Digital cognitive behavioral therapy (CBT) is an effective, scalable, safe, and acceptable intervention for improving insomnia symptoms in pregnant women at less than 28 weeks’ gestation, according to findings published in JAMA Psychiatry. The findings may be promising since anxiety and depressive symptoms improved alongside insomnia for the digital CBT intervention, which is highly scalable, low risk, and effective

Jennifer N. Felder, PhD, from the Osher Center for Integrative Medicine at the University of California, San Francisco, and colleagues conducted a randomized clinical trial to evaluate the effectiveness of digital CBT in 208 adult women (mean age, 33.6±3.7 years) who were pregnant for up to 28 weeks’ gestation and either reported elevated insomnia symptom severity or met the criteria for an insomnia disorder. Participants were randomized to receive either digital CBT (n=105) or standard treatment (n=103) for insomnia.

Digital CBT involved 6 weekly remote sessions (available via website or iOS app), each lasting approximately 20 minutes. This approach comprised sleep restriction, stimulus control, relaxation techniques, cognitive therapy, and sleep hygiene and education. Participants completed the Insomnia Severity Index at 10 weeks (postintervention) and 18 weeks (follow-up) after randomization; they used diaries to log their own sleep efficiency, duration, quality, and caseness. Women receiving standard treatment had no limits placed on the receipt of nonstudy treatments, including medication and psychotherapy.

A total of 68 women (64.8%) completed all 6 sessions. The mean gestational age was 17.6±6.3 weeks at baseline, and the majority of participants were white (66.3%) and married or cohabiting (94.2%). The sample also largely represented a high socioeconomic status, with 86.5% having a college degree and 67.8% earning $100,000 or more per year. Both groups experienced 3 adverse events each, mainly miscarriages.

Compared to women who received standard treatment, those who received digital CBT experienced greater improvements in insomnia symptom severity from baseline to postintervention (time-by-group interaction, difference = −0.36; 95% CI, −0.48 to −0.23; χ2 = 29.8; P <.001; d = −1.03). The digital CBT group had significantly higher remission rates as well (44.0% vs 22.3%; P =.002). Furthermore, alongside greater reductions in secondary sleep outcomes in the digital CBT group, participants in the experimental condition also experienced significantly reduced depressive (difference, -0.21; 95% CI, -0.30 to -0.11; P <.001) and anxiety (difference, -0.188; 95% CI, -0.26 to -0.10; P <.001) symptoms. Improvements from baseline to follow-up were similar to those from baseline to postintervention.

The study may be limited by the fact that participants were mostly wealthy, white, and highly educated; results may differ for patients from other backgrounds.

“Although more women randomized to receive digital CBT-I experienced remission in insomnia symptoms compared with those randomized to receive standard treatment, most women continued to experience at least subthreshold symptoms,” the investigators noted. The findings may be promising since anxiety and depressive symptoms improved alongside insomnia for the digital CBT intervention, which is highly scalable, low risk, and effective.

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A new study suggests that whereas most patients will not suffer immediate mental health effects, certain complications could emerge later, The results of the meta-analysis suggest that certain disorders such as anxiety and post-traumatic stress disorder may persist for months or even years in patients severely affected by Covid-19.

In order to understand the long-term effects of severe Covid-19 infection, U.S. researchers have reviewed symptoms in people affected by other forms of coronavirus, notably SARS and MERS.

The meta-analysis of 65 peer reviewed studies and seven pre-prints on the observed psychiatric consequences of more than 3,550 severe infections with SARS (2002), MERS (2012) and Covid-19.

The study was limited to cases treated in hospital and therefore does not apply to patients who experienced milder symptoms or were asymptomatic.

The results of the analysis, published in The Lancet Psychiatry suggest that whereas most patients will not suffer immediate mental health effects, certain complications like depression, anxiety, fatigue, and post-traumatic stress disorder (PTSD) could emerge in the months and years that follow hospitalisation.

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(HealthDay)—Insomnia may significantly increase the risk that older adults will be unable to shake off depression, researchers say.

For the study, the investigators analyzed data on nearly 600 people over age 60 who visited primary care centers in New York City, Philadelphia and Pittsburgh. All had some level of depression.

Compared to patients whose sleep improved, those with worsening sleep problems were about 28 times more likely to be diagnosed with major depression at the end of the 12-month study.

Patients whose sleep worsened also had nearly 12 times the odds of minor depression and were 10% more likely to report having suicidal thoughts, according to the Johns Hopkins Bloomberg School of Public Health study.

The report was recently published online in the journal Sleep.

Compared to patients whose sleep improved, those with persistent, but not worsening, insomnia were more likely to have lasting depression. But their risk was not as high as patients whose sleep got worse.

“These results suggest that, among older adults with depression, insomnia symptoms offer an important clue to their risks for persistent depression and suicidal ideation,” said study senior author Adam Spira, a professor of mental health at Johns Hopkins in Baltimore.

“We can’t say that the sleep disturbances we’re seeing are necessarily causing the poor depression outcomes,” he said in a Hopkins news release. “But the results suggest that older adults who are being treated for depression and whose sleep problems are persistent or worsening need further clinical attention.”

Spira said the findings also suggest that treatment of sleep problems should be explored as a way to improve depression symptoms in older adults, as well as poor mental and health outcomes related to disturbed sleep.

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Washington: What can bolster the risk of cancer and early death in mid-aged adults with high blood pressure, type 2 diabetes, stroke is less sleeping hours! Yes, it has been found that these adults are at a high risk of cancer and dying early if they sleep for less than six hours a day. The findings were published in the Journal of the American Heart Association.

“Our study suggests that achieving normal sleep may be protective for some people with these health conditions and risks,” said lead author Julio Fernandez-Mendoza, Ph.D., associate professor at Pennsylvania State College of Medicine and sleep psychologist at the Sleep Research & Treatment Center of the Penn State Health Milton S. Hershey Medical Center in Hershey, Pennsylvania.

Researchers analyzed data of more than 1,600 adults (20 to 74 years old, more than half women) from the Penn State Adult Cohort who were categorized into two groups as having stage 2 high blood pressure or Type 2 diabetes and having heart disease or stroke.

Participants were studied in the sleep laboratory (1991-1998) for one night and then researchers tracked their cause of death up to the end of 2016. In this study, of the 512 people who passed away, one-third died of heart disease or stroke and one-fourth died due to cancer.

People who had high blood pressure or diabetes and slept less than 6 hours had twice the increased risk of dying from heart disease or stroke. People who had heart disease or stroke and slept less than 6 hours had three times the increased risk of dying from cancer.

The increased risk of early death for people with high blood pressure or diabetes was negligible if they slept for more than 6 hours. “Short sleep duration should be included as a useful risk factor to predict the long-term outcomes of people with these health conditions and as a target of primary and specialised clinical practices,” Fernandez-Mendoza said.

Sleep duration in this study was based on observing one night’s sleep, which may be affected by the first-night effect where participants sleep significantly worse the first night in a lab compared to other consecutive nights, which is the type of sleep study routinely used in clinical practices.

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A 55-year-old woman came in for an evaluation of ear drainage that has been going on for two to three years. She also reported getting “cross-eyed” when she presses her ear. She has a history of childhood ear surgery, and underwent two procedures within a one-year span about 20 years ago. Her ear examination showed that her tympanic membrane was intact and retracted. Fresh drainage was present in the ear canal. Palpation of the posterior ear canal wall showed that the medial aspect of the cartilaginous canal had a depression. Wet keratin debris was found after placing a loop curette in the deep area. Her audiogram showed a maximum conductive hearing loss. Her CT scan is on the right.
Diagnosis: Iatrogenic Cholesteatoma with Horizontal Canal Fistula
Many surgeons perform cholesteatoma surgery to remove the skin growth, make sure that no cholesteatoma remains, and reconstruct the ossicles. When dealing with patients with previous ear surgery (particularly two surgeries in quick succession), clinicians tend to presume that the surgery was for cholesteatoma. However, clinicians should thoroughly examine the ear of these patients. First, pay close attention to the post-auricular wound to determine if a previous mastoidectomy was performed. This helps rule out a mastoid fistula. Palpation of the wound may reveal a depression, which would likely correspond to a previous mastoidectomy. In children, the mastoid cortex tends to grow and close over time. Therefore, a depression may not always be palpated in a child who underwent a mastoidectomy.

Next, examine the tympanic membrane and pars tensa thoroughly. All debris should be removed from the tympanic membrane, preferably using a microscope and a small hook to separate the debris from the membrane. This is done to make sure that no perforations or new cholesteatomas are present. Keratin debris coming out of a cholesteatoma often appear as cerumen on the tympanic membrane. Using the term “wax on the TM” in patient charts, which is a common practice, should be avoided because cerumen-like debris on the tympanic membrane is highly suggestive of cholesteatoma. This debris needs to be removed for a full examination of the tympanic membrane. If it cannot be easily removed, ear drops can be applied to soften the debris and allow for suction.

Granulation tissue on the tympanic membrane or at the medial aspect of the canal should always be met with suspicion. Granulation, especially in the posterior superior quadrant or the pars flaccida area, should be considered as a possible sign of cholesteatoma. This condition causes an intense inflammatory reaction that may result in the development of granulation tissue. Since the pars flaccida area (superiorly) and the posterior superior quadrant are the most common areas of cholesteatoma development, any granulation tissue in those areas needs treatment and further workup to uncover the underlying cholesteatoma. Deep retractions are likely cholesteatomas that need further imaging workup, particularly if the patient experiences recurrent drainage. The depth of a retraction can be measured using an angled endoscope or a blunt angled 3 mm hook to palpate the depth of the retraction under microscopy. Check on the patient soon to make sure he or she does not get lost to follow-up.

Finally, the posterior canal wall needs to be evaluated from the tympanic membrane level to the meatus. This necessitates pulling the speculum out a bit to evaluate the lateral aspect of the canal. Since the debris in the ear canal can obscure a mastoid fistula, the posterior canal should be gently palpated with an angled curette to find any occult fistulas.

Horizontal nystagmus that occurs when pumping the tragus is a worrisome sign in a patient who has undergone previous surgery. The differential diagnosis of this phenomenon includes perilymph fistula or semicircular canal dehiscence. Traditionally called Hennebert’s sign, this condition was considered sign of perilymph fistula and has been associated with syphilitic ear disease during the pre-antibiotic era. Syphilis can cause destruction of the inner ear (otic capsule) bone and lead to canal dehiscence. Today, Hennebert’s sign is associated with superior canal dehiscence. However, the case of this patient was most suspicious for horizontal canal fistula caused by occult cholesteatoma. Examination of her CT scan showed an erosion of the horizontal canal anteriorly (Fig. 1). The large defect in the lateral canal wall and mastoid suggested a mastoid-canal fistula development, which is usually iatrogenic and caused by not straightening the lateral canal (Koerner) flap at the end of the surgery. In chronic ear surgery, an incision is generally made in the posterior ear canal skin so the tympanic membrane can be seen through the post-auricular wound. At the end of the surgery, these two flaps need to be straightened. If the tip of the lateral or medial canal flap is folded under, the folded skin can continue to grow and form an iatrogenic cholesteatoma, which can grow for many years before it is diagnosed.

The patient’s imaging showed a large defect in the mastoid (Figs. 2 and 3). It is unclear if the defect was from previous surgeries or from a canal-mastoid fistula or cholesteatoma. However, MRI imaging can help differentiate cholesteatoma from fluid, scar tissue, or other soft tissue. T2-weighted imaging can show if the tissue has high water content and appear brighter than the brain (Fig. 4). Cholesteatomas as small as 5 mm can be detected using axial (echoplanar) diffusion-weighted imaging (DWI). A non-echoplanar diffusion-weighted imaging sequence (a.k.a. HASTE sequence) can differentiate cholesteatomas as small as 3 mm. In this patient, the DWI sequence showed that the soft tissue in the mastoid was most likely a cholesteatoma (Fig. 5).

To treat a cholesteatoma that causes horizontal canal fistula, the fascia has to be removed and covered immediately. Ideally, the membranous canal is covered with the fascia, bone putty, and a thin Silastic® sheet, which is placed to prevent the adherence of other tissues (e.g., cartilage tissue). This way, the canal is less likely to get injured in any future ear surgery.

In some cases, the cholesteatoma may be strongly adherent to the membranous portion of the horizontal canal and cannot be separated without potentially injuring the membranous canal. Violating the membranous canal can cause deafness if inflammatory mediators or bacteria enter the perilymphatic space. Therefore, in these cases, the cholesteatoma is left on the membranous canal and exteriorized. This allows any keratin (dead skin) produced by the cholesteatoma to exit into the ear canal and not accumulate and cause more destruction. However, this leaves the patient with the same dizziness problem when pressure is place on the ear.

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