Low dose exogenous melatonin plus evening dim light and time in bed scheduling advances circadian phase irrespective of measured or estimated dim light melatonin onset time: preliminary findings.

STUDY OBJECTIVES: The purpose of the present study was to preliminarily evaluate whether knowing the dim light melatonin onset (DLMO) time is advantageous when treating delayed sleep-wake phase disorder (DSWPD) with low dose melatonin treatment plus behavioral interventions (i.e., evening dim light and time in bed (TIB) scheduling). METHODS: In this randomized, controlled, double-blind trial, 40 adults with DSWPD were randomly assigned to 4 weeks of 0.5 mg timed to be administered either 3 hours before the DLMO (measured DLMO group, n = 20) or 5 hours before sleep onset time per actigraphy (estimated DLMO group, n = 20), in conjunction with behavioral interventions. The primary outcome was change in the DLMO (measured in-home). Secondary outcomes included sleep parameters per diary and actigraphy (sleep onset and offset times and total sleep time), Morningness-Eveningness Questionnaire (MEQ), Multidimensional Fatigue Inventory (MFI), PROMIS-Sleep Disturbance (SD), PROMIS-Sleep Related Impairment (SRI), and Pittsburgh Sleep Quality Index (PSQI). Mixed effects models tested for group differences in these outcome. RESULTS: After applying the Bonferroni correction for multiple comparisons (significant p-value set at ˂ .004), there were significant main effects for visit on all outcomes except PSQI and total sleep time per wrist actigraphy and diary. There were no group by visit interactions for any of the outcomes (p > .004). CONCLUSIONS: Scheduled low dose melatonin plus behavioral interventions may improve many circadian and sleep parameters regardless of whether melatonin administration is scheduled based on estimated or measured DLMO. A larger-scale trial is needed to confirm these preliminary findings. CLINICAL TRIAL REGISTRATION: Clinicaltrials.gov Identifier: NCT03715465; Name: The Clinical Utility of Measuring the Circadian Clock in Treatment of Delayed Sleep-Wake Phase Disorder; URL: https://clinicaltrials.gov/study/NCT03715465.

Circadian Interventions as Adjunctive Therapies to Cognitive-Behavioral Therapy for Insomnia.

The circadian system plays a key role in the sleep-wake cycle. A mismatch between the behavioral timing of sleep and the circadian timing of sleepiness/alertness can contribute to insomnia. Patients who report primarily difficulty falling asleep or early morning awakenings may benefit from circadian interventions administered adjunctively to cognitive-behavioral therapy for insomnia. Specific circadian interventions that clinicians may consider include bright light therapy, scheduled dim light, blue-blocking glasses, and melatonin. Implementation of these interventions differs depending on the patient's insomnia subtype. Further, careful attention must be paid to the timing of these interventions to ensure they are administered correctly.

Morning light treatment for traumatic stress: The role of amygdala reactivity study protocol.

BACKGROUND: Exposure to trauma can result in various mental health disorders including anxiety, depression, and posttraumatic stress disorder (PTSD). Although psychotherapies and pharmacotherapies exist for the treatment of these disorders, many individuals fail to receive treatment and among those who do, many remain symptomatic. Therefore, it is critical to continue developing new interventions for traumatic stress that target underlying mechanisms of pathology and offer a safe and acceptable alternative to current treatments. Morning light treatment has good potential as a novel non-invasive, low risk treatment for traumatic stress. Evidence suggests that morning light may improve traumatic stress by reducing reactivity in the amygdala, a brain region implicated in the pathophysiology of PTSD and anatomically linked to circadian photoreceptors in the eye. METHODS: In this study, we aim to establish a significant dose-response relationship between duration of morning light treatment and reduction in amygdala reactivity among individuals with traumatic stress symptoms (NCT# 04117347). Using a transdiagnostic approach, sixty-six individuals with a history of a DSM-5 criterion A trauma and traumatic stress symptoms will be recruited to participate in a 5-week study. Participants will be randomized across three treatment arms based on morning light treatment duration: 15-minutes, 30-minutes, or 60-minutes of light treatment per day for four weeks. To evaluate amygdala activity, participants will undergo fMRI at pre-treatment, mid-treatment, and post-treatment. Participants will also complete clinical assessments and self-report measures of PTSD, depression, and anxiety at pre-treatment, mid-treatment, and post-treatment. DISCUSSION: Morning light therapy may be an acceptable, feasible, and effective treatment for individuals suffering from traumatic stress. Identifying mechanistically relevant targets, and the doses needed to impact them, are critical steps in developing this new treatment approach for the sequelae of traumatic stress.

Snoring and depression symptoms in pregnant women.

OBJECTIVE: Pregnant patients are vulnerable to both depression and sleep-disordered breathing, and both convey risks for maternal and fetal outcomes. Previous research has indicated that sleep-disordered breathing is associated with depression, but further information related to the risk of depression based on timing of onset of snoring is needed. DESIGN: When presenting to clinic for their initial prenatal visit, pregnant patients completed a packet of questionnaires, which included measures related to depression (Edinburgh Postnatal Depression Scale) and snoring. Habitual snoring was defined as snoring 3 or more nights per week. RESULTS: In total, 1367 women were included and 34.1% reported habitual snoring, either chronic (24.4%) or pregnancy-onset (9.8%), with increased frequency of pregnancy-onset habitual snoring in later stages of pregnancy. Unadjusted analyses suggested increased odds of depressive symptoms in chronic and pregnancy-onset habitual snoring groups relative to nonsnorers (odds ratio [OR]: 2.01, 95% confidence interval [CI]: 1.39, 2.92, P < .01; OR: 2.50, 95% CI: 1.54, 4.07, P < .01, respectively). These findings were maintained after adjusting for maternal age, marital status, gestational age, and parity (chronic habitual snoring OR: 1.69, 95% CI: 1.14, 2.53, P < .01; pregnancy-onset habitual snoring OR: 2.79, 95% CI: 1.35, 5.78, P < .01). CONCLUSIONS: Maternal snoring may be a risk factor for prenatal depressive symptoms. Pregnancy-onset habitual snoring confers additional risk for depression compared to not snoring during pregnancy.

Perinatal Insomnia and Mental Health: a Review of Recent Literature.

PURPOSE OF REVIEW: The perinatal period is a time of high risk for insomnia and mental health conditions. The purpose of this review is to critically examine the most recent literature on perinatal insomnia, focusing on unique features of this period which may confer specific risk, associations with depression and anxiety, and emerging work on perinatal insomnia treatment. RECENT FINDINGS: A majority of perinatal women experience insomnia, which may persist for years, and is associated with depression and anxiety. Novel risk factors include personality characteristics, nocturnal perinatal-focused rumination, and obesity. Mindfulness and physical activity may be protective. Cognitive-behavioral therapy for insomnia is an effective treatment. Perinatal insomnia is exceedingly common, perhaps due to factors unique to this period. Although closely linked to perinatal mental health, more work is needed to establish causality. Future work is also needed to establish the role of racial disparities, tailor treatments, and determine whether insomnia treatment improves perinatal mental health.

Obstetrician-gynecologists' screening and management of depression during perimenopause.

OBJECTIVE: Depression in women is more common during perimenopause (the time period around and during menopause) than pre and postmenopause. Obstetrician-gynecologists (ob-gyns) play a vital role in the detection and management of depression symptoms in women because for many women ob-gyns are the first and most frequent point of medical contact. This study assessed ob-gyns' screening practices and management of depression in perimenopause. METHODS: A survey regarding depression during perimenopause was sent to 500 practicing ob-gyns who were fellows of the American College of Obstetricians and Gynecologists and members of the Collaborative Ambulatory Research Network. RESULTS: The survey response rate was 41.8% (209 of 500 surveys returned). Over a third of respondents (34.1%) reported that they did not regularly screen perimenopausal patients for depression. Higher-quality education about depression, respondent sex, and personal experience with depression were associated with higher rates of screening. While 85.7% of respondents believed that they could recognize depression in perimenopausal women, only about half (55.8%) were confident in their ability to treat these patients. CONCLUSION: Increased education of ob-gyn physicians related to depression during perimenopause may increase the screening and treatment of women during this phase of life.

Depression during perimenopause: the role of the obstetrician-gynecologist.

Depression in women is more common during perimenopause (the transition to menopause) than at other times in the life cycle. Symptoms of depression may be different in perimenopausal women compared to younger or older women, and are often dismissed as part of normal menopause. This is an expert narrative review. There are several evidence-based screening modalities which can be integrated into routine women's health visits, and can facilitate distinguishing between depression and normal perimenopausal symptoms. There is emerging evidence regarding the effect of hormonal changes on the development of perimenopausal depression and its optimal treatment, though critical research gaps remain. Obstetrician-gynecologists and other primary care providers play a vital role in the detection and management of depression in women. Providers caring for women during perimenopause have a unique opportunity to diagnose depression in their patients and identify appropriate treatment options.

The neuropsychological phenotype of Chediak-Higashi disease.

BACKGROUND/OBJECTIVES: Chediak-Higashi Disease (CHD) is a rare autosomal disorder, purported to have cognitive and neurological impairments. Prior descriptions of cognitive impairment, however, are solely based on subjective, unstructured observations rather than on formal neuropsychological measures. METHODS: Four pediatric and 14 adult patients with diagnostically confirmed CHD were administered a neuropsychological battery assessing memory, attention, processing speed, psychomotor speed, language fluency, executive function, and general intelligence. Nine of the adult patients received follow-up evaluations to elucidate the longitudinal progression or stability of cognition over time. RESULTS: Pediatric CHD patients performed within the average range. Adult patients, however, performed below average on nearly all measures administered, and endorsed subjective reports of learning difficulties and poor academic performance in childhood. In particular, patients struggled with memory and psychomotor speed tasks, with 75% or more of patients scoring in the bottom 2.3 percentile in these two domains. No significant declines in cognition were observed among the patients who completed follow-up evaluations (M = 39.90, SD = 8.03 months between visits). Exploratory analyses suggested that adult patients who had classic CHD and previously received bone marrow transplants (BMTs; n = 3) exhibited moderately greater cognitive impairment than adult patients who had atypical CHD and had not received BMTs (n = 10). CONCLUSIONS: Adult patients with CHD uniformly exhibit deficits in multiple domains, but in psychomotor speed and memory, in particular. Based on their neuropsychological profile, their ability to hold jobs and succeed in school may require support and special accommodations. The source of cognitive deficits is probably multifactorial including central nervous system involvement in CHD, and, for those transplanted, BMT-related side effects and complications. Absence of cognitive decline at three-year follow-up is encouraging but does not exclude progression at a slower time-scale. Future work should elucidate the possible effects and timing of BMT on cognition, as well as the mechanisms driving neuropsychological impairment in CHD.

Cognitive Behavioral Therapy for Insomnia in Patients with Medical and Psychiatric Comorbidities.

"Insomnia is highly comorbid with other mental health and medical conditions and adversely affects quality of life and daytime functioning. Cognitive behavioral therapy for insomnia (CBT-I) is a safe and efficacious treatment for insomnia in the context of various comorbid conditions. In this article, the authors outline considerations for delivering CBT-I in patients with the most common co-occurring medical and mental health conditions, review the evidence for CBT-I in these populations as well as special considerations for its application, and highlight future areas for research in the area of CBT-I for comorbid medical and psychiatric conditions."

Perspectives on global health amongst obstetrician gynecologists: A national survey.

Objective To characterize contemporary attitudes toward global health amongst board-certified obstetricians-gynecologists (Ob-Gyns) in the US. Methods A questionnaire was mailed to members of the American College of Obstetricians and Gynecologists. Respondents were stratified by interest and experience in global health and group differences were reported. Results A total of 202 of 400 (50.5%) surveys were completed; and 67.3% ( n = 136) of respondents expressed an interest in global health while 25.2% ( n = 51) had experience providing healthcare abroad. Personal safety was the primary concern of respondents (88 of 185, 47.6%), with 44.5% (57 of 128) identifying 2 weeks as an optimal period of time to spend abroad. The majority (113 of 186, 60.8%) cited hosting of local physicians in the US as the most valuable service to developing a nation's healthcare provision. Conclusion Despite high interest in global health, willingness to spend significant time abroad was limited. Concerns surrounding personal safety dovetailed with the belief that training local physicians in the US provides the most valuable service to international efforts. These attitudes and concerns suggest novel solutions will be required to increase involvement of Ob-Gyns in global women's health.

Electronic Health Record Adoption among Obstetrician/Gynecologists in the United States: Physician Practices and Satisfaction.

Implementation of electronic health records (EHRs) has historically been lower among obstetrician-gynecologists (ob-gyns) than many physician groups. This study described ob-gyns' adoption and use of EHR systems in practice, as well as barriers and benefits to implementation. Surveys asking about the physicians' use of EHR, satisfaction with systems, and what features they found most or least helpful were mailed to 1,200 ob-gyns. An overall response rate of 57.4% was achieved, with 559 returning completed surveys. Over three-quarters of responders reported that they used an EHR system or planned to implement one. Physicians without EHR tended to be older, were more likely to be male, have a solo practice, and describe themselves as Asian/Pacific Islander. Over 63% of those physicians who use EHR reported being satisfied with their system, while 30.8% were not satisfied. Ob-gyns who reported satisfaction had a younger mean age (M = 52.98, SD = 8.87) than those not satisfied (M = 56.30, SD = 8.59; p = .002). Use of EHR systems among ob-gyns has increased in recent years and overall satisfaction with these systems is high. In spite of this, barriers to implementation are still present and increased outreach to certain groups of ob-gyns, including older practitioners and those in solo practices, is needed.

The role of glucocorticoids and corticotropin-releasing hormone regulation on anxiety symptoms and response to treatment.

The stress response has been linked to the expression of anxiety and depression, but the mechanisms for these connections are under continued consideration. The activation and expression of glucocorticoids and CRH are variable and may hold important clues to individual experiences of mood disorders. This paper explores the interactions of glucocorticoids and CRH in the presentation of anxiety and depressive disorders in an effort to better describe their differing roles in each of these clinical presentations. In addition, it focuses on ways in which extra-hypothalamic glucocorticoids and CRH, often overlooked, may play important roles in the presentation of clinical disorders.

Attitudes and Beliefs Regarding the Utility of Robotically Assisted Gynecologic Surgery Among Practicing Gynecologists.

While use of robotic-assisted surgery has increased rapidly, little is known about the attitudes and beliefs of practicing gynecologists regarding the utility of the technology. We surveyed a large sample of gynecologists to examine their attitudes and beliefs about the benefits, utility, and factors driving use of robotic-assisted gynecologic surgery. A 51-item survey was mailed to 600 fellows or junior fellows of the American College of Obstetricians and Gynecologists. The survey included questions on use of robotic surgery, decision-making, and beliefs regarding the technology. Responses were stratified based on whether the respondent used robotic surgery or not. A total of 310 responses were received including 27.8% who used robotic surgery in their practices. Hysterectomy was the most commonly performed procedure. Opinions about the use and effectiveness of robotic procedures varied based on whether an individual was a robot user. Eighty-two percentage of robot users and 21% of nonrobot users believed robotic surgery provided benefits over laparoscopic (p < .0001). Among both groups, the ability to increase access to minimally invasive surgery and marketing were believed to be the greatest drivers of use of robotic surgery. Attitudes and beliefs about the effectiveness of robotic gynecologic surgery are highly variable among clinicians.

Racial and Ethnic Disparities in Preterm Birth Among American Indian and Alaska Native Women.

OBJECTIVES: Preterm birth disproportionately affects American Indian/Alaska Native (AI/AN) women. This disparity in birth outcomes may stem from higher levels of exposure to psychosocial, sociodemographic, and medical risk factors. METHODS: This paper reviews relevant research related to preterm birth in American Indian and Alaska Native women. CONCLUSIONS: This narrative review examines disparities in preterm birth rates between AI/AN and other American women, and addresses several maternal risk factors and barriers that contribute to elevated preterm birth rates among this racial minority group. Additionally, this paper focuses on recent evidence that geographical location can significantly impact preterm birth rates among AI/AN women. In particular, access to care among AI/AN women and differences between rural and urban areas are discussed.

Brief Report on Obstetricians'/Gynecologists' Distribution of Scarce Resources.

On a day-to-day basis, doctors must decide which treatments are most beneficial for their patients, and which make the most sense in terms of costs. In medical decision making, factors such as efficiency and cost-effectiveness can be particularly challenging to navigate because many of the most expensive procedures encountered in medical practice are also high-stake treatments for patients. One-hundred-six obstetricians-gynecologists (Obs/Gyns) completed a survey asking them to allocate the following resources in scenarios in which they are scarce: human papilloma virus (HPV) vaccinations, mammograms, and in vitro fertilization (IVF) treatments. Additional questions focused on how fairness and cost-effectiveness factored into the allocation decisions of each group. Results indicated that Obs/Gyns were more efficient in their distribution of HPV vaccinations and mammograms than in their distribution of IVF treatments. More efficient responding was associated with placing less emphasis on fairness in decision making. This study demonstrates the differences that exist in the emphasis that physicians place on medical evidence, cost, outcomes, and perceptions of fair (equal) allocation when faced with different costs and health impacts.

Bridging progestogens in pregnancy and pregnancy prevention.

Steroid hormones have been in use for more than a half a century as contraceptive agents, and only now are researchers elucidating the biochemical mechanisms of action and non-target effects. Progesterone and synthetic progestins, critical for women's health in the US and internationally, appear to have important effects on immune functioning and other diverse systems. Apart from the contraceptive world is a separate field that is devoted to understanding progesterone in other contexts. Based on research following a development timeline parallel to hormonal contraception, progesterone and 17-hydroxyprogesterone caproate are now administered to prevent preterm birth in high-risk pregnant women. Preterm birth researchers are similarly working to determine the precise biochemical actions and immunological effects of progesterone. Progesterone research in both areas could benefit from increased collaboration and bringing these two bodies of literature together. Progesterone, through actions on various hormone receptors, has lifelong importance in different organ systems and researchers have much to learn about this molecule from the combination of existing literatures, and from future studies that build on this combined knowledge base.

Obstetrician/gynecologists' experiences with electronic health record systems: a narrative study.

OBJECTIVE: To explore the experiences of obstetrician/gynecologists (ob/gyns) with regard to the use of electronic health record (EHR) systems in practice. STUDY DESIGN: Surveys were mailed to 1,200 ob/gyns, with an overall response rate of 57.2%, 402 of whom currently use an EHR system. The survey included questions about the physicians' use of EHR systems as well as what features they found most or least helpful. In addition, a focus group of 6 practicing ob/gyns at a university-based hospital was conducted in which they were encouraged to give free responses about their experiences working with EHR systems. Responses from surveys and the focus group were analyzed for frequency by the investigators. RESULTS: The majority of ob/gyns who used an EHR reported being satisfied with that system (61.4%). The most commonly reported impediments to EHR use were time needed, ineffective templates, note quality, interference with patient interactions, and expense. The most commonly cited positives were electronic medication prescription (e-scribing) capabilities, efficiency, and ease of access to notes, including legibility. CONCLUSION: In spite of increased adoption of EHR systems, more work is needed to improve ob/gyn satisfaction with EHR systems.

Survey of American obstetricians regarding group B streptococcus: opinions and practice patterns.

OBJECTIVE: The objective of the study was to evaluate attitudes and practice patterns of obstetricians related to screening for group B streptococcal colonization and providing intrapartum antibiotic prophylaxis against early-onset neonatal infections with group B streptococcus. STUDY DESIGN: We mailed a survey to 546 members of the American College of Obstetricians and Gynecologists, including members of the Collaborative Ambulatory Research Network and non-Collaborative Ambulatory Research Network members. Stratified random selection was used to generate samples from both of these groups. RESULTS: The survey response rate was 60% for Collaborative Ambulatory Research Network members and 42% for non-Collaborative Ambulatory Research Network members. Of the 206 respondents who reported providing prenatal care, 97% collect screening samples at 35-37 weeks' gestational age. Anatomic sites used to collect samples were more variable: 62% include lower vagina and rectum, 26% include lower vagina and perianal skin but not rectum, and 5% include neither the perianal skin nor the rectum. First-line agents for intrapartum antibiotic prophylaxis were penicillin (71%), ampicillin (27%), and cefazolin (2%). For patients reporting a nonanaphylactic penicillin allergy, drugs used for intrapartum antibiotic prophylaxis were more varied: cefazolin (51%), clindamycin (36%), vancomycin (8%), and erythromycin (5%). For patients undergoing a labor induction starting with a cervical ripening agent, less than 40% typically give the first dose of intrapartum antibiotic prophylaxis before or at the time of cervical ripening agent administration, and 15% wait until the patient reaches the active phase of labor. CONCLUSION: Gaps in knowledge and reported practice related to the prevention of early-onset neonatal group B streptococcus infections were similar to gaps in implementation of guidelines demonstrated in past studies. New approaches to improve implementation are warranted.

Need to know: the need for cognitive closure impacts the clinical practice of obstetrician/gynecologists.

BACKGROUND: Need for cognitive closure (NFCC) has been shown to be a consistent and measurable trait. It has effects on decision making and has been associated with more rapid decision making, higher reliance on heuristics or biases for decision making, reduced tolerance for ambiguity, and reduced interest in searching for alternatives. In medical practice, these tendencies may lead to lower quality of decision making. METHODS: This study measured NFCC in 312 obstetrician/gynecologists using a survey-style approach. Physicians were administered a short NFCC scale and asked questions about their clinical practice. RESULTS: Obstetrician/gynecologists with high NFCC were found to be less likely to address a number of clinical questions during well-woman exams, and were more likely to consult a greater number of sources when prescribing new medications. CONCLUSIONS: NFCC of physicians may have an important impact on practice. It is possible that increased training during residency or medical school could counteract the detrimental effects of NFCC, and steps can be taken through increased use of electronic reminder systems could orient physicians to the appropriate questions to ask patients.

The evolution of music and human social capability.

Music is a core human experience and generative processes reflect cognitive capabilities. Music is often functional because it is something that can promote human well-being by facilitating human contact, human meaning, and human imagination of possibilities, tying it to our social instincts. Cognitive systems also underlie musical performance and sensibilities. Music is one of those things that we do spontaneously, reflecting brain machinery linked to communicative functions, enlarged and diversified across a broad array of human activities. Music cuts across diverse cognitive capabilities and resources, including numeracy, language, and space perception. In the same way, music intersects with cultural boundaries, facilitating our "social self" by linking our shared experiences and intentions. This paper focuses on the intersection between the neuroscience of music, and human social functioning to illustrate the importance of music to human behaviors.