suggesting the lack of Se-independent GSH peroxidase in human retina. Large individual variations were obtained for GSH concentration and the different activities tested; the apparent correlation with age of these findings is currently under investigation.

Prevention of the acute neurotoxic effects of phenytoin on rat peripheral nerve by H7, an inhibitor of protein kinase C

The neurotoxic effects of a single dose of phenytoin (150 mg/kg body weight) alone or 30 min after H7 (a protein kinase C inhibitor) injection (20 mg/kg body weight) were investigated in terms of peripheral neuromuscular function and Na+,K(+)-ATPase activity of the sciatic nerve. This intraperitoneal injection of phenytoin induced complete blockade of muscle action potentials in the dorsal segmental muscles of the rat tail evoked by electric stimulation of the caudal nerve and a 40% decrease in the Na+,K(+)-ATPase activity of the rat sciatic nerve when compared with control values, measured as the difference between total and ouabain-insensitive ATPase activity. Prior administration of H7 resulted in the complete prevention of both effects. Implications of protein kinase C inhibition in phenytoin neurotoxicity are discussed.

Oxygen toxicity in the nervous tissue: comparison of the antioxidant defense of rat brain and sciatic nerve

Nervous tissue, central and peripheral, is, as any other, subject to variations in oxygen tension, and to the attack of different xenobiotics; these situations may promote the generation of activated oxygen species of free radical character. Results are presented showing that the content of total glutathione (GSH) in brain is 10-fold that found in the sciatic nerve of the rat (2620 vs. 261 nmol/g wet weight, respectively). The existence of a relatively high superoxide dismutase activity in peripheral nervous tissue, when compared with brain or liver, in combination with the DT-diaphorase activity detected in the sciatic nerve might represent an effective defense mechanism against quinone toxicity, as is also discussed. Nervous tissue, both central and peripheral lack Se-independent GSH peroxidase activity. Finally, the activities of other glutathione-related enzymes studied in the sciatic nerve are very low, when compared with the central nervous tissue, thus suggesting a higher susceptibility of peripheral tissue to oxidative stress damage, since GSH concentration and/or any GSH-related enzymatic activities, e.g. GSH peroxidase or glutathione disulfide reductase, might become limiting.

Antioxidant and glutathione-related enzymatic activities in rat sciatic nerve

The present work tries to establish the antioxidant capacity of the peripheral nervous tissue of the rat, in terms of the enzymatic activities present in this tissue that either prevent the formation of activated species as the semiquinone radical (DT-diaphorase), protect against activated oxygen species (superoxide dismutase, glutathione peroxidase), conjugate natural toxic products or xenobiotics (glutathione S-transferase, especially the activity conjugating 4-hydroxy-nonenal), or complete the glutathione system metabolism (glutathione disulfide reductase, gamma-glutamyl transpeptidase). All the activities studied are lower in this tissue than they are in liver, except for gamma-glutamyl transpeptidase. The relevance of the results obtained and its possible relationship with different neuropathies is discussed. It is concluded that the peripheral nervous tissue is by far less protected than the liver against oxidative damage.