Preliminary evidence of psychological improvements and increased maternal-fetal attachment associated with a mindfulness sleep programme: secondary analysis of uncontrolled data in 11 pregnant women with insomnia disorder

Treating insomnia during pregnancy improves sleep and depressed mood. However, given well-established links between poor sleep and a broad spectrum of adverse maternal outcomes, the benefits of insomnia care may reach beyond sleep and depression. The present study evaluated the preliminary efficacy of 'Perinatal Understanding of Mindful Awareness for Sleep' (PUMAS)-a mindfulness sleep programme tailored to pregnancy that combines behavioural sleep strategies and meditation-for enhancing everyday mindfulness and maternal-fetal attachment, as well as for alleviating anxiety, repetitive thinking, and sleep-related daytime impairment. We conducted a secondary analysis of a single-arm proof-of-concept trial of 11 pregnant women with fifth edition of the Diagnostic and Statistical Manual of Mental Disorders diagnosed insomnia disorder who completed PUMAS (six sessions), which was delivered in an individual format via telemedicine video. Pre- and post-treatment outcomes included the Cognitive and Affective Mindfulness Scale-Revised (CAMS-R), Maternal-Fetal Attachment Scale (MFAS), Generalised Anxiety Disorder seven-item survey (GAD-7), Perseverative Thinking Questionnaire (PTQ), Daytime Insomnia Symptoms Response Scale (DISRS), and the Patient-Reported Outcomes Measurement Information System Sleep-Related Impairment Scale (PROMIS-SRI). Symptom changes were evaluated with paired-samples t tests. Results showed PUMAS patients reported large increases in CAMS-R (Cohen's dz  = 1.81) and medium-large increases in MFAS scores (Cohen's dz  = 0.73). Moreover, PUMAS patients reported large reductions in scores on the GAD-7 (Cohen's dz  = 1.09), PTQ (Cohen's dz  = 1.26), DISRS (Cohen's dz  = 1.38), and PROMIS-SRI (Cohen's dz  = 1.53). Preliminary evidence suggests that a mindfulness-based perinatal sleep programme may benefit several domains of maternal wellbeing beyond sleep and depression. PUMAS substantially enhanced patient ratings of everyday mindfulness and maternal-fetal attachment, while reporting alleviations in anxiety, perseverative thinking, insomnia-focused rumination, and sleep-related daytime impairment.

Effects of oxybate dose and regimen on disrupted nighttime sleep and sleep architecture

Many components of sleep are disrupted in patients with narcolepsy, including sleep quality, sleep architecture, and sleep stability (ie, frequent awakenings/arousals and frequent shifts from deeper to lighter stages of sleep). Sodium oxybate, dosed twice nightly, has historically been used to improve sleep, and subsequent daytime symptoms, in patients with narcolepsy. Recently, new formulations have been developed to address the high sodium content and twice-nightly dosing regimen of sodium oxybate: low-sodium oxybate and once-nightly sodium oxybate. To date, no head-to-head trials have been conducted to compare the effects of each oxybate product. This review aims to give an overview of the existing scientific literature regarding the impact of oxybate dose and regimen on sleep architecture and disrupted nighttime sleep in patients with narcolepsy. Evidence from 5 key clinical trials, as well as supporting evidence from additional studies, suggests that sodium oxybate, dosed once- and twice-nightly, is effective in improving sleep, measures of sleep architecture, and disrupted nighttime sleep in patients with narcolepsy. Direct comparison of available efficacy and safety data between oxybate products is complicated by differences in trial designs, outcomes assessed, and statistical analyses; future head-to-head trials are needed to better understand the advantage and disadvantages of each agent.

Once-nightly sodium oxybate (FT218) improved symptoms of disrupted nighttime sleep in people with narcolepsy: a plain language summary

WHAT IS THIS SUMMARY ABOUT?

This is a plain language summary of a published article in the journal CNS Drugs. Narcolepsy is a rare sleep condition. Most people with narcolepsy experience disrupted nighttime sleep and have poor quality of sleep. Sometimes these symptoms are not easily diagnosed as a symptom of narcolepsy. Sodium oxybate is an approved treatment for narcolepsy. The only version of sodium oxybate that was available until 2023 required people to take their sodium oxybate at bedtime and then again in the middle of the night. The US Food and Drug Administration (FDA for short) has approved a once-nightly bedtime dose of sodium oxybate (ON-SXB for short, also known as FT218 or LUMRYZ™) to treat symptoms of narcolepsy in adults. These symptoms are daytime sleepiness and cataplexy, which is an episode of sudden muscle weakness. The once-nightly bedtime dose of ON-SXB removes the need for a middle-of-the-night dose of sodium oxybate. The REST-ON clinical study compared ON-SXB to a placebo (a substance that contains no medicine) to determine if it was better at treating symptoms of disrupted nighttime sleep associated with narcolepsy. This summary looks at whether; ON-SXB was better than placebo at treating symptoms of disrupted nighttime sleep.

WHAT WERE THE RESULTS?

Compared to people who took placebo, people who took ON-SXB had fewer number of changes from deeper to lighter sleep stages and woke up less during the night. They also reported that they slept better at night and felt more refreshed when waking up in the morning. People with narcolepsy sometimes take alerting agents to help with sleepiness during the day, but alerting agents can cause difficulty sleeping at night. This study showed that people who took ON-SXB had better nighttime sleep even if they were taking alerting agents during the day. The most common side effects of ON-SXB included dizziness, nausea (feeling sick to your stomach), vomiting, headache, and bedwetting.

WHAT DO THE RESULTS MEAN?

A once-nightly bedtime dose of ON-SXB is a narcolepsy treatment option for people without the need for a middle-of-the-night dose of sodium oxybate.

Efficacy of once-nightly sodium oxybate (FT218) in narcolepsy type 1 and type 2: post hoc analysis from the Phase 3 REST-ON Trial

STUDY OBJECTIVES

Post hoc analyses from the phase 3 REST-ON trial evaluated efficacy of extended-release once-nightly sodium oxybate (ON-SXB; FT218) vs placebo for daytime sleepiness and disrupted nighttime sleep in narcolepsy type 1 (NT1) and 2 (NT2).

METHODS

Participants were stratified by narcolepsy type and randomized 1:1 to ON-SXB (4.5 g, week 1; 6 g, weeks 2-3; 7.5 g, weeks 4-8; and 9 g, weeks 9-13) or placebo. Assessments included mean sleep latency on Maintenance of Wakefulness Test (MWT) and Clinical Global Impression-Improvement (CGI-I) rating (coprimary endpoints) and sleep stage shifts, nocturnal arousals, and patient-reported sleep quality, refreshing nature of sleep, and Epworth Sleepiness Scale (ESS) score (secondary endpoints) separately in NT1 and NT2 subgroups.

RESULTS

The modified intent-to-treat population comprised 190 participants (NT1, n = 145; NT2, n = 45). Significant improvements were demonstrated with ON-SXB vs placebo in sleep latency for NT1 (all doses, p < .001) and NT2 (6 and 9 g, p < .05) subgroups. Greater proportions of participants in both subgroups had CGI-I ratings of much/very much improved with ON-SXB vs placebo. Sleep stage shifts and sleep quality significantly improved in both subgroups (all doses vs placebo, p < .001). Significant improvements with all ON-SXB doses vs placebo in refreshing nature of sleep (p < .001), nocturnal arousals (p < .05), and ESS scores (p ≤ .001) were reported for NT1 with directional improvements for NT2.

CONCLUSIONS

Clinically meaningful improvements of a single ON-SXB bedtime dose were shown for daytime sleepiness and DNS in NT1 and NT2, with less power for the limited NT2 subgroup.

Somno-Art Software identifies pathology-induced changes in sleep parameters similarly to polysomnography

Polysomnographic sleep architecture parameters are commonly used to diagnose or evaluate treatment of sleep disorders. Polysomnography (PSG) having practical constraints, the development of wearable devices and algorithms to monitor and stage sleep is rising. Beside pure validation studies, it is necessary for a clinician to ensure that the conclusions drawn with a new generation wearable sleep scoring device are consistent to the ones of gold standard PSG, leading to similar interpretation and diagnosis. This paper reports on the performance of Somno-Art Software for the detection of differences in sleep parameters between patients suffering from obstructive sleep apnea (OSA), insomniac or major depressive disorder (MDD) compared to healthy subjects. On 244 subjects (n = 26 healthy, n = 28 OSA, n = 66 insomniacs, n = 124 MDD), sleep staging was obtained from PSG and Somno-Art analysis on synchronized electrocardiogram and actimetry signals. Mixed model analysis of variance was performed for each sleep parameter. Possible differences in sleep parameters were further assessed with Mann-Whitney U-test between the healthy subjects and each pathology group. All sleep parameters, except N1+N2, showed significant differences between the healthy and the pathology group. No significant differences were observed between Somno-Art Software and PSG, except a 3.6±2.2 min overestimation of REM sleep. No significant interaction 'group'*'technology' was observed, suggesting that the differences in pathologies are independent of the technology used. Overall, comparable differences between healthy subjects and pathology groups were observed when using Somno-Art Software or polysomnography. Somno-Art proposes an interesting valid tool as an aid for diagnosis and treatment follow-up in ambulatory settings.

Epworth sleepiness scale: A meta-analytic study on the internal consistency

OBJECTIVE/BACKGROUND

The Epworth Sleepiness Scale (ESS) is one of the most used self-reported instruments to assess sleepiness. Thus, several adaptations into different Languages have been performed worldwide over the years. The scale has produced disparate psychometric properties when applied in different settings. In the current study, our aim was to perform a Reliability Generalization meta-analysis of the Cronbach᾽s alphas of all published studies on ESS, specifically with a psychometric focus.

PATIENTS/METHODS

Three reference databases (Scopus, PubMed and Web of Science) were searched since 1991 to October 2022 and all the records on psychometric or validation studies that reported Cronbach's alphas, from clinical and nonclinical groups, were included. In total, data from 46 publications (63 estimates) were extracted, comprising 92,503 participants.

RESULTS

Using a Random-Effects Model, the cumulative Cronbach's alpha for the 63 estimates was about 0.82 (CI: 0.798, 0.832) which can be considered as a good measure. However, and as expected, it was observed a high level of heterogeneity (I2 = 98.96%). Moderation analyses considering setting, date, continent, risk of bias, sex, age and language were performed in order to account for the heterogeneity. Even so, only the variables study setting and continent were significant, and had little importance in explaining the heterogeneity.

CONCLUSIONS

The ESS is a reliable tool to measure sleepiness; however, further studies are needed to investigate what variables might explain the observed variability. Moreover, it will be important to include empirical studies beyond psychometric ones.

Reducing cognitive arousal and sleep effort alleviates insomnia and depression in pregnant women with DSM-5 insomnia disorder treated with a mindfulness sleep program

Objectives

Combining mindfulness with behavioral sleep strategies has been found to alleviate symptoms of insomnia and depression during pregnancy, but mechanisms for this treatment approach remain unclear. The present study examined nocturnal cognitive arousal and sleep effort as potential treatment mechanisms for alleviating insomnia and depression via a mindfulness sleep program for pregnant women.

Methods

Secondary analysis from a proof-of-concept trial of 12 pregnant women with DSM-5 insomnia disorder who were treated with Perinatal Understanding of Mindful Awareness for Sleep (PUMAS), which places behavioral sleep strategies within a mindfulness framework. Data were collected across eight weekly assessments: pretreatment, six sessions, and posttreatment. Measures included the insomnia severity index (ISI), Edinburgh postnatal depression scale (EPDS), pre-sleep arousal scale's cognitive factor (PSASC), and the Glasgow sleep effort scale (GSES). We used linear mixed modeling to test cognitive arousal and sleep effort as concurrent and prospective predictors of insomnia and depression.

Results

Most patients reported high cognitive arousal before PUMAS (75.0%), which decreased to 8.3% after treatment. All insomnia remitters reported low cognitive arousal after treatment, whereas half of nonremitters continued reporting high cognitive arousal. Both nocturnal cognitive arousal and sleep effort were associated with same-week changes in insomnia throughout treatment, and sleep effort yielded a prospective effect on insomnia. Lower levels of nocturnal cognitive arousal and sleep effort prospectively predicted reductions in depression.

Conclusions

The present study offers preliminary evidence that reducing sleep effort and nocturnal cognitive arousal may serve as key mechanisms for alleviating insomnia and depression via mindfulness-based insomnia therapy. ClinicalTrials.gov ID: NCT04443959.

Perinatal Understanding of Mindful Awareness for Sleep (PUMAS): A single-arm proof-of-concept clinical trial of a mindfulness-based intervention for DSM-5 insomnia disorder during pregnancy

OBJECTIVES

Cognitive-behavioral therapy is effective for prenatal insomnia, but unresolved cognitive arousal limits patient outcomes. Therapies aimed at reducing cognitive arousal may benefit pregnant women with insomnia. This proof-of-concept trial evaluated Perinatal Understanding of Mindful Awareness for Sleep (PUMAS, which combines mindfulness with behavioral sleep strategies) on insomnia, depression, and cognitive arousal.

METHODS

A single-arm trial of 12 pregnant women with DSM-5 insomnia disorder (n = 5/12 with comorbid depression) who received six sessions of PUMAS delivered individually via telemedicine. Pretreatment and posttreatment outcomes included the insomnia severity index (ISI), Edinburgh postnatal depression scale (EPDS), pre-sleep arousal scale's cognitive factor (PSASC; nocturnal cognitive arousal), perinatal-focused rumination (appended to PSASC), and Glasgow sleep effort scale.

RESULTS

Eleven of 12 patients completed all sessions. Intent-to-treat analyses revealed a 10.83-point reduction in ISI (Cohen's dz = 3.05), resulting in 83.3% insomnia remission. PUMAS produced large reductions in EPDS (Cohen's dz = 2.76 in depressed group), resulting in all five baseline depressed patients remitting from depression. PUMAS produced large reductions in nocturnal cognitive arousal, perinatal-focused rumination, and sleep effort (all Cohen's dzs>2.00). Patients were highly satisfied with PUMAS and identified the telemedicine format and meditation app as positive features of its delivery. Patients rated sleep restriction and guided meditations as the most helpful treatment components.

CONCLUSION

Prenatal insomnia patients were highly engaged in PUMAS, which produced large acute reductions in insomnia, depression, and cognitive arousal. These findings support the concept and feasibility of PUMAS for pregnant women with insomnia who present with or without comorbid depression.

CLINICALTRIALS

GOV ID

NCT04443959.

A multicenter, double-blind, placebo-controlled, randomized, Phase 1b crossover trial comparing two doses of ulotaront with placebo in the treatment of narcolepsy-cataplexy

BACKGROUND

Ulotaront (SEP-363856) is a novel agonist at trace amine-associated receptor 1 and serotonin 5-HT_1A receptors in clinical development for the treatment of schizophrenia. Previous studies demonstrated ulotaront suppresses rapid eye movement (REM) sleep in both rodents and healthy volunteers. We assessed acute and sustained treatments of ulotaront on REM sleep and symptoms of cataplexy and alertness in subjects with narcolepsy-cataplexy.

METHODS

In a multicenter, double-blind, placebo-controlled, randomized, 3-way crossover study, ulotaront was evaluated in 16 adults with narcolepsy-cataplexy. Two oral doses of ulotaront (25 mg and 50 mg) were administered daily for 2 weeks and compared with matching placebo (6-treatment sequence, 3-period, 3-treatment).

RESULTS

Acute treatment with both 25 mg and 50 mg of ulotaront reduced minutes spent in nighttime REM compared to placebo. A sustained 2-week administration of both doses of ulotaront reduced the mean number of short-onset REM periods (SOREMPs) during daytime multiple sleep latency test (MSLT) compared to placebo. Although cataplexy events decreased from the overall mean baseline during the 2-week treatment period, neither dose of ulotaront statistically separated from placebo (p = 0.76, 25 mg; p = 0.82, 50 mg), and no significant improvement in patient and clinician measures of sleepiness from baseline to end of the 2-week treatment period occurred in any treatment group.

CONCLUSIONS

Acute and sustained treatment with ulotaront reduced nighttime REM duration and daytime SOREMPs, respectively. The effect of ulotaront on suppression of REM did not demonstrate a statistical or clinically meaningful effect in narcolepsy-cataplexy.

REGISTRATION

ClinicalTrials.gov identifier: NCT05015673.

A two-night polysomnography preliminary study in pregnant women with insomnia: suicidal ideation and nocturnal cognitive arousal prospectively predict objective nocturnal wakefulness

Study objectives

Sleep disruption is common in pregnancy, manifesting as insomnia in half of pregnant women as well as increasing objective nocturnal wakefulness across gestation. Despite potential overlap between insomnia and objective sleep disturbances in pregnancy, objective nocturnal wakefulness and its potential contributing factors remain uncharacterized in prenatal insomnia. The present study described objective sleep disturbances in pregnant women with insomnia and identified insomnia-related predictors of objective nocturnal wakefulness.

Methods

Eighteen pregnant women with clinically significant insomnia symptoms (n = 12/18 with DSM-5 insomnia disorder) underwent two overnight polysomnography (PSG) studies. Insomnia symptoms (Insomnia Severity Index), depression and suicidal ideation (Edinburgh Postnatal Depression Scale), and nocturnal cognitive arousal (Pre-Sleep Arousal Scale, Cognitive factor) were assessed before bedtime on each PSG night. Unique to Night 2, participants were awakened after 2 minutes of N2 sleep and reported their in-lab nocturnal (i.e. pre-sleep) cognitive arousal.

Results

Difficulty maintaining sleep was the most common objective sleep disturbance affecting 65%-67% of women across both nights, which contributed to short and inefficient sleep. Nocturnal cognitive arousal and suicidal ideation were the most robust predictors of objective nocturnal wakefulness. Preliminary evidence suggested nocturnal cognitive arousal mediates the effects of suicidal ideation and insomnia symptoms on objective nocturnal wakefulness.

Conclusions

Nocturnal cognitive arousal may facilitate upstream effects of suicidal ideation and insomnia symptoms on objective nocturnal wakefulness. Insomnia therapeutics reducing nocturnal cognitive arousal may benefit objective sleep in pregnant women presenting with these symptoms.

Tilting refractive x-ray lenses for fine-tuning of their focal length

In this work, we measure and model tilted x-ray refractive lenses to investigate their effects on an x-ray beam. The modelling is benchmarked against at-wavelength metrology obtained with x-ray speckle vector tracking experiments (XSVT) at the BM05 beamline at the ESRF-EBS light source, showing very good agreement. This validation permits us to explore possible applications of tilted x-ray lenses in optical design. We conclude that while tilting 2D lenses does not seem interesting from the point of view of aberration-free focusing, tilting 1D lenses around their focusing direction can be used for smoothly fine-tuning their focal length. We demonstrate experimentally this continuous change in the apparent lens radius of curvature R: a reduction up to a factor of two and beyond is achieved and possible applications in beamline optical design are proposed.

A 2023 Update on Managing Insomnia in Primary Care: Insights From an Expert Consensus Group

Objective: To evaluate the status of management of insomnia disorder, describe gaps in current recognition and treatment, identify current guidance for optimal management, and develop up-to-date educational recommendations for primary care providers.

Participants: Four insomnia experts representing primary care, psychiatry, and clinical research were selected based on clinical expertise, educational qualifications, and research experience. A patient with insomnia was also included.

Consensus Process: The Insomnia Working Group met in March 2022 to review data on available therapies (including medications approved since publication of current guidelines) and share current best practices for evidence-based multimodal treatment of insomnia disorder.

Conclusions: Insomnia is highly prevalent but underdiagnosed and undertreated. It is increasingly recognized as a distinct disorder, not merely a symptom arising secondary to another medical or psychiatric illness. The subtypes of sleep disturbance-reports of difficulty falling or staying asleep, insufficient sleep duration, early waking-and the presence of next-day impairment and common comorbid conditions require a targeted, individualized approach to therapy. Challenges exist in treating insomnia with commonly used on- and off-label drugs, including low-dose antidepressants, benzodiazepines, and benzodiazepine receptor agonists because of the risk of adverse effects, including impaired next-day functioning. The dual orexin receptor antagonists have a novel mechanistic target and offer an alternative pharmacologic choice. Optimal outcomes for insomnia require a comprehensive approach that includes lifestyle and behavioral strategies to mitigate maladaptive thoughts and behaviors related to sleep and selection of pharmacotherapy based on individual patient complaints and characteristics.

Pre-pandemic sleep reactivity prospectively predicts distress during the COVID-19 pandemic: The protective effect of insomnia treatment

The COVID-19 pandemic is a rare stressor that has precipitated an accompanying mental health crisis. Prospective studies traversing the pandemic's onset can elucidate how pre-existing disease vulnerabilities augured risk for later stress-related morbidity. We examined how pre-pandemic sleep reactivity predicted maladaptive stress reactions and depressive symptoms in response to, and during, the pandemic. This study is a secondary analysis of a randomised controlled trial from 2016 to 2017 comparing digital cognitive behavioural therapy for insomnia (dCBT-I) against sleep education (N = 208). Thus, we also assessed whether dCBT-I moderated the association between pre-pandemic sleep reactivity and pandemic-related distress. Pre-pandemic sleep reactivity was measured at baseline using the Ford Insomnia Response to Stress Test. In April 2020, participants were recontacted to report pandemic-related distress (stress reactions and depression). Controlling for the treatment condition and the degree of COVID-19 impact, higher pre-pandemic sleep reactivity predicted more stress reactions (β = 0.13, ± 0.07 SE, p = 0.045) and depression (β = 0.22, ± 0.07 SE, p = 0.001) during the pandemic. Further, the odds of reporting clinically significant stress reactions and depression during the pandemic were over twice as high in those with high pre-pandemic sleep reactivity. Notably, receiving dCBT-I in 2016-2017 mitigated the relationship between pre-pandemic sleep reactivity and later stress reactions (but not depression). Pre-pandemic sleep reactivity predicted psychological distress 3-4 years later during the COVID-19 pandemic, and dCBT-I attenuated its association with stress reactions, specifically. Sleep reactivity may inform prevention and treatment efforts by identifying individuals at risk of impairment following stressful events.

Insomnia Complaints and Perceived Immune Fitness in Young Adults with and without Self-Reported Impaired Wound Healing

Background and Objectives: Adequate sleep and an effective immune system are both essential to maintain a good health status. The current study aimed to determine the nature of insomnia complaints and perceived immune fitness among Dutch young adults with and without self-reported impaired wound healing. Materials and Methods: A total of (n = 2033) Dutch students (83.8% women) completed an online survey. Perceived immune fitness was assessed with a single-item scale and insomnia complaints with the SLEEP-50 insomnia subscale. The sample comprised a control group without self-reported impaired wound healing (n = 1622), a wound infection (WI) group (n = 69), a slow healing wounds (SHW) group (n = 250), and a COMBI group that experienced both WI and SHW (n = 92). Results: Comparisons with the control group revealed that individuals of the SHW and COMBI groups reported significantly poorer perceived immune functioning, increased insomnia complaints and daytime fatigue, and poorer sleep quality. Conclusions: Individuals with self-reported impaired wound healing have a poorer perceived immune functioning, increased insomnia complaints, daytime fatigue, and poorer sleep quality.

A Nationally Representative Survey Assessing Restorative Sleep in US Adults

Restorative sleep is a commonly used term but a poorly defined construct. Few studies have assessed restorative sleep in nationally representative samples. We convened a panel of 7 expert physicians and researchers to evaluate and enhance available measures of restorative sleep. We then developed the revised Restorative Sleep Questionnaire (REST-Q), which comprises 9 items assessing feelings resulting from the prior sleep episode, each with 5-point Likert response scales. Finally, we assessed the prevalence of high, somewhat, and low REST-Q scores in a nationally representative sample of US adults (n= 1,055) and examined the relationship of REST-Q scores with other sleep and demographic characteristics. Pairwise correlations were performed between the REST-Q scores and other self-reported sleep measures. Weighted logistic regression analyses were conducted to compare scores on the REST-Q with demographic variables. The prevalence of higher REST-Q scores (4 or 5 on the Likert scale) was 28.1% in the nationally representative sample. REST-Q scores positively correlated with sleep quality (r=0.61) and sleep duration (r=0.32), and negatively correlated with both difficulty falling asleep (r=-0.40) and falling back asleep after waking (r=-0.41). Higher restorative sleep scores (indicating more feelings of restoration upon waking) were more common among those who were: ≥60 years of age (OR=4.20, 95%CI: 1.92-9.17); widowed (OR=2.35, 95%CI:1.01-5.42), and retired (OR=2.02, 95%CI:1.30-3.14). Higher restorative sleep scores were less frequent among those who were not working (OR=0.36, 95%CI: 0.10-1.00) and living in a household with two or more persons (OR=0.51,95%CI:0.29-0.87). Our findings suggest that the REST-Q may be useful for assessing restorative sleep.

Assessing the genotoxicity and carcinogenicity of 2-chloroethanol through structure activity relationships and in vitro testing approaches

The detection of 2-chloroethanol in foods generally follows an assumption that the pesticide ethylene oxide has been used at some stage in the supply chain. In this situation the Pesticide Residues in Food Regulation (EC) 396/2005 requires 2-chloroethanol to be assessed as if equivalent to ethylene oxide, which has been classified as a genotoxic carcinogen. This review investigated whether this is an appropriate risk assessment approach for 2-chloroethanol. This involved an assessment of existing genotoxicity and carcinogenicity data, application of Structure Activity Based Read Across for carcinogenicity assessment, biological reactivity in the ToxTracker assay and micronuclei formation in HepaRG cells. Although we identified there is an absence of a standard oral bioassay for 2-chloroethanol, carcinogenicity weight-of-evidence assessment along with data on relevant structural analogues do not show evidence for carcinogenicity for 2-chloroethanol. The absence of genotoxicity was demonstrated for 2-chloroethanol and suitable analogues. In contrast, ethylene oxide showed reactivity towards markers indicative of direct DNA damage which is consistent with what is known about its mode-of-action. These data facilitate the understanding of 2-chloroethanol and given that it is not a genotoxic carcinogen suggest it must be assessed relative to non-cancer endpoints and a health protective Reference Dose should be established on that basis.

Once-nightly sodium oxybate (FT218) demonstrated improvement of symptoms in a phase 3 randomized clinical trial in patients with narcolepsy

STUDY OBJECTIVES

To assess the efficacy and safety of FT218, a novel once-nightly formulation of sodium oxybate (ON-SXB), in patients with narcolepsy in the phase 3 REST-ON trial.

METHODS

Narcolepsy patients aged ≥16 years were randomized 1:1 to uptitration of ON-SXB (4.5, 6, 7.5, and 9 g) or placebo. Three coprimary endpoints were change from baseline in mean sleep latency on the Maintenance of Wakefulness Test, Clinical Global Impression-Improvement rating, and weekly cataplexy attacks at 9, 7.5, and 6 g. Secondary endpoints included change from baseline on the Epworth Sleepiness Scale. Safety included adverse drug reactions and clinical laboratory assessments.

RESULTS

In total, 222 patients were randomized; 212 received ≥1 dose of ON-SXB (n = 107) or placebo (n = 105). For the three coprimary endpoints and Epworth Sleepiness Scale, all three doses of ON-SXB demonstrated clinically meaningful, statistically significant improvement versus placebo (all p < 0.001). For ON-SXB 9 g versus placebo, increase in mean sleep latency was 10.8 versus 4.7 min (Least squares mean difference, LSMD [95% CI], 6.13 [3.52 to 8.75]), 72.0% versus 31.6% were rated much/very much improved on Clinical Global Impression-Improvement (OR [95% CI], 5.56 [2.76 to 11.23]), change in mean weekly number of cataplexy attacks was -11.5 versus -4.9 (LSMD [95% CI], -6.65 [-9.32 to -3.98]), and change in Epworth Sleepiness Scale was -6.5 and -2.7 (LSMD [95% CI], -6.52 [-5.47 to -2.26]). Common adverse reactions included nausea, vomiting, headache, dizziness, and enuresis.

CONCLUSIONS

ON-SXB significantly improved narcolepsy symptoms; its safety profile was consistent with SXB. ON-SXB conferred efficacy with a clearly beneficial single nighttime dose.

CLINICAL TRIAL REGISTRATION

ClinicalTrials.gov: NCT02720744, https://clinicaltrials.gov/ct2/show/NCT02720744.

0463 Sleep Assessed by Actigraphy during Discontinuation of Chronic Hypnotic Use

Introduction

Inability to discontinue chronic hypnotic use by people with insomnia remains a clinical problem. Sleep was recorded by actigraphy during a two-week discontinuation in an on-going “blinded” clinical trial in which people with insomnia were instructed to discontinue their study medication after 6 months of nightly use.

Methods

DSM-V diagnosed people with insomnia (n=39, 34 females), aged 26-61 yrs, with no other sleep disorders, unstable medical or psychiatric diseases or drug dependency completed the clinical trial. Participants were randomized to zolpidem XR (12.5 mg), eszopiclone (3 mg) or placebo nightly for 6 months (blinded groups A: n=15, B: n=11, C: n=13). After 6 months, over a 2-week choice period, they were given the instruction to discontinue their nightly hypnotic use with an opportunity, if necessary, to self-administer either 1, 2, or 3 capsules of their assigned medication (zolpidem XR 6.25 mg, 6.25 mg, placebo; eszopiclone 2 mg, 1 mg, placebo as capsules 1, 2 and 3 respectively; or 3 placebos). Sleep was recorded by actigraphy and sleep latency (LAT), wake after sleep onset (WASO), and sleep efficiency (SE) were determined.

Results

Twenty subjects (51%) stopped taking study medication when told to discontinue, while 19 took a median of 3 capsules over the 14 nights. The number of capsules chosen declined from week 1 to week 2 (p&lt;.005), while WASO (7-night means) increased from week 1 to week 2 (p&lt;.02). However, LAT, WASO, and SE never went beyond the 7-night means recorded at baseline. Discontinuation night 1 and 2 also did not differ from baseline nights 1 and 2.

Conclusion

Most participants successfully discontinued hypnotic use when instructed to do so. While some degree of sleep disturbance returned, it never exceeded the baseline levels.

Support (If Any)

NIDA, grant#: R01DA038177 awarded to Dr. Roehrs.

0440 Subjective Sleep Outcomes with Lemborexant Among Subjects with Insomnia and Clinically Meaningful Decreases on the Insomnia Severity Index

Introduction

Lemborexant (LEM) is a dual orexin receptor antagonist approved in multiple countries for the treatment of adults with insomnia. In Study 303 (NCT02952820), LEM provided significant benefit on sleep outcomes including patient-reported (subjective) sleep onset latency (sSOL) and wake after sleep onset (sWASO) versus placebo (PBO). This post-hoc analysis assessed these measures in Insomnia Severity Index (ISI) responders, defined as subjects with clinically meaningful reductions (≥7 points) in ISI total scores (ISI-TS).

Methods

Study 303 was a 12-month, PBO-controlled (first 6mo), randomized, double-blind, phase 3 study in subjects with ISI-TS ≥15 (moderate to severe insomnia). Subjects (n=949; Full Analysis Set [FAS]) received LEM (5mg [LEM5]; 10mg [LEM10]) or PBO for 6mo. Changes from baseline (CFB) in sSOL (min) and sWASO (min) at 6mo were analyzed in ISI responders from the FAS and in subjects with severe insomnia (baseline ISI-TS ≥22), using mixed-effect model repeated measurement analysis.

Results

At 6mo, 175 (LEM5), 151 (LEM10), and 124 (PBO) subjects were ISI responders; of these, 46 (LEM5), 48 (LEM10) and 29 (PBO) had severe insomnia. CFB in the FAS in median sSOL was significantly greater with LEM5 (−21.8) and LEM10 (−28.2) versus PBO (−11.4; both P&lt;0.001). ISI responders also had significantly greater decreases in sSOL with LEM (LEM5: −26.7, P&lt;0.01; LEM10: −32.6, P&lt;0.001) than PBO (−18.0). In ISI responders from the severe insomnia subgroup, greater CFB in median sSOL was observed with LEM10 (−41.4) than with PBO (−32.1; P&gt;0.05), but not with LEM5 (−32.9, P&gt;0.05).Least-squares mean (standard error) CFB in sWASO in the FAS was −46.8(3.7) with LEM5 (P&lt;0.001), −42.0(3.7) with LEM10 (P&lt;0.05), versus −29.3(3.6) with PBO. In ISI responders, CFB in sWASO was greater with LEM10 (−52.7[4.0], P&gt;0.05) and significantly greater with LEM5 (−58.9[3.8], P&lt;0.01) versus PBO (−43.6[4.4]). In ISI responders from the severe insomnia subgroup, greater CFB was observed with LEM5 (−91.6[9.5]) versus PBO (−70.2[11.1]); P&gt;0.05); CFB with LEM10 (−71.4[9.0]) was similar to PBO.

Conclusion

ISI responders including those from the severe insomnia subgroup reported greater CFB in sSOL and sWASO than the FAS that was somewhat dose dependent. LEM generally showed benefit versus PBO.

Support (If Any)

Eisai Inc.

0336 Sleep Time and Risk Taking Behaviour in Night Shift-Workers

Introduction

Night shift-workers are integral in a multitude of industries. Many night shift-workers experience sleep loss, which may impact their risk taking behaviour.This study aimed to identify the correlation between total sleep time (TST) and shift-workers' engagement in risk-taking behavior.

Methods

53 night shift-workers participated in the experiment. Polysomnography was conducted to determine the TST of shift-workers prior to completing a task that measured risk taking behaviour. This task simulated a driving scenario in which participants must decide whether or not to proceed at a yellow traffic light. Participants were not informed of the duration of the yellow light, which varied unpredictably in duration. The task consisted of 16 trials, and participants earned points that translated to a cash incentive (25 points = 25 cents). Participants either earned or lost 25 points depending on the success of each trial. Failure was defined as running a red light. Those who proceeded at every trial were categorized as insensitive to risk.

Results

The data revealed that those insensitive to risk had a significantly lower TST value.Those insensitive to risk had a lower mean sleep time (374 minutes, SD=75) compared to those sensitive to risk (415 minutes, SD= 42), p =.01 (Cohen’s d=0.67).

Conclusion

Sleep time is associated with risk-taking behavior in night shift-workers. This study offers insight into the amplification of risk taking behaviours within night shift-workers posed by sleep loss, possibly leading to errors and injuries in the workplace. This association may also suggest that implementation of measures to increase sleep for night shift-workers could decrease risk-taking behaviours.

Support (If Any)

K23HL133186

0462 Baseline Sleep Disturbance and Inability to Discontinue Chronic Hypnotic Use

Introduction

Clinicians prescribing hypnotics remain concerned regarding the inability to discontinue hypnotics after chronic use, which has never been directly tested in a controlled prospective study using self-administration choice methodology. This study reports on difficulty discontinuing medication as a function of basal sleep disturbance in insomnia subjects instructed to stop taking their study medication after 6 months of nightly use.

Methods

DSM-V diagnosed insomnia subjects, aged 23-61 yrs, (n=39, 34 females), with no other sleep disorders, unstable medical or psychiatric diseases or drug dependency completed the trial. Following a screening polysomnogram participants were randomized to zolpidem XR (12.5 mg), eszopiclone (3 mg), or placebo nightly for 6 months (blinded groups A: n=15, B: n=11, C: n=13). After 6 months, nightly use, over a 2-week choice period, they were instructed to discontinue hypnotic use, but if necessary, to self-administer either 1, 2, or 3 capsules of their assigned “blinded” medication (zolpidem XR 6.25 mg, 6.25 mg, placebo; eszopiclone 2 mg, 1 mg, placebo as capsules 1, 2 and 3 respectively; or 3 placebos).

Results

Over the 14 nights 20 subjects took zero (51%) capsules; among the 19 taking capsules the median number chosen was 3. Most took one capsule per night; 6 took &gt; 1 capsules on a given night. Importantly 1 subject took every capsule (42) available. Overall, the number of capsules taken declined from week 1 to 2 (p&lt; .005). Those with baseline PSG SE &lt;81% did not reduce capsule choice from week 1 to 2 (p&lt;.02). Group A choose more capsules than groups B and C (p&lt;.01).

Conclusion

The majority (85%) of the participants discontinued 6-month nightly hypnotic use (i.e. took &lt; 6 total capsules over the 14 discontinuation nights) and among those taking capsules the rate declined from week 1 to 2. Baseline SE &lt;81% may help identify those with difficulty discontinuing.

Support (If Any)

NIDA, grant#: R01DA038177 awarded to Dr. Roehrs.

0401 Efficacy of Once-Nightly Sodium Oxybate (ON-SXB; FT218) By Narcolepsy Type: Post-hoc Analyses From the REST-ON Trial

Introduction

Once-nightly sodium oxybate (ON-SXB; FT218) was evaluated for treatment of narcolepsy in the phase 3 REST-ON trial (NCT02720744). Significant improvement was shown for the three coprimary endpoints mean sleep latency on the Maintenance of Wakefulness test (MWT), Clinical Global Impression of Improvement (CGI-I) rating, and weekly number of cataplexy attacks overall (all P&lt;0.001 vs placebo) and in post-hoc analyses by narcolepsy type (NT1/NT2) for MWT and CGI-I (all P&lt;0.05). Post-hoc efficacy analyses of objective and subjective measures of disrupted nighttime sleep and daytime sleepiness by narcolepsy type were conducted.

Methods

Participants aged ≥16 years were randomized 1:1 to receive ON-SXB (1 week, 4.5 g; 2 weeks, 6 g; 5 weeks, 7.5 g; 5 weeks, 9 g) or placebo. Mixed-effects models for repeated measures were used to calculate P values for change from baseline vs placebo at weeks 3 (6 g), 8 (7.5 g), and 13 (9 g) for secondary REST-ON endpoints of Epworth sleepiness scale (ESS) score, sleep shifts (ie, the number of shifts from stages N1, N2, N3 and rapid eye movement [REM] sleep to Wake and from N2, N3 and REM sleep to N1), nocturnal arousals (NA), and patient-reported sleep quality and refreshing nature of sleep (100-point visual analog scale).

Results

Of 190 participants, 145 had NT1 (ON-SXB, n=73; placebo, n=72) and 45 had NT2 (ON-SXB, n=24; placebo, n=21). Improvements with ON-SXB vs placebo were reported for shifts to a lighter stage of sleep (NT1: 6, 7.5, 9 g, all P&lt;0.001; NT2: 6 and 7.5 g, P&lt;0.05; 9 g, P&lt;0.001), NA (NT1: 6 g, P&lt;0.05; 7.5 and 9 g, P&lt;0.01; NT2: 6 g, directional improvement; 7.5 and 9 g, P&lt;0.05), and sleep quality (NT1: 6, 7.5, 9 g, all P&lt;0.001; NT2: 6, 7.5, 9 g, all P&lt;0.05). Significant improvements in ESS and refreshing nature of sleep for ON-SXB vs placebo were reported for NT1 (6, 7.5, 9 g, P≤0.001) with directional improvements observed for the NT2 subgroup.

Conclusion

Results of these subgroup efficacy analyses are generally consistent with previously reported REST-ON endpoints and support ON-SXB treatment efficacy in adults with NT1 or NT2.

Support (If Any)

Avadel Pharmaceuticals

0449 Correlations Between Sleep Parameters and ISI Total Score in Subjects with Moderate to Severe Insomnia Treated with Lemborexant

Introduction

Lemborexant (LEM) is a dual orexin receptor antagonist (DORA) approved in multiple countries for the treatment of adults with insomnia. In Study 303 (NCT02952820), LEM provided significant benefit on subject-reported sleep measures versus placebo (PBO). This post hoc analysis investigated whether changes from baseline in sleep parameters with LEM are correlated with insomnia disorder severity.

Methods

Study 303 was a randomized, double-blind, PBO-controlled (first 6mo [Period 1]), phase 3 study. During Period 1, subjects received LEM 5mg (LEM5), LEM 10mg (LEM10), or PBO. During Period 2 (second 6mo), LEM subjects continued their assigned dose and PBO subjects were rerandomized to LEM5 or LEM10 (rerandomized subjects not reported here). The correlation between changes in subject-reported sleep parameters (sleep onset latency [sSOL], wake after sleep onset [sWASO], sleep efficiency [sSE], total sleep time [sTST]) and insomnia disorder severity, as assessed by the Insomnia Severity Index total score (ISI-TS) were evaluated in the Full Analysis Set (FAS; ISI-TS ≥15) and in a subgroup of subjects with severe (ISI-TS ≥22 at baseline) insomnia over 12mo for LEM and over 6mo for PBO.

Results

Among 949 (PBO=318; LEM5=316; LEM10=315) subjects, 223 (PBO=65; LEM5=84; LEM10=74) had severe insomnia at baseline. Within each sleep parameter and severity group, baseline values were similar across treatments. Overall, strong to very strong correlations were observed between changes from baseline in sleep parameters and decrease in ISI-TS, regardless of treatment, as determined by correlation coefficients for sSOL (LEM5=0.973 [P=0.0053]; LEM10=0.997 [P=0.0002]; PBO=0.844 [P=0.361]), sSE (LEM5=–0.937 [P=0.0188]; LEM10=–0.992 [P=0.0008]; PBO=–0.950 [P=0.2018]), sWASO (LEM5=0.937 [P=0.0187]; LEM10=0.996 [P=0.0003]; PBO=0.979 [P=0.1299]), and sTST (LEM5=–0.876 [P=0.0515]; LEM10=–0.974 [P=0.0050]; PBO=–0.933 [P=0.2346]). Strong to very strong correlations were also observed in subjects with severe insomnia: sSOL (LEM5=0.818 [P=0.0904]; LEM10=0.823 [P=0.0868]; PBO=0.828 [P=0.3788]), sSE (LEM5=–0.860 [P=0.0616]; LEM10=–0.975 [P=0.0048]; PBO=–0.961 [P=0.1792]), sWASO (LEM5=0.871 [P=0.0544]; LEM10=0.936 [P=0.0194]; PBO=0.875 [P=0.3213]), and sTST (LEM5=–0.843 [P=0.0729]; LEM10=–0.969 [P=0.0095]; PBO=–0.974 [P=0.1449]).

Conclusion

Across the study period, changes from baseline in reported nocturnal sleep parameters correlated with reductions in severity of insomnia disorder regardless of insomnia severity at baseline.

Support (If Any)

Eisai Inc.

0402 Efficacy of FT218, a Once-Nightly Sodium Oxybate Formulation, in Patients With Narcolepsy: Post-hoc Sensitivity Analyses From the REST-ON Trial

Introduction

In REST-ON, once-nightly sodium oxybate (ON-SXB; FT218) achieved significant improvement (P&lt;0.001) vs placebo for all coprimary endpoints: Maintenance of Wakefulness test (MWT) mean sleep latency, Clinical Global Impression of Improvement (CGI-I) rating, and weekly number of cataplexy attacks (NCA).

Methods

Individuals aged ≥16 years were randomized 1:1 to receive ON-SXB (1 week, 4.5 g; 2 weeks, 6 g; 5 weeks, 7.5 g; 5 weeks, 9 g) or placebo. Post-hoc sensitivity analyses were conducted with methods to handle missing data: completer population; placebo-based multiple imputation (MI) with missing not at random assumption; analysis of covariance (ANCOVA); and tipping point-based MI of worsening values until P&gt;0.05.

Results

Completers (ON-SXB, n=69; placebo, n=79) showed significant improvement (P&lt;0.001) with 6, 7.5, and 9 g ON-SXB vs placebo on all coprimary endpoints; with 9-g dose, mean (95% CI) differences vs placebo were 6.0 min (3.3–8.7) on MWT and –6.6 (–9.6 to –3.6) in NCA; 72.3% and 31.6%, respectively (odds ratio [OR], 5.7 [95% CI: 2.8–11.6]), were CGI-I responders. All ON-SXB doses achieved significant improvement (P&lt;0.001) vs placebo on all coprimary endpoints with placebo-based MI and ANCOVA. With placebo-based MI, mean (95% CI) differences vs placebo (9-g dose) were 5.4 min (2.8–8.0) on MWT and –6.4 (–11.3 to –3.7) in NCA; 63.0% and 28.5%, respectively (OR, 4.3 [95% CI: 2.3–8.0]), were CGI-I responders. With ANCOVA, mean (95% CI) differences vs placebo (9-g dose) were 6.0 min (3.6–8.5) on MWT and –6.4 (–9.0 to –3.8) in NCA; CGI-I rating difference was –1.0 (–1.3 to –0.7). With MWT tipping point MI, between-treatment differences lost significance with worsening of 7.0, 5.2, and 4.3 min from baseline for 6, 7.5, and 9 g, respectively (implausible for 7.5- and 9-g doses). When withdrawals from ON-SXB were imputed as “not improved,” CGI-I remained significant (all 3 doses, P&lt;0.001). Mean NCA remained significant for all 3 doses vs placebo with worsening trajectories imputed; positive results were not tipped over with plausible values.

Conclusion

These results support the robustness of the primary efficacy data for ON-SXB for narcolepsy treatment.

Support (If Any)

Avadel Pharmaceuticals

0406 Efficacy of Once-Nightly Sodium Oxybate (ON-SXB; FT218) Across Stimulant Use Subgroups: Post-hoc Analyses From the REST-ON Trial

Introduction

In the REST-ON trial (NCT02720744), once-nightly sodium oxybate (ON-SXB; FT218) was associated with significant improvement vs placebo for mean sleep latency on the Maintenance of Wakefulness test (MWT) and Clinical Global Impression of Improvement (CGI-I) rating in the overall population (both P&lt;0.001) and in subgroups of participants taking concomitant stimulants (both P&lt;0.05). Post-hoc analyses of ON-SXB efficacy on disturbed nocturnal sleep (DNS) and Epworth Sleepiness Scale (ESS) score were conducted.

Methods

Participants (≥16 years of age) with narcolepsy type 1 or 2 were randomized 1:1 to ON-SXB (1 week, 4.5 g; 2 weeks, 6 g; 5 weeks, 7.5 g; 5 weeks, 9 g) or placebo. Mixed-effects models for repeated measures calculated P values for change from baseline vs placebo at weeks 3 (6 g), 8 (7.5 g), and 13 (9 g) in ESS score, sleep shifts (ie, number of shifts from N1, N2, N3, and rapid eye movement [REM] sleep to Wake and from N2, N3, and REM sleep to N1), nocturnal arousals (NA), and patient-reported outcomes of sleep quality and refreshing nature of sleep on a 100-point visual analog scale.

Results

In the modified intent-to-treat population (n=190), 119 participants took concomitant stimulants (ON-SXB, n=66; placebo, n=53); 71 did not take stimulants (ON-SXB, n=31; placebo, n=40). Improvements with ON-SXB vs placebo were reported: ESS (stimulants: all doses, P≤0.01; no stimulants: 6 g, directional improvement; 7.5 g, P&lt;0.01; 9 g, P&lt;0.001), sleep shifts (stimulants: 6 g, P&lt;0.01; 7.5 and 9 g, P&lt;0.001; no stimulants: all doses P&lt;0.001), NA (stimulants: 6 g, directional improvement; 7.5 g, P&lt;0.01; 9 g, P=0.001; no stimulants: 6 and 7.5 g, P&lt;0.05; 9 g, P=0.01), sleep quality (stimulants: 6 and 7.5 g, P&lt;0.01; 9 g, P&lt;0.05; no stimulants: all doses P&lt;0.001), refreshing nature of sleep (stimulants: 6 and 9 g, P&lt;0.05; 7.5 g, P&lt;0.001; no stimulants: 6 and 7.5 g, P&lt;0.01; 9 g, P=0.001).

Conclusion

Data from these post-hoc analyses were consistent with the previously reported results from REST-ON and support the efficacy of ON-SXB for EDS and DNS, as measured by objective and subjective endpoints whether or not stimulants were concurrently used.

Support (If Any)

Avadel Pharmaceuticals

Polished diamond X-ray lenses

High-quality bi-concave 2D focusing diamond X-ray lenses of apex-radius R = 100 µm produced via laser-ablation and improved via mechanical polishing are presented here. Both for polished and unpolished individual lenses and for stacks of ten lenses, the remaining figure errors determined using X-ray speckle tracking are shown and these results are compared with those of commercial R = 50 µm beryllium lenses that have similar focusing strength and physical aperture. For two stacks of ten diamond lenses (polished and unpolished) and a stack of eleven beryllium lenses, this paper presents measured 2D beam profiles out of focus and wire scans to obtain the beam size in the focal plane. These results are complemented with small-angle X-ray scattering (SAXS) measurements of a polished and an unpolished diamond lens. Again, this is compared with the SAXS of a beryllium lens. The polished X-ray lenses show similar figure errors to commercially available beryllium lenses. While the beam size in the focal plane is comparable to that of the beryllium lenses, the SAXS signal of the polished diamond lenses is considerably lower.

ID23-2: an automated and high-performance microfocus beamline for macromolecular crystallography at the ESRF. Corrigendum

A revised version of Table 2 of Nanao et al. [J. Synchrotron Rad. (2022). 29, 581-590] is provided.

Examining Patient Feedback and the Role of Cognitive Arousal in Treatment Non-response to Digital Cognitive-behavioral Therapy for Insomnia during Pregnancy

OBJECTIVE

Insomnia affects over half of pregnant and postpartum women. Early evidence indicates that cognitive-behavioral therapy for insomnia (CBTI) improves maternal sleep and mood. However, standard CBTI may be less efficacious in perinatal women than the broader insomnia population. This study sought to identify patient characteristics in a perinatal sample associated with poor response to CBTI, and characterize patient feedback to identify areas of insomnia therapy to tailor for the perinatal experience.

PARTICIPANTS

Secondary analysis of 46 pregnant women with insomnia symptoms who were treated with digital CBTI in a randomized controlled trial.

METHODS

We assessed insomnia, cognitive arousal, and depression before and after prenatal treatment, then 6 weeks postpartum. Patients provided feedback on digital CBTI.

RESULTS

Residual cognitive arousal after treatment was the most robust factor associated with treatment non-response. Critically, CBTI responders and non-responders differed on no other sociodemographic or pretreatment metrics. After childbirth, short sleep (<6 hrs/night) was associated with maternal reports of poor infant sleep quality. Patient feedback indicated that most patients preferred online treatment to in-person treatment. Although women described digital CBTI as convenient and helpful, many patients indicated that insomnia therapy would be improved if it addressed sleep challenges unique to pregnancy and postpartum. Patients requested education on maternal and infant sleep, flexibility in behavioral sleep strategies, and guidance to manage infant sleep.

CONCLUSIONS

Modifying insomnia therapy to better alleviate refractory cognitive arousal and address the changing needs of women as they progress through pregnancy and early parenting may increase efficacy for perinatal insomnia.Name: Insomnia and Rumination in Late Pregnancy and the Risk for Postpartum DepressionURL: clinicaltrials.govRegistration: NCT03596879.

ID23-2: an automated and high-performance microfocus beamline for macromolecular crystallography at the ESRF

ID23-2 is a fixed-energy (14.2 keV) microfocus beamline at the European Synchrotron Radiation Facility (ESRF) dedicated to macromolecular crystallography. The optics and sample environment have recently been redesigned and rebuilt to take full advantage of the upgrade of the ESRF to the fourth generation Extremely Brilliant Source (ESRF-EBS). The upgraded beamline now makes use of two sets of compound refractive lenses and multilayer mirrors to obtain a highly intense (>10¹³ photons s^-1) focused microbeam (minimum size 1.5 µm × 3 µm full width at half-maximum). The sample environment now includes a FLEX-HCD sample changer/storage system, as well as a state-of-the-art MD3Up high-precision multi-axis diffractometer. Automatic data reduction and analysis are also provided for more advanced protocols such as synchrotron serial crystallographic experiments.

DSM-5 insomnia disorder in pregnancy: associations with depression, suicidal ideation, and cognitive and somatic arousal, and identifying clinical cutoffs for detection

Study Objectives

The study had three primary goals. First, we estimated survey-assessed DSM-5 insomnia disorder rates in pregnancy, and described associated sociodemographics, and sleep-wake and mental health symptoms. Second, we derived cutoffs for detecting DSM-5 insomnia disorder using common self-report measures of sleep symptoms. Third, we identified clinically relevant cut-points on measures of nocturnal cognitive and somatic arousal.

Methods

Ninety-nine women (85.9% in the 2^nd trimester) completed online surveys including DSM-5 insomnia disorder criteria, the Insomnia Severity Index (ISI), Pittsburgh Sleep Quality Index (PSQI), Presleep Arousal Scale's Cognitive (PSASC) and Somatic (PSASS) factors, and Edinburgh Postnatal Depression Scale.

Results

DSM-5 insomnia disorder rate was 19.2%. Insomnia was associated with depression, suicidality, nocturnal cognitive and somatic arousal, and daytime sleepiness. An ISI scoring method that aligns with DSM-5 criteria yielded excellent metrics for detecting insomnia disorder and good sleep. Regarding quantitative cutoffs, ISI ≥ 10 and ISI ≥ 11 (but not ISI ≥ 15) were supported for detecting DSM-5 insomnia, whereas ISI ≤ 7 and ISI ≤ 9 performed well for detecting good sleep. PSQI cutoff of 5 was supported for detecting insomnia and good sleep. The optimal cutoff for nocturnal cognitive arousal was PSASC ≥ 18, whereas the optimal cutoff for somatic arousal was PSASS ≥ 13.

Conclusions

Insomnia disorder affects a large segment of pregnant women. Empirically derived cutoffs for insomnia, good sleep, cognitive arousal, and somatic arousal may inform case identification and future perinatal sleep research methodology.

Efficacy of the triple-combination SM-1 in a 5-h phase advance transient insomnia model

Thomas Dahl, PO Box 404, Guilford, CT 06437 USA. Email: tadahl@outlook.com. The objectives of the study were to demonstrate the efficacy and safety of SM-1 in a circadian challenge model of transient insomnia. Randomized, double-blind, placebo-controlled cross-over study utilizing a 5-h phase advance model of transient insomnia. Subjects were 85 healthy adults reporting a history of transient insomnia, with an average age of 38.9 years. Both SM-1 and placebo were administered to all subjects in a randomly assigned sequence, with at least 1 week between treatments. The primary endpoint was total sleep time determined by polysomnography. Secondary endpoints included wakefulness after sleep onset, latency to persistent sleep, number of awakenings, subjective total sleep time and subjective sleep onset latency, total sleep time by quarters of the night, subjective number of awakenings, and sleep quality. Safety endpoints included adverse events, Karolinska Sleepiness Scale, Digit Symbol Substitution Test, and predischarge evaluation (tandem gait and Romberg tests). SM-1 provided an increase of 94.4 min in total sleep time over placebo (p < 0.0001). Wakefulness after sleep onset, subjective total sleep time, subjective sleep onset latency, and total sleep time in the first quarter of the night also showed significant improvement. SM-1 was well-tolerated with both type and frequency of adverse events being comparable to placebo, and no residual sleepiness upon awakening (i.e., after 8 h). SM-1 provided a robust and statistically significant increase in total sleep time compared to placebo in a circadian model of transient insomnia, without evidence of next-day impairment.

Validation of Somno-Art Software, a novel approach of sleep staging, compared with polysomnography in disturbed sleep profiles

Study Objectives

Integrated analysis of heart rate (electrocardiogram [ECG]) and body movements (actimetry) during sleep in healthy subjects have previously been shown to generate similar evaluation of sleep architecture and continuity with Somno-Art Software compared to polysomnography (PSG), the gold standard. However, the performance of this new approach of sleep staging has not yet been evaluated on patients with disturbed sleep.

Methods

Sleep staging from 458 sleep recordings from multiple studies comprising healthy and patient population (obstructive sleep apnea [OSA], insomnia, major depressive disorder [MDD]) was obtained from PSG visual scoring using the American Academy of Sleep Medicine rules and from Somno-Art Software analysis on synchronized ECG and actimetry.

Results

Inter-rater reliability (IRR), evaluated with 95% absolute agreement intra-class correlation coefficient, was rated as "excellent" (ICCAAAvg95% ≥ 0.75) or "good" (ICCAAAvg95% ≥ 0.60) for all sleep parameters assessed, except non-REM (NREM) and N3 sleep in healthy participants (ICCAAAvg95% = 0.43, ICCAAAvg95% = 0.56) and N3 sleep in OSA patients (ICCAAAvg95% = 0.59) rated as "fair" IRR. Overall sensitivity, specificity, accuracy, and Cohen's kappa coefficient of agreement (κ) on the entire sample were respectively of 93.3%, 69.5%, 87.8%, and 0.65 for wake/sleep classification and accuracy and κ were of 68.5% and 0.55 for W/N1+N2/N3/rapid eye movement (REM) classification. These performances were similar in healthy and patient population.

Conclusions

The present results suggest that Somno-Art can be a valid sleep-staging tool in both healthy subjects and patients with OSA, insomnia, or MDD. It could complement existing non-attended techniques measuring sleep-related breathing patterns or be a useful alternative to laboratory-based PSG when this latter is not available.

489 Pivotal Phase 3 Study of FT218, a Once-Nightly Sodium Oxybate Formulation, in Patients With Narcolepsy: REST-ON Primary Results

Introduction

Sodium oxybate (SO) is an effective treatment for patients with narcolepsy; however, currently available SO formulations require twice-nightly dosing. The purpose of this study was to evaluate efficacy and safety of FT218, an investigational once-nightly controlled-release SO formulation, for the treatment of excessive daytime sleepiness and cataplexy in patients with narcolepsy types 1 (NT1) and 2 (NT2).

Methods

This was a randomized, double-blind, placebo-controlled, multicenter study in patients with narcolepsy ≥16 years old. Patients were randomized 1:1 to receive FT218 or matching placebo: 4.5 g/night for 1 week, 6.0 g/night for 2 weeks, 7.5 g/night for 5 weeks, and 9.0 g/night for 5 weeks (maximum treatment duration, 13 weeks). Coprimary endpoints were mean sleep latency (minutes) on maintenance of wakefulness test (MWT), Clinical Global Impression-Improvement (CGI-I) of sleepiness, and weekly number of cataplexy attacks (NCAs; NT1 only).

Results

A total of 212 patients were randomized and received study treatment (FT218, n=107; placebo, n=105). FT218 showed significant (P&lt;0.001) improvement vs placebo in mean sleep latency on MWT for all evaluated doses; LS mean difference (minutes) between FT218 and placebo was 6.13 at 9.0 g (week 13), 6.21 at 7.5 g (week 8), and 4.98 at 6.0 g (week 3). A higher proportion of patients receiving FT218 were much/very much improved on CGI-I vs placebo (72% vs 31.6% at 9.0 g; 62.6% vs 22.8% at 7.5 g; and 40.1% vs 6.1% at 6.0 g; all P&lt;0.001). LS mean difference between FT218 and placebo in mean weekly NCAs was significant (P&lt;0.001) for all doses: −6.65 at 9.0 g, −6.27 at 7.5 g, and −4.83 at 6.0 g. The most common adverse reactions were nausea, vomiting, headache, dizziness, enuresis, and decreased appetite.

Conclusion

All evaluated doses of FT218 showed significant improvement vs placebo in mean sleep latency on MWT, CGI-I, and weekly NCAs. FT218 was generally well tolerated and the most common adverse events were consistent with known side effects of SO.

Support (if any)

Avadel Pharmaceuticals.

490 Efficacy of FT218 on Polysomnographic Measures of Sleep Continuity in Patients With Narcolepsy: Results From the REST-ON Trial

Introduction

Disturbed nocturnal sleep (DNS) is a common symptom in patients with narcolepsy, characterized by fragmented sleep, including frequent brief nightly awakenings. Sodium oxybate (SO) is an effective treatment for narcolepsy; however, currently available formulations must be taken twice nightly. FT218 is an investigational once-nightly controlled-release formulation of SO. Here, we evaluated the efficacy of FT218 on polysomnographic (PSG) measures of DNS and number of arousals (NAs) in patients with narcolepsy types 1 and 2.

Methods

This was a randomized, double-blind, placebo-controlled, multicenter study. Patients with narcolepsy aged ≥16 years were randomized 1:1 to receive FT218 or matching placebo: 4.5 g/night for 1 week, 6.0 g/night for 2 weeks, 7.5 g/night for 5 weeks, and 9.0 g/night for 5 weeks. Secondary endpoints included PSG measurements of DNS (defined as shifts to wake/N1 from N1, N2, N3, and REM) and NAs (defined per AASM Scoring Manual guidelines [v2.6]).

Results

Patients receiving FT218 had significant improvements vs placebo in DNS; the LS mean difference between FT218 and placebo was −22.63 for 9.0 g (week 13), −17.70 for 7.5 g (week 8), and −11.00 for 6.0 g (week 3) (all P&lt;0.001). Patients receiving FT218 also had significant reduction in number of NAs vs placebo; the LS mean difference between FT218 and placebo for NAs was −23.68 (P&lt;0.001) for 9.0 g, −19.41 (P&lt;0.001) for 7.5 g, and −11.29 (P=0.021) for 6.0 g. The most common adverse reactions were nausea, dizziness, enuresis, headache, decreased appetite, and vomiting.

Conclusion

FT218 at all evaluated doses showed significant reduction in DNS and number of NAs vs placebo for all doses of FT218 evaluated. FT218 was generally well tolerated; the most common adverse events were consistent with known SO side effects. FT218 could offer a new once-nightly treatment option for DNS in patients with narcolepsy as demonstrated by PSG measures.

Support (if any)

Avadel Pharmaceuticals.

336 Effect of Lemborexant Versus Placebo and Zolpidem on REM Sleep by Quarter Night Intervals in Older Adults with Insomnia Disorder

Introduction

Effects of the dual orexin receptor antagonist lemborexant (LEM) on sleep architecture in adults ≥55y with insomnia disorder were assessed in Study E2006-G000-304 (Study 304; SUNRISE-1; NCT02783729). These post hoc analyses of Study 304 examined the acute effect of LEM on REM pressure (REM latency [REM-L] and REM by quarter of the night [QoN]).

Methods

This study was a 1mo, randomized, double-blind, placebo- and active-controlled (zolpidem tartrate extended-release 6.25mg [ZOL]) study of LEM (5mg, LEM5; 10mg, LEM10). Subjects received placebo (n=208), ZOL (n=263), LEM5 (n=266), or LEM10 (n=269). Two nights of PSGs were recorded at baseline, first 2 (N1/2), and last 2 (N29/30) treatment nights.

Results

Baseline REM-L (minutes) was similar across treatments (98.4–101.4). Significant decreases from baseline in REM-L were observed for LEM5 (−42.6 [53.9]) and LEM10 (−49.6[52.9]) vs placebo (−6.9[54.5]) and ZOL (0.2[54.2]) on N1/2 (all P&lt;0.0001). No difference was observed for ZOL vs placebo. Baseline REM (minutes) for each QoN was similar across treatments. In Q1, mean(SD) REM (minutes) on N1/2 was 16.5(9.7), 19.7(10.5), 10.3(8.2), and 8.5(7.6) for LEM5, LEM10, placebo, and ZOL, respectively. The difference was significant for LEM5 and LEM10 vs placebo and ZOL (all P&lt;0.0001), and ZOL vs placebo (P&lt;0.05). In Q2, mean(SD) REM on N1/2 was 19.2(9.4), 21.6(10.0), 17.9(8.9), and 17.2(9.3) for LEM5, LEM10, placebo, and ZOL, respectively. The difference was significant for LEM10 vs placebo (P&lt;0.0001) and for LEM5 and LEM10 vs ZOL (P&lt;0.01, P&lt;0.0001, respectively). No difference was observed for ZOL vs placebo. In Q3, mean(SD) REM on N1/2 was 23.3(10.3), 25.9(9.7), 20.8(9.4), and 22.8(9.9) for LEM5, LEM10, placebo, and ZOL, respectively. The difference was significant for LEM5, LEM10, and ZOL vs placebo (P&lt;0.01, P&lt;0.0001, P&lt;0.05, respectively) and LEM10 vs ZOL (P&lt;0.001). In Q4, mean (SD) REM on N1/2 was 23.8(9.4), 26.1(11.0), 21.6(10.9), and 22.5(10.1) for LEM5, LEM10, placebo, and ZOL, respectively. The differences were significant for LEM5 and LEM10 vs placebo (P&lt;0.05, P&lt;0.0001, respectively), and for LEM10 vs ZOL (P&lt;0.0001). Generally, similar findings were noted at N29/30; these data will be reported.

Conclusion

LEM, but not ZOL, acutely increases REM pressure as evidenced by REM latency and REM duration per quarter.

Support (if any)

Eisai Inc.

488 REST-ON: Efficacy of FT218 for Daytime Sleepiness, Sleep Quality, Hallucinations, and Sleep Paralysis in Patients With Narcolepsy

Introduction

Sodium oxybate (SO) is an effective treatment for narcolepsy; however, currently available formulations must be taken twice nightly. FT218 is an investigational once-nightly controlled-release formulation of SO. Here, we evaluated the efficacy of FT218 on excessive daytime sleepiness (EDS), self-reported sleep quality/refreshing nature of sleep, sleep paralysis (SP), and hypnagogic hallucinations (HH) in patients with narcolepsy.

Methods

In this phase 3, randomized, double-blind, placebo-controlled, multicenter study, patients aged ≥16 years with narcolepsy type 1 or 2 were randomized 1:1 to receive FT218 or matching placebo: 4.5 g/night (1 week), 6.0 g/night (2 weeks), 7.5 g/night (5 weeks), and 9.0 g/night (5 weeks). Secondary efficacy endpoints included EDS using the Epworth Sleepiness Scale (ESS), sleep quality/refreshing nature of sleep using a visual analog scale (VAS), and SP and HH using a sleep symptom diary.

Results

A total of 212 patients were randomized and received study medication (FT218, n=107; placebo, n=105). Patients receiving FT218 had significant improvement vs placebo in EDS on the ESS: LS mean difference on ESS score between FT218 and placebo was −3.86 for 9.0 g (week 13), −3.16 for 7.5 g (week 8), and −2.06 for 6.0 g (week 3) (all P&lt;0.001). Sleep quality/refreshing nature of sleep on VAS was also significantly improved with FT218 vs placebo (P&lt;0.001 for all doses). Patients receiving FT218 reported less SP vs placebo (P&lt;0.05 at all doses). Baseline values for HH were low in both treatment groups; HH was similar for both treatment groups at all study visits. The most common adverse reactions were nausea, dizziness, enuresis, headache, decreased appetite, and vomiting.

Conclusion

At all evaluated doses, treatment with FT218 significantly improved EDS, sleep quality/refreshing nature of sleep, and SP vs placebo. FT218 was generally well tolerated; the most common adverse events were consistent with known SO side effects.

Support (if any)

Avadel Pharmaceuticals.

Predicting circadian misalignment with wearable technology: validation of wrist-worn actigraphy and photometry in night shift workers

STUDY OBJECTIVES

A critical barrier to successful treatment of circadian misalignment in shift workers is determining circadian phase in a clinical or field setting. Light and movement data collected passively from wrist actigraphy can generate predictions of circadian phase via mathematical models; however, these models have largely been tested in non-shift working adults. This study tested the feasibility and accuracy of actigraphy in predicting dim light melatonin onset (DLMO) in fixed night shift workers.

METHODS

A sample of 45 night shift workers wore wrist actigraphs before completing DLMO in the laboratory (17.0 days ± 10.3 SD). DLMO was assessed via 24 hourly saliva samples in dim light (<10 lux). Data from actigraphy were provided as input to a mathematical model to generate predictions of circadian phase. Agreement was assessed and compared to average sleep timing on non-workdays as a proxy of DLMO. Model code and an open-source prototype assessment tool are available (www.predictDLMO.com).

RESULTS

Model predictions of DLMO showed good concordance with in-lab DLMO, with Lin's concordance coefficient of 0.70, which was twice as high as agreement using average sleep timing as a proxy of DLMO. The absolute mean error of the predictions was 2.88 h, with 76% and 91% of the predictions falling with 2 and 4 h, respectively.

CONCLUSION

This study is the first to demonstrate the use of wrist actigraphy-based estimates of circadian phase as a clinically useful and valid alternative to in-lab measurement of DLMO in fixed night shift workers. Future research should explore how additional predictors may impact accuracy.

Sleep and alertness disturbance and substance use disorders: A bi-directional relation

The majority of the literature describing the relation of sleep/alertness disturbance and substance use disorders (SUD) has focused on the disruptive effects of substances with abuse liability on sleep and alertness. Rarely have studies or literature reviews assessed or discussed how sleep/alertness disturbance affects substance use. This paper focuses on the sleep/alertness disturbance side of the relation. We argue that the relation is bi-directional and review evidence showing that sleep/alertness disturbance affects all phases of the addiction cycle, including the initiation, maintenance and relapse of SUD. We review a variety of substances across all phases of the addiction cycle and conclude sleep/alertness disturbance is a critical factor in both understanding and treating SUD.

Materials Imaging and Dynamics (MID) instrument at the European X-ray Free-Electron Laser Facility

The Materials Imaging and Dynamics (MID) instrument at the European X-ray Free-Electron Laser (EuXFEL) facility is described. EuXFEL is the first hard X-ray free-electron laser operating in the MHz repetition range which provides novel science opportunities. The aim of MID is to enable studies of nano-structured materials, liquids, and soft- and hard-condensed matter using the bright X-ray beams generated by EuXFEL. Particular emphasis is on studies of structure and dynamics in materials by coherent scattering and imaging using hard X-rays. Commission of MID started at the end of 2018 and first experiments were performed in 2019.

Copeptin reliably reflects longitudinal right ventricular function

BACKGROUND

Data is limited evaluating novel biomarkers in right ventricular dysfunction. Normal right heart function improves the prognosis of patients with heart failure. Therefore, this study investigates the association between the novel biomarker copeptin and right heart function compared to NT-proBNP.

METHODS

Patients undergoing routine echocardiography were enrolled prospectively. Right ventricular function was assessed by tricuspid annular plane systolic excursion (TAPSE) and further right ventricular and atrial parameters. Exclusion criteria were age under 18 years, left ventricular ejection fraction < 50% and moderate to severe valvular heart disease. Blood samples were taken for biomarker measurements within 72 h of echocardiography.

RESULTS

Ninety-one patients were included. Median values of copeptin increased significantly according to decreasing values of TAPSE (P = 0.001; right heart function grade I: tricuspid annular plane systolic excursion; TAPSE > 24 mm: 5.20 pmol/L; grade II: TAPSE 18-24 mm: 8.10 pmol/L; grade III: TAPSE < 18 mm: 26.50 pmol/L). Copeptin concentrations were able to discriminate patients with decreased right heart function defined as TAPSE < 18 mm (area under the curves [AUC]: copeptin: 0.793; P = 0.001; NT-proBNP: 0.805; P = 0.0001). Within a multivariable linear regression model, copeptin was independently associated with TAPSE (copeptin: T: -4.43; P = 0.0001; NT-proBNP: T: -1.21; P = 0.23). Finally, copeptin concentrations were significantly associated with severely reduced right heart function (TAPSE < 18 mm) within a multivariate logistic regression model (copeptin: odds ratio: 0.94; 95% confidence interval: 0.911-0.975; P = 0.001).

CONCLUSIONS

This study demonstrates that the novel biomarker copeptin reflects longitudinal right heart function assessed by standardized transthoracic echocardiography compared with NT-proBNP.

Recognizing and Treating Excessive Daytime Sleepiness in Patients With Narcolepsy

Sleep disorders such as narcolepsy can cause excessive daytime sleepiness (EDS). The diagnosis of narcolepsy is often delayed by years. Clinicians can improve the recognition of EDS and diagnosis of sleep disorders using screening tools such as the Epworth Sleepiness Scale and other tests. By following up with patients who present with EDS and continuing to assess until a cause is found, clinicians can lessen the time to diagnosis and initiate appropriate treatment. Fortunately, existing pharmacologic interventions are effective in reducing EDS for many patients, but elimination of EDS for most patients has not been achieved. Some interventions also show efficacy in cataplexy. Nonpharmacologic strategies should also be discussed with patients. Clinicians must monitor EDS during ongoing treatment so that residual symptoms can be addressed. Research suggests a causative role for hypocretin deficiency in narcolepsy, and treatments ameliorating this deficiency are needed. ​.

Simultaneous determination of six antibiotics in human serum by high-performance liquid chromatography with UV detection

Antibiotics are widely used in intensive care patients to treat severe infections. To avoid bacterial resistance or toxic side effects, the determination of serum concentration of ABs is advisable. Therefore, in this study, we developed and validated a simple and fast high-performance liquid chromatography method with UV detection for the simultaneous determination of four β-lactam ABs (meropenem, imipenem, ceftazidime, and piperacillin) and two coadministered substances (cilastatin and tazobactam) in human serum. Sample preparation required a simple protein precipitation by methanol. The separation of the ABs occurred within a timeframe of 17 min. For this purpose, we used a Kinetex F5 column with a linear gradient of acetonitrile and phosphate buffer (pH 6.9). The UV detector recorded two separate chromatograms at 220 and 295 nm simultaneously. Validation has demonstrated that the method is linear, accurate, and precise within the clinically relevant range for each substance.